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DEPOSITED  IN 

Boston  Medical  Library, 

'  BY  THE 

'UBLIC  LTijRARYOF  THE 


City  c 


■^CN. 


THE  FRANCIS  A.  COUNTWAY  LIBRARY  OF  MEDICINk 
HARVARD  MEDICAL  LIBRARY-BOSTON  MEDICAL  LIBRARY 


MEDICAL  RECORD 


A   Weekly  yournal  of  Medicine  and  Surgery 


EDITED    BY 

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


SURGEON  TO  ST.   FRANCIS  HOSPITAL,   NEW*  YORK  ,*    CONSULTING    SURGEON  TO   THE    NEW  YORK  CANCER    HOSPITAL,  AND  CONSULTING 
PHYSICIAN-IN-CHIBF  TO  THE  HOSPITALS  OP  THE  HEALTH  DEPARTMENT  OF  THE  CITY  OF  NEW  YORK 


THE  FRANCIS  A.  C0UN7WAY 

LIBRARY  0.  •• '  HiCliC 

BGB'iua  MA 

OCT  z  -i  2003 

JULY  7,  1894  — DECEMBER  29,  1894 


NEW    YORK 
WILLIAM    WOOD    &    COMPANY 

1894 


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Trow  Directory, 

Printing  and  Bookbinding  Company, 

201-213  East  \ith  Street ', 

New  York. 


LIST   OF  CONTRIBUTORS  TO  VOL.  XLVI. 


Abbott,  Dr.  George  E.,  New  York. 
Abrahams,  Dr.  R.,  New  York. 
Abrams,  Dr.  Albert,  San  Francisco, 

Cal. 
Adams,  Dr.  Robert  S.,  New  York. 
Aiken,  Dr.  Hugh  K.,  Laurens,  S.  C. 
Aiken,  Dr.  Wm.   F.,  Savannah,  Ga. 
Alger,  Dr.  Ellice  M.,  New  York. 
Ambrose,    Dr.    Daniel    R.,    New 

York. 
Ashmead,  Dr.  Albert  S.,  New  York. 
Aulde,  Dr.  John,  Philadelphia,  Pa. 

Baginsky,  Dr.  Rudolf,  Berlin,  Ger. 

Bannan,  Dr.  Theresa,  Syracuse, 
N.  Y. 

Barry,  Dr.  John  H.,  Long  Island 
City,  N.  Y. 

Baruch,  Dr.  Simon,  New  York. 

Bashore,  Dr.  Harvey,  West  Fair- 
view,  Pa. 

Beck,  Dr.  Carl,  New  York. 

Beebe,  Dr.  Alfred  L.,  New  York. 

Bellamy,  Dr.  Russell,  New  York. 

Benedict,  Dr.  A.  L.,  Buffalo,  N.  Y. 

Biggs,  Dr.  Hermann  L.,  New  York. 

Blair,  Dr.  Louis  E.,  Albany,  N.  Y. 

Bleyer,  Dr.  J.  Mount,  New  York. 

Blumenthal,  Dr.  Oliver  A.,  Syra- 
cuse, N.  Y. 

Bogle,  Dr.  J.  C,  Danville,  Ky. 

Bosworth,  Dr.  F.  H.,  New  York. 

Bottoms,  Dr.  Frank  A.,  New  York. 

Brandenburg,  Dr.  F.  D.,  Cleve- 
land, Ohio. 

Brewster,  Dr.  J.  D.,  Windsor,  Vt. 

Briggs,  Dr.  M.  D.,  Champlain,  N.  Y. 

Brown,  Dr.  Sanger,  Chicago,  I1L 

Bull,  Dr.  William  T.,  New  York. 

Bullitt,  Dr.  James  B.,  Globe,  A.  T. 

Cadwallader,  Dr.  Rawlins,  Fall 
River  Mills,  Cal. 

Callender,  Dr.  C.  H.,  New  Boston, 
Mass. 

Carleton,  Dr.  Th.  B.,  Sabathu,  In- 
dia. 

Carroll,  Dr.  C.  H.,  Pavaris,  Fla. 

Cartwright,  Dr.  Silas  S.,  Roxbury, 
N.  Y. 

Caverly,  Dr.  Q  S.,  Rutland,  Vt. 

Chapin,  Dr.  H.  D wight,  New  York. 

Chapman,  Dr.  W.  L.,  Lynn,  Mass. 

Clark,  Dr.  L.  Pierce,  Middletown, 
Conn. 

Cleaves,  Dr.  Margaret  A,  New 
York. 

Coleman,  Dr.  Warren,  New  York. 

Collins,  Dr.  Joseph,  New  York. 

Collyer,  Dr.  H.  L.,  New  York. 

Comegys,  Dr.  C.  G.,  Cincinnati,  O. 

Conklin,  Dr.  W.  J.,  Dayton,  Ohio. 

Conn,  Dr.  H.  W.,  Middletown,  Conn. 

Cordier,  Dr.  A.  H.,  Kansas  City, 
Mo. 

Craig,  Dr.  Thomas  C,  U.  S.  Navy. 

Crary,  Dr.  George  W.,  New  York. 

Crosse,  Dr.  W.  A.,  Jenkinton,  Pa. 

Crossfiild,  Dr.  Fred.  S.,  Hartford, 
Conn. 

Cushing,  Dr.  Clinton,  San  Fran- 
cisco, Cal. 


Dalrymple,  Dr.  F.  W.,  New  Rochelle, 
N.  Y. 

Daly,  Dr.  W.  H  ,  Pittsburg,  Pa. 

Dana,  Dr.  Charles  L.,  New  York. 

Dawbarn,  Dr.  R.  H.  M.,  New  York. 

Dickinson,  Dr.  George  S.,  Erie,  Pa. 

Dickinson,  Dr.  R.  L.,  Brooklyn, 
N.  Y. 

Dixon- Jones,  Dr.  Mary  A.,  Brook- 
lyn, N.  Y. 

D'Oench,  Dr.  F.  E.,  New  York. 

Dowd,  Dr.  Charles  N.,  New  York. 

D wight,  Dr.  Thos.,  Nahant,  Mass. 

Eastman,  Dr.  Jos.,  Indianapolis,  Ind. 
Edes,  Dr.  Robert  T.,  Boston,  Mass. 
Ely,  Dr.  John  Slade,  New  York. 
Embden,  Dr.  Oscar,  Brooklyn,  N.  Y. 
Engman,  Dr.  Martin  F.,  New  York. 
Estes,  Dr.  W.  L.,  South  Bethlehem, 

Pa. 
Ewing,  Dr.  A.  C,  Salt  Lake  City, 

Utah. 

Fischer,  Dr.  Louis,  New  York. 

Flagg,  Dr.  R.  N.,  Yonkers,  N.  Y. 

Foster,  Dr.  Burnside. 

Francis,  Dr.  Richard  P.,  Mont- 
clair,  N.  J. 

Frank,  Dr.  J.,  Chicago,  111. 

Freeman,  Dr.  Leonard,  Cincinnati, 
Ohio. 

Freeman,  Dr.  Rowland  Godfrey, 
New  York. 

Friedenwald,  Dr.  Julius,  Balti- 
more, Md. 

Gage,  Dr.  W.  V.,  McCook,  Neb. 

Gardner,  Dr.  H.  D.,  Scran  ton,  Pa. 

Garrigues,  Dr.  Henry  J.,  New 
York. 

Getz,  Dr.  Charles,  Baltimore,  Md. 

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

Gifford,  Dr.  H.,  Omaha,  Neb. 

Gleason,  Dr.  W.  S.,  Newburg,  N.  Y. 

Godfrey,  Dr.  Guy  C.  M.,  U  S.A. 

Goffe,  Dr.  J.  Riddle,  New  York. 

Goldstein,  Dr.  Samuel,  New  York. 

Gorton,  Dr.  Eliot,  Morris  Plains, 
N.J. 

Gowers,  Dr.  W.  R„  London,  Eng- 
land. 

Grandin,  Dr.  Egbert  H.,  New 
York. 

Grissim,  Dr.  J.  D.,  Paterson,  N.  J. 

Groom,  Dr.  W.  S.,  Britt,  la. 

Gross,  Dr.  M.,  New  York. 

Guthrie,  Dr.  W.  E.,  Bloomington, 
111. 

Hance,     Dr.    Irwin     C,    Saranac 

Lake,  N.  Y. 
Hartley,  Dr.  Frank,  New  York. 
Hartwig,  Dr.  Marcell,  Buffalo,  N. 

Y. 
Hawkes,    Dr.   J.   Marshall,    New 

York. 
Healey,  Dr.  Joseph  S.,  New  York. 
Heffron,  Dr.  J.  L.,  Syracuse,  N.  Y. 
Herrick,  Dr.  H.  J.,  Cleveland,  O. 
Herrick,  Dr.  J.  F.,  Ottumwa,  la. 
Higgins,  Dr.  F.  W.,  Syracuse,  N.  Y. 


Hill,    Dr.   J.   Sutcliffe,    Bellows 

Falls,  Vt. 
Hill,  Dr.  W.  J.,  Statesville,  N.  C. 
Hinde,  Dr.  Alfred,  Chicago,  111. 

HOCHLERNER,  Dr.  R. 

Hoelscher,  Dr.  J.  H.,  Chicago,  111. 
Hopkins,  Dr.  George  G.,  Brooklyn, 

N.  Y. 
Horton,  Dr.  D.  B.,  Batavia,  N.  Y. 
Horton,    Mr.   Thomas,    Monlclair, 

N.J. 
Howell,  Dr.  J.  Morton,  Washington 

Court-House,  O. 
Hupp,  Dr.  J.  C,  Wheeling,  W.  Va. 
Hutton,  Dr.  T.  J.,  Shenandoah,  Pa. 

Ill,  Dr.  Edward,  Newark,  N.  J. 

Jacobi,  Dr.  A.,  New  York. 
Jacobson,   Dr.   Nathan,    Syracuse, 

N.  Y. 
Jaisohn,    Dr.   Philip,    Washington, 

D.  C. 
Jeffery,  Dr.  Aaron,  Radford,  Va. 
Jennings,  Dr.  Charles  G.  R.,  El- 

mira,  N.  Y. 
Johnson,  Dr.  W.  B.,  Patersm,  N.  J. 
Jones,  Dr.  Isaac  J.,  Austin,  Tex. 

Kammerer,  Dr.  Fred.,  New  York. 

Keen,  Dr.  W.  W„  Philadelphia,  Pa. 

King,  Dr.  Herbert  M.,  Grand 
Rapids,  Mich. 

Klebs,  Dr.  Edwin,  Strassburg,  Ger- 
many. 

Knowles,  Dr.  Francis  E.,  South 
Orange,  N.  J. 

Krieger,  Dr.  G.  E.,  Chicago,  111. 

Kunz,  Dr.  S.,  Chicago,  111. 

Lamkin,  Dr.  J.  S.,  Yonkers,  N.  Y. 

Lanphear,  Dr.  Annette  E.,  New 
York. 

Landes,  Dr.  Leonard,  New  York. 

Lanphear,  Dr.  Emory,  St.  Louis, 
Mo. 

Leszynsky,  Dr.  Wm.  M.,  New  York. 

Leyien,  Dr.  Henry,  New  York. 

Leviseur,  Dr.  Fred.  J.,  New  York. 

Lewis,  Dr.  J.  C,  Panama,  N.  Y. 

Liell,  Dr.  E.  N.,  New  York. 

Loyeland,  Dr.  Bradford  C,  Clif- 
ton Springs,  N.  Y. 

McBrayer,    Dr.    L.   B.,    Asheville, 

N.  C. 
McCartie,     Dr.     D.    B.,    Newark, 

N.J. 
McChesney,  Dr.   Willard,   Janes- 

ville,  Wis. 
McCourt,  Dr.  P.  J.,  New  York. 
McCullough,  Dr.  John  W.  S.,  Al- 

liston,  Ont. 
McGee,  Dr.  W.  C,  Little  Sandusky, 

O. 
McGuire,  Dr.  C  Monroe,  Walsen- 

burgh,  Col. 
Macalester,  Dr.  R.  K.,  New  York. 
MacArtney,  Dr.  W.  N.,  Fort  Cov- 
ington, N.  Y. 
MacFarlane,  Dr.  Andrew,  Albany, 

N.  Y. 


IV 


CONTRIBUTORS  TO   VOL.    XLVI. 


MacPhatter,  Dr.  Neil,  Denver, 
Col. 

Magill,  Dr.  Wm.  S.,  Chicago,  111. 

Maine,  Dr.  F.  E.,  Auburn,  N.  Y. 

Maisch,  Dr.  Charles  O.,  New  York. 

Maloney,  Dr.  F.  W.,  Rochester, 
N.  Y. 

Maloney,  Dr.  J.  A.,  Washington, 
D.  C 

Mann,  Dr.  Edward  C,  New  York. 

Marcy,  Dr.  Wm.  A.,  Buffalo,  N.  Y. 

Ma*sh,  Dr.  James  P.,  Troy,  N.  Y. 

Martin,  Dr.  Robert  W.,  Philadel- 
phia, Pa. 

Martin,  Dr.  William  A.,  San  Fran- 
cisco, CaL 

May,  Dr.  Charles  H.,  New  York. 

Mayo,  Dr.  W.  J.,  Rochester,  Minn. 

Mettler,  Dr.  L.  Harrison,  Chicago, 
111. 

Meyer,  Dr.  Willy,  New  York. 

Michels,  Dr.  John,  New  York. 

Miles,  Dr.  Geo.  W.,  Oneida,  N.  Y. 

Milliken,  Dr.  Sam'l  E.f  New  York. 

Moffat,  Dr.  Henry,  Yonkers,  N.  Y. 

Montgomery,  Dr.  Charles  J.,  Au 
gusta,  Ga. 

Moor,  Dr.  William,  New  York. 

Moore,  Dr.  H.  B.,  Colorado  Springs, 
Col. 

Morton,  Dr.  William  J.,  New  York. 

Moser,  Dr.  William,  Brooklyn, 
N.  Y. 

Mullen,  Dr.  J.  J ,  Pittsburg,  Pa. 

MundI:,  Dr.  Paul  F.,  New  York. 

Mynter,  Dr.  Herman,  Buffalo,  N.  Y. 

Nammack,  Dr.  Chas.  E.,  New  York. 

Newton,  Dr.  Richard  C,  Mont- 
clair,  N.  J. 

Norbury,  Dr.  Frank  P.,  Jackson- 
ville, 111. 

Noyes,  Dr.  William,  B.,  New  York. 

Oppenheimer,   Dr.   L.   S.,   Bartow, 

Fla. 
Otis,  Dr.  W.  K  ,  New  York. 
Outerbridge,  Dr.  Paul,  New  York. 
Overholser,  Dr.  W.  P.,  Harrison- 

ville,  Mo. 

Page,  Dr.  Charles  E.,  Boston,  Mass. 
Park,  Dr.  W.  Hallock,  New  York. 
Pendleton,  Dr.    Edward,    Owens- 

boro',  Ky. 
Phelps,  Dr.  A.  M.,  New  York. 
Phelps,  Dr.  W.  C,  Buffalo,  N.  Y. 
Phillimore,  Dr.  R.  H.,  Cookshire, 

Canada. 
Phillips,  Dr.  Geo.  A.,  Ellsworth,  Me. 
Pilcher,  Dr.  James  E.,  U.  S.  Army. 
Plummer,  Dr.  Frederick  H.,  Plymp- 

ton,  Mass. 
Post,  Dr.  Sarah  E.,  New  York. 
Preston,  Dr.  G.  J.f  Baltimore,  Md. 
Pryor,  Dr.  John  H.,  Buffalo,  N.  Y. 
Putnam,  Dr.  W.  E.,  Whiting,  Ind. 

Rankin,  Dr.  D.  N.,  Allegheny,  Pa. 

Richardson.  Dr.  Maurice  H.,  Bos- 
ton, Mass. 

Richmond,  Dr.  Nelson,  Fredonia, 
N.  Y. 

Robinson,  Dr.  Beverley,  New  York. 

Robinson,  Dr.  Byron,  Chicago,  111. 

Rockwell,  Dr.  A.  D.,  New  York. 

Rose,  Dr.  A.,  New  York. 


Rosenberry,  Dr.  H.  L.,  Menominee, 

Mich. 
Roy,  Dr.  P.  S.,  Washington,  D.  C. 
Runge,  Dr.  E.  C,  St.  Louis,  Mo. 
Rupp,  Dr.  Adolph,  New  York. 

Satterleb,  Dr.  Richard  H.,  Buffa- 
lo, N.  Y. 

Schirman,  Dr.  A.,  New  York. 

Schumpert,  Dr.  T.  E.,  Shreveport,La. 

Seitz,  Dr.  Albert,  McMinnville, 
Tenn. 

Sherman,  Dr.  W.  H.,  Yonkers,  N.  Y. 

Shrady,  Dr.  George  F.,  New  York. 

Siegfried,  Dr.  C.  A.,  U.  S.  Navy. 

Smith,  Dr.  C.  B.,  Binghamton,  N.  Y. 

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

Smith,  Dr.  J.  Gardner,  New  York. 

Smith,  Dr.  Stephen,  New  York. 

Smith,  Dr.  W.  Harvey,  Winnipeg, 
Manitoba. 

Smith,  Dr.  Wm.  G.,  Sturgis,  S.  D. 

Snow,  Dr.  Sargent  F.,  Syracuse,  N. 
Y. 

Souchon,  Dr.  Edmond,  New  Or- 
leans, La. 

Southworth,  Dr.  Thomas  S.,  New 
York. 

Spence,  Dr.  Arnot,  New  York. 

Spratling,  Dr.  William  Philip, 
New  York. 

Starke,  Dr.  G.,  New  York. 

Starr,  Dr.  M.  Allen,  New  York. 

Stebbins,  Dr.  Roswell  O.,  New 
York. 

Stedman,  Dr.  Thos.  L.,  New  York. 

Steele,  Dr.  Thomas  B..  Cambridge, 
Md. 

Stephenson,  Dr.  F.  B.,  U.  S.  Navy. 

Stewart,  Dr.  Thomas  M.,  Cincin- 
nati, Ohio. 

Stewart,  Dr.  William  W.,  Colum- 
bus, Ga. 

Storrs,  Dr.  Frances  S.,  Topeka, 
Kan. 

Stowell,  Dr.  Wm.  L.,  New  York. 

Straight,  Dr.  Howard  S.,  Cleve- 
land, Ohio. 

Study,  Dr.  Joseph  N.,  Cambridge 
City,  Ind. 

Summers,  Dr.  J.  Will,  Hammond, 
111. 

Swasey,  Dr.  Edward,  Worcester, 
Mass. 

Sweeney,  Dr.  M.  J.,  Kane,  Pa. 

Thompson,  Dr.  J.  H.,  Kansas  City, 

Mo. 
Thornton,   Dr.   James  B.,  Boston, 

Mass. 
Tingley,  Dr.  Hilbert  B.,  Rockaway 

Beach,  N.  Y. 
Trent,  Dr.  J.  H.,  Brooklyn,  N.  Y. 
Tyrrell,    Dr.    R.   Shaw,   Toronto, 

Canada. 

Valentine,  Dr.  Ferd.  C,  New  York. 
Valk,  Dr.  Francis,  New  York. 
Van  Dyke,  Dr.  F.  W.,  Grant's  Pass, 

Ore. 
Vineberg,  Dr.  Hiram  N.,  New  York. 

Wagner,  Mr.  Charles  W„  Bing- 
hamton, N.  Y. 

Ward,  Dr.  J.  M.,  Cornelia,  Mo. 

Warfield,  Dr.  Clarence,  Galveston, 
Tex. 


Washburn,  Dr.  W.,  New  York. 

Wasse,  Dr.  G.  M.,  Baldwinsville, 
N.  Y. 

Watkins,  Dr.  Robert  L.,  New  York. 

Weber,  Dr.  Leonard,  New  York. 

Webster,  Dr.  David,  New  York. 

Weir,  Dr.  James,  Jr.,  Owensboro, 
Ky. 

Weir,  Dr.  Robert  F.,  New  York. 

Wells,  Dr.  Brooks  H.,  New  York. 

Wendt,  Dr.  Edmund  C,  New  York. 

Werder,  Dr.  X.  O.,  Pittsburg,  Pa. 

White,  Dr.  A.  Campbell,  New  York. 

Wiener,  Dr.  Alexander  C,  Chi- 
cago, 111. 

Wiggin,  Dr.  Frederick  Holme, 
New  York. 

Wirt,  Dr.  Wm.  E.,  Cleveland,  O. 

Wylie,  Dr.  W.  Gill,  New  York. 

Zangger,    Dr.    Theodore,    Zurich, 

Switzerland. 
Zenner,  Dr.  Philip,  Cincinnati,  O. 
Zwisohn,  Dr.  L.  W.,  New  York. 

Societies  from  which  Reports  have 
been  received. 

American  Association  of  Genito- 
urinary Surgeons. 

American  Association  of  Obstet- 
ricians and  Gynecologists. 

American  Climatological  Asso- 
ciation. 

American  Dermatological  Asso- 
ciation. 

American  Electro  -  therapeutic 
Association. 

American  Gynecological  Society. 

American  Laryngological  Asso- 
ciation. 

American  Medical  Association. 

American  Neurological  Associa- 
tion. 

American  Orthopedic  Association. 

American  Pediatric  Society. 

American  Physiological  Society. 

American  Public  Health  Asso- 
ciation. 

American  Surgical  Association. 

Association  of  American  Physi- 
cians. 

British  Medical  Association. 

Canadian  Medical*  Association. 
Congress  of  American  Physicians 
and  Surgeons. 

Medical  Society  of  New  Jersey. 
Medical  Society  of  the  County 

of  New  York. 
Medical  Society  of  the  State  of- 

Pennsylvania.' 
Mississippi  Valley  Medical  Asso 

ciation. 

New  York  Academy  of  Medicine. 
New  York  County  M  bdical  Asso- 
ciation. 
New  York  Pathological  Society. 

Practitioners'  Society  of  New 
York. 

Southern  Surgical  and  Gyne- 
cological Association. 


Medical   Record 

A  Weekly  Journal  of  Medicine  and  Surgery 


Vol.  46,  No.  1. 
Whole  No.  1235. 


New  York,  July   7,  1894 


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©rigitmt  Articles. 

ENTERIC  FEVER  IN  INFANCY. 
By  WILLIAM  B.  NOYES,  M.D., 

NEW  YORK. 

The  recent  epidemic  of  typhoid  fever  in  Montclair, 
N.  J.,  arising  from  a  polluted  milk  supply,  developed  an 
unusually  large  proportion  of  cases  in  young  children. 
We  are  so  apt  to  consider  typhoid  a  disease  of  older 
children  and  adults,  that  cases  occurring  in  earlier  in- 
fancy have  a  fair  chance  of  not  being  diagnosed  unless 
occurring  in  connection  with  other  cases.  Northrop,  in 
his  long  experience  in  the  Foundling  Asylum,  among  ten 
thousand  cases  has  never  had  a  case  of  typhoid,  and  he  has 
never  seen  a  case  under  two  years  in  his  entire  experience. 
Huber  has  seen  but  three  or  four  cases,  Holt  has  seen  no 
cases  under  sixteen  months,  Prudden  has  seen  nothing  of 
it  in  a  pathological  way,  and  others  of  large  experience 
hive  seen  little  of  typhoid  during  the  first  two  years. 

The  first  case  I  wish  to  report  is  one  which  I  followed 
very  closely  during  its  entire  course,  and  can  vouch  for  its 
absolute  accuracy. 

Case  I. — A.   G.   N ,  eleven  months  of  age,  a 

healthy  male  child  of  somewhat  nervous  temperament,  of 
healthy  parents,  with  no  tendency  to  tuberculosis  or  any 
other  disease.  Had  suffered  from  scarcely  any  of  the  or- 
dinary diseases  of  childhood.  He  was  taken  to  Montclair 
for  a  visit  of  ten  days  soon  after  weaning,  and  was  fed  on 
milk  diluted  with  barley-water,  not  boiled  or  sterilized. 
He  rapidly  improved  in  health  during  these  days.  Soon 
after  his  return  to  the  city  he  became  fretful,  restless,  and 
had  a  slight  fever  attributed  to  his  "  cutting  teeth. ' '  When 
I  saw  him  first,  except  for  a  slight  angina  and  a  temper- 
ature of  1020  F.  in  the  evening,  there  was  nothing  char- 
acteristic or  positive  in  his  condition  except  the  proba- 
bility that  he  was  developing  something.  For  two  days 
he  improved,  though  still  with  a  moderate  temperature. 
On  the  next  day  he  had  a  roseola,  which  disappeared  in  a 
few  hours. 

March  27th. — His  temperature  was  102. 6°  a.m.  ;  103. 8° 
F.,  p.m.  ;  and  for  the  first  time  he  appeared  very  sick. 
Moderate  diarrhoea  with  collicky  pains,  straining  at  stool. 
Tongue  coated.     Vomiting  occasionally. 

Diagnosis,  gastro-enteritis.  Treatment,  a  mixture  of 
hydrochloric  acid,  pepsin,  and  bismuth. 

March  28th.— Temperature,  102. 6°  to  1040  F.  Mod- 
erate diairhoea  with  colic. 

March  29th. — Temperature,  102. 6°  to  103.40  F.  Di- 
arrhoea with  frequent  stools  of  a  very  foul  odor.  Tongue 
coated  white;  tip  and  sides  red.  Lungs  gave  phys- 
ical signs  of  bronchitis.  No  angina.  Slight  dulness 
under  the  left  scapular.  Breathing  rather  high-pitched 
and  rapid.  Very  fretful.  Hands  brought  frequently  to 
the  head  as  if  suffering  pain.  Pupils  equal.  No  other 
definite  symptoms. 

March  30th. — Temperature,  101.80  a.m.  to  102. 8°  F. 
p.m.  Condition  somewhat  better.  Lung  symptoms  less 
marked. 

April  1st. — Temperature,  102. 20  a.m.,  1030  F.  p.m. 
Patient  being  in  better  condition,  it  was  decided  to  move 
him  back  to  the  country  for  a  change  of  air,  and  to  es- 
cape suspected  plumbing.  No  bad  results  from  the  trip. 
Dr.  H.  B.  Whitehorn,  of  Verona,  N.  J.,  after  this  time 
associated  with  me  in  the  case.     During  the  two  weeks 


which  had  elapsed  since  he  had  left  Montclair,  about  fifty 
cases  of  typhoid  fever  had  developed,  and  about  this  time 
it  was  publicly  recognized  that  the  origin  of  every  one  of 
these  cases  was  due  to  one  cause  alone,  the  polluted  milk 
served  to  the  families  of  all  the  cases  by  one  dairyman, 

G ,  who  had  two  cases  of  typhoid  in  his  family  one 

month  before,  and  had  infected  his  well,  and  used  the 
well-water  to  wash  the  cans  and  bottles.  The  baby  had 
fed  for  ten  days  on  this  milk.  The  combination,  there- 
fore, which  now  appeared  before  us,  of  a  high  continued 
temperature  during  the  past  week,  the  coated  tongue,  with 
clean  margin,  some  tympanites,  all  this  pointed  directly 
to  a  diagnosis  of  typhoid.  The  stools,  which,  on  a  nap- 
kin, appeared  similar  to  an  ordinary  stool  in  diarrhoea 
trouble,  examined  in  a  vessel  were  not  unlike  the  typical 
pea  soup  discharges. 

April  2d. — Temperature,  1040  F. ;  pulse,  160 ;  respi- 
ration, 25  ;  stools,  4.  Rose  spots  first  seen  on  abdomen 
and  chest,  very  marked,  disappearing  on  pressure ;  very 
distinct  when  bathed.  Patient  coughed  occasionally  and 
vomited  once  or  twice.  Another  case  of  typhoid  in  the 
family,  the  nurse  of  the  baby,  who  had  used  the  same  in- 
fected milk,  diagnosed  at  this  time. 

April  3d. — Temperature  lower,  1030  F. ;  pulse,  160; 
respiration,  25.  Tlie  diet,  which  had  consisted  of  steril- 
ized milk  and  barley-water,  was  not  agreeing  well,  vomit- 
ing and  diarrhoea  being  troublesome.  Changed  to  a 
combination  of  Pasteurized  milk,  lime-water,  and  cream, 
which  was  afterward  well  borne. 

April  4th.— Temperature,  101.50  to  102. 50  F. ;  pulse, 
150;  respiration,  35.  Occasional  coughing;  baby  very 
restless,  giving  signs  of  pains  in  the  head. 

April  5th  to  7th. — Patient  doing  well,  restless  at  times. 
Temperature  reached  ioo°  to  10 1°  F. 

April  8th. — Baby  still  fretful  and  cried  occasionally 
with  a  sharp  shrill  cry.  Some  undigested  milk  in  the 
defecation. 

April  9th. — Baby  slept  fairly  well,  nervous  when  awake, 
same  shrill  cry  as  before.  Temperature  arose  from  1 00. 2  ° 
to  1 040  F.  Pulse,  150;  respiration,  27.  It  was  no- 
ticed that  he  held  his  head  drawn  back  and  made  con- 
tinual motion  with  his  hand  as  if  to  grasp  some  object. 
Pulse  feeble,  extremities  cold  and  somewhat  cyanotic. 
Under  vigorous  stimulation  the  condition  passed  away. 

April  1  oth.— Temperature,  102. 6°  to  1030  F.  Pulse 
over  160.  Patient  somewhat  better,  treated  for  tendency 
to  convulsions  by  sedatives,  and  systematic  heart  stimula- 
tion by  means  of  champagne  and  minute  doses  of  heart 
tonics. 

April  nth.— Temperature,  1010  to  1040  F.  Pulse, 
160  to  180;  respiration,  30.  A  condition  of  irregular 
pulse  and  cyanosis  was  noticed  which  reacted  to  heart 
stimulation.  Condition  of  rigidity  of  the  neck,  opis- 
thotonos, general  hyperesthesia,  inco  ordination  of  eye- 
balk,  peculiar  cry,  with  occasional  convulsive  movements 
of  the  hands,  became  now  very  marked.  Dr.  Huber,  of 
New  York,  called  in  consultation. 

April  1 2th. — Condition  of  patient  very  poor.  Tem- 
perature, 102. 40  to  104.80  F.  An  irregular  feeble  pulse 
and  great  restlessness  calling  for  careful  heart  stimula- 
tion. Urine  carefully  examined,  no  trace  of  albumin 
found.  A  third  case  of  typhoid  fever  in  the  family  de- 
veloped at  this  time. 

April  13th.— Temperature,  102. 20  to  103. 40  F.  Res- 
piration, 30  to  40  Rapid  and  shallow.  Pulse  152, 
slightly  irregular.     One  very  bad  spell  in  the  afternoon, 


MEDICAL    RECORD. 


[July  7,  1894 


the  most  serious  attack  of  collapse  thus  far,  with  cyanosis 
and  faint  pulse,  checked  by  vigorous  stimulation  and 
high  hot  enema. 

April  14th  — Temperature,  101.5°  to  Io2.8°  F. ;  pulse, 
152  to  no;  respiration,  55  to  53;  difficulty  in  getting 
him  to  swallow  anything  except  champagne,  which  he 
took  readily.  At  times  the  convulsive  movements  and 
symptoms  of  heart  failure. 

April  15th. — Statu  quo.    Temperature,  ioi°  to  103°  F. 

April  1 6th. — Quiet  day  until  a  severe  collapse  in  the 
afternoon,  which  was  nearly  fatal.  All  forms  of  stimula- 
tion were  used  from  2  to  6  p.m.,  including  artificial  res- 
piration, oxygen,  electricity,  and  other  agents,  without 
response.  Vomiting  of  a  greenish-brown  fluid.  A  com 
bination  of  tincture  of  musk,  aromatic  spirits  of  am- 
monia, spirits  of  camphor,  and  a  one  per  cent,  solution 
of  nitroglycerine,  one  minim  of  each  every  five  minutes 
in  the  mouth  by  a  medicine  dropper,  was  followed  by 
improvement  and  restoration  to  a  fairly  good  condition. 

April  17th. — Temperature,  104°  F. ;  pulse,  152.  Con- 
vulsions and  collapse  at  5  a.m  ;  died  from  heart  failure 
and  respiratory  paralysis,  10  a.m. 

Of  1 15  cases  of  typhoid  and  similar  cases  occurring  in 
Montclair  and  vicinity,  where  the  infected  milk  was  sold, 
7  were  reported  of  three  years  of  age  or  younger,  all  hav- 
ing been  fed  on  this  milk. 

Case  II. — Reported  by  Dr.  Smith.  Girl,  aged  three, 
previously  healthy,  had  subsisted  entirely  on  the  milk 

from  the  G dairy.     When  first  seen,  March  1 2th,  had 

diarrhoea,  tympanites,  eruption,  and  all  the  symptoms  of 
typhoid.  The  case  ran  an  uneventful  course  and  termi- 
nated after  two  weeks. 

Case  III. — Reported  by  Dr.  Brown.     B.  B ,  aged 

eighteen  months.  Female,  one  of  three  children,  aged 
one  and  a  half,  three,  and  five  years,  respectively,  who 
were  all  attacked  with  typhoid ;  sick  about  twenty-eight 
days,  with  bronchial  catarrh,  high  temperature,  very  fret 
ful,  constipated ;  no  rash,  mouth,  or  nerrous  symptoms ; 
diagnosis,  typhoid,  on  account  of  the  epidemic. 

Case  IV. — Reported  by  Dr.  Newton.     H.  B ,  aged 

eleven  months.  Male.  Treated  from  April  1st  to  April 
1  ith ;  entire  illness,  sixteen  days.  Eruption  present,  eight 
to  ten  petechiae  noted.  Temperature  about  1020  F.  Some 
tympanites.  Moderate  diarrhoea.  Yielded  readily  to  a 
diet  of  boiled  milk  and  pepsin.  Dr.  Newton  was  first 
called  in  to  see  the  patient  on  account  of  sore  mouth,  and 
found  an  aphthous  condition  of  the  mouth,  gums  sore  and 
bleeding.  Tongue  had  a  heavy  brownish-white  coat. 
Breath  offensive.  Colicky  pains  until  relieved  by  calomel. 
Patient  had  an  uneventful  run  of  fever  and  short  con- 
valescence; never  vomited,  and  never  refused  his  bot- 
tle. 

Case  V. — Reported  by  Dr.  Wilson,  of  Bloomfield. 
Infant,  aged  thirty  months.  First  seen  about  April  25th. 
Sick  two  weeks.     Eruption  present.     A  mild  case. 

Case  VI. — A  boy,  under  three  years,  reported  by  Dr. 
Shelton,  of  Montclair,  suffered  from  typhoid  at  the  same 
time  that  a  brother,  aged  five  years,  and  a  sister,  aged  six 
years,  all  having  been  fed  on  the  infected  milk.  Fever 
lasted  four  weeks,  varying  from  100.50  F.  a.m.,  to  1030  to 
1040  F.  p.m.  Temperature  curve  fairly  typical.  Erup- 
tion present  Extreme  restlessness  and  tendency  to 
scream  out  suddenly  noted.  The  pulse  generally  128,  at 
times  intermittent.  Distended  abdomen,  considerable 
flatulence  at  times.  Frequent  offensive  stools,  somewhat 
formed,  with  greenish  particles.  Urine  negative.  Occa 
sional  coughing.  Otherwise  uneventful  course  and  re- 
covery. The  case  of  the  girl,  aged  six  years,  was  ex- 
ceedingly severe,  with  obstinate  constipation  for  many 
days,  great  prostration,  emaciation,  and  bed-sores. 
Temperature  reaching  104.50  F.  the  second  week. 
Great  restlessness,  coughing,  delirium,  abdominal  pain, 
and  offensive  breath. 

Case  VII. — Communicated  by  Dr.  Brown,  of  Mont- 
clair. Child,  aged  three  years,  very  sick  for  twenty- 
eight  days.  Sister  of  Case  III.  Temperature  running 
from  1030  to  1050  F.  for  some  time.     Marked  nervous 


symptoms  for  several  days.  Great  restlessness,  tossirg 
its  head  from  side  to  side.  Rigidity  of  muscles  of  the 
neck.  Opisthotonos.  Almost  complete  blindness  for 
five  days,  strabismus  at  times,  hydrocephalic  cry.  Tym- 
panitic abdomen,  no  eruption,  no  urinary  symptoms, 
tongue  coated  and  moist.  Picked  at  its  nose  until  the 
nose  became  raw.  Case  recovered  under  treatment  of 
bromides  and  phosphoric  acid.  Constipation  was 
marked.  Dr.  Brown  has  seen  six  cases  of  clear  typhoid, 
under  five  years,  in  this  epidemic,  three  under  three 
years  of  age.  He  recalls  in  previous  years  a  number  of 
cases  with  a  high  fever  running  for  several  weeks,  with 
constipation  more  frequently  than  diarrhoea,  no  noticea- 
ble rash,  which  he  now  considers,  in  the  light  of  his  ex- 
perience gathered  in  Montclair  in  the  recent  epidemic, 
to  have  been  undoubtedly  enteric  fever. 

Case  VIII.— Reported  by  Dr.  Newton.     E.  B , 

girl,  aged  two  and  a  half  years.  Sister  to  Case  IV. 
Actively  sick  about  one  week,  with  temperature  reaching 
1030  F.,  lowest  980  F.  Eruption;  no  diarrhoea. 
Treated  from  April  6th  to  May  5th.  An  exceedingly 
mild  and  uneventful  case.  An  older  sister  of  this  case, 
aged  seven  years,  also  sick  with  typhoid  fever,  with  a 
maximum  temperature  of  1040  F.  Excessive  eruption 
for  two  weeks.  At  one  time  one  hundred  and  fifty 
petechial  spots  on  body  and  limbs. 

We  have  given  our  own  case  in  detail,  not  because  it 
is  the  youngest  case  on  record,  for  it  is  not,  but  the 
cases  on  record  usually  quoted  are  too  abbreviated  to  be 
entirely  trustworthy.  There  are  cases  quoted  by  various 
authors  occurring  soon  after  birth  and  during  the  first 
year.  Pregnant  mothers  contract  typhoid,  and  give 
birth  to  infants  who  develop  symptoms  of  typhoid  a  few 
days  later.  Eichhorst  mentions  the  following  examples 
in  early  infancy :  1.  Found  twice  by  Charceley  in  the 
new-born.  2.  Hastelius  :  In  a  foetus  taken  dead  in  the 
eighth  month  from  its  mother,  who  had  died  from 
typhoid,  there  was  found  splenic  tumor  and  marked  in- 
filtration of  intestinal  follicles  and  mesenteric  glands.  3. 
Neuhaus  has  found  typhoid  bacilli  in  the  organs  of  a 
foetus.  4.  Chantemesse  and  Vidal  found  it  in  the 
blood  of  the  placenta,  and  proved  that  the  typhoid  ba- 
cilli could  be  transferred  to  the  foetus  by  experiment. 
5.  Eberth  in  the  heart  and  in  the  foetal  membranes  and 
placenta,  expelled,  in  the  third  week  of  an  attack  of  ty- 
phoid. 6.  Hildebrand  demonstrated  them  in  the 
spleen,  liver,  mesentery  glands,  and  nervous  system.  7. 
Reher  made  successful  cultures  from  the  fluids  in  the  liver 
of  a  foetus. 

The  youngest  case  recorded  contracting  the  disease  it- 
self is  at  the  age  of  four  and  a  half  months.  Reported 
by  Ogle  in  The  Lancet,  1892.  After  a  week  of  fretful- 
ness,  fever,  and  indefinite  gastro  intestinal  symptoms,  the 
case  yielded,  on  autopsy,  swollen  and  reticulated  Peyer's 
patches  with  ragged  ulcers,  partly  ulcerated  solitary  fol- 
licles, enlarged  mesenteric  glands,  and  enlarged  and  soft- 
ened spleen. 

Earl,  of  Chicago,  reported  a  case,  five  months  four  days, 
with  fever,  diarrhoea  running  a  mild  course  like  an  inno- 
cent gastro-enteritis.  Finally,  after  suddenly  developing 
symptoms  of  collapse  and  symptoms  strongly  resembling 
peritonitis,  the  infant  died,  and  was  found  to  have  swol- 
len solitary  follicles,  partly  ulcerated  Peyer's  patches,  and 
enlarged  mesenteric  glands.     Peritoneum  normal. 

Murchison  showed  intestines  of  an  infant  of  six  months 
to  the  London  Pathological  Society,  which  had  been 
attacked  with  typhoid  at  the  same  time  as  liis  mother, 
and  had  the  typical  lesions  of  typhoid  in  a  marked  degree. 

Henoch  reports  two  cases,  at  six  and  seven  months, 
with  diarrhoea,  splenic  tumor,  bronchial  catarrh,  otitis, 
somnolence,  characteristic  fever  curve.  Autopsy  showed 
very  slight  changes,  slight  swelling  of  single  mesenteric 
glands,  one  Peyer's  patch  swollen.  He  pronounced  the 
cases  as  undoubtedly  typhoid. 

Abercrombie  described  a  case  in  an  infant  of  six 
months  and  one  at  seven  months,  with  autopsy  yielding 
typhoid  lesions.      Shadier    narrates  a  case  of  a  seven 


July  7,  1894] 


MEDICAL    RECORD. 


months1  infant  whose  mother  died  about  the  same  time 
from  typhoid. 

England1  quotes  in  detail  a  case  at  eight  months,  with 
vomiting,  diarrhoea,  tympanites,  enlargement  of  liver  and 
spleen,  rose  spots,  and  fever  for  three  weeks. 

Fuller,  The  Lancet,  1892,  a  case  at  nine  months  char- 
acterized by  diarrhoea,  headache,  continuous  fever,  not 
over  1020  F.  for  ten  days,  tympanites,  pain  on  deep  press- 
ure. Autopsy  showed  the  typical  lesions  of  typhoid. 
Long  *  reports  in  detail  a  case,  of  one  year,  with  typical 
typhoid  symptoms. 

Dr.  Huber  saw  two  cases  some  years  ago ;  one,  an  in- 
fant of  eighteen  months,  the  other,  two  years  and  six 
months,  both  occurring  at  the  same  time  with  other  cases 
in  the  same  family.  Indefinite  symptoms,  but  diagnosis 
clear  from  the  presence  of  other  cases. 

Northrup  had  a  case  of  a  child  two  years  of  age,  in  the 
Presbyterian  Hospital,  who  caught  typhoid  from  its 
mother  who  was  sick  at  the  same  time.  The  eruption 
and  ordinary  symptoms  of  typhoid  were  present.  The 
patient  made  a  prompt  recovery. 

Jacobi  has  seen  many  cases  of  typhoid  in  infancy. 

If  these  cases  are  authentic,  and  there  is  little  doubt 
that  they  are,  we  cannot  help  thinking  that  we  have  be- 
fore us  a  disease,  rare  not  because  it  does  not  occur,  but 
rare  because  it  is  not  recognized  when  it  does  occur. 
Henoch  states  his  firm  belief  that  the  greater  part  of  cases 
formerly  called  gastric  fever  (febris  gastrica  remittens)  are 
really  typhoid.  The  "febriculae"  so  frequently  men- 
tioned in  text-books,  and  vague  intestinal  disorders  so 
often  seen  in  clinics,  with  little  systematic  study  of  their 
temperature,  are  very  often  probably  abortive  typhoid 
fever  in  their  natures,  terminating  between  the  tenth  and 
twentieth  day  with  absorption  of  inflammatory  products 
and  no  ulceration. 

Vogel  reports,  out  of  1,017  cases,  7  under  one  year; 
Montmellen,  out  of  295  cases,  1 5  under  two  years ;  Henoch, 
out  of  280  cases,  8  under  two  years ;  Earl,  out  of  about 
40  cases,  7  under  five  years.  The  undeveloped  condition 
of  the  glandular  structure  of  the  intestines,  as  urged  by 
some  writers,  might  vary  the  pathological  changes  and 
symptoms,  but  cannot  render  infants  of  any  age  proof 
against  infection,  if  they  drink  any  infected  water  or  in- 
fected milk,  or  use  infected  bottles,  or  are  in  close  con- 
tact with  typhoid  patients. 

In  the  prodromal  period  symptoms  are  not  pronounced. 
The  onset  will,  in  most  cases,  be  so  insidious  that  it  must 
be  a  number  of  days  before  a  correct  diagnosis  can  be 
made  with  any  degree  of  certainty.  If  there  is  diarrhoea, 
a  gastro-enteritis  or  entero  colitis  will  explain  all  the 
symptoms  that  have  yet  appeared.  If  there  be  actual  con- 
stipation, or  merely  occasional  movements  consisting  of 
somewhat  altered  or  putrid  stools,  a  diagnosis  of  pto- 
maine poisoning  from  some  undigested  fermenting  sub- 
stance in  the  intestine  will  explain  all  the  symptoms. 
This  is  not  really  a  false  diagnosis,  it  merely  does  not 
state  what  is  the  bacterial  agent  that  causes  the  ptomaine 
poisoning. 

Donkin  states  that  24  out  of  62  of  his  cases  in  children 
showed  a  more  definite  onset  of  the  disease  than  in  adult 
life.  Headache,  shivering,  vomiting,  pain  in  the  belly, 
back,  or  legs.  Henoch  says  that  it  is  rare  to  begin  with 
a  chill.  Brown,  of  Montclair,  has  noted  in  several  cases 
a  rather  abrupt  commencement. 

The  fever  in  the  cases  occurring  in  infancy  is  apt  not  to 
present  a  typical  curve  at  first,  for  there  are  so  many  causes 
that  influence  the  temperature  of  a  child  that  would  not 
affect  an  adult.  The  fever  may  be  moderate  throughout, 
or  it  may  reach  a  high  point  early,  and  the  original  diag- 
nosis be  changed  solely  because  the  temperature  is  too  high 
and  too  continuous  to  be  caused  by  a  simple  enteritis. 

Two  distinct  periods  that  may  be  found  in  the  tempera- 
ture of  an  ordinary  typhoid  in  an  adult:  (1)  disturb- 
ance due  to  the  typhoid  bacilli,  causing  a  sub- continuous 
fever ;  (2)  disturbance  due  to  the  formation  and  separa- 

1  Canada  Medical  Record,  vol.  xx.,  p.  95. 
*  Archives  of  Pediatrics,  1893,  p.  53. 


tion  of  intestinal  sloughs,  causing  a  remittent  fever,  are 
apt  in  early  childhood  to  be  varied  because  the  second 
element  is  imperfect,  short,  or  often  entirely  absent,  due 
to  the  fact  that  the  intestinal  lesions  frequently  undergo 
resolution  without  any  ulcerations  (Keating). 

Gariock  1  states  that  the  process  in  Peyer's  patches  is 
generally  limited  to  the  lymphoid  cells  and  is  superfi- 
cial. The  proliferated  cells  undergo  fatty  degeneration 
and  are  absorbed  without  formation  of  ulcers.  A  fever 
after  fourteen  days  is  due  to  absorption  through  open  ul- 
cers. And  few  children  with  such  ulcers  can  escape  a 
secondary  fever. 

The  milder  degree  of  intestinal  lesions,  and  especially 
the  absence  of  ulcers,  would  make  us  expect  that  we  should 
find  less  abdominal  tenderness,  less  pain,  less  diarrhoea, 
and  less  tympanites  than  in  the  adult,  which  all  recorded 
cases  show  to  be  undoubtedly  true.  Gerhart  states  that 
the  swelling  of  Peyer's  patches  shows  itself  earlier  than  in 
adults,  and  is  seen  with  greatest  frequency  near  the  ileo- 
cecal valve,  often  reaching  •  higher.  This  swelling  is 
sufficient  to  cause  the  patches  to  protrude  out  beyond  the 
mucous  membrane  in  projections  that  are  frequently  the 
seat  of  excoriations  and  little  ulcers.  These  may  later  de- 
velop deep  ulcers  and  sloughs,  as  occurred  in  twenty- 
nine  out  of  his  forty- four  examinations.  On  the  other 
hand,  this  frequently  clears  up  without  ulceration. 
Henoch  holds  that  the  ulcers  are  comparatively  rare  and 
of  small  size.  He  found  them  in  13  out  of  23  autopsies 
of  his  239  cases  in  children.  He  says  that  when  they 
occur  they  are  generally  small,  shallow,  and  instead  of 
occupying  the  whole  of  a  Peyer's  patch  occupy  merely  a 
part.  The  Peyer's  patches  may  form  what  he  calls 
"plaques  molles,"  a  condition  of  fatty  degeneration  of 
the  new-formed  cells  resulting  finally  in  resolution,  or  they 
may  form  hard  plaques,  indicating  an  infiltration  of  the 
entire  gland  tissue  and  tissues  beneath,  which  will  ulti- 
mately result  in  the  foimation  of  ulcers. 

Granted  that  typhoid  fever  is  commoner  than  we  have 
realized,  what  symptoms  will  enable  us  to  recognize  one 
of  these  cases  or  make  an  early  diagnosis  ? 

t.  Any  long- continued  fever  that  will  not  yield  to  ap- 
propriate doses  of  quinine  is  suspicious,  especially  when 
higher  in  the  evening,  and  when  no  existing  conditions 
of  the  throat  and  lungs  or  bowels  suggest  an  explanation. 
A  temperature  remaining  continuously  high,  and  yielding, 
if  systematically  taken,  a  fairly  typical  typhoid  fever  cone 
after  a  few  days.  Jacobi  lays  stress  on  the  probability  of 
typhoid  with  a  continuous  high  fever,  which  is  well  borne 
by  the  infant. 

2.  Gastro-intestinal  disorder,  especially  when  a  decided 
tendency  to  constipation  is  present ;  putrid  stools  of  an 
especially  offensive  character  and  odor  when  there  is  any 
diarrhoea.  If  these  are  only  seen  on  the  diaper  they  will 
not  look  very  different  from  the  green  spinach  stools  that 
occur  in  other  diarrhoeas,  because  the  fluid  is  soaked  up  on 
the  napkin.  If  seen  in  a  vessel,  the  thin,  semifluid  char- 
acter, greenish  particles,  and  all  the  characteristics  of  a 
typical  "  pea- soup  M  stool  are  present.  If  there  is  trouble 
with  insufficient  digestion  of  food,  the  lumps  of  undigested 
casein  will  somewhat  change  the  appearance.  The  lack 
of  acute  symptoms  of  an  intestinal  nature  is  more  char- 
acteristic than  violent  symptoms.  Vomiting  may  or  may 
not  be  present. 

3.  The  first  absolutely  sure  symptom  is  the  appearance 
of  rose  spots,  which  may  come  early  or  late,  or  in  two  or 
three  crops,  and  are  said  by  some  writers  to  occur  quite 
as  regularly  as  the  rash  in  scarlet  fever.  Brown,  of  Mont- 
clair, among  his  six  cases  has  seen  several  with  slight  rash 
or  no  rash  at  all.  Earl  found  them  in  all  his  cases  but 
three. 

Roseola,  or  sudamina,  or  other  indefinite  rashes,  may 
be  present  at  any  stage,  and  possibly  confuse  diagnosis. 

4.  Symptoms  of  headache,  which  a  baby  will  indicate 
by  rubbing  or  picking  at  its  head,  nose,  or  ears,  or  bur- 
rowing its  head  back  in  the  pillows,  but  not  by  active 
head  symptoms  which  would  characterize  meningitis.     As 

1  Transactions  of  the  New  York  Medical  Association,  1891. 


MEDICAL    RECORD. 


[July  7/1894 


the  disease  goes  on  these  head  symptoms  will  frequently 
increase. 

5.  A  tongue  coated  with  yellowish  or  brownish- white 
far,  generally  red  at  the  tip  or  sides.  It  may  be  so  heavily 
coated  and  the  entire  mouth  so  affected  that  a  condition 
resembling  aphthous  stomatitis  may  be  present.  In  the 
case  reported  by  Dr.  Newton  this  was  the  symptom  that 
first  caused  the  physician  to  be  called  in  ;  but  the  con- 
dition  of  sordes  is  not  as  frequent  in  infants  as  in  adults. 

6  Enlarged  spleen  is  very  important  when  found,  but 
not  always  to  be  accurately  demonstrated  in  a  young  child, 
especially  if  tympanites  is  present. 

7.  Tympanites,  sometimes  excessive,  but  in  most  re- 
corded cases  very  moderate. 

8.  Bronchitis  seems  to  be  almost  as  regular  a  symptom 
as  in  measles,  agreeing  with  the  pathological  changes  de- 
monstrated by  Uffelman  of  swelling  and  redness  of  bron 
chial  tubes,  but  the  breathing  is,  later,  too  superficial  to 
make  rales. 

9.  There  may  be  angina*  I  have  seen  it  twice,  once 
in  the  present  case,  and  once  in  an  older  typhoid  patient. 
Henoch  says  that  it  is  not  uncommon.  When  found  it 
is  apt  to  confuse  rather  than  help  the  diagnosis. 

10.  The  stools,  when  carefully  examined  very  early  in 
the  disease,  may  contain  typhoid  bacilli,  but  this  has  very 
rarely  been  detected  in  most  of  the  recorded  cases.  If  it 
could  be,  it  would  b*  of  very  great  importance  as  an  ab- 
solute means  of  diagnosis,  but  after  the  second  week  it  is 
very  rare  to  be  able  to  find  them. 

When  the  diagnosis  is  made  from  the  spots,  spleen, 
tongue,  and  temperature,  as  the  cases  in  children  ad- 
vance, several  variations  in  typical  symptoms  of  adults 
are  to  be  expected.  Ileo  csecal  tenderness  or  gurgling 
is  hard  to  satisfactorily  determine,  and  when  present  is 
worthless  because  it  can  be  found  in  various  other  diar- 
rhoea! diseases  in  children.  The  hard,  dry  tongue,  the 
swollen  tongue,  or  excessive  sordes,  are  rarer  in  children. 
Hemorrhage  or  perforation  is  very  rare.  As  a  whole, 
the  severer  symptoms  common  to  adults  frequently  fail. 

The  nervous  symptoms  are  interesting  and  will  often 
confuse  the  diagnosis  from  the  beginning,  suggesting 
acute,  subacute,  or  tubercular  meningitis,  according  to 
their  severity,  especially  if  the  previous  history  of  the 
child  and  family  is  suspicious.  The  regular  occurrence 
of  headache,  even  in  the  youngest,  has  been  noted ;  and 
though  more  difficult  to  detect  in  the  very  young  infants, 
will,  in  most  cases,  be  suggested  by  the  actions  of  the 
child. 

Intestinal  cases  present  quite  a  variety  of  reflexes  in  the 
head ;  for  instance,  a  constant  picking  of  the  nose,  which 
was  noticed  from  the  beginning  to  the  end  in  my  own 
and  in  other  cases,  instead  of  being  a  local  irritation  is  a 
reflex,  which  Louis  Starr,  called  a  regular  symptom  of  gas- 
tric and  intestinal  irritation.  It  occurs  also  in  tubercu- 
lar meningitis.  Henoch  says  it  is  an  early  typhoid  symp- 
tom, but  may  last  throughout.  Picking  at  ear  may  ac- 
company otitis. 

As  stated  by  Keating,  in  infants  and  young  children 
nocturnal  delirium,  which  an  adult  would  present  in  early 
weeks  of  typhoid,  is  accompanied,  or  more  often  replaced, 
by  sudden  sharp  and  prolonged  outcries,  with  great  rest 
lessness  or  excitement  not  easy  to  pacify.  This  will  re- 
semble a  hydrocephalic  cry,  and  is  again  a  very  startling 
symptom.  Extreme  restlessness  is  almost  sure  to  occur. 
Earl  also  calls  attention  to  continued  crying  at  night, 
stiffness  of  the  neck,  jerking  of  the  muscles.  There  may 
be  apathy  or  a  condition  of  coma,  when  the  muscles 
become  lax  and  the  movements  of  the  eyes  are  no 
longer  co  ordinated.  Blindness  may  occur  as  in  Case 
VII. 

In  spite  of  all  these  symptoms  real  meningitis,  as  a  com- 
plication, though  it  can  occur,  is  exceedingly  rare.  He- 
noch has  never  seen  a  case.  But  the  symptoms  I  am 
about  to  relate  are  very  much  like  the  symptoms  of  men- 
ingitis. 

In  my  case,  about  the  end  of  the  second  week,  following 
a  little  trouble  in  digestion,  vomiting  occurred  and  general 


irritability  increased.  Temperature  rose  four  degrees,  and 
there  developed  a  stiffness  of  the  neck  and  back,  which 
became  after  a  time  a  condition  of  opisthotonos.  There 
was  inco-ordination  of  eyeballs  and  a  peculiar  movement 
of  both  eyes  upward  and  to  the  side,  great  hypersensitive- 
ness  to  sound,  light,  and  touch,  especially  touching  the 
head.  Irregular  and  at  times  convulsive  movements,  es- 
pecially marked  in  the  left  arm  and  leg,  and  continued 
twitching  of  the  fingers.  The  baby  cried  out  frequently 
in  a  new  and  strange  way,  and  the  pulse  became  very 
rapid,  160  to  180,  irregular  and  occasionally  intermittent. 
Respiration  rapid,  irregular,  and  sometimes  sighing.  All 
this  pointed  in  my  mind  almost  certainly  to  an  acute 
meningitis.  Dr.  Huber,  who  saw  the  case  at  this  time, 
while  agreeing  absolutely  with  the  original  diangosis  or 
typhoid  fever,  held  that  the  presence  of  an  active  menin- 
gitis might  be  ruled  out  for  the  following  reasons :  1.  The 
fontanelle  was  depressed,  not  elevated.  2.  The  child 
was  bright  enough  to  notice  things.  3.  No  tache  cere- 
bral. 4.  No  boat- shaped  abdomen.  <.  The  vomiting 
had  not  been  expulsive.  6.  The  photophobia  and  hyper- 
sensitiveness  to  light  and  sound  were  less  than  one  would 
expect  in  an  acute  meningitis.  The  entire  condition, 
acute  as  it  seemed,  he  held  to  be  a  passive  congestion  in 
the  vessels  of  the  brain  caused  by  the  weak  heart,  and 
held  that  heart  stimulation  already  begun  would  remove 
these  symptoms,  which  actually  took  place  within  a  few 
hours. 

I  have  mentioned  this  in  detail  because  it  shows  how 
far  an  extreme  case  of  the  ordinary  nervous  symptoms  of 
typhoid  can  simulate  meningitis.  Henoch  reports  a  case 
of  tremor  and  stiffness  of  the  extremities,  constant  jerk- 
ing of  the  same,  which  showed  on  autopsy  no  brain 
lesion.  Also  one  where  there  was  contracture  of  both 
legs  and  right  arm,  continued  grinding  of  the  teeth, 
yielding  at  autopsy  only  slight  changes.  Also  another 
case  of  a  girl,  four  years  of  age,  who  showed  distinct  stiff- 
ness of  the  neck,  later  actual  opisthotonos,  and  marked  con- 
tracture of  the  neck,  with  grinding  of  the  teeth.  Autopsy 
showed  no  brain  lesion.  Foster  reports  a  case  of  trismus 
and  opisthotonos  which  lived.  Brown's  case  (quoted  as 
Case  VII.)  had  opisthotonos,  blindness  for  several  days, 
and  numerous  other  severe  brain  symptoms,  and  recov- 
ered. Among  other  nervous  symptoms  exaggeration  of 
the  knee-jerk  has  been  noted. 

Marked  and  persistent  tremor  sometimes  occurs,  and 
is  said  by  Donkin  to  point  to  a  deep  ulceration,  a  point 
much  emphasized  in  typhoid  of  adults  by  W.  G.  Thomp- 
son. No  lesions  of  meningitis  were  found  in  these  cases, 
and  cases  resembling  meningitis,  which  occur  occasion- 
ally in  hospitals  and  die,  on  autopsy,  instead  of  the 
lesions  of  meningitis,  frequently  fail  to  show  any  change 
in  the  brain  or  membranes.  The  cases  of  acute  maniacal 
delirium  with  high  fever  and  rapidly  fatal  termination 
which  at  times  occur,  have  no  change  in  the  tissues  out- 
side of  the  blood-vessels.  That  there  has  been  some 
cause  and  some  lesion  is  certain,  but  no  exudation  of 
serum,  fibrin,  or  pulse,  or  even  marked  congestion,  is  to 
be  found.  There  is  left  the  probability  either  of  tempo 
rary  changes  in  the  blood-vessels  and  circulation  which 
have  left  no  traces,  or  more  probably,  some  very  subtle 
delicate  change  that  our  usual  methods  of  preparing 
brain  specimens  do  not  detect.  As  strychnine  affects 
the  cord  centres,  so,  I  believe,  the  ptomaine  of  typhoid 
fever  may  affect  the  brain  centres. 

It  maybe  asked,  in  view  of  these  extensive  nervous  symp- 
toms, how  one  can  be  certain  that  his  case  is  not  one  of  epi- 
demic cerebral  spinal  meningitis,  which  may  begin  like 
typhoid,  run  many  .weeks  with  a  rather  similar  course, 
with  vomiting,  hydrocephalic  cry,  rigidity  of  the  neck, 
and  opisthotonos,  and  all  those  meningeal  symptoms 
mentioned,  an  indefinite  eruption,  and  similar  eye  symp- 
toms, strabismus,  photophobia,  inequality  of  pupils,  and 
even  blindness.  The  resemblance  is  certainly  great,  but 
the  temperature  curve  is  not  characteristic,  generally  not 
over  1020  F. ,  and  there  is  no  regular  evening  rise.  Pain  in 
the  back,  limbs,  calves,  and  thighs  are  more  marked  in  the 


July  7,  1894] 


MEDICAL   RECORD. 


epidemic  meningitis.  The  eruption,  if  present,  is  more 
apt  to  be  like  herpes  than  a  rose  spot,  as  in  typhoid. 
The  pulse  is  almost  invariably  slow  instead  of  rapid,  and 
does  not  follow  the  variations  of  the  temperature  as  in 
typhoid.  There  is  apt  to  be  a  nasal  catarrh,  this  being 
the  method  of  entrance  of  the  bacterial  agent  in  the  epi- 
demic form,  probably.  Joint  complications  are  also  apt 
to  occur.1  The  progress  is  constantly  toward  the  fatal 
outcome,  with  paralysis,  either  hemi-  or  mono-  or  para- 
plegia, while  in  typhoid  recovery  is  to  be  looked  for  in 
a  fair  proportion  of  cases. 

Tubercular  meningitis,  like  the  epidemic  form,  re- 
sembles typhoid,  but  almost  always  has  an  antecedent 
tubercular  trouble  in  some  other  organ,  and  a  more 
gradual  onset.  The  temperature  is  seldom  high,  aver- 
aging 1010,  and  reaching  102. 50  only  near  the  end. 
The  vomiting  is  violent,  frequent,  and  propulsive,  and 
occurs  without  reference  to  food  taken.  Pulse  slow 
and  irregular.  Respiration  sighing,  abdomen  markedly 
boat-shaped,  and  the  skin  may  develop  an  erythema.  At 
first  there  are  marked  and  severe  brain  symptoms  without 
special  "  typhoid  symptoms. "  Later  a  "  typhoid  state  " 
is  sometimes  developed  with  a  rapid  pulse  and  diarrhoea 
that  might  be  confusing  if  compared  without  knowledge 
of  previous  history.  As  a  rule,  the  symptoms  will  be 
first  those  of  a  general  meningeal  irritation,  then  local- 
ized brain  and  meningeal  irritation,  and  finally  symptoms 
of  absolute  paralysis  of  different  brain  areas,  becoming 
more  and  more  complete  until  the  vital  centres  are  in- 
volved and  death  ensues. 

We  have  laid  stress  on  the  low  pulse  in  these  two 
forms  of  meningitis.  In  typhoid  the  pulse  should  vary 
from  90  to  120,  according  to  the  height  of  the  temper- 
ature. It  has  been  observed  from  152  to  180  and  irreg- 
ular, in  cases  that  afterward  recovered. 

The  heart  is  commonly  affected  more  or  less  in  typhoid 
in  infants,  and  Donkin  states  that  a  modification  of  the 
first  sound  is  generally  found  in  most  cases  in  the  second 
week,  and  that  observation  of  the  radial  pulse  alone  is  not 
enough  to  show  how  the  heart  is  working.  In  my  case 
two  very  alarming  spells  of  heart  failure  and  collapse  fol- 
lowed two  very  careful  attempts  to  make  an  examination 
of  the  back  of  the  chest.  I  cannot  too  much  lay  stress  on 
the  necessity  of  keeping  the  little  patient  continuously  on 
the  back,  giving  him  the  benefit  of  the  doubt  and  avoid- 
ing any  risk  from  extensive  physical  examinations,  how- 
ever careful,  extensive  bathing,  or  any  unnecessary 
changing  of  the  position.  Let  objective  symptoms  give 
information  of  any  new  condition  developing  in  the 
lungs,  always  remembering  that  both  lobar  pneumonia 
and  broncho-pneumonia  are  rare  complications.  Hypo- 
static pneumonia  or  oedema  of  the  lungs  must  be  looked 
out  for  and  avoided  by  the  treatment  if  possible.  Ne- 
phritis or  other  urinary  symptoms  are  rare. 

The  duration  of  the  disease  is  variable.  In  190  cases 
of  Henoch,  1 1  terminated  between  the  seventh  and  ninth 
day ;  36  cases  between  the  tenth  and  twelfth,  inclusive ; 
45  between  thirteenth  and  fifteenth ;  40  between  sixteenth 
and  eighteenth ;  25  between  eighteenth  and  nineteenth 
day  ;  39  between  twentieth  and  twenty- third  day  ;  14 
between  twenty  fourth  and  thirtieth ;  6  between  the  thirty- 
fifth  and  forty- fifth  day. 

Collapse  and  sudden  death  are  rare  except  in  the  graver 
cases,  and  owing  to  the  less  extensive  lesion  in  the  intes- 
tines many  children  do  well. 

In  treatment  a  conservative  course  will  commend  itself. 
Tub-baths  will  not  be  well  borne  in  most  cases,  though 
sponging  rather  than  antipyretics  will  best  bring  down 
the  temperature.  The  task  of  choosing  a  food  that  will  be 
digested  and  leave  no  undigested  masses  in  the  stools,  is 
very  difficult,  but  must  be  very  carefully  studied  and 
watched,  or  there  will  be  trouble.  Brown  suggests  con- 
stant under-feeding,  or  a  starvation  treatment.  A  mineral 
acid  and  a  little  bismuth  may  be  all  the  drugs  needed  in 
favorable  cases,  in  others  bromides  or  other  mild  sedatives 
for  the  nervous  symptoms,  and  drugs  by  rectum  rather 
1  Berg  :  Archives  of  Pediatrics. 


than  by  the  mouth  if  there  is  constipation,  will  be  valua- 
ble. For  the  heart  symptoms,  frequently  repeated  doses 
of  champagne  were  found  exceedingly  valuable,  and  were 
well  taken  by  the  patient.  Diffusible  stimulants,  like 
ammonia  and  camphor,  were  quite  as  effective  as  the  more 
powerful  ones,  digitalis,  strychnine,  or  sparteine,  though 
all  were  tried  in  appropriate  doses  at  certain  times.  Heat 
over  abdomen,  and  high  hot  enemas,  were  always  prompt 
and  efficient  means  of  counteracting  collapse  until  the  last. 
In  a  very  severe  collapse  with  cyanosis,  fluttering  feeble 
pulse,  and  failing  respiration,  when  all  other  heart  stimu- 
lants, including  oxygen  and  electricity,  had  failed,  at  the 
suggestion  of  Dr.  Whitehorne  a  combination  of  spirits  of 
camphor,  aromatic  spirits  of  ammonia,  tincture  of  musk, 
and  the  normal  liquid  of  nitro-glycerine,  of  each  one 
minim,  dropped  on  the  tongue  with  a  medicine  dropper, 
was  followed  by  a  change  from  what  had  been  almost  a 
moribund  condition  to  restoration  of  life,  fair  pulse,  and 
a  favorable  condition  for  half  a  day.  The  preparation  was 
absorbed  from  the  mouth  and  acted  quite  as  promptly  as 
a  hypodermic  and  with  far  less  shock  and  irritation  to 
the  infant.  In  an  experience  with  cases  of  collapse  and 
shock  by  no  means  small,  the  writer  has  never  seen  such 
a  prompt  reaction  from  so  desperate  a  condition. 

Two  other  suggestions  will  be  made  as  a  result  of  the 
study  of  these  cases :  1.  Sterilize  or  Pasteurize  all  milk 
used  for  young  children,  and  boil  all  water  during  the 
early  years.  2.  In  all  cases  of  a  diarrhoea!  nature  in  chil- 
dren, disinfect  the  stools — a  measure  indicated  if  it  is  only 
a  simple  summer  diarrhoea,  since  the  more  recent  studies 
in  its  bacterial  origin  and  doubly  indicated  from  the  pos- 
sibility always  present  that  these  cases  may  be  irregular 
or  hidden  typhoid  fever. 


VARIX   OF    THE   RIGHT    AURICLE    ENDING 
IN   RUPTURE. 

By  WM.  G.  SMITH,   M.D., 

STURGIS,   SOUTH   DAKOTA. 

Considering  the  rarity  of  the  above-named  affection 
and  the  interesting  features  of  its  development,  I  will  de- 
tail the  progress  of  the  disease  as  it  developed  in  a  pa- 
tient under  my  care. 

Louis  L ,  of  French  Canadian  parentage,  born  at 

Quebec,  aged  fifty-six,  and  by  occupation  a  teamster,  a 
married  man  although  not  living  with  his  wife  for  several 
years  prior  to  his  last  sickness. 

Mr.  L gives  a  history  of  having  the  diseases  of 

childhood  with  no  ill  effects  following  the  same.  He  was 
an  excessive  tobacco  user  and  an  excessively  hard  drinker 
in  former  years.  He  denies  any  venereal  trouble  and  no 
history  of  any  hereditary  disease  in  ancestors  can  be 
elicited. 

The  above  disease  commenced  on  June  12,  1889, 
while  Mr.  L was  making  a  trip  from  Sturgis  to  Dead- 
wood,  S.  D.,  on  a  rainy  day  when  the  roads  were  very 
muddy.  His  wagon  broke  down,  which  compelled  him 
to  do  some  very  heavy  lifting.  After  one  strenuous  ef- 
fort he  was  suddenly  taken  with  acute  pain  and  oppres- 
sion in  the  mid-sternal  region.  He  continued  his  trip  to 
Deadwood  and  sought  advice,  as  the  pain  was  very  severe 
and  as  he  was  at  the  same  time  suffering  from  the  effects 
of  a  cold.  Treatment  consisted  of  cough  mixtures,  ano- 
dynes, and  counter-irritations. 

On  the  following  i6ih  of  June  he  wrote  me  to  send 
him  some  medicine  for  pain  in  the  chest  and  a  cold.  I 
prescribed  an  expectorant  mixture  containing  an  ano- 
dyne, and  advised  his  return  to  Sturgis  if  he  did  not 
soon  get  relief,  so  I  could  make  an  examination. 

Some  three  days  later  he  reported  at  my  office,  still 
suffering  from  the  acute  pain  in  the  chest.  I  made  a 
careful  examination  and  found  the  acute  pain  located 
over  the  region  of  the  right  auricle  but  somewhat  diffused 
in  area.  I  could  find  no  increased  dulness  on  percus- 
sion. The  heart  beating  was  rapid  and  tumultuous,  the 
pulse  at  the  wrist  was  compressible,  and  the  artery  gave 


MEDICAL    RECORD. 


[July  7,  1894 


somewhat  of  a  cord-like  feel,  and  the  sensation  of  high 
tension  or  blood  pressure. 

The  urine  was  normal  in  every  respect.  There  was 
some  oppression  in  the  chest  and  slight  dyspnoea,  which 
I  took  to  be  of  nervous  origin  due  to  tumultuous  heart 
action.  I  was  unable  to  be  positive  in  my  diagnosis, 
and  treated  on  the  symptomatic  plan.  Gave  a  hydra- 
gogue  cathartic  with  the  effect  of  lowering  blood-pressure 
and  unloading  the  bowels.  Gave  fluid  ex  Tact  of  digitalis 
to  quiet  tumultuous  heart  beating,  and  an  anodyne,  as  the 
pain  showed  great  obstinacy  while  upon  the  above  treat- 
ment. 

I  was  not  satisfied,  and  upon  further  examination  and 
meditation  I  came  to  the  conclusion  that  the  exertion 
had  produced  a  strain  on  the  aorta ;  and  fearing  aneurism, 
I  put  my  patient  on  iodide  of  potash  and  Squibb' s  fluid 
extract  of  ergot,  informing  him  that  he  would  likely  be 
sick  some  time,  and  instructed  him  to  drink  as  little  of 
liquids  as  possible,  not  to  overload  the  stomach,  desiring 
in  this  way  to  keep  the  blood-pressure  as  low  as  possible. 
Also  advised  him  to  avoid  mental  excitement  and  physi- 
cal exertion. 

I  was  favored  in  a  few  days  by  the  pain's  decreasing, 
the  faintness  and  dyspnoea  disappearing,  and  in  four 
weeks'  time  my  patient  felt  in  his  usual  good  health  and 
resumed  his  ordinary  occupation.  The  result  caused  me 
the  more  to  doubt  my  fear  of  aneurism  and  left  the  real 
nature  of  the  disease  in  obscurity,  for  previous  to  this 
sickness  my  patient  had  always  been  very  robust  and 
possessed  an  iron  constitution,  so  to  speak. 

A  year  later,  in  June,  1890,  Mr.  L ,  for  the  first 

time  since  his  previous  treatment,  returned  to  my  office 
complaining  of  the  same  old  pain  and  oppression  in  the 
chest,  which  he  said  had  been  troubling  him  for  the  last 
three  or  four  days.  The  pain  was  so  severe  that  I  gave 
him  an  opiate,  and  instructed  him  to  return  for  an  exam- 
ination as  soon  as  he  was  easier  and  able  to  lie  quietly. 
He  did  so,  and  upon  this  examination  I  found  cardiac 
dulness  slightly  increased  tranversely  to  the  right.  Heart 
action  was  slower,  numbering  fifty-six  pulsations  to  the 
minute,  and  temperature  was  normal.  There  was,  how- 
ever, an  increased  shock  to  the  impulse  beat. 

Remembering  my  former  inclination  to  believe  in  an- 
eurism I  carefully  examined,  but  could  get  no  bruit.  I 
could  get  no  distinct  dulness  separate  and  distinct  from 
that  of  the  heart.  I  could  detect  what  I  took  to  be  a 
tendency  to  atheroma  and  I  proceeded  to  my  diagnosis 
by  the  exclusion  method  ;  but  was  unable  to  entirely  ex- 
clude aneurism,  and  still  I  was  unable  to  make  a  positive 
diagnosis  of  it,  but  inclined  to  that  disease,  and  again 
commenced  my  former  treatment  of  iodide  of  potash  and 
Squibb' s  ergot,  instructing  my  patient  to  avoid  all  alco- 
holic beverages,  to  refrain  as  much  as  possible  from  the 
use  of  tobacco,  to  limit  his  use  of  liquids,  to  avoid  over- 
loading his  stomach  and  to  avoid  mental  excitement  and 
physical  exertion. 

I  gave  cascira  sagrada  for  the  bowels,  which  were  con- 
stipated, a  condition  which  I  must  say  was  very  rare,  for 
the  regularity  of  the  bowels  was  very  marked  even  when 
opiates  had  to  be  administered. 

Daring  the  later  part  of  July,  1890,  I  thought  I  de- 
tected slight  evidence  of  bulging  of  the  thorax  in  the 
raid-sternum  region.  The  apex  beat  at  this  time  was  one 
inch  to  the  right  of  left  nipple  and  three-fourths  of  an 
inch  below  a  line  passing  through  both  nipples. 

Auscultation  gave  negative  results,  as  nothing  abnormal 
could  be  detected  except  the  increased  cardiac  force. 
There  was  no  jugular  pulsation,  as  frequently  occurs  in 
tricuspid  regurgitation  or  dilated  right  ventricle,  no  buzz- 
ing in  the  ears,  no  vertigo,  but  a  slight  tendency  to  syn- 
cope and  a  slow  pulse,  ranging  as  a  rule  from  fifty-six  to 
sixty  to  the  minute. 

This  time  the  pain,  weakness,  syncope,  and  oppression 
did  not  respond  so  quickly  to  treatment,  and  an  occas- 
ional opiate  had  to  be  administered. 

About  this  time  a  travelling  doctor  from  Omaha  was 
making  monthly  visits  to  the  Black  Hills  and  took  in 


Sturgk  The  unrest  that  is  so  liable  to  overtake  a  sick 
person  troubled  my  patient,  and  he  began  to  want  to 
know  how  long  it  would  take  him  to  get  well.  I  told 
him  that  in  my  opinion  he  would  not  be  able  to  resume 

work  during  the  summer.     This  made  Mr.  L all  the 

more  want  to  try  Dr.  P ,  who  was  advertising  quick 

cures,  no  cure  no  pay.     Finally  Mr.  L went  to  see 

the  doctor,  who,  the  patient  said,  would  agree  to  cure 

him  for   $10  in  advance.      Mr.   L offered  to  put 

in  the  bank  the  $10  subject  to  the  doctor's  order  in 
case  of  cure,  but  this  proposition  was  not  accepted. 

My  patient  did  not  improve  as  fast  as  he  thought  he 
ought  to  under  my  treatment,  and  later  put  himself  under 
the  care  of  Edward  J.  Sexton,  a  regular  practising  physician 
of  ability.  In  talking  the  case  over  later  with  Dr.  Sexton 
he  kindly  informed  me  that  his  first  diagnosis  was  dilata- 
tion of  the  left  ventricle,  and  he  treated  him  for  such ;  but 
upon  a  re-examination  he  changed  his  diagnosis  to  aortic 
aneurism,  and  treated  him  accordingly.  The  doctor  in- 
formed me  that  the  pain  was  so  severe  and  rebellious 
that  he  had  tried  all  the  anodynes,  and  the  only  relief, 
which  was  partial,  was  from  morphia. 

The  disease  gradually  progressed,  the  patient  being 
able  to  walk  about,  until  October,  1891,  when  he  was 
stricken  down  with  hemiplegia  of  the  left  side,  lying  for 
several  days  very  near  death's  door,  while  stopping  with 
friends  in  the  country. 

In  January,  1892,  Mr.  L was  removed  to  Sturgis, 

and  as  his  means  of  support  had  been  exhausted  he  be- 
came a  county  charge,  and  again  came  under  my  care,  I 
being  the  county  physician.  At  this  time  he  was  still 
suffering  from  hemiplegia,  although  somewhat  improved 
and  able  to  be  up.  I  put  him  on  tonics  containing  phos- 
phorus and  strychnia,  and  also  made  tri  weekly  applica- 
tions of  faradism,  which  improved  the  muscular  action. 

An  examination  at  this  time  showed  more  marked 
bulging  in  the  right  auricular  region,  and  increased  dul- 
ness, which  extended  farther  to  the  right.  The  apex 
beat  was  marked  and  increased  in  force.  There  was 
dyspnoea  and  a  dry  senseless  hacking  cough  present.  The 
second  heart-sound  seemed  slightly  accentuated ;  a  faint- 
like feeling  was  complained  of,  and  the  pain,  which  was 
described  as  piercing,  tearing,  burning,  aching,  and  wear- 
ing in  character  always  at  the  seat  of  the  bulging,  passing 
posteriorly  to  the  upper  interscapular  region,  most 
marked  at  the  left  of  the  spine,  was  the  most  severe 
symptom,  although  remitting  at  intervals,  and  then  re- 
turning with  increased  vigor. 

I  could  detect  no  murmurs,  no  jugular  pulsation,  no 
bruit,  no  irregularity  in  heart's  rhythm,  no  intermittency  in 
heart's  beating,  no  dulness  separate  and  distinct  from 
that  of  the  heart,  and  no  inequality  in  radial  pulses. 
There  was,  however,  an  increased  cord-like  feeling  in 
radial  arteries,  and  the  anterior  convex  portion  of  the 
bulging  in  the  chest  was  softening,  and  a  pulsating  beat 
was  plainly  felt  on  palpation,  which  gave  the  impression 
of  transmitted  shock  and  some  interference,  with  vesic- 
ular murmurs  at  apices  of  both  lungs. 

Although  still  uncertain  I  felt  quite  positive  the  disease 
was  aneurism  of  the  aorta,  and  at  that  portion  beyond 
the  point  of  the  origin  of  the  left  subclavian  artery,  for 
the  reason  that  there  was  no  inequality  in  radial  pulse. 
I  again  resorted  to  drachm  doses  of  Squibb' s  fluid  extract 
of  ergot  with  scruple  doses  of  iodide  of  potash  three 
times  a  day. 

My  patient  being  indisposed  sufficiently  to  keep  him 
in  bed,  I  could  see  a  slight  diminishing  in  the  size  of  the 
bulging,  which  I  took  to  be  the  result  of  medication ;  but 
in  a  few  weeks  he  regained  his  appetite  and  strength 
enough  to  be  up,  and  no  amount  of  argument  or  per- 
suasion would  make  him  keep  quiet,  and  as  soon  as  he 
began  to  walk  about  the  bulging  began  again  to  in- 
crease. 

As  before  stated  the  severe  pain  was  the  most  trouble- 
some symptom  I  had  to  deal  with,  and  I  found  that  any 
drug  that  lowered  the  arterial  tension  gave  temporary  re- 
lief.    On  one  occasion  my  patient  came  into  my  office 


July  7,  1 894] 


MEDICAL   RECORD. 


nearly  wild  with  pain.  I  had  him  lie  down  on  the  lounge 
and  gave  him  one  minim  of  nitrite  of  amyl,  and  was  sur- 
prised at  the  instant  relief  of  the  pain.  Seeing  the  quick 
results,  I  prescribed  a  mixture  of  nitrite  of  amyl  and  fluid 
extract  of  prun.  virg.,  and  for  some  time  it  acted  admira- 
bly ;  later  1  also  tried  glonoin,  but  it  did  not  act  as  well 
as  the  nitrite  of  amyl.  At  a  glance  one  will  readily  see 
that  the  nitrite  of  amyl  antagonized  the  effect  of  the  ergot 
S3  far  as  it  affected  the  arterial  tension,  and  recognizing 
this  fact  my  first  dose  was  an  experimental  one. 

In  treating  the  pain  I  resorted  to  various  anodynes 
and  somniferous  drugs,  frequently  without  avail,  and  had 
occasionally  to  return  to  morphia  either  by  mouth  or 
hypodermically. 

I  always  advised  the  taking  of  small  amounts  of  liquids, 
the  avoidance  of  stimulants,  restricted  diet  so  as  not  to 
overload  the  stomach,  and  thereby  mechanically  increase 
the  pressure,  avoidance  of  mental  excitement  and  physi- 
cal exertion. 

The  bulging  gradually  increased  until  no  trace  of  rib 
or  cartilage  could  be  detected  by  palpation  at  the  seat 
of  bulging,  and  the  wall i  of  the  sac  became  adherent  with 
the  anterior  chest-walls  so  intimately  that,  in  making  the 
dissection  after  death,  there  appeared  no  division  between 
the  auricular  sac  and  the  chest-wall,  and  the  pulsation  of 
the  local  bulging  could  b;  easily  seen  several  feet  dis- 
tant. 

Palpation  gave  the  impression  of  transmitted  shock. 
As  the  disease  advanced  the  dyspnoea  became  more 
marked,  due,  in  my  opinion,  to  the  pressure  causing  im- 
perfect pulmonary  circulation  and  deficient  aeration  of 
blood. 

There  was,  at  times,  slight  inequality  of  the  pupils, 
never  well  marked.  Patient  suffered  also  from  an  occa- 
sional headache.  The  cardiac  dulness  gradually  in- 
creased to  the  right  and  the  respiration  became  more 
laborious  as  the  pressure  increased. 

There  was  at  no  time  any  dropsy,  no  inequality  of  ra- 
dial pulse,  and  the  cyanosis  was  slight. 

Photograph,    Figure    1,    was    taken    early  in    July, 


Fig. 


1892.  In  the  condition  here  represented  the  patient 
would  occasionally  have  two  or  three  days  at  a  time  com- 
paratively free  from  pain,  and  then  again  it  would  come 
on  in  the  severest  manner,  extending  to  the  left  shoulder 
and  down  the  left  arm  to  the  finger  tips,  similar  in  char- 
acter to  the  subjective  symptoms  in  disease  of  the  cardiac 
valves. 

During  the  last  week  in  July  I  was  called  away  for  a 


few  days,  and  I  had  Dr.  Ira  1,.  Sanderson,  of  Sturgis,  a 
physician  and  surgeon  of  long  experience,  formerly  of 
the  United  States  army,  attend  my  patient,  as  frequently 
hypodermic  injection  of  morphia  had  to  be  administered 
to  allay  the  pain.  After  my  return  Dr.  Sanderson  in- 
formed me  that  he  considered  the  case  as  one  of  aneu- 
rism of  the  aorta. 

I  continued  iodide  of  potash  and  ergot  for  the  reason 
that  I  thought  I  hid  an  aneurism  to  jdeal  with  and  knew 
of  no  better  medication.  About  this  time  difficulty  in 
swallowing  food  developed,  and  the  above  symptoms 
continued,  gradually  increasing  in  severity. 


Fig.  a.— Organ  laid  Open. 

In  this  you  can  readily  see  the  disease  has  made 
greater  strides.  During  the  last  two  months  superficial  ul- 
ceration has  already  commenced  in  that  portion  nearest 
the  right  nipple,  and  its  development  progressed  rapidly 
considering  that  only  ten  days  had  elapsed  since  the  ul- 
ceration commenced. 

During  this  process  of  ulceration  the  patient  had  no 
rest  night  or  day,  morphia  having  no  effect  in  ordinary 
doses,  and  the  hypodermic  injections  were  increased  up 
to  two  grains  per  dose,  and  repeated  every  hour  for  three 
doses  the  day  before  he  died,  as  iupture  seemed  pos- 
sible at  any  minute  and  humanity  demanded  some  relief, 
but  sleep  was  not  produced.  At  my  last  visit,  the  day 
before  his  death,  October  7,  1892,  Theodore  Haas,  a 
druggist,  accompanied  me,  it  being  near  midnight.  I  had 
previously  covered  up  the  ulcerated  portion  of  the  bulg- 
ing with  a  piece  of  lint  smeared  over  with  carbolized  vas- 
eline and  gave  instructions  that  it  should  not  be  removed, 
but  my  patient's  curiosity  became  uncontrollable,  and 
while  my  back  was  turned  he  removed  the  lint,  and 
suggested  more  vaseline.  While  applying  more  vaseline 
to  the  lint  I  heard  him  cry  out,  "  I  am  bleeding  to  death." 
Mr.  Haas  had  just  previously  noticed  him  remove  a 
black  object,  which  was  a  clot  of  blood,  which  acted  as 
a  plug  in  one  of  the  ulcerated  holes,  and  when  removed 
allowed  the  blood  to  flow  out  freely,  which  it  did,  spurt- 
ing probably  some  two  feet  for  a  moment  and  then  grad- 
ually lessening  its  expulsive  force. 

The  blood  was  venous  in  character  and  more  regular 


8 


MEDICAL   RECORD, 


[July  7,  1894 


in  flow  than  it  would  have  been  had  the  blood  been  arte- 
rial. In  half  a  minute  or  less  another  clot  filled  the 
opening. 

My  visits  were  very  frequent  during  the  last  few  days 
of  his  life,  and  I  was  at  his  bedside  a  few  moments  be- 
fore his  death,  which  occurred  at  noon  on  October  8, 
and  it  was  with  great  difficulty  that  he  swallowed  even 
liquids  for  the  last  few  days  of  his  life.  Death  really  re- 
sulted from  inanition,  as  his  inability  to  eat  food  had 
caused  marked  debility  and  excessive  anaemia. 

Thus  ends  the  case  of  our  supposed  aneurism  of  the  aorta, 
and  a  hasty  review  of  the  subjective  and  objective  symp- 
toms, which  have  been  misleading,  in  which  the  underlying 
etiological  factors  produce  appearances  not  especially 
peculiar  to  ir,  but  common  to  a  frequent  and  well  known 
affection  of  the  blood-vessels,  we  can  usually  see  wherein 
our  error  lay,  before  we  detail  the  results  of  the  post- 
mortem examination  perhaps  would  not  be  amiss. 

As  in  aneurism  (intrathoracic)  we  had  pain  in  chest, 
even  extending  to  shoulder  and  down  left  arm  to  fingers, 
and  here  I  would  quote  from  Dr.  Walshe,  who  says, 
"  The  absence  of  symptoms  and  signs  indicative  of  ordi- 
nary affections  of  the  heart  and  lungs  in  an  individual 
suffering  from  persistent  anomalous  disturbance  within 
the  chest,  even  although  he  does  not  exhibit  any  failure 
of  general  health,  affords  strong  motive  for  suspecting  an- 
eurism/1 

We  have  in  our  case  the  disturbance  in  the  chest 
spoken  of,  we  have  failure  of  general  health,  we  have 
dyspnoea,  we  have  some  inequality  in  the  pupil,  not 
marked  ;  we  have  laborious  respiration  with  disturbance 
in  vesicular  murmur,  we  have  difficulty  in  swallowing, 
we  have  the  hacking  senseless  cough,  although  no  paral- 
ysis of  either  pharyngeal  nerve ;  we  have  evidence  of 
atheroma,  as  shown  by  hemiplegia;  we  have  a  pulsating 
or  heaving  expansile  tumor,  although  not  distinct  from 
that  of  the  heart ;  while,  on  the  other  hand,  we  cannot  de- 
tect any  systolic  bruit,  which  is  often  absent  in  aneurism. 
We  cannot  detect  separate  and  distinct  dulness  from 
that  of  the  heart,  we  cannot  detect  any  inequality  in 
radial  pulse. 

My  mistake  in  diagnosis  was  due  to  a  lack  of  proper 
consideration  being  given  to  the  heaving  expansile  im- 
pulse of  the  pulsating  tumor,  which  was  not  distinct  from 
that  of  the  heart,  and  in  my  case  misled  me  by  giving 
the  impression,  by  palpation,  of  transmitted  impulse, 
which  condition  was  caused  by  the  expansile  impulse  be- 
ing interfered  with  by  the  interstitial  inflammation,  which 
caused  an  adhesion  of  the  sacculated  portion  of  the  heart 
to  the  internal  anterior  wall  of  the  chest,  thereby  causing 
a  lessened  elasticity,  lessening  the  expansile  thrust  and 
producing  with  the  impulse  of  the  tumor  a  tendency  to 
shock. 

I  am  aware  that  diagnosis  of  sacculated  ruptures  of  the 
heart's  cavities,  or  as  some  prefer  to  call  them  "  heart 
aneurisms'1  or  "heart  varices,"  are  frequently  not  made 
until  the  patient  reaches  the  post- mortem  table  ;  but 
nevertheless  I  now  consider  this  expansile  impulse,  with 
a  seeming  tendency  to  transmitted  shock,  very  diagnostic 
of  a  sacculated  rupture  of  one  of  the  heart's  cavities, 
when  its  dulness  is  not  distinct  and  separate  from  that 
of  the  heart's  dulness. 

One  other  conclusion  I  shall  draw,  and  that  is  in  refer- 
ence to  the  pain.  In  aneurism  the  pain  is  more  fre- 
quently first  complained  of  in  the  shoulder  or  passing 
down  the  arm  to  the  hand,  while  in  sacculated  heart  cavi- 
ties, as  in  valvular  disease  of  the  heart,  the  pain  is  more 
frequently  first  complained  of  in  the  cardiac  region  and 
then  radiates  to  the  shoulder  and  then  down  the  arm. 

We  will  now  look  at  the  heart  as  it  appeared  on  being 
removed  from  the  body  as  shown  by  photo  marked  Fig- 
ure 3.  Letter  a  represents  aorta  ;  b,  left  innominate  ar- 
tery ;  c,  the  sacculated  portion  of  the  right  auricle  as  rep- 
resented in  Figure  2,  by  the  bulging  in  the  chest ;  z/,  the 
right  auricle  ;  and  e,  the  heart's  apex. 

Viewing  the  heart  as  it  is  laid  open,  as  represented  by 
photo  marked  Figure  2,  a  represents  aorta  laid  open  ;  </, 


the  left  auricle  ;  ard  r,  the  posterior  wall  of  the  right  auri- 
cle ;  and  the  letter  b  intended  to  represent  the  anterior  wall 
of  the  right  auricle,  and  the  rupture  or  hole  in  the  same. 
Letters  e  and/ represent  the  ventricles  ;  and  ^  the  apex 
of  the  heart. 

We  find  the  aorta  dilated,  so  also  the  auricles ;  but 
more  marked  in  the  right  There  is  dilatation  of  supe- 
rior vena  cava,  but  not  excessive. 

Upon  examination  of  the  sacculated  right  auricle  from 
a  pathological  point  of  view,  I  am  of  the  opinion  that  the 
disease  originated  in  a  local  circumscribed  fibroid  condi- 
tion of  the  inner  surface  of  the  anterior  wall  of  the  auricu- 
lar chamber,  which  resulted  in  new  cellular  growth,  there- 
by producing  interstitial  pressure  on  the  muf  cular  fibres 
causing  or  resulting  in  fatty  degeneration.  There  is  no 
doubt  but  that  the  whole  thickness  of  the  anterior  wall  of 
the  right  auricle  at  the  seat  of  the  disease  was  affected 
and  the  muscular  fibres  degenerated. 

The  localized  sacculated  portion  of  the  auricle,  the  seat 
of  the  fibrosis,  presented  a  glistening  fibrous  appearance, 
of  a  dirty  white  or  nearly  grayish  color.  I  believe  the 
fatty  degeneration  exceeded  the  development  of  fibrous 


Fig.  3.— Appearance  on  Removal. 

tissue,  and  as  a  result  the  affected  circumscribed,  area 
softened  and  thinned  at  the  same  time  and  in  this  man- 
ner the  bulging  took  place. 

The  fatty  degeneration  could  easily  be  detected  by 
pal  pa*  ion  and  inspection,  for  it  presented  a  greasy  feeling 
even  after  the  specimen  had  been  in  alcohol  several 
weeks,  as  well  as  a  greasy  aspect.  The  fat  had  in- 
creased considerably,  but  more  markedly  so  in  the  inner 
layer  of  the  sac,  as  manifested  by  the  increased  number  of 
oil  cells,  as  shown  by  examination  with  the  microscope, 
and  every  condition  present  suggested  that  the  limited 
area  of  the  sac,  as  represented  by  the  letter  b,  was  in- 
tensely and  uniformly  affected,  though  sharply  defined  or 
limited.  This  limited  circumscribed  spot  was  circular, 
but  presents  a  more  elliptical  form  in  photo,  caused  by 
the  position  in  which  it  was  held  while  being  photo- 
graphed. 

As  a  usual  rule  the  ventrie'es  are  more  often  affected 
than  the  auricles  ;  indeed  some  authors  doubt  that  the 
auricles  are  ever  affected.  They  are  certainly  occasionally 
the  seat  of  fibroid  degeneration  and  their  walls  may  be 
affected  in  a  limited  area,  which  is  sharply  defined,  and 
through  the  entire  thickness  of  the  walls,  as  illustrated  in 
the  case  before  us. 

In  primary  rupture  of  the  heart  the  immediate  cause  of 

-the  tear  is  probably  an  unnatural,  excessively  energetic 

contraction  of  the  heart,  producing  a  greater  strain  upon 

the  fibres  than   their  degenerated  condition  can  resist. 

This  condition  of  energetic  contraction  can  be  brought 


July  7,  1894] 


MEDICAL   RECORD. 


about  by  excessive  lifting,  straining,  or  perhaps  a  violent 
coughing. 

This  condition,  as  can  readily  be  seen,  would  most 
often  affect  the  ventricles,  as  the  greater  blood  tension 
would  there  exist  during  such  efforts ;  but  I  take  it  that 
in  a  localized,  sharply  denned,  circumscribed  fibroid 
condition,  succeeded  by  fatty  degeneration  in  the  auricle 
in  our  case,  the  force  being  less  than  in  the  ventricle, 
there  would  be  less  liability  to  rupture,  or  a  complete 
tear  through  the  wall ;  but  the  weakened  part  would 
partially  give  way,  and  in  time,  considerably  longer  than 
in  case  of  the  ventricle,  a  sacculated  condition  would  form, 
gradually  distending,  and  through  pressure  on  adjacent 
organs  the  various  symptoms,  as  in  the  case  before  us, 
would  be  produced. 

As  Jenner  pointed  out,  congestion  of  the  walls  of  the 
heart  is  a  cause  of  fatty  degeneration  of  the  muscular 
fibres  ;  but  this  degeneration  is  rarely  simple — more  or 
less  fibroid  growth  is  usually  conjoined.  In  the  present 
case  the  cause  of  the  fatty  degeneration  is  probably  alco- 
holism, the  same  being  the  cause  of  the  atheromatous 
condition,  and  I  take  it  as  the  probable  cause  of  the  fi- 
brosis, augmented,  perhaps,  by  the  tobacco  habit 

In  fatty  degeneration  we  expect  to  find  diminished 
force  of  impulse  and  a  weak  apex  beat,  together  with  en- 
feebled heart  action  ;  but  in  the  present  case  we  find  the 
very  opposite  condition,  and  I  account  for  this  by  the 
fact  that  our  limited  area  of  degenerated  muscular  fibres 
was  in  the  auricle,  and  even  in  forcible  heart  action 
the  tension  was  not  sufficient  to  complete  rupture,  and 
not  sufficient  even  to  prevent  regular  ventricular  con- 
tractions, which  have  more  to  do  with  impulse  and  apex- 
beat,  when  the  muscular  fibres  of  the  ventricles  are  not 
degenerated,  than  do  the  auricles. 

The  energetic  effort  at  lifting,  at  the  first  appearance 
of  pain,  was  probably  the  immediate  cause  of  affecting 
the  diseased  auricle,  and  no  doubt  resulted  in  an  injury 
to  the  diseased  area,  thus  producing  inflammation  and 
local  congestion  and  allowing  every  excessive  increase 
in  blood  pressure  to  add  to  the  mischief  already  existing, 
which  gradually  progressed  until  the  results  as  portrayed 
by  the  photographs  finally  developed. 


CRIMINAL  ABORTION. 

Its  Evils  and  Its  Sad  Consequences. 
By  MARY  A.  DIXON- JONES,   M.D., 


In  law  the  term  abortion  is  applied  to  the  expulsion  of 
the  foetus  at  any  period  of  pregnancy  before  the  term 
of  gestation  is  completed. 

Abortion,  induced  at  any  time,  or  for  any  purpose  ex- 
cept for  the  mother's  welfare,  or  for  the  preservation  of 
the  life  of  the  foetus,  is  a  crime  and  a  murder.  This  foul 
taking  off  has  been  the  cause  of  the  destruction  of  an 
uncounted  number  of  children ;  and  has,  in  unnumbered 
instances,  resulted  in  the  death  or  ill  health  of  the 
mother. 

Under  these  two  heads  I  will  briefly  discuss  a  few 
phases  of  the  subject :  First,  the  danger  to  the  mother ; 
second,  loss  of  infant  life ;  and  third,  as  further  develop- 
ing the  thought,  will  give  instances  of  women  who  have 
sought  to  have  abortion  produced  ;  and  finally,  will  re- 
fer to  the  medico  legal  aspects  of  the  subject. 

As  soon  as  conception  takes  place  the  vital  forces  are 
summoned  to  new  energies  and  new  activities,  dormant 
powers  are  aroused,  and  wonderful  processes  commence. 
The  uterus  and  whole  organism  begin  preparing  for  the 
great  work,  the  growth  and  development  of  a  human 
being,  to  be  perfected  in  the  short  space  of  nine  months. 
To  interrupt  these  processes  is  a  shock — a  shock  to  the 
whole  being,  the  nutritive,  nervous,  and  mental  systems ;  it 
does  violence  to  the  procreative  organs,  and  renders  them 
incapable  of  ever  as  efficiently  performing  their  special 
functions.     Subinvolution  cannot  take  place  as  in  the 


normal  termination  of  pregnancy.  This  gives  rise  to 
multiplied  evils,  the  full  significance  of  which  are,  as  yet, 
not  fully  understood.  The  uterus  and  its  adnexae,  espe- 
cially, suffer  in  many  respects,  swelling  from  the  increase 
of  living  matter ;  then  follow  enlargement,  hyperplasia, 
various  misplacements,  inflammations,  and  fibrous  degen- 
erations ;  in  some  cases,  cancer  or  malignant  growth  is 
the  natural  outcome ;  in  all,  there  will  result  some  trouble 
that,  for  years,  may  give  distress,  suffering,  and  last- 
ing weakness.  Women  may  not  at  first  show  the  full 
sad  effects,  may  even,  after  repeated  abortions,  appar- 
ently do  well ;  but,  though  not  recognized,  grave  con- 
sequences always  follow,  resulting  ofttimes  in  disease  that 
may  become  more  and  more  complicated,  more  and  more 
dangerous,  many  times  terminating  fatally ;  and  always, 
to  some  extent,  shortening  life.  Many  strong,  healthy 
women  have,  by  it,  been  made  invalids  for  life,  and  to 
it  many  date  the  commencement  of  their  sufferings  and 
their  continued  ill  health.  Thomas  says :  *  "  That  this 
criminal  practice  constitutes  a  prolific  source  of  uterine 
disease,  no  one  engaged  in  gynecology  can  for  a  moment 
doubt."  Even  the  sepsis  that  is  apt  to  follow  may  cause 
rapidly  fatal  peritonitis,  or  may  induce  an  incurable  dis- 
ease of  the  uterine  appendages,  which  is  not  only  a  cause 
of  much  suffering  and  ill  health,  but  ofttimes  eventuates  in 
subsequent  and  absolute  sterility.  Septic  inflammation 
most  frequently  destroys  all  functional  capability  of  these 
organs ;  and  in  connection  with  this  I  dare  assert,  and 
believe  the  fact  can  be  fully  substantiated,  infinitely 
more  women  have  been  made  sterile  by  sepsis  introduced 
at  abortion,  or  even  ordinary  labor,  than  results  from  all 
the  cases  of  removal  of  the  uterine  appendages ;  and  this 
disproportion  is  vastly  increased  by  noting  the  fact  that  in 
most  of  the  cases  where  the  diseased  uterine  appendages 
have  been  removed,  the  individuals  had  previously  been 
rendered  sterile  by  the  disease  of  the  named  organs.  I 
have  known  repeated  instances  where  young  married 
women,  even  in  their  first  confinement,  have  by  some 
sepsis  been  forever  deprived  of  the  privilege  of  subse- 
quent maternity,  have  by  this  sepsis  been  made  perma- 
nently sterile.  I  have  known  such  repeated  and  sad  in- 
stances of  this,  and  so  impressed  have  I  been  with  the 
fact  that  I  said  in  an  article  in  the  New  York  Medical 
Journal?  that  "  an  obstetrician  should  be  an  antiseptic 
surgeon.''  As  illustration  and  proof  of  this  we  have 
only  to  refer  to  the  brilliant  obstetric  work  of  many  of 
our  great  antiseptic  surgeons.  James  Murphy,  in  his 
late  address  before  the  Section  of  Obstetrics,  at  the  An- 
nual  Meeting  of  the  British  Medical  Association,1  said: 
"  Puerperal  septicaemia  is  the  most  fatal  disease  that 
childbearing  women  are  exposed  to,  and  though  its  fre- 
quency has  been  discussed  of  late,  its  fatality  has,  I  fear; 
been  but  a  little,  if  at  all,  reduced." 

But  immediately  fatal  results  ofttimes  eventuate  from 
the  attempt  to  produce  criminal  abortion ;  the  shock, 
unexpected  injury,  uncontrollable  hemorrhage — all  make 
a  sad  record  in  this  horrible  work.  The  coarse  brutality 
that  will  allow  one  to  engage  in  it,  is  necessarily  accom- 
panied by  more  or  less  unskilfulness,  that  shows  in  every 
detail  a  lack  of  scientific  refinement  and  natural  delicacy. 
In  the  American  Journal  of  Obstetrics 4  Dr.  Hektoen, 
of  Chicago,  reports  a  case  of  an  abortion,  produced  by  a 
"  Dr.  S.,"  at  the  fourth  month  of  pregnancy;  "the  in- 
sertion of  a  rubber  catheter,  its  disappearance,  rupture  of 
the  uterus,  eventeration  of  the  large  intestines,  and  im- 
mediate death."  It  also  states  that  the  operator,  "Dr. 
S.,"  had  even  pulled  on  thesupposed  placental  cord,  and 
that  the  patient  herself  had  taken  hold  and  pulled  with 
all  her  power,  "in  order  to  expedite  matters !"  Two 
lives  were  thus  sacrificed. 

Dr.  Hektoen,  in  the  same  article,  gives  another  in- 
stance of  an  abortion  at  the  fourth  month,  also  resulting 
in  rupture  of  the  uterus  and  death.     In  the  Pittsburgh 

1  Diseases  of  Woman,  p.  50.     1880. 

9  Another  Hitherto  Undescribed  Disease  of  the  Ovaries,  May  10 
and  17,  1890. 
»  British  Medical  Journal,  August  26,  1893,  p.  453. 
« July,  189a,  p.  69. 


IO 


MEDICAL   RECORD. 


[July  7,  1894 


Medical  Review 1  there  is  reported  a  smiiar  case  of  rupt- 
ure of  the  uterus  from  an  attempted  abortion,  followed 
by  immediate  death.  The  Cincinnati  Lancet  and  Clinic  * 
reports  a  case  of  rupture  of  uterus  and  death.  The  Journal 
<T  Accouchement*  reports  the  case  of  "a  woman,  six  weeks 
pregnant ;  death  followed  almost  immediately  from  the 
attempt  to  introduce  an  instrument  into  the  generative 
organs. ' '  Oskar  Sattler  reports  tetanus  as  following  a  sim- 
ilar attempt.  Stephen  Crowe,  of  Baltimore,4  reports  the 
case  of  "  a  woman  three  months  advanced  in  pregnancy. 
A  tent  was  introduced;  in  the  attempt  to  remove  it 
it  was  broken,  and  three  quarters  remained  in  the  uterus. 
The  patient  was  removed  to  the  Maryland  General  Hos- 
pital; temperature,  1030  F.;  pulse,  140;  abdomen  enor- 
mously swollen." 

Dr.  £.  J.  Ill  *  says :  "A  knitting-needle  was  in  one  in- 
stance forced  through  Douglas's  cul  de  sac  and  the  mesen- 
tery into  the  liver,  to  the  depth  of  an  inch,jwhich  was 
found  after  her  death.1'  He  also  tells  the  case  of  a 
"  crochet  needle,  which  passed  through  the  fundus  into 
the  peritoneal  cavity."  The  Australian  Medical  Jour- 
nal* states  that  "within  a  week  four  women,  in  the 
prime  of  life,  met  death  by  the  forcible  introduction  of 
an  instrument  into  and  through  the  walls  of  the  gravid 
uterus."  Eight  lives  were  sacrificed.  J.  Phillips '  reports 
"a  patient  dying  from  injection  of  nitrate  of  mercury 
into  the  vagina  to  procure  abortion."  In  the  Albany 
Medical  Annals  8  there  is  reported  "an  attempt  to  blow 
air  into  a  uterus  three  months  pregnant,  the  woman  fell 
over  unconscious,  and  expired  a  half- hour  later." 

The  Boston  Medical  and  Surgical  Journal*  reports  the 
case  of  instant  death  from  "  an  attempt  at  criminal  abor- 
tion on  a  strong,  healthy  woman,  in  the  seventh  month 
of  pregnancy,  air  being  forcibly  injected  into  the  uterus, 
causing  instantaneous  death."  The  inter- uterine  douche 
may  have  detached  a  portion  of  the  placenta,  so  that  the 
air  entered  the  circulation  through  the  opened  uterine 
sinuses,  forming  an  air  embolism.  The  entrance  of  air 
into  the  blood-vessels  has  frequently  in  these  attempts 
caused  instant  death. 

In  many  ways  the  effort  to  produce  abortion  may 
be  immediately  fatal.  The  newspapers  of  every  city 
teem  with  reports  of  such  ghastly  deaths.  Many  may 
be  unknown  and  unrecorded,  but  women  hasten  on. 
Many  of  them  are  like  the  daughter  of  the  pious  old  sex- 
ton, of  New  York ;  healthy,  young,  and  full  of  life,  she 
entered  the  operator's  office ;  he  promised  immediate  re- 
lief, she  never  came  out  alive.  The  double  crime  was 
perpetrated.  Uncounted  millions  of  unborn  infants  have 
thus  perished.  There  is  no  darker  page  in  history.  The 
extent  and  fearfulness  of  this  work  is  not  known  or  rec- 
ognized, and  cannot  be  measured.  Those  who  engage 
in  the  traffic  certainly  do  not  comprehend  its  full  import, 
or  understand  the  deep,  dark  iniquity  of  their  deeds.  No 
words  can  depict  its  horrors  or  its  terrible  risks.  It  al- 
ways destroys  the  life  of  one  human  being,  and  possibly 
a  second ;  or,  at  least,  may  make  a  wreck  of  the  poor 
misguided  woman. 

Statistics  state  that  in  New  York  City  there  are  annu- 
ally twelve  or  thirteen  hundred  of  still-births.  Prob- 
ably half  of  the  still-births  are  from  induced  abortion. 
In  fifty  years  this  would  amount  to  over  thirty  thou- 
sand ;  and  counting  other  cities  of  the  Union,  there 
would  be  hundreds  of  thousands  more.  But  even  these 
numbers  are  as  nothing  compared  to  the  millions  of  "  si- 
lent ' '  births  that  are  constantly  being  produced  in  the  ear- 
lier months  of  pregnancy.  As  a  mother  said  a  few  days 
ago,  "  I  have  missed  twice,  but  I  am  going  to  bring  my 
courses  on."     Thousands  of  thoughtless  women  are  do-  - 

1 1867,  p.  22. 

» 1879,  p.  361,  W.  J.  Chenoworth,  Decatur,  111. 
»  Liege,  1888,  vol  ix.,  p.  265. 

•  Maryland  Medical  Journal,  Baltimore,  1892,  vol.  xxvii.,  p.  1013. 

6  New  York  Journal  of  Gynecology  and  Obstetrics,  p.  893,  1892. 
•Australian  Medical  Gazette,  Sydney,  vol.  v.,  p.  39,  1885-86. 

7  Transactions  of  the  Obstetrical  Society,  London,  voL  xxxii. ,  p. 
308,  1890 

•  S.  B.  Ward  :  p.  1,  1889. 

•  Pp.  185-192,  1879. 


ing  the  same  thing ;  and  there  are  unnumbered  "  profes- 
sionals" at  hand  to  help.  The  British  Medical  Jour- 
nal1  gives  the  name  of  an  old  man,  "  Hippolyte  Terle, 
who  confessed  to  having  practised  it  for  years,"  and 
this  man  acknowledged  that  he  "could  not  tell  the 
number  of  times  he  had  committed  the  murder," 
probably  almost  countless.  The  same  journal 2  gives  the 
name  of  another  prisoner  for  the  same  crime,  one  "  Eliz- 
abeth Topham  ;  "  nor  could  she  tell  the  number  of  times 
she  had  produced  illegal  abortion.  Well  did  Professor 
T.  G.  Thomas,  in  his  excellent  work,  say : s  "  Statistics 
showing  the  frequency  of  criminal  abortion  never  have 
been,  and  never  will  be,  written."  There  are  thousands 
engaged  in  the  work,  reaping  their  rich  harvests  ;  and, 
at  the  same  time,  making  a  harvest  of  deaths.  But  the 
most  deplorable  fact  is,  that  there  are  a  multitude  of 
mothers  willing  to  assist,  or,  doing  it  continually. 
Who  can  tell  the  number  of  infant  deaths  ?  A  holocaust 
— a  great  army  of  little  children  are  destroyed.  The 
loss  of  infant  life  is  amazing. 

But,  if  possible,  there  is  yet  a  greater  evil.  The  wom- 
an who  entertains  such  thoughts,  who  has  such  inten- 
tions, the  mother  who  thus  seeks  the  destruction  of  her 
own  child,  thereby  perjures  and  blackens  her  own  soul, 
and  demoralizes  her  whole  moral  being.  It  is  a  prostitu- 
tion of  all  her  higher  nature.  To  think  of  a  mother 
contemplating  the  murder  of  her  own  child  !  studying  to 
destroy  the  being  that  rests  nearest  to  her  own  life,  and 
bound  to  her  by  every  tie  of  kindred,  love,  and  interest. 
What  a  soul- staining  !  Could  anything  be  more  debas- 
ing and  blunting  of  all  the  finer  feelings  and  affections? 
She  who  in  secret  broods  over  such  thoughts,  who  has 
such  intentions,  is  making  of  that  child  and  of  her  chil- 
dren murderers.  The  child  must  take  on  the  then  con- 
dition of  the  parents,  moral  and  physical.  It  is  as  much 
a  part  and  parcel  of  the  parent  as  is  the  lower  order  of 
animals,  where  procreation  is  by  subdivision.  I  could 
imagine  that  he  who  is  guilty  of  signal  crimes  and  mur- 
derous intents  is  born  of  such  a  woman — a  woman  who 
for  days  was  trying  to  compass  his  murder,  and  was  seek- 
ing opportunities  to  do  it  secretly  and  successfully. 

What  reason  do  women  give  for  so  doing  ?  Some  say, 
"  It  is  inconvenient  to  have  a  child  !  "  It  should  be  their 
greatest  happiness.  Others  say,  "  They  have  too  much 
to  do,  too  many  claims  upon  them,  the  demands  of  soci- 
ety, fashion/  etc.  But  this  is  their  first  duty,  and  should 
be  nearest  and  dearest  to  them.  Others  say,  "  A  child 
is  too  much  trouble."  Ah !  an  infinite  source  of  delight 
should  the  care  of  her  little  one  be  to  any  true  mother. 
Others  again  declare  "  they  have  not  the  means  to  sup- 
port it,"  or  that  "  they  want,  for  a  while  longer,  to  take 
their  pleasure,"  "at  some  more  convenient  season," 
say  they.  A  burglar  who  takes  a  man's  life  wants  the 
money,  because  work  is  inconvenient,  he  has  so  many  de- 
mands upon  him,  and  this  may  relieve  him  from  care 
and  trouble,  and  enable  him,  a  while  longer,  to  take  his 
pleasure. 

There  is  more  similarity  between  the  two  than  we  dare 
trace  out.  Women  are  not  taught  to  understand  these 
things,  they  are  not  sufficiently  instructed  as  to  the  won- 
ders of  their  own  being,  or  even  of  the  simplest  laws  of 
life  and  health.  They  do  not  sufficiently  know  the 
great  mysteries  and  beauties  of  life,  that  from  the  mo- 
ment of  conception  a  child  begins  to  live,  that  as  soon 
as  there  is  a  combination  of  the  two  elements,  it  is 
a  human  being.  If  not  then,  will  anyone  say  when 
life  begins,  at  what  time  the  soul  meets  the  body  ?  I 
maintain  that  the  destruction  of  this  new  being,  even 
in  the  earlier  periods  of  existence,  is  as  much  murder  as 
it  would  be  in  the  latter  months  of  pregnancy,  or  in  the 
earlier  periods  of  infancy.  I  hold  that  it  is  as  much 
murder  to  destroy  a  child  that  will  be  born  next  May  as 
one  that  was  born  last  May.  Some  have  asserted  there 
is  no  life  till  it  moves,  or  what  is  understood  as  the 
"  period  of  quickening."     At  the  first  moment  there  is 

1  October  17,  1891.  *  March,  1893,  p.  612. 

8  Diseases  of  Women,  p.  50,  1880. 


July  7,  1894] 


MEDICAL    RECORD. 


11 


motion,  and  there  is  motion  every  moment  of  its  exist- 
ence. The  new  being  unceasingly  moves,  and  the 
powers,  processes,  and  changes,  even  at  this  early  period, 
are  marvellous.  It  is  then  a  human  being.  To  destroy 
it  is  worse  than  vandalism.  To  attack  it  thus,  in  the 
dark  borders  of  its  existence,  in  the  vestibule  of  its 
being,  when  it  is  so  helpless  and  defenceless,  is  a  most 
cruel  warfare,  a  most  unfair  battle,  more  cowardly  than 
the  midnight  assassin,  or  he  who  puts  the  dagger  in  the 
heart  of  the  unsuspecting.  But  it  is  not  the  "  dark  bor- 
ders of  existence.'1  It  is  holy  ground.  Eternal  Wisdom 
is  there  at  work.  "  He  formed  us  in  the  depths."  "  Our 
substance  was  not  hid  from  Him."  '.'  He  breathed  into 
us  the  breath  of  life.'1  From  the  first  it  is  a  living  soul, 
endowed  with  vast  capabilities  and  possibilities.  It  has 
work  in  life  to  do,  and  an  eternal  destiny.  Have  we  a 
right  to  deprive  it  of  its  future  possibilities,  and  oppor- 
tunities of  fulfilling  its  high  mission  ?  Shall  their  unborn 
spirits  go  to  Him,  and  say  they  were  not  allowed'  to  ac- 
complish their  allotted  work?  What  if  the  mother  of 
Washington,  of  Shakespeare,  of  Lincoln,  or  of  Milton 
had  so  acted  ?  In  eternal  light  there  will  be  just  as  sad 
reckoning,  in  every  case.  A  sin  so  terrible  brings  its 
full  and  increasing  evil,  with  arithmetical  progression. 
The  responsibility  is  not  all  in  the  simple  act,  it  carries 
a  weight  beyond.  Are  those  who  help  women  to  do 
this  deed  any  less  to  blame?  Is  not  their  work  the 
blackness  of  darkness,  by  whomsoever  performed  ? 

In  1879  Mrs-  G ,l  the  mother  of  children  and  the 

wife  of  a  prosperous  business  man,  called  at  my  office. 
She  was  then  twenty-eight  years  old  ;  married  six  years, 
had  three  children,  and  one  miscarriage.  She  stated 
that  she  had  found  herself  again  pregnant,  and  wanted 
"  to  get  clear  of  it  3  "  also  said  that  her  miscarriage  was 
brought  on  by  her  physician  replacing  the  womb,  add- 
ing :  "  My  doctor  knows  that  I  am  now  pregnant,  but  he 
does  not  think  I  can  carry  it,  and  that  it  would  be  just 
as  well  to  bring  it  away  now.  He  has  been  trying,  and 
gave  me  aloes,  told  me  half  a  teaspoonful  was  the  dose, 
but  if  I  would  take  three  it  would  make  it  all  the  surer/1 

Here  a  woman  of  some  wealth,  position,  and  a  church 
member,  deliberately  comes  and  asks  me  to  help  her  to 
destroy  her  unborn  child,  saying,  '*  She  is  not  going  to 
have  it,  because  she  has  too  much  to  do."  Murder  was 
in  her  heart.  While  I  had  the  most  intense  disgust  and 
indignation,  I  quietly  told  the  poor  woman  she  ought  to  be 
thankful  and  feel  honored  that  another  member  was  to 
be  added  to  her  household,  that  nothing  was  more 
lovely  or  interesting  than  a  large  family  of  children. 
She  coldly  and  cruelly  replied :  "I  am  not  going  to 
have  this  child,  and  my  family  physician  has  been  giving 
me  pills  to  enable  me  to  get  clear  of  it."  She  gave  me 
his  name,  I  warned  her  of  the  danger,  urged  her  to  de- 
sist, and  asked  her  if  she  had  any  more  right  to  destroy 
that  child  than  any  other  member  of  her  household. 
The  woman  went  home ;  I  feared  my  word  would  not 
sufficiently  impress  her,  so  the  next  day  I  wrote  her,  em- 
phasizing the  same  thoughts.  The  child  was  allowed  to 
live.  He  is  now  a  big  boy,  attending  school.  I  have 
seen  him  many  a  time,  but  how  near  he  came  to  destruc- 
tion !  and  probably  he  will  never  be  as  finely  consti- 
tuted as  if  his  mother  had  not  brooded  over  and  contem- 
plated so  heartlessly  her  own  boy.'s  murder.  When  will 
mothers  look  into  these  things  and  understand. 

In  1866  a  mother  called  to  see  me,  wanting  then  to 
get  rid  of  her  unborn  babe,  saying  that  "  she  had  three 
children,  and  her  husband  was  not  able  to  support  any 
more."  I  inquired  if  she  was  not  willing  to  share  her 
little  with  this  one  also.  I  presented  many  considera- 
tions. She  heeded  nothing,  but,  with  cold  selfishness, 
seemed  determined  on  her  child's  murder.  I  gave  her 
more  serious  words  of  warning.  She  went  I  knew  not 
whither.  This  woman  was  more  cruel  than  the  Hindoo 
mother  who  throws  her  child  into  the  Ganges. 

1  AU  the  circumstances  here  narrated  are  facts.  Names  will  not  be 
mentioned,  whether  the  parties  live  in  Maine  or  Mexico.  The  facts 
belong  to  me,  and  are  accurately  stated. 


One  day,  more  than  twenty  years  ago,  I  was  called  to 
see  a  sick  patient.  It  was  a  home  of  comfort  and  plenty. 
The  young  woman,  scarce  eighteen  years  old,  lay  in  her 
bed ;  she  was  a  delicate,  feeble  girl.  By  her  bedside 
stood  the  mother,  a  refined,  elegant  woman.  The 
mother  simply  called  my  attention  to  her  sick  daughter, 
that  ^she  was  not  regular,  and  that  she  wanted  "her 
courses  brought  on."  My  duty  was  to  find  the  cause  of 
this  retention.  Examination  showed  that  the  patient 
was  two  months  pregnant,  and  my  first  inquiry  was  how 
long  she  had  been  married.  This  revealed  all.  The 
mother,  in  her  deep  grief,  told  the  tale  of  sorrow,  of  the 
daughter's  engagement,  and  the  man  had  gone ! 

This  read  a  whole  lecture  as  to  a  mother's  duties  and  her 
watchful  care,  and  how  she  should  instruct  her  daughters 
in  all  that  is  right,  and  show  them  the  beautiful  side  of 
life.  The  mother  exclaimed :  "  This  must  be  got  away." 
"  But,"  said  I,  "  the  daughter  must  now  do  what  is  right. 
She  cannot  destroy  the  being  to  whom  she  has  given 
life."  "  Ah,"  said  the  mother,  "death  before  dishonor ; 
my  daughter  is  not  going  to  be  disgraced  all  her  days, 
and  the  man  go  scot-free."  I  reminded  the  mother 
again  that  it  was  a  living  child,  and  that  to  destroy  it 
would  be  murder ;  and  besides,  would  imperil  her  own 
daughter's  life. 

I  left  them  in  their  grief.  The  next  day  the  father 
saw  me,  said  "  he  knew  of  my  removing  successfully  a 
tumor  from  the  womb  of  a  lady  who  was  a  friend  of  his 
wife,  and  that  I  could  do  this  just  as  safely."  "  That," 
said  I,"  was  done  to  save  life ;  you  ask  me  to  destroy  life, 
possibly  two  lives."  He  offered  a  price !  "No,"  said 
I,  "  not  for  this  city  full  of  gold,  nor  for  ten  million 
cities  besides,  would  I  take  the  guilt  of  murder  on  my 
soul."  Notwithstanding  all  my  warnings  they  found 
someone  to  do  the  dark  deed.  It  was  done  in  some  way 
or  somehow.  Years  after  I  met  this  young  woman.  She 
was  an  invalid.  She  married,  but  no  babe  ever  came  to 
bless  that  wedlock.  She  had  to  think  of  the  pearl,  the 
priceless  jewel,  that  she  had  thrown  from  her,  and  that 
she  had  destroyed  her  own  child !  If  young  girls  were 
instructed,  if  they  understood,  they  would  be  far  from 
such  work. 

In  18 —  a  young  lady  called  at  my  office.  She  was  the 
only  daughter  of  a  prosperous  merchant,  for  whose 
household  I  had  been  the  family  physician  for  more  than 
a  dozen  years.  I  listened  to  her  sad  story — engaged  to 
be  married— one  false  step !  I  advised  her  if  she  loved 
the  man  to  marry  him,  but  to  go  first  to  her  mother  for 
counsel  and  instruction.  She  did  both,  the  child  was 
saved,  and  the  daughter's  life  was  spared. 

In  1878  a  young  girl  of  education  and  intelligence 
called.  She  was  pregnant  and  her  affianced  gone  !  When 
will  girls  learn  to  do  right,  and  when  will  their  mothers 
instruct  them  in  all  things.  The  principles  of  moral 
rectitude,  planted  deep,  would  deter  from  such  con- 
duct. If  conscience  or  delicacy  does  not  restrain,  they 
might  remind  themselves  of  the  startling  tragedy  of  the 
king's  daughter:  "The  hatred  wherewith  Amnon,  the 
betrayer,  hated  her  was  greater  than  the  love  wherewith 
he  had  loved  her."  I  advised  this  young  girl,  she  trusted 
me,  the  child  lived,  and  she  thus  saved  her  own  health 
and  strength,  and  had  not  the  sin  of  murder  on  her  soul. 
She  must  think  of  the  rest. 

A  few  years  after,  a  grief-stricken  one  called  on  me  as 
a  physician  to  tell  her  tale  of  woe.  I  was  more  than 
grieved  that  she  and  others  so  little  understood  me  as 
to  imagine  that  I  could  or  would  help  in  such  nefarious 
work.  I  attempted  to  give  her  light  and  advice.  Two 
days  after,  the  marriage  rites  were  solemnized. 

Another  in  like  circumstances.  I  gave  her  the  same 
counsel  and  advice,  both  child  and  mother  were  saved ; 
but  what  a  history  of  remorse  and  self-condemnation. 

For  the  young  unmarried  girls  there  might  possibly  be 
some  forbearance,  some  sympathy  for  them,  in  their  des- 
peration and  misery.  They  are  led  on,  deceived  by  false 
promises ;  they  trust,  and  are  left  in  desolation  and  bewil- 
derment ;  they  fly  anywhere,  anywhither  for  help  or  refuge ; 


IS 


MEDICAL  RECORD. 


[July  7,  1894 


but  married  women,  what  excuse  have  they?  For  them 
there  is  the  most  utter  condemnation  and  execration. 

In  1885,  during  the  month  of  December,  a  married 

woman,  Mrs.  C ,  called  at  my  office,  elegantly  and 

expensively  dressed.  She  informed  me  that  she  was  then 
in  the  third  or  fourth  month  of  pregnancy,  and  expressed 
her  determination  to  get  clear  of  the  child,  saying  that 
she  had  suffered  so  much,  had  been  sick  since  her  last 
confinement,  nine  years  previously,  at  which  time  she 
was  ill  in  bed  many  weeks  with  high  fever;  on  the 
eleventh  day  was  not  able  to  turn  her  head,  and  since 
that  time  the  distress  in  her  pelvis  had  continued,  espe- 
cially on  the  left  side.  She  said  further,  "  I  do  not  want 
this  child,  it  is  an  unwelcome  visitor,  and  I  will  get  clear 
of  it.  I  have  taken  ergot  by  the  quart,  and  have  pills 
from  the  physician ;  he  says  he  can  help  me,  but  as  I 
have  to  go  in  the  cars  it  might  endanger  my  life."  I 
explained  to  this  woman  the  danger  of  such  attempts, 
that  it  was  almost  sure  destruction  to  her  own  health, 
that  nothing  was  more  disastrous  than  expelling  prema- 
turely the  foetus,  that  the  uterus  was  not  then  physiolog- 
ically prepared  for  the  work,  and  that  the  injuries  result- 
ing therefrom  might  prove  fatal ;  and  besides,  her  already 
deeply  lacerated  cervix  would  be  an  added  element  of 
danger.  I  also  reminded  her  that  the  child  was  a  living 
being,  even  showed  her  a  papier  mach^  preparation  re- 
presenting the  fourth  month ;  that  at  that  time  the  foetus 
was  a  perfectly  formed  child.  She  looked  at  it,  tears 
came  into  her  eyes ;  she  said,  "  Is  it  so  formed  ?  "  But  she 
soon  controlled  her  feelings,  adding,  "  I  do  not  believe 
God  has  anything  to  do  with  it,  I  shall  get  clear  of  it." 
Can  anyone  realize  the  stony  hardness  of  her  heart  ?  I 
reminded  her  that  this  child  might  one  day  be  a  blessing 
to  her,  probably  was  given  to  comfort  her  in  some  trying 
period  of  life.  Again  I  asked  her,  "  What  right  had 
she  to  interfere  with  its  existence.11  Then  I  told  her 
plainly  and  positively  that  I  would  not,  for  all  she  had, 
and  twice  the  mines  of  Golconda,  help  in  so  foul  a  deed. 
I  heard  nothing  more  from  this  woman  until  the  fifth  of 
the  next  May,  when  I  was  called  to  attend  to  her  con- 
finement. After  the  confinement  she  was  able  to  be  up 
in  nine  days.  A  month  after  I  repaired  successfully  the 
old  laceration  of  the  cervix. 

I  hold  that  a  woman  who  can  understanding^  con- 
template such  work  is  in  no  way  to  be  trusted.  This 
patient  left  without  paying  me  for  the  examination,  or 
the  two  hours'  talk  by  which  the  child's  life  was  saved, 
and  probably  her  own ;  nor  has  she  since  paid  for  my  at- 
tending her  in  confinement,  or  for  the  surgical  operation 
or  the  subsequent  medical  attention.  Also  the  two  phy- 
sicians who  assisted  me  in  the  operation  have  received  no 
financial  pay  for  their  work ;  we  have  only  the  conscious- 
ness of  right  doing. 

The  child  was  a  little  girl,  and  many  times  have  I  seen 
this  little  fairy  playing  in  the  street ;  but  will  anyone  tell 
me  that  her  young  soul  was  not  tarnished  by  such  desires 
on  the  part  of  the  mother. 

Many  beautiful  little  children  are  now  walking  the 
streets  that  I  have  saved — have  prevented  their  mothers 
from  destroying  them.  These  mothers  came  to  me  with 
the  unholy  purpose  and  most  wicked  request.  To  all 
alike  I  have  endeavored  to  show  them  their  error  and 
point  them  to  the  right  course. 

A  good  woman,  the  mother  of  many  children,  a  lady 
of  considerable  wealth,  and  who  for  years  had  been  a 
patient  of  mine,  and  consequently  would  have  been  sup- 
posed to  have  known  better ;  yet  this  woman  joined  with 
her  daughter-in-law  to  destroy  the  latter' s  unborn  child. 
She  coldly  informed  me  that  she  was  going  to  have  it 
done!  I  expressed  my  condemnation  in  the  most  un- 
measured terms,  telling  her  that  it  was  not  only  a  mon- 
strous crime,  but  would  be  a  great  wrong  to  the  daughter. 
I  said  much,  and  presented  many  considerations,  but 
strange,  this  mother  was  firm  and  decided ;  said  her  son 
had  enough  children,  and  that  he  had  to  get  along  in  life. 
The  parties  went  to  a  neighboring  city  to  have  the  crime 
committed,  by  whom  I  do  not  know.     I  knew  that  the 


time  was  fixed.  I  made  one  more  effort  and  wrote  the  fol- 
lowing letter  to  the  mother :  "  May  26,  1880.  I  cannot 
let  this  day  pass  without  giving  you  another  warning.  I 
have  reminded  your  daughter  of  the  great  danger,  that  if 
there  is  one  death  in  a  hundred  she  may  be  that  one.  I 
have  urged  her  to  desist,  now  I  appeal  to  you.  A  child 
that  is  three  months  old  has  as  much  right  to  live  as  one 
who  is  nine  months  old." 

This  letter  was  carried  by  my  faithful  coachman,  and 
delivered  in  person.  The  operator  who  was  engaged  to 
do  the  atrocious  work,  I  suppose,  dared  not  proceed ;  at 
least  the  child  was  saved,  and  possibly,  thereby,  the 
woman's  life  also.  - 

In  1882  I  was  sent  for  to  see  a  Mrs.  M .     She  was 

the  mother  of  a  large  family  of  children,  and  was  then  in 
the  fourth  month  of  her  ninth  pregnancy.  The  uterus 
was  in  extreme  retroversion,  there  was  a  deep  transverse 
laceration  of  the  cervix,  and  the  perineum  gone.  I  re- 
stored the  uterus  to  position,  and  put  in  place  a  Thomas 
Cutter's  pessary,  which  made  traction  from  without  and 
held  the  organ  securely.  The  patient  showed  very  much 
improved  conditions,  was  comfortable,  and  in  every  re- 
spect progressing  well,  when  her  sister,  who  prays  and 
talks  in  meeting,  called  to  see  her,  and  insisted  that  the 
child  be  got  rid  of,  that  the  patient  should  not  be  allowed 
to  suffer,  saying  that  her  sister  had  already  more  children 
than  she  could  take  care  of.  Thus  this  sanctified  woman 
wanted  to  destroy  the  four  months'  old  child,  and  was 
urging  me,  the  physician  in  attendance,  to  do  the  deed. 
I  reminded  her  that  the  patient  was  doing  well,  that  she 
would  suffer  vastly  more  if  such  procedures  were  adopted, 
that  in  themselves  they  were  full  of  peril.  Yet  this  emi- 
nently pious  lady  still  insisted.  It  was  now  my  turn  to 
give  "a  Bible  Reading."  I  only  reminded  her  of  the 
sixth  commandment,  and  then  left,  with  the  authoritative 
command  that  the  patient  should  in  no  way  be  disturbed. 
Four  and  a  half  months  after,  I  attended  the  woman  in 
confinement.  She  was  delivered  of  a  fine,  healthy  boy, 
without  any  unpleasant  symptoms.  A  few  months  later, 
I  repaired  for  this  woman  the  lacerated  cervix  and  peri- 
neum.    She  did  well  in  every  respect. 

Mrs.  B .   The  patient  was  a  happy  wife  and  mother. 

I  had  attended  her  in  several  confinements ;  her  luxurious 
table  was  surrounded  by  many  "olive  vines."  She  re- 
moved to  a  neighboring  town ;  she  sent  for  me.  I  found 
the  patient  very  much  emaciated,  and  the  abdomen  enor- 
mously enlarged.  After  a  most  careful  examination  I 
pronounced  her  in  the  fifth  month  of  pregnancy,  with 
probable  dropsy  of  the  amniotic  coat.  She  was  grieved 
to  hear  of  the  pregnancy,  and  said :  "I  must  get  clear  of 
this ;  I  must."  I  showed  her  a  more  excellent  way.  She 
heeded  my  counsel,  and,  four  months  after,  I  attended  her 
in  confinement.  Amid  the  multiplicity  of  water  there 
was  the  little,  silken-haired  baby.  Subsequently  this 
woman  was  again  pregnant,  and  this  time  was  threatened 
with  a  miscarriage ;  she  sent  for  me ;  I  took  measures  to 
prevent  it.  She  said :  "  Let  it  pass,  let  it  pass,  I  have 
too  many  children."  The  child  was  saved.  He  is  now 
the  pride  of  the  family. 

Many  a  woman  who  asks  that  abortion  may  be  pro- 
duced would  be  very  far  from  it  if  they  understood  what 
it  signified,  or  had  an  idea  of  the  enormity  of  the  crime. 
A  kindly  hearted  woman  came  to  see  me  one  day,  she  was 
in  distress,  she  had  been  unfortunate.  "  The  time,"  said 
I,  "  for  you  to  have  thought  of  these  things  was  before  the 
first  wrong  step,  the  only  way  now  for  you  is  the  path  of 
rectitude. ' '  I  asked  her  if  she  would  deliberately  destroy 
a  human  being.  "Why,"  said  she,  "it  is  not  a  living 
being  until  it  moves. "  "It  moves  a  long  time  before  you 
perceive  the  motion,  and  it  is  a  living  being  from  the  first. ' ' 
She  seemed  almost  frightened  at  the  contemplated  act, 
and  left  saying  on  no  account  would  she  allow  anyone 
to  commit  the  deed. 

In  1888  or  1889  a  patient  came  to  consult  me  for  con- 
tinued ill  health  that  had  existed  since  early  menstrual 
life.  She  had  been  married  a  number  of  years  and  had 
no  children.     I  found  the  cervix  anteflexed,  uterus  re- 


July  7,  1894] 


MEDICAL    RECORD. 


13 


troverted,  and  the  ovaries  enlarged,  prolapsed,  and  con- 
gested. After  some  weeks'  treatment  her  improvement 
in  all  these  respects  was  marked.  The  pain  in  the  pelvis 
very  much  diminished,  the  ovaries  were  reduced  in  size, 
and  were  less  sensitive  and  sore.  A  few  days  before  she  was 
to  return  to  her  home  in  another  city,  to  make  drainage 
more  complete  for  the  uterus  and  the  adnexae,  I  again 
dilated  the  cervix,  remarking  to  the  patient  that  "there 
might  possibly  be  a  chance  of 'her  becoming  pregnant." 
At  the  expiration  of  some  months  the  patient  returned 
for  further  treatment.  I  found  she  was  pregnant,  I  in- 
formed her  of  the  same,  supposing  it  would  be  a  cause  of 
great  joy  and  congratulation.  On  the  contrary,  she  was 
grieved  and  depressed ;  and,  to  use  her  language,  asked 
if  "she  could  not  be  relieved. n  Even  her  husband 
called  and  ventured  to  introduce  the  subject.  I  told  him 
of  the  perils  of  such  procedures,  that  I  considered  his  wife 
extremely  and  unexpectedly  fortunate,  and  believed  it  was 
her  last  chance ;  that  certainly  she  ought  to  consider  it 
her's  and  her  husband's  greatest  happiness. 

The  wife  continued  to  take  sad  views  of  the  situation, 
and  after  their  return  home  she  wrote:  "Oh,  my  dear 
doctor,  if  it  only  had  not  happened.  I  cannot  be  com- 
forted with  your  idea  that  it  is  a  blessing.  Will  you  please 
tell  me  of  something  that  will  take  away  this  sickness  of 
the  stomach,  for  I  feel  that  I  would  rather  die  than  live 
like  this.9' 

Again  she  wrote :  "  When  I  came  home  the  first  time 
I  had  not  felt  so  well  and  happy  in  all  the  years  of  my 
married  life.  Everyone  remarked  how  well  I  looked — but 
oh,  this  trouble — oh,  dear  doctor,  please  help  me  out  of 
it — I  cannot  have  it  so,  and  if  you  will  not  I  will  do 
something.  I  cannot  let  it  go  on.  I  was  so  nervous  at 
night  that  I  felt  I  could  kill  myself.  Please  give  me 
something  or  do  something,  for  it  nearly  makes  me  wild. 
I  want  to  be  free,  that  I  may  get  well  and  take  my  com- 
fort/'    Poor  misguided  woman  1 

I  wrote  the  husband  at  length,  repeating  what  I  had 
said  in  a  previous  conversation.  A  later  letter  from  the 
wife  says :  "  I  have  given  up  all  hope  of  this  passing 
away,  for  it  must  be  three  months.  Oh  dear !  I  have  so 
longed  for  it,  I  know  that  I  shall  never  live  through  it, 
and  sometimes  when  I  think  of  it,  I  feel  like  killing  my- 
self— am  no  more  reconciled.  I  was  in  hopes  to  write  you 
I  was  all  right  once  more,  but  no  such  pleasure  is  mine. 
Good- by,  good  by,  with  love  and  thanks  for  making  me 
as  strong  and  well  as  I  am,  even  if  you  did  get  me  in 
more  trouble  than  I  was  before.1' 

I  warned  the  woman  again  and  again,  yet  she  found 
someone,  in  her  far-off  home,  who  would  undertake  it. 
"September  30,  1890.  My  dear  Doctor:  I  have  been 
very  sick.  I  was  taken  unwell,  and  it  terminated  in  a 
hemorrhage.  The  physician  used  cotton,  sponges,  etc. 
If  I  attempt  to  walk  across  the  room,  the  pains  come. 
What  I  so  longed  for  and  prayed  for  has  happened,  and 
now  I  do  regret  it,  for  it  was  a  little  boy,  and  I  suffered  as 
much  as  if  I  had  gone  through  it  all,  and  nothing  to  show 
for  it.  It  is  five  weeks,  to  a  day,  since  I  was  taken  sick, 
and  here  I  am,  not  out  of  my  room,  and  have  my  nurse 
with  me  yet,  and  am  now  beginning  to  think  I  shall  al- 
ways have  to  keep  her.  I  am  again  flowing,  and  the  last 
two  days  it  has  been  very  bad.  The  doctor  left  me  some 
medicine.  I  am  so  discouraged  that  I  cry  most  of  the 
time.  I  am  so  sore  that  I  can  hardly  move,  and  have 
such  a  heavy  feeling.  Write  me  as  soon  as  you  can  spare 
a  few  minutes,  and  tell  me  how  I  can  get  well,  instead  of 
being  so  sick  and  miserable.'1 

This  poor  young  woman  never  will  be  as  well  as  she 
otherwise  would  have  been.  If  she  had  let  the  pregnancy 
continue,  she  would  have  had  a  normal  parturition,  and 
been  better  physically  and  mentally  than  she  had  been  in 
years ;  and  I  believe  her  hysterical  nervousness,  from  the 
congestion  of  the  ovaries,  would  have  gradually  disap- 
peared. She  is  now  a  sick  woman,  and  it  will  no  doubt 
take  a  long  time  to  repair  the  injury  she  has  done  her- 
self;  and  how  can  she  ever  rest  under  the  thought  of 
having  destroyed  her  own  child,  probably  the  last  that 


will  ever  come  and  ask  for  her  loving  embrace.  This 
poor  woman  could  not  comprehend  die  enormity  and 
danger  of  her  work. 

Some  know  well  all  they  do,  the  full  significance  of 
their  crime,  and  their  doubly  stained  souls  are  filled  with 
deception.  April  20,  1890,  a  woman  called  to  see  me, 
with  a  man  whom  she  said  was  her  husband,  requesting 
to  consult  me  in  my  private  office.  She  gave  her  name, 
and  said,  "  she  had  been  married  twelve  years,  had  one 
child  ten  years  old,  and  was  now  two  months  pregnant, 
and  wanted  to  be  relieved."  I  examined  her  case,  I  told 
her  she  was  not  pregnant,  and  did  not  believe  she  could 
have  a  child  in  her  present  condition.  She  repeatedly 
said,  "  Pass  the  sound,  pass  the  sound."  Under  her  sup- 
posed condition  this  seemed  so  brutal  I  thought  that  a 
woman  who  could  so  speak  was  "  fit  for  treason,  strata- 
gems and  crimes,"  and  conspiracies  /  I  dismissed  her 
from  the  office,  and  in  a  few  minutes  went  into  the  parlor 
to  speak  to  the  "supposed  husband. "  Both  had  disap- 
peared !  I  sent  a  letter  to  the  fictitious  name,  and  to  the 
probably  fictitious  address,  emphasizing  all  I  had  said,  and 
adding  that  the  apparently  innocent  expression,  "  Pass 
the  sound,"  might  be  fraught  with  tremendous  evil ;  and, 
to  my  mind,  in  her  si  pposed  condition,  was  cruel  acd 
wicked. 

One  Saturday  morning,  in  September,  1890,  my  door- 
bell rang ;  I  was  called  to  the  office ;  there  stood  a  young 
married  woman.  She  related  her  clumsy  story.  Without 
ceremony  I  should  have  dismissed  her,  but  wanted  to 
give  her  a  word  of  warning,  and  show  her  the  exceeding 
sinfulness  of  her  proposed  course.  I  called  a  friend  from 
the  parlor,  a  lady  of  rare  intelligence,  who  kindly  added 
to  and  emphasized  all  that  I  had  said.  This  young,  ig- 
norant, coarse  woman,  recovering  herself,  said,  "  It  is  a 
commercial  transaction,  you  give  me  the  medicine,  I 
give  you  the  money."  She  imagined  it  a  fine  argument. 
There  she  stood  with  her  paltry  dollar,  her  husband  prob- 
ably making  $7  or  $9  per  week.  Ten  million  times  the 
wealth  of  Europe  and  Asia  would  have  been  a  trifle  far 
too  small.  Turning  again  to  the  woman  I  said,  "  Abso- 
lutely, if  a  grain  of  medicine  would  enable  you  to  carry 
out  your  vile  purpose,  I  would  not,  for  unnumbered  mill- 
ions, give  it  to  you." 

One  Sabbath  day,  in  September,  a  girl,  some  twenty 
years  of  age  or  over,  called  to  see  me.  A  few  touches 
painted  the  tragic  story.  She  said  she  wanted  her  courses 
brought  on.  "Do  you  know  what  that  means?"  said 
I.  "  It  is  one  way  of  destroying  your  child,  now  two 
months  old.  You  are  sorry  for  what  you  have  done,  and 
want  to  hide  it ;  you  cannot  The  only  right  way  is  to 
have  the  child,  whether  you  marry  the  man  or  not." 
She  left,  promising  that  she  would  go  to  no  one  for  the 
wicked  purpose. 

A  school-girl  came  in  the  summer  of  1887.  She  was 
pregnant,  and  in  distress.  She  said  that  she  was  able  to 
pay  for  it,  and  would  go  where  she  could  have  it  done. 
I  said,  "To  you  it  will  be  especially  dangerous,  you  have 
been  diseased  since  early  menstrual  life."  She  said, 
"There  were  doctors  that  would  do  it  for  money." 
"  Don't  let  anyone  do  it.  Your  only  right  way  is  to  go 
through  with  it.  You  do  not  know  what  may  be  the 
consequences  of  another  course."  I  wrote  the  same  and 
more  in  a  letter  to  her  mother,~requesting  the  daughter 
to  deliver  it.     I  knew  nothing  more. 

One  day  a  beautiful  young  girl,  aged  sixteen,  reared  in 
the  lap  of  luxury  and  wealth,  came  in  a  coupe"  with  her 
affianced  and  false  lover.  She  had  in  her  hands  a  large 
roll  of  bills,  which  she  held  prodigally  and  wanted  to 
give  lavishly.  I  felt  her  very  presence  was  contamina- 
tion. Said  I,  "  You  are  an  only  daughter,  your  mother 
knows  nothing  of  this,  your  father  does  not  know  where 
you  are."  They  had  given  her  every  luxury,  but  had 
not  given  her  the  most  valuable  of  all — parental  control, 
instruction,  and  discipline. 

I  hold  that  children  should  be  educated  in  the  right 
way  and  taught  to  do  right.  If  they  have  coarse  natures 
which  pi  event  them  from  going  in  the  right  path,  they 


14 


MEDICAL  RECORD. 


[July  7,  1894 


should  be  made  to  do  right.  Eli's  only  sin  was  that  he 
did  not  make  his  sons  do  right.  In  unmistakable  terms 
I  gave  the  girl  words  of  warning.  Her  beautiful  face 
listened  kindly  to  all  I  said.  She  went  I  know  not 
whither. 

How  many  are  taken  from  the  home  of  innocence  and 
purity,  scarce  conscious  of  what  they  are  doing ;  they  do 
not  realize  the  heinousness  and  great  wickedness  of  this 
one  false  easy  step.  After !  Oh,  heavens !  The  pall  of 
darkness  comes  upon  them,  they  go  deeper  and  deeper. 

One  young  man  sent  the  following  letter  to  Dr.  Charles 
N  D.  Jones,  when  he  was  House  Surgeon  in  the  Brook- 
lyn City  Hospital : 

"  I  am  in  a  little  trouble,  and  I  want  you  to  help  me 
out,  if  you  can.  A  young  lady  friend  of  mine  I  am  afraid 
is  in  the  family  way.  Now,  I  will  not  keep  it  from  you, 
I  think  I  am  to  blame.  It  has  only  been  a  week,  so  you 
can  fix  her  easily,  I  think.  I  wrote  her  to  come  to  you, 
but  if  she  does  not,  will  you  please  call  and  see  her?  She 
lives  (he  here  gives  the  number  and  street).  You  send 
the  bill  to  me,  and  I  will  fix  it.  She  has  not  had  her 
usual  monthly  sickness,  and  I  am  frightened.  As  soon 
as  you  get  this,  please  call  and  see  her.  Her  name  is 
(he  here  gives  the  name  in  full).  Now,  please  try  and 
get  me  out  of  this  trouble,  and  I  will  be  everlastingly  in- 
debted to  you.  It  is  not  convenient  for  me  to  come  up 
to  the  city,  else  I  would  go  up  and  bring  her  to  you. 
Hoping  that  you  will  be  able  to  fix  her  all  right,  and 
trusting  that  you  will,  of  course,  keep  quiet.  Get  me 
out  of  this  trouble.     I  remain,  etc." 

The  reply : 

"Cut  Hospital,  Brooklyn,  July  31,  1884, 

"  Mr. :  Yours  of  the  29th  received.     Your  friend 

was  here  to  see  me  the  day  before  I  received  your  letter. 
I  must  answer  you  as  I  did  her.  I  would  not  think  of 
doing  the  least  thing  to  bring  on  her  courses,  and  no 
man  in  his  right  mind  would  presume  to  ask  me  to  do 
such  a  thing.  I  most  positively  decline  to  aid  in  any 
such  work.  Yours,  etc., 

"C.  N.  D.  Jones/  ' 

This  trusting  young  girl  was  sent  to  the  office  of  a 
young  doctor  in  a  public  institution,  saying :  "  Send  me 
the  bill,  and  I  will  fix  it"  But  how  will  he,  the  lover, 
ever  fm  it  with  the  young  girl.  That  girl's  mother 
trusted  him ! 

The  way  back  condition,  as  I  have  before  intimated, 
is  that  m 3 thers  should  instruct  their  daughters,  teach 
them  first  parental  obedience,  and  then  all  that  relates 
to  their  high  moral  duties  and  obligations,  unfold  to 
them  the  great  principles  of  life,  of  their  physical  being, 
their  organization,  and  then  tell  and  explain  to  them  the 
beautiful  laws  of  health.  This  is  necessary  for  every  day 
welfare.  Why  should  not  young  ladies  study  these  sub- 
jects as  well  as  rocks  and  stones,  stars  and  flowers? 
Does  she  hesitate  to  examine  a  flower,  acknowledge  it  a 
thing  of  beauty  and  joy  forever?  Just  as  pure  is  it  to 
examine  this  greatest  of  nature's  work.  Girls  are  igno- 
rant and  uneducated,  and  thousands  are  led  into  evil  and 
everyday  violations  of  the  most  ordinary  laws  of  health 
as  well  as  of  morality,  for  want  of  knowledge,  or  because 
they  have  not  been  properly  trained  and  instructed. 

In  1887,  a  young  girl,  scarce  eighteen  years  of  age, 
called  to  see  me ;  she  wanted  to  know  if  she  was  preg- 
nant. I  found  her  in  the  second  month.  She  told  me 
the  sad  story,  and  said  with  burning  tears,  "  It  must  be 
taken  away. ' '  I  could  not  say  to  her,  "  Marry  the  man ! ' ' 
The  one  who  had  so  treated  this  young  girl  had  sacred 
and  legal  obligations  to  another.  I  could  only  say  to 
this  child,  "Go  and  tell  your  mother,  she  is  your  best 
friend ;  but  destroy  the  child,  you  must  not."  If  one  for 
his  wife's  honor  may  shoot  down  the  betrayer,  how  in- 
finitely much  more  does  he  deserve  such  a  fate,  who  leads 
astray  and  blasts  irretrievably  the  young  girl. 

A  sad,  broken-hearted  woman,  lifting  her  beautiful  face 
to  heaven,  vowed  that  she  would  destroy  the  wretch,  the 
author  of  her  misery,  nor  would  she  nourish  or  give  life 
to  the  product  of  his  being.     He  made  her  promises  of 


marriage,  but  left  her  overwhelmed  with  anguish.  Why 
will  women  trust  and  sacrifice  so  much  ? 

Another  young  woman,  of  more  than  ordinary  intelli- 
gence, was  in  despair  and  broken  hearted.  Her  child 
was  born  in  a  public  institution.  As  the  mother  looked 
upon  it  as  from  him  who  had  blighted  her  hopes,  she 
vowed  that  she  would  destroy  it.  It  was  necessary  to 
watch  her  night  and  day;  for,  continually  and  constantly 
she  threatened  the  child's  destruction. 

One,  in  her  shame  and  desperation,  drowned  her  own 
little  helpless  one.  Ever  she  saw  the  little  outstretched 
hands  of  her  own  babe  pleading  for  help.  The  picture 
never  could  be  effaced.  She  became  wild,  her  reason 
dethroned,  but  where  was  her  betrayer?  She  was 
wrecked,  but  no  one  suspected  him  of  wrong  doing. 

"  One  more  unfortunate."  The  young  and  beautiful 
daughter  of  a  goodly  man  trusted  a  young  student  He 
went  to  honor  and  emolument,  she  to  insanity  and  death. 

Thousands  perish  thus  in  misery  and  desolation. 
Women  are  always  the  greatest  sufferers.  Nathaniel 
Hawthorne  relates  a  touching  story  of  human  frailty. 
The  young  and  beautiful  Hester  Prynne  stood  on  the  pil- 
lory of  public  shame ;  a  select  number  of  wise  and  virtu- 
ous persons,  all  with  grim  rigidity  and  cold  severity,  were 
on  a  high  platform,  to  deal  with  this  poor  girl,  touching 
the  vileness  and  blackness  of  her  sin.  There  she  stood, 
under  the  weight  of  a  thousand  unrelenting  eyes  on  this, 
to  her,  a  scaffold  of  execution.  One  of  the  said  righte- 
ous judges  to  condemn  the  young  woman,  was  the  father 
of  her  child  ! 

A  similar  touching  incident  is  related  in  an  ancient 
volume ;  and,  probably,  from  it,  Hawthorne  gets  the  gem 
thought  of  his  classical  story.  Judah,  a  great  man,  high 
in  office  and  high  position,  heard  that  his  daughter-in- 
law  had  played  the  harlot.  His  righteous  soul  was  filled 
with  holy  horror.  "Bring  her  forth,  and  let  her  be 
burned."  The  young  woman  stood  before  the  assembled 
multitude.  "  Discern,  I  pray  thee,  whose  are  these,  the 
signet,  and  bracelets,  and  staff."  Judah  acknowledged 
they  were  his.  Months  before  he  had  met  this  young 
woman  behind  the  rocks,  and  this  pledge  he  had  given 
to  her  S 

A  story  is  told  of  another  judge.  Again,  a  lonely  and 
desolate  woman  stands  before  an  incensed  multitude. 
"  Master,"  said  they,  "she  was  taken  in  the  very  act." 
The  judge,  with  words  of  infinite  wisdom,  said  unto 
them,  "  He  that  is  without  sin  among  you,  let  him  first 
cast  a  stone  at  her."  "  And  they  that  heard  it  went  out 
one  by  one,  and  the  judge  was  left  alone,  and  the  woman 
standing  in  the  midst."  Not  one  of  all  that  vast  multi- 
tude could  cast  a  stone ! 

There  is  another  chapter  of  this  medico-moral  legal 
subject  that  cannot  be  omitted.  Very  lately  a  gentle- 
man, of  high  respectability  and  intelligence,  called,  in- 
forming me  that  his  wife  was  pregnant ;  but  that  neither 
he  nor  she  thought  it  right  to  have  this  child,  adding, 
"  that  any  doctor  who  wanted  a  good  practice  should 
take  care  of  his  families ;  that  this  was  the  physician's 
duty,  and  it  was  done  by  the  best."  I  replied,  "It 
can  be  the  duty  of  no  one ;  and  no  promise  of  practice 
would  be  of  the  least  consideration."  The  gentleman 
unwittingly  mentioned  the  name  of  the  physician  whom 
his  wife  was  then  consulting,  and  stated  that  this  phy- 
sician "had  already  put  something  in  the  womb  that 
had  made  her  flow,"  at  the  same  time  assuring  him,  her 
husband,  that  "ail  would  be  right"  This  gentleman 
also  remarked  that  "  he  had  sent  this  physician  fifty  such 
cases,"  then  quoted  the  words  of  a  medical  man  who  had 
said :  "  Abortion  was  not  legal,  but  it  was  right" 

A  few  months  after,  it  happened  that  I  again  saw  this 
young  man,  and  remarked  to  him,  "  So  your  wife  lost 
her  child.  Do  you  know  how  the  doctor  did  it  ?  "  Be- 
fore thinking,  he  quickly  replied,  "  Ye?,  I  do,  I  know  ex- 
actly how  he  did  it."  Alas,  alas !  it  was  done,  and  by  a 
physician,  and  he  a  member  of  a  County  Medical  So- 
ciety ! 

An  article,  in  the  New  York  Gynecological  Journal 


July  7,  1894] 


MEDICAL   RECORD. 


15 


says : l  "  The  specialist  in  abortion  exists.  He  is  no 
ideal,  but  an  actuality,  a  real  living  man,  as  a  professor, 
ably  rilling  a  chair  in  college,  he  is  perhaps  well  known. 
As  a  specialist  in  abortion,  he  is  recognized  only  by  a 
favored  few." 

An  editorial,  in  the  same  number  of  the  journal  quoted 
above,  says:  "Practices,  not  infrequently  carried  out 
nefariously,  by  reputable  physicians.  Some  hypocriti- 
cally practise  it  in  secret,  while  repudiating  it  in  public.'1 
This  editorial  further  makes  the  startling  announcement : 
' '  It  can  be  no  secret  to  those  of  us  who  have  been  even  a  few 
years  in  active  practice,  that  foeticide,  in  the  early  months 
of  gestation,  is  constantly  performed  with  the  flimsiest 
excuses,  by  prominent  reputable  men  and  women  too,  in 
every  community,"  adding:  "This  has  long  been  a 
plague  spot  in  the  profession.11 

-#  I  cannot  agree  with  the  words  of  the  editor,  or  of  his 
correspondent.  I  absolutely  deny  the  assertions,  though, 
four  times  lately,  I  have  heard  physicians  say,  "  All  do 
it;  "  and  a  member,  at  the  annual  meeting  of  the  Ten- 
nessee State  Medical  Society,  asserted,1  "  I  fear  that  the 
profession  frequently  takes  a  hand  in  the  nefarious  busi- 
ness." This  also  is  untrue.  It  is  not  the  profession. 
It  is  a  few  unworthy  ones  in  it.  In  no  profession  are 
there  men  of  more  exalted  morality,  nobler  aims,  and 
purer  integrity  than  in  the  medical  profession.  They  do 
what  is  right.  With  large-hearted  benevolence,  they  aim 
at  doing  the  best  for  all. 

In  1883, 1  stood  in  the  parlor  of  a  prominent  member  of 
the  County  Medical  Society  above  referred  to;  the  mem- 
ber pointed  from  his  window  diagonally  opposite  to  the 
residence  of  another  prominent  member  of  the  same  so- 
ciety and  said,  "  That  man  will  do  it  any  time  for  $50." 
I  did  not  believe  it  then,  nor  do  I  now.  (But  how  these 
brethren  love  !)  It  is  sadder  to  know  that  one  member 
of  this  same  County  Medical  Society,  and  one  who  held  a 
position  in  the  Health  Department,  was  sentenced  for 
this  offence ;  and,  as  I  am  informed,  others  in  the  same 
society  have  been  under  suspicion. 

The  writer  of  the  article  in  the  New  York  Gyneco- 
logical Journal \  further  says :  "  We  opine  that  the  world 
would  be  better  if  abortion  were  done  oftener." 

What  doctrine  is  this  to  teach  in  a  medical  journal ! 
Certainly,  the  profession  does  not  stand  by  such  teach- 
ing. Good  men,  everywhere,  raise  their  voice  against 
the  evil.1  As  far  back  as  1857,  at  the  annual  meeting  of 
the  American  Medical  Association,  a  committee4  was  ap- 
pointed to  investigate  the  subject,  with  a  view,  if  possi- 
ble, to  the  suppression  of  the  growing  evil ;  which  com- 
mittee, at  the  annual  meeting,  185 9/  made  a  report,  say- 
ing :  "  As  a  profession,  we  are  unanimous  in  our  con- 
demnation of  the  crime ;  and,  as  a  committee,  would  ad- 
vise this  body,  representing,  as  it  does,  the  physicians  of 
the  land,  publicly  to  express  its  abhorrence  of  the  unnat- 
ural and  now  rapidly  increasing  crime  of  abortion — the 
wanton  and  murderous  destruction  of  the  child."  The 
Association  then  unanimously  passed  the  following  reso- 
lution :  Resolved,  "  In  view  of  the  prevalence  and  in- 
creasing frequency  of  the  crime,  publicly  to  enter  an 
earnest  and  solemn  protest  against  such  unwarrantable 
destruction  of  life. ' ' 

But  farther  back  than  this,  Hippocrates,  the  father  of 
medicine,  in  the  Hippocratic  oath,  pledged  each  of  his 
pupils — and  to  which  every  physician  must  swear — never 
to  be  guilty  of  unnecessarily  inducing  miscarriage. 

1  Special  Operation  for  Abortion,  C.  H.  Harris,  Ga.,  p.  84a,  Sep- 
tember, 1892. 

■  Transactions,  fifty-fourth  annual  meeting,  State  of  Tennessee  Med- 
ical Society,  p.  176. 

f8*  I  am  glad  to  record  also  that  this  young  and  vigorous  journal  con- 
demns it ;  it  says  r  "  We  heartily  reprobate  the  article  by  Dr.  Harris, 
not  merely  because  we  are  opposed  on  principle  to  the  practice 
which  he  advocates,  but  equally  because  his'  advocacy  of  them  is  il- 
logical, and  founded  upon  arguments  of  expediency  which  appeal  to 
self-interest  of  the  lower  and  more  dangerous  kind  "  (p.  846). 

*  This  committee  consisted  of  Dr.  H.  K.  Storer,  of  Massachusetts  ; 
L  W.  Blatchfbrd,  of  New  York ;  H.  I.  Hodge,  of  Pennsylvania :  Bar- 
ton, of  South  Carolina ;  G.  A.  Pope,  of  Missouri ;  A.  Lopez,  of  Ala- 
bama ;  W.  A.  Brisbane,  of  Wisconsin ;  A.  J.  Semraes,  of  District  of 
Columbia. 

*  Transactions  American  Medical  Association,  vol.  xii.  ,'1859,  p.  75. 


In  May,  1871,  soon  after  the  startling  disclosures  in 
connection  with  the  professional  abortionists,  Wolff  and 
Lookup,  the  New  York  Academy  of  Medicine  passed  a 
resolution  in  reference  to  the  "wide-spread  crime." 
Again,  September  21st  of  the  same  year,  the  Academy 
adopted  a  set  of  resolutions,  pledging,  "All  its  influ- 
ence, its  efforts  in  support  of  any  legislative  or  other 
measures,  which  our  law  officers  may  propose,  as  offer- 
ing a  reasonable  provision  of  mitigating,  if  not  removing, 
the  perpetration  of  criminal  abortion,  which  is  upon  our 
country/1  The  Medical  Society  of  Berks  County,  Pa., 
passed  similar  resolutions.  The  New  York  Medico- 
Legal  Society  appointed  a  committee 1  whose  report  was 
made  and  unanimously  adopted,  at  the  Society  meet- 
ing held  on  December  14,  1871,  at  the  College  of  Phy- 
sicians and  Surgeons,  of  which  the  following  is  an  ex- 
tract :  "As  the  proper  name  for  the  intentional  destruc- 
tion of  the  foetus  is  murder,  it  is  hoped  that  the  time 
will  arrive  for  its  punishment  as  such." 

At  the  meeting  of  the  Crawford  Medical  Society,1  on 
July  5th,  the  following  resolution  was  passed  :  "  Whereas, 
the  practice  of  criminal  abortion  is  steadily  increasing, 
and  in  numerous  cases  which  prove  fatal — be  it  re- 
solved that  we  petition  the  Legislature  of  this  State,  at  the 
coming  session,  to  enact  a  law  by  which  the  dying  dec- 
larations of  a  person,  who  may  die  from  the  effects  of  a 
criminal  abortion,  shall  be  received  as  evidence  in  trial 
of  anyone  indicted  for  such  offence."  Copies  were  sent 
to  various  medical  societies  for  consideration. 

The  Journal  of  the  American  Medical  Association, 
Chicago,1  calls  it  the  highest  crime — from  some  stand- 
points, at  least — of  which  humanity  is  capable,  and  whose 
prevalence  exceeds  the  highest  estimates."  He  says,  in 
another  number : 4  "  The  obligation  rests  upon  the 
medical  profession  to  propose  a  method  for  checking  the 
fearful  progress  of  this  evil." 

The  Boston  Medical  and  Surgical  Journal : 6  "A  crime 
in  itself  one  of  the  foulest,  and  against  which,  in  times 
past,  the  severest  penalties  have  been  attached,  and  which 
three  hundred  years  ago  subjected  those  convicted  of  its 
committal  to  all  the  penalties  inflicted  on  murderers." 
It  adds :  "  With  regard  to  the  proposed  remedies  for  this 
evil,  we  confess  we  have  little  confidence  in  mere  legis- 
lative enactments.  It  is  rather  to  the  medical  profession, 
and  those  more  immediately  connected  with  the  morals 
of  the  community,  that  we  are  chiefly  to  look  for  the 
true  remedy.  The  physician  may  do  much  by  warning 
his  patients  against  the  dangers  and  guilt  of  this  awful 
crime,  involving,  as  it  does,  the  guilt  of  murder  and  a 
cold  indifference  to  the  most  sacred  privileges  with  which 
woman  is  endowed." 

An  editorial  in  the  Medical  News  *  says  :  "  The  News 
has  contended  that  it  is  the  duty  of  medical  men  to  in- 
struct the  lay  world,  through  the  lay  journal,  concerning 
hygiene  and  medical  truth." 

The  report  of  the  committee  of  the  American  Medical 
Association  *  further  said  :  "  If  to  want  of  knowledge,  on 
a  medical  point,  the  slaughter  of  countless  children,  now 
steadily  perpetrated  in  our  midst,  is  to  be  attributed,  it 
is  our  duty,  as  physicians  and  as  good  and  true  men, 
both  publicly  and  privately,  and  by  every  means  in  our 
power,  to  enlighten  this  ignorance." 

The  Australian  Medical  Journal  said  :  "  We  need  a 
medical  bill  for  the  colony.  Within  a  week  four  women 
in  the  prime  of  life  have  been  sacrificed." 

The  late  Professor  Hodge,  of  Philadelphia,  in  his  in- 
troductory lecture,  quotes  the  ruling  of  Judge  King,  of 
Philadelphia :  "  Every  act  of  procuring  abortion  is  mur- 
der, whether  the  person  perpetrating  such  act  intended 
to  kill  the  woman  or  merely  feloniously  to  destroy  the 

1  This  committee  consisted  of  James  J.  O'Dea,  M.D.,  Elbridge  T. 
Gerry,  M.D.,  George  F.  Shrady.  M.D.,  William  Shrady,  M.D., 
Stephen  Rogers,  M.D. ,  and  Gunning  S.  Bedford. 

8  British  Medical  Journal,  September  24,  1892,  p.  675. 

» 1885.  p.  42 

«  Foeticide  and  its  Prevention,  H.  C.  Markham,  xi.,  p.  805,  1888. 

•  February  16,  i860,  p  65. 

•  September  2,  1893,  p  271 

•  Transactions  of  the  American  Medical  Association. 


i6 


MEDICAL  RECORD. 


[July  7,  1894 


fruit  of  the  womb."  Dr.  Hoag^ays:  "All  believe 
the  practice  to  be  sinful  as  well  as  criminal."  H.  R. 
Storer  says,  in  his  essay :  "  The  offence  is  one  of  the 
deepest  guilt,  a  crime  second  to  none."  J.  B.  W.  New- 
lin"  says:  "To  correct  the  evil,  recommends  that  the 
profession  should  teach  the  public  the  facts  of  embryol- 
ogy, in  so  far  as  they  relate  to  the  enormity  of  this 
crime;  that  they  should  thoroughly  instruct  our  law- 
makers, so  that  laws  may  be  formulated  which  will  let 
no  guilty  one  escape." 

The  writer  in  the  New  York  Gynecological  Journal 
above  quoted,  further  remarks :  "  Poor  women  are  to 
suffer  and  to  sacrifice  everything  at  the  shrine  of  mater- 
nity, as  if  it  were  for  this  alone  they  were  made."  I  re- 
ply, maternity  is  woman's  highest  mission,  and  should 
be  her  greatest  pride.  While  a  woman  may  possibly  ac- 
complish, in  other  directions,  all  that  is  high,  noble,  and 
good,  yet  everything  should  bow  to  maternity.  This  is 
the  shrine  to  which  she  brings  her  noblest  offerings.  Is 
she  educated,  has  she  physical  health,  and  physical  per- 
fection ?  Are  her  mind,  heart,  and  soul  cultured  and 
highly  endowed  ?  It  is  that  she  may  give  birth  to  more 
perfect  and  more  beautiful  children.  This  is  the  end, 
and  should  be  her  highest  aim.  This  also  should  be  the 
object  of  a  mother's  earliest  solicitude  and  training  for 
her  daughter.  To  the  shrine  of  maternity  all  should  be 
dedicated.  As  I  said  in  an  article : a  "  She  is  a  mag- 
nificent woman  who  can  give  birth  to  a  large  family  of 
children  and  still  retain  her  health." 

The  writer  in  the  New  York  Gynecological  Journal 'con- 
tinues :  "  What  sense  is  there  in  allowing  a  woman  with 
diabetes,  albuminuria,  and  the  grave  forms  of  disease,  to 
run  the  gauntlet  of  pregnancy  and  labor  ?  At  once  empty 
the  uterus."  This,  when  life  is  endangered,  may  be  ju- 
dicious; but,  in  general,  if  one's  individual  judgment 
may  decide  whether  it  is  best  for  a  child  in  utero  to 
live,  may  not  the  same  individual  judgment  decide 
whether  it  is  expedient  for  a  boy  or  girl  of  five  or  ten 
years  of  age  to  live.  If,  in  one's  judgment,  a  human  be- 
ing in  utero  may  be  destroyed,  with  equal  right  may  we 
not  destroy  a  human  being  at  any  age  of  existence? 
May  we  not,  at  any  time,  decide  whether  anyone's  life  is 
useful  or  to  the  advantage  of  him  or  herself  and  to  the 
community?  Is  not  this  a  most  dangerous  doctrine? 
Could  a  more  cruel  despotism  exist  ?  A  physician  has 
no  more  right  to  destroy  a  human  foetus,  because  he  im- 
agines it,  in  future  years,  may  be  sickly,  than  he  has  a 
right  to  destroy  the  delicate  baby,  because  it  possibly 
may  have  before  it  years  of  invalidism. 

The  writer  of  the  same  article  next  gives  explicit  di- 
rections as  to  how  abortion  shall  be  produced.  He 
says  :  "  .  .  .  ,"  etc.  He  continues  :  "  Snare  N9.  1 
is  passed  into  the  uterus ;  sweep  the  staff  around  the 
globe  of  the  ovum.  Pull  gently  with  forceps,  until  the 
mass  is  either  extracted  entire  or  cut  in  twain.  In  the 
latter  event,  repeat  the  procedure  until  it  "  (the  baby !) 
"  is  chopped  into  fragments  of  easy  extraction  !  "  Hail 
horrors  !  lay  on,  Macduff.  One  almost  shivers  in  reading 
these  descriptions,  and  for  this  horrible  work  the  writer 
holds  out  the  inducement  of  "  handsome  returns  and  fat 
fees  for  special  services." 

I  maintain  that  all  this  work  is  murderous,  unprofes- 
sional, and  degrading  to  the  high  office  of  a  physician. 
A  physician  stands  as  a  preserver  of  life,  and  should  be 
the  embodiment  of  honor  and  high  morality. 

November,  1893. 

The  Consumption  of  Absinthe. — According  to  some 
statistics  recently  issued  by  the  French  Government,  the 
consumption  of  absinthe  in  France  has  risen  from  57,000 
hectolitres  (1,254,570  gallons)  in  1885,  to  126,000  hecto- 
litres (2,773,260  gallons)  in  1892.  The  increase  in  the 
consumption  of  other  alcoholic  beverages  during  this 
period  has  been  nearly  in  the  same  proportion. 

1  Medico-Legal  Journal,  New  York,  1800-1891,  viii.,  p.  118. 
1  Fifty-fourth  annual  meeting  of  the  Tennessee  State  Medical  So- 
ciety. 
1  Mbdical  Record,  September  9,  1892,  Sterility  in  Woman. 


gr00t*8a  of  piedical  Jfcfcetice. 

Acute  Vertebral  Osteomyelitis. — Dr.  Morian  relates 
two  cases  of  this  rare  disease.  An  important  complies 
tion  consists  in  the  spread  of  the  inflammation  and  suppura- 
tion into  the  spinal  canal.  From  the  front  the  pus  could  not 
so  easily  penetrate  into  the  canal  owing  to  the  ligament, 
but  behind  there  is  a  space  between  the  dura  and  the 
arches  filled  with  a  loose  and  vascular  tissue  to  which  the 
suppuration  has  ready  access.  The  membranes  and  the 
cord  itself  may  also  become  involved.  In  one  case  pus 
escaped  from  the  situation  named  above  when  the  spinous 
process  and  arch  were  removed,  and  in  the  second  case 
die  abscess  extended  from  the  third  cervical  to  the  twelfth 
dorsal,  and  from  here  again  down  to  the  third  lumbar 
vertebra.  The  pleura  or  peritoneum  may  also  become 
involved.  The  suppuration  is  more  likely  to  remain  lo- 
calized behind  the  peritoneum  than  behind  the  pleura. 
Osteomyelitis  of  the  spongy  bones  is  likely,  according  to 
the  author's  experience,  to  run  a  more  unfavorable  course 
than  when  the  long  bones  are  affected.  As  to  the  symp- 
toms, the  onset  was  rapid,  with  fever  and  pain  in  the 
part  of  the  vertebral  column  involved.  The  column  was 
held  rigid.  At  first  the  second  case  resembled  epidemic 
cerebro  spinal  meningitis ;  the  head  was  drawn  back,  the 
neck  and  back  muscles  rigid,  and  the  pupils  unequal. 
Later,  however,  the  pain  became  more  localized,  and  a 
swelling  appeared.  In  the  acutest  cases  death  may  occur 
before  the  site  of  the  disease  can  be  localized.  Preverte- 
bral suppuration  may  cause  diagnostic  difficulties.  Acute 
rheumatism  very  rarely  affects  the  vertebral  column,  and 
then  other  of  its  manifestations  are  present.  Acute  pneu- 
monia or  lumbago  might  be  confounded  with  it.  The 
prognosis  depends  on  the  severity  of  the  toxic  symptoms. 
It  is  more  serious  if  die  dorsal  vertebrae  are  involved,  ow- 
ing to  danger  of  spread  to  the  pleura.  The  abscess  should 
be  opened  as  soon  as  possible,  and  the  focus  of  disease,  if 
it  can  be  got  at,  scraped  away,  or  better  still,  as  in  the 
case  of  the  arches,  removed.  The  first  case  occurred  in 
a  boy,  aged  ten.  He  had  pain  in  the  loins,  headache, 
and  fever.  He  kept  his  back  rigid.  Some  ten  days  or 
so  later  a  swelling  was  found  along  each  side  of  the  lum- 
bar spinous  processes.  This  was  incised,  and  the  spinous 
process  of  the  fourth  lumbar  vertebra  and  apart  of  the 
arch  on  either  side  were  removed,  pus  escaping  from  out- 
side the  dura.  A  swelling  over  the  foot  had  also  to  be 
incised,  and  subsequently  another  one  over  the  humerus. 
The  boy  eventually  made  a  good  recovery.  In  the  sec- 
ond case  of  a  lad,  aged  seventeen,  a  swelling  appeared  in 
the  region  of  the  eleventh  and  twelfth  vertebras  about 
seventeen  days  after  the  onset.  This  was  incised,  and 
the  vertebra  found  bare.  There  was  some  improvement, 
but  the  pleurae  became  involved,  and  the  patient  died. 
The  body  of  the  vertebra  showed  foci  of  pus.  A  com- 
munication was  traced  between  the  pleural  cavities  and 
the  disease.  The  outer  surface  of  the  dura  was  altered. 
Small  abscesses,  were  present  in  the  kidneys.  *The  staphy- 
lococcus was  cultivated  from  each  case. — The  British 
Medical  Journal,       

Four  Children  at  one  Birth,  two  boys  and  two  girls, 
all  healthy  and  well  developed,  is  the  record  of  a  proud 
and  happy  mother  in  Tennessee. 

Mrs.  Kadumbini  Ganguli  was  the  first  native  female 
graduate  of  the  Calcutta  University.  She  passed  the 
L  M.  S.  examination  of  the  Calcutta  Medical  College 
with  credit  seven  years  ago,  and  last  year  became  a  licen- 
tiate in  Medicine  and  Surgery  in  England. 

Konnandy  Cattle. — The  American  Veterinary  Review 
recommends  the  introduction  of  Normandy  cattle  (Coten- 
tine  the  breed  is  called  in  Europe)  to  take  the  place  of 
the  Jerseys  which  are  so  prone  to  tuberculosis.  The  edi- 
tor says  that  in  addition  to  the  fact  that  the  breed  is 
claimed  to  be  the  finest  milking  race  in  the  world,  it  is 
free  from  pleuro-  pneumonia  and  tuberculosis. 


July  7,  1894] 


MEDICAL   RECORD. 


17 


Medical   Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


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


New  York,  July  7,  1894. 


CAUSES  OF  DISEASES  PECULIAR  TO  WOMEN. 

The  causes  of  diseases  peculiar  to  the  female  sex  are 
surprisingly  few  in  number  and  limited  in  character.  Ig- 
norance and  neglect  seem  to  be  the  most  powerful  fac- 
tors in  the  production  of  such  disorders.  A  paper  in  the 
International  Medical  Magazine,  August,  1893,  by  Dr. 
Charles  P.  Noble,  states  that  these  causes  are  about  five 
in  round  numbers.  The  first  in  importance  is  imperfect 
development  of  the  sexual  organs.  Gonorrhoea  comes 
next.  The  third  is  septic  inflammation  following  child- 
birth. The  fourth  is  lacerations  due  to  childbirth. 
And  the  fifth  may  be  said  to  be  mechanical  and  chemi- 
cal, viz.,  constipation,  erroneous  habits  of  living,  and  er- 
rors in  dress. 

Imperfect  development  of  the  sexual  organs  as  a  cause 
of  disease  in  women  is  often  overlooked.  As  a  rule, 
when  the  development  of  the  sexual  organs  is  interfered 
with,  the  development  of  the  whole  body  is  also  arrested. 
Almost  without  exception,  such  women  belong  to  the 
class  of  neurotics.  They  are  especially  liable  to  neuroses, 
especially  chorea,  headache,  and  neuralgia.  Puberty  is 
often  delayed,  and  menstruation  is  always  painful.  The 
pain  belongs  to  the  type  of  the  so-called  ovarian  dysmen* 
orrhoea :  it  begins  a  day  or  several  days,  perhaps  a  week, 
before  the  menstrual  flow,  and  is  especially  felt  in  the 
ovarian  region.  Uterine  dysmenorrhea,  due  to  lack  of 
development  in  the  uterus  (especially  of  the  cervix),  is 
frequently  present.  The  pain  is  paroxysmal,  and  less 
marked  when  the  flow  has  become  fully  established.  Too 
much  school  work  and  too  frequent  examinations  impair 
the  tone  of  the  nervous  system,  stimulate  emotion,  inter- 
fere with  digestion  and  sleep.  Anaemia  and  depraved 
nutrition  follow,  and  these  in  turn  aggravate  the  neurotic 
state.  When  such  girls  arrive  at  puberty  there  is  not 
enough  vital  force  left  over  for  the  proper  development 
of  the  sexual  organs.  The  most  remarkable  cases  of  this 
arrest  of  development  are  to  be  found  among  the  very 
poor,  among  girls  who  have  not  been  forced  at  school, 
and  who  in  some  instances  have  never  been  to  school  at 
all.  The  cause  of  arrest  of  sexual  development  among 
them  is  hard  work  undertaken  too  early  and  steadily,  as 
in  mills  and  factories.  Absence  of  fresh  air,  outdoor  ex- 
ercise, and  this  excess  of  work,  do  for  the  very  poor  just 
what  lack  of  fresh  air,  outdoor  exercise,  and  too  much 
study  and  excitement,  do  for  the  rich.  Menstruation 
among  these  girls  is  tardily  established,  never  perfectly 


performed,  and  may  cease  or  become  irregular  between 
the  twentieth  and  thirtieth  year.  One  common  cause 
of  this  arrest  of  development  in  the  female  sexual 
organs  the  author  has  overlooked,  and  that  is  infectious 
disease  during  childhood.  Scarlet  fever,  measles,  mumps, 
diphtheria,  etc.,  set  up  inflammatory  processes  here  that 
result  often  in  permanent  damage  to  the  tissues.  There  is 
not  only  arrest  of  development  in  these  organs,  but  there 
is  also  destruction  of  their  substance  proper,  due  to  the 
various  poisons  of  infectious  disease.  Neurotic  girls  need 
lighter  tasks  and  more  fresh  air  and  sunshine  than  their 
stronger  sisters,  more  rest,  and  more  sleep.  Any  func- 
tional disease  should  be  attended  to  at  once  and  cured. 
This  will  help  store  up  vital  force  for  the  exigencies  of 
puberty.  When  menstruation  fails  to  appear  at  the  ac- 
customed time,  special  care  is  necessary,  the  case  being 
watched  carefully  till  menstruation  is  fully  established. 
Such  a  plan  as  this  must  of  necessity  diminish  dysmen- 
orrhea and  sterility,  and  laceration  of  the  cervix  and  the 
perineum,  and  also  decrease  the  cases  of  chronic  ovaritis 
and  ovarian  cystomata. 

Gonorrhoea,  one  of  the  most  prolific  sources  of  dis- 
ease in  women,  is  to-day  very  generally  recognized, 
though  a  knowledge  of  its  full  significance  is  of  recent 
date.  Noeggerath,  in  1873,  published  his  paper  on  "  La- 
tent Gonorrhoea  in  Women,' '  and  called  attention  to  its 
serious  ravages.  His  views  met  with  fierce  opposition  at 
the  time,  but  their  truth  has  been  established  by  the  work 
of  modern  abdominal  surgeons.  It  is  now  well  known 
that  gonorrhoea  is  one  of  the  chief  causes  of  uterine, 
tubal,  ovarian,  and  peritoneal  inflammation.  The  exact 
percentage  is  not  yet  determined.  Cities  containing 
great  numbers  of  the  poor  and  the  vicious,  and  of  the 
rich  and  immoral,  give  a  higher  percentage  than  rural 
communities  having  a  more  decent  population. 

Septic  vaginitis,  endometritis,  and  metritis,  are 
well- known  forms  of  puerperal  inflammation.  They  fre- 
quently persist  and  require  treatment  after  the  puerperal 
period.  Aside  from  the  more  rapidly  fatal  cases,  the 
most  serious  result  of  infection  during  labor  is  the  spread 
of  the  septic  inflammation  to  the  uterine  appendages,  giv- 
ing rise  to  salpingitis,  ovaritis,  and  peritonitis.  Some- 
times there  is  perfect  recovery.  More  often  the  result  is 
chronic  inflammation,  with  formation  of  adhesions  to  the 
neighboring  structures,  or  the  collection  of  fluid,  serum, 
blood,  or  pus,  in  the  tubes  or  in  the  ovaries.  How  far 
this  is  due  to  puerperal  septic  inflammation,  and  how  far 
to  latent  gonorrhoea,  is  a  mooted  point.  A  much  less 
frequent  result  of  puerperal  infection  is  acute  inflamma- 
tion or  abscess  of  the  broad  ligaments.  Phlebitis  and  its 
associated  condition,  phlegmasia  alba  dolens,  are  other 
abnornal  manifestations  due  to  puerperal  septic  infection. 
Gonorrhoea  and  puerperal  sepsis  together  cause  fully 
ninety  five  per  cent,  of  all  cases  of  tubo  ovarian  inflam- 
mation. 

Lacerations  due  to  childbirth  are  also  followed  by  con- 
ditions disastrous  to  health.  Those  of  the  pelvic  floor 
are  even  more  important  than  lacerations  of  the .  cervix 
uteri,  since  cystocele,  rectocele,  and  prolapsus  uteri  are 
directly  due  to  them.  Constipation  is  a  bad  habit  com- 
mon to  women,  and  one  that  predisposes  to  the  develop- 
ment of  hemorrhoids,  and  to  uterine  and  ovarian  conges- 
tion, to  retroversion  of  the  uterus  and  prolapse  of  the 
ovaries.     The  full  rectum  can  displace  the  cervix  forward, 


i8 


MEDICAL    RECORD. 


[July  7,  1894 


and  the  straining  at  stool,  especially  if  the  bladder  be  full, 
can  topple  the  uterus  over  backward.  Relaxation  and  loss 
ot  tone  of  the  pelvic  tissues  due  to  congestion,  also  pre- 
dispose to  retroversion  of  the  uterus  and  to  prolapse  of 
the  ovaries.  Constipation  aggravates  the  symptoms  of 
every  pelvic  disease,  partly  by  pelvic  congestion  and  partly 
by  general  deterioration  of  health,  due  to  fecal  absorption 
and  contamination  of  the  blood,  and  by  loss  of  appetite 
and  disordered  digestion.  Indolence,  luxury,  or  the 
'  strained  and  monotonous  life  of  the  poor,  induce  pelvic 
disease.  Tight  corsets,  tight  bands  about  the  waist, 
heavy  clothes,  heavy  skirts,  tend  to  displace  the  abdom- 
inal viscera  downward.  As  rational  dress  is  perfectly 
possible  at  present,  without  sacrifice  of  taste  or  beauty, 
these  evils  are  no  longer  necessities. 

The  remedy  for  diseases  peculiar  to  women,  since  they 
are  so  largely  preventable,  is  to  be  found  in  applied  knowl- 
edge. Growing  girls,  especially  about  the  time  of 
puberty,  require  care  that  will  secure  for  them  a  normal 
development  of  the  sexual  organs.  Gonorrhoea  should 
be  more  vigorously  treated  than  it  is,  the  patient  kept 
under  observation  until  ail  abnormal  discharges  are  ar- 
rested, and  proper  instruction  given  concerning  absti- 
nence in  the  matter  of  sexual  intercourse.  Laceration  of 
the  cervix  and  perineum  are  to  be  repaired  early.  Every 
effort  should  be  made  to  prevent  the  spread  of  infec- 
tious disease.  The  evil  effects  of  constipation,  improper 
dress,  and  erroneous  habits  of  living,  require  constant  and 
careful  explanation.  This  is  pre  eminently  the  duty  of 
the  family  physician,  who  is  brought  in  contact  with  ab- 
normal conditions  in  women  before  they  come  under  the 
specialist's  direct  and  exclusive  observation. 


Dr.  Belkowski  agrees  with  the  other  observers  that  bile 
is  frequently  present  in  the  chyme.  He  finds  that  beet's 
bile  is  particularly  injurious  to  digestion,  much  more  so 
than  that  of  carnivorous  animals. 

He  finds  further  that  the  secretion  of  the  Brlinnerian 
glands  does  not  have  any  digestive  power  when  the  acidity 
of  the  medium  is  over  one  per  cent,  and  that  the  part  which 
it  plays  in  gastric  digestion  is  practically  of  no  impor- 
tance. The  pyloric  secretion  has  an  almost  equally 
slight  value.  Finally  he  finds  that  neither  of  these  secre- 
tions has  any  part  in  neutralising  the  bile,  and  that 
gastric  digestion  can  and  does  go  on  very  well  despite 
the  presence  of  bile.  Hence  a  "  little  bile  on  the  stom- 
ach ' '  is  more  or  less  normal  and  does  no  harm. 

The  duodenal  glands  in  man  are  few  and  probably 
rudimentary  organs,  though  well  developed  in  the  sheep. 
Even  the  pyloric  end  of  the  stomach  may  come  to  be  re- 
garded as  only  vestigial — like  the  appendix. 


THE   PART   OF  THE    BILE   AND    THE   BRUN-- 
NERIAN  GLANDS   IN  DIGESTION. 

A  view  which  many  persons  take  of  their  indigestion  is 
that  they  have  "  bile  on  their  stomachs ; "  and  they  cor- 
roborate this  by  speaking  of  the  bitter  taste  in  the  mouth 
and  of  various  other  evidences  of  a  so  called  "  bilious- 
ness.M  Now  physiologists  have  generally  been  disin- 
clined to  believe  that  bile  often  gets  in  the  stomach,  since 
it  is  poured  out  into  the  intestine  some  distance  below 
the  pylorus  and  since  peristalsis  always  occurs  normally 
in  a  direction  away  from  the  stomach. 

Professor  Herzen,  however,  in  his  observations  on  a 
man  with  a  gastric  fistula,  asserts  that  bile  is  a  very  con- 
stant ingredient  of  the  gastric  juice  or,  rather,  of  the 
chyme  (La  digestion  stomachale,  p.  78).  In  107  out  of 
142  tests,  bile  was  found  in  greater  or  less  quantities. 
This  view  is  supported  by  the  experiments  of  M.  Ch. 
Contejean,  who  in  a  large  number  of  tests  upon  himself 
— a  healthy  man — found  bile  in  the  chyme.  It  is  known 
that  bile  in  any  amount,  however,  retards  and  may  even 
stop  altogether  gastric  digestion.  It  is  stated  that  from 
30  to  50  drops  will  stop  digestive  processes  in  3  c.c.  of 
gastric  juice.  The  theory  has  been  put  forth  by  Schiploff 
that  one  function  of  the  glands  of  Brlinner  is  to  antago- 
nize this  dyspeptic  action  of  the  bile. 

Dr.  J.  Belkowski,  in  the  Revue  Mi  die  ale  de  la  Suisse 
Romande,  has  made  an  elaborate  series  of  experiments  in 
order  to  determine  just  what  function  the  bile  does  play 
in  gastric  digestion  and  what  the  glands  of  Briinner  have 
to  do  in  the  same  process. 


THE  REFORMATORY  INVESTIGATION. 

It  is  gratifying  to  observe  that  the  State  Reformatory  at 
Elmira  is  at  last  being  subjected  to  a  really  judicial  in- 
vestigation. The  verdict  rendered  against  this  most 
famous  of  penal  institutions  a  few  months  ago,  after  an  al- 
leged investigation  prompted  by  a  vicious  newspaper  at- 
tack, was  a  surprise  and  shock  to  every  one  familiar  with 
the  methods  of  the  institution  and  its  marvellous  results 
in  the  reformation  of  youthful  delinquents.  The  present 
investigation  is  apparently  being  conducted  in  a  way  to 
get  at  the  actual  facts.  Thus  far  the  results  are  reassur- 
ing to  those  who  have  looked  to  Elmira  as  the  most  suc- 
cessful reformatory  in  the  world,  and  to  the  movement 
inaugurated  in  this  country  by  Superintendent  Brockway 
as  the  one  reasonable  method  of  turning  back  the  tide  of 
criminality  that  is  rising  so  rapidly  in  most  civilized 
countries. 

No  brief  account  could  possibly  give  a  comprehensive 
idea  of  the  work  done  at  Elmira.  It  is  a  school  whose 
pupils  are  criminals  from  the  lowest  walks  of  life,  illiter- 
ate, vicious,  seemingly  irreclaimable,  and  whose  graduates 
are  men  changed  in  their  entire  mental  and  moral  atti- 
tude— educated,  developed,  regenerated .  The  matriculant 
is  a  criminal  at  war  with  society ;  the  graduate  a  skilled 
tradesman  ready  to  go  out  and  earn  an  honest  living  in 
the  world.  Of  the  several  thousands  treated  at  Elmira, 
more  than  eighty  per  cent,  have  gone  out  thus  regener- 
ated, and  are  now  living  useful  lives.  This  work  has 
made  Mr.  Brockway  famous  the  world  over.  The  United 
States  Bureau  of  Education  in  a  recent  report  says  of  him 
that  he  is  "justly  recognized  in  Europe,  as  well  as  in 
America  [note  the  sequence]  as  the  most  successful  in  the 
actual  reformation  of  the  criminal.,,  For  the  direct 
practical  elevation  of  the  ethical  level  of  our  race,  Mr. 
Brockway  has  perhaps  done  as  much  as  any  other  single 
individual  in  the  world. 

But  it  chances  that  one  part  of  the  admirable  system  by 
which  Mr.  Brockway  has  achieved  such  marvellous  results 
includes  the  application  of  corporal  punishment  to  wilful 
misdemeanants,  as  a  last  resort.  There  was  never  any- 
thing secret  about  this.  Such  punishment  was  always 
administered  by  the  Superintendent  in  person,  after  nu- 
merous charges  had  been  preferred  and  proven,  and  after 
the  misdemeanant  had  been  repeatedly  warned  and  ad- 


July  7#  1894] 


MEDICAL   RECORD. 


19 


monished  by  the  Superintendent.  A  record  of  the  en- 
tire case  was  always  kept  in  the  books  of  the  institution, 
including  not  only  the  fact  of  punishment,  but  the  exact 
number  of  blows  administered.  The  published  annual 
reports  of  the  institution  described  this  portion  of  the  re- 
formative treatment,  and  it  was  perfectly  understood  and 
generally  approved  by  all  persons  familiar  with  the  work 
of  the  Reformatory.  But  about  a  year  ago  a  sensational 
newspaper  in  New  York  made  the  startling  discovery  of 
the  existence  of  this  method  of  treatment,  and  assailed 
the  institution,  with  the  ultimate  result  of  bringing  on 
the  investigation  already  referred  to,  of  which  the  present 
investigation  is  the  sequel. 

At  the  beginning  of  the  present  investigation  the  "  ter- 
rible weapon  "  with  which  the  spankings  were  adminis- 
tered was  produced.  It  proved  to  be  a  strap  twenty- two 
inches  long,  three  inches  wide,  and  three-sixteenths  of  an 
inch  thick,  weighing,  handle  included,  sixteen  ounces — 
an  instrument,  one  would  suppose,  admirably  adapted  to 
produce  a  corrective  tingling  of  the  cuticle,  but  utterly 
incapable  of  producing  the  lasting  injuries  that  were  al- 
leged to  have  resulted  from  its  application.  These  in- 
juries, damaged  spines,  impaired  vision,  and  what  not 
are  rapidly  disappearing  when  subjected  to  critical  exam- 
ination in  the  concrete  by  expert  physicians  called  by 
the  investigating  commission,  or  by  the  medical  member 
of  the  commission,  Dr.  Austin  Flint.  It  is  being  shown 
that  the  inmates  who  furnished  the  adverse  testimony  be- 
fore are  largely  malingerers  and  incorrigibles.  One  of 
them  is  on  record  in  the  book  of  the  Reformatory  as  hav- 
ing committed  about  five  hundred  misdemeanors  and 
breaches  of  discipline,  from  attempted  murder  down,  dur- 
ing the  two  years  of  his  stay  in  the  institution.  The 
marvellously  exact  and  explicit  records  of  the  institution — 
in  themselves  testimony  to  the  great  executive  ability  of 
Mr.  Brockway — when  consulted  in  full  and  not  merely 
in  garbled  extracts,  have  gone  a  long  way  toward  clearing 
up  the  charges  made  against  the  Reformatory  management. 
Admissions  made  by  witnesses  called  for  the  prosecution 
have  also  strengthened  the  case  of  the  defence.  Already 
the  hope  is  justified  that  the  researches  of  the  investigat- 
ing commission  will  lead  to  a  report  fully  restoring  the 
Reformatory  to  its  place  in  the  public  confidence. 


PATENT   MEDICINES   AND   THE   TEXAS   DOC- 
TORS. 

There  are  troublous  times  in  Texas  again ;  but  the  clouds 
are  clearing,  and  the  Lone  Star  is  beginning  to  filter  its 
pellucid  beams  anew  over  a  distempered  world.  It  all 
began  from  a  combination  unfortunately  made  between 
the  Austin  Statesman  and  the  State  Medical  Society. 
The  Statesman  (who  does  not  seem  to  have  quite  grown 
up)  published  the  remarkable  assertion  that  at  a  meeting 
of  the  Society  one  of  the  doctors  spoke  anent  patent 
medicines  as  follows : 

"  No  doctor  who  has  any  consideration  for  his  calling 
will  prescribe  a  patent  medicine  compound  for  a  patient. 
If  he  is  a  doctor  at  all  he  will  write  a  prescription  con- 
taining the  same  ingredients.  By  this  means  the  drug- 
gist is  enabled  to  make  his  percentage  on  the  prescrip- 
tion and  the  doctor  gets  a  rebate.  Now,  if  the  doctor 
prescribes  a  patent  medicine,  the  druggist  only  gets  a 
small  margin  of  profit,  and  the  doctor  gets  nothing  at 


all.     So,  in  consideration  of  this  fact,  if  for  no  other,  a 
doctor  should  never  prescribe  a  patent  medicine. " 

Naturally  such  an  avowal  as  this  led  to  strong  denun- 
ciations by  the  editor,  of  the  medical  men  of  Texas  and 
everywhere  else,  with  incidental  criticisms  of  druggists 
and  their  business  ways.  Slander  loves  a  shining  mark ; 
but  when  it  strikes  the  Texas  doctors,  the  mark  not  only 
shines,  but  corruscates,  with  a  blinding  brilliancy  that 
wilts,  dries  up,  and  utterly  defibrinates  the  slander.  The 
doctors  of  Austin  got  together  and  passed  some  resolu- 
tions, which  we  publish  in  full : 

"  Whereas,  There  recently  appeared  in  the  local  edito- 
rial or  reportorial  columns  of  the  Statesman  an  article 
headed,  '  The  Reason  Why  Doctors  Object  to  Patent 
Medicines,  as  Explained  by  One  of  Them,'  in  which 
article  it  is  asserted  that  the  writer  had  heard  a  delegate 
on  the  floor  of  the  recent  Medical  Convention  in  this 
city  state  in  substance,  '  That,  by  writing  a  prescription 
for  the  same  ingredients  of  which  a  patent  medicine  is 
composed,  the  druggist  makes  a  larger  profit  and  gives 
the  doctor  a  rebate ; '  and,  further,  that  he,  the  said  wri- 
ter, in  a  conversation  with  an  Austin  druggist,  was  in- 
formed by  said  druggist  that  '  it  is  a  common  practice 
for  doctors  to  prescribe  a  small  quantity  of  a  patent 
medicine  and  have  it  put  up  as  a  prescription,  the  drug- 
gist charging  a  much  larger  price  for  this  part  of  the  bot- 
tle thus  dispensed  than  the  whole  bottle  would  be  sold 
for ;  and  by  that  means  he  made  a  larger  profit,  and  gave 
the  doctor  a  rebate.'  Or,  in  other  words,  that  this 
druggist  stated,  in  effect,  that  doctors  and  druggists  are 
in  collusion  to  rob  their  patrons. 

"Resolved,  That  the  statement  that  a  delegate  on  the 
floor  of  the  recent  Medical  Convention  in  this  city,  at 
any  time  during  its  sessions,  made  any  such  statement, 
is  false  and  libellous  upon  the  medical  profession ;  that 
members  of  the  Austin  profession,  who  were  present  and 
heard  all  the  discussion  on  the  subject  of  patent  medi- 
cines, assert  positively  that  no  such  statement  was  made 
by  any  member  or  delegate  at  any  time,  and  that  no 
language  was  used  that  could,  by  any  honest  interpreta- 
tion, be  so  construed. 

"Resolved,  That  the  statement,  by  whomsoever  made, 
that  any  reputable  physician  in  this  city  is,  or  has  been 
guilty  of  any  such  collusion  as  is  in  said  article  attributed 
to  them,  is  false  and  libellous ;  and  we  assert  that  no 
reputable  physician  asks,  expects,  or  would  receive  from 
his  druggist  any  rebate  or  percentage  on  his  prescriptions. 

"  Resolved,  That  the  entire  article  is  a  misrepresenta- 
tion of  facts,  and  an  unmerited  insult  to  the  entire  medi- 
cal fraternity  of  this  city  and  State. 

"J.  W.  McLaughlin,  M.D.,  President  Texas  State 
Medical  Association  ;  T.  J.  Bennett,  M.D.,  President 
Austin  District  Medical  Society;  Q.  C.  Smith,  M.D. ; 
S.  E.  Hudson,  M.D.,  President  Travis  County  Medical 
Society;  R.  M.  Swearingen,  M.D. ;  F.  E.  Daniel, 
M.D.,  Editor  Texas  Medical  Journal ;  A.  N.  Denton, 
M.D. ;  E.  V.  Hamilton,  M.D. ;  T.  J.  Tyner,  M.D." 

This  resolution  not  only  sets  the  Texas  doctors  all 
right,  but  lays  down  the  rules  of  a  correct  and  advanced 
ethics  as  regards  doctors,  druggists,  patent  medicines,  and 
rebates.  The  Statesman  has  been  shown  to  be  an  erring 
mortal  and  no  better  than  a  Populist ;  the  profession  of 
Texas  has  been  vindicated,  and  the  cause  of  morals 
advanced.     After  a  stir  in  Texas  the  air  is  always  clearer. 


20 


MEDICAL  RECORD 


[July  7,  1894 


UDexas  of  tfoe  WSLwk. 

The  Number  of  Medical  Students  at  the  Paris  Faculty 
of  Medicine  has  been  steadily  increasing  until,  from  384 
new  matriculates  in  1885-86,  the  number  has  reached 
719  in  1893-94.  Despite  this  the  size  of  the  teaching 
corps  is  not  increased,  and  the  students  do  not  have  suffi 
dent  personal  instruction  from  the  faculty.  Unless 
something  is  done,  Paris  will  soon  fall  still  further  behind 
as  a  great  teaching  centre. 

Prunus  Virginiana  as  a  Heart  Tonic.— There  is  yet 
another  drug  which  I  venture  to  think  may  be  unknown 
to  some  of  you.  That  is  the  prunus  virginiana  or  Ameri- 
can wild  cherry.  My  attention  was  first  called  to  it  some 
years  back  by  an  article  in  one  of  the  journals  by  Dr. 
Clifford  Allbutt  I  can  reiterate  all  that  he  says  in 
praise  of  the  drug.  It  relieves  the  flagging  and  distended 
ventricle  of  the  chronic  bronchitic,  it  stimulates  the  flap- 
ping chambers  of  the  anaemic,  and  it  increases  the  mus- 
cular tone  in  subjects  recovering  from  fever  and  other 
exhausting  diseases.  It  is  also  givea  with  great  advan- 
tage in  the  irritable  "convulsive"  heart  of  the  over- 
worked man  of  feeble  physique.  It  is  especially  useful  in 
dilatation  of  the  right  heart,  whether  as  a  result  of 
chronic  bronchitis  or  of  mitral  stenosis.  I  use  it  more  in 
private  than  in  hospital  practice ;  and  perhaps  no  drug 
has  brought  me  so  much  credit. — Dr.  Seymour  Taylor, 
in  The  Clinical  Journal, 

Discovery  of  the  Bacillus  of  Acute  Rheumatism.— A 
number  of  the  clinical  features  of  acute  articular  rheuma- 
tism have  suggested  to  the  minds  of  many  the  probability 
that  it  belongs  to  the  ever-growing  class  of  infectious 
diseases.  Its  acute  onset  and  febrile  and  self-limited 
course,  its  complications,  and  the  frequent  involvement 
of  the  joints  as  a  complication  of  many  infectious  dis- 
eases, are  regarded  as  supporting  this  theory.  The  care- 
ful investigation  of  a  typical  case  of  the  disease  by  Sahli 
(Deutsches  Archiv  /.  klin,  Med.,  1893,  P-  451)*  has 
added  the  evidence  of  the  bacteria  themselves.  Endo- 
carditis, pericarditis,  and  pleurisy  were  associated  with 
the  joint  lesions.  There  was  no  suppuration.  Bacterio- 
logical examination  disclosed  the  presence  in  all  the 
lesions  of  a  micrococcus,  identical  morphologically  and 
culturally  with  the  staphylococcus  citreus,  but  of  very 
low  virulence  when  inoculated  into  animals  as  compared 
with  it.  As  there  was  no  ground  to  suppose  a  mixed 
infection  in  this  case,  Sahli  regards  this  germ  as  its  ex- 
citing cause.  He  is  in  doubt  whether  the  germ  discov- 
ered is  a  distinct  species,  or  whether  it  is  merely  a  staphy- 
lococcus citreus  of  degenerate  virulence.  He  is  inclined 
to  the  latter  view  because  of  the  frequent  association  of 
rheumatism  and  endocarditis,  whose  intimate  relation- 
ship to  the  pyogenic  cocci  has  been  repeatedly  shown. 
A  note  appended  to  the  report  of  this  case  states  that  in 
several  other  cases  more  recently  examined,  similar  cocci 
of  low  virulence  have  been  found. 

In  connection  with  this  account,  which  is  abstracted  by 
Dr.  Ely  in  the  American  Journal  of  t lie  Medical  Sciences, 
we  may  call  attention  to  the  statement  of  Dr.  Edward 
Grim  of  Putney  (Lancet,  May  6th),  that  he  finds  the 
blood  in  acute  rheumatism  "charged  with  bacteria  in 
the  form  of  minute  cocci,"  which  are  easily  stained  by 


a  warm  solution  of  methylene  blue.  We  fear  that  Dr. 
Griln  is  troubled  with  muscae  volitantes.  Dr.  Lucatello, 
of  Genoa,  has  shown  at  the  Italian  Medical  Congress  of 
1892,  cultures  of  a  micro  organism  which  he  obtained 
from  cases  of  acute  rheumatism.  The  microbe  was  small, 
round,  and  neither  pyogenic  nor  saprogenic.  Altogether, 
the  evidence  is  as  yet  insufficient  to  place  acute  rheuma- 
tism among  microbic  diseases. 

Another  Plea  for  a  National  Bureau  of  Health.— The 
Maryland  Medical  Journal  says,  editorially :  "  Once 
more  it  seems  necessary  to  arouse  the  profession  to  the 
importance  of  using  every  effort  for  the  passage  of  a  bill 
in  Congress  to  form  a  National  Bureau  of  Health.  It  is 
only  by  united  effort  and  by  constant  appeal  to  our  rep- 
resentatives in  Congress  that  the  end  will  be  attained. 
Not  only  medical  journals,  but  the  lay  press  of  all  parties 
have  made  a  strong  fight  for  the  establishment  of  this  bu- 
reau ;  and  in  our  commerce  with  other  countries  which 
protect  themselves  by  sending  us  their  sick  and  diseased, 
it  is  no  more  than  right  that  we  should  defend  this  fair 
country  against  disease  and  pestilence  from  without.  In 
addition  there  are  filth  diseases,  like  typhoid  fever,  which 
spread  and  do  incalculable  harm  and  which,  without  re- 
spect to  state  and  municipal  boundaries,  spread  from  com- 
munity to  community,  and  it  is  for  the  better  protection 
against  disease  both  from  within  and  from  without  that  a 
bureau  of  health  is  needed.  The  general  work  of  such  a 
bureau  is  shown  in  the  proposed  bill,  which  has  already 
been  printed.1 ' 

The  Idaho  State  Medical  Society  will  hold  its  second 
annual  meeting  at  Boise,  on  Monday,  Tuesday,  and 
Wednesday,  September  10,  n,  and  12,  1894.  The  offi- 
cers of  the  Society  are :  Dr.  W.  W.  Watkins,  of  Moscow, 
President ;  Dr.  C.  L.  Sweet,  of  Boise,  Secretary. 

Dr.  Juan  J.  Ulloa,  of  San  Josl,  who  was  the  official 
delegate  of  the  Republic  of  Costa  Rica  to  the  Pan- 
American  Medical  Congress  in  Washington,  has  been 
appointed  Secretary  of  the  Interior  and  of  Public  Im- 
provements by  the  President  of  Costa  Rica.  Dr.  Ulloa 
is  a  graduate  of  the  Medical  Department  of  the  Univer- 
sity of  New  York,  and  after  serving  on  the  house-staff  of 
St.  Vincent's  Hospital,  practised  for  a  time  in  this  city. 

The  Plague  in  Hong  Kong  is  still  on  the  increase  ac- 
cording to  advices  brought  by  the  steamer  Peru.  Dur- 
ing the  week  ending  June  14th  over  seven  hundred  per- 
sons died  of  the  pest.  Five  British  soldiers  are  among 
the  victims.  The  native  inhabitants  are  fleeing  from  the 
city,  and  it  is  feared  will  spread  the  disease  through  the 
surrounding  districts. 

Dr.  E.  C.  Seguin,  of  this  city,  has  been  elected  a  cor- 
responding member  of  the  Academie  de  Meclecine  of 
Paris. 

Dr.  Ezra  M.  Hunt  died  on  Sunday  last  in  Metuchen, 
N.  J.,  aged  sixty  four.  He  was  a  graduate  of  Princeton 
College  in  the  class  of  '49,  and  obtained  his  medical  de- 
gree from  the  College  of  Physicians  and  Surgeons  in  this 
city  in  1852.  He  was  surgeon  to  one  of  the  New  Jersey 
regiments  during  the  war,  and  had  previously  lectured  for 
a  number  of  years  in  the  Vermont  Medical  College.  Dr. 
Hunt  was  very  prominent  in  health  matters  in  New  Jer- 
sey, and  had  been  secretary  of  the  State  Board  of  Health 
from  the  time  of  its  organization  in  1878. 


July  7,  1894] 


MEDICAL  RECORD. 


21 


Jtactetg  Reports, 
and  jftrogeotts. 

75b>rf  Triennial  Meeting,  held  at  Washington,  D.  C, 
May  29,  30,  31,  and  June  1,  1894. 

(Continued  (com  Vol.  45,  page  799.) 

AMERICAN  LARYNGOLOGICAL  ASSOCIATION. 

Sixteenth  Annual  Meeting,  held  in  Washington,  D.  C, 
May  jo,  31  y  and  June  I,  1894. 

First  Day,  Wednesday,  May  30TH. 

President's  Address. — Dr.  D.  Bryson  Delay  an,  of  New 
York,  said  that  the  object  of  his  address  was  to  review 
the  history  of  the  Association,  study  the  means  by  which  it 
had  attained  success,  estimate  its  present,  and  finally  in- 
vestigate the  methods  by  which  its  mission  of  usefulness 
for  the  future  might  be  most  surely  and  successfully  ac- 
complished. 

The  history  of  the  Association  was  intimately  related 
to  that  of  laryngology,  for  Manuel  Garcia  was  still  living 
and  one  of  its  Honorary  Fellows.  It  was  a  pity  that 
Horace  Green,  who  had  been  the  actual  leader  of  the 
world  in  the  study  of  diseases  of  the  throat,  should  not 
have  lived  to  see  the  Association  established.  The  lar- 
yngoscope was  said  to  have  been  introduced  into  this 
country  in  i860.  By  1878  its  use  was  being  taught  in 
twenty  different  institutions,  and  the  specialty  at  first  op- 
posed by  the  general  profession  had  gained  a  respectable 
position.  The  American  Laryngological  Association  was 
formed  in  1878.  The  motives  which  actuated  its  foun- 
ders were  eminently  philanthropic  and  ambitious.  The 
society  has  been  completely  successful.  Its  meetings  had 
been  held  regularly,  they  had  been  well  attended  and  the 
scientific  work  done  had  been  of  a  high  order,  and  the 
discussions  have  been  remarkably  valuable.  Its  fifteen 
volumes  of  transactions  were  a  great  credit  to  it.  They 
contained  over  three  hundred  and  thirty  papers.  Mean- 
while ten  years  elapsed  before  the  example  of  the  Associa- 
tion was  followed.  In  1888  the  British  Laryngological 
Association  was  formed  by  Sir  Morell  Mackenzie,  and 
later  associations  have  been  started  in  France,  Belgium, 
Italy,  and  Holland.  Local  laryngological  and  rhinolog- 
ical  associations  have  greatly  increased  in  numbers  of 
late  years.  The  first  of  these  was  the  New  York  Lar- 
yngological Society,  founded  by  Dr.  Clinton  Wagner  in 
r873,  and  since  merged  into  the  very  successful  Laryngo- 
logical Section  of  the  Academy  of  Medicine.  Successful 
local  societies  exist  also  in  London,  Berlin,  and  other 
centres.  The  latest  ones  have  been  established  in  Phila- 
delphia, and  Buda  Pesth.  Wherever  such  societies  and 
associations  have  been  established,  their  influence  has 
been  elevating  and  inspiring,  as  shown  in  the  improved 
quality  and  amount  of  the  scientific  work  done  and  in  the 
general  tendency  toward  higher  planes  of  professional 
education  and  culture.  It  is  satisfactory  that  this  move- 
ment should  have  been  started,  and  at  so  great  a  distance 
•  in  advance,  in  this  country.  The  knowledge  of  this,  how- 
ever, should  only  serve  as  a  spur  to  greater  exertion  on 
our  part. 

The  American  Laryngological  Association  has  always 
held  a  leading  place  in  the  general  and  journalistic  liter- 
ature of  the  specialty,  the  Archives  of Laryngology  having 
been  one  of  the  first  special  journals  ever  published.  The 
influence  of  the  Association  upon  its  members  has  been 
stimulating  and  salutary  and  has  resulted  in  great  good 
to  many.  The  great  function  of  the  society  in  the  past 
has  been  that  of  a  teacher.  Herein  lies  its  greatest  hope 
of  usefulness  for  the  future.  It  is  a  teacher  of  teachers, 
and  as  such  should  not  confine  itself  to  laryngology  alone, 
but  should  pay  some  attention  to  the  study  of  pedagogy, 
as  it  relates  to  this  department.  This  has  always  been 
carefully  considered  by  our  Association  as  it  relates  to 


undergraduate  instruction.  Of  late  a  great  advance  has 
been  made  in  medical  instruction  in  the  establishment  of 
graduate  schools.  This  movement,  together  with  the 
great  increase  in  the  literature  of  the  subject,  has  given  to 
laryngology  a  startling  popularity!  and  the  multiplication 
of  the  number  of  practitioners  who  assume  to  treat  dis- 
eases of  the  throat  has  been  very  great  and  has  called 
loudly  for  increased  and  improved  facilities  for  instruc- 
tion. This  want  has  been  met  by  the  graduate  school, 
which,  first  started  in  New  York,  has  become  a  recognized 
factor  in  education  all  over  the  country.  The  greatly  di- 
versified nature  of  graduate  students  as  to  age,  general 
and  special  education,  makes  the  problem  of  their  suitable 
instruction  a  difficult  one.  The  theory  of  graduate  in- 
struction in  this  country  is  a  triumphant  success.  How, 
then,  can  we  best  attain  the  practical  ends  demanded  by 
it?  The  answer  to  this  was  first  given  by  Dr.  Elsberg, 
the  Association's  first  president,  who  was  the  first  and 
best  to  enter  this  field. 

The  most  important  factors  in  the  improvement  of 
graduate  instruction  are :  1.  A  higher  and  more  general 
education  on  the  part  of  the  student  2.  A  modification 
of  the  best  undergraduate  methods  to  suit  the  needs  of 
the  older  men.  3.  More  careful  selection  of  instructors. 
The  future  of  the  Association  is  bright  and  promising.  It 
has  attained  success  in  the  past  only  by  the  exercise  of 
much  labor  and  careful  attention  to  its  best  interests. 
It  would  be  unwise  to  lower  its  standards  in  any  way. 
The  dangers  which  threaten  any  such  institution  are — 
lack  of  interest  on  the  part  of  its  older  members ;  the 
multiplication  of  other  societies ;  and  worst  of  all,  the  in- 
troduction of  politics  and  the  desire  of  self-aggrandize- 
ment. We  cannot  believe  that  such  dangers  can  threaten 
us  so  long  as  we  live  up  to  the  principles  upon  which  the 
society  was  founded. 

A  great  .change  has  taken  place  in  late  years  in  the 
matter  of  special  work,  and  larger  numbers  of  men  are 
engaged  in  it  than  ever  before.  If,  in  this  vast  extension 
of  knowledge,  our  standards  are  to  be  lowered,  and  work 
not  of  the  worthiest  accepted  at  equal  value  with  the 
best,  the  results  will  be  disastrous  to  the  advance  of  true 
science.  Such  a  calamity  we  are  unable  to  foresee. 
Outside  competition  will  only  stimulate  to  higher  attain- 
ment and  higher  skill,  while  from  the  vast  body  of  new 
aspirants  must  arise  men  who  will  penetrate  still  more 
deeply  into  the  hidden  recesses  of  nature.  With  the 
progress  of  science  in  our  department  the  American  Lar- 
yngological Association  is  intimately  associated  and 
largely  responsible.  It  is  to  be  hoped  that  it  will  respond 
to  the  demands  made  upon  it. 

Nasal  Polypus ;  Its  Association  with  Ethmoiditis  and 
Its  Treatment  by  Resection  of  the  Middle  Turbinated 
Body.— A  paper  with  this  .title  was  read  by  Dr.  W.  E. 
Casselberry,  of  Chicago.  An  analysis  of  forty  cases 
confirms  the  view  that  nasal  polypus  is  but  a  symptom  or 
concomitant  of  other  nasal  maladies,  the  most  frequent 
being  various  forms  of  ethmoiditis.  Two  previous  papers 
by  the  author  are  reviewed,  in  the  first  of  which  he  ad- 
vised a  vigorous  surgical  treatment  having  for  its  object 
first  access  to  and  then  eradication  of  the  actual  seat  of 
attachment,  most  frequently  in  the  immediate  vicinity  of 
the  hiatus  semilunaris.  For  eradication  of  the  attach- 
ments, upward  beneath  the  middle  turbinated  body,  he 
has  recently  substituted  for  the  cautery  point,  before  rec- 
ommended, a  small  sharp  curette  with  which  the  borders 
of  the  hiatus  and  the  bulla  ethmoidals  are  well  scraped. 

In  a  supplementary  paper  in  189 1,  he  advised,  as  part 
of  the  radical  treatment,  the  removal  of  the  antero  infe- 
rior part  of  the  middle  turbinated  bone,  in  order  to  give 
freer  access  to  the  actual  points  of  development. 

Additional  experience  with  this  operation  has  but  con- 
firmed its  utility  and  demonstrated  its  harmlessness.  The 
middle  turbinated  body,  a  process  of  the  ethmoid  bone, 
is  rarely  itself  in  a  healthful  condition  in  these  cases,  a 
phase  of  the  subject  which  is  amplified  in  the  present  pa- 
per. Furthermore,  it  appears  from  the  cases  reported  as 
typifying  the  various  forms  of  associated  ethmoid  disease, 


22 


MEDICAL   RECORD. 


[July  7,  1894 


that  polypus  is  commonly  one  of  the  earliest  prominent 
manifestations  of  ethmoiditis,  and  resection  of  the  mid- 
dle turbinated  bone,  in  addition  to  its  efficacy  for  the 
polyps  themselves,  is  regarded  as  a  prophylactic  measure 
against  the  development  of  the  more  serious  suppurative 
type  of  ethmoiditis  and  infection~of  the  maxillary,  fron- 
tal, and  sphenoidal  sinuses,  by  facilitating  drainage  from 
the  ethmoid  cell?. 

A  clinical  classification  of  the  various  conditions  which 
are  found  associated  with  and  underlying  the  formation 
of  nasal  polypus  is  deduced  from  the  analysis  of  forty 
cases,  and  a  case  typifying  the  characteristics  of  each 
group  is  detailed. 

Type  I. — Nasal  Polypus  with  Hypertrophic  Rhinitis. — 
This  is  characterized  by  simple  enlargement  of  the  inferior 
and  middle  turbinated  bodies  and  without  evidence  of 
ethmoiditis  other  than  the  suggestiveness  of  the  polyps. 
Drainage  is  defective,  and  the  accumulation  of  muco- 
purulent secretion  in  the  middle  meatus  seems  to  encour- 
age polyp  growth.  Recovery  without  recurrence  follows 
removal  of  the  polyps  and  reduction  of  the  hypertrophied 
turbinated  bodies  by  the  cautery.  Only  six  of  the  series 
of  forty  cases  were  of  this  type. 

Type  IF. — Nasal  Polypus  with  Simple  Myxomatous 
Ethmoiditis. — This  is  characterized  by  great  enlargement 
of  the  middle  turbinated  bodies,  which  have  a  glistening 
aspect  and  a  pultaceous  touch  indicative  of  oedematous  or 
myxomatous  degeneration ;  pressure  in  the  ethmoid  re- 
gion, productive  at  times  of  infra  orbital  swelling  and 
broadening  of  the  base  of  the  nose. 

After  resection  of  a  considerable  part  of  the  middle 
turbinated  bone  the  muco  periosteum  of  the  parts  of  the 
ethmoid  bone  thus  exposed — the  borders  of  the  hiatus, 
bulla  ethmoidalis,  etc. — is  found  in  a  state  of  myxomatous 
degeneration  and  covered  by  polypoid  excrescences,  the 
same  extending  upward  into  the  ethmoid  cells* 

Fourteen  of  the  series  of  forty  cases  were  of  this  nat- 
ure, and  five  of  them  were  subjected  to  the  operation  of 
resection  of  the  middle  turbinated  bone?. 

Type  III. — Nasal  Polypus  with  Vaso-Afotor  Ethmoi- 
ditis.— This  is  regarded  as  a  variation  of  Type  II.,  and 
presents  the  same  evidences  of  myxomatous  degeneration 
of  the  muco-periosteum  of  the  ethmoid  region.  In  addi- 
tion, asthma  was  a  universal  symptom,  which,  to  some 
extent,  influenced  the  grouping  together  of  these  particu- 
lar cases,  under  the  conviction  that  asthma  of  this  variety 
is  caused  by  a  similar  vasomotor  tumefaction  of  the  bron- 
chioles. 

The  group  comprised  nine  cases,  and  four  of  them  suf- 
fered from  hay  fever,  which  further  indicated  the  posses- 
sion of  a  fundamental  neurotic  habit.  They  were  all 
affected  by  supersensitiveness  to  the  extent  that  various 
irritants,  such  as  dust,  coal  smoke,  fog,  aroma  from 
horses,  etc.,  would  suffice  at  any  season  to  excite  a  form 
of  nasal  tumefaction  suggestive  of  yaso  dilatation,  and  in 
most  cases  the  ethmoid  region  seemed  especially  sensi- 
tive. 

Type  IV. — Nasal  Polypus  with  Suppurative  Ethmoidi- 
tis.— This  is  characterized  by  a  purulent  discharge  from 
the  ethmoid- cells,  co-existing  frequently  with  empyema  of 
the  maxillary,  frontal,  and  sphenoid  sinuses.  It  is  regarded 
as  a  sequel  to  Type  II.  or  Type  III.,  suppuration  occur- 
ring only  after  myxomatous  tissue  has  accumulated  suffi- 
ciently to  obliterate  the  natural  drainage  channels,  which 
view  is  substantiated  by  a  case  in  which  suppuration  of 
the  frontal  sinus  occurred  in  conjunction  with  oblitera- 
tion of  its  outlet.  This  group  comprises  six  cases,  of 
which  five  were  subjected  to  resection  of  the  middle  tur- 
binated bone  on  one  or  both  sides,  in  addition  to  other 
measures. 

Type  V. — Nasal  Polypus  with  Necrosing  Ethmoiditis. 
— Dr.  Woakes'  contention  that  nasal  polypus  indicated  a 
chronic  inflammation  of  the  ethmoid  is  in  large  meas- 
ure substantiated  ;  but  that  necrosis  or  even  caries  of  bone 
is  a  "  usual "  accompaniment  is  not  confirmed,  so  that  it 
would  seem  wise  to  limit  the  term  "necrosing  ethmoi- 
ditis "  to  the  class  of  cases  in  which  necrosis  or,  at  least, 


caries,  actually  exists.     Only  five  cases  were  accompa- 
nied by  unmistakable  necrosis  of  bone. 

Concerning  the  technique  of  resection  of  the  middle 
turbinated  bone,  the  author  has  devised  curved  serrated 
scissors  with 'which  to  cut  the  bone  for  a  variable  dis- 
tance backward,  when  the  operation,  if  not  complete, 
can  be  finished  by  the  snare  or  sharp  forceps.  The  re- 
section need  not  be  completed  at  one  sitting,  but  is  more 
often  accomplished  fragment  by  fragment,  the  latter 
method  alone  succeeding  when  the  middle  turbinated 
body  is  greatly  enlarged  and  closely  impacted  within  its 
space. 

Conversely  if  the  middle  turbinated  body  be  of  normal 
contour  and  present  no  impediment  to  drainage,  to  the 
transmission  of  light  or  instruments,  there  will  then  be  no 
occasion  to  interfere  with  it. 

This  paper  was  discussed  by  Drs.  W.  H.  Daly,  of  Pittf- 
burg;  F.  H.  Bosworth,  of  New  York;  J.  H.  Bryan,  of 
Washington ;  J.  N.  Mackenzie,  of  Baltimore ;  F.  W* 
Hinkel,  of  Buffalo ;  W.  Peyer  Porcher,  of  Charleston ; 
J.  C.  Mulhall,  of  St.  Louis ;  Jonathan  Wright,  of  Brook- 
lyn, and  C.  C.  Rice,  of  New  York.  These  gentlemen  all 
agreed  on  the  main  features  of  their  remarks.  Over- 
zealous  surgery  in  the  nose  should  be  avoided.  One  case 
of  severe  hemorrhage  has  resulted.  In  one  instance,  im- 
mediately after  removal  of  the  turbinated,  severe  parietal 
pain  was  felt  in  the  head.  The  patient  became  demented 
and  died  of  cerebral  abscesses.  The  heart  could  not  be 
examined  at  the  autopsy  and  it  is  possible  that  the  brain 
lesions  in  this  case  came  from  a  cardiac  embolus,  though 
the  patient  had  always  been  in  the  best  of  health  previ- 
ously. Acute  cases  of  ethmoidal  trouble  will  often  sub- 
side under  local  antiphlogistic  measures ;  but  in  the  chronic 
cases  it  is  useless  to  expect  a  cure  without  radical  opera- 
tive procedure. 

Papillary  Hypertrophy  of  the  Vasal  Mucous  Mem- 
brane.— Dr.  Jonathan  Wright,  of  Brooklyn,  N.  Y., 
presented  a  paper  entitled  "  Papillary  Hypertrophy  of  the 
Nasal  Mucous  Membrane  Compared  with  a  True  Papil- 
loma.'1 The  writer  stated  that  there  was  much  confusion 
in  the  literature  of  rhinology,  from  the  loose  use  of  the 
term  papilloma  as  applied  to  intranasal  excrescences. 
Hopmann  has  described  a  pathological  formation,  which 
the  Germans  speak  of  as  papilloma,  but  it  is  not  true  pap- 
illoma at  all.     Such  growths  in  the  nose  are  rare. 

Dr.  Wright  exhibited  drawings  illustrating  the  differ- 
ence between  the  two  conditions  named  in  the  title  of 
his  paper.  The  nasal  growth  was  removed  from  the  mid- 
dle of  the  inferior  turbinated  bone  and  the  true  papilloma 
from  the  uvula.  The  latter  consisted  of  a  thick  stem 
with  irregular  sprouts, — some  simply  conical,  springing 
directly  from  the  central  stem,  but  the  larger  number 
again  divided  into  stems  and  sprouts,  the  whole  looking 
like  a  budding  tuberous  vegetable.  A  drawing  of  the 
nasal  growth  showed  a  symmetrically  rounded  mass, 
divided  by  cross  lines  into  more  or  less  regular  portions 
resembling  the  "mulberry"  hypertrophy,  so  frequently 
seen  on  the  posterior  ends  of  the  inferior  turbinated 
bones.  The  mass  was  sessile,  but  movable,  and  removed 
by  a  cold  snare.  Although  the  operation  was  prolonged 
over  nearly  an  hour,  severe  hemorrhage  resulted  three 
hours  later.  As  contrasted  with  the  true  papilloma,  al-' 
most  any  fold  of  the  nasal  specimen  communicated  with 
the  central  mass,  without  any  appearance  of  a  "  budding  " 
process.  The  line  of  surface  epithelium  was  not  espe- 
cially thickened  or  irregular.  The  papilloma  was  without 
glands,  had  only  small  capillaries,  and  a  slight  branching 
framework  of  connective  tissue.  The  latter  was  covered 
everywhere  by  a  large  number  of  regularly  situated  layers 
of  flat,  epithelial  cells.  The  papillary  hypertrophy  con- 
sisted of  all  the  constituent  parts  of  the  mucous  mem- 
brane of  the  inferior  turbinated  body.  The  dilatation  of 
the  venous  sinuses  was  especially  marked.  Glands  were 
present,  but  scanty.  The  fibro-connective  tissue  was 
greatly  increased.  This,  at  the  periphery,  was  divided 
into  regular  processes  covered  by  epithelium,  and  sepa- 
rated from  each  other  by  depressions  giving  a  nodular 


July  7,  1894] 


MEDICAL   RECORD. 


23 


surface.  These  growths  are  papillary  hypertrophies  of 
the  erectile  bodies  of  the  inferior  turbinated  bones. 
These  enlargements  result  from  a  continuous  and  exag- 
garated  contraction  and  dilatation  of  the  sinuses  in  a 
stroma  deprived  by  chronic  inflammation  of  much  of  its 
elastic  and  muscular  structure. 

Metallic  Electrodes  in  Nasal  Disease. — Dr.  C.  C. 
Rice,  of  New  York,  next  read  a  paper  entitled  "  The 
Use  of  Metallic  Electrodes  in  Nasal  and  Post-Nasal  Dis- 
ease," His  plan  of  treatment  is  to  make  the  positive 
electrode  of  the  circuit  of  some  such  substance  as  copper. 
When  the  current  passes,  the  metal  is  dissolved,  and  a 
new  metallic  salt,  the  oxychioride  of  copper,  is  formed 
and  earned  through  the  tissues  by  kataphoresis.  Allu- 
sion was  made  to  the  experiments  of  Gautier,  Morton, 
Cleaves,  and  others  along  this  line*  There  was  no  proof 
that  the  action  of  the  salt  was  germicidal.  It  was  claimed 
that  the  new  salt  was  actually  carried  into  the  tissues, 
that  it  was  in  this  way  more  efficient  than  a  solution  of 
the  substance  applied  to  the  surface,  and  that  the  patho- 
logical foci,  being  beneath  the  surface,  were  thus  more 
effectually  reached.  Part  of  the  advantage  was  undoubt- 
edly derived  from  the  current  itself  and  from  its  own 
electrolytic  action  upon  the  tissues.  He  had  found  the 
treatment  especially  satisfactory  in  various  forms  of  nasal 
disease  where,  succeeding  the  removal  of  all  offending 
material,  there  was  a  continuous  hypersecretion.  En- 
larged turbinates  could  be  punctured  with  a  copper  nee- 
dle, the  negative  electrode  being  a  flat  sponge  on  the 
nape  of  the  neck.  Succeeding  the  current  was  a  tempo- 
rary coryza,  which  usually  disappeared  in  twenty-four 
hours.  He  had  found  the  copper  needle  preferable  to 
the  cautery  in  epistaxis  from  eroded  spots  on  the  nasal 
septum.  Out  of  twenty  cases  of  these  various  ailments 
he  had  cured  six,  and  benefited  fully  three  quarters  of 
the  remainder.  Paper  discussed  by  Drs.  Wright,  A.  W. 
de  Roaldes,  of  New  Orleans,  J.  O.  Roe,  of  Rochester, 
Daly  and  Casselberry.  All  these  gentlemen  were  unan- 
imous in  doubting  the  accuracy  of  the  various  mille- 
amp£re  metres  which  are  necessarily  used  in  the  foregoing 
electrical  procedure,  and  doubt  was  also  expressed  as  to 
the  distinct  effect  of  the  metallic  salts  as  apart  from  the 
general  stimulating  one  of  the  current  itself. 


ASSOCIATION   OF   AMERICAN    PHYSICIANS. 

Ninth  Annual  Meeting,  held  in  Washington,  D.  C,  May 
29*30,31,  and  June  1,  1894. 

Second  Day,  Wednesday,  May  30TH. 

Modification,  Temporary  and  Permanent,  of  the  Phy- 
siological Characters  of  Bacteria  in  Mixed  Cultures. 
— Dr.  Theobald  Smith,  of  Washington,  D.  C,  read 
a  paper  with  this  title.  The  variability  of  species  of 
bacteria  is  a  most  important  subject.  The  changes  in 
virility  by  passing  through  animals,  and  by  heat  or  chemi- 
cal agents,  are  well  known.  The  objects  of  these  studies 
are  to  determine  the  modification  of  bacteria  when  grown 
in  mixed  cultures.  In  1890  the  accidental  association  of 
proteus  vulgaris  with  a  pathogenic  bacillus  (B.  cholera 
suis)  in  an  agar  culture  produced,  within  a  few  months, 
a  very  marked  reduction  of  the  pathogenic  powers  of  the 
latter.  Repeated  trials  with  mixed  cultures  confirmed 
this  observation.  A  return  of  the  original  virulence  of 
the  pathogenic  species  was  noted  after  it  had  been  culti- 
vated by  itself;  but  this  return  was  preceded  by  a  pro- 
longed period  of  attenuation,  lasting  in  one  instance 
about  nine  months. 

These  results  suggest  the  possible  modification  of  patho- 
genic and  aprophytic  species  in  the  soil  by  similar  agen- 
cies. They  also  throw  some  light  on  the  extent  of  the 
mutually  destructive  action  of  different  species  accident- 
ally vegetating  together.  Dr.  Smith  detailed  at  length 
his  experiments.  He  grew  the  bacilli  of  hog  cholera 
alone,  and  mixed  with  the  proteus  vulgaris.  He  also 
maintained  a  pure  culture  of  the  proteus.  The  result 
upon  the  proteus  of  growing  in  conjunction  with  the  hog- 


cholera  bacillus,  was  the  evolution  of  a  variety  resembling 
the  proteus  mirabilis  and  proteus  Zenkeri  of  Hauser. 

Dr.  Sternberg,  of  Washington,  said  that  a  few  years 
ago  every  bacillus  that  differed  a  little  in  its  action  was 
considered  a  different  species.  Now  we  know  that  many 
are  varieties  of  each  bacillus.  Whether  the  variations  go 
so  far  as  to  produce  species  which  will  not  revert,  we  do 
not  know.  He  said  that  he  had  been  much  misled  by 
this  during  his  studies  in  Cuba. 

Dr.  William  H.  West,  of  Baltimore,  said  that  the 
tendency  now  was  to  identify  species  of  bacilli  by  mor- 
phological rather  than  by  physiological  characteristics. 
He  said  that  the  hog-cholera  bacillus  in 'the  laboratories 
of  Germany  was  probably  a  different  species  from  that 
which  had  been  under  observation  in  Baltimore.  He 
considered  Dr.  Smith's  contribution  valuable. 

Dr.  Smith  closed  the  .discussion. 

The  Effect  of  Various  Metals  on  the  Growth  of 
Pathogenic  Bacteria.— Dr.  Meade  Bolton,  of  Balti- 
more, said  that  some  metals  seem  to  have  no  influence 
upon  the  growth  of  the  bacteria,  while  others  have  a  more 
or  less  marked  inhibitory  action,  as  shown  by  a  broader 
or  narrower  clear  zone  around  the  pieces  of  metal  on 
plates  otherwise  crowded  with  colonies  of  bacteria.  Just 
outside  the  clear  zone,  whether  this  is  broad  or  narrow, 
there  is,  in  nearly  every  case,  a  zone  of  intensified  growth 
where  the  colonies  are  thicker  than  on  other  parts  of  the 
plate. 

In  the  few  tests  as  yet  made  for  this  purpose,  there  was 
entire  absence  of  living  bacteria  in  the  clear  zones.  In- 
oculations from  the  clear  zones  remained  sterile. 

In  some  cases  there  are  three  zones  around  the  metals, 
viz. :  A  clear  zone  immediately  surrounding  the  metal ; 
a  zone  of  intensified  growth,  arid  a  second  narrower  zone 
where  growth  was  inhibited.  It  has  been  possible  to  de- 
tect in  the  medium,  by  chemical  reagents,  the  presence 
of  traces  of  those  metals  that  exert  inhibitory  power. 
The  solution  of  the  metals  in  the  nutrient  medium  takes 
place  independently  of  the  growth  of  bacteria,  as  it  is 
possible  to  detect  the  presence  of  the  metals  in  sterile 
media  in  which  they  have  been  placed,  after  they  have 
lain  for  a  few  days,  at  any  rate.  A  discoloration  of  the 
medium  surrounding  the  metal,  often  makes  a  special  test 
unnecessary. 

Some  metals  have  a  much  more  powerful  inhibitory 
action  than  others,  as  is  shown  by  the  broader  clear  zone. 
There  is  also  some  difference  in  the  different  bacteria 
with  one  and  the  same  metal. 

Some  of  the  metals  that  have  been  tested  were  abso- 
lutely pure;  others  were  commercial  metals,  marked 
chemically  pure,  and  a  few  were  either  impure  or  alloys. 
Silver  has  a  marked  action.  Hence  silver  wire  sutures 
are  less  apt  to  give  stitch  abscesses  than  sutures  of  other 
material. 

Votes  on  the  Observation  of  Malarial  Organisms,  in 
Connection  with  Enteric  Fever. — Dr.  W.  Gilman 
Thompson,  of  New  York,  called  attention  to  the  possi- 
bility of  a  double  infection  with  malarial  and  typhoid 
germs.  A  typical  case  of  typhoid  fever  lasting  fifty- five 
days,  with  eruption,  tympanites,  and  hemorrhage  from  the 
intestine,  complicated  by  chills  and  hyperpyrexia,  during 
the  third  week,  with  appearance  of  malarial  organisms. 
Two  other  typical  cases  of  enteric  fever,  with  the  obser- 
vation of  malarial  organisms,  which  appeared  in  connec- 
tion with  chills  during  convalescence.  Rarity  of  the 
mixed  infection  in  the  vicinity  of  New  York,  which  is 
common  in  the  South. 

Dr.  Osler,  of  Baltimore,  said  that  chills  in  typhoid 
were  common  apart  from  malaria.  He  exhibited  a  chart 
of  the  only  case  of  this  mixed  infection  that  had  been 
seen  at  the  Johns  Hopkins  Hospital.  He  related  a  case 
of  mixed  infection  of  pneumonia  and  pneumia. 

Dr.  F.  P.  Kinnicutt,  of  New  York,  related  a  case  which 
was  mistaken  for  typhoid,  but  which  was  proved  to  be 
malarial. 

Dr.  G.  L.  Peabody  said  that  chills  in  typhoid  were 
sometimes  pyaemic,  and  these  were  of  more  importance. 


24 


MEDICAL  RECORD. 


[July  7,  1894 


He  believed  that  the  frequency  of  "  typhomalaria  "  was 
exaggerated  by  many. 

Dr.  E.  G.  Janeway,  of  New  York,  said  that  he  had 
often  seen  chilis  in  typhoid  due  to  the  administration  of 
antipyretics. 

Dr.  Sternberg,  of  Washington,  said  that  the  so-called 
"typhomalaria"  was  not  such  as  was  shown  by  the 
author,  but  cases  which,  being  mistaken  for  malaria, 
afterward  turned  out  to  be  typhoid.  The  physician,  to 
save  his  reputation,  added  his  final  diagnosis  to  his  pro- 
visional  diagnosis. 

Dr.  J.  C.  Wilson,  of  Philadelphia,  said  that  the  name 
"typhomalaria"  was  unfortunate,  in  that  it  interfered 
with  prophylaxis  in  typhoid  cases. 

Dr.  J.  H.  Musser,  of  Philadelphia,  reported  a  case  of 
mixed  infection  of  scarlatina,  measles,  and  intermittent 
fever. 

Dr.  H  M.  Lyman,  of  Chicago,  and  Dr.  W.  T.  Coun- 
cilman, of  Boston,  reported  cases  bearing  on  the  subject. 

Dr.  F.  C.  Shattuck,  of  Boston,  said  that  chills  in 
typhoid  might  be  due  to  phlebitis  of  inaccessible  veins. 

Dr.  J.  C.  Reeves,  of  Chattanooga,  believed  in  a  fever 
intermediate  between  typhoid  and  malaria. 

Dr.  George  Dock,  of  Ann  Arbor,  had  made  autopsies 
on  many  cases  of  typhomalarial  fever,  and  had  found 
typhoid  lesions. 

Dr.  Thompson  closed  the  discussion  by  emphasizing 
the  importance  of  examining  the  blood  of  fever  patients 
for  malarial  organisms. 

Experiments  in  Artificial  Melanosis. — Dr.  George 
Dock,  of  Ann  Arbor,  Mich  ,  read  a  paper  with  this  title. 
Investigations  in  cases  of  malarial  fever  with  great  pig- 
mentation, show  some  departures  from  the  changes  that 
have  been  described  as  the  result  of  injecting  finely  pow- 
dered substances  (cinnabar)  into  the  circulation.  The 
object  of  the  present  series  of  experiments  was  to  control 
the  older  observations,  and  to  observe  especially  the 
behavior  of  the  various  kinds  of  leucocytes,  as  known  by 
modern  methods,  to  the  foreign  bodies.  The  animals 
used  are  dogs  and  rabbits ;  the  substance  injected,  lamp- 
black suspended  in  normal  salt  solution.  At  this  time 
the  experiments  are  not  finished,  but  have  gone  far 
enough  to  say  that  the  changes  found  are  not  identical 
with  those  in  malaria.  The  greatest  difference  is  the 
slight  participation  of  the  macrophages  in  the  experi- 
mental cases,  as  compared  with  malaria.  The  other  ob- 
servations as  to  the  localization  of  the  pigment  were  con- 
firmed. 

Some  of  the  Chemical  and  Bacteriological  Charac- 
teristics of  Milk.— Dr.  Thomas  M.  Rotch,  of  Boston, 
dwelt  upon  the  importance  of  reaction  in  milk,  in  infant 
feeding.  By  feeding  cows  on  sugar-beets  in  addition  to 
other  food,  the  milk  was  rendered  alkaline.  Alkaline 
milk  is  more  like  human  milk  than  that  usually  obtained. 
Cows  milked  under  antiseptic  precautions  gave  the  fol- 
lowing results :  First  half  of  milking  showed  bacilli. 
Milk  drawn  with  a  sterile  cannula  was  practically  sterile. 
Hence  the  conclusion  is  drawn  that  the  bacilli  came 
from  the  tract  between  the  udder  and  the  end  of  the 
teet.     In  this  way  sterile  milk  is  obtainable. 

Dr.  F.  Forchheimer,  of  Cincinnati,  O.,  Said  that  the 
extreme  importance  of  the  subject  merited  further  investi- 
gation. 

Dr.  T.  Smith,  of  Washington,  agreed  with  the  author. 

Dr.  Rotch  closed  the  discussion. 


MEDICAL  SOCIETY  OF  THE  STATE  OF  PENN- 
SYLVANIA. 

Forty-fourth  Annual  Session,  held  in  Philadelphia,  May 
IS,  16,  and  17,  7894. 

First  Day,  Tuesday,  May  15TH. 

The  Society  was  called  to  order  by  the  president,  Dr.  H. 
G.  McCormick,  of  Williamsport,  Pa.  After  an  opening 
prayer  by  Rev.  A.  B.  Philputt,  an  address  of  welcome  was 
given  by  Hon.  Edwin  S.  Stuart,  Mayor  of  Philadelphia. 


He  recalled  the  fact  that  the  first  hospital  for  the  treatment 
of  the  sick  was  inaugurated  in  Pennsylvania  on  the  appli- 
cation of  Benjamin  Franklin,  and  was  erected  in  Phila- 
delphia, and  from  that  time  until  now  it  has  been  doing 
excellent  work.  The  first  medical  school  and  the  first 
school  of  anatomy  were  also  located  in  Philadelphia. 
Some  time  ago  the  city  contained  many  colleges  which 
were  a  disgrace  to  it,  but  those  have  now  been  wiped  out, 

The  address  of  the  Mayor  was  followed  by  one  of 
welcome  by  Dr.  E.  E.  Montgomery,  of  Philadelphia, 
chairman  of  the  Committee  of  Arrangements. 

Reports  were  made  by  the  secretary,  Dr.  William  B. 
Atkinson,  and  the  Treasurer,  Dr.  G.  B  Dunmire.  Dr. 
Atkinson  said  there  were  now  fifty  county  medical  soci- 
eties in  good  standing,  and  that  the  State  Society  had 
at  present  two  thousand  five  hundred  members.  The 
treasurer  reported  a  total  of  $4,122.24  received  for  1894. 
and  expenses  amounting  to  $2,423.45. 

Dr  George  M.  Gould  then  presented  a  resolution 
calling  upon  the  Legislature  of  Pennsylvania  to  adopt  the 
law  for  the  prevention  of  blindness  in  infants,  recom- 
mended by  the  Committee  of  the  Section  on  Ophthal- 
mology of  the  American  Medical  Association  adopted  by 
the  Legislature  of  the  State. 

Address  in  Surgery. — Dr.  G.  D.  Nutt  said  success  in 
many  operations  is  often  modified  by  the  time  when  and 
place  where  such  operations  have  to  be  performed.  A 
great  responsibility  rests  upon  the  family  physician  in 
many  of  those  diseases  of  a  purely  surgical  nature  or 
tending  that  way.  He  is  usually  the  first  to  see  these 
cases ;  and  unless  an  early  surgical  consultation  is  called, 
the  time  may  pass  when  an  operation  can  be  safely 
performed.  Many  fallacies  are  taught  in  our  text-books 
that  have  been  proven  false  by  modern  surgery,  which 
the  general  profession  are  slowly  but  surely  accepting. 

Modification  of  PirogofTs  Amputation. — Dr.  F.  Le 
Moyne  read  a  paper  with  this  title,  advocating  the  pres- 
ervation of  the  malleoli  and  the  excavation  of  the  retained 
section  of  the  calcis  at  a  point  to  correspond  with  each 
malleolus,  with  the  object  of  gaining  about  three- fourths  of 
an  inch  in  the  ultimate  length  of  the  limb,  and  procuring 
more  accurate  and  permanent  coaptation. 

Psoriasis. — Dr.  George  V.  Shoemaker  showed  cases 
illustrative  of  the  etiology  of  psoriasis.  Two  of  the  cases 
were  frankly  rheumatic,  two  probably  of  arthritic  ten- 
dency, and  the  fifth  was  the  subject  of  chronic  gastro  enter- 
itis. Dr.  Shoemaker  explained  that  psoriasis  is  often  excited 
by  the  presence  of  rheumatism  or  gout,  while  in  other  cases 
it  depends  upon  chronic  disturbance  of  the  digestive  or- 
gans, disease  of  the  liver,  disorders  of  the  blood,  and  mal- 
adies of  the  nervous  system.  He  also  explained  that  the 
appearance  of  the  papules,  patches,  and  scales,  is  charac- 
teristic and  typical,  whatsoever  the  cause.  The  facts  re- 
lating to  its  etiology  are  most  significant  guides  to  treat- 
ment. In  each  case  we  must  endeavor  to  ascertain  the 
origin.  Though  the  lesions  present  exactly  the  same  ap 
pearance,  the  therapy  must  obviously  differ  in  accordance 
with  the  etiology,  and  routine  treatment  of  psoriasis  is  an 
impossibility.  The  defects  of  digestion  and  nutrition 
must  be  corrected;  constitutional  and  approximately 
specific  remedies  must  be  administered,  or  the  state  of  the 
nervous  system  must  be  improved.  The  habits  of  the  diet 
must  be  regulated  or  changed.  The  Doctor  asserted  that 
ingestion  of  thyroid  glands  is  a  mode  of  therapy  service- 
able in  certain  cases.  The  grand  principle  of  treatment 
is  to  determine  the  origin  of  each  case.  Acting  upon 
this  belief  the  Doctor  lays  comparatively  little  stress  upon 
topical  treatment.  Dr.  Shoemaker  said  that  increasing 
experience  convinced  him  that  accuracy  in  tracing  the 
genesis  of  the'disease  pointed  to  an  internal  therapy,  upon 
which  could  be  placed  the  reliance  of  the  profession  more 
firmly  than  upon  local  measures. 

Organic  Stricture  of  the  Urethra. — Dr.  Orville  Hor- 
witz,  in  a  paper  with  this  title,  called  attention  to  the  fact 
that  dilatation  should  be  employed  in  all  cases  of  recent 
strictures  which  are  dilatable,  occurring  in  any  portion  of 
the  urethra,  and  which  are  not  either  resilient,  irritable, 


July  7,  1894] 


MEDICAL  RECORD. 


25 


or  nodular.  This  treatment  is  by  far  the  safest  in  persons 
suffering  from  disease  of  the  heart  or  kidneys,  or  diabetics 
who  are  broken  down  in  health,  who  are  suffering  from 
debility,  or  who  are  advanced  in  years. 

Continuous  dilatation  was  recommended  as  an  adjunct 
to  other  more  radical  means  of  treatment.  It  should  be 
employed  in  tight  strictures  of  the  membranous  portion 
of  the  urethra,  complicated  with  retention  of  urine,  and 
in  those  cases  where  the  stricture  is  of  small  calibre,  when 
located  in  the  fixed  portion  of  the  canal ;  the  patient  is 
thus  enabled  to  pass  water  with  sufficient  ease  to  allow 
him  to  be  prepared  for  ladical  operation. 

Modified  rapid  dilatation  was  advised  for  the  treatment 
of  filiform  strictures,  situated  in  the  neighborhood  of  the 
bulbous  and  membranous  portions  of  the  canal,  which 
are  neither  irritable,  nodular,  nor  resilient,  and  which 
cannot  be  treated  by  gradual  dilatation. 

Internal  urethrotomy  should  be  limited  to  well-organ- 
ized strictures,  situated  within  from  three  and  a  half  to 
four  inches  from  the  meatus. 

Strictures  at  the  meatus,  or  in  the  neighborhood  of 
the  fossa  naviculars,  should  be  divided  on  the  floor  of  the 
urethra,  especially  if  they  give  rise  to  reflex  symptoms. 

Dilating  internal  urethrotomy  should  be  limited  to 
strictures  that  are  well  organized  and  of  long  standing, 
within  from  three  and  a  half  to  four  inches  from  the 
meatus,  which  are  nodular  or  resilient. 

This  operation  should  not  be  performed  on  those  who 
suffer  from  impotence,  neurasthenia,  nocturnal  emissions, 
or  sexual  hypochondriasis. 

In  these  cases  ordinary  internal  urethrotomy,  by  the 
Gross  instrument,  is  advised.  Combined  internal  and  ex- 
ternal urethrotomy  is  commended  in  nodular  strictures 
of  the  penile  portion  of  the  urethra,  and  in  strictures  of 
the  bulbous  portion  of  the  canal.  External  and  internal 
urethrotomy,  with  or  without  a  guide,  is  advised  under 
the  usual  conditions. 

Electrolysis  was  not  recommended. 

Cramming  in  Medical  Schools. — Dr.  Oscar  H.  Allis, 
surgeon  to  the  Presbyterian  Hospital,  stated  that  the 
lengthening  of  the  term  of  study  of  medical  schools  had 
increased  the  number  of  professors,  many  of  whom  were 
not  authors,  and  this  made  note  taking  indispensable. 
That  as  there  was  no  time  for  the  student  to  do  this,  it 
made  it  imperative  that  he  place  himself  under  a  quiz 
master  throughout  his  entire  course.  That  between  lect- 
ures, laboratory  work,  hard  work,  demonstrations,  clin- 
ics, and  quizzing,  he  must  put  in  between  sixty  and 
seventy  hours  a  week.  The  average  class  room  work  in 
schools,  colleges,  and  seminaries,  he  said,  was  three  hours 
a  day  for  five  days.  The  speaker  complained  that  men 
in  medical  schools  were  compelled  to  take  a  three  or  four 
years'  course,  spend  hard-earned  or  borrowed  money  for 
lectures  and  maintenance,  and  be  "  plucked  "  at  the  last 
moment.  Every  man  in  the  seminary  or  school  who  is 
diligent  and  moral  gets  his  degree.  Ten  per  cent,  of 
the  medical  students  fail.  If  a  rigid  entrance  examina- 
tion were  instituted,  many  of  those  who  fail  would  be 
arrested  at  the  outset. 

It  was  urged  that  some  return  should  be  made  to  those 
who  fail ;  that  if  medical  schools  were  compelled  by  law 
to  return  the  fees  for  instruction,  the  number  of  gradu- 
ates would  not  be  diminished,  but  the  ten  per  cent,  who 
now  fail  would  stand  on  a  different  footing.  Such  a 
course  would  compel  medical  schools  to  compare  their 
requirements,  their  methods,  and  courses  of  study,  with 
other  institutions  of  learning.  In  literary  institutions 
class-room  work  counts  more  than  final  examinations. 
In  medical  schools  the  professor  knows  little  of  the  stu- 
dent, classroom  work  has  little  influence,  and  the  final 
examination  decides  the  fate  of  the  applicants.  Dr.  Allis 
declared  that  good,  faithful  men  are  thus  often  sacrificed. 


Second  Day,  Wednesday,  May  i6th. 

Election  of  Officers. — The  session  was  called  to  order  by 
the  president,  and  the  report  of  the  Committee  on  Nom- 


inations was  announced  as  follows :  President,  John  B. 
Roberts,  of  Philadelphia ;  First  Vice-President,  Dr.  S. 
C.  Stewart,  of  Clearfield  County;  Second  Vice  President, 
Dr.  J.  A.  Lippincott,  Allegheny  County ;  Third  Vice- 
President,  Dr.  J.  H.  Wilson,  Beaver  County;  Fourth 
Vice-President,  Dr.  R.  Armstrong,  of  Clinton  County; 
Secretary,  Dr.  William  B.  Atkinson,  of  Philadelphia; 
Assistant  Secretary,  Dr.  H.  G.  Chritzman,  of  Franklin 
County;  Treasurer,  Dr.  G.  B.  Dun  mire,  Philadelphia 
County  ;  Delegates  to  New  York  State  Medical  Society, 
Dr.  I.  W.  Groff,  Montgomery  County ;  New  Jersey  So- 
ciety, Dr.  C.  A.  Rahter,  Dauphin  County;  Maryland 
Society,  Drs.  A.  C.  Wentz,  of  York,  and  P.  R.  Kcons,  of 
Cumberland  County. 

Address  in  Medicine. — Dr.  W.  S.  Foster,  of  Pitts- 
burg, read  the  annual  address  in  medicine.  He  said  that 
recent  advances  in  medical  practice  have  been  the  crys- 
tallization of  therapeutic  measures  by  slow  processes  as 
compared  with  the  picturesque  leaps  and  bounds  that 
have  characterized  surgical  practice,  and  that  tuberculin 
and  cerebrin  have  been  equally  fatuous  attempts  at  rapid 
advance ;  the  first,  a  legitimate  and  therapeutic  attempt, 
the  last,  a  palpably  fraudulent  scheme.  The  recurring 
popularity  of  calomel  and  other  mercurial  compounds  and 
renewed  use  of  digitalis  in  the  continued  forms  was  com- 
mented upon.  Pure  oxygen  was  recommended  as  wor- 
thy of  trial  in  pneumonia  where  the  respiratory  area  is 
greatly  encroached  upon.  The  routine  use  of  antipyret- 
ics was  condemned  as  irrational.  In  the  use  of  anaes- 
thetics, Syme's  principles  were  mentioned  as  bein£  again 
recognized  as  the  correct  ones  for  the  guidance  of  the 
physician.  Ether  was  declared  equally  as  dangerous  as 
chloroform,  while  its  after-effects  upon  the  emunctory 
organs,  it  was  asserted,  make  it  an  agent  to  be  used  with 
the  greatest  caution. 

Christian  Science  in  its  Eolation  to  the  Medical  Pro- 
fession.— Dr.  Hildegabde  H.  Longsdorf,  of  Carlisle, 
read  a  paper  with  this  title.  The  subject,  he  said,  was 
more  important  than  it  might  at  first  sight  appear,  even 
contemptible,  yet  from  the  proneness  of  the  uninformed 
to  exaggerate  and  mystify  disease  all  remedial  agen- 
cies carry  with  them  an  overpowering  influence,  and  to 
the  younger  practitioner  especially  are  baffling  and  vexa- 
tious. Christian  science  wss  probably  the  most  preten- 
tious and  certainly  the  most  successful  of  the  outgrowths 
of  our  modern  high- pressure  civilization,  which,  not  con- 
tent with  its  acknowledged  empire  over  material  nature, 
must  enter  the  realm  of  psychological  phenomena  and  call 
upon  a  too  credulous  public  to  believe  what  it  cannot  ex- 
plain and  revere  what  it  cannot  comprehend.  There 
have  been  many  such  mock  systems  in  former  years. 
Christian  science,  however,  goes  a  step  beyond  any  of  its 
forerunners,  is  one  shade  finer  and  more  plausible  in  its 
theory,  and  more  conspicuously  successful  than  any  simi- 
lar intellectual  epidemic  the  world  has  ever  witnessed. 
These  fatuous  misbeliefs  are  the  intellectual  scandal  of 
the  age,  and  it  becomes  a  puzzling  question  how  to  re- 
gard those  who  honestly  believe  in  them,  and  what 
should  be  the  attitude  of  the  physician  toward  those  who 
aspire  to  the  office  of  healer. 

If  it  were  not  for  the  fact  that  the  doctrine  is  rapidly 
spreading,  gaining  friends  and  influence  among  the  most 
intelligent  classes,  the  subject  might  well  be  dismissed 
with  a  smile  as  one  more  of  the  numerous  phases  in 
which  the  ever- restless  mind  has  manifested  itself.  But 
it  has  a  vast  and  increasing  power,  and  not  only  among 
the  uneducated.  It  has  its  representative  literary  jour- 
nals, and  an  array  of  special  agents  or  missionaries,  a 
respectable  showing  of  institutions  or  metaphysical  col- 
leges, and  a  vast  number  of  private  establishments  for  the 
cure  of  every  disease  under  the  sun. 

The  question  arises,  how  are  we  to  regard  it  and  how 
we  are  to  be  armed  against  its  inroads  ?  It  would  be  out 
of  place  to  argue  against  mental  cures,  and  it  would  be 
idle  to  deny  the  power  of  mind  over  the  body,  but  the 
fact  remains  that  the  process  cannot  be  rationally  ex- 
plained so  that  the  subjects  of  it  can  clearly  understand  it. 


26 


MEDICAL   RECORD. 


[July  7,  1894 


Consequently,  in  endeavoring  to  maintain  our  profes- 
sional self  respect  we  are  in  danger  of  becoming  illiberal, 
narrow  minded,  and  dogmatic.  The  importance  of  some 
definite  restraining  force  for  these  abuses  can  scarcely  be 
overestimated,  and  if  public  opinion  and  the  advanced 
philosophical  science  of  our  era  have  been  powerless  to 
effect  this,  it  would  seem  to  come  into  the  province  of 
legislative  enactment. 

Should  the  Journal  of  the  American  Medical  Associa- 
tion be  Used  to  Promote  Quackery  ?— Dr.  S.  S.  Cohen 
read  a  paper  with  this  title,  which  was  an  arraignment  of 
the  trustees  of  the  Journal  of  the  American  Medical  As- 
solution  for  persisting  in  publishing  advertisements  of 
secret  nostrums,  contrary  to  the  unanimous  resolution  of 
the  association  in  1892. 

After  D:.  Cohen's  remarks  a  series  of  resolutions  for- 
wirded  to  the  State  Medical  Society  by  the  Philadelphia 
County  Medical  Society,  urging  that  action  be  taken  to 
have  such  unethical  advertisements  excluded  from  the 
fournil  of  the  American  Medical  Association  were  dis- 
cussed. These  resolutions  have  all  been  printed  in  vari- 
ous journals  to  which  they  were  sent  at  the  time  of  their 
original  adoption  by  the  Philadelphia  County  Medical 
Society. 

Dr.  Thomas  then  offered  a  resolution,  which  was 
adopted,  that  the  resolutions  of  the  Philadelphia  County 
Medical  Society  on  this  subject  be  sent  to  each  trustee 
of  the  Journal  and  that  the  delegates  of  the  Society  be  in- 
structed to  present  them  at  the  meeting  of  the  American 
Medical  Association  in  San  Francisco  next  month,  and 
that  the  trustees  be  informed  that  it  is  the  sense  of  this 
Society  that  they  would  prefer  to  have  the  publication  of 
the  Journal  discontinued  if  the  money  received  for  such 
improper  advertisements  is  requisite  for  its  continu- 
ance. 

A  resolution  was  adopted  also  to  the  effect  that  if  the 
funds  of  the  association  will  not  permit  the  Journal  to 
be  published  without  a  violation  of  the  code  of  ethics, 
the  trustees  cease  it  publication. 

Croup  and  Diphtheria.— Dr.  B.  H.  Detwiler,  of 
Williamsport,  spoke  of  the  pathology  and  treatment  of 
membranous  croup  and  dwelt  largely  on  the  importance 
of  an  early  diagnosis  of  it  from  the  croup  of  diphtheria. 
Dr.  Detwiler  asserted  that  diphtheritic  croup  has  a  mor- 
tality of  sixty  to  eighty  per  cent,  and  that  the  phlogistic 
treatment  which  he  advised  had  absolutely  no  mortality 
record.  He  dwelt  upon  the  duality  of  the  two  diseases, 
making  the  anatomical  construction  of  the  ciliated  epi- 
thelium tissues  of  the  vocal  dorus  and  the  squamous  epi- 
thelium of  the  pharynx  and  fauces  and  their  inflamma- 
tory products  the  diagnostic  signs  of  duality.  His  plan 
of  treatment  is  to  produce  free  depletion  by  leeches  after 
cyanosis  begins,  with  revulsion  by  cantharidal  blisters  and 
calomel  in  quarter-grain  doses  every  half  hour  till  the 
spinach  stools  are  voided. 

The  Operative  Treatment  of  Muscular  Asthenopia 
(Heterophoria). — Dr.  Charles  Hermon  Thomas  read  a 
paper  with  this  title.  A  number  of  illustrative  cases  were 
reported  which  showed  the  extremely  varied  character  of 
the  symptoms  and  the  favorable  results  of  operation. 
The  subjective  symptoms  of  asthenopia  show  almost  no 
distinct  characteristics  pointing  to  their  origin,  whether 
refractive  or  muscular ;  the  same  headaches  and  the  same 
sense  of  eye  strain  are  complained  of  under  both  condi- 
tions. Graduated  tenotomy  (partial)  is  practicable  and 
efficient  because  of  the  elasticity  of  the  margins  of  the 
tendons.  Muscular  asthenopia  may  present  symptoms  of 
all  grades  of  importance,  from  the  slightest  to  the  most 
serious.  As  in  refractive,  so  in  muscular  asthenopia  the 
gravity  of  the  symptoms  bears  no  constant  relation  to  the 
amount  of  the  physical  defect  or  muscular  error.  As 
much — and  very  much  the  same  kind  of — relief  is  to  be 
expected  from  the  correction  of  muscular  anomalies  as 
from  the  correction  of  errors  of  refraction  and  accom- 
modation, as  might  be  expected  from  the  similarity  in 
the  symptoms.  The  muscular  condition  in  every  case 
should,  as  a  matter  of  routine,  be  as  carefully  investigated 


as  are  the  media,  eye  ground,  the  refraction,  and  the  am- 
plitude of  accommodation. 

An  Epileptic  Colony. — A  resolution  was  offered  and 
ad?pted  that  it  is  the  sense  of  the  Medical  Society  of  the 
State  of  Pennsylvania  that  an  epileptic  colony  should  be 
established  for  the  benefit  of  those  epileptics  whom  the 
commonwealth  is  obliged  to  support,  and  for  others  sup- 
ported by  their  friends.  Copies  of  this  resolution  to  be 
sent  to  the  governor,  speaker  of  the  House,  and  presi- 
dent of  the  Senate,  and  to  the  president  of  the  State 
Board  of  Charities. 

Dr.  H.  G.  McCormick,  president  of  the  State  Board 
of  Examiners  representing  the  Medical  Society  of  the 
State  of  Pennsylvania,  announced  that  the  first  examina- 
tion under  the  new  law  for  license  to  practise  in  Penn- 
sylvania would  be  held  on  June  nth,  in  Philadelphia 
and  Pittsburg  respectively,  the  same  questions  being 
given  to  all  applicants  at  both  cities. 

A  resolution  was  adopted  urging  Congress  not  to  dimin- 
ish the  usual  appropriation  for  the  support  of  the  Library 
of  the  Surgeon  General's  Office  at  Washington. 

Address  on  Mental  Diseases.— Dr.  T.  M.  T.  Mc- 
Kennan,  of  Pittsburg,  read  the  Annual  Address  on  Men- 
tal Diseases.  A  statement  was  made  of  the  progressive 
advancement  in  hospitals  for  the  insane,  and  especially 
in  the  education  and  training  of  nurses.  The  toxic  ori- 
gin of  many  of  the  insanities  was  dwelt  upon  and  espe- 
cial attention  called  to  auto  intoxication  as  a  factor  in 
the  etiology  of  insanity.  The  influence  of  gynecological 
operations  and  pelvic  diseases  in  women  in  causing  in- 
sanity were  touched  upon.  The  relation  of  syphilis  to 
general  paralysis  of  the  insane  was  dwelt  upon,  and  the 
great  probability,  amounting  to  almost  positive  proof,  of 
the  syphilitic  origin  of  general  paralysis.  Trianol  and 
duboisine  were  spoken  of  as  two  new  hypnotic  agents  of 
value,  and  electricity  as  a  valuable  therapeutic  agent. 

Studies  in  Obstetrics  and  Gynecology. — Dr.  Anna 
M.  Fullerton  in  this  paper  presented  her  views  as  to 
the  most  frequent  causes  of  pelvic  disease,  and  the  re- 
sultant decrease  in  the  child-bearing  capacity  of  civilized 
women.  The  opinions  advanced  were  founded  upon  the 
observations  made  by  her  during  eight  years  of  service 
as  physician  in  charge  of  the  Woman's  Hospital  of 
Philadelphia.  The  teaching  that  the  majority  of  pelvic 
diseases  are  of  microbic  origin  was  upheld ;  and  the  vul- 
nerability of  the  woman  of  the  day  to  such  diseases  was 
shown  to  be  the  result  of  general  debility  of  all  the  tis- 
sues in  consequence  of  the  physical  and  mental  strain 
induced  by  the  habits  and  requirements  of  modern  life. 

The  remedy  for  this  evil  was  felt  by  the  writer  to  lie 
in  a  clearer  understanding  of  the  laws  of  reproduction  as 
affected  by  the  changed  conditions  of  civilization ;  and 
especially  in  the  higher  education  of  women,  in  order  to 
give  them  a  proper  appreciation  of  physiological  and 
educational  laws,  and  thus  better  fit  them  to  act  as  guard- 
ians over  the  pre  natal  as  well  as  the  post  natal  influences 
affecting  the  well-being  of  the  child. 

Whooping-Cough. — Dr.  W.  C.  Hollopeter  spoke  of 
the  need  of  a  specific  for  this  specific  disease,  for  as  such 
he  regards  it.  He  said  that  by  most  authorities  this  dis- 
ease was  regarded  as  the  most  fatal  of  all  the  diseases  of 
children  under  one  year  of  age.  This  fatality  is  not 
limited  to  the  first  year  of  life,  but  continues  to  mani- 
fest itself  long  after  this  period  in  broken  health  of  all 
kinds  referable  to  the  respiratory,  intestinal,  as  well  as 
the  various  glandular  organs.  The  speaker  placed  con- 
siderable value  on  the  peculiar  puffiness  of  the  mucous 
membrane  of  the  eyes  and  the  swollen  or  (Edematous 
condition  of  the  whole  of  the  face,  almost  dusky ;  this 
condition  may  exist  for  days  before  the  catarrhal  symp- 
toms have  extended  throughout  the  respiratory  mucous 
membrane.  The  cough  at  this  stage  may  not  be  at  all 
suggestive — it  may  be,  in  fact,  purely  bronchial.  This 
symptom  of  fulness  about  the  eyes,  which  is  quite  as  con- 
stant in  measles  as  in  pertussis,  and  with  measles  it  is  close- 
ly associated  and  must  be  differentiated.  As  measles  are 
diagnosed  by  the  appearance  of  the  eruption  first  on  the 


July  7,  1894] 


MEDICAL  RECORD. 


27 


hard  palate,  so,  he  contended,  whooping-cough  may  be 
diagnosed  in  its  earliest  stage  by  the  characteristic  swol 
len  condition  of  the  eyes  and  face.  He  insisted  upon 
this  factor  as  of  the  greatest  importance,  as  its  recogni- 
tion will  enable  the  physician  to  institute  specific" treat- 
ment early,  when  the  disease  is  yet  local  and  may  be 
brought  more  speedily  under  control.  The  drugs  he  has 
found  most  efficient  in  the  catarrhal  stage  have  been 
hydrogen  peroxide  in  sterilizing  the  naso-pharynx,  and 
assafcetida  occasionally  used  for  the  paroxysms.  Bella- 
donna also  is  to  a  high  degree  beneficial  in  young  chil- 
dren, and  should  be  placed  first.  This  he  pushes  until 
toxic  effects  are  secured,  when  less  suggestive  characteris- 
tics of  the  cough  are  observed. 

Amputation  near  the  Ankle. — Dr.  G.  G.  Davis,  of 
Philadelphia,  showed  four  cases  of  amputation  in  the 
neighborhood  of  the  ankle  as]  a  protest  against  abandon- 
ing these  operations  in  favor  of  amputation  below  the 
knee.  The  first  case  was  a  Chopart  amputation  of  thir- 
teen years ;  never  any  trouble  wearing  a  shoe  made  by  a 
common  shoemaker.  The  second  was  a  Chopart  with 
apparatus,  showing  no  deformity,  and  walking  well  with 
scarcely  a  perceptible  limp.  The  third  was  a  Pirogoff 
with  apparatus,  walking  well.  The  fourth  was  a  double 
amputation  in  a  man  weighing  two  hundred  and  twenty 
pounds.  One  leg  was  removed  below  the  knee — seat  of 
election — and  the  other  a  Pirogoff.  The  patient  stated 
that  the  Pirogoff  was  much  the  more  satisfactory. 

It  was  held  that  in  none  of  these  cases  would  their 
condition  have  been  improved  by  an  amputation  high  up 
on  the  leg. 


Third  Day,  Thursday,  May  17TH. 

Address  on  Hygiene.— Dr.  J.  H.  Wilson,  of  Beaver, 
read  the  Annual  Address  on  Hygiene.  He  spoke  of  the 
reduction  in  the  amount  of  sickness,  and  attributed  it  to 
the  increased  number  and  improved  efficiency  of  the 
boards  of  health.  In  speaking  of  the  practice  of  free 
school  supplies  prevalent  throughout  the  State,  Dr.  Wil- 
son said :  There  is  not  a  pretence  to  give  the  scholars 
the  same  books  and  pencils  as  the  day  before,  and  from 
the  habit  of  children  chewing  lead-pencil*,  diphtheria 
and  other  diseases  may  be  transmitted.  There  should  be 
some  method  of  disinfecting  the  books.  It  would  be 
much  better  for  the  child  to  be  supplied  by  the  parent 
than  to  take  the  risk  under  the  present  method.  Some 
school  boards  need  to  be  taught  that  foul  air  is  heavier 
than  pure  air  and  cannot  be  gotten  rid  of  by  ventilators 
at  the  top  of  a  room.  Dr.  Wilson  went  on  to  speak  of 
the  physician's  duty  in  instructing  those  of  the  masses 
who  come  under  his  care  in  the  simple  laws  of  hygiene, 
such  as  removing  all  the  day  clothing  when  retiring  for 
the  night,  and  washing  the  entire  body  every  day. 
Electricity,  he  said,  is  becoming  recognized  as  a  sci- 
entific agent.  It  has  been  experimented  with  in  puri- 
fying atmospheric  dust  and  in  disinfecting  sewage.  In 
speaking  of  tuberculosis,  Dr.  Wilson  said :  The  annual 
mortality  by  this  disease  in  this  country  is  165,600,  or 
an  average  of  450  a  day.  Dr.  Fletcher's  labors  in  this 
city  have  attracted  much  attention.  He  has  proven  that 
certain  residences  in  this  city,  in  the  Fifth  Ward,  are  in- 
fected by  this  disease.  In  the  discussions  which  followed, 
Dr.  William  P.  Munn,  of  Denver,  said :  We  have  in 
Denver  a  house  to-house  inspection,  conducted  by  a 
trained  sanitary  inspector.  The  inspection  consists  not 
only  of  the  house  and  its  immediate  surroundings,  as  the 
pavements  and  the  alleys  and  sewers,  but  also  the  habits 
of  its  inmates.  The  results  of  these  inspections  are  classi- 
fied and  indexed  in  a  manner  similar  to  cards  used  in 
libraries.  Anyone  contemplating  buying  a  house  can 
go  to  the  Health  Board  and  have  this  information  spread 
out  before  him,  and  see  the  condition  of  the  house. 
Many  people  are  in  this  way  saved  by  the  records  of  the 
Health  Department  from  buying  infected  houses.  "  And, 
in  many  instances,  negligent  landlords,  knowing  that 
their  properties  will  not  be  rented  while  they  are  down 


in  the  health  records  as  bad,  have  them  put  in  a  health- 
ful condition. " 

Prophylaxis  in  the  Treatment  of  Tuberculosis. — Dr. 
Lawrence  F.  Flick,  of  Philadelphia,  in  his  paper  with  this 
title,  asserted  that  a  most  valuable  lesson  taught  by  the 
organic  theory  of  tuberculosis  is  prophylaxis  in  the  treat- 
ment of  the  disease.  Tuberculosis  is  strictly  a  parasitic 
disease.  In  nature's  effort  to  get  rid  of  the  parasite,  re- 
infection is  liable  to  take  place. 

Were  it  not  for  reinfection,  all  cases  of  tuberculosis 
would  get  well.  The  disease  is  really  a  series  of  invasions 
of  the  organism  producing  it. 

The  prevention  of  auto-inoculation  gives  the  key  to  the 
treatment  of  this  disease.  In  so  far  as  this  can  be  ac- 
complished, treatment  is  successful,  and  no  farther. 

Auto-inoculation  can  be  controlled  in  two  ways :  by 
building  up  the  system  of  the  patient  so  as  to  enable  it  to 
resist  new  deposits,  and  by  preventing  the  readmission  of 
the  organisms  into  the  system. 

Strychnine  in  Pulmonary  Consumption. — Dr.  Thomas 
J.  Mays,  of  Philadelphia,  in  his  paper  with  this  title,  claims 
that,  next  to  rest  and  food,  strychnine  in  large  doses  is 
the  most  important  agent  in  the  treatment  of  pulmonary 
consumption.  Begin  with  -fa  of  a  grain,  and  gradually 
increase  to  ^V,  -jV,  or  J  of  a  grain,  or  even  give  it  in 
larger  doses,  four  times  a  day.  According  to  the  author 
it  does  not  produce  albuminuria  or  diabetes,  as  is  gen- 
erally supposed.  It  alleviates  the  loss  of  appetite,  the 
vomiting,  the  constipation,  the  nervousness,  and  sleep- 
lessness, the  pain  in  the  chest,  the  cough  and  expectora- 
tion, the  dyspnoea,  the  weakness  of  the  heart,  and  acts  as 
a  blooi-builder  in  an  eminent  degree.  Its  usefulness 
rests  on  its  influence  over  the  nervous  system,  and  is  an- 
other link,  the  speaker  said,  in  the  chain  of  evidence, 
which  shows  that,  in  the  great  majority  of  cases,  pulmo- 
nary consumption  is  the  direct  result  of  primary  disease  of 
the  pulmonary  nerve-supply. 

Tubercular  Meningitis. — Dr.  Daniel  Longaker,  ot 
Philadelphia,  in  a  short  paper  emphasized  the  frequency 
of  tuberculosis  of  the  mediastinal  glands ;  the  occasional 
dissemination  of  acute  tuberculosis  from  such  foci,  some- 
times general,  but  usually  more  limited — in  the  case  in 
question,  to  the  cerebral  meninges  and  the  spleen.  It 
may  be  latent,  but  frequently  causes  long-continued 
cough,  and  such  cough,  if  associated  with  even  slight  im- 
pairment of  the  general  health,  should  be  looked  on  with 
suspicion.  In  adults  the  general  health  may  be  perfect. 
It  must  be  regarded  as  a  menace  to  the  life  of  the  indi- 
vidual, although  under  favorable  conditions  it  produces 
no  harm  in  the  majority  of  cases.  A  mass  of  authiakosis 
in  the  cheesy  gland,  near  the  bacilli,  seemed  to  prove  in- 
halation as  the  origin  of  the  disease. 

Colorado  Climate  for  Consumptives.  —  Dr.  Wm.  P. 
Munn,  of  Colorado,  said  that  tuberculosis  of  the  lungs  is 
curable.  He  spoke  of  climatic  environment  as  the  great- 
est factor  in  the  battle  of  the  human  organism  against 
micro  organism.  He  said  that  the  climatic  advantages  of 
Colorado  are:  1.  Its  low  absolute  and  relative  humidity. 
2.  Rarity  of  atmosphere  dependent  upon  altitude.  3. 
Sunshine.     4.  Cool  and  equable  temperature. 

The  great  majority  of  cases  of  consumption  if  sent  to 
Colorado,  will  recover,  if  only  sent  early.  Hemorrhagic 
types  of  the  disease  are  especially  benefited.  Residence 
in  Colorado  should  be  permanent,  if  possible,  but  in  no 
case  less  than  five  years. 

Early  recognition  of  pulmonary  consumption  is  essen- 
tial to  its  successful  climatic  treatment.  The  healthy 
children  of  tubercular  parents  now  coming  to  adult  life 
in  Colorado  are  a  strong  argument  against  the  heredity 
of  consumption.  Favorable  climatic  environment  pro- 
tects them  from  the  direct  contagion  of  their  parents  due 
to  residence  in  the  same  home. 

A  Bureau  of  Public  Health. — A  resolution  was  offered 
and  adopted  that  the  society  expresses  its  approval  of  the 
establishment  of  a  bureau  of  public  health,  and  its  opin- 
ion that  the  welfare  of  our  country  would  be  greatly  ben- 
efited thereby,  and  requests  that  the  representatives  of 


28 


MEDICAL    RECORD. 


[July  7,  1894 


our  State  aid  the  passage  of  the  bill  in  Congress  by  their 
earnest  efforts.  A  copy  of  the  resolution  was  ordered  to 
be  sent  to  each  Senator  and  member  of  the  House  of 
Representatives  at  Washington. 

Address  on  Ophthalmology. — Dr.  George  £.  de 
Schweinitz,  of  Philadelphia,  divided  the  art  of  restoring 
health  to  disordered  eyes  into  optical,  surgical,  and  medi- 
cal therapeutics.  After  a  brief  review  of  the  most  im- 
portant advances  in  the  first  two  departments  of  this  di- 
vision, he  addressed  the  Society  on  the  medicinal  and 
non-surgical  ocular  therapeutics.  He  reviewed  subcon- 
junctival injections  of  corrosive  sublimate,  commending 
them  in  selected  cases,  and  described  his  experimental 
work  and  that  of  Dr.  Chasseaud  in  connection  with  intra- 
ocular injections  of  antiseptic  substances,  concluding  that 
this  form  of  medication,  although  presenting  attractive 
features,  had  not  yet  reached  a  safe  status  in  ophthalmic 
practice. 

Abuses  of  mercury  in  the  treatment  of  diseases  of  the 
eye  were  referred  to,  and,  in  the  management  of  optic 
nerve  atrophy,  suspension,  injections  after  the  manner  of 
Brown  S^quard,  and  the  effects  of  various  drugs,  particu- 
larly antipyrin,  strychnia,  and  nitroglycerine  were  de- 
scribed. 

The  relation  of  electricity  to  diseases  of  the  eye  re- 
ceived attention,  especially  the  method  of  treating  optic 
nerve  atrophy  by  means  of  voltaic  alternatives,  and  the 
use  of  the  continuous  current  in  the  management  of  vit- 
reous disease  and  chronic  irido-choroiditis. 

The  medicinal  treatment  of  the  congested  choroid 
coats,  as  the  result  of  eye  strain,  was  insisted  upon  as  an 
essential  aid  in  the  management  of  asthenopia.  Follow- 
ing this,  modern  investigations  in  regard  to  the  untoward 
effects  of  cocaine  were  discussed,  the  new  mydriatic,  sco- 
polamine, was  compared  with  atropine,  and  the  address 
closed  with  a  reference  to  the  proper  method  of  procur- 
ing conjunctival  antisepsis,  as  nearly  as  this  is  possible, 
and  the  danger  of  powerful  germicides  in  relation  to  the 
cornea. 

Dr.  de  Schweinitz  closed  with  a  strong  appeal  to  each 
physician  to  use  his  personal  influence  to  assist  in  secur- 
ing legislative  regulations  for  the  prevention  of  blindness 
from  ophthalmus  neonatorum. 

Treatment  of  the  Corneal  Ulcer  by  General  Practi- 
tioner.— Dr.  S.  Lewis  Ziegler  asserted  that  corneal  ulcer 
is  not  necessarily  dangerous,  but  may  seriously  impair  vis- 
ion, especially  when  central.  Lachrymo-nasal  lesions 
are  the  immediate  cause,  gastrointestinal  disorders  from 
errors  in  diet  are  the  remote  cause ;  constitutional  dys- 
crasiae  may  have  some  influence  as  a  predisposing  cause. 
If  septic  materials  are  present  in  the  ocular  cul  de  sac,  a 
break  in  the  corneal  epithelium  will  court  infection  and 
subsequent  ulceration. 

To  summarize  :  Simple  corneal  ulcer  is  a  purely  local 
inflammatory  process,  arising  chiefly  from  infection  by 
septic  secretions,  and  originating  in  lachrymo  nasal  le- 
sions. 

The  treatment  required  is:  1.  Apply  a  mild  antisep- 
tic, soothing  lotion  to  the  eye,  a  mydriatic  if  needed, 
and  hot  applications  when  indicated.  2.  Treat  the  nose 
locally  with  compound  tincture  of  benzoin  and  the  use  of 
a  cleansing  spray.  3.  Regulate  the  diet,  give  salt-water 
baths,  and  improve  the  hygiene  generally. 

Uterine  Fibroids. — Dr.  Charles  P.  Nobre,  in  a  paper 
with  this  title,  referred  to  the  teaching  concerning  fi- 
broids current  ten  years  ago,  viz. :  1 .  That  the  disease  is 
a  benign  one,  tending  to  a  spontaneous  cure  at  the  men- 
opause. 2.  That  it  never  causes  death.  3.  That  hyster- 
ectomy is  the  most  dangerous  operation  in  surgery,  hav- 
ing a  mortality  of  forty  per  cent.  He  pointed  out  that 
ten  years'  study  of  the  disease  has  demonstrated  :  1.  That 
it  is  a  serious  disease,  almost  invariably  producing  marked 
invalidism,  and  not  infrequently  causing  death  by  hem 
orrhage,  by  undergoing  malignant,  cystic,  or  necrotic 
changes,  by  paving  the  way  for  intercurrent  diseases,  by 
proving  an  obstruction  to  labor,  and  by  piessure  upon 
the  urinary  organs  and  other  abdominal  viscera.     2. 


That  the  menopause  is  delayed  from  five  to  ten  years.  3. 
That  spontaneous  cure  not  infrequently  does  not  follow 
the  menopause,  and  that  many  fibroids  grow  more  rapidly 
after  than  before  that  period.  4.  That  hysterectomy, 
except  in  complicated  cases,  has  been  a  comparatively 
safe  operation.  He  quoted  the  recent  experience  of 
Kelly,  Baer,  Polk,  and  himself  in  hysterectomy — includ- 
ing all  classes  of  cases  as  they  come,  one  hundred  and 
sixty-eight  cases,  nine  deaths,  or  a  mortality  of  five  and 
three-tenths  per  cent 

The  deaths  were  in  the  broken-down  complicated  cases. 
The  failure  of  ergot  and  electricity  and  the  comparative 
failure  of  oophorectomy  to  cure  was  referred  to.  The 
principle  of  early  operation,  now  accepted  for  ovarian 
tumors,  was  urged  in  the  treatment  of  fibroid,  so  that  the 
mortality  can  be  still  further  reduced. 

A  Cause  of  Failure  in  the  Surgical  Treatment  of  In- 
ternal Strabismus. — Dr.  Thomas  F.  Hansell,  in  his 
paper  with  this  title,  said  that  Donders'  theory  of  the 
causation  of  internal  squint  in  hypermetropia  is  incom- 
plete, in  that  he  taught  that  the  excessive  action  of  the 
accommodation  in  overcoming  hypermetropia  induced 
corresponding  excessive  convergence  only;  whereas  its  in- 
fluence is  not  thus  limited  to  the  interni,  but  extends  to  all 
the  muscles  under  the  control  of  the  third  nerve.  Dr. 
Hansell  believes  that  the  simple,  pure,  internal  strabis- 
mus of  hypermetropia,  as  described  by  Donders,  cannot 
exist,  but  must  always  be  complicated  by  an  upward 
strabismus,  for  the  following  reason :  The  stimulus  of  the 
overacting  ciliary  muscle  is  communicated  not  only  to 
the  nucleus  of  the  internus,  but  to  that  of  the  superior 
rectus,  of  the  inferior  rectus,  of  the  inferior  oblique,  and 
of  the  pupil. 

The  nucleus  of  the  levator  palpebral  is  probably  also 
involved ;  but  since  the  function  of  this  muscle  is  to 
elevate  the  lid,  and  not  to  rotate  the  cornea,  its  action  is 
not  relative  to  the  subject  of  this  paper.  Hence  their 
combined  action  is : 

1.  Contraction  of  the  pupil. 

2.  Esotropia,  because  the  external  rectus,  the  antago- 
nist of  the  internal,  receives  no  motor  impulse. 

3.  Hypertropia,  because  the  two  elevators  of  the  cor- 
nea, the  superior  rectus,  and  the  inferior  oblique,  over- 
come by  their  contraction  the  single  depressor,  the 
inferior  rectus,  which  is  the  only  one  of  the  depressors 
belonging  to  the  third  nerve  group,  the  superior  oblique 
having  an  independent  nerve  supply. 

Therefore, 

1.  The  squinting  eye  is  invariably  rotated  inward  and 
upward. 

2.  In  alternating  squint,  fixation  is  transferred  from 
one  eye  to  the  other  at  the  patient's  will,  and  the  non- 
fixing  eye  immediately  turns  inward  and  upward.  Fixa- 
tion with  R.  means  left  hyperesotropia.  Fixation  with 
L.  means  right  hyperesotropia. 

3.  In  constant  squint,  fixation  is  always  made  with  the 
same  eye ;  hence  there  is  no  transference  of  either  esotro- 
pia, or  hypertropia,  and  the  eye  not  used  in  fixation  is 
rotated  inward  and  upward. 

4.  In  concomitant  squint,  binocular  vision  is  established 
by  correction  of  the  refraction  and  tenotomy  of  both 
internal  muscles. 

5.  In  constant  squint,  in  addition,  vertical  equilibrium 
must  be  restored  by  tenotomy  of  the  superior  rectus  of 
the  squinting  and  possibly  of  the  inferior  rectus  of  the 
fixing  eye. 

The  President-elect,  John  B.  Roberts,  of  Philadelphia, 
was  introduced  by  Dr.  McCormick.  He  took  the  chair, 
and  announced  the  appointments  for  the  annual  addresses 
of  next  year  as  follows :  Address  on  Medicine,  Dr.  I.  C. 
Gable,  of  York  County ;  Address  on  Obstetrics,  Dr.  W. 
B.  Ulrich,  of  Delaware  County;  Address  on  Surgery, 
Dr.  C.  L.  Stevens,  of  Bradford  County ;  Address  on  Hy- 
giene, Dr.  Hildegarde  H.  Longsdorf,  of  Cumberland 
County;  Address  on  Mental  Diseases,  Dr.  F.  X.  Der- 
cum,  of  Philadelphia  County  ;  Address  on  Otology,  Dr. 
L.  H.  Taylor,  of  Luzerne  County. 


July  7,  1894] 


MEDICAL  RECORD 


29 


A  QUESTION    OF    FACT  AND    ACCURACY  IN 
STATISTICS. 

Dr.  Spence  takes  Issue  with  Dr.  Beck. 

To  tub  Editor  op  the  Medical  Record. 

Sir  :  My  letter  in  your  issue  of  June  2d,  which  seems  to 
hare  aroused  Dr.  Carl  Beck  to  an  unusual  degree,  as  evi 
denced  by  his  reply  in  your  issue  of  June  16th,  was  not 
intended  as  a  discussion  of  the  doctor's  paper  on  pyo- 
thorax.  It  was  written  simply  to  correct  the  false  con- 
clusion which  he  drew  from  my  article  in  The  St.  Louis 
Clinique. 

I  am  sorry,  after  aiming  to  make  my  remarks  very 
easy  of  comprehension,  he  should,  besides  misinterpret- 
ing so  many  of  its  statements,  consider  the  letter  as  an 
attack  upon  himself.  These  are  hardly  of  sufficient  con- 
sequence that  I  should  take  up  your  space  to  convince 
Dr.  Beck  of  his  errors ;  but  I  must,  in  justice  to  those 
concerned,  reiterate  those  statements  of  mine  which  the 
doctor  has  directly  contradicted. 

I  was  present  at  the  meeting  of  the  County  Medical 
Society  the  evening  Dr.  Beck  read  his  paper,  and  I  state 
again,  "  the  general  opinion  was,  that  free  incision  with 
good  drainage  was  all  that  was  necessary  in  the  majority 
of  cases."  Dr.  Beck  evidently  forgot  that  four  men  dis- 
cussed his  paper,  and  only  one  (one  of  the  surgeons  he 
mentioned)  was  mildly  in  favor  of  resection.  It  seems  to 
me,  therefore,  the  general  opinion  was  as  I  have  stated. 

Dr.  Beck  refers  to  a  patient  on  whom  he  says  he  "  un- 
happily had  the  bad  fortune  to  be  compelled  to  perform 
resection  "  after  Dr.  Ripley  had  made  an  incision.  It 
will  be  my  good  fortune,  while  assuring  him  of  my  sym- 
pathy, to  give  the  doctor  here  the  true  history  of  that 
case.  I  am  surprised  to  find  that  it  differs  so  materially 
from  the  one  published  by  Dr.  Beck,  for  this  appears  to 
be  Case  IX.  of  his  paper. 

The  child,  a  girl  of  six  years  of  age  at  the  time  of  the 
operation,  not  ten  as  published,  was  taken  sick  in  March, 
1893,  ***  pfcim>  pneumonia.  Dr.  Ripley,  in  private 
practice,  saw  the  child  in  consultation  with  the  family 
physician,  and  diagnosed  an  empyema. 

On  April  4,  1893,  Dr.  Ripley  made  a  free  incision  into 
the  chest,  and  after  liberating  a  large  quantity  of  pus,  in- 
troduced a  good  sized  drainage  tube,  dressed  the  wound, 
and  gave  the  necessary  instructions.  He  only  saw  the 
child  once  more,  and  that  was  four  days  after  the  opera 
tion.  On  April  14th,  ten  days  after  the  incision,  the 
family  for  some  reason  became  displeased  with  their 
family  physician  and  dismissed  him.  That  of  course 
ended  Dr.  Ripley's  observation  of  the  case.  Another 
physician  was  now  called,  who  on  the  advice  of  another 
consultant,  sent  the  child  to  St.  Luke's  Hospital,  under 
the  supposition  that  the  other  pleural  cavity  also  con- 
tained pus.  This  proved  to  be  incorrect,  for  so  the  St. 
Luke's  people  decided  after  a  careful  examination  includ- 
ing the  insertion  of  an  exploring  needle.  They  found  no 
pus  in  the  chest  into  which  they  introduced  the  needle. 
Therefore,  as  the  child  was  never  in  St.  Francis  Hospital 
or  in  any  other  except  St.  Luke's,  contrary  to  Dr. 
Beck's  report  she  was  not  "  aspirated  for  empyema  in  a 
hospital  of  this  city." 

The  last  attending  physician  was  recalled  after  the 
child  had  been  sent  home  from  St.  Luke's  Hospital,  and 
by  means  of  a  chain  saw  he  exsected  a  small  piece  of  rib, 
and  introduced  a  drainage-tube  of  very  small  calibre. 
This  exsection  was  done  about  three  weeks  after  the  in- 
cision, and  some  time  later  a  piece  of  this  small  tube 
broke  off  into  the  chest.  It  is  ridiculous  to  say,  as  Dr. 
Beck  does  in  his  history  of  this  case,  this  tube,  "  after  it 
had  courageously  resisted  the  permanent  rush  of  the  re- 
tained pu?,  at  last  resigned  and  broke  beneath  the  safety- 
pin,"  when  you  reflect  that  this  pus  cavity  had  been 
opened  twice  and  was  constantly  draining  during  the 
previous  three  weeks. 


Now  on  May  15,  1893,  less  than  six  weeks  after  Dr. 
Ripley's  incision,  instead  of  six  months  as  he  reports  in 
his  pathetic  history,  Dr.  Beck  exsected  a  piece  of  rib 
three  eighths  of  an  inch  long.  The  parents  showed  me 
these  curios,  the  piece  of  bone  last  exsected  and  the  sev- 
eral drain- tubes,  which  they  keep  for  safety  in  a  little 
plush  lined  jewelry  box. 

Dr.  Beck's  report  of  this  case  now  reads  as  follows : 
"  Four  weeks  later  recovery  was  perfect,  after  the  poor 
child  had  been  aspirated,  incised,  and  resected,  first  with 
saw  and  then  with  shears."  This  reads  well,  but  what 
are  the  facts  ? 

The  mother  tells  me  the  child  was  confined  to  bed 
during  May,  June,  July,  August,  and  into  September, 
the  next  four  months  after  Dr.  Beck's  operation,  and  the 
wound  was  not  healed  until  Christmas,  1893.  Thus,  in- 
stead of  recovery  being  perfect  in  four  weeks,  as  Dr. 
Beck  has  the  presumption  to  tell  us,  the  child  was  four 
full  months  in  bed,  and  recovery  was  not  complete  till 
seven  months  after  Dr.  Beck's  resection. 

These  facts  need  no  comments;  but  they  show  how 
valueless  this  case  is  as  to  the  relative  merits  of  incision 
and  resection.  It  was  a  resection,  following  an  exsec- 
tion. 

I  have  gone  rather  minutely  into  this  history,  in  the 
hope  that  Dr.  Beck  will  copy  it  into  his  casebook,  so 
that  he  may  have  it  at  hand,  should  information  be  again 
requested  of  him.  I  really  trust  he  has  been  more  ac- 
curate in  the  histories  he  has  published  of  the  other 
cases. 

Dr.  Beck  says  in  his  letter,  "  The  value  of  the  fourteen 
histories  which  were  appended  to  my  reasons  why  resec- 
tion is  the  better  treatment,  consists  in  their  unusual  and 
interesting  additional  circumstances."  It  must  be  ad- 
mitted they  are  both  unusual  and  interesting,  especially 
Case  IX.  It  is  very  unusual,  even  after,  according  to  Dr. 
Beck,  the  irrational  operation  simple  incision,  to  have 
fistula?  remain  as  long  as  in  the  case  twenty -six  years  ol 
age,  mentioned  in  his  paper,  and  in  Cases  III.,  V.,  and  VI. 
Certainly  Cases  V.  and  VI.  cannot  be  cited  as  very  en- 
couraging examples  of  the  "  only  rational  method  ot 
treating  empyema."  Surely  the  doctor  does  not  give  to 
resection  the  credit  for  the  recovery  of  Cases  XII.  and 
XIII. ;  for  he  says  he  did  not  operate  on  them  at  all,  the 
first  case  having  expectorated  the  pus,  and  in  the  other  it 
was  absorbed. 

Statistics,  in  order  to  be  valuable,  should  be  as  to  their 
material  facts,  correct. 

Arnot  Spbnce,  M.D. 

70  West  Seventy-west  Street,  June  89,  1894. 


A  LARGE  DOSE    OF    CYANIDE    OF   POTAS- 
SIUM. 

To  the  Editor  or  tub  Medical  Record. 

Sir  :  In  the  issue  of  the  Medical  Record  for  June  9, 
1894,  I  notice  a  criticism  upon  my  report  of  a  case  in 
which  a  large  dose  of  cyanide  of  potassium  was  swallowed 
without  a  fatal  result. 

I  have  just  written  to  my  patient  of  two  years  ago  and 
enclose  his  answer.  Since  it  is  so  naive  and  corresponds 
closely  enough  to  his  first  statement  to  me,  with  which 
I  took  care  not  to  acquaint  him,  I  hope  you  will  print  it 
entire,  simply  suppressing  the  signature. 

In  my  opinion  this  letter  of  my  patient  is  characterized 
by  about  as  much  "  precision  and  exactness  of  detail " 
as  we  are  liable  to  get  in  suicidal  attempts. 

If  my  critic  has  any  cases  in  which  large  amounts  of 
cyanide  were  weighed  and  recorded  before  being  taken, 
I  hope  he  will  publish  them.  As  a  rule,  however,  this 
means  of  satisfying  our  laudable  scientific  curiosity  is  not 
taken  by  the  suicide. 

On  the  part  of  the  doctor  in  this  case,  there  has  been 
no  "  guessing  "  at  all,  as  I  have  simply  reported  the 
statements  of  the  patient. 

I  am  very  sorry  that  my  critic  is  dissatisfied  with  the 
definiteness  of  my  report,  but  I  have  simply  furnished 


3° 


MEDICAL   RECORD. 


[July  7,  1894 


what  I  had  to  give,  hoping  that  it  might  be  of  value  to 
someone  of  my  fellow-laborers. 

Yours  respectfully, 

F.  W.  Higgins,  M.D. 

"  Syracuse,  N.  Ym  June  13,  1894. 
"Dr.  Higgins — 

Dear  Sir:  Yours  of  June  11  at  hand  and  in  reply 
I  went  to  a  drug  store  and  could  not  find  just  such  a 
shaped  piece  of  cyanide  potassine  as  I  took,  but  had  to 
break  it  off  of  a  large  chunk,  and  it  was  rough  and 
ragged  and  weighed  nine  grains.  Now  I  think  the  piece 
I  took  was  heavier,  as  it  was  about  the  same  size  but  was 
a  solid  piece  and  perfectly  smooth  on  all  sides.  I  do 
not  think  it  was  possible  for  any  of  it  to  have  remained 
in  the  glass,  as  it  was  a  hard  chunk,  and  I  swallowed  it 
immediately  after  drawing  about  one  ounce  of  whiskey 
on  it.  Now,  if  you  will  draw  up  such  papers  as  you  want 
and  send  same  to  me  I  will  go  before  notary  public  and 
swear  to  and  save  them.  The  date  was  October  7,  1892. 
Hoping  the  above  will  be  satisfactory,  I  remain  yours, 
and  ready  to  do  you  a  favor." 


MUST    THE    PARSON    PAY? 


To  ■ 


Editok  or  tub  Medical  Rxcokd. 


Sir  :  Periodically  the  question  of  "  Must  the  Parson 
Pay?'1  is  resurrected,  and  at  this  particular  period  it  is 
viable  again.  This  afternoon  I  have  read  an  article  from 
a  Durham,  N.  C,  doctor,  and  an  answer  from  "A 
Minister,1'  both  of  which  are  clear  of  the  true  inward- 
ness of  the  question.  Both  speak  of  the  amount  of 
money  received  by  each,  respectively  and  relatively,  and 
upon  that  base  their  respective  sides  of  the  argument. 
This  is  not  the  question  at  all.  And  there  is  one  which, 
while  very  much  lower  than  the  highest,  will  appeal  to 
the  reason  of  even  the  Durham  M.D.  Indeed,  he  chal- 
lenges the  argument  when  he  says  that,  when  he  had  de- 
termined that  those  well-fed  and  well  paid  North  Caro- 
lina preachers  were  no  longer  "  objects  of  charity,1'  and 
consequently  not  entitled  to  the  doctor's  largess,  with 
a  magnificent  burst  of  generosity  he  increased  his  sub- 
scription to  the  minister's  salary  "  from  $39  to  $50  per 
year."  He  "  had  been  a  member  of  the  church  for 
years,"  and,  of  course,  was  under  obligation,  according 
to  his  own  showing,  to  pay  for  what  he  got  in  preaching. 
How  well  does  he  do  it.  Fifty  dollars  per  year.  Fifty- 
two  Sundays  in  each  of  those  years — two  sermons  each 
Sunday  and  one  Wednesday  evening  at  prayer-meeting, 
give  an  aggregate  of  one  hundred  and  fifty- six  hours  of 
his  preacher's  time  devoted  to  the  doctor's  welfare  every 
year,  for  which  the  doctor  pays  the  munificent  sum  of 
thirty  cents  (in  round  numbers)  for  each  hour's  work. 
If  the  doctor  hasn't  a  wife,  he  ought  to  have,  so  to  the 
two  the  price  is  reduced  to  a  little  over  fifteen  cents  for 
each ;  and  when  he  says  he  has  practised  medicine  at 
Durham  for  twenty  years,  it  is  at  least  presumable  that 
the  doctor  has  averaged  during  that  time  three  children 
to  hear  each  sermon.  So  that  three  cents  is  the  figure 
at  which  his  spiritual  medicine  comes  to  him  per  hour  per 
head.  And  this  takes  no  thought  of  the  many  kindly 
offices  done  by  the  good  pastor  to  the  parishioners  with 
never  a  thought  of  compensation.  Now,  it  seems  perti- 
nent to  ask  the  doctor  if,  when  he  sends  in  the  parson's 
bill,  he  will  in  the  spirit  of  "  the  one  for  the  other," 
which  he  so  insists  upon,  fairly  estimate  his  prescriptions 
at  the  same  royal  fees  which  he  pays  the  parson.  To  a 
man  up  a  very  dwarfish  tree,  it  looks,  if  he  look  with 
good  eyes  and  fairly,  that  the  parson  is  the  one  who 
"  wears  the  yoke,"  and  not  the  doctor,  and  if  the  par- 
son should  "  rebel,"  preaching  would  come  quite  a  good 
deal  higher  to  the  most  of  us  than  it  does  at  present. 
"  Objects  of  charity,"  indeed!  If  there  is  a  man  on 
earth  who  earns  every  dollar  of  his  salary,  it  is  the 
preacher  of  the  gospel.  True,  the  doctor  earns  his — 
true,  the  doctor  does  a  great  deal  of  his  work  for  people 
who  cannot  pay ;  but  it  is  also  true  that  many  members 


of  the  Durham  church  can't  pay  anything  for  their 
preaching,  and  others  won't,  so  that  this  is  only  as  broad 
as  it  is  long.  The  doctor  has  appealed  to  the  quid  pro  quo 
argument,  and  should  be  held  to  it.  The  fee  for  office 
prescriptions  in  smaller  towns  is  usually  $1.  If  the  Dur- 
ham doctors  will,  in  local  society  assembled,  proceed  an 
other  step  in  their  reformation,  and  at  next  report  be 
able  to  show  that  they  each  have  raised  their  church  sub- 
scription to  $156  per  year  for  each  member  of  each  fam- 
ily, then  they  will  have  earned  the  right  to  vaporize 
upon  this  question  some  more,  and  the  preachers  will 
make  no  objection  to  paying  their  medical  bills  like 
other  folks. 

For  shame,  my  brethren !  Blush  to  remember  that 
you  ever  thought  to  say  such  things  before,  and  don't 
ever  do  so  again.  I  intimated  that  there  was  a  higher 
and  better  reason  than  I  have  indicated  for  holding  up 
the  hands  of  these  men,  but  I  am  no  preacher,  and  the 
Medical  Record  is  no  publisher  of  sermons.  I  am  a 
practitioner  of  medicine,  however,  and  I  don't  belittle 
my  profession  when  I  claim  that  we  could  do  less  well 
without  the  offices  of  the  faithful,  conscientious  pastor 
than  he  without  us.  My  pastor — God  bless  him — 
ministers  faithfully  to  my  living  and  has  lovingly  and 
tenderly  buried  my  dead,  and  when  opportunity  offers  I 
shall  serve  him,  glad  to  be  able  to  in  some  measure  show 
my  love  and  gratitude.  Charity,  indeed ;  God  save  the 
mark!  J.  C.  Bogle,  M.D. 

Danvillt,  Kv.,  June  11,  1894. 


Utoedicat  Stems. 

Contagious  Diseases  — Weekly  Statement— Report  of 
cases  and  deaths  from  contagious  diseases  reported  to  the 
Sanitary  Bureau,  Health  Department,  for  the  week  end- 
ing June  30,  1894. 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis 

Measles 

Diphtheria 

Small-pox 

Cholera 

Varicella 

Pertussis 

Erysipelas 

Leprosy ................. 


Cases. 


Deaths. 


99 

48 

7 

6 

63 

10 

4 

4 

86 

10 

23a 

6t 

9 

4 

0 

0 

0 

0 

0 

0 

0 

O 

0 

0 

New  Laws  of  Interest  to  the  Medical  Profession. — 

The  last  Legislature  was  no  exception  to  the  average  run 
of  legislatures  as  to  attempts  made  to  break  down  the 
safeguards  of  the  medical  profession.  One  bill  cut  the 
fee  for  admission  to  the  regents'  examination  from  $25 
down  to  $5  ;  another  made  the  State  pay  the  fee  instead 
of  the  student ;  and  a  third,  in  the  interest  of  the  Faith 
Curists,  provided  that  any  person  may  freely  contract  for 
the  services  of  whomsoever  he  considers  competent  to 
alleviate  suffering,  or  prevent  or  heal  disease,  and  it  shall 
be  lawful  for  persons  so  employed  to  attend,  treat,  nurse, 
and  endeavor  to  heal  the  employing  patient  and  receive 
compensation  therefor,  subject  to  the  medical  laws  of  the 
State  relative  to  improper  practice.  None  of  these  bills 
were  passed. 

A  law  was  passed  providing  that  any  person  holding  a 
diploma  of  date  prior  to  January  1,  1880,  conferring  the 
degree  of  bachelor  or  doctor  of  medicine  from  a  reputable 
incorporated  American  medical  school  or  college,  and 
who  has  been  a  resident  and  citizen  of  this  State  continu- 
ously since  June  1,  1880,  and  who  omitted  or  neglected 
to  register  with  a  county  clerk  as  prescribed  by  law,  shall, 
upon  production  of  his  or  her  diploma  and  satisfactory 
proof  of  such  facts,  as  provided  in  section  two  hereof,  be 
entitled,  upon  payment  of  a  fee  of  $25,  to  receive  from  a 
State  board  of  medical  examiners  recommendations  upon 


July  7,  1894] 


MEDICAL   RECORD. 


3i 


which  the  regents  shall  issue,  under  seal,  a  certificate  of 
the  facts  that  he  or  she  may  register  in  the  clerk's  cffice 
of  the  county  where  he  or  she  may  reside,  which  shall, 
after  such  registration,  be  a  sufficient  license  to  practise 
medicine  in  the  county  where  registered.  Proof  of  such 
residence  shall  be  by  affidavits  of  at  least  two  reputable 
citizens,  whose  reliability  shall  be  certified  to  by  any 
county  or  supreme  court  judge  of  the  State.  Any  person 
desirous  of  securing  the  benefits  of  this  act  must  do  so 
within  one  year  from  the  date  it  takes  effect ;  but  it  shall 
not  be  construed  to  conflict  with  chapter  661  of  the  laws 
of  1893, tne  Public  Health  Law. 

The  Governor  vetoed  an  amendment  to  the  Public 
Health  Law  providing  that  any  person  who,  not  being  then 
lawfully  authorized  to  practise  medicine  within  this  State 
and  so  registered  according  to  law,  shall  practise  medicine 
within  this  State  without  lawful  registration,  or  in  viola- 
tion of  any  provision  of  this  article,  shall  be  deemed  guilty 
of  a  misdemeanor,  and  on  conviction  thereof  shall  be 
punished  by  a  fine  of  not  less  than  $50  for  the  first  offence, 
and  for  each  subsequent  offence  by  a  fine  of  not  less  than 
{100,  or  by  imprisonment  for  not  less  than  100  days,  or 
by  both  fine  and  imprisonment.  When  any  prosecution 
under  this  article  is  made  on  the  complaint  of  any  incor- 
porated medical  society  of  the  State,  or  any  county  medi- 
cal society  of  such  county  entitled  to  representation  in  a 
State  society,  the  fine  when  collected  shall  be  paid  to  the 
society  making  the  complaint,  and  the  expense  incurred 
by  any  such  society  in  such  prosecution,  including  neces- 
sary counsel  fees,  may  be  retained  by  such  society  out  of 
the  penalties  so  collected,  and  the  residue,  if  any,  shall 
be  paid  into  the  county  treasury.  In  vetoing  this  bill, 
the  Governor  said :  "  The  Public  Health  Law  was  con- 
structed upon  the  principle  of  excluding  from  its  provi- 
sions all  but  civil  penalties,  and  transferring  all  criminal 
penalties  to  the  penal  code,  where  they  properly  belong. 
It  was  with  this  idea  that  the  Statutory  Revision  Com- 
missioners, in  revising  the  health  laws,  omitted  from  the 
Public  Health  Law  enacted  last  year  the  penal  provisions 
which  this  bill  contains,  with  the  intention  of  inserting 
them  in  the  penal  code.  As  it  happened,  the  Legislature 
passed  no  bill  making  that  transfer,  and  accordingly  the 
same  provisions  are  now  sought  to  be  re  enacted.  The 
mistake  has  been  made,  however,  of  not  attaching  them 
to  the  penal  code.  To  enact  the  bill  in  its  present  shape 
would  be  to  destroy  partially  the  wise  principle  upon 
which  the  Public  Health  Law  was  framed  and  to  establish 
a  bad  precedent  for  future  legislation." 

A  law  was  passed  providing  that  any  medical  society 
now  organized  in  any  of  the  counties  of  the  State  set 
apart  since  the  passage  of  the  act  of  181 3  to  incorpo- 
rate medical  societies  for  the  purpose  of  regulating  the 
practice  of  physic  and  surgery  in  this  State,  shall,  upon 
complying  with  the  provisions  of  this  act,  enjoy  the  same 
privileges  and  possess  the  same  powers  as  the  societies  in- 
corporated by  virtue  of  said  act  now  enjoy  and  possess, 
but  subject,  nevertheless,  to  the  provision  of  any  acts 
or  parts  of  acts  heretofore  passed  in  relation  to  medical 
societies  or  to  regulate  the  practice  of  physic  and  surgery 
in  this  State.  Before  any  such  society  shall  be  entitled 
to  the  privileges  and  possess  the  powers  as  provided  in 
this  act,  such  society,  at  a  regular  meeting  thereof  or  at  a 
special  meeting  called  for  that  purpose,  after  due  notice 
to  all  its  members,  shall  make  and  file  with  the  Secretary 
of  State  a  certificate  signed  and  acknowledged  by  its 
president  and  secretary,  stating  the  name  of  such  society, 
the  date  of  its  organization,  the  name  and  residence  of  its 
members ;  that  the  said  society,  by  a  majority  vote  of  its 
members,  has  elected  to  become  and  be  a  body  corpo- 
rate under  and  by  virtue  of  said  act,  and  be  subject  to 
the  provisions  of  any  acts  or  parts  of  acts  heretofore 
passed,  and  now  in  force,  in  relation  to  such  societies  or 
the  practice  of  physic  and  surgery  in  this  State.  Upon 
filing  the  certificate  such  society  shall  become  and  be  a 
body  corporate  under  the  name  set  forth  in  said  certifi- 
cate, the  same  as  if  such  society  had  been  incorporated 
under  and  pursuant  to  the  provisions  of  the  said  law. 


The  trustees  of  Columbia  College  were  made  the  legal 
successors  of  the  trustees  of  the  College  of  Physicians 
and  Surgeons  for  the  executing  of  all  trusts  in  the  city  of 
New  York,  and  the  consolidation  was  legalized.  The 
same  city  was  authorized  to  expend  $200,000  for  addi- 
tional buildings  for  the  Gouverneur  Hospital.  The  Gov- 
ernor vetoed  a  bill  changing  the  name  and  increasing  the 
powers  of  the  trustees  of  the  West  Side  German  Dispen- 
sary. The  city  is  to  pay  38  cents  a  day  for  each  infant 
cared  for  in  the  babies'  ward  of  the  Post  Graduate  Hos- 
pital, and  $15  for  each  mother  in  the  Mothers  acd 
Babies'  Hospital.  The  Hahnemann  Hospital,  the  St. 
Mark's  Hospital,  and  the  Manhattan  Hospital  Association 
were  released  from  certain  assessments.  A  charter  was 
granted  to  the  Rochester  Homoeopathic  Hospital.  The 
law  of  1889,  relative  to  the  formation  of  hospital  corpo- 
rations, was  amended  so  that  certificates  must  be  passed 
upon  by  the  courts.  The  Governor  vetoed  and  afterward 
signed  a  bill  for  the  relief  of  the  Goshen  Sanitarium 
Company,  of  Goshen.  He  vetoed  a  bill  forbidding  au- 
topsies in  insane  asylums  or  hospitals  unless  the  author- 
ities of  the  county  from  which  the  deceased  came  had 
been  previously  notified.  An  appropriation  was  made 
for  a  homoeopathic  insane  hospital  on  the  Collins  farm 
in  Erie  County.  A  bill  failed  to  pass  providing  that  in 
all  hospitals  or  asylums  homoeopathic  physicians  shall  be 
appointed  equally  with  physicians  of  the  regular  school. 

None  of  the  amendments  to  the  pharmacy  laws  were 
successful.  One  of  these  provided  for  a  yearly  license 
fee  of  $1.  Another  allowed  an  applicant  to  secure  an 
order  for  a  license  from  the  court  if  not  entitled  to  the 
same  within  three  months  after  the  organization  of  the 
board.  The  Governor  vetoed  amendments  to  Sections 
184  and  187  of  the  Public  Health  Law  so  as  to  enable 
persons  who  have  failed  to  apply  for  their  licenses  as 
pharmacists  within  the  time  prescribed  to  make  applica- 
tion hereafter,  and  also  to  correct  a  clerical  error  in 
the  existing  section  by  changing  the  word  "  resignation" 
to  ' '  registration. ' '  The  only  amendment  made  to  Section 
187  was  to  correct  the  spelling  of  the  word  "pepper- 
mint," and  another  clerical  error  was  made  in  the  bill  by 
changing  the  word  "  usual "  to  "  unusual,"  so  as  to  per- 
mit the  sale  of  unusual  domestic  remedies  by  retail 
druggists  in  the  rural  districts  without  license  as  pharma- 
cists and  to  prohibit  the  sale  by  them  of  usual  remedies. 
The  Governor  stated  in  his  veto  that  the  new  clerical 
error  was  worse  than  the  old  one. 

A  bill  paying  £3,000  a  year  to  the  physician  to  the 
coroner  of  Kings  County  for  autopsies  was  vetoed.  * 
Bills  did  not  pass  :  Providing  that  $15  shall  be  paid  for 
autopsies  ordered  by  coroners  ;  giving  a  salary  of  £3,000 
to  each  of  the  two  coroners  in  Erie  County ;  providing 
for  the  appointment  of  a  State  dental  instructor ;  amend- 
ing the  Public  Health  Law  so  that  a  diploma  may  be  given 
to  anyone  who  had  been  practising  dentistry  for  six 
years  previous  to  June  20,  1879  >  amending  the  same  law 
so  as  to  make  examinations  for  veterinary  practice  more 
stringent,  and  providing  fines  for  violation  of  the  same ; 
extending  to  January  1,  1895,  tne  tmie  f°r  registry  of 
veterinarians  who  have  no  diploma  from  a  college  or  so- 
ciety ;  and  exempting  veterinarians  from  jury  duty.  A 
State  veterinary  college  was  established  at  Cornell  Uni- 
versity, and  150,000  was  appropriated  for  the  same. 

An  amendment  to  the  "charter  of  the  New  York  So- 
ciety for  the  Relief  of  Widows  and  Orphans  of  Medical 
Men  was  passed,  stating  that  the  objects  of  said  society 
are  benevolent,  and  to  afford  relief  to  the  widows,  or- 
phans, and  dependent  relatives  of  medical  men.  An 
amendment  to  the  code  of  civil  procedure  requires  an 
examination  by  a  female  physician  or  surgeon  in  cases 
where  a  female  must  be  examined  physically.  The  pay 
of  police- force  surgeons  in  New  York  City  was  increased 
from  £2,250  to  ^3,000  a  year,  and  the  act  was  made  to 
apply  to  Brooklyn  also.  A  fine  of  $  100  was  ordered  for 
every  omission  in  reporting  deaths,  births,  and  marriages 
in  New  York  City.  A  bill  failed  to  reach  the  Governor 
providing  that  it  shall  be  the  duty  of  the  State  Board  of 


32 


MEDICAL    RECORD. 


[July  7,  1894 


Health  to  make  an  analysis  of  all  patent  medicines  and 
charge  a  fee  of  $50,  and  providing  that  patent  medicines 
shall  not  be  sold  unless  examined  and  approved  by  the 
State  Board.  The  Governor  vetoed  a  bill  prohibiting 
the  giving  away  or  selling  after  October  1st,  next,  of  any 
poison  or  poisonous  substances  in  liquid  form  except  in 
fluted  bottles  labelled  in  the  manner  heretofore  provided 
by  law.  In  his  veto  the  Governor  said :  "  The  questions 
at  once  suggest  themselves  what  is  meant  by  '  poison  or 
poisonous  substances/  why  the  act  should  be  limited  to 
poisons  in  liquid  form,  and  what  is  meant  by  '  fluted ' 
bottles.  A  measure  of  this  kind  might  be  of  service,  bit 
it  should  b;  more  carefully  worded  so  that  it  would  not 
require  a  decision  of  the  courts  immediately  to  deter- 
mine what  it  meant.  A  fluted  bottle  may  be  any  one  of 
a  dozen  or  more  different  styles.  Poisons  and  poisonous 
substances  are  very  indefinite  words." 

Syphilis  as  a  Ground  for  Divorce  —The  Supreme 
Court  of  Vermont  considers,  in  the  recently  decided  case 
of  Ryder  vs.  Ryder,  syphilis  as  a  ground  for  divorce. 
There  is  in  that  State,  as  in  miny  of  the  other  States,  a  law 
which  provides  that  the  marriage  contract  may  be  annulled 
when  at  the  tim*  of  the  marriage  either  party  was  physi- 
cally incapable  of  entering  into  the  marriage  state.  It 
was  found  in  this  case  that  the  wife,  from  whom  the  hus- 
band asked  to  be  divorced,  had,  at  the  time  of  marriage, 
chronic  syphilis,  which  was  incurable ;  that  at  the  time 
the  mm  who  mxrried  her  supposed  her  to  be  chaste; 
that  in  about  two  months  she  communicated  the  disease 
to  him ;  that  he  did  not  know  that  she  had  the  disease 
until  she  communicated  it  to  him;  that  he  voluntarily 
cohabited  with  her  before  and  after  he  knew  of  her  dis- 
ease ;  that  a  child  was  born  to  them  about  a  year  and 
four  months  after  their  marriage ;  that  the  child  was  a 
mass  of  syphilitic  sores,  attributable  to  the  condition  of 
the  mother,  and  soon  died;  that,  at  the  birth  of  the 
child  and  afterward,  the  mother  was  in  about  the  condi- 
tion of  the  child  from  such  sores ;  that  they  both  con- 
sulted a  physician,  who  treated  them  some  time,  when 
she  got  better ;  that  he  believed  from  that  time,  until 
the  child  was  born,  she  had  got  well  of  the  disease,  and 
would  not  be  troubled  again  with  it;  that  he  never  had 
intercourse  with  her  after  the  birth  of  the  child ;  and 
that  at  no  time  could  he  have  sexual  intercourse  with  her 
without  great  danger  of  contracting  the  disease.  Upon 
these  facts,  the  question  presented  to  the  Supreme  Court 
was  whether  the  trial  court  was  in  error  in  refusing  to 
.  annul  the  marriage  A  majority  of  the  court  thought  it 
was.  It  was  not  found  that  the  woman  was  fully  aware 
of  her  condition  at  the  time  of  the  marriage.  It  would 
be  presumed  that  she  was  not.  If  it  were  found  that  she 
was  fully  aware  of  her  condition,  she  would  have  been 
guilty  of  a  fraudulent  concealment  in  not  disclosing  it  to 
him  she  was  about  to  marry.  It  would  be  an  essential  fact, 
entirely  within  her  knowledge,  not  within  his,  nor  open 
to  his  observation  nor  to  his  inquiry  upon  any  reasonable 
principles  which  do  or  should  prevail  in  conducting  the 
negotiations  which  lead  up  to  entering  into  the  contract 
of  marriage. — Cincinnati  Lancet  and  Clinic. 

The  Last  Illness  of  Dr.  Brown  Sequard  —  Dr.  Ogle 
gives  in  The  Lancet  an  interesting  account  of  the  illness 
of  the  late  D;.  Brown-S6quard.  It  appears,  he  says,  that 
for  some  years  past  Dr.  Brown-S£quard  had  not  seemed 
to  his  friends  to  be  in  good  general  health.  He  had,  in 
1889,  teen  the  subject  of  severe  muscular  rheumatism, 
aad  in  the  autumn  of  that  year  he  suffered  from  some 
prostatic  trouble.  From  these  ailments  he  entirely  re- 
covered. During  the  following  winter  and  spring,  when 
at  Nice,  he  had  an  attack  of  whooping-cough,  as  was 
mentioned  in  The  Lancet  at  the  time.  He  was  then 
regularly  using  his  orchitic  fluid  injections.  During  the 
next  two  years  he  remained  fairly  well,  working  very 
hard  and  writing  much,  sometimes  answering  as  many  as 
eighty  letters  in  the  day.  In  the  summer  of  1893  ne  suf- 
fered great  distress  of  mind  owing  to  the  ill-health  of  his 
wife,  and  in  December  he  was  residing  at  Nice  and  was 


confined  to  his  bed,  suffering  from  phlebitis,  when  his 
wife  was  dying.  TTie  consequent  grief  perfectly  un- 
manned him,  and  was  quite  uncontrollable,  and  for  some 
time  he  took  but  little  food  and  was  unable  to  sleep,  re- 
fusing to  leave  the  house.  He  returned  to  Paris  at  the 
beginning  of  March.  Then  came  the  vertigo  and  affec- 
tion of  sight,  followed  by  the  unconsciousness  which  he 
himself  wrote  about  to  Dr.  Waterhouse,  and  from  which 
he  recovered.  Dr.  Dupuy  says  that  at  that  period  the 
speech  remained  "  thick  "  and  embarrassed  at  times,  and 
that  Dr.  Brown- Sgquard  remarked:  "This  is  an  attack 
of  epilepsy,  as  you  can  see."  Instead  of  going  to  bed  as 
desired,  he  wrote  several  letters,  and,  no  doubt,  wrote 
the  letter  to  Dr.  Waterhouse  above  alluded  to,  relating 
his  symptoms  and  speculating  upon  them.  During  the 
following  day  he  was  in  the  same  condition  as  regards 
vertigo,  hemiopia,  and  occasional  thickness  of  speech, 
but  there  was  no  aphasia.  He  was  then  visited  also  by 
his  friends,  Dr.  Dej6vine  and  Professor  Potain,  together 
with  Dr.  Dupuy,  but  could  not  be  persuaded  to  take  ade- 
quate rest  and  nourishment.  On  the  next  day  (Friday) 
he  consented  to  take  meat,  milk,  and  bread  in  small 
quantities  throughout  the  day,  and  was  comparatively 
cheerful.  At  the  close  of  the  day  his  face  became  much 
flushed,  and  the  vertigo  and  hemiopia  very  distressing! 
and  in  consequence  of  this  he  walked  from  one  room  to 
another  on  "  all  fours,"  giving  at  the  time  the  analysis 
of  his  symptoms  and  the  prognosis  of  his  case,  as  if  he 
was  contemplating  and  discoursing  on  the  illness  of  an- 
other person.  During  the  night  of  that  day  he  was  seized 
with  vomiting,  and  in  the  early  morning  it  was  found 
that  he  was  unable  to  speak  and  that  the  left  arm  was 
paralyzed  as  to  power  of  movement.  Dr.  Dupuy  found 
later  on  that  paralysis  of  the  muscles  on  the  right  side  ot 
the  face  existed  and  that  the  tongue  was  protruded  to  the 
right  side.  The  left  leg  and  the  arm  and  leg  on  the  right 
side  were  unaffected.  There  was  no  muscular  spasm  in 
any  part,  no  interference  with  sensation,  either  general 
or  special ;  but  vertigo  was  much  increased,  and  there 
was  external  strabismus  of  the  right  eye.  The  condition 
of  speech  was  the  same,  and  there  was  still  no  aphasia. 
Toward  the  evening  of  the  day  the  face  became  exceed- 
ingly congested  on  several  occasions,  and  the  blood- ves- 
sels of  the  forehead  much  swollen,  and  there  was  droop- 
ing of  the  upper  eyelid  ttf  the  right  eye.  During  the 
morning  of  the  next  day  (Saturday)  he  made  Dr.  Dapuy 
understand  that  he  wishea  to  write  on  a  slate,  but  the 
result  was  unintelligible,  excepting  that  the  word  "  hy- 
peresthesia "  was  recognized.  He  then  saw  some  friends 
with  pleasure.  At  2  am  on  Sunday  he  became  entirely 
unconscious,  and  coma  set  in.  The  axillary  temperature 
rose  to  400  C. — i.e.,  104°  F.,  and  he  died  without  a  strug- 
gle near  midnight.  After  the  cessation  of  breathing  and 
of  the  heart's  action  all  the  muscles  of  the  legs  and  arms 
were  for  several  minutes  in  a  state  of  fibrillary  contrac- 
tion, and  the  axillary  temperature  at  the  point  of  death 
rose  to  41. 50  C. — i.e.,  105  90  F.  No  post-mortem  ex- 
amination could  be  made. 

Prevention  of  Iodism  — Dr.  H.  N.  Spencer  (Jnt.  Med. 
Mag.,  December,  1893),  recommends  the  following 
mode,  due  to  Professor  Hardaway,  of  prescribing  iodide  oi 
potassium ;  the  tendency  to  coryza  is  counteracted  by 
the  nux  vomica  and  amnion io  citrate,  while  the  tonics 
prevent  depression : 

Q .    Iodide  of  potassium J  ss. 

Citrate  of  iron. 

Ammonium. ftft   3j- 

Tincture  of  nux  vomica 3  ij. 

Water .    Jjss. 

Compound  tincture  of  cinchona  to  make  up  J  iv. 
Dose,  one  teaspoonful  in  half  a  glass  of  water  after  meals.     The 
quantity  of  iodide  may  be  increased  to  any  desired  extent  by  adding, 
the  necessary  amount  of  a  saturated  solution. 

Insanity  is  Increasing  in  Ireland,  according  to  a  re- 
cent parliamentary  report. 

The  Fee  for  Medical  Witnesses  in  the  London  police 
courts  is  half  a  guinea,  or  about  $2.50. 


Medical   Record 

A  Weekly  ^Journal  of  Medicine  and  Surgery 


Vol.  46,  No.  2. 
Whole  No.  1236. 


New  York,  July  14,  1894. 


$5.00  Per  Annum. 
Single  Copies,  zoc. 


TEN  YEARS'  EXPERIENCE  WITH  ALEXAN- 
DER'S OPERATION  FOR  SHORTENING  THE 
ROUND   LIGAMENTS  OF  THE  UTERUS. 

Sixty- five  Operations. 
By  PAUL   F.   MUNDE,  M.D., 

NEW  YORK. 

ntOFRSSOR  OF  GYNECOLOGY  AT  THE  NEW  YORK  POLYCLINIC  AND  AT  DARTMOUTH 
COLLEGE  ;  GYNECOLOGIST  TO  MOUNT  SINAI  HOSPITAL  ;  CONSULTING  GYNECOL- 
OGIST IN  ST.   ELIZABETH  AND  THE  ITALIAN  HOSPITALS. 

Soon  after  the  publication  of  Alexander's  little  book  on 
the  operation  revived,  and,  I  believe,  first  actually  per- 
formed by  him,  I,  on  December  12,  1884,  undertook  it 
siccessfully,  following  closely  the  directions  laid  down  in 
Alexander's  work.  I  was  so  much  impressed  with  the 
ease  of  performance  and  the  immediate  and  subsequent 
results  of  the  operation  that,  during  the  next  two  years,  I 
had  six  cases  to  report,  in  four  of  which  I  succeeded  in 
finding  the  ligaments,  in  drawing  them  out,  and  attach- 
ing them  as  recommended  by  Alexander.  My  experi- 
ence with  the  operation  increased  so  rapidly  that  in  the 
American  Journal  of  Obstetrics  for  October,  1888,  I  was 
able  to  report  twenty- three  cases,  with  but  three  failures 
to  find  the  ligaments,  and  *rith  practically  no  failure  in 
the  other  twenty  cases  as  regards  the  permanency  of  the 
result  of  retaining  the  replaced  uterus  in  the  normal  po- 
sition. In  that  article  I  reviewed  at  some  length  the  in- 
dications, results,  and  technique  of  the  operation,  and 
concluded  by  raising  my  voice  very  forcibly  in  its  favor 
as  against  the  later,  more  dangerous,  less  logical,  and 
permanently  less  successful  operations  of  shortening  of 
the  round  ligaments  through  the  opened  abdominal  cav- 
ity, or  ventral  fixation  of  the  fundus  uteri. 

That  article  was  not  read  before  any  medical  society, 
but  was  simply  printed  in  the  above  named  journal, 
where,  of  course,  it  was  seen  by  very  many  members  of 
the  profession,  but  perhaps  did  not  attract  as  much  atten- 
tion as  if  it  had  been  more  widely  circulated  through  the 
columns  of  the  weekly  medical  press,  or  through  the 
"Transactions"  of  the  medical  society  before  which  it 
might  have  been  read.  Hence  I  am  afraid  that  its  precepts 
and  deductions  were  not  so  generally  appreciated  as  they 
should  have  been.  Of  course,  I  can  speak  only  for  my- 
self and  my  own  experience,  and  cannot  expect  that  my 
professional  brethren  will  unhesitatingly  accept  and  fol- 
low my  conclusions.  But  as  I  am  known  to  be  a  con- 
servative operator,  not  only  in  coeliotomy  for  diseased 
ovaries  and  tubes,  but  also  as  regards  other  opera- 
tions which  may  possibly  be  avoided,  I  felt  that  I  was 
entitled,  with  all  due  modesty,  to  more  confidence  and 
belief  than  if  the  operative  furor  had  had  exclusive  pos- 
session of  me.  Nevertheless  I  am  constantly  meeting 
gentlemen  who,  with  quite  as  much  experience  as  my  own 
in  all  sorts  of  gynecological  operations,  still  express  a 
want  of  reliance  in  Alexander's  operation  and  a  prefer- 
ence for  abdominal  section  with  intra-abdominal  short- 
ening of  the  round  ligaments,  or  ventral  fixation,  for  the 
very  same  objects  for  which  I  unhesitatingly  prefer  Alex- 
ander's operation.  It  seems  very  difficult  to  convince 
some  men  that  pelvic  diseases  in  the  female  can  be 
treated  otherwise  than  by  opening  the  abdominal  cavity, 
and  that,  after  all,  in  very  many  cases,  this  should  be  the 


last  resort,  when  all  other  possible  means  have  been  ex- 
hausted. 

Some  of  these  gentlemen  base  their  objections  to  Alex- 
ander's operation  on  the  difficulty  of  finding  the  liga- 
ments or  the  impossibility  of  drawing  them  out ;  others, 
again,  contend  that  the  results  of  the  operation  are  not 
permanent;  and  others,  again,  claim  that  coeliotomy  is 
a  so  much  easier  and  equally  safe  way  of  attaining  the 
same  object.  It  is  scarcely  necessary  for  me  to  say  that 
I  am  perfectly  familiar,  from  a  theoretical  and  practical 
experience  in  gynecology  of  over  twenty  five  years,  with 
the  various  methods  which  are  preferred  to  Alexander's 
operation  by  the  gentlemen  to  whom  I  refer.  I  do  not 
prefer  Alexander's  operation  because  I  have  a  particular 
hobby  in  its  direction,  or  because  I  have  anything  other 
to  gain  by  my  preference  than  supporting  what  I  think 
to  be  best.  I  can  simply  point  to  an  experience  which 
has  now  amounted  to  sixty- five  operations,  and  which, 
with  the  increased  knowledge  of  years,  still  leaves  me  a 
more  and  more  confirmed  supporter  of  the  operation. 

For  minute  details  as  regards  the  technique  and  the 
indications,  I  will  refer  my  readers  to  the  article  pub- 
lished in  the  October,  1888,  number  of  the  Journal  of 
Obstetrics.  I  will  add  but  a  few  brief  remarks  as  to  what 
is  stated  there.  First,  as  regards  the  technique  of  the 
operation  I  will  repeat  that  if  the  ligaments  are  not  found 
it  is  always  the  fault  of  the  operator.  It  is  simply  a 
question  of  careful  attention  to  the  anatomical  landmarks, 
namely,  the  spine  of  the  pubis  and  the  external  inguinal 
ring,  upon  which  depends  the  finding  of  the  ligaments. 
If  the  tissues  are  quickly  divided  down  to  the  fascia  cov- 
ering the  external  inguinal  ring,  this  is  lightly  pricked 
with  the  scalpel,  the  knuckle  of  fat  which  pops  out 
through  the  opening  is  carefully  dissected  out  bluntly 
with  the  handle  of  the  scalpel,  always  being  careful  to 
avoid  detaching  the  bundle  of  fat  from  the  spine  of  the 
pubis ;  if  then  this  bundle  of  fat  is  entirely  lifted  up  from 
the  subjacent  bone  with  mouse  tooth  forceps  or  an  aneu- 
rism needle,  a  slow,  minute,  and  blunt  separation  of  the 
tissues  thus  lifted  up  will  always  succeed  in  revealing  the 
initial  fibres  of  the  round  ligament,  which  usually  lie  at 
the  lower  surface  of  the  bundle  thus  lifted  up,  and  run 
slightly  outward  and  downward,  not  entirely  outward. 
If  traction  upon  the  supposed  fibres  of  the  ligament 
shows  that  it  runs  toward  the  anterior  superior  spinous 
process  of  the  ilium,  the  operator  may  be  sure  that  he 
has  picked  up  fibres  of  the  external  pillar  of  the  ring  or 
of  the  oblique  fascia.  Careful  isolation  of  these  fibres, 
gentle  traction  upon  them  if  they  prove  to  run  in  the 
right  direction,  and  dull  separation  of  the  strand  if  it 
appears  attached  in  the  canal,  will  usually  in  a  few  min- 
utes enable  the  operator  to  draw  out  the  ligament  so  that 
its  identity  is  at  once  apparent  both  to  him  and  the  spec- 
tators. This  point  having  been  reached,  it  is  merely  a 
question  of  gentle,  continued  traction  to  draw  out  as 
much  of  the  ligament  as  is  allowable,  that  is  to  say,  until 
its  increasing  size,  usually  almost  to  that  of  a  lead  pencil, 
shows  that  its  attachment  to  the  uterus  is  approaching. 
If  traction  is  too  severe  and  too  rapid,  or  if  the  liga- 
ment is  either  thin  or  much  adherent,  it  may  easily  be 
broken,  particularly  in  its  lower  two-thirds,  and  may  then 
be  lost  to  future  research,  or,  if  found  again,  will  have 
to  be  picked  up  within  the  depth  of  the  canal.  I  confess 
that  I  still  have  the  impression,  which  I  had  years  ago,  that 
this  operation  requires  all  the  wit  and  dexterity  of  the 
operator  in  order  that  by  some  oversight  or  carelessness 


34 


MEDICAL    RECORD. 


[July  14,  1894 


the  ligament  may  not  be  lost,  broken  off,  or  pushed  aside 
and  thus  lost. 

The  one  unvarying  landmark  is  always  the  spine  of 
the  pubis,  where  I  have  repeatedly  succeeded  in  picking 
up  the  ligament,  which  at  first  I  had  failed  to  isolate  in 
the  bunch  of  fat  lifted  up  according  to  direction.  By 
non-attention  to  this  landmark  the  operator  may  get  to 
one  side  and  manage  to  pick  up  some  other  cord,  even 
drawing  it  out  to  a  small  extent,  as  in  one  case  operated 
on  by  one  of  my  house  surgeons,  until  I,  coming  to  the 
rescue,  satisfied  myself  and  him  that  it  was  the  femoral 
artery,  which  of  course  was  very  hastily  dropped,  fortu- 
nately with  no  evil  results.  By  returning  to  the  spine 
of  the  pubis  and  proceeding  thence  forward,  I  in  a  mo- 
ment, picked  up  the  terminal  fibres  of  the  round  liga- 
ment, isolated  them,  and  drew  out  the  ligament. 

There  will  always  be  in  this  operation  one  drawback, 
and  that  is  the  possibility  that  the  thinness  of  the  liga- 
ments, their  very  diffuse  attachment  to  the  spine  of  die 
pubis,  and  their  uncertain  appearance  in  the  suprapubic 
fat,  further,  the  adhesion  of  such  a  thin  ligament  in  the 
Nuckian  canal,  may  result  in  failure,  either  through  the 
inability  of  the  operator  to  isolate  them  or  in  their  break- 
ing during  his  attempt  to  draw  them  out  In  my  last 
case  the  ligament  on  the  left  side  appeared  to  be  unusu- 
ally friable,  for  it  broke  close  to  its  uterine  origin,  the 
only  instance  where  I  have  seen  it  torn  so  high  up.  By 
passing  the  first  suture  very  deeply  I  managed,  how- 
ever, to  keep  the  left  horn  of  the  uterus  close  to  the  an- 
terior abdominal  wall  and  the  result  was  perfect.  This 
accident,  the  breaking  of  the  ligaments,  is,  in  my  experi- 
ence, the  only  drawback  which  this  operation  possesses. 
And  I  think  by  extreme  care  in  traction  it  also  can  often 
be  avoided. 

I  always  stitch  as  much  of  the  ligament  as  is  not 
drawn  entirely  out  of  the  external  inguinal  ring  into  the 
canal  by  passing  a  number  of  silkworm-gut  sutures 
through  each  pillar  of  the  ring  and  the  ligament  be- 
tween, cutting  off  the  supra  abundant  portion  of  the  lig- 
ament. I  have  very  seldom  found  it  necessary  to  split 
up  the  inguinal  canal  to  the  internal  ring  to  find  the  lig- 
ament, and  then  only  when  the  ligament  had  been  torn  off 
during  my  first  attempts  at  traction.  I  can  see  no  use 
in  opening  the  whole  inguinal  canal  at  first  to  perform 
the  operation.  It  strikes  me  like  a  confession  of  timidity 
at  the  very  outset  to  see  this  done.  I  am  sure  that  out 
of  the  sixty -five  cases  which  I  have  performed  I  have  not 
been  obliged  to  open  the  whole  inguinal  canal  in  more 
than  half  a  dozen  cases.  The  usual  length  of  my  in- 
cision is  not  more  than  two  inches. 

Suppuration  has  occasionally  resulted,  particularly  if 
much  tearing  and  manipulation  was  required  to  find  and 
draw  out  the  ligaments.  I  formerly  employed  a  split 
bone  drainage-tube,  but  have  for  some  years  entirely  dis- 
carded it,  and  cannot  say  that  my  cases  have  done  any 
worse.  Even  if  suppuration  did  take  place  in  the  wounds, 
the  adhesion  of  the  internal  end  of  the  ligament  seemed 
to  be  quite  firm  enough  to  keep  the  uterus  in  position. 

None  of  my  patients  have  ever  shown  the  least  dan- 
gerous symptoms  in  consequence  of  the  operation,  al- 
though several  times  convalescence  was  prolonged  to  four 
and  six  weeks  in  consequence  of  suppuration.  Never 
have  I  seen  an  inguinal  hernia  follow  the  operation.  On 
the  other  hand,  I  have  cured  an  inguinal  hernia  by  the 
operation.  I  have  always  introduced  a  pessary  into  the 
vagina  immediately  after  the  operation,  in  order  to  pre- 
vent undue  strain  upon  the  newly  attached  ligaments, 
and  have  had  it  worn  for  from  three  to  six  months.  Of 
course  if  perineorrhaphy  was  done  at  the  same  sitting  a 
pessary  could  not  be  used. 

As  regards  the  length  of  time  required  to  perform 
Alexander's  operation,  I  would  say  that  much  depends 
upon  the  character  of  the  case.  In  an  easy  case  without 
adhesions  I  have  frequently  succeeded  in  completely 
drawing  out  both  ligaments  in  from  five  to  ten  minutes 
for  each  side.  The  stitching,  of  course,  must  be  care- 
fully done,  and  the  whole  duration  of  the  operation  will 


probably  not  be  less  than  thirty  minutes.  I  need  scarcely 
say  that  it  is  always  imperative  to  draw  out  both  liga- 
ments, since  to  shorten  only  one  ligament  would  result 
in  placing  the  uterus  in  an  oblique  position. 

Second.  As  regards  the  indications  for  the  operation  I 
would  say  that  I  consider  the  lines  very  closely  drawn. 
Only  a  sharply  retroverted  or  retroflexed  uterus,  with 
more  or  less  descensus,  with  more  or  less  relaxed  vaginal 
walls,  with  perfect  mobility  of  the  uterus  and  adnexa, 
justifies  Alexander's  operation.  I  say  justifies,  but  I  do 
not  necessarily  mean  that  these  conditions  are  an  ab- 
solute indication  for  the  operation,  since  in  many  such 
cases  perfect  relief  may  be  given  the  woman  by  a  prop- 
erly adjusted  pessary.  It  is  only  when  a  pessary  cannot 
be  fitted  or  comfortably  worn,  which  will  retain  the 
uterus  and  ovaries  in  their  normal  position,  or  when  the 
patient  insists  upon  being  cured  instead  of  being  merely 
temporarily  relieved  by  a  pessary,  that  we  can  say  that 
Alexander's  operation  is  indicated. 

Whenever  the  uterus  or  appendages  are  adherent, 
Alexander's  operation  is  absolutely  and  positively  con- 
tra-indicated. We  can,  therefore,  not  compare  the  in- 
dications for  Alexander's  operation  and  those  for  ventral 
fixation,  in  my  opinion,  since  the  latter  is  justified  and 
indicated  only  when  adherence  of  the  appendages  or  of 
the  uterus  warrant  our  opening  the  abdominal  cavity  and 
detaching  the  adhesions.  Then,  of  course,  it  is  scarcely 
worth  while  to  do  an  Alexander's,  since  it  adds  very  little 
to  the  danger  to  sew  the  uterus  to  the  anterior  abdominal 
wall.  In  such  cases  of  adherent  uterus  and  appendages, 
however,  where  they  have  been  detached  through  an 
abdominal  incision,  the  operation  of  shortening  the 
round  ligaments  by  doubling  them  upon  themselves,  as 
recommended  by  Wylie,  A.  P.  Dudley,  Mann,  and 
others,  should  be  considered.  I  have  but  one  experience 
with  this  operation,  which  is  still  too  recent  to  enable  me 
to  offer  a  positive  opinion  on  the  subject.  Technically 
it  is  exceedingly  pretty,  logical,  and  easily  effected.  In 
prolapsus  uteri  I  am  not  in  favor  of  Alexander's  opera 
tion,  except  in  so  far  as  it  is  one  in  a  series  of  operative 
measures  by  which  a  retention  of  the  uterus  in  its  normal 
position  in  the  pelvis  is  to  be  attained.  Alone,  Alex- 
ander's operation  is,  in  my  opinion,  of  no  permanent 
benefit  for  prolapsus  uteri.  Neither  do  I  consider  it  ap- 
plicable to  cases  of  anteversion  and  anteflexion  in  which 
it  is  thought  advisable  to  lift  up  or  straighten  out  the 
fundus  uteri  by  drawing  it  up.  In  prolapsus  uteri  my 
experience  is  that  the  round  ligaments  are  not  able  to 
withstand  the  constant  downward  strain  upon  them  of 
the  large  body  of  the  uterus.  In  anteversion  and  ante- 
flexion the  direction  of  elevation  of  the  fundus  produced 
by  shortening  the  round  ligaments  would  be  such  as  to 
drag  the  fundus  against  the  symphysis  pubis  and  produce 
uncomfortable  pressure  on  the  bladder. 

Third.  In  a  very  large  proportion  of  cases  where  Alex- 
ander's operation  is  indicated,  there  exists,  besides  the 
retroversion  and  retroflexion  and  descensus  of  the  uterus, 
a  want  of  tone  or  an  absence  of  the  inferior  uterine  and 
vaginal  supports,  namely,  the  perineum  is  lacerated,  the 
bladder  and  anterior  vaginal  wall  and  the  rectum  and 
posterior  vaginal  wall  are  prolapsed.  While  we  can  very 
easily  lift  up,  and  even  retain  in  position,  the  backward 
displaced  uterus  and  appendages  by  Alexander's  opera- 
tion, it  stands  to  reason  that  a  permanency  of  the  result 
will  be  more  assured  by  restoring  to  their  normal  condi- 
tions the  inferior  supports  of  the  uterus  and  vagina ;  and 
often  also  a  laceration  of  the  cervix  exists  at  the  same 
time  which  maintains  a  chronic  enlargement  of  the 
uterus.  I  therefore  always  combine  with  the  Alexander's 
the  restoration  of  these  various  organs,  so  far  as  possible, 
to  their  normal  conditions.  Thus  if  there  is  a  laceration 
of  the  cervix,  a  retroflexion  with  descensus,  a  lacerated 
perineum,  a  cystocele,  and  a  rectocele,  I  proceed  in  the 
following  order :  1st,  trachelorrhaphy ;  2d,  Alexander's ; 
3d,  cystocele,  Stoltz's  operation  (if  still  necessary  after 
the  uterus  is  replaced);  4th,  rectocele  with  perineor- 
rhaphy (Hegar's  operation)  ;  or,  if  there  be  no  rectocele 


July  14,  1894] 


MEDICAL    RECORD. 


35 


bat  simply  a  lacerated  perineum,  I  restore  the  perineum 
by  the  flap-splitting  method.  I  have  frequently  been 
able  to  perform  this  series  of  operations  in  less  than  an 
hour  and  a  half,  and  I  have  yet  to  regret  having  done  so, 
both  as  regards  the  immediate  result  on  the  patient  (long 
duration  of  anaesthesia,  loss  of  blood)  and  permanent 
results. 

Fourth.  After  the  technique  and  indications  of  the  op- 
eration naturally  comes  the  question  as  to  its  results, 
that  is  to  say,  does  the  uterus  which  has  been  successfully 
placed  in  its  normal  position  by  the  shortening  and 
attachment  of  the  round  ligaments  to  the  inguinal  canal 
remain  in  that  position  for  the  rest  of  the  woman's  life, 
in  spite  of  the  daily  influences  which  tend  to  again  dis- 
place it,  and  particularly  in  spite  of  the  occurrence  of 
pregnancy  and  parturition  ?    This  question  would  be  an 
exceedingly  easy  one  to  answer  if  we  were  able  to  retain 
all,  or  even  the  majority,  of  our  patients  under  observation. 
Manifestly  this  cannot  be  the  case,  since  even  in  private 
practice  comparatively  few  operative  cases  again  present 
themselves,  especially  not  if  they  are  doing  well.     It  is 
usually  only  those  in  whom  the  condition  for  which  they 
were  treated  returns  from  whom  we  hear  in  an  unpleasant 
sense,  either  personally  or  through  friends.     Compara- 
tively few  show  their  sense  of  gratitude  by  presenting 
themselves  for  the  purpose  of  giving  us  the  satisfaction  of 
seeing  how  well  we  have  succeeded ;  hence  I  can  only 
refer  to  a  certain  number  of  my  sixty-five  cases  of  this 
operation  in  support  of  my  statement  that  the  operation 
has  been  a  permanent  success.     Still  the  old  saying,  that 
"  Straws  show  which  way  the  wind  blows,"  may  possibly 
be  applied  to  this  operation.     I  can  but  say  that  of  all 
those  women  upon  whom  I  have  operated  during  the 
last  ten  years  for  shortening  the  round  ligaments,  but 
two  have  come  under  my  personal  observation  in  whom 
the  operation  eventually  proved  a  failure.     In  one  of 
these  the  operation  was  performed  for  prolapsus  uteri,  the 
uterus  being  very  large  and  heavy,  a  case  in  which  I  now 
consider  the  operation  contra-indicated.     In  the  second, 
the  ligaments  had  been  torn  during  their  attempted  extrac- 
tion, and  primarily  the  operation  must  be  considered  to 
have  been  at  least  a  partial  failure.     I  must  add  to  these 
two  cases  three  others  in  which,  in  my  earlier  days,  I 
failed  to  find  the  ligaments ;  here  the  want  of  success 
must  not  be  attributed  to  the  operation,  but  to  the  op- 
erator.    As  regards  the  permanency  of  the  success,  I 
have  had  the  opportunity  to  examine  probably  about  one- 
half  of  my  cases  for  a  period  varying  from  six  months  to 
as  many  years  after  the  operation,  and  in  none  of  them, 
I  can  honestly  say,  have  I  found  the  uterus  to  have  devi- 
ated one  iota  from  the  position  in  which  I  put  it.     At 
the  time  of  my  last  article,  six  years  ago,  I  had  not  had 
the  opportunity  to  see  any  of  my  cases  undergo  the  cru- 
cial test  of  pregnancy  and  parturition ;  but  since  then  not 
only  have  Drs.  Coe  and  Boldt  reported  to  me,  if  I  re- 
member right,  each  two  cases,  and  Dr.  Henry  S.  Stark 
one  instance  of  that  occurrence  which  had  come  under 
their  observation,  in  which  the  uterus  retained  after  con- 
finement the  normal  anteverted  position ;  but  I  myself 
have  seen  four  such,  in  one  of  which  I  saw  the  patient  in 
consultation  for  puerperal  septicaemia  in  her  fifth  con- 
finement, the  other  also  for  puerperal  septicaemia  in  her 
first  confinement,  six  years  after  the  operation,  and  in  all 
these  cases  the  position  of  the  uterus  was  absolutely  nor- 
mal.    I  do  not  suppose  that  it  is  necessary  to  say  that 
the    septicaemia    in    these    cases    had    nothing    to  do 
with  the  Alexander's  operation,  but  was  merely  acci- 
dental.    Some  of  my  operations  performed  during  the 
last  six  months  are  of  course  too  recent  to  enable  me 
to  draw  conclusions  as  to  their  permanency.     I  would 
say  that  during  the  past  eighteen  months  I  performed 
twenty-one  Alexander's  operations,  every  one  success- 
fully. 

In  conclusion,  while  I  do  not  undervalue  the  difficul- 
ties of  the  operation,  and  the  uncertainties  which  will 
always  be  attached  to  it,  I  still  must  assert  my  unquali- 
fied belief  in  it,  in  properly  selected  cases,  in  prefer- 


ence to  the  other  dangerous,  and,  as  regards  permanent 
results,  no  more  certain,  operations  of  ventral  fixation  and 
intra-peritoneal  shortening  of  the  ligaments. 


A  CASE  OF  CASTRATION  FOR  PRIMARY  TU- 
BERCULAR EPIDIDYMITIS  IN  A  PATIENT 
AGED   EIGHTY  ONE.1 

By  C.  L.  GIBSON,  M.D., 

NBW  YORK. 

ATTENDING  SURGEON  ST.  LUKE'S  HOSPITAL  *,     ASSISTANT    SU1.GBON    6T.   MAKY'S 
FREE   HOSPITAL  FOR  CHILDREN. 

It  is  with  a  certain  misgiving  that  I  offer  to  your  atten- 
tion the  description  of  a  single  case,  presenting  neither 
an  extraordinary  rarity  nor  novelty  of  treatment. 

The  subject  of  genito  urinary  tuberculosis,  especially  of 
the  testicle,  presents  many  points  of  interest  in  the  way 
of  frequency,  etiology,  pathology,  exact  diagnosis,  prog- 
nosis, and  treatment.  Every  one  of  these  points  has 
been  and  is  the  subject  of  widely  varying  opinions.  The 
literature  is  simply  terrifying.  A  glance  at  the  pages  in 
the  "  Index  Catalogue  of  the  Surgeon- General's  Library," 
on  the  article  "  Tubercular  Testicle,"  led  me  to  think  it 
highly  presumptuous  on  my  part  to  try  to  add  to  this 
wealth  of  material.  And  yet  it  is  most  disappointing  to 
find  how  often  this  material  fails  to  enlighten  us  on  any 
one  particular  point  on  which  we  seek  information. 
Perhaps  it  is  still  more  astonishing  that  a  work  bearing 
the  promising  title  "The  American  Text  Book  of  Sur- 
gery1' should  dismiss  the  consideration  of  tubercular 
testis  in  exactly  nineteen  lines. 

The  subject  of  this  paper  does  not  pretend  to  settle 
the  many  disputed  points.  I  wish  to  emphasize  some  of 
the  facts  of  this  case  as  a  possible  support  for  the  radical 
treatment  of  tubercular  testicle,  which  I  favor,  although 
in  a  general  way  I  am  ready  to  fall  into  line  with  the 
present  moderate  plan  of  treatment  of  surgical  tubercu- 
losis in  general,  which  has  followed  as  a  healthy  reaction 
against  the  furor  of  attempted  radical  measures  of  the 
previous  decade. 

The  following  is  a  resume  of  the  case  as  furnished  by 
the  hospital  records : 

Henry  W ,  eighty-one  years  of  age,  born  in  New 

foundland,  formerly  a  nurse,  was  admitted  to  St.  Luke's 
Hospital,  New  York,  August  13,  1891 ;  service  of  Dr. 
F.  H.  Markoe,  Attending  Surgeon.  To  his  great  kind- 
ness I  am  indebted  for  the  opportunity  of  treating  and 
reporting  the  case. 

Family  history :  Good. 

Previous  history :  No  rheumatic,  malarial,  cardiac,  pul- 
monary, or  renal  history.  No  previous  disorder  of  the 
genito  urinary  organs,  save  a  single  attack  of  gonor- 
rhoea forty  to  fifty  years  ago.  Double  reducible  inguinal 
hernia  for  fifty  years. 

Present  history:  Nine  days  previous  to  admission, 
while  carrying  a  man  down-stairs,  he  stumbled,  sustaining 
a  strain  referred  to  left  groin.  In  a  day  or  two  the  left 
testicle  became  swollen  and  there  was  tenderness  run- 
ning up  into  the  abdomen.  (He  thinks  the  organ  has 
always  been  a  little  the  larger.)  The  symptoms  described 
increasing,  he  sought  relief  in  hospital  treatment. 

Examination  :  The  left  half  of  the  scrotum  is  occupied 
by  a  globular  mass,  diameter  three  inches,  tense,  elastic. 
At  the  upper  and  posterior  portion  the  thickened  and 
hardened  epididymis  can  be  made  out.  The  cord  is 
somewhat  thickened,  but  smooth.  Tumor  translucent. 
Examination  per  rectum  negative.  No  urethral  dis- 
charge. Double  reducible  inguinal  hernia.  Pigmented 
scars  on  both  legs. 

On  admission  the  temperature  was  980  F.;  pulse,  84 ; 
respiration,  20.  Urine:  Acid,  clear,  specific  gravity 
1.020,  two  per  cent,  albumin ;  no  glucose.  Microscopi- 
cally a  few  red  blood-cells  and  leucocytes. 

Treatment :  Regular  diet,  salts,  suspensory  bandage, 

»  Read  at  the  meeting  of  the  Harvard  Medical  Society  of  New 
York,  January  27,  1894.  The  patient  was  also  presented  at  this 
meeting. 


36 


MEDICAL   RECORD. 


[July  14,  1894 


and  counter-irritation  by  Paquelin  cautery.  The  next 
day  it  was  noted  that  he  was  comfortable. 

August  1 8th. — Pain  continues.  Ordered  ung.  hydrarg. 
locally  daily. 

August  26th  — Condition  unchanged,  explored  with 
hypodermic  needle,  clear  fluid.  Stop  ung.  hydrarg.  Re- 
sume cautery. 

August  28th. — Fluid  about  an  ounce  and  a  half  en- 
tirely evacuated,  giving  considerable  relief. 

August  31st. — Swelling  has  returned,  with  further  evi- 
dences of  inflammation. 

The  diagnosis  of  a  tubercular  epididymitis  had  been 
established  for  some  time.  The  increasing  acuteness 
of  the  symptoms  seemed  to  indicate  operative  inter- 
ference, which  was  accepted  by  the  patient.  Accord- 
ingly, September  1st,  the  preparations  for  thoroughly 
cleansing  the  skin  of  the  operative  field  were  begun. 
Examination  of  the  chest  showed  heart  sounds  distant 
and  feeble.  Lungs  emphysematous,  urine  (previous  to 
operation)  acid,  clear,  sp.  gr.  1.016,  one  per  cent,  albu- 
min, many  leucocysts  and  epithelium,  hyaline  casts. 

September  4th. — I  operated,  having  the  kind  assist- 
ance of  Dr.  Markoe.  Previous  to  etherization  atrop. 
sulph.  gr.  y^,  and  whiskey  3  vj.,  were  given.  An  inci- 
sion one  and  one-half  inch  long,  subsequently  enlarged 
to  two  inches,  from  a  point  over  body  of  pubes  down- 
ward. Spermatic  cord  isolated,  apparently  normal.  It 
was  transfixed  and  tied  high  up  with  catgut  ligatures, 
and  divided.  Constituents  of  cord  isolated,  and  five 
fine  catgut  ligatures  applied.  Coverings  of  testicle  sepa- 
rated and  organ  turned  out,  during  which  purulent  con- 
tents escaped  into  the  wound  to  a  very  slight  extent. 
About  one-third  of  scrotum  ablated  with  testicle.  Mod- 
erate hemorrhage.  Union  by  mattrass  and  continuous 
suture  of  catgut.  No  drainage.  Sterilized  dressing 
over  protective  tissue. 

Ether  was  very  well  borne;  no  nausea  followed. 
There  was  considerable  depression  in  the  first  few  days. 
Stimulating  food  was  diligently  given,  and  he  was  gotten 
out  of  bed  into  a  steamer  chair  in  two  days ;  this  I  think 
doing  much  to  prevent  him  from  getting  into  that  hope- 
less state  of  apathy  when  old  people  are  confined  to  bed. 
Five  days  after  operation  the  dressing  had  to  be  in- 
spected, as  it  got  disturbed  by  moving  him  about  daily. 
There  was  primary  aseptic  union.  A  second  dressing 
for  protection  reapplied.  He  gradually  regained  his 
strength ;  for  several  days  his  mind  was  pretty  feeble, 
but  he  was  able  to  leave  the  hospital  eleven  days  after 
the  operation  in  pretty  good  shape. 

The  testicle  removed  was  thus  reported  on  by  the 
pathologist,  Dr.  J.  S.  Thacher :  "  Microscopical  exam- 
ination shows  typical  tubercular  changes.  There  are  a 
large  number  of  giant-cells,  many  tubercles,  some  tuber- 
cle tissue,  and  a  little  cheesy  degeneration."  There  is 
no  record  of  the  microscopic  changes.  Six  months  ago, 
two  years  after  the  operation,  I  saw  the  patient  again. 
He  was  waiting  in  my  office  for  me  one  very  hot  day, 
feeling  very  comfortable  indeed,  while  I  was  absolutely 
done  up.  Of  the  two  he  seemed  by  far  the  most  vigor- 
ous. The  scar  was  almost  imperceptible,  and  save  some 
disturbances  of  vision  he  was  absolutely  free  from  evi- 
dences of  disease  of  any  kind.  His  mental  condition 
was  as  clear  and  vigorous  as  you  could  expect  of  a  man 
aged  eighty  three. 

This  result  of  this  case  is  exceedingly  gratifying  and 
has  some  points  of  interest.  I  think  there  are  not  a  few 
surgeons,  even  to-day,  who  would  have  refused  this  elderly 
patient  the  radical  operation  of  castration.  Certainly 
the  majority  of  practitioners,  unfamiliar  with  the  actual 
possibilities  of  thorough  modern  surgery,  would  not  have 
suggested  it  to  the  patient.  There  is  a  good  deal  of 
superstitious  horror  still  prevalent  about  the  dangers  of 
castration;  sepsis,  prolonged  suppuration,  secondary 
hemorrhage  do  not  or  should  not  exist,  and  these  former- 
ly made  the  operation  hazardous.  In  this  case  we  real- 
ized that  the  operation  must  be  speedy  and  the  conva- 
lescence smooth.     The  elaborate  preparations  of  the  skin 


prior  to  the  operation  sought  to  overcome  one  of  the 
most  frequent  causes  of  wound  suppuration,  and  rendered 
unnecessary  any  half-hearted  and  inefficient  cleansing  on 
the  operating-table,  which  adds  to  the  time.  The  opera- 
tion was  done  quickly,  and  with  scrupulous  regard  for  the 
details  of  surgical  cleanliness.  The  close  approximation 
of  the  divided  tissues  made  drainage  unnecessary,  obvi- 
ating frequent  change  of  dressings  and  pain  and  leaving 
no  indolent  sinus.  The  administration  of  atropine 
before  the  operation  gave  a  certain  protection  against  ex- 
hausting nausea  after  etherization.  The  immediate 
operative  shock  was  not  marked.  I  have  already  pointed 
out,  in  a  paper  in  the  Annals  of  Surgery  for  October,  1893, 
that  the  occurrence  of  shock  in  operations  in  advanced 
age  is  more  theoretical  than  real. 

The  result  in  this  case  seems  to  point  to  the  occur- 
rence and  radical  cure  of  a  primary  tubercular  epididy- 
mitis by  castration.  This  statement  at  once  brings  us 
into  a  controversy  as  to  the  pathology  and  consequent 
indications.  There  is  the  older  view  that  a  tuberculosis 
of  the  geni to-urinary  system  is  only  a  part  of  the  evidence 
of  a  general  constitutional  infection.  This  is  true  only 
to  a  certain  extent. 

Admitting,  then,  that  there  is  a  genito  urinary  tubercu- 
losis while  the  remainder  of  the  body  is  free,  there  are 
two  views,  the  one,  strongly  upheld  among  others  by 
Guyon,  that  a  tuberculosis  of  the  epididymis  is  never  lo- 
calized to  it,  but  is  accompanied  by,  or  secondary  to,  some 
other  tuberculosis  of  the  genito-urinary  system,  notably 
the  seminal  vesicles.  On  the  other  hand  there  is  the 
view,  supported  by  one  of  the  latest  and  best  works,  Jacob- 
son's  "  Diseases  of  the  Male  Organs  of  Generation,"  that 
the  epididymis  is  usually  the  first  seat  of  the  affection. 

The  figures  indicating  the  relative  frequency  of  phthisis 
in  connection  with  tubercular  testis  are  hard  to  estimate. 
In  a  series  of  102  cases,  of  Terrillon  and  Reclus,  of  tuber- 
cular epididymitis,  57  cases  also  had  phthisis.  Reclus*  s 
thesis  of  1876  found  that  only  one  case  in  three  had 
phthisis ;  the  same  ratio  is  given  by  Wilson.  Again,  from 
the  observations  in  the  Pathological  Institute  at  Prague 
we  find  that  in  1,317  cases  of  phthisis  the  testicle  was  in- 
volved in  the  tubercular  process  only  thirty-seven  times. 

Guyon  denies  the  existence  of  a  localized  tubercular 
epididymitis.  In  26  cases  of  autopsies  of  the  genito- 
urinary tract  the  occurrence  of  foci  confined  to  the  epi- 
didymis was  never  observed.  His  observations  of  222 
cases  of  genito-urinary  tuberculosis  showed  the  following 
relations : 

Forty  cases  of  isolated  genital  tuberculosis ;  74  cases 
of  genito-urinary  tuberculosis ;  108  cases  of  combined 
genito-urinary  tuberculosis.  Now  if  it  were  true  that  tu- 
bercular epididymitis  never  occurs  except  as  part  of  a 
diathesis  or  as  part  of  a  tuberculosis  of  the  genital  or 
genito-urinary  system,  the  indications  for  castration 
would  be  pretty  limited. 

The  evidence  both  of  everyday  clinical  observation 
and  the  statistics  quoted  above,  and,  finally,  the  case  un- 
der consideration,  show  that  a  genital  tuberculosis  may 
exist  independent  of  phthisis.  At  once  the  indications 
for  operation  increase.  Guyon's  statistics  are  those  of  a 
specialist  who  sees  the  late  case  when  a  tubercular  pro- 
cess has  spread.  Early  radical  treatment  would  much 
lessen  the  gloomy  statistics  of  such  specialists.  For  it  is 
evident  that  removal  of  a  diseased  testicle,  if  complicated, 
wej  will  say,  with  disease  of  the  seminal  vesicle,  would 
only  be  a  palliative  operation  with  very  narrow  indica- 
tions. The  truth  of  the  matter  is,  we  do  not  accurately 
know  just  how  the  process  develops.  It  seems  apparent 
that  in  some  cases  it  must  develop  primarily  in  the  epi- 
didymis, the  seminal  vesicle  being  secondarily  involved, 
and  vice  versa.  My  personal  feeling  is  that  the  view 
which  always  makes  the  seminal  vesicle  the  source  of  in- 
fection of  the  epididymis  cannot  be  true ;  certainly  not  in 
the  case  under  consideration  (I  take  it  for  granted  that 
the  epididymis  is  attacked  before  the  testicle,  which, 
however,  is  almost  invariably  attacked  with  the  progress 
of  the  disease).     If  it  were  possible  to  establish  what 


July  14,  1894] 


MEDICAL   RECORD. 


37 


part  of  the  epididymis  is  first  attacked,  some  light  might 
be  obtained  on  the  subject,  although  Mr.  Jacobson  says, 
"  this  is  a  point  which  has  been  much  and  needlessly 
discussed."  In  the  majority  of  cases  the  first  evidence 
of  disease  is  found  in  the  head  of  the  epididymis  where 
the  spermatic  artery  breaks  up  and  one  branch  enters  the 
epididymis.  The  vessels  of  the  epididymis  are  smaller 
and  more  tortuous  than  those  of  the  testicle  or  vas  def- 
erens. This  would  point  to  infection  from  the  blood- 
supply  and  show  the  priority  of  the  process  in  the  epi- 
didymis and  not  the  seminal  vesicle.  The  tendency  of 
tubercular  processes  to  become  localized-  where  the  con- 
dition of  blood-supply  is  most  abundant  and  complex  is 
well  known,  especially  in  the  epiphyses,  while  on  the 
other  hand  in  tuberculosis  of  the  tendon  sheaths  the 
poorly  vascularized  tendons  remain  unaffected  although 
buried  in  tubercular  tissue.  I  think  on  the  whole  we 
can  accept  this  theory  of  infection  by  the  blood  supply 
to  show  that  the  process  is  primary  to  the  epididymis 
and  therefore  admits  of  conditions  favorable  to  operative 
relief.  The  question  of  infection  from  coitus,  and  con- 
sequently of  the  epididymis  secondarily  to  infection  of 
the  seminal  vesicle,  has  but  little  to  support  it,  and 
is  in  the  main  fanciful.  Mr.  Jacobson  says  that  if  the 
theory  were  true,  tubercular  disease  of  the  sexual  organs 
should  be  more  common  than  it  is.  That  tubercular 
testis  is  at  times  congenital,  that  it  follows  upon  injury 
as  in  our  case,  certainly  are  decided  arguments  against 
the  coitus  theory. 

What  guides  have  we  in  general  for  the  treatment  of 
tubercular  testis  ?  We  have  to  consider  the  classes  of 
cases  and  the  classes  of  treatment  available.  I  propose 
the  following  divisions : 

1.  Tuberculosis  of  the  testicle  (or  epididymis  or  both), 
all  other  tubercular  lesions  being  wanting.  2.  Tubercu- 
losis of  the  testicle  and  other  portions  of  the  geni  to-uri- 
nary tract.  3.  Tuberculosis  of  the  testicle  and  chronic 
pulmonary  tuberculosis.  4.  Tuberculosis  of  the  testicle 
and  other  portions  of  the  genito-urinary  tract  and  chronic 
pulmonary  tuberculosis.  5.  Tuberculosis  of  the  testicle 
forming  part  of  a  general  acute  miliary  tuberculosis. 

To  combat  these  conditions  we  have  at  our  disposal : 
1.  General  constitutional  treatment — hygienic,  dietetic, 
climatic,  and  medicinal.  2.  Palliative  measures — evacua- 
tion of  pus,  curetting,  caustics,  thermo-cautery,  resection, 
castration.     3.  Radical  measure — castration. 

In  all  forms  of  the  disease,  save  the  rapidly  fatal  cases 
of  acute  miliary  tuberculosis,  the  general  constitutional 
treatment  should  be  pushed  to  the  fullest  extent  possible. 
It  puts  the  patient  into  the  best  possible  condition  for 
repair  of  damage  and  checking  of  further  invasion.  To 
specify  rally  a  judicious  course  of  treatment  would  be  to 
write  a  good-sized  work.  That  constitutional  treatment 
per  se  is  curative,  forever  stamping  out  the  disease,  I  do 
not  admit — many  early  cases  are  apparently  cured,  many 
severe  processes  are  temporarily  ameliorated.  A  tuber- 
cular focus  in  any  part  of  the  body  is  likely  to  light  up 
again  at  any  time,  although  remaining  dormant  for  years. 
The  literature  gives  many  such  cases.  The  favorable  ab- 
solute reports  that  have  been  quoted  from  time  to  time, 
to  support  the  curative  effects  of  constitutional  treatment, 
either  are  issued  too  early  or  admit  of  doubt  as  to  exact 
diagnosis. 

I  have  said  before,  it  is  indicated  in  every  one  of  the 
^ve  phases  just  described.  Are  there  any  forms  in  which 
it  becomes  the  only  treatment?  How  far  it  will  be  em- 
ployed in  the  fifth  form  is  a  matter  of  expediency.  In 
the  first  form  it  will  play  a  secondary  part,  the  chief  fac- 
tor of  success  being  early  and  radical  removal  of  the  pri- 
mary focus. 

In  the  next  three  forms  it  comes  to  the  front,  as  here 
the  operative  measures  can  only  be  palliative ;  but  in  none 
of  them  is  the  possibility  of  improving  the  patient's  con- 
dition by  interference  excluded,  though  the  benefits  grow 
less  with  the  increasing  complexity  of  the  lesions. 

We  come  now  to  the  application  of  the  paViative 
method.     One  of  these  methods,  resection  of  diseased 


nodules  in  the  epididymis,  is  quasi-radical,  but  presents 
no  particular  advantage,  as  it  will  scarcely  maintain  the 
function  of  the  gland  intact,  and,  being  probably  incom- 
plete, is  a  waste  of  time  when  delay  is  dangerous. 

The  other  varieties,  incision  of  abscesses,  use  of  sharp 
spoon,  packing  with  iodoform  gauze,  cauterizing  with 
chloride  of  zinc,  burning  with  thermo-cautery,  can  never 
be  indicated  in  Class  1,  of  localized  primary  tuberculosis 
of  testis  or  epididymis.  The  remaining  three  forms  may 
all  be  benefited  but  not  cured  by  this  means  of  treat- 
ment. (Strictly  speaking,  Class  3,  localized  tubercular 
epididymitis  with  phthisis,  might  be  included  with  Class 
1,  although  tubercular  disease  would  not  be  banished 
from  the  body  by  an  operation.)  How  far  minor  pallia- 
tive measures,  properly  speaking,  are  to  be  preferred  to 
castration,  even  as  a  palliative  measure,  will  be  discussed 
in  the  consideration  of  that  operation. 

We  come  now  to  the  application  of  castration.  In 
Class  1,  where  our  diagnosis  is  absolutely  trustworthy  as 
to  the  limitations  of  the  disease,  and  we  can  put  the  pa- 
tient in  a  condition  to  withstand  or  avoid  new  formation 
of  tubercular  deposits,  the  result  will  be  exceedingly 
gratifying.  There  are  many  cases  of  total  cures  persist- 
ing for  many  years  which  are  on  record  to  bear  out  that 
statement. 

Great  care  must  be  taken,  though,  to  assure  ourselves 
that  we  are  actually  dealing  with  a  localized  process.  If 
we  grasp  the  spermatic  cord  above  the  tumor,  and  find 
that  it  is  entirely  free  from  enlargement  and  localized 
swelling  and  painless,  we  have  not  yet  assured  ourselves 
as  to  the  condition.  A  most  careful  examination  of  the 
seminal  vesicle  per  rectum  is  necessary;  this  requires 
considerable  knowledge  of  the  normal  condition  to  de- 
tect the  abnormal  in  early  cases.  The  seminal  vesicle 
may  be  recognized  as  diseased,  while  the  cord  appears  or 
is  normal.  This  peculiarity  is  explained  by  the  usual 
limitation  of  the  process  at  one  or  both  of  two  points, 
the  testicular  end  just  above  the  tail  of  the  epididymis, 
and  at  the  distal  end  where  it  joins  the  seminal  vesicle. 

As  to  the  application  of  castration  in  any  of  the  three 
remaining  forms,  it  seems  to  me,  broadly  speaking,  to  be 
indicated  as  a  palliative  measure  in  those,  two  forms 
which  I  have  made  of  the  trouble  in  the  genito-urinary 
tract.  The  indications  are  even  more  positive  in  the 
form  of  localized  testicular  trouble  complicated  by 
phthisis,  provided  the  patient's  general  condition  war- 
rants doing  an  operation  requiring  general  anaesthesia. 
In  this  case,  if  the  patient  can  be  brought  under  favor- 
able circumstances,  the  process  in  the  lungs  may  and  can 
be  arrested  for  a  long  time.  In  any  of  these  conditions, 
as  Mr.  Jacobson  very  judiciously  remarks,  the  patient  is 
relieved  from  one  of  his  two  burdens — tuberculous  lungs 
and  suppurating,  crippling,  perhaps  painful  testis. 

Guyon  goes  so  far  as  to  counsel  invariably  (within 
limits  of  reason,  of  course)  the  use  of  castration  as  a 
palliative  measure,  although  he  absolutely  rejects  its  use 
in  the  early  stages  before  the  testicle  is  materially  in- 
volved. Believing  as  he  does  that  the  process  is  con- 
veyed from  the  seminal  vesicle  to  the  epididymis,  he  re- 
jects the  operation  as  curative,  but  indorses  it  most 
warmly  as  a  palliative  measure.  After  removal  of  the 
testis,  where  there  is  a  geni  to  urinary  tuberculosis  else- 
where, the  relief  from  the  acutely  suppurating  focus  may 
give  the  system  more  vigor  to  combat  the  remaining 
process  and  possibly  retard  it. 

The  presence  of  a  localized  suppurating  focus  was  long, 
and  is  yet,  in  some  quarters,  considered  as  a  noli  me  tangerc% 
for  fear  that  interference  with  it  may  cause  a  general  out- 
burst of  tubercular  trouble.  On  this  point  Guyon  ex- 
presses himself  very  positively  as  follows:  "The  most 
scrupulous  surgeon  may  in  all  conscientious  security  at- 
tack a  suppurating  tubercular  focus  (provided  that  indi- 
cations exist),  without  the  slightest  danger  of  injury  to 
the  general  system.' ' 

That  such  an  outbreak  of  general  symptoms  may  occa- 
sionally arise  as  a  result  of  localized  operative  interfer- 
ence, I  am  not  prepared  to  deny.     I  have  never  seen  it 


38 


MEDICAL    RECORD. 


[July  14,  1894 


occur  after  any  operation  for  the  relief  of  surgical  tuber- 
culosis. 

Being  relieved  of  a  distressing  local  complication  the 
patient  is  better  able  to  go  about,  to  live  an  outdoor  life, 
to  indulge  in  proper  exercise,  all  of  which  are  so  necessary 
for  improvement  of  the  general  health.  Moreover,  he  is 
able  to  return  promptly  to  work :  of  great  importance  to 
a  poor  man  with  a  family.  In  one  case  I  castrated  a 
man  for  a  pretty  advanced  process,  and  he  resumed 
work  as  porter  in  a  wholesale  house  in  ten  days. 

As  opposed  to  castration  are  dangers  of  an  operation, 
apparent  loss  of  virility,  and  consequently  danger  of  hy- 
pochondriasis. 

The  surgeon  must  judge  in  each  individual  case  how 
much  advantage  is  to  be  obtained  from  an  operation, 
how  much  any  given  patient  can  stand.  As  to  the  ap- 
parent loss  of  virility,  the  disappearance  of  both  testicles 
may  produce  a  marked  effect  on  the  mind.  Perhaps  here 
amputation  of  the  worst,  and  mild  palliative  measures  on 
the  other  might  be  indicated.  Or,  as  has  recently  been 
most  successfully  done  by  Dr.  R.  F.  Weir,  a  cylinder  of 
celluloid  resembling  a  testicle  might  be  introduced  into 
the  scrotum  and  allowed  to  become  embedded.  Cer- 
tainly, fear  of  mental  changes  ought  not  to  deter  us  from 
removal  of  one  testicle ;  it  is  more  likely  that  a  better 
effect  is  to  be  looked  for  by  the  removal  of  an  unsightly 
and  disagreeable  condition  which  of  itself  would  natur- 
ally be  an  obstacle  to  sexual  relations. 

The  more  carefully  we  weigh  the  results  of  castration, 
the  little  danger  of  the  modern  operation  properly  done, 
the  wider  seems  to  be  the  field  for  it.  Of  the  further 
operation  of  removing  diseased  seminal  vesicles,  although 
some  few  brilliant  results  are  beginning  to  be  recorded, 
it  is  not  within  the  province  of  this  paper  to  discuss ;  the 
operation  being  still  sub  judtce,  and  at  present  offering 
little  in  its  favor.  Of  course,  if  it  come  to  receive  general 
recognition  the  indications  for  castration  would  be  mark- 
edly increased. 

The  treatment  of  tubercular  disease  by  injection  of  the 
substance  known  as  Koch's  tuberculin,  which  was  re- 
cently hailed  by  the  profession  with  such  hysterical  en- 
thusiasm, has  to  day  no  standing,  and  need  only  to  be 
mentioned  to  be  condemned. 

As  to  the  sclerogenic  method  of  treatment  by  injection 
of  chloride  of  zinc,  which  is  now  on  trial,  I  can  say 
nothing  in  this  connection  as  I  am  unaware  of  its  employ- 
ment in  the  form  of  disease  under  consideration. 

Just  as  in  malignant  disease,  early  interference  must  give 
the  best  chance  of  effecting  a  cure.  The  responsibility 
of  this  rests  chiefly  on  the  recognition  of  the  disease  and 
the  possibilities  of  treatment  by  the  general  practitioner. 

It  is  to  be  hoped  that  our  resources  of  exact  diagnosis 
may  be  multiplied  to  allow  of  treatment  of  the  disease  by 
knowledge  of  its  nature,  without  waiting  to  be  compelled 
by  urgent  symptoms.  The  bacilli  may  be  recognized 
sometimes  in  the  fluid  of  the  hydrocele,  which  occurs  in 
about  one-third  of  the  cases.  The  centrifugal  machine 
may  be  of  use  in  facilitating  the  accumulation  of  solid 
particles.  If  there  is  pus,  the  bacilli  will  probably  be 
found  readily.  Any  of  these  fluids  may  be  used  to  inoc- 
ulate suitable  culture  media.  Or  the  fluid  may  be  used  to 
inoculate  animals  susceptible  to  tuberculosis,  e.g., guinea- 
pigs.  The  semen  is  occasionally  found  to  contain  bacilli ; 
other  means  failing  it  might  yet  afford  a  clew  to  the  exact 
nature  of  the  disease.  And  exactness  is  what  we  want  to 
enable  us  to  move  early.  # 

From  consideration  of  some  of  the  elements  presented 
by  the  case  reported,  the  following  observations  seem 
justified :  That  tubercular  testis  may  occur  as  an  idiopathic 
primary  condition ;  that  it  may  first  appear  in  advanced 
age ;  that  advanced  age  is  no  obstacle  to  successful  in- 
terference. 

I  know  that  many  interesting  points  have  not  been  al- 
luded to — the  present  paper  has  no  pretension  to  exhaust 
the  subject.  Though  I  have  made  no  extensive  search 
on  this  line,  I  think  that  the  great  age  of  the  patient  and 
the  result  make  the  case  unique. 


THE  TRANSMISSION  OF  THE  CHOLERA  SPI- 
RILLUM BY  THE  ALIMENTARY  CONTENTS 
AND  INTESTINAL  DEJECTA  OF  THE  COM- 
MON HOUSEFLY.1 

By  THOMAS  C.  CRAIG,  M.D.f 

PASSBD  ASSISTANT  SUKGSON,    U.   S.   NAVY,   NAVY  YARD,  NSW  YORK. 

While  working  with  cholera  in  the  Hoagland  Laboratory 
of  Bacteriology,  it  occurred  to  the  writer  to  undertake  a 
series  of  experiments  to  ascertain  whether  it  were  possible 
for  the  common  house  fly  to  carry  the  cholera  spirillum 
and  deposit  it,  in  a  living  state,  and  thus  be  one  of  the 
factors  in  the  contagion ;  and  also  to  ascertain  whether 
cholera  was  fatal  to  flies  within  the  time  necessary  for 
them  to  carry  it  to  distant  parts. 

A  fresh  bouillon  culture  was  made  from  the  stock  cult- 
ures in  the  laboratory,  originally  obtained  from  cases  of 
cholera  at  Swinburne  Island  in  1892.  Three  large  flies 
were  caught  and  placed  in  a  small  wide  mouthed  bottle. 
A  small  piece  of  bread  was  then  moistened  with  the  beef- 
tea  cholera  culture,  and  put  into  the  bottle  along  with 
the  flies.  They  eagerly  alighted  on  the  bread  and  fed 
ravenously  on  it.  A  small  amount  of  water  was  given 
them,  and  they  were  thus  left  for  three  days. 

At  the  end  of  that  time  they  were  found  to  be  alive 
and  as  active  as  ever.  They  were  taken  out  and  killed, 
and  their  intestinal  contents  squeezed  out  on  to  a  clean 
cover-glass,  care  being  taken  not  to  let  their  feet  come 
in  contact  with  the  cover-glass.  Some  of  the  expressed 
material  from  the  intestine  of  each  one  was  transferred  to 
sterilized  beef- tea,  and  placed  in  an  incubator.  Smear 
preparations  were  also  made  of  the  expressed  intestinal 
contents,  stained,  and  examined.  In  one  slide  were  found 
a  number  of  fine  bacilli  and  spirilla.  The  spirilla  re- 
sembled very  closely  in  size  and  appearance  those  of  chol- 
era ;  yet  one  could  not  be  sure  until  the  separation  and 
further  testing  and  growth.  At  the  end  of  two  days 
the  tubes  in  the  incubator  were  examined  and  found  to 
be  cloudy,  and  to  have  a  film  very  similar  to  the  film 
seen  on  cholera  cultures. 

Mounted  specimens  were  made  from  the  film  and 
under  liquid,  and  the  field  found  to  be  filled  with  bacilli 
of  varying  sizes,  micrococci,  and  spirilla,  the  latter  to  all 
appearances  identical  with  the  cholera  spirillum.  Dilu- 
tions were  made  from  the  film,  and  under  liquid ;  and 
then  rolled  in  tubes.  Acid  was  then  added  for  the  chol- 
era red  reaction,  but  with  negative  results. 

At  the  end  of  two  days  the  rolled  tubes  had  grown 
numerous  colonies.  In  two  of  the  rolled  tubes  the  cult- 
ures were  very  much  mixed,  while  in  one  tube  (the  one 
made  entirely  from  the  film)  the  colonies  were  all  uni- 
form in  appearance — small,  round,  grayish  white,  slightly 
refracting,  liquefying  colonies  with  crenated  borders. 

Several  beef-tea  inoculations  were  made  from  these 
latter  colonies  and  placed  in  the  incubator ;  stab  cultures 
in  gelatine  were  also  made.  Specimens  mounted  from 
these  colonies  showed  long  and  short  spirilla,  also  the 
comma  shaped  bacillus.  The  spirilla  showed  a  remark- 
able form  in  arrangement.  The  microscopic  field  ap- 
peared to  be  filled  with  long,  curved,  intertwining,  and  in- 
tricately arranged  hair  like  masses,  having  the  appearance 
of  a  tuft  of  curled  hair  like  that  used  in  a  mattress.  This 
appearance  and  arrangement  was  only  found  in  those 
specimens  mounted  from  the  colonies.  It  was  perhaps 
the  arrangement  of  spirilla  just  as  they  grew.  A  colony 
fitted  into  the  wire  loop ;  it  was  then  touched  lightly  in 
half  a  dozen  places  to  a  cover-glass,  and  dried  ;  no  other 
disturbance  being  made.  Invariably  this  same  curled- 
hair  arrangement  of  these  exceedingly  long  spirilla  was 
found. 

At  the  end  of  two  days  the  test-tube  beef-tea  inocula- 
tions were  found  to  be  cloudy  and  to  have  a  film. 

Examination  of  the  hanging  drop  showed  the  field  to 
be  filled  with  comma  shaped  bacilli  and  a  few  spirilla — 
all  in  extremely  active  and  lively  motion. 

The  stab  cultures  in  gelatin  showed,  at  the  end  of  two 

1  Read  before  the  Brooklyn  Pathological  Society,  June  14,  1894. 


July   14,  1894] 


MEDICAL  RECORD. 


39 


days,  growth  along  the  whole  line  of  puncture,  with 
commencing  liquefaction  at  the  top.  Specimens  mounted 
from  the  beef  tea  culture  showed  characteristic  comma 
bacilli  and  spirilla. 

Sulphuric  acid  added  to  the  beef  tea  culture  gave  an 
intense  cholera  red  reaction. 

Bacilli  and  spirilla  of  the  same  shape  and  size  were 
found  in  all  the  beef  tea  inoculations. 

Hydrochloric  acid  and  nitric  acid  each  gave  the  chol- 
era red  reaction ;  the  reaction  with  hydrochloric  acid 
being  the  most  intense  and  lasting  the  longest  without 
fading — at  the  end  of  ten  days  being  almost  as  red  as  on 
the  day  it  was  made. 

The  stabs  in  gelatin  continued  to  grow  and  liquefy 
the  gelatin  in  the  peculiar  glass  funnel  shaped  way  at  the 
top  of  the  stab — while  the  lower  part  of  the  stab  extended 
out  into  the  gelatin  as  a  thin,  velvety,  needle-like  growth. 

Specimens  mounted  from  the  gelatin  culture  showed 
the  comma  bacilli.  Thus  the  recovery  of  the  living  spi- 
rillum of  cholera  from  flies  fed  on  a  culture  of  cholera 
proves  beyond  any  doubt  how  potent  and  important  an 
agent  the  common  house  fly  may  be  in  the  carrying  of 
this  spirillum. 

From  the  fact  of  the  flies  not  dying  within  three  days, 
it  goes  to  show  that  they  are  able  to  withstand  the  toxine 
of  this  culture,  now  two  years  old,  certainly  long  enough 
to  carry  the  infecting  material  great  distances,  and  to 
deposit  it  in  many  places,  each  of  them  becoming 
a  focus  for  infection. 

Investigations  relating  to  this  subject  were  conducted 
by  Simmonds,  and  are  recorded  in  the  Deutsche  medizin- 
ische  Wochenschrift,  1892,  No.  41.  Simmonds  placed 
flies  in  a  bottle  with  cholera  faeces  for  a  few  minutes,  and 
then  allowed  the  flies  to  walk  over  gelatin  plates.  A  series 
of  about  nine  plates  was  arranged,  and  over  each  the  flies 
were  allowed  to  walk.  In  nearly  all  the  plates  the  cholera 
spirillum  was  recovered.  No  attempt  was  made  to  isolate 
the  spirillum  and  grow  it  in  gelatin  stab  cultures  and 
beef-tea,  or  to  try  for  the  cholera  red  reaction. 

It  might  be  argued  that  the  cholera  spirillum,  which  I 
recovered  from  the  flies,  was  conveyed  from  their  feet  or 
their  bodies  on  to  the  cover  glass,  the  same  as  Simmonds 
recovered  his  spirillum,  and  thus  never  entered  their  intes- 
tinal canals.  I  was  very  careful  that  this  accident  should 
not  occur.  Before  the  flies  were  inoculated  their  wings 
were  cut  off;  and  before  their  intestinal  contents  were 
expressed  their  legs  were  pulled  off  and  destroyed.  The 
intestinal  contents  were  forced  out  with  sterilized  forceps, 
and  only  the  small  drop  of  liquid  at  the  end  of  the  rectum 
was  used  for  inoculating  the  beef  tea. 

It  may  be  interesting  here  to  note  that  I  was  unable  to 
get  the  cholera  red  reaction  in  any  of  the  mixed  cultures 
in  beef  tea,  but  never  failed  to  get  it  in  the  pure  cultures 
of  the  spirillum  recovered  from  the  flies  fed  on  the 
cholera. 

During  my  work  with  this  subject  I  was  greatly  aided 
by  the  many  valuable  suggestions  of  Dr.  £.  H.  Wilson, 
the  director  of  the  laboratory,  under  whose  directions  all 
the  manipulations  were  made.  I  intend  to  continue  my 
investigations  in  this  line  further,  and  to  ascertain 
whether  other  bacteria,  such  as  the  typhoid,  anthrax, 
diphtheria,  and  tubercle  bacilli,  can  possibly  be  carried 
and  deposited  in  a  living  state  by  flies. 

Alcohol  and  Sunstroke. — The  late  Surgeon  Parke, 
medical  officer  of  the  Emin  Pasha  Relief  Expedition, 
wrote  shortly  before  his  death  a  "  Guide  to  Health  in 
Africa.1 '  In  speaking  of  sunstroke  he  says  that  he  has 
met  with  comparatively  few  cases  of  it  in  his  African 
service,  and  that  "  he  has  seen  more  cases  of  sunstroke 
occur  during  one  '  field-day '  at  Aldershot  than  during 
seven  years'  medical  experience  in  Africa."  This  im- 
munity from  thermal  fever  he  attributes  naturally  to  the 
use  of  precautionary  measures,  the  most  important  of 
which  is  abstention  from  alcohol.  "  Drink,"  he  says, 
"  is  certainly  the  most  powerful  predisposing  cause  of  the 
development  of  the  symptoms  of  sunstroke." 


TWO  HERNIOTOMIES  IN  A  CHILD  UNDER  FIVE 
YEARS  OF  AGE— BASSINrS  METHOD. 

By  SAMUEL  E.  MILLIKEN,  M.D., 

NEW     YORK. 

The  following  case,  Stanley  H ,  who  first  came  to  me 

from  Newburgh,  N.  Y.,  on  May  22,  1890,  when  a  baby 
of  seven  months,  illustrates  some  of  the  difficulties  met 
with  in  the  mechanical  treatment  of  hernia,  even  at  such 
an  early  age.  Although  exceptionally  intelligent  care 
was  given  the  case  at  home,  the  hernia  being  retained 
for  some  months  at  a  time,  and  with  an  otherwise  healthy 
child,  the  rupture  would  protrude  occasionally  almost 
to  its  original  size. 

At  the  first  visit  there  existed  a  left  oblique  congeni- 
tal inguinal  hernia,  the  size  of  a  small  egg,  which  was 
easily  reducible,  but  was  retained,  only  after  some  diffi- 
culty, with  a  "  Hank  "  truss.  A  celluloid  "  Hood  "  tnws 
was  applied  May  31st,  as  the  worsted  truss  failed  to  hold 
the  hernia.  The  mother  was  instructed  not  to  remove 
the  truss,  even  to  give  the  child  a  lath.  Sufficiently 
frequent  visits  were  made  to  my  office,  as  would  enable 
me  to  readjust  the  truss,  and  see  that  the  pressure  over 
the  inguinal  canal  and  around  the  pelvis  was  uniform. 

To  show  the  weakened  cordition  of  the  inguinal  re- 
gions the  child  acquired  a  hernia  on  the  light  side,  Feb- 
ruary 29,  1892,  when  a  double  truss  was  applied.  This 
second  hernia  could  not  be  accounted  for  by  any  other 
reason  than  the  above,  as  the  general  health  of  the  child 
was  excellent.  The  congenital  hernia  did  not  improve, 
and  it  was  decided  to  perform  the  radical  operation ; 
the  right  or  acquired  hernia,  however,  was  easily  con- 
trolled by  a  truss. 

On  June  20,  1893,  the  reconstruction  of  the  inguinal 
canal  was  performed  after  Bassini's  method.  The  hernia 
being  congenital,  the  sac  was  cut  of!  about  one  inch 
above  the  testis,  and  again  flush  with  the  internal  ring. 
The  conjoined  tendon,  and  the  shelving  process  of  Pou- 
part's  ligament,  were  brought  together  with  interrupted 
sutures  of  kangaroo  tendon,  posterior  to  the  cord  struct- 
ures, while  the  aponeurosis  of  the  external  oblique  was 
closed  with  a  continuous  suture  of  the  same  material,  an- 
terior to  the  cord  structures,  thus  re-establishing  the 
obliquity  of  the  canal.  The  skin  wound  was  sutured 
with  interrupted  catgut,  without  drainage.  The  wound 
healed  under  one  dressing,  without  any  complications, 
and  the  child  was  sent  home  on  the  tenth  day  after 
the  operation,  with  instructions  to  be  kept  in  the  recum- 
bent posture  for  ten  days  longer,  so  as  to  insure  firm 
union  of  the  deeper  structures,  only  a  light  bandage  be- 
ing worn. 

The  hernia  of  the  right  side,  which  had  been  held  for 
so  long,  was  apparently  cured,  and  the  truss  was  therefore 
left  off.  However,  in  a  few  weeks  after  the  child  began 
to  walk,  the  right  hernia  reappeared,  and  a  truss  was  re- 
applied. With  such  an  unsatisfactory  result  from  con- 
servative measures,  I  advised  a  radical  operation  for  the 
right  side,  which  was  not  performed  until  June  21, 1894, 
one  year  and  one  day  after  that  on  the  left  side,  which 
had  proven  so  successful,  without  any  apparatus  being 
worn  afterward. 

During  the  administration  of  the  ether  for  the  opera- 
tion on  the  right  side,  the  hernia  protruded  to  the  mid- 
dle of  the  scrotum,  and  was  the  size  of  a  large  egg.  The 
only  difference  in  technique  in  this  operation,  from  the 
one  on  the  left  side,  was  the  total  extirpation  of  the  sac, 
as  the  hernia  was  acquired  and  not  congenital.  The 
first  dressing  was  changed  on  the  seventh  day,  when  it 
was  found  that  the  catgut  sutures  in  the  skin  were  ab- 
sorbed and  complete  union  had  taken  place.  The  pa- 
tient was  sent  home  on  the  ninth  day  after  the  opera- 
tion, with  a  light  bandage,  and  the  parents  were  in- 
structed to  keep  the  child  in  the  recumbent  posture  un- 
til three  weeks  had  elapsed  after  the  operation. 

Conclusions. — 1.  When  any  difficulty  is  met  with  in 
the  mechanical  treatment  the  radical  operation  should 
be  performed  even  in  young  children. 


40 


MEDICAL    RECORD. 


[July  14,  1894 


2.  If,  after  six  months  or  a  year,  the  truss  has  been 
steadily  worn,  and  there  still  exists  a  flabby  condition  of 
the  inguinal  region,  the  operation  is  also  indicated. 

3.  The  risk  of  operating  on  children,  where  strict 
asepsis  is  observed,  is  little,  if  any,  more  than  in  adults. 

4.  The  chances  for  a  radical  cure  in  children  are 
greater  than  in  adults,  because  of  the  more  perfect  repa- 
rative process  at  that  age. 

5.  The  reconstruction  of  the  canal  is,  par  excellence, 
the  operation,  and,  as  shown  by  Bassini's  statistics,  has 
stood  the  test  of  time. 

6.  To  obtain  the  best  results  a  great  deal  depends 
upon  the  surgical  technique,  and  the  suture  material  em* 
ployed. 

7.  Drainage  should  not  be  employed,  if  the  surgeon  is 
careful  to  observe  the  modern  rules  of  cleanliness ;  for  if 
the  wound  is  infected  during  the  operation  it  must  heal 
by  granulation,  and  the  drainage  tube  is  always  an  addi- 
tional source  of  danger. 

8.  After  primary  and  complete  union  of  the  whole 
wound  no  truss  is  necessary. 

36  Wmt  Firnr-NiNTH  Street. 


IS   THERE  A   NORTHERN  REMITTENT   (NON- 
MALARIAL)   FEVER?1 

By    NELSON   RICHMOND,    M.D., 

PitEDDNIA,  N.   Y. 

The  importance  of  the  above  subject  and  the  interest 
manifested  induce  me  to  write  a  paper  with  the  same  title 
as  that  presented  to  this  Society  a  year  ago.  In  that 
paper,  a  year  ago,  the  claim  was  made  that  there  was  a 
type  of  fever  common  to  Western  New  York,  and,  as  I 
have  since  learned,  more  or  less  common  to  the  entire 
State,  which,  in  my  best  judgment,  was  not  typhoid,  and 
to  which  there  was  no  settled  name  accredited  by  all. 

It  was  asserted  that  some  physicians  did  call  this  type 
of  fever  a  mild  form  of  typhoid,  others  named  it  gastric, 
another  bilious,  another  malarial,  another  remittent, 
and  still  another  simple  continued  fever.  It  was  believed 
that  this  heterogeneity  of  names  was  applied  to  one  and 
the  same  fever,  and  that  the  lack  of  text-book  informa- 
tion concerning  it,  coupled  with  the  astigmatism  of  the 
observer,  made  confusion  worse  confounded.  Various 
authors  were  quoted  to  show  that  either  the  names  had 
no  foundation  in  fact,  or  that  the  symptoms,  as  por- 
trayed, were  not  applicable  to  the  fever  in  question. 

This  paper  will  confine  itself  strictly  to  the  discussion 
of  the  identity  or  non-identity  of  this  type  of  fever  with 
typhoid. 

The  burden  of  proof  seems  to  be  that  it  is  not  typhoid. 
But  the  writer  is  very  anxious  to  be  entirely  satisfied  in 
his  own  mind,  either  that  he  is  right  or  that  he  is  wrong. 
He  is  the  more  anxious,  after  having  had  nearly  fifty 
such  cases,  all  recurring,  and  which  he  never  intimated 
were  typhoid,  to  be  clear  in  his  own  mind  as  to  the  fu- 
ture.    These  cases  carried  a  period  of  thirteen  years. 

The  fever  in  question  is  usually  gradual  in  its  onset, 
protracted  and  uneventful  in  its  course,  and  as  gradual  in 
its  subsidence.  It  is  confined  to  neither  sex.  It  has,  in 
my  experience,  varied  in  age  from  five  to  sixty  years.  It 
has  a  duration  from  twenty-one  to  thirty -five  days.  It 
seems  to  run  in  cycles  of  seven.  The  temperature  gradu- 
ally increases  in  height,  day  by  day,  rarely  going  above 
1030  F.,  maintains  the  highest  mark  for  a  few  days,  and 
as  gradually  fades  away.  The  tongue  is  usually  covered 
with  a  yellowish-white  coating.  Sometimes  the  tongue 
is  clean  throughout  the  entire  illness.  The  countenance 
is  sometimes  dull  and  stupid ;  again  it  is  little  changed. 
Constipation  is  usually  present,  or  the  bowel  may  be  regu- 
lar in  its  evacuations. 

The  patient  is  incline!  to  take  things  very  easy,  and 
not  to  worry  about  himself,  his  convalescence,  or  things 
in  general. 

The  skin  is  usually  dull  in  color  or  jaundiced  in  ap- 

1  Read  before  the  State  Medical  Society,  Albany,  N.  Y.,  February 
6,  1894. 


pearance.  There  is  as  much  emaciation  during  the  prog- 
ress of  the  disease  as  in  typhoid. 

The  pathology  of  the  disease,  as  far  as  I  am  concerned, 
is  a  sealed  book,  for  I  have  never  lost  a  case.  There  is, 
moreover,  seldom,  if  ever,  any  anxiety  on  the  part  of  the 
attendant.  It  is  a  very  comfortable  sickness.  Errors  of 
diet,  during  the  early  stages  of  convalescence,  cause  a  re- 
turn of  the  fever  for  a  few  days. 

Osier,  under  the  heading  "  Mild  and  Abortive  Forms 
of  Typhoid  Fever/ '  says  :  "  It  is  very  important  for  the 
practitioner  to  recognize  the  mild  type  of  typhoid  fever, 
often  spoken  of  as  gastric  fever  or  even  regarded  as  sim- 
ple febricula.  In  this  form  the  symptoms  are  similar  in 
kind,  but  altogether  less  intense  than  in  the  grave  attacks, 
although  the  onset  may  be  sudden  and  severe.  The  tem- 
perature rarely  reaches  1030  F.,  and  the  fever  of  onset 
may  not  show  the  gradual  ascending  evening  record. 
The  spleen  is  enlarged ;  the  rose-spots  may  be  marked ; 
often  they  are  very  few  in  number.  The  diarrhoea  is 
variable;  sometimes  it  is  not  present.  In  such  cases 
the  symptoms  may  persist  for  from  sixteen  to  twenty 
days." 

I  have  given  this  very  liberal  quotation,  not  to 
strengthen  my  own  argument,  but  to  be  perfectly  fair  to 
those  who  believe  that  the  fever  in  question  is  typhoid. 
It  would  be  very  easy,  after  reading  this  description,  to 
argue  after  this  fashion :  "  What  is  the  use  of  trying  to 
prove  that  a  disease  is  less  to  be  feared  than  it  actually  is 
— that  it  has  a  much  less  dreaded  name  than  some  con- 
tend. Osier  is  good  authority !  His  description  fits 
nearly  enough  !  Go  on  and  call  it  typhoid !  Your  pa- 
tient will  get  well  and  you  will  get  the  credit  of  having 
excellent  success  in  treating  typhoid  fever.  They  will 
say  you  never  have  lost  a  case,  perhaps." 

But  the  above  course  of  reasoning  does  not  satisfy  the 
honest,  conscientious  practitioner.  I  will  admit,  how- 
ever, that  one  of  the  weakest  points  in  the  line  of  argu- 
ment is  the  description  of  the  fever.  It  is  so  monoto- 
nous. Crises  and  destructive  symptoms  are  conspicuous 
by  their  absence. 

Let  us  attempt  to  portray  the  symptoms  which  are  ab- 
sent in  this  disease,  and  which  are  so  inseparably  con* 
nected  with  the  name  typhoid. 

You  will  please  remark  that  I  said  nothing  about  rose- 
colored  spots  in  this  disease.  If  they  ever  have  been 
present  they  have  escaped  my  observation.  There  is 
never  any  right  iliac  tenderness.  I  have  seen  cases  where 
there  was  tenderness  in  the  left  iliac  region.  There  is 
seldom  any  diarrhoea — never  any  of  the  pea  soup  charac- 
ter. 

There  is  never  an  anxious  countenance,  rather  the 
reverse,  as  noted.  There  is  never  any  sordes  on  the 
teeth,  never  any  brown,  dry,  or  cracked  tongue — trem- 
bling on  protrusion.  In  fact,  gentlemen,  what  is  ty- 
phoid, and  what  are  typhoid  symptoms  as  generally  un- 
derstood ?  What  does  the  name  convey  to  your  minds 
but  the  above  line  of  symptoms — one  or  all  ? 

We  are  free  to  admit,  however,  that  the  name  typhoid 
is  unfortunate.  Should  "enteric  fever"  be  generally 
adopted,  and  admission  made  that  enteric  fever  meant 
an  involvement  of  different  portions  of  the  alimentary 
canal ;  that  Peyer's  glands  were  involved  in  the  serious 
cases — those  accompanied  by  high  temperature,  brown, 
dry  tongue,  or  delirium — then  the  agitation  of  this  ques- 
tion might  be  considered  unnecessary. 

There  is  no  doubt  that  the  South  furnishes  a  habitat 
for  typhoid  fever  and  malarial  fever  in  all  its  subdivision 
types  of  remittent  and  intermittent  varieties.  There  is 
no  doubt  that  new  sections  of  the  North  present  the 
same  forms  of  malarial  fever.  Malarial  fevers  were  more 
or  less  common  when  this  country  was  new.  Cities  and 
ceitain  regions,  well  defined,  present  them  more  or  less 
clearly  at  present.  But  the  Lake  Erie  region  of  Western 
New  York,  where  this  fever  has  been  studied,  is  a  region 
entirely  exempt  from  malarial  influences.  The  first 
malarial  disease  is  yet  to  be  treated ;  the  first  malarial 
complication  is  yet  to  be  observed  in  years  of  practice. 


July  14,  1894] 


MEDICAL   RECORD. 


4i 


This,  moreover,  has  been  the  testimony  ot  physicians  who 
have  had  a  long  practice  here. 

This  region  may  have  had  malaria  fifty  or  a  hundred 
years  ago.  It  may  naturally  be  inferred  that  it  did.  If 
malaria  prevailed  and  is  now  absent,  may  it  not  have  left 
some  disease  in  its  wake  ?  Some  disease  with  its  actual 
malarial  germ  eliminated  ?  A  disease  subsequent  to  the 
former  and  depending  upon  it,  but  not  similar  ? 

If  the  South  is  to  be  credited  with  these  different  types 
of  fever  ;  if  bilious,  gastric,  typho  malarial,  and  malarial 
— without  meaning  malarial — simply  naming  it  malarial 
for  want  of  another  name — are  to  be  consigned  to  the 
Shades,  what  is  the  North  going  to  do  to  offset  the  ma- 
larial types  in  the  South  ?  Is  it  to  be  argued  that  we  live 
in  the  Garden  of  Eden  ?  A  place  where  they  have  only 
one  type  of  fever  and  that  (under  your  breath)  is  typhoid. 

It  does  seem  reasonable  to  me  that,  as  the  country  is 
developed  and  civilization  advances ;  as  diseases,  under 
better  hygienic  conditions  and  more  wisdom  in  guidance, 
assume  a  less  serious  form,  it  is  a  natural  inference  that  in- 
stead of  losing  the  type  of  disease  entirely,  we  should 
effect  a  modification  of  the  disease.  In  this  case  it  would 
be  a  change,  the  true  malarial  remittent  with  the  germ 
of  Laveran  to  a  remittent  of  the  present  time  without  the 
presence  of  the  germ.  Delay  in  announcing  a  positive 
diagnosis  in  fevers  until  the  tenth  or  twelfth  day,  is 
always  a  wise  precaution,  unless  typhoid  symptoms  pro- 
claim themselves  so  unmistakably  as  to  admit  of  no  ques- 
tion. A  disinfection  of  the  stools  of  all  fever  patients  is  a 
precaution  simple  and  easy  of  observance,  and  restful  to 
the  conscience,  when  a  case  which  admits  of  doubt  de- 
velops symptoms  unmistakably  typhoid. 

Desirous  of  getting  many  individual  opinions  upon 
this  question,  of  being  firmly  settled  in  my  own  mind  by 
a  consensus  of  opinion  of  the  gentlemen  present  that  I 
am  correct ;  or  of  being  fully  convinced,  by  a  full  and 
frank  discussion,  that  the  position  I  have  taken  is  not  a 
tenable  one,  I  stand  before  you  for  judgment. 

As  stated  before,  I  am  firmly  convinced  that  terms  ma- 
larial as  loosely  applied — typho-malarial,  gastric,  bilious, 
and  simple  febricula — should  be  blotted  from  our  text- 
books.    The  nomenclature  should  be  simplified. 

And  yet  the  very  fact  that  these  names  have  crept  into 
our  text-books  is  one  of  the  strongest  proofs  that  there  is 
a  fever  not  typhoid,  not  malarial. 

As  suggested  a  year  ago,  I  believe  the  name  Northern 
Remittent  Fever  describes  this  fever  in  question,  simpli- 
fies nomenclature,  and  is  worthy  of  adoption. 

Frkdonia,  N.  Y. 

VALUE    OF    THIRD    BLOOD-  CORPUSCLE l    IN 
TUBERCULOSIS. 

By  ROBERT  L.  W  ATKINS,  M.D., 

NEW  YORK. 

In  a  paper  read  before  the  Pan-American  Medical 
Congress  at  Washington,  in  September,  1893,  *  stated 
that  the  third  blood-corpuscle  is  a  pathological  product. 
The  statement  has  given  rise  to  criticism,  both  favorable 
and  adverse.  At  that  time,  in  my  paper,  I  gave  the 
proofs  and  reasons  for  my  belief,  and  will  not  go  over 
them  again  here.  Arguments  and  statements  deduced 
from  another's  experience  are  never  as  convincing  as 
one's  own,  and  this  is  a  thing  that  any  physician  can  test 
for  himself  if  he  has  a  good  microscope. 

The  granular  masses,  or  third  blood- corpuscle,  can 
readily  be  seen,  either  alone  or  in  groups.  When  in 
groups  they  are  often  so  pressed  together  that  it  may  be 
confusing  at  first  to  detect  their  shape,  but  a  little  ex- 
perience will  soon  overcome  this  difficulty,  and  you  will 
be  able  to  make  valuable  use  of  this  means  of  diagnosis. 

The  third  blood -corpuscle  is  the  first  indication  of 
tuberculosis,  and  I  assert  that  tuberculosis  in  any  form  is 
impossible  without  its  presence  in  the  blood.  It  makes  its 
appearance  long  before  the  cough,  or  before  any  of  the 
formerly  recognized  signs  and  symptoms  appear.     Not 

*  As  defined  in  Landois  and  Sterling,  Physiology. 


only  is  it  found  in  pulmonary  tuberculosis,  but  in  Pott's 
disease,  hip-joint  disease,  chronic  abscesses,  and  lupus, 
which  diseases  are  recognized  by  the  best  authorities  as 
tubercular.  It  is  also  found  in  some  cases  of  rheumatism 
and  asthma,  and  often  in  people  who  appear  perfectly 
well;  but  it  is  always  the  forerunner  of  tuberculosis. 
If  it  had  been  present  in  my  own  blood  I  should  never 
have  ventured  to  inoculate  myself,  as  I  did  some  time 
ago,  with  tubercle  bacilli ;  and  if  it  had  appeared  after 
the  inoculation  I  should  have  had  reason  to  leel  worried. 
It  did  not  appear,  however,  and  the  event  has  proved 
that  I  was  justified  in  my  confidence  that  tuberculosis 
would  not  develop. 

In  an  article  written  recently  by  Dr.  Charles  Deni- 
son,1  on  "  The  Diagnosis  of  Tuberculosis  by  Tubercu- 
lin Injections,"  he  says  :  "  There  is  an  active  tubercular 
state — pre-tubercular  state  if  you  wish  to  call  it  so — be- 
fore the  tubercle  makes  its  appearance  as  a  factor  in  the 
case."  (This  statement  has  been  made  by  many  others, 
and,  of  course,  has  been  known  for  a  long  time.)  But, 
still  further  he  says :  "  Reference  is  intended  to  those  in- 
tricate, slowly  acting  blood- changes  which  come  under 
the  classification  of  dyscrasia,  which  may  be,  for  all  I 
know,  the  sine  quanon  of  the  bacillus  of  tuberculosis." 

From  my  experience  I  believe  the  third  blood  corpuscle 
to  be  the  sine  qua  non  of  the  tubercle  bacillus,  and  the  for- 
mer to  be  the  means  of  diagnosticating  this  dyscrasia 
which  it  constitutes ;  and  still  further,  I  believe  it  to  be  one 
of  the  foods  of  the  tubercle  bacillus,  and  the  only  seeable 
one  in  the  blood,  for  I  have  demonstrated  that  this  germ 
will  live  in  acute  tubercular  blood,  and  have  published 
the  same  in  previous  articles.  The  following  cases  well 
illustrate  the  diagnostic  value  of  this  corpuscle. 

A  few  days  ago  a  young  lady  called  upon  me  to  have 
her  lungs  examined.  She  had  been  staying  indoors  a  few 
days  on  account  of  a  cold,  but  the  night  before  something 
red  came  up  in  her  throat  like  blood.  As  she  had  taken 
some  wine  that  day  it  was  thought  it  was  possibly  that, 
but  she  was  frightened.  I  examined  her  chest,  and  so 
did  another  physician.  Nothing  was  found  except  a  little 
rough  breathing.  On  examination  of  the  blood  it  was 
found  loaded  with  these  corpuscles,  and  on  that  sign  I 
settled  my  diagnosis  of  hemorrhage  and  tuberculosis. 
Two  days  after,  when  going  up  the  Elevated  stairs,  she 
had  a  severe  hemorrhage  and  has  had  several  since. 
Temperature  went  up,  and  now,  about  two  weeks  after, 
she  is  in  bed  with  high  temperature  and  night- sweats. 
In  my  experience  these  cases  are  not  uncommon. 

Mrs.  H came  to  me  with  a  supposed  case  of  can- 
cer on  the  forehead.  It  was  a  round  ulcer  about  one  and 
a  half  inch  in  diameter,  one  edge  looking  squamous 
like,  it  bleeding  very  easily,  and  most  painfully  sensitive. 
The  neuralgia  was  quite  extensive,  radiating  from  it  all 
over  the  head.  There  were  also  little  nodules  here  and 
there  over  the  forehead.  This  had  been  coming  on  one 
year,  I  believe.  A  microscopical  examination  of  the  blood 
showed  the  tubercular  third  blood-corpuscle  present.  I 
then  made  a  diagnosis  of  tubercular  ulcer  or  lupus,  and 
not  cancer.  The  sore  is  now  healed  fairly  well,  after 
two  months'  treatment. 

Mr.  H ,  a  single  man,  came  to  me  only  a  few  days 

ago,  complaining  of  a  cough  with  expectoration  and 
pains  in  the  chest,  most  of  his  family  having  died  of  tu- 
berculosis. He  only  recently  buried  a  sister,  to  whom 
he  was  very  much  attached,  which  fact  worried  him  in 
regard  to  himself.  A  physical  examination  of  his  chest 
revealed  evidence,  in  connection  with  the  history,  to  say 
that  it  was  the  old  story  of  beginning  consumption.  But 
on  examining  the  blood  no  corpuscles  were  found ;  and 
he  was  put  at  ease  at  once,  for  it  could  not  be  tubercular. 

Many  other  cases  might  be  given,  but  I  will  only  em- 
phasize its  value  as  a  means  of  making  a  negative  diag- 
nosis, i.e.,  to  say  that  the  absence  of  the  third  blood-cor- 
puscle from  the  blood  establishes  the  fact  that  no 
tuberculosis  is  present.  The  disease  with  which  the  pa- 
tient is  affected,  therefore,  must  be  of  some  other  nature. 

1  New  York  Medical  Journal,  February  3,  1894. 


42 


MEDICAL   RECORD. 


[July  14,  1894 


Clinical  gepartment 

THREE   CASES  OF    NERVOUS    DISEASES. 

By  PHILIP  S.  ROY,   M.D., 

WASHINGTON,  D.  C. 

Case  I.  Raynaud's  Disease. — A  colored  boy,  twelve 
years  of  age,  complained  now  and  then  for  three  months 
of  numbness  of  the  right  foot  followed  by  burning  pain, 
particularly  marked  in  the  big  toe,  with  occasional  at- 
tacks of  neuralgia  in  that  foot.  About  two  weeks  be- 
fore I  saw  him  he  also  complained  of  its  feeling  very 
cold — swelling  commenced,  and  he  suffered  intense  pain 
most  of  the  time.  Upon  my  first  examination  I  found 
the  big  toe  as  black  as  ink — pressure  upon  it  lessening 
the  discoloration — and  voluntary  motion  seemed  lost. 
On  my  second  visit  nutritive  alterations  had  occurred — 
blood-blisters  had  formed  and  several  had  broken,  leav- 
ing raw  surfaces.  The  nail  was  loose  and  the  tissue  un- 
derneath ulcerated.  The  asphyxia  had  continued,  and 
to  all  appearances  gangrene  was  about  to  occur. 

I  had  ordered  the  foot  to  be  elevated  and  wrapped  in 
cotton-batting,  and  a  soothing  ointment  applied  to  the 
toe.  Internally  I  gave  the  elix.  phosph.,  iron,  quinia, 
and  strychnia,  with  the  twelfth  of  a  grain  of  morphia  to 
each  teaspoonful.  I  did  not  see  the  case  again,  as  the 
parents  could  not  furnish  either  the  drugs  or  the  proper 
diet — and  I  advised  that  he  be  sent  to  the  Children's 
Hospital,  or  else  that  one  of  the  physicians  to  the  poor 
be  sent  for.  He  had  no  fever  when  I  first  saw  him,  but 
three  days  afterward,  on  my  second  visit,  his  temperature 
was  1030  F.  I  never  compared  the  temperature  of  the 
two  feet. 

Case  II.  Affaire's  Disease. — A  white  man,  forty 
years  of  age,  gave  me  the  following  history :  About  a 
year  before  I  saw  him,  while  at  work,  he  was  seized  with 
violent  vertigo  and  fell  to  the  ground.  Upon  attempt- 
ing to  rise  he  found  it  impossible  to  do  so.  He  was 
told  that  his  face  was  very  pale  and  covered  with  a  cold 
perspiration ;  was  taken  home,  and  for  two  days,  when- 
ever he  opened  his  eyes,  all  objects  seemed  to  whirl 
around  him.     He  vomited  some  the  first  day. 

After  two  days  he  could  walk  about,  but  found  he  was 
very  deaf  in  the  right  ear,  with  constant  noises  in  that 
ear.  Since  the  first  attack  he  has  had  two  others,  and  in 
the  last  of  these  I  saw  him  ;  he  was  then  unable  to  rise, 
and  the  slightest  movement  of  his  head  caused  the  ver- 
tigo to  return.  His  face  was  pale,  with  a  cold  perspira- 
tion, and  the  right  ear  very  deaf.  %  Between  the  attacks 
the  deafness  is  much  better,  though  hearing  is  never  en- 
tirely restored.  I  examined  the  throat  and  external  ear, 
and  could  find  no  disease  to  account  for  the  vertigo.  I 
therefore  conclude  that  his  is  a  case  of  true  Meniere's 
disease.  He  had  been  told  by  his  former  physician 
that  he  had  bilious  attacks. 

Case  III.  Angioneurotic  (Edema. — A  woman,  forty- 
five  years  of  age,  was  suddenly  attacked  with  (edematous 
swelling  in  one  foot,  accompanied  with  gastric  pain  and 
nausea.  On  the  following  day  the  other  foot  became 
swollen ;  this  lasted  three  days,  when  the  swelling  left 
the  feet  and  the  hands  became  affected  in  the  same 
manner.  In  two  days  the  swelling  disappeared  from  the 
hands  and  appeared  in  the  face.  At  the  end  of  a  week 
all  swelling  had  subsided.  The  woman  looked  delicate, 
but  said  her  health  was  good.  Upon  examination  I 
found  no  disease  either  of  the  heart  or  kidneys.  She 
told  me  she  had  had  slight  attacks  of  a  similar  kind.  I 
afterward  saw  her  daughter  with  a  similar  attack,  except 
that  the  swelling  was  confined  to  the  face  and  hands  and 
accompanied  with  nettle-rash,  and  the  gastro-intestinal 
symptoms  were  more  marked.  The  daughter's  attack 
lasted  ten  days — first  one  part  and  then  another  of  the 
face  and  hands  becoming  swollen.  She  had  had  several 
attacks  in  the  three  years  previous.  I  could  find  noth- 
ing in  the  diet  to  account  for  the  nettle-rash,  nor  did  the 
remedies  used  for  nettle-rash  relieve  her.     In  both  cases 


I  gave  the  elix.  of  iron,  quinia,  and  strychnia,  until 
they  were  well  I  do  not  know  that  I  have  had  suffi- 
cient opportunity,  either  from  study  or  observation,  to 
express  an  opinion  upon  the  subject,  but  it  seems  to  me 
that  if  this  disease  is  sufficiently  definite  to  justify  giving 
it  a  separate  description  in  medical  literature,  it  is  only 
because  in  so  doing  we  emphasize  the  importance  of  con- 
sidering the  nervous  system  in  sudden  attacks  of  oedema. 
The  urticaria  which  sometimes  accompanies  the  dis- 
ease (as  it  did  in  one  of  my  cases)  would,  a*  Osier  says, 
make  one  believe  that  the  patient  had  simply  a  case  of 
urticaria — while,  as  in  my  other  case,  purpuric  spots 
would  cause  one  to  fear  some  serious  organic  disease. 
These  cases  of  nervous  disease,  the  clinical  histories  of 
which  differ  so  widely,  are  all  due,  according  to  our  best 
light  at  this  time,  to  vaso-motor  influences.  In  the  case 
of  Raynaud's  disease  I  exclude  all  other  causes  that  might 
produce  similar  conditions.  The  more  persistently  we 
keep  in  mind  the  nervous  system  in  making  diagnosis, 
the  oftener  are  obscure  cases  made  clear  to  us. 


SUMMER  COMFORT   FOR  BABIES:    WITH    A 
HINT   ON   COLDS  AND    HAY    FEVER. 

By  CHARLES  E.  PAGE,  M.D., 

BOSTON,  MASS. 

"  Man  is  not  by  nature  a  clothed  animal,"  said  Carlyle 
in  "Sartor  Resartus,"  and  the  writer  has  three  little  ones, 
aged  respectively  nine  months,  two  and  a  hal£  and  four 
years,  who  seem  to  agree  with  the  Sage  of  Chelsea  ;  they 
are  never  so  happy  as  when  they  are  naked.  Four  years 
ago  (June  14,  1890)  the  eldest,  a  girl,  was  born,  and  dur- 
ing all  the  hot  weather  we  kept  her  comfortable  and 
happy  "in  her  figure,"  literally.  She  was  sufficiently 
blanketed  at  night  and  during  the  cool  of  the  morning 
and  evening,  of  course;  but  in  spite  of  Mrs.  Grundy  she 
was  kept  naked  much  of  the  time,  and  with  unfettered 
limbs  she  was  creeping,  or,  at  any  rate,  hitching,  her  way 
across  the  floor  before  she  was  four  weeks  old.  Her  un- 
usual strength  was  due  to  our  practice  of  non-tending,  as 
well  as  to  die  freedom  of  body  and  limbs. 

The  more  intelligent  of  our  visitors,  to  whom  she  was 
exhibited,  were  delighted  with  the  evidence  of  absolute 
comfort  they  beheld,  and  they  straightway  manifested  a 
disposition  to  help  their  own  little  relatives  as  much  as 
they  could  by  stripping  off  some  of  the  extra  folds  of 
flannel  under  which  the  little  wretches  were  sweltering 
and  half-smothering.  But  someone,  we  never  learned 
who,  informed  the  S.  P.  C.  C.  of  the  outrageous  treatment 
of  the  little  innocent,  and  looked  for  our  arrest  and  sum- 
mary punishment  doubtless,  and  perhaps  the  adoption  of 
the  babe  by  the  State  ;  but  it  so  happened  that  my  little 
Nursery  Guide,  "  How  to  Feed  the  Baby,"  published  in 
1882,  was  dedicated  to  the  Society  for  the  Prevention  of 
Cruelty  to  Children,  and  so  the  President  smiled  be- 
nignly on  the  good  soul  who  lodged  the  complaint,  and 
assured  her  that  if  Dr.  Page's  baby  died  of  frost-bite  dur- 
ing the  summer  the  case  should  be  carefully  investi- 
gated ! 

Something  like  ten  to  twelve  thousand  children  have 
died,  under  the  age  of  five  years,  in  this  city,  since  the  oc- 
currence of  the  little  episode  referred  to,  while  our  little 
girl  continues  to  thrive,  and  to  pull  off  her  shoes  and 
stockings  the  instant  she  enters  the  house  from  her  out- 
ings, and  both  she  and  her  little  brother  have  time  and 
again  distressed  the  maid  by  cutting  up  that  caper  and 
going  barefoot  on  "the  Avenue."  Numbers  two  and 
three  have  since  come  to  us,  and  they  share  their  elder 
sister's  dislike  for  clothes.  All  three  go  barefoot  in  the 
house  all  the  year  around,  and  much  of  the  time  when 
out,  and  wear  very  slight  rig  at  all  times. 

Next  to  a  bad  inheritance — many  children  being  born 
too  tough  to  kill,  while  some  are  so  frail  by  nature  that 
no  kind  of  management  will  enable  them  to  pull  through 
— the  principal  causes  of  infant  mortality  are :  (1)  Exces- 
sive feeding,  digestive  capacity  being  lessened  by  lack  of 


July  14,  1894] 


MEDICAL  RECORD. 


43 


exercise  and  overwrapping ;  (2)  constant  tending,  and 
constant  lack  of  natural  exercise,  so  essential  to  vigor  of 
body  and  digestive  power ;  (3)  excessive  clothing,  so  de- 
pleting in  many  ways  to  the  animal  organism,  the  skin,  a 
breathing  as  well  as  an  excreting  organ,  being  forced  to 
get  on  with  foul  air,  instead  of  fresh,  while  the  pressure 
of  clothing,  all  the  worse  if  a  belly-band  is  used,  inter- 
feres seriously  with  the  circulation  of  blood  in  the  skin, 
etc  ;  (4)  lack  of  fresh  air  in  the  home,  very  few  homes 
being  sufficiently  ventilated. 

"  Why  don't  they  catch  their  death  o'  cold?"  Perhaps 
one  reason  is  that,  H  the  truth  were  known,  none  of  us 
catches  the  disease  in  that  way  ;  it  is  rather  a  disease  of 
accumulation  of  foul  matters  from  the  causes  already 
named,  and  when  the  system  becomes  surcharged  with 
frith  and  certain  symptoms  appear,  we  say — those  of  us 
who  know  no  better — "  He  has  caught  cold  !  "  The  fact 
of  the  matter  is  that  it  is  rather  a  lack  of  cold,  and  hence 
the  prediction  of  Dr.  Felix  Oswald,  that  the  time  will 
come  when  every  sanitarium  wiliAbe  supplied  with  an  im- 
mense refrigerator  for  the  treatment  of  "colds"  (I  can 
never  bring  myself  to  repeat  the  name  except  with  quota- 
tion marks).  The  adult  victims  of  flannels  and  a  diet 
unsuited  to  the  season,  hundreds  of  whom  (physicians  as 
well  as  laymen,  it  must  be  confessed)  flock  to  the  White 
Mountains  every  summer  to  avoid  "hay  fever,"  might 
take  a  hint  here  and  live  in  comfort  in  any  part  of  the 
country.  They  might  go  to  the  mountains  for  fun,  but 
not  as  a  lot  of  sneezing,  overgrown  infants,  to  babble 
about  the  hoped-for  specific.  How  often  I  have  ob- 
served a  babe  who  could  not  suck  and  breathe  at  the  same 
time  for  "  snuffles,"  completely  relieved  within  a  half- 
minute  by  removing  a  large  share  of  its  clothing,  and 
having  a  cold,  damp  towel  pressed  over  the  forehead, 
temples,  and  top  of  the  head,  sending  a  cool  wave  in  to 
relieve  the  congested  parts.  It  should  be  a  cool,  damp 
towel,  by  the  way,  not  ice-cold  for  an  infant ;  but  the 
grown  snuffling  may  employ  more  vigorous  measures. 

867  BOYLSTON  STSBKT. 

NOTES   ON   BRAIN    SURGERY. 
By  W.  E.  PUTNAM,  M.D., 

WHITING,    INP. 

Case  I.     Depressed  Fracture  of  Skull — Amputation  at 

Shoulder  Joint — Recovery. — Andy  P ,  a  Pole,  aged 

nineteen,  tried  to  board  a  freight  train  and  was  thrown 
under  the  cars.  I  saw  him  two  hours  after  the  accident, 
no  effort  had  been  made  to  check  the  hemorrhage.  The 
left  arm  was  fractured  in  three  places  between  the  wrist 
and  shoulder,  and  the  skin  and  subcutaneous  tissue  were 
destroyed  well  forward  on  to  the  chest.  The  patient  did 
not  complain  of  pain,  and  I  took  it  for  granted  that  the 
railroad  shock  was  to  blame  for  this.  After  carrying  him 
two  miles  to  my  office  I  amputated  the  shoulder-joint  by 
a  mixed  method,  using  a  peculiar-shaped  posterior  flap 
and  sliding  some  skin  over  tfre  pectoral  muscles.  Am- 
putation completed,  my  patient  continued  to  sleep  on  and 
on,  and  I  began  to  look  for  "  new  worlds  to  conquer," 
when  I  found  a  three-inch  half  circular  depressed  fracture 
in  the  left  parietal  bone.  No  ether  was  needed,  as  the 
compression  had  caused  what  I  supposed  to  be  railroad 
shock.  I  used  a  carpenter's  chisel  (for  trephine)  and  a 
monkey-wrench  (for  a  mallet).  After  chiselling  away 
enough  of  the  bone,  I  used  the  same  chisel  to  raise  the 
depressed  bone.  By  keeping  a  continuous  stream  of 
water  playing  on  the  seat  of  operation  one  can  see  per- 
fectly just  how  to  hold  his  chisel,  there  being  then  little 
or  no  danger  of  injuring  the  dura  mater.  The  bone  was 
raised,  and  a  strip  of  iodoform  gauze  was  used  as  drain- 
age. One  hour  after  the  operation  the  patient  sat  up  and 
drank  a  cup  of  coffee,  after  which  he  slid  off  the  operating- 
table  and  walked  half  a  dozen  steps  unaided.  In  three 
weeks  he  was  out  again  looking  for  work. 

Case  II.  Compound  Fracture  of  Skull,  Opening  into 
the  Superior  Longitudinal  Sinus%  with  Loss  of  Two  Ounces 
of  Brain  Matter — Recovery. — Swede,  aged  twenty-three. 


Two  laborers  were  wrestling  for  an  iron  hook,  and  the 
hook  came  down  on  top  of  the  patient's  head,  the  sharp 
point  entering  the  superior  longitudinal  sinus.  The  pa- 
tient was  comatose  when  brought  to  my  office.  There 
was  a  swelling  the  size  of  a  goose  egg  on  top  of  the  head. 
A  free  incision  released  the  pressure  on  brain,  and  the 
patient's  heart  and  respiration  improved  immediately. 
When  he  coughed  he  literally  spat  blood  from  the  top  c  f 
his  head,  throwing  blood  fully  four  feet  against  the  wall 
of  my  office.  He  lost  at  least  two  ounces  of  brain  matter. 
I  had  not  seen  very  many  cases  of  brain  surgery  out  here 
in  the  country,  so  I  packed  the  wound  loosely  with  iodo- 
form gauze  and  took  my  patient  twenty  miles  to  the  Rush 
Medical  College,  in  Chicago.  Dr.  N.  Senn  put  a  snap 
forceps  on  each  of  the  divided  ends  of  the  superior  longi- 
tudinal sinus,  and  held  them  in  place  with  a  p] aster- of- 
Paris  dressing  enveloping  the  whole  head.  In  four  days 
the  snap  forceps  were  removed.  In  twelve  weeks  the 
patient  left  the  hospital,  partially  paralyzed  on  one  side, 
but  able  to  walk  by  the  aid  of  a  cane.  I  wish  to  re  cot d 
these  two  simple  cases  for  the  benefit  of  young  surgeons 
who,  like  myself,  are  located  in  country  towns,  where  we 
are  compelled  to  use  our  little  knowledge  and  all  our 
courage  to  save  a  human  life. 


AN    EASY    METHOD    OF     BATHING     IN    TY- 
PHOID FEVER. 

By  WILLIAM  B.  NOYES,  M.D., 

NKW  YOUC. 

Every  new  medical  text-book  and  periodical  accumulates 
statistics  testifying  to  the  brilliant  results  following  the  use 
of  cold  baths  in  typhoid  fever.  The  hospitals  in  which  this 
method  is  chiefly  carried  on  are  almost,  without  excep- 
tion, showing  a  higher  percentage  of  recoveries  than  ever 
before  under  any  other  plan  of  treatment. 

Why  is  it,  then,  that  this  method  is  not  universally 
adopted  and  carried  out  in  private  practice  ?  The  an  • 
swer  is  simple.  Easy  as  it  is  in  a  hospital  with  an  abun- 
dance of  skilled  assistance,  there  is  no  method  of  treat- 
ment in  use  so  difficult  to  carry  out  properly  as  tubbing 
in  typhoid  fever  in  private  families. 

As  the  family  bathroom  is  generally  out  of  the  ques- 
tion on  account  of  its  inconvenient  location,  and  use  by 
others  of  the  household,  it  becomes  necessary  to  buy  a 
large  portable  bath-tub. 

Even  in  cases  where  there  are  two  trained  nurses  it  is 
necessary  to  call  in  the  clumsy  assistance  of  some  mem- 
bers of  the  family  to  help  in  the  lifting  of  the  patient  to 
and  from  the  tub,  and  this  is  a  strain  on  them,  and  not 
unattended  with  risk  to  the  one  who  is  sick. 

There  is  undoubtedly  still  a  widespread  opposition 
among  the  laity,  both  educated  and  uneducated,  to  the 
use  of  "cold  baths"  in  fever.  A  young  physician  must 
have  a  very  strong  hold  on  the  family,  and  enjoy  their 
most  complete  confidence,  to  take  the  risk  of  the  respon- 
sibility, if  the  disease  takes  a  bad  turn  later  from  any 
accidental  complications,  and  even  older  men  will  seme- 
times  hesitate. 

A  physician  of  high  standing  and  extensive  practice  in 
the  city  recently  said  to  me,  "  I  do  not  find  that  tubbing 
is  practicable  in  private  families,  much  as  I  would  like  to 
make  use  of  it  I  have  to  content  myself  with  sponging 
and  packs,  and  have  had  some  success  with  constant  use 
of  an  ice-coil  over  the  abdomen  as  a  substitute.  If  the 
ice-coil  acts  so  well  in  lesions  of  the  peritoneal  coat  of 
the  intestines,  why  should  it  not  have  a  similar  result  in 
lesions  of  the  mucous  coat  ?  " 

But  all  these  three  methods,  sponging,  wet  pack,  or 
ice  coil,  while  they  add  to  the  comfort  of  the  patient,  do 
not  cause  very  decided  or  long  continued  lowering  of  the 
temperature. 

Again,  one  who  has  had  bad  results  from  necessary 
changing  of  the  position  of  a  patient  in  an  advanced 
stage  of  typhoid  to  examine  the  back  of  the  chest,  or 
something  equally  simple,  causing  disagreeable  heart 
symptoms,  will  rather  dread  the  process  of  lifting  a  pa- 


44 


MEDICAL  RECORD. 


[July  14,  1894 


tient  out  of  his  bed  for  any  reason  whatever,  especially 
if  the  patient  is  large  and  the  bed  a  double  one. 

The  following  method,  which  I  once  saw  used  in  a 
hospital  in  Buffalo,  commends  itself  as  a  simple  solution 
of  the  whole  problem.  I  have  never  seen  it  published 
in  any  medical  journal  or  work,  and  am  sure  that  it  has 
not  often  been  tried. 

It  is  a  very  easy  thing  to  slip  a  rubber  blanket  under 
the  patient,  and  raise  the  two  sides  and  the  ends  at  the 
foot  and  head  of  the  bed,  nine  or  ten  inches,  by  a  row  of 
pillows,  bolsters,  sand -bags,  or  simple  boards. 

The  rubber  blanket  ought  to  be  of  double  thickness, 
as  large  as  can  be  purchased,  and  special  care  must  be 
given  to  the  arranging  of  the  corners.  When  this  is 
done  you  have  the  patient  at  the  bottom  of  an  impromptu 
bath-tub,  into  which  you  can  pour  water  at  any  desired 
temperature,  and  in  sufficient  quantity  to  partially  or  en- 
tirely cover  his  body. 

Only  two  inches  of  water  would  be  enough  to  give  a 
cool  sponge-bath  ten  times  as  efficacious  as  the  gingerly 
sponging  possible  under  ordinary  circumstances,  and  if 
the  sides  and  corners  are  firmly  fixed  you  can  easily 
make  this  tub  hold  all  the  water  you  desire.  The  water 
may  be  run  from  the  nearest  faucet  by  a  rubber  tube. 
I  have  found  it  a  simpler  and  equally  successful  method 
to  carry  it  in  pails  and  pour  it  over  the  patient,  starting 
with  tepid  and  gradually  cooling  it  down  to  the  desired 
temperature. 

The  neatest  method  I  have  found  by  experiment  is  to 
use  a  large  "  watering-pot "  with  a  sprinkler,  such  as  is 
used  for  watering  plants.  This  is  a  method  which  will 
not  commend  itself  to  those  who  dislike  humble  and  com- 
monplace methods  to  accomplish  something  that  more 
complicated  and  more  impressive  methods  might  do. 

I  believe  this  kind  of  a  bath  will  always  be  grateful  to 
the  patient,  and  if  it  is  found  necessary  to  use  water  at  a 
decidedly  low  temperature,  would  give  rise  to  less  shock 
than  a  sudden  plunge  into  a  tub  filled  with  very  cold 
water.  The  effect  on  the  temperature  is  the  same  as  it 
would  be  under  the  other  method  with  a  stationary  tub. 

The  water  can  be  removed,  without  spilling  a  drop  on 
the  bed,  by  siphoning  with  a  rubber  tube,  or  dipping  with 
a  small  pitcher  or  cup,  or  sponging.  Then  the  blanket 
can  be  dried  and  left  in  place,  covered  by  a  clean  sheet, 
or  better  yet,  removed  and  dried  in  the  sun. 

All  this  needs  a  little  care,  for  it  would  be  a  very  seri- 
ous and  troublesome  accident  to  soak  the  patient's  bed- 
clothing  and  mattress,  but  the  difficulty  and  risk  to  the 
patient  cannot  be  compared  with  that  attending  the  use  of 
the  ordinary  tub.  And  best  of  all,  in  those  cases  where  the 
family  or  friends  must  do  the  work,  and  the  employment 
of  trained  nurses  is  impossible  on  account  of  expense,  this 
method  can  always  be  successfully  used  when  tubbing 
would  be  out  of  the  question. 

I  have  not  found  one  single  objection  to  the  employ- 
ment of  the  method  in  private  cases,  and  cannot  see 
why  it  could  not  be  used  in  hospitals. . 

164  West  Seventy-thud  Stxbkt. 


HISTORY  AND  TREATMENT  OF  A   CASE  OF 
TRAUMATIC  TETANUS  AND   SEQUELAE. 

By  CHARLES  J.  MONTGOMERY,  M.D., 

AUGUSTA,  GA. 

N ,  colored,  male,  aged  thirty-two ;  occupation,  hostler 

and  yard  boy.  Previous  history :  No  sickness  for  nineteen 
years,  with  exception  of  one  or  two  attacks  of  grippe 
{keeping  at  work,  however,  in  spite  of  it),  and  generally 
in  winter  has  more  or  less  of  bronchitis.  History  and 
treatment  of  case :  With  a  razor  he  cut  a  corn  with  a  cer- 
tain amount  of  healthy  tissue  from  fifth  toe  of  left  foot, 
causing  some  bleeding.  Kept  at  work  for  several  days, 
becoming  by  degrees  very  lame.  By  January  24,  1894,  a 
few  days  after  the  injury,  lameness  and  pain  in  the  foot 
were  so  great  that  discontinuance  of  work  was  necessary 
and  he  went  to  bed.  I  was  called  to  see  him  January 
26th.     At  my  direction,  before  I  reached  his  house,  a 


flax-seed  poultice  was  applied  to  the  foot  and  fifteen  grains 
of  quinine  were  given.  On  reaching  the  bedside  I  found 
him  suffering  considerable  pain  in  the  foot,  which  was 
somewhat  swollen.  Fever  was  present.  A  simple  febri- 
fuge mixture  was  prescribed  containing  a  small  amount 
of  acetate  of  morphine,  and  directions  were  given  for  him 
to  be  sponged  with  cool  water  and  his  bowels  moved  with 
a  blue  pill  followed  by  castor-oil 

January  27th. — He  was  found  to  have  passed  a  restless 
night,  and  suffered  pain  not  only  in  the  fobt,  but  at  the 
base  of  the  spine  and  in  the  left  hip.  Some  pain  about 
the  jaws.  In  addition  to  the  febrifuge  mixture  he  was 
ordered  to  take  chloral,  ten  grains,  that  night,  and  the  same 
amount  the  next  morning. 

January  28th. — Morning  of  January  28th  the  jaws  were 
set,  but  not  too  close  to  take  liquid  food  and  medicine. 
Physostigmine  salicylate,  gr.  ^,  was  given  internally,  re- 
peated once  an  hour  and  again  in  three  and  four  hours 
(this  being  the  only  preparation  of  calabar  been  obtain- 
able), and  a  hypodermic  of  morphine  sulphate,  gr.  ^,  was 
given.  Chloral  was  given  again  that  night,  and  another 
hypodermic  of  morphine.  Temperature  at  this  time  was 
102 j°  F. 

On  the  morning  of  the  29th  the  patient  seemed  to  feel 
slightly  easier,  with  temperature  1010  F.  Fever  mixture 
was  ordered  stopped,  but  physostigmine  continued.  Later 
in  the  morning  he  had  a  violent  convulsion,  and,  having 
been  sent  for,  1  reached  the  bedside  during  a  second 
convulsion.  Having  brought  with  me  a  mixture  contain- 
ing chloral,  gr.  15  ;  bromide  of  potassium,  gr.  30,  in  each 
tablespoonful,  I  forced  his  teeth  slightly  apart  with  a  spoon 
and  gave  him  a  dose  of  this  medicine.  I  ordered  that  it 
be  repeated  every  four  hours,  and  that  immediately  after 
each  dose  he  should  take  morphine,  gr.  ^,  internally 
Physostigmine  was  discontinued.  He  began  to  improve 
immediately  after  the  first  dose  of  the  above  mixture,  and 
never  had  another  convulsion  during  the  whole  progress 
of  the  disease.  That  night  he  felt  comparatively  easy 
and  his  temperature  was  102°  F. 

On  the  morning  of  the  30th  the  temperature  was  ioif  ° 
F.,  the  man  having  passed  a  comfortable  night.  That 
evening  the  temperature  was  io2|°  F.,  pulse  about  no 
and  weak,  and  on  the  morning  of  the  31st,  though  a  com- 
fortable night  had  been  passed,  the  temperature  was  found 
to  be  103  F.  I  now  began  to  administer  infusion  of 
digitalis,  in  teaspoonful  doses,  fifteen  minutes  after  each 
dose  of  the  chloral  mixture.  The  temperature  had  fallen 
on  the  evening  of  the  31st  to  ioi|°  F.,  and  never  again 
rose  above  that  point,  which  I  attribute  largely  to  the 
continued  use  of  infusion  of  digitalis.  By  February  2d 
the  temperature  had  fallen  to  99!°  F.  in  the  morning,  to 
rise  only  to  99$°  F.  in  the  evening,  with  pulse  100.  At 
this  time  the  patient  was  free  from  pain  and  could  open 
his  jaws  about  one  inch. 

The  treatment,  in  addition  to  that  mentioned,  consisted 
in  local  hot  applications,  both  wet  and  dry,  to  the  neck 
and  spine,  dressings  containing  laudanum  to  the  foot,  and 
later  in  the  course  of  the  disease,  massage,  with  hot  cocoa- 
butter,  and  to  move  the  bowels  a  rectal  injection  was 
given  every  three  days. 

Diet  consisted  of  a  glass  of  milk  every  hour,  with 
whiskey,  and  when  he  became  able  to  chew,  semi-solid 
and  then  solid  food  was  taken. 

On  February  3d  the  dose  of  the  chloral  mixture  was 
reduced,  a  dessert-spoonful  (or  gr.  7j^  of  chloral,  15  gr. 
of  bromide)  being  taken  at  each  dose  instead  of  a  table- 
spoonful,  except  the  last  dose  at  night,  which  was  a  table- 
spoonful.  Soon  the  daily  amount  was  still  more  dimin- 
ished, though  not  entirely  discontinued,  till  the  end  of  the 
third  week.  About  the  end  of  the  second  week  the  pa- 
tient was  in  a  low  state  of  delirium  continually,  and  seemed 
to  be  growing  weaker,  and  question  of  amputation  was 
presented.  I  decided  not  to  amputate,  but  dissected 
away  a  portion  of  the  scar  tissue  at  the  site  of  the  ori- 
ginal wound,  which  had  never  been  an  open  wound  since 
I  had  been  attending  the  case.  The  wound  which  I  thus 
made,  as  well  as  a  large  portion  of  the  foot,  which  was 


July  14,  1894] 


MEDICAL   RECORD. 


45 


still  swollen,  was  dressed  with  iodoform  gauze  saturated 
with  laudanum,  and  this  dressing  was  continued  about  a 
week. 

About  the  fourth  week  the  patient  showed  evident  signs 
of  improvement,  which,  though  slow,  were  continuous,  till 
the  nth  of  March,  when  he  complained  of  passing  blood 
at  the  end  of  urination,  which  was  accomplished  with  a 
great  deal  of  tenesmus.  This  condition  was  followed  by 
pain  over  the  pubes.  Suppositories  of  opium  and  bella- 
donna afforded  great  relief,  poultices  but  little ;  ergotole 
and  fluid  extract  of  cannabis  indica  were  given  by  the 
stomach,  flax-seed  tea  prescribed,  and  the  diet  reduced 
again  to  milk.  Examination  of  the  urine,  which  was 
very  turbid,  showed  it  to  contain  a  large  amount  of 
albumin. 

Pain  in  the  back  and  over  the  kidneys  developed  later. 
(Edema  of  the  feet  and  ankles  with  great  tenderness  was 
present.  Dry  cups  were  applied  to  the  loins,  and  later 
hot-water  cloths,  and  digitalis  and  acetate  of  potassium 
administered  internally  ;  also  a  few  doses  of  pilocarpine. 
The  temperature  during  these  complications  ranged  be- 
tween 990  and  1010  F. 

The  temperature  on  March  19th  had  fallen  to  normal, 
with  pulse  at  82,  fairly  strong,  and  the  urine,  though 
cloudy  and  containing  an  abundant  sediment,  was  found 
to  be  free  from  albumin.  Improvement  from  this  time 
has  been  practically  continuous,  and  the  patient  now 
(April  7th),  is  able  to  walk  about  the  house  and  a  lit- 
tle out  of  doors  every  day,  and  is  steadily  gaining 
strength. 

AN  UNUSUAL    CASE  OF   TOXIC  AMBLYOPIA. 
By  F.  E.  D'CENCH,  M.D., 

NEW  YORK. 

M.  G ,  aged  forty,  came  to  my  office  on  account  of 

the  sudden  failure  of  his  sight,  which  had  taken  place 
eleven  days  previously.  The  evening  before  he  had  been 
reading  fine  type  without  difficulty,  whereas  the  follow- 
ing morning  he  could  not  even  see  the  large  capitals  in 
the  name  of  his  newspaper.  As  his  sight  had  grown 
rather  worse  than  better,  he  sought  medical  advice. 

I  found  that,  even  with  the  aid  of  his  glasses,  he  could 
not  count  fingers  at  a  greater  distance  than  four  feet. 
Distinct  sector-shaped  atrophy  of  the  temporal  side  of 
the  optic  nerve.  Pupils  somewhat  contracted,  but  re- 
spond promptly  to  light.  Visual  field  good.  There  is  a 
marked  central  color-scotoma,  especially  for  green  and 
red. 

The  patient  has  smoked  cigarettes  since  he  was  eleven 
years  of  age,  generally  about  ten  or  twelve  a  day,  and 
has  also  used  alcoholic  stimulants,  though  he  has  not 
indulged  in  them  to  excess.  The  diagnosis  was  there- 
fore easy,  and  the  treatment  generally  adopted  in  such 
cases  begun.  Tobacco  and  alcohol  were  entirely  with- 
drawn, and  strychnine  in  increasing  doses  was  injected, 
at  first  every  day,  afterward  every  other  day.  Improve- 
ment in  sight  began  almost  immediately.  In  a  week  it 
was  Y%nt  *a  two  weeks  £fj,  in  three  weeks  j^,  and  so 
on,  until  after  two  months  it  was  Jjj  -f ,  which,  in  view 
of  the  fact  that  there  is  a  myopia  of  \,  with  an  additional 
astigmatism  of  fa,  may  be  regarded  as  normal  sight. 
Faces  seem  slightly  dark  still,  but  he  has  no  difficulty  in 
reading  even  small  print.  There  has  been  no  change 
since  that  time. 

Cases  of  toxic  amblyopia  are  not  uncommon,  and  if 
sight  has  not  fallen  to  too  low  a  level,  the  prognosis  is 
usually  favorable.  Loss  of  vision  is  gradual,  and  the  pa- 
tient will  therefore  generally  consult  a  physician  before 
it  is  too  late.  The  peculiar  feature  of  this  case  lies  in 
the  rapidity  with  which  vision  failed,  dropping  within 
twelve  hours  from  normal  acuteness  to  counting  fingers  at 
a  distance  of  a  few  feet.  Such  a  rapid  loss  is  seen  in  acute 
glaucoma  and  a  few  other  diseases,  but  not  in  amblyopia 
due  to  tobacco  and  alcohol,  and  so  this  case  seemed  to 
me  to  be  worthy  of  being  put  on  record. 


NOTES  ON  PELVIC  AND  GENERAL  MASSAGE. 
By  SARAH  E.  POST,  M.D., 

NEW  YORK. 

Pelvic  Massage. — I  have  recently  attempted  this  treat- 
ment in  three  cases,  in  all  with  a  satisfactory  result.  I 
have  found  it  possible  to  propel  the  contents  of  the  tubes 
down  through  the  uterus  and  to  secure  its  discharge  with- 
out the  usual  recurring  cramps.  By  cramps,  I  mean  tu- 
bal colic.  In  one  case  this  returned  every  second  or 
third  day ;  in  another  it  was  constant.  The  pain  is  in 
the  inguinal  region  and  down  the  front  of  the  thigh.  It 
seems  to  be  due  to  traction  upon  the  peritoneal  attach- 
ments in  the  inguinal  region.  It  is,  I  think,  not  located  in 
the  tube  itself,  for  this  may  be  found  upon  a  higher  level. 
The  pulling  is,  of  course,  to  be  referred  to  the  contrac- 
tions and  movements  of  the  tube.  To  secure  discharge 
without  contraction  and  to  thus  relieve  pain  became  after 
this  discovery  the  main  object  of  the  treatment.  In  a 
case  of  simple  catarrh  of  one  side  the  tube  was  about  the 
size  of  the  ureter.  In  another  case  both  tubes  were 
easily  found.  After  treatment  they  were  softer  ard  might 
escape  the  touch.  This  last  case  had  in  addition  num- 
erous nodules  the  size  of  a  bean  or  pea,  extending  from 
the  side  of  the  uterus,  as  I  recall  the  case,  into  the  iliac 
fossa.  These  nodules  also  disappeared  in  the  course  of  six 
weeks9  massage. 

In  working  upon  the  tubes  I  move  the  index-finger  of 
the  right  hand  back  and  forth  transversely  across  their 
lumen,  beginning  at  the  distal  end,  carrying  the  skin, 
possibly,  the  whole  of  the  abominal  wall,  with  the  finger 
in  this  motion,  gently  persisting  over  each  accumulation 
where  convolution  of  the  tube  has  occurred.  The  tips 
of  the  two  first  fingers  were  used  upon  the  uterus,  the 
kneading  being  generally  restricted  to  the  horns  them- 
selves. At  the  same  time  the  index-  and  middle-finger 
of  the  left  hand  straightened  the  uterus  and  held  it  up- 
right where  there  was  displacement  of  the  body  or  neck. 
In  this  manoeuvre  the  index-finger  was  passed  in  front  of 
the  uterus  and  the  middle- finger  behind  it.  In  a  case 
without  serious  displacement  no  vaginal  manipulation 
was  required. 

The  cases  treated  had  the  tubes  in  place  at  the  sides 
of  the  uterus.  I  would  not  expect  to  benefit  prolapsed 
tubes,  especially  if  adherent  in  Douglas's  space. 

Incidentally  I  was  made  to  recognize  an  unexpected 
position  of  the  oigans.  The  body  of  the  uterus  was  en- 
tirely above  the  symphysis,  and  the  distal  extremity  of  the 
tube  pointed  toward  the  anterior  iliac  spine.  This  position 
is,  I  think,  to  be  traced  to  our  present  modes  of  dress. 
Many  young  women  have  discarded  the  corset,  and  all 
probably  hang  the  skirt  from  a  skeleton  waist,  giving 
freedom  to  the  diaphragm,  and,  as  a  consequence,  eleva- 
tion of  all  the  abdominal  and  pelvic  organs.  In  my  expe- 
rience, however,  this  alteration  is  recent.  Six  >ears  ago 
I  found  this  high  position  and  regarded  it  as  a  deformity. 

General  Massage — Effleurage. — Another  matter  noted 
since  the  publication  of  my  book  seems  to  me  of  consid- 
erable importance.  In  the  course  of  a  bath  it  has  oc- 
curred to  me  to  be  given  the  usual  long  rub,  the  hands 
being  carried  from  the  distal  end  of  the  extremity  up- 
ward, and  from  thence  downward  by  a  return  stroke, 
equally  firm  pressure  being  used.  When  applied  to  the 
arms,  I  found  the  heart  affected  as  follows :  With  the 
up- stroke  came  two  slow,  full  beats ;  with  the  down-stroke, 
two  feebler  beats  or  two  rapid  beats  followed  by  an  in- 
termission. I  am  not  giving  positive  details,  not  at  the 
time  having  access  to  a  graphic  apparatus.  The  sensation 
was,  however,  unpleasant,  and,  upon  my  request  for  up- 
rubbing  only,  I  secured  the  results  of  increased  heart 
pressure  —  a  slowed,  strengthened,  comfortable  pulse. 
The  work  upon  the  lower  extremities  did  not  so  much 
affect  the  heart.  Still  the  influence  of  the  down-stroke 
was  perceptible,  and  I  had  it  omitted  throughout.  An 
element  so  influential  ought,  however,  to  have  some  use- 
ful application.  Possibly  this  may  be  found  in  cases  of 
cyanosis,  pulsating  jugulars,  and  an  overloaded  heart. 


46 


MEDICAL  RECORD. 


[July  14,  1894 


Ovaritis.  —  Wintcenilz's  treatment  is  the  following: 
Rest  in  bed ;  vaginal  injections  of  hot  salt-water;  scari 
fication  of  the  os  uteri  twice  daily ;  rubbing  of  the  abdo- 
men with  an  ointment  composed  of  ichthyol  and  lanoline 
in  equal  parts ;  and  a  teaspoonful  at  bedtime  of  this  mixt- 
ure for  constipation : 

9.    Sulphate  of  sodaA 3  iv. 

Sulphur 3  j. 

Sugar 3  v. 

Ess.  of  peppermint q.  s. 

In  principle  this  is  exactly  GoodelTs  teaching  of  years 
ago.  In  his  "  Lessons  in  Gynaecology,"  p.  386,  he  says 
of  Weir  Mitchell's  rest-cure  for  ovaritis :  "  I  have  seen 
wonderful  cures  from  this  treatment,  and  can  recommend 
it  with  the  utmost  confidence.  Bedridden  patients  have 
been  restored  to  health,  and  chronic  invalids  returned  to 
society." 

Gout  of  the  Intestine. — Many  cases  of  colic,  enter- 
algia,  enteritis,  and  typhlitis,  are  really  gouty  manifesta- 
tions located  in  the  intestine,  according  to  Haig,  who 
uses  salicylate  of  soda  with  great  success  for  such  cases, 
in  doses  of  about  fifteen  grains  every  three  or  four  hours. 
Drugs  like  lead,  mercury,  zinc,  and  even  cocaine,  when 
given  to  gouty  patients,  form  insoluble  urates,  and  an  in- 
testinal crisis  may  be  produced.  Buckworth  observes 
that  persons  do  not  die  of  gouty  intestinal  troubles,  and 
therefore  direct  ocular  pathological  proof  is  wanting. 
At  the  same  time  he  emphasizes  the  fact  of  their  exist- 
ence. From  Haig  and  Buckworth's  observations  it 
may  be  inferred  that  in  women  who  have  gout  or  rheu 
matic  gout  the  so-called  recurrent  peritonitis,  occurring 
most  frequently  just  after  menstruation,  is  in  reality  gout 
of  the  intestine.  There  is  slight  fever  or  a  subnormal 
temperature,  intense  pain  that  gradually  diminishes, 
marked  tenderness  on  pressure,  great  anxiety  and  fear  of 
moving  or  being  touched,  complete  loss  of  appetite, 
general  prostration  and  mental  depression  following,  the 
cycle  completing  itself  in  about  two  or  four  weeks. 
Remedies  directed  to  the  underlying  constitutional  state 
are  the  only  ones  that  permanently  relieve  and  cure. 

Tissue  Metabolism  in  Chlorosis. — There  is  a  transla- 
tion in  the  International  Medical  Magazine  for  April, 
1894,  of  a  lecture  delivered  to  a  private  class  by  Carl 
von  Noorden  on  "Tissue  Metabolism  in  Chlorosis." 
The  cause  of  poverty  of  haemoglobin  in  the  blood  must 
be  due  to  increased  destruction  or  diminished  new  for- 
mation of  the  coloring  matter  of  the  blood,  or  to  a  com- 
bination of  the  two  processes.  Not  one  positive  sign  is 
known  which  proves  that  in  chlorosis  more  haemoglobin 
is  destroyed  than  in  health.  Some  distinct  points  lead 
to  the  belief  that  the  normal  quantity,  and  probably 
much  less,  is  all  that  is  destroyed.  The  defect  is  due  to 
some  error  in  new  blood-formation.  Some  restricted  ex- 
ceptions exist  in  anaemia  caused  by  profuse  acute  hem- 
morrhage  and  by  acute  nephritis.  Here  there  is  an 
oedema  of  the  blood.  The  plasma  is  so  diluted  that  the 
blood-corpuscles  swell  up  and  appear  relatively  poorer  in 
haemoglobin.  In  all  processes  which  induce  much  de- 
struction of  this  constituent  of  the  blood,  as  infectious 
diseases  and  numerous  intoxications,  there  is  principally 
a  destruction  of  cells  (erythrolysis).  For  a  time  iron  as 
a  remedy  fell  into  disrepute,  in  consequence  of  experi- 
ments on  animals,  and  a  few  observations  on  man. 
These  doubts  were  more  often  expressed  by  physiologists 
and  pharmacologists  than  by  practising  physicians.  As 
there  was  no  increase  of  iron  in  the  urine  after  the  ad- 
ministration of  various  iron  preparations,  it  was  argued 
that  no  iron  was  absorbed.  The  weak  point  of  this  rea- 
soning is  of  interest.  The  intestinal  mucous  membrane 
is  the  place  of  excretion  for  the  iron  and  not  the  urine, 
which  is  capable  of  removing  only  a  few  milligrammes. 
Iron  which  gets  into  the  blood-current  accumulates  in  the 
liver  and  spleen,  these  organs,  magnet-like,  attracting  it. 


They  are  the  warehouse  of  the  body  for  superabundant 
iron,  which  is  given  off  very  gradually  by  these  organs, 
and  is  removed  by  the  intestinal  juice  from  the  body. 
How  do  the  iron  salts  which  are  absorbed  act  as  reme- 
dies ?  Is  the  chlorotic  organism  wanting  in  atoms  of  iron 
around  which  the  haemoglobin  molecule  can  be  built 
up  ?  Every  girl  developing  chlorosis  takes  up  in  daily 
food  more  iron  than  the  most  extravagant  estimate  de- 
mands. But  this  iron  is  exclusively  contained  in  nucleo- 
albumins.  There  is  no  doubt  that  the  healthy  organism 
takes  up  iron  from  nucleo  albumins  and  employs  it  for 
the  manufacture  of  haemoglobin.  Why  does  not  the 
chlorotic  patient  do  the  same  ?  Is  absorption  at  fault  ? 
On  the  contrary,  absorption  is  excellent.  Iron  is  ab- 
sorbed, but  is  not  used.  There  is  diminution  of  the 
energy  of  growth  in  the  haematopoietic  organs  (bone 
marrow),  resulting  in  the  non  utilization  of  the  ferrugi- 
nous nucleo-albumins  which  are  brought  by  the  blood. 
So  far  everything  is  proved.  Now  for  the  region  of  hy- 
pothesis. Let  us  suppose  that  the  iron  salts  circulating 
in  the  blood  effect  a  stimulation  of  the  haemopoietic  cells 
of  the  medulla  of  bones,  and  that  the  result  of  this  stim- 
ulus is  an  amelioration  of  the  constitution  of  the  blood. 
On  the  other  hand,  the  nucleo-albumins  containing  iron 
which  are  circulating  in  the  blood  exert  but  a  weak 
stimulus  on  bone  marrow.  Experience  proves  that  in 
the  treatment  of  chlorosis  any  iron  salt  is  more  effica- 
cious than  the  ferruginous  nucleo-albumins,  like  haemo- 
globin, hsemotogin,  haemogallol,  etc,  which  pure  theor- 
ists have  tried  to  foist  on  the  profession.  Arsenic  gives 
good  results.  Yet  success  is  much  greater  when  com- 
bining arsenic  and  iron.  Practical  experience  proves 
this  is  the  best  plan.  At  health-resorts  where  there  are 
carbonated  ferruginous  springs,  resident  physicians  do 
not  recommend  these  waters  to  chlorotic  subjects,  but 
advise  the  mineral  waters  of  Levico  or  Roncegno,  which 
contain  arsenic  and  iron.  These  substances  are  closely 
allied  chemically,  and  exert  on  the  cells  an  effect  that  is 
only  quantitatively  different. 

Idiopathic  Hypertrophy  of  the  Heart  and  Degenera- 
tion of  Heart-muscle. — An  address  upon  the  foregoing 
subject,  given  in  abstract  form  in  the  British  Medical 
Journal,  April  7,  1894,  was  delivered  at  the  Internation- 
al Medical  Congress,  in  Rome,  by  Dr.  S.  Laache,  oi 
Norway.  Idiopathic  hypertrophy  is  defined  as  enlarge- 
ment of  the  heart  without  obvious  anatomical,  or  rather, 
mechanical  obstacles  to  the  circulation.  The  valves 
are  either  intact  or  affected  only  by  lesions  in  no- 
wise proportionate  to  the  clinical  symptoms.  The  eti- 
ology presents  some  points  of  hygienic  or  social  interest. 
The  chief  predisposing  causes  are  heredity,  and  those 
conditions  which  betray  their  influence  by  defective  nu- 
trition. Among  determining  causes  the  most  important 
are  alcoholism  and  excessive  muscular  exertion.  Beer- 
drinking  is  the  chief  cause  of  pure  idiopathic  hypertro- 
phy. Athletics  has  been  considered  the  origin  of  much 
cardiac  hypertrophy.  It  is  now  conceded  that  if  the 
athlete  is  of  proper  age,  properly  trained,  and  abstains 
from  alcohol,  trouble  with  the  heart  does  not  necessarily 
follow  a  reasonable  amount  of  indulgence  in  sport. 
Physical  overstrain  weakens  the  heart,  and  so  does  intel- 
lectual overpressure.  Modern  life  in  cities  is  not  con- 
ducive to  that  mental  repose  which  is  necessary  to  se- 
cure normal  circulation.  The  hygiene  of  the  heart  is 
sadly  neglected.  Sudden  death  from  cardiac  trouble 
seems  to  be  increasing  in  frequency.  Yet  often  the  dis- 
eased heart  possesses  a  power  of  resistance  that  is  almost 
incredible,  and  which  led  Haller  in  his  day  to  apply  to 
it  the  epithet  ultimum  moriens.  In  Pepper's  "System 
of  Medicine?1  Osier  states  that  symptoms  are  not  neces- 
sarily present  in  simple  cardiac  hypertrophy,  since  this 
is  a  conservative  process  and  almost  always  an  unmixed 
good.  The  pulse  of  hypertrophy  not  dependent  on  val- 
vular lesion  is  usually  firm,  full,  and  strong,  of  high  ten- 
sion, and  regular.  It  may  be  increased  in  frequency, 
but  often  is  normal    A  frequent  symptom  is  an  unpleas- 


July   14,  1894] 


MEDICAL    RECORD. 


47 


ant  feeling  about  the  heart,  a  sense  of  fulness  and  dis- 
comfort. Flushings  of  the  face,  noises  in  the  ears,  flashes 
of  light,  and  headache  are  not  uncommon.  The  course 
of  an  ordinary  hypertrophy  divides  itself  into  three 
stages  :  the  period  of  development,  which  varies  with  the 
nature  of  the  original  factor  in  development ;  the  period 
of  full  compensation,  the  latent  stage,  during  which  the 
heart's  vigor  meets  all  the  requirements  of  the  circula- 
tion, and  this  second  stage  may  last  indefinitely ;  and 
the  third  period  is  what  is  called  the  breaking  of  a  com- 
pensating hypertrophy.  It  may  come  suddenly  during 
extra  exertion,  and  death  follow  from  acute  dilatation ; 
or  more  commonly  it  takes  place  slowly,  and  results  from 
degeneration  and  weakening  of  the  heart-muscle,  with 
consequent  dilatation  and  all  its  evils.  The  treatment 
of  hypertrophy  consists  largely  of  measures  directed  tow- 
ard its  maintenance  in  a  degree  proportionate  to  the  ex- 
tra work  which  the  heart  has  to  do.  The  utmost  moder- 
ation in  food,  drink,  and  exercise  must  be  enjoined. 
Quiet  and  regular  habits  are  imperative.  Excesses  of  all 
kinds  quickly  lead  to  impairment  of  the  heart's  action. 
In  the  hypertrophy  associated  with  arterial  and  renal 
disease  a  special  danger  exists  in  the  tendency  to  rupture 
of  vessels.  Vigorous  heart-beat  with  very  high  tension 
in  the  peripheral  arteries  indicates  mischief  which  may 
be  met  by  prompt  measures  to  reduce  the  high  pressure. 
A  brisk  cathartic  may  avert  apoplexy,  and  the  old-fash- 
ioned method  of  bleeding  is  often  justifiable. 

The  Treatment  of  Pruritus. — Leloir  recommends  elec- 
tricity in  pruritus  of  all  types — anal,  vaginal,  and  general 
— and  uses  the  electric  breeze  of  the  static  machine 
with  the  happiest  results.  Mercurial  ointments  give  im- 
mense relief  for  the  time  being.  Crocker  speaks  in 
praise  of  ammoniated  mercury,  gr.  xx.  to  |  j.  of  benzoated 
lard;  also  the  yellow  oxide  of  the  same  strength,  and 
calomel,  gr.  x.  to  3ss.  to  §  j.  External  treatment  is  of 
great  service  in  alleviating  the  itching,  even  if  it  does 
not  cure  the  disease.  Jackson  advises  general  baths  with 
soda  (  %  viij.  to  x.  to  30  gallons},  or  nitric  or  hydrochloric 
acid  (  §  j.  to  30  gallons).  After  the  bath  the  body  is 
to  be  dried  by  wrapping  it  in  a  warm  sheet  and  patting 
it  dry ;  then  the  skin  should  be  smeared  with  vaseline 
and  powdered  with  corn- starch  from  a  dredger.  Bulkley 
first  suggested  cannabis  Indica,  ten  minims  three  times  a 
day,  in  water  after  meals,  gradually  increasing  the  dose 
to  twenty  or  thirty  minims.  For  children  Ellis  recom- 
mends the  daily  use  of  tepid  alkaline  baths;  quinine 
and  cod-liver  oil  for  the  strumous ;  nitro  muriatic  acid  in 
sarsaparilla,  taraxacum,  and  Fowler's  solution.  Bron- 
son  finds  a  solution  of  hydrogen  peroxide  of  great  value 
in  general  pruritus ;  also  an  aqueous  solution  of  ozone, 
used  as  a  toilet  wash,  and  known  commercially  by  the 
name  of  "aquozone."  Faradism  is  often  successful  in 
senile  pruritus,  applied  only  to  the  spine  by  means  of  a 
brush  electrode.  The  cold  douche  is  another  remedy  in 
the  same  line  that  is  sometimes  of  benefit,  and  is  best 
used  in  the  morning.  In  local  and  general  pruritus  the 
following  formula  for  external  application  has  given  ex- 
cellent results : 

3.   Acid,  carbolic 3j. — ij# 

Liq.  potass. 3  j. 

Ol.lini I'y 

M.  Sig. :  Shake  before  using. 

Dust  Diseases  and  their  Prevention. — The  relation 
of  dust  to  pulmonary  affections  is  a  subject  the  investiga- 
tion of  which  has  already  led  to  many  valuable  practical 
results,  and  which  is  still  far  from  being  exhausted. 
Dust  of  a  non  -irritating  nature  is  necessarily  inhaled  into 
the  lungs  of  town-dwellers,  where  it  causes  the  dark  and 
mottled  aspect  so  familiar  on  the  post-mortem  table. 
The  irritating  dust,  on  the  other  hand,  which  is  en- 
countered in  many  occupations,  leads  to  more  or  less 
serious  pathological  conditions  of  the  pulmonary  organs. 
Thus  it  may  cause  bronchitis,  acute  and  chronic,  em- 
physema, asthma,  bronchiectasis,  fibroid  conditions, 
hypertrophy  of  bronchial  glands,  and  phthisis,  with  a 


whole  chain  of  attendant  vascular  disturbances.  These 
dust  diseases,  or  pneumokonioses,  are  met  with,  as  every 
one  knows,  among  millers,  masons,  miners,  grinders,  and 
others  who  follow  occupations  which  habitually  expose 
them  to  a  dusty  atmosphere.  This  injury  is,  in  the  first 
place,  mainly  mechanical,  and  usually  has  a  direct  rela- 
tion to  the  texture  of  the  material  which  furnishes  the 
dust.  In  this  way  steel  particles  are  more  deadly  than 
stone,  and  the  latter  than  flour.  In  other  cases  the  in- 
jury to  workmen  is  partly  mechanical  and  partly  chemi- 
cal, as  in  the  lead  enamel  grinding  trade.  So  much  for 
the  evil,  which  is  obvious  enough,  and  needs  little  more 
than  the  above  passing  reference.  A  great  deal  more 
discussion  is  wanted,  however,  when  we  inquire  as  to 
what  has  been  done  in  the  way  of  prevention.  The  two 
great  preventive  measures  are  undoubtedly  free  ventila- 
tion and  the  introduction  of  wet  processes.  It  is  a  well- 
known  fact  that  the  substitution  of  wet  for  dry  grinding 
in  Sheffield  was  followed  by  a  great  fall  in  the  number  of 
deaths  from  phthisis.  A  similar  principle  might  be  ap- 
plied with  advantage  in  other  trades.  For  instance,  the 
dust  raised  in  grinding  lead  enamel  is  of  a  peculiarly 
deadly  nature,  since  it  acts  both  as  a  mechanical  and  a 
poisonous  irritant.  Lead  enamel  is  practically  insoluble, 
and  there  is  no  doubt  that  many  of  the  steps  in  its 
manufacture  could  be  carried  out  equally  well  by  elutria- 
tion  and  other  wet  methods.  Ventilation,  again,  is 
often  defective  in  the  enamel  factories.  The  beneficial 
action  of  a  free  circulation  of  air  is  probably  due  to  the 
dilution  and  the  removal  of  noxious  particles.  Nowhere 
has  the  improvement  of  ventilation  been  followed  by  bet- 
ter results  than  among  our  mining  population.  To  take 
a  single  instance :  it  has  lately  been  officially  reported 
that  in  the  mining  division  of  Cornwall  the  proportion 
of  deaths  from  phthisis  or  "  miner's  disease  "  has  of  late 
years  decreased.  This  satisfactory  result  appears  to  be 
due  chiefly  to  the  better  underground  ventilation,  conse- 
quent on  the  introduction  of  boring  machinery  and  of 
other  improved  conditions.  Some  years  ago  the  whole 
question  of  miners'  phthisis  was  closely  investigated  by 
the  Royal  Cornwall  Polytechnic  Society,  who  offered 
prizes  for  sound  information,  and  obtained  a  quantity  of 
valuable  matter,  which  is  to  be  found  in  their  annual 
reports  of  that  time.  This  public-spirited  action  affords 
an  excellent  illustration  of  the  good  that  can  be  effected 
by  local  bodies,  if  they  will  only  be  content  to  confine 
their  scientific  ardor  to  subjects  at  their  feet,  so  to  speak, 
and  within  the  grasp  of  an  average  comprehension. 
Conducted  on  such  lines  the  work  of  provincial  associa- 
tions is  likely  to  afford  substantial  help  in  arriving  at 
precise  facts  and  figures  with  regard  to  dangerous  employ- 
ments. They  will  be  also  in  a  position  to  acquire  exact 
information  as  to  methods,  and  to  suggest  improvements 
in  trade  processes.  Their  data  would  then  be  simply 
invaluable  to  the  scientific  man,  in  whose  hands  the  appli- 
cation of  preventive  measures  must  ultimately  be  placed. 
When  thoroughly  sound  conclusions  have  been  arrived  at 
it  is  the  duty  of  legislators  to  frame  laws  in  accordance 
with  the  facts  submitted  to  them.  It  is  a  well  marked 
tendency  of  modern  legislation  to  make  compulsory  all 
measures  that  have  been  shown  to  be  clearly  preventive. 
Bearing  this  in  mind,  one  may  safely  assert  that  the  com- 
pulsory legislation  of  the  future  will  find  a  large  and 
useful  field,  so  far  as  the  happiness  of  many  members  of 
the  community  is  concerned,  in  the  control  of  dust-pro- 
ducing occupations.  Whatever  may  be  done,  it  is  un- 
likely that  the  whole  of  the  mischief  could  be  abolished 
in  each  particular  trade.  The  risk,  however,  could  and 
should  be  reduced  to  its  minimum.  The  steady  aim  of 
the  sanitarian  in  dealing  with  dust  diseases  will  be  levelled 
at  the  preventable  margin,  and  he  will  not  fail  to  make 
due  allowance  for  the  unavoidable  residuum. — Medical 
Press. 

Dr.  Baillon,  the  well-known  botanist  of  Paris,  has 
been  elected  to  foreign  fellowship  in  the  Royal  Botanical 
Society  of  London. 


48 


MEDICAL  RECORD. 


[July  14,  1894 


Medical   Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


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


New  York,  July  14,  1894. 


THERAPEUTICS     AT     THE     INTERNATIONAL 
MEDICAL   CONGRESS. 

It  may  happen  that  the  most  successful  and  largest  med- 
ical congresses  are  not  particularly  rich  in  therapeutic 
work.  Yet,  after  all,  when  the  heat  and  smoke  of  the 
day  are  cleared  away,  one  feels  that  the  important 
query  is  this :  Has  anything  been  said  or  read  which 
will  make  the  treatment  of  diseases  more  sure  and  ef- 
fective ? 

We  have  been  looking  over  the  records  of  the  Interna- 
tional Congress  at  Rome,  and  have  tried  to  find  what 
practical  therapeutical  suggestions  were  made  at  that 
time. 

The  results  of  our  study,  which  has  been  facilitated  by 
a  critical  review  in  the  Gazette  des  Hopitaux,  have  not 
been  very  fruitful,  nor  yet  altogether  barren.  For  ex- 
ample, Dr.  Petresco,  of  Bucharest,  comes  forward  again 
with  further  facts  regarding  his  treatment  of  pneumonia 
with  large  doses  of  digitalis.  He  has  employed  his 
method  now  for  thirteen  years  and  treated  1,192  cases, 
and  he  has  reduced  the  mortality  to  1.22  and  2.66  per 
cent.,  while  under  other  treatment  the  mortality  ranges 
from  7.15  to  35-50  per  cent. 

A  year  ago  we  discussed  Petresco's  method,  which  con- 
sists of  giving  eight  or  ten  or  even  twelve  grammes  of 
digital  leaves  in  twenty-four  hours.  According  to  the 
author,  it  invariably  jugulates  acute  lobar  pneumonia  in  a 
few  days. 

Dr.  Goffredi,  of  Naples,  calls  attention  to  the  value  of 
lactose  as  a  diuretic,  particularly  in  heart  disease.  It  is 
not  so  effective  in  nephritis.  Diarrhoea  is  sometimes 
caused  by  the  lactose. 

Dr.  Pucci  praises  very  highly  the  use  of  phenocoll  in 
malaria.  He  gives  from  one -half  to  one  gramme  a 
day. 

After  having  broken  up  the  paroxysms,  the  drug  is 
continued  five  or  six  days  in  association  with  qui- 
nine or  arsenic.  It  is  also  very  useful  in  malarial  neural- 
gia. 

A  curious  contribution  to  therapeutics  is  that  of  Dr. 
Sanchez  Herrero,  of  Madrid,  who  recommends  a  solution 
of  bromide  of  potash,  50 ;  iodide  of  potash,  5  ;  and  water, 
500,  in  the  treatment  of  epilepsy.  Dr.  Herrero  is  evi- 
dently not  familiar  with  some  of  the  very  ancient  formu- 
las for  epilepsy,  including  that  of  Brown  S6quard.     We 


should  add  that  the  doctor  adds  to  his  treatment  hypnotic 
suggestion  twice  a  week,  and  that  he  has  cured  19  cases 
out  of  30. 

Dr.  A.  Murre,  of  Bologna,  makes  a  protest  against  the 
abuse  of  cold  water  in  the  treatment  of  chlorosis,  but  at 
the  same  time  thinks  that  cold  water  properly  used  is 
better  than  drugs  in  this  condition. 

Dr.  Tison  thinks  that  the  nitrate  of  aconitine  is  useful 
in  facial  erysipelas,  shortening  the  attacks  and  lessening 
the  pain.    He  gives  gr.  Tfo  ten  times  a  day. 

Von  Ziemssen,  of  Munich,  would  have  us  return  to  the 
use  of  transfusion  of  blood,  particularly  in  grave  anae- 
mias. 

The  best  method  is  the  arm-to-arm  one  without  de- 
fibrinating,  but  if  this  is  not  practicable  he  recommends 
subcutaneous  injection  of nondefibrinated  blood.  This 
ought  to  be  given  under  chloroform  and  followed  by 
massage,  as  the  process  is  very  painful.  It  is  safe  to  say 
that  a  treatment  involving  regular  anaesthetization  of  the 
patient  will  hardly  become  popular,  and  certainly  is  not 
safe. 


DR.    MITCHELL    ON    INSANE    ASYLUM    MAN- 
AGEMENT. 

The  address  of  Dr.  S.  Weir  Mitchell  before  the  American 
Medico  Psychological  Association,  at  their  meeting  held 
in  May  last,  has  just  been  published  {Journal  of  Nervous 
and  Mental  Disease),  and  it  promises,  we  believe,  to  ex- 
cite wide  attention.  Dr.  Mitchell,  with  the  consent  of 
the  Association,  took  the  opportunity  to  arraign,  in  the 
severest  manner,  the  present  methods  of  caring  for  aDd 
treating  the  insane  in  America.  He  undertook  the  task 
evidently  with  reluctance,  but  with  a  keen  sense  of  the 
duty  before  him  and  of  the  opportunity  offered  by  the  very 
generous  attitude  of  the  asylum  superintendents.  The 
speaker  fortified  himself  well  for  his  work,  not  only  by  a 
personal  knowledge,  but  by  letters  sent  to  him  from 
nearly  thirty  of  the  leading  neurologists  and  alienists  of 
this  country,  giving  opinions  and  suggestions  regarding 
the  present  methods  of  managing  asylums. 

It  is  unnecessary  to  say  that  Dr.  Mitchell's  address 
is  throughout  an  interesting  and  scholarly  one,  full  of 
wit  and  satire,  yet  withal  not  unkindly  or  in  any  way 
unjust  or  offensive.  And,  after  all,  it  is  the  Boards  of 
Managers,  the  public,  and  the  politicians  which  receive 
the  severest  castigation.  We  wish  we  had  space  to  quote 
the  criticism  upon  managing  boards,  their  make-up  and 
their  methods.  There  are,  of  course,  good  as  well  as 
bad  managers,  but  it  is  true  that  in  the  majority  of  cases 
the  modern  asylum  trustee  has  not  the  slightest  concep- 
tion of  the  higher  and  truer  needs  of  a  hospital  for  the 
insane.  The  prevailing  idea  is  to  look  after  the  farm, 
the  kitchen,  and  laundry,  and  to  get  materials  for  a  sat- 
isfying annual  report  with  forty  per  cent,  of  "cures" 
and  a  balance  to  the  credit  of  the  institution. 

As  for  the  medical  superintendents :  their  weakness,  he 
says,  lies  in  this,  that  they  work  apart  from  their  fellows 
and  are  not  in  touch  with  the  medical  profession  as  a 
whole ;  that  they  aim  only  to  run  smoothly  a  great  hotel 
or  boarding-house,  knowing  little  and  contributing  noth- 
ing to  psychology  or  psychiatry,  and  least  of  all  to 
therapeutics.  Dr.  Mitchell's  final  words  furnish  us  a 
picture  of  the  ideal  hospital  for  the  insane.     We  read  it 


July  14,  1894] 


MEDICAL   RECORD. 


49 


with  delight  at  the  skill  of  the  writer,  as  he  portrays  what 
to  his  fancy  the  present  should,  and  the  future  may,  fur- 
nish us.  But  we  feel  also  a  sense  of  sadness  at  the  dif- 
ference between  the  ideal  and  the  real.  And  we  think 
of  our  own  State  Lunacy  Commission  laboriously  aiming 
to  cut  down  the  price  of  brooms,  and  utterly  forgetful  of 
the  higher  needs  of  hospitals  for  the  insane. 

We  trust  that  Dr.  Mitchell's  address  will  awaken  not 
only  the  conscience  of  those  now  responsible  for  asylum 
management,  but  will  stir  the  public  heart  until  the  poli- 
tics, penuriousness,  aid  incapacity  that  surround  so  much 
of  American  asylum  work  are  abolished. 


THE  POWER  OF  A  DIPSOMANIAC. 

Peter  the  Great  was  an  enormous  consumer  of  brandy, 
and,  to  drop  to  modern  times,  Webster  was  not  strictly 
temperate,  and  Lincoln  had  some  very  able  whiskey- 
drinking  generals ;  but  history  furnishes  no  account  of 
dipsomaniacs  who  were  sound  in  judgment  or  great  in 
action.  Dipsomania  is  a  morbid  condition,  character- 
ized by  the  irresistible  obsession  and  impulse  to  drink, 
coming  on  in  attacks  during  which  the  patient  abandons 
himself  entirely  to  the  craving  for  liquor.  Dipsomaniacs 
may  appear  perfectly  rational  between  their  seizures,  and 
may  transact  business  with  apparent  soundness  of  mind. 
Nevertheless,  they  still  possess  something  unbalanced 
and  false  in  their  mental  make-up.  Dipsomania  always 
occurs  in  persons  who  have  a  psychopathic  constitution  ; 
they  belong  to  the  class  called  by  the  French  the  degen- 
erate. Consequently,  one  will  always  find  in  their  char- 
acter some  peculiarity  which  puts  them  out  of  the  ordi- 
nary, and  among  a  class  which  we  cannot  entirely  trust. 
Their  eccentricities  may  be  harmless,  or  may  be  shown  in 
some  moral  perversion  or  monomaniacal  enthusiasm.  A 
person  who  has  dipsomania  is  essentially  one  whose 
judgment  is  weak  and  whose  actions  may  be  erratic, 
perhaps  picturesque;  or,  on  the  other  hand,  foolish, 
cruel,  or  criminal.  ^ 

The  reports  of  the  present  extraordinary  riots  and  dis- 
turbances which  have  paralyzed  trade,  destroyed  property, 
and  terrorized  whole  communities,  is  shocking,  yet,  under 
the  circumstances,  not  so  very  surprising.  Such  men  some  • 
times  have  a  power  of  eloquence  and  organization  suffi- 
cient to  accomplish  at  times  a  great  good,  but  more 
often  enormous  evil.  But  it  shows  something  vitally  de- 
fective in  the  local  government  of  some  of  our  cities  and 
States,  when  an  irresponsible  enthusiast  can  bring  about 
such  things  as  we  have  witnessed  in  and  about  Chicago 
during  the  past  fortnight. 


ANOTHER  NEW  HOSPITAL. 

The  Chambers  Street  Hospital  is  about  to  move  from  its 
present  quarters  into  a  new  and  larger  building  at  the 
corner  of  Hudson  and  Jay  Streets.  The  present  hospital 
has  been  occupied  since  1875.  I*  was  formerly  a  police- 
station,  and  has  become  quite  inadequate  for  the  work  de- 
manded. The  Chambers  Street  Hospital  has  for  many 
years  done  an  immense  amount  of  valuable  work,  more 
particularly  in  surgical  and  accident  cases.  The  annual 
number  of  visits  to  it  is  over  sixty-five  thousand,  and 
three  ambulances  are  kept  busy  night  and  day.    The 


new  hospital  is  a  large  five-story  building,  fire- proof,  and 
equipped  with  every  modern  convenience. 

Along  with  the  excellent  philanthropical  results  of  the 
Chambers  Street  institution,  there  is  another  which  most 
wiU  consider  minor  and  incidental,  viz.,  it  has  rendered 
a  down  town  practice  impossible.  In  other  words,  acci- 
dent and  emergency  cases  are  all  taken  promptly  to  the 
hospital  and  never  to  a  private  office,  however  well  able 
to  pay  the  patient  may  be.  Of  course,  if  this  is  the  best 
thing  for  the  people  as  a  whole,  the  physician  must  sub- 
mit. At  any  rate,  institutional  medicine  has  full  swing 
in  the  down  town  district. 


fJjeMja  of  Ifce  WLtek. 

Dr.  Solomon  Van  Etten,  one  of  the  oldest  and  best- 
khown  physicians  in  Orange  County,  died  suddenly  at 
his  residence  in  Port  Jervis,  July  7th,  of  apoplexy.  He 
was  sixty-five  years  old.  He  was  a  graduate  of  the  Al- 
bany Medical  College,  class  of  '55.  During  the  civil 
war  he  was  brigade  surgeon  in  General  Terry's  division, 
and  retired  from  the  service  with  the  rank  of  Lieutenant- 
Colonel.  He  practised  medicine  in  Port  Jervis  until  his 
death.  He  ran  twice  for  Assembly  on  the  Republican 
ticket,  was  United  States  Medical  Examiner  for,  the 
Orange  and  Sullivan  district  during  the  administrations 
of  Grant,  Hayes,  and  Harrison,  and  two  years  ago  was 
elected  Medical  Director  of  the  Grand  Army  for  the  de 
partment  of  the  State  of  New  York. 

Dr.  W.  B.  Adamson,  of  this  city,  died  on  July  6th  at 
his  summer  residence  at  Lake  George.  He  was  forty- 
two  years  of  age,  and  was  born  in  Stockton,  England. 

Births  and  Deaths The  Southern  Medical  Review  is 

a  new  monthly  that  comes  to  us  from  Houston,  Tex. 
It  is  edited  by  Dr.  N.  J.  Phenix,  but  arises  from  no  ashes. 
The  Railway  Surgeon  is  the  title  of  a  new  monthly. 
The  National  Medical  News,  the  Epitome  of  Medicine, 
the  Country  Doctor,  the  Weekly  Medical  Bulletin,  the 
American  Gynecological  Journal,  and  the  Atlanta  Jour- 
nal of  Surgery,  Gynecology,  and  Obstetrics  have  ceased 
to  appear. 

Tho  Plague. — The  bubonic  plague,  the  terror  of  Eu- 
rope even  to  the  close  of  the  seventeenth  century,  has 
again  made  its  appearance  in  China,  where  it  is  more  or 
less  endemic,  as  it  is  in  Asia  Minor.  The  British  Medi- 
cal Journal,  while  admitting  the  vividness  of  the  picture 
drawn  by  Defoe,  points  out  that  "  while  there  is  much  ex- 
aggeration in  his  '  Plague  of  London,'  his  description  of 
the  phenomena  of  the  disease  is  fairly  accurate.  The  pres- 
ent title  is  derived  from  the  swelling  in  the  groin.  In  the 
earlier  plague,  a  similar  swelling  in  the  axilla  was  a  frequent 
symptom.  The  disease  is  a  rapid,  malignant,  contagious 
fever,  accompanied  by  buboes,  carbuncles,  and  livid 
spots.  At  least  two  thirds  of  its  victims  die.  Its  symp- 
toms are  violent  headache,  accompanied  with  violent 
tremors  alternating  with  intense  heat.  The  eyes  become 
red  and  assume  a  ferocious  aspect,  resembling  those  of 
victims  of  hydrophobia.  The  pain  extends  from  the 
head  to  the  spine,  joints,  and  limbs.  Then  follow  ver- 
tigo and  delirium.  The  tongue  is  dry  and  yellowish. 
Respiration  is  difficult,  nausea  occurs,  but  rarely  vomit- 


5° 


MEDICAL  RECORD. 


[July  14   1894 


ing.  The  disease  runs  its  course  in  from  three  to  seven 
days.  The  patient  often  dies  in  a  few  hours.  The  first 
known  appearance  of  the  plague  in  Europe  occurred  430 
B.C.,  when  it  depopulated  Athens,  reaching  there  from 
Egypt  by  way  of  Libya.  It  was  brought  into  Europe  by 
the  returning  crusaders,  and  has  frequently  appeared 
since,  always  coming  from  some  part  of  the  Turkish  do- 
minions. It  appears  in  lower  Egypt,  Syria,  and  Turkey 
about  every  seven  or  ten  years.  It  has  often  made  its 
appearance  in  London,  the  most  frightful  visitation  being 
in  a.d.  430,  when  there  were  scarcely  enough  living  left 
to  bury  the  dead  in  all  England.  In  a.d.  716  Constan- 
tinople lost  200,000.  In  1348  Germany  lost  90,000. 
It  has  scourged  various  parts  of  Europe  from  time  to 
time  since,  carrying  off  hundreds  of  thousands  at  each 
visitation.  In  Egypt  800,000  died  in  1792.  The  latest 
visitation  of  which  we  have  an  account  at  hand  was  in 
1 813,  when  it  was  exceedingly  fatal  in  Egypt  and  in 
Malta." 

American  Academy  of  Medicine— The  nineteenth 
annual  meeting  of  the  American  Academy  of  Medicine 
will  be  held  at  the  Waumbek,  Jefferson,  N.  H.,  on 
Wednesday  and  Thursday,  August  29  and  30,  1894. 
The  greater  part  of  the  time  is  to  be  devoted  to  the  dis- 
cussion of  certain  problems  relating  to  the  medico-social 
relations  of  the  medical  profession  to  the  "  dependent 
classes."  Arrangements  have  been  made  for  a  special 
excursion  from  New  York  and  Boston  and  return  at  re- 
duced rates.  A  choice  is  offered  of  an  eleven  days'  ex- 
cursion, including  most  of  the  expenses,  or  of  returning 
immediately  at  the  close  of  the  meeting,  and  is  open  to 
anyone  desirious  of  attending  the  meeting,  whether  mem- 
ber of  the  Academy  or  not.  Any  additional  informa- 
tion about  the  meeting  or  the  excursion  may  be  obtained 
from  Charles  Mclntire,  Secretary,  Easton,  Pa. 

American    Electro  Therapeutic   Association. — The 

fourth  annual  meeting  of  the  American  Electro-Thera- 
peutic Association  will  be  held  in  New  York,  September 
25th,  26th,  and  27th,  at  the  Academy  of  Medicine. 

8alicyd  Chloroform  is  a  combination  of  chloroform 
with  salicyd.  It  is  a  crystallized  substance,  which  on 
warming  gives  off  perfectly  pure  chloroform.  Dr.  Hans 
Schmid  has  used  it  in  one  hundred  and  sixty-six  narcoses, 
and  recommends  it  as  being  safer  and  more  pleasant  than 
the  ordinary  preparations. 

The  German  Commission  of  Anesthesia. — At  the 
Twenty- third  Congress  of  the  German  Surgical  Associa- 
tion it  was  voted  to  continue  the  general  investigation 
into  the  statistics  of  anaesthetics  which  the  society  has 
been  engaged  in  for  the  last  four  years.  Reports  are  de- 
sired until  March  15,  1895.  Consideration  of  the  fol- 
lowing points  is  especially  urged :  Specification  of  the 
time  of  observation,  of  the  anaesthetic  used,  and  the  num- 
ber of  times  exhibited ;  reason  for  administration ;  ap- 
paratus used;  duration  of  unusually  prolonged  nar- 
cosis ;  amount  of  material  used ;  the  concomitant  use  of 
other  drugs,  as  morphia,  and  the  amount;  undesirable 
phenomena  or  sequelae. 

The  Faculty  of  Port  Wayne  College  of  Medicine 
have  adopted  a  three  years'  graded  course,  the  work 
done  in  which  is  based  upon  the  four  years'  graded 
course  recommended  by  the  College  Association. 


A  Death  from  Hydrophobia. — A  case  of  death  from 
hydrophobia  has  occurred  at  the  Pasteur  Institute ;  but 
the  patient  was  already  in  a  hopeless  condition  at  the 
time  he  was  admitted.  Mr.  Walter  E.  Orcutt,  a  hotel 
keeper  of  Northampton,  Mass.,  was  bitten  on  the  wrist 
by  a  pet  dog  on  May  23d,  and  although  the  wound  was 
very  slight,  he  took  the  precaution  of  having  it  cauter- 
ized. It  healed  perfectly,  and  he  thought  no  more 
about  the  matter  until  June  23d,  when  he  was  seized 
with  alarming  symptoms,  and  was  at  once  brought  to  the 
Pasteur  Institute  in  New  York.  His  friends  were  as- 
sured by  the  physician  in  charge,  Dr.  Labadie  (Dr. 
Gibier's  assistant),  that  no  treatment  would  now  be  of 
any  avail,  and  he  died  on  June  26th.  In  this  instance, 
the  more  violent  manifestations  of  rabies  were  in  a  great 
measure  lacking,  but  the  patient  rapidly  succumbed  to 
paralysis  of  the  nervous  centres. 

American  Public  Health  Association. — The  Twenty- 
second  annual  meeting  of  the  American  Public  Health 
Association  will  be  held  in  Montreal,  Canada,  on  Sep- 
tember 25  to  28,  1894,  under  the  presidency  of  Dr.  E. 
P.  Lachapelle,  of  Montreal. 

The  Massachusetts  8tate  Board  of  Registration  of 
Physicians  and  8urgeons. — The  governor  has  made  the 
following  appointments  for  the  first  Board  of  Registra- 
tion under  the  new  Medical  Practice  Law :  E.  J.  Fors- 
ter,  of  Boston,  for  seven  years ;  W.  P.  Bowers,  of  Clin- 
ton, for  four  years ;  D.  B.  Whittier,  of  Fitchburg,  for 
five  years ;  A.  C.  Walker,  of  Greenfield,  for  one  year ; 
S.  H.  Blodgett,  of  Cambridge,  for  three  years;  C.  Ed- 
win Miles,  of  Boston,  for  two  years ;  A.  L.  Chase,  ot 
Randolph,  for  six  years.  Drs.  Forster,  Bowers,  and 
Walker  are  members  of  the  Massachusetts  Medical  So- 
ciety ;  Drs.  Whittier  and  Blodgett  are  members  of  the 
Massachusetts  Homoeopathic  Society;  and  Drs.  Miles 
and  Chase,  of  the  Massachusetts  Eclectic  Society. 

Harvard  Medical  8chool. — The  graduating  class  of 
the  Harvard  Medical  School  this  year  contained  one 
hundrdt  and  twenty- seven  men,  and  was  the  largest  class 
ever  graduated. 

Unsanitary  Edgewater. — The  Richmond  County  (N. 
Y.)  Medical  Society,  in  a  series  of  resolutions,  declare 
that  small- pox  is  prevalent  there  in  consequence  of  the 
neglect  of  the  health  authorities,  that  the  village  for  the 
same  reason  is  in  an  unhealthful  and  filthy  condition, 
and  appoint  a  committee  to  co  operate  with  the  president 
of  the  village,  that  the  necessary  reforms  may  be  made. 

The  Colorado  State  Medical  8oeiety.— At  the  recent 
meeting  of  the  Colorado  State  Medical  Society,  held  in 
Denver,  June  19,  20,  21st,  the  following  officers  were 
elected  for  the  ensuing  year:  President,  Dr.  Hubert 
Work,  Pueblo,  Col. ;  First  Vice-President,  Dr.  J.  R. 
Robinson,  Colorado  Springs;  Second  Vice-President, 
Dr.  E.  Stuver,  Rawlins,  Wy. ;  Third  Vice-President, 
Dr.  Laura  Liebhardt,  Denver,  Col. ;  Treasurer,  Dr.  W. 
F.  McClelland,  Denver,  Col. ;  Corresponding  Secretary t 
Dr.  C.  K.  Fleming,  Denver,  Col. 

Strophanthus  is  a  valuable  and  safe  remedy.  It  is 
a  cardiac  tonic,  a  diuretic,  and  quickly  relieves  pre- 
cordial pain  and  dyspnoea.  The  tincture  is  the  best 
preparation.  It  should  be  given  in  small  (TTlij)  doses, 
gradually  increased  and  combined  with  stimulants  and 


July  14.  1894] 


MEDICAL  RECORD. 


5i 


antispasmodics,  such  as  ammonia  and  ether.  It  is  a 
most  useful  drug  in  aortic  regurgitation,  as  its  power  of 
lengthening  diastole  is  not  so  great  as  digitalis,  nor  has 
it  so  marked  a  cumulative  action ;  and  any  danger  which 
may  lurk  in  its  administration  is  considerably  lessened 
by  its  combination  with  ether. — Dr.  Taylor. 

Hew  York  Polyclinic— Dr.  J.  Riddle  Goffe  has  been 
appointed  Professor  of  Gynecology  in  the  New  York 
Polyclinic. 

On  Periodical  Tasting  of  Eyesight  in  Sohools.— Mr. 
Priestley  Smith  read  a  paper  on  this  subject  recently  be- 
fore the  Ophthalmologic  Society  of  the  United  King- 
dom. Authorities,  he  said,  were  agreed  that  advantage 
would  accrue  from  an  annual  testing  of  the  eyesight  of 
school  children,  and  several  commissions  had  spoken  to 
this  effect,  and  formulated  definite  proposals.  Hitherto 
no  considerable  advance  had  been  made  toward  this  end, 
for  the  proposals  usually  put  forward  had  been  that  the 
refraction  of  every  scholar  should  be  ascertained  once  a 
year  by  the  school  doctor.  It  would  be  a  long  time  be- 
fore every  school  had  its  school  doctor  and  every  school 
doctor  was  an  efficient  oculist.  The  necessities  of  the  case 
could  be  met  more  easily,  and  would,  he  hoped,  be  so  met 
in  a  large  number  of  schools  throughout  the  country  before 
long.  The  governors  of  King  Edward  VI.'s  schools  in 
Birmingham,  which  comprised  about  twenty-two  hun- 
dred boys  and  girls,  aged  from  eight  to  nineteen,  had 
established  three  years  ago  a  periodical  physical  exami- 
nation of  the  scholars  in  regard  to  height,  weight,  chest 
measurement,  eyesight,  and  hearing.  The  eyesight  test 
was  carried  out  by  certain  teachers  appointed  for  the 
purpose.  It  made  no  pretence  of  being  a  scientific  pro- 
ceeding ;  there  was  no  attempt  to  estimate  refraction  or 
diagnose  disease.  Any  such  attempt  was  worse  than  use- 
less unless  the  examiner  were  an  ophthalmic  expert.  In 
every  case  in  which  the  vision  in  either  eye  was  less 
than  six-eighteenths,  an  intimation  of  the  fact  was 
sent  to  the  parent,  and  with  him  rested  the  responsibil- 
ity of  obtaining  the  necessary  advice  and  choosing  the 
adviser.  The  Anthropometric  Committee  appointed  at 
the  last  meeting  of  the  British  Association  for  the  Ad- 
vancement of  Science,  having  Professor  Cleland  and 
Professor  Windle  for  its  Chairman  and  Secretary,  had 
lately  issued  an  inquiry  to  a  large  number  of  schools  as 
to  whether  and  to  what  extent  periodic  physical  exami- 
nation of  the  scholars  was  in  force.  From  the  replies  re- 
ceived it  appeared  that  the  eyesight  was  tested  in  eight 
out  of  four  hundred  and  eighty-three  boys'  schools  in 
England,  Scotland,  and  Ireland  (Whitaker's  list) ;  and 
in  six  of  one  hundred  and  twenty-nine  girls'  schools 
in  England ;  while  color  vision  was  tested  in  three  only 
of  the  whole  number.  Many  of  the  principals,  however, 
expressed  willingness  to  take  up  anthropometric  work 
on  receiving  directions  for  carrying  it  out.  The  speaker 
laid  before  the  meeting  the  printed  directions  which  had 
been  drawn  up,  and  which  were  to  be  sent,  in  the  first  in- 
stance, to  about  two  hundred  schools.  The  eyesight  test 
included  in  this  scheme  was  practically  the  same  as  already 
in  operation  in  the  King  Edward  schools  in  Birmingham. 
It  involved  practically  no  expense  and  very  little  trouble 
to  the  school  authorities,  and  It  interested  at  least  one 
teacher  in  every  school  in  the  eyesight  of  the  scholars. 
In  advocating  this  system,  the  speaker  did  not  in  the 


least  undervalue  the  importance  of  a  thorough  medical 
examination  of  schools,  and  he  knew  that  many  schools 
already  had  duly  appointed  medical  officers  competent 
to  deal  with  errors  of  refraction,  but  these  were  excep- 
tions. By  making  this  simple  eyesight  test  a  part  of  the 
anthropometric  scheme  now  being  so  energetically 
pushed  by  the  Committee  of  the  British  Association  they 
would,  he  was  confident,  attain  the  desired  end  in  a 
large  number  of  schools  where  it  could  hardly  be  attained 
in  any  other  way. 

Lightning  Stroke.—"  Ball  lightning,"  the  fulmen 
globulare  of  the  older  meteorologists,  is  the  most  danger- 
ous and  destructive  of  the  forms  which  lightning  is  known 
to  assume.  Fortunately,  however,  it  is  the  rarest.  A 
narrow  escape  from  death  by  its  stroke  occurred  lately  in 
the  person  of  a  distinguished  surgeon  of  the  Belgian  school, 
Dr.  L.  Dandois,  Professor  of  Surgery  in  the  University  of 
Louvain,  who  had  gone  to  the  neighboring  town  of  Linden 
to  visit  a  patient,  and  on  his  return,  having  alighted  from 
the  train  to  continue  his  homeward  journey  by  road,  was 
overtaken  by  a  heavy  thunderstorm.  The  sky  became  as 
dark  as  at  midnight,  so  as  to  make  it  difficult  for  him  to 
avoid  the  telegraph-poles  standing  at  intervals  along  his 
path.  In  a  few  minutes  a  fire-ball,  as  he  described  it, 
descended  on  him,  its  stroke  hurling  him  off  the  road, 
across  the  ditch  that  ran  parallel  to  it,  and  landing  him 
in  the  adjacent  field.  He  was  holding  a  large  umbrella 
at  the  time,  holding  it  with  both  hands  by  its  wooden 
stick,  which  was  of  uncommon  thickness.  On  coming  to 
himself  after  the  shock,  he  found  the  umbrella  cover  com- 
pletely burnt  off  its  steel  framework,  the  steel  itself  being 
twisted  into  every  sort  of  shape.  The  wooden  handle 
had,  no  doubt,  saved  his  life ;  had  it  been  of  metal  Dr. 
Dandois  is  convinced  that  he  must  have  been  killed  in- 
stantaneously. As  it  was,  fully  ten  minutes  elapsed  be- 
fore he  recovered  the  use  of  his  arms  and  legs,  benumbed 
as  they  were  with  the  shock.  Ultimately  he  was  able  to 
resume  his  walk  homeward. 

The  Treatment  of  Typhoid  Twenty-five  Years  Ago. 

— The  late  Sir  William  Gull  gave  the  following  sensible 
directions  two  years  after  he  had  attended  the  Prince  o 
Wales  during  his  illness.  1.  Typhoid  fever  is  a  disease 
which  runs  a  more  or  less  definite  course.  It  cannot  be 
stopped  or  cured  by  medicines.  2.  The  chief  thing  to 
be  done  at  the  outset  of  an  attack  is  to  send  the  patient 
to  bed,  so  as  to  save  strength  from  the  beginning.  3.  No 
strong  purgative  medicines  are  desirable.  4.  As  the  fever 
develops  and  the  strength  grows  less,  light  food  should 
be  given  at  short  intervals — /.*.,  water,  toast  water,  bar- 
ley-water, milk  and  water,  light  broths  (not  made  too 
strong  or  too  gelatinous).  5.  If  there  be  restlessness  or 
much  agitation  of  the  nerves,  wine  (port,  sherry,  or 
claret),  or  brandy  in  moderate  doses  at  short  intervals. 
This  must  be  directed  medically,  but  in  general  it  may 
be  said  that  the  amount  required  is  that  which  induces 
repose  and  sleep.  6.  The  bowels  may  be  left  to  them- 
selves. If  unmoved  for  twenty-four  or  thirty-six  hours  a 
lavement  of  warm  water  may  be  necessary,  but  this  will 
be  directed  medically.  7.  The  restlessness  or  wakeful- 
ness in  fever  is  best  remedied  by  the  careful  giving  of 
wine  or  spirit  with  the  food,  or  in  hot  water.  Sedatives 
such  as  opium  are  inadmissible — mostly  injurious.  8. 
The  bedroom  to  be  kept  at  a  temperature  of  62  to  65 °  F. 


5* 


MEDICAL   RECORD. 


[July  14,  1894 


9.  Great  care  is  necessary  to  keep  the  bed  clean  and 
sweet.  This  is  most  easily  done  by  having  a  second  bed 
in  the  room,  to  which  the  patient  can  be  removed  for  two 
or  three  hours  daily,  while  the  other  is  thoroughly  aired 
and  the  linen  changed.  10.  All  fatigue  to  be  sedulously 
avoided.  No  visitors  admitted,  and  no  other  person  but 
a  nurse  and  one  attendant  to  help  her.  11.  Patient's 
room  never  to  be  left  unattended  for  a  moment,  as  in  the 
delirium  of  fever  patient  may  jump  from  bed  and  injure 
himself.  12.  As  to  medicines  and  the  treatment  of  com- 
plications, the  immediate  medical  attendant  must  be  re- 
sponsible. 13.  As  it  is  possible  that  the  discharges  from 
the  bowels  in  typhoid  fever  may  be  a  source  of  conta- 
gion, it  is  desirable  that  before  being  thrown  down  the 
closet  they  should  be  largely  mixed  with  Condy's  fluid 
or  some  other  disinfectant.  On  the  same  principle  the 
strictest  cleanliness  must  be  observed  in  the  sick-room. 
14.  There  is  no  reason  to  believe  that  typhoid  fever  is 
contagious  from  person  to  person,  in  the  ordinary  way. 
The  largest  experience  shows  that  it  does  not  extend,  like 
an  ordinary  contagious  disease,  to  nurses  or  others  attend- 
ing upon  patients  suffering  under  the  disease. 

What  Small-pox  Can  Do.— At  the  time  of  the  an- 
nouncement of  vaccination  by  Jenner  small-pox  caused 
more  than  one-tenth  of  all  the  deaths  of  the  human  race. 
Fifty  million  people  died  in  Europe  from  small  pox  dur- 
ing the  eighteenth  century.  In  the  sixteenth  century 
the  disease  appeared  in  Mexico,  and  3,500,000  of  the 
population  yielded  up  their  lives  in  a  few  years,  leaving 
some  provinces  almost  depopulated.  In  1707  in  Iceland 
18,000  died  in  one  year,  the  entire  population  being  but 
50,000.  Seventy  per  cent,  of  the  people  of  Greenland 
died  of  small- pox  in  1734.  Small-pox  is  the  most  fear- 
ful disease  with  which  the  human  race  has  ever  been 
scourged.  Macaulay  tells  us  it  was  always  present,  fill- 
ing the  churchyards  with  corpses  and  leaving  on  those 
whose  lives  it  spared  the  hideous  traces  of  its  power. 
"If  a  modern  traveller,"  says  Dr.  Hyde,  "could  be 
transported  to  London  in  the  early  part  of  the  present 
century,  no  peculiarities  of  architecture,  dress,  or  behav- 
ior, would  be  so  conspicuous  as  the  enormous  number  of 
pockmarked  faces  he  would  encounter  at  every  turn." 
It  spared  neither  rich  nor  poor,  and  even  invaded  the 
palace  of  the  king. 

Awards  at  the  International  Exposition  of  Hygiene 
in  Rome. — The  German  exhibitors  figure  prominently  in 
the  official  list  of  awards  made  by  the  jury  of  the  Inter- 
national Exposition  of  Hygiene  held  concurrently  with 
the  International  Medical  Congress  in  Rome.  From  the 
report  of  the  Exposition  already  given  in  our  columns, 
the  reader  will  be  prepared  to  find  that  the  Imperial  Ger- 
man Gesundheitsamt  received  the  highest  award  (the  great 
diploma  of  honor) ;  while  minor  honorary  diplomas  were 
given  to  the  Prussian  War  Office,  to  the  city  of  Berlin, 
to  the  Bavarian  Ministry  of  the  Interior,  to  the  city  of 
Munich,  to  the  Home  Office  and  War  Office  of  Saxony, 
and  to  other  bureaux  (government  and  municipal)  of  the 
Fatherland,  as  well  as  to  Professors  Salkowski,  Kossel, 
and  Brieger,  of  Berlin ;  Jaffe,  of  Konigsberg ;  Kiihne,  of 
Heidelberg ;  Drechsel,  of  Bern ;  and  C.  Zeiss,  of  Jena. 
The  gold  medal  was  obtained  by  the  Anilin-Fabrication 
Company  of  Berlin ;  by  Schering,  of  Berlin ;  by  Merck, 
of  Darmstadt,  and  by  two  other  German  houses ;  while 


silver  medals  were  literally  showered  on  exhibitors  of  the 
same  nationality  for  contributions  to  sanitary  matSrieL 
Among  the  recipients  were  professors  in  the  various  seats 
of  learning  throughout  the  Fatherland — Berlin  in  point 
of  numbers  heading  the  list.  Italy,  again,  is  well  satisfied 
with  the  appreciation  of  her  mineral  waters  embodied  in 
the  awards  of  the  jury.  On  the  court  representing  the 
Hydrological  Department  were  the  "Dean  of  French 
Hydrology,"  Professor  Labat,  of  Paris,  and  the  head  of 
the  German  hydrological  societies,  Professor  Winternitz, 
of  Vienna,  while  Italian  jurymen  were  the  Senator  Dr. 
Giulio  Bizzozzero,  Professor  of  General  Pathology  in  the 
University  of  Turin,  and  Dr.  David  Borelli,  Professor  of 
Clinical  Medicine  in  the  University  of  Naples.  Among 
mineral  waters,  Italian  and  foreign,  the  highest  award 
was  given  to  that  of  Fiuggi,  which  received  the  silver- gilt 
medal ;  silver  medals  were  adjudged  to  Decref  (Madrid) 
and  Perrin  (Vichy)  for  their  waters ;  and  the  Giesshubl- 
Puchstein,  the  Franz  Josef  Bitterquelle,  and  the  Tuscan 
Cinciano  received  bronze  medals.  Fiuggi,  to  which  the 
place  of  honor  has  been  assigned,  is  a  water  of  great  an- 
tiquity, which,  like  many  good  things  Italian,  has  been 
allowed  to  fall  into  desuetude  till  now,  when  a  vigorous 
effort  is  being  made  to  reinstate  it  in  the  popularity  it 
enjoyed  in  mediaeval  and  classic  times.  Its  source  is  in 
the  Hernican  country  to  the  south  of  Rome,  a  beautiful 
tract  of  the  Apennines  celebrated  by  Virgil,  and  its  effi- 
cacy in  subjects  of  the  uric  diathesis  is  attested  by  clini- 
cians of  the  stamp  of  Dr.  Guido  Baccelli,  President  of 
the  Eleventh  International  Medical  Congress,  the  Senator 
Dr.  Mariano  Semmola,  Professor  of  Clinical  Medicine  in 
the  University  of  Naples,  and,  indeed,  by  nearly  every 
consultant  of  note  throughout  the  peninsula.  It  ought 
certainly  to  be  better  known  in  this  country,  as  its  vir- 
tues, especially  in  gastro  intestinal  catarrh,  notably, 
such  as  proceeds  from  uric  and  oxalic  concretions, 
have  been  attested  by  British  medical  men  practising  in 
Italy. 

M .  Pasteur  on  Babies. — MT  Pasteur  addressed  the  fol- 
lowing reply  to  a  lady  who  recently  wrote  to  him  for  in- 
formation respecting  the  symptoms  of  rabies :  "  M.  Pas- 
teur has  had  pleasure  in  receiving  your  letter  of  May  31st. 
The  bite  of  a  dog  is  only  dangerous  when  the  dog  has 
got  rabies.  If  there  is  any  doubt  in  respect  to  this,  the 
manner  in  which  it  may  be  found  out  is  the  following : 
Put  the  dog  that  has  bitten  where  it  can  do  no  further 
harm.  Have  it  examined  by  a  vet.,  and  if  it  has  the 
rabies  its  characteristic  symptoms  will  not  be  long  of 
being  observed,  and  the  animal  will  certainly  die  in 
eight  days.  If  at  the  end  of  that  time  no  symptoms  of 
rabies  has  been  observed,  the  bite  cannot  cause  hydro- 
phobia, and  there  is  no  reason  that  the  animal  should  be 
destroyed." 

Attending  Physicians  and  Consultation-fees. — An  es- 
teemed correspondent  recently  inquired : 

"  In  consultations,  is  not  the  attending  physician  e;  - 
titled  to  a  consultation-fee  in  addition  to  his  ordinary 
visiting-fee  ?" 

We  answered,  "  Yes." — Medical  News. 

All  the  same,  the  attending  physician  rarely  gets  it,  and 
we  see  no  particular  reason  why  he  should,  though  he 
might  reasonably  charge  double  his  ordinary  fee  if  much 
of  his  time  is  consumed. 


July  14,  1894] 


MEDICAL   RECORD. 


53 


jftrcietg  Reports. 

(ZougzeeB  at  &roettfara  ffftijstciatia 
and  ^urgeoua. 

7Xi></  Triennial  Meeting,  held  at  Washington,  D.  C, 
May  20,  jo,  ji,  and  June  1,  1894. 

(Contkuiad  from  page  a*.) 

AMERICAN  PHYSIOLOGICAL  SOCIETY. 

Seventh  Annual  Meeting,   held  in   Washington,  D.C., 
May  jo  andji,  and  June  i,  1894. 

President  Henry  P.  Bowditch,  M.D.,  of  Boston, 
Mass..  in  the  Chair.  Warren  P.  Lombard,  M.D., 
of  Ann  Arbor,  Mich.,  Secretary. 

First  Day,  Wednesday,  May  30TH. 

A  motion  was  made  to  appoint  a  committee  of  three  to 
consider  the  advisability  of  publishing  an  American  Jour- 
nal of  Physiology ,  and  to  report  at  the  next  meeting  in 
December,  1894.  Committee  appointed  by  the  presi- 
dent, consisting  of  Drs.  Lee,  Porter,  and  Donaldson. 

Effect  of  Fatigue  on  the  Bate  of  Transmission  of 
Hervous  Force. — Dr.  Henry  P.  Bowditch,  of  Boston, 
read  a  paper  with  this  title.  The  most  important  results 
obtained  were  by  noticing  the  results  of  prolonged  stim- 
ulation. Thus  far  there  has  been  discovered  no  produc- 
tion of  heat,  nor  chemical  change,  nor  any  great  amount 
of  fatigue  produced  by  prolonged  stimulation ;  shown  in 
regard  to  the  last  point,  for  example,  by  the  continuous 
action  of  the  vagus  on  the  heart ;  and,  in  Sensory  nerves, 
by  long  continued  pain.     But  is  there  not  some  change? 

The  best  understood  phenomenon  of  nerve  force  or 
function  is,  perhaps,  the  rate  of  transmission,  the  gener- 
ally accepted  average  of  which  is  about  thirty  metres  per 
second.     Is  the  rate  affected  by  prolonged  stimulation  ? 

The  method  used  by  Dr.  Bowditch  in  his  experiments 
was  the  nerve-muscle  method.  To  use  this  effectually, 
there  must  be  some  method  of  "  blocking  "  the  current, 
or  interrupting  it  between  the  nerve  and  the  muscle,  so 
as  not  to  wear  out  the  muscle.  Of  the  various  methods 
of  doing  this,  by  interrupting  the  current,  by  chemical  ac- 
tion {e.g.,  by  action  of  atropia  or  curare  on  the  muscle, 
or  local  application  to  the  nerve,  at  point  of  entrance  into 
the  muscle,  of  ether),  or  by  pressure  (which  latter  Dr. 
Bowditch  found  entirely  useless),  he  chose  the  use  of 
ether,  using  a  mixture  of  so  parts  of  ether,  8  parts  of  six- 
per-cent.  salt  solution,  and  2  parts  of  alcohol. 

He  found  the  current,  or  connection  between  the  nerve 
and  muscle,  blocked  after  application  for  from  one  to  six 
minutes ;  and  on  removal  of  the  ether,  the  nerve  recov- 
ered its  conductivity  in  from  two  to  four  minutes.  His 
first  effort  was  to  obtain  an  average  effect  on  a  number 
of  different  specimens,  in  order  to  compare  with  the 
normal. 

He  found,  however,  that  there  was  a  very  wide  range 
of  results  obtained  by  experimenting  with  frogs'  nerves, 
and  that  the  different  nerves  acted  very  differently.  He 
showed  by  diagrams  that  the  different  effects  showed  a  vari- 
ation of  from  10  to  15  metres  up  to  from  45  to  53  metres, 
after  use  of  ether  or  stimulation,  or  both,  i.e.,  in  the 
lowest  of  his  experiments  the  rate  of  the  first  nerve  was 
15  metres,  and  after  use  of  ether  or  stimulation  it  was  re- 
duced to  10  metres;  and  in  the  highest  case  was  53 
metres,  afterward  reduced  to  43  metres  per  second. 

In  most  cases  the  range  of  each  individual  experiment 
was  not  large,  being  from  5  to  10  metres ;  but  in  some 
was  very  large,  being  in  one  case  from  20  to  40  metres 
per  second.  Dr.  Bowditch  had  found  a  similar  range  in 
the  experiments  of  other  investigators,  e.g.,  in  Helm- 
holtz's  a  variation  from  4  to  20  metres.  He  therefore 
feels  that  with  the  methods  at  present  at  our  command, 
that  we  cannot  hope  to  arrive  at  the  true  normal  stand- 
ard, the  great  variations  depending  upon  conditions 
which  we  cannot  control. 


Dr.  Bowditch  conducted  his  experiments  in  the  usual 
moist  chamber,  at  a  nearly  uniform  temperature.  He 
found  that  rest  did  not  affect  the  results,  i.e.,  the  prepa- 
ration did  not  deteriorate  after  keeping  from  one  to  three 
hours.  In  general  he  found  that  after  use  of  ether  alone 
the  rate  was  somewhat  lower  than  the  generally  accepted 
normal,  viz.,  eighty-two  per  cent,  of  normal  rate;  that 
after  stimulation  it  was  slightly  lower  still;  and  after 
both,  still  lower,  being  about  seventy-six  per  cent,  of 
normal.  But  he  considers  the  decrease  comparatively 
slight;  and  that  thus  far  he  must  conclude  that  pro- 
longed stimulation,  i.e.,  fatigue,  does  not  markedly  affect 
the  rate  of  transmission.  He  hopes  to  continue  the  in- 
vestigation of  this  interesting  question  by  photographic 
and  electro-metrical  methods. 

The  Physiological  and  Therapeutic  Action  of  Nuclein. 
— Dr.  Victor  C.  Vaughn,  of  Ann  Arbor,  read  the  pa- 
per. Physiologically  nuclein  may  be  said  to  form  the 
chief  chemical  constituents  of  the  lining  parts  of  cells, 
the  element  by  virtue  of  which  the  cell  grows,  develops, 
and  reproduces  itself.  It  is  its  function  to  utilize  the 
pabulum  within  its  reach.  It  is  evident,  then,  that  those 
tissues  containing  a  large  number  of  cells  must  contain 
the  relatively  largest  amount  of  nuclein.  It  would  also 
seem  that  it  is  by  virtue  of  their  nuclein  that  the  different 
organs  manifest  their  individual  peculiarities  and  func- 
tions; and  therefore  that  the  nucleins  from  different 
sources  would  be  very  different,  e.g.,  that  from  yeast  dif- 
ferent from  that  from  the  spleen  or  the  thyroid  gland, 
etc.,  the  number  of  kinds  being  limited  only  by  the  num- 
ber of  different  cells. 

It  is  the  chemical  basis  of  the  nuclei  of  the  cells,  some- 
times called  by  the  histologists  chromatin,  from  the  ease 
with  which  it  takes  up  staining  materials.  Chemically, 
the  nucleins  are  proteid  bodies  containing  a  large  amount 
of  phosphorus,  existing  in  the  form  of  nucleinic  acid, 
this  acid  being  the  same  in  all  nucleins ;  but,  combined 
with  different  bases  gives  us  the  different  resulting  nu- 
cleins. On  reduction  and  recomposition  they  yield  some 
of  the  so-called  xanthin  bodies.  In  general  they  are  in- 
soluble in  dilute  acids  and  soluble  in  dilute  alkaloids,  and 
resist  peptic  digestion. 

Some  substances  histologically  nucleins  do  not  yield 
any  xanthin  base,  and  such  are  now  called  para-nucleins, 
and  some  of  these  are  the  antecedents  of  the  true  nu- 
cleins. 

Some  nucleins  are  combined  with  albumins  forming 
nucleo  albumins.  Miescher  was  the  first  to  study  appre- 
ciatingly  the  nucleins,  and  was  the  one  who  named  them. 

He  prepared  his  specimens  for  investigations  from  pus 
corpuscles,  and  later  from  the  yolks  of  eggs. 

In  1874  he  made  his  most  important  contribution  to 
the  knowledge  of  nucleins  by  working  with  the  spermato- 
zoa of  salmon.  In  a  fresh  state  these  were  found  to  be 
very  resistant  to  most  chemical  reagents,  but  were  found 
to  be  destructively  affected  by  dilute  salt  solutions  (ten  to 
fifteen  per  cent). 

The  head  of  the  spermatozoa  was  found  to  be  practi- 
cally free  from  albumin,  and  to  consist  of  nuclein  and 
small  quantities  of  lecithin,  cholesterine,  and  fat. 

The  nuclein  molecule  is  wonderfully  retentive  of  life, 
and  possesses  marked  powers  of  self  recuperation  after  be- 
ing partly  decomposed ;  as  shown  by  the  fact  that  after 
being  partly  decomposed  by  salt  solution,  if  this  solution 
be  diluted  by  the  addition  of  large  quantities  of  water, 
the  nuclein  is  restored  to  its  original  form  and  constitu- 
tion. 

Nuclein  maybe  very  markedly  changed  in  chemical 
composition  and  functional  powers,  without  changing  its 
visible  properties  or  form,  which  would  readily  account 
for  the  failure  oftentimes  to  find,  by  macroscopical  or  mi- 
croscopical examination,  lesions  distinctive  enough  or  of 
sufficient  character  or  extent  to  account  for  the  severity 
of  symptoms  observed  during  life. 

An  artificial  nuclein  has  been  prepared  by  Lieben, 
which,  however,  is  not  a  true  nuclein,  but  a  para- nu- 
clein. 


54 


MEDICAL  RECORD. 


[July  14/1894 


A  close  relation  seems  to  exist  between  nuclein  and  uric 
acid,  judging  from  the  close  relation  of  both  to  the  xan- 
thin  bodies.  Thus  spleen  nuclein  when  oxidized  yields 
uric  acid. 

This  origin  of  uric  acid  from  nuclein  will  explain  the 
origin  of  uric  acid  in  the  mammalian  body,  showing 
really  the  number  of  nucleated  cells  in  the  body  which 
are  being  recomposed  and  not*  as  heretofore  believed, 
being  the  result  of  imperfect  oxidation  of  food  stuffs,  the 
complete  product  of  which  is  urea. 

Some  of  the.  nucleins  have  germicidal  properties 
more  powerful  than  corrosive  sublimate.  The  germicidal 
constituent  of  the  blood  is  nuclein,  furnished  by  the  poly- 
nuclear  white  corpuscles.  Being  thus  germicidal  can  they 
be  used  to  prevent  or  arrest  the  growth  of  germs  in  the 
animal  body ;  and  if  so,  in  what  manner  do  they  act  ? 
Nuclein  seems  to  be  entirely  non  poisonous,  large  doses 
having  been  injected  and  administered  by  mouth  in 
human  beings  with  little  or  no  unpleasant  reaction.  In 
some  cases  it  caused  a  temporary  elevation  of  tempera- 
ture and  a  slight  local  reaction,  but  neither  to  any  dan- 
gerous extent.  He  has  used  it  in  membranous  tonsillitis, 
in  streptococcus  diphtheria,  and  in  indolent  ulcers ;  and 
in  all  cases  with  good  effect.  The  action  of  nuclein  in 
giving  immunity  from  certain  diseases  is  marked,  as 
shown  in  some  cases  where  it  was  used  on  rabbits,  ren- 
dering them  immune  to  the  diplococcus  pneumoniae; 
but  this  is  not  due  to  its  direct  germicidal  action,  but  to 
its  power  of  stimulating  some  organ  whose  duty  it  is  to 
protect  the  body  against  bacterial  invasion. 

Dr.  Vaughn  thinks  that  for  immunity  and  cure  of  in- 
fectious diseases  we  must  look  for,  ist,  Non- poisonous  ger- 
mides  of  cellular  origin;  and  2d,  substances  which  stim- 
ulate the  activity  of  those  organs  whose  function  it  is  to 
protect  the  body  against  those  diseases.  He  thinks  that 
nuclein  fills  both  of  these  demands. 

From  the  investigations  of  Dr.  Huber  he  finds  that, 
"  1,  The  subcutaneous  injection  of  nuclein  increases  the 
number  of  white  blood  corpuscles;  2,  this  increase  oc- 
curs in  both  healthy  and  tuberculous  persons ;  3,  the  in- 
crease varies  with  the  individual ;  4,  the  increase  is  most- 
ly in  the  polynuclear  cells ;  5,  it  generally  appears  with- 
in three  hours,  and  disappears  after  forty-eight  hours." 

Action  of  Calcium  on  the  Heart— Dr.  W.  H.  How- 
ell then  made  an  interesting  demonstration  of  the  effect 
of  calcium  salts  on  the  contractility  of  the  heart.  He 
had  the  heart  of  a  turtle  in  a  bulb,  connected  with  a  very 
delicate  water  manometer ;  and  having  connection  by  a 
stop  cock  with  three  flasks  containing :  1 ,  Normal  sheep's 
blood ;  2,  sheep's  blood  with  the  calcium  salts  precipi- 
tated by  excess  of  sodium  oxalate ;  and  3,  sheep's  blood 
with  excess  of  calcium  chloride.  In  the  first  instance 
the  heart  was  fed  with  the  normal  blood,  showing  nor- 
mal contractions ;  then  it  was  fed  with  the  decalcified 
blood,  upon  which  the  contractions  became  less  frequent, 
the  diastole  being  lengthened,  and  also  irregular  and 
jerky  in  its  action,  finally  coming  almost  to  a  complete 
standstill,  practically  a  potash  paralysis.  Then  the  blood 
with  excess  of  calcium  chloride  was  turned  into  the  heart, 
which  very  soon  began  to  beat  more  frequently  and  regu- 
larly and  was  finally  restored  to  a  practically  normal  con- 
dition. 

Dr.  Howell  said  it  had  been  so  far  impossible  to  decide 
absolutely  whether  it  was  the  absence  of  the  calcium  salts 
or  the  presence  of  the  excess  of  the  oxalates  which  caused 
the  paralysis,  it  being  at  present  practically  impossible 
to  precipitate  all  of  the  calcium  salts  without  an  excess  of 
the  oxalates.  We  cannot  exactly  neutralize  the  calcium 
salts,  as  we  do  not  know  in  any  particular  sample  of 
blood  just  how  much  is  present  in  soluble  and  ergo  pre- 
cipitable  form,  and  how  much  is  in  composition  more  or 
less  stable  with  proteid  and  other  bodies. 

Ptyalinogen  and  Pexinogen.— Dr.  J.  W.  Warren  then 
made  some  remarks  on  the  qualitative  determination  of 
ptyalinogen  and  pexinogen.  The  best  way  of  determin- 
ing the  presence  of  pexinogen  or  the  forerunner  of  the 
mUk  curdling  ferment  was  by  chloroform  water.     Ham- 


merstein,  he  said,  had  found  pexinogen  in  nearly  all  ani- 
mals ;  but  in  the  mucous  membrane  of  the  ox  it  was  not 
found,  the  pepsin  being  there  already  formed.     Dr.  War- 
ren had  found  the  opposite  condition  present  in  his  ex 
periments  with  the  ox. 

Ptyalinogen,  the  forerunner  of  the  salivary  ferment, 
ptyalin,  he  also  determined  by  the  chloroform-water 
method.  He  had  found  it  present  in  almost  every  case 
excepting  in  the  cat.  The  principal  objection  to  the 
chloroform  method  was  the  difficulty  of  entirely  remov- 
ing the  chloroform,  and  the  fact  that,  if  present,  it  gave 
a  reaction  with  Trommer's  test,  simulating  that  of  sugar. 
The  quantity  of  ptyalinogen  is  small  and  yet  it  was  al- 
ways genuine.  In  some  cases,  of  sheep  and  rabbits,  he 
could  get  no  results  either  for  ptyalinogen,  or  for  ptyalin 
itself  in  watery  or  chloroform- water  extracts. 

Dr.  Warren  used  a  one  per-cent.  solution  of  sodium 
fluoride,  which  acts  as  an  excellent  preservative  of  the 
different  ferments  of  the  body,  and  which  does  not  re- 
duce the  reagents  used  for  testing  for  sugar. 

Ptyalinogen  is  not  very  soluble  as  compared  with  the 
forerunners  of  the  other  ferments  of  the  body;  and  is 
apparently  not  so  stable  and  permanent.  No  result  was 
considered  satisfactory  nor  reported  where  the  action  did 
not  appear  within  one  hour. 

Chemistry  of  Muscle.— Dr.  G.  N.  Stewart  then  read 
a  paper  on  this  subject.  He  stated  that  his  first  experi- 
ments had  been  to  get  information  as  to  whether  the 
proteid  substances  usually  said  to  be  present  in  muscle 
tissue,  and  which  had  all  been  derived  chemically  from 
dead  muscle,  existed  as  such  in  living  muscle. 

He  differed  from  and  criticised  Halliburton's  theories, 
as  to  the  presence  of  myosinogen  in  the  muscle  tissue, 
and  the  fact  of  its  clotting  to  produce  the  rigor  mortis  ; 
and  also  criticised  Halliburton's  conclusions  from  his 
method  of  practical  precipitation  of  the  proteid  borders 
of  muscle  tissue. 

Following,  however,  Halliburton's  methods  to  a  cer- 
tain extent,  he  found  the  quantities  of  myosinogin  and 
the  other  proteids  quite  different  in  the  different  muscles 
of  the  body ;  e.g.,  those  in  heart  muscle  different  from 
those  in  the  skeletal  muscles  and  some  differences  in  the 
different  groups  of  the  skeletal  muscles ;  the  larger  per- 
centages of  easily  coagulable  proteids  being  as  a  rule  in 
the  more  active  and  more  easily  irritated  muscles.  The 
rigor  mortis  being  different  in  different  muscles,  are  not 
the  extracts  of  the  different  muscles  also  different  in  the 
quantities  and  coagulability  of  their  proteids  and  is  the 
myosinogen  of  one  different  from  that  of  another  ?  Dr. 
Stewart  thinks  that  such  differences  do  exist. 

In  a  series  of  experiments  on  fifty  frogs'  hearts  and 
skeletal  muscles  he  found  slight  difference  in  the  tem- 
perature at  which  the  proteids  of  these  heart-muscles 
coagulated  and  that  at  which  proteids  from  skeletal 
muscles  from  the  same  frogs  coagulated. 

In  the  case  of  rabbits'  hearts  he  found  the  same  result. 
Also  by  direct  application  of  heat  to  the  muscles,  it 
needed  a  higher  temperature  to  cause  a  "  rigor  mortis  " 
in  the  heart  than  in  the  skeletal  muscles. 

In  the  following  tables,  which  illustrate  these  results  : 

I.  Is  the  percentage  precipitate  occurring  between  470  and  49°  C. 

II.  Between  560  and  580  C. 

III.  Up  to  650  C. 

IV.  The  balance  of  coagulable  proteid  with  boiling. 

Also  according  to  Halliburton's  results  of  fractional  pre- 
cipitation and  his  nomenclature : 

I.  Is  para  myosinogin. 

II.  Is  myosinogin. 

III.  Is  myoglobulin. 

IV.  Is  serum  albumin. 

Halliburton  claimed  that  para-myosinogin  did  not  clot ; 
but  according  to  the  fractional  precipitative  method  Dr. 
Stewart  found  it  present  in  muscle  clot  in  large  quantity, 
and  therefore  judges  it  essential  to  the  formation  of  the 
clot,  and  fully  as  much  so  as  myosinogen. 
These  tables  show  percentage  of  different  proteids,  as 


July  14,  1894] 


MEDICAL   RECORD. 


55 


per  above  explanation,  in  the  heart  and  skeletal  muscles 
of  a  rabbit : 

Heart.  Skeletal. 

Per  cent.  Per  cent 

1 76.I  70.9 

II Slight  19.7 

III *  *  Slight 

IV 23.9  9.41 

In  one  experiment  Dr.  Stewart  heated  a  muscle  from  a 
cat's  leg  at  42  °  C.  for  ten  hours. "  Then  made  extract  of 
it,  and  found  that  all  the  proteids  excepting  serum  albu- 
min were  precipitated  at  about  420  C,  showing  that  the 
rigor  mortis  (thus  artificially  produced)  causes  some 
change  in  the  muscle  proteids,  if  Halliburton's  method  of 
fractional  precipitation,  as  precipitating  pure  chemical 
bodies,  be  accepted. 

In  another  case  Dr.  Stewart  prevented  rigor  mortis  of 
a  muscle  by  pressure,  and  then  upon  making  extract  and 
comparing  it  with  results  from  a  muscle  in  which  rigor 
mortis  had  taken  place  found  very  little  difference  be- 
tween the  two,  as  will  be  seen  from  the  following  table. 
"A"  being  the  one  in  which  rigor  mortis  had  taken 
place ;  "  B  "  being  the  one  in  which  it  had  been  pre- 
vented : 

A.  B. 

Per  cent.  Per  cent. 

1 70.  68.2 

II 21.4  24.8 

III 8.7  6.9 

He  thought  that,  theoretically,  if  muscle  were  exam- 
ined after  rigor  mortis  had  passed  off,  there  should  be 
found  a  difference  in  clotting  power  as  compared  with 
muscle  examined  before  rigor  mortis ;  but  had  not  found 
it  so. 

Dr.  Stewart  concluded  that  the  methods  at  present 
available  for  investigation  of  this  subject  were  incomplete 
and  faulty  and  hoped  for  better  ones  soon. 


Second  Day,  Thursday,  May  31ST. 

Circulation  Time  in  Organs.— Dr.  G.  N.  Stewart, 
of  Harvard  University,  read  the  paper.  As  to  method, 
it  was  necessary  to  cause  some  condition  of  the  blood 
which  could  be  easily  noted,  would  disappear  quickly, 
and  which  would  admit  of  new  and  repeated  observa- 
tions. 

Of  various  possible  methods,  Dr.  Stewart  used  that  of 
injecting  a  quantity  of  salt  solution  into  an  afferent  ves- 
sel, and  then  determining,  by  the  difference  in  conductiv- 
ity of  an  electric  current,  caused  by  the  presence  of  the 
salt  in  the  blood,  the  time  at  which  the  salt  solution  had 
reached  the  efferent  vessel,  thus  giving  the  time  of  cir- 
culation through  the  organ.  The  electrodes  may  be 
placed  upon  the  vessel,  and  do  not  need  to  be  inserted 
into  the  vessel  nor  into  the  blood-current. 

He  found  the  time  of  circulation  longest  in  the  kid- 
ney (occasionally  about  as  long  in  the  spleen),  the  aver- 
age of  many  experiments  being  11.58  seconds.  The  pul- 
monary circulation  time  he  found  the  shortest  of  any 
organ  in  the  body  (excepting  sometimes  the  coronary  cir- 
culation), being  from  two  to  four  seconds.  It  was  also 
more  constant  than  that  of  any  other  organ,  and  might 
well  be  used  as  a  sort  of  unit  or  standard. 

The  liver  circulation  was  from  four  to  seven  seconds ; 
the  thyroid  gland,  five  to  six  seconds,  and  capable  of  re- 
duction by  section  of  the  cervical  sympathetic ;  in  the 
spleen  the  average  time  was  10.95  seconds.  In  one  case, 
using  an  animal  which  had  been  used  previously  to  dem- 
onstrate the  motor  areas,  and  which  had  spasms  during  his 
observation  of  the  pulmonary  circulation,  he  found  that 
time  much  shorter. 

In  another  case,  where  an  overdose  of  chloral  had  been 
given,  he  also  found  the  time  much  reduced,  probably 
due  to  the  marked  dilatation  of  the  whole  vascular  sys- 
tem. For  measuring  the  circulation  time  in  the  intes- 
tines and  the  coronary  vessels,  Dr.  Stewart  used  the 
method  of  pigment  injections,  using  two  per  cent,  so- 
lution of  methylene  blue.    In  the  intestines  the  time  was 


a  trifle  longer  than  the  lungs,  and  about  one- third  as  long 
as  in  the  liver.  The  coronary  time  was  short,  being  about 
three  seconds,  very  little,  if  any,  change  being  caused  by 
stimulation  of  the  vagus ;  if  any  change,  it  was  a  decrease 
of  time,  not  an  increase. 

Dr.  Stewart  claimed  that  the  results  were  not  affected, 
as  some  had  claimed,  by  the  diffusion  of  the  salt  solution, 
as  the  time  during  which  any  one  observation  was  made 
was  not  long  enough  for  any  appreciable  diffusion  td  take 
place. 

Soma  Experiments  upon  Keflex  Vasoconstriction  and 
Vaso  dilatation. — Dr.  W.  H.  Howell  sent  a  paper  with 
this  title,  which  was  read  by  Mr.  R.  Hunt.  The  object 
of  the  experiments  was  to  study  the  conditions  under 
which  a  reflex  fall  of  the  general  blood-pressure  can  be 
obtained. 

If  chloral  be  administered  to  a  rabbit,  and  the  central 
end  of  the  cut  sciatic  nerve  be  stimulated,  a  fall  of  press- 
ure occurs,  instead  of  the  usual  rise. 

It  is  generally  held  that  the  sensory  nerves  contain 
both  pressor  and  depressor  fibres,  and  that  upon  fatigue 
of  the  vasomotor  centres  they  are  more  influenced  by 
the  depressor  than  by  the  pressor  fibres. 

Recently  Kleen  described  that  a  pure  muscular  stimu- 
lation, as  by  kneading  a  muscle,  caused  a  fall ;  whereas  a 
cutaneous  stimulation  caused  a  rise  of  pressure. 

Dr.  Hamell  also  has  shown  that,  by  cooling  the  sciatic 
and  stimulating  the  nerve  peripherally  to  the  cooled  por- 
tion, a  fall  was  caused,  which  was  followed  by  a  rise  if  the 
nerve  were  warmed  and  again  stimulated. 

Dr.  Howell  and  Mr.  Hunt  found  that  when  the  nerve 
was  cooled  that  anaesthesia  had  a  marked  effect  upon  the 
pressure  under  anaesthesia,  caused  by  pressure  on  the  cere- 
brum, in  cats,  the  vagi  being  cut ;  mild  stimulation  of 
the  sciatic  at  the  temperature  of  the  room  caused  a 
marked  rise  of  pressure.  At  io°  C.  the  same  stimulation 
caused  a  fall,  while  at  the  same  temperature  a  strong 
stimulation  caused  a  rise  of  pressure. 

At  50  C.  both  strong  and  weak  stimulation  caused  a 
fall.  At  1 50  both  strong  and  weak  stimulation  caused  a 
rise.  The  change  from  a  fall  to  a  rise  was  often  very 
rapid  after  changes  of  the  temperature. 

Ether,  alone  or  with  other  anaesthetics,  seemed  to  have 
a  marked  influence  in  bringing  out  the  depressor  effects ; 
under  ether  a  rise  was  usually  caused  by  moderate  stim- 
ulation at  the  temperature  of  the  room,  but  a  fall  at 
lower  temperatures.  Curare  seemed  to  have  an  opposite 
effect  to  that  of  ether,  i.e.,  bringing  out  more  promi- 
nently the  pressor  effects.  At  low  temperatures  no  fall 
could  be  obtained  in  the  curarized  rabbit,  and  at  higher 
temperatures  the  rise  was  very  marked. 

Under  acetone  chloroform  the  vaso-motor  centres 
seemed  to  be  not  very  irritable  and  the  changes  in  press- 
ure not  great.  Upon  rhythmical  stimulation  under  press- 
ure anaesthesia,  only  a  rise  was  obtained  varying  directly 
with  the  strength  and  rapidity  of  the  stimuli.  Local  ap- 
plication of  drugs  to  the  nerve  had  little  or  no  effect,  ex- 
cepting that  some,  e.g.,  ether,  completely  blocked  the  im- 
pulses. 

The  cause  of  the  above  effects  cannot  yet  be  fully  an- 
swered. Dr.  HamelTs  method  seems  good  evidence  of  the 
existence  of  two  sets  of  fibres,  pressor  and  depressor,  the 
conductivity  of  the  former  being  more  quickly  diminished 
than  the  latter  by  local  causes.  When  drugs  are  injected 
into  the  circulation,  probably,  or  perhaps,  the  centres 
themselves  are  affected. 

Brain  Centres  of  the  Bladder. — Dr.  Isaac  Ott,  of 
Easton,  Pa.,  gave  the  results  of  a  few  preliminary  ex- 
periments on  the  cerebral  centres  of  the  bladder.  Pre- 
vious experimenters  had  noted  that  electrical  stimulation 
to  the  corpora  quadrigemina  caused  a  contraction  of  the 
bladder.  Dr.  Ott  found  that,  on  cross  section  of  the  aura 
cerebri,  a  flow  of  urine  followed  ;  also  that  when  the  sur- 
face of  the  exposed  crura  was  touched  the  bladder  con- 
tracted. If  small  doses  of  atropia  were  administered  he 
still  got  contraction,  but  failed  to  get  any  after  large 
doses,  e.g.,  gr.  ij.  of  atropine  sulphate  in  an  ordinary  sized 


56 


MEDICAL    RECORD. 


[July  14,  1894 


adult  cat.  He  used  only  mechanical  stimulation.  His 
conclusion  was  that  the  centre  or  centres  lie  in  the 
crura  cerebri,  the  exact  portion  of  the  crura,  however, 
being  not  yet  determined. 

Volume  Changes  in  Muscle  during  Activity  and 
Best. — Dr.  G  W.  Fitz,  of  Harvard  University,  read  a 
paper  with  this  title.  He  used  a  plethysmograph  on 
the  arm,  with  indicators  giving  tracings  showing  the  ra- 
pidity, length,  and  force  of  the  contractions  of  the  mus- 
cles, the  pulse-beat,  and  the  changes  in  volume.  He 
found  changes  in  both  pulse  and  volume,  but  directed 
attention  particularly  to  the  changes  in  volume.  On 
contraction  of  the  muscles,  i.e.,  in  state  of  activity,  the 
volume  was  markedly  diminished^  in  quantity  varying, 
in  different  arms  and  in  different  experiments,  from  20 
to  75  c.c. 

He  found  the  crura  indicated  by  the  plethysmograph 
quite  different  when  repeated  contractions  were  rapidly 
made,  as  in  the  milking  motion,  from  that  where  there 
was  a  single  long-sustained  contraction. 

In  the  stage  of  fatigue  there  was  a  large  variation  in 
the  volume  of  the  arm,  a  marked  filling  up,  or  increase 
of  volume.  With  each  arm  of  same  patient  in  a  plethys- 
mograph, one  exercising  and  the  other  quiet,  there  were 
slight  effects  noted  in  the  quiet  arm  as  well  as  the  marked 
changes  in  the  active  one. 

The  time  taken  to  get  the  maximum  effect  was  from 
fifteen  to  twenty  seconds,  and  a  similar  time  was  taken 
for  the  arm  to  refill.  These  changes,  Dr.  Fitz  claims,  are 
changes  in  the  quantity  of  fluid  in  the  arm,  probably  en- 
tirely in  the  amount  of  blood  in  the  vessels,  the  quantity 
of  lymph  in  the  lymphatic  spaces  not  being  much  affected, 
as  the  time  necessary  to  cause  the  change  is  so  short. 
Also  when  the  shape  and  relative  bulk  of  the  muscles  are 
considered,  and  the  relatively  small  amount  of  other  tis- 
sues in  the  arm,  it  seems  likely  that  the  change  is  lim- 
ited to  the  muscles. 

By  the  contraction  of  the  muscles  the  blood  is 
squeezed  out  of  the  vessels,  both  arteries  and  veins ;  and 
there  is  thus  a  change  in  volume  and  an  anaemia  of  the 
arm,  because  for  the  time  being  the  blood  pressure  is  not 
enough  to  overcome  the  force  of  contraction  of  the  mus- 
cles. When,  however,  the  muscle  becomes  fatigued,  the 
blood  can  force  itself  into  the  vessels,  causing  an  increase 
in  volume,  and  a  congestion  of  the  arm. 

Dr.  William  H.  Howell,  of  Johns  Hopkins  Univer- 
sity, exhibited  some  very  interesting  "  plethysmography 
curves  taken  during  sleep."  He  found  the  arm  con- 
gested during  sleep,  and  contracted  or  anaemic  during 
waking ;  and,  taking  account  of  the  already  known  the- 
ory of  the  absence  of  vasomotor  control  in  the  brain, 
the  quantity  of  blood  there  depending  upon  the  condi- 
tion of  the  circulation  of  the  other  parts  of  the  body,  and 
varying  inversely  as  the  quantity  in  other  parts,  he 
brought  out  a  very  suggestive  indication  from  the  curves, 
of  the  probable  parallelism  between  the  amount  of  blood 
in  the  brain  and  the  condition  and  intensity  of  con- 
sciousness. 

Upon  stimulation  of  any  of  the  centres,  e.g.,  the  au- 
ditory centre  by  any  noise,  the  person  experimented  up- 
on being  asleep,  the  arm  became  anaemic,  indicating  a 
corresponding  congestion  of  the  brain,  this  change  being 
in  direct  proportion  to  the  strength  of  the  stimulus. 

These  experiments  led  Dr.  Howell  to  suggest  a  pos- 
sible theory  as  to  the  cause  of  sleep,  viz.,  that  the  anae- 
mia known  to  exist  in  the  brain  during  sleep,  and 
which  has  so  far  been  considered  to  be  a  secondary  con- 
dition, is  really  the  cause  of  sleep.  The  explanation  of- 
fered was  that  the  circulation  of  the  brain,  or  the 
amount  of  blood,  varies  inversely  to  that  of  the  balance 
of  the  body ;  the  vaso-constrictor  centre  is  in  a  condition 
of  tonic  activity  during  waking,  thus  keeping  the  quan- 
tity of  blood  reduced  in  the  body  and  increased  in  the 
brain;  this  centre  becoming  fatigued,  the  body  vessels 
dilate  and*  fill  up,  those  of  the  brain  empty  themselves, 
and  when  a  certain  level  is  reached  sleep  ensues. 

The  Cardiac  Planrogram.— Dr.  S.  J.  Meltzer,  of 


New  York,  read  a  paper  on  "  The  Cardiac  Pleurogram 
and  the  Nature  of  the  Cardio- pneumatic  Movements." 
If  a  manometer  or  other  recording  apparatus  be  connect- 
ed with  the  mouth,  nose,  or  trachea,  while  respiration  is 
suspended,  respiratory  oscillations  can  be  observed  coin- 
ciding in  time  with  the  cardiac  movements. 

These  were  explained  by  Voit  in  this  way:  During 
systole  an  inflow  of  air  into  the  lungs  occurs  to  counter- 
balance the  effect  of  the  diminution  in  size  of  the  heart ; 
the  opposite  occurring  in  diastole.  Later  Ceradini  rec- 
ognized the  fact  .that  the  change  in  pressure  could  not 
take  place  as  long  as  the  blood  thrown  out  by  the  heart 
reniained  in  the  thoracic  cavity;  but  it  is  only  when  it  is 
leaving  the  thoracic  cavity  that  the  respiratory  move- 
ment occurs.  Therefore  the  cardio-pneumatic  undula- 
tions are  due  not  to  change  in  size  of  the  heart,  but  to 
change  in  the  quantity  of  blood  within  the  thorax. 

Landois  found  a  short  but  distinct  expiration  preced- 
ing the  main  inspiratory  movement,  and  after  this  main 
movement  two  more  small  respiratory  undulations  oc- 
curred before  the  new  cycle  commenced.  Registration 
of  the  respiratory  undulations  may  also  be  made  by  means 
of  apparatus  placed  in  the  oesophagus,  as  done  by  Martins 
and  by  Dr.  Meltzer.  Many  tracings  were  obtained  of 
the  cardiac  movements,  to  which  Dr.  Meltzer  gave  the 
name  of  cardio-mediostinograms.  The  distinctness  of 
these  tracings  seems  to  depend  upon  the  depth  in  the 
oesophagus  at  which  they  were  taken,  least  distinct  in 
the  cervical  region,  sharp  and  clear  in  the  thoracic  por- 
tion, excepting  in  the  immediate  vicinity  of  the  dia- 
phragm, where  they  were  sometimes  wholly  absent.  The 
results  showed  the  same  general  feet,  viz.,  an  inspiration 
at  the  systole,  an  expiration  at  diastole  of  the  heart. 

Dr.  Meltzer  showed  a  number  of  tracings  taken  by  the 
oesophageal  method,  showing  the  curves  of  the  cardio- 
respiratory movements  very  distinctly.  In  general,  in 
dogs,  in  each  cardiac  cycle  there  appeared  a  steep  systolic 
down-stroke,  followed  by  a  gradually  ascending  diastolic 
line  with  some  fine  oscillations,  showing  that  during  sys- 
tole the  pressure  is  suddenly  lowered,  and  during  dias- 
tole gradually  returns  to  its  former  level  This,  as  in  all 
the  oesophageal-cardiac  tracings  from  the  dog,  showed  a 
so-called  negative  pulse. 

In  experiments  on  himself  Dr.  Meltzer  found  also  a 
negative  pulse  in  the  oesophagus  down  to  twelve  centi- 
metres from  the  beginning  of  the  oesophagus ;  below 
fourteen  centimetres  the  pulse  was  positive,  showing  an 
up  stroke  of  the  indicating  lever,  or  an  expiratory  move- 
ment. 

Dr.  Meltzer  referred  to  Haycraft  and  EdieV  experi- 
ments, from  which  they  claimed  that  the  cardio-respira- 
tory  movements  disappeared  upon  lifting  the  heart  away 
from  contact  with  the  lungs,  and  that  the  lungs  really 
acted  as  an  oncometer  placed  about  the  heart,  and  that 
the  air  in  them  is  affected  by  the  cardiac  impulse  just  as 
the  air  in  a  cardiograph  placed  against  the  chest. 

To  test  this  explanation  Dr.  Meltzer  made  tracings  of 
the  cardiac  movements  directly  from  the  pleural  cavity, 
calling  them  cardio-pleurograms. 

From  these  he  obtained  in  general  the  same  results  as 
before,  with  slight  modifications  due  to  the  different  con- 
ditions and  methods,  and  therefore  argues  that  since  both 
heart  and  lungs  were  far  from  the  openings  leading  to 
the  tambour,  the  movements  are  not  due  to  the  lungs 
acting  as  an  oncometer  for  the  heart,  and  that  they  are 
due,  as  at  first  stated,  to  the  change  in  the  quantity  of 
blood  in  the  thoracic  cavity. 

Dr.  Meltzer  thought  that  Haycraft  and  Edie's  results 
were  perhaps  due  to  their  method  of  opening  the  chest, 
which  caused  a  very  abnormal  condition  with  relation  to 
its  surroundings.  In  rabbits  free  access  of  air  to  the 
chest  cavity  caused  the  cardiorespiratory  movements  to 
disappear;  in  dogs  they  were  diminished,  but  did  not 
disappear.  This,  Dr.  Meltzer  thought,  depended  upon 
the  different  arrangement  of  the  organs  in  the  posterior 
mediastinal  space,  in  rabbits  and  in  dogs.  His  conclusion 
was  that  these  cardio-respiratory  movements  were  nor- 


July  14,  1894] 


MEDICAL   RECORD. 


57 


maly  and  undoubtedly  caused,  as  above  stated,  by  the 
changes  in  the  quantity  of  blood  within  the  thoracic 
cavity. 


Third  Day,  Friday,  June  ist. 

Beflaz  Time  of  Winking.— Dr.  W.  P.  Lombard,  of 
Johns  Hopkins  University,  read  a  preliminary  report  of 
experiments  to  determine  this  point.  He  used  a  very 
ingenious  apparatus  for  producing  the  stimulus — a  plunger, 
worked  by  electricity,  striking  the  cheek  about  one  inch 
from  the  outer  canthus  of  the  eye,  the  stimulation  being 
mechanical  An  electric  current  is  broken  at  the  blow 
of  the  plunger,  and  immediately  closed  by  a  spring,  and 
again  broken  by  the  movement  of  the  eyelid  in  winking; 
the  time  between  the  two  breaks  being  measured  gives  the 
time  of  winking.  Tracings  were  taken  on  a  drum,  of  the 
stimulus  and  the  wink,  and  parallel  with  these,  of  the  vi- 
brations of  a  tuning-fork,  of  known  rapidity  of  vibration. 

The  time  varied  somewhat  in  different  persons,  and  in 
the  same  person  at  different  times ;  but  in  general  was  a 
little  shorter  than  that  determined  by  previous  experi- 
ments, being  about  0.04  second.  If  from  this  be  sub- 
tracted the  time  of  transmission  and  the  latent  period  of 
the  muscles,  the  time  will  be  probably  reduced  to  about 
0.03  second. 

An  Improved  Hematocrit.— Dr.  Judson  Daland,  of 
Philadelphia,  showed,  by  request,  his  improved  hema- 
tocrit, for  examination  of  the  blood  by  the  centrifugal 
method.  He  claimed  for  it,  as  advantages  over  the  in- 
struments at  present  in  use,  its  greater  compactness, 
higher  speed  of  revolution  of  the  frame  or  spindle  carry- 
ing the  capillary  tube ;  the  shorter  length  of  the  tube, 
and  its  lens  face,  making  the  reading  easier;  the  new 
scale,  reading  the  normal  amount  of  corpuscles  in  the 
blood  as  one  hundred  per  cent. ;  and  the  fact  that  by  it 
the  blood  could  be  used  in  its  normal  condition  direct 
from  the  circulation  without  dilution. 

A  Short-circuiting  Commutator.— Dr.  W.  P.  Lom- 
bard, of  Johns  Hopkins  University,  showed  an  ingenious 
and  very  simple  short-circuiting  commutator,  affording, 
making,  or  breaking  induction  shocks. 

It  consisted  of  two  hard-rubber  wheels  or  disks,  set  on 
a  brass  shaft,  and  having  in  the  circumference  of  each  a 
brass  plate  connecting  by  contact  with  the  shaft.  One 
of  these  wheels  rotates  on  the  shaft.  Against  these 
wheels  the  usual  brush  rests,  and  by  rotating  one  of  the 
wheels  upon  the  shaft  the  current  of  the  short  circuit  can 
be  made  to  precede,  or  follow,  the  primary  current  at  will. 

The  device  can  easily  be  attached  to  any  apparatus. 

Dr.  Lombard  also  showed  an  improved  hand-rest  for 
use  with  the  ergograph,  whereby  the  usual  variations 
caused  by  the  unconscious  and  involuntary  withdrawal 
of  the  hand  and  arm  from  the  ordinary  hand-rest,  and 
the  use  of  other  muscles  than  the  particular  one  desired, 
can  be  avoided. 

He  also  showed  a  "  non-oxidizable  mercury  key,"  con- 
sisting of  a  hermetically  sealed  "  U  "  tube  in  two  parts, 
a  segment  of  rubber  tubing  connecting  the  two  parts ; 
the  tube  is  partly  filled  with  mercury,  the  balance  being 
filled  with  nitrogen  (for  which  may  be  substituted  hydro- 
gen or  other  non-oxidizing  gas),  no  air  being  in  contact 
with  the  surface  of  the  mercury ;  into  each  end  of  the 
tube  is  soldered  a  platinum  wire ;  and  pressure  on  the 
rubber  segment  of  the  apparatus  causes  the  column  of 
mercury  to  come  into  contact  with  the  wire  at  one  end 
of  the  tube,  thus  completing  the  circuit ;  on  relaxation 
of  the  pressure  on  the  rubber  tube  the  mercury  falls  of  its 
own  weight  away  from  the  wire,  thus  breaking  the  circuit 

Anaeithesia  by  Cerebral  Pressure. — Dr.  G.  T.  Kemp, 
of  Johns  Hopkins  University,  read  a  paper  on  this  sub- 
ject. Of  the  various  methods  for  producing  pressure, 
e.g.,  injections  into  the  subdural  space,  direct  pressure 
after  trephining  with  blunt  instruments,  the  air-bag,  etc., 
he  used  a  thin  rubber  bag  inserted  through  a  cannula, 
which  is  put  into  a  trephine  hole,  and  distended  this  with 
salt  solution. 


His  object  was  to  find  if  the  production  of  anaesthesia 
was  practical  and  practicable,  especially  when  anaesthesia 
by  other  means  was  contra-indicated,  as  in  long-con- 
tinued laboratory  experiments  on  animals,  or  where  it 
was  desirable  to  avoid,  in  any  particular  experiment,  the 
effects,  other  than  anaesthesia,  produced  by  the  drugs 
ordinarily  used  for  that  purpose. 

He  used  chloroform  for  the  primary  operation  of  tre- 
phining and  applying  the  pressure  apparatus,  then  allow- 
ing the  effects  of  the  chloroform  to  pass  off,  noted  the 
effects  of  the  cerebral  pressure.  The  effects  of  slight 
pressure  were  pain  and  stimulation,  especially  of  the 
medullary  centres. 

Ail  these  centres  were  stimulated  early,  and  this  was 
followed  by  exhaustion,  and  later  still  by  paralysis.  The 
vagus  centres  responded  first,  and  respiratory  centres 
became  exhausted  first.  He  found  that  it  was  the  auto- 
'  maticity  of  the  centres  that  was  exhausted,  and  not  the 
centres  themselves ;  as  after  the  suspension  of  their  auto- 
matic action  they  still  responded  promptly  and  vigorously 
to  any  direct  stimulation.  He  found  that  he  could  not 
use  pressure  enough  to  cause  complete  anaesthesia  with- 
out doing  some  damage  to  the  medullary  centres,  this 
fact  being  probably  due  to  the  anaemia  of  the  medulla 
caused  by  the  pressure. 

He  concluded,  however,  that  for  many  experiments  it 
was  a  means  of  causing  anaesthesia  that  was  of  great  prac- 
tical value  for  laboratory  work. 

He  exhibited  a  number  of  beautiful  tracings  showing 
the  results  in  several  experiments,  some  of  them  of  sev- 
eral hours'  duration,  with  the  curves  of  the  respiration, 
blood  pressure,  and  the  artificial  cerebral  pressure. 

Respiratory  Paths  in  the  Cord. — Dr.  W.  T.  Porter 
presented  a  paper  with  this  title.  He  noted  Rosenthal's 
work  on  the  automatism  of  the  respiratory  centre,  and 
the  fact  that  the  exact  location  of  the  centre  had  not  yet 
been  determined.  He  showed,  however,  by  the  fact 
that,  although  some  irregular  movements  of  the  dia- 
phragm take  place  after  separation  of  the  cord  from  the 
medulla,  no  full,  regular,  respiratory  movements  occur, 
that  there  is  no  automatism  in  the  cord  so  far  as  respira- 
tion is  concerned. 

He  then  detailed  many  experiments  made  to  trace  the 
path  or  paths  of  respiratory  impulses  from  the  centre 
through  the  cord. 

His  first  experiment  was  to  make  a  hemi-section  of  the 
cord  on  one  side  at  the  level  of  the  second  cervical  verte- 
bra ;  then  a  hemi-section  on  the  other  side  at  the  level 
of  the  point  of  the  calamus  scriptorius,  of  all  excepting 
a  very  small  portion  of  the  outer  part  of  the  lateral  tract. 

Breathing  stopped  at  once,  but  after  a  few  minutes  of 
artificial  respiration  the  breathing  began  again  and  con- 
tinued. 

Later  the  remainder  of  the  lateral  tract  was  cut,  and 
then  breathing  stopped  again  and  could  not  be  restored 
by  artificial  respiration,  showing  that  the  respiratory  im- 
pulses descend  in  the  lateral  tracts,  and  that  they  do  not 
cross  between  the  two  points  above  mentioned,  at  which 
the  sections  were  made. 

Dr.  Porter  detailed  many  more  experiments  similarly 
carefully  made ;  and  as  to  the  place  of  crossing,  sug- 
gested in  general  three  possible  solutions,  viz.,  the 
crossing  occurs  between  the  bulb  and  the  phrenic  centre, 
or  at  the  level  of  the  phrenic  centre,  or  by  no  definite 
path,  but  diffusely,  anywhere. 

From  his  experiments,  which  were  too  great  in  num- 
ber to  give  in  detail,  he  deduced  the  conclusion  that  the 
respiratory  impulses  pass  down  the  cord  through  the 
outer  part  of  the  lateral  tracts ;  that  they  can  and  do 
cross  on  their  way  down  without  dyspnoea ;  that  they  do 
not  cross  diffusely  in  any  and  all  parts  of  the  cord ;  that 
they  do  not  cross  between  the  level  of  the  bulb  and  that 
of  the  phrenic  nuclei ;  that  they  do  cross  at  or  about  the 
level  of  the  phrenic  nuclei,  viz.,  in  the  region  of  the 
fourth  cervical  vertebra. 

He  further  suggests  the  following  interesting  hypothe- 
sis :  That  the  fibres  descending  in  the  lateral  tracts  and 


58 


MEDICAL   RECORD. 


[July  14,  1894 


transmitting  the  respiratory  impulses  end  at  the  level  of 
the  phrenic  nuclei  in  arborizations;  that  each  phrenic 
motor  cell  has  two  sets,  or  two  sorts,  of  branches,  the 
axis  cylinder  and  the  protoplasmic  or  dendritic  pro- 
cesses ;  that  the  latter  have  two  distributions,  some,  the 
greater  part,  end  on  the  same  side,  the  others  cross  to  the 
other  side  of  the  cord,  and  both  come  into  contact  with 
the  end  arborizations  of  the  fibres  from  the  respiratory 
centres.  Thus  the  end  arborizations  of  each  respiratory 
fibre  are  in  contact  with  phrenic  cells  of  both  sides. 
That  ordinarily  the  impulses  will  follow  the  path  where 
there  are  the  greater  number  of  processes  or  dendrites ; 
but  that  if  this  part  be  disturbed  or  obstructed  or  cut  off, 
they  then  can  take  the  other  one;  crossing  to  the  other  side 
of  the  cord  and  following  down  the  phrenic  of  that  side. 

Dr.  Porter  claims  that  the  only  point  of  this  hypo- 
thesis which  does  not  rest  upon  established  anatomical, 
histological,  and  physiological  facts,  is  the  relation  of 
transmission  to  the  number  of  dendrites. 

Action  of  Strychnine  on  the  Cord — Dr.  A.  R.  Cushing 
read  a  paper  with  the  title  "  Some  Facts  Bearing  on  the 
Action  of  Strychnine  on  the  Spinal  Cord." 

He  claimed  that  there  is  a  coincident  paralysis  and 
stimulation  of  strychnine- poisoning. 

His  method  of  procedure  was  to  expose'  only  a  part  of 
the  cord  to  the  action  of  strychnine  at  a  time. 

He  first  applied  strychnine  about  the  branches  of  the 
brachial  plexus.  The  usual  tetanic  condition  resulted  ; 
but  he  found  that,  although  if  the  upper  extremities  or 
upper  part  of  the  body  were  touched  fthe  usual  tetanic 
spasm  followed ;  if  only  the  lower  limbs  were  irritated 
there  was  no  response  at  all,  or  only  a  feeble  one. 

After  a  few  minutes  he  could  obtain  the  full  results 
from  touching  the  lower  limbs,  owing  to  the  fact  that  the 
strychnine  had  spread  down  the  cord.  When  the  reverse 
experiment  was  tried,  i.e.,  the  lower  part  of  cord  exposed 
to  strychnine,  the  upper  part  being  protected,  the  results 
were  similar;  i.e.,  a  full  response  from  irritation  of  lower 
extremities  and  none  from  the  upper,  until  after  some 
time  had  elapsed,  and  the  strychnine  had  diffused 
through  the  whole  cord.  He  concluded  that  in  order  to 
produce  strychnine  tetanus  it  was  not  necessary  to  apply 
strychnine  to  the  motor  cell  itself  ;  that  strychnine  acts 
chiefly  upon  sensory  cells ;  and  that  the  chief  resistance 
to  strychnine  lies  in  the  sensory  cells. 

The  Society  then  adjourned,  to  meet  in  Baltimore  in 
December  of  this  year. 


AMERICAN  LARYNGOLOGTCAL  ASSOCIATION. 

Sixteenth  Annual  Meeting,  held  in  Washington,  D.  C, 
May  jo,  31,  and  June  1,  1894. 

(Continued  from  page  a*.) 

Second  Day,  Thursday,  May  31ST. 

Results  of  Cutting  Operations  in  the  Nasal  Septum 
was  the  first  paper  of  the  session.  Dr.  Thomas  R. 
French,  of  Brooklyn,  directed  especial  attention  to  per- 
foration oi  the  septum  and  membranous  adhesions  occur- 
ring as  a  result  of  operations  on  the  nasal  septum. 

In  reperforation  he  said  that  as  the  methods  generally 
employed  to  correct  deviation  of  the  septum  were  not  al- 
ways successful,  he  wished  to  present  for  discussion  a 
question  which  had  often  arisen  in  his  mind,  viz. :  If  a 
successful  result  cannot  be  obtained  in  any  other  way, 
are  there  not  conditions  under  which  perforation  of  the 
cartilaginous  septum  can  be  made  a  perfectly  justifiable 
.  procedure  ? 

From  his  study  of  the  result  of  perforation  made  by 
others,  and  from  his  own  and  other  experiences  with 
perforations  with  unhealed  edges,  he  expresses  his  belief 
that,  with  proper  care  in  the  after-treatment,  perforation 
can  be  deliberately  made  without  injury  and  with  great 
relief  in  a  certain  class  of  cases ;  that  if  the  breath-way 
through  the  obstructed  side  cannot  be  obtained  without 
leaving  a  hole  in  the  septum,  such  a  procedure  is  justifi- 
able if  the  patient  can  be  impressed  with  the  necessity  of 


leaving  the  parts  alone,  and  it  is  reasonably  certain  that 
the  case  can  be  carefully  followed  until  healing  of  the 
edges  has  occurred ;  otherwise  it  is  an  unjustifiable  method 
of  operating. 

He,  however,  excepts  from  that  statement  the  perfora- 
tions made  near  the  entrance  of  the  nostrils,  particularly 
in  a  septum  bent  obliquely  across  both  openings,  by  the 
Blandin  punch. 

In  re  membranous  adhesions,  after  reviewing  the  recog- 
nized causes  of  this  annoying  sequel  of  operations  within 
the  nasal  passages,  the  author  called  attention  to  a  cause, 
heretofore  overlooked,  viz.,  that  cut  surfaces  on  the  sep- 
tum will  become  adherent  to  scar-tissue  on  the  turbinates 
made  by  the  gal  vano- cautery  at  some  previous  time. 
Therefore,  in  patients  who  present  for  treatment  whose 
nares  have  never  been  subjected  to  operative  procedures, 
and  in  whom  there  is  need  of  the  destruction  of  turbi- 
nated tissue  and  removal  of  obstructing  cartilage  or  bone, 
the  septum  should  be  operated  upon  first,  when,  after  a 
month  or  more  has  elapsed,  and  it  is  certain  that  the 
mucous  membrane  is  completely  reformed,  the  turbinates 
can  be  safely  destroyed  by  any  method.  When,  how- 
ever, patients  object  to  a  cutting  operation  on  the  sep- 
tum, but  are  willing  to  submit  to  the  destruction  or  re- 
moval of  turbinated  hypertrophy,  preference  should  be 
given  to  the  use  of  the  snare  or  acids  in  order  to  avoid 
the  possibility  of  leaving  a  surface  which  might  become 
adherent  to  a  wound  opposite  in  the  event  of  a  cutting 
operation  on  the  septum  being  performed  later. 

Without  doubt  adhesions  are  frequently  occasioned  by 
saws  with  unprotected  ends,  and  the  unskilful  use  of  . 
trephines  and  cutting  forceps  in  narrow  passages.  A  dis- 
tinct advance  will  be  made  when  all  instruments  used  for 
septal  operations  are  constructed  with  a  view  to  prevent- 
ing the  possibility  of  wounding  the  outer  wall  of  the  nose. 

It  is  a  good  rule,  in  operating  with  the  saw,  to  begin 
the  section  by  cutting  upward,  and  finish  it  by  cutting 
downward.  But  whether  it  is  begun  from  above  or  below, 
the  section  should  be  finished  by  a  cut  from  the  opposite 
direction ;  for  in  this  way  the  maximum  amount  of  tissue 
can  be  removed  from  the  septum  with  the  least  danger  of 
injury  being  done  to  the  outer  wall. 

Dr.  J.  H.  Bosworth,  of  New  York,  said  that  he  had 
been  credited  with  having  said  that  he  had  only  had  one 
perforation  of  the  septum  from  the  use  of  the  saw. 
What  he  did  say,  however,  was  that,  up  to  the  completion 
of  his  first  169  cases  he  had  had  only  one  perforation,  but 
had  had  many  since.  A  perforation  in  the  antero  poste- 
rior direction  is  practically  harmless ;  but  if  it  is  so  shaped 
that  it  presents  a  projecting  edge  or  angle  to  the  current 
of  air,  it  is  harmful. 

Dr.  John  O.  Roe,  of  Rochester,  did  not  believe  that 
with  perforations  in  adults  there  was  danger  of  a  falling 
in  of  the  nose,  but  there  is  a  real  danger  thereof  in  chil- 
dren. Perforation  from  operation  is  bad  surgery.  We 
cut  through  what  we  should  cut  away.  He  believed  that 
the  septal  forceps  devised  by  him  would  prevent  this  ac- 
cident, as,  by  means  of  a  screw  in  its  handle  limiting  the 
approximation  of  the  blades,  this  was  prevented.  The  in- 
tact mucous  membrane  on  the  non-diseased  side  acts  as  a 
splint  to  help  support  the  septal  fragments  till  healing 
occurs. 

Dr.  William  H.  Daly,  of  Pittsburg,  said  that  perfora- 
tion should  be  mentioned  only  to  be  condemned.  These 
cases  don't  stay  cured.  Many  minor  factors  may  con- 
duce to  septal  deviation,  such  as  lying  on  one  side,  the  use 
of  the  handkerchief,  etc.  He  had  had  poor  results  from 
Roberts's  "pin  operation." 

Dr.  C.  M.  Shields  thought  that  the  thickening  found 
in  these  cases  was  nature's  protection  against  further 
bending.  Removal  relieves  the  symptoms,  but  nature 
reproduces  the  deformity.  He  prefers  the  knife  as  the 
puret  communites.  He  makes  parallel  antero  posterior 
incisions  above  the  line  of  deflection  and  joins  them  by  a 
perpendicular  cut  over  the  salient  angle.  He  has  seen 
perforation  result  therefrom. 

Dr.  W.  E.  Casselberry,  of  Chicago,  would  object  to 


July  14,  1894] 


MEDICAL  RECORD 


59 


perforation  on  aesthetic  grounds.  We  need  not  worry 
where  the  condition  results  from  accident.  He  could  not 
accept  Dr.  French's  view,  that  adhesions  result  only  where 
there  is  a  solution  of  continuity  on  both  of  the  oppos- 
ing surfaces.  Naso  pharyngeal  tumors  often  form  adhe- 
sions from  mere  pressure  on  surrounding  surfaces.  Fur- 
thermore, as  to  hemorrhage  from  the  septum :  it  does  come 
at  times  from  the  cut  surfaces,  and  not  from  injuries  to 
the  turbinated  bones. 

Dr.  M.  J.  Asch  alluded  to  the  operation  devised  by 
him  and  presented  to  the  association  a  few  years  ago. 
Few  failures  had  resulted  therefrom. 

Dr.  J.  W.  Gleitsman,  of  New  York,  said  that  the  fail- 
ure to  relieve  the  symptoms  in  many  of  these  cases  arose 
from  the  fact  that,  back  of  the  septal  deformity,  there  is 
frequently  an  enlargement  of  the  inferior  turbinates. 
The  latter  may  swell  up  in  the  air,  rarefied  by  the  septal 
obstruction. 

Dr.  S.  W.  Langmaid,  of  Boston,  asserted  that  our 
operations  ought  to  leave  the  patient  in  better  condition 
than  the  one  in  which  we  found  him.  Adhesions  have 
frequently  resulted  from  caustics,  which  produced  corro- 
sive action,  followed  by  granulation-tissue.  Operation 
should  never  be  undertaken  unless  we  can  keep  a  careful 
watch  on  the  patient  until  healing  has  occurred. 

Dr:  W.  Peyer  Porcher,  of  Charleston,  had  seen 
severe  hemorrhage  follow  the  breaking  up  of  adhesions. 
He  thought  iodoform  gauze  incomparably  the  best  ma- 
terial for  tamponing  in  these  cases. 

Dr.  M.  R.  Brown,  of  Chicago,  believed  that  bleeding 
in  septal  operations  sometimes  came  from  an  injured  tur- 
binate ;  not  always,  however,  as  the  septum  may  bleed 
furiously.  He  has  never  found  it  necessary  to  perforate 
the  septum  intentionally  but  twice,  and  did  it  far  back 
from  the  concave  to  the  convex  side. 

Early  Operation  in  the  Diseases  of  the  Antrum  of 
Highmore. — Dr.  W.  H.  Daly,  of  Pittsburg,  advocated 
an  exploratory  opening  for  purposes  of  diagnosis,  and 
had  treated  twenty-seven  cases  since  1882.  It  was  possi- 
ble to  teach  the  patients  to  irrigate  the  sinuses  by  taking 
water  into  the  mouth,  and  then,  by  a  sort  of  bucco-lingual 
compression,  force  the  fluid  through  the  opening  into  the 
antrum,  so  that  it  would  rinse  out  the  latter  and  escape 
through  the  nose.  As  the  proper  site  for  opening,  he 
advocates  a  point  just  above  the  second  bicuspid  tooth  of 
the  size  of  a  small  goose  quill.  Davidson's  syringe,  with 
a  small  tube  nozzle  of  proper  curve,  makes  the  best  irri- 
gator. Partitions  in  the  antrum  should  be  broken  down. 
A  conical  burr-head  drill  makes  the  best  perforator. 

After  operations  constitutional  symptoms  may  de- 
velop. Pain  in  these  cases  is  often  referred  to  a  point 
above  the  eye.  In  regard  to  the  site  of  operation,  he  finds 
in  many  instances  a  resiliency  of  the  antrum  wall  just  at 
this  point.  The  cheek  will  cover  the  opening,  but  not 
always  prevent  the  entrance  of  particles  of  food. 

Dr.  A.  W.  de  Roaldes,  of  New  Orleans,  said  that  he 
had  found  but  little  difficulty  in  washing  out  the  antrum 
through  the  natural  opening.  If  an  artificial  one  was 
necessary,  it  should  be  relatively  large. 

Dr.  Brown  preferred  to  make  the  opening  low  down 
between  the  roots  of  the  teeth,  and  thus  go  through  a  por- 
tion of  the  alveolus  itself.  Thereby  we  enter  the  antrum 
through  the  floor.  We  may  enlarge  the  opening,  if  nec- 
essary. We  should  remove  the  drainage-tube  early,  as  its 
prolonged  use  keeps  up  the  discharge.  Irrigation  through 
the  natural  opening  is  feasible,  but  tiresome. 

Dr.  J.  H.  Bryan,  of  Washington,  made  a  plea  for 
conservative  surgery  on  this  cavity.  A  diagnostic  open- 
ing could  be  made  through  the  middle  or  inferior  meatus, 
according  to  the  method  of  Moritz  Schmidt.  Duration 
of  the  case  depends  on  its  past  history.  For  irrigation 
only  the  mildest  solutions  should  be  used. 

Dr.  Schields  had  often  found  that  the  discharge 
would  cease  after  the  tube  was  removed.  The  opening 
will  always  close  up  when  the  patient  is  syphilitic. 

Dr.  Casselberry  believed  that  antrum  disease  rarely 
exists  alone.     Other  cavities  are  also  affected  at  the  same 


time.  These  latter  suppurate,  and  so  prolong  the  case. 
Hence,  even  drainage  of  the  maxillary  sinus  can  never 
cure  these  cases.  The  pain  above  the  eye,  mentioned  by 
Dr.  Daly,  may  come  from  coexisting  disease. 

Follicular  Odontoma  Invading  the  Antrum  of  High- 
more. — Dr.  A.  W.  de  Roaldes,  of  New  Orleans,  read  a 
paper,  entitled  "  A  Case  of  Compound  Follicular  Odon- 
toma Invading  the  Right  Antrum  of  Highmore  and  Ob- 
structing the  Corresponding  Nasal  Fossa,  with  a  New 
Apparatus  for  Administering  Anaesthetics,  especially 
Adapted  to  Operations  on  the  Mouth,  Nose,  and  Throat." 
He  said  that  cases  of  that  kind  were  so  rare,  and  our 
American  literature  so  barren  on  this  topic,  that  every 
one  deserved  to  be  made  public. 

The  condensed  history  of  the  case  is  as  follows : 

Young  Daniel  A ,  an  otherwise  healthy  boy,  aged 

nine,  was  first  seen  by  Drs.  Guice  and  Rembert,  of  Natch- 
ez, in  July,  1 89  2.  His  right  upper  jaw  presented  two  points 
of  disease — one  a  fibrous  growth  occupying  the  socket  of 
the  central  incisor  tooth,  and  the  other  a  hard  osseous 
tumor,  covering  a  considerable  portion  of  the  palatal 
bone  back  of  the  missing  canine  tooth,  extending  poste- 
riorly alongside  the  internal  plate  of  the  alveoli  to  near  the 
tuberosity  of  the  maxilla.  Both  growths  were  removed, 
but  in  the  spring  of  1893  the  osseous  tumor  had  re- 
turned! when  it  was  operated  upon  again  during  the  sum- 
mer. A  short  while  after  necrosis  of  the  bone  was  found 
at  the  seat  of  operation,  and  the  antrum  was  found  ex- 
posed. 

When  examined  by  Dr.  de  Roaldes,  a  hard  bony  tu- 
mor was  found  occupying  the  right  cheek,  depressing  the 
vault  of  the  palate,  and  encroaching  upon  the  right  nasal 
fossa,  fused  with  the  alveolar  border,  especially  at  a 
point  corresponding  with  the  missing  canine  tooth. 

A  diagnosis  of  benign  neoplasm  was  made,  probably  an 
osteoma,  but  with  a  possibility  of  an  odontoma ;  this 
recorded  point  to  be  cleared  by  previous  history,  as  to 
eruption  of  teeth,  which  history  was  unobtainable  at  the 
time.  A  radical  surgical  procedure  was  advised,  and  was 
performed  March  4,  1894,  by  a  modified  Vollet's  opera- 
tion ;  the  whole  anterior  wall  of  the  antrum  was  removed 
from  nose  to  tuberosity,  from  alveolar  border  to  orbital 
floor,  and  main  mass  of  obstructed  growth  chiselled  out 
from  place  corresponding  to  canine  fossa.  On  its  sur- 
face were  tufts  of  hard  adherent  tissue ;  a  large  number 
of  smaller  masses,  to  the  number  of  fifty  or  more,  some 
of  them  tooth  shaped,  were  gouged  out  in  all  directions. 
After  thorough  curettage,  cavity  was  packed,  parts  nicely 
sutured  and  bandaged.  Patient  made  rapid  recovery,  and 
returned  home  March  23d ;  and,  twelve  weeks  after,  cavity 
is  two- thirds  filled,  and  photographs  show  scarcely  any 
disfigurement.  Microscopical  examination,  made  by  Dr. 
Borden,  U.  S.  A.,  shows  tumor  to  consist,  as  shown  in 
micro-photograph  and  drawing  of  pathological  speci- ' 
men  presented,  of  hypertrophic  tooth  capsule,  which 
ossified  sporadically  in  places,  producing  a  number  of 
denticles  (50),  which  had  originally  probably  all  been 
bound  together  by  periosteum,  the  denticles  being  em- 
bedded in  the  fibro  -vascular  structure,  much  as  plums  are 
in  a  plum  pudding.  The  denticles  consist  entirely  of 
cementum,  and  the  origin  of  the  tumor  was  connected 
with  the  unerupted  canine  tooth.  No  dentine  or  enamel 
tissue  could  be  found  in  the  specimen.  The  case,  a  very 
interesting  one,  resembles  closely  those  of  Sims,  Bel- 
lander,  and  Mathias,  figured  in  Sutton's  work. 

The  points  of  interest  brought  out  by  the  case  reported 
by  Dr.  de  Roaldes,  and  on  which  he  insisted,  were:  1. 
The  rare  character  of  the  tumor,  which  contained,  as  far 
as  he  knows,  the  largest  number  of  denticles.  2.  Its  very 
uncommon  origin  in  an  unerupted  canine  tooth.  3.  Its 
location  in  the  upper  maxilla,  and,  as  the  above-men- 
tioned cases,  on  the  right  side.  4.  Its  coexistence  at 
one  time  with  another  fibrous  tumor  developed  in  the 
alveola  of  the  right  upper  central  incisor,  probably  itself 
a  fibrous  odontoma.  5.  The  fact  that  odontomata  have 
often  been  taken  for  exostoses,  fibroid  tumors,  etc.  6. 
The  difficulty  of  the  diagnosis,  especially  when  growth  is 


6o 


MEDICAL   RECORD. 


[July  14,  1894 


embedded  in  the  maxilla.  The  consideration  of  the 
duration  of  the  disease,  the  age  of  the  patient,  and  espe- 
cially the  absence  of  one  or  more  teeth,  will  help  to  ensure 
a  precise  diagnosis.  7.  The  propriety  of  avoiding  in 
those  cases  dangerous  operations,  as  has  been  often  done, 
in  removing  the  maxilla,  when  proper  chiselling  and 
enucleation  will  generally  suffice* 

Dr.  A.  W.  de  Roaldes  concluded  by  presenting,  in  the 
name  of  Professor  Souchon,  a  new  apparatus,  devised  by 
him  for  administering  anaesthetics,  and  which  had  been 
of  great  service  in  the  present  case. 

Cookie -Burr  in  the  Larynx. — Dr.  Charles  M. 
Shields,  of  Richmond,  reported  an  extraction  of  a 
cockle-burr  from  the  larynx.  The  patient,  a  farmer 
from  Halifax  Co.,  Va.,  had  observed  one  of  his  hogs  being 
chased  by  some  dogs.  He  rode  after  them  until  the 
bushes  prevented  farther  pursuit  on  horseback,  and,  dis- 
mounting, he  continued  the  chase  on  foot.  This  exer- 
tion made  him  breathe  rapidly  through  the  mouth,  and 
he  was  suddenly  stopped  by  feeling  that  he  had  drawn 
something  into  his  throat  that  prevented  easy  breathing. 

The  foreign  body  was  found  to  be  a  burr  lying  in  the 
glottic  space  at  its  anterior  commissure  and  just  at  the 
lower  level  of  the  cords.  Its  long  axis  was  lying  antero- 
posteriorly,  and  it  was  fastened  firmly  in  position  by  the 
closing  of  the  glottis  on  its  spurs.  It  had  been  grasped 
just  in  the  act  of  passing  through.  The  patient  had  a 
most  sensitive  throat,  and  manipulation  was  thereby  ren- 
dered more  difficult  After  being  sprayed  with  cocaine, 
Mackenzie's  and  other  forceps,  opening  laterally,  were  re- 
peatedly tried  without  success,  because  of  the  inability  of 
getting  the  blades  between  the  burr  and  the  bands  on 
either  side  to  which  it  was  so  closely  adherent.  Then  a 
wire  loop  through  a  curved  cannula  was  likewise  unsuccess- 
fully tried,  the  rapidly  contracting  vocal  bands  flattening 
the  loop.  Cotton  twisted  on  a  curved  probe,  with  the 
hope  of  engaging  the  prickles  in  its  meshes,  met  with  no 
better  success,  and  a  curved  blunt  curette  passed  below 
the  burr  failed  to  extract  it  on  being  withdrawn. 

Just  before  doing  a  tracheotomy,  which  had  now  been 
decided  on,  Schrotter  tube  forceps  were  again  tried. 
This  time,  after  pushing  them  between  the  cords  closed, 
they  were  forcibly  opened  as  the  cords  tightened  on 
them,  and,  being  drawn  forward,  the  blades  slipped 
over  the  burr,  which  was  withdrawn  entire. 

Laryngeal  Neoplasms.— Dr.  Charles  H.  Knight,  of 
New  York,  reported  three  cases  of  this  nature : 

Case  I.  Diffuse  Subglottic  Myxoma. — Partial  removal 
by  the  mouth  with  Mackenzie's  forceps.  Tracheotomy 
under  cocaine  and  radical  extirpation  of  the  growth 
through  the  wound.  Recovery  without  a  bad  symptom. 
No  recurrence. 

Case  II.  Papilloma  of  the  Larynx. — Removal  with 
Mackenzie's  and  the  Schrotter -TUrck  forceps.  Electric 
cauterization  of  the  base  of  a  growth  attached  beneath 
the  right  vocal  band.  Restoration  of  voice  within  three 
weeks,  complete  aphonia  having  existed  for  nearly  eight 
months. 

Case  III.  Multiple  Papilloma  of  the  Larynx.— Re- 
moval with  Mackenzie's  forceps.  Recurrence  and  re- 
moval in  twelve  months.  Second  recurrence  and  re- 
moval in  a  similar  way  five  years  later. 

Dr.  Arthur  O.  Bliss,  of  Philadelphia,  reported  two 
cases  of  malignant  tumors  of  the  larynx. 

Case  I.  Squamous  Epithelioma  of  the  Larynx. — Pa- 
tient, male,  aged  forty-six,  with  negative  previous  history. 
Had  been  growing  hoarse  the  past  two  years.  Had 
gradually  increasing  difficulty  in  respiration  and  en- 
larged glands.  Refused  radical  operation.  Trachea 
opened  through  two  upper  ring®.  Heart  sounds  suggest- 
ed atheroma.  Considerable  albuminuria,  but  no  casts. 
At  the  end  of  the  primary  anaesthesia  (ether)  during  the 
operation,  a  severe  glottic  spasm  resulted.  This  might 
have  been  due  to  accumulation  of  secretion.  After  op- 
eration, was  very  weak  for  a  month,  suffered  much  from 
angina  pectoris,  and  died  suddenly  from  latter  disease. 
Specimen   wa?   shown.     During  life  the  left  arytenoid 


cartilage  and  vocal  band  were  so  swollen  that  subjacent 
cord  could  not  be  seen.  The  right  cord  was  forced  into 
semi-abductor.  There  was  no  odynphagia.  Autopsy 
also  showed  chronic  nephritis,  fatty  heart  muscle,  and 
thickened  pericardium. 

Case  II.  Small  Round  Celled  Sarcoma  of  Larynx. — 
Patient,  male,  aged  fifty- three.  Symptoms  practically  as 
in  Case  I.  Pharynx  was  normal.  The  epiglottis  was  a 
fungoid  mass.  No  laryngitis  was  observed.  The  right 
arytenoid  was  swollen  and  (Edematous.  There  was 
swelling  in  the  supra  thyroid  region,  but  none  over  the 
thyroid.  High  tracheotomy  was  done,  as  the  patient 
refused  radical  operation.  Died  in  one  year  from  ex- 
haustion. Both  of  these  cases  would  have  been  favorable 
ones  for  partial  laryngectomy. 

Laryngectomy  by  a  Haw  Method. — Dr.  Henry  L. 
Swain,  of  New  Haven,  Ct ,  reported  a  case  of  laryngec- 
tomy performed  on  a  German,  aged  forty  two,  who  had 
an  epithelioma  which  had  followed  on  a  simple  fibroma 
of  the  right  vocal  cord,  the  latter  having  been  known  to 
have  existed  for  a  year  previous. 

The  epithelioma  waxed  great  and  filled  the  entire 
larynx,  so  much  so  that  tracheotomy  was  done  under  co- 
caine March  5th.  March  18th  the  larynx  was  removed 
by  Dr.  W.  H.  Carmalt  Incision  was  made  from  the 
thyroid  bone  to  sternum.  A  low  tracheal  opening  was 
made,  and  a  sponge  Trendelenburg  cannula  introduced. 
Cross-incision  made  at  top  of  wound  to  sterno-cleido 
mastoid  muscles  on  either  side.  The  .larynx  was  then 
laid  bare,  and,  bleeding  being  checked,  a  bistoury  was  in- 
serted back  of  larynx  between  it  and  trachea.  The  tra- 
chea being  liberated  by  a  cut  from  a  strong  bistoury,  the 
larynx  was  hooked  up,  and  dissection  begun  from  below 
.upward.  The  anterior  wall  of  oesophagus  was  carefully 
preserved  until  the  arytenoid  cartilages  were  reached. 
A  cross  cut  was  then  begun,  preserving  a  part  of  the  mu- 
cous membrane  of  arytenoids  and  ary-epiglottic  folds. 
The  epiglottis  was  then  cut  across,  its  larynx  freed,  re- 
moved, and  all  bleeding  checked.  The  epiglottis  was 
then  sewed  on  to  the  anterior  wall  of  oesophagus,  thus 
closing  in  the  pharyngeal  cavity  and  cutting  off  all  com- 
munication from  the  wound  in  neck.  Subsequently  the 
wound  in  neck  was  sewed  up  tight,  except  enough  of  the 
lower  part  of  median  incision  to  allow  of  taking  in  the 
upper  rings  of  the  trachea,  which  latter  were  sewed  into 
connection  with  skin  flap,  making  a  circular  opening 
turned  upward  and  forward.  The  wound  was  dressed 
with  plain  dry  dressing.  No  tube  left  in  trachea.  Pa- 
tient stood  operation  beautifully,  although  it  lasted  two 
or  three  hours. 

The  subsequent  healing  of  wound  followed  without  ad- 
venture, save  a  large  stitch  abscess  above  and  back  of 
trachea,  which  healed  in  a  few  days.  Temperature  got 
to  1010  F.  the  second  day,  and  then  went  down  to  nor- 
mal or  nearly  so  and  remained.  The  internal  wound  at 
base  of  epiglottis  was  observed  to  heal  by  first  intention 
and  patient  could  swallow  water  from  the  first,  could  take 
fluid  nourishment  at  the  end  of  a  week  and  regular  hos- 
pital diet  at  end  of  second  week.  Internal  and  external 
wounds  are  both  in  healthy  condition.  Patient  could 
make  no  audible  sounds  at  first ;  later,  hissing  consonants 
were  to  be  perceived,  and  now  the  briefest  sentences  and 
single  words  can  be  distinctly  understood  with  the  back 
turned,  so  that  lip  reading  is  eliminated.  There  is  noth 
ing  more  than  a  whisper  to  the  voice,  but  it  has  gained 
so  much  of  late  in  strength  as  to  promise  more. 

Patient's  condition  at  present  prime,  he  working  at  his 
trade  of  a  carpenter,  wearing  most  of  the  time  a  tube  in 
trachea. 

Third  Day,  Friday,  June  ist. 

Exudative  Pharyngitis. — Dr.  W.  C.  Glasgow,  of  St. 
Louis,  Mo.,  related  the  history  of  a  child,  aged  ten 
months,  large  and  robust,  who  took  cold  and  had  an 
otalgia  without  fever.  Two  days  later,  coryza  came  on  and 
the  temperature  rose  to  1040  F.,  with  morning  remissions. 


July  14,  1894] 


MEDICAL  RECORD. 


61 


Its  course  was  very  irregular,  like  the  fever  of  aseptic  proc- 
ess. Mucus  poured  from  the  nose  in  torrents,  blister- 
ing the  nostrils  and  also  the  skin  wherever  it  touched  the 
latter.  It  was  so  abundant  that  cloths  had  to  be  placed 
around  the  nose  to  take  it  up.  The  excoriations  soon 
became  covered  with  a  whitish  pellicle.  There  was  also 
the  same  secretion  from  the  fauces,  where,  on  tonsils,  uvula, 
soft  palate,  and  pharynx,  the  exudate  appeared.  There 
was  none  in  the  nose.  The  patches  were  white,  elevated, 
and  left  no  raw  surface  on  removal.  They  looked  like 
blisters  containing  solid  albumin.  The  exudation  on  the 
uvula  was  probably  due  to  mechanical  causes.  There 
was  prolonged  aphonia  and  urgent  dyspnoea  with  dys- 
phagia. Fluids  returned  through  the  nose.  The  skin 
lesions  were  like  those  on  the  membranes,  but  the  edges 
were  raised.  Adenopathies  were  wanting.  The  secre- 
tion was  intensely  alkaline.  For  treatment,  sodium 
salicylate  salve,  and  brandy  were  given  internally,  while 
locally  peroxide  of  hydrogen  was  used.  Aristol  served 
well  as  a  dressing  for  the  skin  lesions.  A  suppurative 
otitis  occurred  as  a  sequel.  The  whole  duration  of  the 
case  was  three  weeks.  The  secretion  contained  strepto- 
cocci in  large  numbers,  but  no  Loeffler  bacilli.  Dr.  Glas- 
cow  regarded  the  case  as  one  of  the  protean  forms  of  in- 
fluenza. 

Dr.  Jonathan  Wright,  of  Brooklyn,  thought  that,  as 
streptococci  were  so  very  common,  it  was  difficult  to 
prove  their  causative  relation  in  this  present  case.  He 
had  not  found  in  the  Eastern  cities  such  exudative  forms 
of  influenza  as  had  been  reported  from  the  West. 

Dr.  Glasgow  replied  that  he  had  seen  cases  from  East- 
ern cities.  He  had  found  benzoate  of  soda  most  helpful 
in  all  cases  of  solid  oedema  occurring  in  the  course  of  in- 
fluenza. 

Singer's  Nodes. — Dr.  F.  I.  Knight,  of  Boston,  spoke 
of  the  little  nodule,  as  large  as  a  millet  seed,  or  larger,  ap- 
pearing on  one  or  both  vocal  cords  at  about  the  junction 
of  the  middle  and  anterior  third,  after  strain  of  the  voice 
by  prolonged  use  or  wrong  vocal  methods. 

This  manifestation  should  be  considered  clinically  as 
a  separate  entity,  although  pathologically,  as  far  as  ex- 
aminations hitherto  made  have  shown,  the  nodule  is  of 
the  same  nature  as  those  occurring  in  the  diffuse  form,  to 
which  the  term  trachoma,  sometimes  applied  to  the  sin- 
gle nodule,  should  be  restricted. 

Whether  the  term  chorditis  tuberosa,  which  has  also  un- 
fortunately been  applied  to  the  diffuse  form  as  well  as  the 
single  nodule,  should  be  retained  for  the  latter  is  doubt- 
ful, as  often  there  is  no  general  chorditis ;  but  if  it  is,  its 
use  should  be  restricted  to  the  single  nodule. 

In  regard  to  treatment,  Dr.  Knight  said  that  in  the 
cases  he  had  met  with  up  to  this  time,  by  rest,  and  as- 
tringents  if  there  was  also  inflammation  of  the  surround- 
ing mucous  membrane,  the  voice  had  been  so  far  restored 
that  he  did  not  feel  justified  in  risking  cutting  operations ; 
but  if,  after  this  treatment,  there  should  be  in  any  case 
still  no  useful  voice  he  should  not  hesitate  to  employ  Dr. 
Rice's  guillotine  and  remove  the  protruding  portion  of 
the  growth  if  it  could  be  engaged,  hoping  that  the  re- 
mainder would  be  more  readily  absorbed. 

Dr.  Knight  said  that  he  had  been  unable  to  learn  the 
ultimate  condition  of  the  singing  voice  in  any  of  the 
cases  where  an  operation  had  been  performed,  and  hoped 
that  the  discussion  might  furnish  some  facts  in  this  re- 
gard. 

Dr.  J.  W.  Gleitsman  had  used  the  galvano-cautery 
in  these  conditions  and  had  been  well  satisfied  with  the 
result.     He  also  advocated  chromic  and  trichloracetic 


Dr.  S.  W.  Langmaid,  of  Boston,  looked  upon  the  con- 
dition as  a  circumscribed  definite  tumor.  He  had  seen 
one  case  more  posteriorly  than  those  described  by  Dr. 
Knight.  They  generally  occur  in  women  and  do  well 
unless  chorditis  ensues  The  nodule  is  not  vascular  and 
is  often  the  result  of  a  previous  chorditis.  He  had  seen 
six  or  eight  cases  in  all.  He  expressed  some  doubt  as  to 
the  causative  relation  of  a  wrong  vocal  method,  for  these 


nodules  are  seen  in  singers  who  are  able  to  satisfy  the  ar- 
tistic demands  of  a  critical  public  and  consequently  do 
sing  well.  The  voice  often  improves  sufficiently  to  serve 
for  the  dramatic  stage,  though  its  finer  singing  qualities 
may  be  permanently  lost.  Surgical  procedures  would 
not  necessarily  impair  the  voice  unless  much  injury  was 
done  to  the  edge  of  the  cord.     Curetting  might  suffice. 

Dr.  Porcher  asked  if  Dr.  Knight  thought  that  these 
nodes  ever  developed  into  papillomata ;  Dr.  Knight  re- 
sponded in  the  negative. 

Dr.  Murray  had  seen  four  cases.  One  at  Stoerck's 
clinic  was  treated  with  solid  silver  stick  and  steam  in- 
halations with  a  perfect  result.  The  node  disappeared 
entirely.  One  case  was  in  a  boy  seven  years  of  age,  also 
a  singer. 

Dr.  Wright  had  presented  the  history  of  a  case  before 
the  New  York  Academy  of  Medicine  and  asked  if  its 
members  present  believed  that  there  was  any  relation  be- 
tween the  condition  and  tuberculosis.  If  such  existed  it 
might  be  from  dyscrasia  or  direct  irritation  from  the  • 
lung  lesion. 

Dr.  Swain  had  treated  one  case  with  silver  nitrate. 
The  cord  looked  fairly  well  except  at  one  point,  but  the 
voice  had  not  improved. 

Dr.  John  N.  Mackenzie  had  cured  one  case  of  the 
tuberous  variety  with  lactic  acid  in  concentrated  solu- 
tion. 

Dr.  T.  R.  French  spoke  of  a  case  illustrating  the 
value  of  long-continued  treatment.  The  woman  had 
greatly  overused  her  voice  and  several  nodules  were  vis- 
ible. One  case  looked  as  if  the  cord  had  been  subjected 
to  violence.  He  believed  that  surgical  measures  were 
contra-indicated.  In  the  first  case  mentioned,  local 
treatment  had  been  continued  three  times  a  week  for 
over  two  years  and  a  half,  weak  astringents  being  used. 
The  voice  is  now  completely  restored,  though  she  tires 
more  easily  than  before.  The  edges  of  the  cords  look 
perfectly  straight  but  aret  a  little  thickened  on  one  side. 
He  did  not  believe  in  the  association  of  the  condition 
with  tuberculosis. 

Dr.  W.  K.  Simpson,  of  New  York,  thought  that  the 
cause  lay  rather  in  the  over-use  of  the  voice  than  in  a 
wrong  vocal  method.  The  nodules  might  come  from 
laryngitis  or  from  hemorrhage  in  the  cords,  the  bleeding 
resulting  from  over-use  and  leading  up  to  nodule  forma- 
tion. In  one  instance  a  linear  hemorrhage  on  the  under 
side  of  the  cord  came  up  into  the  middle  line  and  was 
clearly  seen  where  high  notes  were  sounded  by  the  pa- 
tient. 

Dr.  Delavan  did  not  believe  in  the  association  with 
tuberculosis.  The  existence  of  the  two  conditions  is  of 
course  possible.  Nodules  sometimes  appear  in  acute 
laryngitis,  but  the  relation  of  these  to  the  chronic  variety 
is  unknown. 

Sarcoma  of  the  Tonsil. — Dr.  A.  W.  Watson,  of 
Philadelphia,  reported  a  case  of  a  woman  aged  fifty- 
three  who  was  well  till  last  Christmas.  Had  a  severe 
sore  throat,  probably  a  quinsy,  discharging  a  little  pus 
without  relief.  Severe  pain  continued,  running  to  the 
ear.  There  was  moderate  swelling  of  the  left  tonsil  and 
of  the  anterior  faucial  pillar,  which  was  adherent.  With 
this  exception,  there  was  no  infiltration  of  surrounding 
structures.  Considerable  pain  on  swallowing  was  pres- 
ent. 

One  small  gland  was  enlarged  at  the  angle  of  the  jaw, 
and  engorged  capillaries  were  seen  at  the  surface  of  the 
tonsils.  Medicine  did  no  good.  A  deep  incision  was 
followed  by  free  bleeding,  but  revealed  no  pus.  A  piece 
of  the  tonsil  removed  for  examination  showed  the  view 
characteristic  of  round-celled  sarcoma. 

Six  weeks  later,  under  cocaine,  the  tonsil,  held  out  by 
vulsellum  forceps,  was,  along  with  its  adherent  pillar,  re- 
moved by  successive  short  strokes  with  the  galvano-cau- 
tery knife.  Three  weeks  after,  pain  in  the  ear  had  nearly 
gone  and  the  adenopathy  had  disappeared.  There  was 
no  odynphagia.  The  peculiar  features  of  the  case  were 
the  sudden  onset  and  the  presence  of  so  much  pain  and 


62 


MEDICAL   RECORD. 


[July  14,  1894 


dysphagia  in  view  of  the  lack  of  infiltration  of  surround- 
ing structures. 

Importance  of  an  Early  Diagnosis  of  Malignant  Tu- 
mors of  the  Throat. — Dr.  J.  W.  Gleitsman,  of  New 
York,  read  a  paper  with  this  title.  The  author  stated 
that  he  did  not  desire  to  ventilate  the  question  of  the 
possibility  of  an  operation,  in  cases  so  far  advanced  that 
the  decision  had  to  be  left  to  the  patient  as  to  whether 
he  would  prefer  to  slowly  die  after  a  tracheotomy,  or  to 
take  the  risk  of  a  probable  death  by  any  attempt  at  re- 
moval. 

At  the  present  time  there  are  three  methods  of  proced- 
ure which  have  resulted  in  a  certain  number  of  cures. 
The  endolaryngeal  operation  allows  of  temporary  re- 
moval, but  at  times  effects  a  lasting  cure.  If  patieifts 
only  come  under  observation  early  enough  this  method 
should  be  resorted  to  more  frequently  than  it  is.  The 
first  operation  done  in  this  way  for  epithelioma  of  the 
vocal  cords  was  done  by  Schmitzler,  in  1867,  with  no 
•recurrence  twenty  years  later.  Reference  was  made  by 
the  writer  to  several  other  similar  cases  which  are  record- 
ed in  the  recent  literature  of  laryngology. 

A  possible  relief  is  promised  by  the  method  elaborated 
by  Coley,  of  treating  these  tumors  by  inoculations  of 
erysipelas  or  of  its  toxic  products' obtained  by  the  cold 
process.1  One  of  Coley's  patients  had  sarcoma  of  the 
tonsil  which,  under  the  erysipelas  treatment,  diminished 
considerably  in  size  and  had  not  increased  after  two  years. 
Reference  was  also  made  to  the  use  of  methyl  blue  in 
cancerous  tumors.  In  these  latter,  internal  medication 
with  this  agent  has  given  better  results  than  its  local  ap- 
plication. 

Regarding  modern  surgery  the  larynx  and  pharynx  can 
be  considered  as  analogous  to  the  breast  and  uterus. 
But  conversation  with  our  leading  surgeons  elicits  the 
fact  that  by  far  too  large  a  number  of  cases  are  seen  by 
competent  men  only  when  the  patients  have  reached  a 
stage  when  an  operation  is  either  impossible  or  extremely 
hazardous.  Excepting  trauma  and  sepsis,  delay  in  oper- 
ating is  the  most  potent  factor  for  bad  results  in  surgery. 
Early  diagnosis  is  indeed  often  difficult ;  but  when  once 
made,  delay  is  both  unjustifiable  and  unpardonable.  It 
is  better  to  avoid  the  use  of  the  word  "cancer  "  in  our 
necessary  conversation  with  our  patients. 

As  to  the  operation  itself,  the  case  generally  goes  for 
this  purpose  into  the  hands  of  the  general  surgeon ;  and 
the  laryngologist,  therefore,  cannot  be  accused,  by  his 
advocacy  of  operative  measures,  of  selfish  motives.  Each 
case  must  be  decided  on  its  own  merits — as  to  whether 
we  shall  do  a  tracheotomy  only,  or  extirpate  the  larynx 
in  Mo,  or  do  a  modified  laryngectomy  after  Cohen's 
method.  Preniazek,  a  Russian  surgeon,  has  had  thirty- 
seven  cases  of  laryngo  fissure  with  the  head  hanging 
down,  and  has  had  only  two  deaths — one  from  diph- 
theria and  the  other  from  tuberculosis. 

Of  thirteen  cases  under  Dr.  Gleitsman's  own  observation 
the  pharynx  was  involved  in  six,  and  the  larynx  in  seven. 
Of  the  former  four  were  cancer  and  two  sarcoma  (ton- 
sil). Of  the  latter,  six  were  cancer  and  one  alveolar  sar 
coma.  One  case  of  pharyngeal  cancer  was  operated 
upon  three  months  ago  and  feels  well  now.  The  others 
died.  Of  the  two  tonsillar  sarcomas  one  was  inoperable, 
the  other  lived  two  years  without  recurrence  after  re- 
moval, but  died  by  suicide.  Of  the  seven  laryngeal 
cases  the  six  cancerous  patients  are  dead  and  the  sarco- 
matous case  is  living  without  known  recurrence.  Lar- 
yngo fissure,  with  removal  of  the  diseased  tissue,  was 
done  twice ;  unilateral  as  well  as  total  extirpation,  each 
twice  ;  tracheotomy  alone,  once.  Death  resulted  twice 
from  shock,  twice  from  pneumonia  (second  and  third). 
Only  one  had  a  recurrence  after  six  months,  and  died 
from  exhaustion.  One  with  total  laryngectomy  did  well 
for  several  months,  but  died  of  an  intercurrent  appendi- 
citis. 

In  the  discussion  on  the  two  preceding  papers,  Dr. 

1  See  American  Journal  of  Medical  Sciences,  May,  1893 ;  also 
Post-Graduate,  August,  1893. 


Wright  spoke  of  the  difficulty  in  making  an  early  diag- 
nosis in  such  cases,  even  with  the  aid  of  the  microscope, 
until  the  clinical  features  were  well  developed.  He  ex- 
pressed a  polite  scepticism  as  to  the  accuracy  of  Coley's 
results.  Some  people  seem  to  be  immune  against  strep- 
tococcus infection.  The  paper  was  still  further  discussed 
by  Drs.  Swain,  Simpson,  Langmaid.  and  Casselberry. 

Neurasthenic  Throats. — Dr.  W.  Peyer  Porcher,  of 
Charleston,  spoke  of  the  intimate  relations  between  the 
throat  and  the  lungs,  and  how  lesions  in  one  place  might 
excite  symptoms  in  the  other.  Among  the  most  com- 
mon symptoms  of  neurasthenic  throats  were  reflex  cough, 
aphonia,  and  a  spastic  condition  of  the  laryngeal  mus- 
cles. Many  of  these  cases  seem  to  form  the  base  of  a 
subsequent  phthisis.  Illustrative  cases  are  quoted  to  em- 
phasize the  main  points  of  the  paper. 

Carbolic  Acid  in  Cysts  of  the  Larynx.— Dr.  E. 
Fletcher  Ingals,  of  Chicago,  forwarded  a  paper  on 
this  subject.  A  case  of  cyst  of  the  larynx  occurred  in  a 
man,  forty -three  years  of  age,  who  had  experienced  some 
trouble  with  his  throat  for  about  two  years,  but  had  been 
annoyed  by  soreness  for  only  a  month,  though  there  had 
been  considerable  cough  for  the  previous  seven  months. 

When  he  first  presented  himself  there  was  hoarseness 
and  continuous  burning  pain  in  the  throat.  One  brother 
had  died  of  consumption,  but  there  was  nothing  in  the 
patient's  personal  or  hereditary  history  which  seemed  to 
account  for  his  symptoms.  His  general  health  was  good ; 
weight  normal ;  temperature  and  pulse,  normal ;  he  had 
a  deep,  loose  cough,  and  expectorated  about  half  an 
ounce  of  muco-pus  daily,  which  subsequently  appeared 
to  be  the  result  of  a  subacute  laryngo-tracheitis  and  bron- 
chitis. There  were  no  abnormal  physical  signs  over  the 
chest,  but  an  examination  of  the  larynx  revealed  a  large 
swelling  of  the  left  ventricular  band  and  aryepiglottic 
fold,  measuring  about  one  and  one-half  by  one  centimetre, 
antero  posterior  and  lateral  diameters.  The  surface  of 
this  was  uniform  and  smooth;  the  mucous  membrane 
over  it  slightly  congested,  and  the  whole  had  the  appear- 
ance of  a  solid  tumor.  After  a  preliminary  treatment 
with  resolvents,  it  was  determined  to  inject  the  tumor 
with  lactic  acid.  From  ten  to  thirty  minims  of  a  thirty 
per  cent,  solution  of  this  medicine  were  injected  deep 
into  the  growth,  three  or  four  times,  at  intervals  of  two 
or  three  days.  As  the  needle  passed  in,  it  had  the  feel- 
ing of  passing  through  four  or  five  millimetres  of  firm, 
soft  tissue  into  a  cavity.  A  laryngeal  lancet  was  subse- 
quently used,  and  a  small  amount  of  thick,  semi-trans- 
parent, grayish  fluid  escaped,  which  caused  some  dimi- 
nution in  the  size  of  the  tumor ;  the  contents,  however, 
soon  reaccumulated,  and  it  was  found  that  the  injections 
of  lactic  acid  had  no  influence  upon  the  size  of  the 
growth.  It  was  then  determined  to  use  deep  injections 
of  carbolic  acid,  which  was  employed  in  solutions  in 
glycerine  and  water  of  from  eight  to  ten  per  cent,  of  the 
acid,  from  fifteen  to  twenty  minims  being  used  at  each 
injection,  and  the  injections  repeated  once  in  from  five 
to  seven  days.  These  injections  were  repeated  eight 
times  in  all,  twenty  minims  of  the  ten  per  cent,  solution 
being  used  each  of  the  last  six  times.  At  the  end  of  this 
time  the  tumor  had  nearly  disappeared,  and  the  injec- 
tions were  discontinued  with  the  belief  that  the  cyst  had 
been  obliterated.  The  patient  was  subsequently  seen  at 
intervals  of  three  or  four  weeks  for  three  months  after  the 
last  injection,  and  there  had  been  no  return  of  the 
growth.  The  patient  felt  that  his  throat  was  perfectly 
well,  and  it  presented  the  appearance  of  a  normal  larynx. 

The  especial  points  of  interest  in  the  case  consisted  of 
the  deeply  seated  position  of  the  cyst,  and  the  impossi- 
bility of  removing  it  without  removing  a  large  part  of 
one  side  of  the  larynx.  Its  walls  were  so  thick  that 
crushing,  tearing,  or  cutting  operations  were  out  of  the 
question. 

Mycosis  of  the  Pharynx  and  Tonsils. — Dr.  Ingals 
reported  twelve  cases  of  mycosis  of  the  pharynx  and 
tonsil  in  order  to  place  the  histories  on  record.  They 
offered  nothing  specially  new,  but  illustrated  the  great 


July  14,  1894] 


MEDICAL  RECORD. 


63 


superiority  of  cauterization  with  the  galvano-cautery  over 
other  methods  of  treatment. 

Four  of  the  cases  received  practically  no  treatment. 
The  other  eight  were  treated  by  cauterizations  with  the 
galvano-cautery,  and  all  were  cured ;  in  none  has  recur- 
rence occurred  so  far  as  the  author  could  determine. 

An  analysis  showed  that  in  fifty-eight  per  cent,  the 
patient  had  for  many  years  suffered  more  or  less  from 
sore  throat,  and  in  sixty  six  per  cent,  soreness  of  the 
throat  had  been  present  from  four  to  eight  weeks  imme- 
diately preceding  the  discovery  of  the  mycosis.  Symp- 
toms of  dyspepsia  were  present  in  three  cases,  or  twenty- 
five  per  cent,  but  in  fifty  per  cent,  of  the  cases  it  was 
distinctly  stated  that  the  patient  was  in  general  good 
health. 

The  plan  followed  in  the  treatment  had  been  to  burn 
off  the  growth  and  to  pass  an  electrode,  heated  to  a 
bright  red  heat,  about  one  eighth  of  an  inch  into  the 
tissue  beneath  it.  Two  or  three  patches  were  cauterized 
at  each  sitting,  and  the  operation  was  repeated  at  inter- 
vals of  about  five  days,  according  to  the  patient's  con- 
venience, two  or  three  days  being  allowed  to  elapse 
between  the  disappearance  of  the  soreness  caused  by  one 
cauterization  and  the  repetition  of  the  operation. 

The  author  believes  that  in  some  cases  the  disease  had 
existed  for  many  years  before  it  was  discovered;  but  in 
most  of  the  patients  he  had  seen  it  had  apparently  been 
of  only  a  few  weeks'  duration.  From  his  experience  in 
two  of  the  cases  he  believed  that  the  disease  might  some- 
times disappear  under  natural  causes. 

Etiology  of  Bheumatic  Affections  Due  to  Tonsillar 
Diseases. — Dr.  H.  L.  Wagner,  of  San  Francisco,  for- 
warded a  paper  with  this  title  :  The  tonsil  has  been  justly 
termed  by  Gerhard  a  physiological  wound — an  inlet  into 
the  system  guarded  by  leucocytes,  which  we  have  learned 
of  late  protect  the  body  against  the  invasion  of  various 
micro-organisms.  If  through  inherited  or  acquired  pre- 
disposition the  energy  of  these  leucocytes  is  diminished, 
or  if  the  tonsil  in  a  diseased  state  does  not  allow  these 
corpuscles  to  migrate,  then  a  soil  may  be  given  for  infec- 
tious diseases,  such  as  diphtheria,  scarlatina,  tonsillitis, 
follicularis,  etc. 

The  sequences  which  sometimes  follow  these  diseases 
are  important  to  observe :  paralysis  of  various  parts  of 
the  body  after  diphtheria,  and  also  articular- rheumatic 
affections  following  follicular  tonsillitis.  The  results 
gained  by  clinical  studies  and  bacteriological  investiga- 
tions in  follicular  tonsillitis,  followed  by  rheumatic  affec- 
tions, are  what  I  particularly  desire  to  refer  to. 

The  question  which  presents  itself  is :  Whether  these 
rheumatic  affections  are  produced  by  the  germs  (staphy- 
lococcus albus  et  aureus,  Fraenkel's  pneumococcus,  etc.) 
migrating  from  the  tonsillar  tissues  into  other  portions  of 
the  body,  causing  rheumatism— or  whether  they  remain 
in  or  about  the  tonsils,  sending  forth  and  distributing 
their  ptomaines  or  poisonous  products  into  the  system  ? 

The  result  of  my  investigations,  which  I  will  give  you 
in  brief,  show  in  follicular  tonsillitis  a  migration  of  these 
germs,  proving  that  rheumatism  here  is  not  caused  di- 
rectly by  ptomaines. 

Clinical  observations  show  that  the  joints  which  are 
mostly  in  use  are  the  ones  generally  affected;  for  in- 
stance, the  ary-cartilages  of  the  larynx  of  singers  (5  cases), 
the  knee-joints  of  shoe  dealers — owing  to  the  constant 
kneeling  posture  (2  cases),  and  the  wrist  joint  of  violinist 
(1  case),  and  bookkeepers  (2  cases).  Referring  to  the 
two  cases  above,  where  rheumatism  of  the  knee-joint  de- 
veloped, the  bacteriological  investigation  showed  that 
the  synovial  fluid  obtained  by  tapping  of  the  joint  con- 
tained the  same  micro-organisms  as  found  in  the  diseased 
tonsil.  I  was  also  able  to  identify  the  same  germs  in  the 
urine  of  nearly  all  the  cases.  The  family  and  clinical 
history  of  all  these  patients  showed  no  signs  of  rheuma 
tism  before  the  attack  of  this  tonsillar  disease. 

Skulls  of  Cretins. — Dr.  Harrison  Allen,  of  Phila- 
delphia, gave  a  demonstration  on  the  skulls  of  cretins, 
showing  the  peculiar  characteristics  of  this  condition 


as  influencing  the  size  of  the  nasal  chambers.  The  hard 
palate  was  shortened,  the  inferior  meatus  deepened,  and  in 
one  instance  the  maxillary  sinuses  greatly  enlarged.  The 
skulls  were  from  the  Wistar  Museum,  at  Philadelphia. 
He  believed  cretinism  more  common  in  America  than  is 
generally  supposed. 

Election  of  Officers. — At  the  executive  session  follow- 
ing the  reading  of  papers,  Dr.  John  O.  Roe  was  elected 
president  for  the  coming  year.  Rochester,  N.  Y.,  was  se- 
lected as  the  place  of  meeting,  the  date  to  be  determined 
by  the  council. 


OUR  LONDON  LETTER. 

{(From  our  Special  Correspondent.) 

HOSPITAL  SUNDAY — INCORPORATED  MEDICAL  PRACTITION- 
ERS* ASSOCIATION — DEFENCE — PR  OTECTION — BUSINESS 
AFFAIRS  OF  THE  PROFESSION — SIR  B.  W.  RICHARDSON'S 
MISTAKE — COUNTER  PRACTICE — THE  ANTIS  AND  THEIR 
FADS — EXPERIMENTS  IN  HOSPITALS. 

London,  June  9, 1894. 

Hospital  Sunday  is  again  upon  us,  and  to-morrow  most 
of  the  places  of  worship  in  London  will  resound  with  ap- 
peals to  the  benevolent  on  behalf  of  the  suffering.  The 
Lancet,  always  a  warm  supporter  of  this  movement,  has 
this  year  repeated  its  plan  of  publishing  a  special  supple 
ment  in  aid  of  the  work,  and  one  hundred  and  twenty- 
five  thousand  copies  of  an  abstract  of  this  supplement 
have  been  distributed  to  the  ministers  of  the  various  con- 
gregations. This  supplement  was  first  issued  in  1886, 
and  has  been  regularly  continued  since. 

The  Practitioners'  Association  has  been  duly  registered 
as  a  company  limited  by  guarantee  under  the  Companies' 
Acts,  1 862  to  1 890.  Its  name  is  now  the  Incorporated  Med- 
ical Practitioners'  Association,  and  its  objects  apparently 
those  of  protection  societies  generally,  to  which  is  added 
the  promotion  of  various  reforms.  In  pursuit  of  these  laud- 
able  objects,  a  special  issue  of  the  Medical  Times  and  Hos- 
pital Gazette y  a  vigorous  little  two-penny  paper  which  is 
the  descendant  of  the  Students' Journal,  and  the  organ  of 
the  Association,  has  been  largely  circulated,  containing 
full  particulars  of  what  has  been  and  will  be  attempted. 
Hospital  abuses,  remuneration  of  medical  men,  the  ques- 
tion of  nurses  and  midwives,  and  some  law  proceedings 
have  occupied  much  of  the  attention  of  this  Association, 
and  there  is  no  disposition  to  burke  any  of  the  burning 
questions  that  other  bodies  seem  to  neglect.  This  Associ- 
ation seems  really  to  have  had  its  birth  in  the  House  of 
Lords  Committee  on  Hospital  Management,  and  several 
of  its  members  gave  evidence  before  that  committee  on 
the  abuses  of  out-patient  departments. 

I  do  not  know  if  the  Council  of  this  newly  incorporat- 
ed body  expect  to  rival  the  British  Medical  Association, 
but  they  certainly  promise  to  do  work  which  has  hitherto 
been  neglected.  While  they  consider  that  existing  or- 
ganizations successfully  cover  the  field  of  scientific  work 
and  progress,  they  say  they  intend  to  be  above  all  things 
practical  and  to  carry  out  schemes  of  direct  utility  to  the 
members.  The  business  affairs  of  the  profession,  are  there- . 
fore  to  be  added  to  the  great  objects  of  protection  and 
defence.  Accordingly  they  propose  to  appoint  solicitors 
to  work  for  members  at  reduced  charges  (catch  the  law- 
yers so  far  imitating  the  doctors !) ;  to  act  as  agents  in  life 
and  fire  insurance,  and  for  the  transfer  of  practices  and 
to  collect  debts.  The  profits  of  this  kind  of  business — 
which  some  will  think  incongruous — are  to  be  added  to 
the  reserve  fund.  Committees  of  arbitration  are  also  to 
be  formed,  which  may  be  useful  in  settling  disputes  and 
preventing  scandal.  A  defence  committee  would  perhaps 
prevent  some  of  the  prosecutions  that  have  too  often  been 
unjustly  brought  against  medical  men,  and  an  ethical 
committee  might  very  well  warn  practitioners  who  are 
guilty  of  unprofessional  conduct.     You  will  see  that  very 


64 


MEDICAL   RECORD. 


[July  14,  1894 


much  of  this  programme  is  the  neglected  work  of  the 
British  Medical  Association,  and  might  all  be  done  by  it. 
While  it,  however,  ignores  its  duties  and  opportunities,  it 
may  be  desirable  to  establish  another  organization.  The 
British  itself  began  in  a  small  way,  and  it  is  impossible  to 
predict  how  rapidly  the  young  rival  may  grow. 

One  thing  strikes  me  as  a  mistake :  the  little  society 
with  its  little  organ  should  have  pitched  its  subscription 
at  a  figure  in  accordance  with  its  size  and  actual  position. 
It  cannot  all  at  once  compete  with  a  huge  co  operative 
journal  society  which  has  sacrificed  so  much  professional 
honor  for  the  sake  of  a  great  advertising  connection. 

Sir  Benjamin  Ward  Richardson  has  "put  his  foot  in 
it "  with  the  general  practitioners.  He  has  actually  pro- 
posed in  his  Asclepiad  (occasionally  pronounced  as  if 
sleepy-head)  to  legalize  counter-prescribing  by  druggists. 
If  there  is  one  abuse  more  injurious  to  the  profession  and 
dangerous  to  the  public  than  all  others,  surely  it  is  this 
wide-spread  encroachment  of  men  in  a  province  for  which 
they  are  unfitted.  Bad  as  it  is  to  endure  the  competition 
of  unauthorized  and  unqualified  quacks  of  every  kind, 
what  would  the  consequence  be  of  legalizing  the  practice 
of  the  great  shop-keeping  quack?  Convert  every  dis- 
penser into  an  authorized  prescriber,  and  the  "doctor's 
shop  "  would  no  longer  be  a  phrase  to  laugh  at.  Igno 
ranee  would  prescribe  for  all  minor  ailments  a  pennyworth 
of  a  drug  or  a  shilling  nostrum  according  to  the  willing- 
ness of  the  patient  to  disburse.  This  is  certainly  a  solu- 
tion of  the  problem  of  cheap  dispensaries  and  out-patient 
abuse  which  no  reformer  has  contemplated.  I  hope  Sir 
Benjamin  will  have  the  courage  to  say  he  repents  the 
rash  proposal,  which  was  no  doubt  dropped  in  a  thought- 
less moment — an  error  often  committed  by  those  who 
suffer  from  attacks  of  cacasihes  scribendi.  This  is  by  no 
means  the  first  blunder  of  Sir  Benjamin's  on  medico* po- 
litical matters,  but  he  could  hardly  be  betrayed  into  one 
more  serious. 

Mr.  A.  Arnold,  whose  chief  distinction  is  perhaps  his 
name,  has  been  speaking  in  Piccadilly  on  vivisection,  and 
said  if  such  cruelty  to  animals  were  permissible  because 
good  results  were  obtained  we  might  sanction  the  vivi- 
section of  malefactors  and  children.  No  doubt  he  knows 
the  fallacy  of  his  own  foolish  utterance,  but  anything  is 
good  enough  for  an  audience  if  it  will  give  a  little  no- 
toriety. 

Another  cry — apparently  got  up* by  the  crazy  antis 
— is  against  experiments  on  patients  in  hospitals.  It  is 
rather  too  bad  of  these  faddists  to  attack  our  hospitals  on 
the  eve  of  the  Sunday  collection.  But  we  need  not 
wonder,  for  so  many  falsehoods  have  been  circulated  by 
the  anti  this  or  the  antithat  egotists,  and  vouched  for 
by  persons  who  ought  to  know  better,  that  the  most 
monstrous  statements  excite  no  surprise,  although  their 
repetition  by  some  cheap  newspapers  is  bringing  disgrace 
on  the  editorial  function. 


OOPHORECTOMY  vs.  OOPHORECTOMY. 

To  thb  Editor  of  the  Medical  Record. 

Sir :  I  have  noticed  of  late,  especially  among  gynecol- 
ogists, a  mispronunciation  which  violates  all  the  rules  of 
etymology,  and  is  excessively  offensive  to  the  ear  to  any- 
•one  who  remembers  the  origin  of  the  word.  The  word  I 
refer  to  is  "oophorectomy "  which  of  course,  as  your 
readers  well  know,  is  derived  from  the  Greek  word  '&6v, 
an  egg,  a  word  of  two  syllables  and  not  of  one.  It  would 
be  just  as  excusable  to  pronounce  "  zoftlogy  "  "  z55logy,M 
or  "  o61ite,"  "  oolite,"  as  to  unite  the  two  o's  in  the  pro- 
nunciation of  oophorectomy.  The  dictionaries,  as  your 
readers  will  find,  all  put  the  diaeresis  over  the  second  "  o," 
and  I  trust  that  our  gynecological  friends  will  be  willing 
to  introduce  it  into  their  pronunciation,  and  not  offend 
the  ear  and  the  taste  and  violate  the  proprieties  by  such 
mispronunciation. 

Very  truly  yours, 

'     W.  W.  Keen. 

Philadelphia,  June  28,  1894* 


pCedical  Sterna 

Contagious  Diseases  —  Weekly  Statement — Report  of 
eases  and  deaths  from  contagious  diseases  reported  to  the 
Sanitary  Bureau,  Health  Department,  for  the  week  end- 
ing Ny  7>  x*94. 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis 

Measles 

Diphtheria 

Small-pox 

Cholera 

Varicella 

Pertussis 

Erysipelas 

Leprosy 


Caws. 


Deaths. 


58 

102 

9 

3 

52 

11 

0 

2 

61 

8 

201 

47 

11 

4 

0 

0 

0 

O 

0 

0 

0 

0 

0 

0 

The  Orloff-Davidoff  Prize. — A  prize  of  10,000  rubles 
(l5,ooo)  is  offered  by  Count  Orloff-Davidoff  for  the  dis- 
covery of  a  certain  cure  or  preventive  of  cattle  plague. 
The  efficacy  of  the  remedy  is  to  be  proved  by  the  same 
standard  as  those  known  to  science  as  protective  against 
small- pox,  anthrax,  etc.  The  award  of  the  prize  is  in  the 
hands  of  the  Curator  of  the  Imperial  Institute  of  Experi- 
mental Medicine  of  St.  Petersburg,  acting  on  the  advice 
of  a  committee  of  experts  selected  for  the  purpose.  The 
competition  is  open  to  the  whole  world  with  the  excep- 
tion of  active  members  of  the  above-named  institute. 
The  description  of  the  proposed  remedy  must  be  clear 
and  complete ;  it  must  be  sent  in,  under  the  ordinary 
conditions  as  to  concealment  of  the  identity  on  the  part 
of  the  author,  on  or  before  January  1,  1897.  The  award 
of  the  prize  will  be  made  on  January  1,  1899.  If  no 
remedy  satisfies  the  committee,  a  further  competition 
will  take  place,  and  the  award  made  on  January  1,  1902. 
This  may  stimulate  the  search  for  the  desired  remedy, 
but  it  may  also  lead  to  the  suppression  of  any  such  dis- 
covery, if  made,  until  the  award  of  the  committee  is  an- 
nounced. 

Legislators  Going  to  School. — The  German  Cultus- 
Minister  has,  in  response  to  repeated  stimulation  by  a  sani- 
tarian deputy,  consented  to  organize  systematic  courses  of 
instruction  in  matters  appertaining  to  public  health  for  the 
special  benefit  of  members  of  the  German  Legislature. 
Lectures  are  to  be  given  by  the  professors  of  hygiene  of 
the  various  German  universities  on  the  principles  of  hy- 
giene. Probably,  in  the  fear  lest  the  legislators  might  not 
go  to  the  lectures,  it  has  been  arranged  that  the  lect- 
ures are  to  come  to  them,  for  they  will  be  given 
within  the  precincts  of  the  Legislative  Chamber  itself. 
The  idea  thus  put  forth  is  delightful,  and  it  ought  to  be 
Americanized  at  once.  If  we  could  only  have  in  Wash- 
ington lectures  on  economics  for  the  populists,  lectures 
on  statesmanship,  money,  and  taxation  for  Republicans 
and  Democrats,  lectures  on  verbigeration  and  morals 
for  all,  it  would  greatly  promote  the  usefulness  of  our 
law  makers,  and  give  an  enormous  impulse  to  the  activity 
of  our  educators. 

Cold  Baths  in  Whooping  cough. — Dr.  Maurice  Spring- 
er reports,  in  V  Union  M'cdicalc  of  June  2,  1894,  a  case 
of  pertussis  in  a  child  aged  one  month,  in  which  the  sole 
treatment  consisted  in  the  giving  of  cold  baths  to  which 
powdered  mustard  was  added.    The  child  recovered. 

Living  Anatomical  Charts.— The  British  War  Office 
is  considering  the  advisability  of  instructing  all  soldiers 
in  Her  Majesty's  service  in  the  principles  of  first  aid  to 
the  injured.  Some  genius  has  offered  the  startling  and 
original  suggestion  that  every  soldier  should  have  the 
leading  arteries  mapped  out  on  his  body  by  dotted  lines 
tattooed  in  India  ink,  so  that  any  of  his  companions  may 
be  able  to  arrest  dangerous  hemorrhage  should  he  chance 
to  be  wounded. 


Medical   Record 

A  IVeekly  Journal  of  Medicine  and  Surgery 


Vol.  46,  No.  3. 
Whole  No.  1237. 


New  York,  July  21,  1894. 


$5.00  Per  Annum. 
Single  Copies,  ioc. 


©rigitml  QxlitUs. 

FEEDING  AFTER  WEANING.1 
By  WM.  L.  STOWELL,  M.D., 

NEW  YORK. 

Feeding  an  infant  after  it  leaves  its  mother's  breast  in- 
volves the  whole  subject  of  dietetics.  We  have  just 
had  a  course  of  three  lectures  (Professor  Chittenden, 
Cartwright  lectures)  on  one  part  of  digestion,  yet  are  now 
to  compress  the  entire  matter  into  a  ten-minute  review. 
The  review  must  be  cursory  in  the  extreme. 

The  infant  at  birth  is  a  carnivorous  mammal,  composed 
of  nitrogenous  and  fatty  matters,  carbohydrates,  and  salts 
of  lime,  potash,  etc.  To  maintain  the  little  creature,  all 
these  substances  must  be  supplied.  The  mother's  milk 
is  an  emulsion  of  fat  containing  these  ingredients.  It  is, 
therefore,  the  perfect  food.  The  infant  has  a  simple  di- 
gestive tract  which  secretes  very  little  digestive  fluid  of 
any  kind.  The  simple  milk  is  absorbed  with  little  diffi- 
culty and  little  waste. 

With  the  passing  months,  changes  take  place,  anatom- 
ical and  physiological.  At  six  or  eight  months  teeth  ap- 
pear and  the  salivary  glands  become  active.  This  sug- 
gests the  ability  to  eat  a  little  of  the  food  of  adults,  e.g., 
starches.  From  the  eighth  to  the  twelfth  month  the  teeth 
come  more  rapidly,  the  child  becomes  very  active,  uses 
up  tissue,  and  needs  more  material  to  build  with.  Now 
is  the  time  to  wean  and  supply  additional  food.  The 
exact  time  cannot  be  set.  A  mother  who  is  not  strong, 
has  become  pregnant,  or  feels  nursing  a  tax  on  her  con- 
stitution, should  begin  weaning  at  six  or  eight  months. 
Should  the  child  not  thrive,  wean  early.  If  both  mother 
and  child  are  well,  the  physiological  changes  are  such 
that  the  baby  can  leave  the  breast  partly  at  ten  months, 
and  completely  before  a  year.  The  transition  should  be 
gradual  except  in  case  of  acute  illness  of  the  mother. 
Begin  by  giving  cows'  milk  once  or  twice  a  day,  and 
nursing  only  two  or  three  times. 

Human  milk  contains:  proteids,  1.78  per  cent. ;  fats, 
3.83;  sugar,  6.84;  salts,  0.23,  a  total  of  12.68  solids. 
(Leeds's  average  twelve  mothers.)  Cows'  milk  contains : 
proteids,  3. 76;  fats,  3.75  ;  sugar,  4.42  ;  salts,  0.68,  mak- 
ing total  solids  12.61.  (Leeds's  ordinary  bottled  milk.) 
Human  milk  then  differs  from  that  of  the  cow  in  contain- 
ing more  fat,  2.25  per  cent,  more  sugar,  less  salts,  and 
but  half  the  proteids. 

Because  of  the  excess  of  proteids,  cows'  milk  needs  to  be 
diluted  one  third  or  one  half  with  water,  depending  upon 
the  digestive  power  of  the  infant.  The  slight  acidity  of 
cows'  milk  may  be  disregarded  in  infants  of  six  months 
or  over.  Lime-water  or  soda  maybe  added  earlier.  Or- 
dinary dairy  milk  contains  from  ten  to  twelve  per  cent, 
of  cream.  When  such  milk  is  diluted  one  half,  the  fats 
are  too  low ;  extra  cream  must  be  added.  Jersey  milk 
contains  eighteen  to  twenty  per  cent,  of  cream,  and  hence 
requires  only  the  addition  of  water,  and  a  little  sugar, 
possibly.  I  have  raised  Jerseys,  and  raised  babies  on  Jer- 
sey milk,  and  heartily  approve  of  it.  It  is  not  logical  to 
declare  Jersey  milk  too  rich,  and  forthwith  give  directions 
for  adding  cream  to  ordinary  milk  until  it  is  of  Jersey 
standard.  One  dealer  served  me  with  milk  containing 
eighteen  per  cent,  of  cream,  another,  equally  well  known, 

1  Read  before  the  Section  on  Pediatrics,  New  York  Academy  of 
Medicine,  May  10,  1894. 


supplied  milk  only  seven  per  cent,  cream.  Obviously 
the  two  could  not  be  treated  alike.  Ass's  milk  is  very 
nearly  the  same  as  woman's  milk  in  composition.  '  *  Strip- 
pings  "  is  also  better  than  Ordinary  milk,  being  richer  in 
fat.     Neither  is  practicable,  so  they  need  no  discussion. 

In  warm  weather  all  milk  should  be  heated  to  1680  F., 
i.e.,  Pasteurized,  to  destroy  ferments  and  prevent  sour- 
ing. This  temperature  kills  tubercle  bacilli,  typhoid, 
or  other  germs  that  may  be  lurking  in  the  fluid.  The 
process  of  sterilizing  renders  casein  less  readily  coagu- 
lated, destroys  milk-sugar,  and  causes  proteid  matter  to 
adhere  to  fat  globules,  retarding  their  digestion.  These 
changes  are  of  no  importance  clinically,  except  in  weak 
children. 

Perfect  nutrition  demands  waste  and  removal  of  tissue, 
as  well  as  new  aliment,  i.e.,  complete  oxidation.  Sugar 
and  starch  take  up  much  oxygen,  and  if  given  in  too 
great  quantity  will  detract  from  what  should  go  to  the 
albuminoids.  It  is  the  excess  of  one  ingredient  that  so 
often  begins  the  malassimilation  that  ends  as  rickets. 
The  starches  easiest  to  prepare  and  digest  are  potato,  oat- 
meal, and  barley.  The  two  last  are  added  to  milk  as 
diluents  and  for  their  mechanical  effect  on  casein,  even 
in  infants  only  a  few  months  old.  They  have  no  food 
value,  however,  until  six  months,  when  ptyalin  is  present 
in  sufficient  quantity  to  act  on  them.  Oatmeal  prevents 
constipation  by  causing  increase  of  peristalsis,  whereas 
barley  tends  to  check  diarrhoea.  Choose  between  them 
accordingly. 

Condensed  milk  is  a  popular  substitute  for  breast  milk. 
The  weight  of  medical  authority  is  heavily  against  it. 
As  ordinarily  diluted  it  contains  less  than  half  the  albu- 
minoids and  fat  needed,  or  if  diluted  to  their  proper  pro- 
portion the  sugars  aje  doubled.  As  a  natural  result  we 
have  two  kinds  of  babies  brought  up  on  it — one  plump, 
but  without  any  staying  powers  in  case  of  illness,  the  other 
a  starving  little  skeleton.  Condensed  milk  is  only  to  be 
commended  when  travelling,  or  as  a  temporary  change 
when  other  food  disagrees. 

Lactose  forms  one  half  the  solids  of  milk.  Its  oxida- 
tion maintains  the  body  heat.  If  it  be  deficient,  the 
little  infant  wastes  and  starves.  As  the  infant  of  ten 
months  grows  stronger  and  more  hungry  give  him  stale 
bread  or  crusts  to  bite  on.  Zweibach,  and  toasted  bread 
(moistened),  or  crackers  will  also  supply  starch,  partly 
converted  into  dextrin  and  so  easy  of  digestion.  In 
baked  potatoes  the  starch  granules  are  finely  divided,  so 
they  should  be  preferred  to  boiled  potatoes.  By  the 
twelfth  month  soft  boiled  eggs  may  be  given.  In  the  egg 
we  have  fourteen  per  cent,  of  nitrogenous,  and  10.5  per 
cent,  of  fatty  matter.  An  egg  diluted  with  water  and 
sweetened  makes  a  good  substitute  for,  or  addition  to, 
milk.  Soft  boiled  it  digests  in  three  hours.  Additional 
nitrogenous  food  may  be  had  in  broths  of  beef,  mutton, 
or  chicken.  Beef-tea  to  be  of  any  value  should  be  a  cold 
infusion  of  a  pound  of  steak  to  a  pint  of  water,  not  heated 
until  just  before  serving.  Prolonged  cooking  coagulates 
the  albumin  of  meat  and  only  extracts  the  salts.  It  is 
poor  food.  Meats  contain  much  potash  and  lime,  for 
which  reason  Routh  says  children  need  much  meat  to 
build  up  their  bone  and  muscle. 

During  the  beginning  of  the  second  year  the  anterior 
molars  appear,  an  indication  that  the  child  is  ready  to 
masticate  food.  He  may  now  have  rare  roast- beef  to 
chew  and  suck  the  juice  from,  not  to  swallow.  Beef  is 
one  of  our  best  nitrogenous  foods,  containing  20  per 


66 


MEDICAL    RECORD. 


[July#2i,  1894 


cent,  nitrogen ;  next  comes  mutton,  with  18  per  cent. ; 
poultry,  with  21  per  cent.,  and  nearly  4  per  cent,  of  fat. 
Fish  is  18. 1  per  cent,  nitrogen,  and  2.9  per  cent,  fat; 
mutton  is  a  little  easier  than  beef  to  digest  but  not  so 
rich.  Graham  bread,  rice,  and  corn  bread  can  be  added 
to  the  dietary  now  that  there  are  teeth  enough  to  break 
them  up  thoroughly.  Bulky  food  stimulates  digestion 
by  causing  increased  muscular  action  of  stomach  and  flow 
of  juices.  Concentrated  foods  are  to  be  avoided  as  not 
promoting  natural  activity.  However,  liquid  foods  will 
often  check 'vomiting  without  medicine. 

A  thin  sandwich  of  stale  bread  with  scraped  beef  and 
a  glass  of  milk  is  a  good  breakfast  for  a  babe  of  two  to 
three  years  of  age.  A  dish  of  plain  meat-soup  with  baked 
potatoes,  a  boiled  vegetable,  and  bread  will  be  his  dinner 
at  noon.  By  three  o'clock  he  will  want  crackers  and 
milk.  At  six  o'clock  a  cup  of  custard,  or  bread  and  but- 
ter with  milk,  should  be  the  last  meal  of  the  day. 

Physiologists  say  that  children  absorb  three  or  four 
times  as  much  carbon  per  pound  weight  as  adults.  This 
accounts  for  their  eating  so  out  of  proportion  to  their 
weight  compared  with  their  parents. 

At  two  years  of  age,  or  thereabout,  the  child  has  his 
twenty  deciduous  teeth.  He  can  eat  all  plain  food  of  a 
proper  table,  and  thinks  he  should  have  everything  he 
sees.  He  should  not  be  allowed  even  tastes  of  unsuit- 
able articles,  only  such  food  as  is  to  form  his  diet.  All 
fried  food  is  difficult  to  digest.  Re  cooked  meats  are  im- 
proper. All  so-called  rich  food  is  interdicted,  as  the  sys- 
tem is  not  strong  enough  to  wrestle  with  foreign  sub- 
stances or  excess  of  natural  diet. 

During  the  second  year  fruit  is  admissible.  Scraped 
sweet  apples  are  enjoyed,  and  digested  in  one  hour  and  a 
half.  Baked  apples  in  milk  with  crackers  make  a  good 
supper.  Juice  of  oranges  is  good  in  the  morning. 
Bananas,  if  very  ripe  are  rich  in  sugar  and  much  liked  by 
the  little  ones.  When  green  or  unripe,  bananas  are  largely 
starch.  If  eaten  too  green  and  too  rapidly  by  too  young 
a  child  it  is  pernicious  food,  otherwise  good. 


In  arranging  a  dietary  regard  must  be  had  for  season, 
cold  or  hot  climate,  sluggish  or  active  temperament  of 
the  child,  etc.  The  exact  weight  or  exact  age  of  the 
child  is  not  a  proper  criterion.  Two  atoms  of  hydrogen 
unite  with  one  of  oxygen  to  form  a  molecule  of  water; 
but  you  cannot  be  sure  that  a  given  number  of  grains  of 
nitrogen  will  produce  a  definite  number  of  foot  pounds  oi 
force,  or  that  so  much  sugar  will  produce  so  many  heat- 
units. 

It  is  often  forgotten  that  the  child  needs  a  large 
amount  of  water,  even  if  his  diet  be  chiefly  fluid.  I  have 
therefore  included  water  rn  the  table  below,  which  I 
have  compiled  as  a  summary  of  dietetics  in  the  young. 

The  following  dietary  may  serve  as  a  basis  for  direc- 
tions to  parents  and  nurses : 

Frequency  and  Substance  of  Meals. 
8  Months,  5  Meals. 
7       A.M.  (a)  Milk. 

(*)  Milk  and  rusk. 
to.  30    "     (a)  Oatmeal  or  barley  in  milk ;  sugar  or  malt. 

(b)  Beef-tea. 
a       p.m.  (a)  Egg  in  milk,  sweetened. 

(b)  Stale  bread  and  milk. 
5.30     "    (a)  Milk  and  cracker  or  zweibach. 

\b)  Milk  and  oatmeal  or  barley. 
10        "     (a)  Milk.1     Total  milk,  ij  pint. 

I  Year  to  \\  Year* 

7.30  a.m.  {a)  Rusk  or  cracker  and  milk.     Banana. 

(b)  Soft  boiled  egg  ;   milk.     Orange, 
ii         4*     (fl)Milk;  bread  and  butter. 

{b)  Baked  potato;  milk. 
2        p.m.  (a)  Beef-tea;  light  pudding. 

(b)  Bread,  butter,  bread  in  meat  gravy  from  a  roast. 

(c)  Meat,  roast,  to  suck  on. 
5.30     ■'     [a)  Bread  and  milk.     Prune  juice. 

(b)  Cocoa;  custard. 
10  "     {a)  Milk,  if  awake.     Total  milk,  2  pints. 

Two  later  periods  in  childhood  deserve  a  moment's 
consideration. 


Table  of  Food  Values. 


Food. 


I  Nitrogen.   Tis- 

I     iiue  -  forming 

Protcids. 


Human  milk  (Leeds). 
Cows'  milk  (Leeds) . . . 


1. 78 
3-76 


Eggs  (Pavy) 14.00 


Bread  (Letheby) 

Potatoes  (Letheby) 

Beef  cooked  (Ranke),  lean. . . 
fat.... 

Turkey  (Letheby) 

Fowl 

White  fish  (Letheby) 

Apples  (Freseninus) 

Bananas,  ripe  (Corenwinder). 


8.10 


19. 
14. 


Carbon.     Fats. 

3.83 
3-75 

10.50 

I.60 

0.20 

3.60 
29.80 


Carbohydrates. 
Heat-giving. 


Sugar.       Starch. 


6.84 
4.43 


Salts.        Water.    I       Total  solids. 


How  pre-    Hours  for 
pared.  dxges- 


0.23 
0.68 


I.SO 


2.30 


Raw. 


37.00 
3.20         18.80  .     0.70         75- co 


87.32  12.68 

87.39  12.61 


74.00    1  Soft  bM'd.1 

(  HardbTd. 

\   Stale 

*.  ,Hot 

\   Baked.... 
)   Boiled  . . . 


5.10 
4.40 


72.00 
51.00 


C' 


21. CO 
l8  IO 
0.22 
4.82 


3.8o 
2.9O 

Pectine,  2.72 
Fat.        0.63 


7.85 
19.65 


Traces. 


1.20        74. co    

1. 00        78.00    

°«44  I     85.04  I  Insoluble,  2.96 

°«79  73.90     Cellulose,  0.20 


2.00 
2.00 
1 -So 
300 

3.15 
2.00 

3.15 
a. 30 

330 

3.00 

2.30 
4.00 
2.00 


Water,  Croton  (Chandler)  (grains  per  gallon)  sodium  chl.,  0.40;  sulphates  of  potash,  soda,  and  lime,  0.617 1  carbonates  of  lime  and  magnesia, 

2  74  ;  silica,  0.62  ;  organic  matter,  0.67.     Total  solids,  5.03. 


Stimulants. — The  testimony  of  physicians  is  almost 
unanimous  against  alcohol  for  children  in  health.  The 
small  percentage  of  sugar  or  oxidizable  material  in 
wines  and  beer  is  more  than  offset  by  the  injuries  to  di- 
gestion and  the  nervous  system.  All  the  wisest  men  use 
stimulants  guardedly,  even  in  infantile  disease.  Tea  and 
coffee  have  a  very  considerable  value  in  checking  tissue 
waste,  and  indirectly  supplying  nitrogenous  matter  and 
salts ;  but  these  virtues  are  entirely  counterbalanced  by 
the  ill-effects  of  tannin  and  thein ;  the  one  causing  colic, 
etc.,  the  other  making  the  child  nervous,  fretful,  and 
peevish.  Still  the  children  of  the  poor  consume  great 
quantities  of  both.  The  millionaire's  pet  and  the  labor- 
er's youngster  start  with  the  same  anatomy,  but  are 
rarely  reared  on  the  same  diet. 


At  the  sixth  or  seventh  year,  when  the  deciduous  teeth 
fall,  the  child  must  be  urged  to  chew  his  food  thoroughly. 
If  he  begins  to  attend  school  that  will  form  an  excuse  for 
bolting  meals. 

Still  later,  at  puberty,  unusually  rich  or  highly  spiced 
food  should  be  avoided  lest  it  increase  sexual  excitement 
in  the  immature. 

Bring  up  the  child  from  the  beginning  to  eat  slowly 
and  at  regular  times  as  much  as  he  wants.  The  rules  of 
time  and  quantity  will  be  on  a  sliding  scale  in  different 
families.  In  feeding  infants,  as  in  the  whole  practice  of 
medicine,  we  must  fix  the  principles,  and  prescribe  with 
common-sense  according  to  the  case  in  hand. 

38  West  Thirty-sixth  Strbbt. 

»  All  milk  Pasteurized,  if  Jersey,  or  in  warm  weather. 


July  21,  1894] 


MEDICAL    RECORD. 


67 


TYPES    AND    METHODS    OF    RESPIRATION.1 
By  J.  GARDNER  SMITH,  M.D., 

NEW  YORK. 

PHYSICAL  DIRECTOR  HARLEM  BRANCH  Y.  M.  C.  A  ;  SPFCIAL  INSTRUCTOR  IN  PHYS- 
ICAL TRAINING  PUBLIC  SCHOOLS  ;  MEMBER  COUNTY  MEDICAL  SOCIETY  ;  VICE- 
PRESIDENT  HARLEM  MEDICAL  ASSOCIATION  ;  MEMBER  A.  A.  A.  P.  E.,  ETC. 

We  are  told  by  the  best  authority  (Genesis  ii.  17)  that 
when  the  Lord  breathed  into  his  nostrils  man  became  a 
living  soul.  Ever  since  that  time  respiration  and  life  have 
been  closely  related.  In  all  forms  of  animal  life  air  seems 
a  necessary  factor.  In  man  we  know  that  through  the 
lungs  air  enters  the  blood.  Passing  through  the  nostrils, 
the  pharynx,  the  larynx,  the  trachea,  the  larger  bronchial 
tubes,  the  smaller  bronchial  tubes,  the  more  minute  air- 
passages,  and  finally  the  delicate  air-cells,  the  oxygen  of 
the  air  by  a  process  of  osmosis  passes  through  the  micro- 
scopic wall  of  these  cells  into  the  blood ;  and  carbonic- 
acid  gas  passes  from  the  blood  in  the  reverse  direction 
till  it  is  exhaled  again  through  the  nostrils.  Each  breath 
then  carries  oxygen  to  and  eliminates  carbon  dioxide  from 
the  blood. 

This  interchange  depends  upon  the  demand  by  the 
body  ;  the  extent  of  breathing  surface  within  the  lung ; 
the  elasticity  and  action  of  the  thorax  (or  chest) ;  upon 
the  nervous  mechanism  controlling  each,  and,  not  least, 
upon  the  purity  of  the  air  we  breathe.  Bodily  demands, 
of  course,  depend  upon  mental  or  physical  exertion. 
The  man  who  never  makes  much  physical  or  mental  effort 
may  live  to  a  good  old  age,  but  he  is  never  prepared  for 
an  emergency,  such  as  injury  or  disease  of  a  portion  of 
the  lung,  nor  can  he  enjoy  any  violent  effort  with  safety ; 
and  in  his  later  years  his  general  health,  if  it  has  not 
done  so  already,  will  deteriorate. 

The  extent  of  breathing  surface  within  the  lung  varies 
with  the  individual.  His  heredity,  his  early  years,  acute 
or  chronic  disease  of  the  bronchial  tubes  or  lung  sub- 
stance determine  this  condition  to  a  certain  extent.  He 
may,  however,  materially  improve  and  increase  this  func- 
tion by  judicious  respiratory  exercises  (so-called  "  pul- 
monary gymnastics").  This  practice  should  be  begun 
early,  the  earlier  the  better,  and  be  continued  throughout 
life. 

The  capacity  of  the  thorax,  too,  may  be  increased  by 
judicious  exercise  in  breathing.  The  passive  individual 
in  a  healthy  condition  at  each  inspiration  inhales  perhaps 
thirty  cubic  inches  (Kirke)  of  air.  This  is  called  "  tidal " 
air.  The  average  individual  without  special  practice  in 
breathing  or  vigorous  physical  exercise  of  some  kind  can 
inhale  a  variable  quantity  over  and  above  this,  called 
"comple  mental "  air.  Again,  this  individual  can  exhale, 
by  forced  expiration,  a  variable  quantity  over  and  above 
the  ordinary  tidal  air  called  "supplemental"  or  "re- 
serve." There  still  remains  in  the  chest  after  a  forced 
expiration  a  certain  quantity  of  "  residual "  air,  estimated 
(Kirke)  at  one  hundred  cubic  inches.  This  quantity  also 
varies  with  the  ability  of  the  individual  to  contract  all  the 
diameters  of  the  chest  In  my  statistics  of  2,000  men  of 
average  age,  about  twenty-three  years,  the  total  capacity 
of  the  chest  ("complemental,"  "tidal,"  and  "supple- 
mental" air)  was  about  two  hundred  and  fifteen  cubic 
inches,  and  this  quantity  is  about  the  same  for  2,000  men 
since  that  reckoning.  This  capacity  by  practice  was  in- 
creased by  fifteen  cubic  inches  (average)  within  one  year. 

The  interchange  of  air  within  the  lungs  and  the  chest 
capacity  depends  largely  upon  an  intelligent  understand- 
ing of  the  mechanics  of  respiration  and  persistent  practice 
of  the  methods  of  respiration.  Proper  co-ordination  of 
the  muscles  of  the  thorax  is  highly  important.  Many 
men  of  ordinary  intelligence,  and  many  more  with  "  thin 
gray  matter,"  have  no  control  of  the  chest.  Some  do 
not  even  know  how  to  inhale,  to  say  nothing  of  the  prac- 
tice of  the  various  types  of  respiration. 

There  are  three  main  types  of  respiration  in  man — 
superior  thoracic,  diaphragmatic  or  "abdominal,"  and  in- 
ferior thoracic — illustrated  by  the  following  photographs. 

1  Read  before  the  Harlem  Medical  Association,  March  7,  1894. 


Mechanically,  the  thorax  is  a  conical  box  bounded 
laterally  by  the  ribs ;  the  sternum  and  costal  cartilages 
anteriorly;  the  ribs  and  spinal  column  posteriorly ;  the 
diaphragm,  a  dome-shaped  muscle  with  a  tendinous  centre 
forming  the  base.  This  conical  box  is  capable  of  move- 
ment in  every  direction.  Muscles  raise  the  ribs  upward 
and  forward,  increasing  the  an tero- posterior  diameter; 
muscles  rotate  the  ribs  outward  and  upward  and  raise 
them  laterally  like  the  bail  of  a  pail,  inci  easing  the  lateral 
diameter ;  the  diaphragm  moves  downward,  increasing 
the  vertical  diameter. 

The  size  of  the  chest  thus  increased  the  air  within  the 
lungs  becomes  rarefied ;  the  pressure  within  the  thorax 
becomes  less,  and  immediately  the  external  air,  with  its 
continual  pressure  of  fifteen  pounds  to  the  square  inch, 
rushes  in  to  fill  this  a  tendency  to  a  vacuum."  Of  course 
it  is  highly  important  that  the  nostrils  and  other  air-pas- 
sages and  the  chest  and  abdominal  wall  be  free  from  con- 
striction or  obstruction. 

Upper  chest  or  superior  thoracic  breathing  (see  Fig.  1, 


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a  to  b)  may  be  practised  on  command  4<  inhale  "  and 
" exhale, *  or  "one,"  "two,"  and  "three,"  "four."  On 
the  first  command,  or  first  two  counts,  raise  the  upper 
chest,  upper  and  forward,  to  the  fullest  extent  (see  a  to  b). 
Do  not  raise  the  shoulders.  On  command  "  exhale,"  or 
"three,"  "four,1' the  chest  should  recede  (fee  b  to  a) ; 
keep  head  erect.  Pupils  will  grasp  the  idea  more  quickly 
and  better  by  placing  the  left  hand  on  the  upper  chest, 
inhaling  and  exhaling  through  the  nostrils.  This  may  be 
done  to  music  (count  of  sixteen).  The  photographs  show 
the  proper  movement  of  the  chest. 

Abdominal  or  diaphragmatic  breathing  (see  Fig.  2,  a 
to  b).  On  command  "  inhale  "  and  <(  exhale,"  or  "  one," 
"two,"  and  "three,"  "four,"  lower  and  raise  the  dia- 
phragm. This  action  presses  the  abdominal  organs  down- 
ward, and  thus,  on  the  first  command  of  "one,"  "two," 
the  abdomen  protrudes  (see  a  to  b).  Do  not  move  the 
chest  wall  or  bend  the  body. 


68 


MEDICAL   RECORD. 


[July  21,  1894 


To  aid  in  understanding  this  exercise,  press  upper  chest 
with  left  hand  and  place  right  palm  just  below  lower  end 
of  the  sternum.  At  every  inhalation  the  right  hand 
should  be  pushed  forward,  and  on  second  command,  or 
"  three,"  "  four,"  the  abdomen  should  recede  underneath 
the  hand. 

Practise  to  count  of  sixteen  or  more  or  to  music.  Al- 
ways breathe  through  the  nostrils. 

Lower  side  chest  or  inferior  lateral  thoracic  breathing 
(see  Figs.  3  and  4,  a  to  b).  On  command  u inhale"  and 
" exhale, "  or  "one,"  "two,"  and  "three,"  "four,"  dis- 
tend and  contract  the  lower  chest  laterally.  On  the  first 
command,  or  "one,"  "  two,"  the  ribs  are  rotated  outward 
and  raised  laterally  (see  a  to  b\  as  one  would  raise  the 
bail  of  a  pail.  Thus  the  broadest  part  of  the  chest  is  en- 
larged and  much  air  is  inhaled.  The  writer  examined  one 
man  with  this  part  of  the  chest  extraordinarily  developed, 
who  had  a  chest  capacity  of  over  four  hundred  cubic 
inches.  (The  spirometer  recorded  no  higher.)  On  count 
"  three,"  "  four,"  or  "  exhale,"  expel  the  air  by  contract- 
ing the  lower  chest.  In  this  exercise  the  upper  chest 
and  diaphragm  should  remain  passive.  The  backs  of  the 
fingers  or  point  of  index  fingers  pressing  lightly  at  about 
the  ninth  rib  will  enable  one  to  understand  this  rather 
difficult  exercise.     The  best  singers  have  almost  com- 


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plete  control  of  lower  chest  and  diaphragm  and  breathe 
but  little  with  upper  chest. 

Obstacles. — Of  course  it  is  highly  important  in  dia- 
phragmatic and  inferior  thoracic  breathing  that  there  be  no 
constriction  about  the  waist  or  lower  chest.  Many  ladies 
cannot  run  or  exercise  vigorously  mainly  because  of  such 
constriction.  Again,  some  children  find  difficulty  in  breath- 
ing with  the  mouth  closed.  In  most  of  these  cases  there 
is  some  deformity  or  disease  within  the  nostril,  which  should 
receive  surgical  attention.     Another  very  important  con- 


sideration is  pure  air.  The  air  of  a  well-ventilated  room, 
class-room,  or  gymnasium  may  be  beneficial,  but  every 
opportunity  for  practice  in  the  out-of-door  air  should  be 
improved.  Running  or  other  vigorous  exercise  stimulates 
respiration,  because  the  blood  demands  more  oxygen. 
The  individual  who  understands  how  to  use  his  chest  is 
able  to  meet  this  demand  more  readily.  In  the  indi- 
vidual with  a  large  chest  capacity,  who  understands  how 
to  breathe,  who  is  free  from  disease  of  bronchial  tubes  or 
lung-tissue  and  without  heart  disease,  shortness  of  breath 
is  seldom  seen.     Breathing  exercises  are  most  beneficial 


Figs.  3  and  4. 

when  practised  after  muscular  exertion.     They  should 
occupy  an  important  place  in  physical  training. 

The  effects  are  better  development  and  control  of  the 
thoracic  muscles  ;  more  power  in  speaking  and  singing  ; 
a  healthier  condition  of  the  lungs  ;  improved  circulation 
of  the  blood  within  the  lungs ;  more  rapid  and  efficient 
aeration  of  the  blood  ;  better  general  health. 

307  Lbnox  Avrnue. 


New  Drugs  and  New  Names. — Our  esteemed  English 
brethren  must  be  especially  keen  on  new  drugs,  and  in 
particular  on  new  names  of  a  proprietary  character.  A 
casual  glance  through  the  advertising  columns  of  The  Lan- 
cet (which  is  sometimes  considered  a  conservative  jour- 
nal) gives  one  quite  a  new  idea  of  modern  materia  medica. 
The  following  list  of  "  new  drugs  "  is  taken  from  a  single 
issue:  "nepenthe,  malakine,  virol,  pepsalia,  pumitine, 
cactina,  celerina,  antinervine,  cerebrine,  papain,  anestile, 
opiatine,  lintus  tussi,  kreochyle,  vapo-cresoline,  chiralta 
liq.  cocoatina,  izal,  bynol,  bovril  liquor  sedans. " 
These  are  not  all,  but  they  are  sufficient  to  show  the 
pharmaceutist's  fancy,  and  the  appreciation  of  it  by  the 
British  mind.  To  the  student,  and  even  the  recent  grad- 
uate of  medicine,  all  these  things  must  appear  quite  unin- 
telligible, and  he  must  feel  that  having  learned  the  materia 
medica  of  his  text- books,  he  must  begin  again  and  learn 
that  of  the  manufacturer. 


July  21,  1894] 


MEDICAL  RECORD 


69 


A  FEW  APHORISMS   RELATING  TO   OBSTET- 
RICS.1 

By  A.  C.  EWING,  M.D., 

SALT  LAK«  CITY,   UTAH. 

What  to  do,  and  what  not  to  do,  in  the  management  of 
labor — that  is  the  question. 

No  branch  of  a  physician's  practice  requires  more  self- 
poise;  and  where  so  many  complications  arise  command- 
ing our  sympathy  and  demanding  our  skill,  as  that  of  ob- 
stetrics, and  when  disease  and  death  follow  a  normal 
case  of  labor,  the  cause  can  be  traced  to  none  other  than 
to  ignorance  or  mismanagement. 

With  these  preliminary  remarks,  I  shall  advance  a  few 
aphorisms  relating  to  obstetrics. 

1.  Examine  the  urine  a  week  or  so  before  the  ex- 
pected confinement.  Albumin  need  not  cause  alarm, 
unless  present  in  large  quantity,  in  which  case  the 
woman  should  be  restricted  to  milk  diet,  given  one-tenth 
grain  sulphate  spartein  four  times  a  day,  and  bowels  kept 
open  with  cream  of  tartar;  the  object  being  of  course 
to  relieve  congestion  of  the  rt  nal  veins. 

2.  Make  no  digital  examination  without  first  cleansing 
the  hands  and  nails,  together  with  the  external  genitals, 
with  a  solution  bichloride  mercury,  1  to  2,000  and  ethe- 
real soap. 

3.  Empty  the  rectum  thoroughly  with  an  injection  of 
warm  water. 

4.  Make  as  few  examinations  as  possible  during  prog- 
ress of  labor,  and  each  time  dip  the  hand  first  in  the 
antiseptic  solution. 

5.  If  presenting  part  emerges  slowly  from  the  womb, 
do  not  allow  your  impatience  to  so  get  the  better  of  your 
judgment  as  to  induce  you  to  "assist  nature"  by  pulling 
upon  the  os.  I  am  strongly  of  the  opinion  that  about  all 
the  deep  pathological  tears,  calling  for  surgical  interfer- 
ence, found  on  the  right  and  upper  anterior  sides  of  the 
cervix,  are  caused  by  the  ringer  of  the  accoucheur. 

6  If  "  pains  "  are  sluggish,  change  the  position  of  the 
patient. 

7.  Do  not  rupture  the  "bag  of  waters"  too  soon,  as 
it,  when  intact,  favors,  I  believe,  the  posterior  rotation  of 
the  face. 

8.  Should  a  posterior  rotation  of  the  occiput  occur, 
and  nature  fail  after  a  reasonable  length  of  time  to  effect 
a  delivery,  apply  the  forceps  and  turn  the  occiput  to  the 
front,  by  rotating  either  to  the  right  or  left,  as  the  posi- 
tion of  the  babe  would  indicate.2  This  manoeuvre  of  the 
forceps  can  be  executed  without  danger  ir  care  be  exer- 
cised, turning  the  head  not  more  than  a  quarter  of  a  cir- 
cle at  a  time,  then  pausing  a  moment  for  the  shoulders 
to  follow.  After  this  is  accomplished  the  instruments 
should  be  removed  and  re-applied. 

9.  In  making  traction  on  the  child's  head  with  the  for- 
ceps, unlock  them  about  every  thirty  seconds,  else  the 
engorgement  produced  by  continued  pressure  of  the  in- 
struments might  cause  a  hematoma  of  the  brain  or 
dura. 

10.  To  prevent  a  rupture  of  the  perinaeum. 

When  the  occiput  is  emerging  from  the  vulva,  remove 
the  right  hand  from  the  forceps  and  with  it  support  the 
soft  parts,  while  with  the  left  you  continue  slight  traction 
upward  until  the  bridge  of  the  nose  reaches  the  anterior 
border  of  the  perinaeum,  when  the  instruments  are  quickly 
removed ;  now,  in  order  to  avoid  a  rupture,  especially  if 
an  expulsive  effort  is  being  made,  hold  the  head  in  statu 
quo  until  a  relaxation  takes  place ;  then,  with  the  thumb 
and  first  two  fingers  of  the  right  hand,  push  the  perinaeum 
down  and  under  the  chin,  allowing  it  to  rest  on  the  palmar 
surface  of  the  fingers.  The  next  pain  will  expel  the 
head,  which  is  grasped  by  both  hands  and  pulled  up- 
ward— delivering  the  under  shoulder  first. 

1  Read  before  the  Salt  Lake  Medical  Society,  April,  1894. 

9  E.g.f  when  in  a  right  O.  P.  Iliac  position,  turn  the  forceps  to  the 
right,  and  when  in  the  left  O.  P.  I.  position,  turn  to  the  left.  The  child 
can  be  turned,  however,  and  without  danger,  even  when  in  a  direct 
0.  P.  position. 


11.  Should  a  rupture  occur,  repair  the  injury  at  once, 
using  the  large  iron- dyed  silk. 

12.  Do  not  become  impatient  if  the  placenta  does  not 
follow  quickly,  but  wait,  say  a  half  or  even  an  hour,  be- 
fore an  attempted  forcible  delivery  is  made.  Should, 
however,  a  violent  hemorrhage  occur,  empty  the  uterus 
at  once,  by  disinfecting  the  hand,  introducing  it  into  the 
womb,  detaching  the  placenta,  and  allowing  it  .and  the 
hand  to  be  forced  out  together. 

13.  The  source  of  uterine  hemorrhage  following  labor 
arises  almost  always  from  the  open  and  now  no  longer 
useful  utero-placental  vessels.  Nature,  ninety-nine  times 
out  of  a  hundred,  prevents  hemorrhage  arising  from  this 
source  by  filling  up  these  tortuous  vessels  and  plastering 
over  their  open  mouths  with  coagulated  blood.  Therefore: 

14.  Do  not  use  Crede's  method,  and  for  two  reasons: 
first,  that  the  act  of  squeezing  out  the  placenta  dislodges 
at  the  same  time  from  the  anfractuosilies  and  vessels 
this  plastic  coagulum,  inviting  streamlets  of  blood  to  fol- 
low the  non-pressure  of  the  hand,  causing  in  all  prob- 
ability a  hemorrhage  instead  of  preventing  it.  The 
second  reason  is,  that  a  hemorrhage  following  after  this 
method  of  forcible  expulsion,  necessitating,  as  it  usually 
does,  a  constant  hand-pressure  over  the  uterus  for  half  an 
hour  or  more,  while  it  may  not  prevent  absolutely  the  re- 
formation of  nature's  cement,  would,  in  my  opinion,  cause 
paralysis  of  the  contractile  fibres  of  the  womb,  rendering 
them  incapable  of  responding  to  the  stimulus  of  ergot  or 
to  anything  else.  (When  I  see  a  woman  who  is  suffering 
from  uterine  subinvolution,  I  unhesitatingly  lay  it  to  the 
undue  paralyzing  pressure  it  has  received.) 

15.  For  these  passive  hemorrhages  where,  so  soon  as 
the  hand  is  removed  the  hemorrhage  goes  on,  I  rely  on 
one  teaspoonful  of  laudanum  rather  than  two  or  three  of 
ergot. 

16.  After  the  birth  of  the  child,  gently  knead  the  ab- 
domen with  the  finger  tips  of  the  left  hand,  using  barely 
force  enough  to  feel  the  uterus  beneath.  This  gentle 
friction  excites  uterine  contraction  far  better  than  rough 
massage,  expelling  the  placenta  almost  as  quickly,  and  is 
rarely,  if  ever,  followed  by  unpleasant  hemorrhages  or 
after  pains.  This  slight  finger- pressure  should  be  con- 
tinued a  short  time  after  the  placenta  is  expelled. 

17.  In  early  abortions,  before  atrophy  of  the  blood- 
vessels of  the  mucosa  lakes  place,  the  hemorrhage  comes 
greatly  from  this  engorged  mucous  membrane  instead  of 
entirely  from  the  placental  surface,  as  in  full  term.  To 
stop  it,  do  not  use  ergot  or  compression,  but  approximate 
the  inner  surfaces  by  removing  the  decidua  with  the 
placental  forceps  and  dull  curette.  This  is  to  be  fol- 
lowed by  a  hot  antiseptic  (preferably  carbolic  acid)  intra- 
uterine douche. 

1 8.  Have  the  vulva  kept  well  covered  with  sublimated 
cotton  to  catch  the  lochia  and  prevent  hetero-infection  ; 
and,  in  addition,  if  a  clean  and  competent  nurse  is  in  at- 
tendance, order  given,  night  and  morning,  for  five  days, 
warm  antiseptic  vaginal  douches. 

19.  Wash  the  babe's  eyes  the  moment  it  is  born;  and, 
in  dressing  the  navel,  use  borated  cotton  saturated  with 
glycerine. 

20.  Restrict  the  diet  the  first  three  days  only,  after 
which  have  the  bowels  moved  either  by  an  enema  or  the 
compound  licorice  powder.  (If  there  is  much  flatus,  use 
instead  a  full  dose  of  castor  oil  and  turpentine.) 

2 1 .  Keep  the  woman  in  bed  two  weeks  if  possible,  and 
the  first  four  days  give  a  capsule  containing  y2  gr.  eigotine 
and  2j^  grs.  quinine  morning,  noon,  and  night.  This 
tends,  I  believe,  to  prevent  fever  and  hastens  the  process 
of  involution. 

22.  If  surgery  is  your  specialty,  and  you  are  called  to 
a  case  of  confineme nt,  use  extra  precautions  in  cleansing 
the  hands  and  nails ;  in  fact,  it  would  be  wise,  if  your 
practice  in  surgery  is  extensive,  to  let  obstetrics  alone, 
for  I  care  not  how  skilful  you  may  be  (and  surgeons  as  a 
rule  are  skilful),  you  will,  sooner  or  later,  lose  from  septic 
infection  the  wife  of  some  one,  and  it  may  be,  alas  !  the 
wife  of  your  dearest  friend. 


7o 


MEDICAL    RECORD. 


[July  21,  1894 


THE    DYNAMICS    OR    POWER    OF     THE 
INTERNI.1 

By   FRANCIS   VALK,  M.D., 

PROFESSOR  OF  THE  DISEASES  OF  TUB  EYB,   NEW  YORK   I'OST  GRADUATE  SCHOOL 
AND  HOSPITAL. 

In  the  static  condition  of  the  external  muscular  apparatus 
of  the  eyes,  we  find  these  organs  directed  forward,  slightly 
downward,  about  fifteen  degrees  below  the  horizon,  and 
slightly  convergent,  so  that  the  visual  lines  are  directed 
toward  a  point  about  twelve  feet  distant  in  front  of  the 
eyes.  In  this  position  the  visual  lines  will  form  an  angle, 
whose  base  extends  from  each  centre  of  rotation  in  the 
eyes  and  whose  apex  lies  at  the  point  mentioned  above. 
This  angle  is  called  the  muscular  mesoropter ;  and  when 
the  eyes  are  fixed  in  this  position,  the  external  muscular 
apparatus  is  supposed  to  be  completely  at  rest,  with  bi- 
nocular vision. 

Starting  from  this  position  of  rest,  the  eyes  are,  by  the 
active  force  of  the  straight  muscles  of  the  eyes,  moved 
consensually,  in  different  directions,  according  to  the 
sensations  produced  on  the  retina  by  the  rays  of  light. 
It  is  this  active  power  of  the  muscles,  particularly  that  of 
the  interni  and  its  antagonist,  the  externi,  which  I  offer 
as  the  object  of  this  paper. 

In  the  examination  of  the  eyes  and  the  muscular  appa- 
ratus, by  which  we  may  endeavor  to  draw  certain  conclu- 
sions or  arrive  at  any  specific  results,  we  are  accustomed 
to  compare  the  examination  of  one  hundred  cases.  I 
have  therefore  selected  this  number,  from  the  last  cases 
on  my  note-books,  in  the  hope  that  this  examination  may 
be  of  some  service  in  the  correction  of  asthenopic  troub- 
les. For  the  past  year  or  more  I  have  been  interested 
in  the  active  power  or  dynamics  of  the  interni,  and  so 
have  tested  that  power  as  well  as  that  of  its  antagonistic 
muscle  in  this  series  of  cases,  and  I  have  been  somewhat 
surprised  at  the  result.  All  these  cases  have  been  exam- 
ined in  my  office  with,  I  think,  reasonable  care,  and  I 
feel  satisfied  the  results  are  very  nearly  accurate,  and 
will  leave  the  final  results  to  speak  for  themselves,  as  I 
am  not  prepared  to  say  just  on  what  lines  all  these  cases 
may  be  treated. 

When  we  study  the  refraction  of  the  eye,  with  all  its 
complex  apparatus,  each  part  of  which  works  so  beau- 
tifully in  conjunction  with  the  other,  and  the  complica- 
tions that  may  arise,  we  are  apt  first  to  consult  Bonders 
and  note  his  remarks.  So  as  I  turn  to  him  I  find  that 
even  before  his  work  was  published,  or  some  forty  years 
ago,  many  bold  surgeons,  at  that  time,  were  performing 
tenotomy  of  the  externi  for  the  relief  of  asthenopia,  not 
only  in  myopic  cases,  but  in  all  others.  In  many  cases 
they  must  have  been  successful,  but  in  others,  with  the 
usual  enthusiasm  of  the  profession,  it  was  carried  too  far, 
and  the  results  were  far  from  successful,  even  disastrous 
in  some  cases.  Still,  it  was  continued,  more  or  less, 
until  Donders  found  that  most  of  the  cases  of  asthenopia 
were  due  to  a  shortening  of  the  optic  axis,  or  hyper- 
metropia,  and  the  tenotomy  of  the  externi  passed  into 
"innocuous  desuetude."  Then  for  many  years  we  fol- 
lowed the  teachings  of  Danders,  and  gave  convex  glasses 
to  all  our  asthenopic  cases,  until  the  present  day,  when 
we  have  two  questions  presented  to  us.  Firstly,  that 
of  insufficiency  of  the  straight  muscles,  either  in  their 
actions  vertically  or  horizontally,  as  advocated  by  Dr. 
George  T.  Stevens.  And  secondly,  since  we  have  used 
that  excellent  instrument  of  precision,  Javal's  ophthal- 
mometer, we  find  astigmatism,  due  to  the  curvature  of 
the  anterior  surfaces  of  the  cornea,  unless  neutralized  by 
the  curvature  of  the  posterior  surface  (Tschering)  or  that 
of  the  crystalline  lens.  This  is  the  active  cause  of  all 
asthenopia,  and  must  be  corrected. 

I  propose,  at  present,  to  take  a  conservative  view  of 
both  propositions,  and  believe  we  will  find  cases  where 
relief  will  depend  on  either  condition.  Correcting  the 
last  proposition  of  astigmatism  first,  and  then,  in  case  of 

1  Paper  read  before  the  Ophthalmological  Section  of  the  Academy 
of  Medicine,  New  York  City,  November  19,  1893. 


failure,  turning  to  the  first  proposition,  where  I  believe 
we  may  find  success  for  the  relief  of  the  asthenopia. 

In  looking  over  the  literature  of  this  subject  in  our 
text-books,  I  failed  to  find  any  positive  statement  in  ref- 
erence to  the  dynamic  power  of  the  straight  muscles. 
In  Saelberg  Wells's  last  edition,  I  find  the  active  power  of 
the  interni  as  about  twenty  to  thirty  degrees,  and  that  of 
the  externi  as  six  to  eight  degrees.  In  Noyes's  work  on 
"  Diseases  of  the  Eye,"  I  find  the  best  exposition  of  this 
subject ;  but  in  his  table  of  one  hundred  cases  his  results 
seem  very  different  from  my  own  examinations.  He  re- 
ports seventy-fiVe  per  cent,  with  insufficiency  of  the  ex- 
terni, with  nearly  fifty  per  cent  emmetropic,  while  I 
have  only  two  per  cent  emmetropic.  I  cannot  consider 
a  low  degree  of  hypermetropia  as  an  emmetropic  eye. 
Dr.  Stevens  considers  that  the  active  power  of  the  mus- 
cles should  be  respectively  about  fifty  degrees  for  the  in- 
terni and  ten  degrees  for  the  externi,  or  in  the  proportion 
of  five  to  one ;  but  in  my  examinations  I  have  never  found 
them  as  high  as  Dr.  Stevens,  except  where  the  muscular 
power  has  been  exercised  by  prisms,  when  this  result  may 
be  obtained. 

From  my  own  examinations,  I  am  inclined  to  think 
that  if  the  power  of  the  interni  stand  to  that  of  the  ex- 
terni in  the  proportion  of  four  to  one,  or  even  three  to 
one,  we  will  have  no  muscular  asthenopia;  in  other 
words,  the  interni  should  be  three  or  four  times  stronger 
than  the  externi,  for  comfortable  work  at  the  reading 
distance.  This  will  give  sufficient  reserve  power  accord- 
ing to  Landult,  for  all  useful  purposes. 

In  my  examinations,  I  regret  to  say,  I  have  been  dis- 
appointed in  the  tests  for  the  dynamic  power  of  the 
muscles  of  adduction  and  abduction ;  as  with  Von 
Graefe's  vertical  diplopia  test,  Stevens's  phorometer,  and 
Maddox's  rod  test,  I  have  found  some  cases  exactly  op- 
posite to  that  of  the  prism  test.  Hence,  I  have  confined 
my  tests  to  the  simple  power  of  each  individual  muscle  to 
overcome  the  deviation  of  a  ray  of  light  from  a  candle 
placed  at  fifteen  feet,  passing  through  a  prism  with  the 
apex  placed  over  the  muscle  to  be  tested,  using  the 
test  without  a  colored  glass  placed  over  the  other  eye. 
This  method  may  have  its  faults,  but  I  think  we  should 
have  the  eyes  in  the  best  possible  conditions  to  develop 
the  full  muscular  power,  that  is,  the  power  to  fuse  the 
images  by  causing  them  to  fall  upon  the  macula  in  each 
eye. 

I  do  not  think  we  maintain  that  condition  when  we 
reduce  the  retinal  impressions  by  a  disk  of  colored 
glass  or  by  a  vertical  displacement  of  the  images,  so  that 
the  rays  may  fall  upon  a  less  sensitive  part  of  the  retina, 
and  in  both  instances  we  lessen  the  stimulation  for  a  cor- 
rect fusing  of  the  images. 

As  an  instance  of  my  preference  for  this  simple  test,  I 
find  that,  in  forty- eight  cases,  the  vertical  diplopia  test 
agreed  with  the  prism  test  in  only  twenty-nine,  and  was 
exactly  opposite  in  the  remaining  nineteen;  in  other 
words,  the  first  test  would  show  esophoria  or  homony- 
mous images,  indicating  weakness  of  the  externi,  while 
with  the  prism  test  we  would  find  that  the  dynamic 
power  of  the  externi  exceeded  that  of  the  interni,  accord- 
ing to  the  proper  proportion.  Either  one  or  the  other 
must  be  wrong,  and  I  think  we  may  depend  on  that 
which  allows  the  eyes  to  be  tested  under  the  same  condi- 
tions as  exist  when  the  eyes  are  used  at  their  daily  work. 

In  compiling  the  result  of  one  hundred  cases  of  as- 
thenopia I  have  used  the  following  tests.  Refraction, 
phorometer,  vertical  diplopia,  prism  test.  Also  record- 
ing the  treatment,  as  the  correction  of  refractive  errors  if 
present,  the  prism  ordered,  operations,  if  any,  performed, 
with  the  final  result  as  far  as  possible. 

As  regards  the  refractive  errors,  I  have  used  atropine 
in  some  doubtful  cases,  otherwise  not,  as  I  agree  with 
Roosa  that  at  the  present  time  it  is  not  necessary  to  put 
our  cases  to  the  inconvenience  of  blurred  vision,  from 
paresis  of  the  accommodation,  but  I  have  verified  my  trial 
by  glasses,  with  the  retinoscope,  the  ophthalmoscope,  and 
the  ophthalmometer  of  Javal.     I  believe,  when  these  four 


July  21,  1894] 


MEDICAL    RECORD. 


7i 


tests  agree,  we  cannot  be  very  far  from  the  exact  condi-  shall  be  coincident  with  the  rays  of  light  passing  through 

tion  of  refraction  in  our  cases.     I  place  the  examination  a  prism. 

with  retinoscopy  first,  as  I  have  found  that  the  most  re-  You  are,  no  doubt,  all  familiar  with  the  simple  test  of 

liable  and  correct  objective  test  in  reference  to  the  final  placing  the  apex  or  angle  of  the  prism  over  the  position 

results  of  the  vast  majority  of  cases.     It  gives  the  refrac-  of  the  muscle  to  be  tested,  and  increasing  the  size  of  the 

tive  condition  of  the  dioptric  apparatus,  showing  any  astig-  angle  until  the  muscle  loses  its  power  to  form  a  single 

matism  and  the  axis  very  rapidly  and  correctly.     I  use  image,  and  diplopia  results. 

the  plain  mirror  only  at  a  distance  of  forty  inches  and  Taking  this  as  our  test  and  then  as  our  standard  power, 
read  my  results,  as  shown  by  the  retinal  reflex,  without  that  the  muscular  power  of  the  interni  shall  be  to  that 
reference  to  any  so  called  shadows,  or  by  using  a  lens  of  of  the  externi  as  at  least  three  to  one  or,  better,  four  to 
one  dioptry  placed  before  the  eye.  I  may  differ  with  one — Noyes  says  six  to  one,  I  found  in  this  series  only  six- 
some  of  my  colleagues  in  this  respect,  but  I  am  satisfied  teen  cases  with  that  result.  In  the  largest  number,  I 
my  examinations  are  correct,  as  they  have  been  con-  found  the  power  of  the  muscles  equal,  or  as  one  to  one, 
firmed  by  the  examination  under  atropine.  In  many  the  total  number  being  thirty-seven  of  this  series.  The 
cases  I  have  noted  the  existence  of  an  astigmatism  of  one-  rest  of  the  cases  varied  in  the  proportionate  power  of  the 
fourth  of  a  dioptry  by  this  simple  test.  two  muscles,  in  some  the  power  of  adduction  was  too 

The  ophthalmoscopic  test  I  consider  a  very  valuable  great  as  compared  with  abduction,  and  in  otheis  exactly 
and  useful  one,  but  I  have  not  been  able  to  confirm  an  the  reverse  condition,  and  the  power  of  abduction  ex- 
astigmatism  of  less  than  one  half  dioptry,  while  in  the  ceeded  that  of  adduction.  To  place  my  results  in  tabular 
use  of  the  ophthalmometer  of  Javal  I  have  fully  published  form  I  found. 

my  result,  but  I  now  depend  more  upon  the  approxima-  Taking  the  power  of  the  externi  as   one,  then  we 

tion  of  the  mires  and  the  size  of  the  image,  reading  off  have :  one  to  one,  37 ;  to  one  and  a  half,  5 ;  to  two,  20  ; 

the  radius  and  the  degree  of  the  astigmatism  in  dioptries,  to  three,  12 ;  to  four,  4 ;  to  five,  4;  to  twelve,  1  ;  to 

on  the  arc,  than  I  do  upon  the  overlapping  of  the  image  fifteen,  1;  and  to  fifty,  1.     In  all  of  these  the  interni 

of  the  mires.     I  find  these  markings  much  more  correct,  exceeded  the  externi,  except  the  first  thirty-seven  cases, 

while  in  most  cases  it  is  not  necessary  to  allow  the  usual  Now  taking  the  power  of  the  interni  as  one,  and  we 

one-half  dioptry.     It  is  also  difficult  at  times  to  tell  the  have :  one  to  one  and  a  half,  3,  and  one  to  three,  1,  while 

exact  overlapping,  but  we  can  readily  see  when  the  edges  in  three  cases  there  was  a  very  decided  difference  in  each 

of  the  mires  touch  in  the  primary  and  secondary  posi-  eye.     Of  the  entire  number  only  sixteen  were  within  the 

tions.     My  rule  is,  in  all  refraction  cases,  that  these  ob-  standard  limits ;  showing  that  in  a  vast  majority  of  my 

jective  examinations  shall  agree,  and  I  expect  to  find  the  asthenopic  cases  there  was  an  insufficiency  of  the  interni. 

same  result  in  the  trial  by  glasses.  "  Noyes  on  Diseases  of  the  Eye,"  p.  195,  says :  "  In  this 

In  all  these  cases  as  tabled,  the  refraction  was  correct-  proving,  great  diversities  will  appear  according  to  the 

ed  by  glasses  first,  and  a  fair  trial  given ;  and  I  believe,  condition  of  refraction,  especially  will  weakness  of  adduc- 

in  a  large  majority,  they  were  relieved  of  their  asthenopia,  tion  appear,  with  myopia.     On  the  other  hand,  defective 

even  though  the  active  power  of  the  interni  was  found  abduction  will  more  frequently  be  found  in  emmetropia 

far  below  that  of  the  normal  standard ;  but  if  they  were  and  hyperopia  and  astigmatism. ' ' 

not  relieved,  then  I  felt  that  I  must  seek  some  other  I  was  surprised  at  the  above  result,  as  I  expected  it 

cause  for  their  asthenopia,  and  endeavored  to  correct  what-  would  be  similar  to  Noyes' s    examinations;   yet  they 

ever  muscular  insufficiency  I  could  find,  relying  in  all  seem  to  be  just  the  opposite.     We  have  only  forty-nine 

cases  on  the  simple  prism  test.  in  which  the  power  of  adduction  exceeded  that  of  abduc- 

The  refractive  conditions  of  this  series  of  cases  also  tion ;  but  in  only  one  half  of  these  cases  did  it  reach  any- 

seem  to  present  some  features  of  peculiar  interest,  as  they  where  near  this  normal  standard,  as  I  have  suggested ;  and 

do  not  agree  with  any  tables  I  have  noted.     Taking  the  when  it  was  near  this  normal,  then  I  find  that  in  all  my 

cases  in  their  sequence  of  frequency  I  find :  cases  they  were  relieved  by  glasses. 

c.     .  .                ...         .      «                            Case8,  In  four  cases  I  found  the  power  of  the  one  eye  differ- 

£  S^TK^^  -t  from  that  of  the  other,  b£h  the  interni  and  the  ex- 

3.  Compound  myopic  astigmatism,  axis  1800 8  term  being  different  m  their  proportions  to  each  other ; 

4.  Hypermctropia 5  also  in  three  cases  there  existed  a  constant  diplopia, 

5.  Simple  myopic  astigmatism,  axis  1800 4  two  showing  esophoria,  or  weakness  of  the  externi,  of  50 

7.  SrJTsrs-^is::::::::::::::::::::::::::::  J  and v*>-  respectively;  with  one  case  *  exophona,  or 

S.  Simple  hyperopic  astigmatism,  axis  1800 2  weakness  of  the  interni  Of  15   . 

9.  Emmetropia 2  My  treatment  of  this  series  of  cases  has  been  as  fol- 
ia One  eye,  Ah. ,  the  other  Amh 1  lows :  In  all,  the  refraction  was  first  corrected  by  glasses. 

11.  One  eye,  Ah.,_axis  900,  the  other  Ah.  1800 : ........  •  "  When  this  did  not  prove  satisfactory,  I  then  examined 

12.  One  eye,  II.  w.  Ah.,  axis  90  ,  the  other  same,  axis  180  ....   1  .•      „_A_  ^r  lua  M.*\m„  „„  j  :«  ^;«u*-^«  MMM.    **»  _~A*u. 

13.  Compound  myopic  astigmatism 1  the  P°wer  of  the  muscles,  and  in  eighteen  cases,  or  nearly 

14.  One  eye,  Ah.f  axis  900,  the  other  M.  w.  Am.,  axis  900 1  twenty  per  cent.,  ordered  pnsms  combined  with  the  cor- 

»  .  ,  recting  glasses.     In  four  cases  the  interni  was  exercised 

Total IOO  ,              9  °       A,                                              1           »^i_          f    r    r 

by  prisms  three  times  a  week,  with  relief  for  various 

In  most  tables  of  refraction  we  are  accustomed  to  note  periods.     In  two,  partial  tenotomy  was  advised  and  re- 

hypermetropia  as  the  prevailing  condition ; x  but  now,  fused.     In  the  three  cases  with  constant  diplopia,  I  did 

with  the  improved  methods  of  examination  and  perhaps  a  complete  tenotomy ;  and  in  six  cases  I  did  a  partial 

increased  proficiency,  I    find    that  the  largest  number  tenotomy,  with  relief  and  decided  improvement  in  the 

have  simple  hyperopic  astigmatism,  and  the  next  largest  power  of  the  muscles  to  overcome  the  prism  test;  so  that 

the  same    condition,   associated    with    hypermetropia,  in  one-fourth  I  thought  it  advisable  to  correct  the  insuffi- 

these  two  classes  forming  more  than  sixty  per  cent,  of  ciency  as  I  found  it,  before  I  could  get  relief  from  their 

the  entire  number,  and  evidently  the  prime  factor  in  the  asthenopic  symptoms. 

causation  of  asthenopia.  My  indications  for  the  extent  of  my  tenotomies  has 
Passing  now  to  the  test  which  forms  the  object  of  this  been  as  follows  :  If  I  find  there  is  a  constant  diplopia, 
paper,  I  noticed,  in  many  of  my  cases,  examined  in  tjje  with  a  deviation  of  the  visual  lines  of  ten  to  fifteen  de- 
past  year,  that  the  tests  before  mentioned  for  insufficiency  grees  or  more,  I  find  the  muscle  I  decide  to  cut,  with 
did  not  give  satisfactory  results,  so  that  I  have  been  com-  as  slight  a  laceration  of  the  conjunctiva  and  capsule  of 
pelled  to  rely  entirely  upon  the  simple  prism  test.  This  Tenon  as  possible ;  then  with  a  very  small  hook  beneath, 
shows  the  power  of  the  straight  muscles  of  the  eye  to  I  cut  the  tendon  completely  free  from  the  eyeball,  and 
turn  it  on  the  centre  of  rotation,  so  that  the  visual  line  allow  the  wound  to  heal  without  sutures.  I  believe  the 
,  e                  w  e      *v    e.  *    **  j-    i  o    •           ^     «  r  results  of  such  an  operation,  when  the  vision  is  normal  in 

1  See  my  paper  before  the  State  Medical  Society,  on  Our  Refrac-  1«*"1»  v*  °    . "  ,      v/pwi»MVu,  A      -A           ,                    Tr  T    , 

tion  Cases.                                                      y  each  eye,  will  be  about  ten  to  fifteen  degrees.     If  I  de- 


72 


MEDICAL   RECORD. 


[July  21,  1894 


cide  to  perform  a  partial  tenotomy,  then  I  find  my  indi- 
cations in  the  preponderance  of  power  in  one  muscle 
over  its  antagonist,  as  compared  with  what  I  consider 
the  normal  balance  as  before  stated. 

So  if  I  find  the  proportion  as  one  to  one,  and  the  case 
is  not  relieved  by  glasses  after  a  fair  trial  and  thorough  ex- 
amination, I  proceed  to  operate.  This  operation  I  per- 
form by  finding  the  muscle  with  a  very  small  strabismus 
hook ;  then  with  a  very  small  pair  of  scissors  I  cut  the  fi- 
bres of  the  tendon  above  and  below,  always  leaving  one 
small  fibre  in  the  centre  of  the  tendon  intact.  I  have 
found  the  results  of  that  operation  about  three  to  five 
degrees  as  shown  by  the  prism  test. 

We  now  come  to  the  conclusions  that  these  series  of 
cases  seem  to  present : 

1.  That  in  more  than  fifty  per  cent,  of  our  asthenopic 
cases  we  will  find  that  the  power  of  the  externi  exceeds 
that  of  the  interni,  in  comparison  with  the  usual  pro- 
portions that  should  exist  between  these  muscles ;  in  other 
words,  that  insufficiency  of  the  interni  is  much  more  fre- 
qient  than  is  stated  in  the  text  books.  I  found  only 
three  cases  of  insufficiency  of  the  externi. 

2.  That  I  place  very  slight  reliance  on  any  test  for  in- 
sufficiency of  the  muscular  power,  when  we  reduce  the 
visual  impressions  of  one  eye  by  any  means.  Conse- 
quently, I  can  only  rely  upon  the  old  test  of  the  actual 
power  of  each  individual  muscle  to  turn  the  visual  axis 
of  the  eyeball,  coincident  with  a  ray  of  light,  deviated 
by  a  prism,  from  a  candle  placed  at  twenty  feet  from  the 
person  examined.  In  forty  eight  cases  the  vertical  di- 
plopia test  did  not  agree,  and  was  exactly  opposite  to  that 
of  the  prism  test  in  nineteen  cases. 

3.  That  in  cases  where  the  proportions  of  the  muscles 
are  as  one  to  one,  we  may  exercise  the  weak  muscles  for 
a  reasonable  time  or  as  long  as  their  power  will  increase, 
but  I  would  state  that  I  have  found  this  exercise  useful 
only  in  weakness  of  the  interni.  Or  we  may  order 
prisms,  combined  with  the  glasses,  with  the  base  over  the 
weak  muscles.  They  may  afford  relief,  and  I  have  not 
found  any  of  my  cases  develop  a  latent  insufficiency  from 
their  use.  In  some  cases  these  means  afford,  for  a  time, 
complete  relief;  but  there  may  be  a  return  of  the  muscu- 
lar weakness ;  in  other  words,  the  improved  power  ob- 
tained by  exercise  or  prisms  is  not  constant. 

4.  That  in  all  cases  the  error  of  refraction,  either  sim- 
ple or  with  astigmatism,  should  be  corrected  by  suitable 
glasses,  and  these  should  be  worn  for  a  month  at  least, 
before  we  attempt  to  correct  any  muscular  insufficiency. 

5.  That,  in  diplopia,  we  should  do  a  complete  tenot- 
omy, carefully  performed,  with  as  slight  a  laceration  of 
the  tissues  as  possible. 

Lastly,  that,  in  insufficiency  well  marked,  after  the 
results  of  several  trials  with  the  prisms  are  the  same,  we 
miy  then  perform  a  partial  tenotomy,  as  stated,  with  full 
confidence  of  a  good  result. 


Yeaslei  in  Samoa. — Dr.  Davies,  of  Savaii,  Samoa, 
writes  to  the  British  Medical  Journal  an  account  of  the 
first  invasion  of  measles  into  that  island  group.  The 
disease  was  brought  there  in  September,  1893,  aQd  in 
the  following  three  months  about  1,000  of  the  entire 
population  of  34,500  died  from  its  effects.  The  epi- 
demic was  mild  and  few  died  during  the  period  of  fever 
and  eruption,  the  great  mortality  being  due  to  the  se- 
quelae and  complications.  The  deaths  were  principally 
from  gastritis,  enteritis,  diarrhoea,  and  dysentery.  A 
few  died  from  suppressed  measles.  The  craving  the  na- 
tives manifest  for  raw  fish,  unripe  or  over-ripe  fruit,  and 
especially  half  cooked  fresh  pork,  became  morbid  during 
the  period  of  convalescence.  Many,  lest  they  should  be 
told  to  avoid  these,  abstained  from  procuring  foreign 
medicine.  Nine-tenths  of  the  deaths  could  have  been 
prevented  by  care  in  diet,  and  even  the  worst  cases  of 
diarrhoea  and  dysentery  yielded  readily  to  treatment. 
Those  patients  who  placed  themselves  under  intelligent 
medical  supervision,  and  who  followed  out  the  directions 
as  to  medicine  and  diet  nearly  all  recovered. 


(Mittical  §tpnxlment. 

HYDRONAPHTHOL    IN  PHTHISIS    PULMONA- 
LE. 

By   CARL   B.   SMITH,   M.D., 

BIKGHAMTON,   N.    Y. 

Since  January  1,  1893,  *  nave  ^en  using  hydronaph- 
thol  hypodermically  in  the  treatment  of  phthisis  pul- 
monalis  with  the  following  results  :  Out  of  31  cases,  in  all 
stages,  that  I  have  treated  I  have  had  only  9  deaths,  8 
are  enjoying  fair  health  to  day  but  are  incurable  and 
14  have  been  cured  completely.  I  use  it  in  the 
strength  of  grs.  v.  to  3  j  ,  and  the  following  are  the  effects : 
The  hectic  fever  disappears,  the  appetite  returns,  the 
cought  lessens,  the  lungs  clear,  and  the  patient  com- 
mences to  gain  in  weight,  some  having  gained  as  much 
as  four  pounds  in  one  week. 

In  one  case  which  I  tested  with  the  microscope  (Ehr- 
lich  staining)  the  bacilli  were  found  to  disappear  from 
the  expectoration. 

In  all  my  cases  I  did  not  give  either  creosote  or  cod- 
liver  oil,  and  can  only  give  the  credit  of  my  success  to 
the  judicious  use  of  hydronaphthol. 

At  the  present  time,  after  having  practised  this  treat- 
ment for  more  than  a  year,  I  look  for  a  cure,  in  the  in- 
cipient stage,  inside  of  three  weeks ;  in  the  second  stage, 
fifty  per  cent,  cured  inside  of  five  weeks ;  in  the  last 
stage,  life  prolonged  and  some  cures,  but  I  will  have  to 
work  further  in  this  stage. 

Working  from  the  germ  theory  I  used  hydronaphthol  in 
three  cases  of  lobar  pneumonia,  and  in  each  case  the 
temperature  dropped  from  1020  and  1030  F.  to  normal; 
after  the  first  treatment  the  cough  loosened,  and  after 
the  third  treatment  they  were  cured. 


REPORT  OF  A  CASE  OF  FRACTURE  OF  THE 
PELVIS,  FRACTURE  OF  THE  FEMUR,  AND 
LACERATION  OF  THE  BLADDER;  RECOV- 
ERY. 

By  W.  B.  CUNNANE,  M.D., 

SANTA   BARBARA,   CAL. 

Fracture  of  the  pelvis  is  said  to  be  uncommon  in  men, 
rare  in  women,  and  almost  unknown  in  children.  It  is 
usually  produced  by  a  crushing  force,  such  as  a  caving  of 
earth  or  stones  in  a  mine,  catching  the  body  between 
two  objects  moving  in  opposite  directions,  or  the  passage 
of  a  heavy  wheel  across  the  pelvis. 

There  is  usually  a  great  deal  of  obscurity  attending  the 
diagnosis ;  and,  even  when  the  fact  of  the  fracture  is  clear- 
ly made  out,  it  may  be  very  difficult,  or  almost  impossible, 
to  locate  the  exact  line  of  separation.  Examination  by 
rectum,  and  in  females  by  the  vagina,  may  enable  one 
to  arrive  at  greater  certainty,  but  frequently  the  most 
careful  exploration  may  fail  to  determine  the  extent  of 
the  injury. 

The  gravity  of  these  fractures  usually  depends  upon 
the  number  and  extent  of  the  complications  present, 
rather  than  the  injury  inflicted  on  the  bone. 

This  fracture,  especially  when  it  takes  place  in  children, 
occurs  so  infrequently  that  I  deem  the  following  case 
sufficiently  interesting  to  the  profession  to  make  a  re- 
port of  it. 

G.  M was  a  native  of  California,  female,  aged 

five  years,  copper  color,  black  hair  and  eyes ;  well  de- 
veloped but  small  for  her  age.  She  had  measles  when 
three  years  of  age ;  and  one  year  ago  was  confined  to 
fed  four  weeks,  on  account  of  an  injury  to  the  head, 
produced  by  a  fall ;  recovery  complete. 

Her  present  injury  was  caused  on  April  5th,  by  the 
wheel  of  a  truck,  heavily  loaded  with  hay,  passing  diag- 
onally across  the  anterior  surface  of  the  body,  from  the 
middle  of  the  right  thigh  to  the  lower  margin  of  the  ribs 
on  the  left  side. 


July  21,  1894] 


MEDICAL  RECORD. 


n 


On  inspection  :  Dorsal  decubitus ;  the  left  eye  ecchy- 
mosed  and  the  surrounding  skin  abraded  ;  the  left  hand 
presents  a  contused  appearance,  and  there  is  lateral 
bending  of  the  second  finger.  There  is  a  contused  mark, 
about  two  inches  wide,  passing  diagonally  upward  from 
right  to  left,  across  the  pelvis,  just  to  the  left  of  the 
symphysis  pubis.  The  left  lower  extremity  is  lying  on 
its  outer  side  flat  upon  the  bed,  and  drawn  up  toward  the 
trunk.  The  right  lower  extremity  presents  a  shortened 
appearance,  with  some  deformity  about  the  middle  of  the 
thigh ;  the  foot  rotated  outward  and  lying  with  its  ex- 
ternal margin  flat  on  the  bed. 

On  superficial  examination  I  made  a  diagnosis  of 
contusion  of  left  eye ;  fracture  of  second  phalanx  of  sec- 
ond finger  of  left  hand;  oblique  fracture  of  right  femur 
at  junction  of  upper  with  middle  third ;  fracture  of  the 
left  os  innominatum,  or  a  separation  of  its  primary  cen- 
tres, and  probable  injury  to  some  of  the  pelvic  viscera. 
The  fractures  are  all  simple. 

The  pain  incident  to  making  a  careful  examination 
and  applying  treatment  was  so  intense  that  it  was  nec- 
essary to  administer  an  anaesthetic.  Therefore  I  re- 
quested assistance,  and  at  the  suggestion  of  the  family 
Dr.  R.  J.  Hall  was  called.  Having  to  wait  about  two 
hours  for  his  arrival,  during  the  interval  I  gave  morphia 
sulphate  for  the  relief  of  pain. 

As  soon  as  the  doctor  arrived  the  little  patient  was 
placed  under  the  influence  of  an  anaesthetic,  and  with 
the  finger  in  the  rectum  a  careful  examination  was 
made ;  but  we  were  unable  to  secure  distinct  crepitus, 
neither  could  we  make  out  the  exact  line  of  fracture  of 
the  os  innominatum.  The  fractured  femur  was  placed  in 
a  plaster-of-  Paris  bandage  without  extension,  the  plaster 
enveloping  the  hips  and  trunk  to  the  axillae.  She  was 
then  returned  to  bed  and  instructions  given  the  parents 
to  maintain  perfect  quiet,  to  preserve  the  urine  for  future 
inspection,  and  administer  light  nourishment. 

April  6th. — Pulse,  120;  temperature,  1010  F. ;  res- 
pirations, 28.  She  maintains  the  position  originally 
assumed ;  the  kidneys  acted  three  times  during  the  night, 
and  the  urine  contained  a  quantity  of  blood.  She  did 
not  sleep  much  during  the  night,  and  is  crying  with  pain 
in  the  left  inguinal  region.  There  is  extensive  swelling 
in  and  around  the  hip  joint  extending  downward  al- 
most to  the  knee.  The  inner  side  of  thigh,  high  up,  and 
the  left  labia  are  very  much  ecchymosed,  swollen,  hard, 
and  painful  to  the  touch ;  the  swelling  and  ecchymosis 
extending  from  the  symphysis  pubis,  anteriorly,  to  the 
anus,  posteriorly,  not  passing  beyond  the  median  line, 
nor  above  Poupart's  ligament.  The  eye,  hand,  and  right 
lower  extremity  are  doing  very  nicely,  no  swelling  or 
pain. 

We  cut  the  plaster  bandage  where  it  encircled  the  hips 
about  two  inches  up  its  middle,  anteriorly,  for  the  pur- 
pose of  relieving  pressure  on  the  ilium.  Not  finding  suf- 
ficient injury  of  the  external  genitals  to  account  for  the 
discharge  of  blood  in  the  urine,  we  came  to  the  conclu- 
sion that  it  was  produced  by  laceration  of  the  bladder,  or 
internal  portion  of  the  urethra.  Having  arrived  at  the 
above  inference  we  desisted  from  further  examination, 
agreeing  to  await  developments,  and  should  the  symptoms 
indicate  the  necessity  of  it,  perform  laparotomy. 

April  7th. — Pulse,  100;  temperature,  normal ;  respira- 
tions, 25.  The  kidneys  acted  frequently  during  the  past 
twenty-four  hours,  but  the  urine  did  not  contain  any  blood. 
She  is  resting  quietly  now,  and  slept  moderately  well 
during  the  night.  She  maintains  her  original  position ; 
the  swelling  of  left  hip  and  thigh  increasing,  ecchymosis 
more  marked,  and  cries  with  pain  if  disturbed.  The  eye, 
hand,  and  right  lower  extremity  progressing  nicely  toward 
recovery. 

From  April  7th,  to  the  date  of  discharge,  May  5th,  con- 
valescence was  progressive  and  uninterrupted,  except  by 
a  mild  attack  of  rubella,  which  produced  a  slight  rise  of 
temperature,  sick  stomach,  and  looseness  of  the  bowels, 
lasting  about  twenty- four  hours. 

The  dorsal  decubitus ;  the  entire  extremity  lying  on  its 


outer  side  flat  upon  the  bed,  the  thigh  flexed  to  its  extreme 
limit  upon  the  trunk,  and  the  leg  on  the  thigh,  which 
position  was  maintained  during  the  first  three  weeks  pa- 
tient was  confined  to  the  bed ;  the  extensive  exudation 
and  effusion  existing  in  and  around  the  hip  joint  ex- 
tending downward  almost  to  the  knee ;  the  deeply  sit- 
uated ecchymosis  and  exudation  into  the  left  labia,  its 
adjacent  and  subjacent  tissues,  not  passing  beyond  the 
median  line ;  the  pain  incident  to  the  pressure  of  the 
plaster  of  Paris  on  the  ilium  disappeared  immediately 
after  it  was  divided  up  the  middle,  anteriorly;  the 
intense  pain  which  was  produced  whenever  an  attempt 
was  made  to  move  the  limb  or  pelvis,  and  the  dis- 
charge of  blood  in  the  urine,  all  combine  to  form  an 
aggregation  of  symptoms  which  point  to  the  correctness 
of  the  diagnosis.  To  be  sure,  we  were  unable  to  trace, 
with  the  finger  in  the  rectum,  the  line  of  separation,  but 
all  of  the  other  symptoms,  subjective  and  objective,  indi- 
cate fracture  of  the  os  innominatum,  or  separation  of  its 
primary  centres,  and  laceration  of  the  bladder  or  internal 
urethra. 

At  the  present  writing,  June  2d,  she  walks  with  a  per- 
ceptible limp  in  the  right  leg,  which  is  due  to  about  two 
ctm.  shortening ;  there  is,  also,  a  sort  of  a  shuffling  move- 
ment similar  to  that  of  a  woman  after  an  unusually  hard 
confinement ;  otherwise  recovery  is  complete. 


A  NEW  CARDIAC  TONIC   DOSIMETRIC   GRAN- 
ULE. 

Indicated  in  Cases  where  the  Heart's  Action  is 
Irregular,  Weak,  or  Diminished  in  Tone  and  in 

Nutrition. 

By  EDWARD  C.  MANN,  M.D., 

MEDICAL  SUPERINTENDENT  SUNNYSIDB  SANATORIUM,  NBW  YORK  J  MEMBER 
MBD1CAL  SOCIETY  OF  THE  COUNTY  Or  NBW  YORK  ;  MBMBBR  BROOKLYN  PATH- 
OLOGICAL SOCIETY  ;  HONORARY  MBMBBR  MEDICAL  SECTION  IMPERIAL  UNIVBR- 
SITY  OF  KHARKOPP,  RUSSIA;  PRESIDENT  OF  NBW  YORK  ACAD*  MY  OF  ANTHRO- 
POLOGY,   ETC. 

In  the  treatment  of  nervous  and  mental  diseases,  and 
especially  of  inebriety  and  the  morphia  habit,  we  find  me- 
chanical difficulties  and  nutritive  disturbances  associated 
with  valvular  and  neurotic  affections  of  the  heart.  We 
cannot  use  digitalis  in  these  cases  without  the  great  dan- 
ger of  getting  up  a  condition  of  defective  nutrition  and 
secondary  degeneration  of  the  heart.  We  have  in  these 
cases  to  properly  tone  and  increase  the  nutritive  condition 
and  working  capacity  of  an  enfeebled  or  irregular  heart. 
We  want  a  remedy  that  will  at  the  same  time  nourish 
the  heart- muscle  and  slow  a  rapid  and  quicken  a  slow 
heart.  We  want  a  remedy  the  physiological  action  of 
which  will  be  to  establish  a  regular  rhythmical  action  of 
the  heart.  This  we  can  obtain  very  satisfactorily  by  the 
cardiac  tonic  dosimetric  granule  which  we  present  to 
the  profession.  We  are  in  a  position  to  day  to  get  a 
much  higher  degree  of  certainty  in  the  administration  of 
medicinal  agents  by  the  use  of  alkaloids,  glucosides, 
resinoids,  or  organic  acids,  as  medicinal  agents,  instead 
of  the  often  complex  and  variable  crude  drugs  which 
characterized  old  methods  of  treatment.  These  "active 
principles "  are  in  many  cases  transmutation  products, 
that  is,  they  are  obtained  from  the  native  substance  by 
the  action  of  a  series  of  chemical  reagents,  and  sometimes 
by  the  additional  action  of  heat.  Some  of  the  alkaloids 
do  not  exist  in  the  plant,  apomorphia,  for  instance,  which 
cannot  be  extracted  as  such  from  the  opium,  but  is  made 
by  the  action  of  heat  and  hydrochloric  acid,  from  mor- 
phia. In  this  new  method  of  dosimetry,  and  particularly 
by  hypodermatic  dosimetry,  we  can,  by  our  knowledge  of 
the  exact  chemical  identity  of  our  remedy,  and  of  the 
precise  quantity  injected  into  the  system,  determine  the 
nature  and  degree  of  the  effects  of  this  definite  substance 
upon  the  physiological  processes,  both  in  health  and  dis- 
ease, with  a  degree  of  accuracy  hitherto  unknown  in  the 
science  of  medicine.  We  know,  furthermore,  that  an 
exact  amount  of  the  active  principle  reaches  the  lymph 
spaces  and  circulatory  channels,  when  from  its  chemical 


74 


MEDICAL   RECORD. 


[July  21,  1894 


nature  we  can  give  it  hypodermatically.  Never  before 
in  the  treatment  of  disease  have  we  been  able  to  treat  it 
so  exactly  and  obtain  such  certain  and  permanent  relief 
as  we  can  to  day,  by  dosimetry,  and  particularly  by  hypo- 
dermatic dosimetry.  What  we  need  now  is  better  adapt- 
able chemical  forms  of  the  " active  principles/'  alkaloids, 
glucosides,  or  other  definite  active  principles,  and  then  we 
shall  be  in  a  position  to  have  a  new,  exact,  and  scientific 
system  of  therapeutics.  Hand  in  hand  with  this  must 
go  an  exact  system  of  feeding  our  patients  (proteid  diet) 
which  shall  require  the  least  vital  force  and  oxygen  to 
digest,  assimilate,  and  appropriate  the  food  ingested,  and 
give  the  most  force  and  energy. 

The  formula  for  the  cardiac  tonic  dosimetric  granule 
which  I  use  is  as  follows.  Each  dosimetric  granule  con- 
tains: 

R.  Morphia gr.  -ft 

Strychnia gr.  7^ 

Atropine gr.  ¥JT 

Caffeine gr.  Vf 

We  have  here  a  granule  with  a  fixed  therapeutic  activ- 
ity which  can  be  used  hypodermatically,  if  desired,  by  sim- 
ply dissolving  it  in  water,  and  which,  clinical  observation 
proves  most  satisfactorily,  will  impart  to  the  heart  a  bet- 
ter nutritive  vitality,  increased  working-power,  and  a  reg- 
ular rhythmical  action.  It  is  well  to  bring  the  patient 
down  to  a  restricted  diet  of  milk,  buttermilk,  eggs,  or 
raw  oysters,  and  to  correct  all  gastric  or  hepatic  disturb- 
ances, to  relieve  the  alimentary  organs  of  their  engorged 
condition,  states  which  I  always  have  to  direct  my  atten- 
tion to  in  the  affections  of  the  heart  in  cases  of  alco- 
holism, and  very  often  in  cases  of  the  morphia  habit.  The 
use  of  this  dosimetric  granule  we  have  always  found 
followed  by  a  rapid  improvement  in  the  strength  and 
rhythm  of  the  heart's  action  ;  and  we  recommend  con 
fining  the  use  of  digitalis  to  those  cases  where  we  need  a 
powerful  cardiac  stimulant,  in  cases  of  threatened  collapse, 
when  one  or  two  of  the  cardiac  tonic  dosimetric  granules 
may  be  dissolved,  and  a  hypodermatic  tablet  of  ^  gr.  of 
digitaline  added  to  it,  as  the  most  appropriate  heart  stimu- 
lant. Nitroglycerine  and  sulphate  of  sparteine  would 
also  be  indicated  in  such  extreme  cases,  TJT  to  -fo  of  the 
former  by  the  mouth,  with  £  to  £  gr.  of  the  latter  hypo- 
dermatically. I  keep  a  solution  of  the  sulphate  of  sparteine 
made  up  of  the  strength  of  16  grs.  ad  aquse  $j.,  and 
standing  by  this  a  bottle  of  nitro-glycerine  tablets  -fa  gr., 
and  always  use  them  simultaneously  in  emergency  cases. 
In  the  treatment  of  the  morphine  habit  also  I  have  for 
years  been  accustomed  to  rely  upon  this  latter  combina- 
tion for  two  or  three  days  after  complete  withdrawal  of 
the  morphine  to  obviate  and  antagonize  the  psycho  so- 
matic suffering  of  the  patient. 


ANOMALOUS    FCETAL    NUTRITION    IN    TWIN 
GESTATION. 

By  JOHN  C.  HUPP,  M.D., 

WHEELING,    W.   VA. 

On  the  second  day  of  May,  1894,  I  encountered  a  phe- 
nomenon not  heretofore  observed  in  an  obstetrical  ex- 
perience of  forty-seven  years.  The  mother  of  four  chil- 
dren, in  the  seventh  month,  she  alleges,  of  her  fifth  preg- 
nancy, gave  birth  to  very  decidedly  decomposed  twins, 
one  foetus  being  very  many  times  smaller  and  more  com- 
pletely decomposed  than  its  twin  sister.  There  was  only 
one  placenta,  which  was  attached  to  the  ordinary-sized 
cord  of  the  larger  foetus,  which  was  not  larger  than  a 
thread,  encircling  its  neck  three  times,  and  after  tracing 
one  end  to  the  umbilicus  I  traced  the  other  end  to  its 
attachment  to  about  the  middle  of  the  cord  of  the  larger 
foetus,  and  around  this  attachment  there  were  three  or 
four  cherry-like  projections.  The  smaller  foetus,  with  or 
without  a  placenta,  notwithstanding  its  anomalous  con- 
nection, could  not  have  been  nourished  through  a  cord 
so  diminutive,  and  this,  to  me  never-before- heard- of 
union,  doubtless  caused  the  death  of  the  larger  foetus. 


My  impression  is  that  the  insufficient  nutrition  of  the 
smaller  foetus  caused  its  death,  and  the  resulting  pyogenic 
material  was  conveyed  to  the  larger  one  with  fatal  re- 
sult.   

REPORT    OF  THE    USE    OF    CRUDE    TUBER- 
CULIN ON  COWS. 

By  IRWIN   H.   HANCE,  M.D., 

SARAMAC  LAKE,   N.  Y. 

Being  desirous  of  having  the  cows  in  the  Adirondack 
Cottage  Sanitarium  free  from  any  tubercular  taint,  a  test 
was  made  on  the  herd  with  crude  tuberculin.  The  herd 
consisted  of  eight  cows  such  as  are  found  on  the  ordinary 
country  farm ;  to  all  outward  appearances  they  were  free 
from  any  disease.  The  day  preceding  the  first  test  in- 
oculations their  morning  and  evening  temperatures  were 
taken  per  vaginam  for  comparison  and  were  as  follows  : 
May  2 1st.  a.m.  p.m. 

1 100.5  102.6 

2 101. 0  

3 101.0  101.0 

4 100.8  100.8 

5 101.5  101.4 

6 101.4  101.8 

7 loi.a  101.4 

8 100.5  IOI-8 

In  looking  over  the  literature  at  our  command  Dr. 
Hewetson,  of  Montreal,  was  unable  to  find  any  detailed 
account  of  dosage  and  temperatures;  it  was  therefore 
deemed  advisable  to  use  a  small  dose  to  begin  with ; 
double  the  amount  was  given  six  days  later  to  make  the 
test  reliable.  The  solution  used  contained  0.1  of  Koch's 
lymph  in  each  c.c.  The  inoculations  were  all  made  in 
the  loose  folds  of  the  neck,  just  in  front  of  the  fore- 
shoulder.  Needles  with  very  strong  shanks  are  needed 
because  of  the  thick  hide. 

May  2 2d,  8  a.m. — 0.050  was  inoculated  in  each  cow. 
The  temperatures  in  degrees  Fahrenheit  were : 
May  22d.  8  a.m.  2  p.m.  8  p.m. 

1 100.6  101.8  102.4 

2 101.0  101.5  100.8 

3 101.4  100.8  100.8 

4 101.4  100.8  100.2 

5 101.4  101.2  100.6 

6 101.0  101.6  101.0 

7 101.6  101.2  100.6 

8 101.4  101.6  100.8 

A  comparison  of  the  temperatures  for  the  two  days 
shows  a  negative  result. 

May  28th,  7  a.m  — One  decigramme  was  administered 

to  each  cow.  During  the  day  the  temperatures  were 
as  follows : 

May  28th.  7  a.m.  2  p.m.  8  p.m. 

1 100.6  101.8  100.8 

2 101.0  101.4  ZOI.2 

3 iox.4  101.0  100.8 

4 101.4  100.8  100.6 

5..... 101.8  101.2  101.0 

6 iox.6  iox.2  101.0 

7 102.2  101.6  101.4 

8 101.2  101.6  101.0 

On  this  occasion  the  results  were  equally  satisfactory. 

A  single  glance  over  all  these  temperatures  shows  that 
the  normal  temperature  of  a  cow  per  vaginam  is  about 
1010  F.  The  only  exception  was  cow  number  one,  which 
was  an  old  matron ;  her  afternoon  rise  of  temperature 
cannot  be  considered  reactionary  since  the  evening  tem- 
perature of  the  day  on  which  she  received  one  deci- 
gramme of  lymph  was  only  one-fifth  higher  than  that  of 
the  morning. 

The  ease  and  simplicity  of  the  administration,  with 
the  thoroughly  practical  and  efficient  results  of  this  test, 
places  in  the  hands  of  everybody  a  simple  means  of  dis- 
covering this  very  prevalent  disease. 


Two  Deaths  under  Anesthesia  occurred  recently  in 
two  successive  days  in  Birmingham. 


July  a i,  1894] 


MEDICAL  RECORD. 


75 


Medical   Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


Publishers 
WM.  WOOD  8l  CO.,  43,  45,  &  47  East  Tenth  Street 


New  York,  July  ax,  1894. 


SYPHILIS  OF  THE   EPIDIDYMIS. 

In  affections  of  the  testicle,  as  they  are  usually  spoken 
of,  the  diagnosis  is  ever  a  matter  of  great  interest,  and, 
indeed,  often  of  much  importance,  and  it  is  not  enough 
for  the  physician  to  pronounce  the  case  one  of  "  swollen 
testicle  "  and  order  rest  and  hot  poultices.  Many  of  the 
diseases  which  attack  the  various  structures  contained 
within  the  scrotal  envelope  have  been  carefully  studied, 
their  salient  features  pointed  out  to  aid  in  arriving  at 
just  conclusions  regarding  them,  and  their  etiological 
bearings  definitely  traced.  There  are  others  which,  it 
would  seem,  have  not  received  the  attentive  study  their 
more  or  less  frequent  occurrence  demands.  According 
to  Dr.  C.  W.  Allen,  this  is  true  of  the  syphilitic  changes 
which  take  place  in  the  epididymis  while  the  testis  proper 
remains  unimplicated.  In  a  paper  just  published  in  the 
American  Journal  of  the  Medical  Sciences,  he  writes  his 
views  upon  what  we  must  acknowledge  is  a  relatively  little 
discussed  question.  The  first  writings  of  importance  con- 
cerning the  early  syphilitic  epididymitis  are  attributed 
to  Engelstedt  (1861),  and  to  Drow  two  years  later. 
"  Since  then,"  the  writer  says,  "  little  has  been  added 
to  the  literature  bearing  upon  it  if  we  except  the  brief 
writings  of  Szadek." 

We  would  here  like  to  call  attention  to  a  Paris  thesis 
published  by  Cuilleret,  in  1891,  entitled  "  £tude  sur 
I'^pididymite  syphilitique  secondaire,"  which  has  evi- 
dently been  overlooked.  Since  it  touches  upon  some 
points  which  have  been  omitted  in  Dr.  Allen's  paper, 
we  will  review  its  chief  features  and  conclusions.  The 
writer  believes  that  epididymitis  by  itself  is  a  frequent 
manifestation  of  the  secondary  period,  especially  at  its 
beginning,  but  that  it  passes  unperceived,  for  the  double 
reason  that  it  occasions  no  discomfort  and  has  a  marked 
tendency  to  spontaneous  regression.  Habitual  examina- 
tion of  the  organs  alone  can  determine  its  relative  fre- 
quency, for  its  chronic  course  is  benign  and  has  no  ten- 
dency to  permanent  alteration  or  destruction  of  the 
tissues.  The  opinion  is,  however,  expressed  that  its 
presence  indicates  a  rather  pronounced  attack  of  syphi- 
lis, which  should  be  carefully  treated,  and  that  the  prob- 
abilities favor  serious  manifestations  in  the  after-stages. 
The  matter  of  differential  diagnosis  does  not  appear  to 
present  many  difficulties.  Gonorrhoeal  epididymitis  is 
certainly  much  more  frequent,  but  its  acute  and  painful 
symptoms  would  exclude  this  affection,  though  it  would 
that,  as  an  exception,  a  case  may  be  acute.     The 


induration  is  located  in  the  head  of  the  organ  and  is  ex- 
tremely hard.  Diagnosis  from  beginning  tuberculosis 
must  offer  greater  difficulties  where  all  other  signs  of 
syphilis  are  absent,  and  the  element  time,  and  possibly 
test  treatment,  it  seems  to  us,  would  have  to  enter  into 
the  problem's  solution.  The  first  mentioned  paper  takes 
up  a  rather  different  phase  of  the  question,  and  the  prop- 
osition is  advanced  that  syphilis  attacks  the  epididymis 
at  almost  any  stage  as  well  as  in  the  early  secondary 
period,  in  the  absence  of  any  other  evidence  of  the  dis- 
ease, and  when  there  have  been  no  symptoms,  perhaps, 
for  many  years.  This  view  is  supported  by  a  number  of 
clinical  observations,  several  of  which  add  decided  weight 
to  the  arguments,  while  some  of  the  others  are  not  so  con- 
vincing. One  difficulty  which  stands  in  the  way  of  ac- 
cepting the  results  of  treatment  as  strong  proof  of  the 
syphilitic  nature  of  a  pathological  condition,  is  that  mer- 
cury and  the  iodides  are  so  often  beneficial  where  there  is 
not  the  least  suspicion  of  a  specific  taint.  This  may  be 
true  even  of  tuberculous  processes,  as  the  writer  admits  in 
commenting  upon  the  last  of  his  series  of  cases,  and  says 
coincident  evidence  of  tuberculosis  in  other  organs  must 
be  looked  for. 

A  point  in  differential  diagnosis  between  this  and  the 
chronic  enlargement  so  often  left  after  gonorrhoeal  epi- 
didymitis, is  that  in  the  latter  the  tail  of  the  organ  is  the 
part  involved,  while  syphilis  implicates  mostly  the  head. 
There  is  no  doubt  that  castration  is  still  cow  and  then 
performed  for  supposed  tuberculosis  or  malignant  growth, 
where  syphilis  is  the  real  cause  of  the  abnormality. 

For  this  reason  alone  such  clinical  studies  of  the  ques- 
tion are  not  amiss,  for  while  they  aid  in  saving  an  occa- 
sional testicle  by  means  of  the  iodides,  they  tend  to 
bring  about  a  better  understanding  of  the  whole  subject 
of  enlargement  of  the  epididymis ;  and  so  far  as  syphilis 
is  concerned,  it  must  be  confessed  the  field  has  not  been 
overworked. 

THE  RISE   OF   APIUM   GRAVEOLENS. 

It  is  with  considerable  interest  that  we  have  watched  the 
rise  into  therapeutical  prominence  of  that  toothsome  ad- 
junct to  the  dietary,  celery.  Without  any  adventitious 
aids  from  the  physiological  laboratory  or  critical  clinical 
studies,  it  has  become  a  formidable  rival  to  the  mystic 
sarsaparilla  and  ginseng  as  a  popular  remedy.  It  does 
not  pretend  to  purify  the  blood,  to  be  sure,  but  it  calms 
the  nerves,  a  task  of  even  greater  magnitude  in  these 
fin  de  siicle  days.  Apium  graveolens,  or  celery,  is,  we 
believe,  a  close  cousin  to  apium  petroselinum,  or  pars- 
ley, but  somehow  it  is  petroselinum  alone  that  has  won 
serious  medical  attention.  This  latter  plant  is  aperient 
and  diuretic,  and  helpful  in  amenorrhoea,  dysmenorrhea, 
and  allied  female  complaints.  Some  years  ago  Dr.  Ran- 
som asserted  that  celery  also  had  some  influence  on  the 
urinary  secretion.  But  nowhere  is  it  shown  that  it  has 
the  slightest  effect  on  the  nerves.  Yet  we  must  believe 
that  it  does  have  much  effect,  or  discredit  a  very  large 
percentage  of  medical  advertisements  in  the  daily  presr. 
We  are  prepared  to  take  a  most  impartial  view  of  the 
situation,  and  will  be  glad  to  learn  that  celery  has  power- 
ful therapeutic  effects  in  various  directions.  But  we  pro- 
test that  the  burden  of  proof  is  with  the  populace  and 
not  with  the  professors.    At  present  all  that  medical 


76 


MEDICAL   RECORD. 


[July  2i,  1894 


science  can  say  is  that  celery  is  an  agreeable  weed  to  eat 
when  cold  and  white  and  crisp  and  clean.  Indeed,  it 
seems  a  pity  to  put  it  into  a  tincture  and  grade  it  down 
with  sarsaparilla. 


TRANSPORTATION  OF  THE  INSANE  TO  HOS- 
PITALS. 

While  reform  in  the  care  and  treatment  of  the  insane, 
during  the  past  decade  or  two,  has  been  rapid,  and,  in 
some  respects,  radical,  the  manner  in  which  they  are 
carried  to  hospitals  has  received  but  little  attention.  In 
this  State,  for  some  time  past,  a  mild  under-current  has 
been  running  in  the  direction  of  reform  in  this  matter, 
but  so  far  but  little  good  has  been  accomplished.  The 
time  came  long  ago,  when  the  insane  person  should  have 
been  differentiated  absolutely  from  civil  offenders ;  but 
as  a  matter  of  fact,  the  two  are  sadly  confounded  to-day 
by  many  persons  who  have  to  do  with  the  insane  in  one 
way  or  another. 

The  reason  of  this  is  perfectly  plain.  When  a  person 
becomes  insane  (and  we  are  speaking  now  of  persons  in 
the  humbler  walks  of  life,  who  cannot  afford  private  at- 
tendance and  skilled  nurses),  he  promptly  falls  into  the 
hands  of  the  local  constabulary  or  police,  and  especially 
does  he  meet  this  fate  if  he  manifests  the  least  tendency 
to  disturb  the  public  peace,  or  in  any  way  show  violence. 
Dr.  Stephen  Smith,  in  a  very  able  paper  entitled  "  More 
Rational  Treatment  of  the  Insane,"  that  appeared  in  the 
American  Journal  of  Insanity,  January,  1894,  says : 
"  When  a  person  is  alleged  to  be  insane,  our  laws  place 
him  in  the  category  of  persons  who  have  been  accused 
of  civil  offence.  In  many  of  the  States  the  term, '  The 
Accused/  is  employed  in  the  statutes  when  such  a  per- 
son is  referred  to.  This  feature  of  our  law  is  a  relic  of 
the  old  method  of  arresting  the  violent  and  disturbed 
insane  under  the  common  law  of  England.1' 

We  need  not  attempt  to  portray  the  ill-treatment  often 
received  by  the  insane,  man  or  woman,  at  the  hand  of 
these  ignorant  and  harsh  petty  officers  of  the  law.  Too 
often  they  are  manacled,  or  laced  in  a  straight  jacket, 
put  in  prison,  and  fed  on  prison  food,  or  not  fed  at  all, 
if,  by  reason  of  some  delusion,  they  refuse  to  eat.  The 
grossest  of  indignities,  however,  is  left  for  them  to  suf- 
fer when  in  process  of  transportation  to  the  hospital  to 
which  they  have  been  committed  for  care  and  treatment. 
Ttie  superintendent  of  a  hospital  for  the  insane  in  a 
neighboring  State  recently  described  the  manner  in 
which  an  insane  woman  was  brought  to  the  hospital, 
as  follows :  "  She  was  brought  twenty  miles  or  more 
(in  a  wagon)  in  a  drygoods  box.  The  box  was  just 
large  enough  for  her  to  sit  in,  and  this  had  a  blanket 
thrown  over  it,  and  tacked  all  around.  Ropes  had  been 
placed  on  the  sides  to  form  handles.  She  had  not  been 
taken  out  of  the  box,  and  had  not  been  able  to  change 
her  position  from  the  time  of  starting  until  she  reached 
the  hospital,  several  hours.  Imagine  the  condition  in 
which  I  found  her  when  I  tore  the  blanket  covering  off." 
In  the  same  State,  not  long  since,  a  man  was  carried 
half  a  day's  journey  to  the  hospital,  strapped  hard  and 
fast  to  the  top  of  a  coffin.  He  was  in  this  excruciating 
position  for  many  hours.  When  released  in  the  hospital 
he  could  not  stand  or  move  hand  or  foot. 

It  is  difficult  to  give  credence  to  the  two  instances 


cited  above,  but  the  fact  of  their  occurrence  is  vouched 
for  by  a  correspondent  in  whom  we  have  every  confi- 
dence. Of  course,  those  in  charge  of  our  public  hospi- 
tals have  absolutely  nothing  whatever  to  do  with  the 
manner  in  which  patients  are  brought  to  them.  Their 
jurisdiction  begins  only  when  the  patient  has  crossed  the 
threshold  of  the  hospital  door.  There  would  certainly 
appear  to  be  room  for  reform  in  this  direction. 


CEREBRO  SPINAL  MENINGITIS. 

During  the  past  year  cerebrospinal  meningitis  has  been 
epidemic  in  several  localities  in  this  country,  and  among 
them  in  New  York  City.  Dr.  Henry  W.  Berg  has 
made  a  clinical  study  of  this  latter  epidemic  {Archives 
of  Pediatrics),  and  a  discussion  of  his  paper  took  place  at 
the  Academy  of  Medicine  in  April.  The  disease  was 
also  seriously  epidemic  in  Maryland,  and  at  the  instance 
of  the  State  Board  of  Health,  an  investigation  of  it  was 
undertaken  by  Drs.  Simon  Flexner  and  L.  F.  Barker,  of 
Johns  Hopkins  University  {American  Journal  of  the 
Medical  Sciences,  February  and  March,  1894). 

Dr.  Berg  shows. that  the  mortality  from  cerebrospinal 
meningitis  in  New  York  City  rose  from  230  in  1892  to 
469  in  1893.  The  majority  of  the  cases  occurred  in  per- 
sons under  the  age  of  five,  and  there  was  no  especial 
difference  between  the  sexes.  The  greatest  mortality 
occurred  in  May,  but  as  the  disease  took  a  somewhat 
chronic  type,  it  is  assumed  that  it  was  actually  most 
prevalent  during  the  late  winter  and  early  spring.  At- 
tention is  called  to  the  fact  that  the  epidemic  followed  in 
a  measure  the  wake  of  the  influenza,  and  corresponded 
with  a  great  prevalence  of  pneumonia,  facts  which  have 
been  observed  before.  There  seems  to  be  nothing  in  the 
New  York  epidemic  to  point  to  cerebro  spinal  meningitis 
as  distinctly  a  filth  disease,  nor  were  there  any  evidences 
that  it  is  ever  contagious.  The  cases  on  the  whole,  ran 
a  very  chronic  course,  and  there  were  few  instances  of 
the  foudroyant  type  of  the  disease.  The  attacks  began 
with  a  chill  and  fever  or  with  convulsions,  often  accom- 
panied by  propulsive  vomiting  and  headache.  Very 
soon  the  characteristic  symptoms  of  pain  and  rigidity  in 
the  back  of  the  neck,  with  muscular  tenderness  and  pain, 
appeared.  As  a  rule,  there  was  a  herpetic  eruption  on 
the  skin,  and  nasal  catarrh  was  frequent.  As  the  disease 
progressed,  symptoms  of  irritation  and  compression  of 
the  brain  and  cord  developed,  delirium,  photophobia, 
pupillary  and  retinal  changes,  ptosis,  strabismus,  and 
other  paralyses  appeared,  ending  finally  in  stupor. 

In  discussing  the  pathology  of  cerebrospinal  menin- 
gitis, Dr.  Herman  M.  Biggs  was  positive  in  stating  that 
the  disease  presented  no  distinctive  bacteriology  or 
etiology.  Cultures  are  sometimes  sterile,  or  bacteria  of 
various  kinds  may  be  found.  The  pneumococcus  of 
Frankel  is  oftenest  present,  and  after  this  the  strepto- 
coccus and  the  staphylococci  albus  and  aureus.  Dr. 
Biggs  also  asserted  that  cerebral  meningitis  was  always 
cerebro-spinal,  and  that  there  were  no  facts  to  warrant  a 
separation  of  the  two  diseases. 

Dr.  Biggs's  views  are  not  in  accord  with  those  of  Drs. 
Flexner  and  Barker.  These  gentlemen  say  that  the  epi- 
demic and  sporadic  cases  of  cerebro  spinal  meningitis  are 
due  to  a  particular  micro-organism,  the  micrococcus 
lanceolatus,    discovered  by   Eberth    in    1880,  and  by 


July  2i,  1894] 


MEDICAL  RECORD. 


77 


Wechselbaum  in  1886.  This  microbe  is  considered  to 
be  the  cause  of  those  forms  of  meningitis  developing 
epidemically  or  in  association  with  pneumonia.  There 
is,  however,  aD  other  class  of  cases  in  which  it  is  caused 
by  injuries,  or  appears  in  the  course  of  other  infections 
such  as  typhoid  fever,  arthritis,  sepsis,  etc.  Drs.  Flex- 
ner  and  Barker  report  cases  which  corroborate  their  view. 


MEDICINE  AND   MODESTY. 

The  Cincinnati  Lancet- Clinic  insists  that  the  medical 
profession  is  just  as  big  as  any  other  calling,  perhaps  big- 
ger. And  it  wants  a  medical  cabinet  officer  at  Washing- 
ton right  away.  It  says :  "  To-day  the  success  of  the 
army  and  navy  is  more  dependent  upon  the  resources  of 
the  medical  department  of  those  branches  of  national 
service  than  ever  before."  There  is  a  little  anti-climax 
here,  though  the  statement  will  not  be  disputed.  But  our 
contemporary  continues,  with  access  of  emphasis :  "  Very 
much  of  the  efficiency  of  the  Interior  Department  is  de- 
pendent upon  its  medical  staff.  The  finances  of  the 
country  are  at  the  mercy  of  medicine,  while  the  prosper- 
ity of  all  the  people  is  wholly  determined  by  their  condi- 
tion of  health.'1 

This  we  think  is  really  putting  it  rather  strong.  We 
yield  to  no  one  in  appreciation  of  our  calling,  but  it 
seems  to  us  that  the  prosperity  of  our  country  depends  on 
the  ingestion  of  adequate  food,  the  observance  of  law,  and 
the  prosecution  of  our  industries,  as  well  as  upon  sanita- 
tion. Let  us  insist  on  acknowledgment  of  our  true 
merits,  and  upon  the  high  functions  which  public  medi- 
cine fulfils.  They  are  of  sufficient  weight  without  the 
adventitious  trappings  of  an  expansive  fancy  such  as  our 
esteemed  Cincinnati  contemporary  seems  to  possess. 

But  let  us  look  at  what  our  country  needs  first,  and  our 
professional  advancement  later.  The  country  would  be 
benefited  by  a  national  control  of  matters  of  public 
health.  This  can  be  gotten  best  by  not  asking  at  the 
same  time  for  a  cabinet  officer. 


PROFESSOR     WILLIAM     JAMES'S     PLEA    FOR 
THE    MIND-CURERS. 

Professor  James,  after  denying  that  he  holds  any  brief 
for  the  "healers/'  makes  this  extraordinary  plea : — He 
says:  "The  facts  are  patent  and  startling;  and  any- 
thing that  interferes  with  the  multiplication  of  such  facts, 
and  with  our  freest  opportunity  of  observing  and  study- 
ing them,  will,  I  believe,  be  a  public  calamity.  The  law 
now  proposed  will  so  interfere,  simply  because  the  mind- 
curex?  will  not  take  the  examinations.  They  return  to 
science  disdain  for  disdain;  and  nothing  will  please 
some  of  them  better  than  such  a  taste  of  imprisonment 
as  might,  by  the  public  outcry  it  would  occasion,  bring 
the  law  rattling  down  about  the  ears  of  the  mandarins 
who  shall  have  enacted  it. 

"  And  whatever  one  may  think  of  the  narrowness  of 
the  mind-curers,  their  logical  position  is  impregnable. 
They  are  proving  by  the  most  brilliant  new  results  that 
the  therapeutic  relation  may  be  what  we  can  at  present 
describe  only  as  a  relation  of  one  person  to  another  per- 
son ;  and  they  are  consistent  in  resisting  to  the  uttermost 
any  legislation  that  would  make  '  examinable '  informa- 
tion the  root  of  medical  virtue,  and  hamper  the  free  play 


of  personal  force  and  affinity  by  mechanically  imposed 
conditions." 

The  mind-curer  has  surely  an  eloquent  advocate  in  the 
Harvard  professor.  But  no  one  except  those  daily  fa- 
miliar with  the  aspects  of  disease  can  understand  how*1 
specious  and  silly  such  talk  is.  First,  let  us  ask  where 
are  the  "  facts  "  that  are  so  "  patent  and  startling."  Is 
there  a  single  disease  in  our  nosology  which  the  "heal- 
ers "  heal  in  larger  percentage  than  does  rational  medi- 
cine? What  are  the  "  facts  "  about  pneumonia,  fevers, 
phthisis,  cancer,  rheumatism,  and  all  the  familiar  forms 
of  suffering  which  the  physician  meets  and  relieves  daily  ? 
Let  Dr.  James  put  a  "  healer  "  in  charge  of  the  medical 
ward  of  a  city  hospital  and  see  how  "  the  impregnable- 
ness  of  a  logical  position  assists  him  in  pulmonary  oedema 
or  a  failing  heart.  If  there  are  "  brilliant  new  results," 
why  are  they  not  collected,  authenticated,  and  presented 
to  the  world  in  a  way  that  will  bear  honest  inspection  ? 
At  present  they  are  simply  rumors  that  pass  from  one 
fanciful  female  or  over- credulous  psychologist  to  another, 
and  have  about  the  evidential  value  of  the  ghost  stories 
accumulated  by  the  Phantom  Committee  of  the  Society 
for  Psychical  Research. 

The  medical  profession  knows  well  how  much  its  art  is 
limited,  and  eagerly  accepts  any  genuine  help.  But  it 
has  no  evidence  that  mind  curers  do  more  than  amuse 
the  leisure  of  selfish  invalids  and  nurse  the  introspections 
of  feeble  philosophers. 


foetus  at  tUt  'SSEeek. 

The  Escape  from  the  Electric  Chair. — Governor  Flow- 
er has  wisely  respited  Mrs.  Halliday,  the  Monticello 
woman  recently  convicted  of  murder  in  the  first  degree 
and  sentenced  by  the  judge  to  death  in  the  electric  chair. 
The  commission  of  experts  appointed  to  examine  into 
her  sanity  reported  that  she  was  of  unsound  mind.  In 
view  of  the  evidence,  even  on  the  trial,  there  was  no 
other  conclusion  to  be  drawn.  The  sentence  was  accord- 
ingly changed  to  imprisonment  for  life  as  an  insane  con- 
vict. The  Governor  is  to  be  congratulated  on  his  fairness 
and  good  sense.  The  Governor  of  Illinois  might  have 
done  the  same  for  Prendergast  and  with  equal  propriety, 
but  it  is  now  too  late,  as  it  is  with  other  things  he  left 
undone. 

Brooklyn  last  week  had  the  extraordinarily  high  death- 
rate  of  33.4  per  1,000. 

Dr.  Joseph  Pagani,  of  Boston,  died  on  July  15  th.  He 
had  practised  in  the  North  End  for  twenty  years.  He 
was  born  in  Borgomanero,  Italy,  in  1836.  In  1863  he 
was  graduated  from  the  University  of  Pavia.  He  came 
to  America  in  1865,  and  after  a  short  stay  in  New  York 
went  to  Boston.  For  his  kindness  to  Brazilian  subjects 
he  received,  in  1882,  from  Dom  Pedro  the  decoration  of 
Chevalier  de  Buenos  Ayres.  In  1892  he  was  made  Ca- 
zique  and  Baron  Hoxley  in  the  Aryan  peerage  of  Rus- 
sia. He  was  a  distinguished  member  of  several  medical 
societies,  among  which  were  L'Acad^mie  Mddecine  of 
Paris  and  the  Societa  Medicale  di  Roma. 

Dr.  John  Williams,  who  attended  the  Duchess  of  York 
during  her  recent  confinement,  has  been  created  a  baro- 
net. 


78 


MEDICAL    RECORD. 


[July  21,  1894 


Professor  Hermann  Helmholtz  was  taken  suddenly  ill 
on  July  12th,  with  a  brain  lesion  and  now  has  left-sided 
hemiplegia. 

•  The  Plague  in  Hong  Kong  is  reported  to  be  subsiding, 
but  cholera  is  on  the  increase  in  Canton. 

Monuments  to  Medical  Ken. — The  work  of  securing 
funds  for  a  monument  to  Professor  Charcot  is  progress- 
ing favorably,  and  is  receiving  help  from  Germany  and 
other  countries.  A  monument  in  memory  of  the  great 
Russian  surgeon,  Pirogoff,  will  shortly  be  erected  in 
Moscow.  The  subscriptions  for  this  object  already 
amount  to  12,000  roubles  (about  $6,000).  The  monu- 
ment will  appropriately  be  placed  on  one  of  the  open 
places  between  the  blocks  of  the  immense  new  clinique 
in  Moscow. 

Texas  Not  the  State  for  a  Young  Doctor.— A  corre- 
spondent writes  that  he  left  New  York  to  verify  the  well 
advertised  chances  for  the  young  medical  man  in  Texas ; 
but  after  travelling  throughout  the  entire  State  he  found 
every  place  more  than  full,  with  not  a  few  waiting  for 
chances  to  earn  money  enough  to  get  home.  He  says 
there  is  even  a  better  chance  in  New  York. 

The  Immediate  Repair  of  the  Permanent  Cervix  — 

Dr.  H.  D.  Gardner,  of  Scranton,  Pa.,  writes:  "In  the 
article  of  July  7  th  on  the  '  Causes  of  Diseases  Peculiar 
to  Women/  you  say  lacerations  of  the  cervix  and  peri- 
neum should  be  repaired  early.  Now  I,  in  common  with 
many  others,  believe  in  the  immediate  repair  of  the 
perineum ;  I  have  never  tried  to  repair  the  cervix,  but 
think  it  might  be  done,  and  in  order  to  do  this  you  must 
first  find  the  tear.  Now  I  know  of  no  way  so  good  as 
to  look  for  it.  Turn  down  the  bedclothes  and  with  a 
good  light,  lamp  or  candle,  look  and  see  whether  there 
is  a  tear  or  not.  No  power  on  earth  could  prevent  it, 
but  you  can  repair  it  easily  and  quickly.  I  look  upon 
this  as  the  most  important  duty  of  the  obstetrician." 

Bequests  to  Hospitals. — The  late  John  Crerar,  of 
Chicago,  has  bequeathed  to  the  Presbyterian  Hospital  of 
this  city  $25,000;  to  St.  Luke's  Hospital,  $25,000. 

Medical  legislators  and  Medical  Mayors  abound  in 
France.  The  first  to  go  to  the  aid  of  the  murdered 
President  Carnot  was  Dr.  Gailleton,  the  Mayor  of  Lyons. 
Among  the  leaders  of  the  medical  section  in  the  French 
Parliament  are  Professors  Cornil  and  Lanaelongue  and 
Dr.  Leon  Labbe.  These  gentlemen,  says  The  Lancet, 
recently  convened  a  meeting  of  their  fellow  (medical) 
members,  and  the  outcome  of  the  conference  was  the 
formation  of  a  medical  group,  whose  duty  it  shall  be 
to  watch  over  professional  interests  in  the  two  houses. 
M.  Labbe  was  appointed  President,  and  MM.  Cornil  and 
Lannelongue  vice-presidents  of  this  new  group.  The 
freshly  formed  party  has  already  begun  work,  for  it  has 
discussed  a  bill  introduced  by  M.  Labbe  which,  if  adopt- 
ed— and  it  has  every  chance  of  being  carried — will  pro- 
long the  limit  of  age  of  medical  students,  with  regard  to 
their  military  obligations,  from  twenty-six  to  twenty- 
seven  years. 

Death  of  the  Smallest  Kan  in  the  World.— Dudley 

Foster,  said  to  have  been  the  smallest  man  in  the  world, 
died  at  Bridgetown,  N.  S.,  on  June  20th,  of  heart  dis- 
ease, aged  sixteen  years  and  ten  months.  He  was  thirty 
inches  high,  and  weighed  twenty  pounds. 


Antieholera  Inoculation. — An  Indo  European  tele- 
gram states  that  within  the  previous  few  days  three 
further  remarkable  instances  of  the  success  of  M.  Haff- 
kine's  system  of  auticholera  inoculation  had  occurred  at 
Calcutta.  In  the  first  case  four  out  of  the  six  members 
of  a  family  were  inoculated  last  March.  The  cholera 
appeared  in  the  neighborhood  lately,  and  the  disease 
attacked  one  of  the  two  who  had  not  been  inoculated, 
while  the  inoculated  remained  free.  In  the  second  case, 
five  members  of  a  family  consisting  of  eleven  persons 
were  inoculated  in  March.  The  cholera  lately  attacked 
one  of  the  six  who  had  not  been  inoculated.  In  the 
third  case,  six  out  of  a  family  of  nine  were  inoculated. 
When  the  cholera  prevailed  in  the  neighborhood  a  few 
days  later  the  disease  attacked  one  of  the  three  not 
inoculated.  The  Corporation  of  Madras  have  passed  a 
resolution  inviting  M.  Haff  kine  to  visit  that  city  and 
introduce  his  system. 

Sir  Joseph  Lister. — The  Council  of  the  Society  of 
Arts  has,  with  the  approval  and  sanction  of  the  Presi- 
dent, His  Royal  Highness  the  Prince  of  Wales,  awarded 
the  Albert  Medal  to  Sir  Joseph  Lister  "  for  the  discov- 
ery and  establishment  of  the  antiseptic  method  of  treat- 
ing wounds  and  injuries,  by  which  not  only  has  the  art 
of  surgery  been  greatly  promoted  and  human  life  saved 
in  all  parts  of  the  world,  but  extensive  industries  have 
been  created  for  the  supply  of  materials  for  carrying  the 
treatment  into  effect" 

Sterilized  Milk  is  becoming  a  popular  hot-weather 
drink  in  this  city. 

A  Political  Honor  to  a  Physician. —  An  esteemed 
correspondent  writes  from  San  Josl,  Costa  Rica,  to  in- 
form us  that  Dr.  Juan  J.  Ulloa,  who  was  a  delegate 
from  Costa  Rica  to  the  Pan-American  Medical  Congress, 
and  who  is  a  graduate  of  the  Medical  Department  of  the 
University  of  the  City  of  New  York,  has  been  appointed 
Secretary  of  State  in  the  Departments  of  the  Interior  and 
of  Public  Improvements  of  Costa  Rica. 

Dr.  V.  P.  Gibney  has  been  elected  Professor  of  Clini- 
cal Surgery  in  the  College  of  Physicians  and  Surgeons  of 
New  York  City.  4 

Prize  for  an  Essay  on  Tuberculosis.— At  the  Denver 
meeting,  just  closed,  of  the  Colorado  State  Medical  So- 
ciety, the  following  resolution,  offered  by  Dr.  Denison, 
was  carried,  and  Drs.  Charles  Denison,  H.  A.  Lemen, 
and  S.  £.  Sally  were  appointed  as  such  Examining  Com- 
mittee :  Resolved,  That  this  Society  offer  a  prize  of  $  100 
for  the  best  essay  upon  the  following  subject :  The  Diag- 
nosis of  Tuberculosis  by  Microscopic  Examination  of  the 
Blood. 

Asparagus. — English  journals  have  been  actively  dis- 
cussing the  physiological  action  of  asparagus.  The  con- 
clusion reached  is  that  it  is  a  diuretic. 

The  Caul  still  seems  to  have  a  commercial  value.  Wit- 
ness the  following  advertisement  in  a  New  York  daily  : 

"Caul   for    Sale,   reasonable.      Address  ,    box 

,  World,  uptown.' ' 

The  American  Electro-therapeutic  Association  will 
hold  its  fourth  annual  meeting  in  New  York  on  Septem- 
ber 25  th,  26th,  and  27  th,  at  the  Academy  of  Medicine. 
Members  of  the  medical  profession  are  invited  to  attend. 


July  21,  1894] 


MEDICAL   RECORD. 


79 


Society  ^tpovte. 

<&0ugv&&8  at  &mtviaxn  fPqjsicfcros 
and  gnvQ&ans. 

Third  Trienninl  Meeting,  held  at  Washington,  D.   C, 
M*y  29>  30,  jr,  and  June  1,  1894. 

AMERICAN  GYNECOLOGICAL  SOCIETY. 

nineteenth  Annual  Meeting,  held  at  Washington,  May 
29,  30,  and  ji,  1894 

(Continued  from  Vol.  45,  page  769.) 

Second  Day,  Wednesday,  May  30TH. 

President's  Address. — Dr.  Lusk  chose  for  the  subject 
of  his  address  "  The  Proper  Position  of  Recent  Surgical 
Methods  in  the  Treatment  of  Uterine  Fibroids."  There 
is  nothing,  he  said,  which  in  an  equal  degree  marks  in 
gynecology  the  boundary  line  between  the  old  order  of 
things  and  the  new,  as  the  recent  discussion  upon  the  sur- 
gical treatment  of  uterine  myomata.  Myomata  might 
remain  of  small  size  and  produce  no  symptoms.  When 
small  and  the  symptoms  were  slight,  the  surgeon  could 
delay  a  little  and  control  attending  menorrhagia  by  cu- 
rettage, etc.  The  argument  in  favor  of  more  radical 
measures  bee  rase  of  the  supposed  liability  of  myomata  to 
malignant  changes,  especially  in  patients  nearing  the 
climacteric,  clinically  had  not  much  weight. 

Gottschalk,  Franklin,  Martin,  and  others  had  had 
favorable  experience  in  controlling  the  symptoms  and 
growth  of  uterine  fibroids  in  certain  cases  by  tying  the 
uterine  arteries  through  the  vagina.  It  seemed  to  the  Presi- 
dent unwise  bigotry  to  ignore  such  testimony  because 
ligation  of  tfie  uterine  arteries  belonged  to  the  domain 
of  little  things.  Certainly  the  patient  would  prefer  to  be 
relieved  in  that  way  to  having  the  uterus  removed. 

It  .was  a  question  whether  sufficient  attention  had  been 
paid  in  this  country  to  the  large  amount  of  efficient  work 
that  had  been  accomplished  abroad  in  connection  with 
the  enucleation  of  fibroids  by  the  vaginal  passage. 

Chrobak  alone  had  reported  forty-three  cases,  with  but 
one  death.  •  The  tumors  were  cervical,  submucous,  and 
interstitial,  and  varied  in  size  from  a  child's  head  down. 
The  President  related  one  of  his  own  cases  of  this  kind,  in 
which  able  men  had  said.the  tumor  could  not  be  removed 
except  by  opening  the  abdomen.  After  enucleation,  en- 
tire or  by  morcellement,  the  uterus  or  cervix  could  be 
restored  by  plastic  operation.  It  might  seem  a  little 
thing,  but  women  would  prefer  not  to  have  the  scar  left 
by  abdominal  operation,  and  the  danger  of  hernia  was 
shown  by  the  fact  that,  at  Jacob's  clinic,  in  259  cases  her- 
nia occurred  in  38.  By  the  vaginal  method  better  drain- 
age was  secured,  and  there  was  less  shock.  The  results 
by  the  vaginal  method  were  remarkable — P6an,  300  cases 
with  only  six  deaths ;  Richelot  and  Doyen  together,  88 
cases  with  two  deaths.  When  the  tumor  exceeded  in  size 
a  child's  head  experience  taught  that,  as  a  rule,  it  was  ad- 
vantageous to  attack  it  from  above. 

Regarding  castration  for  control  of  symptoms  pertain- 
ing to  fibroids  the  views  of  Martin,  Leopold,  Gusserow, 
Lawson  Tait,  on  their  statistics,  were  quoted  to  show  that 
often  the  procedure  gave  a  satisfactory  result.  Castration, 
however,  was  no  longer  advocated  in  large  tumors  and 
cystic  tumors. 

In  all  cases  where  the  abdomen  had  been  opened,  the 
possibility  of  saving  the  uterus  and  appendages  should 
not  be  lost  sight  of.  All  pedicled  growths  should  be  tied 
and  removed. 

The  views  of  Polk  and  Martin,  particularly,  were  re- 
ferred to  in  the  line  of  sparing  the  healthy  tissue  where 
it  was  necessary  to  remove  disease  of  structure  in  the 
uterus  and  appendages.  There  would  still,  however,  re- 
main a  certain  number  of  cases  in  which,  owing  to  the 
size  of  the  tumor,  cystic  degeneration,  number  of  growths, 


etc  ,  it  would  be  necessary  after  opening  the  abdomen  to 
do  total  extirpation. 

Dr.  Lusk  then  passed  to  a  consideration  of  methods  of 
treating  the  pedicle.  Although  good  results  had  been  ob- 
tained from  fastening  it  into  the  abdominal  wound,  the 
method  had  been  abandoned;  some  patients  returned 
with  a  fistula,  etc.  Complete  removal  and  amputation, 
leaving  the  lower  cervical  segment  only,  were  methods 
advocated  by  the  best  authority. 

Discussion  was  then  called  for  upon  the  papers  of  Drs. 
Lusk,  E.  C.  Dudley,  and  Wathen. 

Dr.  W.  M.  Polk  thought  also  there  could  be  no  one 
method  applicable  to  all  cases  of  uterine  fibroids.  He 
favored  conservative  measures,  retaining  healthy  struct- 
ures, wherever  removal  of  simply  the  diseased  portions 
would  be  likely  to  terminate  in  cure.  This  remark  was 
especially  applicable  in  disease  ot  the  appendages,  for 
even  pus  in  the  tubes  did  not  necessarily  preclude  ovula- 
tion. 

Dr.  Baldy  thought  that  if  myomectomy  was  to  be 
done  at  all,  it  should  be  by  the  abdominal,  not  by  the  va- 
ginal, method.  It  was,  however,  attended  by  danger  of 
hemorrhage,  sepsis,  and  recurrent  disease. 

Drs.  Cushing  and  Gordon  also  advocated  total  re- 
moval of  the  uterus,  as  opposed  to  myomectomy. 

Dr.  W.  Gill  Wylie  believed  in  suiting  the  operation 
and  the  method  of  performing  it  to  the  particular  case, 
and  thought  the  President's  paper  presented  the  subject 
very  justly. 

Dr.  Byford  expressed  similar  views,  and  Dr.  Engel- 
man  regretted  that  some  of  the  gentlemen  had  seemed  to 
show  prejudice  against  attacking  any  cases  of  fibromata 
uteri  per  vaginam,  regardless  of  their  size/ 

Dr.  A.  P.  Dudley  related  a  few  cases  illustrative  of 
the  advantage  of  the  different  procedures  under  different 
circumstances. 

Rupture  of  the  Uterus ;  Palliative  versus  Surgical 
Treatment.  —  The  discussion  upon  this  subject  was 
opened  with  a  paper  by  Dr.  Charles  M.  Green,  of 
Boston.  He  said  :  It  is  improbable  that  any  authority  at 
the  present  time  would  advocate  any  specific  treatment  as 
applicable  alike  to  all  cases  of  rupture  of  the  uterus.  The 
object  of  the  discussion  is  rather  to  arrive  at  the  methods 
most  suitable  for  particular  classes  of  cases,  according  to 
the  condition  and  situation  of  the  patient,  the  availability 
of  surgical  skill,  the  site  and  character  of  the  rupture  and 
manner  of  its  production,  the  extent  to  which  the  child 
has  escaped  into  the  peritoneal  cavity,  the  presence  or 
absence  of  hemorrhage,  the  condition  of  the  uterus  as  re- 
gards sepsis. 

Surgical  treatment  should  embrace,  not  alone  laparot- 
omy, with  or  without  suture  of  the  rent  or  removal  of 
the  uterus,  but  also  the  various  methods  of  drainage  with 
gauze,  wicking,  or  tube,  with  or  without  antecedent  irri- 
gation ;  while  palliative  treatment,  included  the  various 
general  therapeutic  measures  for  sustaining  the  patient, 
relieving  pain,  and  combating  shock,  combined  with 
local  'antisepsis  and  natural  drainage.  The  two  were 
often  advantageously  combined. 

To  one  with  limited  experience  iri  abdominal  surgery 
and  severer  obstetrical  practice,  the  idea  of  laparotomy 
after  rupture  of  the  uterus  was  an  attractive  one,  but  ex- 
tended experience  could  but  convince  that  in  many  cases 
less  radical  measures  gave  better  results. 

Merz's  statistics  of  230  cases,  grouped  under  ten  heads, 
were  given.  Complete  rupture,  181  cases,  with  63  recov- 
eries; incomplete  rupture,  46,  with  19  recoveries. 

Dr.  Green  divided  the  cases  of  uterine  rupture  for  pur- 
poses of  treatment  into  three  classes :  1.  Complete  or  in- 
complete tears  of  the  lateral  or  posterior  walls  of  the 
lower  segment,  with  adequate  provisions  for  vaginal  drain- 
age, hemorrhage  easily  controlled,  no  intestinal  hernia; 
such  cases  often  recovered  under  palliative  treatment, 
drainage,  and  antisepsis.  2.  Complete  tears  of  lower  seg- 
ment, or  moderate  tears  of  uterine  body,  more  or  less 
blood-clot,  etc.,  having  entered  the  peritoneal  cavity ; 
treatment  might  be  by  peritoneal  irrigation  and  drainage 


8o 


MEDICAL   RECORD. 


[July  21,  1894 


with  gauze.  3.  Cases  in  which  extraction  of  child  through 
pelvis  is  impossible  or  inexpedient,  hemorrhage  uncon- 
trollable per  vaginam,  rent  extensive,  irrigation,  trans- 
verse, or  ragged ;  in  such  cases  abdominal  section  is  indi- 
cated. The  propriety  of  suturing  the  rents  must  be 
decided  according  to  the  condition  of  the  uterus  and  the 
edges  of  the  tears ;  when  the  latter  are  very  ragged  and 
infiltrated  with  blood,  when  the  uterus  is  friable  and  ap- 
parently septic,  hysterectomy  promises  better  results  than 
suture. 

The  Palliative  Treatment  of  Rupture  of  the  Uterus. — 
Dr.  Malcolm  McLean,  of  New  York,  read  a  paper  with 
this  title. 

One  of  the  most  constant  and  characteristic  phenom- 
ena connected  with  rupture,  the  author  said,  was  sudden 
recession  of  the  presenting  part.  After  strongly  protest- 
ing against  one  allowing  himself  to  be  led  by  modern 
radical  tendencies  in  surgery  to  operate  in  all  cases  of 
rupture  of  the  uterus  regardless  of  the  particular  condi- 
tions present,  the  field  for  palliative  measures  was  pointed 
out  and  an  illustrative  case  cited.  The  hand  was  intro- 
duced, the  child  was  found,  escaped  through  a  rent  in 
the  right  anterior  wall  of  the  uterus,  so  that  only  the  head 
and  right  arm  were  within  the  uterine  cavity.  In  exam- 
ining the  edges  of  the  wound  it  was  noticed  that  the  sur- 
faces were  completely  shielded  by  the  amniotic  sac, 
which  was  pushed  through  ahead  of  the  limbs  of  the 
child,  forming  a  hernial  sac  into  the  peritoneal  cavity. 
Without  any  difficulty  the  child  was  drawn  back  into  the 
uterus  and  at  once  delivered  by  the  feet.  The  placenta 
with  the  membranes  were  withdrawn,  and  a  considerable 
quantity  of  amniotic  fluid,  meconium,  etc.,  was  brought 
away  in  the  pouch  of  the  amnion  which  had  protruded 
through  the  rent  in  the  uterus.  Believing  that  the  peri- 
toneal cavity,  therefore,  had  not  been  invaded  except  by 
purely  blood  extravasation,  the  case  was  left  to  nature, 
using,  of  course,  antiseptic  douches,  etc.  The  woman 
made  a  good  recovery  after  a  somewhat  tedious  conva- 
lescence while  absorbing  a  considerable  hematocele  in 
the  right  side  of  the  abdomen. 

A  year  and  a  half  later  Dr.  McLean  delivered  the  same 
patient,  and  the  cicatrix  was  distinctly  felt  through  her 
very  thin  abdominal  parietes. 

Stress  was  placed  upon  the  fact  that  the  amniotic  sac 
had  protruded  into  the  rent  and  protected  infection  of 
the  peritoneal  cavity. 

The  President,  Dr.  Lusk,  being  requested  to  speak, 
said  he  believed  that  all  reported  cases  of  rupture  of  the 
uterus  through  the  anterior  wall  had  terminated  fatally. 
When  the  rupture  was  complete,  but  the  child  only  partly 
extruded,  a  small  proportion  of  the  mothers  had  recov- 
ered under  vaginal  extraction  and  subsequent  drainage, 
but  unfortunately  nearly  all  of  them  had  afterward  been 
hopeless  invalids.  Therefore,  if  the  rupture  were  com- 
pletely into  the  abdominal  cavity,  and  the  woman  was  not 
moribund,  he  would  feel  safer  on  returning  home  if  he 
had  opened  and  cleansed  out  the  abdomen,  and  either 
sewed  up  the  rent  or  removed  the  uterus  according  to 
the  case. 

Dr.  Reynolds,  of  Boston,  would  not  agree  with  the 
President  that  patients  who  recovered  after  palliative 
treatment  were  hopeless  invalids,  as  out  of  four  cases  of 
rupture  of  the  uterus  seen  by  him  only  one  died,  three 
recovered,  and,  under  palliative  measures  were  healthy 
subsequently. 

Dr.  E.  C.  Davis  thought  the  thick  uterus  in  multipara 
which  had  ruptured  was  likely  to  be  friable,  very  suscep- 
tible to  infection,  offering  little  hope  of  union  by  suture ; 
therefore  removal  of  the  organ  seemed  preferable. 

Dr.  W.  M  Polk  said  he  felt,  when  brought  before  a 
case  of  rupture  of  the  uterus,  that  he  was  between  the 
devil  and  the  deep  sea — that  is,  death  of  the  patient  from 
sepsis  if  he  did  not  operate,  and  death  from  added  shock 
if  he  did.  Usually  there  was  already  a  state  of  collapse 
which  forbade  a  formidable  operation.  Owing  to  the 
fact  that  operations  per  vaginam  caused  not  more  than 
a  third  the  amount  of  shock  attending  approach  by  the 


abdomen,  one  should,  if  possible,  ligate  the  vessels  from 
below,  and  close  the  lower  uterine  rent  at  least,  or  per- 
haps do  hysterectomy  from  that  direction. 

Dr.  R.  W.  Murray,  of  New  York,  related  four  cases 
of  rupture  of  the  uterus,  the  last  one  seen  with  Dr.  Coe — 
profound  shock,  laparotomy,  death.  This  case  showed 
that  removal  of  the  uterus  (which  was  not  undertaken) 
might  prove  extremely  difficult,  if  not  impossible,  owing 
to  the  great  thickness,  oedema,  and  vascularity  of  the  tis- 
sues. Two  cases  seen  in  private  practice  recovered  under 
palliative  treatment.  If  there  was  no  doubt  of  rupture 
into  the  abdomen  he  thought  it  best  to  resort  to  coeliotomy. 


Third  Day,  Thursday,  May  31ST. 

The  Influence  of  Laceration  of  the  Perineum  on  the 
Uterus  and  the  Operation  for  its  Repair. — Dr.  W.  Gill 
Wylie,  of  New  York,  made  the  following  points  in 
this  paper :  The  main  forces  which  act  on  the  contents 
of  the  abdomen  are  the  muscles,  the  diaphragm  play- 
ing the  principal  part.  When  we  wish  to  keep  the 
abdominal  contents  quiet,  the  diaphragm  and  abdominal 
muscles  are  contracted.  The  axis  of  the  uterus  is  nor- 
mally in  line  with  the  forces  bearing  upon  it  from  above. 
When  it  is  displaced  backward  or  forward  those  forces 
strike  it  broadside  and  act  much  more  powerfully  in 
displacing  it.  The  axis  of  the  rectum  is  at  right  angles 
to  that  of  the  anus,  so  that  when  the  rectum  is  full  it  shuts 
the  anus.  The  force  which  most  influences  the  pelvic  or- 
gans is  straining  at  stool.  The  perineum  tends  to  keep 
the  anus  in  shape  with  relation  to  the  rectum.  Destroy 
the  perineal  support  of  the  rectum  and  the  straining  at 
stool  will  force  the  rectum  forward,  carrying  the  vaginal 
walls  before  it,  producing  so  called  rectocele.  In  repair- 
ing the  perineal  injury  Dr.  Wylie  made  it  one  of  the 
special  objects  to  tilt  the  so-called  rectocele  backward 
and  bring  up  the  depressed  sulci,  or  angles  on  either  side 
over  the  rectocele.  It  differed  from  Dr.  Emmet's  opera- 
tion in  one  regard  at  least,  that  is,  the  area  of  denudation 
was  solid,  whereas  in  Emmet's  a  central  portion  was  left 
undenuded.  The  external  sutures,  extending  to  the  nor- 
mal place  of  the  hymen,  did  not  exceed  four  in  number, 
the  internal  or  those  above  that  point  being  about  the 
same  in  number  and  of  silver  wire.  They  were  left  in 
three  weeks,  in  order  to  give  full  time  for  union  to  occur 
in  the  white  fibrous  tissue  where  the  lesion  had  existed 
long  enough  for  muscular  fibres  to  disappear.  If  the 
central  portion  of  the  area  of  denudation  were  left  un- 
touched it  would  not  prevent  return  of  the  rectocele. 
Where  there  was  rectocele  there  were  also  haemorrhoids ; 
hence  the  necessity  for  treating  these  and  of  stretching 
the  rectum,  a  procedure  which  he  believed  was  commonly 
omitted,  accounting,  in  part,  for  many  failures. 

The  paper  was  discussed  and  criticised  by  Drs.  Noble 
and  Skene.  The  latter  thought  no  one  procedure  adapted 
to  all  kinds  of  tears. 

The  Ultimate  Results  of  Retro-displacement  of  the 
Uterus  by  Pessaries,  with  Special  Referenoe  to  Alexan- 
der's Operation. — Dr.  Francis  H.  Davenport,  of  Bos- 
ton, read  this  paper.  The  conclusions  reached  were,  that 
in  cases  of  uncomplicated  retroflexion  or  retroversion  the 
choice  of  treatment  lay  between  the  use  of  the  pessary 
and  shortening  the  round  ligaments.  Where  the  former 
was  decided  upon  a  cure  could  be  expected  in  about 
twenty- five  per  cent,  of  the  cases.  Where  a  cure  was  ef- 
fected by  pessaries  it  was  usually  within  a  year  or  a  year 
and  a  half  after  beginning  treatment.  A  large  propor- 
tion of  the  patients  not  cured  could  still  wear  a  pessary 
without  discomfort  and  did  not  wish  an  operation.  The 
Alexander  operation  should  be  limited  to  those  cases  in 
which  a  pessary  could  not  be  worn  and  those  preferring 
it  to  the  support ;  to  cases  in  which  vaginal  support  was 
inappropriate;  also  as  supplementary  to  other  opera- 
tions. 

Dr.  Cushing  thought  the  paper  a  very  judicious  one, 
although  he  must  differ  from  some  of  the  conclusions, 
He  did  not  think  statistics  upon  cures  effected  by  pessa- 


July  21,  1894] 


MEDICAL   RECORD. 


81 


ries  of  any  value  in  the  past.  He  believed  with  the 
reader,  that  there  were  few  cases  of  backward  displace- 
ment which  could  not  be  rendered  quite  comfortable  or 
cured  by  pessary,  or  else  there  was  a  complication  which 
rendered  treatment  by  the  Alexander  operation  inappro- 
priate— usually  some  adhesive  band.  Therefore  in  a 
large  proportion  of  cases  where  pessaries  were  not  suc- 
cessful it  was  best  to  open  the  abdomen  and  discover  the 
cause,  rather  than  do  Alexander's  operation. 

Dr.  Clement  Cleveland  had  had  very  good  success 
with  the  retroversion  pessary.  If  a  permanent  cure 
could  be  effected  by  it,  it  would  usually  take  place  with- 
in a  year.  At  the  end  of  that  time  he  allowed  the 
patient  to  decide  whether  she  preferred  an  operation, 
and  if  the  case  were  a  suitable  one  and  the  round  liga- 
ments were  shortened  by  a  correct  procedure  success 
would  follow  in  at  least  seventy -five  per  cent,  of  the 
cases. 

Dr.  G.  M.  Edebohls,  of  New  York,  had  had  less 
success  in  the  cure  of  backward  displacements  of  the 
uterus  by  pessaries  than  had  been  claimed  by  some  other 
gynecologists,  and  since  his  success  with  shortening  the 
round  ligaments  by  the  method  employed  by  him  had 
been  practically  uniform  he  always  resorted  to  this  or 
else  let  the  patient  go  elsewhere  for  treatment  by  the 
pessary.  A  number  of  these  had  returned,  having  tired 
of  wearing  the  support  although  it  gave  no  special  dis- 
comfort ;  then  shortening  the  round  ligaments,  he  had 
sent  them  away  permanently  cured.  Of  course  he  was 
assuming  that  the  cases  were  suitable  ones  for  treatment 
by  either  of  these  methods. 

Dr.  Gkhrung  thought  the  percentage  of  cures  by 
pessary  was  greater  than  had  appeared  from  statistics,  for 
the  reason  that,  when  recurrence  of  the  displacement  had 
taken  place  some  time  after  leaving  off  the  use  of  the 
pessary,  the  case  had  always  been  placed  among  the  fail- 
ures, whereas  it  might  in  reality  have  been  a  cure  with 
recurrence  due  solely  to  renewal  of  the  cause.  While 
the  pessary  might  not  give  that  positive  result  produced 
by  fixation,  it  was  at  least  free  from  the  unnatural  state 
left  by  this. 

Dr.  Dickinson,  of  Brooklyn,  impressed  the  fact  that 
a  permanent  cure  of  uterine  displacement  could  not  be 
expected  so  long  as  women  continued  their  faulty  modes 
of  dress  and  occupations  which  involved  an  unnatural 
position  of  the  body,  especially  of  the  abdominal  and 
pelvic  organs,  and  destroyed  muscular  tone. 

Inflammation  of  the  Ureters  from  a  Medical  Stand- 
point.— Dr.  M.  D.  Mann,  of  Buffalo,  read  a  paper, 
considering  in  a  systematic  manner  inflammation  of  the 
ureters,  its  pathology,  causation,  treatment,  etc.  His 
knowledge  of  inflammation  of  the  ureters  began  only  a 
few  years  ago  when  Dr.  Kelly,  of  Baltimore,  called  at- 
tention to  the  condition;  while  the  disease  was  still 
scarcely  mentioned  in  the  text- books,  he  believed  it  was 
common  and  was  of  great  importance.  Among  the 
causes  he  first  mentioned  injuries  during  childbed  and 
related  a  case.  Of  ascending  ureteritis  from  bladder 
trouble,  he  had  never  seen  a  case  except  of  gonorrhoea! 
origin.  Yet  gonorrhoeal  cystitis  in  .women  did  not  often 
attract  attention.  It  was  probable  that  it  might  lurk  in 
the  ureters  after  it  had  ceased  in  the  bladders,  for  the 
reason  that  treatment  was  commonly  limited  to  the  blad- 
der in  gonorrhoeal  inflammation  which  had  extended  to 
this  organ  or  higher.  Dr.  Mann  did  not  doubt  but 
what  failure  to  relieve  pain  after  coeliotomy  was  often 
due  to  unrecognized  gonorrhoeal  inflammation  of  the 
ureters.  Where  the  ureteritis  was  due  to  inflammation 
extending  downward,  the  cause,  according  to  his  experi- 
ence, was  nearly  always  the  presence  of  renal  calculi  or 
renal  tuberculosis.  He  believed  that  symptoms  attrib- 
uted to  pressure  upon  the  bladder  by  displacement  of 
the  uterus  were  commonly  due  to  an  abnormal  condition 
of  the  urine  and  its  influence  upon  the  ureters. 

Pressure  was  recognized  by  all  writers  as  a  cause  of 
ureteritis,  and  the  author  thought  no  one  would  doubt 
but  what  a  fibroid  tumor  of  the  uterus,  an  ovarian  tumor, 


and  even  cancer  of  the  uterus  might  exert  sufficient  press- 
ure upon  the  ureters  to  cause  inflammation.  But  an  ab- 
normal condition  of  the  urine  was,  in  the  author's  opin- 
ion, the  cause  of  the  great  majority  of  cases.  In  many 
the  urine  was  excessively  acid  and  also  scanty.  While 
containing  a  variety  of  crystals,  the  total  solids  were  apt 
to  be  below  normal.  It  was  sometimes  called  the  con- 
dition of  lithaemia,  and  was  frequently  brought  about  by 
reflex  neurosis  affecting  the  digestive  organs,  and  some- 
times by  certain  foods,  strawberries  being  among  those 
which  acted  obnoxiously  in  some  people.  Tuberculosis 
of  the  ureters  had  been  occasionally  recognized. 

The  diagnosis  rested  upon  the  symptoms,  the  examina- 
tion of  the  urine,  which  should  be  chemical  and  micro- 
scopical, and  upon  palpation  and  inspection.  In  many 
instances  the  ureters  could  be  felt  thickened,  and  on  in- 
spection, which  could  easily  be  made  by  Kelly's  method, 
in  the  area  about  the  vesical  openings  of  the  ureters  might 
be  found  the  seat  of  granulations  or  ulcers,  irritation  of 
which  by  the  abnormal  urine  caused  vesical  tenesmus. 

The  treatment  was  constitutional,  local,  and  sympto- 
matic. Constitutional  treatment  was  specially  important. 
Diet  should  be  corrected,  the  urine  should  be  rendered 
alkaline  and  increased  in  quantity,  and  diaphoresis  in- 
duced at  the  beginning.  Sandal  wood  had  had  a  valu- 
able influence  through  the  urine,  also  some  other  agents 
often  given  internally  in  gonorrhoeal  urethritis.  As  to 
surgical  treatment,  the  author  had  a  few  times  catheter, 
ized  and  dilated  the  ureters,  but  without  special  result. 
Granulations  about  the  mouth  of  the  ureters  could  be 
treated  locally.  Ureteritis  was  apt  to  affect  both  canals, 
but  one  more  than  the  other. 

Drs.  Baldy,  A.  P.  Dudley,  Willis  Ford,  Cushing, 
and  the  author  participated  in  the  discussion.  Dr. 
Baldy  had  seldom  found  ureteritis,  and  thought  it  must 
be  a  rare  condition. 

Symphyseotomy  Versus  the  Induction  of  Premature 
Labor. — Dr.  C.  P.  Noble,  of  Philadelphia,  read  this 
paper.  Three  questions  were  propounded :  1.  Is  embry- 
otomy upon  the  living  child  and  deliberately  selected  a 
justifiable  operation  ?  2.  Is  it  justifiable  in  labors  not 
among  cases  of  contracted  pelvis,  yet  in  which  there  is 
considerable  obstruction  making  such  violent  efforts  at 
version  or  forceps  necessary  as  to  threaten  mother  and 
child,  instead  of  resorting  to  symphyseotomy?  3.  In 
contractions  of  moderate  degree  is  it  better  to  induce  pre- 
mature labor  sufficiently  early  to  permit  of  bringing  forth 
a  living  child,  or  to  let  pregnancy  go  to  term  and  resort 
to  symphyseotomy,  should  this  prove  necessary  ? 

Regarding  the  first  question,  craniotomy  on  the  living 
child,  Dr.  Noble  thought  it  had  been  answered  in  the 
negative.  The  problem  was  not  to  save  the  mother  alone, 
but  to  save  both  mother  and  child  by  a  procedure  which 
gave  hope  of  diminishing  the  mortality  of  both  to  that 
of  the  mother  alone  where  craniotomy  was  resorted  to. 
Dr.  Noble  also  thought  the  second  question  would  in  the 
future  be  answered  in  favor  of  symphyseotomy,  but  he 
did  not  pretend  to  express  anybody's  opinion  but  his 
own. 

In  answering  the  third  question  it  was  necessary  to 
consider  the  mortality  of  mother  and  child  in  premature 
labor  compared  with  that  in  symphyseotomy.  The  gen- 
eral mortality  to  the  mother  in  premature  labor  had  been 
given  as  five  per  cent.;  in  symphyseotomy  as  ten  per 
cent.  Dr.  Noble  believed,  that  in  both  the  figures  were 
entirely  erroneous.  Five  per  cent,  was  undoubtedly  too 
high  a  maternal  mortality  in  induction  of  premature  labor 
for  contraction;  it  should  not  be  higher  that  one  per 
cent,  in  goocU  hands.  Ten  per  cent,  mortality  for  the 
mother  under  symphyseotomy  was  also  entirely  too  high, 
as  it  represented  the  results  in  all  cases,  and  it  was  well 
known  that  the  operation  was  likely  to  be  put  off  until 
the  mother  was  in  very  bad  condition  from  use  of  for- 
ceps, etc.  In  order  to  compare  the  safety  of  the  two 
procedures  only  those  cases  of  symphyseotomy  should  be 
included  in  which  it  had  been  an  elective  operation,  re- 
sorted to  before  injuries  had  been  inflicted  by  forceps, 


82 


MEDICAL    RECORD. 


[July  21,  1894 


etc.  The  maternal  mortality  from  symphyseotomy  under 
favorable  circumstances  should  be  very  low.  The  advan 
tages  to  the  child  over  premature  labor  were  striking,  for 
many  premature  children  died  at  birth,  and  many  more 
succumbed  afterward.  The  author  narrated  a  case  which 
he  had  reported  before,  the  first  one  in  the  world  in 
which  symphyseotomy  had  been  resorted  to  in  preference 
to  premature  labor,  and  the  first  one  in  the  United  States 
in  which  the  patient  had  submitted  to  a  second  symphyse- 
otomy at  a  subsequent  pregnancy. 

The  views  of  the  author  were  substantially  agreed  with 
by  Drs.  R.  W.  Murray,  Charles  Jewett,  Engelman,  and 
Malcolm  McLean. 

Officers :  Dr.  M.  D.  Mann,  of  Buffalo,  was  elected 
President ;  Dr.  H.  C.  Coe  was  re-elected  Secretary.  The 
date  of  the  next  meeting  will  be  the  fourth  Tuesday  in 
May,  1895.     Place  yet  to  be  decided  upon. 


AMERICAN  SURGICAL  ASSOCIATION. 

Fifteenth  Annual  Meeting,  held  at  Washington,  D.  G, 
May  29,  jo,  jr,  and  June  f,  1894, 

(Continued  from  Vol.  45,  page  800  ) 

Third  Day,  Thursday,  May  31ST. 

The  Sargical  Treatment  of  the  So-called  Surgical  Kid- 
ney.—Dr.  R  F.  Weir,  of  New  York  City,  read  a  paper 
on  this  subject.  He  reported  the  case,  he  said,  in  order 
to  show  that  the  prognosis  is  not  always  as  bad  as  we 
hitherto  thought  it.  The  case  was  that  of  a  young  man 
who  had  an  attack  of  pneumonia  some  four  years  ago, 
followed  by  scarlet  fever  and  nephritis.  Albumin  and 
casts  persisted,  and  he  never  regained  his  health. 

Two  months  ago  he  had  an  attack  of  urethritis.  Gon- 
ocjcci  were  present  in  great  numbers.  It  subsided  under 
treatment  of  creoline,  silver  nitrate,  and  zinc  sulphate  solu- 
tion. Twelve  days  prior  to  his  admission  to  the  hospital, 
without  any  assignable  cause,  he  had  a  chill,  preceded  by 
a  temperature  of  1010  F.,  with  vomiting  and  diarrhoea. 
The  next  day  he  had  pain  in  the  loins,  which  was  thought 
to  be  lumbago,  but  on  the  next  day  there  was  great  ten- 
derness over  the  right  kidney. 

During  the  seven  days  between  his  admission  to  the 
hospital  and  the  operation,  he  had  four  chills,  with  tem- 
perature ranging  from  1030  F.  to  1050  F.,  pulse  116  to 
120.  He  passed  fifty  to  sixty  ounces  of  urine  daily.  It 
contained  pus.  It  was  thought  enlargement  of  the  right 
kidney  could  be  made  out,  but  I  thought  it  was  an  ab- 
scess. I  did  not  think  he  had  the  ordinary  condition 
known  as  the  surgical  kidney. 

Operation. — An  incision  was  made  and  the  kidney  ex- 
posed. It  was  twice  its  ordinary  size.  It  was  deeply 
congested  and  swollen,  particularly  on  its  inferior  sur- 
face. Puncture  with  the  aspirating  needle  gave  no  indi- 
cation of  pus,  but  an  incision  revealed  the  nature  of  the 
disease.  It  disclosed  numerous  miliary  abscesses.  The 
kidney  was  rapidly  removed  and  the  wound  packed  with 
iodoform  gauze. 

Result. — Immediately  after  the  operation  the  temper- 
ature dropped  from  1050  F.  to  990  F.,  and  then  remained 
subnormal  for  a  few  days.  The  patient  made  a  rapid  re- 
covery, and  was  discharged  from  the  hospital  three  weeks 
later.  At  the  time  of  his  discharge  the  urine  was  nearly 
normal,  and  no  treatment  was  advised  beyond  spending 
as  much  time  in  the  open  air  as  possible. 

How  often  Does  such  Unilateral  Renal  Trouble  Exist? 
— The  first  question  this  case  would  naturally  suggest  to 
all  surgeons,  is  how  often  may  such  a  fortunate  condition 
of  affairs  be  found  in  cases  of  surgical  kidney  ?  That 
this  form  of  nephritis  is  sometimes  limited  to  one  kidney, 
is  beyond  doubt.  The  statistics  of  one  man  show  that  out 
of  one  hundred  and  thirty  cases  of  surgical  kidney,  nine- 
teen were  unilateral.  From  the  hospitals  of  New  York, 
out  of  seventy-one  cases  of  miliary  abscess,  both  organs 
were  affected  in  fifty- nine,  and  only  one  organ  in  twelve 
cases,  or  about  twenty  per  cent,  of  these  cases,  might  have 
been  treated  successfully. 


Future  Prognosis. — The  speaker  could  not  help  feeling 
more  hopeful  in  the  treatment  of  these  cases  than  in  the 
past.  Even  where  both  organs  are  involved,  something 
should  be  done  in  the  way  of  evacuating  the  pus.  Where 
the  patient's  condition  warrants  it,  and  especially  when 
there  are  symptoms  pointing  to  one  side,  it  is  justifiable 
to  make  exploratory  incisions  on  one  or  both  sides. 

Surgery  of  the  ureters. — Dr.  Christian  Fenger,  of 
Chicago,  read  the  paper. 

Discussion. — The  papers  read  by  Drs.  Tiffany,  Weir, 
and  Fenger  were  discussed  together. 

Dr.  Richardson,  of  Boston,  said  the  examination  of 
the  urine  prior  to  operation  was  most  important,  as  it  was 
often  the  deciding  point  in  doing  operations  which  were 
not  absolutely  necessary.  In  removing  a  kidney  he 
would  prefer  to  go  through  the  abdomen,  which  gave  you 
a  better  opportunity  to  avoid  or  control  hemorrhage. 
The  incision  should  be  large  enough  to  permit  the  exam- 
ination of  both  kidneys.  This  would  also  avoid  the  dan- 
ger, in  unilateral  trouble,  of  removing  the  only  kidney 
the  patient  might  possibly  have. 

Dr.  Mudd,  of  St.  Louis,  thought  the  low  temperature 
and  the  quantity  of  urine  passed  to  be  a  better  indication 
than  albumin  or  casts.  He  also  thought  as  much  of  the 
kidney  as  possible  should  be  saved,  as  the  kidney  had 
great  reparative  power ;  also,  that  it  was  disastrous  to  re- 
move the  kidney  immediately  after  an  injury,  before  the 
patient  had  recovered  from  the  shock  of  the  accident. 
He  thought  it  was  very  difficult  to  determine  by  handling 
whether  you  had  good  kidney  material  or  not.  He  did 
not  approve  of  the  abdominal  incision,  unless  you  were  in 
doubt  about  the  other  kidney,  as  hemorrhage  could  be 
controlled  just  as  well  from  behind. 

Dr.  Nancrede  was  opposed  to  the  abdominal  opera- 
tion, owing  to  the  danger  of  infection  from  the  pus  which 
might  possibly  escape  into  it.  He  insisted  upon  being 
sure  the  patient  had  two  kidneys  before  removing  one. 

Dr.  Carmalt,  of  New  Haven,  said  in  searching  for 
both  kidneys  you  should  bear  in  mind  the  abnormal  po- 
sitions which  may  exist.  In  one  post-mortem  case  he 
found  the  left  kidney  low  down  in  the  pelvis,  and  in  this 
case  a  possible  mistaken  diagnosis  of  one  kidney  might 
have  been  made. 

The  paper  was  further  discussed  by  Drs.  Prewitt, 
Deever,  of  Philadelphia;  Gaston,  of  Atlanta;  Fenger,  of 
Chicago ;  and  Forbes,  of  Philadelphia.  The  last-name^ 
gentleman  exhibited  an  indigo  stone  weighing  one  hun- 
dred and  forty-seven  grains,  with  the  interesting  state- 
ment that  the  patient  had  no  renal  symptoms,  showing 
an  unusual  tolerance  by  the  kidney  of  such  a  large  for- 
eign body. 

Treatment  of  Malignant  Tumors  with  the  Toxinei  of 
Erysipelas. — Dr.  William  B.  Coley,  of  New  York,  read 
the  paper.  He  began  this  treatment  of  multiple  sar- 
coma by  repeated  injections  of  living  cultures  of  erysipe- 
las streptococci  in  1891,  and  gave  the  account  of  ten 
cases.     Six  were  sarcoma  and  four  carcinoma. 

In  four  cases  erysipelas  was  produced,  but  the  marked 
improvement  in  the  cases  where  erysipelas  was  not  pro- 
duced led  the  speaker  to  believe  that  the  curative  action 
was  due  to  the  toxines,  rather  than  to  the  germ  itself. 

In  1892  he  experimented  with  bouillon  cultures  pre- 
pared by  heating  to  ioo°  C,  and  the  effect  was  slightly 
less  than  when  living  cultures  were  used. 

Early  in  1893  he  began  using  cultures  filtered  through 
porcelain  without  subjecting  it  to  heat.  The  toxines  of 
the  bacillus  prodigiosus  prepared  in  the  same  way  were 
used  in  conjunction  with  the  erysipelas  toxines  which  in- 
tensified the  action  of  the  erysipelas  toxines  on  the  sar- 
coma, and  was  much  more  effective  than  that  of  the  ery- 
sipelas toxine  alone. 

Toxine  Must  be  Fresh. — The  toxine  to  be  of  value 
must  be  freshly  prepared  from  very  virulent  cultures. 
All  successful  cases  were  from  cultures  made  from  fatal 
cases  of  erysipelas. 

Results. — Of  twenty  five  cases  of  sarcoma  treated,  six 
were  cured  without  any  recurrence;  nine  showed  marked 


July  21,  1894] 


MEDICAL    RECORD. 


83 


improvement ;  eight,  improvement  slight ;  and  two,  no 
improvement. 

Of  eight  cases  of  carcinoma,  all  but  one  showed  more 
or  less  improvement,  and  in  three  cases  the  improvement 
was  marked. 

The  diagnosis  of  all  these  cases  was  established  by  em- 
inent surgeons  and  pathologists. 

How  do  the  Toxines  Cure  ? — No  rational  explanation 
of  the  action  of  the  toxines  on  malignant  tumors  can  be 
offered,  except  on  the  assumption  that  such  tumors  are  of 
micro-parasitic  origin.  Admitting  this  theory,  explana- 
tion would  be  easy,  viz.:  antagonistic  bacterial  action. 

The  following  were  the  conclusions  of  the  paper:  1. 
The  curative  action  of  erysipelas  upon  malignant  tumors 
is  an  established  fact.  2.  The  action  is  more  powerful 
upon  sarcoma  than  carcinoma.  3.  The  action  is  chiefly 
due  to  the  soluble  toxines  which  may  be  isolated  and 
used  with  safety  and  accuracy.  4.  The  action  is  greatly 
increased  by  the  addition  of  the  toxines.  5 .  The  toxines, 
to  be  of  any  value,  must  be  fresh  and  from  virulent  cultures. 
6.  The  results  obtained  from  toxines,  without  danger,  are 
nearly  so,  if  not  quite,  equal  to  those  obtained  from  a  fresh 
attack  of  erysipelas,  and  inoculations  should  rarely  be  re- 
sorted to. 

Dr.  Keen,  of  Philadelphia,  had  treated  seven  patients 
in  the  same  way  and  manner,  but  in  not  one  of  these 
cases  had  there  been  even  an  arrest  of  growth.  He  had  ob- 
tained reactions  as  high  as  103  °  to  1040  F.,  while  in  some 
cases  no  reaction  took  place.  He  injected  in  the  tissues 
in  some  cases,  and  directly  into  the  tumor  in  others. 

In  one  case  there  was  a  breaking  down  of  the  growth, 
but  when  the  use  of  the  toxines  was  discontinued,  the 
case  went  on  rapidly.  He  had  never  seen  any  harm  done 
further  than  the  rise  of  temperature.  As  his  experience 
with  the  toxines  had  been  limited,  he  could  not  hope  to 
obtain  as  good  results  as  Dr.  Coley. 

Dr.  Park,  of  Buffalo,  had  inoculated  cases  with  erysip- 
elas from  patients  in  the  hospital  wards,  without  results. 
He  got  some  culture  from  Dr.  Coley,  but  the  results  were 
no  better  than  those  obtained  by  Dr.  Keen.  He  thought 
it  a  case  of  different  men  working  in  the  same  manner 
and  obtaining  different  results,  the  most  experienced  get- 
ting the  best  results. 

Dr.  Warren's  experience  was  similar  to  that  of  Drs. 
Keen  and  Park,  but  thought  the  subject  should  be  en- 
couraged in  every  way,  and  conclusions  should  not  be 
jumped  at.  The  question  of  the  character  of  the  reaction 
he  thought  an  interesting  one.  It  was  thought,  where  the 
injection  was  in  the  tissues,  a  fatty  degeneration  of  the 
cells  of  the  sarcoma  took  place,  but  when  the  tumor  was 
injected  it  was  a  necrosis.  It  should  also  be  remem- 
bered that  all  the  cases  were  selected  as  inoperable. 

Dr.  Richardson  stated  that  one  of  the  successful  cases 
was  sent  by  him  to  Dr.  Coley.  In  this  case  there  was  no 
doubt  whatever  about  the  nature  of  the  disease,  and  with- 
out this  treatment  the  patient  would  have  died.  The 
case  was  a  perfect  cure. 

Venous  Tumor  of  the  Diploe  was  the  title  of  a  paper 
read  by  Dr.  L.  S.  Pilcher,  of  Brooklyn. 

History. — The  patient,  a  girl,  fifteen  years  of  age,  at 
the  age  of  five,  fell,  striking  on  the  top  of  her  head.  In 
a  few  days  afterward  a  small,  soft  swelling  appeared,  grad- 
ually increasing  in  size,  causing  no  pain  or  tenderness. 
At  the  end  of  five  years  it  was  lanced  and  a  small  quan- 
tity of  blood  evacuated.  The  swelling  immediately  re- 
filled. It  was  lanced  again  in  a  few  years  afterward,  with 
similar  results.  Nothing  further  was  done  until  her  ad- 
mission into  the  hospital. 

When  admitted  she  presented  a  tumor  over  the  anterior 
fontanelle.  It  was  covered  with  a  thin  skin,  devoid  of 
hair,  and  of  a  bluish  hue.  It  was  soft  and  fluctuating,  and 
diminished  slightly  under  pressure.  It  had  been  enlarg- 
ing and  was  on  the  point  of  bursting. 

Operation. — On  March  14th  the  tumor  was  incised. 
It  consisted  of  a  small  blood-clot  and  fluid  blood.  The 
tumor  was  fed  by  several  channels  leading  from  the  veins 
into  it.      Hemorrhage  was  controlled  by  pressure   and 


tampons.     The  entire  cavity  was  thoroughly  curetted  and 
tamponed  with  gauze,  and  the  opening  sutured. 

•  The  interesting  feature  of  this  case  is  the  fact  that  it 
was  not  a  dilatation  of  any  blood-vessel,  but  a  true  trau- 
matic tumor;  being  an  adventitious  blood-space  fed  by 
channels  from  the  blood-vessels. 

Strangulation  of  Meckel's  Diverticulum. — Dr.  J.  W. 
Elliott,  of  Boston,  reported  the  case.  The  interesting 
features  were  the  symptoms  presented  by  the  patient,  all 
of  which  pointed  to  appendicitis.  Under  manipulation 
a  large,  hard  mass  was  felt  in  the  abdomen.  A  vertical 
incision  was  made  in  the  abdomen,  and  the  appendix 
found  to  be  normal,  and  the  true  nature  of  the  trouble 
revealed.  The  patient  subsequently  died  from  septic 
peritonitis. 

The  paper  was  discussed  by  Drs.  C.  Fenger,  of  Chica- 
go ;  Tiffany,  of  Baltimore ;  and  White,  of  Brooklyn, 
N.  Y.  In  the  discussion  attention  was  called  to  the  fact 
that  a  tumor  near  the  umbilicus  should  direct  attention 
to  the  diverticulum. 

The. Removal  of  Stone  in  the  Bladder. — Dr.  W.  S. 
Forbes,  of  Philadelphia,  read  a  paper  on  this  subject  and 
presented  a  new  lithotrite.  Given  the  problem  of  a  stone 
in  the  bladder,  a  limited  viaduct  through  which  to  reach 
and  remove  it  without  injury  to  the  parts,  we  have  two 
unknown  factors,  viz. :  the  crushing  resistance  of  the 
stone,  and  the  strength  of  the  lithotrite. 

Crushing  Resistance  —  How  Obtained.  —  The  exact 
crushing  resistance  of  a  stone  has  never  been  stated  by 
any  writer,  except  in  vague  terms,  as  tough,  etc.  The 
same  may  be  said  of  the  description  of  the  strength  of  the 
lithotrite,  as  strong,  powerful,  etc.,  all  oT  which  mean 
anything  and  nothing. 

In  order  to  attain  the  necessary  knowledge  in  the  ques- 
tion, it  is  necessary  to  measure  the  crushing  resistance  of 
a  large  number  of  stones  taken  from  the  human  bladder. 
The  conditions  of  science  should  be  weighed,  as  it  were, 
in  the  fine  scales  of  the  jeweller.  A  very  large  number 
of  stones  were  tested  in  the  lithotrite,  which  was  placed 
in  and  worked  by  a  very  powerful  machine,  so  delicately 
and  accurately  constructed  and  adjusted  that  every  ounce 
of  force  applied  in  crushing  the  stone  was  recorded. 

The  New  Lithotrite  has  all  of  the  elements  contained 
in  the  Bigelow  and  Thompson,  but  the  construction  and 
general  lines  of  it,  however,  are  entirely  original  and 
widely  different  from  any  lithotrite  now  in  existence. 
The  penile  and  vesicle  ends  consist  of  a  male  blade  sliding 
within  a  female  blade  and  held  within  the  latter  by  a 
slightly  angular  undercut  slot.  This  prevents  the  male 
blade  rising  out  of  the  female  blade  when  under  a  strain. 
The  greater  the  strain  the  tighter  it  is  held. 

The  long  axis  of  the  shaft  is  straight  to  within  two 
inches  of  the  crook  or  curve,  and  here  rises  to  an 
angle  of  about  three  degrees  until  it  meets  the  curve. 
This  accomplishes  six  important  objects:  easy  intro 
duction  of  the  instrument  over  the  urethra;  increases 
strength  of  female  blade  by  giving  it  support  higher 
up;  allows  a  larger  stone  being  grasped  without  in- 
curring a  longer  female  blade ;  places  the  metal  of  the 
female  shaft  where  it  is  most  needed;  prevents  side 
movement  or  twisting  of  the  male  blade  by  giving  it  a 
deeper  slot  to  move  in,  thereby  supporting  it  higher  up ; 
the  angle  between  the  female  blade  and  the  long  axis  of 
the  shaft  is  the  same  as  if  the  shaft  was  straight  all  the 
way  to  the  curve ;  the  female  blade  has  its  proximal  sur- 
face concave  and  prevents  calculus  slipping  out  when  the 
power  is  applied,  and  tends  to  give  strength  to  the  instru- 
ment ;  it  is  elliptical  and  uniform  in  size  to  within  three 
inches  of  the  crook,  and  here  increases  slightly  in  calibre 
until  it  reaches  the  maximum,  which  is  at  the  crook,  giv- 
ing great  strength  to  the  female,  where  it  is  most  needed, 
and  places  the  extra  metal  within  the  bladder  and  pros- 
tatic portion  of  the  urethra,  where  it  is  easily  accommo- 
dated. 

The  shoe  of  the  female  blade  is  larger  than  the  male 
blade,  so  that  all  debris  is  expelled  and  impaction  of  the 
instrument  is  prevented,  and  the  wall  of  the  bladder  pro- 


84 


MEDICAL  RECORD. 


[July  21,  1894 


tected  from  being  cut  or  pinched.  The  female  blade 
is  elliptical,  giving  thick  septum,  without  increasing  the 
calibre  of  the  shaft.  The  female  blade  is  made  thin  fore 
and  aft,  taking  up  less  room  in  the  bladder.  The  proxi- 
mal surface  of  the  female  blade  is  in  the  form  of  a  wedge 
of  about  forty  five  degrees,  in  order  to  penetrate  the  calcu- 
lus with  the  least  power  of  propelling  force.  The  cross 
ridges  on  the  proximal  surface  of  the  male  blade  prevent 
the  stone  flying  when  broken,  and  the  parallel  spillways 
permit  the  debris  to  escape  without  causing  impaction  of 
the  instrument.  The  spur  rises  to  a  greater  height  on 
the  male  blade,  to  give  it  greater  strength.  This  spur 
interferes  in  no  way  with  the  holding  of  the  stone,  if  it 
does  not  touch  it.  The  great  breadth  of  the  septum  of 
the  female  blade  is  permitted  by  the  elliptical  shaft. 

Handle  or  Screw  Mechanism. — The  handle  or  screw 
mechanism  is  of  the  interrupted  screw  type.  It  consists 
of  the  internal  screw  throughout  the  barrel  having  the 
threads  cut  away  for  the  entire  length  of  the  barrel  at 
alternate  spaces  of  ninety  degrees  each. 

The  screw  barrel  has  an  end  movement  in  the  cylindri- 
cal barrel  of  about  one-sixteenth  inch.  Working  In  this 
barrel  is  a  pair  of  screw  blocks  with  interrupted  screw 
threads  alternating  spaces  of  ninety  degeees  each,  so  that 
they  may  slide  up  and  down  the  barrel  without  engaging, 
but  by  turning  the  handle  they  engage  immediately. 
One  screw  block  is  rigidly  keyed  to  the  screw  handle 
shaft,  and  the  other  so  formed  that  it  has  a  motion  of 
ninety  degrees  around  the  handle  shaft.  When  turned 
to  the  right  it  locks  or  engages.  When  the  calculus  is 
crushed,  the  instrument  may  be  unlocked  simply  by 
turning  the  handle  to  the  left  until  it  stops,  which  is 
never  more  than  half  a  turn. 

Owing  to  the  one  sixteenth  inch  play  of  the  screw 
barrel,  the  cylindrical  handle  readily  adjusts  itself  to  en- 
gage the  threads  of  the  screw  block,  and  the  calculus  is, 
therefore,  never  dropped,  in  order  to  locate  the  instru- 
ment. 

Slow  Thread. — The  screw  thread  is  made  slow  to  in- 
crease the  crushing  strength  and  for  the  important  factor 
of  time.  A  certain  pressure  may  be  applied  to  a  stone 
without  crushing  it,  which,  if  allowed  to  remain  acting 
upon  the  stone  for  a  short  time,  will  crumble  it  without 
further  pressure,  and  thus  the  instrument  is  not  unduly 
strained  The  screw  handle  is  larger  than  the  ordinary 
one.  It  is  made  of  very  thin  sheet  metal ;  strong  and 
light  as  the  lightest  handle  now  employed. 

The  instrument  has  broken  one  hundred  and  fifty- 
eight  calculi,  of  various  shapes,  sizes,  and  degrees  of 
hardness  in  the  testing  machine,  and  been  subjected  to  a 
pressure  of  five  hundred  pounds  between  the  blades  thir- 
teen times.  Its  ultimate  strength  after  this  trying  or- 
deal was  six  hundred  and  fifty  pounds.  Moreover,  after 
this  enormous  pressure,  the  instrument  was  closed  and 
could  have  been  introduced  and  withdrawn  from  the  liv- 
ing human  bladder  with  ease,  and  without  injury  to  the 
parts. 

Extirpation  of  the  Larynx. — Dr.  W.  H.  Carmalt, 
of  New  Haven,  read  a  paper  with  this  title,  dealing 
chiefly  with  the  after  effects.  He  operated  with  the  idea 
of  doing  away  with  the  opening  into  the  mouth.  Many 
had  doubtless  seen  the  case  of  a  man  whose  larynx  was 
taken  out,  who  was  afterward  able  to  sing  and  speak ; 
and  this,  without  any  communication  between  the  mouth 
and  lungs.  The  opening  of  the  trachea  being  directly 
above  the  sternum.  The  man  swallows  a  certain  quan- 
tity of  air  and  makes  a  little  puffing  around  the  trachea ; 
holding  this  for  a  few  moments  he  is  enabled  to  speak. 
He  is  able  to  count  up  to  twenty  when  he  stops  and  re- 
fills his  mouth  with  air.  In  the  speaking  case,  it  was  de- 
termined to  close  the  upper  opening  in  extirpating  the 
larynx. 

History  of  the  Case. — Two  years  ago  the  man  com- 
plained of  hoarseness.  Examination  revealed  only  a 
swelling  of  the  right  vocal  cord.  He  passed  out  of  ob- 
servation until  four  months  before  the  operation,  when 
he  again  came  under  observation  with  a  distinct  swelling 


of  the  vocal  cords  and  the  parts  above.  He  again  passed 
out  of  observation  until  about  two  weeks  before  his  ad- 
mission to  the  hospital,  when  he  was  threatened  with  suf- 
focation. 

The  attacks  of  dyspnoea,  under  local  applications,  be- 
came less  until  after  five  days,  when  he  had  an  attack  of 
dyspnoea  one  night  that  required  tracheotomy  to  prevent 
death.  His  symptoms  subsided,  and  we  were  able  to  wait 
and  prepare  for  the  necessary  steps  of  the  operation. 

Operation. — The  entire  larynx  was  involved  with  a 
cancerous  growth  which  extended  to  the  trachea,  which 
condition  was  not  revealed  by  the  laryngoscope. 

The  entire  larynx,  together  with  the  first  ring  and  up- 
per half  of  the  second  and  third  rings  of  the  trachea,  were 
removed  and  the  opening  into  the  mouth  closed.  The 
epiglottis  was  not  removed. 

Result. — The  day  following  the  operation  he  was  able 
to  swallow  his  food. 

The  operation  was  performed  on  the  5th  day  of  April, 
and  his  recovery  has  been  uninterrupted.  He  is  achiev- 
ing a  voice,  though  it  is  a  poor  one.  He  is  able  to  whis- 
per. 

The  principal  object  of  this  paper  is  to  call  attention 
to  the  fact  that  an  artificial  larynx  is  unnecessary. 

Dr.  Forbes  called  attention  to  the  patient  who  had 
been  operated  upon  in  Philadelphia,  and  said  the  patient's 
ability  of  speaking  was  due  to  his  ability  of  keeping  the 
air  in  his  throat,  on  the  same  principle  as  the  Scotch  bag- 
pipe j  and  by  practice  he  will  improve  in  both  length 
and  quality  of  speech  up  to  a  certain  point.  He  cannot 
vary  his  voice,  such  as  elevate  or  depress  it  The  note 
is  no  more  than  the  same  as  the  bagpipe ;  a  monotonous 
drone,  but  it  is  superior  to  an  artificial  larynx. 

Dr.  Hingston,  of  Canada,  said  one  man  had  his 
tongue  removed,  and  could  speak ;  another  had  his  jaw  re- 
moved and  could  speak ;  and  now  here  is  a  man  without 
a  larynx  and  also  able  to  speak.  He  thought  it  difficult 
to  say  which  was  the  principal  organ  of  speech. 

The  President  closed  the  session  with  a  short  farewell 
address,  and  the  meeting  adjourned  until  its  next  annual 
meeting,  to  be  held  in  New  York  in  the  spring  of  1895. 

The  following  officers  were  elected  for  the  ensuing 
year:  President,  Dr.  F.  S.  Dennis,  of  New  York;  Vice- 
Presidents,  Drs.  D.  J.  R.  Weist,  of  Richmond,  Ind.,  and 
J.  B.  Roberts,  of  Philadelphia;  Secretary,  Dr.  M.  H. 
Richardson,  of  Boston ;  Recorder,  Dr.  DeForrest  Wil- 
lard,  of  Philadelphia ;  Treasurer,  Dr.  N.  P.  Dandridge, 
of  Cincinnati. 


AMERICAN  PEDIATRIC  SOCIETY. 

Sixth  Annual  Meeting,  held  in  Washington,  D.  C,  May 
*9>  3°>  31*  and  June  1,  1894. 

(Continued  from  Vol.  45,  p.  770.) 

Third  Day,  Thursday,  May  31ST. 
Dr.  F.  Forchheimer  in  the  Chair. 

The  Vutritional  Element  in  the  Causation  of  Venroses. 

— Dr.  Christopher,  of  Chicago,  read  a  paper  with  this 
title.  He  began  his  remarks  on  the  triad  of  hereditary, 
anaemia,  and  local  reflex  causes,  as  given  by  Rachford. 
But  as  neuroses  often  occur  in  those  not  anaemic,  i.e., 
oligocythemic,  the  term  malnutrition  is  preferable. 
The  chemical  composition  of  the  nutritional  supply  may 
be  at  fault. 

As  a  definition  "  a  neurosis  is  a  group  of  phenomena 
resulting  from  abnormal  action  or  nutrition."  It  may 
be  due  to  :  1,  Chemically  abnormal  nutrition  ;  2,  physi- 
cally abnormal,  as  heat  or  cold ;  3,  a  toxine ;  or  4,  occur 
under  improper  trophic  influences.  Such  tissue  starva- 
tion may  be  due  to  deficient  quantity  of  nutrition  or  a 
food  incomplete  in  parts  of  its  composition,  e.g.,  fat- 
starvation  =  rickets ;  starvation  of  salts  =  scorbutus. 

Not  all  proteids  are  equally  available  in  digestion,  but 
milk  gives  several,  all  of  which  are  readily  convertible. 
Complete  and  incomplete  starvation  of  tissue  may  coex- 
ist    Hence  we  have  physiological  starvation.     We  may 


July  21,  1894] 


MEDICAL  RECORD. 


85 


also  have  pathological  starvation  from  syphilis,  tubercle, 
etc. 

The  author  counts  the  sweating  of  rickets  a  neuro- 
sis of  fat- starvation.  Under  heredity  he  says,  atavism, 
morphologically,  is  of  no  account,  but  chemically  it 
gives  rise  to  clashing  of  functions  resulting  in  lithsemia, 
for  example.  Neuroses  are  due  to  perverted  action,  but 
as  this  may  occur  in  various  tissues,  the  term  "  histoses  " 
is  suggested. 

Dr.  Rotch  endorsed  the  conclusions  regarding  fat- 
starvation  and  said  that  he  was  making  careful  analyses 
of  the  salts  of  milk,  which  he  hoped  would  prove  of  much 
value  in  our  understanding  the  management  of  rickets 
and  scorbutus. 

A  Case  of  Cyanosis. — Dr.  William  P.  Northrup,  of 
New  York,  exhibited  the  heart  of  a  case  of  congenital 
cyanosis,  which  lived  to  four  and  a  half  years  notwith- 
standing severe  attacks  of  measles  and  pertussis.  The 
heart  showed  a  narrow  pulmonary  artery,  an  opening 
between  the  right  ventricle  and  auricle,  and  hypertrophy 
of  the  right  ventricle.  The  cornus  arteriosus  was  oblit- 
erated, the  foramen  ovale  closed.  As  symptoms  the  child 
had  the  typical  sluggish  peripheral  circulation,  clubbed 
fingers,  constant  dyspnoea,  and  a  purring  thrill  over  the 
base  of  the  heart  with  a  systolic  murmur  in  the  left  third 
interspace.  The  trouble  appeared  due  to  early  foetal  en- 
docarditis. 

The  question  for  discussion  was  whether  cyanosis,  a 
symptom,  should  continue  as  a  name  for  a  disease. 
Most  of  those  present  seemed  to  favor  calling  such  cases 
malformation  of  the  heart,  abandoning  the  term  "  cya- 
nosis." 

nomenclature  of  Diseases  of  the  Mouth  and  of  the 
Gastroenteric  Traot. — The  committee  on  revision  of 
this  subject  presented  its  report  through  the  chairman. 

The  report  was  adopted,  and  will  appear  in  full  later 
in  the  Archives  of  Pediatrics.  The  idea  in  the  revised 
nomenclature  is  to  eradicate  old  and  useless  names,  and 
to  adopt  a  nomenclature  such  as  will  enable  men  in  dif- 
ferent parts  of  the  world  to  understand  what  each  is 
writing  about. 

Election  of  Officers.  —  The  following  officers  were 
elected :  President,  Dr.  F.  Forchheimer,  of  Cincinnati, 
O. ;  First  Vice-President,  Dr.  Lewis  Starr,  of  Philadel- 
phia, Pa.;  Second  Vice  President,  Dr.  August  Seibert,  of 
New  York  City ;  Secretary,  Dr.  Samuel  S.  Adams,  of 
Washington,  D.  C.  ;  Treasurer,  Dr.  C.  W.  Townsend, 
of  Boston,  Mass.;  Recorder,  Dr.  Dillon  Brown,  of  New 
York  City;  Member  of  Council,  Dr.  B.  K.  Rachford. 

The  Early  Diagnosis  of  Pott's  Disease. — Dr.  Dillon 
Brown,  of  New  York,  then  presented  a  long  and  thor- 
ough study  of  "The  Early  Diagnosis  of  Pott's  Disease 
of  the  Spine  in  Children.' '  The  author  went  carefully 
into  the  differential  points  between  this  disease  and 
others  simulating  it,  or  remotely  connected  therewith. 
He  cited  many  cases  in  which  the  patients  had  been 
treated  for  dyspepsia,  peritonitis,  cold  abscesses,  rheu- 
matism, paralysis,  etc.,  the  real  lesion  remaining  long 
unrecognized  or  being  only  found  upon  autopsy. 

On  the  other  side,  cases  were  recorded  having  a  diag- 
nosis of  spinal  caries,  which  proved  to  be  sarcoma  of 
bone,  a  glioma  of  cervical  medulla,  and  the  like.  As 
nearly  all  these  cases  were  reported  by  men  of  large  ex- 
perience, it  shows  the  necessity  of  great  care  and  exact- 
ness in  diagnosis  as  well  as  treatment.  The  disease  is 
now  recognized  as  a  chronic  tubercular  lesion  of  the 
vertebra,  and  as  ninety  per  cent,  of  cases  occur  in  child- 
hood, we  must  be  on  our  guard.  The  presence  of  syph- 
ilis or  traumatism  as  a  cause  must  be  sought  for.  Rheu- 
matism is  to  be  excluded  by  treatment  if  the  symptoms 
are  uncertain. 


Fourth  Day,  Friday,  June  ist. 

Infantile  Myxedema. — Dr.  William  P.  Northrup,  of 
New  York,  read  the  paper,  which  was  a  preliminary  report 
of  two  cases  being  treated  by  thyroid  extract.     In  future 


further  account  will  be  given  of  their  progress.  The 
first,  a  girl,  nine  years  of  age,  was  of  good  family  history, 
the  parents  non  consanguineous.  She  had  lived  in  Ohio 
and  Pennsylvania.  She  had  grown  none  since  nine  months 
of  age,  and  had  but  fourteen  deciduous  teeth.  She  pre- 
sented the  usual  characteristics  of  cretins,  puffy  look, 
parchment  like  skin,  flat  nose,  swollen  tongue,  protuber- 
ant belly,  and  umbilical  hernia.  She  could  say  only  one 
word,  but  was  of  lively  disposition.  This  child  was 
treated  for  eighty  days  with  glycerine  extract  of  sheep's 
thyroid.  The  dose,  one  minim,  three  times  a  day,  in- 
creasing a  minim  a  day  until  the  temperature  remained 
at  ioo°  F.  At  the  end  of  eighty  days  the  child  was 
much  improved,  taking  more  food,  and  having  a  brighter 
countenance. 

The  second  case  was  twelve  years  of  age.  The  same 
treatment  was  employed,  but  the  results  were  less  marked. 

Successful  Treatment  of  Infantile  Myxcedema — Dr. 
Osler,  of  Baltimore,  then  read  a  paper  with  this  title. 

Case  I.  was  a  boy,  aged  four  years  and  eight  months,  who 
took  one  quarter  of  the  thyroid  gland  of  a  sheep  each 
twenty- four  hours.  After  a  time  this  was  administered 
desiccated.  In  fourteen  months  the  boy  grew  four 
inches,  an  unusual  increase.  He  now  walks  and  runs 
about,  and  has  gained  so  much  mentally  that  few  would 
think  him  "  queer.'1  The  myxedematous  appearance  is 
all  gone. 

Case  II.  was  a  male,  aged  nineteen,  who  made  no 
material  gain,  partly  because  treatment  was  omitted  for 
three  months. 

The  third  case  was  lost  track  of. 

In  discussion  Dr.  Carr  referred  to  Dr.  Crary's  case, 
which  is  growing  rapidly  and  gaining  mentally. 

Dr.  Forchheimer  related  three  cases  under  his  ob- 
servation. In  the  first  patient,  a  boy,  aged  nineteen, 
the  thyroid  extract  had  to  be  discontinued  because  of 
the  maniacal  excitement  it  produced.  A  second  case, 
aged  eleven  months,  is  improving  on  the  extract.  In 
Case  III.,  aged  four  years,  there  is  no  change.  The 
treatment  gives  promise  of  benefit,  therefore,  but  is  not  a 
certain  cure. 

Acute  Pyelitis  in  Infants. — Dr.  L.  Emmet  Holt,  of 
New  York,  read  a  clinical  paper  on  the  above  topic. 
Acute  pyelitis  may  follow  any  other  acute  disease.  Case 
I.  was  a  child,  eight  months  old,  nursed.  It  suddenly 
had  a  temperature  of  103.5 °  without  any  discovered  local 
cause,  pneumonia  was  suspected.  The  urine  was  collected 
in  a  two  ounce  conical  glass  and  showed  three  quarters  of 
an  inch  of  pus  and  a  trace  of  albumin ;  there  were  no 
casts,  nor  was  any  treatment  instituted.  The  child  is 
now  well. 

Case  II.  was  a  female  child,  aged  eight  months,  who 
had  been  nine  days  ill.  The  temperature  ranged  from 
1030  to  1060  F.  Symptoms  all  negative  but  pneumonia 
suspected  as  before.  On  the  eleventh  day  the  urine 
showed  pus  and  albumin  with  bladder  epithelium,  but  no 
casts.  There  was  no  dropsy.  Two  days  later  the  urine 
contained-eight  per  cent,  of  pus.  The  child  took  twenty 
grains  of  citrate  of  potash  daily,  and  in  three  weeks  all  pus 
had  disappeared. 

Case  III.  was  aged  nine  months ;  previously  never  ill. 
The  child  had  repeated  chills  in  one  day  and  a  tempera- 
ture reaching  1040  F.  in  the  rectum.  Between  chills  the 
temperature  would  fall  to  normal  and  all  appear  well. 
Two  grain  doses  of  quinine  were  given  every  three  hours. 
On  the  fourth  day  the  child  took  fourteen  grains  of  qui- 
nine. Little  urine  was  passed,  and  that  with  pain.  It 
contained  one-fifth  pus  and  a  little  albumin ;  specific 
gravity,  1. 01 2.  On  the  sixth  day  sixteen  ounces  of  urine 
was  passed  without  irritation  of  the  bladder.  However, 
the  child  took  but  half  its  usual  amount  of  food.  The 
irregular  fluctuations  of  temperature  continued  and  a  few 
granular  casts  were  found  in  the  urine.  Although  the 
spleen  was  at  no  time  enlarged,  Dr.  Ripley,  the  con- 
sultant, advised  more  quinine  hypodermically.  Eighty 
grains  were  thus  administered  in  seventy- two  hours 
without  bad  effect.     The  chills  and  fluctuation  of  tern- 


86 


MEDICAL  RECORD. 


[July  21,  1894 


perature  were  stopped.  Lithia  water  and  hot  fomentations 
were  used  as  treatment.  The  urine  now  was  alkaline  in 
reaction,  sp.  gr.,  1.007,  contains  albumin,  3.6  grains 
of  urea  per  day,  a  few  red  and  many  white  blood-cells, 
with  bladder  epithelium. 

In  review  the  author  noted  that  the  first  case  was  mild 
and  recovered  without  treatment.  The  second  case  had 
a  temperature  about  1050  F.  for  twelve  days,  not  affected  by 
quinine.  Though  the  temperature  was  higher  there  was 
little  prostration.  This  case  occurred  during  the  influ- 
enza epidemic,  and  had  no  suspicion  of  malaria  about  it. 
The  etiology  of  Case  III.  is  doubtful ;  was  it  septic  or 
malarial  ? 

Dr.  Osler  mentioned  a  case,  three  years  of  age,  who 
had  recurring  chills  several  months.  After  each  chill  the 
urine  would  be  turbid,  acid,  and  full  of  pus.  Although 
the  spleen  was  not  enlarged,  the  boy  had  been  saturated 
with  quinine.  Treatment  was  thought  of  no  further 
avail,  but  the  boy  having  a  phimosis,  the  father  wished 
that  remedied.  There  was  no  return  of  the  attacks  after 
the  circumcision.  The  speaker  believes  that  malaria  may 
be  excluded  without  a  blood  examination.'  It  is  a  rule 
that  a  fever  that  resists  quinine  is  not  due  to  malaria. 

Dr.  Seibert  suggested  vulvo  vaginal  catarrh  extending 
into  the  bladder  or  farther  and  causing  suppuration. 

Dr.  Holt,  in  closing,  said  it  had  been  his  fortune  to  see 
a  number  of  cases  of  purulent  infiltration  of  the  kidneys, 
all  of  whom  died.  Such  cases  were  quite  distinct  from 
pus  in  the  pelvis  of  the  kidney.  The  absence  of  mucus 
and  of  alkalinity  assures  the  case  not  being  cystitis. 

Giant  Fingers. — Dr.  F.  Huber,  of  New  York,  ex- 
hibited a  plaster  cast  and  photograph  of  such  a  case.  The 
most  enlargement  and  distortion  was  of  the  second  fin- 
ger. 

Medical  Septicaemia  in  Children  was  the  subject  of  an 
address  by  Dr.  W.  S.  Christopher  of  Chicago.  He 
spoke  in  part  as  follows  :  We  all  see  many  cases  of  fever 
which  do  not  fit  the  description  of  typhoid,  malaria, 
influenza,  or  scarlatina.  This  term  is  not  a  scapegoat, 
but  a  term  under  which  these  endemic  fevers  may  be 
classed  until  we  can  properly  differentiate  them  one  from 
another.  Medical  septicaemia  indicates  that  it  is  non- 
traumatic. The  case  was  then  cited  of  a  child,  aged 
twenty  months,  who  had  a  diarrhoea  of  three  weeks.  The 
temperature  was  105°  F.  but  erratic.  Scarlatina  was 
ruled  out  in  a  few  days,  typhoid  fever  also.  Two  days 
later  it  seemed  surely  to  be  peritonitis.  The  peritoneal 
cavity  was  then  irrigated  with  a  sterile  normal  salt  solu- 
tion. The  following  day  pneumonia  developed,  but  all 
was  recovered  from.  Here  it  is  fair  to  infer  that  the 
same  micro  organism  caused  the  inflammation  of  bowel, 
peritoneum,  and  lung,  whether  appendicitis  or  no  mat- 
ters not. 

In  a  recent  epidemic  of  twelve  such  cases  three  had 
laryngismus  stridulus,  followed  by  fever  for  two  weeks 
and  indigestion.  Eight  similar  cases  occurred  which 
must  be  grouped,  and  medical  septicaemia  is  a  generic 
name  that  suits.  Some  forms  of  dysentery  would  belong 
here,  but  not  the  amoebic  dysentery. 

Dr.  Caille  said  he  should  think  it  difficult  to  distin- 
guish between  a  medical  and  a  surgical  septicaemia. 
True,  it  might  be  often  hard  to  locate  the  source  of  infec- 
tion, but  having  located  it  treat  accordingly. 

Dr.  Fruitnight  thought  such  a  nomenclature  should 
be  deferred  until  the  cases  are  differentiated. 

Dr.  Holt  believed  that  many  such  fulminant  cases 
would  upon  autopsy  prove  to  be  pneumonia. 

Dr.  Adams  considered  the  term  evasive  rather  than 
helpful,  and  thinks  most  such  cases  as  described  are  atypi- 
cal typhoid. 

Dr.  Christopher,  in  closing,  declared  that  an  ana- 
tomical diagnosis  is  useless,  for  we  cannot  know  always 
without  autopsy.  He  therefore  felt  that  there  was  need 
of  the  class  medical  septicaemia. 

Mirror  Writing.— Dr.  George  N.  Acker,  of  Wash- 
ington, exhibited  a  nee;ro  boy,  aged  ten,  who  is  natural- 
ly a  mirror  writer.     He  writes  equally  well  with  either 


hand,  the  left  beginning  on  the  right  side  of  the  paper 
with  the  letters  slanting  to  the  left.  In  playing  marbles 
the  boy's  left  hand  is  the  surest.  The  patient's  personal 
history  and  heredity  were  negative.  His  mind  is  quick 
and  he  is  rather  cunning. 

Before  closing  Dr.  Forchheimer  made  a  few  remarks 
thanking  the  Society  for  the  honor  they  conferred  in 
electing  him  President  for  the  coming  year,  and  with  best 
wishes  "  auf  wiedersehen  "  adjourned  the  meeting  to  next 
year  at  Hot  Springs,  Va. 


AMERICAN   DERMATOLOGICAL  ASSOCIA- 
TION. 

Eighteenth  Annual  Meeting,  held  in  Washington,  May 
29>  JO,  31,  and  June  i,  1894. 

(Continued  from  Vol.  45,  page  764.) 

Second  Day,  Wednesday,  May  30TH. 

Adeno  carcinoma  of  the  Skin  Starting  in  the  Sweat- 
glands. — Dr.  Fordyce,  of  New  York,  exhibited  micro- 
scopic specimens  and  photographs  showing  the  structure 
of  the  malignant  growth.  He  stated  that,  although  a 
number  of  pathologists  had  claimed  a  sweat-gland  origin 
for  certain  clinical  varieties  of  skin  cancer,  only  a  few 
cases  were  on  record  in  which  such  a  point  of  departure 
had  been  proven.  In  the  case  in  question,  the  new- 
growth  is  a  proliferation  of  the  columnar  cells  lining  the 
sweat-glands,  which  broke  through  the  membrana  propria 
and  infected  the  surrounding  connective  tissue.  The 
tumor  was  removed  from  the  leg  of  a  man,  thirty-five 
years  old,  and  was  about  two- thirds  the  size  of  an  egg. 

Dr.  Fordyce  also  demonstrated  the  intra-cellular  bodies 
which  are  looked  upon  by  many  as  the  cause  of  cancer. 
He  expressed  himself  as  a  believer  in  the  parasitic  nature 
of  cancer,  but  was  not  prepared  to  admit  that  its  etiology 
had  yet  been  made  clear. 

Dr.  Hartzell  said  that  the  essential  characters  of  the 
cells  were  not  changed.  He  believes  the  disease  to  be 
of  parasitic  origin,  and  that  the  growth  of  the  cells  was 
more  rapid  when  the  parasites  were  in  greater  number. 

Dr.  Bronson  asked  whether  the  origin  in  the  sweat- 
glands  had  any  effect  upon  the  induration  of  the  lesion. 

Dr.  Fordyce  replied  that  he  had  found  such  epitheli- 
omas to  be  quite  soft. 

Contagiousness  of  XoUuscnm  Contagiosum. — Dr. 
Stelwagen,  of  Philadelphia,  read  a  paper  on  this  ques- 
tion. He  quoted  a  large  number  of  clinical  examples  of 
the  communicability  in  households  and  in  institutions. 
Among  others,  that  of  a  nurse  who  had  received  the  dis- 
ease from  a  child,  who  had  received  it  from  another  nurse. 
The  latter  had  given  the  disease  to  other  children.  He 
quoted  an  example  where  there  were  three  cases  in  one 
family  who  had  infected  a  young  friend  who  played  with 
them.  Also  the  case  where  there  was  an  eruption  in  a 
man  and  his  wife  about  the  genitals.  A  case  where  a 
brother  and  sister  used  the  same  towel  and  were  both  in- 
fected. He  gave  a  very  exhaustive  rtsumS  of  the  re- 
ported cases  of  the  contagiousness  of  the  disease.  In  an 
epidemic  in  a  hospital  for  children,  two  weeks  after  the 
first  case  was  observed,  there  were  forty-one  cases  in  the 
hospital.  The  long  period  of  inoculation  is  remarkable. 
He  doubts  whether  the  psorosperm  is  the  cause  of  the  dis- 
ease. 

Dr.  Fordyce  believed  the  disease  due  to  an  animal 
parasite,  probably  the  psorosperm. 

Dr.  Hartzell  believed  in  the  etiological  relation  of 
psorosperms  and  this  disease. 

Dr.  White  thought  that  there  had  been  no  demon- 
stration that  the  bodies  found  in  the  cells  were  parasitic 
and  introduced  from  the  outside. 

Ichthyosis  Congenita  (so-called  Harlequin  Foetus). — 
Dr.  Sherwell,  of  Brooklyn,  reported  a  case  of  universal 
ichthyosis  in  an  infant.  The  parents  were  absolutely 
healthy  and  had  two  other  children,  both  healthy.  The 
child  was  born  at  term  and  weighed  two  pounds.  The 
whole  surface  of  body  was  covered  with  soft,  horn  like 


July  21,  1894] 


MEDICAL  RECORD. 


87 


scales.  The  scales  on  the  head  were  more  sebaceous. 
The  flexures  were  deeply  fissured.  The  mucous  surfaces 
were  only  slightly  affected.  There  was  slight  ectropion. 
Alkaline  baths  and  inunctions  of  vaseline  and  ung.  aq. 
rosae  were  employed  in  the  treatment.  When  bathing 
and  inunctions  are  neglected,  extensive  scales  form  on 
body.  The  child  has  been  much  improved  by  the  treat- 
ment. 

Protozoa-like  Bodies  of  Herpes  Zoster  ;  a  Contribu- 
tion to  the  Study  of  Psorothermosis. — Dr.  M.  6.  Hart- 
zell  read  a  paper  on  this  subject,  in  which  he  called  at- 
tention to  the  bodies  resembling  protozoa  in  zoster,  vari- 
cella, and  variola.  Pfeiffer  was  the  first  to  describe  them 
as  protozoa,  and  thought  they  gained  access  by  the  inter- 
costal vessels.  There  were  three  varieties.  These 
bodies  have  a  cell  body  proper,  an  internal  capsule,  and 
a  cavity  containing  several  small  oval  bodies.  The  sec- 
ond variety  is  much  larger  than  the  first.  The  body  of 
cell  stains  feebly.  The  internal  capsule  stains  deeply. 
Some  of  the  bodies  are  found  free  and  show  amoeboid 
movements.  He  found  in  a  case  of  recurrent  zoster  the 
same  alterations  as  in  ordinary  zoster.  He  thinks  we 
have  a  metamorphosis  and  increased  vital  activity  of  the 
epithelial  eel  If. 


Third  Day,  Thursday,  May  31ST. 

Angioma  Serpiginosum. — Dr.  J.  C.  White,  of  Boston, 
read  a  paper  entitled  "  Angioma  Serpiginosum  and  Some 
Other  Dermatoses.1' 

In  the  case  of  angioma  serpiginosum,  from  the  border 
of  right  scapula  to  nipple  there  were  twenty-four  le- 
sions of  pin- head  size  and  of  a  red  color.  They  disap- 
peared partially  under. long  pressure.  These  lesions  in- 
crease in  size  and  finally  undergo  evolution  in  the  centre, 
the  border  forming  circles  or  segments  of  circles.  The 
skin  in  the  centre  appears  normal  except  the  red  color. 
New  foci  appear  and  follow  the  same  course.  The  dis- 
ease spreads  in  an  annular  manner  for  an  indefinite  period, 
and  appears  as  pale  scar- tissue  surrounded  by  scarlet 
rings. 

The  writer  said  that  small  aggregations  of  cells  are 
found  in  the  corium  in  this  disease,  which  are  unlike  the 
round  granulation  cells.  Small  places  in  vessels  were 
found  filled  up  with  small  granular  masses,  resembling 
amoeboid  forms  of  lower  organisms.  There  seemed  a  fu- 
sion of  degenerated  cells  in  the  nodules  which  appeared 
to  undergo  degeneration  by  the  strangulation  of  the  blood- 
vessels. The  pathological  anatomy  of  this  disease  has  a 
great  resemblance  to  that  of  the  pigmented  moles. 

Acquired  Idiosyncrasy  for  Quinine  Showing  Peculiar 
Cutaneous  Manifestations. — Dr.  Charles  W.  Allen, 
of  New  York,  read  a  paper  with  this  title.  He  said  that 
the  most  frequent  eruption  caused  by  this  drug  is  an 
erythematous  rash  beginning  on  the  face  and  extending 
over  the  whole  surface.  Other  usual  forms  are  the  urti- 
carial and  papular,  while  the  vesicular,  bullous,  and  pur- 
puric are  less  frequently  seen. 

In  the  case  reported  by  Dr.  Allen  the  subject  had 
previously  been  able  to  take  quinine  in  moderately  large 
doses  without  ill  effects.  The  peculiarities  of  the  case 
reported  are:  1.  That  the  eruption  is  developed  by  a 
very  small  quantity  of  the  drug ;  2.  That  the  lesions  are 
local  and  show  no  tendency  to  spread ;  3.  That  the  lo- 
cation of  the  individual  spots  is  always  the  same.  4. 
That  the  eruption  was  produced  four  times  accidentally 
and  fourteen  times  experimentally.  The  writer  says  that 
the  simple  erythema  of  one  attack  may  in  another  attack 
closely  simulate  an  erythema  exudativum  multiforme. 
The  patient,  in  the  case  reported,  took  a  five-grain  dose 
of  the  sulphate  of  quinine  at  bedtime.  During  the 
night  a  general  pruritus  developed,  and  in  the  morning 
large  erythematous  blotches  were  found  on  certain  parts 
of  the  body — on  the  next  morning  the  prepuce  pre- 
sented large  excoriated  surfaces  suggestive  of  chancroids. 
The  rest  of  the  glans  and  prepuce  was  red  and  sensitive. 
The  quinine  was  discontinued,  and  in  about  a  week  the 


spots  desquamated  and  faded  in  color.  Some  months 
later  the  patient  having  taken  one  "  Monsette  "  pill,  not 
knowing  that  it  contained  quinine  (about  one  grain)  de- 
veloped within  twelve  hours  itching,  burning,  and  prick- 
ling sensations,  and  the  same  spots  appeared  as  before. 
The  whole  prepuce  was  again  excoriated.  He  developed 
the  same  symptoms  in  the  same  year  after  taking  a  cor- 
dial glass  of  coca  wine,  although  in  a  less  pronounced 
way.     The  quantity  of  the  drug  was  exceedingly  small. 

In  this  patient,  a  few  hours  after  taking  about  one  third 
of  a  grain  of  quinine,  the  glans  penis  was  surrounded  by 
a  ring  of  redness  and  the  same  spots  as  before  developed 
on  the  body.  Dr.  Allen  experimented  with  various  salts 
of  quinine,  such  as  the  hydrobromate,  the  hydrochlorate, 
the  bisulphate,  dextro  quinine,  and  the  bimuriate  with 
urea.  The  same  manifestations  invariably  followed. 
These  investigations  prove  that  the  statement  which  has 
been  made,  that  the  acid  and  not  the  case  is  the  offend- 
ing substance,  is  incorrect. 

The  writer  proved  by  experiments  upon  this  case  that 
the  theory  of  reflex  dilatations  of  the  vessels  of  the  skin 
from  stimulation  of  the  sensory  nerves  of  the  stomach  was 
not  applicable.  General  symptoms  followed  holding 
one-fourth  grain  of  the  carbamide  in  the  mouth  for  fif- 
teen minutes.  Quinine  given  in  a  suppository  and  by 
inunction  produced  a  distinct  erythema.  A  weak  solu- 
tion of  quinine  in  alcohol  rubbed  into  the  scalp  caused 
the  same  symptoms.  Dr.  Allen  noticed  in  this  patient  a 
marked  tenderness  on  pressure  over  the  spinous  process 
of  the  second  dorsal  vertebra.  Upon  this  symptom  he 
bases  his  supposition  that  the  eruption  is  due  to  an  an- 
gio  paralysis  of  central  spinal  origin.  He  believes  the 
symmetrical  distribution  and  circumscribed  features  of 
the  eruption  are  explained  by  the  theory  of  nerve  origin, 
as  in  large  doses  the  reflex  function  of  the  cord  is  les- 
sened and  ultimately  abolished.  The  writer  thinks  it 
rational  to  refer  these  skin  changes  to  an  action  upon 
the  cord. 

Symmetrical  Cutaneous  Atrophy  of  the  Extremities. 
— Dr.  Bronson,  of  New  York,  reported  the  case,  which 
was  a  very  rare  one,  only  four  of  the  same  variety  having 
been  found  in  the  literature.  Buchwald,  of  Breslau,  was 
the  first  to  describe  this  form,  and  so  peculiar  were  the 
manifestations  of  the  disease,  and  so  well  delineated  were 
they,  that  the  term  Buchwald's  atrophy  was  suggested. 
The  affection,  which  is  clearly  an  idiopathic  form,  differs 
from  the  ordinary  atrophia  cutis  propria  in  its  symmetry 
and  in  its  tendency  to  gradual  progression  and  in  the  fact 
that  the  atrophy  seems  to  be  of  a  qualitative  kind  as  well 
as  simply  quantitative  or  degenerative. 

The  case  described  by  Dr.  Bronson  affected  a  patient 
forty-five  years  of  age,  who  was  a  working-man  of  fairly 
good  family  and  personal  history,  and  who,  except  for 
the  atrophic  disease,  appeared  to  be  in  possession  of  per- 
fect health.  The  disease  had  begun  about  fourteen  years 
ago,  and  latterly  had  remained  nearly  stationary,  at  least 
so  far  as  the  extent  of  the  disease  was  concerned.  It  oc- 
cupied the  entire  surface  of  both  lower  extremities  from 
the  upper  part  of  the  feet  to  Poupart's  ligament  in  front, 
and  extended  over  the  nates  behind,  leaving  the  cleft  of 
the  nates,  however,  as  well  as  the  genitals,  free.  The 
arms  were  similarly  affected  from  the  base  of  the  fingers 
behind,  and  from  the  wrists  in  front  to  about  the  junc- 
tions of  the  lower  with  the  middle  third  of  the  upper 
arms.  * 

The  chief  marks  of  the  atrophy  were  the  thinning  of 
the  skin,  discoloration,  wrinkling  of  the  surface,  and  a 
multitude  of  shallow  depressions  scattered  over  the  sur- 
face. The  skin  was  everywhere  freely  movable,  and 
could  be  lifted  in  thin  folds  from  the  subjacent  struct- 
ures,, which  folds  subsided  again  to  the  general  level 
slowly  when  released,  as  though  the  skin  had  lost  elas- 
ticity. Everywhere  were  numberless  fine  wrinkles  which 
followed  the  cleavage  lines  of  the  skin — they  enclosed 
smooth,  shiny  interspaces,  and  gave  the  appearance  of 
a  crumpled  piece  of  gold-beater's-skin.  The  wrinkling 
was  most  marked  about  the  joints,  especially  the  knees, 


88 


MEDICAL   RECORD. 


[July  21,  1894 


backs  of  wrists,  and  the  nates.  The  discoloration  was 
due  in  part  to  brownish  pigmentation,  that  was  in  most 
parts  punctate,  in  part  to  the  purple  color  of  the  veins, 
which  showed  through  the  thinned  and  abnormally 
transparent  epidermis  with  uncommon  distinctness,  and 
partly  to.  a  red  reflex  from  the  arterioles.  In  a  recum- 
bent posture  the  color  of  the  legs  and  thighs  was  more 
brown,  but  after  standing  awhile  the  veins  became  turgid 
with  blood,  and  the  surface  appeared  cyanotic.  There 
was  no  impairment  of  sensation  in  the  affected  parts,  but 
rather  hyperaesthesia.  The  hairs  had  nearly  disappeared, 
as  also  the  perspiratory  function. 

Relation  of  Impetigo  Herpetiformis  and  Pemphigus 
Vegetans  — Dr.  Joseph  Zeisler,  of  Chicago,  presented 
a  communication  with  this  title,  in  which  he  said  that 
to  anyone  who  has  carefully  studied  the  literature  and 
the  descriptions  of  impetigo  herpetiformis  and  of  pemphi- 
gus vegetans,  respectively,  it  must  have  become  apparent 
that  while  each  of  these  rare  disorders  seems  fairly  well 
established  as  clinical  entities,  they  have  many  features 
in  common,  which  occasionally  make  their  differentia- 
tion exceedingly  difficult  even  for  the  expert  dermato- 
logist. The  speaker  referred  to  the  writings  of  Duhring, 
Dumesnil  and  Marx,  and  of  Dubreuilh,  who  had  com- 
mented upon  a  case  of  impetigo  herpetiformis  (published 
by  himself  in  1887)  in  a  way  which  shows  that  while 
some  of  them  accept  his  case  as  a  typical  instance  of  that 
disease,  others  considered  it  as  an  example  of  pemphigus 
vegetans.  The  points  of  similarity  of  the  two  diseases 
are  there  more  fully  detailed.  The  prevalence  in  women, 
the  inception  on  some  mucous  membrane,  the  peripheral 
extension  of  the  cutaneous  lesions,  the  localization  on 
certain  places  of  predilection,  the  occurrence'of  vegeta- 
tions on  places  where  moisture,  warmth,  and  friction 
exert  an  influence,  the  fatal  termination,  the  obscurity 
of  the  etiology  and  pathology  are  referred  to  more  partic- 
ularly. The  differentiation  in  a  doubtful  case  will  have 
to  be  made  according  to  the  principle  de  potiore  dehomi- 
natio  fiat,  i.e.,  where  miliary  pustules  form  the  chief  le- 
sions during  most  of  the  time,  impetigo  herpetiformis  will 
be  declared,  while,  if  bullous  lesions  predominate,  pemphi- 
gus will  be  the  diagnosis.  The  writer  thinks  the  criti- 
cisms of  various  writers  concerning  the  description  of  such 
rare  cases  are  unjust,  for  the  reason  that  variations  from 
the  well-established  type  of  any  disease  are  always  liable 
to  occur. 

Dr.  Bronson  showed  a  combined  comedo- expressor 
and  dermal  curette  of  his  invention. 

Dr.  Gilchrist,  of  Baltimore,  showed  some  micro- 
scopical preparations  containing  protozoa. 


AMERICAN  NEUROLOGICAL  ASSOCIATION. 

Twentieth  Annual  Meeting,  held  in  Washington,  Z>.  C, 
May  jo  andji,  and  June  1,  1894. 

(Continued  from  Vol.  45,  page  772.) 

Second  Day,  Thursday,  May  31ST. 

A  Hew  Neuroglia  Stain. — Dr.  W.  J.  Morton,  of 
New  York,  presented  some  microscopic  slides  showing 
the  new  neuroglia  stain  of  Weigert,  presented  to  him  by 
Dr.  Weigert  on  a  recent  visit  to  his  laboratory  in  Frank- 
fort. The  neuroglia  fibres  are  stained  blue,  while  the 
nerve  elements  are  either  not  stained  at  alltor  at  least  very 
faintly.  The  medullary  sheaths  do  not  accept  the  stain, 
and  thus  the  field  is  left  clear  for  the  differentiation  of 
the  neuroglia  fibres.  Dr.  Weigert  is  not  yet  quite  ready 
to  publish  this  new  stain,  although  he  has  been  at  work 
upon  it  for  five  years ;  no  specimens  have  hitherto  been 
exhibited  on  this  side  of  the  Atlantic. 

Multiple  Neuromata. — Dr.  Morton  also  read  a  paper 
entitled  "  A  Case  of  Multiple  Neuromata,  with  Exhi- 
bition of  Microscopic  Sections  of  a  Large  Neuroma  Re- 
moved from  the  Ulnar  Nerve.'1  The  tumor  developed 
upon  the  ulnar  about  half  way  between  the  elbow  and  the 
wrist,  and  was  about  the  size  of  a  hen's  egg.  Cutting 
down  upon  the  mass  with  a  view  of  severing  and  suturing 


the  nerve  if  necessary,  or  of  dissecting  out  so  far  as  pos- 
sible its  strands,  he  found  that  the  tumor  was  lying  quite 
free,  except  for  a  few  thread  like  adhesions,  within  a  cap- 
sule, and  that  the  nerve  traversed  this  capsule  from  end 
to  end,  in  five  separated  bundles.  It  was  therefore  pos- 
sible to  enucleate  the  tumor  and  replace  the  nerve  strands 
without  the  slightest  injury  to  the  latter. 

The  tumor  was  a  myxo-fibroma.  The  encapsulation 
of  the  tumor,  and  at  the  same  time  the  confinement  of  the 
nerve  bundles  to  the  capsule,  was  novel  and  of  importance 
to  bear  in  mind  in  further  operations  upon  such  growths. 

Grossed  Knee-jerk. — Dr.  Guy  Hinsdale  and  Dr.  J. 
Madison  Taylor,  of  Philadelphia,  presented  a  com- 
munication with  this  title.  It  was  based  on  studies  of 
over  one  thousand  cases  of  nervous  disease  observed  at 
the  Infirmary  for  Nervous  Diseases,  Philadelphia,  and 
the  institutions  for  feeble-minded  at  Carlisle,  Pa., 
and  Vineland,  N.  J.  In  using  the  term  crossed  knee- 
jerk,  it  is  meant  that,  the  patella  tendon  being  struck, 
the  opposite  leg  is  instantly  made  to  approach  its  fellow ; 
hence  the  phrase  "  in  knee  jerk,"  or  "contra-lateral  knee- 
jerk/'  may  be  used  to  describe  this  action.  The  move- 
ment observed  in  the  limb  opposite  to  that  in  which  the 
patella  tendon  is  struck  is  not  an  extension  of  the  leg  so 
much  as  an  adduction  of  the  thigh  (vastus  internus  and 
aureus).  The  best  attitude  for  eliciting  the  movement 
is  not  that  which  permits  the  freest  knee-jerk,  such  as 
sitting  on  the  edge  of  a  table.  It  demands  rather  more 
ease  of  lateral  motion  of  the  thigh.  This  is  accomplished 
very  well  by  seating  the  subject  at  ease  in  a  chair  with 
the  body  erect  and  the  knees  ten  or  twelve  inches  apart, 
with  the  knee  joint  at  rather  an  obtuse  angle,  the  feet 
being  advanced  a  few  inches. 

The  phenomenon  is  observed  in  a  small  proportion  of 
normal  persons,  and  in  from  twenty  to  thirty  per  cent, 
of  the  cases  coming  to  a  clinic  for  nervous  disease.  It  is 
observed  in  a  large  majority  of  spastic  cases.  It  is  dis- 
tinctly proved  not  to  be  due  to  a  communicated  shock 
or  jar  to  the  pelvis,  by  reason  of  its  absence  in  all  cases 
of  locomotor  ataxia,  and  its  production  in  favorable  cases 
on  suspending  the  subject  from  the  floor  and  observing 
the  adduction  of  the  thigh  on  tapping  the  patella  tendon 
or,  as  in  one  case  observed,  tapping  the  tendo  Achillis 

Crossed  knee  jerk  is  also  found  to  be  reinforceable. 
Tracings  were  shown  which  recorded,  in  a  normal  subject, 
an  adduction  in  crossed  knee  jerk  of  one-sixteenth  of  an 
inch,  in  a  spastic  one  fourth  of  an  inch,  and  in  the  latter 
case,  under  reinforcement,  half  an  inch.  Reinforcement 
produces  the  movement  in  some  cases  where  it  is  not 
otherwise  evident.  A  case  was  related  in  which  a  very 
slight  tap  on  the  patella  tendon  causes  violent  contrac- 
tions of  both  legs,  causing  the  knees  to  smite  together,  or 
cross  over ;  a  larger  tap  will  cause,  in  addition,  crossing 
of  both  arms  in  a  sort  of  lock  spasm,  requiring  aid  after- 
ward in  stretching  out  the  limbs. 

The  reflex  arc  involved  in  movements  of  this  kind  is 
held  to  embrace  the  cerebrum. 

Dr.  H.  R.  Stedman,  of  Boston,  asked  if  this  condition 
was  not  somewhat  similar  to  the  so-called  allocheiria. 

Dr.  Walton  thought  that  a  practical  result,  bearing 
on  diagnosis,  could  not  fail  to*  follow  careful  and  sys- 
tematic investigations  of  these  anomalous  reflexes.  We 
have  not  exhausted  the  directions  in  which  the  reflex  im- 
pulses may  be  deflected.  He  had  found  not  only  the 
classical  reflex,  described  recently  by  Remak,  of  toe 
flexion  on  stroking  the  inside  of  the  thigh,  but  had  seen 
both  dorsal  and  plantar  flexion  of  toes  on  stroking  vari- 
ous areas  in  the  lower  extremities  in  case  of  broken 
back. 

Dr.  Morton  spoke  of  the  application  of  faradism  to 
the  right  sciatic  nerve  as  having  produced  a  reaction  in 
the  muscles  of  the  left  shoulder. 

Dr.  George  Jacoby  referred  to  a  paper  read  by  him  a 
few  years  ago  in  which  he  had  called  attention  to  the 
phenomenon  of  irradiation  of  the  electrical  current. 

Dr.  Mills  believed  that  the  best  explanation  would 
be  forthcoming  from  a  careful  study  of  the  distribution 


July  21,  1894] 


MEDICAL    RECORD. 


89 


of  cells  and  fibres  in  the  cord  and  their  relation  to  other 
parts  of  the  system. 

The  President  considered  the  title  of  the  paper  an 
unfortunate  one,  and  did  not  look  upon  this  phenomenon 
as  a  crossed  knee-jerk  at  all,  but  as  a  contralateral  muscular 
contraction.  He  thought  its  reflex  character  was  quite 
doubtful  and  that  there  was  no  difficulty  in  accounting 
for  irradiation  on  anatomical  grounds. 

Dr.  Dercum,  of  Philadelphia,  exhibited  a  skull  which 
had  been  kindly  loaned  by  Mr.  Bailey  Willis  of  the 
Geological  Museum.  It  belonged  to  the  Peruvian  Gov- 
ernment, and  its  origin  was  traced  to  pre-historic  times. 
It  was  shown  as  an  illustration  of  the  ancient  method  of 
trephining. 

Recurrent  Oculo-Motor  Paralysis. — Dr.  Knapp,  of 
Boston,  read  a  paper  with  this  title.  A  man  of  forty- 
one,  with  some  nervous  heredity,  had  had  severe  neural- 
gic pain  over  the  left  eye,  with  ptosis,  external  strabismus, 
and  numbness  of  the  face,  a  year  before  he  came  under 
observation.  This  lasted  seven  weeks.  In  December, 
1892,  one  year  later,  he  had  intense  pain  in  the  left  side 
of  the  head,  with  nausea  and  vomiting.  There  was  com- 
plete paralysis  of  the  left  third  nerve,  with  anaesthesia  of 
the  nose  and  cheek  on  the  left  side,  and  paraesthesia  of 
the  forehead.  Photophobia  was  present  The  anaesthetic 
region  was  extremely  tender  on  pressure,  and  there  was 
increased  discharge  from  the  left  nostril.  After  two 
months  the  paralysis  began  to  diminish,  and  after  four 
months  it  had  almost  wholly  disappeared ;  but  the  sensory 
symptoms  still  continued  in  a  lesser  degree.  Statistics 
were  given  of  forty  cases,  and  of  ten  other  cases  of  a 
doubtful  nature.  In  only  six  cases  has  there  been  com- 
plete recovery  from  the  paralysis  in  the  interval  between 
the  attacks,  and  in  four  more  the  pupil  remained  dilated. 
In  seven  cases  there  was  at  first  complete  recovery,  but 
in  the  later  intervals  there  was  some  paresis.  Senator's 
division  into  periodical  and  periodically  exacerbating 
cases  hardly  seemed  warranted,  and,  although  some  of 
the  cases  resemble  migraine,  the  affection  in  most  cases 
is  not  at  all  like  migraine.  Three  autopsies  have  shown 
lesions  involving  the  nerve,  and  most  cases  are  probably 
due  to  such  lesions. 

Dr.  Mills  had  observed  several  cases  of  recurrent 
ocular  palsy  with  involvement  of  the  fifth  nerve.  He 
had  also  seen  cases  of  recurrent  facial  paralysis.  The 
only  probable  explanation  in  most  cases  is  that  of  or- 
ganic lesion.  He  thought  Knapp's  cases  were  probably 
due  to  lesion  of  root  fibres. 

Dr.  Morton  Prince  agreed  with  Dr.  Knapp  in  be- 
lieving that  these  cases  were  caused  by  organic  lesion. 
He  believed  that  pain  as  a  localizing  symptom  possessed 
very  little  value.  He  would  rather  depend  uppn  motor 
and  sensory  paralysis. 

Dr.  Walton  thought  all  cases  could  not  be  classed 
together.  While  many  were  of  nuclear  or  vasal  origin, 
possibly  some  of  the  less  grave  cases  were  due  to  recur- 
ring oedema  or  possibly  vascular  disturbance  at  the  cor- 
tex, which  would  perhaps  explain  the  coincidence  of 
motor  and  sensory  disturbance.  Possibly  some  cases 
were  allied  to  the  severer  form  of  hysteria. 

Dr.  Knapp,  in  closing  the  discussion,  said  that  there 
was  no  case  of  complete  recovery  on  record  where  there 
had  been  both  motor  and  sensory  involvement.  In  cases 
of  syphilitic  origin  where  only  one  or  two  branches  were 
involved,  it  was  more  likely  to  affect  the  nerve  after  it 
had  left  the  pons. 

Circumscribed  Softening  of  the  Pons,  Internal  Cap- 
sule, Oandatnm  and  Lenticula.  —  Drs.  Charles  K. 
Mills  and  John  Zimmer,  of  Philadelphia,  reported  a  case 
which  presented  two  limited  lesions  of  unusual  interest — 
one  in  the  pons,  and  a  second  involving  the  internal  cap- 
sule, and  a  small  segment  of  the  caudatum  and  lenticula. 
The  patient,  a  woman,  aged  forty- two,  had  a  previous 
history  of  alcoholism  and  of  acute  articular  rheumatism. 
Examination  showed  slight  impairment  of  mental  action, 
marked  somnolency,  and  imperfect  articulation.  At 
rest,  the  right  eye  turned  strongly  to  the  right,  while  the 


left  was  not  deviated.  Both  eyes  could  not  be  turned 
together  to  the  left.  The  lateral  movement  of  the  left 
eye  to  the  right  was  also  impaired,  and  slight  nystagmus 
of  both  eyes  was  present.  The  lids  of  the  left  eye  could 
not  be  brought  fully  together.  Right  facial  paresis  was 
present,  but  the  tongue  was  not  deflected  Tendon  and 
muscle  phenomena  were  much  exaggerated  in  the  paretic 
limbs.  Anaesthesia  could  not  be  discovered  in  any  por- 
tion of  the  body.  .About  eleven  days  after  admission, 
she  had  a  second  apoplectiform  attack.  She  was  now  to- 
tally unable  to  articulate,  but  understood  what  was  said. 
She  was  also  unable  to  expectorate,  and  there  was  inter- 
ference with  swallowing.  A  thorough  and  careful  au- 
topsy made  by  Dr.  Guiteras  revealed  a  circumscribed 
softening  of  the  pons.  The  lesion,  at  its  cephalic  ex- 
tremity reached  to  within  1.5  mm.  of  the  ventral  surface 
of  the  pons — laterally  extending  to  the  raphe,  and  about 
the  middle  of  the  pons  slightly  across  the  mesial  line. 
The  area  of  softening  became  smaller  and  more  deeply 
situated  as  it  approached  the  post-oblongata,  which  it  al- 
most but  not  quite  reached.  The  second  lesion  was  re- 
vealed by  a  vertical  transection  of  the  right  basal  ganglia 
and  capsule.  The  widest  portion  of  the  lesion  corre- 
sponded to  the  plane  of  the  cephalic  extremity  of  the  thal- 
amus. It  was  about  1 7  mm.  in  its  antero- posterior  extent. 
The  pontile  lesion  probably  involved  the  root  fibres  of  the 
abducens,  and  the  fibres  connecting  it  with  the  facial 
fibres  or  nucleus.  The  position  of  the  lesion  was  such  as 
,  not  by  any  possibility  to  involve  the  cell-nests  of  these 
nerves.  The  lesion  involved  the  crustal  portion  of  the 
pons,  including  a  portion  of  the  pyramidal  tracts,  and 
the  deep  transverse  fibres.  The  lesion  of  the  internal 
capsule  was  beautifully  localized  near  the  genu,  probably 
involving  the  geniculate  and  speech  tracts. 

Lesion  of  Thalamus ;  Death  from  Intestinal  Hemor- 
rhage.— Dr.  Wharton  Sinkler,  of  Philadelphia,  read 
this  paper.  He  referred  to  the  importance  of  placing  on 
record  all  facts  relating  to  the  function  of  the  thalamus, 
and  stated  that  his  attention  had  been  drawn,  in  con- 
nection with  the  case  which  he  reported,  to  the  observa- 
tions of  Lussana,  Brown-S6quard,  Ebstein,  and  SchifT, 
many  years  ago,  in  which  they  produced  ecchymoses  and 
hemorrhages  into  the  mucous  membrane  of  the  stomach 
and  colon  of  some  of  the  lower  animals,  by  wounding 
the  corpora  quadrigemina  and  optic  thalamus. 

The  patient  was  a  man  aged  sixty-seven,  who  had 
worked  for  many  years  in  a  stone  quarry,  and  had  re- 
ceived frequent  slight  injuries  to  the  scalp,,  in  conse- 
quence of  being  struck  by  fragments  of  stone.  In  July, 
1892,  after  having  been  exposed  to  the  sun,  he  was  sud- 
denly taken  ill  and  had  to  be  removed  to  his  home  in  an 
unconscious  condition,  where  he  was  seized  with  con- 
vulsions, which  lasted  for  the  greater  part  of  two  days. 
After  a  month  he  was  able  to  resume  his  work ;  but  two 
weeks  later  he  began  to  have  epileptiform  convulsions, 
which  recurred  at  irregular  intervals  of  from  one  to  two 
a  week.  The  seizures  were  always  preceded  by  an  olfac- 
tory aura,  the  patient  observing  the  smell  of  burning 
sulphur.  After  a  few  months  the  patient  had  maniacal 
attacks  after  his  fits,  and  was  removed  to  the  Philadel- 
phia Hospital  in  December,  1893. 

There  was  nothing  notable  about  his  condition,  except 
that  the  attacks  of  epilepsy  were  of  the  precursive  form. 
He  would  run  violently,  and  imagined  that  he  was  pur- 
sued by  devils.  Toward  the  end  of  February  he  had  an 
attack  in  which  there  was  rise  of  temperature  without 
any  physical  reason  being  discoverable.  His  intellectual 
powers  failed ;  and  he  gradually  fell  into  a  somnolent 
condition,  which  lasted  for  nearly  three  weeks,  at  the 
end  of  which  time  he  was  suddenly,  without  premonitory 
signs,  seized  with  intestinal  hemorrhage  of  a  profuse  char- 
acter, from  which  he  died  in  about  twelve  hours. 

At  the  autopsy  the  mucous  membrane  of  the  colon  was 
found  to  be  softened  and  deeply  injected,  but  no  lesion 
was  found  in  the  way  of  an  ulceration,  or  rupture  of  a 
vessel  which  would  account  for  the  hemorrhage.  The 
brain  showed  very  marked  evidence  of  an  old  lepto-men- 


9o 


MEDICAL    RECORD. 


[July  21,  1894 


ingitis  over  the  left  hemisphere,  and  there  was  atheroma 
of  the  vessels  of  the  base.  In  the  posterior  right  thala- 
mus there  was  found  a  small  area  of  softening.  It  was 
about  one- third  of  an  inch  in  length,  by  one- fourth  of 
an  inch  in  its  transverse  diameter.  No  other  coarse  le- 
sion could  be  found  in  the  brain. 

Cerebral  Hemorrhage :  Its  Causes  and  Premonitory 
Symptoms.— Dr.  C.  L.  Dana,  of  New  York,  presented 
this  paper,  based  upon  the  study  of  1.00  consecutive  cases 
of  apoplexy  with  hemiplegia,  observed  at  his  clinic  at  the 
Post-Graduate  Hospital,  and  79  cases  of  apoplexy,  with 
autopsy,  observed  in  Bellevue  Hospital ;  30  of  the  latter 
came  under  his  personal  care  and  observation.  Of  100 
non-fatal  cases  36  were  due  to  syphilis.  The  special 
characteristics  of  the  attacks  due  to  syphilis  are  that  they 
occur  in  early  life ;  they  are  often  multiple  in  character, 
and  the  pathological  condition  underlying  them  is  usu- 
ally a  thrombosis  and  softening.  So  far  as  his  experience 
and  records  went  cerebral  hemorrhages  are  rarely  re- 
peated, and  it  seemed  as  if  in  many  cases  the  rupture  of 
an  artery  changed  the  vital  conditions,  as  it  certainly 
does  the  personal  habits,  so  that  the  attack  exercises  a 
conservative  influence  upon  the  individual  and  actually 
tended  to  prolong  life. 

Dr.  E.  D.  Fisher,  of  New  York,  presented  a  report 
of  77  cases.  Fifty  one  had  one  attack ;  16,  two  attacks  ; 
9  had  three,  and  1  had  six  attacks.  All  are  still  living. 
These  cases  were  observed  in  his  service  at  the  city  alms- 
house. The  average  age  at  which  the  first  attack  oc-. 
curred  was  44^  years.  His  observations,  he  thought, 
confirmed  what  had  been  said  by  the  reader  of  the  paper. 
The  longest  duration  since  the  attack  was  twenty-two  years. 

Dr.  Gray,  of  New  York,  thought  that  the  fatal  defect 
in  the  paper  was  that  many  things  were  confounded.  It 
told  us  nothing  as  to  the  frequency  of  apoplexy,  but  left 
us  in  doubt  as  to  the  elements  of  diagnosis. 

Dr.  L.  Weber,  of  New  York,  said  that  while  he  be- 
lieved Dr.  Dana's  deductions  from  his  own  cases  were  oi 
value,  those  from  other  sources  did  not  seem  to  him  to 
be  applicable. 

Dr.  William  A.  Hammond  doubted  whether  life  was 
in  any  way  protected  by  an  attack  of  apoplexy,  as  the 
same  causes  would  persist. 

Dr.  Wharton  Sinkler  had  observed  a  case  in  which  the 
attack  occurred  twenty-five  years  ago.  The  man  did  not 
seem  to  bs  in  any  way  benefited  in  his  general  condition. 

Dr.  Prince  thought  the  fallacy  lay  in  the  statistics  as  to 
those  still,  living,  as  one  cannot  say  how  many  attacks 
they  are  going  to  have. 

Dr.  Dana,  in  closing,  said  it  was  hardly  fair  to  criticise 
his  data,  as  sufficient  time  was  not  permitted  for  the  read- 
ing of  his  entire  paper. 

Lumbar  Puncture  for  the  Removal  of  Cerebro-Spinal 
Fluid. — Dr.  William  Browning,  of  Brooklyn,  N.  Y., 
read  a  paper  with  this  title.  He  reviewed  the  main 
points  in  this  recently  devised  operation.  Brief  notes  of 
a  few  cases  were  given  as  well  as  directions  for  its  per- 
formance.    The  following  conclusions  were  reached : 

1.  The  method  is  simple,  easily  practised  and  rather 
attractive. 

2.  In  itself  it  is  usually  without  danger. 

3.  By  it  we  certainly  can  draw  off  cerebro-spinal  fluid. 

4.  The  quantity  removed  at  short  sittings  has  been 
from  one  to  one  and  a  half  ounce  in  adults. 

5.  This  without  doubt  represents  the  amount  of  free 
fluid  usually  present  in  the  lower  vertebral  canal  even 
when  occluded  above. 

6.  In  internal  hydrocephalus  the  relief,  if  any,  is  but 
very  temporary.  In  the  common  form  due  to  tubercular 
meningitis  the  result  is  not  worth  the  trouble ;  while  in 
the  closed  or  sacculated  forms  it  must  rather  do  harm 
than  good. 

7.  As  a  diagnostic  means,  e.g.,  in  suspected  meningeal 
hemorrhage,  it  is  valuable.  As  an  index  of  pressure  it 
may  also  be  worth  noting. 

8.  It  is  worth  further  trial : — (a)  As  a  passing  relief  in 
brain  tumors  not  complicated  by  hydrocephalus ;  (b)  As 


a  substitute  for  trephining  in  progressive  dementia ;  (c) 
In  certain  spinal  troubles ;  (d)  And  possibly  as  a  means 
of  applying  medication  directly  to  the  spinal  me- 
ninges. 

9.  In  conclusion  it  may  be  said  that,  while  admissible 
in  all  cases  of  brain-pressure,  there  is  as  yet  no  estab- 
lished indication  for  this  procedure  except  for  diagnostic 
purposes. 

Dr.  Mills  said  that  all  operations  of  this  kind  are  un- 
philosophic,  and  would  accomplish  nothing,  as  the  fluid 
reaccumulates.  The  same  may  be  said  of  hydrocephalus. 
Some  good  may  be  done  when  the  fluid  is  either  blood 
or  pus ;  otherwise  it  is  not  indicated. 

Dr.  Dana  had  utilized  this  method  in  three  cases  of  al- 
coholic meningitis  (in  the  so  called  wet-brain).  Two  re- 
covered and  one  died.  In  the  adult  the  operation  is  dif- 
ficult. He  agreed  with  Dr.  Mills  as  to  its  indications 
and  utility.  He  believed  that  the  operation  possessed, 
at  least,  some  rational  foundation. 

Hon-Operative  Treatment  of  Brain  Tumors.— Dr. 
Theodore  Diller,  of  Pittsburg,  was  the  author  of  this 
paper.  The  writer  took  the  view  that  not  all  brain 
tumors  which  could  be  localized  should  be  operated  on. 
He  cautioned  against  regarding  as  successes  those  which 
merely  succeeded  surgically.  The  obstacles  in  the  way 
of  a  complete  success  were  many,  and  the  results  were  dis- 
appointing, in  spite  of  the  rich  and  growing  knowledge  ot 
localization.  Operations  should  not  be  undertaken  un- 
less the  patient  was  getting  worse  in  spite  of  medical  treat- 
ment. 

Dr.  Starr  spoke  of  the  case  of  a  man  with  a  doubtful 
history  of  syphilis  and  all  the  symptoms  of  cerebral  tumor. 
Its  localization  was  a  simple  matter.  Mercury  was  used 
and  iodide  of  potash  was  given  in  doses  of  three  hundred 
grains  daily.  There  was  marked  improvement  in  all 
symptoms;  and  it  seemed  to  be  a  case  cured  without 
operation.  The  patient  died  suddenly,  and  at  the 
autopsy  a  cysto-sarcoma  was  found  without  any  evidence 
of  gummatous  infiltration. 

Dr.  Putnam  believed  we  should  only  operate  when 
there  were  definite  indications. 

Dr.  Sinkler  mentioned  the  case  of  a  man  with  Jack- 
sonian  epilepsy  and  no  history  of  syphilis.  Two  years 
later  all  symptoms  of  tumor  were  present.  Mercury  and 
iodide  were  used,  but  he  became  progressively  worse. 
An  operation  was  performed  but  no  tumor  could  be  dis- 
covered. The  wound  healed  well.  Since  then,  the  pa- 
tient has  improved  steadily  in  all  symptoms. 

Dr  Jacoby  said  that  there  was  a  class  of  cases  present- 
ing all  of  the  symptoms  of  tumor  which  get  well  without 
operation.  He  cited  the  case  of  a  man  with  many  of  the 
symptoms  excepting  optic  neuritis,  where  he  was  unwilling 
to  make  a  positive  diagnosis.  The  Plasmodium  malariae 
was  found  in  his  blood  and  he  made  a  complete  recovery 
under  large  doses  of  quinine. 

The  President  stated  that  we  have  all  been  disap- 
pointed more  or  less  in  the  results  after  operation.  It 
may  be  our  own  fault  on  account  of  the  delay  in  operating. 
He  had  a  similar  experience  to  that  of  Dr.  Starr.  At 
the  autopsy  there  was  found  a  typical  glioma.  The 
symptoms  had  entirely  disappeared  for  several  months. 
In. another  case  with  all  the  symptoms  of  tumor  iodide 
had  been  used,  but  all  symptoms  subsided  after  thorough 
mercurial  inunction. 

An  Electrode  for  Use  in  Diagnosis.— Dr.  W.  M. 
Leszynsky,  of  New  York,  presented  an  electrode  which 
had  been  specially  constructed  with  a  view  to  its  useful- 
ness in  diagnosis. 

Stolen  Grafts. — A  man  has  brought  suit  in  San  Fran- 
cisco for  $25,000  damages,  for  the  loss  of  some  strips  of 
skin  removed  from  his  thigh  and  grafted  upon  the  head 
of  another  patient  in  the  hospital.  He  claims  that  the 
grafts  were  taken  without  his  consent  and  knowledge, 
while  he  was  under  the  influence  of  an  anaesthetic,  given, 
as  he  was  led  to  believe,  to  save  him  from  the  pain  of  an 
examination  that  was  to  be  made  by  the  surgeons. 


July  21,  1894] 


MEDICAL   RECORD. 


91 


ASSOCIATION  OF  AMERICAN  PHYSICIANS. 

Ninth  Annual  Meeting,  held  in  Washington,  D.  C,  May 
29 >  3°>  J1*  and  June  1,  1894. 

(Continued  from  Vol.  45,  page  80a.) 

Fourth  Day,  Friday,  June  i,  1894. 

The  Chemical  Products  of  the  Anaerobic  Putrefaction 
of  Pancreatic  and  Hepatic  Tissues,  and  Their  Effects 
upon  the  Tests  for  Morphine. — Dr.  Victor  C.  Vaughan, 
of  Ann  Arbor,  Mich.,  read  a  paper  with  this  title.  The 
chemical  products  of  putrefaction  are  modified  by  the 
conditions  under  which  the  process  proceeds.  There  are 
always  present,  during  life,  in  the  upper  part  of  the  small 
intestines,  certain  anaerobic  germs  which  produce  indol 
and  its  derivatives.  When  the  host  dies,  these  germs  do 
not  necessarily  cease  to  exist.  They  can  grow,  multiply, 
and  produce  their  special  products  only  in  the  absence 
of  air.  Pancreatic  and  hepatic  tissues  allowed  to  de- 
compose in  the  absence  of  air,  contain  chemical  sub- 
stances which  can  be  extracted  by  the  methods  of  Drag- 
gendorf,  and  which  give  many  tests  similar  to  those  given 
by  morphine. 

The  author  had  demonstrated  these  facts  by  experi- 
ment. This  being  true,  new  tuethods  must  be  sought 
for  the  detection  of  morphine  in  the  human  body  after 
death. 

No  discussion. 

Oastro-enteric  Rheumatism. — Dr.  Henry  M.  Ly- 
man, of  Chicago,  presented  this  communication.  Gastro- 
enteric rheumatism  is  characterized  by  symptoms  as  defi- 
nite as  those  of  articular  rheumatism. 

It  occurs  among  neurotic,  arthritic,  senile,  or  prema- 
turely-aged people. 

It  belongs  to  the  erratic  and  neuralgic  variety  of 
rheumatism. 

Its  pathology  is  as  indefinite  as  that  of  chronic  neuro- 
muscular rheumatism  in  general. 

It  is  probably  due  to  acidity  of  the  stomach,  or  at  least 
to  tie  absorption  of  the  products  of  an  abnormal  digestive 
process.  The  symptoms  come  on  when  the  stomach  is 
nearly  empty,  e.g.,  at  midnight.  The  pains  are  exceed- 
ingly variable,  but  are  distinct  from  gastralgia.  It  is  a  dull, 
deep-seated  pain,  not  influenced  by  motion.  It  shifts 
from  place  to  place.  It  may  be  in  the  cardiac  region, 
it  may  involve  the  pelvic  nerves  and  cause  rectal  or  blad- 
der symptoms,  or  the  sexual  nerves  and  cause  priapism. 
Unlike  dyspepsia,  it  does  not  affect  the  general  health, 
though  the  patient  may  become  anaemic. 

The  treatment  consists  in  providing  warmth  and  dry- 
ness of  the  surroundings  of  the  patient ;  hepatic  and  re- 
nal elimination ;  nutritious  and  easily  digested  food ; 
warm  baths,  and  abundant  exercise. 

Dr.  J.  H.  Musser,  of  Philadelphia,  deprecated  the 
introduction  of  new  terms.  He  would  prefer  "  the  gas- 
troenteric form  of  lithiasis." 

Dr.  J.  £.  Graham,  of  Toronto,  Canada,  expressed 
his  interest  in  the  paper. 

Dr.  Victor  C.  Vaughan,  of  Michigan,  said  :  We  use 
the  term  rheumatism  to  cover  a  great  variety  of  things. 
We  should  make  a  distinction  of  those  pains  caused  by 
uric  acid.  It  might  be  well  to  call  these  pains  described 
above,  gout.  He  called  attention  to  the  fact  that  the 
tendency  of  investigators  was  to  doubt  the  former  teach- 
ing that  uric  acid  was  an  incompleted  stage  in  the  pro- 
duction of  urea. 

Dr.  I.  T.  Dana,  of  Portland,  Me.,  thought  that  rheu- 
matism is  a  conglomerate  pathological  mass.  He  would 
confine  the  term  rheumatism  to  acute  articular  rheuma- 
tism and  give  other  names  to  other  conditions. 

Dr.  Vaughan  agreed  with  the  previous  speaker,  and 
added  that  he  believed  these  diseases  would  ultimately 
be  distinguished  by  examinations  of  the  blood. 

Dr.  Lyman  closed  the  discussion.  He  was  not  satis- 
fied with  the  name,  but  it  was  the  best  he  could  do  in  the 
present  state  of  our  knowledge 

Osteomalacia. — Dr.  George  Dock,  of  Ann  Arbor, 


Mich.,  reported  the  case  of  a  woman,  aged  twenty-five 
years,  a  native  and  resident  of  Michigan,  who  had  a 
marked  case  of  osteomalacia.  The  case  was  probably, 
though  not  distinctly,  of  puerperal  origin.  The  case 
lasted  three  or  four  years,  with  marked  symptoms  for 
two  and  a  half  years,  and  was  characterized  by  the  com- 
mon subjective  symptoms  and  softening,  spontaneous 
fracture,  and  deformity  of  the  bones,  and  excretion  by 
the  kidneys  of  large  quantities  of  lime  salt3  (renal  colic). 
Treatment  had  no  influence  on  the  disease  (lime,  phos- 
phates, etc.). 

Post-mortem. — The  changes  were  very  marked  and  do 
not  throw  any  light  on  the  pathology  of  the  disease  (mi- 
croscopic and  histological  specimens  were  shown). 

He  referred  briefly  to  all  the  cases  hitherto  reported 
in  the  United  States,  which,  excluding  three  of  doubtful 
diagnosis,  are  very  few,  and  do  not  add  materially  to  our 
knowledge  of  the  disease. 


NEW  YORK  PATHOLOGICAL  SOCIETY. 

Stated  Meeting,  January  24,  i8p4- 

George  C.  Freeborn,  M.D.,  President,  in  the  Chair. 

Carcinoma  of  the  Head  of  the  Pancreas. — Dr.  J.  S.  Ely 
presented  such  a  specimen.  A  man  sixty- three  years  ol 
age,  a  shoemaker  by  occupation,  was  seen  by  him  in 
March,  1892,  with  Dr.  Ferrer,  at  the  Out  patient  Depart- 
ment of  the  Roosevelt  Hospital.  He  had  been  well  up 
to  six  weeks  before.  At  this  time  he  began  to  have  pain 
in  the  right  hypgehradrium,  and  detected  a  lump  in  this 
region.  OrvMarch  3d,  he  rather  suddenly  became  jaun- 
diced, and  four  days  later  there  was  a  severe  attack  of 
vomiting,  the  vomitus  being  whitish  and  free  from  blood. 
The  pain  in  the  region  of  the  tumor  continually  increased, 
the  tumor  appeared  to  be  growing  larger,  and  he  had  lost 
much  flesh  and  was  greatly  troubled  with  insomnia  and 
constipation.  When  first  seen,  he  was  much  emaciated 
and  deeply  jaundiced ;  the  tongue  was  dry  and  clean,  and 
the  arteries  hard  and  tortuous.  A  physical  examination 
of  the  chest  gave  the  signs  of  pronounced  emphysema. 
On  the  right  side  was  a  large,  irregular,  nodular  mass 
which  appeared  to  be  the  lower  border  of  an  enlarged 
liver.  The  mass  was  quite  tender  and  slightly  movable 
on  deep  inspiration  and  gentle  manipulation.  No  tumor 
could  be  detected  under  the  enlarged  liver,  or  in  the 
situation  of  the  pylorus.  The  stomach  was  normal  in 
size.     The  temperature  was  99. 8°  F. 

The  case  was  apparently  one  of  carcinoma  in  the  sub- 
stance of  the  liver.  Because  of  the  absence  of  marked 
gastric  symptoms  and  gastrectasia,  and  because  of  the  in- 
tensity of  the  jaundice,  he  had  been  inclined  to  the  opin- 
ion that  the  primary  carcinoma  was  in  the  head  of  the 
pancreas,  or  in  the  common  bile-duct  near  its  entrance 
into  the  duodenum,  the  former  being  considered  the 
more  probable  on  account  of  the  late  appearance  of  the 
jaundice.  After  admission  to  the  hospital  the  pain  was 
relieved  somewhat  by  moderate  doses  of  morphia.  There 
was  quite  free  epistaxis  on  several  successive  days,  and 
this  greatly  prostrated  him,  so  that  on  March  23d,  after 
a  short  period  of  unconsciousness,  he  died  of  exhaustion. 
During  the  two  weeks  he  was  in  the  hospital,  the  tem- 
perature was  not  higher  than  1010  F.,  and  it  only  once 
reached  that  point  four  days  before  his  death. 

The  autopsy  was  made  by  the  speaker  about  twenty- 
four  hours  after  death.  The  body  was  much  emaciated 
and  extremely  jaundiced.  Scattered  through  the  mesen- 
tery were  many  small,  hard  masses,  the  largest  being 
about  half  an  inch  in  diameter.  Many  of  these  were  sit- 
uated at  the  point  of  attachment  of  the  mesentery  and 
intestine.  Around  the  common  bile  duct  was  a  hard 
mass,  1J/2  x  1  x  ^  inches,  which  replaced  the  substance 
of  the  pancreas.  This  mass  was  continuous  with  a  thick- 
ened mass  around  the  common  bile-duct  near  its  mouth. 
Above  this  point  this  duct  was  greatly  dilated.  Scattered 
through  the  liver  were  spherical  masses — both  discrete 
and  conglomerate — which  were  very  abundant  near  the 


92 


MEDICAL   RECORD. 


[July  21,  1894 


lower  border  of  the  liver.  They  presented  the  character- 
istic appearance  of  carcinomatous  nodules  in  the  liver. 
Between  the  nodules  the  liver  substance  showed  dark  cen- 
tres and  light  peripheries  of  the  nodules.  The  gall-blad- 
der was  adherent  by  old  adhesions  to  the  under  surface  of 
the  liver,  to  the  duodenum,  and  to  the  tumor  around  the 
mouth  of  the  common  bile-duct.  The  stomach  appeared 
normal  The  spleen  showed  chronic  congestion  and  in- 
terstitial splenitis.  The  kidneys  were  of  about  the  nor- 
mal size ;  their  capsules  were  moderately  adherent ;  there 
were  some  small  cysts,  and  the  markings  of  the  cortex 
were  indistinct.  There  were  numerous  small  ulcers,  with 
indurated  bases,  situated  on  the  mesenteric  attachment  of 
the  small  intestine,  and  continuous  with  the  small  tumors 
in  the  mesentery.  The  hemorrhage  was  thought  to  have 
occurred  from  some  of  these  ulcers.  The  intestine  con- 
tained much  liquid,  granular,  dark  greenish-brown  fecal 
matter.  The  heart  was  of  normal  size.  There  was  athe- 
roma of  the  aorta.  The  lungs  were  excessively  pigmented, 
and  their  surface  showed  considerable  old  pleurisy. 
Specimens  were  exhibited  under  the  microscope  showing 
intense  athracotic  pigmentation,  lying  in  the  interlobu- 
lar connective  tissue.  This  same  pigmentation  was  also 
quite  abundant  in  the  liver — a  point  worthy  of  note. 
Scattered  through  the  lungs  were  a  dozen  or  more  hard 
nodules,  the  largest  being  three  fourths  of  an  inch  in  di- 
ameter. Microscopical  examination  showed  all  the 
growths  in  the  various  organs,  as  well  as  the  masses  in  the 
mesentery  and  intestinal  wall  to  be  deno-carcinoma,  or  that 
type  of  carcinoma  in  which  the  arrangement  of  the  epi- 
thelial cells  was  such  as  to  suggest  the  acini  of  a  gland. 
This  was  not  the  appearance,  however,  everywhere,  the 
tumor  in  many  places  presenting  the  typical  picture  of 
small  alveolar  carcinoma.  The  structure  of  the  metasta- 
ses was  much  more  uniformly  that  of  adeno-carcinoma 
than  that  of  the  supposed  original  tumor  in  the  head  of 
the  pancreas.  With  regard  to  the  intestinal  lesions,  there 
could  be  no  doubt  that  the  ulceration  was  a  secondary 
result  of  the  involvement  of  the  intestinal  wall  by  metas- 
tases which  formed  in  the  mesentery  at  the  point  of  its 
attachment  to  the  gut.  The  sections  showed  several 
stages  of  the  encroachment  of  these  metastases  on  the  in- 
testinal wall,  and  of  the  resulting  ulceration.  Intense 
congestion  was  visible  in  the  floors  of  some  of  the  ulcers, 
and  it  was  undoubtedly  from  these  that  a  part  of  the  hem- 
orrhage occurred,  evidence  of  which  was  seen  in  the  dark 
granular  material  filling  the  intestine. 

The  speaker  said  that  the  occurrence  of  such  metas- 
tases, with  secondary  involvement  of  the  intestine  and 
ulceration,  he  believed  to  be  rather  unusual.  The  mate- 
rial giving  origin  to  these  metastases  must  have  been  car- 
ried by  the  blood-current. 

A  tumor  of  the  structure  and  location  here  described 
might  have  its  origin  in  the  duodenum,  in  the  common 
bile-duct,  or  in  the  head  of  the  pancreas,  and  it  was  usu- 
ally impossible  to  say  with  certainty  from  which  of  these 
structures  it  originated  in  the  present  case.  But,  as  the 
head  of  the  pancreas  occupied  the  centre  of  the  carcino- 
matous mass  which,  it  was  evident,  was  the  primary  nod- 
ule of  the  tumor,  it  was  believed  to  have  begun  its  growth 
in  the  pancreas.  A  measure  of  support  was  given  to  this 
view  by  the  following  case : 

A  man  sixty-one  years  of  age,  a  varnisher  by  occupa- 
tion, was  treated  in  the  Roosevelt  Hospital,  during  the 
fall  of  1 89 1,  for  chronic  diffuse  nephritis,  and  was  dis- 
charged improved.  On  March  24,  1892,  he  returned, 
stating  that  soon  after  he  left  the  hospital  he  began  to 
feel  weak,  and  to  be  troubled  with  cough  in  the  morn- 
ing, and  occasionally  by  bloody  expectoration,  dyspnoea, 
and  patpitation.  On  March  14th,  he  first  noticed  jaun- 
dice, and  this  had  steadily  increased.  On  admission  he 
was  deeply  jaundiced  and  decidedly  emaciated ;  there 
was  oedema  of  the  legs  and  thighs.  The  tongue  was 
coated  and  dry,  the  arteries  were  very  atheromatous, 
the  pulse  was  96,  regular  and  feeble,  and  he  had 
ascites.  The  temperature  was  990.  Physical  examina- 
tion showed  an  accumulation  of  fluid  in  both  pleural 


cavities,  more  on  the  left  side.  The  hepatic  dulness 
extended  from  the  fifth  rib  to  the  free  border  of  the  ribs. 
He  soon  developed  orthopnoea,  and  died  on  March  26th, 
four  days  after  admission.  The  post  mortem  examina- 
tion was  made  the  same  day  by  Dr.  Ewell,  the  house  phy- 
sician. The  abdominal  cavity  contained  much  bile- 
stained  liquid,  and  the  organs  were  also  bile  stained. 
The  left  pleural  cavity  contained  fluid;  the  heart  was 
somewhat  enlarged,  and  the  left  ventricle  dilated  and 
hypertrophied.  The  mitral  valve  was  thickened  and  cal- 
careous. The  lower  lobe  of  the  left  lung  was  compressed 
and  carneous,  and  contained  a  nodule  of  old  healed 
phthisis,  one- half  inch  in  diameter.  There  was  a  similar 
nodule  in  the  right  apex.  The  peritoneum  around  the 
liver  was  covered  with  a  layer  of  loose  fibrin,  and  the  gall- 
bladder was  distended  and  filled  with  liquid  bile.  The 
cystic  duct  was  apparently  obliterated.  The  liver 
weighed  three  pounds  and  eight  ounces,  and  was  very 
hard,  and  the  interlobular  fibrous  tissue  was  increased. 
The  kidneys  were  small,  the  capsules  adherent,  the  cor- 
tex thin,  and  the  markings  obliterated.  The  spleen  was 
small  and  hard,  and  showed  recent  inflammation  of  its 
capsule,  similar  to  that  seen  in  the  liver,  besides  old  peri- 
splenitis. The  stomach,  duodenum,  and  small  intestine 
were  normal.  The  head  of  the  pancreas  was  hard  near 
its  tip.  Behind  this  was  an  abscess-cavity,  one  and  a 
half  inch  in  diameter,  and  a  second  separate  abscess 
was  found  in  the  tail  of  the  pancreas.  Microscopical  ex- 
amination of  the  hard  mass  showed  it  to  be  an  adeno- 
carcinoma. The  mesenteric  lymph  nodes  near  the  pan- 
creas showed  no  involvement,  and  there  was  no  trace  of 
metastasis  anywhere.  The  death  of  this  patient  from 
Bright's  disease  and  peritonitis,  revealed  a  carcinoma  in 
the  head  of  the  pancreas  in  a  very  early  stage,  while  still 
limited  to  the  original  site. 

The  speaker  said  that  he  had  reported  these  two  cases 
that  they  might  be  compared  with  the  one  presented  at 
the  last  meeting.  Where  jaundice  developed  in  an  old 
person  in  the  manner  described,  and  where  gall-stones 
and  inspissated  bile  could  be  fairly  excluded,  carcinoma  at 
this  point  should  be  thought  of  as  an  extremely  likely 
cause  of  the  jaundice.  In  two  of  the  cases  the  diagnosis 
was  made  of  carcinoma  in  this  region — a  more  exact 
localization  would  of  course  be  quite  difficult.  In  the 
first  case,  he  thought,  from  the  late  development  of  the 
jaundice  after  nodules  had  formed  in  the  liver,  that  there 
was  probably  a  carcinoma  in  the  head  of  the  pancreas 
instead  of  at  the  mouth  of  the  common  bile-duct,  in 
which  case  the  jaundice  would  have  probably  occurred 
earlier. 

Dr.  J.  M.  Byron  said  that  he  was  exceedingly  sur- 
prised at  the  similarity  of  the  structure  exhibited  in  the 
various  organs  in  which  metastasis  had  occurred.  It  was 
well  understood,  of  course,  that  in  a  glandular  organ  like 
the  pancreas  the  growth  might  take  place  on  the  epithe- 
lium of  the  organ,  and  proliferate  and  produce  a  new 
growth  which  would  resemble  the  organ  from  which  it 
sprung  ;  but  when  the  metastasis  occurred,  for  instance, 
from  the  pancreas  to  the  bone,  or  to  another  organ  not 
a  glandular  organ,  he  could  not  understand  how  a  gland- 
uloid  formation  such  as  was  seen  in  the  specimen  could 
take  place.     This  was  the  first  time  he  had  heard  of  it. 

Regarding  the  second  case,  he  asked  whether  the  lungs 
had  been  examined,  and  also  the  exudation  of  blood,  in 
order  to  determine  whether  or  not  there  was  a  primary 
epithelioma  of  the  pleural  cavity. 

Dr.  Ely  replied  that  he  did  not  make  the  autopsy  and 
had  not  been  able  to  see  the  physician  who  had  made  it, 
but  if  there  had  been  anything  noticeable  about  the 
pleura  he  felt  sure  that  it  would  have  been  noted.  There 
was  a  great  deal  of  oedema  and  advanced  ascites,  and  it 
was  thought  at  the  time  to  be  not  an  exudation,  but  a 
simple  transudate. 

Dr.  Byron  said  he  had  asked  this  question  because  he 
was  familiar  with  cases  of  endothelioma  which  had  been 
presented  by  Dr.  H.  M.  Biggs,  and  in  which  the  first 
symptoms  were  those  of  small  exudations  of  bloody  se- 


July  2i,  1894] 


MEDICAL    RECORD. 


93 


rum  into  the  pleural  cavity.  These  had  been  diagnosti- 
cated at  first  as  ordinary  pleurisy,  but  at  the  autopsy  the 
pleura  had  been  found  to  be  greatly  thickened,  and  there 
were  immense  numbers  of  metastases. 

General  Tuberculosis. — Dr.  T.  S.  Southworth  pre- 
sented specimens  from  a  case  of  general  tuberculosis. 
They  were  removed  from  a  child  of  fourteen  months,  in 
the  Nursery  and  Child's  Hospital.  It  was  one  of  twins, 
and  when  born,  in  November,  1892,  weighed  4^  pounds. 
It  was  breast  fed,  and  did  well  up  to  the  spring  of  1893, 
when  it  had  whooping  cough.  At  the  age  of  six  months 
it  weighed  16  pounds.  Last  August  it  began  to  have  a 
slight  cough,  and  since  then  it  steadily  foiled,  until  at 
the  time  of  its  death,  on  January  18,  1894,  it  weighed 
only  2>y±  pounds.  The  chest  was  examined  once  or 
twice  by  the  house  physician,  but  no  very  definite  physi- 
cal signs  were  found.  At  the"  autopsy  the  emaciation 
was  very  noticeable.  The  abdomen  was  distended.  On 
opening  the  thorax  the  right  pleura  was  found  firmly  ad- 
herent over  the  upper  and  middle  lobes  of  the  right  lung, 
and  there  was  a  yellow,  cheesy  mass  found  beneath  the 
pleura,  embedded  in  the  upper  and  middle  lobes  on  the 
anterior  surface.  It  was  adherent  to  the  pleura,  but  not 
to  the  lung  tissue.  When  removed,  it  left  a  rough  cav- 
ity which  did  not  apparently  communicate  with  the 
bronchi.  The  edges  of  this  cavity  were  sharp  and 
slightly  overhanging.  The  upper  and  middle  lobes  of 
the  lung  were  consolidated,  and  showed  tubercles  on  the 
surface.  The  adjacent  bronchial  glands  were  large  and 
cheesy.  The  left  lung  also  showed  scattered  patches  of 
tubercular  infiltration.  The  pericardium  was  adherent 
over  the  left  border  of  the  right  ventricle.  The  heart 
and  valves  were  normal.  The  liver  showed  a  few  tuber- 
cles on  the  surface.  There  was  general  adhesive  peri- 
tonitis binding  together  all  the  abdominal  organs,  but 
there  was  no  fluid  in  the  abdominal  cavity.  The  spleen 
was  covered  with  lymph,  its  capsule  was  opaque,  and 
there  were  a  few  miliary  tubercles  on  its  surface.  The 
kidneys  were  apparently  normal.  Both  the  large  and 
small  intestine  were  covered  with  lymph  and  studded 
here  and  there  with  tubercles  beneath  the  peritoneum, 
and  also  in  the  mesentery.  In  the  large  intestine  were 
some  superficial  ulcerations,  and  other  areas  which  ap- 
peared to  be  suppurating  lymph  nodes  which  had  not 
broken  down.  The  mesenteric  glands  were  much  en- 
larged and  cheesy.  The  nodule  found  embedded  in  the 
upper  part  of  the  right  lung  was  about  the  size  of  a  wal- 
nut. Smears  were  made  from  the  deeper  portions  of  the 
mass,  and  tubercle  bacilli  found.  Small  pieces  were  also 
examined  microscopically,  and  showed  cheesy  degenera- 
tion and  the  remains  of  giant  cells.  There  was  no  defi- 
nite glandular  structure  remaining. 

A  Case  of  Pyuria. — Dr.  F.  Tilden  Brown  presented 
a  report  of  a  case  for  diagnosis.  He  said  that  he  had  had 
a  patient  suffering  from  pyuria  under  his  care  for  five 
months.  The  patient  had  been  bedridden  for  the 
greater  part  of  this  time.  There  was  no  abnormal  tem- 
perature. The  cystoscope  showed  pus  coming  from  the 
left  ureter.  He  had  not  been  able  to  exclude  tuberculo- 
sis of  the  genito-urinary  tract,  although  repeated  search 
had  been  made  for  tubercle  bacilli.  At  times  there  was 
also  a  slight  hematuria  and  some  discomfort  in  the  left 
side  and  left  testis,  suggestive  of  a  renal  calculus.  The 
pain  had  been  accounted  for  by  the  discharge  in  the 
urine  of  certain  shreds.  The  hematuria  had  been  rather 
more  marked  after  exertion.  The  urinary  examinations 
had  been  very  contradictory.  The  speaker  raised  the 
question  whether  we  could  expect  a  tubercular  process  of 
the  kidney  where  there  was  a  profuse  suppuration,  and 
yet  no  associated  micro-organisms  and  no  elevation  of 
temperature.  He  thought  it  would  be  rather  unusual. 
If  due  to  a  stone  in  the  kidney,  one  would  expect  more 
intense  subjective  symptoms.  The  leucocytes  appeared 
to  be  well  formed.  He  had  examined  for  filaria,  bil- 
harzia,  and  similar  organisms,  with  negative  result. 

Dr.  T.  M.  Prudden  remarked  that  in  making  exam- 
inations where  tuberculosis  was  suspected,  it  was  desirable 


to  use  the  sediment  from  large  quantities  of  urine. 
Lately  he  had  been  accustomed  to  ask  for  the  urine  of 
two  or  three  days,  and  after  decanting  the  sediment,  it 
was  placed  in  the  centrifugal  machine,  and  still  further 
concentrated.  By  this  method  tubercle  bacilli  could  be 
found  in  some  cases  where  the  more  usual  methods  of  ex- 
amination gave  only  a  negative  result. 
The  Society  then  adjourned. 


(&oxxz&voxi&mtz. 

OUR  LONDON  LETTER. 

From  our  Special  Correspondent 

HOSPITAL  SUNDAY — MANSION  HOUSE  RECEPTION — ROYAL 
SPEECHES  FOR  HOSPITALS — THE  MIDW1VES'  REGISTRA- 
TION QUESTION — THE  ROYAL  SOCIETY'S  CONVERSAZIONE 
—  THE  ANNUAL  MEETING  —  A  DOCTOR'S  LEGACY  —  OB- 
STETRICAL SOCIETY — DIVISION  OF  BROAD  LIGAMENTS — 
EFFECT  OF  THIS  AND  OOPHORECTOMY  ON  MENSTRUATION 
— OPPOSING    OPINIONS — ADENOMA    OF    CERVIX    WITH    A 

DEPRESSION. 

London,  June  16.  1894 

The  Hospital  Sunday  Fund  promises  to  equal  past 
years,  hut  at  present  only  a  small  proportion  has  reached 
the  Mansion  House.  Up  to  Thursday  evening  ^14,000 
had  been  received.  The  Lord  Mayor  and  Lady  Mayor- 
ess gave  a  reception  on  the  7  th,  in  connection  with  the 
movement.  Our  princes  have  lately  pleaded  the  cause  of 
our  hospitals.  On  Monday  the  Prince  of  Wales  spoke 
for  the  Popular  Hospital,  and  afterward  inaugurated  a 
new  Home  for  Missions  to  Seamen.  On  Saturday  the 
Duke  of  Connaught  spoke  at  St.  Thomas's  Hospital,  and 
it  is  very  lately  that  the  Duke  of  York  presided  at  St. 
Mary's.     This  is  good  work  for  royalty. 

The  Midwives'  Registration  question  continues  to  agi- 
tate professional  circles,  and  Dr.  Carter,  of  Liverpool,  has 
entered  the  lists  against  Dr.  Renton,  who  has  so  long 
waged  war  on  behalf  of  the  profession.  Dr.  Carter's  pre- 
vious appearances  in  medical  politics  are  hardly  calcu- 
lated to  inspire  confidence  in  his  proceedings  or  in  those 
of  the  British  Medical  Association.  It  matters  little,  how- 
ever, what  may  be  done  at  present,  for  no  one  expects 
that  the  Legislature  will  find  time  to  deal  with  the  ques- 
tion this  session,  and  the  Government  is  not  likely  to  add 
to  its  instability  by  attempting  to  pass  a  measure  on  a 
subject  so  much  controverted. 

On  Wednesday  last  the  conversazione  of  the  Royal 
Society  was  held  with  the  usual  eclat.  This  function — 
sometimes  called  "the  ladies'  night" — is  the  one  that 
appeals  to  the  uninitiated,  and  therefore  the  one  occasion 
on  which  the  chief  scientific  society,  so  to  say,  unbends. 
There  were  a  considerable  number  of  photographs  and 
other  interesting  things  exhibited  in  illustration  of  vari- 
ous scientific  matters.  A  curious  if  sombre  exhibit  was  a 
mummy  cloth  calculated  to  have  been  made  in  the 
Fourth  Dynasty,  and  the  strands  were  said  to  be  300  by 
150  per  inch — a  contrast  with  the  140  by  140  of  present 
day  fine  Irish  linen. 

On  Thursday  the  annual  meeting  was  held,  and  the 
new  Fellows  elected.  Among  them  are  some  whose  work 
is  of  much  interest  to  medical  scientists,  and  two  are 
members  of  our  profession — viz.,  Mr.  Watson  Cheyne 
and  Dr.  J.  Rose  Bradford.  The  F.R.S.  is  so  highly 
prized  that  I  may  venture  to  congratulate  these  gentle- 
men on  the  recognition  of  their  work.  It  is  always 
agreeable  to  see  colleagues  obtaining  merited  distinc- 
tions. 

Another  law  case  has  been  settled  honorably  to  the 
profession.  A  will  made  by  a  sick  patient  left  Dr. 
Ormsby  ^3,000,  and  this  will  was  disputed  on  the 
ground  of  incapacity  and  undue  influence.  The  case  ut- 
terly broke  down— "  crumbled  away,"  to  use  the  ex- 
pression of  the  judge— and  the  counsel  for  the  complain- 
ants   threw  up  his  brief   and    publicly  withdrew    all 


94 


MEDICAL   RECORD. 


[July  21,  1894 


imputations.  But  what  is  to  compensate  Dr.  Ormsby 
for  the  expense  to  which  he  has  been  put  and  the  moral 
torture  he  must  have  endured  in  the  interim  ?  It  seems 
a  terrible  thing  that  a  patient  in  dividing  a  property  of 
^86,000  confers  a  doubtful  benefit  on  his  "  dear  friend 
and  confidential  adviser  "  by  bequeathing  him  a  moder- 
ate legacy. 

At  the  last  meeting  of  the  Obstetrical  Society  a  paper 
was  read  by  Dr.  Remfry,  on  "  Ligature  and  Division  of 
the  Upper  Parts  of  both  Broad  Ligaments,  and  the  Re 
suit  of  this  Operation  as  Compared  with  that  of  Removal 
of  the  Appendages.1'  This  plan  was  adopted  in  a  case 
of  bleeding  fibroid,  which  did  not  admit  of  oophorectomy. 
The  paper  compared  the  two  procedures  from  an  ana- 
tomical point  of  view  as  well  as  in  reference  to  the  re- 
sult. In  respect  to  the  theories  as  to  the  amenorrhcea 
after  removal  of  the  appendages,  the  author,  having  dis- 
cussed several,  concluded  that  changes  in  the  circulation 
with  diminished  blood-supply  to  the  uterus  were  the 
chief  factors ;  and  this  conclusion  was  supported  by  the 
case  related,  in  which  menstruation  did  not  return  for 
three  months,  and  the  slightness  of  the  operation  was 
opposed  to  the  shock  theory. 

A  decided  difference  of  opinion  was  expressed  in  the 
course  of  the  discussion  respecting  the  amenorrhcea  after 
oophorectomy.  Dr.  Horrocks  declared  that  in  all  his 
experience  he  had  never  seen  menstruation  continue  for 
any  length  of  time  after  complete  removal  of  both 
ovaries.  It  is  difficult  to  be  sure  that  the  ovaries  are  re- 
moved entire.  He  still  held  that  the  ovaries  were  es- 
sential to  menstruation,  although  not  to  ovulation.  He 
had  never  been  able  to  find  the  nerve  which  was  said  by 
some  to  influence  menstruation,  and  would  like  to  see 
proof  of  its  existence,  but  of  course  he  did  not  doubt  the 
influence  of  the  nervous  system.  In  contrast  with  this 
opinion  Dr.  Duncan  said  he  had  had  four  cases  in 
which,  many  months  after  complete  removal  of  the  ap- 
pendages, the  patients  had  menorrhagia.  He  could  not 
account  for  this  unless  the  ligatures  of  the  stumps  were 
perhaps  exciting  irritation.  He  held  that,  so  long  as  no 
ovarian  tissue  remained  on  the  proximal  side  of  the  liga- 
ture, a  small  amount  on  the  distal  side  was  of  no  impor- 
tance. In  several  cases  he  had  left  portions  of  firm 
ovarian  tissue  to  prevent  slipping  ot  the  ligatures,  be- 
cause the  ovaries  and  tubes  were  so  firmly  matted  down 
in  the  pelvis  that  he  thought  it  safer  to  do  so,  but  in  no 
instance  had  menstruation  occurred.  Dr.  Amand  Routh 
referred  to  the  possibility  of  hemorrhage  from  other 
causes,  and  said  he  had  dilated  in  three  cases  of  persis  - 
ent  hemorrhage  after  removal  of  appendages,  and  in 
two  he  had  found  a  polypus  and  in  the  other  villous 
growths.  He  believed  the  ovaries  acted  through  gan- 
glionic nerves  going  from  them  to  the  uterus,  and,  of 
course,  these  nerves  were  removed  in  oophorectomy,  so 
that  we  cannot  absolutely  ignore  them  as  a  cause  of  men- 
struation. 

Dr.  Routh's  observation  as  to  polypi  is  suggestive  of 
the  possibility  of  such  cause  being  overlooked  before 
oophorectomy,  and  will  no  doubt  put  operators  on  their 
guard  against  such  a  mischance.  Dr.  Remfry' s  case, 
although  interesting,  is  not  unique,  since,  as  mentioned 
by  the  President  (Dr.  Herman),  a  case  has  been  recorded 
by  Dr.  Murphy  and  another  by  Dr.  Kilner  Clarke,  and 
in  them  menstruation  was  not  arrested.  It  has  also  been 
proposed  to  tie  the  broad  ligaments  in  order  to  arrest 
malignant  disease,  but  I  do  not  remember  to  have  seen  it 
recorded  that  the  plan  has  been  adopted.  Dr.  Remfry, 
in  his  reply,  did  not  admit  that  removal  of  the  append- 
ages insured  the  arrest  of  menstruation,  some  published 
cases  being  opposed  to  this,  though  it  is  not  easy  to.  re- 
fute the  objection  that  in  these  cases  the  removal  was  not 
complete. 

Dr.  Braithwaite  next  read  an  account  of  a  case  of 
adenoma  of  the  portio  vaginalis  uteri  forming  a  de- 
pressed sore  or  ulcer.  Drawings  of  the  case  were  exhib- 
ited, and  it  was  clearly  an  unusual  one.  Among  the  re- 
marks made  upon  it  I  may  mention  that,  except  for  the 


depression  of  the  surface  of  the  ulcer,  every  one  would 
have  taken  it  for  an  ordinary  erosion  and  the  suggestion 
that  this  depression  might  possibly  be  accidental,  as  ero- 
sion might  have  occurred  on  a  previously  depressed  area. 
In  support  of  this  is  the  fact  that  the  patient  had  had 
three  children.  Another  suggestion  was  that  the  ade- 
noma had  become  malignant  where  the  ulceration  had 
been  seen,  although  the  microscope  did  not  show  this. 
Still  it  is  very  common  for  these  cervical  adenomas  to 
become  malignant,  and  this  change  may  begin  in  a  very 
limited  area. 

STATISTICAL  FACTS  AND  INACCURACY. 

To  the  Editor  or  the  Medical  Recobd. 

Sir  :  Referring  to  Dr.  Spence's  letter  in  the  Record  of 
July  7th,  I  must  confess  Jhat  I  cannot  attempt  to  un- 
ravel the  garbling  of  my  statements  which  it  contains. 
I  may,  however,  now  quote  from  Dr.  Spence's  letter  : 
"  Statistics,  in  order  to  be  valuable,  should  be,  as  to  their 
material  facts,  correct." 

Dr.  Spence's  doubts,  to  be  euphemistic,  hinge  upon 
my  Case  IX.  To  show  his  correctness  and  minuteness, 
I  may  state  that,  on  June  20th,  the  mother  brought  the 
child  to  my  clinic  at  the  Post-graduate  School,  and  the 
case  was  shown  to  the  students  as  practically  cured. 

Furthermore,  I  translate  the  following  letters  from 
Dr.  Voegtle  and  the  child's  father  (originals  inclosed), 
lest  Dr.  Spence  continues  in  his  error,  which  I  doubt  not 
is  unintentional. 

The  father  writes :  "  .  .  .  I  never  had  the  remot- 
est thought  of  telling  Dr.  Spence  that  my  child  did  not 
recover  until  Christmas.  But  I  did  tell  him  that 
the  wound  was  entirely  healed  toward  the  end  of 
July.     .     .     ." 

Dr.  Voegtle,  of  Long  Island  City,  writes,  under  date 
of  July  10,  1894,  "  .  .  .  Your  dates  regarding  the 
case  of  empyema  in  Ravenswood  are  essentially  correct, 
varying  only  in  the  matter  of  a  day  or  two.  .  .  . 
The  child  was  discharged  from  treatment  on  July  16 
(1893) >  tne  wound  was  healed  in  the  beginning  of 
July.     .     .     ." 

With  the  expression  ot  most  distinguished  considera- 
tion to  Dr.  Spence,  I  am, 

Yours  very  truly, 

Carl  Beck,  M.D. 

July  17,  1894. 


Contagious  Diseases — Weekly  Statement. — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to  the 
Sanitary  Bureau,  Health  Department,  for  the  week  end- 
ing July  14,  1894. 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebrospinal  meningitis 

Measles 

Diphtheria 

Small-pox 

Cholera 

Varicella 

Pertussis 

Erysipelas 

Leprosy 


Cases. 


Deaths. 


95 

100 

17 

6 

57 

9 

2 

3 

59 

4 

190 

49 

4 

4 

0 

0 

0 

O 

0 

0 

0 

0 

0 

O 

The  Lancet's  Investigation  of  the  Electrical  Treat- 
ment of  Sewage. — The  proposal  to  treat  sewage  electri- 
cally was  received  a  few  years  ago  with  considerable 
enthusiasm,  and  many  experts  ventured  to  think  that 
electricity,  which  was  doing  so  many  wonders  in  other 
respects,  would  probably  also  give  assistance  in  the 
direction  of  sanitary  affairs,  and  perhaps  afford  a 
satisfactory  solution  of  the  problem  of  sewage  dis- 
posal, if  not  indeed  of  sewage  utilization.     But  the 


July  21,  1894] 


MEDICAL  RECORD. 


95 


first  attempts  to  utilize  the  electric  current  as  a  sewage 
purifier  met  with  little  success,  owing  to  the  great  prac- 
tical difficulties  that  were  encountered.  We  need  not 
enumerate  them  here.  Suffice  it  to  say  that,  of  the  elec- 
trical processes  which  count  for  anything  now,  there  are 
two  which  continue  to  excite  considerable  interest  and 
curiosity  among  engineers  and  sanitary  experts  at  the 
present  time.  We  refer  to  the  Webster  electrolysis  pro- 
cess and  the  Hermite  system  of  treating  sewage  with  elec- 
trolysed sea- water.  In  the  former  method  the  sewage  is 
actually  exposed  to  the  action  of  the  current,  while  in  the 
Hermite  method  the  sewage  is  submitted  to  the  action  of 
sea- water,  the  composition  of  which  has  been .  partially 
altered  by  the  action  of  electricity.  Briefly,  the  Webster 
process  consists  in  allowing  ordinary  sewage  to  flow 
through  channels  in  which  are  placed  iron  plates  or  elec- 
trodes, set  longitudinally,  with  the  usual  battery  connec- 
tions, with  the  positive  and  negative  terminals  of  a  dyna- 
mo. The  sewage  in  its  passage  through  these  channels  is 
said  to  become  entirely  split  up  by  the  action  of  the  elec- 
tric current  upon  the  chlorides  always  present  in  sewage. 
At  the  positive  pole  the  chlorine  and  oxygen  given  off 
combine  with  the  iron  to  form  a  salt,  which  is  probably 
hypochlorite,  and  at  the  same  time  carbonate  of  iron 
is  assumed  to  exist  in  solution,  which  not  only  deodorizes 
the  fecal  matter  by  removing  sulphuretted  hydrogen 
(FeS),  but  also  acts  as  a  carrier  of  oxygen  from  the  air  by 
being  alternately  reduced  to  ferrous  and  oxidized  back  to 
ferric  oxide.  The  Webster  process,  therefore,  although 
an  electrical  one,  depends  upon  the  production  of  certain 
chemical  salts ;  but  it  is  probable  that  the  efficiency  of 
the  method  depends  largely,  if  not  entirely,  upon  the  fact 
that  the  sewage  is  presented  to  these  chemical  bodies 
while  they  are  in  a  very  active  state — in  fact,  in  statu 
nascendi.  The  Hermite  method  consists  in  the  electrol- 
ysis of  sea  water  and  the  subsequent  flushing  of  the  con- 
tents of  water-closets  with  a  definite  quantity  of  the 
resultant  fluid.  The  Hermite  fluid  is,  therefore,  a  chemi- 
cally active  fluid,  prepared  by  electrical  means.  The  sew- 
age is  never  in  contact  with  the  current,  as  in  the  Web 
ster  process,  nor  does  the  process  pretend  to  secure  the 
precipitation  of  organic  matters.  It  claims,  rather,  to 
effect  the  complete  deodorization  and  sterilization  of 
sewer  contents.  Both  processes,  therefore,  have  one  com- 
mon object  in  view — namely,  the  healthy  •  disposal  and 
not  the  utilization  of  sewage. 

The  Hermite  process  for  the  treatment  of  sewage,  with 
which  the  present  report  proposes  to  deal,  has  been  con- 
ducted on  an  experimental  scale  at  Worthing  during  the 
early  months  of  the  year,  with  the  view  of  its  adoption  in 
accordance  with  the  plan  originated  by  M.  Hermite. 

The  Lance fs  communication  has  shown  that  electro- 
lyzed  sea-water  contains  probably  as  its  chief  active  con- 
stituent hypochlorous  acid,  resulting  from  the  partial 
dissociation  of  magnesium  hypochlorite,  and  that  it  is 
fairly  stable  under  ordinary  circumstances ;  that  it  is  a 
powerful  bleaching  liquid,  being  superior  in  this  respect 
to*  bleaching  powder  solution,  but  not  to  a  solution  of 
bleaching  powder  of  equal  chlorine  value,  in  which  the 
hypochlorous  acid  has  been  liberated  by  the  addition  of  a 
weak  acid  (CO,  or  others,  in  weak  solution) ;  that  it  is  also 
a  powerful  deodorizer,  and  that  in  all  probability  these 
properties  are  due  to  the  united  action  of  oxygen  in  statu 
nascendi  and  chlorine.  These,  in  brief,  are  the  chemical 
properties  of  electrolyzed  sea-water,  and  it  remains  for 
us  to  consider  what  effect  for  good  or  for  evil  such  a 
liquid  of  definite  strength  would  have  when  mixed  in  a 
certain  proportion  with  fecal  matter.  It  deodorizes,  but 
does  not  destroy  or  remove  organic  matters,  although 
there  is  little  doubt  that  certain  of  them  are  partially 
changed,  and  most  probably  those  which  are  more  readily 
putrescible  {vide  the  analysis  of  effluent).  While  these 
things  are  true  and  are  so  far  satisfactory,  there  must  also 
be  certain  drawbacks  in  the  system  which  are  likewise 
indicated  in  these  experiments.  Electrolyzed  sea-water, 
for  instance,  is  rapidly  reduced  in  strength  by  common 
newspaper,  and  as  this  is  an  almost  invariable  accompani- 


ment of  human  dejecta  its  piesence  in  the  sewer  must 
seriously  affect  the  activity  of  the  liquid,  even  if  it  does 
not  withdraw  the  active  constituent  entirely.  Indeed  the 
entire  contents  of  a  sewer  rapidly  appropriate  the  chlorine 
strength  of  the  liquid.  (Compare  also  in  this  regard  the 
bacteriological  experiments  with  stools,  urine,  culture, 
etc.)  The  same  observation  applies  to  soap  or  domestic 
waste,  etc.,  which  rapidly  "  kills  "  oxygenated  chlorine 
compounds.  Again,  it  can  only  be  supposed  that  deo- 
dorization, not  to  say  sterilization,  is  complete  when  the 
chlorinated  body  is  in  excess,  and  an  effluent  containing 
free  chlorine  or  its  equivalent  is  inadmissible  to  rivers. 
The  expense,  moreover,  in  inland  towns  would  be  greater 
since  it  would  be  necessary  either  to  carry  sea-water  or 
to  prepare  it  artificially.  M.  Hermite's  proposal  is  to  es- 
tablish a  producing  centre  in  the  towns  and  to  supply  the 
liquid  through  pipes  into  all  the  streets  and  houses,  much 
in  the  same  way  that  water  and  gas  are  at  present  sup- 
plied. The  adoption  of  such  a  scheme  in  any  place  would 
no  doubt  lead  to  a  sanitary  condition  of  things  hitherto 
unreached,  but  many  excellent  advances  could  be  made 
in  the  same  direction,  it  should  be  remarked,  if  cost  were 
not  an  item  which  so  often  bars  the  way.  Apart,  how- 
ever, from  such  a  scheme,  there  is  no  doubt  that  the  pro- 
duction from  sea-water  of  a  powerful  bleaching  agent  and 
deodorant  is  an  innovation  which  should  afford  very  ma- 
terial aid  to  sanitary  progress.  Thus  for  many  purposes 
the  substitution  of  electrol>zed  sea-water  for  other  and 
more  expensive  agents  in  our  sea-side  towns  and  villages 
would  doubtless  confer  many  advantages.  It  could  be 
used,  for  example — with  desirable  effect  doubtless — to 
flush  the  headings  of  drains  and  sewers ;  it  could  be  dis- 
charged into  sewage  outfalls;  and,  lastly,  the  system 
could  be  applied  on  a  small  scale  for  the  sanitary  treat- 
ment of  hospitals,  barracks,  etc.,  by  means  of  an  auto- 
matic electrolyzer  worked  from  a  central  electric  supply. 
It  should  be  added  that,  except  as  regards  what  has  al- 
ready been  published  in  our  columns,  no  particulars  in 
regard  to  the  actual  cost  of  production  have  as  yet  been 
furnished  by  the  originator  of  the  main  idea. 

An  Interesting  Law  Case. — An  action  for  damages 
has  just  been  tried  in  one  of  the  Paris  courts  which  per- 
haps is  unique  of  its  kind.  A  gentleman  suffering  from 
anaemia  of  a  very  hopeless  type  was  advised  by  his  medi- 
cal attendants  to  submit  to  the  operation  of  transfusion ; 
and  having  consented,  his  gardener  volunteered  to  sup- 
ply the  blood.  Consequently  transfusion  was  performed, 
and  to  the  great  benefit  of  the  patient,  who  recovered 
completely  after  a  short  time.  However,  some  time 
afterward  the  gardener  fell  ill,  and  attributed  his  con- 
dition to  the  sacrifice  he  made  for  his  employer.  He 
accordingly  brought  an  action  against  him  for  damages, 
claiming  the  large  sum  of  60,000  francs,  or  nearly  two 
thousand  five  hundred  pounds.  The  court  ordered  an 
independent  medical  examination  of  the  case;  but  in  the 
meantime  the  man  died,  that  is  to  say,  two  years  and 
three  months  after  the  operation.  The  autopsy  proved 
that  the  gardener  had  succumbed  to  a  carcinoma  of  the 
stomach,  and  the  doctors  gave  their  opinion  that  the 
malady  was  not  affected  by  the  transfusion.  However,  the 
widow  continued  the  suit,  and  last  week  the  court  dis- 
missed the  case  with  costs  against  the  plaintiff. — Med- 
ical Press. 

Physicians  as  Pioneers  in  Temperance  Reform.— At 
the  annual  meeting  of  the  British  Medical  Temperance 
Association  on  May  2 2d,  Dr.  Norman  Kear  said  that, 
more  than  a  hundred  years  before  the  beginning  of  the 
modern  temperance  reformation,  the  voice  of  medicine, 
by  Dr.  Baynard,  in  1702,  thundered  against  the  milder 
intoxicant  liquors.  He  characterized  ales  as  "  unwhole- 
some and  dangerous  liquors,"  and  suggested  the  making 
their  sale  criminal.  A  quarter  of  a  century  later  Dr. 
George  Cheyne,  of  Bath,  commended  abstinence  as 
natural,  healthy,  and  safe,  and  denounced  moderate 
drinking  as  "  unhealthy  and  dangerous/ '  In  another 
quarter  of  a  century,  in  the  Universal  Pharmacopasia, 


96 


MEDICAL    RECORD. 


[July  21,  1894 


Dr.  James  (1747)  approved  the  wisdom  of  Mahomet  in 
forbidding  fermented  liquors  to  his  followers.  Seven 
years  before  the  dawn  of  the  nineteenth  century,  Ben- 
jamin  Rush  taught  that  no  nourishment  and  no  strength 
were  found  in  spirituous  beverages,  followed  a  year  later 
by  Erasmus  Darwin,  who  stigmatized  wine  as  a  perni- 
cious luxury,  injuring  thousands.  In  the  first  days  of  the 
present  century  Beddoes  declared  that  wine,  constantly 
taken  moderately,  was  mischievous  and  enfeebling ;  im- 
mediately after  whom  Trotter,  while  also  declaiming 
against  wine,  reprobated  beer  as  a  poisonous  morning 
beverage.  Over  sixty  years  ago  Physician  -  General 
Cheyne  ardently  championed  abstinence,  as  did  Dr. 
Daniel  Richmond,  of  Paisley,  who  was  one  of  the  found- 
ers of  one  of  the  first  teetotal  societies  in  1832.  To 
these  pioneer  temperance  champions  fell  to  be  added, 
prior  to  1876,  when  the  British  Medical  Temperance  As- 
sociation was  founded,  among  a  host  of  medical  abstain- 
ers, such  outstanding  men  as  Professor  Rolleston,  of  Ox- 
ford, Menzies  and  Burn,  of  Edinburgh,  Kirk,  of  Green- 
ock, Linton,  of  Aberdeen,  McKenzie,  of  Inverness, 
Grindrod,  of  Manchester,  Beaumont,  of  Bradford,  Hig- 
ginbotham,  of  Nottingham,  Fothergill,  of  Darlington, 
Collenette,  of  Guernsey,  Clay,  of  Manchester,  Mudge, 
of  Bodmin,  Thompson,  of  Bideford,  and  Henry  Munroe, 
of  Hull.  Though  the  medical  profession  had  often  been 
abused  for  opposing  the  temperance  cause,  it  was  re- 
markable that  from  the  ranks  of  medicine  had  gone  forth 
unsparing  condemnation  of  beer  and  wine  before  the 
early  temperance  pledge  of  abstinence  from  ardent  spirits 
alone  had  been  publicly  proclaimed.  In  proof  of  the 
sympathy  of  medicine  and  surgery  with  temperance,  Dr. 
Kerr  cited  the  three  great  medical  declarations  on  alco 
hoi,  the  first  in  1839,  given  by  Julius  JefFreys,  the  sec- 
ond in  1847,  by  J°^n  Dunlop.  the  third  in  187 1  by  Mr. 
Ernest  Hart  and  Mr.  Rae. — British  Medical  Journal. 

Therapeutic  Wisdom.— The  American  Druggist  says 
that  among  the  queer  collection  of  stolen  and  confis- 
cated goods,  in  the  private  office  of  Police  Inspector 
McLaughlin,  is  a  medicine  chest  containing  six  compart- 
ments, each  with  five  small  bottles  from  "  Caswell  & 
Massey."  On  the  inside  of  this  case,  written  in  Gothic 
text,  was  this  stanza  : 

For  every  ill  under  the  sun 
There  is  a  remedy  or  there's  none. 
If  there's  one,  try  and  find  it ; 
If  there's  none,  never  mind  it. 

Some  New  Methods  of  Treating  Diseases  of  the 
Stomach  and  Intestine. — Rosenheim  (Bert.  Klinik,  May, 
1894)  first  discusses  the  stomach  douche.  He  uses  a  tube 
with  numerous  side-openings  and  one  larger  terminal 
opening.  Under  pressure  the  water  issues  from  all  these 
orifices,  and  in  this  way  all  parts  of  the  stomach  are  acted 
upon.  The  douche  is  used  morning  and  evening.  By 
this  method  syringing  with  force  against  the  stomach-wall 
is  avoided,  and  by  using  the  douche  when  the  stomach  is 
empty,  matters  serving  for  nutrition  are  not  abstracted. 
The  douching  is  more  easily  done  by  the  patient,  and  the 
tube  does  not  get  blocked.  Besides  warm  douches, 
which  are  sedative  and  but  slightly  stimulating,  water 
containing  common  salt,  chloroform,  silver  nitrate  (1  in 
1,000)  may  be  used.  The  douche  is  useful  in  nervous 
dyspepsia,  chronic  gastric  catarrh  of  moderate  severity, 
and  in  severe  affections  of  the  sensory  and  secreting  ap- 
paratus of  the  stomach,  as  in  gastralgia,  hypersecretion. 
The  addition  of  sodium  chloride  to  the  fluid  is  said  by  the 
author  to  increase  the  HCl  production,  and  that  of  silver 
nitrate  to  diminish  it.  After  the  stomach  is  washed  out 
once  or  twice,  the  silver  solution  is  run  in  and  allowed  to 
remain  half  a  minute.  The  procedure  is  unattended  with 
danger  provided  the  pylorus  be  not  incompetent.  The 
pylorus  is  rarely  incompetent,  and  this  is  readily  ascer- 
tained by  blowing  the  stomach  up.  As  regards  the  elec- 
trical current,  the  exact  indication  as  to  the  kind  is  still 
in  doubt.  For  motor  insufficiency,  the  value  of  electrical 
treatment  is  unquestionable.     The  author  thinks  it  also 


allays  sensory  irritation  symptoms ;  galvanism  should  be 
used  here  with  the  negative  pole  in  the  stomach.  He 
then  speaks  of  recto-abdominal  galvanization  in  cases  of 
motor  weakness  of  the  intestine.  A  case  is  cited  to  show 
the  value  of  electricity  even  when  the  irritation  symptoms 
and  pain  in  the  stomach  are  due  to  organic  disease,  prob- 
ably a  cicatrized  ulcer  The  author  then  discusses  the 
treatment  of  gastric  ulcer  with  large  doses  ofbismutb.  He 
gives  ten  grains  of  bismuth  subnitrate  in  two  hundred 
grains  water  in  the  morning  on  an  empty  stomach,  and 
fifty  grains  of  water  are  drunk  a  little  later.  Finally,  the 
author  speaks  of  the  treatment  of  spastic  constipation  by 
large  oil  clysters ;  four  hundred  to  five  hundred  grains  of 
pure  oil  are  injected,  and  this  is  followed,  if  necessary,  by 
a  water  enema  later;  the  injections  are  given  daily  at 
first.  Instances  are  given  of  the  good  results  of  these 
various  methods  of  treatment. — British  Medical  Journal. 

The  Cause  of  Cancer.— The  weight  of  evidence  seems 
to  point,  then,  to  the  "  sporozoa  "  as  nothing  more  than 
degeneration  products  of  the  epithelial  cells.  This  view 
is  held  by  the  majority  of  those  who  have  studied  them, 
and  is  supported  by  the  irregular  shape  and  occurrence 
of  the  bodies,  by  the  well  recognized  tendency  of  the 
cells  of  carcinoma  to  undergo  degenerative  changes,  by 
the  more  abundant  occurrence  of  the  bodies  in  the  medul- 
lary variety  of  carcinoma  in  which  the  degenerative 
changes  are  most  frequent,  and  in  the  epitheliomata  (flat- 
celled  carcinomata)  of  the  skin  in  which  more  or  less 
ulceration  and  degeneration  have  been  present.  The 
nature  of  the  degeneration  is  undoubtedly  different  in  dif- 
ferent cases.  Some  of  the  appearances  are  explained  as  the 
result  of  degeneration  of  the  nucleus,  some  as  the  result 
of  degeneration  or  vasculation  of  the  cell  body,  and  some 
as  the  result  of  penetration  of  leucocytes,  red  corpuscles, 
or  other  cells  into  and  between  the  bodies  of  dead  or 
degenerate  cells  of  the  tumor.  Stroebe  concludes  that, 
while  a  possible  parasitic  origin  of  carcinoma  cannot  be 
definitely  denied,  there  is  as  yet  no  positive  evidence 
whatever  in  favor  of  such  a  view. — American  Journal  of 
Medical  Sciences. 

Worse  than  the  Climate  of  Colorado  must  be  that  of 
the  Himalayas,  if  one  may  generalize  from  the  experi 
ence  of  Mr.  Conway  in  that  region.  In  a  recently  pub- 
lished book  on  "Climbing  and  Exploration  in  the 
Karakoran  Himalayas,"  in  speaking  of  the  rapid  changes 
of  temperature,  he  relates  the  experience  of  his  party. 
One  morning,  on  the  way  from  Gargo  to  Gilgit,  they  en- 
countered a  violent  storm.  The  wind  blew  a  gale,  the 
snow  was  so  thick  as  to  darken  the  sky,  and  the  cold  was 
intense.  Suddenly  "  the  wind  ceased,  the  sun  came 
over  the  edge  of  the  hill  and  drove  the  frost  away ;  the 
brook  began  to  tinkle  again,  a  cuckoo  called  from  the 
birch  scrub  across  the  glacier,  and  a  bumblebee  droned 
around  the  tents.  A  more  sudden  change  it  would  be 
impossible  to  imagine.  The  sun  was  soon  too  hot,  and 
within  two  hours  the  temperature — which  had  been  down 
to  150  F.—  rose  to  8o°." 

A  Good  Pee.— The  barber  who  cut  Louis  XIV.  for  fis- 
tula in  ano  received  a  present  from  his  grateful  patient 
of  $60,000,  a  fine  estate,  and  a  patent  of  nobility. 

Woman  Is  Not  Pit  to  Practise  Medicine ;  she  is  not 
fit  for  the  elaboration  of  the  arts  and  the  enlargement  of 
the  sciences,  nor  is  she  fit  for  politics.  To  prevent  mis- 
conception we  hasten  to  add  that  these  are  the  words  of 
Dr.  Abeken,  of  St.  Louis,  and  not  ours. 

The  Prenoh  Language  in  Japan. — The  foreign  pro- 
fessors in  the  medical  department  of  the  University  of 
Tokio  are  chiefly  Germans,  and  the  students  are  obliged 
to  learn  that  language.  Until  recently,  says  i9  Union 
Mtdicale,  they  were  also  required  to  learn  English,  but 
they  have  now  requested  the  government  to  allow  them 
to  learn  French  instead  of  English,  giving  as  the  reason 
for  the  change  that  "  Pasteur  and  Charcot  have  no  equals 
in  England,  and  they  (the  students)  wish  to  be  able  to 
read  the  works  of  these  two  savants." 


Medical   Record 

A  Weekly  yournal  of  Medicine  and  Surgery 


Vol.  46,  No.  4. 
Whole  No.  1238. 


New  York,  July  28,  1894. 


$5.00  Per  Annum. 
Single  Copies,  zoc. 


CASES   OF  OSTEOPLASTIC   RESECTION  OF 
THE  SACRUM. 

By  FRED.  KAMMERER,  M.D., 

SURGEON  TO  THB  ST.  FRANCIS  AND  GERMAN     HOSPITALS,  NBW  YORK  CITY. 

It  is  now  generally  admitted  that  the  only  way  of  deal- 
ing effectively  with  certain  ailments  of  the  rectum,  espe- 
cially its  upper  parts,  is  by  approaching  the  seat  of  dis- 
ease from  the  posterior  wall  of  the  pelvis.  It  is  possible 
that  after  greater  experience  with  the  technical  difficulties 
of  the  methods  based  on  incision  of  the  soft  parts  only 
has  been  gained,  the  latter  may  rival  those  procedures, 
which  require  the  permanent  or  only  temporary  removal 
of  parts  of  the  bony  structure  of  the  pelvis  as  a  prelimi- 
nary measure.  At  present  this  is  not  the  case.  The  ex- 
posure of  the  rectum  from  behind,  with  removal  of  the 
coccyx  and  part  of  the  sacrum,  is  still  regarded  by  most 
surgeons  as  better  adapted  to  the  end  in  view  than  sim- 
ple incision  in  the  parasacral  region  (Woeffler)  or 
through  the  soft  parts  lying  between  both  tuberosities  of 
the  ischium  (Schelkly). 

Since  Kraske's  publication,  about  eight  years  ago, 
quite  a  number  of  modifications  of  the  original  have  been 
proposed. 

At  first  the  plan  of  removing  permanently  parts  of  the 
sacrum  and  the  coccyx  seemed  to  be  most  in  favor, 
some  difference  of  opinion  existing  among  surgeons 
as  to  the  line  of  incision  through  the  bone.  Thus 
Kraske  originally  removed  besides  the  coccyx  that 
part  of  the  sacrum  on  the  left  side  lying  below  the  third 
and  including  the  fourth  sacral  foramen,  but  not  ex- 
tending to  the  middle  line  (<*  b  c).  Hochenegg  modi- 
fied Kraske's  incision  to  include  part  of  the  right  half  of 
the  sacrum  (a  d),  and  Bardenheuer  recommended  trans- 
verse section  of  the  bone  below  the  third  sacral  fora- 
mina (a  e,  Fig.  i).     Even  after  removal  of  so  large  a 


Fig. 


piece  of  bone  as  in  Bardenheuer's  operation,  very  little 
discomfort,  if  any,  has  been  experienced  by  the  patients 
who  have  recovered  from  these  operations.  As  draw- 
backs of  these  methods  by  which  parts  of  the  bone  are 
sacrificed,  have  been  mentioned  weakening  of  the  floor 
of  the  pelvis,  interference  with  the  functions  of  bladder 


and  rectum,  loss  of  the  point  ot  attachment  of  the 
sphincter  ani  muscle  at  the  tip  of  the  coccyx  with  con- 
secutive disturbance  of  the  function  of  that  muscle  .and 
kinking  of  the  rectum,  due  to  contraction  of  the  cicatri- 
cial tissue  about  the  end  of  the  divided  sacrum.  In 
a  former  article  l  I  mentioned  that  I  had  not  myself 
observed  any  of  these  symptoms  after  removal  of  the 
lower  end  of  the  sacrum,  but  others  have  occasionally 
seen  them.  On  the  whole,  I  believe  they  are  very  rare. 
We  should  therefore  demand  of  the  osteoplastic  methods 
that  they  possess  technical  advantages,  if  they  are  to  be 
preferred  to  the  more  radical  measures  just  mentioned. 
Is  this  really  the  case?  It  does  not  seem  to  apply  to  the 
methods  of  Hegar,  Kocher,  and  Levy.  These  are  techni- 
cally more  difficult,  and  are  said  by  others  to  unnecessarily 
complicate  wound  treatment.  I  cannot,  however,  speak 
of  them  from  personal  experience.  I  was,  on  the  other 
hand,  more  favorably  impressed  by  the  plan,  which  Ryd)  - 
gier '  recommended  about  a  year  ago,  and  after  giving  it 


a  trial  in  six  cases,  prefer  it  to  either  the  methods  of 
Kraske,  Hochenegg,  or  Bardenheuer,  which  I  have  for- 
merly employed.  Fig.  2  shows  the  various  incisions 
through  the  sacrum  for  temporary  removal  of  the  lower 
end  of  that  bone  and  the  coccyx.  Hegar's  incision, 
dh  bf,  separating  the  bone  but  not  the  soft  parts  in  the 
line  bf,  has  for  its  object  the  elevation  of  the  flap  bfh 
on  b/zs  an  axis.  Kocher  splits  the  coccyx  and  sacrum 
in  the  median  line  and  then  adds  a  transverse  section  of 
the  bone  (h  gf,  h  g  b),  turning  the  flaps  thus  formed  to 
both  sides.  Levy  makes  a  transverse  incision  (bf)  over 
the  sacrum  and  from  its  ends  adds  two  further  incisions 
running  downward  and  outward  (b  c,  fe).  After  divid- 
ing the  bone  in  the  line  bftht  flap  is  turned  downward. 
Rydygier  incises  the  soft  parts,  beginning  at  the  posterior 
superior  spine  of  the  ilium  on  the  left  side  and  running 
down  to  the  tip  of  the  coccyx,  thence  in  the  median  line 
to  the  anus  (a  b  h  a).  After  division  of  the  sacro-sciatic 
ligaments,  the  soft  parts  are  removed  from  the  anterior  sur- 
face of  the  sacrum  by  the  hand  of  the  operator.  A  trans- 
verse incision  is  then  added  below  the  third  sacral  fora- 

»  Mrdical  Record,  February  20, 189a. 
2  Centralblatt  flir  Chirurgie,  No.  I,  1893. 


9» 


MEDICAL  RECORD. 


[July  28,  1894 


mina  (£/)  and  the  bone  divided  along  this  line  with  a 
chisel.  The  flap  /d  his  now  turned  to  the  right  side, 
upon  h /as  an  axis.  With  a  retractor  inserted  at  the  tip 
of  the  flap  (6)  the  latter  can  be  easily  held  aside  and 
manipulations  about  the  rectum  can  be  as  readily  carried 
on  as  when  the  bone  has  been  entirely  removed. 

Case  I  — M.  A.  S ,  aged  forty-two ;  native  of  Ire- 
land. In  the  summer  of  1892  she  began  to  suffer  from 
tenesmus  and  bloody  stools,  and  was  treated  for  hemor- 
rhoids. The  nature  of  her  complaint  being  later  on 
recognized,  she  was  sent  to  St.  Francis  Hospital  for 
operation.  On  examination  a  cancer  of  the  rectum  was 
discovered,  beginning  immediately  above  the  sphincter 
ani  on  the  posterior  wall,  occupying  the  lateral  walls  ot 
the  rectum,  but  leaving  a  small  portion  of  the  anterior 
wall  of  the  gut  intact,  into  which  the  exploring  finger 
could  be  barely  placed.  The  upper  end  of  the  neoplasm 
was  not  reached. 

March  22,  1893. — Rydygier's  osteoplastic  resection  of 
the  sacrum  in  the  knee-elbow  posture,  in  the  presence 
of  Dr.  E.  W.  Cushing,  of  Boston,  and  Drs.  William  Polk 
and  George  EdebohLs,  of  this  city.  Very  slight  hemor- 
rhage during  incision  of  the  soft  parts,  only  a  few  liga- 
tures being  necessary.  Division  of  the  sacro  sciatic  liga- 
ments. It  was  then  a  very  easy  task  to  separate  the  soft 
parts  from  the  anterior  surface  of  the  sacrum  with  the 
aid  of  the  index-finger,  keeping  the  latter  well  against 
the  bone.  The  transverse  incision  was  carried  imme- 
diately down  to  the  bone,  and  a  chisel  about  an  inch 
wide  was  employed  in  severing  the  latter,  beginning 
at  the  left  border  and  moving  the  instrument  over  the 
posterior  surface  of  the  sacrum  to  the  right  With  a 
few  strokes  of  the  mallet  the  bone  was  very  quickly  di- 
vided. After  elevation  of  the  flap  to  the  right  and  dissec- 
tion of  the  tissue  covering  the  rectum,  it  now  became 
apparent  that  it  was  impossible  to  save  the  sphincter  ani. 
The  anus  was,  accordingly,  circumscribed  by  a  new  in- 
cision and  the  entire  lower  end  of  the  rectum  separated 
from  the  surrounding  tissues.  After  free  incision  of 
Douglas's  pouch  and  further  separation  of  the  rectum  as 
far  as  the  promontory  of  the  sacrum,  more  especially 
after  incision  of  the  lateral  folds  of  the  peritoneum, 
forming  the  reflection  from  the  sacrum  upon  the  rectum, 
the  gut  was  easily  drawn  down,  so  that  the  tumor  lay 
well  outside  the  anal  opening.  After  the  closure  of  the 
peritoneum  with  interrupted  catgut  sutures,  amputation 
of  the  rectum  was  done  about  three  fourths  of  an  inch 
above  the  border  of  the  tumor  and  the  end  of  the  gut 
sewed  to  the  margin  of  the  wound  at  the  site  of  the  nor- 
mal anus.  Iodoform  gauze  tampons  were  then  placed 
upon,  and  to  each  side  of,  the  new  rectum,  their  ends 
protruding  from  the  wound-cavity  just  above  the  new 
anus.  The  flap  was  now  returned  and  everywhere  united 
by  sutures  of  silk-worm  and  cat-gut,  excepting  the  parts 
where  drainage  was  to  be  established  by  the  gauze  lead- 
ing from  the  wound-cavity.  Dry  aseptic  dressing  exter- 
nally. The  tampons  were  removed  for  the  first  time  on 
the  fifth  day,  the  external  dressings  having  been  changed 
quite  frequently.  Primary  union  occurred  throughout 
the  sutured  area.  Recovery  uninterrupted.  Complete 
cicatrization  at  the  end  of  the  sixth  week.  Length  of 
the  amputated  portion  about  five  inches. 

September,  1893. — Removal  of  a  small  recurrence  be- 
tween rectum  and  vagina. 

April,  1894. — Patient  in  fair  health  (Fig.  3  shows 
condition  of  external  parts).  There  is  now  a  recurrence 
on  the  posterior  wall,  for  which  the  patient  will  allow  no 
further  operative  interference.  There  is  apparently  firm 
union  of  the  bone  at  the  site  of  division  and  the  appear- 
ance of  the  parts  externally  is,  but  for  the  line  of  union, 
normal. 

Case  IT. — G.  R ,  aged  sixty  eight.      Has  been 

complaining  of  rectal  trouble  for  the  past  two  years 
(pain  during  defecation  and  hemorrhages).  Large  cir- 
cular cancer  of  the  rectum,  mostly  on  anterior  wall,  sev- 
eral inches  above  the  anus.  Cachetic  appearance.  Very 
marked  atheromatous  degeneration  of  arteries. 


April  26,  1893. — Osteoplastic  resection.  Flap  dis- 
sected up,  as  easily  as  in  first  case ;  no  hemorrhage  to 
speak  of;  resection  of  rectum  after  enucleation  of  the 
same  from  the  surrounding  tissues ;  division  of  the  rec- 
tum below  the  tumor,  leaving  about  two  inches  at  the 
anal  end  ;  incision  of  the  peritoneum  ;  resection  of 
about  four  inches  of  the  gut ;  suture  of  the  divided  ends 


Fig.  3.' 

with  catgut;  extirpation  of  many  sacral  lymphatics 
which  are  involved ;  drainage  with  gauze ;  flap  replaced 
and  sutured  as  in  first  case.  Profound  collapse  after  op- 
eration, from  which  the  patient  rallies  well  in  a  few  hours. 
Early  the  next  morning  he  very  suddenly  expires  shortly 
after  drinking.     Autopsy  not  allowed. 

Case  III. — A.  B ,  aged  twenty ;  married.     Nine 

months  ago,  double  salpingo-oophorectomy  was  done  in 
this  city,  in  consequence  of  which  a  fecal  fistula  remained. 
When  first  seen  at  the  German  Hospital  in  September, 
1893,  was  in  poor  general  condition.  Several  fistulous 
openings,  from  which  pus  and  faeces  came  away,  were 
found  in  the  cicatrix  of  the  abdominal  incision.  They 
all  led  to  a  subcutaneous  abscess  cavity,  which  in  its  turn, 
when  incised,  communicated  at  the  lower  end  of  the 
original  incision  with  the  gut  through  a  long  fistulous 
track,  leading  downward  and  backward  into  the  pel- 
vis. A  probe  introduced  into  the  fistula  passes  to  the 
left  of  the  uterus  and  vagina,  but  the  point  of  com 
munication  with  the  rectum  cannot  be  found.  Feeling 
assured,  however,  that  it  did  exist  and  that,  on  account 
of  probable  adhesions,  it  would  prove  a  hazardous  under- 
taking to  attempt  reaching  the  seat  of  trouble  by  an  an- 
terior incision,  I  decided  to  do  osteoplastic  resection 
of  the  sacrum  and  thus  to  get  to  the  opening  in  the 
gut. 

The  operation  was  conducted  as  in  the  other  cases, 
with  the  only  exception  that  the  patient  was  placed  on 
her  right  side,  with  flexed  lower  extremities  and  elevated 
buttocks.  Considerable  hemorrhage  occurred  and  there 
was  a  good  deal  of  delay  on  this  account  in  elevating  the 
flap.  Introducing  a  probe  into  the  fistula,  the  point  of 
which  could  be  felt  from  the  posterior  wound  high  up  on 
the  anterior  surface  of  the  rectum,  I  attempted  to  reach 
this  point  by  dissecting  off  the  rectum  on  the  left  side. 
While  thus  occupied,  the  patient  went  into  a  deep  col- 
lapse, which  necessitated  immediate  interruption  of  the 
operation,  from  which  she  only  fully  recovered  after 
many  hours.  The  wound  cavity  had  been  hurriedly 
tamponed  and  no  sutures  were  applied  to  the  flap.  In 
the  course  of  the  following  two  months  the  cavity  gradu  • 
ally  filled  with  granulations  and  the  flap  fell  into  place. 
At  the  end  of  this  time  the  flap  was  again  raised  and  the 

1  Dr.  Fischlowitz,  house-surgeon  of  the  German  Hospital,  has  very 
kindly  taken  the  photographs  used  in  this  article  for  me. 


July  28,  1894] 


MEDICAL   RECORD. 


99 


same  plan  pursued  in  attempting  to  reach  the  opening  in 
the  rectum.  After  much  labor  I  finally  came  upon  a 
small  cavity,  the  size  of  a  walnut,  on  the  anterior  surface 
of  the  rectum,  far  above  the  plane  of  Douglas's  pouch. 
There  I  found  the  point  of  the  probe.  I  could  just  reach 
the  cavity  with  the  tip  of  my  finger,  but  could  not  find 
the  intestinal  lesion.  A  tampon  was  pushed  down  into 
the  cavity  in  the  hope  that  it  might  heal  by  granulation 
and  the  fistula  thus  close.  The  entire  line  of  incision 
was  again  left  unsutured.  The  wound  has  filled  with 
granulations.  No  more  faeces  have  escaped  during  the 
last  two  months,  either  by  the  anterior  or  posterior  fis- 
tula, both  of  which  still  exist,  however,  but  are  apparently 
closing.  The  incision  along  the  left  border  of  the  sa- 
crum is  still  open  for  about  two  inches,  and  several  at- 
tempts to  close  it  by  secondary  sutures  have  failed.  The 
general  condition  of  the  patient  is  excellent.1 

Case  IV. — J.  F ,  aged  forty-five,  recto  vaginal  fis- 
tula in  the  upper  part  of  vagina  after  extirpation  of  the 
uterus  for  cancer.  An  attempt  to  close  the  same  from  the 
vagina  failed  and  the  patient  was  transferred  to  my  ser- 
vice at  the  German  Hospital  for  osteoplastic  resection  of 
the  sacrum.  Knee  elbow  posture ;  after  elevation  of  the 
flap  the  fistula  was  exposed  by  separating  the  tissue  to 
the  left  of  the  rectum.  Considerable  difficulty  was  ex- 
perienced in  separating  the  rectum  from  the  vagina; 
when  this  was  accomplished  the  edges  of  the  large  open- 
ing in  the  vagina  were  excised  and  the  opening  itself  care- 
fully sutured ;  an  iodoform  tampon  was  introduced,  but 
the  opening  in  the  rectum  was  left  unsutured.  The  flap 
was  returned,  and  the  transverse  and  the  vertical  incision 
below  the  coccyx  were  united  by  sutures.  That  part  of 
the  incision  lying  to  the  left  of  the  sacrum  was  left  open, 
and  from  it  the  tampon  protruded.  The  latter  was  left 
undisturbed  for  eleven  days,  when  the  bowels  were  moved 
for  the  first  time.  Very  soon  the  introduction  of  the  tam- 
pon to  the  site  of  the  old  fistula  became  difficult,  as  the 
wound-cavity  began  to  cicatrize  very  rapidly.  However, 
while  there  appeared  to  be  union  in  the  vagina,  some 
faeces  were  naturally  discharged  by  way  of  the  tam- 


FlG.    4. 

pon  through  the  wound-cavity  and  opening  in  the  rec- 
tum. 

At  this  time  it  became  apparent  that  a  small  fistula  had 
again  formed  in  the  vagina.  Fig.  4  shows  the  condi- 
tion of  the  external  parts  three  months  after  operation. 
The  opening  to  the  left  of  the  sacrum  for  the  tampon  is 
the  only  portion  of  the  original  incision  which  has  not 
closed.  I  now  intended  to  make  an  artificial  anus  and 
to  again  elevate  the  flap  later  on,  but  I  abandoned  this 
idea  on  discovering  extensive  secondary  infiltration  of 
the  lymphatic  system  of  the  pelvis.     The  wound  has  not 

1  The  posterior  incision  is  now  about  entirely  closed,  three  months 
later. 


entirely  closed  yet,  about  four  months  after  operation, 
but  no  faeces  escape  from  it,  and  only  when  the  move- 
ments are  liquid  does  fecal  matter  escape  from  the  va- 
gina. 

Case  V.—H.  B ,  aged  fifty-eight.    For  the  last  two 

years  blood  in  stools  and  lately  great  difficulty  in  defeca- 
tion ;  general  condition  poor.  Two  and  a  half  inches 
from  the  anus  a  cancerous  growth,  almost  entirely  oc- 
cluding the  lumen  of  th^  rectum,  through  which  the  ex- 
amining finger  cannot  be  passed. 

December  21,  1893. — Left  inguinal  colotomy.  Follow- 
ing this  for  several  weeks  irrigations  of  the  rectum,  three 
or  four  times  daily,  from  anus  through  the  colotomy- 
wound. 

January  18,  1894. — Osteoplastic  resection  of  sacrum 
in  knee-elbow  posture.  Resection  of  three  and  one-half 
inches  of  the  rectum,  after  incision  of  Douglas's  cul-de 
sac;  about  one  and  one- half  inch  of  the  anal  end  is  left, 
which  is  sutured  to  the  upper  end  of  the  rectum  in  its  en- 
tire circumference ;  flap  returned  and  sutured  throughout, 
with  exception  of  opening  for  drainage  below  the  coccyx. 
The  peritoneal  cavity  was  not  closed  by  sutures  in  this 
case,  but  tampons  of  gauze,  placed  to  each  side  of  the 
rectum,  were  brought  well  up  to  Douglas's  pouch.  Unin- 
terrupted recovery.  Primary  union,  with  exception  of 
posterior  circumference  of  the  sutured  gut,  where  separa- 
tion and  slight  sloughing  occurred  (Fig.  5)     At  the  end 


Fig.  5. 

of  March  a  small  opening  was  still  present  below  the  coc- 
cyx, which  communicated  with  the  rectum  and  marks  the 
spot  at  which  the  rectal  sutures  gave  way.  Here  there 
is  a  stricture  of  the  gut. 

March  30th,  flap  again  raised.  Excision  of  stricture. 
Finding  it  impossible  to  unite  the  two  ends  of  the  rectum 
on  account  of  tension,  the  plan,  recommended  by  Dr. 
Lange  of  this  city,  of  transplanting  the  anus  upward  and 
backward  after  a  transverse  incision  in  the  perineum  be- 
tween both  tuberosities  of  the  ischium  was  adopted. 
After  carrying  the  incision  well  up  between  vagina  and 
rectum,  the  anus  could  be  moved  for  about  one  and  one- 
half  inch,  making  suture  of  the  approximated  ends  pos- 
sible. The  transverse  incision  in  the  perineum  was 
united  with  silk-worm  gut  in  a  longitudinal  direction. 
After  the  flap  was  again  returned  the  anal  orifice  was 
found  immediately  below  the  coccyx.  The  anus  has 
remained  in  situ,  but  some  separation  occurred  in 
the  perineum.  The  artificial  anus  still  remains  to  be 
closed. 

Case  VL— S.  R ,  aged  seventeen.     Always  well 

as  a  child.  Four  years  ago  severe  attack  of  diarrhoea, 
with  frequent  repetitions  of  the  same  during  the  follow- 
ing two  years ;  then  constipation,  with  much  straining 
during  defecation  and  loss  of  blood  ard  mucus.     Anae- 


IOO 


MEDICAL  RECORD. 


[July  28,  1894 


mic  and  emaciated  girl.  Beginning  about  three  or  four 
inches  above  the  anus  and  extending  upward,  as  far  as 
the  finger  could  reach,  were  a  large  number  of  polypoid 
growths.  Left  inguinal  colotomy  on  December  18, 
1893.  Jus*  below  the  longitudinal  incision  into  the  gut 
a  polypus  about  one  and  one -half  inch  long  and 
measuring  about  one-half  inch  in  its  widest  part,  with 
a  very  slender  pedicle,  is  found  and  removed.  Micro- 
scopical examination  by  Dr.  Schwyzer,  assistant  pathol- 
ogist to  the  German  Hospital,  Showed  it  to  be  an  ade- 
nomatous polypus. 

January  20, 1894. — Osteoplastic  resection  of  sacrum  in 
knee  elbow  posture.  Longitudinal  incision  of  the  rec- 
tum, beginning  about  four  inches  above  the  anus  and  run- 
ning upward  for  two  or  three  inches.  The  entire  mucous 
membrane  lined  with  small  and  large  growths  of  the 
kind  described,  as  far  as  the  finger  can  be  passed  upward 
in  the  gut.  Finding  it  impossible  to  remove  the  growths 
individually,  on  account  of  hemorrhage  and,  above  all, 
their  location,  I  removed  what  I  could  with  a  long  and 
large  Volkmann  spoon  and  tamponed  the  rectum,  as 
hemorrhage  during  this  manipulation  was  quite  alarming. 
No  suturing  of  the  flip ;  tamponade  of  the  wound  cavity 
with  sterilized  gauze;  marked  collapse,  but  patient  ral- 
lied well.  Iodoform  tampon  in  rectum  removed  on  the 
fourth  day  for  the  first  time,  after  which  the  temperature, 
which  had  ranged  from  1010  to  102. 8°  F.,  dropped  to 
normal. 

March  2,  1894. — Closure  of  the  artificial  anus  and  of 
the  longitudinal  incision  in  the  rectum.  For  the  latter  a 
good  deal  of  dissecting  out  of  the  rectum  was  necessary; 


Kic.  6.   • 


silk  sutures,  tampon  of  sterilized  gauze.  On  April  6, 
when  it  is  evident  that  perfect  and  firm  union  has  oc- 
curred in  both  places,  the  resection  flap  is  finally  re- 
turned to  its  original  position  and  retained  there  by  sev- 
eral strong  silk  sutures.  These  sufficed  to  keep  it  in 
place,  the  anterior  surface  of  the  sacrum  having  mean- 
while become  adherent  to  the  rectum.  The  original  in- 
cisions are  still  granulating,  but  will  no  doubt  soon  close 
(Fig.  6J. 

The  improvement  in  the  patient's  condition  is  very 
marked.  The  hemorrhages  from  the  rectum  have  ceased 
entirely,  and  there  is  no  pain  during  defecation,  which 
occurs  normally.  The  patient  has  gained  very  much  in 
weight.1 

In  all  these  cases  I  have  been  impressed  by  the  rapid- 
ity with  which  this  preliminary  operation  can  be  done. 

1 1  have  just  seen  the  patient  three  months  after  the  above  was  writ- 
ten. She  continues  in  excellent  health. "}  There  is  still  a  point  of  gran- 
ulation to  heal,  but  no  fistula. 


While  deprecating  in  general  any  time  limit  in  surgical 
work,  it  is  surely  an  advantage  to  accomplish  something 
in  from  five  to  ten  minutes,  which  otherwise  requires  a 
longer  time,  at  least  in  my  own  experience,  and  that  with 
decidedly  less  hemorrhage.  I  fully  endorse  Rydygier's 
claim,  that  his  osteoplastic  resection  is  a  much  less  bloody 
operation  than  the  permanent  removal  of  coccyx  and  sac- 
rum by  any  one  of  the  other  methods  with  dissection  of 
the  soft  parts  from  the  posterior  surface  of  the  sacrum. 
In  only  one  instance  of  osteoplastic  resection  did  I  meet 
with  considerable  hemorrhage,  in  Case  III.,  where  I 
operated  in  the  lateral  position.  I  consider  the  knee- 
elbow  posture,  which  I  employed  in  all  the  other  cases, 
with  distinct  elevation  of  the  pelvis,  especially  of  the 
sacral  region,  as  the  most  desirable  one  for  rectal  surgery, 
since  it  controls  hemorrhage  through  elevation,  gives  ex- 
cellent access  to  the  field  of  operation,  the  surgeon  stand- 
ing between  the  slightly  separated  thighs  of  the  patient, 
and  facilitates  manipulations  with  the  chisel,  the  pelvis 
being  supported  by  sand  bags  placed  under  the  anterior 
iliac  spines. 

When  the  flap,  including  the  coccyx,  part  of  the  sac- 
rum and  the  integuments,  can  be,  from  the  nature  of  the 
case,  returned  to  its  place  and  sutured,  the  result  will  be 
an  ideal  one  as  regards  restitution  of  the  normal  contour 
of  the  sacral  region,  as  shown  in  Figs.  3  and  5.  In  suturing 
the  transverse  incision  I  have  always  passed  the  needle 
down  to  the  bone,  but  have  never  included  the  bone  itself 
in  a  suture,  by  any  device  whatever.  Notwithstanding, 
in  several  cases  in  which  I  have  had  to  elevate  the  flap  a 
second  time,  I  have  always  found  firm  union  of  bone  sur- 
faces, either  fibrous  or  partly  osseous.  It  is  unfortunate 
that  secondary  operations  so  frequently  become  necessary 
in  rectal  surgery,  for,  even  when  we  have  resected  the 
rectum  and  made  a  circular  suture  of  the  ends,  we  fre- 
quently find  that  the  latter  gives  way  on  the  posterior 
circumference  of  the  bowel.  Such,  at  least,  has  been  my 
own  experience  and  the  experience  of  others  as  well,  I 
believe.  I  have  not,  however,  found  the  operation  of 
raising  the  flap  a  second  time  any  more  tedious  than  the 
first.  Greater  care  must  only  be  exercised  to  avoid  the 
rectum,  which  now  has  been  drawn  close  to  the  anterior 
surface  of  the  sacrum  by  cicatricial  contraction.  But  I 
think,  when  we  are  dealing  with  cases,  such  as  fistula  for 
example,  where  tamponade  of  the  wound*  cavity  becomes 
necessary  for  some  time,  we  should  resist  the  temptation 
of  suturing  the  flap  and  we  should  leave  the  wound- cavity 
entirely  open.  My  attention  was  forcibly  directed  to 
this  point  by  Case  IV.  (Fig.  4),  where  I  got  very  good 
union  of  the  transverse  and  vertical  incisions,  but  in 
which  case  a  successful  tamponade  of  the  deep  wound- 
cavity  (about  six  inches)  was  not  easily  effected  through 
the  small  opening  corresponding  to  the  unsutured  part  of 
the  original  incision.  I  think  this  fact  was  responsible 
for  the  ultimate  re  establishing  of  a  small  vaginal  fistula. 
Such  wounds  ought  to  heal  from  the  bottom  of  the 
wound-cavity  to  avoid  even  the  slightest  retention,  en- 
dangering the  object  in  view,  and  the  best  guarantee  for 
this  is  a  wide  opening,  allowing  free  inspection  and  tam- 
ponade. 

Where  no  sutures  are  used  some  retraction  of  the  flap 
develops  after  a  time.  This  is  no  doubt  much  less  than 
in  flaps  that  are  without  a  bony  substratum.  Even  when 
only  the  lateral  incision  to  the  left  of  the  sacrum  has  re- 
mained open  (Fig.  4)  a  distinct  elevation  of  the  soft  parts 
over  the  sacrum  results  from  the  same  cause,  a  deformity 
which  can,  no  doubt,  at  the  proper  time  be  very  readily 
remedied  by  an  insignificant  plastic  operation.  This  is 
not  so  readily  accomplished  when  no  suturing  at  all  has 
been  done.  There  is  another  fact  worthy  of  considera- 
tion in  this  connection.  It  is  this:  After  some  time 
secondary  operations  on  the  rectum  are  even  more  diffi- 
cult than  the  original  ones,  owing  to  the  development 
of  much  cicatricial  tissue  about  the  gut,  which  makes  the 
latter  more  rigid  and  does  not  in  consequence  permit  the 
approximation  of  such  parts  which  we  may  desire  to  unite 
by  sutures.     From  all  this  we  may  conclude  that  it  will 


July  28,  1894] 


MEDICAL  RECORD. 


101 


be  wise  to  do  secondary  operations  as  soon  as  the  condi- 
tion of  the  patient  will  permit. 

The  cases  of  fistula  which  I  have  reported  have  not 
been  entirely  cured.  They  have  been  much  benefited, 
however,  and  one  of  them  is  very  likely  closing.  I  firmly 
believe  that  in  no  other  manner  ought  these  cases  to  have 
been  approached,  certainly  not  by  an  anterior  laparotomy. 

While  technically  difficult,  the  sacral  route  is  still  the 
easiest  way  to  get  at  the  seat  of  disease  when  the  rectum 
is  affected,  and  also  in  some  cases  in  which  the  uterus  is  to 
be  dealt  with.  Rydygier's  preliminary  operation  is  cer- 
tainly well  devised,  and  being  as  simple  as  the  permanent 
resection  of  the  sacrum,  while  not  disfiguring,  assuredly 
deserves  preference. 


A  CASE  OF  ACUTE   SOFTENING   OF  THE 
BRAIN. 

By  PHILIP  ZENNER,  A.M.,  M.D., 

CINCINNATI,     O. 

CONICAL  LECTUBSR    ON     DISEASES     OF  THE  NERVOUS  SYSTHM  III  THE  MEDICAL 
COLLEGE  OF  OHIO. 

Dr.  Diller's  case  of  acute  softening  of  the  brain,  pub- 
lished in  the  Medical  Record  of  April  28th,  leads  me 
to  report  the  following  case,  which  was  also,  for  a  time, 
believed  to  be  one  of  hysteria,  and  in  which,  as  in  Dr. 
Diller's  case,  the  paralytic  manifestations  were  very  slow 
in  onset.  I  regret  that  my  notes  of  the  case  are  not 
more  complete. 

Mrs.  S ,  aged  fifty-three.     A  brother  and  sister 

died  of  paralysis.  She  was  always  in  good  health  until 
forty-six  years  of  age,  the  time  of  the  menopause.  At 
this  time,  too,  her  husband  had  a  long  and  serious  ill- 
ness, and  underwent  a  dangerous  operation,  all  of  which 
doubtless  assisted  in  developing  her  subsequent  nervous 
malady. 

One  of  the  first  physicians  whom  she  consulted  for  her 
nervous  symptoms — headache,  vertigo,  etc — told  her 
that  she  had  a  brain  tumor,  a  diagnosis  which  was  sup- 
posed to  have  had  a  permanently  ill  effect  upon  her  ; 
at  least  she  was  thereafter  in  constant  dread  of  organic 
nervous  disease.  She  never  regained  her  former  good 
health. 

It  is  difficult  in  a  few  words  to  give  a  clear  idea  of  the 
varied  symptoms  presented  during  the  seven  or  eight 
years  of  her  invalidism.  Her  chief  complaint  was  of 
various  paresthesias,  tingling  sensations  or  the  like, 
which  never  left  her  altogether.  At  first  they  were  only 
in  the  left  hand  and  arm,  subsequently  they  were  in  the 
right  arm  or  both  arms,  and  in  the  face.  Such  sensa- 
tions in  the  mouth  prevented  her  from  wearing  her  false 
teeth  with  comfort,  so  that  for  several  years  she  did  not 
wear  them  at  all  Very  often  she  would  say  there  was 
no  strength  in  her  hand,  she  would  not  cut  her  meat, 
etc.,  though  there  was  no  evidence  of  paralysis. 

At  one  time  when  I  was  called  to  see  her  I  was  informed 
that  for  months  she  had  been  unable  to  write.  On  ques- 
tioning her  she  could  not  tell  why,  could  only  say  she  was 
unable  to  write ;  and  seemed  very  much  rejoiced  when 
by  a  firm  order  on  my  part  I  succeeded  in  getting  her  to 
write.  The  same  was  true  of  reading.  Often  for  months 
she  said  she  could  not  read  She  often  had  a  peculiar 
disturbance  of  speech,  something  similar  to  aphasia ;  she 
would  have  to  grope  for  words  or  sentences,  speak  only 
short  sentences  or  only  a  word  or  two,  and  then  halt  as 
if  unable  to  proceed  farther.  She  would  sometimes  use 
the  wrong  word.  But  she  could  always  give  the  name 
of  an  object  or  individual  This  speech  defect  was  much 
worse  when  emotional,  and  very  much  less  when  she 
was  calm*  She  had  also  various  vaso-motor  disturbances, 
redness,  swelling,  and  perspiration,  in  various  parts. 
With  her  nervous  symptoms  there  was  a  complete  change 
in  her  whole  being,  from  a  cheerful  active  woman  inter- 
ested in  and  interesting  to  everybody,  to  one  who  at- 
tended to  and  was  interested  in  nothing,  crying,  despond- 
ent, her  mind  dwelling  only  on  her  many  ailments. 


The  symptoms,  of  which  only  a  few  have  been  men  - 
tioned,  varied  much  in  intensity.  At  times  they  were  so 
severe  as  to  make  life  a  burden  to  herself  and  her 
family ;  again,  after  a  sojourn  at  the  sea-shore,  or  in  the 
South,  she  improved  so  much  as  to  be  comparatively 
well,  though  still  far  from  being  her  old  self.  Her 
health  was  thought  to  be  the  best  it  had  been  since  she 
first  took  sick,  just  before  the  occurrence  of  her  last  and 
fatal  malady. 

About  January  6  or  8,  1894,  she  began  to  complain 
of  pain  in  the  right  arm.  A  few  days  subsequently  she 
said  to  her  physician  :  "  You  see  my  arm  is  paralyzed." 
On  examining  her  he  found  that  she  could  move  the  arm 
freely.  He  saw  no  evidence  of  paralysis,  and  tried,  in 
vain,  to  convince  her  of  this  fact.  But  it  was  soon  ob- 
served that  she  could  not  move  the  right  hand,  and  in  a 
day  or  two  the.  right  elbow,  and  after  an  interval  of  a 
day  or  more,  the  right  shoulder  also  became  affected. 

1  saw  her  January  14th.  She  walked  with  difficulty, 
leaning  upon  an  attendant  for  support,  but  the  strength 
of  the  different  groups  of  muscles  of  the  legs  appeared  to 
be  good,  a  rough  test  indicating  that  the  muscles  of  the 
right  leg  equalled  in  strength  those  of  the  left.  The 
right  hand  was  altogether  powerless,  and  there  was  but 
little  strength  in  the  muscles  of  the  right  elbow  and 
shoulder.  She  felt  a  light  touch  everywhere  on  the  right 
arm  and  leg,  but  on  the  arm  the  touch  was  not  quite  so 
well  localized  as  on  the  left  arm.  Tendon  reflexes  nor- 
mal, cranial  nerves,  fundi  oculi  normal,  no  headache.    ' 

The  patient  was  in  an  hysterical  emotional  state, 
cried  and  laughed  alternately,  the  feelings  appearing 
to  be  very  superficial.  On  account  of  either  mental 
confusion,  or  inattention,  or  impaired  speech,  there  was 
little  satisfaction  to  be  obtained  from  her  statements. 
She  spoke  little  spontaneously,  often  seemed  not  to  grasp 
the  meaning  of  a  question,  or  paid  no  heed  to  it.  When 
she  spoke  it  was  in  a  faltering  manner,  seeming  to  have 
difficulty  in  finding  and  arranging  her  words.  This  men- 
tal state  did  not  appear  to  be  a  new  feature.  Like  con- 
ditions had  frequently  been  observed  in  bad  periods  in 
former  years.  But  the  apparent  mental  confusion  was 
greater;  this  and  the  appearance  of  a  new  symptom, 
paralysis,  was  all  that  distinguished  her  condition  now 
from  what  was  often  observed  in  her  before. 

I  saw  her  again  January  17th.  Her  mind  was  more 
blunted.  She  scarcely  spoke  any,  and  paid  little  heed 
to  questions,  so  that  the  examination  of  subjective  states 
was  not  satisfactory.  She  was  now  confined  to  her  bed. 
She  apparently  could  not  move  the  right  arm  at  all. 
She  could  move  the  lower  extremities  freely,  though  the 
degree  of  strength  could  not  be  tested.  The  prick  of  a 
pin  was  felt  everywhere. 

After  my  second  visit  an  examination  of  the  field  of 
vision  was  made  by  an  oculist.  By  an  oversight  this  had 
not  been  made  sooner.  He  found  concentric  contrac- 
tion of  the  field  of  vision  of  each  eye.  I  shall  give  my 
reasons  further  on  for  believing  this  observation  was  not 
accurate. 

The  chief  change  in  the  following  ten  days  was  a  con- 
stantly increasing  mental  apathy,  and  disinclination  to 
speak  or  to  move,  and  that  she  ate  less  and  less.  The 
paralyzed  arm  was  somewhat  rigid  much  of  the  time,  so 
that  there  was  some  resistance  to  passive  movements. 
The  latter  were  often  painful.  The  pulse  was  strong,  in 
the  neighborhood  of  80,  temperature  mostly  normal. 

February  zst — Strong  faradic  brush  applied  to  right 
arm  and  leg  very  painful,  in  leg  produced  a  movement, 
a  flexing  at  the  same  time  of  hip,  knee,  and  ankle,  but 
the  arm  remained  motionless.  Temperature  in  left 
axilla,  980,  in  right,  99.80  F.  Can  scarcely  get  any  re- 
sponse from  patient  except  an  occasional  "Yes"  and 
"  No." 

February  3d — Cathartic  given,  and  bed  soiled,  of 
which  she  is  altogether  regardless.  Eats  very  little, 
hebetude  extreme,  temperature  98. 5  °  F.  in  each  axilla. 

February  4th. — Did  not  speak  a  single  word.  Lies 
almost  motionless,  takes  scarcely  any  food. 


102 


MEDICAL  RECORD. 


[July  28,  1894 


February  5th. — I  found  her  in  the  morning  in  a  coma- 
tose condition,  breathing  heavily,  face  somewhat  flushed, 
pulse  90,  temperature  103.10  F.  in  each  axilla.  A  very 
slight  movement  of  the  left  arm  and  leg  could  be  pro- 
duced by  deep  pricking,  right  extremities  motionless 
and  flaccid.  Breathing  regular.  Some  purling  of  the 
lips  with  each  respiration,  but  lips  close  in  swallowing 
(swallowed  a  little  fluid).  When  eyelids  lifted,  eyes 
were  seen  to  move  restlessly  to  and  fro. 

During  the  day  the  temperature  subsided  somewhat 
and  her  condition  appeared  a  little  better.  There  had 
been  a  deep  burn  on  right  leg  a  week  before  through  an 
accident  with  a  hot  brick.  Pressure  in  this  to  day  caused 
a  movement  of  right  leg  with  other  manifestations  of  pain. 

On  subsequent  days  there  were  slight  fluctuations  in 
her  condition,  temperature  varied  from  99  to  102. 5. °  F., 
usually  one  to  one  and  one-half  degree  higher  on  the 
right  than  on  the  left  side ;  pulse  remained  good,  until 
the  last  day  or  two  of  life  when  it  became  rapid  and  fee- 
ble. She  swallowed  liquid  food  without  much  difficulty. 
She  was  sometimes  in  apparently  sound  sleep,  and  at 
times  even  manifested  a  certain  degree  of  consciousness, 
opening  her  eyes,  moaning  "  Oh,  my ; "  and  the  nurse 
thought  that  she  distinguished  between  food  and  bad-tast- 
ing medicine.  The  breathing  had  at  times  something  of 
the  Cheyne-Stokes  character,  at  other  times  it  was  heavy, 
labored,  attended  by  paralytic  puffing  of  the  lips  and 
cheek,  again  there  were  intermissions  of  quiet  healthy 
breathing. 

February  7th. — It  was  first  observed  on  this  date  that 
the  tendon  reflexes  in  right  arm  were  heightened,  and 
they  remained  so  until  the  end.  In  the  right  leg  the  ten* 
don  reflexes  were  at  no  time  excessive.  There  was  no 
subsequent  movement  of  left  leg,  excepting  not  infre- 
quently a  kind  of  tremor  or  clonic  spasm.  On  some 
occasions  the  left  hand  was  found  in  a  state  of  contract- 
ure. During  the  last  few  days  of  life,  the  only  evidence 
that  a  pin  prick  was  at  all  felt  was  that  it  sometimes  was 
followed  by  a  movement  of  the  left  leg.  There  was  at 
no  time  true  facial  paralysis. 

During  the  last  week  of  life  there  was  a  tendency  to 
keep  the  face  turned  toward  the  right.  If  the  head  were 
straightened  she  manifested  pain.  She  died  February 
1 2  th. 

Only  the  contents  of  the  cranial  cavity  were  examined 
post-mortem.  There  was  a  lepto-meningitis  of  light 
grade  confined  to  the  pia  covering  the  convexity  of  the 
hemispheres,  and  most  marked  over  the  softened  areas. 
The  beginning  of  the  right  middle  cerebral  artery  ap- 
peared narrowed  and  thickened,  but  the  vessel  beyond 
was  patulous,  and  not  collapsed.  Otherwise  the  vessels 
at  the  base  were  normal. 

Three  areas  of  softening  were  found  on  the  surface  of 
the  hemispheres.  The  largest  and,  probably,  oldest  was 
in  the  left  motor  area.  It  destroyed  almost  the  entire 
upper  two-thirds  or  three-fourths  of  the  central  convolu- 
tions, and  a  small  part  of  the  contiguous  frontal  and 
parietal  lobes.  The  softening  extended  deeply  into  the 
centrum  ovale,  but  did  not  reach  the  lateral  ventricle. 
The  paracentral  lobule  was  unaffected. 

The  second  area  of  softening  was  in  the  right  occipital 
lobe.  Almost  the  entire  lobe  was  affected,  the  softening 
reaching  to  the  posterior  and  inferior  horns  of  the  lateral 
ventricle.  The  third  and  smallest,  and,  perhaps,  most 
recent  softening,  was  in  the  posterior  part  of  the  second 
frontal  convolution.  The  lesion  just  impinged  upon  the 
ascending  frontal  convolution.  The  softening  extended 
about  one-fourth  of  an  inch  into  the  white  matter. 

The  other  parts  of  the  brain,  as  far  as  could  be  judged 
by  naked  eye  appearances,  were  altogether  normal. 

Bemarks. — The  case  illustrates  the  difficulties  and 
uncertainty  in  the  diagnosis  of  hysterical  paralysis ;  also 
that  the  presence  of  hysterical  conditions — upon  which 
the  diagnosis,  hysterical  paralysis,  must  always  chiefly 
rely — does  not  preclude  the  existence  of  organic  disease. 
This  was  regarded  as  a  case  of  hysterical  hemiplegia, 
until  its  gravity  revealed  the  presence  of  organic  disease. 


The  features  of  the  case  which  lent  it  its  hysterical  as- 
pect were  the  following : 

1.  A  history  of  repeated  hysterical  manifestations,  and 
the  recurrence  in  the  last  illness  of  similar  manifestations. 
Furthermore,  the  paralysis  was  preceded  by  pain  in  the  aim 
— pain  often  excites  hysterical  paralysis — and  by  the  fixed 
idea  that  she  was  paralyzed,  a.  The  hemiplegia  had  pe- 
culiar features,  ordinarily  characteristic  of  hysterical  hem- 
iplegia. There  was  no  facial  paralysis,  which  is  invariably 
true  of  hysterical  hemiplegia.  When  the  diagnosis  hys- 
teria was  made  the  paralysis  was  not  complete ;  and  this 
is  also  the  rule  in  hysterical  hemiplegia.  The  paralysis 
came  on  very  gradually.  This  is  not  uncommon  in  hys- 
teria, whereas  it  is  exceedingly  rare  as  the  result  of  a 
brain  lesion,  excepting  in  cases  of  tumor,  abscess,  scle- 
rosis, or  chronic  softening,  all  of  which  could  be  ex- 
cluded in  this  case. 

Finally,  the  visual  symptom,  concentric  contraction 
of  the  field  of  vision  in  each  eye,  is  most  frequently 
found  in  hysterical  cases.  But  my  impression  is  that 
this  was  a  mistaken  observation.  The  autopsy  revealed 
a  softening  of  the  right  occipital  lobe,  which  would  cause 
the  loss  of  the  left  half  of  the  field  of  vision  in  each  eye. 
It  is  true  we  do  not  know  that  this  lesion  was  already 
present  when  this  examination  was  made ;  but  inasmuch 
as  at  the  time  of  the  examination  the  mental  condition 
of  the  patient  prevented  a  careful  and  perhaps  accurate 
examination,  and  the  vision  was  tested  for  the  very  pur- 
pose of  finding  out  whether  the  field  was  contracted  or 
not,  it  is  not  improbable  that  the  loss  of  one-half  of  the 
field  was  confounded  with  a  contracted  field  of  vision. 

There  were  some  respects  in  which  this  case  did  not 
correspond  to  the  most  common  picture  of  hysterical 
hemiplegia.  The  paralysis  was  right-sided,  the  arm  was 
more  affected  than  the  leg,  and  there  was  no  anaesthesia; 
whereas  in  hysterical  hemiplegia  the  left  side  is  usually 
affected,  the  leg  more  than  the  arm,  and  there  is  often 
more  decided  loss  of  sensation  than  of  power.  But 
these  differences  are  too  common  to  have  much  weight 
in  diagnosis. 

This,  then,  is  one  of  those  not  uncommon  cases 
where  an  hysterical  subject,  with  hysterical  symptoms, 
has  organic  disease.  The  peculiarity  of  this  case  was 
that,  while  the  patient's  history  led  to  the  expectation  of 
new  hysterical  manifestations,  the  new  symptom  in  this 
instance,  the  hemiplegia,  had  in  itself  so  much  that  is 
commonly  characteristic  of  hysteria. 

The  most  striking  festure  of  this  case  is  the  gradual 
onset  of  symptoms.  From  the  very  beginning  there  was 
a  steady  progress  of  the  symptoms,  from  day  to  day,  al- 
most to  the  very  end.  This  was  true  of  the  motor 
paralysis  and  the  mental  impairment.  This  is  not  the 
mode  of  onset  and  course  in  cases  of  acute  softening. 
Wernicke  describes  a  very  rare  disease,  which  he  terms 
chronic  softening  of  the  brain,  wherein  there  is  a  very 
slow  and  gradual  increase  of  motor  and  sensory  paraly- 
sis, which  may  continue  for  months  or  even  a  few  years, 
a  disease  which  Wernicke  believes  to  be  of  an  inflamma- 
tory character.  But  acute  softening,  which  is  due  to  the 
occlusion  of  blood-vessels,  usually  produces  symptoms 
which  are  more  or  less  sudden  in  onset  When  the 
cause  is  embolism  the  symptoms  are  always  ushered  in 
abruptly ;  and  this  is,  also,  largely  true  in  cases  of  throm- 
bosis. Even  in  cases  of  senile  softening  of  the  brain, 
where  the  slow  appearance  of  symptoms  is  most  likely  to 
be  found,  the  latter  mostly  occurs  as  a  series  of  slight 
attacks.  In  Dr.  Diller's  case,  which  belongs  to  this 
order  and  where  the  gradual  onset  was  uncommonly  well 
marked,  the  phenomena  are  explained  by  the  unusual 
pathological  condition  found.  But  my  own  case  was  not 
one  of  senile  softening,  and  I  do  not  know  of  another  of 
its  kind  in  which  occurred  such  a  gradual  development 
of  paralysis. 

In  part  the  latter  was  due  to  the  multiple  lesions, 
which  doubtless  occurred  one  after  another.  Very  likely 
the  lesion  in  the  left  central  convolutions  appeared  first, 
then  that  in  the  right  occipital  lobe,  and  finally  the  area 


July  28,  1894] 


MEDICAL   RECORD. 


io3 


of  softening  in  the  right  frontal  lobe.  The  latter  prob- 
ably accounts  for  the  attack  of  coma  which  came  on  a 
week  before  death,  and  for  the  loss  of  power  in  the  left 
extremities,  though  the  lesion  only  slightly  encroached 
upon  the  motor  area.  That  there  was  no  facial  paralysis 
is  explained  by  the  location  of  the  lesion  in  the  motor 
area. 


SPLENECTOMY,  WITH    THE    REPORT    OF    A 
SUCCESSFUL  CASE.1 

By  W.  J.  CONKLIN,  A.M.,  M.D., 

DAYTON,  O. 

Mrs.  A ,  American,  aged  twenty-nine,  married,  II- 

para,  was  admitted  into  St.  Elizabeth  Hospital,  May  29, 
1893.  The  following  history  was  obtained.  Her  family 
record  is  without  taint,  menstruation  normal,  and  general 
health  but  little  impaired.  Mrs.  A.'s  early  life  was  passed 
in  a  highly  malarious  district  in  Southern  Illinois,  and  up 
to  her  marriage  and  removal  to  Ohio  she  was  subject  to 
frequent  attacks  of  chills  and  fever,  and  carried  almost 
constantly  an  "ague  cake"  in  her  side.  For  several 
years  she  has  been  free  from  malaria  and,  aside  from  an 
attack  of  typhoid  fever,  has  had  no  serious  acute  illness. 

The  symptoms  of  the  disorder  which  now  so  seriously 
interferes  with  the  discharge  of  her  household  duties,  and 
for  which  she  seeks  relief,  first  showed  themselves  about 
two  years  ago.  She  then  began  to  have  abdominal  and 
pelvic  pains,  and  some  months  later  discovered  a  lump 
low  in  the  abdomen.  Examination  disclosed  a  solid, 
freely  movable  tumor,  sensitive  to  touch,  in  the  left  iliac 
region,  dipping  into  the  pelvis,  but  not  connected  with  the 
uterus,  and  a  small  cyst  of  the  right  ovary.  The  uterus 
was  normal  in  size,  but  retroverted. 

Dr.  Jewett,  during  whose  service  she  entered  the  hos- 
pital, made  a  coehotomy,  June  10,  1893.  The  solid 
tumor  proved  to  be  a  displaced  spleen  about  twice  the 
normal  size.  It  was  free  from  adhesions  and  easily  re- 
placed. The  right  ovary,  containing  a  cyst  the  size  of  a 
small  orange,  was  removed.  Left  ovary  normal  The 
abdomen  was  closed  without  drainage.  Convalescence 
was  uneventful  She  was  soon  discharged  with  positive 
instructions  to  wear  constantly  a  properly  fitting  ab- 
dominal supporter,  with  the  hope  of  retaining  the  spleen 
in  position. 

Mrs.  A was  readmitted  into  the  hospital  during 

my  service,  September  23,  1893.  Shortly  after  her  re- 
tarn  home  she  again  began  to  sutler  from  pelvic  symptoms, 
and  for  the  past  two  months  has  had  nearly  continuous 
abdominal  soreness  and  several  severe  paroxysms  of 
pain,  which  drove  her  to  bed  Her  abdomen  has  been 
steadily  enlarging. 

Six  days  ago,  while  doing  the  family  washing,  she  was 
seized  with  agonizing  pain  in  the  abdomen,  which  required 
for  its  control  the  administration  of  morphia.  Vomiting 
of  large  quantities  of  bile-colored  fluid  began  on  the  fol- 
lowing morning,  and  still  recurs  at  intervals.  In  spite  of 
treatment  the  bowels  have  not  been  opened  for  more 
than  a  week.     Temperature  normal. 

On  examination,  the  abdomen  was  found  tympanitic, 
very  sensitive  to  pressure,  and  occupied  by  an  immov- 
able, solid  tumor  which  completely  filled  the  left  side 
from  the  pelvis  to  the  ribs,  and  extended  considerably 
beyond  the  middle  line.  It  could  easily  be  touched  per 
vagina  m. 

The  former  operation  greatly  simplified  the  diagnosis, 
and  left  no  doubt  that  the  tumor  was  the  enlarged  and 
inflamed  spleen.  The  acute  symptoms  were  attributed 
to  intestinal  obstruction,  due  either  to  pressure  from  the 
spleen  or  to  adhesions  at  the  seat  of  the  ovarian  stump. 
The  symptoms  grew  steadily  worse  until  forty- eight 
hours  after  admission,  when  the  bowels  responded  freely 
to  treatment,  after  which  the  vomiting  ceased  and  her 
general  condition  improved.  The  respite  was  of  short 
duration.  The  local  tenderness,  paroxysmal  pains,  and 
1  Read  before  the  Ohio  State  Medical  Society,  May  17,  1894. 


vomiting  returned  accompanied  by  fever.  The  tempera- 
ture ranged  from  990  to  1010  for  ten  days,  and  measured 
100 °  on  the  morning  of  the  operation.  Peritonitis  had 
evidently  supervened,  and  at  a  consultation  of  the  hos- 
pital staff  it  was  decided  that  the  removal  of  the  offend- 
ing spleen  offered  the  only  chance  of  recovery. 

The  operation  was  made  October  7  th,  with  the  assist* 
ance  of  Drs.  Jewett  and  Humphreys,  the  patient  having 
been  anaesthetized  by  Dr.  Reeve,  Jr.  The  parietal  in- 
cision, seven  and  a  half  inches  in  length,  was  made  along 
the  outer  border  of  the  left  rectus.  On  exploring  the 
spleen,  contrary  to  expectations  based  on  the  revelations 
of  the  previous  operation,  it  was  found  adherent  to  the 
abdominal  wall,  omentum,  and  intestines.  The  intestinal 
adhesions  especially  were  firm  and  extensive,  involving 
the  entire  under  and  inner  surfaces  of  the  tumor.  Their 
separation  consumed  much  time,  and  with  the  utmost 
care  the  capsule  of  the  spleen  was  torn  in  several  places. 
The  peritoneum  gave  unmistakable  evidences  of  active 
inflammation.  The  pedicle  was  long,  twisted  through 
three  complete  turns,  and  with  its  engorged  and  tortuous 
vessels  resembled  a  huge  umbilical  cord.  It  was  trans- 
fixed, firmly  tied  with  heavy  twisted  silk,  using  the  Staf- 
fordshire knot,  and  for  greater  security  encircled  with  an- 
other turn  of  the  ligature.  The  ligature  was  cut  short 
and  the  pedicle  dropped,  a  glass  drainage-tube  placed, 
and  the  wound,  on  account  of  the  patient's  condition, 
hastil&cjosed. 

The  hemorrhage  was  slight  and  easily  controlled.  The 
shock,  however,  was  profound  and  wholly  out  of  propor- 
tion to  the  blood  lost  or  the  length  of  the  operation. 
Hypodermatic  injections  of  brandy  and  strychnia  were 
freely  used.  Apart  from  the  shock  which  threatened  to 
prove  fatal  for  hours  after  removal  to  bed,  and  the  tem- 
perature which  for  twelve  days  measured  from  99°  to 
101,0  precisely  as  it  had  before  the  operation,  there  was 
nothing  worthy  of  special  comment  during  convalescence. 
No  satisfactory  explanation  of  the  temperature  curve 
could  be  found  in  the  condition  of  the  wound  or  patient, 
and  indeed,  without  the  thermometer  it  would  not  have 
been  suspected.  At  no  time  was  there  swelling  of  the 
parotid  or  lymphatic  glands.  The  spleen  drained  of  its 
blood  weighed  four  and  a  quarter  pounds,  and  measured 
ten  inches  in  length  by  five  and  a  half  inches  in  breadth. 
It  was  firmer  in  texture  and  darker  in  color  than  the 
normal  gland.  Microscopical  examination,  by  Dr.  Schei- 
benzuber,  showed  thickening  of  the  trabecular  and  inter- 
cellular connective  tissue  and  pigment  in  the  vessel  walls, 
"  a  chronic  hyperplasia  probably  due  to  malaria."  By  an 
unfortunate  oversight,  no  microscopical  examination  of 
the  patient's  blood  was  made  before  or  soon  after  the 
operation ;  at  present  the  proportion  of  the  red  and  white 
corpuscles  is  normal.  Seven  months  after  the  extirpa- 
tion, the  date  of  the  present  report,  Mrs.  A ,  has 

grown  very  fleshy  and  reports  that  she  is  in  excellent 
health  save  in  one  particular — an  overpowering  drowsi- 
ness. When  quiet,  it  requires  constant  effort  to  keep 
awake.  The  habit  seems  to  be  increasing  and  is  a  con- 
tinual source  of  annoyance  and  embarrassment. 

It  is  not  our  intention  to  enter  into  a  detailed  discus- 
sion of  the  surgery  of  the  spleen,  but  propose  simply  to 
supplement  the  above  report  with  a  few  general  com- 
ments. 

Although  practically  a  modern  operation,  splenectomy 
has  a  history  which  runs  far  back  into  the  centuries. 

Dionis  (1733),  quoted  by  Greig  Smith,  speaks  con- 
demningly  of  a  sect  of  surgeons  who  achieved  notoriety, 
about  the  close  of  the  seventeenth  century,  from  their 
operations  of  "  unmilting,"  as  removal  of  the  spleen  or 
milt  was  termed.  The  only  successful  total  extirpations 
for  disease  recorded  previous  to  1867  were  those  of  Zac- 
carelli  (1549)  and  Ferrerius  (1711),  both  of  which  have 
been  discredited,  probably  erroneously,  by  many  authors. 
In  nearly  all  of  the  statistical  tables,  Dr.  G.  Volney  Dor- 
sey,  formerly  a  distinguished  member  of  this  society  and 
an  accomplished  scholar  and  surgeon,  is  credited  with  a 
successful    splenectomy    made    in    1855.     Leddeihose 


104 


MEDICAL  RECORD. 


[July  28,  1894 


refers  to  this  case  as  the  first  authenticated  success- 
ful laparo -splenectomy  on  record.  A  reference  to  the 
original  publication/  for  which  I  am  indebted  to  Dr.  Bil- 
lings, United  States  Army  Medical  Library,  shows  that 
Dr.  Dorsey,  in  this  very  creditable  pioneer  effort  in  splenic 
surgery,  did  not  remove  the  spleen,  nor  is  there  any  evi- 
dence that  he  ever  entertained  such  a  proposition.  The 
operation  was  undertaken  for  the  relief  of  pain  in  an  en- 
larged spleen  of  malarial  origin.  On  opening  the  abdo- 
men extensive  adhesions  were  found  and  treated  as  the 
source  of  trouble.  "I  then  proceeded,"  says  the 
operator,  "  to  break  up  all  of  the  adhesions  of  the  spleen, 
and  endeavored  to  place  this  viscus  as  nearly  as  possible 
in  what  I  conceived  to  be  its  natural  position."  The  in- 
troduction of  splenectomy  into  modern  surgery  dates 
from  the  memorable  case  of  P6an,  who  in  1867  success- 
fully removed  from  a  young  woman  an  enlarged  and 
cystic  spleen.  Since  then  the  operation  has  not  only 
been  accorded  a  place  in  legitimate  surgery,  but  has  been 
extensively  practised  with  fair  success,  though  the  mor- 
tality-rate is  still  higher  than  in  laparotomy  for  any  other 
cause. 

The  indications  for  splenectomy  have  not  been  defi- 
nitely settled.  Taking  as  a  basis  the  tables  of  Drs.  Fus- 
sell,"  Ledderhose,'  and  Zuccarelli,*  and  making  the 
proper  additions  and  corrections,  we  have  the  following 
summary,  which  fairly  represents  the  conditions  for  which 
the  operation  has  been  made  and  the  results  attqped  up 
to  date. 


Num- 
ber. 


Hypertrophy,  simple :  malarial 48 

Leucaemia |  27 

Pseudo-leucaemia a 

Traumatism,  no  serious  lesion  of  spleen.  .J  26 

Traumatism,  rupture  of  spleen {  6 

Floating  spleen    \  95 

Cysts  of  spleen,  simple  :  hydatid 1  6 

Abscess  of  spleen 4 

Sarcoma  of  spleen |  3 

Syphilis  of  spleen    I  1 

Amyloid  disease  of  spleen i  1 

Healthy  spleen j  1 

Total '  xSo 


Deaths. 


26 


Recov- 


Percent- 

|     age  of 
mortality. 


58* 


5 


68 


45* 


Like  all  statistical  tables  promiscuously  gleaned  from 
current  literature,  this  one  must  be  taken  cum  grano 
salts,  since  it  is  always  a  fair  presumption  that  fatal  cases 
are  less  likely  than  successful  ones  to  find  their  way  into 
print. 

The  celebrated  case  of  Franzolini  (1881),  which  how- 
ever has  not  gone  unchallenged,  still  remains  the  only 
successful  splenectomy  for  leucaemia.  With  the  excep- 
tion of  Bardenheuer's  case,  which  died  from  sepsis  on  the 
thirteenth  day,  none  survived  the  operation  longer  than  a 
few  hours.  Hemorrhage  and  shock  were  the  cause  of 
death  in  all  but  three  cases. 

There  are  a  few  writers  (Fulsell,  Adlemann,  Asch) 
who,  in  view  of  the  hopelessness  of  medical  treatment, 
still  look  with  favor  upon  surgical  procedures,  provided 
the  operation  is  made  when  the  gland  is  only  moderately 
enlarged  and  before  profound  alterations  have  taken 
place  in  the  blood.  The  consensus  of  opinion  is,  how- 
ever, strongly  opposed  to  this  view. 

The  insidiousness  of  the  onset  of  leucocythaemia  and 
the  extensive  mutilation  which  splenectomy  implies, 
taken  in  connection  with  the  impossibility  of  eradicating 
the  constitutional  cachexia  which  is  back  of  the  splenic 
enlargement,  will  certainly  tend  to  confine  "  early  oper- 
ation "  within  narrow  limits.  So  far,  the  ghastly  record 
leaves  unimpeached  the  dictum  of  Bryant,  "  that  the 
operation  is  physiologically  unsafe  and  surgically  un- 
sound.1' 

1  Ohio  Medical  Counsellor,  1855. 

*  Universal  Medical  Magazine,  September,  1800. 

8  Deutsche  Chirurgie :  lierausgegeben  von  Professor  Billroth  und 
Luecke,  1890. 

*  Splenectomies  in  Italy :  American  Medico-Surgical  Bulletin,  May, 
X894. 


The  results  in  simple  or  non-leucsemic  hypertrophy 
are  more  encouraging,  although  the  mortality-rate  is  still 
high,  about  58^  per  cent. 

Agnew  (1889)  holds  that  all  cases  of  hypertrophy, 
simple,  malarial,  or  leucaemic,  are  excluded  from  the 
realm  of  operative  surgery.  The  latest  text-book  on 
surgery  takes  the  more  conservative  position  that,  al- 
though hypertrophied  spleens  have  been  successfully 
removed  these  cases  are  for  the  most  part  not  suitable 
for  operation. 

These  statements  are  hardly  sustained  by  the  facts. 
It  is  undoubtedly  true  that  simple  hypertrophy  will  rarely 
in  itself  be  a  sufficient  justification  for  the  performance 
of  splenectomy  ;  but  in  the  presence  of  pressure  symp- 
toms, twisted  pedicle  leading  to  degenerative  changes  or 
disabling  pain,  all  of  which  may  be  caused  by  a  moderate 
enlargement  of  the  gland,  the  operation  is  not  only  justi- 
fiable, but  offers  a  reasonable  probability  of  a  favorable 
issue. 

It  is  very  apparent  that  the  results  are  better  in  the 
later  than  in  the  earlier  operations,  due,  probably,  to  a 
more  thorough  asepsis  and  an  improved  technique,  and 
lead  to  the  hope  of  better  things  yet  to  come. 

The  record  of  the  past  decade  in  the  operations  for 
simple — including  malarial — hypertrophy,  shows  twenty 
recoveries  and  eight  deaths,  a  mortality  of  only  28^  per 
cent,  against  58^3  per  cent,  calculated  upon  the  total 
operations. 

In  discussing  this  phase  of  the  subject  it  is  proper  to 
take  into  consideration  the  brilliant  results  of  extirpation 
for  floating  or  displaced  spleens. 

In  over  fifty  per  cent,  of  these  histories  it  is  specifi- 
cally stated  that  the  spleen  was  enlarged,  while  in  very 
few  it  is  designated  as  normal  in  size.  In  many  of  the 
cases,  as  in  our  own,  the  hypertrophy  was  extreme  and 
gave  rise  to  doubts  as  to  their  correct  classification. 

It  is  difficult  to  estimate  from  the  imperfect  data  at 
hand  the  influence  of  malaria  in  causing  the  enlargement 
which  led  to  the  adoption  of  operative  measures.  It  is 
only  given  as  a  cause  of  the  hypertrophy  in  nineteen 
cases,  of  which  five  died  and  fourteen  recovered.  The 
condition  of  the  blood,  however,  is  a  far  more  important 
factor  in  determining  the  issue  in  a  given  case  than  the 
amount  or  the  nature  of  the  hypertrophy  (non-leucse- 
mic).  In  any  proposed  excision  of  the  spleen  the  blood 
should  be  subjected  to  a  careful  microscopical  examina- 
tion, and  if  the  relations  of  the  corpuscles  are  seriously 
disturbed,  especially  if  the  lymphatic  glands  are  involved, 
operative  procedures  should  not  be  undertaken. 

Splenectomy  for  certain  traumatisms  of  the  spleen  has 
a  much  better  record  than  for  disease.  The  results  as 
displayed  in  the  table,  which  includes  both  total  and  par- 
tial excisions,  are  very  remarkable,  and  especially  when 
the  fact  is  recalled  that  almost  all  of  the  cases  which 
enter  into  it  antedate  the  dawn  of  aseptic  surgery. 

It  is,  however,  worthy  of  more  than  passing  mention, 
that  in  the  recent  literature  of  the  subject  there  are  re- 
corded so  few  removals  of  the  spleen  for  traumatic 
causes,  and  none  for  the  peculiar  traumatism  with  pro* 
trusion  which  gives  the  extraordinary  results  tabulated 
above.  But  unless  interpreted  in  the  light  of  the  case 
histories,  these  figures  would  be  manifestly  misleading. 
The  reports,  so  far  as  they  are  accessible,  show  that  the 
above  results  were  obtained  when  there  was  protrusion 
of  the  spleen  through  or  into  a  parietal  wound  without 
serious  injury  to  the  gland  itself  or  other  viscera. 

The  graver  injuries  included  under  the  head  of  trau- 
matic rupture  have  necessarily  a  high  mortality.  It  is 
fair  to  assume,  from  the  deep-seated  and  protected  loca- 
tion of  the  spleen,  that  when  it, has  received  an  injury 
severe  enough  to  suggest  splenectomy  the  concomitant 
lesions  would  be  profound  and  probably  fatal. 

So  far  as  we  are  able  to  ascertain,  the  case  of  Riegner l 
(1892)  is  thus  far  the  only  successful  extirpation  for  a 
subcutaneous  trauma  of  the  spleen. 

The  intense  surgical  interest  of  this  unique  case 
1  Berliner  klinische  Wochenschrift,  February,  1893. 


July  28,  1894] 


MEDICAL  RECORD. 


105 


prompts  us  to  give  a  brief  resume.  A  lad,  aged  fourteen, 
fell  from  the  third  story  of  a  house  and  struck  on  his  belly. 
Twelve  hours  after  the  accident,  signs  of  internal  hemor- 
rhage supervening,  the  abdomen  was  opened  in  the  middle 
line  ;  the  incision  was  subsequently  enlarged  by  right  and 
left  cross-cuts.  The  spleen  was  found  completely  torn 
across  at  its  middle,  and  the  two  sections  widely  sepa- 
rated. The  spleen  was  removed,  the  abdominal  cavity 
cleansed  of  large  quantities  of  clotted  blood,  and  the  pa- 
tient put  to  bed  much  exhausted.  Convalescence  was 
interrupted  by  gangrene  of  the  foot  and  leg,  which  a  few 
weeks  later  necessitated  amputation  through  the  left 
thigh.  He  recovered  from  both  operations,  and  seven 
months  later  was  in  excellent  health. 

Ledderhose  investigated  the  comparative  merits  of  re- 
section, extirpation,  and  reposition  of  the  protruding 
spleen,  with  the  following  result :  Ten  resections  with 
ten  recoveries ;  eighteen  extirpations  with  eighteen  re- 
coveries, and  four  repositions  with  one  recovery. 

The  conclusion  seems  irresistible  that  in  prolapse  of  the 
spleen  through  an  abdominal  wound,  extirpation,  either 
partial  or  total,  is  a  safer  procedure  than  simple  replace- 
ment However,  this  deduction  is  less  startling  when 
we  reflect  that  there  is  far  less  danger  from  sepsis  and 
hemorrhage  in  a  laparotomy,  with  its  careful  toilet  of  the 
peritoneum  and  better  control  of  bleeding,  than  in 
blindly  replacing  the  protruding  organ.  These  statis- 
tics, contrary  to  the  traditions  of  the  textbooks,  warrant 
the  statement  that  removal  of  the  spleen  is  not  in  itself 
a  highly  dangerous  operation.  An  opinion  which  is  for- 
tified by  the  brilliant  results  in  the  removal  of  floating 
spleens,  already  noticed,  as  well  as  by  the  fortunate  end- 
ing of  the  case  of  Trendelenburg,  in  which  he  removed  a 
healthy  spleen  in  dissecting  out  a  retro-peritoneal  sar- 
coma. 

Hemorrhage  and  shock  constitute  the  great  dangers 
in  splenectomy,  about  seventy  per  cent,  of  the  deaths 
being  attributed  to  these  accidents.  Sepsis  is  largely 
eliminated  by  the  promptness  with  which  the  fatal  issue 
follows  the  operation.  According  to  Mosler,  the  hemor- 
rhagic diathesis  so  constantly  associated  with  splenic  en- 
largements, both  simple  and  leucsemic,  is  often  latent 
and  therefore  unsuspected  before  operative  measures  are 
begun.  The  pedicle  is  the  most  common  seat  of  fatal 
hemorrhage ;  not  infrequently  it  comes  from  the  torn  ad- 
hesions, and  in  a  few  cases  has  been  attributed  to  a  ca- 
pillary oozing  from  the  congested  viscera.  For  greater 
security,  some  operators  advise  the  separate  ligation  of 
the  vessels  of  the  pedicle  in  addition  to  the  ordinary  en- 
circling ligature,  but  Treves  states  that  no  advantage  has 
been  shown  to  attend  this  practice. 

The  shock  is  often  profound  and,  as  in  the  case  herein 
reported,  is  not  easily  explained.  Traction  upon  the 
pedicle  in  manipulating  the  tumor  has  often  brought  on 
dangerous  collapse,  due  probably  to  pressure,  upon  the 
splenic  nerve-plexus.  It  is  not  improbable  that  many 
deaths  credited  to  post-operative  collapse  are  really  the 
result  of  a  slow  intra-abdominal  bleeding. 

The  present  position  of  splenectomy  may  be  briefly 
epitomized  as  follows:  It  is  unjustifiable  in  leucocy- 
thaemia  or  other  conditions  in  which  there  is  extensive 
involvement  of  the  lymphatic  glands,  or  a  notable  in- 
crease in  the  white  blood-corpuscles. 

It  is  indicated  -  in  tumors,  simple  hypertrophies,  and 
other  splenic  enlargements  which  have  proven  rebellious 
to  simpler  measures  and  are  attended  with  danger  or 
serious  disability. 

In  movable  or  displaced  spleens  requiring  interference 
extirpation  is  preferable  to  operative  fixation. 

Severe  traumatisms  of  the  spleen,  with  or  without  an 
external  wound,  or  simple  prolapse  of  the  gland  into  a 
parietal  wound,  demand,  as  a  rule,  immediate  extirpation. 
In  cases  of  protrusion  experience  shows  thai  excision, 
partial  or  total,  is  a  safer  procedure  than  mere  replace- 
.ment 

Removal  of  the  spleen  for  cystic  disease  has  an  ex- 
cellent record,  but  most  authors  advise  a  preliminary 


trial  of  incision  with  drainage.  In  abscess  it  is  better, 
except  in  rare  cases,  to  incise  and  drain  than  to  attempt 
removal  of  the  organ. 


THE  ^DANGERS  OF  GLYCERINE  INJECTIONS 
INTO  THE  UTERUS,  FOR  THE  PURPOSE  OF 
INDUCING  PREMATURE  LABOR. 

By  OSCAR  EMBDEN,  M.D., 

BROOKLYN,   N.  Y. 

T.  Pfannenstiel  publishes  in  the  Centralblati  fur 
Gynecologic,  No.  4,  1894, -an  article  concerning  the 
dangers  connected  with  intra-uterine  injections  of  glyc- 
erine for  the  purpose  of  inducing  premature  labor — a 
method  of  late  frequently  used  in  this  country — and 
gives  the  history  of  two  cases  treated  by  him  with  the 
new  method,  in  the  Gynecological  Clinic  of  Breslau. 

As  I  have  had  the  opportunity  to  observe  one  case 
with  a  very  similar  history,  showing  evidently  the  dan- 
gers of  these  injections,  I  take  the  liberty  to  give  in  the 
following  an  extract  of  the  above  article  together  with 
my  case  and  some  observations  of  my  own.  I  consider 
myself  the  more  justified  in  so  doing,  as  .Pfannenstiers 
first  case  is  not  free  from  objections,  leaving  only  one  of 
his  cases  indisputable. 

In  the  beginning  of  his  article  the  author  states  that 
injections  of  different  liquids  into  the  uterus  (for  instance 
the  injection  of  tar  water :  Cohen's  method)  have  been 
frequently  recommended,  but  generally  very  soon  re- 
jected by  the  profession,  on  account  of  the  dangers  con- 
nected with  these  methods.  Most  of  them,  especially 
Cohen's  mode  of  procedure,  are  said  to  have  one  great 
advantage ;  that  is  prompt  and  sure  action  even  in  cases 
where  the  ordinary  methods  have  failed  to  act 

Following  this  idea,  Pelzer  recommended  the  injection 
of  glycerine  between  the  uterus  and  the  foetal  sac,  two 
years  ago,  publishing  four  cases  treated  by  him  success- 
fully in  this  manner.  Since  that  time  we  have  read  very 
favorable  reports  of  the  new  method,  written  by  different 
distinguished  authors,  none  of  whom  mentions  any  dan- 
gers connected  with  this  treatment. 

Pfannenstiel  tries  to  demonstrate  these  dangers  with 
the  following  two  cases : 

Case  I. — Primipara,  twenty-two  years  of  age,  enters 
the  Clinic  on  September  5,  1892,  in  the  ninth  month  of 
her  pregnancy,  suffering  from  a  very  bad  nephritis.  Her 
legs  and  face  were  oedematous,  she  has  no  appetite,  has 
headache  and  feels  very  weak.  In  the  past  seven  days 
she  suffered  from  dyspnoea.  She  is  anaemic,  badly  nour- 
ished ;  has  a  hyposcoliosis,  but  no  narrowness  of  the  pel- 
vis ;  cyanosis  in  a  slight  degree.  Respiration,  44 ;  tem- 
perature, 97. 70  F. ;  pulse,  130  to  166,  small.  The  urine 
contains  eight  per  cent,  albumin  (Esbach's  method), 
many  casts  and  epithelial  cells,  no  red  blood-corpuscles, 
a  few  white  ones ;  quantity  200  cc  in  twenty  four 
hours. 

September  7th,  6  p.m.: — Injection  of  80  cc.  chemi- 
cally pure  glycerine  between  the  uterus  and  the  foetal  sac 
with  every  possible  precaution.  The  patient  stood  the 
little  operation  very  badly  on  account  of  orthopnoea. 
She  had  a  slight  collapse  before  the  injection  and  a  sec- 
ond one  immediately  after  it,  so  that  she  required  stimu- 
lants. Soon  after  the  injection,  it  was  evident  that  it 
had  been  performed  too  late.  The  breathing  became 
more  and  more  difficult,  the  pulse  became  weaker. 
Temperature,  95. 90  F.  She  never  had  a  single  pain. 
She  died  September  8th,  at  2  a.m. 

The  postmortem  examination  showed  that  she  had 
died  of  nephritis.  Omitting  the  full  report  of  this  exam- 
ination, I  only  mention  that  there  was  one  tablespoon- 
ful  of  blood-colored  urine  in  the  bladder.  The  vesical 
membrane  was  of  a  red  dolor.  The  foetal  sac  was  sepa- 
rated from  the  uterus  over  an  area  of  about  three  inches 
square.     No  glycerine  was  noticeable  at  this  point. 

Case  II. — This  is  a  III.  para  with  a  narrow  pelvis ;  arti- 
ficial labor  four  weeks  before  term.     Pfannenstie]  first 


io6 


MEDICAL  RECORD. 


[July  28,  1894 


tried,  without  success,  Krause's  method  for  some  days : 
he  pushed  in  three  bougies  between  the  uterus  and  the 
foetal  sac 

September  26th,  5  p.m. — Injection  of  100  c.c.  con- 
centrated glycerine.  The  patient  had  immediately  after 
the  injection  very  strong  and  very  painful  contractions. 
These  subsided  after  some  time,  the  uterus  remaining  ex- 
ceedingly sensitive.  There  was  not  any  effect  on  the 
cervix.  One  hour  after  the  injection  the  woman  became 
drowsy  and  cyanotic,  the  temperature  rose  to  102. 20  F., 
the  pulse  became  slower,  68  per  minute.  On  the  previ- 
ous days  it  ranged  between  84  and  92.  This  condition 
continued  for  three  hours.  Then  the  temperature  be- 
came normal,  the  pulse  a  little  more  frequent.  After 
that  the  temperature  remained  normal.  The  urine, 
drawn  off  with  the  catheter,  one  hour  after  the  injection, 
quantity  1  oz.,  was  of  a  blood-red  color.  The  woman 
was  catheterized  every  two  hours :  the  urine  remaining 
as  in  the  beginning  until  ten  hours  after  the  injection, 
when  the  color  began  to  become  lighter  and  twenty-four 
hours  afterward  it  was  normal.  The  urine  contained 
large  quantities  of  albumin  until  forty-eight  hours  after 
the  injection;  it  contained  nearly  no  morphotic  ele- 
ments, except  some  particles  of  hyaline  casts,  no  red 
blood- corpuscles.  The  spectrum-analysis  showed  that 
there  was  methaemoglobin  and  haemoglobin  in  the  urine. 
The  general  feeling  of  the  patient  was  not  disturbed 
after  the  operation,  but  the  appetite  was  poor  for  three 
days. 

Premature  labor  was  successfully  brought  on  by  means 
of  the  colpeurynter.  The  delivery  of  a  living  child  took 
place  September  28th,  at  4.30  p.m.  Puerpernrav  with- 
out complications. 

The  case,  observed  by  myself,  is  as  follows :  Primi- 
para,  aged  twenty-four,  in  the  ninth  month  of  her  preg- 
nancy. She  has  had  albumin  in  the  urine  for  three 
weeks,  the  amount  of  which  is  rapidly  increasing  in  the 
last  few  days,  in  spite  of  a  very  strict  milk  diet  (seven 
per  cent.,  Esbach's  method).  The  quantity  of  the  urine 
is  about  one  quart  in  twenty-four  hours.  The  sediment 
-contains  a  few  white  blood-corpuscles,  no  red  ones,  a 
few  renal  epithelial  cells,  and  a  few  hyaline  casts.  The 
patient  has  a  headache,  feels  sick  to  her  stomach,  and 
very  tired  She  has  slight  oedema  of  the  feet  and  hands. 
Under  these  circumstances  it  seemed  best  to  induce  pre- 
mature labor  as  soon  as  possible. 

March  19,  1893,  x  P-M- — Injection  of  90  c.c.  pure 
glycerine  between  the  uterus  and  foetal  sac  (Dr.  Charles 
Jewett).  This  had  to  be  done  in  chloroform  narcosis, 
as  the  patient  was  very  nervous.  Soon  after  she  recov- 
ered from  the  narcosis  she  had  slight  pains  at  longer  or 
shorter  intervals  until  7  p.m.  At  that  time  the  uterus 
was  very  sensitive,  but  there  were  no  real  contractions. 

At  7.30  p.m.  the  patient  had  a  very  severe  eclamptic 
convulsion  of  about  three  minutes'  duration.  As  it  was 
very  desirable  to  terminate  labor  as  soon  as  possible,  and 
the  cervix  barely  admitting  the  little  finger,  manual  dila- 
tation was  very  skilfully  performed  by  Dr.  Jewett,  at  9 
p.m.,  and  a  living  child  extracted  with  his  own  axio- 
traction  forceps.  The  temperature  was  normal  all  the 
time,  but  the  pulse- rate  was  very  slow,  ranging  between 
50  and  55  per  minute ;  before  the  injection  it  was  78. 
The  urine  was  not  drawn  off  before  delivery.  The  first 
urine  after  delivery— drawn  with  the  catheter — was  of  a 
dark  red  color.  It  contained  no  red  blood-corpuscles, 
but  a  large  quantity  of  haemoglobin.  After  twelve  hours 
the  water  was  only  slightly  colored,  and  twenty-four 
hours  after  delivery  the  color  was  normal.  The  albumin 
disappeared  gradually.  The  next  day  after  delivery  a 
severe  icterus  set  in,  and  the  patient  fell  in  a  semi-coma- 
tose condition,  which  continued  for  six  days.  By  this 
time  the  icterus  and  the  coma  had  disappeared,  and  the 
patient  recovered  gradually. 

In  the  first  place,  it  is  demonstrated  by  these  three 
cases  that  the  glycerine-injections  do  not  act  as  quickly 
as  we  should  expect.  Pfannenstiel  concedes  himself 
that  his  first  case  is  of  little  value  in  this  respect,  as  it 


was  too  far  advanced  for  any  treatment ;  but  his  second 
one  illustrates  clearly  that  the  injections  of  glycerine 
were  of  no  more  use  than  Krause's  method  (introduction 
of  bougies).  My  case  shows  that  there  was,  about  seven 
hours  after  the  injection,  only  a  very  slight  dilatation  of 
the  cervix,  although  the  patient  had  constant  pains  from 
the  beginning. 

Pfannenstiel  is  perfectly  right  in  considering  much 
more  important  than  this  the  fact  that  Pelzer's  method 
is  liable  to  occasion  indisputable  symptoms  of  glycerine 
poisoning.  This  will  be— as  he  says — a  death-blow  to 
the  method. 

Concerning  the  first  case,  he  does  not,  of  course,  con- 
sider the  glycerine  as  the  cause  of  the  woman's  death,  but 
the  nephritis.  He  deems  it  remarkable,  nevertheless, 
that  there  was  found  a  small  quantity  of  blood- colored 
water  in  the  bladder,  the  urine  being  entirely  free  from 
blood  in  the  last  days  before  the  injection  was  performed, 
as  shown  by  frequent  examinations.  Pfannenstiel  tries 
to  find  the  cause  of  this  in  the  injected  glycerine. 

The  second  case  was  undoubtedly  a  case  of  glycerine 
poisoning,  and  although  it  did  not  damage  the  future 
health  of  the  woman  it  kept  her  in  danger  for  some 
time.  The  woman  was  in  perfect  health  up  to  the  time 
of  the  injection ;  the  urine  was  normal.  One  hour  after- 
ward she  had  the  symptoms  above  mentioned. 

In  my  case  there  is  a  woman  with  nephritis,  but  there 
was  not  noticed  at  any  time  before  the  injection  any 
trace  of  blood  in  the  urine.  After  the  delivery  there  was 
a  good  quantity  of  a  dark  red  urine  in  the  bladder.  In 
examining  the  same,  I  failed  to  find  any  red  blood  cor- 
puscles, but  there  was  a  large  amount  of  haemoglobin. 
Therefore  the  cause  of  this  could  not  have  been  an  acute 
congestion  of  the  kidneys,  as  we  at  first  thought — for 
there  was  no  hematuria,  but  a  haemoglobinuria — and  the 
only  explanation  we  could  find  for  this  was  a  decompo- 
sition of  the  blood,  brought  on  by  the  injected  glycerine. 

This  does  not  seem  so  very  strange,  as  we  know — ac- 
cording to  Pfannenstiel — that  glycerine  is  liable  to  occa- 
sion a  decomposition  of  the  blood,  as  Luchsinger,1 
Schwan,*  Filehne,1  L6b6deff,4  and  Wiener*  have  demon- 
strated and  Afanassiew9  has  shown,  experimenting  with 
dogs  and  rabbits,  that  the  haemoglobinuria,  caused  by 
glycerine,  brings  on  a  glomerulonephritis  which  is  fol- 
lowed, after  the  injection  of  more  glycerine,  by  intersti- 
tial nephritis  as  well  as  by  interstitial  hepatitis. 

It  is,  of  course,  strange  that  neither  Pelzer  nor  others 
met  with  a  similar  accident  after  injections  of  glycerine. 

Pfannenstiel  finds  an  explanation  of  this  in  the  fact 
that  Schwan,  L6bedeff,  and  Filehne  have  shown  that  in 
rabbits,  when  the  glycerine  is  brought  under  the  skin, 
haemoglobinuria  always  occurred,  but  that  it  did  not  occur, 
or  in  a  slight  degree  only,  when  it  was  injected  directly 
into  the  veins.  Without  giving  an  explanation  of  this 
remarkable  fact,  Pfannenstiel  deems  it  possible  that,  in 
Pelzer's  cases,  the  glycerine  was  very  rapidly  absorbed 
by  the  circulatory  system,  while  in  his  cases  it  acted  in 
the  decidua  uteri  as  if  it  had  been  injected  by  the  hypo- 
dermic method. 

There  is  another  thing  about  which  I  would  like  to  say 
a  few  words,  that  is  the  icterus  which,  in  my  case,  fol- 
lowed the  haemoglobinuria.  On  this  account  it  seems  to 
me  especially  interesting. 

It  is  not  very  important  whether  this  was,  according  to 
Kuehne's  *  theory,  a  real  haematogenic  icterus,  that  is, 
an  icterus  directly  caused  by  the  pigment  of  the  decom- 
posed red  blood-corpuscles,  or  a  so-called  taemo-hepato- 
genic  icterus,  which  is  said  by  Afanassiew,  who  denies  the 
existence  of  a  real  haematogenic  icterus,  to  be  an  indirect 
result  of  this  decomposition  only.     This  author  thinks 

1  Pflueger's  Archiv,  1875,  p.  503 

9  Eckhard,  Beitrage  zur  Anatomie  of  Physiologic  1879,  T<>1*  ▼»»••  P- 
167. 

*  Virchow's  Archiv,  vol.  cxvii.,  p,  413. 

4  Virchow's  Archiv.  1883,  voL  xci. ,  p.  303. 

*  Archiv  flier  Gynaecologie,  1884,  vol.  xx'iii. 

*  Verhandlungen  des  Kongresses  fuer  innere  Medicin,  1883,  p.  2x6, 
fF. 

T  Virchow's  Archiv,  voL  14. 


July  28,  1894] 


MEDICAL  RECORD. 


107 


that  the  pigment  of  the  destroyed  red  blood  corpuscles  is 
deposited  in  the  liver,  where  the  gall- pigment  is  normally 
formed  out  of  the  blood  pigment,  and  the  icterus  occurs, 
in  his  opinion,  on  account  of  an  overplus  of  gall-pig- 
ment in  the  liver,  a  part  of  which  reflows  into  the  blood. 

Leaving  this  question  undecided,  one  thing  seems  to 
be  indisputable,  and  that  is,  the  icterus  was  caused,  in 
my  case,  either  directly  or  indirectly  by  the  decomposi- 
tion of  the  blood  poisoned  by  glycerine. 

I  would  not  dare  to  say  that  the  semi-comatose  condi- 
tion of  my  patient,  which  disappeared  with  the  icterus, 
was  brought  on  by  the  same  cause.  It  did  not  look  like 
a  uremic  coma,  and  we  were  unable  to  account  for  its 
origin.  It  might  possibly  have  been  one  of  the  indirect 
effects  of  the  decomposition  of  the  blood,  but  it  is  better 
to  leave  this  an  open  question. 

Pfannenstiel  also  points  out  another  danger  of  the  in- 
jection of  concentrated  glycerine,  and  that  is,  according 
to  the  authors  above  cited,  the  possibility  of  a  thrombo- 
sis, which  concentrated  glycerine,  when  brought  into  the 
circulatory  system,  may  produce. 

In  addition  to  ail  these  objections,  there  has  still  to  be 
mentioned  another  danger  connected  with  the  new 
method  as  well  as  with  the  injection  of  any  kind  of  fluid 
between  the  uterus  and  the  foetal  sac,  namely,  the  possi- 
bility of  air  entering  into  the  circulatory  system.  This 
cannot  be  absolutely  avoided,  even  with  every  possible 
precaution. 

All  this  together  seems  sufficiently  to  show  the  great 
dangers  connected  with  Pelzer's  mode  of  procedure.  It 
ought  not  to  be  used  at  all  for  the  purpose  of  inducing 
premature  labor,  but  especially  not,  in  my  opinion,  in 
cases  of  nephritis,  as  we  have  seen  that  the  glycerine  is 
very  liable,  on  account  of  its  irritating  effects  on  the  kid- 
neys, to  make  the  existing  nephritis  worse. 

If,  in  calling  the  attention  of  the  profession  to  the 
dangers  of  Pelzer's  method,  I  shall  have  convinced  them 
that  it  is  not  a  method  for  indiscriminate  use,  I  will  have 
attained  my  object. 

184  Stats  Stkbkt.  Brooklyn,  N.  Y.' 


©litxical  gepartmetit 

AN  ECHINOCOCCUS    CYST    SIMULATING    AS- 
CITES. 

By  MARCELL  HARTWIG,  M.D., 

BUFFALO,    N.  Y. 

D.  R ,  an  Italian,  appeared  in  my  office  February  1, 

1894,  saying  that  he  had  been  sick  about  five  months  with 
loss  of  strength.  Upon  examination  he  presented  all  the 
symptoms  of  ascites,  except  that  there  was  a  very  gradual 
change  of  the  percussion  dulness  in  changing  position, 
and  also  that  there  was  a  remarkable  bulging  of  the  epi- 
gastrium. On  February  5  th  I  tapped  him  midway  be- 
tween the  symphysis  pubis  and  umbilicus.  Over  five 
quarts  of  an  intensely  green  liquid  were  removed.  A 
great  many  brown  lumps  and  flakes  came  along,  some 
with  a  gritty  feel.  The  whole  liquid  appeared  more  vis- 
cid than  ascitic  fluid  usually  does.  Microscopic  exami- 
nation showed  rhombic  dark  brown  crystals,  which  Dr. 
Benedict  found  to  be  bilirubin,  fatty  round- cells,  and 
some  large  rings  with  double  contour  and  two  or  three 
central  dots  which  I  could  but  consider  eggs  of  some 
worm,  but  whether  of  ascaris  or  taenia  I  could  not  de- 
termine. The  liquid  was  rich  in  bile.  After  the  liquid 
was  removed  nothing  unusual  could  be  felt  in  the  ab- 
domen. The  temperature  was  ioo°  F.  in  the  rectum, 
pulse  79.  Five  weeks  after  the  tapping  the  patient  be- 
gan to  feel  uncomfortable  again,  although  he  had  gained 
some  in  weight.  Jaundice  had  not  existed  previously,  nor 
did  such  appear  after  the  tapping.  Fluctuation  was  dis- 
tinct again  and  I  was  almost  ready  to  push  the  trocar 
through  the  old  place,  when  it  became  evident  that  the 
liquid  was  above  that  point,  and  that,  in  standing,  the 


lowermost  parts  of  the  abdomen  gave  a  tympanitic  sound 
up  to  the  middle  point  between  the  symphysis  pubis  and 
umbilicus.  So,  after  an  exploratory  puncture  with  a  hy- 
podermic needle  a  finger's  width  above  the  navel,  I 
pushed  a  good-sized  trocar  in  and  emptied  what  I  now 
believed  to  be  a  sac.  There  were  about  two  and  one- half 
quarts  of  liquid  with  the  former  characters,  only  that  the 
search  for  eggs  proved  futile.  Through  the  cannula  a 
N6laton  catheter,  previously  fitted,  was  introduced  to  the 
depth  of  a  foot,  and  over  it  the  cannula  withdrawn  in 
order  to  establish  permanent  drainage.  Liquid  of  the 
same  character  kept  oozing  from  the  end  of  the  catheter. 
While  I  was  contemplating  how  to  produce  adhesive  in- 
flammation— thinking,  for  example,  of  injecting  tincture 
of  iodine,  as  in  hydrocele,  but  fearing  poisoning — natural 
infection  came  to  my  aid.  The  patient  became  feverish, 
the  temperature  xoften  rising  to  1030  F. ;  the  liquid  be- 
gan to  turn  into  pus  containing  streptococci  only. 
After  a  week's  fever  I  thought  the  •  reaction  plenty 
strong  enough,  and  began  injections  of  peroxide  of 
hydrogen,  which  brought  out  some  crystals  for  a  while. 
The  size  of  the  cavity  began  diminishing.  April  1 7th 
it  admitted  only  850  c.c.  April  25th,  150  c.c. ;  May  3d, 
100  c.c. — at  a  pressure  of  twelve  to  fourteen  inches  of 
water. 

The  patient  was  up  and  around  again.  May  17  th 
liquid  oozes  immediately  next  to  the  catheter.  I  shall 
shorten  the  latter  daily,  as  there  is  no  doubt  the  process 
is  at  an  end  and  the  cavity  gone.  What  else  than  an 
echinococcus  cyst  communicating  with  the  gallbladder 
or  probably  with  a  bile  duct  in  the  liver  could  this  case 
represent  ?  That  the  gall-bladder  did  not  communicate 
with  the  cyst  seems  to  me  probable,  from  the  fact  that  a 
probe  introduced  into  the  channel  of  the  catheter,  after 
the  latter's  withdrawal,  seemed  to  reach  decidedly 
too  far  underneath  the  lower  surface  of  the  liver,  and 
that  the  stools  were  of  natural  color.  This  is  the  first 
case  of  echinococcus  I  have  seen  in  fifteen  years  in  Buf- 
falo, although  I  have  watched  for  it.  The  patient,  liquid, 
and  slides  were  presented  in  the  Buffalo  Academy  of 
Medicine ;  and,  during  the  discussion,  a  gentleman  ex 
pressed  his  fear  that  such  a  method  of  drainage  might 
expose  the  patient  to  leakage  of  fluid  into  the  peritoneal 
cavity  with  resulting  peritonitis.  But  the  danger  seems 
to  me  absent,  even  if  the  cyst  should  retract  off  from  the 
abdominal  wall,  as  long  as  it  is  emptied  well  so  that 
there  is  no  internal  pressure  left.  In  a  few  days  a  chan- 
nel is  formed  of  inter-intestinal  adhesions,  forming  a  per- 
fect pipe,  cutting  off  the  general  peritoneal  cavity. 
Such  a  condition  I  saw  years  ago,  when  I  placed  a  thor- 
ough drain  from  an  abdominal  incision  through  Douglas's 
pouch.  Nothing  would  drain  after  a  few  days,  until  after 
about  fourteen  days  an  abscess  in  the  neighborhood 
emptied  itself  into  the  channel,  which  was  purposely 
kept  patulous  by  the  drain.  The  first  few  days  the  cath- 
eter, properly  fitting  the  trocar  cannula,  will  remain 
fluid-tight  in  the  cyst  as  long  as  there  is  no  internal  press- 
ure ;  afterward  the  adhesions  suffice,  if  the  cyst  is  ever 
so  far  retracted. 

Reynier's l  case  of  peritonitis  after  puncture  of  an  echi- 
nococcus, where  he  warns,  seems  to  me  not  good  com- 
parison, as,  at  least  from  the  report,  it  seems  that  the  cyst 
was  not  entirely  emptied  and  the  drainage  not  main- 
tained. There  is  no  doubt  to  my  mind  that  the  simplici- 
ty of  this  proceeding  is  far  preferable  to  incision  d  deux 
temps  (Volkmann)  or  to  stitching  the  cyst  to  the  ab- 
dominal wall  and  incising.  The  only  difficult  point  is 
to  determine  where  the  probable  root  of  the  cyst  is. 
This  is  important,  in  order  to  insert  the  trocar  in  its 
close  neighborhood,  so  that  the  drain  channel  should 
not  be  too  long.  May  be  that  even  unilocular  ovarian 
cysts  could  be  thus  cured.  Impossible  it  does  not  seem 
to  me  even  for  multilocular  cysts,  although  the  present 
modus  operandi  is  simpler  for  the  latter.  The  future  un- 
doubtedly will  show  a  great  extension  of  this  procedure. 

Another  argument  supporting  my  view  of  the  nature  of 
>  Year-book  of  Treatment,  Lea  Brothers  &  Co.,  1894. 


io8 


MEDICAL    RECORD. 


[July  28,  1894 


this  case  is  Weichselmann's  observation  that  the  connec- 
tive tissue  wall  of  echinococcus  cysts  contains  bile-ducts 
which  readily  open  into  the  cyst  if  the  wall  of  the  latter 
begins  exfoliating.  Thus  it  was  frequently  seen  that 
echinococcus  cysts  began  oozing  bile  alter  having  been 
draining  for  some  while.  Here  this  occurrence  happened 
only  before  the  operation.  The  amounts  of  bile  oozing 
were  seen  as  high  as  one  litre  pro  die,  and  it  is  no  wonder 
that  the  whole  contents  of  our  cyst  seemed  to  have  been 
bile. 

I  have  recently  shown  my  patient  a  specimen  of  tape- 
worm, and  asked  whether  his  dog  in  Italy  three  yean  ago 
used  to  pass  similar  pieces ;  and  he  said  the  dog  did,  while 
he  wondered  about  it.  Usually  there  were  only  two  or 
three  pieces. 


A    CASE    OF    TRANSPOSITION    OF    THE    VIS- 
CERA. 

By  HENRY  J.   HERRICK,  A.M.,  M.D., 

CLEVELAND*   O. 

It  occurs  to  me  that  the  readers  ot  the  Medical  Record 
might  be  interested  in  hearing  of  a  rather  unique  case, 
at  present  in  Lakeside  Hospital,  Cleveland,  in  which  the 
positions  of  the  internal  viscera  seem  rather  mixed. 

John  S ,  a  German  laborer,  twenty-five  years  of 

age,  entered  the  hospital  about  three  weeks  ago  complain- 
ing ot  loss  of  appetite,  weight,  and  strength.  He  had 
eight  brothers  and  sisters,  all  of  whom  died  while  young, 
and  he  has  always  been  delicate  himself,  and  unable  when 
a  boy  to  knock  around  as  his  fellows  did. 

Upon  examination,  this  unusual  state  of  affairs  was 
found :  His  heart  is  normal  in  size  and  correct  in  posi- 
tion, except  that  it  is  on  the  right  side.  The  apex  beat 
is  in  the  fifth  intercostal  space,  and  one  inch  from  the 
nipple,  toward  the  median  line ;  his  liver  is  normal  and 
in  perfect  position,  except  that  it  is  on  the  left  side ; 
while  his  stomach  seems  to  have  changed  places  with  the 
liver,  and  is  on  the  right  side.  His  spleen  could  not  be 
made  out. 
355  Eub  s- 


REPORT  OF  A  CASE  OF  ACUTE  SUPRA-GLOT- 
TIC  (EDEMA  WITHOUT  APPARENT  CAUSE 

By  JOHN  H.  PRYOR,  M.D., 

BUFFALO,  N.  T. 

Thb  term  oedema  of  the  glottis  is  often  used  improperly, 
and  the  grouping  of  ail  cases  of  oedema  of  the  larynx 
under  that  head  leads  to  confusion.  (Edema  of  the  glot- 
tis, or  interior  of  the  larynx,  is  of  relatively  rare«occur- 
rence,  and  in  most  of  the  reported  cases  the  morbid  con- 
dition is  confined  to  the  region  above  the  vocal  cords. 
This  is  particularly  true  of  simple  oedema,  and  for  many 
reasons  an  anatomical  distinction  should  be  made.  The 
term  supra-glottic  oedema  seems  to  answer  the  require- 
ments of  accuracy  and  clearness. 

J.  S- — ,  a  dentist  by  profession,  aged  thirty,  vigorous 
and  healthy,  consulted  me  on  July  15  th  for  difficulty  in 
speaking  and  breathing.  He  had  retired  as  usual  the 
previous  evening,  and  was  awakened  in  the  early  morning 
by  a  slight  sense  of  fulness  and  discomfort  in  the  region 
of  the  throat.  In  the  morning,  thinking  the  trouble 
trifling,  he  went  to  his  office  and  began  his  usual  work. 
The  local  trouble  became  more  urgent,  and  I  saw  him 
about  three  o'clock.  At  that  time  there  were  no  objec- 
tive signs  of  difficulty  in  breathing.  The  face  wore  an 
anxious  look,  but  the  feature  which  immediately  attracted 
my  attention  was  the  peculiarity  of.  the  voice.  The 
sound  was  new  to  me.  It  was  metallic  in  quality  and 
seemed  to  come  from  a  cavern.  I  can  think  of  no  bet- 
ter definition  than  the  word  sepulchral.  Enunciation 
was  distinct,  and  there  was  no  difficulty  in  understanding 
each  word.  The  character  of  the  voice  differed  distinctly 
from  the  muffled  quality  which  is  usually  heard  in  second- 


ary oedema,  and  was  devoid  of  hoarseness ;  an  examina- 
tion revealed  no  evidence  of  acute  pharyngitis  or  rhinitis, 
but  marked  oedema  of  the  epiglottis  and  aryepiglottic 
folds.  The  epiglottis  showed  a  line  of  division  in  the 
centre  which  gave  the  appearance  of  two  large  puff  balls. 
It  was  erect  and  too  firm  to  be  aspirated  into  the  glottis ; 
at  the  base  or  lingual  surface  of  the  right  side  a  large 
bleb  of  about  one  fourth  inch  in  diameter  was  plainly 
seen.  The  aryepiglottic  folds  were  greatly  distended,  and 
infringed  directly  upon  the  surface  of  the  epiglottis. 
Any  view  into  the  larynx  was  impossible,  owing  to  the 
extent  of  the  tumefaction.  The  opening  for  the  admis- 
sion of  air  was  almost  entirely  obliterated.  Only  the 
narrowest  chink  was  visible  when  the  patient  uttered  a 
vowel  sound.  There  was  pronounced  infiltration  of  the 
connective  tissue  of  the  neck  in  the  region  of  the  larynx. 
Pressure  on  the  larynx  did  not  produce  pain,  and  there  was 
no  complaint  of  pain  or  soreness  in  the  throat  or  larynx ; 
simply  a  suffocation  feeling  and  no  general  symptoms 
whatever.  Breathing  eighteen  to  the  minute,  and  tem- 
perature and  pulse  normal.  I  hurried  the  patient  home, 
and  at  four  o'clock  the  voice  became  husky  and  later 
whispering.  The  breathing  grew  more  rapid  and  la- 
bored, and  the  face  very  pale.  Applied  six  leeches  in 
the  region  of  the  larynx.  Ordered  hot  mustard  foot- 
bath, wrapping  in  blankets  and  copious  drafts  of  hot 
lemonade  and  whiskey.  The  sweating  which  followed 
was  most  profuse.  When  the  leeches  dropped  off  the 
swelling  of  the  neck  had  disappeared.  The  neck  was 
then  packed  in  ice  and  the  patient  sent  to  bed.  The 
day  was  unusually  warm  and  the  degree  of  humidity  re- 
markably high,  consequently  steam  was  not  employed. 
At  six  o'clock  the  breathing  was  much  easier  and  the 
voice  could  again  be  heard.  At  eight  o'clock  the  left 
vocal  cord  could  be  seen  and  the  breathing  was  natural. 
I  remained  near  the  patient  to  scarify,  if  necessary.  The 
local  improvement  was  so  marked  at  midnight  that  I  con- 
sidered it  safe  to  leave  him  in  the  care  of  a  nurse. 

Upon  inspection  the  following  morning  the  oedema 
was  confined  almost  entirely  to  one  side,  and  the  same 
afternoon  both  cords  could  be  seen.  They  were  pinkish 
in  hue,  but  showed  no  traces  of  inflammation  or  oedema. 
Whether  the  otdema  was  confined  to  the  epiglottis  and 
aryepiglottic  folds  cannot  be  stated,  but  I  believe  that 
the  loss  of  voice  was  due  to  transitory  congestion  of  the 
cords. 

On  Monday,  forty-eight  hours  after  the  attack,  the  pa- 
tient was  well  and  at  work.  I  have  examined  him  repeat- 
edly since  and  never  found  any  evidence  of  local  disease. 
He  has  never  shown  any  evidences  of  cardiac  or  renal 
disease,  and  I  have  been  unable  to  discover  any  constitu- 
tional condition  which  might  account  for  the  strange  at- 
tack. The  usual  causative  factors  were  absent,  and  after 
searching  the  literature  no  clew  as  to  the  direct  cause  can 
be  furnished.  No  similar  case  has  been  reported,  to  my 
knowledge.  Some  of  the  authors  consider  phlegmonous 
laryngitis  and  oedema  of  the  glottis  as  practically  the 
same  affection.  That  there  is  a  decided  difference  in  the 
two  conditions  cannot  admit  of  doubt,  and  this  reported 
case  of  simple  oedema  emphasizes  the  fact  Cases  of  a 
somewhat  similar  nature  have  been  recorded,  which  owed 
their  origin  to  exposure,  cold,  untoward  drug  action,  etc 
— elements  absent  in  my  case.  The  possibility  of  it  be- 
longing to  the  angio-neurotic  variety  of  oedema  described 
by  Quincke  and  others,  calls  for  comment.  The  cases 
reported  by  Quincke,  Dinkebarger,  Strtiburg,  Osier,  and 
others  were  essentially  different  in  history  and  sympto- 
matology. They  were  mostly  characterized  by  recurrent 
attacks,  skin  eruptions,  digestive  disturbances,  and  a  his- 
tory of  heredity.  Careful  inquiry  and  extended  observa- 
tion only  prove  the  absence  of  all  the  accompanying 
features  which  make  the  so-called  neurotic  oedema  diag- 
nostic. This  condition  is  at  present  obscure,  tfnd  we  are 
not  in  a  position  to  decide  what  should  or  should  not  be 
included  under  this  term. 

The  evanescent  character  of  the  attadk  might  lead  one 
to  explain  the  anatomical  changes  by  ascribing  the  condi- 


July  28,  1894] 


MEDICAL   RECORD. 


109 


tion  to  vasomotor  disturbance,  or  temporary  stoppage  of 
the  lymph-channels.  The  former  seems  most  reasonable, 
although  unaccountable,  and  the  latter  theory  gains  sup- 
port by  the  knowledge  of  the  distribution  of  the  lymphat- 
ics which  Hajek  has  supplied. 

A  more  extended  consideration  of  the  possible  causa* 
tion  might  be  interesting,  but  I  prefer  to  present  the  case 
at  this  time  as  rare  and  most  puzzling,  and  to  state  briefly 
the  following  points  of  clinical  value :  1.  The  absence 
of  any  known  causative  agency  and  constitutional  symp- 
toms. 2.  The  extent  of  oedema,  which  may  occur  with- 
out marked  dyspnoea.  3.  The  peculiar  character  of  the 
voice.  4.  The  marked  benefit  of  prompt  treatment  with- 
out scarification.  5.  The  possibility  of  the  case  belong- 
ing to  a  group  of  obscure  clinical  manifestations  known  as 
angioneurotic  oedema  or  allied  vasomotor  curiosities. 


A  CASE  OF  PNEUMONIA  IN  AN  INFANT  FIVE 
MONTHS  OLD  TREATED  WITH  INHALA- 
TIONS OF  OXYGEN. 

•By  RICHARD   P.  FRANCIS,  M.D., 

SUKGBON  TO  MOUNTAIXSIOB  HOSPITAL,  MONTCLAIB,  M.  J. 

The  following  case  seems  worthy  of  record  because  of 
the  immediate  and  very  gratifying  result  that  followed 
the  use  of  oxygen  when  the  patient  was  in  an  apparently 
hopeless  condition.  Oxygen  has  often  been  used  in 
treating  pneumonia  in  adults  and  children,  but  it  is  be- 
lieved that  its  use  with  infants  is  not  so  common,  and  it 
is  hoped  that  this  account  may  be  of  service  to  anyone 
who  may  encounter  a  similar  case. 

The  patient  was  a  bottle-fed  baby,  five  months  old, 
well  developed  and  nourished,  and  of  healthy  parentage ; 
she  had  always  been  well  up  to  the  time  of  the  present 
illness.  On  March  1, 1894,  after  having  had  a  cough 
for  two  or  three  days,  she  was  taken  with  a  chill.  Physi- 
cal examination  soon  after  showed  a  few  fine  rales  in  the 
right  upper  back,  but  no  dulness  and  no  bronchial 
breathing.  Temperature,  102. 8°  F.;  pulse,  180;  respi- 
ration, 45.  On  March  3d,  bronchial  breathing  devel- 
oped and  the  respirations  reached  100  per  minute, 
while  the  pulse  was  180  and  the  temperature  1050  F. 
Ten  drops  of  brandy  were  given  every  half- hour,  and  a 
cough  mixture  of  muriate  of  ammonia,  fluid  extract  of 
licorice,  and  whiskey  every  two  hours.  The  next  day 
the  circulation  was  very  bad,  the  extremities  became 
cold  several  times,  and  the  face  dusky.  At  5  p.m.  the 
child  was  put  in  a  hot  mustard  bath  and  there  were  given 
twenty  drops  of  brandy  in  which  was  dissolved  a  tablet 
triturate  containing  one  minim  each  of  tincture  of  digi- 
talis and  tincture  of  strophanthus,  one-eighth  of  a  minim 
of  tincture  of  belladonna,  and  one  two-hundredth  of  a 
grain  of  nitro  glycerine.  A  good  reaction  soon  followed. 
From  this  time  on  the  "heart  stimulant"  tablets  were 
given  every  three  hours.  Their  effect  on  the  heart's 
action  was  most  marked ;  not  so  much  in  diminishing  its 
rapidity  as  in  increasing  its  force. 

For  the  next  five  days  the  case  ran  a  fairly  typical 
course — the  pulse  averaging  160  and  the  respirations  120. 
It  is  interesting  to  note  that  on  four  occasions  the  respi- 
rations were  more  rapid  than  the  pulse.  On  March  4th, 
at  12  m.,  respiration,  140;  pulse,  130.  March  5th,  at 
8  a.m.,  respiration,  120;  pulse,  100.  March  6th,  at  4 
p.m.,  respiration,  144;  pulse  140.  March  7th,  at  4  p.m., 
respiration,  130;  pulse,  120.  The  treatment  was  taken 
well,  and  two  or  three  ounces  of  Pasteurized  milk  were 
given  daily.  Special  care  taken  that  the  child  had 
plenty  of  water,  which  she  took  eagerly  and  with  evident 
gratification.  Frequently  brandy  was  administered  in 
twenty-drop  doses  for  four  or  five  consecutive  hours,  to 
stimulate  the  flagging  heart  On  the  morning  of  March 
nth  the  record  of  the  temperature,  pulse,  and  respiration 
showed  them  to  be  the  lowest  since  the  beginning  of  the 
attack,  and  an  examination  of  the  chest  gave  evidence 
of  beginning  resolution.  The  next  day  the  temperature 
was  elevated,  as  were  the  pulse  and  respirations,  and  on 


the  13th  bronchial  breathing  was  found  in  the  left  upper 
back. 

The  pulse  was  weak  and  very  rapid  (180  to  200) ;  the 
respirations  averaged  140  per  minute.  During  the 
morning  brandy  was  given  in  doses  of  ten  or  twenty 
drops  every  half- hour  and  the  "  heart  stimulant "  tablets 
every  two  hours.  As  it  did  not  seem  justifiable  to  push 
these  remedies  further,  and  as  the  infant's  strength  was 
already  much  reduced  by  the  sickness  of  two  weeks,  it 
was  thought  that  the  safest  aid  could  be  obtained  from 
oxygen.  A  cylinder  was  obtained  about  5  p.m.  and  the 
administration  at  once  begun  by  holding  the  mouth- 
piece pressed  to  the  infant's  nostril.  At  this  time  the 
condition  was  alarming  in  the  extreme,  as  may  be  in- 
ferred from  the  fact  that  the  respirations  had  been  140 
all  day,  and  the  day  before  had  at  one  time  run  up  to 
160 ;  the  pulse  was  varying  between  160  and  180  (a  little 
later  it  was  200),  and  the  temperature  was  103. 5 °  to 
10 40  F.  The  heart's  action  was  weak,  the  skin  dusky, 
and  the  whole  condition  was  so  evidently  due  to  lack  of 
proper  oxygenation,  that  it  seemed  almost  self-evident 
what  remedy  was  needed.  The  only  question  was 
whether  the  remedy  could  be  satisfactorily  applied.  But 
almost  as  soon  as  the  stream  of  gas  was  allowed  to  enter 
the  nostril  the  favorable  effect  was  observed.  The  cir- 
culation and  general  condition  improved  as  markedly  as 
when  the  gas  is  given  to  patients  who  are  able  to  co-oper- 
ate in  its  administration ;  the  duskiness  of  the  skin  disap- 
peared, the  respirations  grew  less  shallow  and  slower,  and 
the  whole  appearance  changed  for  the  better. 

Throughout  the  day  of  the  14th,  the  oxygen  was  given 
every  fifteen  minutes  for  five  seconds  at  a  time,  and  dur- 
ing the  subsequent  night  it  was  inhaled  almost  continu- 
ously; the  brandy  was  given  in  ten- drop  doses  every 
half-hour,  and  the  "heart  stimulant "  every  two  hours. 
Early  the  next  morning  the  patient  turned  on  the  left 
side  for  the  first  time  since  the  involvement  of  the  left 
lung.  The  crisis  of  the  disease  was  apparently  reached, 
as  from  now  on  the  symptoms  gradually  ameliorated ;  the 
stimulants  were  diminished  by  degrees  and  the  food  in- 
creased. The  brandy  and  oxygen  were  given  in  alter- 
nate doses  every  half-hour  for  a  day  or  two,  and  not  for 
three  days  was  the  oxygen  altogether  omitted.  The 
patient  had  a  most  satisfactory  and  complete  convales- 
cence, and  is  now  a  vigorous  baby. 


THE  TYPHOID  SPINE. 
By  JOSEPH  N.   STUDY,   M.D., 

CAMBRIDGE  CITY,   IND. 

There  are  certain  sequelae  of  typhoid  fever  which  are 
known  to  physicians,  but  are  rarely  referred  to  in  stand- 
ard text-books  upon  the  practice  of  medicine,  and  only 
occasionally  spoken  of  in  medical  journals. 

The  title  of  this  subject,  so  far  as  I  am  aware  of,  was 
first  referred  to  by  Dr.  Gibney,  of  New  York,  who,  at 
the  American  Orthopedic  Association,  in  1889,  described 
a  sequela  of  enteric  fever,  which  he  termed  the  typhoid 
spine,  an  inflammation  of  the  periosteum  and  the  fibrous 
structures  by  which  the  spinal  column  is  held  together. 

The  only  other  reference  to  such  a  condition  that  I 
know  of  is  in  an  article  published  in  the  American  Jour- 
nal  of  the  Medical  Sciences  for  January  of  the  current 
year,  by  Dr.  William  Osier,  of  Baltimore,  who,  under 
the  title  of  "The  Neurosis  Following  Enteric  Fever, 
Known  as  the  Typhoid  Spine,"  reports  the  histories  of 
four  cases,  and  also  three  cases  of  Dr.  Gibney.  In  brief, 
this  condition  is  spoken  of  as  following  enteric  fever, 
and  has  usually  occurred  after  the  patient  had  so  far  re- 
covered as  to  be  up  and  about.  It  is  characterized  by 
pain  in  the  back,  which,  when  any  movement  is  made 
twisting  or  flexing  the  spinal  column,  is  usually  of  an 
agonizing  nature,  often  causing  the  patient  to  cry  aloud. 
In  some  of  the  reported  cases  fever  was  observed,  while 
in  others  it  was  absent.  Usually  there  was  no  disturb- 
ance of  motor  or  sensory  nerves,  and  further  than  the 


no 


MEDICAL   RECORD. 


[July  28,  1894 


painful  back  there  was  no  indication  of  disease  in  any 
other  part  of  the  body. 

I  desire  to  report  a  condition  observed  after  typhoid 
fever,  which,  for  want  of  a  better  name,  I  have  called 
the  typhoid  spine.  This  case  presented  some  features 
which  are  so  infrequently  seen  that  to  me  it  was  one  of 
more  than  ordinary  interest. 

On  August  10,  1893,  Mr-  w >  aged  thirty-four, 

American,  occupation  undertaker,  father  of  three  chil- 
dren, and  whose  previous  health  had  been  excellent,  was 
taken  with  typhoid  fever.  October  nth,  he  was  dis- 
charged as  being  convalescent.  His  sickness  was  severe, 
and  he  had  had  hemorrhage  from  the  bowels  and  diar- 
rhoea. His  recovery  was  uneventful  until  December 
13th.  At  this  time  he  had  gained  thirty  pounds  in 
weight,  and  had  been  doing  some  work,  which  consisted 
of  a  twisting  or  rotary  movement  of  the  spine,  occasioned 
by  standing  on  the  rounds  of  a  ladder  and  using  a  hand- 
saw. Following  this  appeared  a  painful  affection  of  the 
back,  extending  from  about  the  fifth  dorsal  to  the  third 
lumbar  vertebra.  For  over  three  weeks  the  pain  pro- 
duced by  any  flexion  or  other  movement  of  the  spine  was 
intense,  and  at  times  caused  the  man  to  cry  aloud.  Al- 
most the  entire  time  was  spent  in  a  reclining  chair.  In 
attempting  to  place  the  patient  in  bed  the  pain  produced 
was  so  great  that  no  persuasion  could  induce  him  to 
make  further  efforts.  It  was  only  because  of  the  loss  of 
sleep  and  the  consequent  free  use  of  morphia,  that  the 
effort  was  made  at  this  time. 

There  was  an  increase  of  temperature  reaching  as  high 
as  103^°  F.,  which  continued  for  ten  days,  and  was 
followed  by  rather  free  perspiration.  There  was]  at  no 
time  any  hyperesthesia  or  other  indication  of  either  the 
motor  or  sensory  nerves  being  affected.  No  complaint 
was  made  of  pain  in  any  other  portion  of  the  body.  At 
one  time  a  band-like  feeling  around  the  waist  was  com- 
plained of  for  a  short  time.  No  tenderness  was  observed 
when  pressure  was  made  over  the  seat  of  pain.  Repeated 
examinations  of  the  various  organs  of  the  body  and  of 
the  urine  were  made,  but  were  always  negative  in  their 
results. 

After  ten  weeks  the  patient  has  so  for  recovered  as  to 
be  out,  and  says  he  is  almost  entirely  free  from  pain. 


SOME    MINOR    POINTS  TO  BE   OBSERVED  IN 
ADMINISTERING  CHLOROFORM. 

By  AARON  JEFFERY,   M.D., 

RADFORD,  VA. 

Ever  since  chloroform  and  ether  have  been  in  general 
use,  the  question  of  which  is  the  safest  and  best  anaes- 
thetic has  been  debated  throughout  the  country.  Re- 
cently there  appeared  in  the  Medical  Record  several 
articles  in  support  of  chloroform,  among  the  number  an 
article  by  Dr.  Fisher,  of  California,  headed — "  Chloro- 
form in  Organic  Disease  of  the  Heart."  He  lays  great 
stress  on  the  slow  administration  of  the  drug ;  and  in  my 
opinion  that  is  one  of  the  most,  if  not  the  most,  impor- 
tant point  to  be  observed  in  its  administration. 

By  observing  this  rule,  the  lungs  and  heart  gradually 
become  acclimated,  so  to  speak,  and  the  shock  to  the 
nerve-centre  is  avoided.  If  a  person  could  be  suddenly 
removed  from  a  low  to  a  very  high  altitude,  I  dare  say 
the  same  thing  would  happen  that  often  happens  during 
the  quick  administration  of  chloroform,  namely,  cessation 
of  the  respiration,  and  as  a  consequence,  engorgement 
of  the  heart  and  death.  On  the  other  hand,  if  the 
change  be  gradually  made,  the  person  often  can  stand 
the  change  well,  and,  for  the  same  reasons,  the  slow  ad- 
ministration of  chloroform  may  be  tolerated  when  the 
quick  method  would  cause  death.  In  the  German 
schools  of  medicine,  I  believe  they  all  practise  the  slow 
method,  and  chloroform  is  the  anaesthetic  used  mostly 
by  them. 

There  are  other  minor  points  that  should  be  observed. 
The  patient's  head  should  be  turned  so  as  to  allow  the 


tongue  to  fall  to  one  side.  About  ten  years  ago,  on  one 
occasion,  1  came  very  near  losing  a  patient  on  account 
of  neglecting  to  observe  this  rule.  The  patient's  breath- 
ing stopped  and  the  pulse  became  rapid  and  weak.  1 
discovered  that  this  alarming  condition  was  caused  by 
the  relaxed  tongue  having  fallen  to  the  back  of  the  throat, 
and  thereby  shutting  off  all  air  from  the  lungs.  The 
tongue  was  pulled  out  by  means  of  a  tenaculum,  artificial 
respiration  performed,  and  in  a  short  time  the  man  wa 
breathing  quietly.  As  a  general  rule,  I  think  it  advisabls 
to  administer  an  hypodermatic  injection  of  morphine 
about  fifteen  minutes  before  commencing  the  anaesthetice 
The  nervousness  of  the  patient  is  thereby  lessened,  and. 
the  quantity  of  chloroform  necessary  to  keep  the  patient 
anaesthetized  is  also  lessened,  to  say  nothing  of  the  stimu- 
lating effect  of  the  morphine  on  the  heart's  action. 

One  should  always  have  at  hand  an  hypodermatic 
syringe  loaded  with  whiskey  or  brandy,  a  phial  of  aqua 
ammoniae,  and  some  nitrite  of  amyl,  to  use  in  case  the 
heart  or  respiration  should  fail. 

Nothing  original  is  claimed  in  this  article,  but  I  be- 
lieve if  these  details  are  observed  strictly,  namely,  the 
slow  administration  of  the  drug,  the  previous  administra- 
tion of  morphine  hypodermatically,  the  patient's  head 
kept  on  one  side,  ammonia,  whiskey,  and  nitrite  of  amyl 
at  hand,  that  the  deaths  from  chloroform  inhalations  will 
be  greatly  diminished. 


THE  EXCESSIVE  CONSUMPTION  OF  TEA  AS 
A  CAUSE  OF  MULTIPLE  NEURITIS.  RE- 
PORT OF  CASE.1 

By   WILLIAM   PHILIP   SPRATLING,    M.D., 

NBW  YOKK. 

The  etiology  of  multiple  neuritis  is  quite  extensive  and 
varied.  In  different  countries  the  affection  is  described 
under  different  names.  In  India,  portions  of  South 
America,  and  the  East  and  West  Indies,  it  is  known  as 
beriberi.  In  Japan,  where  it  frequently  occurs  in  epi- 
demics of  great  severity,  it  is  called  kakkt. 

The  causes  of  multiple  neuritis  differ  in  these  widely 
diverse  communities.  In  Japan,  the  matter  of  diet  has 
long  been  held  to  be  an  etiological  factor  of  importance. 
The  inhabitants  of  that  country,  as  we  know,  subsist  al- 
most wholly  on  a  diet  of  fish  and  rice,  and  drink  tea  to 
the  exclusion  of  all  other  beverages.  Among  sailors  on 
shipboard  also,  where  the  disease  is  frequently  found, 
restricted  diet  has  been  regarded  as  a  potent  cause. 

The  causes  of  the  disease,  as  we  find  it  in  this  country, 
are  most  varied.  Among  those  most  usually  recognized 
and  active,  may  be  mentioned  alcohol,  illuminating  gas, 
lead,  arsenic,  strychnia,  and  the  infectious  agents  of  cer- 
tain diseases,  as  typhus,  diphtheria,  small  pox,  malaria, 
and  tuberculosis.  Exposure  to  cold  and  damp,  and  over- 
exertion, are  likewise  causes. 

Go wers  is  of  the  opinion  that  "  endemic  neuritis,  as  it 
occurs  in  Japan,  is  due  to  some  endemic  influence."  It 
is  a  matter  of  common  knowledge  that  the  Japanese  peo- 
ple are  the  greatest  tea-drinking  race  in  the  world.  It  is 
likewise  true  that  the  people  of  no  other  country  suffer  so 
frequently  and  so  violently  from  multiple  neuritis  as  the 
Japanese  do.  Not  only  is  the  disease  present  with  them 
at  all  times  in  an  endemic  form ;  but  it  frequently  sweeps 
over  the  country  in  the  form  of  severe  epidemics. 

Is  there  any  connection  between  excessive  tea  drink- 
ing and  multiple  neuritis  ?  I  think  there  is ;  and  for  this 
reason.  Tea  is  a  recognized  stimulant  of  the  nervous 
system.  Its  prolonged  and  excessive  use  induces  a  train 
of  well-marked  nervous  symptoms,  which  vary  in  indi- 
viduals of  unlike  susceptibilities.  A  brief  reference  to 
the  physiological  action  of  tea,  or  its  alkaloid  theine, 
will  show  this  to  be  true. 

Richardson 8  says,  "  This  alkaloid  exercises  a  special 
influence  on  the  nervous  system,  which,  when  carried  to 

1  Read  before  the  Harlem  Medical  Association,  May  a,  1894. 
9  Preventive  Medicine,  1884,  page  364. 


July  28,  1894] 


MEDICAL   RECORD. 


111 


a  considerable  extent,  is  temporarily,  if  not  permanently, 
injured."  This  author  observed  the  most  characteristic 
effects  of  tea  in  "  tea  tasters/'  persons  who  by  profession 
are  engaged  to  determine  the  qualities  of  tea  by  the  proc- 
ess of  tasting  different  specimens  of  strong  teas.  He 
found  in  such  persons  distaste  for  food,  deficient  appe- 
tite, nausea,  nervous  depression  with  muscular  tremors 
and  feebleness,  constipation,  flatulency,  and  almost  en- 
tire inability  to  sleep. 

Wood  ^ys :  "  Chemically,  the  alkaloid  obtained  from 
tea  and  known  as  theine  is  identical  with  caffeine ;  in- 
deed," he  adds,  "  most  of  the  caffeine  used  in  commerce, 
according  to  Dr.  Charles  Rice,  is  obtained  from  the  tea 
lea£  If,  however,"  he  further  adds,  "  the  experiments  of 
Dr.  Thomas  J.  Mays  are  confirmed,  theine  is  not  physio- 
logically identical  with  caffeine. ' '  Dr.  Mays  asserts,  as  the 
result  of  his  experiments  made  on  frogs,  that  theine  differs 
from  caffeine  as  follows:  1.  Theine  produces  spontane- 
ous spasms  and  convulsions,  while  caffeine  does  not.  2. 
Theine  impairs  the  nasal  reflex  early  in  the  poisoning 
process,  while  caffeine  does  not,  if  at  all,  until  the  very 
last  stage.  Dr.  Mays  also  claims  that  theine  is  a  powerful 
local  anaesthetic. 

Thus  we  see  that  all  the  phenomena  observed  by  Dr. 
Mays  that  were  induced  by  theine,  including  spasms,  con- 
vulsions, abolition  of  nasal  reflex,  and  anaesthesia,  were 
purely  of  nervous  origin. 

The  case  I  have  to  report  is  that  of  W.  S.  W ,  male, 

thirty  years  of  age.  Usually  strong  and  robust,  but  suf- 
fers at  long  intervals  from  very  mild  attacks  of  subacute 
articular  rheumatism.  Does  not  use  liquor  or  tobacco  in 
any  form.  Is  extremely  susceptible  to  the  influence  of 
alcohol,  one-half  ounce  of  any  light  wine  quickly  caus- 
ing flushed  face  and  noticeable  exhilaration. 

Prior  to  Novembei,  1892,  he  had  not  been  a  tea-drinker. 
At  that  time  the  habit  was  formed  of  taking  one-half 
pint  of  strong  tea  at  noon,  and  again  about  four  o'clock 
in  the  afternoon.  Later  the  quantity  consumed  was  in- 
creased to  one  and  one  half  pint  daily,  and  the  increase 
became  gradual  until  from  two  and  one  half  to  three 
pints  were  taken  in  twenty- four  hours.  Six  weeks  after 
this  indulgence  began,  a  mild  tingling  sensation  appeared 
in  the  right  hand,  extending  half-way  up  the  forearm. 
Small  blebs,  due  to  trophic  disturbances,  appeared  on  the 
dorsal  surface  of  the  first  and  second  fingers.  The  skin 
of  the  entire  hand  was  slightly  hypenesthetic,  and  the 
temperature  sense  of  the  member  was  impaired.  At  the 
same  time  it  was  noted  that  the  heart's  action  was  feeble 
and  irregular. 

An  exact  diagnosis  of  the  condition  at  that  time  was 
not  made.  The  use  of  tea  was  stopped,  small  doses  of 
digitalis  given,  the  patient  directed  to  take  long  walks 
daily,  to  eat  simple,  nutritious  food,  and  in  six  weeks  all 
traces  of  the  trouble  had  disappeared. 

The  second  attack  occurred  in  January,  1894,  fourteen 
months  after  the  first.  For  three  weeks  preceding  this 
attack,  strong  tea  was  again  used  in  excessive  quantities. 
The  patient  was  engaged  in  literary  work  and  took  the 
tea  as  a  stimulating  and  refreshing  drink.  The  first 
symptom  noted  this  time  was  pain  in  the  right  wrist, 
dull,  boring,  and  burning  in  character.  It  was  ascribed 
to  rheumatism,  until  pain  of  the  same  character  was  felt 
in  the  right  shoulder,  spreading  over  the  scapula  as  far 
as  the  spine,  and  running  down  through  the  axilla,  along 
the  course  of  the  median  nerve,  as  far  as  the  elbow.  The 
brachial  plexus  was  involved,  and  pressure  applied  to 
any  part  of  the  axillary  space  caused  intense  pain.  The 
chafing  of  the  seam  of  the  undershirt  in  the  armpit 
caused  great  discomfort.  The  median  nerve  was  espe- 
cially involved.  Pressure  over  it  at  any  point  could 
not  be  borne.  Both  of  the  main  nerve-trunks  below  the 
elbow  suffered.  The  first  disturbance  of  the  temperature 
sense  of  the  hand  was  noted  when  the  hand  was  put  in 
water  at  a  temperature  of  500  F.  Pain  was  so  great  that 
it  had  to  be  withdrawn.  The  surface  of  the  hand,  espe- 
cially the  dorsal  portion,  became  painful  to  the  touch. 

1  Therapeutics,  its  Principles  and  Practice,  1892,  page  373. 


The  sensation  was  described  as  being  similar  to  that 
felt  when  the  skin  is  blistered  and  again  brought  into 
contact  with  heat.  A  group  of  three  small  trophic  blebs 
appeared  over  the  carpo-metacarpal  articulation  of  the 
first  finger.  A  similar  group,  but  more  numerous,  de- 
veloped just  below  the  styloid  process  of  the  ulnar.  Be- 
tween the  first  and  second  joints  of  the  phalanges  of  all 
the  fingers,  small,  hard,  deep-seated  nodules  appeared. 
Pressure  over  these  caused  intense  pain.  Picking  up  or 
handling  hard,  firm  substances,  as  a  chair  or  a  book,  was 
accomplished  with  difficulty.  There  was  delayed  trans- 
mission of  pain  and  temperature  sensation.  Remak's 
sign  was  noticeably  present.  This  was  well  exemplified 
by  making  pressure  over  the  nodules  on  the  fingers  above 
described,  or  by  pinching  or  pricking  any  part  of  the 
hand,  when  pain  would  not  be  felt  for  two  seconds  or 
more ;  and  when  it  did  appear,  grew  in  intensity,  and 
after  reaching  its  height,  would  slowly  subside. 

The  motor  symptoms  were  not  so  marked  as  the  sen- 
sory ones,  due  to  the  fact  that  the  disease  did  not  pro- 
gress beyond  the  inflammatory  stage.  There  was,  how* 
ever,  weakness,  and  quick  sense  of  lack  of  power  when 
the  hand  and  arm  were  used.  Writing  was  difficult  and 
could  only  be  done  for  a  limited  period  of  time  without 
rest. 

I  regret  that  I  was  unable  to  test  the  electrical  reac- 
tions of  the  case.  For  diagnostic  purposes,  however,  it 
was  not  needed. 

The  treatment  consisted  of  the  application  of  the 
usual  remedies.  Good  general  tonics,  and  drugs  that 
build  up  the  economy,  are  frequently  indicated.  The 
removal  of  the  cause,  whenever  found,  is,  of  course,  su- 
perior to  all  other  forms  of  treatment  combined.  In 
this  case,  the  use  of  tea  was  absolutely  forbidden ;  out- 
of-door  exercise  in  abundance  prescribed,  the  use  of 
light,  nutritious  food  advised,  and  in  six  weeks  the  dis- 
ease had  entirely  disappeared. 

70  West  Eighty-eighth  Street,  May  i,  1894. 


THE  TREATMENT  OF  QUINSY. 
By  SILAS   S.   CARTWRIGHT,  M.D., 

ROXBURY,  M.  Y. 

Some  years  since  I  saw  the  following  prescription  in  the 
Medical  Record  for  quinsy : 

9.    Norwood's  tincture  ver.  vir gtt.  xxx. 

Morphia  sulphas gr.  jss. 

Aqua 3vj. 

M. — Sig.  Dose  for  an  adult  one  drachm,  to  be  repeated  accord- 
ing to  judgment  in  one  hour,  then  every  two  or  three  hours  accord- 
ing to  the  effect  of  the  morphine. 

I  have  used  this  prescription  several  times ;  in  three  cases 
out  of  four  it  has  aborted  the  disease;  where  suppuration 
has  supervened  the  disease  has  been  more  under  control. 
I  would  give  the  physician's  name  and  residence  but 
have  forgotten  it. 

The  only  other  treatment  has  been  mild  gargles  and  a 
cathartic  of  epsom  salts.  I  have  tried  other  methods  of 
treatment,  but  this  has  been  the  only  satisfactory  one. 


Experiences  with  lew  Anesthetics. — At  the  meet- 
of  the  Acad6mie  de  Medicine  last  week,  M.  Duplay  read 
a  report  on  a  case  of  death  by  bromide  of  ethyl  in  the 
course  of  an  operation.  Hitherto  it  had  been  thought 
that  this  agent  was  innocuous,  but  some  recent  accidents 
(two  deaths)  should  render  surgeons  more  circumspect 
and  more  prudent  in  its  mode  of  administration  and 
cause  them  to  take  some  of  the  precautions  regarded  as 
indispensable  when  chloroform  is  the  anaesthetic.  M. 
Laborde  drew  the  attention  of  his  colleagues  to  a  new 
anaesthetic  mixture  consisting  of  nine  parts  of  chloro- 
form and  one  part  of  ether.  It  would  seem  that  this 
combination  acts  more  promptly  and  with  less  danger 
than  when  either  of  these  agents  is  employed  separately. 
Further,  the  active  properties  of  chloroform  are  atten- 
uated. 


112 


MEDICAL   RECORD. 


[July  28,  1894 


Medical  Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


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


New  York,  July  28,  1894. 


IS    THERE    A    NEED    FOR    MORE    MEDICAL 
COLLEGES  ? 

It  is  so  seldom  that  we  have  outspoken  views  in  matters 
pertaining  to  the  general  welfare  of  the  profession,  in 
different  localities,  that  it  is  worth  while  to  make  note  of 
them  when  they  are  offered,  and  give  them  that  weight 
which  an  honest  conviction  of  the  principles  upon  which 
they  are  founded  makes  manifest.  Although  such  inde- 
pendence of  thought  is  oftentimes  associated  with  un- 
popularity in  affected  quarters,  it  has  its  wide  range  of 
usefulness  in  the  far-reaching  indorsement  of  the  major- 
ity beyond.  It  does  not  matter,  for  the  sake  of  the  prin- 
ciple involved,  whether  or  not  a  new  medical  college  is 
to  be  started  in  Alabama,  or  any  other  State,  but  the 
question  narrows  itself  to  the  necessity  of  any  more 
medical  institutions  of  the  kind  anywhere.  The  dis- 
cussion on  the  true  point  of  issue,  in  the  particular 
case  before  us,  centres  upon  the  possibility  of  quieting 
an  objector  by  giving  him  a  place  in  a  faculty. 

The  failure  to  do  so,  however,  was  emphasized  by  a 
circular  letter  from  him,  which  treats  the  question  in  such 
a  general  and  fair  way,  that  we  quote  extracts  for  the 
benefit  of  all  concerned.  The  reasons  given  have  an  ap- 
plication far  outside  the  limits  of  the  particular  State. 

Dr.  Jerome  Cochran,  of  Montgomery,  Ala.,  is  the 
writer  of  the  letter  referred  to.  He  states  that  the 
said  letter  was  originally  addressed  to  the  Age  Herald, 
but  "  for  reasons  satisfactory  to  all  concerned,  it  was  not 
published  in  that  paper."  This  will  not  hinder,  how- 
ever, other  than  the  readers  of  that  journal  from  a  knowl- 
edge of  his  sensible  view  of  the  situation. 

"  It  was  only  yesterday  that  I  saw  in  the  Age-Herald 
of  June  10th  a  list  of  the  professors  and  lecturers  in 
the  proposed  new  medical  college  in  Birmingham. 
In  the  list  of  lecturers  I  am  surprised  to  find  my  own 
name.  What  authority  you  had  for  publishing  me  to 
the  world  in  that  capacity  I  do  not  know  \  but  it  was 
certainly  done  without  my  knowledge  and  without  my 
consent.  Not  only  so ;  but  it  places  me  in  a  position  of 
considerable  embarrassment;  because  it  must  have  left 
the  impression  in  the  minds  of  those  who  read  the  state- 
ment that  I  was  in  favor  of  the  organization  of  this  new 
medical  college.  But  I  am  not  in  favor  of  it.  On  the 
contrary,  I  regard  the  establishment  of  a  new  medical 
college  in  Alabama  as  in  contravention  of  the  best  in- 
terests of  the  profession  and  the  people,  and  if  my  name 
has  any  influence,  I  should  regret  very  much  to  have  it 


used  for  the  furtherance  of  any  such  enterprise.  I  do 
not  desire  to  be  misunderstood.  I  do  not  object  to  the 
establishment  of  a  medical  college  in  Birmingham  any 
more  than  I  would  object  to  the  establishment  of  such 
an  institution  in  Montgomery,  or  in  Selma.  But  we 
have  already  in  this  country  three  times,  yes,  six  times 
as  many  medical  colleges  as  we  have  any  need  for.  In 
this  opinion  I  am  sure  that  I  will  be  sustained  by  nine- 
tenths  of  the  doctors  in  Alabama — in  the  South — in  the 
whole  of  the  United  States.  This  being  so,  the  further 
multiplication  of  medical  colleges  is  not  a  consummation 
devoutly  to  be  wished ;  and  a  new  medical  college,  in 
Alabama  can  by  no  possibility  be  of  any  benefit  to  any- 
body except  the  gentlemen  personally  connected  with  it. 
It  does  not  fill  a  long-felt  want.  It  does  not  respond  to 
any  demand  of  public  utility  or  convenience. 

"  Not  only  have  we  more  medical  colleges  than  we  need, 
but  we  also  have  more  doctors  than  we  need.  Not  one- 
half  of  the  doctors  in  Alabama  are  now  able  to  make 
decent  livings  by  the  practice  of  medicine.  Neverthe- 
less, the  exploitation  of  a  medical  college  is  a  business  in 
which  honorable  men  may  honorably  engage.  Only  let 
it  be  well  understood  that  it  will  not  contribute  to  the 
welfare  of  the  people  or  to  the  aggrandizement  of  the 
medical  profession." 

He  further  says :  "  In  all  this  I  am  not  taking  any  new 
position.  For  many  years  it  has  been  well  known  in 
Alabama  that  I  have  regarded  the  medical  colleges  as  in 
a  large  measure  the  natural  enemies  of  our  people  and  of 
our  doctors.  In  this  connection  I  beg  to  refer  to  the 
two  addresses  delivered  by  me  before  the  Medical  Asso- 
ciation of  the  State,  one  in  1870  and  the  other  in  1871, 
and  which  were  printed  in  the  Transactions  for  the  years 
mentioned.  In  one  of  these  I  describe  the  creation  of  a 
medical  college  in  these  words :  '  The  process  was  sim- 
ple enough.  It  was  only  necessary  to  form  a  company 
of  seven  or  eight  doctors,  build  a  big  brick  house,  and 
apply  to  a  complaisant  legislature  for  a  charter,  and  lo  ! 
the  thing  was  done.  Full*  fledged  professors  grew  up  in 
a  night  like  Jonah's  gourd ;  diplomas  in  high-sounding 
Latin  and  on  excellent  sheepskin  could  be  ordered  by 
the  thousand,  and  the  only  thing  left  to  do  was  to  get 
students.    But  students  they  must  have  or  perish.' 

"  We  do  not  have  to  seek  far  to  discover  the  cause  of 
antagonism  between  the  medical  colleges  and  the  medical 
profession.  It  is  due  to  the  fact  that  the  great  majority 
of  our  medical  colleges  have  been  built  by  private  enter- 
prise, and  have  been  managed  for  the  private  emolu- 
ment, in  money  and  in  reputation,  of  the  men  who  built 
them.  All  this  is  as  in  the  nature  of  things  we  should 
expect  it  to  be.  But  let  us  call  things  by  their  right 
names." 

By  way  of  further  vindicating  his  position  he  very 
forcibly  remarks :  "  The  most  interesting  chapters  in 
the  history  of  the  American  medical  profession  are  those 
that  describe  the  emancipation  of  the  profession  from  the 
tyranny  of  the  medical  colleges — a  struggle  that  has  been 
going  on  for  the  last  fifty  years,  and  which  is  not  yet 
completely  won.  In  Alabama  we  have  for  the  protection 
of  the  people  and  of  the  profession  against  the  usurpation 
of  the  colleges  the  medical  law  of  1877 — a  sufficient  pro- 
tection as  long  as  it  is  left  us.  But  if  we  had  had  as 
many  medical  colleges  in  Alabama  as  they  have  in  Ten- 
nessee and  Georgia,  we  would  have  been  left,  as  are  the 


July  28,  1894] 


MEDICAL  RECORD. 


"3 


people  of  those  great  States,  to  the  tender  mercies  of 
our  enemies,  the  faculties  of  the  medical  colleges." 

Well  and  truthfully  said,  Dr.  Cochran ;  you  will  evi- 
dently have  the  majority  with  you,  not  only  in  Alabama, 
but  throughout  the  country. 


THE  DIGESTION  OF  MILK. 

The  importance  and  value  of  milk  as  a  diet  is  acknowl- 
edged by  all,  and  needs  no  exposition  here.  Milk  is  not 
only  a  very  nearly  perfect  food,  but  it  is  diuretic,  and 
its  lactic  acid  has  been  found  to  have  germicidal  prop- 
erties on  the  bacillus  communis  coli  (Gilbert  and  Domi- 
nici).  But  despite  all  that  can  be  said  for  milk,  there  are 
many  persons  who  dislike  it,  and  positively  assert  that  it 
does  not  agree  with  them.  The  common  belief  is  that  it 
coats  the  tongue,  produces  a  bad  taste  in  the  mouth,  and 
leads  to  fermentation,  constipation,  and  "biliousness." 
The  physician  often  has  a  hard  time  with  these  galacto- 
phobics.  Sometimes  he  persuades  them  to  try  the  milk, 
and  the  patient  is  surprised  to  find  that  he  is  not  as  much 
disturbed  as  was  expected.  But  more  often  the  patient 
returns  with  the  "no  better"  or  "I  told  you  so"  ex- 
pression on  his  face,  and  reiterates  the  tale  of  his  digestive 
limitations.  Then,  perhaps,  the  doctor  sets  to  work  to 
tinker  the  liquid  into  more  assimilable  shape.  It  is 
boiled,  sterilized,  or  pasteurized ;  or  it  is  diluted  with 
water  or  vichy,  or  sweetened  with  malt,  or  salted  a 
little  to  taste,  or  peptonize*!  to  non-appetizing  bitterness. 
Matzoon,  koumyss,  or  buttermilk  are  then  perhaps  sub- 
stituted. Not  infrequently  a  moderate  degree  of  suc- 
cess is  achieved,  but  there  is  always  a  percentage  of  fail- 
ures. We  welcome,  therefore,  any  substitute  for  milk  or 
means  of  making  it  more  acceptable. 

M.  Bovet,  of  Pougues,  asserts  {Bullet.  General  de  la 
Thcrapcutique)  that  he  has  succeeded  in  making  milk 
digestible  by  adding  to  it  Ugumine.  This  substance  is 
a  vegetable  ferment,  which,  he  says,  acts  upon  the  casein, 
turning  it  into  a  soluble  albuminoid — a  sort  of  lactated 
peptone.  The  legumine  is  also  given  independently  as  a 
food  in  doses  of  fifty  grammes  or  more  a  day.  He  re- 
ports a  number  of  cases  in  which  patients  were  able  to 
take  this  combination  of  milk  and  legumine  when  all 
other  foods  were  rejected. 


THE  NEMESIS  OF  "DOC." 

A  writer  in  The  National  Medical  Review  says  some 
words  regarding  the  significance  of  the  title  "  Doc ' '  which 
are  apt  and  eloquent,  and  which,  we  venture  to  surmise, 
come  from  a  heart  that  has  been  embittered  by  some  sad 
personal  experiences.  "If,"  says  this  writer,  "it  has 
been  your  misfortune  to  be  called  '  doc,'  and  if  this  rec- 
ognition has  become  at  all  general  among  your  friends, 
you  might  as  well  move  to  some  other  place.  A  man 
may  be  called  a  thief,  a  liar,  and  a  dead-beat,  and  yet  he 
may  prosper  and  live  upon  the  fat  of  the  land.  But  once 
let  him  be  called  '  doc,1  and  his  professional  success  is 
at  an  end.  We  would  prefer  to  spend  a  night  in  the  sta- 
tion-house, so  far  as  its  effects  on  our  professional  success 
is  concerned,  rather  than  to  have  our  friends  notice  our 
approach  by  saying,  'There  comes  doc.'  If  a  man 
calls  you  'doc/  you  need  never  expect  a  penny  from 
him  for  any  professional  services  you  could  render.     His 


answer  is  sure  to  be,  '  All  right,  doc,  in  a  few  days  that 
will  be  all  right'  'Doc'  means  disaster.  'Doc'  is 
the  culmination  of  all  calamity.  '  Doc '  is  a  catastro- 
phe given  at  one  stroke.  '  Doc '  is  the  warning  that 
we  have  reached  the  extreme  limit,  of  our  usefulness. 
'  Doc '  is  the  hand  which  points  us  to  the  next  town. 
Shun  it,  my  young  friend,  as  you  would  flee  from  a  Kan- 
sas cyclone  or  a  prairie  fire.  Knock  the  man  down  who 
first  dares  speak  it  to  you,  and  call  upon  the  whole  med- 
ical profession  for  vindication  of  your  righteous  deed." 

There  are  some  people,  alas,  to  whom  all  doctors  are 
just  "  docs."  No  amount  of  dignity  in  appearance,  so- 
briety in  demeanor,  superiority  in  years,  wisdom,  experi- 
ence, wealth,  position,  or  morals  makes  the  slightest  dif- 
ference. The  doctor  is  clapped  on  the  shoulder  and 
affably  saluted  with  the  damning  monosyllable.  Hip- 
pocrates returned  to  earth  bearing  the  dignity  of  supreme 
genius  and  wisdom  would  be  simply  welcomed  back  with 
the  same  "  Here  comes  doc." 

But,  after  all,  "  doc  "  is  the  Nemesis  which  pursues  the 
medical  profession  for  clinging  to  the  mediaeval  practice 
of  affixing  always  the  title  "doctor  "  to  the  physician's 
name.  Of  all  men  of  learning,  the  doctor  alone  thrusts 
his  profession  into  every  phase  and  association  of  his 
life.  He  is  always  Dr.  Brown,  M.D.  No  wonder,  there- 
fore, the  title  has  grown  so  familiar  that  it  signifies  little 
to  the  educated,  and  fails  to  protect  against  the  familiar- 
ities of  the  ill-bred* 


MANAGING  BOARDS  AND  TRAVELLING 
HEALERS. 
There  is  a  hospital  at  Echuca,  Victoria,  N.  S.  W.  It 
is  very  far  away,  but  hospital  managers  are  just  the  same 
on  both  sides  of  the  world.  This  hospital  needed  funds, 
and  an  entertainment  was  organized  for  that  purpose. 
Among  the  chief  attractions  was  to  be  "  Professor  Ta- 
rasco,  the  marvellous  travelling  healer,"  who  was  to  cure 
people  for  various  modest  sums,  all  of  which  would  go  to 
the  hospital.  The  medical  board  entered  a  protest 
against  securing  the  services  of  such  a  person  for  such  a 
purpose ;  but  their  protest  was  almost  unanimously  un- 
heeded, and  the  medical  board  was  asked  to  withdraw 
its  letter.  Some  of  the  medical  men  thereupon  resigned. 
The  affront  would  certainly  justify  such  action. 


The  Cutaneous  Application  of  Certain  Alkaloids  as 
Regulators  of  Thermogenesis.  —  MM.  Guinard  and 
Geley  have  found  that  of  eighteen  alkaloids  applied  in 
solution  or  as  an  ointment  to  the  inside  of  the  thigh  of 
man  or  of  one  of  the  lower  animals,  four  of  them,  viz., 
cocaine,  solanine,  sparteine,  and  helleborine,  have  con- 
stantly the  effect  of  regulating  heat  production.  This  reg- 
ulating effect  is  entirely  due  to  the  action  of  the  drug  on 
the  peripheral  nerves,  and  is  entirely  independent  of  ab- 
sorption through  the  skin.  That  this  is  so  is  proved  by 
the  absence  of  any  such  effect  by  the  introduction  of  the 
same  drug  into  the  system.  No  trace  of  the  alkaloid  was, 
moreover,  discovered  in  the  urine  in  the  above  experi- 
ments. Again,  drugs  commonly  administered  as  anti- 
pyretics—quinine, antipyrin,  phenacetin,  sodium  salicy- 
late, aconitine,  etc. — are  ineffectual  when  rubbed  into  the 
skin.  The  experiments  do  not  show  any  superiority  of 
the  alkaloids  over  guaiacol. 


ii4 


MEDICAL   RECORD. 


[July  28,  1894 


Hears  at  tfoe  WLttk. 

The  Plague  in  China.  —  Surgeon  -  General  Wyman, 
of  the  Marine  Hospital  Service,  has  received  a  report  re- 
garding the  "plague"  in  China  from  Dr.  Stuart  £1- 
dridge,  a  member  of  the  Imperial  Board  of  Health  of 
Tokio,  and  Health  Officer  of  the  Port  of  Yokohama. 
The  report  is  in  the  nature  of  a  warning.  The  plague, 
he  says,  has  been  known  to  be  present  in  the  Yun-Nan 
district  of  Southern  China  for  at  least  fifteen  years,  in 
form  generally  sporadic,  at  times  epidemic  in  malignant 
form.  The  disease  broke  out  in  February,  in  Canton, 
and  almost  simultaneously  was  epidemic  in  Bakhoi,  a 
port  at  the  head  of  the  Gulf  of  Tonquin  not  often  visited 
by  European  trade.  The  epidemic  in  Canton  steadily 
increased  in  March  and  April,  until  in  the  latter  month 
it  had  assumed  gigantic  proportions. 

The  authorities  of  Hong-Kong,  the  centre  of  trade  in 
the  far  East,  half  a  day's  journey  from  Canton,  and  in 
constant  communication  therewith,  utterly  ignored  the 
existence  of  danger  until,  in  the  first  ten  days  of  May,  the 
plague  broke  out  violently  and  extensively  in  Hong-Kong. 

Since  its  appearance  in  Hong-Kong  the  epidemic, 
which  is  unquestionably  a  genuine  bubonic  plague  of  a 
most  malignant  type,  has  steadily  increased  until,  by  the 
latest  reliable  advices,  the  mortality  is  certainly  over  one 
hundred  a  day ;  and  this  despite  the  fact  that  at  least  one 
hundred  thousand  Chinese  and  many  Europeans  have 
evacuated  the  place — the  former,  in  many  cases,  leaving 
on  feeling  the  first  symptoms  of  the  disease,  in  the  hope 
of  dying  in  their  native  villages.  At  least  a  dozen 
Europeans  have  been  attacked,  most  of  them  succumb- 
ing. Since  Dr.  Eldridge's  report,  which  was  written 
about  a  month  ago,  there  has  been  no  marked  progress  of 
the  plague.  If  it  should  reach  Japan  this  country  would 
be  in  some  danger.  Still  it  is  a  disease  that  could  be 
easily  controlled. 

Cabbage  and  Ice-cream  do  not  go  well  together  in  the 
human  subject.  This  physiological  fact  was  tragically 
demonstrated  by  Lena  Carey,  of  Delaware,  who  on  a 
wager  ate  a  large  quantity  of  cabbage  and  followed  it 
with  four  plates  of  ice-cream.     Next  day  she  died. 

The  Eiverside  Hospital  at  Yonkers  has  received  an 
additional  gift  of  150,000  from  Mr.  and  Mrs.  M.  F. 
Cochran. 

Mr.  George  Meredith,  the  greatest  of  England's  living 
novelists,  has  dedicated  his  latest  work  to  a  physician. 
In  this  he  follows  the  example  of  one  of  the  greatest  of 
England's  earlier  novelists,  Mr.  Thackeray. 

The  State  Constitution  and  the  Coroner  System.— The 
obstacle  in  the  way  of  abolishing  the  ridiculous  and  anti- 
quated coroner  system  of  this  State  by  legislation,  has 
thus  far  been  the  bare  recognition  of  the  office  of  coroner 
in  the  Constitution.  "Coroners"  are  included  among 
the  officers  who  must  be  chosen  by  the  "  electors  of  their 
respective  counties/ '  and  who  may  be  removed  by  the 
governor,  and  they  are  mentioned  a  second  time  among 
the  county  officers  who  were  to  hold  office  until  the  ex- 
piration of  the  terms  to  which  they  were  elected  on  the 
going  into  effect  of  the  Constitution  of  1 846.  With  these 
exceptions,  the  office  is  in  no  way  referred  to  in  the  pres- 
ent Constitution,  and  it  is  only  necessary  to  expunge  the 


name  from  two  sections  referring  to  county  offices  to  en- 
able the  Legislature  to  reform  the  whole  system  of  in- 
quiring into  the  causes  of  sudden  death.  There  is  no 
doubt  that  the  gentlemen  appointed  by  the  Academy  of 
Medicine  to  co-operate  with  the  Constitutional  Conven- 
tion will  see  that  the  proper  change  is  made. 

The  Columns  of  The  Lancet  sprout  weekly  with  aspar- 
agus items.  We  had  thought  that  the  matter  was  settled, 
and  that  asparagus  was  to  be  definitely  classed  as  a  diu- 
retic, and  to  an  extent  perfumer  of  the  genito  urinary 
tract.  But  Dr.  Samuel  Wilks  comes  out  in  an  open  letter 
and  states  that  the  contrary  is  true.  Asparagus  is,  he 
says,  in  effect  anuretic,  lessening  the  urinary  flow.  When 
matters  of  this  kind  fail  to  be  settled  by  the  languid  and 
ineffectual  observations  of  the  Old  World,  it  becomes 
necessary  to  call  in  the  aid  of  the  New.  Through  the 
columns  of  the  Medical  Record  it  was  established  that 
the  sick  do  sneeze,  and  we  are  sure  that  our  readers  can 
settle  with  equal  positiveness  the  important  question :  Is 
asparagus  a  diuretic  ? 

The  Modern  Tendency  in  Public  School  management 
is  to  abolish  devotional  exercises,  and  substitute  gymnas- 
tics and  sanitation.  This  tendency  has  reached  its  ex- 
treme in  Vienna,  where  Dr.  Kohn  has  proposed,  in  order 
to  prevent  the  propagation  of  diphtheria  among  school- 
children, to  have  them  inhale  permanganate  of  potassium, 
in  the  form  of  a  spray,  before  leaving  the  classes. 

The  Cholera  prevails  extensively  on  the  continent  ot 
Europe,  cases  being  reported  from  Lubeck,  Nantes,  Ber- 
lin, and  many  places  in  Russia.  In  St.  Petersburg  the 
epidemic  is  rapidly  spreading,  the  new  cases  averaging 
200  daily  and  the  deaths  100.  There  are  over  1,000 
patients  in  the  hospitals  of  the  city.  The  disease  has 
also  broken  out  in  the  military  camp  at  Krasnoe  Selo, 
eighteen  miles  south  of  St  Petersburg. 

Mr.  Gladstone's  Eye  requires  another  operation,  and 
he  has  returned  to  London  to  have  it  performed. 

An  International  Congress  for  the  Protection  of  In- 
fant Lift  was  held  at  Bordeaux  on  July  22,  1895.  It 
consisted  of  three  sections:  1.  A  physical  section,  in 
which  all  questions  relating  to  societies  for  protecting  in- 
fant life,  maternal  charity  criches,  children's  hospitals, 
sanatoria,  etc.,  were  discussed.  2.  A  moral  section, 
for  the  discussion  of  questions  relating  to  the  protection 
of  children  abandoned  by  their  natural  protectors,  ap- 
prenticing, orphan  homes,  and  agricultural  colonies.  3. 
An  administrative  section,  in  which  the  Roussel  law  and 
all  questions  relating  to  the  protection  of  infant  life  will 
be  studied. 

Shorthand  in  Medicine. — In  order  to  promote  the  use 
of  shorthand  by  medical  students  and  practitioners,  by 
enabling  them  to  increase  their  knowledge  at  the  same 
time  of  the  art  and  of  their  profession,  a  small  sheet  01 
clinical  teaching  in  lithographed  phonetic  shorthand  has 
been  issued  by  a  London  firm.  The  paper,  which  will 
be  continued  if  found  to  fill  a  need,  contains  reports  of 
clinical  lectures  by  Dr.  Gowers  and  other  prominent 
London  clinicians. 

Joseph  Hyrtl,  the  distinguished  anatomist,  died  at 
Vienna,  on  July  17th,  aged  eighty- three.  He  was  Pro- 
fessor of  Anatomy  in  the  University  of  Prague  from  1837 
to  1845,  when  he  was  elected  to  a  similar  chair  in  the 


July  28,  1894] 

University  of  Vienna.  He  was  the  author  of  a  "  Manual 
of  Physiological  and  Practical  Anatomy/ '  and  a  "  Manual 
of  Topographical  Anatomy  and  its  Applications." 

A  Collective  Investigation  of  Quacks  has  been  pro- 
posed by  Ernest  Hart.  He  asks  medical  men  to  send  to 
him  the  following  information :  the  name  and  address  of 
the  quack,  the  description  of  his  premises,  one  of  his  ad- 
vertisements, including  a  copy  of  each  book  and  pam- 
phlet, and  cuttings  from  the  local  papers  with  dates ;  a 
memorandum  must  also  be  made  of  the  date  on  which 
the  name,  address,  and  description  of  the  premises  is 
taken  down.  The  member  must  do  this  himself,  and 
preserve  his  original  notes.  The  results  of  the  observa- 
tions should  then  be  catalogued  and  arranged  by  the  dif- 
ferent branches.  It  would  also  be  necessary  to  note  the 
nature  and  condition  of  the  neighborhood  where  the 
quack  purports  to  practise,  and  his  hours  of  attendance. 
If  this  work  is  carried  on  all  through  the  United  King- 
dom, we  should  then  be  in  a  position  to  call  the  attention 
of  Parliament  to  the  prevalence  of  quackery.  I  admit 
that  the  task  is  a  heavy  one,  but  unless  some  such  plan  is 
carried  out  it  will  be  impossible  to  expect  such  drastic  re- 
form in  the  Medical  Acts  as  is  desirable  in  the  public  in- 
terest as  well  as  in  the  interest  of  the  profession.  This 
class  of  quacks  will  scarcely  be  affected  by  the  hitherto 
proposed  amendments  to  the  Medical  Acts. 

The  American  Journal  of  Insanity.— In  a  circular 
dated  July  12th,  the  retiring  editor,  Dr.  G.  Alder  Blumer 
announces  that  the  American  Journal  of  Insanity  has 
been  sold  to  the  American  Medico-psychological  Asso- 
ciation, and  will  be  edited  by  a  committee  consisting  of 
Dr.  Edward  Cowles,  of  Boston;  Dr.  Henry  M.  Hurd,  of 
Baltimore;  and  Dr.  Richard  Dewey  (in  immediate 
editorial  charge),  of  Chicago ;  and  that  until  further  no- 
tice it  will  be  published  in  Chicago. 

The  Income  Tax  and  Professional  Workers.  — It 
is  gratifying  to  notice  that  on  several  occasions  during 
the  discussion  on  the  Budget  proposals  influential  speak- 
ers have  directed  attention  to  the  injustice  of  applying 
the  same  rate  of  taxation  to  income  derived  from  hard 
work,  and  dependent  on  the  life  and  health  of  the  payer, 
as  is  applied  to  income  derived  from  investments.  True, 
no  statesman  has  yet  had  the  courage  or  the  energy  to 
devise  means  for  remedying  this  injustice ;  but  it  is  now 
'  so  clearly  perceived  and  expressed  that  its  redress  cannot 
be  much  longer  delayed. — Lancet. 

The  Vegro  as  a  Hospital  Interne.— In  the  last  exam- 
inations for  position  as  interne  at  the  Indianapolis  City 
Hospital,  a  negro  was  appointed  as  the  best  fitted  among 
a  considerable  number  of  candidates.  The  young  man 
is  of  Massachusetts  birth  and  is  twenty  one  years  old. 
He  is  a  graduate  in  arts  of  the  State  University  of  Mis- 
souri, and  received  the  degree  of  M.D.  from  the  Medical 
College  of  Indiana  in  this  year's  class,  ranking  third  in 
a  class  of  fifty-four,  all  the  others  being  white.  This 
appointment  of  a  negro,  though  fairly  won,  has  caused 
a  most  bitter  outpouring  of  abuse  upon  the  young  man 
and  all  concerned  in  his  appointment.  His  services 
began  in  the  surgical  wards,  whereupon  the  pay  patients 
left  and  the  charity  patients  made  bitter  complaint  at 
what  they  considered  an  indignity.  The  general  char- 
acter of  the  vituperation  can  be  judged  by  the  following 
extracts  from  a  letter  to  one  of  the  local  medical  papers. 


MEDICAL   RECORD. 


"5 


After  bewailing  the  fact  that  during  this  young  man's 
service — which  the  writer  will  only  speak  of  as  "  these 
circumstances  " — no  pay- patients  will  enter  the  hospital, 
and  thereby  the  city  will  lose  some  two  to  five  hundred 
dollars  a  month,  the  letter  continues :  "  The  worst  feat- 
ure of  this  unfortunate  situation  is  that  in  four  months, 
by  rotation,  this  young  man  will  be  placed  in  charge  of 
the  obstetrical  department,  and  white  women,  whose 
only  crime  is  poverty,  must  submit  to  the  unspeakable 
outrage  of  bringing  innocent  children  into  the  world 
under  the  touch  and  manipulation  of  this  son  of  Ham." 
He  then  asks  "  the  Board  of  Health,  who  made  this 
appointment,  the  cringing  politicians  who  prevent  the 
righting  of  the  wrong,  and,  lastly,  all  persons  who  favor 
this  phase  of  negro  equality :  How  would  you  like  to  look 
back  to  the  day  of  your  birth  and  know  that  a  negro 
doctor  helped  to  usher  you  into  the  world  ?  "  In  con- 
clusion he  says :  "  If  the  Indianapolis  city  government 
does  not  place  this  young  man  where  he  will  only  ad- 
minister to  those  of  his  own  race,  as  is  fit  and  proper, 
they  will  rob  the  city  treasury,  degrade  and  humiliate 
many  persons,  benefit  no  one,  and  deserve  everlasting 
contempt  from  every  citizen,  both  white  and  black." 

The  Indian  Medical  Congress. — The  first  Congress  of 
Indian  medical  men  will  be  held  in  Calcutta,  on  Decem- 
ber 24  to  29,  1894.  It  is  proposed  that  the  work  of  the 
Congress  should  be  divided  into  sections  as  follows: 
Medicine  and  Pathology ;  Surgery,  including  Ophthal- 
mology; Obstetrics,  and  Diseases  of  Women  and  Chil- 
dren ;  Public  Health ;  Medico  legal  Medicine  and  In- 
sanity ;  Pharmacology,  specially  Indigenous  Drugs. 
Although  the  Congress  is  primarily  an  Indian  one,  an 
invitation  to  assist  at  its  deliberations  is  extended  by  the 
Executive  Committee  to  medical  men  in  this  and  other 
countries,  some  of  whom  have  already  accepted.  Apart 
from  the  medical  work  of  the  Congress,  which  promises 
to  be  interesting  and  instructive,  there  will  be  the  oppor- 
tunity of  seeing  India  and  visiting  its  chief  cities.  The 
climate  during  the  winter  is  perfect,  the  facilities  of 
travel  excellent,  and  two  or  three  months,  inclusive  of 
the  double  voyage,  would  suffice  not  only  for  the  work 
of  the  Congress  but  for  a  visit  to  most  of  the  chief  cen- 
tres of  interest.  The  journey  from  London  to  Calcutta 
occupies  about  eighteen  days,  via  Brindisi  and  Bombay, 
about  a  week  longer  via  Gibraltar  and  Malta.  The  P. 
and  O.  S.  N.  Co.  have  weekly  steamers  by  both  routes, 
the  British  India  Company  fortnightly  via  Gibraltar. 
The  Messageries  Maritimes  run  from  Marseilles,  the 
Rubattino  from  Genoa,  and  the  Austrian  Lloyds  from 
Trieste.  The  Calcutta  season  is  at  its  height  during 
Christmas  week,  and  the  committee  expect  to  be  able  to 
present  a  varied  programme  of  entertainments,  while  a 
special  committee  has  been  formed  to  attend  to  the  con- 
venience and  comfort  of  visitors.  Any  desired  informa- 
tion may  be  obtained  from  the  secretaries,  Dr.  W.  J. 
Simpson  and  D.  M.  Moir,  5  and  6  Government  Place, 
Calcutta. 

The  Medical  Golden  Rule. — "  I  feel  constrained  for 
once  to  give  you  a  golden  rule.  It  is  never  to  speak  ill 
of  any  of  your  fraternity,  whatever  you  may  think.  You 
will  do  yourself  no  good,  and  it  will  only  be  thought 
that  you  are  jealous." — Dr.  Chestet field s  Letters  to  his 
Son. 


n6 


MEDICAL   RECORD. 


[July  28,  1894 


®0txere00  of  American  Iptgaittetis 

75Mr</  Triennial  Meeting,  held  in  Washington,  D.  C, 
May  29,  jo,  ji,  and  June  1,  1894. 

AMERICAN  ASSOCIATION  OF  GENITO-URI- 
NARY  SURGEONS. 

Eighth  Annual  Meeting,  held  at  Washington,   D.   C, 
May  29,  jo,  andji,  and  June  1, 1894. 

(Continued  from  VoL  45,  page  76a.) 

Second  Day,  Wednesday,  May  30TH. 

Aero-urethrosoopy  with  a  lew  Instrument. — Dr.  W. 
K.  Otis,  of  New  York,  read  a  paper  giving  a  history  of  the 
subject  to  the  present  time  and  showed  his  improved  in- 
strument. Also  cystoscope  with  eye-piece  at  a  right 
angle  for  catheterizing  the  ureters. 

Dr.  Belfield  showed  a  tube  with  catheter  curve,  with 
opening  at  angle  and  light  in  tip  of  tube,  for  use  in  deep 
urethra  and  neck  of  bladder,  and  catheterizing  the  ureters. 

A  Needle-holder  for  the  Hagedorn  Heedle. — Dr. 
Brown,  of  New  York,  presented  an  instrument  of  this 
nature.  The  very  secure  grasp  of  this  small  pointed 
holder — equally  secure  whether  a  very  large  or  a  very 
small  needle  be  used — is  due  to  the  relief  from  strain 
which  the  jaws  of  the  instrument  derive  from  a  consider- 
able degree  of  spring  which  the  handles  have  just  behind 
the  principal  hinge.  The  four  separate  parts  which  make 
up  the  needle  holder  are  readily  detachable.  The  peri- 
neal tube  holder  serves  the  purpose  of  keeping  the  large 
rubber  tube  securely  in  every  position  desired,  whether 
this  be  depth  of  insertion,  or  upward,  downward,  or  lateral 
presentation  of  the  eye  of  the  tube.  It  facilitates  removal 
for  cleansing  or  making  any  little  adjustment  necessary. 
The  patient  can  himself  make  any  such  changes.  In 
case  of  continuous  drainage  these  apparently  minor  points 
are  of  considerable  moment  in  rendering  an  uncomfort- 
able condition  much  more  tolerable  and  manageable. 
Dr.  Brown  also  showed  a  modification  of  the  Clover 
crutch,  with  cross-bar  removed  from  the  field  of  urethral 
instruments 

Discussion  by  Drs.  Bryson  and  White. 

Stone  in  the  Bladder ;  Choice  of  Operation. — Dr. 
William  H.  Hingston,  of  Montreal,  Canada,  read  a 
paper  with  this  title.  In  cases  where  all  the  cutting 
operations  are  equally  practical,  he  prefers  the  lateral 
method,  and  offers  the  following  principles : 

1.  Lithotresis  (and  by  lithotrity  I  mean  that  more  per- 
fect method  which  was  foreshadowed  by  Mercier,  in 
France,  and  brought  to  its  highest  perfection  in  Amer- 
ica). In  all  cases  of  adults  where  the  stone  is  neither 
too  large  nor  too  hard  for  the  lithotrite. 

a.  Lithotresis,  where  the  urethra  is,  or  can  be  made, 
sufficiently  capacious  for  the  crushing  instrument 

3.  Lithotresis  in  children,  however  young,  where  the 
urethra  can  permit  the  passage  of  a  crushing  instrument. 

4.  In  very  young  children  the  cutting  operation  is 
preferable,  the  precise  age  at  which  lithotrity  is  possible 
must  vary  with  the  calibre  of  the  canal,  which  in  young 
children  greatly  varies  in  its  capaciousness  and  in  its 
capacity ;  when  the  urethra  in  the  child  is  not  and  cannot 
be  made  fit  to  receive  the  lithotrite,  the  cutting  opera- 
tion to  be  chosen  is  the  lateral  method. 

5.  In  cases  of  stone  in  the  aged,  where  enlarged  pros- 
tate not  only  prevents  the  stone  being  seized,  but  its  di- 
mensions being  ascertained,  we  should  act  as  if  the  cal- 
culus were  of  large  size  and  incapable  of  reduction,  and 
proceed  to  operate  by  the  suprapubic  method. 

Dr.  Chismore,  of  San  Francisco,  said  the  general 
character  of  the  paper  commended  itself  to  good  sense. 
The  size  and  hardness  of  the  stone  should  not,  in  his 
mind,  exclude  lithotrity.  If  when  the  stone  is  seized  and 
considerable  pressure  is  brought  to  bear  and  it  does  not 
break,  by  waiting,  the  elasticity  and  spring  of  the  in- 


strument in  many  cases  will  work  its  way  through  stone. 
If  this  fails,  should  let  go  and  grasp  the  edge  and  break 
off  in  this  way. 

Dr.  Post,  of  Boston,  related  a  case  of  stone  in  the 
bladder  in  a  child  with  hip  disease,  so  that  he  could  not 
be  put  into  the  lithotomy  position,  and  the  position  of  legs 
was  such  that  lithotrity  could  not  be  performed.  He 
did  a  suprapubic  operation  and  found  the  peritoneum 
adherent  and  extending  down  to  the  pubes,  and  was 
obliged  to  cut  through  it 

Dr.  Bangs,  of  New  York,  said  that  in  choosing  oper- 
ation, the  removal  of  the  stone  is  only  one  thing.  There 
is  a  disease  causing  stone,  and  we  are  frequently  obliged 
to  use  a  cutting  operation  for  drainage  to  bladder  and  pel- 
ves of  kidneys. 

Dr.  William  Judkins,  of  Cincinnati,  showed  a  speci- 
men of  calculi  formed  around  a  stitch  left  in  the  bladder 
after  operation  by  the  suprapubic  method  in  a  case 
where  it  was  impossible  to  get  in  a  crushing  instrument. 

He  thought  this  case  illustrated  the  stone  disease  men- 
tioned by  Dr.  Bangs,  and  he  soon  expected  to  have  to  do 
another  operation. 

Dr.  Watson,  of  Boston,  was  glad  to  get  the  authority 
of  Dr.  Hingston  in  favor  of  the  operation  of  lithotrity. 
The  array  of  cases  presented  byDr.  Chismore  the  previ- 
ous day  was  the  most  remarkable  on  record.  And  he 
would  like  to  ask  Dr.  Chismore  if  he  could  explain  that 
fact- 

Dr.  Chismore,  in  reply  to  Dr.  Watson,  stated  that  in 
his  cases  of  seventy-one  operations  without  a  death,  the 
good  result  was  due  partly  to  the  hardiness  of  the  men 
and  to  the  fact  that  the  stones  were  small,  and  not  en- 
tirely to  the  local  anaesthetic.  He  made  the  operation 
short,  and  if  necessary  completed  it  at  another  time. 

Dr.  Bryson,  of  St.  Louis,  said  he  was  in  accord  with 
the  paper,  and  the  choice  of  operation  depended  on  the 
condition  of  the  bladder  and  urinary  organs,  and  the  size 
and  consistency  of  the  stone.  When  he  chose  cutting 
operations,  it  was  because  of  the  condition  of  the  blad- 
der, kidneys,  and  prostate. 

Dr.  Hingston,  in  closing  the  discussion,  said  that  he 
was  not  wedded  to  any  method.  There  is  no  disease  of 
bladder  and  kidneys  where  lithotrity  is  not  indicated. 
The  stone  causes  the  condition,  and  if  you  remove  the 
cause  the  condition  will  improve.  His  greatest  number  of 
cases  without  death  was  eighteen. 

Urine  Leakage  and  Stricture  Formation.— Dr.  John 
P.  Bryson,  of  St.  Louis,  read  a  paper  of  which  the  fol- 
lowing were  the  conclusions: 

1.  The  close  resemblance  in  the  tissue  elements,  their 
arrangement,  and  effect  upon  the  related  normal  struct- 
ures, point  to  an  identity  of  the  etiological  factor,  and 
give  support  to  the  doctrine  of  urine  leakage 

2.  Observing  the  prolongation  of  the  urethral  epithe- 
lium on  the  fistula  wall  in  an  effort  to  create  an  adequate 
artificial  channel  for  urine,  and  seeing  that  the  epithelium 
lining  the  stricture  also  participates  in  the  battle  against 
urine  leakage,  we  may  take  fresh  hope  of  radically  curing 
strictures  even  of  the  pendulous  urethra,  by  such  means 
as  tend  to  restore  or  rehabilitate  the  urethral  lining. 

3.  Merely  diverting  the  stream  of  urine  for  a  time 
without  such  restoration  of  the  lining  mucous  membrane 
would  fall  into  the  category  of  palliative  treatment,  along 
with  urethrotomy  and  the  various  methods  of  dilatation. 

Dr.  Taylor,  of  New  York,  regretted  that  he  did  not 
bring  specimens  showing  the  stricture  formation  from 
gonorrhoea  to  the  completion  of  the  process.  The  patho- 
logical appearances  do  not  warrant  the  theory  of  urine  leak- 
age. There  is  a  tendency  always  for  the  stricture  to  be 
covered  with  squamous  epithelium,  which  becomes  glazed 
over  and  prevents  urine  leakage.  If  it  was  not  covered 
with  epithelium  it  was  an  ulcer,  and  the  appearance  of 
the  cells  around  an  ulcer  was  not  water- logged. 

Dr.  Bryson,  in  closing,  was  glad  that  Dr.  Taylor 
raised  the  point  of  urine  leakage ;  ail  authors  referred  to 
strictures  as  if  there  were  but  one  form,  when  there  were 
really  two:     1.  Inflammatory,     a.  Cicatricial  stricture 


July  28,  1894] 


MEDICAL    RECORD. 


117 


begins  with  a  multiplication  of  fixed  cells.  The  differ- 
ence between  scar-tissue  and  stricture-tissue  was  that  scar- 
tissue  is  quiescent,  while  stricture  tissue  continues  to  grow. 
The  Possibility  of  Overcoming  Permanent  Stricture 
of  the  Deep  Urethra  without  Kesort  to  External  Ure- 
throtomy.— Dr.  J.  Blake  White,  of  New  York,  detailed 
the  histories  of  two  cases  relieved  without  external  ure- 
throtomy, and  concluded  that,  ordinarily,  an  external 
urethrotomy  might  have  been  thought  necessary,  and 
possibly  performed ;  that  the  spasmodic  element,  always 
present  to  a  greater  or  less  degree  in  deep  organic  struct- 
ures, often  tends  to  obscure  the  judgment  of  the  examin- 
ing surgeon  as  to  the  possibility  of  overcoming  it  through 
less  grave  procedure  than  external  urethrotomy,  and  that 
where  a  deep  organic  stricture,  not  traumatic,  is  present, 
thorough  and  skilful  removal  of  obstructions  in  the  an- 
terior urethra  affords  the  surgeon  every  opportunity  to 
relieve  it  by  careful  dilatation  with  graduated  sounds ; 
since  the  anatomy  of  the  structure  of  the  deep  urethra  is 
such  that  it  yields  more  readily  to  dilatation,  and  ab- 
sorption is  more  likely  to  result  in  this  location  from 
judicious  and  well  directed  pressure  by  the  sound.  In- 
cision at  this  point  is  apt  to  result  in  cicatricial  formations, 
which  are  very  apt  to  necessitate  at  some  future  time  an- 
other operation  for  the  relief  of  the  symptoms  which  ap- 
parently made  the  first  operation  a  necessity. 

Dr.  Taylor,  of  New  York,  thought  the  urethral  spasm 
was  due  to  instruments.  That  if  we  would  use  a  soft 
rubber  catheter  in  those  cases  we  would  have  no  trouble, 
while  it  resented  the  approach  of  the  steel  instrument. 

Dr.  Martin,  of  Philadelphia,  was  glad  to  hear  of  the 
cure  of  stricture  with  the  sound  instead  of  the  knife.  He 
reported  a  case  of  stricture  of  the  deep  urethra  with  per- 
ineal fistula  in  a  patient  who  would  not  consent  to  opera- 
tion. He  finally  got  a  guide  into  bladder  and  dilated  up 
to  10th  to  1 2th  French  size.*  The  man  did  not  return  for 
six  weeks,  and  the  condition  was  as  bad  as  before.  He 
then  dilated  up  to  26th  French,  and  it  had  remained  at 
that  point. 

Dr.  Lewis,  of  St.  Louis,  referred  to  a  case  where  he 
could  easily  pass  a  steel  sound,  but  could  not  pass  a  soft 
catheter. 

Dr.  Bryson,  of  St.  Louis,  said  that  it  is  hard  to  sepa- 
rate two  processes.  When  we  cut  a  band  of  cicatricial 
tissue  we  do  not  destroy  the  band,  but  we  make  dilata- 
tion possible. 

Dr.  Hingston,  of  Montreal,  thought  Dr.  F.  S.  Otis's 
rule  of  gentle  dilatation,  with  cutting  in  the  old  cartilag- 
inous strictures,  the  best. 

Dr.  Brown,  of  New  York,  said  that  there  are  cases 
in  which,  after  internal  urethrotomy,  sounds  can  pass 
through  a  previous  closed  deep  urethra.  Advises  to  do 
internal  urethrotomy  first  and  then  try  sounds. 

Dr.  Otis  said  there  was  no  doubt  that  strictures  can 
be  dilated.  But  in  a  case  like  Dr.  Martin's  he  should 
have  done  the  external  urethrotomy.  He  does  not  agjee 
with  Dr.  Bryson,  that  cutting  does  not  remove  the  strict- 
ure ;  spasmodic  strictures  have  occurred  many  times  in 
his  practice,  and  he  does  not  think  them  due  to  instru- 
ments. 

Exfoliation  of  the  Mucous  and  Submucous  Coats  of 
the  Bladder,  Preceded  by  Renal  and  Vesical  Calculus. 
— Dr.  Alexander  Stein,  of  New  York,  referred  to  the 
feet  that  fifty  cases  have  been  reported,  forty-five  in  fe- 
males and  five  in  males.  After  a  careful  resuml  of  the 
subject,  he  gave  a  detailed  history  of  a  male  case  treated 
by  himself,  which  he  summed  up  as  follows : 

In  summing  up  this  suggestive  history,  we  find  that 
the  nephritic  colic  was  invariably  referred  to  the  left 
groin.  About  six  months  before  he  came  under  observa- 
tion, he  had  retention  of  urine,  in  consequence  of  the 
impaction  of  a  calculus  in  the  urethra.  Shortly  after  this 
there  occurred  an  intra  renal  distention  from  impaction 
in  either. pelvis  of  the  kidney,  or  possibly  at  the  vesical 
extremity  of  the  ureter.  A  swelling  appeared  in  the  left 
lumbar  region,  which  was  doubtless  a  hydro-  and  a  pyo- 
nephritic  tumor.    After  stagnation  of  the  urine  in  the 


pelvis  of  the  kidney,  alkaline  fermentation  was  ob- 
tained, and  a  pyelitis  was  excited  which,  after  the  dis- 
lodgement  of  the  offending  calculus,  and  die  emptying  of 
the  pyo  nephritic  sac  per  viam  naturalem,  there  was  left 
a  favorable  nidus  for  the  subsequent  formation  of  crys- 
tals of  triple  phosphates,  which,  after  descending  into  the 
bladder,  continued  their  destructive  work.  The  stone 
was  removed  by  crushing  and  fragments  washed  out  for  a 
month ;  there  was  a  relief  of  symptoms,  and  then  a  grad- 
ual accession  of  cystitis,  which  was  followed  after  a  time 
by  the  appearance  of  the  exfoliated  shreds,  which  he  con- 
tinued to  pass  for  two  weeks,  in  such  quantities  as  to 
represent  the  entire  lining  of  the  bladder. 


Third  Day,  Thursday,  May  31ST. 

A  Plea  for  the  Excision  of  the  Initial  Lesion.— Dr. 
Edmund  E.  King,  of  Toronto,  Canada,  sent  a  paper  which 
was  read  by  the  Secretary.  The  following  were  its  con- 
clusions :  1,  The  early  excision  of  chancres,  that  is  within 
a  few  hours  after  their  appearance,  will  abort  the  disease; 
2,  the  excision  of  any  unhealed  chancre  will  moderate 
the  subsequent  secondary  manifestations ;  3,  that  it  is*  the 
cleanest,  least  painful,  and  most  scientific  method  of  treat- 
ing the  lesion. 

Epithelioma  of  the  Penis. — Dr.  Edward  Martin,  of 
Philadelphia,  detailed  a  case  operated  on  by  himself  as  a 
text  for  his  paper,  and  presented  the  drawings  of  a  cross 
section  of  the  growth,  showing  typical  epithelial  forma- 
tion. 

Ribbon  sections  were  taken  of  the  whole  substance  of 
the  penis  passing  from  the  centre  of  the  growths  back- 
ward. The  line  of  demarcation  between  the  healthy  and 
diseased  tissue  was,  as  is  usual  in  epithelioma,  rather 
sharply  marked.  In  regard  to  the  etiology  of  the  disease, 
phimosis  is  the  most  common.  He  quotes  various  au- 
thorities regarding  the  contagiousness  of  the  disease,  and 
thinks  that  it  is  not  unreasonable  to  believe  that  the  con- 
tagious nature  of  a  cancer  may  some  day  be  clearly  rec- 
ognized. He  also  refers  to  chancre  occurring  in  the  ci- 
catrix of  a  syphilitic  primary  lesion,  but  the  scar  he 
thinks  simply  acted  as  a  focus  of  lessened  resistance. 

The  prognosis  of  epithelioma  of  the  penis  is  now 
guardedly  favorable.  Before  the  epithelioma  is  fully  de- 
veloped and  only  folliculitis  and  a  few  watery  growths 
present,  prompt  and  efficient  intervention  will  be  fol- 
lowed by  a  radical  cure  in  the  majority  of  cases. 

If  the  disease  progresses  to  the  involvement  of  the  in- 
guinal glands,  the  operations  ordinarily  resorted  to  are 
insufficient  and  recurrence  in  loco  takes  place. 

As  to  the  operation,  this,  in  the  precancerous  stage, 
that  is  when  a  case  cannot  be  clearly  recognized  as  can- 
cer, may  consist  in  thorough  cauterization,  or  in  excision 
followed  by  cauterization.  In  case  the  wound  does  not 
heal  kindly,  amputation  of  the  penis  should  be  performed 
at  once.  If  cross-section  shows  involvement  at  point  of 
amputation,  extirpation  is  indicated.  In  the  latter  case, 
when  there  are  any  remains  of  virility,  castration  is  also 
advisable. 

In  all  cases  where  the  amputation  of  the  penis  is  re- 
quired I  believe  the  groin  should  be  opened  freely  and 
the  entire  chain  of  lymphatic  glands  should  be  removed, 
whether  they  are  enlarged  or  not.  The  two  points  to 
which  the  paper  was  designed  to  call  attention  are :  1. 
That  it  is  not  justifiable  positively  to  deny  the  possibility 
of  contagion  in  epithelioma  of  the  penis.  2.  That  where 
amputation  of  the  penis  is  required  the  inguinal  glands  of 
both  sides  should  be  dissected  out,  even  though  they  are 
not  appreciably  enlarged. 

Dr.  Taylor,  of  New  York,  spoke  of  the  coincidence 
Of  cancer  in  the  syphilitic  as  it  appeared  after  the  syphi- 
Atic  process  had  ceased.  When  occurring  in  a  scar,  as  in 
this  case,  it  was  undoubtedly  due  to  irritation.  In  refer- 
ence to  contagiousness  of  cancer,  he  referred  to  a  case 
whese  the  man,  to  do  penance  for  past  dissipation,  had 
had  frequent  intercourse  with  his  wife,  who  had  cancer  of 
the  womb,  without  any  injurious  result. 


n8 


MEDICAL    RECORD. 


[July  28,  1894 


Dr.  Lewis,  of  St.  Louis,  suggested  the  advisability  of 
castration  in  these  cases,  as  it  diminished  blood  supply 
and  consequent  irritation  which  would  favor  recurrence. 

Dr.  Chismore,  of  San  Francisco,  referred  to  a  case 
which  he  operated  on  by  excision  of  the  cancerous  mass, 
leaving  the  inguinal  glands.  Six  weeks  later  there  was 
no  recurrence  and  inguinal  glands  smaller. 

In  concluding  the  discussion,  Dr.  Martin,  in  reply  to 
Dr.  Lewis,  advised  castration  when  extirpation  of  the 
entire  penis  is  performed ;  when  only  partially  removed 
there  is  a  certain  amount  of  sexual  satisfaction.  The 
question  of  the  contagiousness  of  epithelioma  of  the  penis 
is  still  subjudice,  and  we  may  have  to  regard  it  as  a  con- 
tagious  disease.  Should  advise  a  partial  amputation  and 
then  examine  the  periphery  of  the  stump,  and  if  no  can- 
cerous infiltration,  there  is  little  danger  of  recurrence  in 
loco.     Inguinal  glands  in  all  cases  should  be  removed. 

Inflammation  of  the  Seminal  Vesicles. — Dr.  R.  W. 
Taylor,  of  New  York,  said  that  this  condition  was  not 
recognized  until  the  last  few  years,  and  it  is  mainly 
through  the  writings  of  Mr.  Jordan  Lloyd  that  an  impe- 
tus to  its  study  has  been  inaugurated.  The  affection  is 
almost  always  secondary  to  gonorrhoea,  occurring  in  the 
third  or  fourth  week,  or  to  hyperemia  of  the  posterior 
urethra  due  to  masturbation  and  venereal  excesses,  or  to 
inflammation  of  this  region  due  to  traumatism,  catheteri- 
zation, endoscopy,  and  strong  injections. 

Symptoms  are  similar  to  those  of  posterior  urethritis, 
and  those  given  as  diagnostic  of  the  several  forms  of 
prostatitis. 

Course  is  similar  to  epididymitis,  and  at  the  end  of  a 
week  or  ten  days  the  symptoms  become  ameliorated  and 
resolution  sets  in. 

Chronic  Seminal  Vesiculitis. — This  form  occurs  when 
resolution  fails  in  the  acute  form.  The  symptoms  are 
usually  obscure  and  vague.  These  disturbances  are 
mainly  of  two  forms :  First,  those  of  lowered  power ;  and 
second,  those  of  erythism  of  the  sexual  organs. 

Diagnosis  can  only  be  made  by  rectal  examination. 
The  patient  should  bend  body  forward,  standing  with  feet 
about  a  foot  apart.  The  examiner  can  place  foot  on 
chair.  Elbow  on  knee  to  get  pressure  and  overcome  the 
perineal  muscles.     The  bladder  should  be  full. 

Frequently  the  amputated  vas  deferens  is  mistaken  for 
the  seminal  vesicles. 

Treatment. — Leeches  to  the  perineum,  injection  of 
cold  water  in  the  rectum,  and  packing  rectum  with  ice  if 
the  procedure  is  pleasant  to  the  patient ;  opium  in  sup- 
positories, diluents  and  saline  cathartics  may  be  adminis- 
tered if  required.  Should  an  abscess  form,  it  may  be 
reached  by  means  of  a  long  incision  just  anterior  to  the 
anus,  care  being  taken  not  to  cut  urethra,  prostate,  or 
rectum. 

Treatment  of  the  Chronic  Forms. — By  good  hygiene, 
tonics,  and  the  treatment  of  posterior  urethritis,  if  it  ex- 
ists. He  does  not  agree  with  a  recent  paper  of  Dr.  Ful- 
ler's, of  New  York,  and  shows  two  anatomical  specimens 
to  prove  that  the  seminal  vesicles  are  so  placed  that  it  is 
impossible  to  reach  by  the  finger  sufficiently  to  milk  or 
-strip  successfully. 

Dr.  Allen,  of  Boston,  said  that  diagnosis  could  only 
be  made  by  rectal  examination,  as  the  urinary  symp- 
toms were  not  characteristic.  In  the  treatment  of  termi- 
nal vesiculitis,  he  had  been  discouraged  by  Dr.  Taylor's 
anatomical  demonstration  of  the  normal  position  of  the 
-seminal  vesicles  and  the  inability  to  milk  them.  He 
had  witnessed  in  some  cases  that  after  squeezing  there 
had  been  diminution  in  size. 

Dr.  Martin,  of  Philadelphia,  said  he  had  been  trying 
-for  some  time  to  examine  the  seminal  vesicles  in  all  cases 
of  epididymitis,  and  in  a  few  cases  only  had  he  been  en- 
abled to  make  out  the  seminal  vesicles.  And  in  these 
cases  there  was  the  presence  of  disease  or  chronic  enlarge- 
ment, and  that  it  had  been  impossible  for  him  to  make 
out  by  rectal  examination  a  normal  seminal  vesicle.  He 
showed  several  drawings  representing  what  he  had  felt  in 
certain  cases.     In  most  cases  the  symptoms  were  those  of 


posterior  urethritis,  but  in  three  cases  pain  was  referred  to 
the  hip  of  corresponding  side  and  radiated  down  only 
to  surface  of  thigh.  He  had  found  that  rectal  injections 
gave  the  greatest  relief,  and  for  examination  the  partial 
bending  of  the  body  was  the  best  In  some  cases  the 
lithotomy  position  was  good. 

Dr.  Brewer,  of  New  York,  spoke  of  pressure  in  chronic 
cases  being  followed  by  the  ejaculation  of  a  clear  fluid 
which  rapidly  coagulated.  The  specimen  shown  by  Dr. 
Taylor  proves  that  we  cannot  strip  the  seminal  vesicle 
completely,  but  by  pressure  had  diminished  the  size  and 
found  discharge  containing  spermatozoa  from  the  urethra, 
and  in  these  cases  had  obtained  an  improvement. 

Dr.  Allen,  of  Boston,  would  like  to  put  himself  on 
record  as  agreeing  with  Dr.  Martin  in  the  difficulty  of 
feeling  the  normal  seminal  vesicles,  but  regarding  the 
treatment  he  agrees  with  Dr.  Brewer. 

Dr.  Hayden,  of  New  York,  had  for  some  time  been 
examining  cases  at  the  Vanderbilt  Clinic,  and  added  his 
testimony  to  the  difficulty  of  feeling  the  normal  seminal 
vesicle.  He  was  able  to  feel  them  only  when  there  was 
a  prostatitis  or  epididymitis. 

Dr.  Bangs,  of  New  York,  was  glad  to  hear  that  others 
had  had  difficulty  in  feeling  the  seminal  vesicles,  as  he 
could  only  feel  them  when  enlarged.  Yet  we  can  express 
a  fluid,  but  he  was  not  willing  to  admit  benefit  from  strip- 
ping. 

Dr.  Weir,  of  New  York,  said  that  within  the  urethera, 
the  last  year,  his  attention  had  been  called  to  perineal 
abscesses  from  diseased  seminal  vesicles.  They  can  be 
reached  and  removed,  if  necessary,  by  a  transverse  inci- 
sion in  front  of  anus  until  we  reach  cellular  space,  and 
through  this  reach  the  vesicles,  and  he  had  removed  those 
that  were  tubercular. 

Dr.  Belfield,  of  Chicago,  called  attention  to  the  im- 
portance of  the  sinus  pocularis,  which  varies  much  in  size, 
and  when  swollen  would  produce  swelling  where  we 
would  expect  to  feel  the  beginning  of  the  seminal  vesicles. 

Dr.  Bryson,  of  St.  Louis,  said  the  anatomical  demon- 
stration called  to  mind  conditions  seen  several  times. 
He  was  astonished  to  find  that  the  vas  deferens  was  so 
large,  and  was  probably  frequently  mistaken  for  chronic 
enlargement,  or  for  tuberculosis.  There  was  a  condition 
caused  by  seminal  engorgement,  and  the  symptoms  were 
relieved  by  emptying  a  portion  of  the  seminal  apparatus. 
This  occurred  in  free  livers  who  over-indulged  in  sexual 
intercourse.  They  would  complain  of  pain  in  rectum, 
which  was  almost  constant,  not  due  to  local  causes.  But 
by  introduction  of  the  finger  into  the  rectum  and  empty- 
ing the  distended  pouch  there  would  be  complete  relief 
from  the  pain. 

Dr.  Chismore  reported  a  case  where  he  could  milk, 
from  a  sac  occurring  on  either  side,  3  j-  of  fluid  contain- 
ing an  abundance  of  spermatozoa. 

Dr.  Taylor,  in  concluding  the  discussion,  stated  that 
we  should  be  careful  in  making  pressure  on  distended 
sacs  felt  per  rectum.  The  amputation  of  the  vas  defer- 
ens was  sometimes  so  marked  that  it  could  easily  be  mis- 
taken for  the  seminal  vesicles. 

Surgical  Interference  in  Tubercular  Kidney. — Dr. 
John  P.  Bryson,  of  St.  Louis,  read  this  paper.  In  174 
cases  of  tuberculosis  of  the  genitourinary  tract  observed 
by  the  author,  only  18  gave  unmistakable  evidence  of  in- 
volvement of  the  kidney.  He  gave  in  detail  the  histories 
of  several  cases  treated  by  surgical  methods,  and  gave  the 
rules  usually  followed,  given  as  a  guide  for  surgical  inter- 
ference. The  conclusion  he  had  arrived  at  was,  to  oper- 
ate only  in  cases  of  emergency.  The  probability  of 
trouble  in  the  other  kidney,  its  absence  or  the  presence 
of  chronic  nephritis,  made  the  operation  a  very  serious 
one.  Also  the  fact  that  there  was  probably  tuberculosis 
of  other  parts  of  the  genitourinary  tract,  or  even  of  the 
lungs,  even  to  drain  a  tubercular  cavity  in  any  part  of 
the  body  was  of  doubtful  efficacy.  To  remove  a  stone  or 
to  open  an  abscess  which  is  not  sufficiently  drained  by 
ureter,  or  to  remove  a  suppurating  kidney  which  is  affect- 
ing the  whole  system,  when  we  can  assure  ourselves  of 


July  28,  1894] 


MEDICAL  RECORD 


119 


the  soundness  of  the  opposite  organ,  are  the  only  surgical 
interferences  he  considered  justifiable. 

Dr.  Bangs  said  that  in  closer  study  of  genito-urinary 
tuberculosis  for  the  past  two  years  he  had  become  more 
conservative.  Good  hygiene  was  the  only  cure  for  tuber- 
culosis, and  that  combination  of  gases  known  as  "  fresh 
air."  Vesical  tuberculosis  is  made  worse  by  instrumen- 
tation. He  had  performed  all  kinds  of  operations,  but 
the  result  was  not  good.  He  sends  those  cases  away, 
Southern  California  is  a  favorite  place,  the  warm  climate 
is  less  stimulating  to  kidneys,  and  is  therefore  prefera- 
ble to  cold.  The  effect  of  operation  or  other  traumatism 
is  to  make  the  condition  more  acute.  He  applied  same 
rules  to  tubercular  testicles.  In  the  cystoscopic  examina- 
tion of  the  bladder  he  frequently  found  a  pulpy  condi- 
tion, rarely  only  can  he  find  ulcers.  He  had  begun  to 
look  upon  that  condition  as  tubercular. 

Dr.  Keyes,  of  New  York,  had  not  made  a  special 
study  of  genito-  urinary  tuberculosis,  but  thought  the 
surgeon  should  stand  aside  and  operate  only  in  emer- 
gency ;  there  was  too  much  surgeon  and  not  enough  med- 
icine in  these  cases.  He  has  tried  surgery,  and  it  failed 
to  help  him.  Transplantation  of  the  patient  was  the 
last  means  of  cure.  He  did  not  consider  the  pulpy  con- 
dition spoken  of  by  Dr.  Bangs  always  due  to  tuberculosis. 
He  had  never  seen  it  above,  always  at  the  base  of  blad- 
der; bleeds  on  contact  with  instrument.  He  had  seen  it 
in  strictures  and  pyelitis  where  the  base  of  the  bladder  is 
bathed  in  pus,  also  in  tuberculosis. 

Dr.  Belfield,  of  Chicago,  added  his  testimony  to  non- 
interference in  tuberculosis  of  genito-urinary  tract.  He 
had  operated  eight  times,  and  there  was  only  one  case 
that  gave  him  any  satisfaction.  That  was  one  in  which 
the  drainage  was  kept  up  eighteen  months.  Later  died  of 
general  tuberculosis.  Reported  a  case  of  peri  nephritic 
abscess  which  was  aspirated,  and  sent  to  a  suitable  climate 
with  improvement. 

Dr.  Bryson,  in  concluding  the  discussion,  said  he  did 
not  think  there  was  characteristic  appearance  of  the  base 
of  the  bladder  in  tuberculosis.  The  question  of  involve- 
ment of  the  other  kidney  is  very  important.  He  hoped 
that  the  new  instrument  shown  yesterday  by  Dr.  Belfield 
might  help  us ;  also  the  presence  of  albumin  and  casts  were 
important  in  making  a  correct  diagnosis. 

Cystitis  and  Pyelonephritis,  Due  to  the  Colon  Bacillus, 
Requiring  Nephrectomy. — Dr.  F.  Tilden  Brown,  of 
New  York  City,  related  a  case  which  presented  in  the  sur- 
gical service  of  Dr.  McCosh  at  the  Presbyterian  Hospital, 
and  reported  by  Dr.  Brown  to  bring  out  an  expression  of 
opinion  regarding  the  importance  or  non-importance  of 
the  colon  bacillus  as  a  pathological  agent.  An  interest- 
ing feature  of  the  operation  was  rupture  of  the  renal  artery, 
attended  with  very  serious  hemorrhage,  which  was  suc- 
cessfully controlled  by  long  clamps  left  in  place  for  fifty- 
eight  hours. 

S.  W.   D ,  male,   aged  forty;   widower;  United 

States;  masseur.  No  rheumatism, tuberculosis,  gonorrhoea, 
or  syphilis.  History;  In  1886  sustained  an  injury  to 
the  left  side  by  a  fall,  which  probably  injured  somewhat 
the  left  kidney,  as  slight  functional  impairment  of  urina- 
tion and  sexual  powers  followed.  He  then  began  treat- 
ment by  the  passage  of  sounds.  At  the  end  of  the  fourth 
month  of  this  treatment  he  was  conscious  of  being  hurt 
by  a  larger  sound  than  had  been  passed  before.  Ten 
minutes  later  he  noticed  hematuria.  Cystitis  promptly 
supervened,  and  he  entered  a  hospital  where,  at  the  end 
of  ten  days,  he  was  cured.  Returning  to  his  former 
doctor  he  submitted  to  the  introduction  of  a  sound,  and 
the  next  day  returned  to  the  hospital  with  a  relapsing 
cystitis,  which  soon  extended  to  a  left-side  pyelitis.  He 
was  confined  to  bed  for  three  weeks.  He  had  a  great 
deal  of  pain  and  occasional  hematuria.  After  a  while  he 
noticed  that  the  urine  would  at  times  be  rather  scanty  and 
comparatively  clear.  Again  the  urine  would  suddenly 
increase  in  quantity  and  contain  a  good  deal  of  pus. 

This  state  continued  for  two  years,  when  in  1890  he 
first  noticed  an  enlargement  in  the  region  of  the  left  kid- 


ney. This  abdominal  tumor  was  not  permanent,  but 
regularly  subsided  after  a  brief  period  of  polyuria  at- 
tended with  pyuria.  In  September,  1893,  tne  patient 
substituted  for  boric  acid  solution,  as  a  vesical  lavage, 
peroxide  of  hydrogen,  twenty  per  cent,  solution.  Im- 
mediately after  its  first  employment  he  was  seized  with  a 
chill ;  high  fever  and  sweating  ensued.  At  irregular  inter- 
vals every  few  days  he  now  had  a  repetition  of  these  chills. 
He  noted  extreme  distention  of  the  abdominal  tumor, 
followed  by  its  disappearance,  and  increased  quantity  of 
urine.  Four  such  attacks  were  noted  between  September, 
1893,  and  January  23, 1894,  when  he  entered  the  Presbyte- 
rian Hospital.  At  this  time  his  temperature  was  980  F. ; 
pulse,  84 ;  respiration,  20. 

Physical  examination  was  negative,  except  that  on  the 
left  side  and  well  upward  border  of  the  ribs,  on  deep  pal- 
pation, some  pain  and  resistance  could  be  detected.  As 
the  tumefaction  he  had  himself  been  able  to  notice  did 
not  now  exist,  he  was  kept  under  observation  until  Feb- 
ruary 20th.  During  this  time  his  urine,  drawn  by  steril- 
ized catheter,  gave  a  pure  culture  of  colon  bacilli  grown 
on  agar,  and  tested  by  reaction  on  milk.  The  specific 
gravity  of  urine  was  1.020,  acid,  albuminous;  contained 
pus,  and  occasionally  blood. 

During  the  week  previous  to  February  20th,  pain  in 
left  side  has  been  quite  constant.  Abdominal  distention 
has  increased,  and  a  tumefaction  in  the  left  kidney  region 
has  been  quite  marked. 

Nephrectomy  by  Dr.  McCosh:  Ether.  During  the 
operation  many  firm  adhesions  are  met  with  after  the 
ureter  has  been  ligated  and  divided,  and  while  detaching 
the  upper  segment  of  the  large  pyonephritic  mass  the 
renal  artery  is  ruptured.  During  a  critical  hemorrhage 
the  vessels  are  caught  in  long  clamps,  which  are  left  in 
place  forty-eight  hours.  A  slow  but  uneventful  convales- 
cence ensued.  The  colon  bacillus  is  again  cultivated 
from  the  removed  kidney,  and  again  from  the  urine  on 
April  2d,  and  again  on  May  23d.  The  patient  has 
gained  twenty  pounds.     The  urine  is  free  from  albumin. 

Point  for  consideration :  Was  the  left  kidney  damaged 
by  a  previous  traumatism,  and  thus  rendered  susceptible 
to  ascending  infection  at  the  time  of  acquiring  cystitis? 
And  was  the  cystitis  due  to  a  trauma  inflicted  upon  the 
posterior  urether  by  a  sound,  and  to  a  simultaneous  im- 
plantation of  septic  matter  in  the  form  of  the  bacillus 
colli  communis  ? 

Is  the  continued  presence  of  the  colon  bacillus  in  the 
urine,  despite  bladder  irrigation  with  antiseptics,  to  be 
ascribed  to  the  blind  canal  made  of  the  ligated  ureter  ?  Is 
entire  removal  of  the  ureter  to  be  advocated  in  nephrec- 
tomy for  septic  matter  ?  Does  the  presence  of  the  colon 
bacillus*  at  present  render  the  patient  more  liable  to  a 
pyonephrosis  of  the  remaining  kidney  in  case  it  becomes 
impaired  by  traumatism  or  disease  ? 


Fourth  Day,  Friday,  June  ist. 

Tumor  of  the  Testicle.— Dr.  R.  W.  Taylor,  of  New 
York,  showed  drawings  of  tumor  of  testicle  removed  by 

him.      The  history  was  as  follows:  N.   D ,   aged 

twenty-seven ;  United  States ;  brakeman.  Had  had  gonor- 
rhoea twice.  A  year  ago  patient  said  he  had  a  chancre, 
and  about  the  same  time  he  noticed  a  small  hard  lump 
at  upper  part  of  right  testicle,  increasing  steadily  in  size. 
About  six  months  ago  he  was  struck  in  the  testicle  by  a 
peach,  since  which  time  he  thinks  the  tumor  has  grown 
moreTapidly. 

On  admission  to  hospital  the  testicle  was  enlarged  to 
about  the  size  of  two  fists.  It  was  hard  and  painless,  the 
inguinal  glands  very  large  and  hard.  The  testicle  was 
removed  by  Dr.  Taylor,  and  was  adherent  to  the  scrotum, 
the  inguinal  gland  was  not  removed,  as  the  patient  ob- 
jected. He  was  discharged  cured  in  a  month.  The 
tumor  was  examined  by  Dr.  Van  Giesen,  of  the  College  of 
Physicians  and  Surgeons.  Section  showed  :  1 ,  portions 
of  the  tumor  a  perfect  type  of  adenoma ;  2,   a    less 


120 


MEDICAL   RECORD. 


[July  28,  1894 


perfect  form  of  adenoma  on  the  border  line  of  carcinoma; 
3,  sarcomatous  tissue ;  4,  hyaline  cartilage. 

This  disease  begins  slowly  and  insidiously,  forms  a 
large,  indolent,  smooth,  oval,  dense,  and  sometimes  elastic, 
not  painful  or  tender,  surface,  usually  smooth,  and  even 
later  may  become  bassy  and  fungating ;  sometimes  there 
is  hydrocele,  rapidity  of  growth ;  when  large  produces  a 
dull,  dragging  sensation ;  usually  begins  in  early  life. 
Conche,  in  a  study  of  thirty  cases,  in  twenty-four  of 
which  the  observer  notes  the  affection  developed  between 
the  ages  of  twenty  and  forty.  Uttial  Johnson  described 
a  case  in  a  child,  two  years  and  nine  months  of  age,  in 
which  the  trouble  began  at  the  third  month  of  life. 

Dr.  Bangs  asked  if  Dr.  Taylor  made  the  diagnosis  at 
first  Dr.  Taylor  replied  that  he  gave  internal  remedies 
for  syphilis,  but  the  tumor  got  worse  and  produced  a 
fungating  mass. 

Dr.  Bangs  then  detailed  a  case  in  which  there  was  no 
venereal  history,  the  patient  was  in  general  good  health. 
There  was  an  ulcer  on  anterior  surface  of  scrotum  appear- 
ing like  a  malignant  growth,  had  an  indurated  base 
and  bled  easily;  necrosis  of  the  central  portion  took 
place,  a  portion  was  removed,  and  the  pathologist  sent 
report  of  epithelioma.  The  man  refused  operation,  but 
the  case  healed  up  entirely. 

Dr.  Bryson,  of  St.  Louis,  said  that  in  malignant  and 
tubercular  growths  the  exhibition  of  potassium  iodide 
made  tendency  to  bleed  greater.  He  had  never  seen  a 
case  of  simple  growth — always  more  than  one  element. 
The  surgeon  had  this  before  him.  Make  diagnosis  be- 
tween syphilis  and  these  growths  by  antiseptic  treatment ; 
if  not  syphilitic  or  tubercular  should  be  removed.  Com- 
mends non-removal  of  inguinal  glands,  although  it  does 
not  agree  with  modern  surgical  principles.  He  would 
like  to  ask  Dr.  Bangs  his  rules. 

Dr.  Bangs  replied  that  he  removed  all  enlarged  neigh 
boring  glands  in  all  cases. 

Dr.  Keyes,  of  New  York,  wanted  to  ask  if  in  the  case 
reported  there  was  involvement  of  the  scrotum.  For  if 
the  tumor  is  confined  to  testicle  and  cord,  it  returns  in 
peritoneal  glands.  But  if  the  scrotum  and  surrounding 
tissue  are  involved,  inguinal  glands  should  be  removed. 

Dr.  Bell,  of  Montreal,  detailed  a  case  of  multiple 
tumors  of  the  brain,  and  the  question  of  syphilis  was 
considered.  Later  there  developed  fibrous  growths  of 
the  epididymitis,  the  right  side  grew  slowly  and  became 
as  large  as  the  tumor  described  by  Dr.  Taylor,  and 
showed  multiple  growths.  Growth  on  the  other  side  did 
not  increase,  but  later  in  cord  began  a  large  enchon- 
droma  which  has  now  begun  to  fungate. 

Dr.  Taylor,  in  concluding,  said  that  he  had  given  the 
patient  antiseptic  remedies  for  a  while.  His  duties  as  a 
brakeman  caused  frequent  contusion  and  irritation  of  the 
testicle.  The  tumor  was  fungatory  and  the  inguinal 
glands  were  enlarged.  They  had  grown  smaller  since 
removal,  as  they  frequently  do  in  epithelioma  of  the  penis. 
Perhaps  the  enlargement  is  purely  inflammatory.  He  be- 
lieves in  thorough  removal  of  inguinal  glands  in  such  cases. 

During  How  Long  a  Period  is  Syphilis  Communica- 
ble?— Dr.  James  Bell,  of  Montreal,  reported  a  case 
which  was  thoroughly  treated,  and  married  two  years  and 
eight  months  after  development  of  secondary  symptoms. 
During  this  time  he  took  treatment  regularly  and  showed 
no  evidence  of  the  disease.  His  wife  contracted  genital 
chancre,  and  developed  constitutional  syphilis.  The 
author  gave  history  in  order  to  show  :  1,  That  the  hus- 
band was  properly  treated,  and  was,  as  far  as  could  be 
seen,  free  from  the  disease  when  he  married;  and  2, 
that  there  can  be  no  doubt  as  to  the  diagnosis  in  the 
case  of  the  wife.  For  the  rest  I  believe  the  husband  to 
have  been  perfectly  honest  in  the  matter,  and  the  wife  to 
have  been  in  every  respect  above  suspicion.  In  my 
opinion  this  must  have  been  a  case  of  blood  inoculation. 

The  second  case,  in  which  a  man  contracted  syphilis  a 
few  years  before  he  was  married,  and  before  the  sore  ap- 
peared the  wife  beeame  pregnant  She  never  showed 
any  symptoms  of  the  disease,  although  she  was  given 


protoiodide  of  mercury  pills  up  to  time  of  delivery.  She 
remained  in  good  health  and  was  delivered  in  full  term 
of  a  fine  healthy  child,  which  she  nursed  for  six  months, 
when  her  milk  failed  and  she  was  obliged  to  wean  it 
The  child  (now  nine  months  old)  has  never  shown  a 
sign  of  syphilis,  and  is  a  typically  healthy,  well-nourished 
baby. 

Dr.  Taylor  was  very  much  interested  in  the  two  cases, 
especially  the  first.  In  these  cases  we  must  eliminate  ex- 
tra-genital infection.  It  was  either  a  case  of  great  pertinac- 
ity of  the  lengthjof  the  infecting  period,  or  there  was  a  lover 
somewhere,  and  he  was  inclined  to  the  latter  view. 

Dr.  Bangs  thought  that  as  the  time  was  only  two 
years  and  eight  months,  it  was  not  unusual  for  infection 
to  occur. 

Dr.  Keyes  wished  to  put  himself  on  record  as  thinking 
that  infection,  at  least  up  to  the  end  of  the  third  year,  was 
quite  possible. 

Dr.  Judkins,  of  Cincinnati,  related  a  case  where  a 
man  had  chancre  and  wife  aborted,  although  impregnated 
before  the  development  of  the  primary  sore. 

Dr.  Bell,  in  concluding,  stated  that  he  was  as  scepti- 
cal as  Dr.  Taylor,  but  if  there  was  ever  a  case  where  you 
could  trust  your  evidence,  this  was  surely  one. 

Dr.  CHisMOREmade  a  few  remarks,  resigning  the  chair 
to  Dr.  Bangs,  the  newly  elected  President.  The  Associa- 
tion then  adjourned  until  the  following  year. 


AMERICAN    CLIMATOLOGICAL   ASSOCIATION. 

Eleventh  Annual  Meeting,  held  in   Washington,  D.C., 
May  2p,  30,  31,  and  June  1, 1894. 

(Continued  from  Vol.  45,  page  763.) 

Second  Day,  Wednesday,  May  30TH. 

Climatic  Treatment  of  Phthisis.— Dr.  H.  B.  Moore, 
of  Colorado  Springs,  had  sent  a  paper  entitled  "  A  Plea 
for  the  Earlier  Recognition  of  Pulmonary  Tuberculosis, 
and  the  Adoption  of  Proper  Climatic  Treatment."  Ow- 
ing to  the  absence  of  Dr.  Moore  his  paper  was  read  by 
title. 

Three  Tears*  Experience  in  the  Sanitarium  Treat- 
ment of  Pulmonary  Disease  near  Boston. — The  second 
paper  was  read  by  Dr.  Vincent  V.  Bowditch,  of  Bos 
ton,  with  the  above  title.  He  presented  the  results  oi 
the  treatment  of  pulmonary  disease  for  three  years  at  the 
Sharon  Sanitarium,  near  Boston.  He  referred  to  the  well- 
known  Frankenstein  Sanitarium,  near  Frankfort-on -Main, 
Germany.  It  is  built  on  an  elevation  of  fifteen  hundred 
feet  above  sea-level.  It  was  a  famous  resort  for  the 
wealthy  classes.  The  Sharon  Sanitarium  was  on  a  hill 
four  hundred  feet  above  sea-level.  It  was  for  die  work- 
ing classes,  largely  shop-girls.  He  referred  to  the  City 
Sanitarium  established  in  New  York  by  Dr.  A.  L. 
Loomis,  and  Dr.  Charles  Quimby,  of  that  city. 

It  goes  almost  without  saying  that  the  climate  of  New 
England  is  deemed  unfavorable  for  consumptives  What 
can  we  do  for  the  poorer  classes  ?  It  has  been  cod  liver 
oil,  cough  sirup,  and  advice  about  air  and  food.  Left  to 
old-time  methods  they  slowly  faiL  The  ordinary  Ameri- 
can country  boarding-house  is  not  suited  to  such  cases, 
they  are  badly  ventilated  and  the  food  is  badly  cooked. 

The  building  at  Sharon  is  a  beginning,  it  can  accom- 
modate nine  patients,  all  females.  It  was  purposely  con- 
structed for  an  abundance  of  sunlight  and  pure  air. 
Every  room  is  freely  ventilated.  One  patient  in  a  room. 
Building  has  broad  piazzas,  where  patients  are  kept  out 
in  the  pure  air.  No  carpets  or  mats  within  to  hold  dust. 
No  sweeping  allowed.  Damp  cloths  are  used.  Sputa  are 
destroyed.     Cups  used  for  that  purpose  are  burned. 

The  Sharon  Sanitarium  opened  February  9,  1891.  Of 
48  patients  8  were  bronchitics,  the  remaining  40  had 
various  forms  of  phthisis — 10  had  been  discharged  with 
the  disease  arrested.  In  no  case  did  he  use  the  term  cure. 
The  majority  had  been  away  from  eighteen  to  twenty- 
four  months.     All  reports  from  them  were  favorable.     In 


July  28,  1894] 


MEDICAL    RECORD. 


121 


several  cases  both  lungs  were  involved.  Some  of  these 
left  improved.  In  the  8  arrested  cases  bacilli  were  pres- 
ent in  but  3.  He  often  found  that  the  bacilli  were  not 
present  in  cases  presenting  all  the  evidences  of  phthisis, 
i.e.,  cough,  hemorrhage,  sputa,  malaise,  and  night-sweats 
— in  fact,  all  of  the  usual  symptoms,  but  in  certain  cases 
no  bacilli.  One  case  had  been  in  two  years,  and  had 
gained  twenty- eight  pounds ;  another  got  fat  and  well ; 
another  had  had  cough  and  hemorrhage,  had  gained 
fourteen  pounds  and  a  half  in  four  months.  Now  she  is 
in  California,  with  an  excellent  prospect  for  recovery. 
In  some  twenty-five  per  cent,  the  disease  seemed  to  be 
arrested,  and  there  was  general  improvement  in  thirty- 
three  per  cent. 

Bacilli  had  been  found  in  cases  classed  as  improved. 
In  six  cases  of  this  nature  the  results  had  been  very  satis- 
factory. 

He  advocated  the  sanitarium  form  of  treatment.  Pre- 
vious to  opening  the  Sharon,  he  feared  that  having  such 
patients  in  a  community  would  be  unfavorable  to  them. 
Experience  had  shown  his  error.  What  was  the  effect  of 
the  proximity  of  patients  one  to  another  ?  At  first,  it 
caused  depression,  but  it  soon  wore  off.  They  are  kept 
under  control,  hence  the  direct  benefits  of  such  a  system 
as  the  sanitarium  treatment,  under  skilled  management. 
All  can  be  carefully  watched.  It  was  his  rule  to  receive 
cases  where  the  early  symptoms  were  present.  If  they 
failed  to  improve  in  a  few  weeks,  he  advised  them  to  re- 
tarn  to  their  homes. 

Referring  to  methods  of  treatment,  daily  visits  of  the 
physician — a  sanitarium  should  have  a  resident  physician. 
Their  chief  aims  were  fresh  air  and  good  food.  He 
deems  them  absolutely  necessary  for  recovery.  Exercise 
within  fatigue,  rest  in  the  open  air,  even  in  the  coldest 
days  in  winter,  patients  being  carefully  wrapped. 

As  a  rule  he  avoided  drugs.  Cabinet  treatment  and 
pulmonary  gymnastics  were  most  valuable.  He  had  no 
faith  in  the  germicidal  action  of  drugs  or  vapors.  He 
was  not  wholly  convinced  of  the  value  of  tuberculin. 

In  making  a  brief  report  on  three  years'  work,  he  en- 
deavored to  leave  out  the  personal  equation.  Our  sole 
aim  should  be  to  do  our  best  for  our  patients,  and  in 
reports  to  deal  with  the  truth  and  nothing  but  the 
truth. 

Dr.  Von  Ruck,  of  Asheville,  S.  C.;  deemed  Dr.  Bow- 
ditch's  experience  and  observations  valuable.  Climate 
is  not  so  important ;  it  is  not  so  much  where  it  is  done, 
as  how  it  is  done.  While  practising  in  Ohio,  he  had  had 
about  the  same  results  as  those  given  by  Dr.  Bowditch  in 
fifty-eight  observed  cases.  In  twenty-five  per  cent,  there 
was  arrest,  and  improvement  in  a  third  of  all  under  ob- 
servation. Benefit  may  be  had  at  home  if  patients  will 
do  as  they  are  instructed. 

He  did  not  concur  in  Dr.  Bowditch's  views  regarding 
the  value  of  tuberculin.  He  uses  it  still,  and  to  day  has 
greater  faith  in  it  than  ever.  Early  cases  of  phthisis  want 
to  wait.  They  invariably  think  others  worse  than  them- 
selves. Tuberculin  applied  in  the  earlier  cases,  as  recom- 
mended by  Dr.  Koch,  in  his  hands  gave  excellent  results. 
It  has  a  stimulating  effect  on  the  tissues.  It  can  be 
pushed  to  produce  congestion,  some  using  as  much  as 
100,000  milligr.  in  a  month.  Such  treatment  simply 
does  harm,  and  was  not  indicated  by  Dr.  Koch.  It  was 
overdone.  Using  tuberculin  in  the  smallest  doses  gives 
an  effect  in  from  five  to  ten  hours.  Where  fever  is  pro- 
duced the  limit  of  the  dose  has  been  used.  He  firmly 
believed  that  the  results  will  be  as  good  as  Dr.  Koch  led 
us  to  hope  for,  and  which  the  speaker  firmly  believed  we 
would  attain. 

Dr.  J.  H.  Musser,  of  Denver,  Col.,  said  that  we  had 
reached  a  time  when,  if  tuberculosis  is  properly  managed 
within  certain  limitations,  it  might  be  deemed  a  self-lim- 
ited disease,  and  the  tendency  is  to  cure. 

Plans  and  sanitaria  such  as  those  advocated  by  Dr. 
Bowditch,  deserved  the  warmest  encouragement.  Sani- 
taria within  the  limits  of  cities  for  the  poorer  classes. 
If  a  sanitarium  is  not  properly  conducted  it  will  fail. 


Careless  methods  will  kill  it.  Reference  was  made  to 
the  infectiousness  of  the  disease. 

Dr.  Quimby,  of  New  York  City,  gave  an  account  of 
the  founding  of  the  New  York  Sanitarium,  and  what  they 
hoped  to  accomplish.  A  lady  well  known  in  New  York, 
noted  for  her  charities,  had  enabled  them  to  give  the 
scheme  form  and  substance.  He  was  of  opinion  that 
hitherto  too  much  had  been  said  relative  to  phthisis,  and 
too  little  as  to  the  treatment  of  phthisics.  The  object  of 
the  New  York  Sanitarium  was  to  relieve  the  working 
classes,  and  aid  and  advise  those  having  a  fortnight's  hol- 
iday in  the  year.  The  consulting  staff  of  the  sanitarium 
would  be  requested  to  see  all  cases  on  entrance  and  make 
*  a  forecast  as  to  their  probable  expectation  of  life.  This 
he  wanted  for  the  purpose  of  comparison.  He  outlined 
what  they  hoped  to  accomplish. 

Dr.  Curtain,  of  Philadelphia,  spoke  of  some  results 
at  the  Philadelphia  Hospital,  in  the  phthisis  ward.  Dur- 
ing 1888  and  1889,  the  patients  therein  had  tubercular 
sputum.  In  1890  influenza  appeared,  when  half  of  the 
old  cases  died.  In  1891,  or  after  the  influenza  epidemic, 
out  of  28  cases  15  had  no  tubercle  bacilli.  He  con- 
ducted a  number  of  post-mortems.  Ulceration  of  the 
lungs  was  found,  but  the  closest  examination  of  the  tis- 
sues failed  to  detect  bacilli.  Recently  a  German  bacteri- 
ologist had  found  a  new  bacillus,  different  from  the  tuber- 
cle bacillus ',   this,  he  thought,  might  explain  these  cases. 

Creosote,  Guaiacol,  and  Benzoyl  of  Ouaiacol  in 
Phthisis. — Dr.  Roland  G.  Curtain,  of  Philadelphia, 
read  the  paper.  He  gave  a  resumi  of  his  hospital  ex- 
perience at  the  Philadelphia  Hospital,  stating  that  one 
object  was  to  elicit  a  discussion  on  the  treatment  of  tu- 
berculosis by  creosote  and  guaiacol.  Dr.  Glasgow,  in 
1 89 1,  read  a  paper  on  the  action  of  guaiacol.  In  189  a 
Dr.  Jacobi,  of  New  York  City,  dealt  with  the  treatment. 
Twelve  years  ago  he,  the  reader,  had  used  Declats's 
syrup  of  phenic  acid.  Guaiacol  and  phenic  acid  gave 
much  the  same  results.  Subcutaneous  injections  of  phe- 
nic acid  were  very  painful.  One  patient  frankly  said  that 
ht  preferred  death.  In  his  experience,  as  the  result  of 
the  use  of  phenic  acid,  there  was  an  improvement  in  the 
appetite  and  an  increase  in  flesh,  less  dyspnoea.  Speak- 
ing of  beechwood  creosote,  he  said  that  it  and  guaiacol 
chemically  have  much  in  common.  Dr.  J.  J.  Whittaker 
had  published  results  in  1893.  When  creosote  is  pure  it 
is  harmless  and  easily  borne  by  the  stomach.  It  has  no 
effect  on  the  bacilli.  Some  patients  take  small  and  others 
large  doses.  Creosote  may  produce  hematuria.  In 
those  who  bear  it  best  as  far  as  the  stomach  is  concerned, 
increase  in  weight  follows.  In  acute  phthisis  with  high 
temperature,  no  benefit  results  from  guaiacol.  The  class 
most  benefited  is  that  where  there  is  slight  fever  and 
poor  digestion.  Dyspepsia  is  cured  by  phenic  acid ;  also 
greatly  benefited  by  guaiacol.  He  uses  the  latter  in  the 
form  of  pills.  It  acts  well  in  chronic  ulceration  of  the 
lungs.  He  does  not  believe  that  it  has  any  specific  effect 
on  the  lungs. 

Benzoyl  of  guaiacol  was  introduced  by  a  German  phys- 
ician. He  has  not  found  it  any  better  than  guaiacol,  and 
it  is  expensive.  He  does  not  deem  it  as  reliable  as 
guaiacol.  Guaiacol  is  not  so  liable  to  produce  irritation 
of  the  kidneys ;  when  pure  you  know  what  you  are  ad- 
ministering. 

Dr.  A.  L.  Loomis,  of  New  York  City,  did  not  believe 
that  any  of  the  agents  named  exert  any  special  action  or 
effect  in  the  disease.  In  many  cases  the  patients  seemed 
to  do  just  as  well  without  such  remedies.  When  intro- 
duced into  the  stomach  there  is  no  evidence  that  they 
have  any  other  effect  than  to  improve  the  digestive 
powers  in  a  certain  class  of  patients.  Some  patients  were 
saturated  with  creosote. 

Dr.  Robert  H.  Babcock,  of  Chicago,  had  used  both 
creosote  and  guaiacol.  Some  patients  stood  them  well, 
others  did  not.  He  recalled  a  case  where  one  hundred 
and  fifty  drops  had  been  given  in  twenty-four  hours, 
with  benefit.  Previously  there  had  been  hemorrhage. 
She  was  a  young  woman.    There  was  a  cessation  of  the 


122 


MEDICAL    RECORD. 


[July  28,  1894 


symptoms,  and  the  physical  signs  all  improved.  Many 
patients  cannot  tolerate  it.  It  allays  fermentative  proc- 
esses in  the  digestive  tract.  Guaiacol  is  used  after  meals. 
He  kept  it  up  until  the  urine  became  of  a  dark-green 
olor,  then,  reduced  the  dose  to  one  half,  then  gradu- 
ally began  decreasing  it.  Some  patients  cannot  take 
either. 

Dr.  Von  Ruck,  of  Asheville,  S.  C,  used  creosote  four 
years  ago,  hypodermically.  In  four  cases,  who  persisted 
in  spite  of  suffering,  he  continued  the  remedy  for  two 
months,  they  received  four  grammes  a  day.  He  watched 
the  urine,  tubercle  bacilli  were  present  in  all  the  cases. 
It  had  no  effect  on  the  bacilli.  He  was  satisfied  that 
they  got  good  results  from  creosote.  It  was  particularly* 
beneficial  in  bronchial  cases,  also  of  marked  benefit  in 
gastro  intestinal  cases. 

Dr.  W.  M.  Gibson,  of  Utica,  N.  Y.,  found  that  creo- 
sote had  a  direct  effect  on  the  blood.  Following  a 
moderate  dose  of  creosote  after  a  meal,  there  is  an  in- 
crease in  the  leucocytes,  producing,  he  said,  better  phyga- 
cytosis ;  a  count  of  the  corpuscles  would  prove  it. 

Dr.  Elksner,  said  that  in  hospital  and  private  prac- 
tice he  had  got  very  good  results  with  creosote.  He 
said  that  it  was  most  difficult  to  make  an  early  diagnosis. 
In  many  cases  no  bacilli  were  present,  unless  there  had 
been  infiltration  in  the  lungs;  there  must  be  breaking 
down  to  get  the  bacilli. 

Dr.  J.  B.  Walker,  of  Philadelphia,  deemed  the  odor 
of  creosote  in  the  breath  of  such  patients  very  objection- 
able ;  said  that  whether  the  skin  will  take  it  in  or  not, 
the  skin  will  give  it  out ;  that  such  people  in  street  cars 
and  elsewhere  were  unpleasant.  If  not  anti  bacillary, 
why  give  such  large  doses?  He  believed  it  to  be  anti. 
catarrhal,  and  that  it  has  a  modifying  effect  on  the 
tissues.     It  does  not  kill  the  tubercle  bacillus. 

Dr.  A.  L.  Looms  had  found  tubercle  bacilli  without 
destruction  of  tissue.  They  may  be  present  in  a  patient 
without  any  destructive  changes  in  the  lungs,  or  air-pas- 
sages. He  had  got  bacilli  in  a  case  where  the  lungs  were 
unaffected ;  he  mentioned  the  case  while  examining  the 
chest  of  a  young  man ;  he  had  quite  a  profuse  hemor- 
rhage, some  blood  was  secured,  it  contained  a  little  mu- 
cus. In  it  were  found  a  large  number  of  bacilli ;  again 
he  examined  the  chest  carefully  and  got  no  evidence  of 
pulmonary  disease.  The  patient  had  hemorrhages  for 
three  or  four  days,  the  blood  gave  bacilli ;  there  was  no 
expectoration,  yet  bacilli  were  found ;  that  was  two  and 
a  half  years  ago.  Man  now  seems  well.  Bacilli  may 
lodge  in  the  bronchi.  This  may  occur  without  their  en- 
tering the  lung  tissue.  Tubercle  bacilli  may  get  into  the 
lungs  through  the  lymphatics  and  the  blood  vessels.  In 
the  bronchi  they  cause  local  inflammation.  It  may  be  a 
long  time  in  any  case  before  there  are  real  destructive 
changes,  and  when  such  do  occur  we  get  the  ordinary 
symptoms. 

Dr.  Elksner  respectfully  begged  to  differ  with  Dr. 
Loomis,  he  thought  that  previous  tubercular  infiltration 
was  possible,  and  then  necrosis  of  the  vessel.  The 
majority  of  cases  do  not  give  us  the  presence  of  tubercle 
bacilli.  Even  in  miliary  cases  you  have  great  difficulty 
in  making  a  diagnosis  between  phthisis  and  typhoid 
fever. 

Dr.  Loomis,  in  reply,  said  that  if  a  patient  has  symp- 
toms of  bronchitis,  no  bacilli  will  be  got.  He  would 
hesitate  to  pronounce  a  case  one  of  tuberculosis  unless 
the  sputum  gave  bacilli.  He  was  not  criticising  the 
views  of  others ;  merely  relating  an  experience  in  his  prac- 
tice. 

Dr.  Glasgow  deemed  creosote  very  valuable.  He  had 
not  noticed  any  kidney  effect.  He  gave  from  two 
to  seventy  minims  a  day,  depending  on  the  patient ; 
one  minim  seemed  to  poison  some.  The  creosote  he 
placed  in  a  little  whiskey,  and  that  was  mixed  with  milk 
and  cream.  He  got  striking  results  in  cases  of  bronchial 
phthisis  and  in  alveolar  phthisis.  Creosote  does  not 
have  any  effect  on  the  bacilli,  but  he  thought  that  it  has 
an  effect  on  the  poisons  they  generate.     He  also  believed 


in  the  good  result  of  inhaling  the  vapor  of  creosote  at 
night. 

Dr.  Curtain  closed  the  discussion,  and  expressed  his 
satisfaction  with  the  many  views  elicited. 

State  Prevention  of  Phthisis. — Dr.  Frederick  I. 
Knight,  of  Boston,  read  a  paper  entitled  "  Shall  Any- 
thing be  Done  by  Legal  Authority  to  Prevent  the  Spread 
of  Tuberculosis?1'  Twelve  years  since  the  real  nat- 
ure of  tuberculosis  was  made  public,  but  little  seems  to 
have  been  done  to  cope  with  the  disease  to  prevent  its 
spread.  He  reviewed  the  methods  recommended  by 
various  boards  of  health,  referring  to  the  action  of  the 
Pan-American  Medical  Congress  of  1893,  the  Ameri- 
can Public  Health  Association  of  1893,  and  their  action. 
The  method  adopted  by  the  New  York  Board  of  Health 
of  February,  1894,  was  deemed  an  advance.  Its  manifesto 
he  read  in  extenso.  In  his  State,  Massachusetts,  he 
deemed  the  time  right  for  its  practice.  The  Board  of 
Health  in  Massachusetts  had  issued  a  bulletin  and  a  leaflet 
covering  the  ground.  The  dangers  now  so  well  known  he 
reviewed.     Danger  of  sputa-infected  cattle  and  milk. 

Dr.  Bowditch,  of  Boston,  fully  concurred  in  the  views 
held  by  Dr.  Knight.  He  said  that  we  want  boards  of 
health  to  take  the  happy  medium  between  two  extremes. 
The  poorer  classes  should  be  under  the  observation  of 
such  boards,  the  better  classes  have  their  physicians. 

Dr.  Von  Ruck  referred  to  the  results  at  the  Loomis 
Laboratory,  New  York  City.  Also  to  Tissini's  work. 
Out  of  fifty  six  autopsies  made  by  him  in  ten  or  twelve 
death  was  due  to  accident.  In  them  tubercle  bacilli  were 
found  in  the  bronchi.  He  referred  to  the  disease-resist- 
ing power  of  men  who  ward  off  phthisis  and  other  dis- 
eases when  well — as  in  the  cases  mentioned,  had  warded 
off  phthisis;  but  where  the  vis  medicatrix  nature*  is 
lowered  by  typhoid  fever  or  influenza,  in  such  phthisis 
finds  a  foothold.  He  fully  concurred  in  the  views  ex- 
pressed by  Dr.  Loomis  as  to  bacilli  being  present  where 
there  weie  no  evidences  of  pulmonary  disease. 

Dr.  John  Winters  Brannan,  of  New  York,  referred 
to  several  years'  work  in  New  York  City  on  this  theme. 
The  timely  action  of  the  State  Board  of  Health  of  Michi- 
gan pleased  him.  Its  literature  used  the  proper  terms. 
He  said  that  tuberculosis  was  not  contagious  in  the  old 
sense  of  the  word.  The  Michigan  Board  of  Health  had 
been  very  happy  and  wise  in  stating  that  it  was  "  a  com- 
municable disease."  The  New  York  Board  was  prepared 
to  use  the  word  "  contagious  disease,"  but,  adopting  the 
wise  course  of  Michigan,  used  the  word  "  communica- 
ble/' instead.  Tuberculosis  is  a  communicable  dis- 
ease. 

He  referred  to  the  excellent  work  done  by  the  Board 
of  Health  of  New  York  in  dealing  with  diphtheria.  The 
Board  assisted  New  York  physicians,  and  by  its  judicious 
action  had  the  warm  sympathy  and  countenance  of  New 
York  practitioners. 

Dr.  Wolcott,  of  Boston,  endorsed  Dr.  Knight's 
views,  and  deemed  the  New  York  method  good,  an  ad- 
vance in  the  right  direction. 

Dr.  Andrew  H.  Smith  fully  endorsed  Dr.  Knight's 
statements  and  views.  He  was  in  favor  of  securing  the 
end  sought — protection — with  as  little  friction  as  possible. 

Dr.  Knight  closed  the  discussion.  He  was  very 
much  pleased  that  so  large  and  influential  a  meeting  en- 
dorsed his  views.  He  offered  the  following  resolution,  to 
be  submitted  to  the  Congress  the  following  day : 

"  Whereas •,  The  American  Climatological  Association 
was  founded,  among  other  objects,  to  promote  the  study 
of  the  nature  and  treatment  of  diseases  of  the  respiratory 
organs;  and 

"  Whereas  y  Tuberculosis  is  the  most  fatal  cause  of 
such  diseases ;  and 

"  Whereas ',  Modern  research  has  placed  this  disease 
among  the  infectious,  and  hence,  to  some  extent  at 
least,  among  the  preventable  diseases  ; 

"  Resolved,  That  this  Association  do  strongly  recom- 
mend all  boards  of  health  of  this  country  to  adopt 
means  tending  to  the  restriction  of  the  disease."^ 


July  28,  1894] 


MEDICAL   RECORD. 


123 


Third  Day,  Thursday,  May  31ST. 
Dr.  Isaac  Hall  Platt,  President,  in  the  Chair. 

The  Condition  of  the  Heart  in  Diabetes,  and  its  Rela- 
tion to  Diabetic  Coma. — Dr.  Leonard  Weber,  of  New 
York,  read  a  paper  with  this  title,  which  was  based  upon 
a  study  of  sixty  cases  in  his  practice.  The  majority  of 
the  patients  were  over  forty  five,  and  most  of  them  were 
women.  He  reported  two  cases  in  children — one  case 
in  a  child  aged  twelve,  due  to  scarlatina,  death  occurred 
three  months  later.  Another  case  in  a  child  following  a 
large  use  of  potassium  bromide.  In  cases  after  middle 
life  there  were  no  recoveries.  The  duration  of  the  dis- 
ease was  from  three  to  twenty  years. 

A  complication  of  renal  disease  renders  the  cases  more 
difficult.  The  condition  of  the  heart  must  then  be 
watched.  There  are  cases  where  the  heart  is  weary, 
overworked.  Such  cases  are  often  associated  with  ar- 
terial sclerosis.  The  acetone  odor  can  be  noticed  in  the 
breath,  marked  in  many  cases.  First  syncope,  followed 
by  speedy  cardiac  failure.  Heart  disease  is  not  so  rare 
in  these  cases.  The  speaker  cited  a  case  of  a  lady  aged 
seventy-three,  recently  dead.  She  had  had  the  disease 
thirteen  years.  Three  years  ago  it  showed  itself  in  weak- 
ness of  the  pulse — beats  twenty-four  to  thirty,  perfect 
bradycardia.  Death  was  easy  and  painless.  Her  husband, 
a  broker,  aged  seventy-two,  developed  diabetes.  Lived 
two  years. 

Diabetes  may  be  a  cause  of  neurc-muscular  disease, 
fatty  degeneration  of  the  heart,  etc.  Doubtless,  the 
poisonous  action  of  ptomaines  has  an  important  influ- 
ence. Gastro-intestinal  symptoms  and  marked  dyspepsia 
are  well  known  in  connection  with  diabetes  and  chronic 
interstitial  nephritis.  To  repeat,  the  heart  must  be 
watched  in  all  cases  of  diabetes.  The  diet  in  such  cases 
requires  careful  study. 

Diabetes  is  more  often  a  disease  of  the  whole  system 
than  any  special  organ.  Brain  and  heart  disease,  and 
locomotor  ataxia  may  be  found  as  complications. 

Ds.  Steven  Mackenzie,  of  London,  reported  eighty 
cases  ;  forty- five  died  suddenly.  In  the  profession  there 
is  an  increasing  opposition  to  an  exclusive  meat  diet. 
Adapt  the  therapeutic  requirements  to  individual  cases. 
Study  all  cases  on  their  individual  indications ;  obtain 
from  the  patient  a  minute  history  of  the  case.  Get  also 
fall  life  history.  There  are  no  fixed  rules  for  treatment. 
No  absolute  meat  diet ;  rest  and  massage ;  try  to  get  rid 
of  the  sugar;  try  the  usual  alkaline  treatment;  if  soda 
solutions  do  not  agree  he  gives  opium  in  some  cases ; 
watches  its  effect  on  heart  and  stomach.  Schlott's  method 
is  valuable. 

In  cases  of  diabetic  coma  he  deemed  it  most  impor- 
tant to  evacuate  the  bowels.  Then  fill  the  lower  colon 
with  alkaline  water.     So  far  he  has  seen  no  case  recover. 

Chronio  Heart  Disease  Treated  by  the  Schott  Method 
of  Baths  and  Gymnastics. — Dr.  Robert  H.  Babcock, 
of  Chicago,  read  a  paper  with  this  title.  The  baths  owe 
their  efficacy  to  saline  and  alkaline  constituents,  and 
also  to  their  warm  temperature.  Warm  baths,  in  such 
cases,  as  a  rule,  are  debilitating.  Temperature  should  be 
92°.to  930  F.,  gradually  reduced  to  870  F.  They  feel 
warm  at  920  F;  often  chilly  at  870  F.  The  duration  of 
the  bath  is  limited,  one  bath  a  day.  They  are  omitted 
every  fourth  day.  They  are  given  during  six  months. 
After  each  bath  the  patients  rest  an  hour,  to  rest  the  heart. 
Pulse  is  lower  during  the  bath.  Under  the  baths  there 
is  improvement  in  the  rate  and  quality  of  the  pulse. 
Sphygmographic  tracings  show  the  marked  improvement 
in  the  cardiac  currents.  Baths  lessen  the  rapidity  and 
decrease  the  force  of  the  heart's  action. 

The  baths  act  by  causing  contraction  of  the  cutane- 
ous vessels.  A  cold  bath  is  followed  by  a  slower  and 
stronger  pulse,  and  by  dilatation  of  the  internal  vessels. 
The  modus  operandi  of  the  baths  may  be  described  as 
follows :  First,  patient  may  experience  a  sensation  of 
chilliness,  followed  by  warmth,  due  to  the  gentle  stim- 
ulation of  the  cutaneous  nerves  caused  by  the  salines  in 


the  bath.  The  bath  is  an  aid  to  the  heart  Baths 
slow  and  strengthen  cardiac  contractions.  Light  exer- 
cises, gymnastic  movements  of  flexion  and  extension  of 
the  trunk — a  skilled  attendant  directs  them.  All  exer- 
cise within  fatigue.  No  exercise  is  peimitted  that  em- 
barrasses respiration.  Call  a  halt  when  theie  is  any  evi- 
dence of  dyspnoea.  The  exercise  acts  on  the  heart  and 
circulation  in  much  the  same  way  as  the  baths.  Gym- 
nastics slow  the  rate  and  increase  the  volume  of  the  pulse* 
A  sensation  of  comfort  follows  the  bathing.  Exercise 
improves  the  arterial  circulation.  Cases  so  treated  re- 
ceive permanent  amelioration. 

Dr.  Babcock  reported  19  cases  treated  by  him.  Nine 
males,  10  females.  He  deems  the  treatment  very  risky 
in  cases  of  aneurism  and  arterial  sclerosis.  Schott  does 
not  deem  chronic  interstitial  nephritis  as  contraindicating 
the  treatment. 

Dr.  Roland  G.  Curtin,  of  Philadelphia,  referred  to 
cases  in  the  Philadelphia  Hospital  where  there  was  tem- 
porary diabetes  or  saccharine  urine.  It  was  not  a  serious 
symptom  and  disappeared.     They  appeared  last  fall. 

Dr.  Glentworth  R.  Butler,  of  Brooklyn,  said  that 
the  disease  known  as  diabetes  was  but  a  s)mptom  of 
some  underlying  condition.  It  may  be  caused  by  some 
'lesion  of  the  liver  or  pancreas,  or  the  result  of  one 
of  the  numerous  processes  of  metabolism.  Glyco- 
suria is  the  symptom.  There  are  weak  hearts  in  such 
cases.  General  muscular  weakness  in  that  disease,  and 
the  heart  participates ;  degeneration  of  the  muscular  fi- 
bres of  the  heart.  Cited  a  case  in  his  practice.  Man 
aged  fifty -five.  Urine  showed  a  small  percentage  of  sug- 
ar— one  tenth  of  one  per  cent.  Coma  came  on  without 
any  warning.  Two  months  ago  had  an  attack  of  syn- 
cope, an  examination  revealed  dilatation  of  the  heart. 
Under  treatment  the  heart  improved.  Man  did  well,  ex- 
cept an  attack  of  syncope  of  very  brief  duration,  brought 
on  by  over-exeition.  Regarding  diet  in  diabetes,  he  ac- 
cepts no  fixed  rules.  The  general  condition  of  such  pa- 
tients is  impaired.  He  does  not  believe  in  cutting  off 
all  the  carbohydrates  and  saccharine  substances  at  once. 
He  mentioned  a  case  of  a  pregnant  woman.  Found  lac- 
tose in  the  urine.  It  was  due  to  irritation  of  the  nervous 
system.  She  improved  under  treatment  and  the  symp- 
toms disappeared. 

Dr.  Charles  E.  Quimby,  of  New  York,  referred  to 
the  defect  in  all  our  to  day  methods  in  treating  cardiac 
disease.  Arterial  extension  must  be  present  if  we  are  to 
have  good  circulation.  In  aortic  regurgitant  disease 
there  is  a  slowing  in  the  circulation.  He  thought  that 
the  indications,  in  the  treatment  of  valvular  lesions,  was 
to  hasten  circulation  and  keep  up  the  nutrition  of  the 
body. 

A  lew  and  Distinguishing  Sign  of  Latent  Aneu- 
rism of  the  Aorta. — Dr.  Glasgow,  of  St.  Louis,  Mo., 
said  that  in  most  cases  of  aneurism,  early  in  their  history 
there  was  an  utter  absence  of  dulness  on  percussion. 
That  at  a  later  period  only  were  physical  signs  manifest. 
Then  pressure  symptoms,  etc.,  gave  a  suspicion  of  the 
disease.  He  said  that  his  new  sign  in  thoracic  aneurism 
is  the  presence  of  a  systolic  sound  in  the  brachials— due 
to  vibration  of  their  walls;  that  it  was  synchronous 
with  the  systole  of  the  heart.  It  is  practised  by  having 
the  patient  extend  the  arm  at  a  right  angle  from  the  body, 
and  by  placing  the  ear  over  the  brachial.  The  vibrating 
sound  got  by  the  ear  he  designates  as  his  new  sign  of 
aortic  aneurism.  He  finds  no  mention  of  such  a  sound 
in  the  older  English,  French,  or  German  classics  on 
heart-disease  and  aneurism.  He  gave  reports  on  five 
cases  in  his  practice. 

Dr.  Murray,  of  Washington,  presented  a  patient 
whom  he  regarded  as  a  ''suspect."  The  man  was  a 
negro,  aged  twenty-six.  Pulse,  irregular;  pain  in  the 
left  side ;  pain  in  shoulder  to  wrist  left  side ;  right  side, 
a  small  area  of  dulness ;  no  cardiac  murmur ;  heart  ap- 
parently normal.  He  suspected  aneurism.  Dr.  Glas- 
gow had  called  on  him  ;  he  practised  Dr.  Glasgow's  path- 
ognomonic sign,  and  found  the  brachial  systolic  sound. 


124 


MEDICAL    RECORD. 


[July  28,  1894. 


Dr.  Curtin,  of  Philadelphia,  had  been  working  in 
much  the  same  direction — an  earlier  means  for  discover- 
ing aneurism.  He  thinks  that  digitalis  increases  the 
force  of  the  heart  and  increases  the  aneurism.  Had 
been  experimenting  on  the  effects  of  pressure  on  the 
chest-walls,  with  a  view  to  an  easier  location  of  aneu- 
rism. Had  reduced  chest  circumference  an  inch  and  a 
half;  described  a  method  of  bending  forward  to  facilitate 
feeling  an  aneurism  through  the  suprasternal  fossa. 

Ozone  in  Phthisis. — Dr.  Charles  E.  Quimby,  of  New 
York  City,  read  a  paper  entitled,  "  Ozone  in  Phthisis, 
with  special  reference  to  the  Pneumatic  Cabinet." 

Reviewing  the  medical  history  of  phthisis,  tubercle 
bacilli,  and  medical  agents,  he  said  that  the  use  of  creo- 
sote may  be  due  to  the  lingering  belief  that  it  acts  as  a 
germicide.  Since  he  had  made  a  systematic  study  of 
the  disease,  he  wished  to  attack  it  through  the  systemic 
forces.  He  referred  to  recurrent  tubercular  and  septic 
influences.  For  a  year  past  his  agents  in  treatment  had 
been  three,  alcohol,  creosote,  and  oil  of  cloves. 

Mention  was  made  of  an  apparatus  devised  by  him 
fulfilling  all  requirements.  His  plans  were  available  to 
anyone  interested  in  the  matter.  Next  he  dwelt  at 
length  on  the  powerful  oxydizing  properties  of  ozone. 
It  was  described  as  stimulant.  Reviewing  the  pathology 
of  phthisis  he  said  that  a  large  number  of  cases  were 
adynamic  in  character — a  fact  duly  recognized  by  Koch. 
In  the  disease  there  was  a  degeneration  and  necrotic 
activity. 

The  use  of  the  pneumatic  cabinet  and  ozone  was  de- 
scribed. The  treatment  was  applicable  in  any  stage  of 
the  disease.  He  reported  a  number  of  cases  benefited  by 
the  treatment.  He  makes  no  claim  that  they  are  cured ; 
changes  noted  are  due  to  local  stimulation.  Ozone 
is  a  powerful  stimulant  to  the  mucous  membranes.  It  is 
a  pulmonary  antiseptic,  an  agent  of  known  value.  He 
does  not  know  of  any  remedy  that  will  destroy  tubercle 
bacilli  in  the  tissues.  Effects  of  ozone  on  tubercle  ba- 
cilli in  sputa  are  nil. 

The  ozone  treatment  gives  a  prompt  reduction  in  tem- 
perature. It  gives  a  result  quite  equivalent  of  climatic 
influences.  The  value  of  an  ozonized  atmosphere  in 
phthisis  is  marked.  Some  patients  cannot  take  iron 
without  headache.  Several  of  this  kind  after  the  treat- 
ment have  been  able  to  assimilate  iron.  In  some  cases 
under  cabinet  treatment  the  area  of  respiration  is  re* 
stored.  Believes  that  ozone  meets  the  demands  of  the 
system,  called  it  a  respiratory  food.  It  can  be  generated 
in  houses. 

9  :  Tuberculosis  in  Domestic  Pets. — Professor  Frohner, 
of  the  Berlin  Veterinary  School,  has  recently  made  some 
investigations  as  to  the  prevalence  of  tuberculosis  among 
small  domestic  animals,  the  results  of  which  are  as  im- 
portant as  they  are  interesting.  In  the  clinic  for  small 
animals  during  the  last  seven  years,  out  of  a  total  number 
of  70,000,  only  281,  or  0.4  per  cent,  have  been  found  to 
be  suffering  from  tuberculosis.  The  proportion  of  tuber- 
culous dogs  was  as  low  as  0.04  per  cent. ;  cats  seem  to 
be  considerably  more  subject  to  the  disease,  the  propor- 
tion of  tuberculosis  among  them  being  one  per  cent.  The 
animals  most  severely  affected  are  parrots,  the  ratio  of  tuber- 
culosis among  them  being  twenty  five  per  cent.,  no  doubt 
owing  to  imperfect  acclimatization.  Living  as  these 
birds  mostly  do  in  rooms  constantly  used  by  members  of 
the  family,  their  liability  to  tuberculosis  makes  them 
somewhat  dangerous  pets. — British  Medical  Journal. 

Ascites  and  Resignation. — Dr.  Kelley,  writing  in  the 
Cleveland  Medical  Gazette,  says  that  he  recently  saw  a 
tombstone  in  the  Bunhill  Fields  burying-ground,  Lon- 
don, upon  one  side  of  which  was  the  usual  inscription  of 
nam;,  age,  and  date  of  death,  while  upon  the  other  side 
was  carved  a  clinical  history  reading  as  follows : 

In  67  months  she  was  tap'd  66  times 
Had  taken  away  240  gallons  of  water 
Without  ever  repining  at  her  case 
Or  ever  fearing  the  operation. 


OUR  LONDON  LETTER. 

(From  our  Special  Correspondent.) 

ROYAL  MEDICAL  AND   CHIRURGICAL   SOCIETY CARDIAC  SE- 

QUEUE  OF  INFLUENZA — PAIN  IN  REGION  OF  HEART- 
ACCELERATION  OF  BEATS — A  CASE  OF  ACANTHOSIS  NI- 
GRICANS—  SIR  GEORGE  HUMPHREY,  F.R.S. — HEALTHY 
LONDON — PREVALENCE  OF  SMALL  POX — EXTENSION  IN 
THE  PROVINCES — THE  LEICESTER  CRAZE — THE  LOCAL 
PRESS — DEATHS  OF  PROFESSOR  JOHN  CLAY,  W.  L.  UN- 
DERHILL,   DAVID   TAYLOR,   PROCTOR  S.   HUTCHINSON 

London,  June  20, 1894. 

The  concluding  meeting  of  the  Royal  Medical  and  Chi- 
rurgical  Society  was  held  on  the  12th  inst,  when  Dr.  San- 
som  read  a  paper  on  tachycardia  and  cardiac  pain  after 
influenza.  He  had  met  with  100  cases  in  which  cardiac 
disturbances  had  followed  influenza  at  more  or  less 
distant  intervals.  Of  these  there  were  23  of  pain,  and 
37  of  tachycardia ;  25  irregularity  (arhythmia) ;  5  of 
bradycardia,  and  10  of  organic  disease.  The  present 
communication  dealt  with  the  first  two  sections  of  cases. 
The  pain  experienced  in  the  region  of  the  heart  was  in 
some  cases  paroxysmal  and  in  some  resembled  angina ; 
in  others  it  was  more  or  less  protracted.  It  might  be 
intense  and  sudden,  so  that  some  patients  fell  completely 
unconscious.  In  some  unconsciousness  occurred  paroxys- 
mally  in  the  absence  of  severe  pain.  There  were  not 
the  associated  signs  of  true  angina  pectoris.  Hysteria 
was  excluded,  for  several  patients  were  men,  and  some 
typical  athletes,  who  had  been  in  perfect  health  until  their 
attack  of  influenza.  In  the  cases  manifesting  more  con- 
stant pain  the  beating  of  the  heart  was  often  accompanied 
by  subjective  discomfort ;  there  were  sometimes  tender 
spots  in  the  intercostal  spaces  close  to  the  sternum,  with 
more  deeply  seated  pain  in  defined  situations,  and  in  sev- 
eral instances  symptoms  of  concomitant  neuritis  involving 
some  of  the  nerves  proceeding  from  the  brachial  plexus. 
He  attributed  the  symptoms  to  a  neuritis  affecting  some 
of  the  ganglia  of  the  cardiac  plexuses,  or  to  a  disturbance 
of  the  sensorium  analogous  to  that  in  epileptiform  neu- 
ralgia or  in  visceral  neuralgia.  Quinine  in  five  grain 
doses,  with  antispasmodics,  morphia  sparingly  and  cau- 
tiously administered  subcutaneously,  and  a  course  of  the 
bromides  and  iodides  with  arsenic  were  recommended. 
Good  results  might  follow  the  use  of  a  weak  continuous 
galvanic  current  from  the  nape  of  the  neck  to  the  region 
of  the  vagus.  Next,  as  to  the  cases  of  tachycardia  fol- 
lowing influenza.  It  might  occur  immediately  after  the 
attack  or  after  several  months,  and  continue  for  long 
periods — at  least  eighteen  months.  In  many  cases  the 
heart  was  very  irritable,  quickened  action  being  pro- 
voked by  very  slight  causes  or  occurring  at  intervals 
without  assignable  cause.  It  might  be  accompanied  by 
many,  or  even  by  all,  the  signs  of  Graves's  disease — a 
circumstance  which  was  of  interest  in  the  question  of 
pathology  of  the  latter  affection.  The  most  probable 
initial  cause  was  a  disturbance  of  the  vagus  at  its  origin 
or  in  some  parts  of  its  course,  whereby  its  controlling 
power  over  the  cardiac  contractions  became  impaired ; 
possibly  irritative  lesions  of  the  accelerator  nerves  of  the 
heart,  in  the  cdrd,  in  the  course  of  the  sympathetic  fila- 
ments, or  in  the  ganglia,  might  be  concurring  causes,  and 
in  some  cases  hypersecretion  by  the  thyroid  might  be  a 
subsidiary  cause.  In  the  treatment  of  post-influenzal 
tachycardia  drugs  seemed  to  be  inefficacious  except  as 
modifying  the  associated  symptoms,  but  the  systematic 
use  of  weak  continuous  galvanic  currents  from  the  nape 
of  the  neck  to  the  region  of  the  vagus  might  be  followed 
by  good  results. 

Dr.  Althaus  remarked  that  hysteria  was  met  with  in  a 
considerable  number  of  men.  In  addition  to  the  treat- 
ment which  had  been  adopted,  he  had  employed  salicy- 
late of  soda  with  much  benefit  in  the  early  stages,  while 
later  a  combination  of  phenacetin  and  caffein  gave  ad- 


July  28,  1894] 


MEDICAL   RECORD. 


"5 


curable  results.  The  continuous  galvanic  current  was 
useful,  a  good  effect  being  obtained  by  one  miliiamp&re. 
As  to  the  cause  of  the  tachycardia,  though  there  might 
be  in  some  a  peripheral  neuritis  of  the  vagus,  he  thought 
that  the  cardiac  and  vasomotor  centres  in  the  bulb 
were  more  at  fault.  He  had  never  seen  vomiting  in 
these  cases,  though  it  ought  to  be  common  in  peripheral 
neuritis  of  the  vagus  He  had  seen  polyuria,  glycosuria, 
and  albuminuria  all  follow  influenza,  and  this  latter  sug- 
gested the  medulla  oblongata  as  the  seat  of  the  lesion. 
As  to  the  pathology  of  Graves's  disease,  some  French  ob- 
servers had  considered  it  to  be  a  neurosis  which  left  no 
anatomical  evidence  in  the  nervous  system,  while  German 
physicians  had  attributed  it  to  perverted  nutrition  of  the 
thyroid  body.  He  himself  had  regarded  it  as  an  organic 
disease  of  the  medulla  oblongata,  and  he  rested  his  con- 
clusions on  both  clinical  and  experimental  grounds.  It 
had  been  shown  in  animals  that  if  the  restiform  bodies 
were  injured  the  symptoms  of  Graves's  disease  would  be 
produced,  and  the  results  of  necropsies  on  the  human 
subject  had  revealed  degenerations  in  different  parts  of 
the  medulla.  He  had  never  seen  an  instance  of  com- 
plete recovery  from  Graves's  disease,  the  mortality  from 
which  was  very  considerable,  even  as  high  as  fifty  per 
cent.,  and  in  some  who  died  very  suddenly  the  cause 
appeared  to  be  a  failure  of  the  cardiac  centre  in  the 
medulla.  Mr.  Spencer  Watson  asked  Dr.  Sansom  what 
were  the  signs  by  which  it  was  possible  to  distinguish 
tachycardia  and  heart  pains  due  to  influenza  from  those 
due  to  other  causes ;  and  whether  any  group  of  cardiac 
symptoms  consecutive  to  epidemics  of  influenza  had  not 
before  been  seen  in  association  with  other  diseases.  In 
reply  to  this  and  questions  by  other  speakers,  Dr.  San- 
som said,  the  chain  of  evidence  between  influenza  and 
the  sequelae  seemed  to  be  complete  in  his  cases,  and  he 
had  never  observed  a  similar  grouping  of  symptoms 
without  a  previous  attack  of  influenza.  He  agreed  that 
salicylate  of  soda  was  good  in  the  early  stages  and  in  the 
pyrexial  period,  but  he  had  been  chary  of  pushing  it  on 
account  of  the  liability  of  its  producing  toxic  effects. 
Phenacetin  and  caffein  he  had  found  very  valuable.  As 
to  the  question  of  absolute  recovery  from  Graves's  disease, 
he  had  seen  some  very  bad  cases  get  absolutely  well,  ex- 
cept for  an  occasional  outburst  of  emotional  disturbance 
to  which  so  many  women  were  liable.  As  regarded  the 
urine,  he  had  noticed  exceptionally  large  quantities  of 
nitrogenous  products  excreted,  and  sometimes  albu- 
minuria. He  had  never  seen  glycosuria  in  post  influ- 
enzal tachycardia,  though  he  had  met  with  it  in  Graves's 
disease.  Although  he  had  never  seen  a  typical  case  of 
spasmodic  asthma  due  to  influenza,  yet  he  had  seen 
several  cases  of  marked  dyspnoea  of  a  peculiar  character 
often  spoken  of  as  "  tachypneea."  There  seemed  to  be 
a  general  consensus  of  opinion  that  the  symptoms  noted 
were  due  to  changes  in  the  central  nervous  system,  and 
these  changes  might,  he  suggested,  be  minute  hemor- 
rhages. If  these  hemorrhages  occurred  in  a  region  which 
Impaired  the  function  of  the  vagus,  then  tachycardia 
would  result ;  but  if  they  occurrwi  lower  down,  brady- 
cardia and  cardiac  irregularity  would  be  produced. 

At  this  meeting  Mr.  Morris  showed  a  single  woman, 
aged  thirty-five,  suffering  from  widely  disseminated  dis- 
coloration of  the  skin,  with  diffuse  warty  growths  in  vari- 
ous parts,  which  he  submitted  as  an  example  of  the  dis- 
ease called  by  Unna  "  Acanthosis  nigricans."  Only  two 
similar  cases  had  been  recorded  (Politzer,  Janovsky). 
Nothing  was  known  as  to  its  pathology.  Dr.  Eddowes 
produced  some  sections  taken  from  Politzer's  case.  A 
great  deal  of  discoloration  appeared  to  be  due  to  dirt,  as 
was  the  case  in  ichthyosis.  He  suggested  that  there  was 
a  close  connection  between  this  condition  and  seborrhoeic 
eczema. 

London.  June  30,  1894. 

Sir  George  Humphrey  has  been  so  ill  as  to  give  con- 
siderable anxiety  to  his  numerous  friends.  At  his  best 
he  is  not  very  strong,  and  has  suffered  several  attacks  of 
illness.     This  time  a  severe  abdominal  attack  has  laid 


him  aside,  and  phlebitis,  from  which  he  had  previously 
suffered,  reappeared.  I  am  glad  to  be  able  to  report 
that  during  the  week  convalescence  seems  to  have  set 
in  steadily.  Everyone  is  wishing  him  complete  re- 
covery. 

Although  we  make  such  frequent  complaints  of  insani- 
tary conditions  and  preventable  diseases,  it  is  not  to  be 
supposed  that  Londoners  are  exposed  to  greater  dan- 
gers than  other  citizens.  In  fact,  not  a  few  of  us  have 
long  been  satisfied  that  we  live  in  the  healthiest  city  in 
the  world,  and  our  boast  to  this  effect  is  just  now  sup- 
ported by  official  mortality  records.  For  a  month  past 
London  mortality  has  been  at  the  rate  of  only  16.3  per 
1,000,  while  in  Paris  it  has  been  20.5,  in  Berlin  18.2,  and 
Vienna  22.5.  Even  you  in  New  York  have  been  consid- 
erably above  us,  although  below  Paris  and  Vienna. 

We  are,  however,  by  no  means  free  from  zymotic  dis- 
eases, and  the  continued  prevalence  of  small-pox  is  most 
unsatisfactory.  There  were  fewer  admissions  last  week 
to  the  hospitals.  Still  there  remained  170  cases  under 
treatment.  This  is  21  less  than  the  previous  week,  and 
with  fewer  fresh  cases  reported  we  may  anticipate  a  de- 
cline. But  a  more  serious  circumstance  is  the  diffusion 
of  this  disease  in  the  provinces.  A  great  number  of 
towns  have  now  contributed  their  quota  to  the  records, 
and  although  in  most  of  them  the  outbreaks  have  been 
localized,  the  necessity  of  looking  to  our  armor  has  been 
made  manifest  to  all  but  the  most  perverse  faddists.  Of 
these  Leicester  has  for  some  time  been  the  head-quarters. 
In  that  town  the  local  authorities  have  boasted  of  a 
"  system  "  of  their  own  and  rejected  vaccination.  They 
have  not,  however,  escaped  an  epidemic,  and  the  last  re- 
port of  the  medical  officer  of  health  for  the  town  is  a 
most  instructive  document.  Its  influence  is,  unfortu- 
nately, likely  to  be  lessened  by  the  determined  opposition 
of  the  anti-vaccination  faction,  led  by  Mr.  Biggs,  a  town- 
councillor,  and  a  member  of  the  sanitary  committee,  who 
seems  to  fancy  this  office  qualifies  him  to  pass  judgment 
on  medical  questions ;  for  he  has  not  hesitated  to  enter 
into  controversy  with  the  medical  officer  of  health  and 
to  criticise  his  actions  with  no  little  acerbity.  Moreover, 
this  same  oracle  has  ventured  to  call  in  question  the 
treatment  of  cases  in  the  hospital.  Such  inflated  self- 
assurance  should  open  the  eyes  of  his  fellow-townsmen 
to  the  absurdity  of  being  led  by  one  whose  vanity  is  his 
chief  qualification  for  setting  up  his  private  prejudice 
against  the  views  of  a  profession  of  which  he  has  not  ac- 
quired the  most  elementary  lessons. 

But  a  sadder  spectacle  than  that  of  the  self  opinionated 
town  councillor  is  the  attitude  of  the  local  press,  which 
has  lent  its  influence  to  what  I  suppose  it  imagines  to  be 
the  popular  view,  for  it  is  difficult  to  believe  that  the  staff 
of  a  daily  paper  should  be  completely  blinded  by  the  fad- 
dists. Statistics  are  thrown  about  in  a  manner  that  would 
make  the  real  statistician  aghast,  and  which  tend  to  en- 
courage the  notion  that "  anything  may  be  proved  by  fig- 
ures." I  have  friends  at  Leicester  who  are  intelligent, 
but  the  faddists  at  present  are  in  the  majority.  There 
may  be  a  rude  awakening  for  them  yet.  Of  course  for  the 
time  the  town  enjoys  the  protection  afforded  by  the  vac- 
cination of  the  adult  population  before  the  present  craze 
existed.  When  mothers  learn  how  their  infants  have 
been  sacrificed  to  this  craze  there  maybe  a  wailing  which 
the  most  infatuated  faddists  may  regret  to  have  had  any 
share  in  producing. 

Death,  ever  busy  in  our  ranks  cutting  down  both  young 
and  old,  often  gives  occasion  to  sad  notices  from  my  pen. 
John  Clay,  of  Birmingham,  has  passed  away  after  a  short 
illness,  aged  seventy-three.  Your  readers  will  remember 
how  some  years  ago  he  thought  he  had  found  a  remedy 
for  some  forms  of  cancer  in  chian  turpentine.  But  he 
had  done  good  work  as  obstetric  surgeon  to  the  hospital 
and  professor  at  the  Queen's  College.  He  enjoyed,  too, 
a  large  practice.  On  the  23d  inst.  Mr.  W.  L.  Underhill, 
of  Tipton,  was  buried  in  the  local  cemetery.  He  had 
passed  a  long  and  active  life  in  the  town,  reaching  the 
age  of  eighty.     David  Taylor,  another  veteran  whose 


126 


MEDICAL   RECORD. 


[July  28,  1894 


sons  are  among  us,  died  on  the  16th  inst,  in  his  eighty- 
sixth  year. 

In  contrast  with  these  comes  the  demise  of  Proctor,  the 
second  son  of  Mr.  Jonathan  Hutchinson,  who  died  this 
week,  aged  only  thirty-one.  His  health  had  not  been  ro- 
bust, and  he  had  travelled  in  the  colonies  and  the  States 
before  settling  down  to  practice.  After  doing  so  he  again 
broke  down  and  gave  up  his  London  prospects  and  went 
again  to  Canada.  For  a  time  he  improved,  but  eventually 
returned  to  spend  his  last  days  at  home,  as  many  another 
promising  young  practitioner  has  done.     Sic  transit. 


THE   MEDICAL  OPPORTUNITIES   OF  PARIS. 

To  the  Editor  of  the  Medical  Record. 

Sir  :  A  medical  student,  earnestly  desiring  to  do  best 
work  in  the  best  place,  I  was  surprised  always  and  often 
annoyed  by  the  question  universally  put  to  me  by  my  fel- 
lo  w-  Americans  on  learning  that  I  was  pursuing  my  medical 
studies  at  Paris :  "  But  why  do  you  not  do  all  of  that  in 
America." 

It  was  no  mere  chance  which  decided  me  to  prepare 
myself  there,  but  a  well-grounded  determination  after 
careful  inquiry  in  regard  to  the  advantages  of  the  best 
medical  schools  of  the  United  States,  Great  Britain,  Ger- 
many, Austria,  and  France. 

The  faults  of  others  will  not  form  the  subject  of  this 
paper,  though,  after  detailing  the  preparation  of  a  doctor 
of  medicine  here,  it  might  subsequently  be  interesting  to 
draw  comparisons  between  this,  other  European,  and 
American  requirements  for  a  medical  degree.  The  ob- 
ject of  this  paper  is  merely  to  answer  the  question  of  my 
American  friends  by  outlining  the  work  that  is  required 
here,  and  also  enumerating  the  special  opportunities  of- 
fered at  Paris  for  advanced  and  efficient  work  in  special 
branches  of  medical  science. 

The  paper  may  have  a  public  interest  in  that  public 
attention  should  be  drawn  to  the  preparation  that  is  given 
to  medical  men,  the  doctors  to  whom  each  family  in- 
trusts the  lives  of  its  members  in  times  of  critical  illness, 
and  to  whose  wisdom  and  efficiency  implicit  confidence 
must  be  given.  For  this  the  public  is  interested  that  its 
medical  service  be  adequately  prepared  and  trained. 

Do  we  give  proper  attention,  in  the  requirements  of  our 
medical  schools,  to  insure  an  attendance  and  care  that 
vital  necessity  and  a  public  conscious  of  its  dependence 
should  demand  ? 

Examine  the  preparatory  work  of  the  continental 
medical  student.  Study  the  American  school  in  com- 
parison. Offset  the  vital  and  casualty  statistics  of  the 
two  worlds,  with  due  allowance  for  difference  of  race  and 
climate.  Then  come  to  a  conclusion  founded  upon 
positive  knowledge,  and  not  hearsay  evidence  or  impres- 
sion. 

How  is  a  doctor  trained  in  France  ?  What  is  the  re- 
quirement and  the  signification  of  the  degree  "  Docteur 
en  Medecine  "  of  the  University  of  Paris  ? 

To  commence  the  courses  of  the  medical  school  a  can- 
didate must  be  already  provided  with  the  degrees  of 
"Bachelier  es  Lettres"  and  "  Bachelier  es  Sciences." 
In  short,  a  graduate  of  the  high  standard  colleges  of  the 
United  States  finds  himself  admissible  to  commence  his 
medical  studies  here. 

The  courses  commence  in  the  early  part  of  October, 
and  continue,  with  but  two  weeks'  interruption,  until  the 
middle  of  August,  ten  months.  The  student  follows  a 
full  and  carefully  compiled  programme  of  study  for  four 
years,  before  becoming  admissible  for  his  final  and  severe 
examinations,  three  in  number,  but  each  divided  into 
several  parts.  The  examinations  are  grouped  as  follows. 
At  the  end  of  the  first  year's  work,  examinations  "  in 
course"  of  the  first  year's  studies  must  be  passed,  viz 
chemistry,  the  general  science,  organic  and  inorganic, 
with  applications  to  medicine;  physics  in  like  manner; 
zoology,  in  general,  with  parasitology,  bacteriology,  and 
comparative  anatomy ;  botany,  in  general,  and  materia 


tnedica;  histology,  general  and  technical.  Twenty 
months  later,  or  half  way  through  his  third  year,  the  stu- 
dent presents  himself  for  examination  in  general  and  de- 
scriptive anatomy,  with  practical  exercise  with  the 
cadaver  and  subsequent  demonstration  of  his  preparation. 
This  is  perhaps  the  most  exacting  of  all  examinations,  on 
account  of  the  minutiae  of  detail  and  technique  demanded, 
and  covering  two  years'  work  in  the  dissecting  rooms. 

At  the  beginning  of  the  fourth  year  the  examination  in 
physiology  must  be  passed,  and  after  the  completion  of 
the  fourth  year  come  the  strictly  medical  examinations, 
and  here  lies  the  test  of  four  years'  work.  The  student 
presents  himself  the  fifth  October  after  the  commence- 
ment of  his  medical  course,  for  the  final  and  conclusive 
series  of  examinations  for  his  degree. 

The  first  of  these  comprises  the  subjects  of  operative 
surgery,  external  pathology  and  obstetrics,  with  practical 
demonstrations,  before  a  jury,  of  surgical  operations. 
After  this  examination  (which  is  called  the  first  part  of 
the  third,  lasting  several  weeks,  with  delays  more  or  less 
prolonged  according  to  the  need  of  special  preparation) 
the  student  undergoes  the  last  part  of  the  examination, 
this  time  on  the  subjects  of  internal  pathology,  or  pare 
and  general  medicine. 

Some  time  later,  according  to  the  wish  of  the  student 
and  his  readiness  in  preparation,  comes  the  fourth  exam- 
ination. The  subjects  are  hygiene,  legal  medicine, 
materia  medica,  therapeutics,  and  pharmacology. 

Last  of  all  the  fifth  examination,  and  in  this  one  all 
the  force  of  the  student  must  be  called  into  play.  The 
examination  consists  of  three  clinics,  one  in  medicine, 
another  in  surgery,  and  the  other  in  obstetrics,  made  by 
the  student  before  an  examining  jury,  selected  for  each 
specialty,  each  member  of  which  designates  a  patient 
chosen  at  the  time  of  examination,  giving  the  candidate 
ten  minutes  to  examine  his  case,  but  no  means  of  book 
preparation  or  assistance  other  than  his  own  knowledge 
and  personal  interrogation  of  the  case  in  question.  This 
examination  is  an  affair  of  several  weeks,  and  its  success- 
ful termination  lifts  a  burden  from  the  student's  mind. 
Between  him  and  his  medical  degree  there  is  now  but  one 
step — the  thesis. 

The  thesis  must  be  on  a  medical  subject  chosen  by  the 
student,  and  approved  by  an  examining  committee.  To 
this  subject  are  brought  all  results  of  personal  observa- 
tion and  investigation  possible  for  the  candidate  to 
gather  and  digest.  Much  original  work  and  many  valu- 
able counsels  of  his  masters  are  there  expressed  in  a  well- 
developed  solution,  the  results  of  medical  query  and  theo- 
retical problems  not  before  determined  to  scientific 
satisfaction.  The  thesis  is  a  matter  of  at  least  six  months' 
devoted  labor,  and  it  is  not  rare  to  find  a  thesis  the  re- 
sult of  several  years  of  most  exhaustive  and  thorough 
study.  With  the  presentation,  publishing,  and  public 
sustentation  of  his  thesis,  our  medical  man  reaches  his 
goal ;  and,  with  a  hard-earned  degree,  finishes  his  student 
career  to  commence  the  public  duty  for  which  he  is  so 
well  qualified. 

At  Paris  one  does  not  study  medicine  for  the  "  fun  of 
it ;  "  nor  to  be  called,  in  after  life,  by  the  high  sound- 
ing name  of  "  Doctor."  The  study  costs  too  dearly  for 
that,  and  by  the  bedside,  through  all  those  years  of  ser- 
vice for  the  sick  and  poor,  one  leaves  the  personal 
vanity  that  demands  a  sounding  title.  Nothing  but 
earnest  determination  and  fondness  for  scientific  work 
for  a  chosen  profession  gives  the  courage  to  continue  to 
the  well-merited,  but  poorly  recompensed  end  of  the 
student's  efforts. 

In  preparation  for  the  examinations  the  student  has  re* 
course  to  three  sources,  his  books,  the  instruction  given 
by  the  medical  faculty  and  the  hospital. 

For  the  books  little  need  be  said  ;  the  masters  of  all 
branches  of  the  sciences  are  at  hand,  modern,  complete, 
plentiful,  varied,  and  not  too  expensive. 

The  medical  faculty  of  Paris  belongs  to  the  largest 
university  in  the  world,  and  naturally  has  more  students 
by  several  hundred,  by  official  statistics  of  last  year, 


July  28,  1894] 


MEDICAL   RECORD. 


127 


than  any  other  medical  faculty.  Consequently  the  force 
of  instructors  is  very  large.  The  faculty  counts  thirty- 
five  professorial  chairs  which  give  instruction  throughout 
the  entire  year.  Besides  countless  laboratory  assistants, 
demonstrators,  professor's  aids  and  clinical  aids,  the  force 
of  professors  in  activity  the  present  year  numbers  seventy 
or  more. 

Practical  laboratory  work  is  required  for  the  following 
subjects :  physics,  chemistry,  zoology,  botany,  histology, 
physiology,  anatomy,  pathological  anatomy,  operative 
surgery,  with  short  courses  in  bacteriology,  pharmacology, 
experimental  pathology,  general  pathology,  therapeutics, 
obstetrics,  legal  medicine,  and  hygiene. 

During  the  year  there  are  delivered  by  the  professors 
of  the  faculty,  at  least  twelve  hundred  lectures  and 
seven  hundred  clinics,  so  divided  as  to  give  three 
lectures  a  week  upon  each  of  the  subjects  of  instruction  ; 
but  for  internal  and  external  pathology,  legal  medicine 
and  obstetrics,  twice  that  amount,  one  lecture  every 
day  on  each  subject  throughout  the  school  year,  is  given. 
The  clinical  professors  each  give  two  clinics  per  week. 
They  are  numbered  and  assorted  as  follows:  Medical 
clinics,  four  professors ;  surgical,  four ;  obstetrical,  two ; 
mental  pathology,  children's  diseases,  skin  and  syphilitic 
diseases,  diseases  of  the  nervous  system,  ophthalmic  and 
diseases  of  the  urinary  organs,  each  one  professorial 
clinic. 

After  the  books  and  the  faculty,  but  not  the  least  im- 
portant, comes  the  hospital  work  of  the  student.  For 
the  last  two  years  of  his  course  he  is  obliged  to  serve  in 
the  hospital  two  hundred  and  eighty-four  days  of  each 
year.  Without  this  regular  service  he  cannot  be  allowed 
to  continue  his  medical  course.  Most  of  the  students 
do  much  more  than  this  and  follow  regularly  the  hos- 
pital work  for  four  years  or  more. 

The  students  at  the  hospitals  are  under  the  control  of 
the  physician  in  charge  of  the  service,  the  direct  super- 
vision of  the  chief  of  the  resident  service,  and  subject  to 
the  direction  of  the  house  physician  of  the  service  in 
which  the  student  is  accepted  as  an  aid.  In  this  way  a 
systematized  grade  of  bedside  instruction  and  clinical  ob- 
servation is  maintained  in  all  of  the  hospitals,  while,  at  the 
same  time,  the  student  serving  as  an  aid  must  do  all  the 
practical  work  himself  as  fast  as  he  becomes  well  grounded 
in  its  principles. 

There  are  in  all  twenty  six  hospitals  to  which  the  stu- 
dents have  free  access  and  in  which  they  are  invited  to 
serve  according  to  their  choice.  In  these  hospitals  are 
fifteen  thousand  beds,  always  full.  The  acting  surgeons 
and  physicians  of  this  immense  organization  of  hospi- 
tals are  the  best  practitioners  in  France,  chosen  by 
competitive  examination,  in  a  struggle  where  success 
means  the  only  way  to  establish  a  living  practice  at  Paris. 
All  of  these  surgeons  and  physicians  devote  to  the  hospi- 
tals the  morning  of  every  day  in  the  year,  year  after  year 
until  retired  by  death  or  age. 

In  the  hospitals,  many  clinics  and  lessons  are  given  in 
addition  to  those  under  the  auspices  of  the  faculty  and 
already  mentioned. 

At  present  there  are  given  no  less  than  thirty  such  les- 
sons and  clinics  each  week.  Each  specialty  has  its 
masters  and  its  own  hospital  service;  thus  enabling  the 
student,  already  strong  in  his  general  medical  education, 
to  choose  and  pursue  to  best  advantage  his  chosen  spe- 
cialty. 

In  addition  to  all  of  these  advantages  is  another  that  is 
often  appreciated.  Every  student  of  the  faculty  of  med- 
icine is  admitted  without  charge  to  all  of  the  courses  and 
laboratories  of  La  Sorbonne — i  e.  Faculty  of  Sciences, 
College  de  France  and  of  the  Museum  d'Histoire  Natu- 
relle.  These  three  institutions  give  the  most  advanced 
courses  of  science,  language,  and  philosophy. 

At  the  College  de  France  during  my  course  were  the 
famous  Professors  Berthelot  and  Schiitzenberger  in 
chemistry ;  Brown-Slquard  in  medicine ;  Balbiani,  com- 
parative embryogeny;  Ranvier,  histology;  Ribot,  ex- 
perimental psychology ;  Renan,  the  philosopher ;  Gaston 


de  Paris,  the  philologist  and  so  through  a  list  of  famous 
names  that  this  paper  has  not  space  to  enumerate. 

At  the  Museum  d'  Histoire  Naturelle  were  given  the 
courses  of  Fremy,  Van  Tieghem,  £mile  Blanchard,  A. 
Milne  Edwards,  DeQuatrefages  and  others. 

The  faculty  of  sciences  at  the  Sorbonne  includes  the 
instruction  of  Poincarre,  Javal,  Troost,  Pellat,  Lippman, 
Friedel,  and  Wolf,  with  many  others,  but  less  interesting 
to  the  student  of  medical  science. 

There  remains  another  source  of  instruction  at  Paris, 
the  importance  of  which  to  the  medical  student  demands 
something  more  than  a  mere  mention ;  the  "  Institut 
Pasteur." 

The  "Institut  Pasteur"  is  a  name  well  known  in 
America.  The  man  whose  name  it  bears,  and  his  mar- 
vellous work  need  no  heralding  there.  But  what  is  not 
generally  known  is  the  fine  opportunity  offered  by  the 
institute  for  special  students  in  microbiology.  The  es- 
tablishment of  the  Pasteur  Institute  is  wholly  in  accord 
with  the  educational  policy  of  France— the  best  regardless 
of  cost,  but  instruction  free.  In  consequence,  in  this 
institute,  besides  the  equipment  and  accommodation  for 
the  special  end  for  which  it  is  constituted — the  treatment 
of  hydrophobia — there  are  found  six  special  services  for 
instruction  in  microbiology. 

The  first  is  the  hydrophobia  treatment,  under  the 
charge  of  Professor  Grancher ;  the  second,  general  mi- 
crobiology, Professor  Duclaux;  the  third,  technique  of 
microbiology,  Roux;  the  fourth,  microbiology  applied 
to  hygiene,  Chamberland ;  the  fifth,  morphological  mi- 
crobiology, Metchnikoff;  and  sixth,  comparative  micro- 
biology, directed  by  Gamelela.  These  six  services,  each 
equipped  with  its  special  laboratories  and  apparatus,  com- 
prise about  fifty  workers. 

The  first  service,  treatment  of  hydrophobia,  comprises 
the  work  of  vaccination  of  the  bitten,  by  Drs.  Charrin  and 
Chantemesse,  and  all  studies  relative  to  the  subject  of 
hydrophobia. 

In  the  services  of  general  and  morphological  micro- 
biology, the  chief,  if  not  the  only,  aim,  is  to  study  the 
form  and  functional  properties  of  the  microbe,  in  order 
to  know  if  these  functions  are  constant  or  little  variable 
and  can  consequently  serve  to  characterize  distinct  spe- 
cies; or  if,  on  the  contrary,  these  properties  exist  in 
condition  of  perpetual  change,  vacillating  in  limits  too 
large  to  permit  their  service  for  other  means  than  to  form 
their  classification  in  groups. 

The  variations  of  form  help  to  determine  the  classifi- 
cation question,  but  are  not  alone  sufficient  to  decide  it, 
even  should  they  be  more  distinctly  defined  than  is  the 
case.  The  variation  of  physiological  properties  must 
also  be  determined.  This  is  done  by  the  difficult  study 
in  detail  of  pure  cultures  and  by  means  of  attentively  ap- 
plied chemical  experience  to  test  the  physiological  action. 
The  chemical  side  of  the  question  belongs  to  the  service 
of  general  microbiology.  In  this  laboratory  are  em- 
ployed and  taught  all  the  methods  of  chemical  analysis 
capable  of  serving  in  the  study  of  microbes,  their  needs 
of  nourishment,  methods  of  culture,  and  their  products  of 
secretion  and  excretion. 

The  laboratory  of  microbiology  applied  to  hygiene, 
similar  to  that  of  general  microbiology,  includes  in  its 
work  all  that  concerns  the  hygienic  study  of  air,  soil,  and 
water,  and  also  the  study  and  preparation  of  all  vaccines. 
Mark,  in  passing,  that  had  the  lymph  of  Koch  passed 
through  this  laboratory,  it  would,  in  all  probability,  not 
have  been  amenable  to  the  charge  of  killing  numerous 
invalids,  which  is  now  so  forcibly  pressed  against  it. 

The  two  laboratories  of  comparative  and  technical  mi- 
crobiology are  devoted  to  the  study  of  diseases  of  microbic 
origin,  the  first  as  a  laboratory  of  special  research,  the  sec- 
ond for  special  instruction  and  training.  Into  this  latter 
laboratory  Dr.  Roux  receives  the  entering  students  in  se- 
ries commencing  every  six  weeks.  To  them  are  given  the 
notions  and  all  technical  details  to  render  the  student 
competent  in  questions  of  microbiology.  This  practical 
laboratory  technique  and  study  renders  the  student  capa- 


128 


MEDICAL  RECORD. 


[July  28,  1894 


ble  of  entering  upon  the  advanced  work  and  researches 
of  his  subject.  At  the  end  of  his  six  weeks'  training  he 
passes  into  the  other  laboratory,  chosen  for  his  intended 
line  of  work,  and  where  his  stay  is  limited  only  by  his 
needs  and  his  capacity. 

There  is  a  fee  of  admission,  payable  once  for  all,  and 
a  monthly  tax,  according  to  the  expenses  of  the  labor- 
atory, both  at  a  minimum.  The  animals  necessary  for 
experiment  are  furnished  at  one-half  the  market  price. 
The  instruction  is  free ;  and,  more  than  that,-  the  admin- 
istrative council  exercises  the  right  of  remitting  all  ex- 
penses, even  for  personal  experiment,  to  such  workers  as 
may  be  judged  worthy  of  this  remission  and  thus  be  en- 
abled to  continue  their  studies  without  expense. 

As  will  be  seen,  this  institute,  aside  from  its  special  aim, 
furnishes  instruction  of  great  importance  to  a  medical 
student  interested  in  this  line  of  work. 

With  the  "  Institut  Pasteur  "  closes  the  list  of  medical 
opportunities  offered  in  Paris.  For  these  opportunities 
my  fellow-students  from  the  United  States  and  myself 
were  self-exiled  from  home,  families,  and  friends  for  a 
period  of  five  or  six  years.  For  these  advantages,  we 
worked  with  severe  determination,  resolved  to  overcome 
the  strangeness  of  a  foreign  tongue  and  endure  the  isola- 
tion of  student  life  in  a  great  and  foreign  city.  Were 
we  mistaken  in  believing  Paris  to  possess  superior  advan- 
tages, or  were  our  questioners  badly  informed  ? 

William  S.  Magill,  A.M.,  M.D. 

4656  State  Street,  Chicago,  III. 


gdjcjflical  Stems. 

Contagions  Diseases— Weekly  Statement— Report  of 
cases  and  deaths  from  contagious  diseases  reported  to  the 
Sanitary  Bureau,  Health  Department,  for  the  week  end- 
ing July  21,  1894. 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebrospinal  meningitis 

Measles . 

Diphtheria.!.!!."!!..*."."."!! 

Small-pox 

Oholera 

Varicella 

Pertussis 

Erysipelas 

Leprosy 


Cases. 


Deaths. 


52 

128 

14 

9 

45 

4 

0 

8 

4i 

5 

193 

4i 

4 

a 

0 

0 

0 

0 

0 

0 

0 

0 

0 

0 

The  Use  of  Bromide  of  Ethyl  as  an  Anesthetic  in 
France. — At  a  recent  meeting  of  the  Soctete  de  Chirurgie 
M.  Segond  spoke  on  the  different  methods  of  applying 
anaesthetics  and  their  composition.  He  said  that  for  the 
last  year  all  his  operations  were  done  under  bromide  of 
ethyl  alone  or  inhalations  of  ethyl  followed  by  that  of 
chloroform.  When  the  operation  was  of  short  duration 
the  former  anaesthetic  sufficed  alone,  but  it  was  not  so 
when  the  operation  was  lengthy,  grave,  and  tedious,  such 
as  hysterectomies,  laparotomies,  etc.  No  accident  had 
ever  been  witnessed  out  of  the  four  hundred  and  forty- 
three  cases.  He  always  administered  the  anaesthetic  to 
the  patient  in  the  dorsal  decubitus,  and  where  the  bro- 
mide of  ethyl  alone  was  used  he  poured  at  first  a  few 
drops  on  a  compress  and  presented  it  to  the  patient,  in 
order  to  accustom  him  as  it  were  to  the  odor  of  the 
liquid,  after  which  a  large  dose  was  thrown  on  the  fold, 
which  was  pressed  firmly  over  the  mouth  so  as  to  prevent 
all  communication  with  the  free  air.  In  twenty  seconds 
resolution  was  complete  and  the  period  of  excitement 
was  frequently  wanting.  Where  the  effect  of  an  anaes 
thetic  had  to  be  kept  up  for  some  considerable  time  a 
few  drops  of  chloroform  were  applied  from  time  to  time. 
M.  Bazy  said  that  he  had  tried  bromide  of  ethyl  in  a 
certain  number  of  cases  and  found  it  satisfactory.  M. 
Monod  gave  similar  testimony  to  the  merits  of  bromide 


of  ethyl,  but  said  that  at  the  first  moments  of  the  inha- 
lation the  patient  was  seized  with  such  a  terrible  sensa- 
tion of  anguish  and  suffocation  that  the  speaker  preferred 
without  hesitation  using  chloroform.  M.  Berger.  and 
several  other  members  expressed  themselves  in  the  same 
sense. — Medical  Press. 

Otic  Gymnastics  as  a  Cure  for  Deafness. — Professor 
Urbantschitsch,  of  Vienna,  has  again  brought  his  re- 
puted new  method  of  treatment  before  the  Vienna  Medical 
Society  in  the  form  of  a  lecture  {Medical  Press).  This 
consists  of  selecting  different  sounds  which  are  regularly 
produced  at  the  ear  of  the  deaf  until  he  becomes  familiar 
with  them.  The  sounds  should  be  continued  five  to  ten 
minutes  daily,  or  at  least  three  times  a  week.  This  treat- 
ment is  reputed  to  act  like  magic  on  the  young,  but  is 
slower  in  operation  in  the  aged.  Much  depends  upon 
the  voice,  however,  in  awakening  the  perceptive  power, 
as  the  high  and  deep  tones  are  not  equal  in  effect.  The 
intervals  must  be  filled  in  gradually  with  inter-tones.  If 
a  correct  record  be  kept  during  the  treatment,  the  right 
ear  will  probably  differ  from  the  left  during  the  period. 
After  the  perception  of  speech,  musical  tones  should  be 
practised.  Urbantschitsch  has  constructed  a  harmonica 
with  five  and  a  half  octaves,  which  answers  this  training 
admirably.  As  to  the  time  this  treatment  must  be  con- 
tinued, no  limit  is  fixed,  different  cases  requiring  differ- 
ent durations  before  reaction  sets  in.  Total  deafness  be- 
ing rare,  it  is  considered  that  this  treatment  must  affect  a 
large  number  of  the  two  hundred  thousand  alleged,  by 
statistics,  to  be  helplessly  deaf  in  Europe.  Another  dif- 
ficulty he  pointed  out  in  educating  these  unhappy  pa- 
tients was  the  mental  condition.  In  many  of  these 
cases  the  mind  is  weak,  intelligence  low,  and  education 
difficult  to  impart  even  in  healthy  ears,  hence  we  find 
children  making  rapid  progress  under  treatment.  The 
practical  worth  of  this  treatment  is  often  questioned  if  it 
be  worth  the  trouble,  but  from  a  mere  social  point 
there  is  only  one  answer.  Since  commencing  his  treat- 
ment in  "The  Landesanstalt "  sixty  cases  have  been 
regularly  under  treatment.  At  the  beginning  of  the 
course  not  [one  could  hear  a  sentence,  six  of  them  could 
hear  a  word,  twenty- two  could  perceive  vocal  sounds, 
while  thirty-two  had  a  trace  of  hearing.  To  day  twelve 
could  follow  sentences,  sixteen  words,  twenty-one  vocal 
sounds,  and  eleven  a  trace  of  hearing.  Professor  Gruber 
agreed  with  Urbantschitsch  in  the  training  of  the  young, 
but  considered  the  time  far  too  limited  to  pass  a  definite 
opinion.  He  recollected  visiting  the  Israelitish  deaf 
institution  thirty  years  ago,  where  the  director  practised 
this  treatment  with  vocal  sounds,  and  could  recall  many 
cases  of  children  rapidly  improving.  Toynbee  and  Hin- 
ton,  in  their  "  Handbook  of  Aural  Disease,"  record  many 
favorable  results  by  these  otitic  gymnastics.  He  also  re- 
lated the  case  of  several  families  who  have  quite  recov- 
ered by  this  slow  treatment.  Professor  Politzer  agreed 
with  much  that  had  been  said  by  Urbantschitsch,  but 
was  not  so  sanguine  of  the  future  results.  The  treatment 
was  not  new,  and  therefore  had  a  longer  trial  both  in 
Germany  and  France. 

Physician  to   the  Household  of  the  Ameer. — Dr. 

Lilias  Hamilton  has  recently  gone  to  Kabul  to  serve  as 
physician  to  the  harem  of  Abdurrahman,  the  Ameer  of 
Afghanistan.  She  is  to  have  a  personal  guard  of  six  sol- 
diers, three  of  whom  will  accompany  her  whenever  she 
ventures  out  upon  the  streets  of  the  city.  The  Indian 
Government  has  sought  to  dissuade  the  young  lady  from 
what  it  considers  her  venturesome  undertaking,  and  has 
warned  her  that  she  goes  at  her  own  risk,  and  that  it  dis- 
claims all  responsibility  for  whatever  of  an  unpleasant 
nature  may  befall  her. 

Purification  of  Water. — Alum  has  been  regarded  as 
one  of  the  best  means  of  purifying  water,  but  Teich  has 
found  that  it  has  no  effect  upon  typhoid  bacilli,  and  that 
cholera  germs  are  destroyed  only  after  the  water  has  been 
treated  with  alum  for  at  least  twenty-four  hours. 


Medical   Record 

A  Weekly  yournal  of  Medicine  and  Surgery 


Vol.  46,  No.  5. 
Whole  No.  1239. 


New  York,  August  4,  1894. 


$12.00  Per  Annum. 
Single  Copies,  toc. 


THE  ETIOLOGY    OF  THE   DEFORMITIES  OC- 
CURRING IN  KNEE  JOINT  DISEASE. 

By  A.  M.  PHELPS,  M.D., 

NSW  YORK. 

FtOFESSOB  OF  ORTHOPEDIC  SURGERY  IN  THE  UNIVERSITY  OF  NEW  YORK  AND 
THE  NEW  YORK  POST-GRADUATE  MEDICAL  SCHOOL  AND  HOSPITAL;  PRO- 
PSSSOR  OP  SURGERY  IN  THE  UNIVERSITY  OF  VERMONT  ;  PRESIDENT  OF  THE 
AMERICAN  ORTHOPEDIC  ASSOCIATION  ;   SURGEON  TO  THE  CITY  HOSPITAL. 

Propositions. — i .  In  diseases  of  the  condyles  of  the  femur 
or  the  head  of  the  tibia  the  leg  always  assumes  a  flexed 
position  to  a  greater  or  less  extent.  2.  After  the  limb 
flexes  the  foot  rotates  outward,  and  rotation  increases 
with  flexion.  3.  In  diseases  confined  to  the  patella  the 
limb  never  flexes.  4.  In  disease  of  the  synovial  sac,  or 
fibrous  capsule,  anteriorly,  unattended  with  diseases  of  the 
condyles,  cartilage,  lateral,  or  crucial  ligaments,  the  limb 
remains  straight. 

In  diseases  of  the  entire  joint,  including  the  cartilages, 
the  leg  always  flexes,  whether  there  is  fluid  present  or 
not. 

I  must  qualify  these  propositions  by  saying  that  certain 
pathological  changes  which  may  have  taken  place,  may 
modify  these  deformities.  But  such  exceptional  deform- 
ities are  always  easily  accounted  for,  as,  for  instance, 
that  seen  in  Charcot's  disease,  or  in  cases  attended  by 
complete  destruction  of  either  condyle  or  either  side  of 
the  tibia.  My  observations  have  been  made  in  a  large 
number  of  cases  upon  which  I  have  operated  in  the  Post 
Graduate  and  City  Hospitals,  New  York  City,  and  the 
Mary  Fletcher  Hospital,  Burlington,  Vt.,  and  I  found 
that  the  foregoing  propositions  were  correct,  with  an  oc- 
casional exception,  as  already  noted. 

Many  German  and  English  experimenters  have  tried 
to  account  for  flexion  upon  the  fluid  hypothesis.  It  is 
true  that  when  the  knee  joint  is  forcibly  injected  it  will 
flex  slightly,  to  give  the  greatest  possible  capacity  to  the 
capsule,  but  this  is  insufficient  to  explain  the  deformities. 

Barwell  does  not  attempt  to  explain  them,  but  says 
(Barwell,  p.  106,  Wood's  Library,  1881),  "It  is  true 
that  the  flexors  are  probably  in  all  limbs  stronger  than 
extensors,  but  in  fact  a  mere  examination  will  show  that 
on  the  flexor  side  muscles  are  rigid,  and  on  the  opposite 
side  flaccid.  Our  knowledge  is  as  yet  insufficient  to  ac- 
count for  this  phenomenon." 

The  fluid  hypothesis  is  wrong,  why  ? 

1.  Because  by  far  the  largest  per  cent,  of  knee-joint 
diseases  are  unattended  by  fluid  effusions.  Still  the  same 
picture  of  deformity  is  seen  as  in  those  cases  attended  by 
large  effusions. 

2.  Cases  of  disease,  extra-capsular,  located  in  the  epiph- 
ysis of  the  femur,  or  in  the  head  of  the  tibia,  in  which 
the  joint  was  not  found  involved  at  the  time  of  aspira- 
tion, presented  the  same  picture  of  deformity. 

3.  Large  serous  effusions,  from  synovitis  or  other 
causes,  are  frequently  unattended  with  flexion. 

4.  After  the  joint  is  evacuated  in  large  effusions,  the 
limb  should  again  assume  the  straight  position,  but  it 
does  not. 

These  are  the  chief  and  valid  reasons  why  the  fluid 
hypothesis  is  incorrect. 

The  statement  of  Barwell  just  quoted,  is  incorrect.  I 
have  carefully  weighed  the  muscles  acting  upon  the  leg, 
and  find  that  the  flexors  weigh  eight  pounds  and  the  ex- 


tensors fourteen  pounds  in  the  subject  examined.  The 
quality  of  fibre  of  these  muscles  being  equal,  and  other 
things  taken  into  consideration,  the  extensors  would  be 
stronger  than  the  flexors,  in  the  proportion  of  fourteen  to 
eight,  while  the  limb  is  in  the  straight  position,  as  neither 
group  would  have  the  advantage  of  leverage. 

Experiments  to  Demonstrate  the  Relative  Strength 
of  Each  Group. — Experiment  I. — A  man  was  strapped 
to  a  table,  the  popliteal  space  at  the  end  of  the  table  and 
leg  extending  over.  He  could  sustain  136  pounds  sus- 
pended from  his  foot.  Turned  on  his  face,  the  patella 
at  the  edge  of  the  table  and  limb  extended,  he  could  now 
only  sustain  36  pounds  suspended  from  the  heel. 

These  results  correspond  very  closely  to  similar  ones 
attained  by  Haughton,  of  Dublin.  (See  Haughton's 
"  Animal  Mechanics.") 

Experiment  II. — Subject  standing,  right  leg  flexed  to 
right  angle,  he  could  hold  suspended  from  heel  90 
pounds.  In  other  words,  the  flexor  group  were  55  pounds 
stronger  when  the  leg  was  flexed  than  when  straight. 

Experiment  III.— Subjects  standing  against  bar,  which 
crossed  the  legs  at  right  angles  behind  at  the  popliteal 
spaces,  the  left  toe  of  foot  against  a  spike  in  the  floor  to 
prevent  slipping.  A  strap  around  ankle  of  left  leg  ad- 
justed to  spring  scales,  which  were  pulled  upon  from  be- 
hind, showed  a  resistance  of  the  extensor  group  of  mus- 
cles of  240  pounds. 

Same  subject  was  strapped  on  his  back,  leg  hanging  at 
right  angles  over  the  edge  of  the  table.  The  same  scales 
were  now  pulled  upon  under  the  table,  and  it  was  found 
that  a  pull  of  80  pounds  would  flex  the  leg  still  further, 
a  difference  of  150  pounds  of  resistance  in  the  quadriceps 
group  of  muscles  between  the  leg  flexed  and  extended. 
Then  we  have  this  formula  for  extensor  and  flexor  group : 

1.  Flexors,  first  experiment,  35  pounds.  Extensors, 
same  experiment,  136  pounds.  Difference  of  power  of 
each  operating  with  equal  advantage,  equal  90  pounds. 

2.  Flexors,  same  experiment,  leg  flexed,  greatest  ad- 
vantage of  flexors,  90  pounds.  Extensors,  leg  straight, 
greatest  possible  advantage  for  extensors,  equal  240 
pounds.    Experiment  III.    Difference,  equal  150  pounds. 

Difference  in  favor  of  flexor,  limb  straight  or  flexed, 
55  pounds. 

Difference  in  power  of  extensors,  limb  flexed  or  straight, 
150  pounds.  This  proves  that  the  extensors  are  stronger 
than  the  flexors,  the  proportion  being  240  to  90,  the 
limb  being  straight  to  give  extensors  the  greatest  advan- 
tage, and  flexed  to  give  the  flexors  a  similar  advantage. 
The  limb  when  flexed,  so  modifies  the  strength  of  these 
groups  as  to  make  the  proportion  in  favor  of  the  flexors 
as  90  is  to  80. 

The  extensors  lose  in  power  as  the  limb  flexes,  while 
the  flexors  increase  in  power  in  about  the  same  propor- 
tion. We  all  remember  the  futile  effort  of  one  boy  to 
bend  the  other's  leg  by  putting  his  knee  in  the  popliteal 
space,  and  grasping  the  foot,  the  other  boy  on  his  face. 
And  again,  sitting  on  a  fence  while  hunting,  the  toes 
under  or  behind  a  rail,  one  can  easily  lower  himself  back- 
ward until  the  head  is  on  the  ground,  and  can  quite 
easily  again  resume  the  upright  position.  The  power 
exerted  by  the  quadriceps  group  of  muscles  in  such  a  case, 
acting  as  a  pulley  over  the  end  of  the  femur,  raising  a 
weight  of  150  pounds  on  the  end  of  a  lever  (the  femora) 
of  nearly  two  feet,  must  be  enormous,  amounting  to  hun- 
dreds of  pounds. 

We  will  now  examine  a  knee-joint.     It  is  a  hinge 


*3° 


MEDICAL  RECORD. 


[August  4,  1894 


which,  when  in  the  straight  position,  is  firmly  fixed,  ow- 
ing to  the  tension  of  the  lateral  and  crucial  ligaments. 
This  forces  the  articular  surfaces  firmly  together  and  pre- 
vents lateral  motion.     The  leg  flexed,  there  is  lateral 


Fig.  1. 


Fig.  a. 


motion  of  the  joint,  which  increases  as  the  leg  flexes,  and 
not  only  lateral  but  rotary  motion.  This  is  due  to  the 
relaxation  of  the  crucial  and  lateral  ligaments  by  flexion. 
Another  fact :  the  patella,  and  a  portion  of  the  capsular, 


" '  1 .  ii 


\ 


Fig.  3> 

anteriorly  receives  its  nerve-supply  from  the  obturator, 
and  possibly  from  the  anterior  crural.  The  other  portion 
of  the  joint  is  supplied  from  the  great  sciatic  The  great 
sciatic  supplies  the  flexor  group,  while 
the  obturator  and  anterior  crural  sup- 
ply the  extensor  group.  A  clinical 
fact  is,  that  when  the  entire  joint  is  at- 
tacked with  acute  inflammation,  all  the 
muscles  surrounding  it  are  affected  by 
spasm.  Still  flexion  rapidly  takes  place, 
whereas  disease  of  the  condyles  always 
produces  great  spasm  and  rapid  atrophy 
of  the  flexors,  while  the  extensors  re- 
main quiescent.  Diseases  limited  to 
the  patella  produce  spasm  and  atrophy 
of  the  quadriceps  extensor  femoris,  and 
the  limb  remains  straight. 

Understanding  that  the  extensors  are 
stronger  than  the  flexors ;  that  the  mus- 
cles about  the  joint  are  equally  affected 
by  spasm  when  the  entire  joint  is  dis- 
eased, why  does  not  the  leg  remain 
straight  ?  Before  attempting  to  answer 
the  question, I  desire  to  call  your  atten- 
tion to  these  diagrams.  Fig.  1,  a  lever 
with  a  joint  at  a.  Both  hands  pulling 
ten  pounds,  the  bar  would  not  flex. 
But  the  bar  being  flexed  at  right  an- 
gle puts  one  string  on  the  lever  and  the 
other  around  the  pulley  (Fig.  2).  This 
gives  to  the  string  acting  on  the  lever  a 
tremendous  advantage,  quite  easily  cal- 
culated. This  is  exactly  what  takes  place  when  the  leg 
flexes,  and  explains  the  difference  in  power  as  illustrated 


Fig.  4. 


by  my  experiments.  The  same  mechanics  applies  to  the 
anatomy  of  the  leg,  roughly  represented  by  a  rude  pen- 
cilling (Fig.  3).  A  photograph  of  one  of  my  dissections 
(Fig.  4)  shows  the  biceps  acting  on  the  head  of  the  fibula, 
the  limb  straight,  and  also  the  extensors  and  patella. 
When  this  leg  is  flexed  the  biceps  is  seen  to  act  on  a  lever, 
and  the  extensors  over  a  pulley  (head  of  the  femur).  The 
muscles  being  dried,  do  not  give  an  accurate  idea  of 
their  position  while  contracted,  as  they  fall  in  curves 
on  flexion.  Fig.  5.  The  same  leg  straight,  showing  in- 
side flexors  acting  on  the  tibia.  Fig.  6.  The  same  leg 
flexed.  It  will  be  seen  that  these  flexors  increase  in 
power  as  the  leg  flexes,  by  being  placed  on  a  lever, 
and  the  extensors  decrease  by  being  wound  around  the 
head  of  the  femur. 

Q.  Why  does  the  leg  flex  when  the  entire  joint  is  dis- 
eased, and  all  muscles  are  equally  affected  by  spasm  ? 

A.  When  the  leg  is  straight  the  tension  upon  the 
lateral  and  crucial  ligaments  produces  great  pressure  be- 
tween the  articular  cartilage.  This 
produces  great  pain,  and  the  patient 
to  relieve  this  flexes  the  leg  to  relax 
these  ligaments.  This  at  once  re- 
lieves intra- articular  pressure.  But 
the  flexion  of  the  leg  has  put  the 
flexors  on  a  lever  and  the  extensors 
on  a  pulley.  The  flexion  now  hav- 
ing the  advantage,  will  continue  to 
flex  the  leg. 

Q.  Why  does  the  leg  rotate  out- 
ward? 

A.  Flexion,  by  relaxing  the  late- 
ral and  crucial  ligaments,  permits 
free  lateral  and  rotary  motions  at  the 
knee  joint.  The  biceps  inserted  into 
the  head  of  the  fibula,  and  being  the 
stronger  of  all  the  flexor  group,  and 
having  the  advantages  of  direction 
and  leverage,  rotates  the  leg  out- 
ward. 

Q.  Why  does  the  leg  never  flex 
in  diseases  of  the  patella  alone  ? 

A.  Because  the  reflexes  from  the 
area  of  disease  are  transmitted 
through  the  obturator  and  anterior 
crural  nerves,  which  supply  only  the 
quadriceps.  A  voluntary  effort  to 
relieve  pain  is  also  present.  FlG-  * 

Q.  Why  are  the  extensors  relaxed  in  disease  confined 
to  the  head  of  the  tibia  and  condyles  of  the  femur  pos- 
teriorly ? 

A.  The  reflexes  from  the  area  of  disease  are  trans- 


Fig.  6. 


mitted  through  the  great  sciatic,  which  nerve  supplies  the 
flexors.  Exceptional  deformities  are  produced  from 
pathological  destruction  of  bone  or  soft  parts. 


August  4,  1894] 


MEDICAL   RECORD. 


131 


Conclusion!. — Typical  deformities  are  produced  by 
change  of  leverage  and  action  of  muscles  due  to : 

1.  A  voluntary  effort  to  relieve  pressure  and  pain. 

2.  Involuntary  spasm  and  contraction  of  muscles, 
which  increases  the  deformity  by  advantage  of  leverage 
due  to  flexion. 

3.  Nervous  irritation  of  groups  of  muscles  due  to  local- 
ized lesion  in  or  about  the  joint. 

4.  Exceptional  deformities  are  produced  by  patho- 
logical destruction  of  bone  or  soft  parts. 

5.  Outward  rotation  of  the  leg  is  produced  by  spas- 
modic contraction  of  the  biceps  after  flexion  has  taken 
place.  Flexion  allows  lateral  and  rotary  motion  at  the 
joint. 


GENIUS  AND  DEGENERATION. 
By  JAMES   WEIR,  Jr.,  M.D., 

OWEKSBORO,  KY. 

That  the  psychical  function  or  intellectuality  is  fre- 
quently developed  at  the  expense  of  the  physical  organ- 
ism is  well  known,  and  that  genius  is  seldom  or  never 
unaccompanied  by  physical  and  mental  degeneration  is 
a  fact  that  can  no  longer  be  denied.  I  use  the  word 
degeneration  in  its  broadest  sense,  and  intend  it  to  in- 
clude all  kinds  of  abnormalities.  The  facts  noted  above 
are  by  no  means  recent  knowledge,  but  were  vaguely 
recognized  and  commented  on  centuries  and  decades  of 
centuries  ago  by  the  Hebrews  and  kindred  races  of  peo- 
ple. The  Hebrew  word  nabi  means  either  madman  or 
prophet,  and  it  is  now  admitted  that  most  of  the  proph- 
ets gave  evidences  of  insanity  as  well  as  genius.  The 
Greeks  and  the  Romans  recognized  this  kinship,  and  we 
read  in  the  Bible  of  a  certain  Festus  who,  when  con- 
fronted by  a  man  of  genius  and  being  unable  to  answer 
his  arguments,  said  to  him,  "  Paul,  much  learning  hath 
made  tl*e  mad!"  Lauvergne,  when  speaking  of  the 
oxycephalic  (sugar  loaf )  skull,  an  unquestionable  exam- 
ple of  degeneration,  wrote  many  years  ago,  "This  head 
announces  the  monstrous  alliance  of  the  most  eminent 
faculty  of  man,  genius,  with  the  most  pronounced  im- 
pulses to  rape,  murder,  and  theft." 

The  purpose  of  this  paper  is  to  show  that  wherever 
genius  is  observed,  we  find  it  accompanied  by  degenera- 
tion, which  is  evinced  by  physical  abnormalities  or  men- 
tal eccentricities.  It  is  a  strange  fact,  however,  and  one 
not  noticed  by  Lombroso  or  any  other  writer,  as  far  as 
I  know,  that  mechanical  geniuses,  or  those  who,  for  the 
most  part,  deal  with  material  facts,  do  not,  as  a  rule, 
show  any  signs  of  degeneration.  I  have  only  to  instance 
Darwin,  Galileo,  Edison,  Watts,  Rumsey,  Howe,  and 
Morse  to  prove  the  truth  of  this  assertion.  It  is  only 
the  genius  of  aestheticism,  the  genius  of  the  emotions, 
that  is  generally  accompanied  by  unmistakable  signs  of 
degeneration.  I  hope  to  amplify  this  conclusion  in  some 
future  paper,  but  lack  of  space  forbids  it  at  the  present 
time. 

Saul,  the  first  king  of  Israel,  was  a  man  of  genius  and, 
at  times,  a  mad  man.  We  read  that,  before  his  corona- 
tion, he  was  seized  with  an  attack  of  madness  and  joined 
a  company  of  kindred  eccentrics.  His  friends  and  ac- 
quaintances were,  naturally,  surprised  and  exclaimed : 
"  Is  Saul  among  the  prophets,"  i.e.,  "  Has  Saul  become 
insane."  Again  we  are  told  that  he  was  suddenly  seized 
with  an  attack  of  homicidal  impulse,  and  tried  to  kill 
David.  Before  this  time  he  had  had  repeated  attacks  of 
madness,  which  only  the  harp  of  David  could  control 
and  subdue.  David  himself  was  a  man  whose  mental 
equilibrium  was  not  well  established,  as  his  history  clearly 
indicates.  He  forsook  his  God,  indulged  in  licentious 
practices,  and  was,  withal,  a  very  immoral  man  at  times. 
At  his  time,  the  Hebrews  had  reached  a  high  degree  of 
civilization.  Abstract  ethics  had  become  very  much  de- 
veloped, and  any  example  of  great  immorality  occurring 
during  this  epoch  is  proof  positive  of  atavism  or  degen- 
eration. As  I  have  intimated  before,  many  of  the  ancient 


Hebrew  prophets,  who  were  unquestionably  men  of 
genius,  gave  evidences  of  insanity ;  notably,  Jeremiah, 
who  made  a  long  journey  to  the  river  Euphrates,  where 
he  hid  a  linen  girdle.  He  returned  home,  and  in  a 
few  days  made  the  same  journey  and  found  the  girdle 
rotten  and  good-for-nothing;  Ezekiel,  who  dug  a  hole 
in  the  wall  of  his  house,  through  which  he  removed  his 
household  goods  instead  of  through  the  door;  Hosea 
who  married  a  prostitute  because  God,  so  he  declared, 
had  told  him  so  to  do ;  and  Isaiah,  who  stripped  himself 
naked,  and  paraded  up  and  down  in  sight  of  all  the  peo- 
ple. King  Solomon,  a  man  of  pre-eminent  genius,  was 
mentally  unbalanced.  The  "  Song  of  Solomon  "  shows 
very  clearly  that  he  was  a  victim  of  some  physical  dis- 
order, sexual  in  its  character  and  origin.  The  poems  of 
Anacreon  are  lascivious,  lustful,  and  essentially  carnal, 
and  history  informs  us  that  he  was  a  sexual  pervert. 

Swinburne's  poems  show  clearly  the  mental  bias  of 
their  author,  who  is  described  as  being  peculiar  and  ec- 
entric.  Many  of  the  men  of  genius  who  have  assisted  in 
making  the  history  of  the  world  have  been  the  victims  of 
epilepsy.  Julius  Caesar,  military  leader,  statesman,  poli- 
tician, and  author  was  an  epileptic.  Twice,  on  the  field 
of  battle,  he  was  stricken  down  by  this  disorder.  On  one 
occasion,  while  seated  at  the  tribune,  he  was  unable  to 
rise  when  the  senators,  consuls,  and  praetors  paid  him  a 
visit  of  ceremony  and  honor.  They  were  offended  at  his 
seeming  lack  of  respect,  and  retired  showing  signs  of  an- 
ger. Caesar  returned  home,  stripped  off  his  clothes,  and 
offered  his  throat  to  be  cut  by  anyone.  He  then  ex- 
plained his  conduct  to  the  senate,  saying  that  he  was  the 
victim  of  a  malady  which,  at  times,  rendered  him  incap- 
able of  standing.  During  the  attacks  of  this  disorder 
"  he  felt  shocks  in  his  limbs,  became  giddy,  and  at  last 
lost  consciousness."  Moliere  was  the  victim  of  epilepsy ; 
so  also  was  Petrarch,  Flaubert,  Charles  V.,  Handel,  St. 
Paul,  Peter  the  Great,  and  Dostoicffsky ;  Paganini,  Mo- 
zart, Schiller,  Alfieri,  Pascal,  Richelieu,  Newton,  and 
Swift  were  the  victims  of  diseases  epileptoid  in  character. 

Many  men  of  genius  have  suffered  from  spasmodic  and 
choreic  movements,  notably  Lenau,  Montesquieu,  Buffon, 
Dr.  Johnson,  Santeuil,  Cr6billon,  Lombardini,  Thomas 
Campbell,  Carducci,  Napoleon,  and  Socrates.  Suicide, 
essentially  a  symptom  of  mental  disorder,  has  hurried 
many  a  man  of  genius  out  into  the  unknown.  The  list 
begins  with  such  eminent  men  as  Zeno,  Cleanthes, 
Dionysus,  Lucan,  and  Stilpo,  and  contains  the  names  of 
such  immortals  as  Chatterton,  Blount,  Haydon,  Clive, 
and  David.  Alcoholism  and  morphinism,  or  an  uncon- 
trollable desire  for  alcohol  or  opium  in  some  form  or 
other,  are  now  recognized  as  evidences  of  degeneration. 
Men  of  genius,  both  in  the  Old  World  and  in  the  new, 
have  shown  this  form  of  degeneration.  Says  Lombroso  : 
"Alexander  died  after  having  emptied  ten  times  the 
goblet  of  Hercules,  and  it  was,  without  doubt,  in  an  alco- 
holic attack,  while  pursuing  naked  the  infamous  Thais, 
that  he  killed  his  dearest  friend.  Caesar  was  often  carried 
home  on  the  shoulders  of  his  soldiers.  Neither  Socrates, 
nor  Seneca,  nor  Alcibiades,  nor  Cato,  nor  Peter  the 
Great  (nor  his  wife  Catherine,  nor  his  daughter  Eliza- 
beth), were  remarkable  for  their  abstinence.  One  recalls 
Horace's  line  '  Narrator  et  prisei  Cantonis  seepe  mero 
caluisse  virtus'  Tiberius  Nero  was  called  by  the  Ro- 
mans Biberius  Mero.  Septimius  Severus  and  Mahomet 
II.  succumbed  to  drunkenness  or  delirium  tremens" 

Among  the  men  and  women  of  genius  of  the  Old 
World,  who  abused  the  use  of  alcohol  and  opium,  were 
Coleridge,  James  Thomson,  Carew,  Sheridan,  Steele, 
Addison,  Hoffman,  Charles  Lamb,  Madame  de  StaeH, 
Burns,  Savage,  Alfred  de  Musset,  Kleist,  Caracci,  Jan 
Steen,  Morland  Turner  (the  painter),  Gerard  de  Nerval, 
Hartley  Coleridge,  Dussek,  Handel,  Gliick,  Praga,  Ro- 
vani,  and  the  poet  Somerville.  This  list  is  by  no  means 
complete,  as  the  well-informed  reader  may  see  at  a  glance, 
yet  it  serves  to  show,  however,  how  very  often  this  form 
of  degeneration  makes  its  appearance  in  men  of  genius. 
In  men  of  genius  the  moral  sense  is  sometimes  obtunded, 


13* 


MEDICAL   RECORD. 


[August  4,  1894 


if  not  altogether  absent.  Sallust,  Seneca,  and  Bacon  were 
suspected  felons.  Rousseau,  Byron,  Foscolo,  and  Caresa 
were  grossly  immoral,  while  Casanova,  the  gifted  mathe- 
matician, was  a  common  swindler.  Murat,  Rousseau, 
Wagner,  Clement,  Diderot,  and  Praga  were  sexual  per- 
verts. Genius,  like  insanity,  lives  in  a  world  of  its  own, 
hence  we  find  few,  if  any,  evidences  of  human  affection 
in  men  of  genius.  Says  Lombroso:  "I  have  been  able 
to  observe  men  of  genius  when  they  had  scarcely  reached 
the  age  of  puberty  ;  they  did  not  manifest  the  deep  aver- 
sions of  moral  insanity,  but  I  have  noted  among  all  a 
strange  apathy  for  everything  which  does  not  concern 
them ;  as  though,  plunged  in  the  hypnotic  condition,  they 
did  not  perceive  the  troubles  of  others,  or  even  the  most 
pressing  needs  of  those  who  were  dearest  to  them;  if 
they  observed  them,  they  grew  tender  and  at  once  hast- 
ened to  attend  them ;  but  it  was  a  fire  of  straw,  soon  ex- 
tinguished, and  it  gave  place  to  indifference  and  weari- 
ness." 

This  emotional  anaesthesia  is  indicative  of  psychical 
atavism,  and  is  an  unmistakable  evidence  of  degenera- 
tion. Lombroso  gives  a  long  list  of  the  men  of  genius 
who  were  celibates.  I  will  mention  a  few  of  those  with 
whom  the  English-speaking  world  is  most  familiar: 
Kant,  Newton,  Pitt,  Fox,  Beethoven,  Galileo,  Descartes, 
Locke,  Spinoza,  Leibnitz,  Gray,  Dalton,  Hume,  Gib- 
bon, Macaulay,  Lamb,  Bentham,  Leonardo  da  Vinci, 
Copernicus,  Reynolds,  Handel,  Mendelssohn,  Meyer- 
beer, Schopenhauer,  Camoens,  and  Voltaire.  La  Bruygre 
says  of  the  men  of  genius :  "  These  men  have  neither 
ancestors  nor  descendants;  they  themselves  form  their 
entire  posterity.' ' 

There  is  a  form  of  mental  obliquity  which  the  French 
term  folic  du  doute.  It  is  characterized  by  an  incerti- 
tude in  thought  co  ordination,  and  often  leads  its  vic- 
tims into  the  perpetration  of  nonsensical  and  useless  acts. 
Men  of  genius  are  very  frequently  afflicted  with  this  form 
of  mental  disorder.  Dr.  Johnson,  who  was  a  sufferer 
{torn  folic  du  daute,  had  to  touch  every  post  he  passed. 
If  he  missed  one,  he  had  to  retrace  his  steps  and  touch 
it.  Again,  if  he  started  out  of  a  door  on  the  wrong  foot, 
he  would  return  and  make  another  attempt,  starting  out 
on  the  foot  which  he  considered  the  correct  one  to  use. 
Napoleon  counted  and  added  up  the  rows  of  windows  in 
every  street  through  which  he  passed.  A  celebrated 
statesman,  who  is  a  personal  friend  of  the  writer,  can 
never  bear  to  place  his  feet  on  a  crack  in  the  pavement 
or  floor.  When  walking,  he  will  carefully  step  over  and 
beyond  all  cracks  or  crevices.  This  idiosyncrasy  annoys 
him  greatly,  but  the  impulse  is  imperative,  and  he  can- 
not resist  it.  Those  who  have  been  intimately  associ- 
ated with  men  of  genius  have  noticed  that  they  are  very 
frequently  amnesic  or  "  absent-minded/'  Newton  once 
tried  to  stuff  his  niece's  finger  into  the  bowl  of  his  pipe, 
and  Rovelle  would  lecture  on  some  subject  for  hours  at 
a  time,  and  then  conclude  by  saying :  "  But  this  is  one 
of  my  arcana  which  I  tell  to  no  one."  One  of  his  stu- 
dents would  then  whisper  what  he  had  just  said  into  his 
ear,  and  Rovelle  would  believe  that  his  pupil  "  had  dis- 
covered the  arcanum  by  his  own  sagacity,  and  would 
beg  him  not  to  divulge  what  he  himself  had  just  told  to 
two  hundred  persons." 

Lombroso  has  combed  history,  as  it  were,  with  a  fine- 
tooth  comb,  and  very  few  geniuses  have  escaped  his 
notice.    This  paper,  so  far,  is  hardly  more  than  a  review 
of  his  extraordinary,  comprehensive  work ;  therefore,  I 
will  conclude  this  portion  of  it  with  a  list  of  men  of  gen- 
ius, their  professions,  and  their  evidences  of  degenera- 
tion, as  gathered  from  his  book : 
Carlo  Dolce,  painter,  religious  monomania. 
Bacon,  philosopher,  megalomania,  moral  ancesthest  u 
Balzac,  writer,  marked  epilepsy,  megalomania. 
Caesar,  soldier,  writer,  epilepsy. 
Beethoven,  musician,  amnesia,  melancholia. 
Cowper,  writer,  melancholia. 
Chateaubriand,  writer,  chorea. 
Alexander  the  Great,  soldier,  alcoholism. 


Molifere,  dramatist,  epilepsy. 

Charles  Lamb,  writer,  alcoJiolism,  acute  mania,  melan- 
cholia. 
Mozart,  musician,  epilepsy,  hallucinations. 
Heine,  writer,  melancholia,  spinal  disease. 
Dr.  Johnson,  writer,  chorea. 
Malibran,  epilepsy. 
Newton,  philosopher,  amnesia. 
Cavour,  statesman,  philosopher,  suicidal  impulse. 
Ampere,  mathematician,  amnesia. 
Thomas  Campbell,  writer,  chorea. 
Blake,  painter,  hallucinations. 
Chopin,  musician,  melancholia. 
Coleridge,  writer,  alcoholism,  morphinism. 
Donizetti,  musician,  moral  anesthesia. 
Lenau,  writer,  melancholia. 
Mahomet,  theologian,  epilepsy. 
Manzoni,  statesman, /<?//>  du  doute. 
Haller,  writer,  hallucinations. 
Dupuytren,  surgeon,  suicidal  impulse. 
Paganini,  musician,  epilepsy. 
Handel,  musician,  epilepsy. 
Schiller,  writer,  epilepsy. 
Richelieu,  statesman,  et>tlepsy. 
Praga,  writer,  alcoholism. 
Tasso,  writer,  alcoholism,  melancholia. 
Savonarola,  theologian,  hallucinations. 
Luther,  theologian,  hallucinations. 
Schopenhauer,  philosopher,  melancholia,  omniphobia. 
Gogol,  writer,  melancholia,  tabes  dorsalis. 
Lazaretti,  theologian,  hallucinations* 
Mallarml,  writer,  suicidal  impulse. 
Dostoieffsky,  writer,  epilepsy. 
Napoleon,  soldier,  statesman,  folic  du  doute,  tseudo-epi- 

lepsy. 
Comte,  philosopher,  hallucinations. 
Pascal,  philosopher,  epilepsy. 
Poushkin,  writer,  megalomania.  ^ 

Renan,  philosopher,/*//*  du  doute. 
Swift,  writer,  paresis. 
Socrates,  philosopher,  chorea. 
Schumann,  musician,  paresis. 
Shelley,  writer,  hallucinations. 
Bunyan,  writer,  hallucinations. 
Swedenborg,  theologian,  hallucinations. 
Loyola,  theologian,  hallucinations. 
J.  S.  Mill,  writer,  suicidal  impulse. 
Linnaeus,  botanist,  paresis. 

The  reader  will  observe  that  I  have  made  use  of  the 
comprehensive  word,  writer,  to  designate  all  kinds  of 
literary  work  except  theology  and  philosophy.  The 
above  list  is  by  no  means  complete,  and  only  contains 
the  names  of  those  geniuses  with  whom  the  world  is  well 
acquainted.  When  we  come  to  the  geniuses  of  the  New 
World,  we  find  that  they  are  few  in  number,  and  that 
they  likewise  show  erraticism  and  degeneration.  Poe 
was  undoubtedly  a  man  of  great  genius,  and  his  degen- 
eration was  indicated  by  his  alcoholism.  Aaron  Bun- 
was  the  victim  of  moral  anaesthesia,  and  Jefferson  was 
pseudo  epileptic  and  neurasthenic  Randolph  was  a  man 
of  marked  eccentricity,  and  Benedict  Arnold  was,  mor- 
ally, anaesthetic.  Henry  Clay  was  addicted  to  an  over- 
indulgence in  alcohol ;  likewise  Thomas  Marshall  and 
the  elder  Booth.  Booth  also  had  attacks  of  acute  mania. 
His  son  Edwin  had  paresis,  so  also  had  John  McCulloch, 
John  T.  Raymond,  and  Bartley  Campbell.  A  distin- 
guished statesman  and  politician,  and  a  man  who  stands 
high  in  the  councils  of  the  nation,  has,  for  a  number  of 
years,  given  evidence  of  mental  obliquity,  by  his  uncon- 
trollable desire  for  alcohol.  No  power,  outside  of  bod- 
ily restraint,  can  control  him  and  keep  him  from  indulg- 
ing his  appetite  for  alcohol  when  this  desire  seizes  him. 
One  of  the  most  noted  poets  of  to-day,  whose  verses  stir 
the  heart  with  their  pathos  and  bring  smiles  to  the  gravest 
countenances  with  their  humor,  was,  for  a  number  of 
years,  an  inordinate  user  of  alcohol.  Robert  Ingersoll  is 
undoubtedly  a  man  of  genius  and  of  considerable  origi- 


August  4,  1894] 


MEDICAL  RECORD. 


133 


nality,  and  a  close  study  of  his  writings  shows  conclu- 
sively his  mental  eccentricity.  Judging  wholly  from  his 
printed  utterances,  Mr.  Ingersoll  is  only  a  superficial  sci- 
entist and  mediocre  scholar.  His  power  lies  in  his  won- 
derful word  imagery,  and  his  intricately  constructed  verbal 
arabesques.  He  is  a  verbal  symbolist.  Symbolism,  when- 
ever found,  and  in  whatever  art,  if  carried  to  any  extent, 
must  necessarily  be  an  evidence  of  atavism,  consequently 
of  degeneration. 

Thomas  Paine  gave  evidences  of  a  lack  of  mental  equi- 
poise. We  fincl-scattered  throughout  his  works  the  most 
brilliant,  irrefutable,  and  logical  truths  side  by  side  with 
the  most  inane,  illogical,  and  stolid  crudities.  Among 
other  men  of  genius  who  showed  signs  of  degeneration 
we  may  include  Alexander  Stevens,  Joel  Hart,  Adams, 
Train,  Breckenridge,  Webster,  Blaine,  Van  Buren,  Hous- 
ton, Grant,  Hawthorne,  Bartholow,  Walt  Whitman. 
We  must  not  confound  genius  and  talent — the  two  are 
widely  different.  Genius  is  essentially  original  and  spon- 
taneous, while  talent  is  to  some  extent  acquired.  Gen- 
ius is  an  abnormality,  but  one  for  which  the  world  should 
be  devoutly  grateful.  Psychos,  in  the  case  of  genius,  is 
not  uniformly  developed,  one  part,  being  more  favored 
than  the  others,  absorbs  and  uses  more  than  its  share  of 
that  element,  whatsoever  it  be,  which  goes  to  make  up 
intellectuality,  hence  the  less  favored  or  less  acquisitive 
parts  show  degeneration.  Why  genius  should  exist  is 
one  of  the  unexplained  phenomena  of  nature,  but  that 
it  is  the  result  of  natural  causes  I  have  not  the  slightest 
doubt. 

Movable  Liver. — Dr.  Leube  remarks  on  the  rarity  of 
this  condition.  .  The  ligaments  attaching  the  fiver  to  the 
diaphragm  must  become  loosened.  (The  British  Medi- 
cal Journal.}  Pendulous  belly  due  to  repeated  preg- 
nancies, chronic  ascites,  etc.,  predispose.  He  records  a 
case  in  a  lad,  aged  seventeen,  with  heart  disease  and  gen- 
eral dropsy.  The  abdomen  had  to  be  tapped,  a  fine  tro- 
car being  used,  and  ten,  sixteen,  and  ten  litres  were 
drawn  off  at  different  times.  On  admission  the  umbili- 
cus bulged,  a  fluctuation  thrill  could  be  easily  felt,  and 
the  abdomen  was  dull  all  over,  except  in  the  region  of 
the  stomach.  The  liver  reached  10  ctm.  below  the  ribs 
in  the  mammary  line;  the  surface  was  smooth,  the  con- 
sistency hard,  and  the  organs  pulsating.  Behind,  pul- 
monary resonance  extended  on  both  sides  down  to  the 
eleventh  vertebra.  After  tapping,  a  depression  was 
noted  in  the  upper  part  of  the  right  abdomen,  and 
lower  down  a  projection.  This  tumor  measured  ten  to 
eleven  ctm.  in  the  middle  line,  and  15  ctm.  in  the 
right  mammary  line,  and  over  it  the  percussion  note  was 
dull.  The  lower  border  could  be  followed  from  left  to 
right,  and  the  convex  upper  surface  of  the  liver  felt.  Be- 
tween the  liver  and  the  diaphragm  fluctuation  could  be 
made  out,  and  the  surface  of  the  liver  could  be  dipped 
upon.  The  liver  could  be  readily  pushed  up,  the  pulmo- 
nary resonance  behind  being  then  raised  1  ctm.  The 
fluid  seemed  to  remain  between  the  liver  and  the  dia- 
phragm, whether  the  patient  was  lying  down  or  sitting 
up.  This  was  also  proved  at  the  necropsy,  the  lad  dying 
some  months  later.  The  liver  was  very  movable,  en- 
larged, and  of  the  nutmeg  variety,  with  consequent  in- 
duration. The  suspensory  ligament  was  7^  ctm.  long. 
The  pulmonary  resonance  behind  was  raised  when  the 
liver  was  pushed  up,  owing  to  the  displacement  of  the  fluid 
backward.  An  additional  cause  of  the  mobility  of  the 
liver  may  lie  in  the  loosening  of  its  posterior  attachment, 
for  usually  the  vena  cava  is  firmly  bound  with  the  liver 
and  vertebral  column.  This  case,  as  well  as  another  seen 
by  the  author,  occurred  in  men ;  hitherto  movable  liver 
has  been  exclusively  seen  in  women.  ^ 

Tubercle  Bacilli.— Dr.  Kronig  succeeded  recently  in 
finding  tubercle  bacilli  in  the  blood,  taken  from  the  heart 
post  mortem  of  a  case  of*  acute  miliary  tuberculosis,  by 
means  of  centrifugal  motion.  He  thinks  the  method 
would  also  succeed  with  blood  taken  during  life. 


PASTEURIZED  MILK  AS  SUPPLIED  TO  THE 
POOR  BY  THE  STRAUS  MILK  DEPOT  OF 
NEW   YORK.1 

By  ROWLAND   GODFREY   FREEMAN,    M.D., 

PATHOLOGIST  TO  THE  FC  UN  DUNG  HOSPITAL;  PATHOLOGIST  TO  ST.  MA&Y'S 
FRKK  HOSPITAL. FOR  CHILDREN  ;  ASSISTANT  PHYSICIAN  TO  ROOSEVELT  HOS* 
FITAL,    OUT-PATIENT    DEPARTMENT. 

It  is  the  purpose  of  the  writer  to  describe  some  of  the 
details  of  a  most  worthy  charity,  the  expenses  of  which 
have  been  met  by  one  man,  since  perhaps  other  equally 
charitable  persons  here  or  in  other  parts  may  be  disposed 
to  carry  out  the  same  sort  of  work,  and  may  thus  be  able 
to  benefit  by  the  methods  here  described. 

Since  there  can  be  no  doubt  that  the  milk  supply  may 
be  a  source  of  danger  on  account  of  the  large  number, 
and  possible  pathogenic  character,  of  the  micro- organisms 
contained  in  it,  it  becomes  of  the  greatest  importance  to 
investigate  the  manner  of  this  contamination  and  the 
methods  of  avoiding  its  dangers.  The  most  important 
source  of  contamination  is  undoubtedly  the  dairy,  where 
dirty  and  ignorant  methods  are  almost  universally  em- 
ployed, not  only  during  the  milking  but  in  the  subse- 
quent care  of  the  milk.  Delay  in  transportation  affords 
time  for  the  multiplication  of  the  germs  which  have  en- 
tered the  milk. 

It  is  evident  that  this  danger  may  be  met  in  one  of 
two  ways :  best  by  a  reformation  in  dairy  methods  and 
the  manner  of  transportation,  but  failing  in  this,  by  sterili- 
zation. It  is  the  object  of  this  paper  to  show  how  this 
latter  has  been  accomplished  on  a  large  scale  in  New 
York,  for  the  purpose  of  supplying  milk  to  the  poor. 

As  such  an  undertaking  is  original  and  certainly  worthy 
of  emulation,  and  at  the  same  time  of  great  service  to 
those  members  of  the  profession  who  practise  among  the 
poor,  it  may  be  of  interest  to  know  how  the  work  was 
done  and  what  the  results  were. 

This  enterprise  is  due  to  the  philanthropy  of  Mr.  Na- 
than Straus,  who,  in  the  spring  of  1893,  established  and 
has  since  maintained  a  depot  for  supplying  the  poor  with 
a  good  quality  of  raw  and  sterilized  milk.  His  first  aim 
was  to  obtain  as  pure  a  milk  supply  as  possible,  and  for 
this  purpose  the  dairy  was  inspected  by  Mr.  S.  K.  John- 
son, veterinarian  of  the  New  York1  Board  of  Health,  and 
was  approved  by  him.  The  depot  in  New  York  has  been 
admirably  planned  and  superintended  by  Mr.  A.  L.  Kin- 
kead.  Three  sorts  of  milk  were  provided :  pasteurized 
ordinary  milk,  pasteurized  modified  milk,  and  raw  milk. 

Pasteurization  at  about  750  C.  (1670  F.)  was  used  in- 
stead of  sterilization  at  ioo°  C.  (2120  F.),  under  the  as- 
sumption that  it  furnishes  a  more  nutritious  and  more 
digestible  milk  than  that  sterilized  at  a  higher  tempera- 
ture, and  at  the  same  time  one  which  is  freed  from  dele- 
terious germs.  Pasteurized  ordinary  milk  was  sold  in 
eight- ounce  bottles  at  one  and  a  half  cent  each. 

The  pasteurized  modified  milk  is  simply  a  one-half 
dilution  of  ordinary  milk  with  the  addition  of  sufficient 
sugar  of  milk  to  bring  up  the  amount  in  the  dilution  to 
five  per  cent.,  and  enough  lime-water  to  neutralize  any 
slight  acidity  the  milk  might  have,  and  then  the  mixture 
is  pasteurized. 

In  this  way  a  milk  approximating  somewhat  mothers1 
milk  is  furnished.     The  formula  used  is : 

Sugar  of  milk 12  oz. 

Lime-water 8  oz. 

Milk 1  gal. 

Water 1  gal. 

It  is  evident  that  the  deficiency  in  this  dilution  is  in 
fat.  It  was  intended,  however,  for  very  young  or  sick 
infants,  and  for  these  answered  very  well.  On  the  other 
hand,  to  have  increased  the  fats  would  have  introduced 
some  difficulties.  This  pasteurized  modified  milk  is  dis- 
pensed in  six- ounce  bottles,  a  charge  of  1%  cent  being 
made  for  each  bottle.  With  each  six-  or  eight-ounce  bot- 
tle of  milk  a  sterile  nipple  is  supplied.     A  deposit  is  re- 

1  Read  before  the  Section  of  Pediatrics  of  the  New  York  Academy 
of  Medicine  on  May  10,  1894. 


134 


MEDICAL   RECORD. 


[August  4,  1894 


quired  of  2j£  cents  for  each  six-ounce  bottle  and  nipple, 
and  3  cents  for  each  eight-ounce  bottle  and  nipple. 
It  was  thus  intended  to  furnish  for  infants  and  sick 
children  a  sterile  milk  of  good  quality  in  a  sterile  nursing- 
battle,  with  a  sterile  nipple  through  which  it  could  be 
fed. 

This  milk  depot  was  located  on  a  pier  at  the  foot  of 
East  Third  Street,  that  situation  being  accessible  to  a 
very  large  tenement-house  population.  Awnings  and 
seats  were  put  up  on  the  pier  so  that  the  babies  and  their 
mDthers  could  remain  there  and  inhale  the  fresh  air  from 
the  river. 

The  building  which  was  erected  was,  owing  to  the 
character  of  the  site,  of  necessity  long  and  narrow ;  it 
was  placed  several  feet  from  the  edge  of  the  pier,  so  that 
an  outside  passageway  connecting  the  rooms  was  re- 
served. The  building  was  divided  into  four  rooms.  The 
first  room  is  U3ed  for  sterilizing  the  bottles,  stoppers,  and 
nipples,  and  preparing  and  pasteurizing  the  milk.  The 
second  room  is  occupied  by  large  water-baths  of  iced 
water  for  keeping  the  pasteurized  milk  until  it  is  deliv- 
ered. The  third  room  contains  ice-boxes  for  the  cans  of 
raw  milk  The  fourth  room,  which  is  nearest  the  end  of 
th;  pier,  is  devoted  to  the  business  of  selling  the  milk. 

The  first  of  these  rooms  contains  all  the  apparatus :  the 
ovens  for  sterilizing  the  bottles  at  a  dry  heat  of  1500  C. 
(3020  F.),  the  mixer  used  for  the  preparation  of  the 
modified  milk,  the  pasteurizers,  and  the  trough  of  run- 
ning water  for  rapid  cooling  after  pasteurization.  This 
room  has  a  slanting  cement  floor  which  can  be  flushed 
with  a  hose  for  purposes  of  cleanliness.  The  ovens  for 
sterilizing  the  bottles  are  made  of  sheet  iron  and  heated 
by  gas.  The  bottles,  after  being  thoroughly  cleansed, 
are  placed  in  this  oven,  which  is  then  closed  and  the  gas 
beneath  is  lighted.  The  bottles  are  kept  here  at  a  tem- 
perature of  1500  C.  (30  20  F.)  for  one  hour.  The  bot- 
tles used  were  especially  designed  and  made  for  the  pur- 
pose. They  have  sloping  necks  so  as  to  be  easy  to  clean, 
and  spheroidal  bottoms  so  that  they  will  not  stand  up. 
This  latter  peculiarity  was  introduced  so  that  they  might 
not  be  opened  and  left  standing  uncorked,  thus  allow- 
ing a  further  contamination  of  the  milk  by  bacteria. 

The  method  of  pasteurization  used  is  the  same  as  that 
applied  by  me  to  the  small  apparatus  which  I  described 
two  years  ago.1  The  principle  is  as  follows:  If  into  a 
definite  amount  of  boiling  water,  the  source  of  heat  hav- , 
ing  bsen  removed,  a  properly  proportioned  amount  of 
cold  milk  be  introduced  in  bottles  under  such  conditions 
that  they  will  not  break,  the  temperature  of  the  milk 
will  be  raised  to  the  desired  point,  i.e.,  75 °  C.  (1670  F.). 
The  amount  of  boiling  water  used  in  this  apparatus  is 
such  that,  in  raising  the  temperature  of  the  milk  through 
abDut  6d°  C.  (1080  F.)  it  itself  loses  an  equivalent 
amount  of  heat,  so  that  when  the  milk  reaches  its  maxi- 
mum temperature  the  water  is  of  the  same  temperature. 

The  apparatus  used  at  the  Straus  depot  consists  of 
large  copper  boilers  for  the  water,  and  copper  receptacles 
for  the  bottles  of  milk.  The  boilers  are  twenty- four 
inches  long  and  have  a  groove  encircling  them,  to  indi- 
cate the  point  to  which  they  are  to  be  filled  with  water. 
The  receptacles  consist  of  groups  of  copper  cylinders, 
each  one  just  large  enough  to  contain  one  bottle.  These 
receptacles  are  made  of  different  sizes  for  six-ounce, 
eight-ounce,  or  pint  bottles.  The  apparatus  is  thus 
essentially  the  same  as  the  small  apparatus  referred  to 
above,  except  that  it  is  of  larger  size,  allowing  a  greater 
number  of  bottles  to  be  pasteurized  at  a  time. 

The  method  of  pasteurizing  the  milk  is  as  follows : 
The  boilers  are  first  filled  with  water  to  the  groove  and 
thj  gas  stoves  beneath  them  are  lighted.  The  sterilized 
bottles,  having  been  cooled,  are  now  filled  with  milk  and 
loosely  stoppered  with  rubber  corks  which  have  previ- 
ously been  sterilized  in  boiling  water.  The  stoppered 
bottles  are  then  placed  in  the  hollow  copper  cylinders  of 
the  receptacles,  and  the  space  surrounding  the  body  of 

1  On  the  Sterilization  of  Milk  at  Low  Temperature,  etc.    Medical 
Record,  July  2, 1892. 


the  bottle  in  each  cylinder  is  filled  with  cold  water.  As 
they  are  prepared,  they  are  left  on  a  shelf  until  the  water 
in  the  boilers  generates  steam  vigorously,  indicating  a 
temperature  of  ioo°  C.  (212°  F.).  The  gas  under  the 
boilers  is  then  turned  off,  and  the  receptacles  containing 
the  filled  bottles  are  set  in  the  boiling  water;  the  boilers 
are  then  covered  and  not  disturbed  for  half  an  hour. 
The  milk  here  reaches  a  temperature  of  about  750  C. 
(1670  F.)  in  ten  minutes,  and  remains  at  that  tempera- 
ture for  the  remaining  twenty  minutes.  The  receptacles 
containing  the  bottles  are  then  removed  and  placed  in 
the  tank  of  running  water  for  twenty  minutes,  at  the  end 
of  which  period  the  milk  in  the  bottles  has  reached 
nearly  the  temperature  of  the  surrounding  water,  that  is, 
2o°-25°  C.  (68°-77°  F.).  They  are  then  carried  into 
the  next  room,  where  the  bottles  are  removed  and  placed 
in  racks  in  iced  water  at  a  temperature  of  about  io°  C. 
(500  F.).  They  are  kept  here  until  dispensed.  Suffi- 
cient milk  for  one  day's  use  is  pasteurized,  and  it  is  never 
carried  over. 

As  soon  as  one  lot  of  receptacles  is  taken  from  a  boiler, 
the  gas  beneath  is  lighted,  and  the  temperature  of  the 
contained  water,  now  about  750  C.  (1670  F.),  is  brought 
to  boiling  for  a  new  lot  of  receptacles,  which,  with  their 
bottles,  are  at  once  introduced. 

A  large  number  of  experiments  with  milk  subjected  to 
this  treatment,  show  that  by  it  the  practical  purposes  of 
sterilization  are  accomplished.  With  each  bottle  of  milk 
a  rubber  nipple  is  supplied  which  has  been  sterilized  in 
boiling  water. 

Of  this  pasteurized  milk  twenty-five  hundred  bottles 
were  dispensed  in  a  single  week,  and  thirty-four  thousand 
bottles  wore  supplied  during  the  season.  Five  persons 
were  employed  in  this  depot  during  the  summer  of  1893, 
including  a  cashier,  a  porter,  and  a  scrubwoman.  The 
actual  technical  work  of  pasteurizing  was  accomplished, 
for  the  most  part,  by  one  man.  Many  remarkable  cases 
were  observed  of  infants  and  children  with  bad  surround- 
ing, and  suffering  from  severe  gastrointestinal  disorders, 
who  rapidly  improved  and  attained  good  health  on  sim- 
ply a  good  sterile  food  and  the  fresh  air  of  the  pier.  It 
is  interesting  to  note  that,  although  this  milk  was  often 
kept  in  hot  tenement-houses  where  ice  could  not  be 
afforded,  only  one  case  of  the  pasteurized  milk  turning 
sour  was  reported.  This  case  was  investigated,  and  it 
was  found  that  the  milk  had  been  kept  under  the  kitchen 
stove. 

The  scope  and  technical  facilities  of  this  charity  will 
be  enlarged  this  year.  Six  depots  in  various  parts  of  the 
city  will  be  established.  The  milk  will  be  brought  from 
Delaware  County,  N.  Y.,  the  herd  supplying  it  being 
first  carefully  inspected  by  a  veterinarian  of  the  Board  of 
Health.  Both  raw  and  sterilized  milk  will  be  supplied. 
The  same  formula  will  be  used  for  the  modified  milk, 
which  will  be  dispensed  in  six  ounce  bottles.  Pasteur- 
ized milk  will  be  sold  in  eight- ounce  and  six  teen-ounce 
bottles. 

In  addition  to  pasteurized  ordinary  milk  and  pasteur- 
ized modified  milk,  as  supplied  last  year,  a  pasteurized 
milk  diluted  with  barley  water  and  sweetened  with  cane 
sugar,  and  containing  also  table  salt,  has  been  introduced 
at  the  suggestion  of  Dr.  Jacobi.    The  formula  used  is : 

Table  salt .  i  oz. 

White  cane  sugar 10  oz. 

Milk I  gal. 

Water 1  gal 

This  barley  milk  will  be  dispensed  in  six-ounce  bottles. 
This  depot  will  be  prepared  to  supply  hospitals  and 
dispensaries. 

203  West  Fifty-seventh  Street. 


He  Swallowed  Two  Hundred  Hails. — Gastrotomy 
was  recently  performed  on  an  inmate  of  the  Lancaster 
County  (England)  Lunatic  Asylum,  and  nearly  two  hun- 
dred nails  from  one  and  a  half  to  three  inches  in  length 
were  removed  from  the  sorely  overweighted  stomach. 


August  4,  1894] 


MEDICAL   RECORD. 


135 


SOME  ABNORMAL  CONDITIONS  OF  THE  GEN- 
ERATIVE  ORGANS,  ASSOCIATED  WITH  MEL- 
ANCHOLIA  OR  MANIA1 

By   W.    GILL   WYLIE,   M.D., 
1 

NEW  YORK.    ■ 

It  is  a  generally  recognized  fact  that  abnormal  condi- 
tions of  the  generative  organs  in  women  cause  reflex  dis- 
turbances to  the  nervous  system,  such  as  severe  headaches, 
hysteria,  etc. ;  but  the  fact  that  a  chronic  subinvoluted,  or 
an  enlarged  and  congested  condition  of  the  uterus,  may 
induce  a  typical  case  of  melancholia  in  some  women,  has 
not  yet  been  fully  accepted  by  the  profession.  Tnere 
may  be  an  abnormal  condition  of  the  nervous  system 
present,  and  the  uterine  disease  merely  makes  it  active, 
for  in  many  of  my  cases  other  members  of  the  family 
have  been  mentally  unbalanced,  and  several  times  I  have 
had  tiro  sisters  with  the  same  symptoms.  Even  though 
there  may  be  a  strong  predisposing  cause  in  many  cases, 
caring  the  local  condition  relieves  all  the  symptoms. 
Most  of  my  cases  have  been  in  women  who  have  borne 
children,  but  in  several  instances  I  have  cured  well 
marked  cases  of  what  such  men  as  Spitzka,  Eroy,  and 
Sachs  have  diagnosed  as  cases  of  melancholia,  by  ampu- 
tating a  diseased  cervix  uteri  where  diseased  glands  and 
follicles  had  kept  up  an  enlarged  and  congested  condition 
of  the  uterus  in  virgins.  Some  of  these  cases  complained 
of  no  local  pain,  and  a  profuse  leucorrhsea  was  the  only 
indication  of  uterine  disease,  although  most  of  such  cases 
have  dysmenorrhoea,  backache,  etc.,  due  to  the  local  dis- 
ease, and  as  a  rule  the  nervous  symptoms  would  be 
classed  as  hysterical  rather  than  melancholic.  In  three 
of  th*  cases  brought'  to  me  having  marked  delusions  or 
acute  outbreaks  of  mania,  treatment  of  the  uterus  failed 
to  relieve  them.  In  one  I  could  plainly  define  acute 
salpingitis  and  ovaritis,  and  removal  of  the  appendages 
cured  the  mania.  In  the  second  case  I  could  not  define, 
even  under  ether,  any  disease  of  the  appendages,  but  Dr. 
Spitzka  said  in  his  opinion  the  mental  trouble  was  reflex, 
and  I  made  an  exploratory  incision  and  found  both  Fal- 
lopian tubes  occluded  and  the  distal  ends  filled  and  en- 
larged  with  pus.  The  patient  made  a  complete  recovery, 
although  for  many  weeks  a  trained  attendant  was  with 
her  night  and  day  to  prevent  suicide  before  the  last  oper- 
ation. The  third  case  had  well-pronounced  melancholia, 
and  I  found  a  diseased  cervix  and  subinvolution  ;  this  was 
treated  in  the  usual  way  and  for  several  months  she 
seemed  well,  but  then  all  symptoms  returned.  I  pro- 
nounced the  condition  of  uterus  normal  and  proposed  an 
exploratory  incision,  as  she  had  some  local  pain  on  the 
sides,  but  on  account  of  cost  for  operation,  etc.,  she  re- 
turned home,  and  later  Dr.  Van  de  Walker,  of  Syracuse, 
N.  Y.,  operated  and  found  salpingitis.  The  patient  was 
reported  cured. 

The  three  cases  reported  to-night  are  those  that  have 
b^en  recently  under  my  care,  and  were  all  examined  by 
well-known  alienists.  One  well  marked  case  of  melan- 
cholia, with  decided  outbreaks  of  mania,  was  sent  to  me. 
Although  she  had  a  lacerated  cervix  uteri  and  some  en- 
largement, it  was  not  enough  to  account  for  the  melan- 
cholia ;  so  I  turned  her  over  to  Dr.  L  C.  Gray,  and  he 
treated  her  as  he  liked  for  a  year  or  more ;  but  she  was 
not  cured,  and  then  I  operated  under  ether  for  the  lacera- 
tton,  etc. ;  the  effect  on  the  mental  condition  was  negative, 
but  certainly  did  not  make  her  worse,  and  I  turned  her 
over  again  to  Dr.  Gray.  Without  a  single  exception,  all 
my  cases  were  in  every  instance  seen  in  consultation  and 
examined  by  at  least  one  alienist  of  good  standing,  and 
I  am  sure  that  some  of  the  many  cases  of  melancholia 
treated  by  opium,  rest,  etc.,  could  be  relieved,  if  not  per- 
manently and  radically  cured,  if  a  gynecologist  was  called 
in  consultation.  I  know  that  most  doctors  think  they  can 
examine  and  diagnose  any  serious  disease  of  the  uterus  and 
appendages ;  but  unfortunately  many  of  them  are  merely 
unconscious  of  their  ignorance,  for  all  learned  doctors 

1  Read  before  the  Northwestern  Medical  and  Surgical  Society 
March  ,1894. 


are  not  artists,  their  brains  may  be  great  but  their  hands 
are  not  so  well  trained. 

Case  I. — Mrs.  S ,  aged  thirty-five,  came  to  con- 
sult me,  November  20,  1893.  §ne  s^d  she  had  had  six 
children ;  the  last  four  years  ago.  After  the  third  child 
was  born  she  had  some  unusual  nervous  symptoms,  but 
they  passed  off  after  a  month  or  more.  Since  the  birth  of 
the  last  child  she  had  not  been  well,  had  become  very 
nervous,  and  had  been  treated  for  more  than  two  years 
for  nervous  prostration.  She  imagined  her  husband  did 
not  like  her,  or  that  she  did  not  love  him,  and  everything 
was  wrong ;  and  at  times  she  was  so  depressed  that  she 
was  afraid  she  would  kill  herself.  She  had  recently  been 
treated  by  Dr.  Baruch  with  baths,  etc.,  and  was  improved 
in  her  general  health.  She  looked  in  fair  general  health, 
her  color  was  good.  She  had  no  actual  pain  anywhere, 
and  had  never  had  a  local  examination  since  the  birth  of 
her  last  child.  After  hearing  her  story  I  suggested  that 
all  her  nervous  symptoms  might  be  due  to  subinvolution 
of  the  uterus,  and  she  consented  to  an  examination.  I 
found  a  large  and  soft  uterus  held  back  in  the  pelvis  by 
a  very  hard  tumor  about  the  size  and  the  shape  of  a 
large  kidney ;  it  seemed  to  lay  between  the  bladder  or 
pubic  bone  and  the  uterus,  but  did  not  seem  firmly  at- 
tached. She  gave  a  history  of  excessive  menstruation, 
but  no  other  direct  symptoms  of  local  disease. 

I  advised  consultation  with  Dr.  Sachs,  he  pronounced 
it  a  well-marked  case  of  melancholia,  and  wished  to  give 
her  treatment  and  keep  her  under  observation  for  a  week 
or  two.  Although  I  was  told  afterward  that  several  of 
her  family  had  had  mental  disease,  I  advised  removal  of 
the  tumor  and  treatment  for  the  subinvoluted  uterus. 
She  was  admitted  to  my  sanitarium  December  1st,  and 
Dr.  Sachs  began  the  orthodox  opium  treatment  for  mel 
ancholia ;  under  this  she  was  less  nervous,  but  not  re- 
lieved of  her  depressing  thoughts. 

December  nth,  I  operated  and  removed  this  most  un- 
usual tumor,  which  appeared  to  be  a  fibroid,  detached  en- 
tirely from  the  uterus  and  appendages,  rolled  up  in  the 
lower  end  of  the  omentum,  and  coated  over  with  a  calca- 
reous shell.  The  tumor  has  no  blood-vessels  running 
into  it  and  seems  to  have  been  treated  by  the  surround- 
ing tissues  as  a  foreign  body.  It  is  shaped  something 
like  an  abnormally  large  kidney;  it  was  removed  without 
difficulty  and  the  patient  made  a  good  recovery.  In  less 
than  two  weeks  patient  was  practically  well.  The  uterus 
and  subinvoluted  pelvic  tissues  were  further  treated  by  the 
applications  of  boro-glyceride  cotton  pledgets  put  in  the 
vagina  twice  a  week ;  in  six  weeks  patient  was  dismissed 
cured ;  no  medicine  except  laxatives  used  after  operation. 

Case  II. — Mrs.   K ,  aged  thirty,  was  brought  to 

my  sanitarium  by  her  father  and  brother,  who  were  both 
physicians.  In  the  fall  of  1892  Dr.  W.,  the  brother, 
wrote  me  that  his  sister  had  been  insane  for  four  years, 
and  for  the  past  seven  months  she  had  been  under  the 
care  of  Dr.  Stern,  of  Hartford,  Conn.,  and  seemed  to  be 
practically  incurable,  and  wanted  to  know  if  I  would 
take  out  her  ovaries,  as  he  believed  that  their  disease 
caused  the  insanity.  I  wrote  him  that  I  would  be  glad 
to  see  the  case,  but  I  would  not  agree  to  remove  the  ova- 
ries unless  I  could  make  out  by  local  examination  posi- 
tive indications  of  actual  disease  of  the  ovaries. 

December  28,  1892,  I  examined  her.  She  had  had 
four  children.  Four  hours  previous  to  birth  of  last  child 
she  had  been  well.  Except  for  a  time  after  birth  of  sec- 
ond child,  she  was  very  nervous  and  mentally  much  dis- 
turbed. The  last  labor  was  not  difficult  nor  unusual  in 
any  way,  but  several  weeks  after  labor  she  grew  more 
nervous,  and  marked  symptoms  of  melancholia  came 
on,  which  in  spite  of  treatment,  rest,  etc.,  gradually 
grew  worse.  Dr.  Spitzka  saw  her  and  pronounced  it  a 
case  of  melancholia.  For  the  past  seven  months  she  had 
been  confined  to  Dr.  Stern's  sanitarium  and  was  consid- 
ered insane.  She  had  a  dislike  for  and  was  suspicious  of 
her  husband  and  family,  and  would  get  excited  and  rattle 
off  a  mixture  of  German  and  English  that  no  one  could 
understand  for  hours  at  a  time.     She  was  pale  and  thin, 


136 


MEDICAL    RECORD. 


[August  4,  1894 


but  not  in  very  bad  general  health.  She  needed  constant 
care  and  watching  by  a  nurse.  She  had  been  examined 
locally  by  Dr.  Stern,  but  local  treatment  was  not  deemed 
necessary.  On  local  examination  I  found  a  large, 
soft  uterus,  with  marked  relaxation  and  subinvolution  of 
the  vagina  and  pelvic  blood-vessels.  The  uterus  was 
fully  as  large  as  at  two  months'  pregnancy,  and  the  cervix 
was  greatly  enlarged  and  everted  by  diseased  glands  and 
follicles,  and  was  lacerated  to  some  extent.  There  was 
a  history  of  excessive  menstrual  flow. 

It  was,  in  my  opinion,  a  typical  case  of  subinvolution, 
due  to  disease  of  the  glands  and  follicles  of  the  cervix, 
with  some  laceration  of  the  cervix  at  labor. 

Dr.  Spitzka  saw  her  and  advised  me  to  try  the  local 
treatment  and  operation  to  cure  the  subinvolution,  etc. ,  af- 
ter regulating  her  bowels  and  feeding  her  carefully,  and 
applying  cotton  pledgets  to  the  vagina,  soaked  in  sol. 
boro  glyceride,  twice  a  week. 

On  January  9,  1893,  she  was  etherized  and  I  dilated 
the  uterus,  curetted  it,  and  amputated  the  diseased  tissue 
of  the  cervix  and  sewed  up  the  laceration,  lining  the 
cervical  canal  with  flaps  of  healthy  mucous  membrane 
drawn  in  from  the  vaginal  part  of  the  cervix.  I  also  di- 
lated the  anus  and  tied  off  some  haemorrhoids.  For  sev- 
eral days  after  the  operation  she  was  in  an  excited  state, 
gabbling  her  jargon  most  of  the  time  as  she  had  done  at 
intervals  before,  but  on  the  tenth  day  she  seemed  to  be 
perfectly  rational  and  remained  so  without  interruption. 
Gradually  her  general  condition  improved,  and  after  the 
tenth  day  I  made  the  boro  glyceride  applications  to  the 
vagina  twice  a  week  to  hasten  involution. 

On  January  31st  she  was  discharged  as  cured,  and  went 
to  her  home  in  Brooklyn.  For  several  weeks  she  came 
for  the  simple  local  treatment  twice  a  week.  Her  menses 
became  normal  in  amount  and  were  regular  till  last  fall, 
when  she  went  over  two  weeks  and  then  menstruated 
quite  freely.  Some  of  her  old  mental  confusion  returned , 
but  after  four  or  five  boro  glyceride  applications  to  the 
vagina  she  felt  well.  She  has  gained  flesh  and  strength, 
and  attends  to  all  her  duties  at  home  without  trouble. 

Case  III. — Mrs.  B ,   aged  thirty- two,   admitted 

November  16th,  said  she  had  been  married  eight  years, 
was  always  nervous,  and  several  of  her  family  had  had 
serious  mental  symptoms.  As  a  rule,  she  had  enjoyed 
good  health.  She  had  had  two  children,  and  after  the 
first  child  had  severe  pains  in  her  head  and  was  de- 
pressed, etc. ;  this  gradually  passed  off.  Eighteen 
months  ago  she  had  a  miscarriage,  since  then  she  had 
some  dragging  sensation  about  the  pelvis,  and  had 
gradually  become  very  nervous  and  suffered,  especially 
about  the  time  of  her  menses,  with  severe  occipital  head- 
aches, and  could  not  help  looking  at  this  in  a  depressed 
and  abnormal  way.  She  was  seen  by  Dr.  Spitzka,  who 
said  it  was  melancholia,  probably  caused  by  reflex  disturb- 
ance due  to  disease  of  the  generative  organs.  Local  ex- 
amination revealed  a  large  and  soft  uterus  which  bled  to 
the  touch  of  the  sound  on  the  endometrium.  There  was 
follicular  disease  of  the  cervix  with  a  slight  tear,  and 
there  was  subinvolution  of  the  vagina,  and  a  laceration 
of  the  inner  part  of  the  perinaeum  which  caused  the  lower 
end  of  the  rectum  to  crowd  forward  the  posterior  wall 
of  the  vagina  and  form  a  rectocele. 

November  20,  1893. — The  uterus  was  dilated,  curetted, 
and  the  diseased  tissue  of  the  cervix  removed,  and  lacera- 
tion sewed  up.  The  perineum  was  also  repaired  and  the 
anus  dilated  and  treated. 

The  patient  made  a  good  even  recovery,  and  after  the 
use  of  the  boro-glyceride  cotton  pledgets  twice  a  week 
she  was  dismissed  cured.  Once  since  then  some  of  her 
nervous  symptoms  returned,  but  they  promptly  disap- 
peared after  three  applications  had  been  made  of  the 
boro-glyceride.  I  do  not  mean  that  the  enlarged  condi- 
tion of  the  uterus  which  we  call  subinvolution,  or  the 
other  diseased  local  conditions,  will  cause  melancholia  in 
all,  or  even  in  many  women,  but  will  do  sa  in  some 
cases,  and  that  the  melancholia  seems  incurable  as  long 
as  the  local  disease  remains  uccured. 


Clinical  g^partment 

A  CASE  OF  FACE  PRESENTATION,  WITH  RO 
TATION  INTO  THE  SACRAL  CAVITY. 

By  JAMES   B.    BULLITT,   M.D., 

GLCBK,  A.  T. 

Mrs.   N ,  aged  twenty- one,   had  previously  given 

birth  to  two  healthy,  living  children,  first  becoming  a 
mother  when  seventeen  years  of  age.     During  the  third 
month  of  this  third  pregnancy  she  was  threatened  with 
an  abortion ;  in  addition  to  the  pains,  a  considerable 
amount  of  bloody  mucus  was  discharged,  and  the  mouth 
of  the  womb  was  sufficiently  patulous  to  admit  the  tip  of 
the  index  ringer.     With  the  recumbent  position  and  opi- 
ates the  disaster  was  averted  and  she  carried  the  child 
successfully  until  the  end  of  the  eighth  month.     At  this 
time  I  was  again  called  to  see  her ;  I  found  her  in  con- 
siderable pain,  of  intermitting  type,  referred  to  the  lower 
portion  of  the  abdomen  chiefly,  and  complaining  of  great 
aching  pains  in  the  small  of  the  back.     Palpation  dis- 
closed the  child's  body  in  the  first  position,  head  present- 
ing.    The  mouth  of  the  womb  was  sufficiently  patulous 
to  admit  the  finger,  which  could  feel  the  presenting  head. 
There  was  a  slight  discharge  of  bloody  mucus.     I  sup- 
posed this  to  be  the  beginning  of  labor,  and  left  instruc- 
tions to  be  sent  for  as  soon  as  true  pains  began.     The 
next  morning,  however,  the  condition  was  much  the  same; 
no  true  pains  had  commenced,  and  the  discharge  of 
bloody  mucus  had  ceased.     Five  days  later,  on  Friday, 
I  was  again  called  to  see  the  case ;  true  labor  pains  had 
begun  the  evening  before,  and  the  amniotic  fluid  had 
been  discharged  on  Friday  at  two  o'clock,  it  being  six 
o'clock  when  I  arrived.     Pains  were  recurring  at  intervals 
of  five  minutes,  and  were  strong,  but  no  advancement 
seamed  to  be  made.    The  mouth  of  the  uterus  was  not 
more  open  than  at  the  examination,  five  days  before,  ju^t 
admitting  the  tip  of  the  index  finger.     Gentle  manipula- 
tion permitted  the  introduction   of  two  fingers,  upon 
which  a  diagnosis  of  face  presentation  with  rotation  pos- 
teriorly was  made.     The  fingers  received  the  sensation  of 
the  pelvis  being  bridged  across,  instead  of  being  filled  in 
with  the  round  occiput  as  in  ordinary  occipital  presenta- 
tions.    Under  chloroform,  and  with  the  assistance  oi 
Drs.   Collins  and  Fox,  the  uterine  mouth  was  manually 
dilated ;  and  then,  with  the  hand  in  the  vagina,  two  fin- 
gers on  the  supra-maxillary  bones,  and  thumb  on  the  brow, 
I  made  pressure  upward,  the  other  hand  on  the  abdomen, 
pulling  the  head  in  the  same  direction.     The  head  was 
readily  dislodged;  the  external  hand  then  pushed  the 
occiput  downward,  the  hand  in  the  vagina  pushing  the 
chin  still  farther  upward.1     Conversion  into  an  occip- 
ital presentation  was  readily  effected ;  forceps  were  then 
applied,  and  a  living  child  brought  to  the  light  in  a  short 
space  of  time.     The  whole  procedure  consumed  an  hour 
and  ten  minutes'  time.     The  patient  took  chloroform 
very  badly,  rendering  the  manipulation  more  difficult  and 
more  lengthy  than  there  was  necessity  for.     The  mother 
made  an  absolutely  uneventful  recovery  ;  the  temperature 
was  never  higher  than  990  F.,  and  in  three  weeks'  time 
she  was  able  to  attend  to  her  household  duties.     The  child 
was  a  well  developed  girl,  weighing  seven  and  one- half 
pounds.     There  was  a  marked  facial  paralysis ;  this  has 
gradually  disappeared,  leaving  the  child  as  sound  as  the 
fondest  mother  could  desire. 

The  child's  head  was  of  an  average  size,  not  very  small, 
while  the  mother's  pelvis  was  also  of  average  dimensions, 
not  very  roomy.  In  case  of  failure  to  carry  the  head  up- 
ward and  then  convert  the  position  into  an  occipital  one, 
I  should  have  attempted  rotation  of  the  face  forward. 
Had  this  failed  I  was  prepared  to  do  a  symphyseotomy,  be- 
lieving thereby  it  would  have  been  an  easy  matter  to  slip 
the  occiput  beneath  the  pubic  arch,  from  which  point  de- 
livery would  be  plain  sailing.     Has  the  operation  of  sym- 

1  Manipulation  described  by  Parry.  American  Journal  of  Obstet- 
rics, May,  1875. 


August  4,  1894] 


MEDICAL  RECORD. 


137 


physeotomy  been  so  employed  ?  So  far  as  I  know  there 
has  been  no  report  of  such  a  case,  but  it  would  be  un- 
questionably feasible.  With  the  forceps  and  without 
symphyseotomy,  the  chin  has  been  dragged  down  over 
the  sacrum  and  perinaeum,  when  the  occiput  and  calvarium 
glided  underneath  the  pubes.1  Such  procedure  is  cer- 
tainly of  very  violent  nature,  and  fraught  with  danger  to 
both  mother  and  child. 


A  CASE  OF  LOOSE  CARTILAGE  IN  THE 
KNEE-JOINT. 

By  CHARLES  G.  R.  JENNINGS,  M.D., 

SLMtVA,   N.   Y. 

Mr.  A.  B.  G ,  civil  engineer,  gave  a  history  of  trouble 

with  his  knee,  dating  back  several  years  to  an  injury  re- 
ceived in  foot- ball  at  college.  From  that  time  he  had 
repeated  attacks  of  synovitis.  During  one  of  these, 
while  examining  his  knee  I  discovered  a  floating  carti- 
lage on  the  inner  side  of  the  joint,  which  immediately 
escaped  from  beneath  my  finger  and  could  not  be  found 
again.  For  nearly  a  year  after  that  he  was  comparatively 
free  from  trouble  with  the  knee.  The  cartilage  reap- 
peared unexpectedly  one  day  while  he  was  descending  a 
flight  of  stairs,  and  as  a  result  of  its  becoming  pinched 
between  the  bones  he  almost  fell  headlong.  As  soon  as 
he  recovered  from  the  shock  of  pain  and  surprise,  he 
clapped  his  hand  upon  the  knee  and  felt  the  foreign 
body.  From  that  time  on  it  made  its  appearance  repeat- 
edly at  short  intervals.  It  seemed  to  enjoy  the  freedom 
of  the  whole  synovial  sac.  Wherever  the  sac  extended, 
this  wandering  body  was  liable  to  go,  sometimes  being  felt 
behind  the  knee  in  the  popliteal  region,  sometimes  above 
the  knee  beneath  the  quadriceps  extensor,  at  other  times 
below  the  patella,  but  most  frequently  on  either  side  of 
the  joint.     The  patient  finally  came  to  me  for  operation. 

I  doubted  whether  it  would  be  possible  to  fix  the  car- 
tilage in  an  accessible  part  of  the  capsule  and  keep  it 
there  long  enough  to  administer  an  anaesthetic  and  pre- 
pare for  a  formal  operation,  so  I  resorted  to  the  following 
plan  of  procedure :  First  I  had  the  knee  shaved  and 
thoroughly  scrubbed  with  green  soap  and  washed  with 
ether  and  sublimate ;  then  a  full  antiseptic  dressing  was 
put  on.  The  patient  was  allowed  to  go  where  he  pleased, 
but  was  advised,  whenever  the  cartilage  made  its  appear- 
ance, to  keep  it  in  sight  if  possible  until  I  could  be  noti- 
fied and  remove  it.  In  a  few  days  it  got  pinched  again, 
slipped  to  the  inner  side  of  the  joint,  and  there  he  held  it 
until  I  was  ready  for  the  operation. 

With  my  left  thumb  I  crowded  it  as  far  down  over  the 
head  of  the  tibia  as  possible  and  on  the  inner  aspect  of 
the  joint  The  sac  seemed  very  loose  and  large,  so  that 
the  body  felt  as  if  it  were  at  the  top  of  a  well,  with  a 
strong  tendency  to  fall  back  into  the  cavity.  Cocaine 
was  injected  beneath  the  skin  in  the  line  of  incision.  Then, 
while  pressing  my  thumb  between  the  cartilage  and  the 
general  synovial  cavity,  thus  completely  shutting  off  the 
joint  from  the  pocket  in  which  I  had  the  cartilage  isolated, 
I  cut  down  upon  it  until  the  sac  appeared.  Stopping  all 
hemorrhage,  I  then  incised  the  sac,  when  the  shining  pearly 
button  of  cartilage  presented,  and  was  seized  with  mouse- 
tooth  forceps  and  removed  through  the  slit  very  much  as 
one  slips  a  button  through  a  button- hole.  The  cartilage 
had  no  attachment,  was  a  perfectly  round  flattened  disk, 
three  quarter  inch  in  diameter,  and  upon  one  edge  there 
was  a  short  fringe  by  which  it  had  originally  been  at- 
tached to  the  synovial  membrane.  No  synovial  fluid 
escaped,  nor  did  air  enter  the  joint,  as  I  held  my  thumb 
down  upon  the  bone,  shutting  the  opened  portion  of  cap- 
sule off  from  the  rest.  Catgut  sutures  were  used  for  cap- 
sule and  skin.  No  drainage  was  used,  as  I  felt  confident 
it  would  not  be  needed.  An  ordinary  dry  aseptic  dress- 
ing was  applied,  the  leg  put  on  a  posterior  splint,  and  the 
patient  was  kept  in  bed  for  four  or  five  days.  There  was 
no  rise  of  temperature  whatever  nor  any  local  disturb- 

1  SmeUie,  Hicks,  and  Braua.  Science  and  Art  of  Midwifery  :  Lusk. 


ance.  He  very  soon  left  off  the  splint,  and  resumed 
walking  with  perfect  use  of  the  leg.  The  knee  was  capa- 
ble of  the  fullest  flexion  and  as  good  as  new.  It  is  now 
eight  months  since  the  operation,  and  he  has  had  no 
trouble  with  his  knee  at  any  time  since  the  cartilage  was 
removed. 

In  cases  where  the  cartilage  is  so  freely  movable  and  hard 
to  retain  in  sight,  I  believe  the  above  operation  is  better 
than  to  open  the  joint  in  the  usual  manner  under  anaes- 
thesia and  fish  for  a  loose  cartilage  which  may  require 
very  considerable  manipulation  within  the  synovial  sac 
before  it  can  be  grasped  and  removed. 

27a  Baldwin  Strbht. 


CYST  OF  PHARYNGEAL  TONSIL. 
By  ANNETTE  E.  LAMPHEAR,  M.D., 

NBW  YORK. 

On  February  2, 1894,  G.  M — -,  male,  aged  twenty-four, 
Swede,  cook  by  occupation,  came  to  Dr.  Jonathan 
Wrights  clinic  at  Roosevelt  Dispensary  for  treatment  of 
"catarrh." 

The  patient's  family  history  was  good.  The  personal 
history  was  somewhat  vague.  About  ten  months  ago  he 
had  a  sore  throat,  which  was  probably  a  peritonsillitis. 
Has  had  no  aural  trouble,  no  nasal  obstruction,  but  for 
an  indefinite  time  a  great  deal  of  post-nasal  dropping,  and 
expectorates  very  much  mucus. 

Examination  of  nasal  fossae  and  oropharynx  showed 
nothing  particularly  abnormal,  but  on  introducing  a 
post-nasal  mirror  the  vault  of  the  pharynx  seemed  low. 
This  appearance  was  seen  to  be  due  to  the  projection 
downward  from  the  middle  of  the  vault  of  a  slightly  ob- 
long body  about  the  size  of  a  bean.  The  membrane 
covering  this  projection  was  smooth,  and  differed  none 
in  appearance  from  the  remainder  of  the  naso-pharynx. 
The  diagnosis  of  cyst  was  made  and  verified  by  a  digital 
examination. 

After  cocainization  the  mass  was  removed  with  post- 
nasal forceps,  its  detachment  requiring  considerable  trac- 
tion. The  cyst  cavity  was  filled  with  plugs  of  inspissated 
mucus. 

The  microscopical  examination  of  its  wall  showed  both 
the  outer  and  inner  surface  to  be  covered  with  stratified 
pavement  epithelium.  The  inner  surface  was  smooth, 
excepting  near  its  attachment  to  the  pharynx,  where  there 
were  a  few  crypts.  The  mucous  membrane  was  rich  in 
lymph  corpuscles,  but  there  were  very  few  lymph  fol- 
licles. 

It  would  seem  that  this  cyst  resulted  from  adhesions 
between  the  lateral  folds  of  a  hypertrophied  pharyngeal 
tonsil,  its  wall  being  formed  by  the  complete  closing  in 
of  the  median  fissure.  The  form  of  epithelium,  stratified 
pavement,  I  think,  is  somewhat  unusual,  most  authorities 
giving  the  ciliated  columnar  as  the  type  of  the  naso- 
pharynx. This  is  the  only  case  of  retention  cyst  in  over 
five  thousand  patients  treated  in  the  Throat  Department 
of  Roosevelt  during  the  last  six  years,  and  I  have  been 
able  to  find  only  one  other  case  reported  in  our  American 
journals,  that  of  Dr.  Wright's,  in  the  Philadelphia  Med- 
ical News,  of  1889. 


Extract  of  Leeches  in  the  Prevention  of  Thrombosis. — 
Dr.  Sahli  reported  to  the  International  Medical  Congress 
that  an  infusion  of  leeches  given  by  intravenous  injection 
would  prevent  thrombosis.  From  experiments  made  on 
rabbits  it  was  found  that  an  infusion  of  the  head  of  one 
leech  to  every  two  ounces  of  blood  in  the  body  was  the 
required  dose.  For  a  man  weighing  one  hundred  and 
thirty  pounds,  between  eighty  and  ninety  leeches  would 
be  needed.  As  the  effect  of  the  remedy  is  not  perma- 
nent, it  being  found  necessary  to  repeat  the  injection  at 
short  intervals,  it  is  improbable  that  this  new  medicine 
will  find  a  very  wide  application. 


i3» 


MEDICAL  RECORD. 


[August  4t  1894 


The  Etiology  and  Treatment  of  Hydronephrosis. — 
The  surgical  treatment  of  various  pathological  conditions 
of  the  kidney  has  of  late  years  come  very  prominently  to 
the  front,  thanks  in  great  part  to  the  improvements  that 
have  been  introduced  into  the  technique  of  the  operative 
procedures,  improvements  which  have  had  for  effect  to 
make  nephrectomy  about  as  safe  as  an  ordinary  ovari- 
otomy, and  that  is  saying  a  good  deal.  The  affections  of 
the  kidney  in  which  the  surgeon  has  shown  himself  able 
to  intervene  with  a  fair  amount  of  success  are  hydrone- 
phrosis and  pyonephrosis.  Pyonephrosis  comprises  two 
varieties,  which  require  to  be  distinguished  both  on  patho- 
logical and  on  therapeutical  grounds.  There  is  one  form 
associated  with  calculus.  In  this  form  it  is  pyonephrosis 
from  the  commencement,  and  should  be  dealt  with  pref- 
erably by  nephrotomy  and  drainage,  especially  if  by  the 
removal  of  the  obstructing  calculus  the  patency  of  the 
ureter  can  be  restored.  The  other  form  occurs  as  the  re- 
sult of  suppuration  in  a  hydronephrosis.  In  this  form 
the  disorganization  of  the  secreting  portion  of  the  organ 
is  usually  so  complete  that  nothing  remains  but  to  remove 
the  cyst  which  has  become  a  source  of  danger  to  its  pos- 
sessor. In  a  paper  which  Mr.  Bland  Sutton  recently  read 
before  the  Medical  Society  of  London,  he  pointed  out 
that  to  cause  hydronephrosis  the  obstruction  to  the  flow 
of  urine  must  be  incomplete,  or,  if  complete,  intermittent, 
because  sudden  complete  and  permanent  obstruction  tends 
to  cause  atrophy  rather  than  dilatation  of  the  kidney. 
This  tendency  to  intermission  is  one  of  the  most  remark- 
able phenomena  associated  with  hydronephrosis,  which 
thus  simulates  the  "phantom  tumors "  dear  to  gyne- 
cologists. When  bi- lateral,  the  intermission  may  be 
alternate,  and  the  diagnosis  then  presents  less  difficulty. 
The  most  curious  feature  about  these  cases  of  hydrone- 
phrosis is  that  though  an  obstruction  to  the  flow  of  the 
urine  must  presumably  at  some  time  or  another  have  ex- 
isted, no  trace  of  the  original  obstruction  is  sometimes 
discoverable  during  operation  or  post  mortem.  This  fact 
is  perhaps,  after  all,  not  so  surprising  as  it  looks  at  first 
sight.  It  is  quite  conceivable  that  the  original  condition 
which  gave  rise  to  the  obstruction  may  have  become  oblit- 
erated by  the  grave  changes,  both  in  the  kidney  and  in 
the  neighboring  structures,  involved  by  the  formation  of 
an  extensive  hydronephrosis.  Thus  a  movable  kidney 
which  originally  rejoiced  in  sufficient  mobility  to  kink  or 
otherwise  obstruct  the  ureter,  may  subsequently,  when 
developed  into  a  cyst  of  considerable  dimensions,  have 
contracted  adhesions,  thus  disguising  the  primary  cause 
of  the  obstruction.  It  is  assumed,  moreover,  that  ob- 
struction of  the  ureter  low  down  is  invariably  associated 
with  dilatation  of  the  ureter  right  up  to,  and  including, 
the  pelvis  of  the  kidney.  Mr.  Henry  Morris  pointed  out 
that  this  conception  tended  to  mislead,  because  in  some 
cases  the  ureter  may  bulge  in  a  particular  spot  as  the  re- 
sult of  internal  pressure  acting  on  walls  of  unequal  resist- 
ance, and  that  spot  may  be  near  the  pelvis  of  the  kidney, 
in  which  event  the  dilatation  would  probably  be  con- 
founded with  that  of  the  kidney  pelvis ;  or  the  bulge,  if 
lower  down,  may  compress  the  ureter  above  it  as  an 
aneurism  sometimes  does  in  respect  of  the  artery  on  which 
it  is  situated.  It  follows  that  non-dilatation  of  the  ureter 
throughout  the  whole  or  the  greater  part  thereof  does  not 
preclude  the  possibility  of  the  hydronephrosis  being  due 
to  some  obstruction  low  down.  Hydronephrosis  is  a 
curiously  silent  affection ;  indeed,  the  only  symptom  for 
a  long  time  may  be  an  increase  in  micturition.  This  is 
particularly  the  case  in  respect  of  unilateral  nephrosis, 
which  may  form  without  any  indication  of  renal  disease, 
and  may  remain  unnoticed  and  undiagnosed  until  by  its 
size  it  gives  rise  to  symptoms  incidental  to  the  presence 
of  such  a  growth.  In  the  double  affection  the  same  silent 
course  may  be  pursued,  until  the  kidney  substance  has  be- 
come so  much  degenerated  that  enough  does  not  remain 
to  provide  for  contingencies,  and  then  the  slightest  strain 


on  the  excretory  organs  may  determine  grave  symptoms 
of  renal  inadequacy.  It  is  now  generally  conceded  that 
in  presence  of  a  hydronephrosis,  a  fortiori,  if  suppurating, 
and  provided  the  other  organ  is  in  good  working  order, 
the  best  course  is  to  remove  it  by  nephrectomy.  Inas- 
much as  it  is  essential  to  ascertain  for  certain  the  condi- 
tion of  the  other  organ,  the  surgeon  is  advised  to  proceed 
by  a  median  incision  through  the  front  of  the  abdomen, 
through  which  he  can  without  difficulty  examine  the  con- 
dition of  both  kidneys.  Should  he  deem  it  expedient  to 
remove  the  diseased  organ,  he  then  closes  the  anterior 
wound,  and  turning  the  patient  over,  removes  the  kidney 
through  a  lumbar  incision — that  is  to  say,  without  enter- 
ing the  peritoneal  cavity.  This  is  a  point  worth  bearing 
in  mind  by  gynecologists,  who  not  infrequently  stumble 
on  a  renal  tumor  which  has  been  cut  down  upon  under 
the  impression  that  it  was  ovarian  or  uterine.  In  the 
flurry  of  the  discovery  the  gynecologist  is  tempted  to  go 
ahead  and  to  remove  the  organ  through  the  peritoneum, 
instead  of  closing  the  original  wound  and  attacking  it 
from  behind,  thereby  adding  considerably  and  needlessly 
to  the  risk  of  the  intervention.  Altogether  the  question 
is  a  very  interesting  one,  for  it  is  full  of  promise  in  a  de- 
partment where  formerly  little  or  no  hope  could  be  en- 
tertained of  affording  relief. — Medical  Press. 

Sloughing  of  Cervix  after  Labor;  Bee 0 very.— Dr. 
Magnaux  has  observed  this  complication  in  a  woman, 
aged  thirty-eight,  who  had  been  twenty  times  pregnant — 
twelve  labors  at  term,  one  in  the  middle  of  the  sixth 
month,  and  six  miscarriages,  while  the  twentieth  preg- 
nancy began  at  the  end  of  November,  1892.  She  was 
seen  at  the  Hopital  Tenon  in  April,  when  no  morbid 
history  could  be  traced.  On  August  26,  1893,  labor 
set  in  at  10  p.m.  She  was  delivered  at  9  a.m.  the  next 
morning,  having  been  admitted  into  the  same  hospital. 
The  cervix,  it  was  noticed,  was  never  entirely  effaced, 
and  during  the  efforts  at  expulsion  the  anterior  lip  pro- 
jected at  the  vulva,  and  appeared  (Edematous  and  deep 
violet  in  color.  The  child  was  very  big,  and  there  was 
some  trouble  in  delivering  the  shoulders ;  the  head  had 
presented  in  the  first  position.  The  left  arm  was  dam- 
aged, but  the  child  was  saved.  The  cervix  uteri  of  the 
mother  was  found  next  day  lacerated  on  both  sides.  A 
part  of  the  posterior  lip  was  found  partly  detached.  The 
anterior  lip,  over  three  inches  long,  projected  at  the  vulva ; 
it  was  sloughy.  The  vagina  was  syringed  daily  with 
lysol,  and  the  cervix  painted  with  iodine  and  iodoform 
gauze  passed  into  the  cervical  and  vaginal  canals.  With- 
in a  week  the  sloughy  tissues  had  separated.  By  Sep- 
tember 1 2th,  no  trace  of  any  anterior  lip  remained,  the 
posterior  lip  was  very  thin,  and  about  half  an  inch  long. 
The  child's  left  arm  remains  partially  paralyzed. — Ar- 
chives de  Tocoiogie. 

The  Antiseptic  Power  of  Ichthyol. — As  the  result  of 
recent  experimental  studies  Dr.  Abel  states  that :  1.  The 
ichthyol  preparations  in  weak  solutions,  and  in  a  short 
time,  destroy  the  pyogenic  and  erysipelas  streptococci. 
The  action  of  various  commercial  preparations  is  prac- 
tically identical.  Ichthyol  is  used  with  success  in  the 
suppuration  from  these  cocci.  2.  The  staphylococcus 
aureus  and  albus,  the  bacillus  pyocyaneus,  the  bacillus  of 
typhoid,  ozasna,  and  anthrax,  the  spirillum  of  Asiatic 
cholera,  show  more  or  less  resistance  to  ichthyol,  in  that 
when  pure  it  must  act  upon  them  by  the  hour  in  order  to 
destroy  these  organisms  in  cultures.  3.  The  diphtheria 
bacillus  in  fresh  colonies  is  easily  destroyed  by  weak 
ichthyol  solutions,  while  mature  ones  are  acted  upon 
with  difficulty.  Therefore  it  is  useful  in  diphtheria  only 
in  prophylaxis.  4.  Ichthyol  has  rendered  good  service 
in  the  treatment  of  typhus  and  ozsena,  although  it  can 
only  with  difficulty  make  harmless  these  infections.  5. 
It  is  recommended  that  it  should  be  preserved  only  in  sub- 
stance or  in  a  fifty  per  cent,  solution ;  weaker  solutions 
may  be  culture  mediums  for  micro-organisms.  Weak  so- 
lutions should  be  sterilized  by  heat,  which  has  no  influence 
upon  its  properties. — Ccntralblatt  fur  Baktcrio  logic. 


August  4,  1894] 


MEDICAL    RECORD. 


139 


Medical   Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


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


New  York,  August  4,  1894. 


THE  VALUE  OF  LIFE  IN  CASES  OF  ACCIDENT. 

The  recent  action  of  the  Committee  on  Preamble  of  the 
Constitutional  Convention  of  the  State  of  New  York,  in 
favor  of  retaining  the  limit  of  damages  by  railroad  acci- 
dent resulting  in  loss  of  life  to  five  thousand  dollars,  has 
naturally  given  rise  to  some  adverse  criticism  by  the 
daily  press.  The  objection  taken  is  founded  upon  the 
absurdity  of  allowing  any  limit  for  damages  short  of  kill- 
ing, and  stopping  by  legal  enactment  at  the  sum  of  five 
thousand  when  the  victim  is  entirely  sacrificed.  The 
question  resolves  itself  into  the  ridiculous  solution  that  a 
part  is  of  more  value  than  the  whole.  In  other  words,  it 
appears  to  be  cheaper  to  kill  a  man  outright  than  to 
strain  his  back,  put  out  an  eye,  crush  his  foot,  or  maim 
his  hand.  In  the  former  case  he  is  done  for  at  once,  his 
earning  capacity  is  at  an  end,  and  the  Tailroad  compa- 
nies give  the  price  for  the  carcass ;  while  in  the  other  the 
probabilities  of  his  still  being  able  to  earn  something  of 
a  living  are  offset  against  any  sum  of  damages  within  the 
range  of  the  sympathies  of  the  jury. 

The  real  question  bears  upon  the  earning  capacity  of 
the  victim.  It  is  well  known  that  a  wide  latitude,  in  case 
of  maiming,  is  given  in  determining  the  relative  earning 
capacity  of  different  individuals,  and  damages  are 
awarded  accordingly.  Why  the  relative  value  of  lives 
should  not  in  such  a  score  be  equally  considered  does 
not  appear.  The  life  insurance  companies,  in  questions 
of  life  expectation  at  given  ages,  with  different  surround- 
ings and  with  stated  hereditary  proclivities,  have  reduced 
the  charges  to  mathematical  calculations  and  govern 
their  premiums  accordingly.  But  by  the  present  rule  all 
lives  are  equal  before  the  law,  no  matter  how  young  or 
old  the  victim  may  be,  what  his  earning  capacity  has 
been  proved  to  be,  what  his  future  might  reasonably 
guarantee,  and  what  the  degree  of  loss  may  be  to  his 
dependent  family.  In  this  respect  the  ordinary  day 
laborer,  with  an  earning  capacity  of  two  or  three  dollars 
daily,  is  on  an  equal  footing  with  the  professional  man, 
the  expert  artisan,  or  the  progressive  tradesman  whose 
possibilities  are  almost  without  limit. 

If  we  rest  the  claim  for  damages  upon  the  basis  of  rea- 
sonable expectation  of  earnings,  which,  in  fact,  is  the 
only  way  of  •  proper  adjustment,  we  are  forced  to  admit 
that  the  highest  award  should  be  rendered  in  case  of 
death ;  while  in  mere  maiming  the  parties  accountable 
for  the  same  should  pay  in  proportion  to  the  degree  and 
extent  of  the  incapacity  occasioned  by  the  particular 


injury.  If  the  jury  is  competent  to  decide  the  extent  of 
damages  in  one  case,  why  not  in  the  other  ?  To  the 
medical  man,  who  is  accustomed  to  weigh  all  the  circum- 
stances in  the  cases  of  injury,  this  is  the  only  way  to  do 
justice  to  all. 

The  railroad  companies  are,  of  course,  in  favor  of  the 
statute  as  it  now  is,  the  reasons  for  which  are  too  obvious 
for  mention. 


LAWYERS   ON  THE   FEES  OF  DOCTORS. 

For  some  reason,  lawyers  have  developed  a  special  ten- 
dency to  lessen  the  monetary  value  of  physicians'  services. 
It  is  the  common  experience  that  a  doctor's  bill  which 
has  to  be  visid  by  a  lawyer  will  surely  be  cut  down. 
Laboring  men,  business  men,  corporations,  and  most 
classes  of  society,  even  including  clergymen,  are  usually 
willing  to  pay  for  medical  services ;  but  the  lawyer  seems 
always  to  think  them  appraised  too  high.  This  at  least 
is  the  complaint  which  is  often  made  to  us.  And  quite 
in  harmony  with  this  is  an  editorial  expression  on  the 
subject  by  the  New  York  Law  Journal.  The  editor 
says: 

"  In  dealing  with  rich  patients  and  clients,  physicians 
and  surgeons,  and  lawyers  acting  in  cases  not  involving 
specific  property,  should  make  out  their  bills  not  com- 
mensurately  with  the  wealth  of  their  employer,  but 
simply  on  the  basis  that  he  is  rich  enough  to  pay  what- 
ever is  right  The  charges  should  be  fixed  according  to 
the  practitioner's  standing  and  experience  and  the  amount 
of  labor  involved,  the  customary  rates  of  practitioners  of 
equal  standing  in  the  same  community  for  similar  ser- 
vices being  kept  in  view  as  a  guide  and  a  possible  cor- 
rective. This  general  rule  would  not  preclude  the  accept- 
ance of  smaller  fees  from  poor  people,  but  it  would  debar 
a  practitioner  from  charging  a  man  worth  $  1,000,000 
more  than  one  worth  J  100,000  for  the  same  service.  We 
believe  it  is  essentially  communistic  and  subversive  of 
professional  conscience  and  dignity  to  charge  a  rich  man 
all  that  can  be  screwed  out  of  him,  in  order  to  make  up 
for  what  one  thinks  he  ought  to  have  received  on  account 
of  professional  acts  of  charity  or  mercy." 

The  wording  of  the  above  is  ingenious,  and  the  plea 
made  has  an  air  of  justice.  Certainly  no  one  will  dis- 
agree with  the  statement  that  "a  rich  man  should  not  be 
charged  all  that  can  be  screwed  out  of  him."  But  it 
would  be  inferred  that  no  less  should  be  charged  for  a 
capital  operation  on  a  person  of  very  moderate  means 
than  for  one  done  on  a  multiple  millionaire,  or  a  person 
upon  whose  life  depends  the  safe  and  productive  manage- 
ment of  some  great  industrial,  social,  or  political  work. 
The  fact  is,  we  believe,  that  most  surgeons  have  a  certain 
scale  of  maximum  and  minimum  fees.  The  maximum 
is  a  fixed  one  and  is  applied  to  the  wealthy.  All  would 
apply  it  to  millionaires,  while  few  would  apply  it  to  a 
person  worth  one-tenth  that  sum,  since  this  does  not  by 
any  means  make  him  wealthy  if  he  lives  in  this  town. 


Bellevue  Hospital. — Plans  are  being  made  for  the  re- 
construction of  certain  portions  of  Bellevue  Hospital, 
New  York,  that  part  which  is  used  as  reception  office, 
examination  and  admission  rooms,  besides  store-room  of 
the  hospital. 


T40 


MEDICAL    RECORD. 


[August  4,  1894 


DOCTORS  AND  DEFINITIONS. 

A  certain  weekly  paper  in  this  town  has  adopted  the 
practice  of  publishing  some  scurrility  about  the  medical 
profession  in  each  issue.  This  is  not  a  matter  of  very 
much  importance ;  still  it  possesses  some  academic  in- 
terest to  physicians,  who,  as  a  rule,  take  both  eulogy  and 
satire  in  a  very  equable  manner. 

What  one  might  object  to  as  regards  this  particular 
departure  in  journalism  is  the  fact  that  the  man  who  does 
the  medical  items  in  the  aforesaid  weekly  gets  them  out 
of  ancient  jest  books,  which  is,  we  think,  a  wrong  practice 
and  dishonest  to  his  readers.  For  example,  the  latest 
medical  joke  is  a  "  Definition  of  a  Doctor,1'  this  definition 
being:  "A  person  who,  when  you  are  ill,  comes  and 
guesses  what  is  the  matter  with  you."  Now,  this  is  very 
good  and  amusing,  but  it  is  not  as  good  as  the  definition 
given  by  Voltaire  (a.d.  1740),  to  the  effect  that  "a 
doctor  is  a  person  who  pours  drugs  of  which  he  knows 
little  into  a  body  of  which  he  knows  less."  Yet  it  is  evi- 
dently the  same  idea.  Swift's  satire  was  equally  brilliant. 
"Apollo  was  the  god  of  physic  and  the  sender  of  dis- 
eases. Both  were  originally  of  the  same  trade  and  con- 
tinue so."  And  something  in  the  same  line  was  the  epi- 
gram of  Martial : 

"  Diaulus,  the  doctor,  was  a  sexton  made, 
Though  he  is  changed,  he  changeth  not  his  trade." 

The  material  for  similar  definitions  of  doctors  exists  in 
literature  from  ancient  to  modern  times.  It  is  resur- 
rected at  regular  intervals  and  is  always  the  same.  The 
point  is,  that  doctors  are  ignorant,  useless,  avaricious, 
pretentious,  dishonest,  slayers  of  men,  or  else  that  they 
are  promoters  of  suffering,  heartless,  and  brutal  vivi- 
sectors.  The  jokes  always  show  that  doctors  do  not 
know,  they  only  guess ;  they  do  not  cure,  they  only  pre- 
tend ;  they  do  not  tell  the  truth ;  they  carve  up  living 
animals  who  all  the  time  suffer  conscious  and  excruciating 
agony ;  they  enjoy  the  misery  of  others,  and  they  work 
to  prolong  it ;  their  bills  are  high,  their  labor  light,  their 
responsibilities  trivial,  and  their  rewards  in  money  and 
appreciation  enormous. 

This  is  the  sum  and  substance  of  the  medical  jokes  of 
the  past  two  thousand  years.  They  are  all  in  print,  or 
at  least  samples  of  them,  and  form  a  part  of  accessible 
literature.  We  could  refer  the  amiable  malefactor  who 
writes  his  weekly  medical  jokes  in  this  New  York  paper 
to  the  volumes  in  which  all  the  above  facetiae  are  com- 
piled, but  he  shows  that  he  possesses  it. 

Why  not,  however,  give  the  world  some  new  jest  on 
the  evils  of  medicine,  or  else  give  proper  credit  to  our 
sympathetic  critics  of  the  past  ? 

And  why  not  sometimes  be  pleasant  also  and  show  the 
other  side?  Even  Voltaire,  who  was  a  bigger  man  after 
all  than  the  average  New  York  jest-maker,  said : 

"  Nothing  is  more  estimable  than  a  physician  who, 
having  studied  nature  from  his  youth,  knows  the  prop- 
erties of  the  human  body,  the  diseases  which  assail  it,  the 
remedies  which  will  benefit  it,  exercises  his  art  with 
caution,  and  pays  equal  attention  to  the  rich  and  the 
poor."  

Mr.  Lawton  Tait  was  going  to  move  to  London,  ac- 
cording to  some  of  the  English  papers,  a  year  or  so  ago. 
Now  the  American  papers  state  that  he  is  going  to  Chi- 
cago. 


Hexus  of  Vht  W&cek. 

Rewards  for  Fecundity.  —  The  Province  of  Quebec 
has  a  law  bestowing  100  acres  of  government  land  upon 
every  father  of  a  family  who  has  twelve  living  children, 
issue  of  a  lawful  marriage.  Up  to  the  present  174,200 
acres  of  rich  agricultural  land  have  been  given  away  in 
bounties  to  1,742  fathers  of  twelve  or  more  children,  who 
have  complied  with  the  conditions  of  the  act.  Not  all 
of  these  proud  fathers,  however,  are  satisfied  with  the 
amount  of  the  bounty,  for  instances  of  families  of  twenty 
or  more  children  are  not  rare,  and  the  fathers  of  these 
want  a  proportionately  higher  reward  for  their  patriotic 
efforts.  One  old  gentleman,  Mr.  Paul  Belanger,  of 
River  du  Loup,  wants  300  hundred  acres,  and  bases  his 
claim  upon  the  fact  that  he  has  thirty-six  living  children. 
Another  claimant  for  an  increased  allowance  is  Mr. 
Theoret,  of  St.  Genevieve.  His  wife,  who  is  but  thirty 
years  of  age,  has  presented  him  with  seventeen  children. 
She  has  just  givpn  birth  to  triplets  for  the  second  time  in 
five  years,  and  has  had  twins  three  times.  Mr.  Theoret 
hopes  to  acquire  a  large  portion  of  the  Province  if  his 
wife  will  continue  to  do  her  share. 

Medical  Education  in  China. — Western  medicine  is 
slowly  making  its  way  in  the  Celestial  Empire,  under  the 
fostering  care  of  the  progressive  Viceroy  Li  Hung  Chang. 
The  medical  school  established  by  him  in  Tien  Tsing  is 
in  a  flourishing  condition,  and  it  has  been  decreed  that 
the  medical  officers  of  the  army  and  navy  shall  in  future 
be  taken  from  its  graduates.  The  medical  stores  for  use 
in  both  services  must  first  be  approved  by  the  faculty  ot 
this  school. 

Professor  Max  von  Pettenkofcr  has  resigned  from  the 
University  of  Munich.  The  cable  reports  that  this  has 
aroused  a  great  deal  of  public  indignation,  as  it  is  un- 
derstood that  the  resignation  was  enforced  by  pressure 
from  Berlin  in  consequence  of  Dr.  Pettenkofer  objecting 
to  some  of  the  anti-cholera  measures  recommended  by 
Professor  Koch. 

The  American  Association  of  Obstetricians  and  Gy- 
necologists will  hold  its  seventh  annual  meeting  at 
Toronto,  Ont.,  Wednesday,  Thursday,  and  Friday,  Sep- 
tember, 19,  20,  and  21,  1894,  to  which  a  cordial  invita- 
tion is  extended  to  the  medical  profession. 

The  German  Association  of  Scientists  and  Phy- 
sicians will  hold  its  sixty -sixth  annual  meeting  in 
Vienna  during  the  week  ending  September  30th.  The 
Austrian  Government  has  made  an  appropriation  of 
$5,000  to  defray  the  expenses  of  the  meeting. 

A  Russian  Leper  Colony.  The  St.  Petersburg  cor- 
respondent of  the  London  Daily  Chronicle  states  that  the 
general  governor  of  the  Amoor  province  is  arranging 
in  the  vicinity  of  Nicolaivsk  for  a  colony  of  lepers,  which 
will  be  surrounded  by  a  stockade,  to  prevent  the  patients 
leaving  the  place.  Land  is  being  set  apart  within  the 
enclosure  for  gardens  and  the  necessary  buildings. 

The  Kentucky  School  of  Medicine. — At  the  meeting 
of  the  Association  of  American  Medical  Colleges,  held 
in  San  Francisco  on  June  7,  1894,  the  Kentucky  School 
of  Medicine,  of  Louisville,  Ky.,  was  dropped  from  mem- 
bership in  the  Association. 


August  4,  1894] 


MEDICAL    RECORD. 


141 


The  University  of  Halle  has  been  celebrating  the 
second  centenary  of  its  foundation  on  Thursday,  Friday, 
and  Saturday  of  this  week. 

Dr.  Jules  Comby,  of  Paris,  editor  of  the  Revue  Men- 
suelle  des  Maladies  de  VEnfance,  has  been  created 
Chevalier  of  the  Order  of  the  Crown  of  Italy. 

Dr.  Paul  Berger  has  been  appointed  to  the  chair  of 
Clinical  Surgery  in  Paris,  vacant  through  the  death  of 
Dr.  L6on  Lefort. 

The  Mortality  in  Rio  de  Janeiro,  for  the  second  half 
of  the  month  of  March,  was  at  the  rate  of  65.31  per  1,000 
inhabitants. 

The  Plague  Bacillus.— Dr.  Kitasato,  the  Japanese 
bacteriologist,  has  been  investigating  the  plague  in  Hong 
Kong,  and  believes  he  has  found  the  cause  of  the  disease 
in  a  bacillus  resembling  somewhat  that  of  anthrax.  It 
consists  of  short,  slender,  straight  rods.  Animals  inocu- 
lated with  cultures  of  this  micro  organism  died  with 
symptoms  of  the  plague. 

Tractions  on  the  Tongue  for  Asphyxia. — M.  Laborde 
has  recently  published  a  small  work  on  this  method  of 
treating  the  apparently  dead,  in  which  he  describes  the 
procedure  as  follows :  Seize  the  anterior  third  of  the 
body  of  the  tongue  firmly  between  the  thumb  and  index- 
finger,  using  a  towel  or  handkerchief  to  prevent  slipping. 
Then  make  strong,  repeated,  rhythmical  tractions  on  the 
organ,  from  fifteen  to  twenty  times  a  minute,  imitating 
the  rhythmical  respiratory  movements.  The  operator 
must  be  sure  that  the  root  of  the  tongue  is  drawn  up  with 
each  movement  of  traction,  a  very  easy  thing  to  do  when 
asphyxia  is  profound.  The  first  sign  of  returning  con- 
sciousness is  a  resistance  to  this  drawing  up  of  the  root  of 
the  tongue.  One  or  two  movements  of  deglutition  are 
then  usually  made,  followed  soon  by  a  noisy  inspira- 
tion, which  Laborde  calls  the  "inspiratory  hiccup." 
The  operator  is  cautioned  to  persevere  in  this  procedure 
in  spite  of  apparent  insuccess,  the  author  having  seen  the 
first  indications  of  returning  life  appear  after  tractions 
had  been  practised  for  over  an  hour.  M.  Laborde's  ex- 
planation of  the  mode  of  action  of  this  procedure  is  that 
two  extremely  sensitive  nerves  supply  the  tongue,  namely, 
the  glosso-pharyngeal  and  the  lingual,  while  the  superior 
laryngeal  sends  several  filaments  to  it.  These  nerves, 
taking  their  origin  directly  or  indirectly  fron  the  respira- 
tory centre,  stimulate  it  when  stretched,  and  the  bulb 
stimulates,  in  its  turn,  the  phrenic  nerve  which  supplies 
the  diaphragm. 

A  Medical  Press  Association  is  to  be  established  in 
Germany  after  the  model  of  a  similar  organization  al- 
ready existent  in  France. 

Professor  Czerny,  of  Heidelberg,  who  recently  declined 
the  chair  of  surgery  in  Vienna,  is  said  to  have  been  led  to 
take  this  step  through  a  misunderstanding  of  the  condi- 
tions. The  call  has  now  been  accepted  by  Gussenbauer, 
of  Prague.  Dr.  Mikulicz,  of  Breslau,  was  the  third  can- 
didate nominated  by  the  professorial  college  to  fill  Bill- 
roth's  place. 

Kumyss  Poisoning. — A  number  of  persons  in  one  of 
the  health  resorts  of*  the  Caucasus  were  poisoned  last 
summer  by  ptomaines  in  the  kumyss  which  they  drank. 
An  investigation  showed  that  the  maker  had  neglected  to 


scald  out  his  barrels,  and  he  was  thereupon  sentenced  to 
six  weeks'  imprisonment  and  to  pay  the  costs  of  the  in- 
vestigation. 

A  Lapsus  Calami. — In  the  issue  of  June  30th,  we 
noted  a  fortuitous  combination  of  items,  in  which  the 
notice  of  a  meeting  of  a  medical  society  was  immediately 
followed  by  a  prescription  for  sexual  debility,  and  erro- 
neously attributed  the  same  to  the  Journal  of  the  Ameri- 
can Medical  Association.  Our  esteemed  contemporary 
very  properly  confines  advertisements  of  proprietary 
medicines  to  the  outside  pages  where  they  belong,  and 
we  regret  having,  through  pure  accident,  done  it  this  in- 
justice. 

The  Hospital  for  Consumption  at  Ventnor  has  re- 
ceived a  gift  of  $  1 0,000  from  an  anonymous  donor  in 
memory  of  two  daughters  who  died  from  phthisis. 

Professor  Madelung,  of  Rostock,  has  been  appointed 
Professor  of  Surgery  in  the  University  of  Strasburg  in 
succession  to  the  late  Professor  Luecke. 

Anomalous  Foetal  Nutrition  in  Twin  Gestation. — In 
the  article  with  this  title  by  Dr.  John  C.  Hupp,  published 
in  the  issue  of  July  21st,  the  words,  "  the  cord  of  the 
smaller  foetus,"  were  omitted  in  the  ninth  line.  It 
should  have  read :  "  There  was  only  one  placenta,  which 
was  attached  to  the  ordinary  sized  cord  of  the  larger  foe- 
tus. The  cord  of  the  smaller  foetus,  which  was  not  larger 
than  a  thread,  encircled  its  neck,"  etc. 

Professor  Joseph  Hyrtl,  who  died  recently  in  his 
home  near  Vienna,  at  the  age  of  eighty-four,  was  best 
known,  perhaps,  as  an  anatomist,  but  he  was  besides  a  re- 
markable linguist,  an  original  investigator,  and  an  elo- 
quent lecturer.  He  was  one,  and  the  last  survivor,  of 
the  brilliant  coterie  of  scientists  who  made  the  Medical 
School  of  Vienna  so  celebrated  throughout  the  world. 
A  writer  in  the  London  Telegraph  says  that,  "as  a 
teacher,  Professor  Hyrtl  was  almost  unsurpassed.  He 
was  so  gifted  with  eloquence  that  his  lecture-room  could 
only  with  difficulty  accommodate  the  crowds  of  students, 
of  all  nationalities  that  flocked  to  hear  him.  As  an  orig- 
inal investigator  and  scientist,  Professor  Hyrtl  attracted 
the  warm  admiration  of  his  contemporaries.  He  was  the 
first  German  writer  who  published  an  independent  trea- 
tise on  topographical  anatomy.  His  celebrated  hand- 
book on  that  subject  appeared  in  1847.  With  the  publi- 
cation of  his  '  Lehrbuch  der  Anatomie  des  Menschen,'  of 
which  the  twentieth  edition  has  appeared  this  year,  a 
new  era  was  opened  in  anatomical  text-books.  His 
books  have  been  translated  into  all  European  tongues. 
Professor  Hyrtl's  celebrity  as  a  linguist  is  well  known. 
He  had  so  completely  mastered  the  tongue  of  Cicero 
that  it  became  in  his  mouth  a  living  language,  and  he 
was  always  prepared  to  give  the  fullest  explanations  in 
elegant  Latin  to  all  inquirers.  His  knowledge  of  the 
Greek  classics  also  was  amazing,  and  in  1861  he  deliv- 
ered before  the  Paris  Academy  a  much-admired  extem- 
poraneous lecture  in  the  French  language.  In  his  sev- 
entieth year  he  took  up  the  study  of  Hebrew  and  Arabic 
with  such  success  that  three  years  later  he  was  able  to 
produce  his  remarkable  work  upon  the  anatomical  ideas 
of  the  Jewish  and  Moorish  physicians.  Hyrtl  was  dis- 
tinguished for  his  benevolence,  and,  considering  the 
modest  amount  of  his  income,  his  benefactions  were  as- 


142 


MEDICAL  RECORD. 


[August  4,  1894 


tonishing.  He  supported  poor  students  and  benevolent 
institutions  in  a  generous  fashion.  He  caused  two  or- 
phan institutions  to  be  erected  in  Modling,  near  Vienna, 
to  accommodate  two  hundred  orphans,  and  thus  be- 
stowed on  Lower  Austria  a  gift  that  cost  him  ^30,000." 

The  Cholera. — In  St.  Petersburg  the  epidemic  appears 
to  be  abating  somewhat,  the  number  of  new  cases  daily 
reported  being  reduced  to  about  eighty,  and  of  deaths  to 
between  forty  and  fifty.  The  disease  is  spreading,  how- 
ever, in  Austrian  Galicia  near  the  Russian  frontier,  and 
prevails  to  an  alarming  extent  in  the  district  of  Cracow. 
In  Marseilles  also  many  cases  of  cholera  have  been  re- 
ported during  the  past  week,  and  the  Spanish  consul  in 
that  city  has  informed  his  government  that  the  epidemic 
is  spreading  with  great  rapidity,  although  the  local  au- 
thorities deny  its  presence.  The  disease  is  present  in 
many  towns  in  Belgium  along  the  river  Meuse,  and  thir- 
teen cases  with  six  deaths  are  reported  in  Maastricht, 
Holland,  situated  lower  down  on  the  same  river — another 
fact,  if  any  more  were  needed,  in  support  of  the  theory 
of  the  water-borne  nature  of  cholera,  so  strenuously  in- 
sisted upon,  among  others,  by  Ernest  Hart.  In  Radom, 
in  Russian  Poland,  a  serious  riot  was  occasioned  by  the 
attempt  of  the  authorities  to  bury  the  bodies  of  a  number 
of  persons,  who  had  died  of  cholera,  in  the  cemetery  of 
the  town.  A  mob  resisted  this  attempt  and  compelled 
the  bodies  to  be  taken  elsewhere.  They  then  made  an 
attack  upon  the  hospital  and  carried  a  number  of  sick 
persons  out  into  the  surrounding  grounds.  The  police 
had  hitherto  been  powerless,  but  they  were  reinforced  by 
a  detachment  of  gendarmes,  who  fired  into  the  crowd, 
wounding  many  persons. 

Dr.  Francois  OUment  Maillot  died  in  Paris  on  Sun- 
day, July  29th,  at  the  age  of  ninety  years.  He  was 
made  a  member  of  the  Legion  of  Honor  in  1839,  and 
held  many  high  offices  in  the  civil  and  military  services 
between  1825  and  i860,  and  was  a  retired  medical  in- 
spector of  the  French  army  at  the  time  of  his  death. 

Deaths  from  Sunstroke. — Statistics  of  the  Health  De- 
partment show  that  the  number  of  deaths  from  sunstroke 
in  this  city  in  the  past  four  years  was :  The  deaths  in 
1890  were  62 ;  in  1891,  95 ;  in  1893,  43,  and  until 
July  26th  of  the  present  year,  40.  In  1892,  when  there 
were  320  deaths,  29  occurred  in  June,  252  in  July,  and 
39  in  August.  In  each  year  two-thirds  of  the  deaths 
occurred  among  males. 

The  Cancer  Germ.— Dr.  van  Nissen,  of  Wiesbaden, 
has  found  a  micro  organism  in  cancerous  tissue,  which 
he  is  led  to  regard  as  the  cause  of  the  disease.  In  cult- 
ures the  cell-groups  bore  a  very  close  resemblance  to  the 
so  called  epithelial  cell  nests  of  carcinoma.  He  calls  this 
new  micro-organism  claspodium  cancerogenes,  or,  for  the 
sake  of  brevity,  canceromyces.  The  organism  is  de- 
scribed briefly  in  the  Centralblatt  fur  die  medicinischcn 
Wissenschaften,  No.  21,  1894,  but  the  author  promises 
to  present  a  more  complete  account  of  his  experiments 
shortly. 

Professor  Hothnagel  has  become  unpopular  with  the 
Vienna  students  by  reason  of  his  attempts  to  combat  the 
anti  Semitic  agitation.  The  students  recently  made  such 
an  uproarious  demonstration  that  the  rector  has  ordered 
all  the  courses  in  medicine  to  be  suspended. 


La  Revista  de  Tisiologia  is  the  title  of  a  new  quar- 
terly journal  devoted  to  the  study  of  tuberculosis.  The 
editor  is  Dr.  Valenzuela,  of  Madrid. 

Chloroform  Mortality  in  Melbourne. — An  Australian 
paper  points  out  that  the  mortality  from  the  administra- 
tion of  chloroform  in  Melbourne  is  about  three  per  an- 
num in  a  population  of  450,000. 

The  Use  of  the  Decimal  System  of  Weights  and 
Measures  is  to  be  obligatory  on  physicians  and  pharma- 
cists in  Russia  after  the  end  of  the  present  year. 

Women  are  now  allowed,  through  a  recent  decree  of 
the  sultan,  to  practise  medicine  in  the  Turkish  domin- 
ions. 

The  King  of  Italy  has  given  a  prize  of  $4,000  to 
Drs.  Tizzoni  and  Luciani  for  their  experimental  work  on 
the  functions  of  the  cerebellum.  And  still  the  functions 
are  somewhat  in  doubt,  though  these  gentlemen  have 
advanced  our  knowledge  greatly. 

Sewing-up  Wounds  by  an  electrical  machine  is  one 
of  the  latest  advances  in  surgical  technique. 

Physicians  as  Dispensers  of  their  own  Medioines. — 
According  to  a  bill  now  before  the  French  Senate,  after 
passing  the  Chamber  of  Deputies,  physicians  are  not  to 
be  allowed  to  dispense  any  medicine  at  all. 

The  Hew  Tork  Lying-in  Asylum. — The  managers  of 
the  New  York  Lying-in  Asylum,  which  has  for  many 
years  maintained  an  admirable  out-door  as  well  as  in- 
door maternity  service  for  the  benefit  of  the  poor,  have 
secured,  as  the  future  home  of  their  institution,  the  fine 
old  mansion  of  the  late  Hamilton  Fish,  standing  at  the 
corner  of  Second  Avenue  and  Seventeenth  Street,  and 
fronting  on  Stuyvesant  Square. 

Rochester  (IT.  T.)  Hospital.— The  Board  of  Managers 
of  the  Rochester  State  Hospital  held  its  quarterly  meet- 
ing July  17th,  at  which  meeting  the  plans  and  specifica- 
tions for  a  new  building  and  repairs  made  necessary  by 
the  recent  fire  were  forwarded  to  Albany  for  approval. 
The  appropriation  for  the  new  building  is  $65,000. 

A  Protestant  Hospital — Articles  have  been  filed  for 
the  establishment  of  a  new  hospital  in  the  city  of  Seattle, 
Wash.  The  objects  are  to  found  and  maintain  a  hospital 
under  the  management  of  Protestants,  for  the  medical 
and  surgical  treatment  of  sick  and  infirm  persons,  with 
the  object  of  furnishing  such  treatment,  as  far  as  possible, 
gratuitously  to  the  poor. 

The  Memphis  Board  of  Health  has  sent  a  communi- 
cation to  the  Tennessee  State  Board  of  Health,  calling 
for  such  action  as  will  lead  to  legislation  prohibiting  in- 
fant and  child  life  insurance  within  the  State,  on  the 
ground  that  the  practice  leads  to  criminal  negligence  of 
the  proper  care  of  children,  and  is  to  that  extent  preju- 
dicial to  public  health. 

A  Hew  Fluke  has  beeq  discovered  in  America  by  Pro- 
fessor Ward,  of  Nebraska.  It  is  called  the  Distama 
Ringeri, 

Venereal  Diseases  in  the  British  Army. — Accord- 
ing to  some  statistics  presented  to  the  House  of  Com- 
mons by  the  war  secretary,  out  of  a  total  of  196,534  men 
in  the  British  army  there  were  in  one  year  52,155  ad- 
mitted to  hospitals  to  be  treated  for  venereal  diseases,  or 
more  than  one-quarter  of  the  effective  force. 


August  4,  1894] 


MEDICAL   RECORD. 


H3 


<2p0tt0ttes£  of  American  gbigsiciatiB 
and  Surgeons. 

7)b></  Triennial  Meeting,  held  in  Washington,  D.  C, 
May  2Q,  30,  31,  and  June  1, 1894. 

AMERICAN  ORTHOPEDIC  ASSOCIATION. 

Eighth  Annual  Meeting,   held  at  Washington,  D.  C, 
May  2Q,  30, 31,  and  June  1,  18Q4. 

(Continued  from  Vol.  45,  page  766.) 

First  Day,  Tuesday,  May  29TH. 

The  Etiology  of  Deformities  in  Knee-joint  Disease. — 
Dr.  A.  E.  Hoadley  read  a  paper  with  the  above  title,  in 
which  he  claimed,  after  experimenting  with  eighty  differ- 
ent subjects,  that  the  flexor  muscles  are  under  all  condi- 
tions, except  when  paralyzed,  stronger  than  the  extensors. 
Also,  that  the  flexor  muscles  may  at  certain  times  become 
extensors,  and  that  in  all  ordinary  deformities  of  the  knee 
it  is  not  the  result  of  the  flexors  dominating  over  the 
extensor.  The  cause  of  flexion  in  case  of  disease  was 
rather  due  to  the  pain,  and  consequent  attempt,  on  the 
part  of  the  patient,  to  change  the  position  of  the  joint 

Dr.  Wirt  made  a  demonstration  of  the  mathematics 
involved  in  the  mechanics  of  the  knee-joint. 

Dr.  Whitman  asked  if  the  gastrocnemius  did  not  play 
an  important  part  in  the  deformities  at  the  knee. 

Dr.  Phelps  said  that  the  experiments  of  Dr.  Hoadley 
differed  from  those  of  Haughton,  of  Dublin,  who  had  done 
a  great  deal  to  make  the  subject  plain ;  also  from  his  own, 
which  were  published  in  the  Transactions  of  the  Associa- 
tion last  year.  He  said  that  the  extensor  muscles  lose 
force  as  flexion  takes  place,  while  the  flexors  increase  in 
force  as  the  limit  of  flexion  is  reached.  Rotation  is  pro- 
duced by  the  biceps  muscle,  which  is  absorbed  into  the 
head  of  the  fibula. 

Dr.  Ridlon  said  as  muscles  reach  their  limit  they  lose 
strength* 

Dr.  Hoadley,  in  closing,  said  that  Dr.  Phelps's  experi- 
ments had  been  limited  to  one  case,  while  his  own  series 
rightly  should  have  more  weight.  In  reply  to  Dr. 
Whitman,  he  agreed  that  the  gastrocnemius  muscle  was 
a  powerful  flexor. 

Hoffa's  Operation  for  Congenital  Dislocation  of  the 
Hip-joint. — Dr.  E.  H.  Bradford,  of  Boston,  presented 
a  pathological  specimen  from  a  child  on  whom  he  had 
operated  for  a  congenital  dislocation,  the  patient  dying 
subsequently  from  diphtheria.  The  acetabulum  in  this 
case,  while  somewhat  misplaced,  was  well  formed.  Ow- 
ing to  the  abnormal  position,  he  failed  to  find  the  ace- 
tabulum at  the  time  of  the  operation,  but  had  made  a 
socket  for  the  head  of  the  femur  at  another  place  in  the 
ileum.  The  speaker  said  that  the  specimen  illustrated 
that  there  was  danger  from  curetting  too  freely  into  the 
acetabulum  of  the  cases,  as  the  bone  might  be  perforated. 
He  also  stated  that  Hoffa  was  wrong  in  the  assertion  that 
the  acetabulum  was  the  thickest  part  of  the  pelvis.  A 
specimen  of  rachitic  deformity  of  the  hip  joint  was  pre- 
sented by  the  same  speaker.  The  condition  was  similar 
to  that  described  by  Dr.  Whitman. 

Dr.  Whitman  emphasized  the  point  that  patients 
afflicted  with  congenital  dislocation  of  the  hip  not  only 
suffered  great  disability,  but  oftentimes  had  pain. 

Dr.  Ryan  said  he  had  not  met  with  cases  complaining 
of  pain. 

Dr.  Weigel  agreed  as  to  the  disability,  and  thought 
the  specimen  presented  by  Dr.  Bradford  showed  that 
more  might  be  obtained  by  treatment  by  traction. 

Dr.  DeForrest  Willard  thought  that  if  all  cases  of 
congenital  dislocation  were  like  the  specimen  presented, 
the  operation  would  be  called  for,  as  the  acetabulum  was 
deformed,  and  he  believed  it  would  be  found  even  more 
so  in  the  majority  of  the  cases. 

Dr.  Bartow  spoke  of  a  case  of  congenital  dislocation 
he  had  treated  by  traction,  and  the  head  of  the  bone  re- 
mained in  the  acetabulum. 


Dr.  Wirt  had  seen  cases  who  complained  of  pain  when 
walking. 

Dr.  Phelps  said  dislocation  might  take  place  in  any 
direction.  He  considered  the  operation  justifiable,  as  not 
a  single  case  had  been  cured  otherwise.  Hoffa  had  said 
to  him  that  he  did  not  operate  after  the  patient  was  four 
years  of  age. 

Dr.  Bradford,  in  closing,  confirmed  what  had  been 
said  about  pain  and  disability.  He  considered  it  impor- 
tant to  obtain  union  by  first  intention  in  Hoffa's  opera- 
tion. Dr.  Phelps's  remarks  he  considered  theoretically 
correct,  but  he  had  seen  adults  without  much  disability. 


Second  Day,  Wednesday,  May  30TH. 

Flat-foot. — Dr.  Royal  Whitman,  of  New  York,  opened 
the  discussion  on  this  subject.  He  did  not  believe  that 
flat-foot  is  caused  by  shortening  of  the  tendo  Achilles, 
but  rather  that  it  is  due  to  a  disproportion  of  the  weight 
thrown  on  the  arch  of  the  foot  when  in  a  faulty  position. 
Flat-foot  he  considered  a  dislocation  of  the  bones  of  the 
arch,  which  must  be  reduced  and  kept  so  by  some  form 
of  apparatus  which  will  not  restrict  the  tendinous  or 
muscular  structures  which  assist  in  maintaining  the  arch. 
It  is  usually  advisable  to  forcibly  correct  the  deformities 
under  ether,  even  over-correcting  the  deformity  so  as  to 
produce  a  club-foot,  and  apply  a  plaster- of- Paris  splint  so 
as  to  temporarily  hold  the  foot  in  this  position.  He 
does  not  advocate  the  cutting  operation,  but  considers 
the  prognosis  good  when  his  line  of  treatment  is  followed 
out. 

Dr.  Shaffer,  of  New  York,  in  calling  attention  to 
the  mechanism  said  that  studies  must  be  made  from  the 
normal  foot.  Flat-foot,  he  believed,  was  due  to  shorten- 
ing of  the  gastrocnemius  muscle,  while  paralysis  of  the 
same  muscle  resulted  in  talipes  calcaneus.  The  reason  he 
gave  for  not  having  flat-foot  in  cases  of  talipes  equinus 
was  that  the  relation  of  the  axis  of  the  leg  to  the  medio- 
tarsal  joint  was  changed.  In  no  case  of  flat-foot  was  the 
gastrocnemius  ever  elongated. 

Dr.  Wirt  thought  that  Dr.  Shaffer  was  in  error  as  to 
the  mechanical  principles  involved.  By  his  model  he 
has  shown  a  difference  in  the  force  exerted  on  the  astrag- 
alo  scaphoid  joint  and  the  breaking  down  of  the  arch 
when  the  tendo  Achilles  is  shortened  by  representing 
that  the  heel  rises  in  this  condition,  while  in  the  normal 
foot  he  represents  flexion  of  the  tibia  forward  at  the 
ankle  joint  without  any  rise  of  the  heel.  Now,  in  truth, 
do  we  walk  in  this  manner  ?  In  the  act  of  walking  the 
muscles  of  the  calf  are  contracted.  The  tendo  Achilles 
is  pulled  upon  and  the  heel  rises  from  the  ground,  the 
weight  being  borne  upon  the  ball  during  fully  one- half  of 
the  step.  The  difference  in  length  between  the  normal 
tendo  Achilles  and  one  slightly  shortened  would  be  made 
up  by  a  greater  and  earlier  contraction  than  in  the  case 
of  the  normal,  which  would  put  the  foot  upon  the  ball  in 
about  the  same  length  of  time. 

Dr.  McCurdy  said  that  Marks  had  shown  that  mo- 
tion at  the  ankle  joint  was  not  necessary  for  comfort  in 
walking. 

Dr.  Ketch  asked  Dr.  Shaffer  if  it  was  first  necessary 
that  we  should  have  equinus  before  flat-foot  occurred. 

Dr.  Bartow  thought  the  gastrocnemius  muscle  is  short- 
ened in  flat-foot,  but  that  this  usually  takes  place  after 
the  change  in  the  arch  of  the  foot. 

Dr.  Weigel  suggested  the  taking  of  a  series  of  instan- 
taneous photographs  of  a  man  in  the  act  of  walking,  so 
as  to  test  the  position  of  the  ankle  joint. 

Dr.  Shaffer,  in  closing,  said  it  was  necessary  that  the 
motion  of  the  ankle-joint  be  stopped  at  a  certain  point 
which  throws  the  weight  upon  the  medio  tarsal  joint  and 
thus  produces  flat-foot.  He  had  employed  an  instrument 
for  stretching  the  gastrocnemius  muscle  in  cases  of  flat- 
foot. 

Rachitis.— Dr.  A.  Jacobi,  of  New  York,  in  opening 
the  discussion,  said  that  rachitic  deformities  represented 


144 


MEDICAL    RECORD. 


[August  4,  1894 


a  comparatively  new  disease  in  this  country.  He  re- 
membered when  it  was  difficult  to  find  a  sufficient  num- 
ber of  cases  for  his  clinics.  Some  of  the  appearances  and 
general  physiognomy  of  rachitic  children  are  as  follows : 
Less  hair  on  the  head ;  the  veins  are  more  dilated  ;  the 
head  has  a  quadrangular  appearance  and  may  be  hydro- 
cephalic ;  the  forehead  is  more  prominent,  the  bones  in 
this  region  may  be  two  or  three  times  the  normal  thick- 
ness, this  may  all  disappear,  but  often  some  deformity  re- 
mains ;  the  teeth  are  irregular  and  decay  early ;  the  sec- 
ond crop  are  usually  hard  and  of  a  yellow  appearance ; 
we  may  have  the  Hutchinson  teeth  in  rachitic  children ; 
the  trunk  is  short  in  these  cases,  clavicle  is  thickened  ; 
chest  prominent  anteriorly,  lower  ribs  stand  out,  and  the 
rosary  may  appear  as  early  as  the  second  month.  May 
have  kyphosis  or  scoliosis  of  the  spine ;  pelvis  is  rarely 
deformed,  but  adults  who  have  been  the  subjects  of  rachitis 
may  have  undeveloped  pelves ;  the  sacrum  is  usually  more 
steep  in  the  rachitic  child ;  the  extremities  suffer  greatly 
in  this  condition ;  the  epiphyses  are  painful,  the  diaphyses 
are  usually  bent ;  fractures  are  rare  because  of  the  peri- 
osteal thickening ;  the  ligaments  are  flabby  and  soft ;  the 
periosteum  suffers  from  rachitic  deposits ;  there  may  be 
hemorrhages  during  the  course  of  this  disease  which  are 
not  due  to  scurvy ;  deformities  are  due  to  changes  in  the 
epiphyses,  and  when  calcification  takes  place  growth 
stops.  The  general  system  and  the  muscles,  both  the 
voluntary  and  involuntary,  suffer  as  much  as  the  bones ; 
this  is  not  paralysis  but  simply  a  weakness ;  the  heart  is 
large  and  the  arteries  are  small,  the  cause  and  effect  of 
which  it  is  difficult  to  decide ;  the  stomach  is  dilated ;  con- 
stipation is  usually  one  of  the  first  symptoms.  Other  in- 
ternal organs  may  be  displaced. 

Dr.  Benjamin  Lee,  of  Philadelphia,  said  that  rachitis 
in  its  earlier  stages  was  most  marked  in  the  structures 
where  the  lime  salts  and  phosphorus  should  be  most 
prominent.  The  child  may  appropriate  the  fats  and  yet 
fail  to  assimilate  the  salts.  Constipation  is  usually  pres 
ent,  or  the  patient  may  have  diarrhoea.  It  sleeps  poorly, 
and  this  restlessness  may  be  the  only  symptom  for  the 
first  few  months.  Convulsions  are  not  uncommon ,  twitch- 
ing of  the  muscles  of  the  eyes,  spasm  of  the  muscles  of  the 
larynx,  and  vaso  motor  disturbances  are  common  ;  bron- 
chitis is  very  frequent.  Nerve  starvation,  he  says,  ex- 
plains many  of  these  phenctmena.  The  deformities  the 
result  of  rachitis  are  numerous. 

Diagnosis. — Acute  rheumatism,  he  said,  was  rare  in 
young  children  ;  the  absence  of  snuffles  and  sore  throat 
ruled  out  syphilis.  In  considering  the  prognosis,  the  au- 
thor thought  that  death  was  often  due  to  rachitis  which 
had  not  been  diagnosed.  The  most  important  point  in 
the  treatment  was  diet.  Exercise,  both  passive  and  active, 
he  said,  would  often  prevent  deformities.  One  question 
which  he  brought  out,  regarding  the  sterilization  of  milk 
which  had  become  so  prevalent  during  the  past  few  years, 
was  to  the  effect  that  the  lactic- acid  ferment,  which  is  de- 
stroyed by  this  process,  might  be  necessary  to  take  up  the 
salts.  This  he  thought  was  the  reason  why  the  wealthy 
as  well  as  the  poor  suffered  from  this  disease. 

Dr.  Samuel  Ketch,  of  New  York,  said  that  the  ortho- 
pedist did  not  have  the  opportunity  of  seeing  cases  of 
rachitis  in  their  incipiency.  He  does  not  think  sufficient 
attention  is  paid  to  prophylactic  measures.  Many  of  the 
deformities  are  due  to  faulty  positions  assumed  while  ra- 
chitis is  present,  and  he  suggested  the  use  of  portable 
frames  so  as  to  enable  these  cases  to  get  fresh  air.  Braces, 
he  thought,  should  not  be  used  on  the  very  young,  but 
massage  and  manual  force  would  usually  suffice  to  over- 
come these  deformities.  All  apparatus  applied  to  cases  of 
bow-leg  and  knock-knee  should  be  frequently  observed  by 
the  surgeon,  so  that  its  shape  might  be  changed  to  meet 
the  exigencies  of  the  case.  Massage  should  be  done  in 
all  these  cases,  even  though  they  be  under  mechanical 
treatment.  Frequent  tracings  of  the  deformities  should 
be  made.  Operation  should  not  be  resorted  to  in  rachi- 
tic deformities  until  eburnation  of  the  bones  has  taken 
place. 


Third  Day,  Thursday,  May  31ST. 

Correction  of  Eachitic  Deformities. — Dr.  DeForrest 
Willard,  of  Philadelphia,  said  that  the  deformities  might 
be  corrected  by  apparatus  before  solidification  of  the 
bones  had  taken  place,  but  it  was  often  difficult  to  have 
the  treatment  properly  carried  out  at  home,  and  he  was 
of  the  opinion  that  the  correction  of  the  deformity  by  a 
greenstick  fracture,  produced  by  manual  force,  was 
preferable.  When  it  was  necessary  to  use  the  osteoclast, 
he  said  the  epiphyseal  line  should  be  avoided.  Osteot- 
omy he  considered  frequently  necessary  in  extreme  cases, 
especially  in  large  children  and  adults.  The  anterior 
curves  of  the  tibia,  he  said,  were  extremely  difficult  to 
correct  by  apparatus,  and  for  this,  osteoclasis  by  manual 
force,  or  osteotomy,  should  be  performed.  He  had 
abandoned  the  cuneiform  osteotomy,  as  a  simple  divis- 
ion of  the  bone  had  proven  quite  as  satisfactory.  The 
author  thought  that  osteotomy  was  indicated  nine  times 
out  of  ten.  Osteoclasis,  he  said,  pulpifies  the  soft  parts 
overlying  the  bone.  In  performing  an  osteotomy  he 
does  not  use  the  Esmarch  bandage,  as  the  hemorrhage 
which  takes  place  prevents  infection  from  without 

Dr.  Weigel  asked  Dr.  Willard  if  he  now  advised  the 
use  of  drainage,  after  operating  upon  the  anterior  tibial 
curvatures,  as  he  once  did.  Dr.  Weigel  had  not  found 
the  drain  necessary.  He  thought  more  of  osteotomy  than 
of  osteoclasis. 

Dr.  Ryan,  also,  agreed  that  osteotomy  was  more  exact 
than  osteoclasis.  He  said  that  cuneiform  osteotomy  was 
practically  abandoned,  except  for  anterior  tibial  curva- 
tures. He  asked  Dr.  Weigel  if  he  sewed  up  the  wounds. 
Dr.  Ryan  did  not  think  any  case  should  be  operated 
upon,  before  four  and  a  half  years  of  age,  as  the  deform- 
ity was  likely  to  relapse.  Deformities  often  improve 
without  any  treatment,  as  was  shown  by  a  family  of 
children,  residing  near  his  office,  who  had  received  no 
medical  attention  whatever. 

Dr.  Gillett  had  never  performed  osteoclasis.  He 
preferred  osteotomy.  He  spoke  of  an  accident  following 
osteotomy,  in  which  he  failed  to  get  perfect  correction 
of  the  deformity,  the  patient  became  dissatisfied,  and  he 
was  unable  to  follow  up  the  case. 

Dr.  Cook,  while  he  preferred  osteotomy  to  osteoclasis, 
said  the  results  were  not  always  good. 

Dr.  Bartow  did  not  think  the  fear  of  injuring  the 
soft  parts  was  well  grounded.  In  exceptional  cases, 
where  the  bone  was  hard,  osteotomy  should  be  performed. 
He  thought  it  possible  to  correct  some  of  these  deformi- 
ties, without  even  breaking  the  bone,  by  means  of  the 
osteoclast. 

Dr.  Townsend  said  that  one  of  the  advantages  claimed 
for  osteoclasis  was  that  the  bone  was  broken  without 
being  converted  into  a  compound  fracture. 

When  Mr.  Grattan  visited  America,  he  had  seen  him 
use  his  osteoclast  on  two  different  cases,  and  in  both 
considerable  laceration  of  the  soft  parts  was  produced. 
While  neither  of  these  patients  had  any  trouble  following 
the  laceration  of  the  soft  parts,  he  thought  there  was  con- 
siderable danger  of  getting  such  a  wound  infected  from 
the  instrument,  which  was  not  aseptic,  or  from  the  pa- 
tient himself,  because  the  limb  is  rarely  prepared  for  this 
operation,  as  it  would  be  for  osteotomy. 

Dr.  Coolridge  said  he  thought  a  great  deal  depended 
upon  the  instrument  employed.  With  the  Lorenz  osteo- 
clast he  had  never  seen  the  skin  broken. 

Dr.  Bartow  said  that  he  always  protected  the  skin, 
over  the  region  to  be  operated  upon,  with  moleskin  plas- 
ter. 

Dr.  Ketch  did  not  agree  with  Dr.  Ryan,  that  cases 
got  well  without  treatment.  He  believed,  in  all  in- 
stances, massage  had  been  employed  at  home. 

Dr.  Lee  thought  that  with  osteoclasis  a  simple  con- 
densation, without  displacement  of  the  soft  parts,  would 
result. 

Dr.  Willard,  in  closing,  said  he  rarely  performed  the 
cuneiform  osteotomy  at  present,  as  he  had  gotten  excel- 


August  4,  1894] 


MEDICAL    RECORD. 


145 


lent  results  from  the  simple  linear  division  of  the  bone, 
which  was  just  as  strong  afterward,  and  the  recovery  was 
much  quicker.  When  he  does  perform  cuneiform  oste- 
otomy now,  the  wound  is  left  open  without  drainage,  as 
he  does  not  think  much  of  union  by  blood- clot.  On  the 
contrary,  he  thought  large  blood-clots  sometimes  pre- 
vented the  callus  from  being  thrown  out.  After  all 
osteotomies  he  emphasized  the  importance  of  over- cor- 
recting the  deformity.  The  details  of  after-treatment,  of 
applying  the  plaster  of  Paris,  should  be  done  by  the 
surgeon,  and  not  by  his  assistant. 

Bubber  Heels  for  Patients  with  Pott's  Disease Dr. 

John  Schapps,  of  Brooklyn,  N.  Y.,  presented  a  shoe 
with  the  rubber  heels  attached,  which  he  said  was  em- 
ployed for  the  purpose  of  overcoming  concussion  of  the 
spine  while  walking.  This  simple  procedure  had  given 
considerable  relief  to  the  patients. 

Elastic  Traction  in  the  Immediate  Treatment  of  Club- 
foot.— Dr.  Bernard  Bartow,  of  Buffalo,  read  a  paper 
with  the  above  title,  in  which  he  advised  division  of  the 
contracted  tendons  and  the  correction  of  the  deformity 
in  club-foot  as  early  as  at  three  weeks  of  age.  When 
once  the  foot  is  gotten  into  the  normal  position,  he  ad- 
vises the  use  of  elastic  traction,  because  the  foot  is  not 
restricted,  as  when  immobilized  with  plaster  of  Paris  and 
other  braces,  and  thus  atrophy  of  the  muscles  does  not 
occur.  The  elastic  traction  is  made  by  rubber  bands, 
extending  (1)  from  the  knee  to  the  foot,  for  overcoming 
the  equinus,  and  (2)  others  on  the  outside  of  the  foot, 
for  overcoming  a  varus.  These  rubber  bands  are  fastened 
to  attachments,  which  are  held  in  position  by  adhesive 
plaster.  When  the  two  sets  of  bands  are  applied,  one, 
for  the  purpose  of  abducting  and  rotating  the  foot  out- 
ward, the  other,  for  overcoming  the  equinus,  the  force 
to  be  exerted  can  be  regulated  by  the  number  of  bands. 
It  was  advisable  to  instruct  the  mother,  after  the  adjust- 
ment of  the  above-described  apparatus,  to  manipulate  the 
foot  at  regular  intervals,  so  as  to  over  correct  the  deform- 
ity, by  which  means  the  atrophy  of  the  muscles,  which 
would  occur  if  an  immobilization  apparatus  were  ap- 
plied, is  prevented. 

Dr.  Shaffer  was  of  the  opinion  that  continuous  and 
intermittent  traction  had  their  places.  As  to  nutrition, 
he  had  seen  muscles  develop  very  perceptibly  in  a  few 
weeks  after  intermittent,  forcible  traction. 

Phelps's  Method  for  the  Cure  of  Club-foot  in  Adults. 
— Dr.  William  E.  Wirt,  of  Cleveland,  in  concluding 
his  remarks  on  the  above  subject,  said  that  adults  and 
*  older  children  would  not  endure  the  amount  of  traction 
necessary  to  correct  these  extreme  deformities,  and  that 
even  tenotomies,  combined  with  tarso-clasis,  were  not 
sufficient  to  cure  the  cases,  although  the  deformity  might 
be  temporarily  corrected.  Not  infrequently  it  is  neces- 
sary to  divide  the  plantar  structures  openly,  after  the 
method  of  Phelps,  and  divide  the  tendo  Achilles,  to- 
gether with  the  application  of  tarso  clasis,  to  be  able  to 
overcome  the  deformity.  In  the  worst  cases,  in  addition 
to  the  above,  it  will  sometimes  be  necessary  to  remove 
the  wedge-shaped  piece  of  bone  from  the  tarsus. 

Discussion. — Dr.  WsiGELsaid  the  term  "  cure  "  should 
not  be  applied  to  these  cases  of  club  foot,  as  he  consid- 
ered only  improvement  was  obtained.  He  reported  a 
case  of  double  congenital  club-foot,  and  double  club- 
hand, and  presented  a  photograph  of  the  same  before 
operation.  On  the  right  foot  he  had  performed  Phelps's 
operation,  and  later,  cuneiform  section  of  the  bones  of 
the  leg,  just  above  the  joint.  The  operation  performed 
upon  die  left  foot  consisted  in  the  removal  of  the  head 
of  the  astragalus.  The  Phelps  operation,  he  says,  does 
not  answer  in  the  extreme  cases,  but  must  be  supple- 
mented by  the  removal  of  bone.  He  does  not  agree 
with  Dr.  Wirt  in  his  idea  of  dividing  the  tendo  Achilles 
by  an  open  incision,  but  thinks  the  subcutaneous  method 
just  as  good. 

Dr.  Townsend  said  that  with  all  due  deference  to  the 
Phelps  operation,  it  was  not  always  successful ;  and  he 
believed  the  force  applied  by  the  long  lever,  after  the  in. 


cision  had  been  made,  was  very  essential.    The  Phelps 
operation,  he  considered,  had  a  limited  field. 

Dr.  Ketch  said  that  Dr.  Weigel's  case  suggested  a 
spastic  condition,  nor  did  he  think  the  Phelps  operation 
had  a  broad  field. 

Dr.  Houston,  of  Montreal,  said  he  did  not  think  the 
surgeon  should  be  wedded  to  any  operation.  The  indi- 
vidual case,  he  said,  should  always  be  considered. 

Dr.  Coolridge  spoke  for  Dr.  Myers,  who  had  to  re- 
turn home,  and  described  an  operation  for  club- foot,  in 
which  he  made  a  small  incision  over  the  most  prominent 
bony  deformity ;  through  this  he  inserted  a  scoop  for  the 
purpose  of  removing  the  bone.  Then  the  foot  is  forced 
into  position. 

Tarso-clasis. — Mr.  Nicholas  Grattan,  F.R.C.S.,  of 
Cork,  Ireland,  in  a  paper  on  the  above  subject,  said  he 
had,  during  the  past  two  years,  paid  considerable  atten- 
tion to  the  treatment  of  resisting  cases  of  club-foot.  He 
had  used  the  Thomas  wrench  without  effect,  but  now,  af- 
ter having  made  some  alterations  in  the  osteoclast  which 
he  presented  to  this  Association  in  1892,  he  was  able  to 
exert  sufficient  force  to  produce  fracture  of  the  tarsus, 
which,  he  believes,  is  often  necessary,  and  should  be  re- 
peated at  intervals,  until  resistance  ceases,  and  the  foot 
has  assumed  its  normal  shape  and  position.  If  the  equi- 
nus persists,  tenotomy  of  the  tendo  Achilles  should  be 
performed,  and  it  is  possible  by  this  means,  combined 
with  osteo  clasis  of  the  tibia  and  fibula  close  to  the  ankle- 
joint,  to  permit  the  rotation  of  the  foot  upward,  and  to 
enable  the  patient  to  walk,  on  whom  astragalectomy  had 
failed  to  cure.  Flat  foot  can  be  easily  corrected  by  for- 
cible instrumental  rectification. 

Mr.  Edmund  Owen,  F.R.C.S.,  of  London,  said  he 
had  compared  the  old  fashioned  or  orthodox  treatment 
of  club-foot  with  the  radical  operation  of  Phelps,  and  he 
preferred  the  latter  method.  While  he  had  met  with  re- 
lapses from  the  older  methods,  such  had  not  been  the 
case  since  the  employment  of  the  free  and  open  division 
of  all  constricting  bands  in  the  plantar  region ;  and  for 
the  perfect  correction  of  these  deformities  it  was  often 
necessary  to  open  up  the  astragalo-scaphoid  joint.  The 
foot  is  forced  into  an  over-corrected  position,  that  of 
calcaneo-vulgus.  The  wound  is  treated  openly,  and  a 
fixed  plaster-of  Paris  dressing  applied. 

Dr.  H.  P.  Kaptyn,  of  Abcande,  Holland,  was  pleased 
with  the  results  obtained  from  the  open  operation  of 
Phelps ;  he  had  previously  reported  forty-two  operations 
on  thirty-two  cases,  to  the  International  Congress  at 
Berlin,  of  the  cases  in  Holland  treated  after  this  method. 
t  In  the  newly  born,  he  employed  the  fixed  gypsum  appa- 
ratus. The  cases  treated  by  the  Phelps  method  ranged 
from  nine  months  to  fifteen  years  of  age.  Most  of  the 
cases  were  double.  In  no  case,  did  he  have  to  remove 
any  of  the  tarsal  bones,  nor  even  open  up  the  tarsal  joint, 
as  reposition  of  the  foot  was  always  possible  after  the  con- 
tracted tissues  were  freely  cut. 

Excision  of  the  Knee  for  the  Eelief  of  Crippling  from 
Infantile  Paralysis. — Dr.  Ap  Morgan  Vance,  of  Louis- 
ville, Ky.,  said  he  had  reported  his  first  operation  for  the 
production  of  synostosis  in  1885,  it  having  been  per- 
formed one  year  previously,  to  relieve  the  crippling 
from  infantile  paralysis.  Since  then  he  had  performed 
the  operation  six  times,  making,  in  all  seven  operations 
upon  five  patients.  The  two  eldest  patients,  respectively 
five  and  seven  years  of  age,  died  of  some  inflammatory 
complication  of  the  heart,  possibly  endocarditis.  The 
younger  cases  may  be  subjected  to  this  treatment,  with 
every  possibility  of  success,  but  he  does  not  advise  the 
operation  as  late  as  eight  or  ten  years  of  age. 

Dr.  A.  M.  Phklps,  of  New  York,  presented  some  mod- 
ifications of  his  own  splints,  and  of  those  of  other  sur- 
geons, for  knee  and  ankle  joint  diseases.  The  same 
author  presented  a  new,  improved  celluloid  corset.  He 
said  the  apparatus  combined  neatness,  elegance,  durabil- 
ity, and  lightness. 

An  Improved  Machine  for  Treating  Scoliosis. — Dr. 
Max  Schede,  of  Hamburg,  Germany,  in  a  paper  giving  a 


146 


MEDICAL   RECORD. 


[August  4,  1894 


description  of  an  apparatus,  in  which  the  patient  was  par- 
tially  suspended,  the  shoulders  and  pelvis  being  fixed, 
advised  that  direct  pressure  be  made  over  the  ribs,  over 
the  most  prominent  part  He  advised  the  placing  of  the 
patient  in  the  apparatus,  twice  a  day,  for  half  an  hour 
each  time,  and  the  application  of  as  much  pressure  as 
could  be  borne  with  comfort  A  good  spinal  support  was 
worn  during  the  interim ;  periodical  measurements  of  the 
deformity  should  be  made,  so  as  to  reckon  the  changes. 
Development  of  the  muscles  was  also  to  be  encouraged. 
In  three  months,  the  author  claimed,  appreciable  im 
provement  was  often  noted,  in  the  most  obstinate  cases. 

Infantile  Apoplexy  and  Infantile  Paralysis  — Mr. 
William  J.  Little,  of  London,  suggested  that  copious, 
fatal  apoplexy  in  the  brain  may  occur  during  existence 
in  utero,  and  that  a  lighter  amount  of  apoplexy  in  a  nerve- 
centre,  at  an  earlier  stage  of  uterine  life,  may  be  the 
cause  of  some  of  the  anomalous  conditions  or  congenital 
distortions,  in  which  the  growth  and  development  of  a 
limb  had  been  interfered  with.  The  author  is  of  the  opin- 
ion that  the  imbibing  of  alcohol  in  excess  is  the  cause 
of  the  death  of  infants  in  utero,  and  says  he  recalls  many 
instances  of  congenital  distortions  among  the  well-to  do, 
which  have  been  produced  by  mental  shock  and  mental 
trouble  happening  to  the  pregnant  woman. 

Treatment  of  Deformity  Following  Infantile  and 
Spastic  Paralysis. — Dr.  De  Forrest  Willard,  of  Phila- 
delphia, laid  great  stress  upon  the  prevention  of  deform- 
ity, in  the  above  class  of  cases,  by  means  of  apparatus. 
When  contractures  have  occurred,  it  is  necessary  to  resort 
to  surgical  measures  before  the  apparatus  is  applied. 
Myotomy  and  tenotomy  are  perfectly  safe  operations,  and 
the  muscles  are  placed  in  better  condition  for  action 
than  they  were  before  the  operation .  Forcible  straighten- 
ing,  following  division,  is  usually  necessary.  In  spastic 
paralysis,  lengthening  of  the  tendons  assists  better  locomo- 
tion.    Locomotion  is  the  best  form  of  gymnastics. 

An  Original  Operation  for  Wry  neck.— Dr.  A.  M. 
Phelps,  of  New  York,  had  devised  an  operation  so  as  to 
prevent  scarring,  by  beginning  the  incision  at  the  lobe  of 
the  ear,  which  was  carried  upward,  along  and  behind  the 
ear,  following  the  creases  to  its  superior  angle.  The  in- 
cision was  carried  directly  across,  into  the  hair,  and  ex- 
tended obliquely  downward,  keeping  within  the  hair 
line,  to  the  side  of  the  neck.  This  flap  was  retracted, 
and  the  offending  sterno-cleido  mastoid  cut.  Sometimes 
it  was  necessary  to  divide  that  muscle  at  its  sternal  end. 
The  after-treatment  was  by  a  brace  made  of  straps,  at- 
tached to  a  plaster-of-  Paris  corset,  together  with  gymnas- 
tic exercises. 

Fixation  in  the  Treatment  of  Fractures  into  Joints. 
— Dr.  Ansel  G.  Cook,  of  Hartford,  Conn.,  claimed  that 
it  has  been  conclusively  proven,  by  experiments  on  men 
and  animals,  that  fixation,  per  se,  no  matter  how  long 
continued,  does  not  produce  ankylosis  ;  that  ankylosis 
is  the  result  of  injury  and  consequent  inflammation,  and 
that  early  passive  motion  only  irritates  the  injured 
structures  and  increases  the  production  of  callus,  thus 
bringing  about  ankylosis.  He  thinks  that  immobiliza- 
tion is  only  useful  when  inflammation  is  present,  or  until 
the  broken  bones  and  ruptured  ligaments  have  been 
mended.  From  three  to  eight  weeks  of  immobilization 
is  the  time  usually  required.  Lastly,  passive  motion, 
massage,  and  use,  until  the  tissues  become  normal.  Oc- 
casionally complete  rupture  of  all  adhesions,  under  an 
anaesthetic,  is  required. 

Dr.  Ryan  said  that  passive  motion  should  be  employed 
as  early  as  the  sixteenth  day. 

Dr.  Brackett  asked  Dr.  Ryan  if  he  had  not  been 
careful  to  regard  the  matter  of  pain  produced  by  passive 
motion. 

Dr.  R.  F.  Weir,  of  New  York  did  not  believe  in  early 
passive  motion  in  the  case  of  fractures  into  joints. 

Disease  of  the  Shoulder  joint.  —  Dr.  W.  R.  Town- 
send,  of  New  York,  read  a  paper  with  the  above  title, 
in  which  he  said  out  of  3,000  cases  of  joint  diseases 
only  21  were  diseases  of  the  shoulder  joint.     The  disease 


comes  on  more  slowly  in  childhood  than  in  adult  life. 
Atrophy  of  the  deltoid  muscle  may  be  so  marked,  in 
these  cases,  as  to  simulate  paralysis.  The  sternal  end  oi 
the  clavicle  is  at  times  dislocated,  while  the  shoulder- 
joint  may  be  partially  or  completely  ankylosed.  Loss 
of  function  is  one  of  the  most  prominent  symptoms.  The 
duration  of  the  disease  he  considers  to  be  from  two  to 
three  years.  The  prognosis  should  be  considered  from 
the  general  condition  of  the  patient  and  the  local  con- 
dition of  the  joint.  The  treatment  may  be  by  simple 
rest  in  a  sling,  or  by  fixation  with  plaster  of  Paris.  The 
operative  treatment  may  be  partial  or  complete  excision 
of  the  joint.  Rarely  is  it  advisable  to  excise  the  joint 
before  the  eighteenth  year,  up  to  which  time  partial 
arthrectomy  is  preferable,  so  that  the  growth  of  the  bone 
will  not  be  interfered  with.  The  author  did  not  think 
the  statistics  gathered  before  aseptic  and  antiseptic  sur- 
gery were  understood  should  be  a  criterion  for  our  work 
of  to-day. 

Dr.  Ketch  said  that  Dr.  Judson  once  read  a  paper 
on  this  subject,  in  which  he  explained  its  infrequency 
by  the  comparative  freedom  from  injury  and  the  blood- 
supply  of  the  shoulder-joint.  Dr.  Ketch  had  not  found 
ankylosis  of  such  frequency  as  did  Dr.  Townsend. 

Dr.  Shaffer  said  he  had  an  apparatus  by  which 
traction  was  made  with  an  axillary  crutch,  and  he  does 
not  think  excision  advisable,  as  his  cases  had  usually 
gotten  well  without  abscess.  It  is  sometimes  advisable 
to  break  up  the  adhesions  under  an  anaesthetic. 

Dr.  John  Ridlon  said  he  had  not  seen  any  case 
which  required  excision,  nor  did  any  of  them  go  on  to 
ankylosis  which  would  submit  to  mechanical  treatment. 
He  had  used  the  traction  splint  of  Shaffer  in  a  consid- 
erable number  of  cases,  but  did  not  find  that  they  did  so 
well  as  when  simple  immobilization,  without  traction, 
was  employed,  while,  on  the  contrary,  in  one  or  two 
cases,  the  pain  had  been  increased  by  this  traction  splint. 

The  treatment  which  he  employed  was  to  bind  the 
elbow  to  the  side;  supporting  the  hand  by  sling  or 
"  halter,"  and  covering  the  shoulder,  top  and  side,  back 
and  front,  with  two  or  three  layers  of  stiff  adhesive 
plaster. 

Dr.  Townsend,  in  closing,  said  that  he  felt  all  sur- 
geons had  to  experience  a  period  of  radicalism  in  the 
treatment  of  joints,  which  resulted  in  more  conservative 
views  being  taken.  He  wished  to  emphasize,  however, 
the  difference  between  the  shoulder-  and  hip-joints.  In 
the  former,  he  considered  it  all  important  to  have  free 
movement,  while  in  the  latter  a  weak  or  frail  joint  is 
worse  than  one  which  is  ankylosed. 

Infantile  Scorbutus  in  its  Relation  to  Orthopaedic 
Surgery. — Dr.  Henry  Ling  Taylor,  of  New  York,  in 
a  paper  with  the  above  title,  said  that  infantile  scorbutus, 
due  to  imperfect  feeding,  had  lately  attracted  consider- 
able attention,  over  seventy  cases  having  been  reported 
at  a  recent  discussion  of  the  New  York  Academy  of  Medi- 
cine. The  disease,  he  said,  is  insidious  in  its  onset  and, 
unless  recognized,  may  be  fatal.  The  symptoms,  some 
of  which  may  be  absent  in  any  particular  case,  are:  1, 
a  dusky  pallor ;  2,  emaciation  ;  3,  peevishness  and  gen- 
eral sensitiveness,  which  is  often  excessive;  4,  exqui- 
sitely tender  swellings,  without  local  heat,  near  the  joints 
of  the  lower  extremities,  due  to  subperiosteal  hemor- 
rhage ;  5,  inability  to  move  the  lower  extremities  and 
the  trunk  (pseudo-paralysis) ;  6,  spongy  or  bleeding 
gums  near  the  erupted  teeth ;  and,  most  significant  of 
ail,  7,  rapid  improvement  and  cure  on  diet  of  fresh  milk 
and  orange- juice.  The  peri- articular  swellings  have  been 
frequently  mistaken  for  rheumatism,  which  may  the  more 
happen  as  fever  may  be  present.  A  baby,  a  year  old, 
was  sent  to  the  writer  last  summer,  from  the  South,  for 
treatment  for  a  supposed  spinal  or  hip  affection.  This 
baby  had  been  fed  on  condensed  milk,  and  presented  a 
spinal  projection  at  the  upper  lumbar  region,  with  rigid- 
ity, in  addition  to  the  usual  symptoms.  The  cachexia, 
spongy  and  bleeding  gums,  powerlessness  of  the  legs, 
exquisite  sensitiveness,  and  a  swelling  above  the  right 


August  4.  1894] 


MEDICAL   RECORD. 


H7 


ankle  made  the  diagnosis  clear.  All  the  symptoms  dis- 
appeared, inside  of  three  weeks,  on  a  diet  of  Pasteurized 
milk  and  orange- juice.  As  other  cases  have  been  mis- 
taken for  hip-disease — osteitis  of  the  knee,  sarcoma  of  the 
knee,  and  infantile  paralysis — it  is  particularly  needful 
for  orthopedists  to  bear  in  mind  the  possibility  of  scurvy, 
when  differentiating  infantile  joint  and  paralytic  affec- 
tions.    Discussion. 

Dr.  Ketch  said  that  Dr.  Jacobi,  in  discussing  this 
subject,  did  not  consider  these  so-called  cases  of  pseudo- 
paralysis anything  more  than  weakness. 

Dr.  Gillett  reported  a  case,  and  said  that  he  had 
found  it  difficult  to  distinguish  it  from  rheumatism. 
His  patient,  however,  was  somewhat  older  than  those 
being  discussed. 

Dr.  Shaffer  said  that  the  differential  diagnosis  in 
scurvy  at  this  age  was  from  rachitis,  Pott's  disease,  and 
rheumatism. 

Dr.  Ryan  remarked  that  the  late  Dr.  Knight,  of  the 
Hospital  for  Ruptured  and  Crippled  of  New  York,  had 
spoken  of  the  scorbutic  diathesis. 

Dr.  Taylor,  in  closing,  said  that  he  considered  ra- 
chitis and  scurvy  to  be  different  diseases. 

The  Association  went  into  executive  session,  and  the 
papers  for  the  fourth  day  were  read  by  title. 

Election  of  Officers.— The  officers  elected  for  the  en- 
suing year  were  as  follows :  President,  Dr.  John  Ridlon, 
of  Chicago ;  First  Vice  President,  Dr.  Bernard  Bartow, 
of  Buffalo,  N.  Y.;  Second  Vice-President,  Dr.  L.  A. 
Weigel,  of  Rochester,  N.  Y. ;  Secretary,  Dr.  Royal 
Whitman,  of  New  York ;  Treasurer,  Dr.  E.  G.  Brackett, 
of  Boston. 


Paralysis  in  a  Telephone  Employee.— Dr.  Ewald  re- 
ported at  a  recent  meeting  of  the  Berlin  Medical  Society 
the  case  of  a  young  telephone  operative  who  was  just  put- 
ting two  subscribers  in  communication  with  each  other, 
when  she  felt  a  violent  shock  and  lost  consciousness. 
When  she  came  to  herself  she  was  found  to  have  right 
hemiplegia,  with  contraction  of  the  muscles  on  the  right 
side  of  the  face.  The  latter  disappeared  in  a  few  days, 
and  the  paralysis  of  the  arm  gave  place  to  tremor  with 
ataxia;  the  paralysis  of  the  lower  extremity  persisted 
longer,  but  was  finally  replaced  by  tremor.  In  the  course 
of  some  months  other  nervous  symptoms  appeared,  such 
as  headache,  vertigo,  lumbar  pains,  trembling  of  the 
tongue,  asthenia,  etc.  All  measures  looking  to  relief  of 
these  symptoms  were  ineffectual.  The  question  arose 
whether  the  affection  was  hysterical  in  character,  but 
none  of  the  stigmata  of  hysteria  could  be  found  after  a 
most  careful  examination.  Inspection  of  the  switch- 
board in  the  central  telephone  office  showed  that  the 
operator,  at  the  time  of  making  the  communication,  may 
have  become  part  of  the  circuit,  receiving  the  full  strength 
of  forty  volts. 

The  Value  of  Combining  Heart-tonics.— Convallaria 
majalis  is  a  simple  cardiac  tonic  and  a  safe  remedy.  Its 
action  is  similar  to  that  of  digitalis,  but  not  so  marked. 
It  causes  slowing,  and  increases  the  force  of  the  heart- 
beats. But  it  will  frequently  be  found,  in  lessening  com- 
pensation, that  each  of  the  foregoing  drugs  individually 
fails,  and  disappoints  us  after  a  time.  Then  a  combina- 
tion of  all  three  often  produces  an  effect  little  short  of 
marvellous.  Once  or  twice  in  recent  years  I  have  been 
called  in  consultation  over  cases  of  advanced  mitral  dis- 
ease, in  which  central  failure  has  shown  itself  by  exten- 
sive dropsy  of  the  limbs,  oedema  of  the  lungs  and  liver, 
and  a  general  water-logged  condition  of  the  system.  On 
inquiry  of  my  colleagues  in  attendance  as  to  the  exhibi- 
tion of  digitalis,  the  reply  has  been,  "  He  has  had  it." 
A  similar  response  has  been  given  in  the  cases  of  stro- 
phanthus  and  convallaria.  But  they  had  not  been  given 
collectively — and  when  this  was  done,  benefit  speedily 
accrued  to  the  patient,  and  credit  to  his  medical  ad- 
visers.—Dr.  Taylor,  in  The  Clinical  Journal. 


^merijcatx  ptedicaft  Association. 

Forty-fifth  Annual  Meeting,  held  in  San  Francisco,  Cal.t 
June  s,6,  7,  and  8, 1894. 

(Continued  from  VoL  45,  page  799.) 

SECTION    ON    OBSTETRICS    AND   DISEASES    OF 
WOMEN. 

First  Day,  Tuesday  June  5TH. 

Suprapubic  Hysterectomy. — Joseph  Eastman,  of  In- 
dianapolis, President  of  the  Section,  read  the  annual  ad- 
dress, taking  for  his  subject  the  operation  of  suprapubic 
hysterectomy.  This  operation,  the  speaker  said,  was 
original  with  him,  and  the  method  of  procedure  was  illus- 
trated by  means  of  diagrams  and  instruments. 

The  method  consists  in  tying  the  uterine  arteries  in 
the  broad  ligament  close  to  the  cornua  of  the  uterus,  and 
then  peeling  the  peritoneum  from  the  uterus,  leaving  the 
uterine  arteries  in  the  pelvis.  The  advantages  claimed 
are  the  slight  hemorrhage  and  the  greatly  diminished 
liability  to  septic  infection  by  having  no  ligatures  in  the 
abdominal  cavity.  In  closing  the  abdominal  wound  he 
said  that  the  surgeon  should  expend  greater  efforts  upon 
the  proper  suturing  of  the  peritoneum  than  upon  the  ex- 
ternal appearance,  so  that  the  wound  will  drain  outward 
and  not  into  the  peritoneal  cavity.  He  prophesied  that 
in  the  near  future  the  death-rate  from  the  removal  of 
fibroids  will  be  reduced  to  an  equality  with  that  of  the 
removal  of  ovarian  cysts. 

Operative  Treatment  of  Fibroid  Tumors  of  the 
Uterus — Dr.  Franklin  H.  Martin,  of  Chicago,  then 
read  a  paper  on  this  subject,  in  which  he  made  a  summary 
report  of  six  previously  published  cases,  and  a  first  report 
of  two  recent  cases,  of  his  new  operation  for  fibroids. 
Following  are  the  conclusions  of  the  paper : 

1.  In  hysterectomy  we  have  an  operation  which  is 
bearing  the  test  of  time  well ;  in  selected  cases  in  the 
hands  of  well-trained  men  it  is  the  only  absolute  cure 
yet  demonstrated  for  a  certain  class  of  fibroids. 

2.  The  objections  to  hysterectomy  as  a  cure  for 
fibroids  are  the  long  training  necessary  to  safely  equip 
an  abdominal  surgeon  for  this  most  formidable  of  pelvic 
operations,  the  great  death-rate  of  this  operation  in  the 
hands  of  the  tyro,  the  long  prostration,  accompanied 
frequently  with  nervous  symptoms,  following  otherwise 
successful  hysterectomies,  its  inapplicableness  to  ex- 
tremely exsanguinated  and  otherwise  reduced  patients, 
and  finally  its  inevitable  death-rate  of  at  least  five  per 
cent,  in  the  hands  of  expert  surgeons. 

3.  Removal  of  the  appendages  as  an  operation  for 
fibroids  is  usually  unsatisfactory,  and  should  not  be  re* 
sorted  to  ordinarily,  except  as  a  last  resort  in  a  compli- 
cated case  where  the  abdomen  has  been  opened  for  the 
purpose  of  removing  the  uterus,  and  the  latter  operation 
for  some  reason  has  proved  impracticable. 

4.  If  the  appendages  are  removed  for  the  purpose  ot 
establishing  an  artificial  menopause,  and  for  the  purpose 
of  reducing  small  fibroids  by  modifying  their  nutrition, 
make  sure  to  include  in  the  ligature  the  main  channel  of 
the  ovarian  artery. 

5.  Vaginal  ligation  of  the  base  of  the  broad  ligament 
for  fibroid  of  the  uterus  is  an  operation  still  on  trial.  As 
far  as  we  have  history  of  cases  to  back  the  theories  of  the 
operation  it  has  stood  the  test. 

6.  Vaginal  ligation  of  the  broad  ligament  is  a  minor 
operation  from  the  stand- point  of  mortality,  and  it  is  a 
minor  operation  from  the  stand-point  of  immediate  and 
remote  shock  to  the  patient.  It  can  be  performed  on 
any  patient  without  risk,  in  almost  any  condition  of 
physical  prostration  or  weakness,  so  long  as  she  is  capa- 
ble of  taking  an  anaesthetic. 

7.  The  operation  is  prompt  in  saving  blood.  It  suc- 
ceeds in  cutting  off  one-third  more  blood  to  the  uterus 
than  does  the  Battey-Tait  operation.  Theoretically  and 
practically  it  immediately  checks  uterine  hemorrhages, 


148 


MEDICAL    RECORD. 


[August  4,  1894 


and  at  once  begins  the  diminishing  of  the  myoma  by  de- 
priving it  of  its  nourishment. 

8.  The  operation  of  ligation  of  the  broad  ligament 
does  not  leave  an  abdominal  scar,  does  not  unsex  the 
woman,  as  do  both  hysterectomy  and  the  Battey-Tait 
operation. 

9.  There  are  no  good  reasons  why  ligation  of  the 
broad  ligament  should  not  be  an  early  procedure  in  all 
conditions  of  uncomplicated  fibroids  of  the  uterus  in 
which  the  operation  is  practicable,  even  though  in  a  few 
cases,  subsequently,  a  more  radical  operation  might  be 
necessary. 

10.  The  operation  of  vaginal  ligation  of  the  broad 
ligament  is  practicable  in  all  interstitial  or  moderately 
subperitoneal  fibroids  in  which  it  is  possible  by  careful 
dissection  to  expose  the  base  of  the  broad  ligament  high 
enough  to  include  in  a  ligature  the  uterine  artery  and  its 
branches. 

Dr.  R.  £.  Horton,  of  Illinois,  opened  the  discussion 
on  the  papers  of  the  afternoon,  saying  that  we  must  be 
guided  in  the  selection  of  the  method  by  the  condition 
of  the  case.  He  commended  Dr.  Martin's  operation  for 
controlling  hemorrhage  and  starving  small  fibroids. 

Dr.  McCall,  of  Michigan,  spoke  of  the  President's 
method  as  an  ideal  one,  but  thought  that  in  many  cases 
it  could  not  be  done.  He  recommended  the  conservative 
method  of  Dr.  Martin,  whenever  applicable  and  spoke  of 
the  excellent  results  he  had  had  with  this  operation.  He 
thought  that  the  failures  in  the  operation  of  the  removal 
of  the  appendages  were  largely  due  to  the  fact  that  the 
ligatures  were  not  placed  deep  enough  and  close  enough 
to  the  uterus.  It  is  well  even  to  include  the  cornu  of 
the  uterus  itself. 

Dr.  Lapthorne  Smith,  of  Montreal,  followed  with  a 
plea  for  the  trial  of  electricity  before  more  radical  meas 
ures  are  resorted  to.  He  believed  in  using  the  positive 
galvanic  current  and  constitutional  treatment  for  two  or 
three  months,  and  if  the  case  showed  no  improvement 
then,  operate.  Of  the  operations,  he  preferred  Dr.  Mar 
tin's,  in  which  there  was  no  death-rate,  to  that  which  in 
the  best  of  hands  gave  a  mortality  of  five  per  cent.  Only 
in  extreme  cases  should  the  graver  operations  be  resorted 
to. 

Dr.  McMonagle,  of  San  Francisco,  summarized  the 
dangers  of  fibroids  of  the  uterus  under  the  heads  of  hem- 
orrhage, pressure,  and  malignant  degeneration.  With  re- 
gard to  Dr.  Martin's  operation,  he  inquired,  "Will  the  de- 
generation be  simple  or  malignant  ?  "  The  operation,  he 
felt,  was  still  sub  judice.  He  had  had  the  misfortune  to 
see  electricity  continued  so  long  as  to  change  a  fibroid 
into  a  sarcoma.  He  also  asked  Dr.  Martin,  "What 
if  the  woman  should  become  pregnant  ?  "  also  if  a  starv- 
ing of  the  uterus  might  not  result  in  degeneration  of  mu- 
cous membrane  and  septic  infection.  He  suggested  that 
as  a  preliminary  to  the  operation  the  uterus  be  curetted 
and  stuffed. 

Dr.  H.  O.  Marcy,  of  Boston,  said  that  he  had  never 
used  electricity  that  the  patient  did  not  feel  benefited  by 
it.  He  has  discarded  its  use  for  fibroids.  If  patient  is 
young  and  tumor  small  it  is  best  treated  by  ligation  of 
the  vessels  and  removal  of  the  appendages.  If  the 
growth  is  larger,  removal  of  the  appendages  may  fail. 
He  spoke  of  the  extra- abdominal  treatment  of  the  stump 
as  not  being  ideal  surgery.  It  was  still  resorted  to  sim- 
ply because  the  experience  of  older  men  taught  it  to  be 
safe.  If  surgery  is  aseptic,  nothing  is  gained  by  this 
method.  We  simply  confess  that  we  are  afraid  of  hemor- 
rhage and  infection. 

Dr.  E.  E.  Montgomery,  of  Philadelphia,  thought  that 
the  removal  of  so  large  a  quantity  of  blood  as  in  Dr. 
Martin's  operation  might  cause  degeneration,  sloughing, 
and  danger  of  sepsis.  He  feared  that  the  use  of  elec- 
tricity might  produce  malignant  degeneration. 

In  reply  to  a  question  put  to  Dr.  Marcy,  he  said  he 
had  never  seen  malignant  degeneration  follow  the  use  of 
electricity. 

Dr.  Smith  said,  in  response  to  inquiry,  that  he  never 


employed  gal vano  puncture,  as  it  contained  an  element 
of  danger,  and  the  use  of  electricity  should  be  free  from 
danger.  He  thought  that  the  cases  in  which  electricity 
was  charged  with  causing  malignancy  were  errors  of 
diagnosis.  He  instanced  a  case  in  which  a  supposed 
fibroid,  not  improving  by  electricity,  was  operated  upon, 
when  it  proved  to  be  a  sarcoma  of  the  ovary  in  which 
the  uterus  was  embedded. 

Dr.  Martin,  in  closing  the  discussion,  said  he  wished 
to  eradicate  an  impression  left  on  the  minds  of  some  not 
acquainted  with  him.  He  did  not  believe  that  his  opera- 
tion was  applicable  to  all  cases.  When  the  case  de- 
manded it  he  was  as  ready  to  open  the  abdomen  as  any- 
one. He  said  he  never  knew  a  case  of  malignant  degen- 
eration to  follow  the  use  of  electricity,  but,  on  the  con- 
trary, a  case  of  bleeding  sarcoma,  pronounced  such  by  one 
of  the  most  eminent  pathologists  in  the  United  States, 
had  been  cured  by  him  by  this  method.  He  called  the 
attention  of  the  Section  to  Dr.  Byford's  operation  of 
hysterectomy  as  one  of  the  best. 

With  regard  to  the  results  feared  from  cutting  off  the 
blood-supply  in  his  operation,  he  said  that  in  his  first 
operation  he  was  moved  by  the  same  fears,  and  it  was  the 
least  successful  of  his  cases  because  it  was  not  sufficiently 
thorough.  While  perhaps  two  thirds  of  the  blood-sup- 
ply is  cut  off,  there  is  still  more  than  the  normal  amount 
going  to  the  uterus.  He  thinks  that  pregnancy  can  take 
place,  and  come  to  a  successful  termination,  and  hopes 
to  demonstrate  this  in  the  near  future.  He  stated  that 
as  a  preliminary  to  his  operation  he  always  curetted  the 
uterus,  so  as  to  make  a  clear  field  for  his  vaginal  wounds. 

Dr.  Eastman  showed  that  gangrenous  masses  existed 
in  some  of  the  specimens  of  fibroids  that  he  exhibited. 
He  asked  Dr.  Martin  how  he  could  tell  that  these  did 
not  exist  before  tying  the  broad  ligament.  All  methods 
are  not  applicable  to  all  cases.  If  any  one  method  is 
applicable  to  all,  it  is  that  of  enucleation.  He  thought 
that  if  it  was  necessary  to  drain  through  the  vagina  at  all, 
cut  widely  upon  a  staff  and  pack  the  cervical  canal,  or 
insert  a  tube  surrounded  with  gauze.  He  protested 
against  a  drainage  that  did  not  thoroughly  drain.  He 
thought  the  strongest  point  in  favor  of  the  abdominal 
fixation  method  of  the  stump  was  that  there  was  one 
wound  instead  of  two. 


Second  Day,  Wednesday,  June  6th. 

Placenta  Previa. — Dr.  Llewellyn  Eliot,  of  Wash- 
ington, D.  C,  sent  a  paper  with  this  title,  in  which  he 
designated  placenta  previa,  next  to  puerperal  convul- 
sions, the  most  serious  complication  that  can  occur  in  the 
lying-in  chamber.  The  physician  is  usually  not  called 
until  hemorrhage  has  appeared.  No  woman  should  be 
allowed  to  suffer  from  these  hemorrhages  if  the  child  is 
viable,  for  it  is  as  easy  to  resuscitate  a  child  at  seven 
months  as  it  is  a  child  at  nine  that  has  been  subjected 
to  the  weakening  effects  of  repeated  hemorrhages.  He 
considered  the  proper  procedure  to  be  to  forcibly  dilate, 
turn,  and  deliver,  the  child  acting  as  a  tampon  in  con- 
trolling the  hemorrhage.  He  would  hesitate  to  resort  to 
Caesarean  section. 

Dr.  Eschlemann,  of  Fresno,  said  that  placentae  previse 
were  much  more  common  occurrences  than  generally 
supposed,  a  large  number  of  abortions  being  of  this  char- 
acter, it  being  nature's  method  of  getting  rid  of  them. 
He  objected  to  the  forcible  dilatation  and  introduction  of 
the  hand  for  the  performance  of  version.  All  that  is 
necessary  is  to  dilate  the  cervix  sufficiently  to  introduce 
a  small  forceps,  seize  the  head,  and,  using  it  as  a  tampon, 
bring  it  down  and  deliver  the  child.  The  os  is  usually 
very  dilatable,  particularly  if  the  hemorrhage  has  been 
severe. 

Dr.  McChesney,  of  Philadelphia,  said  that  in  a  case 
of  placenta  previa  there  is  no  time  for  nice  distinctions. 
One  must  use  what  means  he  can  to  dilate  the  cervix, 
turn,  and  deliver.  In  reply  to  a  question  from  Dr.  Whit- 
ney, of  Oregon,  as  to  the  procedure  in  placenta  previa 


August  4,  1894] 


MEDICAL   RECORD* 


149 


centralis,  he  said  the  finger  of  the  hand  should  be  passed 
rapidly  through  the  placental  mass  and  then  proceed  as  in 
a  case  of  lateralis.  Hemorrhage  after  delivery  is  checked 
by  copious  injections  of  hot  water,  massage,  and  ergot,  or 
ergot  and  strychnine  hypodermically  or  by  the  mouth. 

Dr.  Martin,  of  Chicago,  said  that  it  had  been  noticed 
formerly  that  fever  had  invariably  followed  the  delivery 
of  women  in  cases  in  which  it  had  been  necessary  to  in- 
troduce the  hand  into  the  uterus.  We  know  now  the 
cause  of  this.  As  much  care  should  be  taken  in  prepar- 
ing the  hands  preliminary  to  introduction  into  the  cervi- 
cal canal  and  uterus  as  for  a  case  of  laparotomy.  He 
recommended  for  this  purpose  saturated  solution  of  per- 
manganate of  potash  and  oxalic  acid,  as  used  at  Johns 
Hopkins. 

Dr.  Montgomery,  of  Philadelphia,  believed  that 
placenta  previa  was  the  one  condition  in  which  the  life 
of  the  child  should  not  be  considered.  In  central  pla- 
centa previa  hemorrhage  usually  begins  about  the  fifth 
month.  The  patient  may  have  a  fatal  hemorrhage  at 
any  moment.  As  soon  as  the  diagnosis  is  established, 
the  uterine  contents  should  be  evacuated.  When  there 
is  lateral  implantation  and  the  hemorrhage  slight  and 
later,  we  may  temporize ;  but  even  in  these  cases  it  is 
well  to  bring  on  premature  labor.  The  speaker  did  not 
think  Cesarean  section  necessary  or  advisable. 

Dr.  Newman,  of  Chicago,  thought  that  dilatation, 
version,  and  delivery  was  the  best  and  safest  method. 
The  case  should  be  treated  strictly  on  surgical  principles. 
With  regard  to  the  use  of  an  anaesthetic,  he  would  hesi- 
tate to  use  chloroform  after  an  extreme  hemorrhage.  He 
thought  better  work  was  done  with  the  use  of  an  anaes- 
thetic, and  ether  was  safe. 

Dr.  E.  M.  Westley,  of  California,  has  adopted  differ- 
ent methods.  If  the  patient  is  exsanguineous  when  the 
physician  arrives,  the  life  of  the  child  cannot  be  consid- 
ered. At  once  detach  the  placenta  and  bring  it  down ; 
bring  down  the  head  of  the  child  and  deliver.  If  hem- 
orrhage is  slight  and  child  alive,  he  preferred  version  be- 
fore delivery. 

Dr.  Eshlemann,  of  California,  emphasized  the  fact  that 
in  turning  it  was  necessary  to  dilate  the  cervix  to  the 
size  of  the  physician's  hand,  and  run  all  the  risk  of  sep- 
tic infection.  In  introducing  the  forceps  according  to 
his  method  a  dilatation  of  an  inch  was  sufficient. 

Dr.  Carpenter,  of  Pennsylvania,  reported  that  he  had 
had  three  cases  lately.  In  two  he  applied  the  forceps 
high  up  after  getting  head  into  position  by  external 
manipulation.  He  then  brought  the  head  down  so  as  to 
compress  the  placenta,  which  had  previously  been  pushed 
to  one  side.  In  one  case  he  held  the  forceps  in  place 
one  half  hour  before  dilatation  was  accomplished.  The 
patients  were  sustained  by  hypodermic  injections  of 
whiskey  and  strychnine.  In  the  third  case,  one  of  cen- 
tral implantation,  he  found  the  patient  moribund  when 
he  arrived.  He  tore  through  the  placenta  and  found  a 
foot,  which  he  seized,  and  delivered  the  child  as  soon  as 
possible.  The  patient  died.  With  the  hemorrhage  con- 
trolled, the  physician  can  afford  to  wait,  and  he  believed 
that  had  he  been  less  hurried  in  his  procedure,  and  had 
improved  the  delay  by  the  administration  of  proper 
stimulants  he  might  have  saved  his  patient. 

Tetanus  Puerperium. — Dr.  Allison  Maxwell,  of  In- 
dianapolis, sent  a  paper  with  this  title,  in  which  he  gave 
the  clinical  history  of  a  case  of  this  rare  disease  that  had 
occurred  recently  in  his  practice.  He  reviewed  the 
etiology  of  the  disease  and  recommended  in  its  treatment, 
besides  prophylactic  measures,  the  use  of  antispasmodics 
and  antitoxines. 

Dr.  McChbsney,  of  Philadelphia,  in  discussing  this 
paper,  said  that  the  offending  cause  was  some  kind  of 
dirt.  The  disease  presupposed  some  kind  of  infection, 
and  should  have  directed  against  it  local  treatment  aimed 
toward  its  removal.  He  had  had  a  case  in  which  the 
initial  symptoms  of  tetanus  had  appeared  He  used  an 
intra-uterine  douche  of  a  two-quart  1  to  3,000  bichloride 
solution,  every  eight  hours,   following  this  by  water 


which  had  been  recently  boiled.     He  used  at  the  same 
time  hypodermic  injections  of  peptonized  milk. 

Private  Hospitals.— The  President  replied  to  some 
remarks  made  in  the  Surgical  Section  reflecting  upon 
private  hospitals  and  their  owners.  He  said  that  the  at- 
tack upon  private  hospitals  struck  at  the  very  life  of  ab- 
dominal surgery.  It  was  in  a  private  hospital  that  it 
was  born,  nourished,  and  grew  to  full  developed  man- 
hood. He  resented  the  imputation  that  surgeons  would 
be  dishonest  and  use  the  private  hospitals  as  a  means  of 
gain  by  retaining  patients  after  the  need  of  such  retention 
had  ceased. 


Third  Day,  Thursday,  June  7TH. 

Obstetrical  Forceps. — Dr.  Briggs,  of  Sacramento,  read 
a  paper  on  the  "  Function  and  Form  of  Obstetrical  For- 
ceps," using  in  demonstration  instruments  invented  by 
himself. 

Mrs.  £.  S.  Meade,  M.D.,  of  San  Jos6,  in  discussing 
these  forceps,  said  that  they  presented  an  anatomical  de- 
fect, the  pelvic  curve  was  wanting.  She  thought  the  in- 
strument too  complicated.  Great  force  was  not  neces- 
sary in  delivering  a  child  with  instruments.  She  applied 
the  forceps,  used  traction  during  pain,  and  readjusted  the 
instruments  as  it  might  be  necessary  during  the  intervals 
of  pain.  Sometimes  as  long  as  half  an  hour  would  be 
necessary  to  accomplish  the  delivery.  Too  often  phy- 
sicians thought  only  of  quick  work  without  considering 
whether  the  mother  and  child  were  wounded.  She  con- 
sidered that  it  was  impatience  and  lack  of  anatomical 
knowledge  that  destroyed  so  many  uteri  and  peri- 
naeums. 

Dr.  Oscar  Mayer,  of  San  Francisco,  thought  the  com- 
plicated nature  of  the  instruments  was  opposed  to  the 
principles  of  obstetrical  asepsis. 

Dr.  Winterberg,  of  San  Francisco,  thought  it  a  very 
easy  matter  to  find  an  obstetrical  case  in  which  this  and 
all  oiher  necessary  instruments  can  be  placed,  and  the 
whole  thoroughly  sterilized  by  subjecting  to  the  necessary 
heat. 

Dr.  Brown,  of  Mendocino,  Cal.,  objected  to  the  for- 
ceps because  they  lacked  the  proper  curve. 

Dr.  Briggs,  in  closing  the  discussion,  said  that  the 
curve  was  greater  than  it  seemed,  being  equal  to  three 
inches.  It  appeared  less  than  this  because  the  handle 
was  parallel  to  the  axes  of  the  blade,  while  in  the  ordi- 
nary forceps  it  formed  an  angle. 

Massage  in  Gynecology. — Dr.  Oscar  J.  Mayer,  ot 
San  Francisco,  read  a  paper  upon  "  Massage  in  Gyne- 
cology." He  said  the  object  of  uterine  massage  is  to 
bring  about  a  healthier  state  of  the  circulation  and  to  im- 
part tone  to  the  various  structures  of  the  genital  tract. 
It  is  indicated  in  all  disorders  of  chronic  inflammation, 
as  well  as  in  such  diseases  as  cause  uterine  displacements, 
produced  by  relaxation  of  the  ligaments  or  by  pelvic 
exudation,  with  or  without  adhesion.  It  is  very  im- 
portant to  form  a  correct  diagnosis  of  the  disease  and  to 
exclude  all  pyogenic  disorders.  The  speaker  then  went 
into  a  description  of  the  various  methods  employed  and 
the  indication  for  the  employment  of  particular  methods. 
The  indications  for  massage  in  gynecology  are  the  same 
as  those  for  massage  in  surgery.  He  said,  By  massage 
treatment  we  wish  to  produce:  1.  Acceleration  of  the 
absorption  and  retrogression  of  inflammatory  and  trau 
matic  exudation  and  deposits.  2.  Stretching,  loosening, 
disintegrating,  cicatricial,  or  hypertrophied  connective 
tissues,  caused  by  inflammatory  processes.  3.  Stimulation 
of  the  circulation  and  restoration  of  the  normal  elasticity 
and  tone  in  (a)  contracted,  hardened,  and  hypertrophic 
tissues,  or  (£)  relaxed  tissues. 

The  sphere  of  usefulness  may  be  tabulated  as  follows : 
1.  Pelvic  exudations  and  hemorrhagic  infiltrations.  2. 
Chronic  parametritis  and  perimetritis.  3.  Retroversio 
uteri.  4.  Chronic  metritis.  5.  Prolapsus  of  the  uterus 
and  vagina. 

Massage  is  contra-indicated  in  all  diseases  of  the  genital 


*5° 


MEDICAL  RECORD. 


[August  4,  1894 


tract  requiring  perfect  rest  of  the  whole  body  or  of  the 
genital  tract  alone. 

The  best  and  quickest  cures  from  massage  are  observed 
in  chronic  diseases  following  the  puerperal  state.  A 
longer  time  is  required  in  diseases  following  acute  inflam- 
matory processes,  also  when  coincident  with  anomalies  of 
position  of  the  pelvic  organs,  especially  in  retro  derivations 
of  the  uterus.  Even  if  we  do  not  succeed  in  some  cases 
in  restoring  the  uterus  to  its  exact  normal  position  we  can 
obtain  a  symptomatic  cure  without  recourse  to  surgical 
procedure.  The  combination  of  massage  with  electricity 
is  to  be  recommended  in  the  relaxations  of  the  supports 
of  the  uterus,  provided  the  structures  are  intact. 

By  exercising  proper  circumspection  we  can  often 
achieve  more  by  alternating  massage  treatment  with  other 
treatments  than  by  long-continued  massage. 

In  conclusion,  Dr.  Mayer  said  that  massage  does  not 
set  up  for  itself  the  claim  that  it  constitutes  an  independent 
and  sufficient  form  of  treatment.  It  is  only  a  mechanical 
therapeutic  agent,  intended  to  be  used  in  combination 
with  other  tried  and  accepted  remedies  in  effecting  a 
permanent  cure,  or  in  considerably  lessening  the  time 
formerly  required  therefor.  American  gynecologists  have 
been  somewhat  slow  in  accepting  massage  as  a  new  re- 
medial agent  to  be  employed  in  diseases  of  women,  and 
have  been  suspicious  of  the  beneficial  results  that  have 
been  claimed  for  it.  But  the  encouraging  reports  of 
European  authorities,  many  of  them  erstwhile  bitter  op- 
ponents of  massage,  are  favorable  beyond  the  expectations 
of  the  most  sanguine,  and  must  work  a  change  in  this 
American  sentiment. 

Dr.  J.  H.  Barbat,  of  San  Francisco,  bore  testimony 
to  the  great  good  he  had  seen  accomplished  by  massage, 
combined  with  electricity  and  glycerine  tampons,  even  in 
cases  when  the  removal  of  the  ovaries  had  been  recom- 
mended by  competent  physicians.  He  looked  upon  mas- 
sage as  one  of  the  greatest  remedial  agents  of  the  day. 

Dr.  Shuey,  of  Oakland,  Cal.,  said  that  she  had  used 
massage  in  the  painful  menstruation  of  young  women  with 
the  result  of  perfect  relief  from  pain.  They  were  cases  of 
long  standing,  where  none  but  medicinal  treatment  had 
been  tried  She  used  the  massage  every  day  for  three  or 
four  weeks,  and  during  the  menstrual  period  for  three  or 
four  months  afterward. 


MEDICAL  SOCIETY  OF  NEW  JERSEY. 

One  Hundred  and  Tkuenty-eigJith  Annual  Meeting,  held 
at  Lake  Hopatcong,  June  26  and  27,  1894. 

John  G.  Ryerson,  M.D.,  President,  in  the  Chair. 

Reports. — Dr.  Stephen  Pierson,  Chairman  of  the  Com- 
mittee of  Arrangements,  read  an  interesting  programme. 
The  report  of  the  Treasurer,  Dr.  Baldwin,  showed  a  bal- 
ance of  over  four  thousand  dollars.  Dr.  D.  C.  English 
said  the  Committee  on  Ethics  had  had  nothing  to  do. 
The  Committee  on  Honorary  Membership  made  the  fol- 
lowing report : 

The  only  name  presented  at  the  last  meeting  was  that 
of  our  Recording  Secretary,  Dr.  William  Pierson,  and  in 
recommending  him  to  the  Society  for  election  as  honor- 
ary member,  your  committee  take  pleasure  in  referring  to 
his  twenty  seven  years'  consecutive  service,  during  which 
he  has  so  faithfully  and  honorably  discharged  the  arduous 
duties  of  that  office  ;  and  although  he  was  unanimously 
tendered  the  position  of  Third  Vice-President  by  the  Nom- 
inating Committee  at  the  last  session  of  this  Society,  he 
declined  the  honor,  preferring  to  remain  at  his  post  and 
continue  in  the  office  over  which  he  and  his  honored 
father  have  for  over  half  a  century  presided. 

A  standing  vote  was  taken,  none  voting  in  the  nega- 
tive. 

the  Health  of  New  Jersey.— Dr.  D.  C.  English  read 
the  report  of  the  Standing  Committee,  which  included  an 
abstract  of  reports  from  physicians  in  the  different  parts 
Qf  the  State  as  to  contagious  and  other  diseases.     It  ap- 


peared the  year  had  been  a  healthy  one,  there  having 
been  less  of  malaria,  of  diphtheria,  scarlet  fever,  and 
other  infectious  diseases.  In  one  or  two  places  where 
diphtheria  and  typhoid  had  occurred,  they  had  been 
traced  to  the  milk-supply.  Variola  had  been  promptly 
suppressed,  cholera  had  been  kept  out,  the  local  health 
boards  had  shown  more  than  usual  activity.  The  organ- 
ization in  Essex  County  for  a  pure  milk-supply  had  been 
successful,  and  promised  to  be  of  marked  service  in  pre- 
venting the  spread  of  tuberculosis,  diphtheria,  etc 

Prevention  of  Blindness.— Dr.  W#  B.  Johnson  read 
the  report  of  the  Committee  on  the  Prevention  of  Blind- 
ness through  Legislative  Enactment.  The  movement  to 
prevent  blindness  by  legislative  enactment  had  origin- 
ated in  New  York  State,  and  laws  had  been  enacted  in 
that  State,  and  perhaps  half  a  dozen  others.  They  were 
based  on  the  fact  that  blindness  was  due  chiefly  to  con- 
tagious ophthalmia,  and  looked  to  the  cure  of  this  and 
prevention  of  its  spread  to  others  through  use  of  towels, 
etc.  The  ophthalmia  of  the  newly- born  caused  about 
ten  per  cent,  of  all  cases  of  blindness,  and  made  it  im- 
perative that  the  midwife  should  report  cases  at  once  in 
order  that  they  might  receive  timely  treatment,  espe- 
cially that  known  as  Crede's  by  way  of  prophylaxis — 
washing  the  eyes  immediately  after  delivery  and  dropping 
into  them  from  the  pipette  two  per  cent,  solution  of  ni- 
trate of  silver.  On  motion,  the  committee  was  continued 
and  legislation  urged. 

Dr.  William  Perry  Watson  thought  the  license  of 
midwives  should  be  taken  from  them  when  they  failed  to 
report  cases  of  ophthalmia  neonatorum. 

Report  of  Committee  on  Bovine  Tuberculosis. — Dr. 
J.  W.  Stickler,  Chairman  of  the  Committee,  made  the 
report.  He  said  the  committee  had  supposed,  when  it 
went  before  the  Legislature,  that  everybody  was  aware 
that  tuberculosis  existed  in  animals,  and  was  likely  to  be 
transferred  to  man  through  milk  and  flesh.  But  they 
were  mistaken,  and  were  surprised  to  encounter  not  a  lit- 
tle antagonism  to  legislation  in  the  matter,  and  particu- 
larly against  the  bill  which  the  committee  had  prepared 
as  an  efficient  one ;  so  that  instead  of  adopting  this  bill 
another  became  law,  which  on  account  of  its  laxity 
would  probably  prove  quite  useless  in  the  suppression  ot 
tuberculosis  among  cattle. 

Dr.  A.  E.  Conrow  said  it  was  necessary  to  have  the 
co-operation  of  the  farmers  and  the  dairymen  as  far  as 
possible,  and  therefore  the  bill  which  had  been  passed 
met  with  his  approval  until  a  more  radical  law  could  be 
enacted. 

On  motion  the  committee  was  continued,  Dr.  Con- 
row's  name  being  added. 

The  Permanent  Fund. — Since  1868  the  Society  had 
been  accumulating  a  permanent  fund,  the  interest  on 
which,  as  the  Treasurer,  Dr.  Baldwin,  stated,  was  to  be 
used  for  the  publication  of  the  yearly  "Transactions." 
The  sum  had  now  risen  to  over  four  thousand  dollars. 
Motions  had  been  made  from  time  to  time  to  divert  this 
fund  to  some  other  purpose,  especially  to  the  Society  for 
the  Widows  and  Orphans  of  Medical  Men,  which  had  no 
direct  relations  with  the  Medical  Society.  Dr.  Ill  had 
proposed  a  change  in  the  by  law,  turning  the  amount  of 
the  permanent  fund  over  to  the  society  referred  to,  and 
making  the  members  of  the  State  Medical  Society  also 
members  of  the  other.  Drs.  Skinner.  Lielbach,  and 
others  spoke  eloquently  in  favor,  while  Dr.  Baldwin  took 
the  lead  in  opposition.     The  change  was  rejected. 

President's  Address. — Dr.  J.  G.  Ryerson,  of  Boon- 
ton,  chose  for  the  subject  of  his  address,  "  Chronic  Ne- 
phritis and  Lactose."  The  following  were  some  of  W e 
facts  mentioned  in  relation  to  chronic  nephritis,  as  lead- 
ing up  to  the  question  of  a  special  fonn  of  treatment, 
which  in  his  experience  had  given  remarkable  results. 

The  profession  generally,  he  said,  did  not  realize  fully 
the  frequency  of  interstitial  or  cirrhotic  kidney  disease, 
nor  its  distinct  pathology,  its  well-marked  symptoms,  its 
better  prognosis  under  judicious  treatment.  In  a  fair 
amount  of  general  practice  Dr.  Ryerson  had,  within  a 


August  4,  1894] 


MEDICAL    RECORD. 


151 


little  more  than  two  years,  met  with  thirty  three  cases  of 
chronic  nephritis,  twenty-nine  of  which  he  had  diagnosed 
as  cirrhotic.  The  diagnosis  was  frequently  not  made, 
because  the  symptoms  were  mistakenly  attributed  to 
disease  of  other  organs,  which,  if  affected  at  all,  were 
affected  only  secondarily.  Among  the  complications 
were  heart  disease,  pulmonary  disease,  pleurisy,  pneu- 
monia, emphysema,  bronchitis.  The  agents  through 
which  the  different  organs  became  affected  was  probably 
excess  of  one  or  more  of  the  normal  excretions  of  the 
kidney  present  in  the  blood.  Increased  action  was 
demanded  of  the  kidneys  for  its  elimination,  which  called 
for  increased  force  in  circulation,  the  coats  of  the  ar- 
teries in  the  kidneys  became  affected  first,  then  elsewhere 
in  the  body.  Incidentally,  the  President  expressed  dis- 
belief in  the  view  that  men  were  more  often  affected  than 
women,  and  that  alcoholic  drink  was  a  common  cause. 
His  statistics  pointed  in  the  opposite  direction. 

Without  considering  the  large  number  of  symptoms  he 
wound  say  that  an  increase  in  the  quantity  of  urine  with 
low  specific  gravity,  pain  in  the  head,  loss  of  flesh  and 
strength  without  apparent  cause,  were  symptoms  which 
should  direct  attention  to  the  kidneys.  If  there  should 
be  frequent  headache,  palpitation  and  dyspnoea,  general 
dulness,  and  disturbance  of  vision  the  diagnosis  should 
be  clear. 

Dr.  Ryerson  had  first  used  lactose  in  milk,  and  after 
learning  that  the  beneficial  effects  were  due  to  the  lactose, 
he  had  during  the  past  three  years  given  this  alone,  and 
bad  found  it  much  more  efficient  than  in  natural  combi- 
nation. This  was  a  point  on  which  stress  was  laid.  He 
had  now  used  lactose  in  33  cases  of  chronic  kidney  dis- 
ease in  which  he  felt  confident  of  his  diagnosis,  30  hav- 
ing been  cases  of  the  cirrhotic  kidney.  Fourteen  had 
previously  been  treated  by  other  physicians,  and  inn 
the  diagnosis  had  also  been  made  previously.  Emacia- 
tion was  noticed  in  27,  insomnia  in  28,  dyspnoea  in  24, 
pain  in  the  head  in  27,  emphysema  in  n,  heart  compli- 
cations in  13,  the  urine  was  examined  in  22,  and  albumin 
was  found  in  8,  the  average  age  was  53,  males  13,  females 
20.  Six  patients  had  since  died,  and  symptoms  had  re- 
turned after  treatment  in  7.  He  had  also  been  furnished 
with  notes  of  13  cases  treated  by  lactose  by  other  physi- 
cians. In  36  cases  of  the  total  number  lactose  was  the 
only  treatment,  in  the  others  it  was  the  only  treatment 
of  importance.  Lactose  was  given  in  doses  of  from  twenty 
to  fifty  grains.  The  average  duration  of  the  disease  had 
been  fifteen  months.  The  points  of  interest  in  the  treat- 
ment of  chronic  Bright's  disease  by  lactose  might  be 
summed  up  as  follows:  Uniform  certainty  of  effect; 
promptness  of  action;  permanency  of  improvement; 
value  in  diagnosis;  smallness  of  dose  required;  benefit 
not  due  to  diuretic  action ;  difference  in  effect  of  lactose 
taken  in  natural  combination  and  taken  as  he  recom- 
mended, in  the  free  state.  Forty  three  of  the  46  cases 
were  markedly  benefited,  all  but  7  within  three  days. 
In  4  of  the  7  in  which  the  symptoms  returned,  relief  was 
again  obtained  by  lactose.  In  the  43  there  was  no  re- 
turn of  the  symptoms — so  far  as  could  be  learned — within 
six  months.  In  no  cases  was  as  much  as  three  drachms 
of  lactose  prescribed  in  one  day.  The  action  of  the 
remedy,  he  thought,  lay  beyond  the  kidneys,  probably 
in  the  blood. 

Erysipelas  as  a  Complication  in  Abdominal  Surgery. 
—Dr.  George  H.  Ballerav,  of  Paterson,  described  in 
this  paper  three  cases  of  erysipelas,  involving  the  abdom- 
inal wound,  in  patients  operated  upon  by  him  some  years 
ago,  in  the  old  building  of  the  Paterson  Hospital,  the 
origin  of  the  infection  not  being  known,  although  two  of 
the  patients  gave  what  might  be  called  a  history  of  pre- 
disposition to  the  disease.  All  recovered.  Incidentally 
the  author  expressed  preference  for  strict  cleanliness  in 
contradistinction  to  antisepsis  during  operations,  and 
was  apparently  justified  in  his  preference  by  the  results  of 
Mr.  Bantock,  compared  with  Mr.  Thornton's,  who  worked 
in  the  same  hospital. 

Medico-legal  Aspect  of  Abortion. — A  committee  was 


appointed  upon  this  subject,  consisting  of  Drs.  Stickler, 
Baldwin,  and  C.  A.  Adams. 

Observations  on  Cases  of  Movable  Kidney. — Dr.  H. 
G.  Wetherill,  in  this  paper,  expressed  preference  for  the 
incision  parallel  to  the  last  rib,  impressed  the  advantage 
of  operating  with  the  patient  lying  prone,  cylindrical  air- 
cushion  under  the  abdomen  to  push  up  the  kidney,  gave 
preference  to  Dr.  Edebohl's  method  of  anchoring  the 
kidney,  and  cautioned  against  the  use  of  silk,  lest  abscess 
develop  and  lead  to  final  destruction  of  the  organ,  if  not 
to  fatal  sepsis. 

The  paper  was  discussed  by  Drs.  Rogers,  Chandler, 
and  Ballerav. 

Angina  Pectoris. — The  subject  for  discussion  pre- 
sented at  the  last  annual  meeting  related  to  angina  pec- 
toris, its  true  pathology,  and  an  explanation  of  its  sudden 
termination  in  death.  The  gentlemen  who  were  to  open 
the  discussion  were  not  present,  but  Dr.  Baldwin  related 
an  interesting  recent  case  of  death  in  the  first  attack. 
The  man  had  been  in  good  health,  ran  violently  some 
hundred  feet,  felt  nauseated  and  faint,  was  assisted  to  his 
room,  complained  of  pain  and  weight  in  both  arms,  and 
a  feeling  of  depression,  but  there  was  no  evidence  of 
spasm.  This  was.  in  the  morning;  he  was  relieved,  but  in 
the  evening,  while  sitting  up,  he  fell  back  dead.  Post- 
mortem was  not  obtained.  Dr.  Baldwin  thought  ob- 
struction of  the  coronary  arteries  had  much  to  do  with 
angina  pectoris ;  also  affection  of  the  cardiac  nerve  sup- 
ply, especially  in  sudden  death. 

Dr.  Rogers  and  Dr.  Cooper  also  made  some  remarks. 

To  Confer  with  the  Pharmacists.— Delegates  to  cor- 
responding societies  presented  their  reports.  Dr.  Coit, 
who  had  attended  the  meeting  of  the  New  Jersey  Pharma- 
ceutical Society,  offered  a  resolution,  asking  for  the  ap- 
pointment of  a  committee  of  three  to  meet  a  like  com- 
mittee from  the  Pharmaceutical  Society,  to  formulate  some 
plan  which  might  lead  to  more  rational  therapeutics  and 
pharmacy. 

Dr.  Reynolds,  of  the  Pharmaceutical  Society,  read  a 
paper  which  went  to  show  the  necessity  for  closer  rela- 
tions between  the  pharmacist  and  physician,  and  between 
the  two  State  Societies.  The  committee  was  appointed, 
and  consisted  of  Drs.  Coit,  Silver,  and  Lewis. 

Catarrh  of  the  Upper  Air-passages. — The  Third  Vice- 
president,  Dr.  T.  J.  Smith,  read  a  somewhat  exhaustive 
paper  upon  this  subject.  It  was  briefly  discussed  by  Dr. 
W.  B.  Johnson. 

The  Code  of  Ethics.— Dr.  George  T.  Welch,  Chair- 
man of  the  Committee  appointed  to  consider  the  proposed 
revision  of  the  Code  of  Ethics  of  the  American  Medical 
Association,  said  the  committee  had  sent  a  circular  to 
the  district  societies,  and  of  eight  which  had  replied  be- 
fore the  recent  meeting  of  the  American  Medical  Asso- 
ciation, six  were  in  favor  of  the  old  Code,  two  thought  it 
required  modification.  Since  the  American  Medical 
Association  had  already  taken  action,  sustaining  the  old 
Code,  Dr.  Welch  hoped  the  report  would  be  received 
without  discussion  and  the  committee  discharged.  His 
wish  was  granted  by  vote,  but  Dr.  Barker  asked,  and 
finally  obtained,  consent  to  offer  some  resolutions  re-affirm- 
ing the  Society's  allegiance  to  the  Code,  and  read  a  paper 
in  argument  therefor.  The  resolutions  were  almost 
unanimously  adopted. 

Action  on  the  amendments  to  the  by-laws,  proposed  at 
the  last  annual  meeting,  was  deferred  another  year. 

According  to  the  report  of  the  Committee  on  Prize 
Essays  (prize  of  one  hundred  dollars),  this  Society,  like 
many  others,  has  to  do  much  urging  in  order  to  bring 
out  papers  in  competition.  None  had  been  offered  in 
years. 

Officers.— President,  O.  H.  Sproul ;  First  Vice-Presi- 
dent, William  Elmer ;  Second  Vice-President,  T.  J.  Smith ; 
Third  Vice  President,  D.  C.  English ;  Recording  Secre- 
tary, William  Pierson  ;  Corresponding  Secretary,  E.  L. 
A.  Godfrey;  Treasurer,  Archibald  Mercer;  Standing 
Committee,  H.  W.  Elmer,  William  H.  Iszard,  Henry 
Mitchell ;   Committee  of  Arrangements,  G.  E.  Reading, 


152 


MEDICAL   RECORD. 


[August  4,  1894 


James  Mercer,  V.  M.  D.  Marcy,  L.  M.  Halsey,  B.  S. 
Lewis;    Business   Committee,  H.  R.  Baldwin,  W.   B. 
Johnson,  G.  Van  Wagenen,  E.  L.  B.  Godfrey,  Updyke 
Selover. 
Place  of  meeting,  Cape  May ;  time,  June  25  and  26, 

i895-  

SECTION   IN   SURGERY. 
First  Day,  Tuesday,  June  5TH. 

Chairman's  Address. — Dr.  John  B.  Roberts,  of  Phila- 
delphia, said  that  operative  madness  is  rife  in  our  day. 
This  madness  is  endemic  among  those  whose  preliminary 
training  has  been  deficient.  Preliminary  education  is  a 
corrective,  and  a  reaction  is  fast  taking  place.  A  true 
surgeon,  possessed  of  a  thorough  pathological  knowledge, 
must  be  a  man  of  broad  culture  and  have  had  an  adequate 
preliminary  education.  Surgeons  should  be  careful  to 
make  accurate  statements  and  to  refrain  from  criticising 
others.  A  great  surgical  sin  is  the  overlooking  of  the 
influence  of  the  nervous  system  upon  disease.  The 
speaker  condemned  the  evil  of  physicians  controlling 
private  hospitals.  Such  an  institution  is  a  hotel  for  pa- 
tients, and  of  course  chose  interested  are  tempted  to  strive 
to  keep  it  filled  with  long-staying  guests.  The  sin  of 
charging  large  fees  was  also  condemned.  A  man  who 
refuses  his  counsel  to  a  brother  practitioner  because  the 
patient  is  poor,  commits  another  sin,  as  also  does  the  one 
who  charges  for  services  rendered  to  a  physician  or  his 
family.  The  use  of  secret  nostrums  was  denounced  as 
unscientific. 

Malignant  Neoplasms  from  a  Micro-technical  Stand- 
point.— Dr.  A.  P.  Ohlmacher,  of  Chicago,  said  that 
many  things  are  described  as  cancer  parasites  because  this 
subject  has  been  handled  unscientifically.  A  great  num- 
ber of  reagents  have  been  used,  hence  the  diversity  of  re- 
sults, since  artificial  products  are  formed  by  the  reagents. 
It  has  been  found  that  sporozoa  treated  by  different  fixing 
solutions  act  differently.  Some  agents  distorted  the 
spores  and  interfered  with  the  subsequent  staining.  All 
the  present  methods  of  investigation  are  faulty,  and  no 
results  are  to  be  looked  for  until  new  methods  are  devised. 

Early  Surgical  Interference  in  Malignant  Tumors. — 
Dr.  R.  A.  McLean,  of  San  Francisco,  Cal.,  said  that 
malignancy  once  established,  removal  must  be  immediate. 
Recurrence  is  frequent  because  the  laity  delay  until  the 
case  is  hopeless. 

The  causes  of  failure  in  operation  are :  The  size  of  the 
growth,  infiltration,  metastases,  ulceration,  exhaustion, 
and  septicemia.  The  great  mistake  is  in  not  insisting 
on  a  radical  operation.  A  temporizing  policy  is  fatal. 
In  suspected  cases,  carcinosis,  tuberculosis,  and  syphilis 
are  to  be  differentiated.  Early  in  the  case  a  small  opera- 
tion only  is,  as  a  rule,  necessary.  In  operating  take  out 
as  much  as  possible  with  safety,  go  well  around  the  prob- 
able limits  of  infiltration.  In  carcinoma  of  the  tongue 
or  lip,  take  out  the  bone  if  eroded.  In  the  extremities, 
amputate  on  the  proximal  side  of  the  next  articulation 
above  the  growth.  Excision  should  be  practised  in  all 
cases  where  general  health  is  good. 

The  Value  of  Caustics  in  Malignant  Growths. — Dr. 
John  Parmenter,  of  Buffalo,  said  that  many  claims  are 
made  for  caustics,  to  wit :  That  after  their  use  recurrence 
is  less  frequent,  that  the  various  agents  of  this  kind  have 
a  selective  action,  and  that  we  may  obtain  a  reduction  in 
size  of  the  enlarged  lymphatics.  These  claims  are  not 
well  grounded.  The  value  of  caustic  lies  in  the  selection 
of  a  proper  agent  and  the  selection  of  proper  cases.  A 
proper  caustic  is  one  which  entirely  destroys  the  diseased 
tissue,  and  it  should  be  rapid  in  its  action.  Caustics  must 
be  used  in  conjunction  with  common-sense.  Burn  all  the 
diseased  tissue.  Don't  spread  over  too  extensive  a  sur- 
face. Mitigate  as  much  as  possible  the  pain.  Suitable 
cases  are  those  located  in  a  favorable  anatomical  situa- 
tion, and  those  in  which  there  is  no  involvement  of  the 
ymphatic  glands. 


Dr.  L.  Duncan  Bulkley,  of  New  York,  said  that  caus- 
tics are  used  by  quacks,  still  they  have  their  use.  They 
are  indicated  in  (1)  the  early  stages,  and  are  useless  after 
metastases,  extensive  ulceration,  or  glandular  involvement 
have  taken  place.  (2)  In  the  formative  period.  (3)  In 
epitheliomata  in  accessible  regions. 

The  best  form  of  caustic  is  a  mixture  of  wheat  flour, 
arsenic,  cinnabar,  ammonia  muriate,  mercury  bichloride, 
and  zinc  chloride.  Mild  caustics  are  useless,  and  silver 
nitrate  is  of  no  value  whatever. 

Pyrogallic  acid  is  serviceable  after  curetting. 

The  Radical  Cure  of  Malignant  Tumors  by  Operation. 
— Dr.  J.  H.  Wythe,  of  Oakland,  said  that  cancer  is 
often  removed  as  a  palliative  measure.  Cure  by  removal 
can  follow  only  when  the  growth  is  of  local  origin.  Per- 
sistent removal  after  recurrence  is  often  followed  by  per- 
manent cure.  Two  principles  are  to  be  observed,  namely, 
operate  early,  and  remove  a  quantity  of  the  neighboring 
tissue  with  the  growth. 

Dr.  Morrison  said  that  general  practitioners  should 
be  able  to  recognize  and  also  treat  malignant  growths. 
Caustics  are  useless,  and  we  should  always  use  the  knife. 

Dr.  Shiels,  referring  to  Dr.  McLean's  paper  as  re- 
gards differentiating  between  syphilis  and  malignancy  by 
treatment,  said  it  was  not  always  possible,  because  some 
forms  of  gummata  yield  neither  to  iodides  nor  mercury. 

Dr.  Griswold,  of  Pennsylvania,  recited  a  case  where 
he  operated  simply  to  prolong  life.  Caustics  should  be 
used  only  when  the  patient  positively  refuses  surgical 
measures. 

Dr.  Plane,  of  Michigan,  thought  that  there  was  no 
means  of  making  a  prognosis  in  a  large  class  of  tumors. 

Dr.  J.  W.  Cottenhauer,  of  Iowa,  made  the  claim  that 
malignant  tumors  are  never  cured. 

Dr.  Bulkley,  of  New  York,  said  caustics  as  commonly 
used  are  dangerous.  He  believed  that  a  simple  growth 
might  be  made  malignant  by  the  irritation  of  caustics. 

Dr.  Bishop,  of  Pennsylvania,  appealed  to  the  Section 
to  take  a  decided  stand  in  regard  to  caustics.  We  should 
never  allow  the  patient  to  select  the  method  of  treatment. 


Second  Day,  Wednesday,  June  6th. 

Discussion  on  Tubercular  Joint  Disease. — Dr.  Emmet 
Rixford  gave  briefly  the  symptoms  which  are  to  be  de- 
pended upon  in  the  early  recognition  of  this  disease. 

Dr.  R.  H.  Sayre,  of  New  York,  laid  much  stress  on 
the  manner  of  applying  the  plaster  cast  in  the  treatment 
of  joint  disease.  Interest  was  added  to  the  paper  by 
photographs  displayed  to  illustrate  the  various  methods. 

Dr.  S.  Stillman,  of  San  Francisco,  followed  with  a 
paper  on  the  "Treatment  of  Tubercular  Joints  by  the 
Injection  of  Iodoform."  He  dwelt  on  the  technique  of 
the  operation  aud  on  the  location  of  the  tubercular  foci. 

Concussion  of  the  Brain  — Dr.  L.  C.  Lane,  of  San 
Francisco,  read  a  paper  on  this  subject.  After  reviewing 
the  history  of  the  subject  and  giving  a  general  resume'  of 
the  various  theories  brought  forward  in  regard  to  the  sub- 
ject since  1840,  he  went  on  to  explain  why  in  most  cases 
the  diagnosis  was  easy,  whereas  in  other  cases  most  diffi- 
cult, especially  where  there  was  no  history  of  a  blow  or 
a  fall  upon  the  head. 

He  divided  the  cases  into  three  general  classes  or 
grades:  1,  The  mild ;  2,  severe ;  and  3,  the  fatal  cases. 

As  symptoms  of  the  trouble  he  enumerated  vertigo, 
faintness,  weakness,  drowsiness,  and  coma.  The  prog- 
nosis was  dependent  on  the  extent  of  the  injury.  As 
after-effects  in  some  cases,  he  mentioned  melancholia  and 
mania. 

Treatment  of  Fractures  of  the  Lower  End  of  the 
Humerus. — Dr.  Allis  sent  a  paper  with  this  title. 
The  main  point  brought  out  was  the  advantages  to  be 
derived  from  treating  such  injuries  with  the  arm  in  ex- 
tension and  the  patient  in  the  recumbent  posture.  This 
facilitates  the  circulation  of  the  blood,  the  examination 
of  the  part,  and  the  renewal  of  the  applied  dressing. 


August  4,  1894] 


MEDICAL    RECORD. 


153 


Passive  motion  he  said  was  only  to  be  used  in  the  latter 
half  of  the  treatment.  A  lengthy  discussion  then  fol- 
lowed, which  was  represented  on  the  one  side  by  Dr. 
Lane,  who  favored  the  method  employed  by  Allis,  and 
on  the  other  side  by  Dr.  Sayre,  who  favored  the  rectan- 
gular position. 

Discussion  on  Hernia. — Dr.  J.  Ransohoff,  of  Cin- 
cinnati, O.,  emphasized  the  great  importance  of  imme- 
diate operative  interference  in  the  case  of  the  strangu- 
lated hernia,  and  the  great  danger  to  be  apprehended 
from  prolonged  taxis  which  has  a  tendency  to  decrease 
the  vitality  of  the  gut,  as  well  as  to  make  the  subsequent 
operative  procedure  less  favorable  in  its  results. 

Dr.  A.  E.  Rockey,  of  Portland,  Ore.,  then  followed 
with  a  paper  entitled  "  Observations  on  the  Radical  Cure 
of  Inguinal  Hernia."  He  advocated  the  idea  of  opera- 
tive interference  also  in  many  cases  of  long  standing  and 
in  cases  where  the  hernia  is  very  large. 

Dr.  H.  O.  Marcy,  of  Boston,  advocated  the  use  of 
kangaroo  tendon  in  suturing,  in  preference  to  catgut.  A 
lively  discussion  followed,  which  showed  that  there  are  still 
many  adherents  to  the  conservative  method  of  treatment. 

A  Plea  for  the  Better  leaching  of  Anatomy. — Dr. 
Schikl  read  a  paper  with  this  title,  in  which  he  said 
that  among  all  medical  studies,  anatomy  probably  ranked 
first  in  importance.  The  lack  of  interest  shown  by 
students  in  the  study  of  anatomy  was,  he  thought,  largely 
due  to  the  methods  of  teaching.  He  also  laid  great 
stress  on  the  evil  results  consequent  upon  a  deficient 
education  in  this  branch  of  medical  science.  These,  he 
said,  were  not  only  meted  out  to  the  physician,  but  also 
to  the  patient,  who  falling  into  the  hands  of  a  practi- 
tioner with  only  a  superficial  knowledge  of  anatomy  was 
like  a  lamb  being  led  to  the  slaughter,  unconscious  of  the 
danger  which  awaits  him. 


Third  Day,  Thursday,  June  7TH. 

Symptoms  and  Treatment  of  Tumors  of  the  Bladder. 
— Dr.  C.  F.  Buckley,  of  San  Francisco,  read  a  paper 
which  was  mainly  a  detailed  account  of  three  cases  of 
tumors  of  the  bladder,  produced  in  these  patients  un- 
doubtedly by  traumatisms  of  the  perinaeum.  He  indi- 
cated that  in  his  opinion  not  enough  attention  was  paid 
to  injuries  of  this  sort.  Dr.  Buckley  also  exhibited  a 
slate  pencil  removed  from  the  bladder  of  a  male  subject 
by  the  median  operation ;  and  a  collection  of  gall-stones 
removed  from  the  gall-bladder  of  a  patient  during  life. 

Pathology  and  Symptomology  of  Hemorrhoids,  Anal 
Fistulas,  and  Anal  Fissure. — Dr.  David  Powell,  of 
Marysville,  Cal.,  read  a  paper  with  this  title.  Clinically 
he  divided  piles  into  external  and  internal,  although 
their  pathology  is  the  same.  The  veins  involved  are  the 
inferior  and  superior  hemorrhoidal  plexus.  In  their  in- 
itial stage  they  are  nothing  more  than  dilated  rectal 
veins.  Later,  characteristic  changes  take  place  and  the 
tumor  enlarges.  As  causes  he  enumerated  fecal  accumu- 
lations, the  gravid  uterus,  or  some  obstruction  to  the 
hepatic  circulation*  The  internal  he  classified  into:  1, 
venous;  2,  arterio- venous ;  and  3,  the  capillary.  The 
speaker  next  took  up  the  subject  of  anal  fistula.  This 
usually  originates  in  an  ulcer.  It  may  also  be  caused  by 
a  thrombosis  or  tubercular  foci  which  induces  suppura- 
tion. This  trouble  he  said  was  often  not  accompanied 
by  any  urgent  symptoms. 

The  subject  of  anal  fissure  was  next  discussed.  This, 
the  speaker  said,  was  a  most  important  subject  practically, 
not  because  of  its  pathology  but  rather  because  of  the 
pain  and  annoyance  which  invariably  accompany  it. 
Among  the  characteristic  symptoms  he  mentioned  :  Dull 
aching  pain,  aggravated  by  evacuation  of  the  bowel. 
Morning  diarrhoea,  loss  of  blood,  continual  irritation  of 
the  genitourinary  organs,  and  tender  prostate.  The 
constitutional  disturbances  are  often  marked.  If  trouble 
is  unrelieved,  patient  becomes  pale,  anxious,  and  looks 
careworn. 

Dr.  G.  B.  Somers,  of  San  Francisco,  said  the  treat- 


ment of  anal  fistula  was  by  no  means  always  a  simple 
one  on  account  of  two  complications  :  1,  cicatricial  tissue 
was  frequently  found  in  the  canal ;  and  2,  collateral 
sinuses  often  existed,  hindering  the  surgeon  in  his  work. 
In  most  cases  the  fistula  is  preceded  by  an  abscess,  which 
may  be  either  pyogenic  or  tubercular  in  origin,  which  im- 
parts to  the  fistula  its  characteristic  aspect. 

Methods  of  treatment  are  mainly  four:  1,  by  injec- 
tion ;  2,  by  ligation ;  3,  by  Mathew's  fistulatome ;  and 
4,  the  radical  operation  by  the  knife.  Dilatation  of  the 
sphincter,  he  said,  should  always  precede  the  operation. 

Dr.  Thomas  W.  Huntington,  of  Sacramento,  stated 
that  anal  fissure,  though  more  common  between  the  ages 
of  twenty  and  thirty- five,  occurs  at  times  during  infantile 
life  and  in  old  age.  It  occurs  as  often  in  men  as  it  does 
in  women,  a  view  not  generally  held  up  to  this  time. 

The  symptoms  are  morning  diarrhoea,  tenesmus,  in- 
tense paroxysmal  paralyzing  pain  quite  out  of  proportion 
to  the  size  of  the  ulcer. 

There  are  two  general  methods  of  cure :  1,  by  dila- 
tation of  the  sphincter ;  and  2,  by  incision.  Incision 
always  to  be  done  under  anaesthesia.  The  speaker  fav- 
ored the  combined  plan  of  incision  and  dilatation. 

Treatment  of  Stricture  of  the  Urethra.— Dr.  Rosen- 
stein  gave  briefly  his  experience  with  the  employment 
of  gradual  dilatation  and  internal  urethrotomy.  In  sum- 
ming up  he  stated  that  he  decidedly  favored  gradual  dil- 
atation, and  that  in  his  opinion  internal  urethrotomy  will 
eventually  be  abandoned  because  of  the  dangers  asso- 
ciated with  the  operation,  and  because,  in  his  opinion, 
the  cure  after  urethrotomy  was  not  any  more  permanent 
than  after  gradual  dilatation. 

A  lively  and  very  interesting  discussion  now  ensued. 

Dr.  Thomas,  of  Pennsylvania,  said  that  in  certain 
cases  he  decidedly  favored  internal  urethrotomy,  in 
others  divulsion. 

Dr.  Huntington,  of  California,  remarked  that  he 
rather  favored  internal  urethrotomy,  as  gradual  dilatation 
did  not  always  cure  the  discharge. 

Dr.  Dodge,  of  Michigan,  said  he  had  seen  worse  re- 
action from  the  use  of  the  sound  than  from  internal 
urethrotomy. 

A  number  of  other  physicians  gave  their  opinions,  by 
which  it  seemed  to  be  the  consensus  of  most  present  that 
internal  urethrotomy  was  well  adapted  in  many  cases, 
and  that  it  will  always  occupy  a  place  in  surgery. 

It  also  was  thought  by  many  that  the  cure  of  stricture 
is  not  a  permanent  one,  and  that  sounds  have  to  be  used 
at  shorter  or  longer  intervals  to  keep  the  stricture  from 
again  contracting. 


Fourth  Day,  Friday,  June  8th.  * 

Hew  Plastic  Operation  for  Varicocele. — Dr.  O.  J. 
Mayer,  of  San  Francisco,  read  the  paper.  The  feature 
of  the  operation  is  the  transverse  suturing  of  the  longi- 
tudinal wound,  which  method  considerably  shortens  the 
scrotum.  A  case  which  had  been  operated  on  was  pre- 
sented. 

Dr.  Mayer  then  read  a  paper  on  a  "  Bloodless  Vaginal 
Myectomy.' '  The  essential  step  in  the  operation  being 
the  temporary  ligation  of  the  uterine  arteries. 

Acetanilid  in  Medicine  and  Surgery. — Dr.  G.  W. 
Woods,  of  the  United  States  Navy,  Mare  Island,  Cali- 
fornia, read  a  paper  in  which  he  gave  a  brief  account  of 
the  preparation  and  composition  of  acetanilid.  Anti- 
febrin,  he  said,  was  simply  another  name  for  acetanilid. 
It  is  a  good  antipyretic  and  not  poisonous  if  given  in  small 
doses  at  the  commencement,  even  to  children.  It  acts 
slowly  and  is  both  a  diaphoretic  and  diuretic.  It  may  be 
given  in  any  and  all  fevers  and  inflammations.  It  is  a  good 
substitute  for  iodoform  in  venereal  sores.  The  only  thirg 
experienced  on  its  application  to  a  granulating  surface  is  a 
burning  sensation,  which,  however,  persists  only  a  short 
time.  It  is  useful  in  the  dressing  of  all  forms  of  burns,  ul- 
cers, moist  eczema,  gunshot  wounds,  abscesses,  etc.  When 
applied  to  extensive  granulating  surfaces  it  sometimes  pro- 


154 


MEDICAL   RECORD. 


[August  4,  1894 


duces  cyanosis,  which  is  not  due  to  a  disturbance  of  cir- 
culation, but  to  a  deficient  oxygenation  of  the  blood. 
To  sum  up,  the  speaker  said,  acetanilid  is  exceedingly 
useful  because  it  is  cleanly,  odorless,  antiseptic,  desiccat- 
ing, practically  non-toxic,  does  not  crust,  is  easily  re- 
moved, insignificant  cost,  not  altered  by  moisture. 

Contagious  Period  of  Syphilis. — Dr.  Thomas,  of 
Pennsylvania,  emphasized  the  fact  that  he  was  perfectly 
convinced  that  syphilis  is  only  contagious  in  the  primary 
and  secondary  stages,  that  is  only  for  three  to  four  years 
after  the  primary  lesion. 

Dr.  Schiels  reported  a  case  of  multiple,  symmetrical, 
bilateral  lipomata.  The  lipomata  were  not  limited  to 
any  particular  part  of  the  body,  but  occupied  positions 
from  the  neck  down  to  the  groin. 

The  Surgical  Engine  — Dr.  Bonnwbll,  of  Philadel- 
phia, Penn.,  then  read  a  paper  on  this  engine,  which  was, 
he  said,  very  similar  to  the  ordinary  dental  engine.  It 
caused  the  trephine  or  burr  to  revolve  from  a  hundred  to 
twenty  thousand  times  a  minute.  It  is  said  to  be  adapted 
to  the  performance  of  all  sorts  of  surgical  operations,  on 
both  the  soft  parts  and  bony  tissue. 


NEW  YORK  PATHOLOGICAL  SOCIETY. 

Stated  Meeting,  February  14,  1894. 

George  C.  Freeborn,  M.D.,  President,  in  the  Chair. 

Rupture  of  the  Liver. — Dr.  E.  Hooenpyl  presented  the 
specimen.  There  was  extensive  laceration  of  the  organ 
due  to  an  injury,  yet  death  did  not  occur  for  three  weeks, 
and  was  then  due  to  peritonitis  and  septic  infection.  The 
patient  was  said  to  have  had  a  kick  from  a  horse,  yet  he 
received  practically  no  attention  until  about  three  weeks 
later,  when  he  reached  the  hospital  after  a  ride  in  a  street- 
car and  a  short  walk.  He  was  much  exhausted  at  the 
time  of  admission,  and  died  two  hours  later.  At  the 
autopsy  the  body  was  found  to  be  emaciated.  There  was 
no  external  sign  of  injury,  and  no  fracture  of  the  ribs  or 
vertebrae.  There  was  an  intense  peritonitis  with  con- 
nective tissue  bands  uniting  the  coils  of  intestine.  Be* 
hind  the  intestine,  on  either  side  of  the  vertebral  column, 
were  two  large  collections  of  stinking  blood — at  least 
two  quarts  on  either  side.  The  whole  of  the  right  lateral 
border  of  the  liver  was  torn  away,  and  the  right  lobe  was 
exceedingly  friable,  so  that  a  dull  probe  could  be  inserted 
into  the  liver  tissue  for  at  least  six  inches.  The  fact  that 
the  man  survived  the  injury  so  long  was  very  remarkable, 
for  most  cases  of  rupture  of  the  liver  prove  fatal  within  a 
few  hours,  from  hemorrhage. 

Sub-phrenic  Abscess. — Dr.  Hodenpyl  also  presented  a 
specimen  of  sub  phrenic  abscess.  It  had  apparently  re- 
sulted from  a  perforation  of  the  gall-bladder.  The  sub 
j  set  was  a  man  twenty-three  years  of  age,  who  had  been 
excessively  intemperate.  In  the  winter  of  1892  he  had 
severe  colicky  pains  in  the  region  of  the  umbilicus,  lasting 
for  three  weeks.  The  present  illness  began  on  December 
10th,  with  a  nearly  constant  pain  referred  to  the  umbili- 
cus and  upper  abdominal  region.  Two  days  later  he  no- 
ticed the  abdomen  beginning  to  swell,  and  ever  since 
then  it  had  steadily  increased  in  size.  On  admission  he 
was  well  nourished,  and  very  slightly  jaundiced.  There 
was  some  swelling  of  the  feet  and  limbs ;  the  abdomen 
was  considerably  distended,  but  there  was  no  fluctuation ; 
the  temperature  was  ioo°  F. ;  pulse,  112;  respirations, 
24 ;  urine  normal.  Physical  examination  showed  flatness 
over  the  lower  part  of  the  right  lung,  beginning  at  the 
third  space,  and  some  dulness  posteriorly  over  the  left 
lung.  The  heart  was  normal;  splenic  dulness  not  in- 
creased. On  December  2  2d  paracentesis  abdominis  was 
performed,  and  166  ounces  of  slightly  turbid  reddish  brown 
fluid  were  withdrawn.  This  gave  marked  though  tem- 
porary relief.  On  December  25  th  a  needle  was  inserted 
into  the  right  chest  posteriorly  and  some  bloody  serum 
drawn  off,  and  on  the  following  day  paracentesis  was  again 
performed.     Some  reddish-brown  fluid  wa3  evacuated, 


and  this  gave  a  distinct  bile  reaction.  On  December  2  7th 
a  four  inch  vertical  incision  in  the  right  lumbar  region 
was  made,  about  the  level  of  the  umbilicus,  and  on  cutting 
through  the  abdominal  muscles  and  peritoneum  about  two 
and  a  half  litres  of  clear  brownish  fluid  escaped.  The 
incision  was  enlarged  and  disclosed  a  cavity  of  consider- 
able size.  There  was  a  well  marked  line  binding  to 
gether  the  intestines  and  separating  them  from  the  peri, 
toneal  cavity.  In  the  upper  part  of  the  incision  was  a 
rounded  cicatrix  half  an  inch  in  diameter.  The  wound 
was  packed.  After  two  days  the  patient  developed  diar- 
rhoea with  some  blood  in  the  stools,  and  on  January  16th 
he  died.  No  complete  autopsy  was  permitted,  but  the 
liver  was  removed  through  the  abdominal  wound.  Over 
the  whole  right  lobe,  posteriorly,  was  a  large  collection 
of  fibrin  and  pus  immediately  beneath  the  diaphragm. 
Over  the  whole  lower  lobe  of  the  right  lung  was  a  rather 
thick  coating  of  fibrin  and  pus.  There  was  an  intense 
peritonitis  with  organized  adhesions.  The  gall-bladder 
showed  a  circular  opening  about  the  size  of  the  little  finger 
with  rounded  edges.  This  might  have  been  ante-mortem 
or  due  to  the  necessarily  forcible  extraction  of  the  liver. 

The  speaker  said  that  in  most  of  the  cases  of  sub  phrenic 
abscess  that  had  been  reported,  the  condition  was  due  to 
the  extension  of  a  pleuritis,  but  in  this  he  thought  it  was 
rather  due  to  rupture  of  the  gall-bladder. 

Carcinoma  of  the  Stomach. — Dr.  Hodenpyl  next  pre 
sented  a  specimen  of  the  above.  It  was  removed  from  ? 
man,  fifty  years  of  age,  who  had  suffered  for  a  number 
of  years  with  phthisis.  For  the  last  year  of  his  life  there 
were  marked  gastric  symptoms,  particularly  vomiting  of 
"  coffee-ground  "  material.  He  was  so  much  emaciated 
that  the  tumor  could  be  easily  felt  on  palpation  of  the 
abdomen.  There  was  not  much  stricture  of  the  pylorus, 
but  just  above  this  point  was  an  ulcer  one  and  one-half 
inch  in  diameter  and  one  inch  deep.  There  were  sev- 
eral large  capillaries  in  the  base  of  this  ulcer,  from  which 
the  hemorrhage  probably  occurred. 

Dr.  George  P.  Biggs  said  that  last  spring  he  had  pre- 
sented to  the  Society  a  specimen  not  unlike  the  one  of 
sub  phrenic  abscess  just  exhibited.  In  his  specimen 
there  was  a  large  calculus  having  the  shape  of  the  inte- 
rior of  the  gall-bladder,  and  lodged  in  the  common  and 
hepatic  ducts.  There  was  one  quite  large  ulcer  and 
several  small  ones  in  the  fundus  of  the  gall  bladder,  and 
several  collections  of  pus  around  the  gall-bladder  with 
perforation  into  the  pleural  cavity. 

Sarcoma  of  the  Tongue. — Dr.  £.  K.  Dunham  pre- 
sented this.  It  had  been  removed  by  operation,  by  Dr. 
Joseph  D.  Bryant,  from  a  man  sixty-one  years  of  age, 
whose  family  history  was  negative,  except  that  several  of 
the  members  of  the  family  had  died  of  tuberculosis.  The 
man  was  somewhat  alcoholic  in  his  habits,  and  was  accus 
tomed  to  smoke  ten  pipes  of  tobacco  a  day,  using  a 
briar  wood  pipe.  About  eight  months  ago  he  bit  his 
tongue  on  the  right  side,  one  inch  from  the  tip,  causing 
a  blister,  which  by  contact  with  a  rough  tooth  became 
irritated.  A  tumor  slowly  grew  on  this  spot,  and  when 
first  seen  was  three-fourths  of  an  inch  in  diameter.  On 
microscopical  examination  the  structure  of  the  tumor 
appeared  to  be  that  of  a  large  round-cell  sarcoma.  The 
speaker  said  that  the  literature  of  the  subject  was  very 
meagre*  Max  Schreier,  in  the  KUnische  Wochenschrift 
for  June,  1892,  reported  several  cases.  He  also  recorded 
two  cases  in  which  there  was  an  anatomical  diagnosis  of 
sarcoma  of  the  tongue,  but  in  which  no  clinical  history 
was  obtainable.  In  the  cases  which  he  cited  the  majority 
were  at  the  back  of  the  tongue,  and  most  of  them  were 
either  small  round  cell,  spindle-cell,  mixed-cell,  or 
lympho-sarcomata.  The  only  large  round  cell  sarcoma 
reported  was  one  by  Mercier  in  1890,  situated  near  the 
tip  of  the  tongue  on  its  dorsal  surface.  It  was  a  fungous 
growth  attached  to  the  tongue  by  a  thick  pedicle,  and 
was  made  up  of  large  round  cells,  some  of  which  were 
multi  nucleated,  with  a  small  amount  of  intercellular 
stroma  which  could  be  more  or  less  distinctly  traced  from 
the  connective  tissue  surrounding  the  tumor.     In  that 


August  4,  1894] 


MEDICAL    RECORD. 


155 


case,  as  in  the  one  just  presented,  there  was  no  ulceration 
around  the  tumor ;  the  epithelium  was  intact,  and  showed 
no  tendency  to  involve  the  underlying  tissues. 

Dr.  T.  M.  Prudden  said  that  the  specimen  seemed  to 
be  undoubtedly  one  of  sarcoma,  perhaps  of  the  kind 
sometimes  called  angio-sarcoma.  He  had  seen  three  or 
four  small  sarcomata  of  the  tongue,  all  of  the  spindle-cell 
or  small  round- cell  variety.  The  specimen  exhibited 
under  the  microscope  was  so  beautiful,  he  would  like  to 
ask  how  it  had  been  hardened. 

Dr.  Dunham  replied  that  the  whole  tumor  was  first 
hardened  in  a  saturated  solution  of  bichloride  for  five 
hours ;  then  in  seventy  per  cent,  alcohol  containing  some 
iodide  of  potassium,  and  then  successively  in  eighty  per 
cent.,  ninety-five  per  cent.,  and  absolute  alcohol.  The 
section  was  cut  in  paraffin. 

Typhoid  Fever  with  Extensive  Ulceration.— Dr. 
George  P.  Biggs  presented  a  supplementary  report  on 
the  case  of  typhoid  fever  with  extensive  ulceration  of  the 
caecum  which  he  had  presented  some  time  ago  to  the 
Society.  Cultures  from  the  spleen  showed  bacilli  pos- 
sessing all  the  morphological  and  biological  characters 
of  typhoid  bacilli,  including  the  growth  on  potato. 
Cultures  from  the  peritoneal  exudate  showed  the  strepto- 
coccus pyogenes  very  abundant,  with  bacilli  which  had 
apparently  the  characteristics  of  the  colon  bacillus,  in- 
cluding the  development  of  bubbles  of  gas  in  cane  sugar 
•bouillon. 

Pulmonary  Thrombosis  and  Infarctions. — Dr.  George 
P.  Biggs  also  presented  a  supplementary  report  on  this 
recent  case.  It  was  one  of  dilated  heart  with  multiple 
pulmonary  thrombi  and  infarctions.  The  areas  in  the 
lang  showed  the  ordinary  structure  of  hemorrhagic  in- 
farctions, and  branches  of  many  of  the  pulmonary  arte- 
ries showed  distinct  endarteritis.  The  lesion  most  fre- 
quently seen  in  the  sections  was  a  fibrous  thickening  of 
the  intima  with  slight  narrowing  of  the  lumen ;  distinct 
obliterating  endarteritis  was  occasionally  seen.  The 
media  and  adventitia  of  some  of  the  vessels  contained  a 
few  small  round  cells.  The  vessels  of  the  liver  and  kid- 
neys appeared  to  be  normal.  It  was  rather  interesting 
to  note  the  absence  of  any  gross  evidence  of  arterial  dis- 
ease, and  the  evidence  microscopically  of  slight,  but  dis- 
tinct, changes  apparently  limited  to  the  pulmonary  arte- 
ries. The  arterial  disease,  with  the  marked  enfeeblement 
of  the  circulation  present  in  the  case,  fully  accounted  for 
t  le  thrombi,  and  apparently  for  their  presence  only  in 
tie  lung. 

In  connection  with  that  case  the  speaker  reported  one 
presenting  very  similar  lesions.  A  woman,  forty  years 
of  age,  had  had  for  several  years  more  or  less  palpita- 
tion, dyspnoea,  and  oedema  of  the  legs.  She  had  never 
had  rheumatism.  Five  months  before  death  she  had  se- 
vere headache,  cough,  vomiting,  dyspnoea,  and  dimness 
of  vision,  soon  followed  by  oedema  of  the  feet.  The 
urine  became  scanty  and  high-colored.  On  admission, 
the  temperature  was  10 1°  F.,  respirations,  40,  and  the 
pulse,  108 ;  there  were  many  subcrepitant  rales  over  the 
lung  posteriorly.  The  apex  beat  was  in  the  fifth  space, 
$*4  inches  to  the  left  of  the  median  line.  A  faint  sys- 
tolic murmur  was  heard  at  the  apex ;  the  heart  action 
was  regular  and  of  fair  force,  and  the  pulse  had  a  high 
tension;  The  liver  extended  from  the  fifth  space  to  the 
level  of  the  umbilicus.  A  moderate  quantity  of  fluid 
was  detected  in  the  peritoneal  cavity,  and  there  was 
marked  oedema  of  the  lower  extremities.  Examination 
of  the  urine  showed  it  to  have  a  specific  gravity  of  1.014, 
and  to  contain  from  ten  to  twenty  per  cent,  of  albumin, 
with  many  casts.  Twenty  to  twenty-five  ounces  of  urine 
were  voided  daily.  She  was  under  observation  in  the 
New  York  Hospital  for  two  months,  during  which  time 
the  dyspnoea,  vomiting,  headache,  and  scanty  urine  were 
ths  prominent  symptoms.  During  the  last  ten  days  of 
her  sickness  there  was  cough  with  moderate  bloody  expec- 
toration. At  the  autopsy  it  was  noted  that  she  was  an  ex- 
tremely obese  subject,  the  fat  in  the  abdominal  walls  be- 
ing 7  ctm.  in  thickness.     Many  old  pleuritic  adhesions 


were  found,  and  also  a  moderate  increase  in  the  peri- 
cardial fluid.  The  heart  was  considerably  hypertrophied, 
but  predominantly  dilated.  All  the  cavities  were  dis- 
tended with  post-mortem  clots;  all  the  valves  were 
normal;  the  muscular  substance  was  pale,  but  fairly 
firm.  The  coronary  arteries  and  the  aorta  were  slightly 
atheromatous.  There  was  a  thin  thrombus,  1  ctm.  in 
diameter,  at  the  junction  of  the  transverse  and  descend- 
ing portions  of  the  arch  of  the  aorta.  There  were  no 
ante-mortem  thrombi  in  the  heart  itself.  In  the  left 
lung  ante-mortem  thrombi  were  found  in  many  of  the 
larger  branches  of  the  pulmonary  artery  in  both  lobes. 
Many  of  these  thrombi  nearly  occluded  the  vessels,  but 
there  were  no  infarctions  except  two  small  ones  in  the  an- 
terior border  of  the  base,  ij4  ctm.  in  diameter.  In  the 
right  lung  there  were  large  thrombi  in  the  main  subdivi- 
sions of  the  pulmonary  artery,  and  multiple  small  infarc- 
tions scattered  through  the  upper  and  lower  lobes.  The 
largest,  which  was  in  the  posterior  part  of  the  lower 
lobe,  measured  4  ctm.  in  diameter.  The  lungs  were 
generally  congested  and  oedematous.  In  the  common 
iliac  and  femoral  veins  were  large  thrombi  apparently 
completely  occluding  the  vessels.  The  kidneys  showed 
advanced  chronic  diffuse  nephritis.  It  was  quite  possi- 
ble that  some  of  the  infarctions  came  from  emboli  in  the 
femoral  vessels. 

Typhus  or  Typhoid  Fever  t— Dr.  George  P.  Biggs  then 
presented  specimens  from  a  case  seen  first  at  the  Recep- 
tion Hospital,  and  then  at  the  Riverside  Hospital.  The 
patient  was  an  Austrian,  twenty  one.  years  of  age,  who 
when  admitted  to  the  Reception  Hospital  had  a  temper- 
ature of  1050  F.,  with  a  moderately  profuse  eruption 
which  was  regarded  as  that  of  typhus  fever.  He  said  he 
had  been  sick  for  three  days.  The  patient  was  under  ob- 
servation for  eighteen  days,  and  the  history  was  furnished 
by  Dr.  S.  D.  Hubbard,  of  the  Riverside  Hospital.  The 
temperature  for  the  first  three  days  was  between  1050 
and  1060  F.,  and,  during  the  following  eleven  days,  it 
ranged  between  1060  and  1030,  the  average  being  105° 
F.  During  the  last  four  days  it  fell  gradually  from  1030 
to  ioo°,  the  average  being  1020  F.  His  pulse  for  the 
corresponding  periods  was  120  to  124,  then  100,  then 
80,  and  during  the  last  few  days  124.  The  respirations 
varied  between  26  and  36  during  the  entire  time.  Low, 
muttering  delirium  was  noted  on  the  sixth  day  of  the 
disease,  and  was  frequently  present  throughout  the  course 
of  the  disease,  especially  at  night.  The  eruption  was  at 
first  macular,  but  by  the  ninth  day  it  became  petechial. 
The  countenance  was  dull  and  dusky,  and  the  eyes  were 
congested.  The  spleen  was  enlarged  throughout  the 
course  of  the  disease.  There  were  signs  of  obstruction 
of  the  dorsalis  pedis  artery  two  days  before  death.  At 
the  autopsy  it  was  noted  that  he  was  extremely  emaci- 
ated, and  that  rigor  mortis  was  well  marked.  The  toes 
of  the  left  foot  were  of  a  pinkish-red  color,  owing  to  the 
obstruction  of  the  artery.  The  serous  membranes  were 
all  normal.  The  heart  was  distended  with  post-mortem 
clots.  Attached  to  the  inner  surface  of  the  lower  half 
of  the  anterior  wall  of  the  left  ventricle  were  many  firm 
grayish  ante-mortem  clots,  forming  a  mass  about  the  size 
of  a  hen's  egg.  The  ventricular  wall  corresponding  to 
the  attachment  of  these  thrombi  was  only  1  ctm.  in  thick- 
ness, while  at  the  base  it  was  2  ctm.  thick.  There  seemed 
to  be  no  explanation  for  these  variations  in  thickness  of 
the  wall.  The  muscular  substance  was  pale  and  moder- 
ately soft.  The  valves  were  all  normal.  No  ante-mortem 
clots  were  found  in  the  heart,  except  in  the  left  ventricle. 
The  coronary  arteries  and  aorta  were  very  slightly  ather- 
omatous. The  lungs  showed  marked  bronchitis,  but  no 
thrombi  or  infarctions.  The  spleen  was  about  four  times 
its  normal  size,  was  of  a  dark-red  color,  and  contained  an 
infarction  in  the  posterior  portion,  4  ctm.  in  diameter, 
and  two  others  in  the  anterior  portion,  somewhat  smaller. 
The  mesenteric  glands  were  distinctly  enlarged,  measur- 
ing itoi^  ctm.  in  diameter.  The  kidneys  were  exces- 
sively anaemic,  and  their  parenchyma  degenerated.  In 
the  left  one  was  an  infarction,  4  ctm.  in  diameter.    The 


156 


MEDICAL    RECORD. 


[August  4,  1894 


liver  was  soft  and  pale.  The  mucous  membrane  of  the 
whole  ileum  was  moderately  congested  ;  Peyer's  patches 
were  unusually  distinct,  with  a  finely  granular  surface ; 
some  of  them  were  slightly  elevated  and  presented  a  few 
points  of  superficial  ulceration,  two  to  three  mm.  in 
diameter.  The  colon  appeared  to  be  normal.  The 
brain  showed  marked  atrophy  of  the  convolutions,  with 
corresponding  increase  of  the  fluid  in  the  pia. 

The  cause  of  death  in  this  case  appeared  to  be  a  car- 
diac thrombus  with  resulting  multiple  embolism  occur- 
ring as  a  complication  of  some  acute  infectious  disease. 
It  was  diagnosticated  clinically  as  typhus  fever.  The 
speaker  said  he  thought  the  lesions  pointed  rather  to  ty- 
phoid than  to  typhus.  The  points  in  favor  of  typhoid 
fever  were,  first,  the  distinct  enlargement  of  the  mesen- 
teric glands,  which  were  not  usually  enlarged  in  typhus 
fever ;  and  secondly,  the  distinct  but  slight  lesion  of  Pey- 
er's patches.  There  was  no  characteristic  lesion  of  these 
patches,  unless  possibly  the  "  shaven  beard  "  appearance. 
Regarding  the  case  as  one  of  typhoid  fever,  it  would  be 
in  the  fourth  week  at  least.  The  most  reliable  statistics 
placed  the  average  duration  of  typhoid  fever  at  twenty- 
four  to  twenty  eight  days.  In  the  fourth  week,  therefore, 
if  the  disease  had  progressed  favorably,  one  would  expect 
to  find  varying  degrees  of  healing  of  the  ulcerated  Pey- 
er's patches,  and  this  seemed  to  be  the  condition  in  the 
specimens  presented. 

In  this  connection  the  speaker  presented  specimens 
from  a  recognized  case  of  typhoid  fever  on  the  twenty- 
third  day  of  the  attack.  The  patient  was  a  male, 
thirty- five  years  of  age,  in  whom  the  disease  ran  a  per- 
fectly characteristic  course  for  four  weeks.  The  tempera- 
ture remained  nearly  at  the  normal  for  about  three  days ; 
then  it  rose  again  and  continued  high  for  twenty-three 
days,  when  he  died  of  multiple  pulmonary  thrombi  with 
infarctions.  The  autopsy  in  this  case  showed  the  heart 
considerably  dilated  and  flabby,  without  thrombi.  There 
was  an  infarction  in  the  anterior  border  of  the  right  base, 
about  one  inch  in  diameter,  and  four  smaller  ones  in  the 
left  lower  lobe.  In  addition  there  were  many  thrombi  of 
the  size  of  a  split  pea  in  both  lungs,  at  the  bifurcation  of 
the  pulmonary  arteries.  They  encroached  only  moder- 
ately on  the  lumen  of  the  vessels.  The  spleen  was  twice 
the  normal  size,  of  a  deep  red  color,  and  moderately 
soft.  The  mesenteric  glands  were  moderately  enlarged. 
The  kidneys  showed  parenchymatous  degeneration.  The 
liver  was  soft  and  pale.  The  intestines  were  heavily 
coated  with  mucus,  but  appeared  otherwise  normal,  ex- 
cept in  the  lower  portion  of  the  ileum,  where  the  Peyer's 
patches  were  slightly  pigmented  and  presented  a  finely 
granular  surface.  The  colon  showed  a  few  pigmented 
points,  probably  healed  ulcerations,  and  a  few  superficial 
ulcerations  not  yet  healed. 

The  pathological  conditions  in  these  two  cases  were 
very  similar,  yet  the  clinical  history  of  the  first  case  re- 
sembled that  of  typhus,  while  that  of  the  second  case  cor- 
responded with  that  of  typhoid  fever.  In  the  first  case 
death  occurred  about  the  beginning  of  the  fourth  week, 
or  possibly  later;  in  the  second  case  death  occurred 
at  the  beginning  of  the  fourth  week  of  the  relapse.  In 
both  the  intestines  have  evidence  of  lesions  of  Peyer's 
patches  undergoing  repair,  and  also  of  a  slight  enlarge- 
ment of  the  mesenteric  glands,  and  decided  enlargement 
of  the  spleen.  The  cultures  from  the  spleen  in  the  first 
case  developed  nothing  which  could  be  regarded  as  at  all 
characteristic  of  typhoid ;  in  the  second  case  cultures 
were  not  made. 

Sarcoma  of  the  Faoe. — Dr.  J.  E.  Weeks  presented 
this.  Tumor  was  removed  from  the  face  of  a  man  aged 
sixty  five.  About  thirty  years  ago  he  had  noticed  a  small 
tumor  on  the  side  of  the  nose,  which,  after  some  years, 
presented  a  small  ulceration.  This  tumor  was  removed 
in  1870.  About  twelve  years  later,  the  cicatrix  became 
congested  and  the  tumor  recurred.  The  patient  then 
came  under  the  care  of  Dr.  Derby,  who  found  the  growth 
on  the  left  side  of  the  bridge  of  the  nose,  near  the  inner 
canthus,  adherent  to  the  subjacent  tissue,  and  separated 


from  the  canthus  by  a  half- inch  strip  of  healthy  skin.  It 
was  nodular,  irregular,  and  elevated,  and  on  removal  ex- 
posed a  bleeding  surface.  There  was  no  enlargement  of 
the  pre*  auricular  gland  on  that  side.  The  tumor  was  re- 
ferred to  the  speaker  for  examination.  The  posterior  sur- 
face of  the  tumor  was  covered  with  degenerated  epithe- 
lium, and  consisted  chiefly  of  irregularly  cylindrical  and 
club-shaped  hyaline,  homogeneous  masses,  which  took 
eosin  stain  like  connective  tissue.  There  were  small  col- 
lections of  epithelial  cells  between  the  hyaline  cylinders, 
which  penetrated  to  a  considerable  depth.  Pymphoid 
cells  were  quite  numerous,  and  in  some  places  were  seen 
in  the  centre  of  the  hyaline  masses.  There  was  a  scanty 
connective-tissue  framework  in  nearly  all  parts  of  the 
growth.  The  blood-vessels  were  not  found  in  the  centres 
of  the  hyaline  masses,  but  were  quite  plentiful  on  the 
periphery.  The  walls  of  the  arteries  in  the  centre  of  the 
hyaline  masses  were  thickened  and  degenerated,  and 
there  were  extensive  extravasations  of  red  corpuscles  and 
blood  pigment  throughout  the  growth,  indicating  pro- 
found vascular  changes.  This  form  of  tumor,  the  speaker 
said,  had  been  classified  as  sarcoma.  Billroth  described 
a  similar  tumor  in  1866,  which  he  termed  a  "cylin- 
droma. ' '  This  variety  of  new-  growth  was  most  frequently 
met  with  on  the  face,  although  it  had  been  found  at  the 
margin  of  the  anus.  Out  of  twenty-four  tumors  collected, 
fourteen  were  from  the  mesoblastic  elements,  and  ten 
from  epiblastic  elements.  The  hyaline  masses  probably* 
resulted  from  the  degeneration  of  mesoblastic  tissue. 
The  term  cylindroma  should  only  be  employed  as  an  ad- 
jective. 

An  Astragalus. — Dr.  R.  H.  Sayre  presented  an  as- 
tragalus from  a  case  of  club  foot.  The  specimen  had 
been  removed  by  operation  from  a  patient,  aged  twenty- 
six,  with  very  exaggerared  talipes  varo-equinus.  After 
extensive  incision  of  the  soft  parts  on  the  inner  side  of 
the  foot,  he  was  unable,  after  reducing  the  varus,  to  get 
rid  of  the  equinus ;  hence,  the  astragalus  was  enucleated. 
This  bone  presented  a  very  different  appearance  from  the 
normal  astragalus.  Its  superior  articular  surface  was  not 
more  than  one  third  the  usual  size ;  the  body  of  the  bone 
was  almost  completely  absent ;  the  neck  was  much  twisted 
inward  and  the  surface  which  should  articulate  with  the 
scaphoid  was  much  altered.  The  astragalus  was  bent 
downward  on  itself  at  a  very  sharp  angle.  The  larger 
part  of  it  was  entirely  free  from  articulation  with  the 
bones  of  the  leg.  After  removing  it,  it  was  found  that 
the  os  calcis  was  bent  inward  at  an  angle  of  about  45  °,  so 
that  it  was  necessary  to  remove  a  V-shaped  section  from 
the  outside  of  the  os  calcis  in  order  to  efface  this  curve. 
In  these  old  club-feet  it  was  usual  to  find  more  or  less 
distortion  of  the  bones.  This  was  about  the  first  astraga- 
lus that  he  had  felt  compelled  to  remove  in  an  adult  in 
order  to  reduce  the  deformity,  but  the  great  alteration  in 
the  bone  seemed  to  fully  justify  this  procedure.  No 
more  convincing  proof  could  be  given  of  the  importance 
of  overcoming  the  deformity  in  club-foot  while  the  bones 
were  still  flexible. 

Abscess  of  the  Liver. — Dr.  J.  S.  Thacher  presented 
specimens  from  a  case  of  abscess  of  the  liver.  The  man 
was  operated  upon  six  years  ago,  in  Egypt,  for  abscess  of 
the  liver  following  an  attack  of  diarrhoea.  After  wearing 
a  drainage-tube  for  ten  months,  he  recovered  completely, 
and  according  to  his  statement,  remained  well  for  five 
years.  He  entered  the  hospital  last  fall  complaining  of 
diarrhoea  and  some  abdominal  pain.  There  were  a  few 
streaks  of  blood  in  the  faeces,  and  he  had  also  the  symp- 
toms and  urinary  signs  of  nephritis.  The  liver  showed  a 
distinct  enlargement  and  increased  hardness.  He  left 
the  hospital  after  a  few  weeks,  and  did  not  return  until 
ten  days  ago.  When  readmitted,  the  left  lobe  of  the 
liver  was  found  extremely  prominent — a  large,  inegular 
mass  projecting  in  the  epigastrium.  The  right  lobe  of 
the  liver  was  less  prominent  and  softer,  but  was  not 
easily  palpated  on  account  of  ascites.  He  had  been 
twice  tapped  for  ascites.  He  was  tapped  again  in  the 
hospital,  and  the  fluid  on  examination  showed  a  few 


August  4,  1894] 


MEDICAL  RECORD. 


157 


"  budding  cells."  At  the  autopsy  it  was  found  that  the 
part  of  the  liver  which  had  formed  the  tumor  was  not 
that  which  was  most  diseased;  it  was  waxy,  degenerated, 
and  hypertrophied.  The  right  lobe  of  the  liver  was 
deeply  excavated  by  an  enormous  abscess.  The  spleen 
and  kidneys  alio  showed  waxy  degeneration.  The  fact 
that  he  had  been  operated  upon  before  for  abscess  of  the 
liver,  and  that  there  had  been  no  elevation  of  tempera- 
ture in  spite  of  the  large  abscess,  were  the  most  interest- 
ing features. 

Cerebro-spinal  Meningitis. — Dr.  F.  Ferguson  pre- 
sented the  brain  from  a  case  of  cerebro-spinal  meningitis. 
It  was  removed  from  a  man,  thirty- four  years  of  age,  who 
was  admitted  to  the  New  York  Hospital  on  February  5, 
1894.     He  was  found  unconscious  in  the  street,  and  was 
brought  to  the  hospital  in  an  ambulance.     On  admission 
he  was  so  extremely  drowsy  that  it  was  impossible  to  get 
from  him  a  satisfactory  history.     He  stated  that  for  two 
past  weeks  he  had  suffered  from  headache  and  general 
pains,  and  that  the  illness  began  with  chills,  vomiting, 
fever,  and  cough.     He  also  seemed  to  have  some  pain  in 
his  chest.     The  expectoration  was  blood  stained,  and  ac- 
cording to  his  statement  had  been  so  for  two  days.     The 
slightest  touch  appeared  to  cause  him  the  greatest  pain. 
The  temperature  was  102. 40  F.  \  respirations,  36;  and 
pulse,  92.     Physical  examination  disclosed  a  soft  systolic 
murmur  over  the  heart  apex,  but  otherwise  the  thoracic  ex- 
•  animation  was  negative.     His  pulse  was  slow,  regular,  and 
of  good  tension,  with  corresponding  heart  action.    Exami- 
nation of  liver,  spleen,  and  abdomen  was  negative.     He 
was  anaemic,  but  well  nourished.    His  urine  had  a  specific 
gravity  of  1.022  ;  it  contained  no  albumin  or  sugar,  and 
microscopical  examination  was  negative.      The  pupils 
were  contracted.     On  the  day  of  admission  he  had  a 
convulsion  at  4  p.m.,  and  at  this  time  eighteen  ounces  of 
urine  were  drawn  by  catheter.    He  was  restless  and  noisy 
all  night.     The  following  day  he  complained  of  head- 
ache.    The  head  was  shaved  and  an  ice-cap  applied  con- 
tinuously.   The  attending  physician,  Dr.  G.  L.  Peabody, 
made  a  diagnosis  of  meningitis.     He  was  treated  with 
large  doses  of  sodium  iodide.    The  temperature  remained 
at  1020  F.,  while  the  pulse  varied  from  92  to  102,  and  the 
respirations  from  28  to  40.     On  February  7  th  his  temper- 
ature fell  one  degree  in  the  morning,  but  rose  in  the  even- 
ing to  1040  F.,  the  pulse  being  100,  and  the  respirations 
32  per  minute.     He  was  so  noisy  and  restless  that  night 
that  morphine  was  given,  and  on  the  following  day  he 
was  still  restless  and  was  tearing  the  clothing,  although 
unconscious.     At  5  p.m.  his  temperature  was  103. 8°  F. ; 
pulse,  106 ;  respirations,  28,  and  shortly  after  eight  o'clock 
he  died.     At  the  autopsy  both  the  right  and  left  ventri- 
cles were  found  slightly  dilated,  and  the  cardiac  muscle 
was  anaemic.     The  lungs  were  congested  and  contained 
numerous  punctate  hemorrhages  in  the  most  dependent 
parts.     With  the  exception   of  the  spleen,  which  was 
rather  large  and  soft,  the  thoracic  and  abdominal  organs 
presented  pothing  of  special  interest.     On  removing  the 
calvarium  the  dura  mater  was  found  congested  and  firmly 
adherent  to  the  skull  over  the  left  cribriform  plate. 
While  the  meningitis  in  this  location  appeared  older,  ex- 
tension upward  through  the  cribriform  bone  and  dura 
could  not  be  recognized.     The  pia  mater  everywhere 
contained  pus  and  lymph,  which,  however,  were  more 
abundant  over  the  vertex  of  both  hemispheres,  and  over 
the  posterior  surface  of  the  cord  in  the  lumbar  region. 
The  fourth  ventricle  also  contained  pus.    On  microscopi- 
cal examination  of  the  brain  the  pia  mater  everywhere 
was  found  to  be  the  seat  of  intense  inflammation,  with 
great  hyperemia  and  numerous  punctate  hemorrhages. 
On  following  the  vessels  through  the  cortex  they  were 
found  to  be  the  seat  of  innumerable  small  round  cells, 
some  of  them  apparently  in  the  walls  of  the  vessels,  and 
some  in  the  perivascular  spaces.     Adjacent  to  the  dura 
the  cortex  of  the  brain  in  places  was  infiltrated  with  an 
unusual  number  of  small  round  cells,  especially  at  the 
base  of  the  left  frontal  lobe,  where,  over  an  area  of  nearly 
two  centimetres  in  diameter,  the  entire  cortex  of  the 


brain  was  infiltrated  with  pus.  Over  this  area  the  dura 
mater  was  also  extensively  involved.  Collections  of 
small  round  cells  were  also  found  in  limited  areas  along 
its  external  surface.  Examination  of  the  cribriform  plate 
and  the  ethmoidal  sinuses  failed  to  show  any  lesion  be- 
yond intense  hyperaemia.  Bacteriological  examination 
of  sections  revealed  numerous  diplococci,  identical  with 
the  micrococcus  pneumonia  crouposce.  The  speaker  ex 
hibited  culture- tubes  showing  the  characteristic  develop- 
ment of  these  organisms,  anti  also  microscopical  slides. 
He  stated  that  pure  cultures  of  these  organisms  had  been 
taken  from  several  parts  of  the  brain  and  spinal  cord. 
In  the  vast  majority  of  cases  of  cerebro-spinal  meningitis 
examined  by  him  during  tne  past  three  years  this  micro- 
organism had  been  found. 

Acetabular  Form  of  Hip  disease. — Dr.  V.   P.  Gib- 
ney  presented  a    specimen  illustration.      It  was  taken 
from  a  boy  who  was  eight  years  of  age  at  the  time  he 
was  first  admitted  to  the  hospital,  on  January  9,  1889. 
He  had  already  been  treated  for  hip-disease  three  years, 
and  had  worn  a  protection  splint  for  one  year.     On  ad- 
mission there  was  an  immense  abscess  on  the  outer  aspect 
of  the  thigh.     The  inguinal  glands  were  much  enlarged. 
There  was  a  range  of  motion  over  35 °  or  400.     Two 
days  later  the  abscess  was  incised  under  ether,  and  on 
January  26th  another  sac  was  incised.     In  June,  of  1890, 
the  sinuses,  three  in    number,  were  still  discharging. 
They  were  curetted  under  cocaine,  and  this  was  repeated 
on  January  6,  1891.     He  was  discharged  from  the  hos- 
pital shortly  afterward.     At  this  time  the  sinuses  were 
discharging  very  slightly,  the  limb  was  in  good  position, 
and  he  was  still  wearing  a  brace.     On  January  29th  of  the 
same  year  he  was  readmitted  with  the  sinuses  discharging 
very  freely.     Shortly  after  this  an  abscess  was  opened, 
and  from  this  time  until  October  the  sinuses  were  cu- 
retted several  times.     During  the  month  of  October  he 
was  etherized,  and  the  sinuses  on  the  inner  and  upper 
third  of  the  thigh  were  found  to  communicate  with  a  si- 
nus in  the  inguinal  region  above  Poupart's  ligament. 
Tents  were  drawn  through  and  through.     There  was  no 
question  then  about  the  acetabulum  being  perforated. 
Up  to  April,  1893,  these  sinuses  had  variable  discharges, 
and  were  occasionally  curetted.      The  boy  spent  that 
summer  in  the  country,  and  on  his  return  in  the  fall  the 
discharge  from  the  sinuses  was  very  slight.     Early  in  De- 
cember, 1893,  one  ^nus  remaining  above  Poupart's  lig- 
ament was  curetted,  and  the  ilium  found  necrotic.     A 
large  drainage  tube  was  inserted.    The  sinus  was  scraped 
thoroughly  and  a  shell  of  bone  removed.     The  operation 
was  followed  by  high  fever  and  much  pain,  and  a  few 
days  later  an  abscess  formed  at  the  back  of  the  ilium. 
The  boy  died  of  tubercular  pneumonia,  and  the  autopsy 
was  made  by  Dr.  H.  S.  Stearns,  on  January  24,  1894. 
The  base  of  the  left  lung  was  found  to  be  full  of  tuber- 
cular nodules  the  size  of  a  pea.     The  apex  was  oedema - 
tons,  the  remaining  portion  consolidated.      The  whole 
lower  half  showed  a  fairly  intense  pleurisy  with  a  fibrin- 
ous deposit  and  two  ounces  of  pus.      The  left  lung 
showed  a  few  recent  adhesions  behind  a  large  tubercular 
cavity  in  the  lower  part  of  the  lung,  with  trabecular  run- 
ning through  and  through,  and  also  three  or  four  tuber- 
cular deposits  at   the  apex  just  undergoing   softening. 
The  kidneys  were  slightly  enlarged,  nodular  on  the  sur- 
face, with  non-adherent  capsules,  and  markings  distinct. 
The  stomach  and  intestine  were  normal.    The  spleen 
was  decidedly  enlarged,  and  contained  nodular  tuber- 
cles.    The  liver  was  very  much  enlarged,  weighing  four 
and  three  quarter  pounds,  and  was  lardaceous.     The  peri- 
toneal cavity  contained  three  or  four  ounces  of  pus.   The 
specimen  itself  showed  no  disease  in  the  head,  neck,  or 
shaft.     At  the  time  of  section  the  trochanter  itself  pre- 
sented a  normal  appearance,  but  the    acetabulum    was 
broken  down  throughout  the  upper  portion,  and  there  was 
a  large  hole  into  the  pelvis. 


Dengue. — An  epidemic  of  dengue  is  raging  in  Jeddah 
among  the  pilgrims  recently  returned  from  Mecca. 


158 


MEDICAL    RECORD. 


[August  4,  1894 


OUR  LONDON  LETTER. 

(From  our  Special  Correspondent.) 

<X)LLEGE  POLITICS — COMING  ELECTION  AT  COLLEGE  OF  SUR- 
GEONS— RIGHTS  AND  ASPIRATIONS  OF  FELLOWS — WANT 
OF  RIGHTS  OF  MEMBERS — PROPOSED  NEW  CHARTER — DE- 
FENCE OF  MR.  ANDERSONJs  CASE — LAWRIE,  OF  HYDERA- 
BAD IN  ENGLAND — SPECIAL  MEETING  TO  HEAR  HIM — 
QUAIN'S  DICTIONARY — SPREAD  OF  SMALL-POX. 

London,  June  93, 1894. 

"  College  politics/1  as  affairs  connected  with  the  Royal 
College  of  Surgeons  are  commonly  called,  are  just  now  to 
the  fore.  By  the  way,  I  do  not  know  why  one  particular 
college  should  thus  be  spoken  of,  unless  that  the  members 
are  so  numerous  that  the  fellows  may  fancy  that  the  con- 
cerns of  their  smaller  number  interest  the  latter.  They 
do,  indeed,  but  in  a  different  sense.  The  fellows  have  the 
election  of  the  council  and  desire  further  rights.  An 
election  is  just  at  hand  for  three  seats  on  the  council,  and 
there  are  five  candidates.  This  is  the  reason  college  mat- 
ters are  the  subject  of  the  week.  The  members  have  no 
voice  in  this  or  any  other  college  affair,  and"  therefore 
are  only  interested  in  candidates  on  personal  grounds. 
Although  many  questions  arise,  and  there  is  some  expec- 
tation of  a  new  charter  being  applied  for,  it  must  be  con- 
fessed that  the  interest  evinced  in  the  election  is  rather 
languid.  One  candidate,  supported  by  the  association  of 
fellows,  actually  neglected  to  send  in  his  papers  in  due 
time  and  is  therefore  ineligible.  Another  claims  sup- 
port because  he  lives  in  a  provincial  city.  Another  as 
the  senior  fellow.  Another  is  supported  by  the  new 
society  of  fellows,  which  has  no  programme  and  appar- 
ently no  raison  d'Strt.  When  the  few  hundred  fellows 
admit  the  members  to  their  rights,  every  college  matter 
will  interest  the  whole  profession.  Then  a  new  charter 
may  be  of  some  value.  Anent  the  present  position,  the 
association  of  fellows  has  passed  a  resolution  that  "such 
changes  as  the  body  of  fellows  may  desire  should  be  em- 
bodied in  a  new  charter."  Not  a  word  about  what  mem- 
bers may  desire. 

Before  leaving  the  college  I  may  mention  that  the 
council  at  the  last  meeting  appointed  two  of  their  number 
to  represent  the  college  on  a  committee  that  has  been 
formed  to  carry  the  case  of  Mr.  Anderson  before  the 
Judicial  Committee  of  the  Privy  Council.  Important 
civil  rights  are  involved,  and  Mr.  Anderson  has  been 
fighting  the  cause  of  the  profession  as  well  as  defending 
himself 

Surgeon  Lieutenant  Colonel  Lawrie  has  come  from 
Hyderabad  to  still  further  demonstrate  the  results  of  the 
Chloroform  Commission,  which  is  due  to  his  labors. 
He  has  already  appeared  at  one  or  two  of  our  hospitals 
and  been  received  with  the  cordiality  his  work  deserves. 
Further,  it  has  been  arranged  to  hold  an  extra  meeting  of 
the  Royal  Medical  and  Chirurgical  Society  on  July  3d 
for  the  express  purpose  of  hearing  Dr.  Lawrie,  who  will 
endeavor  to  show  that  chloroform  has  no  effect  upon  the 
heart,  and  that  it  is  useless  to  watch  the  pulse  during  the 
administration  of  the  anaesthetic.  Lawrie's  views  are, 
of  course,  well  known,  but  it  will  be  very  interesting  to 
hear  them  from  a  man  of  such  striking  personality,  be- 
sides which  we  may  expect  an  adequate  discussion  when 
our  premier  society  holds  an  extra  meeting  after  the  con- 
clusion of  the  session  for  the  purpose  of  hearing  Sur- 
geon Lieutenant- Colonel  Lawrie. 

A  second  edition  of  "Quain's  Dictionary  of  Medi- 
cine "  was  issued  on  Monday.  This  valuable  work  of 
reference — which  is  so  well  known — first  appeared  nearly 
twelve  years  ago  and  speedily  achieved  success.  Many 
changes  have  taken  place  in  these  twelve  years.  The 
death  of  some  of  the  contributors  has  necessitated  their 
share  of  the  work  being  entrusted  to  others.  A  number 
of  new  articles  are  also  inserted,  among  which  I  may  in- 
stance Greenfield,  on  Microbes;  Sidney  Martin,  on  Im- 


munity and  Phagocytosis;  and  P.  Manson,  on  Negro 
Lethargy.  The  last  named  has  also  revised  his  article 
on  Filaria  Sanguinis  Hominis.  The  rapid  progress  ot 
knowledge  and  the  changing  way  of  regarding  some 
facts  has  in  fact  rendered  revision  necessary  on  the  part 
of  most  of  the  writers  of  the  first  edition,  and  their 
authority  is  perhaps  a  sufficient  guarantee  that  they  have 
done  this  work  carefully.  I  note,  however,  that  the 
venerable  editor  declares  himself  still "  personally  respon- 
sible for  the  work,  of  which  no  portion  has  been  issued 
without  being  carefully  revised  by  him.11  Really,  there- 
fore, Sir  R.  Quain  may  claim  to  be  a  very  industrious 
editor,  for  many  of  the  articles  are  by  the  foremost 
authorities,  and  can  receive  no  additional  importance 
from  any  reviser,  and  the  reading  of  the  two  volumes,  in 
which  the  work  now  appears,  comprising  2,500  pages,  is  a 
task  which  few  aged  physicians  would  care  to  undertake. 
The  spread  of  small-pox  continues  to  create  anxiety 
on  the  part  of  sanitary  authorities.  A  number  of  pro- 
vincial towns  have  suffered,  and  in  not  a  few  cases  the 
disease  has  been  brought  by  tramps,  and  where  vaccina- 
tion has  been  neglected  the  consequences  have  been  such 
as  were  anticipated  by  medical  men. 


RELIABILITY   OF    STATISTICS. 

To  the  Editor  or  the  Medical  Record. 

Sir  :  Dr.  Carl  Beck,  in  his  letter  in  the  Medical  Record 
of  July  2 1  st,  has  very  cleverly  ignored  everything  charged 
against  him,  except  the  date  of  the  recovery  of  the  child 
reported  as  Case  IX.  In  this  matter  he  convicts  himself 
of  inaccuracy,  for  the  dates  he  gives  do  not  not  agree 
with  each  other,  or  with  the  time  mentioned  in  his  pub- 
lished history  of  the  case.  The  history  I  gave  for  Dr. 
Beck's  information  was  obtained  from  the  mother,  who 
nursed  her  child  through  a  serious  illness,  and  must  be 
presumed  to  know  the  time  of  recovery  with  more  cer- 
tainty than  the  father.  Indeed,  even  the  medical  at. 
tendants  seem  to  have  obtained  their  revised  history  from 
her.  In  proof  of  this,  and  to  show  how  little  the  father 
remembered  of  the  particulars,  I  may  quote  from  a  clip- 
ping of  a  letter  from  Dr.  Voegtle,  dated  June  28  and  30, 
1894,  which  Dr.  Beck  sent  me  in  explanation  of  his  ina- 
bility to  give  me  a  few  facts  about  this  case.  Dr.  Voegtle 
writes,  evidently  in  answer  to  a  request  of  Dr.  Beck  to 
obtain  these  facts :  "  Will  attend  to  it  in  the  next  few 
days ;  was  there,  the  wife  is  in  the  country,  and  the  hus- 
band himself  knows  nothing  definitely  about  it." 

As  to  the  relative  merits  of  exsection  and  incision,  of 
what  value  is  Case  IX.  when  I  have  proved  it  to  be  one 
of  resection  following  an  exsection  ? 

Again,  what  value  can  be  ascribed  to  Dr.  Beck's  sta- 
tistics on  exsection  when  they  are  based  on  cases,  among 
which,  as  I  have  shown,  are  some  in  which  no  exsection 
was  performed  ?  Therefore  I  repeat :  Statistics  in  order 
to  be  valuable  should  be,  as  to  their  material  facts,  cor- 
rect. Arnot  Spence,  M.D. 

July  37,  1894.  

TRANSPORTATION  OF  THE  INSANE  TO  HOS- 
PITALS. 

To  the  Editor  of  the  Medical  Record. 

Sir:  In  the  Medical  Record  of  July  21st,  page  76,  in 
regard  to  the  "  Transportation  of  the  Insane  to  Hospi- 
tals," you  say,  "  those  in  charge  of  our  public  hospitals 
have  absolutely  nothing  to  do  with  the  manner  in  which 
patients  are  brought  to  them."  You  are  mistaken  so  far 
as  New  York  State  is  concerned.  It  is  the  practice  for 
the  Superintendent  of  the  Poor  of  the  County  to  notify 
the  asylum  authorities,  and  they  send  attendants  to  take 
the  lunatic  to  the  asylum.  It  is  very  exceptional  in  this 
county  for  private  persons  to  take  lunatics  to  the  hospi- 
tal. I  think  the  rules  of  the  Lunacy  Commissioners  re- 
quire the  insane  to  be  taken  by  their  own  attendants  on 
notice  to  the  hospital  authorities. 

A.  D.  Kennedy. 

Morris ville,  N.  Y.,  July  23,  1894. 


August  4,  1894] 


MEDICAL    RECORD. 


159 


fjfredical  %tems. 

Contagions  Diseases  — Weekly  Statement.— Report  of 
cases  and  deaths  from  contagious  diseases  reported  to  the 
Sanitary  Bureau,  Health  Department,  for  the  week  end- 
ing July  28,  1894. 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Oerebro-spinal  meningitis 

Measles 

Diphtheria 

Small-pox 


Cases, 


9* 

21 

38 

I 

4a 

163 

3 


Deaths. 


1x2 
12 

4 
3 
5 


A  Varied  Diet — An  inquest  was  held  in  London,  not 
long  ago,  on  the  body  of  a  man  who  had  died  suddenly. 
The  man  used  to  make  his  living  by  going  about  to  the 
different  "  pubs  "  in  the  evening,  and  eating  anything 
that  was  offered  him,  for  a  small  monetary  consideration. 
He  died  after  an  operation  for  intestinal  obstruction, 
and  at  the  autopsy  the  following  articles  were  found 
lodged  in  various  portions  of  the  digestive  tube :  A  bul- 
let, twenty  or  thirty  pieces  of  cork,  twenty  pieces  of  tin- 
foil, a  piece  of  string  eighteen  inches  long,  with  coiks 
attached,  and  a  piece  of  leather  nine  inches  long,  with 
a  hook  at  each  end. 

In  Memoriam. — Dr.  Samuel  T.  Hubbard,  the  last  sur- 
vivor of  the  original  members  of  the  New  York  Society 
for  the  Relief  of  Widows  and  Orphans  of  Medical  Men. 

At  a  meeting  of  the  Board  of  Managers  of  the  New 
York  Society  for  the  Relief  of  Widows  and  Orphans  of 
Medical  Men,  the  following  remarks  were  read  by  Dr. 
Andrew  F.  Currier.  On  motion  of  Dr.  Charles  A.  Leale 
they  were  ordered  entered  on  the  minutes  of  the  Board. 
It  was  also  ordered  that  a  sufficient  number  of  copies  be 
printed  and  sent  to  Dr.  Hubbard's  family,  to  the  medi- 
cal journals  of  the  city  for  publication,  and  to  the  mem- 
bers of  the  Society.  It  was  also  ordered  that  they  be 
incorporated  in  the  annual  report  of  the  Society: 
"Died,  June  1,  1894,  Dr.  Samuel  T.  Hubbard,  at  the 
age  of  eighty  six.  This  is  the  last  link  which  bound  us 
to  the  founders  of  this  Society.  Of  the  original  mem- 
bers whose  names  appear  on  the  list  for  1842,  all  are  gone 
now ;  the  last  leaf  has  fallen  from  the  tree.  The  fathers 
are  no  longer  with  us,  they  are  but  a  memory,  a  remi- 
niscence. '  The  king  is  dead,  long  live  the  king ! '  Dr. 
Hubbard  was  our  Nestor,  and  I  do  not  see  how  one 
could  have  been  very  long  in  his  presence  without  being 
strongly  attracted  by  his  most  lovable  personality.  It 
was  not  the  attraction  of  a  weak  old  age,  it  was  not  the 
attraction  of  an  overpowering  intellectuality.  No,  his 
was  the  vigor  of  the  rugged  oak  which  is  in  its  prime 
when  other  trees  around  it  are  decaying,  or  of  the  stanch 
old  ship  with  timbers  sound  and  spars  unbending  after 
many  a  storm,  being  made  of  honest  material  through 
and  through.  He  made  you  think  of  Moses,  with  his 
more  than  fourscore  years,  looking  over  into  the  prom- 
ised land,  his  eye  undimmed  and  his  natural  force  un- 
abated, and  from  the  heights  of  his  serene  old  age  I 
doubt  if  one  ever  saw  him  looking  back  to  the  remote 
days  of  the  past,  and  making  comparisons  unfavorable 
to  the  present.  It  would  not  have  been  like  him  to  do 
so,  for  his  life,  so  far  as  I  have  known  it  or  could  ascer- 
tain, was  one  of  charity  and  beauty.  There  is  some- 
thing about  the  physicians  and  surgeons  of  New  York  of 
half  a  century  ago,  a  subtle  quality,  which  it  seems  to 
me  is  not  developed  to  the  same  degree  with  us.  I  do 
not  mean  genius,  though  Mott  and  Parker  and  Kearney 
Rodgers  and  others  of  our  early  confreres  possessed  that. 
It  may  be  that  it  was  strong  common  sense,  or  some- 
thing allied  to  it,  a  power  of  handling  men  and  women 
to  advantage,  a  savoir-faire,  and,  perhaps,  in  our  more 
assiduous  cultivation  of  science  we  have  somewhat  over- 


looked that  important  qualification.  Such  a  quality  our 
dear  friend  possessed  to  a  considerable  degree.  In  the 
meetings  of  our  Society  how  we  shall  miss  him.  He  was 
always  present,  always  prompt  in  his  attendance,  genial 
and  wise  in  discussion,  leaning  toward  the  broadest 
charity  in  the  objects  for  which  our  Society  is  conducted. 
Peace  to  his  ashes  !  His  memory  will  long  be  fragrant 
among  us. 

"  'His  life  was  gentle,  and  the  elements  so  mixed  in 
him,  that  nature  might  stand  up  and  say  to  all  the  world, 
This  was  a  man  ! ' 

A  Centenarian. — A  woman  is  now  living  in  a  Home 
for  the  Aged  in  Sables  d'Olonne,  France,  who  was  born 
in  1 790,  being,  therefore,  one  hundred  and  four  years  of 
age.  She  is  in  full  possession  of  all  her  faculties  and 
receives  daily  a  number  of  visitors,  who  are  attracted  by 
the  reports  of  her  extreme  age,  entertaining  them  with 
her  lively  conversation  and  witty  repartee. 

The  Bieyele  for  Women. — The  bicycle  has  become 
the  fashion  even  for  women,  and  the  following  wise  ad- 
vice should  prove  of  interest  to  physicians.  Dr.  Laura 
Liebhardt,  in  discussing  before  the  Colorado  State  Medi- 
cal Society  the  question  of  bicycle  exercise  for  women, 
declared  that  "the  majority  ride  with  the  saddle  too 
low,"  and  that  this  is  responsible  for  cramping  of  the 
chest,  straining  the  back,  and  impeding  full  action  of 
the  muscles  of  the  leg.  There  results  a  constant  tension 
of  the  muscles  above  the  knee,  which  gives  a  short,  awk- 
ward stroke,  as  the  reach  is  too  short.  The  seat  should 
be  amply  high  for  the  entire  leg  to  be  extended  and  give 
to  these  muscles  a  second  of  relaxation  on  the  downward 
stroke  of  the  pedaL  The  knee  must  have  perfect  free- 
dom, and  in  this  respect  a  woman  finds  herself  particu- 
larly handicapped,  as  she  is  unable  to  make  the  entire 
stroke  with  the  action  of  the  knee  limited  by  a  dress 
skirt.  In  Paris  they  do  not  stop  with  the  unsightly 
bloomers,  but  have  almost  universally  adopted  the  prac- 
tical, yet  far  too  radical,  knickerbockers.  This  striking 
costume  attracts  but  a  passing  notice,  for  the  rationale  of 
it  all  appeals  to  the  French  mind ;  but  as  we  have  fortu- 
nately not  yet  reached  the  Parisian  standard,  it  is  to  be 
hoped  that  knickerbockers  will  confine  themselves  to 
spins  in  the  mountain?.  Wheelwomen  also  subject  them- 
selves to  needless  jars  by  jumping  instead  of  gliding  from 
the  wheel.  They  should  be  taught  to  mount  and  dis- 
mount from  either  side  as  men  are  wont  to  do.  Corsets 
on  the  wheel,  as  elsewhere,  should  be  denounced  in  the 
strongest  terms,  although  nearly  one  half  of  all  wheel- 
women  tie  up  their  muscles  in  this  barbaric  fashion. 
Many  condemn  cycling  on  the  ground  that  the  move- 
ments are  identical  with  those  called  forth  in  running  a 
sewing-machine.  Machine- running  stimulates  more  the 
faulty  way  of  wheeling,  and  the  position  is  almost  iden- 
tical with  that  assumed  when  the  handle-bars  and  saddle 
are  placed  too  low.  In  wheeling  there  are  a  greater  va- 
riety of  movements  and  less  tension.  Two- thirds  of  all 
women  who  ride  wheels  foolishly  incur  great  risks  by 
riding  during  certain  periods,  even  to  the  extent  of  hill 
climbing,  when  they  should  never  mount  a  wheel,  ex- 
cept for  short  distances,  during  the  first  two  days.  Dur- 
ing the  discussion  the  general  opinion  seemed  to  be  that 
the  saddles  in  use  were  hardly  proper.  The  long,  wide 
saddle  suspended  between  springs  was  considered  very 
much  superior  to  the  rigid  or  hard  models.  A  saddle 
much  wider  throughout  was  considered  desirable,  and 
cases  were  quoted  to  substantiate  this  claim. 

Signs  of  Death. — A  correspondent  of  The  Lancet 
writes  that  he  was  called  to  see  an  old  lady  who  was  be- 
lieved to  be  dead,  but  whose  appearance  was  so  lifelike 
that  the  family  dared  not  bury  her  until  they  were  abso- 
lutely certain  that  death  had  actually  occurred.  To 
quiet  their  apprehensions  the  physician  applied  a  series 
of  tests  with  more  or  less  confusing  results.  The  follow- 
ing were  the  tests  in  the  order  in  which  they  were  ap- 
plied :  1,  Heart-sounds  and  pulse — absent ;  2,  respiration 


i6o 


MEDICAL  RECORD. 


[August  4,  1894 


— absent ;  3,  temperature  of  the  body  60  °  F.,  the  same 
as  that  of  the  atmosphere  of  the  room ;  4,  a  needle  left 
for  some  time  in  the  substance  of  biceps  muscle  showed 
no  signs  of  oxidation ;  5,  electricity — no  response  to  elec- 
trical stimulation  of  the  muscles ;  6,  a  ligature  tied  about 
the  arm  caused  no  swelling  of  the  veins  below  ;  7,  upon 
opening  a  vein  the  blood  was  found  to  be  fluid ;  8,  the 
subcutaneous  injection  of  ammonia  gave  rise  to  a  dirty- 
brown  stain,  said  to  be  indicative  of  commencing  decom- 
position of  the  tissues ;  9,  cautious  movements  of  the 
joints  revealed  a  slight  stiffness  of  rigor  mortis;  10, 
upon  holding  the  hand  up  against  a  powerful  light,  the 
red  line  of  light  between  the  fingers  was  as  distinct  as  in 
the  case  of  a  living  person;  11,  the  temperature  of  the 
room  was  raised,  and  when  evident  decomposition  had 
set  in  the  woman  was  pronounced  dead. 

Hyperpyrexia. — Dr.  Richet  reports  a  case  of  intermit- 
tent fever  in  a  woman  in  which  the  temperature  rose  one 
day  from  1020  in  the  morning  to  1130  F.  in  the  evening. 
On  two  other  occasions  the  fever  rose  to  1150.  Under 
the  influence  of  quinine  the  temperature  fell  to  970,  but 
rose  again  to  1150  F.,  when  the  remedy  was  discontinued. 
The  patient  finally  recovered. 

Explosive  Compounds. — A  Parisian  lecturer  in  speak- 
ing of  the  dangers  of  polypharmacy  enumerated  explosion 
as  one  of  them.  He  had  collected  several  formulae  of 
this  anarchistic  quality,  among  them  being  a  liniment  of 
tincture  of  iodine  and  turpentine,  another  a  mixture  of 
chromic  acid  and  glycerine,  and  a  third  a  tooth-powder 
composed  of  pulverized  charcoal,  cinchona  bark,  and 
chlorate  of  potassium. 

Diseases  of  the  Eeotum Our  esteemed  friend,  Dr. 

Baudoin,  of  the  Progres  M&dical,  takes  an  interest,  and  a 
very  intelligent  one,  in  medical  matters  in  this  country. 
He  is  doing  a  good  work  in  correcting  some  errors  and 
misapprehensions  concerning  America  which  our  French 
confreres  entertain,  and  deserves  our  gratitude  therefor. 
Some  of  our  customs,  however,  strike  him,  not  unrea-  ' 
sonably,  as  peculiar,  if  not  amusing.  Among^  these  is 
the  multiplication  of  specialties,  in  which  he  thinks  we 
have  gone  ahead  even  of  our  English  cousins.  The  spe- 
cialty of  rectal  diseases  is  one  that  recently  engaged  his 
attention,  and  he  has  very  kindly  attempted  to  provide 
its  professors  with  a  name.  He  thinks  they  might  be 
called  rectists,  after  the  analogy  of  oculist  and  aurist,  or 
better  perhaps,  because  longer  and  more  sonorous,  proc- 
tologists. The  Quarfsrly  Journal  of  Proctology  would 
be  an  excellent  nam6  for  our  esteemed  contemporary  by 
the  Falls  of  the  Ohio. 

The  Hew  French  Medical  Law.— The  new  law  regulat- 
ing the  practice  of  medicine  in  France  came  into  force  on 
December  1st.  As  inquiries  are  frequently  made  as  to 
the  conditions  under  which  foreign  doctors  may  practise 
their  profession  in  France,  the  following  explanation  of 
their  position  under  the  new  law  may  be  of  interest. 
We  give  it  on  the  authority,  and  almost  in  the  words,  of 
the  Journal  des  Connaissances  Mtdicales,  the  editor  of 
which  is  Professor  Cornil,  a  member  of  the  French  Sen- 
ate, who  was  president  of  the  committee  which  drafted 
the  law,  and  who,  in  fact,  may  almost  be  described  as  its 
author.  The  new  law  has  taken  away  the  power  formerly 
possessed  by  the  Government  of  authorizing  medical  men 
having  foreign  diplomas  to  practise  in  France.  Under 
the  new  law  no  one  is  allowed  to  practise  unless  he  pos- 
sesses a  French  diploma  of  doctor  of  medicine.  Certain 
facilities  may,  however,  be  granted,  according  to  the  cir- 
cumstances of  the  case,  to  foreign  doctors  wishing  to  ob 
tain  a  French  diploma.  What  these  are  maybe  gathered 
from  a  circular  letter  which  the  Minister  of  Public  In- 
struction has  lately  addressed  to  the  rectors  of  the  medi- 
cal faculties  throughout  France.  The  periodical  registra- 
tions required  of  French  medical  students  may  be  partly 
or  totally  dispensed  with,  but  exemption  from  examina- 
tion can  never  be  more  than  partial.  In  no  case  shall 
candidates  be  exempt  from   examination  in  more  than 


three  subjects.  Such  exemption  as  may  be  allowed  will 
be  granted  by  the  minister  on  the  advice  of  the  faculty 
of  medicine  before  which  the  candidate  wishes  to  pre- 
sent himself,  and  of  the  Consultative  Committee  of  Pub- 
lic Education*  In  considering  applications  the  faculties 
must  concern  themselves  solely  with  the  value  of  the  di- 
plomas and  scientific  works  submitted  to  them  by  candi- 
dates. The  provisions  apply  to  French  citizens  who 
have  obtained  a  medical  qualification  in  some  other  coun- 
try as  well  as  to  foreigners,  and,  indeed,  the  Minister  in- 
structs the  medical  faculties  to  exercise  special  care  in 
weighing  the  claims  of  Frenchmen  who,  on  the  strength 
of  a  foreign  diploma,  ask  for  exemption  from  part  of  the 
tests  which  are  compulsory  in  the  case  of  their  country- 
men who  go  through  the  ordinary  course  at  home.  The 
course  to  be  pursued  by  an  English  medical  man  who 
wishes  to  practise  his  profession  in  France  is,  therefore, 
to  select  one  of  the  recognized  faculties — Paris,  Montpe- 
lier,  Nancy,  Lyons,  Bordeaux,  Lille,  or  Toulouse — and 
submit  to  it  his  papers  with  whatever  records  of  scientific 
work  or  other  claims  to  professional  recognition  he  may 
possess.  He  will  then  be  informed  in  due  course  what 
examinations  he  must  pass  before  he  is  pronounced  dig- 
nus  entrare  in  nostro  dodo  corpore. — The  British  Medical 
Journal 

A  Swiss  Paper  relates  that  of  the  seven  thousand  physi- 
cians who  attended  the  Medical  Congress  in  Rome,  only 
five  hundred  were  invited  to  the  garden  party  in  the 
grounds  of  the  Quirinal,  while  there  were  present  about 
two  thousand  other  persons,  many  of  whom  had  found  a 
way  to  buy  tickets  at  $10  each. 

Phosphorus  Butter.— Comby  {Prat,  des  MaL  des  Enf, 
1893)  recommends  the  following  prescription,  a  modifi- 
cation of  Trousseau's,  for  the  preparation  of  iodo  phos- 
phorated butter,  which  may  be  used  as  a  substitute  for 
cod  liver  oil  in  hot  weather : 

3 .    Fresh  butter 1  lb.  \\  oz. 

Iodide  of  potassium * gr.  iv. 

Bromide  of  potassium gr.  xv. 

Chloride  of  sodium 3ij. 

Phosphorus gr.  \. 

About  one-third  of  an  ounce  daily,  spread  on  bread. 

Greek  Typewriting. — A  lady  in  Cambridge  announces 
in  the  London  medical  journals  that  she  is  prepared  to 
typewrite  Greek  manuscripts.  She  will  have  plenty  to 
do  when  this  is  adopted  as  the  official  language  of  inter- 
national congresses. 

Insanity  from  Tea  drinking. — In  a  report  upon  in- 
sanity in  Ireland,  recently  issued,  attention  is  called  to 
the  immoderate  use  of  tea  as  a  cause  of  mental  disease 
among  the  poorer  classes.  "  While  the  moderate  use  of 
properly  prepared  tea,"  the  report  states,  "is  regarded 
as  innocuous,  or  even  beneficial,  in  its  action  on  the  ner- 
vous system,  its  ill  effects,  when  decocted  or  over-infused, 
on  persons  who  make  it  their  staple  article  of  dietary, 
are  dwelt  on  by  almost  all  the  resident  medical  super- 
intendents in  their  several  reports.  Undoubtedly,  the 
method  of  preparation  adopted,  and  the  excessive  use  of 
this  article  of  diet,  now  so  general  among  our  poorer 
population,  tends  to  the  production  of  dyspepsia,  which 
in  its  turn  leads  to  states  of  mental  depression  highly 
favorable  to  the  production  of  various  forms  of  neurotic 
disturbance."  The  tea  used  is  generally  of  an  inferior 
quality,  and  the  method  of  preparation  is  to  put  a  quan- 
tity in  the  teapot  early  in  the  morning,  and  to  allow  it 
to  stew  during  the  day,  water  being  added  as  required. 
The  excessive  use  of  tobacco,  also,  especially  among  the 
young,  is  thought  to  contribute  in  a  minor  degree  to 
swell  the  statistics  of  mental  failure. 

A  Hew  Lip. — Dr.  Berger  has  presented  to  the  Paris 
Academy  of  Medicine  a  young  woman  whose  under  lip 
was  restored  by  a  graft  taken  from  the  arm.  The  new 
lip  presented  a  very  natural  appearance,  the  vermilion 
border  being  almost  perfect. 


Medical   Record 

A  IVeekly  yournal  of  Medicine  and  Surgery 


Vol.  46,  No.  6. 
Whole  No.  1240. 


New  York,  August  ii,  1894. 


$12.00  Per  Annum. 
Single  Copies,  10c. 


ftrtgitral  Articles. 

CASES  IN  GENITO-URINARY  SURGERY.1 

I.  Excision  of  the  Bladder  for  Epithelioma.  II. 
Excision  of  Tubercular  Seminal  Vesicles,  Testes, 
and  Spermatic  Cords.  III.  Implantation  of  an 
Artificial  Testis  after  Castration.  IV.  Vesical 
Papilloma  of  Unusual  Duration. 

By  ROBERT  F.  WEIR,  M.D., 
nonssOR  op  sukgbxv,  Columbia  college  ;  surgeon  to  tub  new  vork 

HOSFITAI,  ETC. 

Before  presenting  to  you  the  cases  of  excision  of  the 
bladder,  a  few  prefatory  words  on  the  subject  may,  I 
trust,  be  allowed. 

Tumors  of  the  bladder  of  a  malignant  character  are 
encountered  in  about  eighty  per  cent,  of  neoplasms  of 
this  organ.  Tumors  of  any  kind  are  very  rarely  situated 
at  the  summit  or  on  the  anterior  face  of  the  bladder  or  in 
the  trigone  ;  but  the  region  between  the  summit  and  the 
mouths  of  the  ureter,  and  especially  on  the  posterior  wall, 
is  the  usual  site  of  such  growths.  One-half  of  the  cases 
of  carcinoma,  however,  invade  one  or  both  of  the  ureteral 
orifices.  Secondary  growths  occur  quite  late  in  the  dis- 
ease, though  adjacent  gland  infection  is  not  uncommon ; 
but  the  latter  are  usually  situated  within  surgical  reach. 
The  mortality  involving  the  removal  of  a  carcinomatous 
growth  of  the  bladder  reaches,  according  to  Alberran,  to 
nearly  fifty  per  cent.  The  usual  method  for  removing 
vesical  tumors  has  been,  until  quite  recently,  that  of  expos- 
ing the  growth  by  suprapubic  section  of  the  bladder, 
with  its  subsequent  removal  by  the  knife  or  scissors,  the 
surgical  interference  seldom  going  beyond  the  mucous  or 
muscular  layers  at  the  base  of  the  growth.  Recurrence 
after  this  method  of  operation  amounts  to  fifty-seven  per 
cent  The  method  of  a  more  heroic  operation  was  in- 
augurated first  by  Sonnenberg,  in  1884,  who  then  extir- 
pated nearly  the  entire  bladder,  except  the  neck,  trigone, 
and  ureteral  orifices.  The  patient  survived  five  weeks. 
At  the  autopsy  a  new  but  comparatively  small  bladder, 
formed  of  the  remnant  of  that  organ,  and  a  modified 
cicatricial  tissue  was  found.  A  further  step  in  advance, 
however,  was  made  in  1885,  by  Antal,  who  evolved  a 
procedure  which  has  proved  since  of  great  importance  in 
connection  with  the  surgery  of  this  region  of  the  body. 
It  consisted  in  the  demonstration  that  the  peritoneum 
could  be  peeled  off  from  the  summit  and  posterior  wall 
of  the  bladder  without  very  much  difficulty.  Since  that 
time  a  number  of  cases,  nearly  twenty  in  number,  of  re- 
section of  more  or  less  considerable  portions  of  the  blad- 
der walls  outside  of  the  limits  of  malignant  growths  have 
been  undertaken.  The  benefit  that  accrues  from  this 
wider  removal  of  a  malignant  growth  is  seen  at  once  in 
the  diminished  chances  of  recurrence  after  such  operations. 
From  fifty-seven  per  cent.,  as  already  quoted  as  the 
proportion  of  recurrences  after  the  ordinary  removal,  it 
has  been  diminished  by  this  latter  procedure  to  twenty- 
eight  per  cent.  With  the  encouragement  afforded  by 
this  improvement  in  the  technique  of  the  operation,  sur- 
geons have  been  led  to  undertake  the  removal  of  larger 
and  larger  portions  of  the  bladder,  and  even  total  abla- 
tion of  this  organ  has  been  successfully  undertaken. 
Bardenheur,  in  1887,  removed  the  whole  bladder  in  a  man, 

1  Read  at  a  meeting  of  the  Practitioners*  Society,  held  1894. 


aged  fifty  seven,  for  cancer  of  the  base  that  involved  the 
ureters.  This  was  easily  accomplished,  the  peritoneum 
peeled  off  readily,  though  considerable  hemorrhage  was 
encountered  as  the  neek  of  the  bladder  was  divided. 
This  was  readily  checked  by  tamponing  the  parts. 
Death,  however,  resulted  on  the  fourteenth  day  from 
uraemia.  Two  other  extensive  resections,  though  not 
total  ones,  have  since  been  reported  by  the  same  surgeon, 
one  of  which  has  remained  completely  cured  up  to  the 
date  of  the  last  report,  and  one  died  five  months  later 
from  a  recurrence  of  the  disease. 

The  difficulty  connected  with  such  extreme  operations, 
aside  from  the  immediate  results  of  shock,  etc.,  was 
centred  in  the  disposition  of  the  severed  ureters.  Bar- 
denheur, in  his  experiments  on  animals,  endeavored  to 
solve  the  difficulties  by  implanting  them  into  the  rectum, 
but  in  all  the  animals  experimented  upon  death  resulted 
either  from  dilatation  of  the  ureters,  due  to  the  contrac- 
tion at  the  place  of  implantation,  or  a  fatal  issue  ensued 
in  consequence  of  infectious  pyonephrosis  of  rectal  origin. 
Tuffier,  the  French  experimenter,  also  had  the  same  re- 
sult. Similar  fatal  results  have  occurred  in  the  human 
subject  in  nearly  every  instance  where  this  implantation 
into  the  rectum  has  been  resorted  to.1  In  women,  where 
extirpation  of  the  entire  Madder  has  been  twice  resorted 
to,  the  vagina  has  been  used  as  a  retentive  sac  for  the 
urine  with  some  satisfaction;  but  in  the  male  two  other 
methods  have  been  suggested  that  are  more  worthy  of 
trial.  Le  Dentu,  having  accidentally  wounded  the  ureter 
in  a  gynecological  operation,  brought  its  kidney  end  to 
the  abdominal  wall,  where  it  was  fastened  by  sutures. 
The  patient  died  on  the  thirteenth  day.  No  urethral  or 
kidney  changes  were  found.  Pczzi  had  the  same  acci- 
dent in  an  operation  and  resorted  to  the  same  expedient. 
The  patient  recovered  and  uiinated  through  the  abdomi- 
nal wall  for  three  months,  when  the  discomfort  of  this 
discharge  demanded  a  nephrectomy,  which  was  performed. 
The  ureter  and  kidney  showed  no  abnormal  changes. 

While  it  is  probable  that  in  accidents  of  this  nature,  oc- 
curring in  the  future,  such  methods  of  diverting  the  uri- 
nary discharge  will  be  but  seldom  resorted  to,  since  the 
union  of  a  divided  ureter  has  now  been  satisfactorily 
proven  to  be  capable  of  being  accomplished  by  the 
methods  of  Van  Hook  and  Kuster,  yet  the  results  of  the 
abdominal  attachment  of  the  ureteral  end  have,  in  the 
main,  been  encouraging.  A  better  method  than  this, 
however,  exists.  De  Paoli  and  Brusachi  have  shown  us,  by 
experimentation  on  animals  particularly,  that  if  a  small 
portion  of  the  bladder  should  be  left,  let  us  say  after  ex- 
tirpation of  a  tumor  involving  the  ureteral  orifices,  the 
ureters  can  be  inserted  into  the  portion  of  the  remaining 
bladder-walls,  without  subsequent  contraction,  by  first 
making  an  opening  through  the  thickness  of  the  bladder, 
cutting  away  around  this  opening  a  small  circle  of  the 
mucous  membrane,  and  then  pushing  through  the  opening 
in  the  bladder  wall  the  end  of  the  ureter,  having  enlarged 
the  orifice  of  this  by  splitting  it  up  a  short  distance,  as  is 
usually  done  in  the  urethra  in  amputation  of  the  penis, 
and  then  stitching  the  ureteral  mucous  membrane  to  the 
mucous  membrane  of  the  bladder.  External  to  the  blad- 
der-wall this  fixation  is  reinforced  by  other  sutures.  This 
method  is  warmly  indorsed  by  Guyon  and  Alberran,  and 
has  been  successfully   resorted   to  in   the  human  sub- 

1  Chaput :  Centrabl.  f.  Chirurg.,  No.  14,  1894,  reports  a  case  of  im- 
plantation of  divided  ureter  into  colon,  with,  five  months  later,  no  evi- 
dences of  renal  infection. 


162 


MEDICAL  RECORD. 


[August  iif  1894 


ject  by  Penrose,  of  Philadelphia.1  Kummel,  still  bolder, 
after  removing  the  entire  bladder  in  a  woman,  attached 
the  ureteral  orifice  to  the  vesical  end  of  the  urethra. 
His  patient,  however,  did  not  survive  long  enough  to  test 
the  value  of  this  procedure.  Novaro,*  McArthur,*  and 
Baum  have  also  implanted  ureters  into  the  bladder  to  re- 
lieve utero-vaginal  fistulas. 

Another  method  has  been  suggested  which  is  not  so 
attractive.  It  is  based  upon  the  fact  that  a  ligature  of  the 
ureter  determines  usually  atrophy  of  the  corresponding 
kidney.  It  has,  therefore,  been  suggested  that  in  an  ex- 
tirpation of  the  bladder  involving  the  ureteral  orifice  the 
divided  ureter  be  treated  in  this  fashion. 

This  brief  account  of  the  methods  of  undertaking  an 
operation  of  this  extent  would  hardly  be  complete  without 
a  slight  reference  to  the  advantage  claimed  for  the 
enlargement  of  the  operative  field  by  symphyseotomy. 
This  section  will  permit  of  a  separation  of  from  six  to 
eight  centimetres  (two  to  three  inches)  and  thereby  the 
lower  portion  of  the  bladder  will  be  literally  exposed. 
From  experiments  upon  the  cadaver,  as  well  as  my  ex- 
perience on  the  living  subject  which  is  to  be  presently 
related,  I  am  convinced  that  this  latter  addition  to  vesi- 
cal surgical  procedures  will  rarely  be  needed.  The 
bladder  can  be  removed,  or  rather  that  portion  of  it 
usually  involved  in  a  neoplasm  can  be  widely  removed, 
without  much  surgical  difficulty,  by  the  simpler  measures 
of  peeling  off  the  peritoneum,  not  only  from  its  summit 
and  posterior  walls,  but  from  its  lateral  surface,  aided 
by  the  employment  of  the  position  of  Trendelenburg. 

My  first  experience  in  the  removal  of  a  considerable 
portion  of  the  bladder,  and  the  ease  with  which  the 
peritoneum  can  be  lifted  from  that  organ,  occurred  in 
1891,  when  a  man,  fifty-nine  years  of  age,  was  admitted, 
in  the  month  of  December,  to  my  wards  in  the  New 
York  Hospital,  with  a  history-that  eighteen  months  pre- 
viously blood  had  appeared  in  his  urine,  which  after  an 
interval  of  several  months  recurred  and  persisted  up  to 
the  date  of  his  entrance  into  the  hospital.  He  had  but 
slight  pain  in  the  bladder,  with  moderately  frequent  urina- 
tion. The  urine  was  more  or  less  persistently  bloody, 
without  evidence  of  renal  disease  or  sugar.  No  stone 
was  found  in  the  bladder  by  sounding ;  the  prostate  was 
normal  in  size ;  bimanual  examination  gave  negative  re- 
sults. A  cystoscopic  examination,  under  an  anaesthetic, 
revealed  two  tumors  on  the  posterior  wall,  the  right  one 
a  little  larger  than  the  other.  On  December  26th,  with 
a  Petersen  bag  in  the  rectum,  into  which  was  injected  six 
ounces  of  water,  and  with  seven  ounces  of  Thiersch's  solu- 
tion injected  into  the  bladder,  the  patient  placed  in  Tren- 
delenburg's position,  by  a  three-inch  incision  in  the  me- 
dian line  the  bladder  was  exposed,  the  preperitoneal  fat 
"  clawed  "  up  from  the  pubes  toward  the  umbilicus,  and 
the  bladder  then  opened  by  a  vertical  incision.  The  lips 
of  this  incision  were  held  apart  by  silk  ligatures.  A  single 
tumor,  the  size  of  the  distal  phalanx  of  the  thumb,  was 
found  on  the  upper  part  of  the  posterior  wall,  somewhat 
to  the  right  of  the  median  line.  To  effectually  get  be- 
yond the  growth  the  peritoneum  was  stripped  off  from 
the  summit  and  the  posterior  surface  for  a  space  reaching 
from  one  seminal  vesicle  to  the  other  and  down  nearly  to 
the  prostate.  In  so  doing,  at  one  point  a  rent  was  made  in 
this  membrane,  but  this  was  promptly  sewn  up  with  silk 
sutures  and  gave  rise  to  no  further  inconvenience.  A 
triangular  portion,  including  the  tumor,  but  going  widely 
from  its  base,  about  two  and  a  half  inches  on  each  of  its 
sides,  was  finally  removed  from  the  posterior  wall  of  the 
bladder.  As  I  found  considerable  difficulty  in  closing  by 
sutures  the  lower  angle  of  the  space  thus  formed  in  the 
bladder-wall,  I  abandoned  the  attempt  to  close  any  por- 
tion of  the  bladder,  believing  this  to  be  safer  for  the  pa- 
tient. Iodoform  gauze  was  therefore  packed  between 
the  bladder  and  the  peritoneum,  the  bladder  itself  filled 
with  iodoform  gauze  around  a  rubber  catheter  passed  to 

»  American  Journal  of  the  Medical  Sciences,  April,  1894. 
*  CentralbL  f.  Chirurg.,  No.  27,  1893. 
»  Trans.  111.  Med.  Soc.,  1889. 


&Hi  of 
Excision 


Fig.  z. 


the  bottom  of  the  organ  and  the  drainage  accomplished 
in  this  way,  and  by  ordinary  antiseptic  dressings  applied 
over  the  wound  in  the  ab- 
dominal wall.    The  patient  {Turner 

did  well,  his  wound  very 
nearly  closed;  but  on  Feb- 
ruary 19th  he  was  attacked 
by  erysipelas  and  died  four 
days  later,  seven  weeks  after 
the  operation.  At  the  au- 
topsy it  was  seen  that  the 
suprapubic  wound  had  very 
nearly  healed,  the  gap  in  the 
bladder  on  its  posterior  wall 
had  closed  over  by  a  smooth 
cicatricial  surface,  and  ev- 
erything promised  well  if 
life  had  continued  longer. 
This  line  of  excision  of  the  bladder- wall  is  well  shown 
in  Fig.  1,  which  accompanies  this. 

I.  Excision  of  the  Bladder  for  Epithelioma.  Case  I. 
Epithelioma  of  the  Bladder  ;  External  Resection  of  the 
Bladder-walls. — A  man,  aged  fifty -five,  entered  the 
New  York  Hospital,  February  25,  1893,  ^th  ^ 
history  that  in  August,  1891,  he  began  to  pass  blood 
with  his  urine.  This  persisted  with  every  act  of  micturi- 
tion for  several  months,  when  it  stopped  for  four  months 
and  then  recurred.  Other  hemorrhages  at  much  less  in- 
tervals took  place,  until  April,  1892,  when  a  suprapubic 
cystotomy  was  done  by  Dr.  Park,  of  Buffalo,  and  two 
tumors  removed  from  the  bladder,  one  the  size  of  a  wal- 
nut, and  the  other  no  larger  than  a  bean.  A  fistula  con- 
tinued for  a  considerable  time,  but  was  healed  at  the  end 
of  fourteen  weeks. 

In  September,  1892,  another  hemorrhage  occurred, 
and  since  that  time  blood  has  at  irregular  intervals  ap- 
peared in  the  urine.  On  examination  there  was  found 
in  the  abdominal  wall,  just  above  the  symphysis,  in  the 
cicatrices  of  the  previous  operation  and  at  its  upper  part, 
a  tumor  the  size  of  an  English  walnut,  elevated  above 
the  surrounding  skin  and  reddened  on  its  surface  with  an 
indurated  area  surrounding  its  base  about  two  inches  in 
diameter.  A  cystoscopic  examination,  made  by  Dr. 
William  K.  Otis,  revealed  a  tumor  on  the  postero  supe- 
rior wall  of  the  bladder.  There  were  some  enlarged 
glands  of  a  superficial  character  in  each  groin. 

On  March  1st,  under  ether,  with  a  rectal  distention 
by  a  double  Barnes  bag  containing  eight  ounces  of  water, 

Skin 


Lint of  / 
IncisiavL.^ 


^>Twnot& 


Fig.  ». 

and  a  vesical  distention  brought  about  by  the  injection 
of  six  ounces  of  Thiersch's  solution,  two  curved  vertical 
incisions  in  the  abdominal  wall  above  the  symphysis  were 
made,  and  surrounded  the  growth,  which  was  readily 
separated  from  the  muscular  tissues  and  was  found  event- 
ually to  be  attached  to  the  summit  of  the  bladder.  The 
peritoneum  was  then  pealed  off  by  a  blunt  dissector,  aided 
by  light  cuts  from  a  scissors,  from  the  posterior  wall  of 
the  bladder  down  to  the  prostate,  and  on  each  side  as  far 
as  the  seminal  vesicles.  This  whole  exposed  portion  of 
the  bladder  was  excised,  including  a  papillomatous  growth 


August  ii,  1894] 


MEDICAL  RECORD. 


163 


in  its  centre  as  large  as  a  walnut,  as  well  as  the  growth 
rising  out  from  the  summit  of  the  bladder  (see  Fig.  2). 
The  section  of  the  bladder- walls  passed  at  least  from  one- 
half  to  three  quarters  of  an  inch  beyond  the  growths  in 
all  directions.  The  bladder  was  sewn  without  difficulty 
from  the  bottom  with  interrupted  catgut  sutures,  which 
were  purposely  passed  through  all  its  coats ;  and  in  one  or 
two  places  on  its  summit  with  silk-worm  gut  introduced 
only  through  its  muscular  coat  for  additional  support  A 
small  opening  was  left  toward  the  pubis,  through  which 
was  passed  a  Guyon  double  rubber-tube  drain.  The 
wound  in  the  abdominal  wall  was  packed  with  iodoform 
gauze  and  its  upper  end  united  by  silk-worm-gut  sutures. 
Sterilized  dressings  were  applied.  The  patient  did  well 
after  the  operation,  leaving  the  hospital  eight  weeks 
later  all  healed,  holding  his  water  from  three  to  four 
hours.  The  capacity  of  the  bladder  was  from  four  to 
five  ounces.  About  two  weeks  after  the  just-described 
operation  of  exsection  of  the  bladder,  the  glands  in  each 
groin  were  also  extirpated.  A  microscopic  examination 
in  each  of  these  two  cases  of  resection  of  the  bladder 
showed  the  neoplasms  to  be  epitheliomatous  in  character. 
II.  Double  Castration  and  Complete  Extirpation  of 
the  Vesicals  Seminales  and  Yasa  Deferentia  for  Tuber- 
culosis. — Germane  to  the  foregoing  subject  of  excision 
of  the  bladder  is  the  experience  obtained  in  extirpating 
the  seminal  vesicles.  Every  surgeon  has  been  s.t  times 
disappointed,  in  practising  the  operation  of  castration  on 
one  or  both  sides  of  the  testes  affected  beyond  salvation 
by  tubercular  invasion,  at  his  inability  to  divide  the  vas 
deferens  at  a  height  satisfactorily  beyond  the  reach  of  the 
disease,  even  when  this  is  apparently  of  testicular  origin, 
and  is  too  often  compelled  to  leave  the  stump  of  a 
diseased  cord  in  the  wound,  hoping  that,  as  happens 
elsewhere,  nature's  resisting  powers  may  overcome  the 
probable  small  quantity  of  tuberculous  material  left. 
All  the  more  is  this  dissatisfaction  increased  when 
he  finds  either  that  a  tubercular  knot  exists  at  the  same 
time  on  the  corresponding  side  of  the  prostate,  or  possi- 
bly that  a  similar  involvement  can  be  detected  in  the 
seminal  vesicle  of  that  side.  It  is  only  comparatively 
recently  that  endeavors  have  been  made  with  any  en- 
couragement to  more  radically  rid  the  patient  of  his  en- 
croaching disease.  Bungner l  has  advised  that  in  castra- 
tion the  vessels  of  the  cord  should  be  separated  at  :he 
inguinal  ring  from  the  vas  deferens,  duly  ligated  and 
severed,  and  that  traction  should  be  then  made  upon  the 
vas  deferens  to  such  a  degree  that  it  would  tear  across 
oftentimes  at  a  considerable  distanc  1  beyond  the  inter- 
nal ring.  This,  however,  is  an  uncertain  procedure,  and 
while  it  is  not  attended  with  any  risk  it  does  not  com- 
pare in  exactness  or  thoroughness  with  the  methods  that 
have  previously  been  suggested  by  Roux,  of  Lausanne, 
or  Villeneuve,  of  Marseilles.  The  latter  advised  that  in 
such  cases  the  incision,  for  the  castration  should  be  ex- 
tended in  the  abdominal  wall  up  to  and  beyond,  if  nec- 
essary, the  internal  ring,  and  down  to  the  peritoneum, 
which  could  then  by  the  finger  be  separated  from  the 
lateral  walls  of  the  bladder,  using  the  tautened  vas  d  f 
erens  as  a  guide  until  the  top  of  the  seminal  vesicle  was 
reached,  when  the  vas  deferens  could  be  divided  and  ex- 
tracted. Roux  suggested  in  these  cases,  where  the  pros- 
tate or  the  vesicular  seminales  were  involved,  that  a 
semicircular  incision  should  be  made  parallel  to,  and  an* 
terior  to,  the  anus,  and  through  this  the  rectum  separated 
from  the  prostate;  and  if  the  seminal  vesicle  was  in- 
volved, that  at  the  base  of  the  prostate  a  transver  e  inci- 
sion should  there  be  made  in  the  fascia  covering  of  the 
seminal  vesicles,  whereupon  this  portion  of  the  genera- 
tive apparatus  could  then  be  readily  peeled  off  from  the 
bladder  and  removed,  when  the  castration,  either  pre- 
viously begun  or  now  undertaken,  could  be  completed 
after  the  separation  and  ligation  of  the  vessels,  by  mak- 
ing traction  upon  the  vas  deferens,  when  it  ^ould  come 
out  its  entire  length  like  an  earthworm  from  its  hole 
without  any  further  risk  to  the  patient.  The  following 
1  Centralbl.  ftir  Chirurg.,  No.  46, 1893. 


case,  in  which  this  procedure  was  resorted  to,  will  illus- 
trate the  ease,  if  not  the  efficacy,  of  this  manoeuvre. 

Cask  II.  Tuberculosis  of  Testicles,  Prostate,  and  Sem- 
inal  Vesicles. — Ferdinand  R ,   aged    twenty- eight, 

was  admitted  to  the  New  York  Hospital,  October  1 9, 1 892, 
with  the  history  that  he  had  had  "  inflammation  of  lungs ' ' 
when  a  child.  When  fourteen  to  sixteen  years  of  age 
had  enlarged  cervical  glands,  which  did  not  suppurate. 
Four  years  ago  had  gonorrhoea  for  six  months ;  a  year 
later  a  second  attack.  Some  gleet  noticed  at  times  ever 
since.  Six  months  ago  the  left  testicle  was  noticed  to 
be  swollen  to  size  of  an  orange.  It  became  very  tender 
and  painful.  Treatment  by  cold  and  rest  reduced  it  one- 
half,  which  size  persisted.  He  then  suffered  great  vesi- 
cal irritability,  urinating  every  few  minutes,  noticing  a 
few  drops  of  blood  at  meatus  afterward.  Two  months 
later  right  testicle  was  similarly  affected,  both  testicles 
remaining  the  same  size  for  the  past  three  months.  Ves- 
ical irritability  less  for  two  months,  micturition  every 
hour.  General  health  good.  No  tubercular  family  his- 
tory. 

Admission:  Urine  yellow,  acid,  1.010,  trace  of  albu- 
min, pus,  and  blood. 

Examination. — Epididymis  on  each  side  swollen, 
globus  major  and  minor  enlarged,  hard  mass  between 
them.  Each  epididymis  tender  on  firm  pressure,  skin 
not  adherent.  Both  cords  enlarged,  right  more  so. 
Right  seminal  vesicles  much  enlarged,  a  nodule  also  felt 
in  right  side  of  prostate.  Tubercle  bacilli  found  in 
urine,  but  only  when  pressure  per  rectum  was  made  in 
the  rectum  on  the  prostate. 

The  seminal  vesicle  and  prostate  were  therefore  con- 
sidered the  foci  of  disease,  and  in  the  hope  that  relieving 
the  patient  of  these  the  bladder  might  be  spared  perma- 
nent invasion  a  radical  operation  was  advised  and  prac- 
tised. Under  ether  an  incision  was  made  on  right  side 
from  lower  part  of  scrotum  carried  up  over  inguinal  canal. 
Testicle  and  cord  exposed  and  separated  from  speimatic 
vessels  at  internal  ring.  Testicle  softened  in  places  and 
showed  several  cavities  filled  with  pus.  Cord  apparently 
normal.  Fascia  of  external  oblique  muscle  cut  through 
over  canal  and  cord,  vessels  separated  as  high  up  as  possi- 
ble, ligated,  and  cut.  Here  peritoneum  was  accidentally 
opened  about  three  fourths  of  an  inch.  This  was  closed 
by  suture.  This  rent  was  made  in  an  endeavor  to  sepa- 
rate the  peritoneum  from  the  lateral  aspect  of  the  bladder, 
following  the  course  of  the  vas  deferens,  as  suggested  by 
Villeneuve;  but  it  was  not  an  easy  thing  to  do,  and  in 
carrying  it  out,  as  said  before,  the  peritoneal  cavity  was 
entered.  In  the  left  side  an  incision  was  made  exposing 
the  testicle  and  cord,  which  were  separated  from  the 
vessels  well  up  into  the  canal,  vessels  ligated  and  cut. 
The  testicles,  free  from  the  scrotum,  but  attached  to 
their  cords,  were  left  hanging  at  the  internal  rings. 
Roux's  operation  was  then  chosen  to  follow,  with  patient 
in  lithotomy  position  A.  Curved  incision  starting  at 
one  side  of  anus  was  carried  anteriorly  to  other  side, 
allowing  the  anus  and  rectum  to  fall  back.  Incision 
carried  up  until  prostate  and  bladder-wall  were  exposed. 
Here  the  dense  fascia  binding  down  the  vesicles  to  the 
bladder  was  cut  through  transversely,  giving  ready  access 
to  the  ampulla  of  the  vas-  deferens  and  the  seminal  vesi- 
cles. Right  seminal  vesicle  found  dissected  free  from 
bladder  and  removed,  also  the  affected  portion  of  the 
prostate,  and  subsequently  the  other  vesicle.  Both  cords 
with  testicles  and  whole  length  of  the  vasa  deferentia 
were  drawn  out  in  front  from  the  castration  wounds  in 
scrotum.  Then  the  fascia  of  external  oblique  was  sut- 
ured with  catgut  over  a  gauze  drain.  Skin  closed  with 
catgut,  similarly  the  incision  on  left  side  was  treated. 
The  perineal  wound  was  packed  with  iodoform  gauze  and 
sutured  with  two  sutures  on  either  side  of  anus.  Wet 
dressing.     Reacted  fairly  well. 

The  subsequent  history  of  the  patient  was  in  brief  that 
for  the  first  four  weeks  urination  improved  and  the 
tubercular  bacilli  disappeared,  but  this  amelioration  was 
due  to  the  effect  of  a  small  fistulous  track  that  resulted 


1 64 


MEDICAL   RECORD. 


[August  ii,  1894 


from  the  wound  in  the  prostate,  and  which  persisted 
for  nearly  seven  weeks.  After  its  healing  the  bladder 
irritation  increased,  and  injections  every  second  day  of 
ten  per  cent,  iodoform  in  starch  or  glycerine  were  re- 
sorted to  for  some  time  with  benefit.  He  passed  then 
from  observation.  The  scrotal  and  ante-rectal  wounds 
healed  satisfactorily. 

III.  The  Implantation  of  an  Artificial  Testis  after 
Castration. — A  case  little  less  serious  than  those  fore- 
going is  the  attempt  made  to  replace  a  testicle  lost  by 
the  operation  of  castration.  A  man,  thirty-seven  years 
of  age,  who  had  had  for  nearly  two  years  a  tubercu- 
lar involvement  of  both  testes,  the  right  being  most  se- 
riously affected,  was  compelled  by  the  advance  of  his  dis- 
ease to  submit  to  castration.  The  left  testis,  being  less 
diseased,  was  saved  by  a  process  of  scraping  and  packing 
with  iodoform  gauze. 

When  before  the  operation  I  announced  to  him  that 
the  right  testicle  was  so  much  damaged  that  its  loss 
would  be  likely  to  ensue,  he  begged  most  piteously  that  I 
should  not  remove  the  entire  organ.  This  request  I  en- 
deavored of  course  to  comply  with,  but  found  it  impos- 
sible to  do  so ;  but  at  the  completion  of  the  castration  in 
the  ordinary  way  I  was  enabled  to  relieve  his  mental  anx- 
iety by  resorting  to  an  expedient  which  experience  in 
other  directions  had  led  me  to  believe  might  be  success- 
ful here,  and  that  was  tcf  implant  into  the  cavity  of  the 
scrotum  left  vacant  and  surgically  clean  by  the  thorough 
removal  of  the  diseased  parts,  a  ball  of  celluloid  duly  dis- 
infected. This,  about  an  inch  in  diameter,  was  placed  in 
the  former  site  of  the  testis,  and  the  skin  drawn  over 
and  properly  sutured.  Healing  followed  promptly  and 
without  any  difficulty,  and  the  patient  has  now  worn 
this  artificial  testicle  since  May,  1893,  with  a  content- 
ed mind  and  proud  yet  of  his  virile  powers.  I  was  led 
to  this  procedure,  from  two  or  three  successful  attempts 
to  use  celluloid  in  overcoming  defects  and  deformities. 
Two  years  before,  I  had  an  opportunity  of  covering  a  de- 
fect of  the  skull,  produced  by  a  compound  depressed 
fracture,  by  inserting  in  the  space  left  after  the  removal 
of  the  depressed  bone  fragments  a  thin  plate  of  celluloid 
one  and  a  half  inch  by  an  inch  in  diameter.  This  has 
remained  in  situ  without  any  disturbance  to  the  patient 
since  then.  The  little  lad,  the  subject  of  this  experi- 
ment, has  been  already  shown  to  you,  but  I  beg  to  pre- 
sent him  again  for  inspection.  The  idea  of  using  cellu- 
loid as  a  material  to  replace  bone  or  cartilage  defects 
originated  in  the  Vienna  school  with  an  assistant  of  Bil- 
roth  by  the  name  of  Fraenkel.1  Since  then  it  has  been 
resorted  to  a  number  of  times  for  this  particular  defect  in 
the  skull,  and  of  late  for  defects  elsewhere.  It  has  been 
applied,  for  instance,  to  replace  a  loss  in  the  tarsal  carti- 
lage of  the  eyelid.  It  has  also  been  applied  to  remedy 
the  removal  of  the  edge  of  the  orbit,  and  thus  aid  in 
keeping  the  eyeball  in  position.  It  has  been,  moreover, 
used,  even  immediately  after  resection  of  the  superior 
maxilla,  in  every  case  with  advantage.  Very  recently  I 
have  utilized  it  in  three  instances  to  overcome  a  deform- 
ity of  the  nose  from  sunken  cartilages,  for  the  purpose 
introducing  a  portion  of  the  celluloid  suitably  shaped 
to  suit  the  different  deformities ;  placing  the  support  in 
position  either  from  without  through  a  small  incision, 
or  better  still,  from  within  the  nostril.  The  sugges- 
tion of  this  way  of  overcoming  a  very  troublesome  nasal 
deformity  was  made  by  Dr.  Lewis  A.  Stimson,  who 
employed  for  this  purpose  either  gutta-percha  or  alu- 
minum. In  my  judgment,  however,  celluloid  is  a  mate- 
rial much  better  borne  by  the  tissues  than  either  of  the 
two  substances  just  mentioned. 

Following  the  example  set  forth  in  the  case  just  re- 
lated, I  understand  that  another  testis  has  been  artificially 
supplied,  or  simulated  by  a  celluloid  one,  by  my  friend 
Dr.  Guiteras,  in  a  case  shortly  to  be  published,  and  also 
by  Dr.  Hartley  in  a  recent  case. 

IV.  Vesical  Papilloma  of  Unusual  Duration.— The 

1  See  Wiener  klin.  Wochenschrift,  No.  25,  1890,  No.  x6,  1891,  and 
Frey,  No.  3,  1893. 


last  case  that  I  shall  venture  to  bring  to  your  notice,  in 
connection  with  genito  urinary  surgery,  is  one  of  a  tumor 
of  the  bladder,  which,  occurring  in  a  man  of  fifty-two 
years  of  age,  possesses  the  points  of  interest  presented 
briefly  as  follows : 

1.  That  it  had  existed  for  an  unusually  long  time,  for 
the  history  showed  that  the  bleeding  had  persisted  off  and 
on  for  a  period  of  thirty-seven  years.  This  is  beyond  the 
duration  of  the  longest  period  mentioned  by  Guyon  or 
Alberran,  which  was  in  two  cases  respectively  thirty  and 
thirty- one  years. 

2.  That  the  diagnosis  was  made  most  satisfactorily  in 
this  instance  by  the  employment  of  Guyon's  method, 
viz.,  the  urination  of  the  patient  into  three  glasses,  in 
the  last  of  which  the  most  and  freshest  blood  was  found* 
Also,  as  a  corroboration,  that,  after  washing  out  the 
bladder,  a  bimanual  examination  was  made,  the  catheter 
being  left  in  situ,  by  which  manoeuvre  fresh  blood  was 
pressed  out  in  small  quantities  through  the  catheter,  or 
else  was  washed  out  of  the  catheter  after  it  was  withdrawn. 

3.  That  in  this  case  a  cystoscopic  examination  failed 
to  reveal  the  existence  of  the  growth.  This  investigation,. 
I  may  add,  was  made  at  the  hands  of  one  who  was  partic- 
ularly expert  in  the  use  of  this  instrument. 

4.  And  what  is,  after  all,  of  the  most  clinical  impor- 
tance, was  that  the  tumor — a  papilloma  about  one  inch 
and  a  half  in  length  and  one  quarter  of  an  inch  in  diam- 
eter, and  quite  fibrous  in  character,  with  fringes  on  its 
free  ends — was  situated  just  above  and  to  the  right  side  of 
the  meatus  internus  urinarius..  This  tumor  was  detected 
in  a  very  ready  manner  after  the  suprapubic  section  had 
been  made,  by  the  insertion  of  a  large  Ferguson's  glass 
vaginal  speculum.  This  idea  had  been  suggested  by 
Fenwick,  of  London,  who  used  such  a  speculum  as  a 
sort  of  caisson,  even  with  the  bladder  more  or  less  filled 
with  water  or  urine,  in  which  case  the  speculum  was  to  be 
passed  to  the  deeper  part  of  the  bladder,  the  imprisoned 
water  soaked  or  wiped  out,  and  the  bladder  thus  exposed 
carefully  inspected.  I  found  it  better,  however,  to  wipe 
out  the  bladder  as  well  as  possible,  then  introduce  the 
speculum  and  sweep  it  along  the  walls  of  the  viscus ;  and 
in  this  instance,  before  very  long  was  able  to  recognize 
the  tumor  in  the  situation  just  described.  Through  this 
same  speculum,  which  was  about  one  and  a  half  inch 
in  diameter,  I  could  and  did  seize  the  tumor  with  a  for- 
ceps and  with  a  curved  scissors  cut  it  off,  and  then  with 
a  Paquelin  cautery  lightly  touched  its  bleeding  surface, 
and  finally  packed  upon  the  wound,  from  which  the 
blood  did  not  entirely  cease  by  the  light  cauterization, 
a  wad  of  iodoform  gauze  and  hold  it  there  firmly  until 
all  hemorrhage  was  checked.  The  whole  procedure  an- 
swered so  well  these  various  ends  that  I  beg  to  commend 
to  your  notice  the  serviceability  of  this  method  of  exam- 
ination and  operation.  It  commands  a  ready  view  of 
the  whole  of  the  bladder  in  its  lower  and  posterior  parts, 
which  parts  are  most  affected  by  growths.  It  enables  one 
to  readily  recognize  the  mouths  of  the  ureter,  and  to  pass 
into  them,  if  necessary,  instruments  for  their  further  ex- 
ploration, etc. 

The  bladder  in  this  instance,  after  removal  of  the  tu- 
mor, was  sewn  snugly  together,  and  the  abdominal  wound 
left  open.  The  patient  made  a  prompt  recovery,  with  a 
very  trifling  leakage  for  eight  days,  and  has  remained 
well  since. 

The  tumor  was  a  papilloma  with  a  heavy  fibrous 
stroma. 


The  Czar  gave  the  physician  who  treated  him  during 
his  attack  of  pneumonia  last  winter  the  sum  of  $30,000. 

A  Hew  Hanging  Machine  is  to  be  put  to  the  practical 
test  soon  in  Connecticut.  It  is  so  constructed  that  the 
weight  of  the  condemned  criminal  stepping  on  a  platform 
sets  in  motion  the  necessary  machinery  for  his  suspen- 
sion. Some  people  protested  against  its  use  on  the 
sentimental  ground  that  the  man  hanged  would  be  vir- 
tually a  suicide. 


August  ii,  1894] 


MEDICAL  RECORD. 


165 


A  MODERN  IDEA  IN  SCIENTIFIC  MEDICINE. 
By  JOHN   AULDE,  M.D., 

PHILADELPHIA,   PA. 

The  claim  has  been  put  forward,  and  not  without  show 
jof  reason,  that  the  science  of  medicine  lags  behind  the 
other  sciences,  and  that  in  consequence  of  this  backward 
condition  not  only  is  the  average  length  of  life  less  than 
it  should  be,  but  also  that  there  is  an  augmentation  of 
the  total  sickness.  Admitting  that  preventable  diseases  are 
Car  too  common,  and  hence,  as  a  matter  of  course*  the  na- 
tional vitality  lowered  in  proportion,  it  is  still  doubtful  if 
the  charge  above  quoted  is  entitled  to  stand,  since  the 
fact  is  patent  that  much  has  been  accomplished,  even 
within  the  past  decade,  to  alleviate  human  suffering,  to 
control  or  modify  disease,  and  to  prolong  life.  It  would 
be  foreign  to  the  purpose  of  this  article  to  take  account 
of  numerous  and  substantial  advances  effected  in  this 
direction,  since  its  object  is  to  direct  attention  to  a  mod- 
ern idea  in  scientific  medicine  which  gives  promise  of 
working  a  revolution  in  methods  of  practice ;  an  idea 
which  involves  new  and  important  principles  concerning 
our  conception  of  the  phenomena  of  life  itself. 
.  This  modern  idea,  however,  is  not  founded  upon  spec- 
ulative investigation,  for  the  facts  it  embodies  and  the 
conclusions  upon  which  it  rests  have  long  been  recog- 
nized by  intelligent  physicians  on  both  sides  of  the  At- 
lantic. The  novelty  consists  merely  in  the  arrangement 
of  these  facts,  deductions,  and  conclusions  which  neces- 
sarily lead  up  to  this  new  departure  in  the  domain  of  the- 
rapeutics. Indeed,  in  the  light  furnished  by  our  knowledge 
of  life,  chemistry,  experimental  physiology,  pathology, 
and  clinical  observation,  the  truths  here  to  be  recorded 
point  to  the  pressing  need  for  radical  changes  in  methods 
of  treating  disease. 

Neither  does  it  fall  within  the  province  of  this  paper  to 
criticise  or  expatiate  upon  the  more  recent  plans  that 
have  met  with  the  approval  of  the  foremost  physicians 
throughout  the  country.  Suffice  it  to  say  that  the  facts 
presently  to  be  brought  forward  were  practically  incon- 
ceivable without  the  knowledge  recently  acquired  relat- 
ing to  antisepsis. 

By  way  of  recapitulation,  and  as  a  preliminary  to  the 
following  remarks,  it  should  be  stated  that  although  a 
period  of  thirty -five  years  has  elapsed  since  Professor  Vir- 
chow,  the  eminent  scientist,  published  his  memorable 
treatise  upon  "Cellular  Pathology/1  but  little,  com- 
paratively speaking,  has  been  accomplished  since  that 
time.  Professor  Virchow  studied,  and  later  depicted, 
the  retrograde  changes  occurring  in  the  microscopic  cell 
from  disease ;  but  no  one  has  thought  it  worth  while  to 
study  and  depict  the  nutritional  changes  taking  place  in 
the  living  cell  as  a  result  of  medication.  The  conse- 
quence is,  therefore,  that  very  many  remedies  are  given 
on  a  speculative  basis.  True,  a  considerable  number  of 
the  medical  profession  now  claim  to  practise  what  is 
termed  "  rational1'  medicine,  as  contra-distinguished 
from  empirical  medicine;  but  when  the  question  is 
asked  as  to  the  precise  influence  which  remedial  agents 
have  upon  nerve  cells  and  upon  protoplasm,  no  one  can 
be  found  competent  to  answer. 

For  example,  enthusiastic  claims  have  been  made  for 
electricity,  and  we  have  in  the  State  of  New  York,  at 
least,  the  anomalous  spectacle  of  the  same  agent  being 
used  both  to  kill  and  to  cure.  And  when  it  is  considered 
that  no  systematic,  thorough,  and  complete  physiological 
investigations  have  been  made  with  a  view  to  determine 
the  effect  of  this  powerful  agent  upon  the  microscopic 
cell,  we  may  well  pause  before  accepting  literally  the 
conclusions  of  its  active  supporters.  This  reservation  is 
not  pressed  by  reason  of  an  absence  of  clinical  results, 
but  rather  for  the  reason  that  exact  knowledge  is  still 
wanting. 

However,  this  method  of  study  has  recently  attracted 
the  attention  of  the  medical  profession  through  the  re- 
ports of  Professor  Hodge,  of  Clark  University.  This  in- 
genious experimenter  found,  on  exposing  the  nerve-cells 


of  honey-bees  and  pigeons  to  the  stimulating  effects  of 
the  electric  current,  that  certain  appreciable  changes  oc- 
curred ;  but  when  the  action  was  long  continued,  or  the 
current  strength  was  increased  beyon<j[  a  variable  point, 
no  characteristic  change  took  place. 

The  experimental  evidence  undertaken  with  a  view  to 
determine  the  physiological  effects  of  remedial  agents 
upon  the  human  economy  points  to  the  fact  that  the 
true  therapeutic  value  of  a  drug  is  by  no  means  to  be 
measured  by  the  mechanical  effects  produced,  and  it  is 
to  be  regretted  that  the  disposition  to  study  results  rather 
than  methods  and  principles  has  found  favor  with  the 
profession,  because  of  the  vicious  circle  of  reasoning  set 
up  and  the  unstable  foundation  it  affords.  It  is  this  cir- 
cumscribed medical  horizon  which  has  so  seriously  han- 
dicapped the  present  generation  of  physicians.  In  sur- 
gery the  conditions  are  different,  since  the  results  at- 
tending the  use  of  antiseptics  naturally  developed  the 
principles  upon  which  antisepsis  depended,  and  thus  a 
foundation  was  firmly  established  for  asepsis,  or  the 
treatment  of  wounds  by  exclusion  of  the  septic  material. 

The  rational,  treatment  of  disease  should  be  based  upon 
a  knowledge  of  the  effects  which  medicinal  substances 
produce  upon  the  functions  of  the  cell ;  and  since  the 
cells  in  different  portions  of  the  human  economy  have 
special  functions  to  perform,  and  therefore  vary  in 
their  structure,  it  follows  that  no  one  remedy  is  likely  to 
affect  all  cells  in  precisely  the  same  manner.  It  must  be 
evident,  therefore,  to  the  most  superficial  observer, 
that  the  rational  treatment  of  disease  should  be  based 
upon  the  therapeutics  of  the  cell ;  and  to  be  efficient 
we  must  consider  the  effects  of  drugs  which  are  seen  as 
well  as  those  which  are  unseen,  as  there  is  no  doubt  in 
the  minds  of  clinicians  that  metabolic  changes  occur 
which  are  beyond  our  power  to  demonstrate  or  compre- 
hend. 

The  remarkably  favorable  results  attending  the  use  of 
cold  baths  alone  in  typhoid  fever  furnish  evidence  that 
the  economy,  unaided  by  medicines,  can  withstand  and 
finally  eliminate  the  poison  of  this  disease,  and  to  the  re- 
flective mind  it  shows  that  the  ability  to  resist  disease 
depends  upon  the  integrity  and  function  of  the  cell — cell 
metabolism.  Indeed,  in  view  of  the  large  mortality  in 
this  disease  treated  by  the  routine  method  as  contrasted 
with  the  low  percentage  of  fatalities  with  the  bath  treat- 
ment, we  are  almost  forced  to  the  conclusion  that  medi- 
cation has  been  responsible  for  more  deaths  than  recov- 
eries. 

Mercury  and  arsenic  may  be  selected  to  represent  the 
effect  which  poisons  have  upon  metabolism  (tissue- 
change).  Being  foreign  substances  and  distributed  over 
the  system  through  the  blood  and  lymph,  the  organism 
is  intent  upon  their  elimination  because  they  are  proto- 
plasmic poisons.  While  we  may  trace  the  former  to  the 
liver  principally,  and  the  latter  to  the  pulmonary  struct- 
ures or  the  skin,  where  they  are  finally  eliminated,  their 
elimination,  when  given  in  medical  doses,  is  always  at- 
tended by  more  or  less  cellular  activity  beyond  the  nor- 
mal— usually  spoken  of  as  inflammatory  action.  Where- 
ever  found,  they  act  as  protoplasmic  poisons,  and  it  is 
this  property  which  gives  them  their  therapeutic  virtues 
— when  properly  administered. 

Cellular  therapy  is  concerned  in  promoting  stimulation 
without  irritation  and  subsequent  depression,  which  is  ac- 
complished by  selection  of  the  proper  remedy  and  regu- 
lation of  the  dose.  It  should  be  borne  in  mind  that  both 
substances  mentioned  are  active  poisons,  and  that  how- 
ever administered  this  peculiarity  remains, ;'.;.,  the  min- 
imal dosage  lessens  the  degree  of  toxicity,  but  produces 
no  change  in  the  action,  although  it  modifies  the  effect. 

Now,  to  illustrate  the  underlying  principle  of  the  mod- 
ern idea  which  I  wish  to  develop,  suppose  a  physician 
desires  to  relieve  some  chronic  cutaneous  ailment;  he 
administers  arsenic  either  because  he  knows  it  is  "  good  " 
for  such  cases,  or  for  another,  apparently  better,  reason, 
namely,  because  he  is  aware  that  the  drug  is  largely 
eliminated  by  the  skin,  and  that  through  this  process  of 


1 66 


MEDICAL  RECORD. 


[August  ii,  1894 


elimination  cellular  activity  will  be  increased^  Still, 
this  latter  reason  is  extremely  unsatisfactory,  since  it 
lacks  definiteness,  and  besides,  the  claim  will  be  set  up 
that  it  would  be  a  contradiction  of  physical  laws  to  as- 
sume that  protoplasmic  poisons  will  stimulate  the  action 
of  organic  cells  whose  constituent  elements  are  princi- 
pally this  peculiar  substance.  It  will  be  asserted  that  a 
disordered  condition  of  the  cutaneous  structure  means  a 
debilitated  or  exhausted  state  of  the  protoplasm  compos- 
ing the  cells,  and  that  whether  we  consider  the  physical 
or  nervous  mechanism  concerned  in  promoting  their 
activity,  it  would  be  equally  unfortunate  to  expose  them 
to  the  disturbing  and  depressing  influence  of  a  rank 
poison. 

This  process  of  reasoning,  however,  can  easily  be  set 
aside  as  fallacious,  since  clinicians  well  know  the  stimu- 
lating effects  of  arsenic  in  all  cutaneous  affections.  The 
scientific  explanation  appears  to  be  that  as  all  poisons 
are  irritants,  the  degree  of  irritation  may  be  so  modified 
by  dosage  that  the  irritation  is  limited  to  that  of  mild 
stimulation.  Thus,  the  prick  of  a  pin  is  stimulant,  while 
the  stab  of  a  bowie-knife  may  prove  fatal. 

The  idea  of  treating  diseased  conditions  of  the  human 
organism  by  the  exhibition  of  medicaments  which  tend 
to  the  restoration  of  the  function  of  the  cells  in  the  part 
affected  is  a  very  seductive  one,  but  its  practical  adapta- 
tion is  attended  with  difficulty.  The  obstacles  in  the 
way  of  its  tentative  employment  in  many  diseases,  how- 
ever, are  not  insuperable,  owing  to  our  knowledge  con- 
cerning the  physiological  action  of  drugs.  Thus,  a  drug 
which  is  eliminated  through  the  skin,  kidneys,  liver,  or 
pulmonary  apparatus,  will  usually  increase  the  functional 
activity  of  those  structures,'  necessarily  through  augmen- 
tation of  cellular  activity.  But  there  is  a  limit  to  stimu- 
lation thus  produced,  because  when  the  dose  is  large,  or 
the  remedy  long  continued,  the  initial  stimulation  will 
be  followed  by  depression.  The  basis,  therefore,  upon 
which  cellular  therapy  rests,  is  that  of  stimulation  with- 
out irritation,  which  can  be  accomplished  by  the  selection 
of  the  proper  remedy  and  regulation  of  the  dose. 

This  brings  us  to  consider  the  vis  medicatrix  natures  as 
a  factor  in  resisting  disease,  really  nothing  more  than  a 
supposititious  entity  until  within  the  recent  past,  when  we 
have  begun  to  fathom  the  mystery  of  cell  function  and 
cell-life. 

In  order  to  render  comprehensible  what  follows,  it  will 
be  necessary  to  recapitulate  some  of  the  more  important 
conditions  dependent  upon  cell  function  essential  to  the 
enjoyment  of  health ;  and  this  will  afford,  by  reflection, 
a  bird's-eye  view  of  the  so-called  vis  medicatrix  nature* 
as  it  is  now  understood.  To  maintain  good  health  a 
person  should  have  a  sound  digestive  apparatus.  This 
trite  observation  has  more  significance  than  would  appear 
at  first  sight,  owing  to  the  important  changes  which  oc- 
cur after  the  ingestion  of  food,  changes  besides  those 
incident  to  the  conversion  and  absorption  of  the  differ- 
ent kinds  of  food- stuffs.  Reference  is  had  to  "  digestive 
leucocytosis  " — we  may  call  it  a  vital  process — a  phe- 
nomenon characterized  by  the  rapid  multiplication  of  the 
white  blood-corpuscles,  a  peculiarity  which  was  also  noted 
by  Professor  Virchow.  Slightly  modified,  many  of  these 
leucocytes  become  active  agents  in  the  destruction  of 
micro-organisms  and  their  products.  They  enact  the 
role  of  scavengers,  and  are  freely  distributed  throughout 
the  system  along  with  the  red  blood-copuscles  which 
cany  oxygen  to  every  part. 

By  way  of  digression,  it  may  be  mentioned  that  this 
function  of  the  red  blood-corpuscles  is  essential  to  the 
welfare  of  the  tissues.  The  oxygen  is  taken  up  by  the 
protoplasm,  which  in  turn  gives  off  carbonic  acid  and 
other  waste-products,  and  loaded  with  this  burden  the 
little  cells  return  to  the  lungs,  discharge  their  cargo,  and 
again  take  a  new  supply  of  oxygen.  It  is  unnecessary 
to  dwell  upon  this  peculiar  and  interesting  function, 
known  as  internal  respiration,  except  to  note,  in  passing, 
the  use  made  of  the  oxygen  by  the  protoplasmic  cells. 
In  the  first  place,  they  act  as  storage-tanks,  giving  off 


the  gas  as  required  to  keep  up  the  functional  activity 
(combustion) ;  in  the  second  place,  they  can  convert  this 
gas  into  ozone,  which  is  far  more  active  than  the  oxygen 
itself. 

The  presence  of  oxygen  in  the  blood,  in  the  proto- 
plasm, and  in  the  intercellular  fluids  is  not  in  itself  suffi- 
cient to  maintain  the  tissues  and  fluids  of  the  body  in  a 
thoroughly  antiseptic  condition,  owing  to  the  active 
tissue-change,  along  with  the  production  of  waste  products. 
It  remained,  therefore,  to  discover  the  causes  at  work 
which  enabled  the  system  to  resist  disease,  and  scientists 
have  been  richly  rewarded  by  their  investigation  of  the 
function  of  the  white  blood-corpuscle.  From  present 
indications  this  discovery  promises  to  become  the  miss- 
ing link  in  the  so-called  vis  medicatrix  natura,  as  will 
presently  appear.  More  than  ten  years  ago  Professor 
Metschnikoff  taught  that  leucocytes  or  phagocytes  per- 
formed an  important  service  to  the  human  organism, 
namely,  that  they  enveloped  or  surrounded  bacteria  and 
destroyed  them  as  well  as  bacterial  products.  Within 
the  past  year,  however,  several  scientists  have  demon- 
strated that  leucocytes,  through  their  nucleus,  produce  a 
phosphorized  proteid  termed  nuclein,  which  possesses 
active  germicidal  properties.  These  researches  covered 
not  only  the  test-tube  observations,  but  experimental 
studies  upon  animals,  and  showed  conclusively  that  solu- 
tions of  nuclein  employed  in  seasonable  time  would  con- 
fer immunity  against  disease,  and  thus  a  new  factor  was 
added  to  the  modern  idea  of  cellular  therapy,  that  of 
nuclein  therapy. 

The  development  of  this  modern  idea  in  scientific 
medicine,  as  will  be  apparent  from  the  foregoing  brief 
sketch,  is  but  a  question  of  time,  since  it  hinges  alto- 
gether upon  actual  facts,  speculative  hypotheses  being 
kept  entirely  in  the  background.  Even  now,  clinicians 
and  experimental  physiologists  are  earnestly  at  work  in 
the  expectation  that  they  can  further  advance  the  art  of 
healing,  and  doubtless,  ere  long,  we  shall  have  the  satis- 
faction of  asserting  that  practical  medicine  is  really  in 
fact,  as  well  as  in  name,  scientific  medicine. 

14x1  Walnut  Street,  Philadelphia,  Pa. 


REPORT  OF  COMPLICATED  CASES  INVOLV- 
ING UTERUS,  TUBES,  AND  OVARIES, 
TREATED  SUCCESSFULLY;  WITH  A  PLEA 
FOR  CONSERVATIVE  SURGERY  IN  DEAL- 
ING WITH  THESE  APPENDAGES. 

By   PAUL  OUTERBRIDGE,    M.D., 

ATTENDING  GYNECOLOGIST  AT  NEW  YORK  CANCER  HOSPITAL  ;  ACTING  ATTENDING 
GYNECOLOGIST  AT  WOMAN'S  HOSPITAL  OP  NEW  YORK  ,*  ATTENDING  PHYSICIAN  AT 
NEW  YORK  LYING-IN  ASYLUM  ;  ATTENDING  GYNECOLOGIST  AT  DEM1LT  DISPEN- 
SARY; MEMBER  OP  NEW  YORK  OBSTETRICAL  SOCIETY  ;  MEMBER  OF  HOSPITAL 
GRADUATE  SOCIETY  ;  MEMBER  OP  ALUMNI  ASSOCIATION  OP  NEW  YORK  HOSPI- 
TAL ;   MEMBER  OP  ALUMNI  ASSOCIATION  OP  WOMAN**  HOSPITAL,  ETC. 

This  subject  is  one  that  demands  special  attention  from 
the  gynecologist  of  today,  for  operators,  although  more 
careful  at  the  present  time  than  for  years  past,  are  still 
prone  to  remove  tubes  and  ovaries  that,  in  my  opinion, 
could  be  retained  by  the  patient  to  very  great  advantage, 
if  given  a  chance  through  conservative  surgery  to  regain 
their  functions.  There  are,  of  course,  cases  of  salpingitis 
which  time  alone  will  cure  ;  others  that  can  be  and  are 
relieved  by  the  various  non- operative  and  conservative 
methods  advised  by  the  specialist ;  and  still  others  in 
which  abdominal  operative  measures,  either  radical  or 
palliative,  are  imperative  to  effect  a  cure. 

Now  it  is  not  to  the  first  class  of  cases  that  I  purpose 
to  devote  this  paper,  but  to  those  in  which  laparotomy  is 
indicated. 

Dr.  Polk,  of  this  city,  deserves  the  greatest  praise  for 
the  pioneer  steps  taken  by  him  in  calling  our  attention 
to  the  importance  of  saving  the  uterine  appendages  in 
cases  requiring  laparotomy,  and  in  which  there  is  the 
slightest  chance  of  being  conservative.  Martin,  of  Ber- 
lin, was  also  one  of  the  first  to  call  attention  to  this 
point.  Their  work  was  brought  to  our  attention  about 
four  years  ago.    Dr.  Thomas,  *  believe,  has  also  advocated 


August  ii,  1894] 


MEDICAL  RECORD. 


167 


the  same  doctrine  and  reported  as  cured  cases  which  re- 
quired abdominal  section,  and  in  which  the  tubes  were 
not  removed,  but  simply  the  adhesions  were  freed  and 
the  tubes  and  ovaries  left.  Since  first  hearing  Dr.  Polk's 
remarks  on  this  subject,  I  have  made  it  a  practice  to  save 
wherever  it  seems  practicable  to  do  so.  I  am  very  sorry 
to  see  that  he  at  present  advises  removal  of  the  uterus 
when  the  tubes  are  removed. 

I  have  come  to  believe,  after  studying  carefully  the 
various  cases,  both  with  and  without  the  presence  of  the 
menstrual  function,  that  menstruation  is  essential  to  a 
woman's  comfort  and  happiness.  In  the  lower  animals 
we  find  few  if  any  superfluous  organs,  and  when  we  con 
template  the  nervous  system  of  mankind,  the  complicated 
and  delicate  adjustment  of  which  renders  it  all  the  more 
sensitive  to  interference,  we  cannot  but  regard  it  as  es- 
sential that  the  human  being  should  remain  intact  in  the 
matter  of  organs  exercising  a  powerful  influence  on  the 
nervous  system.  Yet  many  operators  assure  their  patients 
that  the  deprivation  of  the  menstrual  function  will  be  at- 
tended by  no  discomfort  or  loss  of  happiness,  but  merely 
by  sterility. 

A  statement  in  detail  of  the  symptoms  of  patients  suf- 
fering from  the  effects  of  loss  of  the  appendages  is  im- 
practicable within  the  limits  of  this  article,  but  I  hope  at 
some  future  time  to  treat  more  fully  of  the  matter. 
Meanwhile  I  will  confine  myself  to  reporting  cases  in 
which  laparotomy  was  essential,  but  in  which  tubes  and 
ovaries  were  allowed  to  remain. 

The  first,  a  Mrs.  L ,  of  Brooklyn,  was  examined  by 

Dr.  Bushong,  who  is  associated  with  me  at  the  Demilt 
Dispensary,  and  myself.  The  uterus  was  firmly  fixed, 
retroflexed,  the  tubes  and  ovaries  matted  to  its  side  and 
behind  it  The  course  of  treatment  followed  was  several 
weeks'  local  tamponading  and  counter-irritation  by  Mon- 
sel's  solution.  Finding  that  this  could  not  relieve,  and 
that  it  was,  in  fact,  entirely  inadequate,  I  advised 
strongly  that  she  go  to  the  hospital  and  submit  to  opera- 
tive measures.  She  seemed  reluctant  to  lose  the  append- 
ages, but  expressed  perfect  willingness  to  undergo  the 
operation  when  informed  that  the  appendages  would  not 
be  removed  unless  their  removal  should  be  absolutely  es- 
sential. 

The  patient  was  thirty-eight  years  of  age,  married,  had 
had  two  children  the  last  six  years  before  operation. 
She  entered  the  New  York  Cancer  Hospital,  February  4, 
1 890,  and  had  operation.  House  staff  assisting.  Median 
incision.  Uterus  retroflexed,  bound  down,  tubes  en- 
larged, congested,  and  their  numerous  adhesions  aided 
in  holding  the  uterus  down.  Ovaries  at  first  could  not 
be  found,  as  the  whole  pelvic  viscera  were  matted  to- 
gether. All  the  adhesions  were  carefully  separated  by 
manipulation.  The  right  tube  was  very  much  enlarged, 
and  at  its  fimbriated  extremity  did  not  seem  pervious. 
Its  canal  was  entered  by  cutting  in  line  with  the  tube 
toward  the  uterus.  This  was  laid  open  for  about  one  and 
a  half  inch,  and  as  there  was  a  thin  and  slightly  puru- 
lent discharge  present  within  the  tube,  it  was  thoroughly 
cleansed  with  hot  water  and  a  sponge.  There  was  very 
little  hemorrhage.  After  this  a  probe  was  passed  down 
through  the  tube  into  the  uterus  without  difficulty. 
Thorough  irrigation  was  done,  and  one  catgut  suture  was 
put  in  at  uterine  end  of  the  tubal  incision.  The  left 
tube  was  in  about  the  same  condition,  except  there  was 
no  purulent-looking  fluid,  and  it  was  incised  in  a  similar 
manner ;  but  no  probing  was  attempted,  and  no  suture 
applied.  The  ovaries  were  enlarged  and  hardened,  con- 
taining a  number  of  small  cysts  which  were  incised  with 
knife,  permitting  thorough  escape  of  all  fluids  contained 
in  them.  The  uterus  and  appendages  now  assumed  a 
normal  position,  but  fearing  that  they  might  again  be- 
come attached  posteriorly,  I  stitched  the  round  ligaments 
to  the  anterior  abdominal  wall  with  four  catgut  sutures, 
two  on  either  side.  The  stitches  were  taken  about  half 
an  inch  from  the  uterus,  the  gut  being  of  a  kind  that 
would  hold  for  at  least  five  days.  The  abdominal  wound 
was  closed  with  usual  silk-worm  sutures.     The  uterus  at 


this  time  was  thoroughly-forward  and  held  there  by  the 
the  suttlres  in  round  ligaments.  Patient  had  a  little  ten- 
derness over  abdomen,  liver,  and  pelvis  for  a  few  days,  with 
some  rise  of  temperature.  Bowels  were  moved  third  day, 
as  is  my  custom,  with  salines.  Patient  went  on  and' 
made  good  recovery,  being  discharged,  with  uterus  in 
good  position  and  slightly  movable,  on  March  2,  1890. 
Two  years  afterward  die  became  pregnant  and  came  to 
see  me  at  the  dispensary  several  times  during  the  carry- 
ing term.  She  seemed  to  carry  the  child  very  comfort- 
ably. The  adhesions  formed  by  suturing  the  round  liga- 
ments to  anterior  abdominal  wall  never  seemed  to  cause 
the  slightest  trouble.  I  am  curious  to  know  whether  the 
adhesions  still  exist  and  are  simply  stretched,  or  whether 
they  gave  way  completely  during  the  ascension  of  the 
uterus. 

She  gave  birth  to  a  child  January  16,  1893,  and  Dr. 
Fulda,  of  107  Kent  Street,  Brooklyn,  attended  her.  She 
says  that  the  labor  was  a  natural  one.  The  utezus  is  now 
in  the  natural  position. 

In  a  similar  case,  where  the  patient  had  never  had 
children,  I  operated,  in  1890,  at  the  Woman's  Hospital. 
In  this  instance  all  adhesions  were  loosened,  the  tubes 
cut  up,  cleansed,  etc.,  and  the  uterus  was  held  forward, 
the  round  ligaments  being  stitched  to  the  anterior  ab- 
dominal wall.  The  patient  made  a  good  recovery, 
though  she  complained  of  pelvic  pain  and  had  a  profuse 
uterine  discharge  for  some  time  after  the  operation,  for 
which  she  was  treated  locally  until  it  cleared  up.  This 
was  undoubtedly  a  gonorrheal  case.  The  uterus  is  now 
in  good  position  and  the  patient  free  from  pain,  though 
she  has  never  had  children. 

Case  three,  unmarried.  Done  at  Woman's  Hospital 
the  past  summer.  In  this  case  suspected  gonorrhoea  to 
be  cause  of  retroflexion  and  adhesions.  Patient  had 
been  in  hospital  a  long  time,  complained  of  much  pain, 
had  recurrent  attacks  of  pelvic  peritonitis,  and  did  not 
improve  with  treatment.  Laparotomy  performed.  Con- 
siderable ascites  in  abdominal  cavity,  adhesions  all  broken 
up.  Uterus  held  forward  by  stitching  round  ligaments 
to  anterior  wall.  In  this  instance  tubes  were  not  divided 
and  thorough  curettement  was  not  done,  although  it  is 
my  custom  to  do  it  thoroughly  in  cases  where  I  suspect 
gonorrhoea.  The  uterus  was  held  in  good  position  by 
operation.  Patient  did  very  well  indeed  for  ten  days, 
when,  three  days  after  removal  of  sutures  a  small  abscess 
appeared  in  the  lower  end  of  the  abdominal  wound.  This 
was  opened  at  once,  and  within  a  few  days  there  developed 
phlebitis  of  right  leg  and  she  was  confined  to  her  bed  for 
some  weeks.  The  position  of  the  uterus  was,  however, 
good,  and  the  organ  fairly  movable.  In  this  case  I  believe 
there  must  have  been  some  infection  of  the  tubes  before- 
hand. I  am  not  aware  of  the  present  condition  of  this 
patient,  but  I  am  not  inclined  to  believe  that  she  has  been 
perfectly  relieved.  Probably  another  operation  will  be 
necessary  to  effect  a  cure. 

In  dealing  with  the  uterus  itself  it  is  also  well  to  be 
most  conservative,  and  at  present  we  are,  I  think,  too 
much  given  to  extirpation  for  a  simple  fibrous  growth  of 
the  organ,  and  even  a  simple  pyosalpinx. 

I  do  not  wish  to  convey  the  idea  that  I  do  not  believe 
in  extirpation  of  the  uterus  when  there  is  any  suspicion  of 
malignancy,  or  even  when  the  uterus  is  riddled  with  pus, 
for  my  views  in  these  cases  are  radical.  Immediate  and 
thorough  removal  of  the  uterus  and  all  available  tissues, 
is  then,  in  my  opinion,  the  only  proper  course  to  pursue. 
I  should  like,  however,  clearly  to  express  myself  as  being 
utterly  opposed  to  removal  of  uterus  for  a  small,  simple 
fibroid,  or  for  a  pyosalpinx,  unless  the  uterus  itself  is 
thoroughly  riddled  with  the  geims.  In  support  of  this 
position  I  refer  to  several  cases  in  which  a  cure  has  ap- 
parently been  effected. 

Case  I. — Mrs.  M ,  private  patient  of  my  friend 

Dr.  J.  A.  Campbell,  with  whom  I  saw  patient,  in  con- 
sultation, October,  1892.  The  case  had  been  previously 
diagnosed  by  us,  and,  after  consultation,  we  concluded 
to  remove  the  fibroid,  and,  if  possible,  without  removing 


i68 


MEDICAL    RECORD. 


[August  ii,  1894 


uterus  or  ovaries,  as  the  patient  w*as  most  anxious  to  have 
children.  Laparotomy  was  done.  Dr.  Campbell  assisting 
me,  early  in  November,  1892.  A  large  fibroid,  weighing 
six  and  a  half  pounds,  was  removed  from  the  fundus  of 
uterus,  care  being  taken  to  dissect  off  the  peritoneal  coat 
and  turn  it  over  or  back.  After  this  was  done  a  curved 
scissors  was  used  in  cutting  off  as  much  of  the  surround- 
ing tissue  as  possible.  In  fact  it  was  removed  down  to 
uterine  tissue.  Then  the  peritoneal  flaps  that  had  been 
sewed  were  sutured  over  with  a  continuous  silk  stitch, 
thus  covering  the  raw  excavated  surface.  The  ovaries 
and  tubes  were  fairly  normal  and  were  left  intact.  An- 
other small  fibroid,  about  the  size  of  a  small  eggt  was  re- 
moved. Patient  made  an  excellent  recovery  under  Dr. 
Campbell's  management,  and  within  a  few  days  Dr. 
Campbell  has  reported  to  me  that  the  patient  is  pregnant 
about  seven  months,  and  is  apparently  in  first- class  con- 
dition. 

Case  II. — Mrs.  C ,  operated  on  June,  1893,  at 

Cancer  Hospital.  Large  fibro  cystic  tumor  of  ovary  and 
tube,  weighing  about  eight  pounds,  and  consisting  prin- 
cipally of  solid  fibrous  tissue,  with  small,  broken-down 
cavity  in  its  centre.  This  stump  was  very  large  and  was 
treated  similarly  to  the  one  just  mentioned.  Patient 
made  a  good  recovery,  and  has  gained  about  forty  pounds 
since  the  removal  of  the  tumor.  She  is  now  perfectly 
well. 

I  must  confess  that  in  this  last  case  my  first  thought 
was  to  extirpate  the  uterus  also,  but  I  believe  the  woman 
is  very  much  better  for  having  the  uterus  and  other  ap- 
pendages left.  I  have  shelled  out  a  number  of  fibroids 
from  uterine  wall  by  doing  laparotomy  first,  then  cutting 
into  the  uterine  wall  and  shelling  fibroid  out.  After 
which  the  two  uterine  edges  are  stitched  together  with 
continuous  catgut  or  silk  suture.  My  results  in  a  con- 
siderable number  of  these  cases  have  been  invariably 
good,  and  I  can  unhesitatingly  recommend  this  pro- 
cedure. 

I  have,  in  addition,  removed  a  number  of  large  fibrous 
growths  from  broad  ligaments,  the  first  about  two  years 
ago  in  private  work,  and  the  last  very  recently  at  the 
Cancer  Hospital.  The  growths  ranged  in  size  from  a 
small  orange  to  a  man's  fist  In  most  of  these  cases  the 
tubes  and  ovaries  were  apparently  normal  and  were  left. 
But  in  the  last  case  the  tube  and  ovary  on  the  side  where 
the  growth  was  situated  were  removed,  as  they  were  bruised 
rather  much  in  the  removal  of  the  tumor,  which,  as  can 
be  easily  understood  from  the  situation  in  the  broad  liga- 
ment and  extending  down  below  the  cervix,  was  very 
difficult  indeed  to  remove  without  removing  the  uterus 
and  all.  All  these  cases  have  been  satisfactory,  and  the 
last  one  will,  I  believe,  prove  a  success  in  every  way. 

I  have  also  operated  successfully  in  a  number  of  liga- 
mentous cysts.  In  most  of  these  I  have  been  successful 
in  saving  the  tubes  and  ovaries.  Much  care  is  always 
taken,  after  the  removal  of  the  intra  ligamentous  cysts  and 
fibroids,  to  stitch  the  divided  surfaces  of  the  broad  liga- 
ments together,  thus  preventing  many  adhesions  and 
much  inflammatory  exudate ;  in  other  words,  leaving  the 
pelvic  organs  in  as  normal  a  condition  as  possible. 

A  good  rule  in  conservative  surgery,  or  in  abdominal 
surgery  of  any  kind,  is  to  cover  all  denuded  surfaces  where- 
ever  there  is  available  tissue  with  which  to  do  it. 

In  closing,  I  would  say  that  as  soon  as  the  abdominal 
cavity  is  opened,  and  before  systematically  attempting  re- 
moval of  any  abdominal  or  pelvic  growth,  it  is  of  the 
highest  importance,  in  every  case,  to  make  an  exact  diag- 
nosis of  the  appendages,  uterus,  and,  in  fact,  of  the  gen- 
eral abdominal  cavity. 

Further,  it  must  never  be  forgotten  that  to  be  conser- 
vative in  the  matter  of  removing  organs  that  can  be  saved 
is  the  highest  and  most  advanced  surgery. 


The  Medioal  Officer  of  Health  to  the  City  of  London 
receives  a  salary  of  $7,500,  and  an  additional  sum  of 
$1,000  as  analyst;  but  he  is  obliged  to  give  his  whole 
time  to  the  duties  of  the  office. 


A  CASE  OF  CHRONIC  PERITONITIS,  WITH  IN- 
TESTINAL  AND  ABDOMINAL  FISTULA— EN- 
TERORRHAPHY— RECOVERY.1 

By  FREDERICK  HOLME  WIGGIN,   M.D., 

PRESIDENT  OF  TUB  SOCIETY  OF  ALU  MM  I  OF  BtLLSVUS  HOSPITAL  ;   VISITING  SUK- 
GBOM  TOTHI  CITV  HOSPITAL,   GrNKCOLOGICAL  DIVISION. 

The  three  great  dangers  the  surgeon  has  to  encounter  in 
dealing  with  the  abdomen  and  its  viscera  are  sepsis, 
hemorrhage,  and  intestinal  adhesions.  Of  these  the  last 
is  by  no  means  of  the  least  importance.  When  not  caus- 
ing immediate  death  by  intestinal  obstruction,  it  fre- 
quently defeats  the  object  of  surgical  interference — the 
complete  restoration  of  the  patient  to  health;  and  in 
many  cases,  while  removing  the  danger  of  sepsis,  it  sub- 
stitutes that  of  intestinal  obstruction ;  while  the  pain  is 
relieved  for  a  short  time  only,  if  at  all. 

The  attention  of  the  writer  was  forcibly  drawn  to  this 
subject,  some  years  since,  by  the  inspection  of  an  abdomi- 
nal cavity  and  its  contents  in  a  patient  who  had  died  of 
intestinal  obstruction  twelve  months  after  an  apparently 
successful  operation  for  pyosalpinx.  This  examination 
revealed  such  extensive  adhesion  of  the  intestines  that 
the  question  arose  whether  the  patient  would  not  have 
been  better  off  if  the  original  operation  had  not  been 
performed.  The  conditions  found  would  have  made  an 
operation  for  the  relief  of  the  obstruction,  which  was  by 
a  band  low  down  in  the  pelvis,  impossible.  The  opera- 
tion was  performed  in  strict  accordance  with  the  tech- 
nique of  the  day,  and  was  not  followed  by  any  signs  of 
sepsis.  The  wound  healed  primarily,  the  patient's  bowels 
moved  early,  and  in  fact  she  made  a  rapid  recovery. 
But  although  her  sepsis  was  relieved,  her  pain  soon  re- 
turned, and  she  had  at  short  intervals  recurring  attacks 
of  intestinal  obstruction  which  were  easily  overcome  by 
mild  measures.  Finally,  being  away  from  her  home 
when  an  attack  of  intestinal  obstruction  came  on,  her 
physician,  ignoring  her  previous  history,  gave  croton-oil 
and  other  cathartics ;  the  violent  peristalsis  induced  forced 
such  an  amount  of  gut  under  a  band  that  it  became 
strangulated,  and  after  some  days1  delay  it  became  gan- 
grenous and  perforated,  with  a  fatal  result.  A  similar  his- 
tory has  followed  successful  operations  of  this  nature  so 
often  that  the  question  is  frequently  asked,  Does  surgery 
do  what  it  claims— cure  the  patient? 

The  gynecological  service  at  the  City  Hospital  re- 
ceives, for  one  reason  or  another,  many  cases  that  have 
had  celiotomies  performed  at  other  New  York  hospitals, 
which  have  eventuated  in  adhesions,  sinuses,  and  ventral 
hernias.  They  are  sent  here  for  secondary  operations, 
having  been  probably  reported  in  good  faith  by  the 
operators  as  "  successful  "  cases.  It  is  for  the  purpose  of 
calling  attention  to  this  subject  of  intra- peritoneal  adhe- 
sions, and  to  offer  a  suggestion  for  their  prevention,  as 
well  as  to  provoke  discussion,  that  the  report  of  the  fol- 
lowing case,  which  has  given  the  title  to  this  paper,  is  of 
interest. 

A.  W ,  a  female,  about  twenty-three  years  of  age, 

was  admitted  to  the  Penitentiary  Hospital  on  BlackweU's 
Island,  April  27,  1892.  Her  history  previous  to  coming 
under  my  care  in  February,  1894,  is  as  follows :  She  said 
that  after  her  first  menstruation,  which  took  place  at  the 
age  of  thirteen  years,  she  had  had  an  attack  of  spinal 
meningitis,  and  had  not  menstruated  again  for  two  years. 
Then  menstruation  had  gone  on  regularly,  and  had  been 
of  the  tri  weekly  type.  It  had  been  profuse,  lasting 
seven  days,  and  being  accompanied  by  much  pain.  She 
had  had  no  children.  One  miscarriage  at  five  months 
had  occurred  during  the  summer  of  1891.  Soon  after 
this  she  had  had  a  syphilitic  eruption,  with  pains  in  her 
bones  and  an  iritis.  During  the  winter  of  1890-91  she 
had  had  a  localized  pain  in  the  left  inguinal  region,  which 
had  been  more  severe  at  the  menstrual  periods.  There 
had  also  begun  to  be  difficulty  and  pain  on  defecation. 

»  Read  before  the  Fifth  District  Branch  of  the  New  York  State  Med- 
ical Association,  at  its  Tenth  Annual  Meeting,  held  in  Brooklyn,  May 
32,  1894. 


August  ii,  1894] 


MEDICAL   RECORD. 


169 


In  the  autumn  of  1891,  she  had  received  a  kick  over  the 
seat  of  pain,  and  after  this  the  pain  had  become  worse, 
and  had  been  accompanied  by  constant  headache  and 
nausea.  She  had  then  become  addicted  to  the  use  of 
morphia  and  cocaine.  Her  bowels  had  moved  regularly. 
It  is  noted  in  the  hospital  records  that  a  vaginal  examina- 
tion, made  in  May,  1892,  showed  her  uterus  to  be  slightly 
anteflexed,  enlarged,  and  tender,  with  a  pin-hole  os,  and 
the  left  ovary  to  be  somewhat  enlarged.  Again,  on  No- 
vember 30th,  a  vaginal  examination  revealed  the  left  ovary 
enlarged  to  the  size  of  a  hen's  egg,  and  also  a  salpingitis 
of  the  right  tube.  Rectal  examination  disclosed  a  strict- 
ure at  two  inches  from  the  anus. 

On  December  14,  1892,  the  rectal  stricture  was  incised 
and  divulsed,  and  on  January  6,  1893,  a  coeliotomy  was 
performed,  and  both  tubes  and  ovaries  removed.  In 
breaking  up  the  adhesions  about  the  right  tube,  it  was 
ruptured,  and  some  yellowish  pus  escaped  into  the  peri- 
toneal cavity.  It  was  removed  by  sponges  wrung  out  in 
a  1  to  20  carbolic  acid  solution.  No  further  particulars 
are  given  except  that  the  wound  was  closed  by  silkworm- 
gut  sutures  passing  through  all  the  layers.  Primary 
union  occurred  except  at  one  point,  near  the  lower  angle 
of  the  incision.  A  week  after  the  operation  a  probe  was 
introduced  at  this  point,  and  pus  welled  up  from  the 
wound.  On  the  fourth  day  after  the  operation  there 
was  a  free  escape  of  pus  from  her  rectum.  Notwithstand- 
ing her  sepsis  her  bodily  temperature  did  not  rise  above 
ioo°,  and  no  antipyretics  were  used. '  On  August  14, 
1893,  it  is  recorded  that  the  sinus  still  persisted,  and  that 
the  patient  was  suffering  much  pain.  A  secondary  coeli- 
otomy was  performed  by  the  surgeon  on  duty.  After 
the  incision  had  been  made,  so  many  and  firm  adhesions 
were  found  that  the  wound  was  closed  without  any  fur- 
ther interference.  After  the  wound  had  healed,  the 
sinus  remained  patent,  and  the  former  symptoms  contin- 
ued unabated.  A  vaginal  examination  made  in  Decem- 
ber, 1893.  revealed  a  large  tumor  on  the  patient's  right 
side,  which  was  very  painful.  The  propriety  of  an  oper- 
ation was  considered,  but  before  it  was  done  there  was  a 
free  discharge  of  pus  per  rectum,  and  the  tumor  subsided. 

On  taking  charge  of  this  service,  February  1st  of  this 
year,  I  found  this  patient  in  a  deplorable  condition,  suf- 
fering from  continuous  pelvic  pain.  Examining  her 
with  one  hand  on  the  abdomen  and  the  other  in  the 
vagina,  a  decided  resistance  and  fulness  were  encoun- 
tered, and  there  was  marked  tenderness  in  the  right  iliac 
fossa.  The  uterus  was  fixed.  The  sinus  at  the  lower 
angle  of  the  old  cicatrix  was  patent,  and  discharged  pus. 
A  rectal  examination  revealed  a  stricture  of  large  calibre, 
and  an  ulceration  at  two  inches  from  the  anus.  The  pa- 
tient earnestly  requested  that  something  be  done  for  her 
relief.  After  careful  consideration  of  the  case,  operation 
was  decided  upon,  and  performed  on  February  14th. 

The  incision  was  made  in  the  line  of  the  old  cicatrix, 
splitting  the  sinus,  which  was  found  to  pass  into  a  cavity 
formed  by  adhesions  of  the  intestines  to  the  anterior  ab- 
dominal wall,  to  themselves,  and  to  the  uterus,  and 
bounded  in  front  by  the  bladder.  Into  this  cavity  was 
poured  a  fifteen-volume  solution  of  hydrogen  dioxide, 
and  after  this  had  been  allowed  to  remain  for  a  few  min- 
utes, it  was  sponged  away  and  the  adhesions  broken  up. 
As  the  intestine  was  freed  from  the  right  side  of  the 
uterus,  a  fistulous  opening  was  discovered,  which  was 
closed  as  soon  as  the  intestine  had  been  sufficiently  freed 
to  allow  of  its  being  brought  outside  of  the  abdomen. 
This  closure  was  effected  by  scarifying  the  peritoneal  coat 
of  the  upper  side,  the  lower  side  being  already  denuded, 
and  by  introducing  a  single  row  of  Lembert  suture. 
The  appendix  was  adherent  low  down  in  the  right  iliac 
fossa,  and  was  freed,  but  not  removed.  After  the  adhe 
sions  which  formed  this  abscess  cavity  had  been  broken 
up  the  intestines  were  found  to  be  very  much  tangled 
and  matted  together.  These  adhesions  were  broken  up 
partly  by  the  finger,  and  partly  by  dissection.  The 
omentum,  which  was  adherent,  was  ligated  and  removed. 
At  one  point  the  peritoneal  coat  of  the  intestine  was 


ruptured  over  an  area  "measuring  %  X  J^  of  an  inch. 
It  was  repaired  by  Lembert  sutures.  The  hydrogen 
dioxide  was  freely  poured  into  the  peritoneal  cavity,  and 
after  a  little  delay,  the  cavity  was  flushed  with  normal 
salt  solution  (0.6  per  cent.),  and  the  cavity  left  full  of  the 
same.  The  temperature  of  the  solution  was  1150  F. 
The  edges  of  the  old  sinus  were  scraped  with  the  sharp 
spoon,  and  the  wound  closed  with  silkworm  gut  sutures 
passing  through  all  the  layers.  No  drainage  was  em- 
ployed. The  time  occupied  by  the  operation  was  two 
hours.  Only  eight  ounces  of  ether  were  used,  but  the 
patient  took  the  ether  badly,  and  this  much  prolonged 
the  operation.  Although  suffering  from  shock,  she  ral- 
lied well  on  the  introduction  of  hot  saline  solution  into 
the  abdominal  cavity,  aided  by  the  hypodermic  injections 
of  glonoin  and  strychnia.  Her  bowels  moved  shortly 
after  the  conclusion  of  the  operation,  and  again  on  the 
third  day,  although  morphia  was  employed  more  or  less 
freely.  No  cathartics  were  given  after  this,  her  bowels 
moved  regularly  several  times  a  day.  The  patient  had 
very  little  nausea.  Beef  peptonoids  were  given  within 
twelve  hours  after  the  operation,  and  were  followed  by 
peptonized  milk  and  semi  liquid  food  on  the  fourth  day. 
Her  temperature,  pulse,  and  respiration  became  normal  on 
the  sixth  day.  Her  pain  was  relieved.  The  wound 
healed  primarily  throughout.  Following  the  operation, 
there  was  a  decided  improvement  in  her  general  appear- 
ance. On  March  20th,  it  was  noted  that  she  was  in 
better  health  than  she  had  been  for  two  years  previously. 
A  vaginal  examination  at  this  time  showed  the  uterus  to 
be  freely  movable.  There  was  no  evidence  of  adhesions 
or  of  tenderness  in  the  pelvis.  Six  weeks  after  the  oper- 
ation the  patient  was  in  sufficiently  good  condition  to 
submit  to  the  removal  of  three  inches  of  her  rectum,  and 
she  is  now  in  good  health,  with  the  exception  of  some 
nervous  disorder. 

As  the  technique  has  been  alluded  to,  it  may  be  well 
to  state  that  in  this,  as  well  as  in  all  other  abdominal 
operations  performed  within  the  past  eighteen  months  by 
the  writer,  all  chemicals  except  hydrogen  dioxide  have 
been  avoided,  reliance  being  placed  entirely  on  steriliza- 
tion of  instruments  by  boiling,  and  on  the  use  of  steri- 
lized salt  solution,  with  the  avoidance  of  the  use  of 
sponges.  The  main  point  of  interest  in  this  case,  aside 
from  the  number  of  celiotomies  submitted  to  by  this  pa 
tient,  and  the  severity  of  the  last  one,  is  the  free  user  of 
the  hydrogen  dioxide  for  the  purpose  of  destroying  the 
old  abscess  cavity  before  breaking  up  the  adhesions,  and 
the  closing  of  the  abdominal  cavity  after  filling  it  with 
the  saline  solution,  for  the  definite  purpose  of  preventing 
the  formation  of  new  adhesions.  Further  experience 
gathered  during  the  past  winter  has  confirmed  the  claim 
made  in  a  former  paper,  that  closing  the  abdominal  cav- 
ity after  filling  it  with  hot  sterilized  salt  solution,  lessens 
shock,  prevents  the  formation  of  adhesions,  aids  in  the 
readjustment  of  the  intestine  and  omentum  to  their 
proper  position,  and  lessens  the  danger  of  septic  perito 
nitis.  To  this  I  may  add  that  after  operations  where  it  is 
so  used  there  is  little  nausea,  and  an  absence  of  the  in- 
satiable thirst  which  formerly  tormented  these  patients, 
and  that  the  bowels  act  more  freely,  often  of  their  own 
accord,  in  spite  of  the  fact  that  morphia  is  used  whenever 
indicated  on  account  of  restlessness.  My  opinion  is  con- 
firmed in  the  belief  that  hydrogen  dioxide  is  a  safe  and 
sure  disinfectant  for  the  peritoneal  cavity.  I  have  used 
it  with  satisfactory  results  in  more  than  twenty  cases. 

In  conclusion,  I  would  like  to  call  attention  to  the 
fact  that,  although  the  duration  of  the  operation  was  two 
hours,  only  eight  ounces  of  ether  were  used.  The  shock 
following  an  operation  is,  in  my  experience,  more  de- 
pendent on  the  amount  of  ether  employed  than  on  the 
duration  of  the  operation,  although  this  is  of  importance. 
Had  not  experience  given  me  faith  that  by  the  use  of 
salt  solution  adhesions  once  broken  up  could  be  pre- 
vented from  reforming,  that  in  hydrogen  dioxide  there 
is  a  safe  and  certain  weapon  for  preventing  and  over- 
coming sepsis  in  the  peritoneal  cavity,  and  that  with  the 


170 


MEDICAL   RECORD. 


[August  il,  1894 


closed  ether  inhaler  a  long  operation  could  be  performed 
with  the  minimum  amount  of  ether,  and  therefore  with 
little  shock,  the  above  described  operation  would  not 
have  been  justifiable,  and  would  not  have  been  under- 
taken. 

55  West  Thirty-sixth  Street. 


INTERNAL   URETHROTOMY  FOR  STRICTURE. 
By  T.  E.  SCHUMPERT,  M.D., 

SHREVKFORT,   LA. 

SURGEON    SHRHVEPORT    CHARITY    HOSPITAL,   AND    MEMBER    NATIONAL  ASSOCIA 
TION   RAILROAD  SURGEONS. 

In  discussing  the  treatment  of  stricture  of  the  urethra 
this  paper  concerns  organic  stricture  only ;  but  before 
entering  upon  its  treatment  proper,  we  will  recapitulate 
briefly  the  pathology  of  stricture,  and  look  casually  at  the 
anatomy  of  the  penis;  by  so  doing  we  will  be  better  able 
to  treat  intelligently  this  disease.  Its  idiopathic  etiology 
in  vastly  the  majority  of  cases  is  gonorrhoea,  though  we 
do  have  some  cases  from  traumatism  to  the  perineum  or 
urethra,  by  say  a  kick,  a  fall  astride  a  box  or  fence,  a 
bruise  while  riding  bare-back,  or  on  the  horn  of  a  saddle, 
by  the  use  of  imperfect  instruments,  or  breaking  one  in 
the  urethra.  It  is  claimed  by  some,  too,  that  strictures 
are  caused  by  too  strong  injections.  I  believe  it  is  pos- 
sible to  make  an  injection  strong  enough  to  produce  a 
stricture  by  using  some  very  powerful  caustic,  but  in 
meeting  the  indications  of  a  gonorrhoea,  this  is  but  rarely 
if  ever  done,  the  subsequent  stricture  to  these  gonorrhoea 
injections  being  only  coincident.  I  use  at  pleasure  for 
cystitis  a  ten,  fifteen,  or  even  twenty  grain  to  the  ounce 
argent,  nitrosae  solution,  injected  into  the  bladder  after 
a  thorough  catheterization,  and  allow  the  patient  to 
void  it  through  the  urethra,  without  any  evil  effects.  It 
is  what,  then,  that  produces  it  in  gonorrhoea  ?  The  ure- 
thritis per  se.  Eighty  five  per  cent,  of  all  strictures  are  so 
caused. 

The  male  urethra  is  about  eight  inches  long,  and 
divided  into  the  prostatic  (one  and  one -half  inch), 
membranous  (three-quarter  inch),  and  spongy  or  pendu- 
lous portion  which  occupies  the  remainder  of  its  length. 
It  is  flexible  and  of  an  unequal  breadth  at  each  of  the 
different  divisions,  being  broadest  at  the  prostatic, 
narrower  at  the  spongy,  and  narrowest  at  the  membra- 
nous portion,  and  any  portion  of  the  urethra  that  is  not 
dilatable  is  strictured.  The  urethra  is  related  to  the  cor- 
pora cavernosa  as  a  ramrod  is  to  the  barrel  of  a  double- 
barrelled  shotgun,  the  corpora  cavernosa  incorporating 
about  one-third  the  circumference  of  same  when  distend- 
ed, with  its  sides  not  in  apposition  as  the  meatus  would 
seem  to  indicate,  but  the  roof  and  floor  kiss  each  other 
in  perfect  co-aptation. 

Stricture  may  be  of  such  a  mild  type  as  only  to  involve  a 
thickening  of  the  mucous  membrane,  or  the  inflammatory 
process  may  lead  out  and  invade  the  delicate  erectile  tis- 
sue, thereby  causing  a  proliferation  of  the  connective- 
tissue  element  and  an  increase  in  the  thickness,  density, 
and  non-elasticity  of  this  membrane  at  the  site  of  strict- 
ure, which  may  be  single  or  multiple.  This  pathologi- 
cal process  takes  place  just  beneath  the  mucous  mem- 
brane, and  not  on  its  surface,  as  was  formerly  believed, 
and  as  the  stricture  grows  older  this  transverse  non- 
elastic  band  grows  tighter  and  contracts  more  firmly. 
We  have  linear,  annular,  and  tortuous  strictures.  They 
are  also  divided  into  passable  and  impassable,  according 
to  their  degree  of  perviousness  to  a  filiform  bougie ;  of 
course,  if  this  instrument  can  be  made  to  enter,  it  falls 
under  the  former  class,  but  if  this  be  impossible,  under 
the  latter. 

About  seventy  five  per  cent,  of  strictures  are  single. 
Otis  places  the  location  of  the  majority  of  strictures 
within  one  and  one  quarter  inch  of  the  meatus,  the 
next  most  common  site  being  about  the  middle  of  the 
pendulous  urethra.  Thomas  has  failed  to  find  in  two 
hundred  and  seventy  autopsies,  or  in  any  patient,  a  pros 
tatic  stricture,  i  e.y  a  stricture  within  one  and  a  half 


inch  of  the  bladder,  that  portion  also  which  lies  beneath 
and  behind  the  arch  of  the  pubis,  and  which  therefore 
from  the  field  of  operation  is  most  obscure  and  diffi- 
cult of  access.  Walsh  found  in  one  hundred  and  eighty- 
five  cases  one  stricture  of  the  membranous  urethra  that 
involved  also  a  portion  of  the  prostatic  urethra,  so  we 
may  very  safely  eliminate  this  portion  of  the  urethra 
from  the  stricture  field;  and  the  fact  that  this  can 
be  done  is  but  another  trace  of  the  Almighty's  wise  and 
sympathizing  hand,  for  even  though  he  has  rightfully 
cursed  the  nation  with  this  malady,  he  places  it  within 
comparatively  easy  reach  of  the  surgeon.  Strictures  do 
occur,  however,  sometimes  as  far  back  as  the  posterior 
membranous  urethra,  i.e.,  four  and  one-half  to  six  inches 
from  the  meatus. 

It  is  a  popular  idea  with  the  majority  of  our  profession 
(prejudiced  by  results  antedating  antisepsis)  that  the  cut- 
ting operation  should  be  the  last  resort,  that  it  should  be 
used  when  all  else  has  failed,  as  the  last  alternative,  and  the 
instruments  recommended  for  this  little  operation  are  al- 
most too  numerous  to  mention ;  but  among  the  most  promi- 
nent are  filiform  bougies,  bougies  not  filiform,  sounds, 
guides,  probes,  rapid  dilators,  urethrotomes,  directors  me- 
atometa,  urethrometa,  bistouries,  etc.  I  think  the  reason 
the  average  practitioner  doesn't  operate  on  his  own  cases, 
but  instead  takes  them  to  a  surgeon  or  a  specialist,  is  be- 
cause whenever  the  patient  is  presented  the  operator 
shoves  under  the  practitioner's  nose  such  an  elaborate  dis- 
play of  mysterious  instruments,  all  of  which  the  latter, 
without  thinking,  believes  to  be  necessary  to  make  the  ex- 
amination or  perform  the  operation,  that  he  himself  is 
humiliated,  and  the  magnitude  of  the  operation  propor- 
tionately exaggerated.  I  have  a  record  of  thirty*  nine 
urethrotomies  performed  by  myself,  thirty  five  of  which 
were  internal,  including  four  impassable ;  the  remaining 
four  were  external  urethrotomies.  The  latter  were  among 
the  first  operations  on  the  urethra  that  I  ever  did ;  they 
were  two  with  and  two  without  a  guide,  one  of  which 
gave  me  as  much  trouble  during  the  performance  of  the 
operation,  and  caused  me  as  much  apprehension  during 
the  after  treatment,  as  any  surgery  I  have  ever  participated 
in.  I  have  since  become  so  impressed  in  favor  of  the 
internal  operation  that  I  have  never  yet  had  occasion  to 
return  to  it  again.  I  have  treated  a  great  many  strictures 
by  dilatation,  but  so  far  as  my  experience  goes  it  has  only 
been  palliative,  for  most  invariably  the  patient  would  re- 
turn again  during  the  course  of  a  few  years  with  his  same 
old  trouble,  notwithstanding  the  fact  that  he  had  been 
taught  and  ordered  to  use  the  bougie  himself  once  or  twice 
a  month.  This  was  not  done,  of  course,  or  it  could  not 
have  possibly  closed ;  but  at  the  same  time,  as  long  as  it 
is  necessary  to  use  an  instrument  this  disease  cannot  be 
considered  cured.  I  find  that  internal  urethrotomy  gives 
the  best  results  and  is  justifiable  in  any  case  occupying 
the  pendulous  urethra,  and  all  strictures  that  I  have  yet 
seen  in  this  locality  are  accessible  by  the  method  which 
I  am  about  to  detail,  which  requires  a  set  of  sounds,  a 
bistoury,  grooved  director,  and  a  set  of  bulbous  bougies  or 
urethrometer ;  this  latter  instrument,  however,  is  not  es- 
sential, though  it  may  often  be  used  very  conveniently  in 
locating  strictures  and  testing  their  extent.  It,  at  any 
rate,  is  a  very  ingenious  little  instrument,  and  reflects 
credit  on  its  inventor,  Professor  Otis.  It  is  generally 
conceded  by  the  profession,  I  believe,  that  bougies  or 
sounds  should  be  used  if  it  be  possible  to  pass  one ;  if  re- 
peated efforts  be  made  without  avail,  however,  then  ex- 
ternal urethrotomy  as  the  last  alternative  must  be  resorted 
to ;  but  before  proceeding  with  this  cutting  operation, 
while  the  patient  is  yet  under  the  anaesthetic,  they  say 
another  attempt  must  be  made  at  introducing  a  filiform 
bougie,  which,  if  successful,  defers  the  operation  perhaps 
indefinitely.  For  an  external  urethrotomy  it  is  best  to 
make  an  incision  two  and  a  half  or  three  inches  long, 
and  the  greatest  precautionary  measures  must  be  observed 
if  performed  without  a  guide,  else  serious  damage  might 
be  inflicted ;  the  wound  is  then  left  to  heal  by  granula- 
tion.  All  impassable  strictures  are  said  to  be  suitable  cases 


August  ti,  1894] 


MEDICAL    RECORD. 


171 


for  this  operation,  but  none  else.  The  wound  made  in 
an  external  urethrotomy  is  necessarily  large,  the  opera- 
tion a  long  and  tedious  one,  two  hours  at  times  may  be 
employed  in  performing  it,  fever  runs  high;  it  is  with 
difficulty  the  patient  is  kept  clean,  and  the  operation  is  not 
at  all  free  from  danger.  Wyeth,  Otis,  Thompson,  and 
quite  a  number  of  others  have  invented  instruments  for 
internal  urethrotomies ;  these  instruments  are  necessarily 
large,  heavy,  and  therefore  cumbersome ;  the  blade  of 
none  of  them  extends  beyond  the  shaft,  and  therefore  are 
not  intended  for  impassable  strictures ;  they  do  beautiful 
work,  however,  on  strictures  admitting  a  No.  7  sound. 

The  bistoury  which  I  use  has  a  perfectly  straight  shank, 
seven  inches  long,  with  a  blade  extending  from  its  point 
one-half  inch  back,  and  presenting  not  exceeding  one- 
quarter  of  an  inch  beyond  the  front  surface  of  the  shank ; 
the  back  of  the  blade  is  exactly  on  a  straight  line  with  the 
back  ot  the  shaft,  even  to  its  point.  My  grooved  di- 
rector is  seven  inches  long  and  fork  shaped,  with  the  han- 
dle of  the  fork  representing  the  groove  of  director  and  the 
prongs  the  handle ;  it  is  made  of  sufficient  strength  to  ad- 
mit of  considerable  pressure  without  bending ;  the  strength 
of  the  director,  however,  must  not  lie  in  its  back,  but 
sides  only,  as  the  back  must  be  thin  in  order  to  allow  the 
back  of  the  knife  to  approach  as  nearly  as  possible  the  roof 
of  the  urethra,  thus  enabling  the  operator  to  incise  the 
stricture  through  its  entire  diameter.  Now,  the  patient 
having  been  placed  in  the  usual  position,  and  a  stricture 
diagnosed,  if  it  be  meatal  surgeons  all  agree  that  it  should 
be  cut  with  a  bistoury,  and  in  this  locality  a  director  is 
not  indicated ;  but  if  it  be  lower,  this  latter  instrument 
becomes  imperative.  With  the  grooved  director  and  bis- 
toury which  I  have  described,  all  pendulous  strictures 
have  fallen  in  the  field  of  internal  urethrotomy  and  easily 
available.  The  penis  is  held  at  right  angles  to  the  body 
with  the  left  hand  of  an  assistant,  while  with  his  right  he 
holds  the  director  firmly  against  its  roof,  with  the  groove 
of  director  presenting  toward  the  patient's  feet,  the  penis 
in  the  meanwhile  being  kept  somewhat  extended.  If  the 
stricture  be  passable,  the  operator  then,  with  the  bistoury 
in  his  right  hand,  glides  it  down  the  director  until  in  the 
locality  of  the  stricture,  this  point  being  marked  by  the 
thumb  and  second  finger  of  his  left  hand,  which  press 
gently  the  sides  of  corpora  cavernosa  in  aiding  to  keep  it 
perfectly  steady,  while  the  index  finger  is  held  in  the  same 
locality  but  against  corpora  spongiosa  to  direct  the 
blade  of  the  knife,  which  may  plainly  be  felt  as  it  cuts 
through  the  stricture,  first  in  front,  then  on  either  side. 
If  the  stricture  be  impassable,  the  director  is  introduced 
until  its  blunt  end  comes  in  contact  with  the  face  of  the 
stricture,  the  penis  being  held  as  before  if  in  the  upper 
pendulous  portion  ;  but  if  lower  and  possibly  in  the  an- 
terior membranous  urethra,  after  the  director  and  knife 
have  been  introduced  beyond  suspensory  ligament,  the 
penis  is  tilted  forward  to  an  angle  of  about  45  °,  the  di- 
rector pressed  firmly  in  the  direction  of  symphysis  pubis 
and  downward  until  in  contact  with  the  stricture ;  the 
knife  is  now  pressed  well  back  against  the  director,  then 
downward  until  the  resisting  stricture  yields ;  three  inci- 
sions are  then  made  as  before  described.  By  actual  ex- 
periment on  the  cadaver,  I  find  that  I  am  able  to  reach  in 
most  cases  by  this  means  the  membranous  urethra.  This 
operation  is  extremely  simple,  very  easy,  and  usually  re- 
quires but  five  or  ten  minutes,  is  performed  with  a  very 
limited,  inexpensive  outlay  of  instruments,  and  I  never 
expect  an  untoward  result ;  is  more  cleanly,  as  the  urine  is 
voided  per  viam  naturalem  instead  of  through  a  vicarious 
passage  in  a  very  clumsy  location.  The  main  points  to 
be  guarded  are,  first,  to  have  a  reliable  assistant,  who 
will  hold  the  penis  and  director  perfectly  steady  and  ex- 
actly as  directed  by  the  operator,  who  must  himself  see  to 
it  that  the  end  of  director  is  in  contact  with  face  of 
stricture,  that  it  is  in  perfect  line  with  the  penis,  and  be 
very  careful  to  pass  his  knife  exactly  in  that  line.  After- 
treatment  consists  in  first  washing  out  the  urethra  with 
peroxide  hydrogen,  then  injecting  copiously  with  gr.  vj. 
to   §  j.  of  boracic  acid ;  this  is  done  seven  or  eight  times 


during  twenty  four  hours,  until  all  discharge  ceases,  and 
a  large  sound  introduced  once  in  four  or  five  days  for  the 
first  month,  once  a  week  the  second  month,  once  in  two 
weeks  the  third,  and  during  the  next  two  months  twice  cr 
three  times  ought  to  suffice.  I  usually,  at  the  same  time, 
put  the  patient  on  some  alkaline  diuretic,  santal  midy 
being  my  preference,  which  is  also  an  astringent  antisep 
tic,  having  special  ac  ion  on  mucous  surfaces.  In  conclu- 
sion, I  would  like  to  say  that  I  have  succeeded  in  passing 
filiform  bougies  that  had  resisted  repeated  previous  at- 
tempts, by  instructing  the  patient  to  allow  his  bladder  to 
become  distended  with  urine,  then  thoroughly  cocainizir  g 
the  urethra  and  allowing  him  to  void  his  urine  while  the 
attempt  is  being  made ;  this  method  is  especially  applica- 
ble to  cases  of  valve  stricture.  In  doing  an  external 
perineal  urethrotomy  once  (without  a  guide)  that  was 
baffling  entirely  my  skill,  I  found  that  much  aid  was  given 
by  the  introduction  of  a  bougie  from  behind  after  a  supra- 
pubic cystotomy  had  been  performed.  I  cut  strictures 
indiscriminately  as  regards  to  class,  and  always  in  three 
directions ;  a  sound  corresponding  with  the  full  capacity 
of  the  urethra  should  be  used  at  once.  This  operation 
may  be  performed  with  pain  reduced  to  a  minimum  by 
the  use  of  cocaine  and  Bumstead's  deep  urethral  syringe. 
The  incisions  must  be  made  in  the  long  axis  of  the  penis ; 
when  they  heal,  they  do  so  with  an  elliptical  patch  for 
each  incision,  thus  increasing  the  calibre  of  the  urethra  by 
the  insertion  of  a  new-formed  tissue  which  is  pathologi- 
cally different  to  that  of  the  stricture.  It  intercepts  the 
force  of  this  contracting  band  and  establishes  another  in 
a  direction  that  rather  favors  the  normal  calibre  of  the 
urethra. 


A  CASE  OF  NON-HEREDITARY  FRIEDREICH'S 
DISEASE.1 

By  CHARLES   E.  NAMMACK,   M.D., 

ATTENDING  IHYSICIAK  TO  NSW  YORK   HOSPITAL,  OUT-PATIENT  DBPAXTMBNT. 

After  the  elaborate  critical  digest  of  Ladame,*  supple- 
mented as  it  was  by  the  scholarly  article  of  Byron 
Bramwell  in  his  magnificent  "  Atlas  of  Clinical  Medi- 
cine," '  it  would  seem  that  little  could  be  added  to  the 
literature  of  Friedreich's  ataxia.  Yet,  Bramwell  states 
that  very  few  isolated  cases  have  been  recorded,  and 
thinks  it  "  not  unlikely  that  the  isolated  cases  (cases  in 
which  only  one  member  of  the  family  is  affected)  pass 
unrecognized."  This  view  is  shared  by  Ladame,  and 
emphasized  recently  by  the  publication  of  an  isolated 
case  by  Hector  Mackenzie,4  who  states  that  the  alternative 
title,  hereditary  ataxia,  for  Friedreich's  disease  may  have 
something  to  do  with  preventing  its  due  recognition. 

Eight  days  before  the  writer  saw  Mackenzie's  article, 
a  little  girl  was  brought  from  Yonkers  to  the  New  Yoik 
Hospital  with  the  following  interesting  personal  history : 

Mary  B ,  aged  fourteen,  born  after  a  normal  labor, 

began  to  have  unsteadiness  in  walking  when  she  was  five 
and  a  half  years  of  age.  Previous  to  this  time  she  had 
an  attack  of  measles  at  the  age  of  two  and  a  half  yeais, 
a  second  attack  of  measles  while  it  was  prevalent  in  the 
family  at  her  fifth  year,  and  six  months  later  had  scarlet 
fever,  followed  by  the  unsteady  gait.  Her  parents  think 
that  diphtheria  did  not  accompany  the  scarlatina.  Her 
gait  has  become  progressively  worse  since.  Some  time 
after  the  development  of  ataxia  in  her  lower  limbs,  she 
was  annoyed  by  jerky  movements  of  hands  and  arms 
when  writing,  and  was  finally  obliged  to  leave  school. 
She  had  headache  every  morning,  and  occasional  shoot- 
ing pains  in  her  legs.  She  has  had  nocturnal  enuresis 
since  infancy,  but  lately  has  been  troubled  by  inconti- 
nence in  the  daytime  also.    Her  case  has  been  variously 

1  Presented  at  the  New  York  Academy  of  Medicine,  Section  on 
Pediatrics,  April  12,  1894. 
•  Brain,  1890. 

•Vol.  I.,  Part  I.,  Edinburgh  University  Press,  1891. 
4  American  Journal  of  the  Medical  Sciences,  April,  1894 


172 


MEDICAL  RECORD. 


[August  11.  1894 


diagnosticated  as  diphtheritic  multiple  neuritis,  chorea, 
precocious  locomotor  ataxia  from  inherited  syphilis,  etc. 
This  is  not  surprising  when  we  reflect  that  Friedreich's 
ataxia  is  one  of  the  rarest  of  all  known  forms  of  nerve 
diseases,  that  the  great  majority  of  medical  men  have 
never  had  the  opportunity  of  seeing  it,  and  further,  that 
they  do  not  expect  to  meet  with  it  in  an  isolated  form.1 

This  child's  family  history  is  unusually  good.  She  is  the 
oldest  of  seven  children.  One  baby  died  at  five  months 
of  "inward  spasms  due  to  teething."  The  other  five 
are  living  and  healthy.  Both  parents  accompanied  her 
to  the  hospital  and  were  apparently  perfectly  sound  and 
healthy.  Three  other  children  in  the  family  have  now 
passed  the  age  at  which  the  unsteady  gait  began  in  Mary, 
without  showing  any  symptom  of  it,  although  their  im- 
munity cannot  be  guaranteed  from  this,  as  stated  by 
Soca.3  Many  exceptions  to  the  rule  formulated  by  him 
are  on  record.8  Neither  parent  knew  of  any  neurotic  or 
degenerative  tendency  among  the  grandparents,  uncles, 
aunts,  or  cousins,  except  that  one  paternal  aunt  died  at 
the  age  of  twenty- two  of  "consumption  of  bowels," 
after  an  illness  of  three  years.  Another  paternal  aunt 
died  of  endocarditis,  contracted  during  the  blizzard  of 
1888.  Four  aunts  and  uncles  are  living  and  well.  Con- 
sanguinity did  not  exist  between  Mary's  parents,  nor  had 
either  ever  suffered  from  alcoholism,  Blight's  disease,  or 
syphilis.  The  writer  considers  it  improbable  that  her 
conception  might  have  occurred  while  either  parent  was 
under  the  influence  of  alcohol.  Mother  has  had  no  still- 
births or  miscarriages.  There  is  no  knowledge  that  any 
near  relative  has  ever  been  ataxic  or  club-footed. 


Living 


Father  . 
Mother. 


fMary.... 


Sisters, 


J  Alice 
lRo«e. 
(Anne 

Father's  Mother. 

Father's  Father. 

Mother's  Mother, 


39 
37 


77 
80 
76 


Condition 
of  Health. 


Age 

at 

Death. 


Cause  How 

of  i  long 

Death.  Sick. 

I 


5  mo.      Convulsions?  1  day. 


Excellent. 

Excellent.  | . 

Excellent. 
I  Excellent. 

Friedreich's  Disease 8}  yr's. 

I  Excellent.  

Excellent  

Excellent.  

Excellent.  

'Excellent.  1 

Excellent. 


Mother's  Father 53  y'rs.  Pneumonia.     lod'ys. 


The  symptomatology  of  the  case  at  present  is  as  follows : 
The  gait  is  very  unsteady  and  rolling  in  character,  and 
child  is  unable  to  stand  with  the  eyes  closed.  Muscular 
power  in  the  legs  is  good,  considering  that  the  child  can- 
not actively  exercise.  Dynamometer  records,  thirty  in 
right  hand,  and  twenty-two  in  left  hand.  Hand  grasp 
seems  almost  as  strong  as  in  other  children  of  her  age. 
The  knee-jerks  are  absolutely  lost.  She  has  some  ataxia 
in  the  upper  limbs,  but  can  thread  a  needle,  and  her 
manner  of  picking  up  a  needle  from  the  table  has  not 
the  so-called  "bird  of  prey"  movement.4  She  pre- 
sents the  characteristic  foot  deformity  of  this  disease. 
Each  foot  is  stumpy  and  short,  and  appears  to  be  com- 
pressed from  before  backward  in  the  antero  posterior 
diameter.  The  instep  is  highly  arched  and  the  dorsum 
of  the  foot  very  prominent.  The  first  phalanges,  espe- 
cially of  the  great  toe,  are  over  extended  and  the  tendons 
of  the  extensor  proprius  pollicis  muscles  stand  promi- 
nently out.  The  feet  are  cold,  and  of  a  purplish  color. 
Lateral  curvature  of  the  spine  is  present.  The  speech  is 
low-toned,  monotonous,  and  harsh,  but  not  "scanning," 
as  in  multiple  sclerosis.  Nystagmus  is  evident  when  eyes 
are  moved  laterally  or  upward,  or  when  the  object  is 
fixed. 

Pupils  are  equal,  of  medium  size,  and  respond  both  to 
light  and  to  accommodation.  No  oculomotor  paralysis. 
Ophthalmoscopic  examination  by  Dr.  Leroy  Pope  Walk- 
er, shows  that  the  temporal  half  of  each  optic  nerve  is 
very  pale  and  the  nutrient  vessels  diminished.  This  con- 
dition is  considered  to  be  fairly  attributable  to  the  child's 

1  Bramwell :  Atlas  Clinical  Medicine,  p.  42. 

*  Ladame:  Brain,  i8qo.  *  Bramwell :  Atlas,  p.  35. 

«  Brain,  1890,  p.  478. 


evident  anaemia.  Choreic  like  twitchings  are  not  present 
now,  but  the  history  shows  that  they  existed  in  an  earlier 
stage  of  case,  and  more  than  one  physician  has  treated 
the  child  for  chorea.  Her  facial  expression  is  anxious, 
rather  than  vacant.  She  does  not  have  the  attacks  of 
impulsive  laughter  often  noticed  in  this  disease.  She 
suffers  from  palpitation  of  the  heart  on  walking,  but  has 
no  valvular  lesion.  Anaemic  bruit  is  present* in  vessels 
of  neck.  Her  headache  is  distinctly  frontal.  She  does 
not  feel  dizzy  in  walking,  but  is  unable  to  co-ordinate 
her  movements.  Sensibility  of  the  skin  to  touch,  heat 
and  cold,  and  pain  is  found  to  be  unimpaired,  although 
not  exhaustively  tested.  Special  senses  not  affected. 
Child  is  bright  and  intelligent,  and  not  irascible.  Her 
sense  of  the  posture  of  limbs  is  good. 

The  clinical  assistant  who  first  saw  the  case  at  the  hos- 
pital considered  it  to  be  locomotor  ataxia  without  Argyll- 
Robertson  pupil,  a  not  impossible  combination.  The 
writer  changed  the  diagnosis  to  that  of  cerebellar  tumor 
without  increased  knee-jerk,  which  is  also  a  possibility. 
But  the  ophthalmoscope  showing  absence  of  optic  neuri- 
tis or  of  postneuritic  atrophy,  a  more  careful  review  ot 
the  case  was  made  and  the  correct  diagnosis  arrived  at. 

The  pathological  anatomy  and  prognosis  are  so  fully 
treated  in  the  articles  of  Ladame  and  Bramwell  as  to  ren- 
der unnecessary  any  mention  in  this  communication. 
The  treatment  is  the  same  as  that  of  locomotor  ataxia. 
Suspension  has  been  tried  in  some  of  the  recorded  cases 
without  any  benefit.  Lena,  an  Italian  writer,  has  re- 
ported 1  two  cases  treated  by  injections  of  organic  nervous 
extracts  after  the  method  of  Dr.  C.  Paul. 

Non  hereditary  cases  may  occur  with  more  frequency 
than  is  usually  supposed.  The  "  Index  Medicus  "  for  1893 
gives  sixteen  references  to  twenty  three  cases  of  Fried- 
reich's disease,  of  which  four  were  isolated  cases,  no  other 
member  of  the  family  being  affected.  Thus  Destree2 
records  a  case,  aged  twenty-one,  brothers  and  sisters 
healthy,  father  an  alcoholic,  died  of  consumption,  one 
paternal  uncle  epileptic.  Senator  *  had  a  case  in  one  of 
five  sisters. 

McCaw4  publishes  a  case  in  which  the  hereditary  his- 
tory broke  down  at  every  turn.  Strong  history  of  tuber- 
cle in  this  family.  Chauffard  5  presents  an  isolated  case 
which  began  at  the  remarkably  early  age  of  three  and 
one  half  years. 

To  these  can  now  be  added  Mackenzie's  case  and  the 
writer's.  It  would  seem  to  be  desirable  that  other  non- 
hereditary  cases  should  be  reported,  in  order  to  eradicate 
the  fixed  idea  that  Friedreich's  ataxia  is  necessarily  a 
family  disease.  The  lesion  in  Friedreich's  disease  is  a 
combined  sclerosis  of  certain  tracts  in  the  posterior  and 
lateral  columns  of  the  cord,  together  with  the  vesicular 
columns  of  Clarke  in  the  gray  matter,  and  the  posterior 
roots.  The  entire  cord  is  also  congenially  smaller  than 
the  normal.  The  diseases  with  which  it  is  likely  to  be 
confounded  are  locomotor  ataxia,  insular  sclerosis,  ataxic 
paraplegia,  chorea,  and  cerebellar  tumor.  The  differen- 
tial diagnosis  is  clearly  given  in  the  article  by  Bramwell 
previously  alluded  to. 

It  has  been  suggested  by  one  writer  •  that  lateral  curva- 
ture of  the  spine  may  give  rise  by  pressure  to  cord  symp- 
toms, but  a  study  of  the  case  cited  will  show  many  and 
marked  differences  in  its  symptomatology  from  that  of 
Friedreich's  ataxia.  Orthopedists  generally  do  not  accept 
the  conclusions  therein  advanced,  but  agree  with  Brad- 
ford and  Lovett  that  lateral  curvature  never  gives  rise  to 
cord  symptoms.7  Although  the  author  predicted  that 
literature  would  soon  teem  with  cases  similar  to  his,  the 
ensuing  two  years  have  not  brought  to  light  the  expected 
inundation. 

99  East  Twenty-fourth  Strkit. 

1  Morgagni :  Milano,  1892,  xxxiv.,  630-652. 

•  Journal  de  Med.,  Chir.  et  Pharmacol.     Bruzelles,  189a,  p.  773. 
■Berlin  klin.  Wochenschrift,  1893  p.  489. 

•  London  Lancet,  1893.  "••  4*4- 

•  Semaine  Medicate.  Paris,  1893,  xiii..  409-411. 
«  Mbdical  Record,  May  98,  1893.  p.  604. 

» Ibid,  p.  605. 


August  ii,  1894] 


MEDICAL    RECORD. 


173 


INCONTINENCE     OF     URINE     AND     FAECES, 
CURED  BY  CIRCUMCISION. 

By  H.  L.  ROSENBERRY,  M.D., 

MENOMINKK,   MICH. 

I  wish  to  report  a  case  that  has  been  very  instructive  to 
me.  In  September,  1893,  I  was  called  to  see  a  child 
with  incontinence  of  urine  and  faeces.  The  child  seemed 
to  be  as  healthful  as  the  average  four-year  old,  and  aside 
from  this  difficulty  had  never  taken  any  medicine.  In 
making  an  examination  I  discovered  what  had  appar- 
antly  been  overlooked  by  the  former  medical  attendants, 
an  elongated  prepuce.  I  said  to  the  parents  that  the 
child  should  be  circumcised  without  delay,  as  that  might 
account  for  the  dribbling  of  the  urine,  but  supposed 
there  was  entire  absence  of  the  sphincter  anL 

On  the  following  day  the  child  was  anaesthetized  and 
the  circumcision  performed.  It  healed  nicely.  At  the 
time  of  the  operation  a  digital  examination  revealed  a 
patulous  anus  with  no  sign  of  a  sphincter  muscle.  Sup- 
posing it  to  be  absent  I,  of  course,  thought  there  would 
be  no  help  for  the  incontinence  of  the  faeces.  When 
complete  healing  had  taken  place  the  bowel  trouble  en- 
tirely subsided,  but  he  still  had  trouble  with  the  retention 
of  urine.  I  tried  various  remedies,  and  finally  used  the 
atropia  (T^  Wyeth's  hypodermic)  tablets,  with  instruc- 
tion to  cease  when  dryness  of  the  throat  appeared.  The 
child  is  more  robust  than  before  and  has  fully  recovered. 

I  am  at  loss  to  explain  the  process,  but  simply  relate  it 
as  a  fact.  Will  your  readers  cite  to  me  similar  cases  if 
they  know  of  such? 

AN   UNUSUAL  ACCIDENT  TO    THE  RESPIRA- 
TORY TRACT. 

By  M.  D.  BRIGGS,  M.D., 

CHAMFLAIN,  M.   T. 

On  the  evening  of  January  25,  1894,  Ernest  L , 

aged  seven,  was  brought  to  my  office  by  his  parents  with 
the  following  history :  About  one  hour  previously,  namely, 
about  6  p.m.,  while  chewing  a  mouthful  of  dried  peas* 
with  which  he  had  been  playing,  he  had  a  little  griev- 
ance and  commenced  crying.  In  the  midst  of  his  sob- 
bing he  sucked  some  of  the  partially  chewed  peas  into 
his  windpipe,  and  at  once  began  to  choke  and  strangle. 
His  father  immediately  seized  him  and  used  such  meas- 
ures as  he  was  able  for  his  relief,  such  as  clearing  out  the 
mouth  and  throat,  inverting  the  child,  and  thumping  his 
back.  He  recovered  his  breath,  after  which  an  emetic 
was  given  and  the  child  brought  with  all  haste  to  my 
office,  something  over  two  miles. 

On  examination  I  found  him  breathing  easily  and 
quietly,  but  the  stethoscope  revealed  plainly  the  fact  that 
some  of  the  material  had  entered  the  respiratory  tract. 
The  laryngoscope  was  unsatisfactory,  as  the  attempt  to 
use  it  brought  on  a  severe  attack  of  dyspnoea,  which 
subsided  after  a  moment  or  two.  Realizing  the  gravity 
of  the  case,  I  advised  taking  the  child  by  first  train  to 
Montreal,  as  it  could  be  easily  reached  in  two  or  three 
hours,  hoping  that  something  there  might  be  done  to 
save  him.  They  decided  to  take  my  advice  and  left  my 
office,  while  I  prepared  to  accompany  them.  In  about 
five  minutes  a  messenger  came  for  me  in  great  haste  from 
a  neighboring  store  where  they  had  stopped  to  make  a 
purchase. 

I  found  the  boy  in  a  state  of  complete  apnoea,  cya- 
nosed,  pulseless,  and  apparently  dead.  Finding  the 
heart  still  beating  I  immediately  laid  him  on  the  counter, 
in  a  position  to  do  a  quick  tracheotomy.  I  had  bared 
the  throat,  found  my  landmarks,  and  in  another  instant 
would  have  made  the  incision,  when  there  came  a  slight 
gasp.  After  a  few  seconds  another  came,  and  I  laid 
down  my  knife.  In  a  few  minutes  he  was  breathing 
fairly  well,  but  lay  in  a  semi-conscious  condition.  There 
was  no  further  thought  of  Montreal,  nor  even  of  taking 
him  home.  A  room  was  secured  at  the  nearest  hotel 
and  he  was  removed  thither.     Another  severe  attack  of 


suffocation  came  on  as  soon  as  we  reached  the  hotel,  in 
which  the  boy  went  through  another  terrible  death- strug- 
gle, and  lay  apparently  dead  on  the  bed,  only  to  again 
revive  for  a  repetition  of  the  dreadful  ordeal,  for  these 
attacks  of  laryngeal  spasm  occurred  again  and  again. 

Dr.  J.  M.  Hackett  and  Dr.  L.  C.  Dodge  were  called 
in  consultation.  All  concurred  in  an  almost  hopeless 
prognosis.  Tracheotomy  seemed  a  forlorn  hope,  and 
was  considered  only  as  a  measure  for  the  relief  of  the 
laryngismus.  The  parents  desired  anything  that  would 
promise  even  a  measure  of  relief.  So  I  did  a  trache- 
otomy with  careful  attention  to  details.  There  was  no 
more  spasm  of  the  glottis,  but  the  operation  gave  no  re- 
lief to  the  dyspnoea  and  cyanosis,  which  steadily  in- 
creased. Sharp  hissing  sounds  could  be  heard  through 
the  tracheotomy  tube  coming  up  from  below.  Death 
took  place  about  twenty-one  hours  from  the  time  of  the 
accidental  entrance  of  the  partially  masticated  peas  into 
the  respiratory  tract.  An  autopsy  could  not  be  ob- 
tained. 

A  FAMILY  HISTORY  OF  DIABETES. 
By  GEORGE  A.    PHILLIPS,  M.D., 

SLLSWOKTH,    MB. 

A  boy  eight  years  of  age  was  seen  by  me  in  January 
of  this  year,  with  well-marked  symptoms  of  diabetes 
mellitus,  excessive  thirst,  emaciation,  urinating  four  to 
six  quarts  daily,  specific  gravity  of  urine  1.046,  with  sugar 
in  considerable  quantities.  The  interest  of  the  case  lies 
in  the  fact  that  three  brothers  of  his  mother  died  of  the 
same  disease,  their  ages  respectively  three,  eight,  and 
seventeen,  the  diagnosis  almost  established  by  the  history 
obtained  by  a  member  of  the  family  was  confirmed  by 
communications  from  Dr.  Thomas,  of  Brewer,  Me.,  and 
Dr.  F.  O.  Perry,  of  Orland,  Me.,  the  physicians  who  at- 
tended the  children  who  died.  The  mother  of  the  child 
whose  history  is  given  above,  and  a  sister  to  those  who 
died,  has  occasional  symptoms  of  the  same  disease. 
There  were  five  children,  three  dying  of  diabetes,  one  of 
typhoid  fever,  and  the  mother  of  child  referred  to. 


HAVE  THE  RED  BLOOD  CORPUSCLES  AMCE- 
BOID  MOVEMENT. 

By  WILLIAM  MOSER,  M.D., 

PATHOLOGIST   TO    ST.   CATHARINE^   HOSPITAL,  BROOKLYN. 

It  is  generally  supposed  that  the  red  blood  corpuscle  is  a 
"  fixed  "  cell,  i.e.,  a  cell  not  capable  of  amoeboid  motion 
like  the  white  blood  corpuscle.  My  observations  are 
not  in  accord  with  this  general  belief.  It  is  true  that 
the  red  blood  corpuscle,  when  obtained  fresh  (by  pricking 
the  finger-tip)  and  examined  under  the  microscope,  will 
not  exhibit  any  property  of  amoeboid  movement,  much  less 
would  it  do  this  if  the  blood  was  heated  and  stained. 
The  blood  corpuscles  when  examined  fresh  rapidly  be- 
come dehydrated,  a  dark  ring  soon  forms  on  their  outer 
border,  looking  like  a  membrane,  many  of  them  become 
shrivelled,  "  cremated,"  the  cell  soon  dies.  But  in  cer- 
tain media  like  the  urine  they  retain  their  vitality  and 
certain  fundamental  differences  can  be  noted.  In  over 
one  hundred  specimens  of  nephritic  urine,  containing 
blood-cells,  I  was  positive  that  in  every  instance  I  could 
detect  in  most  of  the  red  blood- cells  movement.  In 
some  cells  I  could  see  how  the  cell  would  retract  in  cer- 
tain places,  some  becoming  semilunar  in  shape,  others 
could  be  seen  taking  on  various  shapes,  reminding  one 
of  the  condition  known  as  "  poikilocytosis  "  seen  so  fre- 
quently in  progressive  pernicious  anaemia.  Again  the 
ordinary  round  shape  would  become  long  and  narrow, 
and  by  waiting  a  few  seconds  it  would  again  regain  its 
rounded  outline.  All  this  could  be  seen  and  demon* 
strated  in  urine  containing  many  blood  cells.  In  short, 
it  behooves  us  to  examine  the  red  blood  corpuscle  in  the 
urine  more  closely. 

158  Ross  Strut,  Brooklyn. 


174 


MEDICAL   RECORD. 


[August  ii,  1894 


f£)?00ttess  of  fjfoflital  jfcietuce. 

Bacteria  in  Human  Milk. — Dr.  Ringel  contributes 
the  report  of  a  series  of  investigations  upon  the  bacteria 
found  in  human  milk.  Various  observers  had  reported 
having  found  the  staphylococcus  aureus  and  albus,  as 
well  as  the  streptococcus,  both  in  healthy  milk  and  in 
that  from  mothers  suffering  from  puerperal  fever.  Es- 
cherich  examined  25  women.  Of  these,  24  specimens 
were  sterile  and  1  contained  bacilli.  He  again  examined 
13  with  puerperal  fever,  and  found  staphylococcus  in  12  ; 
4  being  of  the  white  and  yellow  variety  intermixed ;  8 
the  white  only,  and  1  of  an  uncertain  form.  Cohn  and 
Neumann  experimented  on  43  cases  of  milk  from  healthy 
women,  and  found  36  containing  staphylococcus  albus, 
1  staphylococcus  aureus  and  pyogenes,  3  staphylococcus 
pyogenes  albus  and  streptococcus  pyogenes ;  in  2  all  the 
above  forms  were  united.  The  writer  made  a  series  of 
investigations,  drawing  and  using  milk  from  the  deeper 
parts  of  the  breast  only,  the  experiments  being  made 
under  the  strictest  antiseptic  precautions.  The  milk  was 
taken  from  12  healthy  and  13  unhealthy  patients.  The 
results  were  as  follows:  3  specimens  were  sterile;  17 
specimens  contained  staphylococcus  pyogenes  albus ;  2 
specimens  contained  staphylococcus  pyogenes  aureus ;  1 
specimen  contained  staphylococcus  pyogenes  albus  and 
aureus ;  2  specimens  contained  staphylococcus  pyogenes 
albus  and  streptococcus  pyogenes.  An  examination  of 
the  mouths  of  nursing  infants  revealed  corresponding 
bacteria  in  their  secretions. — The  American  Journal  of 
the  Medical  Sciences. 

A  Hew  Method  of  Using  Cocaine  for  Local  Ansssthe- 
sia. — Krogius  (CentralbLf.  Chir.,  No.  n,  1894)  de- 
scribes a  new  method  of  producing  cocaine  analgesia, 
which  is  based  on  the  fact  that,  when  a  solution  of  this 
agent  is  injected  into  the  subcutaneous  tissue  near  to  a 
nerve-trunk,  it  causes  loss  of  sensation  over  a  large  zone 
corresponding  to  the  peripheral  distribution  of  this  nerve. 
In  order  to  reach  the  selected  nerve-trunk  with  certainty, 
and  to  apply  the  cocaine  to  several  of  its  branches  at  the 
same  time,  the  author,  in  injecting  the  subcutaneous  tis 
sue,  passes  his  needle  across  the  long  axis  of  the  limb, 
and  as  the  needle  is  thrust  along,  the  solution  is  gradu- 
ally discharged.  An  injection  made  in  this  way  across 
the  root  of  a  finger  will,  in  the  course  of  ten  minutes, 
result  in  analgesia  of  the  whole  digit,  not  of  the  skin 
only,  but  also  of  the  tendons,  the  periosteum,  and  all  the 
deep  structures.  If  one  or  two  injections  be  made  trans- 
versely near  the  wrist,  a  considerable  extent  of  thg  palm 
of  the  hand  may  be  thus  rendered  analgesic.  The  sensi- 
bility of  the  ulnar  side  of  the  hand  as  far  as  the  roots  of 
the  last  two  fingers  may,  it  is  stated,  be  abolished  by  in- 
jecting a  solution  of  cocaine  over  the  ulnar  nerve  at  the 
back  of  the  elbow.  By  injecting  over  both  supra-orbital 
notches,  analgesia  may  be  produced  in  the  whole  of  the 
middle  portion  of  the  forehead.  The  analgesia  caused 
by  this  method  of  using  cocaine  attains  its  greatest  inten- 
sity and  extent  from  five  to  ten  minutes  after  the  injec- 
tion, and  is  maintained  for  a  quarter  of  an  hour  or  even 
longer.  The  author  injects  only  a  weak  (two  per  cent.) 
solution  of  cocaine,  and  keeps  the  patient  recumbent  for 
at  least  a  quarter  of  an  hour  after  the  operation.  This 
method  has  been  practised  with  success  at  Helsingfors,  in 
two  hundred  minor  operations,  such  as  amputation  of  the 
fingers  and  toes,  excision  of  palmar  fascia,  and  phimosis. 

Compression  of  the  Umbilical  Cord  During  Delivery 
by  Forceps Dr.  Swayne  has  recently  again  directed  at- 
tention to  the  danger  to  which  the  child  is  exposed  dur- 
ing delivery  by  forceps,  from  pressure  of  the  extremities 
of  the  blades  on  the  umbilical  cord,  should  it  be  so  situ- 
ated as  to  be  compressed  when  the  forceps  has  been  ap- 
plied (  The  Lancet)  In  a  former  communication  on  the 
subject  Dr.  Swayne  instanced  153  cases  of  forceps  deliv- 
ery. In  23  of  these  the  child  was  either  born  dead,  or 
died  soon  after  delivery ;  in  4  out  of  these  23  cases  he 


attributed  the  death  to  compression  of  the  cord  by  the 
forceps — that  is  to  say,  that  this  injurious  compression 
had  been  noticed  in  the  proportion  of  once  in  38  cases. 
Since  the  time  when  this  series  of  cases  was  published, 
Dr.  Swayne  has  had  71  forceps  cases,  with  10  deaths  of 
infants,  and  among  these  10  stillbirths  there  were  2 
cases  in  which  the  child's  death  was  due  to  pressure  of 
the  forceps  on  the  cord.  In  this  second  series,  then, 
the  accident  in  question  occurred  once  in  35  cases — not 
very  different  from  the  frequency  noted  in  the  preceding 
series.  Spiegelberg's  estimate  of  the  foetal  mortality  in 
forceps  cases  is  seventeen  per  cent.  It  certainly  seems  to 
be  the  fact,  as  Dr.  Swayne  says,  that  this  particular  dan- 
ger— that  is  to  say,  compression  of  the  umbilical  cord  by 
the  forceps — has  not  received  perhaps  so  much  attention 
as  it  deserves.  Dr.  Swayne  still  agrees  with  a  passage 
which  he  quotes  from  a  paper  by  Dr.  Galabin,  published 
in  1877,  namely,  "  that  it  has  not  been  shown  that  the 
majority,  or  any  considerable  proportion,  of  the  stillbirths 
which  now  occur  in  Britain  would  be  preventable  by  a 
more  timely  resort  to  forceps." 

Skin-grafting  for  Keloid. — Broca  recently  excised  from 
the  back  of  the  hand  and  thumb  an  extensive  keloid  fol- 
lowing a  burn.  The  growth  was  half  a  centimetre  in 
thickness,  and  held  the  hand  at  a  right  angle  to  the  fore- 
arm. A  flap  from  the  abdomen  was  then  grafted  upon 
the  hand  and  its  pedicle  severed  in  thirteen  days  after 
the  operation.  There  were  no  drawbacks  of  any  kind, 
and  complete  motion  in  the  hand  and  wrist  was  restored. 

Ingrowing  Hairs. — Dr.  Guthrie  calls  attention  to  a 
condition  of  ingrowing  hairs,  which  presents  itself  in  the 
form  of  bluish- white  pimples,  varying  in  size  from  a  pin's 
head  to  a  small  pea,  situated  usually  about  the  chin  where 
the  beard  grows  the  thickest.  Careful  inspection  of  the 
unshaved  chin  and  cheeks  will  show  here  and  there  the 
presence  of ' '  giant  hairs. ' '  These  are  dark  in  color,  and 
as  thick  as  hog's  bristles.  The  slightest  traction  with 
forceps  suffices  to  painlessly  remove  them.  The  thicken- 
ing is  due  to  the  deposit  of  a  dark,  soft  material,  which 
envelops  the  hair  throughout  its  extent.  This  layer  can 
be  scraped  off,  and  is  soluble  in  liquor  potassse.  The 
hair  itself  is  also  thickened,  and  its  structure  is  blurred 
and  indistinct.  It  is  probable  that  the  little  bluish- white 
pimples  form  by  the  growing  within  the  hair-follicle  of 
what  remains  of  a  broken,  thickened,  and  brittle  hair. 
The  condition  occurs  most  commoifly  on  a  bearded 
face,  but  it  is  sometimes  observed  in  other  situations,  as 
the  axilla,  the  pubes,  the  periphery  of  the  hairy  scalp. 
Under  the  latter  circumstances  the  condition  is  depend- 
ent rather  on  a  blockage  of  the  orifice  of  the  hair-follicle 
than  upon  disease  of  the  hair  itself.  Sometimes,  instead 
of  a  single  hair,  such  a  follicle  will  contain  a  minute 
ring-shaped  tress,  composed  of  a  dozen  or  more  fine 
hairs.  These  are  particularly  common  about  the  under 
surface  of  the  penis,  where  they  often  suppurate  and  dis- 
charge a  foul  smelling  mixture  of  pus  and  decayed  seba- 
ceous matter.  In  treatment  giant  hairs  should  be  re- 
moved by  means  of  forceps,  but  it  is  essential  that  no 
force  be  used.  When  the  little  nodules  have  formed, 
the  overlying  surface  should  be  sterilized  and  an  in- 
cision made  with  a  sharp  tenotomy  knife.  A  portion 
of  hair  will  present,  and  can  easily  be  extracted. — Medi- 
cal News.  

A  Canadian  View  of  Russia  — The  Canadian  Medical 
Record  regrets  that  the  next  International  Medical 
Congress  will  be  held  in  Russia,  "  as  we  fear  very  few 
will  trust  their  lives  in  that  barbarous  country/ '  and 
thinks  that  "  Vienna  or  even  Montreal  would  be  a  much 
more  acceptable  and  more  accessible  place."  Montreal 
might  be  more  accessible  to  the  inhabitants  of  the  North 
American  Continent,  but  we  assure  our  esteemed  con- 
temporary that  Russia  is  not  such  a  dreadful  place. 
Many  of  its  inhabitants  go  clothed  and  eat  with  forks, 
and  the  nihilists  seldom  kill  more  than  sixteen  visiting 
doctors  in  a  week. 


August  ii,  1894] 


MEDICAL    RECORD. 


175 


Medical  Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


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


New  York,  August  11,  1894. 


TOTAL    EXTIRPATION    OF    THE    UTERUS    IN 
DISEASE  OF  THE  ADNEXA. 

The  importance  which  this  subject  has  assumed  of  late 
is  shown  by  the  prominence  assigned  to  it  in  Society 
discussions,  notably  that  held  before  the  American  Gy- 
necological Society  at  its  recent  meeting.  The  general 
practitioner  who  is  not  familiar  with  the  rapid  advances 
in  gynecological  surgery  is  apt  to  be  somewhat  appalled 
by  the  confident  assertion  that  the  uterus  should  be  extir- 
pated in  all  cases  in  which  the  adnexa  are  removed,  on 
the  ground  that  the  organ  itself,  being  diseased  at  the 
same  time,  is  not  only  useless,  but  remains  as  a  constant 
source  of  discomfort,  and  even  of  danger,  to  the  patient 
This,  in  a  word,  represents  the  dictum  of  the  most  ad- 
vanced school,  which  as  yet  has  but  few  followers  among 
us.  A  further  argument,  which  appeals  strongly  to 
abdominal  surgeons,  is  that  by  removal  of  the  uterus  in 
cases  of  extensive  suppurative  disease  of  the  adnexa,  per- 
fect drainage  is  secured  per  vaginam— the  method  which 
is  now  recognized  as  the  ideal  one — as  was  foreshadowed 
by  Sims  a  quarter  of  a  century  ago.  To  this  the  more 
conservative  reply  that  securing  vaginal  drainage  by 
hysterectomy  is  too  heroic  a  procedure,  since  the  same 
result  can  be  obtained  by  retaining  the  uterus  and  drain- 
ing through  Douglas's  pouch. 

As  is  usually  the  case  when  a  novel  and  radical  surgi- 
cal operation  is  first  advocated,  the  adherents  of  hyste- 
rectomy and  its  opponents  see  only  their  side  of  the 
question.  Reading  the  enthusiastic  statements  of  the 
former,  the  occasional  operator  would  infer  that  nothing 
was  easier  and  safer  than  the  extirpation  of  the  uterus 
after  removal  of  the  diseased  adnexa — in  fact,  that  it  was 
comparable  with  a  simple  ovariotomy.  But  it  must  be 
remembered  that  the  few  surgeons  who  report  such  re- 
markably favorable  statistics  are  unusually  skilful  opera- 
tors, who  have  acquired  their  special  aptitude  by  a 
wide  experience  in  hystero  myomectomy.  An  operation 
which  is  easy  for  them  is  formidable  to  one  of  limited 
experience  in  this  work.  Therein  lies  the  danger  to  the 
rank  and  file  of  coeliotomists,  whose  name  is  legion. 

The  technique  of  the  operation  is  the  main  difficulty 
in  the  way  of  the  unqualified  acceptance  of  the  proposi- 
tion that  a  uterus  without  its  tubes  and  ovaries,  and  es- 
pecially a  diseased  uterus,  becomes  a  useless  appendage, 
and  should  therefore  be  extirpated.  No  reasonable  gyne- 
cologist can  deny  that  the  uterus  is  frequently  a  source  of 
trouble,  that  it  may  be  the  cause  of  persistent  pain  and 


hemorrhages,  and  be  open  to  repeated  infection  (gonor- 
rhoea! or  septic)  months,  and  even  years,  after  the  removal 
of  the  diseased  adnexa.  Hence,  even  the  most  conser- 
vative acknowledge  that  there  are  cases  in  which  it 
must  be  admitted  that  it  would  have  been  better  if 
the  organ  had  been  removed  at  the  time  of  the  op- 
eration. But  is  hysterectomy  under  these  conditions 
to  be  recommended  to  the  profession  at  large?  To  this 
we  reply  unhesitatingly  in  the  negative.  Given  a  case 
of  double  pyosalpinx  with  firm  intra-pelvic  and  intesti- 
nal adhesions  in  which  considerable  manipulation  has 
been  necessary,  we  affirm  that  many  patients  are  not  in  a 
condition  to  bear  the  extra  amount  of  shock  involved  in 
removal  of  the  uterus.  In  spite  of  the  advantages  afforded 
by  Trendelenburg's  posture,  there  are  few  surgeons  who 
can  complete  the  additional  operation  in  "  twenty  min- 
utes," as  is  claimed  by  its  advocates.  So  far  as  our  ob- 
servation goes,  twice  that  time-  is  requited.  We  have 
yet  to  see  a  case  in  which  a  difficult  salpingo- oophorec- 
tomy was  supplemented  by  extirpating  the  uterus,  when 
the  shock  was  not  most  marked,  and  the  convalescence, 
when  recovery  followed,  protracted. 

This  point  was  emphasized  by  Dr.  Coe  in  reporting  a 
recent  case  to  the  New  York  Obstetrical  Society,  and 
was  dwelt  upon  by  Dr.  Bache  Emmet  in  the  discussion 
before  alluded  to.  The  latter  gentleman  also  raised  the 
pertinent  question  whether  a  patient  in  private  practice 
would  consent  to  such  a  radical  mutilating  operation  for 
disease  of  the  adnexa,  if  she  were  consulted  beforehand. 
To  perform  such  an  operation  without  her  full  knowledge 
and  co  operation  would  be  assuming  a  responsibility 
which  few  would  care  to  take,  even  in  this  radical  age. 
We  doubt  if  the  average  woman  would  be  sufficiently  in- 
fluenced by  the  arguments  which  appeal  so  strongly  to 
the  abdominal  surgeon,  as  to  take  the  additional  risks 
involved  in  total  extirpation. 


THE  STATUS  OF  CHRISTIAN  SCIENCE  IN  NE- 
BRASKA. 

A  Christian  scientist  in  Nebraska  was  recently  tried  be- 
fore the  District  Court  of  Gage  County,  Neb. ,  on  the  charge 
of  practising  medicine  contrary  to  the  statutes  of  that 
State.  He  was  acquitted  by  the  jury,  but  the  prosecut- 
ing attorney  carried  his  exceptions  to  the  Supreme  Court, 
where  they  were  sustained.  Judge  Ryan  handed  down  a 
decision  in  which  he  said  that  the  fact  to  establish  a  State 
Board  of  Health,  to  regulate  the  practice  of  medicine 
in  Nebraska,  is  as  much  directed  against  any  unauthor- 
ized person  who  shall  profess  to  treat  any  physical  or 
mental  ailment  of  another,  as  against  one  who  practises 
medicine  as  the  term  is  generally  understood. 

The  section  of  the  act  upon  which  this  decision  was 
based  reads  as  follows :  "  Any  person  shall  be  regarded 
as  practising  medicine,  within  the  meaning  of  this  act, 
who  shall  operate  on,  profess  to  heal,  or  prescribe  for, 
or  otherwise  treat  any  physical  or  mental  ailment  of  an- 
other. But  nothing  in  this  act  shall  be  construed  to 
prohibit  gratuitous  services  in  case  of  an  emergency,  and 
this  act  shall  not  apply  to  commissioned  surgeons  in  the 
United  States  army  and  navy,  nor  to  nurses  in  their  legi- 
timate occupations,  nor  to  the  administration  of  ordinary 
household  remedies." 

This  law  is  certainly  rigid,  but  not  too  much  so,  and 


176 


MEDICAL   RECORD. 


[August  ii,  1894 


any  suffering  that  might  arise  from  a  too  strict  applica- 
tion of  it  is  prevented  by  the  emergency  clause.  It 
would  be  impossible  for  a  layman  to  be  punished  for 
saving  life  in  the  absence  of  a  physician,  as  has  actually 
occurred  in  France. 


THE  EYE    AND    SURGICAL    TREATMENT    OF 
EPILEPSY. 

There  has  been  beyond  any  doubt  a  factitious  promi- 
nence given  to  the  treatment  of  epilepsy  and  other  ner- 
vous disorders  by  surgical  treatment  of  the  eye  muscles. 
It  is  the  general  opinion  of  neurologists  that  there  is  lit- 
tle or  nothing  to.  be  gained  by  it,  while,  on  the  other 
hand,  much  harm  may  be  done. 

Dr.  Casey  A.  Wood,  of  Chicago,  has  recently  {New 
York  Medical  Journal)  gone  over  the  subject  very  thor- 
oughly, and  has  called  attention  to  the  numerous  cases  of 
epilepsy  on  record  which  have  been  cured  by  minor  sur- 
gical operations  of  various  kinds.  His  conclusions  are 
worth  presenting  here  :   He  says. 

"  1.  Heterophoria  in  some  form,  latent  or  manifest, 
can  be  shown  to  exist  as  an  ocular  condition  in  fully 
ninety- five  per  cent,  of  all  individuals. 

"  a.  Alone  and  when  associated  with  ametropia  it  is 
not  an  uncommon  cause  of  so-called  asthenopia. 

"  3.  In  the  latter  case  the  correction  of  the  accom- 
panying refractive  error  in  the  large  majority  of  cases  re- 
lieves all  the  symptoms  set  up,  both  by  the  ametropia  and 
muscular  anomaly ;  when  it  does  not,  the  heterophoria 
may  be  said  to  be  responsible  for  the  asthenopia. 

"4.  It  is  highly  probable  that  when  epilepsy  is  in  part 
or  wholly  the  result  of  eye-strain  other  evidence  of  the 
latter  is  present. 

"5.  It  must  follow  from  the  foregoing  that  in  the  eye 
treatment  of  epilepsy  of  any  decided  degree  the  correc- 
tion of  the  ametropia,  and  not  the  correction  of  the 
heterophoria,  is  the  first  and  most  urgent  duty  of  the 
ophthalmologist,  and  that  in  cases  where  both  are  cor- 
rected at  the  same  time  it  is  fair  to  suppose  that  the  re- 
sults, if  any,  are  due  to  the  ametropic  correction. 

"  6 .  In  cases  of  epilepsy  with  heterophoria  and  emme- 
tropia,  or  where  the  correction  of  refractive  errors  has 
failed  to  relieve  the  asthenopic  symptoms  and  the  produc- 
tion of  orthophoria  is  followed  by  cure  of  the  epilepsy 
and  the  asthenopia,  it  is  just  to  say  that  the  operation  on 
the  eye  muscles  or  treatment  of  them  has  produced  the 
effect  of  stopping  the  convulsions. 

"  7.  In  the  absence  of  ocular  symptoms,  apart  from 
the  epilepsy,  an  operation  upon  the  eye  muscles  stands 
in  the  same  therapeutic  relation  to  a  cure  or  relief  of  the 
disease  as  do  other  surgical  procedures  that  have  during 
the  past  century  been  in  vogue,  such  as  tracheotomy, 
setons,  ligature  of  the  vertebral  arteries,  trephining, 
odphorectomy,  circumcision,  castration,  the  actual  cau- 
tery, the  resection  of  stray  scars,  and  so  on. 

"  8.  These  operations  bring  about  a  cure  or  relief  of 
the  epilepsy  (both  idiopathic  and  hystero-epilepsy)  by 
their  powerful  mental  effect  upon  the  patient — a  truth 
long  recognized  by  neurologists. 

"  9.  Genuine  cures  of  epilepsy  by  eye  treatment  of 
any  kind  must  necessarily  be  confined  to  those  cases 
where  a  faulty  ocular  apparatus  acts  as  a  peripheral  irri- 
tant.    It  remains  yet  to  be  shown  that  anomalies  of  the 


extrinsic  muscular  portion  of  that  apparatus  are  to  any 
large  extent  responsible  for  the  seizures  of  epilepsy. 

"  10.  The  eye  treatment  of  epileptics  who  present 
signs  of  ocular  distress  has  not  received  that  attention 
which  the  importance  of  eye-strain  in  the  category  of  re- 
flex irritants  seems  to  call  for.  The  eyes  should  be  care- 
fully examined  in  every  case  of  epilepsy  where  asthe- 
nopic symptoms  are  present  or  are  suspected. 

"11.  I  question  the  wisdom  of  encouraging  the  pro- 
fession, and  through  them  the  laity,  to  believe  that  every 
case  of  idiopathic  epilepsy  is  a  suitable  one  for  eye  treat- 
ment, but  prefer  to  say  that  only  those  cases  are  fit  sub- 
jects, in  the  proper  scientific  sense,  for  eye  treatment 
whose  visual  organs  are  palpably  the  source  of  irritation, 
giving  rise  to  symptoms  generally  included  under  the 
term  eye-strain. 

"12.  That  when  all  remedies  fail,  some  such  opera- 
tion as  Reynolds  suggests— easy  to  perform,  perfectly 
safe,  and  yet  of  a  severity  and  character  tending  to  make 
a  lasting  impression  on  the  patient's  mind — is  indicated. 
I  would  suggest  the  removal,  at  intervals,  of  small  pieces 
of  skin  from  various  parts  of  the  body,  the  denuded  spots 
being  allowed  to  heal  by  granulation." 


APPARENT  DEATH  BY  ELECTRICITY. 

At  a  recent  meeting  of  the  Biological  Society  of  Paris, 
Dr.  d' Arsonval  reported  the  case  of  a  workman  who  was 
caught  between  two  cables  conveying  electricity  from  the 
station  of  La  Chapelle  to  that  of  Epinay-sur-Seine.  The 
current  measured  5,000  volts,  and  the  man  received  the 
full  discharge  for  a  period  of  five  minutes  which  elapsed 
before  the  current  was  shut  off.  It  was  not  known  at 
first  what  caused  the  disturbances  noted  in  the  current, 
and  the  man  was  not  discovered  until  forty  minutes  later. 
He  was  then  apparently  dead,  but  attempts  were  made  to 
resuscitate  him  by  artificial  respiration  after  Sylvester's 
method.  These  failing,  resort  was  had  to  rhythmical  trac- 
tions of  the  tongue.  Respiration  was  in  this  way  gradu- 
ally re  established  and  the  man  made  a  quick  recovery, 
being  none  the  worse  for  his  experience  except  that  he 
suffered  from  the  burns.  The  reporter  believed  that  death 
from  electricity  is  not  immediate,  but  follows  asphyxia 
and  syncope,  conditions  which  may  often  be  removed  by 
treatment.  If  this  is  so,  may  the  criminals  executed  in 
this  State  be  said  to  be  killed  by  electricity  or  during 
the  autopsy  ?  

Reformatories  and  Jails. — An  exchange  says  that 
there  are  1,758  county  jails  and  but  44  juvenile  refor- 
matories in  the  United  States.  In  Great  Britain  there 
are  over  400  reformatories  and  industrial  schools  for 
juvenile  delinquents,  and  the  number  of  prisons  has  been 
reduced  from  113  to  57  within  the  past  ten  years. 

The  Oldest  Man  in  the  World. — A  Frenchman  now 
living  in  Russia  is  said  to  have  attained  the  immense  age 
of  one  hundred  and  twenty- six  years.  From  a  very  in- 
teresting account  of  his  life,  just  published  in  a  Russian 
journal,  it  appears  that  he  was  born  in  Paris  on  April  17, 
1 768.  He  has  a  vivid  recollection  of  the  "  Terror. ' '  He 
joined  Napoleon's  army  in  1798.  He  fought  in  the 
battles  of  Austerlitz  and  Jena,  shared  in  the  campaigns 
of  Egypt  and  Spain,  and  finally  was  one  of  the  four  hun- 
dred thousand  men  who  followed  Napoleon  to  Moscow. 


August  ii,  1894] 


MEDICAL  RECORD. 


*77 


UDexrja  at  ttue  W&ttk. 

The  Cholera  Epidemic  in  Europe  shows  no  signs  of 
abating  as  yet.  The  disease  is  raging  in  many  provinces 
of  Russia  and  in  Galicia,  and  lurks  obstinately  along  the 
shores  of  certain  streams  in  France,  Belgium,  and  Holland. 
In  St.  Petersburg  there  were  313  new  cases  and  240  deaths 
reported  for  the  week  ending  August  4th,  and  in  the  city 
and  province  of  Warsaw  during  the  week  previous  the  new 
cases  numbered  553  and  the  deaths  296.  In  sixteen  in- 
fected districts  in  Galicia  there  were  126  new  cases  and 
83  deaths  on  August  5  th  and  6th.  In  many  towns  in  this 
province  all  industry  and  commerce  are  at  a  complete 
standstill ;  the  rich  have  fled  and  the  poor  are  left  in  a 
starving  condition.  In  Holland  the  disease  is  present  in 
Amsterdam,  Haarlem,  Halfweg,  Dordrecht,  and  Maas- 
tricht, 26  new  cases  and  13  deaths  having  been  reported 
in  these  places  on  August  1st.  Deaths  from  cholera  have 
also  taken  place  in  Dantzic  and  other  towns  in  Eastern 
Prussia.  The  North  German  Lloyd  and  Hamburg  Amer- 
ican Steamship  Companies  are  about  to  erect  buildings  at 
IUowo  and  other  places  on  the  Russo  German  frontier  for 
the  detention  and  examination  of  intending  steerage  pas- 
sengers to  this  country.  The  stations  will  contain  dis- 
infecting apparatus  for  baggage  and  clothing,  and  bath- 
ing-places for  the  emigrants. 

Openings  for  the  Unemployed. — The  war  between 
Japan  and  China  promises  to  be  a  protracted  one,  and 
it  is  probable  that  the  services  of  foreign  surgeons  will 
be  in  demand  in  the  Japanese  army  and  navy,  if  not  in 
the  Chinese  also.  Yet  we  would  not  advise  young  sur- 
geons to  go  to  the  expense  of  a  trip  to  Japan  without 
having  some  definite  assurance  that  their  services  will  be 
wanted.  And  furthermore,  a  law  was  passed  in  i860 
making  it  a  penal  offence  for  citizens  of  the  United 
States  to  take  part  in  a  war  against  a  friendly  nation. 
That  probably,  however,  would  not  apply  to  the  case  of 
non-combatants  such  as  surgeons  and  nurses. 

The  Plague  is  still  epidemic  in  Canton  in  virulent  form, 
the  mortality  being  ninety  per  cent,  of  those  attacked. 
For  the  three  months  ending  July  1st  it  is  estimated  that 
forty  thousand  deaths  have  occurred.  Cholera  has  also 
made  its  appearance  there  in  epidemic  form. 

The  British  Medical  Association. — A  number  of  Amer- 
icans were  announced  to  be  present  at  the  meeting  of  the 
British  Medical  Association  in  Bristol  last  week.  Among 
them  were  Drs.  J.  J.  Chisholm,  G.  M.  Gould,  J.  L. 
Thompson,  G.  T.  Stevens,  Henry  D.  Chapin,  W.  P. 
Northrup,  and  Dillon  Brown.  Dr.  Northrup,  in  addi- 
tion to  several  communications  of  his  own,  read  a  paper 
on  intubation  for  Dr.  Joseph  O'  Dwyer,  who  was  unable 
to  accept  the  invitation  to  be  present  in  person. 

The  Erenoh  Society  of  Dermatology  and  Syphilog- 
raphy  held  its  fifth  annual  meeting  at  Lyons  on  August 
2d  and  two  following  days. 

Dr.  William  J.  Little,  of  London,  "  the  father  of  Eng- 
lish Orthopedy,"  died  on  Saturday,  July  7th,  in  the 
eighty-fourth  year  of  his  age.  He  was  for  many  years 
physician  to  the  London  Hospital  and  lecturer  on  the 
Practice  of  Medicine  in  the  college.  His  first  work,  "  A 
Treatise  on  Club  foot  and  Analogous  Distortions,"  was 


published  in  1839,  and  his  last,  on  "Id -Knee,"  written 
jointly  with  his  son,  Mr.  £.  Muirhead  Little,  in  1882. 
Soon  after  that  he  retired  from  practice  to  pass  the  re- 
mainder of  his  days  at  his  country  residence. 

Dr.  Judson  B.  Andrews,  Superintendent  of  the  Buffalo 
State  Hospital  for  the  Insane,  died  in  Buffalo,  August  3d, 
aged  sixty  years.  He  was  a  graduate  of  Yale  College  in 
the  class  of  1855,  and  received  his  medical  degree  in  1863. 
During  the  War  of  the  Rebellion  he  served  as  a  captain  in 
the  Seventy-seventh  New  York  Infantry,  which  was  organ- 
ized at  Saratoga,  but  resigned  July  16,  1862.  He  is  also 
credited  with  service  as  a  surgeon  in  a  Connecticut  regi- 
ment, but  his  name  does  not  appear  in  the  New  Englard 
roster  of  volunteer  officers.  He  was  ex-President  of  the 
Brie  County  Medical  Society,  a  founder  and  ex- President 
of  the  New  York  State  Medical  Association,  as  well  as 
ex  President  of  the  Psychological  Section  of  the  Ninth 
International  Medical  Congress.  In  1892  he  was  elected 
President  of  the  American  Medico-Psychological  Asso- 
ciation. His  many  years'  service  as  Assistant  Superin- 
tendent of  the  Utica  Asylum,  as  Superintendent  of  the 
Buffalo  Asylum  since  it  was  opened  in  1880,  and  as  the 
working  editor  of  the  American  Journal  of  Insanity,  well 
qualified  him  as  an  expert  in  his  chosen  department,  to 
which,  indeed,  he  contributed  many  enlightened  reforms. 

The  first  French  Congress  of  Internal  Medicine  will 
be  held  in  Lyons,  under  the  presidency  of  Professor 
Gailleton,  mayor  of  the  city,  during  the  week  beginning 
on  Thursday,  October  25  th.  Medical  men  of  any  na- 
tionality may  take  part  in  the  proceedings  on  payment 
of  a  subscription  of  twenty  francs,  but  ail  communications 
must  be  in  the  French  language. 

The  Medical  Publishers'  Association  meets  at  Hot 
Springs,  Va.,  August  13th  and  14th. 

The  American  Journal  of  Insanity  will  hereafter  be 
published  in  Chicago,  under  the  managing  editorship  of 
Dr.  Richard  Dewey.  The  Journal  has  become  the  organ 
of  the  American  Medico-Psychological  Association,  but 
its  general  form  and  scope  will  remain  unchanged. 

Insanity  and  Crime.— At  the  meeting  of  the  British 
Medical  Association,  just  held  at  Bristol,  a  discussion  on 
"  The  Law  in  Relation  to  the  Criminal  Responsibility 
of  the  Insane"  took  place  before  the  Section  on  Psy- 
chology. It  was  opened  by  Dr.  L.  A.  Weatherly,  who 
advocated  a  change  in  the  English  law  on  this  subject. 
At  present  the  law  is  that  if  the  accused  was  con- 
scious that  the  act  was  one  which  he  ought  not  to  do, 
and  if  the  act  was  contrary  to  law,  he  is  punishable.  Dr. 
Weatherly  maintained  that  if  it  is  proved  that  the  ac- 
cused is  certifiably  insane,  and  further,  that  the  crime 
charged  is  the  outcome  of  his  mental  disease,  he  is  en- 
titled to  a  verdict  of  insanity  and  should  be  placed  under 
treatment  in  an  asylum  for  the  insane  and  not  be  pun- 
ished as  a  criminal. 

The  Babathu  Leper  Asylum. — The  annual  report  of 
this  asylum  for  1893  h^  te*n  received.  The  superin- 
tendent acknowledges  with  gratitude  a  ready  response 
to  his  appeal  for  increased  donations,  but  says  that  the 
need  for  help  is  still  urgent.  Several  contributions  were 
received  from  friends  in  the  United  States.  For. the 
benefit  of  those  interested  in  the  study  of  leprosy  some 
excellent  photographs  have  been  taken  of  a  group  of 


i78 


MEDICAL   RECORD. 


[August  ii,  1894 


the  leper  inmates,  and  are  sold  for  the  benefit  of  the 
asylum  at  one  dollar  per  copy,  including  postage,  and  a 
short  history  of  each  person.  The  address  of  the  super- 
intendent is  Dr.  M.  £.  Carleton,  Sabathu,  North  India. 

Pregnancy  at  an  Advanced  Age.— In  the  Berlin  In- 
telligenzblatt  of  July  5th,  among  the  death  notices  was 
one  of  Frau  Marchoun,  sixty*  eight  years  of  age,  the 
cause  of  whose  death  was  said  to  be  puerperal  fever. 

A  Monument  to  Volkmann.— At  the  recent  bicen- 
tenary celebration  of  the  University  of  Halle,  a  monu- 
ment to  Professor  Richard  v.  Volkmann  was  unveiled 
with  appropriate  ceremonies. 

A  Medical  Monk.  —  Dom  Sauton,  a  Benedictine 
monk,  and  a  doctor  of  medicine  as  well,  who  recently  re- 
turned to  Paris  from  a  mission,  both  religious  and  scien- 
tific, to  the  lepers  of  the  Scandinavian  Peninsula,  has 
started  again  on  an  extended  tour  among  the  lepers  of 
Asia  Minor  and  Greece,  and  will  visit  Japan  and  the 
Sandwich  Islands  before  returning  to  France. 

Dr.  Charles  B.  Briggs  succeeds  his  father,  the  late 
Dr.  W.  T.  Briggs,  as  Professor  of  Surgery  in  the  Univer- 
sity of  Nashville. 

The  St.  Louis  "Clinique." — Dr.  Emory  Lanphear 
has  assumed  the  editorial  management  of  the  above- 
named  journal. 

Sterilization  of  Doctors. — It  has  been  proposed  by 
Gutmann  that  stations  be  erected  in  convenient  localities 
in  cities  and  large  towns  where  physicians  may  go  to 
be  thoroughly  disinfected  immediately  after  they  have 
visited  a  case  of  infectious  disease,  and  before  paying 
any  further  visits.  The  operation  will  take  about  fifteen 
minutes,  and  then  the  doctor  may  go  about  his  business, 
proud  in  the  consciousness  of  being  clean  and  no  longer 
a  menace  to  the  health  of  his  fellows. 

The  Iowa  Public  Hall  Association,  whose  aim,  as  an- 
nounced in  the  notice  of  meeting,  is  purely  philanthropic, 
will  hold  its  fourth  annual  session  in  Des  Moines,  Sep- 
tember 6  and  7,  1894.  Membership  in  the  Association 
is  not  limited  to  medical  men,  but  all  interested  in  the 
prevention  of  sickness  are  eligible. 

The    American    Electro  -  Therapeutic     Association 

will  hold  its  fourth  annual  meeting  at  the  Academy  of 
Medicine,  in  this  city,  on  September  25,  26,  and  27, 1894. 
An  interesting  programme  is  announced.  The  President 
of  the  Association  is  Dr.  W.  J.  Herdman,  of  Ann  Arbor, 
and  the  Secretary,  Dr.  Margaret  A.  Cleaves,  of  New 
York. 

Diphtheria  Germs  in  Cheese. — The  Board  of  Health 
in  this  city  recently  received  a  telegram  from  the  Secre- 
tary of  the  State  Board  of  Health,  stating  that  some 
cheese  which  had  been  shipped  to  a  firm  of  provision- 
dealers  contained  Loeffler's  diphtheria  bacilli,  and  re- 
questing that  samples  be  submitted  to  the  bacteriologist 
of  the  Department  for  examination.  This  was  done, 
with  the  result  of  proving  that  the  suspicions  of  the  State 
Board  were  well  founded.  The  shipment  consisted  of 
three  thousand  pounds,  and  the  entire  lot  has  been 
seized  and  destroyed.  There  was  diphtheria  in  the 
family  of  the  farmer  from  whom  the  milk  was  obtained. 
The  tests  thus  far  made  have  been  culture- tests,  but  in- 
oculation experiments  are  to  be  made  on  guinea  pigs. 


Mr.  Gladstone's  Byes  are  now  reported  to  be  so  much 
improved  that  he  is  able  to  dispense  with  goggles. 

Thyroid  Extract  has  lately  been  recommended  in  the 
treatment  of  obesity.  But  it  is  well  to  remember  that 
this  is  a  dangerous  substance,  often  causing  great  weak- 
ness of  the  heart,  and  it  should  be  used  with  caution. 

An  International  Congress  for  the  Protection  of  In- 
fancy will  be  held  in  Bordeaux,  commencing  July  22, 
1895.  The  work  of  the  Congress  will  be  divided  into 
three  sections:  1,  Physical  protection,  in  which  ques- 
tions of  day  nurseries,  infant  and  foundling  asylums,  etc., 
will  be  discussed ;  2,  moral  protection,  in  which  will  be 
considered  orphan  asylums,  country  homes,  the  rescuing 
of  abandoned  children,  etc.,  and  3,  administrative  pro- 
tection, in  which  the  various  laws,  existent  and  proposed, 
relating  to  the  care  of  young  children  will  be  discussed. 

Dr.  Hans  Buchner  has  been  appointed  Professor  of 
Hygiene  and  Director  of  the  Hygienic  Institute  in 
Munich,  to  succeed  Professor  von  Pettenkofer. 

A  Royal  Doctor. — The  Lancet,  with  inconceivable 
temerity,  makes  the  awful  suggestion  that  the  infant  son 
of  the  Duke  of  York  be  educated  as  a  physician  or  sur- 
geon. It  might  not  be  a  bad  thing  for  the  young  man 
to  be  provided  with  a  livelihood  in  case  anything  should 
happen  to  interfere  with  the  exercise  of  his  hereditary 
profession.  Edward  Albert  Christian  George  Andrew 
Patrick  David  Wettin,  M.D.  Lond.,  F.R.CP.  Edin., 
F.RX.S.L,  Defender  of  the  Faith,  etc.,  etc.,  would  be 
quite  imposing. 

The  American  Public  Health  Association  will  hold 
its  twenty-second  annual  meeting  in  Montreal,  on  Sep- 
tember 25-28,  1894. 

Students  in  Leipsic. — The  University  of  Leipsic  is 
disturbed  by  the  gradual  decline  in  the  number  of  its 
students.  Twenty  years  ago  it  stood  at  the  head  of  Ger- 
man universities,  while  to  day  it  has  a  thousand  less  than 
Munich,  and  twice  that  number  less  than  Berlin.  Those 
that  remain  are  studiously  inclined,  however,  for  they  re- 
cently held  a  meeting  in  which  a  resolution  was  passed 
to  abstain  from  beer  drinking  in  the  forenoon,  on  the 
ground  that  early  beer  interfered  with  honest  work. 

The  Earning  Value  of  an  Bye  Mathematically  Ap- 
praised—The earning  value  of  an  eye  depends  on  vari- 
ous conditions ;  it  is  evidently  greater  if  the  remaining 
eye  has  poor  sight  than  if  the  remaining  eye  has  good 
sight ;  for  in  the  first  case  its  loss  would  practically  be 
equal  to  the  loss  of  both  eyes.  Professor  Zehander  has 
furnished  us  with  a  formula  by  which  the  earning  capacity 
of  the  remaining  eye  (and  consequently  the  earning  value 
of  the  lost  eye)  can  be  appraised  for  the  manifold  con- 
ditions of  sight.  The  normal  sight  of  an  eye  being 
valued  at  100,  the  earning  capacity  of  the  remaining  eye 
is  i±jl$jl±jl  =  662<i  per  cent.,  hence  the  loss  of  one  eye 
amounts  to  33^  per  cent,  of  the  former  earning  capacity, 
provided  both  eyes  had  full  vision.  But  suppose  the  vision 
of  the  remaining  eye  is  only  four-fifths,  its  earning  capacity 
would  be  i±y4'g  =  53^  ;  hence  the  lost  eye  would  have 
an  earning  value  of  46^3  per  cent.,  and  thus  the  loss  in 
earning  capacity  can  be  estimated  under  all  conditions  if 
in  the  above  formula  the  degree  of  vision  of  the  remain- 
ing eye  is  substituted  for  100.— Journal  of  the  American 
Medical  Association. 


August  ii,  1894] 


MEDICAL   RECORD. 


179 


jfocietg  Reports* 

drimsstzss  of  American  |p«jsictatis 
and  gvtXQzaus. 

Third  Triennial  Meeting,  held  in   Washington,  D.  C, 
May  29,  jo,  ji,  and  June  1,  1894. 

AMERICAN  NEUROLOGICAL  ASSOCIATION. 

Twentieth  Annual  Meeting,  held  at  Washington,  D.  C, 
May  29,  jo,  ji,  and  June  1,  1894. 

(Continued  from  page  90.) 

Third  Day,  Friday,  June  ist. 

The  Treatment  of  Convalescence  and  the  After-care 
of  the  Insane. — Dr.  Henry  R  Stedman,  of  Boston,  con- 
sidered the  dangers  attending  convalescence  in  insanity 
and  the  precautions  necessary  to  prevent  relapse  or  pro- 
long remissions.  General  rules  and  advice  regarding  the 
prevention  of  insanity  are  not  regarded  even  by  predis- 
posed subjects,  and  are  practically  of  but  little  use.  The 
case  is  different  when  once  an  attack  of  insanity  has 
been  experienced.  Although  in  certain  cases  the  proper 
conduct  of  convalescence  is  vital  to  mental  health,  the 
study  of  this  period  is  confined  to  a  few  scattered  sug- 
gestions in  the  works  on  insanity.  Instances  of  abrupt 
recovery,  with  almost  no  convalescent  stage,  are  rare. 
Although  it  may  happen  in  chronic  cases,  it  occurs,  as  a 
rule,  in  those  of  short  duration — notably  confusional  in- 
sanity and  the. toxic  and  neurotic  insanities. 

Lucid  intervals  or  spurious  convalescences  differ  often 
in  no  respect  from  genuine  recovery,  with  the  single  and 
essential  exception  that  the  sleep  does  not  improve  or  is 
worse.  This  is  a  valuable  indication  in  the  prognosis  of 
permanent  return  to  reason. 

To  the  cardinal  signs  of  convalescence  should  often 
be  added  the  disappearance  of  decided  fear  of  a  return  of 
the  attack  and  dread  of  the  stigma  to  follow.  It  is  im- 
portant to  be  informed  regarding  normal  and  usual  phys- 
ical troubles  of  the  patient,  as  their  reappearance  is  an- 
other and  valuable  indication  of  recovery ;  so,  also,  a 
knowledge  of  the  sequence  of  immediate  prodromata  of 
an  attack.  They  are  often  repeated  in  reverse  order 
while  the  patient  is  getting  well. 

Complete  mental  rest  during  menstrual  epochs,  so 
highly  important  at  this  time,  is  often  disregarded,  and 
application  of  the  mind,  even  to  a  slight  degree,  in  study 
or  other  work,  is  equally  to  be  deprecated. 

Early  discharge  from  the  asylum,  or  from  special  care 
away  from  home,  is  to  be  advised  against,  as  a  rule,  espe- 
cially in  cases  of  melancholia  with  a  history  of  suicidal 
attempts  and  after  acute  mania,  the  most  exhausting 
form  of  insanity,  and  one  which  leaves  the  patient  par- 
ticularly susceptible  to  slight  influences  for  a  long  time. 

On  the  other  hand,  we  should  frequently  advise  early 
removal  in  other  cases  convalescing  from  melancholia, 
particularly  when  homesickness  is  a  marked  feature  and 
occasionally  when  there  is  refusal  of  food.  Certain  cases 
of  mild  mania,  also  paranoiacs  who  are  independent  in 
the  asylum  and  actively  oppose  treatment,  are  steadied 
by  outside  life.  A  change  also  works  well  until  its 
novelty  has  worn  off. 

The  first  year  or  so  after  recovery  is  a  very  critical 
time.  The  reader  gave  a  number  of  indications  in  spe- 
cial cases  and  suggestions  for  prevention  of  relapse. 

The  above  remarks  applied  chiefly  to  well-to  do  pa 
tients.  An  important  branch  of  this  subject  is  the 
means  for  the  after-care  of  the  pauper  insane.  There  is 
practically  no  provision  outside  of  asylums  for  this  class, 
and  practically  little  advice  or  other  help  is  given  these 
unfortunates  on  leaving  asylums.  While  for  the  physi- 
cally sick,  on  the  other  hand,  there  is  abundant  provision 
for  their  care  during  convalescence,  and  the  discharged 
convict  is  greatly  helped  and  encouraged  by  charitable 
societies  for  the  purpose.     Asylum  physicians  often  hesi- 


tate to  set  certain  patients  at  liberty  whose  mental  condi- 
tion seems  to  have  so  far  improved  as  to  make  it  useless 
to  keep  this  class  longer  under  care  (and  even  some  who 
have  fully  recovered),  for  fear  that,  thus  suddenly  thrown 
on  their  own  resources,  without  oversight,  or  perhaps 
means  of  support,  they  will  fall  back  into  their  old  habits 
of  life  which  gave  rise  to  their  insanity.  This  fact,  and 
their  delicate  mental  condition,  often  render  them  easy 
victims  to  designing  people. 

These  and  other  reasons  have  led  to  the  formation,  in 
France,  of  protective  societies,  called  "  Societies  of  Pat- 
ronage "  under  official  auspices.  Their  duties  are  to  aid 
convalescent  or  recovered  pauper  patients  by  gifts  of 
money,  clothing  and  tools,  redemption  of  articles  in 
pawn,  payment  of  rent,  admission  to  convalescent 
homes  in  cottages  intermediate  between  confinement 
and  complete  freedom,  or  in  hospitals  or  house  of  refuge, 
securing  situations  for  them,  and  finally  their  supervision 
wherever  employed.  This  work  continues  during  the 
first  month  or  two  after  the  patient's  discharge.  Similar 
societies  or  means  of  relief  have  been  adopted  in  Eng- 
land and  Scotland.  They  were  described  in  detail. 
There  is  no  better  work  on  the  score  of  both  humanity 
and  public  economy  than  the  adoption  in  this  country 
of  similar  means  for  the  prevention  of  insanity. 

Dr.  E.  D.  Fisher  was  of  the  opinion  that  patients  left 
the  asylum  too  early.  In  cases  where  they  are  oversen- 
sitive regarding  their  previous  incarceration,  some- 
thing must  be  done  to  care  for  them  and  obviate  a  re- 
lapse. He  was  in  favor  of  establishing  convalescent 
homes  for  such  patients,  and  spoke  at  length  in  confirma- 
tion of  the  views  of  the  author  of  the  paper. 

Dr.  Dercum  thought  this  matter  a  very  important 
phase  in  the  care  of  the  insane.  It  is,  however,  quite 
difficult  to  deal  with  individal  cases.  Where  the  element 
of  exhaustion  was  a  prominent  causative  factor,  the  pa- 
tient required  detention  and  care  much  longer. 

Dr.  Starr  was  glad  to  know  that  Dr.  Stedman  favored 
the  earlier  removal  from  asylums  of  melancholies.  One 
of  the  chief  difficulties  was  in  controlling  the  family,  who 
did  not  know  how  to  manage  the  patient  after  his  return. 

Dr.  Jones,  of  Minnesota,  said  that  in  Minnesota, 
since  the  word  asylum  had  been  changed  to  that  of  hos- 
pital, it  had  tended  to  remove  any  of  the  supposed  stig- 
ma that  has  been  usually  attached  to  people  who  have 
been  in  institutions  for  the  insane. 

Dr.  Knapp  and  the  President  concurred  in  the  views 
expressed  by  the  reader  of  the  paper. 

Dr.  Dana  said  that  the  subject  was  of  great  economic 
as  well  as  medical  importance ;  he  would  suggest  that  a 
committee  be  appointed  to  investigate  the  matter. 

This  suggestion  was  then  presented  in  the  form  of  a 
motion,  which  was  carried.  The  President  then  appointed 
as  a  committee  Drs.  Stedman,  Dana,  and  Dercum. 

Exhibition  of  a  Suicide's  Brain  with  Two  Pistol  ball 
Wounds. — Dr.  Burt  G.  Wilder,  of  Ithaca,  exhibited  a 
specimen  and  showed  a  dozen  photographs  of  various  as- 
pects and  blackboard  diagrams  of  the  left  side  and  of  a 
transsection  at  the  level  of  the  fatal  wound. 

W.  I.  B.,  dentist,  thirty-five  years  of  age,  of  Ithaca,  N. 
Y.,  on  April  7,  1894,  was  found  in  his  office,  dead, 
a  ^  revolver  clasped  in  his  right  hand.  There  were 
two  bullet-holes — one  in  the  middle  of  the  forehead,  the 
other  in  the  right  temple,  neither  ball  having  emerged. 
In  accordance  with  his  written  directions,  the  brain  was 
preserved  in  the  museum  of  Cornell  University  as  speci- 
men 3,129. 

The  first  ball,  presumably  deflected  by  the  skull,  passed 
caudo-ventrad  to  the  cranial  floor  and  was  reflected  dor- 
so-caudad  at  nearly  the  same  angle  to  a  point  just  ceph- 
alad  of  the  precommissure,  where  it  lodged,  having  merely 
abraded  the  mesal  surface  of  the  left  frontal  lobe.  The 
second  ball  entered  at  the  right  sub  frontal  gyre,  passed 
obliquely  sinistro-caudo- dorsad,  tore  the  callosum  and 
intervening  structures,  and  emerged  in  the  second  left 
central  fissure.  Since  there  was  no  suspicion  of  foul  play, 
and  documents  in  the  deceased's  handwriting  declared 


i8o 


MEDICAL  RECORD. 


[August  ii,  1894 


his  intention  to  commit  suicide,  the  case  exemplifies  the 
possibility  of  two  self-inflicted  bullet-wounds  of  one  brain. 

The  fissures  present  many  peculiarities.  The  most 
perplexing  is  the  apparent  coexistence  of  two  central  fis- 
sures on  each  side.  The  only  two  such  cases  hitherto 
observed  were  recorded  by  Giacomini  and  Calori.  Sui- 
cide had  been  committed  by  a  grandfather  and  one  uncle 
and  attempted  by  another  uncle. 

Dr.  Dercum  had  examined  a  large  number  of  brains  of 
the  insane,  but  he  had  never  seen  such  an  instance  as  that 
presented  by  Dr.  Wilder. 

Dr.  Dana  said  that  he  had  no  doubt  that  the  anterior 
of  the  two  fissures  was  the  fissure  of  Rolando.  The  in- 
terruption of  this  fissure  on  one  side  by  a  bridging  con- 
volution was  extremely  rare  and  very  interesting.  The 
brain  presented  a  unique  fissuration.  He  could  not 
understand  how  a  primary  fissure  like  the  Rolandic  could 
be  doubled  in  any  event,  and  was  skeptical  of  the  genu- 
ineness of  reported  cases. 

Infantile  Hemiplegia,  Imbecility,  and  Epilepsy; 
Craniotomy;  Marked  Improvement. — Dr.  Edw.  B. 
Angell,  of  Rochester,  reported  a  case  and  read  a  paper 
with  the  above  title.  The  salient  features  of  the  case 
were  forceps  delivery,  succeeded  by  double  ptosis,  occa- 
sional tonic  spasm  of  right  arm,  contracture,  and  hemi- 
palsy  of  right  hand.  Physical  and  mental  development 
were  slow,  and  epilepsy,  with  three  to  five  seizures  daily, 
supervened  three  months  prior  to  the  operation.  At 
time  of  examination  the  child  was  partly  imbecile. 
Skull  measurement  gave  a  cranial  index  of  77 ;  palate 
was  high-arched,  teeth  jagged,  and  right  wrist  and  hand, 
much  smaller  than  left,  were  helpless. 

A  diagnosis  was  made  of  pressure  in  neighborhood  of 
the  hand-centre  of  left  motor  area,  due  either  to  a  hemor- 
rhagic plaque  or  cyst.  Craniotomy  was  decided  upon,  as 
a  tentative  measure,  with  a  view  of  relieving  pressure  and 
consequent  symptoms,  while  avoiding  the  greater  risk  of 
opening  the  dura  necessary  to  removal  of  the  cyst-wall. 
The  operation  was  performed  March  13th  last,  and,  upon 
removal  of  the  trephine  button,  a  subdural  hemorrhagic 
cyst  was  found.  The  cranium  overlying  the  cyst  had  be- 
come very  much  thinned,  and  was  freely  cut  away  beyond 
the  limits  of  the  cyst.  By  an  aspirating  needle  a  half 
drachm  of  fluid  was  removed ;  otherwise  the  dura  was  not 
injured.  The  scalp  incision  healed  readily ;  but,  through 
an  overtight  bandage,  oedema  developed,  and  by  the 
eighth  day  caused  sufficient  pressure  to  develop  a  hard 
convulsion  and  high  temperature.  With  the  remedying 
of  this,  marked  improvement  in  all  the  symptoms  ensued. 
1  At  the  present  time  (three  months  after  the  operation) 
there  has  been  no  recurrence  of  the  epileptic  attacks, 
while  there  has  been  a  commensurate  improvement  in  the 
mental  and  moral  condition. 

Dr.  Mills  considered  it  presumable  that  the  cyst 
which  was  not  opened  was  a  porencephalic  cavity,  and 
that  opening  and  draining  it  would  have  been  useless. 

Dr.  Putnam  agreed  with  Dr.  Mills.  He  said  it  was 
rarely  possible  to  remove  a  cyst  satisfactorily.  In  a  case 
seen  by  him  the  cyst  was  tapped  and  the  drain  left  in. 
Improvement  followed. 

Dr.  W.  A.  Hammond  spoke  of  two  cases  on  whom 
craniotomy  was  performed.  One  was  eighteen  years  of 
age,  and  became  an  imbecile  as  a  result  of  an  injury  to  the 
head.  He  remained  in  this  condition  four  years.  After 
operation  there  was  improvement  at  the  end  of  two 
months.  At  the  end  of  a  year  the  improvement  was 
marked.  In  the  other  case,  of  a  similar  character,  the 
operation  was  followed  by  improvement. 

The  President  said  cysts  differed  in  character.  The 
superficial  cysts  were  due  to  meningeal  hemorrhage  during 
labor,  and  could  be  satisfactorily  treated  by  operation. 

Dr.  Angell,  in  closing  the  discussion,  said  this  was  not 
a  case  of  porencephaly,  but  an  arachnoid  cyst  from  a 
meningeal  hemorrhage. 

Infantile  Amyotrophic  Lateral  Sclerosis  of  the  Fam- 
ily Type. — Dr.  Charles  Henry  Brown,  of  New  York, 
gave  the  history  and  report  of  a  case  of  this  kind.     The 


disease  occurred  in  a  boy  fifteen  years  of  age.  There 
was  marked  emaciation,  particularly  in  the  upper  part  of 
the  body,  and  paralysis  and  atrophy  of  all  the  facial  mus- 
cles, excepting  those  of  mastication.  Fibrillary  twitch- 
ings  were  present  all  over  the  body.  The  superficial  and 
deep  reflexes  were  active.  Ankle  clonus  was  demonstra- 
ble. There  was  double  lateral  curvature  of  the  spine. 
Mentally  the  boy  was  fairly  bright.  He  cries  readily 
and  is  amused  at  trifles.  Is  microcephalic,  and  acts  and 
appears  like  a  child  of  ten.  There  are  evidences  of  a 
general  arrest  of  development.  Dr.  Brown  considers  his 
case  as  belonging  to  one  of  the  family  types  of  infantile 
progressive  bulbar  paralysis,  plus  the  same  implication 
that  is  found  engrafted  upon  the  progressive  poliomyeli- 
tis of  adults,  and  which  gives  us  amyotrophic  lateral  scle- 
rosis. In  muscular  myopathies  the  respiration  is  not  in- 
volved. The  upper  facial  muscles  are  usually  unaffected, 
and  the  "  taper  mouth  "  is  not  observed.  The  atrophy 
is  more  irregular,  more  bilateral ;  that  is,  it  is  worse  on 
one  side.  Electric  reactions  are  not  of  especial  impor- 
tance in  diagnosis.  In  some  reported  cases  of  infantile 
progressive  bulbar  paralysis  they  are  normal ;  in  others, 
degenerative. 

To  place  this  case  among  the  scapulohumeral  or  facio- 
scapulo  humeral  types  of  muscular  atrophy  is  out  of  the 
question.  Though  the  neck  is  much  thinned,  the  scap- 
ulohumeral group  and  the  back  muscles  are  generally  the 
best  the  patient  has.  What  muscles  he  does  possess  are 
active,  and  the  exaggeration  of  reflexes,  the  fibrillary 
twitchings,  and  the  retractions  of  tendons  that  are  present, 
though  slight,  preclude  a  peripheral  origin  of  the  disease. 
As  far  as  is  known,  no  case  of  the  kind  has  ever  been  re- 
ported and  diagnosticated  as  infantile  amyotrophic  lat- 
eral sclerosis  of  the  family  type.  Hoffman's  case,  a  boy 
aged  eleven  years,  closely  resembles  it.  Here,  too,  there 
was  marked  labio-glosso  laryngeal  paralysis,  great  emaci- 
ation of  upper  extremities  of  the  trunk,  extending  down 
below  the  hips,  together  with  exaggerated  reflexes  in 
the  lower  extremities  and  diminished  reflexes  in  the 
upper.  In  Hoffman's  case  the  atrophy  was  probably  too 
extreme  in  the  upper  extremities  to  admit  of  much  re- 
sponse. In  all  the  cases  reported  of  these  bulbar  dis- 
eases belonging  to  groups  of  family  types  there  has  been 
marked  difficulty  of  respiration  and  special  implication 
of  the  upper  branch  of  the  trifacial  nerve. 

Dr.  Knapp  showed  a  microscopic  specimen  from  a  case 
of  amyotrophic  lateral  sclerosis  which  occurred  in  a  man 
aged  fifty  years.  The  disease  progressed  very  rapidly. 
He  died  at  the  end  of  fourteen  months  of  broncho-pneu- 
monia. There  were  no  bulbar  symptoms.  The  section 
presented  showed  marked  vascularity  in  the  sclerosed 
portions  of  the  cord. 

Dr.  Putnam  reported  an  analogous  case  of  bulbar  pa- 
ralysis in  a  young  child. 

Dr.  Preston,  of  Baltimore,  had  seen  a  child  two  years 
of  age  in  whom  spastic  symptoms,  such  as  exaggerated 
knee-jerk  and  ankle  clonus,  developed  soon  after  an  attack 
of  acute  poliomyelitis. 

Ingravescent  Cerebral  Hemorrhage  Treated  by  Liga- 
tion of  the  Common  Carotid  Artery.— Drs.  F.  X.  Der- 
cum and  W.  W.  Keen,  of  Philadelphia,  presented  a  joint 
paper  with  this  title,  reporting  two  cases.  In  the  first 
case  the  symptoms  pointed  to  a  slowly  progressive  capsu- 
lar hemorrhage,  extending  over  three  days  before  ligation 
of  the  common  carotid  was  resorted  to.  The  symptoms 
were  steadily  progressive  and  threatened  a  fatal  termina- 
tion. Ligation  of  the  carotid,  as  proposed  by  Mr. 
Horsely,  promptly  arrested  the  symptoms,  and  the  man 
made  an  excellent  recovery.  Months  afterward  merely 
symptoms  of  a  spastic  hemiplegia  persisted,  but  they  were 
not  very  marked. 

The  second  case  was  one  in  which  the  symptoms 
pointed  to  a  progressive  hemorrhage  occupying  eight 
hours.  The  patient's  condition  was  so  grave  at  the 
time  of  the  operation  that  little  was  hoped  from  it ;  and 
indeed  it  proved  useless,  patient  dying  several  hours 
afterward. 


August  ii,  1894] 


MEDICAL  RECORD. 


181 


Dr.  Dercum  pointed  out  that  the  class  of  cases  in 
which  benefit  is  to  be  hoped  for  from  ligation  of  the 
common  carotid  are  those  in  which  the  hemorrhage  is 
decidedly  ingravescent  in  type.  He  also  dwelt  upon  the 
difficulties  of  a  differential  diagnosis  between  hemorrhage 
and  thrombosis  in  such  cases,  and  pointed  out  that  even 
in  case  of  an  error  in  diagnosis  it  could  not  be  said  that 
the  operation  involved  additional  risk  to  the  brain. 
Finally,  he  suggested  that,  instead  of  ligation  of  the  ves- 
sel, the  expedient  of  compression  of  the  common  carotid 
should  be  tried  in  every  case  of  apoplexy  as  soon  as  the 
physician  arrived.  A  surgeon  is  not  always  at  hand,  and 
besides  compression  of  the  carotid  is  so  simple  a  proced- 
ure that  a  bystander  can  easily  be  instructed  to  apply  it. 
Dr.  Frank  Fry,  of  St.  Louis,  knew  of  several  in- 
stances in  which  the  operation  had  been  done.  All 
proved  fatal.  He  believed  that  none  of  them  were  in- 
dicated or  justifiable. 

Dr.  Knapp  believed  that  the  neurologist  does  not  see  the 
case  until  it  is  too  late  to  make  a  satisfactory  diagnosis. 

The  President  thought  the  chief  difficulty  was  in 
diagnosis,  and  that  the  hemorrhage  was  usually  a  self- 
limited  one. 

Dr.  Dercum,  in  closing  the  discussion,  said  the  opera- 
tion was  only  indicated  where  the  diagnosis  of  ingraves- 
cent apoplexy  was  definite. 

Merycism. — Dr.  W.  A.  Hammond,  of  Washington,  de- 
fined this  condition  as  the  functions  of  rumination  and 
remastication  in  the  human  subject.  Only  about  fifty 
cases  have  been  reported.  Several  cases  were  referred 
to,  among  them  that  of  the  distinguished  physiologist, 
Brown  S6quard,  who  had  acquired  it  as  a  result  of  experi- 
ments performed  upon  himself.  The  case  reported  was 
that  of  a  young  man,  whose  mental  condition  was  impaired 
and  who  was  also  the  subject  of  merycism.  No  special 
treatment  was  undertaken  against  the  merycism,  but  the 
patient  was  trephined  with  the  purpose  of  improving  his 
mental  condition.  There  were  no  unusual  features  con- 
nected with  the  operation ;  but  it  was  noticed  that  re- 
gurgitation did  not  occur  with  the  meals  he  subsequently 
ate  till  on  the  fifth  day,  when  there  was  a  slight  return. 
Eight  days  later  a  similar  button  was  removed  from  the 
corresponding  part  of  the  left  side  of  the  skull.  From 
that  time  (about  six  months  ago)  till  the  present  there  has 
been  no  regurgitation. 

Whether  the  cure  of  the  merycism  in  this  case  was  di- 
rectly due  to  the  operations  on  the  cranium  or  the  re- 
sult of  the  mental  improvement  is  a  question  which  it 
would  be  difficult  to  answer. 

Dr.  Knapp  was  unaware  that  so  few  cases  had  been  re- 
ported in  this  country.  Two  cases  had  come  under  his 
notice.  Both  were  physicians  in  good  mental  condition. 
He  thought  a  distinction  should  be  made  between  con- 
genital and  acquired  merycism. 

Dr.  Lloyd  believed  that  some  cases  should  be  consid 
ered  as  a  neurosis  allied  to  hysterical  vomiting,  such  as 
regurgitation  from  the  oesophagus. 

The  President  had  seen  a  man  who  had  conquered 
the  habit  by  the  exercise  of  his  own  will.  His  views 
were  in  accord  with  those  expressed  by  Dr.  Lloyd. 

Dr.  Hammond  said  that  acquired  merycism  was  al- 
ways due  to  overloading  the  oesophagus  and  to  the  bad 
habit  of  rapid  eating.  He  thought  it  extremely  doubt- 
ful as  to  its  being  a  neurosis. 

Chronic  Chorea. — Dr.  Lloyd,  of  Philadelphia,  exhib- 
ited a  large  number  of  sections  from  the  mid  brain,  pons, 
medulla,  and  spinal  cord  of  a  case  of  chronic  chorea. 

Election  of  Members. — The  following  named  gentle- 
men were  elected  to  active  membership:  Dr.  Ira  Van 
Gieson,  of  New  York ;  Dr.  E.  B.  Lane,  of  Dorchester, 
Mass.  ;  and  Dr.  E.  D.  Bondurant,  of  Tuscaloosa,  Ala. 

Election  of  Officers. — The  officers  elected  for  the  ensu- 
ing year  were :  President*  Dr.  Philip  Coombes  Knapp, 
of  Boston  ;  Vice-Presidents,  Dr.  F.  X  Dercum,  of  Phila- 
delphia, and  Dr.  W.  A.  Jones,  of  Minneapolis;  Secre- 
tary and  Treasurer,  Dr.  G.  M.  Hammond,  of  New 
York. 


AMERICAN  CLIMATOLOGICAL   ASSOCIATION. 

Eleventh  Annual  Meeting,  held  in   Washington,  D.  C, 
May  29,  30,  31,  and  June  1, 1894. 

(Continued  from  page  124.) 

Fourth  Day,  Friday,  June  ist. 

Rarity  of  Phthisis  in  the  Highlands  of  Pennsylvania 
and  Hew  York. — Dr.  Guy  Hinsdale,  of  Philadelphia, 
read  a  paper  with  this  title :  He  said  that,  if  a  physician 
were  asked  to  name  a  district  most  free  from  phthisis  in 
New  England  or  the  State  of  New  York,  he  probably 
would  name  the  Adirondacks.  He  wished  to  draw  atten- 
tion to  a  near-by  region  in  Pennsylvania  and  New  York, 
measuring  12,000  square  miles,  where  the  death  rate 
from  phthisis  was  as  low  as  1  in  1,091  persons  living. 
He  proceeded  to  describe  the  tier  of  counties  plotted  on  a 
map,  and  said  that  as  the  maritime  tier  of  counties  was  ap- 
proached in  New  York  there  is  an  increasing  death-rate. 
The  region  in  Pennsylvania  and  New  York  under  dis- 
cussion had  a  population  of  sixty- two  per  square  mile. 
It  was  largely  an  agricultural  section.  He  claimed  for 
it  elevation  and  an  equable  temperature.  The  moun- 
tains were  covered  with  vast  areas  of  hemlock. 

During  May,  June,  July,  August,  and  September,  it 
offered  an  excellent  climate.  November  to  April,  it  was 
solid  old-time  winter  weather.  The  area  generally  was 
broad,  high  table-land.  Pneumonia  and  pleurisy  are  un- 
common. The  mountain- tops  are  above  fog  and  moist- 
ure. In  McKane  County  in  1880  there  were  1,330  liv- 
ing to  each  death  from  phthisis. 

The  paper  was  discussed  by  a  number  who  knew  the 
region  well  and  endorsed  the  statements  of  the  speaker. 

Meteorological  Data  of  Colorado. — Dr.  Samuel  A. 
Fisk,  of  Denver,  Colo.,  read  a  paper  on  this  subject. 

He  dwelt  on  the  known  advantages  of  Denver.  Its 
high  elevation,  a  mile  above  sea- level,  its  dryness,  etc. 
He  classed  Denver  among  the  cool  climates.  The  winds 
were  from  the  south — dry  winds.  It  is  not  the  windy  lo- 
cality that  many  fancy.  The  climate  is  mild  and  there 
is  less  wind  than  in  Philadelphia  and  New  York."  Col- 
orado is  peculiarly  suited  for  life  out  of  doors,  due  to 
pure  air  and  sunshine. 

The  dust-storms  in  Colorado  were  made  too  much  of 
by  outsiders.  In  fact  the  dust  did  no  harm,  a  fact  too 
well  known  to  admit  of  argument.  He  deemed  the  damp 
air  of  the  East  more  harmful  in  lung  cases  than  dust  in 
the  West.  /,        :     " 

Mr.  Mark  W.  Harrington,  of  Washington,  wished  to 
supplement  what  had  been  said.  He  spoke  of  sunshine  < 
and  wind,  saying  that  the  latter  is  a  variable  quantity. 
The  velocity  of  the  wind  increases  as  we  ascend.  At  the 
level  of  the  street  it  is  one  thing,  another  half  way  up  a 
high  building,  and  still  another  on  its  top,  as  proven  by 
the  anemometer. 

Dr.  Fisk  closed  the  discussion.  He  said  the  soil  was 
dry  and  porous  in  Colorado.  There  was  dust.  Solar 
radiation  made  the  atmosphere  very  dry.  Patients  from 
the  East  should  be  sent  to  a  doctor  in  Colorado  who 
knew  the  climate.  He  would  advise  on  the  proper  local- 
ity. 

Sensible  Temperatures. — Mr.  Mark  W.  Harrington, 
chief  of  the  Weather  Bureau,  Washington,  read  a  paper 
with  this  title.  The  term  "sensible  temperature"  was 
one  of  his  coining.  It  was  the  temperature  felt  by 
the  skin,  that  which  is  felt  at  the  surface  of  the  skin,  as 
on  the  back  of  the  hand.  On  a  sensible  temperature  de 
pends  our  sense  of  comfort  in  hot  weather.  High  shade 
temperatures  do  not  necessarily  mean  discomfort,  if  the 
dew  point  is  low.  In  may  be  1 2  70  F.  in  the  shade,  but  the 
temperature  felt  by  the  skin  may  be  45  °  below  that,  ow- 
ing to  the  temperature  at  dew  point.  On  a  chart  he 
showed  the  shade  temperatures  and  dew  points.  Where 
the  shade  temperature  and  dew  point  intersected,  it  in- 
dicated the  real  or  sensible  temperature,  being  that  felt 
by  the  individual. 

By  way  of  contrast,  he  made  a  comparison  at  no°  F. 


182 


MEDICAL    RECORD. 


[August  ii,  1894 


and  1 15  °  in  the  far  West,  where  such  a  high  temperature 
may  be  less  trying  than  8o°  or  900  at  the  seaboard.  The 
sensible  temperature  of  £1  Paso,  Tex.,  is  similar  to  that 
of  Erie,  Pa. 

There  are  localities  in  the  United  States  where  the 
thermometer  may  run  up  to  1 200  to  1400  F.  in  the  summer. 
The  direct  rays  of  the  sun  seem  to  exert  a  special  stimu 
lus  on  organic  structures.     The  color  of  clothing  is  of 
less  consequence  than  its  looseness. 

Dr.  Guy  Hinsdale  dwelt  on  the  value  of  the  paper ;  it 
had  unfolded  a  new  and  very  instructive  way  of  looking 
at  the  weather  maps.  In  future,  in  consulting  a  weather 
map,  we  should  make  the  correction,  *.*.,  the  difference 
between  shade  temperature  and  dew  point,  to  obtain  the 
sensible  temperature.  All  know  of  the  necessity  of 
making  barometric  corrections  for  reliable  readings';  the 
same  now  will  be  necessary  for  thermometric. 

Dr.  Robert  H.  Babcock,  of  Chicago,  said  the  matter 
had  a  practical  and  important  bearing  on  the  clothing 
of  our  patients.  Patients  should  wear  woollen  underwear 
all  through  the  summer,  that  they  may  not  be  exposed  to 
too  sudden  changes,  particularly  patients  suffering  from 
pulmonary  diseases. 

In  closing,  the  Hon.  Mark  W.  Harrington  said  that 
the  subject  was  new.  He  expressed  the  hope  that  phy- 
sicians would  perfect  it.  He  asked  the  question,  what  is 
the  temperature  of  the  vapor  of  perspiration  ?  He  an- 
swered his  query  by  stating  that  in  a  freely  perspiring 
surface  the  temperature  must  be  greater  than  that  for  the 
evaporation  of  pure  water,  as  perspiration  is  not  a  pure 
fluid. 

Beriberi. — Dr.  Judson  Daland,  of  Philadelphia,  read 
a  paper  describing  several  cases  of  beriberi,  as  studied  by 
him  at  the  Philadelphia  Quarantine  in  a  mixed  crew 
in  a  vessel  from  the  East  Indies.  Temperature  normal ; 
heart  murmur;  epigastric  tenderness;  finger-tips  anaes- 
thetic; again  hyperaesthetic ;  blood  examined  found 
to  be  normal. 

Second  case :  Patient  weak ;  oedema  in  places ;  much 
dyspnoea  on  exertion  ;  pulsating  jugulars ;  extensive  ner- 
vous disturbances;  anasarcous;  tricuspid  murmur;  ex- 
amined blood,  it  was  normal ;  searched  for  parasites  in 
blood,  none  were  found ;  anaesthesia  of  nasal  and  buccal 
mucous  membranes ;  no  knee  jerk ;  lungs  normal ;  dila- 
tation of  right  and  left  ventricles ;  changes  in  cutaneous 
sensibility ;  in  short,  a  case  of  neuritis. 

The  third  case  was  much  the  same  as  Nos.  1  and  2. 
He  deemed  the  cases  interesting,  as  beriberi  is  rarely 
recognized  in  this  country.  It  is  a  disease  of  the  South. 
All  his  cases  were  sailors.  Their  diet  had  been  salt-fish 
of  poor  quality  and  rice. 

Etiology. — A  disease  of  the  East  and  West  Indies. 
Poor  diet  is  deemed  a  predisposing  cause.  Dr.  Ashmead 
thought  it  due  to  causes  produced  in  vessels  with  cargoes 
of  sugar.  A  fermentative  action.  Men  had  no  symp- 
toms of  scurvy.  He  thought  it  a  peripheral  neuritis. 
First  the  Egyptians  in  the  crew  were  affected,  then  the 
others. 

Dr.  A.  Gihon,  of  the  U.  S.  Navy,  was  quite  fa- 
miliar with  beriberi ;  had  seen  it  during  his  sea  service. 
Saw  eight  or  ten  cases  last  fall  when  the  Brazilian  men  of- 
war  were  in  New  York  Harbor.  The  cases  described  by 
Dr.  Daland  were  admirable  word  pictures ;  such  cases  got 
well  under  good  diet  and  improved  hygienic  conditions. 
He  deemed  beriberi  a  disease  of  malnutrition.  He 
did  not  believe  that  sugar  cargoes  had  anything  to  do 
with  it.  Certainly  the  Brazilian  men-of-war  were  not 
sugar-laden.  To  repeat,  he  believed  it  to  be  a  simple 
disease  of  malnutrition. 

Dr.  William  H.  Daly,  of  Pittsburg,  thought  it  might 
be  due  to  ptomaine  intoxication.  There  was  no  degener- 
ation or  disease  properly  so  called.  Thought  that  there 
might  be  digestive  fermentation  and  subsequent  ptomaine 
intoxication. 

Dr.  Wolfred  Nelson,  of  New  York,  asked  Dr.  Dal- 
an  i  if  any  chemical  or  microscopical  examination  of  the 
urine  had  been  made. 


Dr.  Guy  Hinsdale,  of  Philadelphia,  deemed  it  a  dis- 
ease of  nutrition,  and  referred  to  the  views  of  Dr.  Ash- 
mead, who  thought  it  due  to  carbonic-acid  poisoning 
from  cargoes  of  sugar. 

Dr.  Robert  H.  Babcock,  of  Chicago,  asked  if  all  re- 
covered. Wanted  to  know  if  they  were  cases  of  acute 
cardiac  asthenia  with  dilatation,  such  as  we  meet  in 
typhoid  and  kindred  conditions. 

Dr.  Daland,  in  reply,  said,  that  the  cardiac  condition 
was  very  interesting ;  all  recovered  perfectly.  He  deemed 
it  a  neuritism  and  not  a  degeneration.  As  to  Dr.  Hins- 
dale's question,  including  that  of  carbonic- acid  poison- 
ing, he  thought  it  a  specific  infectious  disease  associated 
with  neuritis.  Thought  that  the  crew  had  been  unruly 
and  had  been  punished  by  way  of  the  stomach.  To 
repeat,  the  hearts  returned  to  their  normal  condition.  It 
was  as  Dr.  Robert  H.  Babcock  had  supposed,  a  simple 
cardiac  asthenia,  due  to  want  of  tonicity  in  the  cardiac 
muscle,  where  dilatation  results  from  weakness.  Reply- 
ing to  Dr.  Wolfred  Nelson,  he  said  that  but  one  test  had 
been  made  of  urine;  he  failed  to  remember  that  it  was 
abnormal. 

Dr.  Wolfred  Nelson  referred  to  his  having  seen  the 
disease  while  practising  within  the  tropics  in  South 
America.  Such  cases  generally  died  of  general  anasarca. 
Dr.  Landon  Carter  Gray,  in  his  book,  included  beriberi 
in  his  article  on  "  Neuritis,"  and  such  it  seemed  to  be. 

Malaria. — Dr.  William  H.  Daly,  of  Pittsburgh,  Pa., 
read  the  next  paper,  having  for  title :  "  Some  Practical 
Observations  on  So  called  Malaria. ' '  Dr.  Daly  thinks  the 
malarial  germ  one  of  the  infusoria,  got  in  water  in  low- 
lands and  swampy  regions.  Referred  to  cases  due  to 
drinking  well-water  from  such  lands.  He  did  not  deem 
vapors  in  marshes  as  productive  of  malaria.  Some  be- 
lieve that  malaria  invades  at  night,  that  the  poison  is 
breathed  into  the  system.  He  believes  that  the  poison, 
or  germ,  is  in  the  water.  The  habitat  of  the  germ  is  in 
the  soil.  That  water  in  malarial  districts  always  contains 
the  germ.  So-called  malaria  is  a  water-born  disease, 
the  same  as  cholera. 

Malarial  fever  in  the  United  States  is  clearly  a  pre- 
ventable disease.  In  the  Southern  States  animals  suffer 
from  it.  Well-water  in  the  South  caused  malaria. 
Those  drinking  pure  cistern- water  escaped.  The  latter 
were  healthy  and  ruddy.  To  repeat,  malaria  gets  into 
the  body  through  the  food  channels. 

Dr.  Gihon,  of  the  United  States  Navy,  thought  it  due 
to  aqueous  vapor  as  well. 

Dr.  Wolfred  Nelson  referred  to  an  extended  visit  by 
him  to  the  island  of  Cuba,  and  related  the  experience  of 
his  friend,  the  late  Dr.  John  Hartmann,  formerly  physi- 
cian to  the  Uruguay  Mining  Company,  near  Santiago  de 
Cuba.  The  company  employed  hundreds  of  Spaniards. 
They  were  divided  into  a  day  and  a  night  shift.  The 
night-gang  slept  by  day  and  took  a  hearty  meal  on  go- 
ing to  work.  The  day-gang,  of  course,  slept  by  night. 
Not  a  single  case  of  malaria  in  any  of  its  multiple  forms 
developed  in  the  night- gang,  while  the  men  who  slept 
by  night  and  worked  by  day  had  malarial  and  bilious 
remittent  fevers  constantly. 

Dr.  William  H.  Daly  closed  the  discussion  by  stat- 
ing that  in  five  years  he  believed  his  views  would  be  ac- 
cepted by  the  profession  at  large. 

Physical  Signs  of  (Edema  of  the  Lungs.— Dr.  W.  C. 
Glasgow,  of  St  Louis,  Mo.,  read  a  paper  entitled  "  The 
Physical  Signs  of  Cellular  (Edema  of  the  Lungs,  Consid- 
ered in  their  Relation  to  the  Pathological  Changes." 
The  paper  dealt  with  cases  in  his  practice.  He  deems 
the  disease  due  to  sepsis.  He  detailed  the  symptoms  dur- 
ing life,  and  the  changes  found  post  mortem. 

Said  disease  might  be  due  to  a  gas-producing  organism. 
The  signs  and  symptoms  are  very  perplexing,  and  often 
contradictory.  He  got  riles  resembling  bronchitic  riles. 
Said  that  there  were  different  degrees  of  infiltration  in 
the  cell  walls  and  bronchial  mucous  membrane,  not  as 
stages  but  as  types.  Infiltration  was  sudden,  and  resolu- 
tion may  occur  as  quickly. 


August  ii,  1894] 


MEDICAL   RECORD. 


183 


The  Groise  Isle  Quarantine  Station. — Dr.  Wolfred 
Nelson,  of  New  York,  informally  brought  to  the  atten- 
tion of  some  of  the  members  a  number  of  photographs 
made  by  him  last  fall  while  at  the  Grosse  Isle  Quarantine 
Station,  in  the  St.  Lawrence,  below  Quebec.  The  situa- 
tion is  an  ideal  one,  an  island  twenty-four  miles  down 
the  river,  six  miles  from  one  and  four  miles  from  the 
other  shore.  It  was  an  old  time  and  thoroughly  organ- 
ized Government  station ;  forty  buildings  were  up ;  the 
majority  fully  equipped  with  the  latest  appliances.  They 
*vere  divided  into  first,  second,  and  third  classes,  all  in 
different  localities.  In  case  of  an  emergency  three 
thousand  immigrants  can  be  housed.  The  disinfecting 
plant  is  wholly  of  Canadian  manufacture.  So  extensive 
is  it  that  the  effects  of  one  thousand  immigrants  can  be 
-disinfected  daily— dry  heat,  then  live  steam  at  a  tempera- 
ture of  2300  F. 

Dr.  F.  Montezambert,  Superintendent  of  the  Dominion 
Quarantine  System,  is  in  charge.  He  has  a  trained  staff 
under  him.  There  is  a  special  staff  for  service  afloat. 
Canada  to  day  has  a  station  second  to  none. 

The  Society  was  then  adjourned,  to  meet  next  year  in 
West  Virginia.  

THE   NEW    YORK    PATHOLOGICAL    SOCIETY. 

Slated  Meeting  February  28,  1894. 

George  C.  Freeborn,  M.D.,  President. 

Papillomata  and  Papillomatous  Cysts  of  the  Ovary. — 

The  President  presented  a  series  of  specimens  of  papil- 
lomata and  papillomatous  cysts  of  the  ovary. 

Case  I. — These  specimens  were  removed  by  laparotomy 
by  Dr.  George  M.  Tuttle.  The  patient  was  thirty  years 
of  age,  and  the  mother  of  two  children.  Four  months 
previous  to  the  operation  she  first  noticed  a  tumor  in  the 
left  iliac  region.  Since  then  she  had  lost  flesh  and  had 
had  considerable  pain.  At  the  time  of  operation,  the 
abdominal  cavity  contained  a  small  quantity  of  clear 
serum.  A  large  papillomatous  cyst,  adherent  to  the 
omentum,  was  found  on  the  left  side,  and  a  papillary  mass 
on  the  right.  The  left  ovary  consisted  of  an  irregular- 
shaped,  lobulated  mass  of  papillary  growths,  measuring 
&*4  ctm.  in  its  long,  and  6  ctm.  in  its  short  diameter. 
The  slightly  enlarged  tube  was  attached  to  the  mass  by  an 
elongated  and  thickened  mesosalpinx.  Its  fimbriated  end 
was  occluded  and  rounded  off.  Section  through  the  mass 
showed  an  irregular  shaped  ovary  containing  a  few  fol 
licular  cysts  embedded  in  the  papillary  mass.  The  left 
ovary  was  reduced  to  a  thin-walled  oval  cyst,  to  the 
upper  surface  of  which  was  attached  a  slightly  enlarged 
tube.  Growing  from  the  upper  and  anterior  portion  of 
the  external  surface  of  the  cyst,  and  extending  to  the  tube, 
was  a  lobulated  papillary  mass,  measuring  9^  ctm.  in 
length,  7  ctm.  in  thickness,  and  projecting  5*4  ctm. 
above  the  surface.  On  the  posterior  surface  of  the  cyst 
there  were  also  a  few  small  isolated  papillary  masses.  The 
tube  was  slightly  enlarged,  its  fimbriated  end  occluded, 
and  its  surface  covered  with  adhesions.  Section  showed 
a  small  portion  of  ovarian  tissue  containing  a  few  small 
cysts,  forming  the  upper  portion  of  the  cyst- wall,  the  re- 
mainder being  thin  fibrous  tissue  The  internal  surface 
of  the  cyst  was  studded  with  papillary  outgrowths,  vary- 
ing in  size  from  that  of  a  pin  head  to  that  of  a  cherry. 
From  the  surface  of  the  remains  of  the  ovary  there  was  an 
outgrowth  of  papilloma.  At  the  external  end  of  the  re- 
mains of  the  ovary  was  a  second  cyst,  containing  a  small 
papillary  mass. 

Case  II. — These  specimens  were  removed  from  a  pa- 
tient in  the  service  of  Dr.  C.  Cleveland,  in  the  Woman's 
Hospital.  She  was  unmarried,  and  thirty  years  of  age. 
Ten  months  previous  to  operation  she  noticed  an  enlarge- 
ment of  the  abdomen,  and  six  months  later  three  gallons 
of  a  light  brown  fluid  were  removed  from  the  peritoneal 
cavity  by  tapping.  At  the  operation,  six  months  later, 
two  and  a  half  gallons  of  the  same  kind  of  fluid  were  re- 
moved.    The  right  ovary  showed  an  oval  cyst,  7x5 


ctm.,  from  the  end  of  which  projected  an  irregular,  lobu- 
lated papillary  mass,  10x8  ctm.  Longitudinal  section 
through  the  cyst  and  papillary  mass  showed  that  the  cyst 
grew  from  the  end  of  the  ovary.  It  was  thin- walled  and 
had  a  lobulated  papillary  mass,  4X2^  ctm  in  size, 
growing  from  the  internal  surface  of  the  cyst- wall,  and  ap- 
peared to  be  continuous  with  a  similar  mass  attached  to 
the  outer  surface  of  the  cyst.  The  remains  of  the  ovary 
were  triangular  in  shape,  measured  i}4  x  4}£  ctm.,  and 
were  surrounded  by  a  mass  of  papillary  growth.  The  pap- 
illary mass  was  divided  into  three  lobes,  each  of  which 
was  attached  to  the  ovary  by  a  distinct  pedicle.  The 
left  ovary  was  an  irregular,  papillary  mass,  n  x  Sj4  ctm. 
Section  through  the  mass  showed  its  central  portion  to 
be  composed  of  an  oval  ovary,  5X3  ctm/  The  ovary 
contained  several  small  cysts.  Along  the  upper  surface 
of  the  ovary  there  was  attached  a  slightly  enlarged  Fal 
lopian  tube.  The  papillary  mass  was  composed  of  three 
lobes,  which  were  attached  to  the  surface  of  the  ovary  by 
distinct  pedicles.  Two  of  these  were  rather  broad,  the 
third  was  long  and  slender,  and  was  attached  to  the  outer 
end. 

Case  III. — These  specimens  were  examined  at  the  re 
quest  of  Dr.  George  M.  Tuttle,  who  had  removed  them 
from  a  married  woman,  fifty- two  years  of  age,  the  mother 
of  four  children.  The  menopause  had  occurred  six  years 
previous.  Eight  months  before  operation  she  noticed  an 
enlargement  of  the  abdomen  and  oedema  of  the  lower  ex- 
tremities. At  the  time  of  the  operation  a  tumor  of  the 
abdominal  cavity  was  found  extending  above  the  umbili- 
cus. The  inguinal  lymph  nodes  were  enlarged.  Upon 
opening  into  the  peritoneal  cavity  a  moderate  amount  of 
clear  serum  was  found.  On  the  right  side  was  a  tumor 
growing  from  the  ovary  and  extending  out  between  the 
folds  of  the  broad  ligament.  The  omentum  was  adherent 
to  its  surface.  The  left  ovary  and  tube  were  normal. 
The  omentum  showed  a  papillary  mass  the  size  of  a  cherry 
attached  to  its  lower  border.  Microscopical  examination 
showed  a  small  papillary  mass  distributed  very  generally 
over  the  surface  of  the  trabecular. 

Case  IV. — The  specimen  was  removed  from  a  married 
woman,  thirty  years  of  age,  who  was  in  the  service  of 
Dr.  C.  Cleveland  iu  the  Woman's  Hospital.  She  gave  a 
history  of  gradual  enlargement  of  the  abdomen  extend- 
ing over  a  period  of  six  months  previous  to  her  admis- 
sion. During  the  six  weeks  prior  to  operation  there  was 
a  rapid  accumulation  of  the  ascitic  fluid,  with  loss  of  flesh 
and  strength.  Laparotomy  was  performed  and  revealed 
both  the  ovaries  and  tubes  converted  into  papillary 
masses,  and  so  firmly  adherent  to  the  pelvic  tissues  that 
they  could  not  be  removed.  The  omentum  was  found 
adherent  to  the  uterus  and  intestines  and  filled  with  a 
mass  of  small  cysts.  The  portion  of  the  omentum  pre- 
sented was  removed  and  the  abdomen  closed.  The  pa- 
tient died  twelve  hours  after  the  operation,  of  exhaustion. 
No  autopsy  was  permitted.  The  specimen  consisted  of 
a  rectangular  piece  of  the  omentum,  measuring  1 2  j£  x  1 1 
ctm.,  with  an  average  thickness  of  20  mm.  The  entire 
specimen  consisted  of  a  mass  of  small  cysts,  thin-walled, 
and  containing  papillary  masses  and  a  clear,  thin  fluid. 

Case  V. — This  specimen  was  removed  by  laparotomy 
from  a  woman,  twenty-six  years  of  age,  who  was  admitted 
to  the  service  of  Dr.  Outerbridge  in  the  Woman's 
Hospital.  The  history  stated  that  she  was  married,  but 
had  had  no  children.  Two  years  previous  to  her  admis- 
sion she  had  sharp  pain  in  the  left  iliac  region ;  one  year 
later  she  noticed  a  tumor  and  also  oedema  of  the  lower 
extremities.  The  specimen  was  removed  by  laparotomy, 
and  consisted  of  four  thin-walled  cysts  grouped  around  a 
central  dense  mass,  from  which  there  sprung  an  irregular 
papillary  growth.  Section  showed  all  the  cysts  more 
or  less  ovoid  in  shape,  the  largest  measuring  10  x  8 
ctm. ;  the  next  in  size,  9x6  ctm. ;  the  next,  8x5^ 
ctm.,  and  the  smallest,  6x4^  ctm.  The  interior  of  all 
the  cysts  was  more  or  less  studded  with  papillary  out- 
growths. The  central  dense  mass  was  the  remains  of  the 
ovary,  from  the  surface  of  which  grew  the  papillary  mass. 


i84 


MEDICAL   RECORD. 


[August  iit  1894 


Case  VL — This  specimen  was  removed  by  Dr.  F.  H. 
Markoe.  It  was  a  multilocular  cyst  10  x  12  ctm.  The 
Fallopian  tube  was  attached  to  the  surface  of  the  cyst. 
Section  showed  three  principal  cysts  with  thin  walls,  the 
internal  surfaces  of  all  being  studded  with  various-sized 
papillary  outgrowths. 

A  Cylindroma  of  the  Scalp. — Dr.  £.  K.  Dunham  pre- 
ssnted  a  cylindroma  of  the  scalp.  The  tumor  was  about 
one  and  one  fourth  inch  in  diameter,  one  half  inch 
thick,  and  lenticular  in  shape,  and  was  situated  in  the 
anterior  portion  of  the  scalp  in  the  median  line.  It  had 
been  growing  slowly  for  two  years,  and  was  regarded  as 
a  recurrence  in  the  cicatrix  left  after  the  excision  of  an 
old  wen.  After  the  removal  of  this  tumor  the  patient,  a 
man  aged  seventy,  lived  for  one  year  without  any  sign 
of  recurrence,  and  then  died  of  apoplexy.  An  examina- 
tion of  the  first  sections  had  led  him  to  think  it  was  an 
epithelioma,  but  careful  examination  of  the  thinner  sec- 
tions showed  it  was  a  sarcoma,  and  one  in  which  certain 
elements  had  undergone  hyaline  degeneration.  Micro- 
chemical  tests  were  made  for  hyaline  material,  but  with 
negative  result.  The  specimens  exhibited  under  the 
microscope  showed  the  alveoli  filled  with  small,  round 
cells,  and  among  these  cells  small  hyaline  bodies.  The 
speaker  said  it  had  occurred  to  him  that  these  hyaline 
bodies  were  degenerated  capillary  vessels,  but  he  was 
doubtful  about  this  because  he  had  been  unable  to  find 
any  transition  forms,  and  moreover,  there  was  hyaline 
degeneration  not  only  of  the  bloodvessels,  but  of  the 
fibrous  tissue,  as  the  capsule  exhibited  the  same  degen- 
eration. 

Dr.  £.  Hodbnpyl  agreed  to  the  diagnosis  of  cylin 
droma,  but  objected  strongly  to  the  use  of  the  term 
"  cylindroma/'  which  was  vague  and  unsatisfactory. 

Congenital  or  Infantile  Myxoedema  — Dr.  W.  P. 
Northrup  presented  photographs  of  three  cases.  These 
cases  were  being  treated  by  the  internal  administration 
of  the  glycerine  extract  of  the  yearling  sheep's  thyroid. 
It  had  been  found  that  a  daily  dose  of  three  drops  kept 
the  temperature  at  about  the  desired  point — ioo°  F. 
The  photographs  showed  very  well  the  peculiar  physical 
characteristics  of  these  children. 

Carcinoma  of  the  Liver,  Stomach,  and  Lungs. — Dr. 
E.  Hodenpyl  presented  specimens  from  a  case  of  carci- 
noma of  the  liver,  stomach,  and  lungs.  The  case  was  re- 
markable on  account  of  the  enormous  extent  of  the  lesion, 
the  very  short  duration  of  the  disease,  and  the  very  mod- 
erate discomfort  which  it  caused.  The  patient  was  a  man, 
forty  six  years  of  age,  whose  family  history  and  previous 
history  were  negative.  His  last  illness  dated  back  to  the 
latter  part  of  October,  1893,  when  he  began  to  experience 
a  heavy  sensation  in  the  upper  part  of  the  abdomen,  and  a 
distress  after  eating,  which,  however,  was  not  aggravated 
by  eating.  There  was  no  vomiting,  pyrosis,  or  eructa- 
tion of  gas.  He  gradually  developed  dyspnoea.  When 
admitted  to  hospital,  on  January  31st,  he  was  moderately 
emaciated  and  pale;  the  urine  was  normal.  Physical 
examination  showed  the  heart  and  lungs  to  be  normal. 
Hepatic  dulness  began  in  the  fifth  space,  and  ended  two 
inches  below  the  free  border  of  the  ribs.  The  spleen  was 
not  enlarged.  There  was  a  good  deal  of  constipation, 
but  no  vomiting,  while  he  was  in  the  hospital.  He  died 
comatose.  At  the  autopsy  the  left  lung  was  found 
studded  with  a  moderate  number  of  yellowish- gray  nod- 
ules. The  right  lung  was  considerably  compressed,  the 
liver  was  enlarged,  the  gall  bladder  normal,  and  the 
cystic  duct  pervious.  Extending  along  the  entire  length 
of  the  lesser  curvature  of  the  stomach,  but  not  involving 
either  the  cardiac  or  pyloric  orifices,  was  a  large  card 
nomatous  nodule  the  size  of  a  small  orange,  and  adjoin- 
ing it  a  thickened  portion  of  new-growth  and  a  large 
area  of  ulceration.  The  liver,  together  with  the  pan- 
creas and  stomach,  weighed  fourteen  pounds. 

Hypertrophy  of  the  Prostate  ;  Carcinoma  of  the 
Bladder ;  Hydronephrosis ;  Ohronio  Bright' s  Disease. — 
Dr.  Hodenpyl  also  presented  specimens  removed  from  a 
man, '  sixty-six  years  of  age,  who  was  admitted   to  the 


hospital  on  February  20th.     It  was  impossible  to  obtain         , 
an  accurate  history  from  him.     He  had  been  quite  in- 
temperate.     He  said  that  about  two  months  before  ad-         j 
mission  he  became  very  obstinately  constipated,  and         ! 
there  was  inability  to  urinate  except  in  small  drops.     On 
admission,  there  was  oedema  of  the  legs,  scrotum,  and 
penis ;   his  temperature  was  ioo°  F. ;  respiration,   ao. 
The  urine  was  very  bloody,  alkaline,  had  a  specific  grav- 
ity of  1.013,  aQd  contained  seventy-five  percent  of  al- 
bumin by  volume.     The  daily  quantity  of  urine  voided 
for  three  successive  days  was  six,  two,  and  sixteen  ounces 
respectively.     The  urine  was   drawn    by  the  catheter 
while  he  was  in  the  hospital,  and  was  always  very  bloody.     * 
Physical  examination  showed  fluid  in  the  abdominal  and 
pleural  cavities. 

The  chief  point  of  interest  in  the  case  was  found  on 
the  peritoneal  surface  just  adjoining  the  right  kidney — a 
series  of  intercommunicating  sacs,  many  of  them  ending 
in  blind  pouches  with  thickened  edges.  Some  of  them 
were  ulcerated.  The  ureter  passed  over  this  curious  mass 
into  the  kidney.  The  speaker  said  he  was  unable  to  ex- 
plain this  condition  except  on  the  supposition  that  it  was 
either  a  secondary  growth  or  foetal  remain.  He  would 
report  upon  it  more  fully  at  another  time. 

Dr.  T.  S.  Southworth  presented  the  lungs  from  the 
twin  of  the  child  whose  lungs  were  presented  by  him  re- 
cently. This  child  was  fifteen  months  old,  and  weighed 
at  birth  four  pounds  and  a  half.  Last  May  it  had  severe 
pertussis,  and  in  the  third  week  of  the  disease  a  broncho- 
pneumonia for  six  weeks.  After  this  it  gained  slowly  up 
to  five  weeks  ago.  Two  weeks  ago  it  developed  fever, 
and  fine  crackling  riles  over  the  chest,  anteriorly  and 
posteriorly,  with  a  temperature  of  ioo°  to  1030  F.  It 
died  suddenly.  At  the  autopsy  the  left  lung  showed  ad- 
hesions posteriorly,  and  the  right  lung  general  firm  adhe- 
sions, evidently  older  than  in  the  other  lung.  The  bron- 
chial glands  were  markedly  enlarged  on  the  right  side, 
but  were  not  cheesy.  There  was  consolidation  and  a 
fairly  uniform  white  mottling  of  the  right  lower,  right 
middle,  and  posterior  half  of  the  right  upper  lobes. 
There  was  also  consolidation  of  the  posterior  half  of  the 
lower  lobe  of  the  left  lung,  with  the  same  mottling.  The 
spleen  was  much  enlarged  and  congested.  The  mesen- 
teric glands  were  not  enlarged.  This  child  was  also  sup- 
posed to  be  tubercular,  but  the  lung  showed  the  form  ot 
bronchopneumonia  not  infrequently  mistaken  for  tuber- 
culosis. It  was  worthy  of  note  that  notwithstanding  the 
history  the  bronchial  glands  were  not  cheesy. 

Absoess  of  the  Liver  Mistaken  for  Empyema. — Dr. 
J.  M.  Byron  reported  this  case.  The  case  occurred  in 
Bellevue  Hospital,  and  the  diagnosis  of  empyema  was 
made  because  exploratory  puncture  and  the  physical 
signs  pointed  to  this  condition.  An  opening  was  made 
on  the  right  side  at  the  usual  point,  and  some  pus  with- 
drawn. The  man  died,  and  on  autopsy  absolutely  noth- 
ing was  found  in  the  pleural  cavities  except  a  very  slight 
pleuritis  on  the  right  side.  In  the  posterior  and  upper 
part  of  the  right  kidney,  however,  was  a  very  large  ab- 
scess cavity,  which  communicated  with  the  operation 
wound.  The  diaphragm  .was  intact.  There  was  no  ul- 
ceration in  the  intestines,  or  anything  to  account  for  this 
abscess  in  the  liver. 

Exophthalmic  Goitre. — Dr.  Henry  Power  reported 
a  case  of  exophthalmic  goitre  treated  with  the  thyroid 
extract ;  death  in  six  weeks.  The  only  other  case  of  the 
kind,  so  far  as  he  knew,  had  been  reported  by  Dr.  Owen, 
in  the  British  Medical  Journal.  His  own  patient  was  a 
Swedish  domestic,  twenty-four  years  of  age,  in  whom 
rather  large  doses  of  the  thyroid  extract  were  used — seven 
to  nine  drops  three  times  a  day.  At  first  there  was  gen- 
eral improvement,  and  shrinkage  of  the  tumor  to  half  its 
former  size,  but  this  was  followed  by  a  return  of  the 
former  condition,  and  by  a  deterioration  of  her  general 
health.  The  dose  was  quickly  reduced,  and  finally 
stopped,  but  three  weeks  after  the  last  dose  the  patient 
became  comatose  and  died.  At  the  autopsy,  which  was 
made  twenty  four  hours  later,  it  was  noted  that  there 


August  ii,  1894] 


MEDICAL    RECORD. 


185 


was  marked  emaciation,  together  with  enlargement  of 
the  thyroid.  The  heart,  lungs,  and  kidneys  were  nor- 
mal ;  the  uteras  was  small  and  of  the  infantile  type ;  the 
spleen  was  not  enlarged.  The  thymus  was  present ;  it 
measured  3^  x  ^  x  }i  inches,  and  weighed  13 
gm.,  after  partial  hardening.  The  thyroid  showed 
great  symmetrical  enlargement,  and  weighed  40  gm. 
after  partial  hardening.  The  brain  could  not  be  ex- 
amined. Microscopical  examination  of  the  thyroid 
showed  the  stroma  normal,  and  the  epithelium  greatly 
proliferated.  Some  of  the  alveoli  were  lined  with  cu- 
boidal  epithelium,  others  with  cylindrical  cells,  while 
others  again  had  no  regular  lining.  The  stroma  of  the 
thymus  appeared  to  be  normal ;  the  cells  stained  with 
difficulty.  The  liver  contained  some  fat.  The  kidneys 
were  tabulated  and  contained  hyaline  casts.  They  also 
showed  degeneration  and  congestion. 

Cancer  of  the  (Esophagus.— Dr.  Henry  P.  Loomis 
presented  the  specimen.  The  patient  was  a  man,  fifty- 
three  years  of  age,  who  had  an  excellent  family  history, 
and  also  a  good  previous  history,  except  that  he  said  he 
had  had  a  slight  bronchitis  for  many  years,  His  last  ill- 
ness began  last  August  with  anorexia,  uneasiness  in  the 
epigastrium,  and  slight  vomiting.  The  pain  was  most 
intense  in  the  left  hypochondriac  region  and  near  the 
xiphoid  cartilage.  For  two  months  he  could  only  take 
solid  food  with  difficulty,  and  then  finding  that  solid  food 
caused  pain  he  swallowed  nothing  but  oatmeal  and  milk. 
On  admission  he  was  very  greatly  emaciated,  had  a  hag- 
gard, apathetic  expression,  and  vomited  curdled  milk. 
Physical  examination  of  the  abdomen  showed  an  area  of 
flatness  about  four  inches  in  diameter,  with  its  centre  one 
inch  below  the  xiphoid  cartilage. 

The  autopsy  was  made  thirty  six  hours  after  death. 
No  pathological  lesion  was  found  in  any  of  the  organs 
or  tissues  until  the  stomach  and  oesophagus  were  opened. 
A  firm,  dense,  cancerous  infiltration  was  found  in  the  wall 
of  the  lower  portion  of  the  oesophagus  and  the  oesophageal 
end  of  the  stomach.  About  three  inches  of  their  walls  were 
infiltrated  with  a  dense  mass  which  narrowed  the  opening 
of  the  oesophagus  into  the  stomach  to  such  a  degree  that  it 
was  with  difficulty  that  an  ordinary  penholder  could  be 
introduced  down  the  oesophagus.  There  was  no  ulcera- 
tion or  involvement  of  the  rest  of  the  stomach  wall.  The 
infiltration  presented  the  ordinary  appearance  of  a  scir- 
rhous cancer.  There  was  marked  atrophy  of  the  intes- 
tines. The  patient  apparently  died  of  inanition  due  to 
mechanical  obstruction,  which  interfered  with  the  intro- 
duction of  food  into  the  stomach. 

Cancer,  the  speaker  said,  was  the  most  frequent  form  of 
tumor  met  with  in  the  oesophagus,  and  statistics  showed 
that  the  seat  of  the  tumor  in  this  case  was  the  most  fre- 
quent portion  involved.  The  extreme  narrowing  of  the 
tube  was  due  partly  to  the  infiltration,  and  partly  to  the 
contraction  of  the  newly  formed  connective  tissue  as 
the  result  of  the  irritation  of  the  new  growth.  The  dense 
infiltration  no  doubt  produced  the  feeling  of  obstruction 
which  was  constantly  referred  to  by  the  patient  during 
life.  The  absence  of  ulceration  was  unusual.  The 
oesophagus  and  stomach  at  the  site  of  the  cancer  were 
tightly  bound  to  the  cellular  tissue  behind  them.  The 
tumor  was  diagnosticated  during  life,  and  an  operation 
advised.  If  this  advice  had  been  followed,  no  doubt  the 
patient's  life  would  have  been  prolonged  considerably  by 
the  establishment  of  a  gastric  fistula. 

Primary  Tumor  of  the  Heart  Wall.— Dr.  H.  P. 
Loomis  presented  a  specimen  of  tumor  of  the  heart  wall 
which  had  caused  sudden  death.  At  the  request  of  the 
coroner  a  post  mortem  examination  was  made  on  W. 

J ,  thirty-five  years  of  age,  who  was  found  dead  on 

the  floor  of  his  bedroom  by  the  servant  who  came  to 
awaken  him  in  the  morning.  A  friend,  in  whose  room 
he  had  spent  the  previous  evening,  testified  that  he  left 
him  about  eleven  o'clock,  apparently  as  well  as  ever ; 
but  on  being  questioned  further,  the  witness  recalled  the 
fact  that  his  friend  had  complained  of  some  distress  over 
his  heart  two  or  three  times  while  they  were  together. 


The  man  must  have  died  immediately  on  reaching  his  bed- 
room, for  he  was  found  stretched  on  the  floor  with  his  hat 
grasped  in  his  hand.  Careful  inquiry  was  made  of  his 
friends,  who  stated  that  he  had  not  been  sick  for  years, 
nor  had  he  even  complained  of  feeling  ill  during  the 
month  preceding  his  death.  He  had  attended  regularly 
to  business.  He  was  a  moderate  drinker,  but  at  times  in- 
dulged to  excess.  No  syphilitic  history  could  be  ob- 
tained. The  autopsy  was  made  twelve  hours  after  the 
body  was  found.  He  was  a  robust  man,  of  excellent 
physique,  and  weighed  one  hundred  and  seventy-five 
pounds.  There  were  no  marks  of  external  injury.  The 
liver  and  kidneys  showed  the  lesions  of  extreme  passive 
congestion,  with  moderate  cirrhosis  of  the  liver.  A  most 
careful  examination  of  all  the  other  organs,  including  the 
brain,  failed  to  reveal  the  slightest  abnormality  until  the 
heart  was  opened.  Here  a  lesion  was  found — one  of 
the  rarest  met  with  in  post  mortem  examinations.  A 
circumscribed  tumor  of  a  yellowish- white  color,  firm  in 
consistency,  noncapsulated,  was  found  embedded  in  the 
anterior  wall  of  the  left  ventricle.  Its  dimensions  were 
#  x  i^A  x  2  inches,  and  it  involved  over  one- third  of 
the  wall  of  the  left  ventricle.  Neither  the  endocardi- 
um nor  the  pericardium  over  the  tumor  was  involved. 
The  heart  weighed  sixteen  ounces.  The  left  ventricle 
was  very  much  dilated,  and  as  a  result  there  was  marked 
insufficiency  of  the  mitral  valve.  There  was  no  hyper- 
trophy of  the  heart  wall.  The  valves  were  normal,  as 
was  also  the  endocardium.  A  large,  soft,  red,  non-  ad- 
herent blood- clot  filled  the  cavity  of  the  left  ventricle. 
The  right  ventricle  was  free  from  blood,  slightly  dilated, 
and  its  wall  was  somewhat  thickened.  The  coronary 
arteries  were  normal.  The  thoracic  and  abdominal  aorta 
showed  the  lesion  of  an  extensive  aortitis,  involving  the 
greater  portion  of  its  inner  coat.  A  section  cut  so  as  to 
include  the  heart  wall  and  the  greater  portion  of  the  tu- 
mor showed  on  microscopical  examination  that  it  was 
composed  of  small  round  cells,  with  here  and  there,  near 
the  centre,  cheesy  spots.  In  a  few  places,  giant  cells 
could  be  seen,  as  also  amorphous  basement  substance  be- 
tween the  round  cells.  In  places  young  connective-tissue 
formations  could  be  seen.  The  tumor  was  moderately 
supplied  with  small  blood-vessels  in  its  outer  portion.  It 
was  not  encapsulated.  The  round  cells  could  be  seen 
running  between  the  muscle  fibres  in  its  external  zone. 
Sections  of  the  tumor  were  stained  for  tubercle  bacilli 
with  negative  result.  Gram's  method  failed  to  reveal 
the  presence  of  any  micro-organisms.  From  a  careful  ex- 
amination of  all  portions  of  the  tumor  an  unqualified 
diagnosis  of  a  syphilitic  gumma  was  made.  This  diagno- 
sis was  later  confirmed  by  Dr.  T.  M.  Prudden,  who  ex- 
amined the  specimen. 

Primary  tumors  of  the  heart  are  exceedingly  rare,  al- 
though secondary  tumors  are  not  of  infrequent  occur- 
rence, especially  secondary  carcinomata.  Virchow  in 
his  Archives,  vol.  xv.,  describes  the  following  tumors  as 
being  found  in  the  heart  wall:  sarcomata,  fibromata, 
lipomata,  myxomata,  and  syphilomata.  The  last  he 
says  is  among  the  rarest  tumors  met  with.  This  is  the 
second  case  of  primary  syphilitic  gumma  which  the 
speaker  had  met  with  in  the  last  ten  years,  the  other  case 
being  that  of  a  prostitute,  thirty  years  of  age,  who  died 
of  lobar  pneumonia.  The  present  case  is  also  of  interest 
because  it  was  no  doubt  the  indirect  cause  of  the  man's 
sudden  death,  which  must  be  explained  by  the  sudden 
over- distention  and  inability  of  the  left  ventricle  to  empty 
itself.  Nearly  one-half  the  muscle  fibre  of  the  left  ven- 
tricle wall  was  destroyed  by  the  new  growth. 

Syphilis  is  known  to  affect  the  heart  in  two  ways,  viz. : 
1,  by  the  formation  of  a  gummy  tumor,  as  in  this  case ; 
and  2,  by  setting  up  an  indurated  myocarditis,  the  local- 
ized and  extensive  fibrous  indurations  in  the  muscle  tissue 
being  generally  associated  with  a  fatty  degeneration  of 
the  muscle  fibre.  Cheesy  masses  are  often  found  in  these 
indurated  areas,  and  the  question  has  been  raised  as  to 
whether  they  may  not  be  gummata  in  process  of  ab- 
sorption.   Lancereaux  mentions  two  cases  of  waxy  de- 


1 86 


MEDICAL   RECORD. 


[August  ii,  1894 


generation  of  the  heart  wall  which  he  refers  to  as  one  of 
the  manifestations  of  tertiary  syphilis,  but  his  observations 
have  not  been  confirmed  by  other  observers.  No  doubt 
syphilitic  gumma  in  various  stages  of  development  and 
metamorphosis  is  the  most  characteristic  lesion  of  tertiary 
syphilis  affecting  the  heart. 

Carcinoma  of  the  Wall  of  the  Stomach. — On  behalf 
of  Dr.  Le  Fevre,  Dr.  Loomis  also  presented  a  specimen 
of  carcinoma  of  the  wall  of  the  stomach.  The  specimen 
was  removed  from  a  married  woman,  thirty-one  years  of 
age,  whose  family  history  was  good.  She  had  enjoyed 
good  health  up  to  six  months  after  her  last  confinement, 
or  up  to  one  year  and  nine  months  ago.  She  was  slightly 
anaemic  at  this  time,  but  quickly  recovered.  Five  months 
later  she  came  under  Dr.  Le  Fevre's  care,  complaining 
of  very  severe  pain  in  the  stomach,  accompanied  by 
vomiting.  Her  weight  had  been  reduced  in  a  short  time 
from  one  hundred  and  forty  pounds  to  one  hundred  and 
fifteen.  She  improved  temporarily  under  tonic  treat- 
ment. Four  months  later  there  was  extreme  pain  in  the 
epigastrium,  radiating  through  to  the  angle  of  the  left 
scapula.  With  this  there  was  incessant  vomiting  and 
also  some  fever.  Six  days  later,  the  thickened  wall  of 
the  stomach  was  mapped  out  by  physical  examination. 
She  then  passed  from  under  his  observation.  She  was 
reported  to  have  suffered  constantly.  She  never  vomited 
blood.  At  the  autopsy,  the  body  was  found  to  be  ex- 
tremely emaciated ;  the  lungs,  liver,  and  intestines  were 
normal ;  the  uterus  and  ovaries  were  also  normal.  The 
stomach  was  adherent  to  the  spleen,  and  these  were  ad* 
herent  to  the  upper  portions  of  the  intestine.  There  was 
very  extensive  cancerous  infiltration  of  the  wall  of  the 
stomach,  beginning  at  the  pylorus,  and  involving  by  far 
the  greater  portion  of  the  stomach.  Incidentally,  the 
heart  was  of  interest,  for,  while  presenting  no  organic  dis- 
ease, it  was  as  small  as  the  heart  of  a  child. 

Dr.  Byron  said  he  had  examined  some  of  the  sections 
of  the  tumor  of  the  heart  wall,  and  the  structure  was  not 
at  all  characteristic  of  gumma  of  the  heart.  The  round- 
cell  infiltration  was  very  extensive  and  uniform,  and  all 
of  the  cells  seemed  to  be  nearly  of  the  same  age  without 
any  discernible  degeneration  in  any  portion  of  the  tumor. 
The  giant  cells,  which  reacted  to  eosin  almost  like  mus- 
cular tissue,  seemed  to  him  to  be  simply  muscle  fibres  in 
which  the  inflammation  had  given  rise  to  the  prolifera- 
tion of  the  muscle  nuclei. 

Dr.  Loomis  said  that  as  the  case  had  been  variously 
diagnosticated  as  interstitial  myocarditis,  abscess  of  the 
heart,  sarcoma  of  the  heart,  etc.,  he  would  be  very  glad 
to  have  the  specimen  examined  by  the  Committee  on 
Microscopy.  He  did  not  think,  however,  that  it  was 
possible  that  the  giant-cells  were  really  muscular  nuclei. 

The  specimen  was  referred  to  the  Committee  on  Mi- 
croscopy. 

The  society  then  went  into  executive  session. 


Stated  Meeting,  March  14,  1894. 

George  C.  Freeborn,  M.D.,  President. 

Tuberculosis  of  the  Bladder  and  Kidneys. — Dr.  W. 
G.  Le  Boutillier  presented  specimens  from  a  case  of 
the  above.  They  were  removed  from  a  man  thirty-five 
years  of  age,  who  had  one  testicle  removed  ten  years  be- 
fore, probably  for  tubercular  disease.  There  was  no  his- 
tory of  the  beginning  of  the  tuberculosis.  At  the  time 
of  death  there  was  tuberculosis  of  the  lungs,  of  one  hip- 
joint,  and  of  several  vertebrae.  The  pelvis  of  each  kid- 
ney contained  a  mass  of  cheesy  material  and  several 
cheesy  masses  also  in  the  cortex.  The  right  ureter  was 
much  dilated,  but  there  was  no  evidence  of  obstruction. 
While  the  patient  was  under  observation  some  of  the 
urine  was  injected  into  a  guinea-pig  to  confirm,  if  pos- 
sible, the  tubercular  nature  of  the  disease.  The  guinea- 
pig  was  found  dead  about  eight  weeks  later,  and  exami- 
nation showed  cheesy  masses  at  the  site  of  the  inocula- 
tion and  also  general  peritonitis  and  tubercular  lesions  of 


the  lungs  and  spleen.  Tubercle  bacilli  were  found  in  the 
patient's  urine. 

Bovine  Tuberculosis. — Dr.  George  P.  Biggs  pre- 
sented portions  of  organs  showing  the  characteristic 
lesions  of  bovine  tuberculosis.  The  specimens  were 
brought  to  him  by  a  veterinarian,  who  stated  that  large 
numbers  of  tubercles  were  found  in  the  lungs,  heart, 
mesenteric  glands,  mediastinal  glands,  peritoneum — in 
fact  in  all  of  the  organs.  The  animal  was  a  Jersey  cow, 
and  its  milk  had  been  used  up  to  about  two  weeks  before 
the  animal  was  killed.  It  had  been  slightly  ill  for  a  few 
weeks,  and  had  had  a  slight  dry  cough,  which,  however, 
two  veterinarians  had  said  was  of  no  significance.  The 
animal  also  had  a  good  deal  of  difficulty  in  breathing, 
and  examination  showed  a  large  number  of  dry  rales. 
The  specimens  presented  comprised  portions  of  the  liver, 
spleen,  lungs,  mesenteric  glands,  and  udder.  In  the 
section  from  the  udder  there  were  no  distinct  giant  cells, 
but  rather  epithelioid  tubercles.  The  tendency  to  casea- 
tion was  very  marked.  The  speaker  said  these  caseous 
masses  usually  became  encysted,  and  after  considerable 
time  underwent  calcification.  Unfortunately  no  exami- 
nation was  made  of  the  milk.  Among  the  characteristic 
features  of  tuberculosis  might  be  mentioned,  (1)  a  series 
of  outgrowths  from  the  serous  membranes  often  attached 
together  like  bunches  of  grapes;  (2),  the  tendency  to 
calcification ;  and  (3)  the  proneness  to  the  formation  of 
fibrous  tissues. 

Dr.  Le  Boutillier  asked  for  further  information  re- 
garding the  diagnosis  of  bovine  tuberculosis.  He  under- 
stood that  recently  the  diagnosis  had  been  made  by  in- 
jections of  tuberculin. 

Dr.  J.  S.  Ely  said  that  for  some  months  past  he  had 
been  examining  material  sent  him  by  the  cattle  inspectors 
of  the  State  Board  of  Health.  They  have  been  using  tuber- 
culin quite  extensively  and  with  good  results.  Last  No- 
vember he  went  to  Barren  Island  to  see  some  condemned 
animals  slaughtered.  Out  of  the  seventy- two  cattle,  sixty- 
eight  had  given  the  characteristic  reaction  with  tubercu- 
lin, and  after  slaughtering,  just  sixty- eight  of  the  animals 
were  found  to  be  tubercular.  The  normal  temperature 
of  cattle  was  higher  than  in  the  human  subject,  about 
roa°  F.  After  the  injection  of  the  tuberculin,  the  tem- 
perature rose  within  seven  hours  to  1040  or  105°  F.,  and 
in  the  course  of  four  or  five  hours  more,  fell  to  the  nor- 
mal. This  was  considered  the  typical  reaction.  The 
herd  referred  to  was  a  valuable  one,  being  worth  about 
thirty  thousand  dollars,  and  consequently  the  owner  had 
employed  several  veterinarians  to  examine  the  cattle. 
One  prominent  veterinarian  said  they  were  not  tubercu- 
lar, and  another  coincided  in  this  opinion,  yet  many  of 
the  animals  when  slaughtered  showed  lesions  nearly  as 
pronounced  as  those  seen  in  the  specimens  just  presented. 

Dr.  T.  M.  Pruddbn  said  that  a  farmer  came  to  see 
him  recently  in  regard  to  a  herd  of  Jersey  cattle  which 
he  suspected  had  become  infected  with  tuberculosis. 
Only  about  thirty  cattle  seemed  to  be  sick,  and  as  these 
thirty  gave  the  characteristic  reaction  with  tuberculin, 
they  were  killed,  and  were  found  to  be  tubercular.  The 
owner  then  determined  to  sacrifice  an  apparently  healthy 
animal  to  determine  still  more  definitely  the  value  of 
this  test.  An  animal  which  did  not  give  the  reaction 
with  tuberculin  was  slaughtered  and  was  found  to  be  free 
from  tuberculosis.  The  power  of  this  breed  of  cattle  to 
produce  milk  and  butter  seemed  to  be  at  the  expense  of 
their  resisting  power  to  tuberculosis.  The  very  long 
series  of  experiments  of  Dr.  Ernst,  published  before  the 
Association  of  American  Physicians  in  Washington  some 
years  ago,  and  a  similar  series  in  Germany,  showed  that 
it  was  not  at  all  necessary  to  have  any  involvement  of  the 
udder  to  have  tubercle  bacilli  in  the  milk. 

Osteosis  of  the  Skin  of  the  Foot.— Dr.  Warren 
Coleman  presented  the  specimen.  He  said  that  in 
March,  1892,  Dr.  Sherwell  presented  a  case  to  the  Der- 
matological  Society  for  diagnosis.  The  patient,  a  girl 
six  years  of  age,  of  American  parentage,  had  an  erosion 
in  the  sole  of  the  left  foot  which  the  mother  had  first 


August  ii,  1894] 


MEDICAL  RECORD. 


187 


noticed  about  two  and  a  half  years  previously.  It  was  a 
thickening  of  the  skin  and  subcutaneous  tissue,  occupying 
about  one-third  of  the  plantar  surface  of  the  foot,  chiefly 
under  the  os  calcis,  and  a  little  to  the  outer  side.  It  was 
learned  that  a  year  and  a  half  after  the  lesion  in  the  sole 
had  appeared,  the  fourth  toe  became  involved,  and  grad- 
ually increased  in  size,  the  skin  of  the  entire  toe  taking 
part  in  the  process,  though  the  lesion  was  most  advanced 
in  the  distal  phalanx.  The  enlargement  was  symmetri- 
cal, and  the  toe  attained  a  dianieter  of  1  ctm.  At 
that  time  Dr.  Sherwell  described  the  condition  as 
follows :  "  The  lesion  now  consists  of  a  plaque  of 
cartilaginous  hardness,  studded  here  fend  there  with 
tubercular  nodosities,  about  six  in  number,  the  whole 
occupying  about  one-third  of  the  external  plantar  surface 
of  the  left  foot.  The  skin  and  subcutaneous  cellular  tis- 
sues are  all  involved  in  the  process,  s.ill  the  plaque  can 
be  moved  relatively  freely  over  the  subjacent  tissue.  The 
epithelial  tissues,  while  somewhat  thick  and  horny, 
present  no  other  unusual  features.  There  are  few  sub- 
jective symptoms  while  the  foot  is  at  rest,  but  on  account 
of  the  hardness  it  is  difficult  to  walk  upon,  it  seeming  to 
act  as  a  foreign  body  without  the  irritation  the  latter 
would  cause.  The  little  patient  always  walks  on  the 
ball  of  that  foot.  The  lesion  on  the  fourth  toe  is  of  the 
same  relatively  painless  character,  and  is  curiously 
clubbed  on  top,  and  the  peculiar  cartilage  like  feel  is  also 
present  On  no  other  part  of  the  limbs  or  body  is  any- 
thing that  is  abnormal.  The  child  is  of  healthy  parents 
as  far  as  can  be  ascertained,  and  is  a  healthy  child.  I 
cannot  class  the  trouble  as  scleroderma  or  carcinoma  en 
cuirass t,  and  present  her  for  diagnosis." 

In  December,  1892,  the  plaque  and  fourth  toe  were 
removed  by  operation  and  were  hardened  in  alcohol.  It 
was  noticed  at  the  operation  that  in  cutting  out  the 
plaque  the  knife  met  with  more  resistance  beneath  it 
than  normal  subcutaneous  tissue  would  have  offered,  even 
in  the  sole  of  the  foot. 

It  was  learned  from  Dr.  Sherwell  that  the  growth  had 
recurred  and  was  now  advancing.  The  scar  was  adherent 
to  the  bone,  and  in  front  of  the  scar  the  skin  and  sub- 
cutaneous tissue  were  infiltrated  with  a  substance  which 
from  its  hardness  and  resilience  seemed  to  be  cartilage. 
It  was  of  new  formation,  having  appeared  since  the  time 
of  the  operation.  Dr.  Piffard  decalcified  a  portion  of  the 
growth  in  a  two  per  cent,  mixture  of  nitric  acid  and 
ninety-five  per  cent,  alcohol,  and  as  an  examination  of 
sections  from  this  piece  showed  a  general  infiltration  of 
the  skin  with  bone,  rather  than  a  distinct  tumor  forma- 
tion, he  suggested  the  name  "osteosis."  The  body  of 
the  plaque,  its  advancing  edge,  and  the  toe  were  ex- 
amined. The  latter  was  cut  at  two  different  levels — 
through  the  body  of  the  phalanx,  and  through  the  artic- 
ular cartilage — with  a  view  of  determining  the  origin  of 
the  process.  The  staining  of  the  cells  was  somewhat  in- 
terfered with  by  the  use  of  this  mixture  for  decalcification. 
Twenty  different  sections  were  studied. 

The  sections  through  the  body  of  the  plaque  showed 
cancellous  bone  close  up  to  the  epidermis.  The  spicules 
varied  in  size  and  shape,  and  were  irregularly  distributed 
throughout  the  tissues.  The  interspaces  were  filled 
chiefly  with  fat-cells,  blood-vessels,  and  a  loosely  woven 
connective  tissue.  Small  nerves  were  found  here  and 
there.  The  sweat-glands  and  their  ducts  appeared  nor- 
mal. In  this  part  of  the  growth  the  spicules  were  the 
most  abundant,  which  would  account  in  part  for  its 
greater  hardness,  but  they  were  also  smaller.  There 
were  irregularities  in  their  size  and  shape  apparently  due 
to  absorption.  Frequently  distinct  rows  of  cells  might  be 
seen  along  the  sides  of  the  spicules,  but  as  a  rule  they 
did  not  lie  under  a  definite  membrane.  Large  multi- 
nucleated cells  were  sometimes  associated  with  them,  es- 
pecially where  the  spicules  were  thinnest.  Mingled  with 
the  fet-cells  generally  in  the  interspaces  was  a  tissue  of 
marrow-like  structure,  consisting  of  uni-nucleated  cells  a 
little  larger  than  lymph-cells,  the  nucleus  occupying 
nearly  all  the  protoplasm.     The  large  multi-nucleated 


cells  occurred  with  these,  and  fine  connective-tissue 
fibres  ran  among  them  all  in  different  directions.  Some 
of  the  spicules  consisted  merely  of  a  homogeneous 
ground  substance  with  rounded  or  flattened  cells  scattered 
through  it ;  in  others,  the  cells  were  branched,  and  ar- 
ranged in  irregular  rows,  or  were  disposed  in  concentric 
rows  around  a  central  opening.  No  distinct  fibrillation 
could  be  made  out  in  any  of  them.  As  a  rule,  the  spic- 
ules were  composed  of  irregular  lamellae,  between  which 
were  branching  lacunae,  filled  with  bone  corpuscles. 
Small  blood-vessels  were  included  in  the  larger  masses  of 
bone,  and  in  rare  instances  the  lamellae  were  arranged 
concentrically  around  them,  but  there  was  a  lack  of 
regularity  characteristic  of  the  Haversian  system  in  the 
disposition  of  the  bone  corpuscles.  The  connective 
tissue  immediately  under  the  epidermis  was  very  dense, 
in  fact,  was  almost  tendinous  in  structure. 

The  edge  of  the  plaque  was  not  so  thick,  and  con- 
tained less  bone  than  the  part  just  described.  It  con- 
tained also  masses  of  cartilage.  Some  of  the  cartilage- 
cells  were  branched.  There  was  also  reason  to  believe 
that  a  transformation  of  fibrous  tissue  into  cartilage  was 
taking  place,  for  cells  immediately  adjacent  to  cartilag- 
inous masses  might  be  seen  increasing  greatly  in  number, 
and  arranging  themselves  between  bundles  of  dense  fi- 
brous tissue,  and  becoming  flattened  out.  They  were  of 
the  same  size,  shape,  and  appearance  as  the  outermost 
cells  of  the  cartilage,  and  merged  imperceptibly  into 
them.  They  corresponded  very  closely  with  cells  in  a 
like  situation  in  an  ossifying  tibia  from  a  six  months' 
foetus.  There  was  an  entire  absence  of  rows  of  osteo- 
blasts around  these  centres.  .This  transformation  was 
suggested  in  certain  sections  from  the  older  part  of  the 
growth,  but  in  them,  as  a  rule,  the  ossification  of  carti- 
lage already  formed  was  the  most  prominent  feature. 
The  method  by  which  the  cartilage  extended  would  ex- 
plain the  absence  of  a  periosteal  layer,  but  without  a 
periosteum  it  was  not  so  clear  why  the  osteoblasts  ar- 
ranged themselves  in  definite  rows  along  the  sides  of  the 
calcareous  cartilages. 

In  all  essential  details  ossification  was  proceeding 
regularly.  Many  of  the  spicules  had  ossified  only  so  far 
as  the  deposition  of  calcareous  granules  in  the  cartilagi- 
nous matrix  without  any  noticeable  change  in  the  appear- 
ance of  the  cells.  As  ossification  proceeded  the  cells 
swelled  up,  but  did  not,  as  a  rule,  arrange  themselves  in 
any  characteristic*  manner.  Rows  of  osteoblasts  de- 
veloped along  the  sides  of  the  cartilaginous  masses,  with 
or  without  the  occurrence  of  the  large  multi-nucleated 
cells  or  osteoclasts.  Then  the  irruption  commenced. 
The  irregular  openings  found  in  many  of  the  spicules 
might  be  explained  in  this  way,  for  they  contained  both 
kinds  of  cells.  The  presence  of  these  large  cells,  or 
osteoclasts,  in  certain  of  the  spicules  would  also  suggest 
this  formation  having  burrowed  there  from  the  side. 
Only  in  exceptional  instances  did  the  osteoblasts  lay 
under  a  definite  membrane.  Where  ossification  was 
complete,  both  osteoblasts  and  osteoclasts  had  disap- 
peared, and  the  bone  had  an  irregularly  lamellar  or  con- 
centric arrangement.  The  lacunae  were  branched,  and 
filled  with  bone  cells.  There  were  several  areas  in  which 
typical  ossification  occurred,  with  marked  swelling  of  the 
cells,  their  arrangement  in  definite  rows,  irregular  ab- 
sorption of  the  cartilaginous  matrix,  and  the  entrance 
of  blood-vessels  into  the  spaces  thus  formed. 

A  section  through  the  body  of  the  phalanx  of  the  toe 
showed  a  notable  absence  of  new  bone  in  the  dermis  and 
sub-dermic  tissues.  An  excessive  development  of  very 
dense,  almost  tendinous,  fibrous  tissue  was  the  principal 
cause  of  the  increased  diameter  of  the  toe.  All  the  nor- 
mal elements  of  the  skin  were  present.  The  central 
canal  of  the  bone  contained  spicules  of  irregular  shape 
and  arrangement,  with  fat  cells  and  blood-vessels  filling 
the  interspaces.  The  number  of  bone  corpuscles  was 
noticeably  small  and  there  were  no  osteoblasts  along  the 
sides  of  the  spicules.  In  the  cartilaginous  ring  which 
surrounded  these  and  to  which  they  were  attached,  ossi- 


i88 


MEDICAL  RECORD. 


[August  ii,  1894 


fi  cation  proceeded  regularly.  Bat  there  was  no  perios- 
teum, even  here,  and  at  irregular  intervals  around  its 
periphery  the  transformation  of  fibrous  tissue  into  carti- 
lage, with  a  consequent  extension  of  the  ring,  was  more 
evident,  than  in  sections  from  the  edge  of  the  plaque. 
Where  the  cells  were  distinctly  cartilage-cells,  and  even 
where  they  had  begun  to  swell  and  arrange  themselves  in 
a  definite  manner  for  ossification,  fibrous  bands  could  be 
seen  running  among  them.  Instead,  however,  of  the 
cells  arranging  themselves  in  rows  at  right  angles  to  the 
advancing  line  of  ossification,  they  became  grouped,,  ap- 
parently, from  repeated  subdivision,  the  number  of  cells 
in  such  group  being  a  multiple  of  two.  At  this  point 
absorption  began  with  the  subsequent  building  up  of  the 
spicules  that  were  left.  The  cells  in  the  outer  part  of 
the  cartilage  where  it  was  extending  were  flattened,  and 
some  of  them  were  slightly  branched. 

Concerning  the  sections  through  the  articular  cartilage, 
it  was  worthy  of  note  that  a  true  epidermic  formation, 
consisting  of  all  the  layers  quite  perfectly  developed,  ran 
in  crescentic  form  one-fourth  the  way  around  die  bone, 
and  almost  immediately  adjacent  to  it.  A  number  of 
sections,  as  well  as  the  block  from  which  they  were  cut, 
were  carefully  examined  to  make  sure  that  this  did  not 
result  from  an  accidental  infolding  of  the  skin. 

It  would  appear  that  primarily  there  was  a  hyperplas- 
tic formation  of  very  dense  connective  tissue,  that  this 
was  transformed  into  cartilage,  which  was  extended  by  a 
further  transformation  of  the  adjacent  fibrous  tissue  and 
the  subsequent  ossification  of  the  cartilage.  This  trans- 
formation of  fibrous  tissue  into  cartilage  could  not  be 
regarded  as  a  pure  metaplasia  because  of  the  marked  cell- 
proliferation  accompanying  it  There  was  nothing  to 
warrant  the  belief  that  the  lesion  originated  from  the 
periosteum  or  pre-existing  cartilage.  The  increased  size 
of  the  toe  was  principally  due  to  an  excessive  develop- 
ment of  fibrous  tissue.  The  extension  of  the  cartilagi- 
nous ring  seemed  to  be  simply  a  part  of  the  general  process, 
and  not  the  starting  point  of  it.  If  the  process  had 
begun  by  an  extension  of  the  pre:  existing  cartilage  it 
would  be  reasonable  to  suppose  that  the  plaque  would 
have  been  attached  to  the  underlying  bones,  but  such 
was  not  the  case.  While  it  was  true  that  bone  was  pres- 
ent throughout  the  entire  depth  of  the  sections,  ossifica- 
tion had  been  completed  in  the  parts  just  beneath  the 
epidermis.  As  it  was  probable  that  the  ossification  be- 
gan in  the  cartilage  first  formed,  the  speaker  thought  the 
transformation  first  occurred  in  the  dermis  itself,  or  im- 
mediately below  it.  Metaplasias,  both  physiological  and 
pathological,  were  of  common  occurrence,  but  as  Ziegler 
had  said,  these  metaplasias  "  are  confined  to  the  con- 
nective tissues;  fibrous  tissue,  cartilage,  bone,  mucous 
tissue,  and  adipose  tissue,  are,  so  to  speak,  potentially  con- 
vertible." The  sesamoid  fibro-cartilages  formed  in  ten- 
dons might  be  cited  as  instances  of  the  transformation  of 
fibrous  tissue  into  cartilage.  Arterial  sclerosis  sometimes 
resulted  in  the  formation  of  cartilaginous  patches  in  the 
walls  of  the  vessels.  In  myositis  ossificans  there  was  a 
transformation  of  fibrous  tissue  into  bone.  The  prone- 
ness  of  hyaline  cartilage  to  ossify  was  well  known. 

The  most  rational  explanation  of  the  etiology  of  this 
case  seemed  to  be  that  it  was  due  to  a  congenital  disposi- 
tion to  hyperplasia  and  metaplasia  of  the  connective  tis- 
sue in  the  derma  and  subdermic  structures.  Syphilis 
might  be  excluded,  and  it  could  not  be  ascribed  to  any 
special  irritation  resulting  in  an  inflammatory  condition, 
as  the  history  showed  a  notable  absence  of  signs  of  in- 
flammation. When  bones  developed  in  abnormal  situa- 
tions in  the  body  they  were  usually  the  result  of  long- 
continued  irritation  leading  to  inflammation.  In  rider's 
bones  we  had  an  example  of  bone  formation  from  long- 
continued  pressure,  though  the  ossification  might  be  at 
times  of  syphilitic  origin. 

Occlusion  of  the  Ileo-osBoal  Valve  by  a  Plug  of  Mn- 
ons:  Extreme  Interstitial  Emphysema  of  the  Lungs.— 
Dr.  Jambs  Ewing  presented  the  lungs,  ileum,  and  colon 
which  had  been  removed  from  a  child  who  died  fourteen 


hours  after,  birth.  The  presentation  was  L.  O.  A.  and 
the  labor  natural.  The  second  stage  lasted  one  hour. 
There  was  considerable  asphyxia  of  the  child  at  birth,  so 
that  four  mouth  to  mouth  insufflations  were  made,  after 
which  it  seemed  to  breathe  naturally.  It  was  not  long, 
however,  before  the  breathing  again  became  bad,  and  the 
child  cyanotic,  and  these  symptoms  persisted  until  death. 
One  hour  after  death  the  autopsy  was  made.  The  ab- 
dominal wall  was  tense  and  protuberant.  The  liver, 
which  had  been  pushed  upward,  descended  as  the  abdo- 
men was  opened.  The  lower  six  inches  of  the  ileum 
were  found  collapsed.  Above  this  point  the  intestine 
and  stomach  were  excessively  distended  with  gas.  The 
lower  two  feet  of  the  ileum  contained  a  tough  cord  of 
mucus  which  protruded  through  the  ileo  caecal  valve  and 
completely  occluded  it.  Six  inches  above  the  valve  it 
formed  a  plug  which  was  not  easily  detached.  The 
lungs  showed  great  compression,  especially  in  the  lower 
lobes,  and  while  they  were  largely  atelectatic  they  were 
not  consolidated.  Scattered  over  both  lungs  were  many 
prominent  vesicles  showing  extreme  interstitial  emphy- 
sema. Two  or  three  large  vesicles  covered  two-thirds  of 
the  internal  surface  of  the  right  lung.  The  cerebral  si- 
nuses were  intensely  engorged.  There  was  a  large  blood 
clot  in  the  stomach.  Blood  serum  was  oozing  from  the 
nostrils. 

The  speaker  said  he  had  been  unable  to  find  in  the 
literature  any  reference  to  such  a  peculiar  mucus  cord  as 
the  one  found  in  the  ileum.  The  enormous  quantity  of 
air  in  the  stomach  and  intestine  was  accounted  for  by 
the  insufflations,  the  air  having  expanded  somewhat 
probably  under  the  heat  of  the  body.  The  distention 
interfered  with  respiration  and  proved  the  immediate 
cause  of  death  in  the  infant  already  asphyxiated.  It  had 
been  stated  by  Delafield  that  distention  of  the  stomach 
with  aerated  mucus  might  become  a  serious  complication 
in  bronchitis  in  infants.  Possibly  the  emphysema  was 
caused  by  the  forcible  insufflation,  but  this  hardly  seemed 
sufficient  to  explain  it.  Most  writers  on  the  diseases  of 
children  stated  that  the  chief  cause  of  interstitial  emphy- 
sema was  violent  expiratory  efforts  with  obstruction  to 
the  expired  air.  While  there  was  no  consolidation  the 
compression  of  the  lung  from  the  abdominal  distention 
produced  atelectatic  areas.  The  hemorrhages  and 
venous  congestions  were  due  to  the  asphyxia,  which  was 
the  manner  of  death. 

Dr.  Prudden  said  he  saw  this  mucus  cord,  which  re- 
sembled a  tape-worm  in  many  respects,  although  anyone 
would  avoid  confounding  the  two. 

The  Society  then  went  into  executive  session. 


Haughty  Editors. — A  Philadelphia  contemporary  says 
that  a  gentleman  who  entertained  with  a  banquet  the 
American  Medical  Editors'  Association  in  San  Francisco, 
is  reported  to  be  actively  interested  in  a  much  advertised 
secret  nostrum. 

Death  of  a  Lady  Bicyclist.— The  death  of  the  lady 
cyclist  from  syncope  after  a  bicycle  ride  is,  of  course,  the 
text  for  many  fraternal  warnings,  and  advice  to  lady 
bicyclists  to  give  up  the  enjoyment  of  an  exercise  in 
which  it  is  feared  they  may  indulge  to  excess.  They  are, 
of  course,  told  by  some  that  bicycling  is  unladylike,  if 
not  unwomanly,  and  that  women  do  not  know  how  to 
practise  the  careful  restraint  in  such  matters  to  which 
men  are  accustomed.  They  may  very  well  afford,  how- 
ever, to  treat  all  this  sage  advice  as  at  least  superfluous. 
So  far  from  being  unsuited  for  woman,  bicycling  is  an 
exercise  in  which  they  may  indulge  with  perfect  security, 
and  generally  with  much  advantage.  We  are  persuaded 
that  they  are  as  little  prone  to  excess  in  athletics  as  are 
the  generality  of  men,  and  within  reasonable  bounds  we 
should  like  to  see  cycling  as  generally  practised  by 
women  as  by  men,  and  it  would  be  greatly  to  the  advan- 
tage of  many  cycling  clubs  and  cycling  resorts  that  the 
lady-like  element  should  be  more  largely  introduced. — 
British  Medical  Journal.  , 


August  ii,  1894] 


MEDICAL  RECORD. 


189 


OUR  LONDON  LETTER. 

(From  our  Special  Correspondent) 
THE   EXTRA   MEETING     OF  THE     MEDICO  CHIRURGICAL  SO- 
CIETY— LAWRIE  OF  HYDERABAD   ON  CHLOROFORM — DIS- 
CUSSION  OF    HIS    VIEWS — A     MUNIFICENT    ENDOWMENT 
OF  SCIENCE — THE  INSTITUTE  OF  PREVENTIVE  MEDICINE 

— mr.  a.  balfour,  m.p.,  on  science — the  college 
of  surgeons  election — sir  george  humphry — the 
apothecaries  company. — threatrnings  of  cholera 

circular  of  local  government  board — hospital 

sunday  fund — discontent  of  some  supporters — 
the  chelsea  hospital  inquiry — baronetcy  for  the 
duchess  of  york's  accoucheur — fellows  and  mem- 
bers OF  THE  ROYAL  COLLEGE  OF  SURGEONS. 

London,  July  7,  1894. 

The  extra  meeting  of  the  Royal  Medico-Chirurgical  So- 
ciety which  I  announced  as  arranged  for  in  my  last,  was 
held  on  Tuesday.  The  object  being  to  enable  Surgeon 
Lieutenant- Colonel  Lawrie,  while  in  London,  to  state 
his  views  on  chloroform.  These  views  will  be  familiar  to 
your  readers  from  the  report  of  the  Hyderabad  commis- 
sion, of  which  Dr.  Lawrie  is  the  father.  It  is  there- 
fore unnecessary  to  give  an  abstract  of  his  communica- 
tion to  the  Society,  but  the  conclusions  he  submitted 
were:  i.  That  chloroform  had  no  direct  action  on  the 
heart  In  support  of  this  he  explained  an  enlarged  pho- 
tograph from  the  fed  animal  in  a  cross-circulation  experi- 
ment in  which  chloroform  sent  to  the  heart  alone  pro- 
duced no  effect  whatever.  2.  In  a  similar  experiment 
chloroform  sent  to  the  brain  alone  produced  its  usual 
effects  by  acting  on  the  brain  centres.  3.  He  showed 
the  difference  from  the  same  illustrations  between  taking 
respiration  or  pulse  as  a  guide  to  the  effect  of  chloroform 
when  the  respiration  was  regular.  4.  Similar  differences 
under  the  same  conditions,  but  when  respiration  was  ir- 
regular from  vagus  stimulation.  5.  He  exhibited  a  trac- 
ing to  show  that  chloroform  anaesthesia  without  respira- 
tory complication  was  free  from  risk. 

Looking  at  the  discussion  that  has  taken  place  on  the 
Hyderabad  commission  Dr.  Lawrie  could  not  expect 
these  conclusions  to  meet  with  unanimous  assent,  but  he 
must  be  gratified  with  the  amount  of  support  he  received 
at  the  Society  and  the  great  respect  shown  to  his  labors 
by  even  those  who  cannot  endorse  his  views. 

Drs.  Gaskell  and  Shore  both  spoke.  It  is  known  that 
their  experiments  do  not  exactly  coincide  with  Dr.  Law- 
rie's-  They  admit  that  respiration  fails  first,  but  they 
think  chloroform  has  also  a  direct  action  on  the  heart. 
In  one  of  their  cross-circulation  experiments  the  respira- 
tion continued  five  minutes  after  the  heart  ceased  to 
beat.  Dr.  Brunton  suggested  that  peptones  which  had 
been  used  to  prevent  clotting  of  the  blood,  being  poison- 
ous, might  account  for  some  of  the  results,  and  held  that 
it  was  certain  that  chloroform  paralyzed  the  respiratory 
centre  before  affecting  the  heart.  He  speculated  a  little 
on  the  possibility  that  the  increased  consumption  of 
meat  of  late  years  may  have  some  relation  to  the  in- 
creased fatality  of  chloroform,  especially  as  strong, 
healthy  men,  on  full  diet,  gave  most  trouble,  and  were 
more  likely  to  have  alkaloidal  products  circulating  in  the 
blood. 

Mr.  Horsley  felt  sure  Dr.  Lawrie  was  right  as  to  most 
cases,  and  he  exhibited  a  series  of  tracings  on  the  screen 
to  show  the  mode  of  death  in  bullet  wounds  of  the  brain, 
and  said  it  was  precisely  similar  in  all  cases  of  cerebral 
compression.  Mr.  Bailey  said  the  pulse  should  be 
watched  as  well  as  the  breathing.  Dr.  D.  Buxton 
thought  a  considerable  proportion  of  deaths  were  due  to 
carelessness,  and  only  a  few  to  primary  action  on  the 
heart,  but  he  admitted  that  probably  the  secret  of  safety 
was  to  watch  the  breathing.  Dr.  D.  Newman  had  seen 
two  cases  of  cardiac  failure,  and  in  one  of  them  the  pulse 
stopped,  although  breathing  continued  and. air  entered 


the  chest  freely.  He  thought  the  respiratory  centre 
more  likely  to  fail  than  the  heart.  Dr.  Hewitt  also  men- 
tioned a  case  in  which  respiration  continued  though  no 
pulse  could  be  felt  at  the  wrist,  and  he  thought  that  we 
should  be  led  into  difficulties  if  we  looked  to  the  respira- 
tion alone  in  profound  anaesthesia.  Dr.  Lazarus-Barlow 
exhibited  a  tracing  taken  directly  from  the  heart  of  a 
curarized  animal,  to  show  that  cardiac  failure  began  with 
the  commencement  of  inhalation,  respiration  failing 
later.  Dr.  Silk  declared  that  an  increased  number  of 
deaths  had  taken  place  since  the  Hyderabad  report,  and 
that  though  respiration  should  have  primary  attention 
the  pulse  must  also  be  watched. 

Dr.  Lawrie  in  reply  remarked  that  the  sudden  stoppage 
of  the  heart  in  the  cases  mentioned  could  only  have 
been  produced  by  stimulation  of  the  vagus  through  the 
respiration — that  the  experiments  of  Dr.  Lazarus-Barlow 
indicated  some  damage  to  the  circulation  in  the  lungs. 
He  had  found  no  difference  in  the  effects  of  chloroform 
on  Europeans  and  natives.  In  seven  hundred  cases  the 
pulse  had  been  carefully  watched,  but  gave  no  indication. 
Finally,  he  said  it  is  impossible  to  teach  a  careless  man 
to  give  chloroform  safely. 

Mr.  Mond  has  endowed  scientific  research  in  a  munifi- 
cent manner.  He  has  bought  the  Earl  of  Albemarle's 
mansion,  contiguous  to  the  Royal  Institution,  and  pre- 
sented it  to  that  body.  Further,  he  proposes  to  meet 
the  cost  of  converting  it  into  a  laboratory,  and  equip- 
ping it  for  chemical  and  physical  research.  He  intends 
also  to  endow  it  with  sufficient  income  for  maintaining  it 
and  employing  a  skilled  staff.  This  splendid  addition  to 
our  scientific  resources  is  to  be  called  the  Davy- Faraday 
Research  Laboratory,  and  its  establishment  is  expected  to 
cost  Mr.  Mond  some  ^100,000.  The  old  country  is  not 
yet  destitute  of  munificent  donors. 

The  British  Institute  of  Preventive  Medicine  is  in  a 
fair  way  of  success.  The  site  has  been  purchased  and 
some  important  sums  have  been  secured,  e.g.,  ^10,000 
from  the  Grocers'  Company— one  of  the  most  liberal  of 
the  city  companies ;  ^20,000  from  the  Berridge  trustees, 
and  a  further  ^25,000  is  about  to  be  handed  over  from 
the  same  source.  The  College  of  State  Medicine  will 
also  hand  over  its  plant  and  money  to  the  Institute,  in 
value  above  ,£4,000.  Some  of  the  investigations  I  have 
mentioned  in  previous  letters  were  carried  out  for  the 
Institute,  and  now  that  a  suitable  building  is  about  to  be 
erected  the  silly  opposition  of  the  antis  to  this  under- 
taking may  be  diverted  into  other  channels. 

Mr.  Arthur  Balfour,  who  so  rapidly  rose  to  the  highest 
position  in  Parliament,  is  a  metaphysician  of  no  slight  at- 
tainments and  a  profound  economist.  Speaking  last 
week  at  thd  Economic  Association  he  touched  on  scientific 
investigations  with  a  light  but  firm  hand.  He  said  the 
public  had  never  yet  mixed  themselves  up  in  these  matters 
without  spoiling  the  investigations  and  doing  themselves  a 
great  deal  of  harm. .  When  the  public  took  up  a  question, 
party  feeling — necessary  in  political  affairs — was  sure  to- 
come  in  and  as  sure  to  produce  disastrous  results.  He  in- 
stanced the  question  of  vaccination,  which  the  doctois* 
thought  they  had  settled  on  scientific  principles,  but  on 
which  a  section  of  the  public  who  had  not  studied  it  in  the 
scientific  spirit  were  determined  that  their  feelings  should 
override  science.  Not  being  a  doctor  he  would  not  pro- 
nounce as  an  expert,  but  he  had  no  doubt  that  if  scientific 
questions  were  to  be  decided  by  universal  suffrage,  only 
harm  could  be  done  to  this  suffrage,  while  it  would  be  abso- 
lute ruin  to  science.  If  science  is  wrong,  he  said,  it  could 
only  be  got  right  and  turned  into  the  direction  of  truth  by 
giving  it  free  play  outside  altogether  the  influence  of  popu- 
lar forces.  The  idea  that  a  section  of  the  public  had  an* 
opinion  worth  having  on  such  subjects  was  to  him  ab- 
surd. 

The  elections  at  the  Royal  College  of  Surgeons  took 
place  on  Thursday  (5th). 

Messrs.  Howard  Marsh  and  Reginald  Harrison  were- 
re-elected,  and  the  third  vacancy  was  filled  by  the  elec- 
tion of 'Mr.  JameS  Hardie,  of  Manchester.    The  provin- 


190 


MEDICAL    RECORD. 


[August  11,  1894 


cial  Fellows  have,  therefore,  again  succeeded  in  placing 
one  of  their  number  on  the  Council. 

Sir  George  Humphry  has  continued  to  improve,  and 
is  now  able  to  take  carriage  exercise. 
.   The  apothecaries'  company  has  issued  a  calendar,  and 
an  interesting  document  it  is,  showing  that  it  has  done 
good  work  for  the  profession  in  the  past. 

London,  July  ax,  1894, 

Uneasiness  is  felt  in  many  quarters  at  the  recrudescence 
of  cholera  on  the  continent,  which  is  becoming  in  some 
countries  serious.  About  two  hundred  attacks  a  day  in 
St.  Petersburg,  and  outbreaks  much  nearer  our  shores 
are  certainly  enough  to  make  sanitary  authorities  anx- 
ious. The  local  government  board  has  issued  a  cir- 
cular urging  the  utmost  vigilance  as  to  all  suspicious  cases 
and  promising  favorable  considerations  to  any  proposals 
to  add  diarrhoea  to  the  list  of  notifiable  diseases  for  the 
remainder  of  the  current  quarter,  after  which  the  danger 
may  be  considered  over  for  this  year.  In  former  epi- 
demics the  disease  has  been  more  fatal  in  the  second  year 
oi  its  invasion,  and  many  are  accordingly  asking  each 
other  whether  we  are  now  in  the  second  year,  or  whether 
the  cases  last  year  were  only  stray  ones,  brought  by  ships 
and  infecting  a  few  persons  in  communication  with  them. 
If  so  the  present  may  prove  to  be  the  first  year  of  an  inva- 
sion should  it  pass  our  boundaries.  If  otherwise,  and  last 
year  is  to  be  reckoned  as  the  first  of  an  epidemic,  the 
seeds,  so  to  say,  of  the  disease  have  been  sown  sufficiently 
broadcast  to  cause  anxiety.  Our  sanitarians  speak  con- 
fidently of  our  preparedness,  though  they  admit  the  exist- 
ence of  weak  spots  in  our  armor,  and  if  once  an  epidemic 
gains  a  footing  there  are  many  inland  towns  and  villages 
but  ill  prepared  to  meet  it 

Above  ^42,000  has  already  been  received  for  the  Hos- 
pital Sunday  fund,  and  this  is  nearly  ^3,000  more  than 
last  year's  collection,  while  other  sums  have  yet  to  come 
in.  Much  credit  is  due  to  the  Lancet  for  the  spirited 
way  in  which  it  has  contributed  to  the  success  of  the 
fund.  I  am,  therefore,  rather  sorry  to  notice  that  your 
powerful  contemporary  seems  inclined  to  consider  the 
management  of  the  fund  immaculate  and  endeavors  to 
account  for  the  discontent  that  has  been  evinced  in  a 
manner  that  facts  will  scarcely  support.  "  Bad  manage- 
ment "  is  the  excuse  put  forward  for  refusing  to  in- 
clude some  institutions  in  the  distribution.  The  truth 
is,  in  some  cases,  the  so  unfairly  stigmatized  management 
is  the  expense  of  each  patient,  especially  in  dispensaries 
and  out  patient  special  institutions.  These  expenses  con- 
sist largely  in  the  use  of  drugs  and  appliances  which  the 
specialists  say  cure  the  patients  and  which,  being  costly, 
are  not  much  used  at  great  hospitals  where  rJatients  are 
hurriedly  got  through  in  a  few  seconds  each.  I  know  that 
in  some  cases  this  contention  is  not  without  foundation. 
The  supporters  of  the  fund  are  apt  to  be  angry  too, 
when  a  sermon  is  preached  on  behalf.of  some  institution 
selected  by  the  preacher  or  his  people,  and  when  boxes 
are  distributed  to  collect  for  such  charity.  Now  it  is 
really  the  management  of  the  fund  that  has  led  to  this 
action.  The  large  hospitals,  which,  of  course  have  the 
first  claim,  have  their  friends  on  the  committee  and  very 
scant  justice  has  been  done  to  small,  especially  special 
hospitals.  The  prejudice  against  specialism  has  been 
fostered  by  the  fund  committee  and  their  officials  do 
not  hesitate  to  express  it.  What  more  natural  than  that  a 
preacher  interested  in  a  special  hospital,  knowing  its 
working,  and  perhaps  taking  part  in  its  management, 
should  say,  if  you  refuse  to  include  this  charity  in  your 
list  I  will  give  my  collection  to  it  alone?  This  kind  of 
thing  will  increase  if  lay  officials  are  to  reflect  the  preju- 
dices of  a  party.  In  the  interest  of  hospitals  I  deprecate 
such  divisions,  although  I  am  not  quite  sure  that  they 
may  not  eventually  prevail  and  do  good.  For,  after  all, 
what  is  ^40,000  for  the  rich  metropolis  to  raise  ? 

The  committee  appointed  to  investigate  the  charges 
brought  by  the  medical  officer  of  health  (Dr.  Louis 
Parkes)  against  the  Chelsea  Hospital  for  Women  has 


issued  its  report.  They  say  it  was  the  duty  of  Dr. 
Parkes  to  notice  the  matter,  but  they  do  not  understand 
why  he  omitted  to  inform  the  vestry  that  at  the  time  he 
presented  his  report  the  hospital  had  been  empty  for 
three  weeks,  and  that  he  had  received  a  letter  from  the 
secretary  stating  that  the  works  would  be  carried  out  as 
soon  as  possible  and  completed  before  patients  were 
again  admitted.  They  further  state  their  opinion  that 
a  large  number  of  the  deaths  were  due  to  septicaemia, 
and  that  septic  temperatures  did  not  prevail  in  the  prac- 
tice of  every  member  of  the  staff.  This  seems  to  me 
rather  a  lame  conclusion  or  else  an  insinuation,  unjusti- 
fiable unless  supported  by  facts,  in  which  case  it  should 
have  been  plainly  stated.  The  medical  officer  of  health 
attributed  the  mortality  to  insanitary  conditions.  The 
committee  of  inquiry  offers  no  conclusion  on  this  point, 
which  is  a  vital  one. 

The  occasion  of  the  birth  of  a  son  to  the  Duke  of 
York  has  been  taken  by  the  Queen  to  confer  a  baronetcy 
on  the  physician-accoucheur — Dr.  John  Williams — who 
has  also  attended  other  members  of  the  royal  family, 
and  is  one  of  our  most  eminent  obstetricians. 

The  fellows  of  the  College  of  Surgeons  have  held 
their  meeting  and  congratulated  the  council  on  its  con- 
cessions. The  two  societies  almost  approached  each 
other  and  the  sooner  their  rivalry  disappears  the  better. 
There  was  no  room  for  the  latest  of  the  two,  but  the  mat- 
ter only  concerns  the  exclusive  fellows.  The  council 
has  issued  a  series  of  regulations  for  the  meetings  of 
members.  They  are  admirably  adapted  to  prevent  these 
members  from  doing  anything  except  at  the  council's  bid- 
ding. 

The  constitution  of  the  college  needs  radical  reform. 

The  slight  changes  granted  to  the  fellows  induces  them 
to  ask  to  have  them  embodied  in  a  new  charter.  If  the 
members  do  not  obtain  some  recognition  in  any  such 
proposed  instrument,  they  should  combine  to  oppose  it, 
and  the  privy  council  would  no  doubt  accord  them  a 
hearing  before  recommending  the  grant  of  the  charter. 


THE  PATENT  MEDICINE  SCOURGE. 

To  thb  Editor  op  thb  Medical  Record. 

Sir  :  The  sad  death  of  the  young  woman,  Natalie  D , 

which  recently  occurred  in  Montreal,  should  serve  as  a 
warning  to  the  public,  and  stimulate  the  medical  pro- 
fession to  enter  a  vigorous  protest  against  the  patent 
medicine  scourge  which  is  now  raging  throughout  this 
continent.  At  the  inquest,  held  on  the  body  of  the  de- 
ceased, the  coroner  read  a  few  letters  from  some  women 
asking  for  these  pills  which  the  deceased  had  taken  for 
the  purpose  of  procuring,  abortion.  He  stated  that  he 
produced  these  letters  to  show  what  great  evils  such  arti- 
cles could  do. 

Your  readers  are  only  too  well  aware  that  the  advertis- 
ing columns  of  almost  every  daily  and  weekly  newspaper 
— and  also  of  magazines,  almanacs,  and  pamphlets — con- 
tain glowing  descriptions  of  the  "  miracles  "  which  have 
been  performed  by  Dr.  So-and  so's  pills,  or  some  one 
else's  marvellous  medical  "  discovery."  Surely  it  is  time 
that  the  medical  profession  stepped  in,  and,  una  vouy 
urged  the  proper  authorities  to  place  more  stringent  reg- 
ulations on  the  sale  of  dangerous  and  poisonous  prepara- 
tions. We  have  only  to  glance  through  the  advertising 
columns  of  reputable  publications,  and  we  shall  find  the 
narrative  of  some  unfortunate  sufferer,  who  pathetically 
relates  how  he  or  she  has  been  snatched  from  the  very 
jaws  of  death,  after  having  unsuccessfully  consulted  (?)  all 
"the  leading  physicians"  in  that  particular  section  of 
the  country.  As  a  rule,  a  crude  portrait  of  some  vigor- 
ous  looking  individual  adorns  the  account  in  order  to 
render  the  narrative  the  more  attractive,  and  the  more 
effectually  to  catch  the  public  eye.  I  believe  it  was  the 
late  Lord  Chief  Justice  Coleridge  (England),  who  stated 
that  a  country  was  composed  of  so  many  millions  of  peo- 
ple principally  consisting  of  persons  possessing  a  natu- 
rally dwarfed  intelligence ;    and  .  no  more  satisfactory 


August  ii,  1894] 


MEDICAL   RECORD. 


191 


evidence  of  this  can  be  afforded  than  the  fact  that  a 
patent  medicine  speculator  has  only  to  advertise  a  new 
and  startling  "  discovery/1  and  he  will  immediately  re- 
ceive numerous  testimonials  extolling  his  remedy,  and 
thanking  God  that  such  a  benefactor  to  the  human  race 
has  suddenly  sprung  into  existence.  It  is  surprising  to 
find  how  large  a  number  of  persons  consult  physicians  now- 
adays who  frankly  confess  that  they  have  been  habitually 
using  a  certain  much-lauded  pill,  or  some  other  com- 
pound, which  has  probably  been  purchased  at  a  neighboring 
general  store;  and  only  as  a  final  resort  have  the  purchasers 
been  at  length  compelled  to  seek  medical  advice ;  nor 
can  it  be  disputed  that  thousands  of  women  annually  im- 
peril their  lives  by  employing  dangerous  patent  medicines 
for  escaping  the  consequences  of  marriage,  or  to  avert 
the  trouble  arising  from  illicit  sexual  union. 

The  time  has  arrived  when  both  the  medical  profession 
and  the  public  should  be  protected  from  a  traffic  which 
is  hurtful  to  the  community  and  is  slowly  undermining 
the  practices  of  qualified  medical  men.  It  is  almost  un- 
necessary to  point  out  that  no  case  can  be  successfully 
treated  unless  the  whole  history,  symptoms,  and  environ- 
ment of  that  particular  case  be  properly  studied  and  un- 
derstood. Furthermore  it  is  a  lamentable  fact  that,  in 
all  likelihood,  many  lives  are  lost  which  may  be  directly 
attributable  to  the  reckless  use  of  some  obscure  concoc- 
tion entirely  unsuitable  to  the  disease  for  which  it  is  ad- 
ministered. It  is  readily  conceivable  that,  among  the 
many  thousands  who  purchase  popular  nostrums,  and 
rely  solely  upon  their  supposed  curative  powers,  not  a  few 
go  from  bad  to  worse ;  and  only  when  too  late  do  they 
hasten  to  seek  sound,  practical,  and  judicious  counsel 
from  an  intelligent  medical  practitioner. 

R.  H.  Phillimore,  M.D. 

COOKSHIKB,    QUKBEC,   CANADA, 

Juiy  23,  1894.  

POLITZER'S    OPINION  ON    MEDICAL    EDUCA- 
TION IN  AMERICA. 

To  the  Editor  or  tmb  Mboical  Record. 

Sir  :  The  article  in  a  recent  issue  under  the  heading  "  Is 
there  a  Need  for  more  Medical  Schools  ?  "  recalls  to  mind 
an  interesting  lecture  which  was  delivered  before  the 
Medical  Society  of  Vienna,  by  Professor  Politzer,  in 
March  last. 

The  meeting  was  open  to  all  physicians,  and  many 
Americans,  including  myself,  took  advantage  of  it. 

Professor  Politzer,  it  seems,  was  sent  by  the  Austrian 
Government  to  the  United  States  to  investigate  the  medi- 
cal institutions,  hospitals,  and  surgical  and  medical  ap- 
paratuses. 

What  he  said  regarding  our  medical  institutions  was 
certainly  displeasing  to  the  Americans ;  nevertheless,  it 
was  true.  He  said  that  the  United  States,  with  a  popula- 
tion of  sixty  or  sixty-five  millions,  had  one  hundred  and 
forty  eight  medical  schools,  while  the  total  number  of 
medical  schools  in  Austria  and  Germany  together  was 
twenty  nine.  Russia,  with  a  population  of  about  one 
hundred  millions,  had  nine  medical  schools. 

He  also  mentioned  other  European  countries  with  a 
similar  ratio.  Regarding  the  formation  of  medical  col- 
leges in  the  United  States,  he  said  that  all  that  was  re- 
quired to  organize  a  college  was  a  few  doctors  and  an 
appeal  to  the  Legislature  for  a  charter,  which  was  always 
granted.  This  remark  was  greeted  with  considerable 
laughter. 

He  said  that  almost  every  city  of  any  considerable  size 
had  one  college,  some  two — and  that  new  ones  were  spring- 
ing up  every  day — and  that  occasionally  one  dropped  out 
of  existence.  Some  of  our  schools  gave  degrees  in  two 
years,  but  he  was  glad  to  find  that  some  of  the  better 
schools  had  increased  the  time  to  four  years.  In  Austria 
and  Germany  a  five-and-a-half  years'  course  is  required. 
Oar  hospitals  and  surgical  instruments  he  praised  very 
highly. 

Oliver  A.  Blumenthal,  M.D. 

£01  Waikbn  Street ,  Syracuse,  N.  Y. 


i^edixal  Stems. 

Contagious  Diseases — Weekly  Statement. — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to  the 
Sanitary  Bureau,  Health  Department,  for  the  week  end- 
ing August  4,  1894. 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebrospinal  meningitis 

Measles 

Diphtheria 

Small-pox 


Cases. 


Deaths. 


85 

9i 

21 

7 

40 

5 

2 

7 

27 

5 

146 

37 

6 

1 

The  Late  President  of  the  French  Republic  and  his 
Surgeons. — The  Progr is  Medical  of  June  30th  gives,  on 
the  authority  of  Professor  Poncet,  of  Lyons,  the  follow- 
ing details  as  to  the  surgical  treatment  pursued  in  the 
case  of  the  late  President  of  the  French  Republic.  The 
wound  was  inflicted  at  a  quarter  past  nine  in  the  even- 
ing, and  M.  Poncet,  who  was  at  once  summoned,  found 
M.  Carnot  in  a  state  of  collapse,  and  with  the  aspect  of 
one  at  the  point  of  death.  Tearing  open  the  shirt  and 
underclothing,  M.  Poncet  found  to  the  right  of  the  line  a 
alba,  about  three  centimetres  from  the  ensiform  cartilage, 
parallel  to  the  edge  of  the  false  ribs,  a  wound  from 
twenty  to  twenty-five  millimetres  in  length,  from  which 
black  blood  was  oozing.  He  contented  himself  in  the 
first  instance  with  applying  a  handkerchief  lightly  to  the 
wound,  and  with  the  view  of  preventing  fatal  syncope, 
he  placed  the  President  as  nearly  in  a  horizontal  posi- 
tion as  the  carriage  would  allow,  and  strove  to  rouse  him 
by  speaking  to  him  and  occasionally  tapping  his  face 
with  his  fingers.  On  the  way  to  the  Prefecture,  distant 
about  one  kilometre,  the  President,  who  was  uncon- 
scious, retched  two  or  three  times,  but  did  not  vomit. 
On  arriving  at  the  Prefecture  he  was  laid  on  the  bed 
with  his  head  low,  and  while  waiting  for  aseptic  instru- 
ments M.  Poncet  applied  iced  compresses  to  the  abdomen. 
A  few  minutes  later,  considering  surgical  interference  to 
be  urgently  necessary,  he,  with  the  help  of  Drs.  Masson, 
Monnoyer,  Demandre,  and  Lupine,  and  in  the  presence 
of  Professor  Gailleton,  Mayor  of  Lyons,  and  Drs.  Kelsch, 
Albert,  Fabre,  and  Rebatel,  performed  a  local  laparot- 
omy, no  anaesthetic  being  given  on  account  of  the  col- 
lapsed state  of  the  patient.  An  incision  of  ten  to  twelve 
centimetres  was  made  and  progressively  extended  as  the 
necessity  arose ;  this  incision  was  a  prolongation  of  the 
wound  made  by  the  assassin's  dagger.  A  considerable 
quantity  of  blood  escaped,  and  M.  Poncet,  introducing 
his  left  forefinger  into  the  depth  of  the  wound,  was  able 
clearly  to  make  out  on  the  anterior  surface  of  the  left 
lobe  of  the  liver,  near  the  suspensory  ligament,  a  wound 
of  the  same  dimensions  as  that  in  the  skin.  Separating 
the  edges  of  the  wound  with  forceps  he  saw,  a  little 
above  the  costal  arch,  the  wound  in  the  liver,  into 
which  the  forefinger  penetrated  to  a  depth  of  two  to  three 
centimetres.  Such  rapid  examination  as  was  possible 
failed  to  reveal  any  lesion  of  the  gallbladder,  stomach, 
intestine,  etc.  At  this  stage  of  the  operation  Professor 
Oilier  arrived,  and  M.  Poncet  haying  shown  him  the 
nature  of  the  wound,  and  the  impossibility  of  suturing 
the  wound  in  the  liver — a  procedure,  moreover,  which 
appeared  to  be  useless  in  view  of  the  fact  that  the  bleed- 
ing could  at  once  be  stopped  by  pressure — it  was  agreed, 
having  regard  to  the  collapsed  state  of  the  patient,  sim- 
ply to  plug  the  wound.  Some  fibres  of  the  rectus,  which 
interfered  with  the  manipulations,  were  divided  by  an- 
other incision  of  five  to  six  centimetres  inward  toward 
the  middle  line.  The  wound  was  plugged  with  iodoform 
gauze ;  then  compresses  of  sterilized  gauze  were  applied 
and  fixed  in  place  by  a  body  bandage  drawn  moderately 
tight,  while  an  assistant  kept  up  slight  pressure  with  his 
hand.    At  the  beginning  of  the  operation,  when  the  first 


192 


MEDICAL    RECORD. 


[August  ii,  1894 


incision  was  made,  the  President  recovered  conscious- 
ness, and  said  in  a  clear  voice,  "  Oh  !  doctor,  how  you 
hurt  me."  From  that  time  he  seemed  to  recover 
strength  a  little  and  answered  questions  with  perfect 
distinctness.  He  was  given  small  pieces  of  ice  and  a 
little  iced  champagne,  and  two  subcutaneous  injections 
of  a  gramme  of  ether  were  administered  at  an  interval 
of  twenty  to  thirty  minutes.  The  President  complained 
of  a  certain  difficulty  in  breathing  and  of  pain  in  the 
stomach  and  loins.  At  half-past  twelve  his  voice  was 
still  resonant,  and  he  expressed  his  gratitude  for  what 
was  being  done  for  him.  A  minute  or  two  later  there 
was  some  return  of  the  hemorrhage,  and  convulsive 
movements  occurred  which  caused  the  intestine  to  show 
a  tendency  to  protrude  through  the  wound.  At  thirty- 
eight  minutes  past  twelve  he  died. — British  Medical 
Journal. 

The  Anti  diphtheria  of  Klebs. — Dr.  Oscar  Vulpius 
applies  the  liquid  with  a  long-handled  camel's-hair  brush, 
which  is  readily  managed,  first  to  the  tonsils  and  soft 
palate,  and,  after  thorough  cleansing,  to  the  pharynx. 
With  restless  children  one  must  be  cont&t  with  imper- 
fect treatment,  and  even  with  one  application ;  even  the 
liquid  may  be  expelled  by  vomiting  before,  indeed,  it 
can  reach  the  membrane.  The  results  as  noted  include 
a  marked  subsidence  of  the  fever;  the  membrane  may 
remain  entirely  unchanged  during  the  treatment,  nor, 
indeed,  does  this  treatment  prevent  the  tendency  of  the 
process  to  invade  the  trachea  and  bronchial  tubes,  con- 
sequently it  has  no  influence  in  preventing  croup.  How- 
ever, as  it  is  important  that  the  remedy  shall  be  brought 
into  close  contact  with  the  diseased  surface,  it  should  be 
again  applied  as  soon  as  the  membrane  is  coughed  up. 
In  his  series  of  cases,  nineteen  in  number,  the  percent- 
age of  deaths  was  52.6  ;  omitting  one  case  of  the  rare  ac- 
cident, late  secondary  hemorrhage  after  tracheotomy,  the 
rate  falls  to  fifty  per  cent.  Whether  with  an  improved 
anti-diphtherin,  or  with  possibly  a  combination  with  this 
of  a  diplococcus  poison,  better  results  may  be  obtained, 
the  future  only  will  determine. — Deutsche  medicinische 
Wochenschrift,  1894,  No.  6,  S.  127. 

Thyroid  Feeding  in  Myxcedema.— Dr.  S.  J.  Meltzer 
reports  in  the  New  Yorker  tnedicinische  Monatsschriftt 
No.  4,  1894,  an  interesting  case  of  myxcedema  in  a 
woman,  thirty-seven  years  of  age,  successfully  treated 
with  powdered  thyroid  extract.  At  the  time  of  the  reporj 
the  improvement,  as  shown  by  photographs,  was  most 
marked,  and  there  was  every  reason  to  anticipate  a  com- 
plete recovery. 

Some  Ancient  Theses  for  the  Degree  of  X.D.  Paris. 

— M.  Jules  Roger,  in  his  interesting  book,  "  M6decins, 
Chirurgiens,  et  Barbiers,"  gives  the  following  list  of  sub- 
jects of  theses  sustained*  in  old  times  before  this  faculty : 
1572.  La  necessity  de  la  mort  est  elle  inn6e?  1576. 
Le  foetus,  ressemble-t-il  plus  in  la  mere  qu'au  pere  ?  1 5 89 . 
L'air  est  il  pins  n£cessaire  que  la  nourriture  etlaboisson  ? 
1622  L'eau  est- elle  plus  salutaire  que  le  vin?  1639. 
Doit-on  saigner  une  jeune  fille  folle  df amour?  1643. 
S'enivrer  une  fois  par  mois  est-il  salutaire?  $1646.  La 
femme  est- elle  un  ouvrage  imparfait  de  la  nature?  1662. 
Le  libertinage  amene-til  la  calvitie?  1668.  Les  Pari 
siens  sont  ils  sujets  a  la  toux  quand  souffle  le  vent 
du  nord?  17 14.  Quel  est  le  plus  salutaire,  de  l'eau  pure, 
du  vin  pur,  ou  du  vin  melange*  d'eau?  1745.  Les  littera- 
teurs doivent-ils  se  marier  ?  1)£  naivetk  of  the  preceding 
questions  is  charming,  but  he  must  have  been  a  courage- 
pus  man  who,  even  in  1646,  could  gravely  ask  the  ques- 
tion, "  Is  woman  an  imperfect  work  of  nature  ?  " — Brit- 
ish Medical  Journal. 

Cancer  Houses.— Several  correspondents  of  the  Brit- 
ish Medical  Journal  have  reported  instances  in  which 
the  successive  occupants  of  certain  houses  have  died  of 
cancer.  In  many  cases  there  was  no  history  of  heredity, 
and  often  there  was  no  relationship  between  the  persons 
successively  attacked  with  the  disease. 


A  Convivial  Occasion. — The  doctors  of  the  Girondc 
dined  together  on  Sunday,  June  17th,  at  Pauillac,  and 
the  banquet  was,  according  to  the  Echo,  moistened  by 
2x8  crus  and  340  varieties  of  wine.  The  carte  was  in 
twelve  pages,  setting  forth  in  elegant  typography  the  vir- 
tues of  the  most  reputed  crus  and  the  most  famous  yean. 
There  were  1,400  bottles  to  170  doctors.  This  goes 
ahead  of  the  annual  banquets  of  the  Maine  State  Medi- 
cal Society. 

Lucky  Numbers  and  Lucky  Medical  Students.— Two 
French  medical  students,  M.  Gustave  Lefilliatre  and  M. 
Georges  Labey,  had  recently  a  letter  from  a  solicitor 
named  Leger,  of  Marines,  Seine-et-Oise,  stating  that  the 
late  Dr.  Dubois,  a  medical  man  at  Chars,  had  left  a  will 
by  which  he  bequeathed  all  his  surgical  and  medical  ap- 
pliances, free  of  legacy  duty,  to  two  students  obtaining 
their  degree  at  the  examination  next  after  the  decease  of 
the  testator.  The  two  students  selected  were  to  be  those 
who  came  out  No.  14  and  No.  84  in  the  list.  At  first 
it  was  thought  the  letter  was  a  hoax,  but  the  two  young 
men  went  to  the  place  indicated,  and  were  there  duly 
presented  with  an  exceptionally  fine  collection  of  instru- 
ments and  accessories  of  all  kinds  for  division  between 
them.  They  learned  that  their  being  specially  chosen 
was  due  to  the  fact  that  the  deceased  doctor  bad  twice 
passed  an  examination,  and  that  he  had  on  those  occa- 
sions been  No.  14  and  No.  84  on  the  lists. 

Professor  Gussenbauer,  the  newly  appointed  incum- 
bent of  the  Chair  of  Surgery  in  the  University  of  Vienna 
has  been  elected  President  of  the  Twenty-fourth  Con- 
gress of  the  German  Society  of  Surgery  to  be  held  in 
1895. 

Profitable  Quackery  in  Bussia.— The  police  in  Kicff 
recently  made  a  domiciliary  visit  to  the  proprietor  of 
some  "magic  pills,"  a  former  blacksmith  in  Warsaw.  In 
searching  his  effects  they  found  3,782  letters  containing 
orders  for  pills,  with  enclosures  amounting  in  all  to  over 
$5,000.  The  letters  were  from  persons  of  all  classes,  in- 
cluding priests,  apothecaries,  and  government  officials. 

Sanitation  Sunday. — We  have  labor  day  and  hospital 
Sunday,  and  other  interesting  memorial  occasions,  but 
the  English  churchman  goes  ahead  of  the  record  and  pro- 
poses a  "  Sanitary  Sunday."  The  Church  Sanitary  As- 
sociation suggests  that  the  seventh  Sunday  after  Trinity 
be  known  as  Sanitation  Sunday,  because  the  gospel  for 
this  day  contains  the  record  of  Christ's  disciples  distribu- 
,  ting  wholesome  food  to  those  who  were  already  in  the 
enjoyment  of  fresh  air,  pure  water,  and  abundant  light, 
thereby  indicating  the  Divine  will  that  man  shall  enjoy 
fulness  "  as  well  for  the  body  as  the  soul." 

Instruction  in  Dentistry  in  France. — In  the  French 
Budget  for  1895  is  an  appropriation  of  $15,000  to  pro- 
vide for  the  organization  of  chairs  of  dental  surgery  in 
several  of  the  medical  schools  of  the  country. 

Contract  Medical  Practice. — The  London  (Ont.) 
Medical  Society  has  been  deliberating  on  the  question  of 
contract  or  lodge  practice,  and  offers  the  following  sug- 
gestions looking  to  its  abolition  or  restriction:  "1. 
Apply  for  legislative  authority  to  prohibit  contract  prac- 
tice. With  the  prevailing  contract  rates  at  $1.00  and 
$1.50  per  member,  this  prohibition  might  be  shown  to 
be  in  the  interest  of  the  public  as  well  as 'the  profession, 
inasmuch  as  indifferent  service  is  a  natural  result  of  in- 
adequate remuneration;  or,  2.  Apply  for  legislative 
power  to  fix  a  minimum  tariff  of  contract  rates.  A 
Toronto  medical  journal,  in  December,  1893,  claims,  on 
the  authority  of  a  distinguished  actuary,  that  the  proper 
remuneration  for  contract  practice  in  Canada  is  $4.00  a 
year  per  member ;  or,  3.  Apply  to  the  Legislature  for 
power  to  frame  and  enforce  a  code  of  medical  ethics, 
with  a  view  to  control  the  evil ;  or,  4.  Address  an  ap- 
peal to  every  registered  practitioner  to  discountenance 
the  system.  The  influence  of  such  an  appeal  coming 
from  the  representative  body  of  the  profession  would 
tend  to  bring  the  practice  into  disrepute.11 


Medical   Record 

A  Weekly  yournal  of  Medicine  and  Surgery 


Vol.  46,  No.  7. 
Whole  No.  1241. 


New  York,  August  18,  1894. 


$5.00  Per  Annum. 
Single  Copies,  ioc. 


©riflitial  %x\it\**. 

ANATOMY   OF   CLUB-FOOT. 
By  FRANK  HARTLEY,  M.D., 

NIW   YORK. 

In  the  Annals  of  Surgery  of  March,  1894,  will  be  found  an 
article  written  by  the  author  of  this  paper,  entitled  "  The 
Operative  Treatment  of  Club  foot/'  in  which  the  records 
of  twenty  six  cases  operated  upon  from  1886  to  1893  were 
detailed.  It  was  recommended  in  that  article  that  in  the 
minor  cases,  before  the  thirtieth  month  of  life,  mechanical 
fixation  with  or  without  tenotomies  and  fasciotomies  were 
sufficient.  After  that  age  in  the  child,  tenotomies  and 
fasciotomies  were  to  be  combined  with  a  talus  extirpa- 
tion in  all  cases  where  the  equinus  was  the  prominent  de- 
formity and  the  varus  slight,  provided  the  tenotomies 
and  fasciotomies  had  not  completely  reduced  the  de- 
formity. 

In  those  cases  where,  in  addition  to  the  equinus,  the 
varus  was  marked,  a  limited  cuneiform  osteotomy  in- 
volving only  the  processus  anterior  calcanei  and  the  ar 
ticular  surface  of  the  cuboid,  was  to  be  added,  if  neces- 
sary. 

In  the  adult,  after  the  usual  tenotomies  and  fascioto- 
mies, a  cuneiform  osteotomy  involving  parts  of  the  os 
calcis,  cuboid,  neck  of  talus  and  scaphoid,  was  recom- 
mended if  the  equinus  was  relieved  after  tenotomy.  If 
the  equinus  was  not  thus  relieved,  either  a  partial  or  total 
talus  extirpation  was  to  be  combined  with  a  cuneiform  os- 
teotomy at  Chopart's  joint.  It  was  also  stated  that  the 
severest  forms  of  club  foot  (inveterate  cases)  were  only 
cured  by  both  of  these  procedures.  To-night  I  wish  to 
give  the  results  of  a  dissection  of  two. feet  which  repre- 
sent perfectly  the  highest  degree  of  this  deformity,  and, 
in  my  opinion,  substantiate  the  view  taken  in  so  far  as 
the  inveterate  cases  are  concerned. 

This  specimen  represents  a  club  foot  of  congenital 
origin  and  of  twenty-two  years'  standing,  in  which  the 
rotation  inward  of  the  leg  is  marked,  and  the  position  of 
extreme  supinative  plantar  flexion  and  adduction  is  pres- 
ent in  the  foot. 

The  movements  of  the  joint  surfaces  were  all  limited. 
In  the  talo-crural  joint,  the  movement  was  confined  to  a 
simple  gliding  in  which  the  anteroposterior  was  less 
marked  than  the  lateral  motion.  In  the  talo-calcanean 
joint  scarcely  any  movement  was  appreciated.  In  Cho- 
part's joint  a  movement  corresponding  to  flexion  and 
extension  was  more  marked  than  in  the  other  joints.  In 
none  of  the  joints  was  there  more  than  a  gliding  move- 
ment in  one  or  more  planes.  These  movements  produced 
only  a  limited  change  in  the  relations  of  the  different 
bones  of  the  foot  to  one  another  or  to  the  leg.  The 
borsse  found  consisted  :  1,  Of  a  large  multilocular  cavity 
covering  bearing  points  of  pressure  which  are  sure  to  be 
the  anterior  process  of  the  calcaneus  and  the  dorso  lateral 
surface  of  the  cuboideus;  2,  of  a  smaller  multilocular 
bursa  covering  the  neck  of  the  talus  and  the  lower  por- 
tion of  the  external  malleolus.  The  ligaments  were  not 
peculiar  nor  of  interest.  On  the  external  border  of  the 
foot  a  large  amount  of  fibrous  tissue  was  present,  and 
many  new  bands  of  this  tissue  seemed  to  be  added  to 
the  normal  ligaments.  Upon  the  inner  border  and  sole 
of  the  foot  the  fibrous  tissue  was  not  so  extensively  de- 


veloped, although  the  plantar  ligaments  were  well  marked, 
thick,  and  out  of  all  proportion  relatively  to  the  mus- 
cular tissue.  The  anterior  annular  ligament  was  well 
developed,  thick,  and  strong.  The  external  annular  lig- 
ament consisted  of  a  firm  broad  band  covering  the  pe- 
roneal tendons  as  they  passed  to  the  posterior  surface  of 
the  calcaneus.  The  internal  annular  ligament  was  well 
marked  but  very  short,  on  account  of  the  position  of  the 
foot.  The  muscles,  which  in  the  leg  and  foot  show  a 
marked  atrophy  with  fatty  and  connective-tissue  trans- 
formation, had  the  following  relations,  which  were  pe- 
culiar: 

1.  The  tibialis  anticus  passed  over  the  lower  third  of 
the  tibia,  from  without  inward,  to  the  inner  surface  of  the 
internal  malleolus,  whence  it  descended  to  its  insertion. 

2.  The  extensor  proprius  ^ollicis  passed  through  a 
separate  compartment  of  the  annular  ligament  over  the 


Fig-  1. — Antbkior  Vibw  :  x,  Anterior  annular  ligament ;  a,  tibia  is  anticus  ; 
3,  extensor  hattucis;  4,  extensor  longus  digitorum ;  5,  peroneus  tertius, 

inner  surface  of  the  internal  malleolus,  close  to  and  in 
front  of  the  tibialis  anticus.  It  divided  into  two  ten- 
dons which  were  inserted  into  the  second  phalanx. 

3.  The  extensor  longus  digitorum  passed  over  the 
outer  third  of  the  anterior  surface  of  the  tibia,  in  a  groove 
bounded  by  two  well-marked  prominences.  It  was  cov- 
ered by  the  annular  ligament.  It  divided  into  four  ten- 
dons, which  passed  obliquely  inward  over  the  heads  of 
the  first  and  second  metatarsal  bones  to  the  four  toes. 

4.  The  peroneus  tertius  passed  obliquely  outward  to 
the  base  of  the  fifth  metatarsal  bone  over  the  cuneiform 
bones. 

5.  The  extensor  brevis  digitorum  ^is  scarcely  observ- 
able except  for  its  tendons. 

6.  The  peroneus  longus  and  brevis  passed  beneath  a 
strong  and  narrow  band  of  fascia,  extending  from  the 
external  malleus  to  the  calcaneus,  and  representing  the 
external  annular  ligament,  around  the  external  and  pos- 
terior surface  of  the  calcaneus  (infeiior  surface)  to  their 


194 


MEDICAL    RECORD. 


[August  1 8,  1894 


insertions.  The  former  did  not  touch  the  cuboid  bone. 
It  passed  above  the  level  of  the  anterior  process  of  the 
calcaneus  obliquely,  directed  from  without  downward 
and  inward.  The  latter,  after  passing  over  the  anterior 
process  of  the  calcaneus,  descended  upon  the  lateral 
border  of  the  cuboid  bone  to  its  insertion. 

7.  The  tibialis  posticus  passed  to  the  inner  side  of  the 
internal  malleolus,  its  posterior  border,  beneath  it,  and  to 
its  insertions. 

.  8.  The  flexor  longus  digitorum  passed  to  the  outer 
side  of  the  tibialis  posticus,  beneath  the  internal  malleo- 
.  lus,  to  its  insertion. 

9.  The  flexor  longus  pollicis  passed  through  a  well- 
marked  groove  in  the  tibia,  external  to  the  flexor  longus 
digitorum,  beneath  the  internal  malleolus,  and  was  lost 
in  the  muscles  of  the  foot. 

The  relations  of  the  bones  of  the  foot  to  one  another 


Fig.  a. — Latbkal  Vikw  : 
1,    External    lateral    liga- 
ment ;  a,  peroneus  longus ; 
3,  peroneus  brevis  ;  4,  ten- 
-  do  Achillis. 


Fig.  3. — Posterior  Vikw:  x,  Tendo  AchillU; 
a,  peroneus  longus  ;  3,  peroneus  brevis. ;  4,  tibialis 
posticus  and  flexor  longus  digitorum  ;  5,  flexor 
longus  hallucis  ;  6,  abductor  minimi  digiti. 


and  to  those  of  the  leg,  were  in  general  as  follows :  Most 
striking  in  this  respect  was  the  angle  formed  by  the 
bones  of  the  leg  and  the  calcaneus.  The  position  of  the 
calcaneus  was  one  of  marked  plantar  flexion.  Its  long 
axis  formed,  with  the  articular  surface  of  the  tibia,  an 
angle  of  8o°.  If  we  consider  the  mid-position  of  the 
foot  (talus  or  calcaneus)  to  the  leg  to  be  one  of  a  right 
angle  (900),  and  allow  390  for  the  extreme  of  normal 
dorsal  or  plantar  flexion,  we  have  here  41  °  of  a  forced 
plantar  flexion  of  the  foot.  Less  striking,  but  no  less 
important,  is  the  supination  of  the  calcaneus,  which, 
when  measured,  shows  an  increase  of  500  over  the  nor- 
mal position  of  adult  bone.  There  is  a  slight  adduction 
of  the  calcaneus  present,  which  amounted  to  about  io°. 

On  account  of  the  forced  plantar  flexion,  the  supination 
and  adduction,  the  superior  articular  surfkces  are  altered 


in  their  relative  position  to  the  talus,  and  to  the  tibia  and 
fibula.  Besides  the  articular  surface  for  the  talus,  we  have 
upon  this  surface,  just  in  front  of  the  tuberosity,  nearthro- 
ses for  both  the  tibia  and  fibula.  That  for  the  former  is 
continuous  with  the  external  third  of  the  articular  surface 


j&& 


FlG.  4.— Anterior  Virw  :  i.  Tibia ;  a,  internal  malleolus  with  nearthrosis  be- 
tween it  and  scaphoid  and  internal  cuneiform  ;  3,  external  malleolus  articulation 
with  talu» ;  4,  talus— body  ;  5,  neck  of  talus— inward  angle,  downward  angle, 
oo*  ;  6,  navicular  bone ;  7,  talo-navicular  articulation,  situated  entirely  upon  the 
inner  side  of  neck  ;  8,  nearthrosis  between  internal  malleolus  and  navicular  hone  ; 
9(  internal  cuneiform  ;  10,  middle  cuneiform  ;  it,  external  cuneiform  ;  12,  nearthro- 
sis betwoen  internal  cuneiform  and  internal  malleolus. 

for  the  talus,  and  is  situated  upon  the  superior  surface 
(really  internal).  That  for  the  latter  is  situated  upon  the 
external  surface  (really  superior). 

The  processus  anterior  of  the  calcaneus  is  large  and 
prominent.    It  sustains  the  greater  portion  of  the  weight 


Pig.  5.— Posterior  View  :  1,  Calcaneus  ;  a,  nearthrosis  between  external 
malleolus  and  calcaneus  just  in  front  of  the  tuberosity  and  internal  to  nearthrosis 
between  calcaneus  and  external  malleolus,  concealed  from  view  here,  is  the  near- 
throsis between  the  tibia  and  calcaneus  ;  3.  talus,  all  that  can  be  seen  from  this 
view  ;  4,  internal  malleolus,  articulating  with  the  talus  but  with  the  navicular  and 
internal  cuneiform  by  nearthrosis ;  5,  sustentaculum  tali,  maintaining  articula- 
tions by  nearthrosis  with  the  navicular  bone  :  6,  internal  surface  of  calcaneus  ;  7, 
8,  mark  the  relations  of  peroneus  longus  and  brevis ;  9,  articulations  of  cuboid 
with  inner  surface  of  sustentaculum  tali ;  10,  zi,  ia,  cuneiform  bones ;  13,  navic- 
ular bone. 

of  the  body.     Situated  upon  the  internal  surface  of  the 
neck  of  the  calcaneus  is  the  articulation  for  the  cuboid. 

The  talus  is  situated  in  the  angle  formed  by  the  bones 
of  the  leg  and  the  calcaneus.  Its  superior  surface  articu- 
lates with  the  tibia,  and  is  external  so  far  posterior  as  to 


August  1 8,  1894] 


MEDICAL    RECORD. 


*95 


be  continuous  with  the  inferior  articular  surface  in  its 
outer  half,  and  only  separated  from  the  internal  half  of 
the  same  surface  by  a  5  mm.  strip  of  non-articular  bone. 

The  shape  of  the  body  is  triangular  with  the  apex  pos- 
terior, and  with  the  superior  and  inferior  surfaces  looking 
respectively  upward  and  downward  and  backward. 

The  neck  of  the  talus  forms  with  the  body  an  angle  of 
450  for  the  inward  displacement,  and  of  900  for  the  down- 
ward displacement. 

The  outer  angle  of  the  neck  is  less  prominent  than  the 
internal.  Upon  the  internal  surface  of  the  neck  is  an 
oval  facet  for  articulation  with  the  navicular  bone,  the 
long  axis  of  which  is  placed  at  an  angle  of  450  to  the 
long  axis  of  the  neck. 

ITie  navicular  bone  articulates  with  the  neck  of  the 
talus  only  in  the  external  portion  of  its  posterior  surface, 
while  the  internal  portion  of  the  same  surface  is  non- 
articular  and  is  bent  sharply  upon  the  outer  segment. 

The  long  axis  of  the  navicular  bone  (i.e.,  transverse) 
is  nearly  parallel  with  that  of  the  neck  of  the  talus. 


a  neck.  The  body  is  triangular  in  shape,  with  its  apex 
posteriorly.  The  superior  articular  surface  looks  directly 
upward,  and  is  continuous  along  the  outer  half  with  the 
inferior  articular  surface  at  the  posterior  border,  while 
along  the  inner  half  this  surface  is  separated  from  the 
inferior  by  a  5  mm.  strip  of  non-articular  bone.  The 
inferior  articular  surface  is  directed  downward  and 
backward.  The  outer  half  is  convex,  and  is  directed 
outward.  The  inner  half  is  concave,  and  is  directed 
•slightly  inward.  The  facet  for  the  internal  malleolus 
situated  nearer  the  anterior  than  the  posterior  surface  of 
the  body  is  broad,  flat,  and  continuous  with  the  superior 
articular  surface.  The  facet  for  the  external  malleolus, 
situated  near  the  posterior  surface  of  the  body,  is  narrow 
and  is  separated  from  the  superior  articular  surface  by  a 
strip  of  non- articular  bone.  Just  in  front  of  the  inferior 
articular  surface  is  a  very  small  articular  facet  for  the  an- 
terior and  superior  surface  of  the  sustentaculum  tali. 
Upon  the  inner  side  of  the  neck  of  the  talus  is  situated 
the  articular  facet  for  the  navicular  bone.     The  facet  is 


Fig.  6. — F.  Caixankus.—  i.  External  surface;  a,  nearthrosis  for  external  malleolus,  just  internal  to  it  is  the  nearthrosis  for  tibia  (concealed  here) ;  3,  articular  sur- 
face (external)  for  talus,  the  posterior  portion  of  this  surface  articulates  with  the  tibia;  4,  processus  anterior  calcaneij;  5,  tuberosity.  G.  1,  Internal  surface;  a, 
intern?)  portion  of  articulation  for  the  talus,  the  superior  border  of  which  is  continuous  with  the  surface  seen  F  3  ;  3,  sustentaculum  tali ;  4,  articulation  for  cuboid  ; 
5,  marked  ridge  of  bone  continuous  with  the  sustentaculum  overhanging  and  articulating  with  the  cuboid  at  posterior  internal  angle ;  6,  non  articular,  superior  surface 
of  neck,  covered  by  neck  of  talus. 

H.  Talus  and  Olc\neus — Internal  Surfaces. — 1,  tfody  of  talus  triangular  in  shape  ;  2,  neck  of  talus;  3,  point  at  which  superior  and  inferior  surfaces 
are  continuous  ;  4,  articulation  for  navicular  bone  ;  5,  sustentaculum  tali ;  7.  nearthrosis  with  neck  of  talus  ;  8,  9,  articulations  for  cuboid. 

I.  Talus — Aiiewior  and  Supe-ior  View. — 1,  Super-articular  surface  for  tibia  ;  2,  articular  surface  for  fibula  ;  3,  non-articular  surface  for  fibrous  bands 
between  two  articular  surfaces  of  the  fibula  uniting  the  fibula  and  talus  :  4,  body  of  talus ;  5,  neck  of  talus  ninety  degrees  downward,  forty-five  degrees  inward. 

I.  Inferior  and  Iters- nal  View.— i,  Inferior  articular  surface  for  calcaneus;  a,  articular  surface  for  fibula;  3,  nun-articular  surface  for  fibrous  bands  to 
fibula ;  4,  tibia  articular  surface. 

K.  Navicular  B  n- — Posterior  View  :  1,  Oval  articular  surface  for  articulation  with  inner  surface  of  the  ueck  of  the  talus;  a,  internal  border;  3,  external 
border ;  4,  second  tuberosity,  place  where  it  ought  to  be. 

L.    Superior  View. — 1,  External  border ;  2,  internal  border ;  3,  posterior  border ;  4,  superior  surface. 

If.  Anterior  and  Inferior  View. — 1,  Anterior  surface  of  cuneiform  bone ;  2,  inferior  surface  very  narrow  as  coppared  with  the  superior  surface  in  L.  4 ;  3, 
internal  border ;  4,  external  border. 


This  bone  presents  two  nearthroses.  One  for  the  an- 
terior surface  of  the  sustentaculum  tali ;  the  other  for  the 
internal  malleolus  at  its  anterior  and  inferior  angle. 

The  superior  surface  (anterior)  is  broad.  The  inferior 
is  narrow.  The  external  is  narrower  than  the  internal. 
There  is  no  tuberosity  present,  nor  does  this  bone  articu- 
late with  the  cuboid.  The  transverse  axis  forms  with 
the  transverse  axis  of  the  cuboid  an  angle  of  ninety  de- 
grees. 

The  cuboid  bone  articulates  with  the  anterior  process 
(i.e.,  neck)  of  the  calcaneus  upon  its  internal  surface,  in 
such  a  manner  that  the  weight  of  the  body  is  in  part 
sustained  by  the  dorso  lateral  surface.  There  is  no  sul- 
cus for  the  peroneus  longus  tendon,  nor  is  the  tuberosity 
present.  The  three  cuneiform  bones  articulate  with  the 
navicular  and  cuboid  in  the  angle  formed  by  them. 
Their  position  is  one  of  marked  supination,  adduction, 
and  approximation  of  the  inner  and  outer  bones  toward 
the  plantar  surface.  This  approximation  diminishes 
gradually  as  one  passes  beyond  to  the  metatarsal  and 
phalangeal  bones.  Considering  these  bones  more  care- 
fully, we  find  that  the  talus  is  made  up  of  a  body  and 


oval  in  shape,  and  its  long  axis  forms  with  the'  long  axis 
of  the  neck  an  angle  of  forty-five  degrees.  The  outer 
and  anterior  angle  of  the  neck  is  much  less  prominent 
than  the  internal  and  anterior  angle.  It  seems  to  be 
cut  away.  It  is  more  rounded.  The  neck  itself  is  some- 
what flattened  from  above  downward,  and  is  rounded 
from  side  to  side.  The  long  a*is  of  the  neck  forms  with 
the  antero-posterior  axis  of  the  body  an  angle  of  ninety 
degrees  and  with  the  transverse  axis  an  angle  of  forty*  five 
degrees. 

Calcaneus :  The  position  of  this  bone  is  first  one  of 
nearly  full  extension  (plantar  flexion).  It  forms  with 
the  tibia  an  angle  of  eighty  degrees.  It  is  also  supinated 
sixty  degrees,  so  that  the  nearthrosis  for  the  fibula  k 
situated  upon  the  superior  and  external  border,  and  that 
for  the  talus  upon  the  inner  surface  adjoining  the  near- 
throsis for  the  fibula.  The  bone  is  also  adducted  ten  de- 
grees. 

Upon  the  superior  surface  we  have  four  articular  sur- 
faces for  the  talus,  tibia,  and  fibula.  In  the  position  in 
which  the  bone  articulates  these  surfaces  look  upward  in 
general.     The  articulation  for  the  fibula  looks  upward, 


196 


MEDICAL    RECORD. 


[August  1 8,  1894 


outward,  and  slightly  forward.  Just  in  front  of  the  tu- 
berosity is  also  a  plane  articular  surface  looking  upward 
and  inward,  for  articulation  with  the  outer  third  of  the 
posterior  border  of  the  tibia.  This  surface  is  continuous 
with  the  outer  portion  of  the  articular  surface  for  the 
talus.  These  two  surfaces  are  nearthroses.  Anterior 
and  internal  to  them  is  the  articulation  for  the  talus, 
which  is  inclined  outward  for  the  outer  half,  inward  for 
the  inner  half.  It  is  concavo-convex,  with  its  long  axis 
from  without  downward,  forward,  and  inward.  It  ex- 
tends so  far  forward  as  to  be  closely  applied  to  the  ar- 
ticulation for  the  cuboid.  The  sustentaculum  tali  is 
rudimentary,  placed  at  a  very  low  level  upon  the  inner 
side  of  the  bone,  and  articulates  with  the  talus  and  na- 
vicular bone.  The  processus  anterior  is  enlarged  both 
in  heighth  and  breadth.  The  body  and  neck,  including 
the  processus  anterior,  present  a  marked  concavity  upon 
the  internal  surface,  which  is  increased  in  appearance  by 
the  enlarged  tuber  calcanei  and  anterior  process. 

The  articular  surface  for  the  cuboid  is  entirely  upon 
the  inner  side  of  the  processus  anterior,  with  its  long  axis 
at  right  angles  to  that  of  the  calcaneus.  This  surface  is 
oval  in  shape  and  is  composed  of  two  portions:  The 
lower  for  articulation  with  post  and  external  angle  of  the 
cuboid  ;    the  upper,  which  is  situated  just  beneath  and 


Fig.  7.— N.  Cuboid. — 1,  Inferior  surface;  .*,  interior  border;  3,  exterior  border ;  4,  anterior  sur- 
face ;  5,  articulation  with  calcaneus. 

O.  Antkkior  and  Internal  Surfac*.—  i,  Anterior  surface  ;  2,  internal  surface  with  articulum  for 
cuneiform.  P. — 1,  Posterior  surface  composed  of  two  surfaces,  the  one  external  or  inferior  marked  for 
the  calcaneus,  the  other,  marked  a,  at  the  posterior  internal  angle  for  calcaneus  insertion  of  susten- 
taculum tali. 

<J.  Tibia  akd  Fibula.  Posterior  Vibw.— 1,  Groove  marked  for  tibialis  posterior  and  flexor  longus 
digitorum  ;  a,  groove  for  flexor  longus  pollicis ;  3.  articular  surface  for  calcaneus  ;  non-articular  sur- 
face for  fibrous  bands  attaching  the  fibula  to  calcaneus  and  talus  :  6,  posterior  border  of  inferior  tibial 
articular  surface  with  articular  surface  for  calcaneus  ;  7,  articular  nearthroses  between. 

R.  Fibular  C alc an ku ^Anterior  of  Samb.— i,  Internal  malleolus  ;  a,  facet  for  articulation 
with  navicular  bone ;  3,  outer  border  of  facet  for  articulation  with  cuneiform  bone. 

anterior  to  the  sustentaculum  tali,  for  articulation  with 
the  posterior  and  internal  angle  of  the  cuboid. 

The  internal  border  is  narrower  from  above  down- 
ward and  longer  from  before  backward  than  is  usually 
the  case.     The  tuberosity  is  wanting. 

The  anterior  and  posterior  articular  surfaces  approach 
one  another  inferiorly.  The  posterior  surface  is  concave 
and  encroaches  upon  the  external  aspect  of  the  bone, 
leaving  a  surface  upon  the  inner  posterior  (posterior  sur- 
face) free  from  cartilage.  The  cuneiform  articular  sur- 
faces (anterior  surface),  besides  being  inclined  inferiorly, 
are  slightly  displaced  toward  the  external  border.  The 
bone  is  therefore  more  triangular  in  shape  in  two  direc- 
tions, i.e. ,  toward  the  planta  pedis  and  the  external  border. 
There  is  no  articulation  with  the  cuboid  bone.  The  long 
axis*of  the  navicular  bone  is  parallel  to  the  long  axis  of 
the  neck  of  talus.  The  nearthroses  present  exist  between 
the  internal  border  and  the  malleolus,  between  the  sus- 
tentaculum tali  and  the  inferior  surface  near  the  posteri- 
or border,  and  with  the  talus  at  the  junction  of  its  body 
and  neck. 

The  cuboid  bone  is  more  quadrilateral  than  is  normally 
the  case.  In  new  bone  and  in  the  adult  cuboid,  between 
the  outer  and  inner  border  is  respectively  fifty  per  cent, 
and  fifty  seven  per  cent.    In  our  club  foot,  however,  this 


relation  is  raised  to  sixty  six  per  cent. ,  which  is  in  part  due 
to  the  lessened  oblique  position  of  anterior  articular  sur- 
face. This  articular  surface  forms  with  the  external  bor- 
der in  the  new  born  cuboid  an  angle  of  720,  in  the  adult 
790.  In  our  specimen  it  is  820.  The  tuberosity  of  the 
cuboid  is  wantiog,  so  that  the  height  of  the  bone,  espe- 
cially at  its  posterior  border,  seems  deficient.  There  is 
no  articular  surface  for  the  navicular  bone. 

The  posterior  articular  surface  occupies  more  of  the 
external  surface  than  usual.  This  concavo  convex  looks 
backward  and  slightly  outward,  and  is  continuous  with 
a  nearthrosis  upon  the  posterior  and  internal  angle  for 
articulation  with  the  calcaneus  just  beneath  and  anterior 
to  the  sustentaculum  tali. 

The  articular  surface  for  the  external  cuneiform  bone 
is  well  marked,  occupying  nearly  one  fourth  of  the  inner 
side.  It  is  raised  above  the  surrounding  surface  with  its 
articular  face  directed  downward  and  backward,  but  in 
the  articulated  bone  backward  and  upward. 

The  cuneiform  bones  are  arranged  rather  behind  than 
alongside  one  another.  Their  posterior  surfaces  are  ob- 
liquely inclined,  so  that  they  look  backward  and  upward, 
i.e. j  the  lower  border  projects  further  backward  than  the 
upper  border.  Otherwise  these  bones  present  few 
changes  of  importance. 

In  the  metatarsal  bones  the  rotation  of 
the  diaphysis  inward  900,  and  greater  de- 
velopment of  the  posterior  surface  upon  the 
internal  than  posterior  surface,  are  the  only 
noticeable  features. 

The  tibia  and  the  fibula  are  rotated  in- 
ward about  their  long  axis.  The  malleolus 
externus  is  anterior  to  the  malleolus  inter- 
nus.  The  transverse  axis  of  the  talo  crural 
joint  is  from  in  front  and  externally  to  be- 
hind and  internally;  with  the  transverse 
axis  of  the  body  these  axes  form  an  angle 
of3o°. 

Upon  the  fibular  end,  two  articular  sur- 
faces are  found,  one  for  the  talus  and  one 
for  the  calcaneus  (a  nearthrosis).  These 
are  separated  by  a  non  articular  surface. 
Upon  the  tibial  end  three  articular  surfaces 
are  found,  one  for  the  talus,  one  for  the 
scaphoid,  and  one  for  the  internal  cunei 
form.     The  two  latter  are  nearthroses. 

In  the  clubfoot  of  the  new-born,  the 
neck  of  the  talus  is  not  only  increased  in 
length,  but  its  downward  and  inward  in- 
clination is  respectively  45  °  and  65  ° — 
against  150  and  45 °  in  the  normal  new- 
born talus.  This  inclination  of  the  neck 
accounts  for  the  plantar  flexion,  according  to  Hueter. 

Kocher,  however,  does  not  entirely  agree  with  him  in 
this  view,  since  the  talo-crural  joint  is  in  plantar  flexion, 
as  shown  by  the  displacement  of  the  superior  articular 
surface  backward  and  the  meniscus  found  at  the  poste- 
rior border  of  this  joint.1 

The  angle  between  the  axis  of  the  leg  and  the  talus  in 
calcaneus  was  one  hundred  and  fifty  degrees,  as  found  by 
Kocher  in  the  club-foot  of  a  year  old  child.  Plantar  flex- 
ion is  possible  to  one  hundred  and  thirty  degrees.  This 
leaves  twenty  degrees  of  forced  flexion  in  this  case.  In 
our  specimen  there  is  an  angle  of  one  hundred  and 
seventy  degrees  present,  so  that  we  have  forty-one  degrees 
for  a  forced  plantar  flexion. 

The  articular  surface  for  the  navicular  bone  is  entirely 
upon  the  inner  side  of  the  neck,  oval  in  shape,  with  its 
long  axis  midway  between  the  horizontal  and  vertical 
planes.  In  severe  cases,  the  shape  of  this  articular  sur- 
face is  rounded  and  its  long  axis  is  vertical.  In  our  case 
this  articulation  has  its  long  axis  midway  between  a  ver- 
tical and  horizontal  plane. 

In  the  two  cases  examined  by  Kocher  a  great  differ- 
ence existed  in  the  form  of  the  neck.  In  the  one-year- 
old  club- foot  the  neck  was  abnormally  long.     In  the 

1  Dissection  by  Kocher. 


August  1 8,  1894] 


MEDICAL  RECORD. 


197 


new-born  club-foot  the  neck  was  only  lengthened  upon 
the  outer  side,  in  so  far  as  the  anterior  end  of  the  navicu- 
lar articulation  begins  on  the  mesial  side,  while  it  is 
shortened  upon  the  mesial  side  by  the  displacement  of 
the  articular  surface.  This  difference  in  the  length  of 
the  neck  and  the  position  of  the  talo-navicular  facet  is 
explained  by  Kocher  as  follows  :  "  If  in  utero  the  press* 
ure  continues  till  birth,  the  growth  of  the  neck  is  hin- 
dered and  the  anomaly  consists  in  the  displacement  of 
the  articular  surface.'1  After  birth  an  unhindered 
growth  takes  place,  because  the  opposing  pressure  of  the 
navicular  bone  is  reduced  on  account  of  the  imperfect 
play  of  the  muscles  and  their  unfavorable  position.  If, 
however,  the  pressure  is  relieved  in  utero,  the  length 
of  the  neck  is  evident  at  birth.19 

The  superior  articular  surface  of  the  talus  is  displaced 
posteriorly,  so  that  the  cartilage  approaches  nearly  to  the 
posterior  inferior  border.  It  appears  longer  and  nar- 
rower than  is  normally  the  case.  In  our  specimen,  this 
articular  surface  is  continuous  with  the  inferior  articular 
surface  in  the  outer  half.  The  lateral  articular  surfaces 
are  very  unequally  developed.  The  external  is  filled 
with  fibrous  tissue  in  the  posterior  portion,  while  its  an- 
terior part  is  pushed  nearer  the  neck.  The  internal  is 
very  small.     In  this  particular  our  specimen  is  similar. 

In  the  calcaneus  die  changes  are  simply  an  excessive 
representation  of  the  foetal  over  the  adult  bone.  The 
articular  surface  for  the  talus  inclines  onward  and  back- 
ward, and  its  highest  point  does  not  reach  the  highest 
point  of  the  bone.  Anteriorly,  it  extends  close  to  the 
cuboid  articular  surface ;  such  a  position  of  the  articular 
surface  forms  supination.  The  body  of  the  calcaneus 
and  the  neck  are  of  equal  length.  The  processus  ante- 
rior is  greatly  developed  in  height  and  is  out  of  all  com- 
parison with  that  of  the  new-born.  The  long  axis  is  so 
bent  upon  itself  that  a  concavity  exists  upon  the  inner 
side,  and  the  tuber  calcanei  and  processus  anterior  appear 
strongly  bent  to  the  same  side.  The  articulation  for  the 
cuboid  is  entirely  upon  the  mesial  side  of  the  neck. 
This  bend  in  the  axis  of  the  bone  and  the  position  of 
the  cuboid  articular  facet  produce  great  displacement  of 
the  fore-foot  at  Chopart's  joint. 

The  sustentaculum  tali  is  placed  at  a  much  deeper 
level,  and  is  very  imperfectly  developed.  In  extreme 
cases  it  is  wanting,  since  the  supination  of  the  foot  pre- 
vents its  growth  from  pressure  upon  the  malleolus  in- 
ternus.  The  similarity  between  our  specimen  and  the 
new-born  club-foot  is  striking,  except  for  the  degree  and 
die  nearthrosis.  In  the  navicular  bone,  the  lateral 
border  is  narrower  than  normal,  while  the  inner  border 
is  thicker.  This  change  is  ascribed  to  the  freedom  from 
pressure  for  the  inner  border,  and  to  the  plantar  flexion 
and  supination  for  the  external  border. 

The  anterior  and  posterior  articular  surfaces  nearly 
touch  upon  the  inferior  surface.  The  cuneiform  articular 
surfaces  are  displaced  toward  the  mesial  border,  while 
the  talus  articular  surface  reaches  less  closely  to  the  in- 
ner border  than  is  normally  the  case.  These  changes 
are  evidences  of  pressure  in  the  sense  of  adduction.  The 
navicular  bone  is  consequently  triangular  in  shape,  being 
narrower  externally  and  toward  the  planta  pedis. 

The  tuberosity  is  wanting  or  rudimentary.  The 
changes  in  the  cuboid  are  not  so  constant  nor  marked 
as  in  the  calcaneus.  As  before  stated,  the  relation  of 
the  inner  to  the  outer  border  in  percentages  is  fifty 
degrees  for  the  new-born  and  fifty  seven  for  the  adult 
(Arby)  cuboid.  In  club-foot,  however,  the  anterior 
and  posterior  articular  surfaces  converge  less  externally, 
and  the  bone  is  more  quadrilateral.  It  is  principally, 
however,  the  anterior  surface  which  inclines  less  oblique- 
ly outward  and  backward.  The  tuberosities  cuboidii 
which  bound  the  posterior  border  of  the  sulcus  for 
the  peroneus  longus  are  not  developed,  so  that  the  ver- 
tical diameter  is  much  diminished.  The  thickening  of 
the  bone  behind  the  sulcus  is  scarcely  noticeable.  The 
tuberosity  is  not  developed,  as  its  relations  to  the  tendon 
have  been  lost  by  the  displacement  of  the  tendon  upon 


the  calcaneus.  The  similarity  between  these  two  bones 
(i.e.,  navicular  and  cuboid),  in  the  new-born  and  in  our 
specimen,  are  marked.  The  cuneiform  bones  are  ar- 
ranged behind  rather  than  alongside  one  another.  Their 
posterior  surfaces  incline  obliquely  backward.  The 
tibia  and  fibula  are  less  altered.  They  are  rotated  in- 
ward (most  marked)  in  their  lower  third.  The  malleo- 
lus externus  instead  of  being  posterior  is  anterior,  and 
the  transverse  axis  of  the  joint  runs  from  behind  and  in- 
ternally outward  and  externally. 

It  is  also  interesting  to  note  the  new  articular  facets 
found  in  club  foot.  In  the  club-foot  of  the  new-born 
child  new  articular  facets  (nearthroses)  are  developed. 
1.  On  the  mesial  side  of  the  malleolus  internal  is  found 
an  articular  facet  which  articulates  with  a  similar  facet 
upon  the  mesial  and  superior  surface  of  the  navicular 
bone.  This  articulation  is  entirely  separate  from  the 
talo-navicular  joint,  and  against  its  capsule  rests  the 
tibialis  posticus  tendon  as  it  ascends  beneath  the  navicu- 
laris.  2.  Between  the  internal  malleolus  (its  inferior 
surface)  and  neck  of  the  talus.  3.  Between  the  malleo- 
lus externus  and  the  calcaneus. 

In  our  specimen  the  nearthroses  are  more  numerous, 
and  are  as  follows :  1.  Between  the  posterior  border  of 
the  tibia  and  the  calcaneus.  2.  Between  the  internal 
malleolus  and  the  navicular.  3.  Between  the  internal 
malleolus  and  the  cuneiform  (internal).  4.  Between  the 
external  malleolus  and  the  calcaneus.  5.  Between  the 
sustentaculum  tali  and  the  inferior  surface  of  the  na- 
vicular bone.  6.  Between  the  navicular  bone  and  the 
talus  at  the  junction  of  the  body  and  the  neck.  7.  Be- 
tween the  posterointernal  border  of  the  cuboid  and  the 
calcaneus  beneath  and  anterior  to  the  sustentaculum  tali. 

The  tendons  in  club- foot  of  the  new  born  vary  as  fol- 
lows: 

The  flexor  longus  hallucis  runs  in  a  groove  on  the 
talus  and  tibia  into  the  soft  parts  beneath  the  plantar 
fascia,  without  touching  the  calcaneus. 

The  peroneus  longus  runs  from  the  malleolus  externus 
over  and  beneath  the  calcaneus.  It  does  not  touch  the 
cuboid  bone.  The  tibialis  posticus  runs  from  the  pos- 
terior surface  of  the  tibia  over  the  border  of  the  malleo- 
lus internus.  These  changes  in  the  position  of  the  ten- 
dons existed  also  in  our  case,  though  their  displacement 
was  more  marked  than  has  been  described  in  the  club- 
foot of  the  new-born  or  child. 

These  changes  in  the  shape  of  the  bones,  the  displace- 
ment of  the  tendons,  the  approximation  of  the  points  of 
origin  and  insertion  of  the  muscles,  and  the  new  articular 
facets,  are  sufficient  evidences  of  a  force  exerted  upon  the 
foot  in  the  sense  of  plantar  flexion  at  the  ankle-joint,  and 
supination  and  adduction  in  the  talo-  tarsal  joint  This 
pressure,  which  is  produced  in  utero,  can  be  seen  in  the 
great  majority  of  new  born  children,  but  in  so  mild  a 
degree  that  walking  alone  is  sufficient  to  produce  enough 
formative  and  dorsal  flexion  to  correct  it. 

Chondrification  is  complete  by  the  seventh  "or  eighth 
week  of  foetal  life.  The  articulations  begin  to  be  formed 
at  this  time,  and  are  completed  at  the  fourth  month. 
Short  and  slight  pressures  within  the  joint,  owing  to  the 
softness  of  the  cartilaginous  skeleton,  and  the  rapidity  of 
growth  in  the  foot,  cause  from  this  time  on  deformities  in 
the  bones,  and  secondarily  in  the  position  of  the  ten- 
dons. 

Since  the  abnormal  positions  take  place  before  the 
use  of,  and  at  the  time  of,  the  formation  of  the  muscles, 
rectification  does  not  take  place  afterward,  because  the 
bones  have  become  altered  in  shape  and  the  muscular 
attachments  are  approximated. 

The  earlier  in  foetal  life  such  malpositions  are  initi- 
ated, the  more  pronounced  will  be  the  subsequent  de- 
formity. 

After  birth  the  muscles  tend  to  maintain  or  increase 
an  existing  deformity.  In  the  adult  congenital  club- 
foot, however,  there  is  added  another  factor  in  the  pro- 
duction and  intensification  of  the  deformity,  namely,  in 
the  weight  of  the  body  in  walking.     These  changes,  so 


198 


MEDICAL   RECORD. 


[August  1 8,  1894 


far  as  this  dissection  has  shown!  consist :  1,  In  an  exces- 
sive increase  of  the  deformities  found  in  the  bones  of 
the  new-born.  2,  In  additional  nearthroses.  3.  In  an 
increased  plantar  flexion  at  the  talocrural  joint.  4. 
In  a  marked  supination  and  adduction  in  the  calcaneus. 
5.  In  an  extensive  displacement  of  the  navicular  and 
cuboid  bone  to  the  mesial  side  of  the  talus  and  cal- 
caneus. 6.  In  a  pronounced  rotation  of  the  tibia  and 
fibula. 

A  normal  foot  at  rest  is  one  in  which  the  position  is 
one  of  moderate  supination,  slight  adduction  with  plan- 
tar flexion.  The  axis  in  such  a  foot  runs  in  a  frontal  di- 
rection from  right  to  left  in  the  talo-crural  joint,  and 
the  motions  of  flexion  and  extension  take  place  upon  the 
axis.  Flexion  is  always  accompanied  here  with  slight 
adduction.  All  muscles  before  this  axis  are  dorsal  flex- 
ors (extensors).  Those  behind  it  are  plantar  flexors 
(flexors). 

The  mid-position  is  one  in  which  the  foot  is  at  right 
angles  to  die  leg,  i.e.,  ninety  degrees.  Dorsal  and 
plantar  flexion  can  be  carried  to  thirty-nine  degrees  in 
addition.  Pronation  and  supination  occur  between  the 
tarns  aad  the  foot,  /.<?.,  the  talus,  the  calcaneus,  cu- 
boid, wad  navicular  bones.  The  axis  of  motion  is,  if 
costumed  forward  and  backward,  through  the  calcaneus 
from  behind,  outside  and  below,  anteriorly  above  and 
within,  passing  through  the  sustentaculum  tali  and  the 
neck  of  the  talus.  On  account  of  the  direction  of  this 
axis  we  must  consider  it  as  made  up  of  three  axes :  a  sag- 
ittal, about  which  pronation  and  supination  occur;  a 
perpendicular,  about  which  ab-  and  adduction  occur ; 
and  a  frontal,  about  which  flexion  and  extension  occur. 
With  supination,  adduction  and  plantar  flexion  take 
place.  With  pronation,  abduction  and  dorsal  flexion. 
The  muscles  situated  externally  to  this  axis  are  pro- 
nators, abductors,  and  dorsal  flexors.  Those  situated  in- 
ternally are  supinators,  adductors,  and  plantar  flex- 
ors. For  this  reason,  the  tendo  Achillis  lying  behind 
the  axes  in  the  talo-crural  joint  and  to  the  inner 
side  of  the  axis  of  motion  in  the  talo-calcanean  becomes 
a  plantar  flexor  at  the  talo-crural  and  a  supinator  at  the 
talo-calcanean.  Hence  all  tendons  situated  behind 
and  to  the  inner  side  of  these  joints  cause,  when  short- 
ened, first  plantar  flexion  at  the  talocrural,  and  subse- 
quently plantar  flexion,  supination,  and  adduction  in  the 
talo-caloanean  and  navicular  joints. 

It  must  be  remembered,  however,  that  even  the  mid- 
position  in  the  adult  is  attended  with  a  slight  supination 
in  the  talo-calcanean  joint,  and  that  in  the  new-born  this 
supination  is  often  quite  pronounced.  For  this  reason  a 
greater  frequency  exists  in  all  deformities  tending  to 
varus  over  calcaneus  or  calcaneo-valgus.  Such  supina- 
tion in  foot  axis  corrected  by  the  simple  mechanism  of 
walking  is  overlooked  as  being  a  deformity,  and  only  that 
degree  is  so  classed  in  which  supination  is  not  corrected 
by  walking.  Leuffenbach,  Hueter,  and  Adams  have 
shown  that  this  difference  in  the  axes  of  motion  in  the 
foot  of  the  new-born  and  that  of  the  adult  allows  of  a 
greater  supination  without  an  increased  plantar  flexion 
and  adduction  in  the  former,  while  in  the  latter  greater 
pronation  is  allowed.  In  the  new-born  the  special 
characteristics  of  the  talus  are  increased  length  of  the 
neck  and  its  downward  and  inward  direction,  with  an 
articular  surface  upon  its  inner  side,  the  angles  of  dis- 
placement being  15  °  and  45  °,  respectively.  The  long 
axis  of  the  articular  surface  is  midway  between  a  vertical 
and  horizontal  plane  and  is  oval  in  shape,  whereas  in  the 
adult  this  surface  is  in  a  transverse  plane  and  is  ovoid. 
This  difference  is  due  to  the  fact  that  the  axis  of  talus  in 
the  child  is  nearer  the  axes  of  motion  between  the  talus 
and  calcaneus  than  in  the  adult,  and  hence  the  motion 
at  the  talo-tarsal  joint  is  more  extensive  and  the  joint 
surface  more  rounded.  In  the  calcaneus,  the  great 
length  and  heighth  of  the  processus  calcanei,  the  oblique 
inclination  of  the  superior  articular  process  to  the  inner 
side,  and  the  deep  position  of  the  sustentaculum  tali,  are 
the  principal  features.     The  inclination  of  the  superior 


articular  process  downward  and  inward  mainly,  and  to  a 
less  extent  outward,  favors  supination.  The  reverse  is 
the  case  in  the  adult,  where  pronation  is  favored.  In  the 
new-born  the  length  of  the  neck  is  equal  to  that  of  the 
body.  In  the  adult  it  is  only  one-third  to  one  half  the 
length  of  the  body,  owing  to  the  pressure  of  the  cuboid 
bone  in  the  pronated  position.  The  sustentaculum  tali 
is  deeply  placed  and  slightly  developed.  The  reverse 
condition  is  present  in  the  adult. 

Very  slight  differences  exist  in  the  cuboid  except  in 
the  length  of  their  outer  borders.  In  the  new-born  this 
is  represented  in  per  cent,  as  500  of  the  inner  border. 
In  the  adult  it  is  57 °. 

In  the  treatment  of  a  congenital  club  foot  it  is  neces- 
sary to  reduce  the  plantar  flexion,  the  supination,  the  dis- 
placement at  Chopart's  joint,  and  the  rotation  of  the  leg 
inward.  This  replacement  of  the  foot  must  be  done  so 
that  the  normal  axes  of  motion  are  restored  as  completely 
as  is  possible.  This  can.be  accomplished  either  by  the 
development  of  new  articular  facets  with  perfect  motion, 
or  by  the  extirpation  of  bone  and  syndesmotic  or  anchy- 
losed  joints  with  less  perfect  motion.  The  important 
period  of  life  for  the  accomplishment  of  a  complete  res- 
toration of  the  foot  with  perfect  motion  is,  strictly  speak- 
ing, the  first  thirty  months  of  life.  During  this  period 
the  growth  of  the  foot  is  relatively  greater  than  any  other 
part  of  the  lower  extremity. 

Mechanical  force  and  at  the  most  tenotomies  and 
fasciotomies  are  sufficient  to  correct  deformities  at  this 
time.  After  this  period  great  reliance  upon  the  develop- 
ment of  new  articular  facets  becomes  less  and  less,  and 
we  must  trust  more  and  more  to  operative  procedures, 
viz.,  tenotomies,  fasciotomies,  talus  extirpations,  and 
cuneiform  osteotomies.  Which  of  these  operations  we 
select,  and  the  particular  method  by  which  we  accomplish 
them,  is  to  be  decided  by  the  kind  of  deformity,  the  de- 
gree, and  the  special  peculiarity  of  the  case.  For  the  more 
pronounced  deformities  of  early  youth,  where  mechanical 
treatment,  fasciotomies,  and  tenotomies  have  been  un- 
successful, or  where  no  treatment  has  been  used,  the  talus 
extirpation  alone,  or  with  a  very,  limited  wedge  between 
the  os  calcis  and  cuboid  bone,  or  within  the  os  calcis, 
allows  a  flexion  of  the  foot  to  90  °  at  the  talo-crural,  a 
relief  of  the  supination  in  the  os  calcis,  and  a  reduction 
in  the  displacement  at  Chopart's  joint.  In  the  adult  the 
question  becomes  one  of  the  extent  of  the  equinus  over  the 
varus,  or  whether  they  are  both  equally  marked.  If  the 
equinus  is  the  marked  deformity,  provided  tenotomy  has 
not  allowed  of  its  reduction,  talus  extirpation.  If  varus 
is  the  marked  deformity  and  the  equinus  is  relieved  by 
tenotomy,  cuneiform  osteotomy  at  Chopart's  joint  If 
both  are  equally  involved  in  the  production,  talus  extir- 
pation and  cuneiform  osteotomy.  It  should  be  the  aim 
of  the  operator  to  relieve  the  deformity  completely  and  at 
once.  No  apparatus,  except  possibly  a  high-soled  shoe, 
is  required  when  this  is  accomplished.  No  one  would 
think  of  resorting  to  osteotomy  or  extirpation  of  the  talus 
as  a  primary  operation  in  the  growing  foot.  It  is  enough 
here  to  divide  the  tendons  and  fascia  wherever  they  op- 
pose a  replacement  of  the  foot,  and  an  appropriate  after- 
treatment.  In  the  foot,  however,  where  growth  is  com- 
pleted or  nearly  so,  the  conditions  are  not  the  same. 
Tenotomies  and  fasciotomies  are  done  as  a  preliminary 
step  in  the  operations  of  talus  extirpation  or  cuneiform 
osteotomy,  in  order  to  determine  how  extensively  they  are 
to  be  carried  out.  No  single  method  of  operation ,  whether 
it  be  in  the  class  of  tenotomies,  fasciotomy,  or  a  bone 
operation,  will  suffice  in  the  compound  deformities  of  the 
third  degree,  and  there  should  be  no  hesitancy  in  carry- 
ing out  the  idea  of  complete  and  immediate  restoration 
of  the  foot  in  adults,  especially,  for  the  mortality,  under 
antiseptic  precautions,  is  less  than  one  per  cent.  In  fifty 
cases  of  inveterate  club-foot  in  which  a  bone  operation 
has  been  done,  I  have  never  seen  a  death,  nor  a  case  of 
infection  except  in  one  case.  This  case  was  operated 
upon  a  second  time  with  a  good  result,  the  whole  course 
of  the  treatment  lasting  five  months. 


August  1 8,  1894] 


MEDICAL  RECORD. 


199 


THE  VALUE  OF  ELECTRICITY  IN  DIAGNOSIS 
AND  PROGNOSIS  OF  AFFECTIONS  OF  THE 
PERIPHERAL  NERVES.1 

By  WILLIAM  M.  LESZYNSKY,  M.D., 

NBW  YOKK. 

LBCTUUR  ON  MENTAL  AND  NBRVOUS  DISEASES  AT  THE  NBW  YOKK  POST- 
GSADUATS  MEDICAL  SCHOOL  ,*  NEUROLOGIST  TO  THE  DKMILT  DISPENSARY, 
*TC 

Having  been  asked  to  limit  my  remarks  to  the  value  of 
electricity  in  the  diagnosis  and  prognosis  of  disease  of 
isolated  peripheral  nerves  (neuritis  and  nerve  injuries), 
I  shall  only  venture  to  present  some  of  the  most  promi- 
nent features  relating  to  this  subject. 

It  would  be  superfluous  before  such  a  body  to  dwell  in 
detail  upon  the  essential  methods  of  an  electrical  exam- 
ination, or  to  refer  to  the  various  batteries.  Whatever  I 
may  say  will  no  doubt  seem  trite  to  the  critical  members 
of  this  Society,  who  are  all  more  or  less  familiar  with  the 
use  of  electricity  in  diseases  of  the  nervous  system.  To 
other  physicians,  not  endowed  with  such  special  knowl- 
edge, a  discussion  of  this  nature  is  not  only  timely,  but 
of  the  greatest  practical  importance. 

During  the  last  ten  years  I  have  devoted  much  time 
and  attention  to  the  study  of  electrical  reactions,  par- 
ticularly in  the  various  forms  of  disease  affecting  the 
peripheral  nerves,  which  so  often  result  in  motor  paresis 
or  paralysis.  My  conclusions  are  therefore  based  upon 
personal  observation  in  a  large  number  of  cases,  and  are 
in  a  great  measure  confirmatory  of  the  claims  of  others. 

It  has  been  very  aptly  said  :  "  The  popular  theory  is 
that  the  carrying  out  an  electrical  investigation  requires 
no  special  training,  and  is  within  the  reach  of  anyone 
possessing  a  battery  and  a  superficial  knowledge  of  the 
medical  applications  of  the  current  to  the  human  body. 
.  .  .  The  ablest  physician,  the  most  consummate 
neurologist,  if  he  has  not  submitted  himself  to  the  con- 
ditions required,  and  passed  through  the  ordeal  of  dis- 
cipleship,  will  fail  to  obtain  reliable  results.  .  .  . 
But  little  additional  light  is  shed  upon  the  practical  is- 
sues of  the  case  by  the  reaction  in  a  typical  instance  of 
infantile  or  lead  paralysis,  or  of  advanced  progressive 
muscular  atrophy.  Where  electro  diagnosis  is  of  para- 
mount importance  is  at  the  beginning,  during  the  insidi- 
ous stage  of  numerous  neuropathies.9 

Comparatively  little,  or  no  attention  at  all,  has  been 
given  by  the  general  practitioner  to  the  subject  of  electro- 
diagnosis,  while  the  neurologist  devotes  too  little  time  to 
its  study.  In  all  discussions  or  teachings  on  medical 
electricity  too  much  stress  has  been  laid  upon  its  po- 
tency or  uselessness  as  a  therapeutic  agent;  while  its 
importance  in  diagnosis  and  prognosis  has  been  insuf- 
ficiently recognized  or  neglected.  The  preliminary 
steps  toward  success  in  the  study  of  the  affections  of  the 
peripheral  nerves,  particularly  where  paresis  or  paralysis 
is  a  prominent  symptom,  consist  in  the  acquirement  of  a 
practical  familiarity  with  the  position  of  the  principal  so- 
called  "  motor  points,"  and  a  correct  interpretation  of 
the  various  electro  diagnostic  phenomena  resulting  from 
an  examination  of  the  nerve- trunks  and  muscles. 

By  this  means  we  can  satisfactorily  determine,  in  the 
vast  majority  of  cases,  whether  the  disease  is  situated  be- 
tween the  nucleus  and  the  periphery  of  the  motor  nerves, 
or  elsewhere.  In  two  similar  cases,  whose  pressure  paral- 
ysis is  of  equal  severity,  the  anatomical  causes  may  vary 
considerably  in  their  extent  and  intensity.  It  is  only 
after  an  electrical  examination  that  any  conclusion  can 
be  drawn  as  to  the  approximate  degree  of  damage  to  the 
nerve. 

We  are  also  enabled  to  state,  almost  accurately  in 
many  instances,  what  the  probability  is  as  to  recovery, 
and  to  express  an  opinion  as  to  the  duration  of  the  paral- 
ysis: 

1.  Preservation  of  faradic  irritability  in  nerve  and 
muscle,  with  only  very  slight  decrease  as  compared  with 

>Read  at  the  meeting  of  the  New  York  Neurological   Society! 
February  6, 1804. 
*  De  Wattevfife. 


the  healthy  side,  when  found  two  weeks  after  attack,  is 
of  favorable  import.  Recovery  usually  takes  place  spon- 
taneously within  a  few  weeks  (sep  Cases  I.  and  II.). 

2.  The  faradic  irritability  in  both  nerve  and  muscles 
may  be  very  markedly  diminished  and  accompanied  by 
change  in  the  character  of  the  muscular  contraction, 
which  is  slow  and  somewhat  protracted.  This  may  be 
associated  with  "qualitative"  as  well  as  "serial" 
changes  found  upon  examination  with  galvanism,  i.e., 
the  galvanic  excitability  in  the- nerve  is  present,  though 
diminished,  while  in  both  nerve  and  muscle  AnCC  > 
CaCC  (the  contraction  at  the  closure  at  the  positive  pole 
is  greater  than  at  the  negative).  This  has  been  desig- 
nated by  Erb  as  the  partial  reaction  of  degeneration. 
It  has  been  known  to  ultimately  advance  to  complete 
R.  D.    Recovery  usually  takes  place  in  a  few  months. 

3.  When  die  faradic  irritability  is  lost  in  nerve  and 
muscle,  the  prognosis  remains  doubtful.  It  it  usually 
accompanied  by  loss  of  galvanic  excitability  in  the  nerve. 
When  galvanism  is  applied  to  the  muscle  it  contracts 
slowly,  and  the  reaction  may  he  wore  marked  at  the 
anodic  opening  than  at  the  catbadic  closure.  There 
may  also  be  increased  irritahiKEr  in  the  muscle  as  shown 
by  a  marked  contraction  being  elicited  by  a  current 
which  has  no  effect  whatever  upon  the  healthy  side. 

This  constitutes  the  reaction  of  degeneration  (R.  D.) 
and  is  of  grave  significance.  The  prognosis  is  doubtful 
or  bad,  due  consideration  being  observed  as  to  the  cause 
of  the  lesion.  These  patients  do  occasionally  get  well, 
but  more  rarely  when  the  facial  nerve  is  affected  than  the 
nerves  of  the  extremities.  As  a  matter  of  fact  the  mus- 
cles involved  may  show  various  gradations  in  the  charac- 
ter of  their  galvanic  reaction.  In  my  experience  the 
persistent  increase  in  the  galvanic  excitability  influences 
the  prognosis  more  unfavorably  than  a  mere  change  in 
the  polar  reactions.  This  I  have  found  to  exist  in  cases 
of  facial  paralysis,  but  I  have  never  seen  a  case  of  long 
standing — a  year  or  more — where  a  reaction  in  the  mus- 
cles to  galvanism  could  not  be  demonstrated. 

In  the  extremities,  however,  it  is  well  known  that 
when  recovery  does  not  take  place,  and  the  musculature 
atrophies,  the  galvanic  irritability  gradually  diminishes, 
and  ultimately  no  contraction  can  be  obtained  even  with 
the  strongest  currents. 

It  has  always  seemed  to  me  that  there  is  a  decided  dif- 
ference in  the  course  of  a  facial  paralysis  as  compared 
with  that  of  nerves  in  the  extremities.  It  is  rare  to  see 
atrophy  of  the  facial  muscles  after  a  persistent  paralysis 
from  the  usual  causes,  while  in  the  extremities  atrophy  is 
not  at  all  uncommon.  The  return  of  faradic  irritability 
in  the  facial  muscles  does  not  necessarily  imply  a  recov- 
ery from  the  paralysis.  I  have  found  it  present  in  cases 
that  were  from  two  to  ten  years'  duration  and  of  un- 
doubted peripheral  origin.  See  Case  III.,  in  which  R.  D. 
had  been  present  and  six  months  later  faradic  irritability 
returned,  but  motility  was  not  restored. 

The  following  case  is  still  under  observation :  Annie 

D ,  thirteen  years  "of  age.     Left  peripheral  facial 

paralysis  of  ten  years'  duration.  Right  facial  nerve  re- 
acts to  faradism  30  mm. ;  left,  35  mm. ;  right  facial 
muscles,  32  mm. ;  left,  35  mm.  (slow). 

In  the  Berliner  klin.  Woehenschr.>  October  16, 
1893,  Placzek  reports  four  cases  of  peripheral  paralysis 
(facial  nerve,  3  ;  brachial  plexus,  1),  that  had  existed  for 
periods  ranging  from  two  years  to  twenty- five  years 
(2,  9,  12,  25).  Faradic  irritability  was  preserved  in  both 
nerve  and  muscles.  There  was  only  slight  quantitative 
decrease.  Galvanic  excitability  was  only  slightly  in- 
creased. The  character  of  the  muscular  contractions  was 
normal.  Thus  it  is  clearly  shown  that  despite  the  paral- 
ysis having  persisted  unchanged  for  many  years,  and  the 
nerve  being  impervious  to  the  strongest  voluntary  im- 
pulses, its  reaction  upon  electrical  excitation  indicates 
only  a  slight  quantitative  change  in  irritability.  He  asks 
"  How  are  these  phenomena  to  be  reconciled  with  the 
current  teaching  as  to  the  existence  and  course  of  periph- 
eral paralysis  ?  " 


200 


MEDICAL  RECORD. 


[August  1 8,  1894 


The  only  explanation  given  is  based  upon  the  assump- 
tion of  Erb,  that  the  conductivity  in  nerves  depends  on 
the  axis  cylinders,  while  that  of  electrical  irritability 
exists  in  the  medullary  sheath.  This  view  has  been  con- 
firmed by  the  experiments  of  Schiff  and  Griinhagen.1 
Placzek  therefore  concludes  that  in  the  cases  reported 
the  presence  of  an  axial  neuritis  may  be  the  cause  of  the 
apparently  irreconcilable  phenomena.  I  would  hardly 
be  willing  to  admit  that  these  cases  vitiate  the  teachings 
as  to  the  usual  course  of  the  electro  diagnostic  phenom- 
ena. It  seems  to  me  that 'in  old  cases  accompanied  by 
the  persistent  classical  reaction  of  degeneration,  in  which 
there  is  complete  motor  paralysis  and  muscular  atrophy, 
the  difference  between  the  two  classes  is  merely  one  of 
degree  as  to  the  pathological  process. 

A  further  study  of  the  electrical  reactions  in  old  cases 
of  peripheral  paralysis  may  show  that  in  the  absence  of 
atrophy  the  faradic  irritability  will  be  found  present  in 
every  case. 

On  the  other  hand,  motility  may  be  restored  in  mus- 
cles of  the  extremities,  yet  faradic  irritability  may  re- 
main absent,  or  R.  D:  way  be  demonstrable. 

It  is  well  to  bear  in  mind  that  the  same  electro-diag- 
nostic phenomena  occur  whether  the  lesion  be  situated 
in  the  nucleus  or  in  the  course  of  the  nerve  trunks. 
When  an  eye  muscle  is  paralyzed  it  is  either  the  result 
of  a  lesion  at  the  nucleus,  in  the  trunk  or  branches  of 
the  nerve,  or  in  the  intramuscular  nerve-elements  them- 
selves. The  action  of  the  current  cannot  be  sufficiently 
circumscribed  in  order  to  produce  isolated  contraction 
of  individual  muscles.  Even  if  such  an  examination 
were  feasible,  electricity  could  not  aid  us  in  making  a 
diagnosis  as  to  the  location  of  the  pathological  process. 
As  an  element  in  prognosis  it  is  valueless  for  the  same 
reason. 

The  direct  application  of  an  electrode  and  the  current 
to  the  ocular  conjunctiva  is  a  painful  procedure  and  is 
rarely  tolerated  by  the  patient.  Since  the  use  of  cocaine 
it  was  hoped  that  electricity  could  be  applied  to  the  in- 
dividual ocular  muscles  after  producing  anaesthesia  of 
the  surface  of  the  eyeball.  This  hope  has  not  been  real- 
ized. It  has  been  advised,  and  also  attempted,  to  pierce 
the  conjunctiva  with  a  needle  attached  to  one  of  the 
poles  of  the  battery,  and  thus  apply  the  current  directly 
to  the  affected  muscle.  The  writer  has  tested  this  as  a 
method  of  treatment  in  a  number  of  cases,  but  was 
forced  to  abandon  it.  Even  in  the  hands  of  an  expert 
it  is  not  unattended  with  danger  to  the  delicate  structures 
of  the  eye.  This  is  especially  so  regarding  the  use  of  the 
galvanic  current.  The  facial  nerve  and  the  nerves  of 
the  upper  extremities  are  the  most  accessible  to  electri- 
cal examination,  as  well  as  the  most  frequently  affected 
by  disease.  The  following  histories  selected  from  my 
case  books  will  serve  to  illustrate  the  practical  utility  of 
electricity  as  an  aid  in  diagnosis,  and  also  as  an  auxiliary 
method  in  establishing  an  almost  absolute  prognosis : 

Case  I.     Peripheral  Facial  Paralysis  {Traumatic). — 

November   1,    1892.     A.  K ,  a  boy,  ten  years  of 

age,  was  struck  by  a  base-ball  on  right  side  of  face,  and 
all  branches  of  the  nerve  became  paralyzed  within 
twenty  four  hours.  He  was  seen  three  days  after  the 
injury,  when  paralysis  was  found  to  be  complete.  There 
was  also  slight  disturbance  of  the  sense  of  taste  on  the 
anterior  two-thirds  of  the  tongue  on  the  same  side. 
Slight  diminution  in  faradic  irritability  in  nerve  and 
muscles.  Left,  10  mm. ;  right,  15  mm.  Two  weeks 
later  the  motility  was  returning  in  facial  muscles,  the 
faradic  irritability  being  only  very  slightly  diminished 
— 13  mm.  Galvanic  reaction  normal.  A  favorable  prog- 
nosis was  given.  Complete  recovery  three  weeks  later 
without  treatment. 

Case  II.     Peripheral  Facial  Paralysis  from  Exposure 

to  Cold. — November  9,   1893.     Miss  G ,  seventeen 

years  of  age.  When  seen  three  days  after  beginning  of 
attack  there  was  complete  facial  paralysis  upon  the  right 
side.     No  involvement  of  palate,  but  loss  of  taste  on  the 

1  Zeitschr.  f.  Med.,  Bd.  29. 


anterior  two  thirds  of  tongue  on  the  same  side.  The  left 
nerve  and  muscles  reacted  to  faradism  10  mm. ;  right, 
20  mm.,  showing  an  early  decrease  in  faradic  irritability. 

November  16. — Faradism:  Left,  iomm,;  right,  15 
mm.     Galvanic  reaction  normal ;  prognosis,  good. 

December  3. — Faradism:  Left,  10  mm  ;  right,  18 
mm.     Motility  partly  restored  in  facial  muscles. 

January  20,  1894 — No  evidence  of  paralysis.  Fara- 
dism :  Left,  10  mm. ;  right,  20  mm.  Complete  recovery 
within  ten  weeks  without  treatment. 

Case  III.    Peripheral  Facial  Paralysis  from  Exposure 

to  Cold. — October  25,  1891.     Miss  K ,  twenty-four 

years  of  age.  After  sailing  in  a  storm  became  paralyzed 
on  right  side  of  face.  All  branches  involved.  Was  first 
seen  by  me  nine  weeks  after  attack.  Left  nerve  and 
muscles  reacted  to  faradism  14  mm. ;  right,  no  reaction. 
Galvanism:  Left,  2  Ma  CaCC,  normal  in  nerve  and 
muscles;  right,  no  reaction  in  nerve.  Muscles  react 
slowly  to  1  Ma  AnCC  >  CaCC.  In  other  words,  the 
reaction  of  degeneration  is  present  An  unfavorable 
prognosis  was  given. 

December  1. — The  galvanic  excitability  in  the  muscles 
is  always  found  increased. 

January  31,  1892. — Although  the  faradic  irritability 
has  returned  in  nerve  and  muscles  (quantitatively  dimin- 
ished) recovery  is  incomplete,  and  accompanied  by 
secondary  contracture  in  the  zygomatics. 

June  4. — Condition  unimproved. 

Case  IV.  Peripheral  Facial  Paralysis  from  Expos- 
ure to  Cold. — February  13,  1893.     Mr.    ^ >  mer* 

chant,  forty  eight  years  of  age.  Two  days  after  riding 
on  the  platform  of  an  elevated  railroad-car  during  a  cold 
night  he  first  noticed  paralysis  of  the  left  side  of  face. 
All  branches  are  affected.  No  interference  with  taste. 
Was  seen  three  days  after  attack.  Right  nerve  and  mus- 
cles react  to  faradism  14J  mm.;  left,  20  mm.  (slow). 
Galvanism:  Right,  \\  MaCC;  left,  2  Ma  AnCC  = 
CaCC. 

March  1st. — Left,  loss  of  faradic  reaction  in  nerve 
and  muscles.  Loss  of  galvanic  irritability  in  nerve. 
Facial  muscles  react  slowly  to  1  Ma  AnCC  >  CaCC, 
showing  the  reaction  of  degeneration.  Prognosis  doubt- 
ful. 

February,  1894  (one  year  after  onset  of  attack). — 
Recovery  was  almost  complete  except  in  lower  facial 
muscles. 

Case  V.     Traumatic  Neuritis  of  Left  Ulnar  Nerve. 

— William  H ,  born  in  England,  thirty  years  of  age ; 

diamond  polisher.  Was  first  seen  February  26,  1889. 
Three  weeks  before  he  had  been  cut  on  the  left  wrist  by  a 
broken  bottle.  The  wound  had  healed.  He  complained 
of  numbness  and  tenderness  on  pressure  over  the  ulnar 
distribution  in  the  palm.  Causalgia :  Severe  pain  at  night. 
Paralysis  affecting  the  two  ulnar  fingers.  There  was  anaes- 
thesia in  the  hand  in  the  course  of  the  ulnar  branches. 
Some  atrophy  of  the  adductor  pollicis  and  the  hypothenar 
group  of  muscles.  Faradism :  Right  nerve  and  muscles, 
14}  mm.;  left,  no  reaction  below  the  wrist.  Galvan- 
ism :  Ulnar  nerve — right,  2 J  Ma  CaCC ;  left,  no  reac- 
tion in  forearm.  Muscles — right,  hypothenar  group  in- 
terossei  and  adductor  pollices,  6  Ma  CaCC ;  left,  hypo- 
thenar group  interossei,  6  Ma  AnCC  >  CaCC,  slow  and 
feeble. 

April  5th. — Excessive  pain  had  continued  and  pre- 
vented sleep.  Exploratory  incision  showed  that  the 
nerve  had  been  cut  across  by  the  injury,  and  it  was  found 
in  a  condition  of  typical  degeneration.  The  divided 
ends  were  sutured  and  the  wound  closed. 

May  14th. — Pain  had  subsided.  Anaesthetic  area  had 
diminished,  and  the  tactile  sensibility  was  improved. 
Faradism:  Ulnar  nerve  at  elbow  15  mm.,  only  in  ad- 
ductor pollicis.  No  reaction  in  hypothenar  group. 
Galvanism :  4  Ma  AnCC,  affecting  adductor  pollicis  only. 

October  24th. — The  nerve  conduction  was  steadily  im- 
proving, so  that  5  Ma  CaCC  produced  a  reaction  in  the 
hypothenar  group.  The  strength  in  the  hand  rapidly  in- 
creased and  it  was  ultimately  restored  to  usefulness. 


August  1 8,  1894] 


MEDICAL   RECORD. 


201 


Case  VI.— Paralysis  of  Brachial  Plexus  {Bilateral). 

— F.  S ,  aged  twenty-five,  born  in  the  United  States, 

porter.  Was  first  seen  by  me  September  6,  1890,  and 
gave  the  following  history:  While  intoxicated  he  fell 
asleep  on  the  roof  of  his  house,  during  a  chilly  night, 
August  23d  (two  weeks  ago).  Was  carried  to  bed  in 
the  early  morning  and  awoke  in  the  afternoon  with  both 
arms  paralyzed.  There  was  numbness  in  the  arms  and 
fingers,  which  disappeared  in  a  few  days.  No  pain,  no 
history  of  syphilis  or  rheumatism.  Lower  extremities 
not  affected.  While  asleep  on  the  roof  he  was  wearing 
a  stiff  shirt  collar,  and  he  was  told  that  his  head  was  ex- 
tended backward. 

The  following  condition  was  found  upon  examination : 
Right  upper  extremity :  Paralysis  of  deltoid,  infraspina- 
tus, teres  minor,  and  biceps  group.  Paresis  of  supinators 
and  extensors.  No  triceps  jerk.  No  atrophy.  No 
objective  sensory  disturbance,  but  some  tenderness  on 
pressure  over  supraclavicular  portion  of  brachial  plexus, 
causing  radiation  of  pain  through  the  entire  arm.  Me- 
dian and  ulnar  distribution  not  involved.  All  nerves 
and  muscles  react  well  to  faradism,  23  mm.,  and  also 
upon  irritation  at  Erb's  supraclavicular  point.  Galvanic 
reactions  normal. 

.  Left  upper  extremity :  Paralysis  of  deltoid,  infraspina- 
tus, and  teres  minor  biceps  group  and  latissimus  dorsi. 
Paresis  of  the  subscapulars  and  teres  major,  triceps, 
supinators,  and  extensors.  No  triceps  jerk.  No  atrophy. 
No  sensory  disturbance.  Tenderness  on  pressure  over 
the  brachial  plexus  in  the  neck.  Median  and  ulnar 
nerves  normal.  The  deltoid,  triceps,  and  biceps  group 
react  well  to  faradism,  26  mm. ;  musculo  spiral  nerve, 
31  mm. ;  extensors,  35  mm.  (feeble).  Galvanic  reaction 
normal.  Both  shoulder  joints  relaxed  and  paretic  mus- 
cles are  flaccid.     Lower  extremities  in  good  condition. 

The  treatment  consisted  in  the  application  of  blisters 
over  the  points  of  tenderness  and  the  use  of  the -galvanic 
current  A  favorable  prognosis  was  given.  By  the  end 
of  October  recovery  was  complete. 

From  the  foregoing  history  the  distribution  of  the 
paralysis  and  the  painful  pressure  points  the  diagnosis 
was  made  of  traumatic  neuritis  of  the  brachial  plexus 
resulting  from  pressure.  The  preservation  of  faradic 
irritability  proved  of  service  in  forming  a  prognosis. 
This  is  representative  of  a  class  of  cases  of  peripheral 
paralysis  where  the  faradic  irritability  is  preserved  (or 
only  slightly  diminished)  as  well  as  all  forms  of  sensation. 

Case  VII.  Spontaneous  Degenerative  Neuritis  of  the 
Brachial  Plexus, ' — A  man,  thirty  eight  years  of  age, 
shortly  after  exposure  to  cold  (without  antecedent  history 
of  joint  disease  or  injury)  suffered  from  severe  paroxysmal 
pain  in  the  left  shoulder,  rapidly  followed  by  paralysis  of 
the  deltoid.  After  short  but  varying  intervals  of  freedom 
from  acute  pain  another  paroxysm  would  occur,  accom- 
panied by  additional  paralysis.  These  attacks,  extending 
over  a  period  of  four  weeks,  involved  all  of  the  muscles 
innervated  by  the  circumflex,  suprascapular,  subscapular, 
musculo- cutaneous,  and  musculo-spiral  nerves.  There 
was  anaesthesia  in  the  domain  of  the  circumflex,  external 
cutaneous,  and  radial  nerves.  Well-marked  atrophy  with 
the  reaction  of  degeneration  existed  in  all  of  the  paralyzed 
muscles  excepting  the  biceps  group,  in  which  only  a 
"partial  R.  D."  was  demonstrable.  The  median  and 
ulnar  nerves  were  not  involved.  Almost  complete  re- 
covery took  place  at  the  end  of  two  years.  The  biceps 
group,  presenting  "partial  R,  D.,"  recovered  first,  while 
the  supinator  longus  and  the  extensors  of  the  forearm, 
exhibiting  "  complete  R.  D.,M  were  the  last  to  show  signs 
of  improvement. 

If  electricity  is  to  be  of  any  service  to  us  in  ascertain- 
ing whether  the  nerve-trunk  has  been  divided  or  not  as  a 
result  of  traumatism,  the  examination  must  be  made  as 
soon  after  the  injury  as  possible.  We  can  then  deter- 
mine at  once  if  special  surgical  interference  is  necessary. 

1  **  A  Contribution  to  the  Clinical  Study  of  Spontaneous  Degenera- 
tive Neuritis  of  the  Brachial  Plexus/'  by  the  writer,  Journal  of  Men- 
tal and  Nervous  Diseases,  January,  1890. 


Should  two  or  three  weeks  elapse  before  such  examination 
it  will  be  impossible  to  state  whether  the  absence  of  reac- 
tion is  due  to  traumatic  neuritis  or  to  complete  division  of 
the  nerve.    Exploratory  incision  would  then  be  called  for. 

The  tests  with  the  galvanic  current  require  adequate 
apparatus  and  a  working  knowledge  of  the  relationship 
between  electro-motive  force,  resistance,  and  current 
strength.  It  also  requires  much  time,  patience,  and  per- 
severance.    Hence  its  unpopularity. 

The  musculo-spiral  nerve,  which  seems  to  lose  its  irri- 
tability more  readily  than  most  of  the  other  nerves  of  the 
body,  presents  some  special  peculiarities  that  are  worthy 
of  note.  In  apparently  healthy  people  I  have  very  often 
failed  to  demonstrate  the  faradic  reaction  of  this  nerve, 
and  was  unable  to  satisfactorily  account  for  its  absence. 
This  occurred,  as  a  rule,  in  muscular  individuals,  in 
whom  the  examination  is  occasionally  difficult.  With 
the  small  electrode  over  the  nerve  I  could  not  elicit  a 
response,  even  with  strong  currents,  while  the  extensors 
reacted  normally  upon  direct  excitation.  In  the  ab- 
sence of  evidence  of  disease  I  attributed  this  failure  to 
the  action  of  the  current  producing  muscular  contrac- 
tions in  situ  sufficient  to  throw  the  electrode  aside. 
With  the  electrode,  however,  in  the  same  position — 
without  having  been  removed — and  the  galvanic  current 
substituted,  the  response  would  take  place  promptly.  It 
may  be  that  in  some  of  the  cases  the  faradic  anode  was 
used,  thus  accounting  for  the  absence  of  the  usual  reac- 
tion (vide  infra). 

In  the  Berliner  Deutsch.  mcd,  Wochenschr. ,  1892,  p* 
747,  Dr.  Karl  Gumpertz  claimed  that  it  was  possible  to- 
make  the  anticipatory  diagnosis  of  lead  paralysis  and 
paralysis  due  to  other  forms  of  neuritis  even  in  cases 
where  the  typical  extensor  paralysis  is  absent,  and  where 
the  electrical  reaction  of  the  muscles  suspected  of  disease 
is  shown  by  the  direct  examination  to  be  practically 
normal.  He  called  attention  to  the  fact  that  in  the 
musculo  spiral  nerve  excitation  with  the  faradic  anode 
fails  to  elicit  a  response,  while  with  the  faradic  cathode 
a  distinct  reaction  is  produced.  Subsequently  this  claim 
was  found  to  be  fallacious  by  Dr.  J.  J.  Putnam,1  of  Bos- 
ton. He  discovered  that  this  peculiarity  in  reaction  also 
existed  in  a  certain  proportion  of  apparently  healthy 
people.  I  have  been  enabled  to  fully  confirm  the  state- 
ments of  Dr.  Putnam,  but,  like  him,  am  at  a  loss  to  give 
a  satisfactory  explanation  of  this  phenomenon.  While 
the  cathode  of  the  faradic  break  current  can  easily  be 
recognized  by  its  greater  effect  upon  motor  and  sensory 
nerves,  this  relative  difference  in  the  strength  of  the 
poles  and  their  action  is  insufficient  to  account  for  this 
peculiarity. 

I  have  thus  far  examined  twenty  three  cases  with  the 
following  result :  With  the  faradic  anode  over  the  nerve 
no  contraction  could  be  obtained  in  three  cases  with  a 
strong  and  painful  current,  excepting  in  the  supinator 
longus.  In  two  there  was  no  reaction  whatever  in  the 
distribution  of  the  nerve.  In  all  of  these  five  a  com- 
paratively weak  current  gave  a  well-marked  reaction — 
when  the  faradic  cathode  was  applied.  As  was  to  be  ex- 
pected the  extensors  reacted  normally  upon  direct  exci- 
tation, invariably  requiring  a  greater  length  of  coil  at  the 
anode.  I  am  making  more  extended  investigation  along 
this  line,  and  hope  to  report  the  result  upon  some  future 
occasion. 

The  following  conclusions  will  no  doubt  serve  to  con- 
trovert a  number  of  popular  fallacies  relating  to  this 
subject : 

1.  That  the  value  of  electricity  as  an  accessory  method 
in  diagnosis  and  prognosis  of  disease  of  the  peripheral 
nerves  is  not  as  universally  recognized  as  its  importance 
demands. 

2.  That  the  result  of  this  procedure  often  furnishes 
corroborative  and  conclusive  evidence  where  only  a 
provisional  diagnosis  has  been  made. 

3.  That  the  necessary  technical  skill  in  successfully 
pursuing  such  investigation  and  correctly  interpreting 

1  Boston  Medical  and  Surgical  Journal,  March  30,  1893. 


202 


MEDICAL   RECORD. 


[August  1 8,  1894 


the  result  can  only  be  acquired  through  special  study 
and  practice. 

4.  That  the  use  of  the  faradic  current  alone  is  quite 
sufficient  for  diagnostic  purposes. 

5.  That,  as  a  rule,  the  galvanic  current  is  supplemental 
to  that  of  faradism,  and  in  the  absence  of  faradic  irrita- 
bility in  nerve  and  muscle  it  is  of  the  greatest  service  in 
prognosis. 

6.  That  the  discovery  of  the  reaction  of  degeneration 
is  not  an  essential  feature  in  the  differential  diagnosis  as 
to  the  location  of  the  lesion. 

7.  That  the  peripheral  nerve-fibres  possess  an  inherent 
power  of  regeneration,  which  seems  almost  unlimited, 
the  length  of  time  required  for  the  completion  of  the  re- 
generative process  varying  from  a  few  weeks  to  seven 
years  or  more.  Therefore  in  severe  forms  of  injury  the 
cause,  degree,  and  character  of  the  damage  to  the  nerve 
are  often  of  greater  importance  in  prognosis  than  the 
demonstration  of  the  reaction  of  degeneration. 

8.  That  the  presence  of  R.  D.  or  partial  R.  D.  is  not 
incompatible  with  the  preservation  of  motility  in  the 
same  area.  This  paradoxical  condition  has  been  found 
in  cases  of  lead-poisoning,  and  a  few  others,  but  thus 
far  the  cause  has  been  inexplicable. 

9.  That  strong  currents  are  only  rarely  necessary. 
The  weakest  current  that  will  produce  a  distinctly  per- 
ceptible reaction  is  all  that  is  requisite. 

10.  That  a  decrease  or  disappearance  of  faradic  irrita- 
bility in  nerve  and  muscle  simply  denotes  an  interfer- 
ence with  the  nutrition  in  the  course  of  the  motor  tract 
between  the  multipolar  cells  in  the  anterior  horn  and  the 
peripheral  nerve  distribution.  It  does  not  enable  us  to 
judge  of  the  nature  of  the  pathological  process. 

n.  That  the  character  of  the  reactions  does  not  differ 
whether  the  lesion  be  situated  in  the  cells  of  the  anterior 
horn,  the  anterior  nerve-roots,  the  nerve-trunks,  or  in 
their  ultimate  distribution.  The  same  rule  holds  good  in 
reference  to  the  various  cranial  motor  nerves  and  their 
nuclei,  such  as  the  facial,  hypoglossal,  and  spinal  acces- 
sory nerves. 

12.  When  the  farado-muscular  irritability  is  lost  no 
reaction  can  be  obtained  by  a  rapidly  interrupted  gal- 
vanic current. 

13.  The  secondary  current  from  an  induction  coil 
is  the  one  generally  used  in  testing  faradic  irritability. 
Owing  to  its  high  electro  motive  force  the  resistance 
encountered  in  the  moistened  skin  may  be  considered 
negligible. 

14.  The  difference  in  the  poles  of  the  faradic  current 
is  only  a  relative  one,  and  cannot  be  determined  by  the 
usual  tests  as  applied  to  the  galvanic  current.  The  elec- 
tro-motive force  in  the  secondary  coil  is  greater  at  the 
"break"  than  at  the  "make."  The  electrode  that  is 
felt  to  be  the  stronger  in  its  action  is  usually  considered 
as  the  negative,  or  so  called  "  faradic  cathode." 

15.  In  some  apparently  healthy  individuals  the  mus- 
culo-spiral  nerve  fails  to  react  to  strong  currents  applied 
with  the  "faradic  anode,"  while  a  comparatively  weak 
.current  from  the  "  faradic  cathode  "  calls  forth  a  quick 
response. 

16.  In  a  case  of  undoubted  peripheral  paralysis  the 
faradic  irritability  may  be  preserved,  but  it  almost  in- 
variably requires  a  stronger  current  to  produce  muscular 
contractions  than  upon  the  healthy  side  (quantitative 
decrease).  [The  writer  has  never  seen  a  case  where  this 
could  not  be  demonstrated  within  a  few  days  after  the 
onset  of  the  paralysis.] 

17.  The  character  of  the  muscular  reaction  demands 
attention.  A  slow  and  labored  contraction  associated 
with  decrease  in  faradic  irritablity  denotes  degenerative 
changes. 

18.  The  faradic  irritability  may  return  in  persistent 
cases  of  peripheral  paralysis  without  any  perceptible  im- 
provement in  motility. 

19.  Electro-diagnosis  is  inapplicable  in  paralysis  of  the 
ocular  muscles. 

61  East  Seventy-fifth  Street. 


SOME  FURTHER  OBSERVATIONS  ON  REFLEX 
ASTHMA. 

By  LOUIS  E.  BLAIR,  A.M.,  M.D., 

ALBANY,   M.   Y. 

In  an  article  published  in  the  Philadelphia  Medical  and 
Surgical  Reporter  for  January,  1891,  I  reviewed  a  series 
of  thirty-five  cases  of  asthma,  and  summarized  the  article 
as  follows :  "  I  have  thus  dwelt  at  length  upon  the  various 
theories  and  views  of  writers,  in  order  to  show  what  the 
advanced  sentiment  is  in  regard  to  this  subject  in  medi- 
cine, which  evidently  remains  to  be  written.  Its  present 
treatment  by  therapeutic  means  alone  is  very  unsatisfac- 
tory, as  everyone  will  admit.  Time-worn  remedies  have 
been  discarded  for  newer  ones  more  encouraging,  and 
these  in  turn  abandoned  for  others.  There  is  no  specific 
for  asthma.  Each  case  must  be.  studied  by  itself.  The 
physician  must  satisfy  himself  as  to  the  integrity  of  the 
upper  air  passages,  more  especially  the  nasal  cavities. 
Here  is  the  most  prolific  cause  of  asthma,  a  fact  which 
has  now  been  fully  proven  by  most  careful  writers,  and 
by  most  successful  and  convincing  records  of  treatment. 
In  all  of  the  thirty-five  cases  which  I  have  treated,  ab- 
normalities of  the  nasal  cavities  were  verified ;  and  in  those 
cases  which  were  not  benefited,  I  believe  that  other  and 
remote  nervous  disturbances  were  influential  in  keeping 
up  a  reflex  asthma." 

One  would  think,  from  the  number  of  articles  which 
have  appeared  on  this  subject  in  the  last  three  or  four 
years,  that  all  had  been  said  in  reference  to  it,  and  that 
some  unanimity  of  opinion  existed,  at  least  among  spe- 
cial workers,  from  the  number  of  favorable  cases  which 
have  been  reported.  But  such  apparently  is  not  the 
case.  One  of  the  latest  and  best  books  on  the  throat, 
namely,  that  of  Greville  McDonald,  published  in  Lon- 
don in  1892,  discusses  this  theme  from  the  standpoint 
that  the  reflex  theory  cannot  be  well  sustained  by  physi- 
ological laws  or  practical  results.  His  reasoning,  ana- 
tomically and  pathologically,  is,  I  think,  defective, 
while  his  experience  with  asthmatic  subjects  evidently 
has  been  both  a  limited  and  only  a  partially  successful 
one,  from  his  own  statement.  Nor  do  I  think  that  the 
English  writers  have  yet  grasped  all  the  factors  which 
enter  into  the  problems  of  cause  and  cure  of  this  ail- 
ment. They  even  go  so  far  as  to  say,  in  their  failure  to 
cure  their  patients,  that,  in  the  first  place,  they  do  not 
meet  with  as  many  in  their  practice  as  compared  with 
their  American  confreres ;  and,  in  the  second  place,  it 
is  more  distinctly  an  outgrowth  of  American  neuras- 
thenia, and  the  physicians  on  this  side  of  the  Atlantic 
are  accordingly  better  qualified  to  study  causes  and  ap- 
ply more  suitable  remedies,  being,  of  course,  more  famil- 
iar with  the  weaknesses  and  predispositions  of  their  pa- 
tients. 

The  first  writers  on  reflex  asthma  believed  that  the 
disturbing  cause  was  most  often  found  in  the  nasal  pas- 
sages, and  was  an  obstructive  one,  and  in  some  cases 
brilliant  results  followed  treatment.  It  is  not  necessary 
to  detail  the  work  of  the  pioneers  in  this  new  field. 
Suffice  it  to  say,  that  a  great  many  throat  specialists  be- 
lieve that  where  there  is  no  obstructive  lesion  there  can 
be  nothing  done  for  asthmatics  who  suffer  either  from 
hay  fever  or  perennial  asthma.  Bosworth,  in  his  excel- 
lent monograph  on  asthma,  says :  "A  large  majority,  if 
not  all,  cases  of  asthma  were  dependent  upon  some  ob- 
structive lesion  in  the  nasal  cavity.  This  is  evidenced 
by  the  immediate  relief  from  the  exacerbation  by  the  use 
of  cocaine  in  the  nose,  in  every  case  in  which  I  have 
tried  it,  and,  furthermore,  by  the  cure  of  so  many  cases 
by  the  removal  of  the  obstructive  lesion  in  the  upper  air- 
passages.  ' ' 

I  will  admit  that  obstructions  causing  nerve  irritation 
ought  to  be  removed,  but  there  are  many  cases  where  no 
obstructive  lesion  exists,  or,  at  any  rate,  cannot  be  demon- 
strated, and  yet  the  cocaine  applications  suspend  tem- 
porarily the  paroxysms  of  asthma.  In  these  cases  I  be- 
lieve there  are  exposed  nerve-points,  when  in  the  nasal 


August  1 8,  1894] 


MEDICAL  RECORD. 


203 


cavity,  for  example,  which  may  be  either  sensory  or  part 
of  the  olfactory  system,  which  have  become  hypersensi- 
tive nerve-tumors,  and  are  just  as  effective  in  causing 
asthma  as  obstructions  or  grosser  lesions.  The  causal 
and  offending  substances  may  be  many,  viz.,  tobacco 
dust  or  smoke,  finely  powdered  drugs,  animal  emanations, 
odors  from  the  stable,  from  the  kitchen,  odors  from 
crowded  rooms,  etc.,  any  of  such  odoriferous  particles 
producing  their  distressing  effects,  depending  upon  the 
idiosyncrasy  of  the  victim.  This  term  idiosyncrasy  is 
used  for  the  expression  of  vitiated  nerve  centres,  which 
morbidly  respond  to  causes,  so  slight  even,  which  can- 
not be  appreciated  by  the  physician,  or  sometimes  even 
by  the  patient. 

One  cause  of  failure  in  the  treatment  of  reflex  asthma, 
supposed  to  have  started  primarily  in  the  upper  respira- 
tory tract,  has  been  that,  after  the  surgeon  has  removed 
the  local  causes  of  disturbance,  he. has  failed  probably 
in  one  of  the  most  essential  points  in  the  treatment, 
namely,  to  restore  the  tone  of  the  weakened  nerve-cen- 
tres, where  the  "habit  of  asthma "  has  been  firmly  es- 
tablished, and  where  at  last  local  irritation,  or  even  the 
removal  of  it,  has  but  a  little  influence  in  preventing  the 
nervous  explosions.  I  have  even  found  in  some  patients 
that  simple  exhaustion  from  a  prolonged  day's  work,  the 
fatigue  of  a  railway  journey,  etc.,  would  at  night  develop 
into  an  attack  of  asthma,  which  could  only  be  explained 
by  this  extreme  weakness  in  the  nerve-centres  inhibiting 
the  vaso- motor  system  of  the  bronchial  tubes.  For  this 
reason  discredit  has  been  cast  upon  the  local  treatment . 
of  asthma,  where  local  disturbances  have  been  believed 
to  have  been  eliminated  and  a  cure  has  not  resulted. 
This  so-called  neurotic  element  in  asthma,  as  pointed 
out  by  Beard,  is  more  of  a  result  and  not  a  primary  cause 
of  asthma,  I  believe. 

Greville  McDonald,  in  his  valuable  treatise,  fails  to 
grasp  the  value  of  this  point  in  discussing  the  subject  in 
the  chapter  on  "  Nasal  Asthma."  He  takes  the  view 
that  nasal  obstruction  is  a  cause  of  hay  fever,  and  when 
the  nasal  obstruction  is  eliminated  patients  frequently 
develop  asthma,  a  bronchial  irritation  further  down,  be- 
cause the  nasal  passages  having  been  rendered  more  pa- 
tent, harm  has  been  done  the  patient,  and  as  a  rule  the 
seeming  improvement  in  the  nose  may  be  followed,  and 
moreover  is  apt  to  be  followed,  by  the  ^nore  embarrass- 
ing and  persistent  perennial  asthma.  "  We  must  re- 
member the  possibility  of  rendering  the  asthma  worse  as 
a  consequence  actually  of  the  improved  condition  of  the  . 
nose "  (page  237).  In  the  chapter  on  "  The  Nasal 
Neuroses  "  he  discusses  the  physiological  reflexes,  name- 
ly, lachrymation,  rhinorrhcea,  sneezing,  deglutition,  and 
coughing,  and  says :  "  But  I  have  never  seen  any  other 
evidence  of  reflex  action  than  those  enumerated.  Con- 
sequently the  question  naturally  suggests  itself,  why  in 
conditions  of  disease  should  we  find  reflex  effects  pro- 
duced which  cannot  be  provoked  by  physiological 
means?  Are  we  to  assume  that  paths  along  which  re- 
flex actions  take  their  course  exist  in  pathological  states, 
though  unknown  in  conditions  of  health  ?  "  In  answer 
to  this  I  would  say  that  asthma  is  not  a  normal  reflex, 
and  cannot  be  produced  in  a  state  of  health.  It  is  pre- 
eminently a  pathological  condition  brought  about  through 
a  long  abuse  and  irritation  of  the  nerve-centres  in  direct 
communication  with  sensory  nerve-branches  distributed 
more  especially  over  the  upper  respiratory  tract.  Be- 
sides, I  would  add  that  in  practical  experience  I  have  re- 
peatedly, in  asthmatic  patients,  produced  well-marked 
paroxysms  when  probing  gently  over  the  various  areas  of 
the  nasal  cavities  for  the  purpose  of  completing  a  careful 
diagnosis ;  and  in  just  such  patients  I  have  been  able  to 
accomplish  the  most  good  where  the  reaction  of  asthma 
from  operative  treatment  has  been  most  severe  and  most 
marked,  for  I  have  always  felt  that  I  had  reached  a 
source  of  irritation.  Only  recently  this  was  forcibly 
illustrated  in  a  chronic  asthmatic,  a  lady  over  sixty  years 
of  age,  while  using  the  electro-cautery  in  reducing  hy- 
pertrophied  and  otherwise  diseased  tonsils ;  such  a  severe 


paroxysm  of  asthma  was  called  forth  that,  for  the  time 
being,  it  was  not  possible  to  continue  the  further  treat- 
ment. Bosworth  has  also  called  attention  to  faucial 
irritation  produced  by  an  elongated  uvula  as  causative  of 
asthma,  and  by  removing  it  a  cure  ensued. 

Experience  has  taught,  then,  that  it  is  highly  necessary 
to  place  the  upper  respiratory  region  in  a  condition  of 
physiological  repose  if  any  permanent  good  is  to  be 
looked  for.  Obstructions  and  sensitive  areas  must  be 
corrected.  Indiscriminate  use  of  saw,  knife,  and  cautery 
are  to  be  condemned.  Soothing  oily  sprays  suitably 
medicated,  continued  through  a  period  of  months,  Will 
aid  greatly  to  restore  the  normal  condition  of  things, 
while  the  wholesale  destruction  of  whole  areas  can  only 
result  in  harm.  As  was  hinted  at  early  in  this  paper, 
the  great  source  of  failure  has  been  in  not  looking  after 
the  general  condition  of  the  patient. 

The  constitutional  treatment  of  asthmatics  has  its  cor- 
relation in  the  tonic  treatment  of  chronic  syphilitics. 
It  is  no  secondary  matter.  Unless  you  have  the  blood 
of  the  latter  in  a  state  of  repair,  it  is  useless  to  storm 
them  with  heroic  doses  of  mercury  and  iodide  of  potash, 
for  the  depressing  and  depleting  drugs  will  do  more 
harm  than  good.  And  so  it  is  with  the  victims  of 
asthma.  You  have  to  deal  with  a  depraved  and  vitiated 
nervous  system.  An  early  and  an  earnest  effort  must  be 
made  to  build  up  their  strength.  After  removing  local 
causes  the  next  thing  to  do  is  to  add  nerve  resistance. 
It  is  a  common  occurrence  to  meet  with  cases  which 
have  existed  almost  from  birth,  and  the  belief  is  firmly 
established  that  nothing  can  be  done;  and  laboring 
under  this  erroneous  idea,  the  patient  has  been  content 
with  a  moderate  degree  of  health,  has  been  afraid  of  ex- 
posure to  the  summer  air,  dreading  the  dust  and  pollen, 
while  the  winter  cold  and  dampness  have  likewise  been 
a  source  of  menace;  and  not  having  taken  sufficient 
out- door  exercise,  and  not  being  able  to  follow,  as  a  rule, 
laborious  duties,  the  individual  has  grown  up  with  im- 
paired strength  and  inability  to  pull  out  of  a  wretched 
condition.  It  is  often  marvellous  to  see  how  rapidly 
such  patients  improve  after  the  proper  treatment  has  been 
instituted.  I  will  instance  only  two  cases,  one,  that  of 
a  young  man  twenty- one  years  of  age,  who  had  been  a 
victim  of  asthma  from  birth,  and  was  only  able  to  work 
at  his  trade  as  wheelwright  and  blacksmith  about  one- 
fourth  of  the  time.  Within  six  weeks  after  his  nose  and 
throat  had  been  treated  and  a  tonic  nerve  treatment  in- 
stituted, he  was  cured  and  gained  eighty  pounds  in 
weight  in  the  following  two  years,  while  he  did  not  lose 
a  single  day  from  his  work  on  account  of  his  former 
malady.     The  other  patient  had  a  history  as  follows : 

Mr.  V.  H.  R ,  aged  forty-one,  occupation,  wagon 

merchant,  had  a  history  of  asthma  and  hay  fever  dating 
back  eighteen  years.  Had  tried  all  sorts  of  patent 
asthma  cures ;  had  experimented  at  asthma  sanitariums ; 
had  tried  various  climates  and  health-resorts,  but  all  to 
no  purpose.  Dust,  the  pollen  of  vegetation,  tobacco 
dust  and  smoke,  the  emanations  of  animals,  odors  from 
the  kitchen,  the  smell  of  horses  or  a  stable,  fatigue  from 
a  day's  work,  the  inability  to  sit  in  a  crowded  room  or 
where  a  number  of  persons  congregated,  like  a  church, 
theatre,  etc. ,  riding  in  a  carriage,  and  many  other  slight 
disturbances  which  are  difficult  to  understand — all  of 
these  causes  precipitated  an  attack  of  asthma  which  so 
exhausted  his  vitality  that  it  was  exceptional  when  he 
was  not  compelled  to  go  to  bed  at  seven  in  the  evening, 
being  no  longer  able  to  stay  up.  A  more  unpromising 
case  could  not  well  be  imagined.  And  yet,  within  ten 
weeks  after  beginning  treatment  such  as  has  been  out- 
lined, the  patient  was  virtually  a  new  man.  In  three 
months  he  gained  thirteen  pounds  in  weight,  and  has 
been  quite  free  from  all  the  annoying  conditions  which 
made  existence  a  burden  to  him  for  eighteen  years.  To 
illustrate  the  marked  change  in  this  patient's  case,  where 
formerly  he  could  not  even  ride  behind  a  horse,  he  re- 
cently drove  a  team  of  horses  himself  thirty-three  miles 
over  a  dusty  road  without  any  sign  of  asthma. 


204 


MEDICAL  RECORD. 


[August  1 8,  1894 


.  The  length  of  time  that  asthma  has  existed  is  no  factor 
in  estimating  the  chances  of  a  cure.  The  question  is, 
has  any  permanent  damage  been  done  to  the  nervous 
system  or  air-passages?  If  so,  then  in  either  case  the 
prognosis  will  necessarily  be  a  modified  one. 

204  Stats  S  tkhst. 

INTRA -NASAL    GROWTHS    AS    FACTORS    IN 
AURAL  AND  LARYNGEAL  CATARRH.1 

By  SARGENT  F.  SNOW,  M.D., 

AyRIST  AND  LtKYNGOLOGtST  TO  THK  HOUSt  OP  THt  GOOD  SHKPHBKD  AND  THK 
SYRACUSE  PKCB  DISPENSARY ;  MBMBRK  OP  THK  CENTRAL  NEW  YORK  MEDI- 
CAL ASSOCIATION,  THE  SYRACUSE  ACADEMY  OP  MEDICINE,  THE  ONONDAGA 
COUNTY  MEDICAL  SOCIETY,  ETC. 

Mr.  President  and  Members  :  The  paper  I  shall  pre- 
sent is  one  that  I  read  before  the  Onondaga  County 
Medical  Society  September  15,  1891.  My  object  and 
apology  for  resurrecting  it  is  twofold : 

First;  because  it  contains  observations  on  the  middle 
turbinated  region  of  the  nose,  which  was  then,  and  is 
now,  of  great  interest  to  me,  and  which  I  believe  has 
received  too  little  notice  even  by  the  specialist,  compared 
to  its  fertility  as  a  source  of  neuralgic  and  catarrhal  affec- 
tions. 

Second,  because  I  can  report  the  result  of  treatment 
in  the  patients  mentioned. 

Of  the  three  cases  mentioned,  I  would  say,  two  oc- 
curred in  private  and  one  in  dispensary  practice,  illustrat- 
ing, I  think,  the  importance  of  intra-nasal  disease  as  a 
factor  in  middle-ear,  pharyngeal,  and  laryngeal  catarrh. 

Hoping  that  you  will  pardon  me,  I  read  the  notes  as 
in  the  original  article. 

Case  I. — Mr.  N ,  a  young  man  twenty-five  years 

of  age ;  native  born ;  generally  robust,  and  of  good 
family  history.  About  four  months  ago  he  noticed  an 
impairment  in  the  hearing  of  his  left  ear,  and  a  con- 
ti  nuous  noise  as  of  escaping  steam .  This  went  on  steadily, 
and,  when  he  came  to  me  for  treatment,  I  found  the  left 
drum  membrane  slightly  shrunken,  with  some  opacity, 
especially  in  posterior  quadrant ;  right  drum  membrane 
somewhat  inflamed  around  edges  and  over  malleus; 
left  hearing  distance,  T^ ;  right  hearing  distance,  { J|, 
or  normal. 

Examination  by  tuning-fork  showed  that  in  the  left 
ear  the  bone  conduction  was  ten  seconds  better  than  the 
air  conduction ;  right  ear  normal ;  left  Eustachian  tube 
alio  in  a  state  of  catarrhal  inflammation,  air  being  with 
difficulty  forced  through  it. 

With  such  proofs  before  us,  we  could  not  doubt  that ' 
the  trouble  was  one  of  catarrh  of  the  middle  ear.  No 
history  could  be  elicited  of  acute  trouble  following  any 
of  the  exanthematous  fevers,  or  of  pain  in  ears  at  any 
time;  but  by  posterior  rhinoscopy  I  found  the  post- 
nasal space  roomy,  numerous  varicose  veins  and  in- 
flamed patches  scattered  over  surface  of  membrane, 
particularly  in  neighborhood  of  Eustachian  tubes;  the 
posterior  ends  of  both  middle  and  inferior  turbinates 
covered  with  pale,  hypertrophied  tissue.  Anterior  rhi- 
noscopy showed  septum  a  little  deflected  to  right  with 
large  spur  in  lower  third  touching  and  pressing  against 
inferior  turbinated,  and  another  marked  thickening  in 
the  upper  third  projecting  in  front  of,  and  pressing 
against,  the  middle  turbinated,  which  was  also  enlarged ; 
left  nostril  pretty  well  filled  with  hypertrophied  tissue, 
the  whole  bathed  with  more  or  less  mucus. 

Upon  inquiry,  I  found  that  the  nasal  trouble  had  been 
with  him  for  a  long  time,  while  the  ear  affection  was  of 
comparatively  recent  origin,  and  we  cannot  doubt  that 
it  came  by  gradual  extension  from,  or  in  sympathy  with, 
the  catarrhal  inflammation  within  the  nose.  Do  not  un- 
derstand me  to  say,  in  all  cases  in  which  there  are  septal 
deflections,  ridges,  or  spurs,  we  will  find  catarrh  of  the 
middle  ear,  or  that  all  catarrhal  conditions  of  the  middle 
ear  come  from  septal  deformities ;  far  from  it     I  think 

1  Read  before  the  Onondaga  County  Medical  Society  September 
15,  1891.  Read  again  before  the  Syracuse  Medical  Association  March 
3i,  1893,  giving  result  of  treatment  in  the  cases  reported. 


there  are  many  such  deformities  that  are  perfectly  inno- 
cent, but  I  do  believe  that  whenever  a  deformity  or  over- 
growth in  any  portion  of  the  nose  causes  a  contact  be- 
tween two  surfaces  that  are  not  normally  in  contact,  we 
will  have  a  catarrhal  inflammation  arising  from  such  a 
contact,  which,  acting  in  conjunction  with  the  climatic 
influences  we  have  in  this  section,  is  very  liable  to  ex- 
tend to  either  the  ear  or  throat. 

Professor  St.  John  Roosa,  John  N.  McKensie,  and 
other  authorities  consider  that  fully  seventy-five  percent, 
of  all  ear  troubles  are  caused  by  intranasal  disease. 
McKensie  further  says,  in  vol.  viii.  of  the  "  Reference 
Hand-book:  "  "  It  is  impossible  to  exaggerate  the  part 
which  diseases  of  the  nose  play  in  the  production  of  in- 
flammatory conditions  of  the  middle  ear."  And  my  ex- 
perience thus  far,  gentlemen,  fully  confirms  this  view. 
In  fact,  since  my  attention  was  particularly  called  to  the 
middle  turbinated  bodies  by  an  article  in  the  New  York 
Medical  Journal,  vol.  li.,  p.  309,  1890,  written  by  Dr. 
O.  £.  Douglas,  of  New  York,  I  have  made  more  careful 
examinations  of  this  section  of  the  nose,  and,  as  yet, 
have  found  no  case  of  post-nasal,  middle  ear,  or  laryngeal 
catarrh  which  was  not  accompanied  by  marked  evidences, 
past  or  present,  of  pressure  or  contact  of  some  of  the  sur- 
faces in  this  region.    * 

Many  of  these  cases  have  shown  a  perfectly  normal 
condition  of  nose  in  lower  third,  both  inferior  turbin- 
ated apparently  healthy,  and  patients  claiming  that  they 
had  no  trouble  in  breathing,  each  nostril  being  perfectly 
free ;  their  complaint,  as  they  say,  "  is  further  back  or 
down,"  sometimes  in  the  ear,  sometimes  in  the  larynx, 
and  often  their  only  symptom  is  of  "  something  drop- 
ping into  the  throat." 

A  close  examination  of  the  upper  portions  of  the  nose 
will  show,  almost  invariably,  some  point  or  points  of 
contact  between  the  middle  turbinated  and  the  septum 
or  the  outer  wall  of  the  nose,  which,  though  slight  in 
many  instances,  is,  I  believe,  the  cause  of  a  great,  and 
perhaps  the  whole,  part  of  the  trouble,  particularly  if  the 
contact  be  persistent. 

Case  II. — Mr.  F is  a  public  speaker  with  the  well- 
known  clergyman's  sore  throat.  He  has  been  troubled 
since  childhood  witn  nostrils  closing  up  frequently,  and, 
at  certain  seasons  of  the  year,  having  asthmatic  attacks. 
Often  wakes  and  finds  that  he  has  been  sleeping  with  his 
mouth  open;  extreme  hoarseness  coming  on  with  the 
slightest  cold;  occasional  ringing  in  the  ears,  and  of 
late  an  excessive  amount  of  saliva.  One  year  ago  there 
was  a  complete  loss  of  voice  for  nearly  three  weeks. 

Upon  examination,  I  found  the  whole  pharynx  in- 
tensely congested;  posterior  wall  showing  granulated 
areas ;  uvula  (edematous ;  anterior  and  lateral  pillars  of 
fauces  infiltrated.  Post  nasal  space  showed  same  gen- 
eral appearance  as  the  pharynx.  An  anterior  view  of 
the  nostrils  disclosed  to  us  the  cause  of  his  troubles,  the 
membrane  of  both  inferior  turbinated  being  puffy  and 
thickened,  middle  turbinated  bodies  very  much  over- 
grown in  bony  and  membranous  formation. 

There  are,  of  course,  many  points  of  contact  and  some 
inflamed  and  thickened  tissue  that  must  be  relieved  be- 
fore we  can  expect  to  do  our  patient  permanent  good, 
granting  that  the  nasal  abnormality  is  the  cause  of  his 
pharyngitis.  In  this  instance,  we  have  a  man  who  uses 
his  voice  excessively,  and  at  times,  when  he  is  weary,  I 
have  no  doubt  his  vocal  production  is  faulty.  That,  of 
course,  has  its  influence  on  his  condition,  and  will  have 
to  be  looked  into  and  corrected. 

In  support  of  this  plan  of  treatment,  I  will  quote  from 
Lenox  Brown,  of  London,  in  his  last  edition  of  "  Disease 
of  the  Throat,"  p.  117.  He  says:  "I  have  seldom 
failed  to  find  the  cause  of  the  vocal  lesion  in  the  nose  or 
pharynx,  and  a  cure  effected  by  surgical  treatment  of 
those  regions,  supplemented  by  educational  correction 
of  a  functional  fault  in  production." 

I  will  not  weary  you  with  the  full  notes  of  Cask  HI. — 
Suffice  to  say  that  he  is  a  German,  age  twenty-two,  re- 
ferred to  me  by  Dr.  S ;  general  health  good ;  been  in 


August  1 8,  1894] 


MEDICAL   RECORD. 


205 


this  country  one  year,  and  for  past  three  months  has  had 
difficulty  with  his  throat ;  voice  husky  and  easily  fatigued, 
it  having  been,  at  one  time,  entirely  lost.  He  first 
noticed  a  fulness  in  his  head  and  nose  ten  months  ago. 

Examination  showed  a  decidedly  inflamed  larynx, 
pharynx  infiltrated  with  a  very  red  track  extending  up 
along  lateral  walls  to  po&t  nasal  space ;  turbinated  bodies 
puffy  and  in  stage  of  commencing  hypertrophy ;  bony 
union  between  left  inferior  turbinated  and  lower  third 
of  septum ;  many  points  of  contact  in  both  nostrils. 

Topical  applications  to  the  vocal  bands  and  pharynx 
have  reduced  the  inflamed  conditions  existing  there. 
Cleansing  and  applications  to  the  nasal  tissues,  have 
given  him,  for  the  present,  a  good  breathing  space, 
though  the  bridge  of  bone  and  some  points  of  contact 
still  remain. 

Are  we  warranted  in  considering  these  contacts  and 
deformities  as  etiological  factors  of  his  laryngeal  trouble? 

Referring  to  Sajous's  recent  work  on  "  Diseases  of  the 
Nose  and  Throat,"  p.  336,  we  find  that  he  says: 
"  Chronic  inflammation  of  the  vocal  bands  may  result 
from  repeated  attacks  of  subacute  laryngitis  in  connec- 
tion with  acute  pharyngitis,  but  in  the  majority  of  cases 
it  assumes  the  chronic  form  from  the  first,  unpreceded 
by  acute  symptoms.  Hypertrophic  rhinitis  is  a  frequent 
complication  of  this  affection,  the  chronic  catarrhal  in- 
flammation extending  by  continuity  of  tissue  to  the 
larynx,  which  is  itself  made  subject  to  all  the  exacerba- 
tions which  the  nasal  disease  undergoes.  A  more  fre- 
quent connection  between  the  two  diseases,  however,  is 
the  irritation  kept  up  by  the  post  nasal  discharges,  which 
either  drop  into  the  larynx,  or  trickle  down  along  the 
posterior  pharyngeal  wall  until  the  interarytenoid  com- 
missure is  reached;  here  they  accumulate  to  a  degree, 
and  maintain  the  posterior  portion  of  the  larynx  in  a 
constant  state  of  irritation,  which  is  further  aggravated 
by  the  coughing  and  hacking  induced.  This  cause  of 
chronic  laryngitis  is  insisted  upon  by  Bosworth,  and  I 
can  well  confirm  his  opinion." 

Regarding  prognosis  Professor  Douglass,  in  his  very 
able  article  before  referred  to,  says :  "  Chronic  nasal 
catarrh,  so  called,  is  not  so  difficult  of  cure  as  has  been 
supposed,  for  it  is  the  result  of  removable  causes  in  most 
cases." 

In  the  face  of  these  authorities,  and  the  light  of  our 
present  knowledge,  what  shall  we  do  with  cases  of  chronic 
nasal,  aural,  and  laryngeal  inflammation  ?  Shall  we  patch 
them  up  with  a  gargle  or  spray,  and  send  them  adrift  to 
soon  become  the  prey  of  some  quack  who  has  push,  en- 
terprise, and  the  newspaper  to  help  him ;  or,  shall  we  see 
that  they  continue  on  to  a  removal  of  the  cause,  re- 
lieving the  point  of  contact  or  pressure  by  such  opera- 
tive procedure  as  may  be  necessary,  and  carrying  out 
the  other  treatment  as  may  be  indicated  ? 

If  we  follow  our  plain  duty,  I  believe  that  our  results 
will  be  very  satisfactory,  and  we  can  confidently  expect 
to  soon  throw  off  the  weight  of  opprobrium  that  has  been 
hanging  upon  us  as  a  profession  because  of  our  failure 
in  the  past  to  cure  "  catarrh." 

Since  reading  the  above  before  the  County  Society, 
gentlemen,  I  have  continued  treatment  in  the  cases 
mentioned.  Perhaps  a  description  of  their  present  con- 
dition will  be  of  interest  to  you. 

Case  I. — The  young  man  with  middle-ear  catarrh  has 
proved  especially  interesting  to  me,  strengthening  my  be- 
lief that  pressure  or  contacts  in  the  middle  turbinated  re- 
gions, have  a  marked  influence  over  middle-ear  troubles. 
During  the  first  of  his  course  of  treatment  I  removed  by 
the  saw  the  shelf  of  bone  spoken  of,  and  by  the  galvano- 
cautery  enough  of  the  hypertrophied  tissue  to  give  him 
sufficient  breathing  space,  meanwhile  treating  the  ear 
carefully  by  inflation,  vaporizing  through  Eustachian  ca- 
theter, etc. 

At  the  end  of  three  months  we  found  that  no  improve- 
ment had  been  made  in  his  hearing  distance,  though  his 
nasal  catarrh  was  considerably  relieved.  I  urged  him 
to  submit  to  a  removal  of  a  bean-like  enlargement  found 


on  each  middle  turbinated,  pressing  against  the  anterior 
wall  of  the  nose.  This  he  refused,  and  I  lost  sight  of 
him  until  December  14,  1892,  when  he  returned,  and 
examination  showed  right  hearing  distance  fj#,  left 
hearing  distance  y^,  a  loss  of  three  inches  since  first 
examination. 

During  the  six  months  following  I  operated  on  the 
growths  mentioned,  with  the  result  that  his  hearing  dis- 
tance in  affected  ear  was  increased  to  ^\,  a  gain  of  nine 
inches.  Unfortunately  he  was  called  out  of  town,  and 
we  were  again  interrupted,  though  I  am  informed  that 
he  continues  to  improve.  The  same  aural  medication 
was  given  in  this  as  in  his  first  course  of  treatment. 

If  I  had  not  already  trespassed  too  much  on  your  time, 
I  would  read  you  notes  of  several  more  cases,  in  which 
equally  as  good  and  better  results  have  been  attained  af- 
ter similar  operation  in  the  olfactory  region,  but  in 
which  my  most  careful  ear  treatment  had  failed  to  in- 
increase  their  hearing  distance  previous  to  relieving  the 
contacts  and  pressures  in  the  upper  regions  of  the  nose. 

Added  experience  and  the  recent  observations  of  good 
authorities,  notably  the  article  on  "  Cyst  of  the  Middle 
Turbinated  Bone,"  written  by  Professor  Charles  H. 
Knight,  have  substantiated  the  opinion  I  expressed  in 
1 89 1,  that  pressures  or  contacts  in  the  middle  turbinated 
region  were  very  important,  and  I  would  urge  all  who 
are  doing  intra-nasal  work  to  examine  this  section 
thoroughly,  not  alone  because  of  its  relation  to  ear  and 
throat  troubles,  but  because  of  its  close  connection  with 
asthma,  hemicrania,  and  neuralgic  affections  of  the 
head. 

Operations  here  are  not  necessarily  painful,  if  two  or 
three  applications  of  a  twenty  per  cent,  solution  of  co- 
caine be  carried  well  in  and  along  the  lateral  surfaces  of 
the  offending  overgrowth;  neither  are  they  attended 
with  much  danger  if  proper  after-tieatment  be  given, 
though  close  discrimination  should  be  used  about  the  ex- 
tent and  manner  of  operating,  removing  only  such  por- 
tions as  is  necessary  to  relieve  the  pressure  or  contact. 

Case  II. — The  clergyman  has  had  a  full  course  of 
operative  treatment,  and  a  most  satisfactory  result. 
During  the  past  year  he  has  had  no  attack  of  asthma, 
no  pharyngitis,  laryngitis,  or  ringing  in  the  ears ;  neither 
has  he  been  bothered  by  repeated  colds,  nor  a  stuffed-up 
nose.  In  a  conversation  last  week  he  told  me  that  he 
could  not  estimate  in  money  the  benefit  he  had  de- 
rived. The  specimens  I  now  show  you  I  removed  from 
his  nose  by  the  cold  snare.  As  you  will  see,  they  are 
partly  cystic  in  character,  and  of  unusual  size  (see  photo- 
graph). 


Case  III. — The  young  German  continued  his  treat- 
ment until  the  symptoms  complained  of  were  relieved, 
the  voice  being  fully  restored.  The  shelf  across  left  nos- 
tril was  removed  by  the  electro-trephine,  consequently 
the  pieces  taken  out  were  not  saved,  though  I  recollect 
that  it  was  a  common  osseous  growth  about  an  inch  long. 

In  conclusion,  let  me  say  that  I  have  no  doubt  the 
notes  of  other  specialists  will  show  fully  as  good  results 
as  those  I  have  mentioned,  and  I  would  respectfully  ask 
the  general  practitioner  to  not  pass  over  the  articles  in 
his  journals  relating  to  rhinology,  otology,  or  laryngology, 
but  stop  and  carefully  read  a  few  of  them.  If  he  does  so, 
I  think  disparaging  remarks  made  about  the  treatment 
of  chronic  catarrhal  affections  will  be  less  frequent. 

117  East  Jefferson  Strrrt. 


The  Duke  of  Westminster,  although  he  is  a  vice- 
president  of  St.  George's  Hospital,  refuses,  so  it  is  re- 
ported, to  let  any  of  his  houses  in  the  West  End  of  Lon- 
don to  medical  men,  fearing  that  their  presence  will 
frighten  away  his  fashionable  tenants. 


206 


MEDICAL    RECORD. 


[August  1 8,  1894 


GUNSHOT  WOUND  OF  LUNGS  AND  HEART, 
WITH  SURVIVAL  OF  PATIENT  FOR  FIF- 
TEEN HOURS. 

By  JAMES  P.   MARSH,  M.D., 

TROY,  N.  Y. 

On  April  19,  1894,  at  about  4  p.m.,  D.  R ,  aged  fifty 

years,  and  previously  in  good  health,  received  a  pene- 
trating wound  of  the  thorax.  The  weapon  used  was  pre- 
sumably a  revolver,  shooting  cartridges  known  as  32- 
shot. 

I  was  called  and  arrived  about  twenty  minutes  after 
the  reception  of  the  injury.  He  was  perfectly  conscious 
but  in  an  extreme  state  of  shock,  pulseless  at  the  wrist, 
and  the  heart-sounds  very  faint.  On  the  right  side  of 
the  thorax,  in  the  posterior  axillary  line,  and  entering  in 
the  seventh  intercostal  space,  was  a  punctured  wound, 
but,  noticeably,  no  hemorrhage  occurring  externally. 
Over  the  entire  right  lung  were  numerous  mucous  rales. 
Between  the  nipple  and  the  sternum,  on  the  left  side,  was 
au  area  of  blood  extravasation  about  two  inches  in  diam- 
eter, and  in  the  centre  of  this  area  could  be  felt  a  small 
hard  mass,  presumably  a  bullet.  While  I  was  present 
the  patient  only  once  raised  a  small  amount  of  slightly 
blood  stained  sputa. 

I  ascertained  that  after  receiving  his  wound  D.  R 

walked  or  ran  some  twenty  feet  and  gave  an  alarm,  be- 
fore he  sank  exhausted  and  was  carried  into  the  house 
where  I  found  him.  From  the  family  physician,  who  as- 
sumed charge  of  the  case,  I  learned  that  D.  R ral- 
lied almost  completely  from  the  shock,  that  he  did  not 
raise  any  bloody  sputa,  that  there  were  no  signs  of  peri- 
cardial involvement,  that  the  right  thorax  remained  tym- 
panitic anteriorly  (as  regards  the  posterior  portion  it 
was  not  thought  best  to  examine  on  account  of  the  pa- 
tient's condition),  and  that  he  was  rational  to  the  end, 
which  came  at  about  7.20  a.m.  of  April  20th,  some  fif- 
teen hours  after  the  shooting. 

Dr.  M.  F.  Phelan  and  myself  having  been  directed  by 
the  coroner  to  make  an  autopsy,  we  proceeded  to  do 
so  at  3  p  m.  on  April  20th,  the  notes  of  which  examina- 
tion are  as  follows : 

Rigor  mortis  pronounced.  The  body  is  well  nourished. 
Two  inches  to  the  left  of  the  median  line,  and  five  inches 
below  the  clavicle,  is  a  marked  dark  blue  discoloration  of 
the  skin.  This  area  is  two  and  one  half  inches  in  diam- 
eter and  in  the  centre  is  a  small  hard  mass,  presumably  a 
bullet.  On  the  right  side  of  the  thorax  in  the  posterior 
axillary  line,  and  about  three  inches  below  the  posterior 
fold  of  the  axilla,  is  a  punctured  wound  with  an  area  of 
blood  extravasation  around  it.  This  wound  passes  be- 
tween the  seventh  and  eighth  ribs  in  an  upward  and  for- 
ward direction.  There  is  also  a  marked  bulging  of  the 
right  side  of  the  thorax.  There  is  emphysematous  crep- 
itation over  the  anterior  part  of  the  thorax,  most 
marked  in  the  left  infraclavicular  and  mammary  re- 
gions. An  incision  into  the  area  of  blood  extravasation 
in  the  left  side  reveals  a  bullet,  32-shot,  embedded  in 
the  subcutaneous  fat  one  and  three-quarters  inch  to  the 
left  of  the  median  line  of  the  body. 

Abdominal  fat  three-quarters  of  an  inch  thick,  sub- 
peritoneal fat  normal.  The  diaphragm  is  at  the  fifth  in- 
tercostal space  on  each  side.  The  stomach  is  distended 
with  gas.  The  bullet  wound  in  the  sternum  is  just  within 
the  juncture  of  the  same  with  the  left  fourth  costal  car- 
tilage, and  a  transverse  fracture  of  the  bone  is  produced 
at  this  point.  The  right  pleural  cavity  contains  one 
quart  of  coagulated  and  fluid  blood.  Left  pleural  cavity  is 
normal.  The  pericardium  shows  anteriorly  blood  infil- 
tration, and  contains  about  one  ounce  of  fluid  and  coagu- 
lated blood.  At  the  right  superior  side  it  is  penetrated  by 
two  bullet  holes  which  are  three-quarters  of  an  inch  apart. 
The  right  auricle,  at  the  dog's  ear,  has  a  small  area  of 


extravasation,  and  apparently  a  small  puncture  exists. 
The  auricle  opened  shows  a  puncture  about  one  line  in 
diameter,  and  this  puncture  is  closed  by  a  soft  ante-mor- 
tem clot  one-fourth  inch  in  diameter.  The  remainder  of 
the  heart  structure  is  normal. 

The  right  lung  shows  a  large  ragged  gash  on  the  pos- 
terior surface  of  the  lower  lobe,  .which  in  extending  to 
the  middle  lobe  is  converted  into  a  punctured  wound 
and  passes  out  in  the  anterior  and  upper  border,  and 
then  gutters  the  upper  lobe  for  about  one  inch. 

The  wound  in  the  right  thorax  passes  through  the 
seventh  intercostal  space,  tearing  away  the  lower  border 
of  the  seventh  rib  and  about  one  inch  of  the  intercostal 
artery.  The  liver,  intestines,  and  kidney  are  normal. 
The  brain  is  not  examined.  Track  of  bullet :  It  entered 
at  the  seventh  intercostal  space  in  the  posterior  axillary 
line,  fractured  the  lower  margin  of  the  seventh  rib,  sev- 
ering the  intercostal  artery,  thence  forward  into  the 
outer  and  posterior  surface  of  the  lower  lobe  of  the  right 
lung,  thence  through  the  central  portion  of  the  middle 
lobe,  and  from  thence  to  the  lower  and  anterior  surface 
of  the  upper  lobe,  hence  into  the  pericardium,  again  to 
the  auricle  of  the  heart,  thence  out  of  the  pericardium 
into  and  through  the  sternum  to  the  subcutaneous  fat 
where  it  was  found. 

From  this  it  follows  that  D.  R was  in  a  stooping 

position  when  he  was  shot.  This  adds  another  to  the  list 
of  cases  of  wounds  of  the  heart  which  have  occurred 
without  producing  immediate  death. 


SKIN   GRAFTING. 
By   WILLIAM   H.    MARCY,    M.D., 

BUFFALO,    N.    Y. 

Having  washed  the  healthy  granulations  with  mercuric 
bichloride  1  to  3,000,  or  carbolic  acid  two  percent.,  and 
the  part  furnishing  grafts  with  1  to  1,000  bichloride, 
and  lastly  with  distilled  water,  instead  of  lifting  the  skin 
with  a  needle,  or  instrument  which  injures  the  graft, 
I  have  a  sharp  pair  of  straight  scissors  with  two-inch  cut- 
ting blade.  I  press  the  open  scissors  upon  the  skin  suf- 
ficiently to  bulge  the  integument  between  the  blades,  and 
gently  close,  catching  one  end  of  the  skin,  and  then  in- 
crease or  lessen  pressure  according  to  the  thickness  of 
the  bulging  skin,  and  at  the  same  time  cut.  In  this  way 
I  can  secure  a  graft  from  a  millimetre  to  a  centimetre 
long,  taking  only  the  epidermis.  The  graft  is  then  lifted 
by  a  fine  pair  of  tweezers  from  the  blade  of  the  scissors, 
and  placed,  cut  surface  down,  on  the  granulations.  In- 
stead of  applying  protective  of  pure  rubber  or  gutta- 
percha tissue,  and  over  the  protective  a  wet  compress 
followed  by  oiled  silk,  a  pad  of  absorbent  cotton  and 
bandage,  I  simply  strap  the  grafts,  after  leaving  them 
exposed  fifteen  to  twenty  minutes,  with  adhesive  plaster. 
The  strips  are  applied  basket  fashion,  as  one  would  strap 
an  ulcer.  If  a  discharge  is  to  be  anticipated,  we  may 
leave  a  small  opening  in  the  plaster  to  favor  drainage, 
removing  the  straps  in  thirty- six  to  forty-eight  hours,  or 
we  may  remove  the  straps  in  ten  hours,  and  allow  dis- 
tilled water  to  trickle  over  the  grafts,  then  reapplying 
the  adhesive  plaster.  I  now  put  on  one  or  two  turns  ot 
bandage,  sometimes  putting  one  layer  of  iodoform  gauze 
between  the  strap  and  bandage. 

The  advantage  of  the  adhesive  plaster  is  threefold, 
viz.,  1.  You  can  press  the  grafts  so  tightly  into  the 
healthy  granulations  that  they  cohere  so  that  no  dis- 
charge can  lift  the  graft  from  the  granulation.  2.  No 
dressing  will  hold  the  grafts  in  place,  keep  the  parts  at 
rest,  and  lessen  the  discharge  so  well  as  straps  applied  in 
this  way.  3.  In  removing  the  dressing  there  is  no  dan- 
ger of  the  grafts  clinging  to  the  plaster,  as  the  moisture 
collects  between  the  strap  and  graft,  preventing  adhesion. 
Even  after  subjecting  the  tissues  to  an  injection  of  co- 
caine (four  per  cent.),  I  have  dissected  off  grafts  two  cen- 
timetres square,  and  they  rarely  fail  to  live  when  dressed 
this  way. 


August  1 8,  1894] 


MEDICAL    RECORD. 


207 


'Medical   Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


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


New  York,  August  18,  1894. 


THE  DISPOSAL  OF  GARBAGE. 

About  ten  years  ago  the  city  of  New  York  purchased 
Riker's  Island  for  %  180,000.  The  purchase-money  was 
taken  from  funds  of  the  Department  of  Charities  and 
Correction,  the  ultimate  intention  being  to  place  some 
institutions  of  that  department  on  the  island.  The  sug- 
gestion was  made  that  if  the  penal  institutions  were  re- 
moved from  Blackwell's  Island,  the  southern  portion  of 
that  island  would  make  a  fine  public  park.  The  penal 
institutions  could  be  transferred  to  Riker's  Island,  but  as 
preliminary  to  such  transfer  it  would  be  necessary  to  re- 
claim some  hundreds  of  acres  of  submerged  land. 

Such  reclamation  has  recently  been  attempted.  Bulk- 
heads were  built  about  a  portion  of  the  submerged  lands, 
and  refuse  from  the  city  was  dumped  there  for  several 
months  of  the  present  year,  until  land  to  the  extent  of 
about  thirty  acres  had  been  "  made."  Thus  far  matters 
seemed  to  progress  famously. 

But  then  came  the  hot  weather  of  June  and  July,  and 
with  it  a  natural  sequence  of  events.  About  one-fourth 
of  the  bulk  of  refuse  used  is  putrescible  matter — in  other 
words,  garbage,  well  sown,  of  course,  with  bacteria. 
Stimulated  by  the  favorable  weather  and  the  abundant 
food-supply,  the  bacteria  proceeded  to  multiply  and  feast 
after  the  manner  of  their  kind,  and  in  consequence  the 
new  "  land  "  at  Riker's  Island  sent  forth  a  stench  that 
was  far-reaching  and,  to  human  olfactories,  highly  ob- 
jectionable. As  a  further  natural  sequence  of  events, 
the  residents  of  such  portions  of  New  York  as  lie  within 
range,  so  to  speak,  of  Riker's  Island  threatened  the  city 
authorities  with  mob  law  if  the  nuisance  were  not 
abated.  So  the  scheme  for  making  land  at  Riker's  Isl- 
and was  prematurely  interrupted,  and  the  city  authori- 
ties were  at  their  wits'  ends  to  know  how  to  remedy  the 
stupendous  blunder  they  had  made.  Parenthetically, 
one  may  wonder  why  they  made  the  blunder  in  the  first 
place,  since  they  had  already  had  a  similar  experience  at 
Hart's  Island.  And  for  that  matter,  even  without  such 
experience,  it  ought  not  to  require  occult  powers  of  divi- 
nation to  predict  that  half  a  million  tons  of  mixed  refuse 
piled  together  in  one  spot  would  produce  a  bad  smell  in 
the  present,  and  very  undesirable  building  lots  in  the 
future. 

Be  that  as  it  may,  the  blunder  was  made.  It  is  not 
yet  altogether  remedied,  nor  is  it  plain  as  to  how  it  can 
be  remedied.  The  temporary  nuisance  has,  however, 
been  abated  in  a  very  interesting  way.     A  unique  dis- 


infecting plant  was  established  on  a  boat  anchored  beside 
the  island.  This  plant  consists  essentially  of:  r,  two 
dynamos;  2,  four  vats  each  capable  of  holding  one 
thousand  gallons  of  sea- water;  and  3,  steam- pumps  for 
filling  the  vats  and  disposing  of  their  effluent.  In  each 
of  the  vats  a  set  of  four  electrodes  of  platinum  and  zinc 
are  immersed,  the  current  from  each  dynamo  passing 
through  two  sets  of  electrodes.  When  in  operation, 
chemical  action  in  the  sea-water  is  manifested  by  the 
liberation  of  bubbles  of  gas  about  the  electrodes.  The 
water  acquires  a  distinct  chlorine  odor.  What  actually 
occurs  is  the  transposition  of  the  chlorides  of  the  sea- 
water  into  hypochlorites,  and,  it  is  claimed,  the  produc- 
tion of  a  certain  amount  of  ozone.  The  germicidal 
properties  of  the  hypochlorites  have  long  been  well 
known.  The  process  of  producing  them  on  a  large  scale 
from  sea- water  appears  to  be  the  discovery  of  Mr.  A.  E. 
Woolf,  who  claims  that  the  Hermite  process  now  under 
investigation  in  Europe  (and  recently  described  in  the 
Record)  is  an  imperfect  copy  of  his  methods. 

There  is  no  room  for  doubt  that  the  electrolyted  sea- 
water  is  a  powerful  deodorizer.  At  the  rate  of  almost 
one  hundred  thousand  gallons  a  day,  it  has  been  sprayed 
upon  the  offensive  ground  at  Riker's  Island  for  some 
weeks  past,  and  the  entire  surface  of  the  putrefying  mass 
has  been  rendered  inodorous,  as  we  can  testify  from  per- 
sonal inspection.  This,  of  course,  is  but  a  temporary 
expedient.  What  will  finally  be  done  in  the  matter  re- 
mains to  be  seen. 

It  is  said  that  our  Street  Cleaning  authorities,  encour- 
aged by  the  apparent  success  of  their  deodorizing  plant 
at  Riker's  Island,  have  contemplated  the  establishment 
of  similar  plants  at  the  refuse  dumps  in  the  city,  with  the 
intention  of  using  the  deodorized  refuse  to  continue  the 
filling  in  at  Riker's  Island.  Such  a  plan  cannot  be  too 
severely  condemned.  An  almost  irretrievable  blunder 
has  already  been  made  at  Riker's  Island — a  blunder  that 
has  cost  the  city  dear,  and  which  may  prove  even  more 
expensive  to  future  generations.  That  the  persons  who 
committed  this  inexcusable  blunder  should  now  talk  of 
adding  to  it  in  kind  is  nothing  less  than  outrageous. 
The  matter  is  one  that  should  have  the  attention  of 
citizens  in  general  and  physicians  in  particular.  Public 
sentiment  should  see  to  it  that  not  another  foot  of  ground 
in  or  about  New  York  is  "  made  "  of  putrescible  garbage. 
Follies  enough  of  that  nature  may  be  charged  against 
our  predecessors.  A  generation  that  boasts  the  develop- 
ment of  a  science  of  sanitation  should  not  add  to  them. 
To  reclaim  the  submerged  lands  at  Riker's  Island,  and 
elsewhere,  is  a  capital  scheme.  But  before  the  refuse  of 
the  city  can  be  utilized  for  this  purpose  the  putrescible 
portion  of  it  must  be  rendered  innocuous  by  fire.  No 
other  agent  will  fit  organic  matter  for  such  use.  With 
non-putrescible  refuse,  and  the  ash  of  cremated  garbage, 
the  city  may  reclaim  hundreds  of  acres  of  valuable  land. 
But  to  attempt  to  reclaim  these  lands  with  mixed  refuse, 
as  has  been  done  in  the  past,  is  a  crime  against  future 
generations. 

Chlorate  of  Sodium  is  highly  recommended  by  Bris- 
saud  in  the  treatment  of  carcinoma  of  the  stomach.  He 
gives  it  in  doses  of  four  to  eight  drachms  per  diem.  The 
presence  of  albumin  in  the  urine  is  the  only  contraindi- 
cation to  the  use  of  the  drug. 


208 


MEDICAL  RECORD. 


[August  1 8,  1894 


AN  EARLY  OVARIOTOMIST. 

The  younger,  and  most  of  the  older,  members  of  the 
profession  in  America  have  little  conception  of  the  vio- 
lent opposition  there  was,  fifty  and  even  thirty  years  ago, 
to  the  performance  of  operations  on  the  abdominal  cav- 
ity. Those  who  undertook  such  operations  in  the  face 
of  almost  universal  condemnation  did  so  with  their  repu- 
tations in  their  hands.  They  believed  they  were  right 
and  they  had  the  courage  of  their  convictions,  but  their 
courage  was  of  no  mean  order,  and  entitles  them  to 
grateful  recognition  by  posterity.  We  have  all  heard  of 
McDowell  and  Rogers  and  the  Atlees,  but  we  doubt  if 
the  name  of  Dunlap  is  as  familiar  to  our  readers  as  it  de- 
serves to  be. 

At  the  recent  meeting  of  the  American  Gynecological 
Association  in  Washington,  Dr.  J.  C.  Reeve  read  a  most 
interesting  memoir  (New  York  Journal  of  Gynecology 
and  Obstetrics,  June,  1894)  of  this  pioneer  ovariotomist, 
Dr.  Alexander  Dunlap,  of  Springfield,  O.,  whose  death, 
at  the  ripe  old  age  of  seventy- nine,  occurred  in  January 
last.  Dr.  Dunlap  was  born  in  Ohio,  received  his  educa- 
tion, both  academic  and  medical,  in  that  State,  married 
there,  practised  there,  and  died  there.  He  was  not  a 
cultured  man  in  the  ordinary  acceptation  of  that  term, 
nor  were  books  his  companions.  He  studied,  as  most 
men  of  his  time  were  obliged  to  study,  in  the  school  of 
experience.  He  knew  little  of  what  his  predecessors  had 
done  or  his  contemporaries  were  doing,  but  struck  out 
new  paths  for  himself,  undeterred  by  the  reprobation  of 
others  less  original  and  less  courageous,  and,  in  his  igno- 
rance of  what  other  great  minds  had  conceived  and  exe- 
cuted, unencouraged  by  their  success. 

Dr.  Dunlap's  first  ovariotomy  was  performed  in  1843, 
and  up  to  1868  his  cases  numbered  thirty- eight.  Of 
these  nine  had  resulted  fatally,  one  from  an  overdose  of 
morphine  administered  by  mistake.  During  his  entire 
career  he  performed  four  hundred  and  twenty- eight  ab- 
dominal sections,  with  eighty-three  per  cent,  of  recoveries. 

His  method  of  operating  was  primitive  in  the  extreme. 
Dr.  Reeve  assisted  him  in  some  of  his  earlier  cases,  and 
the  following  are  his  words  in  describing  them  : 

"  Scalpel,  forceps,  and  director  were  the  only  instru- 
ments provided.  The  abdomen  was  opened,  the  cyst  ex- 
posed, then  incised  with  the  scalpel,  and  its  contents 
caught  in  a  wash-basin.  Adhesions  were  separated  as 
the  cyst  was  withdrawn,  or  the  incision  was  extended 
without  hesitation  in  order  to  gain  access  to  them. 
Bleeding  from  separated  adhesions  was  checked  by  the 
application  of  cold  water.  In  one  case  this  was  con- 
tinued for  twenty  minutes  and  no  evil  results  followed. 
In  closing  the  wound  the  stitches  were  not  passed  through 
the  peritoneum.  The  pedicle  was  transfixed  with  a  lig- 
ature of  heavy  silk,  each  half  tied  separately,  then  one 
end  carried  around  the  whole  and  tied  again  ;  one  end 
was  then  cut  short  and  the  other  brought  out  at  the  lower 
angle  of  the  wound,  there  to  haug  until  separated  by 
process  of  ulceration*  This  always  required  weeks,  some- 
times many  months.  In  the  case  of  a  girl,  aged  thirteen, 
operated  on  by  the  writer,  where  this  plan  was  followed, 
more  than  a  year  elapsed  before  the  ligature  came  away, 
and  this  in  spite  of  all  measures  to  hasten  it.  This  mode 
of  treatment  of  the  pedicle  seems  very  strange  in  view  of 
the  fact  that  in  Dr.  Dunlap's  first  case  both  ends  of  the 


ligature  were  cut  short,  the  pedicle  dropped  back,  and  the 
wound  closed.  There  is  not  the  slightest  probability  that 
Dr.  Dunlap  knew,  even  as  late  as  1868,  that  this  was  the 
plan  pursued  by  Nathan  Smith,  in  182 1,  the  second  op- 
erator in  the  United  States,  and  by  D.  L.  Rogers,  of 
New  York,  the  fourth,  in  1829.  It  looks  very  mych  as 
if,  after  his  first  case,  he  informed  himself  as  to  the  plan 
followed  by  McDowell  and  Atlee,  and  made  this  step 
backward  under  the  influence  of  their  example. " 

"  The  treatment  received  by  Dr.  Dunlap,"  says  the 
author  of  this  most  interesting  biographical  sketch,  "  was 
of  the  same  kind  as  that  meted  out  to  McDowell.  The 
comments  of  the  Medico- Chirurgical  Review  of  London, 
then  the  leading  journal  of  the  world,  upon  his  operation 
are  well  known  :  '  We  entirely  disbelieve  that  it  has  ever 
been  performed  with  success — nor  do  we  think  it  ever 
will ! '  The  extent,  the  bitterness,  the  persistency  of  the 
opposition  to  ovariotomy,  the  denunciation  of  those  who 
performed  it,  can  scarcely  be  imagined  now.  It  is  re- 
corded in  the  pages  of  Peasleeand  of  Atlee.  Nor  was 
this  feeling  confined  to  this  country.  Mr.  Ernest  Hart 
has  recently  told  us  that  in  London,  during  the  first  at- 
tempts at  ovariotomy,  Dr .  Robert  Lee,  then  the  leading 
obstetrician,  openly  stated  that  he  was  watching  for  a 
fetal  case  that  he  might  cause  the  operator  to  be  legally 
prosecuted !  He  who  now,  after  fifty  years  of  service, 
would  indicate  the  most  striking  contrast  between  the 
profession  as  it  is  to-day  and  as  it  was  when  he  entered  it, 
would  not  find  that  contrast  in  the  possession  of  anaes- 
thetics nor  in  the  triumphs  of  abdominal  surgery,  where 
even  ovariotomy  has  sunk  to  a  position  of  minor  impor- 
tance ;  but  he  would  find  it  in  the  different  spirit  with 
which  new  doctrines,  new  measures,  and  new  operations 
are  received.  The  Zeitgeist  of  medicine  has  taken  on  an 
entirely  different  form  from  that  of  a  generation  ago." 


THE   DEVELOPMENT    OF  THE    RAILWAY 
SURGEON. 

The  growth  of  the  railway  surgeon  and  of  railway  surgi- 
cal service  is,  we  believe,  a  feature  of  professional  devel- 
opment peculiar  to  this  country. 

There  are  at  present  147,704  miles  of  railways  in  the 
United  States  and  Canada,  and  all  but  17,088  miles  are 
watched  over,  more  or  less,  by  surgeons  in  the  employ 
of  the  corporations.  The  total  number  of  railway  sur- 
geons is  5,466.  The  railways  which  possess  a  hospital 
system  cover  36,751  miles ;  railways  with  a  relief  service, 
13,446  miles;  and  railways  with  a  surgical  service  and 
chief  surgeon,  44,281  miles.  There  is  a  National  Asso- 
ciation of  Railway  Surgeons  with  a  membership  of  1,767 
and  an  organ  called  The  Railway  Surgeon. 

According  to  this  journal  there  are  over  1 20  chief  sur- 
geons, representing  82,032  miles  of  railway  employing 
3,384  surgeons,  "all  of  which  [sic]  are  working  har- 
moniously under  a  chief  surgeon,  who  in  each  instance 
has,  to  a  greater  or  less  extent,  charge  of  the  surgical 
department  of  the  company  he  represents.  We  have 
great  reason  to  rejoice  and  be  glad  and  to  congratulate 
this  association  on  the  work  it  has  accomplished." 

The  Railway  Surgeon  admits  that  there  are  some  who 
assert  that  there  is  no  special  field  for  railway  surgery, 
which  really  cannot  differ,  so  far  as  we  can  see,  from  any 
other  surgery.     We  have  also  heard  the  complaint  that 


August  18/1894] 


MEDICAL   RECORD. 


209 


railway  surgeons  were  notoriously  incompetent  in  neuro- 
logical diagnosis,  and  that  there  was  more  need  of  rail- 
way neurology  and  medicine  than  of  surgery. 

We  have  no  doubt,  however,  that  the  organization  of 
railway  surgeons  into  a  national  body  will  promote  the 
material  interests  of  the  surgeons  and  render  the  work 
done  by  them  more  effective. 


f|imr8  at  tfoe  WLztfo. 

Fear  of  Premature  Burial.— The  will  of  the  late  Mr. 
Edmund  Yates  contained  a  clause  in  which  he  expressed 
the  desire  that  his  jugular  vein  should  be  opened  imme- 
diately after  the  physician  had  pronounced  him  dead,  in 
order  to  prevent  any  possibility  of  his  being  buried 
alive.  The  medical  man  who  performed  the  operation 
was  to  receive  a  fee  of  twenty  guineas. 

The  Inheritance  of  Insanity.— Dr.  G.  Fielding 
Blandford,  President  of  the  Psychological  Section  of  the 
British  Medical  Association,  took  as  the  subject  of  his 
opening  address,  "  The  Prevention  of  Insanity."  One 
of  the  most  important  factors  in  the  etiology  of  the  dis- 
ease, he  said,  is  heredity.  Sir  Benjamin  Ward  Richard- 
son has  made  the  assertion  that  insanity  is  transmitted 
through  the  male  line,  but  the  speaker  held  that  the  re- 
verse is  the  case,  the  taint  passing  through  the  female 
line  rather  than  the  male.  He  did  not,  however,  insist 
so  strongly  on  this  point,  holding  that  the  safest  rule 
was  that  no  one,  man  or  woman,  who  had  had  an  attack 
of  insanity,  should  marry. 

Gift  of  Br.  Wilson  Fox's  Plates  of  Diseases  of  the 
Longs  to  Medical  Schools.— In  a  letter  to  The  Medical 
Press  and  Circular,  Drs.  Sidney  Coupland  and  W.  R. 
Gowers  direct  the  attention  of  the  managers  of  medical 
schools  in  England,  the  Colonies,  and  America  to  the 
fact  that  there  is  a  considerable  number  of  the  surplus 
sets  of  the  colored  plates  of  Dr.  Wilson  Fox's  "  Atlas  of 
Diseases  of  the  Lungs."  These  contain  the  most  perfect 
representation  of  morbid  states  of  the  lungs  ever  pro- 
duced. They  will  be  of  great  value  to  medical  schools, 
if  framed  and  placed  in  the  museum  or  post-mortem 
room.  It  is,  therefore,  proposed  to  give  a  set  to  each 
medical  school  the  dean  or  manager  of  which  desires  it ; 
a  certain  number  will  be  reserved  until  October  to  give 
colonial  medical  schools  an  opportunity  of  obtaining 
them.  Each  set  contains  twenty-five  colored  plates. 
Brief  descriptions  can  easily  be  prepared  from  the  text  of 
Dr.  Fox's  atlas  and  affixed  to  the  plates.  The  cost  of 
packing  and  transmission  amounts  to  is.  in  the  United 
Kingdom,  2s.  6d.  for  America  and  the  Colonies.  This 
sum  should  be  sent,  with  the  application,  to  Messrs.  Min- 
tern  Bros.,  84  Southampton  Row,  London,  W.  C. 

The  Cholera  continues  in  somewhat  milder  form  in 
St  Petersburg,  the  number  of  new  cases  averaging  from 
twenty  to  twenty- five  per  day,  the  mortality  being,  as 
usual,  about  fifty  per  cent,  of  those  attacked.  Isolated 
cases  are  reported  from  many  towns  throughout  Holland, 
showing  a  widespread  infection  in  that  country.  All 
steerage  passengers  for  America  sailing  from  Amsterdam 
or  Rotterdam  are  subjected  to  a  five  days'  quarantine  be- 
fore being  allowed  to  embark.  Amsterdam  and  Maas- 
tricht are  the  two  cities  where  the  disease  prevails  most 


extensively.  One  death  from  cholera  has  occurred  near 
Cologne  and  several  in  the  Danzic  and  Johannisburg 
districts  in  Prussia.  The  disease  has  passed  down  the 
river  Pruth  and  invaded  the  surrounding  districts  in  Bu- 
kowina,  the  capital  of  that  province,  Czernowitz,  being 
seriously  infected.  The  usual  summer  scare  over  a  case 
of  cholera  nostras,  "which  is  pronounced  by  the  doctors 
to  be  a  case  of  genuine  Asiatic  cholera,  "is  reported 
from  a  town  in  Minnesota. 

Lowered  Duties  on  Drugs. — The  Senate  tariff  bill 
lowers  the  duty  on  a  number  of  drugs,  that  on  castor- oil 
being  reduced  fifty  six  per  cent,  below  the  rate  under  the 
McKinley  law,  and  that  on  epsom  salts  thirty-four  per 
cent.  Other  reductions  are,  thirty  per  cent,  on  cod- 
liver  oil,  fifty  per  cent,  on  bicarbonate  of  soda,  twenty 
per  cent,  on  sublimed  sulphur,  eighteen  per  cent,  on 
refined  camphor,  and  twenty-five  per  cent,  on  strychnine. 
The  duty  on  spectacle  lenses. is  reduced  from  sixty  to 
thirty-five  per  cent,  ad  valorem,  a  decrease  of  nearly 
forty-two  per  cent. 

Fourpenoe  a  Visit. — An  English  physician  advertises 
office  consultations  and  medicine  for  fourpence,  visits  at 
the  patient's  house,  including  medicine,  one  shilling,  at- 
tendance and  medicine  at  the  patient's  home,  2s.  6d. 
Sixty  cents  a  week  is  not  an  excessive  charge  for  medical 
attendance,  but  it  is  probably  all  it  is  worth  in  the  given 
instance. 

The  Plague  Bacillus. — Several  investigators  in  China, 
who  have  been  studying  the  plague,  have  announced  the 
discovery  of  a  bacillus,  the  micro  organism  in  each  case 
being  different  from  all  the  others.  Although  time  alone 
will  decide  which  of  these  claims,  if  any,  is  well  founded, 
the  presumption  is  that  Kitasato's  bacillus  is  the  true 
one.  The  disease  still  prevails  in  Canton,  but  has  nearly 
died  out  in  Hong  Kong.  An  official  report  places  the 
number  of  deaths  from  the  plague  in  the  latter  city  up  to 
the  first  of  August  at  2,504. 

Women  Medical  Students  in  Glasgow. — At  the 
graduation  exercises  of  the  University  of  Glasgow,  held 
on  July  26th,  the  degrees  of  Bachelor  of  Medicine  and 
Master  in  Surgery  were  conferred  on  Marian  Gilchrist 
and  Alice  Cumming.  Professor  Charteris  delivered  the 
address  to  the  graduates,  and  in  congratulating  the  fe- 
male recipients  of  degrees  he  expressed  a  hope  that  the 
time  would  come  when  degrees  would  be  bestowed  which 
would  do  less  violence  to  the  sex,  and  that  they  would 
run  as  "spinster  in  medicine"  and  "mistress  in  sur- 
gery." The  abbreviation  of  M.S.,  however,  would  not 
distinguish  the  sex.  This  is  the  first  time  in  the  history 
of  any  of  the  Scottish  universities  that  a  medical  degree 
has  been  granted  to  a  woman. 

Intemperate  Antivivisectionists. — On  the  occasion  of 
the  meeting  of  the  British  Medical  Association  in  Bristol, 
the  local  temperance  advocates  of  the  place,  taking  ad- 
vantage of  the  special  opportunity  of  hearing  the  opinions 
of  the  medical  profession  on  the  temperance  question, 
invited  some  of  the  leading  medical  visitors  to  a  meeting 
held  at  the  Hall  of  the  Young  Men's  Christian  Associa- 
tion. Mr.  Joseph  Storrs  Fry,  who  had  arranged  to  pre- 
side, happened  to  be  also  the  president  of  the  local 
Antivivisection  Association.  Several  gentle  members  of 
the  British  Women's  Temperance  Society,  who  are  also 
members  of  the  Antivivisection  Association,  on  learning 


2IO 


MEDICAL  RECORD. 


[August  1 8,  1894 


that  among  the  principal  speakers  was  Professor  Victor 
Horsley,  raised  an  indignant  protest  against  this  invita- 
tion, and  sent  a  deputation  to  Mr.  Storrs  Fry,  calling 
upon  him  to  decline  to  preside  if  the  invitation  to  Pro- 
fessor Horsley  was  persisted  in.  Mr.  Fry,  instead  of 
complying,  tendered  his  resignation  as  president  of  the 
Antivivisection  Society. 

Professor  Koch  is  reported  by  the  cable  to  have  gone 
to  Woerishofen  to  place  himself  under  the  medical  care 
of  Father  Kneipp,  the  clerical  advocate  of  the  cold- water 
cure. 

Typhoid  Fever  in  Montclair. — Seventeen  persons 
were  reported  ill  with  typhoid  fever  in  Montclair,  N.  J., 
on  August  8th.  It  is  believed  by  some  that  the  disease 
was  conveyed  in  artificial  ice  made  from  undistilled 
water. 

Dr.  Howard  F.  Mitchell  died  in  Troy  on  August  6th. 
He  was  a  graduate  of  the  University  of  Maryland. 

Dr.  John  M.  Todd,  of  Bridgeport,  O.,  died  at  his 
home  on  August  2d,  at  the  age  of  sixty-eight  years.  He 
had  been  an  invalid  for  the  past  five  years. 

The  Twelfth  International  Medical  Congress,  as  is 
now  definitely  announced,  will  be  held  in  Moscow,  in 
August,  1896. 

Awards  at  the  Borne  Congress.— In  a  recent  notice  of 
the  awards  made  at  the  Medico-Hygienic  Exhibition  held 
at  Rome  in  connection  with  the  International  Congress, 
mention  was  accidentally  omitted  of  Oppenheimer,  Son 
and  Co.,  of  London.  This  firm  received  the  only  gold 
medal,  so  it  is  stated,  that  was  awarded  to  any  house  from 
English-speaking  countries. 

The  American  Association  for  the  Advancement  of 
Science  is  in  session  this  week  in  Brooklyn.  The  meet- 
ing opened  on  Wednesday  and  will  continue  for  a  week* 
The  work  of  the  Association  is  divided  among  nine  sec- 
tions, as  follows :  Mathematics  and  astronomy,  physics, 
chemistry,  mechanical  science  and  engineering,  anthro- 
pology, economic  science  and  statistics,  botany,  zoology, 
geology,  and  geography. 

The  American  Academy  of  Medicine  will  hold  its 
nineteenth  annual  meeting  at  the  "  Waumbek,"  Jeffer- 
son, N.  H.,  on  Wednesday  and  Thursday,  August  29  and 
30,  1894.  The  meeting  is  to  be  devoted  chiefly  to  a 
discussion  of  the  condition  of  the  dependent  classes  (the 
young,  the  aged,  the  blind,  delinquents,  etc.)  and  the 
relation  of  the  medical  profession  to  them.  Reduced 
rates  from  New  York  or  Boston,  and  return,  are  offered  to 
members  of  the  Academy.  Dr.  G.  M.  Gould,  of  Phila- 
delphia, is  the  President,  and  Dr.  Charles  Mclntire,  of 
Easton,  Pa.,  Secretary. 

The  American  Pharmaceutical  Association  will  hold 
its  annual  meeting  in  Asheville  on  September  3,  to  8, 1894. 

The  Iowa  Public  Health  Association,  not  the  Public 
Hall  Association,  as  the  types  made  us  say  in  a  recent 
issue,  meets  in  Des  Moines,  September  6,  and  7,  1894. 

Anti-Cholera  Inoculations. — There  were  eight  hun- 
dred and  twenty-six  persons  inoculated  in  Calcutta  for 
protection  against  cholera  during  the  month  ending 
June  24,  1894.  Cholera  occurred  in  three  houses  in 
which  inoculations  had  been  made  upon  some  of  the  in- 
mates, but  all  the  cases  were  among  the  uninoculated, 
none  of  the  inoculated  being  attacked. 


Extra  -  Genital  Syphilis. — The  appearance  of  Dr. 
Bulkley's  recent  work  on  syphilis  insontium  appeals 
to  have  stimulated  research  in  this  field  throughout 
the  world,  and  the  reports  of  cases  of  innocent  or  rather 
extra  genital  infection — for  the  latter  is  by  no  means  al- 
ways innocent,  while  genital  infection  may  be,  as  many 
a  poor  wife  knows  only  too  well — are  appearing  con- 
stantly in  our  foreign  exchanges.  Of  course  the  occur- 
rence of  syphilis  sine  coitu  has  long  been  recognized  by 
the  profession,  if  not  perhaps  by  the  laity,  but  the  mag- 
nitude of  the  danger  and  the  infinite  variety  of  ways  by 
which  the  disease  could  be  spread  to  the  innocent  were 
not  so  fully  appreciated  before  the  publication  of  Dr. 
Bulkley's  timely  treatise  with  the  enormous  list  of  cases 
appended  thereto. 

The  Canadian  Medical  Association  will  hold  its  an- 
nual meeting  in  St.  John,  New  Brunswick,  August  22 
and  23,  1894. 

Eighty-five  Thousand  Dollars  has  been  appropriated 
by  the  Massachusetts  legislature  for  improvements  in 
public  hospitals  and  asylums  in  the  State. 

School  Boards  and  Vaccination. — The  Supreme  Court 
of  Pennsylvania  has  confirmed  the  decree  of  a  lower  court 
to  the  effect  that  school  boards  have  the  right  to  exclude 
from  the  public  schools  children  who  have  not  been  vac- 
cinated. 

Biots  in  China. — Several  missionaries  at  Canton,  Shek 
Lung,  and  other  places  in  China  have  suffered  recently 
at  th*  hands  of  angry  mobs  of  natives.  The  riots  were 
started  by  reports  that  the  missionaries  were  killing  na- 
tives to  convert  their  bodies  into  medicine,  and  that  they 
were  the  direct  cause  of  the  plague. 

The  Metric  System  in  Great  Britain. — At  a  recent 
meeting  of  the  Council  of  the  Pharmaceutical  Society  of 
Great  Britain,  it  was  moved  that  after  January  1,  1895, 
a  practical  knowledge  of  the  metric  system  of  weights 
and  measures  shall  be  required  of  all  candidates  for  the 
minor  examination  in  the  subjects  of  prescriptions  and 
practical  dispensing,  and  that  the  Board  of  Examiners  be 
instructed  to  require  from  candidates  a  general  knowl- 
edge of  posology  in  terms  of  the  metric  as  well  as  the 
British  system  of  weights  and  measures ;  and  in  practical 
dispensing  to  compound  medicines  by  the  metric  as  well 
as  the  British  system  of  weights  and  measures.  After 
some  discussion  the  resolution  was  altered  to  the  effect 
that  the  Board  of  Examiners  should  be  requested  to  con- 
sider the  advisability  of  acquiring  a  practical  knowledge 
of  the  metric  system  of  weights  and  measures  for  the 
minor  examination.     In  this  form  it  was  carried.* 

An  Inebriate  Asylum  in  France. — The  General 
Council  of  the  Seine  has  decided  to  erect  a  large  insane 
asylum  at  Ville-Evrard,  in  which  there  will  be  provision 
for  the  reception  and  treatment  of  male  inebriates.  The 
wing  for  this  purpose  will  accommodate  five  hundred 
patients.  This  will  be  the  first  institution  of  the  kind  in 
France. 

The  Price  of  Opium  has  risen  over  thirty  per  cent,  in 
the  past  month  or  six  weeks,  by  reason  of  the  war  between 
China  and  Japan. 

An  International  Medical  Press  Committee  has  been 
formed  for  the  purpose  of  providing  greater  facilities  for 
the  report  of  the  next  International  Congress. 


August  1 8,  1894J 


MEDICAL    RECORD. 


211 


^ewiema  and  ^otic&s  ot  goalis. 

A  Text-Book  of  Gynecology.     By  James  C.   Wood, 
A.M.,  M.D.,  Professor  of  Gynecology  in  the  Cleveland 
Medical  College,  etc.     With  2 10  Illustrations.     Phila- 
delphia: Boericke  &  Tafel.     1894. 
This  is  a  practical  treatise  on  gynecology  as  understood 
at  the  present  day.    The  author  has  put  on  record  the 
results  of  his  own  experience,  supplemented  by  a  careful 
study  of  the  teachings  of  others.     A  special  feature  of 
this  volume  is  the  introduction  of  a  large  number  of  illus- 
trations from  specimens  of  the  Museum  of  the  Royal  Col- 
lege of  Surgeons,  London.     The  student,  the  general 
practitioner,  and  even  the  specialist,  cannot  fail  to  be 
interested  as  well  as  instructed  by  a  study  of  these  illus- 
trations. 

In  the  purely  surgical  treatment  of  the  diseases  peculiar 
to  women,  Dr.  Wood  is  found  to  be  an  advocate  of 
measures  generally  recognized  as  applicable  in  our  country 
at  the  present  time.  As  regards  medicinal  therapy,  the 
author  gives  the  usual  list  of  drugs  recommended  by 
homoeopathic  practitioners. 

The  mechanical  execution  of  the  volume  is  quite  good, 
bat  some  of  the  drawings  are  too  much  blurred  to  be  en- 
tirely satisfactory.  The  work  is  sure  to  be  appreciated  by 
all  homoeopathic  gynecologists,  and  will  doubtless  be  con- 
sulted by  many  practitioners  of  other  schools.  While 
devoid  of  originality,  the  author  has  succeeded  in  faith- 
fully picturing  American  gynecology. 

A  Practical  System  of  Studying  the  German 
Language.  For  Physicians  and  Medical  Students. 
For  Self-instruction.  By  Albert  Pick,  M.D.  Parts 
I.-VL  Newtonville,  Mass.:  E.  S.  Tanner.  1894. 
This  work  is  intended,  as  its  title  implies,  as  a  help  for 
self-instruction  to  those  whose  linguistic  ambition  does 
not  go  beyond  the  ability  to  read  German  medical  works 
and  to  converse  with  German  patients  in  their  own  tongue. 
This  instruction  is  imparted  by  means  of  a  series  of  short 
essays  on  medical  subjects  in  German,  with  an  interlinear 
translation  and  pronunciation.  These  are  supplemented 
in  each  lesson  by  a  number  of  elementary  phrases  used 
in  conversation,  and  by  some  very  brief,  but  sufficient, 
remarks  on  grammar.  If  the  system  is  carried  out  in  the 
remaining  six  parts  as  it  is  in  those  before  us,  the  work 
ought  to  prove  very  serviceable  in  imparting  to  the  care- 
ful student  such  a  knowledge  of  medical  German  as 
would  enable  him  to  read  books  and  journal  articles  with 
the  aid  of  a  dictionary. 

Essentials  of  Nervous  Diseases  and  Insanity  :  Their 

Symptoms  and  Treatment.     A  Manual  for  Students 

and  Practitioners.     By  John  C.  Shaw,  M.D.    Second 

Edition,   Revised.     Saunders'    Question    Compends, 

No.  21.     Philadelphia:  W.  B.  Saunders.     1894. 

The  author  states  that  this  little  book  is  not  intended 

to  take  the  place  of  more  complete  works  on  nervous 

and  mental  disease,  but  is  to  be  used  somewhat  as  a 

primer  4br  advanced  students.     There  are  forty-eight 

illustrations,  five  sections,  treating  respectively  of  injuries 

and  diseases  of  the  peripheral  nerves,  diseases  of  the 

spinal  cord,  diseases  of  the  brain,  of  functional  nervous 

disease,   and    insanity.     The  appearance  of  a  second 

edition  so  short  a  time  after  the  issue  of  the  first  is,  in 

itself,  commendation  all  sufficient. 

Essentials  of  Anatomy.     By  Charles  B.  Nancrede, 

M  D. ,  Professor  of  Surgery  and  of  Clinical  Surgery  in 

the  University  of  Michigan,  Ann  Arbor,  etc.     Fifth 

Edition.     Philadelphia,  W.  B.  Saunders.     1894. 

Only  such  facts  as  are  really  the  essentials  of  anatomy 

are  here  embodied,  to  render  it  possible  for  the  future 

practitioner  to  recall  later  such  general  impressions  as 

will  make  perfectly  intelligible  current  medical  literature. 

The  illustrations,  one  hundred  and  eighty  in  number, 

are  excellent. 


A  Text  Book  of  the  Diseases  of  Women.     By  Henry 
J.  Garrigues,  A.M.,  M.D.,  Professor  of  Obstetrics 
in  the  New  York  Postgraduate  Medical  School  and 
Hospital.     Philadelphia:  W.B.Saunders.     1894. 
Dr.  Garrigues's  treatise  on  the  diseases  peculiar  to  wom- 
en is  a  concise  exposition  of  the  modern  status  of  gyne- 
cology in  our  country.     Special  stress  is  laid  by  the  author 
on  anatomy  and  embryology,  and  while  this  does  not 
make  the  book  more  valuable  to  the  general  practitioner, 
it  constitutes  a  feature  that  the  scientific  student  will  duly 
appreciate. 

The  subject  of  treatment  is  also  a  distinguishing  feature 
of  this  new  volume.  The  author  has  very  sensibly  adopted 
the  method  of  giving  simple  and  undangerous  methods 
the  preference  over  heroic  achievements  of  "  brilliant  M 
operators.  The  work  can  be  earnestly  recommended  as 
a  faithful  exponent  of  American  gynecology,  conceived 
in  a  spirit  of  moderation  and  conservatism. 

Pachydermia   Laryngis.      Klinische    Geschichte    von 

Dr.  Med.  W.  Sturmann,  Berlin.     Von  der  Berliner 

Medizinischen  Fakultat  preisgekronte  Schrift.     Berlin, 

Verlag  von  S.  Karger.     1894. 

A  Prize  Essay,  of  seventy  pages,   giving  the  clinical 

history,  treatment,  etc,  and  literature  of  the  subject 

A  Manual  of  Nursing  in  Pelvic  Surgery.     By  Lewis 

S.  McMurtry,  AM.,  M.D.,  Professor  of  Gynecology 

in  the  Hospital  College  of  Medicine,  Louisville,  Ky. 

Louisville:  John  P.  Morton  &  Co.     1894. 

Out  of  "working  notes"  prepared  by  the  author  for 

the  use  of  nurses  at  the  Jennie  Casseday  Infirmary  for 

Women   has  grown  this  complete  and  practical  guide 

for  those  engaged  in  the  care  of  women  with  surgical 

diseases  peculiar  to  their  sex.     Its  teachings  are  easily 

understood,  its  form  substantial  and  convenient,  and  its 

ninety- two  pages  contain  directions  and  hints  of  value 

to  those  engaged  in  skilled  nursing. 

The  Human  Element  in  Sex  :  Being  a  Medical  Inquiry 
into  the  Relation  of  Sexual  Physiology  to  Christian 
Morality.  By  Dr.  Elizabeth  Blackwell.  London  : 
J.  &  A.  Churchill.  1894. 
In  this  little  work  Dr.  Blackwell  handles  a  delicate  sub- 
ject in  a  delicate  manner,  yet  is  not  afraid  to  speak  out 
when  necessary  in  a  way  that  permits  of  no  misunder- 
standing. The  author  holds  that  the  ignorance  of  par- 
ents concerning  many  of  the  essential  facts  relating  to 
sex  is  deplorable,  and  a  cause  of  grave  social  ills,  and  she 
offers  this  work  to  the  medical  profession  "  as  an  aid  in 
the  instruction  of  parents  and  guardians  of  the  young," 
which  instruction  she  regards  it  as  the  duty  of  the  physi- 
cian to  impart  on  every  suitable  occasion.  She  has  done 
a  good  work  and  done  it  well. 

Les  Universit£s  des  £tats  Unis  et  du  Canada,  et 
Specialement  leurs  Institutions  medicales.    Par  le  Dr. 
O.    Laurent,   Agrege  Suppleant  a  TUniversite  de 
Bruxelles.     Vingt-deux  Figures  et  Plans.     Bruxelles: 
H.  Lamertin.     1894. 
This  is  a  very  entertaining  account  of  the  universities, 
medical  schools,  and  hospitals  of  the  United  States  and 
Canada,  written  by  one  who  has  seen  all  he  describes, 
and  seen  it  too  with  the  eye  of  an  intelligent  observer. 
All  is  not  praise,  for  the  author  is  quick  to  see  defects 
and  ready  to  note  them,  but  his  judgment  is  in  the  main 
sound.     In  Canada  he  draws  a  comparison  between  the 
French  and  English  universities  by  no  means  to  the  ad- 
vantage of  the  former.    The  book  contains  a  number  of 
illustrations  of  hospitals  and  university  buildings. 

The  Bee-line  Repertory.      By  Stacy  Jones,  M.D. 

Philadelphia :  Boericke  &  Tafel,  1894. 
This  is  a  pocket  therapeutic  guide  for  the  homoeopathic 
practitioner.  It  is  arranged  in  such  a  way  that  those  de- 
siring to  consult  it  may  find  just  what  to  do  for  every 
abnormal  sensation  or  appearance  in  any  part  of  the 
body. 


212 


MEDICAL   RECORD. 


[August  1 8,  1894 


Essentials    of    Practice    of   Pharmacy.      Arranged 
in  the  Form  of  Questions  and  Answers.     Prepared  es- 
pecially for  Pharmaceutical  Students  (Second  Edition, 
Revised).     By  Lucius    E..  Sayre,  Ph.G.,    Professor 
of  Pharmacy  and  Materia  .Medica,  of  the  School  of 
Pharmacy  of  the  University  of  Kansas.    Philadelphia : 
W.  B.  Saunders.    1894. 
This  is  one  of  the  latest  volumes  of  Saunders's  Question 
Compends,  intended,  as  its   title  explains,  for  the  use 
of  students  in  pharmacy.     It  appears  to  be  admirably 
arranged,  and  ought  to  be  of  great  assistance  to  the  con- 
scientious student  who  is  making  a  final  review  before  ex- 
amination. 

De  la    Maladie    de  Basedow,  et  en  Particulier   de 
sa  Pathogenic     Par  Frederick  Chamberlain,   Doc- 
teur  en  Medecine  de  la  Yale  Medical  School,  £tats- 
Unis,  Docteur  en  Mddecine  de  la  Faculty  de  Paris. 
Paris:  Henry  Jouve.    1894. 
In   this  excellent  monograph  Dr.    Chamberlain  treats 
quite  exhaustively  of  exophthalmic  goitre,   and  espe- 
cially of  the  numerous  theories  held  at  different  times  and 
by  different  observers  of  the  pathogenesis  of  the  affection. 
There  is  a  list  of  forty- two  cases  in  which  operative  treat- 
ment was  undertaken,  and  the  work  concludes  with  a  very 
complete  bibliography,  from  the  article  of  Graves  in  1835, 
to  one  by  Marie  published  the  last  day  of  February, 
1894. 

Traitement  des  R&tr&cissements  par  l' Electro- 
lyse Lin£aire.  Par  le  Dr.  J.  A.  Fort,  Ancien  In- 
terne des  Hdpitaux,  Professeur  Libre  d'Anatomie  a 
T  rtcole  Pratique  de  la  Faculte  de  Medecine  de  Paris. 
Paris:  G.  Masson.  1894. 
In  this  exhaustive  treatise  of  five  hundred  and  fifty 
pages  Dr.  Fort  sums  up  all  there  is  to  say  in  favor  of 
linear  electrolysis  as  a  cure  for  stricture.  In  an  intro- 
ductory chapter  the  author  speaks  of  linear  electrolysis  in 
general,  and  in  the  fourth  chapter  describes  the  mode  of 
performing  it,  the  intervening  chapters  being  devoted  to 
a  recital  of  one  hundred  and  forty  cases  of  urethral  strict- 
ure treated  by  this  method.  The  next  chapter  contains 
the  histories  of  twenty-seven  cases  of  complicated  and  ir- 
regular strictures,  and  the  good  results  obtained  by  the 
author.  The  sixth  chapter  is  devoted  to  a  consideration 
of  the  dangers  of  internal  urethrotomy,  and  in  the  final 
chapter  are  the  resumes  of  several  works  bearing  testimony 
to  the  utility  of  the  author's  procedure.  In  the  second 
part  Dr.  Fort  treats  of  linear  electrolysis  applied  to  the 
relief  of  strictures  of  the  oesophagus,  and  reports  a  num- 
ber of  cases  (upward  of  thirty)  in  which  this  method  was 
successfully  employed.  This  procedure  has  one  great 
advantage  over  electrolysis  as  usually  practised  in  this 
country,  in  that  it  is  completed  at  a  single  sitting. 

The  Essentials  of  Chemical  Physiology  for  the  Use 

of    Students.     By  W.    D.    Halliburton,    M.D., 

F.R.S.     Pp.    166.     London:    Longmans,  Green  & 

Co.,  1893. 

This  book  is  written  in  order  to  supply  the  student  with 

directions  for  examining  practically  the  most  important 

of  the  subjects  included  under  the  head  of  physiological 

chemistry.     It  is  also  intended  to  serve  as  an  elementary 

text-book.     It  is  well  illustrated,  and  is  more  complete 

than  most  of  so  called  "  Essentials  "  published  for  the 

benefit  of  the  student. 

Outlines  of  Insanity,  an  Attempt  to  present  in  a  Con- 
cise Form  the  Salient  Features  of  Mental  Disorder; 
Tabulated  and  Arranged  for  Facility  of  Reference  when 
drawing  up  Lunacy  Certificates.  Designed  for  the  Use 
of  Medical  Practitioners,  Justices  of  the  Peace,  and  Asy- 
lum Managers.  By  Francis  Walmsley,  M.D.  Pp. 
154.    London  :  The  Scientific  Press  (Limited).    1892. 

The  purpose  of  this  work  is  indicated  fully  in  its  title. 

It  is  a  short  popular  exposition  of  insanity.    The  author 

has  fulfilled  his  task  creditably,  and  the  book  is  printed  in 

excellent  style. 


Congenital  Affections  of  the  Heart.  By  George 
Carpenter,  M.D.,  Member  of  the  Royal  College  of 
Physicians,  etc.  London :  John  Bale  &  Sons. 
The  book  under  consideration  is  the  embodiment  in 
printed  form  of  demonstrations  on  congenital  malforma- 
tions of  the  heart,  found  of  service  to  a  class  of  students 
who  failed  to  find  in  ordinary  text-books  explanations 
sufficiently  precise  and  clear.  The  history  of  twenty- 
two  cases  is  given,  all  the  theories  as  to  cause  are  con- 
sidered, and  a  very  careful  survey  of  normal  embryonic 
cardiac  development  is  an  interesting  feature.  As  a  sup- 
plement to  larger  works,  as  those  of  Rokitansky,  Kuss- 
maul,  Peacock,  and  others,  this  fills  a  distinct  want. 

Clinical  Manual  for  the  Study  of  Diseases  of  the 
Throat.     By  James  Walker  Downie,  M.B.,  Fellow 
and  Examiner  in  Aural  Surgery  for  the  Fellowship,  of 
the  Faculty  of  Physicians  and  Surgeons,  etc.     New 
York :  Macmillan  &  Co.     1894. 
For  the  use  of  students  and  practitioners,  this  manual  is 
dictated  in  great  part  by  personal  experience,  and  di- 
vided into  two  sections.     In  the  first  systematic  examin- 
ation of  the  throat  is  discussed,  together  with  the  various 
manifestations  of  disease.     In  the  second  and  larger  sec- 
tion individual  diseases  are  considered  in  detail,  accord- 
ing to  their  importance  and  frequency  of  occurrence, 
and  medicinal  and  surgical  treatment.     For  a  book  of 
small  size,  immense  ground  is  covered  and  the  sugges- 
tions given  are  of  practical  value  and  utility. 

Practical  Lectures  in  Dermatology.  By  Condict 
W.  Cutler,  M.S.,  M.D.,  Professor  of  Dermatology, 
University  of  Vermont,  etc.  New  York  and  London  : 
G.  P.  Putnam's  Sons.  1894. 
The  excuse  for  this  work,  not  the  reason  of  its  existence, 
the  author  states  in  the  preface  to  be  the  request  of  the 
students  in  the  medical  department  of  the  University  of 
Vermont  to  have  the  lectures  delivered  in  1892  and  1893 
published  for  convenient  and  ready  reference.  Prepared 
from  stenographic  notes,  the  fifteen  lectures  are  here 
given  with  substantial  accuracy,  and  consider  only  those 
diseases  of  the  skin  which  every  practitioner  is  called 
upon  to  diagnosticate  and  treat  in  an  intelligent  manner. 
The  work  is  plain  and  practical,  and  commends  itself  to 
any  busy  practitioner.  And  herein  lies  its  "  reason  for 
being/1  which  needs  no  excuse. 

Die  Behandlung  der  Leukaemie.  Kritische  Studie 
Von  Dr.  H.  Vehsemeyer.  Berlin:  S.  Karger. 
1894. 
In  this  brochure  the  author  presents  a  very  exhaustive 
review  of  the  various  measures  which  have  been  tried 
with  more  or  less  success  in  the  treatment  of  leucocy- 
thsemia.  Dr.  Vehsemeyer  himself  has  had  such  good 
results  in  one  case  treated  with  the  fluid  extract  of  bar- 
berry, that  he  thinks  this  drug,  or  its  alkaloid,  berberine, 
should  be  given  a  further  trial. 

A  Modern  Wizard.     By  Rodrigues  Ottolengui.     G. 

P.  Putnam's  Sons,  New  York  and  London.  1894. 
This  is  a  story  of  medical  art  and  crime ;  of  murfter  and 
the  workings  of  the  law ;  of  self-interest,  detectives,  and 
hypnotism  ;  of  pride,  vain-glory,  and  hypocrisy ;  of  cli- 
max, anti-climax,  and  finally  life  in-death  by  "sana- 
toxine,M  a  deft  preparation  kept  on  hand  by  the  unscru- 
pulous hero  to  deprive  himself  of  reason  in  order  to  escape 
the  just  punishment  of  his  manifold  misdeeds.  Dr. 
Medjora,  Spanish  and  beautiful,  fascinating  and  mysteri- 
ous, is  left  a  raving  maniac  on  the  last  page,  after  havirg 
disposed  of  one  or  two  wives  according  to  scientific 
methods,  and  been  the  prime  mover  in  many  schemes  for 
his  own  aggrandizement.  The  "  Modern  Wizard  "  is 
intensely  interesting,  sometimes  dramatic,  and  well  writ- 
ten at  intervals.  It  leaves  the  reader  breathless  and  in  a 
mixed  frame  of  mind  :  why  should  an  author  of  so  much 
ability  write  such  a  book,  and  why  should  a  reader  of 
such  intelligence  read  it  ?  This  question  each  must  an- 
swer for  himself. 


August  i8,  1894] 


MEDICAL  RECORD. 


213 


THE  BRITISH  MEDICAL  ASSOCIATION. 

Sixty  second  Annual  Meeting,  held  at  Bristol,  July  31 
to  August  4,  /8p4. 

Special  Report  for  the  M«dical  Record. 

First  Day,  Tuesday,  July  31ST. 

The  first  general  meeting  of  the  sixty-second  annual 
gathering  of  this  Association  was  held  on  Tuesday  morn- 
ing, July  31st,  and  was  numerously  attended.  The  retir- 
ing President,  Dr.  George  Hare  Philipson,  of  Newcastle, 
occupied  the  chair.  Having  submitted  the  minutes,  which 
were  confirmed,  he  said  the  signing  of  those  minutes  was 
his  last  official  duty.  In  vacating  the  chair  he  should 
avail  himself  of  the  opportunity  of  again  expressing  to  his 
hearers  his  sense  of  the  honor  they  had  conferred  upon 
him.  The  remembrance  would  be  one  of  the  happiest 
recollections  of  his  life  that  he  had  occupied  the  chair,  if 
he  might  be  allowed  to  say  it,  of  the  greatest  medical  as- 
sociation in  the  world.  He  thanked  them  for  the  con- 
fidence which  had  been  reposed  in  him,  and  for  the  sup- 
port he  had  received  in  carrying  out  the  duties  of  his 
office.  He  begged  to  offer  them  his  congratulations  upon 
the  meeting  in  Bristol,  and  especially  upon  the  choice  of 
the  distinguished  physician  who  was  to  follow  him  in  the 
presidency.  It  was  now  his  pleasure  to  invite  Dr.  Fox 
to  assume  the  office  as  President,  and  to  offer  him  in  his 
year  of  office  every  good  wish  that  he  might  have  a  pros- 
perous and  happy  year. 

The  President  elect  remarked  it  was  needless  to  say 
how  very  much  obliged  he  was  to  them  for  the  cordial  re- 
ception of  Dr.  Philipson's  introduction.  He  appealed  to 
the  members  to  be  brief  and  to  the  point  in  their  speeches. 

Dr.  T.  Bridgwater  then  moved  a  vote  of  thanks  to 
Professor  Philipson,  and  that  he  be  elected  a  Vice  presi- 
dent of  the  Association.  Dr.  Holman  seconded,  and  the 
resolution  was  carried  with  applause. 

The  report  of  the  Council  was  then  presented.  It  re- 
ferred to  the  pleasure  that  was  felt  in  accepting  the  in- 
vitation to  hold  the  annual  meeting  at  Bristol.  It  was 
remarked  that  the  city  of  Bristol  was  the  headquarters, 
with  Bath,  of  one  of  the  oldest  and  most  active  branches 
of  the  Association,  and  it  was  interesting  to  note  that  the 
first  anniversary  meeting  of  the  Provincial  Medical  and 
Surgical  Association,  now  the  British  Medical  Associa- 
tion, was  held  in  Bristol  in  1834,  under  the  presidency  of 
Dr.  Andrew  Carrick.  It  was  on  record  that  two  hundred 
attended  out  of  a  total  of  three  hundred  and  sixteen. 
Since  the  annual  meeting  last  year  an  important  change 
had  occurred  in  the  Association  by  the  admission  of  medi- 
cal women  as  members,  and  upward  of  forty  had  already 
been  elected.  The  financial  results  had  been  successful. 
The  revenue  had  been  ,£35,367,  or  -£1,223  more  than 
last  year,  while  the  expenditure  was  .£30,126,  or  £1,021 
more  than  last  year,  leaving  a  surplus  or  profit  of  £$  ,150, 
which  had  since  been  invested.  At  the  end  of  Decem- 
ber the  total  excess  of  assets  over  liabilities  was  ,£55,906. 
The  number  of  members  on  the  books  last  year  was  1 4, 703. 
Daring  the  year  988  new  members  had  been  enrolled,  203 
had  died,  398  had  resigned,  leaving  on  the  books  15,090. 
Among  those  members  whose  decease  during  the  past 
year  the  Council  deeply  regretted  to  report  were :  Sir 
Andrew  Clark,  President  of  the  Royal  College  of  Phy- 
sicians, whose  many  virtues  and  generous  nature  caused 
him  to  be  universally  mourned  by  the  profession ;  Dr. 
Brovn-Sequard,  Dr.  George  Graham,  an  ex  President  of 
the  Melbourne  and  Victoria  Branch ;  Dr.  James  C.  Phil- 
lippo,  the  first  President,  and  the  founder  of  the  Jamaica 
Branch — the  first  recognized  colonial  addition  to  the  As- 
sxiation;  and  Surgeon- Major  Parke,  who  received  the 
Medal  of  Merit  in  1890  for  his  brave  conduct  in  the 
Stanley  expedition. 

Dr.  J.  Ward  Cousins,  President  of  the  Council, 
moved  the  adoption  of  the  report  and  financial  state- 


ment. He  said  July  19,  1832,  was  a  proud  day  for 
the  medical  profession,  when,  their  forefathers  of  the 
British  Medical  Association  were  assembled  in  the  Wor- 
cester Infirmary  to  consider  the  proposal  of  Sir  Charles 
Hastings  in  reference  to  the  formation  of  the  Provincial 
Medical  Association.  There  were  140  present,  and  at 
the  first  annual  meeting  in  Bristol,  in  1833,  there  were 
200  present.  The  next  meeting  held  there  was  in  1863, 
and  the  Association  then  mustered  2,000  members: 
Now  they  came  again  with  a  roll  of  over  r 5,000,  with 
an  organization  scattered  all  over  the  world,  with 
Branches  in  India,  Australia,  New  Zealand,  Canada, 
South  Africa,  and  the  Colonies ;  and  he  need  not  tell 
them  a  most  interesting  incident  was  the  admission  of 
41  lady  doctors.  He  wished  all  lady  graduates  in  medi- 
cine were  members,  and  he  firmly  believed  they  would 
be  in  course  of  time.  Referring  to  the  penal  clauses  of 
the  Medical  Acts,  he  said  they  were  practically  moon- 
shine. They  could  not  get  convictions.  The  Parlia- 
mentary Committee  were  anxious  to  amend  the  Medical 
Acts,  as  there  was  no  doubt  at  the  present  time  they 
could  drive  a  coach  and-four  through  them.  The  Asso- 
ciation desired  to  prevent  the  assumption  of  all  sorts  of 
letters  which  assumed  medical  titles.  Then  there  was 
the  University  scheme,  there  was  no  doubt  that  required 
the  supervision  of  the  committee.  The  law  relating  to 
the  employment  of  married  women  in  factories  was  of 
the  utmost  importance,  because  the  health  of  the  future 
population  of  the  country  was  connected  with  it. 
Among  other  questions  alluded  to  was  the  sale  of  poisons. 
That  was  a  move  in  the  right  direction.  He  owned,  for 
his  own  part,  he  should  like  to  see  some  such  system  as 
they  had  in  France,  under  which  the  whole  prescription 
of  the  proprietary  medicine  was  on  the  label.  Then  he 
mentioned  the  Scientific  Grants  Committee,  one  of  the 
objects  of  which  was  to  promote  research.  For  three 
research  scholarships  the  Council  selected  gentlemen  for 
a  term  of  years,  and  large  sums  had  been  granted  for 
scientific  research.  Dr.  Cousins  stated  the  Inebriates 
Committee  had  been  very  active.  As  to  the  medical 
charities,  they  would  always  be  abused  until  human 
nature  was  pulverized  and  made  over  again. 

Surgeon-Major  Ince  then  moved  "  That  this  meet- 
ing regrets  the  great  and  growing  increase  in  the  annual 
expenditure,  as  compared  with  the  income  of  the  Asso- 
ciation ;  and  suggests  to  the  Council  the  expediency  of 
a  careful  and  substantial  reduction  thereof  in  all  depart- 
ments, especially  in  the  matter  of  the  editorial  and  office 
expenses,  which  appear  out  of  all  proportion  to  the  needs 
and  nature  of  the  British  Medical  Journal. ' '  The  Treas- 
urer replied  to  the  point  raised  in  relation  to  the  finances 
and  regretted  the  personal  allusions,  maintaining  that 
the  editor  had  raised  the  Journal to  the  position  of  one  01 
the  best  medical  periodicals  in  the  world.  The  editor 
also  replied,  maintaining  that  he  had  always  endeavored 
to  be  impartial.  He  congratulated  Surgeon  Major  Ince 
for  contributing  to  the  gayety  of  the  meeting,  and  left 
the  audience  to  judge  whether  he  had  given  an  example 
of  the  self  effacement  he  wished  to  apply  to  the  editor. 

Dr.  Ince  said  his  object  had  been  served  by  the  dis- 
cussion and  he  would  withdraw  the  resolution. 

Mr.  R.  W.  Doyne,  representing  the  Oxford  Branch, 
moved  an  amendment  to  the  report  regretting  that  it 
contained  no  reference  to  the  question  of  Medical  Aid 
Associations,  which  had  done  so  much  injury  by  sweating 
members  of  the  profession.  The  amendment  was  sec- 
onded by  Dr.  Mead,  who  said  that  very  cruel  cases  had 
come  before  him  as  Secretary  of  the  Medical  Protection 
Association. 

Dr.  Cousins,  then  read  the  resolution  of  the  Oxford 
Branch :  "  That,  in  the  opinion  of  this  meeting,  medi- 
cal men  ought  not  to  meet  in  consultation  medical  of- 
ficers of  Medical  Aid  Associations  (as  defined  by  the 
committee  of  the  General  Medical  Council),  and  that 
the  Branch  Committee  should  bring  the  matter  before 
the  Central  Council,  and  that  they  (the  Central  Council) 
be  urged  to  bring  the  matter  before  the  annual  meet- 


214 


MEDICAL   RECORD. 


[August  1 8,  1894 


ing. ' '  He  explained  that  the  Council  had  resolved,  with- 
out expressing  any  opinion,  as  they  had  no  evidence  be- 
fore them,  that  it  would  be  better  for  the  Branch  to 
bring  the  matter  before  this  meeting. 

Dr.  Hardy  moved  the  appointment  of  a  committee  to 
consider  the  question,  a  proposition  which  was  ac- 
cepted by  Dr.  Cousins,  whereupon  Mr.  Doyne  withdrew 
his  amendment  and  the  report  of  the  Council  was  then 
agreed  to.  The  report  of  the  Parliamentary  Bills  Com- 
mittee was  then  discussed  for  some  time,  and  eventually 
its  further  consideration  adjourned  to  the  evening  meet- 
ing. 

The  Sermon. — At  three  o'clock  in  the  afternoon  a 
special  service  fras  held  in  the  Bristol  Cathedral  in  con- 
nection with  the  Association's  meeting.  The  mayor  and 
corporation  attended  in  state,  and  they  were  followed  up 
the  nave  in  procession  by  several  members  of  the  Associa- 
tion Council.  Seats  in  the  nave  were  reserved  for  mem- 
bers, and  these,  together  with  other  portions  of  the  cathe- 
dral, were  filled.  Canon  Ainger,  Master  of  the  Temple, 
was  the  preacher,  and  selected  as  his  subject  "The  heal- 
ing by  the  Saviour  of  the  woman  with  the  issue  of  blood." 

This  poor  woman,  he  said,  had  suffered  many  years, 
and  as  St.  Mark  was  careful  to  add,  had  endured  even 
worse  from  the  physicians  who  had  tried  their  various 
experiments  on  her  to  cure  her.  And  yet  she  was  not 
discouraged,  for  at  last  she  had  encountered  a  grave  and 
noble  figure,  moving  to  and  fro  among  men,  doing  good 
in  various  ways.  What  she  had  seen  and  heard  of  this 
New  Teacher  gave  her  faith  to  believe  that  He  was 
destined  to  be  her  healer,  and  that  no  other  treatment 
would  be  of  any  avail.  She  mixed  with  the  crowd  who 
followed  Jesus,  saying,  "  If  I  may  but  touch  the  hem  of 
His  garment  I  shall  be  whole."  Jesus's  immediate  reply 
was  very  marked,  and  not  just  what  might  have  been  ex- 
pected. The  woman's  words  and  actions  seemed  to 
imply  a  purely  mechanical  view  of  the  power  of  Christ ; 
but  our  Lord  at  once  pronounced  it  not  to  be  supersti- 
tion, but  faith.  Not  something  which  degraded  but  that 
which  ennobled.  The  superstitious  view  of  the  healing 
art  had  never  died  out,  and  never  would.  In  these  clos- 
ing days  of  the  nineteenth  century  much  still  existed,  in 
spite  of  education,  so-called,  in  spite  of  improved  schools 
and  school-boards.  Within  the  last  year  the  most  revolt- 
ing forms  had  been  exposed  to  public  gaze.  But  not  in 
exceptional  and  sensational  shapes  alone  did  it  live  in  or- 
dinary life.  There  was  the  credulity  that  believed  in  any 
pretender  to  the  physician's  art,  that  rushed  to  purchase 
any  new  medicine  warranted  to  cure  some  disease  that 
had  baffled  the  researches  of  the  most  learned  men  for 
centuries.  That  state  of  things  was  always  with  us,  a  sign, 
perhaps,  he  said,  of  widespread  intellectual  deficiency. 
Yet  in  spite  of  education  it  throve  amain.  But  in  its 
deepest  causes  it  was  a  moral  more  than  an  intellectual 
deficiency,  this  readiness  to  believe  in  sudden  and  un- 
intelligible results  rather  than  in  the  slow  and  patient 
tracking  out  of  the  secret  of  man's  constitution.  There 
was  a  love  of,  a  craving  for,  magic  deep  seated  in  the 
nature  of  us  all.  It  was  also  found,  in  the  art  of  testing 
men's  souls,  the  same  deep  and  subtle  tendency  existed, 
the  marvellous  loved  for  its  own  sake,  or  recognized  only 
in  what  was  manifest  to  the  eye  rather  than  in  the  slow, 
hidden  workings  of  God's  laws.  This  malady  was  inci- 
dent to  us  all. 

The  preacher  went  on  to  say  that  Christ's  whole  life 
was  an  example  for  the  physician,  and  embodied  the 
principles  of  his  art  and  science,  because  it  pointed  along 
the  road  by  which  all  advance  in  medicine,  as  in  every 
other  science,  has  been  attained  by  the  faithful  and  ear- 
nest watching  and  studying  of  Nature's  methods,  not 
contesting  and  resisting  them,  but  following,  imitating, 
and  tracking  out  her  laws  and  submitting  to  them. 

The  preacher  alluded  to  the  conspicuous  ornament  the 
profession  had  lost  since  its  last  annual  session,  by  the 
death  of  Sir  Andrew  Clark.  He  might  not  be  ranked 
with  the  Hunters,  the  Jenners,  the  Pasteurs,  but  he  did 
a  great  work  in  promoting  men's  happiness.     The  phy- 


sician of  the  soul  must  work  on  the  same  lines  as  the  phy- 
sician of  the  body.  It  was  narrated  of  Sir  Andrew  Clark 
that  he  once  kindly  admonished  a  lady  patient  by  telling 
her  she  got  in  the  way  of  her  own  happiness.  In  con- 
clusion, Canon  Ainger  said  he  should  ill  requite  the  trust 
they  had  laid  on  him  were  he  to  be  guilty  of  even  seem- 
ing.in  these  words  to  instruct  them  in  the  ethics  of  their 
noble  profession.  He  had  touched  upon  that  which  was 
common  to  their  professions,  the  unchangeable  aims  and 
methods  of  the  true  physician,  whether  of  body  or  spirit 
They  and  he  might  be  alike  laborers  in  the  Lord's  vine- 
yard. Let  them  pray  that  their  desire  might  be  neither 
to  make  proselytes  nor  to  gain  patients,  but  to  teach 
those  who  resorted  to  them  for  health  the  eternal  signifi- 
cance and  responsibility  of  life,  to  make  them  to  de- 
sire and  to  have  life,  and  to  have  it  more  abundantly. 
An  offertory  was  then  taken  on  behalf  of  the  Royal 
Medical  Benevolent  College  at  Epsom. 


Evening  Session. 

The  adjourned  general  meeting  was  held  in  the  evening, 
when  the  President,  Dr.  E.  Long  Fox,  Consulting  Phy- 
sician to  the  Bristol  Royal  Infirmary,  delivered  his  ad- 
dress. This,  of  course,  took  precedence  of  the  various 
business  matters  and  discussions  which  had  been  post- 
poned from  the  morning  sitting. 

Presidential  Address. — Dr.  Long  Fox  reminded  the 
meeting  that  thirty  one  years  had  elapsed  since  the  Asso- 
ciation last  met  in  the  historic  city  of  Bristol,  and  men- 
tioned a  number  of  distinguished  men  who  had  taken 
part  in  it,  most  of  whom  had  ceased  from  their  labors, 
but  a  few  were  yet  in  our  midst.  Bristol  had  always 
been  distinguished  by  its  ecclesiastical  associations  and 
by  its  devotion  to  the  crown,  although  it  had  its  opin- 
ions as  to  the  collection  of  "  ship  money."  Its  citizens 
had  a  sturdy  independence  of  their  own  that  often  led  to 
riot,  but  it  was  famous  for  its  healthiness  and  the  lon- 
gevity of  its  inhabitants,  many  of  whom  were  nonagena- 
rians. Its  schools  were  among  the  best  and  the  healthi- 
est in  the  kingdom,  and  its  enterprise  and  prosperity 
might  be  gauged  by  the  enormous  increase  of  Clifton ; 
its  philanthropy  was  no  less  commendable,  and  the 
"  higher  interests  of  man  "  had  a  prominent  position  in 
its  midst.  Latimer  and  Ridley  among  its  citizens  paved 
the  way  for  the  establishment  of  a  freer  and  purer  faith. 

In  Plato's  "  Republic  "  it  was  laid  down  that  in  order  to 
thoroughly  understand  and  sympathize  with  sickness  the 
physician  should  himself  be  afflicted  with  many  ills, 
but  that  this  was  not  necessary  was  proved  by  the  at- 
tention to  the  sick  poor  and  the  criminal,  which  was 
part,  and  no  unimportant  part,  of  the  duty  of  medical 
men,  whose  temperance,  philanthropy,  and  self-abnega- 
tion were  well  known.  It  was  also  the  duty  of  the  phy- 
sician to  give  his  attention  to  the  hereditary  tendency 
to  crime,  and  to  work  against  it  and  improve  the  un- 
happy subject  of  an  evil  heredity. 

All  branches  of  the  medical  profession  had  progressed, 
and  even  that  of  therapeutics  was  now  conducted  on 
healthy  and  scientific  lines.  Medical  science  was  cos- 
mopolitan, and  advancing,  experieniia  docet.  How 
much  was  owing  to  the  medical  officers  of  the  army  and 
navy,  who  had  opportunities  of  studying  diseases  in  their 
outset  of  which  we,  at  home,  only  saw  the  ultimate  re- 
sults. 

What  use  was  the  medical  profession  to  the  State, 
which,  after  all,  was  composed  of  individuals,  each  of 
whom  it  was  the  aim  of  the  physician  to  render  temperate, 
strong,  and  wise?  We  are  a  nation  of  rulers,  and  the  doc- 
tors teach  sanitary  science,  in  the  advancement  of  which 
the  medical  officers  of  health  are  most  important  factors. 

Jenner's  discovery  of  vaccination  laid  the  foundation 
of  the  prevailing  germ  theory  of  disease,  and  is  his 
good  work  to  be  nullified  by  a  crazy  cry  for  the  liberty 
of  the  subject  ?  Bacteriology,  antiseptic  surgery  (Lister- 
ism),  and  the  differentiation  of  the  microbes  of  diseases 
are  of  paramount  importance,  and  it  is  marvellous,  and 


August  1 8,  1894] 


MEDICAL    RECORD. 


215 


not  much  to  our  credit,  that  in  a  country  like  ours  the 
State  holds  aloof  from  their  investigation.  Much,  how- 
ever, has  been  done  to  diagnose  and  remedy  the  various 
diseases  peculiar  to  different  trades,  and  this  partly  owing 
to  the  co  operation  of  enlightened  employers  of  labor,  as 
well  as  to  the  researches  of  such  men  as  Ferrier  and 
Jackson.  Investigations  such  ag.  theirs  have  shown  the 
difference  as  well  as  the  connection  between  the  several 
disorders  that  afflict  humanity,  and  especially  in  the  case 
of  paralysis  that  proceeds  from  alcoholic  excess  and  simu- 
lated locomotor  ataxy.  The  experiments  with  thyroid 
extracts  mark  the  beginning  of  a  new  era  in  scientific 
medicine. 

Much  study  has  been  given  to  the  various  kinds  of 
idiocy,  and  particularly  to  that  form  that  tends  to  make 
the  sufferer  a  criminal,  who,  instead  of  being  punished  by 
fine  and  imprisonment  over  and  over  again,  should  be 
taken  care  of  and  taught.  It  had  been  said  that  the  pop- 
ulation consisted  of  two  classes  only,  the  rogues  who  had 
been  found  out,  and  the  rogues  who  had  not,  but  really 
there  was  but  a  very  small  number  of  those  who  were 
criminals  by  hereditary  descent  in  the  community. 

Biological  research  had  for  its  only  object  the  benefit 
of  mankind,  and  the  hard  work  and  self-abnegation  of 
medical  men  in  this  direction  were  only  typical  of  the 
same  qualities  in  the  nation  of  which  they  formed  part. 

How  much  the  State  owes  to  its  poor-law  medical  offi- 
cers whose  utterly  inadequate  remuneration  it  should 
never  have  sanctioned. 

There  may  not  be  many  total  abstainers  in  the  ranks 
of  the  medical  profession,  but  there  are  a  vast  number  of 
advocates  of  temperance  not  in  the  use  of  alcohol  only, 
but  in  everything.  Alcohol,  however,  has  been  proved 
to  be  not  a  stimulant,  but  a  depressant. 

Dr.  Russell  Reynolds,  President  of  the  Royal  Col- 
lege of  Physicians,  proposed  a  vote  of  thanks  to  the  Pres- 
ident. He  said  that  much  as  he  admired  the  address, 
what  struck  him,  perhaps,  most  forcibly  was  the  admi- 
rable manner  in  which  Dr.  Lane  Fox  had  omitted  some 
topics  as  well  as  dilated  upon  others.  Jenner  had  a  pred- 
ecessor in  bacteriology,  namely  Harvey,  and  that  illus- 
trious discoverer  had  been  anticipated  by  a  Scotch  phy- 
sician, Clarke. 

Dr.  White  briefly  seconded  the  resolution,  which  was 
carried  by  acclamation,  and  Dr.  Fox  replied,  stating  that 
he  would  not  say  much,  as  he  had  no  voice  left.  He  an- 
nounced that  the  matters  adjourned  from  the  morning 
meeting  would  then  be  resumed  and  those  who  were  not 
actively  interested  in  them  could  leave,  which  the  im- 
mense majority  did  forthwith,  only  a  small  proportion 
remaining  to  carry  on  the  discussions. 

The  Medical  Practice  Act — The  President  then  called 
on  Dr.  Horder  to  resume  the  discussion  on  the  Parlia- 
mentary Bills  Committee. 

Dr.  Horder  proposed  as  an  amendment :  "  That  the 
report  of  this  committee  referring  to  the  proposed 
amendment  of  the  Medical  Acts  be  referred  back  to 
them  for  reconsideration.11  He  said  that  in  the  opinion 
of  many  gentlemen  of  the  British  Medical  Association 
those  amendments  were  not  good  enough.  What  the 
profession  needed  was  that  men  outside  the  profession 
who  did  not  assume  titles,  but  who  practised  the  medi- 
cal and  surgical  professions  without  calling  themselves 
doctors  or  licentiates  of  midwifery  or  surgery,  or  ac- 
coucheurs, or  anything  else,  should  be  prevented  from 
practising.  With  regard  to  one  of  the  exceptions  set 
down  by  the  committee,  "  a  person  shall  not  be  guilty 
of  an  offence  under  this  act  if  he  shows  that  he  is  not 
ordinarily  resident  in  the  United  Kingdom,  and  that  he 
holds  a  qualification  which  entitles  him  to  practise  medi- 
cine or  surgery  in  a  British  possession  or  foreign  country, 
and  if  he  do  not  represent  himself  to  be  registered  under 
the  Medical  Acts  " — under  that  exception  they  might  be 
flooded  with  men  holding  bogus  qualifications  from  all 
parts  of  the  world.  At  present,  they  had  ladies — it  was 
doubtful  whether  they  were  entitled  to  the  name — and 
gentlemen  coming  from  America  giving  lectures  in  all 


towns  to  males  and  females  which  could  only  be  men- 
tioned as  indecent  to  the  last  degree.  They  did  every- 
thing they  could  to  place  themselves  before  the  public, 
and  then  simply  swindled  the  folks  out  of  their  hard- 
earned  wages.  If  these  exceptions  to  the  40th  clause 
which  now  existed  were  maintained,  the  country  might 
be  flooded  by  such.  If  they  were  going  to  amend,  why 
not  make  a  good  business  of  it  at  once,  and  insist  that 
there  should  be  reciprocity  between  the  nations  ?  No 
English  doctor  could  practise  in  France  without  passing 
their  required  examinations,  however  high  his  degree, 
and  it  was  not  fair  that  that  state  of  things  should  con- 
tinue, seeing  that  doctors  from  other  countries — France, 
Germany,  Italy,  and  so  forth — were  able  to  come  here 
and  have  their  qualifications  registered  on  the  foreign 
register.  Let  them  deal  with  the  Medical  Acts  in  toto> 
and  not  alone  with  the  1858  act. 

Dr.  Mead,  in  seconding  the  amendment,  mentioned, 
with  regard  to  the  qualifications,  a  case  of  the  Hindu 
oculists  who  were  prosecuted  at  the  Old  Bailey.  He  said 
what  was  wanted  was  an  act  making  a  little  clearer  what 
was  meant  by  obtaining  money  under  false  pretences. 
This  would  put  an  end  to  the  very  dangerous  system  of 
quackery,  which  allowed  men  to  extort  from  the  ignorant 
sums  of  money.  They  wanted  first  a  reform  of  the  views 
of  the  English  judges,  and  secondly,  some  plain  state- 
ment of  the  law.  They  also  required  some  amendment 
of  the  law  as  to  recovery  of  costs. 

Mr.  Ernest  Hart  said  that  instead  of  the  Parliamen- 
tary Bills  Committee  or  himself  being  in  any  way  desir- 
ous of  settling  the  matter  themselves,  or  on  their  own 
responsibility,  the  first  thing  they  did  was  to  lay  the 
facts  before  their  solicitor,  and  to  ask  him  for  his  advice 
in  making  a  new  amendment  clause.  As  that  advice 
hardly  went  fax  enough,  they  took  the  benefit  of  the  ad- 
vice of  the  gentlemen  who  had  been  instrumental  in 
framing  the  Dentists  Acts,  which  was  more  recent,  and 
with  that  help  the  clause  was  farther  extended  and 
amended. 

Mr.  George  Brown  said  it  was  not  their  duty  to  em- 
ploy solicitors  to  tell  them  what  they  required  and  what 
Parliament  would  pass,  but  to  tell  Parliament  what  they 
wanted. 

A  motion  referring  back  the  subject  of  amendment  of 
the  Medical  Acts  for  reconsideration  was  then  put  and 
carried. 

Registration  of  Midwives. — Dr  Lovell  Drags  said 
the  question  of  midwives9  registration  was  specially  re- 
ferred by  the  Parliamentary  Bills  Committee  to  that  meet- 
ing. The  subject  was  one  that  had  had  very  little  jus- 
tice, legislation  being  introduced  without  preliminary 
inquiry  and  investigation.  He  had  very  great  difficulty 
in  ascertaining  at  all  the  reason  upon  which  this  demand 
for  legislation  was  laid.  It  was  said  it  would  be  a  boon 
to  the  poorer  community,  but  it  was  not  very  difficult  to 
show  that  it  could  not  achieve  that  object.  He  claimed 
in  England  the  poor  received  considerable  assistance 
from  those  who  were  the  proper  ones  to  give  it — viz.,  the 
doctors — and  he  was  anxious  to  know  how  the  proposed 
measure  could  be  in  the  interests  of  them,  when  it  was 
shown  by  the  returns  that  in  every  foreign  country  the 
death-rate  was  higher  than  in  England. 

Dr.  Drage's  time  for  speaking  having  expired  he  end- 
ed by  moving  "  That  this  meeting  disapproves  of  the 
principle  of  registration  of  midwives." 

Dr.  More  Madden,  in  seconding  the  resolution, 
agreed  with  the  contention  of  Dr.  Drage. 

Dr.  Woodcock  said  there  had  been  a  good  deal  of 
misunderstanding  as  to  the  position  of  those  who  op- 
posed registration.  They  were  not  for  leaving  things  as 
they  were,  for  nothing  could  be  worse  than  the  present 
state  of  things  whereby  women  had  been  certificated,  or 
had  diplomas  issued  to  them,  indicating  that  they  were 
worthy  of  the  trust  imposed  upon  them.  In  these  days 
of  higher  education,  it  was  simply  a  reproach  to  the  leg- 
islature that  they  should  be  continued.  The  present 
midwife  was  as  much  out  of  date  as  the  barber- surgeon 


2l6 


MEDICAL  RECORD. 


[August  1 8,  1894 


and  the  cunning  leech  of  the  past,  and  he  maintained 
that  those  who  were  to  practise  the  obstetric  art  should 
be  as  well  trained  in  medicine  and  surgery  as  those  prac- 
tising any  other  branch  of  the  profession. 

Dr.  Boxall  agreed  that  the  present  state  was  really 
disgraceful.  How,  then,  could  it  be  improved?  Could 
they  get  rid  of  the  present  mid  wives  ?  If  that  could  be, 
he  thought  that  would  be  the  best  solution,  but  was 
afraid  that  was  impracticable.  The  question  was  a 
national  one,  affecting  the  community  at  large.  The 
select  committee  of  the  House  of  Commons  took  evi- 
dence from  all  sides,  and  they  reported  very  distinctly 
in  favor  of  registration.  It  was  desirable  to  get  the 
midwives  under  control,  but  how  could  that  be  accom- 
plished without  registration  ?  That  was  not  likely  to 
iajure  the  profession.  It  would  not  create  a  lot  of  mid- 
wives,  they  did  not  want  a  single  extra  one,  would  rather 
free  themselves  entirely.  He  hoped  by  such  legislation 
as  seemed  practicable  the  condition  of  the  poor  might 
be  improved,  and  the  interests  of  the  profession  would  be 
duly  preserved. 

Mr.  George  Brown  said  the  way  in  which  the  com- 
mittee of  the  House  of  Commons  conducted  their  in- 
quiry showed  clearly  that  their  sympathy  was  entirely 
with  those  who  approved  the  registration,  and  he  was 
surprised  that  their  report  was  not  even  more  decidedly 
in  favor  of  the  immediate  passing  of  a  measure  for  the 
registration  of  Sairey  Gamp.  It  was  absurd  for  members 
of  Parliament  to  go  behind  the  experience  of  a  man  like 
Dr.  Atthill  and  recommend  the  legislature  to  sanction 
the  registration  of  women  after  three  months1  education. 

After  some  further  discussion  the  resolution  was  put 
and  carried  by  a  majority  of  thirty  four  to  thirteen,  this 
being  the  total  present,  and  the  report  as  amended  was 
then  adopted. 


Second  Day,  Wednesday,  August  xst. 

The  President  read  out  a  list  of  visitors  to  the 
conference  from  various  parts  of  the  world,  and  also 
mentioned  that  representatives  were  present  from  many 
colonial  Branches. 

Dr.  Ward  Cousins  stated  that  the  Council  received 
that  morning  a  very  large  metropolitan  deputation, 
headed  by  Dr.  Russell  Reynolds,  inviting  the  Association 
to  London  for  its  next  annual  Congress.  The  Council 
recommended  that  they  should  accept  the  invitation,  and 
he  need  not  tell  them  that  the  Council  would  do  all  in 
their  power  to  help  the  development  of  the  meeting  so 
as  to  give  entire  satisfaction,  not  only  to  the  whole  Asso- 
ciation, but  to  their  metropolitan  associates..  It  would 
be  a  great  satisfaction  to  know  that  they  had  selected  as 
the  President  the  President  of  the  Royal  College  of 
Physicians.  He  moved  that  the  invitation  to  hold  the 
annual  meeting  for  1895  in  London  be  accepted,  and 
that  Dr.  Russell  Reynolds  be  nominated  as  the  President- 
elect. The  President  seconded,  remarking  he  need 
hardly  say  they  could  not  have  a  better  President-elect, 
or  a  better  place  to  meet  in  than  London. 

The  Address  in  Medicine  was  then  delivered  by  Sir 
Thomas  Grainger  Stewart,  M  D.,  Professor  of  Medi- 
cine in  the  University  of  Edinburgh,  who  said  he  did 
not  propose  to  give  an  address  on  the  general  subject  of 
medicine,  but  would  select  one  special  disease  which  had 
been  much  talked  about  among  us  of  late,  namely,  the 
influenza,  which,  however,  was  no  new  epidemic,  for 
Randolph,  the  ambassador  from  Queen  Elizabeth  to  the 
Queen  of  Scots,  described  it  accurately  in  a  letter  to 
"  Her  Grace."  It  was  called  "the  new  acquaintance," 
because  it  visited  everybody.  There  were  three  types  of 
the  disease,  the  respiratory,  the  intestinal,  and  the  ner- 
vous, while  its  complications  and  sequels  were  numerous. 
Some  of  the  latter  were  purpura  hemorrhagica,  vom- 
iting, anaemia,  gout,  diabetes,  cardiac  symptoms,  dropsy, 
pneumonia,  phthisis,  skin  eruptions,  sweating,  affections 
of  the  urinary  and  reproductive  systems,  albuminuria 
hematuria,  inflammatory  symptoms  as  cystitis,  and  espe- 


cially nervous,  involving  sight,  hearing,  and  smell,  some- 
times increasing  the  power  of  these  senses,  but  more 
usually  decreasing  them.  We  had  considerably  increased 
our  knowledge  of  the  histology  of  the  disease.  It  had 
one  essential  cause,  the  Pfeifferian  bacillus,  which  was 
always  present  and  was  never  found  in  any  other  com- 
plaint. The  result  of  inoculation  with  the  cultivated 
virus  was  unsatisfactory,  for  no  animal,  except  man,  was 
affected  by  this  micro  organism,  not  even  the  monkey. 

This  bacillus  will  only  live  in  the  presence  of  haema- 
toglobin.  It  does  mischief  in  many  ways,  but  chiefly 
by  means  of  the  poisonous  products  it  sets  up  in  the  sys- 
tem. Possibly  it  provided  a  nidus  in  which  other  poi- 
sons found  a  chance  of  ready  development  at  a  time 
when  the  power  of  resistance  of  the  patient  was  dimin- 
ished, for  exhaustion  favors  the  growth  of  micro-organ- 
isms. Some  white  rats  were  inoculated  with  the  bacillus 
of  anthrat,  half  their  number  were  placed  in  a  cage  and 
forced  to  work  the  tread-mill,  the  others  were  allowed 
to  rest ;  the  former  developed  the  disease,  the  latter  es- 
caped 

Two  organisms  coexisting  in  the  same  subject  may 
diminish  the  action  of  one  or  both ;  as  they  may  in- 
crease it.  The  bacillus  of  tubercle  when  associated  with 
the  gonococcus  found  in  green  pus  renders  the  disease  of 
phthisis  much  more  formidable. 

Faulty  innervation  is  at  the  bottom  of  heart  and 
stomach  troubles  following  influenza.  The  malnutrition 
of  the  tissues  causes  a  poisoning  of  the  nerves. 

Causation  of  influenza  is  obscure ;  it  was  once  thought 
to  be  propagated  through  the  air.  H.M.S.  Stag  was  com- 
ing up  the  Channel,  when  a  man  was  taken  suddenly  ill, 
and  in  twenty-four  hours  over  one  hundred  men  were 
laid  down  with  the  influenza.  No  similar  case  has  since 
been  recorded  and  no  one  takes  the  disease  who  has  not 
come  in  contact  with  someone  else  who  had  it.  It  mul- 
tiplies with  extraordinary  rapidity,  so  that  in  twenty- 
four  hours  a  whole  community  may  be  affected. 

The  life-history  of  the  influenza  bacillus  is  peculiar — 
it  will  not  live  in  water,  which  is  good  news  for  the 
teetotallers.  It  cannot  bear  drying  and  must  be  kept 
moist  like  some  people.  (Laughter.)  The  disease  might 
be  stamped  out  by  isolating  those  affected.  At  all 
events,  delicate  people  should  not  frequent  crowded 
schools,  theatres,  or  churches.  Menthol  and  guaiacol 
will  destroy  the  bacillus,  or  at  least  considerably  diminish 
its  activity ;  the  mode  of  administering  is  by  laryngeal 
injection,  which  is  quite  simple  when  you  have  found 
out  the  way  to  do  it.  Phthisical  people  are  the  best 
subjects  for  the  experiment  The  victim  should  yield  at 
once — off  to  bed  and  take  care  of  yourself. 

Dr.  F.  Roberts  proposed,  and  Dr.  Shingleton  Smith 
seconded,  a  vote  of  thanks  to  the  lecturer,  the  former 
declaring  that  he  was  deeply  interested  by  the  assur- 
ance that  the  bacillus  will  not  live  in,  and  cannot  be 
propagated  by,  water ;  he  also  congratulated  him  upon 
the  honor  the  Queen  had  bestowed  upon  him. 

Sir  T.  G.  Stewart,  in  replying,  said  there  was  an  old 
Scotch  proverb  to  the  effect  that  the  best  mirror  is  the 
eye  of  a  friend. 

The  Middlemore  Prise. — The  President  announced 
that  the  Middlemore  Prize  for  1891  had  been  awarded  to 
Mr.  Edward  Treacher  Collings,  F.R.C.S.,  L.R.C.P.,  who, 
however,  was  travelling  in  Persia. 

Dr.  Ward  Cousins  explained  that  the  prize  was  .£50 
interest  on  a  sum  of  money  left  by  the  late  Mr.  R.  Mid- 
dlemore, of  Birmingham,  for  the  best  essay  on  any  sub- 
ject in  ophthalmology,  medicine,  or  surgery. 


Third  Day,  Thursday,  August  2D. 

Address  in  Surgery. — Mr.  Greig  Smith,  Professor  of 
Surgery  in  the  University  College,  Bristol,  then  delivered 
the  address  in  surgery,  taking  as  his  subject,  "  The  Art 
of  the  Surgeon.1' 

After  gracefully  acknowledging  the  honor  paid  to 
Bristol  and  himself  in  his  selection  for  this  duty  he  said 


August  1 8,  1894] 


MEDICAL   RECORD. 


217 


that  former  orators  bad  chosen  to  sing  paeans  on  our  vic- 
tories over  science  and  glorified  scientific  heroes.  It  was 
his  intention  on  this  occasion  to  leave  science  alone  and 
deal  with  the  art,  and  how  we  trained  men  to  practise  it. 
What  was  a  surgeon  ?  A  stranger  might  judge  from  a 
study  of  door  plates  that  there  was  no  difficulty  in  answer- 
ing ;  but  the  word  "  Surgeon  "  on  a  door  usually  meant 
that  its  possessor  was  capable  of  all  branches  of  the  heal- 
ing art  except  surgery.  The  surgeon  in  these  days  of 
high-sounding  titles  was  almost  alone  in  following  a  craft 
called  "handwork  "  whose  title  was  needlessly  humble. 

The  surgeon  was  first  and  foremost  a  physician.  In 
person  or  by.  proxy  he  must  lean  on  medicine.  Besides 
medical  training  he  must  have  special  education  in  his 
handicraft.  In  old  times  the  surgeon  was  the  slave  of  the 
physician,  later  his  enemy,  to  day  his  equal  and  helper. 
Their  rivalry  was  now  a  goodly  and  a  wholesome  one* 
Among  other  arts  and  crafts  surgery  was  unique  in  the 
breadth  of  its  foundation  on  science.  A  surgeon  must 
know  something  of  all  the  sciences,  a  good  deed  of  a  few, 
and  everything  of  two  or  three. 

Was  all  our  display  of  knowledge  genuine  ?  Exami- 
ners seemed  to  have  their  doubts,  so  fearful  were  they 
apparently  that  the  student's  knowledge  might  trickle 
away  unless  he  were  annually  examined.  When  was  the 
importation  of  new  subjects  into  the  curriculum  to  stop? 
The  burden  was  becoming  steadily  heavier  to  bear. 
Should  we  cast  off  some  of  it  as  cumbersome  or  useless? 
Some  said  that  we  have  too  much  anatomy,  that  it  is 
useless  to  the  practical  surgeon,  and  that  physiology  was 
unstable  and  uncertain,  that  the  young  physiologist  gives 
a  dose  of  castor-oil,  on  much  the  same  principles  that 
his  grandmother  acted  on.  Pathology  they  said  was  the 
science  of  too  late.  These  men  were  as  honest  as  their 
opponents.  From  that  very  rostrum  their  views  had  been 
proclaimed.  He  ventured  to  differ.  If  asked,  "  Are  we 
to  lower  surgery  so  that  brains  may  not  be  strained  ?  "  he 
would  answer,  "Let  surgery  rise  if  brains  fall!"  He 
would  not  cast  away  anything,  but  he  would  select,  re- 
arrange, and  raise,  and  have  more  anatomy,  physiology, 
and  more  pathology. 

The  end  of  culture  for  the  multitude  seemed  to  be  to 
nibble  at  science,  dabble  at  art,  and  drivel  over  the  glori- 
ous advances  of  the  century.  Surgery  tolerated  no  daw- 
dling or  dilletanteism.  The  surgeon's  knowledge  must  be 
real  and  thorough  and  practical,  and  he  must  carry  it 
with  him.  He  must  have  the  real  knowledge  of  the 
artist  begotten  of  personal  labor  and  not  of  cribs  and 
mnemonics.  That  surgeon's  armor  was  weakest  at  vul- 
nerable points  who  was  not  protected  by  a  complete 
panoply  of  anatomical  knowledge.  The  complete  sur- 
geon must  not  cease  to  learn  anatomy  in  his  lifetime. 
Only  the  other  day  the  attention  devoted  to  the  vermi- 
form appendix  had  rendered  our  knowledge  of  its  anat- 
omy more  perfect.  Centuries  of  observation  by  the 
morphologist  were  not  equal  for  our  purposes  to  the  few 
months9  work  of  the  practical  surgeon.  No  honest  sur- 
geon dare  let  himself  remain  ignorant  of  any  new  patho- 
logical or  physiological  fact  that  might  bear  on  his  work. 
Bacteriology  was  of  supreme  importance,  and  we  dare  not 
stop  anywhere  in  our  studies  so  long  as  knowledge  ad- 
vanced. 

There  was  real  danger  that  the  claims  of  science  might 
injure  the  art  of  surgery.  It  was  a  pity  that  science 
should  so  often  kill  art.  Certainly  in  surgery  there  was 
no  reason  for  this,  but  science  and  art  could  flourish  to- 
gether. 

The  art  of  the  surgeon  might  be  viewed  from  two 
aspects;  one  side  might  be  called  mechanical,  the  other 
was  closely  allied  to  a  fine  art.  Easily  learnt  as  the 
mechanical  side  was  it  was  worthy  of  being  taught,  and 
it  would  be  good  for  most  surgeons  to  spend  a  month  or 
two  in  a  mechanic's  workshop.  In  respect  of  technical 
sldll  in  handling,  he  would  place  surgeon's  tools  on  a  level 
with  the  sculptor's  spatula  or  chisel,  or  only  a  little 
higher— they  were  mere  accessories  in  the  work  of  the 
brain-compelled  hands. 


The  other  side  of  the  craft  he  would  venture  to  com- 
pare with  that  which  produced  works  of  art  This  side 
was  far  the  most  important  The  highest  part  of  surgical 
fine  art — for  surgery  was  nothing  less — was  braincraft 
uttered  through  the  fingers,  not  mere  dexterity  or  cun- 
ning. The  ringer- surgeon  began  at  the  wrong  end,  he 
ought  to  have  been  a  button- maker.  The  important 
sense  of  touch — the  only  one  in  which  man  excelled  the 
lower  animals — was  trained  through  the  intellect  as  much 
as  the  fingers,  and  was  aided  by  other  senses,  especially 
sight. 

There  were  no  limits  to  the  demands  made  on  the  sur- 
geon's tactile  powers.  Touch  to  the  surgeon  was  what 
hearing  was  to  the  physician.  But  it  was  always  the  in- 
tellect that  interpreted.  It  was  as  true  now  as  twenty 
centuries  ago  that  "  'Tis  mind  that  sees  and  mind  that 
hears ;  all  other  things  are  deaf  and  blind." 

The  sculptor  and  the  surgeon  both  dealt  with  the 
human  body.  Each  art  demanded  from  its  votaries  ab- 
solute fidelity  to  form ;  ignorance  led  to  grief  in  both. 
Their  ways  of  working  were  also  alike.  In  each  the  true 
artist  went  as  far  as  necessary  at  once  without  trifling. 
The  surgeon  who  was  not  an  artist  was  good  at  some 
details,  but  not  in  all,  and  lacked  a  sense  of  true  propor- 
tion. 

The  world  lost  a  great  surgeon  in  Leonardo  da  Vinci, 
and  a  great  artist  in  Sir  Charles  Bell.  What  was  the 
teaching  of  this  art  of  surgery  ?  There  was  no  real  teach- 
ing of  the  art  of  surgery  in  this  country.  We  had  to 
teach  ourselves  by  experience  alone.  The  young  sculp* 
tor  might  with  impunity  make  and  break  figures,  but  the 
young  surgeon  was  not  supposed  to  damage  or  destroy 
human  beings. 

Artist  and  craftsmen  learnt  their  work  with  a  master  to 
correct  their  faults.  Surgeons  alone  were  unassisted  in  this 
way  in  their  art,  although  in  his  science  the  student  had 
guidance  enough.  Operative  surgery  on  the  dead  body 
was  useful  and  indispensably  but  it  was  only  a  step 
toward  operating.  The  art  must  be  taught  to  the  young 
surgeon  while  actually  operating,  and  his  mistakes 
pointed  out  and  his  successes  commended.  What  would 
they  not  give  now  to  have  a  Liston  or  a  Syme  at  their 
elbows  to  teach  them?  JTo  imagine  Liston,  trained  as  he 
was  in  the  cruel  and  exacting  school  of  preanesthetic 
days,  having  before  him  our  science  was  to  realize  the 
ideal  surgeon-artist. 

Apprenticeship  or  pupilage  would  do  something  for 
surgery,  but  we  needed  personal  teaching  in  high  art  by 
competent  masters,  as  was  done  in  medicine  and  obstet- 
rics. 

The  state  would  only  help  those  who  helped  them- 
selves. Let  us  do  so,  and  we  might  one  day  seek  for  a 
Royal  Academy  of  Surgery,  and  a  school  with  teachers 
attached. 

One  of  the  great  surgeons  of  five  hundred  years  ago 
and  more  wrote,  "  Knowledge  is  created  by  additions, 
the  same  man  cannot  lay  the  foundation  and  perfect  the 
superstructure.  We  are  as  children  carried  on  the  neck 
of  a  giant;  aided  by  the  labors  of  our  predecessors  we 
see  all  that  they  have  seen  and  something  beyond."  Let 
us  in  our  love  for  the  new  science  not  forget  the  old  art 
Let  us  graft  our  new  truths  on  the  old  stock  that  they 
may  long  live  and  flourish. 

Mr.  Reginald  Harrison  moved  a  vote  of  thanks 
to  Professor  Greig  Smith  for  his  interesting  address,  and 
said  the  resolution  only  inadequately  expressed  the  in- 
debtedness of  the  Association. 

Mr.  Nelson  Dobson,  of  Clifton,  in  seconding  the  res- 
olution, said  it  was  a  peculiar  privilege  to  do  so  on  that 
occasion  of  a  large  assembly  thanking  his  neighbor 
and  friend.  He  further  expressed  the  gratification  of 
his  brethren  who  practised  in  the  neighborhood  that  one 
of  them  should  have  been  chosen  for  this  honorable  dis- 
tinction. The  good  old  city  of  Bristol,  he  said,  had  made 
the  name  of  Smith  famous  in  surgical  history :  '•  Dick  " 
Smith  and  "  Nat  "  Smith  were  familiar  names  until  the 
present  day,  and  he  believed  that  Greig  Smith  would 


218 


MEDICAL    RECORD. 


[August  18,  1894 


also  be  remembered  not  only  for  his  great  achievements 
in  surgery,  but  for  the  address  he  had  just  delivered. 

The  resolution  was  carried  by  acclamation,  and  briefly 
acknowledged  by  the  Professor. 

Most  of  the  audience  then  dispersed,  leaving  only  a 
few  members  to  transact  the  formal  business,  which  was 
at  once  entered  upon. 

This  included  the  adoption  of  the  Reports  of  the 
Scientific  Grants  Committee,  of  the  Committee  on  Legis- 
lation for  Inebriates,  of  the  Therapeutic  Committee,  of 
the  Medical  Charities  Committee,  of  the  Committee  on 
the  Efficient  Control  of  Railway  Servants'  and  Mariners' 
Eyesight,  of  the  Committee  on  the  Examination  of  School 
Board  Children,  and  of  the  Anaesthetics  Committee. 

(To  be  Continued.) 


NEW  YORK  COUNTY  MEDICAL  ASSOCIATION. 

Stated  Meetings  April  16,  1894. 

Samuel  B.  W.  McLeod,  M.D.,  President,  in  the  Chair. 

The  Paper  Jaoket,  its  History,  and  Applications.— Dr. 
J.  Marshall  Hawkes  read  a  paper  upon  this  subject, 
and  presented  about  a  dozen  illustrative  cases.  Since 
Ambrose  Pare,  in  1 725,  made  his  first  jacket  out  of  beaten 
brass,  the  ingenuity  of  many  men  had  been  devoted  to  the 
production  of  a  jacket  from  material  which  should  pos- 
sess among  other  desirable  qualities  that  of  lightness. 
Wood,  woven  wire,  plaster  of  Paris,  and  various  other 
materials  had  been  employed,  but  all  were  heavy  with  the 
exception  of  felt,  and  this  was  objectionable  because  of 
its  thickness,  tendency  to  break  down,  and  to  absorb  the 
perspiration.  Plaster  was  not  only  heavy,  but  it  disinte- 
grated, absorbed  the  perspiratory  products,  became  offen- 
sive, was  cumbersome,  broke  down,  and  became  useless. 

Dr.  Hawkes  came  to  make  the  paper  jacket,  alter  trying 
nearly  all  possible  materials,  in  a  case  of  injury  to  the 
vertebral  column  in  1887*  He  was  unable  to  adapt  a 
jacket  which  the  patient  could  wear  without  undue  suffer- 
ing, until  the  use  of  paper  was  suggested  by  seeing  some 
workmen  making  buckets  of  this  material.  He  then  sus- 
pended a  patient,  made  a  plaster  mould  on  the  nude  body, 
and  from  this  mould  made  a  solid  piaster  cast,  over  which 
he  constructed  the  paper  jacket  out  of  the  best  manilla 
paper.  Successive  layers  of  paper  were  put  on  and  made 
to  adhere  by  varnish,  shellac,  and  various  cement  ma- 
terials, until  a  thickness  of  about  three  thirty- seconds  of 
an  inch  was  obtained.  The  weight  was  scarcely  fourteen 
ounces.  According  to  the  deformity  to  be  treated,  he 
padded  the  plaster  cast  at  projecting  points  and  cut  it 
down  at  others  on  the  opposite  side,  so  that  in  time  press- 
ure reduced  the  projecting  deformity  and  rilled  up  the 
opposite  cavity  in  the  body  of  the  growing  subject.  When 
the  jacket  was  removed  it  was  replaced  during  suspension. 
Many  persons,  especially  girls,  who  refused  to  wear  the 
plaster  and  other  jackets  or  apparatus  because  of  their 
clumsiness  and  weight,  submitted  to  the  application  of 
the  paper  jacket  early  and  with  pleasure,  because  of  its 
lightness,  accurate  fit,  as  if  it  were  a  corset,  and  because 
of  the  marked  comfort  which  it  afforded.  It  was  well 
known  that  the  weight  of  the  jurymast  or  other  support 
attached  to  the  plaster  jacket  tended  to  break  it  down. 
The  paper  jacket  being  very  strong,  easily  withstood  the 
strain.  Dr.  Hawkes  knew  of  no  disease  of  the  spinal 
column  to  which  it  was  not  applicable.  It  was  important 
that  it  extend  well  down  over  the  hip,  say  to  the  inferior 
spinous  process,  else  the  superincumbent  weight  of  the 
body  would  cause  pressure  pain  along  the  lower  border. 
The  importance  of  a  snug,  light,  well- fitting,  strong  jacket, 
the  wearing  of  which  would  not  be  objectionable  to  the 
most  fastidious  patient,  was  shown  by  the  fact  than  aft 
eminent  surgeon  had  estimated  that  four  per  cent,  of  the 
population  had  some  defect  of  the  spinal  column.  Among 
the  patients  shown  by  the  author  were  some  of  sensitive 
spine  in  neurotic  subjects,  railroad  spine,  and  deformities 
from  other  injuries,  lateral  curvature,  etc.  None  with 
Pott's  disease  happened  to  be  present. 


Dr.  A.  B.  Judson  being  requested  to  open  the  dis- 
cussion, said :  The  management  of  these  cases  is  the  cause 
of  anxiety,  because  the  patient  and  his  friends  do  not 
readily  recognize  the  difference  between  lateral  curvature, 
which  may  persist  without  interfering  with  a  long  and 
useful  life,  and  Pott's  disease,  which  is  a  destructive  proc- 
ess in  itself  and  exposes  the  patient  to  the  risk  of  ab- 
scesses, paraplegia,  greatly  reduced  stature,  and  serious 
deformity.  The  apparatus  shown  is  admirable  and  of 
value  in  the  treatment  of  certain  cases,  but  in  Pott's  dis- 
ease I  would  prefer  an  apparatus  which  enables  us  to 
apply  adjusted  and  regulated  pressure  directly  to  the  pro- 
jection in  an  anteroposterior  direction.  Pott's  disease 
is,  with  the  exception  of  malignant  disease,  the  most 
serious  affection  which  can  attack  the  skeleton.  In  itself 
the  morbid  process  is  curable,  as  is  seen  when  it  occurs 
in  the  ankle,  the  knee,  and  the  hip.  It  is  noticeable  that 
the  disease  is  more  manageable  in  the  smaller  joints,  evi- 
dently for  a  mechanical  reason.  The  muscles  are  more 
able  to  arrest  motion,  and  fixative  apparatus  is  more  effi- 
cient if  the  portion  of  the  body  lying  beyond  the  diseased 
joint  is  of  small  siae.  If  the  hip  joint  or  the  spinal  joints 
are  in  the  acute  stage  of  disease  they  are  unavoidably  dis- 
turbed by  motions  in  other  parts  of  the  body,  but  a  digi- 
tal ioint,  for  instance,  may  easily  be  kept  motionless  and 
unoisturbed  while  violent  motions  are  made  in  other  parts 
of  the  body.  It  is  this  mechanical  disadvantage,  suffered 
by  the  carious  vertebrae,  which  makes  this  disease  almost 
malignant  in  its  persistence.  With  this  in  view  we  must 
admire  the  zeal  which  Dr.  Hawkes  has  infused  into  his 
work.  In  this  way  alone  can  the  details,  which  are  so 
large  a  part  of  all  orthopedic  work,  be  properly  attended 
to.  In  fact  the  personal  element  is  as  important  as  the 
selection  of  a  form  of  apparatus. 

Dr.  von  Donhoff  thought  the  claims  made  for  the 
paper  jacket  were  well  based.  So  far  as  scoliosis  was  con- 
cerned, there  was  a  tendency  for  it  to  go  on  increasing 
in  spite  of  mechanical  treatment  until  nature  arrested  it. 
He  thought  Dr.  Vance,  of  Louisville,  was  first  to  use  the 
suspension  apparatus.  Dr.  von  Donhoff  had  come  to  re- 
gard suspension  as  dangerous,  and  therefore  applied  the 
jacket  on  a  kind  of  hammock,  in  the  horizontal  position. 
He  believed  he  had  himself  first  used  paper,  1874  or  1875. 

Dr.  Newland  expressed  the  opinion  that  the  more 
nearly  one  left  the  patient  alone  the  greater  would  be  his 
success  in  the  treatment  of  curvature  of  the  spine.  Where 
a  brace  was  called  for  the  paper  jacket  would  prove  use- 
ful, but  it  lacked  some  of  the  advantages  pertaining  to 
aluminum. 

Dr.  Millikrn  preferred  the  iron  brace,  but  since  pa- 
tients could  not  always  be  seen  frequently,  the  plaster 
jacket  had  found  a  place.  If  one  could  prevent  further 
deformity  he  would  do  well.  He  thought  Dr.  Bryan,  a 
former  Bellevue  interne,  first  used  plaster  in  this  country. 
He  preferred  putting  on  jackets  in  the  horizontal  posi- 
tion. 

Dr.  Brothers  thought  aluminum  wire  would  come  to 
be. used  for  jackets  in  preference  to  other  material. 

Dr.  Judson  remarked  that  Dr.  Benjamin  Lee,  of  Phila- 
delphia, had  used  suspension  before  the  date  mentioned 
by  Dr.  von  Donoff  as  the  time  when  Dr.  Vance  first  em- 
ployed it,  and  Dr.  Lee  said  he  got  the  idea  from  Dr.  John 
K.  Mitchell,  of  Philadelphia. 

Dr.  Hawkes  said,  in  closing,  that  he  would  not  put 
an  iron  brace  on  a  child  under  any  circumstances.  He 
did  not  believe  any  extension  of  the  spine  could  be  got 
by  placing  the  patient  in  the  horizontal  position.  He 
had  never  seen  danger  or  injury  from  suspension.  That 
actual  diminution  of  deformity  had  been  effected  was 
shown  by  the  successive  casts. 

To  say  to  a  patient  that  her  only  hope  lay  in  nature 
arresting  further  progress  of  the  deformity,  and  then  ask 
for  a  fee,  reminded  him  of  a  picture  in  a  comical  paper, 
representing  a  bruised  and  dilapidated  individual  in  the 
presence  of  a  soothsayer  who,  having  read  in  his  past 
history  that  he  had  met  with  some  accident,  and  predic- 
ted that  he  was  to  fall  heir  to  a  hundred  thousand  dol- 


August  1 8,  1894] 


MEDICAL    RECORD. 


219 


lars,  extended  his  hand  with  the  remark,  "  Two  dollan, 
please." 

Quinine  Amaurosis.— Dr.  J.  Herbert  Claiborne 
read  a  paper  in  which  he  described  a  case  of  quinine 
amaurosis,  mentioned  the  rarity  of  the  affection  and  the 
symptoms  usually  accompanying  the  condition.  There 
were  about  fifty-five  cases  on  record.  His  own  case  was 
seen  with  his  father  in  the  South.  The  eyes  were  examined 
also  by  Dr.  Knapp.  The  man  had  been  taking  consid- 
erable quinine,  and  on  one  occasion,  in  order  to  prevent 
recurrence  of  symptoms  and  assure  rest,  he  swallowed 
nearly  a  handful  of  two- grain  quinine  pills.  Following 
which  was  blindness  which  had  persisted  since,  or  about 
three  years.  There  had  been  only  sufficient  improve- 
ment to  enable  the  patient  to  see  slightly  by  reflected 
light,  less  well  by  direct  or  strong  light 

The  author  reached  the  following  conclusions  with 
regard  to  quinine  amaurosis:  1,  Quinine  in  toxic  doses 
may  produce  blindness ;  2,  the  toxic  dose  is  distinctly 
indeterminate;  3,  the  duration  of  the  amaurosis  varies 
greatly;  4,  the  field  of  vision  remains  contracted;  5, 
the  central  vision  usually  returns  to  normal ;  6.  there  is 
color-blindness  at  first,  color  perception  being  ultimately 
restored  in  the  central  field;  7,  the  ophthalmoscopic 
picture  is  that  of  white  atrophy ;  8,  experiments  on  dogs 
show  that  there  is  atrophy  of  the  entire  optic  tract ;  9, 
the  same  experiments  show  that  the  cells  of  the  cuneus 
are  probably  not  affected ;  10,  treatment  is  of  no  avail. 

Dr.  Claiborne's  case  was  the  severest  on  record. 
The  trouble  with  hearing  had  quite  disappeared. 

The  discussion  was  participated  in  by  Drs.  Hepburn, 
Van  Fleet,  Meeks,  and  the  author.  Dr.  Hepburn 
thought  the  most  curious  point  in  the  case  related  was 
better  perception  of  light  by  reflected  than  by  direct 
light.  The  affection  seemed  to  be  peripheral,  but 
whether  the  toxic  agent  acted  directly  upon  the  nerve  or 
through  the  circulatory  system  was  a  question. 

Ligation  of  Uterine  Artery  for  Control  of  Hemor- 
rhage in  Tumors.— Dr.  A.  H.  Goelet  presented  certain 
gynecological  instruments,  and  illustrated  by  drawing 
ligation  of  the  circular  artery  of  the  uterus  for  control  of 
hemorrhage  due  to  tumors  of  the  uterus,  after  the  manner 
practised  by  Martin,  of  Chicago.  Dr.  Goelet  thought 
he  had  done  this  operation  before  Dr.  Martin. 

The  only  danger  was  in  tying  the  ureter  and  in  sepsis. 
Confinement  was  from  one  to  two  weeks. 

Special  Committee  to  State  Constitutional  Conven- 
tion.— On  motion  of  Dr.  Frank  Ferguson,  the  President 
was  empowered  to  appoint  a  special  committee  of  five  to 
act  with  like  committees  appointed  by  other  medical 
societies,  for  the  purpose  of  looking  after  matters  medical 
before  the  approaching  State  Constitutional  Convention. 

Dr.  Charles  J.  Proben  presented  a  specimen  of  tuber- 
cular dachtylitis,  Dr.  Biggs  having  confirmed  the  diag- 
nosis; also  a  specimen  of  broncho-pneumonia  from  a 
child. 


Stated  Meeting,  May  2i%  1894. 

Samuel   B.  W.  McLeod,  M.D.,  President,   in  the 
Chair. 

The  Medical  Department  of  the  National  Guard,  its 
Status  in  Two  Decades.  —  Dr.  Joseph  D.  Bryant, 
Surgeon-General  of  the  National  Guard  of  the  State  of 
New  York,  spoke  of  the  status  of  the  medical  department 
ten  years  before  and  ten  years  since  1884.  The  National 
Guard  was  composed  of  the  military  and  naval  service, 
all  told  of  about  fourteen  thousand  men,  fifteen  thousand 
being  the  legal  limit.  There  were  about  five  thousand 
men  in  New  York  City,  three  thousand  in  Brooklyn, 
twenty-five  hundred  in  Albany  and  the  country  towns, 
and  about  the  same  number  in  Buffalo  and  surrounding 
counties.  The  National  Guard  served  two  important  pur- 
poses, viz.:  to  serve  the  State  in  case  of  riots,  and  to 
form  the  nucleus  of  an  army  in  case  of  war.  The  naval 
reserves  numbered  four  or  five  hundred.    The  men  en- 


listed for  five  years  and  drilled  once  a  week  for  seven 
months  a  year. 

Medical  Department. — This  was  made  up  of  the  sur- 
geon-general, surgeons  major,  and  assistant  surgeons  of 
the  rank  of  captain  or  lieutenant,  in  all  about  ninety 
medical  men.  Then  there  was  a  hospital  corps  of  in- 
structed non*  medical  men,  and  hospital  stewards,  num- 
bering about  one  hundred  and  fifty-six  men. 

Briefly  stated,  the  duties  of  the  medical  officers  during 
ten  years,  prior  to  1884,  were  simply  to  appear  on  dress 
parade  and  to  add  to  the  social  enjoyment  of  the  officers 
at  whose  pleasure  they  were  appointed.  They  sighed 
papers  in  a  perfunctory  way. 

A  change  has  been  effected  since  1884,  and  today  the 
duties  of  the  medical  officers,  from  the  surgeon-general 
down,  were  much  more  onerous.  Scrutiny  was  not  ex- 
ercised  in  the  appointments,  and  while  the  commanding 
officer  could  name  a  doctor  whom  he  would  like  to  have 
appointed  his  power  ended  there.  Those  selected  had  to 
appear  before  a  medical  examining  board,  and  not  a  few 
of  them  had  failed  to  pass  the  examination.  The  ap- 
proval of  the  surgeon-general  was  requisite  after  the  can- 
didate had  been  recommended  by  the  examining  board. 
Their  duties,  when  appointed,  were  medical  and  educa- 
tional. They  had  to  examine  every  recruit  and  to  look 
after  the  health  of  the  troops.  The  educational  duties 
were  to  give  instruction  to  the  hospital  corps  in  the 
matter  of  giving  first  aid  to  the  injured,  etc.  The  hos- 
pital stewards  were  formerly  undertakers,  butchers,  etc., 
while  to-day  they  were  required  to  be  educated  in  phar- 
macy. Formerly  there  was  no  regular  hospital  or  am- 
bulance corps,  men  acting  only  for  the  occasion,  while 
at  present  a  certain  number  were  appointed  for  this 
position  for  the  whole  period  of  five  years,  and  received 
special  instruction  in  the  care  of  the  wounded.  At  the 
end  of  the  period,  if  they  passed  the  examination,  they 
were  given  a  certificate  and  two  badges,  one  being  that 
of  the  Red  Cross. 

They  had  thus  built  up  in  this  State,  as  had  been  done 
in  a  few  others,  a  complete  system  corresponding  to  that 
in  the  regular  army. 

After  some  remarks  upon  Dr.  Bryant's  paper  by  Drs. 
N.  H.  Henry,  A.  M.  Jacobus,  Brothers,  and  the  author, 
the  Society  listened  to  the  reading  of  the  second  paper 
of  the  evening,  by  Dr.  John  G.  Coyle,  on 

Membranous  Enteritis,  with  Report  of  a  Case. — 
Dr.  Coyle  had  found  few  cases  reported,  but  believed 
the  condition  was  often  overlooked  because  of  neglect  to 
examine  the  stools.  No  fibres  were  found  in  the  dis- 
charged membrane,  it  differing  from  diphtheritic  enteritis 
in  that  regard.  Some  patients  passed  yards  of  mem- 
brane resembling  tape- worm,  for  which  it  had  sometimes 
been  mistaken.  The  disease  was  chronic,  attacks  com- 
ing on  for  slight  cause  in  those  who  were  susceptible. 
The  treatment  related  to  diet,  cleanliness  by  rectal  ene- 
mata,  and  catharsis  as  might  be  indicated.  There  was 
little  fever.  His  own  patient  was  a  woman,  thirty-five 
years  of  age,  who  had  at  times  suffered  from  great  dis- 
tention and  rumbling  in  the  abdomen,  severe  abdominal 
pains  at  the  time  of  the  attacks,  headache,  etc.  The 
condition  probably  dated  from  1885,  since  which  time 
she  had  had  attacks  of  dysentery,  but  membrane  was  dis- 
covered only  the  past  year,  when  Dr.  Coyle  began  to 
examine  the  stools,  and  since  that  time  there  had  been 
discharge  of  non- fibrous  membrane  in  three  attacks. 

Dr.  Gessner  Harrison  had  seen  one  case  of  mem- 
branous enteritis  in  a  patient  who  supposed  the  cast  was 
part  of  a  tape- worm  and  brought  it  to  him.  She  said  her 
brother  had  been  troubled  in  the  same  way. 

In  some  closing  remarks  Dr.  Coyle  dwelt  upon  the 
importance  of  carefully  examining  the  stools  in  gastro- 
intestinal troubles,  just  as  one  would  examine  the  urine 
in  suspected  renal  disease. 

Dr.  T.  H.  Manley  reported  as  delegate  to  the  Inter- 
national Medical  Congress  which  recently  met  at  Rome. 
He  pronounced  the  meeting  a  success,  scientifically  and 
socially. 


220 


MEDICAL   RECORD. 


[August  1 8,  1894 


THE    NEW  YORK    PATHOLOGICAL   SOCIETY. 

Stated  Meeting  April  u,  1894 

George  C.  Freeborn,  M.D  ,  President,  in  the  Chair. 

Carbolic  Aeid  Poisoning. — Dr.  H.  P.  Loomis  pre- 
sented the  following :  A  man  was  taken  suddenly  ill  on 
the  street  and  died  before  the  ambulance  reached  him. 
The  autopsy  showed  that  death  was  due  to  carbolic  acid 
poisoning.  The  specimens  showed  very  well  the  extreme 
congestion  and  corrosion  of  the  larynx  and  oesophagus. 
The  tissues  were  very  well  preserved,  although  they  had 
beeto  kept  in  a  cool  place  for  about  one  week  without 
any  special  preservative  fluid. 

Abscess  of  the  Brain. — W.  J ,  thirty  four  years  of 

age,  was  admitted  to  Bellevue  Hospital  in  a  somewhat 
stupid  condition.  He  answered  all  questions  in  a  loud 
voice.  He  had  been  complaining  for  two  months  pre- 
viously of  pain  in  the  right  side  of  the  head  and  in  the 
right  ear,  and  there  had  been  a  discharge  of  pus  from 
this  ear  for  a  short  time,  but  it  had  ceased  before  his  ad- 
mission to  the  hospital.  The  day  after  admission  he 
suddenly  developed  paralysis  on  the  left  side,  which  was 
more  marked  in  the  left  arm.  After  a  few  hours  the 
stupor  became  profound,  and  he  died  the  following  day. 
At  no  time  was  his  temperature  over  990  F.  A  diagnosis 
was  not  made  during  life.  On  removing  the  brain  there 
was  a  peculiar  yellowish  appearance,  but  no  evidence  of 
an  abscess  until  the  brain  was  cut  open.  The  brain, 
with  the  exception  of  an  abscess  in  the  temporal  lobe  on 
the  right  side,  was  normal,  as  were  also  the  other  organs 
of  the  body.  The  abscess  in  the  temporal  lobe  was 
marked  by  a  cavity  about  an  inch  and  a  half  in  diam- 
eter, and  this  cavity  was  rilled  with  thick,  greenish  pus. 
The  bones  of  the  ear  were  cut  open,  and  in  the  mastoid 
cells  and  the  petrous  portion  of  the  temporal  bone  col- 
lections of  pus  were  found.  There  was  no  meningitis — 
in  other  words,  no  extension  by  continuity.  The  sinus 
was  thoroughly  examined,  but  no  thrombus  was  found. 
Cultures  were  made  only  from  the  abscess,  and  these 
showed  the  presence  of  the  staphylococcus  albus,  the 
cladothrix,  the  bacillus  liquefacieus,  and  a  diplococcus  re- 
sembling Frankel's,  but  its  exact  character  had  not  been 
positively  determined. 

Perforation  of  the  (Esophagus  of  a  "  Sword  swal 
lower." — Dr.  Loomis  also  exhibited  the  diaphragm,  oeso- 
phagus, and  stomach  from  a  man,  thirty- nine  years  of  age, 
who  had  died  within  half  an  hour  after  admission  to 
Bellevue  Hospital.  At  the  autopsy,  on  removing  the 
sternum,  the  left  pleural  cavity  was  found  to  contain  a 
large  amount  of  dark  liquid  with  little  oil  globules  float- 
ing on  top,  and  masses  of  what  appeared  to  be  fecal  mat- 
ter floating  in  it.  The  lung  was  compressed  against  the 
spinal  column,  and  the  heart  was  pushed  over  to  the  mid- 
dle line.  There  was  an  odor  of  acetic  and  butyric  acids 
in  the  liquid.  Thinking  that  possibly  the  intestine  had 
ruptured  through  the  diaphragm  and  had  become  strangu- 
lated, it  was  next  dissected  out,  and  was  found  to  be  free 
throughout  its  entire  extent.  .  The  diaphragm  was  then 
examined  and  found  intact.  The  lung  was  next  carefully 
removed,  and  was  found  to  be  completely  atelectatic 
After  careful  search  it  was  found  that  the  little  finger 
could  be  passed  into  the  left  side  of  the  oesophagus  a  lit- 
tle above  the  diaphragm ;  in  other  words,  there  had  been 
a  perforation  of  the  oesophagus,  leaving  a  clean  cut,  linear 
opening,  2  ctm.  in  length,  extending  down  to  the 
oesophageal  opening  in  the  diaphragm.  There  was  no 
evidence  of  ulceration  or  infiltration.  On  examining  the 
cardiac  end  of  the  stomach  radiating  lines  were  found 
around  the  oesophageal  opening,  which  seemed  to  have 
resulted  from  injury.  All  three  inner  coats  were  gone, 
and  the  peritoneum  laid  bare.  No  other  part  of  the 
stomach  or  oesophagus  was  injured  in  any  way,  and  care- 
ful search  throughout  the  entire  alimentary  tract  failed  to 
reveal  the  presence  of  any  sharp  pointed  or  sharp-edged 
body ;  in  fact,  no  foreign  body  of  any  description  was 
found.  Subsequent  inquiry  showed  that  this  man  had 
been  a  sword-swallower,  and  had  been  performing  almost 


up  to  the  day  of  his  death.  Probably  the  injury  had 
been  inflicted  by  a  sword. 

Diverticula  of  the  Sigmoid  Flexure  of  the  Colon.— 
Dr.  George  P.  Biggs  presented  the  specimen.  It  was 
removed  from  a  woman,  fifty  five  years  of  age,  who  died 
of  chronic  tuberculosis,  chronic  diffuse  nephritis,  and 
cirrhosis  of  the  liver.  About  two  inches  above  the  brim 
of  the  pelvis  there  was  a  hard  mass  in  the  posterior  wall 
of  the  sigmoid  flexure  of  the  colon,  and  on  cutting  into 
this  from  the  outer  surface  a  pocket  was  exposed  which 
contained  nearly  one  drachm  of  thick  yellowish  pus.  It 
measured  2  ctm.  x  1  ctm.,  the  longer  measurement  cor- 
responding with  the  axis  of  the  gut.  The  tissues  around 
this  were  distinctly  indurated,  although  there  was  no 
localized  peritonitis,  the  inflammation  being  entirely  in 
the  adipose  tissue  surrounding  the  sigmoid  flexure. 
After  some  difficulty  a  small  probe  was  passed  through 
a  small  opening  into  the  lumen  of  the  gut.  There  were 
a  number  of  other  diverticula. 

This  condition  of  multiple  diverticula  in  the  colon, 
especially  in  the  lower  portion,  would  be  found  not  to 
be  uncommon,  the  speaker  said,  if  careful  search  were 
made  for  it.  These  diverticula  generally  contained 
fecal  matter.  He  had  never  before  seen  them  inflamed 
as  in  this  case,  although  there  was  no  special  reason  why 
this  should  not  occur. 

Dr.  James  Ewing  said  that  he  had  recently  seen  two 
cases  of  anaemic  colitis  with  marked  ulceration,  in  which 
all  the  normal  diverticula  of  the  sigmoid  flexure  for 
about  one  foot  were  much  dilated,  so  that  they  were 
capable  of  holding  two  or  three  drachms  of  fluid.  They 
were  not,  however,  inflamed. 

Diphtheria  and  Pseudo- diphtheria  Bacilli.— Dr. 
William  H.  Park  presented  cultures  and  cover-glass 
"smears"  of  a  number  of  varieties  of  diphtheria  and 
pseudo  diphtheria  bacilli,  and  briefly  alluded  to  the  views 
that  had  been  held  by  bacteriologists  regarding  the  nat- 
ure of  these  bacilli. 

In  1888  Hofmann  published  the  results  of  some  in- 
vestigations in  which  he  stated  that  besides  finding  the 
diphtheria  bacilli  in  cases  of  true  diphtheria,  he  had  found 
them  in  twenty-six  out  of  forty-five  throats  in  which 
no  diphtheria  had  existed.  Some  of  these  bacilli  were 
shorter,  thicker,  and  more  regular  in  form  than  the 
Loeffler  bacilli,  and  grew  more  readily  on  agar,  the 
growth  being  both  more  luxuriant  and  whiter.  Others, 
however,  were  in  all  respects  identical  with  the  Loeffler 
bacillus  except  that  those  from  healthy  throats  were  not 
virulent.  He  did  not  feel  able  to  state  whether  or  not 
these  two  forms  were  identical  with  the  virulent  diph- 
theria bacilli  of  Loeffler,  or  a  different  form  of  bacteria. 
Loeffler  himself,  and  most  German  writers  have  consid- 
ered them  to  be  altogether  a  different  form  of  bacteria, 
while  Roux  and  Yersin,  most  Frenchmen,  and  some 
Germans  have  looked  upon  them  as  identical.  Roux  and 
Yersin  in  their  studies  on  diphtheria  gave  careful  atten- 
tion to  the  relationship  of  the  so  called  pseudo-diphtheria 
bacillus  to  the  true  one.  The  majority  of  the  bacilli 
they  studied  were  identical  with  the  Loeffler  diphtheria 
bacillus  in  growth,  size,  and  form,  and  differed  simply  in 
not  possessing  virulence.  Exceptionally  they  found 
bacilli  which  were  shorter,  grew  somewhat  more  luxu- 
riantly on  agar  and  in  broth,  and  at  a  somewhat  lower 
temperature  (20°-22°  C.)  than  the  true  diphtheria  bacil- 
lus. This  latter  quality  was  sometimes  only  acquired 
after  the  bacilli  had  grown  some  generations  on  artificial 
media.  The  changes  in  reaction  in  bouillon  caused  by 
the  growth  of  the  bacilli  were  the  same  as  in  the  case  of 
true  bacilli,  but  change  to  acid,  and  later  return  to  alka- 
line reaction  was  more  rapid.  It  was  noted  that  the 
non  virulent  bacilli  were  only  present  in  small  numbers 
in  the  throats,  so  that  the  serum  tubes  usually  contained 
but  one  to  four  colonies. 

In  a  hospital  for  children  in  Paris,  where  cases  of 
diphtheria  were  occurring  from  time  to  time,  cultures 
were  made  from  forty-five  throats,  and  non-virulent 
bacilli  found  in  fifteen.     In  a  village  in  France,  by  the 


August  1 8,  1894] 


MEDICAL    RECORD. 


221 


coast,  where  no  diphtheria  had  been  present  for  a  long 
time,  cultures  were  made  from  the  throats  of  fifty  nine 
children  living  in  a  school,  and  in  twenty  six  of  these 
non-  virulent  bacilli  were  found.  In  an  examination  of 
ten  throats  of  attendants  in  a  diphtheria  hospital  non- 
virulent  bacilli  were  found  once.  Therefore  in  one 
hundred  and  fourteen  healthy  throats  the  bacilli  were 
found  seventy-two  times.  From  these  experiments  they 
concluded  that  a  bacillus  similar  in  all  essential  charac- 
teristics with  the  diphtheria  bacillus,  except  for  its  lack 
of  virulence,  was  a  fairly  common  inhabitant  of  the 
healthy  throat. 

With  regard  to  its  frequency  in  disease,  it  was  noted 
twice  in  six  children  with  mild  sore  throats,  and  five 
times  in  the  throats  of  seven  children  in  which  the  sore 
throat  was  complicated  with  measles.  They  found  that  - 
the  cultures  of  true  cases  of  diphtheria  could  be  distin- 
guished from  those  from  healthy  and  diseased  throats  by 
the  fact  that  the  cultures  from  true  diphtheria  con- 
tained a  great  number  of  colonies  of  the  bacilli,  while 
those  in  which  non-virulent  bacilli  were  present  the 
colonies  were  very  few,  there  never  being  more  than 
from  one  to  four  present  in  one  tube.  Tins. would  be  a 
valuable  practical  guide  if  it  were  only  true. 

The  connection  between  the  most  virulent  and  the 
non-virulent  bacilli  is  shown  by  the  gradations  in  viru- 
lence of  diphtheria  bacilli.  As  a  rule,  the  more  severe 
the  case  the  more  virulent  the  bacilli  were  found  to  be. 
In  cases  which  recover,  the  bacilli  become  less  and  less 
virulent  as  convalescence  progresses.  It  has  been  found 
that  throats  recently  the  seat  of  diphtheria  were  more 
apt  to  contain  the  non- virulent  bacilli  than  were  other 
throats.  They  regarded  occasional  slight  differences  in 
growth,  shape,  and  staining  as  too  slight  and  inconstant 
to  separate  the  virulent  form  from  the  non-virulent. 
They  regard  a  division  founded  upon  the  reaction  to  in- 
oculation of  the  guinea-pig  as  an  arbitrary  one.  It  is 
well  known  that  there  exist  bacilli  which  exhibit  all 
grades  of  virulence  in  guinea-pigs,  some  causing  certain 
death,  some  marked  local  changes,  some  temporary  and 
slight  oedema,  and  some  causing  no  appreciable  reaction 
whatever.  They  believe  that  in  order  to  prove  the  two 
forms  to  be  varieties  of  the  same  bacillus  it  is  necessary 
to  first  derive  the  non*  virulent  form  from  the  virulent, 
and  secondly  to  derive  the  virulent  form  from  the  non- 
virulent.  The  first  they  have  accomplished,  but  in  the 
second  they  have  failed. 

When  grown  for  a  long  time  on  agar  a  temporary 
loss  of  virulence  occurs.  When  the  bacillus  is  grown  in 
broth  through  which  a  current  of  air  is  constantly  pass- 
ing, it  is  found  that  after  two  weeks  the  bacilli  begin  to 
lose  their  virulence,  and  at  the  end  of  four  weeks  they 
become  harmless.  A  few  days  later  the  bacilli  in  the 
culture  will  die.  Just  prior  to  this  time  when  all  living 
bacilli  produce  non-virulent  cultures,  it  has  been  found 
that  some  would  produce  virulent  and  others  non- viru- 
lent cultures.  When  kept  at  45  °  C.  for  three  days  the 
bacilli  were  found  to  possess  many  of  the  characteristics 
of  the  pseudo-bacilli.  They  were  unable,  however,  to 
give  virulence  to  those  bacilli  which  produced  in  guinea- 
pigs  no  effect  whatever.  This  was  true  both  in  those  in 
which  the  loss  of  virulence  had  been  acquired  artificially, 
as  in  those  in  which  it  had  occurred  naturally. 

Escherisch  found  in  one  city,  out  of  seventy  throats 
examined,  non-virulent  bacilli  in  two,  and  in  another 
city,  out  of  two  hundred  and  fifty,  they  were  present  in 
eleven.  *  In  none  of  these  was  diphtheria  present  at  the 
time  of  making  the  cultures.  The  animal  inoculations 
were  made  from  a  forty  eight  hours'  growth  in  glucose 
alkaline  broth,  and  the  quantity  injected  was  equal  to 
half  per  cent,  of  the  weight  of  the  guinea  pig.  With 
these  precautions  he  never  found  any  bacilli  which  had 
the  characteristics  of  the  diphtheria  bacilli  which  did  not 
prove  virulent  in  guinea-pigs.  The  pseudo-bacilli  were  as 
described  by  Hofmann  in  some  of  his  cases,  viz.,  shorter, 
plumper  bacilli,  and  of  fairly  uniform  size.  The  growth 
on  agar  was  more  luxuriant,  and  in  his  cases  whiter  than 


the  Loeffler  bacilli.  This  investigator  has  also  called  at- 
tention to  the  fact  that  the  pseudo-diphtheria  bacilli  show 
a  tendency  to  lie  in  parallel  rows  on  a  cover-glass,  while 
the  Loeffler  bacilli  are  collected  together  in  a  most  con- 
fused manner.  A  further  and  most  important  difference 
was  that  the  pseudo-diphtheria  bacilli  grown  in  litmus 
bouillon  turned  it  blue  after  forty  eight  hours,  while  the 
true  diphtheria  bacilli  produced  acid,  and  turned  the  lit- 
mus red.  There  were  no  exceptions  to  this  rule,  so  that 
where  it  was  impossible  to  make  animal  inoculations  he 
considered  this  would  prove  to  be  in  all  probability  a 
certain  guide  in  doubtful  cases.  With  the  true  bacilli 
there  was  no  relation  observed  between  the  amount  of 
acid  formed  and  the  degree  of  virulence. .  He,  too,  found 
that  in  the  milder  cases,  or  during  convalescence,  the 
bacilli  were  apt  to  be  less  virulent,  but  to  this  rule  there 
were  many  exceptions.  This  investigator  concludes  that 
since  we  have  found  constant  cultural  differences  to  exist 
between  the  true  and  pseudo-diphtheria  bacillus,  we  can 
give  the  pseudo  diphtheria  bacillus  no  diagnostic  value, 
and  further,  we  do  not  find  it  a  frequent  inhabitant  of 
the  throat. 

The  speaker,  continuing,  said  that  if  time  permitted  a 
more  extended  review  of  the  results  obtained  by  others, 
we  would  still  more  clearly  be  brought  to  believe  that 
there  are  several  varieties  of  bacilli  grouped  under  this 
name  of  pseudo-diphtheria  bacilli,  for  how  otherwise 
could  some  observers  affirm  that  the  bacilli  cause  alkaline 
bouillon  to  become  acid,  while  others  equally  good  as- 
sert that  it  becomes  alkaline ;  or  that  some  should  find 
them  to  be  identical  in  all  morphological  and  cultural 
characteristics  with  the  Loeffler  bacilli,  while  others  find 
distinct  and  constant  differences?  Dr.  Park  said  that 
in  the  large  number  of  experiments  carried  out  in  the 
laboratory  by  Mr.  Alfred  L.  Beebe  and  himself,  they 
had  met  with  numerous  examples  of  all  the  forms  de- 
scribed. Cultures  from  330  non  -  diphtheritic  throats 
gave,  in  22,  virulent  Loeffler's  bacilli ;  in  21,  non* viru- 
lent characteristic  bacilli ;  and  in  28,  Hofman's  pseudo- 
bacilli. 

Dr.  Park  then  offered  the  following  classification,  and 
presented  to  the  Society  cultures  in  bouillon  and  on 
agar,  and  cover-glass  smears  representing  each  of  these 
divisions : 

z.  Loeffler's  Diphl/ieria  Bacilli. — Found  in  cases  of 
true  diphtheria,  and  in  persons  brought  in  contact  with 
them.  They  all  produce  the  toxines  described  by  Loef- 
fler, Roux,  Frankel,  and  others.  They  are  subdivided 
into,  a,  bacilli  characteristic  in  growth,  shape,  and  stain- 
ing ;  and  b,  bacilli  not  characteristic,  but  still  having  the 
recognized  slight  variations  only.  All  these  produce 
acid  in  their  growths  in  broth. 

2.  Probably  Loeffler's  Diphtheria  Bacilli.— They  agree 
with  the  above  classes  in  every  way  except  that  they  have 
no  virulence  when  injected  in  animals,  and  do  not  pro* 
duce  the  toxines.    They  are  found  in  healthy  throats. 

3.  Probably  not  Loeffler's  Diphtheria  Bacilli,— The 
growth  on  agar  and  serum  is  far  more  luxuriant  than  is 
ever  seen  with  true  bacilli.  They  first  make  the  litmus 
cloudy,  and  then  give  the  acid  reaction.  They  are  sub- 
divided into,  a.  Shorter,  plumper  bacilli  which  usually 
stain  evenly.  They  grow  rather  more  quickly  on  agar, 
frequently  give  rise  for  the  first  twenty- four  hours  to  a 
cloudy  broth,  and  give  an  alkaline  reaction  with  litmus 
bouillon.  (Probably  a  subdivision  could  be  made  here 
into  those  causing  a  luxuriant  growth  on  agar,  and  those 
which  do  not  do  so,  and  which  are  plumper.)  b.  Bacil- 
li shorter  and  plumper  than  is  usual  in  Loeffler's  bacilli, 
but  taking  a  fairly  characteristic  stain.  This  third  class 
is  found  in  healthy  throats,  and  more  rarely  with  diph- 
theria bacilli  in  cases  of  diphtheria. 

Dr.  H.  D.  Chapin  asked  in  regard  to  examinations 
made  several  weeks  after  dipntheria. 

Dr.  Park  replied  that  if  one  followed  them  up  for  six 
weeks,  they  would  be  found  to  become  less  and  less  viru- 
lent while  retaining  their  morphological  appearances. 
He  had  not  examined  them  after  six  weeks,  but  at  this 


222 


MEDICAL   RECORD. 


[August  1 8,  1894 


time  they  were  apparently  in  about  the  same  condition 
as  in  children  in  whom  they  had  been  found,  and  yet 
who  had  not  developed  any  symptoms  of  diptheria.  The 
diagnosis  was  made  chiefly  on  the  stain,  and  the  varied 
size  and  shape  of  the  bacilli.  These  characters  ranked 
next  in  diagnostic  value  to  animal  inoculations. 
The  Society  then  went  into  executive  session. 


OUR  LONDON  LETTER. 

.(From  our  Special  Correspondent  ) 

CHELSEA  HOSPITAL — MEETING  OF  GOVERNORS — RESIGNA- 
TION OF  STAFF — HEALTH  CONGRESS  IN  LONDON — RE- 
CEPTION BY  LORD  MAYOR — SUCCESSFUL  MEETING — WORK- 
HOUSE BARRACK  SCHOOLS — DEPUTATION  TO  GOVERN- 
MENT— INQUIRY  PROMISED — MASSAGE  SCANDALS — THE 
BRITISH   MEDICAL  ASSOCIATION  WEEK. 

London,  July  a8,  1894. 

The  troubles  of  the  Chelsea  Hospital  for  Women  are  not 
yet  over.  On  Tuesday  last  there  was  a  special  meeting 
of  the  Governors  to  consider  the  report  of  the  Committee 
of  Inquiry.  Lord  Cardigan  took  the  chair,  and  an- 
nounced that  as  far  as  practicable  the  recommendations 
would  be  carried  out.  He  could  not,  however,  see  how 
the  lay  members  of  the  Board  could  control  the  staff  or 
even  ascertain  that  their  work  was  at  all  times  properly 
carried  on.  They  must  depend  for  their  knowledge  on 
the  medical  members  of  the  Board,  and  the  staff  were  thus 
represented  but  did  not  form  a  majority  of  the  Board,  and 
his  Lordship  held  that  this  was  quite  right,  in  which 
opinion  most  men  of  experience  will  probably  concur. 

It  was  announced  that  in  order  to  give  the  Board  and 
Governors  a  free  hand  in  the  reorganization  of  the  hos- 
pital the  staff  had  all  resigned,  but  were  willing  to  con* 
tinue  their  services  pending  the  appointment  of  their 
successors.  Dr.  Fenton,  on  behalf  of  the  staff,  accepted 
the  recommendations  of  the  committee  and  pointed  out 
that  Dr.  Parkes  had  withdrawn  the  expression  in  his  re- 
port as  to  the  "justifiability"  of  certain  operations. 
This  expression,  I  remarked  at  the  time,  was  certainly 
not  a  proper  one  from  a  medical  officer  of  health,  who 
could  not  pretend  to  any  expert  surgical  knowledge. 
Dr.  Fenton  pointed  out  that  although  retracted  by  Dr. 
Parkes  this  is  not  so  well  known  as  it  ought  to  be.  In 
regard  to  the  mortality,  Dr.  Fenton  produced  statistics 
showing  that  in  the  special  departments  of  large  general 
hospitals  there  had  sometimes  been  even  a  higher  death- 
rate.  Thus,  as  an  example,  the  rate  in  ovariotomy  had 
varied  in  six  hospitals  between  4.3  and  22.2  percent., 
and  Chelsea  did  not  reach  this  maximum  in  spite  of  its 
sanitary  defects.  This  only  shows  that  it  is  impossible 
to  draw  conclusions  from  a  percentage  calculated  from  a 
few  cases.  After  the  meeting  the  Board  of  Management 
held  a  sitting  in  order  to  proceed  with  the  reconstitution 
of  the  hospital.  I  hear  that  they  will  proceed  to  elect  a 
new  staff.  To  me  it  seems  they  might  well  follow  the  ex- 
ample of  the  late  staff  and  resign  their  position ;  for,  after 
all,  the  Committee  of  Inquiry  condemned  the  Board  of 
Management,  and  if  anyone  should  resign  they  should, 
and  the  Governors  should  proceed  to  a  new  election. 
But  then,  Governors  are,  as  a  rule,  merely  subscribers — 
only  a  few  take  a  real  interest  in  such  things  and  leave 
the  work  to  those  who  do.  These  give  their  services  and 
have  a  claim  for  consideration  in  case  of  mistakes  or 
neglect,  and  nothing  worse  is  alleged.  At  the  same 
time  the  medical  staff  equally  give  their  services  and  are 
not  responsible  for  management.  But  then  the  medical 
officers  are  the  readiest  scapegoats,  and  in  every  alleged 
abuse  are  sure  to  be  blamed.  Then  they  resign  and 
others  are  only  too  anxious  to  jump  into  their  shoes. 
This  is  the  usual  end  of  every  hospital  scandal. 

The  Health  Congress  has  met  this  week  in  London. 
This  meeting  was  arranged  by  the  British  Institute  of 


Public  Health  at  their  Congress  last  year,  which  was  held 
in  the  University  of  Edinburgh,  when  on  the  proposition 
of  the  Lord  Mayor  of  London  it  was  decided  to  meet 
this  year  in  the  metropolis.  All  the  sanitary  authorities 
in  the  kingdom  were  invited  to  send  delegates,  and 
nearly  two  thousand  were  appointed.  On  Wednesday 
they  were  received  at  King's  College,  by  Dr.  Littlejohn, 
President,  and  Sir  C.  Cameron,  Vice-President.  On 
Thursday  there  was  a  great  meeting  at  the  Mansion 
House,  the  Lord  Mayor  in  the  chair,  supported  by  the 
sheriffs  and  other  city  officials  in  their  robes  of  office. 

Professor  William  R.  Smith,  the  new  President,  having 
been  installed  read  his  address,  which  appropriately 
dealt  with  the  question  of  the  Local  Government  of  Lon- 
don. Curiously  enough,  on  the  eve  of  the  Congress,  the 
British  Medical  Journal  came  out  with  a  spiteful  little 
article  evidently  intended  to  spoil  the  meeting.  People 
asked  each  other  what  it  meant.  It  was  said  that  a 
number  of  men  had  withdrawn,  and  hinted  that  the 
Mansion  House  assembly  would  be  a  failure.  It  would 
have  done  the  editor  good  to  see  how  little  his  own  per- 
sonal withdrawal,  so  ostentatiously  announced,  affected 
the  Congress.  All  sorts  of  comments  are  made,  but  no 
one  seems  to  know  or  care  much  in  what  way  the  mana- 
gers have  trodden  on  the  editorial  corns,  but  it  is  sug- 
gested that  there  has  been  a  lack  of  adulation  toward  the 
D.C.L.  The  Journal  has  at  the  same  time  done  good 
by  agitating  about  the  barrack  pauper  schools,  respect- 
ing which  it  got  up  a  deputation  to  the  President  of  the 
Local  Governing  Board,  who  promised  some  inquiry 
either  by  a  royal  commission  or  a  select  committee  of 
the  House  of  Commons.  It  is  not  impossible  that  such 
inquiry  may  be  more  extensive  than  asked  for.  If  that 
be  the  case  so  much  the  better.  We  need  full  inquiry 
into  our  Poor  Law  system  rather  than  investigations 
restricted  to  one  or  two  cases  at  a  time.  The  deputation 
which  was  received  on  Tuesday  was  a  very  influential 
one,  representing  all  parties,  and  including  women  as 
well  as  men,  a  natural  thing  when  the  interests  of  chil- 
dren are  concerned.  Sir  John  Gorst  introduced  the 
deputation  in  a  moderate  speech  which  the  minister  lis- 
tened to  attentively  and  commended,  but  Mr#  E.  Hart 
was  reminded  that  his  controversial  speech  went  beyond 
his  brief.  He  certainly  deserved  the  rebuke  as  the  sen- 
sational statements  he  made  were  evidently  intended  for 
an  outside  audience.  Mr.  Shaw-Lefevre  looked  at  the 
question  as  a  grave  one,  and  as  he  promised  to  bring  it 
before  his  colleagues  in  the  ministry  with  the  view  of  ap- 
pointing an  inquiry,  the  object  of  the  deputation  was 
obtained. 

Vice  seems  ever  ready  to  raise  its  head  in  large  com- 
munities. It  is  now  asserted  that  some  establishments 
for  massage  are  only  brothels  in  disguise.  The  papers 
are  full  of  the  subject,  and  Truth  admits  that  its  editor 
has  been  for  months  informed  of  the  existence  of  "  facts 
such  as  no  decent  person  could  contemplate  without  hor- 
ror !  "  It  is  to  be  hoped  that  this  new  scandal — the  most 
horrible  of  the  many  that  have  been  exploited — may  lead 
to  such  action  as  shall  deliver  us  from  this  form  of  the 
social  evil  and  some  others  with  it. 

London,  August  4,  1894. 

The  centre  of  gravity  of  the  profession,  so  to  say,  has 
been  shifted  to  Bristol  for  most  of  the  week.  Some  went 
off  on  Monday,  especially  officials,  but  most  were  con- 
tent to  take  a  morning  train  on  Tuesday ;  while  others 
waited  till  afternoon  and  so  missed  the  first  general  meet- 
ing and  the  sermon,  but  were  in  good  time  for  the  sec- 
tions, which  only  began  work  on  Wednesday  morning. 

As  your  several  reporters  will  furnish  you  with  foil  ac- 
counts of  both  the  general  meetings  and  the  sectional 
proceedings,  I  need  only  gather  up  in  thb  letter  some  of 
the  fragments  of  the  more  popular  side  of  the  week's  do 
ings. 

The  attractions  to  the  general  meetings  are  the  ad- 
dresses. At  the  conclusion  of  these,  or,  at  any  rate,  after 
the  vote  of  thanks,  there  is  usually  a  stampede,  only  a 


August  18,  1894] 


MEDICAL    RECORD. 


223 


few  enthusiastic  members  staying  to  transact  formal  busi- 
ness, or  join  in  discussions  of  which  notices  have  been 
given. 

These  discussions,  however,  are  the  only  occasions  on 
which  discontent  can  be  expressed  with  the  council  or 
officials.  It  is  not  to  be  wondered  at  that  among  so 
many  members  differences  of  opinion  and  dissatisfaction 
should  be  found,  and  it  is  well  that  expression  should  be 
given  to  such  sentiments.  I  hear,  however,  that  the  offi- 
cials would  like  to  suppress  them.  The  policy  of  sitting 
on  the  safety-valve  is  not  a  very  safe  one,  and  it  is  possi- 
ble the  officials  may  be  convinced  of  this  in  an  unpleas- 
ant manner  if  they  do  not  take  warning.  The  editor 
came  in  for  the  mingled  manifestations  of  approval  and 
disapproval  to  which  he  is  accustomed,  but  he  is  too 
astute  a  person  to  push  any  further  the  considerable  irre- 
sponsibility which  he  has  managed  to  attain. 

The  exhibitors  of  the  Museum  gave  a  musical  conver- 
sazione on  Tuesday  night,  which  was  numerously  attended 
by  the  residents  as  well  as  the  profession ;  and  then  the 
evening's  proceedings,  a  new  feature,  proved  most  suc- 
cessful. The  band  of  the  Royal  Marine  Artillery  was 
especially  engaged,  and  played  through  a  lengthy  pro- 
gramme of  music  which  was  thoroughly  enjoyed.  The 
general  meeting  not  being  over  till  late  prevented  an 
early  attendance,  but  by  9.30  the  guests  arrived  in  large 
numbers.  There  was  a  little  speaking  and  the  buffet 
arrangements  were  on  a  most  liberal  scale,  and  great 
satisfaction  was  expressed. 

As  to  the  Annual  Museum,  the  present  display  is  per- 
haps the  most  attractive  and  comprehensive  that  has 
been  seen.  The  fine  hall  was  most  effectively  laid  out, 
the  stands  uniformly  placed  with  great  taste,  and  novel- 
ties shbwn  on  all  sides,  many  coming  under  the  head  of 
surgical  instruments  and  appliances.  One  of  the  chief 
features  of  the  show  was  located  in  a  small  room,  and 
had  been  prepared  by  Messrs.  Oppenheimer,  Sons  &  Co., 
Limited,  London,  and  was  in  charge  of  Dr.  Sambon, 
who  has  collected  one  of  the  largest  assortments  of  an- 
tiquities allied  to  medicine  ever  seen  in  England.  He 
proceeded  with  his  researches  for  many  years  on  behalf 
of  the  Italian  Government,  and  says  he  has  found  abun- 
dant proof  that  the  ancients  had  a  more  accurate  knowl- 
edge of  human  anatomy  than  is  generally  believed. 
This  he  asserts  by  showing  many  well-executed  specimens 
of  different  parts  of  the  human  frame  and  its  organs,  in 
terra- cotta,  which  had  been  given  as  votive  offerings  to 
the  deities,  who  were  supposed  to  preside  over  the  wells 
believed  to  possess  curative  powers.  He  has  fine  models 
of  ears,  eyes,  fingers,  and  scalps,  all  of  which  he  says  were 
thrown  into  these  wells  by  persons  who  sought  relief 
from  complaints  affecting  those  parts  of  the  body.  These 
all  date  from  the  Roman  period,  and  display  great  skill,  as 
they  were  the  work  of  ordinary  potters.  This  is  supple- 
mented by  some  three  hundred  surgical  instruments  from 
the  pre-Christian  days  down  to  the  fifteenth  century,  so  it 
will  be  gathered  the  show  is  intensely  interesting.  At 
another  stand  were  shown  an  interesting  collection  of 
optical  scientific  instruments ;  then  there  were  stands  to 
show  the  many  new  departures  in  food  and  physic. 
Messrs.  Ferris  &  Co.  made  their  stand  the  most  attrac- 
tive in  the  hall.  Drugs  naturally  form  a  large  portion 
of  the  show,  and  they  are  supplemented  by  many  special 
preparations.  The  collection  of  surgical  instruments  is 
most  comprehensive.  The  ever-ready  plaster  caddy  is 
also  shown  as  being  Messrs.  Ferris  &  Co.'s  specialty,  for 
keeping  all  kinds  of  surgical  dressings  in  perfect  condi- 
tion without  waste,  and  always  ready  to  hand. 

On  Wednesday  evening,  August  1st,  a  series  of  enjoy- 
able entertainments  took  place  at  Clifton  College. 
These  were  arranged  by  the  President  and  Executive 
Committee,  and  will  be  long  remembered  as  forming  one 
of  the  leading  social  features  of  the  Bristol  Congress.  It 
was  numerously  attended,  and  the  performances  of  the 
Orpheus  Glee  Singers  were  much  appreciated.  These 
singers  have  a  reputation  which  is  not  confined  to  Bris- 
tol ;  no  one  could  have  gone  away  dissatisfied,  for  the 


members  of  Bristol's  great  choir  acquitted  themselves 
admirably.  At  the  end  of  the  concert  there  was  an 
organ  recital,  and  late  as  the  hour  was  before  it  began, 
very  few  of  the  guests  left  before  it  terminated.  Supper 
was  served  in  a  large  tent,  and  after  partaking  of  it  we 
went  and  paid  a  visit  to  the  Zoological  Gardens,  which 
were  charmingly  illuminated  during  the  entire  evening. 
This  most  enjoyable  conversazione  was  brought  to  a 
close  by  a  display  of  fireworks  closing  with  a  set  piece, 
"The  Good  Samaritan,"  which  was  a  well  carried-out 
pyrotechnic  performance.  Then  God  Save  the  Queen 
was  played  and  we  each  retraced  our  ways  to  our 
various  hotels. 

At  11  o'clock  on  the  same  day  there  was  a  grand 
organ  recital  at  the  Colston  Hall  by  the  organist  of  the 
Bristol  Cathedral ;  invitations  were  freely  distributed  and 
there  was  a  large  gathering.  The  programme  was  se- 
lected with  a  view  to  displaying  the  great  compass  of  the 
organ,  and  in  this  was  very  successful.  Moreover,  the 
items  were  full  of  tune  and  finish  and  much  appreciated. 

I  must  not  forget  the  opening  ceremony  of  the  Clifton 
Pump  room  and  Spa,  which  was  publicly  inaugurated  on 
August  1st  by  the  Mayoress  of  Bristol,  and  has  been 
undertaken  and  completed  by  Geo.  Newnes,  M.P.  The 
magnitude  of  the  work  gave  rise  to  difficulties,  and 
would  have  sorely  tried  the  patience  of  less  resolute 
men  than  Mr.  Newnes,  as  will  be  appreciated  when  it  is 
explained  that  the  whole  site  has  been  cut  out  bodily 
from  a  sloping  limestone  rocky  garden,  which  was  ac- 
quired as  being  the  finest  position  in  Clifton  for  the  pur- 
poses contemplated.  It  well  deserves  its  name,  and 
stands  out  in  bold  relief  upon  Sion  Hill,  reflecting  the 
greatest  credit  on  the  architect  and  engineers.  On  this 
occasion  several  speeches  were  made  and  an  illuminated 
address  was  presented  to  Mr.  Newnes.  In  the  evening, 
at  the  invitation  of  Mr.  Newnes,  many  persons  enjoyed 
the  dual  pleasure  of  listening  to  an  excellent  concert  at 
the  Grand  Spa  and  inspecting  the  splendidly  appointed 
Pump  room.  Lovers  of  music  were  also  catered  for  on 
several  other  occasions  during  the  Congress. 

On  Thursday  some  five  hundred  members  were  enter- 
tained at  a  garden  party  at  Ashton  Court,  but  unfortu- 
nately the  weather  was  very  unfavorable;  happily  there 
was.  a  winter  garden  and  museum  in  which  they  could 
take*  refuge.  Another  garden  party  was  also  spoiled,  but 
here  again  in  door  provision  was  made  for  such  an  event, 
an  organ  recital  and  other  entertainments  being  pro- 
vided. During  the  meeting  the  National  Temperance 
League  gave  a  breakfast  to  a  number  of  the  members. 
The  League  has  done  this  for  several  years,  and  their 
breakfast  has  become  a  feature  of  the  annual  gathering. 
On  this  occasion  the  breakfast  was  presided  over  for  the 
first  time  by  the  President  of  the  Association,  Dr.  Long 
Fox,  who  is  himself  an  abstainer,  and  who  in  welcoming 
the  guests  said  he  thought  their  position  as  medical 
men,  with  reference  to  this  question  of  temperance,  was 
that  of  medical  missionaries.  (Hear,  hear.)  There  were 
many  ways  of  helping  and  encouraging  die  movement, 
and  it  was  impossible  to  say  that  many  of  these  ideas 
were  not  very  useful  indeed,  because,  as  the  mind  of  man 
was  various,  so  the  methods  of  man  were  various  also. 
He  was  not  there  to  cavil  at  any  of  these  methods,  as 
some  might  say  that  law  was  of  little  practical  use  unless 
the  common-sense  of  the  nation  had  been  educated  up 
to  its  reception  as  a  national  want ;  but  the  great  prin- 
ciple of  the  National  Temperance  League,  the  good  in- 
fluence of  one  person  upon  another  in  this  temperance 
cause,  would  meet  all  possible  objections.  (Hear,  hear.) 
Great  as  was  the  influence  exercised  by  temperate  medi- 
cal men,  with  the  full  knowledge  they  had  of  how  harm- 
ful alcohol  was  to  vitality,  and  how  injurious  it  was  to 
many  organs  of  the  body,  the  chance  of  turning  a  neigh- 
bor from  the  error  of  his  ways  was  enhanced  a  thousand- 
fold if  the  speaker  were  a  total  abstainer  himself.  (Ap- 
plause.) They  could  do  something  in  the  way  of 
removing  the  stones  from  the  King's  highway.  Already 
one  sixth  of  the  population  had  shaken  itself  from  the 


224 


MEDICAL   RECORD. 


[August  1 8,  1894 


hideous  evil  that  tended  to  the  destruction  of  the  na- 
tion, and  in  the  noble  fight  against  drink,  the  cause  of 
Etverty,  disease,  and  crime,  the  key  note  of  that  and  all 
ndred  societies,  they  might  justly  boast  would  include 
freedom  from  all  excess.  (Loud  applause.)  The  other 
night  Dr.  Annie  Cornall  wished  the  cause  every  success, 
and  said  the  movement  was  especially  important  in  re- 
lation to  women,  because  they  had  such  influence  in  the 
home. 

Speeches  were  also  delivered  by  Professor  Cameron,  of 
Glasgow,  Dr.  Ridge,  Dr.  Mackenzie,  of  Belfast,  Dr. 
Hughes,  of  Wales,  and  Dr.  Norman  Kerr.  Mr.  Robert 
Rae,  the  Secretary  of  the  League,  returned  thanks,  and 
said  the  work  of  the  League  among  the  members  of  the 
medical  profession  was  the  most  successful  they  had  ever 
undertaken. 

I  hear  that  the  dinner  was  well  attended,  but  I  did  not 

fo,  having  partaken  of  as  many  of  these  entertainments  as 
care  to.  For  I  have  found  each  one  very  much  a  replica 
of  the  rest.  So  also  I  was  unable  to  take  the  trip  around 
the  docks,  which  I  hear  about  a  hundred  members  en- 
joyed.   

SHORTHAND  IN  MEDICINE. 

To  thb  Editor  or  ths  Medical  Rbcosd. 

Sir  :  In  order  to  promote  the  use  of  shorthand  in  medi- 
cine, it  is  desirable  that  a  list  should  be  compiled  of  all 
who  use  it.  We  would,  therefore,  ask  each  practitioner 
and  student  who  is  acquainted  with  phonetic  shorthand, 
to  send  his  name  and  address  to  Dr.  Neil,  Warneford 
Asylum,  Oxford,  England. 

The  preparation  of  a  list  of  medical  phonographers  is 
intended  as  a  preliminary  step  to  such  further  measures 
for  mutual  encouragement  and  help  as  may  appear  advis- 
able. 

W.  R.  Gowers,  M.D.,  F.R.C.P., 
Edward  B.  Gray,  M.D., 
James  Neil,  M.D. 


NON  VOLUIT  NOCERE. 

To  thb  Editor  or  thb  Medical  Rbcobd. 

Sir:  In  my  lecture  "  Non  Noceie,"  delivered  before  the 
Eleventh  International  Congress,  which  you  printed  in 
your  issue  of  May  19th,  I  referred  to  a  case  of  idiocy  with 
premature  ossification  of  the  cranial  bones  kindly  reported 
to  me  by  Dr.  Vander  Veer,  and  used  the  following  words : 

"Arthur  McKee  F ,  born,  1891.     Previous  to  his 

birth,  a  miscarriage  and  a  still-birth.  Mother  had  al- 
buminuria every  time  [syphilis?].11 

About  a  week  ago  I  received  from  the  father  of  the  un- 
fortunate baby  a  very  indignant  letter,  dated  June  9, 
1894,  in  which  he  says :  "  I  demand  an  explanation  and 
insist  upon  a  correction  which  shall  appear  in  the  next 
issue  of  the  Medical  Record." 

Now,  Mr.  Editor,  if  after  such  a  long  time  your  space 
and  your  kindness  permit  you  to  publish  all  of  this,  I 
courteously  offer  the  following  "explanation"  of  my 
syphilis  with  interrogation  mark  in  brackets,  viz. :  Suc- 
cessive miscarriages,  to  a  certain  extent  also  persistent  al- 
buminuria and  excessive  bone  proliferation  resulting  from 
an  irritative  nutritive  process,  suggest  the  presence  of 
syphilis  in  a  late  form.  They  do  not  prove  it,  unless  there 
be  corroboration  by  the  history  or  the  physical  exami- 
nation of  the  parents  (mostly  the  father)  or  the  wetnurse. 
The  interrogation  mark  means :  No  certainty  at  all ;  at 
all  events,  justifiable  doubt. 

The  "  correction  "  is  that  "  there  was  no  such  intima- 
tion whatever  in  Dr.  Vander  Veer's  report ;"  that  the 
father  strenuously  denies  syphilis,  and  that,  therefore,  the 
cause  of  the  poor  baby's  abnormal,  both  physical  and 
mental,  condition  is  not  explained. 

Very  sincerely  yours, 

A.  Jacobi,  M.D. 

New  York,  August  5,  1894- 


PALATABLE  AND  DIGESTIBLE  MILK. 

To  thb  Editor  op  the  Medical  Record. 

Sir  :  A  brief  but  suggestive  editorial  in  your  issue  of 
July  28th,  on  the  digestion  of  milk,  prompts  me  to  add 
one  more  to  the  devices  by  which  the  use  of  this  most 
essential  article  of  invalid  diet  may  be  made  more  agree- 
able to  those  who  cannot,  or  think  they  cannot,  take  it 
"straight." 

I  have  never  seen  it  mentioned  in  any  text- book,  and 
it  did  not  come  to  me  from  a  professional  source,  but 
from  a  lady  who  had  been  for  a  long  time  the  patient  of 
the  late  Dr.  Pease,  of  Syracuse.  Whether  it  originated 
with  him  I  cannot  say,  but  perhaps  some  of  your  readers 
in  Central  New  York,  by  whom  he  is  doubtless  as  pleas- 
antly remembered  as  by  myself,  can  tell  me.  It  is  as 
follows : 

A  pint  of  milk  is  gently  warmed.  Into  it  is  dropped, 
very  slowly  and  with  constant  stirring,  about  twenty 
minims  of  the  dilute  hydrochloric  acid  of  the  United 
States  Pharmacopoeia.  The  milk  should  be  stirred  until 
it  cools. 

In  this  way  a  very  fine  flocculent  coagulum  is  pro- 
duced, floating  in  the  whey,  which  is  easily  accessible  to 
the  digestive  secretions,  while  the  whole  fluid  has  lost 
somewhat  of  the  flat  and  cloying  taste  which  makes  it 
unacceptable  to  so  many. 

It  will  be  noticed  that  milk  prepared  in  this  way  dif- 
fers from  the  various  "  wheys  "  in  the  highly  important 
particular  that  the  casein  is  retained  and  used,  instead 
of  being  separated  out  as  a  distinct  product,  while  it 
avoids  the  bitterness  of  pancreatized  milk. 

I  have  found  it  occasionally  of  great  value  when  other 
preparations  have  been  unacceptable  either  to  the  palate 
or  the  stomach.  Robert  T.  Edes,  M.D. 

Boston,  Mass. 


f^Xedital  Stems. 

Contagious  Diseases— Weekly  Statement — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to  the 
Sanitary  Bureau,  Health  Department,  for  the  week  end- 
ing August  11,  1894. 


Cases.        Deaths. 


Tuberculosis 

Typhoid  fever 

Scarlet  fever. ,........••. 

Oerebro-apinai  meningitis 

Measles 

Diphtheria 

SmaJl-pox 


7° 
37 
33 
o 
16 
in 

X 


6 
6 
6 
o 
34 
1 


The  True  Physician  longs  for  the  time  when  in  every 
fellow-practitioner  he  shall  find  a  brother,  a  counsellor, 
a  scholar,  a  gentleman. — W.  J.  Bell. 

Lactate  of  Cocaine  in  Tubercular  Cystitis.— Dr.  Witt- 
sack  has  found  benefit  from  the  instillation  into  the 
bladder,  once  or  twice  a  week,  of  fifteen  drops  of  a  solu- 
tion containing  twelve  grains  of  lactate  of  cocaine  and 
one  drachm  of  lactic  acid  in  one  drachm  of  water.  Lac- 
tate of  cocaine  is  a  white  substance  the  consistency  of 
honey,  readily  soluble  in  water.  It  has  not  yet  been 
obtained  in  a  dry  state. 

Remarkable  Fecundity.— An  instance  is  related  in 
the  Journal  de  Clinique  et  de  Thirapeutique  Infantile* 
for  May  10,  1894,  of  a  woman,  forty-nine  years  old,  who 
had  given  birth  to  twenty- five  children.  She  had  been 
married  three  times  and  had  never  had  twins.  Of  the 
twenty-five  children  nineteen  were  boys,  who  had  all  died 
in  childhood ;  the  six  girls  had  all  lived,  the  youngest 
being  five  and  the  eldest  twenty-eight  years  old.  The 
woman  had  received  a  medal  at  the  Sorbonne  in  recog- 
nition of  her  patriotic  efforts  to  increase  the  population 
of  France. 


Medical   Record 

A  Weekly  yournal  of  Medicine  and  Surgery 


Vol.  46,  No.  8. 
Whole  No.  1242. 


New  York,  August  25,  1894. 


$5.00  Per  Annum. 
Single  Copies,  ioc. 


Original  %x\it\z%. 

THE  CURE  OF  CARCINOMA  OF  THE  BREAST 
BY  RADICAL  OPERATION— OBSERVATIONS 
IN  ONE  HUNDRED  AND  EIGHTEEN  CASES.1 
By  WILLIAM  T.  BULL,  M.D., 

nonssoR  of  surgery,   Columbia   college,  surgeon  to  the  new  York 

HOSPITAL. 

The  following  series  of  cases,  occurring  between  the 
years  1880-94,  are  offered  as  testimony  to  the  value 
of  the  modern  radical  operation  in  cancer  of  the  female 
breast.  In  every  instance  but  one  the  diagnosis  has 
been  confirmed  by  microscopical  examination,  for  which 
Dr.  Frank  Ferguson,  pathologist  to  the  New  York  Hos- 
pital, has  been  responsible  in  the  majority.  To  the 
tracing  of  the  cases  through  this  number  of  years,  and 
keeping  the  records  up  to  date,  January  1,  1894,  Dr. 
Charles  A.  Powers,  surgeon  to  St.  Luke's  and  the  New 
York  Cancer  Hospitals,  has  given  much  time  and  enthu- 
siasm. He  has  been  associated  with  me  in  the  care  of 
many  of  these  patients  during  the  past  five  years.  To 
his  efforts  is  due  the  circumstance  that  but  3  of  the 
118  cases  have  been  lost  sight  of— a  smaller  percentage 
than  is  noted  in  any  other  record.  Weir,  for  instance, 
traced  but  60  of  his  125  patients,  Dennis  was  able  to 
keep  sight  of  but  33  of  71,  and  Curtis  (Medical  Rec- 
ord, No.  24,  1894),  in  collecting  the  statistics  of  eight 
foreign  clinics,  gives  final  results  in  only  813  of  a  total 
of  1,213  cases. 

In  the  matter  of  etiology,  trauma,  previous  inflamma- 
tion, heredity,  and  age,  are  found  to  play  about  the 
same  rdle  as  is  mentioned  by  other  observers.  There  is 
no  noteworthy  difference  from  other  statistics;  and  in 
these  particulars,  as  well  as  in  such  details  as  the  part  of 
the  breast  affected,  the  relative  frequency  of  disease  of 
the  right  or  left  breast,  this  series  gives  no  information 
of  practical  value.  In  passing  I  may,  however,  note  the 
fact  that  of  13  cases  in  which  cancer  existed  in  the  pre- 
vious generation  n  were  found  among  the  recurrent 
and  2  among  the  cured  cases ;  and  furthermore,  that  I 
have  taken  no  notice  of  the  item  of  duration  of  the  dis- 
ease before  operation,  because  the  data  in  most  instances 
are  so  untrustworthy.  I  have  excluded  all  cases  of  second- 
ary operations  (about  twenty  in  number)  performed  on 
patients  with  whom  I  had  no  previous  experience,  and 
have  no  records  of  patients  in  whom  no  operation  was 
advised. 

The  practical  value,  then,  of  this  record  is  in  its  show- 
ing as  regards  the  question  of  cure,  to  which  only  a  por- 
tion of  the  cases  contribute,  because  not  all  operations 
have  been  complete  or  radical  in  character.  As  incom- 
plete operations,  which  are  ten  in  number,  performed  in 
the  years  1880  to  1884,  I  include  those  in  which  the 
breast  only  was  removed  primarily ;  as  complete,  those 
in  which  the  breast  was  excised  together  with  a  liberal 
amount  of  skin  over  it,  the  fascia  of  the  pectoral  muscle, 
and  the  glands  of  the  axilla  embedded  in  their  fat.  This 
thorough  and  admirably  planned  operation  was  first  sug- 
gested by  Moore,  then  advocated  by  Banks,  in  England, 
popularized  by  Volkmann  in  Germany,  and  warmly  sup- 
ported by  Gross  in  this  country ;  and  it  is  now,  I  believe, 
generally  adopted.    It  has  been  performed  in  108  cases 

1  Read  at  a  meeting  of  the  Surgical  Section  of  the  Massachusetts 
Medical  Society,  June  12,  1894. 


without  reference  to  the  condition  of  the  glands  as  de- 
termined by  examination  prior  to  the  operation. 

The  10  incomplete  operations  were  all  followed  by 
recovery ;  the  108  complete  operations  include  4  fatal  re- 
sults, the  cause  of  death  being  in  2  cases  erysipelas ;  in  i, 
chronic  nephritis  and  pneumonia;  in  1,  acute  sepsis  and 
pneumonia.  This  is  a  mortality  percentage  of  3.6  per 
cent.  Curtis,  above  quoted,  finds  a  mortality-rate  of 
"very  nearly  six  per  cent."  in  1,213  cases,  while  Weir 
and  Dennis  have  reported  series  of  125  and  33  cases, 
respectively,  without  death.  For  so  small  a  mortality  it 
seems  hardly  necessary  to  offer  explanations,  but  it  is 
worthy  of  note  that  all  the  patients  were  of  the  hospital 
class,  that  the  two  dying  of  erysipelas  undoubtedly  were 
infected  in  the  hospital,  and  that  the  case  of  acute  sepsis 
owed  its  existence  to  a  streptococcus  invasion  from  an 
undiscovered  source.  Curtis's  statistics  go  back  as  far  as 
1870.  The  mortality  of  the  later  reporters  is  much 
less  than  that  of  the  earlier,  and  in  view  of  several  series 
without  any  mortality,  I  think  it  may  be  averred  that  the 
complete  operation  is  attended  with  but  little  more  risk 
than  the  incomplete,  and  that  in  persons  otherwise 
healthy  and  in  operations  unattended  with  accidents,  it 
ought  not  to  be  greater  than  three  or  four  per  cent.  This 
is  a  very  slight  risk  for  the  patient  affected  with  cancer 
to  take,  especially  in  view  of  the  prospect  of  cure. 

In  order  to  determine  the  proportion  of  cures,  we  can 
utilize  of  the  108  only  those  cases  which  were  operated  on 
prior  to  1 89 1.  Since  that  date  there  have  been  30  opera- 
tions. Deducting  these  and  the  three  which  have  been 
lost  sight  of,  I  have  75  cases.  Of  these  75  cases  3  died 
from  the  operation ;  50  died  from  recurrence  or  metas- 
tasis ;  2  are  still  living  with  recurrence ;  4  died  of  other 
diseases  after  having  passed  the  "  three-year  limit " 
without  manifestation  of  cancerous  disease;  16  are  alive 
and  in  good  health  on  January  1,  1894. 

This  gives  20  cured  cases  out  of  a  total  of  75,  or  26.6 
per  cent.  This  is  a  higher  proportion  of  cures  than  has 
been  previously  reported.  Curtis  gives  20.7  as  the  per- 
centage of  cures  in  the  1,213  cases  ne  collected.  Weir 
"  nearly  twenty,"  and  Dennis  twenty-five  per  cent.  The 
value  of  my  percentage  is  increased,  I  think,  by  the  fact 
already  mentioned,  that  but  3  cases  of  108  have  been 
lost  sight  of. 

Regarding  these  20  cured  cases  more  in  detail,  let  me 
say  of  the  4  who  died  of  other  diseases,  after  passing  the 
"  three-year  limit,"  that 

One  died  at  the  end  of  J  years,  of  pneumonia. 

One  died  at  the  end  of  rf  years,  of  chronic  bronchitis  and  emphysema* 

One  died  at  the  end  of  3!  years,  of  acute  rheumatism. 

One  died  at  the  end  of  3  years,  of  chronic  nephritis. 

The  16  cases  still  alive  and  free  from  recurrence  have 
lived  on  an  average  six  years  and  a  few  days  since  the 
operation.     To  be  more  explicit : 

Two  are  living  and  well  3  years  and  9  months  after  operation. 
Four  are  living  between  4  and  5  years  after  operation. 
Three  are  living  between  5  and  6  years  after  operation, 
One  is  living  between  6  and  7  years  after  operation. 
Three  are  living  between  7  and  8  years  after  operation. 
One  is  living  between  8  and  9  years  after  operation. 
One  is  living  between  9  and  10  years  after  operation. 
One  is  living  10  years  after  operation. 

These  cured  cases  are  all  the  more  significant  because~of 
the  extent  of  time  they  have  remained  cured,  the  average, 
six  years,  being  twice  as  long  as  the  "  three  year  limit." 
Only  2  have  undergone  secondary  operations.    Of  the 


226 


MEDICAL    RECORD. 


[August  25,  1894 


4  who  died  free,  1  had  a  recurrent'nodule  removed  at  the 
end  of  four  months,  and  died  of  rheumatism  over  three 
years  later.  Of  the  16  still  living,  one  had  three  nodules 
removed  at  periods  of  six  months,  seven  months,  and 
eighteen  months  after  the  primary  operation,  and  is  living 
five  and  one  half  years  since  the  last  operation. 

In  computing  the  percentage  of  cases  I  have  included 
in  the  total  of  seventy-five,  the  three  patients  dying  from 
the  operation.  This  class  has  been  deducted  by  some 
reporters.  I  have  excluded  from  the  "  cured  "  list  one 
case  which  died  of  cancer  of  the  oesophagus  nine  years 
after  the  operation  on  the  breast  and  axilla,  having  been 
free  meanwhile  from  recurrence — a  case  which  might  be 
fairly  regarded  as  an  instance  of  fresh  infection,  or  the 
development  of  a  growth  entirely  independent  of  the 
original  disease.  Poulsen l  has  reported  an  instance  of 
cancer  of  the  pylorus  developing  five  years  after  an  opera- 
tion on  the  breast,  which  is  capable  of  a  similar  explana- 
tion. I  have  accepted  the  "  three-year  limit "  as  evidence 
of  cure  in  order  to  make  my  statistics  to  conform  to  those 
of  others.  It  seems  to  be  true,  in  the  majority  of  cases, 
that  recurrence  takes  place  in  loco,  and  metastatic  de- 
posits occur  within  this,  time,  though  instances  of  a 
later  development  of  both  features  are  not  rare.  Curtis, 
from  various  sources,  records  thirty -four  recurrences 
after  three  years  and  up  to  the  seventh  year.  Weir  has 
seen  one  at  sixteen,  and  one  at  twenty  years.  I  am  not 
able  to  give  the  precise  data  of  recurrence  in  many  cases, 
but  can  say  that  the  average  duration  of  life  in  cases  dy- 
ing of  recurrence  or  metastasis  was  less  than  three  years, 
and  that  I  have  observed  no  instances'  of  reappearance 
of  the  disease  after  three  years.  A  four-year  limit  would 
be  undoubtedly  more  accurate.  Judged  by  this  standard, 
my  list  of  cures  would  be  reduced  by  only  5  cases,  mak- 
ing 15  cures  in  75  cases,  or  a  percentage  of  twenty,  the 
same  that  Curtis's  1,213  cases  give  with  the  year  limit. 

The  patients  operated  on  since  1891,  not  available  for 
the  question  of  cure,  are  30  in  number,  of  whom  10,  or 
thirty- three  and  one  third  per  cent.,  are  without  recur- 
rence and  with  prospect  of  cure,  though  an  average  of 
but  fifteen  months  has  elapsed  since  their  operations. 
Two  died  within  eighteen  months  from  the  time  of  oper- 
ation, free  from  cancerous  disease;  1  died  from  the 
operation,  which  is  already  counted  in  the  list  of  deaths ; 
1 1  have  died  of  cancer  already,  and  6  are  living  with 
recurrent  disease. 

The  record  of  the  incomplete  operations  emphasizes 
the  advantage  of  the  complete  or  radical  method  of  treat- 
ment. Of  10  patients  in  whom  only  the  breast  was  re- 
moved, all  died  of  cancer  at  the  end  of  an  average  pe- 
riod of  thirty-four  and  one  half  months,  3  having  under- 
gone several  secondary  operations.  It  is  my  conviction 
that,  except  as  a  palliative  method,  this  form  of  opera- 
tion should  no  longer  be  countenanced.  It  is  unques- 
tionably attended  with  less  risk,  as  numerous  statistics 
have  shown,  but  our  knowledge  of  the  course  of  the  can- 
cerous diseases,  and  the  absence  of  statistical  tacts  to  sup- 
port it,  demonstrate  that  it  is  an  utterly  inadequate 
method. 

<  In  every  case  of  cancer,  whether  the  glands  of  the 
axilla  be  felt  to  be  enlarged  or  not,  the  complete  opera- 
tion should  be  done.  It  removes  not  only  the  diseased 
area,  but  the  parts  more  likely  to  be  affected  by  recur- 
rence, the  skin  and  pectoral  fascia,  which  have  been 
shown  by  Heidenhain  to  be  often  the  seat  of  deposits 
which  may  escape  the  naked  eye.  It  clears  out  the 
axilla,  the  next  resting-place  of  the  neoplasm,  whose 
glands  may  be  enlarged  from  disease  without  their  pres- 
ence being  discovered  by  external  examination.  Only 
in  abnormally  thin  subjects  can  one  be  reasonably  sure 
of  the  condition  of  the  glands,  as  many  surgeons  have 
testified.  It  should  do  more  than  this,  and  that  is,  re- 
move the  parts  between  the  axilla  and  the  breast,  the 
region  through  which  the  lymphatics  pass.  In  my  opera- 
tions, as  the  accompanying  cuts  will  show,  I  have  been  in 
the  habit  of  removing  the  parts  in  one  solid  mass  from  the 
1  Arch.  fUr  Win.  Chir.,  43,  p.  59a. 


inner  periphery  of  the  breast  to  the  apex  of  the  axilla; 
and  this  detail,  which  is  not  generally  insisted  on,  I  re- 
gard as  of  great  importance. 

Without  quoting  other  statistics,  it  may  be  safely  stated 
that  the  complete  operation  has  been,  since  its  introduc- 
tion, attended  with  a  diminishing  mortality  and  an  in- 
creasing percentage  of  cures.  It  has  unquestionably 
been  done  in  many  cases  in  which  it  could  promise  lit- 
tle on  account  of  the  extent  of  the  disease.  One  cannot 
avoid  this  conviction  in  reading  the  histories  of  individ- 
ual patients,  and  I  know  that,  in  many  hospital  and  some 
private  patients,  I  have  performed  operations  under  cir- 
cumstances which  a  maturer  judgment  and  larger  experi- 
ence would  now  regard  as  contra- indications  to  the 
operation.  If  we  could  expunge  from  all  our  lists  the 
number  of  these  advanced  cases,  the  showing  would  be  a 
very  much  more  encouraging  one.     My  notes  are  not 


F10.  1.— Cancer  of  the  Nipple,  Fig.  2.— Cancer  of  Breast  and  AxiBa,  ID 

Breast,  and  Axillary  Glands  fol-  Show  Amount  of  Tissue  Removed, 
lowing  Ulceration  of  the  Nipple 
for  Eleven  Months. 

sufficiently  full  in  the  matter  of  extent  of  the  disease  to 
enable  one  to  make  any  such  distinction.  Such  points 
as  adhesion  to  the  wall  of  the  chest,  involvement  of  the 
pectoral  muscle,  fusion  of  the  cancerous  glands,  and  ad- 
hesion to  the  axillary  vessels  are  rarely  mentioned, 
though  all  or  some  of  these  conditions  have  been  met 
with  in  a  considerable  number  of  cases.  But  in  regard 
to  involvement  of  the  axillary  glands  I  can  give  some 
data. 

Of  the  20  cured  cases  the  breast  alone  was  affected  in 
12,  while  in  8  both  glands  and  breast  were  involved.  Of 
55  cases  dying  (3)  of  the  operation  or  recurrence  (50), 
or  living  with  recurrence  (2),  the  glands  were  involved  as 
well  as  the  breast  in  38,  while  in  10  the  glands  were  free 
from  disease.  In  7  the  condition  is  not  stated.  In 
other  words,  of  the  cured  cases  forty  per  cent,  had  both 
breast  and  axilla  affected.  It  should  be  stated  that  the 
evidence  of  involvement  of  the  glands  in  most  cases  was 
determined  by  microscopic  examination,  and   that  in 


August  J25,  1894] 


MEDICAL  RECORD. 


227 


many  the  deposits  in  this  region  were  detected  only  after 
the  axillary  fat  was  cut  into. 

The  complete  operation,  then,  is  capable  of  effecting 
a  core  even  when  the  glands  are  involved,  and  that  in  a 
considerable  proportion  of  cases ;  and  if  we  make  a  sharp 
distinction  between  the  cases  according  to  the  condition 
of  the  glands,  we  shall  get  the  following  more  encourag- 
ing picture  of  the  75  cases : 

This  condition  was  not  noted  in 17 

Breast  alone  affected  in 22 

Breast  and  glands  affected  in 46 

Total 75 

Of  22  cases  in  which  the  breast  alone  was  diseased,  12, 
or  about  fifty-four  per  cent.,  were  cured,  10,  or  forty-five 
per  cent,  died  of  recurrence.  Of  46  cases  in  which  both 
breast  and  glands  were  involved,  8,  or  seventeen  percent, 
were  cured,  and  38,  or  eighty- two  per  cent,  died  of  op- 
eration, or  a  recurrence,  or  are  living  with  recurrence. 
This  showing  would  support  the  statement  that  in  at 
least  one-half  the  cases  of  cancer  limited  to  the  breast 
alone  the  complete  method  may  be  expected  to  effect  a 
cure.  The  deaths,  it  is  to  be  noted,  are  all  among  the 
cases  where  both  glands  and  breast  are  involved.  De- 
laying the  operative  treatment,  then,  not  only  increases 
the  death-rate  but  diminishes  the  prospect  of  cure.  Pa- 
tients ought  to  be  subjected  to  the  complete  operation  in 
the  earliest  stages  of  the  disease.  There  is  no  longer 
any  excuse  for  delay  on  the  part  of  physicians,  on  the 
ground  that  more  time  is  needed  to  make  a  diagnosis, 
and  the  laity,  if  made  aware  of  the  possibilities  of  cure, 
will  promptly  overcome  the  dread  of  operative  treatment, 
which  is  another  reason  for  delay.  Irregular  practi- 
tioners furnish  the  public  with  the  strongest  representa- 
tions, or  misrepresentations,  of  the  success  of  other 
methods  which  we  know  to  be  of  less  value  than  the 
operative  ones.  Why  should  not  the  regular  profession, 
through  its  public  representatives — the  Boards  of  Health 
—be  equally  active  in  informing  the  people  of  the  dan- 
ger of  delay,  and  the  promise  of  cure  by  early  and  radi- 
cal treatment  ? 

In  a  condition,  the  successful  treatment  of  which  de- 
pends absolutely  on  its  promptness,  exactness  in  diag- 
nosis should  play  a  secondary  rdle.  A  lump  in  the  breast 
is  never  a  "nothing,"  as* it  seems  occasionally  to  be 
termed  by  physicians  who  see  it  first.  It  is  either  an  in- 
flammatory deposit,  or  a  solid  or  cystic  tumor.  Between 
the  two  latter  conditions  it  is  often  impossible  to  distin- 
guish in  large  and  even  small  breasts.  But  the  hypoder- 
mic syringe  and  needle,  which  should  be  used  in  all 
doubtful  cases,  clears  up  this  point  at  once.  With  its 
use  I  have  demonstrated  the  harmlessness  of  cases  which 
have  been  viewed  with  suspicion  or  pronounced  malig- 
nant by  others,  and  in  passing  may  note  that  I  have  en- 
countered thirty  cases  of  simple  cysts  of  the  mamma  in 
the  past  ten  years,  probably  about  ten  per  cent,  of  all  the 
cases  seen.  If  a  tumor  be  thus  proven  to  be  solid,  ex- 
ploratory incision  should  be  made  the  diagnostic  test 
when  its  features  are  doubtful.  Naked-eye  inspection 
will  usually  suffice,  though  the  freezing  microtome  and 
the  nitric  acid  test  of  Stiles,  or  the  "  punch"  devised  by 
Mixter  are  unobjectionable.  They  can  be  employed 
when  the  incision  is  not  allowed.  There  is  no  reason- 
able objection  to  the  incision.  A  benign  growth  de- 
mands operation  almost  as  urgently  as  a  malignant  one, 
for  we  have  ample  testimony  of  the  degeneration  of  these 
tumors  into  malignant  ones  at  or  after  the  menopause. 
Inflammatory  deposits  can  suffer  no  harm  from  incision 
or  renewal.  They  are  liable  to  be  the  precursors  of  can- 
cerous disease,  and  can  be  looked  upon  as  safe,  and  en- 
titled to  be  unmolested,  only  when  they  are  disappear- 
ing spontaneously  after  a  recent  acute  mastitis.  I  have 
two  cases  bearing  on  the  degeneration  of  benign  tumors 
which  are  worth  recording.  The  first,  a  woman,  aged 
forty-five,  noticed  a  rapid  growth  of  a  tumor  which  had 
been  quiescent  in  one  breast  for  sixteen  years.  At  the 
end  of  one  year  the  whole  breast  was  transformed  into  a 


typical  carcinoma,  which  was  removed  without  the 
glands.  Two  secondary  operations  were  done,  followed 
by  local  recurrence,  and  she  died,  at  the  end  of  five  years 
from  the  beginning  of  the  disease,  with  cancer  of  the 
liver.  The  second,  aged  seventy-  five,  carried  for  eighteen 
years  a  small  painless  tumor,  which  in  one  year  involved 
the  greater  part  of  the  breast  and  the  axillary  glands. 
One  complete  and  one  secondary  operation  were  fol- 
lowed by  death  from  cancer  of  the  lungs  and  pleura  after 
twenty  months. 

A  condition  of  chronic  eczema  of  the  nipple  (or 
Paget's  disease)  giving  rise  to  cancer,  I  have  met  with  in 
four  cases,  which  are  noticeable  because  the  duration  of 
the  ulceration  did  not  exceed  one  year,  being  four 
months  in  one,  eleven  months  in  a  second,  and  about  a 
year  in  the  third  or  fourth.  In  two  the  glands  as  well  aa 
the  breast  tumor  underlying  the  ulcer  were  cancerous. 
The  ages  were  forty-eight,  sixty,  fifty,  and  forty  years. 
One  patient,  operated  on  a  year  ago,  is  still  alive  and  free. 
Two  died  of  recurrence  within  two  and  a  half  years. 
One  lived  eighteen  months  free  from  trouble,  to  die  of 
pneumonia.  One  patient  declined  any  investigation  of 
the  axilla,  and  was  obliged  to  undergo  a  secondary 
operation  eight  months  later,  which  revealed  glands 
which  must  have  been  diseased  at  the  time  of  the  primary 
and  incomplete  operation.  The  importance  of  these 
cases  should  not  be  overlooked.  Although  it  has  been 
noted  that  these  eczematous  conditions  often  go  seven 
and  even  ten  years  before  the  development  of  cancer,  it 
ii  proper  to  regard  them  with  suspicion,  and  desirable  to 
treat  them  promptly  by  complete  operation  so  soon  as 
milder  measures  fail. 

In  one  of  the  above  cases,  where  an  ulcer  had  existed — 
refusing  to  remain  healed  under  the  application  of  oint- 
ments for  a  period  of  eleven  months — I  had  a  wedge  of 
the  base  of  the  ulcer  removed  for  examination  by  the 
pathologist,  who  pronounced  it  only  "chronic  inflam- 
mation." In  view  of  the  duration  of  the  ulceration  and 
its  well-known  tendencies,  I  urged  exploratory  incision. 
A  part  of  the  ulcer  deeper  than  the  mass  removed  looked 
surely  cancerous.  The  whole  breast  was  removed,  ard 
the  axilla  invaded.  Subsequent  investigation  showed 
the  breast  to  be  cancerous  in  the  neighborhood  of  the 
ulcer,  and  the  glands  not  to  be  affected.  These  might  be 
considered  cases  of  primary  epithelioma  of  the  nipple, 
but  the  fact  remains  the  same,  that  a  persistent  ulceration 
of  the  nipple  often  leads  to  cancer,  and  must  not  be  neg- 
lected. 

It  has  been  generally  claimed  that  the  complete  and 
even  the  incomplete  operation,  when  it  fails  to  cure, 
prolongs  life  and  makes  its  ending  less  distressing.  I 
have  not  the  data  at  hand  to  give  figures  bearing  on 
these  points,  because  the  duration  of  the  disease,  as 
proven  by  patients,  is  so  indefinite ;  but  I  can  safely  say 
that,  judging  by  the  results  so  far  as  the  duration  of  life 
is  concerned,  in  those  which  have  undergone  secondary 
operations,  and  those  which  have  not,  the  operated  cases 
have  the  advantage.  For  instance,  of  ten  incomplete 
operations  all  died  of  cancer  at  the  end  of  an  average 
period  of  34$  months ;  seven  of  these,  without  secondary 
operation,  lived  on  an  average  of  234  months ;  three,  who 
had  secondary  operation,  lived  an  average  of  58 J  months 
after  the  first  operation.  Of  sixty  patients  with  com- 
plete operation  I  note  forty  seven  who  died  without  any 
but  the  first  operative  interference,  ao-,y^  months;  while 
thirteen  who  had  ore  or  several  operations  subsequent  to 
the  first,  died  30  months  afterward.  But  one  single  case 
is  worthy  of  mention.  A  woman,  aged  fifty,  underwent 
the  complete  operation  for  a  tumor  of  breast  alone  of 
two  years'  duration.  She  died  of  cancer  of  liver,  lungs, 
and  pleura,  at  the  end  of  eight  years  and  eight  months 
after  the  operation,  ten  years  and  over  from  the  outset 
of  the  disease.  In  this  interval  five  operations  were  per 
formed,  including  one  on  the  opposite  breast. 

Operations,  in  my  opinion,  do  prolong  life,  and  Ism 
quite  sure  they  have  a  further  advantage  in  regulatirg 
the  course  of  the  disease,  so  as  to  make  it  more  bearable. 


228 


MEDICAL   RECORD. 


[August  25,  1894 


In  a  certain  number  of  cases  there  is  no  external  outbreak, 
and  the  patient  dies  of  internal  deposits  without  know- 
ing the  nature  of  her  malady.  The  annoyance  of  a  foul 
and  bleeding  ulcer  is  avoided,  with  the  pain  that  comes 
from  involvement  of  the  walls  of  the  chest.  Further- 
more, the  clean  removal  of  the  axilla  diminishes  the 
chance  of  interference  with  the  venous  circulation  and 
the  occasion  of  that  distressing  feature— oedema  of  the 
entire  arm. 

These  facts  encourage  m;  to  advise  secondary  opera- 
tions when  the  growths  are  small  and  freely  movable. 
Several  such  operations  may  be  required  without  materi- 
ally diminishing  the  prospect  of  final  cure ;  but  in  gen- 
eral I  have  little  faith  in  the  value  of  secondary  opera- 
tions, except  as  palliative  measures.  I  believe  it  is  an 
excellent  measure  in  dealing  with  the  first  occurrence  to 
give  an  anaesthetic  and  inspect  thoroughly  the  whole 
line  of  the  cicatrix,  rather  than  to  trust  to  the  removal 
of  the  growth  with  the  use  of  cocaine.  This  "  revision 
of  the  scar,"  as  I  have  termed  it,  done  at  the  moment  of 
the  first  recurrence,  has  enabled  me  to  find  and  remove 
nodules  that  were  not  felt  on  palpation.  The  cocaine 
operations,  of  which  I  have  done  a  number,  have  seemed 
to  me  exceedingly  unsatisfactory. 

In  the  axilla  the  removal  of  recurrent  nodules  or 
glands  is  often  a  matter  of  difficulty,  owing  to  the  pres- 
ence of  cicatricial  tissue  and  the  likelihood  of  finding 
deeper  masses  adherent  to  the  axillary  vein.  Excision 
of  a  portion  of  the  vein  is  required  in  the  latter  event,  a 
procedure  which  I  have  never  known  to  give  rise  to  un- 
pleasant results,  but  which  may  in  its  performance  offer 
an  opportunity  of  wounding  the  vein  several  times  un- 
awares, with  serious  hemorrhage.  In  general,  operations 
for  recurrent  masses  which  are  adherent  either  in  the 
axillary  or  breast  part  of  the  scar,  I  have  found  to  be  of 
no  advantage  whatsoever. 

The  operation  itself  needs  no  description  in  detail,  but 
there  are  several  points  which  are  worthy  of  emphasis. 
The  skin  incision  should  in  general  conform  to  the  oval 
type — a  widely  open  oval — and  extend  from  a  point  near 
the  sternum  to  one  overlying  the  axillary  vessels.  Its 
long  axis  may  be  at  right  angles  to  the  direction  of  the 
pectoral  fibres,  with  a  second  cut  in  the  axillary  region, 
if  the  tumor  be  most  conspicuous  at  the  upper  and  inner, 
or  outer  *nd  lower,  periphery.  Its  outline  is  of  little 
consequence.  Its  distance  from  the  neoplasm  is  of  the 
greatest  importance.  When  the  growth  is  in  the  breast 
I  have  usually  placed  the  incision  at  least  one  inch  from 
the  borders  of  the  gland,  where  it  is  peripherally  situated 
two  inches  from  the  edge  on  the  side  affected.  The  cut 
must  be  made  without  reference  to  subsequent  approxi- 
mation of  the  edges,  though  much  tissue  can  be  advan- 
tageously saved  in  the  axillary  part  of  the  incision,  and 
in  the  majority  of  my  cases  a  primary  union  has  been 
possible.  After  separating  the  mamma  itself  it  is  al- 
lowed to  hang  down,  still  in  connection  with  the  axillary 
part,  till  the  parts  between  the  breast  and  axilla  and  the 
contents  of  the  latter  have  been  separated.  There  is  lit- 
tle danger  of  wounding  the  axillary  vessels  if  the  fascia 
over  the  vein  is  first  clearly  laid  bare  and  the  mass  of 
vessels  and  nerves  .gently  pushed  away  from  the  ratty 
contents,  the  vessels  crossing  the  space  being  clamped 
before  they  are  cut.  The  subscapular  nerves  must  be 
avoided,  but  the  intercosto-humeral  branches  must  not 
be  cut.  After  the  axillary  space  has  been  freed  of  its 
contents,  search  must  be  made  at  the  very  apex,  and  in 
the  region  between  the  two  pectoral  muscles,  where  out- 
lying glands  are  occasionally  found.  In  closing  the 
wound  I  have  given  up  all  sorts  of  relaxation  sutures  and 
come  to  rely  on  fine  catgut.  The  edges  are  brought 
only  loosely  together  without  any  strain,  but  carefully 
approximated  to  the  deeper  parts  with  compresses  sup- 
ported by  adhesive  straps.  The  axillary  space  must  be 
obliterated  by  an  additional  wad  of  gauze.  If  open 
wounds  are  left,  it  is  better,  in  my  opinion,  to  practise 
skin-grafting  after  granulation  has  occurred.  The  opera- 
tions have  naturally,  in  the  course  of  these  years,  run 


through  the  various  modifications  of  antiseptic  dressings. 
The  most  recent  cases  show  the  most  satisfactory  results, 
and  these  have  been  done  on  aseptic  principles,  with 
sterilized  materials  and  without  irrigation  or  drainage. 
Complete  primary  union  without  complication  has  been 
obtained  in  fully  two-thirds  of  the  cases,  and,  where  it  has 
failed,  there  has  been  no  serious  sequelae  nor  prolonged 
suppuration.  In  two  instances  erysipelas  was  fatal. 
Operations  done  in  private  houses  have  produced  uni- 
formly good  results  as  regards  wound  healing.  There 
have  been  no  serious  after-effects  of  these  operations. 
Some  patients  are  much  annoyed  by  a  hyperesthesia  of 
the  skin  on  the  inner  side  of  the  arm,  which  gives  place 
to  numbness  which  gradually  disappears.  This  phenom- 
enon has  been  such  a  frequent  source  of  complaint  when 
the  dressings  are  removed  that  I  usually  lead  patients  to 
expect  it,  and  promise  that  it  will  disappear. 

The  movements  of  the  arm  and  shoulder  joint  have  be- 
come ultimately  perfect  in  all  cases.  I  usually  encourage 
motions  from  the  elbow  on  the  fifth  day,  and  those  of 
the  shoulder  after  the  tenth  day,  and  on  the  average  the 
slight  stiffness  yields  to  natural  exercise  within  three  or 
four  weeks. 

In  closing,  let  me  say  that  I  have  made  no  distinction 
in  this  series  between  the  different  varieties  of  carcino- 


Fig.  3.— Cicatrix,  with  Free  Mobility  of  Ann,  Four  Years  after  Operation. 


ma,  because  of  the  difficulty  of  assigning  many  cases  to 
an  individual  class.  But  I  should  state  that  I  have  uni- 
formly advised  against  operation  in  the  variety  known  as 
"  atrophying  scirrhus,"  occurring  in  old  people,  and  in 
the  rapidly  growing  voluminous  tumors  occurring  be- 
tween thirty- five  and  forty-five,  and  described  as  en- 
cephaloid  or  medullary  carcinoma. 

I  thank  the  Massachusetts  Medical  Society  and  your- 
self, Mr.  Chairman,  for  the  privilege  of  bringing  before 
you  these  results  of  treatment  of  this  most  important  sur- 
gical disease ;  and  I  hope  that  your  experience  may  be 
in  line  with  my  own  and  will  serve  to  strengthen  our 
convictions,  that  the  modern  radical  or  complete  opera- 
tion has  already  cured  from  twenty  to  twenty-five  per 
cent,  of  all  cases  of  cancer  of  the  breast ;  that  it  may  be 
expected  to  cure  at  least  one-half  the  cases  if  applied  be- 
fore the  axilla  is  invaded ;  and  that  it  is  likely  to  have 
an  even  better  showing  if  the  patients  can  be  brought  to 
treatment  earlier  than  they  manage  at  present.  This  can 
be  effected  by  less  attention  to  accurate  diagnosis,  and  by 
giving  up  the  habit  of  waiting  to  see  how  the  tumor  will 
develop,  and  by  relying  on  needle  exploration  and  inci- 
sion. The  incomplete  operation  should  be  abandoned, 
except  as  a  preventive  measure,  or  for  the  relief  of  local 
symptoms.     Benign  neoplasm  and  inflammatory  deposits 


August  25,  1894] 


MEDICAL    RECORD. 


229 


should  be  removed,  and  persistent  ulceration  of  the  nip- 
ple treated  as  cancer.  Secondary  operations  are  of  value 
only  when  the  nodules  are  small  and  free  from  adhesions, 
and  the  "  revision  of  the  scar  "  should  be  performed  in 
the  event  of  the  first  recurrence  after  complete  operation. 
The  risk  of  the  complete  operation  is  slight,  and  it  is  fol- 
lowed by  no  undesirable  after- effects. 

35  Wcst  Thirty-fifth  Street. 


ON  THE  NEW  RELATIONS  OF  PATHOLOGY 
AND  PRACTICAL  MEDICINE  AS  BEARING 
UPON  THE  PATHOLOGICAL  DEPARTMENTS 
OF  OUR   HOSPITALS. 

By  JOHN   SLADE  ELY,    M.D., 

PROFESSOR  OF  PATHOLOGY  IN  THR  WOMAN'S  MSDICAL  COLLEGE  OF  THE  NRW 
YORK  INFIRMARY  I  ASSISTANT  IN  PATHOLOGY  IN  THE  COLLRGB  OF  PHYSICIANS 
AMD  SUBGROMS  i    PATHOLOGIST  TO  BELLEVUB  HOSPITAL. 

In  the  progress  of  every  science  a  period  of  fact  accumu- 
lation must  precede  the  more  strikingly  epoch  making 
one  of  generalization.  Until  generalization  commences 
but  little  practical  application  of  the  facts  accumulated  is 
possible.  Pathology  affords  many  examples  of  the  truth 
of  this  great  principle  of  all  inductive  science.  Its  clear 
perception  stimulated  Morgagni  and  his  followers  to  col- 
lect the  carefully  corroborated  facts  which  a  century  later 
suggested  the  generalizations  of  the  cellular  pathology  of 
Virchow ;  and,  similarly,  the  facts  accumulated  by  Pas- 
teur in  the  study  of  fermentation  and  putrefaction,  made 
possible  the  even  greater  generalization  of  the  causative 
relationship  of  micro  organisms  to  disease.  A  glance  at 
the  influence  of  these  generalizations  upon  the  study  of 
disease  and  upon  the  relation  of  the  pathologist  to  the 
clinician  is  most  suggestive. 

The  enunciation  of  the  fundamental  law  of  the  cellular 
pathology,  omnis  cellula  e  cettula,  drew  attention  to  the 
cell  as  the  ultimate  living  factor  in  the  production  of  the 
lesions  of  disease.  The  cell  and  the  tissues  to  which  it 
gave  rise  thenceforth  became  the  prime  objects  of  study 
to  the  pathologist.  This  resulted  in  the  accumulation  of 
a  vast  fond  of  knowledge  of  the  morbid  anatomy  of  dis- 
ease. The  great  usefulness  of  this  study  to  practical 
medicine  was  evident  in  the  greater  accuracy  of  diag- 
nosis, and,  secondarily,  in  the  juster  appreciation  of  the 
limitations  of  medication.  So  long  as  it  was  the  domi- 
nant force  in  pathology  the  careful  autopsy  and  subsequent 
examination  of  the  tissues  met  all  the  absolute  require- 
ments. They  acted  as  a  check  upon  diagnosis,  showing 
the  clinician  his  error  when  it  existed,  and  so  helping  him 
in  subsequent  cases  of  the  same  nature  to  a  more  correct 
interpretation  of  the  symptoms.  From  the  very  nature 
of  the  case  the  work  of  the  pathologist  was  largely  post 
mortem.  He  was  often  deplorably  ignorant  of  the 
pathology  of  minor  ailments  not  usually  followed  by 
death,  he  had  but  a  secondary  interest  in  symptomatology 
(in  reality  an  important  part  of  pathology  in  its  broader 
sense),  and  he  was  rarely  called  upon  to  assist  the 
clinician  at  the  bedside.  The  position  occupied  by 
pathology  during  this  time  wft,  then,  essentially  that  of 
a  pure  science ;  it  had  but  a  limited  practical  applica- 
tion. 

But,  with  the  development  of  the  idea  of  the  etiological 
relationship  of  micro-organisms  to  disease  a  new  epoch 
lias  opened.  We  have  been  taught  that  many  diseases 
are  the  result  of  the  entrance  into  the  body  and  growth 
there  of  noxious  living  organisms ;  that  the  changes  which 
the  study  of  morbid  anatomy  showed  to  be  characteristic 
of  these  diseases,  are  the  result  of  the  action  of  these  or- 
ganisms upon  the  tissues  of  the  body ;  that  this  action  is 
produced  by  poisonous  substances  elaborated  by  the 
micro-organisms,  some  of  these  toxines  expending  their 
energies  upon  the  tissues  in  the  immediate  neighborhood 
of  the  growing  germs,  while  others  are  diffused  through- 
out the  body,  giving  rise  to  fever,  prostration,  etc., 
symptoms  more  or  less  common  to  all  diseases  of  infec- 
tious origin. 

By  these  discoveries  new  interest  is  awakened  in  the 


alluring  field  of  preventive  medicine,  for  it  has  been  es- 
tablished that  without  the  agency  of  the  specific  micro- 
organism of  an  infectious  disease,  that  disease  can  never 
originate.  Prevent  its  entrance  into  the  body,  and  the 
disease  is  prevented.  Thus,  the  interest  attaching  to  the 
determination  of  every  detail  of  the  life  history  of  the 
microbes  of  disease  becomes  immense,  many  new  prob- 
lems at  once  suggesting  themselves.  What  is  the  path 
of  entrance  of  the  specific  organism  into  the  body ;  in 
the  air  inspired,  in  the  food,  or  through  the  skin  ? 
Through  what  channel  does  it  leave  the  body  of  the  pa- 
tient ?  What  is  the  manner  of  its  dissemination,  its  re- 
sistance to  drying,  sunlight,  heat,  etc.,  its  habitat  during 
the  interval  of  its  transmission  from  one  person  to  an. 
other  ?  Without  a  thorough  knowledge  of  all  these 
points  it  may  be  impossible  to  institute  an  efficient  plan 
of  prevention.  And,  furthermore,  we  inquire  whether, 
in  certain  diseases  in  which  prevention  of  the  entrance 
of  the  infectious  material  into  the  body  may  be  imprac- 
ticable, it  may  not  be  possible  nevertheless  to  induce  a 
condition  of  immunity  to  its  action,  in  this  way  accom- 
plishing the  same  ultimate  result?  Thus  the  influences 
inducing  a  predisposition  to,  and  those  inducing  an  im- 
munity from,  the  action  of  the  contagium  of  infectious 
diseases  must  receive  most  careful  investigation. 

It  must  be  evident,  then,  that  the  determination  of 
the  causal  relationship  of  micro  organisms  to  disease  has 
revolutionized  the  whole  science  of  pathology,  very 
greatly  widening  its  scope  and  increasing  its  usefulness  to 
the  clinician  tenfold.  The  student  of  pathology  must 
in  future  acquaint  himself  with  subjects  which  until  re- 
cently were  supposed  to  have  little,  if  any,  bearing  upon 
disease.  It  is  no  longer  sufficient  for  him  to  confine 
himself  to  the  study  of  morbid  anatomy,  but  he  must 
now  also  search  for  the  living  causes  of  disease,  he  must 
study  their  peculiarities  of  structure  and  growth,  their 
mode  of  action  upon  the  body,  the  toxines  which  they 
elaborate,  their  paths  of  entrance  to  and  egress  from  the 
body,  and  the  various  problems  of  their  destruction  and 
the  prevention  of  their  ravages.  In  his  search  for  the 
cause  of  a  disease  he  need  not  wait  until  death  has 
brought  his  victim  to  the  autopsy  table,  for  experiment 
has  shown  that  often  during  life  the  germs  of  a  disease 
are  present  in  the  blood  and  in  the  various  excreta  of  the 
body,  as  are  also  the  chemical  poisons  which  they  pro- 
duce. Thus,  early  in  the  course  of  the  disease  the  aid  of 
the  pathologist  is  sought  in  diagnosis  through  examina- 
tion of  the  sputum,  vomitus,  blood,  urine,  faeces,  and  va- 
rious inflammatory  products.  Upon  the  result  of  his  ex- 
amination the  subsequent  treatment  of  the  case  will  often 
largely  depend. 

But,  besides  the  changes  in  pathology  wrought  by  the 
study  of  the  causation  of  disease,  the  past  ten  years  have 
added  greatly  to  our  understanding  of  pathological  phys- 
iology, if  the  expression  may  be  allowed,  meaning  there- 
by the  perversions  of  function  which  are  the  result  of 
disease. 

Those  evidences  of  disordered  function  accessible  by 
the  ordinary  means  of  observation,  and  spoken  of  as  the 
symptoms  of  disease,  while  really  a  part  of  pathology  in 
its  broader  sense,  have  come  very  properly  to  belong  to 
the  domain  of  the  clinician,  and  with  them  the  patholo- 
gist has  ordinarily  but  little  to  do.  But  a  multitude  of 
evidences  of  disordered  function  are  inaccessible  to  or- 
dinary observation,  and  for  their  detection  the  services 
of  the  pathologist  are  required.,  Foremost  among  these 
at  the  present  time  are  the  changes  in  the  chemistry  of 
the  body  which  occur  as  a  part  of  disease,  and  the  im- 
mense importance  of  the  study  of  these  changes  may  be 
inferred  from  the  fact  that  chemical  change  has  been 
shown  to  be  a  necessary  part  of  all  vital  process.  Ac- 
cordingly, with  the  aid  of  the  facts  accumulated  by  the 
study  of  physiological  chemistry,  we  are  beginning  to 
build  up  a  pathological  chemistry  which  promises  to  be 
of  great  practical  value.  During  life  the  study  of  the 
chemical  changes  indicative  of  disease  is  of  necessity  re- 
stricted to  the  examination  of  the  various  secretions  and 


*3° 


MEDICAL   RECORD. 


[August  25,  1894 


excretions  of  the  body ;  but  as  the  result  of  the  careful 
study  which  they  have  received  we  shall  soon  be  able  to 
infer  with  much  accuracy,  from  changes  in  their  chemical 
composition  in  disease,  as  to  the  nature  of  the  processes 
upon  which  their  abnormalities  depend.  Already,  exam- 
inations of  stomach  contents,  of  urine,  of  fseces,  of  exu- 
dates and  transudates,  and  of  the  blood  have  become  an 
important  part  of  the  daily  routine  of  the  pathologist. 
He  must  be  acquainted  with  the  best  tests  for  hydrochloric 
acid,  for  pepsin,  and  for  the  abnormal  products  of  diges- 
tion in  the  stomach ;  he  must  be  able  to  determine  the 
quantity  of  albumin,  sugar,  urea,  uric  acid,  sulphates,  in- 
dican,  etc.,  in  the  urine;  he  must  kno*  how  to  detect 
the  results  of  imperfect  intestinal  digestion  in  the  faeces; 
he  must  be  familiar  with  th*  changes  in  the  composition 
of  the  blood  dependent  upon  diseases  of  the  various  or- 
gans of  the  body.  But  these  are  only  a  few  of  the  prob- 
lems suggested  by  the  development  of  pathological  chem- 
istry. Their  immense  importance  to  clinical  medicine 
cannot  but  be  apparent. 

Closely  in  touch  with  the  new  duties  imposed  upon 
the  pathologist  by  the  study  of  the  chemistry  of  disease, 
are  others  which  have  been  suggested  by  the  results  of  the 
investigation  of  the  various  problems  of  immunity.  The 
self-limited  course  of  the  infectious  diseases,  and  the  pro- 
tection afforded  by  one  attack  of  many  of  them  against 
subsequent  attacks  of  the  same  disease,  have  long  been 
recognized.  The  recent  study  of  immunity  explains  this 
by  the  theory  that,  hand  in  hand  with  the  production  of 
the  toxines  of  these  diseases,  there  are  produced  (by  the 
cells  of  the  body,  presumably)  certain  antagonistic  sub- 
stances which  neutralize  the  toxic  principles  and  thus 
prevent  their  action  upon  the  body.  These  antago- 
nistic substances  are  called  "  antitoxines,"  and  the  ex- 
teat  of  their  production  is  supposed  to  measure  the  de- 
gree of  immunity  produced.  It  has  been  found  that 
these  antitoxines  are  present  in  the  blood  of  animals 
rendered  immune  by  artificial  means,  that  the  blood  of 
an  animal  so  immunized  possesses  the  power,  when  intro- 
duced into  the  body  of  other  animals,  of  conveying  its 
immunity  to  them,  and,  more  important  than  all,  of 
ameliorating  the  symptoms  produced  by  a  previous  in- 
oculation with  the  infectious  material.  These  facts  have 
been  shown  to  apply  to  man  as  well  as  to  the  lower  ani- 
mals, and  thereby  has  been  suggested  a  plan  of  treat- 
ment of  infectious  disease  by  means  of  the  blood  serum 
of  immune  animals,  which  appears  most  promising  from 
the  reports  thus  far  published.  It  is  to  the  patholo- 
gist that  the  clinician  must  look  for  the  induction  of  im- 
munity in  animals  and  the  preparation  of  the  blood- 
serum  necessary  for  this  treatment 

Now,  it  must  be  evident  that  the  advances  in  pathol- 
ogy which  we  have  sketched  demand  on  the  part  of  the 
pathologist  a  special  training  for  his  work,  and  the  devo- 
tion to  it  of  an  amount  of  time  and  labor  quite  beyond 
the  possibilities  of  the  clinician.  He  must  now  have  a 
thorough  acquaintance  with  bacteriology,  animal  chem- 
try,  and  toxicology  in  addition  to  his  knowledge  of  path- 
ological anatomy.  He  must  have  trained  powers  of  ob- 
servation and  of  experimental  research,  and  he  must 
have  at  his  disposal  laboratories  equipped  with  every  ap- 
pliance necessary  for  the  conduct  of  his  investigations. 

And  this  leads  us  to  speak  of  the  necessity  of  much 
further  development  than  has  yet  occurred  in  the  way  of 
providing  pathological  laboratories  in  connection  with 
our  hospitals.  We  are  justly  proud  of  the  flourishing 
laboratories  of  pathology  which  have  grown  up  in  con- 
nection with  many  of  the  medical  colleges  of  this  coun- 
try, and  of  the  careful  investigations  of  the  problems  of 
disease  which  are  being  carried  on  in  them.  But  by  the 
development  of  such  a  wide  field  of  practical  applica- 
tions pathology  has,  of  necessity,  become  more  or  less 
divided  into  two  distinct  though  closely  associated  de- 
partments, that  of  the  pure  science  of  pathology  occu- 
pied with  the  theoretical  solution  of  all  the  problems  of 
disease,  and  that  of  the  applied  science  of  pathology  oc- 
cupied with  the  application  of  fill  the  principles  of  the 


science  to  the  practical  uses  of  the  clinician.  Though 
fulfilling  all  the  requirements  ot  the  first,  the  laboratories 
of  our  medical  schools  in  only  a  secondary  way  meet  the 
demands  of  the  second.  Connected  with  educational 
institutions,  they  are  conducted  primarily  for  educational 
purposes ;  the  time  of  those  connected  with  them  has 
many  demands  upon  it  for  routine  work  in  connection 
with  large  classes  of  students ;  and  unless  at  great  ex- 
pense of  time,  the  pathologist  is  never  brought  into  con- 
tact with  the  patient,  because  of  his  distance  from  the 
hospital.  Thus,  the  direct  usefulness  of  the  pathologist 
to  the  clinician  can  be  but  slight. 

It  is  evident,  then,  that  the  true  ground  for  the  devel- 
opment of  pathology  as  applied  to  clinical  medicine  is 
the  hospital  and  its  thoroughly  equipped  laboratories, 
and  we  would  insist  again  that  without  these,  the  clinician 
must  forego  to  a  very  considerable  extent  the  great  as- 
sistance in  his  work  afforded  by  the  pathologist.  It 
is  surely  no  unreasonable  demand  on  the  part  of  the  pa- 
tient, that  his  physician  should  be  in  possession  of  every 
aid  afforded  by  modern  science  in  the  treatment  of  his 
case. 

What,  then,  is  the  equipment  which  a  hospital  should 
have  in  order  to  be  abreast  of  the  times  in  so  far  as  path- 
ology is  concerned?  Besides  the  thoroughly  equipped 
autopsy-room,  with  its  adjoining  refrigerators  for  the 
storage  of  bodies,  there  should  be  laboratories  devoted  to 
histology,  bacteriology,  and  chemistry.  These  should 
be  well  lighted  and  well  ventilated,  and  should  be  suffi- 
ciently large  to  afford  abundant  working  space,  and  to 
contain  all  the  apparatus  required  by  the  most  recent  ad- 
vances in  these  several  branches  of  science,  in  so  far  as 
they  bear  upon  pathology.  The  histological  laboratory 
should  be  provided  with  a  good  outfit  of  microscopes, 
microtomes,  and  everything  necessary  for  the  minutest 
study  of  the  structural  changes  of  the  tissues  in  disease. 
It  should  have  the  best  light  obtainable,  and  should  afford 
ample  shelf  room  for  the  storage  of  the  pathological  ma- 
terial which  must  be  accumulated  for  study.  The  bac- 
teriological laboratory  should  afford  every  facility  for  the 
cultivation  and  study  of  the  micro-organisms  of  disease. 
It  should  be  removed  as  far  as  possible  from  the  possi- 
bility  of  contamination  by  dust  or  other  disturbing  influ- 
ences, and  for  use  in  connection  with  it  there  should  be 
a  room  fitted  up  for  the  accommodation  and  observation  | 
of  animals  used  for  the  experimental  determination  of 
the  pathogenic  action  of  the  bacteria.  The  chemical 
laboratory  should  contain  a  complete  outfit  of  apparatus 
for  the  examination  of  the  various  secretions  and  excre- 
tions of  the  body,  for  the  separation  and  study  of  the 
toxines  of  bacteria,  and  for  the  preparation  of  materials 
for  preventive  inoculation  and  for  the  treatment  of  dis- 
ease by  means  of  the  blood  serum  of  immune  animals. 

All  this  involves  a  considerable  outlay  of  space  and 
money  on  the  part  of  the  hospital,  but  these  are  more 
than  counterbalanced  by  the  many  advantages  to  its  pa- 
tients to  be  derived  from  such  an  equipment.  The  space 
and  light  may  best  be  obtained  in  a  separate  building  es- 
pecially devoted  to  the  pathological  department ;  the  an- 
nual expense  incident  to  the  conduct  of  such  a  depart- 
ment, after  the  first  outlay  for  building  and  equipment, 
would  be  relatively  small. 

And,  finally,  the  hospital  should  be  able  to  command 
the  services  of  a  man  as  director  of  such  a  department,, 
whose  time  and  energies  are  entirely  devoted  to  the 
scientific  development  of  applied  pathology.  It  is  no 
longer  possible  for  pathology  and  practical  medicine  to 
be  carried  on  successfully  together,  and,  since  in  giving 
his  services  to  the  hospital  the  pathologist  must  be  de- 
barred from  other  means  of  support,  he  should  receive  a 
salary  sufficient  for  his  needs  and  sufficient  to  put  men  of 
ability  at  the  command  of  the  hospital.1  The  proper 
conduction,  then,  of  a  pathological  department  such  as 
we  have  endeavored  to  sketch,  demands  the  payment  of 

1  It  would  seem  that  a  fair  criterion  of  the  amount  necessary  for 
this  purpose  might  be  found  in  the  salaries  paid  by  our  universities  ' 

to  their  professors  of  pure  science. 


August  25,  1894] 


MEDICAL    RECORD. 


231 


good  salaries  to  its  director  and  his  assistants,  and  the  af- 
fording them  every  facility  for  scientific  investigation. 

The  educational  and  scientific  power  of  a  hospital 
equipped  as  has  been  suggested  is  simply  inestimable. 
Already  the  Institut  ftir  Infectionskrankheiten  in  Berlin 
has  made  its  influence  felt  the  world  over,  and  it  is  to  be 
hoped  that  America,  by  following  the  lead  thus  shown, 
may  come  to  occupy  the  same  advanced  position  in  the 
onward  march  of  scientific  medicine  which  it  has  long 
held  in  many  of  the  more  purely  practical  branches  of 
our  science. 

THE  SHADY  SIDE  OF  THE  SURGICAL  TREAT- 
MENT OF  TRACHOMA.1 

By  H.  GIFFORD,  M.D., 

OMAHA,  MSB. 

The  surgical  treatment  of  trachoma,  which  dates  back  at 
least  to  the  days  of  ancient  Greece,  has  had,  as  you  all 
know,  a  most  enthusiastic  revival  during  the  past  few 
years;  and  granulated  lids  are  being  treated  with  all 
sorts  of  inventions  and  adaptations,  from  roller  forceps 
to  rasps,  tooth-brushes,  and  pumice  stone.  It  is  not  my 
intention  to  discuss  the  merits  of  these  various  methods ; 
any  one  of  them,  properly  used,  in  connection  with  other 
treatment,  gives  better  results  than  the  treatment  with 
local  applications  of  any  kinds  of  medicines,  alone ;  but 
the  praise  of  them  has  been  so  indiscriminate,  and  the 
disadvantages  and  dangers  of  the  treatment  have  been 
so  little  dwelt  upon,  that  it  is  high  time  for  the  other 
side  of  the  case  to  receive  more  attention.  That  it  may 
be  dear  that  I  have  no  unfounded  prejudice  against  the 
surgical  treatment  of  trachoma,  let  me  state  that  I  have 
been  chloroforming  my  trachoma  patients  and  subjecting 
their  lids  to  the  most  vigorous  surgical  measures,  squeez- 
ing, cutting,  burning,  and  scraping,  according  to  the  case, 
for  nearly  seven  years ;  several  years  longer  than  nearly 
all  the  writers  from  whom  so  much  has  been  heard  on  the 
subject.  Moreover,  as  nearly  one-fourth  of  my  patients, 
bom  private  and  clinical,  come  to  me  for  trachoma  and 
its  effects,  my  experience  cannot  be  said  to  be  limited. 
Furthermore,  I  have  no  idea  of  belittling  the  immense 
advantage  which  surgical  measures  give  us  in  treating  the 
disease.  I  should  not  think  of  trying  to  do  without 
them.  I  merely  wish  to  point  out  that  the  brilliant 
results  claimed  by  so  many  writers  are  not,  as  a  rule,  to 
be  expected,  and  that  disastrous  results  may  follow  their 
use  in  some,  if  not  all,  classes  of  cases.  First,  as  to  the 
brilliancy  of  the  results.  Many  writers  claim  to  cure  the 
great  majority  of  their  cases  in  from  four  to  six  weeks ; 
these  claims,  I  feel  sure,  are  due  to  too  brief  an  observa- 
tion of  the  cases.  The  patients  feel  well  and  look  com- 
paratively well,  but  if  they  are  kept  track  of,  relapsing 
will  be  found  to  be  the  rule ;  and  in  many  cases  I  have 
gained  the  impression  that  corneal  complications  are 
more  apt  to  occur  in  the  relapses  following  so  called 
cures  with  surgical  means,  than  when  medical  applica- 
tions alone  have  been  employed.  Where  the  diseased 
tissue  is  so  localized  that  it  can  easily  be  excised,  squeezed, 
or  scraped  out,  a  cure  can  sometimes  be  effected  with  one 
operation  ;  but,  generally,  after  all  the  surgical  treatment 
that  is  advisable  in  the  course  of  a  month  or  six  weeks,  I 
find  it  desirable  to  have  patients  continue  applications  of 
sulphate  of  copper  for  many  months,  returning  occa- 
sionally for  such  further  surgical  interference  as  may  be 
required. 

With  regard  to  the  dangers  of  surgical  treatment,  the 
bad  results  which  I  have  observed  or  known  to  follow  it 
are,  first,  suppression  of  tear-secretion,  with  resulting 
xerophthalmia ;  second,  ulceration  of  the  cornea,  with 
partial  or  complete  loss  of  sight.  Respecting  the  first 
of  these,  I  have  seen  several  cases  where,  after  excision 
or  squeezing  out,  of  the  upper  retro  tarsal  folds,  the  secre- 
tion of  tears  has  been  decidedly  reduced.  Most  of  these 
patients  experienced  no  serious  inconvenience  from  this 
reduction.  In  one  old  case,  however,  where  the  tracho- 
..  >  Read  before  the  Omaha  Medical  Society,  January  10,  1894. 


ma  in  one  eye  was  reduced  to  a  few  gelatinous  bunches 
in  the  upper  fornix,  near  the  outer  canthus,  these  were 
squeezed  out,  and  in  spite  of  every  precaution  to  prevent 
adhesions,  the  secretion  of  tears  was  almost  entirely  abol- 
ished, so  that  the  patient  was  obliged  constantly  to  use 
vaseline  in  the  eye  to  keep  it  comfortable.  It  is  quite 
possible  that  this  eye  would  have  become  xerophthalmia, 
no  matter  what  treatment  might  have  been  used,  but  it 
was  a  very  unpleasant  experience  to  have  an  eye  which  I 
was  expecting  to  make  useful  and  comfortable,  made  en- 
tirely incurable  within  a  few  days,  as  the  result  of  my 
treatment. 

Slight  corneal  erosions  I  have  seen  develop  in  seve- 
ral cases  immediately  after  surgical  treatment  of  the  lids, 
but  as  in  most  of  these  cocaine  had  been  used  freely,  it  is 
questionable  whether  the  majority  of  them  should  not  be 
laid  at  the  door  of  the  latter.  Really  dangerous  corneal 
trouble  from  surgical  trachoma-treatment,  I  have  ob- 
served only  from  the  aggravation,  by  the  operation,  of 
pre-existing  corneal  affections.  Most  writers  speak  of 
the  rapidity  with  which  corneal  complications  heal  after 
the  lids  have  been  treated  surgically,  and  in  the  great 
majority  of  cases  this  has  been  my  experience  also.  Tra- 
chomatous pannus,  in  particular,  clears  up  with  great 
rapidity  after  proper  surgical  measures.  On  the  other 
hand,  I  believe  that  non-vascular  ulcerations,  whether 
superficial  or  deep,  should  be  considered  positive  contra- 
indications to  any  extensive  surgical  interference  with  the 
lids.  Not  that  they  too  will  not,  as  a  rule,  be  helped  by 
such  interference ;  for  they  generally  heal  promptly ;  but 
in  rare  cases,  without  our  being  able  to  foresee  the  dan- 
gers, they  become  so  rapidly  worse  after  operations  for 
trachoma  that  the  sight  is  severely  injured,  or  entirely 
destroyed,  before  they  can  be  checked.  I  have  had  two 
experiences  of  this  kind  and  know  of  three  others.  The 
first  of  my  cases  was  that  of  a  young  man  with  moderate 
trachoma  and  nearly  clear  cornese,  there  being  only  a 
slight  superficial  ulceration  in  the  upper  half  of  the  left 
cornea.  I  excised  the  upper  retro  tarsal  folds,  put  in  two 
stitches  on  each  side,  and  applied  a  moist  sublimate  dress- 
ing. On  the  second  day  he  complained  of  severe  pain 
in  the  left  eye,  and  on  examining  it  I  found  a  nearly  cen- 
tral ulceration,  about  one  eighth  inch  in  diameter.  This 
healed  slowly,  when  the  stitches  were  removed  and  hot 
applications  used,  leaving  considerable  permanent  im- 
pairment of  vision.  The  stitches  may  have  been  the 
cause  of  the  bad  result  in  this  case,  and  since  then  I  have 
not  used  them  after  excising  the  folds. 

Another  case  was  that  of  a  woman,  aged  forty-two, 
whose  right  eye  had  been  lost  some  years  before.  The 
left  lids  had  some  trachomatous  infiltration ;  the  upper 
three  fifths  of  the  cornea  was. in  a  condition  of  pannus ; 
the  lower  two  fifths  being  clear  except  for  a  small  super- 
ficial ulceration  near  the  lower  border.  Under  chloro- 
form, the  trachomatous  parts  of  the  lids  were  squeezed 
out  with  ring  forceps,  after  which  the  conjunctival  sac 
was  washed  out  every  two  hours  with  a  boracic-acid  solu- 
tion. The  operation  did  not  involve  nearly  as  much 
rough  treatment  as  is  often  required,  and  the  reaction  on 
the  part  of  the  lids  was  no  greater  than  common,  but  the 
ulcer  became  rapidly  worse  and  completely  circumscribed 
the  clear  portion  of  the  cornea,  before  the  most  vigorous 
measures,  including  a  broad  Saemisch  cut,  succeeded  in 
checking  it.  As  it  was,  all  that  portion  of  the  cornea 
which  had  been  clear  became  permanently  dimmed,  and 
until  the  vessels  began  to  clear  off  in  the  upper  part  of 
the  cornea,  I  had  a  practically  blind  woman  on  my 
hands.  I  am  convinced  that  if  the  pannus  had  not  ex- 
isted on  the  upper  part  of  the  cornea,  this,  too,  would 
have  been  involved  in  the  ulceration;  but  the  latter 
stopped  sharply  at  the  border  of  the  pannus,  and  when 
the  vascularization  cleared  up,  as  it  soon  did,  useful 
vision  was  restored. 

In  another  case  which  I  have  seen,  the  trachomatous 
lids  of  a  man  aged  thirty- three  were  squeezed  out  with 
ring  forceps  by  one  of  the  most  competent  and  skilful 
oculists  of  the  West,  who  has  had  an  unusually  large  ex- 


232 


MEDICAL  RECORD. 


[August  25,  1894 


perience  in  the  surgical  treatment  of  these  cases.  Before 
the  operation,  the  man  could  see  well  with  both  eyes, 
though  an  ulcer  existed  in  the  upper  part  of  the  right 
cornea.  After  the  operation,  this  ulcer  spread  so  fast 
that  the  man  never  saw  again  with  the  eye ;  almost  the 
entire  cornea  sloughed,  and  when  I  saw  him,  some 
months  afterward,  the  eye  was  sightless  and  had  to  be 
eviscerated,  on  account  of  infection  of  the  interior 
through  the  scar. 

Another  still  sadder  case,  which  I  have  recently  seen 
was  that  of  a  middle  aged  woman  from  western  Iowa,  who 
had  had  trachoma  for  years.  Finally  her  physician  an- 
nounced that  he  had  a  new  and  sure  cure  for  her  sore 
eyes,  and  proceeded  to  scarify  her  lids  and  apply  what 
was  probably  sublimate  1  to  1,000.  From  her  history, 
she  probably  had  some  moderate  corneal  complication  at 
the  time  of  the  operation ;  at  any  rate,  she  never  saw 
again.  Both  corneas  ulcerated  and  sloughed,  and  when 
I  saw  her,  five  months  later,  both  eyes  were  hopelessly 
blind.  How  miny  similar  cases  are  occurring  all  over 
the  country,  it  is  hard  to  say ;  such  occurrences  are  not 
the  things  that  one  commonly  likes  to  describe  from  his 
own  practice,  but  I  have  recently  noted  a  case  *  from  the 
practice  of  Abadie,  the  ardent  Parisian  advocate  of  the 
tooth  brush  method  of  treating  trachoma,  in  which  a 
woman's  conjunctiva  (not  trachomatous  but  with  a  con- 
junctivitis of  uncertain  origin)  was  brushed  vigorously 
and  the  galvano-cautery  applied  to  a  granulation  tumor 
of  the  conjunctiva ;  whereupon,  a  slight  corneal  infiltra- 
tion which  existed  at  the  time  of  the  operation  promptly 
got  so  much  worse  that  the  whole  surface  of  the  cornea 
was  reduced  to  a  purulent  pulp.  The  patient  is  said  to 
have  eventually  obtained  some  useful  vision  of  the  eye, 
but  for  this  she  certainly  had  to  thank  her  good  fortune 
and  not  her  surgical  treatment.  [Since  this  paper  was 
read,  I  have  learned  of  a  case  not  included  in  the  above, 
in  which  the  scarification  of  the  lids  cost  the  patient  his 
eye.]        :  ^ 

These  cases  make  it  plain,  I  think,  that  surgical  meas- 
ures have  not  simplified  the  treatment  of  trachoma ;  on 
the  contrary,  they  have  made  it  altogether  more  impera- 
tive that  he  who  uses  them  should  be  able  to  examine 
the  eye  with  the  greatest  care  and  discrimination ;  and 
should  be  prepared,  if  unusual  emergencies  arise,  to  treat 
them  promptly  and  vigorously.  Without  these  qualifica- 
tions, the  physician  had  far  better  stick  to  the  old  blue- 
stone  and  nitrate  of  silver  treatment ;  for  with  these 
remedies  the  disease  can  always  be  improved  or  held  in 
check,  and  in  many  cases  cured;  whereas,  if  he  uses 
surgical  measures  at  all  freely,  while  he  may,  as  a  rule, 
obtain  more  brilliant  results,  he  is  liable,  at  any  time,  to 
ruin  an  eye  which  otherwise  would  never  be  lost. 


Medical  Practice  in  Sweden. — In  Sweden  ten  years 
of  study  is  incumbent  on  every  medical  student.  They 
are  so  particular  in  that  enlightened  country  to  have 
their  medical  men  thoroughly  equipped  and  "  ethically 
developed"  that  the  practice  of  homoeopathy  is  forbid- 
den, and  every  globule  of  homoeopathic  medicine  intro- 
duced into  the  country  has  to  be  smuggled  in. — New 
York  Medical  Times. 

Fruit  Eating  to  Cure  All  Ills. — A  new  society  of 
cranks  has  been  started  by  a  former  lieutenant  in  the 
German  Army.  His  name  is  Boeter.  He  is  the  leader 
of  a  new  "  ism,"  and  as  such  sailed  recently  from  San 
Francisco  to  Honolulu.  The  "  Fruitarians  "  is  the  name 
of  the  new  society  he  represents,  and  their  belief— or 
rather  notion — is,  that  modern  civilization  is  full  of  van- 
ities and  strange  notions,  and  greatly  needs  reforming. 
The  members  eat  nothing  but  ripe  fruit,  eschew  cooked 
food  of  any  kind,  and  drink  only  water.  They  are  to 
live  in  huts,  bare  of  the  comforts  of  civilization,  and  go 
naked.  Ex  Lieutenant  Boeter  intends  to  buy  a  large  tract 
of  land  in  the  Sandwich  Islands,  or,  perhaps,  a  small 
island  outright,  for  the  purpose  of  founding  a  colony. 

1  Annates  d'Oculistique,  September,  1893,  p.  187. 


POST-GRADUATE  MEDICAL  STUDY  ABROAD.1 
By  ANDREW  MacFARLANE,  M.D., 

mSTBUCTO*  DC  PHYSICAL  DIAGNOSIS  AND  CLINICAL  MICROSCOPY,  ALBANY  MfjDf* 
CAL  COLLBCB. 

The  student  of  medicine  on  the  eve  of  graduation  looks 
forward  eagerly,  I  am  sure,  to  that  crucial  and  final  test 
— practice — which  demands  that  he  should  competently 
employ  the  principles  which  he  has  learned,  should  ex- 
hibit the  skill  of  which  he  claims  to  be  the  master,  and 
which  in  return  offers  as  a  reward  an  honorable  success. 
In  his  student  days  the  mechanism  of  the  human  organism 
has  gradually  been  spread  before  him,  the  mysteries  of 
diseased  conditions  have  been  carefully,  step  by  step,  un- 
folded to  him,  and  the  potentialities  of  medicine  have 
been  impressed  upon  him  so  that  all  seems  simple,  clear, 
and  logical.  Unfortunately,  the  realities  of  practice  bring 
their  bitter  realizations,  and  what  seems  plain  and  simple 
when  sitting  in  the  amphitheatre  often  appears  dark  as 
Erebus  to  the  beginner  standing  by  the  bedside.  Even 
that  vast  storehouse  of  vaunted  remedies  becomes  at  criti- 
cal times  the  charnel  house  of  our  hopes,  and  diseased 
processes  frequently,  much  to  our  surprise  and  at  times 
to  our  chagrin,  assume  unexpected  phases.  This  inevi- 
table result  is  due  to  the  fact  that  the  mind  of  the  student 
has  of  necessity  been  impressed  with  clear-cut  pictures  of 
distinct  disease-entities,  illustrated  by  carefully  selected 
cases  exhibiting  definite  types  and  none  of  the  vagaries  of 
disease.  Actual  practice,  however,  is  very  different,  and 
our  patients  rarely  show  the  classical  pictures  of  disease. 
Mistake  after  mistake  will,  therefore,  be  made,  and  must 
be  recognized  before  that  training  which  is  essential  to 
satisfactory  medical  work  is  secured. 

The  important  question,  then,  is,  how  is  that  training 
best  obtained  ?  Undoubtedly  the  best  way  is  by  service 
in  a  good  hospital,  where,  under  a  competent  visiting  staff, 
the  house  physician  has  abundant  opportunity  to  see  and 
examine  patients,  watch  carefully  the  course  of  disease, 
study  closely  each  individual  symptom,  and,  what  is  most 
important,  assumes  to  a  very  large  extent  the  responsi- 
bility for  the  care  of  the  patient  and  meets  the  many 
emergencies  which  arise  during  his  term  of  service,  all  <JF 
which  is  a  most  valuable  preparation  for  private  prac- 
tice. 

Fortunately  our  hospitals  need  no  chanticleer  to  sound 
their  praises.  Each  of  you  has  had  frequent  opportunity 
to  see  the  richness  of  the  clinical  material  and  the  value 
of  the  services. 

To-day,  therefore,  I  shall  cursorily  speak  of  the  train- 
ing secured  by  special  postgraduate  study  which  some  of 
you  may  undertake  after  your  hospital  work  and  others 
after  a  few  years  of  private  practice.  The  question  natu- 
rally arises,  where  can  such  work  be  done  most  satis* 
factorily  and  at  the  least  cost? 

Teachers  in  the  large  centres  of  population  have  rec- 
ognized this  need,  and  to-day  there  are  flourishing  schools 
for  practitioners  in  New  York,  Philadelphia,  Boston,  and 
in  some  of  the  Western  cities.  The  advantages  of  these 
native  post-graduate  schools  are  that  they  are  accessible, 
no  foreign  language  must  be  mastered,  the  work  is  espe- 
cially arranged  to  meet  the  needs  of  the  American  practi- 
tioner, and  the  physician  can  easily,  without  great  loss, 
leave  his  practice  for  two  or  three  months  to  brush  up  on 
any  special  line  in  which  he  feels  he  is  weak.  The  disad- 
vantages are  that  no  large  hospitals  are  attached  to  these 
schools,  the  teaching  is  to  a  great  extent  done  with  dis- 
pensary patients,  who  are  necessarily  somewhat  unsatis- 
factory, and  with  American  patients  who  do  not  take 
kindly  to  thorough  examinations  by  classes. 

It  has  been  customary,  however,  for  many  American 
medical  students  to  continue  their  studies  abroad,  espe- 
cially in  German-speaking  countries.  Little  need  be  said 
of  the  medical  work  in  Great  Britain  and  France,  Lon- 
don and  Paris,  though  great  medical  centres  offer  little  to 
the  American  practitioner.  As  the  hospitals  are  scattered, 
much  time  is  lost  in  going  from  one  to  the  other,  and 
1 A  talk  given  to  the  Senior  Class  of  the  Albany  Medical  College.   ; 


August  25,  1894] 


MEDICAL  RECORD. 


*33 


private  instruction,  as  it  exists  in  Vienna,  is  practically 
unknown.  To  the  specialist  who  has  mastered  the  ground- 
work of  his  own  field,  and  who  is  able  to  fully  appreciate 
cases  without  instruction,  the  abundant  clinical  material 
of  London  and  Paris  is  of  inestimable  value. 

It  will  be  well,  I  think,  before  describing  the  character 
of  the  medical  work  in  Germany,  to  consider  briefly  the 
German  university,  and  to  note  in  what  respects  it  differs 
from  a  similar  American  institution.  Nothing  in  Ger- 
many impressed  me  so  much  as  the  large  number  of  great 
universities  whose  fame  re3ts  not  upon  huge  piles  of  stone 
and  mortar,  but  upon  the  scholarship  and  scientific  at- 
tainments of  the  men  connected  with  them.  Germany, 
a  country  only  four  times  the  size  of  the  State  of  New 
York,  has  twenty  universities,  any  one  of  which  is  suffi- 
cient to  make  a  nation  famous  for  scholarship.  These 
universities  are  state  institutions,  endowed  and  controlled 
by  the  Government,  having  similar  requirements  for  en- 
trance, and  covering  exactly  the  same  ground.  The 
German  university  differs  essentially  from  the  American 
in  that  it  is  purely  a  professional  school,  and  in  no  sense 
of  the  word  "  a  college."  Students  before  entrance  must 
have  graduated  from  the  gymnasium,  where  the  course  of 
instruction  has  been  carried  to  what  would  be  equivalent 
to  the  end  of  the  sophomore  year  in  an  average  American 
college.  Here  the  discipline  is  most  rigid  and  severe,  the 
instruction  thorough,  and  the  work  practically  the  same 
in  all  the  gymnasia.  In  the  university  all  is  changed, 
and  the  greatest  latitude  is  allowed  the  student  in  his 
course  of  instruction  and  in  his  attendance  upon  lectures. 
The  student  enters  the  university  to  study  history,  philos- 
ophy, letters,  theology,  medicine,  law,  etc.,  because  in 
Germany  all  candidates  for  the  higher  Government  ser- 
vice, all  teachers  in  academies,  and  all  professional  people, 
must  have  had  an  university  training  or  its  equivalent. 
The  student  is  supposed  at  his  age  of  entrance,  twenty, 
or  more,  to  know  what  his  life  occupation  will  be,  and, 
therefore,  the  line  of  work  he  wishes  to  pursue.  He  ac- 
cordingly matriculates,  pays  for,  and  attends  lecturers 
only  upon  subjects  leading  to  the  end  he  is  seeking. 
There  are  no  recitations,  no  calling  of  the  roll,  and  it  is 
usually  a  matter  of  supreme  indifference  to  the  professor 
whether  the  student  attends  regularly  or  not  his  lectures. 
i  The  student  has  a  lecture-sheet  signed  at  the  end  of  the 
term  by  the  professor,  and  this  is  the  official  evidence  of 
attendance  at  the  requisite  number  of  courses  of  lectures 
when  he  come3  up  for  a  degree.  After  having  attended 
the  required  number  of  courses  of  lectures,  as  shown  by  his 
lecture-sheet,  the  student  may  try  the  examination  for  a 
degree.  For  this  he  has  to  write  a  thesis,  which  he  must 
defend  before  a  committee  of  the  faculty,  and  in  addition 
prove  a  number  of  scientific  propositions  propounded  by 
them.  The  severity  of  the  examination  is  evident  from 
the  fact  that  outside  the  professions  not  more  than  ten 
per  cent,  of  the  students  take  their  degrees.  This  can  be 
explained,  however,  to  some  extent,  by  the  fact  that  all 
mist,  in  addition,  pass  state  examinations.  As  the  uni- 
versity degrees  are  purely  honorary,  and  somewhat  ex- 
pensive, many  do  not  seek  them. 

The  teaching  body  in  a  German  university  consists  of 
the  "  ordentlicher  Professoren,"  full  professors,  "aus- 
serordentlicher  Professoren,"  somewhat  similar  to  our 
adjunct  professors,  though  entirely  independent,  and  the 
"privat-docenten."  The  "  privat-docenten  "  need  a 
word  of  description,  as  they  are  characteristic  of  the  Ger- 
man university  and  play  an  important  part  in  the  instruc- 
tion of  the  American  medical  students.  They  are  young 
men,  thirty  to  forty  years  of  age,  distinguished  for  schol- 
arship, which  has  been  tested  by  special  examinations  in- 
*  volving  original  research  and  extensive  study.  They  are 
permitted,  after  having  thus  shown  unusual  ability,  to  de- 
liver courses  of  lectures  under  the  aegis  of  the  university. 
They  receive  no  salary  from  the  university  except  the  fees 
of  the  students  who  attend  their  lectures.  It  is  therefore 
necessary  for  them  either  to  lecture  upon  some  subject  not 
covered  by  a  professor,  or  to  deliver  lectures  more  attrac- 
tive than  those  of  the  professor. 


The  professors,  adjunct  professors,  and  instructors  an- 
nounce at  the  beginning  of  each  term  (the  winter  term 
extends  from  October  15th  to  March  15  th,  and  the  sum- 
mer term  from  April  15th  to  August  15th)  the  subjects 
of  their  lectures  for  the  ensuing  term,  and  the  student  se- 
lects those  which  he  wishes  to  hear. 

Each  professor  and  instructor  lectures  upon  the  sub- 
ject in  which  he  is  most  interested,  and  with  which  he  is 
therefore  most  familiar,  and  regards  himself  not  as  one 
intended  to  insist  upon  attendance,  to  maintain  disci- 
pline, or  to  compel  students  to  work,  but  as  a  teacher,  i.e., 
one  who  professes  certain  opinions,  a  leader  in  thought 
in  his  field  of  work,  and  who  is  there  to  direct,  clear  the 
way,  and  incite  students  to  earnest  effort  in  the  work  in 
which  they  are  engaged.  As  there  may  be,  and  often  are, 
lectures  delivered  by  the  professors,  the  adjunct  profes- 
sors, and  the  instructors  on  the  same  or  kindred  subjects, 
it  behooves  the  professor  to  keep  abreast  of  the  times  in 
his  lectures,  making  them  attractive  as  well  as  deeply 
scientific,  or  he  will  find  his  lecture-room  deserted  for  the 
more  brilliant  lectures  of  a  young  privat-docent. 

The  adjunct  professors  and  privat-docenten  are  in- 
cited to  advanced  and  original  work  to  attract  the  at- 
tention of  that  most  severe  of  critics,  the  scientific 
world,  and  thus  receive  an  .appointment  to  a  higher  po- 
sition either  in  their  own  or  in  another  German  univer- 
sity. Another  factor  in  stimulating  the  professors  to  a 
high  standard  of  work  is  the  fact  that  students  rarely 
complete  their  course  in  one  university  but  study  in  sev- 
eral, courses  of  lectures  taken  in  one  university  being 
accepted  in  every  other.  Thus  a  medical  student  might 
study  histology  and  pathology  in  Freiburg  where  Ziegler 
is,  obstetrics  in  Munich  under  Winckel,  medicine  in 
Heidelberg  listening  to  Erb,  in  Erlangen  to  Strilmpell, 
or  in  Berlin  under  Leyden,  Senator,  or  Gerhardt,  and 
surgery  in  the  same  university  or  elsewhere.  This  change 
from  one  university  to  another  is,  I  believe,  more  com- 
mon among  non-medical  students,  but  is  still  quite  fre- 
quent among  medical  students. 

The  key-note  of  the  German  university  is  freedom  in 
teaching  and  liberty  in  learning.  This  eternal  principle, 
which  has  made  Anglo-Saxon  governments  and  civiliza- 
tions the  most  advanced  in  the  world,  has  given  to  Ger- 
man intellectual  life  its  present  pre  eminent  position  and 
has  elevated  its  university  system  to  a  plane  far  above 
that  of  any  other  country. 

Briefly,  then,  what  is  the  effect  of  this  system  upon  the 
university,  and  what  is  the  result  upon  the  students? 
It  makes  every  man  completely  independent  in  every- 
thing— mode  of  living,  personal  behavior,  course  of  in- 
struction. It  offers  the  student  complete  courses  of  lect- 
ures and  abundant  opportunity  for  advanced  work  on 
any  university  subject  which  he  may  take  or  not  as  he 
pleases.  The  result  is  that  there  are  the  two  extremes 
among  the  students — the  workers,  who  avail  themselves  of 
the  opportunities  afforded,  and  the  others — the  dawdlers, 
the  lazy,  and  the  mentally  incompetent,  who  simply  idle 
away  their  time  and  fritter  their  opportunities. 

The  American  college  contains  exactly  the  same  hu- 
man elements,  as  nature  is  much  the  same  everywhere. 
With  us,  however,  the  attempt  is  made  to  get  a  fair  aver- 
age, and  the  bright,  hard  working  students  are  to  a  great 
extent  held  back  by  the  lazy  and  incompetent,  with  the 
result  that  the  best  students  do  not  do  as  much  work  as 
they  might,  while,  I  am  afraid,  very  little  good  is  accom- 
plished with  the  others.  All  of  us,  I  am  sure,  know 
many  men,  utterly  incompetent,  who  have  received  college 
degrees  for  which  they  did  no  equivalent  work.  This 
same  principle  of  instruction  is  carried  out  in  the  medi- 
cal schools,  modified  by  the  special  requirements  of  the 
work — laboratory  instruction,  clinical  examination  of 
patients,  surgical  technique,  etc.  It  is  not  necessary  to 
speak  in  detail  of  the  German  medical  schools;  that 
would  require  too  much  time,  and  in  your  case  is  of  no 
special  value  except  in  so  far  as  relates  to  the  work  that 
American  physicians  can  satisfactorily  do  in  them. 

We  shall  therefore  speak  only  of  post-graduate  medi- 


234 


MEDICAL   RECORD. 


[August  25,  1894 


cal  work,  and  shall  divide  the  German  medical  schools 
artificially  into  the  large  medical  centres,  as  Vienna  and 
Berlin,  and  the  smaller,  as  Heidelberg,  Freiburg,  WUrz- 
burg,  etc.  The  advantages  of  the  smaller  university  are 
that  living  is  cheap,  tuition  is  low,  and  the  student  enters 
directly  into  the  German  life,  and  thus  has  an  excellent 
opportunity  to  master  the  German  language.  The  dis- 
advantage is  that  outside  of  laboratory  work  you  can  get 
no  special  instruction,  and  must  take  the  ordinary  lectures 
and  regular  instruction  given  to  the  students.  This, 
while  very  good,  is  not  quite  what  is  sought  by  the 
American  physician,  who  desires  to  crowd  as  much  clini- 
cal work  as  possible  into  a  few  months.  In  the  laborato- 
ries, however,  there  is  always  plenty  of  material,  and 
much  work  can  be  done  alone  with  a  little  help  from  the 
professor  or  his  assistants.  The  advantages  of  the  large 
medical  centres,  especially  Vienna,  are  die  vast  amount 
of  clinical  material  which  can  be  used,  and  the  special  in- 
struction in  every  subject  which  can  be  obtained  from 
trained  and  well  equipped  instructors. 

The  preeminence  of  Vienna  as  a  medical  centre  is  due 
to  its  large  general  hospital.  This  is,  I  believe,  the 
largest  hospital  in  the  world,  and  contains  about  four 
thousand  beds.  There  are  within  its  walls  about  ten 
thousand  births  a  year,  and  ten  to  twelve  autopsies  are 
made  daily  in  its  pathological  institute.  With  a  staff  of 
twenty-four  full  professors,  thirty-eight  adjunct  profes- 
sors, sixty- two  privat  docenten,  and  a  large  number  of 
trained  assistants,  it  has  a  teaching  body  and  clinical  ma- 
terial unequalled  in  the  world. 

The  American  medical  student  goes  to  Vienna  not  for 
the  ordinary  lecture  and  laboratory  work  but  to  receive 
special  training,  which  is  to  a  great  extent  especially  ar- 
ranged for  him  by  the  privat-docenten  and  assistants. 
The  privat-docenten  receive  nothing,  the  assistants  a 
mere  pittance  from  the  hospital.  They  do  not  engage 
in  private  practice  but  busy  themselves  with  special  in- 
vestigations and  advanced  work  in  the  hospital,  with  the 
hope  that  some  day  they  may  be  called  to  a  professor- 
ship in  Vienna  or  in  one  of  the  smaller  Austrian  univer- 
sities. As  they  must  earn  money  in  some  way  while 
waiting,  they  are  allowed  to  use  the  clinical  material  for 
purposes  of  demonstration  in  private  courses.  These 
courses  are  to  a  great  extent  arranged  to  attract  the 
Americans,  as  they  are  the  foreigners  most  lavish  with 
their  money. 

Probably  the  most  satisfactory  courses  given  in  Vienna 
are  those  on  medical  diagnosis,  and  this  is  due  not  only 
to  the  instruction,  but  even  more  to  the  vast  amount  of 
clinical  material  offered  for  investigation. 

There  are  in  the  general  hospital  about  fifteen  hun- 
dred medical  patients;  of  these  all  the  difficult,  unusual, 
and  obscure  cases  are  sent  to  the  wards  under  the  charge 
of  the  teaching  professors,  who  have  each  about  one 
hundred  and  fifty  patients  in  their  divisions.  The  great 
mass  of  ordinary  uninteresting  cases  are  placed  in  wards 
under  the  care  of  non  -teaching  professors.  Patients  also 
are  frequently  transferred  from  wards  under  the  charge 
of  a  teaching  professor  to  other  wards  when  the  disease 
has  been  thoroughly  studied  and  demonstrated. 

The  assistants  of  the  teaching  professors  having  this 
magnificent  clinical  material  are  the  men  who  give  the 
valuable  courses  in  medical  diagnosis.  The  members  of 
a  course,  usually  limited  to  six,  go  to  the  wards  at  a 
fixed  hour,  and  on  a  class  list  find  what  patient  has  been 
assigned  to  each  member  of  the  class.  Every  man  then 
thoroughly  examines  his  patient  for  an  hour,  when  the 
assistant  comes  and  calls  on  a  member  of  the  class  to 
demonstrate  his  case.  He  stands  at  one  side  of  the  head 
of  the  bed,  the  assistant  at  the  other,  while  the  rest  of 
the  class  are  grouped  about  the  bed.  The  demonstrator 
must  give  a  complete  and  exact  diagnosis,  then  make  a 
thorough,  systematic  physical  examination,  the  deduc- 
tions from  which  are  confirmed,  modified,  or  corrected 
in  every  detail  by  the  assistant.  After  the  examination 
the  assistant  goes  rapidly  over  the  case ;  grouping  to- 
gether logically  the  symptoms,  making  clear  the  obscure 


points,  discussing  the  differential  diagnosis,  and  speaking 
a  little  about  the  treatment,  though  this  is  usually  then- 
weak  point.  Two  such  cases  are  demonstrated  every 
day,  and  two  new  cases  added,  so  that  each  case  demon- 
strated has  been  thoroughly  examined  by  every  member 
of  the  class.  The  value  of  this  work  depends  upon  sev- 
eral factors.  First,  the  cases  are  all  difficult  and  inter- 
esting, selected  from  a  large  number,  each  one  of  which 
has  been  carefully  studied  for  the  regular  lectures  of  the 
professor.  Secondly,  the  patients  are  exceedingly  sub- 
missive and  rarely  object  to  thorough  physical  examina- 
tions, even  when  they  cause  great  pain*  Thirdly,  the 
instructor  is  a  splendid  diagnostician,  one  who  is  seeking 
by  his  work  to  create  such  a  reputation  that  he  will  be 
called  to  a  professorship.  One  of  the  men  under  whom 
I  worked  was  at  that  time — 1891-92 — reputed  to  be 
the  best  diagnostician  in  Vienna,  and  since  then  has  been 
appointed  a  professor  in  the  university.  Fourth,  the  men 
doing  the  work  are  imbued  with  the  true  spirit  of  schol- 
arship, seeking  knowledge  not  in  order  to  pass  examina- 
tions and  to  receive  degrees,  but  because  of  its  owA  in- 
trinsic value.  In  much  the  same  way  courses  on  other 
subjects  are  given,  modified  by  the  special  character  of 
the  subject. 

These  courses  range  in  cost  from  15  to  30  guldens 
for  thirty  lessons,  a  gulden  being  about  43  cents.  The 
best  courses  are  all  about  a  gulden  a  lesson,  while  a  very 
few  courses  on  diagnostic  gynecology  and  operative 
gynecology  on  the  cadaver  cost. usually  50  guldens  for 
twenty-four  lessons,  but  in  such  cases  the  class  is  gener- 
ally limited  to  four. 

One  rarely  takes  less  than  five  courses  a  day,  or  more 
than  seven,  for  which  the  tuition  will  range  from  $9  to 
$12  per  week.  The  usual  method  of  living  is  to  hire  a 
room  by  the  month,  where  a  light  breakfast  is  obtained, 
and  to  take  the  other  meals  at  a  restaurant.  One  can, 
however,  if  desired,  secure  a  room  and  full  board  at  a 
fixed  price  in  a  "  pension."  The  cost  of  living  depends 
largely  on  the  personal  factor  and  varies  with  one's 
tastes.  Some  live  decently,  with  economy,  for  about  £24 
per  month,  while  others  spend,  without  extravagance,  eas- 
ily, twice  that  amount.  Fair  limits  per  month  for  abso- 
lute expenses,  tuition,  and  board,  range  from  $60  to 
$  100.  There  are,  in  addition  to  this  sum,  the  inciden- 
tals— Opera,  concerts,  baths,  and  personal  expenses — 
which  would  increase  the  cost  of  living  from  £75  to  £150 
per  month. 

The  first  amount  is  low,  but  not  the  lowest  possible, 
though  it  is  as  low  as  it  should  be,  as  one  should  not 
neglect  to  go  to  the  opera  and  concerts;  while  the  sec- 
ond is  a  fair  allowance,  but  not  at  all  extravagant. 

In  Berlin  there  are  no  courses  given  which  are  just  the 
same  as  those  in  Vienna.  There  are  special  courses  in 
the  spring  vacation  and  just  before  the  winter  semester. 
These  last  four  weeks,  and  often  contain  very  many 
members,  rendering  much  individual  instruction  im- 
possible. During  the  semesters  the  assistants  are  not  al- 
lowed to  use  the  ward  patients  for  private  instruction. 

The  questions  now  arise  as  to  the  knowledge  of  Ger- 
man necessary  for  satisfactory  medical  work,  whether  a 
sufficient  acquaintance  with  the  language  should  first  be 
secured  before  medical  work  is  begun,  or  if  both  may  not 
be  pursued  at  the  same  time. 

Vienna  is  the  only  German  city  where  medical  .courses 
to  any  extent  are  given  in  English ;  but  these  courses  are 
generally  the  poorer  ones,  while  the  best  are  usually  given 
only  in  German.  Explanations  given  in  English  by  one 
having  a  meagre  knowledge  of  the  language  are  not,  as 
a  rule,  I  think,  so  satisfactory  as  when  given  in  German, 
even  if  the  German  of  the  auditor  is  decidedly  limited.   • 

It  may  be  well  to  sketch  out,  rather  vaguely  of  course, 
a  stay  of  a  year  to  a  year  and  a  half  abroad,  and  one  of 
only  six  or  seven  months. 

In  either  case  as  much  German  as  possible  should  be 
learned  before  starting,  and  it  would  be  wise  to  read 
some  standard  German  medical  work,  as  that  of  Striltn- 
pell.     If  an  extended  stay  is  planned,  it  would  be  best, 


August  25,  1894] 


MEDICAL  RECORD. 


*35 


I  believe,  to  spend  the  first  three  or  four  months  in  a 
small  university  town,  as  Heidelberg,  Gttttingen,  Frei- 
burg, etc.  Here  the  knowledge  of  the  German  language 
should  be  the  first  desideratum,  while  laboratory  work 
and  attendance  upon  clinical  lectures  would  be  valuable 
as  German  lessons  and  in  teaching  German  methods  of 
procedure  and  examinations. 

Then,  when  German  verbs  were  no  longer  a  night- 
mare, and  German  construction  a  hopeless  labyrinth, 
Vienna  should  be  the  objective  point  Here  the  special- 
ist in  embryo  could  spend  eight  or  nine  months ;  then, 
later,  two  months  each  in  Berlin,  Paris,  and  London, 
seeing  famous  men,  studying  their  methods  and  examin- 
ing their  enormous  material.  For  one  who  can  spare 
only  six  or  seven  months  abroad,  I  believe  the  result 
will  be  better  if  he  gives  the  first  month  exclusively  to 
Geiman  in  some  small  German  town,  where  there  are 
no  temptations  to  speak  English,  then  go  to  Vienna, 
rather  than  to  proceed  directly  to  Vienna.  The  thought 
no  doubt  arises  why  cannot  German  be  studied  in 
Vienna,  the  physician  taking  at  first  English  courses, 
then,  as  his  acquaintance  with  German  increases,  taking 
those  given  in  German.  This  can  be  and  is  done  by  a 
number,  but,  I  believe,  not  at  all  successfully. 

The  temptations  to  speak  English  in  Vienna  are  so 
great  that  I  doubt  if  any  American  medical  student,  ex- 
cept by  the  greatest  self-denial  and  control,  ever  learns 
in  Vienna  very  much  German. 

The  Americans  there  are  so  numerous  that  they  of 
themselves  form  a  little  society;  they  have  their  church 
and  their  social  organization,  and,  as  these  special 
courses  are  almost  entirely  taken  by  Americans,  all  with 
whom  they  are  thrown  in  contact  are  American.  One 
rarely  becomes  acquainted  with  the  German  students  in 
a  large  university,  and  thus  has  little  opportunity  of 
learning  from  them. 

The  cost  of  a  stay  for  six  months  need  not,  with 
economy,  be  more  than  £450,  with  $200  additional  for 
the  journey  to  and  fro.  For  a  year  it  can  with  economy 
be  done  for  $900,  including  the  journey.  If  a  micro- 
scope, instruments,  books,  and  clothes  should  be  bought, 
or  extensive  pleasure-trips  undertaken,  the  total  would 
necessarily  be  much  increased. 

The  best  time  to  go  to  Vienna  is  in  the  spring,  April 
and  May.  Many  Americans,  who  have  studied  all  win- 
ter, leave  Vienna  at  this  time,  either  to  return  home  or  to 
continue  work  elsewhere ;  on  this  account  it  is  much  eas- 
ier to  get  into  the  best  courses,  and  this  is  especially  the 
case  if  you  have  a  friend  in  Vienna  who  will  prearrange 
work  for  you.  Medical  work  in  Vienna  is  regulated  by 
the  ordinary  commercial  laws  of  supply  and  demand, 
and  as  the  number  of  Americans  is  usually  very  large, 
epecially  in  the  fall  and  winter,  and  the  number  of  de- 
sirable courses  limited,  there  is  an  eagerness  to  get  for 
one's  self  and  one's  friends  the  best,  while  others  have 
often  to  wait  for  months  for  the  same  openings. 

It  is,  however,  always  an  easy  thing  to  start  into  satis- 
factory work  in  Vienna.  The  Anglo-American  Medical 
Association,  whose  secretary,  the  Rev.  Mr.  Gordon,  has 
done  incalculable  kindnesses  to  English-speaking  stu- 
dents, gives  to  new-comers  most  valuable  information  as 
to  rooms,  board,  courses,  etc.,  and  introduces  them  to 
the  older  men,  who  are  usually  kind  in  putting  the 
new-comer  on  the  right  track. 

I  cannot  bring  this  short  and  desultory  talk  to  a  close 
without  saying, a  word  about  the  German .  professor. 
You  can  only  become  intimate  with  him  in  one  of  the 
smaller  universities ;  but  such  an  acquaintance  is  of  itself 
worth  a  stay  at  a  small  university.  His  kindly  welcome 
to  Americans,  his  hearty  greeting  "  Herr  College,"  and 
his  willing  assistance  to  the  earnest  student  make  the 
stranger  feel  completely  at  home.  If  it  be  your  good 
fortune,  as  it  has  been  mine,  to  make  excursions  with 
him,  you  will  find  a  union  of  unaffected  simplicity  and 
true  greatness  which  will  be  a  remembrance  to  be  cher- 
ished, and  an  ideal  to  be  sought  after  during  the  re- 
mainder of  your  lives. 


A  CASE  OF  INSANITY  DUE  TO  THE  MEN- 
STRUAL FUNCTION  —  OOPHOREC  TOMY  — 
RECOVERY. 

By   ELIOT   GORTON,  M.D., 

ASSISTANT  PHYSICIAN  TO  THE  NEW   JERSEY   STATE    HOSPITAL,  MORK1S    PLAINS, 

N.   J. 

In  the  Medical  News  of  May  20,  1893,  appeared  an  ar- 
ticle from  the  pen  of  Dr.  B.  D.  Evans,  Medical  Director 
of  the  New  Jersey  State  Hospital  at  Morris  Plains,  on 
"  Periodic  Insanity  in  which  the  Exciting  Cause  Appears 
to  be  the  Menstrual  Function."  The  doctor  closes  the 
article  by  drawing  a  few  deductions  from  the  case  he  re- 
lates, of  which  the  following  is  a  synopsis :  "  That  in 
many  cases  of  periodic  insanity  the  exciting  cause  may 
be  directly  traceable  to  the  menstrual  function;  and, 
when  the  attacks  are  coincident  with  the  catameniai  flow, 
and  an  apparently  normal  mental  condition  prevails  be- 
tween the  menstrual  periods,  removal  of  the  ovaries  is 
justifiable  even  though  there  be  no  pathologic  lesion." 
He  cites  a  case  of  insanity  of  eight  years1  duration,  which 
attained  to  perfect  mental  and  physical  health  after 
oophorectomy,  and  it  is  the  purpose  of  this  article  to  add 
another  case  to  the  literature  of  the  subject,  my  own 
views  being  in  perfect  harmony  with  the  sentiments 
above  elucidated.  The  following  case  is  interesting  and 
instructive  from  every  point  of  view,  and  not  only  sup- 
ports the  above  deductions,  but  in  its  result  contains 
much  food  for  reflection. 

The  case  to  be  related  is  that  of  a  young  school- girl, 
aged  sixteen,  who,  when  well,  was  inclined  to  be  very 
sociable,  lively,  and  even-tempered.  Hereditary  history 
of  a  maternal  grand-aunt  who  died  insane.  Menstrua- 
tion had  been  regular  and  normal.  She  was  admitted  to 
this  hospital  on  March  23,  1893,  with  the  following  his- 
tory: 

She  had  been  attending  school  until  the  latter  part  of 
September,  1892,  when  she  became  very  much  interested 
in  her  spiritual  welfare  and  became  converted.  Shortly 
after  joining  the  church  her  mother  noticed  that  she  was 
not  at  all  like  her  former  self.  From  a  lively,  sociable, 
bright  girl  she  became  moody,  irritable,  worried,  and  de- 
pressed. When  questioned  by  her  mother  she  admitted 
that  it  was  the  weight  of  her  sins  that  was  troubling  hen 

This  condition  of  depression  steadily  increased  until 
at  Christmas-time,  after  having  on  several  occasions 
threatened  suicide,  she  passed  into  a  semi- stuporous  state, 
eating  but  little  and  sleeping  practically  not  at  all.  She 
remained  in  this  state  of  stupor  for  three  weeks,  when  she 
suddenly  began  to  improve.  The  improvement,  however, 
was  but  temporary  and  of  short  duration.  She  again 
lapsed  into  a  state  of  depression,  but  not  so  profound  as 
in  the  preceding  attack,  and,  apparently  about  to  re- 
cover, she  passed  suddenly  into  so  violent  a  stage  of 
mania  as  to  render  restraint  imperative.  At  this  time 
she  attempted  to  kill  her  mother  and  sister,  and  suc- 
ceeded in  wrecking  much  household  furniture.  Three 
weeks  after  this  maniacal  outbreak  she  was  brought  to 
this  hospital. 

On  admission  she  was  very  quiet  and  lady-like,  talked 
in  a  rational  and  consistent  manner,  and  had  the  appear- 
ance of  being  a  thoroughly  well  girl,  both  physically  and 
mentally.  She  was,  however,  placed  under  careful  ob- 
servation, but  gave  no  evidence  of  mental  instability  un- 
til the  approach  of  the  menstrual  epoch,  the  latter  part 
of  April.  As  the  flow  commenced  she  became  pro- 
foundly depressed,  refused  to  talk  or  eat,  and  for  sev- 
eral days  was  fed  with  a  nasal  tube.  From  this  period 
of  depression  she  recovered  in  time  to  pass  into  a  period 
of  exaltation  as  the  June  menstrual  period  approached. 
She  continued  in  a  state  of  excitement  for  two  weeks,  and 
it  is  from  this  time  onward  that  the  regular  periodicity 
seems  to  have  become  established.  Every  month  there- 
after, for  a  few  days  preceding  and  following  her  men- 
strual period,  she  became  greatly  excited  and  erotic. 
Her  language  during  these  periods  was  offensively  ob- 
scene and  profane;    her  self  control  was  entirely  abol- 


236 


MEDICAL    RECORD. 


[August  25,  1894 


ishei,  and  she  exhibited  many  delusions,  chiefly  of  an 
erotic  character. 

These  periods  usually  were  of  about  ten  days'  duration, 
and,  as  the  menstrual  flow  erased  she  began  to  improve, 
and  in  a  few  days  would  be  apparently  well.  Then  she 
was  extremely  reluctant  to  discuss  her  former  condition, 
and  any  questioning  in  regard  to  it  embarrassed  her 
greatly.  She  was  perfectly  cognizant  of  all  that  hap- 
pened during  the  cycle  through  which  she  had  passed, 
and  the  fact  that  it  was  a  source  of  much  anxiety  and 
mortification  to  her,  would  indicate  that  she  looked  back 
upon  her  actions  and  speech  from  a  comparatively  sane 
stand  point.  To  her  it  was  incomprehensible,  and  she 
begged  to  be  made  well. 

In  December,  1893,  she  was  subjected  to  a  vaginal  ex- 
amination, with  negative  results.  The  ovaries  and  tubes 
were  apparently  in  a  normal  condition,  but  there  was  a 
slight  tendency  to  anteveraion  on  the  part  of  the  uterus. 
Daring  the  examination  the  absence  of  tenderness  was 
especially  noted  and  commented  upon. 

February  1,  1894,  immediately  following  cessation  of 
menstruation  and  consequent  return  to  mental  health, 
she  was  removed  to  the  Mount  Sinai  Hospital  in  New 
York  City,  and  on  February  3d  was  operated  upon  by 
Dr.  Brettauer,  who  removed  both  ovaries  and  tubes. 
With  the  exception  that  the  left  ovary  contained  a  small 
cyst,  the  appendages  were  normal.  She  made  a  rapid 
and  uninterrupted  recovery  from  the  operation,  and  at 
no  time  did  her  temperature  .rise  above  ioo°  F. 

February  19th  she  was  again  returned  to  our  care  in 
excellent  physical  and  mental  condition,  quiet,  rational, 
and  with  the  abdominal  wound  entirely  healed.  For 
one  week  after  her  return  she  remained  quiet  and  orderly, 
with  normal  pulse  and  temperature. 

February  26th,  when  she  should  have  menstruated, 
she  manifested  a  tendency  to  exaltation  with  a  decided 
erotic  impulse.  She  destroyed  a  pair  of  drawers  and 
threw  them  down  the  closet.  Her  movements  were  so 
abrupt  and  nervous  as  to  almost  simulate  chorea.  In  her 
talk  she  was  rational,  but  inclined  to  be  saucy  and  irrele- 
vant. This  period  lasted  but  three  days,  and  was  the  last 
evidence  of  mental  instability  she  ever  presented  to  us. 

At  our  request  she  was  taken  home  by  her  mother  on 
May  31st  last,  but  before  leaving  was  thoroughly  and 
carefully  examined.  The  parts  were  apparently  in  a  per- 
fectly normal  condition,  with  no  evidence  of  any  adhe- 
sions or  signs  of  hernia.  The  scar  on  abdomen  was  not 
at  all  tender  and  there  was  no  soreness  anywhere. 

At  the  present  writing,  five  months  after  operation, 
she  has  remained  perfectly  well,  mentally  and  physically, 
and  has  not  shown  the  slightest  tendency  to  a  return  of 
her  abnormal  mental  condition. 

In  this  case  the  operation  was  performed  as  a  dernier 
ressort,  and  as  embodying  the  only  hope  the  patient  had 
of  escaping,  not  only  from  her  periodical  paroxysms,  but 
from  that  condition  from  which  no  mind  returns,  and 
into  which  she  was  rapidly  drifting— dementia.  The 
operation  intervened,  a  serious  one  it  is  true,  but  the 
patient  survived,  and  is  now,  and  probably  will  continue 
to  be,  a  useful  member  of  society.  Still,  had  she  died  un- 
der the  knife  of  the  surgeon,  will  anyone  contend  that  it 
would  not  have  been  better  so,  than  that  she  should  have 
become  a  hopelessly  demented  atom  of  humanity,  and  a 
life-long  charge  upon  the  State  or  her  friends? 

This  case  differs  from  others  which  have  been  reported, 
in  that  the  period  of  excitement  seemed  to  come  on  as  a 
result  of  the  preparatory  evolution  incident  to  and  pre- 
ceding the  menstrual  Mow.  Whether  this  is  due  to  the 
congestion  which  is  claimed  by  competent  authorities  to 
always  precede  this  function,  is  a  point  to  be  determined, 
but  to  my  mind  it  is  conclusive.  It  is  also  worthy  of  note 
that  three  days  after  the  flow  had  become  established 
there  was  an  appreciable  lessening  of  cerebral  and  motor 
excitement.  This  in  itself  would  tend  to  confirm  the 
opinion  that  congestion  of  the  parts,  concomitant  pressure 
on  nerve-supply,  and  consequent  reflex  irritation  as  a  result 
of  increased  blood-pressure,  is  at  least  a  factor  in  causation. 


We  cannot  fail  to  be  impressed  by  the  many  and 
varied  psychic  disturbances  which  occur  in  sane  women 
at  the  menstrual  period,  not  alone  in  the  delicate  and 
sickly,  but  in  the  more  robust  When  we  take  into  con- 
sideration the  intimate  relation  of  the  brain  with  every 
other  organ  in  the  body  by  reason  of  its  direct  and  re- 
flex connections,  it  can  readily  be  appreciated  how  much 
greater  must  be  the  strain  in  those  who  are  afflicted  with 
a  neurotic  diathesis.  It  is,  therefore,  not  a  matter  of 
theory,  but  a  matter  of  fact,  that  the  menstrual  function 
exerts  a  most  potent  influence  upon  the  nervous  system 
of  woman.  Why  in  some  it  should  be  so  much  more 
severe  than  in  others,  and  become  in  itself  an  element 
of  shock  or  stress  so  great  as  to  dethrone  reason,  can 
only  be  conjectured.  No  two  organizations  are  precisely 
similar,  and  so  many  other  elements,  such  as  physical 
health,  environments,  heredity,  etc.,  must  be  taken  into 
consideration,  that  in  many  cases  of  insanity  where 
menstruation  is  normally  performed,  it  is  well  nigh 
impossible  to  say  with  any  degree  of  certainty  that 
this  function  is  the  cause,  pure  and  simple,  of  the 
insanity. 

Admitting,  however,  that  in  the  cases  under  considera- 
tion the  menstrual  function  is  simply  the  exciting  cause, 
where  this  function  exerts  so  profound  an  impression 
upon  the  nervous  protoplasm  as  to  induce  insanity; 
where,  instead  of  acting  as  a  "safety-valve"  it  becomes 
the  cause  of  mental  explosion ;  then  it  is,  in  my  opinion, 
the  imperative  duty  of  the  physician  to  advise  the  artifi- 
cial production  of  the  menopause.  Especially  will  this 
obtain  in  those  cases  in  which  the  cause  may  be  directly 
traced  to  disorders  of  menstruation,  and  in  which  there 
is  an  hereditary  taint. 

And  in  this  connection  let  me  quote  a  few  lines  from 
Bsvan-Lewis.  He  says,  "  Given  an  organism  predisposed 
by  inheritance  to  insanity,  such  predisposition  will  tell 
with  special  force  at  periods  of  reproduction  and  develop- 
ment." 

I  am  not  one  of  those  who  hold  the  sexual  organs  of 
woman  responsible  for  the  majority  of  her  ills,  and  I 
deprecate  as  much  as  anyone  the  abuse  of  abdominal 
section.  I  maintain,  however)  that  death  is  preferable 
to  chronic  insanity,  and  in  view  of  the  remarkable  and 
brilliant  successes  achieved  by  the  surgeon  along  this 
line,  I  am  convinced  that  we  have  a  field  which  has  been 
but  little  explored,  and  one  which  offers  bright  induce- 
ments as  regards  the  cure  of  insanity  by  the  removal  of 
the  cause ;  and  I  need  only  add  that  the  consensus  of 
opinion  of  many  well-known  writers  confirms  the  state- 
ment that  the  menstrual  function  is  the  cause  of  insanity 
in  a  large  number  of  cases.  Pozzi  says  "the  sexual  ap- 
paratus is  not,  so  to  speak,  an  accessory  wheel  in  the 
female  mechanism;  it  is,  on  the  contrary,  the  chief 
wheel,  and  it  is  to  secure  its  proper  action  that  constant 
economies  and  reserves  are  made  by  nature." 

Dr.  George  H.  Rohe,  in  an  article  considering  the 
legal  aspect  of  this  subject,  published  in  the  Medical  and 
Surgical  Reporter  of  July  15,  1893,  reports  the  result  of 
twenty-two  oophorectomies  embracing  different  forms  of 
insanity.  There  were  twenty  physical  recoveries  and 
two  deaths.  Of  this  number  four  made  an  absolute,  and 
three  a  partial,  mental  recovery.  In  seven  there  was  de- 
cided mental  improvement. 

I  am  confident  that  I  have  seen  several  cases  become 
hopelessly  demented,  or  so  deteriorated  mentally  as  to 
be  beyond  medical  or  surgical  aid,  which,  had  ovariotomy 
been  performed,  would  have  recovered  their  reason. 
There  are  cases  under  observation  to-day  which  I  am 
positive  would  be  greatly  benefited,  if  not  permanently 
restored  mentally,  by  such  an  operation. 

Under  these  circumstances  it  seems  to  me  that  it  ceases 
to  be  a  question  of  whether  or  not  odphorectomy  is  justi- 
fiable. 

I  maintain  that  it  should  be  done  in  all  those  cases  in 
which  the  menstrual  epoch  acts  as  the  exciting  cause  of 
insanity,  and  the  earlier  the  operation  is  performed  the 
better  for  the  patient  and  for  posterity. 


August  25,  1894] 


MEDICAL    RECORD. 


237 


TREPHINING  THE   FRONTAL  BONE   FOR 
CHRONIC   HEADACHE.1 

By  J.  MARSHALL  HAWKES,  M.D., 

NKW  YORK. 

Gentlemen  : — The  case  which  I  am  about  to  present  to 
you,  I  am  sure  will  prove  interesting ;  for  while  the  affection 
is  rare,  when  we  do  find  it  its  incurability  is  exasperat- 
ing. Moreover,  it  is  in  a  comparatively  new  field  of  sur- 
gery, and,  still  more  important,  the  treatment  in  this  and 
two  other  reported  cases  has  been  entirely  successful. 

On  June  31,  1891,  Mr.  M ,  aged  twenty-eight, 

applied  to  the  writer  for  relief  from  headache  of  twenty 
years'  duration. 

The  history  of  the  case  is  as  follows :  When  eight  years 
old,  while  playing  in  a  yard  in  the  downtown  tenement- 
house  district,  he  fell  on  a  curbstone  and  received  a  cut 
in  the  upper  right  quadrant  of  the  forehead,  about  an  inch 
above  the  supra-orbital  ridge  and  parallel  with  it.  His 
mother  took  him  to  the  nearest  druggist  and  had  the  cut 
dressed  with  adhesive  plaster,  after  the  manner  of  the 
time.  The  cut  suppurated  and  healed  slowly.  He  soon 
began  to  suffer  from  headaches  in  the  upper  right  frontal 
region.  They  increased  in  severity  during  his  youth  and 
young  manhood,  until  they  became  quite  unbearable. 
Indeed,  he  was  unfitted  for  work  at  least  one  day  in  the 
week,  and  frequently  for  two  days.  These  headaches 
were  practically  continuous.  If  he  awoke  in  the  night  he 
felt  the  pain,  and  it  was  subject  to  frequent  exacerba- 
tions, accompanied  by  "  attacks/'  as  he  termed  them. 
These  attacks  consisted  of  a  severe  paroxysm  of  pain, 
accompanied  by  dizziness,  making  him  feel  very  weak, 
so  that  he  would  usually,  though  not  always,  fall  wherever 
he  happened  to  be. 

At  no  time  during  these  attacks  did  he  have  a  convulsion 
or  even  a  slight  convulsive  twitching.  He  was  never  un- 
conscious, always  knowing  everyone  about  him.  He 
never  vomited,  nor  bit  his  tongue  or  cheek;  he  never 
hurt  himself  when  he  fell,  nor  did  he  ever  fall  in  a  dan- 
gerous place,  though  he  frequently  remarked  to  his 
friends  that  it  was  strange  that  he  did  not.  He  always 
had  a  premonition  of  an  attack.  No  exciting  causes  were 
apparent,  though  he  declares  if  the  wind  blew  hard  in 
his  face  the  headache  would  become  worse.  He  had 
them  when  a  boy  in  school  and  after  he  began  to  work. 
Again  and  again  he  had  to  be  led  home  by  his  fellow- 
workmen  or  sent  home  in  a  carriage.  He  had  no  more 
"  attacks  "  when  he  was  working  than  when  he  was  not. 
He  had  never  had  any  illness,  not  even  measles. 

The  treatment  of  various  physicians  and  attendance  at 
two  of  the  city  hospitals  for  varying  lengths  of  time,  had 
not  produced  any  amelioration  of  his  condition,  and,  at 
the  time  he  came  to  me,  his  condition  so  preyed  upon 
his  mind  that  he  feared  he  would  become  insane. 

On  examining  his  head  in  the  region  above  indicated,  a 
small  indentation,  scarcely  an  eighth  of  an  inch  in  length 
and  of  only  slight  depth,  was  found,  and  it  was  only 
after  questioning  the  patient  at  great  length  that  he  re- 
membered exactly  when  he  received  the  injury  as  above 
elicited,  though  he  was  positive  of  his  age  (eight)  at 
which  the  headaches  began. 

Since  the  accident  had  happened  so  long  a  time  before, 
and  because  the  writer  could  learn  so  little  of  his  pre- 
vious history,  it  was  deemed  only  prudent  to  eliminate  the 
various  other  causes  of  headache,  such  as  eye-strain, 
stomachic  derangement,  disease  of  the  kidney,  etc.  He 
was  therefore  sent  to  Dr.  Knapp,  who  examined  his  eyes 
and  found  them  both  normal.  He  was  dieted  most 
rigorously  on  milk  and  the  whites  of  eggs  for  some  time, 
without  any  relief. 

As  no  trouble  could  be  found  and  all  medical  treat- 
ment was  unavailing,  the  impression  became  more  and 
more  fixed  that  the  inner  table  of  the  frontal  bone  had 
been  fractured,  and  that  the  resulting  exostosis,  or  possi- 
bly a  pacchionian  granulation  pressing  on  the  brain,  was 

1  Read  at  the  June,  1894,  meeting  of  the  New  York  County  Medical 
Association. 


the  probable  cause,  and  that  trephining  might  give  him 
relief;  certainly  nothing  else  would.  He  readily  con- 
sented, and  on  July  30,  1891,  a  semicircular  incision  was4 
made  surrounding  the  scar  tissue  marking  the  seat  of  the 
accident.  When  the  scalp  was  turned  back  there  was 
seen  to  be  a  slight  depression  in  the  skull  not  over  half  an 
inch  in  length.  Following  the  surgical  indication,  the 
trephine  point  was  placed  in  the  centre  of  this  depression 
and  a  disk  of  bone,  three  quarters  of.an  inch  in  diameter, 
was  removed.  On  examination,  this  disk  was  found 
slightly  thickened  at  its  upper  margin,  where  normally  it 
should  have  been  slightly  thinner.  There  was,  however, 
no  well-defined  mark  of  fracture.  As  the  dura  mater  ap- 
peared perfectly  normal,  there  was  no  call  for  further 
search.  The  trephine  hole  was  carefully  burnished, 
every  rough  particle  being  removed,  so  as  to  leave  no 
possible  chance  for  irritation.  The  scalp  wound  was 
then  carefully  sutured  with  black,  iron- dyed  silk;  no 
drainage  was  deemed  necessary. 

In  five  days  the  stitches  in  the  integument,  thirty- 
seven  in  number,  were  removed.  At  the  first  dressing, 
on  removing  the  bandage,  release  of  the  pressure  caused 
the  patient  to  have  a  slight  epileptiform  seizure;  the 
twitching  of  the  body  was  general.  Conjecturing  that 
the  sudden  removal  of  pressure  was  the  probable  cause  of 
the  trouble,  gentle  pressure  was  made  upon  the  area  rep- 
resenting the  uncovered  portion  of  the  brain,  and  at 
once  the  spasm  ceased.  The  wound  united  promptly  and 
in  seven  days  the  patient  was  on  the  street. 

From  the  moment  of  etherization  until  now,  the  patient 
has  had  no  headache.  He  expresses  himself  as  very  much 
delighted  with  the  result.  He  goes  so  far  as  to  say  that 
he  is  "  beginning  life  anew." 

The  hole  in  the  skull  has  nearly  filled  with  a  fairly 
dense  fibrous  tissue,  through  the  centre  of  which,  how- 
ever, the  pulsation  of  the  brain  can  still  be  seen  and  felt. 

On  looking  over  the  literature  of  the  subject,  I  find 
only  two  similar  cases  reported ;  one  by  Mr.  Horseley,  of 
London,  and  the  other  by  Dr.  Robert  F.  Weir  of  this 
city.  Reference  is  made  to  both  these  cases  in  Dr.  M. 
Allen  Starr's  "  Brain  Surgery,"  page  272.  In  these  two 
cases  there  is  a  history  of  a  blow,  but  there  was  no  sign 
of  fracture  in  either  of  them. 

As  to  the  indications  for  trephining  for  chronic  head- 
ache, Mr.  Horseley  thinks  (and  it  appears  to  be  the 
general  consensus  of  opinion)  that  "  it  is  justifiable  to 
trephine  in  every  case  where  the  pain  is  persistent,  local- 
ized, and  has  resisted  all  medical  treatment,  whether 
there  be  any  fracture  or  not." 

Occasionally,  after  blows  on  the  head  without  fracture, 
there  will  develop  pacchionian  granulations,  which  in 
themselves  may  cause  the  persistent  headache. 

In  virtue  of  the  extremely  low  mortality  from  a  care- 
fully performed  trephining,  there  seems  to  me  to  be  no 
contra  indication  to  the  operation  as  a  last  resort  in  cases 
of  the  above  character. 

1343  Lexington  Avshuv. 


Dr.  Eduard  Sperk  died  a  short  time  ago  in  St. 
Petersburg.  He  was  one  of  the  leading  physicians  of 
Russia  at  the  time  of  his  death.  The  first  twelve  years 
of  his  professional  life  were  passed  in  Eastern  Siberia, 
where  he  was  government  physician  and  afterward  medi- 
cal inspector.  In  1870  he  was  recalled  to  the  capital  to 
take  charge  as  physician-in-  chief  of  the  Kalinkin  Hospi- 
tal. He  devoted  much  time  to  the  study  of  prostitution, 
and  had  written  much  on  the  subject. 

Spring  Knee. — Dr.  Delorme  describes,  in  the  Gazette 
des  Hdpitaux,  No.  42,  1894,  a  condition  in  the  knee  sim- 
ilar in  its  general  features  to  the  well-known  spring  fin- 
ger. Just  before  full  extension  of  the  joint  is  reached 
there  is  a  slight  hitch,  and  then  the  limb  straightens  it- 
self with  a  sharp,  rather  painful  jerk.  Locomotion  is  in 
consequence  rendered  uncertain  and  painful.  In  the 
case  observed  by  the  author  upon  which  his  description 
was  based,  the  interference  with  free  extension  occurred 
only  when  the  patient  was  on  his  feet. 


238 


MEDICAL  RECORD. 


[August  25,  1894 


The  Coexistence  of  Infectious  Diseases.— Dr.  Caiger, 
at  a  recent  meeting  of  the  Epidemiological  Society,  pre- 
sented a  study  on  the  coexistence  or  close  succession  of 
two  or  more  infectious  diseases  in  the  same  individual. 
His  experience  at  Stockwell,  he  said,  had  satisfied  him 
that  such  concurrence  of  infections  was  as  frequent  as 
mere  probabilities  would  explain,  and  that,  so  far  from 
affording  protection  against  other  diseases,  some  certainly 
increased  the  susceptibility  thereto.  (  The  American  Jour- 
nal of  the  Medical  Sciences. )  In  the  last  four  years  he  had 
seen  362  cases  of  two  and  17  of  three  diseases  running 
some  parts  of  their  courses  concurrently ;  in  .200  of  these 
the  acute  febrile  stages  of  two  or  three  coincided.  The 
priority  of  the  several  diseases  was  calculated  from  their 
known  incubation  periods.  The  primary  disease  was 
scarlatina  in  197,  which  was  complicated  by  diphtheria 
in  97  cases,  varicella  in  43,  measles  in  31,  whooping- 
cough  in  13,  erysipelas  in  10,  enteric  fever  in  2,  and 
typhus  in  1.  Scarlatina  was  a  complication  in  no  fewer 
than  88  among  97  in  which  the  primary  disease  was 
diphtheria;  in  20  among  23  of  varicella;  in  14  of  17  of 
whooping  cough;  in  6  of  9  of  enteric,  and  9  of  18  of 
measles,  though  here  diphtheria  accounted  for  another  7. 
Among  the  17  triple  attacks  scarlatina  was  the  primary 
disease  in  9,  and  a  complication  in  4  only,  diphtheria 
holding  the  highest  place  with  9.  During  the  past  six 
years,  48,367  cases  of  scarlatina  had  been  admitted  into 
the  hospitals  of  the  Asylums  Board ;  of  these  3,166,  or 
6.54  per  cent.,  were  complicated,  1,094  with'diphtheria, 
899  with  varicella,  703  with  measles,  and  404  with 
whooping-cough ;  the  relative  numbers  of  diphtheria  and 
whooping-cough  being  probably  owing  to  the  fact  that 
many  had  already  had  whooping-cough  in  infancy,  while 
diphtheria,  though  less  frequent,  might  and  often  did  re- 
cur; these  four  diseases  accounted  for  3,100,  or  all  but 
66.  The  questions  suggested  by  these  figures  were:  1, 
Did  any  disease  render  the  individual  less  or  more  sus- 
ceptible to  infection  by  another?  2,  Did  the  primary 
disease  in  any  way  influence  the  course  or  character  of 
the  secondary  one  as  regards  (a)  incubation,  eruption, 
etc.,  periods;  (6)  severity  of  the  disease;  (c)  distribu- 
tion of  local  phenomena ;  (d)  liability  to  sequelae  and 
other  complications  ?  The  conclusions  at  which  he  ar- 
rived, after  eliminating  the  influence  of  age  incidence, 
seasonal  prevalence,  actual  frequency,  etc.,  were  first, 
that  there  was  no  such  thing  as  antagonism  between  any, 
but  rather  the  reverse,  increased  susceptibility  being 
brought  about,  generally  or  locally ;  that  is,  first,  by  the 
lessened  power  of  resistance  induced  by  a  disease  at- 
tended with  grave  constitutional  disturbance;  and, 
secondly,  by  the  local  inflammations  facilitating  the  de- 
velopment of  the  contagia  of  diseases  known  to  affect 
the  mucous  membranes  or  tissues  in  question.  Thus,  an 
attack  of  varicella  exerted  no  influence  on  any  that 
might  follow,  but  when  scarlet  fever  was  the  primary  dis- 
ease, varicella,  favored  also  by  the  quasi- dermatitis  left 
behind,  might  rival  unmitigated  smallpox  in  intensity  of 
fever  and  extent  of  eruption.  Scarlatina  was  frequent 
and  dangerous  after  diphtheria,  but  diphtheria  following 
scarlatina  was  still  graver,  since  the  scarlatinal  throat, 
teeming  with  staphylococci  and  streptococci,  was  a  perfect 
soil  for  the  bacillus  of  Loeffler.  So,  too,  while  the  gen- 
eral phenomena  of  measles  might  be  aggravated  by  pre- 
vious diphtheria  or  scarlatina,  and  in  the  latter  conjunc- 
tion the  rash  would  be  intensified,  an  attack  of  diphtheria 
following  on  measles  was  even  graver  than  the  post- 
scarlatinal, since  it  inevitably  attacked  the  larynx  and 
trachea,  and  tracheotomy  was  very  rarely  of  any  avail. 
Measles  and  whooping-cough  were  known  to  follow  one 
another,  or  to  coexist,  mutually  increasing  the  suscepti- 
bility of  the  individual.  The  author  had  never  found 
the  incubation  period  of  a  disease  affected,  but  the  pres- 
ence of  scarlatina  accelerated  the  appearance  of  the  rash 
in  measles  by  a  couple  of  days. 


Cystitis  in  Patients  who  Have  never  Had  an  In- 
strument Passed. — Since  it  has  been  recognized  that  all 
cases  of  cystitis  are  the  result  of  infection,  the  catheter 
has  been  regarded  as  the  only  method  by  which  the  in- 
fection of  the  bladder  takes  place.  While  this  method 
ranks  first  in  importance,  it  is  important  to  bear  in  mind 
that,  apart  from  tuberculosis,  cystitis  may  and  does  occur 
in  individuals  who  have  never  been  catheterized,  and  who 
have  never  had  either  a  urethritis  or  infective  disease  of 
the  kidney.  According  to  Dr.  Reymond,  one  not  un- 
commonly meets  with  cases,  usually  advanced  in  life,  the 
subjects  of  enlargement  of  the  prostate,  who  have  never 
been  catheterized,  and  who  have  never  had  symptoms 
pointing  to  infective  disease  of  the  kidney ;  in  whom, 
however,  there  are  symptoms  of  cystitis,  and  the  urine 
contains  pus  and  micro  organisms.  Where  does  the  in- 
fection come  from  ?  Whence  are  the  organisms  derived  ? 
Bacteriological  examination  of  the  urine  in  seventeen 
cases  showed  that  the  bacterium  coli  commune  was  pres- 
ent in  seven,  and  that  other  microbes  were  present  in 
ten.  The  latter  were  such  as  are  normally  met  with  in 
the  urethra,  and  it  is  assumed  that  they  reached  the  blad- 
der by  a  simple  extension  backward,  the  conditions 
which  enabled  them  to  lodge  and  give  rise  to  cystitis 
being  the  residual  urine  in  cases  of  prostatic  enlargement. 
Those  in  which  the  bacterium  coli  commune  was  found 
were  more  acute  in  their  clinical  features.  Of  the  three 
possible  routes  by  which  they  entered  the  bladder,  the 
urethra  and  ureter  were  regarded  as  unlikely.  The  au- 
thor believed  that  they  might  have  passed  from  the  rec- 
tum and  through  the  prostate. — Annates  des  Maladies 
des  Organes  Genito-  Urinaires. 

The  Dangers  of  the  Long  Rectal  Tube. — The  use 
of  the  long  rectal  tube  in  obstruction  of  the  bowel  has 
never  been  looked  upon  with  favor  by  anatomists. 
Nothing  is  more  difficult  than  the  successful  manoeu- 
vring of  the  rectal  tube  through  the  turns  of  the  sigmoid 
flexure.  Hie  question  of  the  value  and  safety  of  this 
tube  having  been  asked  of  the  British  Medical  Journal, 
the  matter  was  referred  to  Mr.  Harrison  Cripps,  who  re- 
plied as  follows :  Traditions  die  hard,  and  notwithstand- 
ing the  condemnation  of  the  long  rectal  tube  by  Brodie, 
Treves,  and  many  other  eminent  authorities,  I  still  find 
that  in  most  cases  of  obstruction  or  supposed  obstruction 
the  tube  has  been  introduced.  Fortunately  these  tubes 
are  fairly  soft,  so  that  in  a  capacious  rectum,  when  they 
impinge  and  are  arrested  about  opposite  the  promontory 
of  the  sacrum,  they  simply  coil  up  and  do  no  harm.  If 
stiffer  ones  are  used  the  patient's  life  is  placed  in  immi- 
nent risk.  A  patient  at  St.  Bartholomew's  Hospital  was 
to  be  operated  on  for  ruptured  perineum.  In  order  to 
increase  the  supposed  efficacy  of  the  injection,  a  quart  of 
soap  and  water,  with  some  ounces  of  oil,  were  injected 
by  means  of  a  long  tube.  The  injection  never  returned. 
A  few  hours  afterward,  owing  to  the  acute  symptoms  of 
the  patient,  I  assisted  one  of  my  colleagues  in  opening 
the  abdomen.  The  soap  and  water  and  oil  we  found  in 
the  abdominal  cavity,  and  a  hole  below  a  reduplicated 
fold  in  the  upper  part  of  the  rectum.  The  patient  died. 
The  idea  that  these  tubes  can  be  generally  passed  into 
and  beyond  the  sigmoid  flexure  is  a  pure  delusion,  save 
in  the  rarest  circumstances.  As  a  means  of  diagnosis,  or 
of  treating  stricture  beyond  the  reach  of  the  finger,  tubes 
of  any  kind  are  absolutely  useless.  If  a  stricture  is 
actually  present  it  would  be  100  to  1  against  the  long 
tube  or  bougie  entering  it,  for  it  would  almost  certainly 
catch  in  the  cul-de-sac  generally  caused  by  the  invagi- 
nation of  the  stricture.  If  a  stricture  be  not  present, 
the  arrest  of  the  bougie  by  the  sacral  promontory  leads 
to  delusive  diagnosis.  Brodie,  in  his  lectures,  alludes  to 
a  case  in  which  a  worthy  practitioner  had  spent  over  150 
hours  in  dilating  a  supposed  stricture  situated  high  up. 
The  treatment  had  extended  over  a  period  of  a  year. 
Brodie,  who  was  present  at  the  post- mortem  examination, 
found  there  was  no  sign  of  a  stricture,  the  bougie  be- 
coming arrested  by  a  curve  of  the  sacrum. 


August  25,  1894] 


MEDICAL    RECORD. 


239 


Medical   Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


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


New  York,  August  25,  1894. 


A  PLEA  FOR  PUBLIC  ANiESTHETIZERS. 

To  an  observant  spectator  of  operations  in  our  hospitals 
ft  is  a  matter  for  surprise  and  wonder  that  fatal  accidents 
so  rarely  result  during  the  administration  of  anaesthetics.. 
No  stronger  argument  could  be  furnished  to  the  advocates 
of  the  use  of  ether  in  preference  to  that  of  chloroform 
than  the  fact  that  the  former  is  recklessly  administered  in 
hundreds  of  instances  by  inexperienced  anaesthetizers, 
yet  without  any  immediate  ill  consequences.  We  use  the 
word  "  immediate  "  advisedly,  because  we  are  convinced 
that  not  a  few  of  the  fatal  cases  of  acute  pulmonary  and 
renal  troubles  which  have  followed  ether  -  anaesthesia 
might  have  been  avoided,  not  by  substituting  chloroform, 
but  by  administering  ether  in  a  proper  manner,  instead 
of  saturating  the  patient  with  it.  Strange  as  it  would 
appear  to  an  intelligent  layman,  hospital  surgeons  con- 
tinue to  delegate  this  important  duty  to  junior  assistants, 
dressers,  and  medical  students,  even  in  the  most  serious 
operations,  in  which  the  constant  and  skilful  surveillance 
of  the  patient  is  a  matter  of  vital  consequence.  Occa- 
sionally a  serious  lesson  is  given,  but  it  is  rarely  heeded, 
until  a  sudden  death  on  the  table  leads  to  a  temporary 
reform. 

We  are  not  exaggerating  when  we  affirm  that  the  aver- 
age junior  interne  does  not  take  the  trouble  to  make  a 
scientific  study  of  the  variations  in  the  pulse  and  respira- 
tion ratio,  the  changes  in  the  pupils  and  muscular  reflexes, 
etc.,  in  a  perfectly  healthy  subject,  while  the  danger  sig- 
nals in  the  case  of  weak  patients  are  often  unheeded,  or 
are  not  recognized  until  the  close  of  a  long  operation, 
when  the  patient  is  in  actual  collapse.  Then  there  is  a 
hasty  resort  to  powerful  hypodermatic  stimulation, 
strychnine,  digitaline,  or  strophanthine,  being  repeated  at 
dangerously  short  intervals,  which  would  have  been  un- 
necessary if  a  hot  saline  enema  containing  whiskey  had 
been  given  before  or  during  the  operation. 

The  entire  responsibility  of  watching  the  pulse  de- 
volves upon  a  young  fellow,  fresh  from  the  medical 
school,  whose  knowledge  is  almost  entirely  theoretical, 
however  great  may  be  his  natural  aptitude  and  powers  of 
observation.  The  rest  of  the  house- staff  are  expected  to 
devote  their  attention  entirely  to  the  operation,  and  it 
must  be  admitted  that  the  junior's  mind  is  too  often  ab- 
sorbed in  its  details. 

The  proper  administration  of  ether  is  really  an  art 
which  few  men  seem  to  acquire  to  perfection.  Witness 
the  annoyance  so  often  experienced  by  surgeons  in  pri- 
vate operations,  when,  from  courtesy  or  necessity,  the 


administration  of  the  anaesthetic  is  entrusted  to  the  fam- 
ily physician,  who,  with  the  best  of  intentions,  either 
pushes  the  anaesthetic  to  the  limit  of  asphyxiation,  or 
allows  the  patient  to  struggle  and  vomit. 

We  are  far  from  asserting  that  the  young  gentlemen, 
who  by  their  zeal  and  fidelity  add  so  much  to  the  pleas- 
ure and  profit  of  our  hospital  services,  do  not  in  many 
instances  become  expert  anaesthetizers,  but  this  requires 
time,  so  that,  as  a  rule,  they  have  only  become  really 
proficient  when  they  are  replaced  by  green  men.  If 
this  criticism  applies  to  the  giving  of  ether,  how  much 
more  forcibly  does  it  apply  to  the  administration  of  chlo- 
roform! Doubtless  this  valuable  anaesthetic  would  be 
employed  much  more  frequently  in  New  York  than  it  is 
at  present  if  surgeons  had  sufficient  confidence  in  the 
skill  and  experience  of  the  anaesthetizer.  In  our  own 
experience  we  have  substituted  ether  in  cases  in  which 
chloroform  was  clearly  indicated,  simply  because  we  did 
not  feel  justified  in  entrusting  the  more  dangerous  anaes- 
thetic to  one  who  was  entirely  ignorant  of  its  physiolog- 
ical action.  Personally  we  would  almost  prefer  to  run 
the  risks  of  employing  ether  in  a  case  of  suspected  renal 
or  pulmonary  trouble,  than  to  incur  the  equal  risks  of 
having  the  patient  killed  by  chloroform. 

Now  this  state  of  things  ought  not  to  be  allowed  to 
continue.  We  believe  that  the  time  will  come  when 
every  large  hospital  will  have  a  regular  salaried  anaes- 
thetizer, who  will  always  be  available,  and  who  will  en- 
joy the  same  confidence  in  his  department  as  the  pathol- 
ogist does  in  his  own.  Operations  will  certainly  proceed 
more  smoothly  and  safely ;  we  shall  hear  of  fewer  deaths 
from  "  heart  failure ;  "  and  cases  of  "  ether  pneumonia/' 
and  of  "acute  uraemia  from  ether,"  will  be  almost  un- 
known. The  advantages  to  the  operator  will  be  im- 
mense. Instead  of  having  his  mind  distracted  by  the 
struggles  of  a  half-anaesthetized  patient,  or  being  obliged 
to  stop  his  work  until  she  is  revived  from  a  condition  of 
asphyxia,  he  will  be  able  to  give  his  entire  attention  to 
the  operation,  relying  on  the  anaesthetizer  to  note  the 
danger  signals,  to  administer  stimulants  when  they  are 
needed,  and  to  keep  him  informed  as  to  when  he  must 
hasten,  or  when  he  can  proceed  deliberately. 

If  the  expense  involved  in  the  employment  of  a  special 
anaesthetizer  is  an  objection  (and  we  admit  that  manag- 
ing-boards are  apt  to  prick  up  their  ears  at  the  mention 
of  any  extra  outlay  in  the  medical  department),  we  sug- 
gest that  a  subscription-list  might  be  started  among  the 
members  of  the  medical  board,  all  of  whom  will  doubt- 
less have,  at  some  time,  suffered  from  the  results  of  the 
mal-administration  of  anaesthetics. 

In  closing  we  cannot  refrain  from  alluding  to  a  dan- 
gerous practice  which  we  have  noticed  in  some  hospitals, 
that  of  allowing  a  nurse  to  hold  the  ether-cone  while 
another  patient  is  being  anaesthetized.  This  is  a  dan- 
gerous custom  (to  which  we  plead  guilty),  and  in  the 
event  of  medico-legal  investigations  would  be  extremely 
difficult  to  justify  in  a  court  of  law.  As  a  fact,  consid- 
erable stress  was  placed  upon  this  point  in  the  case  of 
Dr.  Mary  Dixon-Jones  vs.  the  Brooklyn  Eagle. 

Habitual  good  luck  engenders  carelessness ;  but  there 
is  no  more  striking  example  of  the  inconsistency  of  hu- 
man nature  than  the  fact  that,  while  modern  surgery  de- 
mands the  most  scrupulous  attention  to  details  with  re- 
gard to  the  preparation  of  the  patient  and  the  technique 


240 


MEDICAL    RECORD. 


[August  25,  1894 


of  the  operation,  there  has  been  no  corresponding  im- 
provement in  this  country  in  respect  to  the  administra- 
tion of  anaesthetics. 


THE  CURES  OF  MUCOUS   ENTERITIS. 

M.  Germain  S&e  has  so  many  cures  for  muco-mem- 
branous  enteritis,  that  it  seems  impossible  any  one  suffer- 
ing from  this  usually  intractable  disease  should  fail  to  get 
well.  First  of  all,  M.  Sde  gives  purgatives,  and  his  pur- 
gatives comprise  flaxseed,  senna  and  hydrastis,  castor- 
oil,  and  olive-oil.  As  to  flaxseed,  he  tells  us  that  the 
patient,  immediately  after  each  one  of  the  three  principal 
meals,  should  take  a  tablespoonful  of  pure  flaxseed, 
placed  for  three  or  four  minutes  in  a  quarter  of  a  glassful 
of  cold  water.  If  the  flaxseed  is  objectionable  to  the 
patient,  it  can  be  substituted  with  psyllium.  These 
substances  are  sufficient  in  themselves,  in  the  majority 
of  cases,  to  produce  movements  of  the  bowels,  without 
having  to  resort  to  the  administration  of  the  various 
mineral  waters,  some  of  which,  owing  to  the  sulphate  of 
sodium  present  in  them,  often  give  rise  to  constipation 
afterward. 

Senna  and  hydrastis  are  given  according  to  the  follow- 
ing formula : 

9.     Alcoholic  extract  of  hydrastis  canadensis gr.  xxx.-xxxiv. 

Senna  leaves  bathed  in  alcohol 3  jss. 

M.  and  make  50  pills.     Sig.  :  1  pill  after  each  meal. 

Every  now  and  then  other  things  are  suspended  and  a 
dose  of  castor-oil  is  administered. 

Olive-oil  is  given  either  by  itself  or  in  sugared  tea,  in 
doses  of  from  three  to  four  dessertspoonfuls  the  first  day, 
morning  and  evening ;  the  second  day  at  noon,  the  same 
dose  before  the  second  meal ;  the  third  day,  a  glass  at 
the  same  hours ;  and  the  fourth  day,  a  whole  glass  at 
once.  After  this  the  patient  must  rest  for  four  or  five 
days — that  is,  the  medication  should  be  suspended,  to  be 
again  renewed  as  prescribed.  If  the  first  trial  shows  a 
non  tolerance  of  the  drug  on  the  part  of  the  patient,  the 
method  must  be  abandoned.  Generally,  however,  the 
oil  is  well  borne,  more  so  than  may  be  supposed,  and 
"in  these  cases  the  rauco- fecal  movements  produce  an 
unexpected  relief  and  sometimes  a  cure,  at  least  for  a 
considerable  time." 

Next,  M.  S6e  gives  sedatives,  and  usually  in  the  form 
of  bromides.  But  the  bromides  of  calcium  or  strontium 
must  be  given,  and  not  those  of  potassium  or  sodium, 
since  the  latter,  he  says,  irritate  the  stomach.  In  our  ex- 
perience the  others  do  so  to  just  about  the  same  degree. 

S6e's  formula  is : 

$ .     Bromide  of  calcium, 

Chloride  of  calcium aa   J  ij. 

Distilled  water Oj. 

In  default  of  the  bromides,  he  prescribes  cannabis  in- 
dica,  as  follows : 

Q  •     Solution  of  gum  arabic J  iv. 

Extract  of  cannabis  indica gr-*j- 

M.     Sig.  :  Three  tablespoonfuls  per  day,  one  before  each  meal. 

If  great  pain  is  present,  one  of  the  best  modes  of  pro- 
ducing relief  is  the  administration  of  menthol  in  the  fol- 
lowing manner : 

IJ .     Menthol gr.  ij.-iij. 

Distilled  water Oss. 

Alcohol q.  s.  to  dissolve  the  menthol. 

M.     Sig.  :  Two  tablespoonfuls  by  the  mouth  t.  i.  d. 


To  diminish  fermentation  M.  S6e  knows  of  three  effi- 
cacious means  only  by  which  to  meet  this  indication, 
and  he  is  in  the  habit  of  combining  them.  The  first  is 
the  administration  of  the  phosphate  of  sodium,  which 
he  places  above  any  other  antiputrefactive  or  absorbent 
substance.  With  from  forty*  five  to  sixty  grains  of  phos- 
phate of  sodium  a  day  he  obtained  "remarkable  results.11 
The  amount  of  the  drug  is  divided  into  three  parts,  each 
one  of  which  is  ordered  to  be  taken  in  a  little  water, 
after  meals. 

For  flatulence,  the  best  remedies  are  salicylic  acid  in 
doses  of  three  grains,  and  salicylate  of  sodium  associated 
with  six  grains  of  the  phosphate  of  sodium.  These  drags 
will  at  the  same  time  diminish  the  sensibility  of  the  mu- 
cous membrane.  Borate  of  sodium  or  borax  is  an  ex- 
cellent substitute  for  the  agents  mentioned,  and  it  par- 
ticularly aids  the  digestion  of  milk. 

Yet,  M.  S^e's  salicylic  acid  surely  is  irritating  to  the 
stomach,  and  despite  all  the  remedies  mentioned  most 
cases  of  the  disease,  according  to  text  books,  do  not  get 
well.  However,  we  present  the  views  of  a  hopeful  thera- 
peutist, and  trust  they  may  prove  useful  to  our  readers. 


NAVAL  HOSPITALS. 

So  much  interest  surrounds  the  Government  hospital 
care  of  the  sailors  when  laid  off  from  disease,  but  more 
particularly  when  disabled  from  injuries  received  in 
action,  that  we  pick  up  with  feelings  of  obligation  to  the 
author  a  brochure  entitled  "Notes  on  Naval  Hospitals, 
Medical  Schools,  and  Training  Schools  for  Nurses,"  by 
Dr.  J.  D.  Gatewood,  Passed  Assistant  Surgeon,  United 
States  Navy.  A  sketch  of  hospital  history  prefaces  a 
series  of  interesting  accounts  of  these  special  hospitals  in 
England  and  France,  and  then  follow  descriptions  of  the 
institutions  at  Portsmouth,  Chelsea,  Brooklyn,  Philadel- 
phia, Washington,  Annapolis,  Norfolk,  Pensacola,  Mare 
Island,  and  Yokohama,  under  the  care  of  the  medical 
department  of  the  United  States  Navy. 

In  the  absence  of  a  complete  treatise  upon  the  subject 
these  "  Notes  "  are  welcome,  and  aside  from  their  value 
for  the  historical  data  contained,  the  plans  which  are 
given  of  nearly  all  the  structures  described  make  the 
architectural  feature  one  to  be  consulted  by  those  inter- 
ested in  such  matters. 


Smuggled  Opium. — It  is  estimated  by  the  Canadian 
authorities  that  at  least  100,000  pounds  of  opium,  re- 
fined in  British  Columbia,  are  annually  smuggled  into  the 
United  States. 

Women  Doctors  in  America. — According  to  a  statis- 
tical report  drawn  up  by  M.  Louis  Frank,  of  Brussels, 
there  were  in  1893  on  this  side  of  the  Atlantic  fully 
2,000  women  practising  medicine  in  one  or  other  of  its 
forms  and  inclusive  of  130  homoepathists.  The  majority 
were  ordinary  practitioners,  but  among  the  remainder 
were  70  hospital  physicians  or  surgeons ;  95  professors 
in  the  schools ;  610  specialists  for  the  diseases  of  women ; 
70  alienists ;  65  orthopedists ;  40  oculists  and  aurists ; 
and  finally  30  electro-therapeutists.  In  Canada  there 
is  but  one  medical  school  exclusively  devoted  to  the 
training  of  medical  ladies,  but  in  the  United  States  in 
1893  there  were  ten,  one  of  them  being  a  homoeopathic 
establishment 


August  25,  1894] 


MEDICAL  RECORD. 


241 


%zxo%  of  tfte  WLtzh. 

The  Plague  Bacillus.— In  The  Lancet  of  August  nth 
is  a  short  description,  accompanied  by  illustrations  of 
preparations  made  by  Drs.  Lowson,  of  Hong  Kong,  and 
Kitasato,  of  Japan,  of  the  plague  bacillus  discovered  by 
the  latter.  According  to  Dr.  Lowson's  description,  the 
organism — which  is  a  bacterium  resembling  the  bacilli 
found  in  the  hemorrhagic  septicaemias,  except  that  the 
ends  are  somewhat  more  rounded — when  stained  lightly 
appears  almost  like  an  encapsuled  diplococcus,  but  when 
more  deeply  stained  it  has  the  appearance  of  an  ovoid 
bacillus  with  a  somewhat  lighter  centre,  especially  when 
not  accurately  focussed.  When,  however,  it  is  focussed 
more  accurately  it  is  still  possible  to  make  out  the  diplo- 
coccus form.  It  is  quite  possible  that  the  capsule  has  been 
produced  artificially,  though  in  one  of  the  preparations 
shown  this  does  not  appear  to  be  the  case.  The  positions 
in  which  it  is  most  frequently  met  with — sometimes  appar- 
ently in  almost  pure  cultures — are  the  glandular  enlarge- 
ments which  occur  in  the  groin,  in  the  axilla,  and  in  the 
neck,  though  these  enlargements  are  not  always  met  with 
in  the  rapidly  fatal  cases.  These  enlarged  glands  are 
intensely  congested,  or  rather  they  appear  to  be  infiltrated 
with  blood.  In  this  blood,  which  is  in  a  state  of  disin- 
tegration, mixed  with  the  elements  of  the  glandular  tissue 
which  are  also  broken  down,  the  organisms  are  exceed- 
ingly numerous.  They  are  also  met  with  in  considerable 
numbers  in  the  spleen  and  in  the  other  organs,  in  those 
positions  where  there  is  a  slowing  of  the  circulation  as  it 
passes  through  capillary  networks  or  sinuses,  and  are 
found  even  in  the  blood  in  the  heart  and  larger  vessels. 

The  British  Medical  Association  in  Montreal. — At 
the  annual  banquet  of  the  Association,  Dr.  Osier,  of 
Baltimore,  speaking  for  the  visitors,  suggested  that  the 
Association  meet  in  Montreal  in  the  near  future.  All 
who  attended  would,  he  assured  them,  receive  as  hearty 
a  welcome  there  as  did  the  members  of  the  British  Asso- 
ciation for  the  Advancement  of  Science  a  few  years  ago. 

The  Antitoxin  Treatment  of  Diphtheria. — At  a  recent 
meeting  of  the  Berlin  Medical  Society,  Dr.  Katz  read  a 
paper  on  the  antitoxin  treatment  of  diphtheria  in  the 
Kaiser  Friedrich  Children's  Hospital.  Since  the  open- 
ing of  the  hospital  there  had  been  treated  by  the  usual 
methods  1,081  cases  of  the  disease,  with  a  mortality  of 
38.9  per  cent.  Since  the  middle  of  March  of  the  present 
year  128  cases  had  been  treated  by  antitoxin  injections 
with  a  mortality  of  but  13.2  per  cent.  The  doses  of 
antitoxin  employed  varied  from  5  to  20  grammes  accord- 
ing to  the  severity  of  the  case.  No  injurious  effects  of 
the  drug  upon  the  heart  or  kidneys  were  observed. 

The  Chinese  Fire  upon  the  Bed  Cross. — The  London 
Daily  Telegraph  says  that  it  is  stated  on  high  authority, 
that  in  the  recent  combats  near  Seoul  the  Chinese  fired 
upon  a  Japanese  ambulance  carrying  men  who  wore  the 
Geneva  cross.  They  killed  a  doctor  and  some  hospital 
attendants. 

Discontinuance  of  Examinations  for  the  Medical 
Corps  of  the  Army. — A  recent  act  of  Congress  has  re- 
duced the  number  of  assistant  surgeons  in  the  Army 
from  125  to  no.  There  are  now  115  men  in  this  grade, 
consequently  there  are  no  vacancies  to  be  filled,  and  no 


examining  board  will  be  convened  until  the  number  is 
reduced  by  casualty  or  promotion  below  the  limit  men- 
tioned. In  the  Navy,  on  the  other  hand,  several  vacan- 
cies exist  in  the  Medical  Corps,  and  there  are  not  enough 
applicants  to  fill  them.  One  reason  for  this  is  that 
assistant  surgeons  in  this  branch  of  the  service,  when  first 
appointed,  are  messed  with  recent  graduates  of  Annapolis, 
their  juniors  by  several  years  in  age  and  experience,  and 
it  is  not  until  some  time  has  passed  that  they  are  eli- 
gible for  admission  to  the  wardroom. 

What  Becomes  of  Old  Diplomas  ? — An  advertisement 
in  a  daily  paper  of  recent  date  furnishes  a  partial  solution 
of  the  problem  as  to  what  becomes  of  the  diplomas  of  de- 
ceased physicians.  The  advertisement  in  question  offered 
for  sale  the  diploma  of  a  physician  who  had  recently  died. 
The  price  asked  was  $50.  The  advertiser,  when  he 
learned  that  such  a  sale  would  be  contrary  to  law,  dis- 
creetly withdrew  his  offer,  which  he  said  he  had  made  on 
behalf  of  the  widow. 

The  German  Imperial  Family  and  Vaccination.— An 
anti-vaccination  committee  published  a  report  that  the 
German  emperor  had  refused  to  allow  his  children  to  be 
vaccinated.  After  the  report  had  started  on  its  travel  an 
inquiry  was  made,  and  it  was  found  to  be  without  any 
foundation  in  fact,  for  all  the  princes  have  been  vacci- 
nated just  as  any  other  children. 

Sievitia  Secandi. — Dr.  O'Reilly,  of  St.  Louis,  recent- 
ly appealed  to  the  Board  of  Health  of  that  city  to  exeit 
its  authority  to  prevent  the  wholesale  mutilation  of  wom- 
en at  the  hands  of  local  surgeons.  It  was  stated  that 
many  laparotomies  were  performed  without  the  shadow 
of  an  excuse,  and  that  these  so-called  surgical  operations 
had  but  the  semblance  of  legality  in  their  performance 
to  keep  them  out  of  the  category  of  attempted  or  actual 
manslaughter.  The  St.  Louis  Medical  Review  admits 
that  Dr.  O'Reilly  was  justified  in  his  appeal  to  the 
authorities,  and  that  unnecessary  operations  on  the  ab- 
dominal and  generative  organs  of  women  are  scandal- 
ously frequent. 

Anthrax  in  London. — During  the  past  twenty  years 
118  cases  of  anthrax  have  been  reported  to  the  sanitary 
authorities  in  London.  Of  this  number,  90  were  in  per- 
sons engaged  in  the  hide  and  skin  trade,  5  in  persons 
engaged  in  slaughtering  animals,#7  in  persons  engaged 
in  the  manipulation  of  horsehair  or  the  manufacture  of 
brushes,  one  was  employed  at  a  bacteriological  labora- 
tory, while  in  15  instances  the  source  of  infection  was 
not  traceable.  The  number  of  cases  among  tanners 
shows  a  progressive  decrease,  due,  it  is  said,  to  the  fact 
that  wet  hides  are  taking  the  place  of  dry  hides  in  the 
trade. 

Dr.  Cornelius  Herz,  of  Panama  Canal  notoriety,  who 
has  been  living  in  England  since  the  trial  of  De  Lesseps 
and  others,  has  been  condemned  by  default  to  imprison- 
ment for  five  years,  and  to  pay  a  fine  of  3,000  francs. 
The  sentence  will  be  executed,  if  the  French  authorities 
can  apprehend  him. 

Alcohol  Free  of  Duty.— The  Senate  tariff  bill  admits 
free  of  duty  alcohol  to  be  used  in  the  arts  and  for  medi- 
cinal purposes.  After  its  passage  another  bill  was  intro- 
duced in  the  House  repealing  this  clause,  but  it  has  been 
shelved  with  the  bills  remitting  the  duty  on  sugar  and 
raw  materials. 


242 


MEDICAL   RECORD. 


[August  25,  1894 


Dengue  has  been  epidemic  at  Key  West,  the  disease 
appearing  first  among  the  troops  and  then  spreading  to 
residents  of  the  island. 

Hot  a  Candidate  for  Congress.— The  editor  of  this 
journal  is  not  a  candidate  for  Congress,  as  announced  in 
various  contemporaries.  His  name  will  not  be  men- 
tioned in  the  convention  which  will  be  held  on  this  date. 
The  editor,  however,  cannot  refrain  from  expressing  his 
sincere  thanks  to  those  of  his  contemporaries  who  have 
kindly  and  favorably  noticed  his  candidacy  as  announced 
in  the  secular  press.— Journal  of  the  American  Medical 
Association. 

The  Woman's  Hospital  in  Seoul.— In  this  hospital, 
the  first  of  its  kind  in  Corea,  2,765  patients  were  treated 
during  1893.  Of  this  number  119  were  hospital  cases, 
2,125  were  Ken  at  the  dispensary,  and  521  were  visited 
at  their  homes.  A  large  number  of  the  outside  visits 
were  upon  women  of  the  wealthier  classes,  as  it  is  not  per- 
missible for  women  of  high  rank  to  appear  upon  the 
street,  although  some  of  them  do  come  in  closed  sedan- 
chairs  to  the  hospital.  The  work  has  shown  a  steady  in- 
crease during  the  three  years  that  the  hospital  has  been 
in  existence.  During  1891,  in  round  numbers,  3,000 
dispensary  visits  were  made,  4,500  the  next  year,  and 
6,500  (representing  2,215  patients)  in  1894,  a  total  of 
upward  of  14,000  visits. 

Genius  and  Degeneration.— Dr.  James  Weir,  Jr.,  writes 
that  the  sentence  beginning,  "  Henry  Clay  was  addicted 
to  an  over-indulgence  in  alcohol,"  in  the  article  with 
this  title  in  the  Medical  Record  for  August  4th  (p. 
132),  should  read :  "  Daniel  Webster  was  addicted  to  an 
over-indulgence  in  alcohol." 

Sanitary  Seienoe  in  America.— Dr.  de  Pietra  Santa, 
editor  of  the  Journal  d'Hygiine,  says  that  among  the 
United  States,  Michigan,  Massachusetts,  and  Minnesota 
rank  among  the  countries  of  the  world  in  which  sanitary 
science,  both  theoretical  and  practical,  has  made  the 
greatest  progress. 

The  Health  of  the  Pope The  cable  reports  that  the 

Pope  had  an  alarming  attack  of  syncope  on  Sunday  last, 
but  that  he  is  now  in  his  usual  health.  His  physician, 
in  an  interview  with  the  correspondent  of  a  Berlin  paper, 
stated  not  long  ago  that  the  aged  pontiff  has  no  organic 
disease,  and  suffers  only  from  the  weakness  incident  to 
advanced  age.  His  digestion  is  good  and  he  sleeps  like 
a  child. 

The  Worm  Turns. — Actions  for  malpraxis  are  so  fre- 
quent that  it  is  pleasant  to  hear  occasionally  that  the 
tables  are  turned  and  the  doctor  is  able  to  recover  for 
slander.  Dr.  Thorne,  an  English  medical  man,  has  just 
been  awarded  damages  for  slander  upon  his  professional 
skill  by  one  of  his  patients.  The  defendant  broke  his 
collar-bone  in  the  hunting- field,  and  the  plaintiff  was 
called  in  to  attend  him  professionally.  In  consequence 
of  some  disagreement,  Dr.  Thorne  gave  up  attendance, 
'and  advised  his  patient  to  go  to  another  medical  man. 
Soon  afterward  he  found  that  the  defendant's  charges  of 
malpraxis  against  him  were  being  freely  and  publicly  dis- 
cussed, and  brought  suit  for  slander.  A  number  of  emi- 
nent surgeons  gave  evidence  to  the  effect  that  Dr. 
Thome's  treatment  was  skilful  and  proper,  and  the  jury 
awarded  him  ^25  damages. 


Treatment  of  Quinsy.— Dr.  S,  S.  Cartwright  writes 
that  the  treatment  for  tonsillitis,  referred  to  by  him  in 
the  issue  of  July  28th,  was  first  proposed  by  Dr.  A.  S. 
Hudson,  of  Stockton,  Cal.,  in  an  article  in  the  Medical 
Record  of  September  27,  1890. 

The  Thermogen  is  an  appliance  for  keeping  up  the 
temperature  of  patients  during  an  operation,  doing  away 
with  the  necessity  of  blankets  and  hot- water  bags.  It  is 
in  the  form  of  a  quilted  cushion  with  an  arrangement  of 
fine  wires  inside  by  which  any  desired  degree  of  tem- 
perature may  be  maintained  by  electricity.  It  was  ex- 
hibited at  the  late  meeting  of  the  Royal  Society  in  Lon- 
don. 

A  Lift  saving  Appliance  for  Miners. — Dr.  J.  S.  Hal- 
dane,  of  England,  has  invented  an  apparatus  which,  it  is 
asserted,  will  enable  miners  to  live  from  one  to  three, 
hours  in  the  after-damp  which  fills  a  coal  mine  after  an 
explosion  of  fire  damp.  The  invention  consists  of  a 
steel  case,  holding  compressed  oxygen  and  a  respirator. 
The  whole  apparatus  is  no  larger  than  a  safety-lamp.  It 
was  shown  by  its  inventor  at  the  meeting  of  the  British 
Association  for  the  Advancement  of  Science  in  Oxford. 

The  Cholera  persists  in  Eastern  Europe,  Southern 
France  and  Holland.  The  Czar  has  countermanded  the 
orders  for  the  holding  of  the  army  manoeuvres  at  Smolensk 
owing  to  the  prevalence  of  cholera  in  that  vicinity.  In 
Galicia,  during  the  three  days  ending  last  Saturday,  there 
were  237  new  cases  and  129  deaths,  and  in  Bukowina, 
within  the  same  time,  38  new  cases  and  21  deaths.  The 
Austrian  troops  marching  through  this  district  to  take  part 
in  the  annual  military  manoeuvres  have  assisted  in  spread- 
ing the  disease.  The  Roumanian  Government  has  estab- 
lished a  military  cordon  on  the  frontier  to  prevent  the  in- 
troduction of  the  disease  from  Bessarabia,  but  as  it  cannot 
stop  the  flow  of  the  infected  river  Pruth,  it  is  difficult  to  see 
what  good  the  cordon  will  do.  Owing  to  the  infection  of 
the  Vistula,  and  the  consequent  spread  of  cholera  in  the 
eastern  provinces  of  Prussia,  the  orders  for  the  army  man- 
oeuvres in  the  neighborhood  of  Dantzig  have  been  counter- 
manded. In  many  of  the  towns  in  these  provinces  the 
authorities  have  closed  the  public  baths  and  forbidden 
the  use  of  unboiled  water  and  raw  fruit.  A  death  from 
cholera  was  reported  in  Bordeaux  on  August  10th.  The 
case  was  imported  from  Marseilles,  where  twenty-one 
deaths  occurred  during  the  fortnight  ending  August 
17th.  Cases  are  still  reported  in  Amsterdam,  Rotter- 
dam, Maestricht,  and  other  places  in  the  Netherlands. 
A  death  is  said  to  have  taken  place  from  cholera  in  Chel- 
sea, in  the  southwestern  part  of  London,  and  several 
cases  were  found  among  the  crew  of  the  steamer  Balmore, 
which  arrived  off  Gravesend  from  St.  Petersburg,  on 
August  7th. 

11  Intellectual  California"  is  the  title  of  a  three  vol- 
ume report  of  all  the  congresses  and  other  "  intellectual 
events  in  California  contemporaneous  with  the  period  of 
the  Midwinter  Fair."  The  Transactions  of  the  1894 
meeting  of  the  American  Medical  Association  will  appear 
in  one  of  the  volumes,  which  will  be  ornamented  with 
the  portraits  of  some  three  hundred  of  the  handsome 
members  of  the  Association.  It  is  safe  to  assume  that 
there  will  be  some  three  hundred  medical  subscribers  to 
the  work. 


August  25,  1894]' 


MEDICAL   RECORD. 


243 


jfcrcietg  ^zpovts. 

THE  BRITISH   MEDICAL  ASSOCIATION. 

Sixty-sccona  Annual  Meetings   held  at  Bristol,  July  31 
to  August  4,  1894* 

Special  Report  for  the  Medical  Record. 

Fourth  Day,  Friday,  August  3D. 

(Continued  from  page  ai8.)J 

The  concluding  general  meeting  was  held  on  Friday 
morning,  August  3d.  There  was  a  good  attendance. 
The  President,  who  occupied  the  chair,  introduced  Sir 
Charles  A.  Cameron,  F.R.C.S.I.,  in  a  few  well-chosen 
and  appropriate  remarks. 

Address  in  Public  Medicine. — Sir  Charles  A.  Cam- 
eron, who  was  heartily  received,  then  delivered  the  ad- 
dress in  Public  Medicine.  He  said  they  might  claim 
that  medical  men  stood  pre-eminent  among  those  who 
devised  means  for  prolonging  life  and  lessening  sickness. 
They  were  the  first  to  show  that  pure  water  was  indis- 
pensable to  health,  that  the  efficient  drainage  of  houses 
and  of  towns  was  a  prime  requisite  to  the  maintenance 
of  the  health  of  communities,  that  overcrowding  spread 
disease,  if  it  did  not  develop  it,  and  that  the  high  mor- 
tality associated  with  many  industrial  occupations  might 
be  lessened  by  the  adoption  of  certain  precautions.  The 
lives  saved  by  the  adoption  of  Jenner's  sublime  discovery 
of  vaccination  amounted  to  millions.  In  the  government 
of  modern  communities  the  medical  man  played,  even 
from  a  public  health  point  of  view,  a  very  subordinate 
part,  and  yet  there  were  many  medical  men  eminently 
fitted,  by  their  culture,  experience,  and  ability,  to  hold 
the  office  of  Minister  of  Public  Health,  aye,  even  with  a 
seat  in  the  cabinet ! 

Mortality  rates  in  Town  and  Country. — In  1893  the 
mortality  rate  in  the  towns  was  5.7  per  1,000  in  excess 
of  that  in  the  rest  of  the  country.  The  difference  be- 
tween the  rural  rate  and  that  in  some  of  the  towns  was 
appalling.  Why  had  one  British  town  twice  as  high  a 
mortality  as  another,  and  why  was  the  average  duration 
of  life  so  much  greater  in  rural  districts  than  in  the 
towns  ?  The  causes  were  no  doubt  highly  complex,  and 
many  of  them  were  local.  Among  the  poor  in  all  towns 
birth  and  death-rates  stood  highest.  Their  greater  fecund- 
ity and  high  marriage-rates  compensated  for  their 
enormous  mortality.  The  poorer  a  man  was  the  more 
likely  was  he  to  marry.  It  was  a  remarkable  but  undeni- 
able fact  that  a  man's  desire  for  matrimony  was  in  the 
inverse  proportion  to  his  ability  to  maintain  a  family. 
Figures  showed  the  appalling  mortality  of  the  children 
of  the  poor.  If  the  deaths  of  children  under  five  years 
of  age  were  excluded,  there  would  only  be  a  difference  of 
about  2  per  1,000  between  the  town  and  country  death- 
rates.  A  large  proportion  of  the  lower  classes  in  the 
towns  was  underfed,  insufficiently  clothed,  and  badly 
lodged.  These  unfavorable  conditions  told  most  severely 
upon  the  very  young.  As  higher  death-rates  prevailed 
among  the  poor  than  obtained  in  the  case  of  the  well-to- 
do  classes,  an  undue  proportion  of  very  poor  people  in  a 
town  necessarily  caused  a  higher  death-rate  than  where 
the  poor  were  comparatively  few.  This  would  be  the 
case  even  where  the  general  hygienic  conditions  of  both 
towns  were  much  alike.  It  might  be  considered  that  the 
comparative  poverty  of  towns  might  be  to  some  extent 
determined  by  ascertaining  the  proportion  of  the  popula- 
tion who  were  domestic  servants.  On  the  whole,  they 
found  that  in  the  towns  where  the  domestic  servants 
were  very  numerous  the  death-rates  were  low.  The  per- 
centage of  tenements  which  consisted  each  of  a  single 
room  might,  one  would  suppose,  offer  an  indication  of 
the  poverty  of  a  town.  He  found,  however,  the  most  ex- 
traordinary differences  in  towns,  salubrious  and  other- 
wise, as  regarded  one-room  tenements.  In  the  Scotch 
towns  one-roomed  houses  were  even  more  common  than 
in  England. 


In  Dublin  one-third  of  the  families  lived  in  single 
rooms.  The  high  death-rate  which  characterized  the 
denizens  of  single-room  dwellings  was  largely  the  result 
of  the  miserable  conditions  of  the  people  themselves, 
apart  from  the  state  of  their  dwellings.  If  they  exchanged 
their  one-roomed  dwellings  for  four-room  tenements, 
they  would  still  have  a  high  death-rate  by  reason  of  their 
poverty  and  its  concomitant  evils,  and,  he  feared,  from 
their  intemperance.  It  was  to  be  regretted  that  the 
local  authorities  still  allowed  such  houses  to  be  built. 
In  Dublin  they  could  not  be  erected,  a  by-law  directly 
prohibiting  their  construction.  In  Dublin,  2,700  houses 
had  been  de-  tenanted  and  closed — about  1,000  of  them 
never  to  be  reopened,  without  any  compensation  to  the 
owners.  If  a  municipality  were  wealthy  it  could  do  no 
better  work  than  providing  good  dwellings  for  the  arti- 
sans and  laborers ;  but  if  its  means  were  limited,  it  should 
look  only  to  the  wants  of  the  laboring  and  still  poorer 
classes.  It  was  in  the  dwellings  of  the  very  lowest 
classes  that  the  seeds  of  infective  disease  were  nursed  as 
if  in  a  hotbed.  These  places  were  pest  spots,  and  any 
amelioration  of  their  condition  must  be  a  gain  to  society 
at  large.  The  corporation  of  Dublin  had  been  able  to 
provide  two  room  tenements  with  separate  sanitary  ac- 
commodation of  the  most  modern  style,  at  2s.  per  week, 
and  without  loss  to  the  city  treasury. 

Water  Supply. — The  disuse  of  town  wells  and  the  fil- 
tration of  public  water-supplies  had  done  much  to  lessen 
the  urban  mortality.  The  value  of  filtration  through 
mere  sand  had  until  recently  been  under-estimated ;  but 
the  researches  of  chemists  and  bacteriologists  had  shown 
that  filtration  through  sand  and  gravel  can  be  made 
almost  as  perfect  as  through  charcoal.  The  great  impor- 
tance of  water  filtration  was  painfully  demonstrated  dur- 
ing the  last  epidemic  of  cholera  at  Hamburg.  They 
had  not  yet  determined,  in  relation  to  chemical  analysis, 
the  line  which  divided  a  bad  from  a  good  water,  nor  did 
he  believe  that  such  a  line  could  be  drawn.  One  that 
contained  very  little  organic  matter  might  be  dangerous 
to  drink,  while,  on  the  contrary,  water  with  a  large 
amount  of  organic  matter  had  been  drunk  with  impunity 
for  years.  The  number  of  micro-organisms  in  water  was 
regarded  by  most  bacteriologists  as  a  measure  of  its  purity, 
regardless  of  its  chemical  composition.  The  epidemic  of 
enteric  fever  in  the  Sees  Valley  in  1890  and  1891,  inves- 
tigated by  Dr.  Barry,  of  the  Local  Government  Board, 
had  been  held  to  prove  conclusively  that  this  disease  was 
propagated  by  water.  Dr.  Barry's  conclusions  had,  ot 
course,  been  questioned  and  controverted. 

Sewer  Air. — The  results  of  recent  investigations  in 
reference  to  the  composition  of  sewer  air  showed  that  it 
was  superior,  bacteriologically  at  least,  to  ordinary  air. 
They  could  easily  understand  that  in  the  case  of  well- 
constructed  and  constantly  flushed  sewers,  the  air  in 
them  would  not  differ  from  ordinary  atmospheric  air.  It 
was  the  emanations  from  stagnant  sewage  in  ill-kept  sew- 
ers that  were  to  be  dreaded.  The  ventilating  openings 
in  the  streets  were  generally  objected  to  by  those  who 
lived  opposite  to  them.  Bristol  was,  perhaps,  the  only 
one  of  the  large  towns  in  which  the  sewers  remained  un- 
ventilated.  As  typhoid  fever  was  asserted  the  most 
likely  to  be  produced  by  sewer  emanations,  Bristol  ought 
to  have  more  than  an  average  amount  of  disease,  if  the 
sewer  ventilation  theorists  were  correct.  Statistics  of 
the  mean  death-rate  from  enteric  fever,  in  the  period 
1887  to  1891,  showed  that  five  towns  had  smaller  rates 
than  Bristol,  and  forty-four  had  higher.  If  Bristol  had 
made  a  mistake  in  not  ventilating  its  sewers,  it  had  not 
apparently  paid  any  penalty,  for  in  the  period  1881  to 
1890  only  one  of  the  large  towns  had  a  lower  zymotic 
death-rate.  He  should  feel  disposed  to  adopt  the  Bristol 
plan,  were  it  not  that  there  might  be  some  difficulty,  in 
some  towns  at  least,  in  cleansing  the  sewers.  Typhoid 
fever  was  not  so  prevalent  in  these  countries  or  on  the 
continent  as  it  formerly  was,  but  in  some  towns  typhoid 
fever  had  not  declined,  and  in  a  few  it  had  increased. 
There  was  a  very  general  belief  that  this  disease  was 


244 


MEDICAL    RECORD. 


[August  25,  1894 


almost  wholly  propagated  through  the  media  of  water, 
food,  and  sewer  air ;  but  he  believed  that  the  greater 
number  of  cases  arose  from  the  maUrics  morbi  of  the  dis- 
ease being  absorbed  from  the  air.  Up  to  the  present, 
pathogenic  micro  organisms  had  not  been  frequently  de- 
tected in  the  atmosphere,  but  neither  had  they  been 
found,  except  rarely,  in  water  or  milk  suspected  to  have 
produced  disease.  He  believed  that  typhoid  fever  was  a 
disease  of  the  miasmatic  class,  and  that  it  became  en* 
detnic  in  certain  localities  in  which  the  conditions  of  the 
soil  were  favorable  to  the  development  of  the  micro-or- 
ganisms which  caused  the  disease.  It  had  been  sug- 
gested that  the  waterlogged  condition  of  Dublin  was  the 
cause  of  the  prevalence  of  typhoid  fever,  and  that  the 
obvious  remedy  was  subsoil  drainage.  It  was,  however, 
a  fact  that  the  low  lying  portion  of  Dublin,  where  there 
was  most  typhoid  fever,  was  not  damp,  and  that  the 
ground- water  lay  low  there,  and  that  in  the  parts  where 
the  ground-water  came  much  nearer  to  the  surface  there 
was  least  typhoid  fever.  The  explanation  of  this  was 
not  difficult.  The  cold,  wet  clays  were  unfavorable  to 
the  bacillus  of  the  disease,  whereas  they  had  better  feed- 
ing-ground in  the  loose  and  well-aerated  gravels.  It 
was  stated  that  typhoid  prevailed  most  among  the  upper 
classes.     This  was  not  the  case  in  Dublin. 

The  Future  of  Preventive  Medicine.— The  domain  of 
public  medicine  was  steadily  enlarging  in  every  direc- 
tion. Surely  the  time  must  come  when  the  results  of 
these  researches  would  enable  man  to  extirpate  some  or 
all  of  the  diseases  which  even  now  were  termed  "  pre- 
ventable." England  had  been  described  by  foreigners 
as  the  birthplace  and  home  of  sanitary  science,  and  it 
surely  deserved  the  compliment.  Never  before  in  the 
history  of  the  world  were  thirty  millions  of  people  lo- 
cated on  fifty  thousand  square  miles,  as  was  the  case 
with  the  England  of  to-day.  Of  these  millions  two- 
thirds  resided  in  the  towns,  which  yearly  had  a  quarter 
of  a  million  added  to  their  teeming  population.  In 
Germany  forty-two  per  cent,  of  the  population  lived  in 
towns  containing  two  thousand  and  upward.  Only 
every  tenth  Russian  lived  in  a  town.  Notwithstanding 
the  great  and  continuous  increase  in  its  urban  popula- 
tion, Great  Britain  grew  healthier  and  healthier  from 
decade  to  decade. 

Professor  Corfield,  of  London,  moved  that  the  thanks 
of  the  meeting  be  given  to  Sir  Charles  Alexander  Cameron 
for  his  able  and  interesting  address.  It  was  due  to  Sir 
Charles  that  typhus  had  been  so  effectually  grappled 
with  in  Dublin,  for  it  was  through  his  efforts  that  the  in- 
sanitary dwellings  which  were  the  hotbeds  of  the  dis- 
ease had  been  swept  away  by  hundreds.  The  same 
reason  accounted  for  the  failing  power  of  the  disease  in 
Liverpool.  At  the  same  time  there  was  the  matter  of 
the  increase  of  diphtheria.  Many  causes  were  attributed 
to  this,  and  among  those  which  found  most  favor  with 
the  officials  of  the  Local  Government  Board  were  the 
street  ventilation  of  sewers,  and  the  increased  aggrega- 
tion of  children  in  schools.  Alluding  to  the  probable 
dispensing  with  vaccination,  the  speaker  said  that  the 
opposition  to  this  by  the  medical  profession  had  been  at- 
tributed to  their  desire  to  protect  fees,  but  he  prophesied 
that  if  vaccination  became  non  compulsory  the  public 
would  require  half  as  many  again  medical  practitioners 
as  existed  to-day. 

Dr.  Davies  (the  medical  officer  of  health  of  Bristol) 
seconded  the  resolution,  which  was  carried  by  acclama- 
tion. 

The  various  formal  votes  of  thanks  having  been  given, 
the  President  of  the  Council  (Dr.  Ward  Cousins,) 
moved  a  vote  of  thanks  to  the  President  (Dr.  E.  Long 
Fox)  for  his  genial  courtesy  and  marked  ability  in  con- 
ducting the  business  of  the  congress. 

Dr.  Winterbotham,  of  Bridgewater,  seconded  the  re- 
solution, which  was  carried  with  great  enthusiasm. 

The  President  acknowledged  this  vote  with  a  few  cour- 
teous remarks,  i 

A  motion  on*rthe'agenda  in  the  name  of  Dr.  T.  G. 


Horder,  of  Cardiff,  advocating  an  ethical  section,  was 
accepted  for  consideration  in  the  name  of  the  council. 

A  very  cordial  vote  of  thanks  to  Dr.  Markham  Sker- 
ritt,  who  had  so  well  fulfilled  the  arduous  duties  of  hon- 
orary, secretary,  terminated  the  proceedings. 


SECTION  OF  SURGERY. 
First  Day,  Wednesday,  August  ist. 

The  proceedings  of  the  section  were  opened  by  the 
President,  Mr.  Mitchell  Banks,  with  a  few  remarks. 

President's  Address. — He  said  that  no  formal  address 
was  needed  since  Mr.  Greig  Smith  would,  on  the  follow- 
ing day,  deliver  the  address  on  Surgery.  Referring  to  the 
progress  of  modern  surgery,  he  said  that  in  studying  the 
history  of  the  art  it  was  noticeable  that  those  whose 
names  were  handed  down  to  posterity  were  not  the  intro- 
ducers or  inventors  of  new  methods,  nor  the  brilliant 
operators,  but  the  steady,  practical  observers  who  were 
content  to  have  as  their  motto  "  Festina  Lente."  In 
studying  of  late  years  modern  surgery  and  its  tendencies, 
it  had  sometimes  occurred  to  him  that  we  might  be 
going  too  fast,  but  he  was  happy  to  believe  that  this  ten- 
dency, which  a  few  years  ago  seemed  to  be  strong,  had 
lately  been  much  modified,  at  any  rate  in  Great  Britain. 
It  was  our  proud  boast  that  the  British  surgeon,  when  he 
stood  at  the  bedside,  thought  only  of  the  sufferer  as  a 
patient,  not  as  so  much  material  for  experiment  In  sur- 
gery it  was  best  to  be  sure  that  what  was  new  was  also 
true.  Some  politician  had  suggested  that  it  would  be  an 
excellent  thing  for  the  country  if  no  new  laws  were  made 
for  five  years.  He  would  similarly  suggest  that  it  would 
be  a  good  thing  for  them  if  no  new  drugs  or  new  oper- 
ations were  introduced  for  five  years,  so  that  they  might 
study  and  thoroughly  estimate  the  value  of  those  that 
they  have  already.  He  believed  that  much  time  was 
wasted  in  the  trial  of  old  methods  under  new  names,  be- 
cause they  had  not  been  thoroughly  tried  when  origi- 
nally introduced.  He  referred  to  the  great  harm  done 
by  the  non  publication  of  many  unsuccessful  cases,  by 
which  a  false  idea  was  conveyed  of  the  merits  of  opera- 
tions and  modes  of  treatment.  There  were  nowadays 
certain  misguided  sentimentalists  who,  in  the  lay  press  and 
elsewhere,  abused  modern  surgery.  These  people  were 
antivivisectionists  and  antivaccinationists,  and  when  their 
views  were  a  little  more  obscure  and  exalted — anarchists. 
The  publicity  given  to  surgical  work  and  to  hospitals, 
managed  as  they  were  by  charitable  and  devoted  lay- 
men, was  their  best  defence. 

Operative  Treatment  of  Perforating  Ulcer  of  the 
Stomach  and  Intestines. — Mr.  Pearce  Gould  then 
opened  the  discussion  on  this  subject.  He  said  that  a 
good  many  years  ago  Dr.  Marion  Sims  showed  his  keen 
foresight  in  prophesying  that  it  would  not  be  long  before 
perforation  of  a  gastric  ulcer  would  be  amenable  to 
treatment  by  surgeons,  and  cease  to  be  a  hopeless  condi- 
tion. Eleven  years  ago,  a  distinguished  Bristol  surgeon 
(Mr.  Nelson  Dobson)  read  a  paper  in  which  he  main- 
tained that  the  proper  treatment  of  this  complication 
should  be  by  abdominal  section  and  suture  of  the  open- 
ing in  the  stomach,  or  if  it  proved  to  be  impossible  to 
close  the  perforation,  that  a  gastric  fistula  should  be 
formed.  The  reception  of  these  views  was  not  a  very 
encouraging  one,  but  lately  surgeons  had  more  and  more 
followed  Mr.  Dobson's  advice. 

In  dealing  with  the  subject,  he  would  exclude  all  cases 
due  to  malignant  disease  and  disease  of  the  appendix 
vermiformis,  and  would  first  consider  perforating  ulcers 
of  the  stomach  and  duodenum. 

The  Pathology  of  the  disease  was  mysterious.  It  oc- 
curred oftenest  in  anaemic  young  women,  very  often  of  the 
domestic-servant  class,  and  less  often  in  middle-aged 
men.  He  described  the  classical  symptoms  of  gastric 
ulcer  which,  however,  unfortunately  formed  no  sure 
guide.  They  were  sometimes  entirely  absent.  Statistics 
showed  that  eighty-five  per  cent,  of  those  in  whom  the  ex- 
istence of  ulcer  was  diagnosed  recovered.     In  6$   per 


August  25,  1894] 


MEDICAL  RECORD. 


245 


cent,  perforation  and  death  occurred ;  five  per  cent, 
died  from  hemorrhage,  and  the  remaining  3$  per 
cent,  died  from  exhaustion  and  other  causes.  Per- 
foration occurred  most  often  in  ulcers  of  the  anterior 
wall.  Duodenal  ulcers  were  most  common  in  men. 
Bllroth  had  recommended  that  as  soon  as  ulcer  was 
diagnosed  a  prophylactic  excision  should  be  performed, 
bit  the  speaker  did  not  recommend  this  treatment. 
Among  other  reasons  against  it  were  the  facts  that  so 
many  cases  recovered  spontaneously  or  under  treatment, 
and  that  diagnosis  was  still  very  uncertain  in  regard  to 
the  position  of  the  lesion,  and  some  cases  were  so  acute 
and  perforation  occurred  so  rapidly,  that  there  was  no 
opportunity  of  excision.  When  perforation  was  followed 
by  escape  of  the  contents  of  the  viscus  into  the  general 
peritoneal  cavity,  death  sometimes  occurred  almost  im- 
mediately from  shock.  In  other  cases  shock  might  be 
almost  entirely  absent.  The  success  of  the  operation,  he 
believed,  depended  more  on  the  complete  and  thorough 
cleansing  of  the  peritoneal  cavity — abdominal  toilet — 
than  on  suture  of  the  opening.  He  related  several  cases 
in  illustration  of  this  point. 

Time  of  Operation. — The  operation  should  be  under- 
taken as  soon  as  possible  after  reaction  from  shock  set  in, 
but  it  was  better  to  wait  till  proper  assistance  and  ap- 
pliances needed  for  the  abdominal  toilet  were  at  hand 
rather  than  to  proceed  without  them.  For  Hushing  pur- 
poses he  preferred  boiled  water  containing  one  drachm  of 
common  salt  to  the  pint  ( 20  §  )  to  any  chemical  anti- 
septic solution.  The  solution  should  be  of  the  tempera- 
ture of  from  no0  to  1120  F,  and  it  exercised  a  marked 
restorative  influence  on  the  patient.  Flushing  should  be 
done  in  a  regular  and  systematic  manner,  and  no  time 
should  be  spared  in  making  it  thorough.  It  was  the  one 
essential  step  in  the  operation.  He  thought  that  excision 
of  the  ulcer  was  a  needless  and  useless  proceeding.  In 
every  case  where  peritonitis  was  well  marked  he  made  an 
incision  above  the  pubes  and  drained  the  peritoneal  cavity. 
When  from  the  extent  of  the  disease  or  size  of  the  opening 
it  was  impossible  to  close  it,  the  stomach  should  be  drained. 
Seven  cases  were  recorded  of  operation  followed  by  re- 
covery. 

He  cited  seventeen  cases  of  perforation  from  typhoid 
ulceration  of  the  intestine  which  had  been  operated  on. 
Of  these  one  recovered.  He  excluded  three  cases  of 
doubtful  nature,  all  of  which  recovered.  The  ileum  was 
the  part  affected  in  most  cases,  and  there  was  often  more 
than  one  perforation.  It  must  be  borne  in  mind  that 
perforation  sometimes  occurred  while  cicatrization  was  in 
progress,  and  even  months  after  the  onset  of  the  fever. 
Symptoms  might  be  very  marked  or  slight.  Spontaneous 
recovery  was  very  rare.  Operative  interference  was  only 
to  be  recommended  when  the  fever  had  subsided  or  nearly 
so.  With  regard  to  ulcers  of  the  posterior  wall  of  the 
stomach  which  perforated,  and  sometimes  caused  sub- 
phrenic abscess,  such  abscesses  should  be  opened  and 
drained  from  behind  if  possible,  or  if  opened  in  front  a 
counter-opening  should  be  made  for  drainage  behind; 
this  was  almost  essential. 

Mr.  R.  Maclaren,  of  Carlisle,  said  that  he  had  personal 
experience  of  four  operations  in  such  cases.  Of  these 
three  were  cases  of  gastric  ulcer,  of  which  two  were  fatal 
and  one  ended  in  recovery,  and  one  case  of  typhoid  ulcer 
which  recovered,  operation  having  been  performed  thirty- 
six  hours  after  the  perforation.  Simple  drainage  without 
suture  was  all  that  was  done. 

Mr.  Rutherford  Morrison,  of  Newcastle,  said  he 
had  operated  on  one  case  of  gastric  ulcer.  There  was 
peritonitis  limited  to  the  pelvis.  The  patient  died,  and 
at  the  necropsy  it  was  found  that  the  sutures  held,  the 
opening  was  securely  closed.  The  perforation  opened 
into  the  lesser  sac  of  the  peritoneum.  He  condemned 
excision  of  the  ulcer. 

Mr.  Gilbert  Barling,  of  Birmingham,  gave  details  of 
several  cases  showing  the  difficulties  of  diagnosis  and 
treatment.  He  thought  that  too  optimistic  a  view  was 
taken  generally  of  these  cases.     Operations  for  the  cure  of 


perforating  typhoid  ulcers  were  of  very  doubtful  expedi- 
ency. If  any  operation  were  undertaken  it  should  be  as 
limited  as  possible.  Opium  he  thought  of  great  value  in 
the  treatment  of  the  primary  shock  and  after  operation. 
Suture  in  typhoid  ulcers  was  not  to  be  advised. 

Mr.  Ward  Cousins,  of  Southampton,  spoke  of  the 
benefits  of  incision  and  drainage  alone.  It  was  remark- 
able how  small  a  quantity  of  fluid  escaped  from  the  stom- 
ach in  many  cases.  This  was  due  no  doubt  partly  to 
paresis,  and  hence  the  value  of  opium*  He  believed  that 
flushing  was  a  much  more  critical  procedure  than  was 
generally  thought.  He  would  do  it  as  sparingly  as  pos- 
sible. 

Mr.  Haslan,  of  Birmingham,  had  operated  on  one 
case  that  ended  fatally.  He  would  draw  a  distinction 
between  ulcer  on  the  anterior  wall  of  the  stomach  which 
caused  general  peritonitis,  and  ulcer  of  the  posterior  wall 
which  often  caused  only  localized  inflammation.  Un- 
fortunately the  classical  symptoms  of  ulcer  were  more 
often  present  in  the  latter  class  of  cases.  Shock  often 
came  on  as  late  as  three  or  four  hours  after  perforation* 
The  difficulty  of  the  operation  was  often  increased  by  the 
rotation  of  the  anterior  surface  of  the  stomach  upward  so 
as  to  hide  the  opening.  Having  once  found  the  ulcer  it 
was  wise  not  to  let  it  go  again,  as  in  his  case  much  time 
was  lost  by  neglect  of  this  precaution.  The  edges  of  the 
ulcer  should  be  inverted  and  Lembert's  suture  used.  He 
would  try  to  empty  the  viscus  through  the  wound,  but 
would  not  waste  valuable  time  over  it.  He  was  an  ad- 
vocate of  very  free  and  prolonged  flushing. 

Mr.  Nelson  Dobson,  of  Bristol,  said  that  although 
he  advocated  the  operation  eleven  years  ago,  he  had  not 
had  any  opportunity  of  practising  it.  It  was  intensely 
interesting  to  him  to  find  that  his  suggestion  had  been 
so  generally  adopted.  He  hoped,  however,  that  too  op- 
timistic views  would  not  prevail  and  cause  the  operation 
to  fall  into  disrepute.  He  thought  it  almost  futile  to  wait 
for  shock  to  pass  off.  He  would  operate  as  soon  as  he 
was  satisfied  of  the  diagnosis. 

Mr.  Damer  Harrisson,  of  Liverpool,  generally 
agreed  with  previous  speakers  as  regarded  gastric  ulcer. 
He  doubted  the  occurrence  of  spontaneous  recovery  in 
cases  of  perforating  typhoid  ulcer.  Diagnosis,  espe- 
cially in  the  acute  stage  of  the  fever,  was  often  very  diffi- 
cult. He  described  one  case  in  which  two  ulcers  were 
sutured.  Death  ensued  seventeen  hours  afterward,  and 
it  was  found  that  the  sutures  still  held.  He  would  oper- 
ate as  soon  as  the  diagnosis  was  made,  and  flush  freely ; 
hot  water  he  believed  relieved  shock.  In  one  case  of 
typhoid  fever  in  which  perforation  was  supposed  to  have 
occurred  there  was  distention  and  loss  of  the  liver  dul~ 
ness.  He  opened  the  abdomen  and  found  no  perfora- 
tion but  a  kink  of  the  gut.  The  patient  entirely  recov- 
ered. He  preferred  to  suture  the  opening  in  cases  of 
typhoid  ulceration. 

Mr.  Kendall  Franks,  of  Dublin,  had  operated  on 
one  case  with  a  fatal  result.  Much  was  to  be  learned  from 
failures.  He  would  always  operate  as  soon  as  the  pri- 
mary shock  had  passed  off,  and  would  remove  the  diseased 
tissue  and  pass  the  sutures  through  healthy  tissue.  He 
thought  that  the  occurrence  of  a  second  perforation  in 
one  of  the  cases  cited  by  Mr.  Pearce  Gould  was  a  silent 
witness  to  the  truth  of  his  view.  Flushing  was  essential 
to  success,  but  it  was  difficult  to  clear  out  the  lesser 
omental  cavity  and  the  parts  behind  the  liver  and  spleen. 

Mr.  R.  O'Callaghan,  of  London,  had  operated  un- 
successfully on  two  cases.  He  thought  that  no  other 
condition  in  surgical  practice  showed  such  early  and 
severe  collapse.  Early  operation  was  imperative  without 
waiting  for  reaction  from  shock.  Opium  was  beneficial' 
in  case  of  shock,  but  not  in  collapse. 

Mr.  Pearce  Gould  said  in  reply  that  he  was  no 
advocate  for  delay,  but  he  would  not  operate  during 
primary  shock  when  it  was  present  (it  was  sometimes 
entirely  absent).  After  the  shock  was  rallied  from,  and 
before  collapse  set  in,  was  the  time  for  operation.  As  to 
the  free  excision  advocated  by  Mr.  Kendal  Franks,  he 


246 


MEDICAL  RECORD. 


[August  25,  1894 


said  that  it  was  all  very  well  to  sacrifice  a  few  inches  out 
of  the  twenty  feet  or  so  of  intestine,  but  it  was  a  more 
serious  and  difficult  matter  to  remove  a  large  portion  of 
the  stomach-wall  and  securely  suture  the  remainder, 
whereas  there  was  no  risk  of  inversion  of  the  edges  caus- 
ing trouble  in  the  case  of  the  stomach  as  it  might  in  the 
intestine.  As  to  the  actual  occurrence  of  spontaneous 
recovery  fit>m  perforation  of  a  typhoid  ulcer  it  had  been 
proved  to  occur  sometimes  by  Cayley  and  Murchison's 
researches.  We  must  beware  that,  in  flushing,  septic 
materials  were  not  driven  from  the  wound  into  the  dis- 
tant parts  of  the  peritoneum  and  thus  disseminated. 
Flushing  should  be  begun  at  the  periphery  and  ended  at 
the  wound. 

The  President  in  summing  up  the  discussion  said 
that  the  speakers  seemed  unanimous  as  to  the  question  of 
suture.  Washing  out  of  the  stomach  was  needless  when 
the  natural  drain  by  the  intestines  was  open.  The  ques- 
tion of  spontaneous  recovery  was  important.  It  appeared 
certain  that  in  some  cases  it  had  occurred.  Flushing 
seemed  to  be  generally  approved  of,  but  of  course  it 
might  be  contraindicated  by  the  patient's  condition. 
Finally  he  must  congratulate  the  speakers  on  the  tem- 
perate manner  of  the  discussion  and  the  moderation  of 
their  views.  He  was  glad  to  think  that  we  were  aban- 
doning the  ridiculously  optimistic  views  common  a  few 
years  ago  in  abdominal  surgery. 

Mammary  Tumors. — Mr.  Herbert  Snow,  of  London, 
read  a  paper  on  the  dispersal  of  certain  forms  of  mam- 
mary tumor.  These  were  the  fibroma  of  adolescence, 
tumors  due  to  inflammatory  hyperplasia  and  certain 
tumors  due  to  dilatation  of  ducts.  The  inunction  of 
iodide  of  lead  and  mercury  ointment  four  times  a  day 
would  cause  complete  absorption  of  such  in  a  few  weeks, 
and  so  avoid  the  scars  and  other  drawbacks  of  operation. 
He  narrated  several  cases  in  point. 

There  was  no  discussion  on  this  paper. 

Traumatic  Delirium  Tremens. — Mr.  Damer  Harris- 
son  read  a  short  paper  on  the  treatment  of  traumatic 
delirium  tremens.  He  referred  to  the  method  popular 
in  Lancashire  among  colliers'  wives  to  quiet  uproar- 
iously drunken  husbands.  They  would  send  out  for 
two  pennyworth  of  "Quietner"  (three  grains  of  tartar 
emetic)  and  administer  it  concealed  in  a  pint  of  beer. 
He  had  adopted  a  somewhat  similar  treatment,  which 
was  really  almost  the  same  as  the  old  treatment  of  fever. 
After  morphine  in  full  doses  and  chloral  hydrate  had 
failed  of  any  effect  whatever,  tartar  emetic,  followed  by 
chloral  or  morphine,  produced  complete  cessation  of 
the  delirium,  and  after  its  use  very  small  doses  of  narcot- 
ics took  full  effect.     He  quoted  cases  to  illustrate  this. 

Surgery  of  the  Gall-bladder. — Mr.  Rutherford 
Morrison,  of  Newcastle,  read  a  paper  "  On  some  Points 
in  the  Anatomy  of  the  Right  Hypochondriac  Region,  re- 
lating especially  to  Gall- stones."  He  demonstrated  by 
diagrams  and  drawings  the  existence  of  a  pouch  of  perito- 
neum behind  the  right  lobe  of  the  liver  which  was  of 
importance  in  the  surgery  of  the  gall-bladder.  It  should 
be  drained  through  the  parietes  immediately  below  the 
kidney. 

Hernia  in  the  Aged. — Mr.  R  O'Callaghan  read  a 
paper  on  the  operation  for  strangulated  hernia  in  octo- 
genarians. He  said  that  old  people,  especially  old 
women,  bore  operation  better  than  those  in  the  prime 
of  life.  He  described  three  cases  which  were  all  success- 
ful, although  in  two  of  them  (inguinal  hernia)  the  gut 
was  almost  gangrenous,  and  it  was  with  great  misgivings 
that  he  returned  it,  but  he  decided  to  do  so  because  the 
boundary  between  the  congested  semigangrenous  part 
and  the  healthy  gut  was  ill  defined,  and  after  long  douch- 
ing with  water  at  the  temperature  of  no°  F.  its  appear- 
ance improved.  He  laid  great  stress  on  these  points,  as 
of  great  practical  value.  The  treatment  by  enterotomy 
and  the  formation  of  a  fistula  was  unsatisfactory  and 
fatal.  In  case  of  gangrene  enterectomy,  suture,  and  re- 
turn of  the  gut  was  the  best  treatment.  He  used  no 
chemical  antiseptics. 


Hip-disease  in  the  Aged.— Mr.  T.  P.  Lowe,  of  Bath, 
read  a  paper  on  the  treatment  of  senile  rheumatic  arth- 
ritis of  the  hip  joint  by  forcible  movements.  He  se- 
lected the  hip  joint  as  typical,  and  because  in  old 
people  it  was  the  first,  and  often  the  only,  joint  attacked. 
The  symptoms  were  often  mainly  those  of  sciatica.  Flex- 
ion was  generally  present,  and  was  maintained  by  the  pres- 
ence of  adhesions  which  should  be  broken  through,  an 
anaesthetic  being  given,  if  necessary,  and  in  severe  cases 
a  Thomas's  hip- splint  should  be  applied.  In  mild  cases 
the  recovery  was  instantaneous  and  the  patient  could 
walk  at  once  without  pain.  To  break  through  the  adhe- 
sions the  patient  should  be  laid  prone  and  the  thigh  for- 
cibly raised  while  the  pelvis  was  held  down.  His  experi- 
ence led  him  unhesitatingly  to  affirm  that  synovial  fluid 
could  be  restored  to  a  joint  which  was  dry. 


Second  Day,  Thursday,  August  a©. 

Spinal  Surgery. — Mr.  W.  Thorburn  introduced  the 
discussion  on  "  The  Surgical  Treatment  of  Injuries 
of  the  Spine  and  Spinal  Cord."  To  begin  with,  he 
would  classify  injuries,  dividing  them  into  eight  classes 
as  follows:  1,  Unilateral  dislocation;  2,  bilateral  dislo- 
cation without  recoil  of  the  displaced  bone;  3,  bilateral 
dislocation  with  recoil  of  the  displaced  bone ;  4,  fract- 
ure without  recoil  (diastasis);  5,  fracture  with  recoil; 
6,  injury  of  lamina  or  processes ;  7,  compound  fractures ; 
8,  secondary  lesions — hemorrhage,  meningitis,  etc. 

After  a  careful  survey  and  study  of  the  subject  bis  con- 
clusions were  that  fracture-dislocation  and  dislocation 
were  not  difficult  to  reduce,  but  that  the  chances  of  recov- 
ery of  the  cord  were  not  much  improved  thereby.  A 
cord  once  crushed  was  incapable  of  recovery,  as  was  shown 
by  experiments  as  well  as  clinical  experience.  Any  ap- 
parent recovery  was  due  to  vicarious  conduction,  some 
parts  of  the  cord  having  escaped  damage  and  being  used 
instead  of  those  normally  employed. 

The  advantage  of  reduction  simply  was  that  a  straight 
spine  was  better  than  a  crooked  one  should  the  patient 
recover;  but,  on  the  other  hand,  reduction  of  dislocation 
in  the  cervical  region  was  not  without  danger  to  life,  and 
the  more  dangerous  the  higher  up  the  injury.  Reduction 
might  be  said  to  be  safe  and  useful  in  unilateral  and  some 
bilateral  dislocations.  When  the  dorsal  region  was  the 
site  of  injury  reduction  was  not  often  possible. 

As  to  laminectomy,  in  most  cases  of  injury  it  was  use- 
less because  when  there  was  recoil  of  the  bone  the  lumen 
of  the  canal  was  restored,  and  there  was  no  pressure  in  at 
least  two-thirds  of  the  cases,  and  when  there  was  no  re- 
coil, although  laminectomy  might  be  possible,  yet  there 
was  not  much  hope  of  recovery,  for  nearly  all  the  cases, 
even  when  there  was  recoil,  ended  fatally.  When  the 
continuity  of  tissue  in  the  cord  was  once  interrupted  no 
restoration  took  place.  He  had  found  records  of  two 
hundred  published  cases  and  had  personal  experience  of 
seven.  In  these  seven  he  had  seen  no  material  benefit 
from  laminectony  in  any  case.  Subsequent  improvement 
was  not  due  to  the  operation.     In  compound  fractures 

(such  as  those  caused  by  gunshot)  he  would  remove 
ragments  of  lamina  or  other  bone  simply  as  a  part  of  the 
wound  toilet.  When  the  laminae  were  primarily  injured 
operation  was  useful.  There  was  no  natural  recoil  and 
the  cord  was  generally  less  crushed,  and  while  the  frag- 
ments of  bone  were  usually  small  they  might  be  doing 
harm  by  irritating  and  pressing  on  the  cord.  The  gyp- 
sum corset  was,  no  doubt,  useful  late  in  the  case,  but  he 
was  very  doubtful  whether  it  was  of  use  immediately  after 
the  injury,  while  there  was  danger  of  the  unseen  forma- 
tion of  pressure  sores  and  extensive  sloughing. 

Dr.  H.  L.  Burrell,  of  Boston,  U.S.A.,  said  that  he 
had  a  basis  to  go  upon  of  8  cases  of  laminectomy  of 
his  own  and  4  of  his  colleague's,  besides  the  collected 
records  of  178  cases.  The  hopelessness  of  the  condition 
when  left  to  nature  was  well  known  and  was  demon- 
strated by  him  in  a  paper  on  the  subject  published  in 
1887.     He  then  recommended  that  in  all  cases  of  dis- 


August  25,  1894] 


MEDICAL   RECORD. 


247 


location  and  fracture-dislocation  an  anaesthetic  should  be 
administered  with  as  little  delay  as  possible,  for  irrepara- 
ble damage  was  done  by  allowing  pressure  to  continue 
even  for  one  hour.  The  patient  should  be  suspended 
and  forcible  rectification  practised,  and  a  gypsum  corset 
be  applied.  By  the  use  of  this  method  he  had  secured 
some  brilliant  results,  but  since  the  introduction  of  oper- 
ation he  had  given  it  up  for  laminectomy.  The  do-noth- 
ing treatment  should  certainly  be  abandoned. 

Immediate  reduction  had  increased  the  recoveries  by 
eleven  per  cent,  and  if  such  a  blind  method  did  so  much 
good  an  operation  that  enabled  the  surgeon  to  see  for 
himself  the  exact  condition  and  remedy  the  displacement 
without  doing  more  than  needful  must  certainly  do  still 
more  good.  He  doubted  the  possibility  of  an  exact  dif- 
ferential diagnosis,  and  therefore  would  operate  on  all 


Mr.  C.  B.  Keetley  mentioned  a  case  in  his  own 
practice  in  which  he  applied  a  Sayre's  jacket  without  at- 
tempting reduction.  The  patient  entirely  recovered. 
In  another  case  of  cervical  fracture- dislocation  produced 
by  diving  from  a  height  into  a  swimming-bath,  an  aes- 
thesia  and  paralysis  were  complete  in  both  arms  and 
legs,  but  the  right  arm  was  somewhat  contracted.  He 
operated,  removing  the  laminae  of  the  third  and  fourth 
cervical  vertebrae.  The  lower  margin  of  the  fourth 
lamina  nearly  touched  the  fifth  body.  After  removing 
the  laminae  the  cord  seemed  to  return  to  its  normal 
form,  and  there  was  afterward  some  return  of  power  of 
movement,  but  the  patient  died  on  the  fourth  day.  At 
the  necropsy  it  was  found  that  the  cord  was  cleanly  and 
completely  divided  but  the  dura  mater  was  uninjured. 
He  thought  the  operation  in  general  was  not  a  hopeless 
one,  but  that  we  should  not  be  eager  to  operate.  The 
risk  of  the  operation  itself  was  small.  The  dura  mater 
need  not  be  opened,  and  thus  it  was  a  little  more  danger- 
ous to  operate  on  a  case  of  simple  fracture- dislocation 
than  of  compound.  Still  it  must  be  admitted  that  the 
operation  had  its  risks.  He  had  operated  on  another 
case  of  fracture  in  the  cervical  region,  but  the  patient 
died  almost  immediately.  The  necropsy  showed  fracture 
and  hemorrhage  at  the  base  of  the  skull. 

Mr.  Gilbert  Barling  was  quite  in  accord  with  Mr. 
Thorburn.  We  should  beware  of  reckless  operations 
which  would  only  tend  to  bring  laminectomy  into  con- 
tempt. A  knowledge  of  the  nature  of  the  accident 
would  often  forbid  operation,  because  we  may  often  be 
sore  from  the  extreme  violence  in  indirect  injury  that  the 
cord  is  divided  or  pulped,  and  in  that  case  laminectomy 
was  only  "  a  crude  way  of  administering  euthanasia,  in 
which  we  are  not  justified.1'  He  was  quite  sure  that  the 
operation  had  its  own  risks,  and  therefore  it  was  wrong 
to  employ  it  indiscriminately.  He  described  two  cases, 
one  of  direct  violence  to  the  side  of  the  neck  and  arm — 
palsy,  probably  due  to  hemorrhage,  ending  in  sponta- 
neous recovery,  and  another  of  great  indirect  violence 
causing  displacement  of  the  twelfth  dorsal  spinous  proc- 
ess and  palsy  of  the  bladder  and  lower  limbs.  Now 
two  years  after  the  accident  there  was  complete  recov- 
ery except  for  some  patches  of  anaesthesia.  This  pa- 
tient refused  operation.  This  was  one  of  the  most  hope- 
ful cases  for  laminectomy,  yet  the  operation  would  not 
have  improved  the  result. 

Mr.  Barclay,  of  Bristol,  thought  that  there  was  a 
tendency  to  be  too  cautious  in  these  cases,  but  when 
there  was  a  displacement  of  one  vertebra  from  another, 
with  recoil,  operation  was  hopeless.  When,  however, 
there  was  no  recoil  and  obvious  displacement  we  ought 
to  give  the  patient  the  chance  afforded  by  laminectomy, 
and  if  necessary  chisel  away  the  projecting  edge  of  the 
vertebral  body  which  pressed  on  the  cord.  In  cases  ot 
injury  and  displacement  of  a  process  or  processes,  if 
diagnosed,  he  would  operate,  but  the  diagnosis  was  often 
difficult.  In  cases  where  hemorrhage  was  diagnosed  he 
would  also  operate. 

Mr.  Damer  Harrisson  said  that  in  his  opinion  opera- 
tion was  rarely  called  for;    those  cases  which  he  had 


wished  to  operate  on  and  had  been  prevented  had  gen- 
erally recovered.  Fixation  was  the  best  treatment  for 
fracture- dislocation.  He  used  a  box  splint,  flexed  the 
thighs,  and  drained  the  bladder,  when  it  was  palsied,  by  a 
perineal  section,  and  was  thus  enabled  to  prevent  decom- 
position of  urine  and  cystitis. 

Sir  William  Stokes,  of  Dublin,  did  not  think  that 
laminectomy  alone  could  entirely  relieve  pressure,  be- 
cause the  cord  would  still  be  stretched  over  the  project- 
ing body  in  front.  He  did  not  think  removal  of  the 
projecting  body  possible  without  risk  of  increasing  the 
injury  to  the  cord ;  operation  for  direct  injury  was  much 
more  hopeful.  He  found  that  these  patients  did  not 
bear  fixation*  well,  and  there  was  great  risk  of  sloughing 
under  the  gypsum  jacket.  He  had  never  found  any 
need  of  perineal  section,  but  had  succeeded  in  keeping 
the  urine  and  bladder  healthy  by  the  use  of  boric-lotion 
injections. 

Mr.  Reginald  Harrison  detailed  a  case  showing  the 
benefit  of  immediate  extension.  He  agreed  with  Mr. 
Thorburn  and  others  as  to  the  hopeless  injury  caused  by 
indirect  violence. 

Surgeon- Major  Hatch  was  not  very  sanguine  about 
the  operation.  He  had  had  five  cases  at  the  Jamsetjee 
Hospital  in  India ;  of  these  one  was  a  case  of  in- 
jury  to  the  cervical  region  and  four  of  the  dorsal 
region.  In  the  first  case  there  was  meningitis  present 
at  the  time  of  operation.  No  improvement  followed. 
The  patient  died  three  months  afterward.  Necropsy 
showed  that  there  was  no  pressure,  and  only  slight 
narrowing  of  the  lumen  of  the  canal.  Of  the  four  cases 
of  dorsal  injury  three  died  after  laminectomy ;  in  two 
the  projecting  vertebral  body  was  gouged  away  without 
much  difficulty  and  gypsum  applied  in  the  prone  posi- 
tion ;  one  of  these  died,  the  other  improved  after  four- 
teen days,  and  was  still  improving.  Of  the  other  fetal 
cases,  one  was  found  after  death  to  have  an  abscess  on 
the  canal  below  the  lesion,  the  other  died  at  the  end  of 
a  week.  He  thought  that  reduction  of  the  dislocation 
was  not  at  all  necessary.  The  difficulty  of  diagnosis  was 
very  great,  and  therefore  he  would  operate  to  help  the 
diagnosis,  seeing  that  the  prognosis  was  so  bad.  He  did 
not  think  that  secondary  operations  were  hopeful.  He 
believed  there  was  a  future  before  the  operation. 

Mr.  Jordan  Lloyd  said  that  no  one  surgeon  had  a 
large  personal  experience  of  such  cases.  Fractures  of  the 
spine  varied  much  in  severity.  Fixation  gave  good  re- 
sults. Cases  of  indirect  violence  were .  best  left  alone 
(except  for  fixation),  and  he  would  not  consider  opera- 
tion in  them.  Cases  of  direct  injury — generally  in  the 
dorsal  region — were,  however,  amenable  to  operation. 
He  had  only  operated  on  one  case  of  recent  fracture. 
The  patient  died.  He  would  not  operate  on  such  a 
case  to-day.  He  had,  however,  removed  the  laminae  of 
four  or  five  vertebrae,  eight  years  after  the  injury,  for  in- 
continence of  urine  and  faeces,  and  the  patient  recovered 
control  of  them  completely. 

Mr.  Noble  Smith  claimed  to  have  benefited  a  case 
of  fracture  by  the  application  of  a  spinal  support  press- 
ing on  the  projecting  bone.  He  had  performed  lami- 
nectomy in  one  case  eight  years  after  the  accident.  Im- 
provement followed. 

Mr.  Thorburn,  in  replying,  said  that  there  seemed  to 
be  a  general  agreement  as  to  the  facts.  There  were  at  least 
two  hundred  cases  recorded,  and  probably  many  less  suc- 
cessful cases  not  recorded,  hence,  without  waiting  longer 
we  were  in  a  position  to  judge  of  the  value  of  the  opera- 
tion. He  could  fully  confirm  what  Surgeon- Major 
Hatch  had  said  as  to  the  feasibility  of  lateralizing  the 
cord  and  gouging  away  the  projecting  body.  A  mistake  in 
diagnosing  the  exact  site  of  the  injury  was  not  important, 
it  was  easy  to  extend  the  incision  and  go  further  (gener- 
ally higher). 

Flat-foot — Sir  William  Stokes  read  a  paper  on 
flat-foot  and  described  Gliick's  operation  of  section  of 
the  os  calcisand  tendo  Achillis  in  order  to  slide  the  bone 
downward  and  forward.     He  preferred  to  this  and  to 


248 


MEDICAL   RECORD, 


[August  25,  1894 


Ogston's  operation  a  cuneiform  osteotomy  of  the  astrag- 
alus so  as  to  replace  that  bone  within  yon  Meyer's  tri- 
angle. He  showed  casts  of  a  foot  before  and  after  oper- 
ation. 

Mr.  Keetley  preferred  Ogston's  operation,  but  in  a 
severe  case  he  had  had  to  supplement  it  by  osteotomy  of 
the  tibia  and  first  metatarsal  bone,  thus  producing  a  well- 
shaped  foot ;  but  he  was  bound  to  admit  that  the  patient 
herself  preferred  the  other  foot,  which  was  originally 
equally  deformed,  and  had  not  been  operated  on.  The 
pathology  of  this  deformity  was  most  complex. 

Traumatic  Gangrene. — Mr.  Robert  Jones,  of  Liver- 
pool, read  a  paper  on  a  case  of  acute  spreading  traumatic 
gangrene,  treated  by  amputation  and  swabbing  with  pure 
liquefied  carbolic  acid.  The  patient  was  thirty-two 
years  of  age,  and  had  a  compound  fracture  of  the  fore- 
arm. The  gangrene  spread  very  rapidly,  and  at  the  time 
of  amputation  at  the  shoulder- joint  there  was  swelling 
and  crackling  over  the  pectoral  region  and  above  the 
acromion.  The  soft  parts  cut  through  were  dark,  con- 
gested, and  gaseous.  There  were  practically  no  flaps. 
The  wound  and  intermuscular  spaces  were  freely  swabbed 
with  carbolic  acid,  and  this  was  repeated  at  subsequent 
dressings.  Recovery  followed,  hiccough  night  and  day 
being  the  most  distressing  symptom. 

Mr.  Jordan  Lloyd  had  a  somewhat  similar  experience 
in  two  cases,  aged  thirteen  and  fourteen.  After  amputa- 
tion he  plugged  the  wounds  with  lint  soaked  in  1  to 
1,000  sublimate  solution  and  made  some  sixty  inch  or 
half  inch  incisions  into  the  bronzed  and  brawny  tissues 
above.     Both  patients  did  well. 

(Esophageal  Stricture. — Mr.  Kendall  Franks  de- 
scribed a  case  of  dysphagia  from  a  stricture  of  the  oesoph- 
agus just  below  the  cricoid  cartilage.  At  the  opera- 
tion (cesophagotomy)  it  proved  to  be  due  to  a  smooth 
double  fold  of  mucous  membrane  completely  closing  the 
*  lumen,  except  for  a  slit  like  aperture  (imperceptible  from 
above)  a  quarter  of  an  inch  long.  He  excised  the  dia- 
phragm and  sutured  the  edges  of  the  mucous  membrane 
remaining.  The  external  wound  was  closed  around  an 
oesophagus  tube.  The  patient  recovered.  Such  cases 
were  rare,  only  nine  were  recorded  since  the  seventeenth 
century.  The  pathology  was  obscure.  The  general  opin- 
ion was  that  they  were  congenital,  but  in  this  case  the 
patient  (aged  forty-six)  had  only  had  symptoms  for  three 
years.  Could  it  be  the  result  of  prolonged  spasm  of  the 
muscularis  mucosae  and  circular  fibres?  Mr.  Franks  also 
showed  a  drawing  of  a  case  of  development  of  external 
piles  into  fibroid  tumors  after  an  operation  for  internal 
piles. 


Third  Day,  Friday,  August  3D. 

Ovariotomy. — Mr.  Mayo  Robson  read  a  paper  "  On 
a  Consecutive  Series  of  Ovariotomies  performed  in  the 
Surgical  Clinic  at  a  General  Hospital."  He  brought 
forward  the  details  of  216  consecutive  cases,  without  any 
selection,  as  evidence  that  the  claim  of  obstetricians 
to  have  the  monopoly  of  such  cases  was  unfounded. 
General  surgeons  were  the  best  fitted  to  succeed ;  they 
were  prepared  to  deal  with  any  complication  that  might 
arise.  He  had  done  850  abdominal  sections  with  a  mor- 
tality of  twelve  percent.,  including  cases  of  suppurative 
peritonitis  and  one  desperate  case.  Most  of  his  experi- 
ence was  in  the  wards  of  a  general  hospital. 

Of  the  216  cases,  14  died.  Of  these  two  were  cases 
of  malignant  disease,  in  two  there  was  intestinal  obstruc- 
tion, one  was  admitted  with  peritonitis,  in  one  a  fecal 
fistula  existed  and  the  patient  died  eight  weeks  after  the 
operation,  one  had  a  suppurating  cyst,  one  died  of  bron- 
chitis, caused  possibly  by  ether  (on  this  point  he  held 
strong  opinions),  one  from  heart  disease,  one  was  due  to 
hemorrhage  from  slipping  of  ligature  on  pedicle  of  a 
sessile  tumor  caused  by  vomiting ;  one  death  was  traceable 
to  a  collection  of  sewage  under  the  ward.  The  mortality 
was  six  and  a  half  per  cent. 

The  risk  of  sepsis  was  put  forward  by  obstetric  phy- 


sicians as  an  argument  against  the  performance  of  ovari- 
otomy by  surgeons  who  were  frequently  dealing  with 
septic  wounds,  etc.;  but  he  submitted  that  the  obstetri- 
cian who  might  have  been  attending  cases  of  puerperal 
fever,  and  whose  fingers  were  frequently  in  contact  with 
vaginal  and  other  secretions  was  more  likely  to  convey 
infection.  He  thought  further  that  for  these  reasons 
obstetricians  ought  to  leave  ovariotomy  to  surgeons.  As 
to  diagnosis,  the  surgeon  who  was  familiar  with  various 
non-gynecological  diseases  of  the  abdomen  was  more 
likely  to  be  accurate  than  the  specialist.  He  was  strongly 
in  favor  of  the  maintenance  of  the  distinction  between 
the  physician  and  the  surgeon.  He  emphatically  pro- 
tested against  the  pretensions  of  the  obstetricians.  It 
there  was  to  be  any  specialty  let  it  be  that  of  abdominal 
surgery.  If  a  surgeon  is  fit  to  operate  on  the  kidney  and 
the  intestinal  tract,  surely  he  was  fit  to  operate  on  the  fe- 
male organs  of  generation. 

Mr.  Ward  Cousins  warmly  congratulated  Mr.  Rob- 
son  on  his  cases.  He  thought  that  he  scarcely  did  him- 
self justice,  however,  by  including  so  many  complicated 
cases. 

Mr.  Nelson  Dobson  said  that  in  Bristol  ovarian 
tumors  were  operated  on  as  a  rule  in  the  general  wards, 
with  results  as  good  as  those  in  special  wards  elsewhere. 
He  had  seen  a  case  in  which  ovariotomy  was  undertaken 
by  an  obstetric  physician,  which  proved  to  be  one  of  tu- 
mor of  the  kidney ;  the  mistake  was  entirely  pardon- 
able, but  it  involved  the  performance  of  an  operation 
quite  outside  the  operator's  experience,  and  one  he  would 
not  have  undertaken  had  the  condition  been  diagnosed. 

Mr.  Robson,  in  reply,  said  that  he  could  fairly  have 
separated  his  cases  as  Mr.  Cousins  has  suggested,  but  he 
wished  to  give  a  table  that  could  not  possibly  be  cavilled 
at.  If  so  arranged,  his  mortality  would  be  only  ij4  per 
cent.  Uncomplicated  cases  were  very  rare  in  his  expe- 
rience, there  were  nearly  always  adhesions  or  other  com- 
plications, such  as  twisted  pedicle,  which  always  gave 
rise  to  peritonitis.  He  used  a  temporary  ligature  before 
beginning  to  remove  the  cyst,  when  it  was  possible — 
thus  lessening  the  bleeding  in  dividing  adhesions.  He 
could  not  agree  with  one  speaker,  who  claimed  that  gyn- 
ecology was  all  surgery  and  should  be  the  surgeon's 
province.  Many  cases  were  medical,  such  as  those  of 
slight  disease  of  the  uterine  appendages,  which  were  best 
treated  by  medical  means,  such  as  rest,  and  it  was  most 
unjustifiable  to  operate  on  all  these,  for,  apart  from  any 
risk  of  operation,  it  was  certainly  a  disadvantage  to  a 
woman  to  lose  her  ovaries. 

The  President  traced  the  origin  of  the  pretensions  of 
obstetricians  from  the  days  no  operations  were  done  on 
the  abdominal  cavity,  and  the  treatment  of  ovarian  tu- 
mor was  medical.  He  protested  against  women's  hos- 
pitals, officered  by  men  in  general  practice,  who  had  had 
no  surgical  training  since  their  student  days,  and  were 
not  fit  to  suddenly  plunge  into  capital  operations  any 
more  than  he  (Mr.  Banks)  was  to  turn  a  foetus  in  utero. 
He  adverted  to  the  recent  inquiry  at  a  women's  hospital 
in  London,  which  had  involved  the  resignation  of  the 
staff. 

Papers  were  also  read  by  Mr.  J.  Hutchinson,  Jr.,  on 
"Injuries  of  the  Elbow-joint,"  and  by  Mr.  Mansell 
Moullin  on  "  Treatment  of  Enlargement  of  the  Prostate 
by  Removal  of  the  Testes.1 ' 

The  passing  of  a  cordial  vote  of  thanks  to  the  President,, 
moved  by  Mr.  Ward  Cousins,  closed  the  proceedings. 


SECTION  OF  MEDICINE. 

First  Day,  Wednesday,  August  ist. 

Dr.  F.  T.  Roberts,  as  President  of  this  section, 
opened  it  with  a  few  remarks,  in  which  he  urged  the 
necessity  of  broad  views  in  medicine,  deprecated  the 
tendency  to  specialize,  hoped  this  section  would  always 
maintain  its  position,  and  expressed  his  pride  in  being 
asked  to  preside  over  it  this  year. 

Functional  Diseases  of  the  Heart.— Dr.  Douglas 


August  25,  1894] 


MEDICAL  RECORD. 


249 


Powell  said  that  though  the  term  functional  had  been 
objected  to,  he  rather  favored  it  as  useful  to  designate 
disorders  which  were  independent  of  recognizable  change 
of  structure.  In  the  case  of  the  heart,  the  commonest 
causes  of  such  changes  were  nervous  strain,  shock,  acute 
specific  diseases,  and  such  like.  The  result  is  some  im- 
pairment of  the  cardiac  mechanism,  when  the  pulse  is 
affected  in  its  frequency,  tension,  or  rhythm.  He  depre- 
cated the  term  tachycardia.  Many  of  the  cases  so 
termed  resembled  angina  pectoris.  Others  were  more 
like  Graves's  disease.  Pulse  tension  was  most  important, 
and  the  recurrent  pulse  often  found  with  high  tension 
ought  to  be  carefully  distinguished.  Abnormal  slow- 
ness, the  so  called  "bradycardia,"  is  found  as  a  sequel 
of  typhoid  and  influenza,  and  sudden  changes  from  fre- 
quency to  infrequency,  or  a  normal  rate  with  alternation 
to  either,  have  been  found.  Subjective  symptoms  are 
usually  well  marked,  the  patients  being  often  troubled 
with  a  consciousness  of  such  symptoms  as  irregularity  or 
intermittence.  As  to  treatment,  the  causes  of  mental  or 
physical  over-strain  must  be  removed.  Then  iron  and 
arsenic  are  useful,  and  sometimes  trinitrine  may  be  called 
for.  Dr.  Powell  illustrated  his  paper  by  the  following 
tabular  statement : 


I. 


Cardiac  Vascular 
Hyperesthesia. 


Source  of 

Altered 

Innervation. 


c.  Undue  perception  CentTal  heredi- 
of  heart's  action.  .  tary  neurosis, 
normal  or  altered.  I 

•a.  Oppressed  heart's    Central, 
action  with  raised 
arterial        rcsist- 


Cardiac  plexus. 


3.  Angina  pectoris. 
a,  Vena; 
*,  Vera. 


Exciting  Cause,  j      Method.       Rhythm 


I 


I 


Mental  shock, 
nervous  ex- 
haustion. 

Mental  strain, 
nicotine  con- 
stipation, uric 
acid,  uraemia. 

Mental  emotion 
peripheral  ex- 
citement, vis- 
ceral. 


Variable  de-  Variable 
gree  of  ar-  1  varicose 
terial  ten-  '  tension, 
sion.  ' 

Regular,  with  t     Do. 
arhythmic 
interludes. 

V.  M.   excit.  '  Slow,la- 


causing 
ondary  car- 
diac embar- 
rassment. 


bored, 

quick. 


II 


Heart's  Action 
Accelerated. 


Source  of 

Altered 

Innervation. 


Exciting 
Cause. 


Method.       I  Rhythn 


l_ 


Xm  Paroxysmal  palpi- 

Central. 

Intense   voli- 

«,  Shock  ;  b, 

Regular. 

tation  under  men- 

1   tion  in  emer- 

reaction ;  c%  \ 

tal  excitement. 

gencies. 

cardiac. 

1 

pressure ;  </, 

visceral    re- 

1 

laxation. 

a.  Paroxysmal  palpi- 

Central.              1  Vagus  inhibi- 

Irregular. 

tation   fiom  indi- 

tion. 

rect  vagus  excite- 

ment. 

3.  Paroxysmal  palpi- 

Visceral   irrita- 

Anaemia. 

Irregular. 

tation  from  direct 

tion,  strain, 

vagus  excitement. 

pericarditis, 
endocarditis, 

1    nerve    strain, 

hot  bath,  men- 

tal shock. 

4.  V.  M.  relaxation. 

Variable. 

5.  Sustained     hurry 

Regular. 

of  heart.                 1 

Dr.  P.  M.  Chapman  could  not  agree  that  all  causes  of 
functional  derangements  of  the  heart  are  of  nervous  ori- 
gin, as  irritability  of  muscle  undoubtedly  has  a  disturbing 
influence,  and  also  fatty  degeneration.  Slowing  of  the 
pulse  may  be  due  to  irritation  of  the  vagus,  and  the  best 
remedy  is  faradization  of  the  vagus.  Graves's  disease  is 
often  looked  upon  as  incurable,  but  he  does  not  think 
so,  as  he  has  met  with  instances  of  complete  cure.  The 
manometer  is  indispensable  to  accurate  diagnosis. 

Dr.  James  A.  Lindsay  was  of  opinion  that  the  symp- 
toms of  organic  and  functional  heart  derangements  are 
often  identical,  but  after  excitement  are  more  intense 
in  the  former  than  in  the  latter.  The  condition  of  the 
cavity  walls  affords  conclusive  evidence. 

Dr.  Ernest  Sansom  objected  to  the  term  "func- 
tional/' and  instanced  amaurosis,  which  he  defined  as  a 
disease  in  which  the  patient  saw  nothing  and  the  doctor 
saw  nothing.  Similarly,  in  so-called  functional  derange- 
ments of  the  heart,  the  patient  often  felt  a  great  deal  and 


the  doctor  could  find  nothing  wrong.  Acute  pain  might 
be  present  and  yet  the  heart  show  no  sign  of  disease  or 
even  trouble.  "  Fatty  degeneration  "  of  the  heart  was  a 
huge  bugbear;  but  people  do  not  die  of  it  suddenly;  in 
his  opinion  it  was  more  frequently  associated  with  per- 
nicious progressive  anaemia  than  anything  else. 

Dr.  G.  A.  Gibson  had  met  with  cases  of  cardiac  affec- 
tion where  the  pain  was  localized  in  the  hands  or  the 
wrists,  or  in  the  forearms,  and  believed  these  pains  to  be 
due  to  some  profound  change  in  the  heart  itself,  often 
proceeding  from  dilatation,  and  this  was  frequently  re- 
ferred to  as  proceeding  from  nervous  disturbances. 

Dr.  Shingleton  Smith  said  there  was  no  test  for  car- 
diac neuritis,  and  functional  could  not  be  separated  from 
organic  disturbances;  they  were  thoroughly  mixed  in 
such  diseases  as  goitre,  anaemia,  and  perhaps  in  phthisis. 
However,  the  difficulty  of  diagnosis  should  not  be  allowed 
to  cause  hesitation  on  the  part  of  the  medical  man.  He 
found  nitrite  of  amyl  act  admirably  in  modifying  the 
symptoms  in  cases  of  functional  derangement. 

Dr.  Watson  Williams  found  cactus  grandiflorus  a 
specific  in  these  cases ;  and  observed  that  even  in  health 
the  arterial  tension  was  subject  to  variations. 

Dr.  Harry  Campbell  agreed  generally  with  Dr.  Pow- 
ell, but  believes  functional  cardiac  derangements  to  be 
the  outcome  of  nervous  disturbance,  the  result,  as  often  as 
not,  of  heredity.  Heart  attacks  often  simulated  epi- 
lepsy. 

Dr.  Mandford  believed  that  many  cases  of  functional 
derangement  were  due  to  vascular  tension,  and  the  ef- 
fects of  mental  emotion  were  often  identical  with  the  se 
due  to  fatty  degeneration.  In  such  cases  mental,  as  con- 
trasted with  bodily,  rest  was  of  immense  importance,  and 
gave  instances.  Believed  that  even  moderate  doses  of 
alcohol  had  the  most  mischievous  effects. 

Dr.  Tyson  said  the  slow  heart  of  advanced  age  was 
due  to  organic  lesions,  and  instanced  the  case  of  an  old 
gentleman  who  always  had  what  was  supposed  to  be  an 
epileptic  fit  when  the  pulse  fell  to  22.  Attacks  of  "  slow 
heart "  were  apt  to  come  on  in  the  night  in  elderly  people 
who  had  partaken  freely  of  supper,  and  were  due  to  press- 
ure by  a  loaded  organ  and  the  recumbent  position.  He 
advised  food  to  be  taken  in  the  early  rather  than  a  latter 
part  of  the  evening,  a  recommendation  that  was  received 
with  much  applause. 

Dr.  James  Barr  said  that  the  cardiac  irregularities 
were  evidenced  by  variations  in  the  pulse,  and  that 
the  right  side  was  stronger  than  the  left.  He  had 
seen  the  right  auricle  contract  for  four  hours  after  the 
rest  of  the  heart  had  ceased  to  beat.  It  was  the  stimula- 
tion of  the  blood  that  excited  the  action  of  the  heart, 
and  as  the  right  side  was  the  first  to  receive  the  vital 
fluid  it  was  necessarily  the  stronger  of  the  two ;  corres- 
pondingly, it  was  the  first  to  suffer  from  overwok. 

Dr.  Rattray  related  his  experience  with  the  one 
word  paraldehyde,  which  satisfied  both  the  patient  and 
the  doctor. 

Dr.  F.  T.  Roberts,  in  summing  up,  said  that  he  be- 
lieved in  purely  functional  derangements  of  the  heart, 
and  they  caused  much  suffering  when  there  was  nothing 
wrong  organically ;  he  had  frequently  experienced  it  in 
persons,  also  in  students  coming  up  for  examination. 
Tobacco  was  a  fertile  source  of  functional  cardiac  dis- 
turbance, and  so  was  alcohol.  Many  doctors  were  quite 
satisfied  when  they  detected  a  bruit,  but  he  did  not 
believe  that  an  apical  murmur  signified  much.  He 
believed  also  that  application  of  lanolin  to  the  apical 
cardiac  region  would  be  vastly  more  beneficial  than  drugs 
in  such  cases. 

Dr.  Powell  replied,  and  alluded  to  the  incompressible 
pulse,  which  he  did  not  deny ;  he  thought  that  cardiac 
pain  was  an  erroneous  expression,  as  the  heart  itself  felt 
no  pain.  He  expressed  his  great  satisfaction  that  the 
discussion  on  the  functional  diseases  of  the  heart,  which 
he  had  had  the  honor  to  open,  had  been  characterized 
by  so  much  interest  on  the  part  of  those  who  had  par- 
ticipated in  it. 


250 


MEDICAL  RECORD. 


[August  25,  1894 


Second  Day,  Thursday,  August  2D. 

Pyrexia  and  its  Treatment— Dr.  Hale  White  opened 
the  discussion,  giving  an  able  r£sum6  of  all  that  is  at 
present  known  of  pyrexia  and  the  various  means  resorted 
to  to  combat  it. 

Dr.  Douglas  Powell  had  seen  in  influenza  a  sub- 
normal temperature  quickly  followed  by  a  relapse,  and 
this  because  the  fall  was  due  to  nervous  influences. 
Pyrexia,  he  thought,  was  as  normal  a  feature  of  disease  as 
the  ordinary  temperature  of  the  body  was  of  health,  and 
he  had  thought  he  had  seen  harm  result  from  lowering  it 
below  the  standard  of  the  disease. 

Dr.  Garrett-Anderson  considered  that  temperature 
was' comparatively  unimportant,  and  instanced  the  case 
of  relapsing  fever.  The  temperature  of  children  runs  up 
very  easily ;  also  in  the  case  of  women,  where  there  is 
more  nervous  susceptibility  than  in  the  case  of  men. 
The  temperature  of  a  child  might  run  up  to  1010  F.  and 
above  it,  without  portending  anything  serious;  the  human 
body  was  not  rigidly  bound  down  to  a  temperature  of 
98.40  F.  Then  there  was  the  high  temperature  of  anae- 
mia. Had  known  good  results  follow  the  raising  of  the 
head  of  the  bed,  and  from  the  use  of  the  Swiss  bath. 

Dr.  Osler,  of  Baltimore,  mentioned  the  high  temper- 
ature of  chorea,  which  was  due  to  the  increased  muscular 
action ;  the  more  violent  the  muscular  contractions,  the 
higher  the  temperature,  which  he  had  known  rise  to  1060 
and  1070.  Cases  that  present  a  low  temperature  at  first 
may  often  rise  to  an  abnormal  height.  Systematic  cold 
bathing  in  typhoid  fever  was  as  much  on  account  of  the 
toxaemia  that  existed  as  on  account  of  the  pyrexia ;  was 
surprised  this  plan  of  treating  pyrexia  had  not  found 
greater  favor  than  it  had  in  the  English-speaking  com- 
munities of  the  world.  The  hydro  therapeutic  system  of 
combating  disease  had  certainly  decreased  the  mortality. 
Did  not  believe  that  the  use  of  the  cold  bath  diminished 
the  tendency  to  relapse. 

Dr.  S.  Smith  thought  it  was  strange  that  after 
twenty-five  years  of  trial  it  should  still  be  necessary  to 
discuss  the  question  of  the  cold  bath  in  the  treatment  of 
pyrexia;  but  the  introduction  into  practice  of  various 
antipyretic  medicaments  has  done  away  with  its  necessity, 
though  there  were  cases  in  which  nothing  else  would 
serve.  He  thought  the  bath  might  be  dispensed  with 
where  the  fever  could  be  kept  under  by  the  use  of  anti- 
pyretics. He  had  never  know  any  harm  to  result  from 
administering  a  moderate  dose  of  antipyrin  every  hour, 
and  if  this  could  be  done  the  patient  should  not  be  sub- 
jected to  the  inconvenience  and  shock  of  being  plunged 
into  a  cold  bath ;  but  where  drugs  failed  the  bath  was 
necessary. 

Dr.  M.  Skerritt  rather  liked  the  bath,  and  preferred 
quinine  to  any  other  of  the  antipyretic  class  of  drugs, 
but  in  large  doses,  say  from  thirty  to  forty  grains  for  an 
adult.  The  tendency  to  relapse  was  less  frequent  after 
the  use  of  quinine  than  after  the  administration  of  drugs 
the  action  of  which  was  more  rapid.  As  long  as  there 
was  breath  in  the  body  it  was  not  too  late  to  administer 
the  cold  bath ;  he  instanced  the  case  of  a  man  who  was 
actually  moribund  and  recovered  from  typhus  fever  after 
being  placed  in  a  bath  of  cold  water.  Had  also  found  it 
useful  in  cases  of  rheumatic  fever. 

Dr.  Pope  queried  whether  a  high  temperature  was  not 
an  advantage  to  the  subject  of  a  bacterial  invasion,  other- 
wise why  should  it  have  been  perpetuated?  The  pro- 
duction of  heat  was  due  to  increase  of  the  heart's  action, 
and  antipyretics  act  by  reducing  that  action.  Found 
the  injection  of  cold  water  into  the  rectum  of  great 
benefit. 

Dr.  Tyson  did  not  consider  moving  a  patient,  even 
when  excessive  pyrexia  was  present,  to  be  injurious ;  far 
more  harm  was  likely  to  result  if  the  temperature  had 
fallen  below  the  normal.  The  high  temperature  so  often 
met  with  in  children  readily  disappeared  after  the  ad- 
ministration of  an  aperient.  He  deprecated  the  practice 
of  permitting  young  children  to  paddle  in  the  sea,  and 


believed  it  often  was  the  cause  of  their  temperature  rising 
to  an  alarming  height. 

Sir  T.  Grainger  Stewart  thought  no  medical  prac- 
titioner could  be  adverse  to  the  cold  bath ;  much  depres- 
sion followed  the  use  of  drugs.  What  was  the  best  tem- 
perature for  the  antipyretic  bath?  65 °  to  700  F.  he 
found  distressed  patients,  and  would  not  advocate  it  ex- 
cept in  severe  cases ;  cold  or  tepid  sponging  was  to  be 
preferred,  or  the  rapid  changing  of  ice-cloths  placed  on 
the  abdomen.  The  ice-pack,  too,  was  of  use.  When  he 
had  recourse  to  the  bath  he  used  it  warm,  and  gradually 
cooled  it  by  the  addition  of  cold  water  until  the  desired 
effect  was  produced ;  it  was  thus  a  less  shock  to  the  system 
than  plunging  the  body  at  once  into  cold  water.  In 
rheumatism  he  had  not  found  it  so  useful  as  in  fever,  but 
in  pneumonia  he  had  seen  good  results  follow  its  use. 
He  thought  it  very  likely  that  climatic  influences  had  a 
great  deal  to  do  with  those  varying  results. 

Dr.  Osler  thought  the  bath  of  primary  importance,  it 
had  been  carried  out  successfully  at  Montreal  and  Bris- 
bane and  all  intermediate  points.  It  was  disagreeable  to 
the  patient  and  the  doctor,  and  if  a  better  plan  could  be 
devised  he  would  abandon  it,  but  as  he  saved  many  lives 
by  its  use  he  would  continue  to  have  recourse  to  it  if  it 
were  to  cause  as  much  more  inconvenience  and  trouble 
than  it  did ;  his  only  object  was  to  save  life. 

Dr.  Herbert  Snow  was  surprised  that  do  one  should 
have  mentioned  a  well  known  antipyretic  formerly  much 
in  vogue,  namely,  calomel ;  it  acted,  he  thought,  in  a 
twofold  manner,  aperiently  and  antiaeptically,  by  its  con- 
version into  bichloride  of  mercury. 

Dr.  W.  G.  Kemp  applied  heat  in  the  form  of  hot  bottles 
to  the  feet  when  'depression  followed  the  administration 
of  a  cold  bath.  The  lecturer  had  spoken  of  daily  baths. 
He  advocated  one  every  four  hours.  The  danger  of 
moving  the  patient  was  readily  obviated  by  attention. 
He  thought  doctors  lost  a  great  deal  by  not  using  aconite 
more  freely,  and  recommended  that  die  most  prominent 
symptom  should  be  first  attacked,  it  was  the  disease. 
When  antipyretics  failed  to  produce  their  effect  there  was 
something  beyond  pyrexia  in  the  background. 

Dr.  Heath  favored  antipyrin,  had  a  case  of  pneumo- 
nia with  a  temperature  of  106.  i°  in  a  lad  of  thirteen 
years,  gave  forty  grains  of  antipyrin  in  ten -grain  doses 
every  hour,  and  saved  the  boy,  his  own  son.  Had 
found  much  advantage  from  the  administration  of  creosote 
in  the  pyrexia  and  night  sweats  of  phthisis.  The  suck- 
ing of  ice  was  useful  and  agreeable  to  the  patient,  but 
cold  baths  were  not  applicable  in  private  practice.  He 
believed  that  the  man  who  ordered  them  would  soon 
find  himself  without  any  patients.  He  believed  that  the 
type  of  all  diseases  was  much  lower  to  day  than  a  few 
years  ago. 

Dr.  Garrett- Anderson  said  that  the  relation  of  idio- 
syncracy  to  pyrexia  was  too  often  overlooked. 

Dr.  Mahomed  had  no  faith  in  antipyrin,  he  believed 
it  killed  a  relative  of  his;  has  faith  in  quinine  and  ice- 
pack. 

Dr.  Bently  practised  for  fifteen  years  in  the  tropics, 
and  gave  quinine  in  malarial  fever  in  combination  with 
sulphate  of  magnesia.  Alone,  he  found  it  had  no  effect. 
He  found  ice  and  packing  of  great  use  in  cholera,  even 
when  there  was  collapse.  In  cases  of  influenza  he  used 
antipyrin  and  salycin  combined. 

£>r.  Roberts,  in  summing  up,  thought  pyrexia  was 
often  due  to  unsuspected  nerve  lesions,  and  that  removal 
could  be  effected  with  advantage  in  most  cases  except 
those  of  typhoid  fever.  He  believed  the  possession  of 
a  clinical  thermometer  was  not  an  unmixed  blessing-— to 
the  doctor,  yes;  to  the  patient  and  the  patient's  friends, 
no. 

Dr.  Hale  White,  in  replying,  said  he  would  gladly 
take  away  every  clinical  thermometer  from  the  patients 
and  their  friends,  who  were  often  needlessly  alarmed  by 
its  readings ;  ten  minutes  was  long  enough  to  keep  a 
patient  in  the  bath ;  a  lowering  of  the  temperature  was 
not  necessarily  a  sign  of  improvement. 


August  25.  1894] 


MEDICAL   RECORD. 


251 


Third  Day,  Friday,  August  3D. 

The  Section  met  earlier  and  for  a  shorter  time  this 
day  and  not  so  many  were  in  attendance,  and  of  these 
some  were  anxious  to  get  away  by  an  early  train,  and 
others  to  attend  the  concluding  general  meeting  where 
the  address  in  Public  Medicine  was  to  be  given. 

Ataxia. — Dr.  Ormerod  opened  the  discussion  on  this 
subject.  He  remarked  that  swaying  about  of  the  body 
when  the  eyes  were  closed  was  an  indication  of  the  ex- 
istence of  this  disease ;  curious  to  say,  a  blind  ataxic  was 
affected  in  the  same  way  when  the  eyes  were  shut. 
Ataxia  was  a  symptom  of  disease  in  various  parts  of  the 
body,  but  especially  of  cerebellar  lesions,  and  less  so  of 
the  cerebral  hemispheres,  the  staggering  was  due  to  pa- 
ralysis of  the  muscles  of  the  back  and  legs.  Disease  of 
the  corpora  quadrigemina  gave  rise  to  a  rolling  gait. 
Disease  of  the  spinal  cord  was  not  limited  to  any  set  of 
transverse  fibres,  but  was  most  common  where  disease  of 
the  posterior  part  of  column  existed  ;  it  was  a  late  symp- 
tom of  locomotor  ataxy.  Motor  weakness  may  exist  in 
conjunction  with  ataxia.  Toxic  influences,  expecially 
alcoholic,  set  up  ataxia,  also  follow  rheumatism  and 
gout.  Ataxia  runs  in  families  and  is  ranked  with  tabes, 
but  he  thought  wrongly.  Hereditary  ataxia  is  of  the 
cerebellar  type,  begins  in  the  legs  and  works  up.  Fried- 
reich's disease  is  hereditary  affection  of  spinal  cord. 

Dr.  Roberts  said  he  did  not  know  much  about  ataxia, 
except,  perhaps,  as  a  subject  for  examination. 

Dr.  Andriezen,  of  India,  said  forms  of  ataxia  were 
due  to  alcoholism  and  to  insanity,  with  a  rapid  breaking 
down  of  the  brain  tissue ;  also  to  tabes  which  involved 
the  nerve  cells  in  posterior  tract. 

Dr.  Waldo  thought  it  was  a  symptom  of  brain,  spinal 
cord,  and  peripheral  nerve  lesions,  as  well  as  of  function- 
al disturbances,  as  in  hysteria.  Walking  backward  was 
the  surest  test  for  ataxia. 

Dr.  Gordon  thought  Dr.  Ormerod's  classification  was 
pathological,  and  that  a  good  clinical  one  was  still  a 
desideratum.  The  muscles  were  less  paralyzed  than  not 
acting  in  unison,  not  backing  each  other  up  properly. 
In  chorea  the  attempt  at  voluntary  movement  provoked 
involuntary  movements  of  other  muscles.  Some  thought 
it  was  a  functional  disease,  but  there  was  always  hyper- 
emia, which  had  been  said  only  to  exist  in  cases  that 
went  on  to  a  fatal  termination. 

Dr.  Dawson  Williams  said  that  ataxia  might  follow 
any  of  the  acute  diseases,  even  malaria.  This  association 
of  ataxia  with  acute  diseases  lent  support  to  the  syphilitic 
theory  of  tabes. 

'Hereditary  Ataxia.— Dr.  Mitchell  Clarke  pre- 
sented a  patient,  twenty-one  years  of  age,  suffering  from 
Friedreich's  disease.  The  following  was  the  family  his- 
tory :  Father's  father  died  at  eighty-three  years  of  age, 
he  was  healthy ;  cause  of  death  being  old  age.  Father's 
mother  died  aged  seventy-six,  of  apoplexy.  Father's 
one  brother  committed  suicide.  Father's  one  sister  died 
of  heart  disease.  Mother's  father  living,  aged  seventy- 
t*o,  healthy.  Mother's  mother  died  of  heart  disease. 
Mother's  one  brother  healthy.  Mother's  two  sisters  died 
of  diabetes  within  a  few  months  of  each  other.  Patient 
has  one  brother,  aged  seventeen,  affected  in  same  way; 
one  sister,  aged  fourteen,  strong  and  well.  Three  other 
children  were  still  born,  but  no  further  evidence  of  syph- 
ilis in  parents  could  be  obtained.  Patient  himself  has 
never  had  any  bad  illness.  No  other  case  in  family ;  no 
cousins  affected  with  nervous  disease.  From  the  age  of 
eight  till  thirteen  he  was  continually  frightened  by  his 
parents'  quarrelling.  In  both  brothers  symptoms  are 
similar.  The  first  symptoms  noticed  were  the  difficulty 
in  standing  and  walking,  especially  in  the  dark,  the  pe- 
culiar gait  and  inco  ordination  of  movements.  Onset 
about  five  years  ago;  probably  early  symptoms  not  no- 
ticed ;  in  brother  first  came  on  about  the  age  of  twelve. 
Course  slowly  progressive,  especially  as  to  muscular 
power,  but  remissions  occur. 

A  second  case  was  that  of  a  pale,  pasty-faced  man 


thirty-five  years  of  age,  fairly  well  nourished.  He  had 
lost  the  greater  part  of  his  hair.  He  never  had  any 
severe  illness ;  has  had  gonorrhoea,  but  not  syphilis.  He 
never  had  fits,  or  any  loss  of  consciousness.  He  is  said, 
when  aged  five  years,  to  have  looked  "silly" — that  is, 
he  could  not  stand  still,  rocked  to  and  fro  when  stand- 
ing, and  kept  his  mouth  open ;  he  had  frequent  falls, 
and  appeared  to  throw  himself  about  when  walking.  He 
worked  as  an  errand-boy  till  the  age  of  twenty,  when  he 
had  to  leave  off  on  account  of  falling  frequently  and 
dropping  the  things  he  carried.  Since  then  he  had  been 
unable  to  work  in  consequence  of  growing  clumsiness 
and  weakness,  the  latter  gradually  increasing  so  much 
that  he  has  become  unable  to  stand  without  support. 

The  father  of  the  patient,  a  butcher,  suffered  from  heart 
disease  and  dropsy,  and  died  in  an  asylum,  apparently 
of  melancholia.  His  parents  died  of  old  age,  his  father 
living  to  be  ninety-six ;  one  of  his  sisters  committed  sui- 
cide; family  healthy.  The  mother  is  still  living.  Her 
father's  father  died  at  the  age  of  ninety-nice,  and  her 
mother  at  the  age  of  one  hundred  and  one.  Her  father 
lost  all  his  hair  before  he  was  thirty  years  old,  and  died 
of  diabetes;  her  mother  died  at  the  climacteric  period. 
There  were  two  other  sons  and  another  daughter,  all  of 
whom  survive.  They  had  fourteen  children:  1,  Geor- 
gina,  aged  thirty-seven,  healthy ;  2,  Albert,  aged  thirty- 
five  (one  of  the  patients);  3,  George  (drowned);  4, 
Isaac  (died  of  croup) ;  5,  a  son,  aged  twenty  five  (ex- 
amined and  found  healthy) ;  6,  William,  and  7,  Mary 
Ann  (both  died  at  the  age  of  five  months,  of  "  weak- 
ness"); 8,  Lizzie,  aged  twenty  one  (examined  and 
found  healthy) ;  9,  a  daughter  (died  at  the  age  of  one 
month,  overlaid) ;  10,  Caroline,  aged  eighteen  (one  of 
the  patients) ;  n,  Isaac  (died  at  the  age  of  three  years, 
of  croup) ;  12,  John,  aged  fourteen  (examined  and  found 
healthy) ;  13,  Isaac,  aged  eleven  (one  of  the  patients]) ; 
14,  a  child  prematurely  born  at  seven  months  (died  in 
three  days).  The  father  was  a  heavy  drinker;  no  evi- 
dence of  syphilis  could  be  obtained.  The  mother  is  a 
strong,  healthy  woman,  and  does  hard  work.  Has  never 
suffered  from  fits,  from  any  nervous  affection,  or  any  se- 
vere illness.  She  was  carefully  examined  as  to  state  of 
reflexes,  etc.,  and  found  to  be  normal  in  every  respect. 

Tabes  Dorsalis. — Dr.  Clarke  then  presented  a  third 
patient  with  locomotor  ataxia. 

Symptoms  in  1892.— Chas.  O ,  aged  fifty-three; 

weight,  12  stone  21  pounds;  has  had  syphilis.  Illness 
began  two  years  ago  with  lightning  pains  in  legs,  diffi- 
culty in  walking,  numbness  and  loss  of  power  in  hands, 
girdle-pain,  and  giddiness  increased  in  the  dark. 

March  2,  1889. — Ataxy,  both  of  legs  and  arms,  by  far 
most  marked  in  the  latter;  there  is  considerable  weak- 
ness of  leg  muscles,  with  uncertain  and  high-stepping 
gait;  movements  of  hands  show  great  ataxy;  he  can 
only  button  his  coat  with  difficulty  and  most  clumsily ; 
knee-jerk  present  on  the  left  side,  just  obtained  on  tie 
right  side.  Right  pupil  does  not  react  to  light,  left  re- 
acts only  over  one-third  part  of  circumference  on  tem- 
poral side  (no  other  sign  of  iritis).  Paralysis  of  right 
external  rectus;  optic  disks  pale;  both  fields  of  vision 
irregularly  contracted.  Static  ataxia  and  Romberg's 
symptom  well  marked.  The  metatarsal  joint  of  right 
great  toe  is  affected  with  a  tabic  arthropathy.  Pains 
five  years ;  difficulty  in  micturition  two  years.  His  state 
in  February  was  as  follows:  No  loss  of  sensation,  gait 
extremely  ataxic,  inability  to  turn  round  and  to  stand 
with  eyes  shut  and  feet  together ;  could  not  walk  with- 
out a  stick ;  myosis  and  inequality  of  pupils ;  Argyll- 
Robertson  phenomena;  loss  of  sexual  power,  knee-jerks 
absent,  gastric  and  laryngeal  crises;  rectal  pains,  and 
lightning  pains  in  legs  of  great  severity  nearly  every  day. 

Dr.  Ormerod,  in  reply,  said  he  was  glad  those  who  had 
taken  part  in  the  discussion  had  in  the  main  agreed  with  him. 

Dr.  Roberts  said  that  brought  the  meetings  of  the 
Section  to  a  close.  He  thanked  all  for  their  good  be- 
havior, and  said  further  that  what  he  had  looked  for- 
ward to  with  dread  had  proved  a  pleasure. 


*52 


MEDICAL  RECORD. 


[August  25,  1894 


Hero  %nstvtxmmts. 


A  NEW  ELECTRODE 
APPLICATIONS  OF 
RENT. 


FOR  HYDRO- ELECTRIC 
THE    CONSTANT    CUR- 


By   MARGARET  A.   CLEAVES,  M.D., 

NEW  YORK. 

INSTRUCTOR  IN  ELECTRO-THERAPEUTICS,   NEW    YORK    POST- GRADUATE    MEDICAL 
SCHOOL  AND  HOSPITAL. 

In  the  treatment  of  pelvic  exudates,  ovaritis,  vaginitis, 
simple  and  specific,  pruritus  vulvae,  and  eczema  of  the 
vulva,  I  have  often  felt  the  need  of  applying  the  con- 
stant current  in  such  a  manner  that  every  part  of  the 
diseased  tissue,  of  whatever  nature,  would  be  influenced 
by  it.  This  is  impossible  with  any  electrode  with  which 
I  am  familiar.  All  of  the  electrodes  for  the  application 
of  the  constant  current  in  these  conditions,  whether 
metal  or  carbon  balls  wrapped  with  absorbent  cotton, 
or  clay  and  covered  with  gauze,  I  have  found  objection- 
able. In  the  first  place,  these  electrodes  can  never  be 
used  but  for  one  application  without  being  re-made, 
otherwise  there  is  danger  of  sepsis.  Second,  because  of 
the  very  great  danger,  even  in  careful  hands,  of  produc- 
ing an  eschar,  a  danger  greatly  intensified  in  the  hands 
of  the  non-expert.  Third,  because  of  the  impossibility 
of  bringing  every  part  of  the  diseased  tissue  under  the  in- 
fluence of  the  current,  or  of  utilizing  the  cataphoric 
property  of  the  current  in  order  to  diffuse  into  the  tis- 
sues such  drugs  as  would  be  indicated,  especially  in  dis- 


eases of  the  vulva  and  in  vaginitis,  simple  and  gonor- 
rhoea. Some  time  since  I  adopted  the  plan  of  bringing 
masses  of  pelvic  exudates  under  the  influence  of  the  neg- 
ative pole  by  the  use  of  the  Baudet  de  Paris  method. 
This  method  was  originally  intended  to  be  used  for  con- 
stipation and  intestinal  obstruction.  The  bowel  is  dis- 
tended, to  the  toleration  of  the  patient,  with  salt  water, 
which  serves  as  the  electrolyte,  and  to  the  electrode  is 
attached  the  negative  pole,  the  indifferent  electrode  (an 
Apostoli  pad)  being  placed  over  the  abdomen  of  the  pa- 
tient. It  has  been  possible,  in  this  way,  to  bring  the  ex- 
udative matter  in  the  pelvis  well  under  the  influence  of 
the  constant  current,  and  this  without  the  slightest  dan- 
ger of  producing  a  caustic  action  or  untoward  disturb- 
ance of  any  sort.  Rectal  applications,  however,  are 
open  to  serious  objection,  unless  absolutely  necessary. 
In  casting  about  in  my  mind  for  a  better  method,  the 
idea  occurred  to  me  of  a  vaginal  electrode,  constructed 
in  such  a  way  as  to  enable  me  to  apply  the  constant  cur- 
rent in  the  form  of  a  douche,  either  negative  or  positive, 
and  at  the  same  time  to  carry  out  any  indication  for 
cataphoric  medication,  or  the  diffusion  of  medicated  so- 
lutions into  the  diseased  tissues. 

The  external  part  of  the  electrode,  shown  in  the  cut, 
is  of  hard  rubber,  the  handle  of  which  is  filled  in  with  a 
brass  rod  from  the  point  of  attaching  the  rheophore  at 
A,  up  to  the  attachment  of  the  hose  of  the  fountain- 
-syringe  at  B.  From  B  to  the  end  of  the  tube  C,  where 
the  perforated  cap,  D,  screws  on,  it  is  lined  with  a  tube 
of  carbon. 

Brass,  aluminum,  and  tin  were  all  tried,  but  with  the 
former  only  the  negative  pole  could  be  used,  with  alumi- 


num positive  currents  and  diffusion  of  certain  drugs  was 
possible,  but  with  even  mild  negative  currents  this  metal 
was  attacked.  Block  tin  was  too  readily  oxidized  to 
make  it  advisable,  and  the  expense  of  platinum  and  gold 
precluded  their  use ;  therefore,  carbon  was  selected,  and 
it  bids  fair  to  answer  every  purpose.  The  electrode 
must,  of  necessity,  be  straight,  and  cannot  be  curved  as 
it  could  with  a  metal  tube ;  this,  however,  seems  to  me 
of  but  little  moment.  The  shield,  Et  is  movable,  and 
has  two  rows  of  perforations  through  which  the  surplus 
water  drains  into  the  tube,  F.  To  this  drainage-tube  is 
affixed  a  few  feet  of  rubber  hose,  of  less  diameter  than 
that  on  the  fountain  syringe  through  which  the  water  or 
the  medicated  solution  gains  egress  into  the  vagina,  in 
order  to  retard  the  drainage  and  keep  the  vagina  dis- 
tended during  the  time  of  administration  of  the  current 
This  drainage  hose  is  dropped  into  a  jar  at  the  foot  of 
the  operating- table,  the  syringe-hose  is  attached  at  £, 
the  rheophore  tip  at  A,  and  the  vagina  allowed  to  be- 
come well  distended  with  the  water  or  medicated  solu- 
tion, before  the  current  is  turned  on.  By  firm  and  even 
pressure  of  the  shield  over  the  ostium  vaginae,  with  the 
labia  folded  out,  so  as  to  occasion  no  discomfort  to  the 
patient,  it  is  possible  to  administer  any  quantity  of  the 
douche,  one  to  three  or  more  quarts,  without  getting  a 
drop  upon  the  patient's  clothing. 

I  have  arranged  to  have  a  cushion  of  soft  rubber  placed 
over  the  edge,  as  is  done  in  ether  inhalers,  as  will  be  seen 
in  the  cut.  The  suction  action  thus  produced  will  ren- 
der it  possible  at  any  time  that  full  distention  of  the  vag- 
ina is  obtained,  to  maintain  the  same,  by  shutting  off 
the  drainage-tube  by  means  of  a 
clamp.  The  surplus  water,  how- 
ever, that  remains  with  continuous 
drainage  is  enough  to  penetrate 
every  fold  and  rugae  of  the  vaginal 
mucous  membrane,  as  I  have  de- 
monstrated by  cutting  off  the  inflow 
and  taking  note  of  the  amount  re- 
maining as  it  drained  away. 

The  instrument  is  made  with 
three  different  sizes  of  perforated 
caps,  the  smallest  and  largest  with 
perforations  at  the  side  for  vaginal 
use,  while  the  medium  sized  cap  not 
only  has  the  perforations  at  the  side,  but  at  the  end 
as  well,  and  is  to  be  used  for  rectal  applications.  To 
convert  the  instrument  into  a  rectal  electrode,  the  shield 
should  be  withdrawn.  It  will  readily  be  seen  that  there 
is  no  point  of  contact  of  the  conducting  material  of  the 
electrode  with  the  mucous  membrane  in  either  rectal  or 
vaginal  applications.  The  salt  water  or  the  medicated 
solution,  whatever  its  nature,  is  the  electrolyte.  As  I 
have  intimated,  this  method  of  rectal  application  origi- 
nated with  M.  Boudet,  of  Paris. 

I  have  thus  far  used  this  douche  electrode  in  cases  ol 
pelvic  exudates,  chronic  ovaritis,  salpingitis,  chronic 
vaginitis,  and  in  chronic  eczema  of  the  vulva.  In  a  case 
of  chronic  vaginitis  and  eczema  of  the  vulva  of  twenty 
years'  standing,  with  the  most  intolerable  itching,  for 
which  the  patient  had  resorted  to  various  means  for  re- 
lief, and  obtained  none,  I  have  found  this  electrode  of 
the  greatest  value.  In  this  case  the  entire  mucous  mem- 
brane of  the  inner  aspect  of  the  labia  was  thickened, 
leathery,  and  fissured.  At  the  ostium  urethra  and 
vaginae  the  color  was  an  intense  crimson.  The  same 
condition  extended  into  the  vagina.  There  was  extreme 
sensitiveness  upon  digital  examination,  and  the  patient 
was  worn  and  harassed  by  the  continued  irritation  from 
which  she  had  not  been  free  in  all  these  years,  despite  the 
heroic  measures  that  had  been  used  to  insure  recovery. 
After  one  application  of  the  negative  galvanic  current  in 
the  form  of  a  douche,  there  was  marked  relief  from  the 
constant  irritation  and  a  tendency  to  heal  on  the  part  of 
the  fissures.  After  four  applications  had  been  given,  ex- 
tending over  a  period  of  two  weeks,  the  mucous  mem- 
brane was  found  to  be  as  sound  and  whole  as  that  of  a 


August  25,  1894] 


MEDICAL   RECORD. 


*53 


child,  and  the  congestion  at  the  mouth  of  the  vagina 
and  urethra  had  entirely  disappeared,  the  mucous  mem- 
brane having  returned  to  its  normal  color  and  condition. 
There  was  complete  cessation  of  the  itching  which  had 
made  the  patient's  life  wellnigh  intolerable,  and  a  most 
marked  improvement  manifest  in  her  general  appearance. 

In  making  the  application,  the  tendency  is  for  the 
electrolyzed  water  to  flow  out  against  the  shield,  and  in 
that  way  to  come  in  contact  with  every  part  of  the  mu- 
cous membrane  of  the  vulva.  Patients  find  this  method 
of  applying  the  current  exceedingly  tolerable,  and  in  the 
conditions  for  which  I  have  used  it  thus  far  there  has 
been  an  invariable  expression  of  relief  following  its  use. 

It  is  my  purpose,  in  having  the  electrode  constructed 
of  an  unoxidizable  medium,  to  use  it  not  only  for  the 
application  of  the  constant  current,  but  also  for  the  pur- 
poses of  cataphoric  medication.  In  gonorrhceal  vagini- 
tis— a  condition  which  is  recognized  as  extremely  diffi- 
cult to  treat — it  will  be  possible  by  this  method  to  bring 
not  only  the  os  and  cervix  uteri,  but  every  interstice  of 
the  vagina  as  well,  under  the  influence  of  the  medicated 
solution  and  thus  combat  the  specific  condition.  The 
feet  that  the  gonococcus  penetrates  the  submucous  struct- 
ures, makes  it  very  desirable  that  we  should  be  able  to 
apply  our  remedies  in  such  a  manner  as  to  insure  their 
destruction.  By  cataphoric  medication  this  is  possible, 
as  the  medicament  not  only  comes  in  contact  with  the 
mucous  membrane,  but  is  caused  to  penetrate  more  or 
less  deeply  into  its  structure  according  to  the  strength  of 
the  current  and  the  length  of  the  application. 

By  means  of  anodal  diffusion,  a  solution  of  sulphate  of 
copper  of  requisite  strength  could  be  used  to  advantage 
in  gonorrhoeal  cases.  In  the  later  stages  of  gonorrhoea, 
in  conditions  of  pelvic  congestion,  uterine  catarrh,  and 
in  some  leucorrhceas,  hydrastine  thus  diffused  would  be  of 
much  greater  efficacy  than  in  its  ordinary  administration 
by  the  mouth,  or  by  means  of  vaginal  injections.  Bi- 
chloride of  mercury  in  solution  could  also  be  used  accord- 
ing to  the  indications  and  in  strength  of  from  one  to 
one  thousand. 

That  drugs  thus  used  enter  the  local  and  ultimately 
the  general  circulation,  no  longer  admits  of  doubt.  This 
diffusion  takes  place,  as  a  rule,  from  the  positive  to  the 
negative  pole,  but  in  some  instances  from  the  negative  to 
the  positive. 

In  the  treatment  of  syphilis,  Gartner '  and  Ehrmann 
obtained  not  only  the  specific  action  of  bichloride  of 
mercury  upon  the  disease,  but  ascertained  its  presence  in 
the  urine  as  well  after  from  fifteen  to  twenty  minutes' 
treatment  with  the  galvanic  bath,  containing  from  four 
to  six  grammes  of  the  drug.  The  positive  pole  was  used 
and  a  current  strength  of  100  milliamp&res.  These  ex- 
periments have  been  corroborated  by  Kroneld  in  Pro- 
fessor Lang's  clinic  in  Vienna. 

In  the  treatment  of  gouty  joints  with  bromide  of 
lithium  cataphoresis,  lithium  has  also  been  found  in  the 
urine. 

By  means  of  the  rectal  electrode,  if  the  conducting 
medium  is  of  an  unoxidizable  material,  cataphoric  medi- 
cation may  be  utilized  to  advantage  in  the  treatment  of 
chronic  intestinal  diseases,  such  as  enteritis,  simple, 
pseudo-  membranous,  or  follicular ;  in  intestinal  catarrh,  in 
fermentative  and  putrefactive  conditions,  and  in  chronic 
thickening  of  the  mucous  membrane  of  the  intestines. 

Once  one  is  familiar  with  the  properties  of  the  electric 
current  and  the  technique  of  the  operation,  the  therapeu- 
tic applications  suggest  themselves  in  great  abundance. 

In  all  instances  we  are  enabled  to  avail  ourselves,  not 
only  of  the  electric  diffusion  of  the  drugs,  but  the  phy- 
siological action  of  the  current  as  well. 

.   68  Madison  AvBMUB,lMay  95^1894. 

Dr.  John  Williams,  the  accoucheur  of  the  Duchess  of 
York,  is  a  Welshman  who  was  formerly  a  general  prac- 
titioner in  Swansea. 

*  Lewandoski :  Electro-diagnostik  und  Therapeutic  Wien  und 
Leipzig,  189a. 


A  TYPHOID  FEVER  BED -BATH  APPARATUS. 

By  RUSSELL  BELLAMY,  M.D., 

HOUSK    PHYSICIAH,  SECOND  MEDICAL  DIVISION  BBLLEVUB  HOSPITAL,  NEW  YORK. 

During  the  summer  and  autumn  of  1893  many  cases 
of  typhoid  fever  were  admitted  to  the  wards  of  Bellevue 
Hospital,  and  in  the  different  divisions  many  methods  of 
treatment  were  employed. 

Undoubtedly  the  method  that  yielded  the  best  results 
was  that  of  Brand ;  but,  unfortunately,  it  cannot  be  ex- 
tensively used  in  private  practice  on  account  of  the  great 
expense,  often  five  nurses  being  required,  two  for  night 
and  two  for  day  work,  the  fifth  assisting  at  intervals. 
In  hospitals  this  treatment  can  be  used  to  much  better 
advantage ;  but  as  now  practised,  and  under  the  most 
favorable  conditions,  it  has  many  drawbacks. 

Having  superintended  and  assisted  in  giving  nearly 
twelve  hundred  baths  I  had  an  opportunity  to  note  that 
the  system  must  be  changed  in  order  to  lower  the  mor- 
tality, lessen  the  expense,  and  cause  the  patient  less  men- 
tal agitation. 

The  method  of  giving  a  bath  in  Europe,  and  as  used 
in  this  city  by  Peabody  at  the  New  York  Hospital,  and 
carried  out  extensively  by  W.  Gilman  Thompson  at  the 
Presbyterian  Hospital,  is  used  in  the  second  medical 
division,  under  the  supervision  of  visiting  physician  H.  P. 
Loomis,  and  assistant  visiting  physician  C.  S.  Quimby. 

Present  Method. — The  patient,  after  being  stripped 
and  covered  by  a  thin  sheet,  is  lowered  by  three,  and 
sometimes  four,  nurses  into  a  bath  tub  and  vigorously 
rubbed  for  fifteen  or  twenty  minutes  until  the  desired 
reduction  in  temperature  is  secured.  He  is  then  re- 
turned to  bed,  usually  with  considerable  difficulty.  If  he 
is  stroug,  the  muscles  are  stiffened  and  the  weight  raised 
with  ease.  If  the  power  of  resistance  is  slight,  as  is 
usually  found  to  be  the  case  by  the  twelfth  day  of  the 
disease,  considerable  difficulty  is  experienced  in  lifting 
him  to  the  bed  and  sometimes  a  serious  traumatism  has 
occurred.  At  times  the  patients  complain  of  pain  over 
the  region  of  the  body  where  he  is  handled ;  again  they 
complain  of  experiencing  a  tired  feeling,  and  think  the 
suddenness  of  being  lowered  into  the  water,  or  roughly 
raised,  too  great  a  shock  and  a  rather  heroic  measure. 

The  close  relationship  between  the  visceral  and  parietal 
peritoneum  to  the  abdominal  muscles  is  to  be  consid- 
ered, especially  during  the  period  of  the  disease  when 
hemorrhage  is  most  likely  to  occur,  since  at  this  time  even 
a  mild  traumatism  to  these  muscles  could  do  much  harm. 
I  am  inclined  to  believe  that  many  hemorrhages  and 
severe  attacks  of  peritonitis  will  be  avoided  if  the  bath 
can  be  given  without  the  least  jar  or  exertion  on  the 
part  of  the  patient. 

After  going  over  the  literature  of  typhoid  fever  and 
consulting  many  of  New  York's  most  prominent  physi- 
cians, I  found  that  some  different  mechanism  for  giving 
baths  is  desirable. 

The  apparatus  that  Richard  Kny  &  Co.  of  New 
York  City,  have  so  thoroughly  constructed  for  mer 
consists  of  a  galvanized  iron  bath-tub — one  of  any  de- 
sired material  may  be  substituted  —  6  feet  4  inches 
long,  22  inches  deep,  and  20  inches  wide.  The 
supporting  frame  of  this  tub  is  on  rubber  wheels,  and 
it  is  provided  with  a  siphon  exhaust  -  pipe,  so  that 
every  drop  of  water  can  be  removed  in  a  few  min- 
utes. Supporting  a  comfortable  steel  mattress  within  the 
tub  are  four  stout  copper  chains,  passing  over  pulleys  at 
either  corner  of  the  frame,  and  over  a  similar  set  under 
the  tub.  These  chains  are  connected  with  an  endless 
screw  by  cogs  and  a  bicycle  stop-chain.  The  mechanism 
is  controlled  by  a  crank,  so  that  the  mattress  can  be 
raised  or  lowered  by  reversing  the  wheel.  The  appara- 
tus is  so  arranged  that  the  mattress  can  be  raised  several 
inches  above  the  top  of  the  tub,  or  lowered  to  the  bot- 
tom. On  one  side  a  piece  of  galvanized  iron,  2  feet- 
long  by  6  inches  wide,  is  attached  by  hinges,  and  is- 
used  to  bridge  over  the  space  between  the  tub  and  bed. 

Method  of  Using. — The  patient,  naked,  and  covered 


254 


MEDICAL  RECORD. 


[August  25,  1894 


by  a  linen  sheet,  is  placed  upon  a  heavy  rubber  blanket, 
which  is  perforated  near  the  centre;  the  bathtub  is 
brought  to  the  bedside,  and  the  nurse,  standing  on  the 
outer  side  of  the  tub  and  gently  drawing  the  sheet,  brings 
first  the  patient's  head,  then  buttocks,  and  lastly  feet,  up 
on  the  steel  mattress.  A  comfortable  rubber  pillow  is 
placed  under  the  head.  The  crank  is  reversed,  the 
patient  lowered  into  the  water  suddenly  or  by  degrees, 
the  bath  given*,  the  mattress  raised  to  the  level  of  the 
bed,  and  the  water  having  escaped  through  the  holes  in 
the  rubber  blanket,  the  patient  is  transferred  to  the  bed 
in  the  same  manner  that  he  was  moved  to  the  bath. 


The  steel  mattress  can  be  detached  and  the  whole  ap- 
paratus thoroughly  disinfected.  It  is  painted  with  white 
enamel  and  is  not  clumsy.  In  devising  this  typhoid 
bath-tub  I  had  only  hospital  cases  in  view,  and  the 
manufacturer  has  so  constructed  this  tub  that  it  is 
adapted  to  the  average  hospital  bed.  Its  height  evi- 
dently can  be  modified  as  desired. 

When  we  consider  that  a  bath  can  be  given  by  one 
attendant,  and  the  patient  experience  no  disturbance, 
either  mental  or  physical,  we  feel  that  we  have  done 
something  toward  rendering  the  famous  Brand  system 
more  generally  available. 


Large  Increase  of  Lunacy  in  Great  Britain. — The 
forty-  eighth  report  of  the  British  commissioners  in  lunacy, 
just  issued  as  a  Parliamentary  paper,  says  there  were  in 
the  kingdom,  on  January  1st,  92,067  lunatics,  idiots,  and 
persons  of  unsound  mind,  according  to  the  various  re- 
turns to  the  commissioners.  This  number  is  3,245  in 
excess  of  the  corresponding  returns  from  the  previous 
year,  and  shows  the  largest  increase  in  the  number  of 
lunatics  yet  recorded.  The  report  says:  "This  large 
increase  calls  the  more  for  some  special  consideration, 
because  it  follows  an  increase  of  1,974  in  the  preceding 
year,  that  being  far  above  the  average  for  the  ten  years 
1882  to  1892,  which  was  only  1,300.  The  increase 
seems  to  have  been  fairly  general  throughout  England 
and  Wales,  but  the  predominant  feature  of  the  figures  is 
the  great  increase  shown  in  the  county  of  London,  its 
pauper  lunatics  numbering  on  January  1st,  800  more 
than  they  did  a  year  previously.  It  is  perhaps  right  in 
this  connection  to  point  out  that  from  the  administrative 
county  of  Middlesex,  which  is  fast  becoming  metropoli- 
tan, there  is  shown  from  last  year  an  excessive  increase 
of  103,  against  an  average  for  the  previous  ten  years  of 
42.  From  one  of  the  tables  attached  to  the  report  it 
appears  this  state  of  affairs,  though  alarming,  is  not 
quite  so  serious  when  considered  in  conjunction  with 
the  increase  of  population,  the  ratio  being  one  insane 
person  in  326,  as  against  one  in  331  for  the  previous 
year." 


(&ovrt$vou&zute. 

TRANSFER  OF  THE  INSANE  TO  HOSPITALS. 

To  the  Editor  op  the  Medical  Record, 

Sir  :  In  a  recent  number  of  the  Medical  Record  the 
transfer  of  the  insane  from  their  homes  to  hospitals  is  dis- 
cussed at  some  length,  and  the  writer  of  the  article  criti- 
cises severely  the  system  under  which  such  transfers  are 
made.  His  remarks  are  apparently  intended  to  be  gen- 
eral in  their  application  so  as  to  cover  the  entire  coun- 
try, but  incidentally,  and 
I  have  no  doubt  inadvert- 
ently, unwarranted  strict- 
ures are  made  upon  an  im- 
portant feature  of  the  State 
Care  Law,  now  in  opera- 
tion in  the  State  of  New 
York.  The  errors  can  be 
easily  shown,  and  I  trust 
the  facts  may  receive  the 
publicity  they  merit  in  the 
columns  of  the  Medical 
Record. 

That  cruelties  and  in- 
human practices  were  com- 
mon a  decade  ago  is  only 
too  true.  Indeed  the  writer 
I  might  easily  have  found 
much  more  horrible  in- 
stances of  brutality  than 
those  cited.  The  unfortu- 
nate victims  of  insanity 
were  often  treated  like  fel- 
ons, and  it  was  almost  a  daily  occurrence  that  they  were 
brought  to  hospitals  in  the  strait-jacket,  in  manacles, 
or  bound  with  ropes,  and  usually  in  a  sad  state  of  bodily 
uncleanliness.  This  terrible  state  of  affairs  was  one  of 
the  strongest  arguments  used  to  secure  the  passage  of 
chapter  1 26  of  the  Laws  of  1890,  familiarly  known  as  the 
State  Care  Law.  Section  six  of  this  chapter  specifically 
made  it  the  duty  of  the  President  of  the  State  Commis- 
sion in  Lunacy  "  to  prescribe  regulations  governing  the 
transfer  of  public  insane  patients  from  their  homes  or 
from  poor  houses  to  State  hospitals  by  superintendents  of 
the  poor,  and  concerning  the  clothing  of  State  patients." 
The  President  of  the  Commission  accordingly,  on  Sep- 
tember 10, 1890,  issued  the  following  order : 

"  1.  That  all  county  superintendents  of  the  poor,  or 
town,  county,  or  city  authorities,  before  sending  a  pa- 
tient to  any  State  hospital  see  that  said  patient  is  in  a 
state  of  bodily  cleanliness  and  provided  with  the  follow- 
ing clothing,  to  wit : 

"  (a)  One  full  suit  of  under-clothing.  (£)  One  full 
suit  of  outer  clothing,  including  head- wear,  boots,  or 
shoes. 

"  Between  the  months  of  November  and  April,  both 
inclusive,  there  shall  be  provided,  in  addition  to  the  fore- 
going, a  suitable  overcoat  for  the  men  patients  and  a 
suitable  shawl  or  cloak  for  the  women  patients ;  also 
gloves  or  mittens.  Considering  the  great  danger  always 
present  of  the  introduction  of  contagious  or  infectious 
diseases  into  institutions  where  large  numbers  of  people 
are  congregated,  and  to  avoid  so  far  as  possible  the  in- 
troduction of  such  diseases  by  means  of  wearing  apparel, 
the  clothing  above  provided  for  must,  in  all  cases,  be 
new. 

"2.  In  travelling  by  rail  patients  must  not  be  com- 
pelled to  ride  in  smoking  or  baggage  cars,  except  in  the 
case  of  men  patients  who  may  be  so  violent,  profane,  or 
obscene  as  to  render  their  presence  in  ordinary  passen- 
ger coaches  offensive.  If  any  portion  of  the  route  is  nec- 
essary to  be  traversed  by  a  team  a  covered  conveyance 
should,  unless  impossible,  be  provided.  The  shortest 
practicable  route  should  be  selected ;  the  hour  of  de- 
parture should  be  timed,  so  far  as  possible,  so  as  to  avoid 


August  25,  1894] 


MEDICAL    RECORD. 


255 


the  necessity  of  stopping  over  night  on  the  journey,  and 
so  as  not  to  reach  the  hospital  at  any  unseasonable  hour. 
Whenever  practicable,  a  notice  in  advance,  by  writing  or 
telegraph,  should  be  sent  to  the  medical  superintendent 
of  the  hospital  of  the  coming  of  the  patient.  In  cases 
of  violent  patients  a  sufficient  number  of  attendants 
should  be  provided  to  control  their  actions  without  re- 
sorting to  the  use  of  mechanical  restraints,  such  as  straps, 
ropes,  chains,  handcuffs,  etc. ;  quieting  medicines  should 
not  be  given  to  such  patients  except  upon  the  prescrip- 
tion of  a  physician.  If  it  becomes  necessary  to  remain 
over  night  or  for  a  number  of  hours  at  a  station  on  the 
route,  patients  are  not  to  be  taken  to  jail,  police  station, 
or  lock- up.  Food  in  proper  quantity  and  quality,  and 
at  intervals  not  exceeding  five  hours,  should  be  provided 
for  patients,  but  no  alcoholic  beverages  must  be  given 
unless  upon  prescription  of  a  physician.  Opportunity 
must  be  afforded  for  attention  to  the  calls  of  nature,  and 
the  rales  of  decency  must  be  observed.  In  case  of  the 
employment  of  extra  attendants  in  conveying  violent 
patients,  care  must  be  taken  that  they  are  of  adult  age 
and  of  good  moral  character.  The  provisions  of  the 
statutes  which  require  that  a  woman  attendant  shall  ac- 
company women  patients  when  taken  to  State  hospitals 
must  be  strictly  complied  with. 

"  3.  Any  violation  of  the  requirements  of  this  order 
shall  be  promptly  reported,  so  far  as  known  to  him,  by 
the  Medical  Superintendent  of  the  hospital  to  the  State 
Commission  in  Lunacy. 

"  4.  This  order  shall  take  effect  on  the  first  day  of 
October,  1890. 

"  By  tbf  President  of  the  Commission, 

"T.  E.  McGarr,  Secretary:' 

The  effect  was  immediate.  The  lot  of  the  insane  pa- 
tient was  greatly  improved.  Mechanical  restraint,  which 
had  long  been  discarded  in  the  hospitals,  was  thrown  aside 
by  county  officials  almost  entirely,  and  the  whole  scheme 
of  caring  for  the  insane  in  New  York  State  became  more 
elevated  in  character  in  the  letter  as  well  as  in  the  spirit. 

The  foregoing  comprehensive  order  of  the  Commission 
continued  in  force  for  a  period  of  three  years,  during 
which  radical  reforms  were  accomplished  ;  but  the  best 
results  were  attained  only  when  the  State  Care  Act  be- 
came wholly  operative,  October  1,  1893.  On  that  date, 
under  its  provisions,  the  State  Commission  in  Lunacy 
issued  the  following  order :  "  The  authorities  of  State 
hospitals  for  the  insane  shall  send  trained  attendants  to 
transfer  insane  patients  from  their  homes  or  from  poor- 
houses  to  State  hospitals,  as  provided  by  section  six  of 
chapter  126  of  the  Laws  of  1890.  .  .  .  Whenever 
possible,  a  few  days'  notice  should  be  given  to  the  hos- 
pital authorities  of  the  transfer  of  the  patient,  and  when 
the  case  is  urgent  the  notice  should  be  sent  by  telegraph 
or  telephone." 

It  will,  therefore,  be  observed  that  for  nearly  a  year 
past  the  hospital  authorities  have  regularly  sent  trained 
attendants  to  the  homes  of  patients  as  soon  as  notice  has 
been  received  that  they  have  been  examined  and  certi- 
fied as  insane,  and  have  assumed  entire  charge  of  the 
cases  at  once.  These  attendants  have  been  instructed  to 
see  that  the  orders  of  die  Commission  are  fully  complied 
with  before  starting  for  the  hospital,  and  to  provide  for 
the  patient  every  possible  care  and  attention  during  the 
transfer,  thus  securing  for  him  the  protection  of  the  hos- 
pital at  the  earliest  possible  moment.  At  the  Bingham- 
ton  State  Hospital  this  plan  has  proved  in  the  highest 
degree  satisfactory.  The  attendants  employed  for  this 
special  work  are  competent,  intelligent,  and  kind.  They 
are  thoroughly  trained  in  the  care  of  die  insane,  and  in- 
variably make  their  charges  as  comfortable  as  possible 
during  transportation.  When  women  patients  are  to  be 
brought  to  the  hospital,  women  attendants  are  always 
sent  to  bring  them.  Cared  for  in  this  way  they  usually 
come  calmly  and  are  much  less  disturbed  or  exhausted 
when  they  arrive  at  the  hospital  than  was  often  the 
case  under  the  old  system.     Besides  attending  to  the 


patient's  physical  requirements  our  attendants  succeed 
in  obtaining  good  histories  of  the  cases,  and  thus  mate- 
rially aid  the  physicians  in  deciding  upon  the  proper 
course  of  treatment.  All  this  is  accomplished  at  a  cost 
to  the  State  rarely  exceeding  actual  travelling  expenses. 

Surely  the  reform  accomplished  in  the  method  of 
transporting  the  insane  from  their  homes  to  hospitals  in 
the  State  of  New  York,  during  a  period  of  less  than  half 
a  decade,  merits  stronger  commendation  than  is  to  be 
found  in  the  " undercurrent"  which  the  editorial  states 
.is  now  running  in  the  direction  of  reform. 

Charles  W.  Wagner, 
Superintendent  Binghamton  State  Hospital. 

Binghamtok,  N.  V.,  July  30,  1894. 


THE  INTRODUCTION  OF  LEPROSY  INTO 
JAPAN. 

To  thb  Edith  r  cf  tits  Msric/L  Rbooid. 

Sir  :  Dr.  Beaven  Rake,  of  Trinidad  Leper  Asylum,  re- 
cently called  my  attention  to  the  following  passage,  to  be 
found  in  "  Hirsch's  Geographical  and  Historical  Pathol- 
ogy'1 (translated  from  the  second  German  edition  by 
Charles  Creighton,  M.D. ;  London,  the  New  Sydenham 
Society,  1885):  "In  Japan,  according  to  the  unani- 
mous accounts  of  the  chroniclers,  it  j(leprosy)  must  have 
appeared  as  early  as  the  thirteenth  century  ac  (between 
1234  and  1250)." 

The  authority  for  this  statement  is  given  in  a  footnote 
thus :  "  Schmid,  New  York  Medical  Record,  July,  1869, 

p.  i94M 

On  referring  to  the  Medical  Record  of  1869,  I  find 
the  following  passage  in  "Notes  from  Japan,"  by  H. 
Ernest  Schmid,  M.D.,  White  Plains,  N.  Y.:  "All  rec- 
ords on  that  malady  date  its  first  appearance  in  Japan 
only  as  far  back  as  from  about  1234  to  1250." 

As  Schmid  qualifies  his  statement  with  the  adverb  only, 
he  evidently  means  a  d.  and  not  B.C.  Hirsch,  there- 
fore, seems  to  me  to  lean  on  a  broken  reed  when  he 
alleges  the  authority  of  Schmid. 

There  is  no  written  evidence  in  Japan  that  leprosy  was 
known  there  as  early  as  the  thirteenth  century  before 
Christ.  But  there  is  evidence  that  it  existed  before  1234 
and  1250  a.d.  Under  no  circumstances  could  Schmid 
mean  b.c  ,  there  being  absolutely  no  proof  for  such  a  date. 
It  is  believed  that  leprosy  existed  in  Japan  as  eaily  as  the 
beginning  of  the  eighth  century,  or  even  somewhat  earlier. 
It  may  have  existed  there  as  early  as  it  did  in  China,  that 
is  1 1 22  B.c-314  bc*  But  evidence  to  this  fact  there 
is  none.  There  are  written  evidences  in  Chinese  works 
of  ancient  treatments  of  leprosy  which  date  back,  one, 
2, 000  years,  and  the  other  falls  between  618-690  a.d. 
Dr.  Goto,  now  in  Molokai,  is  authority  for  the  statement 
that  the  disease  was  known  in  Japan  in  718  a.d.  Ac- 
cording to  Dr.  Baelz,  the  Etas,  the  negro  element  of  the 
Japanese  Islands,  are  descendants  of  leper  colonies ;  they 
are  to  day  the  leprous  element  of  the  outcast  population. 
The  origin  of  this  negroid  element  is  mythical ;  it  does 
not  fall  in  historical  times ;  neither,  as  a  consequence, 
does  the  origin  of  leprosy  which  this  element  represents. 
In  this  case  the  disease  is  supposed,  naturally,  by  leprol- 
ogists,  to  have  come  from  Africa.  In  the  Mongolian 
element  of  the  Japanese  it  is  natural  to  admit  that  it  came 
from  China,  which  would  carry  it  back,  at  all  events,  to 
the  epoch  of  the  introduction  of  Buddhism  from  China 
and  Corea,  that  is,  to  the  sixth  century.  There  can  be 
no  other  reasonable  theory  as  to  the  exact  time  when 
leprosy  appeared  in  Japan. 

Dr.  Goto,  of  Honolulu,  writes  me,  under  date  of  July 
8,  1894,  that  since  February  8,  1885,  to  1894,  twenty- 
one  thousand  eight  hundred  and  eighty- one  Japanese  men, 
and  five  thousand  one  hundred  and  ninety- one  Japanese 
women,  emigrated  from  Japan  to  the  Hawaiian  Islands. 
In  this  large  number,  five  men  developed  the  disease  after 
their  arrival,  and  four  were  suspected.  This  is  quite  the 
reverse  of  what  happens  at  the  introduction  of  Chinese 
emigrants.    The  Chinese  seem  to  take  the  disease  quite 


256 


MEDICAL   RECORD, 


[August  25,  1894 


naturally,  and,  indeed,  it  is  they  who  are  believed  to  have 
brought  it  originally  into  the  Sandwich  Islands.  This 
also  would  be  sufficient  to  warrant  the  suspicion  that  the 
disease  in  Japan  came  from  the  Chinese,  as  well  as  it  did, 
if  really  it  did,  come  through  them  to  the  Sandwich 
Islands. 

Goto  remarks  that  the  Japanese  made  no  change  in 
their  diet,  and  that  fish  remained  prominent  therein.  We 
may  remark  in  passing,  that  if  fish  diet  was  a  factor  in  the 
transmission  of  contagion,  there  would  have  been  more  of 
an  outbreak  in  such  a  large  number  of  Japanese  in  nine 
years  (one  person  a  year). 

Dr.  Basadre,  of  Lima,  Peru,  informs  me  that  the  only 
cases  he  has  observed  in  Peru  were  always  Chinese,  never 
Peruvians. 

Dr.  Mufiiz  says  that  leprosy  is  very  rare  in  Peru,  and 
that  only  a  few  (Chinese)  are  affected  by  it.  In  1893 
there  were  only  two  deaths  from  leprosy,  and  at  the  time 
when  Dr.  Mufiiz  wrote  to  me,  there  was  only  one  case  at 
the  Hospital  del  Refugio,  and  it  was  a  Chinaman. 

Hence  we  may  assume  confidently  that  to  Japan,  the 
Sandwich  Islands,  and  to  South  America,  leprosy  came 
from  China. 

Albert  S.  Ashmead,  M.D. 

45  Macdougal  Stkebt,  New  Yomc 


CYANIDE  OR  FERROCYANIDE  OF  POTASSIUM? 

To  the  Editor  or  the  Medical  Recoed. 

Sir  :  One  word  about  the  cyanide  of  potassium  poisoning 
case  mentioned  in  the  Medical  Record  of  July  7th.  It 
is  evident  that  some  drug  was  taken,  but  it  could  not 
have  been  cyanide  of  potassium.  The  patient  says :  "I 
took  a  solid  piece,  perfectly  smooth  on  all  sides ;  "  this 
fact  alone  is  conclusive,  for  cyanide  of  potassium  does 
not  occur  in  that  form,  but  ferrocyanide  of  potassium 
does,  hence  it  must  have  been  the  latter  drug.  It  ap- 
pears that  the  doctor  did  not  see  the  drug  himself,  which 
renders  the  case  doubtful.  Cyanide  of  potassium  is  one 
of  the  most  formidable  poisons  known  to  chemists.  It 
has  destroyed  life  in  a  quarter  of  an  hour,  and  tetanic 
spasms  occur  in  a  few  seconds  or  minutes,  and  run 
through  their  course  with  great  rapidity. 

J.  H.  Trent,  M.D, 

Brooklyn,  N.  Y. 

DOSIMETRIC  MEDICATION. 

TO  THE  EOITOK  OP  THE  MEDICAL  RECORD. 

Sir:  Being  one  who  is  a  believer  in  the  dosimetric 
method  of  administering  medicines,  I  have  read  Dr. 
Mann's  article  on  "  A  New  Cardiac  Tonic  Dosimetric 
Granule'1  with  much  interest.  With  the  general  pur- 
port of  that  article  I  am  thoroughly  in  accord ;  but  I 
regard  it  as  unfortunate  that  Dr.  Mann  uses  the  term 
dosimetric,  as  his  granule  is  not  in  reality  a  dosimetric 
granule  at  all.  On  the  contrary,  its  composition  contra- 
venes three  of  the  fundamental  principles  of  dosimetry : 

1.  Dosimetric  granules  contain  one  medicinal  prin- 
ciple only  in  each  granule. 

2.  They  contain  a  fixed,  usually  minute,  amount  of 
the  drug.  That  is  to  say,  for  instance,  the  morphine 
granule  always  contains  one  milligramme,  the  strychnine 
granule  one- half  milligramme,  and  so  on. 

3.  They  are  made  according  to  the  metric  system. 

It  is  in  the  first  two  of  these  principles  that  the  strength 
of  dosimetry  lies.  The  physician  adjusts  his  treatment 
to  each  particular  case,  giving  so  many  of  one  kind  of 
granule  and  so  many  of  another,  and  can  vary  the  pro- 
portion from  time  to  time,  whereas  if  relying  on  a  num- 
ber of  ready-made  prescriptions  like  Dr.  Mann's,  he  will 
inevitably  in  many  cases  give,  not  what  would  be  the 
best  prescription  for  the  patient,  but  the  nearest  he  hap- 
pens to  have  at  hand,  in  his  case  or  office.  To  my  mind 
nothing  tends  so  much  at  the  present  time  to  hinder  the 
progress  of  scientific  therapeutics  as  the  slovenly  habit, 
which  is  so  wide  spread,  of  using  ready-made  formulae, 


mainly  in  the  form  of  tablet  triturates.     Dosimetry  aims 
among  other  things  at  the  abolition  of  this  habit. 

Perhaps  it  is  hardly  necessary  to  add  that  Dr.  Mann's 
prescription  can  be  represented  approximately  by  the 
dosimetric  granules  already  in  use,  thus : 

Morphine  hydrochlorate. ...  5  granules  (5  milligrammes). 

Strychnine  sulphate I  granule  (4  milligramme). 

Atropine I  granule  (i  milligramme). 

Caffeine I  granule  (1  milligramme). 

G.  M.  Wasse,  M.D.,  M.R  C.S.  Eng. 

Baldwinsvillb,  N.  Y. 


fjfredical  Stems. 

Contagions  Diseases— Weekly  Statement— Report  of 
cases  and  deaths  from  contagious  diseases  reported  to  the 
Sanitary  Bureau,  Health  Department,  lor  the  week  end* 
ing  August  18,  1894. 


Tuberculosis 

Typhoid  ferer 

Scarlet  ferer 

Oerebro-spinal  meningitis 

Measles 

Diphtheria 

Small-pox 


A  Pasteur  Institute  has  been  opened  in  Tunis. 

The  Monument  to  Surgeon  Parke,  the  medical  officer 
of  the  Emm  Pacha  relief  expedition,  which  is  to  be 
erected  in  Dublin,  will  represent  him  in  the  dress  worn 
in  Africa  during  the  expedition,  standing  with  crossed 
arms  leaning  on  a  gun,  resting  the  left  foot  upon  a 
medicine  chest. 

Hasal  Reflexes. — For  the  diagnosis  of  "nasal  reflex 
neurosis  "  Zarniko  requires,  1,  that  every  other  possible 
explanation  should  be  eliminated ;  2,  that  there  should 
be  present  some  local  reflex  symptoms  (for  example,  fits 
of  sneezing),  such  as  are  known  by  experience  to  be  fre- 
quently associated  with  remote  nasal  reflex  neuroses  ;  3, 
that  the  inspection  of  the  nose  should  reveal  such  changes 
as  frequently  set  up  reflex  disturbances ;  4,  that  artificial 
irritation  (probing)  of  some  area  in  the  nose  should  ex- 
cite the  reflex  symptoms ;  and  5,  that  ansesthetization  of 
that  area  should  put  an  end  to  them.  In  some  cases  he 
considers  the  last  two  points  sufficient  ground  for  the 
diagnosis. — British  Medical  Journal. 

The  Value  of  Our  Mistakes.-— It  is  always  a  pleasant 
thing  to  be  right,  but  it  is  generally  a  much  more  useful 
thing  to  be  wrong.  If  you  are  right,  all  that  you  do,  as 
a  rule,  is  to  confirm  your  previous  opinion,  your  previous 
habits  of  reasoning,  and  your  previous  self-esteem.  But 
if  you  are  wrong  you  generally  gain  in  knowledge  and 
gain  perception  of  the  way  in  which  your  method  of 
diagnosis  needs  improvement,  and  the  influence  on  self- 
esteem  is  not  likely  to  do  you  harm.  At  least  that  is  my 
own  experience,  and  I  think  I  have  observed  it  confirmed 
in  others.  But  the  result  is  dependent  on  deliberate  effort. 
There  is  a  strong  temptation  to  smooth  down  error,  and 
it  is  very  easy  not  to  gain  from  it  its  precious  lesson.  It 
is  more  easy  to  fancy  that  there  is  some  accidental  cause 
for  the  mistake  than  frankly  to  perceive  that  it  is  a  fault. 
But  if  you  make  a  deliberate  effort  to  realize  and  to  face 
in  your  own  mind  the  mistake  you  have  made,  to  dis- 
cern its  cause,  and  to  employ  this  perception  as  for  as 
you  can  to  remove  the  cause  and  prevent  a  like  mistake 
in  the  future — if  you  do  this,  almost  every  error  becomes 
one  of  the  precious  experiences  of  your  practical  life. — 
Dr.  W.  R.  Gowers.1 

A  Society  for  the]  Suppression  of  Handshaking,  as 
leading  to  an  exchange  of  microbes,  has  been  established 
in  Baku,  Russia. 


Medical   Record 

A  Weekly  yournal  of  Medicine  and  Surgery 


Vol.  46,  No.  9. 
Whole  No.  1243. 


New  York,  September  i,  1894. 


$5.00  Per  Annum. 
Single  Copies,  ioc. 


i&rigitral  Articles. 

SEWER  GAS  A  CAUSE  OF  THROAT  DISEASE ; 
OR  THE  EFFECT  OF  BAD  DRAINAGE  ON 
THE  THROAT.1 

By  BEVERLEY  ROBINSON,  M.D., 

CLINICAL   PROFESSOR  OF  MKDIC1NR  AT  TIM    BELLEVUE  IOSP1TAL    MEDICAL  COL- 
LEGE, NEW  YORK. 

"  A  great  deal  of  vague  assertion  has  been  made  with 
regard  to  the  effects  of  sewer  gas,  or  as  it  is  better  called, 
sewer  air,  upon  the  human  system.  While  some  look 
upon  it  as  always  poisonous,  and  often  virulent,  others 
consider  it  usually  harmless,  though  unpleasant.  The 
good  health  of  workmen  engaged  constantly  upon  sewers 
is  cited  in  favor  of  this  latter  view."' 

The  opinion  just  quoted  manifestly  shows  that  there 
is  much  of  expressed  opinion  on  this  subject  found  in 
medical  literature  which  is  based  upon  facts  capable  of 
widely  different  interpretation.  In  a  tenement  house, 
let  one  or  more  cases  of  throat  disease  be  suddenly  pres- 
ent, and  the  attending  physician  immediately  suspects 
the  condition  of  the  plumbing.  A  sanitary  inspector 
from  the  Health  Board  is  called.  Untrapped,  filthy 
sinks,  malodorous  water-closets,  a  damp  cellar  containing 
accumulations  of  organic  substances,  animal  or  vegetable, 
in  a  state  of  decomposition  and  giving  off  effluvia,  will 
usually  be  discovered.  Not  infrequently,  in  addition  to 
these  sources  of  disease,  the  peppermint  or  smoke  test 
properly  applied  will  make  known  a  leaky  joint,  or  a 
perforation  of  the  soil  pipe,  which  allows  sewer  air  to 
permeate  the  entire  building.  Which  of  these  conditions 
—or  do  all  combined — occasions  the  throat  affections 
which  have  shown  a  sudden  outbreak,  or  been  present 
more  or  less  continuously  ?  How  difficult  to  decide  in  a 
satisfactory  manner ! 

Whenever,  besides  the  preceding  conditions,  we  find 
overcrowding,  poor  ventilation,  bad  food,  lack  of  per- 
sonal cleanliness,  over- fatigue,  exposure,  anxieties,  pov- 
erty, excesses— how  can  we  properly  estimate  the  rdle  of 
each  determining  or  causative  factor  of  the  throat  disease 
in  its  exact  proportion  ?  Evidently  in  many  instances 
the  task  is  very  difficult,  not  to  say  insuperable.  And 
yet  there  are  unquestionably  numerous  examples  on 
record  in  which  the  impure  air  from  sewers  and  cesspools 
has  seemingly  been  the  means  of  propagating  diphtheria 
and  other  throat  diseases.  Instances,  indeed,  are  not 
wanting  which  go  to  show  that  the  poisonous  decompo- 
sition of  organic  matter  in  sewers  is  in  some  way  con- 
nected with  the  dissemination  of  these  diseases. 

Dr.  Chaumont  publishes  two  cases  in  support  of  this 
opinion.  One  is  that  in  which  a  number  of  children  were 
attacked  with  diphtheria,  apparently  caused  by  a  leakage 
of  sewage  in  a  part  of  the  house  immediately  under  the 
nurseries  of  the  children.  The  other  case  was  that  in 
which  by  a  defect  in  the  sewer- ventilating  pipe  passing 
up  close  to  the  cupboard  in  a  nursery,  there  was  an  escape 
of  sewer- air  into  the  room  occupied  by  a  number  of  chil- 
dren, with  the  effect  of  sickening  the  whole  of  them. 

Dr.  Wilson*  remarks  that  "  in  country  districts  isolated 
outbreaks  of  diphtheria  traceable  to  cesspool  effluvia  are 

1  Read  before  the  Congress  of  American  Physicians  and  Surgeons, 
Washington,  May  30.  1894. 
*  Medical  Record,  August,  1888,  p.  186 
»  Handbook  of  Hygiene,  1877,  p.  71. 


not  at  all  uncommon.  In  these  cases  it  is  generally 
found  that  there  is  a  water-closet  in  the  house  which  itself 
is  badly  ventilated,  and  that  the  closet  drainage  dis- 
charges into  a  cesspool  which  is  completely  covered  up 
and  only  cleaned  out  at  rare  intervals.  The  consequerce 
is  that  any  gases  generated  in  the  cesspool  have  no  out- 
let except  through  the  water  closet  and  into  the  house, 
and  hence  result  attacks  of  diphtheria,  ulcerated  sore 
throat,  and  other  badly  defined  ailments." 

"  From  an  inquiry  instituted  by  the  State  Board  of 
Health  of  Massachusetts  in  1875,  respecting  the  predis- 
posing causes  of  diphtheria,  its  prevalence,  etc.,  it  would 
appear  that  this  disease  has  been  most  severe  in  the  rural 
districts  where  there  are  no  sewers  and  where  the  drain- 
age is  generally  very  bad.  In  some  of  these  places  the 
level  of  the  ground- water  is  high,  and  on  this  account 
when  there  is  high  water  many  cellars  are  damp  or  con- 
tain standing  water.  This  is  probably  one  of  the  worst 
sanitary  conditions  in  connection  with  diphtheria.  It 
helps  perpetuate  it  by  furnishing  a  breeding  place  for  its 
disease  germs  if  they  become  implanted,  and  it  also  favors 
catarrhs  and  sore  throats,  which  render  persons  having 
them  more  susceptible  to  that  disease.  Besides  the  con- 
ditions referred  to,  the  soil  is  often  polluted  from  hcuse 
slops  and  excavated  privy- pits."  l 

"The  belief  that  the  propagation  of  diphtheria  is 
greatly  influenced  by  contaminated  air  from  sewers, 
privies,  soils,  etc.,  or,  in  other  words,  by  filth  infection, 
seems  to  be  gradually  gaining  ground ;  but  at  present  evi- 
dence is  not  sufficient  to  justify  a  decided  opinion." 2 

"  Perhaps  these  faulty  conditions  produce  a  sore  throj  t 
of  a  benign  character  which  affords  a  soil  suitable  for  ir- 
oculation  by  the  diphtheria  germ  when  present  in  the 


air. 


According  to  other  writers,  defective  sewerage,  damp- 
ness, and  lack  of  cleanliness,  account  undoubtedly  for 
most  cases  of  diphtheria  developed  in  private  houses.4 
Indeed  in  some  of  these  instances  the  presence  of  the 
Loeffler  bacillus,  the  true  cause  of  diphtheria,  has  been 
shown  in  the  gases  arising  from  sinks.6  We  owe  this  de- 
monstration to  the  researches  of  Dr.  Fischer,  who  has 
shown  also  that  these  sinks  are  not  properly  flushed,  and 
that  for  this  reason  they  often  become  the  breeding-place 
for  these  and  other  bacteria.  In  commenting  upon  Dr. 
Fischer's  researches  Koehler  states  that  the  portion  of 
the  waste  pipe  of  washstands  and  sinks  between  the  outer 
opening  and  the  first  trap  is  particularly  objectionable 
for  this  reason.  This  portion  of  the  pipe  receives  vary- 
ing amounts  of  organic  matter  and  water,  which  is  ex- 
posed to  and  warmed  by  the  air  of  the  adjoining  room. 
These  are,  of  course,  suitable  conditions  to  produce  an 
excellent  culture  ground  for  many  kinds  of  microor- 
ganisms. The  traps  of  a  house  may,  therefore,  be  in  per- 
fect order,  and  yet  we  may  not  be  safe  from  infectious 
sore  throats.  The  condition  just  referred  to  is  usual,  and 
yet  frequently  cooks  and  others  escape  sore  throats,  at 
least  for  a  time.  When  they  are  otherwise  well,  the 
chances  are  that  they  will  escape ;  when  they  are  ailing 
for  one  reason  or  another,  they  are  more  likely  to  con- 
tract a  sore  throat  from  habitual  contact  with  the  source 
of  contagion  mentioned. 

Many  people,  both  adults  and  children,  before  con- 

1  Report  of  State  Board  of  Health  of  New  York,  1893,  pp.  294,  295. 

*  Buck  :  Hygiene  and  Public  Health,  vol.  i.,  p.  5fo' 

8  Osier :  Practice  of  Medicine,  p.  99. 

4  Medical  Record,  September  30,  1893,  p.  422. 

6  Ibid.,  January  28, 1893. 


^58 


MEDICAL    RECORD. 


[September  \,  1894 


tracting  diphtheria  or  other  affections  of  the  throat  have 
bsen  weak  or  sickly.  The  vitality  of  their  body- cells  is 
already  lowered,  and  they  are  thus  rendered  more  sus- 
ceptible to  the  action  of  virulent  germs.  Many  agencies 
conspire  to  bring  about  this  condition ;  such  are,  notably, 
wet  and  cold,  hunger,  physical  or  mental  depression, 
worry,  and  severe  shock.  In  many  instances  diphtheria, 
follicular  tonsillitis,  and  other  forms  of  sore  throat  have 
been  known  to  follow  exposure  to  some  of  these  causes, 
and  independently,  as  far  as  can  be  known,  of  any  in- 
fection from  dirty  pipes. 

It  is  an  admitted  fact  that  the  throat  swarms  with  bac- 
teria at  all  times,  and  possibly  the  Loeffler  bacillus  is 
among  them  occasionally,1  but  they  are  incapable  ot 
doing  much  harm  to  the  individual  carrying  them  if  he 
be  in  good  health.  Through  the  depressing  influences 
referred  to  they  are  capable  of  multiplying  and  increas- 
ing in  virulence,  and  finally  causing  infectious  sore 
throats.  The  sore  throat  may  be  taken  indeed  by  the 
individual  who  first  receives  or  develops  the  bacillus,  or 
he  may  infect  other  persons  without  himself  having  given 
evidence  of  sore  throat  or  other  disease. 

From  what  precedes,  we  should  see  clearly  how  im- 
portant it  is  to  keep  up  an  excellent  condition  of  general 
health  ia  order  to  avoid  contracting  throat  diseases.  It 
is  also  evident  that  proper  disinfecting  washes  or  gargles 
for  the  mouth  and  throat  are  very  important  to  keep  it 
in  a  condition  where  infective  bacteria  will  not  de- 
velop, or,  if  present,  will  not  take  on  virulent  proper- 
ties. These  precautionary  measures,  which  are  or  may 
be  useful  at  all  times,  and  particularly  for  children,  are 
likewise  specially  desirable  for  the  delicate  ones,  and  in 
times  of  epidemic  or  exposure  in  any  way  to  the  sources 
or  causes  of  infectious  sore  throats. 

The  aggravating  effects  upon  the  condition  of  the 
throat  of  effluvia  from  sewers  and  drains  is,  then,  most 
probable.  While  the  distinct  connection  between  the 
two  conditions  cannot  always  be  determined,  yet  in  very 
many  case3  it  is  clearly  demonstrated.  Moreover,  rea- 
soning by  analogy  it  should  be  true,  inasmuch  as  sew- 
age emanations  are  known  to  aggravate  the  severity  of 
all  the  exanthemata,  erysipelas,  hospital  gangrene,  and 
puerperal  fever  (Rigby)  ;  and  it  would  seem  that  all  dis- 
eases are  more  or  less  affected  by  these  effluvia.9 

That  many  cases  of  tonsillitis  are  immediately  caused 
by  the  air  of  sewers  and  fecal  emanations  scarcely  ad- 
mits of  reasonable  doubt.  The  evidence  in  this  direc- 
tion is  very  convincing,  and  I  am  persuaded  that  I  have 
seen  these  affections  dependent  to  a  great  extent  upon 
the  polluted  air  of  sewers,  cesspools,  and  of  the  soil. 
We  can  properly  explain  the  throat  affection,  it  seems  to 
me,  in  the  same  way  we  do  the  development  of  typhoid 
fever.  "The  morbific  agent  conveyed  through  the 
medium  of  the  air  finds  its  way  into  the  houses  from 
cesspools  improperly  located,  or  from  drain  pipes  imper- 
fectly ventilated  or  badly  trapped,  or  from  impure  soil 
beneath  and  surrounding  the  dwellings.  With  the  doc- 
trine that  the  disease  is  not  in  the  micro-organism  itself, 
but  in  its  products,  we  may  have  floating  matter  which  is 
not  living  and  yet  which  is  infective ;  so  the  gases  of 
certain  kinds  of  decomposition  may  be  sources  of  con- 
tagion without  our  deciding  whether  or  not  they  have 
been  produced  through  the  agency  of  low  forms  of 
life.1 

"  In  some  cases  sore  throats  have  been  confined  to  a 
particular  part  of  the  house,  especially  exposed  to  the 
effluvia  from  badly  trapped  drains;  and  as  the  water 
supply  was  unexceptional,  and  other  sources  of  disease 
could  not  be  found,  there  could  be  no  doubt  as  to  the 
source  of  the  infection." 

1  That  Loeffler  bacilli  are  present  at  times  in  considerable  number 
in  the  mucous  secretions  of  the  tonsils  and  pharynx  of  children  ap- 
parently in  good  health  is  now  clearly  established.  This  important 
and  suggestive  fact  we  owe  to  the  researches  of  Drs.  Chappell  and 
Park     Vide  Mbdical  Record,  April  14,  1894. 

a  Buck :  Hygiene  and  Public  Health,  vol.  i  ,  p.  585  ;  quoted  from 
Parkes. 

»  Report  of  the  Board  of  Health  of  the  State  of  New  Jersey,  1893, 
p.  76. 


Even  though  we  might  be  inclined  to  give  a  different 
interpretation  to  some  facts  of  an  analogous  kind,  yet 
what  we  can  say  is  that  in  many  instances  in  which  the 
bad  sewerage  has  been  partially,  or  more  or  less  thor- 
oughly remedied,  the  throat  affections  have  notably  les- 
sened, or  disappeared  almost  entirely  for  a  while.  In 
this  direction  we  have  the  unbiassed  and  careful  testi- 
mony of  many  judicious  observers.  Thus  Dr.  Billing toD, 
of  New  York,  writes  in  regard  to  the  etiology  of  diph- 
theria :  "  The  relation  of  cause  to  effect  has  been  demon- 
strated  by  the  fact  that  in  some  buildings  which  had 
come  to  be  looked  upon  by  me  as  diphtheria  nests,  there 
has  been  no  recurrence  of  the  disease  for  quite  a  number 
of  years  since  the  evils  referred  to,  viz.,  foul  cellars, 
neglected  cesspools,  bad  plumbing,  untrapped  sinks,  no 
air-shafts,  were  removed  through  the  efforts  of  the  Board 
of  Health.  It  is  probable,  moreover,  that  it  is,  in  some 
degree  at  least,  a  result  of  the  removal  of  these  foci  of  the 
disease  that  the  mortality  from  diphtheria  in  the  ward 
of  which  Dr.  Billington  was  an  out-door  visiting  physi- 
cian, has  become  very  much  less.1  The  experience  of 
Billington  is  corroborated  by  that  of  others.  Thus  "  the 
persistent  attacks  of  enteric  fever  (and  also  diphtheria?) 
which  formerly  occurred  at  Eastney  Barracks  in  England 
were  due  to  sewer-air  being  forced  back  by  the  tide,  no 
traps  or  ventilating  openings  being  supplied ;  since  this 
was  remedied  and  ventilation  carried  out,  no  case  of  fe- 
ver has  occurred."  * 

On  the  other  hand,  I  have  known  diphtheria  and  folli- 
cular tonsillitis  to  occur,  and  not  infrequently,  in  houses 
where  the  closest  investigation  could  show  no  defect 
whatever  in  the  sewerage  of  the  house,  where  the  cellar 
was  clean  and  dry,  where  ventilation  was  excellent,  and 
where,  indeed,  no  discoverable  and  satisfactory  cause 
of  the  kind  referred  to  could  account  for  the  develop- 
ment of  these  diseases.  At  first  thought  this  fact  would 
appear  to  support  those  observers  who  claim  that  insan- 
itary conditions,  due  especially  to  defective  plumbing 
and  drainage,  have  very  little  to  do  in  occasioning  an 
outbreak  of  throat  disease.  This  statement  I  can  only 
admit  in  so  far  as  to  say  that  imperfect  sewerage  is  only 
one  of  the  efficient  causes  of  diphtheria  and  other  throat 
diseases,  and  that  numerous  other  causes  of  these  affec- 
tions may  and  do  exist  These  other  causes,  already  re- 
ferred to,  are  especially  active,  no  doubt,  in  times  of  epi- 
demics. In  cases  of  diphtheria  and  other  throat  diseases 
due  to  endemic  causes,  it  is  quite  clear  at  times  that  the 
bad  sewerage  of  the  house  acts  in  one  of  two  ways  :  First, 
in  causing  a  condition  of  the  throat  upon  which  the 
specific  bacillus  of  diphtheria,  or  other  micro  organism, 
can  graft  itself  more  readily ;  second,  in  developing,  per- 
petuating, or  perhaps  in  originating,  the  specific  bacillus 
or  other  microbe  which  is  frequently  present  in  the  air 
of  a  certain  house  or  locality. 

Again,  in  estimating  the  influence  of  drainage  in  pro- 
ducing throat  disease  in  certain  houses  of  the  rich,  and 
even  though  no  visible  defect  can  always  be  discovered, 
it  must  be  remembered  that  in  view  of  the  complicated 
and  multiform  appliances  of  modern  plumbing,  they 
"  have  seemed  to  multiply  rather  than  to  obviate  the  in- 
sidious dangers  from  noxious  miasms."  a 

Be  it  observed,  also,  that  American  houses,  as  a  rule, 
have  no  other  way  of  changing  the  air  than  by  opening 
the  windows.  Water-closets  oftentimes  are  found  with 
no  connection  with  the  outer  air,  located  in  the  middle 
of  the  house,  and  what  ventilation  there  is,  is  into  the 
rooms  of  the  house.4 

According  to  Jacobi  *  cases  of  diphtheria  which  are 
traceable  to  sewers  are  very  frequent.  Yet  he  shows  how 
in  the  same  house  one  may  see  cases  of  dysentery,  ty- 

1  Diphtheria  and  Croup,  p.  22.  New  York  :  William  Wood  &  Co. 
1889. 

8  Stevenson  &  Murphy  :  Hygiene  and  Public  Health,  vol.  L,  p.  11. 
London,  1802. 

8  Billington,  p.  23. 

4  Parkes  Hygiene,  with  Am.  Supplement.  Wood  &  Co.,  1884,  p. 
526  (Appendix). 

•  Treatise  on  Diphtheria,  p.  34.  Wm.  Wood  &  Co.  New  York, 
1880. 


September  i,  1894] 


MEDICAL    RECORD. 


259 


phoid  fever,  and  diphtheritic  sore  throats,  all  due  appar- 
ently to  a  common  poison. 

This  should  be  admitted,  says  Jacobi,  unless  we  as- 
sign a  triple  character  to  the  poison,  or  banishing  the 
belief  in  specific  influences,  simply  attribute  the  causa- 
tion of  these  diseases  to  the  lowered  tone  of  the  system, 
and  after  this  manner  affording  to  morbid  influences  an 
opportunity  to  exercise  their  power. 

The  following  case,  in  my  personal  experience,  has  in 
this  connection  some  interest.  I  was  called  to  see  a 
case  of  diphtheria  in  the  practice  of  Dr.  Smith  Ely, 
New  York.  In  regard  to  this  case  Dr.  Ely  in  a  letter 
dated  March  12,  1894,  reports  as  follows:  "  In  a  per- 
sistent search  for  a  cause  of  diphtheria  in  the  C 

children,  some  of  the  casing  enclosing  the  drain  pipe  in 
the  water  close*  being  removed,  a  piece  of  the  pipe 
below  the  trap  was  found  to  be  broken  out,  so  that,  of 
course,  the  sewer  gas  mingled  freely  with  the  air  of  the 
house.  This  state  of  things  might  have  existed  for  a 
long  time.  There  was  another  slight  case  of  diphtheria 
in  one  of  the  other  children  at  the  same  time.  In  Sep- 
tember, 1 89 1,  the  same  child  who  had  diphtheria  so 
badly  had  typhoid  fever.  There  were  other  cases  in  the 
neighborhood,  however." 

As  is  so  frequent  in  similar  cases,  the  possibilities  of 
causation  in  infectious  diseases  are  rarely  single,  or 
always  definitely  separated  from  one  another. 

In  certain  families,  diphtheria  and  follicular  tonsillitis 
show  a  tendency  to  spread  even  though  the  sanitary 
conditions  are  of  the  best.1  The  connection,  moreover, 
between  diphtheria  and  preceding  throat  affections  is  oc- 
casionally most  marked.  This  is  probably  the  most  im- 
portant link  between  various  insanitary  conditions  and 
the  diphtheria  which  sometimes  breaks  out  amid  them. 
In  this  sense  defective  house  sanitation  is  often  a  cause 
of  diphtheria  by  producing  a  morbid  condition  of  the  mu- 
cous membrane  which  favors  the  development  of  the 
specific  bacillus,  though  in  other  instances  there  is  reason 
to  believe  that  the  specific  bacillus  might  be  present  in  the 
sewers  of  a  district,  and  thence  gain  access  to  a  house.2 

Moreover,  now  "  many  are  entertaining  the  view  that 
different  microphytes  may  produce  the  same  disease,  or 
that  the  same  microphyte  is  subject  to  modification  in 
virulence  and  in  its  products,  and  that  disease  may  be  in- 
fluenced by  the  quality,  as  well  as  by  the  quantity,  of  the 
invading  irritant."  ' 

Once  the  sewers  have  become  infected  they  may  per- 
haps continue  to  be  so  for  an  indefinite  period.  If,  then, 
for  any  reason,  the  plumbing  fixtures  of  a  particular 
domicile  are  defective,  it  is  readily  appreciable  how  sewer- 
air  laden  with  disease  germs  finds  access  to  it.4 

Observation  and  experience  have  further  taught  us 
that  sewers,  if  not  properly  constructed  and  carefully 
attended  to,  are  more  detrimental  to  health  than  if  there 
were  none  at  all.6 

On  the  other  hand,  it  is  certain  that  in  many  instances 
diphtheria  does  not  require  for  its  development  any  ot 
the  ordinarily  considered  an ti  hygienic  conditions.  So 
far  as  we  can  determine  accurately,  the  growth  of  the  in- 
fectious element  of  the  disease  is  not  invariably  favored  by 
bad  air  or  imperfect  ventilation.  Witness  the  facts  re- 
ported by  Jenner/  who  states  that  he  has  seen  more  cases 
of  this  disease  in  hospital  than  in  private  practice ;  and 
again,  as  showing  how  little  the  untoward  course  of  diph- 
theria is  thus  influenced,  we  note  that  whilst  half  of 
Jenner's  hospital  cases  died,  more  than  half  of  his  private 
cases  died. 

These  opinions  of  Jenner  are  in  a  measure  corrobo- 
rated by  the  results  of  .a  careful  comparison  of  a  large 
number  of  cases  of  diphtheria,  reported  in  Massachusetts 
(Jacobi).  Among  the  conclusions  of  the  official  report 
we  find  that  "  The  contamination  of  the  atmosphere  of 

1  Tenner :  Lectures  on  Fevers  and  Diphtheria.     New  York,  1893. 

*  British  Medical  Journal,  February  24,  1894,  p.  430. 

*  Report  of  Board  of  Health  of  State  of  New  Jersey,  1893,  P-  8a« 

*  Vide  Report  of  State  Board  of  Health  of  New  York,  1893,  p.  516. 

*  Report  of  State  Board  of  Health  of  New  Jersey,  1893,  p.  282, 

*  Jenner :  Loc.  cit. 


the  bed  chamber  by  the  emanations  from  sewers  requires 
further  study.1 ' 

In  this  connection  Dr.  Arthur  Newsholme,  Medical 
Officer  of  Health  for  Brighton,  England,  states  that 
diphtheria  had  increased  in  England  latterly,  and  more 
particularly  in  urban  districts. 

"  In  this  particular  it  differed  greatly  from  other  dis- 
eases of  zymotic  type,  which  had  been  much  mitigated 
in  severity  by  sanitary  improvements."  1 

If  this  fact  be  admitted,  it  is  additional  proof  perhaps 
that  diphtheria  depends  for  its  spread  on  contagion 
direct  from  infected  materials.  The  presence  of  sewers 
favors  its  continued  existence.  Closely  inhabited  local- 
ities do  the  same  thing  also,  by  furnishing  ready  means 
for  communication  of  the  disease.  Thus  in  most  cities 
it  has  become  endemic.2 

Elsewhere8  in  speaking  of  tonsillitis,  I  have  said  :  "  It 
is  perhaps  a  less  familiar  fact  that  exposure  to  a  vitiated 
atmosphere  will  occasion  the  development  of  tonsillitis 
in  children.  Septic  causes  of  tonsillitis  are  also  often 
met  with,  and  I  am  constantly  advised  of  the  fact  that 
defective  drainage  may  give  rise  to  recurrent  attacks  of 
tonsillitis  in  children." 

This  statement  seems  to  receive  corroboration  from 
Osier,4  who  writes,  "  Bad  hygienic  surroundings  appear 
to  have  a  direct  etiological  connection  with  the  disease." 
In  so  many  instances  defective  drainage  has  been  found 
associated  with  outbreaks  of  follicular  tonsillitis  that 
sewer-gas  is  regarded  as  a  common  exciting  cause.  Ber- 
nabei  has  also  found  that  in  many  cases  of  acute  angina 
streptococci  are  discovered,  and  that  these  cases  are  epi- 
demic and  contagious. 

Rendu  and  Bulloche  are  even  of  the  opinion  that  all 
acute  anginas  are  of  bacterial  origin,  and  similar  opinions 
are  held  of  late  by  many  other  observers.5 

In  many  of  these  cases,  according  to  Kingston  Fox,6 
and  Browne,  the  differential  diagnosis  from  acute  tonsil- 
litis due  to  cold  or  other  causes  is  made  by  the  fact  that 
the  septic  cases  are  bilateral  in  the  beginning. 

No  doubt,  as  I  have  observed  frequently,  some  chil- 
dren are  rendered  more  susceptible  to  septic  causes  by 
the  presence  at  the  same  time  of  a  rheumatic  habit  or  a 
strumous  constitution .  Nevertheless,  whenever  recurren  t 
attacks  of  tonsillitis  occur  in  a  child,  or  among  children 
in  the  same  family,  it  becomes  a  duty  to  see  to  it  that 
the  basins,  sinks,  lavatories,  drains,  and  pipes  shall  be 
examined  as  carefully  as  possible,  to  discover  if  there  be 
any  defect  in  the  plumbing  through  which  sewer  gas 
may  gain  entrance  to  the  house.  It  is  important  again 
to  observe  that  frequently  no  doubt  what  is  recognized 
as  sewer- gas  in  our  houses  is  the  result  of  decomposition 
which  takes  place  in  the  house-drains  themselves,  rather 
than  the  result  of  decomposition  in  the  distant  sewer 
forced  into  our  houses  through  the  connecting  drain 
(Waring).  It  is  doubtless  a  fact  that  in  many  instances 
the  gases  formed  within  the  drain  of  a  house  are  far 
more  hurtful  to  health  than  the  gases  which  circulate  in 
the  main  sewers.  This  is  frequently  explained  by  the 
fact  that  pipes  and  drains  of  the  house  have  become 
coated  over  with  slimy  deposits  which  in  time  are  con- 
siderable, and  because  many  of  these  soil  pipes  are  never 
properly  ventilated  by  a  proper  circulation  of  air. 

A  considerable  degree  of  doubt  exists  in  the  minds  of 
some  practitioners  about  the  evil  effects  of  sewer-air  on  the 
throat.  This  arises  probably  from  "  the  notorious  fact 
that  workers  in  sewers  are  remarkably  free  from  disease, 
and  particularly  from  affections  of  the  throat."  Indeed, 
in  the  numerous  citations  which  I  have  referred  to  per- 
sonally, I  have  found  no  case  in  which  one  of  these  men 
is  said  to  have  suffered  from  diphtheria  or  tonsillitis.  In 
many  of  the  cases  of  disease  which  have  been  reported, 

1  British  Medical  Journal,  February  24,  1894,  p.  430. 
a  Vide  Report  of  State  Board  of  Health  of  New  York,  1893,  p.  516. 
8  Cyclopaedia  of  Diseases  of  Children,  Keating,  vol.  ii.,  p.  33a. 
4  Practice  of  Medicine  p.  332.  « 

•  Burnett :  System  of  Diseases  of  the  Ear,  Throat ,  and  Nose,  vol. 
ii.,  pp.  250,251. 
•Transactions  of  the  Medical  Society  of  London,  vol  ix.,  p.  255. 


26o 


MEDICAL    RECORD. 


[September  i,  1894 


the  illness  may  have  been  only  a  coincidence,1  and  in 
no  manner  connected  with  their  profession.  It  may 
also  be  said  in  regard  to  these  cases  of  immunity  that 
these  men  have  become  gradually  acclimatized  to  their 
usual  surroundings,  and  that  the  others  who  were  un- 
favorably affected  by  the  work  in  the  sewers,  had  aban- 
doned it  and  taken  up  employment  of  a  different  kind. 

Whenever  cases  of  diphtheria,  follicular  tonsillitis,  or 
erythematous  sore  throat  occur  in  a  house  where  the 
plumbing  is  found  to  be  defective,  we  should  be  careful 
not  to  ascribe  these  diseases  necessarily  to  this  cause. 
In  what  precedes  it  has  been  shown  that  throat  diseases 
may,  and  often  do,  occur  where  the  drainage  is  bad ;  they 
also  occur  where  the  sewerage  is  in  perfect  condition ;  they 
likewise  appear  where  there  is  no  sewerage  at  all  to  ac- 
count for  the  outbreak.  If  the  sanitary  appliances  are 
defective,  we  are  naturally  inclined  to  hold  them  respon- 
sible for  the  throat  disease.  And  yet,  as  a  fact,  few  of 
our  city,  or  country  houses,  even  of  those  owned  by 
wealthy  people,  come  up  in  their  plumbing  arrange- 
ments to  the  requirements  of  a  careful  sanitary  engineer. 
Despite  this  fact,  the  throat  condition  of  the  majority  of 
people  remains  tolerably  good,  and  the  percentage  of  those 
who  suffer  from  diphtheria,  or  less  severe  disorders  of  the 
throat,  is  comparatively  small.  Again,  there  may  be 
some  cause  of  throat  disease  other  than  that  of  breathing 
sewer-air,  which  has  been  overlooked,  and  yet  ultimately 
is  proven  to  be  the  occasion  of  the  outbreak.  In  illus- 
tration of  this  statement  I  would  cite  an  outbreak  of 
diphtheria  in  the  village  of  Upchurch,  England,  which 
was  finally  attributed  to  the  dust  from  the  collections  of 
refuse  from  London  dustbins  accumulated  in  the  neigh- 
borhood, and  when  the  utter  absence  of  any  other 
source  of  infection  was  affirmed.3 

The  chronic  poisoning  with  sewer-air,  especially  in 
its  relation  with  diseases  of  the  throat,  is,  as  we  have  seen, 
a  subject  to  which  considerable  thought  has  been  given, 
and  yet  the  conclusions  arrived  at  are  uncertain.  Still 
it  would  seem  to  be  fairly  well  established  by  repeated 
observations  that  the  breathing  of  sewer-air  for  any  con- 
siderable length  of  time,  and  even  though  largely  di- 
luted, will  occasion  many  of  the  throat  affections.  The 
clinical  experience  of  numerous  physicians,  the  evidence 
of  sanitarians,  all  point  strongly  to  this  fact.  It  is  also 
proven  that  evil  effects  of  breathing  sewer  gas  on  the 
throat  depend  not  so  much  on  the  quantity  as  on  the 
quality  of  the  gas.  If  the  sewer- air  contain  the  specific 
germs  of  diphtheria,  it  may  become  the  carrier  of  this  dis- 
ease. At  another  time,  when  the  sewer-air  contains  no 
such  specific  germs,  it  will  be  the  bearer  only  of  follicu- 
lar or  erythematous  tonsillitis. 

It  is  probable  that  sewer-air  may  at  times  be  inhaled 
quite  a  long  period  without  developing  any  symptoms  of 
throat  disease.  At  a  later  period,  when  the  sewer-air 
becomes  laden  with  harmful  germs,  a  throat  affection  of 
infectious  type  may  occur  with  certainty.  In  children, 
when  no  specific  disease  germs  are  at  work,  the  symp- 
toms of  chronic  sewer-air  poisoning  are  frequently  those 
of  catarrhal  tonsillitis.  In  times  of  epidemics  the  catar- 
rhal tonsillitis  is  apt  to  assume  a  severe  or  malignant  type,8 
and  a  simple  sore  throat  may,  under  the  influence  of 
sewer- air,  assume  a  very  serious  and  aggravated  form.  In 
children,  particularly,  the  susceptibility  to  the  influence 
of  air  polluted  by  sewage  emanations  appears  to  be 
greatest.  They  easily  become  languid,  and  may  suffer 
from  sore  throat  connected  or  not  with  diarrhoea  or  some 
other  manifest  disturbance  of  the  digestive  tract4 

People  are  more  apt  to  suffer  from  the  evil  effects  of 
sewer-gas  during  the  night  than  during  the  day,  when  the 
body  is  undergoing  active  exercise,  and  when  the  rooms 
are  better  ventilated.  This  is  the  reason  why  we  hear 
patients  say  so  frequently  that  they  have  gone  to  bed 
perfectly  well  and  have  awakened  during  the  night  or  in 

1  Osier  :  Practice  of  Medicine,  p.  261. 

9  The  Journal  of  Laryngology,  March,  1894,  p.  124. 

3  Reference  Hand-book  of  the  Medical  Sciences,  vol.  vi. ,  p.  435. 

4  Bartley  :  Ibid  ,  vol.  vi.,  p.  436. 


the  early  morning  suffering  from  sore  throat.  It  is  quite 
possible  that  the  ordinary  putrefactive  bacteria,  when 
germinating  in  pent-up  sewerage,  may  be  the  cause  of 
the  catarrhal  sore  throats  produced  by  sewer-air.1 

Finally,  it  must  be  obvious  "  that  the  effect  oftentimes 
is  practically  the  same  whether  the  fermenting  sewage  is 
contained  in  sewers,  or  has  soaked  into  the  ground  about 
the  house.  Both  may  pollute  the  air  with  the  sajne  gases 
and  may  produce  like  effects  upon  the  throat.  When 
furnace  fires  are  used  in  the  house,  the  gases  from  a  sewer- 
soaked  soil  may  be  drawn  into  the  rooms  above,  giving 
rise  to  all  the  injurious  effects  of  sewer-air.M  *  "  Or  the 
position  of  the  air  inlet  of  a  furnace  near  a  drain-opening 
or  other  source  of  contamination  may  allow  foul  air  to 
pass  into  the  heating  chamber  of  the  furnace  and  be 
distributed  through  the  house,"  thus  tfbcoming  the  effi- 
cient cause  of  diphtheria,  follicular  tonsillitis,  or  other 
throat  disease. 

The  following  communication  I  am  indebted  for  to  the 
courtesy  of  Dr.  A.  Campbell  White,  House  Physician  at 
the  Willard  Parker  Hospital,  N.  Y.  Dr.  White's  report 
appears  to  me  very  interesting  and  instructive.  Miss 
Graf,  the  nurse  from  St.  Luke's  Hospital,  referred  to  by 
Dr.  Campbell,  was  seen  by  me  both  during  and  subse- 
quent to  her  attack  of  diphtheria. 

"  I  believe  the  impression  is  or  has  been  quite  univer- 
sal that  the  origin  of  epidemics  or  of  individual  cases  of 
this  disease  could  be  traced  to  faulty  plumbing  or  some 
other  condition  giving  rise  to  escape  of  sewer-gas.  That 
such  a  condition  can  be  the  primary  cause  of  diphtheria 
we  are  now  quite  safe  in  denying. 

"  We  are  very  positive  in  asserting  that  the  Klebs-Loef- 
fler  bacillus  is  the  organism  at  the  foundation  of  every 
case  of  diphtheria,  and  we  can  be  almost  equally  positive 
in  saying  that  this  germ  cannot  be  found  in  sewer  gas. 

"If  the  drain- pipes  are  in  a  moist  condition,  as  they 
almost  invariably  are,  it  is  justifiable  to  believe  that  even 
though  these  pipes  may  be  loaded  with  the  bacilli  of 
diphtheria,  the  gases  escaping  will  not  carry  the  infection 
necessary  to  produce  this  disease. 

"  We  can  take  for  an  example,  and  I  think  it  is  a  good 
one,  the  wards  in  our  hospital.  Here  we  have  some  fifty 
patients,  every  one  of  whom  has  the  bacillus  of  Klebs 
and  Loeffler  in  the  throat  or  nasal  passages.  We  can 
compare,  for  sake  of  argument,  these  throats  to  the  sewer 
pipes,  and  the  air  these  patients  are  constantly  exhaling 
to  the  sewer  gases.  Now  the  ward,  of  course,  in  spite 
of  good  ventilation,  is  constantly  filled  with  the  expired 
air  of  patients  suffering,  some  of  them,  from  the  very 
worst  forms  of  diphtheria,  yet  we  have  never  succeeded 
in  obtaining  any  Klebs  Loeffler  bacilli  in  the  air  exam- 
ined, nor  have  any  of  the  attendants,  who  live  twelve 
hours  out  of  twenty- four  in  these  same  wards,  contracted 
the  disease. 

"  We  are  very  firmly  convinced  that  to  contract  this 
disease  direct  contact  is  absolutely  necessary.  Therefore 
sewerage  (containing  the  diphtheria  bacillus)  must  come 
in  direct  contact  with  the  patient  by  contaminating  the 
water,  or  some  other  such  manner,  in  order  to  be  held 
responsible  for  an  attack  of  diphtheria." 

Nevertheless  I  do  not  hesitate  in  saying  that  constant 
exposure  to  sewer-gas  is  a  very  important  element  in 
determining  the  severity  of  an  attack  of  diphtheria,  and 
that  in  many  cases  it  is  the  most  important  factor  in 
bringing  on  a  fatal  result. 

At  the  annual  meeting  of  the  Public  Health  Associa- 
tion, held  in  Baltimore  in  1875,  ^r-  Noel,  after  citing 
many  cases  in  his  own  practice  to  bear  out  his  statement, 
said :  "  We  do  not  say  that  this  gas  is  the  direct  cause 
of  diphtheria,  croup,  etc.,  in  the  sense  of  being  the  one 
and  only  efficient  cause,  but  we  do  contend,  and  we 
defy  criticism  here,  that  in  Baltimore  City  it  has  most 
assuredly  been  the  one  constant  factor  invariably  present 
in  the  most  malignant  and  well  defined  house  epidem- 

1  Loc.  cit ,  p.  436. 

■  Parkes :  Hygiene,  with  American  Supplement  p.  5«6  (Appendix). 
Wm  Wood  &  Co.,  1884. 


September  i,  1894] 


MEDICAL  RECORD. 


261 


ics."  We  can  give  an  excellent  example  in  our  own 
recent  experience.  I  refer  to  the  case  of  Miss  Graf  from 
St.  Luke's  Hospital,  and  the  other  two  nurses  who  at- 
tended the  family  in  Pennsylvania,  a  family  of  seven  or 
eight  members,  living  in  a  house  where  the  plumbing  is 
exceptionally  poor,  and,  as  the  nurses  testify,  where  there 
is  a  constant  odor  of  sewer-gas  penetrating  the  entire 
place.  Now  every  member  of  this  family,  ranging  in  ages 
from  under  five  years  to  twenty-seven  years,  contracted 
the  disease,  and  every  one  died  after  a  comparatively 
short  illness.  This  is  a  most  frightful  mortality.  The 
three  nurses  who  attended  these  cases  also  contracted 
the  disease,  but  immediately  came  to  our  hospital  for 
treatment.  Not  one  of  them  died,  and  only  one  devel- 
oped into  anything  like  the  malignant  form  assumed 
undoubtedly  by  the  cases  in  Pennsylvania.  We  can 
hardly  attribute  this  difference  entirely  to  treatment,  nor 
can  we  say  they  did  not  have  the  same  exposure,  but  I 
think  we  are  justified  in  believing  that  this  marked  dif- 
ference in  mortality  was  more  than  a  little  influenced  by 
the  fact  that  the  former  cases  were  treated  in  a  sewer- 
poisoned  atmosphere,  while  the  more  fortunate  nurses 
were  cared  for  in  a  clean,  well-ventilated  ward  in  our 
hospital,  where  there  is  no  taint  of  sewer -gas. 

Another  important  point  to  remember  is  that  we  are 
now  finding  many  people  in  the  very  best  of  health 
walking  around  with  the  Klebs- Loeffler  bacilli  in  their 
throats  displaying  no  signs  whatever  of  diphtheria. 
Some  of  these  people  later  develop  the  disease,  in  others 
the  Loeffler  bacilli  disappear  without  having  caused  any 
trouble  or  inconvenience.  The  former  have  been  exposed 
to  cold,  have  developed  a  catarrhal  inflammation  of  the 
respiratory  passages,  or  in  some  such  way  the  throat, 
previously  immune,  is  rendered  susceptible  to  the  ba- 
cillus. Now  such  a  person,  with  the  necessary  bacilli  in 
his  throat,  breathing  in  from  day  to  day  the  atmosphere 
laden  with  sewer-gas,  is  almost  certain  to  develop  diph- 
theria, and  we  can  readily  see  how  easy  it  is  to  say  (not 
knowing  that  the  patient  had  previously  the  bacilli  in 
his  throat)  that  such  a  person  contracted  his  diphtheria 
from  the  gas  escaping  from  a  defective  sewer-pipe,  while, 
on  the  contrary,  if  he  had  not  already  the  bacilli  in  his 
throat,  he  might  have  gone  on  indefinitely  breathing 
this  vitiated  air  without  even  developing  the  disease. 

We  have  ample  reason  to  believe  that  sewer- gas  attacks 
the  weak  spots  of  the  patient.  Dr.  F.  Gordon  Morrill 
mentions  this  point  in  the  Boston  Medical  and  Surgical 
Journal  of  1884.  Among  the  diseases  brought  on  by 
sewer-gas  in  this  way  he  mentions,  besides  those  affect- 
ing the  throat,  rheumatism,  gout,  asthma,  pneumonia, 
and  even  neurasthenia. 

The  influence  of  sewer  gas  upon  diseases  of  the  throat 
can  be  summarized  as  follows:  1.  Given  a  patient  with 
a  so-called  weak  throat,  subject  to  frequent  attacks  of 
quinsy,  etc.,  expose  him  to  sewer-gas,  he  will  probably 
develop  amygdalitis.  2.  Given  a  patient  in  good  health, 
with  a  throat  containing  Klebs  Loeffler  bacilli,  expose 
him  for  any  time  to  sewer-gas,  and  he  will  probably  de- 
velop diphtheria ;  or  3.  Given  a  mild  case  of  diphtheria, 
expose  him  to  sewer-gas,  and  the  disease  will  assume  a 
more  malignant  type. 

Therefore,  although  sewer- gas  plays  an  important  part 
in  the  etiology  of  some  throat  diseases,  it  can  by  no  means 
be  held  responsible  as  the  primary  all-efficient  cause. 

The  following  letter  is  also  of  considerable  interest.  I 
saw  the  last  boy  who  died,  in  consultation  with  Dr. 
Chandler,  and  agreed  entirely  with  him  in  regard  to  the 
diagnosis: 

•'South  Orangjb,  May  26,  1894. 

"  Dear  Doctor  :  The  history  you  desire  is  in  brief  as 

follows:  In  April,  1888,  Mr.  C built  and  occupied 

a  house  on Avenue,  Orange,  N.  J.  In  April,  1890, 

his  oldest  son  was  very  sick  with  diphtheria,  but  recov- 
ered. No  unusual  amount  of  sickness  affected  his  family 
for  two  years  later  in  this  house.  He  then  moved  to 
another  town. 

"  A  Mr.  G occupied  the  same  house  after  Mr. 


C- 


vacated.     He  had  a  family  of  three  children.     All 


had  been  previously  well.  They  soon  sickened  of  vari- 
ous disorders  of  no  especial  name  or  magnitude.  After 
living  in  the  house  about  one  year  one  child  developed 
diphtheria,  and  after  a  week's  sickness  died.1  About  a 
month  later,  a  third  child  was  attacked  with  the  same 
disease.  By  the  advice  of  their  physician  they  left  the 
house  on  the  third  day  of  the  child's  sickness,  but  that 
child  also  died. 

"  The  plumbing  and  draining  of  the  house  were  found 
to  be  defective,  the  wash  tray  in  the  butler's  pantry  was 

without  a  trap.     Mr.  C ,  who  first  lived  in  the  house 

used  the  tray,  but  always  kept  the  plug  in  the  outlet  and 

there  was  no  overflow.     Mr.  G did  not  use  the  tray, 

and  the  plug  was  often  out,  and  a  *  bad  odor '  was  no- 
ticed from  the  tray. 

"  An  outlet  pipe,  to  remove  surface  water  which  might 
collect  in  the  cellar,  ran  directly  to  the  cesspool  andVas 
also  without  a  trap.  Thus  there  were  two  vents  from  the 
cesspool  directly  into  the  house. 

"  These  are,  briefly,  the  facts  without  comment.  They 
speak  for  themselves. 

"  Very  truly  yours, 

"  William  J.  Chandler." 


THE   PHONOGRAPH  :    ITS  PHYSICS,  PHYSIOL- 
OGY,  AND  CLINICAL  IMPORT.2 

By  J.  MOUNT  BLEYER,  M.D., 

NKW    YORK. 

VISITING  SURGEON  TO  THE  NEW  YORK  THROAT,  NOSK,  AND  CHBST  HOSPITAL  \ 
LARYNGOLOGIST  GERMAN  WBST-SIOB  CLINIC;  MEMBER  ROYAL  ACADEMY, 
NAPLES,    ITALY,   ETC. 

Before  I  enter  upon  a  demonstration  of  the  under- 
lying principles  and  the  action  of  the  phonograph,  let 
me  occupy  a  moment  of  your  time  by  recalling  those 
special  characteristics  of  the  human  voice,  the  dis- 
tinguishing qualities  of  musical  tones,  etc.,  which  it  is 
necessary  to  keep  before  us  in  order  to  thoroughly 
understand  the  instrument  I  intend  to  dissect,  both 
anatomically  and  physiologically  before  you. 

You  are  all  more  or  less  familiar  with  the  phonograph. 
Five  years  ago  it  was  a  closed  book  to  us.  To-day  we 
presume  to  know  it  from  preface  to  appendix.  I  fancy 
there  are  many  here  in  this  section  who  casually  know 
me  from  the  few  years  of  work  I  have  done  in  experi- 
menting with  the  machine  and  the  fragments  that  from 
time  to  time  have  gone  forth  to  the  profession  from  my 
pen  and  workshop.  I  can  almost  hear  them  say  :  "  Here 
he  is  again ;  what  can  he  have  to  tell  us  now  ?"  My  an- 
swer is  simply  to  let  you  know  the  further  stage  of  per- 
fection to  which  I  have  been  able  to  carry  the  recording 
and  reproducing  with  integrity  the  sounds  and  tones 
which,  aside  from  their  general  scientific  importance, 
must  soon  become  a  valuable  assistant  to  us  in  the  posi- 
tive recognition  of  disease. 

All  sound  begins  in  those  collisions  and  attractions 
among  material  things  by  which  their  parts  are  thrown 
into  tremors.  These  are  almost  as  various  in  quality  as 
the  properties  of  material  substances.  The  sounds  we 
hear  are  but  indices  to  the  vibrations  of  bodies  from 
which  they  proceed,  and  the  multitude  of  such  terms 
as  splash,  roar,  ring,  thud,  crack,  whiz,  squeak,  crash,  il- 
lustrate the  marvellous  diversity  of  characters  which 
material  vibrations  may  take.  In  the  production  of 
noise  the  thrills  of  matter  are  transient  and  irregular, 
but  when  prolonged  and  regular  they  give  rise  to 
musical  sounds.  Vibration  depends  upon  elasticity,  and 
bodies  which  are  capable  of  the  protracted  and  measured 
pulsations  of  music  must,  of  course,  be  highly  elastic. 
All  bodies  vibrate  differently,  and  this  depends  upon  the 
nature,  form,  and  magnitude  of  the  mass  in  motion.  The 
vibrations  of  bells  differ  with  their  sizes  and  the  metals 
and  alfbys  which  compose  them  ;  while  wooden  and  me- 

»  Another  child  was  stricken  with  a  light  attack  of  the  same  character 
before  the  first  child  died,  but  recovered. 
»  Read  before  the  International  Medical  Congress,  Rome,  1894, 


262 


MEDICAL  RECORD. 


[September  i,  1894 


tallic  tubes,  strained  strings,  and  stretched  membranes, 
illustrate  the  same  thing. 

Take  a  tuning-fork  and  set  it  into  vibration  by  draw- 
ing a  violoncello  string  across  its  prongs ;  the  fork  yields 
its  own  characteristic  note,  which  will  be  loud  or  soft  in 
harmony  with  the  manner  in  which  the  fork  has  been  set 
into  vibration  ;  so  long  as  we  use  one  fork  only,  it  is 
obvious  that  ihe  only  vibration  which  can  be  produced 
in  the  sounds  confines  itself  to  a  vibration  of  their  in- 
tensity. If  the  extent  of  the  vibrations  be  small,  the 
sound  resulting  is  feeble ;  its  loudness  increasing  with 
the  excursion  of  the  prongs.  What  is  true  of  the  tun- 
ing-fork is  true  of  any  musical  instrument,  and  hence  the 
loudness  of  musical  sounds  depends  upon  the  amplitude 
of  the  vibratory  space  of  that  which  produces  it.  Now 
take  two  tuning  forks,  differing  in  the  pitch,  and  let  us 
presume  that  one  is  just  an  octave  above  the  other. 
They  may  be  excited  in  such  a  way  that  the  notes  emit- 
ted are  of  equal  loudness,  the  only  point  in  which  they 
differ  being  in  pitch. 

We  all  know  that  the  pitch  of  a  fork  depends  upon 
its  rate  of  vibration,  which  we  can  readily  measure  with 
suitable  apparatus,  and  thus  it  is  comparatively  easy  for 
us  to  accurately  determine  the  pitch  of  a  tuning-fork, 
and  should  we  so  test  the  two  tuning-forks  in  question  we 
would  find  that  the  notes  of  the  one  of  increased  pitch 
would  vibrate  twice  as  fast  as  the  other.  If  the  one,  say, 
makes  one  hundred  oscillations  per  second,  the  other,  an 
octave  higher,  would  make  two  hundred  in  the  same  inter- 
val of  time,  thus  we  may  be  assured  that  the  pitch  of  any 
note  depends  upon  its  rate  of  vibration  and  nothing  else. 

So  having  accounted  for  two  characteristics  of  a  musi- 
cal note,  let  ms  come  to  the  third,  which  is  of  equal,  if 


■      T»        ■J__JJ*A 


\   \   \  \ 


Fig.  x. — A  stretched  firing  showing  a  pendulum  motion  which  makes  only  a  given  number  of  vibrations  in  a  fixed  time. 


not  greater,  importance,  and  by  no  means  so  easy  of  ex- 
planation. I  refer  to  what  we  generally  term  the  "quality. ' ' 
The  French  have  the  more  comprehensive  term  for  it ; 
they  call  it  "  timbre, "  while  the  Germans  have  the 
most  exact  defining  word  in  the  term  "  klang-farbe." 

Klang-farbe  is  that  which  constitutes  the  difference  be- 
tween a  violin  or  an  organ  and  a  piano  forte,  or  between 
two  human  voices;  indeed  we  may  say  between  any 
sounds,  musical  or  otherwise,  which  are  of  the  same  pitch 
and  loudness,  but  readily  distinguishable  from  each  other. 

To  explain  the  physical  cause  of  quality  let  us  suppose 
we  have  a  thin  metallic  wire  stretched  between  two 
points  over  a  sounding  board  (Fig.  1 ).  When  plucked 
at  the  centre  the  wire  vibrates  over  its  entire 
length,  a  loop  being  formed  between  the  two  points. 
The  note  emitted  by  the  wire  when  vibrating  in  this 
manner  is  called  the  fundamental  note.  If  we  should 
dampen  the  wire  at  the  centre  by  laying  across  it  a 
feather  or  quill  pen,  and  pluck  it  at  a  point  midway 
between  the  centre  and  one  end,  both  halves  would 
vibrate  in  the  same  manner  and  independently  of  each 
other.  That  is  to  say,  there  will  be  two  vibrating  seg- 
ments and  a  point  of  rest  or  node  at  the  centre.  But 
the  rapidity  of  vibration  of  each  segment  will  be  twice  as 
great  as  that  of  the  wire  when  vibrating  as  a  whole,  and 
consequently  the  note  emitted  will  be  the  octave  of  the 
fundamental. 

When  damped  at  a  point  one-third  of  the  length  from 
either  extremity,  and  plucked  half-way  between  that 
point  and  the  nearer  extremity,  the  wire  will  vibrate  in 
three  equal  divisions,  just  as  it  vibrated  before  in  two 
divisions;  but  now  the  rate  of  vibration  will  be  "three 
times  as  great  as  at  first,  and  the  note  produced  will  be 
a  twelfth  above  the  fundamental.  Similarly,  by  dampen- 
ing and  plucking  it  at  suitable  points,  the  wire  may  be 


made  to  vibrate  in  four  parts,  five  parts,  six  parts,  etc., 
the  rate  of  vibration  increasing  to  four,  five,  six,  etc., 
times  what  it  was  at  first.  For  example,  let  us  assume 
that  when  the  wire  was  swinging  as  a  whole,  and  sound- 
ing its  fundamental  note,  the  number  of  oscillations 
performed  in  a  second  was  100.  Then  we  see  that, 
by  taking  suitable  precautions,  the  wire  can  be  made 
to  break  up  into  two,  three,  four,  five,  six,  etc.,  vibrat- 
ing segments,  the  rates  of  vibrations  being  respectively 
200,  300,  400,  500,  600,  etc.,  and  the  series  of  notes 
emitted  being  the  octave  above  the  fundamental,  the 
fifth  above  the  octave,  the  double  octave,  the  third  and 
fifth  above  the  double  octave,  and  so  on.  We  now 
come  to  an  important  point,  which  is  this — that,  the 
wire  being  free,  it  is  practically  impossible  to  strike  or 
pluck  it  in  such  a  way  as  to  make  it  vibrate  according  to 
one  of  the  above  systems  alone.  It  will  vibrate  as  a 
whole,  wherever  and  however  it  is  struck;  but  this 
mode  has  always  associated  with  it  or  superposed  upon 
it  some  of  the  other  modes  of  vibration  to  which  we 
have  just  referred.  In  other  words,  the  fundamental 
note  is  never  heard  alone,  but  always  in  combination 
with  a  certain  number  of  its  overtones,  as  they  are  called. 
Each  form  of  vibration  called  into  existence  sings  as  it 
were  its  own  song,  without  heeding  what  is  being  done 
by  its  followers,  and  the  consequence  is  that  the  sound 
which  reaches  the  ears  is  not  simple  but  highly  com- 
posite in  its  character.  The  word  "  clang  "  has  been  sug- 
gested to  denote  such  composite  sound,  the  constituent 
simple  sounds  of  which  it  is  the  aggregate  being  called 
its  first,  second,  third,  etc.,  partial  tones.  All  the  pos- 
sible partial  tones  are  not  necessarily  present  in  a  clang, 
nor  of  those  which  are  present  are   the  intensities  all 

the  same.  For  in- 
stance, if  the  wire 
be  struck  at  the 
centre,  that  point 
cannot  be  a  note, 
but  must  be  a  point 
of  maximum  dis- 
turbance ;  hence  all 
the  even  partial 
tones  are  excluded,  and  only  the  off  ones,  the  first,  third, 
fifth,  and  so  on  are  heard. 

That  characteristic  of  a  musical  note  or  clang  which  is 
called  its  quality  depends  upon  the  number  and  relative 
intensities  of  the  partial  tones  which  go  to  form  it.  The 
tone  of  a  tuning  fork  is  approximately  simple ;  so  is  that 
of  a  stopped  wooden  organ- pipe  of  large  aperture  blown 
by  only  a  slight  pressure  of  wind.  Such  tones  sound 
sweet  and  mild,  but  they  are  tame  and  spiritless.  In  the 
clang  of  the  violin,  on  the  other  hand,  a  large  number  of 
partial  tones  are  represented ;  hence  the  vivacious  and 
brilliant  character  of  this  instrument.  The  sounds  of  the 
human  voice  are  produced  by  the  vibrations  of  vocal 
bands,  aided  by  the  resonance  of  the  mouth.  The  size 
and  shape  of  -the  cavity  of  the  mouth  may  be  altered  by 
opening  and  closing  the  jaws  and  by  tightening  and 
loosening  the  lips.  We  should  expect  that  these  move- 
ments would  not  be  without  effect  on  the  resonance  of 
the  contained  air,  and  such  proves  upon  experiment  to 
be  the  fact.  Hence,  when  the  vocal  bands  have  origi- 
nated a  clang  containing  numerous  well- developed  partial 
tones,  the  mouth  cavity,  by  successively  throwing  itself 
into  different  postures,  can  favor  by  its  resonance  first 
one  overtone  and  then  another,  at  one  moment  this  group 
of  partial  tones,  at  another  that.  In  this  manner  endless 
varieties  of  quality  are  rendered  possible.  Any  one  may 
prove  it  himself  by  making  the  experiments,  that  when 
singing  on  a  given  note  he  can  only  change  from  one 
vowel  sound  to  another  by  altering  the  shape  and  size  of 
his  mouth  cavity. 

The  Propagation  of  Sound. — Having  thus  briefly  in- 
dicated the  physical  causes  of  the  various  differences  in 
musical  notes  and  the  production  of  sounds  by  the  organ 
of  voice,  I  will  now  devote  a  few  moments  to  consider 
how  these  sounds  are  propagated  through  the  air  and 


September  i,  1894] 


MEDICAL   RECORD. 


263 


reach  the  delicate  diaphragm  of  the  phonograph,  while 
recording  any  kind  of  sounds. 

Now,  in  order  that  all  these  multifarious  and  diversified 
tremblings  of  natural  objects  may  be  brought  into  rela- 
tion with  animate  creatures,  a  common  medium  of  com- 
munication is  necessary.  The  air  around  us  is  such  a 
medium.  It  possesses  the  marvellous  power  of  taking  up 
the  numberless  and  ever-varying  thrills  of  material  ob- 
jects and  conveying  them  through  space  with  all  their 
peculiarities.  The  sensitiveness  of  the  air  (if  I  may  so 
speak)  to  the  faintest  tremors  in  material  objects,  and  its 
power  of  transmitting  their  individual  qualities,  are  most 
wonderful.  It  drinks  up  the  infinitesimal  motions  of 
things  and  diffuses  them  swiftly,  simultaneously,  and  in 
countless  myriads  in  all  directions  around. 

That  air  is  the  medium  of  sound  is  proved  by  the  fact 
that  when  vibrations  occur  in  space  void  of  air  the 
silence  is  not  broken.  If  a  bell  suspended  by  a  string  in 
a  vacuum  be  struck,  nothing  is  heard,  although,  if  it  is  in 
contact  with  the  jar,  the  vibrations  are  communicated  to 
the  outer  air  and  sound  produced.  That  air  transmits 
the  kind  of  motion  that  it  receives  is  also  proved  by  the 
fact  that  it  will  take  up  vibrations  at  one  point  and  com- 
municate them  to  a  distant  object  that  is  capable  of 
vibrating  in  the  same  way. 

The  velocity  of  impulses  in  the  air  which  produces 
sound  has  been  well  established,  and  all  kinds  of  shocks 
— the  firing  of  a  gun,  notes  of  a  musical  instrument,  or 
the  voice,  whether  high  or  low,  harsh  or  soft — all  move 
at  the  same  rate.  The  velocity  is  not  affected  by 
changes  in  atmospheric  pressure  or  moisture,  or  by  rain 
or  snow,  but  it  is  affected  by  wind  and  by  tempera- 
ture. 

The  speed  of-sound  is  1.090  feet  per  second  at  the 
freezing-point,  and  increases  about  one  foot  per  second 
for  each  degree  of  ascent  on  the  Fahrenheit  scale. 
Sound  moves  in  air  with  about  the  speed  of  a  cannon- 
ball,  and  at  a  rate  ten  times  greater  than  the  swiftest 
motion  of  air  in  a  hurricane.  The  sound  produced  in 
the  open  air  tends  to  move  in  all  directions  with  equal 
speed,  but  this  tendency  may  be  disturbed  by  various 
conditions.  If  the  whole  mass  of  air  is  moving  in  one 
direction,  sound  will  travel  faster  with  it  than  against  it. 
In  still  air  the  sound  of  a  musket-shot  will  be  heard 
farthest  in  the  direction  of  the  impulse.  Experiments 
have  shown  that  a  person  speaking  in  the  open  air  can 
be  heard  about  equally  well  at  a  distance  of  100  feet  in 
front,  75  feet  on  each  side,  and  30  feet  behind.  When 
an  obstacle  checks  a  sound  in  one  direction  it  can  be 
heard  farther  in  others,  because,  as  a  given  amount  of 
force  produces  a  given  amount  of  motion  if  the  mo- 
tion is  arrested  in  some  directions  it  is  increased  in 
others. 

We  have  now  seen  that  air  is  the  common  vehicle  of 
sound,  and  that  the  sound- impulses  move  in  all  directions 
at  a  high  speed.  But  what  is  it  that  actually  moves  ? 
The  particles  of  air  certainly  not  shot  from  the  vibrating 
body  to  the  ear,  for  then  we  should  live  in  the  midst  of 
storms  ten  times  more  violent  than  tropical  cyclones. 
The  wonderful  elastic  properties  of  gases  here  come  into 
play.  The  vibrations  of  bodies  produce  waves  or  pulses 
in  the  air.  When  a  disturbance  is  produced  at  any  point 
in  an  aerial  at  rest,  sonorous  undulations  spread  out  from 
that  point  in  all  directions.  These  undulations  are  the 
effect  of  the  rapid  vibratory  motion  of  the  air  particles. 
The  analogy  of  water  waves  will  help  us  to  understand 
what  is  taking  place  under  these  circumstances.  If  a 
stone  be  dropped  into  the  still  surface  of  a  pond,  a 
series  of  concentric  circular  waves  are  produced,  each 
wave  consisting  of  a  crest  and  a  hollow.  The  waves 
travel  from  the  centre  of  disturbance,  while  the  drops  of 
water  which  constitute  them  have  an  oscillatory  motion 
in  a  vertical  direction.  That  is  to  say,  following  any 
radical  line,  the  water  particles  vibrate  in  a  direction  at 
right  angles  to  that  in  which  the  wave  is  propagated. 
The  distance  between  two  successive  crests  or  two  suc- 
cessive hollows  is  called  the  length  of  the  wave ;  the 


amplitude  of  vibration  is  the  vertical  distance  through 
which  an  individual  drop  moves.  In  a  similar  manner 
sonorous  undulations  are  propagated  through  air  by  the 
oscillatory  motion  of  the  air-  particles.  But  there  is  this 
important  difference  between  the  two  cases,  that  in  the 
latter  the  vibrating  particles  move  in  the  same  direction 
in  which  the  sound  is  being  propagated.  Consequently 
such  waves  are  not  distinguished  by  alternate  crests  and 
hollows,  but  by  alternate  condensations  and  rarefactions 
of  the  air,  the  transmission  of  which  constitutes  the 
transmission  of  sound.  The  wave  length  is  the  distance 
between  two  consecutive  condensations  or  rarefactions. 
It  depends  upon  the  pitch  of  the  transmitted  sound  be- 
ing shortened  as  the  sound  is  more  acute,  while  the  ex- 
tent of  vibration  of  the  air- particles  increases  with  the 
loudness.  Such  are  the  peculiarities  of  the  vibratory 
motion  in  air  corresponding  to  the  pitch  and  loudness  of 
the  transmitted  sound.  But  what  is  there  in  the  char- 
acter of  the  motion  to  account  for  the  difference  in  qual- 
ity ?  A  little  reflection  will  show  that  there  is  only  one 
thing  left  to  account  for  these,  and  that  is  the  form  of 
the  vibration.  Let  us  mentally  isolate  a  particle  of  air, 
and  follow  its  movements  as  the  sound  passes.  If  the 
disturbance  is  a  simple  one,  produced,  say,  by  the  vibra- 
tion of  a  tuning-fork,  the  motion  of  the  air- particle  will 
be  simple  also,  that  is,  it  will  vibrate  to  and  fro  like  the 
bob  of  a  pendulum,  coming  to  rest  at  each  end  of  its  ex- 
cursion, and  from  these  points  increasing  in  velocity  un- 
til it  passes  its  neutral  point.  Such,  however,  is  clearly 
not  the  only  mode  of  vibration  possible.  If  the  disturb- 
ance be  produced  by  a  clang  comprising  a  number  of 
partial  tones  of  various  intensities,  all  excited  simultane- 
ously, it  is  obvious  that  the  air- particle  must  vibrate  in 
obedience  to  everyone  of  these  tones.  Its  motion  will 
be  the  resultant  of  all  the  motions  due  to  the  separate 
partial  tones.  We  may  imagine  it  starting  from  its 
position  of  rest  to  move  forward,  then  stop  short,  and 
turn  back  for  an  instant,  then  on  again  until  it  reaches 
the  end  of  its  excursion.  In  returning  it  may  perform 
the  same  series  of  to  and- fro  motions  in  the  opposite  di- 
rection, or  it  may  move  in  a  totally  different  way. 
Nevertheless,  however  complex  its  motion  may  be — and 
as  a  rule  it  will  be  exceedingly  complex — its  periodic 
character  will  be  maintained.  All  the  tremors  and  per- 
turbations in  one  wave  will  recur  in  all  the  others. 

Could  we  see  what  takes  place  in  a  room  when  a  tun- 
ing-fork is  in  vibration,  giving  out  a  "single  note,"  we 
should  behold  all  the  particles  of  the  air  agitated  in 
tremulous  sympathy,  and  filling  the  space  with  swiftly 
expanding  spheres  of  spectral  beauty.  Or  were  the  effect 
produced  by  several  instruments  played,  we  should  see 
forms  in  countless  variety  carving  the  air  into  ever- 
changing  figures  of  geometrical  harmony,  and  creating 
the  perfect  music  of  geometrical  forms.  Such  a  revela- 
tion is  impossible  from  the  swiftness  of  movement,  which 
would  baffle  the  eye ;  but  it  would  be  also  impossible, 
because  the  complications  of  movement  would  confuse  it. 
But  where  the  optical  sense  fails  the  auditory  sense  suc- 
ceeds. The  membrane  of  the  ear  receives  the  torrent  of 
motion  and  transmits  it  with  all  its  harmonies.  In  an 
orchestra,  where  scores  of  instruments  are  playing  through 
the  whole  compass  of  the  scale,  the  air  is  cut  into  waves 
or  pulses  by  every  complexity  of  vibration — grave  tones 
mingle  with  shrill,  soft  with  harsh,  fundamentals  are 
merged  in  overtones,  and  the  storm  of  impulses  is  shot 
with  the  speed  of  rifle  bullets  against  the  diaphragm  of 
the  phonograph  as  against  the  tympanum  ;  and  yet  there 
is  no  confusion.  In  all  their  infinite  diversity  of  qual- 
ities the  waves  are  graven  upon  the  little  membranes. 

In  order  to  complete  the  physics  in  this  paper,  I  can- 
not pass  over  it  without  paying  some  attention  to  visible 
sound. 

The  idea  of  getting  a  visual  expression  for  musical  vi- 
brations occurred  to  Chladni,  a  physician  of  the  last  cen- 
tury. He  fastened  a  plate  of  glass  by  its  centre,  and 
then,  having  scattered  some  sand  over  the  surface,  threw 
it  into  sonorous  vibration  by  means  of  a  violin  bow 


264 


MEDICAL   RECORD. 


[September  i,  1894 


(Fig.  2).  The  plate  when  thus  set  in  vibration,  the  sand 
was  tossed  away  from  certain  parts  of  the  surface  and 
collected  in  other  parts,  forming  regular  geometrical  fig- 
ures. The  plate,  like  a  string,  has  one  rate  of  vibrations 
which  belongs  to  it ;  but  again,  like  a  string,  by  "  damp- 
ening1' it  with  a  touch  of  the  finger  or  fingers  in  differ- 
ent points  along  the  edge  the  note  changes,  and  with  it 
the  figure  made  by  the  sand.  The  lines  on  the  plate 
waere  the  sand  settles  are  nodes,  the  lines  of  comparative 
rest.  The  violent  agitation  in  the  parts  left  bare  can  be 
shown  by  mixing  a  little  lycopodium  powder  with  the 
sand ;  this  is  excessively  light,  and  is  caught  in  the  little 
whirlwinds  of  air  generated  about  the  vibrating  segments. 


Fig.  a.— Showing  the  to-antl-fro  excursion  of  a  plucked  string. 

A  little  instrument  invented  by  Professor  Sedley  Tay- 
lor, and  called  the  phoneidoscope,  gives  a  most  exquisite 
illustration  of  music  made  visible.  He  says  that  by  this 
contrivance  it  is  possible,  by  msans  of  a  soap  film,  to  get 
different  figures  for  different  pitches,  for  different  inten- 
sities, and  for  different  qualities  of  tone.  I  did  not  find 
this  instrument  to  answer  in  practice. 

We  are  now  upon  the  very  threshold  of  Mrs.  Hughes's 
voice  figures  of  which  I  have  spoken  in  cxtinso  in  a 
previous  communication,  but  for  the  sake  of  complete- 
ness I  will  recapitulate  some  of  the  important  points 
set  forth  therein.  She  has  reached  the  path  which 
brought  her  to  them  by  the  phoneidoscope.  Her  eido- 
phone  is  constructed  on  the  same  principle  as  the  pho- 
neidoscope ;  in  eidophone,  instead  of  the  frail  lamina  of 
soap-suds,  she  has  a  stretched  membrane  of  india-rubber 
to  receive  the  vibrations,  and  on  this  is  spread  a  thin 
layer  of  some  pasty  substance  which  will  retain  the  record 
made  by  the  vibrations  of  the  membrane.  These  voice- 
flo/rcrs  are  not  the  simple,  visual  forms  corresponding 
with  the  vibrations  of  the  air  set  in  motion  by  the  voice. 
The  waves  generated  in  the  closed  bowl  of  the  eidophone 
are  reflected  again  and  again  from  the  sides  of  the  vessel. 
The  volume  of  air  inclosed  has  its  own  rate  of  vibration ; 
the  stretched  membrane  has  also  its  own  rate,  which  in 
turn  is  modified  by  the  character  and  thickness  of  the 
paste  spread  upon  it.  Added  to  these  are  molecular 
forces  of  cohesion  and  adhesion  between  the  particles  of 
paste,  and  again  between  the  paste  and  the  membrane. 
The  form  which  grows  into  shape  is  the  resultant  of  all 
these  complicated  forces,  and,  in  some  instances,  new 
elements  of  change  have  been  added.  A  glass  plate  is 
placed  on  top  of  the  vibrating  membrane  and  moved 
over  it.  We  have  a  new  body  introduced  with  its  proper 
rate  of  vibration,  besides  a  mechanical  motion  further  to 
complicate  the  problem. 

The  results  are  very  wonderful  and  beautiful,  and  open 
up  a  field  for  investigation  which  is  most  interesting ;  but 
so  far  we  have  the  resultant  of  many  forces,  not  one  of 
which  has  been  weighed  and  measured.  In  a  letter, 
Mrs.  Hughes,  replying  to  some  questions  asked  in  the 
hope  of  greater  accuracy,  says:  "The  notes  producing 


the  figures  vary  necessarily  with  the  weight  of  material 
used  and  the  tension  of  the  membrane,  so  that  any  one 
note  may,  under  different  circumstances,  produce  differ- 
ent figures,  and  conversely,  different  notes  may,  under 
different  circumstances,  produce  similar  figures." 

The  daisy  f jrms  (Fig.  3  )  were  sung  into  shape,  she 
says,  by  extremely  low  notes,  very  softly  sounded,  some 
of  them  by  A  in  the  first  space  of  the  bass  clef— a  won- 
derful note  to  be  reached  by  a  woman's  voice,  whose 
highest  note  is  the  B  flat  above  the  treble  clef,  a  compass 
of  over  three  octaves.  Sometimes  geometrical  foims, 
not  given  in  the  illustrations,  were  produced  by  the 
highest  notes  of  her  voice,  while  the  serpent,  fern,  and 
tree  forms  were  made  by  singing  her  middle  notes  with 
great  intensity. 

Among  some  of  the  first  experimenters  of  hearing  with 
the  eyes,  were  Messrs.  Lissajous  and  Duhamel,  whose  re- 
searches in  that  line  are  known  to  all  of  us.  The  more 
recent  men  who  worked  in  this  field  are  Leon  Scott  and 
Dr.  Koenig.  The  first  is  the  inventor  of  the  phonauto- 
graph,  whose  instrument  gave  a  more  comprehensive 
sound-writing ;  and  the  latter  for  making  sound  visible 
by  a  compound  series  of  flames  produced  by  a  single 
burning  jet  connected  with  two  or  more  tubes,  and  com- 
bined with  a  series  of  resonators.  This  has  been  ex- 
ceedingly serviceable  in  the  elucidation  of  those  obscure 
qualities  of  sounds,  of  which  he  was  enabled  to  distin- 
guish different  voices  and  instruments,  even  when  the 
pitch  and  intensity  of  the  notes  are  the  same. 

It  is  useless  to  dive  into  the  minute  description  of 
those  apparatuses,  etc.,  as  they  may  be  found  in  all  works 
on  modern  physics. 

Early  last  April  I  had  occasion  to  apply  the  principles 
demonstrated  by  the  work  of  Chladni  and^Mrs.  Hughes  to 
another  and  highly  important  branch  of  our  science.  The 
result  of  these  experiments  will  probably  be  made  known 
to  the  members  of  this  Congress  by  my  colleague,  the 
distinguished  American  physician,  Dr.  George  Engle- 
man,  of  St.  Louis,  with  whom  I  was  engaged  in  the  task 
of  bridling  the  faradic  current  and  accurately  measur- 
ing and  calculating  the  number  of  interruptions  of  the 
faradic  machines  used  by  our  electro-therapeutists,  and 
observing  the  physiological  action  at  the  various  rates  of 
interruptions.  Dr.  Engleman,  as  I  understand,  will  detail 
the  exhaustive  research  he  and  I  have  made  in  this  direc- 
tion in  the  section  of  electro  therapeutics  or  physiology. 

By  means  of  sensitive  diaphragms  and  a  dry  powder, 
like  lycopodium,  I  obtained  visual  pictures  of  regular 
geometric  shape  corresponding  accurately  to  the  number 
of  breaks  in  the  current.  In  this  instance  I  employed  a 
hollow  cylinder  about  three  inches  in  diameter  and  about 
six  inches  long,  over  which  I  stretched  an  elastic  mem- 
brane. Upon  the  centre  of  this  membrane  a  small  part 
of  dry  lycopodium  was  dropped  and  the  cylinder  was 
placed  upon  the  diaphragm  of  a  telephone  receiver,  the 
open  end  next  the  diaphragm.  With  each  change  in  the 
number  of  interruptions  in  the  faradic  current,  the  pow- 
der assumed  a  different  geometric  form,  and  we  were  thus 
enabled  to  calculate  the  number  of  interruptions  with 
absolute  accuracy  as  they  ranged  from  3,000  to  50,000, 
and  as  I  have  since  learned,  up  to  102,000  per  minute. 
Some  of  the  figures  resembling  those  of  Hughes  and 
Chladni. 

When  sonorous  undulations  impinge  upon  the  delicate 
diaphragm  of  a  phonograph  the  latter  is  set  in  vibration. 
Its  particles  move  to  and  fro  in  some  way  or  other.  The 
complexity  of  their  motion  will  depend  upon  that  of  the 
air  from  which  it  was  derived.  This  brings  me  to  what 
I  have  to  say  of  the  phonograph  itself. 

In  the  annals  of  modern  inventions  the  phonograph 
(Figs.  4  and  5)  and  its  inventor,  Thomas  A.  Edison, 
will  always  occupy  a  foremost  place.  Years  ago,  had 
a  scientist  had  the  temerity  to  proclaim  that  he  could 
record  and  reproduce  human  speech,  the  sounds  of 
music,  and  other  living  tones,  and  preserve  them  for 
ages  just  as  the  pathologist  guards  his  specimens  from 
the  ravages  of  time,  he  would  have  been  proclaimed  a 


September  i,  1894] 


MEDICAL  RECORD. 


265 


Seaweed  or  Landscape  Form. 


sorcerer  and  perhaps  burned  at  the  stake,  as  were  the     accomplished  was   so  wonderful    that    inventors  were 
so-called  witches  in  my  own  country  only  two  centuries     tempted  to  work  over  it. 

ago.  How  times  have  changed  !  I  need  not  rehearse  But  the  phonograph  of  to-day,  the  novel  and  remark- 
the  early  trials  and  tribulations  of  the 
illustrious  gentleman,  whose  ideas 
crystallized  in  tangible  form  are  be- 
fore you.  It  would  simply  be  a  rep- 
etition of  the  fortunes  of  all  the  great 
observers  whose  work  has  become  his- 
toric. He  fought  against  almost  in- 
surmountable obstacles  and  overcame 
them.  Let  me  briefly  recount  the 
story  of  the  discovery  of  the  phono- 
graph. 

Edison's  early  phonograph  was 
founded  upon  the  discovery,  that  if  a 
delicate  diaphragm  or  sounding-board 
is  provided  with  a  sharp  point  of  steel, 
its  vibrations  under  the  sound  of  the 
humin  voice  will  cause  the  sharp  point 
or  stylus  to  make  a  series  of  impres- 
sions or  indentations  upon  a  sheet  of 
wax  or  other  analogous  material  passed 
beneath  it.  Such  indentations,  though 
microscopic,  are  sufficiently  defined  to 
cause  similar  vibrations  in  the  dia- 
phragm, if  the  stylus  is  again  passed 
over  the  furrow  of  indentations,  and 
this  reproduction  is  loud  enough  to 
be  distinctly  heard.  Thus,  the  pho- 
nograph, in  its  primitive  form,  con- 
sists of  a  little  sounding-board  carry- 
ing on  its  under  surface  a  needle  point, 
and  a  sheet  of  wax  so  held  as  just  to 
touch  the  needle.  The  sound-waves 
of  the  voice  cause  the  sounding  board 
or  diaphragm  to  vibrate  with  a  rapid- 
ity varying  with  the  pitch  of  the  note. 

If  the  wax  sheet  was  made  to  move 
slowly  along  while  the  sound-waves  of 
music,  talking,  or  singing  were  allowed 
to  impinge  upon  the  sounding-board, 
the  result  was  found  to  be  a  continu- 
ous line  of  minute  indentations,  corre 
sponding  in  depth  and  geometric  form 
to  the  outline  of  the  original  sound 
waves. 

These  lines  were  continued  side  by 
side,  until  the  smooth  surface  of  the 
sheet  was  covered  over  with  indenta- 
tions. 

This  done,  on  raising  the  stylus  and 
the  diaphragm  and  again  placing  it  in 
the  first  furrow  of  indentations,  the 
stylus,  as  it  travelled  through  the  series 
of  lines,  caused  the  sounding-board 
again  to  vibrate,  sending  out  an  exact 
repetition  of  the  sounds  as  they  were 
originally  impressed  in  the  wax;  al- 
though somewhat  changed  in  pitch, 
intensity,  and  quality,  they  were  yet 
of  sufficient  accuracy  to  demonstrate 
the  possibility  of  recording  and  re- 
producing living  sounds. 

Photographs  and  measurements  of 
these  tracings  of  the  sound  waves  on 
the  wax  cylinders,  etc.,  were  recently 
made  by  Hermann,  of  the  Konigsberg 
physiological  institute,  and  are  of 
great  interest  in  the  study  of  the  phys 
ics  of  sound. 

The  defects  of  the  first  phonograph 
were  so  great  that  Edison  found  it 
impossible  to  interest  capitalists  in  _         Jh       ™*'    *■         ,M     w   v     p  a    ,k  m^T™   . 

perfecting  it.       At  the  Same  time  emi-  F,G'  >-*h0™*  VulCC  F«™  of  Mrs'  Hughes-Produced  by  Means  of  the  E.dophone. 

nent  men  in  Europe  were  not  wanting,  who  predicted     able  instrument,  has  passed  much  of  its  experimental 
great  things  for  the  phonograph  of  the  future.     What  it     stage.     It  is  now  practically  successful  in  every  respect, 


Serpent  Form. 


Cross-vibration  Figure. 


266 


MEDICAL   RECORD. 


[September  i,  1894 


and  must  be  regarded  as  instrumental  in  opening  up  a 
new  field  for  scientific  research,  and  making  one  more 
application  of  science  to  industry.  Its  aim  is  to  record 
and  reproduce  speech ;  to  make  a  permanent  record  of 
vocal  or  other  sonorous  vibrations ;  to  recreate  these  vi- 
brations in  such  manner  that  the  original  vibrations  may 
be  again  imparted  to  the  air  as  sounds. 

Notwithstanding  all  that  has  been  said  against  the 
properties  of  the  sounds  reproduced  by  the  phonograph, 
there  is  110  doubt  but  that  they  are  reflected  in  absolute 
integrity,  but  somewhat  decreased  in  volume.     In  other 


effects,  begged  M.  Paskos  to  repeat  the  experiment  before 
them  again,  under  such  conditions  as  they  laid  down  fcr 
him.  M.  Paskos  complied  with  this  request,  and  they 
were  absolutely  satisfied  with  the  result.  Others  still  re- 
mained incredulous,  and  it  was  necessary  before  they  ac- 
cepted the  fact  that  speech  should  be  reproduced  in  to 
simple  a  way. 


Fig.  4* 

words,  I  mean  to  say  that  the  record  of  a  sound,  as  it  is 
given  out  or  as  we  hear  it  coming  from  the  phonograph, 
is  an  exact  miniature  of  the  original.  And  this  is  easily 
explained  if  we  bear  in  mind  the  fact  that  the  diaphragm 
can  only  record  those  wave-pulses  which  are  caught  up 
and  encompassed  by  the  recording  trumpet.  The  others 
lose  themselves  in  space,  yet  the  pitch  and  quality  re- 
main unchanged. 

The  phonograph  is  really  a  natural  outcome  of  the 
telephone ;  but  unlike  any  form  of  telephone,  it  is  me- 
chanical and  not  electrical  in  its  action. 

The  following  anecdote  is  told  by  M.  Paskos,  Mr.  Edi- 
son's agent,  who  presented  the  first  phonograph  for  exhi- 
bition before  the  academicians  of  Paris.  It  was  a  curi- 
ous spectacle  to  witness  the  expression  of  the  faces  of 
these  academicians  when  M.  Paskos  caused  the  wonder- 
ful instrument  to  speak.  A  murmur  of  admiration  was 
heard  from  all  parts  of  the  hall,  a  murmur  succeeded  by 
repeated  applause.  The  learned  Academy,  generally  so 
cold,  had  never  before  abandoned  itself  to  such  enthusi- 
asm, yet  some  members  of  a  sceptical  turn  of  mind,  in- 
stead of  examining  the  physical  fact,  ascribed  it  to  moral 
causes,  and  a  report  soon  ran  through  the  room  which 
seemed  to  accuse  the  Academy  of  having  been  mystified 
by  a  clever  ventriloquist.  Certainly  the  spirit  of  ancient 
Gaul  is  still  to  be  found  among  the  French,  even  in  the 
Academy.  One  said  that  the  sounds  emitted  by  the  in- 
strument were  precisely  those  of  a  ventriloquist.  An- 
other asked  if  M.  Paskos's  face  and  lips,  as  he  turned  the 
instrument,  did  not  resemble  the  grimaces  of  a  ventrilo- 
quist. A  third  admitted  that  the  phonograph  might  emit 
sounds,  but  believed  it  was  much  helped  by  the  manipu- 
lator. Finally,  the  Academy  requested  M.  du  Moncel  to 
try  the  experiment,  and  as  he  was  not  accustomed  to  speak 
into  the  instrument  it  was  unsuccessful,  to  the  great 
joy  of  the  incredulous.  Some  members  of  the  Academy, 
however,  desirous  of  ascertaining  the  real  nature  of  the 


The  anecdote  I  have  just  related  cannot  be 
interpreted  to  the  discredit  of  the  Academic  ties 
Sciences,  since  ihe  Academy  is  bound  to  j  re- 
serve the  true  principles  of  science  intact,  acd 
to  accept  startling  facts  only  after  careful  ex- 
amination. ( >wing  to  this  attitude,  all  that 
emanates  from  the  Academy  can  be  received 
with  complete  confidence;  and  we  cannot  ap 
prove  too  highly  of  reserve  which  does  not  give 
way  to  the  first  impulse  of  enthusiasm  and  ad- 
miration* 

Its  present  achievements  in  recording  music 
are  wonderful.  The  phonograph  will  reproduce 
any  kind  of  music — singing,  the  piano,  violin, 
cornet,  oboe,  etc. — with  a  beauty  of  tone  and  accuracy 
astonishing  to  the  musician.  It  is  possible  also  to  mag- 
nify musical  sounds  without  distorting  them,  as  often 
happens  where  speech  is  concerned.  Thus,  when  a 
musical*  is  arranged,  the  phonograph  is  put  up  to  as  to 
be  heard  one  hundred  feet  away.  Even  should  the  pho- 
nograph never  reach  greater  perfection  than  its  present 
stage,  which  is  hardly  possible  in  this  age,  it  is  and  will 


Fig.  5- 

continue  to  be  of  the  greatest  use  to  musicians,  elocu- 
tionists, authors,  editors,  and  physicians.  To  this  last- 
named  profession,  of  which  I  am  a  member,  I  have  been 
the  means  of  directing  their  attention  to  the  practical 
use  of  the  phonograph  in  medicine. 

For  several  years  past  I  have  devoted  considerable  time 
to  studying  the  uses  to  which  as  a  recorder  of  the  sounds 
of  disease  and  organs  in  health,  upon  which  the  physician 


September  i,  1894] 


MEDICAL   RECORD. 


267 


depends  so  much  for  the  accuracy  of  his  diagnosis.  Al- 
ready I  can  say,  notwithstanding  its  many  imperfections, 
the  phonograph  is  made  to  record  many  of  the  character- 
istic sounds  of  disease  of  the  respiratory  apparatus.  For 
example,  when  in  good  voice  the  vocal  expression  of 
singers  may  be  recorded  and  kept  for  comparison  with 
the  sound  produced  in  case  the  vocal  bands  are  affected. 
Time  and  again  have  I  realized  great  benefit  from  the 
phonograph  of  tenors,  baritones,  and  bassos  among  my 
patients,  and  not  only  have  thus  been  able  to  recognize 
the  difference  in  shade  of  tone  and  quality,  and  thus 
direct  my  attention  to  remedying  the  defect,  but  patients 
have  also  been  able  to  recognize  the  deterioration  of  their 
voices  from  the  normal  standard  themselves.  This  is  one 
of  the  reasons  why  I  desire  to  forcibly  place  before  you 
the  possible  advantage  the  phonograph  possesses  in  the 
perfection  of  elocution  and  singing,  and  to  laryngologists 
in  particular. 

-  As  a  specialist  in  the  department  of  medicine  involving 
diseases  of  the  throat,  nose,  and  chest,  I  owe  much  of 
what  little  success  I  have  had  to  the  phonograph.  Nat- 
urally, my  practice  brings  me  into  direct  contact  with 
celebrated  people  of  high  vocal  culture,  many  with  al- 
ready fully  trained  voices,  and  so  from  the  outset  the 
phonograph  which  I  made  as  standards  of  singing,  speak- 
ing, etc.,  represented  a  condition  very  near  the  standard 
of  perfection  which  both  teachers  of  singing  and  elocution 
are  striving  to  attain.  The  excellent  artists  whose  re- 
cords I  have  taken,  and  treasure  very  much,  were  those 
educated  in  singing  in  the  various  methods  of  the  Ger- 
man, Italian,  and  French  schools,  and  representing  over 
and  over  again  these  phonographs,  I  have  been  able  to 
detect  readily  any  change  or  oncoming  change  in  the 
normal  action  of  the  vocal  bands.  It  is  astonishing  to 
hear  the  difference  in  the  methods  that  the  special  train- 
ing of  one  of  these  schools  gives  to  singers,  to  actors,  and 
elocutionists;  and  more  astonishing  it  is  to  compare  singers 
of  a  mixed  school  with  those  whose  singing  is  simply  a 
natural  exponent  of  fine  vocal  organs  plus  the  training. 
The  music  that  is  in  the  well-trained  artist  rings  forth  its 
melody  in  pure  musical  sound  from  out  of  the  indented 
pulse  waves  imprinted  on  the  cylinder  of  wax.  By  util- 
izing these  for  a  comparative  study  with  the  lesser  nat- 
ural and  other  voices,  I  have  reached  much  profit  in  the 
study  of  the  different  shading  of  tones  and  quality  pos- 
sessed by  their  vocal  organs. 

Mr.  Edison's  intention  is  now  nearly  fulfilled  in  being 
able  to  manufacture  a  quantity  of  instruments  as  perfect 
as  the  best  of  the  present  experimental  machines,  and  to 
make  them  so  automatic  in  action  and  so  easily  adjusted 
that  everyone  who  uses  a  sewing  machine  or  typewriter 
or  a  telephone,  can  use  the  phonograph ;  we  concede  at 
once  what  wonderful  field  is  before  it. 

The  price  of  phonographs  is  nominal,  and  the  new  wax 
cylinders  upon  them  cost  scarcely  more  than  writing- 
paper.  Once  a  cylinder  has  been  engraved  or  has  had  a 
message  recorded  upon  it,  it  can  be  passed  through  the 
phonograph  any  number  of  times  apparently  without  de- 
terioration. I  possess  some  valuable  phonograms  which 
have  been  read,  sung,  and  played  thousands  of  times  by 
the  phonograph,  and  no  special  indication  of  wear  is  ob- 
servable. Finally,  bear  in  mind  that  having  once  ob- 
tained a  good  phonogram,  it  can  be  multiplied  and  dupli- 
cated at  small  cost.  What  a  wonderful  prospect  opens 
before  us.  This  duplication  of  phonograms  is  not  known 
to  us  as  yet,  but  no  doubt  experiment  will  give  it  to  the 
public,  and  duplication  will  be  as  common  as  in  pho- 
tography. 

Imagine  what  the  phonograph  will  do  for  the  man  on 
the  borders  of  civilization.  It  will  supply  him  with  books 
in  a  far  more  welcome  shape  than  print,  for  phonographs 
will  read  themselves.  The  mail  will  bring  him  the  latest 
play  from  London,  or  opera  from  Vienna.  If  he  cares 
for  political  speeches,  he  can  have  the  Congressional  Rec- 
ord in  the  shape  of  phonograms.  It  is  possible  even  to 
imagine  that  many  books  and  stories  may  not  see  print 
at  all ;  they  will  go  into  the  hands  of  their  readers  or 


hearers  rather  as  phonograms.  But  think  what  a  musical 
critic  can  do  for  his  public.  He  can  give  whole  arias 
from  an  opera  or  entire  movements  from  a  symphony,  by 
way  of  proof  or  illustration.  The  veiy  tones  of  an  actor's 
or  singer's  voice  might  be  reproduced  in  the  morning 
notice  of  last  night's  important  dramatic  or  musical 
event. 

In  music,  as  already  hinted,  the  value  of  the  phot  ograph 
in  its  present  stage  is  indisputable.  Musicians  are  di- 
vided, probably  always  will  be,  as  to  the  manner  in  which 
certain  famous  symphonies  ought  to  be  conducted. 
The  metronome  marks  used  by  Beethoven  are  at  best 
but  uncertain  guides;  while  no  written  directions  as  to 
dynamic  values,  expression,  etc.,  are  worth  much.  The 
phonograph  will  make  it  possible  for  the  musician  of  the 
future  to  know  exactly  how  our  composers  wished  their 
music  given,  for  it  will  repeat  that  music  as  played  to- 
day, with  every  shade  of  expression,  with  all  its  infinite 
changes  of  time.  Moreover,  the  phonograph  offers  to 
the  composer  that  long  sought  instrument,  an  automatic 
recorder  of  improvisation  upon  the  piano  or  other  instru- 
ment. In  the  far  off  future,  when  our  descendants  *ish 
to  compare  our  simple  little  Wagner  operas  with  the 
complex  productions  of  their  own  times,  requiring,  per- 
haps, a  dozen  orchestras  playing  in  half  a  dozen  differ- 
ent keys  at  once,  they  will  have  an  accurate  phono- 
graphic record  of  our  harmonic  simplicity.  In  logic  we 
say,  that  where  a  premise  is  established  the  deduction  is 
evident.  So  what  can  be  done  in  one  instance  can  be 
done  in  all  other  similar  instances.  Those  persons  who 
smile  incredulously  when  it  is  said  that  the  perfected 
phonograph  will  do  away  with  letter- wiiting,  will  read 
to  us,  sing  to  us,  teach  us  foreign  languages  with  their 
proper  accents,  teach  us  different  methods  of  singing, 
elocution,  give  us  books,  music,  plays,  speeches,  at  al- 
most no  cost,  become  a  constant  source  of  instruction 
and  amusement,  must  have  forgotten  the  ridicule  they 
heaped  upon  the  rumor  that  an  American  inventor 
proposed  to  talk  from  New  York  to  Chicago.  The 
achievements  of  the  phonograph  will  be  no  less  wonder- 
ful than  those  of  the  telephone. 

Marvellous  as  this  instrument  is,  it  is  still  quite  new, 
and  it  is  impossible  to  say  to  what  degree  of  perfection 
it  may  yet  be  carried.  It  has  already  opened  the  door 
to  an  entirely  new  and  untiied  field  in  the  realm  of 
sound.  It  is  a  new  instrument  in  the  hands  of  science, 
wherewith  to  search  out  laws  in  nature  yet  unknown. 
Already  it  has  suggested  many  valuable  uses.  Un- 
doubtedly it  is  the  most  remarkable  invention  of  this 
century. 

If  time  permitted  I  should  talk  more  in  detail  regard- 
ing the  use  of  the  phonograph  as  a  teacher  of  singing, 
elocution,  etc.,  but  from  the  demonstration  of  phono- 
grams one  must  be  satisfied  of  the  truth  and  of  the  value 
of  the  phonograph. 

I  am  still  in  hopes,  and  notwithstanding  the  fact  that 
at  present  the  microphone  is  very  unsatisfactory  in  its 
workings  in  many  respects,  to  be  able  to  record  the 
sounds  of  the  heart  and  respiratory  tract  both  in  health 
and  disease.  The  value  of  such  record,  I  need  not  tell 
you,  would  go  a  great  way  toward  the  practical  education 
of  our  medical  students  in  the  groundwork  of  physical 
diagnosis. 

I  have  already  made  several  records  of  pathognomonic 
sounds,  but  my  work,  owing  to  the  pressure  of  time  and 
the  responsibilities  of  a  large  practice,  is  still  so  in- 
complete that  I  hesitate  to  present  it  to  such  an  august 
body  of  distinguished  medical  men. 

At  the  next  Congress  I  may  show  you  the  cabinet  of 
records,  which  will  demonstrate  aurally  the  sounds  of 
disease  of  the  air- passages  and  heart  just  as  we  hear  them 
in  the  hospital  wards,  and  as  we  recognize  them  from 
the  descriptions  in  otr  books,  of  lessened  or  intensified 
pitch  and  changed  quality. 

In  my  own  specialty  the  phonograph  has  been  of 
much  service.  In  all  diseases  affecting  the  vocal  bands 
we  are  sure  to  have  a  change  in  the  character  of  the 


268 


MEDICAL    RECORD. 


[September  i,  1894 


vocal  sounds.  These  sounds  in  not  a  few  instances  are 
pathognomonic,  but  as  one. 

Experience  and  observation  have  not  been  extensive 
enough,  we  have  as  yet  no  accepted  classification,  without 
which  phonographic  records  would  signify  little.  With 
a  competent  microphone,  as  I  hope  and  feel  it  can  be 
perfected,  both  the  classification  and  recording  of  these 
sounds  will  be  made  so  that  all  of  us,  even  the  general 
practitioner,  will  be  able  to  make  his  diagnosis  more 
positive. 

To  my  American  colleagues,  and  to  those  of  other  coun- 
tries who  may  chance  to  come  to  my  city,  I  extend  a 
cordial  invitation  to  visit  my  workshop,  which  unfortu- 
nately I  could  not  carry  with  me,  and  see  the  work  as  it 
has  progressed  up  to  this  time. 

I  shall  be  ever  ready  to  demonstrate  and  show  you  how 
far  I  have  succeeded,  and  so  give  you  the  ocular  proof 
of  what  I  have  laid  claim  to  in  this  paper. 

460  Lf.XINGTON  AVENUE. 


OBSERVATIONS   ON  PHYSIOLOGICAL  PULMO 
NARY  ATELECTASIS. 

Being  Part  of  a  Report  of  the  Committee  on  Clini- 
cal Medicine  of  The  Medical  Society  of  the 
State  of  California. 

By  ALBERT  ABRAMS,  A.lVf.,  M.D.,  F.R.M.S.,  Chairman  of 
the  Committer. 

SAN    FRANCISCO,   CAL. 

PBOPSSSOK  OP  PATHOLOGY,  COOPER  MKOICAL  COLLKGt;  PRESIDENT  OP  THE  SAN 
FRANCISCO  MEOICO-CHIRURGICAL  SOCIETY  J  YICS-PRBSIDENT  OP  THE  MEDICAL 
SOCIETY  OP  THE  STATE  OP  CALIFORNIA. 

Mr.  President  and  Fellow  Members  :  At  a  previous 
meeting  of  this  Society  I  presented  a  paper  on  "  Pul- 
monary Atelectasis  as  a  cause  of  Anaemia'1  ("  Transac- 
tions of  The  Medical  Society  of  the  State  of  California, 
1892  ").  I  will  succinctly  recount  the  essential  facts  of 
that  paper. 

There  are  present  over  the  thorax  of  apparently  normal 
individuals  constant  areas  of  diminished  lung  resonance, 
varying  from  dulness  to  flatness  as  obtained  by  percus- 
sion. These  areas  vary  in  number  and  situation  as  far  as 
the  individual  case  is  concerned,  but  they  admit  in  the 
Aggregate  of  definite  localization.  The  areas  of  dulness  or 
atelectatic  zones,  as  I  will  call  them,  are  no  longer  demon- 
strable by  percussion  after  repeated  forced  inspirations. 
The  atelectatic  zones  are  dependent  on  circumscribed  pul- 
monary atelectasis,  or  collapse  of  limited  portions  of  the 
lung.  I  have  referred  to  this  form  of  atelectasis  as  physio- 
logical, with  the  object  of  employing  the  term  for  differen- 
tiation only.  The  physiological  atelectasis  under  consid- 
eration is  an  eradicable  condition  dissociated  with  anv 
demonstrable  lesion.  When  the  atelectatic  zones  are  mul  ti- 
plied  or  augmented  in  area,  especially  in  young  people, 
they  are  associated  with  the  symptomatic  complex  of 
anaemia,  and  finally,  when  the  atelectatic  zones  are  dis- 
pelled by  respiratory  gymnastics,  the  syndrome  of  anaemia 
disappears,  while  its  recrudescence  is  always  associated 
with  a  reappearance  of  the  atelectatic  zones. 

My  observations  have  been  extended  since  the  publi- 
cation of  my  original  paper,  and  the  results  attained  con- 
firm my  primary  conclusions.  While  it  is  true,  from  the 
stand-point  of  the  physiologist,  that  the  lungs  during  life 
are  in  a  stretched  condition,  it  is  equally  true,  from  the 
stand-point  of  the  clinician,  that  certain  portions  of  the 
lung  are  collapsed  and  deprived  of  sufficient  air  to  yield 
a  dulness,  or  in  some  instances  a  flatness,  on  percussion. 
These  areas  of  dulness  vary,  as  determined  by  linear  per- 
cussion, from  a  twenty- five  cent  piece  to  a  dollar  in  size, 
or  even  more. 

The  atelectatic  zones  are  only  permanently  absent  when 
the  lungs  are  emphysematous,  and  temporarily  so  after 
repeated  deep  inspirations.  I  have  noted  in  my  investiga- 
tions that  after  forced  inspirations  are  made  the  atelec- 
tatic zones,  in  adults  as  well  as  in  children,  can  be  dis- 
pelled, reappearing  in  a  few  minutes  when  tranquil 
breathing  is  resumed,  and  continuing  so  until  an  in- 


creased demand  is  again  made  on  the  capacity  of  the 
lungs. 

The  facts  just  enunciated  do  not  refer  to  the  areas  of 
lung  tissue  intermediary  to  the  atelectatic  zones,  for  we 
already  know  from  the  observations  of  others,  especially 
Da  Costa,,  that  when  percussion  is  made  over  the  lungs 
by  respiratory  percussion,  as  it  is  called,  at  the  end  of 
full  inspiration,  a  sound  of  higher  pitch  and  vesiculo- 
tympanitic quality  is  obtained ;  whereas  a  held  expiration 
diminishes  the  resonance. 

In  the  accompanying  illustrations  (Figs.  1  and  2)  I 
have  projected  a  composite  picture  defining  the  situation 


Fig.  i.— Showing  Atelectatic  Zones  on  the  Anterior  Surface  of  the  ChesL 

of  the  atelectatic  zones,  based  on  examination  of  over  one 
hundred  apparently  healthy  individuals,  children  as  weD 
as  adults. 

It  may  be  remarked  that  the  atelectatic  zones  on  the 
posterior  surface  of  the  chest- wall  are  more  frequent,  and 
admit  of  more  definite  localization,  than  those  on  the 
anterior  surface  of  the  thoracic  wall. 

The  atelectatic  zones,  as  shown  in  the  illustrations,  do 
not  represent  the  only  areas  of  lung  tissue  that  are  nor- 
mally incapacitated,  for  aside  from  the  fact  that  collapsed 
lung  remote  from  the  chest-wall  will  elude  percussion, 
there  are  other  superficial  areas  of  too  limited  an  extent 
to  yield  a  dulness  on  percussion.     The  practical  conclu- 


F:g.  2.— Showing  Atelectatic  Zones  on  the  Posterior  Surface  of  the  ChesL 

sions  that  can  be  formulated  as  a  result  of  these  observa- 
tions may  be  summarized  under  the  following  groupings : 

1.  The  relation  that  pulmonary  atelectasis  bears  to 
anaemia. 

2.  The  mistakes  that  may  accrue  from  misinterpreta- 
tion of  the  physical  signs  in  the  examination  of  the 
chest,  and  the  correction  of  the  conventional  errors  of 
topographical  percussion. 

3.  The  relation  that  pulmonary  atelectasis -bears  to 
tuberculosis. 

4.  The  aid  afforded  to  auscultation  by  the  elimination 
of  atelectasis. 

1.  I  have  already  shown  in  my  previous  paper  that 


September  i,  1894] 


MEDICAL    RECORD. 


269 


anaemia  of  pulmonary  origin  exists,  and  fui  thermore, 
that  this  anaemia  is  associated  with  extensive  areas  of 
lung  dulness.  That  when  this  latter  is  corrected, 
amelioration  and  recovery  from  the  anaemia  occur.  I 
have  also  referred  in  my  original  paper  to  the  fact  that 
increased  respiratory  activity  is  of  great  therapeutic 
value  in  anaemia  from  any  cause. 

2.  The  mistakes  that  may  accrue  from  misinterpreta- 
tion of  the  physical  signs  of  atelectatic  dulness,  from 
dulness  caused  by  lung  consolidation,  are  many,  and  in 
consequence  of  mistakes  occurring  in  my  own  practice 
and  in  the  practice  of  other  physicians,  I  invariably 
adopt  the  expedient  of  having  the  patient  practise  forced 
breathing  before  making  an  examination  of  the  chest. 

If  inflation  of  the  lung  cannot  be  secured  with  the 
patient  in  the  erect  posture,  I  place  him  in  the  right  or 
left  lateral  posture,  according  to  whether  an  examination 
of  the  left  or  right  lung  is  desired. 

I  have  often  found  that  dulness  produced  by  lung 
consolidation  will  frequently  disappear,  to  be  supplanted 
by  resonance  after  forced  deep  breathing. 

This  fact  may,  to  the  novitiate  in  physical  diagnosis, 
be  mistaken  for  atelectatic  dulness.  Taken  altogether, 
percussion  of  the  lungs  is  an  untrustworthy  method  of 
diagnosis  unless  it  is  controlled  by  auscultation.  I  hold 
that  topographical  percussion,  as  obtained  ordinarily,  is 
of  inconstant  value.  The  limitation  of  organs  by  per- 
cussion, especially  of  the  heart,  will  vary  from  day  to 
day,  and  the  percussional  area  of  dulness  in  the  same 
case,  and  at  the  same  time,  will  be  variously  obtained  by 
different  diagnosticians.  The  borders  of  the  heart,  liver, 
and  spleen  are  dependent  on  the  degree  of  lung  inflation, 
and  must  vary  according  to  the  activity  of  respiration. 

Topographical  percussion  must  always  be  based  upon 
the  state  of  pulmonary  inflation,  and  the  results  governed 
accordingly. 

3.  The  relation  that  atelectasis  bears  to  pulmonary 
tuberculosis  is  an  important  one.  A  properly  inflated 
lung  affords  adequate  protection  against  pulmonary  tu- 
berculosis. A  collapsed  area  of  lung  affords  a  nidus  for 
the  specific  microbes.  The  facultative  anaerobins  thrive 
best  in  an  illy-ventilated  lung.  The  foregoing  state- 
ments are  borne  out  by  theory  and  statistical  evidence. 

Pulmonary  tuberculosis  is  frequently  initiated  by  the 
symptomatic  picture  of  anaemia.  This  anaemia  is  un- 
questionably of  pulmonary  origin,  and  is  associated  with 
demonstrable  atelectatic  zones. 

The  atelectatic  zones  correspond  with  the  destructive 
routes  followed  by  incipient  pulmonary  tuberculosis. 

4.  The  aid  afforded  auscultation  by  elimination  of 
atelectasis  is  obvious.  Auscultation  of  the  lungs  should 
always  be  conducted  with  the  patient  in  different  post- 
ures, the  object  being  to  utilize  the  actual  respiratory 
capacity  of  the  lungs,  thus  eliminating  the  auscultatory 
phenomena  of  atelectasis  and  accentuating  abnormal 
sounds  which  may  be  present. 

I  have  recourse  to  the  following  manoeuvre  for  elicit- 
ing pleural  friction-sounds  when  absent,  and  accentuating 
them  when  present,  by  having  the  patient  lie  on  the  sus- 
pected side  or  region  for  half  a  minute  or  longer,  after 
having  taken  a  deep  inspiration.  This  position  favors 
the  approximation  of  the  two  pleural  la>ers. 

Now,  when  the  patient  adopts  the  sitting  posture  and 
attempts  forced  expiration,  a  friction -sound  is  heard 
which  is  usually  intensified  during  the  subsequent 
inspiration. 

Unless  a  deep  inspiration  is  taken  before  the  patient 
lies  on  the  suspected  side,  crepitant  rales,  concomitants 
of  atelectasis,  will  be  heard.  I  consider  the  foregoing 
manoeuvre  of  more  value  for  diagnosis  than  any  of  the 
methods  usually  described  for  eliciting  and  differentiating 
the  same  phenomena. 


Low  Temperature. — Dr.  George  R.  Dean,  writing  in 
the  Medical  and  Surgical  Reporter  of  June  30,  1894,  re- 
lates a  case  of  cystitis  in  which  the  temperature  fell  on 
several  occasions  to  920  F. 


A  CASE  OF  LYMPHADENOMA  (HODGKIN'S 
DISEASE)  ACCOMPANIED  BY  FEATURES 
CHARACTERISTIC  OF  MYXCEDEMA,  AND 
OTHERS  SUGGESTIVE  OF  ACROMEGALY. 

By  W.  A.  CROSS,  M.D., 

JEMCINION,    PA. 

I  desire  to  put  the  following  case  on  record  on  account 
of  its  unusual  complications,  and  the  manner  of  their  de- 
velopment. 

Mrs.  H ,  aged  thirty-four,  American.    A  person 

of  more  than  ordinary  intelligence,  of  good  family  his- 
tory, and  in  the  enjoyment  of  exceptionally  good  health 
until  the  commencement  of  her  last  illness.  She  was  a 
happy  wife  and  mother.  Menstruation  appeared  at  four- 
teen years,  and  was  always  normally  performed.  She 
gave  birth  to  five  children,  two  boys  and  three  girls,  and 
had  no  miscarriages.  There  was  no  inherited  predispo- 
sition to  glandular  troubles. 

In  July,  1892,  there  developed  a  very  troublesome 
cough  of  a  spasmodic  character ;  the  paroxysms  occurred 
both  day  and  night,  and  greatly  interfered  with  her 
sleep  and  rest.  I  could  not  discover  any  lesion  which 
would  account  for  its  origin  and  persistency.  I  made 
use  of  all  sorts  of  means  for  its  relief,  with  very  poor  suc- 
cess. Antispasmodics  made  some  impression,  but  the 
best  results  were  obtained  from  the  administiation  of  an 
emulsion  of  cod  liver  oil;  this  gave  her  considerable 
relief  for  a  time. 

Her  good  constitution  enabled  her  to  resist  the  evil 
effects  of  these  frequent  paroxysms,  with  the  attendant 
loss  of  sleep  and  rest,  for  a  long  while.  She  remained 
under  my  care  for  one  year,  and  then,  as  I  had  failed  to 
afford  her  any  adequate  relief,  and  had  not  discovered 
the  nature  of  her  disease,  she  proposed  putting  herself 
under  the  observation  of  some  other  physician. 

In  July,  1893,  she  consulted  Dr.  Louis  Jurist,  of  Phila- 
delphia. By  this  time  her  general  health  had  begun  to 
fail ;  she  had  a  cachectic  appearance  suggestive  of  tuber- 
culosis, or  some  malignant  disease.  I  knew  Dr.  Jurist 
to  be  a  careful  observer,  and  tiusted  that  he  might  te 
more  successful  than  I  in  getting  at  the  cause  of  her 
trouble,  and  waited  patiently  for  his  judgment  of  the 
case. 

I  did  not  see  the  patient  again  for  a  period  of  six 
weeks,  and  then,  while  visiting  another  member  of  the 
family  I  had  the  opportunity  of  observing  her  carefully. 
She  still  had  her  cough,  had  lost  much  flesh,  and  was 
very  anaemic.  My  attention  was  called  to  a  swelling  on 
the  right  side  of  the  sternum,  high  up.  I  believed  this  to 
be  connected  with  her  disease  in  some  way,  but  I  did  not 
imagine  its  significance  at  that  time. 

The  next  time  I  saw  the  patient  was  October  22, 1893. 
By  this  time  her  condition  was  such  that  she  could  not 
visit  Dr.  Jurist  at  his  office  in  the  city,  and,  at  his  ie- 
quest,  I  took  charge  of  her  at  her  home. 

I  do  not  know  when  the  myxoedematous  features  fust 
became  apparent,  but  when  I  saw  her  at  this  time  my 
attention  was  attracted  to  them  immediately.  Her  phy- 
sician did  not  write  me  fully  in  regard  to  the  sequence 
of  development  of  the  various  features,  but  said  "  Mrs. 

H 's  case  interests  me  very  much,  and  I  am  obliged 

to  you  for  your  willingness  to  study  it  with  me.  Many 
things  have  passed  through  my  mind  regarding  her  con- 
dition: tubercle,  myxoedtma,  acromegaly,  and  malig- 
nant disease  have  all  had  fair  consideration.  I  do  not 
quite  understand  the  bony  protrusion  on  the  right  of  her 
sternum.  Is  the  growth  in  her  neck  secondary  ?  Her 
wasting  would  indicate  a  serious  encroachment  on  her 
vitality.  Might  she  not  have  a  mediastinal  tumor  ?  I 
would  gladly  hear  from  you." 

My  examination  of  the  patient  at  this  time  discovered 
the  following  conditions :  She  presented  many  of  the 
characteristic  features  of  myxoedema.  The  physiognomy 
was  dull  and  mask  like,  but  not  to  an  exaggerated  degree ; 
the  face  was  not  enlarged  to  the  extent  that  is  usual  in 
these  cases ;  the  skin  was  dry  and  of  a  peculiar  yellow- 


270 


MEDICAL  RECORD. 


[September  1,  1894 


ish  white  color;  both  upper  and  lower  eyelids  were 
swollen,  with  a  puffiness  of  the  tissues  below  the  lower 
lids ;  the  nose  was  thin,  having  a  pinched  appearance  ; 
the  mouth  wa*  natural,  excepting  the  deep  lines  on  either 
side  of  it ;  the  pendulous  lower  lip  was  absent ;  the 
tongue  was  a  little  thickened ;  there  was  a  slight  hesi- 
tancy in  her  speech,  and  articulation  was  not  perfectly 
distinct ;  the  scalp  was  dry,  the  hair  scanty,  dry,  and 
brittle ;  the  hair  which  is  usually  found  on  the  .forearms 
and  legs  hid  disappeared,  also  that  in  the  axilla  and 
about  the  pubes;  the  forearm*  were  enlarged  and  thtck- 
e. led,  particularly  at  the  wrists,  indicating  an  enlarge- 
ment of  the  bony  tissues ;  the  hands  were  large  and 
puffy,  with  a  remarkable  clubbing  of  the  finger-tips;  the 
finger- nails  were  thickened  and  curved  to  an  unusual 
degree ;  the  hands  and  fingers  were  so  swollen  that  they 
were  clumsy,  and  the  patient  could  not  make  use  of 
either  needle  or  pen ;  the  legs  and  feet  showed  the  same 
aba  or  mil  features  as  were  present  in  the  upper  extremi- 
ties. A  pro  nine  at  peculiarity  of  the  foot  was  the  pro- 
jection of  the  calcaneum  and  a  welt  of  hard  tissue  along 
the  outer  aspect  of  the  foot. 

Tnere  was  an  enlarged  gland  about  the  size  of  a  hen's 
egg  on  the  left  side  of  the  neck,  just  above  the  clavicle, 
and  posterior  to  the  sterno-mastoid  muscle.  The  mind 
was  clear,  memory  apparently  unimpaired.  She  con- 
versed intelligently,  had  poor  appetite,  digestion  was  not 
good,  the  bowels  moved  twice  daily,  the  kidneys  acted 
all  right.  She  would  have  slept  will  if  it  had  not  been 
for  the  cough ;  vision  was  normal ;  had  no  pain ;  felt 
weak;  heart's  action  was  rapid  and  impaired;  com- 
pla'ned  of  shortness  of  breath.  There  was  some  diffi 
cilty  ia  swallowing.  The  temperature  ranged  from  980 
F.  in  the  morning  to  990  F.  in  the  evening;  pulse,  105 
in  the  morning;  120  in  the  evening.  Complained  of 
not  feeling  warm;  there  was  no  perspiration.  Passed 
forty-six  ounces  of  urine  in  twenty-four  hours,  of  low 
specific  gravity,  containing  no  albumin,  no  casts,  no 
sugar,  phosphates  in  abundance,  urates  below  normal; 
reaction  acid ;  menstruation  normal. 

The  patient,  although  weak,  was  up  and  about,  over- 
seeing her  household  affairs  ;  locomotion  was  impaired, 
and  she  tired  easily,  but  she  still  possessed  a  considera- 
ble amount  of  will  power. 

A  pondered  extract  of  thyroid  gland  was  administered 
three  times  per  day  for  about  four  weeks,  with  appar- 
ently no  improvement ;  the  raw  glands  finely  minced 
and  taken  with  her  other  food,  were  tried  for  a  while,  but 
these  were  so  distasteful  to  her  that  their  use  was  soon 
discontinued. 

From  the  lart  week  in  November  to  the  middle  of  De- 
cember no  active  treatment  was  employed  ;  during  this 
period  she  grew  rapidly  worse,  the  myxedematous  feat- 
ures became  more  pronounced,  the  cough  was  persist- 
ent, there  was  no  desire  for  food,  and  there  was  a  scanty 
secretion  of  urine ;  for  a  number  of  days  she  did  not  pass 
more  than  one  pint  in  twenty-four  hours.  The  lower 
limbs  became  ©edematous,  she  was  dull  looking  and  act- 
ing, slept  the  most  of  her  time  day  and  night.  The 
sleep  was  a  restless  one,  disturbed  not  only  by  the  cough, 
but  by  ugly  dreams  which  really  amounted  to  hallucina- 
tions. She  could  not  lie  down,  neither  could  she  lean 
back  in  her  chair,  owing  to  the  dyspnoea  occasioned  by 
s  ich  positions.  The  only  way  in  which  she  could  get 
rest  wa3  by  sitting  in  her  chair,  leaning  forward  with  her 
h»ad  resting  upon  a  pillow  placed  upon  a  table  in  front 
of  her.  In  such  a  posture  she  sat  and  slept  the  most  of 
her  time.  Lymphoid  tumors  developed  on  the  right 
side  of  the  neck,  and  in  the  right  axilla.  Menstruation 
was  missed  for  the  first  time  in  November,  and  did  not 
occur  again. 

Dr.  J.  C.  Wilson,  of  Philadelphia,  saw  the  patient,  in 
consultation,  November  22,  1893.  His  diagnosis  was 
lymphadenoma  accompanied  by  features  suggestive  of 
both  myxoedema  and  acromegaly.  He  advised  the  use 
of  the  thyroid  extract,  and  also  Fowler's  solution  to  the 
point  of  toleration. 


A  thyroid  extract  prepared  by  Dr.  George  W.  Crary, 
of  New  York  City,  was  obtained.  As  an  initial  dose  we 
gave  two  drops  three  times  per  day,  this  was  gradually 
increased  until  we  reached  eight  drops  t.Ld. ;  at  this 
point  the  dyspnoea  and  disturbed  heart's  action  became 
so  great  that  it  was  necessary  to  discontinue  its  use  for 
a  couple  of  days.  We  resumed  with  a  two-drop  dose,  and 
added  a  drop  to  the  dose  each  day,  until  fifteen  drops 
t  i.d.  were  taken,  without  any  inconvenience  whatever.. 

As  we  advanced  the  second  time,  her  condition  im- 
proved rapidly ;  her  paroxysms  of  coughing  became  less 
frequent  and  distressing.  She  did  not  sleep  so  much 
through  the  day,  and  her  rest  was  less  disturbed  at  night. 
She  could  lean  back  in  her  chair,  and  could  lie  down  in 
bed.  The  appetite  improved.  She  could  swallow  solids 
without  difficulty,  and  any  reasonable  article  of  food 
could  be  taken  without  discomfort 

I  must  not  neglect  to  state  that  the  arsenic  occasioned 
so  much  gastric  distress  that  we  were  obliged  to  discon- 
tinue its  use ;  the  appetite  did  not  improve  until  after 
the  arsenic  was  dropped. 

The  quantity  of  urine  secreted  steadily  increased  until 
it  reached  seventy-two  ounces  daily;  it  was  analyzed 
frequently,  the  urates  remained  a  little  below  normal  in 
quantity,  phosphates  in  abundance,  no  albumin,  no  casts, 
no  sugar,  specific  gravity  1.020  to  1.025. 

After  the  thyroid  extract  had  been  used  for  about  three 
weeks  the  swellings  in  the  various  parts  of  the  body 
showed  signs  of  decrease.  The  face  was  the  first  to  lose 
its  puffiness.  The  enlargement  of  the  right  forearm, 
wrist,  and  hand  became  reduced  in  size.  One  week  later 
the  same  process  took  place  in  the  left  upper  extremity, 
next  followed  the  right,  and  then  the  left  lower  ex- 
tremity. 

As  the  oedema  decreased  the  skin  lost  its  glazed  ap- 
pearance and  commenced  scaling,  the  new  skin  was  soft, 
and  was  often  moist  with  perspiration ;  a  new  hairy 
growth  appeared  upon  the  arms,  legs,  and  head.  The 
clubbed  condition  of  the  fingers  was  less  apparent,  and 
she  was  able  to  use  her  needle  once  more. 

That  which  interested  and  astonished  me  most  was 
the  attempt  to  correct  the  exaggerated  curve  of  the  fin- 
ger-nails ;  they  rapidly  changed  their  shape,  and  two  of 
them  on  the  right  hand  became  almost  normal  in  ap- 
pearance. 

Tne  oedema  of  the  legs  and  feet  became  so  much  re- 
duced that  the  patient  was  able  once  more  to  wear  her 
shoes,  to  walk  about  her  room,  then  to  go  up  and  down 
stairs,  to  walk  out  upon  the  piazza,  and  finally  to  take  a 
sleigh- ride. 

Tne  glandular  trouble  did  not  improve,  but  went  from 
bad  to  worse.  About  the  middle  of  February  a  retro- 
grade change  commenced,  the  cough  became  more  an- 
noying, the  heart's  action  more  feeble,  the  appetite 
failed.  Swallowing  became  a  distressing  act,  soft  food 
could  be  gotten  down  fairly  well,  but  the  attempt  to 
swallow  liquids  occasioned  a  paroxysm  of  coughing  and 
strangling  which  was  painful  to  witness ;  the  taking  of  a 
meal  was  dreaded,  and  consumed  a  great  deal  of  time. 
Liquids  were  taken  through  a  tube,  and  by  certain  ma- 
noeuvring were  finally  swallowed.  A  stomach  tube  was 
passed  without  much  difficulty,  but  the  patient  preferred 
not  to  use  it,  and  persisted  in  her  own  way  of  getting 
food  and  drink  down  her  oesophagus. 

The  weakened  action  of  the  heart  and  the  accompany- 
ing dyspnoea  necessitated  the  withdrawal  of  the  thyroid 
extract  for  a  few  days.  As  no  relief  was  experienced 
from  its  discontinuance  we  again  resumed  its  administra- 
tion, but  it  had  no  further  control— the  oedema,  dysp- 
noea, dysphagia,  drowsiness,  hallucinations,  and  bodily 
weakness  increased  steadily,  and  she  died  March  15, 
1894. 

Dr.  Jurist  continued  to  see  the  case  at  intervals  durirg 
her  illness,  and  Dr.  Wharton  Sinkler,  of  Philadelphia, 
saw  her  in  consultation  a  few  days  before  her  death. 

Dr.  Boyer,  of  Philadelphia,  made  an  examination  ot 
the  blood  ;  the  result  was  very  interesting.     There  were 


September  i,  1894] 


MEDICAL  RECORD. 


271 


five  million  eight  hundred  thousand  red  corpuscles  to  the 
cubic  millimetre,  and  forty  eight  thousand  white  corpus- 
cles to  the  cubic  millimetre,  or  a  proportion  of  about 
one  white  to  one  hundred  and  twenty  red.  The  per- 
centage of  haemoglobin  was  about  sixty. 

It  is  greatly  to  be  regretted  that  a  post  mortem  could 
not  be  had ;  it  would  have  been  exceedingly  interesting, 
and  would  most  likely  have  thrown  some  light  on  the 
pathology  of  the  disease.  It  would  have  indicated  the 
condition  of  the  spleen  and  internal  lymphatics,  and  would 
have  determined  whether  there  was  present  a  mediastinal 
tumor,  and  would  also  have  shown  the  condition  of  the 
bronchial  glands. 

In  summing  up  the  case,  we  notice  first  the  persistent 
spasmodic  cough.  This  cough  was  evidently  dependent 
upon  either  the  pressure  of  a  mediastinal  tumor  or  en- 
larged bronchial  glands,  perhaps  both.  The  probability 
of  the  existence  of  a  mediastinal  growth  early  in  the 
trouble  is  enhanced  by  the  development  of  the  embar- 
rassed breathing  and  difficult  deglutition  among  the  first 
features  in  the  disease. 

The  cough  had  existed  for  very  nearly  a  year  before 
the  patient  showed  signs  of  cachexia.  During  this  pe- 
riod she  was  to  all  outward  appearances  well.  She  at- 
tended to  her  household  and  social  duties,  was  cheerful, 
had  a  good  appetite  the  most  of  the  time,  the  bowels 
moved  regularly,  and  she  menstruated  normally. 

We  have  next  the  increasing  signs  of  cachexia,  which 
for  a  long  time  could  not  be  accounted  for.  Then  came 
the  tumor  on  the  right  side  of  the  sternum,  followed  soon 
by  the  enlarged  gland  on  the  left  side  of  the  neck,  and 
the  apparent  disappearance  of  the  thyroid  gland. 

With  these  changes  came  the  development  of  the  char- 
acteristic features  of  myxoedema — the  multiplication  of 
the  lymphoid  growths  in  different  parts  of  the  body. 
We  have  the  remarkable  clubbing  of  the  finger-tips,  the 
curve  of  the  finger-  and  toe-nails,  the  apparent  projection 
of  the  calcaneum,  and  the  welt  along  the  outer  edge  of 
the  feet,  suggestive  of  acromegaly. 

The  effect  of  the  thyroid  extract  upon  the  myxede- 
matous features  was  for  a  time  most  remarkable,  followed 
in  a  short  while  by  its  failure  of  control,  with  increasing 
weakness,  stupidity,  hallucinations,  dyspnoea,  cardiac 
palpitation,  suffocation,  and  death. 

Drs.  J.  C.  Wilson  and  Wharton  Sinkler  concur  in  the 
opinion  that  the  case  was  originally  one  of  Hodgkin's 
disease,  and  that  the  myxoedema  occurred  symptomatic 
cally,  as  a  result  of  involvement  of  the  thyroid  gland  due 
to  the  lymphadenoma. 

I  am  inclined  to  the  belief  that  there  existed  a  medi 
astinal  tumor,  as  was  insisted  on  by  Dr.  Jurist,  and  that 
this  growth  was  directly  or  indirectly  the  cause  of  the 
cough  and  of  the  dyspnoea.  Why  the  paroxysms  of 
coughing  should  have  become  less  frequent  and  severe, 
and  the  ability  to  swallow  should  have  improved  under 
the  use  of  the  extract,  I  am  unable  to  understand. 

The  case,  from  any  stand-point,  was  an  exceedingly  in- 
teresting one,  and  worthy  of  putting  on  record. 


Seventeen-Year  Locusts. — The  newspapers  have  re- 
ported several  cases  of  death  following  bites  from  these 
insects. 

A  Haw  Location  for  the  Soul— The  champion  title 
of  the  year  must  surely  be  "  A  New  Systematic  Treat- 
ment of  All  Diseased  Conditions,  from  Strict  Elec- 
trical Polarization,  Adapted  Particularly  for  Examina- 
tions and  the  Treatment  of  Disease.  Embracing  Some 
Entirely  New  Principles  Concerning  Portions  of  Oar 
Organism.  Also,  An  Entirely  New  Motive  Power 
Regarding  the  Cleansing  and  Circulation  of  the  Blood 
by  Strict  Electrical  Polarization,  Locating  Exactly  the 
Ssat  or  Throne  of  that  Eternal,  Immortal,  and  Ever-Con- 
trolling Principle  Denominated  the  Soul  or  Mind,  To- 
gether with  Very  Many  Other  New  and  Important 
Facts  and  Principles.  By  A.  H.  Stevens,  M.D  ,  E.D." 
Dr.  Stevens  locates  the  Soul  in  the  corpus  callosum. 


Where  Our  Drugs  Come  From. — "  Principal  Exports 
to  the  United  States'1  is  the  title  of  a  pamphlet  lately 
issued  by  the  State  Department,  which  is  of  especial  in- 
terest from  the  fact  that  it  gives  the  value  of  our  imports, 
and  the  names  of  the  products,  and  the  countries  from 
which  they  are  derived.     The  report  is  compiled  from 
the  reports  of  the  various  consuls  of  this  country,  and 
the  figures  bearing  upon  the  extent  of  the  drug  and  chemi- 
cal imports  are  interesting  both  on  account  of  the  mag- 
nitude of  the  commercial  interests  involved  in  the  trade, 
and  the  fact  that  they  show  that  the  most  remote  por- 
tions of  the  earth  are  called  upon  to  supply  our  demand 
for  drugs  and  medicines.     The  figures  given,  with  a  few 
exceptions,  cover  the  calendar  year  1892,  and  the  report 
is  arranged  to  show  the  value  of  goods  as  "  declared  for 
export"  in  the  various  consular  districts.      From  the 
Buda  Pesth  and  Vienna  districts  of  Austria  Hungary  we 
receive  drugs  and  chemicals  amounting  to  £122,758.   From 
Trieste  insect  powder  and  flowers  amounting  to  £71,884. 
From   France  our  imports  included   olive  oil,   drugs, 
chemicals,  argols,  dyestuffs,  toilet  articles,  and  perfumery, 
and  amounted  to  £2,564,000.      Germany  furnished  us 
with  drugs,  chemicals,  dyes,  colors,  and  essential  oils  to 
the  amount  of  £9,193,849.   Greece  sent  us  £24,108  worth 
of  sponges.     From  Italy  we  received  olive  oil,  brimstone, 
canary  seed,  crude  glycerine,  soap,   argols,  onis  root, 
almonds,  licorice,  sumac,  and  essential  oils,  valued  at 
£4909,704.     The   Netherlands  sent  us  cacao  butter, 
drugs,  and  dyestufTs  amounting  to  £366,470.     Corkwood 
worth  £1,069,057,  and  argols  worth  £131,805,  came  from 
Portugal.     The  Batoum  district,  Russia,   furnished  us 
licorice  root  valued  at  £624,363.     Spain  furnished  us 
cream  of  tartar,  glycerine,  licorice,  saffron,  corkwood, 
olive  oil,  and  canary  seed  worth  £1,505,505.     Sweden 
and  Norway  sent  us  £82,055  worth  of  cod-liver  oil  and 
oxalic  acid  worth  £18,090.     Little  Switzerland  sent  us 
anilines,  dyestufTs,  and  chemicals  worth  £439,518,  and 
enough  argols  and  beef  extract  to  make  the  total  £475  r 
760.     We  received  from  Turkey,  in  Europe,  £403,013  ; 
attar  of  roses,   £141,929;    gum    tragacanth,   £55,620. 
From  the  United  Kingdom,  which  seems  to  be  a  sort  of 
clearing-house  for  the  world,  we  received  drugs  and 
chemicals  amounting  to  £12,570,180.     British  North 
America  sent  us  £22,003  worth  of  senega  root  and  £12,- 
664  worth  of  sulphur.     Sarsapariila  worth  £67,577  ;  va- 
nilla, £710,580  ;  fustic,  £130,913  ;  gum  chicle,  £475>665> 
and  silver  dollars,  which  are  apparently  a  drug  on  the 
market,  to  the  amount  of  £454.03* >  came  to  us  from 
Mexico.     China  furnished  cassia,  £164,497;  gall  nuts, 
£5,730,  and  rhubarb,  £16,454.    Dutch  India,  gum  damar, . 
£64.729  ;  gum  copal,  £30,452  ;  cassia,  £26,593.     Japan, 
sulphur,  £226,025  ;  menthol,  £23  391  ;  camphor,  £522,. 
152.     Philippine  Islands,  indigo,  £16,369  ;  ylang  ylang 
oil,  £10,002.     Turkey,  in  Asia,  licorice  root,  £1,023,- 
710;  opium,  £451,431.     New  Zealand,  kauri  gum,  £1,- 
997,607.     Tahiti   (Society  Is'ands),   vanilla,    £36,698. 
Honduras,  sarsapariila,  £30,951 ;  chicle,  £4.604.     Brazil, 
copaiba,  £28,958;  guarana,  £8,078;  castor  beans,  £22,- 
774.     Chili,  nitrate  of  soda,  £2,880,643;  iodine,  £57?,- 
313.      Peru,  coca  leaves  and  elixir,   £5,329.     British 
•West  Indies,  sponges,  £236,555  ;  dyewoods,  £186,842  ; 
ginger,   £40,734;     pimento,    £126,400.      Dutch    West 
Indies    (Curasao),    aloes,     £3,047.      Guadeloupe,    va- 
nilla,   £c,66o.      San    Domingo,    dyewoofs,    £38,307. 
Porto  Rico,  bay  rum  and  oil,  £3,494-     Canary  Islands, 
cochineal,  £17,382;    almonds,  £3,877.     British  Africa, 
argols,    £10,088;    palm    oil,   £1,892.      Egypt,   senna, 
£36,627.      Algiers,     corkwood,     £22,159.       Morocco, 
canary,  cumin,  and  coriander  seeds,  £4>735-     Zanzibar, 
cloves,    £289,688;    clove  stems,   £4.058;    gum  copal, 
£51,836.     British  Asia,  Aden,  civet,  £4,898.     Calcutta, 
drugs,  £4,272,076  ;  saltpetre,  £518,845.     Ceylon,  cocoa- 
nut  oil,  £937,331;    cinchona,  £73»l85>   essential  oils, 
£73,015.     Hong   Kong,   opium,    prepared,   £543»°9I  y 
cassia,  £79,170;  medicines,  £51,418.     Singapore,  gam- 
bier,  £733,855  ;  gum  copal,  £119,493  —Pharmaceutical 
Era. 


2/2 


MEDICAL    RECORD. 


[September  if  1894 


Medical   Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


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


New  York,  September  1,  1894. 


THE    CONFIDENTIAL     RELATIONS    OF    THE 
PHYSICIAN. 

The  recent  decision  of  Judge  Cole,  of  the  Supreme 
Court  of  the  District  of  Columbia,  holding  that  physi- 
cians and  lawyers  are  not  exempted  from  giving  testi- 
mony when  called  upon  in  court,  on  the  ground  that 
such  information  was  professionally  confidential,  will 
strike  everyone  who  learns  of  it  with  becoming  surprise. 
The  ruling,  wise  as  it  may  appear  to  the  learned  judge, 
will  be  viewed  by  the  community  at  large  in  a  widely 
different  light.  Were  it  not  that  this  opinion  has  been 
deliberately  rendered  in  a  high  court  of  justice  by  one  of 
its  officers,  it  might  be  looked  upon  as  an  attempt  to 
create  a  cheap  sensation,  or  a  foolish  bid  for  personal 
notoriety.  Fortunately,  however,  its  very  absurdity  is 
its  death-blow.  Physicians  have  heretofore  gone  to 
prison  rather  than  abuse  their  patients'  confidences,  and 
they  will  do  so  again  when  opportunities  force  them  to 
such  extremities,  in  spite  of  judges'  edicts  or  juries1  find- 
ings. The  opinion  of  the  learned  judge  is  contrary  to 
that  of  all  wise  and  good  men  since  civilization  began 
or  social  relations  were  in  any  way  respected.  It  has 
been  the  bulwark  of  the  Hippocratic  oath,  the  funda- 
mental principle  of  legal  pleading,  and  the  corner-stone 
of  the  Christian  religion,  to  respect  and  hold  sacred  the 
privileged  communications  of  such  as  come  to  their  con- 
fessors for  sympathy,  forgiveness,  and  help.  The  very 
stability  of  society,  the  preservation  of  social  relations, 
the  maintenance  of  honorable  intercourse,  the  most 
sacred  obligations  existing  between  members  of  the  hu- 
man family,  rest  upon  the  uncompromising  integrity  of 
those  principles  which  even  in  heathen  ages  have  made 
us  trust  one  another.  And  yet  for  the  sake  of  obtaining 
some  evidence  in  a  divorce  suit  an  expounder  of  the  law 
makes  bold  to  insult  the  higher  instincts  of  our  humanity 
by  aiming  a  blow  at  the  honor  of  every  man  who  hears  a 
confession.  If  we  mistake  not,  the  learned  judge  will 
stand  alone  in  his  opinion,  which  is  in  itself  a  distinc- 
tion sufficiently  gratifying  to  him,  perhaps,  as  opposed 
to  that  of  the  rest  of  mankind,  and  is  worthy  of  remark 
on  that  account.  It  is  difficult  to  imagine  the  great 
harm  that  would  ensue  if  the  professions  of  law  and  medi- 
cine, forgettiog  all  their  time-honored  customs,  their 
treasured  traditions,  and  their  sacred  rights,  should  be 
compelled  to  abide  by  the  absurd,  illogical,  and  damag- 
ing decision  of  our  learned  interpreter  of  legal  obliga- 
tions. Let  any  practitioner  of  medicine  think  for  him- 
self of  the  disastrous  consequences  which  would  result 


from  the  disclosure  in  court  of  those  family  secrets  which 
he  has  been  forced  to  know,  even  within  the  circle  of 
his  own'practice.  And  how  much  more  for  the  profes- 
sion at  large ! 

Fortunately,  however,  the  remarkable  ruling  will  not 
affect  any  medical  or  legal  gentleman  outside  the  juris- 
diction of  the  court  in  question,  and  will  doubtless  be 
very  properly  overruled  in  the  next  test- case.  In  any 
event,  with  the  medical  profession  the  opinion  will  al- 
ways be,  as  it  has  always  been,  that  no  physician  or  sur- 
geon must,  directly  or  indirectly,  under  any  circum- 
stances or  conditions,  at  no  time  or  place,  abuse  the 
confidence  of  anyone  who  has  trusted  to  his  personal 
honor  in  the  dire  extremities  of  sickness  and  suffering. 
The  man  who  would  do  otherwise,  judge  or  no  judge, 
would  disgrace  his  calling,  would  prostitute  the  highest 
obligation  of  his  profession,  and  outrage  the  most  sacred 
trust  that  could  be  imposed. 


THE  DANGER  OF  THE  COMMUNION   CUP. 

We  are  pleased  to  know  that  the  frequent  discussion  in 
these  columns  as  to  the  danger  of  the  communion  cup  in 
propagating  disease  is  bearing  fruit  by  transference  to 
the  columns  of  the  daily  press.  The  public  is  thus  be- 
ing educated  to  the  necessities  of  the  situation,  and 
there  is  a  reasonable  hope  that  the  claims  of  preventive 
medicine  will  be  vindicated  even  against  those  whose 
faith  in  old  forms  have  failed  to  listen  to  reason  before. 

The  following  telling  experience,  detailed  by  Dr.  Al- 
bert S.  Ashmead  in  a  recent  letter  to  the  Sun,  points 
its  own  moral : 

"  The  last  time  I  knelt  at  the  communion  altar  of  the 
Episcopal  Church  there  knelt  at  one  side  of  me  a  pa- 
tient whom  I  knew,  as  I  was  treating  him  at  the  time, 
to  be  a  syphilitic;  his  mouth  had  mucous  patches, 
which  make  the  disease  especially  contagious.  This 
person  took  the  cup  before  it  came  to  me.  Of  course, 
•I  let  the  cup  pass. 

"  At  another  time  the  person  next  to  me,  but  follow- 
ing me  in  the  use  of  the  cup,  was  also  a  patient  of  mine, 
in  an  advanced  stage  of  tuberculosis.  The  mouth  of 
this  person  was  in  a  condition  dangerous  to  his  neighbor. 

"  Of  course,  no  man  who  is  not  a  complete  survival  of 
the  Middle  Ages  can  assert  that,  under  these  circum- 
stances, a  man  (if  he  knew)  should  apply  his  lips  to  a 
probably  dangerously  contaminated  cup,  trusting  in 
the  protection  of  the  Lord,  who  has  allowed  hundreds, 
a  hundred  times,  to  perish  in  burning  or  earth  shaken 
churches,  while  they  were  in  the  very  act  of  worshipping 
Him.M 

Verily  a  little  sermon  in  itself,  and  from  a  churchman 
and  a  physician,  who  views  both  sides  reverently  for 
Christianity's  sake,  and  candidly  for  the  vindication  of 
truth. 

The  Sun,  with  its  usual  vigor  of  diction  and  direct- 
ness of  aim,  thus  valiantly  takes  sides  with  science  and 
fact  as  against  tradition  and  prejudice : 

"  When  a  physician  writes  to  a  newspaper,  as  one 
wrote  to  the  Sun  the  other  day,  that  he  refrained  from 
drinking  from  the  chalice  at  a  recent  celebration  of  the 
Eucharist  in  the  Episcopal  Church,  because  before  him 
two  patients  of  his  had  sipped  from  the  cup,  the  one 
afflicted  with  an  odious  and  the  other  with  a  destructive 


September  i,  1894] 


MEDICAL  RECORD. 


273 


communicable  disease,  reasonable  fears  of  the  danger  of 
the  hallowed  practice  are  excited  even  among  the  most 
devout  of  communicants ;  and  such  fears,  thus  justified, 
are  quickly  and  widely  diffused.  Is  it  unlikely,  then,  is 
it  not  probable,  that  this  alarm  will  become  so  extensive 
and  so  great  that  all  churches  whose  doctrines  require 
that  both  elements  shall  be  administered  to  the  whole 
body  of  communicants  will  be  compelled  to  imitate  the 
Rochester  example,  or  adopt  some  other  method  devised 
for  the  same  purpose,  in  order  to  save  the  communion 
in  both  kinds  from  perilous  disease  ?  " 

The  fact  of  danger  is  indisputable,  and  the  conclusion 
for  safety  is  irresistible.  We  are  confident  that  it  is  only 
a  question  of  time  when,  as  the  Sun  says,  all  churches 
will  be  compelled  to  imitate  the  Rochester  example. 
Contagion  is  no  respecter  of  cups,  men,  or  place,  when 
the  essential  conditions  of  its  propagation  are  present. 
The  Christian  will  never  yield  up  the  cup ;  why  should 
he  object  to  its  being  clean  and  free  from  danger? 
Why  one  contaminated  chalice  against  many  safe  ones  ? 


OPHTHALMIC  HEMICRANIA. 

Under  this  title  in  //  Raccoglitore  medico,  January  10, 
1894,  Dr.  Palombi  gives  an  interesting  account  of  hered- 
itary ophthalmic  hemicraaia,  together  with  a  considera- 
tion of  the  subject  at  large.  The  patient  whose  case  is 
cited  belonged  to  a  neuropathic  family,  his  particular 
trouble  originating  with  the  great  grandfather  and  being 
regularly  transmitted  for  three  generations,  only  one 
person  in  the  entire  family  escaping.  From  his  earliest 
recollection,  the  patient  had  suffered  from  migraine; 
bat  like  his  own  father  and  grandfather,  the  intensity  of 
the  trouble  reached  its  maximum  between  the  ages  of 
fifteen  and  thirty.  The  author  very  justly  criticises  the 
term  ophthalmic  migraine,  or  hemicrania,  to  describe  an 
idiopathic  affection  in  which  ocular  phenomena  are  con- 
tingents, like  the  agraphia,  aphasia,  paresis,  etc.,  that 
sometimes  accompany  it.  The  chief  phenomenon  is  the 
onesided  headache.  The  work  of  Galezowski  and  of 
Charcot  is  passed  in  brief  review,  the  history  of  the 
particular  case  in  this  migrainous  family  seeming  to 
challenge  a  little  the  views  held  by  these  two  ob- 
servers: viz.,  that  hemicrania  is  allied  to  epilepsy,  and 
is  an  affection  with  an  anatomical  substratum  of  chronic 
progressive  basilar  meningitis,  with  secondary  neuritis 
resulting  from  compression.  Errors  have  been  made  in 
regard  to  migraine  by  confounding  it  with  the  various 
pathological  states  with  which  it  may  be  associated.  It 
is  a  protopathic  affection  that  may  develop  in  persons 
otherwise  healthy.  In  the  case  cited  there  had  never 
been  any  premonitory  symptoms. 

The  author  notes  two  periods  in  hemicrania :  the  pe- 
riod of  invasion,  and  the  period  during  which  appear, 
but  not  always,  the  following  symptoms,  enumerated  in 
their  order  of  frequency:  lateral  or  horizontal  hemi- 
anopsia, scintillating  scotomata,  migrainous  amaurosis, 
amblyopia,  tingling  and  paretic  aching,  aphasia,  and 
agraphia.  In  the  same  proportion  that  ocular  phenom- 
ena disappear,  just  as  a  curtain  on  the  stage  is  drawn 
apart  laterally,  tingling  and  heaviness  begin  in  the  fin- 
gers, the  forearm,  the  arm,  and  one-half  of  the  face. 
These  last-named  symptoms  are  usually  confined  to  one 
upper  extremity,  but  the  hemianopsia  and  scotomata  are 


ordinarily  sjmmetrical.  When  the  tingling  begins,  the 
various  painful  symptoms  disappear,  and  then,  if  present 
at  all,  different  forms  of  aphasia  come  on,  of  which  the 
rarest  are  agraphia  and  word-blindness.  The  symptoms 
of  the  first  period  succeed  each  other  singly.  This  is 
their  special  characteristic.  After  a  few  moments  of 
apathetic  repose,  the  second  period  is  ushered  in  by  its 
unique  symptom,  headache.  This  pain  has  a  special 
quality  of  its  own,  and  can  never  be  confounded  by  the 
patient  with  any  other.  It  is  indescribable.  Its  inten- 
sity is  in  proportion  to  those  of  the  other  symptoms  and 
to  the  duration  of  the  attack.  Cerebral  impotence  is 
absolute  while  it  lasts.  The  periodicity  varies.  Palombi 
admits  but  one  cause  for  hemicrania :  heredity.  Excit- 
ing causes  are  numerous,  of  which  the  principal  are  at- 
mospheric pressure,  cold,  constipation,  and  glaring  light. 
Often  the  exciting  cause  is  apparently  wanting,  and  the 
attacks  appear  spontaneously. 

Hemicrania,  or  migraine,  is  a  vasomotor  neurosis. 
Hypothetically,  it  is  possible  to  admit  a  capillary  apo- 
plexy as  the  anatomical  basis  of  the  disorder.  As  pre- 
ventive measures,  the  Italian  observer  finds  quinine  and 
bromides  of  value ;  and  advises  antifebrin  during  the 
attacks.  To  sum  up :  Hemicrania  is  a  distinct  neurosis, 
of  which  the  pathogenesis  and  anatomical  seat  are  un- 
known ;  it  has  characteristic  clinical  features  that  estab- 
lish its  identity,  and  it  is  analogous  to  hysteria  and 
epilepsy,  though  it  presents  no  traits  in  common  with 
them  other  than  heredity. 

Concerning  remedies,  Hirt  speaks  of  citrate  of  caffeine, 
two  grains  three  times  a  day,  for  those  cases  in  which  the 
conditions  of  the  circulation  (increased  tension,  vaso- 
dilatation) give  no  suggestion.  Efforts  must  be  directed 
toward  building  up  the  general  health  by  cold-water 
treatment,  general  faradization  according  to  Beard  and 
Rockwell's  method,  franklinization  with  the  Holtz 
machine,  and  systematic  gymnastic  exercise  at  home. 
Sometimes  lasting  advantage  has  been  obtained  by 
change  of  climate,  travelling,  and  by  a  stay  at  the  moun- 
tains or  seaside.  Gray  recommends  twenty  or  thirty 
grains  of  bromide  during  the  attack,  and  cannabis  indi- 
ca  at  other  times.  For  anaemia,  peptonate  of  iron  in 
three  grain  doses,  three  times  daily,  is  to  be  given  when 
the  condition  is  not  specially  marked;  when  pro- 
nounced general  physical  depression  exists,  quinine  is  to 
be  added.  In  some  cases  of  anaemia  in  which  there  are 
hepatic  symptoms  a  sixtieth  to  a  thirty  second  of  a  grain 
of  bichloride  three  times  a  day  should  be  added  to  the 
iron,  or  the  iron  and  quinine.  Dana  considers  bromide 
of  potassium,  nitro  glycerin,  cannabis  indica,  and  arsenic 
the  best  remedies  for  continued  internal  use.  Cannabis 
indica,  either  with  or  without  arsenic,  is  the  most  trust- 
worthy, and  the  bromides  the  least  to  be  depended  upon. 
To  relieve  the  attacks,  salicylate  of  soda,  caffeine,  anti- 
pyrine,  powdered  guarana,  menthol,  muriate  of  ammonia, 
and  bromide  of  potassium  are  reliable  remedies  for  a 
time,  but  lose  their  effect  as  do  almost  all  other  drugs. 
Rest  is  the  most  important  element  in  the  management 
of  an  attack,  rest  and  perfect  seclusion  from  the  world 
and  affairs. 

Naming  Streets  after  Hedical  Ken.— The  Parisian 
Municipal  Council  has  named  three  streets  in  that  city 
after  Charcot,  Tr61at,  and  Trousseau. 


274 


MEDICAL    RECORD. 


[September  i,  1894 


llcxus  of  tfoe  IS&eefe. 

French  Association  for  the  Advancement  of  Science. 

— The  twenty-third  annual  meeting  of  this  association  was 
held  at  Caen  during  the  week  commencing  August  9th, 
under  the  presidency  of  Professor  Mascait.  Among  the 
papers  read  in  the  Section  of  Natural  and  Medical 
Sciences  was  a  report  by  Dr.  Le  Genole  "  On  the  Dangers 
of  Athletic  Sports  in  the  Case  of  Children. ' '  Dr.  F.  Reg- 
nault  contributed  a  paper  "  On  the  Causes  of  the  Atti- 
tude Assumed  by  Women  during  Parturition ; ' '  Dr.  Cartaz 
one  "  On  a  Special  Variety  of  Stenosis  of  the  (Esoph- 
agus; "  Dr.  Galliard  one  "On  the  Treatment  of  Cer- 
tain Non-syphilitic  Headaches  by  Calomel ;  "  and  Dr. 
Raphael  Dubois  one  "  On  the  Mechanism  of  Sleep.11 

Professor  Billroth' s  Widow  has  been  granted  a  yearly 
pension  of  2,000  florins.  The  law  allows  a  pension  of 
600  florins  only  to  the  widows  of  professors,  and  the 
grant  of  a  larger  sum  is  a  mark  of  especial  favor  from  the 
Emperor  of  Austria. 

The  British  Hedical  Association  will  hold  its  next  an- 
nual meeting  in  London.  Dr.  J.  Russell  Reynolds  is 
the  President-elect,  and  Sir  William  Priestly  will  be 
Chairman  of  the  Reception  Committee.  The  last  meet- 
ing of  the  Association  in  London  was  in  1873,  under  the 
presidency  of  Sir  William  Fergusson. 

The  Tailors  of  Gratz  not  long  since  presented  a  peti- 
tion to  the  Rector  Magnificus  of  the  University,  praying 
that  in  future  no  student  receive  his  doctorate  diploma 
until  he  has  furnished  proof  that  he  owes  his  tailor  noth- 
ing. 

The  Shah  of  Persia,  who  sent  for  Dr.  Galezowski,  of 
Paris,  to  examine  his  eyes,  has  been  found  to  have  no  or- 
ganic disease.  His  general  health  was  poor' and  the 
ocular  trouble  was  purely  functional. 

The  German  Public  Health  Association  will  hold  its 
nineteenth  annual  meeting  in  Magdeburg,  on  September 
19-22,  1894.  The  managers  of  the  Association  have 
been  subjected  to  some  adverse  criticism  for  calling  a 
meeting  so  soon  after  the  International  Congress  of  Hy- 
giene and  Demography  in  Buda  Pesth,  especially  as  many 
of  the  subjects  to  be  discussed  are  the  same  as  those  to 
come  before  the  congress. 

Dr.  Daniel  Cornelius  Danielssen  died  recently  at 
Bergen,  Norway,  at  the  age  of  seventy-nine  years.  He 
was  well  known  as  an  authority  on  leprosy,  to  the  study 
of  which  disease  he  had  devoted  his  entire  life.  The 
wotk  which  gained  for  him  his  reputation  was  written 
conjointly  with  W.  Boeck,  and  contained  the  result  of 
an  investigation  undertaken  at  the  instance  of  the  Nor- 
wegian Government.  It  was  published  in  1847.  It  was 
those  observers  who  established  the  identity  of  leprosy,  as 
seen  in  Norway,  with  elephantiasis  Graecorum.  Dr.  Dan- 
ielssen was  born  in  Christiania,  and  at  the  time  of  his  death 
was  physician  in -chief  to  the  Leper  Hospital  in  Bergen. 

Dr.  Philip  Lonsdale  died  in  Cos  Cob,  Conn.,  on 
August  2 1st,  at  the  age  of  seventy-  seven  years.  Dr.  Lons  • 
dale  entered  the  United  States  Navy  about  fifty  years  ago, 
and  served  as  surgeon  on  Admiral  Farragut's  flagship 
Hartford,  during  the  civil  war.  He  was  medical  director 
in  the  navy  at  the  time  of  his  retirement,  which  took  place 
several  years  ago. 


The  American  Association  for  the  Advancement  of 
Science  will  hold  its  next  annual  meeting  in  San  Fran- 
cisco. The  officers  for  the  coming  year  are :  President, 
E.  W.  Morley,  of  Cleveland,  O.;  Secretary,  F.  W.  Put- 
nam, of  Cambridge,  Mass.;  General  Secretary  >  James 
Lewis  Howe,  of  Louisville,  Ky  ;  Secretary  of  the  Coun 
cil,  Charles  R.  Barnes,  of  Morris  an,  Wis.  The  vice- 
presidents  are  the  chairmen  of  the  various  sections. 

Typhoid  Fever  in  Hontclair. — It  has  been  ascertained 
that  the  cause  of  the  recent  epidemic  of  typhoid  fever  in 
Montclair,  N.  J.,  was  due  to  contaminated  wells.  Four 
wells,  the  water  of  which  was  examined  and  found  to  con- 
tain typhoid  bacilli,  have  been  ordered  to  be  closed. 
The  wells  are  all  on  Bloomfield  Avenue,  in  the  most 
thickly  populated  part  of  the  town,  and  the  pumps  are 
of  easy  access  to  the  public. 

The  Anatomical  Congress  will  hold  its  next  meeting 
at  Basel,  Switzerland,  on  April,  17,  18,  and  19,  1895. 

The  Bottling  of  Mineral  Waters  in  France. — The 
question  of  the  artificial  aeration  of  natural  mineral 
waters  was  recently  up  for  discussion  before  the  Paris 
Academy  of  Medicine.  The  methods  of  bottling  in  use 
at  certain  springs  were  condemned,  and  the  Government 
was  urged  to  adopt  the  following  precautionary  regula- 
tions: 1.  The  sale  of  mineral  waters  which  have  been 
decanted,  or  artificially  rendered  gaseous,  shall  be  pro- 
hibited. 2.  Every  application  to  the  ministry  for  author- 
ization must  be  accompanied  by  the  certificate  of  a  com- 
petent official  that  the  water  has  not  thus  been  already 
manipulated,  and  by  the  written  promise  of  the  propri- 
etor not  to  resort  to  these  processes.  3.  Reservoirs  must 
be  hermetically  closed,  and  should  be  emptied  at  least 
every  twenty-four  hours.  They  are  to  be  so  placed  that 
the  spring  flows  direct  into  the  reservoir.  4.  Bottles 
must  be  thoroughly  sterilized  before  being  filled,  and  all 
causes  of  pollution  during  bottling  are  to  be  most  care- 
fully avoided. 

The  Prize  of  the  Accademia  dei  Lincei. — The  royal 
prize  of  one  thouiand  lire  has  been  divided  equally  be- 
tween Professors  Tizzoni  and  Luciani  for  meritorious 
work  in  the  fields  of  pathology  and  experimental  physi- 
ology. 

The  Origin  of  Typhoid  Fever. — Dr.  Kenwood  read  a 
paper  before  the  Section  on  Public  Health  at  the  Bristol 
meeting  of  the  British  Medical  Association,  in  which 
he  advanced  the  opinion  that  typhoid  fever  might  be 
developed  from  simple  diarrhoea,  the  specific  bacillus 
springing  by  a  process  of  evolution  from  the  bacterium 
coli  commune.  He  believed  that  dogs  might  be  carriers 
of  the  disease,  and  cited  four  cases  in  support  of  this 
view.  In  one  case  an  examination  of  the  stools  passed 
by  a  dog,  prior  and  subsequent  to  the  appearance  of  ty- 
phoid fever  in  a  household  in  which  there  was  no  other 
discoverable  cause,  revealed  the  presence  of  typhoid 
germs. 

Science  Ignored. — "  Whatever  water  the  water- works 
furnishes  has  to  be  taken  as  it  is,  and  we  must  trust  to 
God  for  the  rest,11  is  a  pious  sentiment  attributed  to  the 
Director  of  the  Department  of  Public  Works  of  Pitts- 
burgh, who  is  also  quoted  as  saying  :  "I  don't  put  much 
trust  in  scientists  anyway.  A  theory  is  nowhere  besides 
practice  anyway."  The  faith,  to  say  nothing  of  the 
grammar,  of  this  worthy  director  must  be  of  a  very  high 


September  i,  1894] 


MEDICAL    RECORD. 


275 


order,  such  as  to  move  microbes,  if  not  mountains ;  for  a 
more  efficient  method  of  pouring  the  contagia  of  ty- 
phoid and  other  water-borne  diseases  down  the  throats 
of  the  Pittsburghers  than  that  afforded  by  the  city  water- 
works could  hardly  be  imagined.  This  is  explained 
very  clearly  by  a  diagram  published  in  the  August  issue 
of  the  Pittsburgh  Medical  Review,  The  water  of  the 
Alleghany  River,  polluted  by  sewage  from  the  Work- 
house and  the  Alleghany  City  Poor  Farm,  and  by  the 
surface  drainage  of  the  village  of  Hoboken,  is  deflected 
by  means  of  a  dam  directly  into  the  intake- pipe  of  the 
Pittsburgh  water-works.     Comment  is  needless. 

The  Mississippi  Valley  Hedical  Association  will  hold 
its  twentieth  annual  meeting  in  Hot  Springs,  Ark.,  on 
November  20-23,  1894.  The  President  of  the  Asso- 
ciation is  Dr.  Xenophon  C.  Scott,  of  Cleveland,  and  the 
Secretary,  Dr.  Frederick  C.  Woodburn,  of  Indianapolis. 

Dr.  Bernhard  OrSnhut,  of  this  city,  was  lost  at  sea 
from  the  steamship  Bothnia,  which  arrived  last  Sunday 
in  Boston  from  Liverpool.  It  is  not  known  whether  he 
jamped  or  accidentally  fell  overboard.  He  was  a  gradu- 
ate of  the  College  of  Physicians  and  Surgeons,  but  re- 
tired from  practice  four  years  ago  to  devote  himself  to 
the  real  estate  business.     He  was  forty-  eight  years  of  age. 

The  Antitoxin  Treatment  of  Diphtheria.— The  Board 
of  Health  of  this  city  proposes  to  ask  for  an  appropria- 
tion from  the  Board  of  Estimate  and  Apportionment  to 
enable  it  to  manufacture  diphtheria  antitoxin  in  large 
quantities.  Dr.  Biggs,  the  bacteriologist  of  the  depart- 
ment, has  recently  returned  from  Berlin,  *here  he  went 
to  study  the  method  of  manufacture  and  the  results  ob- 
tained by  the  use  of  this  remedy.  His  report  is  very 
strongly  in  favor  of  the  new  method,  and  it  is  upon  the 
strength  of  this  report  that  the  Board  has  determined  to 
undertake  the  production  of  antitoxin  at  a  cost  suffi- 
ciently low  to  bring  it  within  the  means  of  poor  people. 

A  Conflict  between  State  and  National  Health  Au- 
thorities.— The  Surgeon-General  of  the  Marine  Hospital 
Service  ordered  that  all  vessels  arriving  in  New  Orleans 
from  Central  and  South  American  ports  during  August 
and  September  be  detained  five  days  after  inspection  in- 
stead of  three  days,  as  has  been  the  rule  hitherto.  The 
Louisiana  Board  of  Health  regarded  the  execution  of 
this  rule  as  an  unnecessary  obstruction  to  commerce,  and 
an  appeal  was  made  to  the  Secretary  of  the  Treasury  to 
have  the  order  rescinded.  The  Secretary,  however,  has 
refused  to  interfere. 

The  Cholera  is  believed  to  be  decreasing  in  Europe. 
No  new  districts  have  been  invaded  during  the  past 
week,  and  the  number  of  new  cjses  in  already  infected 
regions  is  slowly  diminishing.  It  is  hoped  that,  with 
the  advent  of  cooler  weather,  the  danger  of  any  further 
spread  of  the  disease  will  be  averted. 

Dr.  Joseph  Bancroft,  one  of  the  leading  physicians  of 
Brisbane,  Queensland,  died  in  that  city  a  few  weeks  ago 
at  the  age  of  fifty- eight.  He  was  born  in  Manchester, 
but  had  practised  in  Brisbane  for  the  past  thirty  years. 

Opposition  to  a  Health  Officer.— A  petition  is  in  cir- 
culation in  Brooklyn  praying  for  the  removal  of  the 
Health  Commissioner  of  that  city.  The  opposition  to 
him  appears  to  have  been  excited  by  the  firm  stand  which 
he  took  relative  to  quarantine  regulations  and  vaccina- 
tion during  the  small-pox  alarm  last  winter  and  spring. 


1 1  Dr.  Oliver  Wendell  Holmes  passed  his  eighty-fifth 
birthday  on  Wednesday  of  this  week  at  his  summer  home 
at  Beverley  Farms,  Mass.  He  is  in  excellent  health, 
walks  a  mile  every  pleasant  morning,  and  takes  a  long 
drive  every  afternoon.  In  an  interview  in  the  Boston 
Advertiser  the  poet  said,  in  reply  to  the  question 
whether  he  was  writing  an  autobiography :  "  I  am  in  the 
habit  of  dictating  many  of  my  recollections,  some  of  my 
thoughts  and  opinions  to  my  secretary,  who  has  in  this 
way  accumulated  a  considerable  mass  of  notes.  Many 
of  these  will  be  interesting  to  my  family  and  intimates, 
some  of  them,  perhaps,  to  a  wider  public  if  I  should  see 
fit  to  make  use  of  them,  or  leave  them  to  be  made  use  of 
by  others.  It  is  the  one  thing  a  person  long  past  the 
active  period  of  life  can  do  with  ease  and  pleasure ;  and 
in  the  midst  of  much  that  might  as  well,  perhaps,  perish 
with  the  writer,  will,  not  improbably,  be  found  memo- 
randa deserving  of  permanent  record. "  Concerning  his 
age  he  said,  that  the  twelfth  septennial  period  had  always 
seemed  to  him  .as  one  of  the  natural  boundaries  of  life. 
One  who  has  lived  to  complete  his  eighty  fifth  year  has 
had  his  full  share,  even  of  an  old  man's  allowance. 
Whatever  is  granted  over  that  is  a  prodigal  indulgence 
on  the  part  of  nature. 

K.  Paquelin's  name  is  familiar  to  medical  mankind  in 
connection  with  his  thermo-cautery ;  he  is,  perhaps,  less 
known  as  the  possessor  of  a  mental  heat-producing  ap- 
paratus which  manifests  its  working  by  an  occasional  out- 
pouring of  verse,  glowing,  as  might  be  expected,  with 
"  words  that  burn."  The  French  journals  have  recently 
published  a  poetic  -effusion  of  his  in  which  the  origin  of 
percussion  is  told  in  classic  style  as  an  accidental  discov- 
ery (Have  not  most  great  discoveries  in  medicine  been 
more  or  less  accidental  ?)  of  Bacchus.  When  Semele 
was  dying,  with  the  future  god  of  wine  still  in  her  womb, 
Vulcan  performed  Caesarean  section,  and  delivered  the 
child,  whom  he  incontinently  inserted  into  his  father's 
thigh.  Here  the  lusty  youngster  kicked  about  so  vigor- 
ously that  he  gave  his  parent  sciatica.  On  escaping 
from  his  prison  he  was  naturally  thirsty,  and  he  soon  be- 
gan to  suffer  from  alcoholic  tremor.  When  sitting  on 
his  favorite  seat,  a  wine-cask,  he  was  constantly  drum- 
ming on  it  with  his  fingers,  and  hammering  it  with  his 
restless  feet.  The  difference  of  resonance  attracted  his 
attention,  and  he  soon  learnt 

du  son  dit  a^rique 
A  discerner  lc  sens  de  celui  dit  hydrique  ; 
II  sut  en  mcme  temps  tracer  sur  son  tonneau 
Exactement  la  ligne  cm  siegeait  le  niveau. 

Man,  we  gather,  soon  learnt  by  Bacchus's  example  .to 
diagnose  the  internal  condition  of  a  wine- cask,  and  Hip- 
pocrates by  and  by  bettered  the  instruction  by  deter- 
mining the  limits  of  the  spleen  by  percussion.  Is  it  too 
much  to  hope  that  M.  Paquelin's  centre  of  poetic  ther- 
raogenesis  may  hold  out  till  he  has  found  a  divine  origin 
for  auscultation,  inspection  of  the  tongue,  and  the  other 
esoteric  mysteries  of  the  medical  art  ? — British  Medical 
Journal, 

University  Befonns  in  Italy. — The  Italian  Govern- 
ment proposes  to  suppress  twenty- three  universities  in  the 
peninsula  and  to  convert  them  into  preparatory  schools, 
creating  in  place  of  them  large  and  thoroughly  well  ap- 
pointed state  universities  in  Rome,  Naples,  and  two  or 
three  other  of  the  larger  cities. 


276 


MEDICAL   RECORD. 


[September  if  1894 


%txitws  and  ^otitis  of  §0joks* 

An  American  Text-Book  of  the  Diseases  of  Chil- 
dren.    Including  Special  Chapters  on  Essential  Sur- 
gical Subjects :  Diseases  of  the  Eye,  Ear,  Nose,  and 
Throat ;  Diseases  of  the  Skin ;  on  the  Diet,  Hygiene, 
and  General  Management  of  Children.     By  American 
Teachers.     Edited  by  Louis  Starr,  M.D.     Physician 
to  the  Children's  Hospital  and  Consulting  Pediatrist 
to  the  Maternity  Hospital,  Philadelphia.     Assisted  by 
Thompson  S.  Westcott,  M.D.,  Attending  Physician  to 
the  Dispensary  for  Diseases  of  Children,  Hospital  of 
the  University  of  Pennsylvania,  Philadelphia.     W.  B. 
Saunders.     1894. 
This  is  a  comprehensive  treatise  on  a  highly  important 
branch  of  practical  medicine.    The  treatment  of  the  va- 
rious subjects  by  the  sixty-three  contributors  is  very  un- 
even, four  minor  topics  being  unduly  expanded  at  the 
expense  of  more  important  subjects.     Nevertheless  the 
work  will  be  found  useful  as  one  of  reference  for  all  those 
interested  in  pediatrics. 

America  may  well  be  proud  of  her  recent  contribu- 
tions to  the  better  knowledge  of  diseases  of  children, 
and  the  work  before  us  fittingly  attests  the  growing  sig- 
nificance attached  to  this  branch  of  general  medicine. 
The  illustrations  are  in  the  main  good,  and  will  be  found 
especially  helpful  by  those  who  have  not  made  a  special 
study  of  paedology.  The  colored  plates  are,  however, 
exceptionally  poor  and  misleading. 

Dermatologische  Zeitschrift.  Herausgegeben  von 
Dr.  O.  Lassar;  Bd.  I.,  Heft  L  Berlin:  Verlag  von 
S.  Karger.  1894. 
The  first  number  of  this  new  and  promising  skin  journal, 
contains  contributions  from  the  editor,  Dr.  Lassar,  and 
such  other  well-known  men  as  Saalfeld,  Kromayer, 
Joseph,  Unna,  etc.  The  prospectus  for  succeeding  num- 
bers is  so  rich  in  original  articles  that  this  department 
will  prove  of  much  interest  to  dermatologist?. 

A  number  of  fairly  good  illustrations  are  bound  in  at 
the  end  of  the  volume,  making  over  120  pages. 

Zur  Behandlung  der  Lungentuberculose  mittels 
Koch'scher  Injectionen.  Von  Dr.  E.  Thorner, 
Sanitatsrath  in  Berlin.  Berlin:  S.  Karger.  1894. 
This  is  a  brief  history  and  critical  study  of  tuberculin  as 
employed  in  the  treatment  of  pulmonary  tuberculosis. 
The  author  regards  this  substance  as  a  valuable  remedy, 
capable  of  curing  the  disease  in  its  early  stages,  and  of 
bringing  about,  very  marked  improvement  in  more  ad- 
vanced cases.  "  It  is,"  he  says,  "  the  most  important 
remedy  we  have  for  the  treatment  of  tuberculosis,  and  it 
is  the  duty  of  every  physician,  even  if  not  to  employ  the 
remedy  himself,  at  least  to  study  impartially  the  results 
of  its  administration." 

Biography    of   Eminent   American  Physicians   and 
Surgeons.      Edited  by  R.   French  Stone,   M.D., 
author  of  "  Elements  of  Modern  Medicine,"  Surgeon- 
General  National  Guard  State  of  Indiana,  Consulting 
Physician  to  Indianapolis  City  Hospital,  etc.  Royal 
8vo,  pp.  751.     Indianapolis:  Carlan  &  Hollenbeck. 
1894. 
This  work  contains  seven  hundred  and  fifty  double- 
columned  pages  of  biography,  with  photo-engraved  por- 
traits of  hundreds  of  medical  men.    The  editor  has  evi- 
dently done  his  best  to  give  an  impartial  record  of  the 
subjects  treated,  and  due  credit  must  be  accorded  him  for 
honesty  of  purpose  and  purity  of  motive.    It  is  obviously 
impossible  to  make  a  work  ot  this  character  beyond  criti- 
cism.    The  most  difficult  of  all  undertakings  is  to  please 
every  great  man  who  may  be  entitled  to  go  down  in  his- 
tory.    Hence  it  is  generally  prudent  to  wait  until  they 
are  dead  and  cannot  talk  back.   It  is  true  the  world  over 
that  "  many  are  called  but  few  are  chosen,"  but  the  dif- 
ficulty is  in  drawing  the  line  between  the  two.    The  edi- 


tor has  succeeded  fairly  well  in  this  line,  although  a  great 
many  of  the  eminent  men  are  heard  of  for  the  first  time. 
Some  partiality  is  shown  for  immediate  neighbors  in  In- 
dianapolis, but  this  can  be  explained  naturally  by  a  better 
knowledge  of  their  merits  than  those  of  other  eminent 
men  in  larger  cities.  As  must  inevitably  happen  in  the 
best  regulated  family,  wondrous  distinctions  will  thrust 
themselves  upon  general  notice.  In  New  York,  Philadel- 
phia, and  Chicago,  the  selections  are  not  such  as  would 
be  made  by  one  having  a  large  acquaintance  with  medi- 
cal men  of  reputation.  Almost  as  a  rule  the  best  men 
have  the  shortest  notices  and  the  fewest  pictures,  but 
they  have  themselves  to  blame  in  not  furnishing  the  nec- 
essary data.  The  accounts  of  distinguished  deceased 
members  of  the  profession  are  singularly  good,  and  add 
important  and  interesting  chapters  to  the  history  of 
medical  achievements  in  America.  The  photo-engrav- 
ures  are  not  well  printed,  although  the  plates  have  evi- 
dently been  carefully  made.  The  book  will  be  interest- 
ing to  a  wide  circle  of  curious  readers,  but  best  of  all,  will 
furnish  valuable  and  trustworthy  data  for  obituary  no- 
tices. 

The  Etiology  of  Osseous  Deformities  of  the  Head, 
Face,  Jaws,  and  Teeth.  By  Eugene  S.  Talbot, 
M.D.,  D.D.S.,  Professor  Dental  Surgery  Woman's 
Medical  College;  Lecturer  on  Dental  Surgery  and 
Pathology,  Rush  Medical  College,  Chicago,  etc.  Third 
Edition.  8vo,  pp.  484.  Chicago:  The  W.  T. 
Keener  Co.  1894. 
The  third  edition  of  this  interesting  work  represents  a 
revision  and  enlargement  of  the  previous  ones,  and 
is  in  so  much  an  improvement  of  them.  The  new  field 
of  inquiry,  as  to  the  relation  of  deformities  of  head,  face, 
jaws,  and  teeth,  to  those  of  other  foims  of  the  degenerate 
type,  is  discussed  with  singular  clearness,  with  a  pains- 
taking examination  of  scientific  data,  and  with  the  result 
of  formulating  very  instructive,  interesting,  and  valuable 
data  for  the  prosecution  of  this  important  department  of 
anthropology.  It  is  thus  shown  that  the  variations  from 
the  normal  type  of  cranial,  facial,  and  maxillary  develop- 
ments are  in  keeping  with  those  associated  with  asym- 
metry in  other  organs,  and  for  the  most  part  are  depend- 
ent upon  the  like  causes  of  hereditary  taint,  racial 
peculiarities,  climate,  and  environment.  The  subject — 
from  the  focal  point  of  interest,  the  mouth— compasses  a 
wide  range  of  collateral  observations,  proving  a  remark- 
able and  instructive  association  of  these  forms  of  defective 
development  with  those  of  the  brain,  the  nervous  centres, 
the  bones,  and  incidentally  with  the  character,  tempera- 
ment, and  hereditary  proclivities  of  the  individual.  The 
illustrations,  over  four  hundred  in  number,  are  mostly 
original  and  represent  in  an  excellent  and  striking  man- 
ner the  leading  types  discussed.  The  work  as  a  whole  is 
carefully  done,  is  thoroughly  scientific  in  tone,  and  adds 
some  very  important  and  original  data  to  the  literature 
of  an  intensely  interesting  study. 

Prompt  Aid  to  the  Injured.     A  Manual  of  Instruction 
designed  for  Military  and  Civil  Use.     By  Alva  H. 
Doty,  M  D.,  Major  and  Surgeon  of  Ninth  Regiment, 
N.G.S.N.Y.      Second    Edition.      i2mo,    pp.    304. 
New  York  :   D.  Appleton  &  Co.     1894. 
The  second  edition  of  this  useful  manual  has  been  en- 
larged by  a  practical  chapter  on  hygiene,  and  the  addi- 
tion of  the  recently  adopted  drill  regulations  for  the  Am- 
bulance  Corps  of  the  United  States  Aimy.     All  the 
subjects  are  treated  in  a  thoroughly  practical  manner, 
and  the  book  will  prove  indispensable  to  all  who  follow 
camp  life. 

Jahresberichte  Cber  die  Fortschritte  der  Anatomie 
und  Physiologie.  XX.  Band,  Literatem,  1891.  II. 
Abtheilung.  Phvsiologie  mit  General  Register  zu 
Band  XI.-XX.  Leipzig :  Verlag  von  F.  C.  W.  Vogel. 
1893. 

With  the  present  volume  and  its  very  complete  index, 

this  valuable  publication  ceases  to  appear. 


September  i,  1894] 


MEDICAL  RECORD. 


27; 


Department  of  the  Interior,  Census  Office. — Vital 
Statistics  of  New  York  and  Brooklyn,  Covering  the  Pe- 
riod of  Six  Years  ending  May  30,  1890.  By  John  S. 
Billings,  Surgeon  United  States  Army,  Expert  Spe- 
cial Agent.  Quarto,  pp.  529.  Washington,  D.  C.  1894. 
This  exhaustive  report  presents  a  number  of  interesting 
features  which  are  quite  novel  in  the  line  of  census  work, 
notably  such  as  the  subdivision  of  the  city  into  sanitary 
districts,  and  the  analyzation  of  the  immediate  surround- 
ings of  stated  conditions  upon  the  death  rates  of  differ- 
ent races  and  classes  of  people.  The  influence  of  hered- 
ity, as  derived  from  the  mother  is  also  shown.  Aside 
from  an  almost  bewildering  array  of  figures,  their  analy- 
sis as  bearing  upon  the  conditions  and  influences  named, 
a  number  of  finely  executed  full-paged  maps  of  New  York 
and  Brooklyn,  are  given,  with  the  subdivision  of  sanitary 
districts  proportionately  shaded  to  illustrate  the  different 
degrees  of  death-rate  from  different  diseases,  accidents, 
suicides,  etc.  Age  appears  to  be  one  of  the  most  im- 
portant factors.  Deaths  of  the  very  young  and  very  old 
take  the  lead.  Of  the  male  population  in  both  cities  over 
fifteen,  over  one  half  are  married.  The  death-rate  was 
greatest  in  the  widowed  and  least  among  the  single. 
The  death  rate  of  consumption  was  nearly  equal  in  both 
sexes,  being  most  fatal  among  the  accountants  and  clerks, 
dressmakers  and  seamstresses,  while  suicide  was  most  fre- 
quent among  the  school  teachers  in  New  York.  Statis- 
tics are  also  presented  of  all  other  diseases  in  their  varied 
and  complex  relations,  affording  an  amount  of  instructive 
and  valuable  information  which  reflects  the  highest  credit 
upon  the  minute  and  painstaking  methods  of  the  talent- 
ed and  accomplished  compiler.  The  work  can  be  stud- 
ied with  the  greatest  profit  by  the  sanitarian  and  econo- 
mist. 

Hydatid  Disease,  Vol.  II.    By  the  late  John  Davies 
Thomas,  M.D.     (London),  F.R.C.S.  Eng.,  etc.    Ed- 
ited by  Alfred  Austin  Lendon,  M  D.     (London), 
Lecturer  on  Forensic  Medical  and  Clinical  Medicine, 
University  of  Adelaide.     8vo,   pp.    166.     London : 
Bailltere,  Tindall  &  Cox.     1894. 
This  volume  consists  of  a  collection  of  papers  on  hy- 
datid disease  by  the  late  Dr.  Thomas,  and  presents  a  well- 
arranged  account  of  the  affection  as  related  to  the  ab- 
dominal organs,  thoracic  viscera,  nervous  system,  bones, 
muscles,  etc.     The  clinical  phenomena  are  also  clearly 
presented,  and  the  treatment  by  operative  procedure  is 
clearly  detailed.     The  first  volume  of  the  series  was  the 
introductory  one  by  the  editor,  while  the  present  one 
contains  wholly  the  views  of  Dr.  Thomas. 

Transactions  of  the  Fifteenth  Annual  Meeting  of 

the  American  Laryngological  Association,  held  in 

New  York,  May,  1893.     8vo,  pp.  165.     New  York  : 

D.  Appleton  &  Co.     1894. 

This  volume  contains  much  that  is  interesting  to  the 

laryngologists.    The  papers  of  Dr.  Delavan  on  neglect  in 

reporting  cancer  operations,  of  Dr.  Lefferts  on  intubation 

in  the  adult,  of  Dr.  Lincoln  on  recurrence  at  a  new  site 

of  a  laryngeal  growth,  and  of  Dr.  Jonathan  Wright  on 

the  structure  of  oedematous  nasal  polypi,  are  worthy  of 

special  note. 

Manual  of  Practical  Anatomy,  in  Two  Volumes.     By 
D.  J.  Cunningham,  M.D.,  Professor  of  Anatomy,  Uni- 
versity of  Dublin.     Edinburgh  and  London  :  Young 
J.   Pentland.     i2mo,  pp.    647.     Philadelphia:  J.  B. 
Lippincott. 
This  is  a  well-arranged,  carefully  written,  and  well  il- 
lustrated work  on  practical  anatomy.     The  author  proves 
himself  to  be  a  good  teacher  in  his  very  natural  method, 
and  in  the  thorough  appreciation  of  the  wants  of  the  stu- 
dent.    In  many  parts  of  the  work  will  be  found  most 
valuable  suggestions  for  an  easier  and  more  direct  man- 
ner of  study  than  is  usual  with  works  of  its  kind.     Much 
attention  is  deservedly  given  to  topographical  anatomy, 
particularly  as  applied  to  the  abdominal  organs.     Many 
of  the  illustrations  are  entirely  new,  while  all  are  good 


and  to  the  point.  It  is  exceedingly  difficult  to  give  any- 
thing strikingly  new  in  a  dissection  manual,  but  the 
author  has  done  a  good  part  in  infusing  an  individuality 
in  the  work  which  will  commend  itself  to  the  reader. 

Braithwaite's  Retrospect,  Vol.  CIX.,  January  to  June, 

1894. 
This  well-known  volume  contains  the  usual  amount  of 
valuable  selections  for  reference  which  have  given  it  such 
a  well-deserved  reputation  among  students  and  practi- 
tioners. 

A  Retrospect  of  Surgery,  January,  1890,  to  January 
1894.    Prepared  by  Francis  J.  Shepherd,  M.D. ,  CM., 
Surgeon  to  the  Montreal  General  Hospital.     8vo,  pp. 
259.     Montreal. 
This  is  a  little  book  of  abstracts  of  the  progress  of  sur- 
gery, reprinted  from  the  Montreal  Medical  Journal,  and 
contains  a  fair  selection  of  the  notable  things  done  in 
that  line  during  the  past  four  years. 

Die  neuesten  Untersuchungen  Ober  die  Patholog- 

ische  Anatomie  und  Physiologie  der  Tabes  Dor- 

salis.      Zwei  Vortrage,  von   E.    Leyden.      Berlin. 

1894. 

This  is  a  small  monograph  written  to  show  that  the 

author,  first  and  many  years  ago,  demonstrated  the  initial 

lesion  of  tabes  to  be  in  the  posterior  spinal  roots.     This 

is  getting  to  be  the  modern  view,  but  it  is  not  yet  entirely 

proven  to  be  the  true  one. 

Lehrbuch  der  Nervenkrankheiten  fOr  Aerzte  und 
Studirende,  von  Professor  Dr.  H.  Oppenheim,  mit 
220  Abbildungen.  Pp.  870.  Berlin  :  Verlag  von  S. 
Karger.  1894. 
The  reputation  of  Professor  Oppenheim  as  a  careful  ob- 
server and  writer,  and  his  long  experience  in  Charity 
wards  and  the  clinics  of  Berlin,  lead  one  to  expect  a 
valuable  treatise  from  him.  There  are  a  good  many 
treatises  on  nervous  diseases  now,  each  having  some 
special  merits.  Perhaps  the  special  merit  of  Oppen- 
heim's  is  the  care  and  detail  which  are  given  to  the 
interesting  but  relatively  rare  diseases.  Thus  syringo- 
myelia gets  nearly  as  much  space  as  cerebral  hemorrhage. 
Brain  parasites  and  sinus  thrombosis  get  more  than 
myelitis.  The  chapters  on  cerebral  syphilis  and  loco- 
motor ataxia  are  particularly  good. 

Turning  to  the  practical  side,  we  find  absolutely  no 
new  suggestions  or  helpful  advice.  For  epilepsy,  neu- 
ralgia, tabes,  etc.,  the  same  list  of  drugs,  the  same  ad- 
vice about  diet,  baths,  and  potash  is  given.  The  author 
shows  himself  keenly  alert  to  every  clinical  phenomenon 
or  pathological  process,  but  he  does  not  take  %  human 
and  curative  interest.  This  is  the  Teutonic  way,  and 
Americans  who  do  like  to  help  their  patients  as  well  as 
to  make  a  local  and  pathological  diagnosis,  are  accused 
of  being  shallow  and  credulous.  Despite  of  our  criticism 
in  this  respect,  however,  we  do  not  hesitate  to  say  that 
Oppenheim's  work  is  the  most  systematic  treatise  which 
any  German  has  written  since  the  ancient  days  of  Rom- 
berg.    It  is  well  and  copiously  illustrated. 

Les  Nouvelles  Id£es  sur  la  Structure  du  Syst£me  ner- 
veux  chez  l'Homme  et  chez  les  Vert£br£s.     Par 
le    Dr.   S.   R.   Cajal.     Edition  fran^aise  revue  et 
augments  par  l'auteur.     Traduite  de  l'espagnol  par 
le  Dr.  L.  Azoulay,  Preface  de  M.  Mathias  Duval.   Avec 
49    figures   dans    le  texte.     Small  8vo.      Pp.    200. 
Paris  :  C.  Reinwald  et  Cie.     1894. 
Professor  Cajal' s  name  is  identified  with  some  of  the 
most  important  of  the  recent  advances  in  the  anatomy  of 
the  nervous  system  obtained  by  the  application  of  me- 
tallic stains.     Cajal  himself  is  one  of  the  very  few  mod- 
ern   Spaniards    who    have    obtained  an    international 
reputation.     No  one  could  better  present  the  new  ideas 
of  the  structure  of  the  nervous  system,  and  the  present 
work  fulfils  its  purpose  admirably,  being  clear  and  ex- 
plicit without  being  cumbersome.      The  author  adds 
descriptions  of  various  new  methods  of  staining. 


278 


MEDICAL   RECORD. 


[September  I,  1894 


£0ci*tg  Reports. 


THE  BRITISH  MEDICAL  ASSOCIATION. 

Sixty-second  Annual  Meeting,  held  at  Bristol,  July  ji 
to  August  4,  1894. 

Special  Report  for  the  Medical  Rkcoka. 
(Continued  from  page  351.) 

SECTION   OF  OBSTETRIC  MEDICINE  AND  GYNECOL- 
.     OGY. 

First  Day,  Wednesday,  August  ist. 

Dr.  J.  G.  Swayne,  the  President,  delivered  a  short  in- 
troductory address.  He  reviewed,  historically,  previous 
meetings  of  the  Association  at  Bristol,  and  referred  to  his 
address  in  1883,  when  he  insisted  on  the  importance  of 
midwifery,  and  that  it  should  stand  next  to  medicine  and 
surgery,  and  not  be  considered  a  specialty.  Since  then  a 
new  race  of  gynecologists  and  abdominal  operators  had 
sprung  up. 

He  drew  attention  to  the  fact  that  medicine  and  sur- 
gery formed  the  subject  of  an  address  each  year,  but  that 
obstetric  medicine  only  occasionally  did  so,  and  thought 
that  that  was  wrong. 

Induced  Labor  in  the  Absence  of  Dystocia. — Dr. 
Robert  Barnes,  of  London,  opened  a  discussion  on 
"  The  Necessity  of  Inducing  Labor  in  Certain  Con- 
ditions of  the  Mothers  not  Obstructing  Delivery."  He 
said  that  as  medical  science  advanced  this  was  a  matter 
which  needed  revision.  We  should  study  the  methods 
of  nature  in  adopting  this  means  of  relief;  the  safety  of 
the  mother  should  be  our  first  consideration,  and  of  the 
child  the  second,  but  frequently  the  two  conditions  ran 
together. 

The  duty  of  the  physician  when  the  pregnant  woman 
was  in  difficulty  was  to  consider  the  means  of  safety  for 
both  mother  and  child,  and  no  problem  in  medicine  was 
more  difficult. 

The  most  remarkable  phenomena  of  pregnancy  were 
increase  in  the  excitability  of  the  nervous  system  and  in- 
crease in  the  blood  and  in  the  blood-pressure.  We  must 
recognize  that  the  struggle  between  pregnancy  and  the 
coexisting  disease  was  strictly  physiological. 

We  must  keep  a  strict  watch  over  each  organ,  but  be 
careful  not  to  press  expectant  treatment  too  far.  Sev- 
eral of  the  conditions  were  those  which  attended  exces- 
sive nerve  tension,  and  were  of  a  convulsive  character,  of 
these  the  first  one  was  vomiting ;  this  was  like  other  con- 
vulsive attacks  and  tended  to  be  rendered  chronic,  each 
attack  helping  to  graft  a  habit  of  vomiting. 

Vomirmg,  in  his  experience,  was  most  severe  in  cases 
where  there  was  nerve  shock  or  depression ;  rapid  disin- 
tegration of  tissue  followed  persistent  vomiting,  and  this 
tended  to  cause  a  condition  of  toxaemia,  ending  in  coma 
and  death.  Vomiting  may  throw  excessive  strain  on  the 
brain  and  cause  cerebral  hemorrhage.  When  rapid  ema- 
ciation with  toxaemic  symptoms  occurs,  the  induction 
of  labor  may  .prove  too  late.  In  cases  in  which  the 
vomiting  is  due  to  excessive  distention  of  the  uterus, 
labor  should  be  induced  early. 

Tetanus  was  a  strong  indication  for  the  induction  of 
labor.  In  chorea  he  thought  that  pregnancy  should  be 
terminated,  and,  as  a  general  rule,  one  should  not  allow 
pregnancy  in  any  convulsive  disorder  to  continue.  In 
insanity  he  would  induce  labor,  though  Dr.  Savage  was 
of  a  different  opinion. 

Vascular  disorders,  the  excessive  blood  pressure  found 
in  pregnancy,  was  sometimes  relieved  by  external  hem- 
orrhage as  epistaxis,  by  serous  effusion,  or  by  vomiting, 
throwing  off  some  fluid,  or  by  dropsical  effusion,  or  might 
result  in  cerebral  hemorrhage.  For  the  excessive  blood- 
pressure  we  should  purge,  and  in  some  cases  venesection 
was  strongly  indicated,  and,  as  a  last  resource,  we  might 
induce  labor. 

Extreme  anaemia  might  render  induction  necessary,  or 
it  might  be  required  when  valvular  disease  of  the  heart 


or  aneurism  was  present.  We  should  carefully  watch 
these  cases  and  induce  labor  when  distress  supervened. 
He  believed  that  pregnancy  aggravated  phthisis,  but  the 
question  of  inducing  labor  was  a  difficult  one.  When 
tumors  coexisted,  as  a  general  rule  it  was  safer  to  let 
pregnancy  go  on.  Repeated  labors  with  a  dead  child 
suggested  the  bringing  on  of  labor  in  a  succeeding  one 
before  death  occurred,  and  he  believed  that  carrying  a 
dead  child  was  injurious  to  a  woman.  In  scarlet  fever 
he  would  induce  labor  if  albuminuria  were  present. 

In  conclusion,  he  would  urge  the  rule  laid  down  by 
Denman,  never  to  perform  the  operation  without  a  con- 
sultation beforehand. 

The  President  said  that  in  an  experience  of  fifty-two 
years  he  had  induced  labor  37  times ;  in  24  of  these 
cases  it  was  done  for  contracted  pelvis.  In  the  re- 
maining 13,  5  times  for  persistent  vomiting,  3  for  ana- 
sarca and  albuminuria,  2  for  hydramnios,  1  for  vaginal 
hemorrhage,  1  for  severe  irritability  of  bladder,  1  for  dis- 
eased placenta. 

Dr.  More  Madden,  of  Dublin,  said  that  where  the 
child  had  died  in  previous  pregnancies  he  would  induce 
labor  as  early  as  the  sixth  month,  and  he  believed  that 
at  that  time  the  child  would  be  viable.  As  regards 
method,  he  preferred  that  of  dilating  the  cervix  by  the 
ringer. 

Dr.  Murphy,  of  Sunderland,  thought  the  most  fre- 
quent of  the  cases  under  discussion  were  those  of  grave 
albuminuria.  As  regards  method,  where  no  hurry,  he 
would  rupture  the  membranes;  where  rapid  delivery  was 
required,  he  would  use  Barnes's  bags.  Where  the  bag 
could  not  be  introduced  he  would  start  with  a  lent. 

Dr.  Murdoch  Cameron,  of  Glasgow,  would  take  ex- 
ception to  the  induction  of  labor  in  fevers.  With  re- 
spect to  uterine  tumors  he  would  not  be  inclined  to  in- 
terfere, unless  the  tumor  were  likely  to  obstruct  labor. 
You  may  remove  the  tumor  without  interfering  with  the 
pregnancy.  He  did  not  think  the  child  was  viable  before 
the  seventh  month,  and  the  nearer  the  eighth  month  the 
labor  was  induced,  the  better.  In  ascites  it  was  some- 
times necessary  to  induce  labor.  In  hemorrhage  and 
eclampsia  he  had  no  hesitation  in  inducing  it,  although 
some  were  still  disinclined  to  induce  it  in  eclampsia. 
He  thought  some  cases  of  violent  vomiting  were  lost  by 
delay. 

Dr.  Heywood  Smith,  of  London,  would  not  induce 
labor  in  cases  of  fibroid  tumor. 

Mr.  J.  W.  Taylor,  of  Birmingham,  called  attention  to 
cases  of  dropsy  and  albuminuria  before  the  child  was  via- 
ble, and  thought  that  these  were  the  cases  in  which  it 
was  most  desirable  to  have  some  settled  rule  laid  down. 

Dr.  Massey,  of  Bournemouth,  related  a  case  of  severe 
dropsy  in  which  he  had  induced  labor  by  passing  a  cath- 
eter between  the  membranes  and  uterine  wall  with  good 
result. 

Dr.  Byers,  of  Belfast,  agreed  in  inducing  labor  in 
cases  of  vomiting  which  persisted  in  spite  of  treatment, 
but  thought  that  all  were  not  agreed  that,  given  albu- 
minuria in  pregnancy,  induction  cf  labor  should  be  de- 
cided upon. 

He  related  three  cases  of  primiparae  all  with  albuminuria 
and  dropsy :  1.  Dead  foetus,  no  interference,  good  re- 
covery ;  he  did  not  interfere  because  the  foetus  was  dead 
and  there  was  no  high-tension  pulse.  2.  Primipara, 
sixth  month,  one- fourth  col.  albumin,  no  high-tension 
pulse,  no  marked  oedema;  treated  by  warm  baths  and 
milk  diet;  living  child  at  term;  good  recovery.  3. 
Much  headache,  high-tension  pulse,  labor  induced. 

Cases  like  the  third  were  more  troublesome  because 
eclampsia  was  likely  to  follow.  Recently  Smyly,  at  the 
Rotunda,  had  found  that  in  a  large  number  of  cases  of 
eclampsia  equally  good  results  were  obtained  by  leaving 
pregnancy  alone  and  injecting  morphia  hypodermically. 

Dr.  Wright,  of  Leeds,  had  in  one  case  been  obliged 
to  induce  labor  for  severe  ptyalism.  In  ovarian  tumors 
would  remove  tumor  and  leave  pregnancy.  Would  use 
solid  bougie  instead  of  catheter. 


September  i,  1894] 


MEDICAL    RECORD. 


279 


Dr.  Aust  Lawrence,  of  Bristol,  urged  necessity  of 
first  inquiring  if  vomiting  were  due  to  any  other  cause ; 
had  seen  cases  in  which  it  was  due  to  acute  yellow 
atrophy  of  liver.  Urged  importance  of  giving  a  good 
trial  of  other  treatment,  especially  of  moral  suasion ; 
would  be  very  chary  of  inducing  labor  in  fever. 

Dr.  Tweedy,  of  Dublin,  said  that  in  the  Rotunda  Hos- 
pital the  induction  of  labor  was  looked  upon  as  a  danger- 
ous proceeding  only  to  be  resorted  to  in  extreme  cases, 
and  it  was  seldom  done  except  for  contracted  pelvis. 

Recently  a  woman  was  admitted  with  fibroid  tumors  at 
the  seventh  month ;  a  Porro's  operation  was  done  at  term. 
He  believed  that  in  only  two  per  cent,  of  cases  of  albu- 
minuria did  eclampsia  follow,  and  they  did  not  induce 
labor  at  the  Rotunda  in  cases  of  eclampsia  in  pregnancy, 
but  treated  the  condition  by  hypodermic  injection  of 
morphia,  one-half  grain  every  half  hour,  with  very  good 
results. 

He  had  never  seen  a  case  of  death  from  vomiting  in 
pregnancy.  In  ovarian  tumor  in  pregnancy  he  would 
open  abdomen  and  remove  tumors. 

Dr.  M.  A.  Scharlieb,  of  London,  had  twice  done  ova- 
riotomy in  pregnancy  with  good  results. 

Dr.  Boxall,  of  London,  had  induced  labor  in  one  case, 
because  of  varicose  veins  in  vulva  which  threatened  to 
burst  Would  be  very  diffident  in  interfering  in  cases 
where  fibroid  tumor  complicated  pregnancy. 

Dr.  Pearse,  of  Southsea,  thought  that  a  mistake  was 
often  made  in  waiting  for  a  viable  child,  and  that  the 
condition  of  the  mother  should  alone  decide  the  neces- 
sity. 

Dr.  Barnes,  in  reply,  said  that  he  had  seen  cases  of 
vomiting  prove  fatal.  As  regarded  method,  preferred 
bougie  to  catheter.  He  did  not  think  digital  dilatation  de- 
sirable. There  was  no  class  of  cases  in  which  the  indue- 
tion  of  labor  was  always  necessary,  and  he  did  not  advo- 
cate it  in  all  cases  of  albuminuria.  In  convulsions,  he 
thought  inhalation  of  nitrite  of  amyl  the  best  treatment. 
He  would  retract  now  an  opinion  he  expressed  years  ago, 
and  would  say  that  when  there  was  ovarian  tumor  and 
pregnancy,  you  should  remove  the  tumor  and  not  the 
pregnancy. 

Uterine  Fibroids. — Dr.  M.  A.  Scharlieb,  of  London, 
then  read  a  paper  on  "  The  Treatment  of  Uterine  Myo- 
mata." She  gave  an  account  of  the  operative  proceed- 
ings in  nineteen  cases.  In  six  she  removed  the  appen- 
dages, and  all  recovered.  In  thirteen  she  removed  uterine 
tumor  and  appendages,  and  two  proved  fatal.  In  one 
she  removed  tumor  only.  In  the  first  six  cases  she 
removed  the  tubes  as  close  to  the  cornua  as  she  could. 

In  the  cases  of  hysterectomy  she  first  ligated  the  bread 
ligaments  outside  the  appendages,  then  ligated  the  uter- 
ine artery.  She  made  flaps  of  the  peritoneum  on  ante- 
rior and  posterior  surfaces  of  uterus,  and  she  carefully 
disinfected  the  cervix  with  pure  phenol.  She  closed  the 
abdominal  wall  with  three  separate  layers  of  stitches. 
In  four  she  used  a  temporary  elastic  ligature,  and  in  all 
these  she  drained.  In  the  remainder  she  tied  all  bleed- 
ing points  and  did  not  drain. 

The  lessons  she  drew  were :  First,  the  importance  ot 
thorough  surgical  cleanliness. 

In  her  cases  the  patient  had  repeated  hot  baths  first, 
then  the  skin  was  disinfected  by  washing  with  soap  and 
water,  alcohol,  solution  of  permanganate  of  potash,  fol- 
lowed by  oxalic  acid.  Then  1  to  2, coo  corrosive  subli- 
mate, and  lastly  a  carbolic  compress  was  left  on  for 
twenty  four  hours.  The  clothes  worn  by  the  patient 
were  also  sterilized.  The  operator  and  assistants 
cleansed  their  arms  and  hands  in  the  same  way  as  the 
patient's  abdomen  was  done,  and  wore  sterilized  linen 
overalls.  The  instruments  were  boiled  and  laid  in  1  to 
20  carbolic,  which  was  diluted  with  boiling  water  at  the 
time  of  operation,  and  they  were  put  down  during  opera- 
tion in  a  shallow  dish  containing  carbolic.  The  sponges 
were  cleansed  with  sulphurous  acid  and  kept  in  carbolic. 

The  second  lesson  to  be  learnt  was  the  importance  of 
handling  the  peritoneum  as  little  as  possible ;  she  did  not 


believe  in  sponging  or  mopping  the  peritoneum,  and 
thought  that  doing  so  encouraged  hemorrhage.  She 
avoided  the  temporary  elastic  ligature  as  much  as  possible, 
because  she  thought  that  there  was  more  oozing  after- 
ward.   She  avoided  drainage  as  much  as  possible. 

The  third  lesson  was  to  tie  the  arteries,  both  uterine 
and  ovarian,  carefully ;  and  the  fourth,  to  treat  the  stump 
intra  peritoneally. 

In  all  cases  there  was  no  sepsis,  and  the  two  which 
proved  fatal  died  from  shock.  She  did  not  leave  a  lig- 
ature on  the  stump;  because  it  caused  death  of  tissue. 
She  drew  attention  to  the  fact  that  only  one  of  the  cases 
was  the  mother  of  children,  the  remainder  being  unmar- 
ried or  sterile. 

Resection  of  the  Uterus. — Dr.  J.  Stuart  Nairne  read 
a  paper  on  "  Resection  of  the  Uterus  for  Fibroid  Tumors 
and  other  Diseases."  He  pointed  out  that  removing 
the  appendages  did  not  always  restore  to  health,  that 
enucleation  of  the  tumor  per  vaginam  or  by  abdominal 
incision  was  dangerous  and  the  results  not  always  satis- 
factory. He  would  propose  what  he  called  resection, 
namely,  to  split  the  uterus,  remove  the  tumor,  and  stitch 
the  remains  of  the  uterus  together,  tying  the  vessels  as 
he  met  with  them.  He  had  treated  three  cases  in  that 
way,  they  had  recovered  and  one  had  since  had  a  child. 

Extirpation  of  the  Uterus  for  Myomata. —Dr.  Smyly, 
of  Dublin,  read  a  paper  on  "  Total  Extirpation  of  the 
Myomatous  Uterus. ' '  He  said  that  the  treatment  of  uter- 
ine myoma  was  still  one  of  the  burning  questions  of  the 
day,  but  that  he  in  this  paper  would  deal  only  with  the 
last  resource  ot  surgery.  He  would  advise,  however,  that 
those  who  were  beginning  to  do  hysterectomy  should 
adopt  the  extra  peritoneal  treatment  of  the  pedicle ;  this 
was  the  only  method  he  adopted  up  to  1892,  since  then 
he  had  only  done  one  case  in  that  way.  What  he  did 
now  was  to  perform  total  extirpation  in  one  of  three 
ways :  By  abdominal  section,  per  vaginam,  by  a  combi- 
nation of  the  two,  or  the  "  mixed  method."  The  dangers 
of  hysterectomy  depended  on  the  stump,  and  by  adopting 
this  method  these  dangers  were  removed.  He  had  done 
fifteen  cases  with  two  deaths.  By  the  mixed  methed, 
eleven  cases  with  one  death.  By  the  abdominal  method, 
two  cases  with  one  death.  By  the  vaginal  methed,  cne 
case,  no  death.  Some  very  large  tumors  among  them. 
One  where  the  uterus  was  as  large  as  a  full*  term  preg- 
nancy and  contained  several  myomata  was  removed  in 
this  way.  He  opened  the  abdomen,  ligatured  the  broad 
ligaments,  then  divided  the  pouch  of  Douglas,  and  lastly 
separated  uterus  from  bladder. 

In  small  tumors  he  had  removed  the  uterus  per  vaginam 
by  morcellement,  and  in  one  case  the  fragments  weighed 
two  and  a  half  pounds;  for  two  days  beforehand  the 
vagina  was  packed  with  antiseptic  gauze,  patient  was 
placed  in  lithotomy  position,  and  cervix  drawn  down  and 
separated  from  bladder.  Pouch  of  Douglas  then  opened 
and  cervix  cut  away,  and  then  uterus  attacked. 

Dr.  Heywood  Smith,  of  London,  congratulated  Mrs. 
Scharlieb  on  her  success;  he  thought  that  soon  all  cases 
would  be  treated  by  the  intra  peritoneal  method  or  by 
complete  extirpation.  Vaginal .  hysterectomy  showed  a 
less  mortality  than  any  other  method,  but  the  best  way 
of  dealing  with  these  tumors  was  not  yet  determined. 

Dr.  Rabagliati,  of  Bradford,  related  a  case  in  which 
a  large  fibroid  disappeared  after  pregnancy,  and  thought 
that  now  too  much  attention  was  directed  to  surgical 
treatment,  and  too  little  to  dietetic  and  medicinal. 

Dr.  Cullingworth,  of  London,  drew  attention  to  the 
extreme  care  which  Mrs.  Scharlieb  paid  to  the  prevention 
of  sepsis,  and  said  that  the  method  resembled  that 
adopted  in  the  Johns  Hopkins  University  Hospital,  as 
published  by  Dr.  Howard  Kelly ;  and  the  same  precau- 
tions had  been  adopted  in  a  maternity  at  Clapham,  car- 
ried on  by  ladies,  with  excellent  results.  He  complained 
that  there  were  not  sufficient  statistics  at  present  to  en- 
able one  to  decide  whether  hysterectomy  was  justifiable 
or  not,  and  that  what  we  really  want  is  an  authentic  his- 
tory of  a  number  of  cases  not  treated  surgically ;  opera 


280 


MEDICAL  RECORD. 


[September  i,  1894 


tions  were  more  frequent  now  because  we  know  that  these 
tumors  sometimes  kill,  but  many  disappear  without 
operation. 

Dr.  Travers,  of  London,  thought  that  cases  after 
hysterectomy  were  never  so  well  able  to  work  for  their 
living  as  after  other  abdominal  operations. 

Dr.  Aust  Lawrence,  of  Bristol,  thought  that  the  sta- 
tion of  life  of  the  patient  often  determined  the  treatment. 
Thus  hysterectomy  was  required  in  the  poor  woman, 
whereas  a  well  to  do  one  who  could  lay  up  might  avoid 
the  operation. 

Dr.  Barnes,  of  London,  would  like  an  authoritative 
opinion  as  to  whether  a  fibroid  tumor  ever  killed,  as  it  had 
recently  been  stated  by  a  prominent  London  physician 
that  they  never  did  so. 

Mrs.  Scharlieb,  in  reply,  said  that  one  seldom  found 
the  appendages  healthy  in  cases  of  myoma;  in  nearly  all 
her  cases  the  ovaries  were  enlarged  and  cystic.  The 
question  of  removal  of  the  appendages  of  the  tumor  de- 
pended on  the  nature  of  the  growth.  Thus  in  large, 
smooth,  uninodular  tumors  removing  the  appendages  did 
not  check  the  growth ;  also  multinodular  tumors,  when  of 
large  size,  needed  the  major  operation,  though  in  two  or 
three  of  her  cases  the  electrical  treatment  had  been  used 
and  had  proved  futile.  She  thought  that  there  was  no 
doubt  that  fibroids  did  sometimes  kill  by  the  hemorrhage 
and  pain,  or  by  pressure  on  the  ureters.  Her  patients 
had  been  able  to  return  to  hard  work  after  the  operation! 
and  no  hernia  had  resulted  in  any  of  her  cases. 


Second  Day,  Thursday,  August  2D. 

Hemorrhage  in  Late  Pregnancy. — Dr.  Smyly,  ot 
Dublin,  opened  a  discussion  on  "The  Treatment  of 
Hemorrhage  during  the  last  Two  Months  of  Pregnancy." 
He  said  that  in  the  great  majority  of  cases  this  was  due  to 
separation  of  the  placenta ;  the  uterus  was  divided  into 
two  distinct  portions,  and  this  difference  which  existed  in 
pregnancy  was  most  apparent  after  parturition.  The 
upper  thick  portion  received  its  blood-supply  directly  from 
the  uterine  and  ovarian  arteries,  and  the  lower  thinned 
portion,  to  which  the  blood  vessels  passed,  from  the  upper 
segment.  The  limiting  line  was  called  the  retraction 
ring ;  the  placenta  was  sometimes  situated  in  the  lower 
segment,  bat  wherever  its  situation  premature  separation 
of  it  caused  hemorrhage.  It  was  not  possible  always  to 
draw  a  line  between  accidental  and  unavoidable  hemor- 
rhage. 

Placenta  praevia  occurred  in  women  who  had  borne 
several  children  rapidly,  also  in  connection  with  an  en- 
larged and  diseased  uterus.  The  placenta  was  seldom 
normal  in  these  cases.  It  was  thinned.  There  were  often 
spaces  in  which  its  tissue  was  deficient,  and  placenta 
succenturiata  occurred.  He  thought  that  an  abnor- 
mally low  attachment  of  the  placenta  might  be  attributed 
to  four  causes :  1.  When  there  was  a  very  large  placenta 
which  could  not  find  room  in  the  uterus.  2.  When  the 
uterine  walls  were  concave  inward,  instead  of  convex,  as 
they  should  be,  and  there  was  an  actual  instead  of  a  po- 
tential cavity.  3.  The  stretching  of  the  cilia  in  endome- 
tritis. 4.  The  placenta  being  developed  from  decidua 
reflexa. 

The  diagnosis  was  made  from  the  hemorrhage  and 
from  feeling  the  placenta.  He  did  not  believe  that  aus- 
cultation was  of  any  value  for  diagnostic  purposes.  The 
hemorrhage  before  labor  may  be  due  to  a  disproportion 
between  the  placenta  and  the  area  of  its  site.  Hemor- 
rhage during  labor  was  due  to  the  distention  of  the 
lower  uterine  segment,  and  its  being  drawn  up  by  the 
action  of  the  longitudinal  fibres,  and  the  detachment  of 
the  placenta  miy  cease  with  the  rupture  of  the  mem- 
branes. 

Treatment. — In  almost  all  cases  the  os  will  admit  two 
fingers  ;  if  so,  bring  down  a  leg  and  then  leave  the  case 
to  nature.  If  further  hemorrhage  occurs,  gentle  pulling 
on  the  leg  will  arrest  it.  There  were  two  conditions  in 
which  this  treatment  was  inapplicable :  1.  When  the  os 


would  not  admit  the  finger ;  in  these  he  would  plug  the 
vagina.  2.  When  the  labor  was  advanced  and  turning 
impossible.  In  these  he  would  rupture  the  membranes. 
He  did  not  recommend  any  other  methods,  and  disap- 
proved of  accouchement  forc£  and  separation  of  the  pla- 
centa by  the  finger.  The  method  which  was  common  was 
bad,  viz.,  to  plug  the  vagina  until  the  whole  hand  could 
be  introduced,  and  then  to  do  internal  version.  This  was 
attended  by  many  dangers,  among  which  he  would 
mention  sepsis,  entrance  of  air  into  veins  causing  sudden 
death,  and  laceration  of  the  cervix. 

The  mortality  of  the  method  he  had  described  had 
been  seven  per  cent.  Of  twenty  cases  lately  treated  two 
had  died. 

Accidental  Hemorrhage. — He  did  not  think  that  an 
accident  would  cause  separation  of  a  healthy  placenta. 
The  commonest  cause  of  this  condition  was  disease  of  the 
endometrium,  and  this  was  frequently  associated  with 
syphilis  and  renal  disease.  The  blood  vessels  were  dis- 
eased and  caused  hemorrhage,  and  this  went  on  if  the 
blood  had  not  free  escape  until  the  pressure  to  which  it 
was  subjected  equalled  the  blood-pressure  in  the  maternal 
vessels.  He  thought  that  concealed  accidental  hemor- 
rhage was  due  to  some  disease  of  the  uterine  wall,  which 
rendered  it  unable  to  resist  the  pressure  of  the  effused 
blood,  and  on  that  account  he  looked  upon  it  as  danger- 
ous because  it  always  betokened  a  diseased  atonic  uterus. 
Treatment  — It  was  impossible  to  lay  down  a  routine 
treatment,  and  he  thought  that  the  importance  of  ruptur- 
ing the  membranes  had  been  overestimated,  and  this  was 
only  useful  when  labor  was  somewhat  advanced.  Some 
cases  required  nothing  to  be  done.  When  the  os  was 
small  he  thought  that  rupturing  was  bad,  as  it  reduced  the 
pressure  in  the  uterus  and  so  favored  further  hemorrhage. 
It  does  not  always  induce  pains,  and  so  blood  flowed  into 
the  partially  emptied  uterus.  It  is  better  in  severe  cases 
to  combat  shock,  and  where  blood  is  escaping  from  the 
uterus  to  use  vaginal  douches  of  hot  water,  followed  by  a 
vaginal  tampon.  He  did  not  think  that  the  tampon 
favored  concealed  hemorrhage.  After  rupturing  the 
membranes  he  would  never  use  tampons.  In  very  bad 
cases  he  believed  that  Porro's  operation  would  be  better 
than  accouchement  ford. 

He  epitomized  his  treatment  thus :  When  os  small,  pre- 
serve membranes;  when  hemorrhage  appeared  exter- 
nally, plug ;  when  labor  advanced,  rupture  membranes 
and  deliver  by  the  best  method  possible. 

Dr.  Robert  Barnes,  of  London,  believed  that  disease 
of  the  uterus  was  the  most  common  cause  of  hemorrhages  ; 
but  that  disease  of  the  placenta  was  also  a  cause.  In 
placenta  praevia  he  would  not  use  accouchement  forc6. 
He  described  the  retraction  ring  long  before  Bandl.  He 
looked  upon  placenta  praevia  as  resembling  ectopic  ges- 
tation, in  that  the  placenta  was  fixed  to  a  part  which  was 
not  adapted  to  receive  it.  When  the  os  was  small  he 
used  his  own  bags.  He  always  preferred  forceps  to  ver- 
sion, where  possible,  as  it  gave  a  better  chance  to  the 
child.     He  did  not  like  the  use  of  the  vaginal  plug. 

Dr.  Byers,  of  Belfast,  had  met  with  cases  of  placenta 
praevia  in  which  the  os  would  not  admit  the  fingers,  and  in 
three  such  cases  he  had  tried  De  Ribes's  bag  with  good  re- 
sults. After  introducing  the  bag,  if  labor  did  not  come  on, 
he  had  found  that  gently  pulling  on  the  bag  would  hasten 
it,  and  would  anvst  any  hemorrhage.  He  had  found 
that  he  could  introduce  De  Ribes's  bag  when  the  os  was 
the  size  of  a  shilling.  In  accidental  hemorrhage  rupture 
of  the  membranes  only  did  harm  when  pains  did  not 
quickly  follow. 

Dr.  More  Madden,  of  Dublin,  was  opposed  to  a  good 
deal  that  Dr.  Smyly  had  said,  and  he  advocated  ac- 
couchement forc£  and  the  vaginal  plug ;  for  the  latter 
purpose  he  used  a  clean  sponge  soaked  in  terebene.  Af- 
ter sufficient  dilatation  had  been  obtained  he  performed 
internal  version,  never  using  bipolar  method.  In  acci- 
dental hemorrhage  he  saw  no  objection  to  rupturing  the 
membranes. 
Dr.  Murphy,  of  Sunderland,  said  that  we  should  rec- 


September  if  1894] 


MEDICAL    RECORD. 


281 


ognize  the  danger  of  placenta  previa,  and  if  the  seventh 
month  had  passed  take  the  case  in  hand  at  once.  He  had 
always  found  in  cases  of  placenta  previa  that  the  finger 
could  be  introduced  into  the  cervix.  He  then  separated 
the  placenta  for  a  short  distance  around  the  os  and  put  in 
a  Barnes  bag,  and  as  soon  as  sufficient  dilatation  had  been 
obtained  he  delivered.  He  thought  that  the  place  to  put 
in  a  plug  was  the  cervix,  and  not  the  vagina. 

Dr.  Murdock  Cameron,  of  Glasgow,  entirely  disap- 
proved of  Porro's  operation  in  any  case  of  accidental 
hemorrhage.  He  advocated  the  vaginal  plug.  He  had 
never  seen  a  case  of  concealed  accidental  hemorrhage. 
When  the  placenta  was  central  he  always  pushed  his 
fingers  straight  through  its  substance. 

Dr.  Scharlieb,  of  London,  believed  in  plugging  with 
iodoform  gauze. 

Dr.  Robert  Boxall,  of  London,  had  investigated  the 
point  on  the  membranes  which  presented  over  the  os  by 
touching  it  with  eosine  at  an  early  stage  of  labor,  and 
locating  the  stained  spot  afterward.  He  found  that  in 
many  of  these  cases  the  placenta  must  have  encroached 
on  the  dangerous  zone,  though  there  were  no  symptoms  of 
placenta  previa,  and  the  latter  was  especially  the  case 
when  the  membranes  ruptured  early.  In  some  cases  ex- 
ternal version  was  possible.  He  drew  attention  to  the 
fact  that  an  accident  was  sometimes  the  cause  of  hemor- 
rhage in  placenta  previa  marginalis.  He  had  examined 
a  large  number  of  placentae,  and  in  several  cases  had  found 
evidence  of  hemorrhage  having  occurred  a  month  or  two 
previously,  when  there  had  been  no  symptoms.  He  im- 
pressed the  necessity  of  inducing  labor  when  hemorrhage 
had  once  occurred.  In  cases  where  there  was  no  dilata- 
tion of  the  os,  the  hot  douche  proved  useful.  In  some 
cases  he  plugged  the  vagina,  using  wool  soaked  in  sub- 
limate solution.  He  had  seen  cases  in  which  the  placenta 
covered  the  greater  part  of  the  interior  of  the  uterus. 

Dr.  Aust  Lawrence,  of  Bristol,  said  that  when  the 
cervix  would  not  admit  the  finger  he  was  in  the  habit  of 
plugging  the  cervix  with  iodoform  gauze.  He  thought 
cases  in  which  there  were  repeated  small  bleedings  were 
more  dangerous  than  those  in  which  the  hemorrhage 
was  at  once  alarming.  He  would  never  leave  the  woman 
until  labor  was  finished  when  once  bleeding  had  set  in. 

Vaginal  Hysterectomy  for  Cancer  of  the  Uterus.— 
Mr.  F.  B.  Jessett,  of  London,  then  read  a  paper  en- 
titled, "  On  Thirty  Cases  of  Vaginal  Hysterectomy  for 
Carcinoma  Uteri,  with  Two  Deaths. "  He  said  that  vag- 
inal hysterectomy  was  now  a  well- recognized  operation, 
and  was  done  in  three  ways :  1,  using  ligatures ;  2,  using 
clamp ;  3,  combined  abdominal  and  vaginal  method. 
He  laid  great  stress  on  the  importance  of  suitable  prepa- 
ration of  the  patient  beforehand.  He  would  have  her 
kept  in  bed  three  or  four  days,  and  syringe  vagina  fre- 
quently. He  dusted  iodoform  of  cervix  through  a  Fergu- 
son speculum,  especially  if  there  was  ulceration.  Tlie 
diet  should  be  light. 

Details  of  Operation. — Patient  in  lithotomy  position, 
using  Clover's  coutelL  Two  Sims  specula  were  passed, 
one  in  front  and  one  behind.  A  sharp  hook  seized  the 
anterior  lip  of  cervix  and  pulled  it  down,  and  cervix  was 
seized  by  two  vulsella.  A  sound  was  passed  into  the 
bladder  to  determine  its  limits.  Strong  scissors  then  di- 
vided the  mucous  membrane  around  the  os.  The  blad- 
der and  ureters  were  separated  by  the  fingers,  special 
care  being  taken  to  free  thoroughly  at  the  sides. 
The  utero  -  vesical  fold  of  peritoneum  was  opened. 
Then  Douglas's  pouch  was  opened  and  the  fore-fin- 
ger of  the  left  hand  passed  behind  and  the  thumb 
in  front  of  the  broad  ligament,  and  the  uterine  artery  on 
each  side  recognized.  A  special  strong  curved  needle 
was  passed  up  at  the  front  of  the  broad  ligament  and 
pushed  through  above  where  the  uterine  artery  was 
felt,  threaded,  and  withdrawn,  and  ligature  tied.  A  pair 
of  pressure  forceps  was  applied  between  the  uterus  and 
the  ligature  and  the  broad  ligament  divided  with  scis- 
sors. The  fundus  was  anteverted  or  retroverted  so  as 
to  bring  the  ovaries  into  view,  and  the  remainder  of 


the  broad  ligament  transfixed  and  tied  in  two  sections, 
the  ends  of  the  ligatures  being  left  long  and  brought 
down  through  the  vagina.  The  anterior  and  posterioi 
peritoneal  flaps  were  seized  with  catch^forceps  and 
brought  down.  A  glass  drainage-tube  was  passed  into 
the  peritoneal  cavity  and  the  vagina  plugged.  The 
plugs  being  removed  on  the  second  day. 

In  two  cases  the  uterus  was  so  large  that  it  could  not 
be  removed  through  the  vagina  entire.  In  these  cases 
it  had  been  advised  to  divide  the  uterus  in  half,  but  he 
preferred  to  treat  them  by  the  combined  method.  The 
patient  being  in  the  same  position,  the  operator  stands 
between  her  legs  to  make  the  abdominal  incision.  The 
uterus  was  then  drawn  up  and  the  broad  ligaments 
tied. 

As  to  the  question  of  clamp  and  ligature,  he  preferred 
ligature,  but  he  thought  that  in  cases  where  the  patient 
was  very  exhausted  the  clamp  might  be  used,  as  it  took 
a  shorter  time.  He  had  invented  a  special  clamp  for  the 
purpose. 

Apex  Treatment. — If  prolapse  of  omentum  or  intestine 
occurred,  he  used  the  speculum ;  packed  the  vagina  daily, 
and  used  douching.  He  had  the  bowels  open  on  the 
third  day.  He  found  it  necessary  to  tie  a  catheter  in  the 
bladder  for  at  least  two  days. 

As  regards  the  results,  cases  only  were  fit  for  this  oper- 
ation in  which  the  disease  was  limited  to  the  uterus,  and 
the  latter  was  freely  movable. 

The  advantages  of  the  clamp  were  that  the  operation 
was  more  rapid.  Its  disadvantages  were  that  the  end 
projected  into  the  peritoneal  cavity  and  might  convey 
septic  matter.  That  it  inevitably  led  to  necrosis  of  the 
tissues  it  grasped.  That  intestinal  obstruction  was  more 
frequent  after  its  use,  and  that  the  ureters  might  be 
caught  between  its  blades.  Also,  that  the  weight  and 
discomfort  to  the  patient  occasioned  by  its  use  were  con- 
siderable. 

As  regards  silk  and  catgut  for  ligatures,  he  preferred 
silk  for  the  uterine  artery,  but  for  the  remainder  of  the 
broad  ligament  catgut  might  be  used.  He  did  not 
stitch  the  peritoneal  flaps,  but  drew  them  down  into  the 
vagina  and  carefully  packed  around  them. 

As  regards  drainage,  he  thought  that  if  there  was  much 
oozing  it  was  safer  to  use  a  glass  drainage-tube.  If  gauze 
were  used,  the  omentum  might  be  entangled  in  it  and 
drawn  out.     Flushing  the  peritoneum  was  useful. 

The  dangers  of  the  operation  were  sepsis,  hemorrhage, 
and  injury  to  ureters.  This  might  be  avoided  by  being  care- 
ful to  thoroughly  separate  bladder,  and  by  taking  care  to 
pass  the  needle  from  before  backward.  Vesico- vaginal 
fistula  might  result,  or  recto-vaginal  fistula  in  virginal 
narrow  vaginae.  In  cases  of  cauliflower  growth  he  would 
remove  the  growth  before  doing  hysterectomy.  He  did 
not  think  it  necessary  to  remove  the  ovaries  and  tubes. 

Dr.  Smyly,  of  Dublin,  had  sometimes  had  occasion  to 
regret  having  performed  the  operation  when  the  disease 
had  been  too  extensive.  The  principal  guides  as  to  the 
amount  of  extension  of  the  growth  were  that  the  uterus 
should  be  mobile  and  the  broad  ligaments  not  invaded 
by  the  growth,  as  shown  by  examination  per  rectum.  He 
preferred  the  method  of  Dr.  Doyen,  of  Rheims.  Both 
flushing  and  suturing  of  the  peritoneum  were  usually  un- 
necessary. 

Dr.  Heywood  Smith,  of  London,  drew  attention  to 
the  danger  of  inverting  the  uterus  when  the  disease  was 
in  the  cervix,  as  being  likely  to  infect  the  peritoneum  ; 
and  said  that  ligature  was  almost  impossible  when  the 
vagina  was  narrow.  He  would  use  the  catheter  as  little 
as  possible. 

Dr.  Aust  Lawrence,  of  Bristol,  drew  attention  to  the 
importance  of  recognizing  that  cancer  in  an  early  stage 
is  curable,  and  of  making  an  early  diagnosis. 

Dr.  Scharlieb  had  found  the  clamp  cause  much  pain 
and  discomfort,  and  was  of  opinion  that  it  retarded 
recovery. 

Dr.  Jessett,  in  reply,  said  that  in  cases  which  had  ex- 
tended too  far  for  operation,  he  would  use  the  curette  and 


282 


MEDICAL   RECORD. 


[September  i,  1894 


pack  the  cavity  with  chloride  of  zinc,  which  brought  away 
a  slough  of  the  diseased  tissue. 

Dr.  More  Madden,  of  Dublin,  read  a  paper  "  On 
Primitive  and  other  Hyper«sthetic  Conditions  of  the 
Vulva  and  Vagina. ' '  The  paper  was  devoted  almost  entire- 
ly to  the  treatment  of  these  conditions.  He  advised  par- 
ticularly cleanliness ;  the  use  of  germicides,  as  corrosive 
sublimate,  and  the  application  of  methylene  blue  to  the 
parts.  He  had  found  this  latter  do  much  good,  but  the 
disadvantage  was  the  coloration  produced,  which  was 
difficult  to  remove.  In  dyspareunia  he  advocated  forci- 
ble stretching  under  ether. 

HaBmatometra. — Dr.  Murphy,  of  Sunderland,  read  a 
paper  entitled  "  Notes  of  a  Case  of  Haematometra  suc- 
cessfully Treated  by  Hysterectomy/ ' 

Patient,  aged  forty- two,  married  ;  never  menstruated ; 
tumor  reaching  two  inches  above  umbilicus;  has  been 
forming  some  months.  On  vaginal  examination  finger 
passed  two  inches  and  was  then  stopped  by  a  septum, 
which  was  found  to  be  the  hymen  unruptured.  No 
swelling  could  be  felt  above  this,  and  no  uterus  could  be 
made  out  on  rectal  examination.  The  tumor  in  the  ab- 
domen was  thought  to  be  ovarian.  On  opening  the  ab- 
domen the  tumor  was  found  to  be  uterus  distended  with 
menstrual  blood  and  with  os  occluded. 

Menstruation.— Mr.  E.  T.  Collins,  of  Cardiff,  read  a 
paper  on  "The  Nervous  Impulses  Controlling  Menstru- 
ation and  Uterine  Hemorrhage."  His  observations 
went  to  prove  that  there  was  a  nerve-centre,  but  that  its 
action  was  reflex  and  not  automatic,  and  depended  on 
irritation  from  the  uterus. 


Third  Day,  Friday,  August  3D. 

Separation  of  the  After-coming  Head. — Dr.  Purslow, 
of  Birmingham,  read  a  paper  entitled  "  An  Account  of 
Four  Cases  in  which  Separation  of  the  After-coming 
Head  had  Occurred  during  Delivery,  and  of  the  Means 
used  to  Extract  the  Head."  He  narrated  the  cases :  The 
first  three  occurred  in  connection  with  premature  de- 
livery before  the  sixth  month,  and  the  head  came  off 
owing  to  obstruction  from  a  tight  cervix.  In  none  of 
the  cases  was  there  any  sign  of  life  in  the  child.  One 
of  the  heads  was  extracted  by  the  finger,  and  the  other 
two  by  ovum  forceps.  In  the  fourth  case  the  child  was 
fully  developed,  but  decomposed,  and  there  was  some 
narrowing  of  the  pelvic  brim;  the  child  had  presented  by 
the  breech,  and  in  endeavoring  to  extract  the  head  came 
off  and  was  left  in  utero. 

Dr.  Purslow  saw  the  case  four  hours  later,  after  several 
attempts  had  been  made  to  extract  by  forceps  and 
crotchet.  He  extracted  by  the  cephalotribe  after  very 
considerable  difficulty,  the  difficulty  arising  from  the 
tendency  of  the  blades  to  slip  off,  owing  to  the  difficulty 
of  applying  them  over  the  centre  of  the  head,  and  from 
the  fact  that  when  they  were  applied  the  lock  was  one 
and  one-half  to  two  inches  within  the  vulva.  The  pa- 
tient made  an  excellent  recovery.  He  reviewed  the 
methods  of  extraction  advocated  by  ancient  and  modern 
authors,  and  concluded  by  advising  recourse  to  the  ceph- 
alotribe as  the  best  means  of  delivery.  Some  of  the 
other  methods  advocated  involved  bringing  the  head 
down  in  such  a  position  that  the  jagged  protruding  ends 
of  the  fractured  cervical  vertebrae  were  apt  to  seriously 
injure  the  vaginal  or  uterine  wall. 

Ectopic  Gestation.— Dr.  Cullingworth,  of  London, 
read  a  paper  "Ona  Case  of  Advanced  Extrauterine  Ges- 
tation in  which  a  Living  Child  was  removed,  the  placen- 
ta left  Undisturbed,  and  the  Abdominal  Wound  entirely 
Closed/'  He  said  that  it  was  sometimes  advised  in 
these  cases  to  wait  for  the  death  of  the  child  before 
operating,  so  as  to  allow  the  placental  circulation  to 
diminish.  It  had  been  advised  at  the  operation  to  leave 
the  placenta  with  the  cord  protruding  from  the  abdom- 
inal wound.  It  had  been  proposed  by  Lawson  Tait  to 
leave  the  placenta  to  undergo  absorption;  the  attach* 
ment  of  the  placenta  at  the  operation  was  dangerous, 


because  the  attachment  of  the  placenta  differed  from 
that  found  in  the  uterus,  and  in  ectopic  gestation  there 
was  no  mechanism  for  arresting  hemorrhage  when  it  was 
detached.  That  absorption  could  occur  was  proved  by 
those  cases  in  which  the  foetus  had  died.  No  operation 
had  been  performed  and  everything,  with  the  exception 
of  the  bones,  had  disappeared. 

In  his  case  the  child  was  alive  at  operation,  the  open- 
ing in  the  membranes  was  sutured,  and  the  cord  cut 
short.  There  was  satisfactory  progress  for  three  weeks, 
on  the  twenty-fourth  day  a  rigor  occurred,  and  on  the 
twenty-sixth  day  he  opened  the  abdomen.  He  found 
purulent  fluid  in  the  remains  of  the  amniotic  sac,  he 
washed  out,  but  the  patient  died  the  same  day. 

Autopsy. — No  suppuration  in  substance  of  placenta; 
child  still  alive  and  well.  In  future  operations  he  would 
allow  bleeding  from  the  divided  end  of  the  cord,  so  as  to 
lessen  size  of  placenta ;  would  divide  cord  quite  close  to 
placenta ;  would  remove  all  the  amnion  possible,  strip- 
ping it  off  from  the  placental  surface,  as  the  sepsis  in  this 
case  arose  from  the  remains  of  the  amniotic  sac ;  and  it 
would  teach  him  to  remove  parts  not  likely  to  cause 
hemorrhage  in  their  removal,  but  likely  from  their  non- 
vascular^ to  decompose. 

Dr.  Aust  Lawrence  narrated  two  cases  in  which 
he  had  operated ;  in  one  the  placenta  was  absorbed  and 
patient  recovered ;  in  the  other  there  was  septicaemia 
and  death  on  the  twenty  fourth  day.  He  would  leave  the 
placenta,  and  if  there  were  symptoms  would  reopen  the 
wound. 

Dr.  Cullingworth,  in  reply,  said  he  would  be  on 
guard  for  septic  symptoms  and  reopen  abdomen  at  once. 
It  was  a  difficult  matter  to  decide,  in  cases  in  which  the 
foetus  had  died,  how  soon  afterward  to  operate.  He 
had  operated  four  weeks  after  and  removed  the  placenta 
with  perfect  ease.  Drainage  should  not  be  used  if  any 
hope  were  entertained  that  the  placenta  would  absorb. 
He  would  strip  off  amnion  right  up  to  margin  of  cord 
and  cut  the  latter  off  as  close  as  was  possible. 

Pseudo-ovarian  Disease. — Dr.  Rabagliati,  of  Brad- 
ford, read  a  paper  on  "  Some  Obscure  Ailments  which 
Simulate  Ovarian  Disease ;  their  Causes  and  Treatment." 
The  cases  he  described  were  often  called  ovarian  neu- 
ralgia. There  was  pain  in  ilio  lumbar  region,  pain  in 
head,  menstruation  tending  to  be  profuse,  slight  leucor- 
rhcea,  and  these  symptoms  persisted  for  years.  On  mak- 
ing an  examination  the  tissues  were  flabby ;  they  were 
suffering  from  "diseases  of  a  lax  fibre"  and  deficient 
nutrition  of  the  affected  parts,  and  the  essential  cause  of 
these  sufferings  was  rheumatism  of  the  muscle  sheaths  of 
the  fibres  of  the  abdominal  and  pelvic  muscles. 

The  affected  muscles,  especially  the  rectus,  were  tender 
to  pressure.  On  passing  the  finger  into  the  umbilicus,  a 
slight  opening  was  felt,  the  edges  of  which  were  sharp 
and  very  tender.  There  was  tenderness  on  pressure  over 
the  erector  spinae  muscle  and  over  the  sacro-iliac  syn- 
chondroses. The  pectoral  muscles  and  those  at  the  back 
of  the  neck  were  also  tender.  The  causes  of  the  condi- 
tion were  malnutrition,  especially  too  little  nitrogene- 
ous  food.  The  symptoms  were  not  due  to  hysteria. 
Treatment  consisted  in  feeding  and  movements  of  the 
muscles  under  pressure ;  these  latter  the  patient  was  in- 
structed to  do  herself,  and  photographs  were  exhibited 
to  show  how  the  movements  were  performed.  Cold 
baths  were  also  used,  and  by  these  means  Dr.  Rabagliati 
said  he  had  cured  cases  for  whom  removal  of  the  ovaries 
had  been  advised. 

The  Section  was  then  adjourned. 


Curiosities  of  Cholera. — It  is  a  fact  of  the  various 
cholera  epidemics  that  have  swept  Europe,  that  in  every 
one  the  mortality  at  Rome  and  Madrid  was  greatest  on 
Sundays,  at  London  and  Berlin  on  Wednesdays,  and  at 
Paris  on  Saturdays.  At  present,  in  St.  Petersburg, 
where  the  death  rate  is  upward  of  one  hundred  daily,  the 
mortality  list  is  increased  one-fourth  on  Saturdays. — 
Medical  Age. 


September  i,  1894] 


MEDICAL    RECORD. 


283 


THE   PRACTITIONERS'    SOCIETY   OF  NEW 
YORK. 

Siatea  Meeting,  April  6,  1894. 

George  L.  Peabodv,  M.D.,  Chairman,  pro  tern. 
Chronic  Double  Parotiditis — Two  Cases. — Dr.  Rob 
ert  Abbe  presented  a  man  and  photographs  of  this  and 
another  case  of  chronic  double  parotiditis.  The  first 
case,  of  which  photographs  alone  were  shown,  occurred 
some  years  ago  in  a  man  whom  he  had  first  seen,  as  he 
was  reminded  later,  in  the  practice  of  Dr.  Weir.  The 
enlargement  of  the  parotid  glands  had  persisted  during 
the  entire  time  the  patient  remained  under  Dr.  Abbe's 
observation,  perhaps  a  year  and  a  half.  Had  at  no  time 
been  attended  by  very  acute  symptoms ;  no  suppuration. 
The  man  presented  was  the  only  other  similar  case  which 
had  come  under  his  observation.  The  glandular  en- 
largement had  existed  over  a  year,  and  had  come  on 
without  apparent  cause,  although  on  account  of  the  ra- 
pidity of  its  development  Dr.  Abbe  had  at  first  supposed 
it  was  due  to  mumps,  a  view  which  proved  to  be  incor- 
rect. Last  summer  the  man  had  had  an  attack  of  appen- 
dicitis,  but  recovered  after  about  two  weeks,  and  was  able 
to  res'ime  business  in  Wall  Street  until  about  two  months 
ago,  when  he  had  another  attack  of  appendicitis,  for 
which  Dr.  Abbe  operated  and  removed  the  suppurative 
appendix.  Since  that  date  the  man  had  felt  better  than 
at  any  time  for  two  years,  had  gained  about  twenty-five 
pounds  in  weight ;  but  there  had  been  no  change  in  the 
parotid  glands  except  that  the  swelling  was  a  little  more 
diffuse  and  a  little  softer,  but  contained  no  fluid. 

In  the  first  case  the  entire  parotid  had  been  involved ; 
in  the  second  only  the  upper  portion  in  front  of  the 
tragus  and  lobule. 

Dr.  Weir  remembered  the  first  case,  of  which  he  said 
Dr.  Abbe  took  the  photograph  for  him.  The  swelling 
was  harder  than  in  the  case  of  the  man  presented,  was  of 
the  entire  parotids,  which  were  swollen  in  equal  degree. 
Surgical  interference  was  not  considered  necessary.  The 
present  case  reminded  him  of  one  recently  seen  in  a 
patient  from  Montreal,  in  which,  however,  the  suspicion 
of  symmetrical  fatty  tumors  was  confirmed  by  the  pres- 
ence of  fatty  growths  in  the  neck. 

Dr.  McBurnby  was  disposed  to  think,  from  the  soft- 
ness of  the  tumors,  the  presence  of  at  least  the  greater 
portion  of  the  parotid  at  a  lower  situation,  and  the  fact 
that  the  man  had  been  growing  fat,  that  the  case  was  one 
of  lipomata  symmetrical  on  the  two  sides. 

Dr.  Abbe  said  he  had  had  in  mind  the  possibility  of 
fatty  tumors,  but  the  growths  had  not  been  so  soft  in  the 
first  place;  they  had  developed  when  the  man  was  in  his 
poorest  health,  before  he  had  begun  to  take  on  flesh,  and 
had  remained  of  the  same  size  since  the  first  month. 

Dr.  Andrew  H.  Smith  remarked,  incidentally  to  the 
question  of  symmetrical  lipomatous  tumors,  that  about 
seven  years  ago  a  patient  entered  the  Presbyterian  Hos- 
pital with  seven  or  eight  symmetrical  lipomata  in  differ- 
ent parts  of  the  body,  there  being  two  on  the  forehead, 
two  on  the  neck,  and  others  located  symmetrically  else- 
where. 

Cholecystenterostomy  by  Murphy's  Button — Recov- 
ery.— Dr.  Robert  Abbe  related  the  case.     In  October 

last  Mrs.  M ,  aged  forty  five,  had  entered  her  fourth 

month  of  profound  jaundice,  with  entire  loss  of  appetite, 
emaciation,  and  exhaustion. 

She  had  never  had  biliary  colic,  and  the  onset  of  this 
attack  was  unaccompanied  by  other  symptoms. 

Examination  showed  her  to  be  very  thin  and  deeply 
jaundiced.  The  gall  bladder  could  be  felt  well  distended. 
No  other  tumor  was  apparent. 

Drs.  C.  W.  Packard,  Archibald  Campbell,  of  Mt. 
Vernon,  and  I  agreed  that  there  was  probably  present  ob- 
structive pressure  from  cancer.  As  the  patient's  condi- 
tion was  critical  I  operated  on  the  chance  of  finding  stone 
obstruction,  and  to  establish  a  new  channel  for  the  bile 
under  any  circumstances. 

I  found  the  common  duct  the  site  of  a  small  hard  mass 


no  larger  than  the  end  joint  of  one's  thumb.  The  gall- 
bladder was  distended  with  a  pint  of  black  viscid  bile ; 
there  were  no  stones  in  it. 

The  tumor  was  movable  and  could  be  pinched  up  be- 
tween the  thumb  and  fingers.  It  was  hard  enough  to  be 
a  stone  bedded  in  an  inflamed  duct,  but  needling  and 
knife  puncture  showed  it  to  be  a  small,  hard  neoplasm. 

Further  operation  of  any  sort  was  prevented  by  the 
extremely  low  condition  of  the  patient  at  this  juncture, 
and  an  external  bile  fistula  was  quickly  established. 
With  assiduous  care  the  patient  rallied  well  under  Dr. 
Campbell's  attendance,  and  made  an  excellent  convales- 
cence. The  jaundice  quickly  disappeared,  strength  and 
appetite  came  back,  and  she  gained  flesh.  The  duct  ob- 
struction remained  absolute.  Stools  continued  white, 
and  a  daily  discharge  of  from  fourteen  to  sixteen  ounces  of 
bile  was  caught  in  a  thin  rubber  bag  secured  to  the  drain- 
age-tube. 

At  the  end  of  three  months  she  was  in  good  condition, 
and  I  operated  to  divert  the  bile  into  the  duodenum. 
The  gall-bladder  was  atrophied,  but  readily  separated 
from  the  under  side  of  the  liver.  Half  a  Murphy's  button 
was  put  into  a  slit  in  the  gall-bladder,  and  half  in  the 
duodenum  six  inches  below  the  pylorus.  The  two  were 
united  and  the  abdomen  closed.  The  purse-string  suture 
of  the  thickened  gall  bladder  made  it  a  little  difficult  to 
draw  the  slit  within  the  grasp  of  the  button,  but  an  out- 
side stitch  perfected  the  union. 

Examination  of  the  small  tumor  of  the  duct  showed 
slight  enlargement  during  the  three  months  since  first 
operation. 

Uninterrupted  convalescence  ensued.  The  button 
was  passed  on  the  twelfth  day. 

Dr.  Abbe  also  presented  two  specimens  from  the  dog's 
intestine,  one  illustrating  end- to  end  union  after  resection 
and  the  use  of  Murphy's  button,  the  other  long  opening 
formed  by  lateral  anastomosis.  There  was  no  doubt,  he 
thought,  but  that  the  button  could  be  used  in  the  human 
intestine  with  greater  security  and  a  more  perfect  result 
than  could  be  obtained  by  any  other  method  with  which 
he  was  acquainted.  The  rim  of  the  button  cut  out  a 
clean  section  of  the  gut,  which  did  not  show  the  tendency 
to  contract  which  was  observed  after  making  a  broad 
suture  line. 

Dr.  Weir  said  fear  had  been  expressed  that  some  time 
one  of  the  buttons  might  fail  to  pass  and  constitute  an 
obstruction.  It  seemed,  however,  that  experience  had 
proven  this  objection  unfounded  in  the  end-to-end  anas- 
tomosis. But  it  had  been  proposed  to  employ  an  elon- 
gated button  for  lateral  anastomosis.  In  the  speaker's 
opinion,  the  one  shown  and  intended  to  accomplish  this 
end  would  prove  a  failure,  as  it  did  not  provide  for  long 
enough  an  opening.  He  inquired  of  Dr.  McBurney 
what  had  been  the  result  in  the  case  at  Roosevelt  Hospi- 
tal in  which  Dr.  Murphy  had  himself  made  end-to  end 
anastomosis  with  his  button. 

Dr.  McBurney  said  the  result  had  been  successful, 
but  other  operations  would  have  to  be  performed,  as  had 
been  intended,  before  the  patient  could  be  dismissed 
from  the  hospital. 

In  reply  to  an  interrogatory,  Dr.  Abbe  said  the  but- 
ton came  away  in  from  seven  to  fifteen  days.  The  quick- 
ness of  the  operation  and  security  obtained  by  thus  sand- 
wiching together  the  ends  of  the  intestine,  recommended 
the  method  particularly  to  those  who  had  not  had  great 
experience  with  the  technique  of  abdominal  surgery. 

Cases  in  Genito-urinary  Surgery. — Dr.  R.  F.  Weir 
read  a  paper  bearing  this  title.     (See  p.  161.) 


A  Medical  Syndicate. — We  read  in  one  of  the  relig- 
ious weeklies  an  enthusiastic  notice  of  the  adoption,  by 
two  churches,  in  a  town  in  Iowa,  of  a  plan  of  assessing 
every  church  member  fifty  cents  a  month;  and  in  return 
offering  free  medical  attendance  and  three  dollars  a  week 
during  illness,  with  the  entire  funeral  expense  in  case  of 
death. — Polyclinic. 


284 


MEDICAL  RECORD. 


[September  1,  1894 


<&otx*Bpou&sncz. 

DR.    EASTMAN'S    METHOD    OF    SUPRAPUBIC 
HYSTERECTOMY. 

To  ths  Editor  op  the  Medical  Record. 

Sir  :  In  the  current  volume  of  the  Medical  Record, 
page  147*  you  speak  of  my  address  before  the  Gyneco- 
logical Section  of  the  American  Medical  Association,  and 
say  that  my  method  consists  of  tying  the  uterine  arteries 
in  the  broad  ligaments  close  to  the  corner  of  the  uterus. 
While  the  ligature  in  a  given  case  may  include  the  uter- 
ine artery,  the  whole  point  of  originality  which  I  claim 
was  that  the  coiling  arteries  given  off  from  the  uterine 
artery  nourished  the  uterus  by  a  plexus,  and  not  by  pen- 
etrating the  uterus ;  therefore,  instead  of  ligating  the 
uterine  arteries  at  all,  I  go  between  them  and  the  uterus, 
peeling  out  even  the  entire  cervix,  and  only  perhaps  oc- 
casionally ligating  some  little  spurting  twig  which  has 
been  abnormally  enlarged. 

If  I  had  said  anywhere  that  I  ligated  the  uterine 
arteries,  then  there  would  have  been  nothing  in  my  meth- 
od to  claim  originality  for.  There  may  not  be  now,  as 
others  had  already  gone  from  below  upward,  peeling 
out  the  uterine  cervix  without  clamp  or  ligature — notably 
Sauter,  of  Constance,  Germany,  three  quarters  of  a  cen- 
tury ago. 

I  repeat,  the  whole  spirit  of  my  essay,  Section  in  San 
Francisco,  read  before  the  Michigan  State  Medical  Society, 
was  to  prove  that  the  coiling  arteries  of  the  uterus  do  not 
penetrate  that  organ,  but  are  spread  out  over  it  in  a  cap- 
illary net-work,  and  that  the  uterine  cervix  can  be  peeled 
out  from  above  downward  without  clamp  or  ligature  to 
control  hemorrhage. 

Joseph  Eastman,  M.D. 

Indianapolis-  August  13,  1894. 


BATHS  IN  INFLAMMATORY  AFFECTIONS    OF 
CHILDREN. 

To  the  Editor  of  tub  Medical  Record. 

Sir  :  More  than  fifteen  years  ago  you  published  an  ar- 
ticle of  mine  on  the  efficacy  of  balneotherapy  in  acute 
bowel  affections  seen  so  frequently,  and  so  deadly,  in  the 
congested  areas  of  ciiies  during  the  heated  term  of  sum- 
mer. I  have  found  this  method  as  reliable  as  ever  in  my 
experience  since  that  time.  I  first  wrote  on  this  subject 
in  a  report  made  to  the  Philadelphia  Medical  Times,  in 
July,  1875,  then  edited  by  Professor  H.  C.  Wood  (where 
it  appears  under  the  head  of  "  Correspondence  "),  and 
subsequently  I  made  reports  once  or  twice  for  the  Medi- 
cal Record. 

The  tropical  heat  of  this  summer,  and  the  fearful  rate 
of  mortality  in  children  under  three  years  of  age  from 
entero-colitis,  leads  me  briefly  to  recall  my  original  pub- 
lications. Dr.  Wood,  after  a  most  successul  use  of 
baths  in  the  Children's  Hospital  on  the  grounds  of 
the  Centennial  Exposition,  1876,  did  me  the  honor  to 
say  (editorially),  in  1877,  »  the  Philadelphia  Medical 
Times:  " It  must  be  granted  to  Dr.  Comegys  the  credit 
of  having  introduced  the  most  life-saving  improvements 
in  modern  therapeutics.' ' 

The  application  of  these  baths  is  so  simple  that  they 
can  readily  be  applied  in  any  house.  We  are  summoned 
usually  to  see  a  child  who  has  already  been  sick  some 
time  and  undergone  household  treatment,  and  we  find  a 
hot  skin];  temperature,  1020  to  1040  F.;  rapid  pulse,  130 
to  150 ;  respirations,  30  to  40 ;  with  frequent  vomiting 
and  purging ;  tongue  and  mouth  dry,  intense  thirst,  in- 
somnia, rolling  of  the  head,  and  uttering  distressing 
cries. 

I  direct  an  immersion  bath  in  hydrant  water,  which 
with  us  in  summer  is  about  750  F.,  and  over  the  forehead 
and  scalp,  the  head  being  held  in  the  hand,  is  poured  a 
stream  of  cistern  water,  65  °  F.  This  operation  is  kept 
up  for  several  minutes — eight  to  ten.  In  a  little  while 
the  child  ceases  to  cry  and  struggle,  and  it  will  drink 


greedily  of  water.  Often  the  lips  become  bluish  and 
the  jaw  trembles.  After  the  bath,  the  patient  should  be 
put  unwiped  in  a  blanket.  The  sedative  effects  of  the 
cold  bath  will  speedily  disappear,  reaction  is  established, 
and  the  child  goes  to  sleep  promptly ;  the  fever  disap- 
pears, the  pulse  has  lost  its  frequency,  the  breathing  is 
slower  and  more  natural,  the  vomiting  and  diarrhoea 
cease. 

For  several  years  past  I  have  ceased  to  use  cold  water 
and  rely  entirely  on  hot  bathing,  always  using  a  water 
two  or  three  degrees  above  the  fever  temperature  of  the 
body,  and  keeping  the  patient  submerged  from  six  to  ten 
minutes;  still,  however,  pouring  cold  water  over  the 
head.  I  have  made  this  change  because  the  use  of  cold 
water  is  so  much  more  painful  or  distressing  to  the  little 
sufferers.  When  they  are  withdrawn  from  the  bath  they 
are  wrapped  in  a  soft  and  warm  blanket,  where  they  will 
sweat  like  a  rain,  and  in  this  way  the  toxines  which  have 
accumulated  in  the  blood,  and  so  depress  the  cardiac, 
arterial,  and  capillary  circulation,  are  eliminated  and 
convalescent  conditions  are  promptly  established.  In 
short,  I  have  ceased  to  use  cold  baths  in  inflammatory 
affections  of  any  form  in  young  children. 

I  will  not  discuss  internal  medication,  but  barely  men- 
tion small  doses — one  eighth  grain — of  calomel  are  very 
useful ;  or,  what  I  like  better,  blue  pill  mixed  with  syr. 
rhu.  aromat. ;  either  remedy  given  in  small  doses  every 
three  hours.  Food:  Good  milk  and  cream  in  equal 
parts  and  a  certain  amount  of  brandy  every  three  hours. 
If  a  fresh  air  location  can  be  obtained,  there  is  very  little 
danger  of  a  relapse. 

C.  G.  Comegys,  M.D. 

Cincinnati,  O.,  August  13,  1894. 


HYGIENIC  TREATMENT  VS.  "EAR-RUBBING," 
FOR  "HAY  FEVER." 

To  tub  Editor  or  the  Mbdicai.  Record. 

Sir  :  A  Hamburg  physician  (according  to  the  Deutsche 
Med.  Zeitung),  whose  condition  from  hay  fever  had  been 
so  severe  as  to  necessitate  his  using  a  closed  carriage  all 
through  the  summer  (sic  !)  has  for  the  past  three  years 
"  been  able  to  lead  an  endurable  existence  during  the  hay- 
fever  season,"  by  means  of  roasting  his  own  ears,  so  to 
say,  "rubbing  them  till  they  became  red  and  hot" 
"  As  soon  as  the  least  sensation  of  fulness  in  the  nose  ap- 
pears, there  is  recognized  a  certain  amount  of  pallor  in 
the  ears.  A  thorough  rubbing  of  the  ears,  at  times  even 
to  contusion,  has  always  succeeded  in  freeing  the  nasal 
mucous  membrane  from  its  congestion.  The  rubbing 
must  be  thorough  and  repeated  as  often  as  the  least  symp- 
tom of  congestion  returns  to  the  nose."  The  doctor 
declares  that  several  patients  have  also  been  relieved  by 
this  method,  and  he  hopes  that  some  other  physician  may 
be  able  to  give  his  patients  some  relief !  This  is  indeed 
a  worthy  ambition.  But  from  the  writer's  point  of  view, 
after  years  of  the  most  complete  success  in  the  manage- 
ment of  the  disease  by  a  perfectly  rational  method,  Dr. 
Ferber's  plan  of  relieving  congestion  of  the  nose  by 
means  of  counter-irritation,  getting  up  a  congestion  of 
the  ears  by  rasping  them  till  they  are  raw,  seems  pitifully 
absurd. 

In  view  of  all  that  we  hear  and  see  of  this  terrible 
enemy  of  the  human  race,  it  would  seem  that  any  remedy 
that  will  enable  a  victim  of  hay  fever  to  "  lead  an  endur- 
able existence  "  in  summer  should  be  widely  published  ; 
but  any  doctor  who  recognizes  this  disorder  as  a  local 
fever,  and  does  not  directly  cool  his  head  instead  of 
warming  his  ears,  ought  to  have  the  latter  soundly  boxed — 
which,  by  the  way,  would  answer  in  place  of  rubbing.  (I 
should  be  sorry  to  have  my  prescription  misinterpreted.) 

Hundreds  of  hay-fever  victims  spend  the  summer  at 
the  White  Mountains  every  year,  where  it  is  said  the 
majority  find  great  relief,  and  some,  indeed,  complete 
immunity  from  the  disorder,  in  spite  of  the  contin- 
uance of  the  very  practices  which  provoke  the  dis- 
ease further  south,  viz.,   winter  dress  and  diet.     At 


September  i,  1894] 


MEDICAL  RECORD. 


285 


the  North  Pole  we  may  guzzle  blubber  and  wear  several 
layers  of  clothing  without  fear  of  fever,  and  so  long  as 
anyone  is  ignorant  or  foolish  enough  to  stick  to  his  win- 
ter dress  and  diet,  as  do,  practically,  all  the  hay- fever 
fiends  the  writer  has  known,  he  must  go  far  enough 
north  to  give  him  something  like  winter  atmospheric 
conditions. 

The  disorder  under  consideration  is  without  doubt 
one  of  surfeit  and  skin  smothering.  A  frugivorous 
and  abstemious  diet,  plenty  of  air-bathing,  and  the 
abandonment  of  all  superfluous  clothing — every  fibre 
of  clothing  beyond  a  respectable  covering  of  the  body 
should  be  regarded  as  superfluous — under- flannels  worn 
while  the  sweltering  wretch  prays  for  a  cold  wave,  what 
language  can  sufficiently  emphasise  such  stupidity? 
This  principle  applied  to  the  limit  makes  hay  fever 
practically  impossible.  The  same  plan  will  speed  the 
core  of  an  acute  attack;  proper  head  cooling  and  a 
East  day  will  do  the  rest. 

The  head  is  to  be  cooled  in  and  in,  moderately  but 
persistently,  till  marked  relief  is  felt,  and  repeated  as 
often  as  the  local  fever  returns.  "  I  was  wonderfully  re- 
lieved in  two  hours,  and  completely  cured  the  second 
day/'  was  the  report  from  a  distant  patient  to 
whom  I  had  wired  the  details  of  treatment.  The  fact 
of  the  matter  is,  we  may  all  not  only  "  lead  an  endurable 
existence"  during  the  summer,  but  we  may  even  be 
aggressively  happy  in  spite  of  torrid  waves,  if  we  keep 
cool,  as  the  artist  mixed  his  colors,  "  with  brains." 

Charles  E.  Page,  M.D. 

8*7  Boylston  Strut.  Boston,  Mass. 


tion  of  the  brain,  and  never  remain  in  the  water  after  a 
feeling  of  chilliness  supervenes. 

Harvey  Bashore,  M.D. 

W»st  Fair vip  w,  Pa.,  August  33,  1P94. 


BATHERS'    "CRAMP." 
Is  it  a  Popular  Fallacy? 

To  the  Editor  of  the  Mpdical  Record. 

Sir  :  We  hear  so  much  during  the  summer  months  of 
cases  of  drowning  caused  by  so  called  "cramp,"  that 
even  an  experienced  swimmer  must  almost  be  afraid  to 
venture  beyond  his  depth.  The  newspaper  article,  com- 
menting on  a  drowning  case,  generally  begins  with  the 
fact  that  the  bather  was  a  good  swimmer,  but  that  he 
suddenly,  when  some  distance  from  help,  stopped  his 
exertions  and  sank;  the  case  is  labelled  "death  from 
drowning  caused  by  cramp." 

Now,  is  this  really  so  ?  Is  the  bather — an  adept  per- 
haps— liable  to  be  struck  down  so  quickly  and  without 
warning  ?  If  it  is  true,  the  danger  from  bathing  in  deep 
water  is  so  great  that  one  is  hardly  justified  in  running 
the  risk. 

I  have  not  had  the  good  fortune  to  analyze  any  case 
of  so-called  "  cramp,"  but  I  have  knowledge  of  a  case 
of  a  young  physician  which,  had  it  resulted  fatally,  would 
probably  have  been  so  called ;  as  it  was,  the  case  did 
not  end  fatally  and  the  young  man  lived  to  tell  the  tale : 
It  was  within  two  hours  after  eating  a  very  hearty 
dinner,  and  after  considerable  exercise,  that  the  bather, 
an  excellent  swimmer,  took  a  plunge,  feet  first  into  the 
cool  (700  F.)  water  of  Hell  Gate ;  immediately  he  arose 
to  the  surface,  an  inconceivable  feeling  of  nausea  came 
on,  and  everything  before  his  eyes  became  hazy;  he 
remembers  that  in  a  mechanical  way  he  kept  his  arms 
and  feet  moving  until  help  arrived,  but  during  the  whole 
procedure  he  was  in  a  dazed  condition — in  street  par- 
lance, he  had  "  lost  his  head  " — the  result  of  the  nausea 
and  possible  congestion  of  the  brain.  Emesis  was  quickly 
followed  by  return  to  health.  Now,  this  I  take  as  an  ex- 
ample of  the  danger  which  may  befall  anyone ;  exhaus- 
tion and  cold  are  others ;  spasmodic  contraction  of  the 
glottis  from  inhalation  of  water  might  be  another ;  in 
fact,  we  have  causes  enough  without  calling  everything 
"  cramp ;  "  and  these  causes  may  be  reduced  to  a  mini- 
mum by  following  some  of  the  well  known  hygienic  rules 
for  bathing,  as  (see  Rohe) :  Never  bathe  within  two 
hour3  after  eating ;  never  plunge  in  cold  water  feet  first, 
but  always  head  first,  so  as  to  avoid  tendency  to  conges 


CONCERNING  THE  TABLET  TRITURATE. 

To  the  Editor  or  the  Medical  Record. 

Sir  :  I  believe  there  is  a  pretty  general  agreement  among 
physicians  that  the  tablet  triturate  is  one  of  the  best 
methods  of  dispensing  medicines.  Of  the  absolute  re- 
liability of  these  goods,  as  made  by  the  best  manufactu- 
rers, there  can  be  no  doubt.  They  are  inexpensive.  They 
are  easily  carried  in  the  ordinary  pocket  case.  The  sub- 
division of  dosage  in  the  case  of  children  and  others,  by 
crushing  the  tablet,  is  convenient.  Not  the  least  of  the 
valuable  features  of  the  tablet  triturate  is  that  it  enables 
the  physician,  by  dispensing  his  own  medicine,  to  limit, 
in  a  measure,  the  tendency  on  the  part  of  some  druggists 
to  counter-prescribing.  I  believe,  therefore,  that  one 
point  in  their  manufacture  is  worthy  of  attention.  I  re- 
fer to  stamping  each  tablet  with  a  number.  This  has  al- 
ways been  the  custom  of  one  large  manufacturer.  I 
learn  that  another  leading  firm  is  about  to  introduce  the 
custom.  This  does  not  seem  to  me  to  be  in  the  interest 
of  the  physician.  I  know  of  some  instances  where  pa- 
tients, who  have  had  tablet  triturates  prescribed  for  them 
by  a  physician,  have  carefully  preserved  a  numbered 
sample,  and  gone  to  a  druggist  with  the  request  to 
"  match  "  it ;  something  after  the  manner  in  which  la- 
dies match  ribbons  at  the  bargain  counter.  The  only 
reason  I  have  ever  seen  given  for  numbering  tablets  is 
that  of  one  manufacturer,  that  if  a  physician  breaks  a 
bottle,  or  if  they  become  mixed  in  any  manner,  he  could 
identify  and  sort  out  the  tablets  by  their  number.  This 
is  hardly  a  practical  point,  and  breakage  is  little  apt  to 
occur.  I  believe  the  tablet  triturate  has  come  to  stay, 
and  I  would  like  to  see  it  manufactured  exactly  right  in 
every  particular. 

Geo.  W.  Milks,  M.D. 

xi  Chiriy  Stbbst,  Oneida,  N.  Y. 


THE  SOCIETY  OF    RUSSIAN  PHYSICIANS. 

To  the  Editor  of  thb  M«nc al  Record. 

Sir  :  In  the  Novoe  Vremya,  the  popular  Russian  daily 
newspaper,  there  lately  appeared  an  account  of  the  pro- 
ceedings of  the  Medical  Association  which  was  founded 
in  memory  of  N.  I.  PirogofT. 

In  connection  with  an  interesting  report  on  juridical 
medicine,  it  was  said  that  the  professional  expert  could 
be  viewed  as  merely  a  part  of  the  legal  machinery,  under 
direction  of  the  judge,  as  a  simple  witness,  and  as  a  per- 
son competent  to  value  the  significance  of  scientific  facts, 
and  to  determine,  through  special  experiences,  the  anat- 
omical changes  brought  about  by  an  injury,  or  the  ac- 
companying psychological  results  ("  data  "). 

As  critique  of  the  foregoing,  and  of  the  whole  subject, 
the  reviewer  stated  that  the  sphere  of  the  medico  legal 
testifier  should  be  enlarged ;  he  should  be  empowered  by 
law,  together  with  the  judge,  to  give  conclusions,  thus 
being  able  to  show  the  necessary  effects  of  the  acts  in 
question ;  and  to  keep  apart  all  malevolent  words  or  in- 
sinuations. Before  the  lawmakers  lies  the  problem  :  i. 
The  relations  of  the  physician  to  the  court,  in  the  field 
of  medical  jurisprudence.  2.  The  peculiarity  and  limits 
of  his  activity.  3.  The  method  of  action  as  to  expert 
testimony ;  especially  the  bearing  of  all  these  on  peda- 
gogic instruction,  which  is  continually  changing  with  the 
advance  of  science. 

After  a  discussion  on  disinfectants  which  had  lasted 
two  hours,  one  of  the  delegates  summed  up  the  matter, 
by  saying:  "The  Zemtsvo  (provincial  legislature)  sent 
me  here  to  find  out  what  capable  experimenters  would 
say — to  learn  something.  I  have  listened  long,  and,  I 
regret  to  say,  have  not  obtained  anything  of  value ;  I  shall 
have  to  go  home  with  empty  hands."     *«—• '-  ;-  ~~*  ♦*»- 


Russia  is  not  the 


286 


MEDICAL  RECORD. 


[September  i,  1894 


only  country  where  vain  words  become  wearisome  to  the 
hungry  mind. 

The  unhygienic  condition  of  houses  and  villages  was 
said  to  be  largely  due  to  the  fact  that  their  location  is 
determined  for  the  convenience  of  governmental  admin- 
istration, leaving  out  of  view  the  topographical  sanitary 
relations.  The  question  of  making  legally  obligatory 
the  participation  of  medical  men  in  the  choice  of  build- 
ing sites  was  considered  by  the  society.  The  section  in 
re  decided  that  a  medical  inspection  of  new  buildings 
was  desirable.  On  account  of  extensive  infectious  dis- 
eases of  the  eyes,  in  villages  scattered  over  the  land,  it 
was  determined  to  recommend  the  use  of  preventive 
means  at  the  time  of  birth. 

The  psychological  division  of  the  congress  adopted  a 
resolution  for  the  appointment  of  a  committee  to  take 
statistics  of  those  showing  evidence  of  mental  infirmity 
and  of  the  insane.  They  hoped,  by  this  means,  to  re- 
lieve many  now  suffering  in  chains  and  hovels.  Inter- 
esting demonstrations  of  nervous  phenomena,  in  the 
perception  of  sensation,  were  given  by  the  section  de- 
voted to  psychiatrics.  One  physician  stated  that  the  in- 
dications of  mental  disease  in  Western  Europe  and  in 
Russia  were  not  identical. 

An  address  was  read  advocating  the  systematic  regis- 
tration of  sickness  and  death  from  tuberculosis,  the  same 
as  in  cases  of  infectious  diseases. 

From  the  remarks  of  one  surgeon  we  learn  that  his 
recent  microscopic  observations,  experiments,  etc.,  make 
probable  the  parasitic  origin  of  tumors,  especially  malig- 
nant ones.  This  tends  to  corroborate  statements  made 
by  other  investigators. 

The  next  meeting  of  the  society  is  arranged  for  the 
spring  of  1896,  in  the  heart  of  Old  Russia,  at  the  sacred 
city  of  Kiev. 

F.  B.  Stephenson,  M.D.,  U.  S.  N. 

Boston,  Mass.,  August  13,  1894. 


OUR   LONDON   LETTER. 

(From  our  Special  Correspondent.) 

the  british  scientific  congress  at  oxford — lord 
Salisbury's  address  as  president — the  outbreak 
of  small-pox — arrival   op  a  case  of  cholera   on 

A   STEAMER — THE     BACILLUS     OF     PLAGUE — DR.       GRIF- 
FITHS— DR.    WIGLESWORTH — SIR  JOSEPH   FAYRER. 

London,  August  tx,  1894. 

No  sooner  have  we  finished  our  trip  to  Bristol  for  the 
British  Medical  Association,  than  we  must  hasten  to 
Oxford  to  attend  the  meeting  of  its  parent — the  British 
Association  for  the  Advancement  of  Science.  This  year 
is  somewhat  exceptional,  as  a  great  political  leader  has 
consented  to  preside,  and  there  are  rumors  that  his  ad- 
dress will  deal  with  the  unsolved  problems  of  science. 
The  President  is  no  other  than  the  Marquis  of  Salisbury, 
who  is  Chancellor  of  the  University  of  Oxford,  but  who 
appears  on  this  occasion  rather  in  the  character  of  his 
F.R.S.  It  is  known  well  enough  to  a  few  that  his 
Lordship's  studies  have  been  by  no  means  confined  to 
the  ancient  learning  or  dimmed  by  his  ardor  in  politics, 
but  have  extended  so  far  in  scientific  directions  as  to 
entitle  him  to  a  high  place  among  practical  scientists. 
In  some  points  his  researches  have  been  greatly  appre- 
ciated, but  no  little  curiosity  was  felt  and  expressed  as  to 
what  he  would  say  in  his  presidential  address.  Let  me 
say  at  once  that  this  address  would  have  been  no  disap- 
pointment had  it  come  from  one  of  the  masters  whose 
whole  life  had  been  devoted  to  science,  and  when  we 
remember  the  other  directions  in  which  Lord  Salisbury's 
mind  has  been  engaged,  it  is  very  remarkable.  He 
showed  himself  at  home  in  the  theories  of  the  chemi- 
cal elements,  in  the  discoveries  of  the  spectroscope,  and 
the  problems  of  the  ether.  From  these  unsolved  enig- 
mas he  passed  to  the  riddle  of  life  and  sketched  with 
a  master-hand  the  controversy  that  has  raged  since 
Darwin's  "  Origin  of  Species  "  appeared.     The  effect  of 


this  work  was  shown  and  its  proved  results  admitted, 
while  the  differences  of  view  existing  were  also  stated. 
The  differences  between  the  mathematicians  and  biolo- 
gists were  touched  upon,  but  his  Lordship  said  he  would 
not  get  into  the  line  of  fire  between  them  by  intervening, 
and  until  the  differences  are  adjusted  laymen  are  justified 
in  giving  a  verdict  of  "  not  proven  "  on  the  tremendous 
issues  raised  by  the  most  advanced  Darwinians.  Then 
came  a  caveat  against  the  "  great  danger  scientific  re- 
search is  running  at  the  present  time,  the  acceptance  of 
mere  conjecture  in  the  name  and  place  of  knowledge,  in 
preference  to  making  frankly  the  admission  that  no  cer- 
tain knowledge  can  be  attained."  This  point  was  illus- 
trated by  a  reference  to  Professor  Weismann's  dictum, 
that  we  must  accept  natural  selection  because,  if  not,  we 
must  fall  back  on  the  agency  of  design,  which  the  pro- 
fessor seems  to  look  upon  as  an  inadmissible  conclusion, 
or  even  a  heresy.  But  Lord  Salisbury's  statement  will 
not  easily  be  met  by  Professor  Weismann,  especially  as 
he  reinforced  his  logic  by  falling  back  on  the  judgment 
of  Lord  Kelvin,  "  the  greatest  living  master  of  natural 
science  among  us,"  and  quoting  the  peroration  of  that 
master's  address  from  the  same  chair,  more  than  twenty 
years  ago,  these  significant  words : 

"  I  have  always  felt  that  the  hypothesis  of  natural  selec- 
tion does  not  contain  the  true  theory  of  evolution,  if 
evolution  there  has  been  in  biology.  ...  I  feel 
profoundly  convinced  that  the  argument  of  design  has 
been  greatly  too  much  lost  sight  of  in  recent  zoological 
speculations.  Overpoweringly  strong  proofs  of  intelli- 
gent and  benevolent  design  lie  around  us,  and  if  ever 
perplexities,  whether  metaphysical  or  scientific,  turn  us 
away  from  them  for  a  time,  they  come  back  to  us  with 
irresistible  force,  showing  to  us  through  nature  the  in- 
fluence of  a  free-will,  and  teaching  us  that  all  living 
things  depend  on  one  everlasting  Creator  and  Ruler." 

Small-pox  is  still  with  us.  The  outbreak  at  St.  John's 
Wood,  which  I  reported,  is  the  most  serious  we  have  had 
since  1885,  DUt  **  appears  to  have  been  conquered  by  the 
determined  and  active  intervention  of  the  sanitary 
authorities.  But  for  the  energy  displayed,  we  might 
have  found  it  extending  to  the  whole  metropolis. 

A  steamer  arrived  off  Gravesend,  from  St.  Petersburg, 
bringing  cholera,  one  of  the  crew  having  died  on  the 
short  voyage.  The  vessel  was  visited  at  once  by  the 
medical  officer  of  health,  and  one  or  two  suspicious  cases 
removed  for  observation.  The  bacteriological  diagnosis 
is  cholera.  We  may  probably  have  other  importations, 
but  if  all  are  as  carefully  segregated  we  may  perhaps  es- 
cape an  epidemic. 

The  bacillus  of  the  bubonic  plague  has  been  sent  to 
London,  and  was  exhibited  at  Bristol  also,  where  a  very 
fine  collection  of  cultivations  of  bacteria  was  shown  by 
the  Institute  of  Preventive  Medicine ;  all  sorts  of  micro- 
organisms were  exhibited  growing  on  various  media, 
and  would  give  the  opportunity  of  acquiring  or  extend- 
ing knowledge  to  most  people,  could  time  be  afforded  for 
serious  study.  Of  course,  in  a  crowd  at  such  an  exhibi- 
tion this  is  impracticable. 

Dr.  Griffiths,  of  Swansea,  to  whose  cruel  case  of  slan- 
der I  have  alluded  in  previous  letters,  has  received  ^500 
from  the  fund  started  in  his  defence,  with  an  illuminated 
address  of  sympathy. 

The  medical  superintendent  of  Rainhill  Asylum,  Dr. 
Wiglesworth,  has  been  stabbed  by  one  of  the  lunatics 
who  had  concealed  a  knife  in  his  sleeve.  The  wound  is 
serious,  and  the  doctor  not  yet  out  of  danger. 

Sir  Joseph  Fayrer  is  about  to  retire  from  the  service  in 
which  he  has  done  such  admirable  work. 


Double  Pay  for  Twins. — A  man  in  Ohio  was  arrested 
not  long  ago  at  the  instance  of  a  woman  who  claimed 
that  he  was  the  father  of  her  unborn  child.  He  was  re 
leased  on  payment  of  #300.  But  when  the  time  came  it 
was  found  that  there  were  twins,  and  the  poor  man  was 
arrested  again,  and  the  penalty  for  his  misdoing  was 
promptly  doubled  by  a  sympathetic  jury. 


September  i,  1894] 


MEDICAL    RECORD. 


2S7 


f^ero  %xi&txximzntB. 

A   LID    ELEVATOR    FOR    CATARACT    OPERA- 
TION. 
By   EDWARD   SWASEY,    M.D., 

WORCESTER,   MASS. 
OCULIST  AND  AURIST  TO    WORCESTER  CITY  HOSPITAL 

The  most  troublesome  instrument  that  is  used  about  the 
eye  in  removal  of  cataract,  and  in  all  operations  in  which 
the  globe  is  opened,  is  undoubtedly  the  speculum.  And 
moreover,  it  is  always  a  possible  means  of  injury  to  the 
eye,  for  the  patient  may  at  any  moment  forcibly  press  it 
down  upon  the  globe  by  the  strong  action  of  the  orbic- 
ularis muscle,  and  if  the  corneal  section  has  been  com- 
pleted, he  will  almost  surely  force  the  lens  out  pre- 
maturely, and  not  infrequently  some  ot  the  vitreous  will 
follow  it. 

Because  of  this  danger,  some  of  our  best  operators  care- 
fully remove  the  speculum  as  soon  as  the  lens  capsule 


r:zz^:^3 


has  been  opened,  and  thus  avoid  this  possible  dangerous 
compression  of  the  incised  globe.  Others  do  away  with 
the  speculum  entirely,  and  elevate  the  upper  lid  by  means 
of  the  lid  elevator,  held  by  an  assistant  But  the  arm  of 
an  assistant  is  unavoidably  more  or  less  in  the  operator's 
way,  and  must  be  worked  around,  even  if  a  trained  and 
trustworthy  hand  of  an  assistant  could  always  be  at  com- 
mand to  hold  the  elevator.  But  an  instrument  which 
securely  holds  the  lid  open,  and  has  its  point  of  anchor- 
age outside  the  lids,  is  much  freer  from  the  danger  of  this 
compression  of  the  eye  than  is  the  speculum,  which  sim- 
ply rests  within  the  lids.  And  at  best,  the  speculum  is 
an  awkward  instrument  to  unlock  and  remove  from  un- 
der the  two  lids,  at  a  time  when  the  utmost  gentleness  is 
necessary  in  every  step  of  the  operation.  At  least  I  have 
found  it  so,  and  seeing  the  simplicity  of  the  lid  elevator, 
I  have  tried  to  make  use  of  it,  and  yet  be  free  from  an 
assistant.  The  little  device  shown  in  these  drawings  ac- 
complishes the  object.  The  lid-hook  of  the  elevator  is 
carved  into  the  shape  shown  at  A,  and  it  then  holds  se- 
curely under  the  lid  ;  the  ordinary  form  is  at  once  tilted 
from  under  the  lid  at  the  first  attempt  to  close  the  lid. 
This  is  attached  by  a  flat-linked  chain  to  a  small,  blunt, 
shallow  hook  on  a  forehead  piece  which  is  securely  held 
in  place  by  the  ordinary  head-band.  The  chain  is  two 
and  a  half  inches  in  length,  and  has  eleven  open  links, 
which  admit  of  fine  adjustment  of  the  lid  elevation ;  the 
hook  gives  an  additional  length  of  half  an  inch.  The 
shallow  hook  allows  the  quick  and  easy  removal  of  the 
chain  without  forcibly  drawing  on  the  lid,  and  once  de- 
tached the  lid  hook  is  as  readily  slipped  from  under  the 
lid  as  any  elevator.  The  flat  links  adjust  themselves  to 
any  angles  that  are  found  from  the  lid  piece  to  the  head- 
band, and  the  whole  field  of  view  is  unobstructed  for 
the  operator.  The  patient  cannot  even  begin  to  close 
his  eye  with  this  in  place. 

The  chief  objections  I  find  to  the  Pyle  instrument1  are 
that  it  projects  forward  from  the  brow  so  far  that  it  se- 

1  Medical  Record,  August  i,  1891,  p.  139. 


riously  obstructs  the  operator's  view,  and  the  adjustments 
are  so  many,  too  much  mechanism  is  required.  I  have 
made  use  of  the  instrument  here  described  in  cataract 
operations,  and  it  certainly  has  advantages  over  the  or- 
dinary speculum ;  it  is  so  quickly  and  easily  removed. 
George  Tiemann  &  Co.,  of  New  York,  made  the  instru- 
ment for  me. 

A   POCKET  PELVIMETER. 
By  HERMAN  L.  COLLYER,  M.D., 

NEW  YORK. 

GYNECOLOGIST  TO  THE  WEST  SIDE  GERMAN  CLINIC,  ASSISTANT  GYNECOLOGIST  TO 
THE  FRENCH  HOSPITAL,  El  C. 

The  measurements  of  the  female  pelvis  are  so  great  a 
necessity  in  obstetrics  that  I  feel  a  simply  constructed, 
inexpensive  instrument,  within  the  reach  of  every  physi- 
cian, would  be  very  acceptable,  and  would  tend  to  en- 
courage pelvimetry  in  the  profession  generally. 

It  is  a  frequent  occurrence  that  a  contracted  pelvis  is 
unrecognized  until  the  labor  has  become  tedious,  at  a 
time  when  symphyseotomy  is  made  difficult  by  the  delay. 

In  my  first  case  of  elective  symphyseotomy,  performed 
successfully  June  5,  1894,  I  was  led  to  devise  some  ac- 
curate, inexpensive  pelvimeter,  possessing  all  the  advan- 
tages of  the  expensive  instruments,  and  correcting  some 
of  their  disadvantages.  As  the  idea  is  purely  original,  I 
may  say,  I  hope  by  the  insertion  of  this  article  my  read- 


ers will  derive  benefit  from  my  endeavors  and  be  encour- 
aged to  practise  pelvimetry  more  extensively. 

The  instrument  is  twelve  inches  long,  elliptical  in 
shape,  capable  of  measuring  to  the  extent  of  fourteen 
inches,  with  a  pivot  hinge  and  thumb-screw  attached  to 
one  end.  At  this  end  there  is  a  semicircular  plate, 
marked  legibly  with  the  metric  system  on  the  one  side, 
and  the  English  system  of  measurement  on  the  other,  in 
a  convenient  position  to  be  read  easily.  The  advantage 
of  having  the  two  systems  together  is  very  great,  as  it 
admits  of  ready  comparison  and  reference. 

Through  the  kindness  of  Mr.  J.  Welker,  instrument- 
maker,  of  this  city,  I  am  able  to  present  to  the  profession 
a  portable  and  inexpensive  pelvimeter,  which  will,  I 
think,  commend  itself  to  everyone. 

109  East  Fifty-fourth  Street. 


Salines  operate  in  three  or  four  hours.  Croton-oil  in 
one  or  two  hours.  Jalap,  gamboge,  and  senna  in  three 
or  four  hours.  Rhubarb  and  castor-oil  in  from  four  to 
six  hours.  Aloes  and  mandrake  in  from  ten  to  fourteen 
hours. — Louisville  Medical  Monthly. 


288 


MEDICAL   RECORD. 


[September  I,  1894 


IJfcedical  Sterna 

Contagions  Diseases— Weekly  Statement— Report  of 
cases  and  deaths  from  contagious  diseases  reported  to  the 
Sanitary  Bureau,  Health  Department,  for  the  week  end- 
ing August  25,  1894. 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-fpinal  meningitis 

Measles 

Diphtheria 

SmaH-poi 


Caies.        Deaths. 


86 

"5 

26 

7 

22 

X 

O 

2 

IX 

2 

"3 

36 

7 

0 

To  Increase  the  Birth-rate  of  France. — Stringent 
laws  have  recently  been  enacted  by  the  French  Govern- 
ment, which,  despairing  of  obtaining  any  increase  in  the 
birth- rate  of  the  land,  is  endeavoring  to  save  the  few 
children  that  are  born.  One  of  these  regulations  forbids, 
under  a  severe  penalty,  anyone  to  give  infants  under 
one  year  any  form  of  solid  food,  unless  such  be  ordered 
by  a  written  prescription,  signed  by  a  legally  qualified 
medical  man.  Other  regulations  are  equally  restricting, 
and,  as  the  French  have  a  knack  of  enforcing  their  en- 
actments, down  to  the  most  trifling  ones,  as  American 
visitors  to  Paris  often  find  to  their  cost,  it  is  probable 
that  many  childish  lives  will  be  saved.  One  could  wish, 
on  seeing  an  East-Side  tenement  mother  feeding  her  few 
months'  old  baby  with  a  peach  or  banana  bought  from 
the  curb  fruit-stall,  after  half  a  day's  exposure  to  the 
August  sun,  that  the  municipality  of  New  York  would 
copy  a  few  of  these  French  regulations.  It  would  vastly 
lessen  the  work  of  the  dispensaries  and  visiting  tenement 
physicians. 

The  Treatment  of  Diphtheria  with  Immunizing  Se- 
rum.— Professors  Ehrlich,  Kossel,  and  Dr.  Wasserman, 
in  Berlin,  have  published  a  paper  on  the  application 
of  curing  serum,  as  invented  by  Professor  Behring,  as- 
sistant of  Professor  Koch.  Behring  had  undertaken  to 
give  an  immunity  from  the  diphtheritic  poison,  and 
after  that  to  get  a  serum  from  the  blood  of  those 
animals,  by  which  he  hoped  to  protect  individuals  of 
the  human  race  against  the  results  of  diphtheria,  as 
well  as  to  cure  the  disease  when  already  developed  in  an 
individual.  Ehrlich,  Kossel,  and  Wasserman  have  fol- 
lowed Behring  in  his  experiments.  They  always  had  in 
view  to  use  the  results  of  their  experiments  for  curative 
purposes.  They  experimented  on  goats.  We  will  say 
nothing  of  the  technical  dates  for  giving  the  serum. 
Two  hundred  and  twenty  patients  with  diphtheria  were 
treated  with  the  serum.  Of  these  there  were  cured  168, 
or  76.4  per  cent.;  52  died.  Tracheotomy  was  performed 
in  67  cases,  of  which  30  died ;  the  rest  recovered.  But 
a  true  insight  of  the  curing  effects  of  the  injections  is 
gathered  only  by  grouping  the  number  of  the  diseased 
people  by  the  days  after  the  infection  on  which  the 
treatment  was  begun : 


Day  after  be- 
gt fining  of 


Treated. 


First  day 6 

Second  day ...  66  (9  tracheot- 
omies.) 

Third  day ao  (8  tracheot- 
omies.) 

Fourth  day ...  39  (14  tracheot- 
omies. ) 

Fifth  day 23  (10  tracheot- 
omies. ) 


Cured. 


64  (7  tracheot- 
omies. ) 

25  (7  tracheot- 
omies. ) 

30  (10  tracheot- 
omies.) 

13  (4  tracheot- 
omies.) 


Died. 


a  (a  tracheot- 
omies. ) 

4  (1  tracheot- 
omy.) 

9  (4  tracheot- 
omies.) 
10  (6  tracheot- 
omies. ) 


Percentage 
of  cures. 


100 
97 

86 
77 
56-5 


It  is  to  be  seen  by  this  table  of  dates  that  the  safety  of 
the  serum  treatment  depends  essentially  upon  the  date 
on  which  the  treatment  of  the  children  is  begun,  and 
that  on  the  first  day  results  were  had  never  seen  before. 
Of  72  children  received  at  the  hospital  during  the  first 
two  days  of  the  disease,  there  were  only  2  deaths ;  of  72 


cases  treated  without  serum  after  statistics  reaching  over 
twenty  five  years,  there  were  25  deaths,  or  34. 7  per  cent 
The  above- named  experimenters  give  the  following 
points  of  view  for  the  treatment  with  their  serum  of  those 
children  sick  of  diphtheria :  1.  The  fate  of  the  children 
depends  upon  the  treatment  during  the  first  three  days  0/ 
the  sickness.  Therefore  the  serum  should  be  injected  as 
soon  as  possible  after  the  beginning  of  the  disease.  2. 
As  there  must  be  a  surplus  of  antitoxine  in  the  sick  body, 
the  dose  of  commencement  should  be,  in  light  cases,  at 
least  200  unities  of  immunization.  In  cases  of  gravity 
and  in  those  tracheotomized,  400  unities  were  needed. 
The  treatment  with  serum  should  be  continued  some 
time  after  ceasing  of  rise  of  temperature  and  of  the  local 
inflammation.  The  total  amount  of  dispensed  serum 
may  reach  in  a  single  case  (in  correspondence  with  the 
gravity  of  the  symptoms)  500, 1,000,  1,500  unities  of  im- 
munization.— Berlin  Correspondent  Journal  of  American 
Medical  Association. 

A  Revival  of  Hindu  Medicine. — The  educated  na- 
tives of  India  intermittently  advocate,  through  the  native 
press,  the  resuscitation  of  indigenous  and  time-honored 
methods  of  treating  disease  which  have' fallen  into  disre- 
pute and  disuse.  The  merits  of  ancient  drugs  and  of 
primitive  practices  and  practitioners  are  on  such  oc- 
casions vaunted  as  being  better  in  themselves  and  better 
adapted  to  the  people  and  circumstances  of  Hindustan 
than  exotic  systems  and  medicines.  It  appears  that  dis- 
pensaries have  been  established  in  the  native  states  of 
Travancore  and  Mysore,  for  the  purpose  of  giving  the 
natives  of  these  territories  the  benefits  of  Hindu  medi- 
cines, which  are  considered  more  congenial,  cheap,  and 
efficacious  than  foreign  medicines.  Foreign  surgery  is 
allowed  to  be  infinitely  superior  to  native,  and  no  at- 
tempt is  made  to  compete  with  that.  It  is  recognized 
that  native  doctors  are,  with  few  exceptions,  ignorant 
and  uneducated,  and  it  is  proposed  to  teach  them 
"chemistry,  physiology,  hygiene,  and  other  kindred 
subjects.  * 

Worse  than  "  Pidgin."— Dr.  W.  P.  Noble,  of  Pao 
Ting  Foo,  China,  sends  us  the  following  letter,  addressed 
to  him  by  a  native  in  government  employ  in  that  city : 
"  I  am  deject  indeed  for  I  got  a  kind  of  measles  and 
cannot  come  to  your  Hospital  because  on  duty  this 
noon;  I  not  know  whether  you  can  come  to  my  office 
or  not,  I  hope  you  come  and  let  you  know  what  measles 
it  is.  If  you  allow  me  well  much  hosanna  recieve  from 
you.  I  cannot  conceal  my  sickness  from  you.  When  I 
make  water  the  water  come  to  the  end  and  stop  there 
until  a  little  while,  then  meander  out  in  that  time  of 
which  I  speak  that  is  very  painful.  I  hope  you  excuse 
me  at  once. 

"Yours  respectifully, 

"  P.  S.  W." 

The  Difference.— When  a  lawyer  defends  a  man  for 
his  life,  and  by  some  technicality  or  shrewdness  he  gains 
his  case  that  lawyer  is  often  spoken  of  as  "  that  man 
who  saved  my  life."  When  a  person  is  stricken  down, 
we  will  say  with  strangulated  hernia,  just  as  sure  death 
as  hanging  unless  relieved,  he  sends  for  the  physician, 
who  understands  this  technicality  of  nature,  and  relieves 
him,  saves  him  not  from  the  gallows,  but  death.  He 
does  not  say  "that  physician  saved  my  life,"  but 
"through  the  providence  of  God  I  escaped  death." — 
Charlotte  Medical  Journal. 

Lively  Apothecaries  and  Deadly  Consequences. — In 
Stendal,  not  long  since,  the  police  forcibly  closed  a  drug- 
store where  they  found  the  proprietor  away,  and  the  two 
clerks  intoxicated.  Before  their  condition  was  discovered 
they  had  compounded  a  number  of  prescriptions,  mixing 
up  various  drugs  without  any  regard  to  directions  or 
dosage. 

The  Plague  in  London  in  1664,  with  which  the  pres- 
ent epidemic  in  China  is  believed  to  be  identical,  caused 
69,000  deaths  out  of  a  total  population  of  460,000. 


Medical  Record 

A  Weekly  yournal  of  Medicine  and  Surgery 


Vol.  46,  No,  10. 
Whole  No.  1244. 


New  York,  September  8,  1894. 


$5.00  Per  Annum. 
Single  Copies,  ioc. 


<&ri0ttrat  Qxtitlts. 

SOME  CONSIDERATIONS  ON  DIFFERENT  TYPES 
OF  EXUDATIVE  INFLAMMATION.* 

A  Study  Based  on  Bacterial  Examinations  from  One 
Hundred  and  Thirty-five  Surgical  Cases. 

By  CHARLES  N.  DOWD,  M.D., 

NEW  YORK. 
ASSISTANT  SURGEON  TO  THK  NEW  YORK  CANCKR  HOSPITAL. 

It  is  evident  that  all  inflammations  which  call  for  sur- 
gical treatment  are  not  alike :  some  spread  in  the  tissues 
rapidly  and  persistently;  some  remain  localized,  but 
cause  necrosis  of  the  involved  tissues;  others  neither 
spread  far  nor  cause  severe  injury  to  the  affected  parts. 
Again,  some  cause  profound  constitutional  disturbance 
with  very  slight  local  effect,  while  others  produce 
extensive  local  disturbance  with  slight  constitutional 
effect.  Some  cause  discharges  of  greenish,  odorous  pus, 
so  profuse  as  to  quickly  saturate  bulky  dressings;  others 
give  only  a  small  amount  of  thin,  sero  purulent  effusion. 
These  differences  are  largely  due  to  the  particular  species 
of  bacteria  which  cause  the  inflammation,  and  to  varia- 
tions in  virulence  which  bacteria  of  the  same  species  may 
show,  although  the  site  of  the  infection  and  the  condi- 
tion of  the  patient  may  have  much  influence. 

In  the  effort  to  investigate  the  subject,  we  have  in  the 
past  year  made  bacterial  studies  from  135  cases  which 
were  seen  in  the  Vanderbilt  Clinic,  the  New  York  Can- 
cer Hospital,  and  in  two  instances  in  the  practice  of  other 
surgeons  who  gave  us  the  opportunity  of  studying  cases 
of  pyaemia. 

Those  seen  at  the  Vanderbilt  Clinic  were  ambulant 
cases ;  a  large  number  of  them  had  acute  forms  of  sup- 
purative inflammation,  which  had  originated  from  small 
wounds  or  had  extended  into  the  subcutaneous  tissues,  so 
as  to  cause  cellulitis  of  greater  or  less  extent.  Some  had 
fresh  wounds  with  little  inflammation  about  them ;  some 
granulating  and  healing  wounds,  and  some  furuncles 
and  abscesses  of  a  less  acute  type. 

Those  seen  at  the  Cancer  Hospital  were  operative 
cases.  In  some  of  them  ulcerating  growths  were  exam- 
ined before  operation ;  in  others  wound  discharges  and 
stitches  were  examined  after  operation. 

The  cases  may  be  clinically  grouped  as  follows : 

Cases. 

Cellulitis 51 

Fresh  infected  wounds 17 

Granulating  wounds. 18 

Healing  wounds  (stitches). 5 

Furuncles 7 

Abscesses 37 

The  material  for  study  was  obtained  on  the  sterile 
swabs  which  have  been  described  by  Dr.  Park.1  They 
are  made  by  twisting  bits  of  cotton  on  the  ends  of  pieces 
of  stiff  wire.  They  were  inserted  into  the  depths  of  the 
wounds  so  as  to  avoid  surface  contamination,  and  were 
immediately  streaked  across  agar  Petri's  plates.  The 
plates  were  then  put  into  the  thermostat  and  the 
growths  studied  in  the  ordinary  way  with  the  microscope, 
and  by  further  gelatine  and  beef- tea  cultures ;  also  by 
animal  inoculations  in  certain  instances.     In  a  large  pro- 

•  Read  before  the  Surgical  Section  of  the  New  York  Academy  of 
Medicine,  March  12,  1894. 


portion  of  the  cases  morphological  studies  of  cover-glass 
preparations  of  the  pus  were  also  made. 

The  bacterial  work  was  done,  with  the  collaboration 
of  Dr.  William  H.  Park,  in  the  Bacterial  La t oratory  of 
the  College  of  Physicians  of  New  York  City,  or  in  con- 
nection with  that  laboratory. 

The  following  table  indicates  in  a  diagrammatic  way 
the  results  of  the  examinations : 


ii 


Streptococcus  pyogenes  alone .        9 

Streptococcus  pyogenes  predominant 23  1 

Streptococcus  pyogenes  relatively  few 3 

Staph,  pyogenes  aureus  alone z  z  1 

Staph,  pyogenes  aureus  predominant 8 

Staph,  pyogenes  aureus  relatively  few Z3 

Staph,  pyogenes  or  epidermis  albus  alone x 

Staph,  pyogenes  or  epidermis  albus  predominant 

Staph,  pyogenes  or  epidermis  albus  relatively  few..  J  zo 

Staph,  cereus  albus 3 

Staph,  citreus z 

No  growths  on  agar 

Very  few  growths  on  agar 

Bacillus  pyocyanus  .. ' 

Bacillus  coli  com  muni 

Overgrown 4: 

Few  undetermined  colonies za 


fflju.srj 

'3 '    - 

3       


v 

u 


In  those  instances  in  which  streptococcus  pyogenes 
are  recorded  "  predominant,"  the  associated  forms  were 
mostly  staphylococci,  and  in  those  instances  in  which 
staphylococci  are  recorded  predominant,  the  associated 
forms  were  mostly  streptococci. 

Analysis  of  the  Tabulated  Besults. — From  all  the 
cases  in  which  there  was  acute  inflammation  accompa- 
nied by  severe  constitutional  symptoms,  abundant  cultures 
of  streptococcus  pyogenes  or  of  staphylococcus  pyogenes 
aureus  were  obtained;  frequently  both  existed  in  the 
same  case.  These  two  organisms  were  by  far  the  most 
important  ones  found,  and  as  there  were  well-marked  pe- 
culiarities in  many  of  the  inflammations  which  they 
caused,  it  may  be  well  to  give  a  somewhat  detailed  ac- 
count of  the  conditions  in  which  they  occurred.  To 
this  we  add  a  description  of  the  conditions  in  which  cer- 
tain other  forms  were  found. 

Streptococcus  Pyogenes. — Among  the  fifty  one  c*ses 
of  cellulitis  studied  there  were  eight  which  showed  a  per- 
sistent tendency  to  spreading  inflammation  with  under- 
mining of  the  tissues,  which  continued  in  spite  of  free 
incision,  careful  packing,  and  mcist  dressing,  and  in  all 
of  these  streptococci  were  found. 

As  an  example  of  this  group  we  may  note  one  in 
which  an  inflammation  which  involved  the  entire  fore- 
arm spread  rapidly  from  a  small  butcher- knife  cut  on  the 
back  of  the  hand ;  free  incisions  were  promptly  made, 
the  wounds  were  carefully  packed  with  gauze,  and  moist 
antiseptic  dressings  were  applied,  much  of  the  time  daily. 
Still  fiie  inflammation  continued  for  more  than  three 
months,  the  fascia  sloughed  away  in  large  pieces,  and 
there  was  a  continual  undermining  of  the  tissues,  with 
the  formation  of  pus  pockets  even  when  healing  was  pro- 
gressing at  the  margins  of  the  incisions;  and  finally  the 
patient  was  left  with  a  stiffened  hand  and  wrist.  Re- 
peated bacterial  examinations  of  the  pus  showed  only 
streptococci  pyogenes  in  the  depths  of  the  wound,  while 
a  few  staphylococci  were  also  twice  found  on  the  sur- 
face. 


290 


MEDICAL    RECORD. 


[September  8f  1894 


The  two  cases  of  pyaemia  illustrated  the  same  charac- 
teristic spreading,  undermining  streptococcus  inflamma- 
tion. In  bov.h;  the  streptococcus  and  staphylococcus 
pyogenes  aureus  were  found  in  the  original  wounds,9 
while  in  the  metastatic  abscesses  the  streptococci  were 
found  without  the  staphylococcus  pyogenes  aureus.  In 
the  first  a  phlegmon  of  the  arm  appeared  a  week  after 
the  operation,  and  progressed  until  it  involved  the 
entire  arm  and  hand ;  a  little  later  there  was  a  similar 
phlegm Dn  in  the  back;  there  was  also  inflammation 
in  several  of  the  joints.  Incisions  were  made  at  differ- 
ent times  in  five  separate  places  in  the  back  and  arm, 
and  pure  cultures  of  streptococci  were  obtained  from  the 
pus  found  at  each  incision;  the  abscesses  were  persist- 
ent ;  the  one  in  the  back  remained  open  six  months,  un- 
til the  patient's  death.  In  the  other  case  the  metastatic 
abscesses  were  of  a  similar  character,  but  less  extensive. 

This  spreading,  undermining  characteristic  of  strepto- 
coccus inflammation  has  been  often  described  and  is  well 
established.  Inflammations  of  this  variety  were  the  most 
virulent  which  we  had  to  deal  with ;  no  available  treat- 
ment seemed  sufficient  to  promptly  limit  the  growth  of 
the  streptococci  in  the  tissues;  cultures  could  be  ob- 
tained from  the  walls  of  the  pockets  after  washing  them 
with  a  1  to  1,000  solution  of  bichloride  of  mercury,  and 
free  and  early  incision  and  packing  did  not  prevent  the 
undermining  process  of  the  inflammation. 

There  was  a  group  of  cases  closely  allied  to  these  in 
which  streptococci  were  always  found;  cases  which 
represent  an  intermediary  phase  between  typical  cellu- 
litis and  typical  erysipelas.  In  the  skin  there  was  indu- 
ration and  an  inflammation  somewhat  less  distinctly  mar- 
ginated  than  in  typical  erysipelas ;  in  the  subcutaneous 
tissue  a  little  pus  was  found. 

The  condition  is  illustrated  by  the  following  case :  A 
healthy  man  scratched  his  hand  on  a  dry-goods  box  one 
week  before  admission  to  the  clinic.  Three  days  later 
he  began  to  have  pain  on  the  anterior  surface  of  the  arm 
j  1st  above  the  elbow,  and  at  the  same  time  he  had  a  chill. 
Oa  admission  there  was  an  indurated  area  on  the  anterior 
surface  of  the  arm  about  5x6  inches  in  extent.  The 
skin  was  oeiematous  and  red.  On  the  outer  side  the 
redness  was  marginated  and  extended  half  way  down  the 
forearm.  Oa  the  inner  side  it  was  not  marginated. 
Temperature,  ioo°  F. ;  pulse,  80.  There  was  hardly  any 
axillary  tenderness  or  enlargement  of  lymph  nodes. 
There  was  no  distinct  fluctuation,  but  an  aspirating  needle 
inserted  just  above  the  elbow  withdrew  pus  from  which  a 
pure  culture  of  streptococcus  was  obtained. 

Most  surgeons  would  not  call  this  erysipelas,  but  in 
the  seven  cases  which  were  of  this  general  type  we  were 
much  puzzled  to  know  whether  we  were  dealing  with  ery- 
sipelas or  cellulitis,  and  in  one  instance  a  patient  who 
had  diffuse  induration  and  inflammation  about  an  infected 
wound,  which  seemed  far  less  like  erysipelas  than  the 
above,  returned  on  the  second  day  with  typical  erysipelas 
so  well  marked  that  no  one  would  question  the  diag- 
nosis. 

Cases  like  these  make  a  chain  of  union  between  erysip- 
elas and  cellulitis,  which  would  lead  us  to  believe  that 
there  is  no  absolute  and  fundamental  distinction  between 
the  two  phases  of  inflammation.  This  is  practically  the 
same  ground  which  bacteriologists  have  taken. 

Passet.2  Rosenbach,8  Prudden,4  Biondi,5  Fraenkel,6 
Roger,7  Welch,3  Baumgarten,*  Kirchner,10  Crookshank,11 
and  many  others,  have  studied  the  relationship  between  the 
streptococcus  pyogenes  and  streptococcus  erysipelatis, 
and  the  weight  of  authority  indicates  that  there  are  no 
constant  differences  between  them,  and  that  the  varia- 
tions are  no  greater  than  are  frequently  seen  in  individuals 
of  the  same  species. 

It  is,  however,  a  point  of  considerable  importance,  that 
infection  from  one  type  of  streptococcus  inflammation  is 
likely  to  reproduce  the  same  type.  Infection  from  erysip- 
elas is  likely  to  cause  erysipelas,  as  all  surgeons  know  and 
as  Fehleisen  n  proved  by  a  series  of  inoculations.  Just 
how  likely  it  is  to  produce  other  forms  of  inflammation 


we  do  not  know,  but  Coley"  in  making  120  inoculations 
to  produce  erysipelas,  only  caused  two  abscesses,  and 
these  he  thought  were  due  to  contaminations  of  staphy- 
lococci Hajek 14  found  that  the  original  type  of  strepto- 
coccus inflammation  was  usually  reproduced  in  inoculated 
animals. 

This  close  alliance  between  erysipelas  and  phlegmonous 
inflammation  is  a  matter  of  much  practical  importance. 
We  fear  erysipelas  and  avoid  all  contact  with  it  when 
engaged  in  operative  work.  The  man  who  would  care 
for  a  case  of  erysipelas  and  then  do  an  operation  or  at- 
tend an  obstetric  case,  would  be  considered  very  culpable. 
Yet  the  same  precautions  are  not  taken  in  regard  to  other 
kinds  of  streptococcus  inflammation.  A  suppurating 
wound  in  which  the  pus  teems  with  streptococci  is  cer- 
tainly more  likely  to  contaminate  the  surgeon's  hands 
than  a  case  of  erysipelas  is,  and  this  contamination  may 
well  be  followed  by  suppuration,  phlegmonous  inflamma- 
tion, or  perhaps  by  pyaemia,  in  the  patient  whom  he  oper- 
ates upon  soon  afterward.  But  such  an  occurrence  would 
be  considered  an  unavoidable  wound  accident,  while  the 
erysipelas,  which  is  more  characteristic,  would  be  traced 
to  its  true  source.  The  danger  of  transmitting  erysipelas 
has  long  been  guarded  against,  because  the  infecting  case 
and  the  infected  case  so  closely  resemble  each  other. 
But  when  we  remember  that  in  any  case  of  streptococcus 
inflammation  we  are  dealing  with  a  germ  which  is  not  to 
be  distinguished  from  that  which  causes  erysipelas,  and 
furthermore,  that  it  is  often  capable  of  causing  an  inflam- 
mation more  virulent  than  erysipelas,  it  is  obvious  that 
the  greatest  care  is  necessary  to  avoid  transmitting  in- 
fection. 

Beside  these  groups  of  cases,  streptococci  were  fre- 
quently found  where  there  was  nothing  particularly  char- 
acteristic. They  were  present  in  65  out  of  the  135 
cases  examined.  They  were  found  in  almost  all  the  cases 
of  severe  inflammation,  but  they  were  also  present  in 
many  of  the  mild  ones,  and  they  did  not  always  cause  a 
spreading  inflammation.  In  one  instance  they  were 
found  in  almost  pure  culture  in  a  finger  bleb  which 
seemed  hardly  more  than  a  large  blister,  and  which  had 
existed  for  several  days  without  showing  acute  inflamma- 
tion. Whether  these  differences  depend  on  the  varie- 
ties of  streptococci  and  their  variations  in  virulence 
on  the  constitution  of  the  patient,  or  on  the  thorough- 
ness of  the  inoculation,  one  can  hardly  state.  Probably 
all  these  factors  have  their  influence.  The  condition 
finds  its  parallel  in  other  forms  of  infection ;  for  example, 
the  bacillus  typhosus  sometimes  causes  only  a  slight  fever 
and  sometimes  causes  death,  and  Loeffler's  bacillus  some 
times  causes  a  slight  sore  throat,  and  sometimes  a  diph- 
theria which  is  quickly  fataL 

Variations  in  the  growth  of  the  streptococci  were  no- 
ticeable. Some  grew  in  long  chains  and  some  in  short 
ones ;  and  the  colonies  differed  in  their  general  appear- 
ance microscopically  and  macroscopically,  also  in  the 
quality  of  imparting  cloudiness  to  the  beef-tea  in  which 
they  grew.  In  view  of  the  work  of  v.  Lingelsheim 15  on 
the  subject,  we  noted  the  relationship  between  the  length 
of  the  chains  and  the  virulence  of  the  infection,  and 
found  that  in  certain  instances  the  short-  as  well  as  the 
long-chained  varieties  were  virulent. 

Staphylococcus  Pyogenes  Aureus. — In  the  entire  series 
of  135  cases  it  was  found  in  pure  cultures  26  times, 
and  in  no  one  of  these  cases  was  there  a  spreading  in- 
flammation. The  cases  of  cellulitis  of  the  hand  illustrate 
this  well — there  were  1 1  of  them  in  which  staphylococcus 
pyogenes  aureus  alone  was  found,  and  in  no  instance  did 
the  inflammation  extend  upward  so  as  to  make  incision 
above  the  wrist  necessary ;  while  in  the  23  cases  in  which 
streptococci  were  the  predominant  bacteria,  there  were  5 
in  which  incision  was  necessary  at  some  point  above  the 
wrist,  and  streptococci  were  found  in  these  incisions. 

A  boil  illustrates  in  a  limited  way  the  type  of  inflam- 
mation which  these  staphylococci  cause :  a  severe  in- 
flammation producing  necrosis  of  tissue  and  giving  a 
comparatively  severe  constitutional  reaction,  but    not 


September  8,  1894] 


MEDICAL    RECORD. 


291 


spreading  widely  by  direct  extension.  Seven  boils  were 
examined,  and  all  had  them  in  pure  culture. 
-  The  following  case  also  illustrates  this  kind  of  inflam- 
mation :  The  patient  sustained  a  compound  fracture  of 
the  middle  phalanx  of  the  ring-finger,  which  was  followed 
by  inflammation  in  the  soft  parts  and  in  the  bones. 
Three  weeks  after  the  injury  amputation  was  done  through 
the  proximal  phalanx,  in  the  hope  of  preserving  a  part  of 
the  ringer,  but  suppuration  continued  in  the  soft  parts  of 
this  stump  for  more  than  two  months.  The  inflamma- 
tion, however,  never  extended  above  the  finger.  It  was 
severe  enough  to  destroy  the  bone  before  the  amputation 
and  to  keep  up  a  most  tedious  suppuration  after  it,  but 
it  did  not  show  any  tendency  to  extend  upward. 

Cultures  were  made  from  this  wound  at  six  different 
times,  and  unmixed  growths  of  staphylococcus  pyogenes 
aureus  were  obtained  in  all  instances  excepting  one ;  in 
that  one  a  contamination — presumably  saprophytic — was 
also  found.  We  are  well  aware  that  these  staphylococci 
may  enter  the  blood  current  and  cause  a  fatal  pyaemia, 
and  that  they  have  been  found  in  many  cases  of  osteo- 
myelitis,16 but  in  this  series  of  cases  they  remained  loca- 
lized even  when  the  streptococci  which  accompanied 
them  in  the  original  wound  caused  metastatic  abscesses. 

These  staphylococci  have  frequently  been  considered 
more  important  than  the  streptococci,  but  the  recent  bac- 
terial studies  indicate  that  the  streptococci  are  the  more 
important  and  the  more  common ;  in  this  series  of  cases 
they  were  certainly  so.  It  is  to  be  remembered  that  the 
staphylococci  grow  in  large  thick  colonies  on  the  agar, 
while  the  streptococci  grow  in  small  thin  colonies; 
hence  it  is  possible  that  in  some  cases  which  have  been 
reported  the  streptococci  may  have  been  covered  by  the 
large  colonies  of  staphylococci.  One  of  the  cases  here 
recorded  shows  how  easily  such  an  error  could  be  made. 
An  infected  wound  was  surrounded  by  an  inflammation 
which  had  the  appearance  of  a  streptococcus  inflamma- 
tion, but  the  first  culture  showed  abundant  staphylococci 
and  very  few  streptococci;  a  second  culture,  however, 
taken  on  another  day  from  an  undermining  part  of  the 
wound,  showed  streptococci  almost  alone.  It  would  ob- 
viously have  been  an  error  to  conclude  from  the  first  ex- 
amination that  this  was  an  instance  of  staphylococcus 
inflammation.  The  difficulties  of  finding  the  colonies  of 
streptococci  are  greater  where  roll  tubes  are  used  than 
with  Petri's  plates. 

Staphylococcus  pyogenes  aureus  was  also  found  in  cer- 
tain instances  in  mild  inflammations  in  which  there  was 
nothing  particularly  characteristic. 

The  inflammations  caused  by  staphylococcus  pyogenes 
aureus  were  much  more  easily  controlled  than  those 
caused  by  streptococci.  Moderate- sized  incisions  with 
gauze  packing  and  moist,  mild  antiseptic  dressing,  were 
usually  quickly  efficient. 

Staphylococcus  Pyogenes  Aldus — Staphylococcus  Epi- 
dermis Albus.— Besides  those  mild  cases  already  referred 
to  there  was  a  group  of  cases  which  showed  a  mild 
form  of  inflammation  and  gave  cultures  of  white  staphy- 
lococci, or  in  certain  instances  of  lemon-colored  staphy- 
lococci. One  could  not  say  that  in  all  mild  cases  only 
these  staphylococci  were  to  be  found,  but  where  they 
alone  were  present  the  inflammation  was  always  of  a 
mild  type. 

The  white  staphylococci  were  found  in  pure  culture  in 
thirteen  cases.  Only  one  of  these  was  a  case  of  cellulitis, 
and  that  was  sufficiently  interesting  to  merit  particular 
attention.  The  point  of  infection  was  apparently  a  pal- 
mar blister  at  the  base  of  the  middle-finger ;  the  inflam- 
mation extended  into  the  palm  and  between  the  fingers, 
and  caused  considerable  swelling  and  superficial  fluctua- 
tion. There  was,  however,  little  pain  or  constitutional 
disturbance,  and  on  incision  the  pus  was  found  to  lie 
mostly  just  below  the  epidermis,  which  was  raised  from 
the  true  skin.  After  incision  the  inflammation  subsided 
very  quickly.  Bacterial  examinations  were  made  four 
different  times,  and  white  staphylococci  were  found  in 
pure  culture  each  time. 


This  was  manifestly  a  very  mild  form  of  inflammation, 
and  the  other  conditions  in  which  the  white  staphylococci 
were  found  indicated  an  equally  mild  action.  Five 
times  stitches  were  examined  from  wounds  which  healed 
aseptically  or  with  only  slight  moisture,  and  from  four 
of  them  pure  cultures  of  the  white  staphylococci  were 
obtained.  They  were  also  found  alone  from  a  needle 
used  in  the  skin  of  a  clean  wound  and  from  a  clean 
drainage  opening.  Once  they  were  found  in  pure  cult- 
ure in  a  blood- clot  under  which  a  resected  finger- joint 
had  healed;  twice  in  old  sinuses  which  led  to  dead 
bone ;  and  they  were  almost  always  found  in  superficial 
granulating  wounds. 

Hence  we  see  that  in  all  instances  they  were  so  found 
as  to  indicate  that  they  had  a  very  mild  infective  power. 
They  were  found  in  association  with  other  bacteria  very 
frequently  in  wounds  which  had  been  opened.  In  these 
instances  it  is  believed  that  they  were  carried  in  from  the 
skin,  and  that  usually  they  were  not  the  cause  of  the 
original  inflammation. 

In  1884-85,  when  the  classical  articles  of  Rosenbach  n 
and  Passet 18  appeared,  describing  the  pyogenic  cocci 
which  they  found  in  acute  inflammations,  the  staphy- 
lococcus pyogenes  albus  was  believed  to  be  of  practically 
the  same  pyogenic  power  as  the  staphylococcus  pyogenes 
aureus  with  which  it  was  usually  associated.  This  belief 
was  based  largely  on  animal  inoculations. 

In  the  only  case,  however,  in  which  Rosenbach  found 
the  albus  in  pure  culture,  the  inflammation  was  of  so  mild 
a  type  as  to  have  been  clinically  considered  gonorrhoea! 
rheumatism  of  the  knee. 

Passet  did  not  record  the  clinical  histories  of  his 
cases.  Since  that  time  numerous  observations  have  been 
recorded  which  indicate  that  they  are  usually  of  very 
mild  pyogenic  power. 

Welch8  has  made  a  very  extensive  study  of  the  subject, 
and  has  found  white  staphylococci  regularly  present  in 
the  skin,  and  frequently  present  at  the  margin  of  healing 
wounds.  He  found  that  they  usually  did  not  interfere 
with  the  healing  of  wounds  if  the  tissues  were  in  good 
condition.  Although  they  might  occasion  stitch  ab- 
scesses or  a  little  suppuration  along  drainage  openings,  or 
where  the  tissues  were  strangulated,  they  might  cause 
severe  inflammation.  Their  pyogenic  power  was  so 
slight  that  he  considered  the  term  staphylococcus  epi- 
dermis albus  preferable  to  staphylococcus  pyogenes  albus. 

Whether  staphylococcus  epidermis  albus  and  staphy- 
lococcus pyogenes  albus  are  the  same  organism,  is  not 
entirely  settled,  but  Welch's  suggestion  that  the  former 
may  be  a  modified  form  of  the  latter,  certainly  meets  the 
requirements  of  the  present  stage  of  the  investigation. 
In  this  series  of  cases  no  effort  has  been  made  to 
separate  them.  Those  colonies  which  remained  white 
on  the  agar  for  several  days,  which  were  morphologically 
like  the  pyogenic  staphylococci,  and  which  fluidified 
gelatine,  were  recorded  simply  as  white  staphylococci. 

Among  the  other  observers  who  have  found  white 
staphylococci  of  mild  infective  power,  we  may  mention 
the  following : 

Grisky  and  Robbw  found  them  in  nineteen  out  of 
forty- five  laparotomy  wounds,  and  they  did  not  prevent 
prompt  healing. 

Bossowski20  found  them  in  wounds  which  were  treated 
aseptically,  but  they  did  not  interfere  with  the  healing  in 
any  marked  degree. 

Lanz  and  Flach,2i  in  examining  wound  discharges, 
found  that  where  staphylococci  pyogenes  aurii  were 
present  there  was  severe  suppuration  in  all  the  cases  but 
one,  and  that  where  the  white  staphylococci  alone  were 
present  the  wounds  regularly  healed  well. 

Many  cases  of  serous  effusion  have  been  reported 
which  contained  the  white  staphylococci.  Levy22  pro- 
duced suppuration  in  rabbits  in  two  instances  from  white 
staphylococci  so  obtained.  For  further  literature  on  the 
subject,  the  reader  is  referred  to  Jordan  w  and  Sternberg.28 

These  observations  indicate  that  the  white  staphy- 
lococci usually  cause  a  much  milder  type  of  inflammation 


292 


MEDICAL  RECORD, 


[September  8,  1894 


than  the  golden  ones.  We  say  usually,  because  we  must 
recognize  the  variations  in  virulence  which  are  shown  by 
all  the  forms  of  bacteria  which  we  are  studying. 

The  question  is  one  of  much  practical  importance : 
here  is  a  form  of  suppuration  which  need  not  be  feared 
as  the  severer  forms  are ;  for  instance,  it  is  possible  for  a 
wound  to  heal  well  under  a  blood  clot  when  these  cocci 
alone  are  present.  It  seems  reasonable  that  granulating 
wounds  which  have  only  this  form  of  infection  should 
have  their  edges  brought  together  and  only  a  very  small 
allowance  for  drainage  made,  and  that  all  wounds  which 
have  only  this  form  of  infection  should  be  treated  with 
little  fear  of  serious  inflammation — staphylococcus  pyogenes 
citrcus. 

In  four  instances,  staphylococci  were  found  which 
appeared  identical  with  the  white  staphylococci  in  all  re- 
spects, excepting  that  after  eight  or  ten  days  they  turned 
to  a  lemon  color  on  agar. 

They  were  found  in  a  superficial  abscess  and  in  heal- 
ing wounds,  and  produced  very  slight  constitutional 
reaction.  They  fluidified  gelatine  slowly,  and  when  in- 
jected under  rabbits'  skins  in  beef-tea  cultures,  they  pro- 
duced only  a  little  induration  and  congestion. 

They  are  much  slower  in  turning  to  a  lemon  color  than 
the  staphylococci  pyogenes  citrei  described  in  the  text- 
books. 

Cases  from  which  no  Bacterial  Growths  Could  be 
Obtained  on  Agar. — There  was  a  group  of  eleven  cases 
from  which  the  pus  gave  no  growths  on  agar.  They 
were  abscesses  presumably  tubercular,  or  buboes,  and  the 
courses  which  they  ran  bear  decidedly  on  the  question 
of  injection  versus  incision  for  these  conditions.  A  case 
of  large  tubercular  abscess  shows  the  point  of  issue.  It 
was  so  situated  as  to  make  the  diagnosis  obscure  until  in- 
cision was  made.  The  incision  liberated  a  large  amount 
of  pus  which  was  sterile,  in  the  sense  that  no  bacteria 
grew  from  it  on  agar.  A  few  days  later,  however,  the  pus 
in  the  wound  contained  streptococci  and  the  symptoms 
changed  accordingly.  There  was  the  febrile  reaction 
and  the  constitutional  symptoms  which  accompany 
the  streptococcus  infection.  It  had  been  impossible 
to  keep  infection  from  the  open  discharging  wound, 
and  the  patient  had  suffered  accordingly.  When  the 
diagnosis  can  be  made  in  such  cases,  it  is  manifestly  wiser 
not  to  open  the  abscess  in  such  a  way  as  to  allow  the  en- 
trance of  the  streptococci. 

Some  of  the  tubercular  cervical  abscesses  showed  a  sim- 
ilar course.  There  is  one  under  observation  at  the  time 
of  writing,  which  was  incised  and  curetted  three  and  a  half 
months  ago,  which  has  discharged  thin  pus  and  formed 
unhealthy  granulations  ever  since  and  is  still  open ;  while 
others  of  a  similar  nature  which  were  aspirated,  and  in- 
jected with  a  ten  per  cent,  mixture  of  iodoform  in  vaseline, 
show  only  a  little  hardening  at  the  site  of  the  abscess. 

Buboes  show  a  similar  condition.  They  frequently  re- 
main open  and  suppurate  for  many  weeks  when  they  are 
incised  and  curetted ;  yet  we  have  seen  two  heal  promptly 
and  well  under  aspiration  and  injection  of  iodoform  and 
vaseline,  and  Otis34  has  reported  many  such  cases. 

The  reported  cases  of  pyosalpinx  in  which  the  pus  is 
found  to  be  sterile,  illustrate  the  same  condition  of  pus 
without  infective  power,  and  such  are  not  to  be  treated 
as  those  cases  are  where  there  is  acute  purulent  inflam- 
mation. 

It  is  possible  that  some  of  the  cases  examined  had 
abscesses  which  had  become  sterile  through  the  dying 
out  of  the  bacteria  which  had  caused  the  original  suppu- 
ration. Further  studies  are  needed  on  this  point.  There 
certainly  were  many  cases  which  were  almost  sterile,  in 
which  only  very  a  few  bacteria  grew  along  a  heavy  streak 
of  pus ;  perhaps  a  dozen  colonies  where  hundreds  of  colo- 
nies would  be  expected  if  the  process  had  been  an  acute 
one ;  hence  it  is  evident  that  bacteria  inclosed  in  an 
abscess  may  show  a  tendency  to  die  out. 

Cases  in  which  the  Bacteria  which  Caused  the  Orig- 
inal Inflammation  were  Replaced  by  Others.  —  Some 
of  the  cases  already  referred  to,  in  which  the  white 


staphylococci  were  found,  belong  to  this  group,  since  they 
were  evidently  carried  into  the  wounds  from  the  skin. 
In  other  cases,  particularly  old  ulcers,  the  bacteria  of 
decomposition  were  found  in  such  numbers  as  to  cover 
all  other  forms  on  the  agar.  In  others,  the  bacillus  pyo- 
cyaneus  was  found.  In  a  recent  monograph,  Schimmel- 
busch,35  called  attention  to  some  interesting  facts  con- 
cerning these  bacilli. 

1.  They  are  regular  inhabitants  of  the  skin,  particu- 
larly in  the  axilla,  the  groin,  and  the  anal  furrow. 

2.  They  are  capable  of  infecting  wounds  which  occur 
where  they  exist. 

3.  They  usually  cause  profuse  suppuration  with  little 
constitutional  disturbance. 

These  characteristics  were  shown  in  the  four  cases  in 
which  we  found  these  bacilli.  In  two  of  them  axillary 
abscesses  which  at  first  contained  streptococci,  afterward 
had  the  bacilli  pyocyanii ;  a  third  case  showed  the  growth 
from  a  mastoid  abscess ;  the  plain  gauze  dressing  in  this 
instance  became  bright  green  over  a  considerable  area ; 
in  the  fourth  case  the  patient  had  a  severe  burn  of  the 
hand,  the  discharge  in  this  case  was  so  profuse  as  to 
quickly  penetrate  a  gauze  dressing  an  inch  or  two  in 
thickness ;  yet  when  some  of  the  metacarpal  bones  were 
removed  the  wounds  healed  well,  the  patient  seemed  to 
suffer  only  from  the  exhausting  effect  of  so  much  pus 
production. 

Healing  occurred  in  all  the  cases  within  a  resonably 
short  time,  and  in  all  suppuration  was  free  but  the  con- 
stitutional symptoms  were  slight. 

Bacillus  Coli  Communis. — It  may  be  mentioned  that 
in  three  cases  of  ischeo-rectal  abscesses  the  bacillus  coli 
communis  was  found.  Neither  of  the  cases  were  partic- 
ularly virulent.  In  both  the  bacillus  grew  in  pure  cult- 
ure on  the  agar  plates.  No  particular  importance  is 
ascribed  to  these  cases  as  their  number  is  so  small. 

Summary. — In  review  we  may  say  that  in  the  ordinary 
cases  which  we  have  seen,  at  least  five  fairly  distinct  types 
of  inflammation  have  been  recognized. 

x.  A  severe  form  of  inflammation  which  showed  a  ten- 
dency to  spread  through  the  tissues,  and  which  was  caused 
by  the  streptococcus  pyogenes. 

2.  A  severe  form  of  inflammation,  more  localized  than 
the  above,  caused  by  the  staphylococcus  pyogenes 
aureus. 

3.  A  mild  form  of  inflammation,  caused  by  staphylo- 
coccus pyogenes  or  epidermis  albus,  or  in  certain  in- 
stances by  the  staphylococcus  pyogenes  citreus. 

4.  Slowly  progressing  inflammation,  in  which  the 
ordinary  pyogenic  cocci  were  not  found;  such  as  cold 
abscesses  and  buboes. 

5.  Inflammation  in  which  the  bacteria  which  caused 
the  original  infection  had  been  replaced  by  other  bac- 
teria ;  particularly  by  the  bacillus  pyocyaneus  and  the 
bacteria  of  decomposition. 

The  inflammations  of  these  groups  call  for  different 
treatment.  The  acute  streptococcus  inflammations  should 
have  early  and  extensive  incisions,  packing  of  the  wounds, 
and  continual  moist  dressing.  The  staphylococcus  pyo- 
genes aureus  inflammations  call  for  similar,  but  somewhat 
less  vigorous,  treatment. 

The  inflammations  caused  by  the  white  and  lemon- 
colored  staphylococci  need  only  small  incision,  and 
wounds  which  contain  only  these  cocci  are  favorable  ones 
for  secondary  suture. 

Abscesses  which  contain  no  pyogenic  .cocci  (such  as 
tubercular  abscess  and  buboes)  should  not  be  so  opened 
and  dressed  as  to  allow  the  entrance  of  these  coed ;  aspi- 
ration and  injection  of  a  ten-percent  mixture  of  iodo- 
form in  vaseline  is  frequently  good  treatment  for  them. 

Cleansing  of  the  wounds  and  the  application  of  non- 
irritating  absorbent  dressings,  are  the  means  to  be  used 
against  the  bacilli  pyocyanii  and  the  bacteria  of  decom- 
position. 

In  a  large  proportion  of  cases  the  bacterial  examina- 
tion can  be  made  in  time  to  guide  the  treatment ;  in  very 
many  cases,  however,  the  characteristics  of  the  inflamma- 


September  8,  1894] 


MEDICAL   RECORD. 


293 


tions  are  sufficiently  well  marked  to  make  this  unneces- 
sary. 

It  is  to  be  remembered  that  bacteria  of  the  same  species 
show  marked  variations  in  virulence,  and  that  those  of 
slight  virulence  do  not  always  show  plainly  the  peculiari- 
ties which  characterize  the  virulent  ones. 


1  Park :  New  York  Mbdical  Record,  No.  6,  1893,  p.  163. 

*  Passet :  Baumgartens  Jahresbericht,  1885,  p.  24. 

*  Rosenbach  :  Ibid.,  1885,  p.  24. 

*  Prudden :  American  Journal  of  the  Medical  Sciences,  April,  1889. 

*  Biondi :  Deutsch.  Med.  Woch.,  1886.  No.  viii.,  p.  132. 

*  Fraenkel:  Centralblatt  Bakt.  u.  Parasit.,  iii.,  1889,  p.  691. 
1  Roger:  Revue  de  Medecine,  xii.,  02. 

*  Welch :  American  Journal  of  the  Medical  Sciences,  x. ,  1891. 

*  Baumgarten  :  Lehrbuch  der  Path.  Mykologie,  p.  329. 

10  Kirchner:  Centralblatt  Bakt.  u.  Parasit.,  1892.  p.  749. 

11  Crookshank :  Seventh  International  Congress  of  Hygiene  and 
Demography,  1891. 

"  Fehleisen  :  Archiv  f.  Klin.  Chir. 

11  Coley  :  American  Journal  of  the  Medical  Sciences,  May,  1893. 
"  Hajek:  Wien  Med  Jahrb.,  1887. 
14  ▼.  Lingelsheim :  Zeitschr.  f.  Hygiene,  1891,  Bd.  x. 
»•  Jordan  :  BeitrJl^e  z.  Klin.  Chir. ,  Bd.  x. ,  p.  587. 
17  Rosenbach :    Die  Mikroorganismen  bei  den  Wund  infections, 
Krank  heiten  des  Menschen,  1884. 

»*  Passet :  l'ortschritte  der  Medicin,  1885. 

'•  Grisky  and  Robb :  American  Journal  of  Obstetrics  and  Diseases 
of  Women  and  Children,  December,  1892. 
*  Bossowski :  Wien  Med.  Woch.,  1887,  Nos.  8  and  9. 
"  Lanz  and  Flach  :  Archiv  I  Klin.  Chir  ,  1892.  Bd.  44. 
n  Levy :  Archiv.  f.  experiment.  Pathol,  und  Pharmakol  ,  Bd.  27, 
.  1890. 

"Sternberg:  Manual  of  Bacteriology,  New  York,  1892. 

»<  Otis  :  Journal  of  Cutaneous  and  Genito- Urinary  Diseases,  May, 

1893- 

*•  Schimmelbusch  :  Sammlung  Klin.  V  or  tag,  No.  62, 1893. 


METHODS    OF    ESTIMATING     THE     HEIGHT 
FROM  PARTS   OF  THE  SKELETON.1 

By  THOMAS  D WIGHT,    M.D.,    LL.D., 

NAHANT,   MASS. 
PARKMAN    PJtOPttSSOR    OF    ANATOMY    AT    HARVARD   UNIVERSITY. 

This  is  an  anatomical  problem  which  of  late  has  been 
coming  into  more  and  more  prominent  notice,  and  is 
applied  both  to  the  determination  of  the  heights  of  ex- 
tinct tribes  and  nations  of  which  the  skeletons  have  been 
found,  and  also  to  the  identification  of  individuals.  It 
is  evident  that  the  process  is  not  necessarily  the  same 
for  these  two  purposes.  In  the  case  of  races  individual 
peculiarities  are  of  little  account,  and  reliance  may  be 
■placed  upon  averages.  This  cannot  be  done  when  the 
question  is  of  the  identification  of  a  certain  skeleton. 

The  purpose  of  this  paper  is  chiefly  to  discuss  the 
methods  to  be  used  for  single  cases,  more  particularly  in 
medico-legal  practice. 

The  process  of  estimating  the  height  from  the  more  or 
less  detached  pieces  of  the  skeleton  may  be  done  accord- 
ing to  either  of  two  very  different  plans,  which  under  cer- 
tain circumstances  may  be  profitably  combined.  These 
plans  are  the  anatomical  and  the  mathematical.  The 
former  consists  simply  in  putting  the  bones  together,  in 
reproducing  the  curves  of  the  spine,  in  making  due  al- 
lowance for  the  soft  jMirts,  and  in  measuring  the  height. 

In  an  essay  on  the  "  Identification  of  the  Human 
Skeleton,"  published  in  1878, 1  gave  certain  rules  for 
this  process.  Since  then  I  have  endeavored  to  perfect 
them,  and  by  means  of  many  measurements  have  obtained 
original  data  for  disputed  points.  I  have  also  studied 
individual  variations  to  ascertain  what  weight  should  be 
given  to  them. 

The  first  step  in  what  I  call  the  anatomical  method  is 
to  place  the  spine  correctly,  which  had  best  be  done  by 
putting  the.vertebrae,  supposing  them  to  be  completely 
separate,  in  a  bed  of  clay  or  of  putty  which  will  admit 
of  their  being  moved  until  properly  adjusted. 

Three  points  call  for  consideration — the  amount  of 
cartilage  to  be  represented  in  each  region,  the  propor- 
tions of  the  different  regions,  and  the  curves ;  but  in 
practice  the  first  two  are  closely  connected.  Instead, 
therefore,  of  giving  the  statements  of  the  amount  of  gris- 
tle to  be  represented  in  each  region,  I  should  proceed  to 

1  Read  before  the  Association  of  American  Anatomists  at  Washing- 
Con,  May  31,  1894. 


give  each  region  the  proper  proportionate  length  accord- 
ing to  my  measurements.  I  have  made  measurements 
following  the  curve  of  the  spine  from  the  atlas  to  the 
promontory  on  fifty  male  and  on  twenty-three  female 
subjects  with  the  following  results,  showing  both  the  ac- 
tual length  of  these  regions  and  their  percentages,  the 
movable  part  of  the  spine  being  reckoned  as  too. 

Male.  Per  cent.  Female.  Per  cent. 

Ctm.  Ctm. 

Cervical 13.3  21.5  12. 1  21.2 

Thoracic l 28.7  46.3  26.5  46. 1 

Lumbar 19.9  32.2  18.7  32.7 

Total 61.9  100.0  57.4  100.0 

It  is  interesting  to  compare  these  results  with  those  of 
others.  Ravenel  measured  the  spines  of  eleven  men  and 
eleven  women  and  Aeby  of  eight  men  and  eight  women. 
Combining  their  results  we  have  for  nineteen  of  each  sex 
the  following  proportions : 

Male.  Female. 

Cervical 21.7  21.7 

Thoracic 46.7  46.5 

Lumbar 31 .4  32.4 

Total 99.8  100.6 

In  my  measurements,  as  well  as  in  these,  the  disks  at 
the  junction  of  two  regions  are  reckoned  with  the  upper 
one.  It  appears  from  this,  and  especially  from  my  fig- 
ures, that  these  proportions  are  essentially  the  same  in 
the  two  sexes,  though  I  agree  with  other  authorities  in 
finding  the  lumbar  region  a  little  longer  in  woman,  rela- 
tively. It  is  clear  that  if  the  vertebrae  are  arranged  so  as 
to  make  the  regions  correspond  to  these  proportions,  the 
more  intricate  question  of  the  amount  of  gristle  belong- 
ing to  each  will  take  care  of  itself.  The  question  of  the 
curves  is  more  difficult,  and  one  which  does  not  admit  of 
a  definite  solution,  for  the  reason  that  they  vary  in  young 
people,  at  all  events,  with  the  time  of  day,  and  in  all, 
except,  perhaps,  the  very  old,  with  the  position  of  the 
body.  Individual  variations  are  also  endless.  It  might 
be  of  use  to  follow  Humphry's  suggestion  that  a  line 
dropped  from  the  middle  of  the  odontoid  passes  through 
the  middle  of  the  body  of  the  second  and  twelfth  thoracic 
vertebrae  and  through  the  anterior  inferior  edge  of  the 
fifth  lumbar.  Should  a  few  vertebrae  be  wanting  this 
system  of  proportions  is  all  the  more  valuable.  In  case 
of  an  extra  vertebra,  which  mopt  frequently  occurs  in  the 
lumbar  region,  I  have  found  that  the  whole  length  of  the 
spine  is  not  necessarily  increased  beyond  the  average, 
nor  always  longer  in  proportion  to  the  height,  but  that 
the  proportion  of  the  lumbar  region  is  invariably  so.  In 
cases  of  only  eleven  thoracic  vertebrae  it  is  presumable 
that  the  thoracic  region  is  short,  but  though  I  have  several 
such  specimens  in  my  collection,  unfortunately  I  have  no 
measurements  taken  when  the  parts  were  fresh.  I  have 
records  of  a  female  spine  with  thirteen  thoracic  vertebrae 
in  which  the  percentages  were :  cervical,  19.9  ;  thoracic, 
50.6;  lumbar,  29.4;  the  length  being  61.6  ctm.,  very 
long  for  a  woman. 

If  it  be  asked  whether  anomalies  of  number  in  the 
spine  are  sufficiently  numerous  to  be  taken  into  account, 
I  would  say  that  in  so  far  as  this  affects  the  proportion  of 
the  spine  to  the  height  it  shall  be  considered  later,  that 
as  far  as  it  concerns  putting  the  bones  together  it  obliges 
the  expert  to  disregard  the  arbitrary  rules  of  proportions 
and  to  arrange  the  vertebrae  as  best  he  can.  If  there  are 
no  complications  he  should  find  this  no  insuperable  diffi- 
culty. 

It  is  to  be  observed  that  I  disregard  entirely  the  lower 
portion  of  the  spine,  as  it  is  very  liable  to  vary  and  has, 
moreover,  no  influence  on  the  height. 

The  spine  being  settled,  the  next  step  is  to  put  it  on 
the  pelvis.  Of  course  the  inclination  of  the  latter  has  a 
great  influence  on  the  height,  and  unfortunately  this  is 
just  the  point  which  is  most  difficult  to  settle.  As  I 
stated  in  1878,  what  Hermann  von  Meyer  calls  the  nor- 

1  In  accordance  with  a  vote  of  the  Association  of  American  Anato- 
mists, I  have  adopted  the  term  "  thoracic  "  in  place  of  "  dorsal." 


294 


MEDICAL  RECORD. 


[September  8,  1894 


mal  conjugate  is  probably  a  more  trustworthy  guide  than 
the  conventional  angle.  This  is  a  line  passing  from  the 
top  of  the  symphysis  to  the  middle  of  the  third  sacral 
vertebra,  on  which  a  transverse  line  can  usually  be  seen. 
This  imaginary  line  forms  an  angle  of  thirty  degrees  with 
the  horizon.  We  may,  moreover,  strive  to  make  the 
notch  of  the  acetabulum  look  directly  downward  and  to 
bring  the  anterior  superior  spines  of  the  ilia  into  the 
same  vertical  plane  as  the  spines  of  the  pubes.  Never- 
theless, many  pelves  will  occur,  especially  those  of  which 
the  first  vertebra  is  transitional,  for  which  the  anatomist 
must  rely  on  his  general  knowledge  and  good  judgment 
rather  than  on  rule. 

The  pelvis  being  then  in  place,  the  bones  of  the  leg 
are  to  be  added  and  due  allowance  made  for  the  soft 
parts.  In  putting  the  thigh-bone  into  the  socket  care 
must  be  taken  that  it  does  not  touch  the  upper  border, 
from  which  it  is  separated  by  cartilage.  The  lateral  in- 
clination must  also  be  borne  in  mind — in  other  words, 
the  condyles  must  rest  on  a  level  The  very  slight  an- 
teroposterior slant  may  be  disregarded. 

At  the  knee  about  6  mm.  may  be  added  and  about  as 
much  more  for  the  two  joints  of  the  ankle.  The  addi- 
tion of  12  mm.  for  the  soft  parts  of  the  sole  of  the  foot  is 
not  far  off,  though  of  course  it  is  liable  to  variation. 
The  skull  is  then  to  be  placed,  allowing  3  mm.  for  the 
joint  between  it  and  the  spine,  and  about  six  for  the 
scalp.  According  to  Topinard  35  mm.  are  to  be  added 
to  the  skeleton  for  all  these  soft  parts,  a  statement  not 
materially  different  from  mine.  It  is  probably  equally 
correct. 

I  shall  now  consider  the  application  of  the  mathemat- 
ical method,  and  later,  cases  in  which  the  two  may  be 
profitably  combined.  The  mathematical  method  rests 
on  the  proportion  of  certain  bones  to  the  height,  and  it 
is  obvious  that  even  if  these  proportions  were  collected 
from  thousands  of  specimens,  as  Manouvrier  remarks, 
these  would  give  us  no  certainty.  There  are  persons 
with  short  legs  and  persons  with  long  legs,  and  there- 
fore no  single  rule  of  proportion  can  be  true  for  both. 
This  method,  therefore,  is  to  be  used  when  we  can  do  no 
better.  Ishallshowlaterwhatthepossibleerroramountsto. 

In  medico-legal  works  some  very  insufficient  tables 
are  still  quoted ;  but  of  late  years  this  matter  has  received 
particular  attention,  especially  in  France,  which  has  at 
last  set  this  department  of  science  on  a  comparatively 
stable  basis.  Three  observers  especially  concern  us. 
They  are  Topinard,  Rollet,  and  Manouvrier. 

Topinard  calculates  proportions  based  on  observations 
giving  the  following  ratios  of  certain  bones  to  the 
height  =  100  :  humerus,  20;  radius,  14.3;  femur,  27.3  ; 
tibia,  22.1.  Thus,  knowing  the  length  of  one  of  these 
bones,  we  have  only  to  multiply  it  by  100,  and  divide  it 
by  the  corresponding  ratio.  This  should  give  the 
height  of  the  skeleton,  to  which  he  adds  3.5  ctm.  for  the 
soft  parts. 

Rollet  went  further.  He  measured  fifty  male  and  fifty 
female  bodies  before  dissection  and  measured  the  three 
long  bones  of  each  arm  and  leg.  He  then  constructed 
tables,  reckoned  proportions,  and  gave  five  different 
methods  of  finding  the  height.  Any  one  of  the  six  chief 
long  bones  may  be  used,  or  the  average  result  of  calcu- 
lation from  each.  His  favorite  method  is  by  means  of 
tables,  one  for  each  sex,  and  a  simple  rule  of  three. 
He  proceeds  thus :  the  length  (L)  of  a  bone  being 
known,  we  find  the  length  of  the  bone  nearest  to  it  in  the 
table  (B)  and  the  average  height  (H)  corresponding  to 

B.     Then  weknow  thatasB  :  L  =  H  :  X  or  X  =  -  -  • 

He  gives  also  a  rapid  method,  which  consists  simply  in 
multiplying  the  length  of  the  bones  by  certain  numbers. 
Thus  multiplying  the  male  humerus  by  5.06,  the  female 
by  5.22,  the  radius  by  6.86  or  7.16,  the  femur  by  3.66 
or  3.71,  the  tibia  by  4.53  or  4.61,  gives  the  person's 
height  in  centimetres. 

The  most  recent  paper  is  that  of  Manouvrier.  He 
criticised  Rollet's  tables  because  of  his  hundred  subjects 


fifty- one  were  sixty  years  or  more.  Their  spines,  there- 
fore, had  probably  become  shorter  than  normal,  thus  in- 
juring their  proportions.  He  formed,  therefore,  new 
tables  from  Rollet's  by  rejecting  these  fifty-one  senile 
cases,  which  happily  were  divided  as  evenly  as  possible 
between  the  sexes,  and  by  rearranging  the  tables  so  as 
to  make  the  scale  of  the  length  of  each  bone  the  basis  ot 
calculation  instead  of  the  scale  of  the  heights ;  obviously 
the  proper  course.  He,  moreover,  measured  the  femur  in 
its  normal  position  instead  of  taking  its  greatest:  length, 
as  Rollet,  following  Topinard,  had  done.  Further,  as 
these  bones  had  been  measured  when  fresh,  he  pointed 
out  that  in  the  case  of  dry  bones  2  mm.  should  be  added 
to  their  length.  Finally,  he  claims  that  as  the  recum- 
bent body,  and  the  dead  body  presumably  still  more, 
gains  in  length,  at  least  2  ctm.  should  be  deducted 
from  the  result  in  calculating  the  height  of  the  living 
person.  His  method  was  then  to  look  for  the  length  of 
the  known  bone  in  his  tables  which  gave  the  correspond- 
ing height.  If  the  precise  length  was  not  there,  to  find 
its  distance  from  the  nearest  and  to  make  a  suitable  al- 
lowance in  the  height  Such  is  the  mathematical 
method  as  applied  to  the  long  bones. 

In  a  previous  paper  I  attempted  to  find  the  ratio  of 
the  length  of  the  sternum,  excluding  the  ensiform  carti- 
lage, to  the  height  of  the  body.  My  measurements  em- 
braced seventy  men  and  thirty-nine  women.  I  found 
that  the  average  ratio  in  men  was  9.65  per  cent-  By 
subdividing  tins  set  into  groups  I  found  that  in  the  short- 
est men  the  sternum  was  relatively  a  little  longer  and  in 
the  tallest  a  little  shorter,  but  the  extreme  variations  of 
groups  (not  of  individuals)  was  only  from  9.56  per  cent,  to 
9  98  per  cent.  The  average  of  the  thirty-nine  women  was 
9.22  per  cent.  After  the  exclusion  of  a  small  number 
of  cases  the  range  of  variation  was  remarkably  small. 
Since  then  I  have  observations  on  seventy-nine  men  and 
thirty-one  women  which  bring  the  totals  to  one  hun- 
dred and  forty-nine  men  and  seventy  women.  The  to- 
tal average  is  9.59  per  cent,  for  the  men  and  9.08  per 
cent,  for  the  women,  showing  that  on  the  average  the 
male  sternum  is  distinctly  longer  relatively  to  the  height. 
None  the  less  this  cannot  be  commended  as  a  method  of 
estimating  the  height  in  individual  cases.  The  obvious 
reason  is  the  very  common  occurrence  of  very  peculiar 
sterna.  It  is  one  of  the  least  stable  parts  of  the  skeleton. 
While  I  believe  that  a  typical  sternum  has  a  fairly  con- 
stant ratio  to  the  height  in  each  sex,  variations  are  so 
numerous  that  this  method  must  be  discarded. 

I  have  added  a  new  method  of  my  own,  namely,  the 
estimation  of  the  height  from  the  length  of  the  spine 
measured  in  a  straight  line  from  the  top  of  the  atlas  to 
the  promontory  of  the  sacrum,  thus  excluding  the  most 
variable  regions,  the  sacral  and  coccygeal.  The  tables 
which  I  have  used  were  constructed  from  measurements 
of  fifty-six  male  and  twenty-one  female  spines  made  after 
the  completion  of  dissection,  the  basis  being,  according 
to  Manouvrier's  plan,  the  length  of  the  spines,  not  the 
scale  of  heights.  Instead  of  dividing  the  number  of  ob- 
servations into  equal  parts,  I  have  thought  it  better  to 
arrange  them  in  groups  containing  all  the  observations 
of  every  3  ctm.  Thus  my  fifty- six  male  spines  comprised 
three  of  less  than  57  ctm.  (the  shortest  being  56.4),  four- 
teen from  57  to  60,  twenty-four  from  60  to  63,  twelve 
from  63  to  66f  and  three  longer  ones  (the  longest  being 
69.8).  I  then  reckoned  the  average  ratio  of  each  group 
to  the  height  and  found  the  coefficient  by  which  to 
multiply  any  spine  falling  within  any  group.  It  is  evi- 
dent that  this  method,  while  giving  very  good  data  for 
the  lengths  represented  by  large  groups,  must  be  of  little 
value  for  the  extremes,  represented  by  few  bones.  Still 
it  seems  to  me  more  trustworthy  on  the  whole  than  the 
plan  of  dividing  the  fifty-six  spines  into  four  groups  of 
fourteen  or  into  eight  groups  of  seven.  It  makes  all 
but  the  extreme  groups  more  homogeneous.  The  weak- 
ness of  these  may  be  frankly  admitted.  As  to  the  age  of 
the  subjects,  several  old  ones  have  been  admitted,  thus 
twenty  among  the  males  were  sixty  or  more  and  seven 


September  8,  1894] 


MEDICAL    RECORD. 


295 


among  the  women.  Here  I  give  simply  the  coefficients 
by  which  to  multiply  the  length  of  spine.  All  that  is 
needed  is  to  find  the  group  in  which  it  belongs  and  mul- 
tiply by  the  given  coefficient. 

Malhs.  Fbmalp. 

Length  of  Spine                      Coefficient  Length  of  Spine                      Coefficient. 

Under  57  ctm 2.93    Under  54  ctm  ...   2.94 

From  57  to  60 2. 84    From  54  to  57 2.82 

From  60  to  63 2.78    From  57  to  60 2.79 

From  63  to  66 2. 79    Above  60 2.76 

Above  66 2.65 

As  the  spines  grow  longer  the  coefficient  decreases, 
excepting  that  in  the  male  table  it  is  practically  the  same 
for  two  groups. 

For  several  years  it  has  been  my  custom  to  measure 
the  height  and  certain  other  dimensions  of  subjects  be- 
fore dissection,  and  later  to  measure  the  length  of  hu- 
merus, radius,  femur,  and  tibia,  and  that  of  the  spine  both 
in  a  straight  line  and  following  the  curves.  Anyone 
who  has  had  experience  in  the  dissecting-room  will 
understand  that  for  various  reasons  I  often  did  not  get 
all  these  measurements  on  both  sides,  nor  of  all  these 
bones.  Instead  of  constructing  new  tables  of  my  own 
for  the  long  bones  I  have  chosen  twenty  male  and 
twenty  female  subjects,  with  few  exceptions  under  sixty 
years  old.  In  all  every  humerus,  radius,  femur,  and  tibia 
had  been  measured  on  both  sides  and  the  average  length 
taken  as  a  starting-point.  From  this  the  height  has  been 
calculated  from  every  one  of  the  four  bones  and  the 
average  of  the  four  results  taken  as  the  answer,  accord- 
ing to  the  methods  of  Topinard,  Rollet,  and  Manouvrier 
successively. 

I  have  added  in  using  Topinard's  method  the  3. 5  ctm. 
which  it  requires.  Perhaps  I  have  been  somewhat  un- 
just to  Rollet  by  using  his  rapid  method  instead  of  the 
one  which  is  his  first  choice,  but  as  presumably  Manou- 
vrier's  modifications  of  Rollet's  tables  must  be  considered 
an  improvement,  the  method  I  have  followed  permits  us 
to  judge  whether  this  more  complicated  process,  for 
which  tables  are  necessary,  has  any  marked  advantage 
over  Rollet's  very  simple  rapid  one. 

I  do  not  find  any  striking  difference  between  the  value 
of  humerus,  radius,  femur,  and  tibia  as  a  basis  of  calcula- 
tion. Naturally,  as  I  believe  Manouvrier  remarks,  we 
should  choose  the  longer  bones  as  having  the  smaller  co- 
efficients by  which  therefore  any  error  is  multiplied  a 
smaller  number  of  times  than  if  the  bones  were  shorter 
and  the  coefficient  larger. 


Female. 


Malf. 


i 


I- 


? 

s 


g 


:J 


I 


8 


4 

754 
470 
100 
7i 

7^7  I  5* 

S*>  .  36 

556  37 
15  67 

A9  54 

Aiz  »? 

747  56 

Ac  40 

557  ,  37 
5*x  34 
653  *4 
755  42 

<t  38 

547  47 

53*  68 


i'o.9 
16c. a 
163.0 
163.5 
163.6 
168.4 
169.0 
169. 1 
169.2 
17a.  1 
172.6 
173.6 
173.1 
174.4 
«74-9 
178-0 
181. 3 
18S.7 
188. a 
i9i-5 


157.7 
j  *58.8  , 

165.0  I 
«6i.3  I 
I75.a 
172.0 

I  171.7  ! 

172  2 
•  173. 1  , 

1751  . 
,  1745 
I  174.8 
1  1743 
1  1758 

!  167  9 
176.3 
183.2 
185.6 
199.0 


Average  error. 


—3-a 
—2-4 
+  1.7 
+  1-5 
—2.3 
+  6.8 
+  3.0 
+  2.6 
+  3.0 
+  x.o 
*-2.S 

+1.9 
+  1.7 

— O.I 

+  0.9 

— XO.I 

—50 
—2.5 

—2.6 

-1-8.5 
316 


1539 
154-9 
159.6 
161. 1 
1575 
172. 1 
1679 
167  8 
168.3 
169.3 
171.3 
170.6 
171. o 
170.4 
172.0 
164.9 
172-5 
179-2 
187.8 
195  o 


—7  o 

-6-3 

—2.4 

!  —2.4 

—0.1 

+  3-7 

— x.x 

—13 

l  —0.9 

■  —2.8  . 

—i-3  ■ 
— 2.0  I 
— 2.x  ; 

.  —40 
—2.9 

— 131 
—8.8 
-6.5 
—0.4 

_  +  3-5 

3-93 


160.3 
>  160.9 
163.8 
164.6 
162.5 

1677 

167.2 

I   167.7 

,  168.1 

,  168. x 

I  168.8 

1692 

168.7 

168.5 

166.x 

170.0 

175.x 

177.0 

188.3 


— 1.8 

+  I.X 

— I.I 

+  1.5 
—1.3 
— 1.9 
—1.5 
—4.0 
—4.5 

-3.8 

—3.9 
—5.7 

-6.4 

—  xi.9 

— 10.6 
—11. a  1 
—3-2 

4.38 


170. 1       +8.9 


X61.8  ; 
167.5  ' 
165.8  I 
167.2 

I    164.7  ' 

I    i69-5 

168.6 

I    173.7 

!  1757 

1743 

168.7 

1  168.7 

175-9  I 

»79  9  ! 

!   iSt-3  I 

1   183. 1 


—1.7 
+  39 
—a.6 
—1.8 

—4-5 
—a.6 
—4.0 

+  X.I 

+  a.6 

—6.2 
-9-3 

-H 
-6.9 
-8-4 

4-45 


N.H. — The  numbers  in  the  first  column  are  solely  for  the  identification  of  the 
body  in  my  notes. 


Topi- 
nard. 


Number  of  errors  not  over  1  ctm ...  3 

Total  number  not  over  a.  5  ctm x  1 

Errors  from  2.5  to  5  ctm 6 

Errors  above  5  ctm 3 


Rollet 


Manou- 


Spine. 


83 
C8 


< 

60 
20 
63 
ax  23 
47i  33 
729  a6 
566  41 
746  23 
461  51 
450  51 
A6  41 
733  19 
583  30 
565      3i 


646 


I      * 


481 
in 


SI 

32) 


50 
24 

12         55 

619     ao 
563     26 


149.0 

140  2 

-8.8 

no.  1 

-89 

M4- 4 

-4.6 

1*2.0 

+  3  0 

151 .° 

148.6 

—2.4 

148  6 

—2.4 

151   7 

+  0.7 

152.2 

+  1.2 

152.2 

154  6 

+  2.4 

154.8 

+  2.6 

1 55  7 

+  3-5 

150.8 

—  1  4 

154- 4 

M5-3 

—9.1 

145.2 

—9.2 

148.8 

-5-6 

159  © 

+  4-5 

155 .0 

158.1 

+  3  1 

158.2 

+  3  2 

1570 

+a.o 

155-7 

154-2 

—  1  5 

153.6 

— 2.1 

155.6 

— O.l 

1559 

+0.3 

156.2 

157-8 

+  1  6 

158.2 

+  2.0 

157.5 

+  13 

158.2 

+  3.0 

156.3 

154  9 

—1.4 

155.2 

— l    1 

155-7 

-0.6 

156.5 

+  0.2 

1566 

163.7 

+  7.1 

164. 1 

+  7-5 

160.5 

+  3-9 

153-6 

—3.0 

157-1 

160.8 

+  3-7 

161. 1 

+  4.0 

158.2 

+  1.1 

156.7 

-O.4 

158.7 

1550 

-3-7 

155.3 

-3  4 

156. 1 

—  a.6 

1595 

+  O.8 

1590 

146.4 

— 12.6 

146.4 

—12.6 

M9-3 

-9.7 

166.8 

+  7-8 

160.0 

1557 

-4-3 

156.2 

-38 

156.1 

—3.9 

159  3 

-O.7 

160.8 

1569 

—3  9 

1571 

-37 

156.9 

—3-9 

1579 

-2.9 

161.9 

166.9 

+  5.0 

168.3 

+  6.4 

163.0 

+  i.i 

1590 

-2.9 

162.9 

157  9 

—5.0 

i~59° 

—39 

157.8 

-Si 

163.8 

1594 

—4-4 

159.4 

—4-4 

158.4 

-5-4 

160.4 

~3i 

165.3 

164.9 

—0.4 

165.4 

+  0.1 

161. 2 

—4  1 

166.9 

+  1.6 

168.0 

164. 1 

—3-9 

164.6 

—3-4 

163.3 

—4-7 

166.4 

—  1.6 

171.2 

164.6 

-6.6 

164.9 

--6.3 

161. a 

— 10. 0 



—    - 

- 

— 

Average  error 4-54, ,    4-55 


3.69  ' 


Number  of  errors  not  over  x  ctm 
Total  number  not  over  2.5  ctm. . . 

Errors  from  2.5  to  5  ctm 

Errors  above  5  ctm 


Topi- 
nard* 


Rollet.    I 


Manou- 


Spine. 

3 

10 
6 


In  seventeen  of  each  sex  I  have  also  the  length  of  the 
spine.  The  tables  are  arranged  according  to  heights. 
After  each  column  is  one  of  errors,  showing  whether  the 
result  was  too  great  or  too  little.  It  is  evident  that  the 
errors  on  the  minus  side  very  much  predominate,  the 
exceptions  being  by  Topinard's  method  and  by  the  spine 
in  the  male  table.  It  is  also  seen  at  a  glance  that  the 
worst  results  by  all  methods,  and  especially  by  that  of 
the  spine,  are  in  the  male  table.  The  summing  up  at  the 
foot  of  the  tables  is  particularly  instructive  and  curious. 
It  shows  that  for  the  males,  if  we  take  the  average  error 
as  the  criterion,  the  methods  rank  in  order  of  merit  as 
follows:  Topinard,  Rollet,  Manouvrier,  spine;  for  the 
women  the  order  is  spine  first,  Manouvrier  second, 
Topinard  and  Rollet  practically  even  for  third  place. 
If  we  judge  by  the  number  of  results  within  2.5  ctm.  the 
standing  is  materially  the  same.  Comparing  the  results 
of  the  two  tables,  Topinard's  method  seems  the  best. 
In  seventeen  of  forty  cases  his  error  is  less  than  2.5  ctm., 
and  in  thirty- two  not  over  5  ctm.  There  is  little  to 
choose  between  Rollet  and  Manouvrier,  but  as  the  lat- 
ter's  results  for  the  most  part  err  by  defect  I  should  not 
deduct  2  ctm.  to  make  up  for  lengthening  in  the  recum- 
bent position. 

On  the  whole  it  seems  that  in  about  one  quarter  of 
the  cases  the  error  is  likely  to  exceed  5  ctm.  or  two  inches. 
Conversely  that  in  three-quarters  of  the  cases  it  is  possi- 
ble to  reckon  the  height  reasonably  closely.  When  we 
consider  that  the  height  is  a  variable  quantity  at  different 
times  of  day  and  according  to  position,  that  moreover 
the  accurate  height  of  comparatively  few  people  is  known, 
we  must  feel  that  to  come  within  one  inch  (as  occurs  in 
about  one-half  the  cases)  is  very  satisfactory,  and  with- 
in two  inches  is  not  bad.  The  fact  must  be  frankly  ad- 
mitted, however,  that  a  greater  error  than  two  inches  is 
bad,  and  that  this  occurs  about  once  in  four  times. 

In  studying  the  tables  we  find  that  the  error  from  the 
spine  is  by  no  means  always  on  the  opposite  side  from 
the  error  from  the  long  bones,  as  one  would  expect.  In 
one  case  (653)  the  error  by  every  method  is  very  consid- 
erable, and  all  are  by  defect.  I  can  only  suggest  by  way 
of  explanation  (the  possibility  of  some  blunder  being  al- 
ways admitted)  that  there  may  have  been  uncommon 
thickness  of  the  soft  parts,  a  large  head,  and  great  in- 
clination of  the  pelvis.  After  writing  these  words  I  find 
in  point  of  fact  that  the  top  of  the  trochanter  is  on  the 
average  of  the  two  sides  about  9  ctm.  above  the  symphy-s 
sis.    This  seems  incredible ;  but  an  error  in  transcribing 


296 


MEDICAL  RECORD. 


[September  8,  1894 


these  figures  before  dissection  could  have  no  connection 
with  the  subsequent  measurements.  I  am  inclined  to  be- 
lieve, therefore,  that  the  subject  must  have  been  a  pecul- 
iar one.  In  some  cases  in  these  tables  all  the  results  are 
wonderfully  concurrent,  thus  on  a  man  (100,  aged  31) 
the  errors  of  the  four  results  range  from  2.4  ctm.  to  1.5 
and  in  a  woman  (746,  aged  23)  from  1.4  ctm.  to  0.2. 

As  to  whether  the  occurrence  of  anomalies  of  number 
of  the  vertebrae  is  so  frequent  as  to  throw  discredit  on  the 
spine  as  a  basis  of  calculation,  the  reply  is  somewhat  un- 
certain. Since  I  have  looked  for  such  anomalies  I  have 
found  them  with  a  frequency  which  is  surprising,  though 

1  am  not  able  to  express  it  in  figures.  I  question,  how- 
ever, whether  they  give  rise  to  any  greater  variation  than 
comes  from  the  uncertain  length  of  the  legs. 

We  have  now  to  consider  cases  in  which  certain  parts 
are  wanting  by  supplying  which  we  should  be  able  not  to 
rely  solely  on  proportions.  Let  us  suppose  that  the  pel- 
vis is  wanting,  or  so  shattered  as  to  be  useless,  though 
we  have  both  the  legs  and  the  spine.  The  problem  is 
evidently  how  high  to  place  the  promontory  above  the 
trochanters.  The  height  of  the  promontory  above  the 
symphysis  is  often  stated  as  from  about  3^  to  4  inches 
(say  from  9  to  10  ctm.).  This,  I  believe,  came  originally 
from  Naegele's  statement  that  in  well-formed  women  it 
is  about  3^4  inches.  From  my  own  observations  I  should 
giro  the  distance  at  about  9.5  ctm.  for  man  and  10.5  ctm. 
for  woman.  We  need,  therefore,  to  know  the  relation  of 
the  height  of  the  symphysis  to  that  of  the  great  trochan- 
ter. I  find  from  measurements  before  dissection  from 
118  male  and  37  female  white  bodies  that  in  the  males 
the  trochanter  is  on  the  average  1.1  ctm.  higher  than  the 
symphysis,  and  3  mm.  in  females.  Having  in  view  the 
greater  height  of  the  promontory  above  the  symphysis  in 
women,  we  may  without  serious  error  reckon  that  the 
promontory  id  10.5  ctm.  above  the  trochanter  in  either 
sex. 

Topinard  ,  gives  provisionally  the  following  distances 
on  a  vertical  line  of  landmarks  above  the  hip  in  the  male 
of  medium  height :  From  the  anterior  superior  spine  of 
the  ilium  to  the  head  of  the  femur,  6  ctm.;  from  the  head 
to  the  greater  trochanter,  2  ctm. ;  thence  to  the  pubes, 

2  cm. 

In  certain  cases  we  may  have  recourse  to  the  propor- 
tionate height  of  the  symphysis,  which  is  admittedly  not 
far  from  the  middle  in  both  sexes,  although  there  are  dif- 
ferences of  opinion  on  certain  points,  as  in  particularly 
tall  or  short  persons.  From  dissecting-room  measure- 
ments of  no  males  and  32  females  I  find  that  the  pubic 
height  equals  in  men  51.4  per  cent,  and  in  women  50.3 
per  cent. ;  the  differences  obtained  by  dividing  like  meas 
urements  of  each  sex  into  a  longer  and  shorter  half  were 
absolutely  insignificant,  none  reaching  a  half  of  one  per 
cent.  None  the  less  I  should  esteem  this  proportion  of 
most  value  in  medium  heights.  Quetelet,  it  may  be 
mentioned,  puts  the  pubic  height  at  .508  of  the  whole  in 
man,  and  .498  in  woman.  Practically,  considering  the 
vagueness  of  the  height  and  the  insignificance  of  one- 
thousandth  of  it,  we  may  for  persons  of  medium  height 
call  the  symphysis  the  middle  point  in  women  and  a  lit- 
tle (say  1  ctm.)  above  it  in  men. 

Should  the  head  be  wanting  we  must  make  a  suitable 
addition  to  the  height  of  the  spine.  Sappey  gives  13  3 
ctm.  as  the  average  male  height  from  the  front  of  the 
foramen  magnum  to  the  vertex  of  the  skull,  and  12.5  ctm. 
for  the  female.  To  this  1  ctm.  more  should  be  added  for 
the  space  between  the  top  of  the  spine  and  the  border  of 
the  foramen  magnum  and  for  the  scalp,  reckoned  to- 
gether. 

Perhaps  it  might  be  useful  to  remember  that  the  top  of 
the  spine  is  on  a  level  with  the  anterior  nasal  spine  and 
with  the  lower  border  of  the  auditory  meatus. 

Should  the  foot  be  wanting  we  might  add  for  astrag- 
alus, os  calds,  and  soft  parts  9  ctm.  for  man,  and  8  ctm. 
for  woman.  I  cannot,  however,  claim  any  great  accuracy 
for  this  procedure. 

1  L' Anthropologic,  fourth  edition,  1884,  p.  341. 


By  these  methods  it  is,  I  believe,  possible  to  estimate 
the  height  to  within  5  ctm.  in  three-quarters  of  the  cases 
when  it  is  done  solely  by  the  method  of  proportions. 
When  the  most  important  parts  of  the  skeleton  are  pres- 
ent there  seems  no  reason  why  the  error  should  ever 
reach  that  amount.  Indeed  the  only  reason  why  so  large 
a  margin  should  be  allowed  is  the  difficulty  of  knowing 
what  the  true  height  may  have  been,  and  the  further  fact 
that  as  it  is  not  a  constant  quantity,  it  never  can  be 
known  certainly. 

CRIMINAL  PSYCHOLOGY. 
Bv  J  AS.  WEIR,  Jr.,  M.D., 

OWMNSBOBOUGH,   KY. 

In  an  article  which  appeared  in  the  Medical  Rec- 
ord, January  13th,  entitled  "  Criminal  Anthropol- 
ogy," I  showed  by  photographs  and  original  sketches 
that  the  criminal  was,  anatomically  and  physiologically, 
an  abnormal  man,  and  also  that  he  was,  unquestion- 
ably, an  atavism.  With  the  permission  of  the  reader  I 
will  quote  some  of  the  closing  sentences  of  the  above- 
mentioned  article,  and  they  shall  form  the  text  from 
which  the  present  paper  will  be  elaborated.  "  Atavism 
has  hurled  him"  (the  congenital  criminal)  "back  thou- 
sands of  years,  and  has  placed  him  beside  his  pithecoid 
ancestor.  He  is  a  savage  in  the  midst  of  civilization. 
His  customs  and  desires,  his  responsibilities  and  religion 
are  those  of  a  savage,  born  and  dead  centuries  and  dec- 
ades of  centuries  ago.  .  .  .  Poor  unfortunates! 
Are  they  to  be  held  responsible  for  Nature's  vagaries  ? 
Enlightened  humanity  has  a  difficult  problem  to  solve 
when  asked  the  question,  '  What  will  you  do  with  the 
criminal? '  "  Ethics,  concrete  and  abstract,  are  the  re- 
sult of  psychical  evolution.  Abstract  ethics,  pure  and 
refined,  have  reached  a  high  point  in  civilized  man, 
while  concrete  ethics,  ethics  necessary  for  the  preserva- 
tion of  species  living  in  communities  (social  law),  have 
reached  an  equally  high  point  among  savages,  and  some 
of  the  lower  animals,  e.g.,  the  social  hymenoptera  and 
some  of  the  birds  and  mammals.  Most  savages  are 
purely  animal  in  their  natures,  and  have  none  of  the  re- 
fined psychical  emotions  which  ennoble  the  possessor 
of  abstract  ethics,  civilized  man.  Parental  love,  conju- 
gal affection,  fraternal  love  such  as  civilized  man  experi- 
ences, are  unknown  to  the  savage.  Even  the  love  of 
God  is,  with  him,  material  and  concrete.  The  love  of 
the  beautiful  in  Nature  is,  in  the  savage  entirely  absent, 
or,  if  present  at  all,  it  is  only  so  in  its  material  sense. 
His  love  of  the  beautiful  (ornament)  is  rude  and  uncul- 
tivated, and,  in  its  gratification  he  scarcely  excels  the 
rude  decorative  attempts  of  some  of  the  lower  animals, 
e.g.,  the  bower-bird,  humming-bird,  spider,  etc.  His  ass- 
theticism  is  coarse  and  unrefined,  and,  in  truth,  is  not 
elevated  above  his  gross  animal  desires.  His  drama,  his 
poetry,  and  his  art  appeal  to  his  carnal  nature.  He  is 
essentially  an  animal  devoid  of  every  refined  psychical 
emotion.  I  hold  that  the  congenital  criminal  not  only 
resembles  the  savage  anatomically  and  physiologically, 
but  that,  psychically,  the  savage  is  also  his  archetype. 
It  will  be  necessary,  in  order  to  prove  this,  to  discuss 
the  ethics  and  aesthetics  of  savages  and  compare  them 
with  the  ethics  and  aesthetics  of  congenital  criminals. 
Personally  I  am  not  acquainted  with  the  psychology  of 
the  savage  except  for  that  knowledge  derived  from  read- 
ing the  observations  of  others,  but  with  the  psychology 
of  the  criminal  I  am  thoroughly  conversant,  having 
lived  with  him  in  two  of  the  largest  cities  in  the  United 
States. 

In  the  following  description  of  the  savage  and  his 
habits,  I  have  borrowed  freely  from  the  works  of  Hall, 
De  Quatrefages,  Nares,  Lubbock,  Markham,  Lyons, 
Ross,  Reclus,  Day,  and  Bancroft.  I  will  not,  however, 
distract  the  reader's  attention  by  sprinkling  my  text  with 
references.  The  Eskimos  or  Inoits  are  a  primitive  race 
inhabiting  the  most  northerly  habitable  portions  of  the 
globe ;  and  it  was  in  these  people,  before  contact  with  civ- 


September  8,  1894] 


MEDICAL   RECORD, 


297 


ilized  man  had  contaminated  them,  that  we  found  evi- 
dences of  concrete  ethics  and  aesthetics,  such  as  we  have 
every  reason  to  believe  existed  in  all  primitive  races  of 
men  at,  or,  a  short  time  after,  the  inception  of  psychi- 
cal evolution.  The  Inoit  habitation  is  communal ;  a 
whole  community  may  dwell  in  one  house.  The  central 
part  of  this  house,  where  the  ever-burning  lamp  is  placed, 
is  common  to  all.  Cords  are  stretched  across  the  other 
portions  of  the  house  dividing  it  into  imaginary  stalls  or 
boxes,  and  these  stalls  are  occupied  by  one  or  more  fami- 
lies. There  is  no  other  fire  save  that  of  the  lamp,  which 
serves  to  melt  the  ice  and  snow  for  drinking-water. 
There  is  an  utter  absence  of  that  which  we  term  mod- 
esty. The  inhabitants  of  the  "  kachim,"  owing  to  the 
great  heat  generated  by  so  many  bodies  in  one  small 
room,  strip  off  their  clothes  and  go  about  entirely 
naked.  "There  is  no  natural  want  or  physiological 
function  which  they  hesitate  about  satisfying  in  public." 
They  are  dirty,  squalid,  ill- smelling.  They  are  un- 
washed, though  fond  of  the  vapor-bath ;  this  they  in- 
dulge in  for  the  same  reason  that  hogs  will  indulge  in 
mud-baths,  for  the  gratification  it  affords.  They  some- 
times bathe  their  faces  in  decomposed  urine,  but  this 
they  do  for  a  religious,  or,  rather  medico-religious  fe- 
tisch,  for  they  regard  the  bladder  as  the  seat  of  the  soul. 
The  use  of  urine  as  an  emollescent  and  a  medicine  is  al- 
most universal  among  savage  races.  The  Wahabis  and 
Ugoyos  of  East  Africa,  the  Banians  of  the  Momba, 
the  Chewsures  of  the  Caucasus,  the  Silesians,  the  Be- 
douins, and  the  Arabs  all  use  it.  Even  in  France  and 
Spain  it  is  used  by  certain  people  as  an  emollescent  and 
a  dentifrice.  We  will  see,  at  the  proper  time,  what  a 
prominent  place  it  occupies  in  the  materia  medica  of  the 
congenital  criminal. 

"  In  Aleutia  those  most  nearly  related  to  each  other 
contract  a  union,  the  brother  with  the  sister,  and  some- 
times the  father  with  the  daughter."  Langsdorf  re- 
proached an  Aleutian  for  so  doing;  he  replied,  "Why 
not?  the  otters  do  it!  "  Between  husband  and  wife 
there  is  no  conjugal  affection.  They  are  not  at  all 
jealous.  The  Aleutian  offers  his  wife  to  the  guest  as 
freely  as  he  offers  the  chunk  of  seal-blubber.  His 
friends  are  welcome  to  enjoy  her  if  they  arc  mar- 
ried and  are  in  a  position  to  return  the  favor.  Im- 
moral !  Wrong  !  Not  a  bit  of  it.  Remember  that  these 
people  are  mere  animals  and  have  no  knowledge  of  ab- 
stract ethics;  they  see  nothing  wrong  in  a  woman  de 
daring  that  one  husband  is  not  enough  for  her.  It  used 
to  be  the  custom  in  Florence  for  the  women  to  demand 
in  their  marriage  contracts  the  right  to  take  a  lover. 
The  Aleutian  girls,  enjoying  full  liberty  during  their 
girlhood,  demand  at  their  espousals  the  right  of  the  ei- 
eisbeat.  During  the  absence  of  the  legitimate  husband 
the  cicisbeo  takes  his  place.  Brothers  frequently  marry 
the  same  woman;  in  fact,  among  the  Thlinkets  and 
Koloshes,  adelphogamy  is  the  rule.  The  Nair  girl  calls 
in  any  man  who  is  convenient  and  complaisant,  who 
goes  through  the  marriage  ceremony  with  her,  and  places 
the  /*/*,  the  Hindu  equivalent  of  our  wedding-ring, 
round  her  neck.  He  is  feasted,  and  then  politely  shown 
the  door.  The  wife  is  then  at  liberty  to  receive  as  many 
other  men  as  she  sees  fit,  but  the  husband — never !  That 
would  be  disgraceful  and  highly  immoral. 

I  might  enumerate  hundreds  of  kindred  customs  and 
habits  in  savage  races,  but  do  not  consider  it  necessary ; 
I  merely  wish  to  establish  the  fact  that  conjugal  affec- 
tion does  not  exist  among  savages.  The  savage  mother 
has  the  same  affection  for  her  offspring  as  the  cat  or  the 
dog  has  for  hers.  She  attends  to  it  just  as  long  as  it  is 
helpless,  "but  as  soon  as  it  is  able  to  look  into  the  pot 
standing  erect,  she  leaves  it  to  itself  and  seems  to  forget 
all  about  it."  Where  polyandry  exists  it  is  not  reason- 
able to  expect  that  the  man  has  any  regard  whatever  for 
the  children  of  his  wife.  This  is  true  also  where  polyandry 
and  polygamy  exist  combined  together.  In  his  poetry 
and  his  drama,  and  the  savage  is  a  born  poet  and  actor, 
the  savage  depicts  the  scenes  of  his  every  day  life.     The 


events  of  the  hunt,  in  the  field  or  on  the  flood,  are  re- 
cited or  acted  with  wonderful  realism.  Love  enters  into 
a  number  of  their  poems,  but  it  is  an  intensely  sensual 
love,  a  carnal  and  an  animal  love.  Rapine,  lust,  and 
feasting  go  hand  in  hand,  and  tread  the  measures  of 
every  savage  dance  together. 

The  savage  is  a  creature  of  to-day ;  he  lets  to  morrow 
take  care  of  itself.  When  there  is  plenty,  he  gorges  him- 
self with  food  to  repletion ;  when  there  is  nothing  to  eat, 
he  fasts  with  stoical  equanimity.  Says  Captain  Lyons : 
"  Knillitleuk  had  already  eaten  until  he  was  half  seas  over. 
He  was  dropping  asleep,  with  a  red  and  burning  face 
and  open  mouth.  His  wife  was  cramming  him,  stuffing 
bits  of  half-boiled  meat  down  his  throat  with  the  help  of 
her  first  finger,  steering  clear  of  his  lips.  She  carefully 
watched  the  process  of  deglutition,  and  immediately  filled 
up  any  void  that  might  appear  in  the  orifice  with  a  stopper 
of  raw  fat.  The  happy  man  did  not  stir ;  he  moved  noth- 
ing but  his  molars,  chewing  slowly,  and  not  even  open- 
ing his  eyes.  From  time  to  time  a  stifled  sound  escaped 
him,  a  grunt  of  satisfaction."  The  Mescalero  Apaches 
tighten  their  belts  around  their  empty  stomachs  and  go 
in  quest  of  prey,  nothing,  in  the  shape  of  an  animal, 
comes  amiss  to  them  as  food  while  out  on  a  marauding 
expedition.  Grasshoppers,  lizards,  snakes,  a  chance 
bird,  anything  is  eagerly  devoured  in  order  to  sustain 
life  until  they  can  make  a  grand  coup  on  some  un- 
guarded ranch.  At  the  right  moment  they  rush  in,  kill 
the  men,  and  carry  off  the  women,  children,  horses,  and 
mules.  They  then  turn  and  strike  a  bee  line  for  home, 
driving  their  captives  before  them,  nor  do  they  halt 
until  they  have  regained  their  encampment,  where  they 
are  received  with  yells  of  welcome.  Immediately  a 
bacchanalian  orgy  of  feasting  begins.  A  horse  is 
knocked  on  the  head  and  devoured  before  his  flesh  has 
ceased  to  quiver ;  nor  do  they  stop  for  cooking  until  the 
edge  of  their  hunger  has  been  considerably  blunted. 

The  savage  is  essentially  a  believer  in  witchcraft,  and 
most  of  them  are  devil-worshippers.  They  are  intensely 
superstitious,  and  see  in  every  event  of  nature  wonderful 
auguries  and  prophetical  signs. 

Among  the  Inoits  and  kindred  races  individual  property 
does  not  exist.  All  things  are  held  in  common.  When 
these  people  visited  a  ship  for  the  first  time,  they  picked 
up  anything  which  pleased  their  fancy.  They  did  not 
consider  it  stealing.  ' '  A  man  cannot  steal  from  himself, '  * 
said  an  Aleut ;  "  what  is  yours  is  mine,  and  what  is  mine 
is  yours.     The  Great  Mother  has  given  to  all  alike." 

So  much  for  the  savage ;  now  let  us  consider  his  con- 
gener, the  congenital  criminal,  who,  to  a  certain  extent, 
is  modified  by  his  surroundings.  When  Marco  Polo  wrote 
his  celebrated  work  people  considered  him  a  romancer. 
When  an  Indian  returns  to  his  tribe  after  a  visit  to  Wash- 
ington and  relates  to  his  brethren  the  wonders  he  has 
seen  in  his  travels,  they  move  their  hands  before  their 
mouths  and  shake  their  heads.  Deaf  mutes  make  the  same 
signs  when  they  wish  to  express  incredulity. 

I  expect  that  some  of  my  readers  will  consider  me  a 
second  Marco  Polo,  and  will  treat  me  with  the  same  scant 
ceremony  that  the  unsophisticated  Indians  bestow  upon 
their  travelled  brother ;  yet  I  assure  them,  in  advance, 
that  the  following  history  of  the  criminal  is  true  in  every 
particular.  Men  are  prone  to  disbelieve  because  they 
cannot  see  the  wound  in  the  side  with  their  own  eyes,  and 
cannot  place  the  tips  of  their  fingers  in  the  punctured 
palms.  St.  Thomas  was  only  intensely  human,  and  I  do 
not,  therefore,  have  the  poor  opinion  of  him  which  most 
people  have.  Man  is  a  veritable  terra  incognita  to  most 
men,  though  they  do  not  know  it,  and  when  an  observer 
tells  them  that  he  has  discovered  something  new  about 
man,  doubting  Thomases  spring  up  everywhere.  I  only 
ask  such  critics  to  live  as  I  have  lived,  with  and  among 
criminals,  and  they  will  soon  cease  to  be  infidels.  I  can- 
not be  elaborate  in  a  non  technical  article,  neither  can  I 
go  into  certain  details  without  giving  offence,  but,  strip- 
ped of  unnecessary  verbiage  and  absolutely  devoid  of  all 
false  sentiment,  the  following  history  is  but  a  plain  nar- 


298 


MEDICAL   RECORD. 


[September  8,  1894 


Tative  of  the  ethics  and  aesthetics  of  the  criminal,  revealed 
to  me  by  a  personal  and  intimate  acquaintance  with  him 
in  his  daily  life.  Those  in  authority,  whose  duty  it  is  to 
watch  and  guard  against  the  criminal,  will  tell  you  that  crim- 
inals  herd  together,  and  during  my  intercourse  with  them 
I  always  found  them  living  in  circumscribed  communities. 
Remember  always  that  in  this  paper  I  am  speaking  of  the 
congenital  criminal  and  not  the  professional  criminal,  nor 
the  occasional  criminal.  Let  me  say,  also,  that  the  so- 
called  "tough"  is  not  usually  a  congenital  criminal. 
The  tough  will  fight  and  will  commit  other  anti-social 
acts ;  he  will  even  commit  murder,  but  he  is  generally 
incited  thereto  by  whiskey  or  by  passion.  He  never 
commits  murder  for  the  sake  of  personal  benefit  like  the 
congenital  criminal.  He  is  not  an  habitual  thief,  nor  is 
he  ever  guilty  of  incestuous  acts ;  moreover,  the  tough 
will  work,  but  the  congenital  criminal  never,  unless  com- 
pelled. The  tramp  is  hardly  ever  a  congenital  criminal ; 
he  is,  usually,  only  an  occasional  criminal. 

Perhaps  the  reader  will  be  interested  in  learning  how  I 
obtained  my  passport  to  thiefdom.  I  obtained  it  on  one 
occasion  in  the  following  manner :  In  the  first  place,  I 
called  on  the  chief  of  police  and  explained  the  object  of 
my  researches  and  my  plan  of  operations.  I  deemed  this 
necessary,  so  that  if  "  run  in,"  I  might  have  a  friend  at 
court.  I  then  hired  a  room  in  an  office  building  and 
furnished  it  with  a  desk  and  some  chairs,  and  for  several 
days,  lounged  about  the  low  saloons  in  the  poorest  and 
most  criminal  section  of  the  city.  I  saw  any  number  of 
criminals,  but  bided  my  time ;  I  was  looking  for  a  typical 
criminal,  a  chief  in  his  tribe.  I  seldom  or  never  make  a 
mistake  in  my  diagnosis  of  criminality,  and  so  soon  found 
the  very  man  for  whom  I  was  looking.  A  few  drinks  of 
"red  eye"  and  several  "rum  holers,"  made  him  com- 
panionable. I  explained  to  him  that  I  had  come  to  the 
city  from  an  inland  town  where  I  had  barely  escaped 
being  "pinched"  for  "flim-flamming;"  that  I  knew 
where  a  "  trick  could  be  turned  "  in  the  city  if  I  had  some 
one  to  help  me.  He  readily  agreed  to  furnish  the  tools 
and  render  me  all  the  help  necessary  for  half  the ' '  boodle, ' ' 
so  I  deliberately  planned  with  him  to  rob  my  own  room. 
I  had  placed  in  the  desk  in  this  room  twenty  five  dollars, 
and  to  make  a  long  story  short,  I  assisted  him  in  burglariz- 
ing my  own  room  and  in  robbing  myself.  We  divided  the 
money,  and  he,  as  I  expected,  then  invited  me  to  go  with 
him  to  his  "  mot  cab,"  *  *.,  woman's  room.  It  was  here 
that  I  made  the  acquaintance  of  the  congenital  criminal. 
This  colony  of  criminals  numbered  about  two  hundred, 
and  were  herded  together — men,  women,  and  children — 
in  two  small  tenements.  Sometimes  a  dozen  men,  women, 
and  children  would  be  found  occupying  one  small  room. 
No  modesty  was  observed  by  these  people.  A  tub  or 
bucket  did  duty  as  a  necessary,  and  the  calls  of  nature 
were  attended  to  publicly.  As  it  was  summer,  and  the 
weather  very  warm,  these  people  stripped  themselves  naked 
when  in  their  rooms,  the  younger  ones  even  running  about 
the  house  and  into  the  courts  entirely  nude.  The  women 
had  their  favorite  "  cully,"  but  almost  everyone  of  them 
practised  polyandry.  Some  of  them  did  this  secretly, 
'  bat  most  of  them  were  open  in  their  adultery,  and  the  men 
were  fully  aware  of  the  fact.  Prostitution  was  a  source 
of  revenue  in  which  the  putative  husband  shared  without 
any  shame  or  compunctions  of  conscience.  He  only 
grumbled  when  his  "  mot "  did  not  bring  in  much  money. 
In  this  colony  I  saw  two  examples  of  incest,  one  a  father 
living  with  his  daughter,  and  another,  a  brother  living 
with  his  sister.  There  were  probably  many  more  in- 
stances, but  they  were  cursory  and  did  not  attract  my  at- 
tention. These  people  were  fully  aware  of  the  fact  that 
these  acts  were  considered  criminal  by  people  not  belong- 
ing to  their  tribe,  and  that  they  would  be  punished  if  ap- 
prehended. They  had  nothing  to  fear,  however,  from 
their  associates,  for,  like  the  Aleutians,  they  saw  nothing 
wrong  in  it.  "Why  not?  the  otters  do  it!"  When 
the  head  of  the  family  goes  off  on  a  marauding  expedition, 
and  he  is  frequently  absent  for  weeks  at  a  time,  he  leaves 
his  partner  in  charge  of  the  family.    This  man  is  the 


cicisbeo  of  the  woman,  and  during  the  absence  of  the  hus- 
band fulfils  all  of  his  duties.  These  men  are  true  savages 
in  the  treatment  of  their  women ;  they  beat  and  maltreat 
them  on  all  occasions,  and  almost  every  woman  in  the 
colony  bore  the  marks  of  her  * '  cully's ' '  brutality.  Here, 
also,  I  saw  many  instances  of  sexual  perversion.  These 
disgusting  performances  cannot  be  described  or  even 
hinted  at.  Suffice  it  to  say  that  the  religio  sexual  abomi- 
nations of  the  Aleutians  have  their  autotypes  among  their 
civilized  (so  called)  congeners.  The  girls  become  pros- 
titutes early  in  life.  They  are  nominally  match  sellers 
or  flower-venders,  and  do  a  thriving  trade  among  the 
brokers  and  various  agents,  etc.,  who  have  their  offices 
down  in  the  city.  One  little  girl,  not  ten  years  old, 
showed  me  a  twenty-dollar  gold-piece  which  she  declared 
had  been  given  her  by  a  certain  "  grave  and  reverend 
seignior, ' '  high  up  in  banking  circles.  The  money  which 
these  precocious  little  sinners  (ought  I  to  call  them  sin- 
ners ?  I  am  convinced  that  they  do  not  consider  them- 
selves such),  take  in  is  given  to  their  mothers.  When 
these  girls  arrive  at  a  marriageable  age,  say  from  fourteen 
to  eighteen  years,  they  "  take  up  "  with  some  man  in  the 
colony  and  become  his  "mot,"  or  woman.  The  boys 
are  thieves  from  earliest  childhood.  They  sometimes  sell 
newspapers,  but  do  this  merely  to  mask  their  real  busi- 
ness, which  is  pocket-picking.  When  older  they  become 
sneak-thieves,  thugs,  and  burglars.  The  criminal,  like 
the  savage,  is  improvident  and  wasteful.  When  he  has 
made  a  successful  haul  he  lives  on  the  fat  of  the  land. 
The  "  growler  "  fairly  smokes,  it  is  "  rushed  "  so  rapidly! 
The  pots  and  kettles  in  the  scantily  furnished  kitchen 
corner  are  filled  to  overflowing.  The  women  are  all  en- 
gaged in  rude  cookery,  while  the  men  prepare  for  the 
coming  feast  by  stimulating  their  stomachs  with  numer- 
ous potations.  The  dinner  is  served  and  all  fall  to,  like 
veritable  savages  as  they  are,  and  eat  and  drink  until 
slumber  overtakes  them.  The  criminal  delights  in  bright 
colors  and  tawdry  jewelry.  His  aestheticism,  like  that  of 
the  savage,  is  rude  and  uncultivated.  He  will  cover  his 
fingers  with  enormous  rings,  and  will  wear  cravats  and 
handkerchiefs  of  the  most  pronounced  colors ;  he  does 
this,  however,  when  on  dress  parade.  When  on  business 
bent,  like  the  savage,  he,  almost  literally  strips  himself 
to  his  breech-clout ;  he  does  not  care  to  have  his  move- 
ments hampered  by  "bum  togs"  when  he  is  about  to 
' '  crack  a  box. "  He  is  filthy  and  uncleanly  in  his  habits ; 
he  never  bathes  from  one  year's  end  to  another.  Para- 
sites swarm  on  his  person,  and  the  odor  of  his  body  is  rank 
and  animal-like.  His  knowledge  of  medicine  and  the 
kindred  sciences  is  crude  and  savage.  Incantations,  sor- 
ceries, and  simples  (some  of  the  latter  are  horrible  and 
disgusting  compounds)  are  his  materia  medica.  I  ac- 
cidentally sprained  an  ankle  while  with  these  people,  and 
was  treated  by  an  old  crone  of  the  colony.  She  bathed 
the  foot  and  ankle  with  decomposed  urine,  all  the  while 
mumbling : 

•'  From  toe  to  knee,  from  knee  to  toe, 
In  and  alx>ut  the  devils  go ; 
Chase  'em,  liquor,  chase  'em  fast, 
And  from  this  foot  drive  'em  at  last." 

This  treatment  proved  very  efficacious,  for  the  pain 
vanished  and  the  swelling  disappeared  as  if  by  magic. 
Urine  is  a  favorite  lotion  with  the  congenital  criminal. 
The  women  use  it  as  a  face  wash,  and  the  men  consider 
it  the  best  medicine  in  the  world  for  bruises  and  con- 
tusions. 

The  congenital  criminal  has  his  god,  but  he  is  not  the 
God  of  the  Christian.  He  is  the  god  of  luck  or  chance, 
and  his  wishes  are  consulted  and  obeyed  with  as  much 
fidelity  by  them  as  are  those  of  the  Christian's  God  by 
his  devotees.  Bad  Luck  is  their  devil,  and  he  is  treated 
with  as  much  consideration  as  his  antithesis,  Good  Luck. 
Here  is  where  the  devil  worship  of  the  Aleutian  is  paral- 
leled. Here  we  see  an  evidence  of  concrete  ethics  such 
as  we  find  in  all  savages ;  there  is  no  abstract  love  of 
God  such  as  civilized  Christians  feel.  The  congenital 
criminal,  like  the  savage,  recognizes  the  good  and  evil 


September  8,  1894] 


MEDICAL  RECORD, 


299 


principles,  but  he  applies  them  to  his  personal  welfare 
and  not  to  his  spiritual.  He  is  a  savage,  and  the  idea  of 
morals  has  not  yet  been  evolved  in  his  brain. 

The  savage  and  the  congenital  criminal  are  born  poets, 
and  both  love  a  certain  kind  of  play-acting.  Like  the  sav- 
age, the  criminal  likes  to  witness  scenes  akin  to  his  every- 
day life  and  aspirations,  acted  on  the  stage.  The  border 
drama,  in  which  there  are  many  murders  and  much  crime, 
is  his  great  delight.  He  cares  nothing  for  comedy,  un- 
less it  is  obscene  and  lasciviously  suggestive.  He  loves 
music  and  dancing,  but  both  the  music  and  the  dance 
must  be  carnally  exciting,  or  he  will  have  none  of  them. 
He  is  a  poet,  and  almost  invariably  speaks  in  figurative 
language ;  so  is,  and  does,  the  savage.  His  poems  de- 
pict his  every- day  life,  because  he  is,  from  the  nature  of 
things,  essentially  a  realist.  All  are  familiar  with  the 
lucubrations  emanating  from  our  jail-birds.  Most  of 
the  poems  obtained  by  myself  cannot  be  printed.  Some 
of  them  are  real  poetry,  though  based  on  obscene  and 
lascivious  topics,  and  expressed  in  rude,  slangy  language. 
The  criminal  is  an  artist  also,  and  his  work  is  strikingly 
like  that  of  the  savage.  His  drawings  are  mostly  porno- 
graphic, depicting  men  and  women  in  immodest  and  las- 
civious attitudes,  and  according  to  Mayhew,  savages  are 
guilty  of  the  same  thing.  The  congenital  criminal  is 
born  with  his  tendency  to  criminality  firmly  stamped  on 
his  brain ;  it  is  an  inheritance  from  his  father  and  his 
mother.  He  considers  the  laws  of  society  to  be  all 
wrong ;  his  social  laws,  his  ethics,  are  the  only  right 
ones.  His  logic  is  all  wrong  with  us,  but  all  right  with 
him.  The  congenital  criminal  is  a  moral  imbecile ;  no 
amount  of  punishment  will  ever  evolve  in  his  brain  any 
idea  of  morality.  This  is  an  established  fact,  and  can- 
not be  gainsaid.  But  he  is  antisocial,  therefore  danger- 
ous ;  what  shall  we  do  with  him  ? 


PROVISIONAL  TREATMENT  OF  INSANITY. 
By  SANGER   BROWN,  M.D., 

CHICAGO,  ILL. 

LATE  ACTING  MEDICAL  SUPERINTENDENT  OF  THE  BLOOMINGDALE  ASYLUM,  NSW 
YORK  ;  PROFESSOR  OF  MBDICAL  JURISPRUDENCE  AND  HYGIENE  RUSH  MEDICAL 
COLLEGE  ;  ATTENDING  NEUROLOGIST  COOK  COUNTY  HOSPITAL  ;  MEMBER  OF 
THE  LONLON  NEUROLOGICAL  SOCIETY. 

I  wish  to  deny  at  the  outset  any  intention  of  assuming 
a  hostile  attitude  toward  the  asylum  treatment  of  the 
insane,  or  that  it  is  the  main  purpose  of  my  communica- 
tion to  advocate  the  home  treatment  or  care  of  the  in- 
sane. I  preface  what  I  have  to  say  in  the  above  manner 
in  order  to  escape,  if  possible,  from  the  imputation,  which 
a  hurried  reader  might  charge  to  me,  of  being  in  the 
main  opposed  to  the  asylum  treatment  of  insanity,  and 
in  a  general  way  favoring  by  preference  the  home  treat- 
ment of  the  disease.  I  do  this  because  experience  has 
taught  me  that  in  medical  societies  or  gatherings,  where 
I  have  thrown  out  any  suggestions  along  the  lines  con- 
sidered in  this  paper,  I  have  almost  invariably  been  mis- 
understood by  a  few  at  least,  if  not  by  the  majority. 
I  feel,  however,  that  the  subject  is  one  of  considerable 
importance,  and  even  at  the  risk  of  being  misunderstood 
I  shall  venture  to  express  myself  upon  it. 

My  principal  proposition  is  that  when  it  is  demon- 
strated in  a  given  case  that  insanity  actually  exists,  it 
does  not  necessarily  follow  that  it  is  the  best  practice  to 
immediately  send  the  patient  to  an  asylum.  It  is  the 
purpose  of  this  paper  to  present  arguments  in  support  of 
this  proposition. 

From  fifty  to  seventy  five  years  ago  the  asylum  or  mad- 
house was  for  the  most  part  a  place  for  the  custodial  care 
of  violent  or  dangerous  lunatics,  and  it  was  rather  the 
exception  that  the  chief  officer  was  a  medical  man ;  and 
if  a  medical  man,  it  was  perhaps  a  still  greater  exception 
if  he  devoted  much  time  to  the  actual  study  of  insanity 
in  its  varied  aspects.  Howbeit  there  were  a  few  con- 
spicuous exceptions,  and  by  way  of  digression  I  want  to 
take  this  occasion  to  say  that  we  are  more  indebted  to 
them  for  the  advancement  that  has  been  made  in  the 


treatment  of  the  insane  than  we  are  generally  aware  of. 
It  was  the  common  practice  in  those  days  to  leave  the 
care  and  treatment  of  the  insane  in  asylums  mainly  to 
the  attendants,  the  physician  seeing  and  prescribing  for 
them  mainly  at  the  attendant's  suggestion  ;  in  many 
instances  large  quantities  of  the  favorite  "  sleeping  po- 
tions" and  "quieting  draughts"  were  placed  in  the 
hands  of  attendants  with  instructions  how  to  use  them. 
As  can  readily  be  understood,  it  generally  happened  in 
these  times  that  the  attendant  really  knew  much  more 
about  the  actual  problems  of  treating  the  insane  than  the 
physician,  and  if  he  told  the  physician  that  this  patient 
needed  quieting  medicine,  and  that  one  must  be  kept 
strapped  to  a  chair,  and  another  must  be  kept  locked  in 
his  room,  his  word  was  law,  and  said  patients  were  often 
so  treated,  not  for  days  and  weeks,  but  continuously  for 
long  months  and  years.  But,  somewhere  about  twenty 
or  thirty  years  ago,  resident  medical  c  fficers  more  or  less 
generally  began  to  actually  make  a  study  of  the  care  and 
treatment  of  the  insane,  until  now  it  is  rather  the  ex- 
ception for  attendants  to  know  more  about  any  part 
of  the  treatment  of  insanity  than  asylum  physicians. 
Though  it  would  be  both  instructive  and  interesting  to 
trace  step  by  step  the  changes  as  they  have  occurred,  it 
may  be  asserted  quite  safely  that  within  the  above-men- 
tioned time  there  ft  no  department  of  medicine  in  which 
there  has  been  a  more  striking  metamorphosis  or  a  more 
practical  advancement. 

Cases  that  for  years  had  lived  behind  bars,  in  their 
own  filth,  having  their  food  passed  to  them,  either  in 
the  public  jail,  public  madhouses,  or  at  the  house  of 
some  relative,  under  the  new  order  of  things  in  the  mod- 
ern asylum  were  often,  much  to  the  astonishment  of  their 
relatives,  found  in  a  condition  of  cleanliness  and  com- 
parative comfort,  successfully  employed  at  some  healthful 
out-door  occupation. 

To  all  classes  of  observers  this  change  appeared  quite 
marvellous,  and  to  none  more  so  than  to  the  general  prac- 
titioner of  medicine,  so  that  he,  urged  on  by  the  reports 
of  the  medical  officers  of  the  hospitals  for  the  insane, 
soon  came  to  adopt  the  routine  practice  of  promptly 
sending  all  patients  to  an  asylum  whenever  the  existence 
of  actual  insanity  was  demonstrated ;  and  on  the  whole  it 
is  probable,  if  the  practitioner  had  never  served  on  the 
medical  staff  of  an  asylum  and  thus  had  an  opportunity 
of  gaining  a  practical  acquaintance  with  insanity,  that  this 
was  the  wisest  course  for  him  to  pursue.  He  did  not 
know  at  all  how  his  patient  would  be  treated  when  he 
reached  the  asylum.  He  was  only  thoroughly  convinced 
from  his  reading  and  observation  that  to  send  the  pa- 
tient to  an  asylum  was  the  proper  thing,  and  he  often 
surmised  that  there  were  some  mysterious  influences  in 
operation  which  were  in  some  way  beneficial  and  which 
were  favored  by  the  association  together  of  a  compara- 
tively large  number  of  the  insane.  This,  like  most  sur- 
mises, was  very  far  from  the  actual  fact. 

To  prevent  the  patient  from  injuring  himself  or 
others,  to  see  that  he  have  proper  food,  rest,  sleep,  exer- 
cise, occupation,  and  diversion,  and  do  not  fall  into  per- 
nicious habits,  is  the  main  purpose  at  the  asylum ;  it  is 
not  easier  to  do  this  with  two  or  more  patients  than  with 
one,  it  is  only  more  economical ;  it  could  always  be  some- 
what more  effectively  accomplished  with  one  patient. 
There  is  no  mystery  about  it  whatever ;  natural  aptitude 
and  a  thorough  familiarity  with  the  various  phases  of  the 
disease  are  the  essential  elements  of  success  in  the  treat- 
ment of  insanity,  if  only  the  necessary  funds  are  at  hand. 

Now,  while  it  is  always  within  the  power  of  the  very 
wealthy  to  equip  a  private  establishment,  with  a  resident 
medical  attendant  for  the  exclusive  treatment  of  a  single 
individual,  and  whether  the  case  is  curable  or  not  such 
treatment  may  be  made  superior  to  any  other,  it  often 
happens  that  cases  are  seen  where,  without  any  great 
expense  the  indications  of  treatment  can  be  better  carried 
out,  say  in  a  general  hospital  or  a  private  family  other 
than  that  of  the  patient,  than  in  an  asylum,  and  if  it  be 
a  young  person  with  an  acute  attack,  a  considerable  ex- 


300 


MEDICAL   RECORD. 


[September  8,  1894 


pense  ought  to  be  incurred  in  order  to  provide,  for  a  time 
at  least,  proper  treatment  outside  of  an  asylum. 

Asylums  have  grown  to  be  so  numerous  and  such  a 
large  number  of  young  medical  men  are  employed  as 
assistants,  that  now  there  is  coming  to  be  quite  a  large 
sprinkling  of  practitioners  outside  of  asylums  who  have  a 
practical  knowledge  of  insanity,  men  who  know  when 
brought  in  contact  with  a  case  how  it  ought  to  be  treated, 
and  whether,  in  view  of  all  the  circumstances,  it  is  neces- 
sary to  hurry  the  patient  off  to  an  asylum  or  not. 

I  shall  not  at  this  time  attempt  to  describe  the  particu- 
lar class  of  patients  most  suitable  to  non  asylum  or  pro- 
visional treatment,  nor  the  measures  to  be  adopted  to 
meet  these  indications,  my  purpose  being  to  try  to  im- 
press upon  the  mind  of  the  practitioner  the  importance 
of  carefully  studying  every  case  of  insanity,  satisfying 
himself  as  to  the  diagnosis  and  prognosis  and  then  con- 
sidering how  the  indications  for  treatment  may  be  best 
met. 

Such  cases  are  often  somewhat  perplexing  and  trouble- 
some, and  I  fear  it  has  been  too  much  the  practice  of  late 
years,  sanctioned  by  usage,  not  by  science,  to  dismiss 
them  hastily  to  an  asylum,  without  due  regard  to  facts 
or  consequences. 

34  Washington  Strest. 


grogves*  of  Medical  gtimce. 

The  Effect  upon  the  Nursling  of  the  Mother's  Diet. 
— The  feeding  of  infants  on  artificial  foods  is  a  grow- 
ing evil  for  which,  although  they  inveigh  against  it, 
physicians  are  in  a  large  degree  responsible.  Efforts  are 
made  to  explain  the  evil  away  on  such  grounds  as  the 
desire  of  the  mother  to  avoid  the  inconveniences  of  her 
natural  duties,  or  of  changed  conditions  of  life  causing 
inability  to  furnish  food  in  sufficient  quantity,  if  at  all, 
or  of  deficient  quality  of  the  mother's  milk,  or  other  con- 
ditions, for  all  of  which  the  mother  is  responsible.  These 
conditions  do  exist  in  a  greater  or  less  degree,  but  aside 
from  actual  and  acute  disease,  the  maternal  conditions 
may  be  tersely  summed  up  in  the  statement  that  the 
mother  is  unwilling  to  make  the  sacrifices  necessary  if 
she  performs  her  duty  to  her  child.  The  responsibility 
of  physicians  lies  in  weakly  conceding  to  the  patient's 
desires,  in  place  of  strenuously  insisting  upon  the 
mother's  every  effort  to  carry  out  the  provisions  of  nature. 

In  these  days  of  milk- foods,  prepared  foods,  substi- 
tutes for  mother's  milk,  etc.,  mothers  do  not  under- 
stand that  the  nature  which  provides  organs  for  bearing 
children,  also  provides  organs  for  nursing  children,  and 
intends  that  these  organs  should  be  for  use  rather  than 
ornament.  She  does  not  realize  that  the  products  of 
modern  science  at  best  are  but  poor  substitutes  for  the 
products  of  nature.  If  the  physician  would  insist  upon 
the  mother  performing  her  natural  functions  despite  her 
assertions  that  she  "cannot  nurse  the  child,"  "never 
could  nurse  her  children,"  "  didn't  have  milk  enough," 
"  nipples  too  small  or  too  tender,"  or  "  milk  left  her  in 
two  or  three  months,"  etc. — if  the  physician  should  in- 
sist, and  the  mother  persist,  both  would  be  surprised  to 
find  that  long  abused  nature  would  still  be  willing  to  do 
her  proper  work.  Patient  endurance  of  discomfort,  per- 
sistent effort,  and  proper  food  will  eventually  demonstrate 
the  ability  to  nurse  their  infants,  in  nine  out  of  every 
ten  mothers  who  assert  the  necessity,  in  their  individual 
cases,  for  "  bringing  up  the  baby  on  the  bottle."  And 
that,  too,  without  scouring  materia  medica  for  imaginary 
galactagogues,  and  likewise  to  the  very  great  benefit  of 
both  mother  and  infant. 

During  his  six  years'  service  at  the  Preston  Retreat 
Dr.  Joseph  Price  gave  the  medical  profession,  through 
that  institution,  some  most  valuable  object  lessons  in 
obstetrical  science.  There  was  no  secret  in  the  methods 
used  to  make  that  institution  the  model  maternity  of  the 
world,  so  far  as  professional  results  are  concerned.     His 


guiding  principles  were  care,  cleanness,  and  common 
sense.  The  strictest  supervision  of  every  detail,  scrupu- 
lous practical  cleanness  and  not  so  much  of  theoretical 
cleanliness,  and  simplicity  in  all  matters,  enabled  him  to 
complete  his  service  with  a  mortality  record  never  equalled 
in  private  or  public  maternity  work.  It  was  a  law  with 
him  "  to  allow  the  mother  to  bear  her  own  children," 
and  it  was  equally  the  rule  to  require  each  mother  to 
nurse  her  own  infant  during  her  stay  in  the  institution. 
So  very  rare  were  exceptions  to  this  rule  necessary,  that 
a  nursing  bottle  could  not  be  found  in  the  entire  insti- 
tution. The  patients  in  the  Retreat  were  in  no  respect 
an  exceptional  class,  save  in  the  fact  that  so  large  a  pro- 
portion of  them  were  ill-nourished  and  impoverished  in 
physical  health  when  they  entered  the  hospital — con- 
ditions  which  would  entitle  them  to  claim  inability  to 
nurse  infants.  Another  fact  of  interest  was  noted, 
namely,  that  many  mothers,  who  while  in  the  house 
furnished  abundant  food-supply,  and  left  the  institution 
with  thriving  babies,  would,  after  leaving,  put  the  baby 
on  the  bottle  as  a  matter  of  personal  convenience,  and  in 
a  surprising  proportion  of  such  cases  would  lose  the 
babies  within  a  few  months. 

The  moral  to  be  drawn  is  that  almost  every  woman 
who  can  bear  a  child  can  nourish  it.  Attention  to  the 
body  functions,  generous  supply  of  simple,  nourishing 
food,  and  early  and  persistent  efforts  to  establish  and  de- 
velop the  mammary  secretions  were  the  only  methods 
used  to  secure  these  results.  In  general  practice  the 
physician  is  too  apt  to  give  up  the  contest  too  early  or  to 
rely  upon  some  form  of  stimulants  to  the  glands,  which 
eventually  proves  delusive  if  not  injurious.  It  is  a  com- 
mon practice  to  administer  alcoholic  beverages  in  the 
form  either  of  ale,  beer,  or  porter  to  nursing  women  for 
the  purpose  of  increasing  the  milk  supply.  Beyond 
question  these  articles  are  capable  of  doing  much  injury 
to  both  mother  and  child,  and  their  indiscriminate  em- 
ployment for  such  purposes  should  be  interdicted. 

Dr.  J.  W.  Byers,  in  the  Annals  of  Gynecology  and 
Pediatry,  has  made  some  pertinent  remarks  on  this  sub- 
ject. He  says :  "  The  truth  is,  in  this  practice  of  using 
alcoholic  drinks  the  profession  has  followed  the  customs 
and  whims  of  the  laity,  rather  than  the  usual  process  of 
instructing  and  leading  the  latter.  That  there  are  con- 
ditions and  circumstances  in  which  the  administration 
of  malt  liquors  is  of  decided  benefit  to  both  mother  and 
child,  no  one  will  undertake  to  gainsay.  But  that  they 
are  indicated  in  every  instance  of  deficient  lacteal  secre- 
tion, or  that  the  exigencies  of  the  case  ever  render  neces- 
sary their  use  to  the  extent  as  is  commonly  employed, 
none  can  maintain  or  justify.  The  promiscuous  and 
general  practice  of  using  malt  liquors  by  nursing  women 
is  irrational,  does  a  vast  amount  of  harm,  and  often 
causes  disease  in  the  suckling.  We  know  that  the  mam- 
mary gland,  for  all  practical  purposes,  may  be  con- 
sidered as  an  organ  possessing  functions  of  a  twofold  or 
mixed  character,  namely,  secretion  and  excretion. 
Under  normal  physiological  conditions  the  first  of  these 
processes  is  in  almost  exclusive  operation,  though,  as 
shown  by  experiences,  the  slightest  alteration  in  the  con- 
dition of  the  organism,  whether  of  an  emotional,  medi- 
cal, or  dietetic  character,  may  so  change  this  secretion 
that  it  becomes  to  all  purposes  and  effects  an  excretion, 
and  an  innocuous,  healthy  pabulum  for  the  child  is  con- 
verted into  a  deleterious  or  poisonous  substance.  Ex- 
perience is  very  general  in  showing  that  the  milk  fats  and 
albumins  in  increased  proportions  have  a  decidedly  in- 
jurious effect  upon  the  digestion  of  the  infant  when  taken 
into  the  stomach  in  excessive  quantities.  From  a  number 
of  experiments  conducted  by  Zaleski  he  found  these 
substances  in  the  milk  in  excessive  proportions  whenever 
the  mother  had  partaken  of  alcohol.  In  each  case  where 
the  mother  was  tested  with  malt  liquors,  the  fat  and  al- 
bumin appeared  and  caused  more  or  less  disorder  and 
distress  of  the  digestive  apparatus  of  the  suckling.  These 
deleterious  influences,  however,  were  not  the  worst. 
Analysis  of  the  milk  further  revealed  the  fact  that  it 


September  8,  1894] 


MEDICAL  RECORD. 


301 


actually  contained  alcohol  and  the  micro-organisms 
peculiar  to  malt  liquors ;  that  the  liquor  drank  by  the 
mother  actually  passed  out  in  toto  through  the  mammary 
gland  and  on  into  the  child's  stomach,  and  there  pro- 
duced all  the  phenomena  incident  to  digestive  disorders 
and  febrile  disturbances.  These  facts  point  to  the  belief 
and  support  the  attitude,  that  the  mammary  gland  under 
certain  conditions  exercises  the  function  of  an  excretory 
organ,  and  that  under  some  circumstances  it  becomes 
nothing  more  than  a  filter  through  which  the  food  and 
drink  taken  by  the  mother  passes  directly  into  the 
stomach  of  the  child.  This  being  true,  we  are  in  a  position 
to  understand  and  appreciate  the  importance  of  the  rela- 
tion of  the  diet  of  the  mother  and  the  well  being  of  the 
child.  When  we  prescribe  alcohol  for  the  mother,  we 
at  the  same  time  do  so  for  the  child.  The  diet  of  the 
mother  is  a  stage  in  the  milk- producing  process,  and  the 
milk  she  produces,  is,  in  every  instance,  the  result,  and 
only  the  result,  of  the  food  of  which  she  partakes.  If  it 
be  improper,  unsuitable,  or  contaminated,  the  milk  will 
express  this  in  a  proper  ratio.  In  the  case  that  beer  or 
ale  is  administered  it  will  find  this  outlet,  and  while  it 
does  not  evidence  deleterious  influences  to  the  extent  of 
producing  the  worst  results  in  the  form  of  either  colic, 
indigestion,  or  diarrhoea,  in  every  instance  its  effects  are 
present,  and  these  are  always  among  the  possible  results 
of  its  use.  The  effects  of  fat  and  albumin,  when  present 
in  breast  milk  in  excessive  proportions,  in  producing  evil 
effects  on  the  child  are  too  well  recognized  to  dwell  upon. 
That  the  more  severe  of  stomach  disorders — gastrointes- 
tinal catarrh,  enteritis,  or  even  cholera  infantum — are  due 
to  these  substances,  as  a  result  of  the  abuse  of  malt 
liquors  in  the  mother,  is  certain,  though  such  is  not 
generally  admitted  or  recognized.  Take  care  not  to 
advise  a  woman  whose  milk  supply  is  reasonably  full  to 
resort  to  beer  or  other'  liquors  in  order  to  increase  it. 
Always  impress  upon  them  the  increased  risk  to  the  child 
incurred  by  using  them." — The  Medical  and  Surgical 
Reporter. 

The  Effects  of  Quinine  on  Pregnancy. — A  collective 
investigation  of  this  subject  has  been  recently  undertaken, 
with  these  conclusions:  1.  The  existence  of  pregnancy 
is  no  bar  to  the  administration  of  quinine.  2.  For  fevers 
and  other  affections  during  pregnancy  in  which  quinine 
is  indicated,  the  effects  of  the  drug  are  more  marked  than 
those  of  any  other.  3.  That  abortion  following  the  ad- 
ministration of  quinine  is  either  the  result  of  the  original 
malady  or  the  effect  of  idiosyncrasy.  4.  That  allowing 
for  an  idiosyncrasy,  in  cases  in  which  a  tendency  to  abor- 
tion exists,  and  in  others  as  a  matter  of  precaution,  qui- 
nine is  best  administered  combined  with  a  sedative 
(opium).  5.  Hence  the  old-standing  view  of  the  action 
of  quinine  on  the  duration  of  pregnancy  is  not  borne  out 
by  the  clinical  experience  collected  in  the  replies. — In- 
dian Medico- Chirurgical  Review. 

Dermographismus. — Dr.  Ehrmann  describes  a  pecul- 
iar condition  of  the  skin  occurring  under  various  circum- 
stances, and  depending  for  its  appearance  upon  mechani- 
cal irritation.  He  distinguishes  three  degrees  of  this 
condition  :  In  the  first  there  appears  one  after  another 
contraction  of  the  cutaneous  muscular  tissue,  with  anaemia 
of  the  parts  affected,  then  hyperemia,  and  finally  transu- 
dation ;  in  the  second  the  muscular  contraction  is  very 
slight,  the  anaemia  is  not  so  marked,  and  there  is  hyper- 
aemia  of  the  superficial  layers  of  the  skin  only ;  and  in 
the  third  there  is  only  transitory  reddening  of  the  skin. 
But  the  more  common  form  of  case  is  that  in  which,  on 
the  portion  of  skin  affected,  small  raised  patches  of  oedema 
appear  around  the  roots  of  the  hair,  so  that  on  stroking 
the  skin  with  some  blunt  body,  or  even  by  the  pressure 
of  the  clothes,  or  a  button,  etc.,  only  an  isolated  group 
of  white  papules  appear,  which  cause  an  irritation  of  the 
skin  and  consequently  soon  lose  their  characteristic  ap- 
pearance, owing  to  being  scratched  by  the  patient.  In 
such  cases  cutaneous  pruritus  is  diagnosed  a  "  pruritus 
nervosus. ' '   In  some  cases  recorded  the  appearance  closely 


resembles  that  of  lichen  ruber  planus.  Ehimann  draws 
a  distinct  difference  between  dermographismus  and  urti- 
caria. The  latter  is  caused  by  the  action  of  some  toxic 
substance,  this  being  derived  from  some  affection  of  the 
skin  or  of  the  digestive  organs,  or  some  pathological  prod- 
ucts are  formed  (auto-intoxication)  ;  but  he  admits  that 
in  some  cases  of  urticaria,  in  which  the  nervous  system  is 
affected,  that  disease  and  dermographismus  may  exist  to- 
gether. This  condition  has  been  observed  after  mental 
excitement,  such  as  fright,  or  in  cases  of  neurasthenia 
and  hysteria.  He  considers  the  influence  of  the  nervous 
system  as  sufficient  to  produce  dermographismus,  and 
that  the  presence  of  a  toxic  substance  is  not  necessary. 
Examination  of  the  urine  demonstrated  the  presence  of 
indican  in  only  one  out  of  fourteen  cases. — Allgemeine 
Wiener  Medicinische  Zeitung. 

Epidemic*  Skin  Disease. — At  a  recent  meeting  of  the 
Dermatological  Society  of  Great  Britain,  Dr.  Savill 
showed  eleven  cases  of  dermatitis  which  had  attacked 
nearly  five  hundred  children  in  a  day  school  where  the 
average  daily  attendance  was  about  one  thousand.  {The 
Lancet)  It  was  thought  by  their  teachers  to  be  ring- 
worm of  the  face,  and  they  were  taken  to  a  neighboring 
hospital  for  such,  but  it  was  shown  not  to  be  ringworm 
because  the  scalp  had  not  been  attacked  by  the  disease  in 
any  case,  and  no  characteristic  spores  or  mycelium  could 
be  found  after  careful  search.  Moreover,  the  disease  re- 
sembled a  dry  eczema  occurring  in  patches,  not  healing 
in  the  centre  as  ringworm  does,  nor  had  they  the  raised 
border.  They  were  chiefly  on  the  face,  though  some  of 
the  children  had  patches  on  the  arms  and  legs.  In  the 
discussion  which  followed,  Dr.  Stephen  Mackenzie  re- 
garded the  condition  as  a  common  and  comparatively 
trivial  affection;  but  Dr.  Savill  pointed  out,  in  reply, 
that  the  cases  of  these  children  very  closely  resembled 
the  youngest  of  the  cases  with  the  epidemic  skin  disease 
described  in  1891.  Many  of  the  cases  of  this  disease  he 
had  subsequently  seen  (such  as  those  at  the  Bethnal 
Green  Workhouse  in  1893)  ^^  been  very  much  milder 
than  the  1 89 1  cases ;  and  it  would  be  a  matter  for  subse- 
quent inquiry  and  research  whether  the  cases  of  these 
school  children  belonged  to  the  same  category  or  not. 
At  any  rate,  there  seemed  evidence  to  show  that  the  dis- 
ease, whatever  it  might  be,  was  a  contagious  one,  spread- 
ing as  it  had  done  so  extensively  in  this  school  among 
children  who,  when  not  at  school,  must  live  under  such 
varying  conditions  of  environment  that  it  would  be  hard 
to  find  a  local  cause  in  operation  common  to  them  all. 

Treatment  of  Appendicitis. — Dr.  Swain  holds  that, 
since  about  ninety  per  cent,  of  cases  of  appendicitis  re- 
cover spontaneously,  early  operative  interference  in 
nearly  every  form  of  appendicitis  is  not  justifiable. 
{Therapeutic  Gazette!)  Cases  of  simple  and  plastic 
appendicitis  are  to  be  treated  by  rest  in  bed,  moderate 
amount  of  liquid  diet,  purgatives,  rectal  injection  if  nec- 
essary, local  application  of  leeches  or  fomentations,  and 
hypodermics  of  morphine  for  the  relief  of  pain.  As  soon 
as  pus  is  present  operation  is  indicated.  This  may  be 
performed  during  the  first  week,  but  is  more  commonly 
required  during  the  second.  When  in  doubt  as  to  the 
presence  of  pus,  there  is  usually  no  great  harm  in  delay- 
ing operation.  If,  however,  the  symptoms  are  steadily 
growing  worse  and  the  pulse  becoming  rapid,  operation 
is  indicated.  Section,  then,  is  called  for  in  suppurative 
cases,  in  cases  where  there  is  good  ground  for  suspecting 
deep  suppuration,  and  also  in  the  relapsing  and  rapidly 
perforating  cases.  The  best  incision  is  the  oblique  one, 
placed  at  right  angles  to  an  imaginary  line  drawn  from 
the  right  superior  iliac  spine  to  the  umbilicus.  This 
should  be  from  two  to  four  inches  long,  and  should  be 
placed  about  two  or  three  inches  internal  to  the  iliac 
spine.  In  suppurative  cases  the  incision  should  be  placed 
over  the  seat  of  suppuration,  since  thus  there  is  less  risk 
of  opening  the  peritoneal  cavity.  The  appendix  should 
be  removed  in  suppurative  cases  only,  when  this  operation 
is  readily  effected  without  opening  the  general  cavity. 


302 


MEDICAL  RECORD, 


[September  8,  1894 


The  risk  of  fecal  fistula  is  lessened  by  suturing  the  mus- 
cular and  mucous  walls  of  the  stump  of  the  appendix,  and 
then  invaginating  this  into  the  caecum  and  stitching  the 
peritoneum  over  it. 

Safranin  Reaction  in  Sputum. — A  simple  test  as  an 
aid  to  diagnosis  is  suggested  by  Zenoni.  {The  Lancet.) 
It  depends  upon  the  fact  that  mucin  is  colored  yellow  by 
safranin,  while  albumin  is  stained  red.  In  the  sputum  of 
bronchitis  mucin  predominates,  while  in  that  of  pneu- 
monia there  is  a  much  larger  proportion  of  albumin. 
Zenoni,  therefore,  prepares  a  cover-glass  specimen  of  the 
sputum  by  spreading  the  latter  out  in  a  thin  layer  on  the 
former,  places  it  at  once  in  absolute  alcohol,  and  leaves 
it  for  a  quarter  of  an  hour ;  by  the  end  of  that  time  the 
film  becomes  coagulated  and  fixed  to  the  glass.  The 
preparation  is  then  stained  in  a  half  saturated  aqueous  so- 
lution of  safranin.  When  the  cover-glass  is  removed  it 
is  partially  dried  and  then  placed  on  a  white  ground  and 
examined.  If  it  is  stained  a  yellow  color  mucus  pre- 
dominated in  the  sputum,  and  the  case  may  be  assumed 
to  be  one  of  bronchitis  only,  while  if  a  red  color  appears 
albumin  was  the  chief  constituent,  and  pneumonia  was 
probably  the  condition  present.  This  test,  if  proved  to 
be  trustworthy,  would  be  a  considerable  aid  to  diagnosis 
in  those  cases  in  which  the  physical  signs  of  pneumonia 
are  doubtful.  Especially  would  it  be  of  value  in  the 
case  of  children  if  a  sample  of  sputum  could  be  obtained, 
as  can  usually  be  done  with  a  little  trouble.  But  further 
trial  will  be  required  before  it  can  be  generally  accepted. 

The  Surgical  Treatment  of  Perforation  from  Gastric 
Ulcer. — Few  cases  offer  more  temptation  to  the  advent- 
urous surgeon,  and  in  few,  unfortunately,  have  his  en- 
deavors been  rewarded  with  less  success  than  those  of 
rupture  of  a  gastric  ulcer  into  the  peritoneal  cavity. 
The  affair  seems,  on  the  face  of  it,  so  absolutely  simple ; 
the  patient  may  be  in  perfect  health,  with  the  exception 
of  this  little  perforation  and  the  resulting  extravasation 
of  the  contents  of  the  stomach  into  the  peritoneum,  and, 
moreover,  in  the  majority  of  cases  in  which  the  rupture 
has  been  sudden  and  the  symptoms  typical,  the  perfora- 
tion has  been  in  accessible  regions— on  the  anterior  wall 
of  the  stomach — and  yet,  so  for,  few  attempts  to  sew  up 
the  opening  seem  to  have  been  attended  with  success. 
Great  interest,  therefore,  attached  to  the  case  reported 
by  Mr.  Morse,  of  Norwich,  England,  in  which  a  young 
woman  having  symptoms  of  gastric  ulcer  was  suddenly 
seized  with  symptoms  of  perforation,  and  was  treated  by 
him  successfully  by  means  of  celiotomy  and  suture  of 
stomach.  Abdominal  section  was  performed  within  five 
hours  of  the  accident ;  the  contents  of  the  stomach  were 
found  in  the  peritoneal  cavity ;  the  viscus  was  withdrawn 
aad  a  perforation  found ;  the  stomach  was  thoroughly 
washed  out  and  the  wound  united.  No  food  was  given 
by  the  mouth  for  sixty  hours,  and  in  three  weeks  the  pa- 
tient was  well.  The  points  of  importance  conducing  to 
the  success  of  this  case  would  seem  to  be,  1,  early  opera- 
tion, before  irrevocable  septic  mischief  has  arisen  through 
absorption  from  the  peritoneal  surface ;  2,  washing  out 
the  stomach  as  a  preliminary  to  introducing  the  sutures ; 
this  was  managed  by  introducing  a  large  cannula  through 
the  perforation,  and  alternately  filling  this  viscus  with 
water  and  emptying  it  until  the  fluid  came  away  clear ; 
3 ,  drawing  the  stomach  out  through  the  wound,  so  as  to 
perform  the  washing  and  suturing  with  facility ;  and  4, 
most  important  of  all,  the  very  great  care  taken  to  thor- 
oughly wash  out  the  peritoneum.  The  manoeuvre 
adopted  by  Mr.  Morse,  with  this  object,  will  probably 
be  useful  for  other  purposes  also.  Instead  of  merely 
passing  a  tube  to  the  various  regions  of  the  abdomen, 
leaving  the  return  water  to  wash  out  the  fragments,  two 
large  tubes  were  passed  side  by  side  to  every  part  of  the 
cavity,  and  the  flushing  was  continued  at  each  spot  until 
the  return  fluid  was  clear ;  by  this  arrangement  the  ex- 
travasated  stomach  contents  were  washed  out  through 
the  tube,  instead  of  drifting  in  the  stream  from  one  part 
of  the  abdomen  to  another.    It  is  to  be  hoped  that  other 


surgeons  will  be  able  to  obtain  like  success  in  the  treat- 
ment of  this  otherwise  very  fatal  accident.  On  a  very 
different  footing  stands  the  proposal  to  treat  perforation 
of  the  bowel  in  enteric  fever,  as  was  shown  by  the  dis- 
cussion at  the  Medical  Society  of  London  on  March 
9th.  The  patient  is  already  seriously  ill,  and,  although 
the  accident,  of  course,  happens  suddenly,  the  signs  of 
its  occurrence  are  often  by  no  means  typical.  The 
stupor  of  the  patient  leads  to  the  symptoms  being  more 
or  less  masked,  the  moment  of  onset  may  not  be  discov- 
erable, the  pain  may  not  be  severe,  and  the  patient  may 
only  seem  to  pass  from  a  bad  into  a  worse  condition. 
Moreover,  the  ulcers  are  generally  multiple  and  the  in- 
testine rotten,  so  that  the  stitches  may  have  to  be  in- 
serted in  unhealthy  tissues,  possibly  even  in  the  bases  of 
other  ulcers  !  A  certain  number  of  such  cases  also  re- 
cover under  medical  treatment.  The  operation,  then, 
would  seem  a  much  less  hopeful  one  than  that  for  per- 
foration of  gastric  ulcer. — Medical  News. 

Extramedian  Incision  in  Laparotomy Dr.  Flatau 

has,  since  1890,  abandoned  the  practice  of  cutting  in 
the  median  line  in  ovariotomy  and  other  abdominal 
operations  performed  on  women.  Out  of  thirty  three 
cases  where  the  incision  was  made  outside  the  middle 
line,  not  one  has  been  complicated  by  hernia  of  the  ci- 
catrix. He  cuts  one  centimetre,  or  two-fifths  of  an  inch, 
to  the  left  of  the  linea  alba,  laying  bare  the  rectus,  the 
fibres  of  which  are  easily  parted  (The  British  Medical 
Journal),  In  only  three  or  four  of  the  cases  did  he  di- 
vide an  artery  that  required  ligature ;  pressure  forceps 
were  always  sufficient  to  stop  hemorrhage  from  veins. 
After  a  little  gentle  pressure  on  the  muscle  all  oozing 
ceased,  and  the  wound  was  quite  dry  by  the  time  the 
peritoneum  was  divided.  Flatau  objects  to  washing  the 
edges  of  the  wound  with  carbolic  lotion,  as  the  irritation 
thus  set  up  may  interfere  with  immediate  union.  He 
has  never  met  with  any  difficulty  in  manipulating  on  the 
right  side  of  the  abdominal  cavity,  the  incision  being 
made  on  the  left  of  the  middle  line.  He  uses  braided 
silk,  carefully  boiled,  for  the  sutures.  He  enters  the 
suture  close  to  the  edge  of  the  integument,  includes  as 
much  muscle  and  peritoneum  as  possible,  and  brings 
the  suture  out  close  to  the  opposite  edge  of  the  skin. 
This  method  prevents  the  turning  in  of  the  edges  of  a 
wound  made  through  thin  atrophied  parietes,  so  often 
seen  where  the  tumor  is  of  large  size. 

Lactophenin  in  Enterio  Fever. — Dr.  Von  Jaksch  has 
tried  lactophenin  in  eighteen  cases  of  typhoid  fever,  and 
finds  the  results  very  encouraging.  Some  of  the  cases 
were  severe,  with  great  prostration,  hypostatic  pneu- 
monia, or  other  complications.  The  drug  may  be  ad- 
ministered in  one  half  to  one  grain  doses  in  starch  cap- 
sules, up  to  six  grains  in  the  day  if  necessary,  according 
to  its  antipyretic  and  sedative  effect.  No  unpleasant 
symptoms  were  produced  by  the  drug,  except  in  one 
case,  where  the  first  one  half-grain  dose  produced  sick- 
ness and  vomiting ;  but  even  here  subsequent  doses  pro- 
duced no  bad  effects.  On  two  occasions  the  pulse  was 
felt  to  be  somewhat  irregular  while  the  drug  was  being 
administered.  The  drug  lowered  the  temperature,  and 
the  subsequent  reactionary  rise  of  temperature  was  unac- 
companied by  shivering  except  in  one  case  out  of  about 
three  hundred  and  sixty  miscellaneous  cases  in  which  the 
drug  was  given.  The  great  advantage  claimed  for  lacto- 
phenin in  typhoid  fever,  however,  is  its  sedative  action ; 
delirium  vanishes,  the  mind  becomes  clear,  and  the  pa- 
tients all  experience  a  pleasant  subjective  feeling,  such 
as  is  given  by  no  previous  method  of  treatment ;  appe- 
tite quickly  appeared  in  all  cases.  To  what  extent 
chance  played  a  part  in  the  happy  results  obtained,  and 
whether  the  drug  really  cuts  short  the  course  of  the  dis- 
ease must  be  left  as  questions  to  be  decided  by  further 
observations.  No  protection  against  hemorrhage  or 
relapses  can  be  expected  from  this  drug  any  more  than 
from  other  methods  of  treatment. — Centralblatt  fuer  in- 
nere  Median,  j* 


September  8,  1894] 


MEDICAL   RECORD. 


303 


Medical  Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


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


New  York,  September  8,  1894. 

PATERNAL  IMPRESSIONS. 

• 

A  sex  war  is  threatened.  While  the  retention  of  the 
time- honored  "  male  "  in  the  Constitution  is  trembling  in 
the  balance,  a  British  innovator  is  making  a  stealthy 
claim  for  the  recognition  of  "  paternal  "  impressions  over 
the  well-known  maternal  variety  of  prenatal  influence. 
Dr.  Cullen  is  the  "  surgeon-accoucheur,"  as  he  styles  him- 
self, who  unblushingly  publishes  in  the  Provincial  Medi- 
cal Journal  his  vindication  of  fatherhood  in  so  serious  a 
matter  as  the  transmission  of  impressions  to  the  unborn. 

It  is  quite  safe  to  assume  that  an  outraged  motherhood 
will  not  calmly  submit  to  this  unheard  of  masculine  en- 
croachment on  a  prerogative  founded  in  nature  and  sanc- 
tioned by  medical  tradition. 

At  the  outset  of  his  learned  discourse  the  "  chirurgien- 
accoucheur"  is  inclined  to  be  a  trifle  apologetic,  which 
modest  spirit  is  hardly  in  keeping  with  the  revolutionary 
nature  of  his  doctrine.  He  admits  that  the  modern 
physiologist,  with  microscope  in  one  hand  and  his  last 
mounted  slide  in  the  other,  is  undeniably  sceptic  about 
all  matters  incapable  of  material  demonstration,  and 
sometimes  overlooks  the  fact  that  much,  if  not  all,  prog- 
ress is  but  the  pursuit  of  theory. 

We  cannot  follow  the  author  too  closely  in  his  chase 
of  theory,  though  the  mental  exercise  is  doubtless  brac- 
ing and  exhilarating  enough.  Dr.  Cullen  is  lucid  in  style 
and  simple  in  diction.  There  is  no  mistake  about  his 
views.     For  example : 

Concerning  the  ovule,  he  personally  inclines  to  the  be- 
lief that,  "  apart  from  the  theory  of  continuity  provided  by 
the  latent  germ  idea,  which,  up  to  a  certain  point,  seems 
incontrovertible,  the  latent  germ  contains  very  little  of 
the  individuation  of  the  parent  organism  prior  to  the  be- 
ginning of  maturition  in  the  Graafian  follicle,  and  that 
the  inheritance  of  the  maternal  characteristics  continues 
from  that  point  to  impregnation  and  onward  to  the  ex- 
pulsion of  the  embryo  from  the  uterus.  The  element  of 
chance,  which  forms  a  law  in  the  pollination  of  plants,  has 
no  analogy  here,  since  the  conditions  are  not  similar,  for 
we  presume  that  ovules  and  spermatozoa  are  equal  one  to 
the  other,  and  capable  of  similar  results  under  similar  and 
suitable  circumstances.19 

It  is  certainly  comforting  to  be  assured  that  the  human 
father  does  not  procreate  in  the  haphazard  fashion  of 
plants.  This  brings  us  to  the  author's  chief  contention, 
namely,  that  the  male  element  has  influences  upon  the 
female  beyond  that  of  mere  fertilization,  and  that  these 
influences  should  be  termed  paternal  impressions. 


The  following  narrative  ought  to  be  conclusive  to  all 
except  frivolous  sceptics :  "  A  friend,  resident  in  Spring- 
barn,  possessed  a  fine  female  dog  of  pure  Dalmatian  breed. 
Accidentally  she  mated  with  another  who  was  no  choice 
of  her  master,  and,  to  the  latter*  s  supreme  disgust,  pre- 
sented him  with  a  generation  of  collie  mongrels.  This 
was  bad,  but  when  informed  that  his  Dalmatian  was  now 
ruined  for  breeding  purposes,  he  declined  to  credit  the 
statement  and  resolved  to  test  it  for  himself.  In  process 
of  time  he  had  her  warded  by  a  pure,  male  dog  of  her 
own  breed,  belonging  to  a  gentleman  in  Kilsyth,  and  on 
this  occasion  she  dropped  six  puppies — three  of  them, 
however,  being  perfect  collies  to  such  details  even  as  the 
claws.  Here,  it  is  evident  that  the  mother  not  only  im- 
presses the  conception,  but  the  conception  retaliates  with 
the  paternal  impress.  The  same  law  holds  good  with 
swine,  cattle,  horses,  and  other  animals.  Nisbet,  in 
1  Heredity  and  Marriage,1  refers  to  it  as  occurring 
among  widows  who  have  married  again  and  borne  chil- 
dren resembling  those  by  their  first  husbands.  Sir  J.  Y. 
Simpson  related  to  Dr.  Harvey  a  similar  fact  Poultry 
may  bear  a  sequence  of  fecundable  eggs  from  one  impreg- 
nation.   This  is  an  allied  paternal  impression." 

The  eminent  "  chirurgo-obstetrician  "  is  at  all  events 
impartially  complimentary.  After  having  told  us  that 
husbands  are  more  circumspect  than  plants,  he  makes 
"  honors  easy  "  by  informing  the  reader  that  "  widows 
who  have  married  again  "  may  be  classed  with  certain 
mammals  and  selected  poultry. 

What  have  the  ardent  woman  suffragists  to  say  about 
the  next  quotation  ? 

"In  attempting  to  explain  paternal  impressions  it  is 
necessary  to  prove  paternal  superiority.  That  woman  is 
not  the  aggressive  equal  of  man  is  a  fact  and  not  a  fault. 
Menstrual,  maternal,  mammary,  and  emotional  features  in 
her  nature  prevent  her  equality,  and  where  a  striking  in- 
dividual exception  has  occurred  it  has  been  at  the  expense 
of  what  we  define  as  feminine  characteristics.  The  intel- 
lectual female  becomes  masculine  from  the  very  charac- 
teristics which  mark  her  distinction.  Her  physical  nature 
with  remarkable  frequency  possesses  the  same  distinction, 
and  is  barren  in  a  reproductive  sense.  The  same  law  ap- 
plies no  doubt  to  men  of  genius  also,  and  is  explicable  in 
the  sense  that  you  cannot  both  have  your  cake  and  eat'it. 
External  mental  expenditure,  if  it  may  be  so  termed, 
when  intense  and  complete,  leaves  nothing  for  internal 
transmission,  and  Galton's  industrious  work  on  '  Heredi- 
tary Genius '  notwithstanding,  genius  is  not  hereditary. 
The  exceptional  female  whose  talents  have  given  her  a 
masculine  equality,  has  only  really  unsexed  herself,  which 
is  an  instinctive  acknowledgment  that  prepotency  rests 
with  the  male.  The  ancient  Greeks  who  through  Plato 
and  Aristotle  gave  us  systems  of  logic  and  philosophy 
which  denote  the  highest  powers  of  reasoning,  never 
doubted  this  ascendancy.  "orvAoc  oucov  iratScs  tUrw 
ap<r€v€s"  (Male  children  are  the  pillars  of  a  house)  was 
a  dictum  among  them.  So  believed  the  Latin  races,  and 
so  others.  Pedigree  everywhere  is  reckoned  through  the 
male,  and  this  is  no  arbitrary  proceeding  but  the  instinct 
of  circumstances,  and  the  outcome  of  accumulated  experi- 
ence." 

We  are  also  reminded  that  "  the  testicle  is  a  most  deli- 
cately sensitive  structure.  A  squeeze  will  illustrate  this. 
That  its  sensitiveness  is  not  purely  local,  but  has  a  consti- 


304 


MEDICAL   RECORD. 


[September  8,  1894 


tutional  effect,  may  be  proven  by  the  same  means.  Of  its 
nerve-supply  and  the  ganglionic  nature  of  it,  there  can 
therefore  be  no  doubt,  and  that  it  has  a  function  beyond 
a  merely  local  secretion  of  the  male  element  there  can  be 
as  little  doubt,  for  it  is  evidenced  by  the  mental  change 
produced  by  castration.  Similarly,  the  dementia  noted 
to  follow  the  loss  of  the  ovaries  in  the  female  proves  not 
only  the  loss  of  the  tissue  itself,  but  the  loss  of  a  contin- 
gent portion  of  the  perfect  organism,  and  one  primarily 
and  absolutely  in  touch  with  the  sensorial  functions." 

In  his  final  summing  up  the  author  tells  us  that,  the 
immature  ova  and  sperm-cells  are  simply  latent  germs 
minus  those  vital  and  dynamic  conditions  which  mature 
them  and  constitute  their  activity  after  their  conjunction, 
but  which  in  the  case  of  the  male  element  have  been 
fully  impressed  upon  it  prior  to  this  union.  With  the 
beginning  of  maturity  in  the  Graafian  follicle  begins  the 
impress  of  the  maternal  characteristics  upon  the  ovule, 
which  continue  until  full  maturity  of  the  conception  in 
the  uterus — the  conception  and  maternal  organism  being 
marked  by  a  mutual  and  striking  affinity.  This  is  also 
evidenced  even  in  nursing,  as  it  is  well  known  that  excite- 
*  ment  of  the  mother  affects  the  nursling  through  the  milk. 

The  spermatozoon,  unlike  the  ovule,  must  be,  and  is, 
fully  equipped  at  the  moment  of  impregnation  with  all 
the  characteristics  of  the  male  organism.  The  necessity 
of  this  special  equipment  is  arranged  for  by  a  much  more 
complex  and  detailed  organ  of  reproduction  in  the  male. 
While  the  female  characteristics  are  conveyed  to  the  ovule 
by  the  sympathetic  system,  they  are  continued  to  the  ovum 
by  the  nutrition.  In  the  male  the  paternal  characteristics 
are  conducted  through  a  special  ganglionic  centre,  and 
are  impressed  upon  the  spermatozoon  during  an  elaborate 
and  tedious  transit  through  specially  arranged  tubing. 

This  ganglionic  or  reproductive  nerve-centre  in  the 
male  becomes  active  near  the  completion  of  growth,  and 
its  development  is  accompanied  by  those  symptoms  which 
mark  the  arrival  at  adolescence.  At  this  period  all  roads 
lead  to  Rome,  all  thoughts  lead  to  reproduction — until 
the  function  is  established. 

That  the  function  is  dependent  upon  an  active  and 
complete  connection  with  an  intelligent  sensorium,  is 
proved  by  the  fact  that  male  imbeciles  are  impotent,  and 
also,  I  think,  by  the  fact  that  imaginative  and  emotional 
races  are  the  most  prolific.  Were  the  reproduction  pow- 
ers contained  in  the  latent  germ  they  would  be  independ- 
ent of  subsequent  mental  development.  The  fact  also 
that  diseases  such  as  syphilis,  contracted,in  adult  life,  affect 
the  product  of  conception,  and  through  it  the  mother, 
proves  that  the  spermatozoon  is  very  literally  an  up  to- 
date  creation,  and  that  it  very  fully  represents  a  concen- 
trated extract  of  the  mature  paternal  organism.  That  the 
male  element  has  an  influence  on  the  female  organism 
over  and  above  that  of  fertilization,  is  incontrovertible ; 
her  first  impregnation  has  literally  a  double  result ;  with 
the  conjunction  of  the  respective  elements  there  develops 
a  mutual  product  whose  resemblance  to  the  male  organ- 
ism would  be  infinitesimal,  were  its  initial  activities  not 
potent  enough  to  affect,  and  afterward  modify,  those  of 
the  mother. 

Consequently  the  reproductive  elements  are  latent 
germs  in  the  first  instance,  which  attain  maturity  by 
being  charged  with  organic  impressions  from  the  parent, 
much  after  the  manner  of  charging  a  phonograph  with 


messages ;  which  messages  are  liberated  in  the  female  sys- 
tem after  meeting  the  suitable  medium  of  the  similarly, 
though  not  equally,  charged  ovule ;  or,  to  use  another 
metaphor,  if  we  consider  the  individual  as  a  book,  each 
spermatozoon  is  an  index  of  the  contents,  but  how  printed, 
is  a  conundrum  precisely  on  a  level  with  how  facts  or 
ideas  are  recorded  in  memory,  and  we  can  conceive  no 
material  method  for  the  performance  of  that  function. 

To  append  any  further  comments  to  this  brilliant 
resume  would  be  to  invite  possible  misconceptions,  which 
must  not  be  thought  of  in  connection  with  paternal  im- 
pressions.   

PAIN,  PLEASURE,  AND  ESTHETICS. 

The  physician  is  more  apt  to  think  of  pain  in  connection 
with  its  avoidance  by  anaesthetics,  than  he  is  to  associate 
it  in  any  way  with  pleasure  and  aesthetics.  It  is  witbthe 
psychology  of  pain  that  the  author  of  a  book,  fresh  from 
the  press  of  Macmillan  &  Co.  has  to  do,  and  he  treats  of 
it  together  with  its  correlate  pleasure,  laying  stress  upon 
their  special  reference  to  aesthetics.  In  the  first  chap- 
ters the  place  which  pleasure  and  pain  should  occupy  in 
psychological  classification  is  sought  to  be  determined,  as 
well  as  the  relationship  between  them.  The  conclusion 
is  reached  that  they  must  be  looked  upon  as  general 
qualities,  one  of  which  must,  and  either  of  which  may, 
belong  to  any  fixed  element  of  consciousness.  In  the 
course  of  his  examination  the  author  further  concludes 
that,  we  must  assume  the  existence  of  an  impulse  within 
ourselves  which  leads  us  to  produce  results  which  have 
the  power  to  attract  others  to  us.  This  impulse  might 
be  identified  with  the  art  impulse.  The  reader  will 
understand  the  trend  of  these  preliminaries  when,  further 
along,  the  attempt  is  made  to  prove  that  all  efforts  to 
discover  special  qualities  in  beautiful  objects  which  de- 
termine their  beauty  have  invariably  failed.  The  mental 
state  of  the  observer  of  the  beautiful  in  art  and  nature 
must  be  studied,  and  principles  of  unity  sought  on  which 
to  base  the  philosophic  treatment  of  the  subject.  Es- 
thetics are  considered  as  a  branch  of  the  science  of  pleas- 
ure and  pain,  but  the  author  believes  only  those  pleas- 
ures to  be  aesthetic  which  are  permanently  pleasurable 
in  the  memory.  The  aesthetic  field  is  thought,  therefore, 
to  vary  with  different  races  and  different  individuals,  and 
in  the  same  individual  at  different  times ;  changing  with 
his  change'  of  conception  as  to  what  is  worthy  in  the 
world  surrounding  him.  To  correct  the  individual  taste 
it  is  necessary  to  recognize  the  standard  of  others,  and  to 
compare  it  with  the  taste  of  the  educated  and  refined. 
It  is  futile  to  try  to  force  our  standard  upon  others. 

Upon  page  215  the  author  gives  the  basis  for  pleasure- 
pain  phenomena.  "Pleasure,"  he  says,  "implies  use 
of  surplus  stored  energy,  while  pain  implies  a  subnormal 
reaction  to  a  given  stimulus.''  Pain,  in  other  words,  is 
determined  by  the  reception  of  a  stimulus  to  which  the 
organ  is  incapable  of  reacting. 

The  author,  Henry  Rutgers  Marshall,  shows  himself  to 
be  quite  at  home  with  this  very  intricate  problem,  and 
one's  confidence  is  secured  from  the  start  by  the  thor- 
ough acquaintance  displayed  with  the  views  of  other 
writers.  Even  if  one  cannot  accept  all  the  theories,  it 
will  repay  the  reader  for  the  difficulties  in  gaining  ac- 
quaintance with  the  author's  terminology,  and  some  new 
ideas  will  be  found  advanced. 


September  8,  1894] 


MEDICAL  RECORD. 


305 


Uetus  of  thz  Wtezk. 

Vaccination  in  the  Publio  Schools. — The  an ti- vaccin- 
ationists in  Brooklyn  have  been  waging  war  against  the 
health  authorities  in  that  city  with  varying  success,  but 
have  been  worsted  in  their  latest  contest  relating  to  the 
public  schools.  Under  the  recent  decision  of  Justice 
Bartlett  of  the  Supreme  Court,  the  principals  are  em- 
powered to  reject  all  pupils,  who  cannot  produce  certifi- 
cates that  they  have  been  vaccinated. 

Maladies  of  High  Personages.— The  Czar  of  Russia 
is  ailing,  but  just  what  his  malady  may  be  is  uncertain, 
one  report  being  that  he  is  suffering  from  the  results 
of  repeated  attacks  of  influenza,  another  that  he  has  a 
renal  calculus.  The  Shah  of  Persia  is  troubled  with  his 
eyes,  and  is  in  poor  general  health.  The  King  of  Siam 
is  a  victim  of  the  chloral  habit.  The  Count  of  Paris  is 
dying  from  carcinoma  of  the  stomach.  Signor  Crispi, 
the  prime  minister  of  Italy,  is  slowly  recovering  from  in- 
juries received  in  a  fall.  The  Queen  of  Italy  is  suffering 
from  nervous  shock  occasioned  by  the  sudden  death  of 
one  of  her  attendants  in  her  presence.  The  Pope  is 
subject  to  frequent  attacks  of  syncope.  The  wife  of 
Prince  Bismarck  is  ill,  and  the.  Prince  himself  is  so  agi- 
tated over  her  condition  that  it  is  feared  that,  should  she 
not  recover,  he  will  break  down  entirely.  Dr.  Schwen- 
inger has  been  called  to  Varzin  to  be  present  in  case 
the  condition  of  his  illustrious  patient  should  grow  worse. 
Mr.  Gladstone  was  recently  operated  upon  for  cataract. 
The  young  King  of  Spain  is  very  delicate,  though  no  def- 
inite disease  has  as  yet  declared  itself.  President  Cleve- 
land is  reported  to  be  suffering  from  malaria  and  the 
effects  of  overwork. 

A  Hospital  for  Consumptives  is  to  be  erected  in 
Toronto,  Canada,  Mr.  W.  J.  Gage,  of  that  city,  having 
made  a  contribution  of  £25,000  toward  that  purpose. 

The  Tri-State  Medical  Society,  embracing  in  its 
membership  the  three  States  of  Georgia,  Alabama,  and 
Tennessee,  will  hold  its  next  annual  meeting  at  the 
Kimball  House,  Atlanta,  on  October  9th,  10th,  and 
nth. 

A  Prize  Essay  on  Tuberculosis. — The  Colorado  State 
Medical  Society  offers  a  prize  of  $100  for  the  best  essay 
upon  "  The  Diagnosis  of  Tuberculosis  by  Microscopic 
Examination  of  the  Blood."  The  paper  is  to  be  of  such 
a  length  that  not  more  than  thirty  minutes  would  be 
consumed  in  its  delivery.  The  name  of  the  author  must 
be  kept  secret.  Essays  in  competition  for  the  prize 
should  be  sent  to  Dr.  Charles  Denison,  Denver,  not 
later  than  April  1,  1895. 

Kiss  Florence  Nightingale  is  an  honorary  president  of 
the  Tropical  Section  of  the  International  Congress  of 
Hygiene  and  Demography,  in  session  this  week  in  Buda- 
Pesth. 

Sunstroke.— Surgeon-major  Martin  recognizes  three 
forms  of  sunstroke,  viz. :  The  congestive  or  cerebrospinal, 
the  syncopal,  and  the  pulmonary.  In  all  these  cases  he 
says  death  appears  to  be  due  to  the  absorption  and  non- 
elimination  of  the  toxines  or  leucomaines  produced  in  ex- 
cess by  great  muscular  fatigue,  and  which  rapidly  poison 
the  system.  This  toxic  saturation  of  the  body  is  facilitated 
by  damp  heat  and  stormy  weather  as  much  as  by  insola- 


tion properly  so  called.  When,  in  spite  of  precaution,  a 
soldier  is  attacked,  he  must  be  at  once  taken  to  a  shady 
or  cool  place,  his  clothes  loosened  so  as  to  facilitate 
breathing,  artificial  respiration  should  be  practised,  while 
an  assistant  at  the  same  time  produces  corresponding 
compression  over  the  body.  While  artificial  respiration 
is  being  performed  the  head  of  the  sufferer  is  covered 
with  a  cooling  bandage,  sinapisms  are  applied9  to  the 
lower  limbs,  and  a  subcutaneous  injection  is  given  every 
hour  of  one  Pravaz  syringeful  of  ether.  In  the  synco- 
pal or  pulmonary  form,  in  which  the  nervous  system  is 
prostrated,  it  is  better  to  give  injections  of  caffeine,  as  much 
as  a  gram  in  the  twenty- four  hours,  and  in  the  conges- 
tive form,  while  cold  affusions  are  applied  to  the  head  and 
sinapisms  to  the  extremities,  to  give  subcutaneous  injec- 
tions of  pilocarpine  to  produce  profuse  perspiration ;  and 
then  to  aid  in  the  elimination  of  the  toxines  purgative 
enemata  must  also  be  given. — London  Correspondence  of 
the  American  Practitioner  and  News. 

Quack  Nurses — Quackery  is  contagious  and  wide- 
spread. There  are  quacks  not  only  in  medicine,  but  the 
infection  seems  also  to  have  invaded  the  profession  of 
nursing.  From  Detroit  comes  the  announcement  of  the 
organization  of  a  "  Correspondence  School  of  Health 
and  .Hygiene,"  which  proposes  to  give  "instruction  by 
the  correspondence  method  in  the  care  of  the  sick." 
The  course  of  instruction,  it  is  believed,  "  if  thoroughly 
studied  by  a  reasonably  intelligent  person,  will  render 
the  pupil  as  truly  a  trained  nurse  as  the  great  majority  of 
those  who  come  from  the  training  schools.  ...  No 
previous  training  or  study  is  required  other  than  the 
ability  to  read  and  comprehend."  As  to  age,  sixteen  is 
not  considered  too  young  nor  fifty  too  old.  It  needs 
scarcely  be  said  that  the  art  of  nursing  is  not  to  be  ac- 
quired by  correspondence,  from  reading,  or  even  from 
didactic  lectures ;  these  measures  may  aid  in  the  compre- 
hension of  the  principles  upon  which  intelligent  and 
rational  nursing  is  based,  but  actual  experience  by  the 
bedside,  in  the  hospital-ward,  and  in  the  sick-room,  is 
absolutely  essential. — Medical  News. 

Large  Families  do  not  seem  to  be  so  very  rare  even 
in  these  latter  days.  We  recently  referred  to  the  fecun- 
dity of  Canadian  women,  and  now  England  comes  to  the 
front  with  large  families.  A  London  family  paper  not 
long  since  offered  a  prize  of  one  guinea  to  the  woman 
subscriber  who  could  prove  that  she  had  the  greatest 
number  of  children.  The  prize  was  divided  between  two 
women,  each  of  whom  had  twenty-five  children.  The 
first  sixteen  women  entered  on  the  list  of  competitors  had 
a  total  number  between  them  of  two  hundred  and  eighty- 
eight  living  children. 

Freckles. — A  paragraph  seasonably  going  the  round  of 
our  exchanges  attributes  to  Hager  the  assertion  that 
freckles  can  be  removed  by  the  application,  every  other 
day,  of  an  ointment  composed  of  white  precipitate  and 
subnitrate  of  bismuth,  each  one  drachm ;  glycerine  oint- 
ment, half  an  ounce. 

Diphtheria  Antitoxin. — At  a  late  meeting  of  the  Ber- 
lin Medical  Society  Dr.  Baginsky  criticised  rather  un- 
favorably the  report  of  the  antitoxin  treatment  of  diph- 
theria made  at  a  previous  meeting  by  Katz,  to  which  we 
referred  in  a  recent  issue.  He  said  that  the  credit  of  the 
discovery  was  due  to  Bogola,  of  Sienna,  who  first  made  in- 


3o6 


MEDICAL    RECORD. 


[September  8,  1894 


oculations  of  a  diphtheritic  material  in  1868.  Analyzing 
Kate's  report,  he  said  that  of  128  cases  only  14  died,  and 
from  these  deaths  those  attributed  to  scarlatina,  septic 
poisoning,  etc.,  were  eliminated,  leaving  a  mortality  from 
the  disease  or  the  drug  of  only  about  thirteen  per  cent. 
But,  if  the  same  process  of  elimination  was  carried  out 
in  cases  treated  by  the  ordinary  methods,  he  believed  that 
the  difference  in  favor  of  the  new  mode  would  be  found 
to  be  very  slight,  if  indeed  there  was  any. 

The  Mortality  of  European  Cities. — The  annual 
death-rate  per  1,000  of  the  following  cities,  as  computed 
for  the  returns  for  the  first  week  in  August,  is :  Paris,  19 ; 
Brussels,  19;  Amsterdam,  12;  Rotterdam,  17;  The 
Hague,  15;  Copenhagen,  15;  Stockholm,  15;  Chris- 
tiania,  16 ;  St.  Petersburg,  62  ;  Moscow,  43 ;  Berlin,  19 ; 
Hamburg,  19;  Dresden,  19;  Breslau,  33;  Munich,  26; 
Vienna,  23 ;  Prague,  24 ;  Buda-Pesth,  25  ;  Trieste,  30 ; 
Rome,  16;  London,  17;  Liverpool,  27;  Birmingham, 
14;  Manchester,  21;  Dublin,  20;  Edinburgh,  14;  Shef- 
field, 18,  and  Swansea,  10.  The  excessive  rate  for  the 
Russian  cities  is  due  largely  to  the  epidemic  of  cholera. 

Boraoie  Acid. — The  greater  part  of  the  crude  boracic 
acid  imported  into  England  comes  from  Tuscany,  in  the 
immediate  neighborhood  of  Castelnuovo.  It  is  originally 
dissolved  in  the  waters  of  an  underground  hot  lake,  which 
sends  off  steam  charged  with  about  three  per  cent,  of 
boracic  acid  through  many  openings,  called  "  fumerolles," 
on  the  surface.  The  steam  is  condensed,  and  the  add 
dissolved  in  fresh  water,  from  which  it  is  crystallized  in 
tubs.  The  acid  is  then  packed  in  casks  and  shipped  from 
Leghorn  to  England,  where  it  is  refined  into  the  pure 
pulverized  boracic  acid  familiar  to  our  readers. — Medical 
Press. 

A  Medical  School  for  Women  is  about  to  be  established 
in  St.  Petersburg  under  Government  auspices.  A  similar 
institution  was  organized  through  private  initiative  a 
number  of  years  ago,  but  was  soon  closed  by  the  authori- 
ties, and  since  that  time  the  Government  has  always 
frowned  upon  the  higher  education  of  women. 

Professor  Josiah  Parsons  Cooke,  Professor  of  Chemistry 
at  Harvard,  died  at  his  summer  residence  at  Newport,  on 
September  3d.  He  was  sixty  seven  years  of  age.  He 
was  graduated  from  Harvard  in  1848,  and  had  been  con- 
nected with  the  University  in  a  teaching  capacity  since 
1850. 

The  Eighth  International  Ophthalmological  Congress 
was  held  in  Edinburgh  during  the  first  week  in  August, 
under  the  presidency  of  Dr.  Argyll  Robertson.  Drs. 
Henry  Power  and  Swanzy  were  elected  vice-presidents, 
Dr.  Berry,  general  secretary,  and  Drs.  Parent,  Hess,  and 
Fergus,  assistant  secretaries.  The  honorary  presidents 
elected  were:  Drs.  Panas,  Meyer,  Landolt  (France), 
Zehender,  Leber,  Hansen  Grut,  Reymond  Snellen,  Roosa, 
Knapp,  Critchett,  Priestley  Smith,  Little,  Pridgin  Teale, 
and  Reid. 

In  his  presidential  address  Dr.  Robertson  referred  to  the 
death  of  Donders  and  Becker  which  had  occurred  since 
the  seventh  Congress  was  held  in  Heidelberg  in  1888. 
In  Donders  he  said  had  been  lost  one  of  the  greatest 
ornaments  of  the  world  of  science,  and  in  Becker  the 
ophthalmological  world  had  lost  an  able  surgeon  whose 
discoveries  in  the  anatomy  and  pathology  of  the  lens  were 
classical.     He  referred  also  to  the  absence  of  Helmholtz, 


the  greatest  physicist  of  the  age,  and  expressed  the  earnest 
hope  that  he  might  have  a  rapid  recovery  from  his  serious 
illness. 

The  Cholera  has  not  decreased  much  during  the  past 
week,  neither  has  the  disease  invaded  new  territories, 
with  the  exception  of  Austrian  Silesia.  It  is  reported  to 
be  terribly  virulent  in  Russian  Poland,  where  the  phy- 
sicians are  unable  to  cope  with  it  owing  to  the  fact  that 
the  inhabitants  conceal  their  sick  and  treat  them  with 
domestic  remedies,  fearing  that  the  doctors  will  experi- 
ment upon  them.  Thirty  of  the  seventy-four  political 
districts  of  Galicia  are  infected,  200  new  cases  and  95 
deaths  having  been  reported  there  on  August  31st.  The 
disease  has  been  introduced  into  Silesia  by  the  Austrian 
troops  returning  from  the  manoeuvres  in  Galicia.  In 
Germany,  during  the  two  weeks  ending  September  3d, 
there  were  121  new  cases  and  53  deaths.  Isolated  cases 
continue  to  be  reported  from  Amsterdam,  Rotterdam, 
Maastricht,  and  other  towns  in  Holland  and  Belgium. 

Electrical  Treatment  of  Bed  Hoses.— Dr.  Helling 
says  that  a  red  nose  is  due  to  contraction  of  the  arterioles 
and  dilatation  of  the  veinlets.  He  claims  to  have  cured 
a  number  of  cases  by  the  application  of  a  continuous 
current  of  moderate  intensity  for  five  to  ten  minutes 
daily. 

A  Cattle  Quarantine  Station.— All  horned  cattle, 
sheep,  and  swine  imported  into  this  country  must  be  kept 
in  quarantine  for  a  period  until  all  danger  of  the  devel- 
opment of  tuberculosis,  pleuro-pneumonia,  foot-and- 
mouth  disease,  anthrax,  or  hog  cholera  has  passed.  The 
period  of  quarantine  for  cattle  is  ninety  days,  that  for 
sheep  and  swine  fifteen  days.  The  Government  pro- 
vides the  quarters  for  the  animals  free  of  expense  to  the 
owners,  but  the  latter  must  pay  for  the  transportation  of 
the  animals  to  and  from  the  station,  and  for  their  keep 
when  there.  There  are  stations  of  this  kind  at  several 
places  along  the  coast,  but  the  most  important  one  is  at 
the  Garfield  Farm,  near  Passaic,  N.  J. 

The  Dangers  of  Thyroid  Extract.— Dr.  W.  D.  James 
reports  in  the  June  number  of  the  British  Journal  of 
Dermatology  a  case  of  glycosuria  caused  by  thyroid  ex- 
tract given  for  the  relief  of  psoriasis.  The  patient  was  a 
medical  man,  had  taken  the  extract  in  small  doses  for 
some  time  without  effect  upon  the  disease,  and  then  in- 
creased the  dose  quite  suddenly.  At  the  end  of  a  week 
he  began  to  suffer  severely  from  depression,  with  frequent 
flushings  and  palpitations.  The  nervous  symptoms  in- 
creased, and  the  patient  felt  and  looked  a  very  old  man. 
Before  another  week  elapsed  his  thirst  became  unquench- 
able ;  the  quantity  of  urine  greatly  increased,  the  breath- 
ing became  embarrassed,  the  pulse  rose  to  132  per  minute, 
and  the  smell  of  acetone  was  detected  in  the  breath. 
The  urine  had  a  specific  gravity  of  1.032,  and  sugar  was 
freely  found  by  all  tests.  The  thyroid  treatment  was  at 
once  stopped,  and  antidiabetic  diet  adopted,  with  the  re- 
sult that  the  quantity  of  sugar  decreased  daily,  and  disap- 
peared entirely  in  a  few  days.  No  improvement  was 
noted  in  the  psoriasis. 

A  Definition. — A  London  daily  paper  explains  to  its 
readers  the  term  "  exploratory  incision,"  which,  it  says, 
"  means  quarrying  into  a  patient  on  the  chance  of  dis- 
covering some  disease  in  an  internal  organ  which  is  cura- 
ble by  its  removal." 


September  8,  1894] 


MEDICAL   RECORD. 


307 


glewijKttXB  un&  gtotijcea  of  §taolt8. 

Index  Catalogue  of  the  Library  of  the  Surgeon- 
General's  Office,  United  States  Army.     Vol.  XV. 
Washington,  Quarto,  pp.  842.     Government  Printing 
Office.     1894. 
Vol  XV.  of  this  well-known  series  is  somewhat  smaller  in 
bulk  than  its  predecessors.     Its  contents  are  from  Uni- 
versidad — Vzoroff,  and  covers  6,152  author  titles,  repre- 
senting 3,312  volumes,  and  4,235  pamphlets.     It  also  in- 
cludes   8,596    subject     titles    of  separate    books    and 
pamphlets,  and  35,667  titles  of  articles  in  periodicals. 
Its  editor  and  compiler,  Dr.  John  S.  Billings,  still  has 
charge  of  the  work,  and  is  to  be  congratulated  on  its  ap- 
proaching completion. 

Weekly  Abstracts  of  Sanitary  Reports  (1-52),  vol. 

viii. 
The  volume  contains  the  voluminous  weekly  reports  of 
the  Supervising  Surgeon  General  of  the  Marine  Hospital 
Service  for  the  first  half  of  the  year  1893,  has  1,300  pages 
of  contents,  and  is  of  value  chiefly  to  the  sanitarian  and 
statistician  in  need  of  official  data. 

Burdbtt's  Hospital  and  Charities  Annual,  1894, 
being  the  Year  Book  of  Philanthropy.  Fifth  year. 
By  Henry  C.  Burdett.  London:  The  Scientific 
Press,  Limited.  New  York :  C.  Scribner's  Sons. 
This  useful  volume  is  replete  with  information  regarding 
the  charities  of  the  English-speaking  world,  and  notwith- 
standing its  nearly  six  hundred  pages  is  a  marvel  of  con- 
densation. It  touches  upon  almost  every  subject  in 
which  philanthropy  is  concerned;  it  discusses  philo- 
sophical problems,  character  and  cost  of  work  done, 
sources  of  revenue,  as  well  as  directs  into  proper  channels 
the  contributions  of  that  very  large  class  who  disburse 
in  a  perfunctory  way  a  moiety  of  their  income,  without 
the  least  care  for  its  destination.  A  paragraph  upon  the 
professional  philanthropists,  who  live  on  their  share  of 
the  subscriptions,  well  portrays  an  aberrant  species  not 
unknown  even  in  our  millennial  hemisphere.  The  group- 
ings of  hospitals,  asylums,  homes,  and  orphanages  are 
admirable,  and  constitute  a  coup  <T  ail  as  searching  as 
comprehensive.  In  fact,  in  this  annual,  besides  the 
enormous  labor  bestowed  upon  its  compilation,  about 
which  the  general  reader  takes  but  little  thought,  there 
is  a  wealth  of  texts  capable  of  being  amplified  into 
many  sermons.  To  say  the  least,  the  author  has  made 
an  encyclopaedic  addition  to  a  much  needed  literature 
for  the  physician  who  looks  beyond  the  mere  emolu- 
ments of  his  profession. 

The  Truth  about  Homceopathy.     By  Dr.  W.  H.  Hol- 

combe.  Philadelphia:  Boericke  &  Tafel.  1894. 
This  is  a  posthumous  manuscript  which  is  a  defence  of 
homceopathy.  Although  it  contains  no  new  argument, 
it  is  well  written,  and  as  such  may  be  considered  a  desir- 
able addition  to  the  class  of  literature  to  which  it  be- 
longs. 

Annales  de  l'Institut  de  Pathologie  et  de  Bact£rio- 
logie  de  Bucharest,   publtees  par  Victor  Babes, 
Professeur  a  la  Faculty  de  M£decine  et  Directeur  de 
rinstitut.     Deuxteme  Ann6e,    1890.      4to,   pp.    506. 
Bucharest,  1893. 
This  handsome  volume  is  the  third  part  of  the  "  Annals 
of  the  Institute  of  Pathology  and  Bacteriology  of  Bucha- 
rest," and  contains  the  papers  published  from  that  labor- 
atory during  the  year  1890.     Thirteen  papers  in  all  are 
included,  the  majority  of  which  are  here  given  in  both 
the  French  and  Roumanian  languages.     All  have  ap- 
peared before  in  different  medical  periodicals ;  they  are 
here  collected  for  convenience  of  reference.     Among 
them  are  three  papers  on  glanders  and  its  bacillus,  one 
on  scarlatinal  nephritis,  two  on  the  association  of  bac- 
teria in  the  production  of  disease  in  general,  and  of  the 


lesions  of  tuberculosis ;  three  on  different  phases  of  tuber- 
culosis, including  the  results  of  treatment  of  lupus  by 
tuberculin,  and  an  exhaustive  paper  on  the  different 
forms  of  the  Plasmodium  malaria?.  Many  of  the  papers 
are  handsomely  illustrated  by  colored  plates. 

Transactions  of  the  New  York  State  Medical  Asso- 
ciation, for  1893,  vol.  x.  Edited  by  E.  D.  Ferguson, 
M.D  ,  New  York.  8vo,  pp.  585. 
This  volume  contains  the  usual  variety  and  number  of 
valuable  communications  from  its  talented  contributors, 
and  is  in  every  way  the  equal  to  any  of  the  former  edi- 
tions, which  is  saying  all  we  can  in  its  praise.  The 
frontispiece  is  an  excellent  portrait  of  the  late  Dr.  A.  L. 
Carroll,  one  of  the  founders  of  the  Association,  whose 
obituary  by  Dr.  Gouley  is  a  model  of  its  kind  and  well 
befitting  the  subject.  A  very  comprehensive  decennial 
index  also  adds  to  the  value  of  the  volume. 

The  Practice  of  Medicine.  By  Edwin  M.  Hale, 
M.D.,  author  of  "New  Remedies/ '  "Diseases  of 
the  Heart."  Emeritus  Professor  of  Theory  and  Prac- 
tice, Chicago  Homoeopathic  Medical  College,  etc.  8vo, 
pp.1018.  Chicago:  Gross  &  Delbridge.  1894. 
This  work,  which  is  very  complete  in  its  way,  is  in- 
tended more  especially  for  practitioners  of  homoeopathy, 
although  it  has  a  strong  liberal  tendency  toward  what 
the  author  styles  the  old  school  of  practice.  The  author 
is  certainly  very  liberal  in  his  views,  refreshingly  dog- 
matic in  his  condemnations,  and  emphatically  positive  in 
drawing  the  line  between  what  is  and  is  not  tenable  in 
the  present  accepted  doctrines  of  disease.  There  is  no 
mistaking  what  he  means  when  he  gives  the  results  of  his 
personal  experience  in  "proving"  and  in  the  ultimate 
results  of  treatment.  The  reader  everywhere  in  the  text 
finds  the  different  drugs,  of  large  and  small  degree,  in 
strange  relations  with  each  other,  that  are  hardly  explain- 
able on  the  score  of  a  compromising  liberalism  as  to  their 
respective  actions.  With  a  laudable  effort  to  reconcile 
treatment  to  the  latest  discoveries  in  bacteriology,  he  is 
hardly  consistent  in  his  attempt  to  explain  the  action  of 
germicides  with  the  doctrine  of  similiasimilibuscurantur. 
The  task  is  professedly  a  difficult  one,  and  he  makes  as 
good  a  showing  as  is  possible  under  the  circumstances. 
His  descriptions  of  the  clinical  phenomena  of  disease 
are  terse  and  to  the  point,  and  are  made  especially  inter- 
esting by  numerous  historical  references  not  usually  found 
in  similar  works.  The  chapters  are  short,  the  subjects 
numerous,  and  their  discussion  interesting  and  suggestive. 
The  frontispiece,  which  is  the  only  illustration  in  the 
work,  gives  an  excellent  likeness  of  the  author  with  his 
autograph. 

Medical  Journals  not  Appreciated. — The  following 
reply  was  returned  to  a  circular  letter  soliciting  subscrip- 
tions to  a  certain  medical  journal : 

Faribault,  Minn. 

Your  Copy  of  the Jurnal  come,  and  the  letter 

to — askin  me  to  send  fifty  cens  and  git  it  fur  a  yeer.  .  I 
don't  nead  no  jurnals.  When  I  git  a  tuff  case  I  go  off 
inter  sum  secrit  plase  and  tell  the  lord  all  about  it  and 
wate  for  him  to  put  inter  my  minde  what  ter  do.  That's 
bettern  jurnals  and  syklopedes  and  such.  If  we  hed  more 
lord  trustin  docters  and  less  colleges  weed  fare  better. 
The  lord  noes  morn  all  the  doctors  and  if  we  go  to  him 
fur  noledge  it  ill  be  bettern  jurnals. 

Fraternally  in  the  lord, 

A  Christun  Docter. 

P.  S. — I've  practist  medisen  morn  fifty  yeers.  Yore 
ken  publish  this  letter  if  you  want  ter. — Northwestern 
Lancet 

Royal  Ladies  who  Smoke. — A  census  has  been  taken 
of  the  cigarette-smokers  among  the  ladies  of  the  courts 
of  Europe,  and  it  has  been  found  that  the  majority  of 
them  indulge  more  or  less  openly.  Among  them  are  the 
Queens  of  Italy,  Spain,  and  Portugal,  the  Czarina,  and 
the  Empress  of  Austria. 


3o8 


MEDICAL   RECORD. 


[September  8,  1894 


jtacietg  3$ep0Vts. 

CANADIAN  MEDICAL  ASSOCIATION. 

Jhventy  seventh  Annual  Meeting,  held  in  St.  John,  N.  £., 
August  22  and  2j,  18Q4. 

(Special  Report  for  the  Medical  Record.) 

Dr.  T.  T.  S.  Harrison,  of  Selkirk,  Ontario,  the  Presi- 
dent of  the  Association,  called  the  meeting  to  order,  and 
introduced  several  delegates  from  foreign  medical  soci- 
eties. Among  these  were  Dr.  L.  Duncan  Bulkley,  of 
New  York,  delegate  from  the  American  Medical  Asso- 
ciation, and  Dr.  Jonah,  of  Eastport,  from  the  Maine 
Medical  Society.  Drs.  Charles  O'Reilly,  I.  H.  Cam- 
eron, and  J.  E.  Graham,  delegates  of  the  Ontario  Med- 
ical Association,  were  also  present.  A  large  number  of 
new  members,  chiefly  from  the  Maritime  Provinces, 
were  admitted.  Letters  of  regret  were  read  from  Sir 
Charles  Tupper,  Drs.  Osier,  Marcy,  Bray,  Mullin,  and 
-  McLean. 

Epilepsy.— Dr.  Hattie,  of  Halifax,  read  a  paper  with 
this  title,  dealing  chiefly  with  theories  concerning  the 
etiology  of  the  affection.  He  gave  an  extended  report 
of  certain  experiments  and  of  the  post-mortem  changes 
that  he  had  observed.  These  changes,  however,  he 
thought  might  be  rather  the  result  of  the  nerve  storm 
than  the  cause  of  it.  The  most  probable  cause  lay  in 
the  action  of  some  toxic  irritant,  itself  the  product  of 
some  systemic  disease.  Anaemia  is  present  in  most  cases 
of  epilepsy,  and  the  speaker  thought  that  this  might 
possibly  be  the  condition  upon  which  the  disturbance 
depended.  On  the  supposition  that  the  poison  might 
be  absorbed  from  the  intestinal  tract,  he  had  adminis- 
tered intestinal  antiseptics  in  conjunction  with  the  bro- 
mides, and,  comparing  the  number  of  paroxysms  occur- 
ring under  this  method  of  treatment  with  the  number 
observed  when  the  bromides  alone  were  administered,  he 
was  led  to  the  conclusion  that  there  was  at  least  a  modi- 
cum of  truth  in  his  assumption.  Under  the  new  method 
there  was  a  very  marked  diminution  in  the  number  and 
frequency  of  the  attacks. 

The  paper  was  discussed  by  Drs.  Cameron,  of  Toronto, 
and  Wright,  of  Ottawa. 

Antagonism  of  Erysipelas  and  Tuberculosis. — Dr. 
Muir,  of  Truro,  reported  a  case  of  tuberculous  disease  of 
the  arm  which  had  been  cured  by  accidental  infection 
with  erysipelas.  The  patient  was  a  woman,  thirty- nine 
years  of  age,  who  had  suffered  from  well-marked  and  typ- 
ical tubercular  ostitis  of  the  arm  for  fourteen  years.  Ex- 
amination of  the  discharge  from  the  sinuses  showed  the 
presence  of  the  tubercle  bacillus.  The  sinuses  were 
opened  and  scraped  and  an  iodoform  dressing  was  ap- 
plied, but  little  or  no  improvement  followed  the  opera- 
tion. Five  weeks  later  the  wound  became  accidentally 
infected  with  erysipelas.  The  patient  was  very  seriously 
ill  for  some  time,  but  finally  made  a  good  recovery  from 
the  erysipelas,  soon  thereafter  it  was  observed  that  the 
original  trouble  was  improving,  and  in  a  comparatively 
short  time  the  tuberculous  disease  was  entirely  healed. 
The  speaker  exhibited  some  photographs  showing  the 
condition  after  the  attack  of  erysipelas. 

Presidential  Address. — The  subject  of  the  President's 
address  was,  "  My  Experience  and  Observation  in  the 
Practice  of  Medicine  Extending  over  Half  a  Century." 
The  address  dealt  chiefly  with  the  clinical  signs  and 
treatment  of  the  various  diseases  commonly  met  with 
among  the  early  settlers  in  the  woods,  of  the  more  usual 
domestic  remedies  employed  by  these  pioneers,  and  of 
the  difficulties  and  hardships  of  the  medical  practitioner 
in  those  days.  He  referred  also  to  the  fact  of  the  dis- 
appearance of  miasmatic  diseases  and  murrain  since  the 
country  had  been  extensively  cleared  up  and  drained, 
and  dwelt  upon  the  problem  as  to  how  and  by  what 
means  the  specific  germ-diseases  were  introduced  into  a 
new  country.     He  did  not  believe  that  the  specific  causes 


could  originate  de  novo,  yet  it  was  often  difficult  or  im- 
possible to  say  whence  they  came.  The  latter  portion 
of  the  address  was  devoted  to  a  discussion  of  the  matter 
of  inter-provincial  registration,  which  he  favored,  and 
which  he  thought  it  was  in  the  power  of  this  Association 
to  bring  about. 

A  vote  of  thanks  was  moved  by  Dr.  Bayard,  of  St. 
John,  seconded  by  Dr.  Hingston,  of  Montreal,  and  car- 
ried with  much  enthusiasm.  Dr.  Wright,  of  Ottawa, 
moved,  and  Dr.  I.  H.  Cameron,  of  Toronto,  seconded, 
that  a  committee  be  appointed,  representing  the  various 
provinces,  to  consider  the  suggestions  made  in  the  Presi- 
dent's address,  in  relation  to  the  question  of  inter-pro- 
vincial reciprocity  in  medical  practice. 

Appendicitis. — Dr.  James  Bell,  of  Montreal,  read  a 
paper  with  this  title,  which  was  based  upon  the  results  of 
his  work  in  the  Montreal  General  Hospital  during  the  past 
eleven  months.  He  had  had  forty  eight  cases,  of  which 
forty  were  operated  upon ;  all  of  the  patients,  both  those 
operated  upon,  and  those  treated  expectantly,  recovered, 
except  three.  The  speaker  believed  that  all  cases  of  ap- 
pendicitis should  be  in  the  hands  of  the  surgeon  from 
the  beginning  of  die  attack,  and  in  the  majority  of  in- 
stances an  operation  should  be  resorted  to  as  soon  as  the 
diagnosis  was  definitely  established. 

Dr.  Hingston,  of  Montreal,  discussed  the  question 
from  the  conservative  side.  He  had  prevented  the  oper- 
ation, he  said,  about  thirty  times,  and  only  in  one  case  did 
he  regret  that  he  had  not  counselled  the  surgical  interven- 
tion. He  did  not  want  the  younger  members  of  the  As- 
sociation to  go  away  with  the  idea  that  operation  was 
the  first  thing  to  be  thought  of  in  every  case  of  appen- 
dicitis they  might  have.  They  could  not  argue  from  the 
results  of  Dr.  Bell's  cases,  for  in  the  first  place  Dr.  Bell 
was  an  able  and  experienced  surgeon,  and  in  the  second 
place  the  cases  that  came  under  his  care  were  for  the 
most  part  of  a  very  serious  character  and  really  calling 
for  operation. 

Sir  James  Grant,  of  Ottawa,  reported  two  cases  he 
had  had  which  seemed  at  first  to  be  fit  for  operation,  but 
one  was  in  a  gouty  and  the  other  in  a  rheumatic  subject. 
He  did  not  operate,  and  both  cases  recovered.  He  did 
not  believe  that  the  cause  of  the  inflammation  in  these 
cases  was  the  presence  of  a  foreign  body  in  the  vermiform 
appendix. 

Dr.  Shepherd,  of  Montreal,  pointed  out  that  the  sur- 
geons always  got  the  worst  cases,  so  that  it  was  difficult 
from  a  comparison  of  statistics  to  determine  just  what 
was  the  proportion  of  cases  which  should  be  operated 
upon  and  how  many  should  be  treated  by  medical  means. 
His  idea  was,  as  a  rule,  to  operate  after  the  acute  attack 
had  subsided.  He  thought  that  the  tender-point  of 
McBurney  should  be  referred  not  to  the  appendix  but 
to  the  inflamed  condition  of  the  mesenteric  glands,  for 
the  appendix  might  be  found  on  the  right  side,  in  the 
pelvis  or  up  under.  Strange  was  in  favor  of  non-inter- 
ference until  the  presence  of  pus  could  be  made  out. 
He  had  usually  refrained  from  operating  during  the  acute 
stage,  and  had  never  had  cause  to  regret  it. 

Dr.  Cameron,  of  Toronto,  said  he  followed  Treves  in 
this  matter ;  wait  until  pus  forms,  then  open  and  drain. 
He  thought  that  it  would  be  unfortunate  if  the  experi- 
ence of  a  hospital  surgeon  of  skill  should  be  permitted  to 
determine  the  matter  one  way  or  the  other. 

Dr.  Bell,  in  reply,  said  that  it  was  conceded  by  all 
that  no  man  could  say  definitely  just  when  to  operate  in 
all  cases.  Out  of  the  forty  cases  in  which  he  had  oper- 
ated there  was  perforation  in  thirty-two ;  in  three  the 
appendix  was  gangrenous,  in  two  it  was  bound  down  by 
adhesions ;  in  three  other  cases  the  symptoms  pointed  to 
very  grave  inflammation,  yet  no  abscess  was  found  and 
the  gut  was  not  perforated.  He  used  to  follow  the  ex- 
pectant plan,  and  his  losses  were  much  greater  than  now. 
The  most  extreme  mortality  after  these  operations  is  two 
or  three  per  cent.  If  the  patients  were  let  alone,  perfora- 
tion and  collapse  might  occur  at  any  moment.  The  very 
mild,  or  rather  short,  cases  in  which  all  the  symptoms 


September  8,  1894] 


MEDICAL    RECORD. 


309 


passed  away  within  twelve  hours,  need  not  be  interfered 
with,  for  they  were  probably  cases  of  csecitis.  He  be- 
lieved that  the  method  advocated  by  Treves  was  not  ac- 
cording to  the  principles  of  true  surgery. 

Eye-strain  Headaches. — Dr.  Morrison,  of  St.  John, 
read  a  paper  with  this  title.  These  headaches  had  been 
treated  by  tenotomy,  but  this  was  dealing  with  the  effect 
only  and  not  with  the  cause;  the  operation  relieved 
some  of  the  reflex  troubles  for  a  time,  but  the  ultimate 
result  was  not  good.  The  real  trouble  was  an  imperfect 
curvature  (it  might  be  very  slight)  of  the  cornea.  This 
condition  added  to  the  work  of  the  delicate  muscles  of 
accommodation,  when  much  near  work  was  to  be  done 
with  the  eyes,  and  overtaxed  the  ciliary  muscle,  from 
which  resulted  the  distressing  reflex  headache.  The 
pain  was  usually  situated  in  the  neighborhood  of  the 
temples,  but  sometimes  extended  to  the  occiput  and 
down  the  back  of  the  head.  Numbness  sometimes  oc- 
curred in  other  parts  of  the  body,  and  digestive  disturb- 
ances were  likewise  at  times  a  marked  symptom.  A 
proper  correction  of  the  myopia,  hypermetropia,  and 
astigmatism,  together  with  the  administration  of  tonics, 
removed  the  insufficiency.  The  speaker  reported  some 
of  the  cases  of  headache  that  he  had  been  called  upon  to 
treat,  where  the  proper  management  of  the  trouble  had 
been  neglected  because  no  examination  of  the  eyes  had 
been  made.  The  muscle  would  recover  just  as  a  sprained 
limb  would  if  properly  treated.  The  use  of  suitable 
glasses  was  a  crutch  for  the  over-strained  ciliary  muscle. 

Diseases  of  the  Ovaries  and  Fallopian  Tubes. — Dr. 
Lapthorn  Smith,  of  Montreal,  followed  with  a  paper 
on  the  treatment  of  diseases  of  these  organs.  The  sub- 
jects of  gonorrhoea!  and  tuberculous  salpingitis,  tumors 
of  the  ovaries,  and  ovarian  congestion  were  dwelt  upon, 
their  most  prominent  symptoms  pointed  out  and  their 
treatment  sketched.  Many  cases  were  reported  and 
numerous  pathological  specimens  shown. 

Influence  of  the  Mind  Upon  the  Body. — Dr.  Bayard, 
of  St.  John,  delivered  the  Address  on  Medicine, 
taking  this  as  his  title.  He  gave  a  brief  .r£sum6  of  the 
general  anatomical  and  physiological  features  connected 
with  the  nervous  system,  and  pointed  out  that  various 
mental  phenomena  were  causative  of  marked  changes  in 
the  body,  particularly  in  respect  to  the  action  of  the 
vasomotor  nerves.  He  had  known  pain  to  disappear  in 
the  presence  of  sudden  danger,  and  he  quoted  Hunter 
as  saying :  "  My  life  is  at  the  mercy  of  any  scoundrel 
who  chooses  to  put  me  in  a  passion,"  and,  strange  to 
say,  that  was  the  cause  of  his  death.  It  is  believed  that 
the  elaboration  of  the  blood  constituents  is  interfered 
with  when  the  individual  is  under  emotional  excitement. 
The  speaker  then  discussed  many  of  the  various  nervous 
troubles  so  common  at  the  present  day,  and  suggested 
methods  for  their  treatment. 

In  connection  with  one  of  the  points  referred  to  in 
the  address,  Dr.  Bayard  moved,  and  Dr.  Hingston  sec- 
onded, that  in  the  opinion  of  the  Association,  the  sys- 
tem of  education  generally  pursued  in  the  Dominion  of 
Canada  draws  too  largely  upon  the  brain- tissue  of  chil- 
dren, and  materially  injures  their  mental  and  bodily 
health.  It  was  objected  that  this  resolution  was  too 
sweeping  in  its  wording,  and  that  there  was  no  sugges- 
tion as  to  what  department  of  the  school  system  was  at 
fault,  nor  as  to  what  portion  of  the  Dominion  the  strict- 
ures more  especially  applied.  Our  young  people,  Dr. 
Cameron  said,  were  not  suffering  from  too  much  educa- 
tion, neither  were  their  elders  for  that  matter.  The 
educational  system  had  been  the  subject  of  the  best 
thought  of  the  best  men  in  the  country,  and  he  believed 
the  motion  was  altogether  too  condemnatory.  A  resolu- 
tion was  than  passed  that  the  matter  be  referred  to  a 
committee,  consisting  of  Drs.  Powell,  Hingston,  Gra- 
ham, and  Bayard,  to  report  at  the  next  meeting. 

Functional  Hepatic  Disorder. — Dr.  J.  £.  Graham,  of 
Toronto,  presented  a  communication  entitled  "  Some 
Functional  Derangements  of  the  Liver,1'  in  which  he  re- 
viewed the  history  of  the  physiology  and  pathology  of  the 


liver,  and  showed  that  there  are  other  and  no  less  impor- 
tant functions  of  the  organ  than  the  secretion  of  bile. 
He  outlined  the  work  of  the  liver  and  demonstrated  the 
very  important  functions  that  it  has  to  perform  in  the 
human  economy.  Its  importance  as  a  blood  elaborating 
and  fat-forming  organ  in  the  foetus  must  be  great,  since 
we  know  that  it  is  equal  in  weight  to  all  the  rest  of  the 
body  at  the  end  of  the  first  month,  in  the  proportion  of 
one  to  three  at  the  end  of  the  third,  and  of  one  to  six- 
teen at  the  end  of  the  fifth  month.  The  speaker  then 
discussed  the  question  of  "  hepatic  inadequacy,"  a  con- 
dition induced  by  the  action  of  certain  poisons  upon  the 
hepatic  cells.  The  hepatic  cells  stored  up  the  glycogen 
until  it  was  needed  by  the  economy,  and  when  this 
function  was  impaired  various  clinical  phenomena  were 
observed.  As  regards  the  treatment  of  "biliousness," 
the  exact  cause  of  this  condition  should  be  searched  for 
and  found,  if  we  were  to  hope  for  success  in  relieving  the 
trouble.  The  diet  should  be  most  carefully  attended  to ; 
starchy  foods  should  be  absolutely  forbidden,  but  milk, 
because  of  its  ready  assimilation  and  diuretic  action, 
should  be  regarded  as  of  great  value.  The  reader  rec- 
ommended certain  forms  of  exercise  as  of  value  in  as- 
sisting the  circulation.  Massage  over  the  gall-bladder, 
as  promoting  the  egress  of  bile,  is  helpful,  and  free  pur- 
gation is  essential.  He  then  discussed  the  various  drugs 
used  in  hepatic  disorders,  calomel,  euonymus,  podophyl- 
lum, etc.,  and  their  several  indications.  When  the  elab- 
oration of  urea  is  incomplete,  treatment  directed 
toward  an  increase  of  metabolism — massage,  bathing, 
the  drinking  of  mineral  waters,  etc. — is  to  be  recom- 
mended. The  great  point  to  aim  at  is  to  secure  and,  if 
possible,  restore  the  integrity  of  the  hepatic  cells. 

Brain  Operations. — Dr.  Hingston,  of  Montreal,  re- 
ported four  cases  of  brain  operation,  two  of  which  were 
for  epilepsy.  One  was  for  the  relief  of  paralysis  of  cer- 
tain muscles  of  the  arm  in  a  young  man  who  had  received 
an  injury  to  the  skull  some  twenty  years  before ;  there 
was  also  spasm  of  some  of  the  muscles  of  the  face.  The 
operation  afforded  almost  complete  relief.  The  speaker 
employed  a  trephine  two  inches  in  diameter,  which  he 
contended  was  much  superior  in  some  respects  to  those 
in  ordinary  use  and  of  smaller  size. 

Amputation  at  the  Shoulder-joint. — Dr.  Shepherd, 
of  Montreal,  related  the  history  of  a  case  in  which  he 
had  removed  the  entire  upper  extremity  for  a  chondro- 
sarcoma involving  the  shoulder  joint,  and  another  of 
removal  of  a  large  enchondroma  of  the  pelvis.  The  first 
operation  had  been  but  seldom  performed,  this  being  the 
first  that  was  on  record  as  having  been  done  in  Canada. 

The  paper  was  discussed  by  Drs.  Hingston,  Cameron, 
and  Steves. 

Prevention  of  Tuberculosis.— Dr.  Inches,  of  St  John, 
read  a  paper  with  this  title,  in  which  he  advocated  the 
necessity  of  increased  activity  on  the  part  of  the  profes- 
sion, the  public,  and  the  government  in  dealing  with  this 
disease.  The  patients  themselves  needed  much  instruc- 
tion in  regard  to  the  disinfection  of  sputa,  so  as  to  lessen 
the  danger  to  others  in  the  house.  Even  in  well-kept 
consumption  hospitals,  he  said,  there  is  some  danger  of 
infection.  He  dwelt  upon  the  difficulties  connected 
with  notification,  registration,  and  isolation.  He  bad 
found  it  very  difficult,  even  among  his  wealthy  patients, 
to  secure  isolation  and  fresh  air,  and  of  course  it  is  infi- 
nitely more  difficult  to  secure  such  among  the  poorer 
classes,  who  are  often  not  in  position  to  carry  out  the 
necessary  measures  looking  to  this  end.  The  speaker 
held  that  special  sanitaria  should  be  established,  so  that 
every  patient  who  could  not  be  properly  looked  after  at 
home  might  find  a  place  where  his  necessities  could  be 
attended  to. 

Treatment  of  the  More  Ordinary  Skin  Diseases. — Dr. 
L.  Duncan  Bulkley,  of  New  York,  read  an  interesting 
paper  on  the  treatment  of  skin  diseases  by  the  general 
practitioner.  He  said  that  there  were  really  only  a  few 
skin  diseases  that  made  up  the  bulk  of  those  coming  under 
the  care  of  the  general  practitioner,  and  if  we  learned  to 


3io 


MEDICAL   RECORD. 


[September  8,  1894 


diagnose  and  treat  these  we  should  be  in  position  to  cure 
the  greater  number  of  diseases  of  the  skin ;  the  few  rare 
cases  could  be  sent  to  a  specialist.  He  urged  the  neces- 
sity of  paying  more  particular  attention  to  each  individual 
case,  and  of  not  treating  all  alike  because  they  had  a  dis- 
ease with  a  common  name ;  routine  should  be  avoided, 
and  careful  inquiry  should  be  made  into  every  detail  of 
the  patient's  system  and  habits.  The  history  of  the 
eruption,  and  of  former  eruptions,  the  family  tendencies 
as  to  the  presence  of  asthma,  rheumatism,  etc.,  should  all 
be  made  the  subject  of  painstaking  inquiry.  If  the  gen- 
eral practitioner  were  well  acquainted  with  acne,  eczema, 
and  syphilis,  he  would  be  able  to  treat  satisfactorily  the 
majority  of  cases  of  skin  diseases  that  came  under  his  care. 
As  to  eczema,  too  much  was  often  done — the  disease  was 
over  treated.  He  had  grown  more  and  more  convinced 
of  the  great  necessity  of  constitutional  treatment  in  all 
these  cases  of  skin  affections,  and  had  often  had  occasion 
to  observe  that  the  correction  of  some  fault  in  diet  or 
mode  of  life  was  sufficient  to  effect  a  cure.  The  speaker 
further  emphasized  some  of  the  more  important  points  to 
be  observed  in  the  treatment  of  acne,  syphilis,  psoriasis, 
and  urticaria. 

The  Contagiousness  of  Tuberculosis. — Dr.  J.  F.  Mac- 
do  nald,  of  Nova  Scotia,  read  a  paper  with  this  title,  in 
which  he  advocated  the  bringing  of  the  matter  of  the  con- 
tagiousness of  this  disease  before  the  people  through  the 
medium  of  the  public  press.  He  favored  a  system  of  reg- 
istration, careful  disinfection,  government  inspection  of 
infected  places,  the  establishment  of  sanitaria,  and  the 
enactment  of  laws  to  hinder  the  infected  from  spreading 
the  contagion. 

Nasal  Cauterization. — Dr.  Kirkpatrick,  of  Halifax, 
presented  a  communication  on  the  subject  of  cauteriza- 
tions of  the  nasal  mucous  membrane,  in  which  he  uttered 
a  warning  note  against  the  indiscriminate  introduction 
of  strong  caustics  into  the  nasal  cavity.  He  had  seen  en- 
tire destruction  of  the  membrane  and  other  serious  con- 
sequences follow  an  abuse  of  these  remedies,  which  were, 
however,  of  such  exceeding  value  when  properly  and  ju- 
diciously employed. 

Other  papers  read  were :  "  Adhesions  of  the  Soft  Pal- 
ate, and  their  Treatment,"  by  Dr.  Hamilton,  of  Mon- 
treal; "The  Present  Status  of  Asthenopia,"  by  Dr. 
Buller,  of  Montreal;  "  Hysteropexy,' '  by  Dr.  K.  N. 
Fenwick,  and  "A  Medico-legal  Romance,"  by  Dr. 
Steves,  of  St.  John. 

After  the  customary  votes  of  thanks,  the  meeting  was 
closed  by  the  President.  It  was  decided  to  hold  the 
next  meeting  of  the  Association  in  Kingston,  Ontario. 

Typhoid  Fever  and  Vaccination.— Doctor  William 
Finder  observed  that  after  typhoid  fever  patients  recover 
they  are  very  susceptible  to  vaccination.  This  observa- 
tion has  been  verified  many  times  during  a  number  of 
years,  and  the  writer  suggests  that  others  confirm  or  dis- 
prove the  theory.  So  satisfied  is  Dr.  Finder  with  the 
correctness  of  the  observation,  that  he  now  re  vaccinates 
his  typhoid  patients  as  soon  as  they  recover  from  the 
fever. — Medical  News. 

Erysipelas  Toxins  in  Malignant  Disease.— The  fol- 
lowing are  the  conclusions  of  Dr.  William  B.  Coley,  in 
an  article  on  this  subject  in  the  American  Journal  of  the 
Medical  Sciences  for  July,  1894:  1.  The  curative  action 
of  erysipelas  upon  malignant  tumors  is  an  established 
fact.  2.  This  action  is  much  more  powerful  in  sarcoma 
than  in  carcinoma.  3.  This  action  is  chiefly  due  to  the 
toxines  of  the  erysipelas  streptococcus,  which  may  be  iso- 
lated and  used  with  safety.  4.  This  action  is  greatly  in- 
creased by  the  addition  of  the  toxines  of  bacillus  prodi- 
giosus.  5.  The  toxines,  to  be  of  value,  should  come  from 
virulent  cultures  and  should  be  freshly  prepared.  6. 
The  result  obtained  from  the  use  of  toxines  without  dan- 
ger are  so  nearly  quite  equal  to  those  obtained  from  an 
attack  of  erysipelas,  that  inoculation  should  rarely  be  re- 
sorted to. 


AMERICAN  MEDICAL  ASSOCIATION. 

Forty-fifth  Annual  Meeting f  held  in  San  Francisco,  CaLt 
June  J,  6,  7,  and  8,  1894. 

(Continued  from  VoL  45,  page  799.) 

SECTION   ON   PRACTICE   OF   MEDICINE. 

Third  Day,  Thursday,  June  8th. 

Typhoid  Fever. — Dr.  John  Eliot  Woodbridge,  of 
Youngstown,  O.,  read  a  paper  on  this  subject  in  which 
he  claimed  that  typhoid  fever,  if  a  germ  disease,  and  of 
this  he  felt  confident,  could  be  aborted.  The  disease 
was,  he  said,  on  the  increase,  and  was  limited  by  no  geo- 
graphical lines.  The  author  claimed  that  he  could  cure 
every  case  of  typhoid  fever  if  he  saw  it  early  enough. 
Treatment  by  means  of  antiseptics  such  as  thymol,  guia- 
col,  eucalyptol,  etc.,  was  the  course  pursued  by  him  in 
these  successful  cases. 

Diagnosis  and  Treatment  of  Diseases  of  the  Stomach  by 
the  Stomach -Tube.— Dr.  A.  W.  Perry,  of  San  Franciso, 
Cal.,  stated  that  most  disorders  of  the  stomach  depend- 
ed upon  fermentations  or  abnormal  accumulations  in 
quantity  or  quality  in  that  organ.  The  fermentations 
were  acetic,  lactic,  butyric,  cellulose,  etc.  Lactic-acid 
fermentation  develops  normally  within  fifteen  to  twenty 
minutes  after  digestion  commences,  but  is  held  in  check 
by  the  hydrochloric  acid  of  the  gastric  juice.  Acetic 
and  butyric  fermentations  are  prevented  by  a  more  rapid 
and  complete  emptying  of  the  stomach.  By  means  of 
the  stomach- tube  we  can  determine  dilatations,  and 
determine  the  chemical  composition  of  the  stomach  con- 
tents. Spasm  of  the  glottis  may  interfere  with  the  intro- 
duction of  the  tube.  To  overcome  this  the  speaker  is  in 
the  habit  of  touching  the  back  of  the  pharynx  with  his 
finger.  Cocaine  may  be  used.  In  some  cases  the  circu- 
lar fibres  of  the  oesophagus  contract  and  thus  obstruct 
the  passage  of  the  tube.  Reflex  spasm  of  the  glottis  is 
the  obstacle  in  the  greater  number  of  cases.  The  stom- 
ach-tube should  be  used  only  every  other  third  or 
fourth  day.  During  the  intervals  the  internal  adminis- 
tration of  an '  antifermentative  is  recommended.  The 
speaker  uses  resorcin,  gr.  v.,  after  meals,  and  finds  this 
does  not  interfere  with  the  digestive  processes.  The  use 
of  the  stomach-tube  will  prove  valuable  in  the  diagnosis 
of  cancer  and  ulcer  of  the  stomach,  by  allowing  a  quanti- 
tative test  for  hydrochloric  acid. 

The  author  finds  lavage  of  benefit  in  the  treatment  of 
the  following  stomach  disorders :  Acute  and  chronic  gas- 
tric catarrh,  dilatation  of  the  stomach,  not  dependent 
upon  pyloric  stricture,  various  fermentations,  causing  re- 
flexes, cancer,  ulcer,  and  finally  in  obstinate  singultus. 

Dr.  Freeman,  of  Indiana,  commended  the  paper  and 
suggested  a  method  to  render  the  oesophagus  tolerant. 
In  his  experience  he  found  that  by  the  frequent  use  of 
the  oesophageal  bougie  between  the  acts  of  lavage  the 
oesophagus  established  a  tolerance  of  the  tube. 

The  Law  of  Equivalence  in  Medical  Science. — Dr. 
R.  W.  Murphy,  of  San  Francisco,  Cal.,  expressed  the 
belief  that  before  many  years  have  passed  prophylactic 
measures  will  be  discovered  for  such  diseases  as  Bright's 
disease,  cancer,  tuberculosis,  etc.,  as  has  already  been  the 
case  with  the  small-pox,  hydrophobia,  etc.  He  called 
attention  to  the  great  diversity  of  treatment  directed  tow- 
ard the  same  disease,  and  believed  we  should  have  more 
practical  textbooks  and  drug  action,  both  as  regards 
maximum  and  minimum  dosage. 

He  predicted  that  the  physician  of  the  future  would  be 
the  man  who  closely  watches  the  dual  action  of  his  drugs. 
In  the  case  of  calomel,  cited  as  an  instance,  we  may  find 
physicians  recommending  a  dosage  varying  from  ^  grain 
to  60  grains  for  the  same  disease  and  under  apparently 
the  same  conditions.  The  same  may  be  said  regarding 
almost  all  of  the  drugs  in  use. 

Among  other  remedial  agents  electricity  is  largely 
employed  without  thought  of  the  law  of  equivalence. 
Experiments  should  be  a  thing  of  the  past 

The  following  papers  were  read  by  title:  "Cham- 


September  8,  1894] 


MEDICAL   RECORD. 


3ii 


pagne  and  Strychnine  in  Chest  Troubles  of  the  Aged,"  by 
Dr.  Edward  Buxton,  of  National  City,  Cal. ;  "  The  Treat- 
ment of  Erysipelas,"  by  Dr.  James  M.  Anders,  of  Phila- 
delphia, Pa. ;  "  The  Use  of  Turpentine  in  the  Treatment 
of  Diphtheria,"  by  Dr.  E.  W.  Kellogg,  of  Milwaukee, 
Wis  ;  "  Lung  Gymnastics  in  the  Treatment  of  Chronic 
Disease,"  by  Dr.  L.  P.  Walbridge,  of  Decatur,  111. ;  "A 
Clinical  Study  of  Scarlatina  at  High  Altitudes,"  by  Dr. 
J.  N.  Hall,  and  Dr.  William  P.  Munn,  of  Denver,  Col. 


THE  NEW  YORK  PATHOLOGICAL  SOCIETY. 

Stated  Meeting,  April  25, 1894. 

George  C.  Freeborn,  M.D.,  President,  in  the  Chair. 

Abnormalities  of  the  Heart — Dr.  L.  Pearce  Bailey 
presented  two  specimens  showing  abnormalities  of  the 
heart.  The  first  one  showed  a  fourth  cusp  to  the  aortic 
valve,  and  also  some  vegetations.  The  second  specimen 
was  from  a  child  who  had  died  at  birth  from  prolapse  of 
the  umbilical  cord.  A  fibrous  cord  was  found  stretched 
across  the  aorta. 

Primary  Thrombosis  of  the  Pulmonary  Artery. — Dr. 
George  P.  Biggs  presented  specimens  of  the  above.  A 
man,  forty-seven  years  of  age,  had  been  brought  to  the 
New  York  Hospital  in  a  bad  condition,  supposed  to  be 
suffering  from  pneumonia.  No  history  was  obtainable, 
and  he  died  a  few  hours  after  admission,  and  without  a 
careful  record  of  the  case  having  been  made.  At  the 
autopsy  the  first  feature  of  interest  observed  was  a  great 
depression  of  the  diaphragm,  especially  on  the  left  side. 
On  the  right  side  it  was  at  the  fifth  intercostal  space, 
and  on  the  left  at  the  eighth  intercostal  space  in  the 
mammary  line.  It  had  pushed  the  spleen  down  until  its 
upper  border  was  on  a  level  with  the  upper  border  of 
the  left  kidney.  From  the  left  pleural  cavity  1,200  c.c. 
of  a  greenish  serum  had  been  collected,  and  this  fluid 
was  found  to  contain  fibrin  in  considerable  quantity. 
The  heart  was  so  much  displaced  as  to  be  almost  en- 
tirely to  the  right  of  the  median  line.  The  entire  left 
lung,  with  the  exception  of  the  upper  half  of  the  upper 
lobe,  was  compressed  by  this  fluid.  The  pleura  was 
thickened  and  in  the  recent  state  was  covered  with  fibrin. 
There  was  no  evidence  of  a  recent  tubercular  process  in 
the  lung  itself,  or  in  the  pleura,  except  at  one  point — a 
small  cheesy  nodule  in  the  parietal  pleura.  On  scraping 
this  and  staining  it,  it  was  found  to  contain  a  large 
number  of  tubercle  bacilli. 

The  pleurisy,  the  speaker  said,  was  probably  of  tuber- 
cular character,  although  the  lesions  of  tuberculosis  in 
the  lung  appeared  to  be  all  of  a  chronic  character.  The 
lung  of  the  opposite  side  was  poorly  aerated.  There 
were  a  number  of  adhesions  at  the  apex,  and  in  the  upper 
half  of  the  upper  lobe  were  a  number  of  pigmented 
fibrous  cicatrices  with  small  cheesy  areas  scattered 
through  it.  The  pulmonary  artery  going  to  the  lower 
lobe  contained  a  large  ante-mortem  thrombus,  which  was 
rather  soft,  but  distinctly  adherent  to  the  vessel  wall  just 
beyond  the  origin  of  this  branch*  from  the  main  pulmo- 
nary artery  of  that  side.  The  pulmonary  tissue  supplied 
by  this  vessel  was  very  much  congested,  but  was  not 
cedematous,  and  there  was  consolidation.  The  thrombus 
seemed  to  have  almost  entirely  occluded  the  lumen,  but 
the  usual  effects  of  thrombosis  were  not  very  well 
marked.  The  heart  was  not  nearly  as  much  dilated  as 
one  would  have  expected  with  such  extensive  impairment 
of  the  lungs.  The  valves  were  normal  except  for  slight 
atheromatous  patches  near  their  bases  on  the  left  side. 
The  coronary  artery  showed  quite  marked  atheroma, 
especially  near  its  origin.  The  muscle  of  the  heart  ap- 
peared to  be  perfectly  normal.  There  were  no  other 
lesions  of  importance.  The  pericardium  was  not 
affected. 

The  speaker  said  that  the  first  case  of  primary  throm- 
bosis which  he  had  presented  to  the  Society  was  thought 
to  be  very  unusual,  and  some  of  the  areas  were  thought 
to  be  pneumonia.     He  was  sure  that  the  case  just  pre- 


sented was  the  fourth  of  the  kind  that  he  had  seen  this 
winter,  in  which  all  possible  sources  of  emboli  had  been 
sought  for,  yet  none  found.  One  of  the  other  cases  was 
quite  similar  to  this  one,  the  opposite  pleural  cavity 
being  filled  up  with  fluid.  From  the  appearance  of  the 
organs  in  this  case  at  the  autopsy,  it  was  not  evident  why 
it  should  have  resulted  in  this  way,  except  that  the  fluid 
had  been  allowed  to  remain  so  long  that  it  had  inter- 
fered with  the  action  of  the  heart  and  the  circulation  in 
the  opposite  lung,  thus  causing  death. 

Small  Bound-cell  Sarcoma  of  the  Ovary. — The  Presi- 
dent presented  the  half  of  a  sarcomatous  ovary  which 
had  been  removed  from  a  married  woman,  twenty  nine 
years  of  age,  who  had  had  one  child  five  years  before. 
The  tumor  was  supposed  to  have  begun  its  growth  shortly 
after  the  birth  of  the  last  child,  four  and  a  half  years 
ago.  It  continued  to  grow  until  it  measured  16  x  12 
ctm.,  and  weighed  1,100  gm.  If  this  history  were  re- 
liable, it  would  seem  to  indicate  a  very  slow  growth  for 
a  small  round-cell  sarcoma. 

Sarcoma  of  the  Ovary. — The  President  also  presented 
a  sarcoma  of  the  ovary  engrafted  on  an  ordinary  cyst- 
adenoma.  The  specimen  had  been  removed  from  a 
woman  forty  five  years  of  age,  who  had  had  five  chil- 
dren, the  last  one  fourteen  years  ago.  This  tumor  had 
been  first  noticed  nine  years  ago.  She  had  suffered  from 
flooding  at  intervals  up  to  one  year  ago.  The  tumor 
had  remained  about  the  same  size  until  two  months  ago, 
when  it  had  suddenly  began  to  grow  very  rapidly.  At 
the  time  of  the  operation  it  measured  26  x  13  ctm.  On 
close  examination  the  central  portion  of  the  tumor  was 
found  to  be  made  up  of  an  ordinary  cyst-adenoma,  and 
small  cysts  filled  with  colloid  material.  Around  the 
periphery  was  a  sarcomatous  mass — a  mixture  of  small 
and  large  round  cell  sarcoma  in  which  the  large  cells 
seemed  to  predominate,  and  the  stroma  was  rather 
scanty. 

The  speaker  said  he  thought  it  .had  been  an  ordinary 
cyst-adenoma  up  to  the  time  when  the  growth  had  be- 
come so  rapid,  and  that  at  this  time  the  sarcomatous  de- 
generation had  begun.  Probably,  if  the  tumor  had  been 
left  alone  the  whole  mass  would  have  been  converted 
into  a  sarcoma.  This  was  one  of  the  first  well-marked 
examples  of  sarcomatous  degeneration  that  he  had  met 
with.  He  had  examined  upward  of  1,000  ovaries,  and 
out  of  this  number  had  found  only  from  five  to  seven 
sarcomata. 

Dr.  George  P.  Biggs  referred  to  one  case  of  large 
cystic  tumor  of  the  ovary  which  he  had  seen,  in  which, 
from  the  gross  appearance,  it  was  thought  to  be  multilocu- 
lar  cyst,  but  on  microscopical  examination  it  had  been 
found  to  be  distinctly  made  up  of  sarcomatous  tissue,  as 
if  a  change  had  begun  to  take  place  in  it  similar  to  that 
found  in  the  specimen  just  presented. 

Dr.  Freeborn  said  that  on  a  previous  occasion  he  had 
presented,  in  connection  with  a  large  series  of  ovarian 
tumors,  one  other  specimen  of  sarcomatous  degeneration. 
It  was  a  multilocular  cyst  which  had  been  reduced  to 
three  main  cysts.  On  microscopical  examination  the 
septa  of  these  cysts  had  proved  to  be  sarcomatous. 

Dr.  S.  T.  Armstrong  said  that  the  only  case  he  had 
seen  was  in  1880,  in  the  female  hospital  in  St.  Louis. 
The  patient  was  an  unmarried  woman  who  had  been  pre- 
viously confined  in  an  insane  asylum  for  acute  mania  for 
three  years.  No  abnormal  condition  connected  with  the 
ovary  had  been  found.  She  recovered  from  the  mania, 
and  finally  entered  the  hospital  in  a  wretched  condition. 
She  died  shortly  afterward. 

Dr.  Thomas  H.  Manley  said  that  solid  tumors  of  the 
ovary  were  sometimes  carried  for  years  with  but  little 
inconvenience  except  that  due  to  weight,  and  he  was 
familiar  with  a  few  cases  occurring  in  those  past  the 
menopause,  in  which  there  was  no  question  about  a  re- 
duction having  taken  place  in  the  size  of  the  growth, 
and  having  been  accompanied  by  an  amelioration  of 
the  symptoms.  He  would  ask  whether  this  sarcomatous 
degeneration  was  to  be  regarded  as  a  malignant  change, 


31* 


MEDICAL  RECORD. 


[September  8,  1894 


or  rather  as  a  process  whose  object  was  to  hasten  resorp- 
tion. He  had  seen  a  specimen  exhibited  recently  at  the 
Harlem  Medical  Association  by  Dr.  McLean,  in  which  a 
tumor  had  been  honey  combed,  leaving  only  a  core. 

The  President  said  he  did  not  think  that  anyone  had 
ever  seen  a  carcinoma  or  adenoma  in  the  abdomen  dis- 
appear, except  by  operation.  It  was  well  known  now 
that  after  the  menopause  solid  tumors  of  the  ovary  and 
uterus  did  increase  in  size,  but  he  thought  that  in  the 
vast  majority  of  cases,  if  these  tumors  could  be  examined 
and  their  structure  determined,  it  would  be  found  that 
they  belonged  to  the  fibroid  order.  He  could  not 
accept  the  theory  that  this  sarcomatous  change  was  a 
conservative  effort  of  nature,  because  in  his  case  the 
history  showed  that  two  months  ago  there  had  been  a 
rapid  increase,  and  from  both  macroscopical  and  micro- 
scopical study,  it  appeared  that  this  sarcomatous  change 
had  taken  place  at  the  time  that  the  growth  of  the  tumor 
had  become  so  rapid.  The  tumor  referred  to  by  Dr. 
Mauley  was  a  pure  cystic  sarcoma  which  had  probably 
started  as  a  solid  sarcoma.  It  had  overgrown  itself,  so 
to  speak,  and  hence  necrosis  had  taken  place  in  the  cen- 
tral portion.    This  was  not  the  condition  in  his  specimen. 

The  Society  then  went  into  executive  session. 


Stated  Meeting,  May  9,  1894. 

George    C.   Freeborn,    M.D.,    President,    in   The 
Chair. 

A  Lacerated  Spleen. — Dr.  Thomas  H.  Manley  pre 
sented  a  lacerated  spleen.  It  had  been  removed  from  a 
young  sailor  who  had  fallen  from  a  mast,  a  distance  of 
twenty  feet,  and  striking  against  a  rail,  had  sustained 
an  injury  in  the  region  of  the  spleen.  There  was  no  dis- 
turbance of  the  sensorium,  but  there  was  profound  and 
persistent  shock,  and  he  was  in  this  condition  when  first 
seen  by  the  speaker  in  consultation  with  his  colleague, 
Dr.  Charles  B.  White.  There  was  no  visible  injury  to  the 
abdominal  wall,  and  no  distinct  dulness  on  the  injured 
side.  There  had  been  slight  retching,  but  no  vomiting 
except  a  little  mucus.  The  symptoms  pointed  to  in- 
ternal hemorrhage,  or  to  perforation  of  the  intestine. 
The  only  pain  complained  of  was  localized  below  the 
left  nipple.  Assuming  that  there  might  have  been  a 
perforation  of  the  intestine,  laparotomy  was  resorted  to. 
The  peritoneal  cavity  was  found  to  be  filled  with  blood 
which  was  escaping  freely  from  the  spleen.  A  portion  of 
the  border  of  this  organ  had  been  torn  nearly  off.  The 
lacerated  fragment  was  quickly  ligated  and  removed,  but 
the  man  died  on  the  operating-table. 

The  speaker  said  that  he  did  not  think  it  was  possible 
in  the  living  subject  to  produce  a  laceration  of  the  spleen 
by  a  blow  or  fall,  unless  this  violence  was  sufficient  to 
produce  disorganization  of  the  overlying  muscular  tissues, 
which  was  not  the  case  in  this  instance.  His  theory  was 
that,  as  the  man  was  only  about  twenty  years  of  age,  and 
the  bones  were  not  yet  fully  ossified,  the  spleen  had  been 
caught  by  the  movable  thorax  and  crowded  up  against 
the  spine.  He  would  like  the  opinions  of  the  members 
on  this  point. 

Dr.  T.  M.  Prudden  said  he  had  seen  several  cases  in 
which  there  had  been  laceration  of  the  liver  without  in- 
jury to  the  abdominal  wall. 

The  President  said  that  within  the  past  eighteen 
months  several  cases  of  extensive  rupture  of  the  liver  had 
been  presented  to  the  Society,  and  in  these  there  had 
been  no  evidence  of  injury  to  the  abdominal  walls. 

Cranio-Tabei. — Dr.  Thomas  S.  Southworth  pre- 
sented a  specimen  of  cranio-tabes.  The  calvarium  was 
very  thin,  and  showed  the  condition  of  cranio  tabes  par- 
ticularly well  on  the  left  parietal  bone.  The  specimen 
had  been  taken  from  a  child  of  about  nine  months,  who 
had  given  every  evidence  of  rachitis.  It  had  been 
thought  at  one  time  that  possibly  hydrocephalus  was  de- 
veloping, but  the  measurements  of  the  head  were  found 
to  be  no  greater  than  normal.    At  the  autopsy,  no  un- 


usual quantity  of  fluid  was  found  in  the  ventricles  of  the 
brain. 

Uric-Aoid  Infarcts  of  the  Kidney.— Dr.  Southworth 
also  presented  a  specimen  from  the  same  child,  showing 
uric-acid  infarcts  of  the  kidney.  He  said  it  was  not 
uncommon  to  find  in  the  newly  born,  that  the  pyramids 
of  the  kidneys  were  filled  with  minute  particles  of  uric 
acid  or  urates,  but  masses  of  the  size  shown  in  this  speci- 
men were  certainly  unusual.  This  condition  raised  the 
question  of  clinical  interest — were  these  masses  dissolved 
and  absorbed,  or  were  they  passed  along  the  ureters?  If 
the  latter  occurred,  it  would  afford  an  explanation  of 
much  of  the  colic  and  persistent  crying  of  young  in- 
fants. 

Dr.  O.  C.  Ludlow  said  that  his  clinical  experience 
had  abundantly  confirmed  the  truth  of  this  suggestion 
about  the  causation  of  much  of  the  colic  in  the  newly 
born.  It  was  not  uncommon  to  see  such  a  sediment  on  the 
the  diaper,  or  about  the  meatus  urinarius,  and  under  such 
circumstances  it  would  be  found  that  the  administration 
of  alkalies  would  quickly  relieve  the  colic,  and  at  the 
same  time  cause  the  disappearance  of  the  sediment. 

Sarooma  of  the  Antrum  of  Highmore. — Dr.  R.  C. 
Myles  presented  the  pterygoid  process  and  posterior 
part  of  the  antrum  of  Highmore,  and  the  pterygoid  mus- 
cles, which  had  been  removed  from  a  case  of  sarcoma  of 
the  antrum  of  Highmore.  The  patient  was  a  man  thirty 
years  of  age,  who  had  been  referred  to  him  by  Dr.  Wyeth 
for  examination.  A  portion  of  tissue  removed  by  the 
curette  from  the  antrum  was  submitted  to  Dr.  Prudden, 
who  found  it  to  be  a  large  round-cell  sarcoma.  It  was 
growing  very  rapidly.  All  of  the  sarcoma,  as  well  as  the 
superior  maxilla,  were  removed  by  Dr.  Wyeth  two  months 
ago.  The  patient  is  doing  well,  and  so  far  there  has  been 
no  recurrence.  At  first,  owing  to  the  loss  of  the  ptery- 
goids, the  mouth  was  drawn  to  one  side,  but  practice 
had  overcome  this  difficulty.  These  cases  of  malignant 
disease  of  the  antrum  were  not  usually  diagnosticated 
until  the  disease  was  far  advanced.  There  were  ordi- 
narily very  few  symptoms,  and  hence  at  first  these  cases 
were  apt  to  be  obscure.  He  thought,  if  diagnosticated 
sufficiently  early,  all  of  them  would  recover.  He  would 
therefore  strongly  advocate  an  exploratory  operation  for 
diagnostic  purposes. 

Exostosis  and  Ecchondroma  of  the  Vomer  was  also 
presented  by  Dr.  Myles.  It  had  been  situated  between 
the  perpendicular  plate  of  the  ethmoid  and  the  vomer, 
just  beneath  the  sphenoid  bone.  He  had  found  that  in 
nearly  every  instance  the  cartilage  had  extended  up  to, 
or  very  nearly  up  to,  the  sphenoid  bone.  The  specimen 
was  concave  on  one  side. 

A  Water-sampling  Apparatus. — Dr.  T.  M.  Chees- 
man  exhibited  the  apparatus.  He  said  it  involved  no 
new  principle,  but  was  an  adaptation  of  a  device  de- 
scribed in  "  Fluegge's  Micro- Organismen,"  and  originat- 
ed, he  believed,  with  Pasteur.  Its  object  was  to  collect  a 
sample  of  water  from  a  given  level  in  a  vacuum  bulb  by 
breaking  off  the  end  of  the  capillary  tube  when  the 
bulb  had  reached  the  desired  level  in  the  water.  Glass 
bulbs,  2.5  ctm.  in  diameter,  and  having  a  neck  2  ctm.  in 
length,  are  drawn  out  into  capillary  tubes,  and  these  are 
given  a  double  bend.  The  gaseous  contents  of  the 
bulbs  are  then  driven  out  in  the  usual  way  by  evaporat- 
ing a  few  drops  of  water  in  them,  and  then  sealing  the 
ends.  In  such  a  bulb  the  surface  of  tap  water  could  be 
easily  collected  by  breaking  off  the  end  of  the  tube  with 
the  finger.  The  sample  thus  obtained  should  then  be 
placed  in  a  large,  cotton-plugged  sterilized  tube,  and 
carried  in  an  ice  pail  to  the  laboratory.  The  object  of 
the  apparatus  exhibited  was,  however,  to  facilitate  ob- 
taining samples  at  different  depths  or  from  inaccessible 
places.  It  had  been  suggested  by  Dr.  Prudden,  and 
had  been  elaborated  by  the  combined  talent  of  several 
others.  Its  utility  had  been  fully  demonstrated  in  actual 
practice. 

The  apparatus  consists  of  a  metal  tube  of  small 
calibre,  and  about  one  metre  in  length,  divided  off  into 


September  8,  1894] 


MEDICAL  RECORD. 


3*3 


equal  ports.  To  the  lower  end  of  this  tube  are  soldered 
two  rings  for  supporting  two  vacuum  bulbs.  Beneath 
these  two  rings  are  two  broken  rings  arranged  to  slide  on 
the  end  of  the  tube.  They  are  held  in  place  by  a  rub- 
ber strap  or  band. 

In  collecting  samples,  the  capillary  ends  of  the  bulbs 
are  broken  off  when  they  have  been  immersed  respectively 
at  the  levels  from  which  it  is  desired  to  take  samples  of 
the  water.  The  breaking  off  of  these  ends  is  accom- 
plished through  the  instrumentality  of  small  copper  wires 
attached  to  their  bent  ends,  and  actuated  by  the  finger 
of  the  operator.  Breakage  is  facilitated,  and  fracture  at 
the  desired  point  is  insured,  by  making  a  cut  previously 
in  the  glass  with  a  file  or  diamond  at  the  proper  point. 

Formalin  and  Bacterial  Growth.— Dr.  Cheesman  also 
exhibited  specimens  showing  the  effect  of  formalin  in 
arresting  the  growth  of  bacteria,  and  its  effect  on  gela- 
tine already  fluidified  by  bacterial  products.  Formalin, 
he  said,  was  a  forty  per  cent,  solution  of  formaldehyd 
(C  H20),  a  gaseous  body  produced  by  subjecting  methyl 
alcohol  to  oxidation.  It  is  soluble  in  water  in  all  pro- 
portions, and  is  placed  on  the  market  in  a  forty  per  cent, 
solution.  As  it  is  very  inflammable,  care  must  be  taken 
about  employing  it  near  a  light  or  fire,  and  it  is  impor- 
tant that  the  preparation  should  have  been  recently  pre- 
pared, as  it  loses  its  properties  by  keeping. 

Dr.  Cheesman  then  exhibited  the  following  specimens : 

The  first  one  was  a  potato  which  had  been  cut  in  half 
without  antiseptic  precautions,  and  one-half  smeared  with 
the  soil  clinging  to  the  outside  of  the  potato,  and  the 
other  half  with  a  culture  of  B.  prodigiosus.  Both  halves 
had  been  kept  for  fourteen  days  in  an  air-tight  jar, 
charged  with  the  vapor  of  formalin.  No  growth  had 
developed. 

The  second  specimen  showed  the  effect  of  formalin 
vapor  upon  a  culture  of  B.  mycoides  in  gelatine,  grown 
for  three  days  at  a  temperature  of  an  ordinary  room  be- 
fore being  subjected  to  the  formalin  vapor.  The  growth 
had  been  arrested  and  the  fluidified  gelatine  on  the  sur- 
face had  become  solid.  The  medium  still  remained 
clear,  but  had  undergone  a  slight  change  in  color. 

The  third  specimen  was  a  "  roll  tube  "of  B.  subtilis, 
one  of  the  most  actively  fluidifying  species.  The  growth 
had  been  arrested  by  the  formalin  vapor. 

The  fourth  specimen  was  a  water-plate  upon  which, 
after  two  days  of  growth,  about  1  c.c.  of  formalin  had 
been  placed,  and  the  cover  sealed  on  with  paraffine.  The 
growth  had  been  completely  arrested. 

The  speaker  said  that  formalin  had  the  peculiarity  of 
rendering  solid  gelatine  which  had  once  been  fluidified  by 
bacterial  products.  So  far  as  he  knew,  ordinary  gelatine 
as  well  as  that  which  had  been  fluidified  by  bacteria,  was 
thus  rendered  incapable  of  being  liquefied  by  heat.  It 
was  claimed  by  those  who  had  introduced  formalin,  that 
the  microscopical  appearances  of  the  bacteria  colonies 
were  not  affected  by  the  formalin.  If  this  were  true,  it 
would  be  useful  for  making  microscopical  "  mounts  "  of 
colonies  cut  from  gelatine  plates.  The  cut  section  from 
the  gelatine  could  be  placed  on  a  slide,  surrounded  by 
gelatine,  covered  with  glass,  and  placed  in  an  atmosphere 
of  formalin.    It  could  be  varnished  to  prevent  drying. 

The  President  remarked  that  he  had  seen  a  published 
statement  by  one  experimenter,  to  the  effect  that  the 
heat  from  a  Bunsen  burner  would  char  the  gelatine  which 
had  been  acted  upon  by  formalin,  but  would  not  fluidify 
it 

Epithelioma  of  the  Hand. — Dr.  Henry  Power  pre- 
sented microscopical  sections  of  an  epithelioma  of  the 
hand.  According  to  the  clinical  history,  the  patient,  a 
man  seventy-five  or  eighty  years  of  age,  had  had  an 
epithelioma  on  the  back  of  the  hand  for  about  eight 
years.  He  suddenly  developed  marked  jaundice,  ema- 
ciated rapidly,  and  died  in  eight  weeks.  At  the  autopsy 
the  organs  were  found  to  be  normal  except  the  liver  and 
gall-duct.  The  latter  was  distended  and  contained  some 
gall-stones.  There  was  a  growth  in  the  neighborhood  of 
the  common  bile-duct,  which  completely  occluded  it   It 


seemed  to  be  composed  of  adenoma,  some  fibroma,  and 
in  places  closely  resembled  in  structure  the  epithelioma 
of  the  hand.  The  latter  showed  very  large  epithelial 
"  pearls,"  and  also  some  peculiar  cells  which  gave  the 
appearance  of  having  a  thick  capsule. 


Uenr  Qnetvnmznta. 

A  NEW  ASEPTIC  TREPHINE. 
By  EMORY  LANPHEAR,  M.D.,  Ph.D., 

ST.    LOUIS,  MO. 

PROFESSOR  OF  OPERATIVE  SURGKSY  AND  CLINICAL  SURGERY  IN  THE     ST.   LOUIS 
COIABGI  OF  PHYSICIANS  AND  SUSCHONS. 

Surgeons  who  have  had  much  experience  in  opening 
the  skull  by  means  other  than  the  chisel,  will  bear  out 
my  assertion  that  the  ordinary  Gait  trephine  is  not  and 
cannot  be  made  aseptic ;  furthermore,  it  is  exceedingly 
liable  to  get  out  of  order  at  a  most  inopportune  moment. 
The  Roberts  trephine  was  made  to  overcome  this  diffi- 
culty; while  it  is  a  thoroughly  aseptic  instrument,  it 
possesses  the  disadvantage  of  being  liable  to  drop  to 
pieces  at  the  most  unfortunate  and  critical  point  of  the 
operation ;  otherwise  it  is  perfectly  satisfactory.  Bear- 
ing in  mind  the  faults  of  these  two  instruments,  I  have 
sought  to  remedy  the  deficiencies  by  the  invention  oi 
the  trephine  here  pictured. 


This  instrument  consists  of  but  three  pieces ;  it  can  be 
taken  apart  in  an  instant;  and  is  thoroughly  aseptic. 
The  sharp  blade  is  attached  to  a  large,  strong  metal 
handle  through  which  passes  the  centre  pin,  held  in  place 
by  a  little  key  which  transfixes  shaft  and  pin.  Upon 
withdrawal  of  the  key  the  centre  pin  can  be  removed 
without  taking  the  saw  from  its  groove,  if  so  desired. 
The  hole  for  the  centre- pin  is  large,  of  smooth  bore,  and 
can  be  readily  cleaned  with  a  piece  of  gauze,  and  the 
whole  instrument  can  be  boiled  without  danger  of  rust- 
ing. 

Acknowledgment  of  indebtedness  to  Messrs.  Tiemann 
should  be  made  for  valuable  suggestions  in  regard  to 
modification  of  original  plan. 


Trismus  neonatorum. — Dr.  I.  Stefanesco,  writing  in 
Spitalul,  No.  8,  1894,  says  that  the  greatest  mortality 
among  the  new- born  in  the  district  of  Ilfov,  in  Rouman- 
ia,  is  from  tetanus  arising  from  infection  through  the  um- 
bilicus. In  a  careful  study  of  a  series  of  these  cases  he 
has  found  that  the  chief  cause  of  this  infection  is  the 
practice,  very  common  among  women  in  the  country 
districts,  of  being  delivered  lying  on  a  bed  of  straw  in 
supposed  imitation  of  the  Virgin  Mary. 


314 


MEDICAL   RECORD. 


[September  8,  1894 


A  NEW  UVULATOME. 
By  SAMUEL  GOLDSTEIN,  M.D., 

NEW  YORK. 

ASSISTANT  SURGEON,   NEW  YORK  THROAT  AND  NOSE  HOSPITAL  ;   ASSISTANT  SUR- 
GEON, OUTDOOR  DEPARTMENT,  MOUNT  SINAI  HOSPITAL. 

Amputation  of  the  uvula,  in  vogue  even  as  far  back 
as  the  Hippocratic  era,  is  to-day  classed  among  minor 
operations  upon  the  throat.  The  instruments  used  dur- 
ing primitive  ages  hardly  find  a  place  in  the  armamen- 
tarium of  the  surgeon  of  this  progressive  age.  Then  the 
unfortunate  possessor  of  this  organ,  when  hypertrophied 
or  relaxed,  suffered  much  torture  in  its  abscission.  Even 
to-day,  with  the  many  modified  and  complicated  instru- 
ments, the  patient  is  often  compelled  to  undergo  much 
shock  through  delay  in  the  proper  working  mechanism 
of  such  appliances. 

With  the  means  at  hand,  however,  the  general  prac- 
titioner, as  well  as  the  specialist,  finds  no  hesitancy, 
when  deemed  necessary,  in  removing  a  portion  of  this 
organ. 

After  having  tried  many  of  these  instruments  with  the 
usual  amount  of  success,  I  was  compelled  to  resort  to  the 
use  of  the  forceps  and  curved  scissors. 

In  the  use  of  these  simple  instruments,  both  hands  of 
the  operator  are  engaged ;  the  tongue  must  be  depressed 


either  by  the  patient  himself,  or  by  the  aid  of  an  assis- 
tant. 

The  patient  is  left  in  full  possession  of  his  senses,  and 
comprehends  fairly  well  what  is  about  to  ensue. 

That  alone  to  the  sensitive  mortal  creates  very  often 
a  feeling  akin  to  fear,  and  a  wish  that  the  operation  were 
speedily  performed. 

It  has  been  my  experience,  in  the  main,  in  amputa- 
ting the  uvula,  to  meet  a  class  of  patients  whose  throats, 
on  account  of  the  condition  of  this  pendulous  organ, 
were  extremely  sensitive,  and  to  whom  the  touch  of  the 
tongue  depressor,  unless  very  carefully  used,  occasioned 
considerable  gagging. 

This  would  delay  and  prolong  operative  work. 

In  just  such  cases  I  have  experienced  much  difficulty 
in  having  the  patient  properly  depress  his  tongue,  thus 
preventing  expeditious  and  successful  performance  of 
this  otherwise  simple  operation. 

With  these  facts  in  view,  believing  that  some  simple 
contrivance  could  be  planned  whereby  the  surgeon  him- 
self could  perform  the  entire  operation,  without  inter- 
vention of  either  patient  or  assistant,  I  have  made  this 
uvulatome,  hoping  that  it  will  supply  for  others,  as  it 
has  for  me,  a  long-felt  want 

^  In  drawing  the  plans,  I  have  endeavored  to  keep  in 
view  the  following  points : 

1.  That  the  instrument  be  so  constructed  as  Xofit  and 
cut  uvulae  of  any  diameter,  whether  hypertrophied  or  re- 
laxed. 

2.  That  the  knife  be  concealed,  so  as  to  give  the  pa- 
tient no  cause  to  fear  operative  procedure. 

3.  That  the  entire  operation  be  performed  by  the  sur- 
geon'himself. 

4.  That  the  instrument  can  be  readily  taken  apart  for 
cleaning. 

This  uvulatome  consists  of  an  upper  and  lower  set  ot 
rings  or  claws,  and  between  these  a  concealed  knife. 

Each  set  of  claws  (there  being  two  segments  to  each 
set)  is  attached  to  a  staff.  A  cannula  incloses  them  at 
their  narrowest  parts.  It  is  by  the  backward  and  forward 
movements  of  this  cannula  (at  the  lower  end  of  which  is  a 
ring  for  the  thumb)  that  the  claws  are  drawn  together, 


holding  the  uvula  firmly,  and  relaxed,  releasing  the 
uvula. 

Between  the  staffs  of  the  claws  is  the  staff  of  the  knife 
(which  is  released  by  the  cannula  being  pushed  forward, 
lifting  a  catch)  to  which  two  rings  are  attached.  The 
knife  glides  between  the  two  claws  and  its  action  depends 
upon  the  backward  and  forward  movements  of  the  index 
and  middle  fingers  in  the  rings  attached  to  the  staff. 

Each  set  of  claws  is  so  arranged  that  the  tongue  of  the 
one  fits  between  the  two  lips  of  the  other. 

The  upper  set  have  their  inner  surfaces  smooth,  so  as 
not  to  injure  the  stump  of  the  uvula,  while  holding  it 
firmly ;  the  lower  claws  have  their  inner  surfaces  serrated, 
in  order  to  better  hold  the  amputated  part,  after  the 
uvula  has  been  cut. 

The  working  mechanism  is  as  follows : 

The  uvula  is  examined,  and  the  exact  amount  to  be 
amputated  is  determined.  The  surgeon  depresses  the 
tongue  with  the  left  hand  (holding  the  uvulatome  in  the 
right),  and  with  the  thumb  in  the  ring  at  the  end  of  the 
cannula,  and  the  index  and  middle  fingers  in  the  rings  on 
either  side  of  the  staff  of  the  knife,  place  the  uvulatome 
in  position,  encircling  the  uvula. 

The  thumb  ring  is  pushed  forward  (from  the  operator), 
thus  pushing  the  cannula  over  the  claws,  and  bringing 
them  together  grasping  the  uvula  tightly ;  then  with  the 
index  and  middle  fingers,  poll 
backward  (toward  the  opera- 
tor), cutting  through  the  uvula. 
The  operator  should  bear  in 
mind,  that  it  is  very  important 
to  first  grasp  the  uvula  well  with 
the  claws,  before  bringing  the 
knife  into  action. 
To  release  the  stump,  the  op. 
posite  action  of  the  thumb  opens  the  claws ;  and  like- 
wise, the  opposite  action  on  the  staff  of  the  knife  pushes 
that  backward. 

The  amputated  portion  of  the  uvula  will  be  found 
caught  in  the  serrated  teeth  of  the  lower  set  of  claws, 
which  for  this  purpose  are  made  to  fit  closer  together,  so 
as  to  grasp  the  part  of  the  uvula  about  to  be  cut,  more 
tightly.1 

I  wish  to  express  my  thanks  to  Messrs.  Geo.  Tiemann 
&  Co.,  for  the  excellent  and  thorough  manner  in  which 
they  have  executed  my  plans. 

166  East  Ninety-third  Street. 


The  Predilections  of  French  Woman  Students. — 
Of  the  total  number  of  women  university  students  in 
Paris,  155  are  on  the  list  of  the  medical  faculty,  164  on 
the  list  of  the  faculty  of  letters,  7  in  the  department  of 
science,  and  3  in  that  of  law.  Of  the  155  medical  stu- 
dents, however,  only  16  are  Frenchwomen,  while  of 
the  164  students  under  the  faculty  of  letters,  141  are  of 
French  birth. 

Gold  Mines  in  Cemeteries. — A  writer  in  Le  Temps, 
of  Paris,  has  been  travelling  in  America,  and,  of  coarse, 
relates  his  "  impressions."  What  struck  him  particularly 
was  not  the  Falls  of  Niagara,  the  inquisitiveness  of  re- 
porters, or  the  consumption  of  pie,  but  the  fillings  in 
American  teeth.  He  has  consulted  the  statisticians  and 
finds  that  the  amount  of  gold  annually  pounded  into  our 
dental  cavities  reaches  the  respectable  figure  of  800  kilo- 
grammes, representing  a  value  of  half  a  million  dollars. 
All  this  precious  metal  is  buried  with  the  Yankees  when 
they  die,  and  consequently  at  the  end  of  three  short  cen- 
turies the  cemeteries  of  the  United  States  will  contain  gold 
to  the  value  of  $150,000,000.  He  thinks  this  will  prove 
too  tempting  to  the  practical  mind  of  the  future  American, 
and  foresees  the  day  when  companies  will  be  organized  to 
mine  the  cemeteries  and  recover  the  gold  secreted  in  the 
jaws  of  deceased  ancestors. 

»  Should  troublesome  hemorrhage  follow  the  operation,  the  emer- 
gency can  be  met  by  reclamping  the  claws  of  the  uvulatome  over  the 
stump,  and  keeping  it  in  this  position  until  all  bleeding  has  ceased. 


September  8,  1894] 


MEDICAL  RECORD. 


315 


OUR  LONDON  LETTER. 

(From  our  Special  Correspondent.) 

HOLIDAY  SIGNS — THE  TEMPERANCE  BREAKFAST — DR.  LONG 
FOX'S  ADDRESS  —  IS  LUNACY  INCREASING?-* PROFESSOR 
JEBB   ON   THE   UNIVERSITIES — A    QUINQUENNIAL  CENSUS 

DEATH   OF   DR.    C    R.    ALDER  WRIGHT — A  STATUE  TO 

SYDENHAM THE    NEW    ELEMENT    IN    THE   AIR  —  THE 

OPHTHALMOLOGICS  CONGRESS — THE  MIDWIVES*  QUES- 
TION— POOR  LAW  SCANDALS — THE  CHELSEA  HOSPITAL — 
CHOLERA — SMALL  POX — DR.  WIGLESWORTH. 

London,  August  17, 1894. 

The  holidays  have  begun  in  earnest.  The  exodus  from 
Bristol  was  rapid,  and  except  a  few  who  went  to  Oxford, 
most  of  our  friends  have  left  London.  Still  it  is  not 
quite  accurate  to  say  "  London  is  left  without  doctors," 
as  some  people  are  fond  of  remarking;  for  there  are 
plenty  to  do  all  the  work  that  has  to  be  done,  and  some 
of  those  who  remain  in  town  declare  they  have  too  much 
time  on  hand,  and  would  be  glad  of  more  practice. 
After  the  Bristol  week,  with  its  discussions  and  un- 
bounded hospitality,  a  little  repose  is  a  relief;  and,  then, 
a  change  of  air  will  be  most  acceptable. 

Among  agencies  at  the  Bristol  meeting  outside  the  As- 
sociation the  breakfast  given  by  the  National  Temperance 
League  was  most  notable.  This  is  the  twenty- fifth  year 
in  which  the  League  has  given  a  breakfast,  and  on  this 
occasion  Dr.  Long  Fox,  the  President  of  the  Association, 
occupied  the  chair  and  delivered  a  most  impressive  ad- 
dress. He  did  not  attempt  to  go  over  the  old  arguments 
nor  to  offer  new  ones  respecting  the  temperance  question, 
but  contented  himself  with  pointing  out  the  immense  in- 
fluence of  his  professional  brethren,  and  making  an  ear- 
nest appeal  to  them  to  use  that  influence  aright.  "  We 
want  more  power  and  greater  influence,"  said  Dr.  Fox, 
"and  when  we  see  whole  families  in  the  lowest  state  of 
degradation  from  the  drunkenness  of  one  parent  or  both, 
and  now  and  then  trace  the  change  to  prosperity  on  giv- 
ing up  the  drink,  it  seems  to  me  one  of  the  strangest 
things  on  earth  that  anybody  should  shrink  from  be- 
ing an  apostle  of  temperance."  When  the  cheers  that 
greeted  this  sentiment  had  subsided  the  President  added  : 
"  Speaking  in  the  presence  of  some  of  the  most  thought- 
ful and  excellent  members  of  our  body,  may  I  say  if  we 
have  light  on  this  subject  it  behooves  us  to  use  it  in  a 
missionary  spirit.  We  can  do  something  in  tins  way  to 
remove  the  stones  from  the  king's  highway.  The  cry 
comes  down  to  us,  '  Watchman,  what  of  the  night  ? '  It 
hath  been  long,  O  Lord !  and  very  dark,  but  already  over 
thine  eternal  hills  the  red  light  gloweth  that  heralds  the 
approach  of  morning.  Already  out  of  the  people  of  our 
beloved  land  some  sixth  part  have  shaken  themselves  free 
by  thy  grace  from  the  hideous  evil  that  tends  to  the  de- 
struction of  the  nation.  We  look  for  thy  sun  to  rise  ere 
long  and  flood  this  chosen  country  of  thine  with  fuller  and 
deeper  light  from  thee.  God  grant  that  the  coming  gen- 
eration may  see  a  nobler  and  more  effectual  fight  against 
this  great  evil,  the  most  pregnant  cause  of  poverty,  disease, 
and  crime.  May  the  common-sense  of  England  and  the 
righteousness  of  England  so  permeate  the  daily  life  of 
the  nation  that,  by  and  by,  there  will  be  no  need  of  this 
society  or  of  kindred  societies,  because  the  freedom  of 
which  we  so  justly  boast  will  include  freedom  from  all 
excess."  Among  the  speakers  who  followed  were  Pro- 
fessor Murdoch  Cameron,  Drs.  J.  J.  Ridge,  W.  G.  Mac- 
kenzie, Roger  Hughes,  and  Norman  Kerr.  All  these 
made  good  points,  but  I  may  safely  say  not  one  produced 
so  deep  an  impression  as  the  testimony  of  Dr.  Long  Fox, 
who  showed  his  earnestness  by  snatching  time  to  attend 
this  breakfast  amid  the  numerous  distractions  to  which 
he  was  subjected  as  President  of  the  British  Medical  As- 
sociation. This  noteworthy  breakfast  was  on  Thursday 
morning.     In  the  evening  of  the  same  day  the  dinner  of 


the  Association  was  celebrated  as  usual,  when  wine  was 
served  as  freely  as  ever,  and  as  much  nonsense  was  talked 
as  usual — so  at  least  I  gather ;  but  I  did  not  spend  my 
evening  at  that  dinner. 

Is  insanity  on  the  increase,  is  a  question  that  the  news- 
papers have  often  taken  up,  sometimes  giving  expression 
to  alarming  forebodings.  It  has  always  seemed  to  me  that 
the  facts  did  not  justify  the  sensational  statements  that 
have  been  freely  circulated,  and  the  "  Report  of  the  Lunacy 
Commissioners  "  does  not  substantiate  them  so  far  as  I 
have  been  able  to  examine.  The  census  statistics  show 
that  there  is  a  considerable  reserve  of  cases  unknown  to 
the  commissioners,  and  this  reserve  has  fallen  from  17.7, 
in  1871,  to  10.9  in  1891.  In  those  twenty  years  the 
cases  known  to  the  commissioners  increased  from  82.3 
per  cent,  to  89.1 ;  but  this  only  shows  that  a  larger  num- 
ber had  passed  into  asylums,  and  so  became  known  to 
the  commissioners.  Statistics  also  show  that  new  cases 
were  fewer  in  the  last  decade  than  in  the  preceding  one, 
and  the  increase  so  freely  talked  about  is  therefore  partly 
due  to  the  accumulation  of  cases,  which  has  been  brought 
about  through  the  decreased  mortality  and  increased  lon- 
gevity of  the  insane.  There  has  been  an  increase  in  the 
ratio  of  insanity  to  the  population,  but  it  is  all  confined 
to  the  old,  or  rather  to  those  above  forty  five  years  of 
age.  It  can  hardly  be  supposed  that  this  is  due  to  new 
cases  at  advanced  ages,  and  it  seems  clear  that  all  the  ap- 
parent increase  has  had  no  real  existence.  Improved 
treatment,  greater  willingness  of  the  public  to  resort  to 
asylums,  decreased  death-rate,  increased  longevity,  accu- 
mulation of  old  cases,  and  other  causes  account  for  the 
figures,  and  we  may  reassure  ourselves  that  the  nation  is 
not  becoming  insane. 

Professor  Jebb  has  published  his  very  interesting  address 
at  the  Cambridge  University  Local  Lectures  Association, 
in  which  he  takes  broad  views  of  the  duties  of  our  old  uni- 
versities. The  address  is  entitled  "  The  Work  of  the 
Universities  for  the  Nation,"  and  is  worthy  of  the  pro- 
fessor's great  reputation.  Passing  by  his  happy  sketch 
of  the  earlier  history  of  these  seats  of  learning,  he  points 
out  how  they  have  enlarged  their  scope  and  have  at 
length  stepped  out  from  their  own  gates  to  extend  their 
influence  in  a  wider  sphere.  No  doubt  many  still  have 
misgivings  as  to  this  movement ;  but  so  far  it  seems  to  have 
succeeded,  and  will  probably  be  the  means  of  drawing  a 
larger  number  into  nearer  association  with  the  universi- 
ties. Mere  technical  instruction  is  not  their  proper  work, 
but  rather  to  bring  students  to  see  and  apply  general 
principles  to  all  their  work— even  in  the  most  technical 
employment.  In  no  branch  is  the  higher  culture  of 
greater  importance  than  in  the  sciences  which  underlie 
medicine,  and  the  influence  of  the  universities  on  the 
profession  is  most  important.  Our  relations  with  other 
learning  have  grown  more  intimate  in  spite  of  our  devo- 
tion to  science,  and  the  Association  has,  I  have  no  doubt, 
been  mutually  benefited. 

London  is  to  have  a  quinquennial  census — to  be  begun 
in  1896.  This  is  not  undertaken  for  statistical  ends  in 
general,  but  in  order  to  carry  out  the  arrangements  for 
the  equalization  of  rates.  This  measure  seems  to  be  just, 
but  the  richer  parishes  will  contain  a  considerable  num- 
ber of  dissentients  to  this  view.  The  County  Council 
is  to  be  saddled  with  the  expense,  which  will  amount  to 
;£6,ooo  or  ,£7,000.  No  doubt  it  will  tend  to  the  accu- 
racy of  vital  statistics  and  be  useful  for  other  purposes, 
but  the  manner  in  which  it  is  brought  about,  as  a  sort  of 
side  issue,  is  characteristic  of  the  ways  of  politicians. 

The  medical  school  of  St.  Mary's  Hospital  has  sus- 
tained a  serious  loss  in  the  decease  of  Dr.  C.  R.  Alder 
Wright,  F.R.S.,  the  distinguished  lecturer  on  chemistry. 
His  many  researches  are  familiar  to  all  who  have  paid 
any  attention  to  the  progress  of  chemistry.  His  share  in 
the  discovery  of  apomorphine,  and  his  work  on  the  alka- 
loids of  aconite,  are  the  most  important  from  a  medical 
point  of  view,  but  they  are  only  a  small  part  of  his  scien- 
tific investigations.  He  lectured  at  St.  Mary's  for  nearly 
a  quarter  of  a  century,  and  his  many  pupils  will  regret  his 


3i6 


MEDICAL  RECORD. 


[September  8,  1894 


death.  He  took  the  Doctorship  in  Science  at  the  Lon- 
don University  soon  after  that  degree  was  instituted,  and 
has  contributed  to  the  repute  in  which  it  is  held. 

London,  August  23,  1894. 

At  the  Oxford  meeting  of  the  British  Association  for  the 
Advancement  of  Science  a  pleasant  event  was  the  unveil 
ing  of  the  statue  of  Sydenham  by  the  President  of  the 
Association  and  Chancellor  of  the  University,  Lord  Sal- 
isbury. On  behalf  of  All  Souls'  College,  Sir  Henry  Ar- 
land  begged  the  acceptance  of  the  statue  by  the  Univer- 
sity, and  the  Chancellor  in  accepting  it  made  graceful 
allusion  to  Sir  H.  Arland's  work,  and  to  the  growth  and 
renewal  of  the  study  of  nature,  of  which  the  museum 
where  they  were  assembled  was  the  outcome.  It  is  curi- 
ous that  Sydenham,  who  was  a  Fellow  of  All  Souls',  did 
not  take  his  degree  at  Oxford,  but  at  Cambridge,  and  it 
has  been  conjectured  that  this  was  due  to  his  Roundhead 
proclivities  or  connections,  but  we  redly  have  hardly 
any  reliable  information  about  him  until  he  had  estab- 
lished his  position  as  the  leading  physician  of  his  day. 
It  is  sometimes  said  that  he  was  never  admitted  as  Fellow 
of  the  London  College  of  Physicians  on  account  of  po- 
litical feelings,  but  there  is  no  proof  of  this.  The  col- 
lege was  very  likely  as  much  a  clique  as  it  is  in  our  own 
day,  and  Sydenham,  like  some  of  our  contemporaries, 
might  object  to  show  subserviency  to  the  governing 
clique. 

Of  course,  the  sensation  of  the  Oxford  meeting  was  the 
announcement  that  a  new  elementary  body  had  been  iso- 
lated in  the  atmosphere.  You  will  have  heard  of  all  this 
from  other  sources,  so  that  I  shall  only  say  a  word.  This 
new  element — if  indeed  it  be  one — is  even  more  remarka- 
able  than  nitrogen  for  its  indifferent  qualities.  Perhaps 
it  may  be  after  all  another  form  of  nitrogen,  but  on  this 
chemists  have  not  had  time  to  come  to  an  agreement. 
But  the  discovery,  or  even  the  looking  for  an  unrecog- 
nized element  in  the  atmosphere,  is  full  of  suggestion  for 
the  future,  to  say  nothing  of  the  reproof  it  offers  for 
neglecting  to  do  so  in  the  past. 

The  International  Ophthalmic  Congress,  the  eighth  of 
the  series,  has  been  celebrated  at  Edinburgh  under  the 
presidency  of  Dr.  Argyll  Robertson,  who  referred  in  his 
address  to  the  circumstance  that  the  first  department  of 
medicine  to  institute  such  a  congress  was  ophthalmology. 
That  was  thirty-seven  years  ago.  The  deaths  of  Don- 
ders  and  Becker  since  the  last  Congress  (which  was  held 
at  Heidelberg  in  1888)  were  touched  upon  with  due  rev- 
erence, and  the  illness  of  Helmholtz  was  spoken  of  with 
sympathy.  There  were  some  one  hundred  and  fifty 
members  present  at  this  Congress,  and  I  hear  that  some 
valuable  papers  were  brought  forward. 

Dr.  Rentoul  is  continuing  his  campaign  on  the  mid- 
wives'  question.  He  has  just  issued  a  pamphlet  entitled, 
"  The  Proposed  Formation  of  an  Inferior  Order  of  Mid- 
wifery Practitioners:  A  Reply  to  Dr.  William  Carter's 
pamphlet."  This  reply  is  one  that  will  give  much  satis- 
faction to  a  large  number  of  medical  men.  The  few 
who  are  so  anxious  to  recognize  midwives  and  register 
them  are  very  fond  of  putting  forward  the  plea  of  suffer- 
ing parturient  women,  as  if  their  opponents  were  not 
equally  humane.  The  truth  is,  there  are  too  many  doc- 
tors in  most  localities,  and  it  is  no  wonder  they  do  not 
relish  the  proposal  to  register  midwives.  Consulting  ac- 
coucheurs have  little  experience  of  the  requirements  of 
the  people. 

Scandals  connected  with  the  Poor  Law  seem  to  multi- 
ply, or  perhaps  it  is  that  they  are  being  made  more  pub- 
lic. Some  of  these  I  have  already  reported  and  others 
are  cropping  up.  The  British  Medical  Journal  has  been 
busy  in  the  matter  lately,  the  editor  following  up  the  in- 
vestigations set  on  foot  so  many  years  ago  by  the  Lancet, 
and  claiming  credit  for  work  undertaken  and  paid  for  by 
the  proprietors  of  the  Lancet  The  infirmaries  are  some 
of  them  well  managed,  but  it  must  be  admitted  that  the 
nursing  is  in  a  great  many  inferior — and,  in  some  it  may 
almost  be  said  there  is  no  nursing  at  all/ 


The  Chelsea  Hospital  for  Women  has  taken  the  next 
step  in  its  reorganization  by  electing  its  honorary  staff. 
This  has  been  reduced  in  number  and  a  couple  of  out- 
siders have  been  introduced.  The  others  have  been 
chosen  from  the  former  staff,  which,  as  you  will  remem- 
ber, had  resigned.  We  shall  hear  more  of  the  matter 
yet.  Already  some  statements  have  appeared  on  behalf 
of  the  staff  which  go  far  in  support  of  the  view  I  have  ex- 
pressed. 

The  cases  of  cholera  in  a  vessel  arriving  in  the  Thames 
have  been  reported  as  real  Asiatic  cholera,  the  comma 
bacilli  having  been  found.  Another  suspicious  death 
occurred  in  Battersea  and  was  submitted  to  Dr.  Klein, 
but  in  this  case  he  was  unable  to  confirm  the  suspicion 
from  bacteriological  examination.  Every  precaution  is 
being  taken  to  guard  the  port  of  London,  and  cases  of 
diarrhoea  on  board  vessels  arriving  are  ordered  to  be  noti- 
fied. 

Small- pox  continues  to  hold  its  ground,  though  with 
considerable  variations  from  week  to  week.  In  the  last 
return  there  were  only  22  cases.  There  were  10  deaths 
registered,  of  which  7  were  in  the  parish  of  Marylebone, 
where  Dr.  Blyth  has  been  most  active  in  preventing  the 
spread  of  the  disease.  He  is  well  supported  by  his  sani- 
tary authorities,  who  seem  conscious  of  their  responsi- 
bilities, and  we  have  little  doubt  that  all  necessary  meas- 
ures will  be  taken.  The  outbreak  has  given  a  much 
needed  impetus  to  vaccination,  in  spite  of  the  follies  of 
the  antis.  A  strictly  localized  outbreak  produces  infi- 
nitely more  alarm  than  a  more  wide-spread  epidemic,  and 
thus  inoculates  a  larger  number  of  people  with  fear,  and 
there  is  a  rush  to  the  vaccination  stations. 

Dr.  Wiglesworth's  wound  was  more  serious  than  at 
first  reported.  The  carotid  artery  was  wounded  and 
had  to  be  tied.  He  walked  through  a  corridor  for  some 
distance  to  his  house,  applying  pressure  himself  until  as- 
sistance was  obtained.  It  is  satisfactory  to  learn  that  he 
is  going  on  well. 

MEDICAL  COLLEGES  AND  THE  MEDICAL 
PROFESSION. 

To  the  Editor  of  the  Medical  Record, 

Sir  :  Perhaps  many  interested  readers  with  far  abler  pens 
than  mine  will  feel  in  perfect  accord  with  the  quoted 
remarks  of  Dr.  Cochran,  as  found  in  the  Medical  Rec- 
ord of  July  28th,  editorially  referring  to  the  marked  in- 
crease in  the  number  of  medical  colleges  in  the  United 
States. 

Statistics  yearly  show  a  great  army  enlisted  in  the 
study  of  medicine,  and  comparatively  large  classes  of 
graduate  students.  It  is  amazing  to  think  of  the  num- 
ber of  these  so-called  medical  colleges.  It  is  also  a  mat- 
ter of  wonder  and  more  than  apparent  concern  to  regular 
practitioners  where  the  army  of  annual  recruits  are  to  go. 
Here  in  Ohio,  with  a  dozen  times  as  many  colleges  as 
are  needed,  and  with  a  large  migration  of  young  doctors 
from  other  States,  we  now  startle  the  population  of  our 
great  State  with  the  fact  that  every  three  hundred  and 
fifty  people  have  their  physician.  This,  of  course,  is 
only  approximate,  for  there  never  can  be  an  even  distri- 
bution, and,  if  there  could,  every  physician  well  knows 
that  it  requires  an  allotment  of  eight  hundred  to  one  thou- 
sand persons  to  even  earn  a  livelihood  in  the  practice  of 
medicine. 

Dr.  Cochran  suggests  the  only  real  remedy.  Let  every 
State  follow  the  example  of  Alabama  and  limit  the  num- 
ber of  colleges  chartered.  Let  the  requirements  in  the 
few  allowed  be  in  accord  with  the  professional  spirit  of 
the  age. 

There  is  no  excuse  for  even  this  great  State  having 
more  than  two  medical  colleges.  The  writer  can  name 
medical  colleges  in  this  State  where  clinical  work  in  any 
department  is  entirely  unknown.  Yet  the  degree  that 
ought  to  signify  so  much  is  belittled.  Perhaps  Pennsyl- 
vania has  fewer  medical  schools  compared  with  her  great 
importance  and  population  than  many  of  the  other  States. 


September  8,  1894] 


MEDICAL    RECORD. 


3*7 


But  who  can  honestly  claim  that  old  Pennsylvania  really 
needs  more  than  two  or  three  high-grade  medical  schools? 
So  we  might  go  over  the  list  of  States  with  the  s&me  re- 
sult. 

It  seems  far  more  just  that  each  State  should  have  cer- 
tain colleges  of  high  standard  which  would  put  every 
State  and  the  whole  medical  fraternity  on  equal  footing, 
than  that  young  men  graduating  recently  should  be  sub- 
jected to  a  senseless  so-called  examination  by  one  of  the 
several  State  boards  for  the  ostensible  purpose  of  experi- 
mentation. So  far  as  its  protective  features  go  for  the 
people  at  large,  it  is  simply  a  sham.  The  author  can. 
name  three  examiners  on  one  of  the  most  prominent 
State  boards  who  never  attended  but  two  five-month 
terms  of  lectures  in  their  lives.  Every  physician  in  prac- 
tice knows  how  soon  he  forgets  many  of  the  even  impor- 
tant details  of  a  subject,  and  how  soon  he  gets  notions 
peculiar  perhaps  only  to  himself.  Is  it  just  to  expect 
such  men  to  be  able  to  give  a  student  graduating  from  a 
well  conducted  school  an  impartial  and  strictly  righteous 
test  ?  We  believe  it  to  be  neither  fair  for  examiner  nor 
for  the  student.  The  whole  idea  of  State  board  exami- 
nation is  a  sham,  and  will  surely  be  exploded  ere  many 
years,  as  it  most  heartily  deserves  to  be. 

One  good  general  law  providing  for  the  regulation  of 
the  number  of  medical  colleges,  the  establishment  of  a 
certain  adequate  standard,  the  abolition  of  quackery,  and 
one  fair  but  very  thorough  collegiate  test  by  a  combined 
board  of  faculty  of  college  and  corresponding  State  au- 
thorities would  do  more  good,  give  better  satisfaction  to 
the  profession,  afford  at  least  more  than  a  show  of  real 
protection  to  the  people,  and  be  vastly  fairer  to  those 
young  men  and  women  who  filled  the  requirements.  In 
addition,  no  good  reason  can  be  given  why  one  such  test 
should  not  be  accepted  as  satisfactory,  wherever  the  per- 
son interested  might  wish  to  locate  and  practise. 

W.  C.  McGee,  M.D. 

Littlk  Sandusky,  O. 


CLIMATE    AS    AFFECTING    THE    PRINCIPLES 
OF  APPLIED  THERAPEUTICS. 

To  thb  Editor  of  thr  Medical  Record. 

Slr:  Too  much  attention  is  given  by  the  teacher  of 
therapeutics,  in  the  average  medical  school,  to  exact 
dosage,  minimum  and  maximum  doses,  and  the  specific 
action  of  drugs,  and  not  enough  to  the  circumstances 
which  may  attend  any  case  to  which  a  physician  may  be 
called. 

The  beginning  practitioner  is  all  at  sea.  He  has  been 
taught  that  he  can  accomplish  certain  or  positive  results 
by  the  use  of  such  therapeutic  agents  as  have  come  into 
use  in  the  progress  of  medicine.  Accordingly,  he  gives 
a  dose  and  then  watches  for  it  to  act  characteristically 
and  immediately,  as  he  would  watch  the  dial  of  a  steam 
gauge  when  a  fire  is  built  in  the  furnace  of  a  steam  boiler. 
Not  getting  the  expected  result,  he  mumbles  "  idiosyn- 
crasy "  to  himself  and  tries  another  drug.  He  hops  from 
one  to  another  and  is  tortured  by  anxiety,  fear  of  failure, 
dread  of  public  condemnation,  etc.  If  he  is  so  fortunate 
as  to  meet  with  cases  which  would  not  require  any  prompt 
and  decided  measures  until  he  can  begin  to  shape  his 
senses  and  learn  the  practical  use  of  drugs,  he  will  gradu- 
ally learn  that  which  ought  by  some  means  to  have  been 
taught  him  in  college,  but  which  seldom  or  never  is 
taught. 

How  few  authors  or  teachers  of  medicine  ever  consider 
the  matter  of  how  climate  may  influence  the  action  of 
drugs,  or  of  what  particular  drugs  may  be  modified  in 
their  action  by  differences  in  climate.  The  text  or  teacher 
says  that  a  certain  drug  produces  such  an  effect  if  given 
in  such  a  dose,  at  such  a  time  of  the  day.  Its  action  is 
modified  by  the  diet  of  the  patient,  perhaps  by  the  dis- 
ease from  which  he  is  suffering,  and  by  some  other  drugs 
which  should,  or  should  not,  as  the  case  may  be,  be  ad- 
ministered along  with  the  drug  under  consideration. 
Then  follows  a  list  of  the  uses  of  the  drug,  but  seldom  a 


list  of  the  abuses  of  the  same,  which  would  be  of  vastly 
more  importance  to  the  student  and  patients. 

Drugs,  which  in  New  England,  the  Middle,  and  upper 
Mississippi  Valley  States  produce  a  characteristic  action, 
may  utterly  fail  to  characterize  themselves  in  the  South 
or  on  the  Pacific  coast.  Cathartics  which,  in  the  States 
east  of  the  Rocky  Mountains  and  above  Mason  and 
Dixon's  line,  produce  their  effect  when  given  in  such 
doses  as  are  prescribed  by  the  faculty  in  those  regions, 
produce  small  or  no  effect  on  the  Pacific  coast  Nar- 
cotics are  less  effectual  here  and  more  depressing  in 
their  subsequent  effects.  The  much  lauded  and  most  ex- 
cellent system  of  milk  diet  is  limited  to  a  minority  of  the 
class  of  cases  to  which  it  would  be  applicable  in  other 
portions  of  our  country.  Many  small  children  will  not 
take  milk  when  well,  and  cannot  take  it,  no  matter  what 
the  process  of  preparing  it  may  be,  when  they  are  sick. 
While  the  climate  here  is  such  that  butter  seldom  gets 
rancid  or  unpalatably  soft,  even  when  subjected  to  the 
ordinary  temperature  of  the  air,  yet  milk  from  healthy 
cows,  and  handled  and  kept  in  the  most  cleanly  manner, 
will  ferment  and  curdle  in  less  than  twelve  hours,  unless 
scalded  or  boiled.  People  who  were  fond  of  milk  as  an 
article  of  diet  on  the  other  side  of  the  Rockies  come  to 
dislike  it  here.  Very  few  native-born  Californians  ever 
touch  milk  after  once  becoming  accustomed  to  a  general 
diet.  Very  few  can  take  milk  when  sick.  It  is  a  most  ex- 
asperating affair  at  times  to  find  a  suitable  diet  for  the 
sick.  As  a  rule,  meat  broths,  free  from  fat  and  reasona- 
bly condensed,  administered  in  quantity  of  from  three  to 
five  ounces  to  an  adult  every  two  or  three  hours,  is  our 
mainstay  in  the  class  of  cases  which  we  are  told  to  keep  on 
milk  in  the  East.  The  milk  will  curdle  in  tough  masses 
and  be  vomited,  or  set  up  a  diarrhoea  clue  to  fermentation 
and  sadly  aggravate  the  case. 

Lobar  pneumonia  and  capillary  bronchitis  axe  more 
frequent  than  other  forms  of  acute  pulmonary  disease. 
Pneumonia  rarely  gives  as  high  a  temperature  here,  or  as 
characteristic  symptoms  as  in  countries  having  rigorous 
winters,  and  rarely  terminates  by  crisis,  but  by  lysis. 

It  is  harder  to  decide  upon  the  proper  time  to  admin- 
ister stimulants,  and  a  greater  quantity  will  be  tolerated 
than  in  the  eastern  portion  of  the  United  States. 

All  diseases  are  apt  to  follow  a  slower  course  than  in 
the  East,  and  convalescence  is  much  slower  and  less  sure. 

In  regard  to  the  much  lauded  climates  of  the  South- 
west, to  which  many  patients  are  shipped  who  are  suf- 
fering from  pulmonary  troubles,  I  feel  sure  that  few  phy- 
sicians would  continue  to  send  patients  there  if  they 
could  see  the  country.  The  mental,  moral,  and  physi- 
cal conditions  are  all  depressing  to  any  new-comer,  un- 
less he  be  philosophical  enough  to  make  the  best  of  the 
poverty  of  nature.  The  alkali  dust,  barren  plains,  hot 
days,  and  cold  nights,  with  ragged  Indians,  dirty,  ragged, 
nomadic,  mixed  inhabitants,  poor  food,  poor  accommo- 
dations, absence  from  home  and  friends,  strange  climate, 
and  fatigue  of  a  long  journey,  make  a  combination  of 
most  unsuitable  circumstances  for  an  invalid.  The  tour- 
ist on  a  pleasure  excursion  sees  only  the  best,  hears  the 
best,  tastes  the  best,  and  believes  the  best.  More  can  be 
done  for  pulmonary  cases,  especially  when  the  disease  is 
well  advanced,  by  keeping  them  in  a  pleasant,  well- ven- 
tilated room,  kept  at  a  constant  temperature  throughout 
the  twenty-four  hours,  and  the  best  hygienic  measures 
carried  out,  together  with  such  remedies  as  the  necessity 
of  the  case  may  require  from  time  to  time,  than  in  any 
or  all  of  the  health  resorts  of  the  earth.  This  may  not 
be  the  popular  view  of  the  case,  but  it  is  the  practical 
side  of  it. 

E.  A.  Smith,  M.D. 

Santa  Claka,  Cal.,  August  13,  1894. 


The  Value  of  a  Doctor's  Health.— Dr.  W.  S.  Lump- 
kin, of  Atlanta,  Ga.,  sued  that  city  for  $  10,000  damages, 
alleging  that  the  injurious  fumes  from  an  open  sewer  had 
ruined  his  health.  The  jury  found  in  his  favor  to  the 
amount  of  $400. 


3i« 


MEDICAL   RECORD. 


[September  8,  1894 


f^edical  Stems. 

Contagious  Diseases— Weekly  Statement— Report  of 
cues  and  deaths  from  contagious  diseases  reported  to  the 
Sanitary  Bureau,  Health  Department,  for  the  week  end- 
ing September  1,  1894. 


Cuat. 

Deaths. 

62 

108 

33 

14 

17 

3 

0 

4 

14 

a 

113 

33 

13 

2 

Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis . 

Measles 

Diphtheria 

Small-pox 


Quackery  is  rampant  in  Paris,  though,  perhaps,  they 
have  not  as  many  faith  healers  and  itinerant  impostors  as 
we  have  in  America ;  yet  there  is  a  larger  proportion  of 
regularly  educated  physicians  who,  weary  of  the  restraints 
imposed  by  the  regular  profession,  boldly  announce  their 
wares  through  every  sort  of  advertising  medium.  And 
why  should  they  not,  when  the  venerable  scientist, 
Brown -Sequard,  is  the  greatest  sinner  of  them  all? 
Everywhere,  on  lamp-posts,  in  urinals,  in  railway  sta- 
tions, and  in  the  most  out-of  the-way  places  along  railroad 
lines,  in  every  direction,  one  will  see  large  banner  posters 
advertising  the  "  Sue  de  Brawn  Sequard;  tres  pre- 
cieux,"  etc.,  for  nervousness,  diminished  sexual  power  in 
men  or  women,  old  or  young. — Paris  Correspondent  of 
Medical  and  Surgical  Reporter. 

Dr.  L.  C.  Lane  is- the  leader  of  the  Cooper  school  fac- 
tion of  the  profession  in  San  Francisco.  He  has  recently 
donated  a  handsome  hospital  to  Cooper  Medical  College, 
which  college  already  occupies  a  handsome  building  for 
college  purposes,  donated  by  Dr.  Line.  A  marble  tab- 
let in  the  auditorium  of  the  college  informs  the  reader 
that  the  building  was  erected  out  of  funds  earned  by  Dr. 
Lane  in  his  profession.  As  the  site  and  buildings  must 
have  cost  on  toward  a  half-million  of  dollars,  Dr.  Lane 
has  likely  made  more  money  out  of  his  professional  work 
than  any  other  medical  man  who  has  ever  lived. — Medi- 
cal Sentinel. 

Portland's  Hospitals. — While  we  have  much  to  felici- 
tate ourselves  upon  regarding  the  character  of  the  work 
of  our  Portland  hospitals,  says  the  Medical  Sentinel,  yet  a 
visit  to  a  city  of  any  considerable  size,  or  to  a  city  the 
size  of  Portland,  will  convince  anyone  that  in  numbers, 
at  least,  Portland  falls  far  behind  in  this  matter.  Take 
San  Francisco,  for  instance.  A  half-dozen  hospitals 
there  are  equal,  for  San  Francisco,  to  what  the  hospitals 
here  are  for  Portland.  Their  larger  capacity  will  com- 
pensate for  the  difference  in  the  size  of  the  two  cities. 
But  beyond  these  there  are  about  twenty  five  other 
hospitals  in  San  Francisco.  It  is  quite  likely  that  a 
number  have  to  struggle  vigorously  to  subsist,  but  the 
fact  that  they  do  subsist  year  after  year,  is  evidence 
that  there  is  a  place  for  them.  •»  A  city  has  to  reach  a 
certain  size  before  hospitals  devoted  to  special  lines,  or 
managed  for  special  nationalities  or  civic  divisions  of 
mankind  will  flourish.  Portland  is  fast  approaching  such 
period.     It  may  have  reached  it. 

Sterilization  of  Catgut  by  Heat.— Professor  M.  Schul- 
ler,  of  Berlin,  says  (Aerztl.  Praktiker,  No  30,  1894)  that 
the  question  of  sterilization  of  catgut  is  of  importance 
not  only  to  the  surgeon  and  gynecologist,  but  to  every 
general  practitioner.  The  physician  should  not  content 
himself  with  the  material  offered  by  druggists  and  dealers 
in  surgical  supplies,  but  he  should  be  able  to  sterilize  it 
himself.  The  methods  thus  far  employed  to  sterilize 
catgut  are  tedious,  and  for  the  most  part  unreliable.  The 
author  first  tried  dry  heat,  but  gave  this  up  as  being  too 
tedious.  He  then  experimented  with  hot  fluid,  of  differ- 
ent kinds.     None  proved  as  satisfactory  as  oleum  lavan- 


dulae,  an  ethereal  oil  free  from  oxygen  and  of  very  agree- 
able odor.  Catgut  loosely  rolled  up  in  rings  is  placed  in 
a  wide-mouthed  bottle  containing  lavender  oil.  The 
bottle  is  to  be  filled  up  to  the  stopper,  which  latter 
is  to  touch  the  surface  of  the  oil.  Care  is  to  be  taken 
that  all  the  catgut  in  the  bottle  is  well  covered,  because 
parts  which  have  been  above  the  surface  of  the  oil 
during  the  process  of  sterilization  will  become  brittle. 
The  bottle,  hermetically  closed,  is  placed  in  the  steam 
sterilizer  and  there  subjected  for  a  half  hour  to  a  temper- 
ature of  from  106  to  no°  C.  The  catgut  having  been 
sterilized  in  this  manner  is  supple  and  does  not  tear  under 
ordinary  force.  The  catgut  is  removed  from  the  bottle 
by  means  of  sterilized  forceps  for  immediate  use,  or  to  be 
placed  in  sterilized  water  or  in  carbolic  acid  solution 
until  needed  for  use.  The  lavender  oil  possesses  the 
special  advantage  over  many  other  fluids,  especially  oils, 
in  that  the  same  oil  can  be  used  repeatedly. 

Prize  Essay  of  the  Colorado  State  Medical  Society. 
— The  conditions  for  the  $100  Prize  Essay  voted  by 
the  Colorado  State  Medical  Society  (June  21,  1894)  on 
the  following  subject :  "  The  Diagnoses  of  Tuberculosis 
by  Microscopic  Examination  of  the  Blood."  Prefeteoce 
to  be  given  to  new  evidence  and  the  detection  of  the 
pretubercular  stage.  All  stages,  however,  to  be  included 
and  microscopically  differentiated.  Paper  to  be  con- 
densed to  read  in  thirty  minutes  time ;  to  be  typewritten 
and  the  authorship  kept  secret  till  the  award  of  tjie  ex- 
amining committee  is  made  known.  Prize  open  to  any- 
one; essay  to  be  written  in  the  English  language  in 
comprehensive  style  and  as  free  from  purely  technical 
expressions  as  possible ;  accuracy  of  definition  and  clear- 
ness of  diction  considered.  The  committee  to  reserve 
the  award  for  an  essay  they  deem  sufficiently  meritorious, 
i.e.,  the  rules  to  be  observed  enabling  a  diagnosis  to  be 
made  from  the  blood  alone  without  the  patient  being 
seen.  A  prize  committee  of  three  was  appointed,  Drs. 
Charles  Denison,  H.  A.  Lemen,  both  of  Denver,  and 
Dr.  S.  E.  Solly,  of  Colorado  Springs.  (Dr.  L.  A.  Fisk, 
of  Denver,  alternate),  and  all  essays  to  be  handed  in 
under  seal  by  April  1, 1895. 

The  following  test  is  suggested  as  not  unreasonable : 
Seven  persons  being  in  one  room,  representing,  respec- 
tively, a  person  in  health,  a  case  of  anaemia,  one  of 
leucocythemia,  one  pretubercular,  and  three  representing 
the  three  stages  of  consumption  i.e.,  1st,  infiltration,  2d, 
softening,  and  3d,  excavation  (advanced  and  extensive). 
In  another  room  the  microscopic  examination  of  the 
blood  of  several  of  those,  to  determine  from  whom  the 
specimens  were  taken.  It  is  expected  that  the  ordinary 
use  of  the  },  -fo,  ^ ,  or  ^  immersion  lenses  will  answer. 
If  not  and  there  is  any  doubt,  full  explanations  as  to 
instruments  or  lenses  used  should  be  furnished. 

The  Association  of  American  Medioal  Colleges. — 
Resolutions  adopted  at  a  meeting  held  in  San  Francisco, 
Cal.t  June  7,  1894. 

Resolved,  That  colleges,  members  of  this  Association, 
shall  require  of  all  matriculates  an  examination  as  fol- 
lows :  1.  An  English  composition  in  the  handwriting  of 
the  applicant  of  not  less  than  two  hundred  words ;  said 
composition  to  include  construction,  punctuation,  and 
spelling.  2.  Arithmetic,  fundamental  rules,  common 
and  decimal  fractions,  and  ratio  and  proportion.  3. 
Algebra — through  quadratics.  4.  Physics— elementary 
— ^age-  5*  Latin — An  amount  equal  to  one  year's 
study,  as  indicated  in  Harkness  Latin  reader.  (The 
above  resolution  does  not  apply  to  students  exempt 
from  the  entrance  examination,  as  per  Sec.  2,  Art.  III.) 

Resolved,  That  the  following  classes  of  students  be 
recognized  as  entitled  to  apply  for  advanced  standing  in 
colleges  members  of  this  body:  a.  Such  graduates  of 
recognized  colleges  and  universities  as  have  completed 
the  prescribed  courses  in  chemistry  and  biology  therein. 

b.  Graduates  and  matriculates  of  colleges  of  homoeopathy. 

c.  Graduates  and  matriculates  of  colleges  of  eclectic 
medicine,    d.  Graduates  and  matriculates  of  colleges  of 


September  8,  1894] 


MEDICAL   RECORD. 


3i9 


dentistry  requiring  tiro  or  more  courses  of  lectures  before 
conferring  the  degree  of  D.D.S.  e.  Graduates  and  ma- 
triculates of  colleges  of  pharmacy.  /.  Graduates  and 
matriculates  of  colleges  of  veterinary  medicine.  It  is 
provided,  however,  that  the  above  class  of  students  be 
required  to  comply  with  the  provisions  of  the  entrance 
examination,  and  to  prove  their  fitness  to  advanced  stand- 
ing by  an  individual  examination  upon  each  branch 
below  the  class  he  or  she  may  desire  to  enter. 

Resolved,  That  students  graduating  in  1899  or  subse- 
quent classes,  be  required  to  pursue  the  study  of  medicine 
four  years,  and  to  have  attended  four  annual  courses  of 
lectures  of  not  less  than  six  months'  duration  each. 

The  Medical  Profession  in  Texas  is  not  a  Unit,  if  we 
may  be  allowed  to  form  a  conclusion  from  a  perusal  of 
the  pages  of  the  Texas  Health  Journal  In  the  issue  for 
July  Dr.  Cunningham  has  an  article  with  the  vigorous 
title :  "  The  Amazing  Infatuation  of  the  Texas  State 
Medical  Association  in  Pompously  Parading  its  Appalling 
Ignorance  of  the  First  Principles  of  Sanitary  Legislation  ; 
and  its  Unbounded  Cheek,  and  Unmitigated  Gall  in 
Presuming  to  Instruct  Congress  in  the  Proper  Perform  - 
formance  of  its  Duties — Succinctly  Set  Forth.1 ' 

The  Physicians  of  Louisville  are  obliged  to  pay  a  li- 
cense fee  of  1 10  a  year  to  the  city. 

Penetrating  Wound  of  the  Abdomen. — Dr.  Dumitru 
Popescu  reports  in  Spitalul,  No.  12,  1894,  the  case  of  a 
peasant  sixty-five  years  old  who  fell  from  a  hay-rick,  im- 
paling himself  upon  a  pitch-fork,  one  prong  of  which 
passed  through  the  abdomen.  He  remained  suspended  for 
a  time,  until  the  weight  of  his  body  broke  the  prong  and 
he  fell  to  the  ground.  After  himself  pulling  out  the 
penetrating  body  he  went  home,  and  five  days  later  ap- 
plied for  relief  at  the  hospital.  The  abdominal  wound 
was  suppurating  and  there  were  symptoms  of  intestinal 
strangulation.  Laparotomy  being  performed,  there 
were  found  to  be  some  adhesions  and  a  hernia  of  the 
epiploon  through  the  rectus  muscle.  The  strangulation 
was  relieved,  and  the  inflamed  epiploon  severed,  and  the 
peritoneal  cavity  thoroughly  irrigated  with  sterilized 
water.  The  man  made  a  good  recovery.  The  fork  had 
entered  in  the  left  hypochondrium,  and  passing  through 
the  abdomen,  had  again  penetrated  the  peritoneum  and 
torn  the  rectus  muscle,  but  had  been  then  arrested  by 
the  elasticity  of  the  skin. 

The  Michigan  "Jag  Cure  Act. "—The  Legislature  of 
Michigan  recently  enacted  a  curious  statute  known  as 
the  "Jag  Cure  Act."  It  allows  a  justice,  upon  the  con- 
viction of  a  disorderly  person,  instead  of  requiring  a  re- 
cognizance for  good  behavior,  to  accept  recognizance 
conditioned  that  the  defendant  will  take  the  cure  for  the 
liquor  habit  in  conformity  with  the  rules  and  regulations 
of  some  corporation  administering  the  cure.  The  su- 
preme court  of  Michigan  has  held  the  act  unconstitu- 
tional, on  the  ground  that  it  remits  the  nature  and  extent 
of  the  punishment  to  the  determination  of  the  fluctuat- 
ing rules  of  a  private  corporation,  and  transfers,  in  a 
measure,  the  pardoning  power  of  the  governor  to  that 
body. — Scientific  American. 

Treatment  of  Gonorrhoea  at  the  Hooker  Hospital — 
At  the  Necker  is  the  most  complete  arrangement  for  the 
study  of  gonorrhoea  to  be  found  in  Europe.  The  clinic 
is  under  the  charge  of  Professor  Guyon,  while  the  out- 
patients' department  is  conducted  by  Dr.  Ganet. 

Each  case  is  thoroughly  examined  physically  and  the 
discharges  microscopically  before  treatment  is  given,  care- 
ful histories  taken,  and  all  changes  in  treatment  recorded. 
As -the  daily  clinic  is  large,  the  statistics  from  such  a 
place  should  be  exceeding  valuable  and  reliable. 

The  irrigators  proposed  by  Professor  Guyon  are  in  con- 
stant use,  both  in  acute  and  chronic  gonorrhoea  and  in 
cystitis.  The  liquid  is  placed  one  and  one-half  yard  (or 
metre)  above  the  bed  or  table  upon  which  the  patient 
lies,  and  the  force  thus  obtained  is  sufficient  to  convey 
die  liquid  into  the  bladder,  a  small  glass  tip  at  the  end 


of  the  rubber  tube  being  held  firmly  in  the  meatus.  In 
this  manner  he  uses  the  potassium  permanganate  treat- 
ment. From  one  to  two  litres  of  a  watery  solution  of 
potassium  permanganate,  in  varying  strengths,  from  1  to 
4,000  to  1  to  1,000,  depending  upon  the  stage  of  the 
disease,  are  passed  into  the  bladder  once  or  twice  daily, 
the  patient  raising  himself  to  a  sitting  posture  and 
emptying  his  bladder  from  time  to  time.  In  this  way  ' 
the  bladder  may  be  thoroughly  irrigated  without  the 
passage  of  a  catheter,  which,  in  cases  of  stricture,  will 
often  be  of  considerable  advantage.  In  the  same  way 
solutions  of  silver  nitrate  (1  to  1,000),  and  of  sublimate 
(1  to  5,000),  are  used  in  cystitis.  Professor  Guyon  also 
uses  stronger  solutions  of  silver  nitrate  (one  per  cent,  to 
five  per  cent.)  and  of  cupric  sulphate  (two  per  cent,  to 
seven  per  cent.)  in  obstinate  cases  of  gonorrhoea. — Paris 
Correspondent  TTierapeutic  Gazette. 

Cauterizing  Ovaries  instead  of  Removal  of  them. — 
Dr.  Pozzi,  at  Hopital  Broca,  has  now  practised  cauteri- 
zation of  painful  ovaries  for  over  two  years,  and  consideis 
the  plan  very  successful  In  one  case,  in  which  he 
operated  upon  both  ovaries,  the  woman  has  since  given 
birth  to  a  child.  He  performs  his  laparotomies  in  the 
ordinary  recumbent  position ;  -draws  the  ovaries  out  of 
the  abdominal  opening.  If  the  ovary  is  totally  diseased 
he  removes  it ;  but  if  a  part  is  found  to  be  healthy,  he 
amputates  the  affected  portion,  cauterizes  the  stump, 
then  sews  the  end  with  silk.  If  there  are  some  small 
cysts,  he  opens  them  by  touching  with  the  Paquelin 
point.  The  ovary  being  returned  to  the  abdomen,  he 
examines  and  treats  the  other  in  a  similar  manner. 
Often  as  many  as  six  small  cysts  are  opened  in  this  way 
in  each  ovary. — Paris  Correspondent  Therapeutic 
Gazette. 

Old  Age  and  the  Death-rate. — Only  906  persons  in 
a  million  die  from  senility,  while  1,200  succumb  to  gout, 
18,400  to  measles,  27,000  to  apoplexy,  7,000  to  erysipe- 
las, 7,500  to  consumption,  48,000  to  scarlet  fever,  25,000 
to  whooping-cough,  30,000  to  typhoid  and  typhus,  and 
7,000  to  rheumatism.  The  averages  vary  accord- 
ing to  locality,  but  these  are  deemed  pretty  accurate  as 
regards  the  population  of  the  globe  as  a  whole. — Medical 
Age. 

Lady  Mary  Wortley  Montagu  on  Inoculation.— In 
an  article  in  the  Popular  Science  Monthly  for  July, 
1894,  Mrs.  Plunkett  quotes  the  following  account  of 
small-pox  inoculation  from  Lady  Mary  Montagu's  let- 
ters :  "  Apropos  of  distempers,  I  am  going  to  tell  you  of 
a  thing  that  I  am  sure  will  make  you  wish  yourself  here. 
The  small-pox,  so  general  and  so  fatal  among  us,  is  en- 
tirely harmless  here  by  the  invention  of  ingrafting,  which 
is  the  term  they  give  it  here.  There  is  a  set  of  old 
women  who  make  it  their  business  to  perform  the  opera- 
tion in  the  month  of  September,  when  the  great  heat  is 
abated.  People  send  to  one  another  to  know  if  any  of 
their  family  has  a  mind  to  have  the  small  pox.  They 
make  parties  for  the  purpose,  and  when  they  are  met — 
commonly  fifteen  or  sixteen  together — the  old  woman 
comes  with  a  nutshell  full  of  the  matter  of  the  best  sort 
0/  small-pox,  and  asks  what  vein  you  will  please  to  have 
opened.  She  immediately  rips  open  the  one  that  you 
offer  to  her  with  a  large  needle,  which  gives  you  no 
more  pain  than  a  common  scratch,  and  puts  into  the 
vein  as  much  venom  as  can  lie  upon  the  head  of  her 
needle,  and  after  binds  up  the  little  wound  with  a  hol- 
low bit  of  shell,  and  in  this  manner  opens  four  or  five 
veins.  The  Grecians  have  commonly  the  superstition  of 
opening  one  in  the  middle  of  the  forehead  and  in  each 
arm  and  on  the  breast,  to  make  the  sign  of  the  cross ; 
but  this  has  a  very  ill  effect,  all  the  wounds  leaving  little 
scars,  and  is  not  done  by  those  that  are  not  superstitious, 
who  choose  to  have  them  in  the  legs  or  in  that  part  of 
the  arm  that  is  concealed.  The  children  or  young  pa- 
tients play  together  all  the  rest  of  the  day,  and  are  in 
perfect  health  till  the  eighth ;  then  the  fever  begins  to 
seize  them,  and  they  keep  their  beds  two  days,  very 


3*o 


MEDICAL    RECORD. 


[September  8,  1894 


seldom  three.  They  have  very  rarely  above  twenty  or 
thirty  in  their  faces,  which  never  mark ;  and  in  eight 
days'  time  are  as  well  as  before  their  illness.  Where 
they  are  wounded  there  remain  running  sores  during 
their  distemper,  which  I  doubt  not  is  a  great  relief  of  it. 
Every  year  thousands  undergo  this  operation,  and  the 
French  ambassador  says  that  they  take  the  small-pox 
here  by  way  of  diversion,  as  they  take  the  waters  in 
other  countries." 

Restriction  on  the  Sale  of  Patent  Medicines.— A  bill 
has  been  introduced  in  the  Iowa  Legislature  providing 
that  every  patent  medicine  offered  for  sale  in  that  State 
shall  have  a  printed  statement  on  the  wrapper  giving  the 
ingredients  of  the  preparation.  The  penalty  for  dis- 
obedience to  this  law  is  a  fine,  not  exceeding  $  100,  or 
imprisonment  for  six  months  in  the  penitentiary. 

Strophanthus  is  recommended  by  Dr.  Skworzow  in 
the  treatment  of  inebriety.  In  the  few  cases  in  which 
he  has  tried  it,  it  was  given  in  seven-drop  doses  of  the 
tincture.  It  gave  rise  to  vomiting  and  profuse  dia- 
phoresis and  quickly  excited  a  distaste  for  alcohol  which 
was  said  to  persist  after  the  withdrawal  of  the  drug. 

Unequal  Dilatation  of  the  Pupils  is  regarded  by 
Dentrfe  as  a  sign  of  great  value  in  the  diagnosis  of  pul- 
monary tuberculosis.  It  is  present,  he*  says,  in  the 
majority  of  cases  of  this  disease. 

Books  as  Carriers  of  Infection.— Dr.  McNicoll,  an 
English  health  officer,  states  in  a  recent  report  that  a 
book  was  kept  under  the  pillow  of  a  small- pox  patient 
until  his  death.  It  was  then  taken  in  charge  by  his  son, 
who  lived  in  another  part  of  the  town,  and  after  being 
kept  without  disinfection  for  four  weeks  in  his  house, 
was  offered  for  sale  to  an  artisan,  who  kept  it  overnight. 
While  there  the  artisan's  wife  perused  the  book,  with  the 
result  that,  fourteen  days  later,  she  developed  the  rash  of 
small-pox. 

BOOKS   RECEIVED. 

Manual  of  Practical  Anatomy:  Upper  Limb,  Lower 
Limb,  Abdomen.  By  D.  J.  Cunningham.  Vol  I.  660  pages, 
8vo,  illustrated.  Published  by  Young  J.  Pentland,  Edinburgh  & 
London.  Imported  by  J.  B.  Lippincott  Company,  Pa.  Price, 
$7.00. 

Manual  op  Practical  Anatomy  :  Thorax,  Head,  and 
Neck.  By  D.  J.  Cunningham,  M.D.  Vol.  II.  8vo,  647  pages, 
illustrated.  Published  by  Young  J.  Pentland,  Edinburgh  ana  Lon- 
don.    Imported  by  J.  B.  Lippincott  Company,  Philadelphia,  Pa. 

Clinical  Medicine  :  A  Manual  for  the  Use  of  Students 
and  Junior  Practitioners.  By  Dr.  Judson  S.  Bury,  London. 
8vo,  468  pages,  illustrated.  Published  by  J.  B.  Lippincott  Com- 
pany, Philadelphia,  Pa.     Price,  $6.50. 

Diseases  of  the  Nose  and  Throat.  By  F.  De  Havilland 
Hall,  M.D.  8vo,  524  pages,  illustrated.  Published  by  P.  Blakis- 
ton, Son  8c  Co.,  Philadelphia,  Pa.     Price,  $3.00. 

Human  Physiology.  By  John  Thornton,  M.A.  8vo,  436 
ages,  illustrated  Published  by  Longmans,  Greene  &  Co.,  New 
fork.     Price,  $1.50. 

Transactions  of  the  Fifteenth  Annual  Meeting  of  the 
American  Laryngological  Association,  held  in  the  City 
of  New  York,  May  22,  23,  and  24,  1893.  8vo,  165  pages,  illus- 
trated.    Published  by  D.  Applet  on  &  Co.,  New  York. 

The  Diseases  of  the  Will.  By  Th.  Ribot.  8vo,  134 
pages.  Published  by  the  Open  Court  Publishing  Co.,  Chicago,  111. 
Price,  75c. 

Small  Hospitals.  Establishment  and  Maintenance.  By 
Dr.  A.  Worcester.  And  Suggestions  for  Hospital  Archi- 
tecture, with  Plans  for  a  Small  Hospital.  By  William 
Atkinson,  Architect,  8vo,  114  pages,  illustrated.  Published  by 
John  Wiley  &  Sons,  New  York.     Price,  $1.25. 

An  Illustrated  Dictionary  of  Medicine,  Biology,  and 
Allied  Sciences,  Including  Pronunciation,  Accentuation, 
Derivation,  and  Definition  of  the  Terms  Used  in  Medi- 
cine, Surgery,  Anatomy,  Etc.  By  George  M.  Gould,  M.D. 
Royal  octavo,  1,633  pages,  illustrated.  Publishers,  P.  Blakiston, 
Son  &  Co,  Philadelphia,  Pa.  Price,  Full  Sheep,  net,  $10.00; 
Half  Morocco,  net,  $10.00;  Half  Russia,  with  Thumb  Index,  net, 
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Medical  Chemistry.  By  Elias  H.  Bartley,  M.D.  Third 
Edition.  8vo,  684  pages,  illustrated.  Published  by  P.  Blakiston, 
Son  &  Co.     Price,  $3.00. 


page 
Yorl 


Text  Book  of  Abdominal  Surgery.  A  Clinical  Manual 
for  Practitioners  and  Students.  By  Skene  Keith,  F.R.C.S. 
Edin.,  assisted  by  George  E.  Keith,  M.B.,  CM.  8vo,  jo8  pages, 
illustrated.  Published  by  J.  B.  Lippincott  Company,  Philadelphia, 
Pa. 

Index-Catalogue  of  the  Library  of  the  Surgeon-Gen- 
eral's Office,  United  States  Army.  VoL  XV.  Royal  oc- 
tavo, 842  pages.     Washington,  D.C 

Retrospect  of  Surgery.  By  Francis  J.  Shepherd,  M.D. 
8vo,  259  pages.     E.  M.  Renouf,  Montreal,  Can. 

Essentials  of  Anatomy.  By  Charles  B.  Nancrede,  M.D. 
8vo,  388  pages.  Illustrated.  W.  B.  Saunders,  Philadelphia,  Pa. 
Price,  $1.00. 

Essentials  of  Nervous  Diseases  and  Insanity.  By  John 
C.  Shaw.     8vo,  194  pages.     Illustrated.     W.  B.  Saunders. 

Practical  Lectures  in  Dermatology.  By  Condict  W. 
Cutler,  M.D.  8vo,  233  pages.  G.  P.  Putnam's  Sons,  New  York. 
Price,  $2.00. 

Uric  Acid  in  Causation  of  Disease.  By  Alexander  Haig. 
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Price,  10s.  6d. 

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A  Manual  of  Instructions  in  the  Principles  of  Prompt 
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A  Clinical  Manual.  By  Dr.  Andrew  MacFarlane.  8vo,  139 
pages.  Illustrated.  G.  P.  Putnam's  Sons,  New  York  City.  Price, 
$1.25. 

Diseases  of  the  Skin.  By  Malcolm  Morris.  8yo,  555  pages. 
Illustrated.     Lee  Bros.  &  Co.,  Philadelphia. 

Bee  Line  Repertory.  By  Stacy  Jones,  M.D.  i6mo,  210 
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An  International  System  of  Electro-Therapeutics  for 
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edition.  8vo,  780  pages.  Published  by  H.  K.  Lewis,  London, 
England.     Price,  21s, 

Essentials  of  Diseases,  Eye,  Nose,  and  Throat.  By 
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pages.  Illustrated.  Published  by  W.  B.  Saunders,  Philadelphia, 
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Transactions  of  the  Indiana  State  Medical  Society, 
1893.     8vo,  378  pages.     Indianapolis,  Ind. 

Atlas  de  Laryngologie  et  de  Rhinologie.  By  A.  Gonguen- 
heim,  and  J.  Glover.  Quarto,  illustrated.  Published  by  G.  Masson, 
editeur,  120  Saint  Germain,  Paris,  France.     1  Vol.     Price,  50  fr. 

Precis  de  Clinique  Thbrapeutique.  By  le  Dr.  A.  F.  Plicque. 
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Transactions  of  the  Association  of  American  Physi* 
cians.     Vol.  IX.,  1894.     Held  at  Washington. 

Beard's  Nervous  Exhaustion  (Neurasthenia).  Third  and 
enlarged  edition.  By  George  M.  Beard,  M.D.  Edited,  with  Notes 
and  Additions,  by  A.  D.  Rockwell,  M.D.  8vo,  292 pages.  E.  B. 
Treat,  New  York  City. 

Hand-book  of  Obstetric  Nursing.  By  Francis  W.  N. 
Haultain,  M.D.,  and  Tames  Haig  Ferguson,  M.D.  Small  octavo, 
243  pages.     Illustrated.     J.  B.  Lippincott  Co.     Price,  $1.00, 

Transactions  of  the  Medical  Society  of  th*  State  of 
California.     Session  of  1894.     San  Francisco,  Cal. 

A  Treatise  on  Appendicitis.  By  George  R.  Fowler,  M.D. 
8vo,  190  pages.  Illustrated.  Published  by  J.  B.  Lippincott  Co., 
Philadelphia.   Price,  $2.00. 

The  Science  of  Vital  Force.  By  W.  R.  Dunham,  M.D. 
i2mo,  198  pages.     Published  by  Damrell  &  Upham,  Boston. 

Sharp's  Tracts  on  Homceopathy.  8vo,  232  pages,  Pub- 
lished by  Boericke  &  Tafel,  Philadelphia,  Pa.     Price,  75c. 

A  System  of  Genito  Urinary  Diseases,  Syphilology,  and 
Dermatology.  By  various  authors.  Edited  by  Prince  A.  Mor- 
row, A.M.,  M.D.  8vo,  976  pages.  Illustrated.  Published  by  D. 
Appleton  &  Co.,  New  York  City. 


Medical   Record 

4  Weekly  yournal  of  Medicine  and  Surgery 


Vol.  46,  No.  11. 
Whole  No.  1245. 


New  York,  September  15,  1894. 


$5.00  Per  Annum. 
Single  Copies,  ioc. 


©riflitml  %xXit\zs. 

REPORT  TO  THE  NEW  YORK  CITY  HEALTH 
DEPARTMENT  ON  THE  USE  OF  BACTERI- 
OLOGICAL EXAMINATIONS  FOR  THE  DIAG- 
NOSIS  OF  DIPHTHERIA.    . 

By  HERMANN  M.  BIGGS,  M.D., 

NEW  YORK. 
PATHOLOGIST  AMD  DIRRCTOR  OP  THB  BACTBRIOLCGICAL  LABORATORY. 

Early  in  January,  1893,  a  communication  was  addressed 
to  the  Health  Board  of  New  York  City  recommending 
the  systematic  employment  by  the  Health  Department 
of  bacteriological  examinations  for  the  diagnosis  of  diph- 
theria. This  recommendation  was  made  in  view  of  the 
following  considerations  there  detailed : 

"  1.  The  practical  differentiation  of  diphtheria  from 
other  diseases  affecting  the  upper  air-passages  is  of  great 
sanitary  importance. 

"  2.  It  is  admitted  by  all  clinicians  of  experience  in 
this  disease  that  it  is  often  impossible,  either  from  the 
riimral  history  or  the  anatomical  lesions,  or  both,  to 
make  an  accurate  diagnosis  of  diphtheria.  There  are  no 
constant  differences  which  separate  the  simple  non-con- 
tagious forms  of  inflammation  from  the  diphtheritic  and 
communicable  types,  and  it  is  only  in  a  rather  small  pro- 
portion of  cases  that  an  early  and  reliable  diagnosis  can 
be  arrived  at  from  any  data  obtainable.  The  records  of 
the  Health  Department  of  New  York  City  have  shown 
this  in  a  very  striking  way.  In  the  cases  of  suspected 
diphtheria  under  treatment  at  the  Willard  Parker  Hos- 
pital, in  which  the  diagnoses  were  made  by  the  Depart- 
ment inspectors  and  confirmed  by  the  Department  diag- 
nosticians before  the  removal  of  the  patients  to  the 
hospital,  subsequent  bacteriological  examinations  showed 
that  from  thirty  to  fifty  per  cent  of  these  cases  were  not 
diphtheria,  but  were  cases  of  pseudo-diphtheria. 

"3.  All  recent  bacteriological  investigations  made  to 
show  the  value  of  such  examinations  for  the  diagnosis  of 
diphtheria  are  in  accord  in  stating  positively  that  reli- 
able conclusions  may  be  reached  by  this  method  in  from 
twelve  to  twenty-four  hours.  These  investigations  in- 
clude those  made  by  Baginsky  in  Berlin,  Martin  in 
Paris,  and  Koplik  and  Park  in  New  York.  The  results 
arrived  at  in  these  investigations  have  been  confirmed  by 
the  subsequent  histories  of  the  cases  examined.  In  those 
cases  in  which  bacteriological  examinations  have  shown 
the  absence  of  the  Klebs  Loeffler  bacillus,  the  mortality 
has  varied  from  one  to  five  per  cent.,  and  the  cause  of 
death  has  usually  been  broncho  pneumonia,  and  not  the 
local  disease ;  while  in  those  cases  in  which  bacteriolog- 
ical examinations  have  shown  the  presence  of  the  Klebs- 
Loeffler  bacillus,  the  mortality  has  varied  from  twenty  to 
nearly  fifty  per  cent.  Further,  it  has  been  demon- 
strated that  in  the  cases  in  which  the  Klebs- Loeffler  ba- 
cillus is  not  found  there  is  little  danger  of  the  transmis- 
sion of  the  disease  to  others ;  while  from  the  cases  of 
true  diphtheria  (as  shown  by  bacteriological  examina- 
tions), even  when  the  disease  is  of  the  mildest  type,  fre- 
quent and  numerous  instances  of  infection  have  been  re- 
corded. 

"  4.  The  employment  of  bacteriological  examinations 
for  the  diagnosis  of  diphtheria  would  have  an  important 
influence  on  the  work  required  of  officials  of  the  De- 
partment and  the  cost  of  this  work.     Bacteriological  in- 


vestigations in  diphtheria  have  shown  that  accurate  con- 
clusions can  be  arrived  at  as  to  the  nature  of  the  dis- 
ease in  most  cases  within  fourteen  hours.  Investigations 
made  by  Dr.  Park,  at  the  Willard  Parker  Hospital,  show 
the  Department  has  in  the  past  provided  for  the  main- 
tenance and  treatment  of  a  large  number  of  patients 
having  pseudo  diphtheria.  This  has  been  at  a  large  un- 
necessary annual  cost,  and  the  facilities  of  this  Depart- 
ment for  the  treatment  of  cases  of  true  diphtheria  have 
been  thereby  limited.  In  addition  to  this,  under  the 
regulations  of  the  Department  at  present,  a  large  num- 
ber of  cases  of  pseudo- diphtheria  must  be  repeatedly  vis- 
ited by  inspectors,  and  the  rooms,  clothing,  etc.,  after  con- 
valescence, thoroughly  disinfected.  This  is  at  a  further 
large  cost  to  the  Department,  and  the  expenditure  of 
much  valuable  time.  If  the  Department  was  prepared  to 
avail  itself  at  once  in  all  cases  of  means  for  the  bacterio- 
logical diagnosis  of  diphtheria — as  this  can  be  arrived  at 
in  so  short  a  time — any  definite  action  could,  as  a  rule, 
be  held  in  abeyance  until  a  conclusion  as  to  the  nature 
of  the  disease  had  been  reached.  In  those  cases  in  which 
the  results  showed  the  disease  was  pseudo  diphtheria,  the 
Department  would  be  at  once  relieved  frcm  further  ac- 
tion. 

"  During  the  year  1891,  4,874  cases  of  diphtheria  were 
reported  to  this  Board,  and  so  far  as  can  be  judged  from 
the  data  at  hand,  at  least  one-third,  and  perhaps  more,  of 
these  were  not  diphtheria. 

"  5.  The  resort  to  bacteriological  examinations  for  the 
differentiation  of  true  diphtheria  from  pseudo  diphtheria 
would  constitute  an  important  step  in  advance. 

"The  Health  Department  of  New  York  City  deter- 
mined during  the  cholera  outbreak  in  1893  to  depend 
solely  on  bacteriological  examination  for  the  diagnosis 
of  Asiatic  cholera.  No  State  or  Municipal  Sanitary 
Board  has  as  yet  officially  adopted  bacteriological  ex- 
aminations for  the  diagnosis  of  diphtheria,  but  in  this 
city  these  would  be  of  far  greater  value  in  the  diagnosis 
of  diphtheria  than  in  the  diagnosis  of  cholera,  became  of 
the  greater  prevalence  and  constant  presence  of  diph- 
theria here.  The  formal  recognition  of  this  method  by 
the  Board  would  be  received  by  the  profession  as  an  im- 
portant indication  of  the  determination  of  the  Board  to 
keep  the  work  of  the  Department  thoroughly  abreast  of 
the  most  recent  discoveries  of  scientific  medicine. 

"  6.  In  addition  to  the  work  on  the  diagnosis  of  diph- 
theria, there  would  naturally  arise  from  such  examina- 
tions investigations  as  to  the  best  methods  to  prevent 
the  extension  of  this  disease." 

In  the  report  just  quoted,  the  appointment  of  Dr.  Will- 
iam H.  Park  as  bacteriological  diagnostician  and  in- 
spector of  diphtheria,  was  recommended.  Dr.  Park's 
name  was  suggested  because  of  the  special  investigations 
that  had  been  carried  on  by  him  during  the  previous  year 
in  the  hospitals  under  the  control  of  the  Health  Depart- 
ment, and  because  of  his  special  training  and  fitness  for 
this  position. 

After  some  unavoidable  delay,  early  in  May  of  1893, 
Dr.  Park  was  appointed,  in  accordance  with  the  reccm- 
mendation,  "  Bacteriological  Diagnostician  and  In- 
spector of  Diphtheria." 

The  Health  Board  at  that  time  determined  to  make 
use  of  bacteriological  examinations  for  the  diagnosis  of 
diphtheria,  not  only  in  all  cases  admitted  to  the  hospital 
wards,  but  also  in  all  cases  of  suspected  diphtheria  occur- 
ring in  the  city  where  the  co  operation  or  consent  of  the 


322 


MEDICAL    RECORD. 


[September  15,  1894 


attending  physician  could  be  obtained.  This  action 
was  determined  on  with  a  view  to  giving  precision  to 
the  work  of  the  Department  in  the  prevention  of  this 
disease. 

During  the  first  weeks  after  the  commencement  of  this 
work  the  number  of  cases  examined  weekly  was  compara- 
tively small,  but  this  number  has  continually  increased 
until,  during  the  last  few  months,  a  large  proportion  of 
all  the  cases  of  suspected  diphtheria  occurring  in  the 
city  have  been  subjected  to  bacteriological  examination. 

As  the  scope  and  extent  of  the  work  increased,  it  was 
found  it  would  be  impossible  for  Dr.  Park  to  perform  all 
of  the  actual  bacteriological  examinations,  and  Mr.  Alfred 
L.  Beebe,  inspector  of  bacteriology  in  this  Department, 
was  assigned  to  assist  him. 

From  the  beginning  those  in  charge  of  the  work  had 
little  doubt  of  its  ultimate  success,  but  they  appreciated 
the  importance  of  the  change  that  was  made  in  the  sani- 
tary management  of  this  disease,  and  did  not  feel  assured 
that  the  physicians  of  this  city  would  quickly  avail  them- 
selves of  the  opportunities  thus  afforded  to  them. 

At  first,  as  far  as  possible,  the  inspector  of  diphtheria, 
or  special  inspectors  assigned  to  this  duty,  visited  physi- 
cians who  reported  cases  of  diphtheria  and  explained  to 
them  the  purposes  of  the  work.  These  inspectors  made 
inoculations  from  cases  only  after  a  request  or  the  specific 
consent  of  the  attending  physician  had  been  received. 
After  a  short  trial,  however,  it  was  evident  that  a  large 
majority  of  the  physicians  of  New  York  would  be  glad  to 
avail  themselves  of  the  assistance  offered  by  the  Depart- 
ment. A  further  step  was  then  taken  to  increase  the  fa- 
cilities for  such  examinations.  A  number  of  depots  were 
established  throughout  the  city  (these  now  number  about 
forty)  where  culture-tubes  and  the  directions  required  for 
making  the  inoculations  could  be  obtained  by  physicians 
without  charge.  These  depots  were  generally  established 
at  drug  stores,  at  convenient  points,  and  arrangements 
were  made  for  the  collection  of  the  tubes  left  at  these 
depots  by  Department  collectors  late  in  the  afternoon  of 
each  day.  For  convenience  and  safety  in  transporting 
the  tubes,  small  wooden  boxes,  holding  culture-tubes, 
were  supplied  from  each  of  the  depots.  Each  box  con- 
tains all  that  is  required  for  making  a  culture,  i.e.,  a 
culture-tube,  a  swab  for  inoculating  it,  and  a  blank  for 
recording  the  name,  address,  etc.,  of  the  patient.  Each 
box  with  its  contents  is  known  as  "  a  culture  outfit'1 

The  following  cards,  giving  directions  for  making  the 
cultures  and  the  addresses  of  the  depots  where  tubes 
could  be  obtained,  were  also  supplied  with  the  tubes : 

Hralth  Department. 
Division  op  Pathology,  Bacteriology,  and  Disin- 
fection, Bacteriological  Laboratory, 
White,  Centre,  Elm,  and  Franklin  Streets. 

Directions  for  Making  Cultures  in  Cases  of  Suspected 
Diphtheria. 

The  patient  should  be  placed  in  a  good  light,  and,  if  a  child, 
properly  held.  In  cases  where  it  is  possible  to  get  a  good  view  of 
the  throat,  depress  the  tongue  and  rub  the  cotton  swab  gently,  but 
freely,  against  any  visible  exudate. 

In  other  cases,  including  those  in  which  the  exudate  is  confined 
to  the  larynx,  avoiding  the  tongue,  pass  the  swab  far  back,  and  rub 
it  freely  against  the  mucous  membrane  of  the  pharynx  and  tonsils. 
Without  laying  the  swab  down,  withdraw  the  cotton  plug  from  the 
culture-tube,  insert  the  swab,  and  rub  that  portion  of  it  which  has 
touched  the  exudate  gently  but  thoroughly  back  and  forth  all  over 
the  surface  of  the  blood -serum.  Do  not  push  the  swab  into  the 
blood- serum,  nor  break  the  surface  in  any  way.  Then  replace  the 
swab  in  its  own  tube,  plug  both  tubes,  put  them  in  the  box,  and 
return  the  culture  outfit  at  once  to  the  station  from  which  it  was 
obtained. 

A  report  will  be  forwarded  the  following  morning  by  mail,  or 
can  be  obtained  by  telephone,  after  12  noon. 

Culture   Out/its  can  be   Obtained  from  the  Following   Station*  Free  0/ 
Cost: 

East  Side. 

71a  Tremont  Avenue Eichwort  .  67th  St.  and  3d  Ave Hoykendorff 

E38th  St.  and  3d  Ave Fraser    45th  St.  and  3d  Ave Goetting 

135th  St.  and  Madison  Ave Marsh  I  43d  St.  and  Park  Ave Schoonmaker 

116th  St.  and  3d  Ave Engelhard  t    41st  St.  &  Park  Av.,Van  Horn  &  Ellison 

115th  St.  and  rat  Ave  New  ,  29th  St.  and  4th  Ave Bagoe 

110th  St  and  Madison  Ave Barnes  1  12th  St.  and  ad  Ave Proben 

105th  St.  and  3d  Ave Aaron s tarn  I  1  ith  St.  and  Avenue  A Montesser 

86th  St.  and  Park  Ave Falkenrecht  1  Spring  St.  and  Bowery. Minor 


West  Side. 


135th  St.  and  7th  Ave Breen 

125th  St.  and  8th  Ave Spear 

i22d  St.  and  7th  Ave Hetneinann 

98th  St.  and  Columbus  Ave..  Rosen  son 

93d  St.  and  Columbus  Ave Dorn 

73d  St.  and  Boulevard Kerley 

72d  St.  and  Columbus  Ave. .  Cassabeer 

411  West  59th  St Dougherty 

46th  St.  and  5th  Ave. . .  Bartlett  &  Liell 


36th  St.  and  9th  Ave Rupp 

29th  St.  and  5th  Ave Frazer 

22d  St.  and  9U1  Ave Smirh 

157  8th  Ave Lins 

148  8th  Ave -Udey 

12th  St.  and  6th  Ave Ridgeway 

8th  St.  and  6th  Ave Rigdov 

283  Bleecker  Sl McCord 

172  Varick  St J© 


Form  of  Blank  with  each  "Culture  Outfit." 
Return  swab  and  both  tubes. 

DIPHTHERIA. 

Name  of  Maker  of  Culture 

Date  Time 

Name  of  Patient  Age 

Address 

Att.  Phys.  Address 

Duration  of  Disease 

I  low  Contracted 

Can  Case  be  Isolated  ? 

Location  of  Membrane 

Was  Inoculation  Satisfactory  ? 

Clinical  Diagnosis 

Return  swab  and  both  tubes. 

The  diagnosticians,  and  later  the  medical  inspectors 
of  the  Department,  were  supplied  with  leather  pocket- 
cases,  containing  a  number  of  culture-tubes  and  swabs, 
and  were  given  instructions  regarding  the  methods  of 
making  the  inoculations.  These  arrangements  being 
completed,  the  following  circular  was  delivered,  by  spe- 
cial messengers,  at  the  office  of  every  physician  in  this 
city: 

Health  Department, 
No.  301  Mott  Street,  New  York,  July,  1893. 

Circular  of  Information  Concerning  the  Use  ok  Bacte- 
rial Cultures  for  the  Diagnosis  of  Diphtheria. 

Recent  bacterial  investigations  have  shown  that  a  considerable 
proportion  of  the  cases  of  pseudo-membranous  and  exudative  in- 
flammations of  the  throat  and  upper  air-passages,  commonly  consid- 
ered as  diphtheria,  and  having  the  anatomical  appearances  found  in 
diphtheria,  are  not  true  diphtheria.  These  cases  may  be  called 
pseudo-  or  false  diphtheria. 

It  has  also  been  shown  that  a  considerable  number  of  cases  which 
are  apparently  false  diphtheria  prove  on  bacterial  examination  to 
be  true  diphtheria.  While  in  true  diphtheria  the  mortality  is  very 
high  and  the  danger  of  transmission  to  others  is  great,  in  false  diph- 
theria the  mortality  is  low  and  the  danger  of  infection  slight.  The 
differential  diagnosis  between  true  and  false  diphtheria  can  be  made 
by  bacteriological  examination  within  twelve  hours,  while  without 
this  the  differentiation  is  difficult  or  impossible. 

The  Health  Department  is  now  prepared  to  make  use  of  bacte- 
rial cultures  for  diagnosis  in  all  cases  of  suspected  diphtheria  occur- 
ring in  the  city,  and  desires  that  in  every  case  either  the  physicians 
should  themselves  make  the  inoculations,  or  should  authorize  an  in- 
spector to  make  them.  They  should  be  made  in  every  suspicious 
case  at  the  earliest  possible  moment,  for  during  convalescence  the 
specific  organisms  often  disappear  from  the  throat,  and  the  full 
benefit  of  a  positive  diagnosis  is  not  obtained  unless  it  is  made  early 
in  the  disease.  , 

The  inoculations  are  made  by  gently  rubbing  a  cotton  swab 
against  the  throat,  and  then  drawing  it  over  the  surface  of  the 
culture-medium.  When  the  physician  desires  to  himself  make  the 
culture  (and  this  is  usually  the  better  plan,  for  it  can  be  done  earlier 
and  is  more  agreeable  to  the  family),  he  can  obtain,  free  of  cost,  a 
culture  tube  and  swab,  and  the  simple  directions  necessary  for 
their  use,  at  any  one  of  the  druggists  whose  addresses  are  given. 
After  the  inoculation  the  tubes  are  to  be  returned  at  once  to  the 
dniggist  from  whom  they  were  obtained.  The  tubes  will  be  col- 
lected by  the  Department  every  evening. 

In  cases  where  an  inoculation  has  not  been  made  by  the  attending 
physician,  the  medical  inspector  will  make  one,  unless  for  any  rea- 
son the  physician  requests  that  none  be  made  when  he  notifies  the 
Department  of  the  case. 

The  diagnosis  will  be  ready  by  noon  of  the  following  day.  The 
attending  physician  can  obtain  this  immediately  by  telephoning  to 
the  laboratory,  or  when  this  is  not  done,  he  will  be  notified  by  mail. 
Cases  which  prove  to  be  false  diphtheria  will  not  be  visited  by  the 
Health  Department  inspectors.  Cases,  on  the  other  hand,  which 
prove  to  be  true  diphtheria,  will  be  subjected  to  the  usual  rules  and 
regulations  covering  contagious  diseases. 

The  materials  required  for  making  inoculations  can  be  obtained 
from  the  druggists  named,  free  of  cost. 

All  communications  on  this  subject  should  be  addressed  to  Dr. 
Hermann  M.  Biggs,  Chief  Inspector  Pathology,  Bacteriology,  and 
Disinfection,  No.  42  Bleecker  Street  (Telephone  "  1191  Spring"). 

By  order  of  the  Board  of  Health, 

Charles  G.  Wilson,  President. 

Emmons  Clark,  Secretary, 


September  15,  1894] 


MEDICAL    RECORD. 


3*3 


As  soon  as  it  was  possible  to  still  further  enlarge  the 
work,  a  new  investigation  was  instituted.  This  was  the 
determination,  by  bacteriological  examination  of  second- 
ary cultures  from  the  throats  of  convalescent  cases  of 
diphtheria,  how  long  the  bacilli  of  diphtheria  persist  dur- 
ing convalescence. 

After  a  sufficient  number  of  examinations  had  been 
made  to  draw  accurate  conclusions,  the  following  circu  - 
lar  was  printed,  and  ordered  to  be  sent  to  the  physician 
with  the  report  of  the  result  of  the  bacteriological  exam- 
ination of  the  first  culture.  In  it,  the  important  an- 
nouncement is  made  that,  in  the  future,  no  case  will  be 
considered  free  of  the  contagion  of  diphtheria  until  this 
fact  has  been  established  by  culture  test. 

Health  Department. 

Division  of  Pathology,  Bacteriology,  and  Disinfection, 

No.  301  Mott  Street,  New  York,  189—. 

No.  42  Blef.cker  Street. 
To  Dr.  -. 

Sir  :  During  the  last  few  months  a  series  of  investigations  have 
been  made  in  the  bacteriological  laboratory  of  the  Health  Depart- 
ment to  determine  how  long  the  Loeffler  bacilli  remain  in  the  throat 
after  the  disappearance  of  all  false  membrane  in  cases  of  diph- 
theria. 

The  results  obtained  are  extremely  significant,  and  have  caused  the 
Department  to  establish  a  new  rule  regarding  the  discharge  from 
observation  of  patients  who  have  suffered  from  diphtheria,  and  re- 
garding the  time  of  disinfection  of  the  premises. 

During  the  past  three  months  405  cases  of  true  diphtheria  have 
been  subjected  to  repeated  bacteriological  examinations  performed 
at  short  intervals  during  the  course  of  the  disease  and  during  con- 
valescence. 

In  all  of  these  cases  cultures  were  made  at  the  beginning  of 
the  disease,  again  after  the  lapse  of  three  or  four  days,  and 
finally  at  short  periods  after  the  complete  disappearance  of  the  false 
membrane,  until  the  throat  was  found  to  be  tree  from  the  diphthe- 
ria bacillus.  In  245  of  these  405  cases  the  diphtheria  bacilli  disap- 
peared within  three  days  after  the  complete  separation  of  the  false 
membrane ;  in  160  cases  the  diphtheria  bacilli  persisted  for  a  longer 
time,  namely :  in  103  cases  for  seven  days,  in  34  cases  for  twelve 
days,  in  16  cases  for  fifteen  days,  in  4  for  three  weeks,  and  in  3  for 
five  weeks  after  the  time  when  the  exudation  had  completely  disap- 
peared from  the  upper  air-pa  sages.  In  many  of  these  cases  the 
patients  were  apparently  well  many  days  before  the  infectious  agent 
had  disappeared  from  the  throat.  These  results  show  that  in  a 
considerable  proportion  of  cases  persons  who  have  had  diphtheria 
continue  to  carry  the  germs  of  the  disease  in  their  throats  for  many 
days  after  all  signs  and  symptoms  of  the  disease  have  disappeared. 
No  doubt  the  disease  is  largely  disseminated  by  these  persons  who 
are  apparently  well,  and  who  mingle  with  others  while  their  throat 
secretions  still  contain  the  diphtheria  bacilli. 

These  experiments  have  led  the  Health  Department  to  adopt  the 
role,  that  no  person  who  has  suffered  from  diphtheria  shall  be  con- 
sidered free  from  contagion  until  it  has  been  shown  by  bacteriologi- 
cal examination,  made  after  the  disappearance  of  the  membrane 
from  the  throat,  that  the  throat  secretions  no  longer  contain  the 
diphtheria  bacilli,  and  that  until  such  examinations  have  shown 
such  absence  all  cases  in  boarding-houses,  hotels,  and  tenement- 
houses  must  remain  isolated  and  under  observation.  Disinfection 
of  the  premises  therefore  will  not  be  performed  by  the  Department 
until  examination  has  shown  the  absence  of  the  organisms. 

Secondary  cultures,  as  in  the  case  of  primary  cultures,  may  be 
made  by  the  attending  physician,  if  he  so  desires ;  otherwise  they 
will  be  made  by  the  inspector  of  the  district  in  which  the  case  oc- 
curs. This  applies  only  to  cases  occurring  in  boarding-houses,  ho- 
tels, and  tenement-houses — not  to  those  in  private  houses. 

In  this  connection  an  interesting  observation  has  been  made 
showing  that  in  diphtheria  cases  which  have  been  subjected  to  fre- 
quent irrigation  with  antiseptic  solutions  from  the  beginning  of  the 
disease  the  bacilli  disappear  more  rapidly  than  in  those  in  which 
such  irrigations  have  not  been  employed.  The  Department  would 
feel  grateful  for  any  data  which  the  physicians  of  this  city  may  fur- 
nish as  to  the  treatment  employed  in  each  case,  in  order  that  more 
reliable  conclusions  may  be  reached  as  to  the  best  mode  of  treat- 
ment. 

It  has  been  also  found,  that  occasionally  when  culture-tubes  are 
inoculated  immediately  after  irrigation  of  the  throat  with  antiseptic 
solutions,  the  cultures  do  not  show  any  Loeffler  bacilli,  although 
subsequent  examinations  may  demonstrate  their  presence.  This  ob- 
servation should  be  noted  in  making  inoculations. 
Very  respectfully, 

Hermann  M.  Biggs,  M.D., 
Chief  Inspector  of  Pathology,  Bacteriology \  and  Disinfection. 

Approved  by  the  Board  of  Health. 

Charles  G.  Wilson,  President. 
Emmons  Clark,  Secretary. 


Blank  to  be  filled  out  and  returned  with  secondary  cult- 
ures. 

Return  swab  and  both  tubes. 

Diphtheria— Later  Cultures. 

Number  of  Culture,  2d,  3d,  4th,  5th,  6th,  7U1,  8th. 
Date  Inspector  or  Physician 

Name  of  Patient  Laboratory  Number 

Address 

Duration  of  Disease 

Is  the  place  ready  for  disinfection  if  the  culture  is  found  free  from 
diphtheria  bacilli  ? 

During  the  first  few  months,  in  order  to  test  the  results 
of  the  examinations  and  to  make  the  liability  to  error  as 
slight  as  possible,  the  following  plan  was  adopted : 

All  cases  which  yielded  no  diphtheria  bacilli  were 
turned  over  to  special  inspectors,  who  made,  if  possible, 
in  every  case,  a  second  culture,  and  followed  up  the  pa- 
tient for  some  time  after  recovery.  From  the  informa- 
tion thus  secured,  the  bacteriologists  of  the  Department 
were  able  to  decide  more  and  more  surely  how  far  they 
could  base  an  absolute  diagnosis  on  the  examination  of 
a  culture. 

In  the  first  circular  issued,  the  Health  Board  an- 
nounced that  cases  which  proved  on  bacteriological  ex- 
amination to  be  false  diphtheria,  would  not  be  kept  under 
the  observation  of  the  Department.  Some  physicians 
who  heartily  approved  of  the  work  of  the  Department  in 
its  treatment  of  diphtheria,  believed  that  in  this  step  it 
had  proceeded  too  far,  and  that  the  false  cases,  though 
less  contagious  than  the  true,  were  yet  sufficiently  so  to 
render  isolation  and  supervision  necessary.  From  a  large 
experience  the  Health  Board  believed  these  cases  were  so 
rarely  serious  in  their  results,  and  were  so  little,  if  at  all, 
contagious,  that  visits  from  Department  inspectors  were 
unnecessary.  Nevertheless,  before  issuing  the  circular, 
one  hundred  and  fifty  consecutive  cases  were  investigated, 
all  sources  of  contagion  sought  for,  and  the  patients  kept 
under  observation  for  two  weeks  after  convalescence.  In 
none  of  these  was  isolation  or  disinfection  required.  The 
evidence  obtained  so  completely  confirmed  the  previous 
experience  that  the  Health  Board  felt  justified  in  con- 
cluding it  was  unnecessary  to  exercise  any  sanitary  super- 
vision over  cases  of  false  diphtheria.  Those  who  believe 
they  have  met  with  cases  of  false  diphtheria  which  have 
been  the  cause  of  severe  or  fatal  illness  in  others,  have 
probably  either  mistaken  the  nature  of  the  first  case,  or 
have  been  dealing  with  some  other  infectious  disease  (such 
as  scarlet  fever),  in  which  the  inflammation  of  the  throat 
is  merely  a  secondary  lesion. 

In  order  to  make  the  possibility  of  error  in  the  routine 
work  as  small  as  possible,  for  some  months  the  follow- 
ing circular  has  been  mailed  to  physicians  with  every  re- 
port : 

Health  Department. 

Division  of  Pathology,  Bacteriology  and  Disinfection, 
No.  4a  Bleecker  Strbet. 

New  York,  February  20,  1894. 

To  Physicians  :  It  is  the  earnest  desire  of  the  Health. Depart- 
ment that  the  service  in  the  bacteriological  diagnosis  of  diphtheria 
be  made  as  perfect  as  possible  and  as  useful  to  physicians  as  it  can  be 
made.  When  cultures  are  left  at  any  of  the  depots  before  4  P.M., 
it  is  the  aim  to  return  in  every  case  a  report  of  the  bacteriological 
diagnosis  on  the  following  day.  Reports  are  mailed  before  one 
o'clock,  and  should  be  delivered  to  the  physician  before  the  last  mail 
of  the  day.  Earlier  reports  can  be  obtained  by  applying  to  the  Lab- 
oratory by  telephone  (No.  1191  Spring)  after  12  M. 

When  the  bacteriological  diagnosis  does  not  harmonize  with  the 
clinical  facts  and  the  history,  as  shown  by  antecedent  or  subsequent 
cases  of  diphtheria,  and  where  there  are  any  defects  or  reasons  for 
complaint  regarding  the  service  in  any  respect,  physicians  are  ear- 
nestly requested  to  report  these  promptly  to  the  Chief  Inspector,  Dr. 
H.  M.  Biggs,  No.  42  Bleecker  Street.  Knowledge  of  defects  in  the 
service  can  only  reach  the  Department  through  such  reports,  and 
the  service  can  only  thus  be  improved  and  perfected. 

Physicians  are  requested  to  read  carefully  the  accompanying  circu- 
lars describing  the  character  of  the  work  and  method  of  procedure, 
and  to  follow  exactly  the  instructions  given.  Thus  uniformity  in 
method  and  accuracy  in  results  will  be  insured. 

Hermann  M.  Biggs,  M.D., 
Chief  Inspector  of  Pathology,  Bacteriology \  and  Disinfection. 


3^4 


MEDICAL  RECORD. 


[September  15,  1894 


Depending  on  the  results  after  the  examination  of  pri- 
mary cultures,  one  of  the  following  blanks  is  filled  out 
and  mailed  to  the  attending  physician  before  12  m.  of 
the  day  following  that  on  which  the  culture  was  made : 


Dr. 


Nkw  York, 


189- 


Dear  Sir  :  The  examination  of  the  culturesmatle  by  inoculating 
the  tubes  with  the  exudation  from  the  throat  of  on 

shows  the  presence  of  the  diphtheria  bacilli. 
The  case  is  therefore  one  of  true  diphtheria. 


Chief  Inspector. 


Inspector  of  Diphtheria. 


Health  Department. 

Division  of  Pathology,  Bacteriology,  and  Disinfection, 

Bacteriological  Laboratory,  42  Bleeckrr  Street. 


Dr. 


New  York, 


189— 


Dear  Sir  :  The  examination  of  the  cultures  made  by  inoculating 
the  tubes  with  the  exudation  from  the  throat  of  on 

docs  not  show  the  presence  of  any  diphtheria  bacilli. 

The  case  is  therefoie  not  true  diphtheria,1  but  pseudo-  or  false 
diphtheria,  and  no  further  cognizance  will  be  taken  of  it  by  the  De- 
partment unless  by  the  special  request  of  the  physician  in  attendance. 


Chief  Inspector. 


Inspector  of  Diphtheria. 


Health  Department. 

Division  op  Pathology.  Bacteriology,  and  Disinfection. 

Bacteriological  Laboratory,  42  Bleeckbr  Street. 

Nkw  York,  189— 

Dr. 

Dear  Sir  :  The  examination  of  the  cultures  made  by  inoculating 
the  tube  with  the  exudation  from  the  throat  of  on 

does  not  admit  of  an  exact  bacteriological  diagnosis,  for 
the  following  reasons: 

A.  The  inoculation  was  made  at  so  late  a  period  in  the  disease 
that  it  is  possible  that  the  diphtheria  bacilli,  though  now  absent, 
were  at  an  earlier  time  present. 

B.  The  growth  on  the  culture  media  was  so  scanty  that  it  is  prob- 
able that  the  inoculation  was  not  properly  made,  or  that  some  anti- 
septic had  been  applied  to  the  throat  shortly  before  obtaining  the 
material  for  inoculating  the  tube. 

C  The  culture  media  was  badly  contaminated. 
D.  The  serum  in  the  tube  was  too  dry  to  permit  of  the  growth  of 
the  diphtheria  bacilli. 

a.  Another  culture  is  requested. 

b.  The  case  will  be  treated  as  one  of  diphtheria. 

c.  The  case  will  be  treated  as  one  of  false  diphtheria  unless  the 
physician  in  charge  of  the  case  requests  otherwise. 


Chief  Inspector. 


Inspector  of  Diphtheria. 


After  the  examination  of  each  secondary  culture  and 
depending  on  the  result  of  the  examination,  one  of  the 
following  blanks  is  filled  out  and  forwarded  to  the  at- 
tending physician  and  to  the  Chief  Inspector  of  Disinfec- 
tion: 

Laboratory  Xo. 

Hbalth  Department. 

Division  of  Pathology,  Bacteriology,  and  Disinfection. 

Bacteriological  Laboratory,  No.  43  Bleeckrr  Street. 


Dr. 


New  York, 


189- 


Dbar  Sir  :  The  examination  of  the  culture  made  by  inoculating 
the  tube  from  the  throat  of  on  shows  the  pres- 

ence of  the  diphtheria  bacilli. 

The  case  is  therefore  not  yet  ready  for  disinfection,  but  needs  a 
further  culture. 

Hermann  M.  Biggs,  M.D., 

Chief  Inspector. 
William  H.  Park,  M.D., 

Inspector  of  Diphtheria. 

Laboratory  A7». 

Hkalth  Department. 

Division  of  Pathology,  Bacteriology,  and  Disinfection. 

Bacteriological  Laboratory,  No.  4a  Bleeckbr  Street. 


Dr. 


New  York, 


189- 


Dear  Sir  :  The  examination  of  the  culture  made  by  inoculating 

1  This  conclusion  is  based  on  the  supposition  that  the  directions 
have  been  properly  carried  out  and  that  the  inoculation  was  made  be- 
fore the  commencement  of  convalescence.  After  convalescence  is 
established  the  bacilli  often  disappear  from  the  exudate. 


the  tube  from  the  throat  of  on  does  not  show 

the  presence  of  any  diphtheria  bacilli. 

The  case  is  therefore  ready  for  disinfection,  if  the  other  circum- 
stances allow. 


Inspector  of  Diphtheria. 


Chief  Inspector. 


In  the  beginning  of  this  work  some  physicians  familiar 
with  bacteriological  investigation  feared  that  it  was  Dot 
safe  to  trust  the  inoculation  of  the  culture-tubes  to  physi- 
cians unskilled  in  bacteriological  methods.  The  Depart- 
ment has  found,  however,  that  physicians  may  as  a  rule 
be  relied  on  to  carefully  follow  the  simple  directions  as  to 
the  procedure  required  to  make  satisfactory  inoculations 
of  culture-tubes,  and  that  the  diagnoses  based  on  the  bac- 
teriological examinations  of  such  tubes  can  be  safely  ac- 
cepted. 

A  communication  was  forwarded  to  the  Health  Board 
in  November,  1893,  recommending  the  adoption  of  an 
amendment  to  the  Sanitary  Code,  which  should  include 
so  called  "  membranous  croup  "  with  the  contagious  dis- 
eases concerning  which  the  Department  requires  reports 
from  physicians.  This  recommendation  was  based  on  the 
results  of  the  bacteriological  examinations  of  a  consider- 
able number  of  cases  of  croup,  which  showed  that  more 
than  eighty  per  cent,  of  them  were  really  cases  of  laryn- 
geal diphtheria. 

The  detailed  results  of  the  work  for  the  first  year,  both 
as  to  the  bacteriological  examination  of  suspected  cases 
of  diphtheria  and  the  experimental  work  on  questions 
allied  to  this,  are  contained  in  the  appended  report  from 
the  Bacteriological  Laboratory,  by  Dr.  William  H. 
Park,  Bacteriological  Diagnostician  and  Inspector  of 
Diphtheria,  and  Mr.  Alfred  L.  Beebe,  Inspector  of  Bac- 
teriology, by  whom  this  work  has  been  performed. 

There  is  also  appended  a  report  from  Dr.  A.  Campbell 
White,  Resident  Physician  at  the  Willard  Parker  Hos- 
pital, detailing  the  results  obtained  from  an  important 
series  of  investigations  made  to  determine  the  influence 
on  the  persistence  of  the  diphtheria  bacilli  of  systematic 
irrigation  of  the  throats  of  diphtheria  patients  with  vari- 
ous antiseptic  and  cleansing  solutions.  The  results  are 
not  as  satisfactory  as  had  been  hoped  for. 

The  question  is  naturally  and  properly  asked,  as  to 
what  influence  this  work  has  had  on  the  prevalence  of 
diphtheria  in  this  city  ?  In  reply  to  this  it  can  only  be 
said  that  there  has  been  a  large  increase  in  the  number  of 
cases  of  diphtheria  occurring  during  the  last  year  in  many 
of  the  large  cities  of  the  world,  and  New  York  has  suf- 
fered from  this  semi-epidemic  influence,  but  to  much  less 
extent  than  some  other  cities.  The  number  of  cases  re- 
ported weekly  had  begun  to  increase  before  the  initiation 
of  this  work  and  this  increase  has  continued  notwithstand- 
ing it.  The  total  number  of  cases  reported  during  the 
last  year  has  been  considerably  greater  than  during  the 
previous  year,  but  the  number  of  cases  apparently  occur- 
ring in  the  city  has  been  unquestionably  increased  by  the 
more  universal  reporting  of  cases  by  physicians.  It  is, 
of  course,  impossible  to  say  how  much  greater  the  real  in- 
crease of  cases  would  have  been  without  the  work  which 
has  been  carried  on  by  the  Department,  and  the  inability 
of  the  Department  to  completely  control  the  spread  of 
the  disease  will  be  readily  understood  by  reference  to  the 
description  of  the  methods  of  dissemination  of  the  dis- 
ease contained  in  the  detailed  report  from  the  Bacterio- 
logical Laboratory  appended  herewith. 

It  may  be  said  in  conclusion  that  the  success  of  this 
new  departure  of  the  Health  Department  of  New  York 
city  has  far  exceeded  all  anticipation.  The  Health  Board 
was  the  first  sanitary  board  in  the  world  to  officially 
adopt  and  provide  for  the  making  of  such  bacteriological 
examinations,  and  the  course  of  the  board  in  this  matter 
has  been  carefully  watched  by  sanitary  authorities  in  vari- 
ous parts  of  the  world.  Constant  inquiries  have  been 
made  as  to  the  conduct  of  the  work,  and  many  requests 
for  circulars  and  for  information  as  to  the  manner  in  which 
the  work  is  carried  on  have  been  received.     Numerous 


September  15,  1894  J 


MEDICAL    RECORD. 


325 


representatives  of  other  health  departments  have  been  in- 
structed, in  the  Bacteriological  Laboratory,  in  the  meth- 
ods employed ;  and  the  plan  of  work,  as  devised  by  this 
Department,  has  been  adopted,  without  modification,  by 
the  health  authorities  of  many  other  cities. 

THE   SURGICAL  TREATMENT    OF  SURGICAL 
KIDNEY. 

By  ROBERT  F.  WEIR,  M.D., 

PBOPCS>OK   OF     SUEGSKY  IN  THE  C  >LLRGE  OF   PHYSICIANS  AMD   SURGBONg,    NEW 
YOKK  ;   SURG  ION  TO  TdB.  NEW  YORK  HOSPITAL,   ETC. 

Suppurative  pyelo-nephritis,  suppurative  interstitial  ne- 
phritis, and  surgical  kidney  are  the  ordinary  names  given 
to  a  disease  which,  originating,  as  a  rule,  in  the  bladder, 
generally  affects,  according  to  Delafield,1  both  kidneys. 
This  observer  gives  the  following  excellent,  though  brief 
description  of  the  pathological  changes  usually  found  in 
this  affection. 

"The  pelves  of  the  kidneys  are  congested  and  coated 
with  pus  or  fibrin.  The  kidneys  themselves  are  swollen, 
congested,  and  studded  with  foci  of  pus  The  smallest 
foci  are  not  visible  to  the  naked  eye,  but  with  the  micro- 
scope collections  of  pus  cells  are  found  between  the 
tubes,  with  swelling  and  degeneration  of  the  epithelium, 
within  the  tubes.  The  larger  purulent  foci  look  like  white 
streaks  or  wedges  running  parallel  to  the  tubes,  and  are 
surrounded  by  zones  of  congestion.  The  larger  abscesses 
replace  considerable  portions* of  the  kidneys.  The  ureters 
are  in  some  cases  inflamed,  their  walls  thickened,  and  their 
inner  surface  coated  with  pus  or  fibrin.  The  bladder 
presents  regularly  the  lesions  of  acute  or  chronic  cystitis. 
It  is  a  very  fatal  disease.  So  far,"  continues  Delafield, 
"as  I  know,  all  the  cases  die,  and  when  nephritis  is 
once  established  there  is  no  further  control  over  thecase." 

This  may  be  said  to  represent  very  fairly  the  impres- 
sion common  to  the  profession  from  various  authoritative 
sources  concerning  this  very  frequent  complication  of 
acute  or  chronic  inflammatory  and  obstructive  affections 
of  the  bladder.  The  following  case,  however,  shows 
that  some  modification  may  be  made  in  the  foregoing 
statement  concerning  the  prognosis  of  such  cases. 

Henry  W.  D ,  a  young  man,  twenty-five  years  of 

age,  was  admitted  to  the  surgical  wards  of  the  New  York 
Hospital  on  April  2,  1894,  with  the  history  that  four 
years  previously  he  had  had  pneumonia,  which  was  fol- 
lowed a  few  months  later  by  an  attack  of  scarlet  fever, 
accompanied  by  nephritis.  From  this  latter  complica- 
tion albumin  and  casts  persisted  for  a  considerable 
length  of  time  afterward  in  the  urine.  He  never  en- 
tirely regained  his  health,  though  previous  to  this  time 
he  had  been  noted  as  an  athlete.  About  one  year  ago 
he  had  a  mild  attack  of  urethritis,  which  did  not  extend 
to  the  deep  urethra.  Three  months  ago  he  contracted  a 
second  and  severe  urethritis,  which  invaded  the  bladder. 
He  suffered  from  an  increased  frequency  of  urination, 
with  tenesmus  and  a  discharge  of  blood  and  pus.  Gono- 
cocci  were  present  in  this  discharge  in  great  numbers. 
This  trouble  subsided  gradually  under  local  treatment, 
which  consisted  of  irrigation,  at  first  daily  with  a  one 
per  cent,  solution  of  creolin,  then  with  a  quarter  of  a 
grain  solution  of  silver  nitrate  every  third  day,  supple- 
mented by  irrigation  twice  a  day  with  a  quarter  of  a 
grain  solution  of  zinc  sulphate.  During  the  last  month 
applications  had  been  made  to  the  posterior  urethra  with 
a  Keyes  syringe.  Two  weeks  later  urination  had  so  far 
improved  that  the  bladder  was  evacuated  but  once  in 
every  four  hours.  The  urine  was  acid  in  reaction ; 
specific  gravity,  1024 ;  but  still  contained  considerable 
pus  and  about  ten  per  cent,  of  albumin.  About  twelve 
days  prior  to  his  admission  into  the  hospital,  without  any 
assignable  cause,  the  last  instrtftnentation  being  nearly  a 
week  anteriorly,  he  developed  a  chill,  succeeded  by  a 
temperature  of  1010  F.,  with  prostration,  vomiting,  and 
diarrhoea.  These  symptoms  subsided  on  decubitus,  with 
fluid  diet,  subnitrate  of  bismuth,  and  oxalate  of  cerium. 

1  Letters  on  Practical  Medicine  and  Pathology,  1800. 


Eleven  days  ago,  that  is,  the  next  day  to  the  above  at- 
tack, pain  in  the  loins  was  first  complained  of  and  was 
of  the  character  of  lumbago.  The  next  day  he  suffered 
a  relapse  of  his  febrile  symptoms,  the  temperature  rose 
to  1030  F.,  and  the  pain  in  the  back  increased  in  sever- 
ity. Tenderness  could  be  readily  excited  by  bimanual 
examination  in  the  renal  region,  particularly  on  the 
right  side.  By  the  rectum  the  bladder  was  normal,  nor 
was  there  any  increase  in  the  frequency  of  urination. 
Two  days  later  the  temperature  had  fallen  to  1010  F.  ; 
but  the  lumbar  tenderness  increased  and  was  more 
markjed  in  the  right  loin  and  hypochondrium.  He  was 
then  admitted  to  the  New  York  Hospital  on  the  medical 
side,  where,  after  a  temporary  stay,  he  was  transferred  to 
the  surgical  division. 

During  the  seven  days  that  elapsed  between  his  en- 
trance into  the  hospital  on  March  28th,  to  April  4th, 
when  surgical  interference  was  resorted  to,  he  had  four 
chills,  the  temperature  rose  daily,  ranging  between  1030 
and  105^°  F.  When  seen  by  me  April  3d,  in  con- 
sultation with  Dr.  Peabody,  the  physician  then  on  duty 
in  the  medical  ward  of  the  hospital  (to  whom  the  case 
had  been  first  referred  as  one  of  severe  typhoid  fever,  but 
by  whom  this  diagnosis  was  speedily  rejected),  the  pa- 
tient's condition  was  a  most  serious  one.  The  urine 
was  discharged  in  quantities  ranging  from  fifty  to  sixty 
ounces  per  diem.  It  was  moderately  turbid,  contained 
pus,  and  was  voided  without  much  bladder  irritation; 
pulse,  1 16  to  1 20.  Pain  was  complained  of  in  the  right 
lumbar  region.  Pressure  in  that  place  alone,  or  conjoined 
with  pressure  in  front,  gave  rise  to  a  decided  tenderness. 
This  was  not  experienced  on  the  left  side.  Some  ten- 
demess  was,  however,  found  on  both  sides,  but  after  re- 
peated trials  it  was  found  to  be  confined  to  the  spinal 
muscles  themselves.  For  when  pressure  was  brought  to 
bear  directly  over  the  region  of  the  kidney  external  to 
the  erector  spins  muscles,  no  pain  was  developed  on  the 
left  side  but  considerable  on  the  right  side.  Moreover, 
by  bimanual  examination  on  the  right  side,  it  was 
thought  that  an  enlargement  of  the  kidney  could  be 
made  out.  My  own  impression  at  that  time  was  that 
the  patient  had  probably  an  abscess  of  the  kidney,  or 
possibly  several  such,  of  considerable  size.  I  did  not 
think  that  he  had  the  ordinary  condition  known  as  the 
"  surgical  kidney,"  because  of  the  single-sided  nature  of 
the  symptoms  and  its  somewhat  slow  development.  I, 
however,  felt  that  there  was  urgency  in  his  case  and  that 
an  exploratory  incision  should  be  made  down  to  the 
kidney  and  this  organ  opened  in  the  hope  of  evacuating 
the  contained  matter.  It  was  considered  advisable  in 
the  condition  of  the  patient,  to  fully  acquaint  his  family 
of  the  great  risk  the  operation  might  bring  the  patient 
into  and  the  possibility  of  not  affording  him  any  benefit 
whatever  if  it  should  be  proven  to  be  a  general  renal  in- 
fection. Any  hope  of  relief,  however,  was  grasped  at 
by  them,  and  under  ether  anaesthesia  on  April  4th,  with 
the  patient  in  the  usual  position,  an  incision  was  made 
just  outside  the  quadratus  lumborum  muscle  from  the 
twelfth  rib  down  to  the  crest  of  the  ilium,  and  thence 
forward  to  and  a  little  above  the  anterior  superior  spine 
of  the  ilium,  the  flap  raised  up  and  the  kidney  exposed. 
It  was  found  to  be  twice  its  usual  size.  It  was  irregular- 
ly and  deeply  congested,  and  also  irregularly  swollen, 
particularly  so  on  its  inferior  surface.  Puncture  in  two 
or  three  directions  with  the  aspirator  needle  gave  no  evi- 
dence of  pus.  An  incision  was  then  made  along  its  ex- 
ternal border,  about  its  middle,  and  revealed  imme- 
diately the  nature  of  the  disease.  This  incision,  an  inch 
in  length  and  nearly  an  inch  in  depth,  disclosed  on  its 
two  sides  numerous  miliary  abscesses  and  streaks  of 
hemorrhages  and  pus  which  showed  that  we  had  to  do 
with  an  ordinary  surgical  kidney.  The  rather  desperate 
venture  was,  however,  taken  of  advising  and  practising 
an  extirpation  of  this  infected  and  infecting  kidney,  bas- 
ing this  action  upon  the  assumption  that  no  symptoms 
pointed  decidedly  toward  an  invasion  of  any  great  ex- 
tent of  the  left  side. 


326 


MEDICAL  RECORD. 


[September  15,  1894 


With  the  ample  room  afforded  by  the  incision  just  de- 
scribed (Kftnig's)  the  kidney  was  rapidly  enucleated, 
heavy  silken  ligatures  being  passed  around  it,  and  its 
pedicle  secured.  The  kidney  was  separated  beyond  the 
ligature,  the  wound  packed  lightly  with  weak  iodoform 
gauze  and  the  lower  edge  of  the  wound  secured  by  silk- 
worm gut  sutures. 

Immediately  after  the  operation  the  temperature 
dropped  from  105 °  F.  to  990  F.  and  remained  subnor- 
mal the  three  following  days,  with  a  moderate  amount  of 
vomiting.  From  the  fourth  day  onward  the  patient 
made  an  uninterrupted  and  rapid  recovery,  being  dis- 
charged from  the  hospital  on  April  20th,  three  weeks 
later.  At  that  time,  his  urine,  though  not  absolutely  free 
from  pus  cells,  was  nearly  normal.  However,  it  con- 
tained still,  on  bacteriological  examination,  a  few  but  a 
diminishing  number  of  the  rods  of  the  colon  bacillus, 
but  no  treatment  was  thought  advisable,  except  that  he 
should  spend  as  much  time  the  present  summer  in  the 
open  air  as  the  ordinary  rules  of  hygiene  demanded. 

The  report  of  the  pathologist  of  the  hospital,  Dr.  Fer- 
guson, on  the  removed  kidney,  is  that  it  measured  14  x 
6}£  x  4  ctm.  and  that  its  capsule  was  thickened  and 
adherent.  Various  cut  surfaces  beside  the  exploratory 
incision  showed  a  great  number  of  abscesses  of  miliary 
size  in  the  pyramids  and  also  in  the  cortex.  The  kidney 
substance  also  contained  a  large  number  of  minute  hem- 
orrhages ;  the  pelvis  was  dilated,  its  mucous  membrane 
contained  many  small  hemorrhages  but  was  otherwise 
pale.  No  gonococci  were  found  on  bacteriological  ex- 
amination, but  numerous  colonies  of  the  bacillus  coli  com- 
munis were  developed  under  culture. 

I  will  simply  add  to  the  foregoing  history  that  though 
the  literature  of  the  surgery  of  the  kidney  is  now  so  large 
that  it  may  already  include  the  consideration  of  this 
question  of  surgical  kidney  in  its  application  for  relief  by 
surgical  measures,  yet  I  have  so  far  failed  to  find  any 
similar  cases ;  carrying  my  investigation  in  the  Index 
Medicus,  however,  only  as  far  back  as  the  year  1886. 

The  first  question  that  comes  to  the  mind  of  every  sur- 
geon reading  this  report  is,  How  often  may  such  a  fort- 
unate condition  of  affairs  be  found  in  cases  of  surgical 
kidney  ?  I  had,  of  course,  known  that  surgical  kidney  was 
occasionally  one-sided,  but  believed  this  to  be  a  very 
rare  occurrence,  but  its  frequence  was  unknown  to  me. 
An  imperfect  endeavor  has  nevertheless  been  made  to  get 
some  further  light  upon  this  latter  point.  I  cannot  pre- 
tend to  have  made  anything  more  than  a  cursory  examina- 
tion for  data  in  this  direction,  but  it  is  not  difficult  to 
place  the  fact  squarfely  in  position  that  this  form  of  sup- 
purative nephritis  may  not  infrequently  be  confined  to 
but  one  side.  For  instance,  Goodhart,  in  an  article  in 
Guy's  Hospital  Reports  of  1874,  collected  270  cases  of 
deaths  from  urinary  disorders,  and  in  these  were  130 
cases  of  surgical  kidney,  as  follows  :  In  100  strictures,  41 
of  suppurating  kidney,  of  these  3  cases  one  side  only  af- 
fected. In  27  prostatic  hypertrophy,  20  suppurating,  1 
confined  to  one  side.  In  14  cancers  of  the  bladder,  6 
suppurating,  2  confined  to  one  side.  In  44  stone,  31 
suppurating,  8  to  one  side.  In  29  cancer  uteri,  etc.,  6 
suppurating,  o  to  one  side.  In  56  from  paraplegia,  26 
suppurating,  56  to  one  side.  This  makes  an  average  of 
14&  per  cent,  for  onesided  renal  infection. 

In  the  article  whence  these  statistics  were  taken,  how- 
ever, the  condition  of  surgical  kidney  is  more  or  less 
mixed  up  with  single  or  multiple  abscesses  of  considera- 
ble size.  Therefore,  its  value  is  not  as  great  as  it  would 
otherwise  be.  I  have  taken  pains,  therefore,  to  collect 
from  the  records  of  the  New  York  and  of  St.  Luke's 
Hospitals,  in  this  city,  forty-five  cases,  of  which  six  were 
one  sided  in  their  lesions,  and  also  from  the  brochures  of 
Malherbe,  aDe  la  Ftevre  dans  les  Maladies  des  Voies 
Urinates,"  1872,  and  of  Bazy,  "  Des  Lesions  des 
Reins/ '  etc.,  1880,  other  cases,  in  six  of  which  one-sided 
lesions  existed,  which  make  a  total  of  71  well-defined, 
undoubted  acute  cases  of  surgical  kidney.  Of  these  both 
organs  were  affected  in  59  cases  and  only  one  organ  in  12 


cases,  that  is  to  say  there  were  about  twenty  per  cent  that 
could  be  attacked,  other  things  being  equal,  surgically. 
We  can,  therefore,  feel  more  hopeful  in  such  conditions 
than,  I  must  admit,  I  certainly  have  been  in  the  past. 

From  the  manner  in  which  the  kidney  substance  pout- 
ed out  beyond  the  divided  capsule  after  the  first  incision 
was  made  into  this  organ  I  could  not  but  feel  on  reflec- 
tion that  even  in  those  cases,  perhaps,  where  both  sides 
were  involved,  something  might  be  done  for  the  relief  of 
tension  as  well  as  for  the  egress  of  pus,  etc,  by  means  of  a 
free  incision  similarly  made  into  the  kidney  substance. 

Hence,  in  conclusion,  with  the  happy  experience  of  the 
present  case  I  would  consider  it  hereafter  justifiable,  if 
the  patient's  general  condition  would  warrant  it,  in  a 
case  of  acute  septic  invasion  of  the  kidneys  to  make  on 
one  or  both  sides  an  exploratory  incision  not  only  in  the 
hope  of  relieving  the  acute  interstitial  invasion,  but  also 
of  perhaps  encountering  a  larger  and  well  defined  focus 
of  pus,  which  pathological  condition  cannot  always,  it  is 
fully  understood,  be  readily  discriminated  from  the  more 
dangerous  lesions  of  the  veritable  surgical  kidney. 
Should  the  symptoms  point,  as  in  the  case  just  narrated, 
to  one  kidney  only,  or  should  a  double  exploratory  inci- 
sion show  the  same  result,  a  nephrectomy  may  with  some 
hope  now  be  resorted  to. 


END  TO  END  INTESTINAL  ANASTOMOSIS  BY 
THE  USE  OF  MURPHY'S  BUTTON,  WITH 
REPORT  OF  CASE. 

By  WILLIAM  W.  STEWART,  M.D., 

COLUMBUS,   GA. 

On  February  27,  1894,  I  was  asked  by  Drs.  C.  L.  Will- 
iams and  R.  E.  Griggs  to  operate  upon  a  case  of  stran- 
gulated hernia  which  that  day  had  fallen  into  their  hands 
as  city  physicians. 

History. — E ,  male,  aged  twenty-three ;  occupa- 
tion butcher.  Well  developed,  six  feet  in  height.  From 
earliest  recollection  had  been  troubled  with  an  oblique 
inguinal  hernia  of  left  side,  which  previously  had  been 
easily  controlled  by  the  wearing  of  a  truss.  February 
25th  arose  at  6  a.m.,  and  before  applying  truss  bathed 
and  dressed.  While  thus  occupied  hernia  came  down, 
causing  with  its  descent  some  pain,  which  attracted  his 
attention.  On  trying  to  reduce  hernia  he  found  he  was 
unable  to  do  so,  and  summoned  medical  assistance. 
Opiates,  cold  and  hot  applications,  taxis,  and  the  usual 
rdle  of  methods  of  relief  were  tried  successively  by  his  at- 
tendants with  no  avail.  This  was  continued  till  the 
morning  of  the  27th,  when  case  was  reported  for  the  hos- 
pital. Patient  was  immediately  removed  by  the  order  of 
Drs.  Griggs  and  Williams  to  the  hospital,  where  at  3  p.m. 
I  first  saw  him.  Condition  at  that  time  was  one  of  pro- 
found shock.  Limbs  flexed  upon  the  abdomen.  Facial 
expression  pinched  and  drawn.  Some  tympanites ;  pulse, 
145  to  160 ;  respirations  quick  and  jerky ;  constant  hic- 
cough ;  vomiting  persistent  prior  to  entering  hospital. 

At  3.30  p.m.,  in  the  presence  of  Drs.  C.  L.  Williams, 
J.  H.  McDuffie,  and  J.  P.  Martin,  of  Birmingham,  Ala., 
and  assisted  by  Drs.  George  J.  Grimes,  R.  E.  Griggs, 
and  McD.  Blanchard,  the  operation  was  performed. 
Ether  was  administered;  site  of  operation  was  well 
scrubbed  with  tincture  of  green  soap  and  hot  water  and 
shaved,  then  washed  with  bichloride  solution  of  1  to 
1,000.  An  incision  was  then  made  from  a  point  just 
above  external  ring  to  bottom  of  scrotum.  Tissues  were 
swollen  and  oedematous ;  sac  being  opened,  there  gushed 
out  three  to  four  ounces  of  blood-stained  serum,  having 
some  bad  odor,  which  brought  into  view  a  large  purplish 
black  mass  adherent  to  bottom  of  sac,  which  proved  to 
be  omentum.  This  beiqg  drawn  to  one  side,  a  mass  of 
small  intestine  about  ten  inches  in  length  was  exposed. 
Intestine  and  omentum  both  proved  gangrenous  and  ex- 
tremely friable.  Internal  and  external  ring  were  then 
both  incised,  freeing  the  strangulation  and  giving  more 
room  for  operative  procedure.     Gangrenous  intestine 


September  15,  1894] 


MEDICAL    RECORD. 


327 


was  drawn  well  out,  and  a  shoemaker's  stitch  with  a  knot 
in  each  stitch  was  taken  through  mesentery  along  entire 
length  of  gut  to  be  excised,  thus  controlling  perfectly 
all  hemorrhage.  Intestine  was  then  grasped  by  two  as- 
sistants just  past  the  gangrenous  demarcation  between 
thumb  and  forefinger,  and  well  compressed.  Then  with 
scissors  ten  inches  of  gangrenous  gut  was  excised.  A 
purse-string  suture  was  then  introduced  into  both  ends 


Fig.  z. 


of  gut  and  Murphy's  button  adjusted,  by  which  both 
peritoneal  surfaces  were  brought  into  perfect  apposition. 
Sutures  were  then  placed,  closing  gaps  in  mesentery. 
Gut  was  carefully  cleansed  and  dropped  back  into  ab- 
dominal cavity. 

Attention  was  now  turned  to  the  omentum,  which 
formed  the  principal  bulk  of  the  hernial  mass,  eighteen 
inches  of  which  proving  gangrenous  and  friable,  its  re- 
moval was  necessary.  Same  ligature  stitch  was  introduced 
as  was  used  in  mesentery,  and  mass  excised.  Sac  was  then 
carefully  freed  and  transfixed  with  silk  ligature  and 
stump  sewed  into  wound.  Wound  was  closed  with  silk- 
worm-gut sutures  and  tight  compression-bandage  applied. 
Condition  of  patient  from  first  to  last  was  very  bad,  ra- 
dial pulse  often  becoming  almost  imperceptible,  calling 
for  frequent  hypodermic  injections  of  strychnia,  nitro- 
glycerine, and  whiskey.    After  being  placed  in  bed  a 


Fig.  a. 

hot,  normal  salt  solution  enema  was  given,  which 
quickly  raised  volume  of  pulse. 

By  morning  patient  reacted  nicely  and  continued 
comparatively  free  from  pain.  Pulse  remained  high, 
140 ;  temperature  ranged  from  990  to  ioo°  F.  till  the 
third  day,  when  it  reached  normal. 

On  the  third  day  high  enema  was  given,  which  was 
followed  by  copious  action.  These  were  continued  every 
second  day,  each  time  being  followed  by  passage  of  fe- 
cal matter  till  the  thirteenth  day,  at  which  time  the  but- 
ton was  passed  and  immediately  followed  by  three  large 


movements  slightly  streaked  with  blood,  since  which  no 
blood  has  appeared,  bowels  continuing  to  move  twice 
daily.    Abdominal  wound  healed    kindly;    wound  in 
scrotum  did  not,  as  some  of  the  cellular  tissue  became 
gangrenous  and  was  removed,  this  being  caused  by  the 
strangulated  condition  in  which  it  remained  for  so  long. 
Diet  was  restricted  to  milk  till  the  fifteenth  day. 
This  method  of  end  to  end  intestinal  anastomosis  has 
advantages  so  patent  that  it  im- 
mediately  recommends    itself   to 
every  abdominal  surgeon.     Its  ad- 
vantages are:  1.  The  rapidity  with 
which    anastomosis   can    be  per- 
formed.    2.  The  normal  continu- 
ity of  the  lumen  of  the  gut  is  re- 
tained.   3.  The  perfect  apposition 
of  peritoneal  surface  under  gen- 
tle pressure,  thereby  guaranteeing 
prompt  and  perfect  union.    4.  Ap- 
position  produced    prevents  per- 
fectly escape  of  gases  into  peri- 
toneal cavity.      5.  When  button 
passes  there  is  nothing  left  in  in- 
testinal coat  other  than   normal 
tissues. 
Dr.  Murphy,  by  his  genius,  has  made  all  abdominal 
operators  his  debtor  through  the  gift  of  his  "button," 
a  perfect  mechanical  contrivance  which  changes  often 


Fig. 


extremely  difficult  and  hazardous  procedures  to  rapid 
and  much  safer  operations. 

The  button,  as  now  manufactured,  is  of  nickel  plated 
brass.  The  material  used  in  its  manufacture  can,  I 
think,  be  improved  upon  by  substituting  aluminum  for 
the  brass,  thereby  reducing  its  weight,  which  will  facili- 
tate its  passage  from  the  intestine. 


SOME  PRACTICAL  OBSERVATIONS  ON  SO- 
CALLED  MALARIA  BEING  A  WATER-BORNE 
DISEASE.1 

By  W.  H.  DALY,  M.D., 

PITTSBURG,    PA. 

The  writer  has  for  the  past  twenty  or  more  years  spent 
probably  an  average  of  two  months  annually  in  the  rec- 
reative sports  of  the  field,  forest,  and  stream.  The 
largest  proportion  of  these  holiday  jaunts  have  been 
passed  in  the  lowlands,  or  in  the  swamps  of  the  lake-sides 
or  sea-side,  in  the  pursuit  of  wild-fowl  shooting.  Many, 
if  not  most  of  these  regions  were,  and  are  generally  ad- 
mitted to  be,  intensely  malarial  in  character,  notably  the 
vast  Kankakee  swamps  in  Indiana. 

In  former  years,  before  the  writer  had  noticed  certain 
conditions,  and  used  certain  precautions,  he  was  subject 
to  malarial  disease  of  a  continuous  or  recurrent  type, 
clearly  traceable  to  his  having  drunk  the  shallow  well- 
and  swamp- water  of  these  regions. 

Observations  and  studies  on  the  subject,  and  investiga- 
tions made  in  various  districts  from  Manitoba  to  Louis- 
iana, and  all  along  the  southern  coast  of  the  Atlantic 
Ocean,  and  of  Cuba,  Yucatan,  and  other  districts  in 
Mexico,  lead  the  writer  to  the  conclusions  that  so  called 
malarial  disease  is  not  easily,  if  at  all,  contracted  by  in- 
haling so-called  malaria  or  bad  air,  of  the  low,  swampy, 
or  new  lands,  but  it  is  distinctly,  if  not  almost  exclusively, 
due  to  drinking  the  water  that  has  come  into  contact 
with,  and  become  infected  with  the  malarial  germs  or  in- 

»  Read  before  the  meeting  of  the  American  Climatological  Associa- 
tion, in  Washington,  May  29.  1894. 


3** 


MEDICAL  RECORD. 


[September  15,  1894 


fas  via  that  exist  in  the  earth  and  waters  of  the  swamp 
and  lowlands.  This  germ  does  not  ordinarily,  if  at  all, 
fbat  in  the  air  during  th;  day,  nor  does  it  find  easily  a 
vehicle  in  the  fog  or  vipors  of  the  night. 

Indeed  it  is  difficult  to  understand  how  one  is  to  avoid 
the  night-air,  even  if  it  is  conceded  to  be  deleterious — a 
conclusion  I  much  doubt.  Does  any  other  air  than  night- 
air  exist  at  night  ?  Is  it  possible  to  breathe  any  other  ? 
Is  there  any  habitation  sufficiently  sealed  against  the  out- 
side air  to  make  the  breathing  of  outside  night- air  im- 
possible ? 

I  understand  the  United  States  Navy  Department  years 
ago  nude,  aid  they  may  still,  for  aught  I  know,  make,  a 
point  of  advising  the  anchorage  of  war  vessels  in  streams 
and  waters  of  malarial  districts  so  as  to  avoid  the  air- 
currents  from  the  swamps  near  by,  lest  the  air,  laden 
with  poison,  should  be  inhaled  by  the  officers  and  sail- 
ors. 

I  will  venture  to  say  that  no  air  from  the  foulest  swamp 
can  be  more  deadly  than  the  foul  air  that  is  produced  by 
the  emanations  from  the  air  passages,  and  from  effete 
m  tfter  from  human  beings  crowded  into  the  hold  of  a 
ship.  That  sort  of  air  is  indeed  malarial,  while  the 
swamp  air  I  believe  to  be  comparatively  safe  and  whole- 
some, but  of  the  swamp  water  beware  for  any  other  pur- 
pose than  ablution. 

I  am  fully  aware  that  in  taking  the  ground  I  here  oc- 
cupy I  may  be  considered  to  be  too  radical,  and  that 
my  position  may  bs  regarded  as  untenable.  If  so,  I 
can  only  answer  that  every  observing  medical  man  must 
and  is  bound  to  tell  honestly  and  fairly  what  he  has  gath- 
ered from  his  own  experience,  observation,  and  studies, 
and  it  must  be  considered  that  my  observations  have  been 
prolonged,  extensive,  and  fairly  intelligent,  and  made 
not,  so  to  speak,  second-hand,  but  personally  and  upon 
the  ground  in  districts  distinctly  malarial,  and  that  dur- 
ing the  years  that  I  and  others  had  been  careful  to  avoid 
the  mists  and  fogs  of  the  malarial  regions,  as  well  as  the 
out-door  night-air,  but  all  the  while  using  the  surface-, 
swamp-,  or  shallow  well  waters  for  drinking,  I,  as  well  as 
others  of  my  friends,  suffered  from  malaria,  so  called; 
Dut  later  on,  and  during  the  past  twelve  years,  while  ab- 
staining from  drinking  the  surface-  or  well  water,  and 
with  the  utmost  freedom  of  exposure  to  the  out-door 
night-air,  fogs,  rain,  and  mists,  at  all  times,  night  and 
day,  we  have  enjoyed  complete  immunity. 

Whoever  has  shot  wild  fowl  knows  full  well  that  the 
best  opportunities  come  to  a  sportsman  amid  storm  and 
rain,  with  the  early  mists  of  the  morning,  and  when 
the  marshes  are  redolent  with  the  vapors  of  the  evening, 
just  at  nightfall,  when  the  wild  fowl  are  flying  to  and  fro, 
seeking  their  favorite  haunts  in  the  marshes  to  sleep. 

Then  there  is  the  journey  of  miles  homeward  to  the 
club-house,  farm  house,  or  camp,  in  the  small  ducking- 
boat,  that  brings  one  to  the  fireside  possibly  not  earlier 
than  eight  to  ten  o'clock  at  night,  so  that  exposure  is 
positive,  and  close  to  the  marsh  and  water,  as  one  is 
sitting  in  a  small  boat. 

I  mention  the  foregoing  as  relevant,  since  medical  men 
are  still  the  readers  and  learners  from  the  classic  text- 
books of  Watson,  Tanner,  and  Niemeyer,  not  to  speak 
of  many  others. 

Tanuer  says,  in  his  most  attractive  style :  "  It  is  worth 
remembering  that  malarial  districts  are  most  dangerous 
at  night,  and  that  this  poison  lies  low,  or,  as  Dr.  Watson 
says,  Moves  the  ground.'  "  And  Dr.  MacCullach  says: 
"  It  is  a  common  remark  in  many  parts  of  Italy,  that  as 
long  as  laborers  are  in  an  erect  position  they  incur  little 
danger,  but  that  the  fever  attacks  those  that  sit  or  lie  on 
the  ground.' ' 

All  of  the  older  and  most  of  the  new  text  books  lay 
stress  upon  the  strictly  malarial  feature  of  the  disease, 
that  is  to  say,  that  the  poison  is  breathed  into  the  sys- 
tem. Some  of  the  newer  writers,  it  is  true,  give  some 
prominence  to  the  source  of  contagion,  from  drinking 
the  infected  land-  or  swamp-water,  but  still  adhere  to  the 
belief  in  the  medium  of  the  air  as  a  chief  or  equal  source 


of  infection.  This  latter  belief  is  a  gross  fallacy  in  my 
opinion,  and  will  not  stand  the  test  of  practical  proof,  if 
the  factor  of  drinking  land-  and  swamp-water  is  elimi- 
nated. 

In  recent  years,  through  the  digging  up  and  renewing 
oT  the  aqueducts,  which  for  centuries  had  supplied  the 
city  of  Rome  with  drinking  water,  it  was  discovered 
that  many  of  her  wealthy  and  leading  citizens  had,  dur- 
ing the  period  of  her  grandeur  and  decadence,  actually 
been  guilty  of  clandestinely  draining  the  sewage  from 
their  country  and  suburban  villas  into  the  very  aque- 
ducts that  supplied  the  city  and  their  fellow  citizens  with 
drinking  water. 

Can  there  be  a  greater  example  of  public  degradation, 
and  can  any  evidence  be  stronger  than  this,  that  a  larger 
part  of  the  Roman  fever,  which  is  unmistakably  mala- 
rial, has  been  due  to  contaminated  drinking-water  rather 
than  to  infected  air  ? 

As  I  say,  during  these  earlier  years  that  I  and  others 
of  my  sportsmen  friends  drank  freely  from  the  running 
brooks  and  streams  and  from  the  swamps,  we  also  en- 
dured for  the  sake  of  the  sport  of  shooting  wild  fowl, 
an  occasional  shake  with  the  ague  and  many  of  the  other 
disagreeable  symptoms  that,  while  they  do  not  amount 
to  an  actual  chill,  make  one  feel  about  as  wretched  as  it 
is  possible  for  one  to  feel  and  go  about.  And  I  and  the 
others  were  all  the  time  taking  heavy  doses  of  quinine  as 
an  antidote.  In  fact,  no  trip  was  ever  taken  to  the 
swamp  for  wild  fowl  without  plenty  of  quinine  and  a  lit- 
tle whiskey. 

But  during  the  past  twelve  years,  and  since  we  have 
avoided  drinking  the  surface-water,  and,  when  it  was  pos- 
sible, even  the  deeper  well-water  of  the  region  except 
after  boiling  the  same,  I  have  been  quite  free,  as  have 
been  others  of  my  friends  whom  I  have  advised. 

If  one  cannot  get  boiled  water  any  other  way,  it  is  well 
enough  to  take  the  water  that  has  been  boiled  in  a  brew- 
ery, viz.,  in  form  of  beer. 

It  is  now  generally  conceded  that  the  malarial  germ 
is  the  cause  of  the  fever.  Lemaire,  Klebs,  Crudeli,  and 
others  have  isolated  certain  forms  of  bacillus,  which 
they  believe  to  be  specific  of  malaria.  Laveran  first, 
and  Richard  and  Marchiafava,  and  Cella,  also  found  in 
the  blood  three  forms  of  protozoa,  one  of  which  partic- 
ularly produced  intermittent  fever  by  inoculation.  The 
germ  is  infusorial,  and  exists  in  the  water  and  soil.  . 

E  Maurel,  in  the  Semaine  MidicaUJ  announced  to  the 
French  Association  for  the  Advancement  of  Science, 
that  it  is  always  easy  to  distinguish  a  healthy  from  a  ma- 
larial soil. 

The  water  from  the  malarious  districts  always  contains 
numerous  micro-organisms,  some  of  which  are  possibly 
Laveran's  corpuscles  in  an  early  stage  of  their  develop- 
ment, but  it  is  not  yet  certain  that  the  germ  has  been 
isolated  outside  of  the  human  body. 

In  regard  to  the  real  value  of  Laveran's  corpuscles  in 
the  production  of  malaria,  he  himself  believes  them  to 
be  indirectly  concerned  in  the  production  of  the  infec- 
tion, although  their  relation  to  it  has  not  been  absolutely 
demonstrated.  It  is  probable,  according  to  Rougette,2 
that  the  malarial  microbe  gives  rise  to  symptomatic  fever 
by  reason  of  its  activity  in  producing  leucomaines.  Dur- 
ing the  access  of  fever  the  microbe  is  eliminated  by  nat- 
ural emunctories. 

The  liver  is  a  destroyer  of  leucomaines ;  *  but,  as  my 
paper  is  upon  the  question  of  the  manner  in  which  the 
so  called  malarial  infection  enters  the  human  body) 
whether  through  the  air-passages,  or  the  digestive  tract 
by  means  of  drinking-water,  I  must  not  wander  into 
other  phases  of  the  subject.  I  am  firmly  convinced  that 
farther  investigation  will  as  surely  lead  us  to  the  knowl- 
edge that  so  called  malaria  is,  strictly  speaking,  a  water- 
borne  disease,  as  it  is  that  we  are  now  being  led  to  the 
right  conclusion,  by  Ernest  Hart  and  others,  that  chol- 

1  Annual  Universal  Medical  Sciences,  1888. 

■  L*  Union  M6dicale. 

*  Annual  Universal  Medical  Sciences,  1888. 


September  15,  1894] 


MEDICAL  RECORD. 


3*9 


era  is  also  a  water-borne  disease ;  and  it  is  our  duty  to 
educate  the  profession,  and  the  public,  especially  those 
who  make  up  the  population  of  the  malarial  districts, 
that  it  is  the  water  they  drink,  and  not  the  air  they 
breathe,  that  decides  whether  they  will  suffer  from  ma- 
laria or  not. 

It  is  a  great  pleasure  to  have  come  into  contact  with 
many  of  the  intelligent  medical  men,  who  practise  in 
the  southern  and  malarial  districts  of  our  country,  whose 
beliefs  are  far  in  advance  of  the  vague  and  obsolete  views 
of  many  of  our  writers  of  text- books.  If  there  were  as 
many  such  men  in  our  profession  as  there  ought  to  be, 
the  use  of  quinine  as  an  antiperiodic  would  soon  become 
unnecessary.  In  fact  I  regard  the  malarial  type  of  fever, 
in  the  United  States  at  least,  as  clearly  preventable  as 
any  other  disease  that  we  have  to  deal  with,  and  by  the 
simple  method  of  drinking  only  carefully  collected  and 
uncontaminated  rain-water,  which,  as  a  simple  precaution, 
might  be  boiled. 

I  have  observed  on  some  of  the  plantations  of  the 
South,  that  among  certain  cattle  and  horses  that  have 
been  shipped  from  the  North  for  breeding  purposes, 
many  of  those  that  were  turned  out  on  the  marshes  to 
drink  the  surface-water  sooner  or  later  sickened  and 
died  with  what  was  known  as  climatic  fever  (malarial) ; 
but  the  animals  that  were  kept  stabled,  and  drank  only 
the  deep  well-  and  cistern-water,  would  thrive  as  well  as 
they  did  in  the  North. 

In  the  British  Medical  Journal  of  October  21,  1893, 
Oswald  Baker,  surgeon  of  the  British  Army,  writes  that 
on  the  steamer  Scindia,  which  sailed  from  Bombay  for 
Marseilles  on  August  5,  1893,  there  occurred  several 
cases  of  acute  malarial  fever  that  were,  from  the  account 
given  by  Mr.  Baker,  clearly  traceable  to  the  drinking- 
water,  which  was  taken  on  the  ship  at  Bombay,  and  not 
in  any  way  due  to  the  air  that  the  patients  breathed. , 

It  is  a  pleasure  to  note  in  the  medical  journals — the 
great  educators  of  those  who  write  text-books — the  accu- 
mulating testimony  of  careful  observers,  who  agree  with 
my  observations  and  experience  herein  set  forth. 

In  the  Medical  Record  of  January  28, 1893,  E.  D.  S. 
writes  that  five  out  of  a  family  of  six,  adults  and  children, 
had  suffered  pretty  continuously  for  the  past  six  years 
with  malaria  (so  diagnosticated  by  the  best  physicians), 
at  times  being  quite  seriously  ill,  with  temperature  1040 
F.  Quinine  was  administered.  Seven  months  ago  a 
Pasteur  filter  was  introduced,  and  quickly  every  symptom 
of  malaria  disappeared.  Another  family  had  the  same 
experience. 

Dr.  L  L.  Von  Wedekind,  U.  S.  Navy,  in  the  Medi- 
cal Record  of  February  n,  1893,  gives  a  history  of 
some  cases  which  indicate  that  to  drinking  the  land- 
water  was  traceable  the  cause  of  malarial  fever  on  the 
coast  of  southwestern  Africa.  The  doctor  says  "  that 
land-water  is  considered  as  a  cause,  and  a  prominently 
exciting  cause,  with  naval  medical  officers,11  as  is  proven 
by  the  orders  issued  by  medical  officers  of  the  differ- 
ent ships  serving  on  the  coast,  prohibiting  the  use  of 
native  water  for  drinking  purposes. 

In  the  region  about  Elizabeth,  N.  J.,  some  years  ago, 
in  conversation  with  some  well-educated  medical  men — 
among  others  Drs.  W.  J.  Lumsden  and  Oscar  McMullen, 
who  were  and  are  careful  observers,  I  learned  that  their 
outbreaks  of  malarial  fever  (fresh  cases)  usually  occurred 
in  the  early  autumn,  following  a  period  of  rainfall  and  a 
few  subsequent  warm  days,  but  new  cases  only  occurring 
among  those  who  drank  the  land-water. 

The  inhabitants  who  used  the  storm-water,  carefully 
stored  in  clean  cisterns,  especially  above  ground,  uncon- 
taminated with  the  soil- water,  are  immune  from  the  at- 
tacks, and  while  the  disease  during  the  past  two  years 
has  presented  some  varying  features  to  these  gentlemen, 
such  as  catarrhal  jaundice,  of  an  endemic  character, 
traceable  to  malarial  influence,  as  well  as  other  forms, 
there  does  not  appear  to  be  anything  to  controvert  the 
evidence  that  these  patients  took  their  malaria  in  water, 
either  as  drink,  or  upon  the  leaves  of  the  turnip-top, 


greens,  kale,  spinach,  cabbage,  or  other  vegetables  that 
grow  close  to  the  ground  and  have  surface  water  on  their 
leaves.  These  vegetables  are  abundant  and  usual  in  the 
culinary  supplies  of  the  region. 

One  may  ask,  Why  do  not  the  New  Yorkers  and  Phil- 
adelphians  also  get  malaria  from  the  same  surface-water, 
dew,  and  moisture  upon  the  leaves  of  these  same  vege- 
tables, shipped  from  this  productive  region  to  those  cit- 
ies ?  The  answer  might  well  be  that  they  do  unless  the 
leaves  are  well  washed  in  uncontaminated  running- water 
before  being  presented  for  use  as  table  food. 

Dr.  R  E.  Boyken,  of  Smithfield,  Isle  of  Wight  County, 
Va.,  informed  me  that  thirty  years  ago  he  had  studied 
this  subject,  and  had  since  induced  as  many  of  his  pa- 
tients and  fellow- citizens  of  his  county  as  possible  to 
adopt  the  cistern-water  as  a  beverage,  and  all  those  fam- 
ilies who  fell  in  with  and  followed  out  his  views  are  of 
healthy  and  ruddy  complexion  and  iree  from  malarial 
disease,  while  those  who  continued  to  drink  the  land- 
water  are  subject  to  attacks  of  malarial  fever. 

That  so  called  malaria  is  an  autochthonous  disease,  find- 
ing its  way  into  the  human  body  through  the  food  chan- 
nels, there  can  be  little  or  no  doubt  in  the  mind  of  the 
original  and  unfettered  observers. 

It  is  true  we  have  not  found  what  we  know  to  be  the 
malarial  germ  and  isolated  it  outside  of  the  human 
body,  and  we  are  not  sure  either  that  we  have  found  the 
typhoid  germ  in  the  soil  or  in  the  suspected  drinking- 
water;  yet  we  are  quite  sure  that  we  trace  typhoid 
origin  through  these  sources. 

Let  us  eliminate  the  atmospheric  factor  in  malaria  by 
noting  in  each  case  if  the  soil-,  surface-,  or  shallow  well- 
water  has  been  drunk  by  the  patient.  If  this  has  been 
done,  the  case  is  obviously  one  that  has  been  exposed  to 
the  infection  in  its  most  potent  form.  There  can  be  no 
scientific  question  more  strictly  in  the  line,  and  touching 
the  true  object,  of  this  learned  Association  than  this,  and 
it  is  to  be  hoped  that  in  the  future  papers  will  be  invited 
from  those  who  have  had  an  opportunity  of  observing 
data  bearing  upon  this,  the  chief  phase  of  this  unsettled 
question. 

We  do  not  merely  want  a  rehash  of  old  dogmas  from 
the  text- books,  or  echoes  from  time-worn  unfounded 
opinions,  garbled  by  one  so-called  authority  from  an 
antecedent  authority,  but  let  us  have  the  fresh  and  un- 
biased observations  and  views  of  the  thousands  of  intelli- 
gent medical  men  who  have  the  opportunity  in  their 
own  neighborhoods  to  make  original  observations  and 
report  them. 

Dr.  W.  J.  Lumsden,  of  Elizabeth,  N.  J.,  recently 
wrote  me  that  his  case- books  show  that  fully  ninety- eight 
per  cent,  of  patients  who  have  suffered  from  malaria  for 
the  past  ten  years  got  their  supply  of  drinking-water 
from  the  dug  wells  of  the  region.  Those  inhabitants 
who  used  the  water  from  driven- wells,  thirty  or  more 
feet  deep,  have  had  an  unmistakable  improvement  in 
health.  A  driven- well  is  made  by  driving  an  iron  pipe 
with  a  perforated  inlet  down  deep  into  the  earth,  through 
strata  of  clay  or  mail,  which  seals  off  the  surface  land- 
water.  So  it  will  be  understood  that  the  water  from  the 
driven-well  is  pretty  securely  sealed  against  surface- 
water  by  its  small  calibre  and  tight  fit  in  the  soil  through 
which  it  penetrates. 

Since  writing  this  article  I  observe  the  growth  of 
medical  opinion  is  gaining  strength  along  the  lines  and 
in  the  direction  of  the  contention  of  this  paper.  The 
Journal  of  the  American  Medical  Association,  of  May 
12,  1894,  contains  the  following : 

"  Dr.  Richard  H.  Lewis,  of  the  North  Carolina  State 
Board  of  Health,  has  prepared  a  circular  letter  for  the 
medical  men  of  his  State,  regarding  the  influence  of  well- 
water  in  the  production  of  fever  and  ague.  He  gives  a 
homely  illustration  in  the  recited  history  of  two  families 
who  resided  as  next-door  neighbors  in  one  of  the  eastern 
towns  of  his  State.  The  two  families  each  contained 
two  adults — father  and  mother — and  seven  children. 
The  two  families  were  friendly,  but  their  homes  were 


330 


MEDICAL   RECORD. 


[September  15,  1894 


sufficiently  separated  to  require  independent  water-sap- 
plies  for  each.  One  family  drank  from  what  was  re- 
garded with  pride  as  '  the  best  well  in  town/  the  other 
of  rain-water  caught  in  wooden  tanks.  The  members  of 
the  first  family  were  constantly  sick  with  malarial  disease 
of  one  kind  or  another.  Those  of  the  second  never  had 
even  a  chill." 

It  is  the  wish  to  build  up  a  line  of  testimony  of  a  like 
character,  if  such  can  be  obtained  through  the  medical 
men  of  North  Carolina.  To  this  end  he  has  written  the 
appended  letter,  giving  an  invitation  to  a  co-operative 
study  of  the  well-water  origin  of  malarial  diseases. 

"  Dear  Doctor  :  The  evidence  that  malarial  diseases 
are  introduced  into  the  system  in  many,  if  not  most,  in- 
stances through  the  medium  of  the  drinking-water,  is  to 
my  mind  conclusive.  The  water  containing  the  germs,  or 
Plasmodia,  is  surface-  or  superficial  soil-water.  Those 
living  in  malarial  districts  who  confine  themselves  to 
water  from  cisterns  or  wells  driven  or  bored  beneath  the 
stratum  of  marl  or  impervious  clay — in  other  words,  be- 
yond the  water  which  soaks  down  from  the  surface — are 
to  a  large  extent  free  from  attacks.  If  the  people  of  our 
eastern  counties  could  be  generally  convinced  of  this 
fact,  and  thereby  induced  to  act  upon  it,  the  health 
conditions  of  that  really  fine  section  would  be  revolu- 
tionized for  the  better.  To  bring  this  about  is  the  ob- 
ject of  the  Board  of  Health.  In  order  to  do  this,  facts 
must  be  presented  to  them  in  the  concrete — not  by  il- 
lustrations from  '  Asia  and  Spasia  and  t'other  side  o' 
Hillsborough,'  so  to  speak,  but  by  instances  from  among 
their  own  neighbors.  I  write  to  ask  you  if  you  know 
any  facts  bearing  on  this  subject,  and  if  so,  that  you  will 
write  them  to  me  in  detail  at  your  earliest  convenience. 
Give  me  the  name  and  post-office  of  the  head  of  the  fam- 
ily having  the  experience.  If  not  personally  familiar 
with  the  facts,  send  me  the  name  and  address,  that  I 
may  write  to  him  direct." 


WATER  IN  DIET  AND  THERAPEUTICS. 
By  BRADFORD  C.  LOVELAND,  M.D., 

CUFTOM  SPRINGS,   N.   Y. 

The  subject  of  water  in  diet  and  in  therapeutics  is  one 
which  has  engaged  the  thought  of  medical  men  more  or 
less  since  the  infancy  of  the  art.  Yet  I  fear  it  is  to-day 
given  very  superficial  attention  by  too  many  of  the  pro- 
fession. 

The  Medical  Record  of  March  3, 1894,  gives  a  very 
interesting  editorial  on  water,  setting  forth  its  ancient 
prestige,  and  undoubted  worth  in  combating  disease, 
but  refers  principally  to  its  external  use. 

I  might  fill  this  paper  with  observations  and  experi- 
ence as  to  its  external  use,  but  my  object  is  to  show  its 
use  in  diet,  and  in  internal  medicine. 

Among  the  earliest  medical  writers  we  find  water 
praised  in  terms  which  could  not  apply  to  any  other  article 
of  food,  or  remedy  in  disease. 

Galen  said :  "  Cold  water  quickens  the  action  of  the 
bowels,  provided  there  be  no  constrictions  from  spasms, 
when  warm  water  should  be  used. 

"  Cold  drink  stops  hemorrhage,  and  sometimes  brings 
back  heat.  Cold  drinks  are  good  in  continued  and 
ardent  fevers." 

In  biliousness,  plethora,  obstinate  ophthalmia,  spasms, 
headache,  gastric  fever,  hiccough,  cholera  morbus,  he 
recommended  tepid  or  warm  water  drinking. 

Celsus  recommended  water  in  fulness  of  the  stomach, 
headache,  pains  in  the  joints,  diarrhoea,  hemorrhoids,  and 
in  hysterical  and  hypochondriacal  conditions. 

Hoffman  pronounced  water  a  universal  remedy.  He 
asserts  that  "  it  is  suited  to  all  persons  at  all  times." 

Cheyne  said,  "  Without  all  peradventure  water  was  the 
primitive  original  beverage,  and  is  the  only  simple  fluid 
fitted  for  diluting,  moistening,  and  cooling." 

But  enough  quotations ;  suffice  it  to  say  that  the  in- 
ternal use  of  water  as  a  remedy  has  been  prescribed  and 


written  upon,  from  the  earliest  times,  by  such  men  as 
Gregory,  Londe,  Sir  John  Ross,  Lanzani,  Drs.  Currie, 
Forbes,  and  John  Bell. 

In  the  early  part  of  this  century  Priessnitz,  while  using 
so  many  external  water  treatments,  did  not  fail  to  see  the 
great  value  of  its  internal  use.  And  his  followers,  in  the 
early-time  "Water  Cure  "  in  this  country  used  to  pre- 
scribe the  drinking  of  water  in  quantities  which  would 
seem  to  most  of  us  to  be  incredible. 

In  the  present  time  it  seems  more  popular  for  physi- 
cians to  prescribe  some  bottled  water  with  a  thrilling 
prophecy  of  rapid  cure  on  the  label,  when,  in  reality,  any 
good,  wholesome  water  would  do  quite  as  much,  or  per- 
haps more,  good ;  for  patients  will  hardly  drink  enough 
to  benefit  them  when  it  costs  them  from  twelve  to  twen- 
ty five  cents  or  more  a  quart.  And  besides  that,  they 
will  frequently  abstain  from  drinking  ordinary  water  be- 
cause they  have  been  ordered  to  drink  Wild  Cot  Lithia 
Water. 

What  is  the  mission  of  water  in  the  body? 

Besides  the  object  of  relieving  thirst,  it  acts  as  a  sol- 
vent for,  and  an  aid  to  the  absorption  of,  all  the  digested 
food  material,  which  it  takes  with  it  on  its  way  to  the 
blood. 

The  water  in  the  blood  forms  a  medium  for  holding  in 
solution  and  suspension  all  the  organic  and  inorganic 
compounds  needed  for  the  nourishment  of  the  tissues,  and 
also  the  effete  materials  on  their  way  to  the  various  ex- 
cretory organs. 

As  the  water  filters  out  through  the  kidneys  and  the 
glands  of  the  skin,  again  its  solvent  power  is  used,  as  it 
carries  with  it  the  urea,  creatine,  phosphates,  sulphates, 
chlorides,  and  other  useless  materials  from  which  the  blood 
needs  constant  cleansing. 

Should  water,  then,  become  deficient  in  the  body  from 
any  cause,  osmosis  in  every  part  must  be  impeded  to  a 
greater  or  less  degree,  as  there  are  varying  degrees  of  se- 
lective affinity  for  water  in  the  different  organs. 

Perhaps  the  bowels  are  the  first  to  suffer,  becoming 
constipated  from  lack  of  moisture  in  the  intestinal  secre- 
tions ;  then  the  liver,  the  bile  becoming  thick.  Next  the 
kidneys  suffer,  being  compelled  to  excrete  too  concen- 
trated a  secretion. 

Too  great  concentration  leads  to  precipitation  of  solu- 
ble ingredients,  forming  calculi,  as  gall-stones  or  renal 
calculi. 

Then,  too,  we  will  find  the  digestive  fluids  are  too  thick 
and  cannot  accomplish  their  work  well. 

Another  most  serious  consequence  of  lack  of  fluid  in 
the  blood  is  the  congestions,  both  primary— from  over- 
work of  certain  organs,  as  the  liver  and  kidneys — and  re- 
flex— from  nervous  irritations,  these  commonly  occurring 
in  the  head  and  spine. 

The  lack  of  fluid  in  the  blood  also  predisposes  to 
arterial  degeneration  with  its  accompanying  evils,  and 
the  uric-acid  diathesis  may  in  part  be  traceable  to  such  a 
cause,  for  the  concentration  of  blood  and  secretions  ren- 
ders assimilation  or  oxidation  more  difficult  and  less  per- 
fect. 

Then,  again,  the  abnormally  concentrated  blood,  with 
the  retention  of  excrementitious  material,  acts  as  a  slow 
poison,  producing  mental  depression  and  other  symptoms. 

When  there  is  a  marked  increase  in  the  amount  of 
water  ingested  for  a  few  days,  or  even  for  a  few  weeks,  it 
may  be  that  the  only  apparent  action  is  on  the  kidneys, 
but  later  the  bowels  and  skin  will  show  the  effect  by  be- 
coming more  active. 

That  the  blood  may  be  changed  by  the  judicious  use 
of  water,  I  have  abundant  evidence,  as  two  or  three  cases 
will  prove. 

Case  I— July  8,  1893,  Mrs-  D ,  aged  thirty- 
five,  came  to  me  with  the  impression  that  she  was  anaemic 
from  chronic  malaria,  complained  tha,t  she  felt  unreason- 
ably and  unaccountably  depressed,  seemed  to  have  lost 
her  love  for  her  children  and  her  home.  Suffered  with 
gas  in  her  stomach.  Was  taking  a  prescription  contain- 
ing iron,  arsenic,  and  quinine.    She  had  been  complain- 


September  15,  1894] 


MEDICAL  RECORD. 


33* 


ing of  above  symptoms  only  for  a  few  weeks.  On  exami- 
nation I  told  her  that  she  was  not  anaemic  but  the  reverse, 
and  had  a  congested  stomach  and  liver,  and  asked  her  if 
she  was  accustomed  to  drink  water.  Her  reply  was  : 
"  Very  little,  for  I  am  seldom  thirsty."  An  examination 
of  blood  was  necessary  both  to  convince  her  that  she  was 
not  anaemic,  and  also  that  she  needed  to  drink  water. 
Blood  examination  showed,  haemoglobin,  one  hundred 
and  eighteen  percent;  red  corpuscles,  6,440,000  to  c.mm. 
Treatment :  Moderate  doses  of  nux  vomica  and  hydrastis, 
six  to  eight  glasses  of  water  daily,  and  a  diet  largely  of 
vegetables  and  grain  foods.  On  the  27th  of  the  same 
month  blood  examination  showed,  haemoglobin,  one  hun- 
dred and  five  per  cent;  red  corpuscles,  5,480,000  c.mm. 

With  the  change  in  blood  had  come  a  change  in  her 
digestion  and  a  removal  of  sufficient  of  her  bad  feelings, 
mental  and  otherwise,  so  that  she  went  home  and  again 
took  up  the  care  of  her  family.  Keeping  up  the  water- 
drinking  and  diet  at  home. 

Case  II.— February  20,  1893,  Mrs.  P ,  aged  forty- 
eight,  rheumatic  gout,  subacute,  six  months'  standing, 
had  not  menstruated  in  two  years.  Inquiry  showed 
chronic  constipation.  She  rarely  ever  drank  water, 
except  in  the  tea  or  coffee  she  took  at  her  meals.  Had 
been  a  nervous  invalid  previous  to  her  present  illness.  I 
could  not  induce  her  to  drink  water  until  I  had  shown 
her  the  concentrated  state  of  her  blood  by  examination. 
She  always  insisted  that  it  gave  her  a  load  in  her  stomach. 

February  20th. — Haemoglobin,  one  hundred  and  twenty 
percent.;  red  corpuscles,  7,080,000  c.  mm.  Treatment: 
Diet,  meat  sparingly;  vegetables,  fruit,  and  grain  foods 
freely,  except  sugar  and  white  bread.  Water,  aj£  to  3 
quarts  per  day.  Medicine:  Phosphate  soda,  30  grains 
before  each  meal  in  a  glass  of  hot  water. 

April  5th. — Blood  examination:  Haemoglobin,  one 
hundred  and  ten  per  cent. ;  red  corpuscles,  5,020,000 
cmm.     Treatment  continued. 

June  2d. — Haemoglobin,  one  hundred  per  cent. ;  red 
corpuscles,  4,120,000  cmm.  During  the  above  time  her 
constipation  was  cured.  Her  arthritis  stopped  attacking 
new  joints,  and  the  inflammation  subsided  in  the  ones 
already  diseased.  The  disease  has  remained  checked, 
although  several  of  the  joints  in  her  hand  are  still,  and 
will  probably  remain,  stiff. 

Case  III.— February  25,  1893,  Mrs-  J-  p >  aged 

forty-four,  plethoric  habit,  suffered  from  acid  stomach 
and  had  repeatedly  passed  biliary  calculi.  The  last  at- 
tack of  the  kind  occurring  after  she  came  under  my  care. 
Had  almost  constant  pain  and  feeling  of  pressure  in  head 
and  back  of  neck. 

February  25th. — Blood  examination:  Haemoglobin, 
one  hundred  and  eighteen  per  cent. ;  red  corpuscles, 
6,800,000  cmm.  Treatment :  Diet,  such  as  to  exclude 
concentrated  starchy  foods  and  sugar,  and  limiting  meat 
to  one  meal  a  day.  Water,  2^  to  3  quarts  per  day. 
Medicine :  Phosphate  of  soda,  30  grains,  in  a  glass  of  hot 
water  before  each  meal.  Treatment  continued  till  June 
6th,  when  blood  examination  showed,  haemoglobin,  one 
hundred  and  eight  per  cent ;  red  corpuscles,  6,300,000 
cmm.  This  was  a  chronic  case,  so  that  improvement  was 
slow,  but  all  the  troublesome  symptoms  were  much  les- 
sened, and  while  I  have  not  seen  her  since  June  last,  I 
heard  from  her  frequently  until  last  December,  during 
which  time  she  had  continued  the  treatment  and  had  also 
continued  to  improve. 

The  above  cases  will  be  sufficient  to  illustrate  what  I 
consider  the  influence  of  water  on  a  considerable  class  of 
cases,  for  while  I  did  give  medicines,  still  I  think  the  re- 
sults were  due  much  more  to  diet  and  water  than  to 
medicine.  

Dentistry  and  the  Postal  Service. — The  regulations 
of  the  British  Post-Office  require  that  every  unsound 
tooth  shall  be  taken  out  of  an  applicant's  head  before  he 
can  be  employed.  An  unfortunate  girl  who  recently  was 
examined  for  promotion  had  fourteen  teeth  taken  out  at 
one  sitting. 


A  COMPARATIVE  STUDY  BETWEEN  THE  RE- 
SULTS OBTAINED  BY  EXAMINATION  OF 
THE  STOMACH  CONTENTS  BY  MEANS  OF 
A  STOMACH-TUBE  AND  EINHORN'S  STOM- 
ACH-BUCKET. 

By  GEORGE  S.   DICKINSON,   M.D., 

•RIB,    PA. 

The  examination  of  the  stomach  contents  serves  the  pur- 
pose of  ascertaining  the  chemical  condition  of  the  gas- 
tric juice.  As  is  well  known,  the  main  point  of  examina- 
tion is  to  determine  the  amount  of  HC1  present,  or  the 
total  acidity,  and  the  presence  of  the  ferments  pepsin  and 
rennet.  The  acidity  is,  as  a  whole,  formed  by  the  presence 
of  free  HC1,  the  lesser  part  by  acid  salts  and  acid  albu- 
minates, except  in  grave  pathological  conditions,  when 
we  find  the  acidity  to  consist  of  organic  adds,  the  prin- 
cipal one  being  lactic  acid. 

f  The  chemical  examination  of  the  stomach  contents  is 
best  made  either  one  hour  after  Ewald's  test  breakfast, 
or  three  or  four  hours  after  Leube's  test  dinner.  The 
test  breakfast  consists  of  a  roll  without  butter,  and  a  cup 
of  weak  tea  without  sugar  or  milk. 
^  The  test  dinner  consists  of  thirteen  fluid  ounces  ot 
either  flour  or  barley  soup,  two  ounces  of  scraped  beef, 
one  and  two-thirds  ounce  of  wheat  bread. 

Einhorn  and  Ewald  prefer  the  test  breakfast  for  cor- 
rect examination.  The  examination  is  best  performed 
as  follows :  First,  test  with  litmus  paper,  to  ascertain  if 
the  contents  be  acid,  alkaline,  or  neutral ;  the  next  step  is 
to  test  with  congo  paper,  to  ascertain  the  presence  of  free 
acids.  The  Uffelmann's  reaction  or  test  serves  to  show 
the  presence  of  lactic  acid.  This  test  is  performed  as 
follows :  Take  about  two  drachms  of  a  two  per  cent, 
phenol  solution  in  a  test  tube,  then  add  a  drop  of  liq. 
ferri  sesquichlorati.  If  lactic  acid  be  present  in  any 
quantity  the  solution  will  turn  canary  yellow. 

To  determine  the  total  acidity,  take  five  c.c.  of  the 
obtained  gastric  contents  which  has  been  filtered,  and 
add  a  drop  of  phenolphthalein ;  after  this  is  done  add 
as  much  of  a  one-tenth  standard  solution  of  sodium  hy- 
drate until  the  filtrate  begins  to  turn  red,  then  multiply 
the  number  of  c.c.  of  the  sodic  solution  used  by  twenty, 
which  gives  us  the  total  acidity.  After  having  ascertained 
the  total  acidity,  the  next  step  is  to  determine  the  amount 
of  free  HC1  present.  This  is  done  by  adding  a  drop  of 
congo  red  to  five  c.c.  of  the  filtrate,  then  by  adding  the 
one-tenth  sodic  solution  until  the  filtrate  begins  to  turn 
reddish- brown. 

The  quantity  of  the  reagent  used,  multiplied  the  same 
as  in  ascertaining  the  total  acidity,  gives  the  amount  of 
free  HC1  present.  Having  found  the  quantity  of  free 
HC1  present,  we  look  for  the  ferments,  the  most  impor- 
tant one  of  which  is  pepsin ;  but  as  the  presence  of  one 
ferment  shows  the  presence  of  the  other,  there  is  hardly 
any  necessity  of  making  other  than  the  test  for  rennet. 

This  test  is  performed  as  follows:  Take  about  two 
drachms  of  milk  and  add  a  few  drops  of  gastric  juice, 
then  place  in  warm  water  for  ten  to  fifteen  minutes.  If 
rennet  is  present  the  milk  will  become  curdled,  and  will 
not  flow  out  of  the  glass. 

Having  now  described  the  usual  method  of  examining 
the  stomach  contents  obtained  by  means  of  the  tube,  I  shall 
briefly  describe  Einhorn's  bucket  and  the  method  of  its 
use,  and  append  hereto  a  table  of  the  results  of  the  exam- 
ination made  of  the  contents  of  the  stomach  of  the  same 
individuals  and  at  the  same  time,  firstly  by  the  stomach- 
tube,  and  secondly  by  Einhorn's  bucket,  showing  com- 
parative results  obtained  from  both  methods. 

As  is  well  known,  the  insertion  of  the  tube,  although 
the  procedure  is  not  a  difficult  one,  is,  notwithstanding, 
very  disagreeable  to  some  people,  and  sometimes  its  use 
is  not  allowable,  especially  in  cases  where  there  is  a  sus- 
picion of  ulcer.  Einhorn1  devised  the  stomach- bucket, 
to  be  used  instead  of  the  tube  in  cases  of  very  nervous 
people,  and  also  where  the  tube  would  be  otherwise 
1  Max  Einhorn :  Mbdical  Record,  July  19, 189a 


33* 


MEDICAL   RECORD: 


[September  15,  1894 


objectionable.  The  bucket  is  of  solid  silver,  about  three- 
fourths  of  an  inch  in  length,  shaped  like  an  empty  cap- 
sule, and  has  a  little  rod  at  the  top  where  the  silk  is  fas- 
tened. On  one  side  is  a  wedge-shaped  opening  and  on 
the  other  is  a  small  hole  about  the  size  of  a  pin-head, 
which  acts  as  a  vent.  The  bucket  will  hold  about  half  a 
drachm.  The  method  of  introduction  is  as  follows :  A 
silk  thread  is  fastened  to  the  arch  of  the  bucket  and  a 
knot  is  made  at  a  distance  of  sixteen  inches  from  the  at- 
tachment ;  then,  in  order  to  obtain  a  sample  of  the  stom- 
ach contents,  the  patient  is  asked  to  open  his  mouth 
widely  and  the  bucket  is  placed  on  the  root  of  the 
tongue,  almost  in  the  pharynx,  when  the  patient  should 
be  told  to  swallow.  The  vessel  after  a  short  time,  one  or 
two  minutes,  enters  the  stomach.  As  soon  as  the  knot 
of  the  thread  is  at  the  lips,  the  bucket  is  in  the  stomach, 
for  the  distance  from  the  teeth  to  the  cardiac  orifice  is 
usually  sixteen  inches.  The  bucket  is  permitted  to  re- 
main there  for  about  five  minutes  and  then  withdrawn. 
Daring  the  withdrawal  of  the  apparatus  a  resistance  is 
usually  felt  at  the  introitus  oesophagi.  To  overcome  this 
difficulty,  when  the  apparatus  is  at  that  narrow  point  the 
patient  should  swallow.  By  the  act  of  swallowing  the 
larynx  is  pushed  forward  and  upward,  and  thus  the  pas- 
sage is  free  and  the  bucket  can  be  withdrawn  easily.  If 
the  stomach  is  not  empty,  the  bucket  returns  filled,  and 
the  amount  is  sufficient  for  making  various  important  tests. 
In  people  suffering  from  an  abundant  secretion  of  the 


a  very  small  amount.  Having  ascertained  the  presence 
of  HC1,  the  acidity  can  be  approximately  determined  by 
gradually  diluting  one  drop  of  the  contents  with  water, 
until  the  above-mentioned  Guenzburg's  reaction  for 
HC1  begins  to  disappear.  Normally  the  stomach  con- 
tents can  be  diluted  from  eight  to  ten  times,  and  yet  ob- 
tain Guenzburg's  reaction.  In  this  way  cases  where  we 
are  able  to  dilute  five  times,  or  even  less,  must  be  con- 
sidered as  cases  of  subacidity,  and  cases  where  we  are  able 
to  dilute  more  than  twelve  times  as  cases  of  hyperacidity. 
In  cases  where  no  acidity  whatever  is  found,  we  have  to 
deal  with  anacidity. 

The  test  for  rennet  is  done  as  previously  described. 

Take  much  care  in  introducing  the  bucket,  and  yon 
will  not  meet  with  any  failures.  The  silk  should  be  good 
and  strong,  and  must  be  changed  very  often.  It  is  best 
to  speak  to  your  patient  while  the  bucket  is  being  swal- 
lowed, or  to  make  him  laugh,  in  order  to  assist  the  backet 
into  the  stomach.  We  very  seldom  meet  with  persons 
who  cannot  swallow  the  bucket.  The  bucket  has  been 
used  by  many  in  this  country  and  in  Europe ;  Stockton, 
of  Buffalo,  Fenwick,  of  London,  Stewart,  of  Philadelphia, 
and  others.  Tweedy  (in  the  Dublin  Medical  Journal 
of  Medical  Science  of  February,  1894)  reports  cases  in 
which  he  has  used  it  advantageously. 

While  studying  under  Dr.  Einhorn,  of  New  York,  I 
made  the  following  examination  to  compare  the  two 
methods : 


E 

I 


Name. 


Date. 


W.  M.. 

F.  G 


anuary  3, 1894 — 
'ebruary  25,  1894. 


3  M.  S. . .  January  5,  1894  . . . 
4jM.  K . . .  February  11.  1894. . 
5  A.  H...!  January  5,  1894... 
6JF.  G.. .  I  February  15,  1894 

7  W.  G...  .February  15,  1894.. 

8  W.  S . . .  'February  4,  1894. 


Stomach  Tube. 


Stomach  Bucket. 


Time  when  examined. 


One  hour  after  breakfast. . . 

One  hour  after  breakfast. . . 

One  hour  after  breakfast. . . 
.  J  One  hour  after  breakfast. . . 
.  One  hour  after  breakfast . . . 
.  I  One  hour  after  breakfast. . . 

One  hour  after  breakfast. . . 
.  1 20  minutes  after  breakfast. . 

9  M.  B . . .  I  February  8,  1894. . . .  One  hour  after  breakfast. . . 

jo  S.  S . . . .  I  January  2,  1894 One  hour  after  breakfast. . . 

njK.  K. . . .  January  2,  1894 One  hour  after  breakfast. . . 

12  W.  F . . .  March  3,  1894 1  >i  hour  after  breakfast .... 


HCl.    Acidity.]    ^^ 


I  I 

Rennet.    HCl. 


13  S.  L... 


March  4,  1894. 


.  Two  hours  after  breakfast. 


100 

96    I 
xco 
94     , 

*>     1 

80 

76 

68 
54 
40 


86 
80 
82 
75 
70 
60 
56 

56 
40 


I  Present. 
Present. 
Present. 
Present 
Present. 
Present. 
Present. 
Present. 

Present. 
Present. 
Present. 
Present. 


I  How  many 
l      times  di-    Rennet 
luted. 


Remarks. 


18  + 
20  + 
x8  + 
«5  + 
22  + 
6+ 
8  + 
15  + 

8  + 
7  + 


5  + 


Present.  ;A  very  nervous  patient. 
I  Present.  1 
'Present.  I 
Present.  ■ 
Present. 
Present.  | 
Present. 
Present.  One  hour  after  meal  stomach  was  empty. 

A  case  of  hyperkinesis. 
Present. 
Present 

I       o        Very  little  contents  with  tube. 
Present  Too  small  amount  of  stomach   contents 

with  tube  to  make  examination. 
Present.  Too  little  to  make  acidimetric  test. 


mucous  membranes  the  bucket  might  become  filled  with 
mucus  before  entering  the  stomach,  and  then,  in  emptying 
the  vessel,  one  would  find  clear  mucus  instead  of  chyme. 
In  such  cases  it  is  necessary  to  make  the  trial  again  and 
to  cover  the  opening  with  a  thin  gelatinous  capsule,  which 
keeps  away  the  mucus  from  the  vessel  on  its  way  to  the 
stomach ;  there  the  capsule  is  quickly  dissolved  and  the 
stomach  contents  can  now  enter  the  bucket.  On  its  return 
from  the  stomach,  the  bucket  being  filled,  the  mucus  can- 
not, to  any  extent,  enter  into  it.  As  with  the  tube,  the 
best  time  to  use  the  bucket  is  one  hour  after  Ewald's  test 
breakfast.  The  bucket  should  always  be  dipped  into 
warm  water  before  using,  in  order  to  wet  the  inside  so 
that  the  stomach  contents  may  readily  enter  it.  After 
using  the  bucket,  as  well  as  any  other  part  of  stomach 
apparatus,  it  should  be  washed  in  an  antiseptic  solu- 
tion. 

The  method  of  examination  of  stomach  contents 
obtained  by  means  of  the  bucket  is,  according  to  Ein- 
horn, as  follows :  The  contents  are  emptied  on  a  small 
porcelain  dish,  then,  by  means  of  litmus  paper,  as- 
certain whether  the  contents  be  acid  or  not ;  if  acid  it 
will  turn  the  paper  red.  With  congo  paper,  whether 
there  are  free  acids  or  only  acid  salts,  die  presence  of 
free  acids  turns  the  congo  paper  blue,  otherwise  the 
paper  remains  unchanged.  If  there  are  free  acids  the 
test  should  be  made  to  ascertain  the  presence  of  HCl. 
For  this  purpose  take  one  drop  of  the  contents,  and  one 
drop  of  Guenzburg's  solution,  and  mix  them  thoroughly 
in  a  porcelain  dish,  which  is  then  heated  over  an  al- 
cohol lamp  until  the  fluid  evaporates;  a  cherry- red 
color  appears  in  the  same  spot  if  HCl  be  present,  even  in 


As  a  whole,  from  this  table  we  can  see  that  the  method 
of  ascertaining  the  acidity  by  means  of  dilution  of  stom- 
ach contents  obtained  by  Einhorn's  bucket  corresponds 
closely  with  the  results  obtained  by  the  acidimetric  sys- 
tem, although  there  are  sometimes  exceptions  (as  for  in- 
stance Case  6).  The  stomach-bucket,  and  the  simple 
method  of  testing  the  gastric  juice  as  ^described  above 
deserve  high  recommendations. 

438  East  Sixth  Strkst,  Erik,  Pa. 


The  Consumption  of  Beer. — According  to  some  sta- 
tistics compiled  in  Vienna  there  was  a  vast  consumption 
of  beer  in  the  world  during  the  year  1893,  amounting  to 
over  4,500,000,000  gallons.  Germany  heads  the  list 
with  1,202,132,074  gallons,  an  increase  of  34,000,000 
over  1892,  the  consumption  being  thirty-three  gallons 
per  head,  ranging  from  sixty-two  gallons  in  Bavaria  to 
twelve  gallons  in  Lothringen;  Great  Britain  second, 
1,165,752,000  gallons,  or  thirty  per  head ;  America,  in- 
cluding the  whole  of  the  western  hemisphere,  is  third, 
with  more  than  1,000,000,000  gallons,  or  sixteen  per 
head.  More  than  7,270,000  tons  of  malt  and  82,000 
tons  of  hops  were  used  in  the  manufacture  of  the  beer 
for  the  world. 

The  American  Medical  Association. — The  State  of 
Virginia  with  over  2,800  physicians  has  38  members  in 
the  American  Medical  Association ;  North  Carolina  with 
1,600  physicians  has  17  members ;  Texas  gives  from 
her  3>7oo  doctors  71  members;  Mississippi,  21;  Ken- 
tucky, 87 ;  Maryland,  49  5  Louisiana,  29 ;  South  Car- 
olina, 18. — The  Southern  Clinic. 


September  15^  1894] 


MEDICAL   RECORD. 


333 


POINTS  TO   BE  REMEMBERED  IN  THE  PRAC- 
TICE OF  ANTISEPTIC  SURGERY. 

By   EDWARD   PENDLETON,  M.D., 

OWBNSBORO',   ICY. 

i.  Remember  to  boil  instruments  for  thirty  minutes  be- 
fore an  operation,  when  time  permits. 

2.  Remember  to  use  clean,  filtered,  boiled  water  in  all 
operations. 

3.  Remember  to  immerse  instruments  only  in  a  car- 
bolic or  Listerine  solution ;  the  mercurial  solution  blackens 
the  instruments  and  ruins  the  edges. 

4.  Remember  not  to  dip  soiled  cotton  in  an  antiseptic 
solution,  after  it  has  been  about  the  wound ;  use  a  new 
piece. 

5.  Remember  not  to  touch  a  sponge  or  instrument 
that  has  fallen  upon  the  floor ;  it  might  get  back  into  the 
vicinity  of  the  wound  again. 

6.  Remember  to  put  the  suture  or  ligature  back  into 
the  antiseptic  solution  when  it  has  touched  anything  that 
is  not  aseptic. 

7.  Remember  that  the  surgeon  and  his  assistants  are 
to  scrub,  cleanse,  and  disinfect  their  hands  and  forearms 
before  an  operation. 

8.  Remember  that  the  vicinity  of  the  wound  is  to  be 
shaved,  scrubbed,  cleansed,  and  disinfected. 

9.  Remember  not  to  use  a  rubber  bandage  in  forcing 
blood  out  of  a  part,  like  a  gangrenous  or  tuberculous 
limb,  but  simply  apply  constrictor  above  the  point  of 
disease. 

10.  Remember  to  use  no  antiseptic  upon  the  peritone- 
um or  any  of  the  viscera ;  if  the  operation  was  aseptic, 
antiseptics  could  do  no  good ;  if  the  operation  was  not 
aseptic,  antiseptics  could  not  make  it  aseptic. 

11.  Remember  to  try  always  to  arrest  a  bleeding  ar- 
tery by  torsion,  only  use  the  ligature  as  a  dernier  ressort. 

i2#  Remember  that  venous  and  capillary  hemorrhage 
can  be  arrested  by  the  application  of  a  hot  mercurial  lo- 
tion to  the  bleeding  surface. 

13.  Remember  to  use  cocaine  in  amputating  toes, 
fingers,  etc.,  and  in  circumcision. 

14.  Never  give  ether  when  albumin  is  present  in  the 
urine,  or  when  there  is  any  pulmonary  trouble. 

15.  Remember  always  to  open  an  abscess  by  a  free  in- 
cision, wash  out  abscess  cavity  with  a  carbolic  solution 
(1  to  10),  insert  a  perforated  drainage  tube  in  the  deep- 
est part,  and  apply  a  moist  antiseptic  dressing. 

16.  Remember  to  wash  gun-  and  pistol-shot  Wounds  in 
a  mercurial  lotion  (1  to  3,000),  and  pack  the  wound  with 
iodoform  gauze,  so  that  it  can  heal  from  the  bottom. 

1 7.  Remember  to  use  black  pins  in  surgical  dressings ; 
they  will  not  rust  and  can  be  more  readily  seen. 

18.  Remember  to  let  all  rubber  goods,  such  as  cathe- 
ters, rubber  bandages,  fountain  syringes,  rubber  sheets, 
rubber  bags,  rubber  aprons,  dry  before  they  are  put  away. 

19.  Remember  to  boil  all  instruments  that  have  been 
used  about  a  person  with  cancer,  syphilis,  or  tuberculosis, 
in  a  carbolic  solution  (1  to  30). 

20.  Remember  always  to  cleanse  a  hypodermic  needle, 
and  run  a  piece  of  wire  through  it  after  it  has  been  used. 

21.  Remember  to  thoroughly  wash,  cleanse,  and  dry 
all  instruments  after  each  operation. 

22.  Remember  to  use  gauze  sponges,  which  can  be 
thrown  away  after  they  have  been  used. 

23.  Remember  to  use  silk  in  suturing  parts  about  the 
face. 

24.  It  is  not  necessary  to  have  a  easeful  of  instru- 
ments to  perform  an  operation,  only  a  few  are  at  times 
necessary. 

25.  Remember  always  to  cleanse  and  disinfect  a  cathe- 
ter after  it  has  been  used ;  the  most  common  source  of 
infection  of  the  bladder  is  by  an  unclean  catheter. 

26.  Remember  to  use  moist  antiseptic  dressings  in  all 
septic  cases,  such  as  abscesses,  bone  felons,  lymphadenitis, 
etc.,  or  where  primary  union  is  not  expected. 

27.  Remember  to  remove  silk  sutures  on  the  third  or 
fourth  day. 


28.  Remember  that  the  edges  of  a  wound  have  to  be  in 
exact  apposition,  and  no  turning  under  is  to  be  present 
if  union  by  first  intention  is  desired. 

29.  Remember  to  dust  iodoform  over  the  line  of  su- 
tures covered  by  iodoform  gauze,  cotton,  tissue,  and  a 
rubber  bandage. 

30.  Remember  to  use  the  fingers  in  anointing  instru- 
ments instead  of  putting  the  instruments  which  are  soiled 
into  the  ointment. 

529  Locust  Street. 

EXCISION  OF  HEAD  AND  FOUR  INCHES   OF 
SHAFT  OF  HUMERUS,   WITH    CASE.1 

By   W.  E.  GUTHRIE,    M.D., 

BLOOMIKGTGN,   ILL. 

It  is  not  my  purpose  to  enter  into  an  historical  discus- 
sion of  resection  of  the  upper  end  of  the  humerus,  nor  to 
describe  the  minutiae  of  the  operation  except  in  so  far 
as  may  be  necessary  to  show  the  feasibility  of  the  opera- 
tion, and  the  possibility  of  procuring  return  of  function 
in  the  injured  member. 

Reports  of  investigators  prove  that  this  resection  is  no 
more  dangerous  than  amputation  at  the  shoulder-joint, 
and,  if  successful,  the  result  amply  compensates  for  the 
increased  trouble  of  the  excision.  If  done  for  old  dis- 
location of  shoulder  with  anchylosis,  or  for  disease  of 
the  head  of  the  humerus  where  there  is  not  extensive 
destruction  of  tissue,  the  periosteum  can  be  saved,  and 
thus  much  of  the  bone  be  restored.  Experience,  how- 
ever, has  generally  shown  that  the  best  result  to  be 
expected  in  most  cases  is  a  loose  flail-like  joint.  Gun- 
shot wounds,  which  have  been  the  most  common  cause 
for  this' operation,  usually  produce  so  much  destruction 
of  tissue  as  to  make  the  salvation  of  periosteum  a  difficult 
matter.  Especially  is  this  true  when  the  wound  is 
inflicted  by  a  shot  gun  at  close  range.  The  shot  strike 
the  bone,  and  then,  scattering,  carry  destruction  into  the 
tissues  around  the  joint.  If  the  amount  of  bone  excised 
be  large,  and  a  generous  amount  of  periosteum  be  un- 
saved, the  arm  may  be  immobilized,  using  the  body  for  a 
splint,  and  a  flail  joint  expected,  or  the  end  of  the  hume- 
rus may  be  placed  in  the  glenoid  fossa,  and  anchylosis 
almost  certainly  awaited. 

From  all  the  reports  of  this  operation  which  I  have 
been  able  to  collect  and  study,  it  appears  that  such  a 
favorable  result  as  I  have  had  the  good  fortune  to  obtain 
in  the  case  to  be  presented  to  you  to  day  is  remarkably 
rare. 

October  22, 1893,  James  H ,  eighteen  years  of  age, 

was  near  Towanda,  111.,  hunting  squirrels  with  a  shot- 
gun loaded  with  small  shot.  Being  somewhat  wearied 
by  his  tramping  he  sat  down  on  a  rail  fence  to  rest  and 
refresh  himself,  placing  the  stock  of  his  gun  on  the  rail 
below  and  holding  the  barrel  loose  in  his  arms  before 
him.  By  some  means  the  butt  of  the  gun  slipped  from 
its  resting  place  and  fell,  striking  the  hammer  on  the 
rail  and  discharging  the  piece.  The  entire  charge  (shot, 
burnt  powder,  and  wads),  together  with  shreds  of  cloth- 
ing, tore  through  the  anterior  border  of  the  axillary  space, 
severing  in  its  course  the  pectoralis  major,  long  head  of 
the  biceps,  the  anterior  fibres  of  the  deltoid,  part  of  the 
short  head  of  the  biceps,  the  infraspinatus  and  teres 
minor  muscles,  crushing  the  head  of  the  humerus  and 
shattering  the  upper  portion  of  its  shaft,  and  destroying 
the  insertion  of  the  subscapularis  and  supraspinatus  mus- 
cles. After  shattering  the  bone  the  shot  scattered  in 
every  direction  through  the  enveloping  muscles.  The 
opening  through  the  skin  was  at  least  an  inch  and  a  half 
in  diameter,  its  margins  ragged  and  bruised. 

He  was  soon  seen  by  Dr.  W.  H.  Reedy,  of  Towanda, 
who  picked  out  some  pieces  of  bone,  and  had  him  re- 
moved to  his  home,  about  six  miles  away,  and  advised 
that  I  be  called. 

It  was  several  hours  after  the  accident  when  I  reached 
his  bedside.     He  had  partially  reacted  from  the  shock ; 

1  Read  before  the  Illinois  State  Medical  Society,  May  x6,  1894. 


334 


MEDICAL   RECORD. 


[September  15,  1894 


but  as  he  had  not  sufficiently  reacted  for  operation,  and 
there  was  very  little  hemorrhage,  and  the  lights  at  our 
disposal  were  poor,  the  wound  was  cleaned  and  tempo- 
rarily dressed,  awaiting  the  morrow  for  operative  atten- 
tion. Sunday  morning,  October  23d,  assisted  by  Drs. 
Reedy  and  Anderson,  the  patient  was  anesthetized  with 
A.C.E.,  and  the  axillary  artery  being  in  good  condition, 
resection  of  the  head  and  upper  four  indies  of  the  shaft 
of  the  humerus  was  done.  The  wound  was  enlarged  up- 
ward to  a  point  even  with  the  top  of  the  head  of  the 
humerus,  and  through  this  opening  the  pieces  of  bone 
were  removed  one  by  one,  care  being  taken  to  strip  the 
periosteum  from  each  piece  before  removal,  and  a  portion 
of  bone  was  scraped  off  with  each  muscular  insertion  into 
the  broken  bone.  The  removal  of  the  periosteum,  ten- 
don, and  muscle  was  surprisingly  easy  by  reason  of  the 
chisel-edged  raspatory  used.  The  fragments  being  re- 
moved, the  point  of  the  shaft  was  pushed  up  through  the 
wound  by  an  assistant  and  sawed  off  even  with  a  chain- 
saw.  The  most  time  was  consumed  and  the  greatest 
difficulty  encountered  in  cleaning  out  the  shot,  burnt 
powder,  scraps  of  clothing,  and  dead  muscular  tissue. 
He  had  been  under  the  anaesthetic  two  hours  and  a 
quarter  before  I  was  satisfied  that  I  had  made  the  wound 
as  clean  as  possible.  The  cavity  was  then  carefully 
washed  out  with  a  sublimate  solution,  and  about  two 
ounces  of  a  ten  per  cent,  solution  of  iodoform  in  ether 
poured  into  the  depths  of  the  wound,  and  the  latter 
thoroughly  packed  with  iodoform  gauze. 

Ordinarily  I  believe  it  good  practice  to  raise  the  arm 
before  dressing  until  the  end  of  the  severed  humerus  rests 
in  the  glenoid  fossa.  In  this  case  I  did  not  follow  this 
course,  fearing  that  the  great  destruction  of  tissue  in  the 
neighborhood  of  the  joint  would  later  infect  the  open 
end  of  the  bone  and  cause  suppuration  and  perhaps  sep- 
sis. So  the  axilla  was  thoroughly  padded,  the  arm  left 
at  the  side  in  a  natural  position,  the  forearm  placed 
across  the  chest,  and  the  whole  immobilized  by  numerous 
strips  of  adhesive  plaster.  There  was  no  subsequent 
hemorrhage,  no  pain,  no  elevation  of  temperature  above 
one  hundred  degrees.  Through  the  gauze  there  was  a 
copious  serous  oozing.  Two  days  later  the  gauze  was 
removed  without  disturbing  the  arm,  two  drainage-tubes 
were  inserted,  one  downward  to  the  end  of  the  humerus 
and  one  backward  into  the  depths  of  the  wound,  and  the 
portion  of  the  opening  made  by  my  knife  was  closed  by 
suture.  As  stated  before,  there  was  no  pain  and  no  in- 
flammation. The  only  complication  was  vomiting  and 
pyrosis  for  several  days.  Otherwise  he  made  an  uninter- 
rupted recovery.  Drainage  by  means  of  rubber  tubes, 
and  later  silkworm  gut,  was  kept  up  for  several  months, 
a  stray  shot  coming  away  occasionally.  For  several 
weeks  it  has  been  entirely  healed.  It  is  now  a  little 
more  than  six  months  since  the  operation.  As  you  see, 
there  is  no  shortening  of  the  arm.  Nature  has  replaced 
the  bone  removed  by  another  growth,  the  upper  end  of 
which  you  can  feel  rests  in  the  glenoid  fossa ;  the  axilla 
is  of  full  capacity.  When  I  push  upward  on  his  elbow 
you  see  I  raise  the  whole  shoulder,  thus  proving  the  bone 
has  been  entirely  restored.  This  young  man  is  a  farmer, 
and  prides  himself  that  he  has  "  made  a  hand  "  on  the 
farm  this  spring.  He  milks  the  cows  with  both  hands, 
feeds  himself  with  the  left  hand  (the  injured  side),  and, 
although  the  range  of  mobility  of  the  arm  is  not  large,  it 
is  gradually  increasing  with  restored  muscular  power,  and, 
all  things  considered,  the  result  is  very  satisfactory.  I 
show  you  also  the  portion  of  bone  removed  by  me.  I 
have  had  the  pieces  placed  in  their  natural  relation  to 
each  other  and  glued  together.  A  portion  of  the  head 
you  see  is  missing,  the  portion,  I  suppose,  that  was  re- 
moved at  the  scene  of  the  accident. 

As  near  as  I  can  find,  this  case  is  unique  on  account 
of  the  amount  of  bone  restored  and  the  remarkable  res- 
toration of  function  in  so  short  a  time. 


The  Contagiousness  of  Tuberculosis  is  denied  by  Dr. 
Sprae,  of  Norristown,  Pa. 


gttpgness  at  gfcjeaical  Science. 

Care  of  the  Mouth  in  Sick  Persons.— Rosenbach  says 
that  in  many  illnesses  there  is  almost  sure  to  be  second- 
ary trouble  in  the  mouth  if  preventive  measures  be  not 
taken  {The  British  Medical  Journal).  A  warning  sign 
is  dryness  and  redness  of  the  tongue  and  mucous  mem- 
brane of  the  mouth,  with  difficulty  in  swallowing ;  fur- 
ther signs  are  an  evil  odor  from  the  mouth,  coated 
tongue  and  gums,  bleeding  of  the  gums,  etc.  Just  as 
special  care  of  the  mouth  is  required  in  patients  with 
carious  teeth,  smokers,  and  chewers  of  tobacco,  so  it  is 
also  in  the  case  of  unconscious  or  paralyzed  persons ;  pa- 
tients with  fever  or  suffering  from  chronic  digestive  com- 
plaints; those  taking  medicines,  such  as  mercury  or 
iodides,  or  who,  on  account  of  general  weakness,  have  to 
take  strong  alcoholic  drinks;  but,  perhaps,  the  most 
important  class  of  those  in  whom  special  care  of  the 
mouth  must  be  taken  are  patients  with  fever.  Parasites 
are  always  present  in  the  mouth,  but  it  is  only  when  the 
tissues  are  weakened  that  they  undergo  invasion  by  these 
parasites,  which  become  then  really  pathogenic.  There 
is  nothing  which  one  can  do  for  sick  persons  which  is 
unimportant,  and  by  neglect  in  the  care  of  the  mouth 
convalescence  may  be  retarded.  Rosenbach  concludes 
with  the  following  rules :  (1)  Patients  with  good  diges- 
tive powers,  free  from  fever,  and  with  no  loss  of  con- 
sciousness require  no  more  than  the  ordinary  care  of  the 
mouth.  (2)  In  children  and  very  old  patients  the  less 
solid  food  taken  the  greater  should  be  the  care  with  the 
mouth.  They  should  rinse  the  mouth  out  several  times 
a  day  with  lukewarm  water  containing  a  little  common 
salt,  tincture  of  myrrh,  or  eau  de-Cologne  added  to  stim- 
ulate secretion.  When  there  is  a  tendency  to  bleeding 
of  the  gums,  or  when  the  teeth  are  bad,  a  pinch  of  pow- 
dered boric  acid  may  be  twice  daily  rubbed  in  between 
the  lips  and  gums.  Patients  with  false  teeth  should  re- 
move their  false  teeth  when,  owing  to  loss  of  appetite 
or  chronic  gastric  disturbance,  they  cannot  take  solid 
food.  (3)  In  patients  with  partial  loss  of  consciousness 
the  mouth  should  be  examined  several  times  a  day  for 
small  sores,  such  as  may  arise  from  the  pressure  of  the 
teeth  on  the  lips,  etc.  Such  sores  should  be  powdered 
with  a  little  boric  acid  or  chlorate  of  potash,  and  the 
cracks  at  the  corners  of  the  lips  heal  quickly  if  dried 
with  a  clean  towel  and  treated  with  boric  acid  or  vase- 
line. The  mucous  membrane  may  be  stimulated  by 
wiping  the  tongue  and  mouth,  and  pressing  on  the 
tongue  with  a  moist  towel  every  two  or  three  hours ;  if 
necessary,  the  hinder  part  of  the  tongue  should  be 
cleaned  with  a  wad  of  cotton- wool  fastened  to  a  stem. 
If  the  patient  sleep  with  the  mouth  open  the  air  in  the 
room  must  be  kept  moist ;  a  moistened  layer  of  muslin 
laid  on  the  mouth  may  be  of  some  service.  (4)  Patients 
with  fever  should  have  something  to  drink — cold  water 
or  weak  lemonade — at  least  every  hour ;  one  must  not 
wait  until  the  patient  asks  for  drink.  Besides  preventing 
dryness,  the  fluid  maintains  the  activity  of  the  glands 
and  the  whole  function  of  the  mucous  membrane.  Many 
patients  are  prevented  from  drinking  by  a  painful,  dry, 
and  cracked  condition  of  the  lips,  and  therefore  all  fev- 
erish patients  should,  from  the  commencement  of  their 
illness,  have  their  lips  rubbed  several  times  a  day  with 
vaseline  or  fat.  In  protracted  cases  of  fever  the  mouth 
may  also  be  swabbed  out  with  oil,  fat,  or  greatly  diluted 
glycerine. 

Total  Abstainers  in  the  Indian  Army. — The  Army 
Temperance  Society  of  the  British  army  in  India  has 
grown  from  13,000  members  in  1890  to  over  22,000 
members  to-day.  Out  of  1,100  regimental  courts- mar- 
tial for  1893,  onty  39  ***  t0  try  members  of  the  Tem- 
perance Association,  and  of  2,680  courts  martial  of 
all  classes  for  that  year,  only  73  concerned  temperance 
men. 


September  15,  1894] 


MEDICAL  RECORD. 


335 


Medical  Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


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


New  York,  September  15,  1894. 


AS  OTHERS  SEE  US. 
Last  year  medical  men  and  matters  on  this  side  of  the 
Atlantic  were  observed  and  freely  commented  upon  by 
that  veteran  medical  journalist,  Mr.  Ernest  Hart.  We 
have  again  been  subjected  to  observation  and  comment 
.  by  one  of  our  transatlantic  brethren — a  German.  A 
book  recently  published  by  Dr.  Placzek,1  a  Berlin  neu- 
rologist and  litterateur,  pictures  the  medical  profession 
in  this  country  with  the  pen  of  a  discriminating  observer. 
The  surprise  and  pleasure  which  the  revelations  of  his 
journey  produced  upon  the  author  are  quite  naively  told. 
A  few  extracts  from  the  work  may  enable  us  to  "  see  our- 
selves as  others  see  us." 

In  his  introduction,  the  author  expresses  surprise  and 
admiration  of  the  spirit  which  pervades  our  eleemosynary 
institutions.  "  The  European  physician,  whose  vision  is 
narrowed  by  the  diminutive  size  of  his  own  country,  does 
not  conceive  that  beyond  the  wild-heaving  Atlantic  there 
lies  the  land  of  promise,  par  excellence,  a  land  of  im- 
measurable resources,  in  which  the  talents  of  the  indi- 
vidual may  hew  out  a  career  unimpeded  by  European 
class  distinction.'1  The  author  believes  that  the  pilgrim- 
ages now  made  to  Europe  by  our  physicians  will  cease ; 
that  schools  will  ere  long  be  created  whose  disciples,  as 
"  thoroughly  educated  as  their  European  colleagues,  will 
reach  out  toward  the  goal  of  knowledge  with  the  same 
zeal,  the  same  ability,  and  the  same  thoroughness. ' '  With 
the  penetration  of  a  skilled  observer,  Dr.  Placzek,  in  de- 
scribing our  hospital  system,  emphasizes  the  fact  that  we 
do  not  rely  upon  the  state  for  aid  as  they  do  in  Germany, 
but  "  the  cruel  help  yourself,"  which  rules  in  all  branches, 
permeates  also,  strange  as  it  may  seem,  all  purely  humane 
efforts."  Nor  is  he  slow  to  recognize  that,  "  while  our 
institutions  built  and  maintained  by  the  state  are  often 
sadly  defective,  most  of  those  initiated  by  private  enter- 
prise are  models  of  astonishing  completeness."  .  He 
acknowledges  that  the  European  errs  in  regarding  the 
American  as  a  "dollar  hunter"  devoid  of  all  sentiment, 
citing  as  evidence  the  fact  that  a  vast  stream  of  money 
flows  constantly  into  the  coffers  of  our  hospitals,  much  of 
which  is  given  "  in  memory  of  a  wife,  son,  or  daughter," 
as  recorded  pathetically  on  tablets  over  some  of  the  beds. 
The  shadowy  side  of  the  picture  is  brought  out  in  his 
reference  to  the  fact  that,  despite  their  great  wealth,  these 
corporations  accept  the  services  of  medical  men  without 
compensation,  and  that  the  lay  directors  entirely  control 

1  Die  Medicinische  Wissenschaft  in  den  Vereinigten  Staaten.  Rei- 
sestudien  von  Dr.  med.  S.  Placzek,  Nervenarzt  in  Berlin.  Leipzig : 
Georg  Tbieme.    1894. 


the  affairs  of  the  hospital.  He  especially  condemns  the 
authonty  of  the  superintendent,  which  he  erroneously 
regards  as  supreme  in  all  our  hospitals.  The  comfort  and 
elegance  of  our  hospitals  are  brought  into  striking  con- 
trast with  those  of  Germany,  and  this  is  emphasized  by 
well  executed  illustrations.  Our  ambulance  system  and 
our  training-schools  for  nursing  elicit  the  author's  highest 
encomiums,  and  are  held  up  as  examples  worthy  of  imi- 
tation. He  is  struck  by  the  extravagance  in  the  arrange- 
ment of  our  dispensaries  (which  he  calls  the  children  of 
sorrow  of  medical  practice) ;  he  justly  condemns  the  reck- 
less disregard  of  the  interests  of  the  profession  displayed 
in  their  administration.  Under  the  caption  of  "  Thera- 
peutic Tendencies,"  the  author  alludes  to  the  contrast 
between  German  therapeutic  nihilism  and  the  implicit 
faith  in  drugs  of  the  average  American,  which  he  attrib- 
utes to  imperfect  education.  He  assigns  the  latter  as  a 
cause  of  the  glaring  disregard  of  the  newer  therapeutic 
methods,  citing  rational  hydrotherapy  as  an  example. 
"  The  process  of  development  through  which  this  thera- 
peutic method  is  passing,  in  order  to  conquer  the  position 
to  which  it  is  entitled,  will  always  be  noteworthy  in  the 
history  of  American  medicine.  To  the  zeal  of  a  New 
York  physician,  who  is  conducting  the  battle  for  the 
introduction  of  this  powerful  agent  with  unflagging 
industry,  the  credit  will  be  due  if  the  opposition  to 
this  method,  which  has  long  ago  attained  recognition 
in  Europe,  shall  be  overcome."  He  finds  electro-diag- 
nosis and  therapeutics  as  little  "the  general  property 
of  the  profession  here  as  it  is  in  Europe,  and  he  regrets 
to  note  that  massage  is  entirely  in  the  hands  of  laymen." 
Our  insane  asylums  receive  extensive  notice,  and  many 
illustrations  are  furnished  to  emphasize  their  elegance 
and  comfort.  Our  quarantine  system  is  regarded  as  too 
exacting ;  its  excessive  demands  being  illustrated  by  the 
detention  of  the  Normannia  last  summer.  "  The  Amer- 
ican's fear  of  contagion  is  well  known ;  he  expects  pro- 
tection from  the  quarantine  officer;  "  thus  Dr.  Jenkins's 
rigorous  measures  are  condoned,  the  European  idea  of 
the  American  doctor,  that  he  is  a  sort  of  inferior  being,  a 
practical  merchant,  is  regarded  as  a  great  error  by  the 
author.  "Reality  develops  quite  a  different  picture," 
says  he.  "  In  vain  do  we  look  over  there  for  the  large 
and  showy  signs  announcing  the  doctor  to  be  "a  prac- 
tical physician,  surgeon,  and  accoucheur,  or  specialist  for 
larynx,  throat,  or  n  ose. ' '  Not  even  the  well-  known  ' '  free 
to  the  poor"  is  found  anywhere.  Nothing  of  all  this, 
only  a  small'  sign  in  the  inside  of  a  window  stating  the 
doctor's  name  and  office  hours."  An  extract  from  the 
Code  of  Ethics  concludes  this  interesting  chapter,  with 
the  statement  that  our  "  codex  of  morals  is  far  more  strict 
than  that  customary  in  Germany." 

Our  educational  facilities  are  fairly  well  presented,  they 
are  concluded  with  a  just  criticism  upon  the  following 
defects:  1.  Imperfect  preparatory  education.  2.  Ex- 
cessive theoretical  instruction.  3.  Insufficient  clinical 
teaching.  4.  Insufficient  practical  activity.  5.  Brevity 
of  course  of  study. 

Our  sanitary  and  hygienic  affairs  are  largely,  and  upon 
the  whole  favorably,  commented  upon. 

Taking  the  book  as  a  whole,  we  have  reason  to  be 
proud  of  the  impression  made  upon  a  representative 
German  colleague,  whose  clearness  of  perception  is  equalled 
by  the  fairness  of  his  criticisms. 


OO 


MEDICAL  RECORD. 


[September  15,  1894 


SOME    EXPERIENCES    OF    THE    DOCTOR'S 
WIFE. 

The  doctor's  wife  has  had  many  kind  and  sympathetic 
things  said  about  herself  and  her  lot.  A  whole  book  has 
even  been  written  regarding  her  trials,  her  duties,  and 
her  pleasures.  The  theme  is  a  fertile  one ;  and  a  Brook- 
lyn doctor's  wife  has  recently  and  -happily  enriched  it 
through  the  columns  of  the  New  York  Times.  Some  of 
her  comments  will  no  doubt  wake  responsive  notes  in 
the  minds  of  the  many  doctors'  wives  who  read  the  Med- 
ical Record. 

"  The  apologies  of  the  people  who  do  not  employ  my 
husband  as  a  physician/'  says  the  Brooklyn  lady,  "  are 
the  funniest  things  yet.  It  is  an  extremely  delicate 
thing  to  receive  these  apologies  in  a  delicate  manner. 
You  really  do  not  know  what  to  do.  I  think  sometimes 
a  doctor's  wife  who  says  just  the  right  thing  must  be  in- 
spired. You  have  to  say  the  very  best  things  you  can 
for  the  physicians  they  employ.  This  is  a  big  world  and 
a  hard  world,  and  it  is  always  best  to  say  all  the  good 
you  can  about  every  one.  People  are  apt  to  ask  your 
advice,  too,  about  which  you  consider  the  best,  the  reg- 
ular or  the  homoeopathic  school  of  medicine,  but  al- 
though they  ask  the  question  they  are  very  likely  to  feel 
terribly  grieved  if  you  say  anything  against  either  school. " 

It  is  a  standing  grievance  with  some  wives  that  they 
have  to  be  called  "  Mrs.  Doctor." 

"  How  many  times,"  she  says,  "I  hear  that  expres- 
sion. People  do  not  seem  to  realize  that  you  got  the 
'Mrs.'  alone  and  not  by  degrees,  but  by  just  a  few 
words.  The  certificate  one  gets  at  that  time  has  nothing 
to  do  with  degrees  or  '  Mrs.  Doctor.'  I  suppose  it  is  be- 
cause of  '  Mrs.  Doctor '  that  there  is  hardly  anything  I 
have  not  been  asked  to  do  when  the  doctor  was  out, 
from  setting  a  broken  arm  to  pulling  a  tooth.  And  the 
people  will  not  see  why  I  cannot  do  it. 

"  One  man  wanted  a  prescription.  He  said  he  knew 
exactly  how  the  signs  looked  on  paper,  if  I  would  only 
make  them.  The  druggist  would  not  give  him  the  medi- 
cine without  the  paper.  Another  man  could  give  an  ex- 
act description  of  the  bottle  some  medicine  was  taken 
from  if  I  would  only  get  it  for  him." 

The  Brooklyn  doctor's  wife  would  evidently  be  glad  to 
join  the  "  Society  for  the  Abolition  of  the  Doctor's 
Title,"  for  she  says : 

"  The  life  in  a  house  behind  a  brass  sign  seems  to  me 
different  from  other  lives.  There  you  are  ticketed. 
When  you  stand  in  the  window  you  are  not  a  private 
woman  in  a  private  house.  You  are  Mrs.  Doctor  So-and- 
So  to  every  one  who  happens  to  look  your  way. 

"  You  are  never  sure  of  an  evening,  and  you  may  sit 
waiting  with  gloves  on  until  long  past  calling  time,  and 
the  doctor  won't  come  after  all.  To  be  a  doctor's  wife 
means  to  go  to  dinner-parties  alone,  with  your  escort  ar- 
riving perhaps  with  the  second  or  third  course.  It  is  a 
dual  life,  with  the  doctor's  wife  spreading  herself  like  thin 
varnish  over  it  all.  Then,  and  it  is  not  the  least  of  all, 
the  doctor's  wife  has  to  look  after  the  family  carving." 

From  all  of  which  we  should  infer  that  if  a  young 
woman  were  to  take  any  advice  about  marrying  a  doctor 
it  should  be  Punch's  general  admonition:  "Don't." 
Fortunately  advice  is  not  asked  as  to  matrimony  by  the 
woman  of  to-day. 


fjcxrrs  of  Ifee  SSSCeefc. 

Free  Alcohol. — The  result  of  the  unintentional  plac- 
ing by  the  new  tariff  bill  of  alcohol  used  in  the  arts  on 
the  free  list  will,  it  is  said,  reduce  the  price  of  tinctures, 
perfumery,  and  spirit  varnish  from  fifty  to  sixty  per  cent. 

Milk  from  Tuberculous  Cows. — In  a  recently  issued 
Agricultural  Department  report,  on  tuberculosis  in  cat- 
tle, by  Theobald  Smith,  chief  of  the  animal  pathology 
department,  it  is  stated  that  investigations  undertaken 
by  the  department  show  that  the  milk  of  tuberculous 
animals  is  not  so  infrequently  infected  as  supposed.  Milk 
of  animals  in  the  earliest  stages  of  the  disease  and  with 
perfect  udders,  does  not  contain  tubercle  bacilli.  Only 
those  showing  signs  of  labored  breath  and  emaciation 
should  be  gravely  suspected,  and  their  milk  excluded  at 
once  from  sale. 

A  Statue  to  Claude  Barnard  will  be  unveiled  at  Lyons 
on  October  26th.  The  French  Academy  has  appointed 
MM.  J.  Bertrand  and  Brunetiere  to  represent  it  on  the 
occasion.  The  Academie  des  Sciences  will  be  repre- 
sented by  MM.  Chauveau  and  Bouchard.  As  the  first 
French  Congress  of  Internal  Medicine  will  be  in  session 
in  Lyons  at  the  time,  it  is  expected  that  the  ceremony 
will  be  exceptionally  brilliant. 

The  American  Academy  of  Medicine. — At  the  annual 
meeting  of  the  American  Academy  of  Medicine,  held  at 
Jefferson,  N.  H.,  the  following  officers  were  elected: 
President,  J.  McFadden  Gaston,  M.D.,  of  Atlanta; 
Vice-Presidents,  Rufus  P.  Lincoln,  M.D.,  of  New  York ; 
William  T.  Smith,  M.D.,  of  Hanover;  Helen  C.  Put- 
nam, M.D.,  of  Providence;  Victor  C.  Vaughan,  M.D., 
of  Ann  Arbor ;  Secretary  and  Treasurer,  Charles  Mcln- 
tyre,  M.D.,  of  Easton,  Pa.;  Assistant  Secretary,  Edgar 
M.  Green,  M.D.,  of  Easton,  Pa.;  Member  of  Council, 
Charles  C.  Bombaugh,  M.D.,  of  Baltimore.  The  next 
meeting  will  be  held  in  Baltimore,  May  4,  1895. 

Deaths  from  Chloroform. — From  August  10th  to  Sep- 
tember 1st,  there  were  three  death}  from  chloroform  an- 
aesthesia in  London  hospitals. 

A  Hew  Pulmonary  Disease — "Pulmonea." — Dr.  J. 
W.  Power,  of  Caylloma,  Peru,  says  in  The  Lancet  that 
pulmonea  is  a  name  given  by  the  native  Peruvian  miners 
to  an  affection  of  the  chest  simulating  acute  pneumonia 
in  the  consolidation  stage,  and  might  easily  be  mistaken 
for  it.  In  these  altitudes  (15,600  feet)  the  sudden  daily 
extremes  of  temperature  (750  to  380  F.  average)  natural 
to  the  climate,  and  the  inhalation  of  the  irritating  dust 
of  the  dry  stamps  of  the  mills  and  smelting  fumes,  make 
cases  of  pulmonea  of  daily  occurrence.  Miners  with 
pulmonea  will  present  themselves  complaining  of  inabil- 
ity to  woik,  of  a  dull  pain  under  the  heart  and  between 
the  shoulders,  of  cough  and  sometimes  blood  spitting, 
and  distress  of  breathing.  Inspection  of  the  chest  shows 
increased  and  quickened  breathing.  There  is  increased 
vocal  fremitus,  with  marked  dulness  on  percussion,  and 
increased  resonance  over  both  lungs  at  the  back  of  the 
chest — under,  as  it  were,  the  seat  of  pain.  Sometimes 
roughened  breathing  can  be  heard,  but  not  tubular. 
However,  there  are  no  febrile  symptoms,  and  the  ab- 
sence of  these  and  the  tubular  breathing  are  the  only 
differences  between  the  two  affections.     I  have  made  ne- 


September  15,  1894] 


MEDICAL  RECORD. 


337 


cropsie  of  two  men  whom  I  had  previously  treated  for 
pulmonea,  who  had  died  from  the  effects  of  mining  acci- 
dents, and  in  both  cases  I  found  the  glands  in  the  pos- 
terior mediastinum  greatly  enlarged,  inflamed,  and 
thickened,  forming  a  compact  mass  in  a  situation  which 
would  just  correspond  to  the  seat  of  pain,  and  I  have  no 
doubt  that  these  glands  were  the  cause  of  the  symptoms 
and  physical  signs  which  I  have  described.  Their  con- 
dition was  probably  caused  by  the  irritating  matter  con- 
tinually inhaled  by  the  men.  With  regard  to  treatment, 
painting  the  back  with  iodine,  and  syrup  of  the  iodide  of 
iron  given  internally,  with  a  few  days  in  the  froth  air, 
will  remove  all  the  unpleasant  symptoms,  but  not  the 
physical  signs. 

A  Hew  Oat. — The  various  medical  societies,  acade- 
mies, sections,  etc.,  which  are  about  to  begin  the  fall  and 
winter  season  will  be  interested  in  learning  that  Lord 
Raleigh  has  discovered  a  new  kind  of  gas,  resembling 
nitrogen. 

Pasteur's  Vaccination. — The  authorities  of  Lower 
Austria  have  decided  that  a  station  for  vaccinating 
against  rabies  shall  be  established  in  the  neighborhood 
of  Vienna. 

St.  Louis  has  an  Electric  Ambulance. — The  St  Louis 
authorities  have  adopted  a  plan  of  conveying  patients 
from  the  Dispensary  to  the  city  hospital  by  means  of  an 
electric  railway  ambulance.  A  street  car,  with  electric 
motor  attachments,  has  been  fitted  up  as  an  ambulance, 
and  the  system  has  been  successfully  put  to  work.  It  is 
intended  to  run  the  car  to  all  parts  of  the  city  in  response 
to  ambulance  calls.  The  car  will  be  permitted  to  make 
an  average  speed  of  twelve  miles  an  hour. 

The  Tri-8tate  Medical  Society,  with  membership  from 
Illinois,  Iowa,  and  Missouri,  will  meet  in  Jacksonville, 
111.,  October  2  and  3,  1894.  Valuable  papers  are  prom- 
ised from  leading  members  of  the  profession  of  Chicago, 
St.  Louis,  Kansas  City,  Indianapolis,  Keokuk,  Spring- 
field  and  other  places.  A  large  and  profitable  meeting 
is  anticipated. 

The  Cholera. — The  epidemic  in  Russia  has  assumed 
large  proportions  again  during  the  past  week,  or  else,  as 
is  very  probable,  the  invasion  of  new  districts  for  several 
weeks  past  was  kept  secret  by  the  authorities  until  the 
number  of  cases  became  so  great  that  further  conceal- 
ment was  impossible.  During  the  week  ending  Septem- 
ber 8th,  6,376  new  cases  and  3,192  deaths  were  reported 
in  Russia  proper,  and  the  weekly  average  of  new  cases  in 
Russian  Poland  is  5,000,  with  a  mortality  of  about  fifty 
per  cent.  The  disease  is^very  prevalent  in  Nijni-Novgorod, 
where  the  annual  fair  is  now  being  held.  In  Gaiicia 
and  Bukowina,  during  the  three  days  ending  September 
9th,  there  were  533  new  cases  and  304  deaths.  Since 
the  beginning  of  the  epidemic  there  have  been  6,958 
cases  of  cholera  and  over  3,000  deaths  in  these  provinces. 
The  weekly  average  of  new  cases  reported  in  Germany  is 
about  50.  It  is  believed  that  the  Rhine  is  infected,  as 
cases  have  occurred  on  the  Rhine  steamers.  The  disease 
is  undoubtedly  epidemic  in  Marseilles,  although  the  au- 
thorities persist  in  their  denials  that  cholera  is  present 
there.  Most  of  the  Mediterranean  ports  have  established 
quarantine  against  that  city.  Other  towns  in  France  in 
which  one  or  more  cases  of  the  disease  have  occurred  are 
Paris,  Bordeaux,  Lassay,  Rheims,  Reuil,  and  Mancelsur- 


Scille.  An  increase  in  the  number  of  cases  is  also  re- 
ported from  Belgium,  eleven  deaths  having  occurred  in 
Liege  on  September  5th,  and  new  cases  are  constantly 
being  discovered  in  towns  on  the  Meuse  and  Sambre 
rivers,  and  also  in  places  along  the  Maas,  which  is  the 
continuation  of  the  Meuse  in  Holland.  A  Bavarian  im- 
migrant died  in  Cumberland,  Md.,  a  few  days  ago  with 
symptoms  pointing  to  cholera,  but  an  investigation  by 
the  Marine  Hospital  authorities  has  shown  that  the  case 
was  not  one  of  Asiatic  cholera. 

Failure  of  Halftone's  Inoculations. — A  dispatch  to 
the  London  Times  iiova  Calcutta,  dated  September  nth, 
says  that  during  the  recent  cholera  epidemic  at  Lucknow 
several  soldiers  who  were  inoculated  with  Dr.  Haffkine's 
virus  were  attacked,  and  that  the  proportion  of  mortality 
among  them  was  the  same  as  among  ordinary  patients. 
This  contradicts  the  results  of  the  experiments  conducted 
by  Drs.  Haftkine  and  Simpson,  in  Calcutta  last  June.  It 
was  then  said  that  few,  if  any,  of  those  inoculated  were 
attacked  by  the  disease,  or  if  attacked  they  promptly  re- 
covered. 

Dr.  William  G.  Dabney  died  recently  from  typhoid 
fever  in  Charlottesville,  Va.  He  was  graduated  from  the 
Medical  Department  of  the  University  of  Virginia  in 
1868,  and  at  the  time  of  his  death  was  professor  of  ob- 
stetrics and  the  practice  of  medicine  in  that  institution. 

The  International  Congress  of  Hygiene  and  Demog- 
raphy, which  closed  its  session  in  Budapest,  on  Satur- 
day last,  will  hold  its  next  meeting  in  Madrid. 

Hong  Kong  is  officially  declared  to  be  free  from  the 
plague,  and  the  port  was  opened  to  commerce  on  Sep- 
tember 10th. 

Yellow  Fever. — The  steamer  Samuel  Tyzak,  which 
arrived  in  Baltimore  from  Havana  on  August  31st,  had 
four  cases  of  yellow  fever  on  board.  One  of  the  men 
died  in  the  Maryland  University  Hospital,  and  another 
occupied  a  bed  in  one  of  the  wards  before  the  nature  of 
his  disease  was  discovered.  The  bark  Alice,  also  from 
Havana,  is  at  quarantine  at  Cape  Henry,  with  three 
cases  of  the  same  disease. 

Dr.  ffoah  Sanborn  died  in  Bayonne,  on  September 
6th.  He  was  born  in  Tamworth,  N.  H.,  in  1837,  but 
had  been  a  resident  of  Bayonne  for  twenty-two  years. 
He  served  throughout  the  Civil  War  as  a  surgeon  in  the 
Northern  Army,  and  at  the  time  of  his  death  was  one  of 
the  attending  staff  of  the  Bayonne  City  Hospital. 

Signor  Crispi,  Prime  Minister  of  Italy,  is  reported 
to  be  suffering  from  a  cataract. 

The  Craig  Epileptic  Colony. — It  is  probable,  as  we 
learn  from  authentic  sources,  that  the  epileptic  colony 
will  not  be  opened  for  actual  work  under  two  or  three 
years.  There  is  perhaps  already  some  trouble  about 
patronage. 

Dr.  George  Thomas  Jackson,  of  this  city,  has  been 
appointed  foreign  Secretary  for  the  United  States  of  the 
Third  International  Congress  of  Dermatology  to  be  held 
in  London,  July  31  to  August  4,  1895. 

Hog  Cholera  is  epidemic  in  Lyons  County,  Kan. 
Over  four  thousand  hogs  are  said  to  have  already  died 
from  the  disease,  and  many  breeders  have  lost  their  en- 
tire stock. 


33» 


MEDICAL   RECORD. 


[September  15,  1894 


Dr.  Charles  H.  Williamson  died  on  Monday,  Septem- 
ber 10th,  at  St.  John's  Hospital,  in  Brooklyn,  in  his 
sixty-eighth  year.  He  was  born  in  Virginia,  and  served 
as  a  medical  officer  in  the  United  States  Navy  for  some 
years  preceding  the  breaking  out  of  the  rebellion,  when 
he  joined  the  Confederacy.  At  the  close  of  the  Civil 
War  he  served  as  surgeon  in  the  Pacific  Mail  Steamship 
Company. 

The  Cause  of  Liverpool's  High  Death-rate.— Some  re- 
marks having  been  made  about  the  high  rate  of  mortality 
in  Liverpool,  the  medical  officer  of  health  in  that  city  has 
prepared  an  explanatory  statement,  in  which  he  attributes 
the  apparent  unhealthiness  of  the  town  to  the  density  of 
the  population,  there  being  no  rural  or  semi-rural  districts 
within  the  municipal  area,  as  there  are  in  other  places. 
While  in  Liverpool  there  are  1 14  houses  to  the  acre,  there 
are  only  39.9  in  Manchester,  38  in  Birmingham,  and  so 
on  to  Huddersfield,  which  has  only  8  to  the  acre. 
The  death-rate  in  Liverpool  is  23  per  1,000,  and  in  Man- 
chester only  18  2;  but  taking  the  township  district  of 
Manchester,  which,  to  a  certain  extent,  corresponds  to 
Liverpool,  the  death  rate  there  is  27  per  1,000,  which  is 
greater  than  that  of  Liverpool.  Turning  to  London, 
which,  he  says,  is  a  very  difficult  place  to  say  anything 
about,  the  average  death-rate  is  21.3,  but  in  what  may  be 
called  the  urban  district  of  London  the  rate  is  26.  The 
death-rate  in  Liverpool  during  the  last  six  months  was 
materially  below  the  average  of  the  last  ten  years. 

English  as  a  Universal  Language. — At  the  session  of 
the  American  Social  Science  Association  in  Saratoga  on 
September  4th,  Mr.  D.  G.  Porter,  of  Waterbury,  Conn., 
read  a  paper  on  "  English  as  a  Universal  Language." 
He  said  that  in  the  present  century  there  had  been  a  de- 
mand for  a  universal  language.  French  and  the  so  called 
Volapuk  had  been  advocated,  and  there  had  been  a  de- 
mand for  the  revival  of  the  Latin  tongue  ;  but  the  Eng- 
lish, the  youngest  of  all  the  great  tongues,  seems  to  be 
the  survivor  in  the  struggle  for  the  supremacy.  It  was 
largely  owing  to  the  fact,  he  said,  that  it  was  the  lan- 
guage which  grew  from  the  necessities  of  the  common 
people,  without  regard  to  the  rules  of  orthography  or 
grammar.  He  traced  the  formation  of.  the  English  lan- 
guage from  the  beginning  of  the  fourteenth  century,  when 
the  Norman-French  that  had  been  forced  on  Great  Brit- 
ain as  the  language  of  its  court  and  legal  tribunals  was 
forced  to  compromise  with  the  Saxon- Danish,  which  was 
spoken  by  the  peasantry,  so  that  all  classes  of  people 
could  converse  and  comprehend  each  other,  and  from 
the  necessities  that  urged  that  compromise  has  grown 
that  which  requires  that  the  spoken  English  should  be  the 
universal  tongue,  for  of  its  energy,  begotten  by  the  com- 
pounding of  races,  grew  the  commercial  supremacy  of 
England  and  her  colonies,  that  had  encircled  the  world 
and  carried  with  it  the  English  speech,  until  now  com- 
merce requires  it,  and  it  is  even  supplanting  French  as 
the  tongue  of  diplomacy. 

Mr.  Porter  is  evidently  not  a  reader  of  the  Medical 
Record,  otherwise  he  would  have  had  something  to  say 
concerning  the  powerful  claims  of  modern  Greek  to  gen- 
eral acceptance  as  the  universal  language  of  science.  Of 
course,  if  we  believed  English  had  any  chance  of  being 
adopted  as  the  international  means  of  communication, 
we  should  gladly  urge  its  claims ;  but  we  fear  there  is 


little  hope  of  this.  It  is  commonly  said  that  our  tongue 
is  understood  and  spoken  by  all  educated  men  in  Europe, 
but  anyone  who  has  attended  an  International  Medical 
Congress  on  the  continent  knows  how  little  truth  there 
is  in  this  assertion.  Of  the  three  official  languages, 
English  is  the  only  one  that  is  tortured  beyond  all  rec- 
ognition by  the  official  translators,  and  of  all  the  orators 
at  the  general  and  section  meetings,  those  speaking  in 
English  have  the  smallest  and  the  least  attentive  audi- 
ences. 


aftttutttg. 


PROFESSOR  HERMANN  LUDWIG  FERDINAND 
VON  HELMHOLTZ. 


BHKLUf.   GEBMANY. 


Professor  Helmholtz,  the  celebrated  physicist,  died  of 
apoplexy  in  Berlin  on  Saturday,  September  8th.  He  was 
born  in  Potsdam  in  1821,  and  was  educated  as  a  physi- 
cian, serving  his  term  in  the  Charity  Hospital.  He  turned 
his  attention  almost  immediately  to  the  physical  sciences, 
and  published  his  first  book  on  "  The  Conservatism  of 
Force  "  when  twenty- six  years  old.  The  following  year 
he  was  called  to  the  chair  of  anatomy  in  Berlin,  and  the 
year  after  that  became  Professor  of  Physiology  at  Konigs- 
berg.  Subsequently  he  filled  the  same  chair  at  Bonn 
(1855)  and  at  Heidelberg  (1865),  and  in  1871  was  called 
to  the  professorship  of  physical  science  in  Berlin,  formerly 
held  by  Gustavus  Magnus.  It  was  during  his  Stay  in 
Konigsberg  that  he  invented  the  ophthalmoscope  and  the 
ophthalmometer.  He  wrote  about  one  hundred  and 
fifty  scientific  papers  and  contributed  largely  to  the  phys- 
iology of  vision  and  hearing.  Among  his  published 
works  of  physiological  interest  were:  "The  Nerves  of 
the  Invertebrata; "  "Heat  Generated  by  Muscular 
Action;"  ''Measurements  Affecting  the  Periodical 
Contractions  of  Muscles  and  the  Distribution  of  the 
Nerves  Contained  in  Them ; "  "  A  Method  of  Measuring 
Small  Intervals  of  Muscular  Action;"  a  "Manual  of 
Physiological  Operations." 

He  published  on  optics,  "A  Sketch  of  the  Construc- 
tion of  the  Living  Eye,"  in  1851 ;  "The  Theory  of 
Permanent  Colors,"  in  1852;  "The  Sight  of  Man,"  in 
1855;  and  the  "Manual  of  Physiological  Optics,"  in 
1856.  In  1862  he  published  his  "  Theory  of  the  Impres- 
sions of  Sound,"  and  a  little  later  a  work  which  attracted 
wide- spread  attention,  entitled  "  Sensations  of  Tone  as  a 
Physiological  Basis  for  the  Theory  of  Music." 

He  loved  science  for  its  own  sake  and  looked  for  his 
reward  in  the  pleasure  occasioned  by  the  search  for 
knowledge  rather  than  in  that  caused  by  the  possession  of 
knowledge  itself.  He  developed  this  thought  and  showed 
the  spirit  which  had  animated  his  life  work  in  the  course 
of  an  oration  which  he  pronounced  on  Gustavus  Magnus, 
his  predecessor  in  the  chair  of  physical  science  in  Berlin. 
"  Knowledge  alone,"  he  said,  "is  not  the  design  and 
object  of  men  on  earth.  Although  science  awakens 
and  cultivates  the  most  subtle  forces  of  the  human  mind, 
yet  he  who  studies  only  to  know  will  not  find  the  true 
object  of  his  existence  in  this  world.  ...  A  thor- 
ough knowledge  of  the  operation  of  the  natural  and  men- 
tal forces  is  all  that  scientists  can  attempt  to  acquire. 
The  student  must  feel  himself  rewarded  by  the  pleasure 
found  in  hailing  new  discoveries,  new  victories  of  human 
effort  and  human  thought,  over  opposing  material  forces. 
He  can  find  pleasure  in  the  beauty  which  a  well  arranged 
department  of  knowledge  exhibits,  in  the  coherence  of 
relation  between  its  different  parts,  perceiving  how  one 
part  grows  out  of,  or  is  developed  by,  others,  and  he 
must  find  high  enjoyment  in  the  consciousness  of  having 
contributed  to  the  growing  chapter  of  general  informa- 
tion, in  thus  assisting  to  manifest  the  supremacy  of  man 
over  the  forces  and  material  of  nature." 


September  15,  1894] 


MEDICAL   RECORD. 


339 


dPlinical  §^m^tmtxxL 

LARGE  DOSE  OF  SULPHONAL  FOR  A  CHILD. 

By  J.  SUTCLIFFE  HILL,  M.D., 

BSLLOWS   FALLS,  VT. 

Believing  that  the  presentation  of  facts  as  a  result  of 
our  observation  in  cases  that  come  under  our  care  is  of 
interest  to  our  professional  brethren,  and  serve  as  lessons 
for  our  guidance  in  similar  cases  in  future,  is  my  only 
reason  for  presenting  the  following: 

On  February  24th,  at  7  p.m.,  I  was  hastily  summoned 
to  the  bedside  of  a  child,  aged  eighteen  months.  I  found 
an  eclectic  physician  (?)  present  and  learned  that  the 
child  was  taken  sick  on  the  Tuesday  preceding  with 
some  form  of  bowel  trouble.   . 

Status  prasens :  Child  apparently  unconscious,  pupils 
contracted,  breathing  shallow,  but  regular,  pulse  120. 
On  questioning  the  eclectic  he  informed  me  that  at  9 
a.m.  he  had  given  8  grains  of  sulphonal,  and  at  n  a.m. 
8  grains  more,  at  1  p.m.  8  grains  more,  and  between  3 
and  4  p.m.  10  grains,  making  in  all  34  grains  in  a  little 
over  six  hours.  As  the  child  was  breathing  regularly 
and  the  pulse  was  good  I  deemed  it  a  good  case  to  wait 
and  watch  the  effect  of  suphonal  in  large  doses  and  so 
stayed  with  the  patient  all  night. 

The  parents  had  promised  me  full  control  of  the  case 
before  I  saw  the  patient.  The  child  slept  profoundly 
over  six  hours,  and  as  the  parents  had  become  quite 
anxious  for  their  little  one,  I  managed  to  rouse  the  baby 
and  gave  a  few  drops  of  aromatic  spirits  of  ammonia ;  the 
child  a|ain  fell  into  deep  sleep  and  slept  four  hours, 
when  I  repeated  the  ammonia.  This  continued  for  over 
twenty-four  hours,  when  the  child  could  be  more  easily 
roused  and  called  for  nourishment.  During  this  time 
there  had  been  difficulty  in  making  water.  There  was 
one  peculiarity  that  was  very  apparent  when  the  child 
was  recovering  from  the  effect  of  the  sulphonal,  viz., 
ptosis  of  both  eyes,  which  continued  for  four  days,  and 
was  very  marked. 

The  case  ended  in  complete  recovery,  no  trouble  either 
of  stomach  or  bowels.  To  me  it  was  a  very  interesting 
case  as  I  have  never  prescribed  over  10  grains  of  sul- 
phonal at  one  dose  in  adult  cases. 


A  CASE  OF  CHOLECYSTENTEROSTOMY  WITH 
THE  AID  OF  THE  MURPHY  BUTTON— RE- 
COVERY. 

By  HENRY  MOFFAT,  M.D., 

ATTENDING  SURGEON,   ST.  JOSEPH'S  HOSPITAL,   YCNKBRS,  N.  Y. 

The  following  case  seems  to  me  to  present  some  features 
of  interest*  and  I  trust  will  not  be  inappropriate,  now  that 
so  much  attention  is  being  paid  to  the  surgery  of  the 
gall-bladder. 

L.  S — — ,  a  widow,  aged  thirty  nine,  a  German  do- 
mestic, was  admitted  first  to  the  surgical  ward  of  St.  Jo- 
seph's Hospital  on  November  19,  1893,  suffering  from 
intense  biliary  colic  with  a  marked  distention  of  the  gall- 
bladder. She  was  on  the  verge  of  collapse,  and  chole- 
cystotomy  was  immediately  performed  by  my  colleague, 
Dr.  G.  N.  Banker,  who  was  on  duty  at  that  time.  He 
removed  eight  large  and  six  small  stones.  The  patient 
made  an  uninterrupted  recovery  and  was  discharged,  De- 
cember 23d,  with  a  biliary  fistula,  which  persisted  for 
about  ten  days  longer,  and  finally  closed  spontaneously. 
She  had  one  slight  attack  of  colic  during  January,  which 
was  easily  relieved,  and  remained  well  till  February  5th, 
when  she  was  again  seized  with  most  violent  pain  in  the 
same  region  as  before — the  tumor  reappeared  and  rapidly 
increased  in  size.  She  was  immediately  brought  back  to 
the  hospital  and  came  under  my  care. 

On  admission  she  was  again  in  a  partially  collapsed 
condition,  slightly  jaundiced,  vomiting,  and  suffering 
intensely,  with  a  rapid  and  feeble  pulse  but  no  elevation 


of  temperature.  The  gall-bladder,  swollen  to  the  size  of 
a  large  orange,  could  be  easily  made  out  below  and  to 
the  mesial  side  of  the  former  incision.  In  view  of  her 
previous  history,  and  believing  that  it  would  be  extremely 
difficult  to  assure  myself  of  the  freedom  of  the  common 
duct  in  a  secondary  operation,  I  determined  to  perform 
cholecystenterostomy,  using  one  of  Murphy's  anastomo- 
sis buttons.  In  this  view  my  colleagues,  Drs.  Banker, 
Benedict,  and  Pyne  concurred.  The  patient  was  there- 
fore immediately  etherized  and  an  incision,  about  four 
inches  long,  was  made  three-fourths  of  an  inch  to  the 
left  of  the  old  scar,  parallel  to  and  about  two  inches 
from  the  median  line,  extending  from  one  inch  below 
the  free  border  of  the  ribs  almost  to  the  level  of  the  um- 
bilicus. The  thickened  and  adherent  peritoneum  was 
carefully  incised  and  the  distended  gall-bladder  was  im- 
mediately disclosed,  though  it  was  so  bound  down  and 
covered  by  old  and  strong  adhesions  that  only  about  one 
square  inch  of  its  surface  could  be  cleared  for  manipula- 
tion. The  aspirator  was  used,  and  about  two  ounces  of 
slightly  bile-tinged  serous  fluid  was  drawn  out.  The 
presence  of  a  stone  could  not  be  detected,  but,  feeling 
perfectly  assured  that  the  common  duct  was  obstructed, 
I  proceeded  with  the  operation.  The  only  loop  of  in- 
testine which  could  be  approximated  with  any  degree  of 
safety  was  the  hepatic  flexure  of  the  colon.  I  attempted  to 
drag  one  or  two  loops  of  the  ileum  to  the  point,  but  found 
that  strong  adhesive  bands  prevented,  and  had  I  suc- 
ceeded, would  undoubtedly  have  produced  dangerous  and 
probably  fatal  constriction  of  the  bowel  The  male  but- 
ton was  therefore  placed  in  the  colon  in  the  manner  de- 
scribed by  Dr.  Murphy,  and  the  female  button  in  the 
gall- bladder.  This  latter  procedure  was  attended  with 
considerable  difficulty,  for  the  following  reasons : 

1.  The  adhesions  from  the  previous  operations  had 
bound  the  gall-bladder  firmly  down  at  the  bottom  of  the 
wound. 

2.  The  surface  freed  from  adhesion  was  so  limited- that 
it  was  found  impossible  to  make  the  two  stitches  de- 
scribed by  Dr.  Murphy  on  one  side  of  the  incision ;  one; 
however,  proved  just  as  satisfactory  in  this  case. 

3.  The  walls  of  the  gall-bladder  were  more  than  one- 
fourth  of  an  inch  in  thickness,  renderiog  it  difficult  to 
make  them  slip  into  the  cup  of  the  button  when  the  ligature 
was  pulled  taut.  The  buttons,  being  then  safely  in  place, 
were  pushed  home  and  a  satisfactory  approximation  of 
the  parts  was  made  without  any  undue  tension  on  the 
surrounding  tissues.  As  there  had  been  some  unavoid- 
able leakage  from  the  gall  bladder,  I  packed  down  to  the 
bottom  of  the  cavity  a  strip  of  iodoform  gauze  and  closed 
the  rest  of  the  wound  with  sutures  through  the  abdom- 
inal wall  and  peritoneum. 

The  patient  made  an  uninterrupted  recovery.  Her 
bowels  were  readily  moved  on  the  third  day  by  a  dose  of 
magnesium  citrate,  and  on  the  seventh  day  a  gall-stone 
about  the  size  of  a  hickory-nut  was  passed  per  rectum. 
She  was  allowed  to  sit  up  on  the  eleventh  day,  and  dis- 
charged at  her  own  request  on  the  eighteenth  day  after 
the  operation.  The  abdominal  wound  was  entirely 
healed,  with  the  exception  of  a  small  superficial  granulat- 
ing surface,  which  soon  cicatrized  over ;  but  she  had  not 
passed  the  button.  Dr.  Banker  saw  her  several  times 
after  she  left  the  hospital,  and  anxiously  awaited  the  ap- 
pearance of  the  button.  It  was  not  until  March  2d,, 
twenty-five  days  after  the  operation,  that  it  was  finally 
passed.  She  was  at  that  time  seized  with  colicky  pains 
over  the  whole  abdominal  region,  and  a  dose  of  castor-oil 
produced  the  long-expected  button.  She  has  since  been 
in  perfect  health  and  attending  to  her  duties. 

In  reviewing  the  case  the  following  points  might  be 
noted :  1.  The  comparatively  easy  accomplishment,  with 
the  aid  of  Murphy's  button,  of  an  operation  which  is  ac- 
knowledged by  all  surgeons  to  be  one  of  the  most  diffi- 
cult. To  effect  a  perfect  anastomosis  between  a  loop  of 
intestine  and  a  gall-bladder  with  thickened  walls,  and 
bound  firmly  down  in  such  an  inaccessible  position,  with- 
out the  aid  of  any  mechanical  contrivance,  would  call  for 


340 


MEDICAL    RECORD. 


[September  15,  1894 


the  highest  technical  skill  and  would  be  attended  with 
the  gravest  difficulties.  From  my  experience  in  this  case 
I  feel  certain  that  the  Murphy  button  has  proved  a  most 
valuable  assistant. 

2  It  must,  however,  be  noted  that  the  danger  of  the 
button  becoming  lodged  somewhere  in  the  intestinal  tract, 
is  not  by  any  means  as  trivial  as  Dr.  Murphy  wished  us 
to  understand.  In  the  above  case,  from  the  fact  that  a 
gall-stone  was  passed  on  the  seventh  day,  it  must  be  in- 
ferred that  the  button  had  at  least  partially  sloughed 
away ;  for  the  stone  was  too  large  to  pass  through  the 
lumen  of  the  button.  And  yet,  in  spite  of  the  fact  that 
the  colon  was  used,  it  took  twenty-five  days  for  the  but- 
ton to  pass  out  of  the  body.  There  was,  however,  no 
obstruction  at  any  time,  and  the  bowels  moved  every  day. 

3.  The  use  of  the  colon,  while  not  desirable,  was  ab- 
solutely required  in  this  case  for  the  reasons  given  above, 
and  is  not  without  precedent.  Treves  quotes  a  case  of 
Mr.  Mayo  Robson  in  which  the  hepatic  flexure  of  the 
colon  was  used  for  the  same  reason. 

4.  The  effect  of  the  loss  of  the  physiological  action  of 
the  bile  in  the  small  intestine  will  be  worthy  of  further 
observation.  At  present  writing,  two  months  after  the 
operation,  the  patient  is  in  perfect  health,  has  gained  in 
flesh  and  strength,  and  her  bowels  are  acting  in  a  per- 
fectly healthy  manner. 


A  SUCCESSFUL  PLASTIC  OPERATION  OF  THE 
FACE. 

By   J.  J.  MULLEN,  M.D., 

PITTSBUBC,   PA. 

Os  December  10,  1893,  assisted  by  Drs.  H.  Atkinson, 
of  Connellsville,  Pa.,  and  J.  D.  Mullen,  of  Dunbar,  Pa., 
where  the  operation  took  place,  I  performed  a  plastic 
operation  on  the  face  of  a  girl,  aged  twelve,  who  had  her 
right  eye  and  cheek  entirely  destroyed  by  the  accidental 
discharge  of  a  loaded  gun  in  the  hands  of  her  brother. 
She  presented  a  most  pitiable  appearance  ;  the  lower  eye- 
lid was  firmly  adherent  in  the  cicatrix  on  the  face  at 
right  angles  to  its  former  or  normal  position.  The  cica- 
trix resulting  from  loss  of  skin,  fascia,  muscles,  and  bones 
was  permeated  with  powder  and  lead,  extending  from 
the  orbital  space  along  the  nose  down,  and  included  the 
upper  lip,  running  obliquely  over  the  lower  jaw  up  along 
the  face  close  to  the  ear  to  the  outer  commissure  of  the 
eye.  After  satisfying  myself  that  the  stump  remaining 
from  loss  of  the  eye  had  cicatrized  perfectly  and  no  irre- 
gular nodule  remained,  I  dissected  the  lower  eyelid  out 
of  the  scar  and  threw  it  over  the  patient's  nose  in  a  pair 
of  catch  forceps.  I  now  made  a  free  and  clear  dissection 
of  the  scar  from  the  points  described,  with  the  exception 
of  a  small  portion  along  the  nose  and  close  to  the  eye, 
which  subsequently  answered  a  good  purpose.  The  dis- 
section of  the  scar  was  not  attended  by  much  bleeding, 
although  I  used  a  very  sharp  scalpel.  The  dissection  be- 
ing completed  (which  was  the  least  difficult  part),  an  in- 
cision from  the  margin  of  the  dissected  wound  on  the 
lower  jaw,  on  the  ear  side  of  the  wound,  down  on  the 
neck,  three  inches  or  more  in  length  and  one  and  a  half 
inch  in  width,  its  distal  end  being  freed  and  the  proxi- 
mal at  a  point  immediately  below  the  ear,  turned  at  right 
angles,  was  brought  up  to  within  one  half-inch  of  the  eye, 
where  it  was  sutured  to  a  small  margin  of  sound  skin. 
The  other  flap  was  secured  by  going  down  on  the  chin 
and  neck,  leaving,  however,  a  portion  of  sound  and  un- 
disturbed skin,  which  divided  the  space  from  which  the 
flaps  were  removed ;  it  was  also  turned  at  right  angles  on 
the  lower  jaw  and  its  free  end  secured  to  the  small  piece 
of  cicatricial  tissue  I  left  on  the  nose  at  the  time  of  dis- 
section. Both  flaps  were  now  sutured,  one  along  the 
side  of  the  nose,  and  the  other  to  a  slight  margin  of 
sound  skin  along  the  ear.  The  two  free  edges  now  in  the 
middle  of  the  wound  were  united  with  catgut  sutures. 
A  V-shaped  opening  was  made  at  the  outer  commissure 
of  the  eye  into  sound  skin  and  the  eyelid  was  brought 


into  it  and  secured  by  a  suture,  which  was  passed  from 
above  downward  into  the  wound  and  there  tied.  The 
denuded  surface  on  the  neck  was  covered  by  freeing  the 
skin  and  fascia  on  both  sides  and  suturing  them  to  the 
island  of  undisturbed  skin  which  was  left  when  the  flaps 
were  removed.  The  wound  being  thoroughly  dried  was 
dressed  with  boracic  acid,  and  the  dressing  being  secured 
in  the  usual  way  the  patient  was  placed  in  bed,  where  she 
remained  for  eight  days.  Many  of  the  sutures  were  ab- 
sorbed on  the  sixth  day,  the  whole  of  them  were  removed 
two  days  later,  and  complete  union  had  taken  place  in 
the  wound.  The  dressing  was  scarcely  soiled  during  the 
healing  process.  The  result  was  very  gratifying  to.  all 
concerned. 

A  LARGE   DOSE  OF  MORPHINE. 
By    W.  S.  GROOM,   M.D., 

BRITT,  IA, 

September  22,  1893, 1  was  called  out  of  bed  to  go  into 
the  country  to  see  Airs.  P .  I  found  her  in  great  dis- 
tress and  unable  to  describe  her  symptoms  very  accu- 
rately. So  thinking  to  relieve  her  distress  and  make 
my  diagnosis  afterward,  I  gave  a  hypodermic  of  %.  grain 
of  morphia,  which  I  repeated  in  ten  minutes,  as  there  was 
not  the  slightest  result.  In  twenty  minutes  I  prepared 
the  third  dose,  but  I  naturally  hesitated  in  giving  it.  I 
asked  her  if  she  ever  took  any  opiate?  She  said,  "  Yes." 
"Howoften?"  Iasked.  "Everyday."  "Howmuch?" 
"  Thirty  grains. ' '  Well  that  staggered  me,  but  after  care- 
ful investigation  I  found  it  to  be  correct.  She  showed 
me  an  ounce  bottle  of  P.  &  W.  label,  said  that  she  took 
that  much  every  sixteen  days.  She  showed  me  a  J£  -ounce 
bottle  that  she  had  opened  in  the  morning,  and  prepared 
her  morning  dose,  but  she  was  unable  to  retain  it.  I 
prepared  a  solution  of  fifteen  grains  morphia  in  very 
hot  water,  and  gave  it  hypodermically.  It  filled  my  hy- 
podermic five  or  six  times.  The  result  was  magicaL 
One  ounce  P.  &  W.  morphia  every  sixteen  days  beats  the 
record  of  any  case  I  ever  heard  of. 


FRACTURE  OF  THE  HEAD  OF  THE  FIBULA 
BY  MUSCULAR  ACTION. 

By  D.  B.  HORTON,  M.D., 

BATAVIA,   N.   V. 

The  only  excuse  in  offering  a  report  of  this  case  is  its 
extreme  rarity  in  practice,  and  the  peculiar  scientific  in- 
terest connected  with  such  an  accident.  I  was  called  to 
see  E.  E ,  aged  sixty-four,  on  the  morning  of  Janu- 
ary 29,  1889,  and  as  I  entered  his  room  he  stated  that 
he  had  broken  his  leg.  I  asked  how  he  knew  it  was 
broken,  and  he  replied,  "  Because  I  felt  it  and  heard  it 
snap,  and  cannot  walk  upon  it."  I  readily  diagnosed  a 
fracture  of  the  head  of  the  fibula  of  the  right  leg,  three- 
fourths  inch  from  the  upper  extremity  of  the  bone.  The 
fragments  were  separated  one -half  inch,  but  could  be 
easily  brought  together  and  crepitus  obtained.  As  he 
said  that  nothing  struck  his  leg  and  there  was  no  abra- 
sion of  the  skin,  my  curiosity  was  excited,  and  I  drew 
out  the  following  history  of  the  case:  While  coming 
home  the  night  before,  walking  over  a  bad  sidewalk,  his 
right  foot  caught  in  a  hole  in  the  walk,  causing  him  to 
stumble  six  or  eight  feet,  and  finally  fall  off  the  side  next 
to  the  fence.  On  attempting  to  rise  he  found  his  leg 
useless,  and  he  crawled  along,  and  by  the  aid  of  a  piece 
of  board  finally  reached  home,  fifteen  or  twenty  rods 
distant.  It  seems  that  while  falling,  and  just  at  that  par- 
ticular time  when  the  knee  was  twisted  outward,  leg 
slightly  adducted  and  slightly  flexed  upon  the  thigh,  and 
the  foot  on  the  walk,  and  he,  still  in  an  upright  position 
and  making  a  desperate  effort  to  save  himself  from  fall- 
ing, heard  a  snap  like  a  bone  breaking,  and  his  leg  gave 
way.  After  a  careful  study  of  these  parts  it  will  be 
plainly  seen  that  this  position  is  the  only  one  in  which 
this  accident  could  take  place  without  traumatism.    The 


September  15,  1894] 


MEDICAL    RECORD. 


34* 


head  of  the  fibula  is  so  protected  by  the  external  tuber- 
osity of  the  tibia  that  only  by  the  leg  being  bent  upon 
the  thigh  is  it  in  a  measure  exposed,  and  then  by  a  vio- 
lent contraction  of  the  biceps  the  bone  gives  way  at  its 
weakest  part  I  found  by  flexing  the  leg  upon  the  thigh 
to  about  forty  degrees  that  the  parts  were  easily  retained. 
I  applied  a  compress  and  bandage  for  a  few  days,  and  then 
a  plaster-of- Paris  bandage  for  four  weeks,  holding  it  in  this 
flexed  position,  obtaining  bony  union  and  good  result. 

TREATMENT    OF    CEREBRO  -  SPINAL    MENIN- 
GITIS. 

By  T.  J.  HUTTON,  M.D., 

SHENANDOAH,  PA. 

The  uniformly  successful  results  of  the  following  plan 
of  treatment  for  this  malady  has  been  one  of  the  chief 
joys  of  my  professional  life. 

The  intense  cerebral  form  is  usually  attended  with 
constipation  that  is  almost  obstipation :  here  open  the 
bowels  with  calomel  or  turpentine  enemata.  The  mild 
constipation  met  with  in  some  cases  of  the  cerebro  spinal 
form  of  malady  is  easily  controlled  by  mild  laxatives — 
phosphate  of  soda  in  tepid  milk,  or  simple  warm-water 
enemata.  I  write  now  of  the  cerebro  spinal  form,  and 
the  essence  of  the  treatment  is :  Put  the  patient  into  a 
mild  dozy  condition  by  small  doses  of  bromide  of  po- 
tassa  and  opium,  graduated  to  the  age  of  the  patient  and 
repeated  often  enough  to  maintain  the  dozy  condition. 
Draw  a  good  blister  over  lower  dorsal  spine  by  canthari- 
dal  plaster  sized  to  suit  the  age.  Keep  hot  flat  irons  or 
bottles  filled  with  hot  water  to  the  patient's  feet.  Feed 
the  patient  every  hour  or  two  with  an  ounce  or  few 
ounces  (according  to  age)  of  warm  milk  and  eggnog 
alternated  with  beef-juice — not  beef- water.  A  suitable 
doze  formula  for  a  patient  aged  ten  or  twelve  years  would 
be  about  as  follows : 

3.   Potass,  bromid. 3jss. 

Sol  opii  comp.  (Squibb' s) J  jss. 

Syr.  zingib., 
Aq.  caryophy., 

Aq.  pur U  q.s.  ft.    3    iv. 

M.  S.:  A  tcaspoonful  every  two  or  three  hours  by  day;  less 
often  by  night. 

A  suitable  eggnog  formula  is  as  follows : 

3 .    Granulated  sugar I  tablespoonfuL 

Pure  rye  whiskey I  tablespoonful. 

Fresh  milk 1  tumblerful. 

A  fresh  egg  well  beaten  up. 
Hot  water  enough  to  fill  a  com- 
mon-sized tumbler. 

What  will  this  treatment  do?  One  thing  it  will  not 
do — it  will  not  enrich  undertakers.  I  have  practised 
since  187 1 ;  have  in  that  time  treated  quite  a  few  cases 
of  this  malady ;  have  had  no  death  to  date. 

A   CASE  OF  ENTEROLITH. 
By  W.  C.  PHELPS,  M.D., 

BUFFALO,   N.    V. 

I  first  saw  the  patient  three  years  ago,  when  she  was 
suffering  from  a  severe  pain  in  the  abdomen  on  the  right 
side.  There  were  some  induration  at  the  seat  of  pain, 
but  it  soon  passed  away  and  no  operative  procedures  were 
attempted,  though  an  exploratory  incision  was  thought  of. 
After  this  attack  she  was  in  good  health  excepting  a  pain, 
of  a  neuralgic  character,  in  her  left  arm,  which  was  almost 
always  present.  She  was  in  her  usual  health  until  June 
21st,  when  she  was  taken  with  a  severe  colicky  pain.  I 
was  called  to  see  her,  and  relieved  her  with  a  hypodermic 
injection  of  morphine.  She  was  able  to  ride  out  that  day 
in  the  evening  and  thought  that  she  had  entirely  recov- 
ered. On  the  morning  of  the  following  day,  however, 
she  was  again  attacked,  and  began  to  pass  bloody  mucus 
from  her  bowels.  Thinking  that  a  dysentery  was  being 
developed  I  ordered  one  and  one-half  ounce  of  castor- 
oiL  In  three  hours  she  had  a  movement  of  the  bowels, 
and  a  large  stone,  weighing  over  half  an  ounce,  was 


passed,  with  immediate  relief  to  all  her  symptoms,  includ- 
ing the  pain  in  the  arm,  which  had  been  very  severe 
during  the  continuance  of  the  pain  in  the  abdomen.  I 
think  that  this  stone  was  impacted  in  the  small  intestine, 
and  was  the  cause  of  the  patient's  illness  three  years  ago, 
and  that  it  passed  into  the  large  intestine  at  the  time  of 
her  recovery,  and  had  since  been  lodged  in  that  portion 
of  the  alimentary  canal  until  it  was  finally  expelled  by 
the  dose  of  castor-oil.  Authors  state  that  it  is  always  a 
matter  of  years  during  which  enteroliths  are  forming,  even 
as  long  as  thirty  years — generally  not  less  than  six. 


A   CASE    OF    PSEUDO-RABIES    COMPLICATED 
BY  DELIRIUM  TREMENS. 

Bv  J.  D.  GRISSIM,   M.D., 

HOUSE  PHYSICIAN  TO  ST.   JOSEPH'S  HOSPITAL,   PATBBSON,   N.   J. 

On  August  1 2th  a  man,  twenty- six  years  of  age,  a  ple- 
thoric German,  applied  for  admission  at  St.  Joseph's 
Hospital,  giving  the  following  history : 

Eight  weeks  previously  he  had  been  bitten  by  a  dog, 
whose  teeth  penetrated  the  coat  and  clothing,  sinking 
into  the  shoulder  and  leaving  marks  over  the  deltoid 
and  in  the  axilla.  The  dog  had  shown  no  signs  of 
rabies  but  was  immediately  killed.  The  patient  declared 
he  thought  no  more  of  the  matter  until  some  weeks  later 
when  some  of  his  associates  suggested  the  possibility  of 
hydrophobia  and  depicted  to  him  the  horrors  of  the  dis- 
ease. He  became  apprehensive  concerning  his  welfare, 
and  his  anxiety  increased  more  and  more  until  he  began 
drinking  heavily  to  drown  his  thoughts,  which  he  said 
constantly  dwelt  on  this  one  subject. 

On  the  evening  before  entering  the  hospital,  August 
1  ith,  he  had  difficulty  in  swallowing  a  glass  of  beer,  which 
increased  his  mental  worry,  and  he  spent  a  sleepless 
night  Upon  admission  to  the  hospital  I  found  him  ex- 
ceedingly nervous  and  morose,  dysphagia  present  to  a 
well-marked  degree,  preceded  by  tremor  of  the  entire 
body,  and  he  objected  seriously  to  the  customary  bath, 
both  before  and  during  the  process.  He  was  admitted 
at  4  p.m.  At  7  p.m.  he  was  given  chloral,  20  grs. ;  bro- 
mide of  potassium,  3j-,  which  dose  was  repeated  at 
midnight,  with  %.  gr.  morphine  hypodermically.  He 
passed  a  very  restless  night,  sleeping  for  only  a  few  mo- 
ments, waking  with  terrified  cries.  On  the  following 
morning  the  patient  was  able  to  drink  milk  with  ease, 
but  when  he  was  urged  to  drink  water  dysphagia  was 
more  marked  and  accompanied  by  peculiar  sounds  from 
the  throat.  Temperature,  99$°  F.  ;■  pulse,  85  per  minute. 
He  was  exceedingly  nervous  and  restless  ail  day.  In  the 
afternoon  he  had  hysterical  spells  of  sobbing  and  terror 
without  any  apparent  cause,  and  said  that  he  realized 
that  he  was  acting  peculiarly  but  could  not  control  him- 
self. 

Afternoon  temperature,  ioo°  F. ;  pulse,  90.  At  9 
p.m.,  besides  the  bromide  and  chloral,  he  was  given  y2 
gr.  morphine  hypodermically,  after  which  he  slept  a 
short  time. 

At  11  p.m.  he  attempted  to  jump  out  of  the  window, 
but  was  caught  by  an  attendant.  I  was  summoned,  and 
found  the  patient  violently  delirious,  imagining  he  was 
pursued  by  police  and  that  they  were  concealed  in  the 
room.  He  made  frequent  efforts  to  get  to  the  window, 
muttering  incessantly  in  German  and  English,  and  in 
fifteen  minutes  became  so  violent  that  I  was  obliged  to 
summon  three  attendants  I  had  stationed  conveniently, 
and  it  required  the  united  efforts  of  us  four  to  hold  him 
in  bed  until  he  could  be  chloroformed  and  a  canvas 
sheet  applied.  As  a  result  of  his  violent  and  persistent 
struggles  his  heart  action  was  about  200  per  minute, 
and  his  breathing  labored  and  irregular.  His  face  was 
much  congested,  and  his  skin  very  hot  and  dry.  I 
thought  venesection  advisable,  and  while  he  was  still 
under  chloroform  I  drew  a  quart  of  blood  from  the  me- 
dian basilic.  This  blood  was  at  first  very  dark  and 
thick,  but  later  became  normal  in  color  and  consistency. 


342 


MEDICAL   RECORD. 


[September  15,  1894 


His  pulse  improved  in  character,  but  not  in  rate,  and 
respiration  became  less  rapid,  but  was  still  very  irregu- 
lar. He  was  given  twenty-five  minims  of  tincture  of 
digitalis  hypodermically,  but  it  had  little  apparent  ef- 
fect upon  the  pulse.  As  the  effects  of  the  chloroform 
wore  off,  his  struggles  continued,  and  he  died  four  hours 
after  the  first  appearance  of  delirium  from  sheer  exhaus- 
tion. 

The  case  is  one  of  interest  from  the  fact  that  a  very 
peculiar  neurotic  affection  should  have  been  rendered 
fatal  by  an  intercurrent  disease  brought  on  by  the  pa- 
tient's efforts  to  cure  himself. 


RESULTS  FROM  CIRCUMCISION. 
By  JOHN  W.  S.  McCULLOUGH,  M.D., 

ALLISTOK,   OMT. 

Among  others,  two  cases  are  called  to  my  mind,  illustra- 
tive of  the  value  of  circumcision,  by  the  article  of  Dr. 
Rosenberry,  in  the  Medical  Record  of  August  nth. 

Case  I. — Boy,  aged  three  and  a  half,  very  intractable, 
incontinence  of  urine  day  and  night ;  treated  with 
strychnine  and  belladonna,  then  with  strychnine  and 
atropia  sulphate.  These,  however,  failed.  The  prepuce 
was  very  long  and  tight,  so  I  performed  circumcision, 
using*  cocaine  anaesthesia.  A  complete  recovery  from 
the  incontinence  followed. 

Case  II. — Boy,  aged  one  month.  Two  years  ago  a 
child  in  the  same  family,  then  of  the  same  age  as  the 
present  patient,  had  severe  indigestion,  for  which  no  treat- 
ment was  of  any  value.  I  advised  circumcision,  as  the  boy 
had  a  tight  and  elongated  prepuce.  The  operation  was  re- 
fused, and  eventually  the  child  died.  In  the  present  in- 
stance the  child  had  indigestion,  screaming  fits  at  night, 
and  failed  to  thrive.  The  prepuce  was,  as  in  the  former 
case,  long  and  tight,  the  orifice  being  extremely  small. 
My  advice  that  circumcision  be  performed  was  concurred 
in  by  the  consultant,  Dr.  J.  Harlan  Reed,  of  Homing's 
Mills.  I  did  the  operation  without  any  anaesthesia,  and 
used  a  couple  of  silk  sutures  on  either  side  of  the  central 
tear  in  the  mucous  membrane.  The  wound  healed  with- 
out any  trouble  and  the  child's  indigestion  and  scream* 
ing  were  gone  almost  from  the  hour  of  operation.  Used 
when  required,  there  is  no  doubt  of  the  value  of  this  little 
procedure.  

PILOCARPINE  IN  THE  TREATMENT  OF 
ACUTE  AND   CHRONIC  URTICARIA. 

By   R.  ABRAHAMS,   M.D., 

MBW  YORK. 
ATTSMDIMG  PHYSICIAN  TO  MOUNT  SINAI  HOSPITAL,  OUT-DOOM  DEPARTMENT. 

My  humble  desire  in  this  paper  is  to  call  the  earnest 
attention  of  the  profession,  particularly  at  this  time  of  the 
year,  to  the  admirable  action  of  a  drug  in  a  disease  which 
very  often  baffles  the  therapeutic  ingenuity  of  the  general 
practitioner  as  well  as  the  specialist.  The  symptom  of 
symptoms  which  the  physician  is  called  upon  to  combat 
in  acute  or  chronic  urticaria  is  the  terrible  itching.  It 
is  hardly  an  exaggeration  to  say  that  this  symptom  is 
responsible  for  the  many  constitutional  disturbances  fre- 
quently observed  in  this  disease.  The  hydrochlorate 
of  pilocarpine  promises  immediate,  certainly  eventual, 
relief  and  cure  of  all  the  symptoms  and  the  disease  itself 
in  a  great  majority  of  cases. 

I  do  not  wish  to  be  understood  as  saying  that  pilocar- 
pine is  a  specific  for  urticaria  in  the  sense  that  mercury  is 
in  syphilis  or  quinine  in  malaria,  for,  in  the  nature  of 
things,  no  drug  can  be  a  specific  in  a  disease  of  a  varied 
and  obscure  etiology.  But  the  claim  is  emphatically 
made  that  the  alkaloid  will  cure  where  all  other  means 
will  fail  to  relieve.  Not  to  weary  the  reader  with  a  long 
list  of  successful  cases,  observed  both  in  private  and  dis- 
pensary practice,  I  shall  mention  but  three,  which  are  at 
present  most  prominent  before  my  mind,  occurring  re- 
spectively in  a  man,  woman,  and  child.     Let,  however, 


every  man  try  for  himself  and  be  convinced.  Let  him 
employ  this  treatment  after  all  other  treatments  prove  of 
no  avail,  my  request  being  only  that  he  observe  the  con- 
ditions hereafter  mentioned,  which  are  so  essential  to  a 
good  result. 

Case  I. — A  friend  of  mine,  a  physician,  had  an  attack 
of  acute  urticaria.  The  burning  and  itching  were  dis- 
tressingly intense.  He  was  restless  and  sleepless,  with- 
out appetite  and  patience.  Before  I  saw  him  he  had  ex- 
hausted pretty  nearly  the  entire  list  of  remedies.  After  • 
one  hypodermic  injection  of  pilocarpine  he  was  relieved 
The  second  injection  cured  him. 

Cask  II. — A  lady,  about  fifty-five  years  of  age,  suffered 
a  very  severe  attack  of  urticaria.  Her  body  and  face 
were  one  mass  of  burning  wheals.  I  saw  her  in  the 
morning ;  gave  a  hypodermic  injection  of  pilocarpine. 
At  my  second  visit  in  the  evening,  all  I  found  left  of  the 
hives  was  the  thankful  victim  to  tell  the  tale  of  her  by- 
gone woes. 

Cask  IIL — A  child,  two  and  one-half  years  of  age, 
suffered  from  a  lichen  urticaria  for  the  last  two  years, 
always  worse  in  the  summer.  I  found  the  child  in  a 
most  miserable  condition,  pale  and  emaciated,  no  sleep 
at  night  from  the  perpetual  itching  and  scratching. 
Treatment  was  kept  up  at  various  places  and  by  various 
men  during  the  entire  period.  Six  weeks  ago  I  saw  the 
litde  sufferer  for  the  first  time  and  at  once  put  him  on 
pilocarpine  internally.  A  week  later  the  child's  rest 
was  undisturbed  at  night  and  his  appetite  markedly  im- 
proved. To-day  the  child  is  free  from  all  urticarial 
miseries,  and  his  health  is  in  a  first-rate  condition. 

The  employment  of  pilocarpine  in  the  treatment  of 
urticaria  is  not  entirely  new,  nor  yet  is  it  very  old.  The 
latest  works  on  skin  diseases  and  materia  medica,  as  far 
as  I  could  ascertain,  hardly  mention  it.  My  first  les- 
son in  this  new  application  of  the  drug  I  learned  in 
Dr.  Lustgarten's  skin  clinic  (Mount  Sinai  Hospital  Dis- 
pensary), with  which  I  was  connected  as  assistant  for 
nearly  three  years.  The  drug  there  is  used  freely  and 
satisfactorily,  and  on  more  than  one  occasion  Dr.  Lust- 
garten,  in  private  conversation,  extolled  the  virtues  of  pilo- 
carpine in  the  disease  in  question.1  I  am,  however,  well 
aware  of  the  fact  that  this  medicinal  agent  foiled  to  be  of 
service  in  the  hands  of  some  good  men,  even  skin  special- 
ists. The  failure,  it  seems  to  me,  is  due  to  one  of  three 
causes :  Either  the  urticaria  was  badly  complicated  by  ec- 
zema, the  result  of  scratching  or  strong  applications,  or  the 
diagnosis  was  questionable,  or  the  alkaloid  was  impure. 
A  case  in  point :  After  relating  my  excellent  results  with 
pilocarpine  in  urticaria  to  an  able  physician  he  promised 
to  furnish  me  with  corroborative  evidence  from  his  exten- 
sive practice.  A  few  days  later  he  returned  with  evi- 
dence— of  disappointment.  At  my  request  I  was  shown 
the  patient,  and  found  the  fair  dame  a  victim  of  a  mild 
scabies  instead  of  hives. 

Now  as  to  the  mode  of  administration  and  dosage.  An 
adult  should  get  it  under  the  skin,  and  a  child  by  mouth. 
The  dose  for  an  adult  is  from  one-sixth  to  one-half  a  grain, 
repeated  every  day  or  every  other  day,  or  oftener.  For  a 
child  one  year  old,  the  dose  is  from  one-twentieth  to  an 
eighth  of  a  grain  in  distilled  water  every  evening  at  bed- 
time. For  a  child  from  two  to  three  years  old,  the  dose 
is  from  one-fifteenth  to  one-sixth  of  a  grain.  By  admin- 
istering the  alkaloid  gradually,  feeling  one's  way  as  it 
were,  no  untoward  accident  should  be  anticipated. 
Adults,  however,  seem  to  be  more  susceptible  to  its  in- 
fluence than  children.  A  good  precaution  is  to  remain 
with  the  patient  after  exhibiting  the  medicine  from 
fifteen  to  twenty  minutes,  and  when  given  to  children 
mothers  should  be  instructed  to  use  a  little  red  wine  or 
claret  should  the  child  show  signs  of  weakness.  I  have 
seen  only  one  man  that  complained  of  marked  weakness 
after  a  hypodermic  injection,  and  two  patients  were 
severely  salivated.     The  first  was  restored  by  a  little 

1  Brief  reference  was  made  by  the  doctor  to  the  action  of  jaborandi 
in  urticaria  at  a  recent  meeting  of  the  New  York  Dermatological  So- 
ciety (Journal  of  Cutaneous  and  Genito- Urinary  Diseases,  June,  1894). 


September  15,  1894] 


MEDICAL   RECORD. 


343 


claret  and  the  other  two  were  relieved  by  holding  ice  in 
the  mouth. 

It  seems  that  in  order  for  pilocarpine  to  be  palliative 
or  curative  in  acute  or  chronic  urticaria,  it  must  make 
the  patient  sweat  freely.  I  found  that  free  perspiration 
is  promptly  and  with  a  comparatively  smaller  dose  pro- 
duced in  an  adult  than  in  a  child,  and  herein  is  my  guide 
to  the  increase  or  diminution  of  the  dose. 

To  sum  up :  1.  Pilocarpine  in  urticaria  is  the  drug  par 
excellence.  2.  Be  sure  of  the  diagnosis.  3.  Before  in- 
stituting your  treatment,  clear  off  complicating  lesions. 
4.  Get  a  pure  drug.  5.  Have  patience.  6.  Push  the 
drug  to  the  point  of  tolerance. 

In  conclusion,  I  wish  to  state  that  in  two  cases  of 
jaundice  where  the  itching  was  quite  annoying  pilocar- 
pine proved  useful,  and  I  have  seen  it  also  allay  the 
burning  and  tingling  sensations  in  other  affections  of  the 
skin. 

156  Clinton  Street. 

UNSUCCESSFUL  EMPLOYMENT  OF  POTAS- 
SIUM PERMANGANATE  IN  A  CASE  OF  MOR- 
PHINE POISONING. 

By  C.  MONROE  McGUIRE,  M.D., 

WALSBNBURGH,  COL. 

Having  read  in  the  Medical  Record,  and  various  other 
medical  journals,  of  the  many  experiments  with  potassium 
permanganate  with  varying  results,  I  have  been  urged  to 
report  my  case,  where  the  so-called  antidote  was  tried  in 
a  case  of  an  adult  and  found  wanting. 

I  submit  the  following  brief  report,  and  will  warn  my 
professional  brethren  to  beware  of  trying  any  new  remedy 
until  its  physiological  and  pathological  effects  are  known 
to  be  as  represented,  as  I  came  near  losing  my  patient 
by  relying  on  permanganate  of  potassium. 

On  the  evening  of  March  15th  I  was  called  to  see  Mr. 

M ,  a  travelling  salesman,  married,  and  of  good 

habits.  He  had  lost  his  position  through  no  fault  of  his 
own,  and  was  very  despondent.  I  found  him  nervous, 
pale,  nauseated ;  had  been  vomiting  at  frequent  intervals 
for  the  past  three  days.  No  appetite,  bowels  torpid,  dull 
headache ;  he  said  he  did  not  think  he  needed  medical 
aid,  but  his  wife  felt  uneasy  about  him. 

When  I  had  examined  him  thoroughly  and  prescribed 
for  him,  I  did  not  feel  that  I  had  struck  the  "  key-note  M 
as  to  the  cause  of  his  present  condition.  I  assured  him 
he  would  doubtless  be  kept  in  for  two  or  three  days  only. 

On  the  evening  of  March  16th,  at  5.30  o'clock,  I  was 

hastily  summoned  to  see  Mr.  M .   The  messenger  said 

he  was  dying  (during  the  day  it  was  known  he  had  lost 

his  position,  so  my  first  thought  was,  Mr.  M has  made 

an  attempt  to  take  his  own  life  rather  than  stand  the  dis- 
grace of  being  discharged).  On  entering  the  room  I 
found  him  lying  upon  a  bed  in  a  profound  coma,  face 
cyanosed  to  a  purplish  dark  color,  breathing  almost  en- 
tirely suspended,  heart  slow  and  strong.  He  had  taken 
the  opiate  only  about  one  hour  before,  as  it  was  afterward 
ascertained ;  the  pupils  were  markedly  contracted ;  he 
could  not  be  made  to  recognize  the  loudest  of  noises.  I 
was  sure  he  had  taken  morphine.  I  lowered  his  head, 
raised  a  window,  and  practised  artificial  respiration  till 
he  breathed,  then  I  gave  him  atropine  sulph.,  gr.  ^,  hy- 
podermatically.  Thinking  the  morphine  had  been  all 
absorbed,  as  I  did  not  know  at  what  time  he  had  taken 
it,  I  did  not  use  the  stomach-pump.  Finally  I  got  him 
to  swallow,  and  gave  him  FE.  ipecac.  3  ss.  by  the  mouth, 
which  in  the  course  of  an  hour  and  a  half  produced 
marked  emesis.  During  this  time  several  persons  had 
come  in,  and  we  had  him  upon  his  feet  supported  by  two  or 
three  men,  and  made  him  walk,  or  carried  him  rather,  in  a 
perpendicular  position  until  he  finally  could  speak  and 
breathed  without  being  told  or  made  to  do  so  by  pressure 
over  the  chest.  I  gave  him  strong  black  coffee  and  more 
atropine  sulph.  while  he  was  being  walked  around,  until 
he  seemed  out  of  danger  or  in  a  favorable  way  to  recovery. 
About  this  time  my  wife,  Dr.  Eva  M.  McGuire,  came  in 


and  corroborated  my  diagnosis.  The  patient's  wife,  of 
course,  expected  him  to  die  and  asked  me  several  times 
what  I  thought  of  his  chances  for  recovery ;  I  told  her  I 
thought  he  would  live,  but  to  satisfy  her  sent  for  my 
friend,  Dr.  W.  H.  Earnest. 

At  the  time  the  messenger  went  the  doctor  was  in  the 
country,  so  it  was  some  time  before  he  came,  perhaps 
three  hours  after  I  had  first  been  called.  The  doctor 
hearing  of  the  probable  ingestion  of  an  opiate  brought 
with  him  one  pound-bottle  of  potassium  permanganate. 
He  also  corroborated  our  diagnosis.  He  proposed  potas- 
sium permanganate  in  three-  or  four-grain  doses  by  the 
mouth,  saying  that  he  was  not  at  all  sure  of  its  antidotal 
powers,  but  thought  it  worth  trying.  I  agreed,  though  I 
felt  sceptical  of  it.  At  the  time  when  Dr.  Earnest  came, 
I  had  not  given  any  atropine  for  some  time,  and  Mr. 

M was  so  that  he  recognized  all  who  came  in.     At 

this  time  he  was  propped  up  in  bed,  when  we  gave  him 
three  or  four  grains  of  potassium  permanganate.  He 
seemed  to  be  in  a  fair  way  to  recover,  though  the  pupils 
were  still  markedly  contracted.  In  perhaps  twenty 
minutes  after  the  ingestion  of  the  potassium  permanganate 

Mr.  M sank  into  a  deep  coma;  he  could  not  be 

roused  by  shouting  into  his  ears,  the  breathing  stopped, 
he  became  cyanosed  to  a  dark  color,  and  life  seemed  to 
be  gone.  I  again  practised  artificial  respiration,  but  this 
time  without  any  success  at  all.  He  had  not  breathed 
for  two  or  three  minutes.  During  all  this  time  Drs. 
Earnest  and  Eva  McGuire  stood  by,  when  finally  I  raised 
him  up  and  Dr.  Earnest  and  I  carried  him  in  a  perpen- 
dicular position  to  the  veranda,  where  we  gave  him  to 
two  strong  men  who  supported  him  in  an  upright  posi- 
tion till  he  breathed.  When  he  had  been  walked  in  the 
open  air  I  gave  him  another  hypodermatic  injection  of 
atropine,  gr.  -fa9  and  strythnia,  gr.  -fa.  This  was  repeated 
in  an  hour,  when  his  pulse  became  stronger  again.  He 
complained  of  dryness  of  the  fauces  and  called  for  water 
frequently ;  we  gave  him  strong  coffee  too.  At  10  p.m. 
Drs.  Earnest  and  Eva  McGuire  went  home.  Relays  of 
men  walked  with  him  till  12  p.m.,  when  I  allowed  him  to 
go  in  the  house  and  sit  up  in  a  chair.  I  had  to  tell  him 
to  breathe  for  about  one  and  one-half  hour  longer,  when 
I  allowed  him  to  go  to  sleep,  and  he  only  breathed  seven 
to  eight  times  per  minute.  I  finally  let  him  go  to  bed, 
but  sat  by  him  till  6  a.m.,  when  he  breathed  twelve 
times  per  minute.  He  made  a  good  recovery,  and  con- 
fessed that  he  had  taken  morphine. 


PSORIASIS  TREATED  BY  THYROID  EXTRACT 
WITH   NEGATIVE  RESULT. 

By  CHARLES  E.  NAMMACK,  M.D., 

VISITING  PHYSICIAN,  GOUVERNEUR  HOSPITAL,  NEW  YORK. 

Julius  R ,  aged  seventeen,  tailor,  native  of  Russia, 

was  admitted  January  4,  1894.  Eleven  weeks  before  ad- 
mission an  eruption  appeared  on  his  face  and  extended 
over  the  entire  body,  including  the  scalp,  with  the  ex- 
ception of  the  palms  and  soles.  Considerable  itching  at- 
tended the  eruption.  The  case  presented  the  classical 
appearance  of  psoriasis  universalis,  with  a  more  extensive 
distribution  than  the  writer  had  ever  before  seen,  the 
patches  assuming  all  sorts  of  features  as  to  size  and  shape, 
and  every  region  of  the  body  being  covered.  The  mu- 
cous membranes  were  not  affected.  The  patient  had 
never  had  a  previous  attack,  nor  could  it  be  traced  to 
either  parent.  He  is  an  underfed  and  overworked  boy, 
employed  in  a  "  sweater  "  shop.  He  gives  no  history  of 
alcoholism,  rheumatism,  syphilis,  or  venereal  disease. 
He  was  treated  by  arsenic,  alkaline  baths,  and  external 
inunctions  in  the  usual  way,  until  January  23d,  when  my 
colleague  at  the  New  York  Hospital  Out  Patient  Depart- 
ment, Dr.  Prince  A.  Morrow,  called  my  attention  to 
Byrom  BramweH's  report  of  the  efficacy  of  thyroid  extract 
in  similar  cases  {British  Medical  Journal,  October  28, 
1893).  A  specimen  was  obtained  from  the  New  York 
Biological  Institute,  and  administered  in  gradually  in- 


344 


MEDICAL  RECORD. 


[September  15,  1894 


creasing  doses,  hypodermatically,  up  to  twenty- five  minims 
twice  a  day,  without  the  development  of  any  physiologi- 
cal action  from  the  extract,  and  without  any  perceptible 
influence  on  the  eruption.  All  other  medication  had 
been  stopped  at  the  time  the  thyroid  administration 
was  begun.  Through  the  kindness  of  Dr.  Morrow  an- 
other preparation  of  thyroid  extract,  prepared  by  Dr. 
Crary,  was  then  obtained,  and  the  patient  was  given  five 
drops  of  this  twice  a  day,  and  the  dose  increased  gradu- 
ally until  he  had  taken  fifteen  drops  twice  each  day.  No 
other  medicine  was  used.  He  received  the  usual  ward 
diet  and  was  allowed  to  be  out  of  bed.  The  thyroid  ex- 
tract did  not  increase  the  bodily  temperature,  nor  accel- 
erate the  pulse,  but  a  noticeable  effect  of  its  administra- 
tion was  a  marked  increase  in  the  daily  excretion  of 
urea,  confirming  the  results  reported  by  Dr.  Ord  and 
Mr.  White  {Therapeutic  Gazette,  January  15,  1894).  If 
it  be  true  that  thyroidectomy  increases  the  toxicity  of  the 
urine,  and  that  the  function  of  the  thyroid  body  is  an  ex- 
cretory one  (Medical  Record,  February  24, 1894,  p.  246), 
these  observations  have  a  peculiar  interest,  and  the  use  of 
thyroid  extract  a  wide  therapeutic  field.  In  this  partic- 
ular case  it  carried  the  amount  of  urea  excreted,  on  a 
diet  not  very  rich  in  nitrogen,  up  to  from  875  to  1,025 
grains  daily.  Its  effect  upon  the  eruption,  however,  was 
negative,  such  improvement  as  occurred  being  fairly  at- 
tributable to  the  rest  and  hospital  life.  It  was  therefore 
discontinued  on  the  fifty-fourth  day. 

»9  East  TwsNTY-rotnmi  Street,  March  as,  1894- 


PREMATURE  LABOR  BEFORE  THE  SIXTH 
MONTH- SURVIVAL  OF  THE  CHILD  FOR 
ONE  WEEK. 

By  W.  J.  HILL„M.D., 

STATESVILLE,    K.  C. 

Upon  July  13  th  last  I  was  called  to  see  Mrs.  C at 

two  o'clock  in  the  afternoon,  and  at  five  o'clock  the 
labor  was  completed  in  a  natural  way.  Very  little  blood 
was  lost ;  the  womb  contracted  tightly,  and  the  woman 
did  well  generally.  On  January  18th  she  menstruated 
last.  Everything  went  along  all  right  until  she  was 
three  and  a  half  or  four  months  gone,  when  she  took 
a  trip  of  twelve  miles  into  the  country  in  a  rough  wagon. 
Not  being  in  the  habit  of  riding  she  became  very  tired. 
That  night  "  her  sickness  "  came  on  her.  Being  some- 
what alarmed,  she  came  home  at  once,  believing  she  would 
miscarry.  From  this  time  on  until  her  confinement  the 
loss  of  blood  was  continuous,  amounting  at  times  to 
flooding.  Despite  my  efforts  to  control  it  by  keeping 
her  in  bed  and  the  free  use  of  ergot  and  other  remedies, 
I  was  importuned  from  time  to  time  by  herself  and  hus- 
band to  bring  on  labor,  but  insisted  on  waiting  as  long 
as  her  life  was  not  endangered,  until  the  child  was  viable. 
Very  little  quickening  was  felt.  In  fact,  she  was  so  sure 
it  would  be  born  dead  that  she  did  not  prepare  any 
clothes  for  it 

The  presentation  was  the  one  most  usual.  Though  the 
second  stage  was  not  protracted,  yet  the  child  was  livid 
and  presented  every  appearance  of  being  lifeless.  As  is 
my  habit,  I  suspended  it  head  downward,  and  in  a  mo- 
ment I  saw  evidences  of  life.  By  my  aid  in  artificial 
respiration  it  soon  began  to  cry ;  I  then  in  a  few  mo- 
ments had  it  snugly  wrapped  in  soft  warm  wraps,  and 
had  it  laid  away.  After  I  had  seen  that  the  mother  was 
made  comfortable,  I  turned  my  attention  again  to  the 
child ;  I  refused  to  allow  it  to  be  washed  for  two  days, 
neither  did  I  allow  it  to  be  handled  to  dress  it.  It  was 
at  first  allowed  the  sugar  cloth,  then  it  was  put  upon  its 
mother's  milk,  which  was  milked  from  the  breast  and  fed 
to  it  from  a  bottle  and  nipple.  Afterward  it  took  the 
breast.  It  slept  well,  bowels  were  regular  in  their  action, 
as  were  also  the  kidneys.  It  lived  for  seven  days.  The 
nails  were  only  shaped,  but  the  infant  had  plenty  of 
hair.  No  vernix  caseoea  present.  It  was  born  with  the 
membrana  pupillaris  present.  It  measured  eleven  and  a 
half  inches  and  weighed  one  pound  and  two  ounces. 


The  morning  after  it  was  born  I  could  cover  the  face 
from  view  with  a  silver  dollar.  The  mother  has  borne 
four  other  children,  and  always  went  to  full  term.  The 
child  was  allowed  to  get  cold,  and  this  I  think  caused 
its  death.  Upon  examination  I  found  that  a  consider- 
able portion  of  the  placenta  bore  evidences  of  having 
been  detached  for  some  time.  There  was  very  little 
fluid  in  the  sac  >  it  was  of  a  brownish  color  with  con- 
siderable sediment  in  it.  This  fluid  also  came  from  the 
mouth  and  nose  of  the  child  at  birth.  The  mother 
made  an  excellent  recovery. 


TREPHINING   FOR   TRAUMATIC   CLOT. 
By  GEORGE  G.  HOPKINS,  M.D., 

SUBCKON  TO  ST.  JOHN'S  HOSFITAL,   ETC..   BROOKLYN,   M.  Y. 

Charles  Bolts,  aged  twenty- seven ;  sea  captain,  single* 
Admitted  to  hospital  September  16,  1893. 

Eighteen  days  previous,  during  a  severe  storm,  he  was 
struck  on  the  eminence  of  the  left  parietal  bone  by  the 
main  boom  and  knocked  overboard;  he  had  strength 
enough  to  catch  a  rope  and  was  pulled  aboard.  His 
yacht  was  shortly  driven  ashore  and  wrecked,  and  he 
was  pulled  ashore  by  some  of  his  crew  in  a  semi-con- 
scious condition.  Later  he  lost  consciousness,  but  for 
how  long  a  period  I  have  been  unable  to  ascertain. 

On  admission  to  the  hospital  the  patient  was  unable 
to  give  a  clear  statement  of  anything  that  had  occurred 
during  the  eighteen  days  that  had  elapsed  since  the  in- 
jury had  been  received.  From  friends  who  had  watched 
him  constantly,  it  was  ascertained  that  his  actions  were 
very  erratic.  He  would  insist  on  going  long  distances 
to  see  friends,  and  when  he  reached  his  destination  he 
wondered  why  he  had  come.  He  would  stand  for  hours 
in  the  rain  and  refuse  shelter,  but  would  not  or  could 
not  give  any  reason  for  so  doing,  etc. 

He  complains  of  headache,  constant  and  severe,  the 
greatest  pain  being  over  the  site  of  the  traumatism ; 
has  persistent  nausea  with  vomiting  and  constipation. 

Examination  :  Head  found  to  be  symmetrical  on  both 
sides.  Tenderness  exists  over  left  parietal  bone  about 
two  thirds  distance  from  external  auditory  meatus  to  me- 
dian suture.  Pupils  are  equal,  responding  slowly  to 
light.  Puke,  75;  temperature,  97.50  F.  Urine,  sp.  gr. 
1. 01 6,  acid,  amber  color,  no  albumin,  no  casts,  no 
sugar. 

There  is  no  tubercular,  rheumatic,  nor  syphilitic  his- 
tory. Had  drank  heavily  a  few  weeks  before  the  in- 
jury. 

September  21st. — To  this  date  the  patient  had  been 
on  the  medical  side  under  care  of  Dr.  J.  E.  Langstaff, 
who  transferred  him  to  the  surgical  side,  and  he  came 
under  my  care.  Vomiting  very  frequent.  Bowels  ob- 
stinately constipated.  Headache  persistent,  and  at  times 
delirium. 

Ordered, 


B .  Potassii  iod 

'•       brom.... 
M.     S  :  T.i  d. 

$.  Chloral  hydrat  ... 
Spir.  chloroformi . 
M.     S  :  T.i.d. 


gr.  lij. 
v. 


Pul.  glycyrrh.  comp.,  3j.f  repeated  every  four  hours 
until  a  free  action  of  bowels  is  secured.  Hydrobromate 
hyoscin.,  gr.  Tfo-  p.r.n. 

2 2d. — Bowels  moved  freely.     Condition  improved. 

23d,  a.m. — Has  retained  both  medicine  and  nourish- 
ment for  twenty-four  hours;  p.m.,  had  a  severe  attack 
of  vomiting. 

24th. — Three  movements  during  the  night.  Retains 
nourishment  and  medicines.  Slept  seven  hours.  The 
first  sleep  of  more  than  a  few  minutes  since  admission  to 
the  hospital. 

October  7th. — Patient  steadily  improved  till  to-day. 
He  was  allowed  to  leave  his  bed  and  go  about  for  an 


September  15,  1894] 


MEDICAL   RECORD. 


345 


hour.     Nausea,   frequent  vomiting,  and    headache;  re- 
turned. 

8th. — Consultation  by  Drs.  Burge,  Rand,  Rochester, 
LangstafT,  Fairbairn,  and  Hopkins.  The  consultation 
decided  "symptoms  due  to  shock,"  Dr.  Hopkins  dis- 
senting, considering  "  symptoms  due  to  clot."  I  consid- 
ered operative  interference  imperative.  Not  being  sus- 
tained, concluded  to  wait  as  symptoms  were  abating. 

nth  — Symptoms  all  aggravated  again. 

1 2th. — Headache  constant  and  severe.  Determined 
to  trephine  over  the  seat  of  pain. 

Operation  at  3.30  p.m.  I  operated  in  the  presence  of 
the  staff,  assisted  by  Drs.  Wallace,  Simmons,  and  Hotch- 
kiss.  Anaesthetic,  ether.  A  curved  incision  was  made 
through  the  scalp  over  the  left  parietal  region,  the  skin 
and  subcutaneous  tissues  were  dissected  backward,  the 
periosteum  was  elevated,  a  seven-eighth  inch  trephine 
was  applied  over  arm  centre,  and  a  button  of  bone  re- 
*  moved.  The  dura  mater  was  slightly  lacerated  by  the 
trephine.  Dura  incised  and  turned  back,  and  a  clot  one 
fourth  of  an  inch  in  diameter  found  partly  organized  and 
removed.  There  was  a  pretty  free  hemorrhage,  but  it  was 
easily  controlled  by  pressure.  Pad  of  iodoform  gauze  in- 
serted in  the  wound  after  douching  with  Thiersch's  solu- 
tion. Dressing,  iodoform  gauze ;  returned  to  bed.  But- 
ton of  bone  not  returned,  having  become  soiled. 

13th. —  Comfortable  night,  temperature,  ioo°  F. 
Has  lost  power  of  right  arm. 

14th. — No  motion  in  arm  or  leg  on  right  side,  some 
difficulty  in  speech.  Headache  entirely  gone,  nourish- 
ment retained. 

15  th. — Wound  dressed,  found  perfectly  aseptic.  When 
dressing  was  removed  power  returned  to  both  leg  and 
arm. 

19th. — Leg  motion  good,  but  that  of  arm  impaired. 
Speech  thick.  Headache  only  occasionally,  and  very 
slight  No  vomiting  since  the  operation.  Sleeps  all 
night,  and  hallucinations  and  delirium  have  disappeared. 
His  general  condition  is  greatly  improved. 

December  17  th. — Patient  discharged  from  hospital. 
Right  leg  has  recovered  perfect  power,  speech  is  good. 
Full  power  in  right  arm  has  not  returned,  though  he  can 
use  it  for  all  ordinary  purposes,  and  it  is  steadily  improv- 
ing.    Headache  gone,  eats  and  sleeps  naturally. 

June  22,  1894. — He  has  now  been  at  sea  for  some 
months  and  is  perfectly  well,  but  lacks  strength  in  the 
three  smaller  fingers  of  the  right  hand. 

This  case  bears  strongly  upon  a  theory  I  have  long 
held,  that  there  are  many  simple  or  weak-minded  and 
epileptic  people  in  the  world  who  have  received  a  trau- 
matism, and  who,  had  they  been  promptly  relieved  by 
surgical  procedures,  would  have  been  saved  from  a  living 
death. 

TREPHINING    FOR    DEPRESSED    FRACTURE 
TWO  INCHES  IN  DIAMETER. 

By   GEORGE  G.    HOPKINS,   A.M.,   M.D., 

B^OOKL 'N,   K.  Y. 

Leonora  B ,  aged  five.  Admitted  to  St.  John's  Hos- 
pital May  4, 1894,  apparently  in  a  dying  condition.  She 
had  been  kicked  by  a  horse  over  the  right  temporal  and 
parietal  region,  causing  a  fracture  which  was  two  inches 
in  diameter  and  depressed  at  its  centre  full  half  an  inch. 
I  proceeded  to  operate  under  chloroform,  assisted  by 
Drs.  Rand,  Fairbairn,  Simmons,  Search,  and  Panton. 
'All  aseptic  precautions  were  observed,  an  oval  incision 
was  made  extending  beyond  the  line  of  fracture  on  all 
sides,  which  was  two  full  inches  in  diameter.  The  treph- 
ine was  applied  at  the  junction  of  the  two  smallest  frag- 
ments and  a  Ji  inch  button  of  bone  was  removed,  the 
greater  portion  being  taken  from  the  sound  bone.  The 
smallest  piece  was  removed  with  forceps,  as  it  had  pene- 
trated the  cerebral  substance,  which  was  oozing,  and  to 
have  raised  it  would  have  lacerated  the  cerebrum  still 
more.  Before  the  bones  could  be  elevated  to  their  nor- 
mal position  it  was  necessary  to  remove  from  the  larger 


fragment  its  outer  edge  for  an  inch  in  length  by  a  quar- 
ter of  an  inch  in  width. 

The  difficulty  of  replacement  did  not  end  here,  as  a 
third  fragment  was  removed  before  satisfactory  repo- 
sition could  be  accomplished.  As  a  result  of  the  opera- 
tion, we  had  removed  one  piece  of  bone  half  an  inch 
square,  and  portions  of  bone  around  two- thirds  of 
the  circumference  of  the  fracture.  A  silkworm  gut 
drain  was  introduced  between  the  overlying  tissues 
and  the  calvarium.  The  edges  of  the  muscles  and  skin 
were  partly  sutured.  A  piece  of  sterilized  gauze  was  in- 
troduced at  right  angles  to  the  silkworm  gut,  and  the 
flap  closed  over  it.    Douches  were  of  Thiersch's  solution. 

The  wound  was  left  undisturbed  until  the  ninth,  when 
it  was  found  perfectly  aseptic,  no  pus  having  formed. 
Gut  and  gauze  were  then  removed.  On  the  eleventh 
the  wound  was  again  dressed,  and  is  still  perfectly  aseptic. 
On  the  thirtieth  the  wound  was  entirely  healed. 

The  temperature  never  rose  above  normal.  The 
child  was  allowed  to  go  home.  Its  mind  is  perfectly 
clear  and  has  been  throughout. 

"  No  injury  to  the  head  is  so  slight  that  it  may  not 
cause  death,  and  none  so  severe  that  a  patient  may  not 
recover  from  it.*'       

PERMANGANATE    OF  POTASSIUM   IN  OPIUM* 
POISONING. 

By  C.   H.   CALLENDER,   M.D., 

M1W  BOSTON,  MASS. 

H.  C.  W ,  seven  years  of  age,  child  of  well  to  do 

parents.  Has  never  been  a  very  healthy  boy,  and  on  the 
night  of  June  16th  suffered  from  a  slight  bronchial 
trouble  which  kept  him  awake  the  greater  part  of  the 
time.  At  7.30  a.m.  of  June  17th  the  nurse  gave  him,  as 
she  supposed,  two  drachms  of  arom.  syr.  rhei.  He  had 
then  eaten  a  good  breakfast,  played  around  a  few  min- 
utes, complained  of  being  sleepy,  and  gone  to  bed. 

His  mother,  who  was  at  this  time  confined  to  her  bed 
in  the  same  room,  knowing  that  he  had  not  rested  the 
previous  night,  thought  it  nothing  strange  that  he  should 
be  sleeping  and  paid  little  or  no  attention  to  him.  At 
10.50  a  m.,  some  three  hours  after  taking  the  dose,  I  was 
hurriedly  called  (my  office  being  less  than  seventy  five 
yards  from  the  patient's  home).  I  found  the  child  in 
his  night  dress  lying  in  his  nurse's  lap  ;  face  pallid, 
shrunken,  agonized ;  pulse  almost  imperceptible ;  respi- 
ration very  slow  but  not  stertorous ;  skin  covered  with 
cold  sweat.  Asked  what  he  had  taken,  and  was  assured 
that  there  had  been  nothing  but  some  cough-syrup  dur- 
ing the  night,  and  the  rhubarb. 

Knowing  the  child  as  well  as  I  did,  and  having  seen 
him  while  visiting  his  mother  the  evening  before,  being 
sure  that  independent  of  the  cough  he  was  in  better 
health  than  he  had  enjoyed  for  a  long  while,  I  felt  so 
certain  that  he  had  obtained  poison  in  some  manner  and 
of  some  sort  that,  without  asking  any  more  questions  or 
making  any  more  careful  examination,  I  hurried  to  the 
office  for  stomach-pump,  medicine  case,  etc.  I  was 
probably  not  gone  two  minutes*  but  before  I  was  again 
in  the  house  the  mystery  had  been  explained,  and  the 
bottle  labelled  rhubarb  had  been  found  to  contain  lauda- 
num. 

The  pupils  were  very  much  contracted.  Considering 
the  length  of  time  since  the  dose  had  been  taken  I 
thought  the  pump  would  be  of  little  avail,  and  gave  a 
hypodermic  of  whiskey,  ordered  some  hot  water  in  bot- 
tles, and  then  the  thought  of  permanganate  of  potassium 
came  to  me  I  was  not  certain  that  I  had  any  of  the 
drug,  but  fortunately  found  about  fifteen  grains,  and  dis- 
solved this  amount  in  three  ounces  of  water.  It  was 
probably  not  more  than  five  minutes  after  the  nurse,  on 
going  to  the  boy's  cot,  found  something  was  wrong,  be- 
fore I  had  given  him  the  first  injection  of  permanganate. 
I  used  the  ordinary  hypodermic  syringe  holding  xxx. 
minims,  and  injected  deep  every  time. 

At  10.56  a.m.  I  gave  the  first  injection  in  the  left  arm. 


346 


MEDICAL   RECORD. 


[September  15,  1894 


The  pulse,  which  was  very  unsteady,  was  46;  respira- 
tions, 8  to  the  minute.  Twenty- five  minutes  later  a 
second  injection  was  given  in  the  same  arm,  and  ten  min- 
utes after  this  the  pulse  was  54  and  more  steady ;  respi- 
ration 12. 

At  11.30  a.m.  a  third  injection  was  made  in  outer  part 
of  the  thigh.  While  introducing  the  needle  I  thought 
he  attempted  to  move  the  leg  a  little.  Five  minutes 
later  I  put  my  finger  on  the  eyeball  and  the  lid  closed 
quickly.  I  noticed  the  pupils  had  dilated  considerably. 
Ten  minutes  later  I  called  the  child  by  name  loudly,  as 
I  had  done  a  number  of  times  before.  He  opened  his 
eyes  and  made  a  slight  attempt  to  start  up,  as  a  person 
would  when  suddenly  aroused  from  sleep. 

The  fourth  and  last  injection  was  given  at  a  quarter  to 
twelve  o'clock,  and  he  fought  against  it  pretty  strongly. 
Pulse  now  68;  respiration  16  to  18. 

Although  he  still  seemed  drowsy,  he  easily  recognized 
the  people  in  the  room,  and  would  call  them  by  name 
when  requested  to  do  so.  With  a  person  on  each  side 
we  now  walked  him  about  the  room  for  a  while.  At 
noon  I  felt  safe  in  leaving  him,  and  returning  in  one 
hour's  time  found  pulse,  respiration,  and  eyes  practically 
normal.  I  saw  him  again  in  the  evening,  and  with  the 
exception  of  some  little  pain  at  the  points  of  injection  I 
could  not  see  but  that  he  acted  and  felt  as  well  as  ever, 
and  he  has  continued  in  good  health  to  date. 

The  case  is  very  much  like  one  I  witnessed  while  a 
student,  some  eight  years  ago,  that  proved  fatal.  The 
child,  who  was  but  eight  years  of  age,  took  but  little  over 
a  drachm  of  laudanum,  was  in  the  hands  of  a  good  phy- 
sician in  two  hours'  time.  The  coma  was  not  so  pro- 
nounced as  in  my  case ;  but  in  spite  of  external  warmth, 
friction,  heart  stimulants,  whiskey,  and  atropia,  he  never 
awoke.  Therefore,  taking  both  cases  in  view,  I  feel  just 
as  sure  as  a  person  can  be  of  anything  in  this  world  that 
the  child  owes  his  life  to  the  permanganate  of  potash. 
It  was  not  over  one-half  hour  before  the  patient  began 
to  show  signs  of  improvement,  and  it  was  simply  won- 
derful how  quickly  he  recovered  after  he  once  began  to 
do  so. 

A  PAINLESS    LABOR. 

Dr.  Robert  N.  Flagg,  of  Yonkers,  N.  Y.,  writes: 
"  Having  attended  a  painless  case  of  labor  in  a  primipara, 
I  am  inclined  to  ask  the  question,  How  often  do  we  see 
a  normal  delivery  ?  The  rarity  of  the  experience  in  my 
practice,  as  well  as  in  that  of  other  practitioners  with 
whom  I  have  conversed,  leads  me  to  give  a  brief  ac- 
count of  its  progress. 

"  An  American  woman,  born  of  Scotch  parents,  aged 
twenty- one,  married  eighteen  months,  ushered  in  her 
first  confinement  by  the  rupture  of  the  membranes  some 
three  weeks  before  the  expected  time.  This  happened  in 
the  early  afternoon,  and  at  nine  o'clock  I  was  sent  for,  as 
it  was  still  a  question  whether  the  labor  was  in  progress. 
I  found  the  patient  seated  up  in  bed,  not  as  yet  having 
had  a  pain,  but  a  pressure  at  intervals  of  about  fifteen 
minutes.  On  examination  I  was  surprised  to  find  the  os 
welltfilated,  thinned  out,  and  every  evidence  of  the  com- 
pletion of  the  first  stage.  I  returned  in  an  hour,  finding 
the  head  descending  in  the  O.  L.  A.  position,  and  very 
steady  pressure  about  every  five  minutes.  The  patient 
still  disclaimed  having  any  pain,  and  as  the  pelvis  was 
small  and  the  descent  rather  slow,  I  put  on  the  forceps 
and  brought  the  head  down  upon  the  perineum.  Before 
I  had  time  to  remove  the  instruments,  the  head  was 
delivered,  followed  by  the  shoulders  and  body  of  a  nine- 
pound  boy.  The  advent  of  this  good- sized  baby  was 
greeted  by  the  cheery  voice  of  the  mother  exclaiming, 
'  I  have  not  had  a  single  pain.' 

"  I  had  watched  her  through  the  second  stage  with  great 
interest,  and  can  say  that  with  the  exception  of  some  de- 
cided straining  and  a  redness  of  the  face,  there  was  no 
sign  of  the  labor  whatever.  The  placenta  came  away 
easily,  and  the  lying-in  period  was  uneventful.     There 


was  no  lack  of  normal  sensation  about  the  pubic  region, 
and  her  husband  assured  me  afterward  that  she  was  not 
devoid  of  sexual  feelings. 

"  Using  the  term  in  a  polite  as  well  as  pharmacal  sense, 
I  consider  this  defecation  of  a  baby  as  a  missing  link,  lost 
in  the  progress  of  the  race  and  the  over-development  of 
nerve- tissue. 

"  Here  was  something  perfectly  natural,  but  so  like 
the  animals  that  one  of  my  good  patients  considered  it 
decidedly  unscriptural." 

A   CONGENITAL  DEFORMITY. 

Dr.  James  B.  Thornton,  of  Boston,  Mass.,  writes: 
"  From  time  to  time  the  question  of '  maternal  impres- 
sions '  is  brought  up  by  reports  of  interesting  and  pecul- 
iar cases.  To  vary  the  monotony  of  the  expression  sup- 
pose we  use  that  of  paternal  impression  and  briefly  detail 
a  case  to  support  the  term. 

11  At  4.30  a.m.,  August  1 8th,  the  writer  was  summoned 

to  attend  Mrs.  H.  L.  E ,  in  her  first  confinement 

Birth  was  uneventful.  On  the  following  day  attention 
was  called  to  a  growth  on  the  outer  side  of  the  left  little 
finger,  near  the  junction  of  the  middle  and  terminal  phal- 
anges. This  growth  was  a  veritable  polypus  (with  a  fine 
pedicle  about  half  an  inch  in  length^  and  about  the  size 
of  a  large  pea,  but  flattened  rather  than  round.  Exami- 
nation showed  it  to  be  of  a  heloid  consistency,  and  sec- 
tion of  pedicle  caused  but  a  small  drop  of  blood  to  ap- 
pear. 

"  The  paternal  interest  in  the  matter  was  made  apparent 
by  the  father  showing  me  a  sessile  growth  in  identically 
the  same  location  on  his  own  hand,  and  which  he  stated 
was  congenital,  and  had  been  a  source  of  much  anxiety  to 
his  parents,  who  feared  it  was  of  a  malignant  nature.  In 
his  case  the  tumor  had  never  been  operated  upon,  and 
had  slowly  grown  smaller  from  his  birth.  If  I  can  be- 
lieve what  was  told  me,  the  father  and  mother  both  made 
an  early  examination  of  the  baby  in  question  soon  after 
its  arrival,  to  find  their  fears  confirmed." 

MEMBRANOUS  ENTERITIS. 

Dr.  J.  M.  Ward,  of  Cornelia,  Mo.,  writes:  "At  a 
recent  meeting  of  die  New  York  County  Medical  Asso- 
ciation Dr.  Coyle  mentioned  a  case  of  membranous  enter- 
itis where  the  treatment  was  correction  of  diet,  rectal  in- 
jections as  a  means  of  cleanliness,  and  keeping  the  bowels 
regular.  He  does  not  say  that  he  cured  the  case  by  that 
treatment,  and  I  venture  to  say  that  he  did  not.  Early 
this  summer  I  had  a  similar  case,  that  I  cured  by  the  in- 
ternal administration  of  tar,  and  the  daily  injection  of 
tar-water.  I  received  the  treatment  from  Mr.  David 
Wark,  of  New  York.     Here  is  what  he  says : 

" '  Treatment :  Make  of  North  Carolina  tar  a  mass 
with  wheat  flour  and  a  few  drops  of  water.  Cut  into 
three-grain  pills  or  put  in  capsules.  Give  four  pills  two 
hours  after  meals.  On  retiring  use  an  enema  of  three 
ounces  of  tar- water  and.  retain.  In  a  week  or  less  the 
bowels  begin  to  move  freely  and  normally,  and  all  the 
local  and  systemic  symptoms  begin  to  disappear.  It 
takes  from  two  to  three  weeks  to  effect  a  cure.  A  grain 
or  two  of  the  extract  of  wahoo  as  an  intestinal  tonic, 
three  times  a  day,  completes  the  cure.'  " 


A  Dog  Receives  Hospital  Care. — The  citizens  of  Bay- 
reuth  are  mildly  indignant  because  the  favorite  St.  Ber- 
nard dog  belonging  to  the  Wagner  family  was  treated  in 
the  city  hospital.  Dr.  Landgraf,  the  family  physician,  and 
also  surgeon  to  the  hospital,  received  the  animal  and  oper- 
ated upon  him  in  the  regular  operating-room  of  the  hos- 
pital. The  worthy  burghers  have  petitioned  the  City 
Council  to  pass  a  resolution  condemning  Dr.  Landgrat 
for  his  action. 

The  Universities  of  Holland,  four  in  number,  have 
2,972  students,  of  whom  19  are  women. 


September  15,  1894] 


MEDICAL  RECORD* 


347 


jftocietg  Reports. 

THE  NEW    YORK    PATHOLOGICAL  SOCIETY. 

Stated  Meeting,  May  2j,  1894. 
George  C.  Freeborn,  M.D.,  President,  in  the  Chair. 

Rupture  of  the  Urinary  Bladder. — Dr.  Eugene  Hoden- 
pyl  presented  specimens  from  a  case  of  extensive  rupture 
of  the  urinary  bladder.  They  had  been  removed  from  a 
woman  sixty  years  of  age,  who  had  stated  that  six  days 
before  her  admission  to  the  hospital  she  had  noticed  an 
inability  to  move  the  legs  or  to  urinate.  She  had  re- 
ceived little  or  no  treatment  up  to  the  time  of  her  ad- 
mission. She  was  then  found  to  be  somewhat  apathetic ; 
the  abdomen  was  distended ;  there  was  complete  paraly- 
sis of  the  lower  extremities,  and  a  small  quantity  of 
urine  was  escaping  by  drops  from  the  bladder.  The 
next  morning  she  was  noticed  to  be  gradually  failing  in 
strength,  and  a  few  hours  later  she  died.  At  the  autopsy 
the  abdominal  cavity  was  found  distended  with  fluid 
which  was  slightly  tinged  with  blood ;  there  was  no  evi- 
dence of  peritonitis.  At  the  fundus  of  the  bladder  was 
a  linear  rupture,  almost  two  inches  in  length.  The 
bladder  was  very  large,  and  the  mucous  membrane  was 
intensely  congested.  The  other  abdominal  organs  and 
the  thoracic  organs  were  normal.  The  dorsal  portion  of 
the  spinal  cord  showed  minute  areas  of  softening,  and 
the  diagnosis  of  disseminated  myelitis  was  afterward  con- 
firmed by  a  microscopical  examination. 

It  was  quite  remarkable  that  there  had  been  so  little 
discomfort  and  such  slight  inflammatory  action  notwith- 
standing the  amount  of  urine  in  the  abdominal  cavity. 
It  was  unfortunate  that  a  bacteriological  examination 
had  not  been  made  to  determine  the  presence  or  absence 
of  bacilli  in  this  fluid.  The  microscopical  examination 
showed  intense  congestion  of  the  bladder  mucous  mem- 
brane, but  no  inflammation.  The  rupture  must  have 
been  due  to  over-distention. 

Prostatic  Abscess. — Dr.  George  P.  Biggs  presented 
a  number  of  specimens  of  prostatic  abscess,  and  made 
some  remarks  on  this  subject  based  upon  a  study  of  the 
autopsy  records  of  the  New  York  Hospital  for  the  past 
twenty-five  years.  In  these  records  he  had  found  ten 
cases  of  prostatic  abscess,  after  excluding  a  few  cases 
which  were  apparently  peri-urethral  abscesses,  and  did 
not  definitely  involve  the  prostate  itself.  Case  of  tuber- 
cular prostatitis  had  also  been  excluded. 

The  first  specimen  presented  was  from  a  man  twenty- 
two  years  of  age.  He  had  given  a  history  of  gonorrhoea 
lasting  for  three  months  before  his  present  illness.  He 
had  recovered  from  his  attack  entirely  at  the  time  of  his 
admission  to  the  hospital.  Five  days  previous  to  his 
coming  to  the  hospital,  he  was  seized  with  retention  of 
urine,  and  was  catheterized  daily.  On  admission,  the 
temperature  was  1020  F.,  and  the  pulse  112.  Examina- 
tion showed  a  stricture  in  the  deep  urethra.  On  the  same 
day  he  had  a  chill  and  a  temperature  of  1 05  °.  There  were 
repeated  chills  after  this,  with  a  morning  temperature 
of  990  and  a  evening  temperature  of  1050.  Four  days 
after  admission,  a  swelling  appeared  in  the  perineal  re- 
gion associated  with  some  local  pain  and  tenderness.  A 
median  incision  was  made,  and  considerable  pus  evacu- 
ated from  the  neighborhood  of  the  deep  urethra.  The 
patient  died  two  hours  later.  At  the  autopsy,  the  spleen 
was  found  to  be  considerably  enlarged  and  quite  soft ; 
there  was  an  abscess  five  ctm.  in  diameter,  and  numerous 
smaller  abscesses  in  the  left  kidney.  The  right  kidney 
contained  two  small  abscesses.  The  pelves  and  ureters 
were  much  dilated  and  inflamed.  The  bladder  wall  was 
thickened,  and  contained  a  small  quantity  of  purulent 
urine.  The  left  lobe  of  the  prostate  was  the  seat  of  a 
deep  abscess,  1  ctm.  in  diameter,  from  which  a  probe 
could  be  passed  to  a  peri  urethral  abscess  3  ctm.  in  di- 
ameter, located  just  in  front  of  the  prostate.  The  me- 
dian perineal  incision  had  passed  from  the  perineal  ab- 


scess into  the  urethra.  The  entire  urethral  mucous 
membrane  was  thickened  and  covered  with  a  false  mem- 
brane. There  were  evidences  of  a  large  calibre  strict- 
ure in  the  bulbous  portion  of  the  urethra.  There  was  a 
perforation  in  the  left  side  of  the  urethra  just  in  front  of 
the  urethral  orifice,  and  this  communicated  with  an  ab-  < 
scess  in  the  left  lobe  of  the  prostate. 

The  patient  died  nine  days  after  the  infection  of  the 
genito-urinary  tract,  and  the  cause  of  infection  was  prob- 
ably the  catheterization  which  was  necessary  before  his 
admission  to  the  hospital. 

The  second  case  was  that  of  a  man  fifty-four  years  of 
age,  who  gave  the  usual  history  of  stricture.  Before 
his  admission,  sounds  had  been  passed  tor  the  relief  of 
this  condition.  Ten  days  before  his  admission  to  the 
hospital,  he  noticed  a  swelling  in  the  right  perineal  re- 
gion, and  this  increased  rapidly  in  size.  On  admission, 
the  temperature  was  102. 6°  F.,  and  his  pulse  40,  and 
the  urine  contained  a  large  amount  of  albumin  with 
granular  casts.  An  abscess  was  found  on  the  right  side 
of  the  anus,  and  it  was  incised  the  next  day  and  consid- 
able  fetid  pus  escaped.  After  this  the  temperature  was  not 
so  high.  About  nine  days  after  the  first  symptoms,  he 
developed  considerable  irritability  of  the  bladder,  and 
examination  of  the  urethra  showed  a  stricture  at  four 
inches,  which  would  only  admit  a  filiform  bougie.  Two 
weeks  after  the  onset  of  the  first  symptoms,  external 
urethrotomy  was  performed,  and  the  urethra  was  cut  to 
No.  2,  French.  After  this  the  temperature  ranged  from 
990  and  1020.  The  patient  became  at  first  stupid,  and 
then  unconscious,  and  finally  died  of  heart  failure  eight- 
een days  after  the  performance  of  the  external  urethrot- 
omy. No  chills  were  recorded.  At  the  autopsy,  the 
Kidneys  were  found  to  be  the  seat  of  quite  extensive 
chronic  diffuse  nephritis,  and  contained  also  multiple 
miliary  abscesses.  The  pelves  and  ureters  were  dis- 
tended with  purulent  urine,  and  the  mucous  membrane 
was  inflamed.  The  bladder  was  greatly  hypertrophied, 
and  the  mucous  membrane  was  inflamed  and  coated  with 
pus*  The  prostate  had  been  converted  into  a  series  of 
communicating  abscesses,  which  had  a  capacity  of  two 
abscesses.  A  pin-hole  opening  connected  the  abscess 
with  the  urethral  canal.  The  pus  had  infiltrated  the 
connective  tissue  behind  the  prostate  as  far  as  the  pelvic 
peritoneum,  but  there  was  no  pelvic  peritonitis.  There 
was  an  incised  wound  in  the  perineum  which  commu- 
nicated with  the  bulbous  portion  of  the  urethra,  but  had 
not  opened  into  the  prostatic  abscess. 

The  interesting  features  were  (1)  a  prostatic  abscess 
developing  a  few  days  after  the  dilatation  of  the  stricture 
with  sounds,  and  (2)  the  relatively  low  temperature,  the 
highest  being  102. 6°.  The  cause  of  death  was  general 
urinary  infection. 

The  third  case  was  that  of  a  man  fifty  years  of  age. 
He  denied  ever  having  venereal  diseases.  Four  weeks 
prior  to  his  admission  he  developed  rather  suddenly  a 
headache  and  a  temperature  of  about  1030  F.  Two 
weeks  later,  quite  violent  symptoms  of  cystitis  appeared, 
associated  with  retention  of  urine.  Catheters  were  used 
daily  for  two  weeks  previous  to  his  coming  to  the  hospi- 
tal. On  admission,  his  temperature  was  ioo°  F. ;  respi- 
ration, 34;  pulse,  32.  There  was  a  large  fluctuating 
mass  felt  in  the  anterior  rectal  wall.  He  was  catheter- 
ized, and  fifty-two  ounces  of  urine  drawn  off.  The  urine 
was  acid,  and  contained  five  per  cent,  of  albumin  with 
considerable  pus  and  blood.  He  had  a  chill  on  the  fol- 
lowing day,  and  a  temperature  of  103. 40  F.  He  de- 
veloped delirium,  and  a  high  temperature  persisted.  The 
abscess  was  opened  by  a  high  perineal  incision  and  con- 
siderable pus  evacuated,  but  the  symptoms  were  not 
relieved.  He  died  in  a  condition  of  coma  a  few  days 
later.  The  autopsy  was  made  thirty  hours  after  death. 
The  spleen  was  three  times  the  normal  size,  and  quite 
soft.  The  kidneys  showed  moderate  chronic  diffuse 
nephritis,  and  contained  a  few  groups  of  miliary  ab- 
scesses in  their  cortices.  The  pelves  and  ureters  were 
inflamed  and  distended  with  purulent  urine.     The  blad- 


34« 


MEDICAL    RECORD. 


[September  15,  1894 


der  contained  about  four  ounces  of  purulent  urine ;  the 
muscular  wall  was  hypertrophied ;  the  mucous  membrane 
was  softened,  thickened,  and  of  a  greenish  color  and  there 
was  a  small  mass  of  fibrous  exudation  at  the  base.  The 
prostate  had  been  destroyed  by  suppurative  inflamma- 
tion, the  pus  being  situated  in  indistinctly  outlined 
spaces,  having  ragged  walls,  and  not  communicating  freely 
with  each  other.  The  incision  in  the  left  side  of  the 
perineum  had  drained  most  of  the  abscesses  on  the  left 
side  of  the  prostate,  but  those  on  the  right  side  were  still 
full  of  pus.  A  sharply  defined  circular  opening,  2  mm. 
in  diameter,  was  located  in  the  anterior  rectal  wall,  and 
this  communicated  with  one  of  the  abscesses  in  the  right 
lobe  of  the  prostate.  There  was  another  opening, 
2  mm.  in  diameter,  and  in  the  left  side  of  the  floor  of 
the  urethra  just  at  its  beginning.  This  communicated 
with  an  abscess  2  ctm.  in  diameter,  located  just  behind 
the  trigone.  This  abscess  did  not  seem  to  communicate 
with  any  of  the  others.  The  urethra  was  congested 
throughout,  but  was  normal  in  calibre.  The  mucous 
membrane  in  the  bulbo  membraneous  portion  was  super- 
ficially lacerated  in  a  longitudinal  direction,  probably 
from  the  rough  use  of  the  catheter.  An  immediate  bac- 
teriological examination  of  the  pus  evacuated  at  the  time 
of  the  operation  was  made,  and  absolutely  nothing  found 
in  the  cultures  except  the  staphylococcus  pyogenes  aureus. 
However,  in  the  fresh  pus  stained  on  a  slide,  there  were 
also  some  diplococci  of  uncertain  character.  Cultures 
taken  at  the  autopsy  developed,  in  addition  to  the  sta- 
phylococcus pyogenes  aureus,  a  bacillus  which  grew  very 
rapidly  and  which  was  regarded  purely  as  a  contamina- 
tion. 

The  points  of  interest  in  this  c&se  were,  the  develop- 
ment of  the  cystitis  and  the  accompanying  prostatic 
abscess,  apparently  as  a  complication  of  some  acute 
febrile  process.  He  had  been  catheterized  for  two  weeks 
previous  to  his  coming  to  the  hospital.  The  abscess 
cavities  in  the  pro3tate  were  of  large  size.  The  one  on  the 
right  side  communicated  with  the  rectum,  while  that  on 
the  left  side  communicated  with  the  urethra,  although 
neither  of  the  perforations  were  sufficient  to  drain  the 
abscesses.  The  chills  were  frequent  and  the  fever  rela- 
tively high.  The  patient  died  of  general  urinary  infec- 
tion including  the  kidneys.  The  cause  of  the  suppuration 
seemed  to  be  the  staphylococcus  pyogenes  aureus,  although 
the  other  germs  found  in  the  fresh  pus  which  failed  to 
grow  in  the  culture,  might  have  had  some  bearing  on  it. 

The  fourth  case  was  that  of  a  Russian,  twenty-two 
years  of  age,  who  was  brought  to  the  hospital  in  an  am- 
bulance after  internal  urethrotomy  had  been  done  at  a 
physician's  office.  The  hemorrhage  had  been  so  pro- 
fuse that  a  large  catheter  had  been  tied  in  the  urethra, 
and  the  patient  hurriedly  sent  to  the  hospital.  The 
urine  was  found  to  be  loaded  with  pus  and  blood.  On 
the  day  following  his  admission  his  temperature  was 
1 04. 50.  The  next  day  he  had  a  slight  chill,  and  the 
temperature  remained  high.  An  abscess  had  then  de- 
veloped in  the  supra-clavicular  region  on  the  left  side. 
He  became  delirious  and  died  nineteen  days  after  ad- 
mission. The  autopsy  revealed  an  extensive  broncho- 
pneumonia and  an  acute  pleuritis.  The  spleen  was 
three  times  the  normal  size  and  very  soft.  The  kidneys 
were  much  congested  and  swollen,  but  contained  no  ab- 
scesses. The  bladder  contained  a  small  amount  of  pus, 
and  was  acutely  inflamed.  The  left  lobe  of  the  prostate 
was  enlarged,  and  on  incision  was  found  to  contain  a 
large  collection  of  pus.  The  axillae  and  supraspinous 
fossae  contained  abscesses  holding  about  six  ounces  of 
pus.  The  cause  of  death  was  a  pyaemia,  the  kidneys 
and  ureters  not  being  affected. 

The  fifth  case  was  that  of  a  man  twenty-eight  years 
of  age,  from  whom  no  previous  history  could  be  ob- 
tained, owing  to  his  being  in  a  comatose  condition  at 
the  time  of  entering  the  hospital.  At  this  time  his  tem- 
perature was  normal,  but  on  the  following  day  it  was 
1020  F.,  and  it  remained  between  990  and  1020  F.  for  a 
period  of  three  weeks.     He  remained  constantly  coma- 


tose, and  catheters  were  used  to  evacuate  the  bladder. 
At  the  autopsy  the  cause  of  death  was  found  to  be  the 
rupture  of  an  aneurism  of  the  vertebral  artery.  Both 
kidneys  were  congested ;  the  left  contained  a  number 
of  miliary  abscesses ;  the  right  contained  no  abscesses. 
The  bladder  was  intensely  congested,  and  contained 
purulent  urine.  The  prostate  contained  an  abscess  in- 
volving not  only  the  prostate  but  the  peri-urethral  tis- 
sues in  front,  and  communicating  with  the  prostatic 
portion  of  the  urethra  and  extensively  invading  the  tis- 
sues into  the  pelvis.  In  this  case,  infection  was  evi- 
dently the  result  of  catheterization  during  the  comatose 
stage.  The  point  of  interest  was  the  infection  of  one 
kidney  only.  The  abscess  communicated  with  the  be- 
ginning of  the  prostatic  portion  of  the  urethra.  There 
was  no  chill,  and  only  a  moderate  elevation  of  tempera- 
ture. 

The  sixth  case  was  that  of  a  man  twenty  years  of  age, 
who  had  sustained  a  fracture  of  the  spine  as  a  result  of 
diving  in  shallow  water.  It  was  necessary  to  catheterize 
him.  After  this  had  been  done  several  weeks,  he  de- 
veloped a  chill,  followed  by  a  temperature  of  104. 6°  F. 
He  then  became  delirious.  The  urine  was  found  to  con- 
tain blood  and  pus  in  large  quantities.  The  temperature 
remained  between  1020  and  1050  F.  for  sue  weeks.  He 
passed  into  a  state  of  low  delirium,  and  finally  died  as  a 
result  of  fracture  of  the  spine  and  infection  of  the  genito- 
urinary tract.  The  autopsy  showed  the  spleen  to  be 
large  and  soft.  The  kidneys  were  the  seat  of  chronic 
diffuse  nephritis,  and  contained  many  miliary  abscesses. 
The  bladder  was  hypertrophied  and  filled  with  purulent 
urine.  There  was  a  large  abscess  about  the  neck  of  the 
bladder,  surrounding  the  urethra  and  communicating 
with  the  rectum  by  two  small  openings,  two  and  a  half 
inches  above  the  sphincter.  There  was  no  communica- 
tion between  the  urethra  and  the  abscess,  or  between  the 
bladder  and  the  abscess.  The  fever  was  relatively  high 
— 102.60  to  1 04. 6°  F.  for  six  weeks.  The  cause  of  in- 
fection was  catheterization.  The  communication  was 
with  the  rectum,  and  not  with  the  urethra. 

The  seventh  case  was  a  man  thirty-seven  years  of  age, 
who  gave  a  history  of  having  first  had  gonorrhoea  eigh- 
teen years  before,  and  six  or  seven  attacks  since  that 
time.  He  had  noticed  symptoms  of  stricture  for  twelve 
years.  A  stricture  in  the  anterior  portion  of  the  urethra 
was  cut  to  No.  31  French.  On  the  following  day  there 
was  a  chill,  with  a  temperature  of  104  6°  F.  The  tem- 
perature ranged  high— 101.80  to  105. 20  F.  for  a  period 
of  seven  days.  The  autopsy  showed  the  spleen  to  be 
large  and  soft.  The  kidneys  were  the  seat  of  multiple 
miliary  abscesses,  and  both  pelves  and  ureters  were  di- 
lated and  distended.  There  was  a  laceration  of  the  ure- 
thra just  at  its  communication  with  the  bladder  on  the 
left  side.  The  left  lobe  of  the  prostate  contained  a  large 
abscess,  which  communicated  with  the  urinary  tract  at 
the  site  of  the  laceration  above  mentioned — *'.*.,  prac- 
tically at  the  urethral  orifice.  The  abrasion  was  appar- 
ently made  during  life,  probably  from  the  passage  of  a 
hard  instrument.  The  left  knee-joint  contained  this 
pus. 

The  eighth  case  was  that  of  a  man  sixty- four  years  of 
age,  who  gave  a  history  of  chronic  nephritis  for  four 
years.  He  had  been  frequently  catheterized,  owing  to 
retention  of  urine.  He  died  of  uraemia,  without  sus- 
picion that  the  genito  urinary  tract  had  been  infected. 
The  autopsy  showed  advanced  chronic  diffuse  nephritis, 
but  no  abscesses  in  the  kidney.  The  bladder  was  hyper- 
trophied, and  its  mucous  membrane  thickened  and  ulcer- 
ated. There  were  abscesses  in  both  the  lateral  lobes  of 
the  prostate,  and  also  in  front  of  the  prostate.  There 
was  in  this  case  simply  an  involvement  of  the  bladder 
and  of  the  prostate,  the  pelves,  ureters,  and  kidneys  not 
being  affected. 

The  ninth  case  was  that  of  a  man  forty-two  years  of 
age,  who  had  had  gonorrhoea  twelve  years  before  com- 
ing under  observation,  and  constant  gleet  since  that 
time.     He  had  applied  at  dispensaries  for  retention,  and 


September  15    1894] 


MEDICAL   RECORD. 


349 


had  been  catheterized  and  treated  with  sounds  without 
avail.  Examination  showed  a  stricture  located  at  the 
bulbo-membranous  junction,  and  a  smaller  one  near  the 
meatus.  The  latter  was  cut.  Following  this  there  was 
a  chill  and  a  temperature  of  101.80  F.  The  temperature 
fell  to  99. 40  on  the  following  day,  but  rose  again  to 
102. 20  F.  The  urine  was  diminished  in  quantity.  He 
died  eighteen  days  after  admission.  At  the  autopsy,  the 
spleen  was  found  to  be  quite  large ;  the  kidneys  were  the 
seat  of  advanced  pyelo-  nephrosis,  but  there  were  no  ab- 
scesses in  the  kidneys.  The  ureters  and  pelves  were  di- 
lated and  inflamed ;  the  bladder  wall  was  considerably 
hypertrophied  and  its  mucous  membrane  acutely  in- 
flamed. The  bladder  contained  a  small  amount  of  puru- 
lent urine.  There  was  an  incision  in  the  floor  of  the 
anterior  portion  of  the  urethra.  The  stricture  at  the 
bulbo  membranous  junction  had  not  been  operated  upon 
in  any  way. .  There  were  two  openings,  one  on  each 
side  of  the  urethra,  just  at  the  beginning  of  the  prostatic 
urethra,  and  they  led  into  abscess  cavities  in  the  pros- 
tate, having  a  capacity  of*  one  ounce.  In  this  case,  the 
pelves,  ureters,  and  bladder  were  infected,  but  the  con- 
nective tissue  proper  escaped. 

The  speaker  said  that  out  of  the  ten  cases  of  prostatic 
abscess  in  which  the  records  had  been  examined,  six 
gave  venereal  histories,  three  denied  such  a  history,  and 
in  one  no  record  was  made  in  regard  to  it.  Catheters 
were  used  and  appeared  to  be  connected  with  the  infec- 
tion in  five  cases.  In  one  case  there  was  a  question  as 
to  the  use  of  the  catheter,  no  record  having  been  made 
in  regard  to  this  point,  yet  no  good  explanation  had 
been  offered  of  the  source  of  infection.  In  three  cases 
the  infection  was  directly  due  to  the  operation  of  inter- 
nal urethrotomy.  In  one  the  symptoms  followed  dilata- 
tion of  an  old  stricture  by  sounds.  Seven  of  the  ab- 
scesses were  large,  and  three  comparatively  smaU.  Five 
of  them  communicated  with  the  urethra  only,  and  all  of 
these  communicated  with  the  urethra  in  the  posterior 
portion  of  the  prostatic  urethra.  One  communicated 
with  the  rectum  alone;  one  with  both  rectum  and  ure- 
thra ;  and  three  small  ones  did  not  communicate  with 
either  urethra  or  rectum.  In  five  cases  there  was  cystitis 
and  double  pyeio-nephritis ;  in  one,  cystitis  and  pyelo- 
nephritis  of  one  kidney ;  in  one,  cystitis  and  pyelo- 
nephrosis;  in  one,  pyaemia  with  pyelonephritis;  in 
one,  pysemia  without  pyelonephritis;  and  in  one  case 
there  was  no  infection  beyond  the  prostate.  In  three 
of  the  cases  the  temperature  ranged  between  1040  and 
1050  F. ;  in  five  between  990  and  1020  F. ;  in  two  there 
was  no  record  of  temperature,  but  it  was  probably  quite 
•  low. 

In  all  but  one  of  the  cases  there  was  a  history  of  the 
use  of  instruments  in  the  urethra  some  time  previous,  or 
the  infection  followed  immediately  upon  the  operation 
of  internal  urethrotomy.  There  was  evidently  secondary 
infection,  and  it  was  quite  possible  that  the  severity  of 
the  symptoms  might  depend  somewhat  on  the  organisms 
producing  the  infection.  The  possible  causes  of  death 
were  pyaemia,  septicaemia,  peritonitis,  or  a  simple  genito- 
urinary infection  exclusive  of  other  diseases.  Septicae- 
mia was  likely  to  occur  in  cases  where  there  were  large 
abscesses  without  secondary  deposits  of  pus.  Peritonitis 
might  occur  from  extension  of  the  inflammation  to  the 
connective  tissue  of  the  pelvis  to  the  pelvic  peritoneum. 

The  prognosis  should  be  guarded,  owing  to  the  fre- 
quency with  which  prostatic  abscess  was  associated  with 
general  infection  of  the  urinary  tract.  In  eight  of  these 
cases  the  kidney  was  involved.  It  would  seem  that  the 
most  frequent  cause  of  death  was  infection  of  the  upper 
portion  of  the  urinary  tract. 

Dr.  Samuel  Alexander  said  that  much  credit  was 
due  to  the  reader  of  the  paper  for  the  way  in  which  he 
had  grouped  his  facts.  There  were  acute  abscesses  oc- 
curring as  a  result  of  gonorrhoeal  infection  of  the  urethra, 
and  they  were,  perhaps,  more  common  than  the  chronic. 
They  were  due  to  secondary  infection,  either  through 
sounds  or  injections,  and  were  marked  clinically  by  the 


sudden  onset  of  the  symptoms — a  chill  and  a  much 
higher  temperature  than  was  usually  present  in  the 
chronic  cases.  The  diagnosis  was  not  difficult  if  a  rectal 
examination  were  made ;  the  symptoms  could  be  quickly 
relieved  by  operation.  He  thought  that  all  the  cases  just 
presented  should  be  grouped  as  chronic  abscesses,  because 
the  condition  which  predisposed  to  the  infection  was 
chronic.  Most  of  the  cases  there  seemed  to  be  a  pre- 
vious pathological  condition  of  the  urinary  tract.  In 
half  of  the  cases  there  was  a  stricture  of  the  urethra,  and 
the  autopsy  showed  secondary  changes  in  the  bladder 
and  kidneys,  thus  predisposing  to  general  infection  of 
the  genito  urinary  tract.  One  stnking  peculiarity  oi 
this  series  of  cases  was  the  large  size  of  the  abscesses. 
In  most  of  the  cases  he  had  seen  clinically  the  abscesses 
had  not  been  nearly  so  extensive.  We  should  distin- 
guish between  abscess  of  the  prostate  and  periprostatic 
abscess.  Regarding  the  prognosis,  he  would  say  that  it 
depended  more  upon  the  pre-existing  condition  of  the 
urinary  tract  and  the  severity  of  the  infectirg  cause  than 
upon  anything  else.  Death  was  most  rapid  and  the  ab- 
scess formation  most  extensive  in  those  cases  in  which 
there  was  a  serious  lesion  of  the  urethra,  causing  obstruc- 
tion, congestion,  and  infection.  Regarding  the  mode 
of  infection  in  the  cases  in  which  no  catheter  had  been 
used,  the  speaker  said  obstruction  in  the  urethra,  by  caus- 
ing urinary  overflow  and  congestion,  led  to  infection. 
This  condition  occurred  most  frequently  in  patients  over 
forty  five.  The  perineal  operation  was,  of  course,  the 
one  above  all  others  for  the  relief  of  prostatic  abscess, 
and  the  moment  such  an  abscess  was  suspected  an  open- 
ing should  be  made  in  the  perineum.  Where  suppura- 
tion extended  upward  into  the  prevesical  space  this 
operation  was  necessary ;  but  in  addition  to  this  it  was 
essential,  as  shown  in  the  cases  under  discussion,  that 
dissection  should  be  made  between  the  prostate  and  rec- 
tum and  all  the  pockets  evacuated,  and  the  abscess  cav- 
ity curetted  and  treated  aseptic  ally. 

Dr.  Thomas  H.  Manley  said  that  in  those  cases  in 
which  the  spinal  cord  had  been  destroyed  in  the  lumbar 
region  as  the  result  of  injury,  there  were  various  modes 
of  death,  the  most  common  being  by  infection  of  the 
genito  urinary  tract.  Owing  to  the  long,  tortuous  ure- 
thra of  the  male,  this  mode  of  death  was  much  more 
common  in  males  than  in  females.  While  he  thought 
all  must  agree  as  to  the  good  results  of  careful  asepsis, 
the  fact  still  remained  that  some  subjects  were  morbidly 
sensitive  to  the  passage  of  any  instrument  into  the  ure- 
thra. In  cases  of  over  distention  from  paralysis  of  the 
bladder  he  had  found  that,  in  spite  of  every  precaution, 
infection  and  death  were  liable  to  result. 

Dr.  George  P.  Biggs  said  that  the  cases  reported  in 
the  paper  were  old  ones,  and  in  most  of  them  infection 
had  occurred  from  catheterization  by  the  patient  himself, 
or  by  some  incompetent  person,  previous  to  the  admission 
of  the  patient  to  the  hospital.  The  importance  of  mak- 
ing a  free  opening  should  not  be  overlooked,  for  one  of 
the  cases  showed  that,  notwithstanding  the  communica- 
tion of  the  abscess  and  the  perineal  opening,  drainage 
was  not  at  all  adequate  to  the  needs  of  the  case. 

Congenital  Absence  of  One  Kidney  and  Ureter. — Dr. 
R.  G.  Freeman  presented  specimens  from  a  case  of  the 
above.  They  were  taken  from  a  child  aged  ten  months, 
who  up  to  a  few  days  before  death  had  been  perfectly 
well.  It  then  developed  croup,  was  intubated,  and  died 
from  broncho*  pneumonia  and  extension  of  the  mem- 
brane. The  right  kidney  and  right  ureter  were  absent. 
The  left  kidney  was  quite  large,  weighing  three  ounces. 
Three  such  cases  had  been  presented  to  the  Society — 
one  by  Dr.  Northrup,  in  1887 ;  two  by  Dr.  Thacher, 
in  1892 ;  and  one  by  Dr.  Hodenpyl,  last  year.  The 
condition  was  said  to  be  quite  rare,  and  the  left  one  was 
the  one  most  commonly  absent. 

The  Society  then  adjourned. 

Many  Suicides  of  boys,  from  twelve  to  sixteen  years  of 
age,  have  recently  been  reported  in  London. 


35° 


MEDICAL  RECORD. 


[September  15,  1894 


Uexrj  Instruments, 

AN  IMPROVED   CILIA  FORCEPS. 
By  CHARLES  H.  MAY,  M.D., 

CHIEF  OP  CLINIC,  DEPARTMENT  OF  OPHTHALMOLOGY,  VANDHRBILT  CLINIC,  COL- 
LEGE Or  PHYSICIANS  AND  SURGEONS,  MBDICAL  DEPARTMENT  OP  COLUMBIA 
COLLEGE,  NEW  YORK. 

Epilation  of  the  lashes  is  a  very  simple  process ;  but 
frequently  it  is  rendered  difficult  and  tedious  on  account 
of  the  improper  and  clumsy  shape  of  the  cilia  or  epilat- 
ing  forceps  in  the  market.  In  blepharitis  and  in  trichi- 
asis in  which  epilation  is  performed  there  is  no  diffi- 
culty in  pulling  out  the  coarser  lashes ;  but  the  fine  and 
short  hairs  often  give  us  much  trouble,  especially  when 
they  become  moistened  and  slippery  from  tears  and  dis- 
charges of  the  lids ;  then  we  are  apt  to  find  that  the  for- 
ceps no  longer  catch. 

To  obviate  this  difficulty,  I  have  had  a  forceps  con- 
structed which  is  a   modification  of  one  I  purchased 


tine  of  office  practice.    The  cut  gives  a  sufficiently  clear 
picture  to  render  further  description  unnecessary. 

In  the  cut  the  handle  appears  attached  at  a  greater 
angle  than  experience  has  shown  to  be  desirable,  the 
drawing  having  been  made  from  the  first  specimen  of  the 


of  Windier,  in  Berlin,  and  which  is  referred  to  as 
"Brecht's"  in  his  catalogue.  In  general  shape  it  re- 
sembles the  cilia  forceps  now  in  use ;  it  differs  merely 
in  the  construction  of  the  extremities  or  points.  These 
are  claw-shaped,  delicate,  having  a  width  of  *y2  mm. 
The  edges  are  curved,  one  being  convex,  the  other  con- 
cave ;  they  are  so  arranged,  through  a  slight  difference  in 
curvature,  that  pressure  exerted  in  clasping  the  instru- 
ment tightens  the  grasp  upon  the  hair  and  holds  it  firmly, 
without  any  danger  of  cutting  it  off.  The  instrument 
has  given  great  satisfaction  and  has  done  away  with  the 
annoyances  already  mentioned.  It  is  manufactured  by 
Meyrowitz. 

69a  Madison  Avenue,  New  York. 

AN  IMPROVED  CONICAL  RECTUM  SPECULUM. 
By  ROBERT  W.  MARTIN,    M.D., 

PHILADELPHIA,    PA. 

An  instrument  of  precision  applicable  in  the  treatment  of 
two  out  of  every  three  patients  who  seek  the  office  of  the 
physician  for  treatment  of  the  more  ordinary  diseases  of 
the  rectum  is  certainly  a  desideratum. 

When  I  presented  my  new  ano  rectal  speculum  to  the 
profession  through  the  Times  and  Register  (October  5, 
1889),  five  years  ago,  I  thought  I  had  an  appliance  as 
nearly  perfect  as  it  was  possible  to  make.  And,  indeed, 
for  very  many  of  the  applications  and  minor  operations 
within  the  rectum  it  was,  and  remains  to  me,  indispensable. 
But  longer  use  made  it  manifest  that  something  was 
needed  to  supplement  its  usefulness.  Consequently,  a 
year  ago,  taking  the  ordinary  conical  speculum  and  en- 
larging its  field  of  view,  I  had  it  made  on  the  model  of 
a  symmetrical  cone,  truncated  at  a  small  angle,  so  that 
the  obturator  would  fall  into  position  without  the  trouble 
and  delay  of  adjusting  it  to  some  particular  line  or  mark 
on  the  base  of  the  cone.  The  outer  end  of  the  obturator 
was  supplied  with  a  milled  head  of  large  diameter  to 
facilitate  its  removal. 

The  base  of  the  speculum  was  fitted  with  a  firm  handle 
of  extra  length  and  large  grip  adjusted  to  what  was  con- 
ceived to  be  the  proper  angle.  Thus  was  made  an  ap- 
pliance with  which  any  portion  of  the  lower  half,  or  more, 
of  the  rectum  and  intra- anal  tissues  might  be  brought  into 
view  by  successive  small  portions  for  the  purpose  either 
of  inspection  or  treatment. 

I  have  never  used  an  appliance  that  has  given  me  such 
supreme  satisfaction  in  treating  follicular  ulceration,  poly- 
poid, and  other  small  growths,  which  constitute  a  very 
large  proportion  of  the  cases  of  anal  and  rectal  diseases 
the  physician  is  called  upon  to  treat  in  the  ordinary  rou- 


speculum  manufactured.  It  is  now  made  with  the  handle 
attached  at  a  much  smaller  angle  with  the  axis  of  the 
speculum,  making  it  as  efficient  in  treating  a  patient  with 
protuberant  buttocks  and  deep  seated  anus  as  one  with 
wide-apart  tuber  ischii  and  a  more  accessible  anus. 

I  am  indebted  to  Messrs.  George  Tiemann  &  Co.  for 
their  precision  in  executing  my  designs  for  the  correction 
of  what  was  faulty  in  the  old  and  the  addition  of  what  is 
new  to  form  a  perfect  new  out  of  a  faulty  old  form  of 
speculum. 

X17  South  Sixtkenth  Street,  August  15,  1894. 

A   SNARE  WIRE  RECEIVER. 
By  GEORGE  E.  ABBOTT,  M.D., 

NEW  YCBK. 

This  can  hardly  be  called  a  new  instrument.  Yet  to 
some  it  may  be  a  new  and  useful  adjunct  to  their  snare. 

The  usual  routine,  now,  is  to  find  the  spool  of  wire, 
then  the  cutting  forceps,  guess  at  the  length,  cut,  drop 
the  spool,  say  something,  wind  up,  and  with  difficulty 
fasten  the  springy  wire,  adjust  the  wire,  and  find  it  makes 
too  small  a  loop,  or,  worse  yet,  too  large  a  one,  for  the 
screw  has  been  "  run  up  "  as  far  as  possible ;  but  the  polyp 
has  not  yet  been  cut  off  and  the  snare  is  thus  anchored  in 
the  patient's  nose,  to  be  delivered  only  by  main  force — 
of  course  not  by  pulling  upon  the  whole  snare,  but  by 
a  straight  pull  upon  the  rod,  through  the  cannula  thus 
severing  the  growth. 

The  better  way  is  to  make  a  trial  wire  first,  allow  its 
ends  to  bend  up  at  least  a  quarter  of  an  inch,  so  as  to 
hold  well,  "run  up  "  the  screw  and  be  sure  the  entire 
loop  will  be  drawn  within  the  cannula,  so  as  to  com- 
pletely divide  the  tissue  within  its  grasp,  with  a  few  turns 
to  spare  for  possible  slipping  or  stretching  of  the  wire. 

With  this  as  a  sample,  straighten  the  wire  of  the  spool, 
and  cut  fifteen  or  twenty  lengths. 


Now  cut  a  glass  rod  (scratch  with  edge  of  file  and 
snap  it  in  two)  one  inch  longer  than  the  wires,  so  as  to 
allow  of  corks  at  either  end ;  heat  the  ends  red  hot  so  as  to 
round  off  the  sharp  edges ;  put  in  the  bottom  cork  and 
cut  it  flush  with  the  end  of  the  glass,  now  the  wires  and 
the  cork  at  the  top.  You  will  thus  have  saved  time  and 
labor,  and  very  much  annoyance  when  the  patient  is 
anxiously  waiting  for  you  to  operate.  A  simple  tube 
can  be  made  by  rolling  some  writing  paper  several  times 
around  a  pencil  or  other  cylinder. 

125  West  Eighty-second  Street. 


September  15,  1894] 


MEDICAL    RECORD. 


35i 


(&owesvon&f>ucz. 

EXAMINATION  FOR    CANCER-CELLS   IN  THE 
LIVING  TISSUE. 

To  ths  Editor  op  the  Msdical  Rkcokd. 

Sm  :  While  reading  the  article  in  the  Medical  Record 
of  August  25,  1894,  on  "The  Cure  of  Carcinoma  of  the 
Breast  by  Radical  Operation,' '  by  Dr.  William  T.  Bull, 
the  idea  occurred  to  me,  Why  not,  in  operating  for  the 
cure  of  malignant  disease,  make  a  microscopic  examina- 
tion of  the  living  tissues  of  the  wound,  to  ascertain 
whether  all  the  cancer-cells  have  been  removed.  If  the 
examination  should  reveal  diseased  structure  still  there, 
it  could  be  removed  before  the  wound  is  closed.  If 
practical  and  practicable  it  seems  to  me  that  this  would 
be  a  great  advantage  to  the  patient,  giving  her  a  better 
chance  for  her  recovery,  and  reducing  the  mortality 
from  carcinoma.  It  would  also  lessen  the  number  of 
secondary  operations.  Could  not  a  microscope  be  so 
constructed  that  with  it  the  living  tissues  of  the  wound 
might  be  examined  in  situ,  after  the  growth  had  been 
removed  and  before  closing  the  wound  ?  If  this  could 
be  done  I  think  it  would  be  very  useful,  as  cancer-cells 
are  frequently  left  just  in  the  edge  of  the  wound.  Of 
course  this  is  but  a  crude  idea,  but  I  would  like  to  know 
what  the  readers  of  the  Medical  Record  think  of  it  and 
its  practicability. 

Albert  Seitz,  M.D. 

McMlNNVILLK,  TENN. 

SOME   SURGICAL  OBSERVATIONS  OF  DR.  FR. 
RAVOTH. 

To  the  Editor  of  the  Msdical  Rkcord. 

Sir  :  Some  years  ago  Dr.  Fr.  Ravoth  published  a  small 
volume  containing  short  papers  on  a  variety  of  surgical 
conditions.  The  book  is  dated  1873,  an(^  issued  by 
Ferdinand  Enke,  Erlangen. 

It  is  thought  that  the  author's  views  on  varicose  veins, 
varicocele,  etc.,  might  be  of  interest,  inasmuch  as  such 
procedures  are  not  found  in  some  of  the  more  recent 
text-books  on  surgery,  and  seem  worthy  of  consideration. 

In  the  paper  on  the  "  Treatment  of  Varicocele  by 
Means  of  a  Truss,"  the  author  refers  to  other  writers,  to 
the  results  of  treatment  of  hernia  with  truss,  etc.,  and 
states  that  under  pressure  of  a  truss-pad  the  varicocele 
lessens  in  size,  the  testis  soon  becomes  larger,  and  more 
consistent,  while  the  pain  in  the  testis  and  cord  ceases. 
The  enlarged  veins  being  due  to  the  weight  of  the  blood, 
if  by  appropriate  constriction  the  vein  is  relieved  from 
this  strain  the  part  below  the  point  occluded  will  re- 
cover itself.  He  believes  that  this  mild  method  is  more 
efficacious  than  the  many  ways  of  operative  interference, 
which  are  not  free  from  danger. 

These  ideas  may  be  applied  to  other  venous  varices, 
e.g.,  in  the  legs.  (The  treatment  of  aneurism,  by  press- 
ure on  the  distal  side  of  the  tumor,  may  be  referred  to 
in  this  connection.) 

The  other  papers  are  also  of  interest  to  the  scientific 
anatomist,  surgeon,  and  practitioner.  In  this  relation 
worthy  of  special  notice  is  his  description  of  the  surgical 
anatomy,  with  treatment  of  shoulder  and  elbow,  and  dis- 
locations of  them.  He  does  not  believe  that  there  is,  in 
any  sort  of  sickness  or  injury,  an  absolutely  pathognomonic 
sign.  Strong  disapprobation  is  expressed  for  the  practice 
of  making  a  "  snap  diagnosis,"  on  which  follows  the 
hunting  up  of  symptoms  to  support  the  a  priori  judg- 
ment. On  the  contrary,  the  correct  method  consists  in — 
1,  Investigation  of  the  history  and  cause;  2,  inspection; 
3,  palpation,  or  manual  examination.1  Such  truths  will 
bear  oft  repeating. 

The  faulty  union  of  fractured  patella  is  attributed  less 
to  imperfect  nutrition  than  to  failure  in  keeping  up  co- 
aptation, for  which  bandaging  should  be  applied  to  the 
whole  limb,  and  not  merely  in  the  vicinity  of  the  lesion. 

»  Loc.  cit,  pp.  2IO,  21 1. 


The  same  ideas  apply  to  fracture  of  the  shaft,  etc.,  of 
other  bones.  Bandaging  restrains  slight  displacement 
of  fragments  by  muscular  or  other  mechanical  action, 
thus  allowing  the  healings  to  approximate  thsX prtma  in- 
tentione. 

F.  B.  Stephenson,  M.D.,  U.S.N. 

TWO  MORE  CASES  OF  PREVENTIVE  INOCU- 
LATION OF  IMMUNIZED  SCARLET  -  FEVER 
BLOOD  SERUM. 

To  the  Editor  of  thk  Medical  Record. 

Sir  :  One  of  my  sons,  aged  seven,  being  stricken  with 
scarlet  fever,  I  have  inoculated,  on  the  second  day,  two 
of  my  other  children,  who  had  not  had  this  disease,  aged 
five  and  two  years.  The  blood  serum  was  taken  from 
their  older  brother,  aged  nine  years,  who  had  had  scarlet 
fever  six  years  before.  Two  drops,  taken  from  a  blister 
on  his  breast,  were  used  for  each  child,  and  there  was 
one  inoculation  only  for  each.  There  was  no  real  isola- 
tion— separate  bedrooms  during  the  night,  but  free  inter: 
course  during  the  day.  Now,  the  ninetieth  day,  no  in- 
fection has  been  observed. 

Albert  S.  Ashmead,  M.D. 

Naw  York,  August  31,  1894. 


Contagious  Diseases— Weekly  Statement.— Report  of 
cases  and  deaths  from  contagious  diseases  reported  to  the 
Sanitary  Bureau,  Health  Department,  for  the  week  end- 
ing September  8, 1894. 


Tuberculosis 

Typhoid  fever , 

Scarlet  fever 

Cerebro-spinal  meningitis. 

Measles 

Diphtheria 

Small-pox 


Cases. 


:i 


69 
29 

o 

17 

no 

16 


Deaths. 


107 

20 

4 

3 

o 

27 

X 


The  Dangerous  Anti- Vaccinationists. — One  of  the 
most  striking  testimonies  to  the  mischief  that  a  knot  of 
active  anti-vaccinationists  can  do  is  shown  in  the  expe- 
rience of  Stuttgart,  the  capital  of  Wiirtemberg,  between 
the  years  1864-1869.  Stuttgart  was  the  focal  point 
from  which  radiated  anti-vaccination  influence,  and,  in 
consequence,  not  only  many  private  citizens  but  the 
militia  of  that  city  were  "  unprotected/'  It  had  a  pop- 
ulation of  1,760,000  souls  less  than  New  York,  yet  in 
the  five  years  indicated  there  were  no  less  than  11,092 
cases  and  800  deaths.  During  that  time  there  were  34 
cases  in  the  army  of  the  whole  country,  but  not  a  death ; 
and  now  that  vaccination  and  revaccination  are  not 
only  compulsory,  but  done  under  a  faithful  inspection, 
the  German  army  is  the  bright,  conspicuous  example, 
shining  like  a  beacon,  for  all  the  world  to  follow.  If 
Germany  could  build  an  impassable  fence  between  her- 
self and  Russia,  the  whole  country  would  soon  show  it- 
self completely  freed  from  the  pest ;  but  there  is  always 
an  immigration  from  Russia  into  Germany  of  persons 
from  that  land,  where  the  persistence  of  cholera  shows 
the  inability  to  cope  with  epidemics. — Mrs.  -H.  M. 
Plunkktt,  in  The  Sanitarian,  August,  1894. 

Medicaments  Derived  from  Coal-Tar.— As  a  conse- 
quence of  the  progress  made  in  the  manufacture  of  col- 
oring materials  from  coal-tar,  physiologists  and  physicians 
have  been  able  to  experiment  with  a  host  of  new  prod- 
ucts, some  of  which  have  found  a  place  as  therapeutic 
or  antiseptic  agents.  The  substances  submitted  to  such 
experiments  are  of  very  diverse  nature,  but  there  is  ob- 
served in  them,  nevertheless,  a  limited  number  of  char- 
acteristic groupings.  They  are  phenols,  acetylated 
amines,  and  sulphonated,  sulphuretted,  iodated,  and  chlor- 


352 


MEDICAL    RECORD. 


[September  15,  1P94 


ated  derivatives  of  the  aldehydes.  Methodical  experi- 
ments have  not  been  numerous  enough,  and  the  data  fur- 
nished  by  biological  chemistry  are  not  precise  enough  to 
allow  us  to  establish  any  relation  between  the  constitution 
of  these  bodies  and  their  physiological  p  roperties,  pro- 
vided any  exists.  Their  applications,  in  fact,  exhibit 
many  anomalies.  We  see  products  that  are  very  differ- 
ent as  to  constitution  act  upon  the  organism  in  a  similar 
manner,  and  substances  that  are  analogous,  from  a 
chemical  point  of  view,  produce  very  different  therapeu- 
tical effects.  With  the  information  that  we  possess  upon 
this  subject  it  is  hazardous  to  draw  absolute  conclusions. 
The  number  of  organic  bodies  proposed  as  antiseptics  or 
as  medicinal  products  is  very  large,  and  one  or  more  new 
medicaments  are  observed  to  make  their  appearance  every 
day.  We  can  mention  but  a  limited  number  here,  in 
selecting  the  most  important  of  them.  We  have  arranged 
these  substances  as  antithermics  and  analgesics,  and  hyp- 
notics and  antiseptics.  There  is  nothing  absolute  about 
this  classification.  A  large  number  of  these  products  has 
at  the  same  time  several  of  these  properties.  For  exam- 
ple, chloral,  which  we  place  among  the  hypnotics,  is  an 
analgesic,  and  is  even  employed  as  an  antiseptic,  and 
asaprol  is  at  the  same  time  an  antiseptic  and  an  anal- 
gesic. 

1.  Antithermics  and  Analgesics. — Of  all  the  artificial 
antithermics,  antipyrine  or  analgesine  is  the  most  widely 
used  up  to  the  present.  It  is  derived  from  phenyl- 
hydrazine,  which  is  itself  obtained  by  dinitrating  aniline 
and  in  reducing  the  dinitro  benzol  thus  obtained.  This 
phenyl-hydrazine  is  afterward  condensed  with  aceto  acetic 
acid,  and  then,  finally,  the  product  is  submitted  to  a 
methylation.  We  have  at  last  the  dimethyl-phenyl- 
pyrazolon  that  constitutes  antipyrine.  It  is  very  soluble 
in  water,  and  this  property  permits  of  administering  it 
under  the  most  varied  forms — a  quality  that  is  highly 
appreciated  in  pharmacy.  It  must  be  observed,  how- 
ever, that,  as  a  general  thing,  solubility  has  no  relation 
whatever  with  the  quickness  of  action  and  assimilation  of 
a  medicament.  Phenacetine,  while  being  but  slightly 
soluble  in  water,  acts,  nevertheless,  as  quickly  as  antipy- 
rine. The  success  of  antipyrine  has  evoked  a  series  of 
experiments  with  the  object  either  of  preparing  substitute 
antipyrines  and  of  analogous  pyrazolons,  or  of  associating 
it  chemically  with  other  substances.  In  the  first  order 
of  ideas  has  been  produced  tolypyrine,  which  is  a  para- 
methylated  antipyrine  in  the  phenylic  nucleus,  and  then 
chlorated,  bromated,  etc.,  antipyrines.  In  the  second 
series  antipyrine  has  been  associated  with  salicylic  acid, 
and  this  has  given  salipyrine.  Tolysal  is  the  salicylic 
combination  corresponding  to  tolypyrine.  Apropos  of 
hypnotics,  we  may  mention  hypnal,  which  is  a  derivative 
of  antipyrine  and  chloral.  Thalline  and  kairine  are 
quinoleic  products  that  have  been  proposed  likewise  as 
antiseptics.  Among  the  oldest  analgesics  and  antither- 
mics we  find  acetanilide  and  antifebrine,  which  are  pre- 
pared by  treating  aniline  with  anhydrous  acetic  acid. 
If,  instead  of  operating  with  aniline,  we  start  from 
hydroxylated  aniline,  that  is  to  say,  from  a  product 
which  is  both  phenol  and  amine,  and  etherify  it  before 
acetylation,  we  shall  have  phenacetine  or  phenedine. 
Thymatecine  is  the  phenedine  of  thymol,  and  exalgine 
is  derived  from  the  acetylation  of  methyl  aniline.  Sali- 
cylate of  soda  has  been  for  some  time  employed  as  an 
antirheumatic.  Salicylic  acid  is  a  carboxylated  phenol, 
that  is  to  say,  a  body  that  is  at  once  phenol  and  benzoic 
acid.  It  is  prepared  by  passing  a  current  of  carbonic 
acid  over  phenate  of  soda  at  a  high  temperature.  Sev- 
eral applications  have  been  found  for  its  derivatives, 
among  which  may  be  mentioned  salipyrine,  that  we  have 
spoken  of  above,  and  salol,  which  we  shall  find  among 
the  antiseptics.  Asaprol  has  the  same  action  as  salicylate 
of  soda.  It  is  obtained  by  treating  beta-naphthol  with 
sulphuric  acid  at  a  low  temperature.  It  is  the  sulphuric 
ether  of  beta-naphthol.  It  is  offered  in  the  state  of  cal- 
cium salt  very  soluble  in  water.  Under  the  name  of 
abrastol  it  has  been  used  as  a  microbicide. 


2.  Hypnotics  and  Various  Medicaments. — One  of  the 
most  frequently  employed  hypnotics  is  chloral,  which  is 
the  hydrate  of  trichlorated  acetaldehyde.  An  endeavor 
has  been  made  to  associate  it  with  various  organic  sub- 
stances. In  this  way  have  been  prepared :  Chloralose, 
which  is  a  combination  of  chloral  and  glucose ;  hypnal, 
which  is  due  to  the  union  of  one  molecule  of  antipyrine 
and  one  of  chloral ;  and  somnal,  which  is  obtained  from 
chloral  and  urethane.  Sulphonal  is  likewise  a  very 
efficacious  hypnotic,  but  its  constitution  has  no  relation 
with  that  of  chloral.  Chemically,  it  is  called  the  dietby  1- 
sulphone  of  dimethyl  methane.  It  is  formed  by  the 
combination  of  acetone  with  ethyl- mercaptan.  Trional 
and  tetronal  form  part  of  the  same  series.  For  skin  dis- 
eases there  have  been  proposed  dermatol,  which  is  the 
subgallate  of  bismuth;  sulphaminol,  obtained  by  the 
action  of  sulphur  upon  meta-oxidi  phenyl- amine;  resor- 
cinol,  which  is  a  combination  of  iodoform  and  resorcine  ; 
and  lysophane,  which  is  chemically  called  triiodo  meta- 
cresol.  Tumenol,  thioline,  and  sulphonated  thiophene 
are  designed  for  the  same  use.  Piperazine,  a  nitrated 
product  of  the  closed-chain  series,  is  diethylene-diamine. 
One  of  the  processes  of  preparing  it  consists  in  causing 
ammonia  to  act  upon  bromide  of  ethylene.  Orexine 
serves  to  stimulate  the  appetite.  It  is  a  hydrochlorate  of 
phenyl-dihydro-  quinazoline. 

j.  Antiseptics. — Among  the  organic  antiseptics,  we 
find,  especially,  bodies  with  phenolic  and  aldehydic 
functions,  and  halogenated  derivatives.  Phenol,  beta- 
naphthol  and  guaiacol  are  characterized  by  the  phenolic 
grouping  OH  directly  connected  with  the  benzolic  or 
naphthalic  nucleus.  The  use  of  a  large  number  of  phe- 
nolic derivatives  has  been  recommended.  Thus,  salol  is 
salicylate  of  phenol,  and  betol  is  the  salicylate  of  beta- 
naphthol.  The  union  of  benzoic  acid  with  naphthol  gives 
benzo-naphthol.  Abrastol,  of  which  we  have  above 
spoken  under  the  name  of  asaprol,  is  the  salt  of  calcium 
of  the  sulphuric  ether  of  beta-naphthol.  It  is  a  microbi- 
cide at  present  proposed  for  the  preservation  of  wine. 
Among  the  phenolic  products  of  less  importance  we 
may  mention  alumnol,  sozol,  daphtherine,  phenoline, 
cresine,  and  microcidine.  Iodoform  is  triiodated  me- 
thane, analogous  to  chloroform  as  regards  constitution. 
This  antiseptic  has,  as  well  known,  an  insupportable 
odor.  An  endeavor  has,  therefore,  been  made  to  substi- 
tute odorless  and  likewise  iodated  substances  for  it. 
Among  the  bodies  proposed  to  this  effect  we  may  men- 
tion diiodoacetylene  or  diiodoform.  In  order  to  prepare 
this  alkaline  hypoiodites  are  made  to  act  upon  an  aque- 
ous solution  of  acetylene,  or  water  upon  a  mixture  of 
iodine  and  carbide  of  barium,  or  else  by  treating  acety- 
lene with  iodine  in  the  presence  of  an  excess  of  potassa 
at  a  low  temperature.  There  likewise  exists  a  tetraiodo- 
acetylene.  The  other  iodated  derivatives  are :  Traumatol 
(iodo  cresylol),  aristol  (iodo-thymal),  iodol  (tetraiodo- 
pyrol),  and  sozoiodol  (diiodo-paraphenate  of  sodium). 
Formol,  which  has  recently  been  proposed  as  an  antiseptic, 
is  form-aldehyde.  It  has  the  great  advantage  of  being 
volatile,  and,  consequently,  of  penetrating  to  the  very 
interior  of  the  objects  to  be  disinfected.  Ichthyol,  any- 
tine,  thiol,  and  thiolinic  acid  are  sulphonated  and  sul- 
phuretted derivatives  of  organic  and  mineral  oils  employed 
in  this  state  and  that  serve  as  solvents  for  products  insol- 
uble or  but  slightly  soluble. 

Among  the  substances  mentioned,  a  small  number 
only  will  doubtless  receive  the  sanction  of  practice,  but 
the  road  is  laid  out.  On  the  one  hand,  syntheses  are 
multiplying  with  the  object  of  finding  new  series,  and, 
on  the  other,  the  natural  alkaloids  are  the  object  of  nu- 
merous studies.  With  the  means  now  at  the  disposal  of 
chemistry,  it  is  possible  to  study  the  active  principles  of 
digitalis,  belladonna,  and  a  host  of  other  natural  products. 
We  shall  certainly  succeed  in  giving  such  alkaloids  a 
greater  energy,  perhaps  new  properties,  and  even  replace 
them  by  substances  of  which  the  syntheses  will  be  only 
the  results  of  a  study  of  the  products,  of  their  reduction 
and  of  their  decomposition.— Scientific  American. 


Medical   Record 

A  Weekly  ^Journal  of  Medicine  and  Surgery 


Vol.  46,  No.  12. 
Whole  No.  1246. 


New  York,  September  22,  1894. 


$5.00  Per  Annum. 
Single  Copies,  xoc. 


Original  Articles. 

THE  TREATMENT  OF  ABORTION.1 

Bv  BROOKS  H.  WELLS,  M.D., 

ADJUNCT  PROFESSOR  OP  GYNECOLOGY,  NEW  YORK  POLYCLINIC;  FELLOW  OP  THE 
NEW  YORK  ACADEMY  OF  MEDICINE,  THE  NEW  YORK  OBSTETRICAL  SOCIETY, 
ETC. 

I  am  prompted  to  write  upon  a  somewhat  worn  subject 
by  the  fact  that  during  the  past  year  I  have  met  with  an 
unusually  large  number  of  cases  of  incomplete  abortion 
which  have  been  allowed  to  run  on  until  they  have  de- 
veloped more  or  less  grave  septic  conditions,  or  have 
become  seriously  anaemic  from  the  continued  bleeding. 

These  cases,  which  I  might  use  as  illustrative,  were 
none  of  them  from  my  clinic  at  the  Polyclinic,  where  we 
see  them  only  too  frequently,  and  where  poverty,  igno- 
rance, and  often  previous  treatment  by  equally  ignorant 
midwives  lead  us  to  expect  conditions  otherwise  inex- 
cusable, but  were  all  of  them  from  the  upper  and  middle 
classes,  and  were  referred  to  me  by  intelligent  physicians. 
So  it  seems,  in  spite  of  all  that  has  been  said  and  written 
in  favor  of  active,  efficient,  and  early  interference, 
many  practitioners  prefer  to  take  the  chances  of  time 
and  ergot  in  the  hope,  sometimes,  it  must  be  admitted, 
realized,  that  all  will  finally  come  right.  Others,  recog- 
nizing the  necessity  of  action,  but  with  an  imperfect 
technique,  partially  succeed  in  clearing  out  the  uterus  by 
the  aid  of  the  ringer  or  curette,  and  in  the  attempt  carry 
infection  into  the  uterine  cavity. 

It  is  true  that  cases  of  incomplete  or  neglected  abor 
tion  do  not  usually  die,  either  from  the  continued  hem- 
orrhage or  from  sepsis ;  they  struggle  through  a  period  of 
acute  anaemia,  or  fever  and  prostration,  and  finally  may 
recover  perfectly,  but  more  often  are  left  with  a  chronic 
infection  affecting  the  endometrium  or  extending  also  to 
the  tubes  and  peri  uterine  structures,  a  condition  which, 
in  the  light  of  modern  pathology,  we  cannot  consider 
inconsequential,  knowing  that  it  so  frequently  leads  to 
the  most  serious  pelvic  trouble.  The  truth  of  this  state- 
ment  may  be  easily  proved  by  reference  to  one's  private 
case- book,  or  by  the  records  of  any  large  gynecological 
clinic.  Thus,  out  of  five  thousand  consecutive  gyneco- 
logical cases  which  have  come  under  my  observation  at 
the  New  York  Polyclinic  fourteen  hundred  and  ninety- 
two,  nearly  thirty  per  cent.  (29.8),  had  aborted  one  or 
more  times,  and  of  these  five  hundred  and  thirty-five, 
nearly  thirty-six  percent.  (35 .8),  suffered  from  disease 
of  the  uterus  or  appendages  directly  traceable  to  infection 
following  abortion.  It  is  safe  to  say  that  the  immediate, 
thorough,  and  aseptic  removal  of  the  ovum,  or  its  frag- 
ments, in  these  cases  would  have  prevented  the  greater 
part  of  this  disease  and  its  attendant  disability. 

Before  discussing  our  subject  further  it  is  necessary  to 
understand  what  we  mean  by  abortion,  and  to  sketch 
briefly  its  causes,  diagnosis,  and  course. 

Abortion  is  defined  by  nearly  all  lexicographers  as 
"  expulsion  of  the  foetus  before  the  seventh  month,  or  be- 
fore viability ;  "  but  to  insure  clearness  it  is  advisable  to 
limit  the  word  to  its  stricter  sense,  of  "  expulsion  of  the 
ovum  before  the  end  of  the  third  month,"  and  to  employ 
the  term  "  miscarriage "  for  expulsion  between  that 
period  and  the  time  when  the  foetus  becomes  viable. 

Abortion  or  miscarriage  may  be  from  pathological 
1  Read  before  the  New  York  Academy  of  Medicine,  April  26,  1894. 


causes  affecting  the  fetal  or  maternal  organism,  or  may 
be  induced. 

Maternal  causes  may  be  systemic — from  poisons  cir- 
culating in  or  conditions  impairing  the  mother's  blood,  or 
disturbing  the  circulation  mechanically,  as  syphilis,  ma- 
laria, the  exanthemata  or  other  fevers  of  severe  type ;  chol- 
era, poisoning  by  CO,  CO,,  and  other  gases ;  salts  of 
certain  metals  (lead,  copper,  etc.),  and  vegetable  alka- 
loids; albuminuria,  cholaemia,  iithiasis,  anaemia;  and 
visceral  (liver,  lung,  and  heart)  disease  affecting  vascular 
tension. 

Maternal  causes  may  be  local — from  retro-displace-. 
ment  of  the  uterus,  pelvic  adhesions,  endometritis,  pel- 
vic or  uterine  tumors.  They  may  be  reflex — from  gastric, 
rectal,  or  mammary  irritation,  mental  shock,  or  excessive 
emotion,  exhaustion  of  nerve-force,  as  in  chorea  or  in 
epilepsy. 

Fetal  causes  may  be  primary  or  the  result  of  maternal 
dyscrasia,  and  include  disease  of  the  fetal  envelopes,  as 
fatty,  hydatidiform,  or  fibrinous  degeneration,  or  in  flam- 
mation  or  hemorrhage  of  the  chorion  or  placenta, 
death  of  the  embryo,  or  any  malformation  affecting  the 
circulation  of  the  foetus  and  causing  hydramnion  or  oli- 
gohydramnion. 

Finally,  abortion  may  result  from  combinations  of  any 
of  these  causes.  Induced  abortion  may  be  accidental, 
legitimate,  or  criminal.  Accidental  causes  may  be  uter- 
ine traumatism  from  blows,  falls,  wounds,  excessive  or 
violent  coitus,  etc.,  and  we  might  again  include  here  ex- 
cessive emotion  and  mental  shock.  Criminal  abortion 
may  be  from  general  violence,  mechanical  injury  to  the 
uterus  or  ovum,  or  from  the  administration  of  certain 
drugs. 

The  symptoms  vary  with  the  time  at  which  the  abor- 
tion occurs.  If  within  the  first  six  weeks  the  woman 
may  complain  only  of  a  moderate  amount  of  lumbar  pain, 
dull  and  heavy  or  cramp  like,  or  there  may  be  no  pain 
and  an  amount  of  hemorrhage,  which  she  may  consider  as 
simply  an  excessive  menstruation.  Very  often  she  does  not 
recognize  the  passage  of  any  shreds  of  tissue,  or  clots, 
and  the  abortion  passes  unnoticed.  At  other  times  por- 
tions of  chorion  remain  behind,  and  she  comes  to  the 
physician  complaining  of  the  prolonged  spotting  or  flow. 
Later,  and  up  to  the  time  when  the  placenta  is  fully  de 
veloped,  the  lumbar  pains  are  more  marked,  the  cramps 
more  severe  and  rhythmical,  and  the  hemorrhage  much 
greater  in  amount.  If  the  abortion  be  the  result  of  nat- 
ural causes  and  the  death  of  the  ovum  has  occurred  sev- 
eral days  before  its  expulsion,  it  usually  comes  away 
entire.  If  the  ovum  is  alive,  or  if  the  abortion  be  in- 
duced by  mechanical  means,  the  foetus  usually  escapes, 
leaving  the  whole  or  a  part  of  the  chorion  behind. 

Bimanual  examination  shows  the  uterus  enlarged,  soft, 
except  during  a  contraction,  the  cervix  softened  and 
more  or  less  dilated,  and  often  with  a  portion  of  the  ovum 
plugging  the  os.  After  the  expulsion  of  the  entire 
ovum  the  pains  and  bleeding  cease  and  the  uterus  con- 
tracts. If  a  portion  of  chorion  or  placental  tissue  be  re- 
tained, the  bleeding,  pain,  and  dilatation  may  continue 
until  it  is  expelled,  or  the  cervix  may  contract,  the  pains 
become  slight  or  cease,  the  bleeding  stop,  and  the  mass 
be  retained  either  to  disintegrate  and  come  away  in  the 
discharge,  to  become  septic,  or,  exceptionally,  to  develop 
into  a  fleshy  mole.  Rarely  there  may  be  death  and  in- 
fection of  the  ovum  without  producing  either  pain,  hem- 
orrhage, dilatation,  or  foul  discharge,  the  only  symptoms 


354 


MEDICAL    RECORD. 


[September  22,  1894 


being  cessation  of  uterine  growth,  followed  by  irregular 
slight  chills  and  septic  fever. 

After  the  third  month  the  symptoms  approach  more 
nearly  to  those  of  a  premature  labor.  We  have  the  rhyth- 
mic pains,  the  hemorrhage,  which  i3  apt  to  be  more  pro- 
fuse, the  dilatation  of  the  os,  and,  more  often,  the  spon- 
taneous evacuation  of  the  entire  contents  of  the  uterus. 

Abortion  may  be  considered  inevitable  when  the  result 
of  a  cause  that  cannot  be  removed,  when  the  pains  are 
severe  or  rhythmical,  the  hemorrhage  profuse,  the  os  widely 
dilated,  or  when  any  portion  of  the  ovum  has  been  ex- 
pelled. 

Threatened  abortion  may  sometimes  be  averted  when 
the  cause  is  a  remediable  one,  and  the  pains,  bleeding, 
and  dilatation  are  only  moderate.  When  abortion  be- 
comes inevitable  one  of  two  things  happens,  either  the 
uterus  empties  itself  entirely,  or  a  portion  of  the  ovum  is 
retained.  In  the  first  case  the  uterus  contracts,  the  pain 
and  hemorrhage  cease,  there  is  a  pinkish  flow  for  a  few 
days,  involution  proceeds  normally,  and  the  condition 
remains  practically  the  same  as  before  conception.  If, 
however,  portions  of  placenta  or  chorion  remain  in  the 
uterus  the  clinical  picture  is  changed.  The  symptoms 
noted  diminish  at  first,  but  do  not  entirely  disappear ;  the 
pain  may  cease  for  a  time  and  then  reappear,  and  the  frag- 
mjnts  be  expelled,  or  the  os  may  contract  and  the  frag- 
ment be  retained  until  it  gradually  breaks  down  and  passes 
iway  with  the  discharges.  In  this  latter  case  the  bleed- 
ing continues,  as  a  persistent  leakage,  often  for  from  three 
to  six  weeks,  and  may  reduce  the  patient  to  an  extreme 
degree  of  anaemia,  though  it  in  itself  rarely  kills.  Very 
often,  and  almost  certainly,  if  this  incomplete  abortion 
be  the  result  of  criminal  interference  with  the  ovum,  the 
retained  tissues  become  infected  and  we  have  aseptic  pro- 
cess begun  which  may  induce  serious  and  persistent  pelvic 
disease  or  directly  destroy  life.  Sepsis  is  the  condition 
most  to  be  dreaded,  the  condition  to  be  most  carefully 
watched  for,  the  condition  to  be  most  vigorously  fought 
against.  We  must  always  be  on  the  watch  for  its  first 
symptom,  and  when  we  recognize  it,  whether  it  be  as  an 
elevation  of  temperature,  a  chill,  or  a  fetid  discharge,  we 
must  remember  its  probable  source  and  explore  the  cavity 
of  the  uterus.  Septic  material  may  be  there  even  though 
the  cervix  be  perfectly  contracted  and  hard,  though  there 
b*  no  hemorrhage,  no  discharge,  and  possibly  no  other 
local  symptom.  I  have  seen  several  instances  to  which 
this  description  would  apply,  one  of  which  ended  in  death. 
But  the  sepsis  is  not  usually  of  a  virulent  type,  the  case 
runs  on,  the  woman  recovers  from  the  immediate  danger, 
but  the  fever,  the  hemorrhage,  the  infection,  have  inter- 
fered with  involution ;  the  uterus  remains  large,  heavy, 
and  soft,  and  is  apt  to  become  retro  displaced ;  the  in- 
fected mucosa,  thickened,  soft,  and  friable,  becomes  the 
seat  of  a  chronic  endometritis  which  may  at  any  time  lead 
to  tubal  and  ovarian  trouble,  and  the  woman  suffers  in- 
definitely from  the  metrorrhagias,  the  pelvic  pains,  and 
the  systemic  depreciation  which  accompany  these  condi- 
tions. 

Treatment.— A  local  examination  is  always  impera- 
tively necessary  when  any  of  the  signs  of  impending  abor- 
tion appear.  Then,  if  the  symptoms  are  not  marked,  if 
the  pains  are  slight  and  irregular,  the  bleeding  moderate, 
the  os  not  much  dilated,  and  the  cause  one  that  can  be 
remedied,  as,  for  instance,  retroversion,  we  may  hope 
by  absolute  rest  in  the  recumbent  position,  by  the  ad 
ministration  of  full  doses  of  opium,  and  viburnum  by 
suppository,  or  morphia  hypodermically,  and  by  the  re- 
position of  the  displaced  uterus,  to  carry  the  patient 
through  her  period  of  danger  and  allow  the  gestation  to 
continue.  If  the  cramps  are  regular  and  well  marked, 
the  hemorrhage  considerable,  and,  particularly,  if  the  os 
be  dilated,  these  hopes  will  not  be  realized,  the  loss  of 
the  ovum  becomes  inevitable,  and  it  is  our  duty  to  hasten 
its  expulsion.  As  the  method  of  procedure  now  varies 
according  to  the  period  of  gestation,  we  may  draw  a  line 
of  division  at  the  end  of  the  third  month  and  consider 
the  case  as  either  "  abortion  "  or  "  miscarriage." 


Abortion. — As  the  uterus  before  the  end  of  the  third 
month  is  still  comparatively  small  and  will  not  allow  the 
accumulation  of  any  considerable  amount  of  blood  in  its 
cavity,  the  use  of  the  tampon  is  sometimes  permissible 
before  the  expulsion  of  the  foetus,  not  so  much  to  check 
bleeding  as  to  excite  more  vigorous  expulsive  contrac- 
tions. When  expelled,  the  patient  is  to  be  put  in  the 
dorsal  position  on  a  Kelly  pad,  the  vagina  and  cervix 
thoroughly  cleansed  by  a  douche  of  hot  soap-suds  rubbed 
into  all  folds  and  crevices  by  the  fingers,  and  followed 
by  irrigation  with  1  to  4,000  warm  bichloride  solution. 
Then  a  strip  of  sterile  iodoform  gauze  is  carefully 
packed  into  the  cervix  and  the  vagina  tamponed.  This 
packing  is  removed  in  from  eight  to  twelve  hours,  and 
afterward  the  ovum  will  be  found  loose  in  the  vagina  or 
in  the  dilated  os.  If  at  this  time  no  portion  of  the  ovum 
be  expelled,  that  is,  if  its  envelopes  be  still  intact,  the 
packing  may  be  carefully  repeated.  If  any  portion  of 
the  ovum  has  been  expelled,  the  remainder  should  be 
removed  at  once,  either  with  the  finger,  which  can  sel- 
dom be  used  at  this  early  period,  with  the  ovum  forceps, 
or  with  the  dull  curette. 

If  there  be  reason  to  believe  that  the  abortion  has  re- 
sulted from  criminal  interference,  if  the  case  has  been 
allowed  to  run  on  for  many  days,  if  there  b»  endometritis 
or  any  form  of  sepsis,  the  os  should  be  dilated,  prefer- 
ably after  the  administration  of  an  anaesthetic,  the  frag- 
ments of  the  ovum  removed,  and  the  whole  interior  of 
the  uterus  scraped  carefully  and  thoroughly  with  the 
sharp  curette,  washed  clean  with  a  strong  watery  solu- 
tion of  iodine  and  packed  with  a  strip  of  sterile  iodoform 
gauze.  This  gauze  should  be  removed  in  twenty-four 
hours  and  the  vagina  irrigated.  If  septic  symptoms  con 
tinue,  the  uterine  cavity  may  be  again  irrigated  with  the 
iodine  solution,  and  a  fresh  strip  of  gauze  carried  to  the 
fundus. 

The  effective  and  safe  manipulation  of  the  curette  and 
gauze  in  this  manner  presupposes  on  the  part  of  the  oper- 
ator a  certain  amount  of  skill  and  familiarity  with  its  use. 

Miscarriage. — After  the  third  month  the  use  of  the 
tampon  for  haemostatic  or  other  purposes  is  reprehensible, 
as  the  uterus  is  then  larger  and  dilatable,  so  that  a  dan- 
gerously large  amount  of  blood  may  accumulate  in  its 
cavity.  If  the  hemorrhage  from  a  miscarriage  is  moder- 
ate, the  treatment  may  be  expectant  for  a  limited  time 
until  the  entire  ovum  or  the  foetus  be  expelled.  If  the 
foetus  alone  be  discharged,  the  remaining  portions  of  the 
ovum  should  be  immediately  removed  with  the  ringer, 
aided,  if  necessary,  by  the  ovum  forceps  or  large  curette. 
If  the  hemorrhage  be  profuse  there  should  be  no  delay, 
the  os  should  be  dilated  and  the  uterus  cleared  out  at 
once.  Where  there  is  sepsis  the  indication  is  for  the  use 
of  the  sharp  curette,  irrigation,  and  packing,  as  already 
described. 

When  we  have  legitimate  reason  for  inducing  abortion 
it  is  best  done  by  immediate  clearing  out  of  the  uterus 
after  anaesthesia  and  rapid  dilatation,  the  uterus  being 
washed  clean  and  a  strip  of  gauze  introduced  for  drain- 
age. When  miscarriage  becomes  necessary  the  prelimi- 
nary dilatation  is  usually  best  secured  by  the  employ- 
ment of  an  aseptic  tupelo  tent  of  the  largest  size  that 
can  be  inserted  into  the  os,  then,  if  the  ovum  be  not 
spontaneously  and  completely  expelled  it  is  removed 
digitally  or  with  instrumental  aid. 

To  avoid  danger  and  secure  success  in  these  manoeu- 
vres it  is  necessary  that  they  be  done  aseptically  and  by 
one  accustomed  to  surgical  cleanliness.  The  hands  and 
arms  of  the  operator  should  be  scrubbed  for  five  minutes 
with  a  stiff  brush  with  soap  and  hot  water,  and  then 
soaked  for  the  same  time  in  a  1  to  1,000  bichloride  solu- 
tion. The  instruments  can  either  be  wrapped  in  a  towel 
and  boiled  at  the  time  in  a  weak  solution  of  soda  for  fif- 
teen minutes,  or  may  be  carried  already  sterilized,  and 
laid  on  a  sterilized  towel  ready  for  use.  A  strip  or  strips 
of  sterile  iodoform  gauze  should  also  be  prepared  and 
wrapped  in  a  sterile  cloth. 

Tupelo  tents  may  be  sealed  separately  in  small  enve- 


September  22,  1894] 


MEDICAL  RECORD. 


355 


lopes  and  baked  for  half  an  hour,  and  are  then  ready  for 
use  when  wanted.  The  Kelly-pad  requires  most  careful 
attention,  and  must  be  thoroughly  washed  in  running 
water,  rinsed  in  the  bichloride  solution,  and  carefully 
wiped  dry  each  time  after  use.  The  fountain  syringe 
used  for  irrigation  may  be  scrubbed  in  hot  water  and 
soaked  in  bichloride,  or  boiled  if  used  where  there  is  a 
suspicion  of  sepsis.  The  patient,  after  having  had  her 
bladder  and  bowels  emptied,  is  to  be  placed  in  the  dorsal 
position  on  a  table ;  or  the  hips  may  be  brought  to  the 
edge  of  the  bed,  a  firm  bearing  surface  for  the  Kelly- 
pad  being  secured  by  a  table-leaf,  ironing-,  or  lap-board ; 
and  the  external  genitals  and  vagina  thoroughly  cleansed 
with  hot  soap-suds,  two  fingers  being  used  to  rub  over  the 
mucosa  of  vagina  and  cervix.  This  should  be  followed 
by  irrigation  and  rubbing  with  a  1  to  4,000  bichloride  so- 
lution. The  parts  adjacent  to  the  vulva  and  the  exposed 
portion  of  the  pad  are  then  covered  with  wet  sterilized 
towels  and  the  operation  performed. 
In  conclusion,  I  may  state  my  position  briefly  as  follows : 
Recognizing  that  any  interference  with  the  uterine 
cavity  must  be  looked  upon  as  a  possible  source  of  infec- 
tion, and  must  be  made  aseptically  and  with  antiseptic 
precautions  to  be  free  from  danger,  I  strongly  urge  that 
in  every  case  where  abortion  or  miscarriage  begins 
acutely  and  from  natural  causes,  the  ovum  be  removed  by 
the  finger,  ovum  forceps,  or  curette,  within  twenty-four 
hours  after  the  abortion  be  Considered  inevitable,  if  the 
entire  ovum  be  not  then  already  expelled,  complete  ex- 
pulsion being  indicated  usually  by  cessation  of  pain  and 
hemorrhage.  In  cases  where  a  portion  has  been  expelled, 
where  we  find  serious  hemorrhage,  where  the  ovum  is 
dead,  where  we  have  reason  to  suspect  criminal  inter- 
ference, where  there  has  been  continual  spotting,  foul 
discharge,  or  fever,  the  uterus  should  be  explored  and 
emptied  at  once,  as  any  delay  greatly  increases  the  risk 
of  sepsis.  The  sharp  irrigating  curette,  followed  by  gauze 
drainage,  should  always  be  used  where  there  is  septic 
material  present,  or  where  the  endometrium  is  diseased, 
in  other  conditions  the  finger  or  a  dull  instrument  is  suf- 
ficient. 

71  Wbst  Forty>fipfh  Stkebt. 


▲  Reminiscence  of  the  Late  Professor  Hyrtl. — A  cor- 
respondent of  The  Lancet  says  that  the  famous  anatomist 
who  has  just  died  at  Vienna  was  always  considered  an 
eccentric  man  because  his  dress,  his  manners,  and  his 
mode  of  life  differed  in  some  respects  from  those  of  other 
people.  It  was  particularly  his  time- worn  garments  that 
made  him  conspicuous,  and  he  used  in  his  walks  the  same 
soiled  blouse  which  he  wore  while  engaged  in  his  labo- 
ratory or  in  gardening — his  favorite  hobby.  This  charac- 
teristic of  Hyrtl  gave  frequent  occasion  for  ludicrous  inci- 
dents, at  which  he  himself  used  to  laugh  most.  A  few 
years  back,  when  he  was  still  in  possession  of  his  eyesight, 
he  was  accustomed  to  walk  to  Liesing,  a  charming  Vien- 
nese suburb,  where,  in  the  beer-garden  of  the  brewery,  he 
refreshed  himself  with  a  glass  of  its  well-known  beverage. 
One  afternoon  he  entered  the  garden  and  seated  himself 
near  a  table  at  which  a  few  merry  Viennese  burghers  were 
engaged  in  diminishing  the  contents  of  a  dish  of  stewed 
fowl.  These  gentlemen  had  no  idea  of  the  identity  of 
the  newly  arrived  guest,  and  after  eying  his  simple  twill 
suit  came  to  the  conclusion  that  he  must  be  an  inmate  of 
the  Liesing  asylum  for  the  poor.  A  good  portion  of  the 
meal  having  been  left  uneaten,  one  of  the  guests  called 
the  waiter  and  told  him  to  take  what  was  left  to  the  poor 
man  sitting  near  them.  The  famous  savant,  appreciating 
the  joke,  ate  a  few  morsels  and,  after  expressing  his 
thanks,  left  the  garden.  A  few  moments  later  two  waiters 
carried  in  a  big  bowl  from  which  the  heads  of  champagne 
bottles  were  protruding.  "  We  have  ordered  no  cham- 
pagne !  "  cried  the  burghers,  and  their  astonishment  may 
easily  be  guessed  on  their  being  informed  that  "  the  inmate 
of  the  local  asylum  for  the  poor  "  had  sent  them  the  cham- 
pagne as  a  mark  of  his  gratitude  for  the  stewed  fowl,  and 
that  the  donor  was  no  less  a  personage  than  Professor  Hyrtl. 


SOME  RECENT  MEASURES  IN  THE  TREAT- 
MENT OF  EPILEPSY,  WITH  SPECIAL  REFER- 
ENCE TO  THE   USE  OF  OPIUM. 

A  Year's  Experience  with  Flechsig's  Plan.1 
By  JOSEPH  COLLINS,   M.D., 


VISITING  PHYSICIAN  TO  THB  HOSPITAL  FOR  NBRVOUS  DISEASES  ;  ATTENDING 
PHYSICIAN  IO  ST.  MAlK'fi  HOSPITAL;  INSTRUCTOR  IN  NERVuUS  AND  MENTAL 
DISEASES  IN  THB  NBW  YORK  POST-GRADUATE  MEDICAL  SCHOOL. 

The  treatment  of  epilepsy  to  day  is  about  as  unsatisfactory 
as  it  was  ten  years  ago.  That  is,  a  decade  that  has  wit- 
nessed a  considerable  addition  to  our  knowledge  of  the 
causation  and  pathogenesis  of  this  disease  has  seen  no 
striking  addition  made  to  its  therapy. 

It  is  not  presumptuous  to  say  that  notwithstanding  the 
persistency  with  which  other  measures  have  been  ad- 
vocated and  the  extravagant  results  claimed  for  them, 
that  to  day  bromide  of  potash  would  not  be  exchanged 
for  all  the  other  means  combined.  I  do  not  mean  to  de- 
cry the  value  of  other  measures,  nor  in  any  way  to  depre- 
cate their  claims  in  the  treatment  of  this  disease,  but 
merely  to  state  what  I  believe  to  be  a  fact. 

That  there  is  no  dearth  of  activity  in  searching  for  a 
more  curative  agent  than  the  bromides  in  this  disease  one 
can  satisfy  himself  by  glancing  at  the  literature  of  the 
subject  from  year  to  year.  Although  many  agents  are  rec- 
ommended but  few  are  chosen,  after  a  more  or  less 
thorough  trial.  Among  the  measures  recommended  within 
the  past  few  years  those  deserving  of  consideration  have 
been  more  particularly,  1,  borax;  2,simulo;  3,antipyrin 
andantifebrin;  4,nitro-glycerine;  5,antirabicvirus,under 
which  may  be  included  for  purpose  of  convenience  the 
"  organic  extracts ;  "  6,  the  various  combinations  of  the 
bromides. 

Among  those  recommended, but  having  very  little  claim 
for  their  consideration,  are  1,  hypnotism ;  2,  hydrastinine ; 
3,  salicylates ;  4,  duboisine,  picrotoxin,  cannabis  Indica, 
belladonna,  etc. ;  5,  amylene  hydrate;  6,  osmic  acid  and 
sclerotinic  acid. 

Since  Gowera  recommended  the  use  of  borax  in  epilepsy 
twenty-five  years  ago,  it  has  been  used  more  or  less  in 
obstinate  cases  that  resisted  the  bromide  treatment,  and 
in  cases  where  for  some  reason  the  bromides  could  not  be 
administered.  It  has  taken  a  definite  place  in  the  thera- 
peutics of  this  disease,  as  is  attested  by  tnany  of  the  moat 
trustworthy  clinicians.2 

Its  efficiency  compares  in  no  way  with  the  bromides ; 
but  as  an  alternate  and  adjuvant  of  the  bromides  it  is, 
when  given  in  proper  doses  (about  3  ij.  per  diem),  a  use- 
ful and  valuable  addition  to  our  therapeutic  resources  in 
this  disease.  Its  efficaciousness  is  frequently  seen  in  con- 
trolling night  attacks  while  the  continuous  administration 
of  the  bromides  prevent  the  day  attacks.  The  drawbacks 
to  its  use  are  the  frequency  with  which  it  causes  distress- 
ing attacks  of  eczema,  psoriasis,  impairment  of  the  diges- 
tion and  nutrition,  and  even  toxic  effects.  Enthusiastic 
reports  of  its  efficacy  and  curativeness  now  and  then  crop 
up/  but  they  are  generally  accompanied  by  such  mea- 
greness  of  detail  or  absence  of  a  judicial  weighing  of 
evidence,  that  they  are  to  be  taken  with  circumspec- 
tion. 

The  place  held  by  simulo  in  the  treatment  of  epilepsy 
does  not  compare  favorably  with  borax.  Since  its  intro- 
duction by  Dr.  W.  Hale  White  in  1888  it  has  apparently 
never  been  extensively  used.  Although  White's  report 
of  its  use  in  seven  cases  was  encouraging,  Eulenberg,  who 
tried  it  in  both  hysteria  and  epilepsy,  was  not  favorably 
inclined  to  it.  Given  in  doses  of  from  a  half  to  two 
drachms  of  the  tincture  three  times  daily,  it  will,  in 

1  Read  before  the  New  York  Academy  of  Medicine.  April  5,  1894. 

•  Folsom  :  Boston  Medical  and  Surgical  Journal,  1886 ;  Mai  ret :  Le 
Progres  Medicale,  February  6,  189a ;  Stewart :  Alienist  and  Neu- 
rologist, January,  1891  ;  Fere  and  Lamy :  Nouvelle  Iconographie  de 
la  Salp&riere,  November  and  December,  1889 ;  Russell  and  Taylor  : 
Lancet,  May  17   1890. 

8  Dijoud  :  Lancet,  July  18,  1891. 


356 


MEDICAL  RECORD. 


[September  22,  1894 


some  cases,  especially  of  haut  mal,  give  gratifying  re- 
sults, as  it  has  done  in  one  patient  at  present  under 
the  writer's  observation.  It  in  no  way  compares  with 
the  bromides. 

Antipyrin  and  antifebrin  have  been  used  more  exten- 
sively in  epilepsy  than  have  most  new  remedies,  and  in 
many  caies  with  gratifying  results.  Lemoine 1  was  struck 
by  the  value  of  the  first  of  these  in  a  case  which  always 
occurred  at  the  menstrual  period,  in  one  associated  with 
migrain  and  in  another  of  the  type  of  epilepsia  larvata  or 
psychical  epilepsy.  McCall  Anderson  and  Jack  report 
a  case  of  traumatic  epilepsy  cured J  in  three  months  by 
the  administration  of  antipyrin  in  doses  beginning  with 
five  grains  three  times  a  day  and  increased  one  grain  a 
day.  The  cure  was  effected  when  the  patient  reached  a 
dose  of  twenty-five  grains.  It  is  unnecessary  to  comment 
on  this  case,  except  to  repeat  that  a  case  diagnosed, 
treated,  and  recorded  as  cured  all  within  six  months 
should  not  be  taken  too  seriously. 

SalmV  experience  with  antipyrin  was  not  so  satisfac- 
tory. In  fact  he  thought  the  results  of  its  use  were  quite 
negative.  When  given  in  conjunction  with  the  bromide 
of  ammonium,  as  has  been  recommended  by  Wood,  it 
has  given  very  gratifying  results  and  is  attested  by  Potts,4 
May,*  and  Dana.0 

A  combination  of  antipyrin  with  the  other  bromide 
salts  is  probably  as  serviceable  as  the  combination  with 
bromide  of  ammonium.  Arcade'  reported  cessation  of 
attacks  for  four  months  in  moderate  epileptics  under  this 
treatment.  The  general  consensus  of  opinion  in  refer- 
ence to  antipyrin  and  antifebrin  is  that  the  former  is 
preferable,  and  when  given  in  from  five  to  ten-grain  doses 
three  to  four  times  daily  it  materially  enhances  the  value 
of  the  bromides  in  the  treatment  of  idiopathic  epilepsy, 
particularly  in  the  less  aggravated  clinical  forms. 

Nitro-glycerine  has  been  used  to  a  considerable  degree 
in  idiopathic  epilepsy.  It  has  been  specially  recom- 
mended in  cases  that  are  attended  with  vasomotor  aura. 
One  of  the  most  recent  writers  who  calls  attention  to  its 
use  is  Osier.0  It  is  most  serviceable  in  cases  of  petit  mal 
and  must  be  given  in  large  doses,  two  to  five  drops  of  a 
one  per  cent,  solution,  and  in  such  doses  it  is  apt  to  pro- 
duce intensely  disagreeable  symptoms.  Its  value  as  a 
therapeutic  agent  in  epilepsy  is  slight. 

Attention  was  first  called  to  the  beneficial  effects  fol- 
lowing anti-rabic  inoculation  of  epileptics  by  the  cessa- 
tion of  attacks  in  two  children  who  had  been  inoculated 
for  rabies  by  Pasteur.'  Other  cases  showing  the  benefi- 
cial results  of  this  form  of  treatment  have  been  reported 
by  Charcot,10  Giovanni,11  and  Ariostigni.12 

It  is  distressing,  however,  to  have  to  repeat  that  these 
cases  were  reported  too  early  to  be  of  very  much  service 
in  determining  the  value  of  anti-rabic  virus  as  a  form  of 
treatment. 

It  should  be  remarked  here  that  some  of  the  cases  (Char- 
cot's) were  shown  to  gatherings  of  medical  men  merely  to 
demonstrate  the  effect  the  inoculations  had  in  checking 
the  attacks  temporarily.  It  is  sufficient  comment  on  this 
way  of  breaking  epilepsy  to  say  that  the  results  of  its  use, 
limited  though  it  has  been,  nor  any  theory  on  which  its 
efficacy  might  possibly  be  based,  have  not  appealed  to  the 
medical  profession.  A  more  recent  treatment  of  epilepsy, 
and  one  which  has,  to  my  mind,  absolutely  no  raison 
d'etre,  has  been  introduced  by  Babes,  of  Bucharest,  and 
Gibier,  of  New  York.  It  consists  of  the  hypodermatic  in- 
jection of  the  extract  of  the  cerebrum  of  the  sheep, 
freshly  prepared.  Although  the  two  investigators  quoted 
above  have  made  serious  claims  for  its  efficacy,  it  is  prob- 

1  Gaz.  Med.  de  Paris.  No.  52,  1887. 

9  American  Journal  of  the  Medical  Sciences,  May,  1891. 

9  Neurologisches  Centrbl.,  No.  11,  1887. 

4  University  Medical  Magazine,  October,  1890. 

•  Detroit  Medical  Age,  July  25,  1891. 

•  Text-book  of  Nervous  Diseases,  1893. 

7  Wien.  Med.  Presse,  Nos.  13-15,  1889. 

8  Journal  of  Nervous  and  Mental  Diseases,  1888,  p.  38. 
e  Wien.  Med.  Presse,  No.  24,  1892. 

10  Lancet,  May  28,  1892. 

11  British  Medical  Journal,  September  4.  1892. 
,a  Revista  de  ciencias  medicas,  July  5,  1892. 


ably  no  exaggeration  to  say  that  this  agent  is  as  nearly 
useless  in  the  treatment  of  epilepsy  as  any  substance  which 
a  physician  essays  to  employ  with  a  considerable  eclat  can 
possibly  be. 

Not  even  the  remotest  rational  explanation  can  be  ad- 
vanced for  its  use.  The  substance  cerebrin  has  no 
physiological  action  which  would  suggest  it  to  be  an 
anti  epileptic  agent.  At  the  present  day  no  one  will 
gainsay  the  statement  that  the  "  organic  "  extracts  de- 
pend for  any  activity  that  they  may  possess  on  their 
chemical  constitution.  And  when  introduced  into  the 
system  they  act  and  can  only  act  just  as  analogous  chemi- 
cal substances  obtained  from  other  sources  do. 

No  analogy  between  the  use  of  the  thyroid  in  myxe- 
dema or  the  use  of  the  thymus  in  pseudohypertrophic 
paralysis  can  be  advanced  to  explain  the  use  of  cerebrine 
in  epilepsy.  The  brain  is  not  a  secretory  organ,  as  are 
the  thyroid  and  thymus,  and  its  constituents  are  easily 
separable  by  the  chemist.  These  chemical  constituents, 
or  as  many  of  them  as  are  not  inert,  are  responsible  for 
any  change  that  the  patient  has  in  his  symptoms  while 
being  subject  to  treatment  by  these  extracts. 

The  report  of  cases  of  epilepsy  treated  by  this  method 
by  Babes  is  so  glowing  and  enthusiastic,  and  the  state- 
ment of  his  results  are  so  indefinite  that  one  need  make 
no  comment. 

Gibier  has  published  two  articles  in  which  he  details 
the  results  that  he  has  obtained.  A  careful  examination 
of  his  report  will  show  that  the  results  barely  warrant 
him  in  his  conclusion,  a  very  modest  one,  "  That  the 
method  is  beneficial  in  adding  to  the  favorable  effects 
derivable  from  other  therapeutic  agents." 

Everyone  who  has  much  to  do  with  the  handling  of 
epileptics  knows  how  susceptible  they  are  to  new,  and 
especially  novel,  methods  of  treatment  and  how  frequently 
the  attacks  are  for  quite  long  periods  amenable  to  such 
procedures.  The  personal  factor  in  the  handling  of  the 
cases  reported  by  Gibier  will  probably  account  to  a  con- 
siderable degree  for  the  amelioration  of  symptoms  that 
they  present.  Further  it  may  be  said  that  there  is 
scarcely  a  remedy  that  has  been  advocated  for  epilepsy 
that  has  not,  in  the  hands  of  its  advocate,  given  far  better 
results  than  has  brain  injections.  I  do  not  wish,  how- 
ever, to  criticise  it  harshly,  but  merely  to  express  an  opin- 
ion as  to  its  entire  worthlessness  and  uselessness. 

The  various  combinations  of  bromine,  such  as  bromide 
of  camphor,  of  nickel,  of  lithium,  of  strontium,  of  arsenic, 
ethyl  bromate,  rubidium-ammonium  bromide,  etc.,  have 
had  their  advocates  and  are  in  many  cases  of  great  ser- 
vice, not  only  as  adjuvants  to  other  plans  of  treatment 
but  as  exchange  materials  for  the  bromide  of  potash  and 
soda  when  the  system  does  not  well  tolerate  the  continued 
tenancy  of  the  latter. 

Fer6  has  recommended  the  bromide  of  strontium,  but 
others,  with  the  exception  of  Deny,1  who  have  utilized 
this  suggestion,  have  not  been  able  to  corroborate  his  good 
opinion  of  the  drug.  Halsted,  however,  reports  with 
some  favor  his  use  of  this  salt.  The  bromide  of  zinc  and 
the  bromide  of  nickel  have  both  been  extensively  used. 
The  latter,  originally  recommended  by  Dr.  Costa,  was 
found  to  be  quite  useless  by  Bourneville,*  who  gave  it  a 
very  extensive  trial.  Bromide  of  zinc  has  been  given  by 
Hammond,  Charcot,  Bourneville  and  other  clinicians, 
but  there  is  so  much  uncertainty  about  this  salt,  both  in  re- 
gard to  its  dose  and  its  action,  that  it  would  be  better  not 
to  consider  its  use  at  all.  For  instance,  it  has  been  recom- 
mended by  the  writers  mentioned  above  in  doses  varying 
from  5  to  30  grains,  while  a  recent  number  of  the  Phar- 
maceutical  Gazette  stated  its  dose  to  be  from  one  half  to 
one  grain.  Ethyl  bromate  has  been  recommended  by  Do- 
nath  *  in  doses  from  30  to  40  drops  three  times  daily  and 
increased  to  twice  this  amount  if  the  stomach  will  stand 
it.  He  recommends  its  administration  with  oil  of  pep- 
permint or  in  capsules. 

1  Semaine   Medicale.  August  10,  1892. 

2  Progrbs  Medicale,  No.  26,  1889. 

•  Therapeutische  Monatschrift,  June,  1F91. 


September  22,  1894] 


MEDICAL  RECORD. 


357 


Corroborative  evidence  of  Donath's  estimate  of  the 
value  of  ethylene  bromate  is  given  by  Olah,1  who  finds 
that  the  attacks  are  milder  and  less  frequent,  and  that  it 
does  not  produce  bromism.  The  objections  to  its  use 
are  its  extreme  volatility  and  unstableness. 

The  less  important  measures  against  epilepsy  that  have 
been  enumerated  above  may  be  disposed  of  very  rapidly. 
If  our  conception  of  the  pathology  of  epilepsy  is  correct, 
or  anything  approaching  correctness,  it  is  an  insult  to  our 
intelligence  to  speak  of  the  curative  effects  of  hypnotism 
in  this  disease. 

The  use  of  hydrastinine,  as  recommended  by  Arkhan- 
gelsky,3  has  not  been  successful  in  the  hands  of  other 
physicians. 

Whatever  virtue  the  salicylates  may  have  in  the  treat- 
ment of  epilepsy  should  be  attributed  to  their  action  as 
intestinal  antifermentatives.  A  fact  that  is  too  well 
known  to  need  emphasis  is,  that  frequently  attacks  of 
epilepsy  may  be  diminished  nearly  fifty  per  cent,  in  fre- 
quency by  treating  the  alimentary  canal  exclusively. 

Duboisine,  picrotoxin,  cannabis  indica,  and  bella- 
donna should  in  no  sense  be  considered  of  sufficient  im- 
portance to  attempt  to  combat  epilepsy  by  any  one  of 
them  alone.  They  are  frequently  of  use  as  adjuvants  to 
the  bromides,  particularly  in  combating  some  untoward 
symptom  produced  by  the  latter.  Amylene  hydrate, 
which  was  first  recommended  by  Wildermuth,'  has  been 
found  by  Dunn  *  to  be  entirely  useless,  and  even  danger- 
ous, in  the  treatment  of  epilepsy.  This  conclusion  is 
substantiated  by  Umphenbach 5  and  Drews,0  who  found 
that  this  drug  greatly  increased  the  mental  confusion 
in  epileptics  and  caused  considerable  disturbance  of 
sleep.  It  should  be  dropped  entirely  from  the  therapeu- 
tics of  epilepsy. 

Osmic  acid  has  likewise  been  shown  to  be  of  absolutely 
no  use  in  the  treatment  of  epilepsy.  Sclerotinic  acid 
has  been  tried  by  Bourneville  and  Bricon  in  twelve  cases 
of  epilepsy,  and  in  some  of  these  the  frequency  of  the  at- 
tacks was  lessened.7  It  was  noticed  that  some  of  the 
patients  to  whom  the  sclerotinic  acid  was  administered 
decreased  rapidly  in  weight.  This  fact  alone  would  mili- 
tate against  its  use  in  the  treatment  of  this  disease. 

Of  the  non-medicinal  ways  of  treating  epilepsy,  the 
eye  treatment  has  received  the  most  attention.  All  neu- 
rologists are  keenly  aware  of  the  fact  that  epilepsy  may 
be,  and  frequently  is,  excited  reflexly  and  that  not  in- 
frequently the  source  of  this  pathologic  reflex  is  some  er- 
ror of  refraction,  or  defect  in  the  eye  muscles,  and  that 
the  correction  of  this  faulty  condition  will  be  followed  by 
the  relief  of  the  trouble  which  it  caused.  They  are  like- 
wise aware  of  the  fact  that  although  attacks  of  epilepsy 
may  have  been  excited  originally  by  defective  conditions 
of  the  eye,  that  not  infrequently  treatment  of  the  eyes 
alone  will  not  cure  the  disease,  and  this  for  two  reasons 
in  particular.  First,  the  eye  defect  may  have  been 
merely  the  exciting  cause  in  a  patient  predisposed  to  epi- 
lepsy. That  is  to  say  such  a  patient  might  have  the  epi- 
leptogenous  areas  of  his  brain  brought  into  activity  by 
many  other  factors,  for  instance,  by  fright,  fatigue,  over- 
eating, over-heating,  etc.,  and  the  relief  of  such  exciting 
factors  would  not  cure  the  disease,  no  more  does  the 
relief  of  the  eye  defect.  In  the  second  place,  if  a  patient 
has  had  a  number  of  epileptic  attacks,  that  is,  if  the  mo- 
tor cells  of  the  epileptogenous  areas  have  been  subject  to 
a  repetition  of  explosions,  each  succeeding  one  lessens 
the  chances  of  recovery,  and  particularly  do  they  lessen 
the  chances  of  spontaneous  recovery  on  the  removal  of 
the  cause  which  excited  the  first  attack.  The  cessation 
of  attacks  goes  hand  in  hand  with  the  improvement  of 
nutrition  of  the  cortical  motorial  cells,  and  all  our  efforts 
should  be  in  that  direction.     Not  alone  the  eye  but  all 

1  Wiener  Medical  Presse,  1891,  No.  21. 

2  Wratsch,  No.  ao,  1892. 

1  NeuroL  Central.,  1889,  p.  451. 
4  Journal  of  Mental  Science,  October,  1891. 
'"  Munch,  med.  Wochenschr.,  No.  4,  1891. 
■  Therapeutische  Monatshefte,  No.  io,  1890. 
7  Arch,  de  Neurol.,  xii.,  xiv.,  and  xv.,  xvi.,  1888. 


sources  of  peripheral  irritation  should  be  carefully  and  in- 
telligently examined  and  re-  examined.  Especially  should 
the  highly  specialized  sense  organs  be  examined  and  any 
departure  from  the  norm  should  be  labored  with  till  it  is 
overcome.  After  it  has  been  corrected  the  physician 
will  find  that  all  his  therapeutic  resources  are  still  neces- 
sary to  combating  the  disease  which  unfortunately  still 
continues  to  exist.  It  is  then  that  the  plan  of  treatment 
seeking  the  bettered  nutrition  of  the  epileptogenous  areas 
should  be  employed  to  its  full  extent. 

The  eye  plan  of  treatment  of  epileptics,  even  when 
looked  at  with  a  most  charitable  critical  eye,  does  not 
deserve  the  laudations  of  most  of  its  advocates.  It  can 
never  be  more  than  a  factor  in  the  treatment  of  the  dis- 
ease. If  we  should  decide  to  treat  epilepsy  on  the  eye 
plan  perhaps  it  would  be  best  to  have  a  symposium  of 
medical  men,  each  one  of  whom  would  combat  the  fac- 
tor which  he  considered  the  important  one.  Then, 
«when  all  are  finished,  the  patient  will  recover  in  the 
hands  of  the  physician  who  gives  him  iron,  and  arsenic 
and  the  iodides  and  other  measures  that  will  stimulate 
hsematogenesis  and  tissue  repair. 

When  one  considers  the  unsatisfactoriness  of  the  treat- 
ment of  epilepsy  and  the  futility  of  so  many  of  the  meas- 
ures which  are  periodically  lauded  as  having  great  and 
peculiar  virtues,  it  is  not  surprising  that  most  ph>sicians 
are  animated  by  a  wholesome  spirit  of  scepticism  in  ap- 
proaching the  trial  or  consideration  of  any  newly  recom- 
mended substance.  A  considerable  number  are  advo- 
cated every  year,  but  appeals  for  their  recognition  fall  on 
deafened  ears,  and  the  freezing  reception  exteffded  to 
them  cuts  them  off  at  their  very  inception,  and  thus 
saves  much  useless  work  on  the  part  of  the  physician  and 
much  harmful  experience  on  the  part  of  the  patient. 
Occasionally,  however,  a  plan  of  treatment  is  suggested 
that  appeals  to  us  in  no  uncertain  way.  One  based  on  a 
laudable  hypothesis,  or  one  that  involves  no  shrivelling 
of  our  intellect  to  understand  how  it  may  act,  or  one 
that  has  been  tried  by  an  observer  who  from  his  labors 
and  reputation  deserves  to  be  heard,  and  who  recom- 
mends it  because  he  has  seen  it  do  good,  and  offers  it  to 
his  fellow-workers  without  explanation.  It  is  to  such  a 
plan  of  treatment  that  I  wish  to  invite  your  attention. 

About  a  year  ago,  Professor  Flechsig,  of  Leipsic,  pub- 
lished a  short  article  on  a  new  method  of  treating  epi- 
lepsy which  in  his  hands  had  given  most  gratifying 
results.  It  consists  in  administering  opium  in  the  shape 
of  the  extract  or  pill  in  large  doses  for  a  period  of  six 
weeks.  The  dose  of  opium  in  the  beginning  is  from  one- 
half  to  one  grain,  and  this  is  gradually  increased  until 
the  patient  is  taking  fifteen  grains  or  more  per  day,  in 
doses  of  from  three  to  four  grains.  The  maximum  dose 
is  reached  by  the  end  of  the  first  week.  At  the  end  of 
six  weeks  the  opium  is  suddenly  stopped,  and  for  it  bro- 
mide of  potassium  or  sodium  in  doses  of  one-half  drachm 
four  times  daily  is  substituted.  After  these  large  doses  of 
bromide  have  been  kept  up  for  some  time  the  dose  is 
gradually  decreased  until  the  patient  is  taking  less  than 
two  scruples  per  day.  The  sudden  cessation  of  admin- 
istering the  opium  and  the  exhibition  of  the  bromide  is 
quite  essential. 

Being  cognizant  of  the  fact  that  opium  in  small  doses 
when  combined  with  bromides  is  frequently  of  great  ser- 
vice in  lessening  the  severity  of  attacks  of  epilepsy  the 
plan  of  treatment  suggested  by  Flechsig  appealed  to  me 
and  I  determined  to  give  it  a  thorough  trial  in  a  large 
number  of  cases  selected  from  private,  hospital,  and  dis- 
pensary practice,  and  examine  the  results  of  such  treat- 
ment at  the  end  of  one  year.  About  fifty  patients 
have  been  subjected  to  this  plan  of  treatment.  A  few 
cases  I  shall  detail,  and  content  myself  with  presenting 
the  results  observed  in  the  others  in  tabular  form. 

The  twenty  cases  considered  in  the  first  table  I  had 
under  almost  daily  observation,  and  the  conclusions 
reached  regarding  this  plan  of  treatment  is  based  largely 
on  the  facts  therein  set  forth.  The  sixteen  cases  con- 
sidered in  the  second  table  I  did  not  have  under  such 


358 


MEDICAL   RECORD. 


[September  22,  1894 


Table  I. 


No. 

Name. 

Age.    Sex. 
14      Fe. 

Duration  of 
Epilepsy. 

Frequency  oi  Fits 

under  Bromide 

Treatment. 

Character  of  Attack. 

Cessation  of  Fits 
after  Opium. 

3  months. 

Frequency  of  Fits 
after  Relapse. 

Once  in  3  months. 
1  a  month. 

Remarks. 

1  '  F.  M. 

1    3  years. 

Once  a  week. 

Haut  and  petit  mal. 

Dispensary  patient. 

2  1  H.  N. 

22  '  M. 

1     6      " 

1  to  2      4| 

Haut  mal. 

5        " 

Private  patient 

3      M.  S. 

9     Fe. 

6      " 

1  to  3      •• 

Haut  and  petit  mal. 

5 

No  relapse. 

Dispensary  patient. 

4 

M.  P. 

21      M. 

1     1  year. 

2  to  3      " 

Haut  mal. 

8        " 

4l                 <( 

«•                " 

5 

H.  B. 

16  1  Fe. 

6  years. 

6 

Haut  and  petit  mal. 

2  weeks. 

Every  4th  day. 

Private  patient. 

6 

A.  F. 

22  '  M. 

i     8      •• 

7 

Haut  mal. 

6       » 

1  a  month. 

Hospital  patient 

7 

e.  s! 

16  !  M. 

1     9      " 

9 

Haut  and  petit  mal. 

4      " 

1  a  week. 

«•              i< 

8 

23  ,  M. 

20     " 

6 

<•                II                   M             (1 

7       " 

2  a  month. 

••              ** 

9 

C.  F. 

27  i  M. 

,     9      " 

2              " 

Haut  mal. 

1  8       " 

Every  3  weeks. 

.. 

10 

A.  S. 

26     M. 

;  25  " 

2              u 

1. 

1  week. 

1  a  month. 

<• 

11 

L.  M. 

21  1  Fe. 

7  " 

1              " 

*•        it 

5  weeks. 

2  a  month. 

.. 

12 

E.  R. 

20  j  Fe. 

l     4      " 

3 

Haut  and  petit  mal. 

1  2      " 

Once  in  2  weeks. 

" 

13 

t* 

27     M. 

10 

1              •• 

Haut  mal. 

!4      " 

3      " 

Dispensary  patient 

14 

IS  '  Fe. 

1     3      *4 

3 

.. 

1  7      <. 

2      «• 

i<                ** 

IS 

B.  D. 

24     Fe. 

1      " 

1              " 

U                (1 

5  months. 

u               4         «. 

Private  patient. 

16 

M   S. 

28     Fe. 

11      " 

2 

•  »        •• 

I  5  weeks. 

1  a  week. 

Hospital  patient 

17 

D.  M 

21     Fe. 

5      " 

4 

Haut  and  petit  mal. 

7      " 

3  a  month. 

.. 

18 

E.  H. 

27  |  M. 

i     7      *l 

2               " 

Haut  mal. 

!  6      " 

3 

Private  patient. 
•  Hospital  patient 

19 

M.  Mc. 

19     Fe. 

1    5      " 

4 

Haut  and  pelit  mal. 

3      " 

1  a  week. 

20 

J.L. 

17  ,  M. 

6      •• 

|3 

Haut  mal. 

|  1  month. 

2        " 

Dispensary  patient 

Table  II. 
The  following  16  cases  have  been  under  observation  for  four  months  only. 


1 

No.   ,    Name. 

Age. 

Sex. 

Duration  of 
Epilepsy. 

Frequency  of  Fits 

under  Bromide 

Treatment. 

Character  of  Attack. 

Cessation  of  Fits 
after  Opium. 

Frequency  of  Fits 
after  Relapse. 

Remarks. 

I   !   D.  S. 

Us 

M. 

13  years. 

2  daily. 

Haut  mal. 

1  week. 

4  a  week. 

Hospital  patient. 

2  1  J.  K. 

3  W.  D. 

1  26 
40 
27 

M. 
M. 
M. 

1    12        " 
20        " 

8      ■• 

4  a  week. 

3    l4 
1     ■' 

Haut  and  petit  mal. 
Haut  mal. 

No  improvement. 
2  weeks. 

•1                << 

4  1   1.  L. 

5  G.  Y. 

1  in  2  weeks. 

M 

38 

M, 

11      " 

5    " 

Haut  and  petit  mal. 

11  days. 

2  a  week. 

6  1  T.  M. 

■  <H 

M. 

i  a6      .. 

7     4' 

«i               << 

6  days. 

3 

**                                        *' 

7      S.  H. 

39 

M. 

1  I4      " 

3     " 

11               <i 

2  weeks. 

3 

l< 

8  |  W.  M. 

SO 

M. 

1  18      " 

10    «• 

Petit  mal. 

17  days. 

2 

.1                                         .1 

9     . 

.  O. 

22 

M. 

,    IO        ,4 

2    *' 

Haut  and  petit  mal. 

10      " 

1        » 

"                                        " 

IO      ' 

.  K. 

26 

M. 

i     7      " 

2     " 

•  1                           u 

3  weeks. 

3  a  month. 

** 

II      i     ' 

.  W. 

61 

M. 

22      " 

3    " 

•  1                 (• 

13  days. 

No  improvement. 

1  a  week. 

*•                                        »• 

12  '  B.  G. 

38 

M, 

1  IS      .. 

5    " 

Haut  maL 



•  •                                        «. 

13  1  W.  H. 

,  46 

M, 

1     6     » 

2     4i 

5  days. 

2  a  week. 

" 

14     D.  M. 

45 

M. 

|  11      «< 

3     *4 

11      11 

15      " 

1        M 

15  |  H.  C. 

1  55 

M. 

20     " 

6    «• 

Haut  and  petit  mal. 

9     " 

2        •' 

ii                                        .1 

16     J.  D. 

5i 

M. 

1  17      " 

. 

ii               11 

3  weeks. 

2        " 

close  surveillance.  They  were  very  old  subjects  and 
my  principal  desire  in  subjecting  them  to  the  treatment 
was  to  determine  whether  the  results  would  militate 
against,  or  corroborate  the  results  obtained  in  the  first 
twenty  cases.  In  a  general  way  it  may  be  said  that  the 
results  were  not  so  satisfactory. 

A  study  of  Table  I.  shows  that  all  the  cases  with  one 
exception  (Case  5)  were  benefited.  It  further  shows 
that  in  two  cases  (Cases  3  and  4)  the  fits  have  not  re- 
turned. The  time  elapsed  in  these  cases  is,  however, 
not  of  sufficient  length  to  refer  to  them  in  any  way  as 
cured.  And  I  wish  to  emphasize  the  point  that,  although 
the  attacks  have  ceased,  I  do  not  consider  them 
cured,  and  they  are  still  taking  four  scruples  of  potassium 
bromide  a  day.  In  several  of  the  cases  the  character  of 
the  attack  after  the  relapse  was  frequently  of  a  different 
nature  than  that  before  the  attack.  That  is  the  family 
of  the  patient  or  the  hospital  nurse,  as  the  case  might  be, 
would  describe  them  as  "mere  fainting  spells "  and 
make  light  of  them.  I  have  observed,  however,  as  time 
went  on  that  these  "  spells  "  gradually  become  more 
severe  as  the  number  of  attacks  increase  after  the  relapse. 
Another  fact  which  I  would  point  out  is,  that  in  every 
case,  almost  without  exception,  the  maximum  dose  of 
opium  was  reached  and  persevered  in  with  comparatively 
slight  trouble.  Some  of  the  patients  who  were  cogni- 
zant of  what  they  were  taking  complained  rather 
bitterly  and  rebelled,  but  particular  attention  to  the 
bowels  and  a  good  deal  of  out-door  exercise  served  to 
keep  them  moderately  comfortable.  Sometimes  it  was 
necessary  to  administer  strong  coffee  to  combat  the  drow- 
siness, particularly  during  the  first  week  when  the  opium 
was  being  increased  rapidly. 

While  the  patients  were  taking  opium  there  was  no 
marked  change  in  the  frequency  of  the  fits.   Some  of  the 


patients  had  a  lesser  number,  particularly  toward  the 
latter  end  of  the  six  week's  period,  while  others  had  them 
with  customary  frequency. 

Notwithstanding  the  fact  that  no  sinister  results  ac- 
companied the  administration  of  opium  in  such  large 
doses,  I  feel  it  incumbent  on  me  to  say  to  any  one  who 
would  apply  this  plan  of  treatment,  that  the  most  watch- 
ful and  scrutinizing  care  is  necessary,  especially  during 
the  first  weeks,  until  the  patient  becomes  accustomed  to 
the  large  doses. 

The  most  satisfactory  results  were  obtained  in  very 
chronic  epileptics,  and  particularly  those  who  were  not 
responsive  to  large  quantities  of  bromide.  In  epilepsy 
dependent  on,  or  associated  with,  gross  organic  lesion  of 
the  brain  the  treatment  seemed  to  give  better  results  than 
in  pure  idiopathic  epilepsy.  By  gross  organic  lesion  I 
mean  epilepsy  associated  with  old  cerebral  hemorrhage 
and  softening  and  epilepsy  associated  with  defective  de- 
velopment. 

I  can  but  state  my  convictions  relative  to  this  plan  of 
treatment  in  the  following  conclusions : 

1.  The  plan  suggested  by  Flechsig  is  not  a  specific  in 
the  treatment  of  epilepsy. 

2.  In  almost  every  case  in  which  this  plan  of  treat- 
ment has  been  tried  there  has  been  a  cessation  of  the  fits 
for  a  greater  or  lesser  time. 

3.  A  relapse  generally  occurs  in  a  period  varying  from 
a  few  weeks  to  a  few  months. 

4.  The  frequency  of  fits  after  the  exhibition  of  opium 
is,  for  the  first  year  at  least,  lessened  more  than  one  half. 

5.  The  attacks  occurring  after  the  relapse  are  much  less 
severe  in  character  than  those  that  the  patient  has  been 
accustomed  to  having. 

6.  This  plan  of  treatment  is  particularly  valuable  in 
ancient  and  intractable  cases. 


September  22,  1894] 


MEDICAL    RECORD. 


359 


7.  In  recent  cases  of  idiopathic  epilepsy  it  cannot  be 
recommended. 

8.  The  opium  plan  of  treatment  is  an  important  ad- 
juvant to  the  bromide  plan  as  ordinarily  applied. 

9.  The  opium  acts  symptomatically,  and  merely  pre- 
pares the  way  for  and  enhances  the  activity  of  the  brom- 
ides and  other  therapeutic  measures. 

10.  This  plan  of  treatment  permits  the  use  ot  any 
other  substances  which  are  known  to  have  a  beneficial 
action  in  epilepsy. 

I  will  cite  briefly  the  history  of  a  few  unselected  cases 
taken  from  hospital,  dispensary,  and  private  case-books, 
showing  the  effect  of  the  treatment  I  may  say  that  all 
of  these  patients  were  handled  with  bromides  for  a 
longer  or  shorter  time  previous  to  being  put  on  the 
Flechsig  plan. 

Case  I.     Dispensary. — F.   M ,   female,  colored, 

aged  fourteen.  Family  history  tubercular ;  personal  his- 
tory good.  Never  had  convulsions  when  a  child ;  was 
always  bright,  vivacious,  and  smart ;  talked  early  and 
walked  early.  First  attack  when  eleven  years  of  age ; 
cause  unknown;  character  of  attack,  haut  mal.  Fre- 
quency of  attacks  about  three  a  month  and  getting  more 
frequent.  Character  of  aura,  headache  for  some  hours. 
Physical  condition,  good ;  mental  condition,  backward ; 
she  has  a  great  many  evidences  of  mental  deterioration. 
Head  symmetrical ;  no  other  somatic  evidences  of  de- 
generacy. 

Put  on  opium  treatment  September  20th.  Reached 
thirteen  grains  a  day  at  end  of  first  week.  At  this  time 
took  thirteen  pills  at  one  time  and  suffered  from  toxic 
effect,  but  recovered  without  difficulty.  Put  on  kalium 
bromide,  3ss  4.  i.  d.,  November  1st.  Patient  reported 
once  a  week  till  January,  then  stopped  for  two  weeks. 
Returned  February  8th  and  said  she  had  had  a  fainting 
spell,  while  the  medicine  had  been  stopped.  Bromide 
in  20  gr.  doses  4  i.  d.  continued.  No  attacks  since  that 
time.  Result :  one  attack  of  petit  mal  in  six  months, 
Mental  condition  about  the  same. 

Case  II.  Private.— H.  N ,  male,  aged  twenty- 
two,  salesman.  Maternal  side  of  family  neurotic  heri- 
tage. Paternal  great  uncle  had  epilepsy.  Attacks  be- 
gan when  he  was  sixteen  years  of  age.  Cause,  not  attrib- 
utable. Had  one  spasm  when  a  child,  caused  by 
eating  unripe  fruit.  Was  bright  mentally  and  strong 
physically,  as  a  boy.  Character  of  attack,  haut  mal. 
Time  of  occurrence,  always  at  night.  Frequency,  in 
the  beginning  they  occurred  about  once  in  six  months ; 
now  they  come  once  or  twice  a  week.  Mentally  he  is 
deteriorating,  forgetful,  depressed;  cannot  concentrate 
his  mind.     Physically  not  robust. 

Put  on  opium  treatment  April  30th.  Maximum  dose, 
fifteen  grains,  reached  in  eight  days,  and  continued  till 
June  1 6th.  No  change  in  attacks  in  point  of  form  or 
frequency  while  taking  opium. 

June  15th. — Substituted  bromide  of  potassium,  3  ij. 
per  diem,  for  opium.    Reports  once  a  week. 

November  28th. — Three  attacks  in  succession  the 
same  night.  Had  not  been  taking  medicine  for  five 
days. 

December  18th. — Nocturnal  attack. 

March  27,  1894. — Reports  one  attack  since  Decem- 
ber. 

Result :  Four  attacks  in  nine  months.  Physical  and 
mental  improvement. 

Case  III. — M.   S female,  nine  years  of   age. 

One  sister  died  of  hydrocephalus.  She  did  not  walk  till 
two  years  of  age,  and  began  to  talk  when  six.  Attacks 
first  began  at  the  age  of  three  years.  They  were  then 
of  the  petit  mal  character,  and  gradually  increased  in  fre- 
quency until  her  eighth  year,  when  they  were  occurring 
once  or  twice  a  week.  From  her  eighth  year  she  has 
had  both  petit  mal  and  grand  mal.  Mentally  the  pa- 
tient is  quite  defective.  Evidence  of  somatic  degen- 
eracy well  marked. 

Patient  put  on  opium,  gr.  j.,  t.i.d.  for  three  weeks; 
then  on  double  the  quantity  for  the  next  three  weeks ; 


then  on  triple  the  quantity  for  the  next  four  weeks. 
Middle  of  November  put  on  potassium  bromide,  30 
grains  four  times  a  day. 

It  is  necessary  to  mention  that  this  little  patient  was 
the  only  one  of  the  entire  number  that  developed  symp- 
toms of  the  opium  habit.  On  substituting  the  bromides 
for  the  opium,  such  symptoms  of  the  opium  habit  as 
diarrhoea,  anorexia,  restlessness,  irritability,  and  sleep- 
lessness showed  themselves,  but  were  easily  ccmbafed 
with  hydrotherapy  and  small  doses  of  chloral.  She  has 
had  no  attacks  for  upward  of  five  months.  Mentally 
there  is  some  gratifying  improvement.  She  helps  her 
mother  about  the  house ;  can  be  trusted  to  go  errands 
and  the  like.  During  the  administration  of  the  bromide 
she  has  had  restoratives,  such  as  iron  and  cod- liver  oil, 
in  such  quantities  as  she  could  dispose  of. 

Case  IV.— M.  P male,  twenty- one  years  of  age; 

heavy  drinker.  One  brother  had  attacks  for  upward  of 
twelve  years  and  recovered  at  the  end  of  that  time. 
One  year  ago  after  a  heavy  drinking  bout  he  had  an 
attack  of  pneumonia  and  while  convalescing  from  this 
he  had  his  first  epileptic  attack.  After  this  they  oc- 
curred two  to  three  times  a  week,  and  both  in  the  day 
and  in  the  night.  Has  an  aura  starting  from  the  stomach 
accompanied  by  cardiac  palpitation.  Mental  condition 
good. 

Put  on  opium  August  2  2d  and  continued  for  six 
weeks.  Then  bromide  in  30-grain  doses  four  times  a 
day.     Result,  no  attacks  since  cessation  of  opium. 

Case  V. — H.  B female,  sixteen  years  of  age. 

Mother  died  of  tuberculosis.  Had  convulsion's  *hen 
three  and  a  half  years  of  age.  Then  was  quite  free  from 
attacks  till  ten  years  of  age.  Talked  and  walked  early 
and  learned  easily  until  her  tenth  year,  when  she  bad 
severe  attacks  of  haut  mal.  Three  or  four  months  later 
she  had  a  second  attack  and  since  that  time  they  have 
increased  in  frequency.  Concomitant  with  the  increase 
in  the  number  of  attacks  has  been  mental  deterioration, 
so  that  now  she  is  quite  demented.  Three  yeais  ago 
she  had  an  attack  of  chorea,  and  while  ailing  with  this, 
she  had  a  left  side  hemiplegia  which  disappeared  in 
about  a  fortnight.  Her  mind  has  been  gradually  gettirg 
weaker,  and  for  the  past  six  months  she  has  bad  visual 
and  auditory  hallucinations.  Always  before  an  attack 
she  complains  that  her  eyes  hurt  her.  Evidence  of 
somatic  degeneracy,  such  as  stunted  stature,  torsus  pala- 
tinus,  over  exposure  of  gums,  defective  lobulation  of 
ears,  crowding  of  teeth,  broad,  flat  nasal  arch  very  ap- 
parent. For  the  past  six  months  she  has  had  at  least 
six  attacks  a  week,  for  two  or  three  hours  after  an  attack 
she  is  entirely  non  compos  mentis. 

Put  on  opium  January  10,  1894,  and  for  the  next  six 
weeks  while  on  opium  the  attacks  were  not  so  frequent 
as  formerly. 

February  28th. — Put  on  kalium  bromide.  No  attacks 
for  two  weeks,  since  then  an  attack  about  every  fourth 
day. 

Case  VI.— A.  F male,  aged  twenty- two,  of  neu- 
ropathic heritage.  First  attack  of  epilepsy  when  four- 
teen years  of  age.  Attributing  cause,  a  severe  fright. 
The  fits  occurred  about  every  three  weeks  for  the  next 
four  years.  Since  that  time  the  attacks  have  been  get- 
ting more  frequent,  although  he  has  been  under  con- 
tinual treatment.  In  the  month  previous  to  the  begin- 
ning of  the  opium  treatment  he  had  twenty-seven  attacks 
—seventeen  day  attacks  and  ten  night  attacks,  all  of  tfce 
haut  mal  type.     Patient  put  an  opium  May  25,  1893. 

The  following  is  a  record  of  his  attacks  while  taking 
the  opium  r  May  25th,  six  attacks;  June  10th,  two  at- 
tacks; June  nth,  one  attack,  followed  by  a  maniacal 
outbreak.  Rectal  injection  of  30  grains  of  chloral 
hydrate  and  60  grains  of  bromide  of  potassium,  hypoder- 
matic injection  of  yfa-  grain  hyoscy amine  hydrobro- 
matis,  and  ice  cap  to  the  head. 

June  1 2th. — Patient  rational. 

July  1 8th.— Opium  stopped  and  given  instead  bromide 
of  potassium,  30  grains  four  times  a  day. 


36o 


MEDICAL  RECORD. 


[September  22,  1894 


August  27th. — Two  "  fainting  "  spells. 

October  24th. — Petit  mal 

October  25th. — Petit  mal. 

November  3d. — Petit  mal. 

December  2d. — Two  attacks  of  petit  mal. 

January — No  attacks.     Patient  left  the  hospital. 

Case  VII. — J.  N ,  male,  sixteen  years  of  age,  no 

family  history.  Has  had  fits  since  seventh  year.  Cause, 
severe  fright.  The  form  that  the  attacks  take  is  vari- 
able, occasionally  they  are  of  procursive  type,  some- 
times petit  mal  and  sometimes  very  severe  attacks  of 
haut  mal.  In  the  month  preceding  the  opium  treat- 
ment he  had  thirty-eight  fits.  Mentally,  patient  is  en- 
tirely demented.  Opium  stopped  and  bromides  substi- 
tuted July  25  th. 

The  following  is  the  record  of  attacks  for  the  re- 
mainder of  the  year :  August,  four  attacks ;  September, 
one  attack;  October,  three  attacks,  all  of  petit  mal 
type ;  November,  five  attacks ;  December,  three  attacks, 
one  of  the  haut  mal  type.  Patient  transferred  to  the 
asylum. 

Case  VIII. — E.  S ,  male,  twenty-three  years  of 

age.  Negative  family  history.  Has  had  fits  since  child- 
hood. Attributable  cause,  fright.  Mentally  the  patient 
is  morose,  stupid,  wrathy,  and  scarcely  ever  speaks  unless 
angered.  In  month  previous  to  establishing  the  opium 
treatment  he  had  twenty-four  attacks.  Opium  stopped 
July  25th  and  bromides  substituted.  The  following  is 
the  record:  September,  1893,  two  attacks;  October, 
two  attacks;  January,  1894,  two  attacks;  February, 
one  attack ;  March,  three  attacks. 

This  patient  has  undergone  a  remarkable  mental 
change  for  the  better,  is  now  cheerful  and  bright  and 
works  continually  about  the  ward. 

Case  IX. — C.  F ,  male,  twenty  seven  years  of  age. 

Negative  family  history.  Has  had  fits  since  he  was 
eighteen  years  of  age.  At  first  they  occurred  at  night, 
but  for  some  years  past  he  has  had  both  night  and  day 
attacks.  He  has  about  eight  attacks  a  month,  in  each 
one  of  which  more  than  an  hour  elapses  before  he  re- 
covers consciousness.  Mentally  the  patient  is  deranged, 
and  spends  most  of  the  time  praying.  He  received  the 
opium  in  the  regular  way  and  was  put  on  bromides  Au 
gust  2,  1893.  He  suffered  no  attack  up  to  October  1st, 
when  he  was  transferred  to  the  surgical  ward  that  he 
might  be  operated  on  for  a  malignant  growth  of  the 
cheek.  Since  then  he  has  had  a  few  light  attacks. 
Mentally  he  is  greatly  improved. 

Case  X  — A.  S ,  male,  twenty-six  years  of  age. 

Paternal  uocle  has  epilepsy.  This  patient  had  convul 
sions  when  a  child  after  an  attack  of  scarlet  fever. 
When  ten  years  of  age  had  his  first  severe  fit.  He  has 
been  under  almost  continual  treatment  in  this  country 
and  Germany  since  his  boyhood,  but  the  attacks  have  be- 
come more  frequent  and  severe.  Sometimes  he  will  have 
three  or  four  attacks  in  a  day  and  then  will  not  have  a 
repetition  for  a  week.  Most  of  the  attacks  are  in  the 
day.  Mentally  and  physically  the  patient  is  in  fairly 
good  condition.  Patient  put  on  opium  June  10th  and 
stopped  August  2d. 

The  record  from  that  tim;  is,  August  6th,  two  "faint- 
ing "  spells;  November  28th,  two  attacks  of  petit  mal ; 
Februarys,  1894,  one  haut  mal;  February  10th,  petit 
mal ;  March  7th,  petit  mal. 

In  conclusion  it  gives  me  great  pleasure  to  acknowl- 
edge the  many  valuable  suggestions  received  from  Dr.  C. 
L.  Dana  relative  to  the  prosecution  of  this  trial,  and  to 
thank  him  for  placing  at  my  disposal  the  extensive  ma 
terial  of  his  clinic  at  the  New  York  Post  Graduate  Medi- 
cal School. 

To  Dr.  E.  D.  Fisher  my  best  thanks  are  due  also  for 
allowing  me  the  privilege  of  his  wards  at  the  Alms 
Home.  Trie  valuable  and  untiring  aid  rendered  me  by 
my  successive  house  physicians,  Drs.  Hedges,  Grandy, 
aud  Worth,  at  the  Hospital  for  Nervous  Diseases  is  grate- 
fully acknowledged. 

43  W*st  Thirty-ninth  Street. 


A  RARE  CASE  OF  SCLERO  CORNEAL  STAB- 
GREAT  LOSS  OF  VITREOUS  —  COMPLETE 
COLLAPSE  OF  GLOBE  —  INTRA  -  OCULAR 
HEMORRHAGE  —  TREATMENT  WITHOUT 
ANY  PAIN— GLOBE  SAVED. 

By  DANIEL  R.  AMBROSE,  M.D., 

KKW  YOKK. 

This  case  is  interesting  not  only  from  its  rare  character 
and  result,  but  also  from  the  novel,  yet  very  simple, 
treatment.  In  his  chapter  on ' '  Wounds  and  Injuries  of  the 
Sclerotic/1  Soelberg  Wells  says:  "When  the  wound  is 
very  extensive  and  a  large  portion  of  the  contents  of  the 
globe  has  escaped,  and  there  is  no  hope  of  restoring  any 
sight,  it  is  better  to  excise  the  eyeball  at  once,  more 
especially  if  it  is  to  the  patient  a  matter  of  great  moment 
(as  among  the  poorer  classes)  to  be  cured  as  soon  as 
possible,  and  to  be  free  from  further  inflammatory  at- 
tacks." l 

In  a  large  hospital  and  dispensary  practice,  extending 
over  a  period  of  fifteen  years,  I  have  never  seen  an  in- 
cised wound  of  the  eye  so  deep,  extensive,  and  appar- 
ently hopeless  as  the  following : 

M.  W ,  aged  twenty  nine,  butcher,  came  to  my 

office,  Sunday  afternoon,  February  7, 1886,  with  his  right 
eye  covered  with  cloths,  over  which  was  tied  a  handker- 
chief. After  removing  these  the  lids  were  closed  and 
sunken  as  in  a  case  of  extreme  phthisis  bulbi.  After 
separating  the  lids  the  eyeball  appeared  not  more  than 
one  fourth  its  normal  size,  so  great  was  the  collapse  from 
an  incised  wound  commencing  on  nasal  side  of  sclera, 
apparently  one- fourth  of  an  inch  from  the  limbus  con- 
junctivalis,  near  the  horizontal  diameter,  and  extending 
forward  and  slightly  upward  to  one  eighth  of  an  inch 
from  the  temporal  limbus  conjunctivalis,  cutting  through 
sclera,  choroid,  and  retina,  and  extending  through  cor- 
nea, iris,  ciliary  processes,  zonula,  and  splitting  or  dis- 
placing the  lens,  which  in  all  probability  escaped  with 
the  gush  of  the  vitreous.  The  iris  was  divided  through- 
out the  entire  extent  of  the  corneal  portion  of  the  wound. 
There  is  intraocular  hemorrhage,  and  very  probably  de- 
tachment of  the  retina.  A  portion  of  vitreous  had  lodged 
in  the  scleral  portion  of  the  wound,  occupying  about 
one  fourth  of  its  extent,  which  I  did  not  disturb.  The 
iris  prolapsed  through  the  entire  length  of  the  corneal 
portion  of  the  wound,  and  with  the  convex  surface  of 
Daviel's  spoon  I  gently  pushed  it  back  within  the  corneal 
margins.  He  is  a  strong,  muscular  man,  but  very  pale 
and  nervous  from  anxiety,  and  said  that  while  in  a 
stooping  position  gathering  up  the  entrails  of  a  hog,  a 
drunken  companion,  who  was  scraping  down  an  adjoining 
animal  with  a  knife,  recklessly  thrust  the  point  of  the 
instrument  upward  into  his  eye,  with  the  above  result. 

In  consequence  of  the  sudden  and  unexpected  blow 
between  the  involuntary  contractions  of  the  lids,  these 
escaped  entirely  and  the  eyeball  received  the  whole  force 
of  the  blow.  My  first  thought  was  to  close  the  scleral 
portion  of  the  wound  with  a  suture.  My  second  thought 
was  not  to  do  so.  Why  ?  No  one  could  surely  predict 
firm  union  of  the  corneal  margins  in  such  an  extensive 
wound  within  forty-eight  hours.  And  in  a  strong  man 
like  this,  in  such  a  state  of  nervous  depression,  there  fbust 
surely  follow  within  forty-eight  hours,  and  probably 
within  twenty-four  hours,  a  vigorous  reaction,  with  a 
reformation  of  vitreous  and  aqueous  humors,  which,  in 
rapidity  and  force,  would  cause  an  intra- ocular  pressure 
similar  to  that  in  glaucoma  fulminans,  which  a  so  exten- 
sive corneal  incision  in  almost  the  horizontal  diameter, 
where  little  or  no  support  could  be  obtained  from  the 
lids,  and  with  but  a  weak  adhesion,  would  hardly  be  able 
to  resist ;  and  if  the  corneal  adhesion,  which  I  hoped  to 
obtain,  should  give  way,  all  would  be  inevitably  lost. 

I  told  the  patient  that  he  might  be  prepared  for  total 
loss  of  sight  in  that  eye,  and  that  there  was  a  strong  prob- 
ability that  the  wounded  eye  would  have  to  be  removed, 
but  at  the  same  time  I  hoped,  with  care  and  regular  at- 

1  Page  214,  Soelberg  Wells. 


September  22,  1894] 


MEDICAL  RECORD. 


361 


tention  to  be  able  to  save  the  eyeball.  By  leaving  the 
scleral  portion  of  the  wound  open  as  a  safety-valve,  and 
giving  firm  but  comfortable  support  to  the  cornea  with 
compress  and  bandage,  I  hoped  to  prevent  a  reprolapse 
of  iris  and  obtain  primary  union  of  the  corneal  portion  of 
the  wound  and  save  a  globe  which  would  disfigure  but 
little,  if  any,  and  save  him  the  annoyance  and  expense 
of  an  artificial  eye  every  eighteen  months  or  two  years. 
So  I  carefully  and  gently  cleansed  the  eye  with  soft 
cloths  and  lukewarm  water,  put  in  two  drops  of  a  four- 
grain  solution  of  atropine,  and  repeated  this  four  times 
at  intervals  of  about  five  minutes,  and  then  applied  a  firm 
bat  comfortable  compress  and  bandage,  and  sent  him 
home  with  an  injunction  to  send  for  me  if  he  had  any 
pain. 

The  first  layer  of  cotton  in  contact  with  the  eye  was 
saturated  with  glycerine.  About  7  p  m.  he  sent  a  boy 
for  medicine.  I  did  not  send  anything,  but  went  to  his 
rooms  in  a  tenement-house,  where  I  found  him  sitting 
with  a  bright  lamp  directly  in  front  of  him,  with  a  room- 
ful of  people,  who  were  talking  rather  excitedly  from  the 
effects  of  stimulants.  All,  except  his  own  family,  were 
immediately  directed  to  leave  the  room,  and  he  was  in- 
structed to  have  the  lamp  behind  him  and  to  keep  quiet. 
He  said  he  did  not  have  any  pain,  but  only  a  slight  sore 
feeling  and  feared  it  might  get  worse  during  the  night, 
and  therefore  sent  for  medicine  to  have  it  ready  in  case 
of  necessity.  After  he  had  been  quiet  about  half  an 
hour  he  said  he  felt  quite  comfortable,  so  I  gave  him 
nothing  and  did  not  disturb  the  bandage,  and,  after  di- 
rections to  sleep  with  his  head  and  shoulders  well  raised, 
I  left  him. 

February  8th. — Twenty-four  hours  after  his  first  visit 
he  returned  to  my  office,  a  distance  of  nine  blocks,  and 
said  he  had  passed  a  very  comfortable  night,  and  had  not 
had  the  slightest  pain  or  sore  feeling  since  I  left  him. 
After  cautioning  him  to  keep  his  eyes  closed  I  removed 
the  dressing.  The  eyeball  had  filled  out  considerably, 
but  not  quite  equal  in  size  to  the  fellow-eye ;  the  lids  are 
natural,  there  not  being  the  slightest  appearance  of  in- 
flammation at  the  margins.  After  gently  washing  the 
lids  with  a  soft  cloth  and  lukewarm  water,  and  slightly 
pulling  down  the  inner  corner  of  lower  lid  and  dropping 
a  four  grain  solution  of  atropine  four  times,  about  five 
minutes  apart,  into  the  eye,  I  reapplied  compress  and 
bandage  as  before. 

February  9th. — Returned  and  says  he  has  not  had  any 
pain,  and  rested  quite  comfortably  the  night  before; 
dressing  removed ;  the  eyeball  has  filled  out  equal  to  its 
fellow,  and  the  lids  appear  quite  natural.  Eye  gently 
washed ;  atropine,  compress  and  bandage  as  before. 

February  10th. — Has  had  no  pain,  though  the  eye  is 
now  fuller  and  more  prominent  than  its  fellow,  and 
margin  of  the  upper  lid  is  slightly  red  and  swollen. 
After  directing  him  to  make  no  effort  to  open  his  eyes, 
I  gently  and  slightly  raised  the  upper  lid  and  was  much 
gratified  to  find  thorough  primary  corneal  union  all 
along  the  line.  The  vitreous  which  had  lodged  in  the 
scleral  wound  has  entirely  disappeared;  treatment  the 
same. 

February  nth. — The  upper  lid  is  more  swollen  than 
yesterday,  but  he  says  he  has  not  had  the  slightest  pain ; 
treatment  the  same. 

February  1  ath. — The  swelling  of  lids  is  more  extensive 
than  yesterday,  and  they  bulge  forward  considerably,  are 
red  and  glazed  and  have  all  the  appearances  of  a  severe 
panophthalmitis  in  full  bloom,  except  the  pain,  which 
is  entirely  absent;  treatment  the  same.  For  the  last 
two  days  the  cotton  compress  has  been  quite  wet  with 
water,  but  only  a  trace  of  muco-pus. 

February  13th. — Has  had  no  pain.  Appearances  the 
same  as  yesterday ;  treatment  same. 

February  14th.  —  Has  had  no  pain.  Appearances 
about  the  same  as  yesterday,  except  that  the  lids  do  not 
appear  quite  so  tense,  and  there  is  a  little  more  pus  to  be 
seen  when  the  margins  of  the  lids  are  separated ;  treat- 
ment the  same.     Without  recording  the  monotonous 


daily  details,  from  this  time  on  there  was  a  gradual  sub- 
sidence of  the  inflammatory  action,  without  any  pain 
and  without  the  slightest  change  in  treatment.  It  was  a 
noticeable  feature  of  this  case  throughout  the  treatment 
that  there  was  less  suppuration  than  I  had  ever  before 
seen  in  an  inflammation  of  such  a  violent  degree. 
Nothing  occurred  worthy  of  special  note  until  February 
28,  1886,  when,  the  eye  having  much  improved,  the 
swelling  and  redness  of  the  lids  having  entirely  disap- 
peared, but  there  being  still  a  slight  degree  of  conjuncti- 
vitis, with  marked  injection  of  the  superficial  and  deep 
ciliary  vessels  extending  all  around  the  cornea,  but  most 
marked  near  the  seat  of  the  scleral  wound,  he  attended 
church,  which  had  not  been  warmed,  at  7  a.m.,  while 
the  thermometer,  as  reported  by  morning  papers,  was  at 
ten  degrees  above  zero.  While  at  his  devotions  he  felt 
a  chill  run  through  his  body,  and  his  eye  felt  as  though 
something  was  in  it ;  he  said  he  thought  a  portion  of  the 
cotton  compress  had  gotten  into  the  eye.  I  removed 
the  dressing,  but  there  was  nothing  in  the  eye,  and  the 
symptom  he  described  was  caused  by  increase  of  con- 
junctivitis brought  on  by  cold  while  at  church.  I  then 
directed  him  to  remain  in  his  room  until  the  weather 
became  warmer,  and  there  I  gave  him  the  same  daily 
attention  without  the  slightest  change  in  treatment. 
This  increase  of  conjunctivitis,  with  its  accompanying 
symptom,  as  though  something  was  in  the  eye,  was  re- 
lieved in  forty- eight  hours;  but  I  confined  him  to  his 
rooms  and  continued  the  same  daily  treatment  for  one 
week  until  the  cold  wave  had  passed  and  the  weather 
had  become  milder. 

March  15th. — He  can  distinguish  a  white  shirt  bosom, 
a  white  hat  with  a  black  band  around  it,  and  my  hand 
at  about  three  feet,  but  he  cannot  count  fingers  at  any 
distance.  As  he  had  to  return  to  work  and  would  be 
daily  exposed  to  a  varied  atmosphere,  and  also  dust,  and 
as  the  injection  of  the  deep  and  superficial  ciliary  vessels 
continued,  I  thought  it  safer  to  continue  the  treatment 
at  intervals  of  every  second  day  until  May  10,  1886, 
when  the  bandage  was  removed  and  the  eye  protected 
with  a  light  pad  of  cotton,  over  which  was  placed  a 
paste- board  covered  with  black  silk. 

The  small  margin  of  the  scleral  wound,  of  one-six- 
teenth of  an  inch  beyond  the  ciliary  zone,  healed  much 
more  quickly  and  kindly  than  that  part  running  directly 
through  the  ciliary  zone,  which  healed  very  slowly  and 
was  long  marked  by  the  injection  of  the  superficial  and 
deep  ciliary  vessels.  The  paste-board  with  dark  silk  ard 
slight  pad  of  cotton  was,  in  consequence  of  his  occupa- 
tion and  frequent  exposure  to  variable  temperature,  con- 
tinued until  June  26,  1886,  when  all  appearance  of  in- 
flammation and  irritation  about  the  eye  had  entirely 
disappeared,  and  the  ciliary  vessel*',  both  shallow  and  deep, 
had  regained  their  normal  condition,  and  there  were 
neither  perceptible  bulging  nor  depression  of  the  sclera, 
one  of  which  is  almost  the  invariable  result  of  wounds  ex- 
tending through  the  ciliary  zone.  The  scleral  portion  of 
the  scar,  which  can  be  easily  seen,  measures  six  thirty- 
seconds  of  an  inch  from  the  limbus  conjunctiva  lis.  The 
direction  of  the  line  of  the  incision  iuns  from  a  point  on 
the  nasal  side  of  the  sclera  six  thirty-seconds  of  an  inch 
from  the  limbus,  and  about  five  degrees  below  the  hori- 
zontal diameter,  and  extends  to  a  point  on  the  cornea 
one-eighth  of  an  inch  from  the  temporal  limbus  cor  juncti- 
valis  and  about  five  degrees  above  the  horizontal  diameter. 
There  is  anterior  synechia  to  both  lips  of  corneal  incision 
throughout  its  entire  length,  except  a  small  portion  at 
the  lower  margin  of  the  pupil  about  the  size  of  the  head 
of  a  small  pin,  which  is  perceptible  when  under  the  influ- 
ence of  atropine.  The  globe  appears  of  full  size  and 
good  shape,  but  the  cornea  is  flattened. 

During  a  large  dispensary  and  hospital  service  extend- 
ing over  a  period  of  more  than  fifteen  years  I  have  seen 
a  great  variety  of  ir  juries  and  deformities  of  the  cornea, 
but  have  never  before  seen  a  case  like  this  resulting  from 
a  wound,  the  cornea  markedly  flattened,  yet  apparently 
equal  in  ail  of  its  diameters  to  that  of  the  unir  jured  eye. 


362 


MEDICAL  RECORD. 


[September  22,  1894 


Neither  can  I  remember  of  ever  having  read  of  such  a  case. 
[Flattening  of  the  cornea  without  any  diminution  of  its 
diameters  may,  and  often  does,  exist  as  the  result  of  old 
age,  and  may  be  caused  by  glaucoma  as  the  result  of 
long  and  marked  increase  of  the  intra  ocular  pressure, 
which,  while  it  causes  the  globe  to  approach  the  spherical 
shape,  stretches  the  ciliary  nerves  which  run  between  the 
sclerotic  and  choroid,  and  paralyzes  them  to  a  greater  or 
less  degree.] 

The  flattening  of  the  cornea  in  this  case  is  due  to  one, 
or  both,  of  two  causes :  1st.  The  oblique  course  of  the 
knife  through  the  ciliary  region  not  only  divided  the 
ciliary  muscle  and  ligament,  but  also  some  of  the  ciliary 
nerves,  causing  paralysis  of  the  former.  [Although  the 
system  of  ciliary  nerves  are  mainly  derived  from  one  (the 
ophthalmic)  of  the  sensory  branches  of  the  fifth  pair,  it 
receives  motor  power,  through  the  medium  of  the  ciliary 
ganglion,  by  a  branch  derived  from  the  third  nerve.]  2d. 
The  extensive  anterior  synechia  along  both  lips  of  the 
corneal  incision  very  probably  exerts  some  influence  in 
producing  this  flattened  condition  of  the  cornea.  There 
is  a  slight  depression  without  any  discoloration  along  the 
line  of  the  scleral  portion  of  the  scar.  This  reminds  me 
of  a  ditch  which  has  been  filled  up  almost  to  the  surface 
with  the  surface  portion  of  the  soil  through  which  it  had 
been  dug  in  consequence  of  the  long  neglect  of  a  lazy 
farmer. 

What  does  it  indicate  ?  That  union  by  retina,  con- 
nective tissue,  and  conjunctiva  has  taken  place ;  there 
being  no  direct  adhesion  of  the  edges  of  the  sclera.  Of 
what  importance  is  that  ?  Remember  the  last  question, 
for  under  the  head  of  Suggestions  this  very  shallow  ditch 
will  be  again  alluded  to  and  its  importance  will  there  be 
pointed  out. 

November  6,  1886. — He  can  distinguish  my  hand 
from  one  to  three  feet,  but  he  cannot  see  fingers  at  any 
distance.  The  image  of  the  hand,  or  other  objects,  is, 
after  a  few  seconds,  lost.  It  may  be  asked,  Why  not  per- 
form an  iridectomy  and  give  this  man  a  larger  pupil  and 
more  light  in  that  eye  ?  At  first  this  may  seem  very 
plausible,  but  very  probably  there  is  detachment  of  the 
retina  to  a  considerable  extent  (and  it  would  be  miracu- 
lous if  there  were  not  some  degree  of  detachment  of  the 
retina  after  such  a  sudden  evacuation  of  almost,  if  not 
quite,  the  entire  contents  of  the  vitreous  chamber),  and 
an  iridectomy,  at  best,  could  give  very  slight,  if  any,  im- 
provement where  there  is  detachment  of  the  retina; 
while  the  risk  of  starting  an  irido-choroiditis  by  doing 
an  iridectomy  where  there  is  such  an  extensive  anterior 
synechia,  and  very  probably  degeneration  of  the  iris,  which 
might  not  only  destroy  the  faint  vision  he  now  has  but 
also  cause  atrophy  of  the  globe,  is  considerable.  There- 
fore, for  the  best  interest  of  the  patient  I  deem  it  wiser  to 
let  well  enough  alone. 

Dr.  J.  F.  Gray  saw  this  patient  with  me  during  and  at 
the  termination  of  the  treatment,  June  16,  1888.  It  is 
now  over  two  years  and  four  months  since  the  accident 
occurred,  and  there  is  not  the  slightest  symptom  of  irri- 
tation in  either  eye.  The  tension  is  normal,  being  the 
same  as  that  of  the  fellow  eye.  The  horizontal  diameter 
of  the  right,  or  injured  cornea,  from  limbus  to  limbus  is 
-fourteen  thirty-seconds  of  an  inch,  while  the  correspond- 
ing diameter  of  the  left  cornea  is  fifteen  thirty- seconds  of 
an  inch.  The  vertical  diameter  of  the  left  cornea  from 
limbus  to  limbus  is  fourteen  thirty-seconds  of  an  inch,  and 
the  vertical  diameter  of  the  right  or  injured  cornea  is 
also  fourteen  thirty- seconds  of  an  inch.  Measurement  of 
palpebral  fissures  directly  over  the  centres  of  pupils, 
while  patient  is  looking  straight  forward,  shows  the  fol- 
lowing results :  When  the  measure  approaches  the  left 
eye,  as  near  as  possible  without  contact,  he  can,  after  a 
few  trials,  control  the  involuntary  contractions  of  the 
lids,  and  then,  while  looking  straightforward,  the  fissure 
over  the  centre  of  the  pupil  is  fourteen  thirty-seconds  of 
an  inch ;  but  after  several  trials,  as  with  the  left,  the  lids 
of  the  right,  or  injured  eye,  in  spite  of  strong  efforts  to 
control  them,  will  contract  as  the  measure  approaches, 


and  during  this  contraction  the  palpebral  fissure  of  the 
right,  or  injured  eye,  is  eleven  thirty-seconds  of  an 
inch — three  thirty- seconds  of  an  inch  less  than  that 
of  the  good  eye.  But  when  I  wave  my  finger  up  and 
down  several  times  commanding  him  to  follow  the 
finger  with  his  eyes  and  look  at  nothing  else,  and  then 
suddenly  bring  my  finger  to  a  rest  on  my  right  eyebrow, 
I  can  then  approach  his  injured  eye  with  the  measure 
without  any  apparent  contraction  of  the  lids,  and 
then  the  palpebral  fissure  of  that  eye  is  twelve  thirty- 
seconds  of  an  inch  over  the  centre  of  the  pupil — or  only 
two  thirty  seconds  of  an  inch  less  than  that  of  the  good 
eye.  This  temporary  exercise  of  the  eyes  and  mental 
diversion  removed  that  nervousness  shown  a  few  moments 
before  in  the  injured  eye,  and  which  had  caused  the  con- 
traction of  the  lids  as  the  measure  approached  them,  in 
spite  of  his  efforts  to  control  them.  I  remarked  that  the 
lids  of  the  injured  eye  were  not  much  nearer  to  each 
other  than  those  of  the  good  eye,  to  which  his  wife  re- 
plied, "  Oh !  I  didn't  think  anything  of  that,  for  I  have 
always  noticed  that  the  lids  of  the  right  eye  were  a  little 
contracted ;  "  and  the  patient  said,  "  That  is  so,  the  lids 
of  the  wounded  eye  have  been  contracted  almost  as  long 
as  I  can  remember."  According  to  these  statements  the 
result  is  better  than  I  at  first  supposed.  He  has  per- 
ception of  shadows  at  two  feet.  There  is  a  white  film 
occupying  the  space  of  the  small  pupil. 

October  25, 1890. — It  is  now  over  four  years  and  eight 
months  since  the  accident  occurred,  and  the  eye  remains 
in  the  same  condition  as  noted  June  16,  1888. 

November  26, 1893. — It  is  now  seven  years  and  nine 
months  since  the  accident  occurred,  and  his  wife  says, 
when  he  remains  sober  his  eye  looks  as  well  as  it  did 
June  16,  1888. 

In  this  case  no  antiseptic,  except  cotton  saturated  with 
glycerine  as  an  external  dressing,  was  used.  Several 
years  ago  I  obtained  primary  union  in  cases  not  favored 
with  good  hygienic  surroundings  where  the  flesh  had  not 
only  been  torn,  but  dragged  from  its  attachment  by  ma- 
chinery and  the  glancing  force  of  some  instrument,  by 
gently  cleansing  and  carefully  adjusting  the  related  parts 
and  dressing  the  wound  with  cotton  saturated  with  glyc- 
erine and  the  patient's  blood. 

Under  what  more  unpropitious  circumstances  can  it  be 
imagined  that  an  eye  will  ever  be  operated  on  than  ex- 
isted in  the  above  case,  which  was  cut  in  the  roughest  man- 
ner possible,  with  a  coarse  and  filthy  knife,  and  almost 
directly  through  the  horizontal  diameter  of  the  cornea, 
where  the  least  support  could  be  obtained  from  the  lids, 
dividing  it  into  two  equal  parts ;  and  in  the  foul,  moist, 
and  comparatively  warm  atmosphere  of  a  slaughter-house 
for  hogs,  reputed  the  most  filthy  of  all  animals,  whence  he 
had  to  go  over  half  a  mile — twelve  and  a  half  blocks — 
before  his  eye  was  cleansed  and  dressed. 

There  was  no  suppuration  within  the  eye  nor  in  the 
margins  of  the  wound.  The  conjunctiva  was  the  only 
tissue  from  which  pus  could  be  seen  to  issue,  and  it  was 
markedly  less  than  I  had  ever  before  seen  in  a  case  of  so 
violent  reaction,  and  this  yielded  in  due  time  to  atro- 
pine and  unadorned  cleanliness.  And  he  did  not  have 
pain  enough  throughout  the  whole  time  of  treatment  to 
deprive  him  of  one  moment's  sleep.  The  mouth  of  the 
scleral  wound  was  daily  exposed  to  pus  from  the  con- 
junctiva for  about  two  weeks,  but  this  gave  me  no  anxiety 
after  I  saw  firm  corneal  union  had  taken  place,  because 
a  full  and  boiling- over  capsule  effectually  prevented  the 
entrance  and  accumulation  of  any  foreign  liquid. 

The  earnest  attention  of  the  ophthalmic  surgeon  is  re- 
quested to  the  last  sentence  above,  for  in  the  class  of 
cases  to  which  I  believe  much  good  may  be  done  by  the 
timely  use  of  the  operation  which  will  be  described  fur- 
ther on,  there  will  always  be  some  degree  of  conjunctival 
suppuration,  and  however  much,  he  may  be  impressed 
with  its  utility  in  relieving  intra-ocular  tension,  and  in 
promoting  free  circulation  through  the  eye,  and  thereby 
preserving  its  nutrition,  he  may  still  be  deterred  from 
giving  his  patient  the  benefit  of  it  for  fear  that  the  con- 


September  22,  1894] 


MEDICAL   RECORD. 


363 


junctival  pus  might  enter  the  scleral  incision  and  accu- 
mulate within  the  eye,  and  more  than  counteract  all  the 
benefit  that  might  otherwise  be  derived  from  the  opera- 
tion. My  chief  anxiety,  therefore,  in  this  case,  was  that 
the  scleral  opening  might  unite  before  the  inflammatory 
reaction  could  be  checked,  or  had  spent  its  force,  and  in 
consequence  of  its  speedy  union  the  circulation  through 
the  globe  might  become  obstructed,  and  its  nutrition,  as 
well  as  that  of  the  cornea,  become  impaired,  and  thereby 
defeat  the  purpose  for  which  I  had  intentionally  left  the 
scleral  portion  of  the  incision  open. 

The  favorable  features  of  this  case  may  be  fairly  attrib- 
uted to  simple  cleanliness,  firm  and  comfortable  support 
to  the  cornea,  atropine,  and  more  than  all  else,  to  the 
continued  relief  of  intra-ocular  pressure  until  the  inflam- 
matory reaction  had  spent  its  force.  The  intra-ocular 
pressure  was  kept  continually  relieved  by  keeping  the 
scleral  portion  of  the  wound  continually  open  as  a  safety- 
valve,  free  circulation  through  the  globe  being  thereby 
permitted,  and  its  nutrition,  as  well  as  that  of  the  cornea, 
preserved,  and  suppuration  within  the  eye  prevented,  and 
lessened  to  a  considerable  degree  from  the  conjunctiva. 
It  may  be  supposed  that  these  happy  results  were  due  to 
the  age  and  vigor  of  the  patient  and  to  an  unusual  vital- 
ity of  the  tissues  of  his  eye.  But  to  such  an  hypothesis  I 
would  reply  that  the  best  results  I  have  had  after  opera- 
tions for  cataract,  or  seen  in  the  practice  of  others,  have 
been  in  elderly  and  moderately  emaciated  people  who 
did  not  seem  to  have  vigor  and  vitality  enough  to  get  up 
a  forceful  reaction;  while  the  worst  results  that  I  have 
witnessed  have  been  in  stout  and  vigorous- looking  people. 
It  should,  however,  be  borne  in  mind  that  an  opposite 
extreme  may  exist  where  the  vitality  is  so  low  and  the 
reparative  lymph  so  deteriorated  that  union  of  the  cor- 
neal incision  after  extraction  may  not  take  place,  and 
then  may  follow  sloughing  of  the  cornea,  panophthalmitis, 
and  atrophy  of  the  globe,  in  spite  of  all  that  can  be  done. 

For  many  years  I  have  watched  with  much  interest  the 
results  of  cataract  extraction,  in  the  practice  of  others  as 
well  as  my  own,  and  have  seen  in  several  cases,  after  the 
most  skilful  extraction  by  different  operators  and  the 
most  careful  after-treatment,  the  eyelids  become  swollen, 
red,  and  glazed,  with  much  pain  in  the  globe  and  radiat- 
ing along  the  course  of  the  supra-trochlear,  infra-troch- 
lear,  nasal,  and  temporo-malar  nerves ;  and  in  spite  of  the 
careful  use  of  all  known  remedies  the  patient  would  pass 
sleepless  nights  and  wearisome  days,  and  the  sight,  which 
was  obtained  immediately  after  the  operation,  and  which 
so  cheered  the  despondent  mind,  gradually,  and  some- 
times rapidly,  become  dimmed  until  no  object  could  be 
distinguished,  and  his  hopes  sink  away  never  to  return. 
I  do  not  know  anything,  except  the  dying,  which  has 
caused  me  more  melancholy  feelings  than  the  watching 
of  these  unfortunate  cases. 

Some  years  ago  it  occurred  to  me  that  something  be- 
yond the  routine  treatment— some  secondary  operation 
which  would  relieve  tension,  and  keep  it  relieved  until 
the  inflammatory  reaction  had  been  checked,  or  had 
spent  its  force — should  be  tried  early  in  these  violent 
cases;  but  operative  procedures,  except  paracentesis  of 
the  cornea,  in  the  acute  stages  of  such  cases,  have  been 
objected  to  by  some  of  the  most  eminent  ophthalmic  sur- 
geons, and  countenanced  by  none  that  I  am  aware  of, 
on  the  ground  of  increased  irritation  which  would  inevi- 
tably follow.  This  objection  is  perfectly  valid  and  well 
taken  so  far  as  the  old  and  long  used  method  of  relieving 
tension — by  paracentesis  of  the  cornea — is  concerned. 

For,  although  by  the  use  of  cocaine  complete  anaes- 
thesia of  the  conjunctiva  and  cornea  may  be  obtained, 
and  the  former  rendered  insensible  to  the  grasp  of  the 
forceps,  and  the  latter  to  the  cut  of  the  knife,  the  iris 
is  bat  little,  if  at  all,  affected  by  it;  and  although  an 
expert  surgeon  may  avoid  tearing  or  pricking  the  iris 
he  cannot  prevent  it  bulging  forward  when  the  aque- 
ous escapes.  And  this  slight  displacement,  and  possibly 
rubbing  against  the  knife  of  so  sensitive  a  tissue  as  the 
inflamed   iris,  must  cause  some   degree  of  irritation. 


However,  if  the  relief  of  tension  temporarily  obtained 
by  paracentesis  of  the  cornea  could  be  safely  made  con- 
tinuous at  the  surgeon's  will,  without  the  necessity  of 
repetition,  it  might  in  a  great  measure  compensate  for 
the  irritation  produced  by  it.  But,  unfortunately, 
there  is  no  way  at  present  known  by  which  that  desirable 
result  can  be  safely  accomplished.  The  corneal  incision 
will  primarily  unite  within  twenty-four  or  forty- eight 
hours ;  the  inflammatory  process  of  the  iris  and  choroid 
is  not  checked ;  the  aqueous  and  vitreous  humors,  which 
are  incompressible  substances,  rapidly  reform ;  the  cap- 
sule, if  possible,  is  still  further  distended  until  it  has  per- 
haps lost  all  of  its  resiliency,  and  this  factor  in  the  pro- 
motion of  the  intra-ocular  circulation  is  lost;  the 
circulation  becomes  obstructed  and  consequently  the  nu- 
trition becomes  impaired,  and  then  follows  the  formation 
of  pus  within  the  eye.  Leeches,  ice-cloths,  warm  douches, 
and  other  remedies,  have  for  many  years  been  used  to  check 
this  inflammation,  and  when  it  is  of  a  mild  nature  and  of 
but  moderate  force  are  sufficient  to  subdue  it.  But  I 
have  seen  several  cases  under  the  care  of  different  sur- 
geons which,  after  the  timely  and  assiduous  application 
of  the  usual  remedies,  were  but  slightly,  if  at  all,  relieved 
by  them ;  the  inflammation  continued  until  suppuration 
within  the  eye  occurred ;  the  sight  became  greatly  im- 
paired; nay,  totally  lost  To  meet  and  prevent  such 
emergencies  I  would  suggest  sclerotomy  before  any  de- 
struction of  tissue  had  taken  place,  if  possible.  It  is  not 
here  claimed  that  sclerotomy  is  a  new  operation,  for,  on 
the  contrary,  it  is  quite  ancient ;  but  the  method,  pur- 
pose, and  regard  for  neighboring  parts,  as  will  be  further 
on  described,  I  have  never  seen  nor  even  heard  sug- 
gested. 

Under  the  head  of  "  Treatment  of  Glaucoma,1'  Stellwag 
says :  "The  paracentesis  of  the  sclera,  moreover,  in  con- 
nection with  the  emptying  of  a  portion  of  the  vitreous,  has 
been  recommended  for  a  long  time  as  a  means  of  lessen- 
ing the  hardness  of  the  globe  (Mackenzie).  Since,  how- 
ever, the  technical  performance  of  the  operation  was  not 
adapted  to  produce  a  permanent  relaxation  of  the  scle- 
rotic, it  could  only  obtain  transient,  and  therefore  un- 
satisfactory results."  Its  union  with  the  iridenkleisis 
(Critchett,  Coccius)  has  theoretically  very  much  to  be  said 
for  itself,  but  is  to  be  avoided  on  account  of  favoring 
cystoid  cicatrices,  and  subsequent  threatening  irritation. 
The  proposal  to  draw  out  the  iris  very  much  in  iridec- 
tomy, in  order  to  rupture  the  zonula,  and  thus  to  establish 
a  connection  between  the  vitreous  and  aqueous  humors 
(Coccius),  should  find  few  friends,  in  consideration  of  the 
dangers  which  can  accrue  to  the  nutrition  of  the  lens, 
and  even  of  the  entire  globe,  from  a  partial  rupture  of  the 
ciliary  body."  * 

From  the  above  it  may  be  seen  that,  in  addition  to 
the  fact  that  the  operator  "  could  only  obtain  transient, 
and  therefore  unsatisfactory  results  "  for  one  purpose  for 
which  the  paracentesis  of  the  sclera  had  been  employed, 
there  was  also  another  important  cause  why  the  operation 
had  been  followed  by  not  only  unsatisfactory  results,  but 
also  even  worse,  by  its  "  favoring  cystoid  cicatrices  and 
subsequent  threatening  irritation,"  and  "  in  considera- 
tion of  the  dangers  which  can  accrue  to  the  nutrition  of 
the  lens,  and  even  of  the  entire  globe,  from  a  partial 
rupture  of  the  ciliary  body,"  viz.,  that  the  paracentesis 
of  the  sclera  had  been  done  through  the  ciliary  zone. 

Suggestion  1— Method  of  Operating.— The  patient 
having  been  placed  on  his  back  and  anaesthetized,  the 
surgeon,  with  fixation-forceps,  grasps  a  fold  of  conjunctiva 
near  the  cornea,  midway  between  the  external  and  infe- 
rior recti  muscles,  and  gently  turns  the  eye  downward 
and  slightly  outward.  An  assistant  raises  the  upper  lid 
with  his  finger.  A  thin  Graefe  knife,  well  sharpened 
and  thoroughly  cleansed,  and  with  its  cutting  edge  di- 
rected toward  the  posterior  extremity  of  the  eye,  and  its 
sides  parallel  with  the  longitudinal  axis  of  the  globe, 
so  as  to  guard  as  much  as  possible  against  cutting  any 
of  the  ciliary  nerves,  is  inserted  in  the  point  midway 
1  Stellwag-:  Fourth  edition,  p.  318. 


364 


MEDICAL  RECORD. 


[September  22,  1894 


between  the  superior  and  internal  recti  muscles  and  five 
thirty  seconds  of  an  inch  from  the  limbus  conjunctival, 
and  passed  directly  through  all  the  coats  to  the  vitreous, 
the  blade  being  pushed  inward  only  far  enough  for  its 
point  to  pass  through  the  retina,  lest  damage  be  done  to 
the  vitreous,  when  the  incision  is  extended  backward  six 
thirty- seconds  of  an  inch.  The  length  of  the  scar  in  the 
above  case  from  the  limbus  conjunctival  backward  on 
the  sclera  is  six  thirty-seconds  of  an  inch,  and  the  poste- 
rior two  thirty  seconds  of  an  inch  of  the  incision  healed 
very  much  more  rapidly  and  kindly  than  the  anterior 
four  thirty-seconds  of  an  inch  of  the  scleral  portion  of 
the  wound  did ;  and  this  fact  indicates  that  in  the  hori- 
zontal diameter  four  thirty  seconds  of  an  inch  from  the 
limbus  backward  cover  all  those  sublime  structures  lying 
within  the  Ciliary  zone,  the  wounding  of  which  by  acci- 
dent or  design  has  always  disappointed  the  hopes  of  the 
surgeon  and  terminated  so  disastrously  to  the  patient. 

Argument. — Gray  says:  "The  larger  processes  are 
each  about  one-tenth  of  an  inch  in  length  and  hemi- 
spherical in  shape,  their  periphery  being  attached  to  the 
ciliary  ligament  and  continuous  with  the  layers  of  the 
choroid ;  the  opposite  margin  is  free  and  rests  upon 
the  circumference  of  the  lens.  .  .  .  The  ciliary 
muscle  .  .  .  forms  a  .  .  .  circular  band,  about 
one-eighth  of  an  inch  broad,  on  the  outer  surface  of  the 
fore  put  of  the  choroid.  It  consists  of  two  sets  of  fibres, 
radiating  and  circular.  The  former  .  .  .  arise  at 
the  point  of  junction  of  the  cornea  and  sclerotic,  and, 
passing  backward,  are  attached  to  the  choroid  opposite 
to  the  ciliary  processes.  The  circular  fibres  are  internal 
to  the  radiating,  .  .  .  and  have  a  circular  course 
around  the  insertion  of  the  iris."  l  Of  the  sclerotic, 
Gray  says:  "In  front  the  sclerotic  is  continuous  with 
the  cornea  by  direct  continuity  of  tissue,  but  the  opaque 
sclerotic  overlaps  the  cornea  rather  more  on  its  outer 
than  on  its  inner  surface. "  Of  the  cornea,  Gray  says : 
"  It  is  not  quite  circular,  being  a  little  broader  in  the 
transverse  than  in  the  vertical  direction,  in  consequence 
of  the  sclerotic  overlapping  the  margin  above  and  be- 
low." 2 

^  From  this  eminent  authority  it  will  be  seen  that  one* 
eighth  of  an  inch  from  the  corneo -sclerotic  junction  ex- 
tending backward  covers  those  very  important  parts  ly- 
ing within  the  ciliary  zone ;  and  from  the  last  quotation 
that  the  cornea  is  "  a  little  broader  in  the  transverse 
than  in  the  vertical  direction,  in  consequence  of  the 
sclerotic  overlapping  its  margin  above  and  below. " 
Gray  says  the  eyeball  in  its  antero  posterior  diameter  is 
"about  nine-tenths  of  an  inch,"   which,  reduced,  is 

28* 
equal  to- -  -  of  an  inch.    The  average  height  of  the 

normal  cornea  from  limbus  to  apex,  measured  in  the 
horizontal  diameter,  from  thirty  to  forty  years  of  age,  is, 

2A 
so  far  as  I  have  examined,  about  —  of  an  inch ;  while  at 

3- 
about  sixty  years  of  age  it  is  about  A  of  an  inch.  In  the 
following  estimate  I  will  calculate  from  the  greater  height 
because  the  shortening  of  the  eyeball  in  old  age  is  due,  so 
far  as  is  at  present  known,  solely  to  the  flattening  of  the 
cornea. 

Therefore  — J  _  — ?  =  |j  of  an  inch,  which  represents 

the  average  length  of  the  eyeball  of  the  adult  from  the 
corneo  scleral  junction  to  its  posterior  end.  Now  from 
||  take  fa  of  an  inch  in  the  location  proposed  for  this 
operation,  and  there  will  remain  $£  of  an  inch;  at  the 
point  of  five  thirty-seconds  of  an  inch  from  the  limbus 
backward,  the  scleral  incision  begins  and  extends  back- 
ward six  thirty-seconds  of  an  inch  and  then  there  will  re- 
main fifteen  thirty  seconds  of  an  inch  of  the  posterior 
part  of  the  eyeball,  or  more  than  half  of  the  twenty-six 
thirty  seconds  of  an  inch,  which  represents  the  average 
length  of  the  eyeball  from  the  corneoscleral  junction 
to  its  posterior  extremity;   and  therefore  the  posterior 


1  Gray :  Eleventh  edition,  pp.  810-812. 


■  Ibid.,  pp.  806,  807. 


extremity  of  the  incision  will  be  above  the  equatorial  di- 
ameter of  the  vitreous  chamber  when  the  patient  is  on 
his  back.  Under  no  circumstances  should  the  knife  be 
passed  into  the  vitreous  chamber  at  a  point  less  than  five 
thirty-seconds  of  an  inch  from  the  limbus  conjunctival, 
except  for  the  removal  of  a  foreign  body. 

The  incision  made  as  above  described,  will  not  muti- 
late the  iris,  ciliary  muscle,  ligament,  processes,  or  zon- 
ula, all  of  which  should  be  carefully  avoided. 

In  the  location  above  described  the  incision,  when 
the  patient  is  lying  on  his  back,  is  above  the  equatorial 
diameter  of  the  vitreous  chamber ;  and  when  lying  on  the 
side  of  the  operated  eye,  as,  when  not  otherwise  directed 
patients  instinctively  and  almost  invariably  do,  the  in- 
cision will  be  above  the  vertical  diameter ;  and  when  in 
the  erect  position  it  will  be  above  the  horizontal  diame- 
ter. In  either  of  these  positions  which  the  patient  is 
most  likely  to  assume,  and  to  which  by  special  instruc- 
tions he  should  be  confined  during  treatment,  the  open- 
ing is  always  above  the  corresponding  diameter  of  the 
vitreous  chamber,  and  excessive  leakage  cannot  occur 
even  should  the  vitreous  have  degenerated  to  a  liquid 
condition.  While  at  the  same  time  the  open  incision 
permits  sufficient  leakage  of  the  constantly  forming  se- 
rous vitreous,  caused  by  the  inflammation,  to  prevent  in- 
crease of  intra-ocular  pressure,  and  thereby  not  only  pre* 
serves  the  resiliency  of  the  capsule,  but  also  permits  free 
circulation  through  the  globe  and  preserves  its  nutrition 
as  well  as  that  of  the  cornea  until  the  inflammatory  ac- 
tion is  checked,  or  has  spent  its  force.  The  scleral  mar- 
gins will  not  unite  directly,  and  when  treated  by  com* 
press  and  bandage,  as  further  on  directed,  the  opening 
through  all  the  coats  will  remain  slightly  ajar,  and  pre- 
vent its  closing  too  soon  by  retina,  connective  tissue, 
and  conjunctiva.  Should  this  open  suggestion  excite  the 
amazement  of  the  reader  he  may  restrain  his  astonishment 
and  bear  in  mind  that  the  location  designated  for  the 
incision  is,  from  its  complete  covering  by  the  upper  lid 
under  ordinary  circumstances,  but  more  especially  when 
the  eye  is  turned  upward,  as  patients  involuntarily  do 
when  there  is  much  inflammation,  almost  if  not  quite  as 
secure  from  the  atmosphere  as  though  it  were  a  subcuta- 
neous tenotomy.  As  soon  as  the  incision  is  completed, 
carefully  remove  forceps  without  making  any  pressure  on 
the  globe,  drop  in  atropine  on  inside  of  lower  lid, 
cleanse  and  close  the  lids,  and  apply  a  clean  soft  cloth 
saturated  with  vaseline  or  pure  glycerine,  and  carefully 
apply  compress  of  clean  cotton  by  filling  up  the  inequal- 
ities about  the  orbit  until  the  cotton  is  well  raised  above 
the]  supraorbital  ridge,  and  over  this  apply  firmly,  but 
comfortably,  a  flannel  bandage  one  and  a  half  inch  wide 
and  four  yards  long,  carrying  a  layer  of  bandage  over 
the  operated  eye  four  times,  and  pin  it  carefully  that  it 
will  not  slip.  When  compress  and  bandage  are  care- 
fully applied,  they  are  comfortable  and  almost  as  firm  as 
a  plaster-of -Paris  dressing,  and  will  remain  so  for  twenty- 
four  hours,  when  they  should  be  removed,  the  eye  genu 
ly  bathed  with  soft  cloth  and  lukewarm  water,  and  fresh 
dressings  applied.  The  patient  should  be  directed  to  lie 
with  head  and  shoulders  elevated  at  an  angle  of  thirty  or 
forty  degrees. 

The  advantages  claimed  for  this  operation,  when  per- 
formed within  the  prescribed  limits,  purposes,  and  after- 
treatment,  are :  1.  Quick  relief  of  pain.  2.  Instead  of  in- 
creasing irritation  it  will  relieve  that  which  already 
exists.  3.  It  will  relax  tension  and  permit  free  circula- 
tion through  the  globe.  4.  It  will  preserve  the  nutrition 
of  the  globe  and  cornea  more  than  any  other  remedy  at 
present  known. 

From  the  history  and  result  of  this  case  I  believe 
three  valuable  lessons  may  be  learned. 

1.  That  in  extensive  incised  wounds  of  the  eyeball,  even 
when  the  sclerotic  is  involved,  and  when  a  "  large  por- 
tion of  the  contents  of  the  globe  has  escaped  and  there 
is  no  hope  of  restoring  any  sight,"  even  "  among  the 
poorer  classes,"  the  surgeon  should  not  at  once  jump  to 
the  conclusion  that  the  destructive  operation  of  enuclea- 


September  22,  1894] 


MEDICAL    RECORD. 


365 


tion  of  the  eyeball  is  inevitable,  but  he  should  by  meas- 
ures, not  necessarily  drugs,  reasonably  adapted  to  the 
circumstances  of  the  case,  endeavor  to  at  least  preserve 
the  globe.  When  the  globe  is  preserved  without  any  ir- 
ritation, although  the  sight  may  be  lost,  it  is  far  more 
comfortable  and  economical  for  the  poor  man  than  an 
artificial  eye,  which  has  to  be  removed,  cleansed,  and  re- 
inserted every  night  and  morning,  and  renewed  every 
eighteen  months  or  two  years ;  to  say  nothing  of  the  ir- 
ritation often  caused  by  an  improperly  fitted  artificial 
eye  and  consequent  atrophy  of  conjunctiva.  Unless 
there  be  ciliary  irritation  long  after  the  inflammation  of 
the  globe  has  disappeared,  the  danger  of  sympathetic 
ophthalmia,  according  to  my  experience,  has  been  largely 
exaggerated. 

2.  That  the  surgeon  should  not  waste  time  in  a  severe 
case,  except  it  be  syphilitic,  in  the  delusive  effort  to  cure 
suppuration  in  the  eye  with  drugs,  and  especially  if  the 
patient  be  one  of  "  the  poorer  classes,"  to  whom  it  is  a 
-matter  of  great  moment  to  be  cured  as  soon  as  possible," 
and  with  die  greatest  amount  of  preservation  of  his  nat- 
ural organ. 

3.  That  if  so  good  a  result  can  be  obtained  in  a  case 
with  the  cornea  split  into  two  equal  parts,  and  under 
such  unfavorable  conditions,  by  the  aid  of  a  sclerotic 
safety-valve,  it  is  reasonable  to  hope  for  far  better  results 
under  more  propitious  circumstances  where  the  surgeon 
may  perform  a  timely  sclerotomy  in  a  location  where 
neither  the  cornea  nor  any  of  those  important  parts  lying 
within  the  ciliary  zone  can  be  injured. 

Suggestion  a. — To  mention  sclerotomy  at  any  part 
where  the  instrument  must  enter  the  vitreous  chamber  as 
a  probable  cure  for  glaucoma  in  the  face  of  its  past  his- 
tory, and  of  what  some  of  the  most  eminent  men  in  the 
medical  world  have  written  about  it,  and  especially  at  an 
age  when  there  is  an  operation  for  glaucoma  which  has 
been  in  unrivalled  use  for  about  a  quarter  of  a  century, 
and  which  has  in  many  cases  given  very  fair  results,  may 
appear  like  a  reckless  suggestion.  In  presenting  its 
claims  to  the  profession  it  will  therefore  be  needful  to 
compare  its  advantages  and  disadvantages  with  those  of 
the  operation  now  in  use,  viz.,  the  broad  paracentesis  of 
the  sclera  through  its  most  anterior  zone  into  the  aque- 
ous chamber,  combined  with  an  iridectomy.  The  ad- 
vantages of  the  last- mentioned  operation  are :  1.  That  the 
instrument  pierces  only  the  anterior  scleral  zone  and 
does  not  enter  the  vitreous  chamber.  2.  When  early  and 
skilfully  performed  it  has  in  many  cases  given  very  fair 
results,  that  is,  complete  relief  of  pain  and  a  fair  amount 
of  vision.  Its  disadvantages  are :  1.  That  it  necessitates 
the  destruction  of  a  large  portion — about  one-fifth— of 
the  iris ;  not  because  the  destruction  of  this  tissue  is 
essential  to  the  cure  of  the  disease,  but  because  of 
the  danger  of  its  prolapse  if  not  destroyed,  and  the  dif- 
ficulty of  restoring  it  when  prolapsed,  and  its  great  lia- 
bility to  lead  to  dangerous  irritation.  2.  Its  location  is 
not  only  favorable  for  the  prolapse  of  the  iris  when  a 
large  portion  of  it  is  not  excised,  but  even  after  such  ex- 
cision the  margins  of  the  wounded  iris  are  very  liable  to  be 
caught  in  the  lips  of  the  scleral  incision  and  lead  to  dan- 
gerous and  irreparable  irritation.  3.  The  excision  of  the 
segment  of  iris,  as  is  required  in  its  performance,  close  up 
to  its  ciliary  attachment,  may,  in  the  hands  of  an  inex- 
pert operator,  cause  a  rupture  of  the  zonula  and  endanger 
the  safety  of  the  globe.  4.  Cataract  may  be  caused  by 
the  point  of  the  instrument  piercing  the  capsule  of  the 
lens  during  the  performance  of  the  operation,  and  this 
accident  is  quite  probable  in  the  hands  of  an  inexpert 
operator.  5.  The  more  or  less  dazzling  caused  by  the 
greater  volume  of  light  admitted  through  the  coloboma 
formed  by  the  iridectomy.  6.  The  increased  danger  of 
hemorrhage,  in  the  hemorrhagic  diathesis,  from  the  cut- 
ting of  so  many  blood-vessels  in  the  excision  of  the  seg- 
ment of  iris.  7.  The  increased  risk  of  sympathetic  glau- 
coma in  the  fellow-eye  as  the  early  result,  upon  an  already 
existing  predisposition,  of  the  shock  from  the  wounding 
of  so  many  ciliary  nerves  in  making  the  broad  incision 


through  the  anterior  scleral  zone  and  the  excision  of  so 
large  a  portion  of  iris;  this  increased  irritation  in  a 
weakened  nervous  system,  conveyed  through  the  ciliary 
branches  derived  from  the  ophthalmic  division  of  the  fifth 
pair  to  the  ciliary  ganglion,  and  thence  by  its  sympathetic 
root  to  the  cavernous  plexus,  and  thence  through  "the 
filaments  prolonged  on  to  the  anterior  communicating 
artery  form  a  small  ganglion,  the  ganglion  of  Ribes, 
which  serves,  as  mentioned  above,  to  connect  the  s>m- 
pathetic  nerves  of  the  right  and  left  sides  "  1  to  the  other 
eye,  causing  or  increasing  the  secretion  of  serous  vitre- 
ous and  an  increase  of  intraocular  tension.  8.  "  It  also 
exceptionally  occurs  that  directly  after  the  iridectomy 
the  resistance  of  the  globe  increases  markedly,  the  globe 
even  becomes  of  a  stony  hardness.  Such  cases  always 
run  an  unfavorable  course,  according  to  previous  expe- 
rience" (Liebreich •).  9.  "In  cases  of  glaucomatous 
degeneration,  iridectomy  is  apt  to  make  the  disease 
worse,  as  it  usually  causes  extensive  intra- ocular  hemor- 
rhage." ■ 

The  advantages  of  sclerotomy  into  the  vitreous  cham- 
ber, when  performed  in  the  location  and  within  the 
limits  above  prescribed  for  the  relief  of  intra- ocular 
tension  in  panophthalmitis  or  glaucoma  are:  1.  There 
is  no  destruction  of  iris  or  of  any  other  tissue.  2.  It 
is  performed  in  a  position  where  the  iris  cannot  prolapse 
and  cannot  be  caught  between  the  lips  of  the  scleral  in- 
cision, and  therefore  no  subsequent  irritation  can  arise 
from  that  source.  3.  There  being  no  iridectomy  in 
this  operation  there  is  not  the  slightest  danger,  with  the 
most  ordinary  care,  of  disturbing  the  continuity  of  the 
zonula  or  ciliary  processes.  4.  With  ordinary  care 
there  is  no  danger  of  causing  cataract  by  the  point  of 
the  instrument  piercing  the  capsule  of  the  lens.  5. 
There  can  be  no  dazzling  from  an  increased  volume  of 
light  because  there  will  be  no  coloboma  of  iris.  6.  The 
danger  from  hemorrhage,  in  a  hemorrhagic  diathesis, 
will  be  less  because  there  is  no  destruction  of  tissue  and 
a  much  smaller  number  of  blood-vessels  divided.  7. 
There  will  be  much  less  risk  of  sympathetic  glaucoma 
in  the  fellow- eye  because  there  will  be  much  less  injury 
done  to  the  ciliary  nerves;  not  more  than  one,  and 
probably  none,  of  these  nerves  will  be  wounded  if  the 
operator  is  careful  to  make  the  incision  in  a  straight 
line,  parallel  with  the  longitudinal  axis  of  the  globe.  8. 
The  firm  compress  and  bandage,  as  already  prescribed 
for  use  after  the  operation  for  the  relief  of  intra-ocular 
tension  in  panophthalmitis,  will  help  to  keep  the  in- 
cision open  and  to  promptly  afford  relief  to  any  increase 
of  tension  which  may  be  caused  by  hemorrhage,  and 
will  be  an  aid  in  checking  hemorrhage  in  glaucomatous 
degeneration,  which  is  so  liable  to  be  made  worse  by  an 
iridectomy. 

The  chief  disadvantages  of  sclerotomy  into  the  vitreous 
chamber  are  two  long  standing  objections  which  have 
disappointed  the  hopes  and  baffled  the  skilful  efforts  of 
some  of  the  most  eminent  surgeons  throughout  the 
civilized  world  for  over  a  quarter  of  a  century,  viz.,  1. 
"  Since,  however,  the  technical  performance  of  the  opera- 
tion was  not  adapted  to  produce  a  permanent  relaxation 
of  the  sclerotic,  it  could  only  obtain  transient  and  there- 
fore unsatisfactory  results :  "  *  2.  "Its  union  with  the 
iridenkleisis  (Critchett,  Coccius^)  has  theoretically  very 
much  to.  be  said  for  itself,  but  is  to  be  avoided  on  ac- 
count of  favoring  cystoid  cicatrices,  and  subsequent 
threatening  irritation.'1  * 

The  result  of  the  foregoing  case,  upon  which  these 
suggestions  are  based,  clearly  proves  that  these  last  two 
objections  can  be  avoided ;  for  there  is  not  the  slightest 
show  of  a  cystoid  cicatrix,  and  the  very  shallow  ditch 
along  the  line  of  the  scleral  incision,  which  has  been 
covered  over  and  nearly  filled  to  the  surface  by  a  nor- 
mal conjunctiva — the  surface  soil  through  which  it  had 
been  dug — proves  without  a  doubt  that  there  is  perma- 
nent relaxation  of  the  sclerotic.    I  believe  these  last  two 

1  Gray :  Eleventh  edition,  p.  789. 

*  Stellwag :  Fourth  edition,  p.  323.    *  Ibid.,  p.  324.    <  Ibid.,  p.  318. 


368 


MEDICAL    RECORD. 


[September  22,  1894 


parts  of  the  body.    These  cases  are,   of  course,  not 
classed  as  rheumatic  in  the  list  given  above. 

Eight  of  the  cases  were  evidently  directly  due  to  ex- 
posure to  wet  and  cold,  such  exposure  as  might  readily 
induce  an  attack  of  inflammatory  rheumatism, 

Nine  cases  occurred  in  connection  with  phthisis.  Was 
the  pleurisy  merely  a  part  of  the  phthisical  process  al- 
ready established,  or  was  it  an  intercurrent  affection? 
The  patients  almost  invariably  laid  the  pleuritic  process 
to  exposure  to  cold.  This  of  course  is  not  the  best  of 
evidence.  They  got  well  with  remarkable  rapidity  on 
anti-rheumatic  treatment  Rheumatism  "goes  to  the 
weak  spot" — in  this  case  to  the  serous  investment 
of  the  lung.  The  pleurisy  was  readily  cured.  The 
phthisical  process  persisted.  It  is  reasonable  to  sup- 
pose that  these  pleurisies  were  non  tubercular,  but  due 
to  rheumatic  attacks  during  the  course  of  a  chronic 
phthisis. 

A  few  years  ago,  while  engaged  in  surgical  work  ex- 
clusively, I  treated  numerous  cases  of  synovitis  of  the 
knee-joint  with  effusion,  due  to  injury,  by  means  of  plas 
ter-of-Paris  splints  and  the  usual  surgical  procedures. 
Since  then  I  have  learned  that  there  is  another  aspect  of 
these  cases,  that  a  man  who  sprained  his  knee  severely 
did  not  necessarily  get  an  effusion  into  the  joint ;  but, 
given  a  sprained  knee  and  a  "  touah  "  of  rheumatism,  and 
you  would  bs  very  apt  to  find  it.  So  with  pleurisy  oc- 
curring in  the  case  of  a  man  who  breaks  a  rib,  in  the 
syphilitic  or  in  the  tubercular  subject,  there  may  be 
more  than  one  element  at  work. 

Looking  at  it  in  this  light,  the  necessity  for  fine  points 
of  differentiation  between  pleurodynia — the  old-fashioned 
false  pleurisy — and  pleurisy  proper  is  not  so  apparent. 
Purely  from  a  practical  stand-point  it  matters  little  whether 
the  rheumatism  is  in  the  chest-wall,  in  the  costal  pleura 
lining  the  same,  or  in  the  pulmonary  pleura  immediately 
in  contact  with  the  latter.  In  a  case  of  articular  rheu- 
matism we  do  not  inquire  so  particularly  as  to  whether 
the  external  parts  only  are  involved,  or  whether  the 
synovial  membrane  is  also  inflamed.  There  are  few 
cases  of  pleurisy  which  do  not  on  careful  examination 
show  strong  evidences  of  pleurodynia  or  muscular  rheu- 
matism in  the  chest- wall,  in  addition  to  the  signs  of 
fluid  effusion,  the  pain  from  pleuritic  irritation,  and  the 
other  classical  symptoms  of  a  full-fledged  pleurisy. 
Wnen  we  have  a  rheumatic  joint  do  we  treat  the  synovial 
membrane  or  the  capsular  ligament  ?  Do  we  not  rather 
treat  the  rheumatism  as  a  whole,  and  the  local  lesions 
when  indications  call  for  it. 

A  disease  so  widespread  as  rheumatism,  a  disease 
which  is  acknowledged  to  be  capable  of  affecting  almost 
any  portion  of  the  anatomy,  is  fully  capable  of  producing 
pleurisy,  and  it  only  remains  for  a  sufficient  number  of 
careful  observations,  made  with  the  end  in  view  of  settling 
this  point,  to  establish  the  truth  of  this  matter. 

It  may  be  added  here  that  I  find  it  not  uncommon  for 
a  moderate  pleural  effusion  occurring  during  the  course  of 
an  inflammatory  rheumatism  to  be  overlooked.  Cough 
and  dyspnoea  may  be  absent,  and  the  pain  in  the  side  is 
easily  accounted  for.  That  it  is  a  more  common  com- 
plication than  is  usually  considered  I  am  fully  con- 
vinced. 

This  list  of  cases  attests  the  value  of  the  salicylates  in 
promoting  absorption  of  pleural  exudates.  Compare 
and  contrast  this  general  plan  of  treatment  with  that  ad- 
vocated by  Loomis,  who  gives  opium  the  most  prominent 
place ;  with  Flint,  who  advises  bloodletting,  opium,  and 
aconite ;  with  Pepper,  who  says  that  the  "  treatment  is 
symptomatic ;  "  with  the  blisterers,  the  tappers,  and  the 
"  vis  medicatrix  "  nihilists. 

Can  it  be  that  we  have  something  yet  to  learn  in  re- 
gard to  this  disease  beyond  the  best  way  to  keep  an  as- 
pirator valve  in  perfect  order,  to  sterilize  a  trocar,  or  to 
improve  on  Estlander's  operation  of  thoracoplasty  ?  Must 
we,  on  the  other  hand,  go  back  to  blind  empiricism  and 
give  salicylate  of  soda  because  it  is  "good  "  for  pleurisy, 
or  antipyrin  because  it   "absorbs"  the  effusion?    Or 


shall  we  bear  in  mind  the  diathesis,  the  underlying  con- 
dition, the  predisposing  cause,  the  etiological  factor  ? 

A  theory  of  some  sort  is  better  than  empiricism.     Let 
this  stand  or  fall  as  it  deserves. 


NEPHRITIS    OF    PREGNANCY    AND    ITS     SE- 
QUELS. 

By  EDWARD  NICHOLAS  LIELL,  M.D., 

NEW  YORK. 
LECTURER  M  GYNECOLOGY,  NEW  YORK  POLYCLINIC. 

In  proportion  as  our  knowledge  of  the  nature  of  disease 
and  the  action  of  remedies  increases,  the  practice  of 
medicine  becomes  more  rational  and  its  basis  more 
sound. 

Though  aware  of  the  dangers  not  infrequently  attend- 
ing the  nephritis  of  pregnancy,  especially  so  in  relation 
to  complicating  eclampsia,  we  are  still  far  from  being 
enlightened,  definitely,  as  to  the  reason  why  albumi- 
nuria so  frequently  attends  pregnancy.  It  is  immaterial, 
in  its  clinical  aspect,  whether  a  distinct  nephritis  exists 
previous  to  or  follows  upon  the  pregnant  state,  or 
whether  the  condition  existing  during  pregnancy  be  a 
distinct  nephritis  or  a  simple  albuminuria,  the  compli- 
cations arising  are  practically  of  equal  importance. 

Many  theories  have  been  advanced  to  account  for  the 
development  of  a  nephritis  or  albuminuria,  but  their 
value  is  unfortified  when  applied  to  etiology  as  a  whole. 

That  which  has  gained  considerable  ground,  and 
which  has  been  strengthened  post-mortem,  is  pressure 
of  the  lower  uterine  segment  upon  the  ureters,  causing 
compression  with  subsequent  dilatation  of  the  latter; 
more  especially  is  this  so  in  primipare,  where  the  ab- 
dominal walls  are  comparatively  tense. 

As  the  gravid  uterus  gradually  enlarges,  there  is  an 
added  pressure  upon  the  various  adjacent  vessels,  causing 
a  venous  stasis.  As  regards  the  value  of  this  pressure 
theory,  it  may  be  well  to  state  that  record  has  been 
made  of  various  cases  of  ovarian  tumors  of  large  size,  as 
also  uterine  fibroids,  which  were  complicated  with  albu- 
minuria, in  which,  after  operation,  the  albumin  disap- 
peared almost  immediately. 

In  this  connection,  I  would  offer  the  query:  May  not 
the  reflex  phenomena  of  nerve  irritation,  which  so  often 
accompanies  the  pregnant  state,  prove  a  prominent  factor 
in  the  etiology  ?  The  state  of  the  general  nutrition,  oc- 
cupation, and  habits  of  life  of  pregnant  women,  have 
little,  if  any,  apparent  influence  in  the  etiology — a  rather 
remarkable  feet. 

Having  in  mind  pregnancy  in  its  early  stage,  there 
can  be  no  question  of  the  substantial  gain  derived  from 
a  more  careful  attention  to  the  state  of  the  kidneys; 
especially  in  primipare,  we  should  ever  recognize  the 
importance  of  early  and  repeated  examination  of  the 
urine,  enabling  us  generally  to  forestall  any  impending 
renal  complication. 

In  a  nephritis  existing  previous  to  pregnancy,  exam- 
ination of  the  urine  should  be  made  at  the  outset  and 
continued  during  pregnancy. 

Taking  a  known  case  of  nephritis,  existing  either  pre- 
vious to  or  consequent  upon  pregnancy,  we  should  bear 
in  mind  the  fact  that  the  management  of  such  case  is 
of  prime  importance ;  it  should  have  reference  particu- 
larly to  three  things :  The  relative  amount  of  albumin 
present,  the  presence  of  casts,  and  as  to  their  number, 
and  a  fair  amount  of  urine  excreted  daily. 

Very  rarely  we  may  find  that  examination  of  the  urine 
will  prove  negative  as  to  albumin,  yet  the  microscope 
will  detect  an  occasional  cast ;  such  a  case  demands  our 
closest  attention. 

The  presence  of  casts  in  the  urine,  a  warning  only  too 
significant,  would  lead  us  to  surmise  a  lurking  danger  of 
eclampsia  during  the  final  stage  of  pregnancy,  during 
labor,  or  subsequent  thereto. 

A  few  words  here  on  the  subject  of  eclampsia.  To 
enumerate  the  various  explanations  that  have  been  given 


September  22,  1894] 


MEDICAL    RECORD. 


&7 


for  any  length  of  time.  When  the  stomach  would  toler- 
ate it  the  fluid  subsided  rapidly.  As  soon  as  the  remedy 
had  to  be  omitted  it  reaccumulated.  This  occurred 
several  times  during  the  first  week  or  ten  days,  and  fur- 
nishes strong  proof  of  the  efficacy  of  the  salicylate  in  pro- 
moting absorption  of  the  pleural  exudate.  Eventually, 
on  account  of  the  irritable  condition  of  the  stomach,  it 
was  abandoned,  and  salol  with  antipyrin  substituted. 
This  case  has  still  some  dulness  at  the  base  of  the 
pleural  cavity,  not  due,  however,  to  the  presence  of 
fluid  but  to  pleuritic  thickening.  The  same  condition 
is  observed  to  a  slight  degree  in  two  other  cases  of  like 
character. 

No  claim  is  made  that  salicylate  of  soda  is  a  specific  in 
pleurisy  with  effusion,  or  in  dry  pleurisies.  But  that  it 
will  reduce  the  effusion,  abate  the  cough,  relieve  the  pain, 
and  cure  the  patient  more  rapidly  and  effectually  than 
any  other  remedy  with  which  I  am  acquainted,  this  much 
I  am  certain  of. 

Neither  is  there  any  claim  for  priority  in  the  use  of 
this  remedy,  as  I  am  well  aware  that  Germain  S6e,  Au- 
frecht,  and  many  others  have  advocated  its  use.  But 
some  three  years  ago,  without  the  knowledge  that  it  was 
used  by  others  in  this  disease,  I  began  the  use  of  this 
remedy  in  pleurisies  of  rheumatic  origin,  and  was  so 
well  pleased  with  the  results  that  I  had  no  hesitation  in 
extending  its  use  to  cases  which  were  not  obviously  rheu- 
matic, using  it  since  then  persistently  in  all  cases  which 
were  non-purulent.  It  would  be,  of  course,  as  absurd  to 
rely  on  the  use  of  this  remedy  in  empyema  as  to  treat  a 
suppurative  knee-joint  on  the  alkaline  plan. 

In  cases  Nos.  24  and  33  two  distinct  attacks  of  pleurisy 
occurred,  with  an  interval  of  about  one  year.  The  pa- 
tient was  on  anti-syphilitic  treatment,  and  when  the  effu- 
sion took  place  the  only  modification  of  the  treatment 
was  the  addition  of  full  doses  of  the  salicylate. 

Nine  cases  occurred  in  connection  with  phthisis.  In 
no  case  was  a  pleurisy  the  starting-point  of  a  phthisis. 
Two  cases  occurred  during  convalescence  from  measles — 
one  as  a  complication  of  scarlet  fever ;  five  followed  or 
were  coincident  with  the  various  forms  of  pneumonia,  but 
in  these  cases  the  pneumonia  played  a  secondary  part 
where  the  two  were  present  at  the  same  time. 

Are  the  results  noted  due  solely  to  chance — to  the 
happy  use  of  a  so-called  specific?  Or  is  the  secret  of 
success  in  these  cases  due  to  the  recognition  of  the  under- 
lying factor — the  rheumatic  diathesis  ? 

Pleurisy  is  not  a  fatal  disease.  Under  any  ordinary 
plan  of  treatment  the  vast  majority  of  cases  eventually 
recover.  A  few  develop  extensive  pleuritic  adhesions 
and  thickening,  some  empyemas,  and  still  others  run 
into  phthisis  or  interstitial  pneumonia.  As  previously 
noted,  three  of  the  cases  cited  developed  pleuritic  thick- 
ening. As  these  cases  were  severe,  as  the  disease  had 
existed  in  each  instance  for  some  length  of  time  before 
treatment  was  instituted,  and  as  they  were  the  kind  of 
cases  which,  according  to  my  previous  experience,  usually 
developed  pus,  I  have  reason  to  be  satisfied  that  they  re- 
covered with  no  further  trouble  than  the  pleural  thicken- 
ing. 

Is  pleurisy  rheumatic  in  its  origin?  Practically  I 
have  found  that  the  average  run  of  cases  is  purely  rheu- 
matic. 

Loomis  says  "  the  etiology  of  acute  pleurisy  is  some- 
times very  obscure."  He  states  that  it  occurs  in  con- 
nection with  injuries,  pyaemia,  the  exanthematous  fevers, 
acute  and  chronic  alcoholism,  acute  rheumatism,  Bright's 
disease,  pneumonia,  etc.  Flint,  giving  practically  the 
same  causes,  mentions  that  "  it  is  developed  occasionally 
in  connection  with  acute  articular  rheumatism."  Wil- 
son, in  "  Pepper's  Practice  of  Medicine,1'  makes  no  men- 
tion of  it  as  a  cause  of  dry  pleurisy,  and  mentions  it 
merely  as  occasionally  associated  with  pleurisy  with  effu- 
sion. Other  writers  lay  especial  stress  on  tuberculosis  as 
the  usual  causative  factor.  Still  others  advocate  the  mi- 
crobic  origin.  In  fact,  the  list  of  possible  causes  is  so 
long  and  so  indefinite  as  to  resemble  in  its  length  and 


uncertainty,  at  least,  a  chapter  on  the  etiology  of  acute 
rheumatism. 

If  these  writers  represent  the  profession  as  a  whole,  if 
this  is  the  generally  accepted  view  of  the  causation  of 
pleurisy,  then  I  am  compelled  to  take  issue  with  them. 
I  believe  that  the  most  prominent  cause  of  pleurisy  is 
rheumatism.  I  wish  it  distinctly  understood  that  I  do 
not  hold  that  every  case  of  pleurisy  is  rheumatic.  That 
the  suppurative  pleurisies  are  due  to  infection  by  the  di- 
plococcus  of  Fraenkel,  by  streptococci,  or  by  staphylo- 
cocci is  admitted.  That  simple  pleurisies  may  arise  in 
other  ways  is  conceded.  But  that  the  commonest  cause 
is  rheumatism  I  am  convinced — rheumatism  pure  and 
simple,  rheumatism  as  an  intercurrent  affection,  or 
rheumatism  engrafted  upon  some  chronic  tubercular  or 
other  previously  existing  disease. 

In  reviewing  the  reasons  which  led  me  to  arrive  at  this 
conclusion  I  find  that  they  are  numerous. 

To  properly  appreciate  them  a  careful  comparison  of  the 
two  diseases  is  necessary.  The  reader  will  bear  in  mind 
that  it  is  but  fair  to  contrast  the  pleuritic  inflammation 
with  the  purely  synovial  inflammation  in  joint  rheuma- 
tism. The  pleura  is  a  serous  membrane,  a  gliding  joint 
if  you  will,  or  an  enlarged  bursa,  between  the  lung  and 
the  chest-wall.  Its  function  is  to  allow  full  movement 
and  to  prevent  friction,  and  it  is  lubricated  with  a  serous 
fluid.  In  other  words,  it  is  a  modified  joint,  not  be- 
tween two  bones,  but  between  the  lung  and  the  thoracic 
wall.  Gray  says  that  the  synovial  membrane  "  resem- 
bles the  serous  membranes  in  structure,  but  differs  in  the 
nature  of  its  secretion,  which  is  thick,  viscid,  and  glairy." 
This  is  a  difference  in  degree,  not  in  kind.  We  do  not 
use  successfully  the  same  lubricant  for  a  lumber-wagon 
and  for  the  delicate  mechanism  of  a  watch,  yet  the  prin- 
ciple is  identical.  That  the  joint  surface  and  the  pleural 
surface,  or  perhaps,  more  properly,  the  joint  cavity  and 
the  pleural  cavity,  are  similar  in  structure,  in  secretion,  in 
function,  and  in  the  character  of  their  inflammatory  af- 
fections, is  evident.  That  slight  variations  are  found  is 
but  to  be  expected. 

Pleurisy  may  be  acute,  subacute,  or  chronic.  So  also 
a  rheumatic  joint.  Pleurisy  may  result  in  the  formation 
of  fibrin,  serum  and  fibrin,  serum,  fibrin  and  pus,  or 
new  connective  tissue.  It  may  be  dry  or  wet,  suppura- 
tive or  adhesive.  Compare  this  with  the  changes  which 
occur  in  the  synovial  membrane  of  the  knee-joint,  for  in- 
stance. Have  we  not  all  seen  a  "  dry  "  rheumatic  joint 
with  distinct  crepitus  like  that  of  pleurisy ;  joints  with 
effusion  from  rheumatism ;  joints  with  fibrous  anchylosis 
from  this  cause,  and,  though  more  rarely,  abscess  in  the 
knee-joint  from  a  neglected  rheumatic  effusion  which  be- 
came infected  with  pyogenic  germs  ? 

A  comparison  of  the  statements  of  the  majority  of  our 
writers  in  regard  to  the  etiology  of  pericarditis  and  of 
pleurisy  might  be  instructive.  Wilson,  in  "Pepper's 
Practice,1'  states  that  "by  far  the  most  important  cause  of 
pericarditis  is  acute  articular  rheumatism,"  yet  he  merely 
gives  passing  mention  of  rheumatism  as  a  possible  cause 
of  pleurisy.  Other  writers  take  practically  the  same  stand . 
Yet  in  what  essential  does  the  one  closed  sac  of  serous 
membrane  differ  from  the  other  either  in  structure  or  in 
function  ?  Why  should  rheumatism  patronize  the  one 
exclusively  and  boycott  the  other?  Surely  such  par- 
tiality is  unfair !  Let  rheumatism  attack  something  of 
its  size,  and  not  pitch  solely  into  the  smaller  neigh- 
bor. 

An  analysis  of  the  forty- four  cases  in  the  list  throws 
some  light  on  the  subject.  Sixteen  cases  occurred  in 
connection  with  acute  rheumatic  attacks,  one  with  ton- 
sillitis of  a  rheumatic  nature  (?),  and  one  with  severe 
rheumatoid  arthritis.  This  is  in  itself  a  strong  argument. 
A  personal  acquaintance  with  these  cases  and  the  mem- 
bers of  their  immediate  families  shows  something  which 
does  not  appear  from  the  list  of  cases — that  the  rheu- 
matic diathesis  played  an  important  part  in  many  of 
the  cases  which  could  not  be  classed  as  directly  due  to, 
or  associated  with,  distinct  rheumatic  attacks  in  other 


37° 


MEDICAL  RECORD. 


[September  22,  1894 


tion  has  been  relieved.  The  great  prevalence  of  ear  dis- 
ease everywhere  is  also  well  understood,  and  the  con- 
nection between  diseases  of  the  nose,  ear,  pharynx,  and 
larynx.  In  diseases  of  the  ear  and  upper  air  passages,  as 
I  see  them,  there  is  always  two  main  considerations,  the 
local  and  the  constitutional,  or  the  condition  of  the  nose 
and  the  condition  of  the  apices  of  the  lungs. 

You  often  see  cases  in  which  both  conditions  exist. 
The  question  to  decide  then  is  which  condition,  the  local 
or  the  constitutional,  is  the  one  which  has  most  to  do  in 
causing  the  disease  of  the  ear,  pharynx,  tonsil,  or  larynx. 
These  two  conditions  do  not  account  for  everything,  I  am 
well  aware,  and  yet  they  claim  consideration  always  as 
regards  prognosis  and  treatment. 

The  importance  of  apex  catarrh  in  ear  disease  was 
forcibly  impressed  upon  me  three  years  ago,  when  I  was 
in  general  practice  and  a  visiting  physician  to  one  of 
the  hospitals.  A  boy,  aged  twenty,  whose  language  no 
one  could  understand,  was  brought  to  the  hospital.  The 
only  history  we  could  obtain  was  that  he  had  been  sick 
for  six  weeks  and  had  had  no  medical  attention.  He 
had  a  large  accumulation  of  pus  in  the  mastoid  region, 
and  the  house  surgeon  had  lanced  the  abscess  before  my 
morning  visit,  at  which  time  I  saw  the  case  with  one  of  the 
surgeons.  The  ordinary  local  treatment  in  such  cases 
was  proposed,  and  also  it  was  suggested  that  calomel  and 
rhubarb  should  be  given  because  of  the  marked  gastro- 
intestinal disturbance.  I  was  not  at  all  convinced  that 
the  local  condition  accounted  altogether  for  the  boy's 
condition,  but  thought  it  wisest  to  make  no  suggestion 
as  to  apices.  A  few  days  later  he  died  from  a  profuse 
hemorrhage  of  the  lungs. 

Nearly  one  half  of  all  the  cases  of  ear  disease  in 
patients  from  eight  to  forty  years  of  age  that  pass 
under  my  observation  have  also  apex  catarrh.  Many 
have  hypertrophic  rhinitis.  Both  conditions  require 
attention.  While  the  increased  susceptibility  to  colds 
accounts  for  the  acute  inflammations  of  the  middle 
ear  that  are  so  often  seen  in  patients  with  apex  catarrh, 
I  have  been  repeatedly  surprised  at  the  number  of  cases 
of  chronic  middle- ear  inflammation  that  present  them- 
selves on  account  of  their  increased  suffering  under  a 
similar  constitutional  condition.  These  patients  are  often 
people  who  have  suffered  for  years  from  marked  loss  of 
hearing,  and  who  have  ceased  to  believe  that  there  was 
any  hope  of  relief.  Upon  the  development  of  an  apex 
catarrh  they  begin  to  suffer  more  from  catarrh  of  the 
upper  air- passages  and  to  complain  more  from  the  sub- 
jective symptoms.  The  examination  of  the  ear  often 
reveals  simply  marked  changes  from  an  old  inflammation, 
and  yet  no  trace  of  any  acute  trouble.  Such  cases  under 
creosote,  without  any  local  treatment,  very  soon  regain 
their  usual  amount  of  hearing.  Even  cases  of  posterior 
adenoids  in  children  over  eight  years  of  age  are  often  as- 
sociated with  an  apex  catarrh.  There  is,  of  course,  no 
connection  between  the  diseases.  Whether  chronic  catar- 
rhal conditions  of  the  nose,  naso-pharynx,  or  pharynx 
predisposes  a  patient  to  an  apex  catarrh  is  an  open  ques- 
tion. For  my  part  I  do  not  believe  it.  I  can  under- 
stand how  such  conditions  might  be  responsible  for  an 
ordinary  chronic  bronchitis,  but  not  how  an  apex  catarrh 
— a  localized  capillary  bronchitis — could  be  dependent 
upon  any  such  cause.  Posterior  adenoids  in  many  cases 
cause  few  symptoms.  If  an  apex  catarrh  occurs  in  such 
a  patient,  the  posterior  adenoids  become  more  trouble- 
some because  of  repeated  fresh  colds,  and  the  patient  pre- 
sents himself  for  relief.  The  statement  made  as  to  pos- 
terior adenoids  applies  equally  to  chronic  nasal  catarrh. 

The  course  of  an  acute  follicular  tonsillitis  may  be  very 
greatly  modified  when  occurring  in  a  patient  with  an  apex 
catarrh.  The  first  few  days  there  is  nothing  different 
from  the  ordinary  symptoms.  At  the  time,  however,  at 
which  one  expects  the  swelling  of  the  tonsil  to  begin  to 
subside,  and  the  tenderness  to  diminish,  they  are  found 
to  be  as  marked  as  in  the  first  two  days  of  the  disease. 
In  some  cases  the  swelling  subsides  about  as  fully  as  in 
the  uncomplicated  case,  and  yet  the  tenderness  upon 


swallowing  is   entirely   out   of  proportion  to  anything 
one  can  see  in  the  throat. 

Two  years  ago  in  February  a  girl,  aged  sixteen,  pre- 
sented herself  at  the  clinic.  She  had  been  under  obser- 
vation three  months  before,  for  three  or  four  weeks,  with 
an  apex  catarrh.  After  improving  upon  creosote  she  had 
discontinued  her  visits.  Three  weeks  before  coming 
under  observation  the  second  time  she  had  had  an  acute 
sore  throat,  from  which  she  had  not  yet  recovered.  Dur- 
ing this  time  she  had  been  able  to  swallow  only  liquid 
food.  The  swelling  of  the  tonsils  had  largely  passed 
away,  but  the  reddening  was  marked  and  the  tenderness 
upon  swallowing  very  great  A  re  examination  of  her  chest 
revealed  a  well  marked  apex  catarrh  still  present.  She 
was  given  drop  doses  of  creosote  every  hour.  Within 
twenty-four  hours  she  swallowed  solid  food.  The  local 
condition  rapidly  recovered,  but  the  girl  continued  her 
constitutional  treatment  for  a  number  of  months. 

This  is  simply  one  of  many  cases  that  have  passed 
under  my  observation.  They  are  by  no  means  rare. 
Three  such  cases  consulted  me  last  week.  A  large  num- 
ber of  the  cases  of  subacute  or  chronic  laryngitis  in  people 
in  middle  life  are  associated  with  an  apex  catarrh.  Many 
of  these  cases  have  also  a  hypertrophic  rhinitis.  Both 
conditions  have  an  influence  upon  the  larynx.  Both 
ought  to  be  treated  of  course.  What  to  promise  such  a 
patient  as  to  the  improvement  of  the  throat  for  the  first 
three  months  is  a  difficult  question.  Every  such  case 
improves  in  many  ways  when  the  course  of  the  apex 
catarrh  is  a  hopeful  one.  The  great  majority  of  cases 
recover  of  the  laryngeal  trouble  within  a  few  weeks  after 
cauterization  of  the  nasal  hypertrophies  and  the  adminis- 
tration of  creosote.  In  a  small  proportion  of  cases, 
although  the  patient  improves  in  every  way,  the  laryngeal 
inflammation  persists.  After  a  few  weeks'  local  treatment 
my  rule  is  to  inform  such  patients  that  they  must  not 
expect  to  be  entirely  relieved  of  the  throat  symptoms 
until  they  have  regained  their  general  health — until  the 
disturbances  in  the  mucous  membranes,  of  which  the  in- 
flammation of  the  larynx  is  only  a  part,  shall  have  passed 
away.  It  is  recommended  that  stubborn  cases  of  chronic 
laryngitis  be  painted  with  increasing  strengths  of  nitrate 
of  silver  solution.  • 

I  have  never  considered  it  advisable  to  pursue  such  a 
course  in  a  laryngitis  of  this  kind.  If  one  failed  to  con- 
sider the  constitutional  condition  of  his  patient,  or  did 
not  know  that  exceptionally  a  laryngitis  might  pursue 
such  a  course,  the  local  condition  might  receive  over- 
treatment.  There  is,  to  my  knowledge,  no  way  of  deter- 
mining which  case  will  promptly  recover,  and  which 
case  will  persist,  it  may  be,  for  months. 

If  the  practitioner  overlooks  the  constitutional  condi- 
tion, he  fails  to  accomplish  for  the  local  condition  what 
he  otherwise  might  do.  This  statement  I  realize  because 
I  have  only  learned  it  from  many  a  humiliation.  I  shall 
never  forget  a  child,  aged  six,  that  I  had  treated  for 
nasal  catarrh  for  a  number  of  weeks,  and  could  not  un- 
derstand why  the  catarrh  was  not  relieved.  There  was 
nothing  in  her  appearance  to  make  me  suspicious  of  an 
apex  catarrh.  Finally,  I  examined  her  chest  and  found 
the  key  to  the  situation  at  one  apex.  Under  bcnzosol 
her  nasal  condition  passed  away,  almost  at  once.  If 
either  condition  must  be  overlooked,  the  local  is  of  lesser 
importance,  and  unless  the  specialist  looks  beyond 
the  local  condition  the  patient  had  better  be  in  the  hands 
of  the  sensible  general  practitioner.  The  local  condition 
is  easy  of  diagnosis,  the  patient  has  made  the  diagnosis 
himself,  and  will  always  insist  on  attaching  undue  impor- 
tance to  it.  He  has  not  as  yet  found  out  that  his  vitality 
is  below  par.  It  is  useless  to  say  much  to  such  a  patient 
in  the  beginning  of  his  treatment.  I  aim  to  say  enough 
to  impress  upon  his  mind  my  belief  that  there  is  more  at 
fault  than  the  local  conditions.  He  soon  sees  for  him- 
self that  my  opinion  of  his  case  is  correct.  When  this 
time  has  arrived  he  will  accept  the  statement  that  he  will 
be  far  from  well  when  the  local  difficulty  is  relieved.  It 
is  not  claimed  that  the  course  of  the  local  condition  is 


September  22,  1894] 


MEDICAL  RECORD. 


37i 


especially  modified  by  the  knowledge  of  the  catarrhal 
condition  at  the  apex,  t.e.,  the  catarrhal  condition  of  thfe 
mucous  membranes  of  the  entire  body. 

Cases  of  apex  catarrh  recover  upon  any  tonic  treat- 
ment. The  specialist  who  gives  iron  because  his  patient 
is  anaemic,  and  then  treats  the  local  condition,  is  going  to 
benefit  his  patient ;  or  if  he  administer  stomachics  be- 
cause there  is  a  disturbance  of  the  gastrointestinal  tract, 
the  results  will  be  satisfactory. 

And  yet  how  a  specialist  can  intelligently  treat  the 
ear  and  upper  air-passages  without  taking  into  careful 
consideration  the  facts  herein  stated  is  a  mystery  to  me. 
There  is  little  science  in  administering  iron  because  a 
patient  is  anaemic  The  cause  of  the  anaemia  ought  to 
be  found.  If  it  is  found  to  be  due  to  an  apex  catarrh, 
creosote  is  a  much  more  satisfactory  remedy. 

I  might  have  summed  up  the  entire  paper  in  one  or 
two  sentences,  and  yet  the  subject  has  been  treated  at  this 
length  in  the  hope  that  this  view  of  disease  of  the  upper 
air-passages  might  be  helpful.  This  is  the  result  of  years 
of  study.  Such  conditions  certainly  exist  in  Cleveland. 
During  1888  and  1889  it  was  my  privilege  to  work  for  a 
number  of  months  in  the  ear,  throat,  and  nose  clinics  in 
Vienna,  and  yet  I  never  heard  anything  concerning  the 
condition  I  have  endeavored  to  describe  in  this  and  a 
succeeding  paper.  I  never  saw  any  observation  made  as 
to  the  pulse  and  temperature  in  the  out-patients.  It  has 
been  no  easy  matter  to  attempt  to  put  my  ideas  on  paper. 
Whether  I  have  succeeded,  the  reader  must  judge. 


A    FEW  WORDS  IN    REFERENCE  TO    LIVING 
CELLS  VERSUS  STAINING. 

By  WILLIAM  MOSER,  M.D., 

PATHOLOGIST  TO   ST.   CATHARINE'S  HOSPITAL,   BROOKLYN,  N.   V. 

I  recently  stated '  that  "  I  was  becoming  more  and  more 
convinced  that  Virchow's  teaching  not  to  stain  tissues 
was  the  best. ' '  Of  course  this  does  not  apply  to  bacterio- 
logical examinations,  but  to  general  pathological  work, 
such  as  the  examination  of  tumors,  etc.  By  this  state- 
ment I  did  not  intend  to  underestimate  the  value  of  re- 
cent advances  made  in  processes  of  staining,  such,  for 
instance,  as  Golgi's  method  in  the  examination  of  the 
nervous  system,  but  rather  to  draw  the  attention  of  the 
profession  to  the  fundamental  difference  between  a  living 
cell  and  a  dead  cell — to  living  tissue  and  dead  tissue — 
facts  which  have  not  been  sufficiently  considered.  The 
great  objection  to  our  ordinary  laboratory  examinations 
lies  in  eliminating  artificial  products,  and  in  the  radical  dif- 
ference which  must  and  does  exist  between  the  living  and 
the  dead  cell.  My  own  observations  on  the  blood-cells, 
which  I  have  lately  published  and  to  which  I  wish  to  revert 
merely  for  purpose  of  illustration,  show  that  the  red 
blood  corpuscle  which  does  not,  as  a  rule,  with  few  ex- 
ceptions, stain  with  methylene -blue  by  our  regular  labora- 
tory method,  will  do  so  when  this  substance  is  given  in- 
ternally. While  the  red  blood-corpuscle  will  imbibe 
methylene-blue  when  given  internally,  it  does  not  do  this 
in  all  cases  alike.  I  mean  that  it  is  influenced  by  various 
factors — by  the  condition  of  the  cell.  In  some  cases  it 
will  take  weeks  to  become  stained,  while  in  pernicious 
anaemia  it  will  stain  readily.  Even  on  the  dead  red 
blood-corpuscle  this  tendency  in  pernicious  anaemia  to 
imbibe  not  alone  methylene-blue,  but  other  stains,  has 
previously  been  noted.  But  it  becomes  more  manifest  on 
the  living  cell.  It  has  long  been  known  that  the  nucleus 
of  a  cell  has  a  special  affinity  for  certain  stains,  viz. ; 
Carmine,  haematoxylin,  aniline,  hence  the  term  "  chro- 
matin "  (nuclein),  which  Fleming  applied  to  it.  During 
the  process  of  karyokinesis  the  mass  of  threads  formed 
are  chromatic,  while  certain  threads  are  achromatic  (do 
not  imbibe  these  stains).  My  observations  on  the  nuclei 
of  the  white  blood- corpuscles  in  which  methylene-blue 
had  been  given  internally,  that  is  in  dealing  with  living 
cells,  prove  to  me  beyond  doubt  that  the  term  "  chroma* 

1  St.  Catharine's  Hospital  Report,  1893. 


tin"  for  the  nucleus  of  a  cell  has  not  been  misplaced. 
While  it  must  be  admitted  that  on  the  living  cell  the  pro- 
toplasm imbibes  the  stain,  it  rarely  does  it  so  markedly 
as  does  the  nucleus.  It  has  long  since  been  demonstrated 
that  certain  intra-cellular  parasites,  such  as  the  Plasmo- 
dium malaria,  which  usually  finds  its  habitat  within  the 
red  blood  corpuscle,  has,  like  the  nucleus  of  a  cell,  a 
special  affinity  to  imbibe  certain  stains.  This  can 
readily  be  seen  by  our  ordinary  method  of  staining  this 
parasite  with  methylene  blue  in  the  laboratory.  Indeed 
some  writers l  regard  this  affinity  of  the  Plasmodium  for 
methylene-blue  as  quite  characteristic,  and  think  that 
this  property  will  often  enable  us  to  distinguish  it  from 
other  intracellular  parasites.  By  giving  the  stain  inter- 
nally this  affinity  of  the  Plasmodium  to  imbibe  it  can 
readily  be  demonstrated.  And,  strange  to  note,  it  will, 
in  a  brief  space  of  time,  cause  the  disappearance  of  the 
Plasmodium  from  the  cell,  or,  in  fact,  from  the  blood. 
My  observations  on  this  point  confirm  those  of  Mati- 
enzo,a  who  first  made  known  this  fact.  It  was  for  that 
reason  that  he  recommended  methylene-blue  in  the  treat- 
ment of  malaria  in  some  cases  in  place  of  quinine,  etc.  It 
is  to  be  regretted  that  it  does  this,  because  if  the  living  cell 
with  its  parasite  retained  the  stain,  like  the  nucleus  or 
nuclei  of  the  white  blood-corpuscles,  what  a  splendid  op- 
portunity it  would  afford  us  to  study  the  life  history  of 
the  Plasmodium  malaria  !  I  believe  we  may  yet  find  a 
stain  to  do  this.  I  have  tried  eosine,  but  was  unsuc- 
cessful It  is  possible  that  we  may  be  more  successful 
with  carmine  or  haematoxylin.  It  is  apparent  that  while 
we  can  stain  the  blood-cells  during  life  we  cannot  do  this 
with  all  cells  in  the  body.  If  this  were  so,  what  a  differ- 
ence it  might  produce  in  histology  and  pathology  ! 

158  Ross  Strbst,  Brooklyn,  E.  D. 


TREATMENT   OF    FRACTURES  AND    SPRAINS 
OF  THE  ANKLE  BY   MASSAGE. 

Bv  ALEXANDER  C.  WIENER,  M.D., 

CHICAGO,  ILL. 

While  there  has  been  great  activity  in  all  branches  of 
operative  surgery,  and  strenuous  efforts  have  been  made 
to  improve  present  methods  and  to  introduce  new  ones, 
yet  in  the  treatment  of  fractures  there  has  prevailed  a 
manifest  reluctance  to  change  the  old  and  approved 
methods.  What  else  can  account  for  the  total  disregard 
paid  to  the  theses  delivered  by  Lucas  Champonni&re  at 
the  Paris  Soctet6  de  Chirurgie,  June  26,  1886,  on  the 
treatment  of  fractures  by  massage  ?  His  ideas  suggested 
a  complete  revolution  in  the  treatment  of  fractures,  al- 
though this  method  of  treatment  has  nowhere  received 
such  general  recognition  as  in  France. 

The  treatment  by  massage  fulfils  in  general  the  three 
following  conditions  :  1.  It  shortens  materially  the  time 
of  recovery  and  lessens  the  period  of  ossification.  2.  It 
gives  better  results  functionally.  3.  It  lessens  the  pain 
of  the  treatment. 

Since  then  massage  has  been  recommended  for  all  ar- 
ticular and  periarticular  fractures ;  but  in  no  case  has  it 
produced  more  striking  and  indisputable  results  than  in 
the  treatment  of  fractures  of  the  ankle  and  the  various 
sprains  of  the  foot.  In  such  cases  this  is  the  classic 
treatment.  When  we  consider  that  the  expectant  treat- 
ment of  immobilizing  the  foot  in  splints  or  in  plaster  re- 
quires at  least  thirteen  weeks  for  the  recovery  of  a  fract- 
ure of  both  bones,  two-thirds  of  this  time  being  required 
to  overcome  the  stiffness  of  the  joint  and  the  atrophy  of 
the  muscles  resulting  from  the  immobilization,  a  method 
of  treatment  tha^diminishes  the  time  by  one-half  is 
worthy  of  consideration. 

A  simple  sprain  of  the  foot  treated  by  the  expectant 
method,  that  is,  by  bandages  and  rest,  renders  the  foot 
useless  for  twenty-five  days  on  (an  average,  whereas  the 
patient  treated  by  massage  can  move  about  freely  after 


1  Adler :  Protozoa  and  Their   Relation  to  Carcinoma. 
Journal  of  the  Medical  Sciences,  January,  1894. 
9  La  Gaceta  Medica,  1893. 


American 


37* 


MEDICAL   RECORD. 


[September  22,  1894 


eight  days.  Twenty-five  per  cent,  of  all  the  fractures 
that  occur  affect  the  ankle.  The  sprains  to  which  this 
joint  is  subject  are  numberless ;  and  what  a  wide  field  this 
opens  to  the  physician,  who,  as  a  rule,  prefers  to  take  an 
active  part  in  the  process  of  recovery  rather  than  to  ap- 
ply a  bandage  and  see  himself  reduced  to  the  part  of  a 
passive  spectator. 

The  diagnosis  of  fractures  of  the  ankle  offers  no  diffi- 
culties ;  but  I  beg  to  be  permitted  to  say  a  few  words  re- 
garding the  mechanism  of  the  different  fractures,  since 
an  understanding  of  this  is  essential  to  successful  treat- 
ment. Fracture  of  the  inner  malleolus  is  produced  by 
the  forced  lowering  of  the  inner  and  raising  of  the  outer 
margin  of  the  food.  The  deltoid  ligament  being  the 
first  to  meet  the  force  is,  as  a  rule,  not  torn,  but  tears 
off  the  end  of  the  tibia,  to  which  it  is  attached.  The 
foot  is  then  allowed  to  roll  around  its  inner  border  into  a 
most  pronated  position.  The  outer  malleolus  is  driven 
against  the  outer  border  of  the  calcaneus,  and  in  most 
cases  the  end  of  the  fibula  breaks  off  six  or  seven  centi- 
metres from  its  lower  end  (Pott's  fracture).  The  next 
most  frequent  cause  of  fracture  of  the  inner  malleolus  is 
dorsal  hyperflexion  of  the  foot.  The  simple  fracture  of 
the  outer  malleolus  (Dupuytren's  fracture)  is  produced 
by  forcing  the  foot  down  on  its  outer  border.  In  many 
cases  only  the  outer  ligament,  that  is,  the  ligament  cal- 
caneo-fibulare,  is  torn  in  consequence  of  the  supination 
of  the  inner  border  of  the  foot,  but  usually  the  lower 
three  centimetres  of  the  fibula  are  broken  off  transverse- 
ly. The  fragments  are  not  usually  dislocated,  being  held 
in  place  by  the  ligament  tibio  fibulare.  The  action  of 
the  force  upon  the  joint  affects  only  the  ligaments 
immediately.  If  they  are  not  torn  they  transmit  the 
force  to  their  place  of  attachment  to  the  bone  and  thus 
a  solution  of  continuity  is  produced.  The  mechanism 
of  the  simple  sprain  of  the  ankle  joint  and  its  fracture  is 
the  same,  the  difference  lying  only  in  the  intensity  of 
the  force  exerted.  This  difference  is  still  slighter  when 
we  consider  the  great  extravasation  of  blood  in  the  ankle- 
joint  which  is  produced  in  tearing  the  ligaments. 

Massage  has  for  its  object  the  prevention  of  the  normal 
degeneration  and  the  removal  of  the  blood  from  the 
joint  and  the  oedema  from  the  soft  parts.  The  treatment 
during  the  first  eight  days  is  of  the  utmost  importance. 
The  blood  must  not  be  allowed  to  coagulate ;  the  process 
of  regeneration  in  the  bone,  which  begins,  at  the  latest, 
a  few  hours  after  the  injury,  must  be  accelerated  by  stimu- 
lation.1 The  pain  must,  as  a  rule,  be  relieved  in  three  or 
four  sittings.  Massage  must  begin  immediately,  pro- 
vided there  is  no  dislocation  of  the  bone.  In  fractures 
of  both  bones  the  astragalus  has  lost  its  position,  the  foot 
wabbles  about  and  frequently  the  astragalus  is  dislocated 
backward.  As  the  bones  always  consolidate  in  the  posi- 
tion which  they  take  of  themselves  or  in  which  they  are 
placed,  an  immediate  reposition,  if  necessary  under  an 
anaesthetic,  and  retention  in  this  position  are  indispen- 
sable. These  are  the  only  cases  in  which  immobilizing 
is  indicated.  The  foot  is  placed  with  light  pressure  in  a 
position  perpendicular  to  the  leg,  and  then  placed  in  a 
plaster  cast ;  a  woollen  or  silk  stocking  may  be  used 
next  to  the  limb  and  a  three  inch  plaster- of- Paris  band- 
age applied.  The  bandage  reaches  to  the  upper  third  of 
the  leg  and  encloses  the  whole  foot  except  the  toes.  For 
strengthening  the  cast  at  the  sole  of  the  foot,  a  strip  of 
paste-board  may  be  included.  After  three  days  a  return 
to  a  wrong  position  need  not  be  feared.  The  bandage 
is  removed  and  treatment  by  massage  begins.  If,  as 
occurs  occasionally,  the  astragalus  again  becomes  dislo- 
cated, a  paste-board  splint  may  be  made,  which  can  be 
easily  put  on  or  removed.  Massage  MP  recent  sprains  or 
fractures  is  to  be  practised  under  the  same  aseptic  pre- 
cautions as  for  recent  wounds.  The  foot  and  leg  are  to 
be  thoroughly  cleaned  with  warm  water,  soap,  and  brush, 
the  hair  removed  and  the  skin  then  carefully  dried.  The 
physician's  hands  must  also  be  thoroughly  cleaned. 
Disinfecting  agents  must  not  be  used,  as  they  irritate  the 
1  Formativer  Reiz,  Virchow. 


skin  too  much.  The  epidermis  always  presents  minute 
openings  through  which  pus-forming  agents  may  pene- 
trate and  find  rich  soil  in  the  extravasated  blood.  The 
limb  is  then  well  anointed  with  sweet-oil  or  vaseline,  and 
placed  on  a  solid  support.  If  there  is  a  tendency  to  a 
return  of  the  dislocation  in  the  first  few  days  after  the  re- 
moval of  the  bandage  the  foot  must  be  held  in  the  proper 
position  by  an  assistant.  In  simple  sprains  I  prefer  to 
apply  massage  while  seated,  the  patient's  limb  being  sup- 
ported on  my  knee. 

Massage  consists  in  a  gentle  pressure  of  the  volar  sur- 
faces of  the  united  fingers  moving  in  a  centripetal  direc- 
tion. At  first  one  must  avoid  touching  the  fracture  and 
must  not  continue  the  sitting  too  long.  The  first  treat- 
ment should  not  exceed  ten  minutes.  From  the  fourth 
sitting  on,  each  one  should  occupy  at  least  twenty  min- 
utes. For  practical  reasons  I  would  have  only  one  sitting 
a  day  and  make  them  somewhat  longer.  In  making  the 
passage  from  the  periphery  toward  the  centre,  the  blood 
exudate  and  oedematous  fluid  are  pressed  toward  the 
lymph  spaces  and  urged  toward  the  heart.  How  power- 
fully the  lymph  currents  are  stimulated  is  shown  by  the 
fact  that  after  a  few  days  the  lymphatics  of  the  legs  and 
thigh  become  visible  from  the  coloring  matter  of  the 
blood  which  they  contain.  The  hyperemia  of  the  veins 
and  the  troublesome  throbbing  and  heat  in  the  joint  are 
also  promptly  removed  and  the  rich  arterial  blood  sap- 
ply  promotes  the  healing  of  bones  and  ligaments.  The 
muscles  preserve  their  elasticity  and  the  equilibrium  of 
their  metabolism ;  their  contractions  assist  the  flow  of  the 
blood  into  the  more  deeply  lying  veins.  The  painful  con- 
tractions which  follow  the  over-stretching  of  the  muscles 
and  tendons  disappear  rapidly.  The  most  immediately 
favorable  result  of  the  massage  for  the  patient  is  the  fact 
that  the  treatment  after  three  or  four  painful  sittings  be- 
comes almost  painless ;  for,  with  the  removal  of  the  ex- 
travasation, the  pressure  on  the  sensory  nerve  ceases.  At 
the  end  of  the  sitting  the  abundant  oil  on  the  surface  is 
removed  with  alcohol,  which  has  a  pleasing,  cooling 
effect  on  the  stimulated  skin.  The  fractured  limb  is 
wrapped  in  a  cloth  moistened  with  cold  water  and  the 
air  kept  out  by  a  covering  of  oil-cloth.  These  coverings 
are  changed  every  two  or  three  hours.  A  little  acetate 
of  lead  or  witch-hazel  may  be  added  to  the  water.  Ice 
should  never  be  applied  to  the  fracture ;  it  coagulates  the 
extravasated  blood  too  rapidly  and  produces  anaemia;  in 
short,  all  the  beneficial  effects  of  the  massage  are  undone 
by  ice.  Hot  water,  1  oo°  to  1 05  °  F. ,  in  form  of  local  baths 
applied  for  half  an  hour  each  day  assists  the  massage  by 
removing  the  extravasated  fluid. 

The  second  essential  in  treating  sprains  and  fractures 
by  massage  is  not  to  immobilize  the  joint.  All  immo- 
bilizing of  the  foot  hinders  the  recovery  and  lessens  the 
usefulness  of  the  foot.  The  only  exception  to  this  rule 
has  already  been  mentioned.  Since  in  fractures  of  the 
inner  malleolus  the  foot  is  always  inclined  to  be  pronated, 
that  is,  to  be  flat-footed,  especial  attention  should  be  given 
to  the  position  of  the  foot.  The  leg  should  rest  on  a  solid, 
somewhat  elevated  support.  The  sole  of  the  foot  presses 
against  a  smooth,  polished,  square  board,  which  is  placed 
at  right  angles  to  the  support,  and  in  such  a  manner  that 
the  inner  border  of  the  foot  stands  higher  that  the  outer. 
If  the  astragalus  during  the  treatment  is  inclined  to  be- 
come dislocated  backward,  an  elastic  cushion  should  be 
placed  under  the  heel,  so  that  the  bone  will  be  held  in 
place  by  the  weight  of  the  leg.  The  pes  valgus  position 
of  the  foot  is  most  easily  corrected  by  the  application  of 
an  elastic  flannel  bandage ;  but  the  joint  must  be  left 
freely  movable.  The  advantages  in  not  immobilizing 
the  joint  are  apparent.  The  flexors  and  extensors  of  the 
foot  remain  in  continuous  activity  and  in  the  perpendic- 
ular position  of  the  foot  the  antagonizing  muscles  main- 
tain their  equality.  The  pressure  of  the  foot  against  a 
fixed  surface  provokes  continuous  elastic  movements  in 
the  ankle  around  a  transverse  axis,  which  prevents  the 
formation  of  synovial  adhesions  and  atrophy  of  the  artic- 
ular cartilages.     The  mobilization  of  the  joint  fulfils  for 


September  22,  1894] 


MEDICAL    RECORD. 


373 


the  most  part  the  same  indications  as  the  massage ;  both 
are  equally  important  factors  in  the  cure,  they  combine 
and  co-operate  with  each  other.  The  maintenance  of 
the  muscular  tonus  produces  a  continuous  auto-massage. 
The  patient  himself,  not  being  hindered  by  any  band- 
age, is  continually  tempted  to  test  his  progress ;  he  makes 
active  movements  in  the  injured  joint,  even  when,  as  at 
first,  the  sensations  are  not  agreeable ;  he  is  interested 
in  hastening  the  progress  of  the  cure  by  its  own  activity. 
According  to  my  experience,  it  is  not  advisable  to  make 
passive  movements. 

In  more  serious  sprains  of  the  foot,  the  recovery  re- 
quires four  to  eight  days ;  in  simple  fractures  of  the  outer 
malleolus  ten  to  twenty- one  days;  in  fractures  of  both 
ankles,  especially  with  dislocations  of  the  fragments  and 
luxation  of  the  astragalus,  the  time  is  variable,  usually 
from  four  to  six  weeks.  The  eight  clinical  histories  which 
Lucas  Champonni&re  gives  in  his  lecture  are  all  cases  of 
fracture  of  the  outer  malleolus.  Only  once  was  the  inner 
malleolus  also  dislocated.  In  no  case  was  there  disloca- 
tion or  abnormal  mobility  in  the  ankle-joint.  They 
were  all  treated  with  massage  from  the  first  day  without 
immobilizing  bandages.  Champonntere  considers  the 
first  day  on  which  the  patient  can  walk  without  assistance 
as'  the  day  of  recovery.  The  shortest  time  was  twelve 
days,  the  longest  twenty- eight, 'average,  twenty  and  two- 
tenths  days.  '^TiT*  -  >         !*'• %       -», "? 

In  the  City  Hospital  in  Magdeburg,' sprains  and  fract- 
ures of  the  foot  are  treated  by  massage  since  the  year 
1888.  I  had  the  honor  of  proposing  the  new  mode  of 
treatment  to  my  chief,  Dr.  Hagedorn,  lately  deceased, 
and  we  obtained  results  which  were  new  and  surprising 
to  both  of  us.  The  number  of  cases  treated  in  the  years 
1888  to  1891  was  about  one  hundred.  We  considered 
the  patient  cured  when  he  had  recovered  the  use  of  his 
foot.  The  average  duration  in  sprains  was  seven  days, 
in  single  fractures  of  the  outer  malleolus  twenty  days. 

It  would  take  too  long  to  illustrate  the  simple  cases 
by  clinical  histories.  I  shall  limit  myself  to  a  few  typical 
cases  and  shall  give  the  preference  to  the  severer  one. 

Cass  I. — Man,  twenty-eight  years  of  age.  Fracture 
of  the  external  malleolus  without  dislocation.  Consider- 
able extravasation  of  blood  in  the  ankle-joint.  Massage. 
No  bandages.  Got  up  in  ten  days  and  walked  without 
a  cane.     In  twenty- two  days  able  to  work. 

Case  II. — Strong  laborer,  forty-two  years  of  age. 
Admitted  into  the  hospital  November  6,  1888;  dis- 
charged December  8th ;  the  time,  thirty-two  days.  Fract- 
ure of  the  left  internal  malleolus ;  dislocation  of  the 
lower  fragment,  2ctm.;  foot  not  actively  movable,  hang- 
ing loose  at  the  ankle-joint ;  traumatic  swelling  of  the 
whole  leg  below  the  knee.  Careful  reposition.  Massage 
did  not  remove  extravasated  blood  as  rapidly  as  usual. 

Case  III. — Blacksmith,  twenty-three  years  of  age; 
admitted,  July  29,  1888 ;  discharged  cured,  August  20th; 
time,  twenty- two  days.  Fracture  of  both  malleoli  with 
considerable  dislocation  of  the  fragments.  Pes  varus 
position.  After  careful  reposition,  massage ;  but  as  it 
caused  too  great  pain,  it  was  discontinued  for  two  days; 
limb  placed  in  Volkmann's  splint.  From  August  1st  the 
pain  decreased  rapidly.  Massage  twice  a  day,  ten  min- 
utes each  time.  August  8th,  the  patient  was  able  to 
stand  on  his  foot ;  foot  freely  movable  in  all  directions. 

Case  IV. — Healthy  sailor,  forty-six  years  of  age,  ad- 
mitted October  30,  1888;  discharged  December  13th; 
time,  forty-four  days.  Typical  Pott's  fracture.  Foot 
hanging  loose  from  the  astragalo-tibial  articulation ;  an 
audible  sound  in  making  passive  movements.  Repo- 
sition, massage.  When  discharged  had  still  slight 
oedema  evenings. 

Case  V. — Typical  Pott's  fracture.  Admitted  Novem- 
ber 14,  1889;  discharged  December  12th;  time  twenty- 
eight  days.  Foot  after  reposition  inclined  to  become 
dislocated  backward,  necessitated  the  use  of  Volkmann's 
splint  for  the  first  seven  days  in  connection  with  the 
massage  treatment.  Tendency  to  talipes  position ;  re- 
covery complete.     Considerable  callus  on  each  side. 


Case  VI. — Fireman,  twenty-five  years  01  age;  ad- 
mitted February  10,  1890;  discharged  March  5,  1890; 
time,  twenty- three  days.  Typical  Potts'  fracture ;  great 
extravasation  of  blood  in  ankle-joint,  which  could  not 
be  actively  moved ;  no  dislocation.  No  immobilization ; 
massage.  February  16th  all  movements  of  the  ankle- 
joint  painless ;  beginning  callus  formation. 

Case  VII. — Laborer,  forty-six  years  of  age,  admitted 
December  6,  1888;  discharged  February  16,  1889; 
seventy-two  days.  Pott's  fracture  of  the  left  ankle ;  great 
dislocation  of  the  foot  outward  (pronation);  coEsid  era- 
able  extravasation  of  blood  into  the  ankle-joint.  Mas- 
sage; the  foot  was  held  in  pes  valgus  position  by 
wrapping  in  flannel ;  formation  of  callus  weak  at  first ; 
resorption  of  the  extravasated  blood  followed  promptly. 
On  the  twenty-first  day  of  treatment,  the  patient  got  out 
of  bed  contrary  to  orders  and  walked  about,  before  the 
ends  of  the  fracture  were  consolidated.  The  foot  as- 
sumed in  consequence  a  flat-footed  position  very  difficult 
to  correct  Extensive  formation  of  callus  did  not  begin 
until  the  eighth  week.  At  the  time  of  his  discharge,  the 
ankle-joint  was  freely  movable  actively  and  passively  in 
all  directions;  position  of  the  foot  normal;  walking 
without  pain. 

All  these  cases  were  injuries  occurring  in  healthy  per- 
sons. The  period  of  treatment  exceeded  six  weeks  in 
only  one  case.  This  case  is  given  on  account  of  its 
abnormal  duration  and  the  lack  of  sufficient  formation  of 
callus.  As  a  rule,  an  abundant  callus  formation  is  char- 
acteristic of  the  treatment  by  massage ;  the  periosteum 
reacts  to  the  formative  stimulus  of  the  massage  so  actively 
that  later  on  in  the  treatment  the  point  of  fracture  had 
better  be  left  out  of  the  field  of  massage.  According  to 
more  recent  experience  it  would  be  better  in  such  cases 
to  allow  the  patient  to  move  about  with  ankle  encased 
in  a  well-fitted  plaster  bandage  properly  padded  with  a 
thin  layer  of  cotton.  At  first,  from  motives  of  prudence 
and  because  we  could  not  free  ourselves  entirely  from 
the  immobilizing  of  the  joint,  we  used  Volkmann's 
splint,  especially  at  night.  Later,  in  severe  dislocations, 
as  described  above,  plaster  of- Paris  and  pasteboard  band- 
ages were  used.  If  the  patient  is  restless  or  asleep,  or  if 
he  has  delirium  tremens,  a  light  pasteboard  bandage  may 
be  used. 

The  duration  of  the  treatment  depends  not  only  on 
the  severity  of  the  fracture,  the  amount  of  the  extravasa- 
tion and  the  recurring  faulty  position  of  the  foot,  but 
also  on  the  general  health  of  the  patient,  his  determina- 
tion and  energy,  as  well  as  the  skill  of  the  physician  and 
his  ability  to  render  the  patient  able  to  bear  the  very 
considerable  pain  of  the  first  few  sittings.  In  general, 
treatment  requires  longer  in  women  than  in  men.  Con- 
tra-indications  in  the  treatment  of  massage  are :  Psychi- 
cal disorders,  wasting  diseases  (tuberculosis,  diabetes)  as 
well  as  all  synchronous  acute  or  chronic,  septic  and 
pyaunic  processes.  Injuries  to  the  skin  over  the  region 
to  be  treated  must  be  protected  against  infection  by  seal- 
ing the  wound  with  iodoform  collodion  and  aseptie 
absorbent  cotton. 

When  the  patient  again  returns  to  his  work  oedema- 
tous  swelling  of  the  injured  joint  sometimes  occurs,  or  the 
foot,  when  too  severely  used,  again  takes  the  flat-foot 
position.  To  prevent  this  the  patient  must  for  a  few 
weeks  support  the  injured  limb  with  a  bandage  of  elastic 
flannel  or  silk,  so  as  to  raise  the  inner  margin  of  the  foot. 
Leather  shoes,  not  too  wide,  but  comfortable,  with  a  cork 
sole  on  the  inner  side  of  the  foot,  prevent  an  incorrect 
position.  For  rapid  resorption  of  the  superfluous  forma- 
tion of  bone,  tepid  salt  baths  may  be  used  and  rubbing: 
with  an  ointment  containing  iodine  and  iodide  of  potash. 

The  treatment  of  fractures  and  sprains  must  undoubt- 
edly be  conducted  by  the  physician  himself,  and  only 
when  no  more  complications  need  be  feared  should  the 
massage  be  intrusted  to  a  skilful  and  experienced  nurse. 

It  is  to  be  regretted  that  massage,  the  salutary  effect  of 
which  on  the  organism  has  been  recognized  by  the  oldest 
civilizations,  such  as  the  Chinese,  and  later  the  Greeks,. 


374 


MEDICAL   RECORD. 


[September  22,  1894 


should  be  degraded  to  unworthy  purposes  in  our  modern 
civilization  and  should  be  practised  by  people  whose  total 
ignorance  of  the  human  organism  and  the  characteristics 
of  diseases  occasions  more  harm  than  good.  I  am,  there- 
fore, well  aware  of  the  difficulties  which  have  yet  to  be 
overcome  before  the  practice  of  massage  in  its  various 
forms  will  be  taken  up  by  the  physician  and  recognized 
by  the  public  as  a  necessary  and  desirable  accessory  of 
the  conscientious  physician  in  the  exercise  of  his  profes- 
sion. 


^voQvess  at  f^tjedical  jKcience. 

Renewed  Virulence  of  Staphylococci  after  a  Long 
Period  of  Latency. — Dr.  Schnitzler  relates  the  case  of  a 
patient  who,  at  the  age  of  seven  years,  received  a  severe 
injury  to  the  right  leg,  resulting  in  a  localized  osteo- 
myelitis of  the  tibia.  This  subsided  in  about  six 
months,  after  discharge  of  pus  and  sequestra  (The 
British  Medical  Journal),  The  patient  had  been  quite 
free  from  symptoms,  local  or  general,  for  thirty-five 
years,  when  he  was  suddenly  attacked  by  severe  pain  in 
the  former  seat  of  disease,  attended  by  much  general 
febrile  disturbance.  The  signs  of  localized  osteitis 
quickly  became  manifest ;  there  was  no  discharge.  On 
chiselling  through  the  dense  and  thickened  bone  at  the 
seat  of  disease,  a  closed  cavity,  the  size  of  a  walnut,  con- 
taining granulations  and  pus,  was  found.  In  the  granu- 
lations staphylococcus  pyogenes  aureus  was  present  in  a 
very  virulent  condition,  as  shown  by  inoculation  of  rab- 
bits. Schnitzler  adduces  reasons  for  believing  that  the 
cocci  had  lain  dormant  in  the  cavity  for  the  long  period 
mentioned,  being  brought  once  more  into  activity  by  cir- 
cumstances unknown.  He  rejects  the  supposition  that 
a  fresh  supply  of  cocci  had  been  received  into  the  circu 
lation  and  deposited  at  the  diseased  spot.  He  points 
out  that  staphylococcus  pyogenes  aureus  is  capable  of 
existing  upon  nutrient  media  under  unfavorable  condi- 
tions for  a  very  long  period,  and  argues  that  a  cavity 
containing  granulation  tissue  well  supplied  with  blood, 
such  as  was  present  in  this  case,  offers  a  very  favorable 
prospect  for  the  prolonged  existence  of  micro-organisms. 
There  is  frequent  renewal  of  nutriment  and  removal  of 
waste  products.  The  case,  in  Schnitzler's  opinion, 
shows  that  pyogenic  cocci  are  capable  of  remaining  la- 
tent in  the  human  body  for  a  great  period  of  time,  again 
becoming  virulent  on  some  chance  disturbance  of  the 
normal  processes  of  metabolism.  _> 

Starting-Points  of  Tuberculous  Disease  in  Children. 
— At  a  recent  meeting  of  the  Medical  Society  of  London, 
Dr.  J.  Walter  Carr  read  a  paper  based  on  120  necropsies 
upon  children  suffering  from  tuberculous  disease,  in 
which  he  drew  the  following  conclusions : 

1.  Tuberculous  disease  commences  usually  in  the 
glands,  the  liability  being  at  its  maximum  during  infancy 
and  early  childhood,  and  rapidly  decreasing  in  later 
childhood.  But,  of  the  120  cases,  the  disease  had  al- 
most certainly  commenced  in  the  glands  in  70,  or  58.3 
per  cent,  (including  13  in  which  glands  only  were  in- 
volved), and  in  1 7  more,  or  14.2  per  cent.,  there  was  con- 
siderable probability  at  least  that  the  glands  were  the 
primary  focus.  Including  doubtful  cases,  the  glands 
formed  the  primary  focus  in  64.5  per  cent,  of  those 
under  five,  and  in  only  37  per  cent,  of  those  above  that 
age. 

2.  Tuberculous  lesions  in  the  cervical  glands,  as  in 
the  joints,  may  arise  by  infection  through  the  blood- 
stream, but  caseation  of  the  bronchial  and  mesenteric 
glands,  when  primary,  is  usually,  if  not  always  due  to  di- 
rect infection  from  the  organ  with  which  they  are  con- 
nected, it  having  been  shown  that  bacilli  may  pass 
through  the  lungs  or  the  intestinal  walls  without  produc- 
ing any  recognizable  lesion,  and  that  they  then  enter  the 
lymphatic  channels  and  not  the  blood-vessels. 

3.  Tuberculous  disease  starts  much  more  frequently 
in  the  thorax  than  in  the  abdomen,  and  certainly  far 


more  often  in  the  thoracic  than  in  the  mesenteric 
glands.  Of  the  120  cases,  in  79  the  disease  probably 
started  in  the  thorax  (in  54  certainly,  and  in  12  possibly 
in  the  bronchial  glands) ;  in  20  in  the  abdomen  (in  1 2 
certainly  and  in  2  possibly  in  the  mesenteric  glands) ; 
and  in  6  in  either  one  or  the  other  cavity.  In  only  2 
cases  were  the  cervical  glands  the  probable  primary  fo- 
cus. The  conclusion  is  that,  though  infection  undoubt- 
edly does  occur  through  the  intestines,  and  especially 
(as  experiments  on  animals  have  shown)  through  milk, 
yet  infection  through  air  is  by  far  the  more  frequent  and 
important.  The  disease  is  so  commonly  generalized  in 
children  that  figures  merely  giving  the  frequency  with 
which  different  parts  are  affected  are  of  little  value,  the 
important  point  being  to  ascertain  where  the  disease  is 
most  advanced — that  is,  where  it  probably  commenced. 

4.  Caseation  of  internal  glands,  from  the  frequency 
with  which  it  is  found  after  death,  must  often  exist  alone 
and  quite  unsuspected,  being  doubtless  in  many  cases 
quite  impossible  of  diagnosis,  and  it  is  very  necessary  to 
realize  its  frequency  and  importance  when  dealing  with 
obscure  febrile  conditions  in  children. 

5.  In  regard  to  treatment,  prophylaxis  is  by  far  the 
most  important ;  and  as  it  is  probably  impossible  to  pre- 
vent bacilli  from  obtaining  access,  we  must  try  to  in- 
crease the  resistive  powers  of  the  system  to  their 
entry,  aWrve  all  by  keeping  the  mucous  membranes 
healthy,  by  dealing  promptly  with,  and  if  possible  pre- 
venting, rickets — the  great  cause  of  catarrh  in  early 
childhood — and  by  taking  especial  care  of  children  dur- 
ing convalescence  from  acute  specific  fevers,  which  so 
depress  the  vitality  of  the  body  generally,  and  the  resist- 
ant power  of  the  mucous  membranes,  as  well  as  the  filter- 
ing power  of  the  glands  in  particular. — British  Medical 
Journal, 

The  Cause  of  the  Mai  de  Montague  Experimentally 
Determined. — The  Paris  correspondent  of  The  Lancet 
writes  that  it  is  proposed  to  bore  a  tunnel  or  chimney 
extending  from  the  base  to  the  summit  of  the  Jungfran. 
In  this  chimney,  whose  height  will  be  four  thousand 
metres,  it  is  intended  to  install  a  lift  destined  to  convey 
passengers  to  the  top  of  the  mountain;  but  sinister 
warnings  of  the  dreaded  mat  de  montagne,  which,  it  is 
said,  will  surely  make  the  tourist  repent  his  temerity, 
have  brought  the  project  to  a  standstill.  Struck  by  the 
fact  that  this  malaise  affects  mountain-climbers  at  an  ele- 
vation of  about  three  thousand  metres,  while  aeronauts 
only  suffer  when  they  have  reached  double  that  height, 
M.  Regnard  concludes  that  the  difference  is  explained 
by  the  factor,  muscular  fatigue,  which  is  present  in  the 
first  and  absent  in  the  second  case.  In  order  to  solve 
the  problem  he  places  under  a  bell  jar  two  guinea-pigs 
equally  developed,  of  whom  one  has  to  work  a  wheel 
(the  climber)  while  the  other  is  at  rest  (the  aeronaut). 
The  air  of  the  bell- jar  is  then  progressively  exhausted  so 
as  to  reproduce  the  atmospheric  conditions  obtaining  at 
different  heights.  At  a  pressure  equivalent  to  three 
thousand  metres  the  climbing  guinea-pig  showed  signs 
of  distress,  and  at  four  thousand  eight  hundred  metres 
he  renounced  the  struggle  and  remained  lying  on  his 
back.  The  aeronautic  guinea  pig,  on  the  other  hand, 
appeared  quite  comfortable  up  to  an  elevation  of  six 
thousand  metres,  and  his  condition  became  serious  only 
at  a  height  of  eight  thousand  metres.  This  experiment 
appears  to  prove  that,  although  some  of  the  symptoms 
of  the  mal  de  montagne  are  doubtless  due  to  the  rarefac- 
tion of  the  air,  the  chief  determining  cause  is  fatigue, 
and  the  resulting  exaggerated  consumption  of  oxygen. 
M.  Regnard  opines  that  tourists  who  venture  on  the 
Jungfrau-lift  expedition  will  reach  the  top  in  good  con- 
dition. Should  this  prognostication  be  true,  it  consti- 
tutes one  more  proof  of  the  usefulness  to  speculators  of 
the  much-maligned  experiments  conducted  in  the  phys- 
iological laboratory.  Rabid  anti-viyiaectionists  cannot 
now,  however,  logically  avail  themselves  of  the  above* 
mentioned  mode  of  transit  to  the  top  of  the  Jungfrau. 


September  22,  1894] 


MEDICAL   RECORD. 


375 


Medical  Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


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


New  York,  September  22,  1894. 


THE    ANTITOXIN   TREATMENT   OF  DIPH- 
THERIA. 

The  report  of  Dr.  Biggs  to  the  New  York  City  Health 
Department  on  the  value  of  the  antitoxin  treatment  of 
diphtheria  has  naturally  excited  great  interest  in  lay  as 
well  as  medical  circles.  The  work  in  this  direction  was 
not  unfamiliar  to  our  readers,  for  reports  of  it  have  been 
published  from  time  to  time  in  these  columns.  It  is 
rather  unfair  that  Professor  Koch  should  be  getting  the 
credit,  since  it  is  not  he  who  has  been  making  the  inves- 
tigations, but  Behring,  Aronson,  Katz,  Surinow  and 
others.  Early  in  August,  Dr.  H.  U.  Walker  gave  an 
account  of  the  results  that  had  been  obtained  in  Berlin 
{British  Medical  Journal,  August  18th).  Katz's  report 
of  the  employment  of  Aronson's  antitoxin  in  the  Berlin 
Children's  Hospital  shows  best  what  the  effects  of  treat- 
ment are. 

Dr.  Ratz  states  that,  "  In  the  last  threeyears,  1891  to 
1893,  1,081  cases  of  diphtheria  have  been  treated  in  the 
hospital,  of  which  421,  or  38.9  per  cent,  died,  the  mor- 
tality in  the  respective  years  being  32.5  per  cent,  in 
1 89 1,  35.4  per  cent  in  1892,  and  41.7  per  cent,  in  1893. 
From  the  commencement  of  this  year  up  to  March  14th, 
86  cases  have  been  treated,  with  38  deaths,  or  a  mortal- 
'  ity  of  41.8  per  cent.  On  the  latter  date  the  antitoxin 
treatment  was  commenced  and  employed  in  128  out  of 
151  cases  admitted  to  the  hospital,  23  cases  not  being 
subjected  to  it  for  various  reasons.  In  the  128  cases  so 
treated  only  17  deaths  occurred,  the  mortality  thus  fall- 
ing from  41.7  to  13.2  per  cent.  In  all  his  clinical  ob- 
servations Dr.  Katz  is  able  to  say  that  on  no  occasion 
could  any  deleterious  effect  be  ever  attributed  to  the  em- 
ployment of  the  antitoxin  solution.  If  renal  inflamma- 
tion did  occur,  it  followed  quite  a  normal  course,  no  bad 
effect  could  be  observed  upon  the  rhythm  or  tone  of  the 
heart  and  pulse. 

Quite  lately  Dr.  Katz  has  inoculated  72  children  who 
had  been  exposed  to  the  disease.  Of  these  only  8  were 
attacked,  and  they  so  slightly  as  to  be  free  from  any  evil 
consequences. 

Dr.   Thomas  Eastes  reports,  in  the  British  Medical 
Journal  of  August  25th,  seven  cases  of  diphtheria  suc- 
cessfully treated  by  the  new  method.     He  also  gives  a 
description  of  the  technique  which  we  reproduce  here. 
He  says: 

"  The  syringe  I  have  used  is  Debove's,  a  beautiful  but 
complicated  and  expensive  instrument.    Any  syringe 


will  do  that  can  be  sterilized  either  by  boiling  or  immer- 
sion for  a  few  hours  in  a  five  per  cent,  solution  of  car- 
bolic acid,  but  it  is  better  if  it  will  hold  at  least  5  c.c.  (85 
minims).  The  skin  should  be  washed,  and  then  cleansed 
with  absolute  alcohol  where  the  injection  is  to  be  made. 
The  dose  should  be  1  c.c.  to  produce  immunity  for  any 
aged  over  three,  half  that  for  younger  children.  For 
cure  during  the  first  two  or  three  days  under  two  years  of 
age,  2  to  3  c.c. ;  from  two  to  ten  years  of  age,  5  c.c. ; 
over  ten  years  of  age,  10  c.c.  j  after  the  third  day  in  a 
severe  case  twice  as  much.  If  worse  symptoms  should 
ensue  after  the  injection  the  dose  should  be  repeated  in 
twelve  hours.  It  seems  doubtful  whether  any  symptoms 
whatever  are  caused  by  the  injection,  and  in  cases  of  ex- 
ceptional severity  larger  doses  still  should  be  used. 
Usually  there  will  be  distinctly  less  oedema  and  a  fall  in 
temperature  in  from  twelve  to  twenty-four  hours,  and  a 
most  marked  improvement  in  the  general  condition  in 
forty- eight  hours.  The  advantages  of  this  treatment  are 
many  in  addition  to  its  efficacy.  The  injection  once  for 
all  into  the  tissues  of  the  back  gives  very  little  pain,  and 
there  is  no  more  interference  with  the  patient  required  at 
all — no  more  painting,  spraying,  or  swabbing  the  throat, 
no  tearing  off  false  membrane — and  consequently  a  most 
welcome  diminution  of  suffering  and  distress." 

In  this  connection  it  may  be  stated  that  simpler 
methods  of  preparing  an  antitoxin  have  been  described 
by  Surinow  (Ber.  Klin.  Woch.,  July  23d).  On  the 
ground  of  the  change  from  toxin  to  antitoxin  being  a 
chemical  one,  he  has  endeavored  to  induce,  by  oxida- 
tion or  reduction  processes,  properties  in  the  serum  of 
healthy  or  diseased  animals  like  those  possessed  by  im- 
mune animals.  Positive  results  were  obtained  only  by 
electrolysis.  By  exposing  100  c.c.  of  dog's  serum  to  a 
current  of  120  to  140  milliamperes  from  three  to  four 
hours,  the  author  obtained  a  serum  which,  when  inject- 
ed into  animals,  produced  a  rise  of  temperature.  The 
change  produced  in  the  serum  is  due  to  an  alteration  in 
the  albumin.  Many  animals  were  infected  with  diph- 
theria, etc.,  and  then  treated  with  this  simple  electro- 
lyzed  "serum.  They  all  died,  however,  notwithstanding 
that  a  high  temperature  was  produced.  The  author  then 
took  ordinary  serum,  or  its  constituents,  and  inoculated 
it  with  diphtheria  culture.  After  some  time  toxins  were 
produced.  A  globulin  culture  was  also  made,  but  in 
this  no  toxins  were  developed.  The  serum  or  serum  al- 
bumin cultures  were  then  electrolyzed,  and  it  became 
evident  that  the  toxins  could  then  be  converted  into 
antitoxins.  Animals  were  inoculated  with  diphtheria, 
and  then  treated  with  the  antitoxins  thus  obtained. 
Some  of  the  experiments  were  not  successful,  but  it  was 
thought  that  a  more  powerful  antitoxin  could  be  ob- 
tained* It  was  found  out  that  electrolysis  of  a  bouillon 
diphtheria  culture  also  converted  the  toxins  into  anti- 
toxins. After  a  certain  time  a  color  reaction  is  devel- 
oped in  the  electrolyzed  fluid,  and  at  this  time  the  elec- 
trolysis should  cease.  Some  successful  experiments  are 
then  recorded  where  the  antitoxins  from  this  electrolyzed 
bouillon  were  used  instead  of  those  from  electrolyzed 
serum  or  serum  albumin.  It  was  found  that  a  single 
large  dose  administered  subcutaneously  was  more  effi- 
cient than  divided  doses.  The  antitoxins  were  harmless 
to  the  animals,  and  preserved  their  properties  for  a  long 
time. 


376 


MEDICAL   RECORD. 


[September  22,  1894 


SARSAPARILLA,  CELERY,  AND  RED  CLOVER. 

We  have  at  different  times  referred  to  the  curious  popu- 
larity of  sarsaparilla  and  its  growing  rival,  celery.  It  is 
abundantly  shown  that  neither  of  these  plants  have  any 
real  therapeutic  properties.  A  third  candidate  for  popu- 
lar favor  is  "red  clover,"  and  this  seems  equally  defi- 
cient in  therapeutic  or  physiological  properties*.  Ac- 
cording to  the  announcements  clover  extract  has  a 
"  great  and  growing  reputation  as  a  blood-purifier,  and 
as  a  specific  for  cancers."  The  number  of  individuals 
whose  "cancers  "  are  said  to  have  been  aborted  or  dis- 
persed by  clover-tea  is  legion.  It  is  not  only  good  for 
"cancers,"  but  for  other  morbid  productions,  even 
"carbuncle"  and  "scrofula." 

It  is  needless,  says  the  Boston  Medical  and  Surgical 
Journal^  to  say  that  no  medicinal  principle  has  yet  been 
obtained  from  the  trifolium.  We  shall  expect  next  to 
see  an  extract  from  the  potato  or  turnip  vaunted  for  can- 
cer or  syphilis !  There  is,  by  the  way,  still  a  belief  in 
certain  localities  that  the  tomato  is  a  cause  of  cancerous 
growths !  Our  contemporary  adds :  It  is  hard  to  account 
for  the  repute  that  clover  has  acquired  among  the  laity 
of  this  country  as  a  remedy  for  cancer.  In  many  parts 
of  New  England  we  know  it  to  be  almost  impossible  for 
a  person  to  have  a  suspicious  growth  of  any  kind  with- 
out being  urged  to  take  clover,  and  the  urging  is  per- 
sistent. In  a  certain  neighborhood  near  Boston,  one 
woman,  afflicted  with  growing  scirrhus,  is  said  to  have 
consumed  in  extracts  and  infusions  of  red  clover  the 
product  of  a  ten  acre  lot ;  but  without  saving  her  life. 
The  fact  that  the  cancers  do  not  disappear,  despite  the 
free  use  of  the  antidote,  appears  to  detract  in  no  measure 
from  the  sale  or  use  of  the  preparation. 

There  is  no  sound  basis  for  the  reputation  which  red 
clover  has  acquired,  and  the  only  persons  who  have  ever 
derived  any  advantage  from  the  use  of  clover  in  cancer, 
furuncle,  or  various  "  humors,"  are  the  venders  of  cer- 
tain extracts,  fluid  and  solid,  which  are  in  growing  de- 
mand. 

THE   GAS   HABIT. 

The  so  called  "exposures  "  made  by  the  daily  papers  are 
often  sensational,  exaggerated,  and  unjust.  A  reporter 
of  The  Herald,  however,  has  done  some  service  by  in- 
vestigating one  of  the  compound  oxygen  establishments 
in  this  city.  Oxygen  is  a  substance*  which  to  the  lay 
mind  represents  all  that  is  fresh  and  pure  and  life-sus- 
taining in  the  line  of  gases.  "  Compound  oxygen  "  is 
a  term  which  gives  the  impression  that  it  is  something 
several  times  better  than  oxygen.  Hence  it  is  a  name 
that  has  long  been  popular  with  the  fakirs.  Some  ad- 
vertised preparations  of  it  have  been  inhaled,  some 
taken  internally,  all  with  the  result  of  receiving  numer- 
ous testimonials.  The  establishment  whose  methods 
have  lately  been  exposed  dispensed  under  the  name  of 
"  compound  hydrogen  "  a  gaseous  mixture  of  about  two 
parts  nitrous  oxide  and  one  part  atmospheric  air.  This 
was  administered  by  means  of  an  elaborate  apparatus 
which  enabled  the  patient  to  recline  at  his  ease  and  in- 
hale the  gas  slowly  and  intermittently.  The  stimulant 
effect  of  the  mixture  was  thus  obtained  without  inducing 
anaesthesia  or  unconsciousness.  Patients  describe  the 
effect  as  very  delightful,  and  many  returned  for  weeks 


and  months  in  order  to  enjoy  this  seductive  form  of 
inebriety* 

There  seems  little  doubt  that  a  gas  hatih  or  a  form  of 
gas-inebriety  can  be  induced  by  this  promiscuous  admin- 
istration of  the  "  compound  oxygen."  One  case  indeed 
is  on  record  (Robert's  Intoxications n)  in  which  a  per- 
son acquired  the  habit  and  eventually  became  insane. 
The  ether  habit  and  chloroform  habit  are  well  known, 
and  there  is  no  reason  to  doubt  that  given  the  opportu- 
nity, the  nitrous-oxide  habit  may  be  formed  also.  The 
effects  of  this  gas  are  usually  very  temporary  and  it 
would  require  a  good  deal  of  time  for  serious  results  to 
ensue,  provided  the  anaesthetic  were  given  with  care. 
But  it  is  well  known  that  nitrous  oxide  is  not  a  perfectly 
safe  substance.  Deaths  from  its  use  have  occurred,  and 
cases  of  serious  nervous  disorder  are  reported  to  have 
followed  its  administration.  It  is  in  fact  a  poison,  and 
we  believe  that  it  should  not  be  administered  except  un- 
der the  direction  of  duly  qualified  persons.  The  dis- 
penser of  the  "  compound  oxygen  "  is  said  not  to  be  a 
physician,  and  he  certainly  is  not  registered  as  such. 
Establishments  for  giving  nitrous  oxide  to  patients  would 
come  in  the  same  class  as  establishments  for  giving  chlo- 
roform or  ether  or  administering  hypodermics  of  mor- 
phine. There  is  no  use  for  such  places;  they  do  not 
subserve  the  public  good ;  they  are,  on  the  contrary, 
dangerous,  and  we  should  judge  entirely  unlawful. 

It  is  about  time  that  "  compound  oxygen  "  humbugs 
were  exposed  and  the  people  made  acquainted  with  their 
true  character. 


THE  TREATMENT  OF  CHRONIC  HEART  DIS- 
EASE  BY   BATHS   AND   MASSAGE. 

The  mechanical  treatment  of  chronic  heart  disease  has 
now  been  accepted  by  the  profession  as  having  a  certain, 
though  limited,  value.  This  treatment,  as  oftenest  em- 
ployed, consists  in  regular  pedestrian  exercise  over 
fixed  courses  which,  as  a  rule,  have  a  gradual  ascent. 
Gymnastic  exercises  at  home,  and  baths,  supplement 
this. 

In  addition  to  this  method  of  cardio- therapy,  we  hear 
periodically  of  the  special  method  devised  by  the 
brothers  Schott,  of  Nauheim.  A  pilgrim  to  that  spot. 
Dr.  W.  Bezly  Thome,  has  recently  described  again  the 
remarkable  efficacy  of  the  Schott  treatment,  and  has  re- 
ported a  number  of  illustrative  cases  (Lancet,  May  5, 
1894).  The  patients  who  are  treated  at  Nauheim  follow 
a  method  which  has  been  elaborated  "after  eighteen 
years  of  study,"  though  we  doubt  if  there  is  much  differ- 
ence between  what  is  done  now  and  what  was  done  eight 
years  ago.  The  measures  employed  consist  of  baths 
and  passive  and  active  movements  known  as  Wider- 
standgymnastik.  The  most  frequently  employed  are 
those  containing  one  and  a  half  per  cent,  of  sodium 
chloride,  one  and  a  half  per  thousand  of  calcium  chloride 
and  salts  of  iron,  with  a  variable  proportion  of  carbonic 
acid  gas.  They  possess  a  natural  temperature  of  88°  to 
950  F.  The  baths  are  given  daily,  and  are  followed  by 
an  hour's  repose  in  the  recumbent  posture ;  while  in  the 
bath  the  patient  is  subjected  to  various  movements. 
The  extremities  are  slowly  flexed,  extended,  abducted, 
adducted,  rotated,  etc.,  by  the  operator,  while  the  patient 
breathes  slowly  and  makes  resistance. 


September  22,  1894] 


MEDICAL   RECORD. 


377 


The  effects  are  manifest  in  a  diminution  of  cardiac' 
dilatation  and  slowing  of  the  pulse  rate.  The  exact 
technique,  of  course,  can  only  be  acquired  by  experience, 
but  the  baths  themselves  can  be  artificially  prepared,  and 
there  seems  to  be  no  reason  why  physicians  in  this  coun- 
try should  not  be  able  to  apply  successfully  the  treat- 
ment. 

THE  PNEUMATIC   CABINET. 

Those  who  have  heard  that,  some  four  years  ago,  the  last 
of  the  stock  of  pneumatic  cabinets  had  been  sold  for  old 
iron,  will  perhaps  be  surprised  to  know  that  Dr.  C. 
E.  Quimby,  according  to  a  reprint  just  received,  has  not 
given  up  his  instrument  nor  allowed  this  method  of  treat- 
ing phthisis  to  pass  wholly  into  oblivion.  While  ac- 
knowledging his  ignorance  of  what  the  cabinet  can  do 
alone  in  the  cure  of  phthisis,  he  claims  to  demonstrate 
that,  scientifically  applied,  it  must  act  favorably  in  con- 
junction with  other  measures  of  proven  value.  After  six 
years'  experience,  the  writer  believes  that  "  from  seventy- 
five  to  eighty  per  cent,  of  localized  tuberculosis,  if  seen 
reasonably  early  in  the  first  stage,  can  be  brought  to  and 
kept  in  a  condition  of  practical  cure  by  the  use  of  the 
pneumatic  cabinet  and  adjuvant  measures  other  than  cli- 
mate." Disseminated  tuberculosis  subacute  and  third 
stage  cases  are  found  to  be  correspondingly  relieved  and 
benefited. 

The  alternation  during  each  respiration  of  negative 
differentiation  and  negative  pressure  is,  the  writer  be- 
lieves, the  most  comprehensive  motion  of  the  cabinet,  and 
one  which  has  received  little  attention.  The  value  of 
full  inspiration  until  circulatory  equilibrium  is  estab- 
lished and  exhalation  into  the  rarefied  air  of  the  cabinet, 
is  explained,  and  it  is  shown  how  the  blood  is  pumped 
into  and  out  of  the  lung  in  the  physiological  direction 
without  increase  of  vascular  tension. 

In  fine  the  claim  is  advanced,  that  the  cabinet  acts  cur- 
atively,  to  a  greater  or  less  degree,  upon  all  the  factors  of 
phthisis  except  the  bacillus  itself. 


%zws  at  Xhz  WLz&k. 

Further  Hews  About  Diphtheria  Antitoxin. — In  the 
Berliner  klinische  Wochenschrift  of  September  3d,  Bea- 
ring publishes  a  paper,  in  which,  among  other  points,  he 
deals  with  the  question  of  dose.  He  states  that  the  se- 
rum prepared  and  tested  under  his  own  supervision  and 
that  of  Ehrlich  is  now  issued  in  two  forms — No.  I.  and 
No.  II.;  No.  II.  is  two  and  a  half  times  stronger  than  No. 
I.  No.  I.  is  sufficient  for  the  treatment  of  a  case  of 
diphtheria  in  a  child  under  ten  years  of  age,  if  it  be  seen 
on  the  second  or  third  day.  In  cases  of  longer  standing, 
in  those  of  a  very  severe  type  in  young  children,  and  in 
adults,  a  repetition  of  the  injection  will  be  necessary. 
No.  II.  serum  acts  more  surely  and  rapidly  in  these  cases, 
but,  owing  to  the  difficulty  of  rendering  the  animals 
sufficiently  immune  to  provide  a  serum  endowed  with  im- 
munizing powers  so  strong,  a  constant  supply  cannot  be 
insured.  The  estimation  of  the  exact  strength  of  the 
serum  is  a  difficult  matter,  and  it  must  be  recognized  that 
the  strength  is  liable  to  vary  with  the  commercial  source 
from  which  it  is  obtained.     Behring  and  Ehrlich  have 


devised  a  method  of  expressing  the  strength  in  figures. 
Their  No.  I.  (quality  and  quantity)  contains  10  c.c, 
which  is  equal  to  600  antitoxin  normals,  and  is  sufficient 
for  one  case  with  the  limitations  already  mentioned. 
No.  II.  contains  11.5  c.c.  of  a  strong  serum,  and  is 
equivalent  to  about  1,500  antitoxin  normals.  Behring 
now  estimates  that  the  death-rate  of  cases  treated  within 
forty-eight  hours  of  the  onset  of  the  disease  with  No.  I. 
ought  not  to  exceed  five  per  cent.  The  dose  to  be  in- 
jected as  a  prophylactic  in  persons  liable  to  be  exposed 
to  diphtheria  is  set  down  by  Behring  at  60  antitoxin 
normals,  or  one-tenth  of  No.  I.  After  infection,  that  is 
during  the  incubation  stage,  he  believes  that  150  anti- 
toxin normals  ought  to  avert  the  development  of  the  dis- 
ease. 

M.  Crispi  will  soon  be  operated  upon  for  cataract. 

A  Monument  to  Volkmann  was  unveiled  on  Septem- 
ber 4th,  and  one  to  Dr.  Testelin,  of-  Lith,  on  the  same 
day.  A  monument  to  Quatrefages  has  recently  been 
completed. 

Dr.  Theophilus  Patterson,  of  Salem,  N.  J.,  died  at 
his  residence  in  that  city  on  September  7  th.  He  was 
born  in  Salem  County  in  1827,  and  was  graduated  from 
the  Jefferson  Medical  College,  Philadelphia,  in  1848, 
being  a  pupil  of  Dr.  J.  K.  Mitchell,  the  father  of  Dr.  S. 
Weir  Mitchell  He  almost  immediately  began  practice 
in  Salem  and  lived  there  in  the  active  exercise  of  his  pro- 
fession for  forty-six  years.  He  was  always  interested  in 
educational  matters,  and  was  largely  instrumental  in  rais- 
ing the  standard  of  the  public  schools  in  Salem  during 
a  number  of  years  in  which  he  held  the  office  of  city 
superintendent.  A  wife  and  four  children,  one  of  them 
also  a  physician,  survive  him. 

Dr.  Horace  Ingersoli  died  a  few  days  ago  at  Salem, 
Mass.,  at  the  age  of  eighty -three.  Besides  medicine  he 
also,  at  different  periods,  studied  and  practised  theology 
and  law.  He  was  a  friend  of  Hawthorne,  and  was  cred- 
ited by  the  latter  as  being  the  one  who  suggested  the  in- 
cidents in  the  "  Scarlet  Letter.'' 

Cycling  in  Paris. — A  Paris  correspondent  writes  that 
there  are  over  one  hundred  thousand  cyclists  in  that  city, 
that  nearly  all  the  leading  physicians  ride,  next  come 
the  lawyers,  then  the  deputies,  officers,  and  even  the  In- 
stitute; the  family  physician  prescribes  the  exercise  as 
the  most  health- giving  ever  devised. 

Japanese  Nurses. — A  corps  of  trained  female  nurses 
has  been  despatched  from  the  Tokio  Training  School  to 
the  military  hospital  at  Seoul,  and  others  are  being 
trained  for  this  service.  Throughout  all  Japan,  it  is  said, 
the  women  have  caught  the  war  fever,  and  the  greatest 
enthusiasm  prevails.  A  number  of  women  of  high  rank 
have  offered  to  go  to  the  seat  of  war  as  volunteer  nurses, 
and  others  have  even  offered  to  raise  a  corps  of  female 
soldiers. 

A  Quick  Answer. — A  correspondent  sends  us  a  story 
told  of  an  old  country  doctor  down  East.  In  the  latter 
years  of  his  life  his  ankles  became  very  weak,  necessitat- 
ing the  wearing  of  a  pair  of  steel  braces.  One  day,  as 
the  old  gentleman  was  shuffling  along  on  Exchange 
Street  in  Bangor,  Me.,  some  young  wag  called  out: 
"Hi,  doctor,  hi,  you  are  interfering!  "  "Not  with 
other  folks  business,  young  man  !  "  retorted  the  doctor. 


378 


MEDICAL    RECORD. 


[September  22,  1894 


Yellow  Payor  of  a  malignant  type  is  reported  to  be 
epidemic  in  the  coast  regions  of  Nicaragua. 

Traction  on  the  Tongue  in  Hysteria.— Th.  Balade 
(Gaz.  des  H6p.  de  Toulouse,  July  28th)  has  in  two  cases 
made  very  violent  hysterical  attacks  cease  by  traction  on 
the  tongue,  the  organ  being  drawn  with  some  force  out 
of  the  mouth,  and  kept  in  that  position  for  some  min- 
utes. This  procedure  was  successful  when  every  other 
treatment  had  failed. 

Dr.  8.  Hembury  Smith  died  on  September  12th,  in 
Brooklyn,  N.  Y.  He  was  born  in  England  in  1810,  and 
was  graduated  in  London  in  183 1.  He  studied  later  and 
practised  in  Stockholm;  he  came  to  this  country  in  1847, 
settling  in  Cincinnati.  He  afterward  came  to  New  York, 
where  he  was  engaged  for  a  number  of  years  in  the  manu- 
facture of  artificial  mineral  waters. 

To  Celebrate  the  Discovery  of  Anaesthesia.— Mr. 
Charles  J.  Wells,  of  Hartford,  is  announced  to  be  the 
only  living  descendant  of  Dr.  Horace  Wells,  the  discov- 
erer of  anaesthesia.  He  is  said  to  be  taking  a  deep 
interest  in  the  arrangements  now  in  progress  for  celebrat- 
ing the  fiftieth  anniversary  of  his  father's  great  contribu- 
tion to  surgical  practice.  Mr.  Wells  has  been  consulted 
by  the  committee  from  the  Connecticut  Dental  Associa- 
tion, which  has  charge  of  the  arrangements  in  this  city, 
and  is  in  complete  accord  with  the  project  for  a  bronze 
tablet  to  be  placed  on  the  site  that  was  occupied  fifty 
years  ago  by  the  discoverer's  office. 

What  a  Maniac  oan  Stomach  — One  of  the  medical 
officers  of  the  County  Asylum,  Lancaster,  contributes 
to  The  Lancet  an  account  of  an  operation  upon  a  luna- 
tic from  whose  incoherent  statements  it  was  suspected 
that  he  had  swallowed  some  nails.  Forceps  passed  into 
the  stomach  having  failed  to  extract  any  foreign  bodies, 
though  they  could  be  felt  from  the  outside ;  it  was  de- 
cided to  attempt  to  relieve  the  man  by  operation.  On 
incision,  the  stomach  was  found  to  be  occupied  by  a 
mass  of  rusty  nails,  many  of  them  nearly  three  inches  in 
length,  and  some  very  sharp,  bent,  and  twisted.  Their 
removal,  naturally,  was  very  tedious,  as  many  of  them 
could  only  be  extracted  one  at  a  time.  A  piece  of 
matted  hair,  nearly  two  inches  in  length,  was  also 
found.  In  all,  there  were  removed  from  the  stomach 
one  hundred  and  ninety-two  nails  (the  majority  being 
two  and  a  half  inches  in  length,  and  many  even  longer), 
half  a  screw-nail,  a  piece  of  brass  wire,  a  carpet  tack, 
several  small  pieces  of  stick,  a  button,  and  the  mass  of 
hair  already  mentioned.  The  whole  weighed  one  pound 
nine  and  one- half  ounces.  Several  pieces  of  wood  were 
found  in  the  patient's  intestines,  but  no  nails. 

The  Country  Doctor  and  Post-Graduate  Study. — The 
editor  of  the  Post  Graduate  has  made  an  interesting 
analysis  of  the  place  of  residence  of  three  thousand  eight 
hundred  and  twenty- four  matriculates  of  the  New  York 
school.  The  students  were  divided  into  four  classes, 
according  as  they  came  from  large  cities,  having  a  popu- 
lation of  over  one  hundred  and  fifty  thousand  ;  medium 
cities,  having  a  population  of  over  twenty-five  thousand  ; 
small  cities,  having  a  population  of  over  ten  thousand ; 
finally  towns  and  villages.  We  find  from  the  figures 
that  have  been  furnished  us  that  there  is  a  pretty  even 
distribution  of  matriculates  in  all  four  classes.     The 


towns  and  villages,  however,  rank  at  the  bottom  with 
six  hundred  and  ninety- five  students,  while  the  medium 
cities  are  at  the  top  of  the  list  with  eleven  hundred  and 
four.  On  the  whole,  one  can  see  that  it  is  die  medium 
cities  and  large  towns  that  furnish  the  greater  number 
of  matriculates.  The  number  from  the  large  cities  is 
relatively  small.  Another  interesting  fact  which  is  de- 
veloped by  the  study  of  tables  is  this :  The  physicians 
from  the  towns  and  villages  are  coming  to  us  in  increas- 
ing number  every  year.  During  the  first  four  years  of 
the  school,  not  more  than  twenty- five  or  thirty  came 
from  this  class,  but  in  the  last  year  or  two  the  numbers 
have  exceeded  one  hundred,  and  last  year  the  villages 
and  towns  of  the  United  States  furnished  as  many  stu- 
dents as  the  large  cities. 

This,  adds  the  editor,  is  certainly  an  interesting,  and 
we  would  add  a  hopeful,  sign.  It  shows  that  the  doc- 
tors in  the  smaller  places  are  making  a  living,  and  a  lit- 
tle more,  and  what  is  still  better,  it  shows  that  they 
possess  a  desire  to  keep  abreast  of  the  times,  and  that 
this  desire  is  even  keener  than  that  which  the  city  phys- 
icians have ;  for  it  must  be  remembered  that  it  requires 
no  small  sacrifice  for  a  country  doctor  to  leave  his  prac- 
tice, turning  over  his  patients  to  the  care  of  a  brother 
physician  with  whom  his  relations  may,  perhaps,  have 
been  sometimes  a  little  strained,  and  of  whose  experience 
and  skill  he  has,  perhaps,  himself  once  expressed  a  slight 
amount  of  doubt.  But  it  is  evident  that  a  country  doc- 
tor is  bound  to  learn,  and  that  he  is  learning  and  is 
keeping  as  alert  in  every  direction  as  his  city  brother. 

The  Late  Dr.  Albert  B.  Miles,  House  Surgeon  of  the 
Charity  Hospital  of  New  Orleans,  left  $10,000  each  to 
the  following  institutions :  Medical  Department  Tulane 
University  of  Louisiana ;  Charity  Hospital  of  New  Or- 
leans ;  and  the  Hotel  Dieu,  also  of  New  Orleans. 

Fighting  the  Diploma  Trade.— Dr.  C.  T.  Metcalf, 
Secretary  of  the  Indiana  State  Board  of  Health,  has  in- 
structed the  county  boards  of  health  to  notify  clerks  of 
court  to  refuse  licenses  on  the  diplomas  of  the  "  Marion 
Physico  Medical  School  of  Indiana  and  Marion." 

Physicians'  Protective  Association. — The  first  annual 
meeting  of  the  Physicians'  Protective  Association  of  De- 
troit was  held  September  4th.  Reports  of  officers 
showed  a  prosperous  year,  $9,916  in  outstanding  ac- 
counts having  been  collected.  Officers  for  the  ensuing 
year  were  elected  as  follows :  President,  Dr.  L.  J.  Len- 
nox ;  Vice  President,  Dr.  R.  H.  Stevens ;  Secretary, 
Dr.  P.  M.  Hickey ;   Ireasurer,  Dr.  S.  H.  Knight. 

The  Office  of  Coroner  to  be  Abolished. — The  Consti- 
tutional Convention  at  Albany  has  adopted  the  first 
amendment  abolishing  the  office  of  coroner  in  this  State 
as  a  constitutional  office.  The  purpose  of  the  amend- 
ment is  said  to  be  to  make  it  possible  for  the  Legislature 
to  provide  that  only  physicians  shall  exercise  the  duties 
now  performed  by  elected  coroners. 

The  Medical  Society  of  the  Missouri  Valley  held 
its  seventh  annual  meeting  in  Council  Bluffs,  Iowa,  on 
Thursday,  September  20th.  The  programme  contained 
the  titles  of  twenty- five  papers  presented  by  members  of 
the  Society  from  Missouri,  Jowa,  and  Nebraska.  Dr. 
A.  F.  Jonas,  of  Omaha,  was  President,  and  Dr.  F.  S. 
Thomas,  of  Council  Bluffs,  Secretary. 


September  22,  1894] 


MEDICAL  RECORD. 


379 


BEAVEN  NEAVE  RAKE,  M.D., 

TRINIDAD,   WIST  INDIES. 

With  profound  regret  we  notice  the  death  of  Dr. 
Beaven  Neave  Rake.  A  cablegram  received  in  London 
announced  the  sad  event.  He  died  in  Port  of  Spain, 
Trinidad,  British  West  Indies,  August  24th,  of  fever — 
presumably,  yellow  fever,  as  it  has  prevailed  there  in  epi- 
demic form  for  several  months  past. 

Dr.  Rake  was  one  of  the  world's  recognized  specialists 
in  leprosy.  He  had  made  its  study  the  work  of  his  life. 
2  he  Lancet^  London,  September  1st,  referred  to  him  as 
having  been  "  one  of  the  greatest  authorities  "  on  that 
disease. 

Ere  entering  on  the  study  of  medicine  and  surgery  he 
had  received  a  thorough  classical  education.  He  be- 
came a  member  of  the  Royal  College  of  Surgeons  of 
England  in  1879,  a  Licentiate  of  the  Royal  College  of 
Physicians  of  London  in  1880,  a  Bachelor  of  Medicine, 
University  of  London,  1881,  and  a  Doctor  of  Medicine 
of  the  same  in  1882.  He  had  had  seven  years'  hospital 
experience  in  London,  one  year  on  the  Continent,  one 
year  in  the  East  Indies,  studying  leprosy,  and  nearly  ten 
years  as  Chief  Medical  Officer  at  the  Trinidad  Lepers' 
Asylum. 

He  was  a  member  of  the  Pathological  Society  of  Lon- 
don, the  British  Medical  Association,  Pan-American 
Medical  Congress,  Washington,  1893,  Trinidad  Medical 
Society,  etc.,  etc. 

He  was  a  faithful  and  indefatigable  worker,  a  man  of 
keen  perceptive  powers  and  sound  judgment.  His  early 
training  had  eminently  fitted  him  for  the  government 
appointment  at  Trinidad.  He  was  an  able  and  prolific 
writer.  His  original  observations  have  been  published 
in  England  in  The  Lancet  In  America  the  Medical 
Record  published  his  last  paper — being  a  concise  sum- 
mary of  his  observations.  That  paper,  specially  pre- 
pared, appeared  in  its  columns  a  few  months  ago. 

All  students  of  leprosy  will  remain  profoundly  grateful 
for  the  veritable  "arsenal  of  facts"  that  he  has  left  on 
record.  His  name  will  ever  rank  as  an  original  worker 
and  thinker. 

While  on  the  Anglo-Indian  Commission  he  and  his 
associates  examined  the  histories  of  over  two  thousand 
cases  of  leprosy ;  in  but  two  instances  could  contagion 
have  been  a  factor ;  sensationalism  in  medicine  he  dep- 
recated. For  twenty-eight  years  past  the  Sisters  of  Char- 
ity have  had  exclusive  charge  of  the  Trinidad  Lepers' 
Asylum ;  not  an  instance  can  be  cited  where  they  have 
become  infected. 

At  the  Pan-American  Medical  Congress  he  read  a 
paper  on  leprosy  before  the  Section  on  Dermatology, 
and  addressed  the  Sections  of  Hygiene  and  Climatology 
on  the  same. 

Death,  in  selecting  him  at  the  early  age  of  thirty-six, 
has  taken  from  us  a  bright  and  shining  light;  but  "  his 
good  works  will  live  after  him."  He  died  like  a  brave 
soldier,  fighting  disease  during  an  epidemic.  He  had 
warm  friends  the  world  over.  The  warm  shake  of  the 
hand,  the  frank,  manly  glance  of  the  eye,  will  be  re- 
membered. He  was  one  of  God's  greatest  works — "  a 
true  man."  His  genial  manners  and  quiet  dignified 
way  have  left  a  living  impress  on  his  time  and  profession. 
He  leaves  a  widow  and  three  little  sons.  The  highest 
compliment  that  can  be  paid  a  member  of  our  profession 
is  his  first  due—"  He  did  his  duty." 


A  Comfortable   Ailment    Desired Lady  medicals 

are  at  times  hard  pressed  for  patients,  as  the  following 
little  wail  will  show:  "  Wanted — the  care  of  an  invalid 
lady  of  means  (comfortably  ill),  who  will  appreciate  best 
of  medical  skill  and  competent  nursing ;  with  kindly, 
sympathetic  attention.  Address  Lady  Physician,  Herald 
Agency,  708  Columbus  Av." 


QPlittixal  gjqrartmettt 

TABES  DORSALIS    IN  A    WOMAN  TWENTY- 
THREE  YEARS  OLD. 

By  L.    PIERCE  CLARK,    M.D., 

MIDDLBTOWN,   COKN. 

This  case  of  tabes  dorsalis  in  a  woman  but  twenty- 
three  years  old,  came  under  my  observation  when  I  was 
house  physician  at  the  workhouse  hospital,  on  Black- 
well's  Island.  She  was  admitted  to  the  hospital  and  re- 
mained there  for  four  weeks,  during  which  time  she  made 
little  or  no  improvement. 

Five  years  previous  to  her  admission  she  contracted 
syphilis  in  a  very  severe  form,  and  its  treatment  was  al- 
most entirely  neglected  until  the  tertiary  symptoms 
made  their  appearance,  when  she  took  the  baths  at 
Hot  Springs,  Ark.,  for  six  months.  But  they  gave  her 
little  relief.  For  seven  years  she  had  used  alcoholic 
stimulants,  taking  sometimes  twenty  or  thirty  drinks  a 
day.     The  remainder  of  her  history  is  as  follows : 

Name  A.  D ;  aged  twenty- three ;  single ;  had  been 

a  prostitute  for  six  years ;  family  history  good.  She  had 
never  been  sick  before  her  present  illness ;  at  least  not 
sufficient  to  incapacitate  her  for  her  abnormal*  occupa- 
tion. The  present  attack  began  about  eight  months 
prior  to  her  admission  to  the  hospital.  After  one  of  her 
usual  debauches,  lasting  four  days,  she  complained  of 
faint  and  dizzy  sensations,  which  came  on  every  three 
or  four  days,  and  lasting  only  an  hour  or  so.  These 
attacks  gradually  increased  until  they  were  of  almost 
daily  occurrence,  lasting  three  or  four  hours  each  time. 

One  month  from  these  first  symptoms  of  dizziness,  etc. , 
vomiting  and  sharp  lancinating  pains  in  the  epigastrium 
began.  The  vomiting  was  projectile  in  character,  and 
the  pains  in  epigastrium  radiated  from  a  central  point  in 
all  directions,  especially  toward  the  vertebral  column. 
This  attack  was  also  attended  by  purging.  It  lasted  for 
two  days,  during  which  time  she  was  obliged  to  remain 
in  bed.  Notwithstanding  the  severity  of  the  attack  she 
recovered,  so  as  to  be  about  on  the  third  day,  and  was  as 
well  as  ever,  save  the  faint  and  dizzy  sensations  which 
continued  to  trouble  her  greatly,  when  she  had  taken 
considerable  exercise.  For  the  next  five  months  she 
used  stimulants  very  freely. 

At  the  time  of  her  admission  to  the  workhouse  on  the 
charge  of  "soliciting,"  she  had  the  appearance  of  one 
who  had  been  suffering  from  syphilis  and  the  abuse  of 
alcohol  for  a  long  .time,  although  she  was  in  fair  physical 
health.  She  was  unable  to  walk  to  any  great  extent,  and 
complained  constantly  of  sharp,  darting  pains  in  legs, 
inability  to  see  clearly,  and  occasionally  saw  double. 
These  eye  symptoms  had  been  more  or  less  prominent 
for  past  two  months. 

Physical  examination  revealed  entire  absence  of  knee- 
jerk,  immobility  of  pupils,  the  right  being  a  little  larger 
than  the  left.  The  girdle  sensation  was  present  around 
upper  and  lower  abdomen.  There  was  swaying  on  stand- 
ing and  the  gait  was  markedly  ataxic.  There  was  also 
present  some  inco-ordination  of  upper  extremities.  The 
feet  were  numb  and  cold,  and  the  cutaneous  sensation  to 
pin- prick  was  perceptibly  delayed  and  diminished  over 
lower  extremities. 

On  her  discharge  her  symptoms  remained  about  the 
same,  except  the  gait,  which  showed  some  improvement, 
probably  because  the  alcohol  had  nearly  all  left  the  sys- 
tem. 

This  case  was  diagnosed  on  admission  as  one  of  alco- 
holic neuritis,  because  of  her  alcoholic  condition  at  the 
time  of  her  arrival  at  the  workhouse,  and  the  subjective 
symptoms.  But  upon  obtaining  a  syphilitic  history,  and 
the  presence  of  the  effects  of  syphilis  yet  remaining, 
together  with  the  absence  of  a  great  many  of  the  symp- 
toms found  in  alcoholic  neuritis,  such  as  diminished 
motor  power,  tenderness  along  course  of  nerves,  and 


38o 


MEDICAL    RECORD. 


[September  22,  1894 


atrophy  of  any  of  the  muscles,  we  had  sufficient  evidence 
to  cause  a  more  careful  inquiry  into  the  case,  which  re 
suited  in  the  above  diagnosis  of  tabes  dorsalis.     No 
mental  symptoms  were  present. 

It  is  just  possible  that  a  peripheral  neuritis  of  alcoholic 
origin  was  present  in  this  case  together  with  tabes. 

The  early  vomiting,  pains  in  epigastrium,  and  purging 
which  came  on  without  any  apparent  cause  and  disap 
peared  entirely  in  two  days,  seems  to  me  to  be  a  form  of 
visceral  crisis  quite  frequently  found  in  tabes.  I  think 
the  case  is  one  of  considerable  interest,  as  it  is  an  in 
stance  of  tabes  dorsalis  in  a  young  woman  but  twenty- 
three  years  old. 

Her  after  history  is  unknown,  as    she  passed  from 
under  my  observation  after  leaving  the  hospital. 


REMARKABLE    USE     OF    BICARBONATE     OF 
SODIUM. 

Dr.  Robert  G.  Feek,  of  Hamilton,  N.  Y.,  writes: 
"  William  G — —,  who  resides  in  the  town  of  Dekalb, 
near  Hamilton,  St.  Lawrence  County,  N.  Y. ,  was  suffering 
from  disease  of  the  Stomach  about  twenty-five  years  ago. 
He  states  that  he  spent  all  his  earnings  in  doctoring  till 
about  twenty-one  years  ago,  when  he  tried  saleratus,  which 
gave  him  relief.  Since  then  he  has  used  it  constantly  and 
is  now*  using  the  twenty-second  hundred  pounds.  He 
carries  it  with  him  wherever  he  goes.  He  is  sixty  one 
years  of  age,  father  of  eleven  children,  and  does  all 
the  work  t)f  a  farm  of  one  hundred  and  ten  acres  except 
an  occasional  extra  help.  He  purchases  his  saleratus  by 
the  barrel.  These  statements  are  authentic,  as  inquiry 
•will  prove.  The  saleratus  is  taken  in  a  dry  state.  At 
first  it  was  taken  in  small  quantities,  but  now  in  doses'  of 
one  half  ounce,  and  to  the  quantity  of  overtTo  pounds  a 
week." 

A    FOREIGN    BODY    IN    THE    EYE    FOR    SIX 

YEARS. 

By  THOMAS   M.  STEWART,   M.D., 

CISClNXAri,    c. 

Cases  of  foreign  bodies  in  the  eye  are  interesting  to  eye 
surgeons,  because  of  the  many  important  questions  that 
they  involve.  The  case  herewith  reported  is  interesting 
because  of  the  length  of  time  the  foreign  body  was  re- 
tained, with  the  history  of  pain  and  redness,  and  abso- 
lutely no  irritation  occurring  in  the  sound  eye. 

The  patient  was  a  married  man,  aged  forty  yean. 
Six  years  previous  to  his  first  visit  to  me,  while  watching 
miners  at  work,  a  piece  of  coal  struck  him  in  the  right 
eye.  He  was  at  once  removed  to  his  home,  and  a  sur- 
geon summoned.  After  some  weeks  he  was  discharged 
from  the  surgeon's  care,  but  with  a  blind  eye.  The  iris 
was  occluded,  the  small  pupillary  space  presented  to 
view  a  cataractous  lens.  Subsequently,  the  man  sought 
medical  aid  for  the  relief  of  severe  lightning  like  pains 
in  the  injured  eye.  The  pains  continued  from  time  to 
time.  I  found  the  eye  a  little  red,  no  pains  on  palpa- 
tion of  the  ciliary  body,  but  pressing  the  eye  backward 
and  a  little  outward,  he  complained  of  severe  cutting  pain. 
He  was  then  taking  morphine  for  the  relief  of  the  pain ; 
he  took  several  one-fourth  grain  pills  every  day,  and 
when  the  attacks  were  very  severe  he  took  mare. 

From  the  history  of  the  case,  evidence  of  having  been 
struck  in  the  eye  by  a  flying  missile,  the  occluded  pupil, 
cataractous  lens,  and  the  history  of  pain  from  the  time  of 
injury,  I  advised  enucleation.  Two  days  later  he  gave 
his  consent,  and  the  eye  was  removed  in  the  ordinary 
way.  Adhesions  were  cut  away  at  the  back  of  the  globe. 
Section  of  the  eye  showed  the  adhesion  of  the  iris  to  the 
opaque  lens,  and  the  vitreous  was  dark  brown  in  color. 
Close  to  the  optic  nerve  was  found  an  enlargement,  due 
to  a  piece  of  coal  6  mm.  square,  ragged  at  one  end. 
This  pushed  the  sclera  backward,  and  had  become  firm- 
ly imbedded.  A  firm  adhesion  also  held  it  to  the 
nerve. 


The  question  of  enucleation  had  been  considered,  but 
it  was  thought  that  the  pain  was  entirely  neuralgic,  com- 
ing in  paroxysms  aggravated  by  change  in  temperature 
and  humidity  of  atmosphere.  The  sound  eye  had  been 
interrogated  for  recession  of  the  near  point,  and  other 
symptoms  of  sympathetic  inflammation.  These  points 
determined  his  medical  advisers  upon  no  interference. 

To  my  mind  there  was  no  question  as  to  the  necessity 
for  operation,  it  was  a  clear  case  for  the  rule  to  enucleate 
an  eye  subject  to  attacks  of  redness  and  pain,  the  vision 
of  which  has  been  destroyed  by  an  injury. 


THE   SWALLOWING   OF  A   HAT-PIN,  AND  ITS 
SUBSEQUENT  EXTRACTION. 

By   THOMAS   B.   STEELE,    M.D., 

CAMBRIDGE,  MD. 

I  had  yesterday,  July  15th,  the  most  extraordinary  case 

of  surgery  I  ever  saw,  or  that  has  ever  occurred  in  this 

part  of  the  country. 
About  three  weeks  ago  I  was  called  in  to  see  a  colored 
child  (female)  a  little  over  three  years  old. 
She  complained  of  severe  pain  at  the  inner 
extremities  of  the  two  lower  ribs  of  the  left 
side.  She  kept  her  body  constantly  bent  over 
to  that  side  as  far  as  she  could  get  it,  and  a 
little  forward.  In  this  position  she  was  some- 
what relieved,  but  was  never  entirely  free 
from  pain.  She  had  but  very  little  fever,  if 
any,  and  her  appetite  and  digestion  were  fairly 
good. 

About  ten  days  ago  a  protuberance  the  size 
and  shape  of  section  of  an  ordinary  hen  eggf 
made  its  appearance  just  over  the  seat  of  pain. 
As  her  mother  and  the  rest  of  the  family  insisted 
so  strongly  that  nothing  had  occurred  to  ac- 
count for  her  symptoms,  I  was  forced  to  the 
conclusion  that  by  some  forgotten  accident  the 
cartilages  at  the  enlarged  spot  had  been  dislo- 
cated from  the  ribs,  or  a  growth  of  some  kind, 
most  probably  an  abscess,  was  forcing  its  way 
there  to  the  surface.  Last  night  I  was  sent  for 
in  a  great  hurry  to  see  her,  as  the  sharpened 
end  of  a  hat-pin  had  made  its  appearance 
through  the  middle  of  the  lump.  And  such  I 
found  to  be  the  case.  By  slight  pulling  the 
pin  would  come  out  five  or  six  inches,  but  was 
retained  by  its  large  bullet  shaped  end. 

The  pin  penetrated  the  cartilage  of  the 
eleventh  rib,  instead  of  coming  out  between 
the  ribs,  where  there  was  less  resistance,  and  as 
nothing  could  be  done  without  keeping  her 
constantly  under  the  influence  of  chlorofonr, 
and  I  could  not  do  so  unassisted,  I  sent  for  Dr. 
B.  W.  Goldsborough.  After  some  difficulty  he 
succeeded  in  enlarging  the  opening  in  the  car- 
tilage and  in  extracting  the  pin. 

Last  night  her  mother  remembered  that 
some  children  told  her  the  child  had  swal- 
lowed, the  day  before  she  complained  of  be- 
ing sick,  a  hat-pin,  but  she  thought  it  so  un- 
likely that  it  had  escaped  her  memory.  This 
morning  she  is  more  comfortable.     Rather  a 

large  quantity  of  water  flows  from  the  opening,  which 

shows  that  it  connects  with  the  stomach. 


A  Patient  in  one  of  the  Paris  hospitals  was  recently 
scalded  to  death  in  a  bath  through  negligence  of  the 
nurse. 

Breast  Tumors  in  Women.— A  "  lump  in  the  breast/' 
previously  to  twenty  five  years,  may  often  be  "  severely 
let  alone ; "  one  after  thirty  five  can  be  disregarded  only 
by  the  surgeon  who  is  reckless  to  the  verge  of  criminal- 
ity.— Dr.  Herbert  Snow  in  The  Practitioner,  August, 
1894. 


September  22,  1894] 


MEDICAL   RECORD. 


38i 


(&avrzsvon&2ucz. 

OUR  LONDON  LETTER. 

(From  our  Special  Correspondent ) 

VACATION — CHOLERA  PROSPECTS — THE  OPIUM  COMMISSION 
— THE  REPORT  OF  THE  LUNACY  COMMISSIONERS — THEIR 
VIEWS   ON   BEER. 

London,  September  1,  1894. 

London  is  just  now  more  depleted  of  her  doctors  than 
daring  the  brief  meeting  at  Bristol,  for  a  considerable 
number  have  set  out  on  their  autumnal  holiday.  In  the 
few  Bristol  days  we  had  scarcely  time  to  miss  them,  for 
those  who  went — or  a  large  proportion  of  them — returned 
to  town  before  leaving  for  any  length  of  time.  The  ap- 
pearance of  "students'  numbers' '  of  the  journals  is  an 
indication  that  the  opening  of  the  winter  session  is  only 
just  a  month  ahead.  Then  the  active  teachers  will  be 
obliged  to  be  at  home,  and  even  the  fashionable  consult- 
ants will  begin  to  return. 

We  have  passed  the  first  of  the  two  most  dangerous 
months  in  respect  to  cholera ;  but  September  has  several 
times  been  a  month  of  invasion,  and  as  the  disease  is  still 
epidemic  on  the  Continent  the  danger  is  obvious.  Hither- 
to the  weather  has  been  in  our  favor,  but  there  is  now  a 
prospect  of  hot,  damp  days,  which,  if  long  continued, 
may  cause  any  seeds  sown  last  year  to  spring  up.  Whether 
we  are  to  escape  altogether  or  suffer  from  such  recrudes 
cence,  or  to  be  invaded  afresh  is  therefore  a  favorite  topic 
of  conversation  and  the  speculations  indulged  in  are  some- 
times more  curious  than  instructive.  After  a  long  spell 
of  cool,  wet  weather,  the  last  two  days  have  been  hot, 
yet  dull  and  misty.  The  ground  in  the  country  is  no 
doubt  saturated  with  moisture  enough  to  give  us  a  damp 
atmosphere  as  the  sun  pours  down  its  rays.  If  cholera 
invade  us  it  will  therefore  have  a  condition  favoring  its 
spread,  and  with  all  our  sanitarians'  efforts  it  is  impossible 
to  pronounce  all  our  defences  to  be  impregnable.  The 
Local  Government  Board  are  prepared  to  act  with  energy. 
Inspectors  are  ready  to  visit  suspicious  cases,  and  provi- 
sion is  made  for  a  bacteriological  examination  of  faeces 
forwarded  with  a  clinical  record  of  the  case.  Expert  ad- 
vice and  assistance  is  therefore  at  the  disposal  of  those 
who  may  have  to  meet  suspicious  cases,  and  in  the  coun- 
try the  officers  of  health  seem  equally  ready  with  help. 
If  any  port  or  sanitary  authority  should  be  caught  nap- 
ping the  results  may  be  disastrous,  but  we  may  still  hope 
this  will  not  happen. 

The  report  of  the  Opium  Commission  will,  I  under- 
stand, not  be  issued  until  Christmas,  but  rumor  is  pretty 
busy  as  to  its  contents.  Some  persons  profess  to  have 
precise  information — others  are  evidently  guided  by  their 
judgment  of  the  evidence.  The  former  say  the  report 
will  be  unanimous,  and  I  hope  they  may  be  right,  for 
that  would  probably  deliver  us  from  the  "  opium  ques- 
tion "  for  some  time  to  come.  Both  former  and  latter 
agree  that  the  report  will  be  conclusive  against  any  inter- 
ference by  the  state  with  the  cultivation  and  use  of 
opium.  If  so,  it  will  be  in  accord  with  the  evidence  ten- 
dered by  those  medical  men  who  have  had  the  best  op- 
portunity of  judging  by  their  residence  and  official  posi- 
tions in  India. 

I  may  recur  for  a  moment  to  the  Lunacy  Report,  which 
I  have  previously  noticed.  In  some  quarters  surprise  is 
felt  at  the  prepossession  of  the  commissioners  in  favor  of 
beer  in  the  dietary.  Again  and  again  regret  is  expressed 
in  the  reports  at  the  absence  of  beer  or  something  else. 
Thus,  respecting  the  Surrey  Asylum,  the  remark,  "  workers 
only  have  beer,"  is  evidently  made  in  a  deprecatory 
spirit.  At  Norwich  it  is  remarked,  "  One  gentleman 
complained  of  the  stoppage  of  the  dinner  beer,  which, 
we  understand,  has  been  general  throughout  the  hospital. ' ' 
At  Colney  Hatch  the  commissioners  observe,  "  Beer  is 
not  given  to  the  workers,  which  we  regard  as  a  mistake, 
as  it  keeps  down  the  percentage  of  employed  patients." 
It  is  curious  that  encouragement  should  thus  be  given  to 


the  plan  of  inducing  patients  to  work  by  paying  them 
in  beer.  The  commissioners  defend  their  approval  ot 
intoxicating  beverages  thus :  "  The  asylum  is  not  a  re- 
formatory ;  and  claiming  to  be  advocates  of  temperance, 
which  total  abstinence  is  not,  we  think  that  the  with- 
drawal from  the  temperate  of  their  past  life's  beverage 
irritates,  whereas  every  effort  should  be  made  to  alleviate 
the  morbid  discontent  of  the  sober  patients,  in  propor- 
tion to  whom  the  drunkards  are  few.  These  last,  if  in 
the  incipient  stage  of  their  vice,  so  soon  recover  that  they 
must  be  discharged  too  soon  for  the  eradication  of  that 
vice ;  if  they  be  old  stagers,  they  come  to  the  asylum 
wrecks  of  humanity,  and  their  condition  is  too  chronic 
for  discharge,  except  through  death.  We  deem  it  our 
duty  to  repeat  our  colleagues'  objections  in  1892  to  what 
is  in  no  sense  a  proceeding  in  the  cause  of  true  temper- 
ance, which  is  the  avoidance  of  excess."  I  am  not  in- 
clined to  controvert  this  curious  manifestation  of  the 
commissioners'  penchant,  nor  would  I  go  so  far  as  to 
assert  that  a  glass  of  small  beef  would  have  an  apprecia- 
ble effect  on  the  majority  of  the  patients.  But  I  cannot 
compliment  the  commissioners  on  their  logic,  and  there 
are  other  issues  involved,  as  there  are  also  in  the  case  of 
workhouses,  as  to  which  the  beer  question  is  continually 
cropping  up.  The  rate-payers  may  object  to  provide 
this  luxury  to  persons  who  in  large  proportion  owe  their 
distress  to  too  free  indulgence  in  it.  Then  these  very 
reports  contain  a  series  of  tables,  some  of  which  show 
the  predisposing  and  exciting  causes  of  the  patients'  lu- 
nacy. As  may  be  anticipated  these  statistics  confirm 
those  with  which  your  readers  are  familiar,  and  prove  the 
terrible  idle  that  alcohol  plays  in  the  production  of  in- 
sanity. I  think  the  comissioners  would  find  a  difficulty, 
in  expounding  these  figures  so  as  to  support  their  views, 
which  certainly  do  not  seem  quite  up  to  date  from  a  sci- 
entific point  of  view.  It  will  therefore  not  surprise  me  if 
some  controversy  should  be  raised  on  the  question. 


WHO   IS  TO  BLAME? 

To  thb  Editor  op  thk  Medical  Rbcokd. 

Sir  :  One  of  the  great  and  much  admired  minds  of  the 
century  has  emitted  the  sentiments  that, 

"  Work  without  hope  draws  nectar  in  a  sieve, 
And  hope  without  an  object  cannot  live." 

After  a  fashion  these  lines  were  recalled  to  my  mind  by 
Dr.  McGee's  ardent  letter  published  in  -to-day's  Medi- 
cal Record.  The  lines  of  the  poet- philosopher  can  be 
applied  to  the  evil  complained  'of  by  Doctors  Cochran 
and  McGee,  and  many  other  good  men,  both  as  to  its 
cause  and  its  therapeutics. 

Dr.  McGee  would  have  "  one  good  general  law  "  for 
limiting  the  number  of  medical  colleges,  and  the  number 
of  medical  colleges  being  limited  by  law,  he  would  ex- 
pect "  a  better  satisfaction  to  the  profession  "  to  follow. 
Another  blessing  flowing  from  this  law  of  numerical 
limitation  would  be,  Doctor  McGee  says,  "at  least  more 
than  a  show  of  real  protection  for  the  people."  May 
one  not  ask  why  the  "  better  satisfaction  "  of  the  pro- 
fession needs  the  protecting  hand  of  the  lawyer  ?  Law 
means  lost  innocence,  lost  manliness,  and  as  a  prohibi- 
tive help  positive  only  by  negation.  What  does  "  real 
protection  for  the  people  "  mean  ?  Is  the  profession  be- 
coming a  band  of  beggars  because  this  very  profession 
in  some  sections  of  the  country  is  developing  medical 
schools  and  professors  in  superabundance?  Quite  the 
contrary.  Those  medical  men  who  are  impoverishing 
the  profession  by  making  it  cheap,  and  who  besides  are 
committing  a  sort  of  wholesale  homicide  by  inundating 
the  public  with  medical  humbugs  very  much  after  their 
own  pattern  find  the  business  profitable.  And  while 
such  business  pays  such  men,  can  any  other  conclusion 
be  drawn  than  that  both  the  public  (the  people)  and  the 
profession  rather  like  it  ?  All  things  thrive  by  what  they 
feed  on,  and  the  schools  and  the  professors  of  whom 
complaint  is  made  are  no  exception  to  this  natural  law. 


382 


MEDICAL  RECORD. 


[September  22,  1894 


The  people  who  will  have  them  deserve  to  have  them. 
Why  do  these  particular  men  hurry  to  establish  schools 
and  make  themselves  professors?  It  is  because  they 
hope  to  gain  power  thereby,  and  to  turn  that  power  and 
eclat — the  prestige  of  a  name — into  money  ! 

If  they  are  not  honorable  men,  they  are  ambitious 
and  they  are  practical.  They  do  not  weave  the  cloth  of 
gold  from  moonbeams.  Their  hopes  are  very  material, 
and  their  object  extremely  selfish.  They  are  not  idealists. 
Indeed  they  resemble  Napoleon  I.  in  their  hatred  of 
idealists.  Now  the  idea  of  professor  is  an  actual  ideal- 
ism with  the  great  body  of  the  laity.  It  is  not  the  legal 
conception.  It  is  often  an  idealism  that  borders  on  the 
mythical.  The  professor  of  medicine  (or  surgery)  to 
most  layman  is  a  man  who  knows  when  the  practitioner 
does  not  know.  The  professor  to  the  layman  is  the  man 
who  can  do  when  the  practitioner  fails  or  is  powerless. 
The  professor  to  the  layman  is  the  man  who  has  done 
his  best  to  make  the  practitioner  a  capable  man.  The 
people  have  an  ideal  doctor  in  mind  when  they  think  of 
the  medical  professor.  And  it  is  this  ideal  that  these 
would  be  medical  schools  and  their  would  be  professors 
deflower,  and  make  the  most  of  to  their  own  selfish 
satisfaction.  We  must  not  be  too  hard  in  our  judg- 
ments of  the  people  just  because  a  laudable  ideal  is 
theirs.  The  people  are  always  right  in  the  end,  only  it 
takes  them  such  a  long  while  sometimes  to  distinguish 
between  brass  and  gold.  Then,  too,  are  not  the  better 
elements  in  and  out  of  the  profession  parts  of  the  peo- 
ple? The  making  of  prohibitive  laws,  or  agitating  for 
them,  are  worthy  ways  of  letting  loose  our  altruistic  and 
philanthropic  propensities,  when  we  do  not  forget  our 
other  and  more  important  social  and  professional  obliga- 
tions. It  is  no  more  than  just  that  every  philanthropist, 
altruist,  and  ameliorist  be  the  model  he  is  clamoring  for 
some  one  else  to  be.  And  besides  clamoring  for  legis- 
lation— which  is  right  in  its  way— each  decent  practi- 
tioner, as  occasion  offers,  can  do  a  good  deal  toward 
killing  away  the  falsehoods  on  which  the  evils  under  con- 
sideration feed,  by  themselves  emulating  the  lay  ideal  of 
the  professor,  and  by  teaching  the  laity  who  are  and 
who  are  not  not  legal  professors,  but  real  and  worthy 
professors.  Perhaps  decent  and  intelligent  practitioners 
have  contributed  more  than  a  mite  toward  the  making 
of  the  layman's  myths,  and  from  which  they  feel  ill 
effects  every  now  and  then. 

Adolph  Rupp,  M.D. 

New  York,  September  8,  1894. 


HYDROPHOBIA  STATISTICS  DESIRED. 

To  the  Editor  or  thb  Medical  Record. 

Sir  :  Will  you  permit  me,  through  your  columns,  to  ask 
that  my  professional  brethren  will  communicate  to  me 
the  occurrence  of  cases  of  so-called  hydrophobia  in  their 
practice  for  the  year  1894,  from  January  1,  and  so  on 
until  the  end  of  this  year  ? 

I  would  like  in  all  cases  to  learn  :  1,  The  sex  and  age 
of  patient ;  2a,  the  kind  of  animal  that  is  credited  with 
the  inoculation ;  2d,  its  state  of  health ;  2C9  the  provo- 
cation to  bite  (if  any  existed) ;  2d,  the  reasons  why  the 
animal  was  (if  it  was)  deemed  rabid ;  3,  the  seat  of  the 
bite  (or  other  mode  of  inoculation) ;  4,  the  fact  and 
method  of  cauterization  (if any);  5,  the  time  between 
the  inoculation  and  the  outbreak ;  6,  the  symptoms  of 
the  outbreak,  the  occurrence  of  mania  or  imitation  of 
dog  actions ;  7,  the  remedies  used  and  doses,  with  their 
seeming  effect ;  8,  the  issue  of  the  case  and  when  death 
occurred ;  9,  the  investigations  made  to  exclude  the  pres- 
ence of  disease  other  than  so-called  hydrophobia;  10, 
the  findings  on  autopsy,  if  one  was  held. 

I  shall,  of  course,  acknowledge  in  future  publications 
aid  received  in  continuing  my  studies  in  regard  to  this 
subject. 

Yours  respectfully, 

Charles  W.  Dulles. 

4iox  Walnut  Street,  Philadelphia,  Pa. 


"THE  PHONOGRAPH;  ITS  PHYSICS,"  ETC. 

To  the  Editor  or  the  Medical  Record. 

Sir  :  An  article  under  the  above  title  appeared  in  your 
issue  for  September  1,  1894,  by  J.  Mount  Bleyer,  M.D., 
from  which  I  quote  the  following :  "  Photographs  and 
measurements  of  these  tracings  of  the  sound-waves  on  the 
wax  cylinders,  etc.,  were  recently  made  by  Herman,  of 
the  Konigsberg  Physiological  Institute,  and  are  of  great 
interest  in  the  study  of  the  physics  of  sound."  I  desire 
to  call  attention  to  the  fact  that  drawings  and  measure- 
ments of  tracings  of  voice  records  upon  a  wax  cylinder  of  a 
phonograph  were  made  by  me  in  1888,  and  the  same,  with 
an  article  entitled  "A  Study  in  Physiological  Acoustics — 
Preliminary  Notice/'  were  sent  to  your  journal  for  publi- 
cation. 

The  article  appeared  in  the  Record  for  November  17, 
1888,  p.  589,  but  the  graphic  representations  were  not 
published  because  you  did  not  have  space.  In  the  article 
by  me  I  state :  "  I  have  shown  the  number  of  vibrations 
to  inch,  entire  length  of  letter  or  word,  total  number  of 
vibrations  to  each,  and  also  depth  of  imprint."  If  there 
was  a  disposition  to  credit  our  own  countrymen  for  scien- 
tific research  and  investigation  more,  and  less  tendency  to 
look  abroad,  it  would  be  better  for  the  profession  and 
our  country  as  well. 

J.  A.  Maloney,  M.D. 

1424  Q  Struct,  N.  W.,  Washington,  D.  C. 


A   FALSE   REPORT  OF  PREMATURE  BURIAL. 

To  thx  Editob  or  thb  Medical  Reoobd. 

Sir  :  Some  time  ago  a  patient  handed  me  a  slip  cut 
from  one  of  our  daily  papers,  wherein  was  related,  with 
the  usual  minute  detail,  a  case  of  "Buried  Alive." 
The  incident  was  said  to  have  happened  near  the  town 
of  Lester,  Minn.,  and  the  victim  was  said,  upon  disin- 
terment, to  have  been  found  completely  turned  upon  the 
face,  the  flesh  torn  by  the  finger*  nails,  and  the  hands 
filled  with  hair  torn  from  the  head.  As  my  patient  was 
a  lady  of  nervous  temperament,  who  dreaded  for  herself 
or  husband  a  similar  terrible  fate,  I  determined  to  run 
the  lie  to  earth,  and,  accordingly,  wrote  to  the  post- 
master, inclosing  the  slip,  and  asking  him  to  report. 
The  following  is  his  reply : 

Lester,  Minn.,  August  23,  1894. 
Dear  Sir  :  In  reply  to  your  request  will  say,  that  I 
have  taken  time  to  thoroughly  investigate  the  matter  and 
find  "it  is  not  true.9'  It  is  true  he  was  removed,  but, 
he  was  found  in  the  coffin  the  way  he  was  placed  there. 
I  never  heard  of  the  matter  until  I  got  your  letter. 

Respectfully. 

C.  O.  Perusis. 

And  that  is  all  the  foundation  there  was  to  this  tale. 
S.  S.  J. 

A  Simple  Remedy  for  Cough. — Dr.  Charles  E.  Page, 
of  Boston,  says  that  the  best  remedy  for  cough  he  has 
ever  found  is  a  teaspoonful  of  moderately  hot  water, 
taken  every  time  a  paroxysm  of  cough  comes  on. 

Intra  uterine  Injections  in  Antiquity. — At  a  recent 
meeting  of  an  Edinburgh  medical  society  Dr.  Ballantyne 
quoted  from  a  paper  by  Dr.  Koromilas,  a  Greek  physi- 
cian, in  which  it  was  claimed  that  there  was  evidence  in 
the  writings  of  Hippocrates,  Oribasius,  Paulus  ^Egineta, 
and  Galen  to  show  that  these  authors  were  acquainted 
with  the  use  of  intra- uterine  injections.  Hippocrates 
divided  the  generative  organs  into  three  parts — first,  the 
external  genitals ;  second,  the  genital  organ  or  vagina ; 
and  third,  the  uterus.  He  also  used  for  each  a  special 
kind  of  substance  to  be  injected :  wine  with  honey  for 
the  external  genitals,  goose  grease  for  the  vagina,  and 
oil  with  honey  for  the  uterus.  Dr.  Koromilas  believed 
that  Hippocrates  was  the  first  to  make  intrauterine  in- 
jections. 


September  22,  1894] 


MEDICAL  RECORD. 


383 


IJXMicat  Stems. 

Contagious  Diseases— Weekly  Statement— Report  of 
cues  and  deaths  from  contagions  diseases  reported  to  the 
Sanitary  Bureau,  Health  Department,  for  the  week  end- 
ing  September  15, 1894. 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis 

Measles 

Diphtheria 

Small-pox 


Cases.       Death*. 


98 

108 

26 

13 

17 

2 

0 

4 

14 

3 

ic6 

30 

9 

2 

Unfortunate  Fingers. — Dr.  George  Corrie,  of  Blossom 
Hill,  Va.,  gives  the  following  history,  in  the  Virginia 
Medical  Monthly,  of  a  family  of  finger- losers :  "  George 
Williams,  negro,  had  two  fingers  *  hurt  by  the  cars,1  ne- 
cessitating amputation  (by  some  other  doctor  than  my- 
self). His  father  is  minus  an  index,  I  having  amputated 
it  after  contact  thereof  with  the  proverbial '  buzz  saw.1 
I  have  amputated  the  right  digitus  auricularis  of  one  of 
George's  nephews,  the  hand  having  been  caught  in  an 
apple-giinder.  I  relieved  another  of  George's  nephews 
of  his  left  digitus  auricularis,  the  boy  having  fallen  while 
carrying  a  sharp  axe,  the  edge  of  which  severed  all  tis- 
sues, artery,  and  nerve,  and  entered  the  first  joint.  All 
these  finger-losers  lived  at  one  time  in  the  same  house." 

The  Decline  of  Marriage. — Mr.  Grant  Allen  has 
undertaken  to  explain  why  marriage  is  less  common  to- 
day than  it  was  a  century  ago  :  "  Thirty  or  forty  years 
ago  young  men  used  to  rush  by  blind  instinct  into  the 
toils  of  matrimony — because  they  couldn't  help  them- 
selves. To  day  they  shilly-shally,  they  pick  and  choose, 
they  discuss,  they  criticise,  they  say  foolish  things  about 
the  club  and  the  fiat  and  the  cost  of  living.  They  be- 
lieve in  Malthus.  Fancy  a  young  man  who  believes  in 
Malthus !  But  they  don't  marry,  and  it  is  because  they 
are  less  of  young  men  than  formerly.  Wild  animals  in 
confinement  seldom  propagate  their  kind.  Only  a  few 
caged  birds  will  continue  their  species.  Whatever  up- 
sets the  balance  of  the  organism  in  an  individual  or  a 
race,  tends  first  of  all  to  affect  the  rate  of  reproduction. 
Civilize  a  red  man  and  he  begins  to  decrease  at  once  in 
numbers.  Is  not  the  same  thing  true  of  us  ?  Civiliza- 
tion and  its  works  have  come  too  quickly  upon  us.  The 
strain  and  stress  of  correlating  and  co-ordinating  the 
world  we  live  in  are  getting  too  much  for  us.  Railways, 
telegraph,  the  latest  edition  have  played  havoc  at  last 
with  our  nervous  system.  We  are  always  on  the  stretch, 
rushing  and  tearing  perpetually.  We  bolt  our  breakfast, 
we  catch  the  train  or  'bus  by  the  skin  of  our  teeth.  The 
tape  clicks  perpetually  in  our  ears  the  last  quotation  in 
Eries,  the  telephone  rings  us  up  at  inconvenient  mo 
ments.  Something  is  always  happening  somewhere  to 
disturb  our  equanimity.  Life  is  one  turmoil  of  excite- 
ment and  bustle.  Financially,  'tis  a  series  of  dissolving 
views;  personally,  'tis  a  rush;  socially,  'tis  a  mosaic  of 
deftly  fitted  engagements.  Drop  out  one  piece  and  you 
can  never  replace  it.  You  are  full  next  week  from  Mon- 
day to  Saturday — business  all  day,  what  calls  itself  pleas- 
ure (save  the  mark  !  )  all  evening.  Poor  old  leisure  is 
dead.  We  hurry  and  scurry  and  flurry  eternally.  One 
whirl  of  work  from  morning  till  night ;  then  dress  and 
dine ;  one  whirl  of  excitement  from  night  till  morning. 
A  snap  of  troubled  sleep,  and  again  da  capo.  Not  an 
hour,  not  a  minute,  we  can  call  our  own.  The  first  gen- 
eration after  Stephenson  and  the  Rocket  pulled  through 
with  it  somehow.  They  inherited  the  sound  constitu- 
tions of  the  men  who  sat  on  rustic  seats  in  the  gardens 
of  the  twenties.  The  second  generation — that's  you  and 
me — felt  the  strain  of  it  more  severely.  New  machines 
have  come  in  to  make  life  still  more  complicated ;  tele- 


grams, Bell  and  Edison,  submarine  cables,  evening  pa- 
pers, perturbations  pouring  in  from  all  sides  incessantly ; 
the  suburbs  growing,  the  hubbub  increasing,  metropoli- 
tan railways,  trams,  bicycles  innumerable ;  but  we  still 
endured,  and  presented  the  world  all  the  same  with  a 
third  generation.  That  third  generation — ah,  me  !  there 
comes  the  pity  of  it !  One  fancies  the  impulse  to  many 
and  rear  a  family  has  wholly  died  out  of  it.  It  seems  to 
have  died  out  most  in  the  class  where  the  strain  and 
stress  are  greatest.  I  don't  think  young  men  of  that 
class  to  day_have  the  same  feelings  toward  women  of  their 
sort  as  formerly.  With  certain  classes  and  in  certain 
places  a  primitive  instinct  of  our  race  has  weakened. 
The  present  crisis  in  the  marriage  market  is  due  not  to 
clubs  or  the  comfort  of  bachelor  quarters,  but  to  cumula- 
tive effect  of  nervous  over-excitement." 

'  Taking  His  Telephone  to  Bed. — A  Pittsburgh  physi- 
cian has  devised  a  way  of  taking  his  telephone  to  bed, 
so  that  he  can  answer  calls  without  rising.  He  has  his 
telephone  hung  upon  hooks,  in  his  office,  the  connections 
being  made  by  the  telephone  coming  in  contact  with  an 
electric  board  which  he  has  had  constructed.  He  also 
has  wires  run  to  his  bedroom,  where  another  electric 
board  has  been  placed.  The  doctor  may  be  said  to  take 
his  telephone  to  bed  with  him  every  night.  He  takes  it 
from  the  hooks  in  his  office,  carries  it  under  his  arm  up 
to  his  bedroom,  and  places  it  upon  the  hooks  there. 
Should  any  calls  come  during  the  night,  he  can  answer 
them  without  leaving  his  room,  thereby  getting  the  use 
of  two  telephones  for  the  price  of  one. 

Morphinism  in  Medical  Men. — It  is  a  fact — striking 
though  sad — that  more  cases  of  morphinism  aie  met  with 
among  medical  men  than  in  all  other  professions  com- 
bined. It  is  too  true  that  a  very  large  proportion  of 
cases  in  general  are  found  in  our  own  fraternity.  In  a 
paper,  "Opium  Addiction  among  Medical  Men,"  pre- 
sented in  the  Medical  Record  eleven  years  ago — June 
9,  1883 — reference  was  made  to  the  dismissal  within  a 
week  of  a  half-dozen  doctors  recovered  from  this  disease, 
and  attention  called  to  the  surprising  frequency  with 
which  it  occurs  in  this  particular  class.  Another  decade 
of  professional  work  exclusively  given  to  the  betterment 
of  such  patients  has  brought  no  decrease  in  this  number; 
indeed  the  reverse  has  quite  steadily  obtained,  so  that  in 
a  paper,  "  The  Ethics  of  Opium  Habitues,"  Medical  and 
Surgical  Reporter,  September  8,  1888,  in  a  r&sumi  of 
300  cases,  we  noted  118  doctors,  and  of  125  most  re- 
cently under  my  care  62  were  medical  men ;  and  the 
latest  reference  to  my  record  shows  a  still  larger  propor- 
tion, being  more  than  seventy  per  cent. — Dr.  J.  B.  Mat- 
tison  in  the  Journal  of  the  American  Medical  Associa- 
tion, August  4,  1894. 

Migraine  in  Infancy. — Intelligent  observation  and  ac- 
cumulating experience  show  that  infancy  does  not  es- 
cape many  of  the  neuroses  (perhaps  we  may  learn  to  say 
none  of  the  neuroses)  observed  in  mature  life.  The 
diagnosis  is  obviously  embarrassed  by  the  difficulties  at- 
tendant upon  the  elicitation  of  symptoms.  Thus,  it  has 
been  conclusively  demonstrated  that  infants  and  young 
children  may  be  unequivocally  hysterical,  and  there  is 
reason  to  believe  that  they  may  be  similarly  affected  with 
migraine.  Evidence  in  support  of  the  latter  proposition 
is  furnished  by  the  report  by  Dr.  Betz  of  the  case  of  a 
female  infant,  thirteen  months  old,  that,  at  a  time  when 
influenza  was  prevalent,  was  seized  with  an  attack  of  fe- 
brile gastrointestinal  catarrh,  attended  with  diarrhoea. 
In  the  course  of  this  illness  the  infant  was  seized  with 
twitching,  affecting  principally  the  hands  and  arms,  oc- 
curring intermittently  and  also  during  sleep.  It  further 
indicated  by  gesture  its  complaint  of  pain  in  the  head. 
Consciousness  was  perverted,  but  not  lost.  It  was  ob- 
served that  the  child  manifested  a  tendency  to  grasp  the 
left  side  of  its  head  and  to  lie  upon  its  left  side,  and  on 
examination  the  left  side  of  the  head  was  found  to  be 
somewhat  smaller  in  size  than  the  right,  while  further 
investigation  disclosed  the  fact  that  an  elder  sister  and 


384 


MEDICAL   RECORD. 


[September  22,  1894 


the  mother  both  presented  a  similar  asymmetry  and  suf- 
fered from  attacks  of  migraine.  The  interesting  features 
of  the  case  are  the  age,  the  sex/  the  heredity,  and  the 
asymmetry  of  the  face.  In  a  diagnostic  connection  it  is 
pointed  out  that  on  palpation  the  temperature  may  be 
found  higher  on  the  affected  side  than  upon  the  opposite 
side,  and  that  during  the  attack  of  pain  the  upper  lid 
upon  the  affected  side  displays  a  tendency  to  droop. 
Therapeutically,  general  rather  than  special  measures  are 
indicated.  Diathetic  and  hereditary  tendencies,  as  well 
as  complicating  conditions,  are  as  far  as  possible  to  be 
corrected  or  removed.  Opium  may  be  used  internally 
and  topically  with  caution ;  ice-water  compresses,  topi- 
cal applications  of  menthol,  cocaine,  or  ether  may  aid  in 
the  relief  of  pain. — Medical  News. 

Diseases  of  the  Heart  in  Typhoid,  Scarlatina,  and 
Diphtheria. — Dr.  Rhomberg  points  out  that  the  paren- 
chymatous and  interstitial  processes  are  not  closely  con- 
nected in  the  tissues  of  the  heart.  In  typhoid  the  higher 
grade  of  parenchymatous  degeneration  advances  rapidly 
to  the  end  of  the  second  week ;  but  later  this  morbid 
change  is  not  so  great.  Interstitial  myocarditis,  on  the 
other  hand,  only  makes  its  appearance  at  the  end  of  the 
second  week,  when  the  parenchymatous  has  run  its 
course.  In  scarlet  fever  the  interstitial  myocarditis  may 
begin  to  make  its  appearance  on  the  fourth  day,  but  its 
intensity  is  not  reached  till  the  end  of  the  second  week. 
Diphtheritic  myocarditis  makes  its  appearance  later  than 
scarlet  fever,  usually  about  the  seventh  or  ninth  day,  and 
its  intensity  is  reached  about  the  beginning  of  the  third 
week,  and  is  continued  even  into  convalescence.  Rhom- 
berg has  seen  myocarditic  bands  from  diphtheria  in  the 
third  week.  Leyden  has  recorded  several  in  the  fourth 
week  well  advanced.  In  typhoid,  Rhomberg  has  met 
with  these  in  the  third  week.  The  symptoms  during  the 
fever  period  are — great  weakness  of  heart,  irregularity 
and  smallness  of  the  pulse,  probably  with  dilatation. 
The  best  sign  of  dilatation  of  the  left  ventricle  with  ir- 
regular contractions  is,  according  to  Leyden,  galopp- 
rhythmus.  Traube  considered  sudden  sinking  of  the  pulse 
"  frequenz "  an  ominous  sign  in  diphtheria.  Leiber- 
meister  considered  the  pathological  increase  of  tissue 
fluid,  as  oedema  of  the  ankles,  a  dangerous  symptom. 
Dilatation  is  frequently  met  with  in  typhus  by  the  mid- 
dle of  the  second  week ;  observable  by  the  soft  and  empty 
pulse.  In  diphtheria  Rhomberg  can  only  relate  one  case 
of  dilatation  occurring  in  the  first  week.  On  the  other 
hand,  he  has  found  it  after  a  few  days  in  scarlet  fever, 
continuing  two  or  four  weeks. — Medical  Press. 

Intestinal  Toxins. — Two  cases  were  related  at  the 
Clinical  Society  recently,  one  by  Dr.  Lauder  Brunton 
and  Mr.  Watson  Cheyne,  the  other  by  Mr.  Silcock, 
which  illustrates  well  the  important  role  played  by  the 
toxins  developed  by  decomposition  of  the  intestinal 
contents  in  some  cases  of  intestinal  obstruction.  The 
first  was  one  in  which,  after  repeated  attacks  of  ap- 
pendicitis, a  somewhat  gradual  obstruction  developed, 
without  tenderness  or  local  signs  of  recent  inflamma- 
tion. On  laparotomy  being  performed  it  was  dis- 
covered that  the  caecum  was  matted  and  tied  down  by 
general  adhesions,  but  not  strangulated  by  a  band. 
After  separating  the  adhesions  it  became  possible  to 
squeeze  the  contents  of  the  small  intestines  into  the 
colon,  showing  that  the  constriction  was  removed.  Be- 
fore the  operation  the  patient  had  been  in  a  state 
of  the  most  absolute  collapse;  after  it  he  improved 
somewhat  for  a  time,  but  soon  again  relapsed,  and 
seemed  as  bad  as  ever,  until,  after  discharging  a  couple 
of  very  offensive  motions,  his  condition  rapidly  im- 
proved, and  he  recovered  without  any  further  trouble. 
Mr.  Silcock's  case  was  apparently  one  of  acute  obstruc- 
tion from,  or  at  any  rate  accompanied  by,  peritonitis. 
Laparotomy  was  done,  but  from  the  matting  of  the  in- 
testines it  was  impossible  to  discover  the  exact  cause,  or 
in  fact  the  position,  of  the  obstruction.  Ultimately, 
however,  the  distended  small  intestine  was  attached  to 


the  abdominal  wall,  and  a  large  amount  of  offensive 
faecal  matter  was  drained  away.  In  this  case,  also,  the 
collapse  was  profound,  so  that  during  the  operation  he 
was  thought  to  be  dead  ;  but  after  the  discharge  of  the 
offensive  intestinal  accumulation  rapid  recovery  took 
place,  the  natural  action  of  the  bowels  was  restored,  and 
the  wound  healed,  although  apparently  the  only  thing 
the  operation  did  was  to  empty  the  bowels  of  their  con- 
tents. These  cases  put  in  striking  light  the  fact,  which 
is  perhaps  not  so  constantly  borne  in  mind  as  it  might 
be,  that  the  fatal  results  of  intestinal  obstruction  are  not 
entirely  due  to  the  local  mischief  at  the  seat  of  the  block, 
the  strangulation,  the  volvulus,  or  the  intussusception, 
but  depend  largely  upon  the  absorption  by  the  intestines 
above  it  of  the  toxins  produced  by  the  decomposition  of 
their  contents.  These  symptoms  of  sapraemic  intoxica- 
tion are  no  doubt  often  absent,  but  where  they  exist, 
where  with  low  temperature  there  is  thready  pulse  and 
general  failure,  the  emptying  of  the  bowel  may  clearly 
be  as  important  a  means  of  saving  life  as  the  relief  of 
the  strangulation. — The  British  Medical  Journal. 

Prostitution  in  Berlin  is  increasing  very  rapidly.  Ac- 
cording to  a  recent  report  of  a  committee  of  the  Berlin 
Medical  Society,  the  members  of  the  demi  monde  were 
estimated  to  number  from  40,000  to  50,000.  In  1886 
the  number  of  professional  prostitutes,  those  recognized 
as  such  by  the  police,  was  3,006,  and  this  had  increased 
in  1 89 1  to  4,364. 

Death  of  an  Aged  Priest. — A  Greek  priest  died  re- 
cently in  Trikhala,  Thessaly,  at  the  reputed  age  of  one 
hundred  and  twenty  years.  He  had  had  charge  of  the 
parish  in  which  he  died  for  ninety- nine  years. 

Cure  of  Deafness. — Dr.  Barclay  reports  in  the  St.  Louis 
Courier  of  Medicine  for  June  a  case  of  deafness  from 
chronic  aural  catarrh  almost  entirely  relieved  by  an  opera 
tion  setting  free  the  anchylosed  ossicles. 

Dr.  d'Arsonval  has  been  elected  to  the  Paris  Academy 
of  Sciences  to  fill  the  vacancy  caused  by  the  death  of 
Dr.  Brown  Sequard.  M.  d'Arsonval  was  long  associated 
with  his  predecessor- in  the  latter's  experiments  with  ani- 
mal extracts.  

BOOKS   RECEIVED. 

Practical  Manual  of  Mental  Medicine.  By  Dr.  E.  Regis. 
Translated  by  Dr.  H.  M.  Bannister.  i2mo,  692  pages.  Press  of 
the  American  Journal  of  Insanity,  Utica,  N.  Y. 

Chemistry,  Medical  and  Pharmaceutical.  By  John  Att- 
field.  8vo,  794  pages.  Illustrated.  Published  by  Lea  Bros.  &  Co. 
Philadelphia,  Pa. 

A  Practical  Treatise  on  Orthopedic  Surgery.  By  Jas. 
K.  Young.  M.D.  8vo,  446  pages.  Illustrated.  Published  by  Lee 
Bros.  &  Co.,  Philadelphia,  Pa. 

A  Manual  of  Hygiene.  By  Mary  Taylor  Bissell,  M.D.  8vo, 
3.}8  pages.  Illustrated.  The  Baker  &  Taylor  Col,  New  York  City. 
Price,  $2.00. 

A  Text- Book  of  Practical  Therapeutics,  with  Special 
Reference  to  the  Application  of  Remedial  Measures  to 
Disease  and  their  Employment  upon  a  Rational  Basis.  By 
Hobart  Armory  Hare,  M.D.  8vo,  740  pages.  Published  by  Lea 
Bros.  &  Co.,  Philadelphia,  Pa. 

Transactions  of  the  Forty-Ninth  Annual  Meeting  of 
the  Ohio  State  Medical  Society.  Held  at  Zanesville,  0. 
8vo,  488  pages.     Published  by  Order  of  the  Society. 

A  Treatise  of  the  Principles  and  Practice  of  Medicine. 
By  Austin  Flint,  M.D.  8vo,  1143  pages.  Published  by  Lea  Bros. 
&  Co.,  Philadelphia,  Pa. 

Antiseptic  Surgical  Technique  By  Hunter  Robb,  M.D. 
8vo,  264  pages.  Illustrated.  Published  by  J.  B.  Lippincott, 
Philadelphia,  Pa.     Price,  $2.00. 

Transactions  of  the  Michigan  State  Medical  Society, 
for  the  year  1894.  Vol.  18.  Published  by  the  Society.  Dciroit, 
Mich. 

Myxedema;  Cretinism,  and  the  Goitres,  with  some  of 
their  Relations.  By  Edward  T.  Blake,  M.D.  8vo.  89  pages. 
Illustrated.  Price,  3s.  6d.  Published  by  John  Wright  &  Co.:  Bris- 
tol, England. 

The  Insanity  of  Over-Exertion  of  the  Brain.  By  J. 
Batty  Tuke,  M.D.  8vo,  66  pages.  Illustrated.  Price,  6d.  Pub- 
lished  by  Oliver  &  Boyd,  Edinburgh,  Scotland. 


SUPPLEMENT    TO    THE    MEDICAL    RECORD.      September  29,  ISM. 


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Diphtheria  colonies.  Diphtheria  colonies.    Luxuriant  growth. 

COLONIES  OF  BACILLI,   20  HOURS  GROWTH  ON  AGAR,  X  124  DIAM. 

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Pseudo-diphtheria  colonies. 


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INDIVIDUAL  BACILLI  AND  COCCI   GROWN   ON   BLOOD   SERUM,   X    IOOO  DIAM.         false  diphtheria 


Small  wooden  box  holding  culture  tube  and  sterile  cotton  swab.     Actual  size. 

PHOTOGRAPHS   OF    DIPHTHERIA  AND   PSEUDO-DIPHTHERIA   BACILLI.— PARK   &  LEAMING. 


Medical   Record 

A  Weekly  yonrnal  of  Medicine  and  Surgery 


Vol.  46,  No.  13. 
Whole  No.  1247. 


New  York,  September  29,  1894. 


$5.00  Per  Annum. 
Single  Copies,  ioc. 


®vigfaml  Articles. 

DIPHTHERIA  AND  PSEUDO-DIPHTHERIA. 

A  Report  to  Hermann  M.  Biggs,  M.D.,  Pathologist 
and  Director  of  the  Bacteriological  Laboratory, 
on  the  Bacteriological  Examination  of  5,611 
Cases  of  Suspected  Diphtheria,  with  the  Results 
of  Other  Investigations  on  the  Diphtheria  and 
the  Pseudo  diphtheria  Bacillus.  From  the  Bac- 
teriological Laboratory  of  the  Health  Depart- 
ment of  New  York  City. 

By  WILLIAM  HALLOCK  PARK,  M.D., 

BACTERIOLOGICAL  DIAGNOSTICIAN  AND  INSPECTOR  OF  DIPHTHERIA,  FELLOW  IN 
FA7H0TOGY,  COLLEGE  PHYSICIANS  AND  SURGEONS,  COLUMBIA  COLLEGE,  NEW 
YORK, 

AND 

ALFRED  L.  BEEBE,  Ph.B., 

INSPECTOR  OF  BACTERIOLOGY, 
NEW  YORK. 

From  May  4,  1893,  to  May  4,  1894,  there  were  5,611 
cases  of  suspected  diphtheria  subjected  to  bacteriological 
examination.  In  31255  of  these  the  Loeffler  bacilli  (the 
bacilli  of  true  diphtheria)  were  found  to  be  present,  and 
these  cases  were  thus  proven  to  be  true  diphtheria.  In 
1,540  no  diphtheria  bacilli  were  present  in  the  cultures, 
and  as  these  had  been  carefully  made  at  an  early  period 
of  the  disease,  the  cases  from  which  they  were  taken  may 
be  considered  as  proven  not  to  have  been  true  diphtheria. 
In  816  cases,  although  no  diphtheria  bacilli  were  found 
in  the  cultures,  yet,  for  various  reasons  (either  because 
they  were  made  after  the  fourth  day  of  the  disease,  or 
the  exudate  was  imperfectly  obtained  from  the  throat,  or 
the  culture  media  had  become  contaminated  or  were  too 
dry),  the  cases  from  which  the  cultures  were  obtained 
were  considered  to  be  of  a  doubtful  nature,  so  far  as  the 
bacteriological  examination  was  concerned,  although 
they  were  probably  not  diphtheria. 

Thus  we  find  in  5,611  cases  of  suspected  diphtheria 
that  about  fifty-eight  per  cent,  were  proven  to  be  true 
diphtheria,  twenty  seven  per  cent,  to  be  false  or  pseudo- 
diphtheria,  and  fifteen  per  cent,  to  be  of  somewhat  doubtful 
character.  It  would  probably  be  just  to  consider  that  sixty 
per  cent,  were  true  and  forty  per  cent,  were  false  diph- 
theria. 

Bex,  Age,  and  Mortality  in  the  Cases  of  True  Diph- 
theria.— In  a  large  percentage  of  the  cases  the  sex  was 
given,  and  in  these  there  were  fifty- four  per  cent,  females 
and  forty-six  per  cent,  males,  a  fairly  even  division. 
The  statistics  reveal  some  interesting  facts  as  to  the  influ- 
ence of  age  on  the  occurrence  of  true  diphtheria,  as  well 
as  on  the  mortality  of  the  disease.  The  ages  of  persons 
attacked  ranged  between  three  weeks  and  seventy  years. 
The  ages  and  mortality  were  determined  in  ^625  cases 
and  were  as  follows : 


Age. 


1  st  13  mos. 


No 


Mortal- 


Cases   ,*£**. 


Age 


No. 
Cases. 


'No.  Cases!  *£ 

5ve^   I    *?' 
Average.  I  Cem> 


ad 

3i 

5th 


Ith    •• 


7th 


«4 

109 

% 

193 

163 


u 


t" 


7th  to  xoth  year 
10th  to  15th  year. 
15th  to  20th  year, 
aoth  to  30th  year. 
30th  to  50th  year.  , 


992 
117 


4« 
13 


97  + 
«3  + 


Ml 


»5 

5 


The  number  of  cases  increased  with  each  twelve  months 
of  life  up  to  the  fourth  year  and  then  gradually  dimin- 
ished. The  mortality  was  highest  in  the  first  two  years 
of  life,  and  then  steadily  diminished  until  adult  life  was 
reached,  when  it  again  slowly  increased. 

Scarlet  fever  was  associated  with  diphtheria  in  about 
five  of  every  thousand  cases.  Exact  figures  cannot  be 
given. 

Age  and  Mortality  in  False  or  Pseudo-diphtheria. — 
It  has  been  the  general  rule  of  the  Department  to  take 
no  further  cognizance  of  cases  of  false  diphtheria  after 
the  culture  has  demonstrated  the  absence  of  the  diph- 
theria bacilli. 

In  order,  however,  to  compare  the  mortality  and  the 
communicability  of  false  diphtheria  with  that  of  true 
diphtheria,  450  cases  of  the  false  were  carefully  inves- 
tigated by  sanitary  inspectors  detailed  for  this  work* 
These  cases  comprised  300  occurring  in  the  fall  months 
and  150  occurring  in  the  following  spring.  The  cases 
were  taken  in  consecutive  order  and  are  believed  to  be 


average  cases. 

Age. 

Age. 

*3 

<8. 

1  st  12  mos. 

2d        " 

3d      44 

4th     » 
5th    '• 
6th     " 
7th     » 

1 2  i  °  1 

1 17  s»  \y  7 

47  °.  P 

\    16   '    29   !      .. 

34   !  0     !  V   a 
3«   1  °       ) 

7th  to  xoth  year. 
10th  to  15th  year. 
15th  to  20th  year, 
soth  to  30th  year. 
30th  to  50th  year. 
Over  50  years. 

63 
63 
44 
63 

'7 

2 

21 
12  + 

9- 
6  + 

1  — 

H 


'■.\ 


*f 


Total  mortality  in  all  cases 


1  Two  deaths  due  to  scarlet  fever.  *  One  death  due  to  scarlet  fever. 

*  One  death  due  to  scarlet  fever. 

In  the  450  cases  investigated  there  weie  1 1  deaths,  or 
about  two  and  one- half  per  cent,  mortality.  Of  the  450 
cases  42  were  complicated  by  scarlet  fever,  and  of 
these  42  4  died.  In  six  of  the  450  cases  measles 
occurred  as  a  complication,  and  these  all  recovered. 
Of  the  two  deaths  which  occurred  among  the  adults, 
one  was  of  a  man  of  seventy  years  who  was  suffering 
from  a  serious  valvular  lesion  of  the  heart,  and  the 
other  was  of  a  young  adult  female  *  who  died  of  sep- 
ticaemia. 

The  five  deaths  occurring  in  uncomplicated  pseudo- 
diphtheria  in  children  under  five  years  of  age  were  all  in 
cases  in  which  the  larynx  was  affected,  and  in  three, 
more  or  less  broncho- pneumonia  developed  as  a  compli- 
cation. 

True  and  Pseudo-diphtheria  of  the  Larynx  (Mem- 
branous Croup). — The  statistics  gathered  of  the  location 
of  the  disease  in  the  true  and  false  cases  are  of  special 
interest.  There  were  286  of  the  cases  examined  in 
which  the  disease  was  entirely  or  chiefly  confined  to  the 
larynx  or  bronchi,  and  of  these,  283  were  in  children 
and  3  in  adults.  In  the  cultures  of  229  of  the  286, 
characteristic  Loeffler  bacilli  were  found,  and  the  cases 
were  thus  proven  to  be  true  diphtheria.  Of  the  229 
cases  in  which  the  Loe filer  bacilli  were  found,  167 
showed  no  pseudo  membrane  or  exudate  above  the 
larynx,  while  in  the  remaining  62,  although  the  larynx 

*  The  history  in  brief  of  the  second  case  was  as  follows :  Three 
weeks  before  death  the  disease  began  with  a  swelling  of  one  tonsil 
and  its  surrounding  tissues.  A  week  later,  the  tonsil  was  incised  but 
no  pus  obtained,  and  about  the  incision  a  dirty  brown  pseudo  mem- 
brane formed.  Later,  the  tonsil  and  surrounding  tissue  became 
necrotic  and  sloughed  off,  then  the  ulceration  extended  to  the  phar)  nz 
and  the  other  tonsil,  and  was  still  progressing  when  the  patient  died 
of  sepsis  and  exhaustion. 


386 


MEDICAL  RECORD. 


[September  29,  1894 


was  mainly  involved,  there  was  also  some  membrane  or 
exudate  present  on  the  tonsils  or  in  the  pharynx.  In  57 
out  of  the  286  examined,  no  diphtheria  bacilli  were 
found,  but  in  17  of  these  the  cultures  were  unsatisfactory. 
Excluding  the  17  doubtful  cases,  there  were  40  cases 
of  pseudo-diphtheria  in  which  the  diphtheria  bacilli  were 
certainly  absent.  The  disease  was  confined  to  the 
larynx  or  bronchi  in  27  of  the  40,  while  more  or  less 
exudate  or  membrane  was  present  on  the  tonsils  or  in 
the  pharynx  in  13. 

Table  of  Results  ok  Examinations    of   Cases  of  "  Mem- 
branous Croup." 


Cases. 


Diphtheria 
Bacilli 
found. 

Diphtheria 

Bacilli  not 

found. 

167 

a? 

6a 

*3 

Cases  in  which  the  exudate  was  confined  to  the  larynx 

or  bronchi 

Cases  in  which  the  exudate  was  chiefly  confined    to 
the  larynx   or  bronchi,   but  other   parts  somewhat 

involved. 

Cases  in  which  satisfactory  cultures  were  not 

obtained 17 

Total  cases  examined 286 

Diphtheria 229 

Pseudo-diphtheria 40 

Doubtful 17 


We  find,  therefore,  that  of  the  cases  of  acute  laryn- 
gitis in  children  which  have  been  subjected  to  bacterio- 
logical examination  in  the  laboratory  of  the  Health 
Department  during  the  past  twelve  months,  about 
eighty  per  cent,  have  proved  to  be  undoubtedly  cases  of 
diphtheria,  and  of  the  remaining  twenty  per  cent,  only 
fourteen  per  cent,  were  certainly  not  diphtheritic. 

Not  only  have  the  bacteriological  examinations  shown 
that  a  large  proportion  of  the  cases  of  acute  croupous 
laryngitis  in  children  (commonly  designated  by  the 
name  membranous  croup)  are  diphtheria,  but  the  De- 
partment inspectors  have  frequently  found  that  these 
cases  were  apparently  the  cause  of  characteristic  pharyn- 
geal diphtheria  in  others. 

Th»  comparatively  small  number  of  laryngeal  cases 
examined  is  partially  due  to  the  fact  that  membranous 
croup  has  not  been  considered  a  contagious  disease,  and 
reports  of  such  cases  have  not  been  required  by  the 
Health  Department;*  and  partially  to  the  custom  of 
Department  Inspectors  to  not  make  cultures  in  cases 
which  have  been  intubated,  or  which  seem  so  sick  that 
the  family  may  think  injury  had  been  done  by  in- 
serting the  swab  in  the  throat.  The  cases  in  which 
no  cultures  are  made  are  treated  as  cases  of  true  diph- 
theria. 

The  Kelation  Between  the  Length  of  the  Bacillus 
and  Its  Virulence. — Some  investigators  have  believed 
the  degree  of  virulence  possessed  by  the  diphtheria  ba- 
cilli could,  to  a  certain  extent,  be  judged  by  their 
length.  The  longest  bacilli  were  supposed  to  be  the 
most  virulent ;  those  of  medium  length  less  so,  and  the 
shortest  little,  if  at  all,  virulent.  By  observing  this 
characteristic  it  was  thought  cultures  might  become  help- 
ful in  prognosis.  Very  careful  notes  have  been  made  on 
this  point  in  the  examination  of  the  bacteria  from  the 
original  serum  tubes  in  1,613  cases. 

The  results  of  the  examinations  are  shown  in  the  fol- 
lowing table: 

*  An  Amendment  to  the  Sanitary  Code  was  adopted  by  the  Board  of 
Health  on  June  6, 1894,  by  virtue  of  which  membranous  croup  is  re- 
garded as  laryngeal  diphtheria,  and  hereafter  physicians  will  be  re- 
quired to  report  such  cases  to  the  Health  Department. 

Notk  — Many  experienced  physicians  still  find  difficulty  in  believ- 
ing that  cases  in  which  the  exudate  or  pseudo-membrane  is  entirely 
absent  from  the  pharynx  and  tonsils  are  those  of  true  diphtheria  It 
is  also  often  difficult  to  persuade  parents  that  such  cases  are  diph- 
theria, as,  for  instance,  a  child,  agel  five,  subject  to  attacks  of  bron- 
chitis and  slight  laryngitis,  developed  a  croupy  cough.  For  diagnos- 
tic purposes  a  culture  was  made  and  the  diphtheria  bacilli  were 
found  to  be  present.  It  was  with  the  greatest  difficulty  that  the 
parents  could  bi  made  to  consider  the  case  a  serious  one  and  to 
quarantine  the  child.  Under  suitable  treatment,  on  the  fifth  day  the 
child  ssemed  nsarly  recovered,  and  now  the  parents  became  sure  it 
was  not  a  case  of  diphtheria,  stopped  all  precautions,  allowed  the 
child  to  go  out,  etc.  A  relapse  followed,  the  laryngeal  symptoms  in- 
creased, and  the  child  died  in  thirty-eight  hours,  of  asphyxia,  intuba- 
tion being  refused. 


Bacilli  of  average  size  found  in 1*368 

'*      longer  than  average  found  in 8a 

41      shorter'*           ••               •»     67 

**      short,  not  characteristic  in  shape  and  evenly 
stained,    of  which    many    were   pseudo-diphtheria 

bacilli 66 

Total  cases  examined 1.613 


Mortality 
Per  Cent. 


26 
*7 
35 


The  results  obtained  from  this  examination  of  1,613 
cultures  therefore  indicate  that  in  New  York  the  great 
majority  of  cases  of  diphtheria  yield  in  cultures  bacilli  of 
medium  size,  which  are  characteristic  in  shape  and  man 
ner  of  staining.  In  a  moderate  number  of  cases  the 
bacilli  found  are  much  longer,  and  in  about  an  equal 
number  they  are  much  shorter.  Both  the  clinical  histo- 
ries and  the  animal  experiments  show  that  whenever  in 
their  shape  and  in  the  way  in  which  they  take  the  stain- 
ing fluid  the  bacilli  are  characteristic,  no  information  as 
to  their  virulence,  either  in  men  or  animals,  can  be 
gathered  from  their  length.  Those  bacilli,  on  the  other 
hand,  which  are  short  and  stain  uniformly  with  methyl- 
blue,  usually  prove  to  be  of  the  pseudo  diphtheria  type, 
and  have  no  virulence  in  animals. 

The  Bacteriology  of  Diphtheria  — So  many  inquiries 
have  been  sent  to  the  Department  regarding  the  methods 
employed  for  the  general  bacteriological  examinations  of 
suspected  cases  of  diphtheria,  that  it  has  been  thought 
desirable  to  include  in  this  report  a  condensed  account 
of  the  facts  which  have  been  brought  out  in  the  various 
bacteriological  investigations  of  diphtheria,  together 
with  a  description  of  the  characteristics  of  the  diph- 
theria bacilli  which  must  be  known  in  order  to  make 
bacteriological  examinations  for  diagnostic  purposes. 

It  is  hoped  that  with  these  additions  this  report  may  be  . 
of  greater  practical  assistance  to  many  who  have  begun 
or  are  about  to  begin  similar  work. 

Successive  Investigations  Showing  the  Specific  Causal 
Relation  of  the  Diphtheria  Bacillus  of  Klebs  and  Loeffler 
to  Diphtheria. — In  the  year  1883,  bacilli,  which  were 
very  peculiar  and  striking  in  appearance,  were  shown  by 
Klebs l  to  be  of  constant  occurrence  in  the  pseudo  mem- 
branes from  the  throats  of  those  dying  of  true  epidemic 
diphtheria.  One  year  later  Loeffler2  published  the  re- 
sults of  a  very  thorough  and  extensive  series  of  investiga- 
tions on  this  subject.  He  found  the  bacillus  described 
by  Klebs  in  most,  but  not  in  all,  cases  of  throat  inflamma- 
tions which  had  been  diagnosticated  as  diphtheria.  He 
separated  these  bacilli  from  the  other  bacteria  present 
and  obtained  them  in  pure  culture.  When  he  inoculated 
these  bacilli  upon  the  abraded  mucous  membrane  of  sus- 
ceptible animals,  pseudo-membranes  were  produced,  and 
frequently  death  followed.  If  a  certain  amount  of  a 
bouillon  culture  was  injected  subcutaneously  into  guinea- 
pigs,  death  was  caused  with  characteristic  lesions.  Loef- 
fler's  failure  to  find  the  bacilli  in  every  case  examined  is 
now  explained  by  the  fact  that  certain  varieties  of  pseudo- 
membranous inflammation  not  due  to  the  diphtheria  ba- 
cillus, such  as  occur  especially  in  scarlet  fever,  were  then 
wrongly  considered  to  be  true  diphtheria. 

In  1887/  further  studies  by  Loeffler  added  to  the 
oroof  of  the  dependence  of  diphtheria  on  the  diphtheria 
bacilli.  In  1888,  D'Espine  found  the  bacilli  in  fourteen 
cases  of  characteristic  diphtheria,  and  proved  them  to  be 
absent  in  twenty-f  jut  cases  of  mild  sore-throats  which, 
clinically,  were  believed  not  to  be  cases  of  diphtheria.  In 
the  same  year,  the  first  report  of  the  results  of  the  very 
important  investigations  of  Roux  *  and  Yersin  was  pub- 
lished, and  the  dependence  of  diphtheria  on  the  diph- 
theria bacilli  may  be  considered  to  have  been  established. 
Roux  and  Yersin  found  that  diphtheria  bacilli  were  pres- 
ent in  all  characteristic  cases  of  diphtheria,  and  that 
these  bacilli  possessed  the  cultural  and  pathogenic  quali- 
ties of  those  described  by  Loeffler.  They  found,  too, 
when  the  bacilli  were  inoculated  upon  the  healthy  mu- 
cous membrane  of  the  trachea  of  the  rabbit,  no  result 


September  39,  1894] 


MEDICAL  RECORD. 


3*7 


followed;  but  if  the  inoculation  was  made  on  the 
abraded  membrane,  phenomena  occurred  which  strikingly 
resembled  those  present  in  membranous  laryngitis  in 
man,  i.e.,  congestion  of  the  mucous  membrane  followed 
by  the  formation  of  a  pseudo  membrane,  oedematous 
swelling  of  the  tissues,  and  of  the  glands  of  the  neck, 
dyspnoea,  stridulous  breathing,  and  asphyxia.  Injections 
of  cultures  beneath  the  skin  of  rabbits  and  guinea  pigs  in 
sufficient  quantity  caused  their  death  in  from  thirty  six 
hours  to  five  days,  the  period  varying  in  ratio  to  the  sus- 
ceptibility of  the  animal,  and  the  number  and  the  viru- 
lence of  the  bacteria  introduced.  The  same  results  fol- 
lowed the  i  ejections  of  filtered  cultures,  showing  the 
products  formed  by  the  growth  of  the  bacilli  were  by 
themselves  capable  of  causing  the  general  lesions. 

Roux  and  Yersin  were  also  able  to  produce  in  animals 
characteristic  diphtheritic  paralysis.  They  produced 
this  in  many  cases  where  the  inoculated  animals  did  not 
succumb  to  a  too  rapid  intoxication.  Paralysis  com- 
menced in  a  pigeon  three  weeks  after  the  inoculation  of 
the  pharynx,  and  after  all  membrane  had  disappeared 
and  the  animal  seemed  to  have  completely  recovered. 
In  rabbits,  the  paralysis  usually  commenced  in  the  pos- 
terior extremities,  and  then  gradually  extended  to  the 
whole  body,  causing  death  by  paralysis  of  the  heart  or 
respiration.  In  rare  instances  the  muscles  of  the  neck 
or  of  the  larynx  were  first  paralyzed,  and  thus  character- 
istic symptoms  were  caused.  The  authors  conclude: 
"  The  occurrence  of  these  paralyses,  following  the  intro- 
duction of  the  bacilli  of  Klebs  and  LoefHer,  completes 
the  resemblance  of  the  experimental  disease  to  the  natu- 
ral malady,  and  establishes  with  certainty  the  specific 
rdleoi  this  bacillus.1' 

Finally,  the  microscopical  changes  in  the  internal  or- 
gans of  animals  dying  of  experimental  diphtheria  pro 
d'iced  by  the  bacilli  have  been  shown  by  Welch  and 
Flexner,*  and  by  Babes *  and  others,  to  be  essentially  the 
same  a?  those  produced  by  diphtheria  in  man,  and  thus 
a  still  further  proof  is  afforded  of  the  specific  rdle  of  this 
bacillus. 

The  results  of  the  various  observations  detailed  above 
have  since  been  confirmed  by  a  great  number  of  com- 
bined clinical  and  bacteriological  investigations,  so  that 
all  who  have  studied  the  bacteriology  of  diphtheria  would 
now  agree  with  the  following  statement  made  by  Welch 7 
in  an  address  on  diphtheria:  "All  the  conditions  have 
been  fulfilled  for  diphtheria  which  are  necessary  to  the 
most  rigid  proof  of  the  dependence  of  an  infective  dis- 
ease upon  a  given  micro-organism,  viz.,  the  constant 
presence  of  this  organism  in  the  lesions  of  the  disease, 
the  isolation  of  the  organism  in  pure  culture,  the  repro- 
duction of  the  disease  by  inoculations  of  pure  cultures, 
and  similar  distribution  of  the  organism  in  the  experi- 
mental and  in  the  natural  disease.  In  view  of  these 
facts,  we  must  agree  with  Prudden,8  that  we  are  now  jus- 
tified in  saying  that  the  name  diphtheria,  or  at  least, 
primary  diphtheria,  should  be  applied,  and  exclusively 
applied,  to  that  acute  infectious  disease  usually  associated 
with  a  pseudo-membranous  affection  of  the  mucous  mem- 
brane, which  is  primarily  caused  by  thq  bacillus  called 
the  bacillus  diphtheria?  of  LoefHer.11 

Pseudo  or  False  Diphtheria. — Under  this  general  title 
are  included  all  cases  of  pseudo  membranous  or  exuda- 
tive inflammation  of  the  mucous  membranes  in  which  the 
diphtheria  bacillus  is  absent.  The  thorough  considera- 
tion of  the  bacteriology  of  this  form  of  inflammation  is 
to  be  reserved  for  a  later  report,  but  it  is  necessary  to 
touch  on  a  few  points  here. 

Since  LoefHer 2  in  1889  first  described  a  class  of  pseudo- 
membranous inflammations  of  the  throat  in  which  the 
diphtheria  bacilli  were  absent  and  cocci  present,  it  has 
been  established  that  a  certain  proportion  of  the  inflam- 
mations of  the  respiratory  mucous  membranes,  which 
closely  resemble  the  less  characteristic  cases  of  diphtheria, 
are  not  due  to  the  diphtheria  bacilli  but  to  cocci,  espe- 
cially to  streptococci. 
.   It  has  been  found  that  streptococci  are  commonly 


present  in  the  throats  ot  healthy  persons,  or  at  least  in 
the  throats  of  persons  living  in  large  cities,  and  that 
other  forms  of  cocci,  especially  the  pneumococci  and  sta- 
phylococci, are  apt  to  be  associated  with  them.  These 
germs  seem  to  live  in  the  throat  without  creating  any 
disturbance  there  so  long  as  the  mucous  membranes  are 
healthy,  but  under  certain  conditions,  as  when  the  mucous 
membrane  has  been  made  vulnerable  by  exposure  to  cold 
or  other  deleterious  influences,  or  by  the  poison  of  scarlet 
fever,  measles,  or  some  other  disease,  the  streptococci, 
alone  or  associated  with  other  cocci,  are  able  to  attack 
the  mucous  membrane  and  to  cause  an  inflammation* 
This  may  be  of  any  degree  of  intensity  from  a  simple 
inflammatory  hyperemia  to  an  inflammation  with  the 
extensive  production  of  pseudo  membrane  or  with  ulcer- 
ation. Such  inflammations,  when  associated  with  the 
formation  of  a  pseudo-membrane,  are  known  as  pseudc- 
diphtheria.  The  exudate,  or  pseudo  membrane,  in  pseudo- 
diphtheria  is  usually  confined  to  the  tonsils,  but  other 
parts,  such  as  the  larynx,  pharnyx,  and  nostrils,  may  be 
invaded. 

It  has  been  found  that  the  percentage  of  mortality  in 
tfiese  cases  is  far  less  than  in  diphtheria,  and  that  the 
disease  is  seldom,  if  ever,  communicated  to  others. 

The  Proportion  of  Cases  of  Suspected  Diphtheria  which 
upon  Examination  Prove  to  be  True  Diphtheria. — As 
soon  as  careful  investigation  had  demonstrated  it  was  pos- 
sible, with  proper  precautions,  to  separate  by  bacterio- 
logical examination  the  cases  of  true  from  the  cases  of 
fake  diphtheria,  large  numbers  of  cases  suspected  to  be 
diphtheria  were  examined  bacteriologically.  The  re- 
ports from  hospitals  in  which  all  cases  of  diphtheria  and 
oi  suspected  diphtheria  were  examined,  are  of  especial 
interest  as  showing  the  proportion  of  cases  of  true  to 
false  diphtheria.  The  results  from  these  hospitals  are 
all  the  more  valuable  because  the  cases  came  from  all 
parts  of  the  various  cities  in  which  the  respective  hospi- 
tals were  located,  and  hence  special  local  conditions  were 
not  likely  to  greatly  influence  the  general  results  ob- 
tained. Thus  Baginsky,8  in  Berlin,  found  the  diphtheria 
bacilli  in  120  out  of  154  suspected  cases;  Martin,10  in 
Paris,  in  126  out  of  200 ;  Park,11  in  New  York,  in  127  out 
of  244 ;  Janson,12  in  Switzerland,  in  63  out  of  100 ;  and 
Morse,1*  in  Boston,  in  239  out  of  400.  Thus  from  twenty 
to  fifty  per  cent,  of  the  cases  sent  to  diphtheria  hospitals 
did  not  have  diphtheria. 

If  we  examine  the  reports  of  examinations  made  under 
some  special  conditions,  as  during  an  outbreak  of  some 
contagious  disease  in  a  hospital  for  children  we  find  the 
results  may  differ  in  a  striking  manner. 

Thus  in  1889  Prudden14  made  bacteriological  exami- 
nations of  24  fatal  cases  of  pseudo-membranous  inflam- 
mation of  the  tonsils,  pharynx,  and  larynx.  In  none  of 
these  were  the  LoefHer  bacilli  found  to  be  present.  These 
cases  occurred  in  two  hospitals  for  children  in  New  York, 
in  which  both  scarlet  fever  and  measles  were  at  the  time 
prevalent.  During  the  past  year  we  have  examined  the 
exudate  from  46  fatal  cases  of  suspected  diphtheria  oc- 
curring in  the  same  institutions  and  found  the  bacilli 
present  in  44  of  them. 

If  scarlet  fever  and  measles  (but  not  true  diphtheria) 
were  prevailing  in  an  institution,  it  is  evident  the  bacilu 
would  be  absent  from  the  pseudo- membranes  occasionally 
occurring  in  the  throat  as  a  complication  of  these  diseases. 

The  Mortality  in  True  Diphtheria  and  in  Pseudo* 
Diphtheria. — All  observers  have  found  the  mortality  was 
far  higher  in  those  cases  in  which  the  diphtheria  bacilli 
were  present  than  in  those  in  which  they  were  absent. 
In  true  diphtheria  the  mortality  has  been  found  to  vary 
from  25  per  cent,  to  70  per  cent.,  while  in  pseudo  diph- 
theria it  varies  from  o  per  cent,  to  20  per  cent. 

The  death-rate  in  cases  of  pseudo- diphtheria  occurring 
in  hospitals  averages  far  higher  than  the  death  rate  out- 
side of  such  institutions.  The  reason  for  this  is  chiefly 
to  be  found  in  the  fact  that  it  is  mainly  the  graver  cases, 
especially  those  suffering  from  laryngeal  obstruction, 
which  are  removed  to  the  hospitals. 


388 


MEDICAL   RECORD. 


[September  29,  1894 


Laboratory  Technique.  Collection  of  the  Blood-serum 
and  its  Preparation  for  Use  in  Cultures. — A  covered 
glass  jar,  which  has  been  thoroughly  cleansed  with  hot 
water,  is  taken  to  the  slaughterhouse  and  filled  with 
freshly  shed  blood  from  a  calf  or  sheep.  The  blood  is 
received  directly  in  the  jar  as  it  spurts  from  the  cut  in 
the  throat  of  the  animal.  After  wiping  the  edge  of  the 
jar,  it  is  covered  with  the  lid  and  set  aside  where  it  may 
stand  quietly  until  the  blood  has  thoroughly  clotted. 
The  jar  is  then  carried  to  the  laboratory  and  placed  in 
an-ice  chest.  If  the  jar  containing  the  blood  is  carried 
about  before  the  latter  has  dotted,  very  imperfect  separa- 
tion of  the  serum  will  take  place.  It  is  well  to  inspect 
the  blood  in  the  jar  after  it  has  been  standing  a  few 
hours,  and  if  the  clot  is  found  adhering  to  the  sides,  to 
separate  it  by  a  rod.  The  blood  is  allowed  to  remain 
twenty-four  hours  on  the  ice,  and  then  the  serum  which 
surrounds  the  clot  is  siphoned  off  by  a  rubber  tube  and 
mixed  with  one- third  its  quantity  of  nutrient  beef  broth, 
to  which  one  per  cent,  glucose  has  been  added.  This 
constitutes  the  Loe  filer  blood-serum  mixture.  The 
broth  used  to  mix  with  the  serum  is  prepared  as  follows  : 
One  pound  of  finely  chopped  lean  beef  is  allowed  to 
soak  in  one  litre  of  water  in  a  cool  place  for  at  least 
twelve  hours.  The  meat  and  fluid  arc  now  dumped  into 
a  cheese  cloth  or  towel,  and  the  fluid  squeezed  out.  To 
this  solution  one  per  cent,  of  peptone,  one  per  cent,  of 
glucose,  and  one- half  per  cent,  of  common  salt  are  added. 
It  is  well  to  test  the  reaction  of  the  mixture,  and  if  it  is 
found  to  be  acid,  to  render  it  neutral  by  adding  a  few 
drops  of  a  solution  of  caustic  soda  or  carbonate  of  soda. 
The  whole  is  now  boiled  for  half  an  hour,  and  filtered 
through  absorbent  cotton  or  filter-paper.  If  the  broth 
is  to  be  kept  it  should  be  placed  in  flasks  and  then  steril- 
ized. The  Loeffter  blood-serum  mixture  when  ready  is 
poured  into  tubes,  which  should  be  about  four  inches  in 
length  and  two  thirds  of  an  inch  in  diameter.  These 
tubes  should  first  be  plugged  with  cotton,  and  sterilized 
by  dry  heat  at  1500  C.  for  one  hour.  Care  should  be 
taken  in  filling  the  tubes  to  avoid  the  formation  of  air- 
bubbles,  as  they  leave  a  permanently  uneven  surface 
.  when  the  serum  has  been  coagulated  by  heat.  To  pre- 
vent this,  the  end  of  the  pipette  or  funnel  which  contains 
the  serum  should  be  inserted  well  into  the  test-tube. 
About  2  c.c.  are  sufficient  for  each  tube.  The  tubes 
having  been  filled,  are  now  to  be  coagulated  and  steril- 
ized. The  tubes  are  placed  at  the  proper  angle  and  then 
kept  for  two  hours  at  a  temperature  just  below  the  boil- 
ing point.  For  this  purpose  a  Koch  serum-coagulator 
or  a  double  boiler  serves  best,  though  a  steam  sterilizer 
will  suffice.  If  the  latter  is  used,  a  wire  frame  must  be 
arranged  to  hold  the  tubes  at  the  proper  inclination,  and 
the  degree  of  heat  must  be  carefully  watched,  as  other- 
wise the  temperature  may  go  too  high,  the  serum  actually 
boiled,  and  the  culture  medium  thus  spoiled.  After  ster- 
ilization by  this  process  the  tubes  containing  the  sterile, 
solidified  blood-serum  can  be  placed  in  covered  tin-boxes 
and  kept  for  months.  The  serum  thus  prepared  is  quite 
opaque  and  firm.  A  mixture  of  blood-cells  renders  the 
serum  darker,  but  it  is  not  less  useful. 

The  Swab  for  Inoculating  Culture-tubes. — The  swab 
to  inoculate  the  serum  is  made  as  follows :  A  stiff,  thin 
steel  rod,  six  inches  in  length,  is  roughened  at  one 
end  by  a  few  blows  of  a  hammer,  and  about  this  end  a 
little  absorbent  cotton  is  firmly  wound.  Each  swab  is 
then  placed  in  a  separate  glass  tube,  and  the  mouths  of 
the  tubes  are  plugged  with  cotton.  The  tubes  and  rods 
are  then  sterilized  by  dry  heat  at  about  1500  C.  for  one 
hour,  and  stored  for  future  use.  These  cotton  swabs 
have  proved  much  more  serviceable  for  making  inocula- 
tions than  platinum-wire  needles,  especially  in  young 
children  and  in  laryngeal  cases.  It  is  easier  to  use  the 
cotton  swab  in  such  cases,  and  it  gathers  up  so  much  more 
material  for  the  inoculation  that  it  has  seemed  more  re- 
liable. 

For  convenience  and  safety  in  transportation  "  a  cult* 
ure  outfit"  has  been  devised  which  consists  of  a  small 


wooden  box  containing  a  tube  of  blood  serum,  a  tube 
holding  a  swab,  and  a  record  blank.  These  "  culture 
outfits  "  may  be  carried  or  sent  by  messenger  or  express 
to  any  place  desired,  and  are  kept  at  stations  scattered 
throughout  the  city  for  the  free  use  of  physicians. 

Directions  for  Inoculating  Culture- tubes  with  the  Ex- 
udate in  Cases  of  Suspected  Diphtheria. — The  patient 
should  be  placed  in  a  good  light,  and,  if  a  child, 
properly  held.  The  swab  is  removed  from  its  tube,  and 
while  the  tongue  is  depressed  with  a  spoon  it  is  passed 
into  the  pharynx  (if  possible  without  touching  the 
tongue)  and  is  rubbed  gently  but  firmly  against  any 
visible  membrane  on  the  tonsils  or  in  the  pharynx,  and 
then,  without  laying  the  swab  down,  it  is  immediately  in- 
serted in  the  blood  serum  tube,  and  the  portion  which 
has  been  previously  in  contact  with  the  exudate  is  rubbed 
a  number  of  times  back  and  forth  t>ver  the  whole  surface 
of  the  serum.  This  should  be  thoroughly  done,  but  it  is 
to  be  gently  done,  so  as  not  to  break  the  surface  of  the 
serum.  The  swab  is  replaced  in  its  tube  and  both  tubes,  ( 
their  cotton  plugs  having  been  inserted,  are  returned  to  ' 
the  box  and  sent  to  the  collecting  station.  The  blank 
forms  of  report  which  accompany  each  outfit  should  be 
completely  filled  out  and  forwarded  to  the  station  with 
the  tubes. 

Where  there  is  no  visible  membrane  (it  may  be  present 
in  the  nose  or  larynx)  the  swab  should  be  thoroughly 
rubbed  over  the  mucous  membrane  of  the  pharynx  and 
tonsils,  and  in  nasal  cases,  when  possible,  a  culture 
should  also  be  made  from  the  nose.  In  little  children 
care  should  be  taken  not  to  use  the  swab  when  the  throat 
contains  food  or  vomited  matter,  as  then  the  bacterial 
examination  is  rendered  more  difficult.  Under  no  con- 
ditions should  any  attempt  be  made  to  collect  the  mate- 
rial shortly  after  the  application  of  disinfectants  (espe- 
cially solutions  of  corrosive  sublimate)  to  the  throat.  If 
any  of  these  instructions  have  not  been  carried  out,  the 
fact  should  be  carefully  noted  on  the  record  blanks. 

The  Examination  of  Cultures. — The  culture  tubes 
which  have  been  inoculated  as  described  above,  are  kept 
in  an  incubator  at  370  C.  for  twelve  hours,  and  are  then 
ready  for  examination.  On  inspection  it  will  be  seen 
the  surface  of  the  blood- serum  is  dotted  with  very  numer- 
ous colonies,  which  are  just  visible.  At  this  time  no 
diagnosis  can  be  made  from  simple  inspection.  (If, 
however,  the  serum  is  found  liquefied,  or  shows  other 
evidences  of  contamination,  the  examination  will  prob- 
ably be  unsatisfactory.)  A  microscopical  preparation  is 
now  made  by  placing  a  tiny  drop  of  water  upon  a  clean 
cover-glass,  and  then  a  platinum  needle  is  inserted  in  the 
tube,  and  quite  a  large  number  of  colonics  are  swept  with 
it  from  the  surface  of  the  culture  medium.  The  bacteria 
adherent  to  the  needle  are  washed  off  in  the  drop  of 
water  previously  placed  on  the  cover  glass  and  smeared 
over  its  surface.  The  bacteria  on  the  glass  are  then  al- 
lowed to  dry  in  the  air.  The  cover-glass  is  then  passed 
quickly  through  the  flame  of  a  Bunsen  burner  or  alcohol 
lamp  three  times  in  the  usual  way,  covered  with  a  few 
drops  of  Loeffler's  solution  of  alkaline  methyl  blue,  and 
left  without  heading  for  ten  minutes.  It  is  then  rinsed 
off  in  clean  water,  dried,  and  mounted  in  balsam.  ^ 

In  the  great  majority  of  cases  one  of  two  pictures 
will  be  seen  with  the  -fa  oil  immersion  lens  ;  either  an 
enormous  number  of  characteristic  Lex  filer  bacilli  with  a 
moderate  number  of  cocci,  or  a  pure  culture  of  cocci 
mostly  in  pairs  or  short  chains  (see  photographs).  In 
a  few  cases  there  will  be  an  approximately  even  mixt- 
ure of  Loeffler  bacilli  and  cocci,  and  in  others  a  great 
excess  of  cocci.  Besides  these,  there  will  be  occasion- 
ally met  preparations  in  which,  with  the  cocci,  there  are 
mingled  bacilli  more  or  less  resembling  the  Loeffler 
bacilli,  but  not  characteristic.  These  bacilli,  which  may 
be  either  the  less  characteristic  diphtheria  bacilli  or  the 
pseudo-diphtheria  bacilli  (see  photographs),  are  especially 
frequent  in  cultures  from  the  nose. 

In  not  more  than  one  case  in  twenty  will  there  be  any 
serious  difficulty  in  making  the  diagnosis,  if  the  serum- 


September  29,  1894] 


MEDICAL    RECORD. 


389 


tube  has  been  properly  inoculated.  In  such  a  case  an- 
other culture  may  clear  up  the  doubt,  or  it  may  be  neces- 
sary to  obtain  the  bacilli  in  pure  culture. 

The  Direct  Microscopical  Examination  of  the  Exudate. 
— An  immediate  diagnosis,,  without  the  use  of  cultures, 
is  often  possible  from  a  microscopical  examination  of  the 
exudate.  This  is  made  by  smearing  a  cover  glass  with  a 
little  exudate  from  the  swab,  drying,  staining,  and  ex- 
amining it  microscopically.  This  examination,  however, 
is  much  more  difficult  and  the  results  more  uncertain 
than  when  the  covers  are  prepared  from  cultures.  The 
bacilli  from  the  membrane  are  usually  less  typical  in 
appearance  than  those  found  in  cultures,  and  they  are 
mixed  with  fibrin,  pus,  and  epithelial  cells.  They  may 
also  be  very  few  in  number  in  the  parts  reached  by  the 
swab,  or  bacilli  may  be  met  which  closely  resemble  the 
Lceffljr  bacilli  in  appearance,  but  which  differ  greatly  in 
growth  and  In  other  characteristics.  When  in  a  smear 
containing  mostly  cocci  a  few  of  these  doubtful  bacilli 
are  present,  it  is  impossible  either  to  certainly  exclude  or 
make  the  diagnosis  of  diphtheria.  Although  in  certain 
cases  this  immediate  examination  may  be  of  the  greatest 
value,  it  is  not  a  method  suitable  for  general  use. 

Characteristics  of  the  Diphtheria  Bacillus. — When 
cover-glass  preparations  made  from  the  blood  serum 
tubes  are  examined,  the  diphtheria  bacilli  are  found  to 
possess  the  following  characteristics : 

The  diameter  of  the  bacilli  varies  from  0.3  to  0.8  m., 
and  the  length  from  1.5  to  6  m.  They  occur  singly 
and  in  pairs,  and  very  infrequently  in  chains  of  three 
or  four.  The  rods  are  straight  or  slightly  curved,  and 
usually  are  not  uniformly  cylindrical  throughout  their 
entire  length,  but  are  swollen  at  the  ends,  or  pointed 
at  the  ends  and  swollen  in  the  middle  portion.  Even 
from  the  same  culture  different  bacilli  differ  greatly 
in  their  size  and  shape.  The  two  bacilli  of  a  pair  may 
lie  with  their  long  diameter  in  the  same  axis,  or  at  an 
obtuse  or  an  acute  angle.  The  bacilli  possess  no  spores, 
but  have  in  them  highly  refractile  bodies.  They  stain 
readily  with  the  ordinary  aniline  dyes,  and  retain  their 
color  after  staining  by  Gram's  method.  With  an  alkaline 
solution  of  methyl-blue,  the  bacilli,  from  blood-serum 
cultures  especially,  and  from  other  media  less  constantly, 
stain  in  an  irregular  and  extremely  characteristic  way. 
The  bacilli  do  not  stain  uniformly.  Certain  oval  bodies, 
situated  in  the  ends  or  in  the  central  portion,  stain  much 
more  intensely  than  the  rest  of  the  bacillus.  Sometimes 
these  highly  stained  bodies  are  thicker  than  the  rest  of 
the  bacillus ;  again  they  are  thinner  and  surrounded  by  a 
more  slightly  stained  portion.  The  bacilli  seem  to  stain 
in  this  peculiar  way  at  a  certain  period  in  their  growth, 
so  that  only  a  portion  of  the  organisms  taken  from  a 
culture  at  any  one  time  will  show  the  characteristic  stain- 
ing. In  old  cultures  it  is  often  difficult  to  stain  the  ba- 
cilli, and  the  staining,  when  it  does  occur,  is  frequently 
not  at  all  characteristic. 

Growth  on  Blood-serum. — If  we  examine  the  growth 
of  the  diphtheria  bacillus  in  pure  culture  on  blood  serum 
we  will  find  at  the  end  often  to  twelve  hours  little  colo- 
nies of  bacilli,  which  appear  as  pearl  gray  or  whitish 
gray  slightly  raised  points.  The  colonies  when  separated 
from  each  other  may  increase  in  forty-eight  hours  so  that 
the  diameters  may  be  a  quarter  of  an  inch.  The  borders 
are  usually  somewhat  uneven.  Those  colonies  lying  to- 
gether fuse  into  one  mass,  especially  if  the  serum  is 
rather  moist.  During  the  first  twelve  hours,  the  colonies 
of  the  diphtheria  bacilli  about  equal  in  size  those  of  the 
streptococci ;  but  after  this  time  the  diphtheria  colonies 
become  larger  than  those  of  the  streptococci,  nearly 
equalling  those  of  the  staphylococci.  The  diphtheria 
bacilli  in  their  growth  never  liquefy  the  blood  serum. 

Growth  on  One  Per  Cent.  Alkaline  Glycerine-agar, 
and  Method  of  Obtaining  Pure  Cultures. — It  is  frequently 
desired  to  obtain  the  diptheria  bacillus  in  pure  culture. 
This  is  most  readily  accomplished  by  removing  with  a 
platinum  needle  a  portion  of  the  mixed  growth  of  bac- 
teria in   a  serum  tube  and   lightly  streaking   it    over 


the  surface  of  the  nutrient  agar*  contained  in  a  Petri 
dish. 

Though  the  growth  of  the  diphtheria  bacilli  upon  agar 
is  less  certain  and  luxuriant  than  upon  serum,  the  appear- 
ance of  the  colonies  when  examined  under  the  microscope 
is  more  characteristic. 

If  the  diphtheria  colonies  develop  deep  in  the  substance 
of  the  agar,  they  are  usually  round  or  oval,  and,  as  a  rule, 
present  no  extensions,  but  if  near  the  surface,  commonly 
from  one,  but  sometimes  from  both  sides,  they  spread 
out  an  apron -like  extension  which  exceeds  in  surface  area 
the  rest  of  the  colony.  When  the  colonies  develop  en- 
tirely on  the  surface,  they  are  more  or  less  coarsely  granu- 
lar, are  nearly  translucent,  and  usually  have  a  darker 
centre.  The  edges  are  sometimes  jagged,  and  frequently 
shade  off  into  a  delicate  lace-like  fringe ;  at  other  times 
the  margins  are  more  even  and  the  colonies  are  nearly 
circular.  With  a  high  power  lens  the  edges  show  sprout- 
ing bacilli  (see  photographs).  The  colonies  are  grayish 
or  grayish  white  by  reflected  light,  and  pure  gray  or  with 
olive  tint  by  transmitted  light. 

The  growth  of  the  diphtheria  bacillus  upon  agar  pre- 
sents certain  peculiarities  which  are  of  the  utmost  prac- 
tical importance.  While  the  bacilli  from  the  majority  of 
cases  grow  rather  feebly,  some  grow  luxuriantly.  If  a 
large  number  of  the  bacilli  from  a  recent  culture  are  im- 
planted upon  a  properly  prepared  agar  plate,  a  certain 
and  fairly  vigorous  growth  will  always  take  place.  If, 
however,  the  agar  is  inoculated  with  the  exudate  of  a 
throat  which  contains  but  few  Loeffler  bacilli,  no 
growth  whatever  of  the  bacilli  may  occur;  while  the 
tubes  of  coagulated  blood- serum  inoculated  with  the  same 
exudate  contain  them  abundantly.  Again,  agar  prepared 
from  broth  made  from  different  specimens  of  beef,  or  to 
to  which  different  peptones  have  been  added,  varies  some- 
what as  to  its  suitability  for  the  growth  of  the  bacilli. 
Because  of  the  uncertainty  of  obtaining  a  growth  by  the 
inoculation  of  agar  with  a  few  bacilli,  or  with  bacilli 
of  diminished  vigor,  agar  is  a  far  less  reliable  medium 
than  blood  serum  for  use  in  cultures  made  for  diagnostic 
purposes,  and  is  therefore  not  to  be  recommended.  All 
agar  should  be  tested  by  means  of  a  pure  culture  of  the 
diphtheria  bacillus  before  being  used  experimentally. 

Growth  in  Broth. — All  the  varieties  of  the  Loeffler 
bacillus  experimented  with  have  grown  in  slightly  alka- 
line broth  with  or  without  the  addition  of  one  per  cent 
glucose.  The  characteristic  growth  is  one  showing  fine 
grains.  These  deposit  along  the  sides  and  bottom  of  the 
tube,  leaving  the  broth  nearly  clear.  In  some  cultures 
for  twenty-four  to  forty- eight  hours  there  is  a  more  or 
less  diffuse  cloudiness,  and  exceptionally  a  film  forms 
over  the  surface  of  the  broth.  On  shaking  the  tube  this 
film  breaks  up  and  slowly  sinks  to  the  bottom.  All  the 
varieties  tested  caused  the  alkaline  broth  to  become  acid, 
or,  at  least,  distinctly  less  alkaline,  within  forty-eight 
hours. 

Animal  Inoculations  as  a  Test  of  Virulence. — Animal 
experiments  form  the  only  reliable  method  of  determining 
with  certainty  the  virulence  of  the  diphtheria  bacillus. 
For  this  purpose  alkaline  glucose-broth  cultures  of  forty- 
eight  hours1  growth  should  be  used  for  the  subcutaneous 
inoculation  of  guinea  pigs.  The  amount  injected  may 
vary  from  one-fourth  to  one-half  per  cent,  of  the  body- 
weight  of  the  animal  inoculated.  In  the  great  majority 
of  cases,  when  the  bacilli  are  virulent,  this  amount  causes 
death  within  seventy-two  hours.  In  the  autopsy  the 
characteristic  lesions  .described  by  Loeffler  are  found ; 
namely,  at  the  seat  of  inoculation  there  is  a  grayish  focus 
surrounded  by  an  area  of  congestion ;  the  subcutaneous 

The  agar  is  prepared  by  adding  one  per  cent,  of  agar  to  the  re- 
quired quantity  of  broth.  This  broth  is  prepared  in  the  same  way  as 
that  used  in  the  blood-serum  mixture  already  described,  except  that 
it  contains  no  glucose.  The  agar  must  be  thoroughly  dissolved  in 
the  broth,  and  to  accomplish  this  it  is  necessary  to  boil  the  mixture 
for  from  three  to  six  hours.  Before  filtering,  sufficient  alkali  must  be 
added  to  make  the  agar  slightly  but  distinctly  alkaline.  Finally,  six 
per  cent,  of  glycerine  is  added,  and  the  mixture  sterilized  in  flasks. 
When  needed  it  is  melted  and  poured  into  sterilized  Petri  dishes  in  a 
thin  layer. 


390 


MEDICAL   RECORD. 


[September  29,  1894 


tissues  for  an  extensive  area  around  are  congested,  and  at 
times  very  oedematous;  the  adjacent  lymph  nodes  are 
swollen  and  the  serous  cavities — especially  the  pleural — 
frequently  contain  an  excess  of  fluid,  usually  clear,  but  at 
times  turbid;  the  lungs  are  usually  congested.  If  the 
organs  are  subjected  to  microscopical  examinations,  the 
lesions  described  by  Welch  and  Flexner,*  Babes/  and 
others  are  found.  There  are  numerous  smaller  and  larger 
masses  of  necrotic  cells  which  are  permeated  by  leuco- 
cytes. The  heart  and  the  voluntary  muscular  fibres 
usually  show  degenerative  changes.  The  number  of  leu- 
cocytes in  the  blood  is  increased.  From  the  area  sur- 
rounding the  point  of  injection  virulent  bacilli  may  be 
obtained,  but  in  distant  areas  and  organs  they  are  only 
ocasionally  found. 

Bacilli,  which  in  cultures  and  in  animal  experiments 
have  shown  themselves  to  be  characteristic,  may  be  re- 
garded as  certainly  true  diphtheria  bacilli,  and  as  capa- 
ble of  producing  diphtheria  in  man  under  favorable  con- 
ditions. 

Original  Investigations.— A  large  portion  of  the  daily 
work  in  the  laboratory  has  consisted  in  the  routine  ex- 
amination of  the  cultures  received  each  day.  Besides 
this,  however,  a  number  of  important  questions  have 
been  studied  experimentally,  of  which  the  most  important 
are  the  following : 

1.  How  much  reliance  can  be  placed  on  the  bacterio- 
logical diagnosis  made  from  the  examination  of  a  cult- 
ure inoculated  with  the  exudations  in  the  throat  of  a 
case  of  suspected  diphtheria  ? 

2.  If  in  cultures  bacilli  are  found  which  possess  the 
shape,  size,  and  staining  characteristics  of  the  diphtheria 
bacillus,  can  they,  without  further  cultural  or  animal 
experiments,  be  considered  as  virulent  diphtheria  ba- 
cilli? 

3.  What  is  the  period  of  time  during  which  virulent 
diphtheria  bacilli  remain  in  the  throat  after  the  disap- 
pearance of  the  exudate  or  pseudo-membrane  ? 

4.  (a)  What  relation  has  the  pseudo-  and  the  non- 
virulent  diphtheria  bacillus  to  the  true  virulent  bacillus  ? 

(b)  Are  virulent  diphtheria  bacilli  ever  present  in 
the  throats  of  healthy  persons  who  have  been  in  contact 
with  diphtheria  ? 

5.  To  what  degree  is  pseudo- diphtheria  communica- 
ble? 

6.  What  are  the  means  by  which  diphtheria  is  trans- 
mitted ? 

1.  How  much  Reliance  can  be  Placed  on  the  Bacterio- 
logical Diagnosis  made  from  the  Examination  of  a  Culture 
Inoculated  with  the  Exudations  in  the  Throat  of  a  Case 
of  Suspected  Diphtheria  ? — During  the  first  few  months,  in 
order  to  test  the  results  of  the  examinations  and  to  make 
the  liability  to  error  as  slight  as  possible,  the  following 
plan  was  adopted : 

All  cases  in  which  the  cultures  yielded  no  diphtheria 
bacilli  were  turned  over  to  special  inspectors,  who  made, 
whenever  possible,  a  second  culture,  and  followed  up  the 
case  during  the  illness,  and  for  some  time  even  after  its 
recovery. 

By  means  of  the  information  thus  obtained  the  bacte- 
riologists of  the  Department  were  able  more  and  more 
surely  to  decide  how  far  they  could  base  absolute  diag- 
noses on  cultures,  especially  when  made  by  others. 
Many  physicians,  as  well  as  the  inspectors,  gradually  be- 
came so  skilled  in  making  inoculations  that  it  was  possi- 
ble to  rely  certainly  on  the  results  obtained  from  the  ex- 
amination of  their  cultures ;  while,  on  the  other  hand,  it 
was  found  that  caution  was  necessary  in  accepting  the 
inoculations  of  others,  and  in  such  cases  a  second  culture 
was  requested. 

After  a  year's  trial  the  following  conclusions  have 
been  arrived  at :  The  examination  by  a  competent  bac- 
teriologist of  the  bacterial  growth  in  a  blood-serum  tube 
which  has  been  properly  inoculated  and  kept  for  four- 
teen hours  at  the  body  temperature,  can  be  thoroughly 
relied  on  in  cases  where  there  is  visible  membrane  in  the 
throat,  if  the  culture  is  made  during  the  period  in  which 


the  membrane  is  forming,  and  no  antiseptic,  especially 
no  mercurial  solution,  has  lately  been  applied. 

In  cases  in  which  the  disease  is  confined  to  the  larynx 
or  bronchi,  and  where,  therefore,  there  is  no  visible  exu- 
date against  which  the  swab  can  be  rubbed,  surprisingly 
accurate  results  can  be  obtained  from  the  examination  cf 
cultures,  but  in  a  certain  proportion  of  cases  no  diph- 
theria bacilli  will  be  found  in  the  first  culture,  and  yet 
will  be  abundantly  present  in  later  ones,  the  bacilli  hav- 
ing probably  been  coughed  up  more  freely  as  the  disease 
progressed.  We  believe,  therefore,  that  absolute  reliance 
for  a  diagnosis  cannot  be  placed  on  a  negative  result  in  a 
single  culture  from 'the  pharynx  in  purely  laryngeal 
cases. 

In  nasal  diphtheria  a  negative  result  may  be  obtained 
from  a  culture  made  from  the  throat,  and  yet  the  bacilli 
be  found  in  cultures  from  the  nose. 

In  making  a  diagnosis  from  the  examination  of  a  cult- 
ure it  is  essential  to  know  the  duration  of  the  disease  in 
the  case  from  which  it  was  made,  because  although  ba- 
cilli may  remain  present  and  alive  in  some  throats  for 
many  weeks,  it  is  nevertheless  important  to  remember 
they  may  vanish  early  and  suddenly,  and  that,  therefore, 
the  cultures  cannot  be  certainly  relied  on  after  the  mem- 
brane begins  to  disappear. 

The  use  of  antiseptics  shortly  before  making  the  inoc- 
ulation of  a  culture  tube  may  render  the  culture  useless 
for  diagnosis.  It  has  been  found  in  a  few  instances  that 
a  culture  made  from  a  case  of  diphtheria  shortly  after  a 
thorough  irrigation  with  a  1  to  4,000  solution  of  bichlo- 
ride of  mercury  gave  no  diphtheria  bacilli,  though  one 
made  just  before,  and  one  made  some  time  later,  gave 
them  abundantly.  It  is  a  curious  fact  that  under  such 
circumstances  a  vigorous  growth  of  other  organisms  may 
take  place. 

The  above  conclusions  are  true  only  when  the  inocu- 
lations have  been  properly  made,  and  in  judging  cultures 
received  from  physicians  in  general,  the  greatest  care 
must  be  taken.  Some  cultures  are  made  carelessly,  and 
some  evidently  without  taking  the  pains  to  even  read  the 
instructions,  or  to  glance  at  the  condition  of  the  coagu- 
lated serum  in  the  tube.  If,  therefore,  when  no  diph- 
theria bacilli  are  found,  the  bacterial  growth  is  scanty, 
the  media  dry  or  contaminated,  or  the  inoculation  in  any 
way  faulty,  the  case  must  be  referred  back  for  another 
culture.  The  second  culture  in  these  cases  not  infre- 
quently contains  the  bacilli  when  the  first  did  not 

The  absence  of  the  bacilli  in  a  culture  proves  the  case 
to  be  one  of  false  diphtheria  only  when  it  has  been  possi- 
ble to  make  it  under  the  proper  conditions. 

2.  If  in  Cultures  Bacilli  are  found  which  Possess  the 
Shape*  Size,  and  Staining  Characteristics  of  the  Diphtheria 
Bacillus,  can  they,  without  Further  Cultural  or  Animal 
Experiments,  be  Considered  as  Virulent  Diphtheria  Ba- 
cilli?— Since  it  is  the  custom  in  the  laboratory  of  the 
Health  Department  to  make  a  bacteriological  diagnosis 
in  suspected  cases  of  diphtheria  from  the  examination  of 
the  growth  upon  the  original  blood  serum  tube,  without 
waiting  for  further  cultural  or  animal  experiments,  it 
is  of  the  greatest  practical  importance  to  ascertain  to 
what  extent  bacilli  appearing  upon  the  serum  in  every 
way  characteristic  of  the  diphtheria  bacilli  can  be  as- 
sumed to  be  virulent. 

To  test  the  virulence  of  bacilli  it  is  necessary  to  ob- 
tain them  in  pure  culture,  for  otherwise  it  would  be  im- 
possible to  determine  whether  the  changes  produced  in 
the  inoculated  animal  were  due  to  the  supposed  diphtheria 
bacilli  or  to  other  micro-organisms  injected  with  them. 
It  is  further  necessary  to  grow  the  bacilli  in  proper  media 
and  to  inoculate  susceptible  animals  at  a  period  when  the 
growth  of  the  bacilli  in  the  media  has  reached  its  maxi- 
mum. It  is  only  when  these  precautions  have  been  fol- 
lowed that  accurate  results  will  be  obtained.  The  pres- 
ent almost  uniform  practice  is  to  inoculate  half  grown 
guinea-pigs  with  from  one- quarter  to  one  half  per  cent, 
of  their  body- weight  of  a  forty-eight  hours'  culture  of  the 
bacilli  grown  at  37°  C.  in  simple  nutrient  or  glucose  alka- 


September  29,  1894] 


MEDICAL    RECORD. 


39i 


line  broth.  It  is  important  to  remember  that  it  is  not 
safe  to  decide  because  the  growth  derived  from  one  ba- 
cillus is  not  virulent  that  all  the  bacilli  from  that  throat 
are  not  virulent.  The  cultures  from  several  bacilli  must 
be  tried.  The  majority  of  those  who  have  inoculated 
bacilli  derived  from  pseudo  membranes  and  possessing 
the  characteristics  of  the  Loeffter  bacilli  have  found,  as 
Loeffler  did,  that  they  were  always  virulent.  The  re* 
searches  of  Hofmann,15  Beck/6  and  others,  however,  show- 
ing that  in  a  certain  number  of  healthy  throats  there 
were  bacilli  which  closely  resembled  the  Loeffler  bacillus 
and  yet  were  not  virulent,  stimulated  others  to  subject 
the  bacilli  from  large  numbers  of  cases  of  suspected  diph- 
theria to  the  test  of  animal  inoculation. 

In  1890  Roux  and  Yersin17  published  the  results  of 
some  examinations  as  to  the  virulence  of  the  bacilli  ob- 
tained from  100  cases  of  diphtheria.  Fifty- five  of  these 
were  fatal  cases,  and  in  all  of  them  virulent  bacilli  were 
found,  although  in  a  few,  together  with  many  virulent 
bacilli,  there  were  a  few  non- virulent  ores.  Among  the 
45  cases  which  recovered,  many  were  very  mild,  and  in 
10  of  them  they  found  no  bacilli  of  sufficient  virulence 
to  cause  the  death  of  guinea  pigs,  when  injected  in 
moderate  amount.  From  all  of  them,  however,  they  ob- 
tained bacilli  capable  of  causing  inflammation  in  the 
guinea-pig  at  the  point  of  injection.  This  varied  from 
slight,  transient  oedema  to  extensive  necrosis.  From 
further  experiments  they  proved  similar  bacilli  were 
able,  under  proper  conditions,  to  regain  their  virulence. 
They  further  showed  in  these  milder  cases,  among  many 
non  virulent  or  slightly  virulent  bacilli,  there  were  usually 
a  few  virulent  ones ;  therefore  they  believed  in  most  of 
these  ten  cases  fully  virulent  bacilli  may  have  been  present 
in  the  throat  with  the  slightly  virulent  ones,  which  by 
chance  were  used  for  the  inoculations.  In  similar  inves- 
tigations carried  on  in  a  different  locality  somewhat  dif- 
ferent results  were  obtained.  Escherich 18  was  unable  to 
obtain,  from  a  large  number  of  diphtheria  cases  studied, 
any  bacilli  having  the  characteristics  of  the  Loeffler  ba- 
cillus which  were  not  virulent,  and  only  a  few  which,  in 
injections  of  one-quarter  per  cent,  of  the  body  weight  of 
a  forty  eight-hour  bouillon  culture,  did  not  kill  guinea- 
pigs  within  forty-eight  hours.  Koplik,19  in  New  York, 
in  testing  the  virulence  of  bacilli  from  mild  cases  of  ton- 
sillar diphtheria,  found  them  in  every  case  fully  virulent. 

In  Baltimore  Welch*0  and  Abbott  in  eight  cases  of 
diphtheria  found  the  bacilli  in  every  case  fully  virulent. 
In  a  later  investigation,  in  which  a  large  number  of 
healthy  and  slightly  inflamed  throats  were  examined, 
Abbott M  found  in  the  cultures  from  three,  bacilli  resem- 
bling the  Klebs- Loeffler  bacilli,  but  lacking  virulence. 
These  will  be  considered  bacteriologically  in  connection 
with  the  pseudo  diphtheria  bacilli,  but  the  cases  are  of 
sufficient  interest  to  be  briefly  quoted  in  the  present  con- 
sideration of  the  virulence  of  bacilli  obtained  from  throats 
in  which  inflammatory  lesions  have  appeared  which  more 
or  less  resemble  diphtheria. 

Case  I. — Adult,  aged  fifty- nine,  while  in  hospital  de- 
veloped a  laryngitis  and  pharyngitis.  The  uvula,  tonsils, 
and  faucial  pillars  became  swollen  and  (Edematous,  of  an 
intense  crimson  red  color,  and  covered  with  a  thin,  gray- 
ish-white, slightly  adherent  exudate.  In  five  days  the 
patient  completely  recovered.  Bacteriological  examina- 
tion showed  abundant,  apparently  characteristic  diph- 
theria bacilli,  which,  when  inoculated,  proved  not  to  be 
virulent. 

Case  II. — Adult,  similar  lesions  to  last ;  well  on  ninth 
day.  Bacteriological  examination  :  Abundant  bacilli,  in 
appearance  similar  to  Klebs-Lceffler  bacillus,  but  not 
virulent. 

Case  III. — Girl,  aged  eleven ;  acute  tonsillitis,  with 
small  white  plug  in  one  crypt.  Quick  recovery.  Bac- 
teriological examination :  Apparently  characteristic  Loef- 
fler bacilli,  but  not  virulent. 

It  must  remain  a  matter  of  doubt  whether  some  colo- 
nies from  these  cases  would  have  been  found  to  possess 
virulence  if  more  had  been  tested  as  to  this  characteristic. 


These  cases,  as  well  as  those  of  Roux  and  Yersin,  show 
that  now  and  then  the  bacilli  from  cases  suspected  to  be 
diphtheria  have  little  or  no  virulence. 

Original  Investigations. — In  order  to  determine  the 
virulence  of  the  bacilli  obtained  in  the  ordinary  routine 
examinations  from  suspected  cases  of  diphtheria,  blood- 
serum  cultures  from  twenty  cases  were  selected  in  which 
bacilli  were  found  having  the  characteristic  appearance 
of  the  virulent  diphtheria  bacilli.  The  cultures  tested 
were  selected  before  any  information  was  possessed  of 
the  severity  of  the  case  from  which  they  were  obtained 
and  were  used  for  experiments  on  animals. 

Virulence  of  the  Bacilli  found  in  Twenty  Cases  of 
Throat  Inflammations  of  such  a  Character  as  to 
arouse  a  Suspicion  of  the  Existence  of  Diphtheria. 


Sevei  ity. 


•Very  mild  case.  Sick  only 
four  or  five  days 

Moderately  severe  case.  Sub 
sequendy  contracted  scar- 
let fever 

Mild  case    

Mild  case 

Mild  case 

Very  mild  case.  Culture 
taken  after  disappearance 
of  membrane 

Very  mild  case , 

Fatal  case,  and  cause  of  se-j 
vcre  case  in  mother | 

Mild  case 

Mild  case.  Adult ;  never  in  I 
bed 

Removed  to  Diphthetia  Hos- 
pital.    Severe  case 

Rather  mild  case 

Very  mild  case 

Fatal  case-     Croup 

Fairly  severe  case,  followed 
by  measles 

Moderately  severe  case 

Moderately  severe  case  . .   . 

Fatal  case.    Croup 

Very  mild  case 

Contracted  from  a  mild  case. 
No  membrane  present 


458 


305 
350 
goo 
405 


430 
4x0 


435 

390 


40  hours.     14-19  days. 


ra  days. 

!  45  hours. 
40  horn  ?. 
40  hours. 


34-32  days. 
6  days. 


i-5 
i.5 


T.33 
i-33 


40  hours.     13  days. 
I  40  hours.  1 


•  40  hours. 
'  40  hours. 


P.  16  days. 
P.  38-41  days 


210 

0.5 

2*b 

620 
479 
675 

o.5 
3-33 

2 
i-5 

443 
435 
510 
475 
500 

''•33 
1.C6 

x.66 

250 

« 

50  hours.     P.  44  days. 

40  hours. 

25  hours.     P.  42  day?. 
40  hours.     P.  20-74  days. 
40  hours. 

40  hours.     P.  1 5-23  days. 
4  days  .     P.  15-19  days. 
40  hours. 
40  hours.  I 
40  hours. 

40  hours,  j 


We  find,  therefore,  that  the  bacilli  obtained  from 
twenty  cases  of  suspected  diphtheria,  two- thirds  of  *hich 
were  very  mild  cases,  proved  in  every  case  to  be  virulent, 
and  in  all  but  three  fully  so.  If  these  results  are  con- 
sidered in  connection  with  those  obtained  by  other 


American  and  European  observers,  we  must  conclude 
that  for  diagnostic  purposes  all  bacilli  found  in  throat 
inflammations  suspected  to  be  diphtheria,  which  possess 
the  morphological  and  cultural  characteristics  of  the 
Lceffler  bacilli  must  be  regarded  as  virulent  unless  ani- 
mal inoculations  prove  otherwise.  Further,  it  should  be 
remembered  (as  shown  by  Roux  and  Yersin,  and  as  con- 
firmed by  others  and  by  ourselves)  that  the  absence  of 
virulence  in  a  culture  derived  from  one  bacillus  is  not 
sufficient  to  prove  that  cultures  from  other  bacilli  from 
the  same  case  would  not  be  virulent. 

In  three  of  the  above  cases  the  cultures  from  the  first 
colony  selected  were  not  virulent,  while  from  others  they 
were  fully  so. 

3.  What  is  the  Period  of  Time  during  which  Virulent 
Diphtheria  Bacilli  Remain  in  the  Throat  after  the  Dis- 
appearance of  the  Exudate  or  Pseudo-membrane  ? — If  a 
piece  of  membrane  be  removed  from  a  throat  during  the 
period  of  invasion  of  diphtheria  and  examined  micro- 
scopically or  by  cultures,  the  presence  of  abundant  diph- 
theria bacilli  will  be  noted.  If,  a  few  days  later,  *hen 
the  membrane  has  begun  to  loosen,  another  bit  be  exam- 
ined the  diphtheria  bacilli  will  be  found  to  be  partly  or  at 
times  wholly  replaced  by  other  micro  organisms,  mostly 
cocci.  If,  several  days  after  the  complete  disappearance 
of  the  membrane,  cultures  be  made  from  the  mucus  of 
the  throat,  it  will  be  found  the  bacilli  of  diphtheria  in 
many  cases  will  have  disappeared  from  the  throat. 
This  rule  is  not,  however,  without  many  exceptions,  for 
it  will  be  frequently  found— days  after  the  complete  dis- 
appearance of  the  membrane  and  after  the  return  of  the 


392 


MEDICAL  RECORD. 


[September  29,  1894 


throat  to  a  healthy  condition — fully  virulent  bacilli  lin- 
ger in  the  throat. 

If  we  examine  the  researches  of  others  regarding  this 
matter  we  find  the  following  facts : 


Severity  of  the  Diph- 
theria in  the  Case.     | 


I  LengthofTime  dur- 1 
I  ing  which  the  Ba-J 
I     cilTi  had  persisted 

^fii!??    *"£  Results  obtained  from  the  Inocula- 
tion of  Guinea-pigs. 


pearance  of  the 
Exudate  when 
they  were  tested 
as  to  their  Vim-' 
lence. 


Roux  and  Yersin  :  ' ' 
Mild  case. 


Mild  case.  j 

3     Severelaryngealcase. 
4!     Severe  case. 
5     Mild  case. 

6*    Mild  case.  I 

7'     Laryngeal  case. 

I 

8  Severe  case.  I 
I 

^Koplik  : »» 

9  Mild  case. 

10  Mild  case. 
|Loeffler :  «  \ 

11  Moderate  case. 


3  days.  Guinea-pig  died    in    twenty  four 

hours. 
3  days.  I  Fully  virulent.     Killed  in    a  few 

I     hours, 
x  1  days.  Guinea-pig  died  in  three  days. 

14  days.  Guinea-pig.    Fully  virulent. 

9  days.  Some  colonies  virulent,  some  not 

I  virulent.  For  one  week  more, 
I     non- virulent  bacilli  were  found. 

7  days.  Virulent  and  non-virulent  colonies. 

I  For  four  days  more  only  non-vir- 
ulent bacilli  found. 

15  days.  I  On  the  twelfth  day,  all  virulent. 

On  the  fifteenth,  some  virulent  tnd 
some  not  virulent. 
2  months.         I  Produced  a  slight  local  oedema  only 
.     when  injected  into  guinea-pigs. 
j  Fully  virulent. 
14  days.  Virulent.    A  week  later  the  bacilli 

7  days.  '     obtained  were  not  virulent. 

Fully  virulent.    (This  was  twenty- 

8  days.  fourth  day  of  the  disease.) 


Eicherich :  1S  In  a  number  of  cases  the  Loeffter  bacilli 
were  found  to  persist  after  the  disappearance  of  the  mem- 
brane. In  all  of  these  the  bacilli  were  as  virulent  as 
those  obtained  at  the  height  of  the  disease. 

Morse  "  in  twenty- five  cases  found  the  average  length 
of  time  the  Loeffbr  bacillus  remained  in  the  throat  after 
the  disappearance  of  the  membrane  was  ten  days. 

The  average  duration  was  the  same  for  both  nose  and 
throat,  although  in  some  cases  the  bacilli  were  found  in 
the  throat  much  longer  than  in  the  nose,  and  vice  versa. 
The  bacilli  disappeared  in  one  case  the  day  after  the 
throat  was  clear,  in  another  three  days  after,  and  in  an- 
other four  days  after.  The  longest  periods  during  which 
they  persisted  were  twenty-two  and  twenty-seven  days. 
The  bacilli  were  tested  from  only  one  case,  and  these 
were  fully  virulent  ten  days  after  the  disappearance  of 
the  membrane  from  the  throat. 

Tobiesen28  found  virulent  diphtheria  bacilli  in  the 
throats  of  24  out  of  46  patients  at  the  time  of  their  dis- 
charge from  the  hospital.  The  majority  were  children 
between  six  and  twelve  years  of  age.  The  following 
table  gives  the  length  of  time  after  convalescence  that 
the  diphtheria  bacilli  were  found : 


Severity  of  Case. 


I    Number  of 


Persistence  of  Bacilli  after 

Disappearance  of  Membrane 

at  Time  of  Examination 

at  Discharge. 


Days. 

Mild 1                            4 

Moderate 5                            4 

Moderate 4                            5 

Moderate 4                            6 

Mild   x  I                 8 

Moderate !  x  I                 8 

Moderate x  ,                 9 

Severe [  1  I                 9 

Moderate '  x                            xo 

Mild   x  ,               xo 

Moderate x                           xi 

Severe    x                             16 

Moderate    x                           aa 

Moderate [  x  ,               31 

j  24  214        Average,  8JJ 

In  the  twenty-two  in  which  the  bacilli  were  not  found 
the  length  of  stay  in  hospital  of  the  patients  after  conva- 
lescence was  about  the  same.  Tobiesen 's  studies  indicate 
that  the  existence  of  throat  lesions  rendered  the  condi- 
tions more  favorable  for  the  persistence  of  bacilli.  The 
virulence  of  the  bacilli  was  proven  in  19  out  of  the  24. 
In  16  cases  the  guinea-pigs  died  within  a  period  of  fifty 
hours,  and  the  autopsies  showed  typical  lesions ;  in  2, 
local  necrosis  developed,  followed  by  death  in  one  ani- 


mal and  recovery  in  the  other.  In  the  last  case  the  ani- 
mal developed  paralysis  five  weeks  after  the  local  symp- 
toms had  disappeared.  From  these  results  he  draws  the 
following  conclusions : 

In  19  out  of  the  24  persistent  cases  the  Loeffler  bacilli 
proved  virulent,  and  the  probability  is,  they  were  also 
virulent  in  the  5  not  tested.  In  other  words,  one  half  of 
the  patients  who  are  allowed  to  leave  the  hospital  under 
the  usual  conditions  carry  virulent  bacilli  in  their  throats, 
and  are  capable  of  giving  diphtheria  to  others.  Clinical 
investigation  alone  can  decide  the  frequency  with  which 
these  convalescent  cases  infect  others.  This  investiga- 
tion must  be  carried  on  with  great  caution.  In  the  24 
investigated  by  Tobiesen  he  excluded  those  where  nu- 
merous cases  had  occurred  in  the  house  besides  the  ones 
under  investigation.  Among  those  remaining  he  dis- 
covered one  where  the  convalescent  child  was  the  almost 
certain  cause  of  diphtheria  in  another. 

Original  Investigations. — In  order  to  test  the  virulence 
of  the  bacilli  in  the  throats  of  convalescent  cases  they 
were  obtained  in  pure  culture  from  the  healthy  throats 
of  sixteen  convalescent  diphtheria  cases  and  used  for  the 
inoculation  of  guinea-pigs.  The  following  table  gives 
the  results  of  these  experiments : 


fc   I 


Severity  of  Diph- 
theria in  the  Case. 


M 


1    -  '  "i 

Dav 

1  .Rather  severe  case. .  8 

JMild  case xo 

Mild  case la 

Severe  case x8 

,  Moderate  case 6 

Mild  case '  33 


1  Very  mild  case 12 

I  Mild  case '  8 

,  Very  mild  case 35 

Very  mild  case  (na- 
sal)    10 

Mild  case 1  6 

MUd  case 8 

Mild  case I  xa 


Virulence. 

**- 

Life  of  Guinea- 

2** 

pig  after 

<* 

Injection. 

* 

< 

c.c. 

30a 

1.33       60-70  hours. 

250 

0.50         8  days. 

290 

x.25        13  days. 

229 

1. 00         0  days. 

549 

x.25        14  days. 

226 

x  .00      ( Extensive  necro- 

sis with  filial  re- 

covery). 

440 

x.50  (    40 hours. 

310 

2.00       40  hours. 

505 

x.66 

40  hours. 

Persistence 
from  Incep- 
tion of 
Disease. 


i* 


Fairly  severe  case 


Mild  case 50 


»53 

490 
45* 
3°> 
347 
4x0 


2.00 
x.66 
x.33 
«-33 
i-33 
3  00 


40  hours. 
40  hours. 
40  hours. 
40  hours. 

5  days. 

2  days. 


Days.  Days. 
13  17 


f     14 
16 

30 


»4 
«3 

«9 


In  each  case,  in  testing  the  virulence  of  the  bacilli  de- 
rived from  it,  we  employed  the  last  culture  or  the  next 
to  the  last  culture  made  from  it  in  which  the  bacilli  were 
found  to  be  present.  The  results  in  the  sixteen  cases 
tested,  as  well  as  in  those  before  recorded  by  others, 
prove  conclusively  that  the  bacilli,  which  in  a  certain 
proportion  of  cases  persist  in  the  throat  after  an  attack  of 
diphtheria,  are  always  virulent  for  some  time.  In  the 
exceptional  cases  in  which  the  bacilli  persist  for  a  very 
long  time,  it  is  found  they  occasionally  lose  their  viru- 
lence a  few  days  before  their  final  disappearance;  while 
in  other  cases  they  retain  their  virulence  to  the  end. 
That  the  cases  themselves  are  not  so  liable  to  spread 
diphtheria  is  probably  because  of  the  relatively  small 
number  of  bacilli  present  in  convalescent  throats  as  com- 
pared with  the  number  found  in  those  showing  the  lesions 
of  diphtheria. 

During  the  last  year  2,566  cultures  have  been  made 
from  the  throats  of  convalescent  cases  of  diphtheria  in 
order  to  determine  the  length  of  time  during  which  the 
Loeffler  bacilli  persisted.  The  cultures  were  made  at 
short  intervals  after  the  complete  disappearance  of  the 
exudate,  until  the  throat  was  found  to  be  free  of  diph- 
theria bacilli.  The  custom  was  to  make  the  second 
culture  three  days  after  the  complete  disappearance  of 
the  membrane,  and  then,  when  necessary,  to  make 
further  cultures  about  every  fourth  or  fifth  day.  Com- 
pleted observations  in  605  consecutive  recovered  cases 
give  the  following  facts :  In  304  of  these  605  cases  the 
diphtheria  bacilli  disappeared  within  three  days  after  the 
complete  disappearance  of  the  exudate;  in  301  cases 
the  diphtheria  bacilli  persisted  for  a  longer  time,  viz.,  in 


September  29,  1894] 


MEDICAL    RECORD. 


393 


176  cases  for  seven  days ;  in  64  cases  for  twelve  days ; 
in  36  cases  for  fifteen  days;  in  12  cases  for  three 
weeks ;  in  4  cases  for  four  weeks ;  in  4  cases  for  five 
weeks ;  and  in  2  cases  for  nine  weeks  after  the  time  when 
the  exudate  had  to  all  appearances  completely  disap- 
peared from  the  upper  air-passages. 

4.  (a)  What  Relation  has  the  Pseudo-  and  Non-viru- 
lent Diphtheria  Bacillus  to  the  True  Virulent  Bacillus? 
— In  1888  Hofmann  published  the  results  of  the  bacteri- 
ological examinations  of  a  number  of  diseased  and  healthy 
throats,  which  for  a  time  threw  doubt  on  the  specific 
character  of  the  Loeffler  diphtheria  bacillus.  Further  re- 
search has  entirely  dispelled  the  confusion  which  his  dis- 
coveries seemed  to  make,  but  the  results  of  these  studies 
and  of  similar  ones  on  the  virulent  and  non-  virulent 
bacilli  are  of  such  practical  importance  in  relation  to  the 
bacteriological  diagnosis  of  cases  of  suspected  diphtheria 
that  a  detailed  account  of  the  work  of  die  subsequent  in- 
vestigators, as  well  as  that  of  the  Health  Department,  will 
be  presented. 

Hofmann's  16  results  were  similar  to  those  of  Loeffler, 
in  that  he  found  the  virulent  bacillus  in  all  of  eight  cases 
of  true  diphtheria,  but  in  further  search  he  was  surprised 
to  find  in  the  throats  of  twenty-six  out  of  forty-five  per- 
sons, none  of  whom  was  suffering  from  diphtheria,  a 
bacillus  which  very  closely  resembled  the  Loeffler  bacillus. 
Some  of  these  persons  were  suffering  from  scarlet  fever, 
measles,  or  some  other  disease,  while  many  were  entirely 
healthy.  The  bacilli  from  a  number  of  these  healthy 
throats  were  obtained  in  pure  culture  and  inoculated  into 
animals.  The  majority  had  no  virulence  whatever.  The 
bacilli  from  the  different  cases  varied  somewhat  in  their 
characteristics.  Some  in  appearance,  manner  of  staining, 
and  growth  on  media  seemed  identical  with  the  Loeffler 
bacillus,  while  others  presented  slight  but  constant  differ- 
ences.    Between  the  extremes  were  many  gradations. 

Those  bacilli  which  did  not  possess  all  the  character- 
istics of  the  virulent  bacillus  differed  in  the  following  re- 
spects: They  were  shorter,  thicker,  and  more  uniform 
in  size.  On  agar  they  grew  in  whiter  and  thicker  colo- 
nies whose  circumference  was  more  circular  and  less 
notched.  They  also  grew  at  a  lower  temperature  than 
the  virulent  bacilli  (200  to  220  C). 

Hofmann  was  undecided  whether  all  of  these  bacilli 
were  really  Loeffler  diphtheria  bacilli,  which  had  lost 
their  virulence,  or  whether  they  were  a  different  species 
of  bacteria  and  of  a  saprophytic  nature.  He  was  also 
undecided  whether,  even  among  these  non-virulent  ba- 
cilli, there  might  not  be  included  different  species.  Hof- 
mann's death  prevented  further  attempts  on  his  part  to 
solve  this  problem,  and  different  investigators  since  that 
time  have  been  divided  in  their  opinions ;  some  taking 
the  view  that  these  bacilli  were  derived  from  true  Loeffler 
bacilli,  having  merely  lost  their  virulence;  others  that 
they  were  a  different  species,  having  no  connection  with 
the  Loeffler  bacillus ;  and  still  others  consider  the  matter 
as  undecided.  The  results  of  two  other  important  series 
of  investigations  should  be  considered  here,  those  of 
Roux  and  Yersin,  and  those  of  Escherich. 

Roux  and  Yersin  found  in  a  hospital  for  children  in 
Paris,  where  cases  of  diphtheria  occurred  from  time  to 
time,  that  fifteen  out  of  forty  five  children  contained  in 
their  healthy  throats  non-virulent  bacilli  resembling  the 
Loeffler  bacillus.  In  a  French  village  where  no  diph- 
theria had  been  present  for  a  long  time  they  made  cult- 
ures from  the  healthy  throats  of  fifty-nine  children  living 
in  a  school.  In  twenty-six  of  these  non  virulent  bacilli 
were  found. 

In  an  examination  of  the  throats  of  ten  attendants  in  a 
diphtheria  hospital,  non-virulent  bacilli  were  found  once. 
Thus,  in  one  hundred  and  fourteen  healthy  throats  the 
non  virulent  bacilli  were  found  forty-two  times.  In  all 
of  these  throats  the  bacilli  were  present  in  very  small 
numbers.  They  found  the  same  bacilli  twice  in  six 
children  with  mild  sore  throats,  and  five  times  in  seven 
children  sick  with  measles.  It  should  be  noted  that 
these  examinations  were  made  chiefly  in  a  hospital  and 


in  a  school,  both  for  children,  and  in  both  of  these  the 
children  were  confined  together  for  considerable  periods 
of  time,  and  the  direct  transmission  of  the  bacilli  from 
one  throat  to  another  would  be  likely  to  occur.  The 
unusually  large  percentage  of  children  in  which  they 
were  found  might  thus  be  accounted  for. 

The  bacilli  found,  when  studied  in  pure  culture, 
differed  somewhat  from  each  other.  The  majority  were 
identical  in  all  their  characteristics  with  the  Loeffler  ba- 
cillus, except  as  to  their  lack  of  virulence.  The  minority 
resembles  those  described  by  Hofmann,  being  shorter 
and  thicker  and  growing  at  a  lower  temperature  than  the 
characteristic  Loeffler  bacilli.  They  made  the  important 
observation  that  non-virulent  bacilli,  which  they  tested, 
when  grown  in  broth,  caused  the  same  changes  in  the  re- 
action as  the  virulent  forms,  namely,  from  alkaline  to 
acid  in  forty-sight  to  seventy-two  hours,  and  later  back 
again  to  alkaline  in  the  course  of  some  weeks.  These 
changes  were  found  to  occur  even  more  rapidly  in  the 
cultures  of  the  non-virulent  than  of  the  virulent  bacilli. 
Roux  and  Yersin  regarded  the  occasional  sb'ght  differ- 
ences in  growth,  shape,  and  staining,  as  too  slight  and 
inconstant  to  distinguish  the  virulent  from  the  non-vir- 
ulent bacilli.  Animal  experiments  alone  sufficed  to 
determine  the  question  of  virulence,  and  they  regarded  as 
arbitrary  a  division  founded  on  the  reaction  of  the  guinea- 
pig  to  inoculation ;  since  they  found  bacilli  from  cases  of 
diphtheria  may  possess  every  degree  of  virulence,  from 
those  which  cause  death  within  twenty-four  hours  to  those 
which  cause  only  a  temporary  oedema.  With  such  varia- 
tions it  is  a  difficult  matter  to  determine  what  should  be 
the  proper  line  of  division  between  the  virulent  and  the 
non-virulent  bacilli. 

To  fully  prove  these  bacilli  belong  to  the  same  species 
they  believe  it  is  necessary  to  derive  non-virulent  bacilli 
from  the  virulent  ones,  and  to  give  virulence  to  those 
entirely  lacking  it. 

They  found  it  was  possible  to  produce  an  attenua- 
tion of  the  virulence  of  the  bacilli  in  a  number  of  ways. 
For  instance,  if  a  current  of  sterile  air  is  kept  passing 
through  a  broth  culture  of  diphtheria  bacilli,  maintained 
at  a  temperature  of  39^°  C,  after  about  two  weeks  some 
of  the  bacilli  begin  to  lose  their  virulence,  and  at  the  end 
of  about  four  weeks  all  of  the  bacilli  have  lost  all  of  their 
virulence  and  produce  non-virulent  cultures.  A  little 
while  after  losing  their  virulence  the  bacilli  remaining  in 
the  culture  died. 

They  also  found  that  if  from  time  to  time  cultures  were 
made  from  dried  bits  of  membrane,  a  period  finally  came 
when  the  bacilli,  although  alive,  had  become  non-viru- 
lent.    Thus  they  had  fulfilled  the  first  condition. 

The  attempt  to  restore  to  bacilli  the  virulence  which 
they  had  entirely  lost  was  not  so  successful.  They  found 
it  possible  to  greatly  increase  the  virulence  of  bacilli  by 
injecting  them  together  with  a  virulent  culture  of  the 
streptococcus  of  erysipelas.  The  bacilli  obtained  from 
animals  which  had  succumbed  to  this  double  inoculation 
were  found  to  have  fully  regained  their  virulence.  Roux 
and  Yersin  were  unable,  on  the  other  hand,  to  give  back 
virulence  to  those  bacilli  which  had  been  completely 
robbed  of  their  virulence  by  the  above  methods,  or  to  those 
which  had  no  virulence  originally  when  obtained  from 
the  throat.  Thus  of  the  two  proofs  necessary  to  establish 
the  identity  of  the  virulent  and  the  non- virulent  forms, 
they  had  obtained  the  first  fully,  the  second  only  par- 
tially. 

As  additional  proof  of  the  identity  of  the  virulent  and 
non-virulent  bacilli,  they  brought  forward  the  fact  that 
they  found  the  latter  more  frequently  in  patients  recently 
convalescent  from  true  diphtheria  than  in  those  who  had 
never-  had  the  disease,  and  that  the  bacilli  which  had  ar- 
tificially been  deprived  of  their  virulence  frequently  were 
changed  in  other  respects,  so  as  to  resemble  in  all  ways 
the  bacilli  which  were  originally  lacking  in  virulence. 
From  their  studies  they  concluded  the  non-virulent  atd 
virulent  bacilli  were  one  and  the  same  species  of  bacteria. 

If  we  now  turn  to  the  work  of  Escherich  we  find  results 


394 


MEDICAL    RECORD. 


[September  29,  1894 


which  tend  to  show  the  virulent  and  some  of  the  non- 
virulent  bacilli  are  different  species  of  bacteria. 

He  first  lays  stress  on  the  methods  to  be  employed  in 
testing  the  virulence.  He  advises  that  the  animal  inocula 
tions  be  made  always  from  broth  cultures,  which  have  been 
grown  for  forty-eight  hours  at  zilA°  C.,  and  that  the 
amount  of  the  culture  be  regulated  by  the  size  of  the  ani- 
mal. Under  these  precautions  he  found  the  bacilli  from 
every  case  of  diphtheria  examined  to  be  fully  virulent, 
and  in  a  few  cases,  where  he  obtained  characteristic  ba- 
cilli from  the  healthy  throats  of  persons  exposed  to  diph- 
theria, he  found  them  also  to  be  virulent. 

Escherich  did  indeed  find  in  a  moderate  number  of 
throats  of  persons  not  suffering  from  diphtheria  a  non- 
virulent  bacillus  similar  to  those  described  by  Hofmann. 
Thus  in  Munich  he  found  this  non-virulent  bacillus  in 
2  throats  out  of  70,  and  in  Graz  in  n  out  of  250,  or  13 
times  in  320  cases.  These  bacilli,  however,  all  possessed 
certain  cultural  and  morphological  characteristics  which 
were  sufficient  to  separate  them  from  the  virulent  bacilli. 
They  were,  as  in  some  described  by  Hofmann,  plumper 
and  shorter  than  the  Loeffler  bacilli  and  more  uniform 
in  size.  The  growth  on  agar  was  more  luxuriant  and 
whiter  than  is  the  case  with  the  diphtheria  bacilli.  He 
noticed  two  new  points  of  difference  which  seemed  to  him 
important.  The  non-virulent  or  pseudo-  diphtheria  ba- 
cilli, when  spread  on  a  cover- glass,  lie  in  parallel  rows, 
while  the  virulent  diphtheria  bacilli  lie  at  every  angle  and 
in  the  most  varied  positions.  The  second  difference  was 
still  more  marked.  He  found,  as  had  all  others  who  had 
noticed  this  point,  that  the  virulent  bacilli  in  their  growth 
in  alkaline  bouillon  changed  the  reaction  of  the  bouillon 
to  acid  in  the  course  of  forty-eight  hours.  The  amount 
of  acid  formed  differed  in  different  cultures,  and  had  no 
relation  to  the  degree  of  virulence.  He  then  noticed  the 
pseudo  diphtheria  bacilli  always  made  the  bouillon  more 
alkaline  instead  of  acid.  Therefore,  if  at  the  end  of 
forty-eight  hours  litmus  was  added  to  the  different  bouil- 
lon-cultures it  turned  red  in  the  virulent  ones,  and  blue 
in  the  pseudo-diphtheritic  non-virulent  ones.  Although 
this  will  be  referred  to  again  it  should  be  noticed  that 
this  difference  in  reaction  was  not  found  by  Roux  and 
Yersin  in  the  cultures  of  the  non-virulent  bacilli  tested 
by  them. 

Escherich,  in  conclusion,  states  his  position  as  follows : 
"  Since  we  have  found  constant  cultural  differences  be- 
tween the  true  and  the  pseudo-diphtheria  bacilli  we  can 
give  the  pseudo  diphtheria  bacilli  no  diagnostic  value. 
We  do  not  find  it  to  be  a  frequent  inhabitant  of  the 
mouth.  Chronic  throat  inflammations  and  measles  seem 
to  render  the  throat  more  liable  to  its  invasion.1' 

He  did  not  find,  as  Roux  and  Yersin  and  Fraenkel  had, 
that  it  was  possible  to  determine  from  the  abundance  of 
the  colonies  of  bacilli  present  whether  they  were  com- 
posed of  virulent  or  non-virulent  bacilli. 

Up  to  the  present  time  the  results,  so  far  as  they  are 
known  to  the  writers,  are  given  in  the  following  tables : 


ESCHSKICH." 


VON    HOWAXN.1* 


LoEFFLB*V 


Some  bacilli  identical  with  those  Somewhat  larger  than  virulent 
of    Loeffler,    others     were'    bacilli,  and  more  tendency  to 
shorter,    thicker,   and    morej    produce  swollen  ends, 
uniform  in  size.  i 

Similar  to  virulent.  |  Similar  to  virulent. 

Sometimes  identical  with  Loef- Similar  to  virulent. 

fler  bacilli ;   again  found  ( in 

larger  and  somewhat  whiter t 

colonies.  I 

Growth  on  agar.   Grows   more   luxuriantly   and  Colonies  had  less  iagged  edges 

spreads  more  on  the  surface. !     and  were  of  a  whiter  hue. 

May  become  of  a  dirty  brown 

color  in  central  part  of  col- 
onies. ' 
In  45  throats,  comprising  some  Once  with  virulent  bacilli  from 

healthy  and  some  the  scat  of     a  case  of  diphtheria. 

non  -  diphtheritic    innamma-j 

tions,  they  were  found  in  a6.  : 
«     .......         •  \v 


Morphology. 


Growth  in  bout! 
Ion  and   reac- 1 
tion. 

Growth  on  blood- 
serum. 


Frequency    met 
with. 


Opinion  as  to  the  Is  doubtful  whether  these  non    Believes  them  to  be  of  a  differ 
nature  of    the 
bacilli. 


virulent  bacilli  belong  to  thel    ent  species,  but  only   to  be 
same  species  as  the  virulent     separated  by  animal  cultures, 
diphtheria  bacilli,  or  whether 
they  are  of  a  different  species. 


Morphology. 


BaocJ* 


Shorter,  plumper  bacilli  as  a 
rule,  but  some  more  like  viru- 
lent bacilli. 


Quicker  and 
growth. 


more  luxuriant  in 


Bacilli  shorter,  plumper,   and 
more  uniform  in  size.     When 
a  drop  of  bouillon-culture  is 
smeared  on  a  cover-glass  the 
I     bacilli  are  found  to  lie  in  par- 
allel rows. 
Growth  in  bouil- :  More  luxuriant  growths,    with 
Ion  and  reac-     tendency  to  cause  cloudiness; 
tion.  when  grown  in  neutral  litmus 

I    bouillon  the  litmus  turns  bluej 
after  a  or  3  days.  . 

Growth  on  blood-  Fairly  characteristic,  but  apt  to' Somewhat  more  luxuriant  and 
serum.  j     be   a   more    luxuriant   andj    of  a  more  yellow  color, 

whiter  growth. 
Growth  on  agar.  Grows    more   luxuriantly    and 
I     spreads  more  on  surface ;  may 
become   brow  nish  in  color 
'     after  some  days, 
met  In  Munich  in  a  out  of  70. ' 
In  Graz  in  11  out  of  250 
1    healthy   throats    and 
those  the  seat  of  non- 
I     diphtheritic  lesions  ex- 
1     amined. 
to  Believes  that  they  have  no  rela- 
of    tion  to  the  virulent  diphtheria 
,    bacilli,  and  that  they  can  be 
separated   pretty   accurately 
I    by  cultural  differences. 


Frequency 
with. 


Opinion  as 
the  nature 
the  bacilli. 


t    ?3 
3»o 


Colonies  less  jagged  on  margin 
and  more  yellow  in  hue. 


In  66  well  children  found  in  23;  m 
41  non-diphtheritic  affections 
in  14,  or  in  a  total  of  107  found 
them  in  36.  Also  along  with 
virulent  bacilli  in  true  diph- 
theria. 

Believed  that  the  non- virulent 
forms  found  by  him  were  of  a 
different  species  from  the  vir- 
ulent, and  were  saprophytic  in 
nature. 


Kofuk,"  1ST  Paper. 


Kopuk,"  »d  Pates. 


Morphology. 


Short,  plump,   uniform  in  size. 
Take  a  more  uniform  stain. 


Growth  in  bouil-  More  luxuriant,  cloudy  at  first, 
Ion  and  reac-  afterward  clearing,  with 
tion.  abundant  deposit;     bouillon 

acid  after  forty-eight  hours. 

Growth  on  blood-  More  luxuriant  and  spreading. 

serum. 
Growth  on  agar.  More  luxuriant  and  spreading. 

Frequency    met  In  4  mild  throat  inflammations, 
with. 


Opinion    a  s   t  o  Are  of  a  different  species  from 
the  nature  of     Loeffler  bacilli 
the  bacilli. 


Identical  in  form  and  size  with 

virulent     and    characteristic 

stain. 
Cloudy  ;  less  abundant  , 

in  bouillon  to  which  j 

has   been    added; 

alkaline   after  forty -eight 
1     hours. 

More  luxuriant,  opaque,  and 
j  whiter  growth. 
1  More  luxuriant,  opaque,  and 
I  whiter  growth. 
I  In  a  following  true  attack  of 
I  diphtheria.  For  first  three 
!     weeks  found  virulent  bacilli; 

then  for  two  weeks  there  were 

non-virulent  forms. 


Morphology. 


Growth  In  bouil 
Ion  and  reac 
tion. 


Growth  on  blood 


ROUX  AMD  YbKSXN.4 


Abbott.11 


Majority  identical  with  virulent  Bacilli  from  3  cases  were  identi- 
bacilh.  The  m i n o r it y  of  cal  with  virulent  forms ;  from 
shorter,  plumper,  and  morel  1  they  were  larger  than  the 
uniform  variety.  virulent  average. 

Characteristic,  except  for  slight  .Growth  in  bouillon  same  as  in 
cloudiness.  Changes  of  broth;  virulent  forms,  except  the 
were  same  as  in  virulent  changes  from  alkaline  to  acid, 
forms,  but  somewhat  more  and  later  back  again  to  alka- 
rapid.  '    line  were  more  rapid  than  in 

case  of  virulent  bacilli. 
Same  as  in  virulent  .Characteristic, 

serum. 
Growth  on  agar.  Same  as  in  virulent,    varying  Two  of  4  characteristic,  x  more 
,     within  the  limits  noticed  in:    luxuriant  in  growth,  and    1 
different  virulent  cultures.  giving  colonies    with  darker 

I  I    central  portion. 

Frequency    met,  In  104  healthy  children's  throats  Four  times  in  53  throats.   Some 
with.  found  41   times ;    10    adults     healthy,    others    the  seat    of 

j  once.  In  6  mild  throat  in-  moderately  severe  inflamma- 
I  nammations  twice;  in  7  sick  tions. 
with  measles  5  times, 
t  o,  Believed  the  non-virulent  to  be  Non-virulent  bacilli  having;  all 
of  the  same  species  as  the  other  characteristics  of  viru- 
virulent ;  they  were  simply  an  lent  bacilli  to  be  of  same  spe- 
attenuated  form.  cies. 

.Pseudo  diphtheria  bacilli  to 
show  constant  cultural  difler- 


Opinion   as 
the   nature  of 
the  bacilli.        | 

Note. 


I 


Frabnkbl." 


Maxtin." 


Morphology. 

Growth  in  bouil- 
lon and  reac- 
tion. 

Growth  on  blood- 
serum. 

Growth  on  agar. 


Frequency     met 
with. 


Opinion  as  to. 
the  nature  of 
bacilli. 


Identical  with  virulent  forms.      Short,  plump  bacilli. 
Characteristic  I 


.Characteristic. 
Characteristic. 


More  moisu  luxuriant,  and 
whiter.  Grow  at  room  tem- 
peratuie. 

In  quite  a  number  of  diphtheria 
cases  running  a  mi* M 


In  number  of  healthy  conjunc 

tiva;  and  in  some  cases  of  mild 

tonsillitis,  and  with  viiulent 

bacilli  in  diphtheria.    Figures 

not  given. 
Believes  the  virulent  and  non-  An  attenuated  form  of  the  viru- 

virulent   to  be  of  the   same     lent  diphtheria  bacillus. 

species  and  includes   under 

non-virulent,    some     causing! 

local  reaction.  I 


September  29,  1894] 


MEDICAL    RECORD. 


395 


If  we  review  the  remaining  literature  of  this  subject 
we  find  some  investigators  have  been  led  by  their  results 
to  adopt  views  similar  to  those  of  Roux  and  Yersin, 
others  to  those  of  Escherich,  and  still  others  have  been 
forced  to  content  themselves  with  the  position  of  Hof- 
mann,  viz.,  that  we  are  not  yet  in  a  position  to  affirm 
whether  all  these  bacilli  are  of  one  or  of  different  species 
of  bacteria. 

If  we  inspect  closely  the  descriptions  of  the  non-  viru- 
lent bacilli,  we  find  there  seem  to  be  two  forms  which 
stand  out  distinctly  as  separate  varieties  with  which  the 
others  can  be  grouped  : 

1st.  Bacilli  which  are  in  all  respects,  except  that  they 
lack  virulence,  identical  with  the  Loeffler  bacillus,  and 
which,  like  it,  produce  an  acid  in  their  growth  in  broth- 
cultures. 

2d.  Bacilli  which  are  shorter,  plumper,  and  more  uni- 
form in  size  than  the  (characteristic)  Loeffler  bacilli,  and 
which  produce  an  alkali  in  their  growth  in  broth- cult- 
ures. 

As  we  look  over  the  tables  we  see  that  some  observers 
have  chanced  to  find  one  of  these  varieties,  some  the 
other,  and  some  both.  This  has  led  to  the  present  con- 
fusion. 

Table  Showing  Results  of  Cultures  Made  from  the 
Throats  of  Healthy  Persons  where  there  has  been 
no  History  Obtained  of  Direct  Contact  with  Diph- 
theria. 


From  Where. 


Virulent 
Total  Casev  Characteri s- 


N.   Y.   Dispensary  (by  Dr. 

JohnH.  Huddkston).... 

Northern  Dispensary 

VanderbUt  Clinic 

Throughout  the  City 

College    Phys.    and    Surg. 

(Students) 

N.  Y.  F.  H.  Dispensary.  .. 
Orthopedic  Hospital : 

Female  Ward 

Male  Ward  (through  kind- 
ness of  Dr.  Chappeil). . 
N.  Y.  Foundb'ng  Hospital, 

(by  Dr.  Adams) 

Totals. 


Non-viru- 
ilent  Charac- 


Non-viru- 
lent  Pseudo- 


<u  leases,  ^naraciens-  L«j.»:„n:«i.  ;ienc  rseuao 
Nos.        ,tic  Diph«he-,ten*^Ph-    diphtheiia 


ria  Bacilli, 


theria 
Bacilli. 


Bacilli. 


x  to  151  , 
15a  to  163 
264  to  189  ! 
190  to  "93  | 

294  to  34a  ! 
343  to  857 

358  to  167 

268  to  275 

27610330 


330 


27 


A  Comparative  Table  of  Non-virulent  and  Pseudo-diph- 
theria Bacilli. 


NON-VIXDLBMT  DlPHTHBRIA  BACILLI. 


Pseudo-diphtheria  Bacilli. 


Case  No.  and  New  York,  66.  New  York,  7a.!  ^,£52!  ™d  .  New  York,  iox. 
Source.       j      CThroat)  (Throat.)     I        (JE^tf*  (Throat.). 


Examination  of  Abundant  Abundant  Abundant  short,  Abundant  short, 
bacilli  in  pri-     large  charac-     characteris-,    even-  stained     even  -  stained 


mary    cult- 
ure. 


tenstic  diph- 
theria bacilli. 


I 


tic    diphthe-1    bacilli.      (See 
ria  bacilli.  photograph   of  I 

pseudo  -  diph- 
theria bacilli.) 


bacilli  (pseudo- 
diphtheria). 


Growth  in  pure,  Characteristic  Characteristic.  Fairly  character- Character  is  tic 

istic      appear-:     appearance    of 

ance   of   colo-l    colonies, 
nies.  I 

Coarsely  granu-  Fairly  typical, 
lar  colonies,!  More  heavily 
with  jagged,  pigmented  and 
rough  borders,, 
ana  of  aboutj 
equal  thickness 


culture  on j 
serum     at 
37*°  C. 
Agar. 


appearance 
of  colonies. 

Fairly    typical ;  Not  typical  col- 
colonies. 


u  n  i  f  o  r  mly 
thicker  than  is 
characteristic 
of  the  virulent 
bacilli.  Colo- 
nies nearly  cir- 
cular, with  even 
borders. 

Growth  in  neu-  Characteristic  Not  character-  Typical     growth  Formation  of  thin 
tral    glucosei    acid  at  end     istic     Broth     in  rather  coarse     pellicle      and 

broth.  j     of  forty-two     cloudy      for,  

hoars.  j    two  a  a  y  s  ;  1 

acid  at  end 

I  '    of  forty  eight 

'                          j    hours.      m  _ 

Virulence  _  i  n  Guinea  -pig,  Guinea  -pig,  Guinea  -  pig,  405  Guinea  «  pig,  400 
guinea-pigs.       2x6    g  m  s .  ;      164  g  m  s  . ;  I    gnu. ;  3  c.   c.      gms. ;    2  c.  c 
3.33      c\  c-      *-33      c«.  c-|    No  reaction.     ,     No  reaction. 
No  reaction.      No  reaction. 
Omkal  notes.    B  rone  hit  is.  1  Intestinal    ca-  Healthy  throat.     Bronchitis.      No 
Diphtheria     tarrh.       No  |    history  of  con- 

in     house'    history  off  '    tagion. 

three   weeks1    contagion.     1 
previously. 
Female.  {Female.  Male. 


throughout ; 
brownish  hue 
by  transmitted' 
light  ; 


grains.  Alka-' 
fine  reaction  at 
end  of  forty- 
eight  hours. 


slight  diffuse 
cloudiness.  Al- 
kaline reaction 
at  end  of  forty- 
eight  hours. 


Sex.... 

Age 1  year. 


15  months.         37  years. 


xo  years. 


Original  Investigations  — In  order  to  study  these  vari- 
ous bacilli  and  to  clear  up,  if  possible,  some  of  the  .ques- 
tions connected  with  their  classification,  cultures  were 
made  upon  blood  serum  from  330  healthy  throats  (chil- 
dren 280,  adults  50). 

When  any  of  the  varieties  of  bacilli  described  above 
were  discovered  in  the  cultures  they  weie  isolated,  and 
in  the  great  majority  of  cases  tested,  as  to  their  virulence, 
on  guinea-pigs.  The  results  of  these  studies  are  given 
in  the  tables  above.  The  bacilli  formed  may  be  divided 
into  three  groups. 

1.  Virulent  Loeffler' s  diphtheria  bacilli,  characteristic 
in  growth,  producing  acid  in  bouillon. 

2.  Bacilli  identical  with  Loeffler's  diphtheria  bacillus 
in  growth,  producing  acid  in  bouillon,  but  having  no 
virulence. 

3.  Bacilli  not  having  all  the  characteristics  of  the 
Loeffler  bacillus  in  growth,  producing  alkali  in  bouillon, 
and  having  no  virulence. 

In  the  above  table  we  find  bacilli  possessing  the 
characteristics  of  the  virulent  diphtheria  bacilli  except 
that  of  virulence  were  found  in  24  cases,  namely : 

Nos.  7>  33*  52>  63»  66>  72>  io3>  io5>  "o,  114,  124, 
132,  188,  189,  190,  191,  192,  193,  198,  212,  258,  259, 
260,  297. 

These  bacilli  were  abundant  in  the  primary  cultures 
from  17  cases,  and  present  in  small  numbers  only  in  the 
cultures  from  7. 

They  were  on  the  average  a  little  longer  than  the  viru- 
lent bacilli  from  the  cases  of  suspected  diphtheria  ex- 
amined on  the  same  days.  In  broth  the  bacilli  from  13 
of  the  24  cases  grew  characteristically,  while  from  6  they 
caused  a  more  or  less  dense  cloudiness.  It  was  found, 
however,  that  sometimes  the  virulent  bacilli  produced 
the  same  effect,  though  never  to  the  same  degree,  as  the 
bacilli  from  case  191.  In  5  cases  the  bacilli  were  not 
grown  in  broth.  In  all  the  cases  in'which  broth  cult- 
ures were  made  (19)  the  bacilli  produced  acid  in  their 
growth.  When  their  acid-producing  power  was  com- 
pared with  that  of  an  equal  number  of  virulent  cultures 
no  marked  difference  could  be  noted.  Some  virulent  ba- 
cilli were  found  to  produce  more  acid  than  the  non- viru- 
lent ones,  while  others  produced  less. 

Upon  blood-serum  the  bacilli  grew  in  a  manner  char- 
acteristic of  the  Loeffler  bacillus. 

Upon  agar  the  bacilli  from  1 1  cases  grew  as  the  viru- 
lent bacilli  usually  grow,  while  from  7  they  grew  in  a 
less  typical  manner,  but  always  in  ways  seen  exceptionally 
in  the  virulent  form.  Guinea-pigs  were  inoculated  with 
the  bacilli  from  15  cases.  The  lack  of  virulence  in  the 
bacilli  from  the  remaining  9  cases  was  taken  for  granted 
from  their  close  association  with  the  15  tested.  Half- 
grown  guinea-pigs  were  employed,  and  they  were  in- 
oculated under  die  skin  with  from  one- half  to  three- 
fourths  per  cent,  of  their  weight  of  a  forty-eight  hour 
broth  -  culture.  In  only  one  animal  was  there  any 
appreciable  reaction,  and  in  this  the  local  induration 
caused  passed  away  within  four  days.  A  very  slight 
degree  of  immunity  was  given  to  some  of  the  pigs  by  the 
injection. 

The  bacilli  persisted  in  4  of  the  throats  for  four  weeks, 
in  1  for  three  weeks,  in  3  for  two  weeks,  and  in  some  of 
the  others  for  shorter  periods. 

Column  three  of  the  table  shows  that  in  27  cases 
pseudo-diphtheria  bacilli  were  found  corresponding  to 
those  described  by  Hofmann  and  Escherich  and  photo- 
graphed by  Koplik.19  Upon  agar  some  of  the  bacilli 
grew  in  a  similar  manner  to  the  diphtheria  bacilli,  while 
others  grew  as  described  in  the  table  given  opposite. 
The  bacilli  were  smaller,  shorter,  thicker,  and  more  uni- 
form in  size  than  the  Loeffler  bacilli  and  always  formed 
alkali  in  their  growth  in  broth.  These  bacilli  were 
never  virulent  in  animals. 

Guinea-pigs  were  inoculated  with  large  amounts — one- 
half  to  one  per  cent,  of  their  weight — of  broth  cultures 
of  bacilli  obtained  from  8  cases  without  showing  any  re- 
action. 


39« 


MEDICAL   RECORD. 


[September  29,  1894 


As  is  shown  in  column  one  of  the  table,  virulent 
diphtheria  bacilli  were  found  in  8  of  the  330  cases. 

They  were  in  all  probability  derived  from  mild  cases 
of  unrecognized  diphtheria,  or  from  healthy  children  who 
were  carrying  the  bacilli  in  their  throats.  The  number 
of  such  infected  children  is  indicated  by  the  results  of 
studies  described  in  the  following  pages. 

4.  (b)  Are  Virulent  Diphtheria  Bacilli  ever  Present  in 
the  Throats  of  Healthy  Persons  who  have  been  brought  in 
Contact  with  Diphtheria  t — The  search  for  the  origin  of 
obscure  cases  of  diphtheria  has  revealed  the  fact  that  it  is 
possible  for  the  human  throat  to  become  the  habitat  of 
the  virulent  Loeffler  bacillus  without  any  visible  lesions 
resulting.  Thus  Loeffler1  found  the  virulent  bacillus 
once,  Fraenkel ,4  twice,  and  Escherich  tt  found  it  in  sev- 
eral cases.  In  one  of  Escherich's  cases  the  history  is  so 
significant  as  to  be  worth  repeating.  It  was  noticed 
among  the  children  coming  under  the  care  of  a  certain 
apparently  healthy  nurse  a  number  of  cases  of  diphtheria 
were  developing.  A  bacteriological  examination  being 
made,  her  throat  was  found  to  contain  very  numerous 
virulent  diphtheria  bacilli.  These  remained  present  and 
virulent  for  weeks.  A  similar  and  interesting  case  is  re- 
ported by  Feer."  In  a  diphtheria  epidemic  occurring  in 
a  hospital  ward,  due  to  a  single  infection,  the  throats  of 
seven  children  became  infected.  The  infection  caused 
fatal  diphtheria  in  four,  an  acute  angina  without  mem- 
brane in  two,  and  no  symptoms  whatever  in  one.  In  all 
of  these  the  bacilli  were  abundant  and  equally  virulent. 
Many  similar  examples  have  been  met  with  by  us. 

A  very  interesting  investigation  has  been  carried  on  to 
determine  how  frequently  the  throats  of  healthy  children 
became  infected  in  families  where  one  is  sick  with  diph- 
theria, and  where  little  or  no  isolation  is  possible. 

As  will  be  seen  by  the  following  tables,  the  throats  of 
the  healthy  children  of  fourteen  families,  in  which  one  or 
more  of  the  other  members  had  diphtheria,  were  exam- 
ined. There  were  in  all  forty-eight  healthy  children. 
In  fifty  per  cent,  of  these  diphtheria  bacilli  were  found ; 
forty  per  cent,  developed  later,  to  a  greater  or  less  extent, 
the  lesions  of  diphtheria. 


No.  of  Cases  ex- 

amined aside 

L.    Bacilli 
found  in — 

L.    Bacilli 

MILY. 

from  the  Original 

not 

Remarks. 

Case  of  Diph- 

found in — 

theria. 

A. 

X 

0 

x         Isolation  partial. 

B. 

3 

3 

0         No  isolation  ;  all  three  cases 
subsequently      developed 
diphtheria. 

C. 

a 

X 

1         No  isolation 

D. 

X 

X 

0         No  isolation 

£. 

3 

X 

a         No  isolation. 

F. 

A 

I 

3        '  Isolation  partial. 

G. 

5 

3 

a         Isolation  partial. 

H. 

4 

3 

x         No  isolation. 

I. 

4 

X 

3         Isolation  partial. 

k. 

8 

3 

5         Isolation  partial. 

4 

X 

3 

Isolation  partial. 

L. 

3 

X 

X 

Isolation  partial. 

M. 

5 

3 

a 

Isolation  partial. 

N. 

1 

X 

0 
»4 

No  isolation. 

- 

48 

84 

Of  the  above  cultures  in  which  the  Loeffler  bacilli  were 
found,  in  six  the  virulence  was  tested  in  the  usual  way. 
The  results  are  stated  in  the  following  table : 


2  Amount 
v  I  Bouillon- 
m      cult.  inoc. 


Guinea- 
pig-. 
Weight 


B.' 
G. 
H. 
K. 
M. 
N. 


t 


x.33 

1-33 

x.66 


337  gm. 
205  gin. 
332  gin. 
300  gin. 
490  gm. 
950  gm. 


Virulence. 


Clinical  History. 


day 


Died  in  40  hrs.  I  Developed    fatal  diph. 
I     after  cult  was  taken. 
Died  in  44  hrs.: Developed  tonsillar  diph.  2  days 

after  cult  was  taken. 
Died  in  48  hrs.  No  subsequent  development  of 

diphtheria. 
Died  in  40 hrs.' No  subsequent  development  of 
diphtheria. 
No  subsequent  development  of 

diphtheria. 
No  subsequent  development  of 
diphtheria. 


Died  in  40  hrs. 
Died  in  40  hrs. 


In  considering  the  high  percentage  of  cases  in  which 
the  virulent  Loeffler  bacillus  was  found,  it  must  be  re- 


membered in  these  families  the  conditions  were  the  best 
possible  for  the  transmission  of  the  contagium. 

In  numerous  instances  cultures  have  been  made  from 
the  throats  of  healthy  children  in  families  where  the 
diphtheria  case  was  well  isolated ;  in  such  cases  the  ba- 
cilli have  been  found  in  less  than  ten  per  cent,  of  the 
children. 

It  may  be  interesting  to  detail  here  two  instances  out 
of  many  observed  in  which  the  virulent  bacilli  of  diph- 
theria derived  from  healthy  throats  have  been  the  cause 
of  diphtheria  in  others. 

1.  A  child  was  admitted  into  a  hospital  ward  in  an 
anaemic  condition  and  with  a  chronic  coryza.  Five  days 
later  four  children  in  his  neighborhood  developed  diph- 
theria. Two  of  these  died.  In  seeking  the  cause  of  the 
diphtheria  suspicion  was  directed  to  the  child  by  a  slight 
nasal  discharge.  Bacteriological  examination  showed 
this  secretion  contained  many  diphtheria  bacilli.  On 
further  examination  it  was  found  the  child  came  from  a 
family  in  which  three  weeks  before  there  had  been  a  case 
of  diphtheria. 

2.  In  a  family  of  eight  children  one  child  sickened 
with  diphtheria ;  and  a  second  child,  a  baby,  was  sent  to 
a  neighbor.  The  next  day  cultures  showed  this  baby,  as 
well  as  two  of  the  other  children,  all  of  whom  were  ap- 
parently healthy,  were  infected  with  diphtheria  bacilli. 
The  three  apparently  healthy  but  infected  children,  as 
well  as  the  sick  one,  were  at  once  quarantined,  but  al- 
ready one  of  the  family  to  which  the  baby  had  been  sent 
had  contracted  diphtheria  from  it 

The  practical  value  of  bacteriological  examinations  of 
the  throats  of  healthy  children  in  families  where  isolation 
has  not  been  carried  out  in  the  first  days  is  further  shown 
by  the  fact  that  those  children  in  whom  the  bacilli  are 
found  are  extremely  apt  to  develop  diphtheria  in  the 
course  of  a  few  days,  when  no  cleansing  treatment  is 
adopted,  while  they  seem  much  less  liable  to  do  so  if  kept 
under  treatment. 

The  detection  of  the  virulent  bacilli  in  throats  prevents 
the  dissemination  of  diphtheria  by  allowing  us  to  isolate 
those  infected.  A  very  striking  instance  of  this  was  the 
following:  In  a  family  of  four  children  one  was  sick 
with  diphtheria.  The  Department  Inspector  found  three 
other  children  in  the  same  bed  with  the  sick  one,  who 
was  constantly  spitting  upon  and  soiling  the  bedclothes. 
He  made  cultures  from  these  three  children,  whose 
throats  appeared  healthy,  as  well  as  from  the  sick  one ;  all 
contained  abundant  characteristic  Loeffler  bacilli.  (These 
were  later  shown  to  be  virulent  by  the  inoculation  of 
guinea-pigs.)  When  the  Inspector  visited  the  same 
family  three  days  later,  he  found  two  of  the  previously 
healthy  children  had  meanwhile  sickened  and  died,  and 
that  the  third  was  severely  ill.  This  child  finally  re- 
covered. 

From  the  observations  detailed  above  we  cannot  es- 
cape the  conclusion  that  all  members  of  an  infected 
household  should  be  regarded  as  under  suspicion,  and  in 
those  cases  where  isolation  is  not  enforced,  the  healthy 
as  well  as  the  sick  should  be  prevented  from  mingling 
with  others  until  cultures  from  the  throat  have  shown 
the  absence  of  bacilli  or  a  sufficient  lapse  of  time  gives  the 
presumption  that  they  are  not  carriers  of  the  contagium. 

Summary  and  Conclusions  on  Diphtheria  Bacilli  in 
Healthy  Throats. — We  have  found  that  children,  and 
to  a  less  extent  adults,  who  are  brought  in  direct  contact 
with  true  cases  of  diphtheria  very  often  receive  the  diph- 
theria bacilli  into  their  throats,  and  that  these  bacilli 
may  persist  and  develop  in  these  throats  for  days  or 
weeks.  In  some  cases  we  have  found  that  true  diph- 
theria followed  the  appearance  of  the  bacilli  in  the  res- 
piratory passages,  while  in  others  no  disease  developed, 
though  they  might  be  the  source  of  diphtheria  in  others. 
The  examination  of  the  throats  of  three  hundred  and 
thirty  healthy  persons  in  whom  no  contact  with  diph- 
theria was  known,  revealed  the  presence  of  virulent 
bacilli  in  but  eight  persons,  two  of  whom  later  developed 
diphtheria. 


September  29,  1894] 


MEDICAL  RECORD. 


397 


We  must  conclude,  then,  that  virulent  diphtheria 
bacilli  are  to  be  found  in  the  throats  of  a  small  propor- 
tion of  healthy  persons  throughout  the  city,  and  that 
they  have  been  derived  either  directly  from  diphtheria 
cases  or  from  those  who  have  been  in  contact  with  them. 
The  examinations  of  the  throats  of  the  three  hundred 
and  thirty  healthy  persons  showed  that  in  twenty- four 
bacilli  existed  in  every  way  identical  with  the  Locffler 
bacillus,  except  that  they  were  not  virulent  in  animals. 
As  the  bacilli  in  cases  of  true  diphtheria  are  known  to 
gradually  lose  their  virulence,  and  as  this  loss  of  viru- 
lence can  be  caused  artificially,  it  seems  to  the  writers 
that  these  bacilli,  characteristic  except  as  to  virulence, 
should  be  regarded  as  true  diphtheria  bacilli  which  have 
lost  their  virulence. 

The  examination  of  the  same  throats  showed  that,  in 
twenty-seven  there  were  bacilli  present  which  were  so 
uniform  in  their  peculiarities  as  to  staining,  size,  shape, 
and  the  production  of  an  alkali  instead  of  an  acid,  that 
there  seems  to  us  to  be  even  more  reason  to  separate 
them  from  the  diphtheria  bacillus  than  there  is,  for  ex- 
ample, to  separate  the  colon  bacillus  from  that  of  ty- 
phoid. 

Table  I.— False  Diphtheria. 


Table  II.—  False  Diphtheria. 


! 


*•  £       Z 

£.6  i=3 


•< 


H 

r 


•!  4 


4  years 

iz  years 
a  years 
1*  yew 

8  years 
6  years 
3  years 
6  years 

9  years 


I  Mild 


Severe 
Mild 


to    a      12        6>  years 
11     3   <  *3  [     3  years 


«3 
M 
15 

16 
17 
18 

"9 


3 

15 

4 

16 

z 
4 

2 

4 

«9 

3 

ao 

4 

ax 

a 

as 

3   i  »3 
a      ** 


a  years 
xz  years 
15  years 
ai  years 
9  years  j 

3  years  ( 
5  years  , 

xo  years  ' 
8  years 

4  years 


I 

I 

7  days 

a  days 
30  days 
5  days 


1 

Recov. 


7  days 
5  days 
3  days 
9  days 
5  days 


zo  days 


7  days 
5  days 


days 
days 
days 
days 
days 
days 
days 
days 
days 
days 


*3  o 
»4  5 
•5    5 


«7  © 

a8  a 

«9  3 

30  o 

3*|  a 

3»!  1 

33  3 

34  a 

35  4 

36  3 

37!  3 

3«  3 

39  3 


40 
4X 

43 


as  [     3i  years       •• 

96  j  31  years  i      " 

37  '     7  years         •» 

*8  '     4  years  |  Severe 
29        9  years     Mild 


xi  year     Severe 
ai  years  <  Mild 
35  years 


6  years 

x+year 

xo  years 

a  1  years 


Severe 
Mild 


37  *9  years 

38  7  years 

39  a  years 


a  years 


1 


41  a  years 

4a  ao  years 

43  30  years 

44  3  years 


a  days  t 
xa  days  < 

3  days  ; 
14  days 

a  days  ' 


45 
46 
47 
4»: 

1 


45 

46 

49 
SO 
5* 
5« 

i  53 
54 


3  years  I 
19  years 
2}  years 
6  years  j 
a  years  | 
z8  years 
ai  years 
3r  years 
24  years 
8  years 


Severe 

MUd 


Severe 

Mild 


7  days  I 
7  days  I 

5  days  i 
7  days 

7  days 

6  days  ' 
a  days  I 

l 
4  days 
a  days 
4  days  ' 

9  days 

7  days 
3  days 
x  day 
7  days 


4  days 
xo  days  < 
xo  days 

7  days  I 

7  days 

5  days 


jo    o  ,  55  ,     a  years  ' 


Severe  I  xo  days 

Mild     '  3   days 

a         I  4   2ayS 

**        j  30  days 


10  days 


History  of  Contagion,  etc. 


Came  from  a  house  where 

diphtheria  was  present. 
None. 

Complicated  by  pneumonia. 
None. 


These  two  cases  occurred 
together. 

These  two  out  of  the  four 
children  attacked  nearly 
together ;  one  with  simple 
tonsillitis,  the  other  with 
suppurative  tonsillitis. 

Complicated  by  scarlet 
fever. 

None. 

The  child  was  first  taken 
sick ;  a  few  days  later  the 
servant  developed  sore 
throat. 

None. 


Another  mild  sore  throat  in 

house. 
None. 


These  cases  occurred  at 
same  time  in  family.  No 
others  developed  in  house. 

Complicated  by  pneumonia 

None. 

Exposed  to  scarlet  fever. 

None. 


Case  of  true  diphtheria  in 
another  family  in  house. 

Scarlet  fever  in  family. 

None. 

Scarlet  fever  in  house  one 
month  before. 

Scarlet  fever  in  house  one 
month  before. 

None. 

The  mother  in  the  first  case 
was  never  really  sick  :  the 
child  had  very  slight  ton- 
sillitis. 

None. 


Another  case  in  house. 

None. 

Scarlet  fever  as  compli- 
cation. Other  cases  of 
scarlet  fever  in  house. 

None. 


J.9 

g  (s. 

9 '3 


il     4  i 


2 

E 

3 

Z 

8 

«7 

rt 

M 

U 

< 

16 

17 
18 


»3 
«4 
as 

I 

26 

a7 


«3 
3  I   M 
X5 

x6 

17 


18 
>9 

3    I    20 


*9      3 


to  I     3     as      9   years 


8    years 
5    years 


1 


Mild 


Histoiy  of 
Contagiousness. 


30  years        '* 

3a  years        " 

ix  years        *• 

16  years        '* 

19  years        " 

X9  years  (  Severe 


19   years 

Mild 

a    years 

Severe 

16   years 

MUd 

12    years 

4   years 

** 

a    years 

3t  years 

tt 

4    years 

a    years 

8    years 

11 

3   years 
xa    vears 

», 

6   years     Severe 


33  1    4   years     Mild 
1      34  '    ai  years  i      " 
4  1  as       5    years 
1      36       9    years        ,4 
4  I  27     20   years        ■• 


I 


I 


4     38  j  2a   years     Severe        7  days 


32     3 


33 
34I 

35 

36 

3! 

39 
40 
4» 
4« 


45 
46, 


JO> 


29  6  years  j  Mild 

30  1    5  years  '•  Severe 

31  '    3  years  Mild 

3a     as  years        u 

33  »3  years        " 

34  4i  years  ;      «c 

35  26  years  .      *• 

i 

36  '    8  mos.   .  Severe 


37      5   years  1 


54  I  x6  years  1 

55  I    6  years  , 

56  I  X5  years  , 

57  j    7  years  j 


xa  days 
ax  days 

5  days 

1 
xo  days  { 

6  days  1 
xo  days  I 

5  days 


14  days  : 


30  days  ' 


9   years  : 

Mild 

x  day 

30   years  ! 

Severe 

5  days 

a    years  ' 

MUd 

4  days 

37   years 

Severe 

14  days 

4   years 

MUd 

4  days 

so   years  > 

;; 

4  days 

9   years  1 

x  day 

ax    years  > 

•* 

7  days 

20   years  1 

5  days 

x    year    , 

Fatal 

7  days 

5t  years        u 

ai  years  r  Mild 

ijyear    1  Fatal 

xiyear    |      '• 

19    years  ,  Mild 
30   years  [      *' 


7  days 


7  days 

5  days 

3  days 

6  days 

7  days 

4  days 
3  days 


Recov.     First  case  one  week  pre- 
»*      I      vious    to   second.       No 

I     others  in  house. 
'•        None. 


Died 


Scarlet  fever  in  house. 
Followed    surgical    opera- 
tion on  throat. 
Scarlet  fever  in  house. 
None. 


i  Scarlet  fever  in  house. 

<4  *i  It  It 

'  None. 

These  tv<o  children  were 
taken  sick  together ;  one 
with  mild  "croup,"  the 
other  with  tonsillitis. 

None. 

Scarlet  fever  as  complica- 
tion. 
j  Scarlet  fever  previously  in 
;      house. 
Scarlet  fever  as  complica- 
tion. 
I  None. 


Measles  in  house. 

This  and  following  case  oc- 
curred in  same  house, 
one  week  apart. 

These  three  children  slept 
together.  Two  had  very 
I  mud  sore  throats,  while 
the  third  had  a  more  se- 
vere attack,  complicated 
by  mumps. 

None. 

These  two  cases,  mother 
and  child,  had  sore 
throats  within  three  days 
of  each  other. 

Complicated  by  scarlet 
fever.  Other  cases  in 
family. 

Scarlet  fever  as  complica- 
tion. 

A  sister  had  scarlet  fever. 

None. 
•1 

None.  m    Suppurative   ton- 


Recov. 


None. 


Complicated  by  erysipelas. 

Membraneous  laryngitis 
and  scarlet  fever. 

Scarlet  fever  from  preced- 
ing. 

None. 

Complicated  by  scarlet  fev- 
er contracted  from  sister. 

None. 

These  two  cases  occurred 
in  the  same  house  a  few 
days  apart. 

None. 


I 


We  have  never  found  bacilli  possessing  these  peculi- 
arities to  be  virulent,  nor  have  they  seemed  to  have  any 
connection  with  diphtheria.  It  seems  to  us  that  to  these 
bacilli  alone  the  name  pseudo-diphtheria  bacillus  should 
be  given.  The  few  bacilli  which  do  not  seem  to  come 
under  either  of  these  divisions  must  await  further  study 
before  being  classified. 

5 .  To  what  Degree  is  Pseudo-diphtheria  Communicable  f 
— In  the  general  circular  issued  by  the  Department,  it 
was  announced  that  cases  which  bacteriologically  proved 
to  be  false  diphtheria  would  not  be  kept  under  the  super- 
vision of  the  Department.  Some  who  approve  heartily 
of  the  rest  of  the  work  of  the  Board  in  its  dealings  with 
diphtheria  believe  in  this  step  it  has  made  a  mistake, 
and  that  the  pseudo-diphtheria  cases,  though  less  con- 
tagious than  the  true,  are  yet  sufficiently  so  as  to  render 
isolation  necessary.  From  the  experience  obtained  in 
the  diphtheria  hospital;  it  was  believed  these  cases  were 


398 


MEDICAL  RECORD. 


[September  29,  1894 


so  little,  if  at  all,  contagious,  that  visiting  by  the  De- 
partment inspectors  was  unnecessary.  Nevertheless,  to 
investigate  this  question  thoroughly,  four  hundred  and 
fifty  cases  of  false  diphtheria,  as  nearly  consecutive  as 
possible,  were  investigated,  all  sources  of  contagion 
sought  for,  and  the  cases  followed  up  for  two  weeks 
after  complete  convalescence.  In  none  of  these  was 
isolation  or  disinfection  enforced  by  the  Health  De- 
partment. 

Table  I II. —True  Diphtheria  Cases  from  the  same  Dis- 
trict as  the  False  Diphtheria  in  Table  I. 


Summary  of  Tabulated  Cases. 


J.     I 


I 


^ 


*,  5 

al  4 

3  x 

4  4 

5  1 

6  3 


12. 


39 
4o, 

41 

4»| 
43 

44 
45 
46 
47 
48 
49 
50 
I 


I    4  years     Moderate 

xi  years  •         " 

3  years  I  Severe 

a  years  .  Slight 

xo  years  I      " 

1    3  years     Moderate 


1 


Poor    Recov. 


History  of  Contagion,  etc. 


75   years  f 
I    8       5    years  ** 

1    9  ■    6   years     Slight 


a    years 
3   years 


x  J  10  j 

V'! 

4  I  xa  I  xo   years 

13  I    8    years 

14  I    7   years 


15  4r  years 

16  '    xiyear 

I 


Slight 


Severe 
Slight 

Severe 


Good  Died 

None  Recov. 
Good         " 
1  None         " 


Good 

None  *• 

Poor  , 

Good    Died 
NTone    Recov. 

Good 


19 


a  years  (  Moderate 

5  years  ■  ** 

9  years  .  " 
1 

3  years  '  Severe 

4  years  I  *• 

6  years  j  Slight 


33  '    5    years     Severe 
,  94  '    3   y«*r»  I       " 
25  :    8    years  I  Mild 


87' 

a8 


99 
30 
3» 
3a 


6  36 
x  97 
x  ,  a8 

x      99 

4     30 

3» 

1  3a 

33 
34 


a    years     Moderate 
4    years 
3   years 


5   years 

5  years 

6  years 
9  years 
if  year 
5   years 


Slight 

Moderate 
»» 

Severe 


Moderate 


a      35  -    3    years  '  Slight 


36  j    3    years     Malignant 

37  '    6   years  ' 


'  Slight 
,  Malign 


Poor 
Good 


Poor 


None 
Good 


Poor 

Good 
Poor 


Died 
Recov. 


33     »     38  I    4   years     Moderate      Good 


Severe 
Moderate 


No 


1 

I  39  a  years 

x      40  i  s  years 

4     41  7  years 

42  3  years 


(  43  8  years  '  Severe 

a  I  44  7  years  I       " 

45  ,  30  years     Moderate 

x      46  ,    a  years     Malignant 

a     47  4  years     Severe 

48  a  years     Slight 


Poor 

1      «« 
Good 

<4 

I  None 


49  , 

50  1 


3   years  _        " 
5    years  !  Severe 


51  I    a  years  *' 

5a  i    5  years  ■• 

53  8  years  j  Slight 

54  9  years  Severe 

55  !    7  years  " 

56  6  years  Moderate 

57  I    8  years  Slight 

58  4  years  Severe 

59  18  years  !  Moderate 

60  '      K  vMrc  !  " 


I        _w  ^ 

3     60  "    s    years  J 


Poor 
Good 


None 
Poor 
Good 


Died 
Recov. 


Died 

j  Recov. 

Died 
it 

Recov. 


Died 
Recov. 


Died 
Recov. 


Died 
Recov. 


Died 
Recov. 


None. 

Previous  case  four  weeks 

before. 
None. 

•t 

'  Other  cases  in  school. 
Two  days  before  two  chil- 
dren in  same  family  died 
of  ••  diphtheria."  At 
time  of  culture  child  was 
not  sick,  but  developed 
diphtheria  later. 

I  N°ne* 

Two  children  had  just  died 
'      of  diphtheria  in  family. 
1  None. 

From  Case  3.  which  was  in 
I      adjacent  room. 

None. 

Sent  away  for  safety  from 

family    in   which    there 

was  a  case  of  diphtheria. 

Fatal   case   previously   in 

family. 
Servant    had    just    come 
from  Case  9,  where  there 
had  been  three  cases  in 
family. 
None. 

Case  of  diphtheria  on  floor 
below. 
j  Two  fatal  cases  just  pre- 
vious to  this  case. 
I  Other  cases  in  school. 
■  None. 

From  a  candy  store.    The 
I      proprietor's    child     had 
diphtheria.      This   store 
seemed  the  cause  of  sev- 
eral cases  in  street,  and 
'      in  a  school. 
Previous  case  in  house. 


None. 


'  A  case  six  weeks  before  in 
house. 

•  None. 

I  From  cases  in  school 
From  brother, 
»«  *• 

■  None. 

•  From  school 
'  None. 

I  From  brother. 
From  school  or  from  a  case 
next   door   three   weeks 
before. 
From  family. 
j  From  a  case  in  school. 

This    and    following    case 
1      had  symptoms  of  a  cold 

only. 
From  family. 
I  From  school. 
I  From  family. 

None. 
'  Had  had  a  previous  case 
one  week  before  in  fami- 
ly.   Had  just  moved  to 
new  house. 
I  None, 
i  From  Case  14,  originating 

from  school. 
None. 

Prom  case  next  door,  or 

from  school. 
From  school 


None. 


Table  I.  (50  Fam-  Table    II    (50 


ilies)  Pseudo- 
diphtheria. 


Families  (Pseu- 
do  diphtheria. 


Table  III.  (50 
Families)  True 
Diphtheria. 


Total  number  cases !  56 

History  of  contact  with  other 

cases 7 

No  history  of  contact 49 

Families  in  which  more  than  ! 

one  case  developed j  5 

Recovered I  56 

Died o 

Cases  complicated  by  scarlet 

fever I  4 


7 
50 

41 
53 
4» 


33 
»7 

3 

17 


»  Two  had  scarlet  fever. 

*  Three  of  which  had  scarlet  fever. 

*  Six  others  had  been  in  contact  with  scarlet  fever,  but 
acteristic  rash. 


showed  any  char- 


This  is  such  an  important  question  that  the  results  of  the 
investigation  of  one  hundred  consecutive  cases  are  given 
here  in  tabular  form.  As  a  comparison,  a  similar  table 
is  given  of  fifty  consecutive  cases  of  true  diphtheria 
which  were  taken  from  the  same  district  and  at  the  same 
time  of  the  year  as  the  first  fifty  cases  of  pseudo-diph- 
theria. 

We  find,  therefore,  in  113  cases  of  false  or  pseudo- 
diphtheria,  occurring  in  100  families,  that  14  occurred 
at  the  same  time  with,  or  shortly  after,  some  other  case, 
and  that  it  is  possible  to  assume  the  disease  had  been  di- 
rectly communicated  to  them.  In  9  of  the  100  families 
more  than  one  case  developed.  In  these,  as  in  the  other 
350  cases  of  pseudo  diphtheria  investigated,  it  did  not 
seem  secondary  cases  were  any  less  liable  to  occur  where 
the  primary  case  was  isolated,  than  when  it  was  not.  In 
this  connection  we  must  remember  mild  throat  inflam- 
mations are  very  frequent,  especially  in  the  early  spring 
months,  and  that  it  is  quite  possible  where  two  cases 
occurred  in  a  family  together,  or  within  a  short  period 
of  each  other,  that  they  may  have  both  been  due  to  ex- 
posure to  some  common  condition  rather  than  to  direct 
transmission.  The  presence  in  nearly  all  healthy  throats 
in  New  York  City  of  streptococci  renders  this  assumption 
almost  a  probability.  The  presence  of  the  same  germs 
in  healthy  throats  as  in  those  of  patients  suffering  from 
pseudo  diphtheria  prevents  us  from  deciding  the  point 
by  bacteriological  examinations.  A  good  illustration 
of  the  difficulty  in  determining  whether  these  cases  are 
communicable  is  the  following : 

In  a  family  of  eight  there  were,  a  mother,  aged  forty- 
five,  six  children  whose  ages  ranged  from  twenty- five  to 
ten,  and  a  grandchild  aged  two.  The  family  lived  on 
the  top  floor  of  a  tenement.  Two  days  before  being 
visited  by  the  Inspector  of  Diphtheria  a  heavy,  wet  snow 
had  fallen,  which,  as  the  roof  leaked,  caused  the  walls  to 
become  very  damp.  The  next  morning  four  of  the  chil- 
dren were  attacked  by  more  or  less  severe  tonsillitis, 
which  later  developed  follicular  deposits  or  croupous 
patches.  On  the  following  day  the  baby  had  an  attack 
of  croup.  All  recovered  and  no  further  cases  developed 
in  the  tenement.  Here  the  exposure  to  dampness  cer- 
tainly seems  to  be  the  explanation  of  the  first  four  cases 
of  tonsillitis,  but  the  occurrence  of  laryngitis  in  the  baby 
might  with  equal  justice  be  considered  as  due  to  the 
dampness,  or  as  the  result  of  communication  from  the 
others. 

Even  if  further  investigation  should  seem  to  prove  the 
14  cases  of  pseudo-diphtheria  out  of  113  tabulated  which 
were  found  to  have  had  some  connection  with  other 
mild  sore  throats,  were  due  to  contagion  and  not  to  the 
simultaneous  effects  of  atmospheric  or  other  deleterious 
conditions,  there  would  still  be  an  important  practical 
objection  to  sanitary  supervision  or  enforced  isolation. 
All  of  the  14  cases,  except  3  who  had  scarlet  fever,  were 
mild,  and,  indeed,  leaving  out  of  consideration  the  cases 
which  occurred  as  complications  of  scarlet  fever,  there 
was  only  1  death  in  103  cases  of  pseudo-diphtheria,  and 
in  this  case,  as  has  been  said,  there  was  no  history  of  in- 
fection or  contact  with  other  cases. 

6.    What  are  the  Means  by  which  Diphtheria  is  Trans- 


September  29,  1894] 


MEDICAL    RECORD. 


399 


milted? — The  facts  brought  out  by  the  investigations  of 
the  Department  throw  important  light  on  the  manner  in 
which  diphtheria  is  transmitted. 

As  related  to  this  question  let  us  first  consider  very 
briefly  what  is  known  of  the  duration  of  life  of  the  Lcef- 
fler  bacillus  outside  of  the  body. 

In  actual  experiments  the  Lceffler  bacillus  has  been 
found  to  live  for  long  periods  of  time,  namely :  by  Hof- 
mann,on  blood  serum,  for  one  hundred  and  fifty- five  days; 
by  Lceffler  and  by  one  of  us  (Park)  for  seven  months ; 
and  in  gelatine  by  Klein,  for  eighteen  months.  The 
bacilli  have  been  found  to  live  in  bits  of  dried  membrane 
by  Lceffler  for  fourteen  weeks,  by  us  for  seventeen,  and 
by  Roux  and  Yersin  for  twenty  weeks.  Dried  on  silk 
threads,  Abel "  reports  they  may  sometimes  live  for  one 
hundred  and  seventy  two  days,  and  upon  a  child's  play- 
thing, which  had  been  kept  in  a  dark  place,  they  lived 
for  five  months. 

As  examples  of  the  manner  in  which  diphtheria  may 
be  contracted,  he  gives  the  following  from  Johannes- 
sen:" 

A  teacher  developed  diphtheria  from  passing  the  night 
in  a  room  in  which  three  weeks  before  a  fatal  case  had 
occurred. 

A  child  developed  diphtheria  after  putting  on  the 
clothing  worn  by  a  child  which  had  died  of  diphtheria 
two  months  before. 

In  a  number  of  isolated  dwellings  diphtheria  devel- 
oped nearly  a  year  after  previous  outbreaks,  without 
there  being  any  apparent  possibility  of  a  new  infection 
taking  place  from  outside. 

We  ourselves  have  met  with  a  number  of  cases  where 
the  infected  bedding  or  clothing  has  undoubtedly  been 
the  source  of  the  infection. 

Sources  from  which  Virulent  Bacilli  may  be  Received. 
— 1.  From  the  pseudo  membranes,  exudate,  or  discharges 
from  diphtheria  patients.  2.  From  the  secretions  of  the 
nose  and  throat  of  convalescent  cases  of  diphtheria  in 
which  the  virulent  bacilli  persist.  3.  From  the  throats 
of  healthy  individuals  who  have  acquired  the  bacilli  from 
being  in  contact  with  others  having  virulent  germs  on 
their  person  or  clothing.  In  such  cases  the  bacilli  may 
sometimes  live  and  develop  for  days*  or  weeks  in  the 
throat  without  causing  any  lesion. 

When  we  consider  it  is  only  the  severe  types  of  diph- 
theria that  remain  isolated  during  their  actual  illness  the 
wonder  is,  not  that  so  many,  but  that  so  few  persons  con- 
tract the  disease.  This  seems  to  be  more  remarkable 
when  we  observe  that,  in  a  city  like  New  York,  the  whole 
tenement-house  district  at  least  is  an  infected  area.  This 
has  become  evident  from  the  observations  made  by  the 
Department. 

It  has  been  the  practice  of  the  Department  during  the 
last  year  to  plat  upon  a  city  map  the  location  and  date 
of  every  case  of  diphtheria  in  which  the  diagnosis  had 
been  settled  by  bacteriological  examination.  After  sev- 
eral months  the  map  presented  a  very  striking  appearance. 
Wherever  the  densely  crowded  tenements  were  located, 
there  the  marks  were  very  numerous,  while  in  the  dis- 
tricts occupied  by  private  residences  very  few  cases  were 
indicated  as  having  occurred.  It  was  also  apparent  the 
cases  were  far  less  abundant,  as  a  rule,  where  the  tene- 
ments were  in  small  groups,  than  in  the  regions  of  the 
city  where  they  covered  large  sections.  At  the  end  of 
six  months  there  were  square  miles  in  which  nearly  every 
block  occupied  by  tenement- houses  contained  marks 
indicating  the  occurrence  of  one  or  more  cases  of  diph- 
theria; and  in  some  blocks  many  cases  (fifteen  to  twenty- 
five)  had  occurred. 

As  the  platting  went  on  from  time  to  time  the  map 
showed  the  infection  of  a  new  area  of  the  city,  and  often 
the  subsequent  appearance  of  a  local  epidemic.  It  was 
interesting  to  note  two  varieties  of  these  local  epidemics ; 
in  one  the  subsequent  cases  evidently  were  from  neigh- 
borhood infection,  while  in  the  second  variety  the  infec- 
tion was  as  evidently  derived  from  schools,  since  a  whole 
school  district  would  suddenly  become  the  seat  of  scat- 


tered cases.  At  times  in  a  certain  area  of  the  city,  from 
which  several  schools  drew  their  scholars,  all  the  cases  of 
diphtheria  would  occur  (as  investigation  showed)  in  fam- 
ilies whose  children  attended  one  school,  the  children  of 
the  other  schools  being  for  the  time  exempt. 

Another  fact  noted — perhaps  as  important  as  the  fore- 
going— was  that  with  the  most  careful  inquiry  it  was 
impossible  to  find,  in  about  one-half  of  the  cases  of  diph- 
theria which  first  occurred  in  a  house,  any  connection 
with  preceding  cases  of  diphtheria. 


An  Average  Section  of  the  City  in  which  each  Dot  indicates  where  a  Case  of 
Diphtheria  Occurred  during  a  Period  of  Six  Months. 

The  two  following  histories  are  instructive  as  showing 
that  special  conditions,  which  are  largely  unknown  to  us, 
determine  in  every  individual  the  occurrence  or  escape 
from  diphtheria  under  exposure.  Two  children  in  a  family 
were  taken  sick  with  diphtheria  and  removed  to  the  hos- 
pital. The  servant  who  was,  and  remained  apparently, 
healthy  went  to  another  family,  where  the  youngest  child 
developed  diphtheria  a  week  later.  In  the  meantime  a 
case  developed  in  the  family  living  in  the  next  apartment. 
There  were  in  this  latter  family  three  other  children 
which  were  not  isolated  at  all  from  the  sick  child,  yet 
none  of  these  developed  diphtheria. 

The  child  of  a  man  who  kept  a  candy  store  developed 
diphtheria ;  there  were  four  other  children  in  the  family 
and  these  were  in  no  way  isolated  from  the  sick,  yet  none 
of  them  developed  diphtheria,  but  children  who  bought 
candy  at  the  store,  and  other  children  coming  in  contact 
with  these  in  school  developed  diphtheria.  The  second- 
ary cases  ceased  to  develop  so  soon  as  the  candy  store 
had  been  closed. 

Many  similar  histories  could  be  given  to  illustrate  the 
fact  that  the  majority  of  persons,  and  even  perhaps  the 
majority  of  children,  are  not  ordinarily  very  susceptible 
to  diphtheria,  and  that  in  addition  to  receiving  the  germs 
of  the  disease  into  the  respiratory  passages  they  must 
be  in  a  condition  favorable  to  the  development  of  the 
disease,  and  their  mucous  membranes  must  be  vulner- 
able. 

It  seems  to  be  generally  true  that  the  more  malignant 
a  case  of  diphtheria  is,  the  more  likely  it  is  to  cause  diph- 
theria in  others.  This  may  be  due  to  the  high  grade  of 
virulence  possessed  by  the  bacilli  or  to  the  peculiar  asso- 
ciation of  other  micro-organisms  in  the  membrane,  or  to 


400 


MEDICAL  RECORD. 


[September  29,  1894 


the  wider  dissemination  of  the  infectious  matter  through 
the  discharges. 

It  is  also  well  known  that  young  children  are  much  more 
susceptible  to  diphtheria  than  older  persons.  It  is  com- 
paratively rare  for  the  parents  of  children  sick  with  diph- 
theria to  contract  the  disease,  although  in  nearly  every 
case  they  must  at  some  time  receive  the  germs  into  their 
throats. 

Conclusions. — 1.  All  inflammations  of  the  mucous 
membranes  due  to  the  diphtheria  bacillus  of  Loeffler 
should  be  included  under  the  name  diphtheria,  and  in 
this  report  they  have  been  so  included.  An  acute  hyper- 
emia of  the  mucous  membrane,  caused  by  the  Loeffler 
bacilli,  is  considered  as  truly  diphtheria  as  an  inflamma- 
tion with  pseudo-membrane  or  exudate,  and  a  case  in 
which  the  lesions  are  confined  to  the  larynx  or  bronchi 
as  truly  diphtheria  as  one  in  which  the  tonsils  and  phar- 
ynx are  involved. 

2.  Under  pseudo  diphtheria  should  be  included  all  in- 
flammations of  the  mucous  membranes  which  simulate 
true  diphtheria  and  which  are  due  to  streptococci,  or, 
more  rarely,  other  cocci. 

3.  The  name  croup,  or  membranous  croup,  should  be 
regarded  as  a  term  merely  indicating  that  the  location 
of  the  pseudo-membranous  or  exudative  lesion  is  in  the 
larynx,  and  not  as  describing  the  nature  of  the  disease, 
whether  diphtheritic  or  pseudo-diphtheritic.  In  New 
York  City  at  the  present  time  eighty  per  cent,  of  the 
cases  of  "  croup  "  are  diphtheria. 

4.  The  examination  of  cultures  made  upon  solidified 
blood-serum  under  the  conditions  insisted  on  by  the 
Department  form  a  reliable  method  for  determining 
whether  the  diphtheria  bacillus  is  present  or  absent  in  a 
throat  For  diagnostic  purposes  cultures  should  be  made 
before  the  pseudo  membranes  or  exudate  begins  to  dis- 
appear. 

5.  Virulent  diphtheria  bacilli  were  apparently  present 
in  about  one  per  cent,  of  the  healthy  throats  in  New 
York  City  at  the  time  of  these  examinations.  Diphtheria 
was,  however,  rather  prevalent  at  this  time.  Most  of  the 
persons  in  whose  throats  they  existed  had  been  in  direct 
contact  with  cases  of  diphtheria.  Very  many  of  those 
whose  throats  contained  the  virulent  bacilli  never  develop 
diphtheria.  We  must  therefore  conclude  that  the  mem- 
bers of  a  household  in  which  a  case  of  diphtheria  exists 
should  bs  regarded  as  sources  of  danger,  unless  cultures 
from  their  throats  show  the  absence  of  virulent  diphtheria 
bacilli. 

6.  The  bacilli  found  in  the  original  serum  cultures, 
which  in  appearance  and  staining  are  identical  with  the 
typical  Loeffler  diphtheria  bacillus,  may  be  regarded,  for 
diagnostic  purposes,  as  virulent  diphtheria  bacilli,  if  the 
cultures  have  been  made  either  from  throats  containing 
exudate,  or  from  those  of  persons  who  have  been  in  con- 
tact with  true  diphtheria,  for  investigation  has  shown  that 
over  ninety-five  per  cent,  of  such  bacilli  are  virulent. 
Bacilli,  on  the  other  hand,  which  resemble  the  pseudo- 
diphtheria  type  must  be  subjected  to  both  cultural  and 
animal  experiments  before  their  nature  or  virulence  can 
be  judged. 

7.  All  bacilli  which  are  identical  with  the  virulent 
Loeffler  diphtheria  bacillus,  morphologically,  biologi- 
cally, and  in  staining  by  reagents,  should  be  classed  with 
the  diphtheria  bacilli,  whether  they  have  much,  little,  or 
no  virulence  when  tested  on  guinea-pigs.  Bacilli  which 
have  entirely  lost  their  virulence  rarely,  if  ever,  regain 
it.  They  probably  are  incapable  of  causing  diphtheria, 
for  the  twenty-four  cases  in  which  they  were  found  by 
us  never  developed  any  lesions,  nor  were  they  the 
original  of  any  case  of  diphtheria,  so  far  as  could  be 
ascertained. 

8.  The  name  pseudo-diphtheria  bacillus  should  be  re- 
garded as  applying  to  those  bacilli  found  in  the  throat 
which,  though  resembling  the  diphtheria  bacilli  in  many 
respects,  yet  differ  constantly  in  others  equally  impor- 
tant. These  bacilli  are  rather  short,  and  are  more  uni- 
form in  size  and  shape  than  the  typical  Loeffler  bacillus. 


They  stain  equally  throughout  with  the  alkaline  methyl- 
blue  solution,  and  produce  alkali  in  their  growths  in  bouil- 
lon. They  are  found  in  about  one  per  cent,  of  tke  healthy 
throats  in  New  York  City,  and  seem  to  have  no  connec- 
tion with  diphtheria.    They  are  never  virulent. 

9.  One  or  more  varieties  both  of  streptococci  and  of 
other  forms  of  cocci  exist  in  the  great  majority,  and 
possibly  in  all,  of  the  healthy  throats  in  New  York  City. 
Cultures  from  the  throat  in  cases  of  pseudo-diphtheria 
contain  more  cocci,  especially  more  streptococci,  than 
those  from  healthy  throats,  but  otherwise  do  not  seem  to 
differ. 

10.  The  investigations  of  the  Health  Department  have 
given  striking  evidence  of  the  marked  difference  in  mor- 
tality between  true  and  pseudo  diphtheria,  for  while  it 
was  twenty-seven  per  cent,  in  diphtheria,  it  was  under 
two  per  cent,  in  pseudo  diphtheria. 

n.  The  combined  clinical  and  bacteriological  inves- 
tigation of  over  five  thousand  cases  has  demonstrated 
clearly  the  fact  that  many  of  the  less  characteristic  cases 
of  diphtheria  and  pseudo  diphtheria  are  so  similar  in 
appearance,  symptoms,  and  duration,  that  it  is  impossi- 
ble to  separate  them,  except  by  bacteriological  examina- 
tions. In  the  more  severe  cases,  and  after  the  disease 
,  has  fully  developed,  cultures  are  less  necessary,  although 
their  systematic  use  is  desirable. 

12.  Persons  who  have  suffered  from  diphtheria  should 
be  kept  isolated  until  cultures  prove  the  bacilli  have 
disappeared  from  the  throat,  for  not  only  are  the  bacilli 
which  persist  in  the  throat  virulent,  but  they  are  not 
infrequently  the  cause  of  diphtheria  in  others.  Where 
cultures  cannot  be  made,  isolation  should  be  continued 
for  at  least  three  weeks  after  the  disappearance  of  the 
membranes,  for  our  experience  has  shown  that  it  is  not 
unusual  for  the  bacilli  to  persist  that  length  of  time. 

13.  In  pharyngeal  cases  in  which  thorough  irrigation 
of  the  nostrils  and  throat  with  1  to  4,000  bichloride  of 
mercury  solution  has  been  practised  every  few  hours, 
the  bacilli  have  not  remained  in  the  throat  for  as  long  a 
time  after  the  complete  disappearance  of  the  pseudo-mem- 
brane as  when  no  antiseptic  has  been  employed.  Other 
antiseptic  and  cleansing  solutions  may  be  also  useful. 

14.  Inflammation  of  the  mucous  membranes  due  to 
streptococci,  either  alone  or  associated  with  other  cocci, 
are  usually  mild  in  character.  These  inflammations  may 
be  more  serious  when  the  lesion  is  located  in  the  larynx, 
or  when  they  are  complicated  by  scarlet  fever  or  measles. 

15.  While  the  streptococci,  and  perhaps  other  forms  of 
cocci,  may  be  considered  as  the  primary  etiological  factor 
in  pseudo  •  diphtheria,  yet,  in  die  majority  of  cases  at 
least,  certain  predisposing  factors,  such  as  exposure  to 
cold  or  other  deleterious  influences,  or  the  presence  of 
certain  infectious  diseases,  appear  to  be  of  great  impor- 
tance in  determining  the  occurrence  of  the  disease. 

The  streptococci  which  under  these  conditions  ap- 
parently cause  the  disease  are  probably  those  which  had 
for  a  long  time  existed  in  the  throat,  and  not  those 
freshly  derived  through  communication  with  other  cases 
of  pseudo-diphtheria.  In  a  small  number  of  cases,  in- 
deed, the  histories  suggest  a  direct  communication,  but 
the  causation  may  be  equally  well  explained  by  the  sup- 
position that  the  second  case  shared  with  the  original 
one  the  same  predisposing  cause. 

16.  The  slight  mortality  and  the  usual  mildness  of  the 
cases  of  pseudo-diphtheria  do  not  warrant  us  in  enforc- 
ing isolation,  even  if  further  investigation  produce  posi- 
tive proof  that  this  disease  is  directly  communicable. 

With  the  results  of  these  investigations  before  us  we 
can  appreciate  the  difficulty  of  exterminating  diphtheria 
from  a  city  like  New  York.  On  the  one  hand,  we  have 
cases  of  diphtheria  scattered  all  through  the  city,  many 
of  which  are  so  mild  as  to  be  unrecognized,  and  on  the 
other  hand,  we  have  the  crowded  tenements  with  their 
ignorant  and  shifting  population,  where  proper  isolation 
of  the  patient  from  other  members  of  the  family,  or  of 
the  family  from  other  inmates  of  the  building,  is  usu- 
ally impossible  unless  harsher  measures  are  adopted  than 


September  29,  1894] 


MEDICAL   RECORD. 


401 


are  now  customary.  With  stricter  isolation  of  patients, 
and  intelligent  and  systematic  supervision  of  the  schools 
and  tenements,  we  can  certainly  reduce  the  number  of 
cases  of  diphtheria  in  the  city,  but  the  total  extermina- 
tion of  the  disease,  under  the  existing  conditions  of  life 
here,  does  not  seem  probable  unless  one  can  acquire  new 
means  to  combat  the  disease. 

Bibliography. 

I  Klebs :  VerhandL  des  Zweiten  Congress,  f.  In.  Medicin,  1883. 

*  Loeffler :  Mitth.  aus  d.  Kais.  Gesundheitsamte,  Bd.  2,  1884. 
»  Loeffler :  Berlin.  Klin.  Wochen. ,  1890,  No.  39. 

*  Roux  and  Yersin  :  Ann  ales  de  l'lnst.  Pasteur,  ii.,  1888,  p.  620. 

«  Welch  and  Flexnor :  Bulletin  of  the  Johns  Hopkins  Hospital,  Oc- 
tober, 1891. 

*  Babes :  Virch.,  Archiv.,  Bd.  119,  S.  463. 
▼  Welch :  Medical  News,  May  16,  1801. 

*  Prudden :  Medical  Record,  April  18,  1891. 

*  Baginsky  :  Berlin.  Klin.  Wochen. ,  February  29,  1892. 
"  Martin :  Annales  de  d'Inst.  Pasteur,  May,  1892. 

II  Park:  Medical  Record,  July  30,  and  August  6,  1882  ;  Febru- 
ary 11,  1893. 

w  Janson  :  Hygiea,  April,  1891. 

"Morse:  Boston  Medical  and  Surgical  Journal,  1894,  and  Medical 
and  Surgical  Reports  of  the  Boston  City  Hospital,  1894. 

i«  Pipdden :  American  Journal  Medical  Sciences,  April,  1889. 

"  Hofmann  :  Wiener  Medicin.  Wochenschrift,  No.  3,  1888. 

"  Beck:  Zeitschr.  f.  Hygiene,  Bd.  viii.,  1890 

17  Roux  and  Yersin  :  Annales  de  l'lnst.  Pasteur,  1890. 

"  Escberich:  Berlin.  Klin.  Wochen.,  1893.  Nos.  21-23. 

»  Koplik :  New  York  Medical  Journal,  August  27,  1892 ;  March 
xo,  1894. 

»  Welch  and  Abbott:  Bulletin  of  Johns  Hopkins  Hospital,  Febru- 
ary and  March,  1892. 

*l  Abbott:  Bulletin  of  Johns  Hopkins  Hospital,  August,  October, 
and  November,  1891. 

*»  Loeffler:  Deutsche  Med.  Woch.,  1890,  Nos.  5  and  6. 

«  Tobiesen :  Centralbl.  fur  Bakt.,  1892.  Bd.  xiiM  No.  17. 

*  Fraenkel :  Berlin.  Klin.  Wochen.,  1893,  No.  11. 

»  Feer :  Mitth.  aus  Klin.  u.  Med.  Inst,  der  Schweiz,  Hefte,  7,  1894. 

*  Abel :  Berlin.  Klin.  Wochen.,  1894. 

*7  Johannesen :  Difterius  forekomst  i  Norge,  1888,  p.  204. 


THE  AFFINITY   OF  GOUT  AND   RHEUMA- 
TISM. 

By  R.  SHAWE  TYRRELL,  M.D.,  L.R.C.P.  Lond., 

TORONTO,  CANADA. 

The  time,  no  doubt,  is  rapidly  drawing  to  a  close  when 
retention  of  excess  of  excrementitious  matter  will  any 
longer  be  tolerated  daring  the  treatment  of  diseases  in 
general. 

Not  a  score  of  years  ago  the  practice  in  London  was, 
as  everybody  knows,  to  lock  up  the  bowels  for  a  fort- 
night or  more  during  the  course  of  enteric  fever,  and  this 
mode  of  treatment  was  instituted  by  the  very  man,  viz., 
Murchison,  who  enlightened  the  medical  world  on  the 
subject  of  lithaemia,  and  as  his  custom  in  typhoid  fever 
has  long  since  been  abandoned,  so  also  has  his  theory 
regarding  the  production  of  lithaemia  been  brought  into 
question.  The  object,  however,  of  this  paper  is  to  en- 
deavor to  show  the  close  relation  which  exists  between 
gout  and  rheumatism.  And  if  the  cause  of  gout  is,  and 
has  been  for  some  time  quite  apparent  and  beyond  dis- 
pute, viz.,  uric  acid  in  excess  in  the  system;  and  if,  on 
the  other  hand,  the  cause  of  rheumatism  is  still  in  doubt, 
may  it  not  be  justifiable  to  draw  attention  to  this  close 
resemblance  between  these  diseases,  and,  if  possible,  to 
explain  why  their  effects  are  somewhat  different. 

I  well  remember  the  late  Dr.  Murchison  diagnosing  a 
case  of  severe  inflammatory  affection  of  the  elbow  joint, 
which  was  not  preceded  by  a  local  injury,  as  a  first  at- 
tack of  gout,  and  his  opinion  was  corroborated  by  subse- 
quent events.  This  case,  I  need  hardly  say,  occurring 
on  one  of  the  larger  joints  as  a  primary  attack,  would 
probably  suggest  die  conviction  to  many  minds  of  so- 
called  rheumatic  origin.  And  Garrod  says,  "  It  is  not 
uncommon  to  hear  a  patient  call  the  disease  gout  as  long 
as  it  is  confined  to  the  feet,  but  rheumatism  or  rheumatic 
gout  when  the  upper  extremities  become  attacked,  al- 
though the  same  condition  of  the  system  which  causes  the 
one  gives  rise  to  the  other.11  One  naturally  infers  that 
the  patient  referred  to  above  calls  his  disease  what  his 
physician  does,  and  that  a  certain  amount  of  doubt  is  in 
many  cases  manifest  in  regard  to  its  etiology,  particularly 
if  the  disease  be  of  a  chronic  character  or  situated  in  the 


muscles;  many  aches  and  pains  and  neuralgias  which 
were  formerly  designated  rheumatic  are  now  held  to  be 
lithaemic,  and  give  way  under  an  eliminative  mode  of 
treatment.  It  is,  I  say,  in  the  chronic  forms  of  rheuma- 
tism and  gout  that  one  notices  the  resemblance  is  the 
most  marked.  I  think  that  lumbago,  which  is  consid- 
ered a  form  of  muscular  rheumatism,  is  always  lithaemic 
in  origin,  and  certainly  purgation  and  diaphoresis  have, 
in  my  hands,  given  more  satisfactory  results  than  the  ac- 
cepted mode  of  treatment  by  acupuncture.  Osier  says, 
"persons  of  a  rheumatic  or  gouty  habit  are  certainly 
more  prone  to  this  affection.9 '  Here  again  we  have  an 
uncertainty  expressed. 

Dr.  Beverley  Robinson,  of  New  York,  has  stated  that  in 
his  hay- fever  patients  he  has  frequently  noticed  a  rheu- 
matic habit,  while  Dr.  Bishop,  of  Chicago,  and  I  have 
independently  proved,  at  least  to  our  own  satisfaction, 
that  the  affection  is  lithaemic  in  origin.  There  is,  no 
doubt,  in  that  pronounced  form  of  gout  occasioned  by 
an  excess  of  alcohol  some  characteristic  appearances 
which  frequently  stamp  it  as  a  distinct  affection  from 
acute  rheumatism,  caused,  I  will  state,  by  a  loaded  con- 
dition of  the  system  due  to  inactive  organs,  plus  some 
exciting  cause ;  but  in  many  cases  the  physician  is  severely 
taxed  before  he  arrives  at  any  definite  conclusions,  pos- 
sibly because  there  has  been  noticed  not  only  an  alco- 
holic habit,  but  also  defective  elimination ;  with  expos- 
ure. In  the  one  case  the  attack  has  been  occasioned 
solely  by  the  effects  of  an  excess  of  alcohol  or  its 
products  circulating  through  the  blood.  In  the  other 
case  the  supply  of  alcohol  or  food  may  not  have  been  in 
excess,  but  due  to  faulty  elimination — the  effete  products 
circulate  through  the  blood  and  give  rise  to  the  inflam- 
matory condition  known  as  rheumatism.  The  hypothe- 
sis which  I  rely  upon  is,  that  both  gout  and  rheumatism 
are  due  to  inefficient  elimination ;  if  in  the  one  case  the 
kidneys,  bowels,  and  skin  could  be  made  to  do  excessive 
duty  we  would  have  no  gout,  and  if  this  same  activity 
could  be  constantly  kept  up  we  would  have  no  rheuma- 
tism. If  this  be  tenable  I  think  we  are  approaching 
the  cause  of  rheumatism,  and  may  possibly  class  it  with 
gout  under  the  term  "Lithaemia."  Now  in  regard  to 
the  results  of  these  affections  Garrod  says  that  in  all 
cases  of  gout  you  have  a  diseased  condition  of  the  kid- 
neys, and  it  is  well  known  that  one  finds  a  small  amount 
of  uric -acid  and  urates  in  the  urine  in  cases  of  gout 
due  to  this  diseased  condition,  and  consequently  one 
naturally  expects  that  this  uric  acid  and  urates  will  make 
their  appearance  somewhere,  which  always  occurs  fre- 
quently, but  not  always,  in  the  joints ;  but  in  the  case  of 
rheumatism  the  kidneys  are  not  diseased,  and  hence  you 
do  not  have  a  deficiency  of  uric  acid  and  urates  in  the 
urine,  but  an  excess,  and  consequently  you  would  not 
look  for  uric  acid  in  the  blood  or  deposits  of  urates  or 
biurates  in  the  joints  or  elsewhere,  because  the  kidneys 
being  active  and  healthy  are  able  in  time  to  carry  them 
off,  so  that  this  distinction  between  gout  and  rheumatism, 
in  regard  to  uric  acid  in  the  blood,  and  biurates  of  soda 
in  the  joints,  is  explained  by  the  condition  of  the  kid- 
neys. I  have  had  many  cases  of  so-called  rheumatism 
which  have  in  after-years  developed  the  usual  symptoms 
of  gout,  and  I  explain  the  fact  in  this  way,  that  at  first 
the  kidneys  were  active  and  healthy  and  afterward  be- 
came diseased. 

Again,  youth  is  the  special  time  for  rheumatism,  when 
the  kidneys  are  liable  to  be  healthy.  Middle  age  is  the 
choice  time  for  gout,  when  these  organs  are  more  prone 
to  disease.  And  in  this  connection  I  may  say  that  expe- 
rience has  taught  me  that  there  is  a  transitional  stage  be- 
tween healthy  and  diseased  kidneys  when  chemical  and 
microscopical  examinations  of  the  urine  is  of  small  prac- 
tical value. 

I  have  stated  that  rheumatism  is  caused  by  a  loaded 
condition  of  the  system  (by  this  I  mean  an  excess  ot 
uric  acid  and  urates),  plus  an  exciting  cause,  viz.,  cold 
and  dampness ;  this  exciting  cause  occasions  an  explo- 
sion, as  it  were,  in  this  way.     That  it  not  only  shuts  off 


402 


MEDICAL   RECORD. 


[September  29,  1894 


all  excretion  by  the  skin,  but  also  causes  a  congested 
condition  of  the  internal  organs  which  interferes  with 
their  eliminative  action,  particularly  that  of  the  liver, 
and  hence  you  have  the  system  suddenly  charged  with 
waste  products,  so  that  cold  is  essentially  the  exciting 
cause  in  producing  this  congested  condition  which  pre- 
vents elimination  as  is  evidenced  from  the  fact  that  in 
tropical  climates  we  find  no  rheumatism.  Do  you  not 
always  find  a  state  of  constipation  in  acute  rheumatism, 
and  is  not  purgation  combined  with  diaphoresis  the  most 
satisfactory  mode  of  dealing  with  this  disease  ?  as  it  is 
also,  in  my  experience,  the  most  efficient  way  of  cutting 
short  an  attack  of  gout,  and  it  is  hardly  necessary  to  say 
that  the  large  class  of  dyspeptics  which  we  come  across 
daily  are  relieved  most  effectually  by  purgation;  in  fact, 
elimination  by  the  bowels  and  skin  probably  relieves 
more  suffering  and  avoids  more  acute  attacks  of  illness 
than  all  other  forms  of  treatment  combined.  I  have 
been  in  the  habit  for  several  years  of  advocating  the  the- 
ory that  in  order  to  enjoy  good  health  it  is,  as  a  rule, 
not  only  necessary  that  the  bowels  should  be  moved 
daily,  but  that  they  should  be  freely  moved  daily,  and  I 
think  that  if  this  principle  were  urged  to  a  greater  extent 
than  it  is  we  would  have  much  less  rheumatism  and  gout, 
or,  as  I  will  take  the  liberty  of  saying,  a  marked  diminu- 
tion in  cases  of  Hthaemia  in  general. 


KLEBS  -  LOEFFLER    BACILLUS  IN    HEALTHY 
THROATS  AND  IN  MEASLES  THROATS. 

By  ROBERT  S.  ADAMS,  M.D., 

KBSIDRNT  PHYSICIAN  NEW  YORK  FOUNDLING  HOSPITAL.  NMW  YORK. 

As  the  present  belief  in  this  city  is  that  the  Klebs- Loef- 
fler  bacillus  in  nose  or  throat  is  diagnostic  of  true  diph- 
theria, and  its  absence  characterizes  false  diphtheria, 
and  that  until  the  bacilli  are  absent  from  the  nose  or 
throat,  no  matter  how  long  after  the  disappearance  of  a 
pseudo-membrane,  the  case  is  to  be  considered  as  one 
of  true  diphtheria,  the  following  account  of  a  series  of  in- 
vestigations made  at  the  New  York  Foundling  Hospital, 
in  March  of  this  year,  Dr.  J.  J.  Reid  attending,  may 
prove  of  interest : 

Seventy- nine  cultures  in  all  were  made.  All  cultures 
were  sent  to  the  Board  of  Health  and  examined  by  the 
inspector  of  diphtheria,  Dr.  Park.  Of  these  79  tultures 
51  were  made  from  throats  that  appeared,  clinically 
speaking,  perfectly  healthy,  while  28  were  made  from 
throats  of  children  during  or  shortly  after  the  eruption 
of  measles.  Of  the  51  clinically  healthy  throats  10  were 
in  perfect  health  and  in  a  nursery  entirely  free  from  dis- 
ease, and  12  were  convalescent  or  surgical  cases  in  hos- 
pital, but  able  to  be  about,  and  enjoying  in  general  ex- 
cellent health.  Nineteen  were  made  from  throats  of 
children  coming  to  the  Outdoor  Department.  In  these 
5 1  healthy  throats  the  Klebs-Loeffler  bacillus  was  found 
in  7  cases,  while  1  had  suspicious  bacilli  which  in  sub- 
sequent cultures  seemed  to  be  pseudo-diphtheritic  ba- 
cilli. Only  one  of  these  cases  has  since  developed  any 
clinical  symptoms  of  diphtheria,  viz.,  laryngeal  diph- 
theria and  stenosis  requiring  intubation.  He  recovered, 
but  died  of  pneumonia  one  month  after  stenosis  had  dis- 
appeared. 

In  the  28  measles  throats  Klebs-Loeffler  bacilli  were 
found  in  9  cases,  pseudo-diphtheritic  bacilli  in  3  cases, 
and  suspicious  bacilli  in  2  more,  one  of  which  proved  to 
be  genuine  Klebs-Loeffler.  Of  these  10  cases  of  Klebs- 
Loeffler  bacilli  in  measles  throats  none  showed  any  clin- 
ical manifestations  of  diphtheria,  while  the  one  showing 
at  first  suspicious  bacilli,  and  afterward  true  Klebs  Loef- 
fler,  died  of  bronchopneumonia,  but  showed  no  mem- 
brane in  air- passages  post  mortem.  The  pneumonia  was 
the  typical  catarrhal  pneumonia  of  measles.  Almost  all 
the  cultures  were  made  from  children  of  three  to  four 
years  of  age,  and  were  made  with  the  greatest  care.  In 
many  cases  extra  cultures  were  made  subsequently  for 
greater  certainty.    To  take  up  the  cases  somewhat  more 


in  detail :  Cases  I.  to  X.  were  made  on  one  floor  of  the 
hospital  proper  from  convalescent  children  who  were  al- 
lowed to  eat  at  the  same  little  table  in  an  adjoining 
room  and  play  together.  When  the  reports  of  Klebt- 
Loeffler  in  two  of  the  cases  were  received,  they  were 
promptly  isolated  and  treated. 

Case  I.  (Culture  No.  3). — Eugene  W ,  aged  three, 

suffering  from  anaemia,  well  nourished,  no  cough,  called  . 
"  doll  baby  "  from  his  perfect  face  and  pettish  actions. 
Soft  blowing  murmur,  generally  heard  best  over  pulmon- 
ary interspace,  which  disappeared  entirely  under  treat- 
ment until  at  the  time  culture  was  made  it  could  no  longer 
be  heard  and  child  seemed  perfectly  well.  Three  days 
after  culture  was  made  laryngeal  diphtheria  developed, 
and  intubation  became  necessary ;  tube  removed  on  fifth 
day,  reinserted  on  sixth  day,  and  finally  removed  four 
days  later;  patient  gradually  improved,  but  remained  in 
weakly  condition  and  died  of  broncho-pneumonia  a 
month  after  first  intubation.  Culture  of  this  case  proved 
virulent  in  guinea  pigs. 

Case  II.  (Culture  No.  1). — Denny  C ,  aged  four, 

convalescent  from  croupous  pneumonia  for  two  weeks 
and  playing  around  with  the  other  children.  Throat 
appeared  perfectly  normal,  culture  contained  many  typi- 
cal Klebs-Loeffler  bacilli,  which  proved  virulent  in 
guinea- pigs.  No  membrane  or  further  manifestations  of 
diphtheria  appeared,  and  a  little  treatment  soon  removed 
bacilli.  Has  been  perfectly  well  since.  An  interesting 
point  in  connection  with  these  two  histories  is  that  three 
days  later  No.  4  developed  typical  diphtheritic  patches 
on  both  tonsils,  and  cultures  showed  abundant  Klebs- 
Loeffler.  She  recovered  nicely  under  treatment,  and 
culture  about  a  week  later  showed  no  Klebs  Loeffler, 
none  having  been  found  in  her  original  culture. 

Culture  No.  2. — Maggie  W ,  a  child  suffering  from 

marked  rachitis  showed  two  well-marked  patches  of 
pseudo-membrane  a  few  days  after  original  cultures; 
some  temperature,  enlarged  glands,  prostration,  etc., 
but  no  Klebs  Loeffler  were  found  in  original  or  two  later 
cultures.  Hers  was  an  obstinate  case,  but  she  recovered 
after  vigorous  treatment.  Now  here  were  ten  children 
not  having  been  exposed  to  diphtheria,  in  good  general 
condition,  with  apparently  perfectly  healthy  throats,  no 
enlarged  tonsils,  nor  adenoids,  nor  nasal  catarrh,  one  of 
whom  developed  laryngeal  diphtheria,  apparently  giving 
diphtheria  to  another,  and  infecting  one  with  true  and 
another  with  false  diphtheria. 

Culture  No.  7,  who  had  suspicious  bacilli  at  first  cult- 
ure, showed  pseudo-diphtheritic  bacilli,  but  no  further 
manifestations  of  diphtheria,  and  the  bacilli  disappeared 
with  treatment. 

The  following  cases  were  in  other  wards : 

Case  III. — Stephen ,  aged  five,  tubercular  osteo- 
arthritis ankle,  showed  Klebs-Loeffler  typical,  but  no 
further  sign  of  diphtheria,  and  treatment  begun  shortly 
after  isolation.     Showed  no  further  bacilli. 

Case  IV. — Thomas   C ,   granular  conjunctivitis, 

showed  typical  Klebs-Loeffler.  No  further  manifestations 
of  diphtheria. 

Case  V. — Annie  W ,  talipes  equino  varus,  with 

special  shoe  fitted.  Klebs-Loeffler  found,  but  no  subse- 
quent diphtheria. 

The  two  cases  from  the  Out-patient  Department  showed 
true  Klebs-Loeffler,  but  treatment  removed  bacilli,  and 
no  further  symptoms  appeared. 

Of  the  28  measles  cases,  in  which  cultures  were  made 
in  all  but  6  at  time  of  eruption,  typical  Klebs-Loeffler 
were  found  in  10  cases.  Four  of  these  had  croupy 
coughs,  but  only  one  of  them  had  Klebs-Loeffler,  while 
one  had  pseudo-diphtheritic  bacilli.  None  showed  any 
further  trouble  with  the  throats,  the  peculiar  cough 
doubtless  being  due  to  a  greater  degree  of  catarrhal  in- 
flammation of  the  larynx.  Two  of  these  cases  died  of 
pneumonia,  but  no  membrane  was  found  post  mortem. 

From  these  cases,  to  sum  up,  we  note : 

1.  Of  51  healthy  throats,  Klebs-Loeffler  bacilli  in  7; 
that  is,  28  healthy  throats  in  hospital,  5  Klebs-Loeffler; 


September  29,  1894] 


MEDICAL    RECORD. 


403 


19  healthy  throats  in  Out-patient  Department,  2  Klebs- 
Loeffler.  Nearly  one  in  seven  is  the  proportion  of  Klebs- 
Loeffler  in  healthy  throats. 

2.  Probable  infection  of  a  case  from  the  Klebs-Loeffler 
bacilli  in  a  throat  in  which  at  time  of  culture  they  were 
doing  apparently  no  harm. 

3.  Occurrence  of  severe  pseudo-diphtheria  in  a  throat 
which  contained  no  Klebs-Loeffler. 

4.  Cases  of  pseudo  -  diphtheritic  bacilli  in  healthy 
throats. 

5.  The  occurrence  of  Klebs-Loeffler  bacilli  in  10  out 
of  28  cases  of  measles  throats,  or  in  about  one-third  of 
cases  examined,  but  apparently  not  adding  clinical  man- 
ifestations of  diphtheria  at  a  time  when  they  should 
have  found  it  easiest,  i  e.f  in  inflamed  measles  throats. 
The  bacilli  were  removed  with  much  greater  difficulty 
from  half  of  the  measles  throats,  they  apparently  finding 
the  inflamed  mucous  membrane  a  good  habitat.  As  all 
of  these  cases  were  promptly  isolated  and  treated  as  soon 
as  bacilli  were  found,  no  idea  of  the  virulence  of  the 
bacilli  can  be  obtained  other  than  the  few  cultures  inoc- 
ulated in  animals.  All  of  these  children  have  been  under 
observation  for  the  past  three  months,  and  none  of  them, 
save  the  single  case  requiring  intubation,  have  since 
showed  any  sequelae  or  further  manifestation  of  diphthe- 
ria. 

THE  CERVICAL  GANGLION  OF  THE  UTERUS. 
By  BYRON  ROBINSON,  M.D., 

CHICAGO,   ILL, 

It  would  astonish  any  student  to  know  how  little  has 
been  published  in  regard  to  the  nervous  system  of  the 
female  genitals  which  is  of  an  original  character.  The 
reason  for  this  is  at  once  apparent  when  one  pursues  the 
study  for  several  years.  Of  course,  the  simplest  and  easi- 
est way  is  to  dissect  the  genitals  of  man  and  animals. 
Bat  few  do  that.  And  besides,  to  dissect  with  value  and 
discrimination  requires  time,  experience,  and  patience. 
The  best  way  is  to  secure  an  infant  cadaver  and  drop  it 
in  alcohol  for  several  weeks,  and  for  comparison  secure 
some  six  to  eight  weeks'  foetal  pigs  from  the  slaughter- 
house and  treat  them  likewise. 

To  get  at  the  parts  most  readily,  open  the  infant's  ab- 
domen and  take  away  the  hip-bone.  Unjoint  it  at  the 
sacro-iliac  joint,  then  cut  it  away  at  the  tip  of  the  ischial 
spine,  and  then  saw  through  the  pubic  rami  at  the  centre 
of  the  obturator  foramen.  The  field  is  now  clear.  Next, 
observe  the  course  of  the  hypogastric  plexus  just  beneath 
the  peritoneum  at  the  promontory  of  the  sacrum.  It 
will  show  itself  like  white  threads  shining  through  the 
peritoneum.  The  white  lines  are  the  hypogastric  plexus 
and  should  be  carefully  followed  by  a  sharp-pointed 
scissors  as  far  as  the  region  of  the  cervix.  Now,  with 
gentle  care,  clear  away  the  various  tissues  from  the  roots 
of  the  first,  second,  third,  and  fourth  sacral  nerves.  It 
will,  by  this  time,  be  clear  to  the  sight  that  the  lower 
end  of  the  hypogastric  plexus  and  the  branches  from  the 
sacral  nerves  (especially  the  third  and  fourth)  converge 
near  the  cervix  into  a  mass  of  white  tissue.  This  mass 
of  whitish-gray  tissue  is  the  ganglion  of  the  cervix  uteri. 
So  far  as  I  can  ascertain,  this  ganglion  was  first  described 
by  a  physician  named  Walter.  The  existence  of  the 
ganglion  has  been  denied  by  Snowbeck,  of  the  English, 
and  by  Kilian,  of  the  French.  The  defenders  of  the 
ganglion  are  chiefly  Lee  (1842)  and  Frankenhausen 
(1867).  The  names  of  those  who  have  worked  at  this 
ganglion  are  very  few  even  to  this  day.  The  only  work- 
er on  this  ganglion  that  I  know  of  in  the  last  generation 
is  Dr.  Jastrobef,  of  St.  Petersburg,  in  the  clinic  of 
Professor  Slavjansky.  Dr.  Jastrobef  used  thirty  bodies 
to  secure  anatomical  and  pathological  knowledge.  I 
have  been  working  at  the  nervous  system  of  the  female 
genitals  for  some  Ave  years,  and  I  did  not  become  aware 
of  Dr.  Jastrobefs  labors  until  August,  1894.  Nearly 
every  worker  in  this  subject  comes  to  essentially  the 
same  conclusions,  but  some  little  manifestations  arise 


which  induce  said  observer  to  think  every  other  investi- 
gator overlooked.  Lee  and  Frankenhauser  showed  with 
anatomical  positiveness  the  largeness  and  solidity  of  the 
cervical  ganglion ;  while  Snowbeck  and  Kilian  tried  to 
belittle  its  size,  and  even  its  existence.  Jastrobei's  short 
account  simply  sides  with  the  idea  that  the  cervical  gan- 
glion is  a  mere  plexus  of  nerves. 

After  careful  dissecting  (man  and  animals)  I  must  say 
that  the  cervical  ganglion  is  a  veritable  ganglion,  just  as 
the  superior  cervical  ganglion  is.  The  cervical  ganglion 
is  a  real  ganglion.  It  is  true  it  varies  in  shape  and  size, 
as  all  sympathetic  ganglia  do.  But  it  i§  constant  and 
real.  I  shall  carry  on  this  investigation  for  the  next  few 
years  in  man  and  animals  and  prove  its  constancy.  The 
last  cadaver  which  I  dissected  for  the  purpose  of  identi- 
fying the  ganglia  for  study  was  that  of  a  woman  about 
seventy  years  old. "  The  ganglion  was  fully  three-fourths 
of  an  inch  long,  and  over  one-fourth  of  an  inch  wide. 
It  was  a  thick,  hard,  irregularly  shaped  mass  of  nerve- tis- 
sue receiving  the  hypogastric  plexuses  and  the  branches 
of  the  sacral  nerves,  and  sending  out  many  small  nerves 
to  the  uterus,  bladder,  and  rectum.  The  ganglion  in  this 
special  case  received  all  the  branches  of  the  sacral  nerves 
before  they  entered  the  uterus,  and  all  the  nerves  of  the 
hypogastric  plexus,  except  two  or  three,  before  they  were 
sent  to  the  uterus.  It  appears,  then,  that  the  cervical 
ganglion  is  the  distributor  of  nerves  to  the  uterus.  It  is 
no  doubt  the  ganglion  of  the  uterus.  Its  business  is  to 
control  the  uterus.  Leashes  of  nerves  start  out  of  this 
ganglia  to  the  uterus,  bladder,  and  vagina.  The  vagina 
was,  next  to  the  uterus,  the  favored  organ  for  numerous 
strands.  The  ganglia  lie  near  the  cervix,  one  on  each 
side.  In  the  above  case  the  right  cervical  ganglion  was 
much  more  solid  and  compact  than  the  left.  More  than 
a  dozen  branches  could  be  counted  going  to  the  uterus, 
to  the  vagina,  and  to  the  rectum,  in  the  order  of  abund- 
ance. In  this  case  of  a  woman  seventy  years  of  age  the 
ganglion  was  perfect  and  distinct,  as  it  is  in  an  infant 
cadaver.  The  wonderfully  intimate  nervous  connection 
of  the  uterus  to  both  rectum  and  bladder  should  be  a  les- 
son to  the  gynecologist.  The  uterus,  rectum,  and  blad- 
der are  richly  supplied  by  many  strands  from  the  same 
great  trunk  (hypogastric  plexus).  It  is  almost  impossible 
to  irritate  one  organ  without  the  other  two  being  brought 
directly  into  the  disturbed  field. 

During  the  last  five  years  I  have  had  many  subjects 
(man  and  animals)  to  study  the  sympathetic  nervous  sys- 
tem, and  one  fact  has,  time  and  time  again,  impressed  me. 
This  fact  is  the  widespread  and  profoundly  intimate 
nervous  connection  of  the  kidney  and  genitals.  So  far 
as  the  nerve  connection  is  concerned  the  organs  should 
be  written  genito-urinary,  with  a  distinct  hyphen.  The 
explanation  arises  in  embryology,  where  both  genital  and 
urinary  organs  arise  from  the  same  source — the  Wolfian 
body.  I  wish  to  give  credit  for  this  same  idea  to  Dr. 
Frankenhauser,  whose  work  I  was  able  to  secure  only  a 
few  months  ago,  as  it  is  out  of  print.  A  glance  at  a  well- 
dissected  sympathetic  nervous  system  lying  in  situ  would 
enable  a  physician  to  cast  aside  forever  an  error  long 
propagated  in  obstetrics,  and  to  my  own  knowledge 
taught  even  to  this  day  from  obstetric  chairs.  It  con- 
cerns pressure  over  the  sacral  promontory  to  stop  post- 
partum hemorrhage.  It  is  taught  that  pressure  com- 
presses the  aorta  so  that  the  blood  is  checked  from  going 
to  the  uterus.  A  few  actual  trials  in  obstructing  the  aorta 
by  pressure  will  soon  dispel  the  delusion.  The  facts  in 
the  case  are  that  the  irritation  of  the  hypogastric  plexus 
(in  attempting  to  compress  the  aorta)  induces  the  uterus 
to  contract.  The  more  pressure  and  vigorous  irritation 
applied  to  the  sacral  promontory  the  more  vigorous  and 
certain  will  be  the  uterine  contractions,  so  that  the  ex- 
planation of  how  post-partum  hemorrhage  is  checked  by 
compressing  the  aorta  is  certainly  wrong.  The  mechan- 
ism is  accomplished  by  the  irritation  of  the  hypogastric 
plexus.  So  far  I  have  not  had  the  opportunity  of  dissect- 
ing a  pregnant  uterus,  to  determine  whether  the  cervical 
ganglia  enlarge,  but  both  Lee  and  Frankenhauser  say 


404 


MEDICAL    RECORD. 


[September  29,  1894 


they  do.  It  is  probable,  however,  that  John  Hunter  is 
correct  in  his  suggestion  that  it  is  the  connective  tissue, 
and  not  the  nerves  themselves,  which  enlarges  in  preg- 
nancy. Almost  every  investigator  of  the  uterine  nerves 
has  come  to  the  opinion  that  it  is  the  infant  cadaver 
which  serves  the  best  purpose.  The  nervous  system  of 
the  infant  is  disproportionately  large  and  is  plain  to  the 
eye,  and  it  can  easily  be  separated  from  the  delicate  con- 
nective tissue.  The  cervical  ganglia  are  very  plain  in 
the  infant.  Two  to  four  nerve-branches  pass  along  with 
the  ovarian  vein  and  artery  to  the  ovaries.  At  the 
junction  of  the  tube  and  uterus  (i.e.,  at  the  origin  of  the 
round  ligament)  the  ovarian  and  uterine  nerves  join — 
anastomose.  The  cervical  ganglion ,  of  course,  shrink  after 
the  menopause,  but  its  shrinkage  must  be  limited,  as 
many  of  its  branches  supply  the  rectum  and  bladder,  or- 
gans which  persist  in  further  use.  Yet  it  appears  to  me 
that  the  rectum  and  bladder  in  old  female  cadavers  are 
considerably  atrophied  as  well  as  the  uterus. 

Jastrobef  in  his  short  article  notes  that  in  disease  of 
the  genitals  on  one  side  the  ganglion  of  the  same  side  is 
affected.  He  reports  two  cases  where  the  ganglion  and 
the  genitals  of  the  same  side  were  both  diseased.  As  a 
considerable  portion  of  the  cervical  ganglia  rests  on  the 
vagina,  even  total  extirpation  of  the  uterus  would  include 
but  a  very  small  part  of  the  ganglia,  for  the  cervical 
ganglia  are  situated  too  low  down  to  be  included  in  the 
extirpated  uterus.  These  few  remarks  may  call  attention 
to  the  cervical  ganglion  of  the  uterus,  its  limited  litera- 
ture, the  varied  opinions  as  to  its  existence,  shape,  and 
size,  as  well  as  the  slight  records  of  its  functions  and 
pathology. 


grograsB  of  Igftedical  Science. 

The  Significance  of  the  Venous  Pulse.— Dr.  James 
Mackenzie  divides  the  venous  pulse  into  two  forms,  the 
auricular  and  the  ventricular.  The  former,  he  says, 
presents  distinct  evidence  of  the  functional  activity  of 
the  right  auricle.  In  this  form  there  is  also  a  wave  due 
to  the  ventricle,  and  as  it  increases  the  auricular  wave 
decreases  and  finally  disappears,  and  thus  the  ventricular 
venous  pulse  is  developed.  The  latter  form  is  a  more 
advanced  stage  than  the  auricular,  and,  as  during  its 
development  there  is  a  gradual  fading  of  the  auricular 
wave,  there  is  a  period  when  such  terms  do  not  sufficiently 
denote  the  character  of  the  pulse;  but  the  terms  are 
convenient  for  descriptive  purposes.  The  ventricular 
venous  pulse  appears  only  when  there  is  organic  disease 
of  the  heart  itself  (most  commonly  in  valvular  disease). 
When  failure  of  the  heart  is  functional  and  not  due  to 
organic  disease  of  the  valves,  the  auricular  pulse  persists 
to  the  end.  Similar  types  of  pulse  may  be  recognized 
in  the  liver.  Here  the  pulse  appears  only  when  there  is 
organic  disease  of  the  heart.  In  many  respects,  says 
Dr.  Mackenzie,  more  information  regarding  the  various 
cavities  of  the  heart  can  be  obtained  from  the  study  of 
the  venous  pulse  than  from  that  of  the  arterial  pulse. 
Thus,  during  a  cardiac  revolution  the  arterial  pulse  is  in 
free  communication  with  but  one  chamber,  the  left 
ventricle,  only  a  portion  of  the  time,  whereas  in  the 
venous  pulse  the  effects  of  the  right  auricle  during  its 
systole  and  its  diastole  may  be  observed,  while  the  time 
of  the  appearance  of  the  ventricular  wave  gives  informa- 
tion regarding  the  degree  of  incompetence  of  the  tricus- 
pid orifice.  Information  may  be  gathered  regarding  the 
exact  time  of  closure  of  the  pulmonary  valves,  and  the 
persistence  of  the  ventricle  in  systole  for  a  short  time 
after  the  outflow  through  the  arterial  orifices  has  ceased 
may  be  noted.  There  is  also  distinct  evidence  of  the 
diastole  of  the  right  ventricle  in  the  venous  pulse.  In 
heart  failure  the  venous  pulse  affords  information  of  a 
kind  entirely  different  from  that  supplied  by  other 
means.  Its  appearance,  increase,  decrease,  and  disap- 
pearance may  give  evidences  of  changes  in  the  blood- 


pressure  quite  inappreciable  by  any  signs  given  by  the 
arterial  pulse.  While,  as  a  general  rule,  an  increase  of 
the  venous  pressure  implies  a  diminution  of  the  arterial 
pressure,  that,  nevertheless,  is  not  always  the  case.  Al- 
though in  some  cases  the  disappearance  of  the  venous 
pulse  is  a  sign  of  the  restoration  of  the  body  to  a  health- 
ier condition,  yet  in  other  cases  it  may  precede  a  fatal 
termination.  In  these  last  cases  there  is  also  a  failure  of 
arterial  pressure.  In  pulse  irregularities  no  true  knowl- 
edge of  the  action  of  the  different  chambers  of  the  heart 
can  be  obtained  except  by  the  study  of  the  venous  pulse, 
and  this  study,  says  the  author,  throws  a  new  light  upon 
the  heart's  movements,  and  reveals  a  variety  of  them 
hitherto  unsuspected. — New  York  Medical  Journal. 

Obliteration  of  the  Superior  Vena  Cava. — According 
to  the  Paris  correspondent  of  The  Lancet,  Dr.  Merlin  has 
published  the  details  of  a  case  of  plugging  of  the  superi- 
or vena  cava — a  very  rare  phenomenon ;  but  what  con- 
stitutes a  still  greater  rarity  is  the  recovery  of  Dr.  Mer- 
lin's patient,  who  has  since  (a  space  of  four  years) 
remained  well.  His  patient  was  a  man,  aged  thirty  four, 
who,  after  an  effort,  was  affected  with  a  swelling  of  the 
face  which,  spreading  to  the  whole  head,  rendered  it  of 
an  enormous  size.  The  cheeks  were  puffed  out,  oedema- 
tous,  the  eyes  bulging  out  of  the  orbits,  the  lips  (espe- 
cially the  lower)  double  the  normal  volume,  the  tongue 
swollen  so  that  the  mouth  could  hardly  contain  #it,  and 
articulation  was  difficult.  The  oedema  of  the  neck  was 
great,  the  circumference  having  increased  from  thirty- 
nine  to  fifty-six  centimetres.  The  jugular  veins  were 
dilated,  and  the  establishment  of  collateral  circulation 
was  apparent  from  the  presence  of  varicosities  at  the 
base  of  the  neck.  The  oedema  was  marked  as  low  down 
as  the  base  of  the  thorax,  and  the  patient  had  attacks  of 
dyspnoea.  The  voice  was  cavernous,  cough  was  frequent, 
and  deafness  was  complete.  The  upper  extremities  were 
much  less  swollen  than  the  face  or  trunk.  Below  the 
umbilicus  there  was  no  oedema.  The  patient  denied 
having  had  syphilis.  He  was,  nevertheless,  ordered  one 
drachm  of  potassium  iodide  per  diem,  with  the  result 
that  considerable  improvement  began  as  early  as  the 
second  day.  The  improvement  continued  progressively, 
and  he  was  discharged  in  a  month  cured.  As  above 
mentioned,  the  recovery  has  been  since  (for  four  years) 
maintained. 

Suprarenal  Tumor. — According  to  the  Berlin  corre- 
spondent of  the  Medical  Press  Dr.  Lazarus  showed  a 
preparation  before  the  Gesellschaft  taken  from  a  child, 
aged  three  and  a  half,  which  had  been  received  into  hos- 
pital in  the  middle  of  February.  According  to  the 
mother's  story  the  disease  commenced  with  pain  in  the 
body,  which  soon  began  to  swell.  In  the  right  upper 
part  of  the  abdomen  a  firm,  hard  swelling  was  found,  which 
was  taken  for  disease  of  the  liver.  The  lungs,  heart,  and 
kidneys  appeared  to  be  healthy ;  the  child  became  feeble 
and  pale,  the  haemoglobin  of  the  blood  fifty  per  cent., 
and  at  no  time  in  the  history  of  the  case  was  there  fever. 
Repeated  punctures  from  the  margin  of  the  ribs  to  the 
umbilicus,  over  the  region  of  the  swelling,  emitted  very 
little  fluid,  of  which  the  microscopical  examination  gave  no 
confirmation  of  a  malignant  character.  Closer  diagnosis 
revealed  a  renal  tumor.  The  child  rapidly  emaciated, 
while  the  weight  of  the  body  as  quickly  increased,  till, 
eight  days  after  admission,  it  died.  On  section  the  ab- 
domen was  found  to  be  filled  with  a  tumor ;  the  total 
weight  of  the  child  was  thirty-seven  pounds,  the  tumor 
alone  twelve  pounds,  which  originated  from  the  left  supra- 
renal body,  which  was  firmly  adherent  to  the  cortical  sur- 
face of  the  kidney.  The  small  bowel  was  pressed  upward 
and  backward,  the  stomach  and  large  intestine  were 
crushed  into  a  small  space  on  the  right  side  of  the  dia- 
phragm. During  life  no  discoloration  of  the  skin  was 
present.  Over  the  surface  of  the  tumor  small  nodules 
were  found  rising  in  knots,  which,  on  examination,  proved 
to  be  sarcomatous  degeneration.  The  liver  appeared  as  a 
sheet  of  paper  enveloping  the  tumor. 


September  29,  1894] 


MEDICAL   RECORD. 


405 


Medical   Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


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


New  York,  September  29,  1894. 


TYPHUS  AND  TUBERCULOSIS. 

At  a  recent  congress  of  hygiene  in  France,  two  impor- 
tant subjects  received  special  attention :  the  spread  of 
contagious  diseases,  especially  typhus  and  small-pox,  by 
tramps  and  other  vagabonds ;  and  the  social  as  distin- 
guished from  the  hereditary  causes  of  tubercular  con- 
sumption, this  disease  being  probably  the  greatest  physi- 
cal evil  known  to  humanity. 

Typhus  had  been  practically  absent  from  Paris  for 
seventy  years,  until  last  year,  when  tramps  brought  it 
into  a  night  refuge  at  Amiens.  It  soon  spread  to  other 
institutions  and  to  the  soldiers1  barracks,  in  spite  of  ener- 
getic disinfection  and  segregation.  This  year  it  has  ap- 
peared as  virulently  as  ever,  and  is  tending  to  become 
endemic  in  France.  Deschamps  read  the  first  paper  on 
the  subject  of  typhus,  stating  that,  unlike  most  epidemic 
diseases,  this  is  one  which  easily  attacks  persons  in  per- 
fect health  and  without  physical  defect  or  predisposition, 
ending  mortally  with  them  oftener  than  with  those  of 
weakened  or  inferior  constitutions.  The  tramp  who  has 
not  as  yet  the  slightest  exterior  or  visible  symptom  of 
typhus  may  already  give  it  to  those  with  whom  he  comes 
in  contact  or  leave  it  behind  him  in  the  night  refuge,  es- 
pecially during  the  ten  or  twelve  days  before  he  finally 
comes  down  with  the  disease.  Contagion  is  ever  to  be 
feared  when  cure  seems  to  be  complete.  Dronineau 
spoke  of  the  tendency  of  typhus  to  fix  itself  permanently 
in  a  region  to  which  it  once  gains  admittance.  It  was 
thought  best,  however,  by  others,  not  to  suppress  the 
night  refuges,  as  these  combine  public  safety  with  public 
charity.  Constructed  of  brick  or  stone,  with  framework 
and  furniture  exclusively  of  iron,  such  refuges  could  each 
morning  be  thoroughly  disinfected  and  the  straw  of  the 
floor  and  beds  be  burned.  In  concluding,  the  associa- 
tion decided  to  ask  the  ministers  of  the  interior  and  of 
agriculture,  that  sanitary  inspectors,  both  of  men  and 
beasts,  might  enjoy  permanently  the  powers  now  granted 
them  only  during  a  period  of  a  declared  epidemic.  Re- 
*  publican  France  accepts  the  duty  of  sheltering  its  vaga- 
bonds, and  should  also  have  the  right  of  preventing  the 
contagion  of  disease  to  its  citizens. 

An  interesting  feature  of  the  meetings  was  a  paper  by 
Tison  on  pulmonary  tuberculosis,  to  which  he  attributes 
one  quarter  of  the  whole  number  of  deaths  in  Paris  and 
in  other  large  cities  everywhere.  At  once  infections  and 
contagious,  very  difficult  to  expel  when  it  has  once  in- 
vaded the  organism,  tuberculosis  remains  the  cause  of 


death  that  science  has  least  succeeded  in  mastering. 
The  preventive  measures  that  might  be  taken  by  society, 
correspond  to  the  three  great  social  causes  of  tuberculosis 
as  distinguished  from  hereditary  predisposition.  These 
are  "  troglodytism,"  alcoholism,  and  excessive  labor, 
three  influences  most  at  work  between  the  ages  of 
eighteen  and  forty-five.  Troglodytism  is  that  condition 
of  modern  society  that  lodges  human  beings  in  small 
rooms,  insufficiently  supplied  with  pure  air  and  light,  simi- 
lar to  the  cave  dwellings  of  the  prehistoric  troglodytes, 
with  advantages  on  the  side  of  the  cave  dwellers.  They 
crept  into  their  holes  only  to  sleep  or  to  shelter  them- 
selves from  storm  or  attack,  spending  most  of  their  time 
hunting  and  fishing  in  the  open  air.  The  modern  cave- 
dweller  spends  most  of  his  time  in  a  luxurious  hole  or 
apartment  house,  and  but  little,  comparatively,  outside 
in  the  open.  Alcoholism,  as  a  cause  of  pulmonary  tuber- 
culosis, must  not  be  confounded  with  drunkenness,  which 
is  uncommon  in  France.  By  alcoholism,  Tison  means 
that  light  but  constant  sipping  of  liquors  and  brandy, 
especially  before  and  after  meals,  which  daily  comes 
more  and  more  to  prevail  among  the  men  and  women  of 
France.  In  nearly  all  of  these  drinks  there  is  from  fifty 
to  seventy  per  cent,  of  pure  alcohol ;  and  even  when 
water  dilutes  them,  more  alcohol  enters  the  system  than 
can  well  be  borne.  Modern  chemists  find  that  alcohol 
does  little  more  than  pass  through  the  system  without 
change  or  assimilation,  remaining  as  a  clog  to  liver  or 
brain  when  not  eliminated.  Even  when  it  has  disap- 
peared, a  morbid  condition  of  the  organs  by  which  it  is 
eliminated  remains.  The  forced  elimination  of  alcohol 
by  the  lungs  is  a  direct  cause  of  pulmonary  tuberculosis. 
The  physiological  impoverishment  resulting  from  insuffi- 
cient nourishment,  Tison  states  with  much  bitterness,  is 
due  largely  to  the  adulteration  of  important  articles  of 
food  and  drink.  In  ordinary  canned  goods  there  is  only 
a  trace  of  genuine  food.  Modern  legislation  allows  the 
counterfeiting  of  food  and  drink,  and  punishes  severely 
the  counterfeiting  of  money.  When  the  public  health  is 
considered  as  important  as  the  public  purse,  there  will 
be  less  pulmonary  consumption. 


A  PRIVATE  AMBULANCE   SERVICE. 

In  this  city  all  the  ambulance  service  has  been  furnished 
by  the  public  or  private  hospitals.  The  city  is  divided 
into  districts,  and  connection  with  the  hospitals  and 
police  stations  is  established  by  telegraph  and  telephone. 
The  system  works  well,  though  at  times  the  service  is 
slow.  When  a*  person  who  is  very  ill  needs  some  con- 
veyance to  his  home  or  a  private  hospital  he  has  usually 
to  go  to  some  of  the  large  hospitals  and  hire  an  ambu- 
lance for  his  purpose.  This  is  expensive,  and  often  slow 
and  annoying.  There  are,  we  believe,  some  specially 
arranged  carriages  by  which  an  invalid  can  be  conveyed 
from  the  ferry  or  a  train  to  his  destination.  Recently 
an  enterprising  firm  has  undertaken  to  establish  a  private 
ambulance  service  which  may  be  called  upon  at  any 
hour  of  the  night  or  day  for  the  convenience  of  small 
institutions  or  physicians  in  private  practice.  Already 
we  are  informed  that  some  of  the  private  hospitals  are 
using  this  service,  and  as  its  rates  are  much  more  reason- 
able than  those  of  the  public  ambulances,  it  seems  as 
though  it  would  supply  a  demand. 


406 


MEDICAL   RECORD. 


[September  29,  1894 


SNAKE-POISON  A  TOXIC  PROTEID. 

In  Science  Progress  for  September,  W.  Halliburton  has 
a  most  interesting  paper  on  snake-poison.  Not  the  least 
strange  of  the  many  puzzling  facts  in  connection  with 
the  proteids,  says  the  author,  is  that  many  of  them  are 
poisonous.  The  proteids  are  the  most  important  class 
of  chemical  substances,  forming  the  most  essential  of  the 
.  constituents  of  a  diet,  and  are  the  most  constant  and 
abundant  of  the  materials  obtainable  from  protoplasm 
and  living  structures  generally.  Yet  practically  nothing 
is  known  of  their  chemical  constitution.  The  poisonous 
proteids  are  not  distinguishable  by  any  well-marked  or 
physical  properties  from  the  non-poisonous  or  food  pro- 
teids. Both  animals  and  vegetables  furnish  poisonous 
proteids;  notably  jcquirity  seeds  and  the  yellow  lupin 
in  the  vegetable  kingdom,  and  snake-poison  among  ani- 
mals, together  with  the  proteids  in  the  serum  of  the 
conger-eel  and  other  fish,  and  the  proteid  poisons  found 
in  certain  spiders.  Proteid  poisons  are  also  formed 
during  ordinary  digestive  processes  in  the  human  ali- 
mentary canal,  from  the  proteids  taken  as  food.  Nor- 
mally animals  are  protected  from  this  poison  by  the 
lining  membrane  of  the  alimentary  tract,  so  that  no 
proteose  or  peptone  is  found  in  blood  or  lymph  during 
the  most  active  periods  of  digestion.  The  cells  of  this 
membrane  possess  many  remarkable  properties,  but  one 
of  the  most  important  is  this  power  of  regenerating 
albumin  from  peptone. 

Allied  to  the  albumoses  of  ordinary  gastric  activity  are 
the  similar  products  produced  by  bacteria.  In  some 
cases  poisons  produced  by  the  growth  of  micro-organ- 
isms are  alkaloidal  in  nature.  In  by  far  the  greater 
number  the  toxic  product  is  a  proteid.  There  is  still  an- 
other important  class  of  proteid  poisons,  the  nucleo- 
albumins  obtained  by  suitable  methods  from  most  'of  the 
cellular  organs  of  the  body.  Out  of  all  the  work  neces- 
sary to  make  the  foregoing  discoveries,  the  practical 
recognition  of  the  alezines  or  protective  proteids  has 
been  reached.  These  alexines  appear  to  belong  to  the 
nucleoalbumin  class  also.  In  small  doses  they  confer 
immunity  on  animals  to  large  doses  of  similar  poisons. 
The  long  hidden  secret  of  the  modus  operandi  of  vaccin- 
ation and  other  forms  of  protective  inoculation  begins  at 
last  to  be  revealed. 

The  small  quantity  of  poisonous  proteid  that  the  snake 
secretes  is  atoned  for  by  its  quality.  One  thousandth 
part  of  a  grain  of  the  Australian  black  snake's  poison  in- 
variably kills  a  rabbit  five  pounds  in  weight  in  about  a 
hundred  seconds.  And  this  deadly  proteid  is  as  yet  un- 
distinguishable  by  chemical  methods  from  those  in  daily 
use  as  foods ! 

In  the  researches  on  the  venom  of  the  Australian  black 
snake,  Martin  and  Smith  found  it  necessary  to  exclude 
various  classes  of  poisons,  as  well  as  to  determine  posi- 
tively the  nature  of  the  venom.  They  excluded  in  the 
first  place  by  appropriate  experiments  the  presence  of 
micro-organisms,  ferments,  alkaloids,  ptomaines,  and 
crystalline  acids.  Next  they  showed  that  the  poison  it- 
self was  a  proteid  mixture,  containing  three  distinct 
proteids,  one  an  albumin,  and  the  other  two  albumoses. 
The  albumin  is  not  virulent,  but  the  two  albumoses  (cor- 
responding to  proto-  and  hetero-albumoses  of  Kilhne) 
are  extremely  poisonous.    They  each  have  the  same 


physiological  action,  and  this  is  the  same  as  that  pro- 
duced by  the  venom  itself.  Momentary  boiling  of  the 
venom  does  not  impair  its  activity,  but  prolonged  boil- 
ing for  days  destroys  its  virulence. 

The  most  marked  local  effect  of  serpent  proteid  poi- 
son is  oedema.  The  general  symptoms  consist  of  twitch- 
ing and  convulsions  in  non  lethal  doses.  Continued 
fluidity  of  the  blood  has  been  noted  by  numerous  ob- 
servers in  the  case  of  various  snake-poisons.  Martin 
found  that  different  doses  produced  different  results; 
and  these  results  show  a  great  resemblance  between  the 
action  of  the  venom  and  that  of  tissue-fibrogen  and 
nucleo  albumin.  Does  the  poison  contain  nucleo-albu- 
min,  which  itself  is  a  proteid  united  to  a  substance  rich 
in  phosphorus  called  nuclein?  Snake- venom  contains 
no  nucleo  albumin ;  and  its  action  not  only  opens  up  a 
novel  aspect  of  the  subject  of  snake-poisoning,  but  also 
sheds  light  on  the  vexed  question  of  blood  coagulation. 


GRIEF,   EMOTION,   AND  INFECTION. 

Many  violent  maladies  have  been  supposed  to  have  been 
produced  under  the  operation  of  moral  influences.  Fear 
has  been  considered  capable  of  provoking  erysipelas. 
Laennec  believed  that  griefs  and  annoyances  were  im- 
portant constituents  in  the  frequency  of  tuberculosis  in 
large  cities.  Reproaches  and  agitation  have  been  known 
to  be  shortly  followed  by  puerperal  infection,  in  cases 
that  were  doing  perfectly  well  up  to  the  untimely  inter- 
ference of  parents  or  relatives.  Many  observers,  ac- 
cording to  FM9  in  the  Popular  Science  Monthly,  for 
January,  attribute  an  important  part  in  the  etiology  of 
the  diseases  of  women  in  child-bed  to  moral  affections. 
Theories  recently  put  forth  to  explain  contagion  and 
immunity  from  infectious  disease  seem  to  agree  with  the 
facts  in  the  case.  One,  that  mesodermic  cells  are 
charged  with  the  protection  of  the  organism,  explains 
why  diminutions  of  circulation  and  decrease  in  the  cali- 
bre of  the  blood-vessels  is  necessarily  unfavorable  to  the 
sally  of  protective  cells  and  phagocytosis.  Asthenic 
emotions,  from  this  point  of  view,  lead  to  the  same 
condition  as  traumatism,  fatigue  (Charcot,  Boyen); 
chill  (Pasteur,  Wagner,  Platania,  Chairin) ; '  inanition, 
(Canalis,  Morpurge)  ;  loss  of  blood  (Serafini)  ;  and  ner- 
vous sections  (Ruffer,  Roger,  Herman). 

That  grief  prostrates,  often  causing  physical  disease 
and  sometimes  death,  has  long  been  a  matter  of  every- 
day knowledge.  The  way  in  which  such  effects  are 
brought  about  has  been  the  subject  of  careful  study  by 
an  investigator  named  Bassi,  who  has  recorded  observa- 
tions on  animals  which  apparently  died  in  consequence 
of  capture.  Birds,  moles,  and  a  dog,  finally  succumbed 
to  conditions  that  correspond  in  the  human  animal  to 
acute  nostalgia  and  a  "broken  heart."  These  humble 
cousins  of  the  human  race  were  examined  post  mortem. 

Generally  there  was  hyperemia,  says  The  Lancet%  some- 
times associated  with  capillary  hemorrhages  of  the  ab- 
dominal organs,  more  especially  of  the  liver,  with  fatty 
and  granular  degeneration  of  their  elements,  and  some- 
times bile  was  found  in  the  stomach  with  or  without  a 
catarrhal  condition.  The  clinical  symptoms  were  at 
first  those  of  excitement,  especially  in  the  birds,  and  fol- 
lowed by  depression  and  persistent  anorexia.  The  theory 
suggested  by  Dr.  Bassi  is  that  the  nervous  disturbance  in- 


September  29,  1894] 


MEDICAL    RECORD. 


407 


terferes  with  the  proper  nutrition  of  the  tissues  in  such  a 
way  as  to  give  rise  to  poisonous  substances — ptomaines — 
which  set  up  acute  degeneration  of  the  parenchymatous 
^elements  similar  to  that  which  occurs  in  consequence  of 
the  action  of  certain  poisonous  substances,  as  phosphorus, 
or  to  that  met  with  in  some  infectious  disease.  In  sup- 
port of  this  view,  it  may  be  remembered  that  Schule  ear- 
lier found  parenchymatous  degeneration  in  persons  dead 
from  acute  delirium,  and  that  Zenker  found  hemorrhages 
into  the  pancreas  in  persons  who  had  died  suddenly. 


MENTAL  SEDATIVES. 

Thousands  of  men  and  women,  says  the  London  Specta- 
tor, use  novels  as  mental  sedatives,  read  them  to  steady 
their  nerves.  Busy  brain-workers,  or  those  who  other- 
wise exhaust  their  nervous  energies,  want  some  form  of 
mental  sedative.  They  cannot  rest  while  doing  nothing. 
In  order  to  quiet  the  thinking  machine,  it  must  be  kept 
gently  at  work.  The  easier  and  more  mechanical  that 
work  is  the  better,  but  the  mental  powers  must  just  be 
kept  running.  A  douche  of  fiction  quiets  them,  so 
novels  are  poured  over  the  weary  in  a  gentle  easy 
stream.  This  physical  need  creates  the  novel  market. 
To  one  accustomed  to  use  fiction  to  soothe  his  mind, 
there  comes  a  positive  craving  for  novels,  like  the  crav- 
ing for  any  other  sedative.  Hence  the  demand  for 
fiction,  good  or  bad,  of  a  kind  that  does  not  obtain  in 
other  forms  of  literature.  And  if  the  novel  is  in  a  for- 
eign language,  be  it  said  in  passing,  the  sedative  effect  is 
complete. 


%txos  of  ttxe  WStesk. 

The  Progress  of  Medicine  in  China. — The  Viceroy  Li 
Hung  Chang  has  established  in  Tientsin  an  imperial 
medical  college,  with  a  staff  of  western  (English)  medical 
men  who  assist  native  Chinese  in  teaching.  A  four  years' 
graduated  course  is  required  and  a  well-equipped  hospi- 
tal has  been  built. 

Cesario's  Body. — Professor  Lacassagne  applied  to  have 
Cesario's  body,  in  order  to  make  a  post-mortem  examina- 
tion. Menacing  letters,  it  appears,  were  sent  to  the 
medical  faculty,  and  the  body  has  been  buried.  Thus 
probably  interesting  pathological  and  physiological  data 
have  been  lost,  and  it  is  shown  that  the  anarchist  does 
not  favor  scientific  any  more  than  he  does  social  prog- 
ress. 

On  the  Use  of  Cinnamon  and  Other  "  Cures  "  for 
Cancer.— Mr.  J.  W.  Hulke  writes  to  The  Lancet  that  a 
regulation  of  the  Middlesex  Hospital  respecting  its  in- 
patient cancer  wards  requires  the  surgeons  in  charge  of 
these  to  try  every  alleged  remedy  the  composition  of 
which  is  not  "  secret  "  and  for  which  obviously  there  are 
not  sufficient  grounds  for  judging  that  its  effect,  if  any, 
will  be  injurious.  A  letter  from  Dr.  J.  Carne  Ross  hav- 
ing been  published  in  The  Lancet  on  the  great  value  of 
cinnamon  in  cancer,  it  was  agreed  to.  try  the  drug  in  the 
way  recommended.  Five  cases  were  chosen  as  best  ful- 
filling the  conditions  under  which  Dr.  Ross  had  obtained 
the  best  results.  Three  were  uterine  cases,  one  was  rec- 
tal, and  one  was  a  case  of  recurrent  masses  in  the  neck 
everywhere  covered  with  sound  skin.     The  preparation 


used  was  made  by  slowly  boiling  one  pound  of  Ceylon 
sticks  with  three  pints  of  water  till  the  bulk  was  reduced 
to  one  pint.  Half  a  pint  was  drunk  daily.  Four  of  the 
patients  were  under  observation  in  the  hospital  the  whole 
time ;  the  fifth  patient  was  treated  for  part  of  the  time 
as  an  out-patient.  In  four  of  the  cases  administration 
was  continued  for  between  two  and  three  weeks,  after 
which  the  drug  became  intolerable  to  the  patient  and  was 
vomited.  The  patient  in  the  fifth  case  continued  to  take 
it  for  a  month  before  he  begged  to  have  it  changed.  In 
three  of  the  cases  there  was  definite  evidence  of  increase 
of  the  growth  during  the  administration.  In  none  was 
there  any  evidence  of  relief  of  the  pain,  and  in  no  case 
was  it  possible  to  diminish  the  dose  of  morphia  or  opium, 
but  rather  this  had  to  be  increased  with  the  increase  of 
the  growth  or  as  the  drug  lost  its  power  from  custom. 
Mr.  Hulke  adds :  "  It  has  fallen  to  me  to  make  trial  of 
various  remedial  measures,  suggested  here  and  abroad  for 
the  relief  and  cure  of  sufferers  from  cancer,  in  the  course 
of  some  twenty-five  years  or  thereabouts.  Of  such  "  phar- 
maka"  I  may  mention  "  Fells'  paste  M  (the  active  in- 
gredient in  which  is  zinc  chloride  colored  with  red  snake- 
root),  slow  injection  of  acetic  acid  through  a  capillary 
tube,  sundry  escharotic  pastes  and  powders  having  arse- 
nic as  their  essential  component,  condurango,  and  more 
recently  Chian  turpentine ;  also  besides  these  the  dietetic 
treatment  laid  down  by  Beneke,  without  and  with  the 
association  of  arsenic  administered  internally  recom- 
mended by  Esmarch.  Several  years  ago  the  conjecture 
that  cancer  might  have  a  parasitic  origin  induced  me  to 
try  cinnamon,  being  influenced  in  the  selection  of  this 
by  the  common  ascription  of  germicidal  properties  to 
aromatic  oils,  and  by  my  recollection  that  my  old  teacher, 
Dr.  A.  Farre,  held  strongly  that  cinnamon  had  something 
like  a  specific  or  particular  influence  over  some  uterine 
functions,  a  belief  which  led  him  to  prescribe  large  doses 
of  the  tincture  in  certain  cases  of  dysmenorrhcea.  I  gave 
cinnamon  a  long  trial,  chiefly  in  cases  of  cancer  of  the 
uterus,  but  also  in  that  of  other  organs.  The  result  was 
wholly  negative. 

The  Craig  Epileptic  Colony. — Dr.  Frederick  Peter- 
son, President  of  the  Board  of  Managers  of  Craig  Col- 
ony, writes  that  our  informant  was  in  error  in  the  state- 
ment, recently  published  in  these  columns,  that  the 
epileptic  colony  would  not  be  opened  under  two  or  three 
years.  The  colony  will  be  opened  for  actual  work,  he 
says,  next  spring.  ''There  are  six  hundred  patients 
eagerly  waiting  in  the  almshouses  of  the  State  to  patron- 
ize the  colony;  besides  which  the  managers  are  receiving 
daily  letters  from  numberless  unfortunates,  not  in  alms- 
houses, anxious  to  enter  the  colony  as  soon  as  they  can 
be  received." 

Dr.  George  W.  Davis,  of  Holyoke,  Mass.,  died  in 
that  city,  on  September  18th.  He  was  born  on  March 
26,  1847,  aQd  was  graduated  in  medicine  from  the  Ver- 
mont University  in  1868.  He  began  practice  in  Crafts- 
bury,  Vt,  but  removed  to  Holyoke  in  1871  where  he 
resided  continuously  up  to  the  time  of  his  death.  The 
cause  of  his  death  was  disease  of  the  heart  following  an 
attack  of  influenza  in  1892. 

A  New  Charity  has  been  organized  at  Brooklyn, 
known  as  the  Non-Sectarian  Hospital  and  Home  for 
Epileptics,  having  accommodations  for  forty  inmates. 


4o8 


MEDICAL   RECORD. 


[September  29.  1894 


The  New  Tork  State  Association  of  Railway  Sur- 
geons.— The  annual  meeting  of  this  Association  will  be 
held  at  the  Academy  of  Medicine,  in  this  city,  on  No- 
vember 15th  next  All  railway  surgeons  of  the  State 
are  invited  to  be  present.  The  Secretary  of  the  Associ- 
ation is  Dr.  J.  B.  Hulett,  of  Middletown,  N.  Y. 

The  Southern  Surgical  and  Gynecological  Associa- 
tion.— The  Seventh  Annual  Session  of  this  Association 
will  be  held  in  Charleston,  S.  C,  on  November  13th, 
14th,  and  15th.  Papers  will  be  presented  by  a  number 
of  the  leading  surgeons  and  gynecologists  of  the  South. 
The  medical  profession  is  cordially  invited  to  attend. 
The  President  of  the  Association  is  Dr.  Cornelius  Kol- 
lock,  of  Cheraw,  S.  C. 

Dr.  Albert  H.  Buck,  of  No.  14  East  45th  Street,  New 
York,  writes:  "On  page  810  of  the  Medical  Record 
(issue  of  June  30,  1894),  I  speak  of  Dr.  Frederic  Lange, 
the  distinguished  surgeon  of  this  city,  as  Dr.  Theodore 
Lange.  You  will  do  me  a  favor  if  you  will  insert  a  suit- 
able correction  of  this  error  in  one  of  the  next  issues  of 
the  Medical  Record. 

The  Malarial  Organism  in  the  Blood  Plaque.— Dr. 
George  J.  Preston,  of  Baltimore,  writes:  "In-  examin- 
ing the  blood  of  a  considerable  number  of  malarial  cases 
this  summer,  I  observed  quite  frequently  a  speck  of  pig- 
ment in  the  blood  plaques.  Careful  observation 
showed  beyond  any  doubt  that  this  pigment  possessed 
motile  properties.  Generally  there  was  but  one  clump 
of  pigment,  occasionally  two  or  three  granules.  At  first 
the  single  granule  was  mistaken  for  a  nucleus,  but  it  was 
soon  noted  that  the  supposed  nucleus  moved  from  one 
part  of  the  plaque  to  another.  The  movement  is  not  the 
rapid  zigzag  motion  of  the  free  malarial  organism,  but 
a  much  slower  motion.  The  pigment  can  be  seen  to 
slowly  change  its  place  in  the  plaque,  now  in  the  centre, 
now  at  the  periphery.  In  patients  taking  methyl  blue 
the  pigment  was  slightly  stained.  The  organism  was 
observed  most  frequently  in  the  blood  of  patients  taken 
during  the  chill  or  a  few  hours  before  or  after  the  par- 
oxysm. It  was  seen,  however,  sometimes  in  the  inter- 
paroxysmal  period.  The  physiology  of  the  blood  plaque 
is  still  so  uncertain  that  this  note  is  recorded  in  the  hope 
that  further  observation  may  confirm  the  presence  of  the 
malarial  organism  in  this  structure. " 

The  American  Medical  Publisher's  Association. — The 
first  annual  meeting  occurred  at  Hot  Springs,  Va.,  on 
August  13th  and  14th.  After  the  transaction  of  the  usual 
routine  business,  the  president,  Dr.  Landon  B.  Edwards, 
read  a  paper  on  "Advertising  and  Advertising  Agen- 
cies. "  Upon  motion,  it  was  decided  that  all  annual 
meetings  hereafter  should  be  held  just  prior  to  the  ses- 
sions of  the  American  Medical  Association,  the  next 
meeting  being  set  for  Monday,  June  5,  1895,  at  9  A*M> 
in  the  Utah  House,  Baltimore. 

Dr.  Oharles  H.  Dare,  of  Bridgeton,  N.  J.,  died  on 
August  25th.  He  was  for  seventeen  years  County  Phy- 
sician, and  was  Surgeon  of  the  Fourth  New  Jersey  Na- 
tional Guard. 

A  Worm  Specialist  on  Third  Avenue  advertises  to  re- 
move the  worm,  head  and  all,  in  two  hours.  This  hard- 
ly gives  taenia  Solaris,  which  is  naturally  a  slow  animal, 
a  fair  show. 


Dr.  Jacob  Newkirk,  of  Binghamton,  N.  Y.,  died 
August  13th,  aged  eighty- nine. 

Dr.  Charles  H.  Williamson,  formerly  a  surgeon  in  the 
United  States  Navy,  died  at  St.  John's  Hospital,  Brook- 
lyn, N.  Y.,  in  the  sixty-ninth  year  of  his  age.  He  was 
a  native  of  Portsmouth,  Va.,  and  a  graduate  in  medicine 
from  the  University  of  Pennsylvania. 

Railway  Accidents. — From  the  advance  sheets  of  the 
Statistics  of  Railways  in  the  United  States  prepared  by 
the  Interstate  Commerce  Commission  for  the  year  end- 
ing June  30,  1893,  the  following  statistics  are  prepared 
and  published  in  the  Railway  Surgeon. 

Comparative    Summary  op  Railway    Accidents    for  the 
Years  Ending  June    30,  1893,  1892,  1891,    1890,    1889* 

AND    1888: 


Year. 

Employers. 

Passengers. 

Other  Persons. 

Total. 

| 

| 

Killed. 
3,727 

Injured. 

Killed.  |  Injured. 

Killed. 

injured. 
5*435 

Killed. 
7.346 

Injured. 

1893.. 

3L729 

299 

3,229 

4»3»o 

«^393 

1892... 

a.  554 

28,267 

376 

3i»*7 

4,a»7 

•    5iX58 

7.147 

36,65* 

1891... 

2,660 

26,140 

293 

a,97* 

4,076 

I    4.769 

7.©»9 

,   3*«» 

1890... 

a.45« 

22,396 

286 

a,4»5 

5,598 

4,206 

6.335 

1   *9»<«T 

1889... 
1888... 

1,972 

20,0*8 

3x0 

2,146 

3.54X 

I     4.X35 

5.8*3 

26,300 
t   »5»*w 

1     8,070 

20,148 

3X5 

2,138 

8,897 

3.63a 

5.282 

A  Hopeful  Candidate. — A  late  applicant  before  the 
Texas  Examining  Board  was  asked :  "  What  is  histol- 
ogy ?  "     "  Histology  is  the  history  of  medicine." 

"  What  system  of  medicine  do  you  practise  ?  "  "  The 
Vanderbilt  and  St.  Louis  systems,  and  sometimes  the 
homeopath  system." 

"What  is  the  homeopath  system,  as  you  call  it?'* 
"Sweatin'  the  patient." 

The  Abuse  of  the  Reprint. — It  is  a  courteous  and 
commendable  custom  for  an  author  who  has  written  an 
article  of  real  value  to  send  reprints  thereof  to  libraries 
for  reference,  to  his  friends  for  preservation,  and  to  those 
pursuing  the  same  line  of  investigation,  who  might  not 
otherwise  become  so  soon  acquainted  with  his  researches. 
When,  however,  the  reprint  is  used  merely  to  advertise 
the  fact  that  the  writer  is  peculiarly  skilful  in  a  certain 
specialty  it  is  less  commendable ;  and  when  it  is  used  to 
advertise  Messrs.  Enterprise  &  Paywell's  Panacea,  or 
some  similar  substance,  it  becomes  anything  but  com- 
mendable. These  thoughts  are  suggested  by  the  receipt 
of  a  pamphlet,  reprinted  from  a  journal  published  in  a 
neighboring  city,  and  bearing  the  title  "  Functional 

,"  by  X.  Y.  Z.,  M.D.,  Professor  of in  the 

,   etc.,   which    publication,   although  ostensibly 


coming  to  us  from  the  author,  is  quite  evidently  circu- 
lated as  an  advertisement  by,  and  at  the  expense  of,  the 
firm  whose  "trade-mark"  product  is  therein  recom- 
mended (no  doubt  honestly)  as  a  sovereign  remedy  for 
the  affection  in  question.  Apart  from  all  questions  of 
propriety,  men  who  permit  their  names  thus  to  be  mis- 
used are  very  shortsighted.  Their  advice,  however  un- 
justly, comes  to  be  looked  upon  with  suspicion,  as  not 
wholly  scientific  and  disinterested ;  and  their  reputation 
becomes  upon  a  par  with  that  of  the  "  advance-agents  " 
of  theatrical  notorieties — an  honorable  reputation  when 
one  does  not  pretend  to  be  other  than  an  advance-agent. 
The  advertising-reprint  and  the  reading-notice  are  twin 
growths  of  the  same  poisonous  root,  and  should  be 
utterly  condemned  by  thinking,  self  respecting  physi- 
cians.— Medical  News. 


September  29,  1894] 


MEDICAL   RECORD. 


409 


©liuital  gejrartroenk 

SECONDARY    SUTURE    OF    THE    SCIATIC 
NERVE. 

By   LEONARD   FREEMAN,  M.D., 

PATHOLOGIST  CINCINNATI  HOSPITAL  ;  SURGEON  TO  CHRIST'S  HOSPITAL,  CINCIN- 
NATI,   O. 

On  July  19,  1889,  a  colored  boy,  aged  nineteen,  was 
brought  to  the  Cincinnati  Hospital  suffering  from  a  cut 
across  the  left  thigh.  The  incision,  which  reached  to 
the  bone,  began  about  two  inches  below  the  trochanter 
major  and  extended  backward  and  downward  for  a  dis- 
tance of  about  fire  inches.  The  wound  soon  healed, 
but,  according  to  the  history  of  the  case,  sensation  re- 
mained absent  in  the  foot  and  the  limb  could  not  be 
used  freely. 

On  August  15,  189 1,  he  again  entered  the  hospital, 
about  twenty-fire  months  after  the  original  injury. 
Paralysis  and  atrophy  of  the  muscles  of  the  leg  and  foot 
were  present,  with  some  atrophy  of  the  thigh.  Sensa- 
tion was  absent  on  the  entire  outer  side  of  the  leg  and 
on  the  sole  and  dorsum  of  the  foot,  except  in  a  line 
about  one  and  one-half  inch  broad  along  its- upper  and 
inner  aspect.  The  anaesthetic  area  was  dry  and  covered 
with  a  scaly,  whitish  epithelium,  and  was  separated  in  a 
beautifully  distinct  manner  from  the  adjacent  soft,  dark, 
and  moist  skin.  There  was  oedema  of  the  foot,  and  the 
nails  of  two  or  three  toes  were  missing.  A  large,  deep, 
trophic  ulcer  occupied  the  under  surface  of  the  heel. 

It  was  difficult  to  make  the  man  understand  that  there 
could  be  any  connection  between  the  injury  to  his  thigh 
above  and  the  trouble  in  the  foot  below ;  he  suspected 
that  we  wished  to  "experiment"  on  him.  Finally  he 
consented  to  an  operation,  and  about  twenty -seven 
months  after  its  division  the  sciatic  nerve  was  reunited 
with  sutures. 

A  longitudinal  incision  six  inches  in  length  was  made, 
with  the  line  of  the  old  cicatrix  as  a  centre.  The  infe- 
rior segment  of  the  nerve,  owing  partially  to  its  atrophy, 
was  found  with  some  difficulty.  The  superior  segment 
revealed  itself  at  once  by  the  spindle-shaped  bulbous  en- 
largement, the  size  of  an  English  walnut,  which  occu- 
pied its  extremity.  This  was  removed  by  a  wedge- 
shaped  incision  with  its  apex  well  within  the  normal 
nerve  above.  Below  the  old  injury  the  nerve  was  much 
atrophied,  its  fibres  spreading  out  and  losing  themselves 
in  the  cicatrix.  These  stringy  fibres  were  separated  as 
thoroughly  as  possible  from  the  surrounding  tissues,  and 
the  end  of  the  nerve  resected.  The  distal  and  proxi- 
mal nerve-sections  were  then  repeatedly  and  forcibly 
stretched  with  as  much  force  as  was  considered  safe,  in 
order  to  bring  them  closer  together. 

On  flexing  the  knee  and  extending  the  hip  it  was  pos- 
sible to  approximate  the  ends  of  the  divided  nerve,  the 
separation  between  which  had  at  first  been  at  least  four 
inches.  Catgut  sutures  were  employed,  some  being  tied 
to  portions  of  the  neurilemma  and  others  introduced 
through  the  body  of  the  nerve  itself,  the  end  of  the  distal 
segment  being  dove-tailed  into  the  Y-shaped  incision  in 
the  end  of  the  proximal  segment. 

The  operation  and  subsequent  dressings  being  con- 
ducted with  aseptic  and  antiseptic  precautions,  the 
wound  healed  by  first  intention,  the  knee  being  re- 
tained in  flexion  and  the  hip  in  extension  by  plaster  of 
Paris. 

On  the  third  day  following  the  operation,  wishing  to 
demonstrate  the  absence  of  sensation  in  my  patient's 
leg,  I  suddenly  stuck  a  pin  into  the  part.  The  result 
was  startling;  the  man  gave  a  yell,  and  raised  very 
pointed  objections  to  a  repetition  of  the  experiment. 
This  was  the  first  intimation  which  we  obtained  of  re- 
turning sensation. 

On  the  eighth  day,  quoting  from  the  history,  "  sensa- 
tion is  greatly  increased/1  and  "  the  scaly  appearance  of 
the  skin  over  the  entire  leg  is  disappearing,  and  the  cuti- 


cle approaching  more  nearly  its  normal  condition.  The 
ulcer  on  the  foot  is  healing  steadily." 

In  two  weeks,  during  which  time  sensation  gradually 
returned  to  the  leg,  the  plaster  splint  was  removed  and 
the  patient  instructed  to  straighten  his  limb  slowly  and 
carefully,  a  little  each  day.  On  the  outer  surface  of  the 
foot,  and  more  especially  about  the  little  toe,  the  power 
of  feeling  remained  markedly  deficient. 

In  seventeen  or  eighteen  days  the  history  reads, 
"  sensation  is  gradually  passing  to  the  foot,  and  now 
deep  prickings  with  a  pin  can  be  felt  in  the  little  toe." 
In  about  three  weeks  the  patient  was  walking  about  on 
crutches.  In  a  month  from  the  date  of  the  operation 
the  skin  of  the  leg  had  recovered  its  softness  and  smooth- 
ness, and  had  almost  returned  to  the  normal,  while  the 
ulcer  was  nearly  healed.  Sensation  having  become  even 
abnormally  acute  in  places. 

At  the  end  of  about  five  weeks  the  patient  insisted  on 
leaving  the  hospital.  He  could  walk  well  without  the 
use  of  crutch  or  cane,  the  ulcer  was  healed,  and  the  skin 
of  the  leg  nearly  normal.  There  was  some  sensation  in 
the  foot,  although  very  deficient  on  the  outer  border, 
but  sensation  in  the  leg  was  nearly  what  it  should  be. 
The  muscular  paralysis,  however,  had  improved  little  if 
any. 

In  July,  1892,  nearly  a  year  after  the  operation,  the 
patient  was  again  in  the  hospital.  The  ulcer  on  the 
foot  was  present,  although,  as  near  as  could  be  ascer- 
tained, it  had  healed  and  broken  out  several  times. 
Unfortunately  nothing  was  mentioned  in  the  history  as 
to  sensation  or  motion  in  the  foot. 

On  May  24,  1894,  the  patient  was  again  examined. 
The  leg  above  the  ankle  was  perfectly  normal ;  the  skin 
being  soft  and  moist  and  the  sensation  perfect.  The 
foot,  however,  was  in  bad  condition — a  large  and  deep 
ulcer  occupied  the  posterior  surface,  while  another 
smaller  ulcer  had  appeared  on  the  outer  edge  of  the  foot 
near  the  little  toe.  In  fact,  the  condition  of  the  foot 
was  such  that  amputation  was  resorted  to  in  order  to  rid 
the  patient  of  his  incumbrance. 

After  a  careful  search  of  all  the  literature  at  my  dis- 
posal, I  have  been  able  to  find  but  three  other  cases  of 
secondary  suture  of  the  sciatic  nerve — although  there 
have  probably  been  others — one  by  Welhouse  and  one  by 
Langenbeck,  in  1876,  and  one  by  Weir,  in  1882.  Wy- 
eth,  although  he  did  not  suture  the  sciatic  itself,  re- 
united to  that  nerve  the  severed  internal  and  external 
popliteals. 

Langenbeck's  operation  was  made  two  and  a  half  years 
after  the  injury  to  the  nerve ;  and,  similarly  to  my  own, 
was  followed  by  a  return  of  sensation  on  the  third  day. 
The  patient,  a  man,  aged  nineteen,  had  motor  paralysis  in 
the  leg  and  foot,  together  with  anaesthesia  of  the  area  sup- 
plied by  the  sciatic.  A  large,  deep  ulcer  existed  near  the 
base  of  the  fifth  metatarsal  bone.  The  operation- wound 
healed  by  second  intention.  The  ulcer  filled  up  rapidly, 
and  sensation  returned  steadily  to  the  parts,  some  portion 
even  becoming  hypersesthetic. 

At  the  end  of  a  year  the  patient  was  again  seen.  Motor 
paralysis  was  still  as  complete  as  before  the  operation. 
Considerable  of  the  sensation  which  had  been  gained 
was  found  to  have  again  disappeared,  although  a  certain 
amount  of  improvement  remained,  and  the  ulcer  had  not 
broken  down. 

In  Wyeth's  case  the  popliteal  nerves  were  sutured  to 
the  sciatic  ten  weeks  after  the  injury.  Sensation  began 
to  return  in  five  days,  and  was  almost  fully  restored  at  the 
end  of  twenty  two  days.  The  ulcers  which  had  appeared 
on  the  foot  healed  rapidly.  After  two  months,  sensation 
still  existed  in  the  part,  accompanied  by  considerable  pain. 
The  subsequent  history  is  not  given. 

In  Welhouse's  case  complete  paralysis  of  the  sciatic 
followed  an  injury  to  the  left  thigh  just  below  the  gluteal 
mass.  He  operated  nine  months  after  the  injury,  the 
wound  healing  in  two  or  three  weeks.  The  first  few 
signs  of  returning  sensation  and  motion  did  not  occur  for 
three  months,  and  it  required  two  years  for  the  leg  to 


4io 


MEDICAL   RECORD. 


[September  29,  1894 


regain  its  original  usefulness.  At  the  end  of  that  time 
only  a  slight  oedema  and  a  subnormal  temperature 
remained  of  the  original  disturbance. 

Weir  sutured  the  sciatic  nine  years  after  its  division. 
There  was  no  gain  in  motility,  but  some  in  sensation,  and 
great  improvement  in  the  trophic  changes,  which  had 
progressed  to  ulceration. 

It  strikes  one  in  this  connection  that  too  much  stress 
should  not  be  laid  on  the  healing  of  ulcers,  because  con- 
finement to  bed  after  an  operation  must  have  a  tendency 
in  itself  to  produce  improvement. 

Considering  the  history  of  my  own  case  and  that  of 
Langenbeck,  it  seems  reasonable  to  suppose  that  the  ul- 
timate disappearance  of  sensation  which  had  reappeared 
following  the  operation  might  have  been  due  to  pressure 
on  the  nerve  from  cicatricial  contraction.  This  view  is 
strengthened  by  a  case  reported  by  Tillaux,  in  which 
suture  of  the  median  was  followed  by  restoration  of  func- 
tion which  subsequently  disappeared.  A  second  opera- 
tion revealed  a  cicatricial  mass  pressing  on  the  nerve,  the 
removal  of  which  rapidly  restored  the  lost  functions. 
Pye  describes  a  similar  case.  I  have  myself  seen  in  a 
case  operated  upon  by  Dr.  Dandridge  the  removal  of  a 
cicatricial  band,  which  pressed  upon  a  nerve,  greatly  ben- 
efit the  motor  and  sensory  disturbances  which  had  resulted. 

Where  there  is  much  danger  of  such  cicatricial  con- 
traction, might  it  not  be  practicable,  at  least  in  regard 
to  the  deep-seated  sciatic,  to  conduct  the  sutured  neive 
over  the  dangerous  region  through  a  suitable  aluminum 
or  other  light,  non  absorbable,  non-  compressible  cylin- 
der? Aseptic  bodies,  such  as  drainage-tubes,  bullets, 
gauze,  wire,  etc.,  heal  into  the  tissues  without  any  diffi- 
culty or  irritation,  even  splinters  of  wood  sometimes  do 
this,  and  there  seems  to  be  no  reason  why  an  aluminum 
cylinder  should  not  do  the  same.  In  addition,  Gluck 
asserts  that  nerves  regenerate  more  rapidly  over  long  dis- 
tances when  their  severed  ends  are  connected  by  a  bone 
drainage-tube.  Vaulair  mentions  a  case  in  which  a 
regeneration  of  two  inches  was  thus  obtained  after  a  lapse 
of  four  months,  the  new  nerve-substance  originating  by  a 
process  of  proliferation  from  the  end  of  the  proximal 
segment  alone. 

The  suturing  of  nerves,  although  rather  a  recent  surgi- 
cal procedure,  has  been  done  a  great  number  of  times, 
especially  in  connection  with  the  median  and  ulnar;  and 
the  results,  particularly  if  the  operation  is  undertaken  at 
the  time  of  the  injury,  or  soon  afterwards,  are  generally 
excellent.  But  in  cases  where  weeks,  months,  or  even 
years  have  elapsed  the  chances  ot  success  are  not  so  good. 
Successful  cases  have  been  recorded,  however,  after  a  great 
lapse  of  time.  Jessup,  for  instance,  operated  on  the 
median  nerve  nine  years  after  it  had  been  divided,  and 
succeeded  in  obtaining  restoration  of  function. 

F.  J.  Hodges  has  collected  108  cases  of  secondary 
nerve-suturing,  including  Bran's  33  cases,  with  eighty- 
eight  per  cent,  of  successes.  This  percentage  is  probably 
too  high.  There  are  a  number  of  reasons  why  it  is  easy 
to  be  mistaken  in  the  assumption  that  reunion  of  a  di- 
vided nerve  has  taken  place.  It  must  be  remembered 
that  there  is  such  a  thing  as  anastomosis  of  nerves  as  well 
as  of  arteries,  and  that  these  anastomotic  filaments  may 
take  on  the  sensory  functions  of  the  injured  nerve.  The 
areas  of  innervation  of  nerves  also  at  times  overlap  each 
other  to  a  greater  or  lesser  extent,  so  that  sensation  is 
only  slightly  or  temporarily  interrupted  by  division  of  a 
nerve-trunk.  It  has  been  asserted  by  Brown  S6quard 
that  irritation  of  the  proximal  end  of  a  divided  nerve, 
such  as  would  result  from  an  operation,  would  so  stimu- 
late the  spinal  centres  that  a  reflex  and  heightened  sensi- 
bility would  be  communicated  to  alien  filaments  going  to 
the  anaesthetic  area,  leading  the  operator  to  think  that 
the  nerve  operated  upon  had  been  reunited. 

It  is  of  course  possible  that  something  of  this  sort  may 
have  taken  place  in  either  of  the  cases  described  above. 
In  such  a  process  as  that  just  mentioned  motion  is  not 
apt  to  return  to  any  marked  extent,  even  though  the 
restoration  of  sensation  be  complete.     As  regards  mo- 


tion, deception  is  easy.  Patients  become,  in  the  course 
of  time,  quite  expert  in  overcoming  the  loss  of  power  in 
a  set  of  muscles,  by  the  use  of  others.  Also  the  natural 
elasticity  of  the  tissues,  especially  when  aided  by  con- 
tractures, may  cause  movements  which  seem  as  if  pro- 
duced by  nerve  action.  For  instance,  if  the  flexors  of 
the  hand  are  paralyzed,  the  opposing  muscles  will  extend 
the  fingers,  which  may  partially  flex  themselves  again 
simply  from  elastic  contraction  of  the  muscles  and  ten- 
dons. A  reliable  sign  of  nerve  regeneration  is  probably 
the  return  of  the  faradic  excitability  of  the  muscles. 

It  is  a  common  thing  for  sensation  to  return  first,  fol- 
lowed after  a  time  by  motion.  Motion  may  not  appear 
at  all,  or  only  after  the  lapse  of  weeks,  months,  or  eren 
years,  and  then  it  may  be  but  partial.  The  case  may 
improve  for  a  time,  and  then  grow  progressively  worse  ; 
which  may  be  due  occasionally,  as  I  have  stated,  to 
cicatricial  contraction.  Absolute  failure  cannot  be  de- 
clared, however,  until  two  or  three  years  have  elapsed. 

It  is  truly  astonishing  how  soon  sensation  will  some- 
times reappear.  Tillaux  states  that  following  suture  of 
the  median  four  years  after  its  division  all  the  functions 
of  the  nerve  reappeared  in  three  hours ;  and  we  read  of 
cases  of  immediate  suture  in  which  recovery  of  taction 
took  place  within  fifteen  minutes,  or  even  as  soon  as  the 
nerve  ends  were  approximated  (Segond). 

Catgut  is  probably  the  best  material  to  employ,  al- 
though silk  and  even  silver  wire  have  been  used.  The 
suture  may  pass  directly  through  the  substance  of  the 
nerve,  in  which  case,  for  obvious  reasons,  a  Hagadorn 
needle  is  better  than  one  with  sharp  edges ;  or  they  may 
include  only  the  neurolemma.  In  the  latter  method  a 
small  portion  of  the  sheath  may  advantageously  be 
caught  in  a  knot  on  either  side,  so  as  to  prevent  tearing 
out  of  the  thread.  Or  both  these  methods  may  be  em- 
ployed in  conjunction,  which  seems  to  be  ordinarily 
preferable,  as  it  permits  of  accurate  adjustment  of  the 
divided  surfaces,  and  at  the  same  time  gives  considerable 
strength  to  the  union. 

In  case  the  ends  of  the  divided  nerve  have  contracted 
too  far  to  be  easily  brought  together,  one  of  several  ex- 
pedients may  be  adopted  :  Gluck  has  suggested  that  the 
extremities  of  the  segments  be  connected  by  a  section  of 
decalcified  bone  drainage  tube,  in  order  that  the  nerve 
may  regenerate  along  its  lumen.  By  use  of  this  proced- 
ure Vaulair  succeeded  in  obtaining  a  regeneration  of  two 
inches  after  four  months. 

Experiments  have  been  carried  out  on  animals  which 
show  that  sections  of  nerves  may  be  grafted  from  one 
animal  to  another,  and  probably  from  animals  to  man. 
Nerves  have  occasionally  been  successfully  spliced — a 
flap  turned  down  from  one  segment  being  joined  to  a 
flap  from  the  opposing  segment,  similarly  to  the  way  in 
which  tendons  are  spliced. 

The  distal  portion  of  a  divided  nerve  may  also  be 
grafted  into  the  side  of  an  adjacent  nerve,  or  onto  the 
proximal  end  of  a  second  nerve  if  it  be  likewise  divided. 
Good  results  have  been  thus  obtained.  Again,  both  the 
proximal  and  distal  ends  may  be  grafted  onto  another 
nerve  at  different  levels,  so  as  to  use  the  latter  as  a  con- 
ducting medium  for  a  short  distance.  Billroth  resected 
a  portion  of  the  humerus  in  crder  to  bring  the  ends  of 
the  divided  nerve  closer  together. 


Explosive  Power  of  Modern  Bullets. — Dr.  Du  Bois 
Reymond  has  been  making  experiments  to  record  the 
effect  of  the  modern  German  rifle-bullet,  and  finds  it 
very  destructive.  The  bullet  of  the  old  style  rifle,  he 
says,  bored  only  a  comparatively  small  hole  through  the 
portions  of  the  body  through  which  it  passed,  whereas 
the  new  bullet  has  an  astonishing  explosive  effect.  If, 
for  instance,  the  ball  passes  through  the  head  of  the 
corpse,  the  skull  is  burst  asunder  in  all  directions,  and 
very  little  of  the  head  remains.  The  speed  of  the  bullet 
is  so  great  that  when  it  meets  an  obstacle  it  explodes  like 
a  Prince  Rupert's  drop  and  destroys  all  the  tissues 
around  it. 


September  29,  1894] 


MEDICAL   RECORD. 


411 


TUBERCULOSIS  OF  THE  LARYNX  AND 
PHARYNX.1 

By  FRED.  S.  CROSSFIELD,  M.D., 

HARTFORD,  CT. 

I  do  not  propose  in  the  present  paper  to  bring  forward 
new  ideas  respecting  the  theory  or  treatment  of  this 
form  of  laryngeal  disease.  My  purpose  is  rather  to  state 
my  experience  with  it,  and  to  outline  the  course  of 
treatment  I  have  adopted,  and  the  results  that  have 
followed. 

I  have  selected  two  cases  entirely  unlike  in  their  gen- 
eral features,  and  I  shall  give  the  histories  of  these  cases 
in  detail. 

The  first  case  is  that  of  a  young  woman,  aged  twenty- 
three,  American,  unmarried,  of  slight  build,  employed 
in  a  silk  mill.  She  was  brought  up  amid  the  most 
favorable  hygienic  surroundings,  and  her  health  had 
always  been  good.  There  was  nothing  unfavorable  in 
the  family  history.  Her  father,  mother,  brother,  and 
two  sisters  were  living,  and  in  good  health. 

She  came  to  me  with  the  following  history :  In  the 
month  of  May,  r886,  at  the  age  of  eighteen,  she  was 
injured  by  a  runaway  horse.  She  was  thrown  some  dis- 
tance, striking  upon  the  side  of  her  head ;  the  injury 
caused  concussion  of  the  brain  and  meningitis  followed. 
This  sickness  lasted  three  months,  at  the  end  of  which 
time,  having  regained  her  health,  she  went  back  to  her 
work  in  the  mill.  About  three  months  afterward  she 
took  a  severe  cold,  and  from  that  time  her  health  failed. 
Aside  from  a  sense  of  continued  fatigue,  she  complained 
only  of  her  throat,  where  she  felt  a  constant  burning 
irritation  with  a  desire  to  cough,  but  no  expectoration. 
Deglutition  produced  but  slight  discomfort.  Her  throat 
was  not  examined  at  this  time.  Her  physician  told  her 
she  was  overworked  and  run  down,  and  advised  her  to 
go  to  Vermont  for  a  change.  She  deferred  the  trip, 
however,  until  June  of  the  following  year,  1887.  Mean- 
while the  discomfort  in  the  throat  increased,  dysphagia 
being  added.  She  remained  in  Vermont  thirteen 
months.  Soon  after  her  arrival  improvement  began, 
and  it  continued  during  her  stay.  Her  weight  in- 
creased from  88  pounds  to  io8#  pounds.  The  throat 
difficulty  entirely  disappeared,  and  she  says  she  felt  per- 
fectly well. 

Three  months  after  returning  to  her  home  she  resumed 
her  position  in  the  mill  and  worked  steadily  until  June, 
1 89 1 — three  years.  At  this  time  there  was  a  recurrence 
of  the  throat  trouble. 

I  first  saw  her  in  October  of  the  same  year.  Up  to 
this  time  there  had  never  been  an  examination  of  the 
throat,  nor  had  she  received  any  local  treatment.  Her 
condition  was  as  follows:  Pale,  emaciated,  easily  fa- 
tigued, no  appetite,  slight  rise  in  temperature  in  the 
latter  part  of  the  day.  Deglutition  was  painful  and  a 
troublesome  cough  interfered  with  sleep  and  with  the 
taking  of  proper  nourishment ;  the  expectoration  at  this 
time  was  muco-purulent.  The  voice  was  husky  and  at 
times  lost.  The  lungs  were  repeatedly  examined,  but 
were  always  found  free  from  disease. 

On  examination  the  pharynx  was  found  to  be  reddened 
and  covered  over  the  entire  surface  with  a  thick,  tena- 
cious, ropy  mucus,  streaked  with  blood.  This  mucus 
being  wiped  away,  several  small  ulcerations  were  no- 
ticed upon  the  posterior  wall,  hardly  deeper  than  the 
mucous  membrane.  The  larynx  presented  the  same 
appearance  but  without  ulceration.  The  epiglottis  and 
vocal  cords  were  reddened  and  slightly  oedematous. 

The  patient  was  placed  upon  a  nutritious  diet,  and 
cod-liver  oil,  iron,  and  wine  were  administered.  The 
local  treatment  consisted  of  thoroughly  cleansing  the 
surface,  and  afterward  applying  lactic  acid,  twenty- five 
per  cent,  every  second  day. 

In  three  weeks  the  ulcerations  had  healed,  the  parts 
had  assumed  their  natural  color,  and  what  little  oedema 

1  Read  Jn  the  Section  of  Laryngology,   New   York  Academy  of 
Medicine,  May  24,  1893. 


there  was  had  disappeared.  The  voice  regained  its  nor- 
mal quality,  and  the  appetite  and  strength  returned* 
The  secretions  frcm  the  pharynx  and  larynx  were  exam- 
ined microscopically,  but  no  tubercle  bacilli  were  found. 
I  therefore  considered  the  condition  one  of  simple 
catarrhal  ulceration.  The  existence  of  s)  philitic  taint 
was  considered  highly  improbable,  as  the  local  condi- 
tions were  wholly  unlike  those  found  in  syphilitic  lesions 
of  the  larynx.  Furthermore,  the  social  position  of  the 
family  would  not  warrant  any  such  supposition. 

I  did  not  see  this  patient  again  until  four  months  later, 
in  February,  1892.  The  old  trouble  had  apparently 
reappeared  with  increased  intensity.  She  was  pale  and 
had  grown  rapidly  weak  and  emaciated.  She  had  night- 
sweats,  and  coughed  constantly,  the  expectoration  being 
tenacious  mucus.  The  voice  was  now  entirely  lost. 
The  pain  in  swallowing  was  severe,  and  her  sleep  much 
disturbed.  In  fact,  the  general  condition  was  discourag- 
ing in  the  extreme.  The  pharynx  was  one  mass  of 
ulceration,  from  a  point  a  little  below  the  uvula  down 
and  into  the  larynx.  The  ulceration  was  shallow — but 
little  below  the  surface— and  covered  with  a  grajfeh, 
tenacious  mucus.  The  epiglottis  was  enlarged  by  infil- 
tration to  twice  its  normal  size,  and  ulcerated  nearly  its 
whole  length.  The  arytenoids  were  also  infiltrated  and 
ulcerated.  An  imperfect  view  only  could  be  had  of  the 
vocal  cords.  Though  oedematous,  I  do  not  think  they 
were  ulcerated.  The  entire  surface  of  pharynx  and 
larynx  had  a  peculiarly  blanched  and  sodden  appearance. 

The  lungs  were  examined  carefully  at  different  times, 
always  with  the  same  negative  results ;  but  microscopical 
examination  of  the  secretion  from  the  pharynx  now 
showed  unmistakable  signs  of  tuberculosis.  Cod  liver 
oil  and  iron  were  administered  as  before,  and  inhalations 
of  oxygen  were  given  frequently.  The  surfaces  were 
thoroughly  cleansed,  and  the  ulceratiois  were  curetted 
after  applying  a  ten  per  cent,  solution  of  cocaine. 
Lactic  acid,  fifty  per  cent.,  at  first,  and  afterward  undi- 
luted, was  nibbed  into  the  surface.  Several  applications 
were  required.  Improvement  began  right  away.  The 
ulcers  healed  rapidly,  so  that  at  the  end  of  six  weeks 
healthy  cicatrices  marked  their  former  location.  The 
oedema  gradually  subsided  and  the  membrane  throughout 
resumed  its  normal  condition  and  function.  At  the 
same  time  her  general  health  improved. 

It  is  now  a  year  since  cicatrization  was  completed,  and 
she  continues  well  and  says  she  is  stronger  than  she  has 
been  for  several  years.  I  have  recently  examined  the 
throat,  and  could  find  no  evidence  of  there  having  been 
such  wide-spread  destruction.  I  hope  to  be  able  to  re- 
port favorably  upon  this  case  at  some  future  time. 

It  was  to  me  an  extremely  interesting  case,  both  be- 
cause the  whole  progress  was  unusual,  and  because  it  was 
a  case  of  primary  tuberculosis  of  the  larynx  and  pharynx 
of  extreme  severity,  and  demonstrated  what  can  be  done, 
even  in  what  would  seem  to  be  a  hopeless  case,  toward 
alleviating  the  distress,  if  not  absolutely  producing  a 
cure. 

The  second  case  that  I  shall  describe  was  that  of  a 
printer,  twenty- seven  years  of  age,  American,  married. 
His  father,  brother,  and  one  sister  died  of  consumption, 
and  he  had  had  general  tuberculosis  himself  for  a  year  and 
a  half  previous  to  his  coming  under  my  care,  in  November, 
1889,  and  at  that  time  he  had  also  been  suffering  for 
three  months  with  throat  complications. 

I  saw  the  patient  at  his  home,  he  being  too  weak  to 
come  to  my  office.  I  found  him  pale,  emaciated,  very 
weak,  and  able  to  sit  up  only  a  few  moments  at  a  time. 
The  cough  was  constant  and  painful ;  respirations,  40  ; 
pulse,  120;  temperature,  io2^°F.;  voice  entirely  lost ; 
dysphagia  marked.  The  pain  on  swallowing  was  so  se- 
vere that  he  could  take  no  nourishment,  nor  even  swallow 
the  secretions  from  the  mouth.  The  pharynx  and  larynx 
on  inspection  presented  the  characteristic  pale,  sodden 
appearance,  and  large  superficial  ulcers  were  found  upon 
the  posterior  wall  of  the  pharynx  and  upon  the  soft  palate. 
Infiltration  was  everywhere  present.     The  larynx  was 


412 


MEDICAL    RECORD. 


[September  29,  1894 


cedematous  and  ulcerated.  The  epiglottis  was  nearly 
covered  with  ulcerations,  and  was  so  much  enlarged  by 
infiltration  that  no  satisfactory  view  of  the  larynx  and 
vocal  cords  could  be  had.  A  rhinoscopic  examination 
showed  a  large  ulcer  upon  the  posterior  wall  of  the  phar- 
ynx on  a  level  with  the  Eustachian  orifices,  and  ulcers 
were  also  found  upon  the  septum,  and  on  the  middle  and 
inferior  turbinated  bodies  on  both  sides. 

Several  small  nodules  were  also  seen  upon  both  sides 
of  the  septum,  but  none  upon  the  outer  walls  of  the 
nose. 

The  prostration  of  the  patient  was  so  great  that  I  did 
not  dare  to  resort  at  once  to  curettement,  indeed  I  had 
grave  doubts  that  such  treatment  would  be  warranted  at 
all.  A  five  per  cent,  solution  of  cocaine  was  sprayed 
into  the  nasal  cavities,  pharynx,  and  larynx  every  three 
hours  for  four  days,  and  whiskey  and  oxygen  were  ad- 
ministered freely.  On  the  fifth  day  there  was  an  evident 
improvement  in  his  general  condition,  and  he  had  taken 
considerable  nourishment  I  then  ventured,  after  applying 
a  ten  per  cent,  solution  of  cocaine,  to  curette  the  pharynx, 
afterward  rubbing  well  into  the  surface  undiluted  lactic 
acid.  Liter  the  ulcerations  in  the  nasal  cavities  and  the 
larynx  were  similarly  treated.  Though  this  procedure  is 
usually  very  painful,  it  was  not  especially  so  in  this  case. 
Improvement  began  immediately,  and  the  patient  said 
he  felt  much  relieved.  Cicatrization  was  everywhere  ap- 
parent, and  nourishment  was  taken  in  sufficient  amount, 
without  difficulty,  and  with  relish.  He  slept  well  and 
awoke  refreshed.  He  increased  in  strength  and  was 
able  to  be  up  and  about  the  house  most  of  the  day. 
Within  four  weeks  the  ulcerations  had  all  healed,  and 
the  epiglottis  had  nearly  resumed  its  usual  size.  The 
vocal  chords  were  slightly  oedematous,  however,  and  the 
voice  remained  husky. 

The  patient  gradually  failed,  and  died  from  general 
tuberculosis  five  months  after  local  treatment  was  begun. 
There  was  no  return  of  the  discomfort  in  the  throat,  and 
an  examination  of  the  throat  and  nose  a  week  before 
death  showed  the  membrane  very  free  from  ulceration, 
bat  in  a  pale,  slightly  ceiematous  condition  throughout. 

This  caie  presents  one  especially  interesting  feature — 
the  appearance  of  ulcers  and  nodules  within  the  nasal 
cavities.    I  have  never  seen  this  condition  before. 

B  jsworth,  in  his  work  on  "  Diseases  of  the  Nose  and 
Throat,"  vol.  i.,  states  that  twenty-seven  cases  with  this 
complication  are  reported  in  medical  literature,  and 
these,  from  lack  of  positive  evidence,  he  reduces  to 
twenty. 

There  can  be  no  doubt  regarding  my  second  case,  be* 
c  mse  abundant  evidence  of  tuberculosis  was  found  micro- 
scopically. 

This  case  also  demonstrates  the  efficacy  of  curettement 
and  lactic  acid,  even  in  hopeless  cases  of  general  tubercu- 
losis with  laryngeal  complication,  in  relieving  the  distress 
referable  to  the  throat,  and  giving  comparative  comfort 
to  th;  sufferer  during  the  few  remaining  weeks  of  his  life. 

It  has  been  said  that  it  is  only  by  looking  backward 
that  we  can  wisely  look  forward.  It  is  certainly  interest- 
ing to  note  the  progress  which  has  been  made  during  the 
pait  few  years  in  the  theory  and  treatment  of  this  disease. 
Some  of  the  older  writers  make  no  mention  of  the  tuber- 
cular form  of  laryngitis  as  a  primary  disease.  Quoting 
from  an  article  written  upon  this  subject  in  1883,  it  says, 
"Primary  laryngeal  tuberculosis  may  possibly  occur, 
but  the  few  claimed  cases  of  its  occurrence  are  at  least 
open  to  doubt  as  to  correctness  in  diagnosis."  Another 
writer  says :  "  Neither  the  catarrh  nor  the  ulceration  of 
phthisical  subjects  present  any  characteristic  signs  by 
which  they  could  be  recognized  as  such."  Heinze,  writ- 
ing in  1879,  states  that  of  1,226  deaths  from  phthisis 
51.3  per  cent,  had  laryngeal  ulcerations.  He  also  says 
that  ulcerations  were  never  found  with  tuberculosis  of 
other  organs  when  the  lungs  were  intact. 

The  microscope  and  the  demonstration' of  a  specific 
bacillus  make  the  diagnosis  much  less  obscure.  The 
advancement  along  these  lines,  and  the  knowledge  de- 


rived from  experimental  investigation,  now  place  these 
cases  in  the  list  of  remediable  diseases. 

February  1,  1894. — The  patient  in  the  first  case  re- 
ported is  still  in  good  health,  with  no  indications  of  a 
return  of  the  laryngeal  trouble. 


THE  RELATIONSHIP  BETWEEN  BOVINE  AND 
HUMAN  TUBERCULOSIS,  WITH  THE  RE- 
PORT OF  A  CASE. 

By  W.  H.  SHERMAN,  M.D., 

ATTENDING  SUXGZOM  TO  ST.  JOHN**  KIVBSSIDB  HOSPITAL,   YONKOtt,   K.  T. 

Veterinary  Report, 
By  J.  S.  LAMKIN,  D.V.S., 

YJNKXKS,  N.  Y. 
GBADUATS  OF  AM  SKI  CAN  VSTSRINABY  COLLEGX. 

The  following  case  deserves,  in  my  opinion,  to  go  on 
record  as  a  contribution  to  the  important  subject  of  the 
etiological  relationship  between  human  and  bovine  tuber- 
culosis. The  brief  history  herewith  given  is  sufficient  to 
thoroughly  establish  the  diagnosis,  and  the  veterinary 
report,  in  connection  with  that  of  the  pathologist,  would 
seem  to  indicate  that  the  disease  of  the  cattle  bore  a 
causative  relationship  to  that  of  the  young  patient. 

B.  H ,  male,  aged  four.  Well  nourished  and  of  aver- 
age size.  Maternal  grandfather  died  of  phthisis  some  years 
ago.  Mother  died  as  the  result  of  an  accident.  Family 
history  otherwise  entirely  negative.  His  nurse  had, 
about  a  year  previously,  attended  her  daughter  who  died 
of  consumption.  She  did  not  contract  the  disease,  how- 
ever, nor  did  any  of  the  servants  in  the  house  have  tu- 
berculosis in  any  form.  The  boy's  previous  history  is 
good.  He  has  slight  adenoid  vegetations  in  the  vault 
of  the  pharynx,  which  render  him  prone  to  attacks  of 
bronchitis.  Two  years  ago  he  had  a  mild  attack  of 
pneumonia,  and  one  year  ago  a  second  attack;  from 
both  of  these  he  recovered  entirely,  and  for  one  year  has 
had  no  cough  nor  illness  of  any  kind.  His  development 
has  been  good,  and  his  growth  and  dentition  normal. 
His  uncooked  food  has  all  been  raised  on  the  place,  and 
it  is  believed  that  he  has  never  eaten  raw  fruit  from 
market  until  thoroughly  peeled. 

I  was  called  to  see  him  on  February  21,  1894,  as  it 
was  observed  that  he  walked  with  a  spastic  gait,  on  his 
toes,  and  that  he  would  frequently  tumble.  From  this 
time  on  he  gradually  but  progressively  developed  the 
classical  symptoms  of  meningitis,  namely,  spastic  con- 
traction, thickness  in  speech,  difficulty  in  deglutition,  loss 
of  power  to  protrude  the  tongue,  lack  of  co-ordination, 
opisthotonos,  etc.  On  March  5th  Dr.  M.  Allen  Starr, 
Professor  of  Neurology  at  the  College  of  Physicians  and 
Surgeons,  New  York  City,  saw  him  in  consultation,  and 
confirmed  the  diagnosis  of  meningitis,  probably  tuber- 
cular. 

Treatment — Iodides  and  bromides.  In  spite  of 
treatment  the  disease  progressed  in  the  usual  way  until 
death  occurred  on  March  27  th.  No  autopsy  was  allowed. 
During  the  latter  part  of  the  boy's  illness,  having  some 
suspicion  in  regard  to  his  milk  supply,  I  requested  Dr. 
J.  S.  Lamkin,  Veterinary  Surgeon,  to  inspect  and  exam- 
ine the  cows  on  the  place,  with  the  result  as  shown  in  his 
report  hereto  appended. 

Veterinary  Report. 

On  March  22,  1894, 1  was  requested  by  Dr.  W.  H. 
Sherman  to  visit  and  examine  three  cows,  which  were 

stabled  on  the  place  of  Mr.  B ,  Yonkers,  N.  Y.,  with 

a  view  of  determining  whether  they  were  the  subjects  of 
tuberculosis.  Two  of  these  animals  were  the  property 
of  Mr.  B ,  and  the  third  was  owned  by  his  son  in- 
law.    The  mixed  milk  was  consumed  by  all  the  members 

of  the  household,  including  B.  H ,  a  boy  four  years 

of  age,  who  was  at  this  time  suffering  from  tubercular 
meningitis.  A  short  time  previous  to  my  first  visit  the 
cows  had  been  examined  by  a  local  veterinarian  who 
gave  them  a  "clean  bill  of  health.'1     The  attending 


September  29,  1894] 


MEDICAL   RECORD. 


4i3 


physician,  Dr.  Sherman,  being  dissatisfied  with  this  ex- 
amination, as  by  physical  examination  alone  it  is  some- 
times impossible  to  detect  tuberculosis  in  cattle,  asked 
me  to  see  the  animals  and  express  my  opinion  as  to  the 
presence  or  absence  of  tuberculosis. 

Inspection  showed  that  they  were  thoroughly  well- 
housed,  well  cared  for,  and  well-nourished. 

Physical  examination  failed  to  disclose  anything  which 
could  lead  to  any  suspicion  that  they  were  other  than 
perfectly  healthy,  except  an  enlargement  and  thickening 
of  one  section  of  the  udder  of  one  cow  (No.  3).  None. 
of  them  were  (or  had  been)  suffering  from  cough,  dysp- 
noea, or  respiratory  disturbances  of  any  kind.  After  a 
consultation  with  the  family  and  the  attending  physician 
it  was  decided  to  employ  the  tuberculin  test,  the  writer 
being  thoroughly  impressed  with  its  value  as  a  diagnostic 
agent.  Accordingly,  on  March  23d,  the  temperatures 
of  the  three  animals  were  taken  at  8.30  and  10.30  p.m. 
At  1 1  p  m.,  in  each  case,  2*4  c.c.  of  a  ten  per  cent,  solu- 
tion of  tuberculin  in  one  per  cent,  solution  of  carbolic 
acid  was  injecled  hypodermatically  after  the  hair  over  the 
shoulder  had  been  removed  and  the  hide  rendered 
aseptic. 

The  following  morning  (March  24th)  at  6  a.m.  the 
temperatures  were  again  taken,  and  every  three  hours 
thereafter  until  9  p.m. 

The  following  table  shows  the  results  obtained  : 


« o.-=       a « 


§5  !  §*    £2  '  §3 


Dei 


s 


DcK. 
Fah. 


Deg.    Deg.  ,  Deg. 
Fab.  ,  Fah.     Fah. 


Com  No.  1. — Five  -  101.0    Tuberculin     101.2  '  101.2     101.4  '  101.4 

Tears    of    age.  1  ■    injection              I 

Pale  red  Alder-  |  2}  c.c.  of 

nev.      Not     in  'ten     per              , 

caff.                     I  j    cent  solu-              ' 

I  '     lion. 

Cow  No.  2.— Six  101.4    Tuberculin    101.4    104.2 

years    of    age.  >  injection 

Brown     Jersey  ,  2}  c.c.  of 

or       Alderney.  ,  ten     per 

Aborted     1  a  s  t  (  '    cent,  solu- 

Angusk    Due>  tion. 

to  calve  in  May .  ( 

Cow  No.  3.— Ten  ;  100.6  ,  Tuberculin 

years    of    age.  !  injection 

Cream  -  colored  ,  24  c.c.  of 

y.  Aborted  ten     per 

nber.  1  cent,  solu- 

Not  in  calf.  tion. 


<v  a. 


4 

■8, 


De*. 
Fah. 
101.9 


Fa£ 


xo6.o    X04.2    104.2    104.4 


100.3  1  102.2 


I 


105.8 


104- 2  ,  103.4 


March  95,  9  a.m.,  temperatures  all  normal. 

These  results  seemed  to  prove  that  two  of  the  three 
cows  (Nos.  2  and  3)  were  the  victims  of  tuberculosis,  al- 
though this  seemed  difficult  to  believe  in  the  case  of  Cow 
No.  a,  who  showed  every  other  evidence  of  the  most 
robust  health.  In  view  of  the  results  of  this  test  the 
writer  communicated  with  the  Secretary  of  the  New  York 
State  Board  of  Health  requesting  that  the  Board  send  an 
inspector  to  condemn  and  destroy  the  two  cows  which 
reacted  to  the  test,  and  recompense  their  owner. 

As  there  was  considerable  delay  in  obtaining  the  de- 
sired permission  to  destroy  and  examine  the  animals 
post  mortem,  it  was  decided  to  retest  all  three  of  them. 
This  second  test  was  conducted  in  the  same  manner  as 
before,  except  that  the  injection  was  given  at  9  p.m. 
April  1st. 

The  following  table  shows  the  results  obtained : 


,  April  1, 

April  1, 

April  it 

April  7, 

April  a, 

.April  a, 

'    12  M. 

0  P.M. 

to. 30  P.M. 

9  A.M. 

12  M. 

1  3  P.M. 

1 

Deg.F 

Deg.F. 

Deg.F. 

Deg.F. 

i  Deg.F. 

Cow  No.  1.— Pate    102. a 

xoi.2 

Tuberculin   injec- 

101.6 

101.8 

!   101.5 

red  Alderney. 

tion   a}  c.c  of  ten 

, 

percent  solution. 

< 

CowNo.3. — Brown 

xox.6 

101.4 

Tuberculin  injec- 

103.2 

,  »°5-8 

■      X04.0 

Jersey     or     Al- 

tion  2}  c.c.  of  ten 

derney. 

per  cent,  solution. 

1 

CowNo.x, — Cream 
colored  jersey. 

103.8 

xox.6 

Tuberculin   injec- 
tion af  c.c.  of  ten 
per  cent,  solution. 

xoi.2 

t 

102.4 

i 

ioa.2 

It  will  be  noticed  from  this  table  that  Cow  No.  3  did 
not  present  the  characteristic  reaction  as  in  the  original 
test 

On  April  16th  the  two  cows  which  responded  to  the 
test  were  slaughtered  and  a  post-mortem  examination  was 
conducted  by  Dr.  £.  F.  Brush,  of  Mount  Vernon,  Professor 
of  Cattle  Pathology  in  the  American  Veterinary  College, 
and  the  writer,  in  the  presence  of  several  physicians  and 
veterinarians,  with  the  following  results : 

Cow  No.  3  (White  Cow)  — The  thickened  mass  from 
the  udder  was  first  removed.  It  apparently  consisted  of 
fibrous  tissue,  a  few  small  cysts,  and  a  little  caseous  mat- 
ter, but  no  gross  appearance  of  tuberculosis  wss  observed. 

The  mediastinal  glands  were  markedly  involved,  rang- 
ing from  the  size  of  a  marble  to  that  of  a  lemon,  with 
cheesy  degeneration  well  advanced.  There  were  also 
tubercular  masses  of  various  sizes  in  the  lung  substance 
beneath  the  pleura. 

Cow  No.    2   (Black  Cow)  — Mediastinal  glands  en 
larged,  but  not  to  so  great  an  extent  as  in  Cow  No.  3,  the 
largest  mass  being  about  the  size  of  a  large  marble — 
caseous  degeneration  well  under  way. 

Small  nodular  masses  in  lung  under  pleura  with  cheesy 
centres.  On  section  the  lungs  were  found  to  be  studded 
with  tubercles  in  various  stages  of  development.  Liver 
and  kidneys  not  involved  in  either  cow.  Specimens  from 
the  mediastinal  glands  and  lungs  of  both  animals,  and  a 
portion  of  the  mass  from  the  udder  of  No.  3,  were  sub- 
mitted to  Dr.  George  A.  Tuttle,  of  New  York,  Patholo- 
gist to  the  Colored  Home  and  Hospital,  for  microscopical 
examination. 

His  report  is  here  appended. 

"New  York,  May  1,  1894. 

"  Dear  Doctor  : — The  examinations  of  the  pieces  of 
tissue  from  the  two  cows  resulted  as  follows : 

"  White  Cow,  No.  3. — Lung :  A  cluster  of  tubercles 
about  the  size  of  large  peas  in  and  beneath  the  pleura. 
The  centres  of  these  tubercles  consisted  of  soft  cheesy 
material.  Microscopic  examination  showed  mirute  tu- 
bercles in  various  stages  of  development.  Tubercles 
consisting  of  epithelioid  cells  and  giant  cells.  Older 
tubercles  with  considerable  fibrous  tissue  and  with  tubercle 
tissue  and  giant  cells  around  the  edges ;  and  others  with 
cheesy  centres  and  tubercle  tissue  and  giant  cells  around 
the  edges.  Tubercle  bacilli  found  in  moderate  num- 
bers. 

"  Mediastinal  gland,  about  the  size  of  an  egg,  consisted 
of  a  thickened  capsule  containing  a  mass  of  soft,  yellow, 
cheesy  material.  Sections  of  the  capsule  showed  tuber- 
cular inflammation,  tubercles  with  cheesy  centres,  and 
epithelioid  cells  and  giant  cells.  Not  examined  for  tu- 
bercle bacilli. 

"  Udder  contained  several  cheesy  nodules.  Sections 
through  these  showed  considerable  diffuse  inflammation 
and  infiltration  with  leucocytes,  also  a  number  of  minute 
tubercles  of  epithelioid  cells,  but  no  giant  cells.  Not  ex- 
amined for  tubercle  bacilli. 

"Black  Cow,  No.  2. — Lung  tissue:  Result  of  exami- 
nation identical  with  that  of  lung  of  White  Cow,  No.  3. 

"  Bronchial  gland  found  in  the  piece  of  lung  showed 
characteristic  changes  of  tubercular  inflammation,  cheesy 
degeneration,  tubercle  tissue,  and  giant  cells. 
"  Respectfully, 
(Signed)        "George  A.  Tuttle,  M.D. 

"936  West  Forty-fourth  Stkebt.'' 


April  3,  temperatures  not  taken. 

April  4,  temperatures  normal,  except  Cow  No.  2  —  ioa.6°  F. 


Large  Families  in  tforth  Carolina. — Dr.  J.  M.  Hays, 
of  Greensboro1,  N.  C,  writes :  "  A  proposoi  arecent  item 
in  your  columns  in  regard  to  the  fecundity  of  women,  I 
wish  to  state  that  in  Granville  County,  N.  C,  there 
lives  a  mulatto  woman,  the  wife  of  Daniel  Boone,  who  is 
the  mother  of  twenty  seven  living  children,  several  of 
whom  have  been  my  patients.  This  family  belongs  to  a 
rather  large  class  in  that  section  popularly  known  as  the 
'  issue  free,'  they  and  their  ancestors  for  several  genera- 
tions having  never  been  slaves.'1 


4H 


MEDICAL   RECORD. 


[September  29,  1894 


METHOD  OF  TESTING  FOR  ALBUMINURIA. 
By  PHILIP  JAISOHN,  M.D., 

WASHINGTON,   D.  C. 

There  are  innumerable  methods  for  testing  for  albu- 
minuria, but  one  must  select  the  best  process  and  use  it 
constantly  in  order  to  be  thoroughly  familiar  with  the 
msthod,  and  derive  practical  benefit  therefrom. 

Among  the  commDn  methods,  the  one  most  frequently 
used  by  the  practitioners  is :  Boil  the  urine,  then  add  a 
few  drops  of  nitric  acid  to  ascertain  whether  or  not  the 
urine  is  cloudy.  But  this  method  is  too  inaccurate  to  be 
of  any  service ;  and  there  13  another  method  known  as 
Heller's  te3t,  which  consists  in  adding  nitric  acid  care- 
fully to  the  urine  contained  in  a  test-tube,  and  observ- . 
ing  whether  or  not  a  band  of  cloudiness  exists  at  the 
junction  between  the  urine  and  the  acid.  This  method 
is  preferable  to  the  former,  yet  there  is  a  chance  of  mak- 
ing a  mistake;  because  if  there  should  be  phosphates 
present  in  the  urine,  there  will  be  a  cloudy  band,  which, 
however,  differs  from  the  cloudy* band  caused  by  al 
bumin ;  but  it  is  sometimes  very  deceptive  to  the  inex- 
perienced eye. 

I  know  another  test,  which  is  as  follows  :  First  acidu- 
late the  urine  with  acetic  acid.  (Filter  it  if  turbid.) 
Fill  the  test-tube  one  third  to  one-half  with  the  reagent 
composed  of  the  following  ingredients :  Bichloride  of 
mercury,  8  grains ;  tartaric  acid,  4  grammes ;  distilled 
water,  200  c.c. ;  glycerine,  20  cc. ;  and  then  add  the 
urine,  drop  by  drop.  By  this  method  one  can  detect 
albumin  in  the  urine,  when  present  in  the  proportion  of 
1  to  50,000.  This  is  the  most  delicate  test  known ; 
even  more  delicate  than  the  trichloracetic- acid  method, 
which  is  considered  one  of  the  most  delicate. 

But  I  have  come  to  the  conclusion  that  these  two 
methods  are  of  no  practical  use  for  clinical  purposes,  be- 
cause by  them  one  can  detect  albumin  in  the  majority  of 
cases,  whether  healthy  or  unhealthy.  This  is  especially 
true  of  the  bichloride  of  mercury  test.  I  have  exam- 
ined twenty  specimens  of  healthy  urine  and  have  found 
albumin  in  eighteen  cases,  by  the  mercurial  reagent,  which 
shows  the  worthlessness  of  the  test.  It  is  a  well  known 
fact  that  even  healthy  people  pass  a  very  small  quantity 
of  albumin  during  certain  hours  of  the  day ;  especially 
during  digestion,  and  there  is  no  pathological  signifi- 
cance in  this. 

However,  if  one  applies  such  a  delicate  test  as  the  one 
I  mentioned,  the  albumin  will  show  plainly,  and  will 
cause  unnecessary  apprehension  to  the  physician  as  well 
as  to  the  patient. 

There  is  one  method  I  am  in  the  habit  of  using,  and 
which  I  consider  the  most  reliable  and  practicable.  It 
is  more  accurate  than  the  method  of  boiling  the  urine 
and  adding  a  few  drops  of  nitric  acid,  and  not  so  deli- 
cate as  the  trichloracetic  acid,  or  the  mercurial  mixt- 
ure. 

Put  a  few  drops  of  liquor  potassii  in  a  test-tube  full  of 
urine  and  filter  it.  Fill  the  test-tube  one-half  with  the 
filtrate;  then  add  fifteen  to  eighteen  drops  of  fuming 
nitric  acid.  By  this  time  the  clear  urine  will  be  some- 
what cloudy  if  it  contains  albumin.  Boil  it  over  an 
alcohol  lamp  or  Bunsen  flame,  and  let  it  stand  for  one 
half  hour.  There  will  be  a  sediment  of  whitish  flakes  or 
brownish  granules.  Boil  it  again  and  observe  whether 
or  not  these  will  dissolve.  If  it  is  albumin  they  will  not 
dissolve  by  the  second  boiling. 

This  is  a  fact  of  especial  importance  to  medical  exam- 
iners for  insurance  companies.  It  is  their  duty  to 
guard  against  the  admission  of  undesirable  persons  to  the 
companies  with  which  they  are  connected.  But,  at  the 
same  time,  they  must  not  apply  too  delicate  a  test  in 
examining  the  applicant's  urine ;  as,  by  applying  such 
test,  the  albumin  is  apt  to  be  found  in  most  cases,  re- 
sulting in  the  rejection  of  the  applicant  upon  the  ground 
that  he  has  albuminuria.  Of  course  such  rejections  by 
the  medical  examiner  will  be  a  loss  to  the  company. 

On  the  other  hand,  the  medical  examiner  makes  a 


grave  mistake  who  applies  such  a  crude  and  inaccurate 
■method  as  boiling  the  urine,  and  adding*  a  few  drops  of 
nitric  acid,  and  then  declares  that  there  is  no  albumin ; 
and  the  applicant  is  accepted,  even  though  he  may  have 
albuminuria.  The  last-named  test  will  not  always  bring 
out  the  albumin,  unless  there  be  a  considerable  amount 
in  the  urine. 

Admitting  applicants  to  the  companies  on  the  strength 
of  such  a  test,  in  my  opinion,  is  running  a  great  risk. 
The  method  I  prefer,  and  already  described,  is  really  the 
nodification  of  so-called  "heat  and  nitric  acid  test." 
If  albumin  shows  by  this  test,  it  is  a  case  for  clinicians 
to  watch  the  patient  more  carefully,  and  for  the  examin- 
ers of  insurance  companies  to  be  justified  in  rejecting  the 
applicant. 

I  may  add  here,  that  examination  of  urine  should  be 
required  by  the  army,  navy,  and  marine  hospital  service, 
in  connection  with  physical  examination  of  candidates 
for  soldiers,  officers,  and  sailors. 

There  is  no  other  secretion  or  excretion  in  the  human 
body  which  gives  more  information  about  the  internal 
affairs  of  the  constitution  than  urine,  and  it  is  therefore 
a  subject  deserving  a  careful  study  and  investigation. 
It  is  hoped  that  in  die  near  future  all  the  practitioners  in 
the  land  will  realize  the  importance  of  this,  and  examine 
the  urine  of  their  patients  whenever  it  is  possible.  It  is 
true  that  most  general  practitioners  have  neither  time 
nor  facilities  to  do  the  chemical  and  microscopical  exami- 
nation of  the  discharges  of  their  patients ;  but  it  is  ad- 
visable for  them  to  have  this  kind  of  work  done  by  some 
one  who  has  experience,  skill,  and  time  to  do  it.  It  is 
a  justice  to  the  patient  as  well  as  to  the  attending  physi- 
cian. 


THE  DOCTOR'S  WIFE. 

To  ths  Editor  of  th*  Mumcal  Record. 

Sir:  Your  editorial  on  "Some  Experiences  of  the 
Doctor's  Wife,"  in  last  week's  issue,  strikes  the  key-note 
of  your  innate  gallantry,  which  doubtless  will  cause 
many  physicians'  help  (?)  mates  to  induce,  I  almost  said 
compel,  their  derelict  husbands  to  subscribe  to  the 
Medical  Record. 

At  the  risk  of  appearing  less  chivalrous  than  we  would 
like  the  entire  profession  to  be,  I  crave  a  little  space 
anent  your  comments  on  the  Brooklyn  physician's  wife 
who  enriched  the  columns  of  the  Tribune  with  her  ex- 
periences. 

Ab  initio,  the  tone  of  discontent  which  characterizes 
the  quotations  you  publish  is  all  too  prevalent  among 
physicians'  wives.  They  should  rather  be  proud  to  have 
been  selected  by  men  who  sacrifice  themselves  for  the 
good  of  humanity. 

Madam  says,  in  connection  with  her  life  as  a  physi- 
cian's spouse  that  "  this  is  a  big  world  and  a  hard 
world. ' '  Big  in  a  sense  it  is,  to  those  who  have  travelled 
much,  eg.,  from  the  Bridge  to  the  "  L  "  terminus  and 
back.  But  those  who  voyage  from  continent  to  conti- 
nent, find  distance  annihilated  and  the  world  made  very 
small  by  the  people  they  meet,  especially  those  who  find 
nothing  but  cause  for  complaint  in  their  destinies.  The 
latter,  like  your  fair  writer,  find  it  also  a  hard  world. 
They  forcibly  suggest  the  woman  who,  on  reaching 
heaven  was  welcomed  by  her  optimistic  husband  with : 
"  Well,  at  least  you  will  say  that  this  is  a  pleasant 
place  !  " 

"  To  people  of  a  certain  taste,  it  may  be,"  she  sniffed, 
"but  your  professional  engagements  doubtless  left  you 
no  time  to  select  a  dry  cloud  for  me.  I  am  consequently 
full  of  rheumatism,  and  this  wretched  halo  neither  sits 
straight  on  me  nor  has  it  any  pretence  to  style.  Had  it 
been  a  fetid  ulcer,  or  a  broken  bone,  or  some  filthy 
disease  on  some  immoral  low  wretch,  you  would  have 
given  it  attention,  but  as  to  me " 


September  29,  1894] 


MEDICAL   RECORD. 


415 


An  anthem  by  the  celestial  choir  drowned  the  re- 
mainder of  her  speech. 

Madam  objects  to  being  "Mrs.  Doctor."  I  once 
tried  to  meet  this  objection  by  saying  that  German 
women  are  very  proud  of  the  marital  title  "  Frau  Doc- 
tor;" the  fair  objector  sneered  that  this  was  "too 
tonic"  (pray  remember  it  was  her  pun).  But  would 
your,  or  rather  the  Tribune's  Brooklyn  medical  spouse 
rather  be  Mrs.  Butcher,  Mis.  Baker,  or  Mrs.  Candlestick- 
maker?  If  so,  why  did  she  elect  to  become  "Mrs. 
Doctor?"  If  she  made  so  serious  a  mistake  in  her 
choice,  why  does  she  flaunt  it  before  the  world  in  a 
widely  circulated  medium?  Why  does  she  advertise 
that  intellectual  smallness  which  prevents  her  appreciat- 
ing the  exalted  position  she  occupies  ? 

She  says  that  the  certificate  she  obtained  at  the  marital 
altar  "  has  nothing  to  do  with  degrees."  She  is  mani- 
festly, then,  one  of  that  class  which  cannot  be  elevated 
by  association  with  her  husband.  What  if  she  has  been 
asked  to  "  set  a  broken  arm  or  pull  a  tooth  when  the 
doctor  (with  a  lower-case  initial)  was  out  ?  "  Would  there 
be  anything  degrading  in  having  learned  to  apply  a 
temporary  dressing,  or  in  cleansing  the  cavity  and  for 
the  time  being  stuffing  the  tooth  with  cotton  soaked  in 
laudanum  ?  Aside  of  thus  holding  the  case  for  her  hus- 
band— of  course  I  refer  to  the  broken  arm — would  it  not 
be  better  if  she  gave  attention  to  relieving  human  suf 
fering,  rather  than  to  be  moaning  her  lot  and  incident- 
ally trying  to  besmirch  the  profession  ? 

Madam  objects  to  life  in  a  house  behind  a  brass  sign. 
She  correctly  explains  the  cause  with  "  when  you  stand 
in  the  window  you  are  not  a  private  woman  in  a  private 
house."  A  woman  who  properly  attends  to  her  house 
and  family  has  no  time  to  stand  in  the  window. 

Madam  complains  that  the  physician's  wife  is  not  sure 
of  her  evening  amusements,  and  finishes  with  a  pathetic 
protest  that  she  must  "look  after  the  family  caiv- 
mg. 

What  hardships  indeed  !  While  her  husband  loses  the 
very  entertainments  from  which,  by  the  way,  his  wife 
does  not  abstain,  he  is  earning,  by  the  hardest  of  hard 
work,  the  means  for  her  to  enjoy  fife  and  leisurely  com- 
plain about  it.  And  as  to  the  family  carving — a  man 
who  would  allow  his  wife  to  carve  while  he  goes  off  to 
save  a  life,  is  capable  of  any  iniquity,  even  so  vile  a  one 
as  to  neglect  to  button  her  shoes. 

When  one  reaches  the  age  that  entitles  reminiscences, 
one  cannot  but  recall  antitheses.  I  once  had  occasion 
to  call  on  a  successful  practitioner,  whose  home  life,  be- 
cause of  its  happiness,  was  the  object  of  much  comment. 
The  doctor  was  not  at  home.  His  wife  urged  me  to 
wait  for  the  doctor,  as  she  had  sent  for  him  a  moment 
before  I  explained  that  I  was  not  a  patient,  but  a 
colleague.  "I  am  so  glad,  Doctor,"  she  responded, 
"  won't  you  come  in  quickly,  please.  I  have  a  man  on 
the  operating- table  with,  I  think,  his  posterior  tibial 
artery  cut.  I  controlled  the  hemorrhage  with  an  im- 
provised tourniquet,  but  of  course  would  not  attempt  to 
ligate." 

I  then  observed  that  Mrs.  Doctor  (with  a  capital  ini- 
tial) had  stained  her  elegant  dress  with  blood.  Her  hat 
and  gloves  were  on  the  floor  of  the  operating-room ;  the 
patient  was  lying  with  his  injured  leg  raised  on  an  in- 
verted chair,  the  trousers  and  drawers  (I  blush  for  the 
Brooklyn  Madam  at  their  mention)  slit,  and  as  neatly 
applied  a  tourniquet  as  I  ever  saw  controlling  the  bleed- 
ing. 

Just  then  her  husband  came  in.  She  assisted  him  at 
the  ligation ;  pride  in  her  husband  and  in  herself  gleamed 
in  her  eyes  and  when  all  was  done,  she  patted  him  af- 
fectionately on  the  cheek  and  said,  "Good  boy,  dar- 
ling." 

"  But,  dearest,"  he  said,  "you  have  lost  the  matinee 
in  consequence,  and  your  new  dress  is  ruined." 

"  What  is  a  mating*  or  a  dress  to  seeing  a  good  oper- 
ation performed  by  a  good  surgeon,  and  that  surgeon  my 
husband?" 


That  woman,  whose  name  may  not  have  been  Harris, 
was  proud  to  possess  her  husband;  she  sought  happiness 
in  b?ing  "  the  wife  of  Dr.  Harris,"  and  did  not  complain 
of  the  world  not  calling  him  "the  husband  of  Mrs. 
Harris." 

Is  it  a  wonder  that  such  a  man  succeeds  ?  He  leaves 
home  with  encouragement  from  her ;  he  hurries  home 
when  tired,  exhausted,  and  in  doubt,  to  get  more  en- 
couragement and  stimulus  for  study  and  work  from  her ; 
she  is  all  and  everything  to  him ;  both  are  happy,  and 
she  consequently  does  not  fly  into  print  to  proclaim  what 
.a  miserably  wretched  creature  she  is — probably  because 
she  fails  to  wreck  her  husband's  career. 

Are  these  lines  too  severe  for  Mrs.  Brooklyn  Doctor's 
Wife?  Perhaps.  But  as  she  is  one  of  very  many  who 
talk  exactly  as  she  writes,  the  reproof  may  not  be  mal- 
apropos. 

Yet  the  morbidity  she  expresses  is  not  her  mult.  In 
reality  she  should  not  be  blamed.  The  real  culprit  is 
her  husband — he  should  not  have  been  such  an  idiot  as 
to  marry  her,  nor,  having  married  her,  so  great  an  ass  as 
to  permit  such  sentiments  to  grow  in  her. 

Ferd.  C.  Valentine,  M.D. 

'Tub  Winchestbh,"  1212-1348  Broadway,  Nhw  Yokic 


"AS  OTHERS  SEE   US." 

To  thb  Editor  of  the  Mbdical  Rkoosd. 

Sir:  Having  read  the  leading  article  entitled  "As 
Others  See  Us,"  in  the  Medical  Record  for  September 
15,  1894,  which  article  treats  on  Dr.  Polaczek's  book, 
"  The  Medical  Science  in  the  United  States,"  I  think  it 
may  interest  your  readers  to  learn  what  another  German, 
Professor  Dr.  M.  Schdller,  of  the  University  of  Berlin, 
who  has  visited  America,  has  said  on  Dr.  Polaczek's  pub- 
lication. He  writes  in  Der  atztliche  Praktikery  No. 
32,  as  follows : 

"  The  book  disappoints  us  in  so  far  as  it  contains  just 
the  least  of  that  which  the  title  promises  to  give.  The 
author  confounds  science  with  practical  medical  arrange- 
ments for  instruction,  with  the  modes  of  providing  for  the 
sick  in  public  hospitals,  with  institutions  of  public  hygiene, 
etc.  A  picture  of  medical  science  in  the  United  States, 
on  account  of  the  part  which  the  Americans  have  taken, 
and  which  is  by  no  means  a  small  one,  in  the  progress  of 
medical  science,  for  instance  in  the  field  of  anatomy, 
surgery,  pharmacology,  and  especially  operative  gyne- 
cology, the  reader  of  the  book  will  look  for  in  vain. 
What  the  author  gives  in  his  book  are  treatises  on  Amer- 
ican hospitals,  on  therapeutic  currents,  on  the  caring  for 
the  insane,  on  the  American  physician,  on  American 
universities,  on  the  sanitary  and  hygienic  conditions  of 
the  large  cities.  We  find  everywhere  the  intention  to 
give  the  German  reader  a  true  picture,  to  do  justice. 
According  to  our  judgment  the  author  has  but  succeeded 
in  the  chapters  on  the  Insane,  on  Quarantine,  on  Sani- 
tary and  Hygienic  Conditions  of  the  Large  Cities,  on  the 
American  Physician.  The  chapters  on  the  American 
Hospitals  and  the  American  Universities  are,  it  is  true, 
quite  correct  in  what  they  give,  but  they  do  not  by  far  ex- 
haust the  subject  treated.  In  regard  to  the  hospitals,  we 
notice  in  America,  as  it  is  quite  natural  in  such  a  large 
continent  with  different  distant  States  and  cities,  and 
therefore  different  climates,  considerable  variety  in  re- 
gard to  architectural  plans  and  inner  organization.  Be- 
sides, some  of  the  arrangements  which  differ  from  those 
in  Germany  are  not  specific  American,  but  originally 
English.  Especially  incomplete,  however,  appears  the 
superfi:ially  written  chapter  on  American  Universities. 
We  cannot  overlook  some  of  those  easily  recognizable 
drawbacks  of  the  specific  American  University  education, 
but  we  should  not  overlook,  either,  the  fact  that  just  at 
present  mighty  exertions  are  made  in  almost  every  State 
to  remedy  the  existing  evils,  and  to  make  the  medical 
instruction  more  profound." 

A.  Rose,  M.D. 

New  York. 


416 


MEDICAL   RECORD. 


[September  29,  1894 


IJfceftical  items. 

Contagious  Diseases  —  Weekly  Statement. — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to  the 
Sanitary  Bureau,  Health  Department,  for  the  week  end- 
ing September  22,  1894. 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis . 

Measles 

Diphtheria 

SmaJl-pox 


Case*. 


Deaths. 


68 

84 

*7 

7 

38 

5 

0 

0 

24 

5 

107 

«5 

5 

3 

The  Anti-tetanic  Serum  and  How  to  Use  it. — In 

the  treatment  of  tetanus  an  anti- tetanic  serum,  obtained 
from  the  horse  and  prepared  in  the  dry  state  and  sent  out 
in  tubes  each  containing  four  to  five  grammes,  is  a  little 
more  than  the  minimum  dose  considered  curative  in  the 
case  of  a  man.  The  substance  is  to  be  dissolved  in  dis- 
tilled water,  and  injected  subcutaneously.  The  dose 
must  vary  according  to  the  gravity  of  the  symptoms,  and 
requires  to  be  repeated  in  smaller  quantity  for  several 
days.  In  regard  to  the  cases  hitherto  reported,  doubt 
has  been  expressed  by  some  as  to  the  severity  of  the  at- 
tack, it  being  well  recognized  that  the  less  acute  forms  of 
tetanus  by  no  means  partake  of  the  gravity  which  attaches 
to  those  of  more  acute  onset.  These  doubts  are,  how- 
ever, in  some  cases  ill-founded,  and  now  that  the  ma- 
terial for  the  treatment  can  be  stored  and  kept  at  hand 
we  ought  quickly  to  accumulate  sufficient  evidence  to  de- 
cide on  its  utility  in  surgical  practice. — British  Medical 
Journal. 

Anarohists,  Anti-vacoinators,  and  Anti-Pastenrists. 

— Anarchists,  anti-vaccinators,  and  and  Pasteurists  ap- 
pear to  be  foregathering  just  now  in  a  friendly  and  in- 
structive fashion.  The  anarchists  have  been  assembling 
at  a  friendly  meeting  at  the  house  of  the  president  of  the 
Anti-  vivisection  League  in  Paris,  and  a  little  outdoor 
gathering,  including  a  quaint  collection  of  "  Anti  V 
generally,  to  protest  against  the  British  Institute  of  Pre- 
ventive Medicine  has  had  its  little  innings  and  is  reported 
in  all  the  papers.  It  is  just  as  well  that  these  wild  people 
should  have  their  silly  say  unanswered  and  without  com- 
ment. But  it  is  rather  painfully  comical  to  find  a  min- 
ister and  a  man  of  Mr.  G.  W.  Russell's  culture  writing 
to  them  to  announce  that  he  detests  Pasteurism — and  of 
course  also  Listerism.  Why  not  add  that  he  has  a  con- 
tempt for  the  equator  and  grave  doubts  about  gravita- 
tion ?  It  reads  oddly  at  this  moment  when  the  whole 
world  has  been  meeting  to  do  honor  at  every  quarter  of 
the  globe  to  its  two  greatest  benefactors — Pasteur  and 
Lister,  and  on  the  day  after  Lord  Salisbury's  eulogy 
urbi  et  orbi  of  the  Listerian  conquests  as  among  the  few 
great  positive  victories  of  modern  science  on  which  he 
could  definitely  congratulate  mankind.  But  oddity  is 
the  badge  of  the  anti- party,  who  delight  in  posing  as 
"against  all  science'1  and  "agin  all  government,"  and 
appear  to  think  that  there  is  something  progressive, 
emancipated,  and  metaphysical  in  this  attitude.  To  be 
logical,  Mr.  Russell  should  add  the  inevitable  converse 
of  his  proposition,  and  declare  that  he  loves  small- pox, 
is  much  attached  to  hydrophobia,  and  adores  blood-poi- 
soning and  high  hospital  mortality.  This  would  put  him 
quite  in  sympathy  with  his  friends,  the  orators  in  the  cart 
to  whom  he  addressed  this  interesting  missive. — British 
Medical  Journal. 

A  Monument  to  Semmelweiss. — During  the  session  of 
the  Congress  of  Hygiene  and  Demography  at  Budapest, 
a  monument  was  unveiled  to  Semmelweiss,  the  precursor 
of  Lister.  As  long  ago  as  1847  he  urged  the  necessity 
of  washing  of  their  hands  in  an  antiseptic  solution  by 
surgeons  prior  to  undertaking  an  operation. 


The  Sterilization  of  Bread.— At  the  meeting  of  the 
British  Medical  Association,  on  August  3d,  the  investi- 
gations of  Mr.  Walsh,  of  London,  and  Dr.  Waldo,  of 
Southwark,  as  to  whether  baking  sterilizes  a  loaf  of  bread, 
were  the  subject  of  an  interesting  discussion.  Mr.  Walsh 
read  a  paper  based  on  a  large  series  of  experiments.  Its 
main  conclusion  was  that  baking  does  not  necessarily 
destroy  the  vitality  of  micro  organisms  contained  in 
dough.  With  regard  to  temperature,  they  had  found 
that  the  average  maximum  temperature  in  the  centre  of  a 
large  loaf  varies  from  163. 40  to  1860  F  ,  and  in  a  small 
loaf  from  186. 8°  to  2030  F.  As  the  heat  increases 
steadily  in  the  centre  of  a  loaf,  any  organisms  present 
are  exposed  for  a  short  time  only  to  the  maximum  tem- 
perature reached.  The  average  microorganism  will 
withstand  a  prolonged  exposure  to  a  much  higher  tem- 
perature without  being  destroyed.  Spores  are  much 
more  resistant  again,  so  that  on  theoretical  grounds 
alone,  having  ascertained  the  maximum  temperatures  in 
the  centre  of  the  loaf  during  baking  to  be  those  men- 
tioned, they  might  venture  to  predict  that  organisms  (or 
their  spores)  would  not  be  destroyed  by  the  process  of 
baking.  By  the  method  of  plate  cultivations  they  suc- 
ceeded in  obtaining  thirteen  different  species  of  micro- 
organisms from  the  centre  of  recently  baked  (a  few  hours 
after  baking)  loaves.  The  latter  were  obtained  from 
bakeries  in  different  parts  of  London,  rich  and  poor. 
Numerous  experiments  were  carried  out  for  them  by  Mr. 
Walter  Severn  on  sixty- two  loaves.  It  was  clearly 
shown,  if  the  results  were  trustworthy,  that  certain  non- 
pathogenic organisms  are  able  to  survive  the  process  of 
baking. 

Some  Carious  Life  Insurance  Details.— According  to 
the  Medical  Press  it  appears  that  in  Germany  a  man 
who  loses  both  his  hands  in  an  accident  can  claim  the 
whole  of  bis  life  insurance  money,  if  he  be  insured,  on 
the  grounds  that  he  has  lost  the  means  of  maintaining 
himself.  The  loss  of  the  right  hand  reduces  the  claim 
to  from  seventy  to  eighty  per  cent,  of  the  total ;  that  oi 
the  left  to  from  sixty  to  seventy  per  cent. ;  the  thumb  is 
valued  at  from  twenty  to  thirty  per  cent. ;  the  right 
index  finger  at  from  fourteen  to  eighteen  per  cent ;  and 
so  the  reduction  continues  until  the  little  finger  is 
reached,  when  the  percentage  is  put  down  at  from  nine 
to  twelve.  No  figures  are  given  as  to  the  value  of  the 
various  segments  of  the  lower  extremities. 

Cramps  in  the  Legs  in  Diabetes.— Unschuld  calls 
attention  to  an  early  symptom  of  diabetes,  which  is 
seldom  mentioned  by  writers  on  the  subject  but  which 
is  yet  frequently  found,  and  may  assist  in  an  early 
diagnosis  of  the  affection.  This  symptom  consists  in 
cramps  in  the  calves  of  the  legs,  and  is  found  in  about 
twenty- six  per  cent,  of  all  cases.  The  pains  occur  with 
especial  frequence  in  the  morning  upon  waking,  and 
occasionally  also  during  the  night,  when  they  are  usually 
accompanied  by  a  desire  to  urinate.  They  are  rarely 
troublesome  in  the  daytime,  unless  after  a  nap  or  a  bath. 
Cramps  of  this  nature,  occurring  in  a  person  in  feeble 
health,  should  always,  Unschuld  holds,  suggest  the  ne- 
cessity of  an  examination  for  sugar. 

The  Confidential  Relations  of  the  Physician. — A 
correspondent,  "  Medicus,"  writes :  "  Your  view  of  the 
decision  of  Judge  Cole  in  your  editorial  of  September 
1st,  is  doubtless  that  of  the  majority  of  the  medical  and 
legal  professions,  but  the  learned  jurist's  action  must  be 
based  upon  the  ruling  of  the  Attorney- General  of  the 
United  States  and  Supreme  Court,  since  the  Naval 
Regulations  require  medical  journals  (containing  as  they 
must  do,  a  record  oi  personal  and  family  secrets  '  pa- 
tient's confidences'  and  'privileged  communications9 
necessary  for  diagnosis  and  for  pension  claims)  to  be 
'  subject  at  any  time  to  the  inspection  of  the  captain 
and  fleet  surgeon.'  This  violation  of  the  spirit  of  the 
Hippocratic  oath  is  not  required  in  the  army  nor  in  the 
Marine  Hospital  Service." 


Medical   Record 

A  Weekly  Journal  of  Medicine  and  Surgery 


Vol.  46,  No.  14. 
Whole  No.  1248. 


New  York,  October  6,  1894. 


$5.00  Per  Annum. 
Single  Copies,  ioc. 


<$rijjitial  Articles. 

THE  TREATMENT  OF  DIPHTHERIA,  WITH  SPE- 
CIAL REFERENCE  TO  THE  EFFICACY  OF 
ANTITOXIN. 

By  ADOLF  BAGINSKY,  M.D., 

A.    O.    PROPS3SOR  OP  PEDIATRICS,    UNIVERSITY  OP  BERLIN. 

In  i 89 i  I  published,  in  the"Archiv  ftlr  Kinderheil- 
kunde,"  a  paper  on  "The  Therapeutics  of  Diphtheria 
from  die  Kaiser  and  Kaiserin  Friedrich  Children's  Hos- 
pital," in  which  I  stated  that  certain  requirements  of  the 
remedy  should  be  formulated :  i.  The  remedy  should 
be  capable  of  destroying  the  diphtheria  bacillus  at  the 
seat  of  infection  without  injuring  the  surrounding  tis- 
sues or  the  body.  2.  The  remedy  should  prevent  the 
formation  of  pseudo-membranes,  which  latter  might 
cause  laryngeal  stenosis  and  asphyxia.  3.  The  remedy 
should  prevent  and  neutralize  the  products  of  the  bacilli 
in  the  blood  and  lymphatic  circulation,  possibly  also  the 
septic  material  in  the  nerves. 

The  therapeutic  measures  consisted  in  applying  local 
treatment  to  the  pharynx,  and  strengthening  nourish- 
ment, with  cardiac  tonics.  Other  remedial  agents,  when 
the  diphtheritic  process  extended  to  the  larynx,  threaten- 
ing laryngeal  stenosis,  were  tracheotomy  and  intubation. 

The  local  remedies  used  were  those  which  had  both  a 
solvent  and  an  antiseptic  effect,  namely :  Acid,  salicylic, 
1-2  to  1,000  for  gargling  and  irrigation  with  the  syringe ; 
acid,  boricum,  3  per  cent. ;  kali  hypermanganic,  3  per 
cent;  iodid.  chlorid.,  1  to  2,000;  auro-natrio-chlorat,  1 
per  cent.,  for  swabbing.  Acidum  lacticum,  10  per  cent., 
for  swabbing ;  2  per  cent,  for  spraying.  Acidum  car- 
bolicum,  alcoholic  solution  of  5  percent.,  for  swabbing; 
2  per  cent,  to  3  per  cent,  for  gargling.  HgClt,  1 
to  3,000,  for  gargling ;  1  to  500  for  swabbing.  Oleum 
cirri  for  spraying;  acid,  acetic,  2  per  cent,  to  3  per 
cent,  for  gargling,  and  5  per  cent,  for  swabbing.  01. 
terebinth,  for  inhalation.  Ichthyol,  2^  per  cent.,  sub- 
limat.,  1  per  cent.,  watery  solution. 

Iod-phenyl  mercurial  preparation  by  a  chemist  (Gold- 
mann)  is  at  present  being  tried.  Ferric  chloride  is 
applied  as  an  ointment  with  pledgets  of  cotton,  and 
mechanical  friction  avoided. 

Of  all  remedies  mentioned  thus  far,  those  containing 
bichloride,  and  after  the  latter  the  3  per  cent,  (alcoholic) 
carbolic  solution  proved  most  efficient.  Boric  acid, 
salicylic  acid,  iod  trichlorid.,  and  auro  natrio  chloratum 
were  absolutely  inefficient  and  useless.  Acetic  acid 
proved  useless.  The  kali  hypermangan.  proved  bene- 
ficial against  the  fetor,  but  negative  in  diphtheria.  The 
ol.  citric,  and  ol.  terebinth,  were  decidedly  inefficient ; 
the  latter  was  used  in  a  steam  spray.  I  am  decidedly  op- 
posed to  the  application  of  load  caustic  treatment,  hav- 
ing always  had  deleterious  results  from  it.  Besides  sol- 
vent remedies  like  lactic  acid,  and  aq.  calcis,  5  per  cent, 
to  10  percent,  solutions  of  papayotin  were  used,  and  were 
applied  with  cotton  swabs ;  this  did  not,  however,  pre- 
vent the  extension  of  the  process  to  the  larynx.  Besides 
the  local  remedies  mentioned,  an  ice-bag  externally  and 
cracked  ice  internally  were  used,  until  the  inflammatory 
infiltration  of  the  pharyngeal  mucous  membrane  had 
disappeared.  Subacute  and  chronic  swellings,  rather 
late  hyperemias  in  the  pharynx,  were  treated  with  a 


tannin  solution,  1  to  80,  with  twenty  parts  of  glycerine 
added. 

In  two  cases  treated  with  submucous  injections  of  3 
per  cent,  carbolic  solution  (Heubner),  injected  in  the 
vicinity  of  the  infiltrated  tonsil,  they  were  decidedly  use- 
less, and  showed  at  post  mortem  hemorrhages  at  the  seat 
of  the  injection.  Among  internal  remedies  sherry,  port 
wine,  champagne,  and  Greek  Alicante  wine  were  used. 
Cognac,  subcutaneous  injections  of  camphor  in  oil,  and 
10  per  cent,  alcoholic  solution  were  also  employed.  In 
mild  cases  1  to  2  per  cent,  kali  chloric,  was  used,  but 
was  always  discontinued,  fearing  nephritic  complications. 
The  same  was  true  of  ol.  terebinth.,  which  most  children 
vomited.  Decoct  china,  10  to  100,  and  added  to  this, 
aq.  chlori.  ten  parts ;  tinct  ferri  chlorati  seth. ;  tinct. 
ferri  pomati;  and  papayotin  wine  were  used  internally. 
Inhalations  of  oxygen  did  at  times  redden  the  lips  and 
mucous  membrane  of  very  sick  children,  but  did  not 
have  any  curative  action. 

To  counteract  the  deleterious  effects  of  heart  failure 
subcutaneous  injections  of  strychnine,  camphor,  and  caf- 
feine were  used.  I  have  recently  discarded  entirely  the 
use  of  strychnine.  The  complications — pneumonia,  pleu- 
ritis,  nephritis— were  treated  in  the  regular  way.  Anti- 
pyretics must  be  very  cautiously  used  in  all  complications 
following  diphtheria;  even  cold  packs  must  be  cautiously 
administered.  Of  244  cases  125  were  cured,  9  were 
transferred,  9  refused  to  be  treated,  5  were  convalescing, 
95  died.  The  mortality  was  40.04  per  cent.  Thirty- 
seven  of  these  cases  were  of  the  severe  gangrenous  septic 
diphtheria,  and  all  died.  Deducting  the  latter,  and  in- 
cluding a  great  number  in  which  tracheotomy  was  per- 
formed, there  remains  a  mortality  of  23.01  per  cent. 

Since  the  time  of  the  German  and  French  authors, 
more  especially  of  the  Koch  school,  things  have  changed 
considerably.  Behring  is  credited  with  giving  us  a  new 
remedy  for  diphtheria.  In  an  elaborate  book  published 
by  Behring  he  details  the  subject,  and  treats  of  it  ex- 
haustively. Behring  uses  the  blood  serum  of  animals 
immune  against  diphtheria  as  a  specific  remedy  for  the 
treatment  of  diphtheria,  or  for  the  prophylaxis  of  cases 
having  been  exposed  to  diphtheritic  infection.  Associ- 
ated with  Behring  have  been  Ehrlich,  Wassermann,  and 
Wernicke,  besides  a  great  many  others.  Hans  Aronson 
has  followed  the  directions  of  Behring,  and  has  made  a 
serum  which  appears  to  be  equally  as  good,  if  not  better, 
than  that  made  by  the  former  gentleman. 

In  the  Kaiser  and  Kaiserin  Friedrich  Hospital  in  Ber- 
lin we  have  used  an  antitoxin  which  was  generously  given 
to  us  by  Aronson.  The  results  obtained  by  the  use  of 
antitoxin  have  been  reported  by  one  of  my  assistant 
physicians,  Dr.  Katz.  From  March  14th  until  July 
25th,  163  cases  of  diphtheria  were  treated,  including 
numerous  malignant  cases.  Of  this  number  only  23 
died,  so  that  the  mortality  was  14-37  per  cent.  This 
excellent  percentage  has  never  yet  been  equalled  with 
our  best  form  of  treatment  even  in  the  mildest  epidem- 
ics. Among  the  fatal  cases  there  were  several  tubercu- 
lous children,  and  several  whose  genuine  diphtheria  was 
complicated  with  scarlet  fever,  so  that  the  mortality  of 
uncomplicated  cases  of  diphtheria  will  be  much  less.  It 
is  difficult  to  say  if  a  nephritis  would  have  appeared  as 
well  without  as  with  the  injections.  The  course  of  ne- 
phritis in  the  cases  treated  with  antitoxin  were  exactly  the 
same  as  otherwise.  Severe  cases  of  nephritis  following 
injections  were  never  noticed;  whereas  several  cases 


4i8 


MEDICAL   RECORD. 


[October  6,  1894 


with  severe  albuminuria  had  wonderful  improvement  fol- 
lowing the  use  of  antitoxin  injections.  The  heart  did  not 
show  any  difference  in  rhythm,  or  in  the  heart-sounds, 
or  in  the  character  of  the  pulse.  On  the  fourth  day  fol- 
lowing an  injection  a  small  abscess  appeared  in  one 
case,  which  was  treated  by  incision,  and  rapidly  healed. 
Child  discharged  cured. 

Several  cases  showed  exanthema  following  an  injec- 
tion, especially  on  the  extremities  and  in  the  region  of 
the  knee-joint.  No  elevation  of  temperature  accompa- 
nied the  exanthema,  nor  was  there  pain.  They  appeared 
like  scarlet  fever,  but  in  small,  confluent  places,  with  no 
temperature  and  rapid  disappearance,  proving  them  to 
be  simple  exanthemata. 

Other  cases  looked  like  measles.  There  was,  how- 
ever, no  desquamation  noticeable.  There  were  four 
typical  cases  of  urticaria  of  the  whole  body.  Katz  no- 
ticed in  a  four  year  old  child  a  distinct  capillary  pulse 
when  the  nettle-rash  appeared.  Constitutional  symp- 
toms were  never  noticed,  and  erysipelas  never  occurred. 
The  membranes  in  the  pharynx  behaved  variously.  In 
some  they  appeared  to  spread,  while  in  others  they 
seemed  to  disappear.  Not  one  single  case  had  laryngeal 
diphtheria  nor  stenosis  after  the  injection.  Those  cases 
with  laryngeal  stenosis  and  croupy  cough  were  admitted 
with  these  symptoms,  and  all  were  treated  either  by 
tracheotomy  or  intubation  soon  after  their  admission. 
In  one  case,  a  child  with  excessive  dyspnoea  (laryngeal) 
was  tracheotomized,  and  recovered.  The  glands  did  not 
seem  to  be  influenced  by  this  treatment.  There  was  no 
specific  action  noticeable  which  could  be  attributed  to 
this  remedy.  Some  cases  appeared  very  bright;  this 
might  have  been  the  case  otherwise. 

The  temperature  showed  nothing  of  interest.  In  two 
children  there  was  a  sudden  rise  followed  by  a  sinking 
to  normal.  In  most  cases  the  temperature  sank  after 
the  injection.  If  the  pulse  was  bad,  the  heart-sounds 
weak,  and  the  rhythm  irregular,  the  remedy  did  not 
seem  to  influence  the  same.  At  times,  absence  of  patel- 
lar reflexes,  processes  of  accommodation,  rhythm  of  the 
heart,  paralysis  of  the  musculi  aducentes,  paresis  of  the 
respiratory  miscles  frequently  appeared.  Dsath  took 
place  in  the  sams  manner  as  in  ordinary  cases.  Among 
the  cases  mentioned  several  died  of  pneumonia,  paraly- 
sis of  the  heart,  and  septicaemia.  Those  that  died  of 
croup  were  so  far  gone  that  we  did  not  expect  to  save 
them;  still,  tracheotomy  was  performed,  and  large  mem- 
branes pulled  out  of  the  bronchial  tubes.  Of  the  septic 
cases  three  were  admitted  moribund,  and  a  fourth  case 
was  in  a  typical  state  of  septic  diphtheritis.  Pneumonia 
cases  that  died  were  of  the  severest  kind.  Improvement 
appeared  so  freqiently  during  its  course  that  at  times 
thsre  was  good  hope.  In  those  children  (brothers  and 
sisters)  where  at  times  the  disease  was  treated  within  the 
first  few  days,  the  mortality  was  less  than  10  per  cent. 
In  former  timjs  the  mortality  among  children  where 
tracheotomy  was  performed  was  much  greater ;  whereas 
formerly  from  22  per  cent  to  24  per  cent,  were  cured, 
since  using  the  antitoxin  on  severest  cases  34. 30  per 
cent,  were  cu^ed.  It  was  difficult  to  ascertain  the  cause 
of  the  disease.  Twenty-five  cases  which  had  been  exposed 
to  diphtheria  were  carefully  examined  a  number  of  days, 
and  all  developed  diphtheria.  As  they  were  examined 
daily,  they  were  attended  when  the  first  symptom  ap- 
peared. Not  one  of  these  developed  nephritis  nor  car- 
diac trouble.  Their  sisters  and  brothers,  who  had  been 
previously  admitted  to  the  hospital,  some  as  severe  cases, 
died.     All  twenty-five  cases  were  discharged  cured. 

Dr.  Aronson  gave  us  a  mild  solution  of  his  remedy, 
which  was  used  in  seventy  two  cases  for  immunity.  Of 
all  these  cases  but  eight  took  sick  very  mildly  and  re- 
covered easily.  We  learned  that  much  larger  doses  were 
necessary  to  produce  immunity  in  children.  Not  one 
case  relapsed  nor  showed  a  single  symptom.  It  will 
therefore  appear  that  we  have  been  using  a  remedy  which 
deserves  further  trial.  If,  therefore,  the  remedy  will 
give  even  more  beneficial  results  than  heretofore,  then 


we  have  in  the  blood  serum  therapeutics  inaugurated  by 
Behring  one  of  the  greatest  triumphs  in  the  annals  of 
medicine.  

DIPHTHERIA  ANTITOXIN  OR  HEALING  SE- 
RUM IN  THE  TREATMENT  OF  DIPHTHERIA. 

By  LOUIS  FISCHER,  M.D., 

MSW  YORK. 

1NSTSUCTOX  IN  DI5BASB8  OF  CHILDREN  AT  THS  NEW  YOKK  POST-GKADUATS 
MBDICAL  SCHOOL  AND  HOSPITAL;  PHYSICIAN  TO  THE  CHILOBBN'S  DEPART- 
MENT OP  GBRMAtt  POUKLIMK,  PHYSICI  U*  TO  THE  MESSIAH  HOME  FOE  CHIL* 
DXKH,  ETC 

While  in  Berlin  a  month  ago,  Professor  Baginsky  gave 
me  every  possible  opportunity  for  acquainting  myself 
with  the  new  antitoxin  treatment  for  diphtheria.  The 
clinical  experience  seen  abroad  is  my  reason  for  detailing 
the  method  for  use  in  both  hospital  and  private  practice 

It  will  be  proper  to  state  that  at  present  two  kinds  of 
"serum"  are  being  used.  They  vary  only  in  strength 
and  are  made  by  rival  firms. 

The  one  firm  sells  it  under  the  name  of  "  Behring- 
Ehrlich  Heilserum,"  the  other  is  "  Aronson  Heilserum." 

As  I  saw  but  a  limited  number  of  cases  of  diphtheria  at 
the  Institut  fiir  Infektions  Krankheiten  (Koch),  by 
courtesy  of  Dr.  Wassermann,  I  will  confine  jnyself  more 
particularly  to  the  consideration  of  Aronson's  serum, 
with  which  my  experience  is  more  extended. 

This  serum  is  a  clear,  colorless  liquid  of  thick  consist- 
ence, quite  sticky,  and  has  a  slight  carbolic  odor.  In 
order  to  preserve  it,  it  is  mixed  with  0.2  per  cent 
tricresol,  as  some  of  the  organic  material  might  otherwise 
decompose. 

Two  objects  are  sought  for  in  using  antitoxin:  1. 
Immunity  during  an  epidemic,  or  where  a  person  has 
been  exposed  to  diphtheria.  2.  Healing  after  the 
disease  exists. 

In  giving  antitoxin  it  has  been  customary  not  to 
neglect  the  other  usual  forms  of  treatment,  and  it  will  be 
interesting,  I  hope,  to  detail  a  typical  case. 

The  place  for  injecting  the  antitoxin  is  behind  and  be- 
tween the  shoulder  blades  and  also  the  connective- tissue  of 
the  arm  and  the  thigh.  Gentle  massage  at  a  slight  dis- 
tance from  the  point  of  injection  is  done  to  diffuse  the 
injection ;  but  this  is  not  absolutely  necessary. 

Of  almost  two  hundred  cases  treated  in  the  Kaiser  and 
Kaiserin  Friedrich  Hospital  but  one  abscess  appeared, 
which  was  incised  and  healed  promptly.  No  reaction 
followed  injections. 

It  will  be  remembered  that  when  Koch's  tuberculin 
was  injected,  fever,  chills,  diaphoresis,  etc.,  were  noticed, 
which  made  a  typical  and  distinct  reaction  as  the  result 
of  the  injection.  These  phenomena  were  evidently  the 
natural  consequences  of  a  septic  material  thrown  into  the 
circulation,  as  was  demonstrated  by  Dr.  Shrady  and 
others  who  used  the  lymph  in  New  York. 

When  antitoxin  is  injected,  however,  there  is  no  re- 
action. The  quantity  used  varies  according  to  the  sever- 
ity of  the  symptoms,  the  gravity  of  the  epidemic,  and  the 
age  and  vitality  of  the  patient.  In  some  cases  one  injec- 
tion suffices,  whereas  in  others  a  second  injection  on  the 
succeeding  day  may  be  required.  The  usual  dose  is  5 
to  10  cc,  hypodermically.  At  times  20  c.c.  is  ad- 
ministered when  a  very  rare  epidemic  exists. 

The  instrument  used  is  an  ordinary  hypodermic 
syringe  with  asbestos  fitting,  which  can  be  sterilized  in  a 
Bunsen  burner,  or  the  Koch's  syringe  is  used  in  some 
hospitals  abroad. 

Exanthemata,  the  rash  of  scarlatina  or  measles,  re- 
sembling typical  urticaria,  sometimes  appeared  following 
injections,  but  without  an  evolution  of  temperature. 
These  eruptions  last  several  days  and  then  disappear 
without  special  treatment. 

Malignant  cases  of  diphtheria  are  greatly  improved 
and  frequently  recovered;  quite  frequently  even  cases 
with  laryngeal  stenosis  recover  rapidly,  and  in  which 
tracheotomy  was  even  performed. 

Professor  Baginsky,  who  has  prepared  a  special  paper 


October  6,  1894] 


MEDICAL  RECORD. 


419 


for  the  Medical  Record,  will  give  a  detailed  account  of 
the  use  of  antitoxin,  by  Dr.  Katz,  under  his  directions. 
All  of  his  assistant  physicians,  notably  Dr.  Lewin,  in  the 
diphtheria  pavilion,  gave  me  detailed  accounts  of  their 
cases,  which  are  virtually  the  same  as  Professor  Baginsky 
has  reported.  Complications  were  rarely  noticed,  and 
symptoms  of  cardiac  weakness  directly  attributable  to  the 
antitoxin  were  not  observed. 

The  immunity  conveyed  by  an  injection  of  antitoxin 
lasts  about  three  or  four  months,  after  which  it  will  be 
wise  to  repeat  the  injection. 

Dr.  Hans  Aronson  told  me  that  the  serum  made  by 
Schering's  factory  is  much  stronger  than  Behring's,  and 
expressed  it  by  saying  that  his  serum  of  400  Einheiten 
was  equivalent  to  800  of  some  specimens  obtained  by  him. 

It  is  the  aim  of  Aronson  to  produce  a  serum  much 
more  concentrated  than  the  one  in  use  at  present,  for  he 
informed  me  that  5  gm.  of  the  present  serum  was  as 
strong  as  one  litre  or  500  gm.  of  what  was  previously 
made  in  the  beginning  of  the  manufacture  of  this  remedy. 

The  following  case  is  the  first  one  in  which  I  have  had 
occasion  to  use  antitoxin  in  private  practice. 

DoraT ,  aged  eleven,  a  healthy,  well-nourished 

girl,  had  been  ill  about  one  day.  On  the  same  floor  of 
this  tenement-house,  in  an  adjoining  room,  a  boy,  aged 
fifteen,  was  sick  with  diphtheria,  being  attended  by  Dr. 
Schmid.  My  patient  was  exposed,  and  her  cautious 
mother  examined  her  throat  and  discovered  some 
patches.  When  I  first  saw  her  I  found  the  temperature 
in  the  axilla  io2-|°  F.  There  was  intense  thirst,  general 
pains  in  the  body,  marked  malaise,  dysphagia,  and  a 
headache.  Pseudo-membranes  covered  both  right  and 
left  tonsils  and  the  posterior  pharyngeal  wall.  I  ordered 
a  placebo,  and  returned  with  Dr.  Gerlach,  at  present  a 
physician  at  the  New  York  Post-Graduate  Medical  School. 

I  first  made  a  culture  from  the  throat,  the  report 
proved  Klebs  Loeffler  bacilli,  verifying  the  clinical  diag- 
nosis. I  then  injected  5  c.c.  of  serum  with  a  small 
hypodermic  syringe,  at  which  injection  quite  some 
serum  was  wasted.  I  then  took  a  better  syringe,  and 
having  sterilized  the  point  in  an  alcohol  lamp,  injected 
5  c.c.  of  Aronson's  serum  in  the  back  by  pinching  a 
fold  of  skin  between  the  shoulder-blades.  No  reaction 
followed.  The  next  day  my  little  patient  was  greatly 
improved  in  both  subjective  and  objective  symptoms. 
Greenish-yellow  pseudo  membranes  remained  about  two 
days  following  the  injection,  and  on  the  third  day  no 
trace  of  membranes  were  visible,  although  the  pharynx 
and  tonsils  were  still  inflamed.  On  the  fourth  day  no 
sign  of  the  disease  remained,  and  the  little  girl  was  up  and 
seemed  to  be  quite  hungry.  The  general  malaise  seemed 
to  pass  off  about  one  day  after  the  injection.  This  is 
near  the  sixth  day  and  the  membranes  have  entirely  dis- 
appeared. The  child  eats  and  sleeps  well  and  is  appa- 
rently in  perfect  health. 

This  little  patient  was  attacked  much  more  severely 
than  the  first  child  that  infected  her.  My  patient  eats 
and  sleeps  well,  and  is  apparently  very  bright.  A  careful 
examination  of  the  urine  was  made.  Albumin  sparingly 
and  an  excess  of  phosphates  were  present.  The  trace  of 
albumin  also  disappeared.  No  reaction  followed  the  in- 
jection of  antitoxin. 

In  the  same  family  one  other  child  has  received  2 
c.c.  of  serum  as  a  prophylactic.  m  I  am  anxious  to  see 
if  she  will  be  infected  or  remain  immune. 

In  some  severe  cases  much  larger  doses  may  and 
should  be  used,  for  Aronson  told  me  in  Berlin  that  he 
frequently  injected  50  c.c.  at  one  injection,  and  this 
may  even  be  repeated  on  the  following  day,  although 
the  usual  dose  injected  was  10  c.c. 

This  will  convey  a  general  idea  of  how  this  remedy 
may  be  employed,  and  if  we  can  rely  on  statistics,  then 
we  have  in  antitoxin  not  only  a  positive  remedy  in 
diphtheria,  but  the  beginning  of  a  new  form  of  treatment 
which  will  eventually  save  the  lives  of  thousands  of 
patients. 

187  Second  Avbnub. 


SURGICAL  PROBLEMS  IN  INTRA-PELVIC  AND 
ABDOMINAL  DISEASES. 

By  A.  H.  CORDIER,  M.D., 

KANSAS  CITY,   MO. 

Some  time  ago,  while  doing  special  work  in  a  large 
Eastern  city,  I  had  many  opportunities  to  see  the  work 
of  the  various  operators,  and  it  was  a  noticeable  fact 
that,  while  one  operator  would  have  a  mixture  of  the 
worst  neglected  and  complicated  cases  imaginable,  in- 
cluding old  adherent  and  caseous  Fallopian  tubes  and 
ovaries  in  emaciated  and  septic  patients,  another  opera- 
tor's cases  would  be  confined  to  the  removal  of  cystomas 
and  plastic  vaginal  and  cervical  cases.  This  led  me  to 
inquire  of  one  of  the  operators  why  he  did  not  have  so 
many  "  pus  cases  "  as  some  of  his  confieres.  He  replied 
that  he  believed  that  "  the  woods  are  not  full  of  them/' 
as  some  would  have  us  believe.  A  few  days  later  I 
visited  this  same  gentleman's  clinic,  which  is  a  large 
one,  and  in  two  hours  I  found  six  pairs  of  old,  seques- 
trated Fallopian  tubes  full  of  pus,  carried  around  by  six 
of  the  most  careworn  and  miserable-looking  women 
imaginable.  They  had  their  vaults  frescoed  with 
Churchill,  and  were  directed  to  return  for  another  dec- 
oration the  following  week. 

Conservatism  is  a  grand  principle,  but  unfortunately, 
in  the  hands  of  skilful  men  the  application  of  this  rule 
is  only  too  frequently  responsible  for  destructive  or  com- 
plicative delays,  if  I  may  use  such  a  term.  Conservatism 
is  a  prophylactic  if  early  and  intelligently  carried  out  or 
applied.  It  is  equally  injurious,  if  used  with  this  same 
idea  in  view,  in  cases  where  time  and  experience  have 
demonstrated  its  futility. 

Occasionally  an  article  appears  in  some  of  the  many 
valuable  medical  journals  of  our  country  entitled  "A 
Plea  for  Conservatism,"  or  the  like.  That  these  articles 
are  well  worded  by  conscientious  practitioners  in  most 
instances  no  one  will  doubt,  and  to  one  unaccustomed 
to  seeing  the  true  pathology  from  a  practical  stand- point, 
they  carry  with  them  weighty  evidence  that,  with  rare 
exceptions,  all  surgical  procedures  for  the  relief  or  cure 
of  the  same,  are  unnecessary  and  unwarrantable.  But  to 
him  who  has  handled  these  cases  surgically,  and  under- 
stands their  progress,  the  position  of  the  so-called  con- 
servative is  not  well  taken.  Many  are  attempting  to  do 
this  class  of  surgery  (pelvic)  who  have  not  the  anatomi- 
cal or  pathological  knowledge  or  practical  experience  to 
enable  them  to  make  a  diagnosis  between  an  operable  or 
non-operable  case.  To  this  class  sermons  on  qualifica- 
tions and  attainments  should  take  the  precedence  of 
lectures  on  operative  conservatism. 

Good  missionary  work  is  being  done  in  this  field  by 
educating  the  general  practitioner  and  the  specialist  that 
they  should  go  hand  in  hand  in  their  work.  By  friendly 
discussions  and  exchange  of  views  on  topics  of  vital  im- 
port to  both,  the  patients  reap  the  benefit  of  the  com- 
bined council. 

We  have  men  of  renown  in  this  country  as  operators 
and  authors,  whose  utterances  along  the  line  of  so-called 
conservatism  are  producing  much  mischief  and  causing 
many  deaths  by  the  adoption  of  these  false  doctrines  by 
lesser  lights.  After  seeing  much  of  the  work  of  some  of 
these  men  I  am  surprised  to  see  some  of  their  ideas  in 
print  so  foreign  to  the  practice  actually  pursued  by  them 
in  their  work.  One  is  almost  tempted  to  doubt  the 
sincerity  of  some  of  their  utterances. 

We  should  advise  against  the  removal  of  sound  organs, 
but  at  the  same  time  endeavor  to  impress  upon  our  asso- 
ciates the  necessity  for  early  surgical  work  where  experi- 
ence with  like  cases  has  demonstrated  the  futility  of  any 
other  course. 

Operations  for  the  removal  of  diseased  appendages  are 
not  followed  by  the  same  amount  of  reflex  disturbance 
as  are  those  cases  where  sound  organs  are  removed  to 
cure  (?)  a  globus  hystericus,  or  the  like — an  unwarrant- 
able procedure.  Most  women  with  suppurating  diseased 
tubes  and  ovaries  are  unsexed  by  the  pathology,  and  lm 


420 


MEDICAL   RECORD, 


[October  6,  1894 


have  had  women  with  these  diseases  at  an  age  too  early 
for  a  normal  menopause  to  present  all  the  climacteric 
•phenomena.  In  many  cases  it  is  not  a  question  of 
"Will  this  woman  have  an  exaggeration  of  the  meno- 
pause phenomena  if  we  operate?1'  so  much  as  "Will 
she  be  free  from  pain  aftei  the  operation,  and  can  she 
recover  without  the  aid  of  surgery?  "  These  questions 
have  been  answered  many  times,  both  by  non  interfer- 
ence in  the  cases,  with  failures,  and  by  demonstrations 
at  the  operating-table — the  successes.  Women  whose 
appendages  are  diseased  to  such  an  extent  as  to  require 
removal  are  sick  women,  and  are  necessarily  in  that  low 
vital  state  that  where  there  is  an  inherent  tendency  to 
insanity  or  neurasthenia  the  surgical  procedure  for  the 
removal  of  the  diseased  structures  may  precipitate  the 
m?ntal  phenomena  to  an  exaggerated  and  disagreeable 
degree.  , 

If  we  are  not  to  remove  life-endangering  and  comfort- 
breaking  pathological  processes  when  found,  pray  tell 
us  what  are  we  to  do?  Fold  our  hands  and  let  nature 
(pathology)  take  its  course?  Or  do  worse,  visit  these 
cases  with  poultices,  Churchill,  and  hypodermics  ?  We 
can  illy  afford,  as  true  surgeons,  to  cater  to  the  plea  that 
the  poor  sufferer  will  be  robbed  of  her  womanly  traits ; 
that  she  will  be  despondent,  lose  her  sexual  desires,  suffer 
from  flushes  and  flatulence,  and  that  her  husband  (too 
often  responsible  for  the  wife's  sufferings)  will  become 
dissatisfied  with  the  post  operative  condition  of  his  wife. 
I  have  never  seen  a  woman  suffering  with  diseased  ap- 
pendages where  the  disease  was  of  sufficient  severity  to 
require  removal  of  the  organs,  who  was  not  a  sexually 
useless  and  despondent  wife,  and  a  sick  woman  as  well. 
Sound  organs  should  not  be  removed.  Any  condition 
that  may  be  induced  by  the  surgical  procedure  may  like- 
wise be  induced  by  the  continuance  of  the  disease  re- 
quiring the  surgery. 

I  believe  the  sexual  system  is  located  elsewhere  than 
in  the  tubes  and  ovaries.  The  nymphomaniac  manifests 
not  only  an  increased  sexual  desire,  but  a  loss  of  self- 
control,  often  with  hallucinations  and  delusions,  the 
whole  cycle  having  its  origin  in  the  cerebrum. , 

Radicalism  is  a  dangerous  expression  to  use  ;  equally 
harmful  is  the  term  conservatism  applied  to  a  disease  the 
tendency  of  which  is  to  destroy  function,  make  life 
miserable,  or  produce  death  if  too  long  a  delay  of  a 
proper  procedure  for  its  cure  is  permitted. 

Many  cases  early  in  the  history  of  the  malady  are 
permanently  cured  by  intelligent  and  skilled  surgery. 
The  same  case,  if  allowed  to  run  an  uninterrupted  course 
for  any  length  of  time,  may  assume  proportions  or  char- 
acters of  some  magnitude  or  danger  that  to  attempt  to 
relieve  the  same  would  not  only  be  fraught  with  danger 
from  the  operation,  but  the  crippled  surrounding  organs 
would  preclude  the  possibility  of  a  complete  restoration 
to  health. 

These  are  cases  that  bring  disappointment  to  the  pa- 
tients and  friends,  as  well  as  to  the  sanguine  physician 
and  surgeon,  run  up  the  mortality,  and  give  surgery  a 
bad  name. 

It  is  the  early  removal  of  diseased  structures,  the  his- 
tory of  which  is  to  continue  a  downward  course,  that 
gives  us  a  nil  mortality,  the  patient  renewed  health,  and 
the  family  physician  increased  confidence  in  the  justifi- 
ability of  the  operative  procedure. 

Early  operations  are  not  only  curative  measures,  but 
prophylactic  methods  as  well.  It  is  not  only  the  diseased 
and  worse  than  useless  organs  and  structures  the  true 
abdominal  surgeon  is  removing,  but  he  is  liberating 
sound  imprisoned  organs,  the  function  of  which  is  essen- 
tial to  life.  This  is  not  only  life-saving  work,  but  a 
comfort-giving  procedure.  No  true  surgeon  is  clamor- 
ing for  a  thousand  or  ten  thousand  laparotomies,  but  is 
ever  pleading  for  timely  needed  work — is  ever  pleading 
for  the  recognition  of  the  necessity  for  quick  surgery  in 
cases  where  surgery,  at  some  time  in  the  history  of  the 
malady,  becomes  necessary. 

No  one  at  this  time  would  think  of  advising  a  woman 


to  wait  until  the  growth  was  so  large  or  her  physical 
condition  such  that  she  could  not  walk  a  mile,  before 
having  the  tumor  removed,  as  was  done  a  few  years 
ago,  by  a  great  writer.  This  would  be  dangerous  con- 
servatism. 

It  is  as  absurd  to  call  the  removal  of  a  sequestrated 
Fallopian  tube  and  ovary  a  mutilation,  as  it  is  to  call  an 
amputation  of  a  hopelessly  injured  leg  a  mutilation. 
These  operations  are  performed  to  fulfil  strictly  surgical 
indications — saving  life  and  relieving  suffering.  It  is  a 
daily  occurrence  to  see  reported  that  a  case  diagnosed  as 
appendicitis  has  recovered.  That  this  is  true  no  one  will 
doubt.  Many  cases  reported  as  recovered  have  since 
died  from  recurrence  of  the  disease,  and  many  an  appen- 
dix, supposed  by  the  medical  attendant  to  be  dangling 
healthfully  in  the  peritoneum  of  his  patient,  is  saturated 
with  Miiller's  fluid  or  alcohol,  in  a  specimen  jar,  while 
the  patient  has  long  since  died  from  a  perforation,  or  has 
been  saved  by  good,  timely  surgery.  No  operation  in 
surgery  has  a  higher  mortality  than  that  of  the  delayed 
operations  for  the  removal  of  a  diseased  vermiform  ap- 
pendix, but  if  done  early  the  procedure  has  an  almost  nil 
mortality.  A  late  writer  reports  twelve  cases  treated  on 
the  expectant  plan  with  two  deaths  (sixteen  per  cent, 
mortality),  and  two  cases  with  recurrent  attacks  (six- 
teen per  cent,  of  recurrences).  The  writer  says  of  the 
two  who  died  that  they  were  almost  in  articulo  mortis 
when  first  seen  by  him.  He  does  not  tell  us  whether  he 
put  on  a  fresh  poultice  and  hid  from  view  the  big  ab- 
scess bulging  in  the  right  iliac  fossa,  or  gave  the  patient 
an  extra  dose  of  opium  to  relieve  the  pain  of  the  sufferer 
and  obtund  the  senses  of  the  doctor.  These  cases  should 
have  been  seen  by  a  good  surgeon  who  would  have 
stopped  all  opiates  and  let  out  the  pus,  applying  the 
same  surgical  principles  to  this  locality  as  to  other  parts 
of  the  body:  "When  you  find  pus,  let  it  out."  Ap- 
pendicitis is  a  surgical  disease,  and  the  surgeon  should 
see  the  case  with  the  physician  as  soon  as  the  diagnosis 
of  appendicitis  is  made.  Let  the  physician  and  the  sur- 
geon watch  the  case  together. 

The  modern  application  of  the  principles  of  surgery  as 
applied  to  diseased  Fallopian  tubes  is  the  same  that  has 
been  practised  for  ages  as  applied  to  the  surface  of  the 
body.  A  felon  is  lanced,  the  earlier  the  better.  The 
good  surgeon  does  not  advise  delay,  and  while  waiting 
paint  the  finger  with  Churchill  or  apply  hot  irrigation. 
As  soon  as  evidences  are  present  that  pus  is  forming  he 
lets  it  out. 

How  thankful  the  abdominal  surgeon  would  be  could 
he  lift  up  a  pus-filled  Fallopian  tube  without  entering  the 
peritoneum,  "  rip  it  up  the  back  M  (as  suggested  by  a  late 
writer),  scrape  it  out,  destroy  all  the  remaining  epithe- 
lium, and  by  redressing  it  restore  its  calibre  so  that  the 
spermatozoa  may  throng  its  canal  and  pregnancy  take 
place,  just  as  though  this  culture  tube  had  not  been  a 
hot-bed  for  gonococci  and  other  pathogenic  bacteria  for 
months  previous. 

All  cases  of  salpingitis  are  not  operable  cases,  but  the 
majority  of  cases  seen  by  the  specialist  are  old  purulent 
cases  with  tubes  filled  with  pus  and  caseous  dibris  strict- 
ured  in  one  or  more  places,  uterine  and  abdominal  ostia 
closed.  Here  it  is  conservatism  to  remove  these  danger- 
ous sequestra. 

Hardly  a  week  passes  without  seeing  one  or  more  cases 
of  far  advanced  cancer  of  the  cervix  uteri  extending  into 
the  broad  ligaments,  bladder,  or  rectum.  These  are  in- 
operable cases  when  so  far  advanced.  Again  I  see  cases 
where  a  diagnosis  of  a  cauliflower  growth  has  been 
made,  which  proves  to  be  a  badly  lacerated  cervix,  with 
the  resulting  local  mischief  attending  an  unhealed  tear  in 
this  locality.  Surgical  diseases  should  be  attended  by  the 
surgeon  in  conjunction  with  the  regular  medical  attend- 
ant. The  time  to  operate,  if  necessary  at  all,  could  then 
be  arrived  at  mutually  and  timely. 

When  the  masses  are  educated  in  every  sense,  when 
gonorrhoea  is  stamped  from  the  face  of  the  globe, 
when  the  perniciousness  of  criminally  induced  abortions 


October  6,  1894] 


MEDICAL    RECORD. 


421 


and  the  dangers  of  the  indiscriminate  use  of  the  sound 
are  understood,  then  there  will  be  less  necessity  for  the 
practitioner  to  hurl  at  the  specialist  his  "  bucket  or  bar- 
rel of  ovaries;"  then  the  specialist  will  cease  his  cry 
against  needless  tinkering  and  dangerous  procrastination ; 
then  our  women  will  have  their  babies  at  full  term,  in 
the  good  old  way.  Until  this  goal  is  reached,  the  use  of 
the  knife  will  be  found  necessary  in  properly  selected 
cases  to  relieve  the  suffering  and  save  the  lives  of  these 
unfortunate  women  with  diseases,  the  result  of  the  above- 
mentioned  causes. 

A  STUDY  OF  THE  MEDICAL  ASPECT  OF  FOUR 
RECENT  CASES  OF  ACUTE  APPENDICITIS.1 

By  JOHN  L.  IIEFJPRON,  M.D., 

PROFESSOR  OF  THERAPEUTICS  AMD  CLINICAL  MEDICINE,   COLLEGE  OF  MEDICINE, 
SYRACUSE  UNIVERSITY. 

Mr.  President,  and  Members  of  the  Onondaga 
County  Medical  Society  :  As  a  preliminary  to  the 
study  of  the  salient  features  in  the  four  recent  cases  of 
appendicitis  which  it  is  proposed  to  discuss  to-day, 
it  will  be  necessary  to  give,  briefly,  the  history  of 
each  case,  from  its  inception  to  the  time  when  surgical 
treatment  was  resorted  to. 

Case  I. — Mr.  G.  K ,  aged  thirty-nine,  a  Ger- 
man, of  sturdy  build,  weighing  about  two  hundred 
pounds.  He  worked  all  day  July  25,  1893,  at  his  trade, 
stone-cutter,  doing  heavy  work.  He  had  a  diarrhoea,  at- 
tributed to  indiscreet  eating,  of  which  he  made  no  com- 
plaint until  he  returned  from  his  work  in  the  evening. 
His  diarrhoea  continued  during  the  night,  with  occasional 
vomiting  and  colicky  pains. 

In  the  morning,  not  being  relieved,  he  sent  for  me.  I 
found  the  patient  in  bed,  and  an  examination  showed,  in 
addition  to  the  above  symptoms,  that  the  pain,  which 
had  at  first  been  indefinite  in  location,  had  become 
limited  to  the  right  iliac  region,  though  it  radiated,  in 
paroxysms,  from  this  point  upward  and  inward  toward 
the  umbilicus,  but  was  never  intense. 

Palpation  revealed  slight  tenderness,  most  marked  over 
McBurney's  point,  but  also  extending  to  a  considerable 
area  in  every  direction. 

Percussion  indicated  an  area  of  diminished  resonance 
in  the  right  iliac  fossa. 

His  pulse  was  70,  of  fair  strength  and  volume,  and 
his  temperature  was  normal.  A  tentative  diagnosis  of 
appendicitis  was  made,  and  he  was  given  an  opiate  and 
saloL 

At  the  evening  visit  it  was  found  that  he  had  had  a 
severe  chill,  lasting  several  minutes,  which  was  followed 
by  an  increase  in  the  pulse-rate  and  fever,  with  sweat- 
ing. At  this  visit  his  pulse  was  90,  and  his  temperature 
was  ioo°  F.  He  had  vomited  twice  during  the  day;  his 
bowels  had  moved  several  times,  and  the  pain  was  more 
intense,  though  not  constant,  land  the  tenderness  was 
increased.  There  was  some  tympanitis,  so  a  saline  was 
added  to  the  treatment.  .  The  family  were  apprised  of 
the  serious  nature  of  the  disease,  and  were  told  if  no 
decided  improvement  was  manifested  by  morning,  surgi- 
cal measures  must  be  resorted  to. 

July  27th. — Patient  was  seen  about  10.30  a.m.  He 
had  passed  a  fairly  comfortable  night ;  his  bowels  had 
moved  early  in  the  morning,  the  stool  being  a  watery 
discharge  of  very  foul  odor,  but  containing  scarcely  any 
fecal  matter.  His  pulse  was  100,  and  of  diminished 
strength  and  volume ;  his  temperature  was  1020  F. 
There  was  a  little  increase  in  tympanites,  the  abdomen 
being  quite  soft,  but  the  pain  was  more  marked,  and 
the  tenderness  was  much  greater,  and  most  exquisite  over 
McBurney's  point. 

The  opiate  treatment  was  continued,  and  the  family 
notified  that  I  would  bring  a  surgeon  at  the  earliest  pos- 
sible moment  in  the  afternoon. 

At  4.30  p.m.  Dr.  Jacobson  saw  the  case  with  me.  At 
this  time  the  temperature  had  fallen  to  1010  F.,  but  the 

1  Read  before  the  Onondaga  County  Medical  Society,  May  8,  1894. 


pulse  had  increased  to  116,  and  was  irritable.  The  local 
symptoms  were  aggravated,  both  pain  and  tenderness 
having  increased  since  morning,  and  the  abdomen  was 
somewhat  distended.  It  was  agreed  that  the  only  hope 
was  in  an  immediate  operation,  which  was  at  once  ac- 
ceded to,  and  prepared  for,  and  accomplished  by  six 
o'clock — forty- eight  hours  from  the  time  he  had  com- 
plained of  any  abdominal  trouble,  and  thirty  hours 
after  there  had  been  any  elevation  of  temperature  or  in- 
crease of  pulse  rate. 

A  general  septic  peritonitis  and  a  gangrenous  appen- 
dix were  disclosed,  the  details  of  which  will  be  given  by 
the  operator.  Death  followed  about  twenty  hours  after 
this  operation. 

Case  II. — R.  H.  L ,  fifteen  years  of  age,  a  student 

in  Colgate  Academy,  Hamilton,  N.  Y.,  having  a  good 
family  history  and  no  previous  abdominal  trouble.  He, 
with  his  society  fellows,  participated  in  a  "  peanut  bum," 
on  Saturday  night,  March  17,  1894,  consuming  peanuts, 
bananas,  and  soda-water,  as  only  a  fifteen-year  old  boy 
can.  All  went  merry  until  Tuesday  night,  March  20th, 
when  he  was  attacked  with  severe  diarrhoea  and  vomiting, 
keeping  him  busy  all  the  early  hours  of  March  21st.  On 
that  day  a  physician  was  called,  and  placed  him  under 
treatment,  evidently  wavering  in  his  diagnosis  between  a 
possible  typhoid  fever,  which  was  endemic  in  the  neigh- 
borhood of  his  boarding-house,  and  appendicitis.  His 
temperature  was  1010  F.,  and  his  pulse  correspondingly 
rapid ;  he  had  considerable  pain  and  tenderness  in  the 
right  iliac  region,  which  was  somewhat  masked  by  a 
strain  of  the  abdominal  muscles,  received  in  practice  on 
the  base- ball  field.  He  was  up  and  around  during  the  day, 
however,  and  partook  of  the  usual  supper  served  to 
healthy  boys. 

March  2  2d. — The  pain  was  considerably  diminished,  as 
well  as  the  tenderness,  and  the  diarrhoea  and  vomiting 
had  ceased,  but  his  temperature  and  pulse  remained 
slightly  above  the  normal. 

March  23d. — He  was  in  about  the  same  condition, 
and  was  advised  by  his  physicians  to  return  home.  In- 
formation was  sent  me  that  he  was  probably  coming 
down  with  typhoid  fever,  a  fear  which  was  quite  reason- 
able. At  n  p.m.  he  came  into  my  office,  having  walked 
from  the  Central  Depot  with  his  father,  who  had  met 
him  at  the  train.  After  securing  the  above  history 
an  examination  was  made :  The  pulse  was  100 ;  temper- 
ature, 101^°  F.  Complained  very  little  of  either  pain 
or  tenderness ;  abdomen  flat  and  soft ;  palpation  dis- 
closed a  point  of  considerable  tenderness  at  McBurney's 
point,  and  a  tumor  was  distinctly  made  out  in  this  loca- 
tion, about  the  size  and  shape  of  a  butternut.  There 
was  dulness  over  the  descending  colon,  as' well  as  over 
the  tumor.  Thinking  there  were  more  peanuts — though 
being  positive  in  a  diagnosis  of  appendicitis — a  mercu- 
rial was  prescribed.  As  the  patient  was  suffering  from 
acute  bronchial  catarrh,  a  sedative  was  also  given. 

March  24th. — Patient  had  a  good  night.  Pulse,  100 ; 
temperature,  ioo°  F.;  had  three  movements  of  the  bow- 
els ;  is  very  hungry,  but  is  allowed  no  solid  food.  Local 
symptoms  unchanged.  A  daily  improvement  in  every 
symptom  was  recorded  until 

March  28th. — At  this  visit  his  pulse  was  92 ;  tempera- 
ture, 1020  F.  No  complaint  of  abdominal  symptoms 
from  patient,  but  examination  reveals  an  increased  area 
of  dulness,  not  particularly  tender,  and  tumefaction  in 
right  iliac  fossa  evident  to  the  eye ;  abdomen  elsewhere 
flat  and  not  tympanitic ;  bowels  have  not  moved  in  two 
days.  Closer  questioning  gives  the  added  information 
that  the  patient  had  a  "weak  spell  "  during  the  after- 
noon, followed  by  free  sweating.  Arrangements  were 
immediately  made  for  consultation  with  a  surgeon. 

March  29th. — Dr.  Jacobson  saw  the  patient  with  me 
at  8.30  a.m.  At  that  time  his  pulse  was  90 ;  tempera- 
ture, 99jV°  F.  He  had  passed  a  pretty  good  night; 
tumefaction  more  noticeable  even  than  yesterday,  and 
the  tumor  distinct  and  larger.  It  was  agreed  that  an 
immediate   operation    was  imperative.      Arrangements 


422 


MEDICAL    RECORD. 


[October  6,  1894 


were  accordingly  made  and  abdominal  section  was  done 
at  3  p.m,  the  tenth  day  after  onset  of  symptoms.  The 
appendix  was  gangrenous  throughout  its  entire  length, 
and  was  embedded  in  a  large  blood-clot,  under  which 
were  about  two  ounces  of  foul  pus.  The  patient  made 
an  uninterrupted  recovery  and  is  now  about  the  house. 

Case  III.— P.  W.  G ,  aged  thirty-one,   Scotch- 

man  by  birth;  tall  and  slim.  Of  good  family  and 
personal  history.  Went  to  Toronto,  Canada.  March 
28,  1894,  at  3  p.m.  was  attacked  with  cramps  in  the 
bowels,  and  with  vomiting,  but  no  diarrhoea,  which  he 
attributed  to  the  drinking-water.  He  returned  to  Syra- 
cuse by  the  earliest  train,  and  called  me  the  following 
evening. 

In  addition  to  the  above  history,  an  examination  re- 
vealed considerable  fulness  of  the  abdomen ;  no  tumor 
or  tumefaction,  but  distinct  tenderness  at  McBurney's 
point.  His  pulse  was  100,  and  his  temperature  ioi^° 
F.  His  bowels  had  not  moved  in  two  days  so  he  was 
given  sulphate  of  magnesia  and  carbonate  of  magnesia,  in 
moderate  doses,  in  peppermint-water  every  hour  until 
his  bowels  moved  freely,  and  Tully  powder  sufficient  to 
control  excess  of  pain. 

March  30th. — Pulse,  92 ;  temperature,  99^°  F. ; 
bowels  had  moved  three  times ;  abdomen  flat,  and  no  pain 
except  on  motion.  Tenderness  is  marked,  and  dulness 
in  the  right  iliac  fossa  was  detected,  but  no  distinct  tu- 
mor. At  10  p.m.  Dr.  Jacobson  was  called  in  consulta- 
tion. Pulse,  84;  temperature,  1010  F.;  symptoms  un- 
changed, but,  in  addition  to  slight  dulness,  could  detect 
slight  tumor  in  the  region  of  the  appendix.'  It  was 
agreed  to  continue  conservative  treatment,  but  to  be  ready 
for  operation  at  any  moment. 

March  31st. — Pulse,  82  ;  temperature,  990  F.,  in  the 
morning,  and  pulse,  80 ;  temperature,  9&&0  F.,  in  the 
evening,  with  improvement  of  all  the  symptoms. 

April  1st. — Pulse,  72;  temperature,  98TV°  F.  No 
pain,  little  tenderness,  but  tumor  distinct. 

April  2d. — Pulse,  70 ;  temperature,  990  F.  All  symp- 
toms favorable. 

April  3d. — Pulse,  80;  temperature,  1010  F.  Bowels 
moved  twice,  and  had  twinges  of  pain  previous  to  each 
movement.     Tumor  somewhat  increased. 

April  4th. — Pulse,  90;  temperature,  ioo^°  F.;  res- 
piration, 22.  Considerable  pain  during  the  night;  tu- 
mor increased  in  size,  and  tumefaction  evident  on  exten- 
sion of  right  leg.  Dr.  Jacobson  was  called  and  an 
operation  agreed  upon,  which  was  performed  at  3  p.m. 
A  post-csecal  gangrenous  appendix,  surrounded  by  about 
an  ounce  of  vile  pus,  was  removed;  and  the  patient  is 
now  convalescent. 

Case  IV.— W.  B ,  aged  twenty-five,  English  by 

birth ;  an  engraver.  Was  seized  with  pain  in  the  stom- 
ach and  vomiting  late  in  the  evening  of  April  24th.  The 
pain  persisting  and  the  vomiting,  bilious  in  character, 
continuing,  he  sent  for  medical  aid  in  the  afternoon,  and 
was  seen  by  Dr.  Jacobson  at  3  30  p.m.  Examination 
showed  that  his  pulse  was  105  ;  temperature,  ioi^6  F.; 
abdomen  dull  on  both  sides  over  a  great  portion  of  the 
area  below  the  umbilicus;  sensitive  at  various  points, 
and  most  tender  to  pressure  about  an  inch  below  McBur- 
ney's point;  tongue,  dry  in  centre  and  brown;  pains 
paroxysmal.  Salol,  phenacetin,  and  pepsin  were  pre- 
scribed. At  11  p.m.  patient  was  seen  again;  he  had 
had  no  severe  pain  since  afternoon  visit  and  had  not 
vomited;  pulse,  90;  temperature,  ioo°  F.;  tongue  more 
moist ;  abdomen  softer ;  dulness  limited  to  caecum ; 
marked  tenderness  on  pressure  in  right  iliac  fossa.  He 
was  prescribed,  hourly,  fifteen  grains  of  sulphate  of  magne- 
sia and  five  grains  of  carbonate  of  magnesia. 

April  26th. — Patient  had  rested  so  well  that  he  had 
little  medicine ;  pulse,  72  ;  temperature,  98^°  F.;  ab 
domen  a  little  more  tympanitic ;  tongue  moist,  slightly 
furred;  no  changes  in  dulness;  diminished  tenderness. 
Saline  mixtures  to  be  continued.  At  6.30  p.m.,  pulse, 
80 ;  temperature,  99^°  F.  Patient  had  vomited  once 
during  the  day ;  local  symptoms  and  signs  unchanged ; 


bowels  not  having  responded  to  salines,  enema  was  ad- 
vised. 

April  27th. — Passed  a  comfortable  night;  vomited 
once  on  getting  up  to  help  himself  to  milk ;  bowels  had 
moved  very  freely;  tongue  a  little  dry ;  puke,  80;  tem- 
perature, 99tV°  f->  local  symptoms  unchanged.  At 
10.30  p.m.  I  saw  the  patient  in  consultation  with  Dr. 
Jacobson.  Pulse,  72;  temperature,  99^°  F.;  abdomen 
flat  and  soft ;  dulness  in  limited  area  in  right  iliac  fossa 
below  the  line  from  the  umbilicus  to  the  anterior  superior 
spinous  process,  and  tenderness  confined  to  this  area. 
As  his  general  symptoms  had  improved  since  an  earlier 
evening  visit,  and  the  local  symptoms  had  not  progressed, 
it  was  agreed  to  send  the  patient  to  the  hospital  early  in 
the  following  morning  and  meet  there  in  consultation, 
prepared  for  operation,  if  indicated. 

April  29th,  8.30  a.m. — Patient  was  seen  in  St  Joseph's 
Hospital.  He  had  passed  a  restless  night,  but  without 
severe  pain ;  area  of  dulness  was  increased  very  slightly, 
and  degree  of  tenderness  was  heightened ;  pulse,  6S ; 
temperature,  100^°  F.  Because  of  the  increase  in  local 
manifestations  it  was  agreed  that  the  operation  should 
be  done  at  once.  An  intensely  congested,  mahogany- 
colored  appendix  and  mesentery  of  unusual  development, 
with  points  of  degeneration,  evidently  on  the  rapid  road 
to  complete  tissue-death,  were  removed;  and  this  pa- 
tient is  now  on  a  fair  way  to  recovery. 

Four  cases  are  very  few  from  which  to  make  deduc- 
tions of  absolute  value,  but  when  they  are  fair  representa- 
tives of  all  forms  of  acute  septic  appendicitis  which  have 
come  under  our  observation  in  the  past,  the  total  number 
of  which  is  considerable,  they  are  worthy  of  considera- 
tion. 

The  physician  is  the  person  who,  ordinarily,  is  first 
called  to  see  the  patient  suffering  from  appendicitis.  The 
existence  of  bellyache  is  not  commonly  associated  with 
the  thought  of  the  surgeon  and  his  knife  in  the  mind  of 
the  average  man.  Accordingly,  an  ability  to  make  an 
early  diagnosis  and  to  appreciate  the  relative  value  of  the 
symptoms  and  physical  signs  is,  for  the  physician,  of  the 
utmost  importance ;  but  of  still  greater  importance  is  the 
ability  not  only  to  determine  the  proper  medical  aid  to 
be  extended,  but  to  decide  when  surgical  interference  is 
to  be  invoked. 

Let  us  first  consider  the  early  symptoms  presented  in 
these  cases.  They  were  abdominal  pain  and  tenderness, 
vomiting,  diarrhoea  or  constipation,  fever,  and  an  accel- 
erated pulse. 

The  abdominal  pain  was  the  initial  symptom  in  each 
case.  It  preceded  the  vomiting,  the  diarrhoea,  and  the 
consciousness  of  tenderness,  and  the  fever  and  the  in- 
crease of  pulse-rate  followed  in  its  train.  It  was  not 
distinctly  localized  at  first  in  any  case,  but  in  from  twelve 
to  twenty-four  hours  it  was  distinctly  felt  by  the  patient 
to  be  most  intense  in  the  right  iliac  region,  and,  when 
paroxysmal,  to  radiate  thence.  The  pain  varies  in  char- 
acter. It  may  be  paroxysmal  and  intense,  suggesting 
colic ;  or  it  may  be  dull  and  constant.  In  either  case  it 
was  always  exaggerated  by  motion  and  by  pressure,  so  that 
the  patient  assumed  a  position  protecting  the  affected  parts 
to  the  greatest  possible  extent.  In  walking,  he  bends 
forward;  in  bed,  he  is  easiest  lying  on  the  right  side 
with  his  knees  drawn  up.-  Pain  is  a  common  symptom 
of  all  abdominal  disturbances ;  but  pain,  at  first  vaguely 
defined,  but  soon  distinctly  localized  in  the  region  of 
the  appendix  and  increased  by  motion,  is  of  itself  almost 
pathognomonic,  and  could  exist  in  acute  diseases  in  only  a 
very  few  other  pathological  conditions,  which  fortunately 
have  distinctive  symptoms  of  their  own,  like  invagina- 
tion, volvulus,  and  stercoral  typhlitis. 

Tenderness  always  accompanies  pain.  There  may  be 
several  sensitive  places  in  the  abdomen,  as  observed  in 
one  of  these  cases,  but  careful  palpation,  with  a  single 
finger-tip,  will  locate  the  point  of  greatest  tenderness 
exactly  over  the  origin  of  the  appendix.  McBurney  has 
rendered  us  the  greatest  service  in  giving  us  an  exact 
point  at  which  the  appendix  originates  in  all  normal 


October  6,  1894] 


MEDICAL   RECORD. 


423 


8,  a  point  one  and  a  half  to  two  inches  from  the  an- 
terior superior  spinous  process  of  the  ilium,  on  a  line 
drawn  from  it  to  the  umbilicus.  In  the  fourth  case  re- 
ported, the  point  of  most  exquisite  tenderness  was 
located  nearly  an  inch  below  this  line,  but  the  short, 
thick,  inflamed  appendix  was  disengaged  from  exactly 
the  region  diagnosed.  In  my  experience  this  is  the 
only  instance  of  displacement  of  the  appendix,  even  to 
so  slight  an  extent ;  but  there  are  many  cases  recorded 
where  the  appendix  has  occupied  an  unusual  position,  as 
under  the  right  lobe  of  the  liver  and  even  in  the  left  iliac 
fossa. 

Dr.  Edebohls,  at  the  last  meeting  of  the  New  York 
State  Medical  Society,  read  a  paper  demonstrating  the 
possibility  of  palpating  the  appendix,  in  every  case  where 
the  abdominal  wall  is  not  too  thick,  by  deep  pressure 
from  above  with  counter  pressure  from  the  posterior  wall 
of  the  abdomen,  in  a  line  from  the  umbilicus  to  the  spine 
of  the  ilium.  I  do  not  question  but  that  a  practised 
observer  could  attain  such  precision,  but  in  cases  of 
acute  appendicitis  the  procedure  is  unwarrantable,  except 
in  the  very  inception  of  the  disease,  as  the  force  neces- 
sary to  compress  the  abdominal  tissues  against  the  pos- 
terior abdominal  wall  would  be  sufficient  to  rupture  a 
degenerated  appendix. 

Vomiting  was  a  symptom  present  in  each  of  the  cases. 
Of  itself  it  is  a  symptom  of  little  value ;  but,  in  connec- 
tion with  those  already  mentioned,  aids  in  the  formation 
of  a  diagnosis.  The  vomiting  in  all  the  cases  which  I 
have  seen  has  been  most  severe  in  those  following  gross 
indiscretion  at  the  table.  It  has  seemed  to  me  possible, 
that  just  as  vomiting  mechanically  empties  the  stomach 
and  the  liver,  and  even  the  trachea  and  large  bronchi,  so 
it  might  mechanically  force  some  of  the  contents  of  the 
cecum  into  the  appendix  and  thus  originate  conditions 
of  overdistention,  giving  rise  to  strangulation  and  in- 
flammation of  this  organ,  particularly  where  colonies  of 
bacilli  coli  communis,  virulently  active  in  fermenting  in- 
testinal contents,  were  forced  through  the  so-called  valve 
of  the  appendix.  But  I  do  not  know  that  any  such 
origin  of  appendicitis  has  been  demonstrated  or  sug- 
gested. 

In  two  of  our  cases  diarrhqpa  was  marked,  and  in  these 
two  there  was  a  distinct  history  of  most  indiscreet  inges- 
tion of  a  large  amount  of  food  difficult  of  digestion.  My 
other  cases  bear  out  this  observation.  In  two,  constipa- 
tion was  marked,  so  that  neither  diarrhoea  nor  constipa- 
tion can  be  considered  as  diagnostic  of  this  disease. 
Either  condition  seems  to  depend  on  other  factors  than 
the  existence  of  an  inflamed  appendix. 

Fever  was  not  an  initial  symptom  in  any  of  these* 
cases,  though  it  developed  in  each  case  sooner  or  later, 
and  was,  in  none  of  them,  a  symptom  upon  which  reli- 
ance could  be  placed,  either  for  early  diagnosis  or  for 
prognosis.  In  the  first  case,  where  septic  peritonitis  had 
developed  within  twenty-four  hours,  the  temperature  was 
lower  on  the  day  of  the  operation  than  on  the  day  be- 
fore. 

In  the  fourth  case,  the  temperature  and  the  pulse  were 
both  near  the  normal  at  the  time  of  the  operation  and  had 
not  been  high  at  any  period.  In  both  of  these  cases 
there  was  no  attempt  at  walling  off  the  seat  of  the  inflam- 
matory action  from  the  rest  of  the  abdomen.  In  the 
second  and  third  cases  the  temperature,  at  first  elevated, 
returned  to  the  normal  with  the  amelioration  of  the 
primary  symptoms,  and  became  gradually  elevated  with 
the  development  of  the  tumor.  In  both  of  these  cases 
an  abscess  cavity  was  established,  more  or  less  perfectly, 
protecting  the  adjacent  tissues  from  infection.  With  the 
establishment  of  septic  peritonitis,  in  the  first  case,  the 
pulse  became  more  rapid  and  of  wretched  character,  and 
at  the  same  time  the  temperature  fell ;  a  similar  phe- 
nomenon has  been  observed  in  four  other  cases  of  ful- 
minating appendicitis  with  very  rapid  general  infection 
that  have  come  under  my  notice. 

For  a  primary  diagnosis  I  regard  the  pulse  and  the 
temperature  as  of  very  little  importance.     On  the  other 


hand,  the  increased  puke  rate  and  the  elevation  of  tem- 
perature attending  the  development  of  the  tumor,  seem 
to  indicate  the  formation  of  a  perityphlitic  abscess;  and 
a  greatly  increased  pulse*  rate,  with  lessened  volume  and1 
strength,  and  with  a  falling  temperature,  is  suggestive  of 
general  septic  infection. 

To  sum  up :  Right-sided  abdominal  pain,  increased  by 
motion  and  by  pressure,  with  tenderness  on  point  press- 
ure most  exquisite  over  the  origin  of  the  appendix,  with 
vomiting,  and  some  disturbance  of  the  circulation  and 
temperature,  coming  on  suddenly  in  a  person  previously 
healthy,  are  sufficient  to  establish  a  diagnosis  of  acute 
appendicitis. 

The  discussion  of  the  prognosis  and  the  indication  for 
surgical  treatment  I  shall  leave  to  my  collaborator. 

It  remains  for  the  physician  to  say  when  the  surgeon 
shall  be  called  in  consultation.  To  this,  the  only  an- 
swer must  be,  so  soon  as  a  diagnosis  is  made.  I  know 
of  no  absolute  signs  that  unequivocally  indicate  the 
moment  when  medical  aid  is  of  no  further  utility,  and 
when,  to  save  the  life  of  the  patient,  surgery  must  te 
resorted  to.  The  surgeon  should  be  associated  with  the 
physician  from  the  outset,  and  should  share  with  him  the 
responsibility  of  the  cage,  and  to  his  experience  and 
judgment  must  be  referred  the  question  of  the  ne- 
cessity of  any  operation  and  the  time  when  it  should  be 
made. 

Concerning  the  medical  treatment,  little  need  te 
said.  Locally,  cold  alone  is  appropriate  in  the  begin- 
ning, and  is  best  applied  by  the  coil.  If  tumor  is  form- 
ing and  is  slow  in  development,  heat  may  be  of  utility 
in  hastening  the  process.  This  was  exhibited  in  the 
second  case,  seen  four  days  after  its  inception,  and  op- 
erated on  the  tenth  day. 

Internally,  opium  is,  in  my  opinion,  by  far  the  most 
appropriate  in  all  cases  where  it  agrees ;  and  no  fears  of 
"  masking  the  symptoms,"  as  some  surgeons  put  it, 
should  be  entertained.  This  drug  gives  physiological 
rest;  and,  more  than  that,  it  controls  the  inflammatory 
process,  actually  diminishing  the  calibre  of  the  arterioles 
of  the  mesentery  and  peritoneum  better  than  any  other 
drug  yet  used. 

If  the  colon  be  filled  with  fecal  matter,  a  mild  saline, 
just  sufficient  to  remove  this  cause  of  embarrassment,  is 
appropriate,  and  for  the  purpose  I  know  of  no  prescrip- 
tion superior  to  the  one  used  in  our  cases,  namely,  fifteen 
grains  of  sulphate  of  magnesia,  with  five  grains  of  the  car- 
bonate of  magnesia,  in  half  an  ounce  of  peppermint- 
water  every  hour  until  the  desired  result  is  obtained. 
This  mixture  is  well  borne  by  the  stomach,  and  is  effi- 
cient after  a  few  doses.  The  diminution  of  the  abdom- 
inal contents,  from  the  emptying  of  the  gut  of  fecal  mat- 
ter and  of  gas,  was  most  marked  in  the  cases  where  it  had 
been  used,  and,  at  the  time  of  the  operation,  the  free- 
dom from  interference  of  inflated  intestines  much  facili- 
tated the  operation. 

If  general  peritonitis  develop,  possibly  the  saline  treat- 
ment alone  is  more  scientific ;  but  of  this  I  confess  I  am 
not  yet  thoroughly  convinced.  In  such  an  event  I  have 
yet  to  see  a  case  which  has  recovered  from  either  medi- 
cal or  surgical  treatment,  however  skilfully  it  may  have 
been  applied. 

Salol  is  of  great  value,  as  in  so  many  intestinal  dis- 
eases, by  its  efficiency  in  controlling  fermentative  pro- 
cesses in  the  intestinal  canal. 

The  diet  should  be  entirely  restricted  to  fluids ;  and, 
so  long  as  vomiting  continues,  nothing  but  barley-water 
or  oatmeal-water  or  ice-water  should  be  permitted. 
With  the  amelioration  of  the  primary  s)  mptoms  diluted 
milk,  with  a  tablcspoonful  of  lime-water  to  each  glass, 
may  be  allowed. 

If  these  cases,  as  well  as  all  the  others  I  have  seen, 
teach  anything,  it  is  that  an  early  diagnosis,  the  timely 
association  of  a  surgeon  in  the  management  of  the  case, 
and  the  harmonious  working  together  of  the  physician 
and  surgeon  will  save  many  valuable  lives  that  otherwise 
might  be  lost  to  the  world. 


424 


MEDICAL   RECORD. 


[October  6.  1894 


FOUR  RECENT  CASES  OF  ACUTE  APPENDICI- 
TIS, CONSIDERED  FROM  THEIR  SURGICAL 
ASPECT. 

By  NATHAN  JACOBSON,  M.D., 

SYRACUSE,  N.  Y. 

FROFESSOB  OP  CLINICAL  SURGERY,   COLLEGE    OF    MEDICINE,  SYRACUSE    UNIVER- 
SITY; SURGEON  TO  ST.  JOSEPH'S  HOSFITAL. 

Before  entering  upon  a  consideration  of  the  surgical 
questions  in  the  cases  under  discussion,  permit  me  to 
complete  their  records  as  given  by  Dr.  Heffron. 

Case  I. — G.  K ,  seen  at  4.30  p.m.,  July  27,  1893. 

Although  the  temperature  had  fallen  since  the  morning 
from  102. 50  to  ioi°  F.,  the  increase  in  the  pulse-rate  from 
100  to  116,  and  the  marked  aggravation  of  local  signs 
indicated  rapid  progress  of  the  inflammatory  process.  It 
was  therefore  decided  to  operate  at  once.  The  prepara- 
tion was  hastily  made.  Despite  anaesthesia  the  patient 
strained  constantly  throughout  the  operation.  His  chest 
was  more  or  less  filled  with  mucus,  and  respiration  in 
consequence  impeded. 

A  straight  incision  along  the  dextral  border  of  the  rec- 
tus muscle  was  made,  about  three  inches  in  length.  Im- 
mediately upon  incising  the  peritoneum  there  was  a 
profuse  discharge  of  sero  pus.  Upon  the  deeply  injected 
intestines,  at  various  points,  inflammatory  deposits  were 
present.  As  soon  as  the  peritoneal  discharge  was  re- 
moved, the  appendix  was  sought  for  and  easily  found. 
Readily  separated  from  its  slender  adhesions,  it  was  seen 
to  be  angry,  swollen,  and  perforated,  and  so  gangrenous 
that  in  the  attempt  to  seize  and  draw  it  up  the  forceps 
broke  off  its  end.  Liquid  faeces  exuded  from  its  perfora- 
tions. It  was  cut  off  close  to  the  caecum,  the  stump  cau- 
terized with  pure  carbolic  acid,  and  the  presenting  sur- 
faces irrigated  with  a  saline  solution.  A  glass  drainage- 
tube  was  carried  down  to  the  stump,  and  about  it  iodoform 
gauze  was  introduced,  and  the  ordinary  surgical  jdressing 
applied. 

At  midnight  the  patient  was  seen  again.  His  tempera- 
ture had  gone  to  102. 8°  F.  ;  the  pulse  was  so  feeble  that 
it  could  hardly  be  counted.  A  great  amount  of  bron- 
chial secretion  was  present.  The  lips  were  blue,  the 
extremities  cold  and  discolored,  respirations  were  frequent. 
The  surface  dressings  were  badly  stained  and  therefore 
changed,  and  strychnia,  digitalin,Jand  nitro  glycerine  ad- 
ministered hypodermically. 

At  nine  o'clock  in  the  morning  the  patient  was  found  to 
be  bright,  and  reported  himself  as  feeling  materially  bet- 
ter. His  pulse,  however,  was  not  improved ;  tempera- 
ture, io4°F.;  lessened  bronchial  secretion  permitted  freer 
breathing,  the  abdomen  was  distended,  tongue  dry,  urine 
had  not  been  voided.  From  this  hour  the  patient  stead- 
ily failed,  the  pulse  soon  became  imperceptible,  the  patient 
collapsed,  and  death  resulted  at  1.30  p.m. 

Dr.  May  made  a  bacteriological  examination  of  the 
appendix  and  reported  that  it  presented  a  pure  culture  of 
the  bacillus  coli  communis. 

Case  II. — R .  H.  L .     Seen  on  the  tenth  day  of  his 

attack  at  9  a.m.,  March  29, 1894,  temperature  was  99. 50  F., 
pulse,  90.  The  local  manifestations  were  entirely  out  of 
proportion  to  the  mildness  of  the  constitutional  one. 
The  right  leg  and  thigh  were  flexed.  Upon  extending 
the  extremity  the  right  side  of  the  abdomen  became  im- 
mediately prominent.  An  area  of  dulness  present  in  the 
right  iliac  fossa,  reached  within  one*  half  of  the  median 
line.  A  localized  tumor  was  evident ;  fluctuation  could 
be  made  out.  Diagnosis  of  appendicicular  abscess  was 
made,  and  operation  advised. 

At  3  p.m.  an  oblique  incision  was  made  over  the  outer 
border  of  the  tumor,  that  is,  about  an  inch  from  the  brim 
of  the  pelvis,  its  centre  opposite  the  anterior  superior  spi- 
nous process.  The  peritoneum  when  reached  was  found  to 
be  tense.  Upon  incising  the  tumor,  pus  and  blood  were 
discharged.  The  abscess  cavity  was  thoroughly  walled  off. 
It  was  occupied  by  an  infectious  thrombus,  in  the  centre 
of  which  was  the  gangrenous  appendix,  collapsed  and  in 
a  state  of  sphacelus.     The  slightest  effort  to  remove  the 


blood-clot  awakened  profuse  bleeding.  The  cavity  was 
therefore  irrigated  with  a  hot  normal  saline  solution  and 
packed  with  iodoform  gauze.  Throughout  the  operation 
the  patient,  who  was  suffering  from  an  acute  bronchial 
catarrh,  took  ether  so  wretchedly  that  the  anaesthesia 
gave  us  more  trouble  than  did  the  operation. 

Just  before  the  operation  the  temperature  was  taken,  and 
was  found  to  be  101.50  F.  It  steadily  fell  to  normal,  at 
which  point  it  was  found  at  10  p.m.  On  the  following 
day  there  was  a  slight  rise  to  100. 20  F.,  but  after  this  it  re- 
mained substantially  normal.  On  the  second  day  after 
operation,  the  dressing  being  removed  from  the  abscess 
cavity,  it  was  irrigated  with  a  sublimate  solution  of  1  to 
8,000.  The  blood-clot  was  easily  washed  away  and 
no  further  bleeding  occurred.  The  dead  portion  of  the 
appendix  separated  spontaneously.  April  1st  its  stump 
could  be  seen  already  covered  by  granulations.  The  en- 
tire abscess  cavity  cleansed  itself,  and  five  days  after  the 
operation  presented  nothing  but  a  healthy  granulating 
surface.  Iodoform  gauze  was  carried  gently  to  the  bot- 
tom, protecting  the  stump  of  the  appendix,  but  firmly 
packed  at  the  surface  in  order  to  distend  the  opening. 
Within' a  short  time  the  wound  was  thus  rendered  funnel- 
shaped.  The  cavity  granulated  rapidly  from  the  bottom. 
May  1st,  it  being  entirely  healed,  an  abdominal  supporter 
was  applied  and  the  patient  allowed  to  be  up  and  about. 

Case  III.— P.  W.  G .    At  the  visit,  made  late  in  the 

evening  of  March  30,  1894,  the  third  day  of  his  sickness, 
an  examination  revealed  the  presence  of  a  large  area  of 
dulness  in  the  right  iliac  fossa,  describing  a  quarter  of  a 
circle,  with  a  radius  of  at  least  three  inches.  Within  this 
tumefied  area  we  were  able  to  recognize  as  more  distinct 
a  tumor  located  opposite  the  anterior  superior  spinous 
process.  There  had  been  improvement  in  pulse,  facial 
expression,  and  general  condition,  although  the  tempera- 
ture was  not  reduced.  With  this  condition  we  felt  justi- 
fied in  deferring  the  operation  for  the  night.  Dr.  Hef- 
fron reported  the  improvement  in  local  and  general 
manifestations  on  the  following  day  to  be  so  decided  that  it 
seemed  possible  that  the  patient  might  recover  without 
operation.  I  did  not  see  him  again  until  10.30  a.m., 
April  4th,  the  eighth  day  of  his  sickness.  The  tumefac- 
tion had  in  the  meantime  entirely  disappeared,  and  a  dis- 
tinct tumor,  two  inches  in  length  and  one  and  one-half  in 
width,  was  present  opposite  the  anterior  superior  spinous 
process.  It  reached  externally  to  the  brim  of  the  pelvis. 
Temperature,  1010  F. ;  pulse,  80.  Operation  was  acceded 
to,  and  as  soon  as  preparations  could  be  completed  was 
undertaken.  An  oblique  incision  four  inches  in  length 
.was  made  about  three-quarters  of  an  inch  from  the  bnm 
of  the  pelvis,  well  toward  the  outer  border  of  the  tumor. 
Upon  carrying  the  incision  downward,  despite  its  extreme 
dextral  location,  I  entered  the  free  peritoneal  cavity. 
The  following  condition  was  found :  A  loop  of  small  in- 
testine adherent  to  the  caecum  was  directly  under  the 
incision,  both  large  and  small  intestines  were  of  normal 
appearance,  the  tumor  lay  posterior  to  the  caecum  and 
well  against  the  outer  border  of  the  pelvis. 

Protected  by  firm  adhesions  at  this  point  from  the  gen- 
eral peritoneal  cavity,  it  was  apparent  that  it  would  be 
both  difficult  and  hazardous  to  enter  the  abscess  cavity 
through  the  abdominal  route.  The  incision  into  the 
peritoneum  was  therefore  closed  and  the  transversalis  fas- 
cia sutured  over  it  Through  the  same  surface  incision 
I  now  dissected  closely  to  the  brim  of  the  pelvis,  until  I 
reached  a  point  deep  enough  to  feel  the  tumor  behind  the 
caecum.  In  doing  this,  at  the  upper  angle  of  the  incision, 
the  omentum  came  into  view.  Surrounding  the  abscess 
cavity  with  gauze  pads  I  incised  it.  It  contained  offen- 
sive pus,  and  a  long,  cord-like,  gangrenous  appendix.  The 
pus  was  carefully  mopped  out.  At  the  lower  angle  the 
abdominal  cavity  was  likewise  entered  and  protected  by 
gauze  pads.  Everything  being  thoroughly  cleansed  with  a 
1  to  1,000  sublimate  solution,  the  appendix  was  tied  off 
as  close  to  its  base  as  possible.  Here  it  was  surrounded 
by  a  firm  exudate.  Iodoform  gauze,  carefully  folded  to 
prevent  any  ravelling,  was  first  carried  down  to  the  bot- 


October  6,  1894] 


MEDICAL  RECORD. 


425 


torn  of  the  wound  to  protect  the  intestines  below,  and 
then  above  against  the  omentum.  Finally  the  cavity 
proper  was  filled.  The  usual  surgical  dressing  was  ap- 
plied. 

Temperature  before  operation,  101.80  F.,  at  10  p.m. 
98. 8°  F. ;  pulse  75.  The  following  morning,  temperature 
990  F. ;  pulse,  75 ;  no  vomiting  had  occurred.  Catheteri- 
zation was  necessary  the  first  night,  but  not  again.  The 
dressings  were  not  removed  until  the  end  of  the  third  day, 
at  which  time  it  was  found  that  protective  adhesions  existed 
on  all  sides.  The  odor,  however,  was  very  strong.  The 
skin,  for  an  area  of  two  inches,  was  found  reddened  and 
infiltrated,  and  upon  lifting  up  the  inner  flap  the  muscular 
tissues  as  well  as  the  aponeuroses,  infected  by  the  dis- 
charge, had  become  gangrenous.  For  the  following  four 
days  care  was  required  in  dressing  the  wound.  All  gan- 
grenous structures  were  thoroughly  removed,  sublimate 
solution,  1  to  1,000,  was  carefully  rubbed  into  every  nook 
and  corner,  and  in  {this  manner  by  April  12th  all  dead 
structures  had  been  cleared  away  and  the  entire  wound 
surfaces  presented  healthy  granulations.  From  this 
period  the  patient  progressed  rapidly  to  a  complete  re- 
covery. 

Case  IV. — W.  B .    During  the  first  twenty  hours  of 

his  sickness  he  received  no  medical  attention.  At  my 
first  visit,  pain,  vomiting,  fever,  but  without  characteris- 
tic local  manifestations,  were  present.  In  the  course  of 
seven  hours  marked  improvement  in  the  general  symp- 
toms occurred.  Tenderness  at  a  fixed  point  in  the  right 
iliac  fossa  appeared  and  continued.  The  fecal  collection 
in  the  caecum  was  cleared  away  by  the  exhibition  of  sa- 
lines. The  morning  visit,  on  April  2  7  th,  disclosed  the  fol- 
lowing condition :  Temperature,  99  20  F.;  pulse,  80;  he 
had  passed  a  comfortable  night ;  the  tenderness  remained 
undecreased  ;  there  was  no  dulness.  By  evening,  how- 
ever, the  patient,  having  passed  the  entire  day  comforta- 
bly, sleeping  most  of  the  time,  exhibited  a  temperature 
of  100. 6°  F.,  and  for  the  first  time  there  was  an  area  of  dul- 
ness lying  a  little  higher  than  the  point  of  tenderness,  not 
well  defined  but  readily  recognized.  The  disease  was 
evidently  progressing.  Dr.  Heffron  saw  him  soon  after 
with  me  and  confirmed  the  diagnosis,  but  agreed  that 
operation  could  be  deferred  until  morning.  He  was 
taken  to  St.  Joseph's  Hospital  at  8  a.m.,  April  28,  1894. 
His  pulse  was  68,  firm  and  regular ;  temperature,  100. 20  F. ; 
tongue  was  moist,  area  of  dulness  increased  and  now 
about  two  inches  in  length  and  one  in  width.  He  was 
prepared  for  operation. 

An  oblique  incision  was  made  four  inches  in  length 
and  one  inch  from  the  anterior  superior  spinous  process. 
Upon  opening  the  peritoneal  cavity,  there  was  no  dis 
charge  of  serum  or  pus ;  the  caecum  was  readily  recognized, 
drawn  inward,  and  the  presenting  abdominal  structures 
were  covered  by  gauze  pads  wrung  out  of  a  sublimate  so- 
lution. The  finger  recognized  the  appendix,  which  upon 
being  lifted  out  was  found  to  be  deep  purple  in  color, 
greatly  infiltrated,  with  an  equally  thick  mesentery  ad- 
herent to  it,  throughout  its  entire  length.  Its  free  ex- 
tremity was  on  the  point  of  gangrene ;  upon  the  mesen- 
tery, beginning  ulceration  was  evident.  The  entire  mass 
was  about  two  inches  in  length  and  one  and  one- half  in 
its  transverse  diameter.  The  appendix  and  its  mesentery 
were  ligated  separately  with  silk,  and  the  few  drops  of  pus 
which  were  extruded  were  caught  as  it  was  severed. 
Everything  was  carefully  washed  with  a  sublimate  solu- 
tion of  1  to  1 ,000.  At  no  point  was  there  evidence  of  ad- 
hesions. Iodoform  gauze  was  carefully  packed  about  the 
stump,  walling  off  the  omentum  and  intestines.  The 
peritoneum  and  abdominal  walls  were  sutured  to  within 
an  inch  of  the  lower  end  of  the  incision  and  the  wound 
dressed  as  usual. 

At  the  conclusion  of  the  operation,  the  patient's  pulse 
was  69,  and,  at  5  p.m.,  temperature,  98. 50  F. ;  pulse,  68. 
The  outer  dressings  were  changed  on  the  following  day, 
but  the  packing  in  the  wound  was  undisturbed  until  the 
fifth  day.  He  required  catheterization  on  the  night 
following  the  operation.    Temperature  until  the  day 


before  the  change  of  the  deeper  dressings  were  made, 
reached  no  higher  point  than  ioo°  F. ;  at  this  time, 
however,  it  was  101.20  F.  The  wound  was  carefully 
irrigated  with  a  normal  saline  solution,  cautiously  dried 
and  carefully  packed  with  iodoform  gauze.  The  wound 
cavity  could  be  seen  to  be  outlined  by  the  intestines 
covered  with  a  grayish  layer  of  inflammatory  exudate. 
It  was  thought  advisable  not  to  disturb  the  bowels  until 
the  sixth  day,  when  they  were  moved  by  an  enema.  On 
the  seventh  day,  three  one  drachm  doses  of  Epsom  salts, 
at  intervals  of  four  hours,  were  administered,  and  a  large 
movement  was  secured,  followed  by  two  other  watery 
discharges.  The  abdomen  was  at  no  time  distended. 
General  abdominal  tenderness  and  a  dry  tongue  were 
present  on  the  day  following  the  operation,  but  after 
this  no  symptoms  suggesting  peritoneal  disturbances 
appeared.     The  patient  made  an  uninterrupted  recovery. 

Section  of  the  appendix  disclosed  the  presence  of  pus. 
At  its  free  extremity,  corresponding  to  the  site  of  gan- 
grene, was  an  infectious  thrombus.  Upon  bacteriologi- 
cal examination,  Drs.  May  and  Levy  report  having 
found  a  pure  culture  of  the  bacillus  coli  communis. 

The  four  cases  to  which  your  attention  has  been 
invited  this  afternoon,  present  varying  types  of  acute 
infectious  inflammation  of  the  appendix.  The  first,  be- 
cause of  its  malignant  and  rapidly  progressive  character, 
is  described  as  fulminating.  In  the  second  and  third, 
the  inflammatory  process  reaching  beyond  the  appendix, 
and  invading  peri- appendicular  structures  occasioned 
abscess  formation.  In  the  second  the  pus  collection  was 
superficially  placed,  but  in  the  third  it  was  buried  behind 
the  caecum.  The  fourth  case,  beginning  probably  as  a 
catarrhal  appendicitis  became  changed  in  character  by 
the  occurrence  of  an  infectious  inflammation  of  the 
blood-vessels. 

What  to  do  for  a  given  case  of  appendicitis,  at  once 
becomes  a  most  serious  question.  Which  cases  will 
progress  happily  without  surgical  aid  and  which  can  be 
saved  by  timely  operation,  are  the  questions,  the  answer 
to  which  requires  not  only  rare  diagnostic  acumen,  but, 
in  their  management,  careful  medical  and  energetic  yet 
painstaking  surgical  intervention. 

I  am  less  ready  than  I  was  eighteen  months  ago  to 
maintain  that  much  the  larger  percentage  recover  by 
medical  treatment  alone.  Every  case  of  appendicitis 
should  be  seen  during  its  first  twenty- four  hours  so  fre- 
quently that  the  physician  can  satisfy  himself  of  either 
decided  improvement  in  both  local  and  general  manifes- 
tations or  detect  any  disposition  to  progression.  The 
wise  course  is  that,  from  the  outset,  the  case  should  be 
watched  by  both  physician  and  surgeon.  Of  the  two,  I 
believe  more  stress  should  be  placed  upon  the  local  than 
the  constitutional  manifestations.  If  there  be  equal  dis- 
appearance of  both  general  and  local  symptoms  during 
this  period,  there  is  no  need  to  feel  that  surgical  aid  is 
to  be  invoked.  Aside  from  the  careful  administration  of 
salines  and  intestinal  antiseptics,  the  less  medicine  pre- 
scribed for  the  patient,  the  better.  Nothing  should  be 
administered  which  in  any  way  is  to  mask  the  symptoms ; 
the  exhibition  of  opiates,  by  relieving  the  pain,  lulls  the 
patient  into  a  feeling  of  security  and  prevents  his  proper 
conception  of  the  degree  of  his  suffering. 

The  only  safe  rule  to  follow  is,  that  evidence  of  con- 
tinued progression  at  the  end  of  twenty-four  to  thirty  six 
hours  justifies  and  indeed  calls  for  operation.  Even  the 
cases  remaining  stationary  during  this  period  must  be 
viewed  with  suspicion.  The  cases  presented  in  these 
papers  indicate  very  clearly  that  there  may  be  mitigation 
of  all  and  complete  disappearance  of  most  of  the  symp- 
toms and  yet  during  the  period  of  their  subsidence  the 
diseased  process  has  gone  on  steadily.  The  pulse  may 
become  lowered,  the  temperature  sink  to  normal,  and  all 
this  time  gangrene  may  be  advancing  or  ulceration  im- 
minent. With  improvement  in  constitutional  sy  mptoms, 
the  local  signs  demand  the  closest  attention.  An  in- 
crease of  tenderness,  the  appearance  of  tumefaction,  the 
development  of  a  tumor,  mean  much  more  than  any 


426 


MEDICAL  RECORD. 


[October  6,  1894 


variation  in  pulse  and  temperature,  or  the  feelings  of  the 
patient.  The  first  evidence  of  dulness  in  the  fourth 
case,  despite  apparent  general  improvement,  was  the  sig- 
nal for  operative  intervention. 

When  the  patient  is  overwhelmed  by  an  infectious  in- 
flammation as  virulent  as  that  presented  in  the  first  case, 
or  when  septic  peritonitis  has  manifested  itself  as  a  later 
complication,  the  hope  of  aid  by  medical  means  is  gener- 
ally abandoned.  But  under  these  circumstances  the 
surgeon's  art  is  equally  powerless.  It  is  in  the  other 
group  of  acute  cases,  with  less  violent  manifestations, 
that  it  becomes  a  question  of  vital  moment  to  decide 
when  the  opportune  •time  for  operation  has  arrived. 

Operations  are  described  as  early  and  late.  An  early 
operation  implies  its  performance  during  the  period  in 
which  the  inflammation  is  still  limited  to  the  appendix. 
The  element  of  time  is  not  the  only  consideration  in  de- 
termining whether  or  not  the  operation  be  early.  If  dur- 
ing the  first  twenty  four  hours  of  an  appendicular  inflam- 
mation the  infection  has  spread  through  the  lymph- vessels 
of  an  unperforated  organ,  or  has  extended  from  one  dis- 
organized and  involved  the  entire  peritoneal  cavity,  it  is 
evident  that  the  operation  then  performed  is  early  in  point 
of  time,  but  too  late  to  avert  wide  spread  and  probably 
fatal  septic  inflammation.  On  the  other  hand,  an  opera- 
tion performed  on  the  third  day,  as  in  our  last  case,  while 
not  done  upon  as  early  a  day,  was  still  timely,  for  by  it 
we  did  no  doubt  avert  septic  peritonitis. 

Late  operations  are  those  performed  after  abscess  for- 
mation has  occurred,  walled  off  by  firm  adhesions ;  the 
mere  incision  of  these  abscesses  is  a  comparatively  simple 
operation.  But  during  the  period  of  their  formation  it 
is  often  a  matter  of  great  difficulty  to  determine  whether 
the  patient's  chances  may  not  be  improved  by  delaying 
operation  until  nature  has  rendered  her  fullest  assist- 
ance. There  is  a  group  of  cases  seen  from  the  third  to 
the  fifth  day  of  sickness,  when,  as  Richardson  puts  it,  we 
may  hesitate  whether  we  may  not  be  too  late  for  an 
early  operation  and  too  early  for  a  late  one.  Done  at 
this  period,  he  believes  no  operation  in  surgery  more 
difficult  than  the  removal  of  the  appendix  without  infect- 
ing the  general  peritoneal  cavity.  This  situation  pre- 
sented itself  in  our  third  case.  At  the  end  of  the  third 
day  a  tumor  was  beginning  to  form  in  the  midst  of  the 
tumefied  area.  An  operation  done  at  this  time  would 
have  been  an  entirely  different  procedure  from  the  one 
undertaken  on  the  eighth  day. 

To  perform  a  radical  operation,  the  rule  must  be, 
operate  early.  That  this  injunction  adds  greatly  to  the 
security  of  the  patient,  is  apparent  in  studying  the  re- 
sults obtained  by  Fowler  in  127  cases  operated  on  by  him. 
Of  58  operated  on  during  the  first  three  days,  eighty-three 
per  cent,  recovered;  of  9  on  the  fourth  day,  sixty- six 
per  cent. ;  of  26  on  the  fifth  and  sixth  days,  fifty  eight 
per  cent. ;  of  18  on  the  seventh  and  eight  days,  fifty  per 
cent. ;  while  of  9  on  the  ninth  and  tenth  days,  thirty- 
three  per  cent. 

The  great  fatality  attending  his  late  operations  is  not 
in  accord  with  my  experience.  The  operator  probably 
sought  to  do  more  than  give  vent  to  the  contents  of  the 
appendicular  abscess,  and  by  breaking  down  the  protec- 
tive barriers,  infection  gained  admission  into  the  perito- 
neal cavity. 

Increasing  experience  adds  to  the  operator's  ability  to 
deal  with  these  cases.  Preparations  for  the  operation 
must  be  hurriedly  made.  These  cannot  be  as  thorough 
as  in  an  ordinary  laparotomy.  The  operator  may  be 
handicapped  by  the  facilities  at  his  disposal.  The  sur- 
faces purified  as  well  as  possible,  the  site  of  his  incision 
is  selected  according  to  the  period  at  which  the 
operation  is  undertaken.  The  length  of  the  incision 
should  be  sufficient  to  afford  the  most  free  access  to  all 
diseased  surfaces.  Dealing  with  an  acute  infectious 
inflammation,  nothing  is  calculated  to  produce  more 
serious  consequences  than  an  inadequate  incision,  which 
must  prevent  both  the  protection  necessary  for  the  ab- 
dominal viscera  and  the  delicacy  of  manipulation  abso- 


lutely required.  In  our  first  case  the  incision  was  verti- 
cal, along  the  outer  border  of  the  rectus  muscle.  This 
was  indicated  because  the  acuteness  of  the  attack  foretold 
that  we  would  be  obliged  to  enter  the  free  peritoneal 
cavity.  Evidence  of  septic  peritonitis  at  once  encoun- 
tered, presented  the  most  dubious  outlook  for  the  patient. 

The  steps  taken  in  the  course  of  the  operation  have 
been  indicated  in  the  history.  A  glass  drainage-tube 
was  used  in  the  first  case.  In  the  operations  which  I 
have  performed  since  that  time,  I  have  used  only  gauze 
drainage,  and  have  reason  to  believe  that  this  procedure 
is  much  the  wiser  one.  The  abdominal  cavity  was  irri- 
gated with  a  saline  solution.  Although  this  receives  the 
strong  endorsement  of  most  of  the  surgeons  it  was  futile 
with  us.  The  Germans  say  that  "  Spuelerei  ist  Spiel- 
erei " — that  is  to  say,  "  irrigation  is  child's  play." 

Of  thirty- two  cases  in  which  general  peritonitis  was 
encountered  by  Fowler,  not  a  single  recovery  occurred. 
Others  claim  to  have  been  more  fortunate.  This  has, 
however,  been  my  experience  in  three  cases  in  which 
I  encountered  it  in  operating. 

In  Case  IV.,  in  which  likewise  an  early  operation  was 
undertaken,  we  were  fortunate  enough  to  secure  the  re- 
moval of  the  appendix  with  its  mesentery,  the  one  about 
to  become  gangrenous  and  the  other  on  the  verge  of  ul- 
ceration, before  further  infection  had  been  awakened. 
No  adhesions  were  present,  but  the  greatest  care  was 
taken  to  protect  by  gauze  pads  all  visceral  contact  with 
any  infectious  matter.  The-  appendix  and  its  mesentery 
after  ligation  presented  a  stump  so  broad  and  infiltrated 
that  it  was  impossible  to  undertake  what  in  chronic 
cases  is  an  ideal  step,  namely,  to  dissect  up  a  cuff  of  the 
peritoneal  investment,  invert  the  remainder  of  the  stump, 
and  secure  the  serous  coat  over  it  by  a  Lembert  suture. 
We  were  obliged  to  content  ourselves  with  its  purifica- 
tion by  means  of  the  sublimate  solution  and  the  thermo- 
cautery. 

Iodoform  gauze  was  carried  into  the  wound.  The 
four  strips  carefully  placed  around  the  stump  were  in- 
folded in  such  a  manner  as  to  prevent  a  free  edge  of  the 
gauze  presenting  itself  at  any  point.  This  is  essential, 
that  none  of  the  threads  may  adhere  to  the  abdominal 
structures,  and  greatly  facilitates  the  removal  of  the  pack- 
ing. Allowed  to  remain  for  four  or  five  days,  nature 
throws  about  the  gauze  a  protective  wall.  This  usually 
averts  future  general  infection. 

The  second  case  was  of  all  the  most  simple,  but  ex- 
hibits a  pathologic  peculiarity,  which  as  far  as  I  can  learn 
is  quite  unique.  The  destructive  process  had  evidently 
reached  the  vascular  supply  of  the  appendix.  The  ver- 
miform process,  collapsed  and  gangrenous,  was  found  in- 
bedded  in  an  infectious  blood- clot.  The  surgical  steps 
taken  with  this  patient  have  been  amply  justified  in  his 
very  rapid  recovery.  The  wound  quickly  cleansed 
itself,  and  in  fact  it  has  never  been  my  experience  to  see 
a  cavity  fill  up  so  quickly  as  did  this.  Great  aid  to  its 
accomplishment  was  the  manner  in  which  the  gauze  was 
inserted.  At  each  dressing,  by  carefully  carrying  it  to 
the  bottom  of  the  wound,  lightly  placing  it  here,  and 
then  distending  the  upper  portion  as  much  as  possible 
by  firm  packing,  we  secured  within  a  few  days  a  funnel- 
shaped  wound,  sloping  gently  from  the  sides  to  the 
centre,  and  gave  it  at  the  same  time  the  largest  possible 
area  for  granulation. 

Case  III.  presented  a  most  serious  surgical  problem. 
The  incision  was  made  well  toward  the  pelvic  brim, 
inasmuch  as  it  was  recognized  that  the  tumor  could  thus 
be  more  easily  reached.  In  taking  this  step,  we  disre- 
garded the  usual  instructions  given,  which  are  to  make 
the  incision  over  the  most  prominent  portion  of  the 
tumor.  This  was  also  done  in  Case  II.  It  seems  to 
me  wiser  in  performing  a  late  operation  to  attempt,  if 
possible,  to  establish  an  extra  peritoneal  route.  This  is 
accomplished  better  by  making  the  incision  as  far  out- 
ward as  possible,  rather  than  over  the  most  prominent 
portion  of  the  tumor. 

After  entering  the  peritoneal  cavity,  two  courses  were 


October  6,  1894] 


MEDICAL    RECORD. 


427 


left  open  to  us.  Good  surgeons  state  that  with  post- 
cecal abscess,  it  is  sometimes  necessary  to  reach  it  by  the 
abdominal  route  and  to  drain  through  the  ud implicated 
intestinal  structures.  Aside  from  the  impossibility  of  se- 
curing drainage  through  an  up  hill  channel,  the  virulent 
infection  which  manifested  itself  within  a  few  days  after 
the  operation  in  this  case  and  produced  such  destructive 
gangrene  of  the  abdominal  walls,  I  believe  shows  the 
wisdom  of  the  course  pursued.  Such  intense  infection 
could  not  have  been  withstood  by  the  intestines,  and 
must  have  produced  a  rapidly  fatal  spreading  peritonitis. 
On  the  other  hand,  closure  of  the  peritoneum  and  the  trans 
versalis  fascia  over  it,  permitted  us,  by  means  of  another 
incision  through  the  muscular  structures,  to  reach  the 
brim  of  the  pelvis,  and  by  careful  dissection  the  abscess 
was  exposed  and  entered  through  its  outer  wall.  Even 
here  we  could  not  avoid  exposing  the  omentum  above 
and  the  intestines  below.  After  three  days,  however, 
protective  adhesions  sealed  up  the  extremities  of  the  ab- 
scess cavity  and  free  drainage  was  permitted.  More 
than  this,  the  removal  of  all  gaDgrenous  structures  was 
made  possible.  The  appendix  was  readily  exposed  and 
removed.  Again  the  use  of  iodoform  gauze,  placed  after 
the  manner  described,  secured  not  only  limitation  of  the 
abscess  cavity,  but  also  the  desired  funnel-shaped  wound. 

The  recommendation  to  enter  these  abscesses  by  in- 
cision through  the  rectum,  it  is  evident  could  not  have 
yielded  as  satisfactory  a  result.  The  fear  that  extra- 
peritoneal incision  in  the  late  cases  may  not  be  suffi- 
ciently radical,  because  of  the  possible  existence  of  mul- 
tiple abscesses,  is,  I  believe,  no  longer  regarded  as  well 
grounded.  These  rarely,  if  ever,  occur  late,  although 
frequently  present  early.  In  both  of  the  cases  reported 
the  sudden  recurrence  of  fever  indicated  to  the  medical 
attendant  that  the  opportune  moment  for  operation  had 
arrived. 

The  importance  of  the  surgical  attention  required  by 
these  cases  after  operation  is  not  sufficiently  appreciated. 
I  esteem  it  the  duty  of  the  surgeon  to  personally  super- 
intend the  change  of  dressings  until  there  is  no  further 
possibility  of  infection.  This  can  be  done  many  times 
only  at  a  great  sacrifice  of  time,  but  the  best  interests  of 
the  patient  demand  it. 

It  must  be  evident  that  the  three  cases  which  have  re- 
covered by  operation  could  none  of  them  have  been 
saved  by  other  than  surgical  intervention.  In  the  ful- 
minating cases  complicated  early  by  septic  peritonitis, 
the  prognosis  is  almost  hopeless.  Where  this  complica- 
tion appears  at  a  later  period,  a  gloomy  termination  is 
likewise  to  be  feared.  I  feel  confident  that  twenty  four 
hours  later  this  would  have  been  the  situation  in  Case 
IV. 

With  a  clearer  conception  of  the  nature  of  these  infec- 
tious inflammations  and  the  improving  technique,  largely 
the  work  of  American  surgeons,  the  percentage  of  recov- 
eries will  probably  increase  in  the  future,  if  operation  be 
done  sufficiently  early  to  anticipate  the  frightful  results 
of  microbic  invasion.  I  regret  that  in  all  of  the  four 
cases  bacteriological  examinations  were  not  made,  but 
in  two  the  facilities  for  the  same  were  not  at  hand. 

The  increasing  importance  given  each  year  to  the  sur- 
gical treatment  of  infectious  appendicitis  may  be  regarded 
by  some  as  uncalled  for  and  unjustifiable.  From  my 
standpoint,  however,  it  is  directly  in  the  line  of  conser- 
vative surgery.  We  remove  a  part  not  essential  to  the 
animal  economy,  but  thereby  we  have  saved  life. 

Laws  Relating  to  the  Practice  of  Pharmacy. — The 

Agricultural  Department  in  Washington  has  published  a 
report  upon  the  laws  regarding  pharmaceutical  practice 
in  the  different  States  and  Territories  of  the  Union.  It 
shows  that  there  are  no  laws  on  the  subject  in  Idaho, 
Indiana,  Montana,  Nevada,  Arizona,  and  the  Indian 
Territory.  In  Maryland,  there  is  a  law  which  applies, 
however,  only  to  the  city  of  Baltimore.  The  compilation 
is  based  on  reports  made  by  the  various  State  pharma- 
ceutical associations. 


THE  THYROID    TREATMENT    OF   PSORIASIS, 
AND  OTHER  SKIN  DISEASES. 

By  GEORGE   W.   CRARY,  M.D., 

NEW  YOBK. 

ASSISTANT  ATTENDING  SURGEON,    ROOSEVILT    HO&NTAI,  OUT-PATIENT  DEPART- 
MENT. 

Since  Davies  and  Bramwell  reported  their  remarkable  re- 
sults following  the  use  of  th)roid  preparations  in  psoria- 
sis and  some  other  diseases  of  the  skin,  the  method  has 
been  perhaps  somewhat  widely  employed,  though  but 
comparatively  few  reports  have  been  published.  Below 
I  give  briefly  the  histories  of  nine  cases  of  psoriasis  that 
I  have  had  under  this  treatment  for  varying  periods 1  fol- 
lowed by  a  short  summary  of  previously  reported  cases. 

Case  I. — Male,  aged  twenty-six;  disease  of  three 
years'  standing,  with  recurrent  attacks ;  longest  period  of 
exemption  was  one  month.  Eruption  in  large  and  small 
patches  of  general  distribution.  General  condition  fair. 
Temperature  before  treatment  was  98$°  F.  Doses  of 
glycerice  extract  (gr.  xxiv.  to  3  j)2  rose  from  9  to  15 
drops  daily,  in  three  divided  doses.  Highest  tempera- 
ture during  treatment  was  ioo°  F.  After  two  or  three 
days'  treatment,  the  irritation  was  allayed.  Complained 
of  pain  in  joints.  Treatment  continued  for  two  weeks. 
No  improvement. 

Case  II. — Male,  aged  thirty  six ;  seven  months'  stand- 
ing; small  spots  general  in  distribution;  very  irritable. 
Temperature  before  treatment  was  ioo^°  F.  Dose  of 
extract  was  9  to  18  drops  daily.  During  treatment  tem- 
perature varied  from  9 7  j4°  to  98$ °  F.  Irritation  much 
lessened.  General  condition  improved.  Marked  sheep 
odor  to  perspiration.  Treatment  continued  for  five 
weeks.     No  improvement. 

Case  III. — Female,  aged  thirty  nine;  eruption  for 
two  and  one  half  years,  in  spots  over  body  with  excep- 
tion of  face,  neck,  and  chest.  General  condition  gcod. 
Temperature  before  treatment,  990  F.  There  was  con- 
siderable hypertrophy  of  thyroid  gland.  Dose  of  extract 
was  15  to  40  drops  a  day.  Temperature  during  treat- 
ment, 98!°  F.  Irritation  allayed.  Duration  of  treat- 
ment was  six  weeks.  No  improvement,  and  even  grew 
worse. 

Case  IV. — Male,  aged  twenty-five ;  two  years'  stand- 
ing, but  disappears  in  summer;  small  spots  upon  aims 
and  chest.  General  condition  poor.  Temperature  be- 
fore treatment  was  98$°  F.  Daily  amount  of  extract,  15 
to  45  drops.  During  treatment  temperature  between  970 
and  97  j°  F.  Skin  between  spots  much  softened.  Irri- 
tation lessened.  Pain  in  arm.  General  condition  im- 
proved. Duration  of  treatment  *as  eight  weeks.  No 
improvement. 

Case  V. — Male,  aged  forty- six  ;  eruption  for  ten  years, 
severe  and  general.  General  condition  poor.  Temperature 
before  treatment,  99^ °  F.  Daily  amount  of  extract  was 
from  r 5  to  36  drops.  Temperature  during  treatment^e- 
tween  970  and  990  F.  Skin  between  patches  became  soft 
and  velvety.  Irritation  lessened.  Sheep  odor  very  pro- 
nounced. General  condition  improved.  Treatment  con- 
tinued for  twelve  weeks,  with  one  interruption  of  two 
weeks.     Eruption  much  improved. 

Case  VI. — Male,  aged  fifty;  eruption  for  twenty 
years,  and  is  general  and  severe.  General  condition 
poor.  Temperature  before  treatment,  9&j4°  F.  Daily 
amount  of  extract  varied  from  15  to  75  drops  a  day. 
Temperature  during  treatment  ranged  from  97$°  to  ioo° 
F.  Intercurrent  attack  of  facial  erysipelas  and  later  of 
cellulitis  of  leg,  from  external  infection.  Sheep  odor 
very  marked.  Skin  not  affected  by  disease  became  very 
soft  and  smooth.  Pains  in  joints.  Treatment  continued 
for  eleven  weeks.     Very  marked  improvement. 

Case  VII. — Female,  aged  thirty ;  disease  of  ten 
years'  standing ;  small  spots  upon  upper  and  lower  ex- 
tremities and  upon  chest.     General  health  is  fair.     Tem- 

1  These  cases  were  treated  at  the  Out-Patient  Department  of  the 
Roosevelt  Hospital  with  the  kind  permission  of  Dr.  Frank  Hartley, 
the  Attending  Surgeon. 

9  Medical  Record,  June  17,  1893. 


428 


MEDICAL  RECORD. 


[October  6,  1894 


perature  before  treatment  was  100  j£°  F.  Daily  amount 
was  from  15  to  60  drops.  Temperature  during  treatment 
varied  from  970  to  99$°  F.  Irritation  very  much  al- 
layed. Skin  not  affected  became  soft  and  smooth. 
Treatment  for  fourteen  weeks.     No  improvement. 

Case  VIII. — Female,  aged  thirty  ;  two  years'  stand- 
ing, not  severe  but  general.  Temperature  before  treat- 
ment, 98^°  F.  Daily  amount  was  10  to  30  drops. 
Temperature  during  treatment,  98$°  F.  Treatment 
continued  for  three  and  a  half  weeks.  No  improve- 
ment. 

Cask  IX.— Female,  aged  twenty-three;  disease  of 
two  years*  duration,  and  upon  legs  and  thighs.  General 
condition  fair.  Disease  persisted  throughout  a  recent 
pregnancy.  Temperature  before  treatment,  99  °  F. 
Daily  amount  taken  was  from  15  to  30  drops.  Temper- 
ature during  treatment  varied  from  98^°  to  98$°  F. 
Irritation  not  lessened.  Pain  in  back.  Duration  of 
treatment  was  five  weeks.  No  improvement;  grew 
much  worse. 

We  have  here  nine  cases  of  psoriasis,  in  which  im- 
provement has  been  noted  in  only  two,  and  in  these 
two  the  response  to  the  treatment  has  been  very  slow  and 
not  distinctly  progressive.  It  may  be  objected  that  in 
some  of  these  cases  the  treatment  has  been  of  short 
duration,  but  where  cures  have  been  reported  the  im- 
provement became  manifest  very  early.  That  the  thy 
roid  has  a  beneficial  effect  upon  the  skin  in  myxoedema 
is  most  certain,  and  indeed  it  is  equally  certain  that  in 
other  conditions  such  an  effect  is  produced,  for  in  all  the 
above  cases  the  skin  between  the  patches  or  spots  of  the 
eruption  became  soft  and  smooth.  The  thyroid  extract 
has  a  very  profound  effect  upon  general  nutrition,  and 
perhaps  especially  upon  the  skin,  and  to  this  js  due  the 
changes  noted.  I  have  been  struck  in  the  above  cases 
with  the  absence  of  a  rise  in  temperature  following  the 
treatment,  for  in  most  of  the  cases  the  temperature  has 
fallen  to  the  subnormal  and  remained  there,  the  fall 
roughly  being  in  proportion  to  the  dose.  In  some  the 
rheumatic  pains,  frequently  noted  during  thyroid  ad- 
ministration, were  present  and  complained  of.  In  many 
of  the  cases  there  was  a  marked  and  unpleasant  odor  of 
mutton  or  lamb  to  the  perspiration. 

Below  I  give  a  short  table  of  the  cases  of  psoriasis 
treated  by  thyroid,  the  reports  of  which  have  already 
appeared: 


Reporter  and 
Reference. 


in 

•S5     I  W 


1 


2  z 


.1' 

r 


Average  Daily 
Dose. 


Da  vies :       Brit.    Jour. 

Derm.,  1893.  v.  257. 
B.      Bramwell :     Brit  i 

Med.  Jour.,  1893,  ii. 


«l 


L9R'illips:  Brit  Med.      a 

Jttur.,  1893,  ii.  1x52.   1 
T.  Jones  :   Brit.   Med.      x 

Jour.,  1893,  ii.  1424. 
B.  Squire  :  Brit.  Med.      2  I 

Jour.,  X804,  i.  13. 
J.  F.  G.  DM:   Lancet, 

London,  1894.  i.  19. 
P.  Abraham :    Lancet,    49 

London,  1894,  i.  94. 
W.  Anderson :  Lancet 

Ixmdon,  1894,  i.  94. 
John    Gordon  :      Brit., 

Med.  Jour.,   1894,  i. 

186. 


I 


. .   I  Tabloids,  gr.  v. 
a     Extract,  1™,  xv. 


,   . .  I  Tabloids,  gr.  xxx. 
I  Extract,  Til  x.-xv. 
I     x  ;  Tabloids,    gr.   xv.- 
xx. 
Extract,  tq,  xx. 
I  . 


2  1     Tabloids,  gr.  xv. 

x8!    16  (   15  (  Tabloids,  gr.  xv. 


I 


x      Extract,  T?l  xx. 


Duration 
of  Treat- 
ment. 


6  wks.  and 

3  mos. 
2  to  3  mos. 

a     and    3 

mos. 
23  days. 

19  and  31 

days, 
x  month. 


3  weeks. 
7  weeks. 


1  Eleven  of  these  improved  cases  received  other  treatment,  and  should  therefore 
be  eliminated  in  drawing  conclusions. 
9  Syphilitic  psoriasis,  no  other  treatment. 

We  have  left  before  us,  then,  including  my  own  cases  just 
reported,  77  cases  of  psoriasis  which  have  been  treated 
by  thyroid  preparations.  Of  these  in  six,  or  about  eight 
per  cent.,  the  treatment  has  been  followed  by  a  cure. 
Twenty-two  have  been  improved,  but  of  these  we  must 
deduct  the  n  cases  of  Abraham's  which  received  also 
other  treatment,  and  then  we  have  66  cases  treated,  with 
17,  or  twenty- five  per  cent.,  improved.  Of  the  49  cases 
which  were  not  benefited  by  the  treatment,  ai  grew  dis- 
tinctly worse. 


Other  diseases  of  the  skin  than  psoriasis,  and  the  re 
ported  results  are  no  more  encouraging : 

Davis :  Ichthyosis,  one  case,  improved ;  chronic  ecze- 
ma, one,  improved. 

Phillips:  Eczema,  one,  no  result;  xeroderma,  one, 
marked  improvement. 

Dill :  Acne  rosacea,  one,  no  result. 

Abraham:  Lichen  planus,  5  cases — 3  improved  with 
other  treatment  combined.  Eczema;  7  cases — 3  im- 
proved, other  treatment  also.  Chronic  urticaria,  2  cases, 
both  grew  worse.  Prurigo  senilis,  1  case — no  result  A 
case  of  "  peculiar  papular  eruption,"  1  case — improved, 
other  treatment.  Lupus,  5  cases,  other  treatment  also, 
improvement. 

While  then  we  know  that  in  myxoedema,  and  in  other 
conditions  also,  the  administration  of  thyroid  prepara- 
tions is  followed  by  marked  changes  in  the  skin,  render- 
ing  it  soft  and  smooth  and  moist,  we  must  look  upon 
these  changes  as  merely  nutritive,  and  while  possibly  in 
some  cases  such  changes,  if  more  thoroughly  understood, 
could  be  used  as  an  aid  in  therapeutics,  I  think  we  have 
little  reason  to  believe  that  thyroid  extract  is  in  any  di- 
rect way  curative  of  any  real  disease  of  the  skin  or  its 
appendages. 

15a  West  Fibty-seventh  Steeet. 


THE   MANAGEMENT  OF   ABORTION.1 
By   EDWARD   J.    ILL,   M.D., 

NEWARK,   N.   J 

FELLOW  Or  THE  AMERICAN  ASSOCIATION  OF  OBSTETRICIANS  AND  GYNECOLO- 
GISTS ;  SURGEON  TO  WOMAN'S  HOSPITAL  ;  GYNECOLOGIST  TO  ST.  BARNABAS 
HOSPITAL  ',  CONSULTING  GYNECOLOGIST  TO  GERMAN  HOSPITAL  OP  NEWARK, 
N.  J.;  CONSULTING  GYNECOLOGIST  TO  ALL  SOULS  HOSPITAL,  OF  MORRJSTOWW, 
N.  J.,  ETC. 

The  main  object  of  a  paper  to  be  read  before  a  society  is 
to  furnish  material  for  discussion.  With  this  in  view  it 
will  be  my  object  not  to  present  an  exhaustive  discourse, 
nor  an  opinion  of  writers.  I  wish  to  present  for  your 
consideration  and  discussion  such  a  method  of  treatment 
as  I  have  followed  for  a  number  of  years,  and  with  what 
I  consider  very  good  results.  How  important  this  mat- 
ter is  to  me  will  be  shown  when  I  tell  you  that  I  was 
called  upon  lately  to  treat  five  septic  abortions  in  a  week. 
I  would  divide  the  management  of  abortion  into  two 
parts:  1st.  The  prevention  of  abortion,  and  2d,  the 
management  after  we  have  once  satisfied  ourselves  that 
the  product  of  conception  must  be  expelled. 

It  will  be  proper  to  touch  upon  the  causes  of  abortion, 
since  its  prevention  will  in  some  measure  depend  on  this 
factor.  I  consider  it  as  very  rare  to  count  external  in- 
jury, a  jolt  or  jar,  as  a  potent  factor  in  the  production 
of  abortion. 

At  the  outset  we  will  understand  that  disease  of  the 
foetus  or  chorion  may  produce  abortion  as  well  as  disease 
of  the  mother.  In  this  respect  there  is  still  a  wide  field 
for  observation  and  study. 

Among  the  diseases  of  the  mother  may  be  mentioned : 
Retroflexion  of  the  uterus,  chronic  hyperplasia  of  the 
uterus,  chronic  endometritis,  laceration  of  the  cervix 
uteri,  pelvic  peritonitis,  or  rather  its  results,  prolapse  of 
uterus,  syphilis,  and  chronic  nephritis. 

When  we  find  a  retroflexed  pregnant  uterus  it  will  be 
necessary  to  replace  it  to  its  normal  position  with  the 
greatest  possible  care  and  gentleness.  This  having  been 
accomplished  we  may  congratulate  ourselves  in  having  in 
all  probability  prevented  an  abortion.  The  same  can  be 
said  of  a  complete  prolapsus.  When,  however,  the  fifth 
month  of  gestation  is  over  the  uterus  can  no  longer  be 
replaced,  and  it  either  means  death  to  the  mother,  or  ar- 
tificial interruption  of  gestation.  In  the  other  instances 
of  which  I  have  spoken,  our  treatment  must  be  directed 
to  the  peculiar  condition  before  conception  takes  place. 
An  exception  to  some  extent  is  syphilis  and  chronic  ne- 
phritis. A  lady  of  this  town  had  aborted  fourteen  times 
in  succession,  and  became  mother  of  a  living  child  after 

1  Read  before  a  gathering  of  medical  gentlemen  at  the  house  of  Dr. 
S.  Pierson,  Morristown,  N.  J. 


October  6,  1894] 


MEDICAL    RECORD. 


429 


an  operation  for  deep  laceration  of  the  cervix.  Only  the 
other  day  I  was  told  of  a  woman  who  gave  birth  to  a 
living  and  healthy  child  after  having  aborted  six  times 
before  the  third  month  of  gestation.  The  patient  was 
known  to  have  syphilis,  and  was  under  antisyphilitic  treat- 
ment for  five  months. 

I  believe  that  after  longer  observation  we  shall  be  able 
to  discard  the  term  habitual  abortion,  since  we  shall  find  a 
cause  for  all  these  cases.  In  the  treatment  of  threatening 
abortion  we  are  first  confronted  with  the  very  important 
question  :  Are  there  stitt  well-founded  prospects  of  pre- 
venting an  abortion  or  is  it  beyond  our  reach  ?  If  we 
have  decided  for  the  former  the  patient  must  be  instructed 
to  keep  quiet  on  the  first  appearance  of  a  bloody  dis- 
charge or  bearing-down  pain,  her  lower  bowel  should 
be  kept  emptied,  her  diet  a  bland  one,  sexual  intercourse 
stopped,  and  opium  or  cannabis  indica  administered. 

When  shall  we  know  that  our  endeavors  are  in  vain  ? 
The  safest  symptoms  are  when  the  cervical  canal  has  di- 
lated sufficiently  to  allow  the  finger  to  touch  the  ovum, 
or  when  the  os  internum  is  dilated  to  such  a  degree  that 
the  cervix  and  the  corpus  uteri  shall  form  one  cavity. 
We  would  also  know  that  our  endeavors  are  in  vain  when 
pieces  of  the  decidua  have  been  passed,  or  when  there  is 
a  fetid  discharge  from  the  uterus.  The  latter  is  a  sure 
symptom  that  some  parts  of  the  ovum  have  undergone 
necrosis  and  death. 

As  a  rule  an  abortion  is  sure  to  take  place  when  the 
patient  has  lost  blood  for  a  length  of  time  in  large  quan- 
tities, accompanied  with  labor-pains.  I  have  seen  preg- 
nancies continue,  however,  when  the  patients  had  one  or 
two  large  hemorrhages,  as  well  as  I  have  known  a  child  go  to 
full  term  when  there  was  a  bloody  mucous  discharge  for 
several  weeks.  "  When  we  feel  certain  that  the  product  of 
conception  will  be  cast  off,  then  it  becomes  our  duty  to 
relieve  the  patients  as  soon  as  possible  so  as  to  prevent 
their  undergoing  the  ordeal  following  retained  secun- 
dines. 

If  we  have  reason  to  believe  that  the  ovum  is  intact 
and  the  uterus  is  doing  its  work  well,  and  gradually 
emptying  itself,  then  we  had  better  not  be  meddlesome. 
We  can  render  the  uterus  valuable  assistance  in  its  en- 
deavors by  a  large,  hot  vaginal  douch  or  a  tampon.  A 
large,  hot  rectal  injection  will  often  be  of  signal  value. 
Occasionally  I  was  forced  to  assist  the  uterus  by  instru- 
mental dilatation  of  the  os  externum,  and  then  I  used 
GoodelTs  dilator  with  much  satisfaction. 

So  long  as  the  ovum  is  intact,  the  uterus  will  probably 
have  no  difficulty  in  forcing  it  out,  and  when  it  lies  in 
the  cervical  canal  can  be  removed  easily  by  the  finger 
with  a  sweeping  motion.  At  times  we  will  be  confronted 
by  a  severe  hemorrhage,  often  of  an  alarming  character. 
Here  an  iodoform  gauze,  or  a  clean  cotton  tampon  will  do 
its  work  well.  It  should  be  introduced  through  a  large 
cylindrical,  or  a  Sims  speculum,  and  care  be  taken  to 
plug  the  vagina  around  the  cervix  and  os  very  thoroughly. 
If  the  uterus  itself  is  to  be  plugged  it  can  only  be  done 
through  a  Sims  speculum,  the  patient  lying  on  her  back 
with  the  hips  over  the  lower  end  of  a  table.  The  vagina 
and  cervix  should  be  thoroughly  cleansed,  the  speculum 
introduced,  and  the  cervix  drawn  down  with  a  tenacu- 
lum forceps.  A  narrow  pair  of  dressing  forceps  pushes 
a  long  narrow  strip  of  gauze  into  the  uterus  until  this  or- 
gan is  filled. 

This  is  by  all  means  the  safest  and  surest  remedy.  I 
would  warn  against  the  use  of  all  styptics  on  account  of 
the  great  danger  of  sepsis.  Occasionally  we  will  succeed 
in  delivering  the  ovum  in  toto  by  a  combined  abdominal 
and  vaginal  compression  performed  in  the  following  way : 
Two  fingers  of  the  right  hand  are  placed  anterior  to  the 
cervix  in  an  anteversion  and  posterior  to  the  cervix  in 
a  retroversion,  while  the  left  hand  seeks  the  uterus  from 
the  abdomen  and  on  its  posterior  or  anterior  surface,  as 
the  case  may  be,  makes  pressure  in  the  direction  of  the 
dingers  in  the  vagina.  When  the  ovum  has  been  broken, 
or  a  finger  once  introduced  into  the  uterine  cavity,  then 
an  instrumental  delivery  with  curretting  of  the  endo- 


metrium becomes  a  necessity.  It  becomes  a  life-saving 
operation  when  the  patient  shows  signs  of  sepsis.  In 
these  cases  it  is  my  custom  to  operate  in  the  following 
way.  The  patient  being  under  the  influence  of  an  anaes- 
thetic, is  placed  in  the  lithotomy  position  on  a  table 
with  the  hips  well  down  over  the  lower  end.  A  Kelly 
perineum  pad  or  ordinary  oil  cloth  is  placed  under  the 
patient,  so  that  all  fluids  are  directed  to  a  pail  or  bucket 
below.  The  vulva  and  vagina  are  then  thoroughly 
washed  with  soap  and  hot  water,  and  disinfected  with  a 
hot  solution  of  mercuric  bichloride,  1  to  4,000.  A  Sims 
speculum  is  now  introduced  and  held  by  an  assistant, 
who  also  holds  the  right  leg  of  the  patient  and  the  irri- 
gating tube,  while  the  left  leg  is  held  by  a  second  assist- 
ant, who  also  administers  the  anaesthetic. 

The  anterior  lip  of  the  cervix  is  caught  up  with  a 
tenaculum,  or  what  is  better,  a  tenaculum  forceps,  and 
drawn  down  somewhat  so  as  to  straighten  the  canal. 
The  canal  is  now  thoroughly  dilated,  if  necessary,  by  an 
Ehlinger  or  Goodell  dilator,  and  the  cavity  of  the  uterus 
thoroughly  curretted  with  a  sharp  instrument,  or  else,  if 
large  pieces  of  tissue  were  left  they  should  first  be  re- 
moved with  a  broad  bladed  dressing  forceps.  There  is 
very  little  danger  of  wounding  the  uterus  unless  sepsis  is 
far  advanced.  Under  these  circumstances  we  must 
manipulate  very  carefully,  for  I  have  seen  a  curette 
pushed  right  through  the  fundus  of  the  uterus  into  the 
peritoneal  cavity.  The  horns  and  fundus  must  receive 
our  especial  attention  in  curetting,  as  these  are  the  most 
difficult  parts  to  clean. 

During  all  this  a  constant  stream  of  a  solution  of  mer- 
curic bichloride,  1  to  4,000,  is  poured  upon  the  cervix. 
When  the  uterus  has  been  thoroughly  curetted  the  cavity 
is  also  irrigated  with  the  same  solution,  preferably 
through  a  return  catheter.  The  whole  procedure  of 
curetting  and  irrigating  should  be  repeated  to  assure 
ourselves  of  the  successful  accomplishment  of  our  object. 
Let  me  here  say,  that  it  must  be  done  systematically; 
thus  the  anterior  wall,  the  posterior  wall,  the  right  horn, 
the  left  horn,  and  the  fundus  are  scraped  in  the  order 
mentioned. 

As  the  uterus  has  now  been  thoroughly  cleansed  the 
vagina  is  also  irrigated.  The  fluid  remaining  in  the 
vagina  is  mopped  up  with  a  piece  of  iodoform  gauze, 
and  a  strip  of  the  same  material  is  laid  into  the  cervical 
canal  and  to  the  fundus  of  the  uterus  for  drainage.  The 
tenaculum  forceps  can  now  be  removed  and  the  vagina 
loosely  filled  with  gauze.  If  there  is  reason  to  fear  hem- 
orrhage, and  there  is  none  if  we  have  removed  the  cho- 
rion and  decidua  thoroughly,  it  is  well  to  fill  the  uterus 
tightly  with  gauze,  which  must  be  done  with  one  long 
strip.  In  either  case  the  gauze  is  removed  in  twenty- 
four  hours.  If  the  patient  has  no  fever  a  vaginal  douch 
of  one  per  cent,  solution  of  carbolic  acid  may  be  or- 
dered. If  she  still  has  fever,  the  uterus  should  be  irri- 
gated again,  and  a  strip  of  gauze  again  inserted  into  the 
cavity.  Great  care  should  be  taken  that  the  strip  of 
gauze  is  not  too  wide,  otherwise  it  will  be  the  means  of 
blocking  up  the  uterine  discharge. 

Instead  of  reapplying  the  gauze,  we  may  choose  to 
irrigate  the  uterus  every  four  hours  with  sterilized  water, 
or  a  solution  of  mercuric  bichloride  of  1  to  10,000,  until 
there  is  no  more  fever,  or  until  we  are  satisfied  that  the 
germs  have  gone  beyond  the  cavity  and  mucous  mem- 
brane of  the  uterus. 

From  what  has  been  said  I  would  draw  the  following 
conclusions  : 

Since  an  abortion  is  a  pathological  and  not  a  physio- 
logical condition,  as  is  a  birth  at  time,  it  must  be  treated 
on  other  principles  than  the  latter.  In  many  cases  our 
interference  becomes  necessary  because  we  deal  with  con- 
ditions which  favor  a  retention  of  the  secundines,  as, 
for  instance,  a  broken  ovum,  a  displaced,  a  septic  or 
otherwise  diseased  uterus.  When  we  can  foresee  the 
probability  of  a  retention  we  must  use  such  efforts  as 
will  further  its  expulsion,  provided  it  can  be  done  by 
such  means  as  will  not  produce  injury  to  the  mother. 


430 


MEDICAL    RECORD. 


[October  6,  1894 


Id  this  condition,  like  in  many  others,  to  do  a  thing  half 
is  worse  than  not  to  do  it  at  all. 

In  a  majority  of  cases  a  clean  finger  is  the  best  instru- 
ment. However,  if  the  whole  ovum  and  decidua  have 
not  come  away,  then  the  forceps  and  the  sharp  curette 
find  their  places,  the  latter  for  thorough  removal  of  the 
uterine  decidua. 

A  temperature  of  ioo°  R,  or  above,  is  always  a  dis- 
tinct indication  for  an  immediate  cleansing  out  of  the 
uterus.  The  vulva,  vagina,  cervix,  instruments,  and 
hands  should  be  made  thoroughly  aseptic  before  an  op- 
eration is  permitted. 

In  septic  cases  large,  hot  antiseptic  intra-uterine  in- 
jections should  follow  the  cleansing  out  of  the  uterus, 
and  the  uterus  should  be  drained  by  gauze.  Let  me 
also  say  that  I  have  never  seen  any  good  come  from 
ergot  given  previous  to  emptying  the  uterus. 


THE  USE  OF  THE  RESORCIN  TEST  FOR  THE 
DETECTION  AND  QUANTITATIVE  ESTIMA- 
TION OF  THE  FREE  HYDROCHLORIC  ACID 
OF  THE   GASTRIC  JUICE.1 

By  JULIUS  FRIEDENWALD,  A.B.,  M.D., 

BALTIUJRS,  MD. 

CUMICAL  PXOrCSSOX  OP  DISEASES    OP    TIM  STOMACH,    COLLEGE    OF    PHYSICIANS 
AND  SURGEONS  ;  VISITING  PHYSICIAN   BAY  VIEW  HOSPITAL,    BALTIMORE. 

Since  the  chemical  examination  of  the  gastric  secretion 
has  assumed  such  importance  in  the  diagnosis  and  treat- 
ment of  diseases  of  the  stomach,  it  is  important  that  the 
simplest  as  well  as  the  most  reliable  tests  available  should 
become  better  known.  It  is  for  this  reason  that  the  re- 
sorcin  test  of  Boas  is  brought  forward,  and  it  will  be  the 
object  of  this  paper  to  show  that  with  it  quite  as  reliable 
results  can  be  obtained  as  with  Giinzburg's  reagent, 
which,  though  more  commonly  employed,  possesses  cer- 
tain disadvantages. 

In  1888  Boas ■  first  published  the  report  of  his  reagent, 
consisting  of: 

Resorcin  resub .• 5 

Sacch.  alb 3 

Spiritus  dilut IOO 

and  claimed  for  it  an  accuracy  equal  to  that  of  Giinzburg's 
phloroglucin  vanillin  *  test.  Boas's  reagent,  like  Giinz- 
burg's, reacts  only  to  free  hydrochloric  acid  and  never 
to  organic  acids.  The  reaction  is  carried  out  as  follows : 
A  few  drops  of  the  solution  are  heated  gently  in  a  porcelain 
dish  with  an  equal  quantity  of  gastric  filtrate  to  complete 
evaporation ;  a  red  mirror  is  produced  when  free  hydro- 
chloric acid  is  present.  Puriz,4  A.  Meyer,*  and  Leo  *  con- 
firmed Boas's  statements  in  regard  to  the  accuracy  of  this 
test.  Yet  the  reagent  has  never  gained  the  popularity 
that  it  deserves.  Stewart 7  almost  habitually  employs  the 
phloroglucin  test,  but  in  the  few  instances  in  which  he  has 
resorted  to  the  resorcin  test  the  results  have  been  equally 
satisfactory.  In  such  excellent  works  as  the  new  editions 
of  Hoppe-Seyler's  "  Physiological  Chemistry,"  and  Von 
Jaksch's  "  Clinical  Diagnosis,"  this  test  is  not  even 
mentioned,  though  far  inferior  tests  are  described. 

My  own  observations  with  this  reagent  lead  me  to  be- 
lieve that  it  is  not  only  quite  as  reliable  for  the  detection 

1  From  the  Clinical  Laboratory,  College  of  Physicians  and  Surgeons, 
Baltimore. 

a  Boas :  Ein  neues  Reagens  fur  den  Nachweis  Freie  Salzsaure  in  Ma- 
geninhalt.  Centralbl.  fur  Klinisch.  Med  ,  1888,  No.  45,  und  Diagnos- 
tic und  Therapie  der  Magenkrankheiten,  1  Theil,  S.  134. 

*  Gfinzburg:  Neue  Methode  zur  Nachweis  freier  Salzsaure  im  Ma- 
geninhalt.  Centralb.  f  Klinische  Med.,  1887,  No.  40.  GQnzburg's 
reagent  consists  of : 

Phloroglucin 2.0 

Vanillin 1.0 

Alcohol  absol 30.0 

4  Puriz  :  Ueber  eine  neue  Quantitative  Reaktion  auf  freie  Salzsaure 
ein  MagensafL     Centralb.  fur  klin.  Med.,  1890,  S.  452 

8  Mever :  Ueber  die  neueren  und  neuesten  Methoden  des  qualita- 
tiven  >?achweises  freier  Salzsaure  im  Mageninhalt.  Dissert.  Inaug., 
Berlin,  1890. 

*  Leo :  Diagnostik  d.  Krankheiten  d.  Verdauungsorgane.  Berlin, 
1890,  S.  98. 

T  Stewart :  Hare's  System  of  Therapeutics,  vol.  ii.,  pp.  897,  898. 


of  free  hydrochloric  acid  as  the  phloroglucin  test,  but 
that  it  can  be  as  well  used  for  quantitative  examinations 
as  the  latter,  and  perhaps  with  greater  advantage.  The 
accuracy  of  both  tests  is  about  the  same.  It  varies, 
however,  according  to  the  various  substances  in  solution 
with  the  hydrochloric  acid.  According  to  Leo,1 .004 
per  cent,  of  hydrochloric  acid  in  a  purely  watery  solution 
may  be  detected  by  GQnzburg's  reagent,  and  .006  per 
cent,  by  the  resorcin  test,  while  in  the  presence  of  other 
compounds  such  as  peptones,  a  much  higher  per  cent  of 
hydrochloric  acid  may  be  remain  undetected  by  either 
test.     The  following  is  taken  from  his  tables : 


Substances  in  Combination  with  the  Wa- 
ter)- Solution  of  HC1. 


Percentage  of  HC1  at  which  a  Reaction 
May  Still  be  Obtained. 


^dSP*  Resorcin.     Phloroglucin. 


Water 0.00a 

Acid  potassium  phosphate.      Acidity  =, 

19V10  alkali 0.008 

Albumen,  1  Albumen  to  200  HaO 0.00a 

Pepion,  2  per  cent 0.002 

Bread  paste,  30  grammes  to  aoocc  HsO  0.003 

NaCK  one  per  cent 0.003 

Grape  sugar,  1  per  cent 0.002 

Starch  paste,  2  per  cent. 0.003 


0.006 


0.09 
0.08 
0.16 

0.03 
0.05 
0.16 

0.03 
0.0037 

0.007 

O-OIX 

0.03 
0.007 
0.007 
0.007 

Inasmuch  as  certain  substances,  such  as  albuminous 
compounds,  combine  with  a  part  of  the  hydrochloric  acid 
and  neutralize  it,  it  was  necessary  for  comparison  in  the 
above  cases  to  obtain  the  absolute  quantity  of  free  HC1 
by  a  very  accurate  quantitative  method,  not  relying  on 
the  quantity  of  the  HO  which  was  added  in  the  mixture. 
According  to  recent  observations  of  Kossler  *  the  most 
accurate  method  is  the  calcium  carbonate  test  of  Leo. 
From  my  own  experiments  concerning  the  limit  of  ac- 
curacy of  phloroglucin  and  resorcin  respectively,  I  have 
found  the  following  results : 


Substances  ia  Combination  with  the  Wa- 
tery Solution  of  HC1. 


Percentage  of  HQ  at  which  a  Reaction 
May  Still  be  Obtained. 


IX5°TeSaCl1   Re*orcin.     Phloroglu 


Water 0.00a 

Acid    potassium    phosphate.    Acidity  = 

19V10  alkali  0.009 

Albumin,  t  Albumin  to  200  HaO 0.003 

Pepton,  a  per  cent 0.003 

Hread  paste,  30  grammes  to  200  c.c  HaO  0.003 

NaCI,  1  per  cent 0.003 

Grape  sugar,  1  per  cent o.coa 

Starch  paste,  2  per  cent 0.003 


0.007 

0.004 

0.080 

0.060 

0.17 

0.17 

0.04 

0.04 

0.003 

0.007 

0.007 

0.007 

0.0  X 

0.01 

These  experiments  show  that  Boas's  reagent  is  quite  as 
sensitive  as  that  of  Gilnzburg,  and  that  it  may  readily  be 
employed  for  the  detection  of  small  quantities  of  HC1  in 
place  of  the  former  reagent.  In  order  to  show  that  the 
resorcin  test  may  also  be  utilized  for  quantitative  purposes 
in  the  estimation  of  free  hydrochloric  acid,  I  have  made 
a  number  of  quantitative  estimations  of  the  free  hydro- 
chloric acid  in  a  number  of  specimens  of  gastric  juices, 
comparing  the  results  obtained  by  Boas's  and  Giinzburg's 
reagents  with  those  of  the  more  accurate  method  of  Leo. 
The  method  employed  for  the  resorcin  estimation  is  simi- 
lar to  the  one  of  Mintz,*  when  the  estimation  is  made 
with  phloroglucin. 

The  'examination  is  made  as  follows :  To  ten  c.c. 
of  gastric  filtrate  -fa  normal,  NaOH  is  added  until  a 
reaction  can  no  longer  be  obtained  by  testing  with  Boas's 
reagent.  If,  for  example,  no  reaction  occurs  after  adding 
1.3  c.c.  decinormal  NaOH,  but  a  positive  reaction 
was  still  present  with  only  1.2  c.c.  of  NaOH,  then  the 
amount  of  free  HC1  equals  1.25  calculated  for  100  cc 
=  12.5,  which  multiplied  by  .00365  =  .00456,  the  absolute 
per  cent,  of  free  hydrochloric  acid  in  100  cc.  of  gastric 

1  Leo  :  Diagnostik,  S.  09. 

1  Kossler  :  Zeitschrift  flir  Physiologische  Chemie.  Bd.  xviL,  Seite, 
107. 

*  Mintz :  Ein  einfache  Methode  zur  qualitativen  Bestimmung  der 
freien  Salzsaure  ein  Mageninhalt.  Wiener  Klin.  Wochenschrift,  1889* 
No.  20,  und  1 891,  No.  9. 


October  6,  1894] 


MEDICAL   RECORD. 


43i 


secretion.    This  method,  like  the  one  of  Mintz,  gives 
merely  approximate  but  sufficiently  reliable  results. 


Number. 

Acidity  de- 
termined 
by    phen- 
opthalein. 

Per    cent,    free 
HQ     accord 
ing  to  Leo. 

Per    cent,     free 
HC1     accord- 
ing to  Mintz. 

Per     cent,     free 
HC1  by  means 
of    Boas'f    re- 
agent. 

1 

1       '  *      ' 

0.08665 

008391 

0.081942 

? 

28 

0.08541 

0.08121 

0.07921 

3 

33 

0.090a  5 

0.08154 

0.08916 

4 

4» 

0.13656 

0.09982 

0.09971 
0.18492 

5 

68 

0.19027 

.          0.18341 

6 

6i 

0.29035 

0.24  72  x 

0.84654 

7 

56 

0.19877 

0.17793 

0.17343 

8 

1       72 

0.314 16 

0. 19926 

0.19997 

9 

1       75 

0.23591 

0.22021 

0  33154 

10 

67 

0.21976 

0.30987 

0.30791 

XI 

80 

0.31999 
0.09984 

0,21337 

0.2.8*7 

1a 

!            3° 

0x8963 

0.08728 

*3      *• 

1            41 

0.13x43 

1              0. 13 102 

0.11994 

M 

44 

0.14227 

O.XJ2I3 

0.1 5982 

15 

12 

0.11929 

0.108ia 

0. 10927 

16 

0.28984 

0.369X5 

0.26303 

\l 

* 

0.18824 

O.I430a 

0.14059 

0.30981 

O.27536 

0.37316 

>9 

^ 

o-34453 

O.31247 

0. 33243 

so 

46 

0.154 10 

0.14739 

0  14327 

The  above  table  shows  that  while  neither  Giinzburg 
nor  Boas's  reagents  give  perfectly  reliable  figures,  results 
sufficiently  accurate  for  practical  purposes  may  be  ob- 
tained with  either.  It  yet  remains  to  show  the  advan- 
tages of  the  resorcin  test  over  phloroglucin. 

1.  Phloroglucin  is  quite  unstable  and  frequently  de- 
composes when  kept  for  some  time.  Boas  has  recog- 
nized this  fact  and  has  modified  the  formula  thus  : 

9 .    Phloroglucin 2.0 

Vanillin 1.0 

Alcohol  (eighty  per  cent. ) 100.0 

making  it  more  stable. 

The  resorcin  test  may  be  kept  for  years  in  a  dark  col- 
ored bottle  without  undergoing  decomposition  or  in  any 
way  losing  its  sensitiveness. 

2.  Resorcin  can  be  had  at  any  pharmacist's,  at  a  trifling 
expense,  while  phloroglucin-vanillin  is  a  comparatively 
expensive  substance  which  can  only  be  purchased  from 
the  agents  of  the  European  manufacturers.  I  have  re- 
peatedly used  with  advantage  filter-paper  dipped  in  Boas's 
reagent  and  allowed  to  dry  to  make  the  tests,  in  a  man- 
ner similar  to  the  phloroglucin  test-paper  of  Rosenheim1 
and  Boas.  * 

RECENT  INVESTIGATIONS  OF  THE  THERA- 
PEUTIC VALUE  OF  ORGANIC  FLUIDS,  ESPE- 
CIALLY SPERMINE,  IN  STERILIZED  SOLU- 
TIONS.* 

By  G.  E.  KRIEGER,  M.D., 

CHICAGO,  ILL. 

Some  five  years  ago  the  eminent  physiologist  and  neurolo- 
gist, Brown  Slquard,  established  the  fact  that  the  tes- 
ticles of  young  animals  contain  chemical  substances  of 
high  dynamo-genetic  properties,  and  since  then  a  great 
many  scientific  investigations  have  been  made  in  order 
to  reveal  the  character  of  those  agents.  The  novelty  of 
this  discovery  has  led,  at  first,  to  very  different  criticisms, 
and  the  prevailing  incredulity  that  anything  could  exist 
which  would  be  of  such  a  remarkable  power  as  claimed 
by  the  author,  rendered  the  majority  of  the  profession 
unquestionable  opponents  of  the  new  doctrine.  The 
announcements  of  Brown-S6quard  regarding  injections 
of  testicular  juice  on  patients  suffering  from  nervous  and 
functionary  debility,  were  ridiculed  and,  frequently  with- 
out examination,  Brown-S6quard's  statements  were  flatly 
denied. 

The  efforts  on  the  part  of  the  inventor  of  this  method 
could  not  prevent  advantage  being  taken  of  some 
failures  and  septic  accidents,  probably  due  to  a  lack  of 
asepsis  in  the  preparation  of  the  remedy,  or  during  its 
application,  and  for  quite  a  while  bis  method  seemed  to 
be  condemned  as  well  by  the  public  as  by  the  profession. 

1  Rosenheim :  Deutsch.  Med.  Wochenschrift,  1891,  No.  49. 
3  Boas :  Diagnostic  u.  Therapie  der  Magenkrankheiten,  Leipzig, 
1891,  Seite,  134,  and  Deutsche  Med.  Wochenschrift,  1891  S.  1080. 
*  Read  before  the  Chicago  Medical  Society,  March  5th. 


However,  reports  of  other  experimenters  became  more 
and  more  encouraging,  and  what  first  had  been  looked 
upon  as  a  worthless  idea  of  an  enthusiastic  head,  is 
to-day  considered  a  discovery  of  the  greatest  therapeutic 
value.  In  fact  the  remarkable  results  obtained  in  some 
nervous  affections,  which  previously  were  irremediable, 
have  made  the  subject_worthy  of  the  most  careful  inves- 
tigation. 

In  1878  the  German  chemist,  Phil.  Schreiner,  as  de- 
scribed in  the  Annals  of  Chemistry  and  Pharmacology, 
found  and  analyzed  in  testicular  juice  a  substance, 
called  spermine,  which,  at  first,  by  other  chemists  was 
declared  identical  with  sethylenimin.  Later,  however,  by 
the  ingenious  researches  of  Professor  Alexander  Poehl,  in 
St.  Petersburg,  it  was  proven  that  spermine  is  an  organic 
base  with  characteristic  properties,  and  that  it  can  be 
prepared  from  almost  any  organ,  especially  the  various 
reproductive  glands  of  animals. 

Professor  Poehl's  first  publication  of  these  investiga- 
tions in  the  St.  Petersburg  Medical  Society,  in  1890, 
was  received  with  great  interest  by  the  Russian  and  Ger- 
man profession,  and  was  soon  followed  by  clinical  exper- 
iments of  noted  medical  men,  who  all  agreed  that  sper- 
mine is  the  active  principle  of  Brown-  S6quard's  fluid 
and,  as  a  first-class  stimulant,  a  therapeutic  of  unlimited 
value. 

Such  prominent  physicians  as  Dr.  Rotchinin  and 
Professor  Tarchanow  in  St.  Petersburg,  have  reported  a 
great  number  of  cases  treated  successfully  with  spermine 
injections,  some  of  which  I  would  like  to  mention. 

Case  I. — Gentleman,  fifty- three  years  of  age,  suffering 
from  asthma,  angina  of  the  chest,  and  very  low  action  of 
the  heart,  was  treated  with  ten  injections,  after  which  all 
symptoms  greatly  improved.  He  could  climb  stairs 
without  trouble. 

Case  II. — Another  gentleman,  sixty  years  of  age,  with 
short  breath,  pain  in  the  chest,  low  pulse,  recovered 
also  very  rapidly. 

Case  III. — A  physician,  seventy  years  of  age,  with 
paralysis  of  the  right  leg  and  arm,  paralysis  of  right 
facial  nerve,  and  aphasia,  showed  marked  improvement 
after  the  second  injection. 

Case  IV. — A  man,  sixty-five  years  of  age,  with  dia- 
betes (4. 7  per  cent,  sugar),  dizziness,  general  debility, 
so  that  he  could  not  walk,  was  jgreatly  benefited  by  the 
injections.  The  sugar  was  reduced  to  about  two  per  cent. 

From  these  and  many  other  experiments,  Dr.  Rotch- 
inin came  to  the  following  conclusions :  The  effect  of 
spermine  injections  is  that  of  a  strong  stimulant,  and 
corresponds  with  those  obtained  by  injections  of  Brown- 
S6quard's  fluid.  It  has,  however,  several  advantages 
over  the  latter.  1.  No  danger  of  local  inflammation,  as 
frequently  observed  after  the  use  of  Brown-Slquard's 
fluid.  2.  No  fever  or  other  symptoms  caused  by  septic 
elements.  3.  Equality  of  concentration  of  the  fluid  ad- 
ministered. 

According  to  Professor  Tarchanow's  investigations,  a 
direct  effect  of  spermine  injections  upon  the  blood's  cir- 
culation has  been  observed.  The  action  of  the  heart  is 
greatly  retarded,  and  the  height  of  the  pulse  and  its 
strength,  as  shown  by  the  sphygmograph,  five  times,  and 
even  more,  increased.  These  phenomena  are  explained 
by  a  stimulation  of  the  nervous  centres,  especially  the 
heart  ganglia  and  the  vasomotor  nerves.  Doctors  Sich* 
arew  and  Hubbenet,  in  the  St.  Petersburg  Kalinkin 
Hospital,  reported  the  following  interesting  case : 

A  woman,  twenty-nine  years  of  age,  who  had  suffered  for 
thirteen  years  from  syphilis,  was  treated  with  blue  oint- 
ment for  the  last  six  years.  She  became  very  anaemic; 
had  at  the  time  three  ulcers  on  her  forehead,  two  of 
which  affected  the  bone ;  on  the  right  radius  periostitis 
gummosa,  which  made  the  movement  of  the  hand 
very  painful;  inflammation  of  the  right  knee-joint, 
which  was  greatly  swollen  ;  periostitis  on  the  right  tibia ; 
oedema  on  lower  limb  and  foot ;  movability  of  the  right 
knee-joint  but  fifteen  degrees;  gait  very  uncertain, 
digestion  poor,  frequent  diarrhoea,  pulse  weak.     In  this 


43* 


MEDICAL   RECORD. 


[October  6,  1894 


condition  the  patient  was  put  under  the  treatment  of 
spermine  injections.  The  pulse  strength  in  the  right 
hand  and  general  feeling  improved  after  the  second  in- 
jection. Pain  of  the  right  wrist  decreased,  oedema  of 
the  leg  disappeared,  and  even  the  movability  of  the  knee 
was  restored  almost  to  the  normal  condition  after  five 
injections.  The  pulse,  being  106  before,  fell  to  86. 
The  digestion  became  normal,  and  the  muscular  strength 
increased  about  fifty  per  cent,  within  ten  days. 

Another  startling  effect  was  obtained  by  Dr.  Procho- 
row  on  a  man  who  suffered  from  chronic  ulcers  of  the 
lower  leg,  and  who  for  several  months  had  been  treated 
in  a  hospital  without  success.  After  the  second  injection 
the  ulcers  commenced  to  heal,  and  within  three  weeks 
the  patient  was  cured.  From  such  and  a  great  many 
other  results,  published  by  competent  authors,  one  is 
justified  in  concluding  that  spermine  has  doubtless  some 
dynamo-genetic  power,  and  it  remains  to  be  explained 
what  function  it  has  as  a  normal  factor  of  the  organism. 

We  know  that  by  the  chemical  change  of  material 
some  products  originate  which  are  poisonous  to  the  sys- 
tem, and  are,  therefore,  by  the  aid  of  some  glandular  or- 
gan, discharged  from  the  circulation.  Without  doubt 
such  poisonous  products  must  have  antagonists  which 
render  them  comparatively  harmless  during  their  pres- 
ence in  the  body,  and  in  this  way  prevent  auto-intoxica- 
tion. Therefore  such  agents  are  of  substantial  impor- 
tance to  the  system.  In  an  average  healthy  organism  a 
physiological  balance  is  observed  between  these  two 
chemical  opponents.  If  the  noxious  products  increase, 
or  the  stimulating  agents  decrease,  it  means  a  lack  of 
resistance  and  strength — a  disposition  to  disease.  If, 
on  the  other  hand,  the  stimulating  agents  are  predomi- 
nating, it  means  vigor  and  health.  If  such  is  the  case, 
why  should  it  not  be  possible,  by  the  introduction  of 
such  stimulating  agents  into  the  system  with  which  the 
organism  defends  itself,  to  overcome  the  lack  of  resist- 
ance brought  on  by  any  cause  which  is  detrimental  to 
health? 

The  difficulty,  of  course,  will  be  to  prove  that  the 
substance  artificially  obtained  is  identical,  or  at  least 
similar,  to  those  prepared  in  the  organism.  It  is  not 
very  long  ago  that  Charcot  and  Leyden  made  the  dis- 
covery that  in  certain  diseases  on  the  surface  of  the 
lungs,  spleen,  and  other  organs,  small  crystals  appeared, 
the  significance  of  which  was  not  understood  until  later 
examinations  revealed  their  chemical  composition.  The 
crystals  found,  especially  in  asthmatic  persons,  and 
known  as  Charcot  Leyden  crystals,  are  nothing  else 
but  phosphate  of  spermine.  These  crystals  have  also 
been  found  in  the  discharges  of  persons  with  typhoid, 
consumption,  cholera ;  in  leucaemia  and  other  diseases. 
By  their  discharge  from  the  circulation  the  organism  of 
such  patients  evidently  lost  a  quantity  of  spermine,  and 
therefore  such  stimulation  to  the  nervous  centres  as  would 
be  necessary  to  check  the  power  of  weakening  elements. 
The  evidence  of  the  chemical  relation  between  these 
crystals  and  spermine  led  to  the  treatment  of  asthmatic 
persons  with  injections  of  spermine,  and,  as  anticipated, 
generally  with  good,  sometimes  with  excellent,  success. 
Lately  I  treated  a  case  which  greatly  improved  after  ten 
injections.  There  can,  therefore,  be  no  doubt  that 
spermine  has  a  stimulating  effect  upon  those  centres  to 
which  the  cause  for  asthmatic  attacks  is  attributed. 

Not  less  remarkable  results  were  obtained  in  cases  of 
neurasthenia  and  anaemia.  Professor  Sicharew1  reported 
several  cases  of  severe  neurasthenia  with  agrophobia 
and  claustrophobia — those  strange  phenomena  in  persons 
who  become  dizzy  and  nervous  while  being  on  a  wide 
field,  and  who  feel  frightened  when  inclosed  in  a  room 
— in  which  cases  these  symptoms  disappeared  after  in- 
jections of  spermine.  In  another  case  of  severe  anaemia 
the  person  referred  to  had  nine  or  ten  hysteric  spells 
daily,  suffered  from  insomnia  and  great  weakness ;  perfect 
cure  was  obtained.  An  old  gentleman,  sixty-three  years 
of  age,  with  general  debility,  apathetic  to  his  surround- 

»  B;rl.  Klin.  Woch.,  No.  40,  1891. 


ings,  unable  to  follow  a  conversation  or  to  move  about, 
improved  so  much  that  he  could  walk  alone  and  grew 
stronger  physically  and  mentally. 

A  special  effect  seemed  to  be  obtained  by  spermine 
upon  the  spinal  plexus ;  quite  a  number  of  cases  of  loco- 
motor ataxia  have  been  reported  in  which  either  a  per- 
fect and  lasting  cure,  or  at  least  a  great  improvement, 
was  the  result  of  spermine  injections. 

A  patient  of  Dr.  Sicharew,1  fifty-three  years  old,  with 
myelitis  of  the  lumbar  part  of  the  spinal  cord,  causing 
paresis  of  the  lower  extremities,  incontinence  of  urine, 
constipation,  and  loss  of  his  sexual  energy,  recovered 
after  nine  injections. 

To  quote  from  the  statistics  of  182  cases  recently  pub 
lished  in % the  Berlin  Klin.  Woch.,  an  exceedingly  good 
effect  was*  secured  in  52  cases  of  neurasthenia.  Only  2 
did  not  show  an  improvement.  From  14  cases  of  loco- 
motor ataxia,  12;  from  23  with  other  nervous  troubles, 
21  improved.  Also  57  with  general  debility,  9  with 
scorbutus,  14  with  consumption,  have  shown  a  favorable 
effect. 

Very  much  interested  by  all  these  reports,  I  have  made 
this  subject  a  special  study  for  over  a  year,  and  have  in- 
vestigated the  therapeutic  value  of  spermine  on  my  pa- 
tients. To  have  sufficient  material  without  depending 
on  the  Russian  drug,  which  is  very  expensive — about  two 
dollars  a  dose — I  have  experimented  for  fourteen  months 
in  my  laboratory,  fitted  up  for  the  purpose  of  securing  an 
equally  effective  substance,  and  finally  succeeded  in  get- 
ting the  specimen  I  wished  to  obtain.  I  also,  by  the 
courtesy  of  Professor  Poehl,  in  St.  Petersburg,  with 
whom  I  communicated,  got  into  possession  of  a  quan- 
tity of  his  preparation,  which  I  used  to  compare  the 
effects  obtained  from  his  spermine  and  the  one  prepared 
by  myself.  The  result  was  equally  favorable  in  cases 
selected  for  this  treatment.  I  have  since  been  supported 
in  the  investigation  of  the  therapeutic  value  of  my  prod- 
uct by  other  gentlemen,  who  are  present  to  night,  and 
wish  to  demonstrate  the  result  of  some  cases  which  have 
been  treated  during  the  last  three  months. 

Case  I. — Mrs.  H ,  thirty-nine  years  of  age,  five 

feet  three  inches  high,  very  stout,  weighs  one  hundred  and 
ninety  pounds.  Has  always  menstruated  regularly,  but 
generally  with  great  pain.  Was  married  sixteen  years 
ago,  has  two  children.  Since  the  last  two  years  she  has 
suffered  from  abdominal  and  lumbar  neuralgia,  for  which 
she  was  repeatedly  treated,  without  success.  The  ab- 
dominal organs  are  in  a  normal  condition.  Patient  had 
also  frequent  palpitations  and  neuralgic  pain  of  the  heait, 
was  very  irritable,  nervous,  and  easily  frightened ;  could 
not  sleep  well,  and  complained  of  frequent  headaches. 
In  this  condition  she  came  to  me  three  weeks  ago.  Tak- 
ing the  symptoms  described  as  caused  by  general  neuras- 
thenia, I  advised  her  to  be  treated  by  spermine  injec- 
tions. After  one  injection  of  a  ten  grain  spermine 
solution  she  felt  easier  and  quieted.  She  received  one 
dose  daily  for  nine  days,  during  which  she  evidently  im- 
proved. On  the  fifth  day  she  stated  that  all  her  ailments 
had  left  her,  and  her  husband  claimed  that  she  had 
changed  remarkably.  It  is  now  twenty  days  since  the 
first  injection  was  given,  and  for  the  last  two  weeks  the 
patient  has  felt  perfectly  well. 

Case  II. — Another  treatment  I  began  on  this  gentle- 
man, who  is  seventy  years  of  age,  and,  as  you  see,  in 
apparently  very  good  condition.  He  was  never  sick  up 
to  his  sixty-fifth  year ;  in  1889  he  had  an  attack  of  inflam- 
matory rheumatism  of  the  joints;  in  1890  was  treated 
for  gravel  in  the  bladder,  which  disappeared  after  the 
use  of  lithia  water,  and  since  the  last  four  years  com* 
plains  of  neuralgic  pain  in  the  head  and  lumbar  regions, 
heaviness  in  the  legs,  general  weakness,  and  insomnia.  I 
attributed  these  symptoms,  naturally,  to  his  advanced 
age,  and  thought  spermine  would  refresh  him.  The  in- 
jections, given  as  usual  in  the  back,  affected  him  in  a 
peculiar  way.  He  claimed  to  feel  them  all  through  his 
chest  as  a  warm,  stimulating  agent,  and  soon  assured  me 
1  Petersburg  Med.  Ges.,  February  26,  1891. 


October  6,  1894] 


MEDICAL  RECORD. 


433 


of  their  good  effect  upon  his  general  health.  The  neu- 
ralgic pain  in  the  back,  and  weakness  in  the  limbs  disap- 
peared, his  sleep  and  strength  improved,  the  headache 
became  less,  and  taking  all  together,  he  says  he  feels 
twenty  five  years  younger. 

Case  III. — Of  special  interest,  I  think,  is  another  case 
which  I  would  like  to  present,  and  about  which  I  would 
be  glad  to  hear  the  opinion  of  some  gentlemen  who 
make  diseases  of  the  nervous  system  a  specialty.  From 
the  most  apparent  symptoms  I  may  call  it  a  case  of 
spinal  sclerosis,  but  it  seems  to  me  that  there  are  also 
other  atrophic  processes,  possibly  of  a  cerebral  nature. 
As  far  as  I  could  learn,  the  history  is  as  follows :  The 
patient,  a  man,  fifty  seven  years  of  age,  five  feet  ten 
inches  tall,  weighed  two  hundred  and  thirty  pounds,  was 
always  in  good  health  up  till  March,  1893.  He  did  not 
indulge  in  alcoholic  drinks,  never  suffered  from  syphilis, 
but  was  a  heavy  smoker.  In  March,  1893,  ne  com- 
plained of  slowly  growing  weakness  -in  the  right,  later  in 
the  left,  leg.  His  limbs  were  as  if  burdened  by  weights. 
Then  a  constant  dizziness  in  the  head  set  in.  He  was 
treated  for  apoplexy,  with  no  effect.  The  weakness  of 
his  legs  progressed  until  they  would  not  carry  him  any 
more.  His  dizziness  also  grew  worse ;  he  became  irrita- 
ble, nervous  ;  could  not  sleep,  but  had  fair  appetite  and 
digestion.  He  was  under  the  treatment  of  several  physi- 
cians, the  last  of  whom  supposing  the  disease  was  of 
syphilitic  origin,  put  him  under  inunctions  and  iodide  of 
potash.  The  patient  lost  about  thirty  pounds.  His  con- 
dition, however,  did  not  improve,  and  when  I  saw  him 
first,  on  February  6th,  I  found  the  following  state  : 

A  man,  strongly  built,  sat  in  an  arm-chair,  his  features 
showing  signs  of  despair,  his  eyes  were  clear  but  un- 
steady ;  he  was  unable  to  rise,  or  even  to  raise  his  legs, 
but  could  move  his  arms  pretty  freely.  His  grasp  was 
weak,  and  the  movement  of  the  hand  and  arm  somewhat 
inco-oxdinated ;  for  instance,  when  he  wanted  to  reach 
for  something  he  foiled  to  strike  it.  The  fingers  spread 
apart,  trembled;  on  the  fingertips  and  under  the  sole 
he  had  a  numb  and  prickling  sensation.  He  was  free  of 
pain,  but  complained  of  a  heavy  and  dizzy  feeling  in  his 
head.  Reflex  of  the  pupils  was  good.  When  lifted  from 
the  chair  he  could  stand,  his  legs  spread  apart  about 
eighteen  inches.  With  closed  legs  he  tumbled.  He 
also  became  very  uncertain  with  his  eyes  closed.  Sup- 
ported on  either  side  he  tried  to  walk;  the  legs  were 
moved  with  difficulty  and  inco-ordinately ;  the  feet  were 
swung  forward  and  set  down  with  force,  as  though  the 
patient  was  uncertain  in  reaching  the  floor ;  brought  back 
to  his  chair  he  felt  very  tired.  The  sensibility  of  the 
skin  and  reflex  of  the  patella  were  but  little  disturbed. 
The' functions  of  the  bladder  and  rectum  have  lately  be- 
come weak,  the  patient  has  frequent  pressure  to  pass 
urine,  the  examination  of  which  showed  nothing  ab- 
normal. Examination  of  the  eyes  showed  atrophy  of  the 
left  optic  nerve,  otherwise  no  characteristic  signs.  For 
the  last  two  months  he  has  been  unable  to  lie  down,  was 
obliged  to  sit  up  all  night,  and  compelled  to  sleep  in  his 
chair.  He  also  complained  of  an  almost  constant  ring- 
ing noise  in  his  ears. 

In  this  condition  I  subjected  him  to  a  treatment  of 
spermine  injections,  with  the  following  effect :  After  five 
injections  he  could  easily  rise  and  stand  with  his  heels  and 
toes  closed,  without  tumbling.  He  got  fifteen  injections 
altogether  and  is  now  able  to  walk  fairly  well,  and  even 
to  climb  stairs  with  some  effort.  He  feels  a  great  deal 
stronger,  can  lie  down  and  sleep  sometimes  all  night. 
During  this  treatment  I  avoided  any  other  therapeutic 
aid.  The  only  symptom  that  still  annoys  him  is  the 
dizziness  in  the  head,  to  which  he  pays  so  much  more  at- 
tention after  being  relieved  from  the  confinement  to  his 
chair. 

On  these,  and  quite  a  number  of  other  cases,  I  have 
studied  the  effect  of  spermine  injections,  and  have  had  in 
some  of  them  surprisingly  good  results,  while  the  rest 
were  more  or  less  favorably  affected.  One  feature  I 
would  like  to  emphasize ;  spermine  seems  to  be  a  direct 


antidote  against  the  bad  effects  of  anaesthetics,  probably 
due  to  the  stimulation  of  the  heart  action.  In  1891  the 
Russian  surgeon,  Weljaminoff,  and  recently  I,  myself,  have 
observed  that  patients  who  received  one  spermine  injection 
shortly  before  an  operation  was  to  be  performed,  had  a 
splendid  narcosis,  and  no  nausea  or  any  other  bad  effect 
after  they  awoke.  In  order  to  ascertain  if  their  condition 
was  really  obtained  by  the  action  of  spermine,  I  have  ex- 
perimented in  the  Chicago  Hospital  on  a  patient  who 
had  to  take  ether  several  times.  He  was  a  man  of  thirty- 
nine  years  of  age,  upon  whom  I  was  going  to  perform 
Lange's  or  Whitehead's  operation  for  haemorrhoids.  He 
received  a  fifteen-grain  spermine  solution  shortly  before 
the  anaesthetic  was  given.  He  was  one  hour  and  a  half 
under  the  influence  of  ether ;  had  a  splendid  narcosis, 
and  when  he  awoke  felt  perfectly  well.  Eight  days  later 
I  gave  him  again  some  ether  to  remove  the  stitches  with- 
out using  spermine.  He  then  was  only  fifteen  minutes 
under  the  influence  of  the  narcotic,  but  it  took  him  all 
day  to  overcome  the  nausea  and  bad  feeling  with  which 
he  awoke.  It  is,  of  course,  a  question  in  how  many 
cases  such  a  favorable  effect  will  be  obtained,  and  I  do 
not  doubt  that  frequently  the  injections  may  fail  to  act  as 
desired,  but  still  I  think  it  may  be  worth  trying. 

Before  I  conclude  I  wish  to  say  a  few  words  about  the 
chemical  and  physiological  properties  of  spermine. 
Spermine,  according  to  the  analysis  of  Phil.  Schreiner,1 
is  a  substance  with  the  chemical  formula  Cs  H6  N.  Like 
other  bases  it  forms  salts  when  in  contact  with  acids  or 
metals.  Some  of  these  salts  are  long  prismatic  crystals 
which,  though  prepared  by  chemicals,  retain  the  physio- 
logical properties  that  spermine  possesses.  Such  crystals 
I  have  photographed  from  microscopical  specimens ;  the 
specimens  were  obtained  from  preparations  from  different 
organs:  No.  1,  from  testicles  of  a  young  bull;  No.  2, 
from  ovaries  of  a  young  cow.  Nos.  3  and  4,  prepared  in 
a  different  way,  are  not  as  pure  as  the  first  ones ;  No.  3  is 
made  from  a  small  quantity  of  genuine  Brown-  Seqaard's 
fluid ;  No.  4,  from  an  extract  of  pancreas.  Regarding 
the  chemical  composition,  spermine  belongs  to  the  group 
of  the  imins,  and  has  at  first  by  some  chemists  been 
taken  for  sethylenimin,  which  has  the  formula  C,H4NH  ; 
that  is,  the  same  elements,  but  in  another  group.  By 
the  investigations  of  Professor  Poehl  this  opinion  has 
been  proved  to  be  a  mistake.  He  found  that  spermine 
is  a  base/ir  se,  with  certain  characteristic  properties  dif- 
ferent from  those  substances  with  equal  elements.  Some 
of  its  reactions  are  :  1.  With  chloride  of  gold  it  forms  a 
yellow  precipitate,  which  later  changes  into  fiat  crystals. 
2.  With  chloride  of  platina  it  forms  a  crystalline  precipi- 
tate. 3.  With  sodium  of  tungstate  it  gives  a  cloudy  pre- 
cipitate soluble  in  alkalies,  insoluble  in  acids.  The 
most  characteristic  property  is  a  smell  like  human  sperma, 
if  spermine  is  brought  in  contact  with  chloride  of  gold 
and  metallic  magnesia.  I  have  here  a  sample  of  such 
combination,  and  you  may  convince  yourselves  that  my 
preparation  really  contains  spermine.  It  was  for  these 
reactions  that  I  worked  over  a  year  and  made  many 
thousands  of  experiments ;  after  which  I  learned  to  under- 
stand why  such  a  noted  firm  as  Merck  &  Co.  pronounced, 
in  the  Pharmaceutical  Zeitschrift  for  Russia  in  1890, 
that  they  did  not  succeed  in  preparing  this  valuable  sub- 
stance. The  same  statement  has  been  made  by  other 
chemical  firms ;  and  I  think  this  is  the  reason  why,  up  to 
date,  spermine  has  not  appeared  in  the  list  of  our  modern 
therapeutics.  Professor  Poehl  himself  said,  in  the  Berlin 
Klin,  Woeh.,  1891,  "  The  conditions  by  which  spermine 
crystals  may  be  obtained  from  solutions  which  contain 
spermine  are  sometimes  very  difficult  to  determine ;  " 
and  I  also  have  found  that,  when  I  repeated  the  same 
process  on  the  same  preparation,  I  would  at  times  not  ob- 
tain the  same  crystallization  as  previously  found. 

Regarding  the  physiological  action  of  spermine,  chemi- 
cal and  physiological  experiments  have  revealed  the  fact 
that  the  stimulation~and  otherwise  beneficial  effects  from 
spermine  injections  are  very  natural.     Since  it  is  known 

1  Ann.  Chem.  Pharm.,  1878,  194. 


434 


MEDICAL   RECORD. 


[October  6,  1894 


that  spermine  is  not  only  an  important  factor  of  the  re- 
productive glands  in  the  male  as  in  the  female  organism, 
but  also  exists  in  the  thyroid  gland,  the  thymus,  pancreas, 
spleen,  and  other  organs,  it  has  become  evident  that  sper- 
mine is  a  normal  substance  circulating  in  the  blood, 
which  has  to  and  does  accomplish  a  certain  task  in  the 
economy  of  life.  Medical  science  was  greatly  mistaken 
when  it  was  believed  that  some  organs,  as  the  spleen, 
subrenal  glands,  and  others,  were  of  no  use  in  a  biological 
respect,  and  could  just  as  well  be  parted  with.  By  the 
bad  effect  obtained  from  the  extirpation  of  the  thyroid 
gland  we  have  been  convinced  that  in  this,  as  in  other 
glands,  a  substance  is  produced  which  is  absolutely  neces- 
sary for  our  system,  and  which  is  probably  similar  to 
spermine ;  and  so  I  believe  that  an  important  function 
of  those  organs  is  the  production  of  spermine.  The  fact 
that  male  animals  deprived  of  their  sexual  glands  in  their 
early  days  cannot  compete  in  strength  with  their  brothers, 
who  are  still  in  possession  of  these  vital  organs,  has  led 
to  the  interesting  experiment  on  dogs  to  inject  spermine 
as  a  substitute.  Of  four  young  dogs,  all  brothers,  two 
treated  this  way,  after  being  castrated,  grew  twice  as  large 
and  strong  as  the  other  two.  The  incorporation  of  such 
substances  as  are  produced  in  our  glands  into  the  blood 
is  therefore  a  very  natural  support  of  a  physiological 
process. 

The  manner  in  which  spermine  acts  upon  the  organ- 
ism has  been  carefully  studied  by  Tarchanoff,  Poehl,  and 
others,  who  are  of  the  opinion  that  the  stimulative  effect 
of  spermine  is  due  to  its  great  oxidizing  power.  This 
theory  is  supported  by  the  following  facts  : 

1.  Metallic  magnesia  in  solution  of  the  chloride  of  a 
metal  changes  into  oxide  of  magnesia  by  the  influence 
of  spermine  in  very  small  quantity. 

2.  The  blood,  if  influenced  by  chemical  agents  which 
diminish  its  oxidizing  power,  as  chloroform,  oxydul  of 
nitrogen,  strychnia,  urea,  can  be  brought  to  its  normal 
condition  by  the  support  of  spermine.  This  explains  the 
favorable  effects  of  spermine  injections  during  and  after 
the  narcosis. 

3.  A  direct  test  for  the  oxidizing  power  of  spermine 
was  obtained  by  quantitative  examinations  of  the  urine 
before  and  after  spermine  injections,  which  showed  a 
stronger  oxidation  of  the  albuminoids  after  the  injec- 
tions. 

From  these  facts  it  does  not  seem  strange  that  in  dis- 
eases which  diminish  the  oxidizing  energy  of  the  blood 
and  nervous  system,  as  in  neurasthenic,  anaemic,  cachec- 
tic persons,  spermine  injections  have  a  very  favorable 
effect.  The  same  observation  has  been  made  in  auto- 
intoxications, that  is,  in  diseases  where  the  products  of 
the  regressive  albumin  metamorphosis  accumulate  in  the 
organs. 

A  very  important  factor  for  the  effect  of  spermine  is 
the  alkalinity  of  the  blood.  As  a  rule,  in  all  the  named 
diseases,  as  well  as  in  acute  fevers,  as  typhoid,  scarlet, 
pneumonia,  erysipelas,  the  blood  possesses  a  higher  de- 
gree of  acidity,  in  which  spermine  becomes  insoluble, 
and  therefore  inactive.  If  the  acidity  is  neutralized,  as, 
for  instance,  in  diabetes,  by  the  use  of  Carlsbad  salts, 
the  spermine  gets  its  activity  again,  and  the  improved 
oxidation  causes  the  disappearance  of  sugar  in  the  urine. 
The  same  result  has  been  obtained  without  alkalizing 
the  blood  by  artificial  introduction  of  spermine.  As  the 
latter  is  a  normal  substance  of  the  organism  its  applica- 
tion is  an  imitation  and  support  of  nature,  and  therefore 
entirely  harmless  if  used  under  certain  precautions. 

It  is  different  from  Brown-Slquard's  fluid,  inasmuch  as 
the  latter  contains  a  number  of  substances,  as  kreatin, 
kreatinin,  hypoxanthin,  lecithin,  guanin,  nuclein,  and 
so  on,  which  do  not  benefit  and  may  hurt.  Further- 
more, as  it  is  known  that  the  organs  from  which  the 
emulsion  known  as  Brown-S6quard's  fluid  is  obtained 
often  contain  the  germs  of  disease  and  other  products, 
the  toxines  cannot  be  eliminated  by  the  way  the  fluid  is 
prepared,  and  is,  in  a  strict  sense  of  asepsis,  not  a  safe 
method.    The  injections  are  sometimes  followed  by  an 


abscess,  an  accident  that  has  recently  occurred  in  this 
city  in  the  hands  of  a  physician  of  very  high  standing,  a 
complication  I  have  never  seen  reported  nor  observed 
after  spermine  injections. 

The  isolation  of  the  active  principle  is  therefore  of 
vital  importance,  and  besides  has  the  advantage  that  the 
dose  can  be  regulated,  which  is  impossible  in  Brown- 
S6quard's  fluid,  because  no  one  can  tell  how  much  sper- 
mine it  contains.  The  solution  I  use  is  equal  to  two  per 
cent.,  and  always  bacteriologically  tested  before  being  put 
in  flasks,  so  I  am  sure  it  will  be  aseptic;  and  although  I 
do  not  claim  that  it  will  have  the  desired  effect  in  every 
case,  on  the  contrary  am  fully  prepared  to  see  occasion- 
ally a  failure,  I  think  the  subject  is  worth  trying. 

As  far  as  the  technique  is  concerned,  I  have  found  it 
advisable  to  use  a  series  of  from  ten  to  fifteen  injections, 
one  a  day,  commencing  with  small  doses,  about  five  to 
ten  minims,  and  gradually  increasing  the  dose  to  twenty 
minims.  The  number  of  doses  required  is,  however,  a 
matter  of  personal  judgment,  and  sometimes  two  or 
three  injections  are  sufficient  to  secure  a  remarkable 
effect. 

In  order  to  keep  this  solution  perfectly  aseptic  I  have 
put  up  single  doses  in  separate  flasks,  as  the  one  demon- 
strated. They  are  opened  by  hitting  against  the  neck, 
which  will  break  at  the  mark.  The  fluid  is  then  taken 
out  with  a  hypodermic  needle,  which  should  always  be 
thoroughly  cleansed  before  and  after  using.  The  most 
aseptic  instrument  for  the  purpose  is  a  syringe  with  a 
piston  of  asbestos.  It  seems  practical  to  inject  very 
slowly  after  the  skin  has  been  thoroughly  sterilized. 
With  these  precautions,  I  have  never  had  any  trouble, 
except  slight  local  irritation. 

In  conclusion,  I  wish  to  resumS  the  different  effects 
obtained  by  spermine  injections  in  various  diseases 
treated  by  other  physicians  and  myself: 

1.  The  action  of  the  heart  is  stimulated.  (Drs.  Hub- 
benet,  Sicharew,  Rotschinin,  Nicholsky,  Philipps,  Tarch- 
anow,  Krieger.) 

2.  The  respiration  becomes  easier,  more  regular,  and 
less  frequent.  (Drs.  Nastjukoff,  Rotschinin,  Injaseff- 
sky.) 

3.  The  general  feeling  improves.  (Drs.  Stange,  Kis- 
sel, Rotschinin,  Hubbenet,  Ritter,  Krieger.) 

4.  The  muscular  strength  increases.  (Drs.  Tarcha- 
now,  Sicharew,  Rotschinin.) 

5.  Sleep  and  appetite  improve.  (Drs.  Nicholsky, 
Wikterow,  Philipps,  Krieger.) 

6.  CEdema,  due  to  lack  of  power  in  the  arterial  sys- 
tem, disappears.  (Drs.  Hubbenet,  Sicharew,  Rotsch- 
inin.) 

7.  Sugar  in  the  urine  decreases.  (Drs.  Tarchanow, 
Poehl.) 

8.  Ataxy  of  muscles,  especially  caused  by  spinal 
troubles,  decreases.  (Drs.  Sawitsch,  Wiktorow,  Hubbe- 
net, Krieger.) 

9.  Neuralgia,  especially  of  lumbar  origin,  disappears. 
(Drs.  Rotschinin,  Ritter,  Krieger.) 

10.  The  sexual  functions  are  stimulated.  (Drs.  Sicha- 
rew, Hubbenet,  Tarchanow,  Krieger.)  This  may  be 
taken  as  a  result  of  general  improvement,  but  in  my  esti- 
mation should  not  be  considered  a  specific  effect. 

11.  The  functions  of  the  bladder  and  kidneys,  also  of 
the  intestinal  tract,  improve. 

12.  Local  reactions  are  either  of  a  slight  and  harmless 
nature  or  do  not  happen  at  all. 

Although  such  favorable  results  have  been  recorded  in 
hundreds  of  cases,  I  do.  not  wish  to  say  that  they  will 
always  be  obtained,  and  we  have  to  be  prepared  in  some 
cases  to  miss  the  desired  effect.  The  exceptions,  how- 
ever, do  not  speak  against  the  method  as  a  whole,  but 
rather,  as  the  Latin  phrase  says :  "  Exceptio  firmai  reg- 
u/um." 

1003  Columbus  Msmokial  Building. 


Professor  Onssenbaner,  of  Prague,  has  been  elected 
President  of  the  German  Surgical  Congress  for  1895. 


October  6,  1894] 


MEDICAL   RECORD. 


435 


gvoffczsa  ot  Udjeflical  Sttiznce. 

The  Treatment  of  Pelvic  Abscess. — According  to  the 
Berlin  correspondent  of  the  Medical  Press,  Dr.  L.  Lan- 
dau recently  gave  an  address  on  this  subject.  He  said  that 
with  the  perfection  of  gynecological  technique  gynecolo- 
gical diagnosis,  as  regarded  the  individual  operations,  had 
not  advanced  with  great  pace.  For,  first  of  all,  diseases 
had  to  be  discovered  for  given  operations ;  and  in  the  sec- 
ond place  a  large  series  of  diseases  of  unequal  importance 
had  been  grouped  together  under  collective  names,  and 
had  been  frequently  submitted  without  discrimination  to 
a  single  operative  treatment.  This  was  especially  the 
case  as  regarded  pelvic  suppurations,  where  the  usual 
diagnoses— pelvic  abscess,  pelvic  suppuration,  adnexitis 
— were  used  without  distinction  for  simple  non-suppura- 
tive  inflammation  in  the  tubes  or  ovaries,  or  peritoneum, 
as  well  as  for  multiple  extra-  and  intra-peritoneal  ab- 
scesses. He  had  above  all  endeavored  to  fix  an  exact 
pathologico  anatomical  basis  and  a  rational  division  of 
pelvic  suppurations.  He  distinguished  in  the  large  group 
of  extra-  or  intra-peritoneal  abscesses,  the  abscesses  in 
pre  formed  spaces  (pyometra,  pyosalpinx)  and  those  not 
in  pre  formed  spaces  (abscesses  in  paravaginal,  parami- 
tral  tissues,  in  subperitoneal  pelvic  tissues,  and  in  the  con- 
nective tissue  of  the  abdominal  walls),  with  intermedial 
position  of  ovarian  abscess.  The  abscesses  might  be  sin- 
gle or  multiple,  or  in  the  most  varied  combinations. 
The  cause  was  always  an  infection.  Among  these  was 
the  gonorrhoea^  the  puerperal,  and,  "last  not  least/' 
the  infection  of  medical  assistance  (from  the  sound,  cu- 
rette, intra-uterine  injections,  caustics,  operations  on  the 
cervix,  and  vagina).  These  abscesses  terminated  very 
differently.  Inspissation,  absorption,  and  spontaneous 
cure  might  take  place,  or  perforation  into  the  neigh- 
boring organs,  and  spontaneous  cure  or  perforation  into 
the  peritoneum  with  circumscribed  or  general  fatal 
peritonitis  and  pyaemia.  Occasionally  death  took  place 
from  amyloid  disease.  The  old  motto,  Ubi  pus  ubi 
evacua,  was  to  be  firmly  held  to,  and  this  was  to  be  car- 
ried out  wherever  the  pus  was  accessible  by  simple,  spar- 
ing, conservative  methods.  Incision  came  first  under 
consideration.  This  was  before  all  indicated  with  soli- 
tary uncomplicated  pus  cavities,  whether  lying  within  or 
without  the  peritoneum,  or  whether  done  from  the  vagina 
or  abdominal  wall.  It  should  not  be  done  through  the 
rectum,  as  he  had  observed  that  healing  was  difficult. 
He  made  abdominal  incision  either  above  or  below  Pou- 
part's  ligament,  at  one  sitting  where  dulness  was  com- 
plete, at  two  sittings  if  intestine  apparently  intervened. 
The  first  incision  as  for  ligature  of  the  iliac  artery,  push- 
ing up  the  peritoneum,  packing  with  iodoform  gauze,  etc. 
A  means  of  distinguishing  abscesses  from  induration,  ex- 
udation, and  fibroids,  indispensable  in  many  cases,  was 
exploratory  puncture.  It  at  the  same  time  formed  an 
important  preliminary  to  the  incision.  When  operating 
from  the  vagina  it  was  always  done  at  one  sitting.  Soli- 
tary abscesses  in  the  pelvis  of  whatever  kinds  were  to  be 
treated  in  this  way,  even  pyosalpinx  when  the  pus  was  in 
one  cavity. 

Considering  the  good  results  obtained  by  simple  in- 
cision, the  attempt  was  justifiable  to  try  it  in  multiple  ab- 
scesses (double  one  cavities,  pyosalpinx,  etc.).  The 
causes  of  recurrence  might  be  in  fineness  of  the  walls  of 
the  abscess,  in  adhesive  fixations  preventing  the  walls  of 
the  abscess  foiling  in  or  otherwise.  For  cases  in  which 
simple  incision  would  evidently  be  insufficient,  as  in 
multilocular  pyosalpinx  with  or  without  perforation 
into  the  pelvis  or  abdomen,  bladder  or  multiple  perime- 
tric and  perisalpingial  abscesses,  a  variety  of  other  pro- 
cedures had  been  practised,  of  which  he  would  only  men- 
tion historically  the  little-promising  sacral  and  para-sacral 
incision.  Here  laparotomy  was  the  operation  usually 
practised,  with  removal  of  the  abscess  walls  and  its  con- 
tents. He  had  treated  one  hundred  and  forty -one 
cases  of  inflammatory  and  suppurative  tubal  disease  by 


laparotomy,  with  a  mortality  of  2.8  per  cent.  This 
undeniable  good  result  coincided  with  those  of  other 
operators  (Chrobak,  Schanta,  Zweifel,  and  others). 
But,  unfortunately,  as  observation  had  shown,  the  per- 
manent results  were  not  equally  favorable.  Complete 
cures  took  place  in  only  from  sixty  to  eighty  per  cent. 
(Chrobak,  Schanta,  Landau).  The  reasons  for  this  were 
threefold:  1.  In  the  disadvantages  of  laparotomy  itself 
(abdominal  hernia,  adhesion  of  intestine  and  omentum 
to  wound  and  to  one  another,  etc.).  a.  In  recurrences 
of  inflammation  and  suppuration  through  impossibility 
of  removing  all  excitors  of  inflammation.  3.  In  the  pur- 
ulent nature  of  the  disease. 

Then  arose  the  question,  how  could  these  disadvan- 
tages be  guarded  against?  The  first  step  thereto  at- 
tended by  success  was  made  in  France ;  in  the  first  place 
by  P6an,  «nd  after  him  by  Segond,  Doyen,  Richelot. 
The  uterus  was  removed,  and  excellent  results  had  been 
reported  from  this  method  of  treatment.  But  want  of 
exact  pathological  data  made  it  difficult  to  determine  the 
value  of  such  a  mutilating  operation.  Spurred  on  by 
the  statements  of  P&n  and  Segond,  and  instructed  by  a 
number  of  vaginal  extirpations  of  uterus  performed  since 
1881,  he  had  treated,  since  May,  1893,  twenty-six  cases 
by  the  French  vaginal  procedure.  He  had,  however, 
deviated  from  this  method  in  two  essential  points,  and 
had  extended  the  limits  of  the  operation  as  laid  down  by 
these  authors.  He  had  never  contented  himself  with  re- 
moving the  uterus  and  leaving  behind  the  adnexa,  but 
had  always  removed  the  diseased  parts.  He  had  adhered 
to  this  principle  so  firmly  that  when  it  was  impossible  to 
root  out  all  the  disease  per  vaginam,  he  had  also  opened 
the  abdomen  from  above.  He  had,  moreover,  operated 
in  this  way  on  women  when  there  was  not  only  a  simple 
double  inflammatory  disease,  but  in  cases  of  complicated 
pelvic  abscess.  His  definition  of  complicated  pelvic  ab- 
scess was  one  when,  independent  of  double  pyosalpinx 
or  ovarian  abscesses,  there  were  present  perisalpingial, 
periphoritic,  or  multiple  isolated  intra-  or  extra  perito- 
neal abscesses;  thus  perisalpingitis  purulenta,  perime- 
tritis purulenta,  pyocele  uterina,  retro- peritoneal  sup- 
purations. Such  were  cases  that  could  neither  be 
treated  by  simple  incision  from  the  vagina  nor  through 
the  abdominal  walls  by  laparotomy,  as  it  would  either  be 
impossible  or  would  be  too  dangerous  to  carry  out  the 
operation.  In  all  these  cases  there  were  multiple  collec- 
tions of  thick,  yellow,  or  green  stinking,  decomposing, 
or  creamy  pus.  In  some  cases  there  was  fistulous  com- 
munication into  the  bladder  or  rectum,  most  of  the  cases 
were  disabled  from  long-standing  disease,  and  six  had 
been  repeatedly  treated  in  other  hospitals.  In  a  large 
number  operation  had  been  already  performed  with  tem- 
porary success  (puncture,  ( incision,  resection,  laparo- 
tomy). In  some  cases  the  attachments  to  the  rectum, 
and  especially  the  sigmoid  flexure  and  to  the  bladder, 
were  so  firm  that  in  carrying  out  the  principle  of  remov- 
ing all  diseased  parts  the  walls  of  these  organs  were  torn. 
In  two  cases  of  vesical  fistula  originating  in  this  way  he 
had  operated  there  and  then,  once  from  the  vagina  and 
once  from  the  abdomen.  In  two  ruptures  of  the  sigmoid 
flexure  he  had  performed  circular  resection.  The  whole 
of  the  twenty-eight  cases  were  cured  by  the  operation. 

The  Treatment  of  Typhoid  Fever  in  Children.— -At 
the  onset  of  the  attack,  when  the  diagnosis  is  still  uncer- 
tain and  resembles  in  some  respects  the  fever  due  to  gas- 
tric disorder,  it  is  well  to  administer  small  doses  of  calo- 
mel with  a  little  milk-sugar,  and  to  give  a  rectal  injec- 
tion of  an  infusion  of  chamomile  in  boiled  water,  with 
four  per  cent,  of  boric  acid,  morning  and  night  {Thera- 
peutic Gazette),  Internally,  to  give  from  a  coffee-  to  a 
dessert-spoonful  every  two  hours  of  the  following  prescrip- 
tion: 

3 .     Benzonaphthol gr.  xiij-xxx. 

Syrup  of  peppermint |  j. 

Syrup J  iv. 

In  the  way  of  nourishment  the  patient  may  be  given 


436 


MEDICAL   RECORD. 


[October  6,  1894 


every  two  hours  a  very  small  cup  of  milk,  to  which  may 
be  added  as  a  stimulant  a  little  coffee,  tea,  cognac,  or  a 
very  slight  flavoring  with  vanilla  or  chocolate.  In  cases 
where  the  diagnosis  is  thoroughly  assured  after  the  calo- 
mel has  acted,  it  is  well  to  prescribe  citrate  of  magnesium 
to  move  the  bowels  and  large  rectal  injections  morning 
and  night  of  a  borated  solution  already  named ;  or, 

$.     Naphthol gr.  iij. 

Boiled  water Oij. 

To  be  used  in  four  equal  quantities. 

Internally,  an  antiseptic  dose,  composed  as  follows,  is 
useful : 

3 .     Benzonaphthol gr.  xv.-xxx. 

Salicylate  of  magnesium 3  ss.-  3  j. 

Syrup  of  peppermint 3  vj. 

Simple  syrup J  iv. 

If  there  is  a  bitter  taste,  it  is  well  to  replact  the  sali- 
cylate of  magnesium  by  the  salicylate  of  bismuth.  Of 
this  mixture  give  a  teaspoonful  every  two  hours,  and 
morning  and  night  administer  a  capsule  or  cachet  con- 
taining two  to  four  grains  of  the  hydrochlorate  of  qui- 
nine, or  else  give  the  same  dose  by  injection  or  supposi- 
tories. If  the  headache  is  severe,  replace  the  quinine  by 
antipyrin ;  spongings  with  tepid  water  may  be  resorted 
to,  and  care  should  be  taken,  by  the  use  of  a  boric-acid 
mouthwash,  to  keep  the  mouth  clean.  If  the  fever  is 
of  great  intensity,  the  same  treatment,  with  the  addition 
of  constant  spongings  with  cooler  water,  is  to  be  followed, 
and  should  the  nervous  disturbance  be  very  great,  small 
doses  of  coffee  or  of  chloral  may  be  used,  but  antypyrin 
is  not  to  be  employed.  In  grave  cases  the  baths  are 
given  even  more  frequently,  as  often  as  is  necessary  to 
keep  the  temperature  down.  For  the  nervous  agitation 
the  following  mixture  may  be  prescribed  : 

9 .     Hydrate  of  chloral gr,  yj.-xv. 

Tincture  of  musk gtt.  xx.-xl. 

Syrup  of  orange 3  j. 

Water J  ij. 

Cold  compresses  are  to  be  applied  to  the  head,  if  there 
is  delirium.  In  cases  showing  marked  adynamia  the 
cold  should  be  applied  to  the  head  and  the  following 
mixture  given  : 

B .     Hoffmann's  anodyne gtt.  x.-xv. 

Malaga  wine J  j. 

Syrup  of  mint |j. 

Water |iij. 

A  teaspoonful  to  a  tablespoon ful  every  hour. 

In  cases  of  typhoid  fever  in  which  there  seems  to  be 
great  cardiac  depression,  the  pulse  being  feeble  and  show- 
ing evidences  of  collapse,  it  is  well  to  use  the  following 
injection  hypodermically  morning  and  night : 

Q .'    Caffeine gr.  xxx. 

Tjenzoate  of  sodium gr.  xlv. 

Distilled  water,  enough  to  make f  j. 

Ten  to  twenty  minims  of  this  may  be  used. 

Where  complications  such  as  bronchitis,  broncho-pneu- 
monia, etc.,  arise,  the  same  treatment  is  to  be  continued 
.as  that  just  given,  but  the  cold  spongings  are  to  be 
stopped  and  a  cotton  jacket  is  to  be  applied  to  the  chest. 
Morning  and  night  a  mustard  sinapism  should  be  applied 
to  the  chest  and  the  stimulating  treatment  already  indi- 
cated employed. 

During  the  period  of  convalescence  the  baths  are  di- 
minished as  the  temperature  approaches  the  normal. 
Soups,  broths,  and  thoroughly  softly  cooked  meats  and 
pulpy  vegetables  are  allowed,  and  the  following  tonic 
mixture  given  in  the  dose  of  a  dessert-spoonful  three  times 
a  day: 

Q .     Tincture  of  gentian, 

Tincture  of  cinchona,  of  each J  v. 

Fluid  extract  of  kola TTLlxxv. 

Champagne  also  is  sometimes  useful  if  it  agrees  with 
the  patient.  Should  hemorrhage  from  the  intestine  com- 
plicate the  case,  absolute  rest,  with  local  application  of 
cold,  is  to  be  resorted  to.  Small  doses  of  opium  may  be 
administered  by  the  mouth,  and  every  two  or  three  hours 
two  or  three  drops  of  perchloride  of  iron  are  to  be  em- 


ployed. Ice-compresses  should  be  applied  over  the  belly. 
Where  there  is  danger  of  sloughs  and  abscesses  it  is  well 
to  wash  the  part  with  a  four-percent,  solution  of  boric 
acid,  and  afterward  apply  iodoform  or  salol.  Abscesses, 
of  course,  should  be  opened,  drained,  and  irrigated  with 
mild  antiseptic  solutions.  For  the  prophylaxis  of  typhoid 
fever  the  discharges  of  the  patient  should  he  received  in 
a  five-per-cent.  solution  of  sulphate  of  copper  or  in  a  1  to 
1 ,000  solution  of  bichloride  of  mercury.  The  milk  which 
is  taken  by  the  patient  should  be  carefully  sterilized,  and 
after  the  case  recovers  careful  disinfection  of  all  the  ves- 
sels used  by  the  patient  should  be  carried  out. 

The  Value  of  Boiled  Milk  as  an  Article  of  Diet. — 
Every  practitioner  of  medicine  knows  that  in  the  treat- 
ment of  certain  cases  of  diarrhoea,  where  an  absolute  milk 
diet  is  required,  better  results  follow  the  use  of  boiled  milk 
than  of  raw  milk,  and  for  this  reason  it  has  become  a  popu- 
lar idea  among  the  laity  and  members  of  the  profession  that 
cooked  milk  is  the  more  digestible.  However  this  may  be 
in  clinical  experience,  it  is  certain  that  experimental  re- 
search does  not  justify  this  conclusion.  Ten  years  ago  the 
late  Dr.  Randolph,  of  Philadelphia,  made  an  interesting 
series  of  experiments  to  determine  this  point.  A  number 
of  men  in  perfect  health  were  given  raw  milk  to  drink ; 
an  equal  number,  equally  healthy,  were  given  a  similar 
quantity  of  boiled  milk.  An  equal  time  after  the  inges- 
tion of  the  liquid  a  hypodermic  injection  of  apomor- 
phine  was  administered  to  each,  and  a  careful  examina- 
tion made  of  the  vomited  matters  to  determine  how  far 
the  process  of  digestion  had  proceeded.  In  every  in- 
stance it  was  found  that  the  raw  milk  was  more  digested 
than  the  cooked,  and  as  Randolph  graphically  expressed 
it,  "  We  obtained  proof  that  in  making  milk,  nature 
made  that  compound  most  easy  of  digestion." 

The  experiments  of  Crolas,  on  the  other  hand,  seem 
to  point  to  a  different  result,  for  he  believes  as  a  result 
of  his  studies  that  boiling  has  no  action  whatever  on  the 
casein  or  lactose,  and  removes  from  the  liquid  a  small 
quantity  of  butter,  which  is  entangled  with  the  film  of 
albumin  which  forms  on  the  surface  of  the  milk.  He 
also  thinks  that  boiling  increases  the  quantity  of  the  free 
soluble  phosphates,  and  concludes,  in  opposition  to  the 
studies  of  Randolph,  that  boiled  milk  is  equivalent,  if 
not  superior,  to  raw  milk. 

The  correct  solution  of  the  problem  probably  lies  in 
the  class  of  cases  to  which  the  milk  is  administered. 
There  is  no  doubt  whatever  that  raw  milk  is  more  diges- 
tible than  boiled  to  the  healthy  individual,  and  it  is  an 
undeniable  fact  that  boiled  milk  is  far  more  constipating, 
and  that  an  attempt  to  place  a  patient  upon  a  diet  of 
boiled  milk  would  more  certainly  tend  to  disorder  diges- 
tion and  assimilation  than  a  similar  attempt  with  the  raw 
article.  In  Bright' s  disease,  diabetes,  and  similar  con- 
ditions in  which  a  milk  diet  is  desirable,  we  may 
therefore  conclude  that  raw  milk  is  the  liquid  to  be  em- 
ployed, whereas,  in  cases  of  diarrhoea,  the  boiled  milk  is 
by  far  the  best  preparation.  We  have  already  pointed 
out  in  earlier  leading  articles  that  both  raw  and  boiled 
milk  have  their  digestibility  very  much  increased  by  be- 
ing somewhat  diluted  with  any  sparkling  water,  or  by  the 
addition  of  a  sufficient  quantity  of  salt  to  give  a  distinct 
flavor. — Therapeutic  Gazette. 


Treatment  of  Vaginismus. — In  a  paper  read  before 
the  British  Medical  Association,  Dr.  T.  More  Madden 
held  that  vaginismus  is  ordinarily  of  constitutional  or 
neurasthenic  origin,  and  is  frequently  associated  with  a 
morbid  condition  of  the  pudic  nerves.  Hence  he  relies 
chiefly  on  constitutional  treatment  in  combination  with 
local  nerve-stretching.  To  effect  this  he  recommends 
forcible  dilation,  under  ether,  of  the  vagina,  so  as  to 
thoroughly  stretch,  or  even  partially  rupture,  the  fibres 
of  the  affected  pudic  nerve  and  its  terminal  branches. 
If  this  treatment  be  adopted,  Dr.  Madden  believes  that 
it  will  seldom  be  found  necessary  to  resort  to  operative 
treatment  for  thecureof  dyspareunia  caused  by  vaginismus. 


October  6,  1894] 


MEDICAL  RECORD. 


437 


Medical  Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


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


New  York,  October  6,  1894. 


BRIGHTS   DISEASE  AND  ITS  INSANITIES. 

Bright's  disease  in  its  various  forms  is  so  common  and 
dreaded  a  malady  that  all  the  phenomena  connected 
with  it  are  justly  objects  of  importance  to  every  practi- 
tioner. One  particular  phase  of  the  Brightique  state  is 
mental  disturbance.  Concerning  this,  much  has  been 
written  of  late,  so  much,  indeed,  that  tie  matter  has  be- 
come rather  beclouded  than  otherwise  by  the  learned, 
scholastic,  and  not  very  accordant  contributions  of  alien- 
ists. One  writer  has  placed  uremic  poisoning  among 
the  frequent  causes  of  insanity  and  the  starting-point  of 
nearly  all  cases  of  melancholia.  Dr.  Savage,  on  the 
other  hand,  as  the  result  of  several  hundred  examinations 
of  the  urine  of  the  insane,  declares  that  he  has  rarely 
found  albuminuria. 

There  can  be  no  doubt  of  the  importance  of  the  arte- 
rio-renal  sclerosis  associated  with  Bright's  disease  in 
causing  many  of  the  insanities  of  middle  and  late  life. 
The  psychical  symptoms  which  develop  in  connection 
with  kidney  disease  are  usually  grouped  in  three  classes. 
There  is  first  the  acute  delirium  which  sometimes  is  asso- 
ciated with  acute  nephritis  due  to  some  infection.  The 
uremic  poisoning  here,  if  it  exists,  is  only  one  factor, 
and  the  delirium  itself  is  classed  as  a  "  nonvesanic" 
insanity,  i.e.,  it  is  not  insanity  at  all  in  the  technical 
sense. 

Uremic  or  Brightic  insanity  proper  occurs  only  under 
two  forms.  In  the  one  the  patient  has  no  insane  hered- 
ity or  tendency,  but  is  perhaps  of  neurotic  temperament. 
The  poisons  of  the  uremic  state  in  such  an  individual 
affect  the  nutrition  of  the  brain,  there  is  some  arterial 
spasm  or  thickening  of  the  walls,  and  the  total  amount 
of  blood  sent  to  the  brain  is  inadequate.  The  patient 
suffers  from  a  mild  and  quiet  mania  which  is  allied  to 
dementia.  He  improves  or  gets  worse  with  the  course 
of  the  albuminuria,  and  if  that  disappears  he  may  get 
entirely  well.  In  the  other  cases  the  patient  is  a  person 
predisposed  to  insanity,  and  the  renal  trouble  acts  simply 
as  an  exciting  cause.  The  form  of  mental  trouble  in 
these  cases  is  not  much  affected  by  the  albuminuria.  It 
may  be  a  monomania,  a  melancholia,  or  some  more  ex- 
citable state. 

When  the  practitioner  notes  the  appearance  of  mental 
symptoms  in  a  case  of  chronic  Bright's  disease,  it  is  of 
the  first  importance  that  he  make  himself  familiar  with 
the  history  and  diathesis  of  his  patient.  If  the  insanity 
is  of  the  first  type  and  due  mainly  to  the  renal  trouble, 


treatment  directed  to  this  will  often  relieve  and  even 
cure  the  patient.  He  can  be  treated  at  his  home.  In 
the  second  class  of  cases  the  outlook  is  more  uncertain ; 
serious  outbursts  may  occur,  and  restraint  in  some  insti- 
tution is  indicated. 

THE  COMPOSITE  PHYSICIAN. 

Professor  H.  P.  Bowditch  has  published  in  McClure's 
Magazine  two  series  of  pictures  of  twelve  Boston  physi- 
cians with  their  composite  photographs.  The  second 
series  and  its  composite  represents  the  same  gentlemen 
five  years  later.  Dr.  Bowditch' s  article  is  a  contribution 
to  science  rather  than  to  the  beautiful.  We  say  this 
after  a  really  unbiassed  and  sympathetic  search  for  a 
handsome  man  among  the  twelve  esteemed  and  eminent 
confreres.  We  do  not  find,  to  be  sure,  any  striking 
type  of  the  opposite  kind ;  there  are  no  features  that  are 
absolutely  Socratic  in  their  curves  or  their  as)  mmetry. 
But  it  is  evident  that  Boston's  twelve  have  not  won  suc- 
cess through  the  meretricious  aid  of  personal  loveliness. 

There  is  no  Antinous  there ;  no  Apollo,  or  any  of  the 
quality  that  used  so  seductively  to  "  hang  upon  the 
cheek  of  night"  in  the  Cleopatra  days.  However, 
classic  authority  says  it  is  a  nuisance  to  be  too  beautiful — 
"miseria  nimis  pulchrum  esse  hominem."  And  we 
note  that  the  individual  Boston  physician  is  interesting, 
and  his  composite  a  most  agreeable-looking  gentleman. 
The  age  of  the  composite  is  about  forty.  The  hair  is 
thin,  and  the  parting  is  nearer  the  right  ear  than  urban 
fashion  dictates.  He  wears  a  heavy  mustache  with  the 
ghostly  suggestion  of  an  imperial.  The  nose  turns  up  a 
trifle  and  reveals  well-defined  nostrils,  suggesting  an 
absence  of  Semitic  and  a  touch  of  Celtic  blood.  There 
is  a  deep  naso  oval  fold  indicating  a  consciousness  of 
life's  burden  and  responsibilities.  The  forehead  is  high 
and  broad  as  in  all  types  of  successful  men  except  the 
artist.  The  eyes  are  those  of  a  composite,  bright  and 
kindly.  The  collars  and  ties  date  back  into  the  last 
decade. 

Altogether  the  Boston  composite  is  a  good  type  of  a 
man,  not  resembling  in  the  least  any  of  the  individuals  of 
which  it  is  made. 

TUBERCULOSIS  AND  BUTTER. 

It  is  hard  to  get  away  from  the  malign  influence  of  the 
cow.  Such  at  least  is  the  case  if  we  may  trust  the  inves- 
tigations of  bacteriologists  and  sanitarians.  The  statis- 
tics of  slaughtered  animals  in  Prussia,  Hanover,  Switzer- 
land, and  other  European  countries  show  that  from  two 
to  twelve  per  cent,  of  the  cattle  are  tuberculous,  and 
though  their  flesh  is  not  often  dangerous,  yet  the  milk 
must  in  most  cases  have  been  so.  We  can  guard  against 
tuberculous  milk  by  sterilization,  but  now  danger  is 
threatened  us  from  the  butter.  Several  years  ago  Heim 
showed  that  butter  from  tuberculous  milk  contained  ba- 
cilli and  could  produce  infection.  Bang  (Dcut.  Zcitsch. 
/.  T/iiermed,  vii.,  p.  5)  reached  similar  conclusions. 

Professor  Roth,  of  Zurich,  has,  however,  recently 
made  experiments  of  more  striking  significance  {Cor- 
respond, bl.  /.  Schweit.  Aertz.).  He  went  into  the 
markets  and  purchased  butter  from  twenty  different 
sources  representing  different  cantons  of  Switzerland. 
He  then  inoculated  guinea  pigs  with  this  butter.     In 


43« 


MEDICAL    RECORD. 


{October  6,  1894 


eighteen  series  of  experiments  the  results  were  negative, 
but  in  two  the  inoculations  were  followed  by  tubercu- 
losis. In  other  words,  ten  per  cent,  of  the  butter  of 
the  Swiss  markets  contained  tubercle  bacilli. 

Quite  independently  of  Roth,  Dr.  Brusaferro,  of 
Turin,  made  experiments  with  the  butter  of  the  Italian 
markets.  In  nine  tubs  he  produced  infection  once, 
which  gives  about  the  same  proportion  as  Roth's. 

It  is  not  to  be  supposed  that  ten  per  cent,  of  market 
butter  is  necessarily  dangerous,  for  in  many  instances 
the  number  of  bacilli  is  small  and  quite  unable  to  cope 
with  the  juices  of  the  stomach.  Still,  infected  butter  is 
not  safe  to  the  predisposed,  and  the  fact  of  its  existence 
in  Europe  at  least  should  be  borne  in  mind.  What 
makes  the  matter  additionally  serious  is  the  fact  that 
there  is  not,  so  far  as  we  know,  any  practical  way  of 
sterilizing  butter.  ■ 

AN  ANTI-OPIATE  SOCIETY. 

An  Anti- opiate  Society  has  been  organized  in  this  city, 
and  announces  that  its  objects  are  to  use  such  means  as 
may  be  considered  best  to  prevent  the  unnatural  use  and 
the  abuse  of  opium  and  its  preparations,  and  of  cocaine, 
chloral,  etc. 

We  are  told  that  there  are  now  in  the  United  States 
one  and  a  half  million  men  and  women  who  habitually 
use  opium  in  some  of  its  forms.  Twenty  years  ago  there 
were  less  than  three  hundred  thousand  opium  users  in 
the  same  territory.  The  extent  to  which  this  vice  is  in* 
creasing  may  be  inferred  from  these  figures  :  in  the  city 
of  Chicago,  25,000  persons  are  addicted  to  the  habit ; 
in  New  York  City,  over  50,000  ;  and  in  St.  Louis  about 
20,000  are  slaves  of  this  merciless  tyrant. 

It  is  added  that  "  There  are  other  thousands  of  habitual 
users  of  morphine  who  would  never  have  touched  it  had 
they  not  been  ignorant  of  its  powers,  influence,  and  ef- 
fects. It  is  such  ignorant  ones  that  the  Anti- opiate  So- 
ciety is  trying  to  reach  with  informa'  ion  regarding  the 
nature  of  the  insidious  drug,  and  with  warnings  to  the 
young  and  unwary  against  a  vice  so  delusive  and  so  dan- 
gerous, trying  to  reach  them  before  they  have  become 
hopelessly  degraded  by  its  influence." 

The  increase  and  the  prosperity  of  the  various  "  anti " 
societies  is  one  of  the  evidences  of  the  development  of 
altruism  as  well  as  of  intelligence  in  modern  times.  Some 
of  these  societies,  unfortunately,  show  more  altruism  than 
intelligence.  We  trust  that  the  present  organization  will 
not  be  of  such  kind.  There  is  indeed  little  room  for  ex- 
aggeration in  describing  the  evils  of  the  opium  habit ; 
and  there  is,  we  fear,  among  some  physicians,  though 
they  are  vastly  in  the  minority,  a  disposition  to  be  care- 
less in  prescribing  the  narcotics.  Perhaps  the  one  thing 
which  general  practitioners  least  realize  is  the  quickness 
with  which  a  tenacious  habit  is  formed.  The  constant 
use  of  opium  for  a  few  weeks,  for  example,  will  as  a  rule 
establish  a  habit  hard  to  break. 

On  the  other  hand,  we  regret  to  see  the  new  society 
starting  out  with  exaggerated  and  unsupported  statements 
of  the  prevalence  of  the  opium  habit.  Fifty  thousand 
opium  users  in  New  York  City  means  that  one  out  of 
every  twenty  adult  persons  is  a  habitu6.  This  is  too 
absurdly  untrue  to  need  contradiction.  Our  advice  to 
the  new  society  is  to  re  write  its  circular,  and  afterward 
to  be  earnest  but  also  honest. 


%zxo%  of  ttte  W&etk. 

Death  of  Dr.  Francis  0.  Kosher,  of  Coeymans,  H .  Y. 
— Dr.  Francis  G.  Mosher  died  September  2  2d,  at  his 
residence,  Coeymans,  N»  Y.,  of  cancer,  aged  seventy- 
one.  He  was  a  great  sufferer  for  many  months  previous 
to  his  death,  but  continued  his  work  up  to  within  a  short 
time  of  his  death,  completing  forty- six  years  of  practice. 
He  was  fitly  mourned  by  the  entire  village,  and  all 
business  was  suspended  during  the  funeral  ceremonies. 

Dr.  Charles  A.  Powers  has  resigned  his  position  as  At- 
tending Surgeon  to  St.  Luke's  Hospital,  and  to  the  New 
York  Cancer  Hospital,  and  has  removed  to  Denver,  Col. 

Medical  Society  of  Virginia. — The  Twenty-fifth  Ar- 
nual  Session  of  this  Society  will  be  held  in  Richmond, 
Va.,  beginning  October  23,  1894.  An  interesting  pro- 
gramme is  offered.  The  president  of  the  society  is  Dr. 
William  P.  McGuire,  of  Winchester,  and  the  secretary, 
Dr.  Landon  B.  Edwards,  of  Richmond.  The  address 
to  the  public  and  profession  will  be  delivered  by  Dr.  R. 
S.  Martin,  of  Stuart,  Va. 

Physicians  on  a  Strike. — The  daily  papers  state  that 
the  physicians  of  Mount  Vernon,  N.  Y.,  are  on  a  strike. 
They  have  announced  that  they  will  not  examine  luna- 
tics, because  the  Board  of  Supervisors  of  Westchester  has 
cut  down  the  charge  from  $  10  to  $$  for  each  case.  There 
are  two  insane  prisoners  in  the  Mount  Vernon  jail  wait- 
ing the  result  of  a  doctor's  verdict. 

Chicago  has  22  general  and  16  special  hospitals,  with 
3,409  beds. 

The  Chicago  Health  Board  has  adopted  the  New  York 
plan  of  supplying  culture- tubes  and  making  microscopic 
examinations  in  cases  of  suspected  diphtheria. 

Women  in  Medicine. — Without  egotism,  we  think  that 
the  women  in  medicine  as  a  class  are  superior  to  men  as 
a  class ;  because  it  is  the  picked  woman,  the  ambitious 
woman,  whose  desires  are  above  the  common  level,  who 
enters  the  profession.  It  takes  grit  and  gumption  to  be 
a  woman  physician  even  to  day,  for  the  woman  in  the 
profession  must  have  a  double  motive  for  success :  she 
must  succeed  for  her  own  sake  as  well  as  for  the  reputa- 
tion of  capability  all  women  desire.  This  may  not  seem 
fair,  but  it  is  nevertheless  true.  —  Woman's  Medical 
Journal. 

Medical  Journals  in  the  United  States. — There  are 
two  hundred  and  twenty- one  medical  journals  published 
in  the  United  States,  but  then  there  are  one  hundred 
thousand  ph>  sicians. 

Take  a  Vacation. — Dr.  Alexander  Stone  says :  "  Doc- 
tor, whatever  you  do,  do  not  forget  to  take  your  vaca- 
tion. I  can  assure  you  that  you  will  be  able  to  do  more 
work,  better  work,  make  more  money,  enjoy  life  fuller 
and  live  longer,  if  you  work  eleven  months  in  the  year, 
than  you  would  if  you  labored  for  twelve."  But  per- 
haps some  of  the  doctors'  hearers  feel  as  the  tramp  did 
when  advised  to  take  three  regular  meals  a  day. 

A  Medical  Populist. — The  Medical  Sentinel  says  that 
the  democrats  and  populists  of  North  Dakota  have  nom- 
inated Dr.  M.  F.  Merchant,  of  Ellendale,  for  State  Com- 
missioner of  Labor.  The  Sentinel  adds:  "  Of  all  the 
nominations  made  so  far  this  fall  in  any  of  the  States, 


October  6,  1894]  MEDICAL 

this  is  one  of  the  most  appropriate.  What  man  of  all 
men  understands  so  well  what  ' labor9  means?"  Dr. 
Merchant  is  perhaps  the  first  medical  populist  who  has 
run  for  office. 

Sugar  as  an  Oxytocic. — A  French  obstetrician,  Morso, 
asserts  that  sugar  is  an  excellent  and  useful  stimulator  of 
uterine  contractions  during  labor.  He  gives  an  ounce 
dissolved  in  eight  ounces  of  water,  and  reports  ten  suc- 
cessful cases.  Sugar  is  a  direct  stimulant  to  smoothe 
muscular  fibres. 

A  Hew  Method  of  Giving  Thyroid  Extract. — Dr. 
Edward  Blake  writes  to  the  Provincial  Medical  Journal 
that  in  a  case  of  myxoedema  in  which  thyroid  extract  was 
not  tolerated  by  the  mouth,  twice  a  day,  after  hot 
sponging  and  vigorous  towelling,  the  body  was  well 
rubbed  all  over  with  the  following  mixture : 

IJ .     Thyroidine io  parts. 

Ether 60  parts. 

Lanoline 480  parts. 

A  rise  in  the  temperature  of  one  degree  followed  the 
inunction,  showing  that  the  extract  was  really  absorbed. 
This  proceeding  was  well  borne,  and  was  followed  by 
satisfactory  results. 

The  Library  of  the  French  Academy  of  Medicine  — 
Dr.  Dureau,  the  librarian  of  the  Academy  of  Medicine 
at  Paris,  gives  some  interesting  details  concerning  his 
charge  in  a  recent  report.  The  library  contains  147,405 
volumes,  including  pamphlets,  of  which  8,164  were  con- 
tributed during  1893.  Tne  greater  part  of  these  works 
was  due  to  generous  benefactors.  Among  other  curiosi- 
ties the  library  contains  a  collection  of  six  thousand  en- 
gravings and  portraits  of  medical  men,  the  greater  number 
having  been  presented  by  a  country  doctor  named 
Munaret,  who  for  upward  of  forty  years  has  been  an 
ardent  collector. 

Further  Reports  Upon  the  Value  of  the  Antitoxin 
Treatment  of  Diphtheria  — M.  Roux  has  communicated 
the  following  statistics  with  regard  to  the  trial  of  the 
remedy  at  the  Hdpital  des  Enfants  Malades  in  Paris. 
Between  February  1st  and  July  24th,  448  children  were 
admitted  into  the  diphtheria  pavilion.  Of  this  number 
109  died;  a  mortality  of  24.33  Per  cent-  This  was  to 
be  contrasted  with  the  mortality  in  the  four  previous 
years,  when  3,971  cases  were  admitted,  and  51.71  per 
cent.  died.  The  improvement  in  the  death-rate  attribu- 
table to  the  treatment  was  therefore  27.38  per  cent.  If 
compared  with  the  mortality  among  the  cases  of  diph- 
theria admitted  during  the  same  period  into  the  Hdpital 
Trousseau  the  results  appeared  still  more  satisfactory. 
Of  500  children  admitted  into  that  hospital  316  died;  a 
mortality  of  63  20  per  cent.  A  critical  examination  of 
the  statistics  for  this  year  involved  the  drawing  of  a  dis- 
tinction between  cases  of  true  and  false  diphtheria.  Of 
the  448  children  admitted  into  the  diphtheria  pavilion, 
bacteriological  examination  showed  that  128  were  not 
infected  with  true  diphtheria;  further,  20  of  the  cases 
were  already  moribund  when  admitted.  There  re- 
mained, therefore,  300  cases  which  afforded  a  fair  test  of 
the  efficacy  of  the  treatment ;  they  yielded  78  deaths,  a 
mortality  of  twenty  six  per  cent.,  which  was  to  be  con- 
trasted with  an  earlier  series  of  cases  subject  to  the  same 
eliminations  bat  treated  by  other  methods,  which  gave  a 
mortality  of  fifty  per  cent.    The  rule  had  been  to  give 


RECORD. 


439 


an  injection  of  the  serum,  which  was  obtained  from  the 
horse,  immediately  after  the  admission  of  the  child. 
The  injection  was  not  repeated  if  bacteriological  exami- 
nation showed  that  the  case  was  not  one  of  true  diph- 
theria. In  none  of  these  cases  was  the  injection  fol- 
lowed by  any  unfavorable  symptoms ;  it  was  not  painful, 
and  if  made  with  aseptic  precautions  was  not  followed 
by  any  local  disturbance.  In  cases  of  true  diphtheria  a 
second  injection  was  given  twenty-four  hours  after  the 
first,  and  as  a  rule  this  was  sufficient.  If  the  tempera- 
ture remained  elevated  a  third  injection  was  given.  As 
a  rule  a  child  received  an  amount  of  serum  equivalent  to 
one-thousandth  of  its  weight,  but  in  a  few  cases  the  quan- 
tity reached  one-hundredth  of  the  child's  body  weight. 
Under  the  antitoxin  treatment  complications  were  ob- 
served in  only  a  few  cases,  but  in  some  paralysis  super- 
vened. Occasionally  during  convalescence  an*  urticarial 
eruption  was  observed,  apparently  due  to  the  injections. 
The  treatment  appeared  to  diminish  the  liability  to  albu- 
minuria. Dr.  Aronson,  of  Berlin,  states  that  he  em- 
ploys serum  of  the  immunized  horse,  which  is  three  times 
stronger  than  that  of  Professor  Behring.  In  the  five 
months  ending  with  July  he  had  treated  with  his  serum 
192  patients  suffering  from  diphtheria,  as  ascertained  by 
bacteriological  examination.  The  mortality  was  four- 
teen per  cent.  In  twenty-three  cases  the  children  were 
moribund  when  admitted;  eliminating  these  there  re- 
mained 169  cases  with  19  deaths — a  mortality  of  11. 2 
per  cent.  This  contrasted  with  a  mortality  in  the  same 
hospital  varying  in  the  three  years  before  the  adoption 
of  the  antitoxin  treatment  from  32.5  per  cent,  to  41.7 
per  cent.  Eighty- two  cases  had  been  treated  by  the 
serum  in  other  hospitals  in  Berlin,  and  the  general  mor- 
tality of  the. whole  series  of  274  cases  was  15.3  per  cent. 
He  had  also  employed  the  antitoxin  serum  with  the  ob- 
ject of  producing  immunity  in  the  children  belonging  to 
families  in  which  one  case  of  diphtheria  had  occurred. 
Among  the  130  children  thus  inoculated  2  only  con- 
tracted diphtheria,  and  that  of  a  very  mild  type. 

The  Health  of  the  Czar.— There  seems  to  be  no 
doubt  that  the  Czar  of  Russia  is  seriously  ill,  though  the 
reports  as  to  the  nature  of  his  malady  are  very  contra- 
dictory. He  has  been  said  to  have  diabetes,  influenza, 
simple  coryza,  rheumatism,  mental  disease,  Bright 's  dis- 
ease, epilepsy,  and  apoplexy.  It  appears  probable,  how- 
ever, that  the  trouble  from  which  he  is  suffering  is  ne- 
phritis, following  upon  the  attack  of  influenza  and  pneu 
monia  with  which  he  was  visited  last  winter.  Professor 
Leyden,  of  Berlin,  was  called  to  see  the  Czar  in  con- 
sultation with  his  regular  physician,  Dr.  Zakharin,  and 
has  advised  him  to  pass  the  coming  autumn  and  winter 
in  some  mild  climatic  resort  in  southern  Europe.  He 
has  gone  temporarily  to  Livadia  in  Greece. 

Medical  Legislators  in  Prance. — The  medical  mem- 
bers of  the  French  Parliament  held  a  meeting  on  June 
2 1  st  in  the  Palais  Bourbon,  and  decided  on  forming  an 
extra-parliamentary  group  which  should  occupy  itself 
with  the  examination  of  the  numerous  questions  concern- 
ing the  medical  profession,  the  organization  of  charitable 
institutions,  and  the  public  health.  There  are  in  the  two 
Chambers  no  fewer  than  forty  seats  occupied  by  members 
of  our  profession ;  and  there  are  also  two  medical  men 
in  the  Cabinet,  Drs.  Lourties  and  Viger. 


440 


MEDICAL    RECORD, 


[October  6,  1894 


The  Southern  Surgical  and  Gynecological  Association 

will  hold  its  seventh  annual  session  at  Charleston,  No- 
vember 13th,  14th,  and  15th.  The  meeting  promises  to 
be  the  most  successful  in  the  history  of  the  organization. 
Papers  will  be  presented  by  the  leading  surgeons  and 
gynecologists  of  the  South.  The  medical  profession  is 
cordially  invited  to  attend.  Dr.  Cornelius  Kollock,  of 
Cheraw,  S.  C,  is  president,  and  Dr.  W.  £.  B.  Davis,  of 
Birmingham,  Ala.,  secretary. 

A  Hew  Carriage  for  Medical  Ken. — Medical  men, 
says  The  Lancet,  will  be  interested  in  a  new  "  inter- 
changeable "  or  "  convertible  "  carriage,  which  has  re- 
cently been  introduced.  It  has  been  shown  at  the 
Coaching  Exhibition  recently  held  at  the  Royal  Aqua- 
rium. It  is  a  radical  change  in  the  method  of  building 
convertible  carriages.  The  inventor  builds  a  foundation 
consisting  of  wheels,  undercarriage,  and  driving  seat, 
and  upon  this  he  places  the  movable  bodies,  forming  an 
open  or  a  close  carriage  of  perfect  shape  in  either  case, 
and  free  from  such  defects  as  draught,  rattle,  and  com- 
plication of  parts.  This  carriage  will  enable  its  owner 
in  crowded  towns,  where  coach-house  room  is  scarce  and 
dear,  to  keep  an  open  and  a  close  vehicle — for  there  are 
practically  two  carriages  in  the  space  usually  occupied  by 
one.  The  change  from  brougham  to  victoria,  or  vice 
versa,  is  readily  and  easily  made  in  the  coachhouse,  and 
the  carriage  in  either  form  cannot  be  distinguished  from 
the  ordinary  private  brougham  or  victoria. 

Treatment  of  DiarrhoBa,  Whooping-cough,  and  Noc- 
turnal Enuresis  at  the  Evelina  Hospital  for  Sick  Chil- 
dren.— At  this  season  of  the  year,  writes  the  London 
correspondent  of  The  Therapeutic  Gazette,  the  most 
common  ailment  in  the  medical  department  is  diarrhoea. 
Dr.  Fenwick  tells  me  that  his  experience  leads  him  to 
rely  chiefly  upon  antiseptics  in  such  conditions.  His 
favorite  remedy  is  benzo-naphthol,  which  is  given  in 
grain  doses  thrice  daily,  even  to  very  young  children. 
It  will  be  remembered  that  benzo-naphthol  is  a  benzoate 
of  /3-naphthol,  and  that  it  is  said  to  break  up  in  the 
intestine  into  its  constituents,  both  of  which  have  an 
antiseptic  action.  Another  remedy  much  used  in  this 
condition  is  carbolic  acid,  which  is  given  in  minim  doses, 
either  as  a  mixture  or  in  the  form  of  perle.  Some  of  the 
physicians  prefer  creolin,  giving  it  in  drop  doses  on 
sugar,  and  in  many  cases  this  treatment  is  highly  success- 
ful. Its  nauseous  odor  and  taste,  however,  prevent  its 
finding  favor  with  children.  Lastly,  creosote  is  used  by 
some,  but  this  is  open  to  the  same  objections,  and  to  a 
greater  degree,  as  those  already  referred  to  in  regard  to 
creolin.  Whooping-cough  comes  so  often  under  treat- 
ment that  it  has  been  deemed  desirable  to  devote  a  whole 
ward  to  the  treatment  of  this  affection.  The  most  suc- 
cessful of  all  drugs  at  present  in  vogue  is  bromoform.  It 
is  given  in  doses  of  from  1  to  5  minims,  either  suspended 
in  syrup  or  in  a  mixture,  the  taste  being  concealed  by 
means  of  paregoric  or  some  other  flavoring  ingredient. 
The  drug  does  not  appear  to  alter  the  duration  of  the 
affection,  but  is  most  useful  in  checking  the  paroxysms 
of  cough  and  vomiting.  I  do  not  know  whether  it  is  a 
matter  of  common  observation  in  other  institutions,  but 
I  am  given  to  understand  that  quite  a  large  proportion 
of  the  serious  cases  of  whooping-cough  admitted  at  the 
Evelina  develop  miliary  tuberculosis  after  admission. 


Another  ailment  frequently  met  with  in  all  children's 
hospitals — nocturnal  incontinence — is  generally  treated 
by  the  application  of  the  faradic  current,  used  as  strong 
as  the  patient  can  bear  it.  One  pole  is  applied  to  some 
neutral  ppint,  such  as  the  nape  of  the  neck,  and  the 
other  is  applied  to  the  perineum,  the  latter  electrode 
being  more  or  less  cone-shaped,  and  provided  with  a 
movable  covering  of  either  chamois  leather  or,  better,  of 
amadou.  With  this  arrangement  a  fresh  covering  can  be 
used  for  each  patient.  Improvement  is  generally  very 
rapid,  and  the  trouble  often  ceases  after  a  few  appli- 
cations of  the  current.  Should  it  relapse,  a  renewal  of 
the  treatment  is  attended  with  equal  success.  Treat- 
ment by  such  means  is  found  to  be  far  more  successful 
than  by  any  of  the  drugs,  such  as  belladonna,  which  were 
formerly  employed,  but  which,  if  used  at  all,  are  given 
solely  as  adjuncts  to  the  electrical  treatment. 


Society  Reports. 

AMERICAN  ASSOCIATION  OF  OBSTETRICIANS 
AND  GYNECOLOGISTS. 

Seventh    Annual  Meeting,   held  in    Toronto,    Ontario, 
September  19,  20,  and  21,  1894. 

First  Day,  Wednesday,  September  19TH. 

The  Association  met  in  the  Council  Chamber  of  the 
College  of  Physicians  and  Surgeons  at  10.15  a.m.,  and 
was  called  to  order  by  the  Second  Vice-President,  .Dr. 
George  F.  Hulbert,  of  St.  Louis,  Mo. 

An  Address  of  Welcome  on  behalf  of  the  local  medi- 
cal profession  was  delivered  by  Dr.  James  Thorburn, 
which  was  responded  to  by  Dr.  Hulbert. 

The  Incision  in  Abdominal  Surgery — Methods  and 
Results. — Dr.  J.  Henry  Carstens,  of  Detroit,  read  a 
paper  with  this  title,  of  which  the  following  is  a  sum- 
mary : 

1.  With  a  small,  narrow- bladed,  sharp  knife,  make  a 
clean  incision  through  the  skin  of  the  necessary  length, 
and  with  another  sweep  or  two  cut  through  the  lineaalba, 
muscle,  etc  Lift  the  peritoneum  with  your  fingers,  open 
it,  and  enlarge  the  incision.  The  use  of  the  forceps  to 
lift  the  tissues,  or  the  grooved  director  is  unnecessary. 

2.  In  closing  the  abdominal  incision  use  animal  liga- 
ture, kangaroo  tendon,  and  catgut.  First  carefully  brirg 
together  the  peritoneum  in  a  running  stitch,  then  the 
transversalis  fascia,  and  the  rectus  if  the  incision  is 
through  this  muscle.  Then  carefully  bring  together 
edge  to  edge  the  tendinous  insertion  of  the  oblique 
muscles.  The  fat  and  loose  cellular  tissue  above  can  be 
brought  together  in  one  or  two  tiers,  according  to  thick- 
ness. Bring  the  skin  together  carefully  with  Marcy's 
cobbler  stitch,  thus  burying  all  your  sutures. 

3.  Then  seal  with  collodion,  and  if  everything  con- 
nected with  the  operation  has  been  carefully  aseptic,  ab- 
solute primary  union  will  take  place,  and  the  different 
layers  of  the  abdominal  wall  will  have  been  brought  to- 
gether as  near  as  possible  as  they  were  in  the  fir>t  place, 
and  no  hernia  will  result. 

4.  In  cases  of  extensive  umbilical,  ventral,  or  other 
hernias,  it  is  best  to  bring  the  peritoneum  together  with 
an  over-and-over  stitch  of  kangaroo  tendon  or  catgut ; 
to  make  a  flap  splitting  operation  of  the  ring,  which  is 
brought  together  with  silkworm  gut  or  silver  wire,  which 
are  buried,  and  then  the  fat  and  skin  are  united  with  the 
buried  animal  suture. 

Plastic  Surgery  in  Gynecology. — Dr.  Joseph  Price, 
of  Philadelphia,  read  a  paper  on  this  subject,  in  which  he 
said  that  the  practice  of  surgery  in  all  its  branches  re- 
quired a  mechanical  trend  and  an  ability  to  devise  means 
to  accomplish  a  given  end.  In  order  to  mend  a  perineum 
intelligently,  the  mechanism  of  labor  must  be  understood 


October  6,  1894] 


MEDICAL    RECORD. 


441 


and  the  lines  of  fracture  appreciated.  In  cases  of  seri- 
ous pelvic  invasion  with  accompanying  lacerated  cervix, 
it  is  often  better,  or  imperative;  first  to  do  the  pelvic 
operation,  and  to  follow  this  at  another  time  with  the 
cervical  repair.  The  author  condemns  the  plan  advised 
by  some  to  perform  internal  and  external  operations  at 
one  sitting.  Perineal  tears  always  occur  at  certain  parts 
of  the  perineal  structure.  These  tears  are  either  lateral, 
under  the  ramus  of  the  pubes,  or  central,  extending  from 
the  vagina  toward  the  rectum.  The  tears  toward  the  rec- 
tum tend  to  run  around  it  rather  than  through  it,  owing  to 
the  differentiation  of  structure  in  these  two  tubes.  The 
tears  of  the  vagina  are  always  from  within  outward,  from 
above  downward,  and  that  therefore  the  external  or  skin 
operations  for  perineal  lacerations  are  essentially  unscien- 
tific procedures.  All  operations  for  the  restoring  of  the 
integrity  of  these  parts  should  be  done  in  the  lines  of 
their  destruction,  and  therefore  from  within  outward  and 
from  above  downward.  When  the  skin  of  the  perineum 
is  involved,  mending  of  this  is  merely  a  cosmetic  proced- 
ure. The  cosmetic  element  too  often  predominates  in 
many  of  the  so-called  perineal  devices.  The  silk-worm 
gut  with  shot  is  by  far  the  most  preferable  material  to  be 
used  for  sutures.  As  little  tissue  as  possible  is  to  be  in- 
cluded within  the  ligature,  and  strangulation  is  to  be 
avoided. 

The  Care  of  Pregnant  Women.— Dr.  W.  B.  Dewees, 
of  Salina,  Kan.,  read  a  paper  in  which  he  held  that  the 
paramount  duties  of  the  obstetrician  in  the  study  and 
care  of  pregnant  women  may  be  classified  as  follows  :  1. 
To  discover  if  the  patient  be  actually  pregnant.  2.  To 
determine  positively  if  the  impregnation  be  uterine  or 
normal  as  contradistinguished  from  tubal,  abdominal, 
or  abnormal  pregnancy.  3.  To  carefully  note  the  preg- 
nant woman's  history,  including  her  age,  primiparity,  or 
multiparity,  environments,  station  in  life,  general  condi- 
tion of  health,  period  of  gestation,  as  well  as  her  dress, 
food,  drink,  and  habits  of  life.  To  make  repeated  ex- 
aminations of  the  urine  and  ascertain  the  tempera- 
ture from  the  time  pregnancy  is  established  to  the 
termination  of  gestation.  4.  To  make  a  physical  exam- 
ination for  the  purpose  of  accurately  determining  the 
diameter  of  the  pelvic  straits ;  the  symmetry  and  size  of 
the  bony  outlet ;  the  integrity,  condition,  and  position 
of  the  vagina,  uterus,  and  other  intra-pelvic  viscera,  and 
adjacent  structures ;  the  state  of  the  abdominal  muscles ; 
the  presence  or  absence  of  hernia,  varicose  veins,  tu- 
mors, etc.,  the  shape,  size,  and  condition  of  the  breasts  and 
nipples ;  the  condition  of  the  heart,  lungs,  mind,  stom- 
ach, bowels,  etc.  5.  To  observe  the  state  of  the  foetus, 
its  strength  and  viability,  as  well  ps  the  implantation  of 
the  placenta.  The  thoughtful  obstetrician  will  advise 
his  patient  as  to  the  requisite  regime.  The  conscious- 
ness of  his  full  duty  will  impulse  him  to  insist  upon  :  1. 
Absolute  regular  hours  and  wholesome  environments. 
2.  Plain  but  nutritious  and  wholesome  food  and  drink, 
being  principally  composed  of  fresh  lean  meats,  fresh 
fruits,  pure  milk,  and  distilled  water.  3.  A  proper 
amount  of  exercise,  by  walking  or  light  labor  on  foot, 
and  maintaining  the  correct  erect  posture.  4.  An  open 
condition  of  the  bowels  and  skin,  which  is  to  be  chiefly 
maintained  by  proper  diet,  exercise,  and  bathing,  the 
wearing  of  flannels,  warm  low-heeled  shoes,  and  loose 
garments,  and  in  rare  cases  the  proper  use  of  laxatives 
and  hot-water  enemas. 

Appendicitis,  With  Report  of  Oases. — Dr.  George 
S.  Peck,  of  Youngstown,  O.,  read  this  paper. 

Case  I. — Operation  during  interval  of  attacks ;  ob- 
struction; July  6th  did  second  operation;  recovery. 
Operation  July  27,  1894.  Appendix  buried  in  mass  of 
strong  adhesions  between  ileum  and  caecum  containing 
large  fecal  concretion.  Appendix  removed  in  segments. 
Ileum  returned  to  abdominal  cavity.  During  first  six 
days  highest  temperature  ioo°  F. ;  pulse,  100.  On  the 
fifth  day  four  attacks  of  vomiting,  fourth  containing 
fecal  matter.  August  4th  reopened  incision ;  found 
about  three  feet  from  ileo-csecal  valve  complete  obstruc- 


tion by  band  of  dense  adhesions.  Obstruction  liberated, 
ileum  brought  out  in  the  incision,  and  abdominal  cavity 
packed  with  gauze.  During  entire  day  of  August  1st 
pulse  ranged  from  140  to  160;  vomiting  fecal  matter 
continued  at  frequent  intervals ;  tympanites  increasing. 
Seven  o'clock  symptoms  of  obstruction  continued,  be- 
coming worse  every  hour.  As  a  temporary  expedient  a 
small  opening  was  made  in  ileum,  fetal  matter  and  flatus 
came  away  in  large  amount ;  vomiting  ceased  and  tym- 
panites disappeared.  From  the  thirteenth  day  to  the 
present  time  patient  has  had  from  one  to  three  daily 
passages  per  rectum ;  sat  up  for  the  first  time  the  thirty- 
third  day.  Discharged  from  hospital  on  the  fifty-fifth 
day  after  first  operation. 

Case  II. — Operation  during  the  fourth  day,  first  at- 
tack. Large  appendix  removed,  containing  two  drachms 
of  pus  and  fecal  concretion.  Adhesions  broken  up,  in- 
cision packed  with  iodoform  gauze.  Uninterrupted  re- 
covery. Discharged  from  hospital  twenty- eighth  day 
after  operation. 

Case  III. — Operation  third  day  of  third  attack.  Peri- 
toneal cavity  opened,  adhesions  broken  up ;  large  ap- 
pendix removed ;  uninterrupted  recovery. 

Case  IV. — Operation  during  tenth  day.  Death  from 
septic  peritonitis  in  sixty- five  hours.  Large  abscess  cav- 
ity evacuated;  appendix  gangrenous  and  detached; 
washed  out  by  irrigation.  Autopsy  revealed  general  sep- 
tic peritonitis. 

Case  V. — Perforating  appendicitis.  Operation  dur- 
ing third  day  of  attack.  Death  from  septic  peritonitis 
twenty-seven  hours  or  more  after  operation. 

Case  VI. — Similar  to  previous  one,  died  from  general 
septic  peritonitis. 

Appendicitis;    Observations    Based  on  a   Clinioal 

Study  of  Eighty-four  Oases Dr.  W.  G.  McDonald, 

of  Albany,  presented  a  communication  with  this  title. 
Out  of  the  great  amount  of  literature,  controversial  and 
otherwise,  three  important  landmarks  are  established : 

1.  That  for  all  practical  purposes  all  inflammatory  proc- 
esses in  the  right  iliac  fossa  arise  from  the  appendix. 

2.  That  practically  the  appendix  is  always  intra-perito- 
neal,  and  that  any  operation  undertaken  for  appendicitis 
that  does  not  involve  the  entering  of  the  peritoneum  is 
false  in  its  surgical  conception.  3.  That  idiopathic  peri- 
tonitis does  not  occur.  That  many  cases  diagnosticated 
as  such,  are  really  cases  of  perforating  appendicitis.  The 
author  classified  the  varieties  as  1,  acute  perforating,  ful- 
minating appendicitis  with  general  peritonitis ;  2,  acute 
suppurating  appendicitis  with  local  plastic  peritonitis  and 
abscess ;  3,  subacute  appendicitis,  variously  termed  ca- 
tarrhal, chronic,  relapsing,  or  obliterating  appendicitis,  or 
appendicular  colic.  The  perforation  occurs  very  much 
earlier  than  is  commonly  believed.  That  acute  suppurative 
appendicitis  with  local  peritonitis  presents  the  most  fav- 
orable field  for  operation  during  fhe  attack.  The  removal 
of  the  appendix  is  to  be  undertaken  with  great  circumspec- 
tion when  it  lies  in  the  wall  of  an  abscess  cavity.  The 
third  group  of  cases  do  not  require  operations  during  the 
first  attack,  but  if  repeated  attacks  occur,  operation  dur- 
ing quiescence  is  demanded.  Operative  results  in  these 
cases  are  most  favorable. 


Second  Day,  Thursday,  September  20TH. 

Ligation  of  the  Uterine  Arteries  for  the  Cure  of  Fi- 
broid Tumors  and  Oheoking  Hemorrhage. — Dr.  W.  B. 

Dorsett,  of  St.  Louis,  read  a  paper  with  this  title.  The 
object  of  which,  he  said,  was  to  establish  his  priority  in 
resorting  to  ligation  of  the  uterine  arteries  for  the  cure 
of  fibroids.  He  made  observations  during  December, 
1889,  anc*  January  and  February,  1890,  and  reported  a 
case  of  atrophy  of  the  genitalia  and  described  the  tech- 
nique of  the  operation  of  ligation  of  the  uterine  arteries 
for  the  cure  of  fibromatous  growths  in  a  paper  read 
before  the  St.  Louis  Medical  Society,  May  17,  1890,  and 
which  was  published  in  the  St.  Louis  Courier  of  Medi- 
cine. 


442 


MEDICAL   RECORD. 


[October  6,  1894 


Remarks  on  the  Surgical  Treatment  of  Intussuioep- 
tion  in  the  Infant  Baled  on  Two  Successful  Cases.— Dr. 
Henry  Howitt,  of  Guelph,  Ont,  read  the  paper.  In 
it  he  recommends  early  abdominal  section  as  being  the 
best  method  of  treatment  to  reduce  the  high  mortality 
rate  of  intussusception  in  early  infancy.  Of  the  two 
cates  cited,  one  child  was  at  the  time  of  operation  under 
three,  and  the  other  under  six  months  of  age.  In  regard 
to  the  steps  of  the  operation,  among  other  things  he  ad- 
vises a  small  median  incision ;  evisceration ;  reduction 
by  pressure  on  apex  of  intussusceptum,  while  the  intus- 
susception is  drawn  in  the  opposite  direction ;  and  forc- 
ing the  contents  of  ileum  into  colon  before  returning  the 
intestines  to  abdomen. 

Dr.  Robert  T.  Morris,  of  New  York,  demonstrated 
a  method  of  intussusception  in  rabbits. 

Treatment  of  Distention  of  the  Fallopian  Tubes  With- 
out Laparotomy  and  Removal.— Dr.  Frank  A.  Glas- 
gow, of  St.  Louis,  read  a  paper  which  was  intended  to 
bring  before  the  profession  a  method  of  curing  tubal 
distention  by  means  of  intra-uterine  treatment,  in  contra- 
distinction to  laparotomy  and  removal.  By  this  means 
the  uterine  ends  of  the  tubes  are  made  more  patulous  and 
a  discharge  takes  place  from  the  tube  through  the  uterus. 
He  called  attention  to  the  fact  that  the  tubes,  as  far  as 
his  observation  goes,  are  always  pervious  at  the  outer 
extremity  of  the  cornu,  hence  when  removing  them  we 
must  always  clamp  them  before  cutting.  The  obstruc- 
tion must  be  within  the  uterine  wall,  probably  in  the 
endometrium,  and  also  to  the  fact  that  gonorrhoea!  in- 
flammation is  not  an  adhesive  inflammation,  and  hence 
it  does  not  follow  that  the  tubes  have  a  true  atresia  fol- 
lowing this  inflammation.  His  opinion  is  that  the  clos- 
ure is  due  to  a  swelling  of  the  endometrium,  and  hence  a 
closure  at  the  uterine  end  takes  place.  When  this  in- 
flammation and  swelling  are  overcome  by  pressure  and 
antisepsis,  the  tubes  become  patulous  again.  The  intra- 
abdominal pressure  will  cause  fluid  in  any  pendant  por- 
tion of  the  tube  to  ascend  into  the  uterus.  The  above 
procedure  can  be  carried  out  in  three  different  ways : 

1,  By  gradually  packing  with  gauze  without  anaesthesia; 

2,  by  rapid  dilatation  of  the  cervix  and  packing  with 
gauze  after  curetting — this  is  done  under  anaesthesia — 

3,  his  own  method  of  dilating  by  means  of  antiseptic  or 
sterilized  elm-bark  tents.  These  tents  are  small  strips  of 
elm  bark  made  just  long  enough  to  enter  the  cervix  com- 
pletely and  not  press  on  the  fundus.  They  should  be 
kept  in  an  alcoholic  solution  or  bichloride  of  mercury, 
1  to  4,000,  and  have  a  short  string  attached,  by  means  of 
which  they  may  be  withdrawn.  They  are  partially 
broken  in  a  number  of  places  for  the  purpose  of  making 
them  more  pliable.  They  may  be  dipped  into  glycerine 
or  water  just  before  introduction.  These  tents  may  be 
used  when  it  would  be  impossible  to  pack  with  gauze. 
He  had  treated  twenty  or  more  cases  during  the  past 
year,  and  does  not  recall  one  in  which  he  did  not  get 
some  discharge  from  the  tent.  All  of  the  cases  were 
either  cured  or  very  much  benefited. 

Inflammatory  Disease  of  the  Uterus  and  Appendages 
and  of  the  Pelvic  Peritoneum.— Dr.  William  W.  Pot- 
ter, of  Buffalo,  presented  a  communication  with  this 
title.  He  began  by  recalling  the  well-known  fact  that 
the  pathology  of  pelvic  disease  has  been  entirely  recon- 
structed since  i860,  and  that  now  we  had  come  to  re- 
gard inflammation  of  the  pelvic  peritoneum  as  generally 
symptomatic  of  disease  of  the  ovaries  or  Fallopian  tubes, 
or  both.  Mr.  Tait,  within  the  last  ten  or  twelve  years, 
together  with  men  who  have  worked  abreast  of  him — 
some  of  whom  are  members  of  this  Association — have 
driven  out  the  theory  of  pelvic  cellulitis  that  for  so  long 
held  sway,  and  now  peri-  and  parametritis  have  been 
dropped  from  the  gynecological  vocabulary.  The  strug- 
gle has  been  a  long  one,  but  abdominal  surgeons  have 
demonstrated  the  truth  of  this  proposition,  viz.,  that  pus 
originating  outside  of  the  tubes  or  ovaries  in  the  non- 
puerperal state  is  a  very  rare  condition,  and  that  speak- 
ing generally  pelvic  are  pus  tubes.     The  largest  number 


of  women  in  the  consulting  rooms  of  gynecologists  are 
those  suffering  from  pelvic  inflammation  or  its  residues, 
hence  the  importance  of  the  subject  under  discussion 
cannot  be  overestimated.  But,  he  asserted,  it  is  only 
within  the  past  seven  or  eight  years  that  anything  like 
uniformity  of  opinion  as  to  the  causes  and  proper  treat- 
ment of  pelvic  inflammation  have  been  adopted.  Now, 
just  as  we  are  beginning  to  agree  as  to  the  essentials 
governing  these  cases,  we  are  told  by  a  number  of  agree- 
able gentlemen  who  call  themselves  conservatives  that 
these  diseases  do  not  demand  operation,  but  that  they 
can  be  cured  in  most  instances  by  tentative  measures, 
such  as  diet,  rest,  electricity,  and  the  like.  By  denounc- 
ing the  work  of  abdominal  surgeons  as  unnecessary  mu- 
tilation, and  stigmatizing  it  as  castration  or  unsexing 
women,  they  have  created  a  panic  among  the  medical 
journals  that  is  reaching  far  into  the  ranks  of  the  pro- 
fession. Hie  effect  of  this  is  to  turn  back  the  wheels  of 
time  and  stay  the  advance  of  progress,  with  harmful  re- 
sults to  suffering  women.  It  must  be  admitted  that  these 
so-called  conservative  men  are  clever,  which  makes  their 
subtle  and  dangerous  doctrine  all  the  more  damaging  in 
its  results. 

Dr.  C.  A.  L.  Reed,  of  Cincinnati,  discussed  the  clin- 
ical history  of  inflammatory  disease  of  the  uterus  and 
appendages  and  of  the  pelvic  peritoneum;  Dr.  L.  S. 
McMurtry,  of  Louisville,  the  causation  and  pathology ; 
Dr.  James  F.  W.  Ross,  of  Toronto,  diagnosis  and  prog- 
nosis; Dr.  M.  Rosenwasser,  of  Cleveland,  the  treat- 
ment, along  with  Drs.  A.  Vander  Veer,  J.  Henry  Car- 
stens,  and  Dr.  Joseph  Price. 

Pus  in  the  Pelvis  and  Abdomen— its  Diagnosis  and 
Treatment. — Dr.  Joseph  Hoffman,  of  Philadelphia, 
said  that  pus  in  the  abdominal  and  pelvic  cavities  had 
been  treated  and  considered  with  far  more  leniency  than 
pus  anywhere  else  in  the  human  economy.  It  was  the 
tramp  manifestation  of  all  disease.  He  considered 
briefly  the  various  organs  in  which  pus  makes  its  ap- 
pearance, and  in  the  order  of  frequency  he  mentioned 
the  kidneys,  appendix  vermiformis,  tubes  and  ovaries, 
liver,  pancreas,  and  spleen.  Eaxh  case  should  be  treated 
according  to  the  demands  it  makes  and  according  to  its 
complications.  There  was  no  use  in  doing  an  ideal 
operation  and  have  the  patient  die  when  it  is  over. 
Ideal  work  was  that  which  gives  the  best  result  in  the 
line  for  which  it  was  done.  Surgery  of  the  abdomen 
was  a  work  of  self  denial,  of  trial,  of  unexpected  com- 
plication, and  lurking  disaster.  He  best  can  rise  to  it 
who  has  for  his  motto,  "  My  Patient.  Nothing  bat 
for  the  good  of  her  who  trusts  me.1'  Self  seeking  care- 
lessness of  lives  has  its  place  in  the  carnage  of  inter- 
necine strife,  not  in  the  shadowy  sorrows  of  suffering 
humanity,  of  dying  women. 

A  New  Operation  for  the  Radical  Cure  of  Inguinal 
and  Femoral  Hernia. — Dr.  C.  A.  L.  Reed,  of  Cincin- 
nati, described  the  operation  as  follows :  The  incision  in 
inguinal  hernia  is  made  from  a  point  two  inches  above 
Poupart's  ligament,  midway  between  the  anterior  supe- 
rior spinous  process  of  the  ilium  and  the  spine  of  the 
pubis,  obliquely  downward  and  inward  as  nearly  as  pos- 
sible consistent  with  the  access  of  the  inguinal  canal  to 
a  point  at  the  base  of  the  scrotum.  The  dissection  is 
then  carried  into  both  scrotal  and  pelvic  cavities.  The 
protruding  viscera  is  then  reduced  and  carefully  in- 
spected after  being  brought  out  above.  The  sac  is  then 
carefully  dissected  from  its  scrotal  connections  and  re- 
versed by  invagination.  It  is  then  opened  by  two  in- 
cisions, one  toward  the  pubes,  the  other  toward  the 
ilium,  being  thus  converted  into  an  anterior  and  a  pos- 
terior flap.  The  cord  is  now  dissected  loose  and  placed 
in  the  canal,  now  denuded  of  its  peritoneum  at  its  outer 
angle.  The  internal  ring  is  closed  by  several  interrupted 
sutures,  animal  or  buried  silk,  these  sutures  being  applied 
beneath  the  peritoneal  flaps  formed  by  splitting  the  sac, 
care  being  taken  that  in  the  closure  of  the  ring  undue 
pressure  shall  not  be  brought  to  bear  upon  the  cord. 
The  posterior  peritoneal  flap  is  now  excised,  the  stump 


October  6,  1894] 


MEDICAL   RECORD. 


443 


being  ligatcd  should  there  be  any  necessity  for  doing  so. 
The  anterior  flap  is  carried  across  the  now  obliterated 
internal  ring,  and  stitched  by  interrupted  sutures  to  the 
posterior  parietal  peritoneum.  The  external  ring  is  now 
closed  by  passing  a  number  of  sutures  through  its  pillars 
externally  to  the  cord,  which  is  now  fixed  in  the  internal 
(pubic)  angle  of  the  outlet  of  the  canal.  The  incision 
into  the  abdomen  is  closed  by  interrupted  figure  of  eight 
sutures,  the  internal  loop  embracing  the  peritoneum,  the 
aponeurosis]  of  the  transversalis  and  of  both  oblique 
muscles,  and  the  external  loop  embracing  the  superficial 
fasciae,  fat,  and  skin.  These  sutures  should  not  be  more 
than  three-fourths  of  an  inch  apart.  The  incision  into 
the  scrotum  may  be  closed  in  the  ordinary  way.  Drain- 
age should  not  be  employed  except  in  the  presence  of 
marked  oozing  or  obvious  infection. 

Ovariotomy. — Dr.  A.  Vander  Veer,  of  Albany,  pre 
sented  a  report  of  one  hundred  and  forty  five  operations 
done  for  removal  of  ovarian  tumors  and  pathological 
conditions  associated  with  the  ovaries  and  uterine  append- 
ages only.  He  gav$  a  careful  review  of  the  subject  of 
the  preparation  of  patient,  embodying  all  the  strong 
points  pertaining  to  the  technique  of  such  work,  placing 
great  stress  upon  the  importance  of  the  room  in  which 
the  operation  was  to  be  done  being  put  in  a  thoroughly 
aseptic  condition,  and  thorough  cleanliness  of  the  pa- 
tient herself.  The  operations  comprise  all  the  varieties 
of  pathological  conditions  met  with  in  connection  with 
the  ovaries  and  tubes.  The  histories  of  the  cases  were 
somewhat  interesting.  Thirty-nine  gave  a  history  of 
phthisis,  fifteen  of  cancer,  fifty-seven  of  irregularity  of 
menstruation.  The  mortality  amounts  to  eleven  per 
cent.  While  not  'criticising  adversely  the  methods  of 
other  operators  in  closing  the  wound  by  means  of  differ- 
ent rows  of  sutures,  kangaroo  tendon,  and  other  forms, 
yet  he  has  no  reason  to  give  up  his  usual  method 
of  closing  the  wound  by  deep  sutures  of  silk  worm- 
gut,  placing  them  three  or  four  to  the  inch,  taking  in 
carefully  only  a  margin  of  the  skin,  a  portion  of  the 
fascia  and  muscles,  and  not  to  exceed  one- quarter  of  an 
inch  in  width  of  the  peritoneum  itself,  placing  much 
stress  upon  the  importance  of  careful,  thorough,  com- 
plete apposition.  The  causes  of  death  in  the  seventeen 
cases  were  as  follows :  Obstruction  of  the  bowels  due  to 
a  coil  of  small  intestines  becoming  attached  to  the  stump 
of  the  pedicle,  causing  death  on  the  fourth  and  fifth  day, 
two  cases.  Septic  peritonitis,  two  cases.  Immediate 
hemorrhage  from  the  pedicle,  slipping  of  the  knot, 
within  six  hours  after  the  operation,  though  the  wound 
was  reopened,  the  vessels  secured,  abdomen  flushed,  and 
hemorrhage  controlled,  one  case.  Undoubted  hemor- 
rhage from  the  pedicle,  causing  general  peritonitis,  al- 
though no  distention  of  the  bowels  was  present,  death 
on  fourteenth  day,  one  case.  Shock  within  twelve 
hours  after  operation,  one  case.  Shock  within  twenty- 
four  hours  after  operation,  one  case.  Autopsy  in  both 
cases  revealed  everything  in  good  condition.  Pulmo- 
nary infarction  on  sixth  day,  one  case.  Aggravated  dia- 
betes, one  case.  Exhaustion  on  the  sixth  day,  no  other 
apparent  cause  found,  one  case.  Another  case  of  ex- 
haustion on  the  third  day,  symptoms  in  the  last  two 
cases,  including  an  autopsy  not  revealing  any  other 
cause.  Multilocular  ovarian  cyst,  tapped  twice,  opera- 
tion complicated  with  four  months'  pregnancy,  one  case. 
Puerperal  septicaemia,  one  case.  Intestinal  obstruction 
on  twenty-first  day,  one  case.  Advanced  age  compli- 
cated with  the  recent  effect  of  an  attack  of  la  grippe,  one 
case.  Delayed  operation  in  a  case  of  extra-uterine  preg- 
nancy possibly  four  months,  one  case. 

Hydrosalpinx.— Dr.  A.  H.  Cordier,  of  Kansas  City, 
read  a  paper  with  this  title.  He  said  articles  had  ap- 
peared in  medical  journals  by  the  so-called  conservative 
writers  in  the  last  few  months,  in  which  aspiration  or 
catheterization  of  the  Fallopian  tubes  filled  with  liquid 
of  any  character  had  been  advocated  as  a  procedure  of 
relief  and  cure.  Such  articles  had  engendered  a  retro- 
grade tendency  on  the  part  of  many,  and  it  is  sure  to  be 


at  the  expense  of  an  increased  mortality  from  subsequent 
operative  procedures  to  cure  these  cases  after  abandon- 
ing the  unsurgical  and  uncertain  tinkering.  Hydrosal- 
pinx had  been  looked  upon  as  the  least  hazardous  of  all 
inflammatory  results  to  the  Fallopian  tubes.  The  writer 
claimed  that  hydrosalpinx  was  a  sequel  of  some  old  in- 
flammatory diseases  of  the  tubes,  an  offspring  of  a  viru- 
lent process  that  had  wrought  permanent  and  irrepara- 
ble injury  to  the  delicate  structures  of  the  tubes.  The 
writer  did  not  consider  hydrosalpinx  as  a  retention  cyst. 
Cases  were  rarely  diagnosed  prior  to  operation.  A  digi- 
tal examination  of  one  of  these  cases  causes  less  pain 
than  is  produced  in  examining  a  pyosalpinx.  In  one 
case,  occurring  in  the  essayist's  practice,  the  uterine  ex- 
tremity of  the  tube  was  largely  dilated  and  filled  with  a 
clear  fluid,  while  in  the  ampulla  there  existed  a  collec- 
tion of  pus,  separated  from  the  clear  fluid  by  a  closed 
stricture. 

Inflammatory  Disease  of  the  Uterus  and  Appendages 
under  Various  Modes  of  Treatment.  —  Dr.  Joseph 
Price,  of  Philadelphia,  said  that  the  methods  of  treat- 
ment of  pelvic  disease  may  be  broadly  classed  as  those 
that  are  proved,  and  those  that  are  experimental.  Many 
of  the  operations  now  successful  were  formerly  failures 
because  of  the  insufficient  knowledge  of  how  to  deal 
with  a  wounded  gut,  how  to  make  an  anastomosis,  or  to 
do  a  bowel  resection.  Hence  it  is  to  be  put  down  as  a 
postulate  in  pelvic  surgery  that  no  man  has  a  right  to  at- 
tempt it  who  does  not  know  how  to  deal  with  all  the 
complexities  of  intestinal  surgery.  To  know  when  to 
stitch  and  when  not  to  stitch  the  intestine  is  as  necessary 
as  to  know  when  and  when  not  to  operate.  The  leav- 
ing of  pus- tubes  to  recover  of  themselves  is  just  one  step 
removal  from  stuffing  them  with  gauze  and  trusting  to 
Providence.  To  puncture  and  evacuate  and  stitch  a 
suppurating  cyst — say  a  real  ovarian  cyst — would  be  de- 
rided out  of  sight,  and  yet,  said  the  essayist,  we  have 
operators  who  do  not  hesitate  to  do  this  with  the  smaller 
pus- tube. 

Dr.  George  H.  Rohe,  of  Catonsville,  Md.,  said  that 
conservative  surgeons  were  very  much  shocked  at  first 
by  the  proposition  to  remove  the  uterus  together  with 
the  adnexa  in  cases  of  inflammatory  disease  in  the  pelvis. 
However,  the  operation  has  won  its  way  against  opposi- 
tion, and  must  now  be  considered  as  an  elective  proced- 
ure in  cases  of  extensive  suppuration  with  adhesion,  and 
especially  in  those  cases,  so  numerous,  in  which  the  en- 
dometrium is  likewise  the  seat  of  purulent  inflammation. 
Gonorrheal,  puerperal,  or  tubercular  inflammations  and 
dense  adhesions,  with  displacement  of  the  uterus,  demand 
removal  of  this  organ  as  well  as  of  the  appendages  if 
permanent  good  results  are  expected.  Total  extirpation 
of  the  uterus  and  appendages  by  the  vaginal  method  for 
pelvic  suppuration  was  first  done  by  Pean  in  1886. 
Pean,  Segond,  Doyen,  Jacobs,  and  Landau  have  per- 
formed the  operation  upward  of  five  hundred  times  with 
an  average  mortality  of  less  than  five  per  cent.  The 
operation  by  the  vagina  is  easier  than  abdominal  extir- 
pation, and  in  the  hands  of  most  surgeons  who  have 
performed  it,  is  attended  by  less  shock.  It  leaves  the 
parts  in  condition  for  perfect  drainage.  The  after- 
treatment  is  simple.  Patients  may  sit  up  in  a  week  or 
ten  days.  Forceps  are  preferred  to  the  ligature  for 
hemostasis. 

How  Shall  we  Seal  with  Pelvic  Inflammatory 
Troubles  ?— Dr.  W.  B.  Dorsett,  of  St.  Louis,  Mo.,  pre- 
sented a  paper  with  the  following  conclusions :  1.  Pus  in 
quantities  is  hard  to  deal  with  down  in  the  pelvis  in  lap- 
arotomy cases,  and,  if  possible,  should  be  evacuated  prior 
to  taking  out  the  tubes  and  ovaries,  either  through  the 
cul  de-sac  of  Douglas,  or  if  between  the  layers  of  the 
broad  ligament,  at  the  side  of  the  uterus,  laparotomy 
should  be  done  at  some  future  time.  2.  Pus  sacs  in  the 
tube  near  the  uterine  end  of  the  tube  can  be  evacuated 
through  the  uterus  by  packing  the  horn.  3.  Parametritis 
or  cellulitis  of  the  ancients  is,  except  under  rare  instances, 
a  secondary  trouble  due  to  a  foul  uterine  cavity.     Clean 


444 


MEDICAL  RECORD. 


[October  6,  1894 


out  the  cavity  and  stop  the  source  of  poison,  and  you  do 
the  best  thing  possible  to  be  done. 

The  Relations  of  Renal  Insufficiency  to  Surgical 
Operations. — Dr.  C.  C.  Frederick,  of  Buffalo,  reported 
observations  based  on  nearly  three  hundred  operations  at 
the  Buffalo  Woman's  Hospital,  supplemented  by  the 
experience  of  several  prominent  operators.  By  renal 
insufficiency  is  meant  any  condition  of  the  urine 
which  shows  deficient  elimination  of  waste  products, 
whether  from  functional  inactivity  or  from  disease  of  the 
kidneys.  Whether  renal  insufficiency  is  a  contra-indica- 
tion  to  operation  depends  on  the  consideration  of  three 
factors :  1.  The  amount  and  nature  of  the  insufficiency. 
2.  The  character  of  the  lesions  for  which  operation  is  pro- 
posed. 3.  The  causal  relation  which  the  patient's  disease 
holds  to  the  renal  insufficiency.  Every  patient's  urine 
before  operation  should  be  collected  for  twenty-four 
hours,  except  when  operation  is  urgent,  as  in  ruptured 
ectopic  pregnancy,  for  example.  In  examination  of 
urine  the  important  fact  to  ascertain  is,  whether  the  kid- 
neys are  crippled,  or  in  full  or  nearly  normal  functional 
activity.  Women  with  chronic  endometritis  are  espe- 
cially liable  to  functional  insufficiency.  Most  gynecolog- 
ical patients  who  are  run  down  physically  present  the 
same  condition.  A  knowledge  of  the  state  of  the  patient's 
kidneys  is  of  value  to  the  operator  and  anaesthetizer. 
Renal  insufficiency  renders  the  patient  more  liable  to 
shock  from  operation,  and  a  slower  convalescence. 

The  Cause  of  Thirst  following  Abdominal  Section.— 
Dr.  Eugene  Boise,  of  Grand  Rapids,  Mich.,  after  stat- 
ing the  generally  accepted  proposition  that  thirst  is  a 
sensation  indicating  that  the  tissues  of  the  body  are  in 
want  of  more  water,  argues  that  the  sensation  as  felt  in 
the  mouth  and  throat  is  reflex,  and  that  the  real  point 
from  which  the  sensation  arises  is  in  the  abdominal  vis- 
cera ;  that  from  these  the  sensation  is  conveyed  to  the 
consciousness  by  fibres  of  the  sympathetic  system  of 
nerves ;  that  while  ordinary  thirst  is  caused  by  the  with- 
drawal of  water  from  the  tissues  to  refill  the  veins  depleted 
by  excessive  perspiration  or  otherwise,  the  thirst  following 
abdominal  section  is  caused  by  the  withdrawal  of  water 
from  the  abdominal  viscera  to  fill  veins  partially  collapsed 
by  reason  of  diminished  blood-supply  because  of  contrac- 
tion of  the  arteries  of  the  viscera.  He  briefly  stated 
those  physiological  facts  which  are  universally  accepted 
or  have  been  experimentally  proven  on  which  the  theory 
is  based :  1.  Thirst  is  a  sensation  indicating  that  the 
tissues  need  more  water.  2.  The  sensation  felt  in  the 
throat  is  reflex.  3.  The  origin  of  the  sensation  is 
believed  by  leading  physiologists  to  lie  in  the  sympathetic 
system  of  nerves,  because  (a)  no  cerebrospinal  nerves 
can  be  found  which  convey  the  sensation  to  the  con- 
sciousness, and  (£)  nutrition  is  presided  over  by  the 
sympathetic  system,  and  thirst  is  a  disturbance  of  nutri- 
tion. 4.  The  origin  of  the  sensation  is  probably  from 
the  abdominal  organs,  because  (a)  these  are  so  rich  in 
sympathetic  fibres,  and  (3)  introduction  of  water  into 
the  stomach  so  instantaneously  allays  thirst.  5.  The 
sensation  invariably  follows  the  withdrawal  of  any  con- 
siderable amount  of  fluid  from  the  body ;  the  withdrawal 
of  such  fluid  causes  proportionate  collapse  of  veins  and 
capillaries.  6.  Capillaries  tend  to  remain  at  normal 
tension,  and  when  suddenly  collapsed  in  any  degree  at- 
tempt to  regain  that  tension  by  taking  water  from  the 
surrounding  tissues.  7.  Irritation  of  sympathetic  nerves 
causes  contraction  of  the  arterioles  supplied  by  such 
nerves.  8.  Sudden  contraction  of  the  arterioles  supply- 
ing any  organ  is  followed  by  lessened  tension  in  the  cap- 
illaries and  small  veins  of  that  organ.  9.  Abdominal 
section  invariably  causes  direct  and  reflex  irritation  of 
the  abdominal  sympathetic  nerves.  10.  Such  irritation 
causes  contraction  in  some  degree  of  the  arterioles  of  the 
abdominal  viscera,  with  subsequent  lessened  tension  in 
their  capillaries,  and  compensatory  withdrawal  of  water 
from  their  tissues.  And  is  it  not  probable  that  such  cir- 
culatory disturbances  give  rise  to  the  sensation  of  thirst  ? 

President's  Address. — Dr.  Rohe  then  delivered  his 


address.  He  selected  for  his  subject  "  Intestinal  Ob- 
struction following  Operations  in  which  the  Peritoneal 
Cavity  is  Opened.  He  said  obstruction  of  the  bowels 
causes  between  one  and  two  per  cent,  of  the  deaths  fol- 
lowing ovariotomy  and  other  operations  involving  open- 
ing of  the  peritoneal  cavity.  Sir  Spencer  Wells  lost  n 
out  of  his  first  series  of  1,000  cases  of  ovariotomy  from 
this  cause.  Fritsch  places  his  mortality  from  ileus  post 
laparatomian  at  1.6  per  cent.  Klotz  has  reported  31 
cases  of  intestinal  obstruction,  with  five  deaths  due  to 
this  complication,  in  a  series  of  421  abdominal  sections, 
and  148  vaginal  extirpations  of  the  uterus.  The  speaker 
had  seen  a  case  where  the  small  intestine  was  doubled 
upon  itself,  and  so  firmly  adherent  that  the  gut  was  en- 
tirely impervious.  Similar  cases  have  been  reported  by 
Skutsch  and  Turtle.  Joseph  Price  quotes  an  interesting 
case  from  Louis,  where  an  adherent  ovarian  cyst,  emp- 
tied by  the  trocar,  so  dragged  upon  the  bowel  as  to 
cause  obstruction.  Volvulus  sometimes  occurs  after  ab- 
dominal section,  but  probably  only  after  some  previous 
adhesion  or  constriction  of  the  bowel.  Two  cases  re- 
ported by  Nieberding  illustrate  this.  The  symptoms  of 
intestinal  obstruction  post  laparatomian  are  essentially 
the  same  as  those  of  primary  obstruction.  ^  Klotz  has 
had  much  success  in  treating  acute  obstruction  follow- 
ing abdominal  section  by  the  following  method:  As 
soon  as  symptoms  indicating  obstruction  appear,  he 
washes  out  the  stomach  with  from  four  to  six  quarts  of 
warm  salt  solution.  Should  this  fail  to  relieve  the  symp- 
toms he  repeats  it,  and  then  passes  into  the  stomach 
through  a  tube  a  large  dose  (one  and  a  half  to  two 
ounces)  of  castor-oil.  In  all  cases  so  treated  the  active 
peristaltic  movements  set  up  caused  passage  of  flatus  and 
faeces  within  ten  hours.  Evidently  it  is  only  in  cases  of 
fresh  and  friable  adhesions  that  this  method  can  be  suc- 
cessful. Rectal  injections  of  water  or  air  may  at  times 
be  curative  when  the  obstruction  is  due  to  intussuscep- 
tion, volvulus,  or  soft  adhesions  of  the  lower  portion  of 
the  intestine,  but  where  the  obstruction  is  due  to  cords 
or  bands  they  can  manifestly  be  of  no  avail. 


Third  Day,  September  21ST. 

Vephreetomy. — Dr.  L.  H.  Dunning,  of  Indianapolis, 
Ind,  reported  four  cases  of  this  operation,  of  which  the 
following  is  a  synopsis : 

Cass  I. — Nephrectomy  for  painful  movable  kidney. 
An  unsuccessful  nephrorrhaphy  had  been  done  two  and  a 
half  years  previously.  The  patient  had  been  bedridden 
four  years.  A  lumbar  nephrectomy  was  done,  the  pa- 
tient recovering  and  obtaining  entire  relief  from  pain. 
The  author  deplores  the  necessity  of  removing  a  healthy 
kidney  only  because  movable  and  painful.  He  thinks 
that  the  success  of  recent  methods  for  anchoring  the 
kidney  will  obviate  the  necessity  of  such  a  procedure. 

Case  II. — Nephrectomy  for  persistent  hydronephrosis 
due  to  stricture  of  the  ureter  at  its  pelvic  extremity. 
The  tumor  was  mistaken  for  an  ovarian  one.  It  was  re- 
moved by  a  median  abdominal  incision. 

Case  III.  —Sarcoma  of  the  kidney  in  a  child  two  years 
old.  Nephrectomy  and  recovery.  The  tumor  had  been 
discovered  only  four  weeks  previously.  A  median  in- 
cision (abdominal)  was  employed. 

The  writer  has  collected  the  histories  of  twenty  cases 
of  sarcoma  of  the  kidney  operated  upon  since  1885  in 
children  under  five  and  a  half  years  of  age.  Of  these 
five  perished,  and  fifteen  survived  the  operation,  thus 
showing  a  mortality  of  twenty-five  per  cent.  This  is  a 
surprising  decrease  in  mortality,  and  is  probably  due  to 
improved  details  in  technique  rather  than  to  radical 
changes  in  the  method  of  operation. 

Case  IV. — Nephrectomy  for  uretero-vaginal  fistula 
following  vaginal  extirpation  of  a  cancerous  uterus.  The 
operation  was  done  four  weeks  after  the  hysterectomy. 
The  ureter  was  torn  across  in  enucleating  a  nodule  of 
cancerous  tissue  from  the  folds  of  the  broad  ligament  on 
removal  of  the  uterus.    Nephrectomy  was  done  four  weeks 


October  6,  1894] 


MEDICAL   RECORD. 


445 


subsequently  because  of  intermittent  closure  of  the  fis- 
tula and  the  morbid  mental  condition  of  the  patient. 
The  cancer  had  recurred  in  seven  weeks,  and  patient 
died  three  months  later  of  exhaustion  and  septicaemia. 

Progressive  Cutaneous  Atrophy  of  the  Vulva  (Krau- 
rosis vulva). — Dr.  C.  A.  L.  Reed,  of  Cincinnati,  read 
a  paper  with  this  caption.  He  reported  six  cases  in 
which  the  pathological  and  clinical  features  were  char- 
acteristic. The  first  changes  obvious  to  the  naked  eye 
consist  of  small  vascular  areas  around  the  introitus  va- 
ginas. These  areas  are  not  elevated,  as  if  seats  of  merely 
inflammatory  engorgement,  but  are  slightly  depressed 
relatively  to  the  adjacent  epithelial  surfaces.  They  are 
exquisitely  painful  to  the  touch,  and  efforts  at  sexual  in- 
tercourse are  generally  agonizing  and  futile.  About  this 
same  time  inspection  will  reveal  a  narrowing  of  the  vag- 
inal orifice  associated  with  diminished  elasticity  of  the 
structures.  The  cutaneous  or  muco-cutaneous  surfaces 
will  now  be  observed  to  have  lost  a  certain  proportion 
of  their  pigment,  giving  them  a  more  or  less  translucent 
appearance,  which  increases  until  it  becomes  so  trans- 
parent that  the  larger  capillaries  and  minute  ecchymoses 
may  be  readily  discerned  beneath  it.  The  skin  thus  af- 
fected becomes  tense,  effacing  in  a  more  or  less  degree 
all  of  the  normal  folds  of  the  vulva  and  narrowing  the 
vaginal  orifice  until,  in  the  case  of  a  multipara,  "  incredul- 
ity may  be  excused  when  the  patient  states  that  she  has 
borne  children." 

Knowledge  relative  to  progressive  cutaneous  atrophy 
of  the  vulva  is  too  nebulous  to  justify  final  conclusions. 
That  which  seems  to  be  conclusively  demonstrated  may 
be  summarized  as  follows:  1.  Progressive  cutaneous 
atrophy  of  the  vulva  is  a  distinct  disease.  2.  It  is  of  very 
rare  occurrence.  3.  It  is  essentially  inflammatory  in  char- 
acter, differing  from  other  inflammations  of  the  skin  in 
the  marked  progressive  atrophy  which  succeeds  the  stage 
of  hyperemia  and  infiltration.  4.  It  is  limited  in  its 
manifestations  to  the  vulva.  5.  It  is  manifestly  not  of 
syphilitic  origin.  6.  Its  etiology  is  so  obscure  as  to  sug- 
gest a  primary  causal  lesion  in  the  trophic  nerve-supply 
of  the  vulva.  7.  The  affected  areas  may  be  successfully 
excised. 

Dr.  George  F.  Hulbert,  of  St.  Louis,  read  an  inter- 
esting paper  on  "  The  Element  of  Habit  in  Gynecic 
Disease,"  an  abstract  of  which  would  not  do  justice  to 
its  author. 

One  of  the  interesting  features  of  the  meeting  were  re- 
marks on  intestinal  anastomosis  and  a  beautiful  demon- 
stration of  the  uses  of  the  Murphy  button  by  Dr.  J.  B. 
Murphy,  of  Chicago. 

Restoration  of  Intestinal  Continuity  Without  Me- 
chanical Devices.— J3r.  W.  £.  B.  Davis,  of  Birming- 
ham, Ala.,  said  that  the  purpose  of  this  paper  was  not  to 
claim  originality  for  any  special  technique,  but  rather  to 
consider  the  various  operations  and  to  show  that  me- 
chanical devices  can  in  a  great  proportion  of  cases  be 
better  dispensed  with  by  the  surgeon  who  has  had  much 
experience  in  intestinal  work,  either  on  the  lower  ani- 
mals or  on  the  human  intestine.  Still  there  is  a  place  in 
anastomotic  work  for  bone  plates,  catgut  plates,  and  other 
devices  of  this  sort,  and  the  Murphy  button,  but  the 
experienced  surgeon  will  find  the  field  of  their  applica- 
tion very  limited.  These  devices  are  of  great  assistance 
to  the  surgeon  of  limited  experience  in  this  class  of  work, 
and  should  be  recommended  in  the  event  of  an  operation 
having  to  be  done  by  one  who  has  not  had  the  oppor- 
tunity of  becoming  familiar  and  skilled  in  suturing  of 
the  intestines.  The  Murphy  button  is  a  valuable  device 
for  cholecystenterostomy,  and  is  superior  to  anything  yet 
suggested  for  that  purpose.  The  button  is  so  small  that 
it  can  pass  through  the  intestine  without  causing  any 
trouble,  and  it  can  be  depended  upon  with  almost  abso- 
lute certainty  to  produce  satisfactory  adhesion  and  a 
competent  opening  between  the  gall-bladder  and  intes- 
tine. The  end-to-end  operation  or  circular  enterorrhaphy 
is  a  dangerous  procedure,  from  the  fact  that  injury  to  the 
mesenteric  border  is  liable  to  produce  sloughing,  and  it 


is  never  possible  to  say  that  a  surgeon  will  not  have  this 
complication  follow  the  operation.  Besides  any  stitch 
method  in  the  end  to  end  operation  requires  so  much 
time  that  it  should  be  objected  to  usually  on  that  ac- 
count. The  Murphy  button  can  be  used  very  satisfac- 
torily for  this  purpose,  and  where  end-to-end  operation 
is  to  be  resorted  to,  Dr.  Davis  is  of  the  opinion  that  this 
device  could  be  used  unless  the  surgeon  is  an  expert  in 
intestinal  suturing.  The  operation  of  Abbe  is  a  plausible 
one,  but  it  is  not  so  reliable  as  the  one  which  has  proven 
satisfactory  in  the  experimental  work  of  the  author. 
The  incision  is  not  made  so  long  as  in  the  case  of  Abbe, 
and  is  about  three  inches  in  length.  In  the  case  of 
gastro  enterostomy  the  intestine  and  stomach  are  both 
brought  into  the  wound,  and  the  incision  three  inches  in 
length  made  in  both.  Interrupted  sutures  are  taken 
through  coats  of  the  bowel  and  stomach  around  the  en- 
tire length  of  the  incisions  and  are  tied  on  the  inside, 
the  last  stitch  being  tied  on  the  outside  and  turned  in.  A 
continuous  outside  safety  stitch  is  then  taken  through  the 
peritoneal  and  muscular  walls.  In  bringing  the  small 
intestine  together  the  same  procedure  is  followed,  the 
interrupted  through  -  and  -  through  stitch  of  large  silk 
being  taken  instead  of  an  over-hand  stitch,  as  recom- 
mended by  Abbe,  and  only  one  row  of  outside  sutures, 
which  may  be  interrupted  or  continuous,  preferably  the 
latter.  This  operation  can  be  done  very  quickly,  and  is 
more  reliable  than  the  various  ones  with  mechanical  aids 
to  anastomosis.  Particularly  is  this  method  of  operating 
valuable  in  cases  of  simple  stricture  of  the  bowel,  and 
there  will  be  a  great  many  of  these  cases  now  inasmuch 
as  there  are  more  operations  done  on  the  intestines. 

Dr.  F.  Blume,  of  Allegheny,  Pa.,  reported  a  very 
interesting  case  of  cholelithiasis  in  a  woman,  thirty-seven 
years  of  age,  in  which  the  number  of  calculi  removed,  be- 
sides minute  concretions,  was  one  hundred  and  twenty- 
three,  weighing  fourteen  drachms.  The  stone  removed 
from  the  gall- bladder  weighed  four  and  three  quarter 
drachms. 

The  Season  why  Patients  Beoovar  from  Tuberculosis 
of  the  Peritoneum  after  Operation. — Dr.  Robert  T. 
Morris,  of  New  York,  stated  that  he  had  been  experi- 
menting with  a  view  to  determining  the  reason  for  the 
cure  of  tuberculosis  of  the  peritoneum  after  operation,  it 
being  a  well-known  fact  that  more  than  eighty  per  cent, 
of  these  cases  recover  as  a  result  of  simply  exposing  the 
peritoneal  cavity  to  the  air.  Dr.  Morris  collected  fluid 
from  the  abdominal  cavity  of  patients  with  tuberculosis 
of  the  peritoneum,  placed  it  in  an  incubator  for  forty- 
eight  hours,  and  developed  the  bacteria  of  putrefaction 
which  would  ordinarily  enter  in  such  fluid  exposed  to 
the  air.  From  this  fluid  Dr.  Eiloart  then  isolated  a 
toxalbumin,  the  product  of  the  growth  of  putrefactive 
bacteria  in  this  peritoneal  fluid.  The  toxalbumin  em- 
ployed to  destroy  tubercle  bacilli  in  culture-tubes  de- 
stroyed them  very  promptly.  A  control  experiment, 
which  was  not  yet  completed,  was  in  progress  for  deter- 
mining if  these  bacteria  were  absolutely  dead.  How- 
ever, enough  had  been  proven  to  show  that  tuberculosis 
of  the  peritoneum  recovers  after  operation  because  putre- 
factive bacteria  produce  a  toxalbumin  in  the  fluid  which 
is  fatal  to  tubercle  bacilli  in  the  peritoneum.  The  rea- 
son why  it  is  more  effective  in  curing  cases  of  tuberculo- 
sis of  the  peritoneum  than  tuberculosis  of  the  knee-joint 
is  because  the  lymphatic  anatomy  of  the  peritoneum  is 
such  that  any  toxic  agent  absorbed  by  the  lymphatics  of 
the  peritoneum  is  brought  into  close  contact  with  the 
entire  structure ;  whereas  in  the  knee-joint  the  lymphat- 
ics are  fewer  and  with  more  definite  channels. 

Election  of  Officers.—  President,  Dr.  J.  Henry  Carstens, 
of  Detroit,  Mich. ;  First  Vice-President,  Dr.  W.  E.  B. 
Davis,  of  Birmingham,  Ala. ;  Second  Vice-President,  Dr. 
Henry  Howitt,  of  Guelph,  Ont. ;  Secretary,  Dr.  William 
Warren  Potter,  of  Buffalo,  N.  Y. ;  Treasurer,  Dr.  X.  O. 
Werder,  of  Pittsburgh,  Pa. 

The  place  of  meeting  for  1895  was  referred  to  the  Ex- 
ecutive Council  for  decision. 


446 


MEDICAL  RECORD. 


[October  6,  1894 


(&0tvesvon&mtt. 

OUR  VIENNA  LETTER. 

(From  our  Special  Correspondent) 

THE  EIGHTH  INrERNATIONAL  CONGRESS  OF  HYGIENE  AND 
DEMOGRAPHY  AT  BUDAPEST — FOREIGN  DELEGATER  PRES- 
ENT— OPENING  OF  THE  INTERNATIONAL  HYGIENE  EXHI 
BITION — RECEPTION  OF  THE  DELEGATES  BY  THE  ARCH- 
DUKE CHARLES  LEWIS — THE  SEMMELWEISS  MEMORIAL — 
WORK  OF  THE  SECTIONS — THE  CAUSE  OF  CHOLERA — 
CREMATION — IMMUNITY,  NATURAL  AND  ACQUIRED — TY- 
PHOID FEVER  AND  THE  WATER  SUPPLY. 

Vienna,  September  13,  1894. 

The  Eighth  International  Congress  oi  Hygiene  and 
Demography,  which  has  just  been  closed,  was  brilliantly 
successful.  About  three  thousand  members,  among 
whom  representatives  from  various  countries  of  the  world 
participated  in  it.  The  number  of  ladies  present  was 
about  three  hundred.  The  Co  ogress  was  opened  on  Sun- 
day, September  2d,  at  eleven  o'clock,  by  the  Archduke 
Charles  Lewis  of  Austria,  in  the  place  of  the  Emperor, 
who  is  the  protector  oi  die  Congress,  but  who  was  pre 
vented  from  being  present  at  the  opening  ceremonies. 
The  Archduke  emphasized  the  great  importance  of  the 
Congress,  which  served  the  purposes  of  humanity  and  civ- 
ilization. The  endeavors  of  the  members  of  former  in- 
ternational hygienic  congresses  to  practically  realize  the 
resolutions  of  the  Congress  were  partly  crowned  with 
success,  and  on  this  occasion  the  Archduke  alluded  to 
the  fact  that  in  various  states  new,  regular,  and  obliga- 
tory courses  on  the  principles  of  hygiene  had  been 
introduced  into  the  public  school  instruction. 

The  Archduke,  who  hitherto  had  spoken  in  French, 
then  began  to  speak  in  Hungarian,  and  saluted  the  beau- 
tiful capital  of  Hungary,  congratulating  her  on  the  dis- 
tinction which  the  Congress  had  bestowed  on  her  by 
chosing  their  city  as  the  place  of  present  meeting.  He 
did  not  doubt  that  the  Hungarians  would  sustain  on  this 
occasion  their  world-wide  reputation  for  hospitality. 

The  Archduke  Charles  Lewis  then  declared,  in  the 
name  of  the '  King-Emperor,  the  Congress  opened. 
Among  the  foreign  representatives  who  afterward  ad- 
dressed the  Congress  I  will  only  mention  Professor 
Leyden,  of  Berlin,  who  spoke  in  German ;  Professor  v. 
Inama-Sternegg,  of  Poland  (German) ;  Dr.  Bergerau,  of 
France  (French) ;  Dr.  Billings,  of  the  United  States 
(French);  Dr.  Crocq,  of  Belgium  (French) ;  Dr.  Corfield, 
of  England  (English) ;  Professor  Don  Amalis  Girneno,  of 
Spain  (French") ;  Professor  Bambos,  of  Greece  (French) ; 
Dr.  Luigi  Bodis,  of  Italy,  (Italian) ;  Professor  Erismann, 
of  Russia  (Russian  and  French) ;  Dr.  Joao  Lopez  de 
Silva  Martins,  of  Portugal  (French) ;  Dr.  Hansen,  of 
Norway  (French),  and  others. 

At  1  p.m.  the  International  Hygienic  and  Demographic 
Exhibition  was  opened  in  the  "  Polytechnicum."  This 
was  divided  into  six  sections,  namely,  sewage  of  towns, 
general  exhibition  of  Germany,  Austria-Hungary,  and 
various  other  countries,  cremation,  and  balneology. 

On  Sunday  evening  the  Congress  was  received  at  court 
by  his  Imperial  and  Royal  Highness  the  Archduke 
Charles  Lewis,  where  a  splendid  banquet  had  been  pre- 
pared for  the  guests.  This  meeting  presented  a  particu- 
larly picturesque  appearance  owing  to  the  different 
dresses  of  the  representatives  of  the  various  states.  The 
President  of  the  Congress,*State  Minister  of  the  Interior 
Hieronymi,  presented  the  delegates  of  the  foreign  states 
and  the  other  prominent  members  of  the  Congress  to  the 
Archduke,  who  addressed  them  in  French  and  German, 
directing  to  them  questions  referring  to  their  specialties 
and  their  countries.  I  wish  to  mention  on  this  occa- 
sion as  an  interesting  incident  of  the  Congress  the  so- 
called'"  Semmelweiss-Sitzung,"  held  on  Sunday  afternoon 
in  the  buildings  of  the  Academy  of  Medicine.  Semmel- 
weiss  was  the  first  to  introduce  antisepsis  into  obstetri 


cal  practice,  but  during  his  life  his  doctrines  attracted 
little  favorable  notice,  and  he  was  even  persecuted  by  his 
colleagues.  Medical  science  had  long  ago  acknowledged 
the  immortal  services  which  Semmelweiss  had  rendered 
to  the  science  of  obstetrics  and  to  humanity,  and  Hun- 
gary, which  is  always  ready  to  reward  the  merits  of  her 
great  men,  decided  on  doing  the  last,  and  pay  due  homage 
to  her  great  citizen,  who  was  born  at  Budapest.  A  com 
mittee  had  been  established  for  the  erection  of  a  monu 
ment  in  honor  of  Semmelweiss,  and  in  the  meeting  now 
referred  to,  Professor  K6zmarszky,  of  Budapest,  presi- 
dent of  the  committee,  made  a  report.  A  sum  of  12,586 
florins  had  thus  far  been  collected;  but  subscriptions 
toward  the  erection  of  the  monument  were  still  being 
taken.  Professor  Ferdinand  Hueppe,  of  Prague,  de- 
livered an  address  on  Semmelweiss,  which  was  re- 
ceived with  great  enthusiasm  by  all  present.  The 
members  then  betook  themselves  to  the  cemetery  in 
which  Semmelweiss  is  buried,  to  assist  at  the  ceremony  of 
the  unveiling  of  his  monument.  On  this  occasion  Pro- 
fessor Hueppe  spoke  again,  and  Professor  Chautemesse, 
of  Paris,  delegate  from  France,  answered  in  feeling 
words,  saying,  among  other  things,  that  if  all  the  chil- 
dren whose  lives  Semmelweiss  had  saved  were  still  living, 
the  city  of  Budapest  would  be  unable  td  hold  them  all. 

On  Monday  the  sections  of  the  Congress  proceeded  to 
their  work.  There  were  nineteen  sections,  and  the  num- 
ber of  the  papers  announced  amounted  to  nearly  eight  hun- 
dred, all  of  which,  of  course,  could  not  be  read.  The  sec- 
tions on  hygiene  were  most  frequented,  and  among  these, 
particularly  the  first,  second,  and  third  sections,  in  which 
questions  „of  bacteriology  and  blood  serum  therapy  were 
most  eagerly  discussed.  Among  the  lectures  which  were 
delivered  on  the  first  day,  that  of  Princess  Christian  of 
Schlesweig-Holstein,  on  the  advances  in  nursing  science, 
as  well  as  on  the  spread  of  sanitary  and  hygienic  knowl- 
edge in  England  during  the  past  few  years,  attracted 
great  attention. 

In  the  other  sections  the  discussions  on  diphtheria 
and  cholera  were  among  the  most  interesting.  The 
discussions  upon  cholera  were  opened  by  Dr.  Baker,  of 
Paris,  and  Professor  Gruber,  of  Vienna.  The  latter 
pointed  out  that  besides  the  bacillus  of  Koch,  there 
must  still  be  some  others.  The  famous  Paris  scientist, 
Professor  Elie  MetschnikofF,  spoke  to  the  same  effect, 
and  said  that  the  vibrio  of  cholera  could  not  be  the  sole 
cause  of  cholera.  There  were  people  who  had  ingested 
pure  cultures  of  cholera  bacilli  without  becoming  in- 
fected with  the  disease.  He  had  found  in  the  stomach 
and  the  intestines  other  bacteria,  which  either  favored 
or  checked  the  development  of  the  specific  microbe. 
Those  in  whose  stomach  or  intestines  there  were  bacteria 
which  favored  the  development  of  the  cholera  bacillus 
became  affected  with  cholera,  while  those  in  whose  sys- 
tem the  antidotal  bacteria  were  to  be  found  remained 
immune.  Professor  MetschnikofF  added  that  he  had 
thus  succeeded  in  provoking  cholera  in  animals  which 
had  hitherto  been  thought  to  be  immune. 

The  Section  on  State  Hygiene,  which  was  presided 
over  by  Professor  Kratter,  of  Graz,  formulated  the  fol- 
lowing unanimous  resolutions  with  reference  to  crema- 
tion : 

1.  The  least  dangerous  and  most  rapid,  and  at'  the 
same  time  cheapest,  method  of  disposal  of  dead  bodies 
is  cremation. 

2.  Cremation  is  the  best  substitute  for  suitable  ceme- 
teries where  these  are  wanting. 

"3.  Cremation  is  of  the  greatest  importance  for  the 
welfare  of  peoples  in  times  of  epidemics. 

4.  The  governments  of  the  various  countries  must  be 
invited  to  permit  of  a  facultative  legal  cremation,  and 
thus  provide  for  an  excellent  means  of  prophylaxis 
against  epidemics. 

In  the  first  section  of  hygiene  Professor  Hans  Buch- 
ner,  of  Munich,  delivered  a  lecture  on  the  subject  of 
immunity  and  immunization,  in  which  he  arrived  at  the 
following  conclusions : 


October  6,  1894] 


MEDICAL    RECORD. 


447 


1.  The  natural  power  of  resisting  infections,  the  so- 
called  "  natural  immunity/1  is  due  to  quite  different 
conditions  and  causes  than  the  artificial  or  acquired  im- 
munity. Both  are  conditions  which  in  principio  differ 
from  each  other,  and  which  must  scientifically  be  sepa- 
rately considered  and  inquired  into,  though,  practically, 
they  may  occur  simultaneously  in  the  same  individual. 

2.  The  natural  power  of  resistance  is  due,  on  the  one 
hand,  to  the  bactericidal  influence  of  certain  dissolved 
constituents  of  the  organism,  the  so-called  "alexines," 
and,  on  the  other  hand,  to  a  congenital  power  of  re- 
sistance of  the  tissues  and  the  cells  of  the  body  against 
bacterial  poisons.  This  natural  power  of  resistance  can- 
not, as  a  rule,  be  conferred  through  the  blood  on  other 
organisms. 

3.  The  leucocytes  play  an  important  part  among  the 
natural  means  of  protection  of  the  organism,  but  they  do 
not  do  so  through  their  virtue  as  'phagocytes,  but  only 
by  means  of  dissolved  substances  which  they  secrete. 
Phagocytosis  is  only  a  secondary  appearance. 

4.  The  immunity  which  is  artifically  produced,  or 
which  is  acquired  later  in  life,  is  due  to  the  presence  of 
modified  specific  bacterial  products,  which  have  become 
deprived  of  their  poisonous  influence  —  the  so-called 
"  antitozines ; "  these  are  to  be  found  either  in  the 
blood  or  in  the  tissues  of  the  body,  or  in  both.  The 
antitoxines,  and  also  the  immunity  produced  by  their 
action,  can  be  transmitted  by  means  of  the  blood  or  the 
milk. 

5.  The  effect  of  the  antitoxines  is  not  due  to  direct 
destruction  of  the  specific  bacterial  poisons  by  mutual 
contact.  The  effect  is  only  produced  within  the  body, 
and  by  means  of  the  same,  as  the  faculty  of  the  living 
parts  of  the  body  to  resist  the  specific  poisons  becomes 
thus  increased. 

Dr.  I.  Polak,  of  Warsaw,  read  a  paper  on  "  The  Re- 
lation between  Typhoid  Fever  and  Drinking-water." 
He  presented  tables  of  the  mortality  in  Warsaw  since 
1877,  which  showed  that  among  the  infectious  diseases, 
such  as  small  pox,  measles,  scarlet  fever,  typhoid,  ty- 
phus, diphtheria,  and  croup,  the  mortality  from  typhoid 
fever  had  considerably  diminished  since  1887,  when  the 
new  water- works  were  established  in  that  city,  and  new 
measures  for  sewage  were  adopted.  Daring  the  period 
from  1879  *°  x886  the  mortality  from  typhoid  fever  in 
Warsaw  amounted  to  from  60  to  105  deaths  in  100,000 
inhabitants,  whereas  in  the  period  from  1887  to  1893, 
it  only  amounted  to  from  18  to  30  deaths.  Another 
table  which  Dr.  Polak  showed  related  to  gastro  enteritis, 
pneumonia,  phthisis,  and  bronchitis.  In  this  case  the 
regular  decrease  in  the  mortality  from  pulmonary  phthi- 
sis and  bronchitis  was  also  alleged  as  being  the  result 
of  the  better  conditions  of  the  drinking-water  in  that 
city. 

The  festivities  before  and  during  the  Congress  were 
numerous  and  brilliant,  and  gave  convincing  proof  of 
the  Hungarian  hospitality. 


IS   MALAJUA   A  WATER  BORNE  DISEASE? 

To  the  Editor  or  the  Mbdical  Record. 

Sir  :  I  wish  to  add  my  experience  and  observation  to  the 
line -of  inquiry  pursued  by  Dr.  W.  H.  Daly,  of  Pittsburg, 
Pa.,  in  his  most  excellent  paper  in  the  Medical  Record 
of  September  15,  1894  regarding  malarial  infection.  In 
the  summer  of  188 1,  while  employed  under  the  directions 
of  Major  G.  J.  Lydecker,  U.  S.  A.,  in  the  construction 
of  the  KampsviUe  Lock  (Illinois  River  Improvement), 
Ramps ville,  Calhoun  Co.,  111.,  I  had  occasion  to  ob 
serve  the  effects  of  drinking-water  on  persons  tempo- 
rarily residing  in  this  malarial  district,  as  well  as  upon 
the  native  inhabitants.  The  land  immediately  adjacent 
to  the  lock  site,  was  known  as  bottom-land — it  was  over- 
flowed at  each  high- water  season — and  was  poorly 
drained,  being  very  flat.  Water  stood  in  the  bogs  or 
swamps  until  the  dry  weather  of  summer  had  completely 
evaporated  it.    Drinking-water  was  obtained  for  the  men 


employed  in  the  construction  of  the  lock  foundation  from 
drive-wells,  put  down  to  the  depth  of  about  twelve  or  fif- 
teen feet.  The  men  employed  on  the  dredge  and  tow- 
boats,  and  the  officers,  used  filtered  river-water. 

Among  the  many  laborers  who  sought  employment 
were  forty  Swedes,  who  had  arrived  in  this  country,  from 
their  native  land,  about  ten  days  before  coming  to  the 
lock ;  they  were  a  vigorous,  well  nourished  body  of  men, 
eager  for  work.  They  took  board  in  quarters  near  the 
lock,  and  drank  water  from  the  drive- well.  Within  ten 
days  one  of  them  was  taken  down  with  malaria,  and  be- 
fore two  weeks  had  elapsed  ten  or  more  had  succumbed; 
one  died  and  two  were  seriously  ilL  At  the  end  of  a 
month  but  three  were  able  to  continue  work;  one  of 
these  had  no  malarial  symptoms  at  all ;  he  worked  on 
one  of  the  boats,  where  he  also  lived ;  he  drank  filtered 
river  water.  Now  all  of  these  men  seemed  peculiarly 
susceptible  to  malarial  infection,  and  as  quickly  as  they 
could  returned  to  Chicago  to  escape  its  ravages.  The 
men  who  worked  on  the  boats  escaped  the  disease.  The 
natives  who  drank  of  the  well-water  were  not  so  much 
affected,  yet  quite  a  number  of  them  had  to  quit  work. 
The  wells  used  by  the  natives,  however,  were  located  on 
the  edge  of  the  bluffs,  about  one-half  mile  from  the  river. 
Here  we  have,  I  think,  marked  evidence  of  the  infection 
coming  from  drinking-water ;  for  all  the  employees,  offi 
cers  and  all,  were  situated  under  like  atmospheric  con- 
ditions, and  exposed  to  the  same  heat,  etc.,  during  the 
day,  yet  those  who  used  river-water  escaped  while  those 
using  drive  or  open  well-water  were  afflicted.  Some 
three  and  one  half  years  spent  in  engineering  work  on 
the  Illinois  River  confirmed  my  belief  in  the  possi- 
bilities of  infection  from  water-supply  rather  than  from 
atmospheric  conditions. 

I  endorse  Dr.  Daly's  views, 

Frank  P.  Norbury,  M.D. 

Jacksonville,  III. 

IS   IT  TIME  TO   CALL  A  HALT? 

To  thk  Editor  of  the  Mbdical  Record. 

Sir  :  It  is  a  continual  surprise  to  me  the  indifference  of 
many  oculists  about  the  accurate  adjustment  of  glasses. 
Many  jewelry  stores  have  professional  refractionists,  and 
a  widely  circulated  jewelry  monthly  devotes  several  col- 
umns each  issue  to  the  instruction  and  answering  absurd 
queries  from  men  in  stores  who  fit  glasses.  I  know 
reputable  physicians  who  send  patients  to  these  stores  be- 
cause they  get  better  work  done  than  some  oculists  do. 
Isn't  it  about  time  more  attention  was  paid  to  accurate 
refractive  work,  or  are  we  to  lose  sight  of  this  in  the 
chase  after  some  ignis  fatuus  like  trifling  muscular  de- 
fects. 

The  phoria  craze  has  reached  the  stage  where  conser- 
vative men  are  met  with  pitying  smiles  if  they  venture 
to  suggest  that  some  cases  of  asthenopia  can  be  relieved 
by  proper  glasses.  The  last  two  days  of  the  Pan-Ameri- 
can Congress  the  ophthalmological  section  was  in  the 
hands  of  the  phoria  men,  who  pounded  the  table  in  their 
enthusiasm  concerning  wholesale  muscle-cutting.  They 
stated  that  many  operations  were  often  necessary,  and 
admitted  that  the  result  was  not  invariably  satisfactory. 
Their  ideas  about  glasses  were  inferred  when  a  well- 
known  disciple  said  that  a  weak  myopic  lens  should  be 
given  the  patient  if  it  seemed  comfortable,  no  matter 
whether  the  victim  was  myopic  or  hyperopic. 

No  one  denies  that  muscular  insufficiency  occasionally 
calls  for  operation,  but  it  is  a  pity  to  lose  sight  of  the 
good  that  lean  be  accomplished  by  proper  glasses.  If 
one  eye  sees  as  well  as  the  other,  if  both  are  equally  re- 
lieved of  strain,  then  the  glasses  are  right,  and  the  mus- 
cles will  adjust  themselves  in  the  majority  of  cases. 
Such  being  a  fact,  which  would  seem  more  sensible,  fit 
the  eyes  properly,  or  hack  the  muscles  forty  times  with 
no  assurance  but  that  another  forty  may  be  necessary. 
Richard  H.  Satterlee,  M.D. 

189  Delaware  Avenue,  Buffalo,  N.  Y. 


448 


MEDICAL   RECORD. 


[October  6,  1894 


THE    ANTIDOTAL    ACTION    OF    POTASSIUM 
PERMANGANATE  IN  OPIUM  POISONING. 

To  tub  Editor  op  tub  Medical  Record, 

Sir  :  In  your  issue  of  September  15th  I  notice  an  article 
by  Dr.  C.  Monroe  McGuire,  under  the  heading  "  Un- 
successful Employment  of  Potassium  Permanganate  in  a 
Case  of  Morphine  Poisoning/'  and  in  justice  to  Dr. 
Moor  (the  original  claimant  to  the  discovery  of  this  an- 
tidote), who  no  doubt  has  become  very  tired  of  answer- 
ing uncalled-for  questions  and  criticisms  upon  a  subject 
which  has  been  very  carefully  explained,  and  by  himself 
and  others  successfully  operated,  I  would  suggest  that  Dr. 
McGuire  read  Dr.  Moor's  original  article  in  order  to  un- 
derstand that  his  (Dr.  Moor's)  representations  can  in  no 
way  be  called  a  failure  as  an  antidote  in  the  case  he 
mentions. 

It  struck  me  at  the  time  that  Dr.  Moor  had  very 
plainly  and  concisely  pointed  out  to  his  medical  brethren 
that  after  the  ingestion  of  morphia  in  lethal  doses, 
the  administration  of  potassium  permanganate  would 
chemically  oxidize  and  render  inert  the  amount  of  the 
poison  still  in  the  stomach  at  the  time  of  the  administra- 
tion; in  other  words,  the  part  of  the  morphine  with 
which  it  comes  in  direct  contact.  He  does  not  claim 
that  it  has  any  other  effect,  and  his  best  proof  of  the  effi 
cacy  of  the  drug  as  a  local  antidote  was  his  experimenta- 
tions upon  himself,  which  prove  his  absolute  faith,  which 
I  think  no  one  will  question,  and  again,  other  prominent 
medical  men  have  had  very  successful  results  from  its  use. 

How  are  physiological  or  pathological  effects  of  a  drug 
to  be  determined  except  by  such  methods  ? 

Many  of  our  most  important  discoveries  have  been  un- 
derstood only  by  such  means  and  accident,  and  I  do  not 
think  Dr.  Moor's  results  should  be  denied  and  decried 
until  good  grounds  are  had  for  so  doing ;  and  particu- 
larly upon  the  grounds  given  in  Dr.  McGuire's  article, 
where  the  stomach  had  been  relieved  of  every  particle  of 
the  poison,  both  by  emesis  and  into  the  circulation,  pre- 
vious to  the  administration  of  the  permanganate.  So 
what  I  cannot  understand  is,  why  permanganate  should 
have  been  given  at  all  in  the  case  mentioned,  for  it  is 
not  claimed  to  be  a  physiological  antidote,  and  at  that 
time  there  was  no  use  for  a  chemical  action. 

Under  the  circumstances  I  do  not  see  why  Dr. 
McGuire  should  have  been  surprised  at  a  depressing 
effect  upon  a  stomach  and  system  so  weakened  by  emetics 
and  physiological  antidotes,  and  in  which  there  was  no 
morphine. 

Clarence  Warfield,  M.D. 

Galveston,  Tsx. 

THE    MARRIAGE    OF    SYPHILITICA 

To  thk  Editor  or  the  Medical  Record. 

Sir  :  For  the  purpose  of  securing  reliable  statistics  on 
the  subject  of  the  marriage  of  syphilitica,  I  desire  to  en- 
list the  assistance  of  those  of  your  readers  who  have  had 
experience  which  will  be  of  value  in  determining  the  pe- 
riod when  this  disease  ceases  to  be  communicable  and 
inheritable.  I  shall,  therefore,  esteem  it  a  great  favor 
on  the  part  of  any  physician  who  will  send  me  answers 
to  the  following  questions,  and  due  credit  will  be  given 
in  a  future  publication  to  those  who  desire  to  aid  me  in 
this  work. 

1.  What  is  the  latest  period,  from  the  date  of  the  ini- 
tial lesion,  that  you  have  known  the  disease  to  be  com- 
municated by  a  patient  who  has  been  from  the  first  under 
your  observation  ? 

2.  What  is  the  latest  period,  from  the  date  of  the  ini- 
tial lesion,  that  you  have  known  (a)  a  syphilitic  man, 
or  (£)  a  syphilitic  woman  to  become  the  parent  of  a 
syphilitic  child  ? 

3.  Have  you  ever  known  syphilis  to  be  either  commu- 
nicated or  handed  down,  at  a  later  period  than  four  years 
from  the  date  of  the  initial  lesion,  by  an  individual  who 
has  been  constantly  under  your  observation  during  that 
time? 


In  answering  these  questions  I  should  like  a  brief  but 
complete  history  of  each  case  and  an  account  of  the 
treatment  that  has  been  pursued. 

I  hope  by  this  means  to  obtain  the  experience  of  a 
large  number  of  observers,  and  to  reach  a  fairly  reliable 
conclusion  as  to  the  time  when  we  may  safely  permit  our 
syphilitic  patients  to  marry. 

Yours  very  truly, 

Burnside  Foster,  M.D. 


fjtoedtatl  Stems. 

Contagious  Diseases  — Weekly  Statement.— Report  of 
cases  and  deaths  from  contagious  diseases  reported  to  the 
Sanitary  Bureau,  Health  Department,  for  the  week  end- 
ing September  29,  18^4. 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis 

Measles 

Diphtheria 

Small-pox 


135 

83 

33 

10 

ai 

2 

2 

2 

8 

2 

87 

3i 

6      , 

3 

Mr.  W.  Salmon  is  the  oldest  member  in  years,  as  well 
as  by  appointment,  of  the  Royal  College  of  Surgeons  of 
England.  He  was  born  in  1790,  and  was  admitted  to 
the  College  in  1809. 

Myxcedema. — Dr.  G.  P.  Marner,  of  Marion,  Kan.,  in 
a  paper  read  before  the  Kansas  State  Medical  Society, 
on  May  4,  1894,  reports  a  case  of  myxcedema  successfully 
treated  with  thyroid  extracts.  The  patient  was  a  mar- 
ried woman,  aged  thirty-eight,  in  whom  the  first  symp- 
toms appeared  about  ten  years  ago.  The  disease  had 
progressed  slowly  but  steadily.  Treatment  was  bqgun  on 
New  Year's  Day  with  the  exhibition  of  a  five-grain  pow- 
der every  day.  From  the  beginning  of  the  treatment 
she  improved  rapidly,  and  on  April  28th  was  apparently 
cured.  Her  weight  had  decreased  in  four  months  from 
one  hundred  and  seventy  to  one  hundred  and  fifty  pounds, 
and  the  transformation  in  her  general  appearance  was  so 
great  that  her  most  intimate  friends  scarcely  recognized 
her. 

Longevity  in  Bussia. — In  the  province  of  KiefF,  dur- 
ing 1893,  there  were  fourteen  deaths  of  persons  over 
one  hundred  years  of  age.  In  the  city  of  Kieff  one  man 
died  aged  one  hundred  and  ten  years,  while  within  the 
suburban  circle  two  women  died  aged  respectively  one 
hundred  and  two  and  one  hundred  and  four  years.  In 
Berditcheff  two  men  reached  the  ages  of  onejiundred 
and  one  and  one  hundred  and  fourteen  years  respectively. 
In  Vassilkoff  another  died  in  his  one  hundred  and  fif- 
teenth year.  In  the  same  district  there  died  a  woman 
aged  one  hundred  and  five ;  in  Svenigorodka,  a  man  of 
one  hundred  and  ten  years ;  in  Tarastscha,  another  one 
hundred  and  fifteen ;  in  Uman,  two  men,  aged  respec- 
tively one  hundred  and  six  and  one  hundred  and  two 
years ;  in  Radomytzel,  two  aged  respectively  one  hun- 
dred and  three  and  one  hundred  and  seven  ;  and  lastly 
a  man  of  one  hundred  and  five  years  died  at  Tcher- 
kassy.  The  united  ages  of  these  fourteen  persons 
amounted  to  1,489  years.  A  man  is  still  living  in  Sara- 
toff  who  has  already  celebrated  126  birthdays. 

A  Missionary  to  Lepers  in  Trouble.— Miss  Kate 
Marsden,  who  achieved  some  notoriety  some  years  ago 
as  a  missionary  to  the  Siberian  lepers,  was  recently  ac- 
cused oi  acts  unbecoming  a  missionary.  The  charges 
were  investigated  by  a  committee  in  St.  Petersburg,  with 
the  result  that  Miss  Marsden  has  been  called  upon  to 
give  up,  in  accordance  with  a  promise  made  at  die  be- 
ginning of  the  investigation,  all  decorations,  letters,  etc., 
bestowed  upon  her  by  royal  and  imperial  well-wishers. 


Medical   Record 

A  Weekly  Journal  of  Medicine  and  Surgery 


Vol.  46,  No.  15. 
Whole  No.  1249. 


New  York,  October  13,  1894. 


$5.00  Per  Annum. 
Single  Copies,  zoc. 


Qfcrtgitral  Articles. 

THE  NECESSITY  OF  INTERNATIONAL  SANI- 
TARY REGULATIONS  GOVERNING  THE  MI- 
GRATION OF  LARGE  BODIES  OF  PEOPLE 
IN  THE  PREVENTION  OF  THE  SPREAD  OF 
CONTAGIOUS  AND   EPIDEMIC  DISEASES. 

Illustrated  by  the  International  Sanitary  Confer- 
ence of  Paris,  1894  l 

By  STEPHEN   SMITH,    M.D., 

NSW  YORK. 

Those  diseases  which  are  classified  as  contagious  and  in- 
fectious are  the  common  enemies  of  mankind.  Every 
hum  in  being  inherits  a  predisposition  to  these  affections. 
No  one,  therefore,  is  exempt  from  an  attack,  on  pioper 
exposure,  by  reason  of  nationality,  civilization,  rank,  or 
condition.  In  their  spread  these  pestilences  have  no  re- 
gard for  the  lines  which  bound  nations,  but  wherever 
man  finds  his  home  there  they  find  a  congenial  soil  for 
propagation. 

The  influence  of  these  diseases  upon  the  history  of  our 
race  has  always  been  disastrous.  They  have  proved 
more  fatal  to  human  life  than  all  other  causes  combined ; 
they  have  destroyed  the  armies  of  conquerors  whom  no 
earthly  power  could  resist ;  they  have,  indeed,  obliter- 
ated from  the  earth,  as  by  an  omnipotent  force,  whole 
races  of  mankind.  They  have  often  given  the  death- 
blow to  an  advanced  civilization,  or  have  left  a  strange 
enduring  impress  on  the  intellectual  life  of  great  nations. 
The  historian  states  that  among  the  causes  which  brought 
about  the  fall  of  the  might  and  civilization  of  Greece 
and  Rome  must  be  mentioned  destructive  pestilences 
which  swept  over  the  Eastern  and  Western  Roman  Em- 
pire during  the  period  between  antiquity  and  the  Mid- 
dle Ages  (Ziemssen). 

The  problem  of  preventing  and  suppressing  these 
scourges  of  the  race  has  been  studied  exhaustively  in  an- 
cient and  modern  times,  but  with  very  different  degrees 
of  success.  To  the  ancient  student  their  origin  remained 
a  mystery  which  no  means  at  his  command  could  pene- 
trate. With  all  his  research  he  could  discover  neither 
their  causes  nor  the  laws  governing  their  propagation. 
One  solitary  fact  of  vast  importance  was  impressed  upon 
his  mind  by  the  abundant  opportunities  for  observation, 
viz.,  that  complete  non-intercourse  of  the  sick,  and  his 
personal  effects,  with  the  well  was  a  reliable  means  of 
protection  and  prevention.  Hence  came  the  famous 
institution  of  quarantine,  or  forty  days'  isolation  of  ves- 
sels from  infected  ports,  a  period  believed  to  be  suffi- 
ciently long  for  the  destruction  of  the  contagium.  Its 
true  significance  was  non-  intercourse  of  the  sick  with 
the  well.  This  was,  indeed,  the  only  means  by  which  a 
city  could  at  that  time  protect  itself  from  an  invasion  of 
the  pestilence.  And  even  now  cities  and  states,  when 
left  to  their  own  individual  resources  against  epidemic 
diseases,  find  quarantine  the  most  effective  measure 
which  they  can  adopt.  It  is  true  that  the  quarantine  of 
to  day  differs  greatly  from  the  quarantine  of  the  past. 
Formerly,  time  was  the  chief  feature  relied  on  to  destroy 
the  contagious  principle,  and  hence  the  period  of  deten- 
tion was  of  long  duration.     Now,  detention  is  enforced 


1  Read  at  the  Annual  Meeting  of  the  New  York  Medical  Associa- 
tion, October  10,  1894. 


only  during  the  period  necessary  for  the  destruction  of 
the  contagium  by  germicides,  or  of  the  incubation  of  the 
germs  of  disease.  Still,  quarantine  means  the  detention 
of  the  traveller  and  his  effects,  and  of  articles  of  com- 
merce liable  to  convey  infection. 

Though  the  rigors  of  the  ancient  quarantine  have 
been  relaxed,  it  was  not  until  within  the  last  decade  that 
there  began  to  be  a  clear  conception  of  a  method  of  sub- 
stituting for  them  measures  far  more  effective,  and  com- 
paratively free  from  inconvenience,  either  to  traveller  or 
to  commerce.  This  was  the  co  operation  of  the  states 
exposed  to  the  epidemic  in  well  -  concerted  measures 
against  a  common  enemy. 

The  first  step  toward  international  action  in  regard  to 
public  sanitation  and  maritime  quarantine  was  taken,  in 
1847,  by  the  French  Government,  which  has  always  been 
foremost  among  the  nations  of  Europe  in  advancing 
sanitary  science.  Preliminary  to  the  calling  of  an  Inter- 
national Sanitary  Conference,  she  appointed  medical 
sanitary  agents  in  the  East.  The  posts  of  observation 
thus  created  were  at  Constantinople,  Smyrna,  Beirut, 
Alexandria,  Cairo,  and  Damascus.  The  information  in 
regard  to  sanitary  conditions  in  those  cities  derived  from 
these  sources  formed  the  basis  for  the  Conference  of 
Paris,  which  was  convened  on  invitation  from  the  French 
Government  in  1851.  Twelve  powers  were  represented 
by  delegates  at  this  conference.  The  results  obtained 
were,  a  relaxation  of  the  rigor  of  quarantine  in  Mediter- 
ranean ports,  and  a  scheme  of  rational  maritime  prophy- 
laxis. 

Thus  was  inaugurated  international  hygiene,  a  system 
of  sanitatary  administration  which  seems  destined  to 
control,  suppress,  and  finally  exterminate  contagious  and 
infectious  diseases. 

Nine  International  Sanitary  Conferences  have  since 
been  called,  and  six  have  been  held.  The  earlier  Con- 
ferences were  not  fruitful  of  immediate  results.  The 
field  of  labor  was  new  and  unexplored,  and  diplomatic 
questions  arose  which  greatly  interfered  with  that  har- 
mony of  action  of  states  essential  to  success.  The  dis- 
cussions of  representatives  of  different  states,  did,  how- 
ever, improve  the  sanitary  administration  of  each.  But 
their  greatest  value  appeared  in  the  better  understanding 
which  the  states  of  Europe  came  to  have  of  the  aims  and 
purposes  of  each  other  when  discussing  measures  of  pre- 
vention against  a  common  enemy.  Mutual  confidence 
was  in  a  measure  established,  which  led  to  far  more  ef- 
fective work  in  future  Conferences.  This  was  apparent 
in  the  Conference  of  Venice,  the  seventh  in  the  series, 
held  in  1892,  which  was  called  to  consider  the  means  of 
preventing  direct  communication  between  Europe  and 
the  infected  regions  of  India,  by  way  of  Egypt  and  the 
Mediterranean  ports.  The  Conference  succeeded,  first, 
in  regulating  the  duration  and  method  of  quarantine  in 
the  Suez  Canal;  second,  in  preventing  the  passage 
through  the  Canal  of  infected  vessels ;  third,  in  requiring 
disinfection  of  suspected  vessels ;  fourth,  in  creating  the 
Council  of  Alexandria,  with  a  preponderance  of  Euro- 
pean influence. 

The  resolutions  adopted  by  the  Conference  were  em- 
bodied in  an  agreement  which  was  signed  by  the  plen- 
ipotentiaries and  afterward  ratified  by  the  powers  rep- 
resented —  the  first  formulated  conclusions  of  any 
Conference  made  authoritative  by  the  signatures  of  the 
plenipotentiaries. 
Still  greater  progress  was  made  toward  the  creation  of 


45° 


MEDICAL   RECORD. 


[October  13,  1894 


international  laws  by  the  Eighth  Sanitary  Conference, 
which  met  at  Dresden,  March,  1893.  The  programme 
proposed  for  consideration  the  following  subjects : 

1.  The  duty  of  a  Government  when  cholera  is  reported 
within  its  territory. 

2.  The  measures  to  be  taken  when  cholera  exists  in  a 
neighboring  country. 

The  Conference  decided  that  the  declaration  of  the 
presence  of  contagious  diseases  is  obligatory,  and  that 
every  means  should  be  taken  to  prevent  its  spread.  It 
formulated  a  system  of  sanitary  measures  which  afforded 
a  maximum  of  protection  for  public  health  with  a  mini- 
mum of  restriction  to  travel  and  traffic ;  it  fixed  the 
period  of  detention  and  isolation ;  it  defined  the  dis- 
tinction between  medical  surveillance  and  observation ; 
and  finally  it  permitted  a  person  arriving  from  an  infect- 
ed port  to  proceed  to  his  destination,  but  it  maintained 
a  rigid  observation  of  him  during  the  period  of  incuba- 
tion of  the  cholera  germ.  The  resolutions  of  this  Con- 
ference were  followed  by  a  convention  which  was  signed, 
with  but  one  or  two  exceptions,  by  all  of  the  powers 
represented. 

These  last  two  Conferences  proved  conclusively  that 
international  agreements  could  be  made  designed  to  pre- 
vent an  invasion  of  Europe  by  cholera,  which,  though 
placing  severe  restrictions  upon  commerce  and  travel, 
were  not  incompatible  with  the  laws  and  customs  of  the 
contracting  powers.  But  valuable  as  these  agreements 
might  prove  to  be,  they  were  simply  barriers  erected 
around  the  immediate  frontier  of  the  state  against  a  foe 
whose  habitat  was  in  the  far  distant  delta  of  the  Ganges. 
Modern  science  has  proved  conclusively  that  the  germs 
of  this  plague  have  never  left  their  native  soil  except  when 
they  were  conveyed  by  human  agency.  Repeated  epi- 
demics had  also  demonstrated  the  fact  that  cholera  never 
invaded  the  districts  of  Northern  and  Western  Asia  ex- 
cept when  large  bodies  of  people  made  pilgrimages  to 
the  holy  places  of  the  Orient.  The  chief  and  most 
important  of  these  pilgrimages  was  that  to  Mecca  by  the 
pilgrims  of  India.  It  was  equally  demonstrated  by  re- 
peated observations  that  cholera  reached  Europe  only 
through  its  pilgrims  who  visited  the  holy  places  of 
Asia,  and  especially  Mecca.  It  became,  therefore,  a  well- 
established  fact  that  the  transmission  of  the  cholera  in- 
fection from  India  to  Europe  was,  in  its  first  stage, 
through  the  pilgrimages  of  the  Mussulmans  from  India  to 
Mecca,  and  other  places  of  resort.  At  these  places  it 
was  transferred  to  the  European  pilgrim,  who  conveyed 
it  to  Europe.  It  was  evident  that  the  international  rules 
and  laws  enacted  did  not  meet  existing  conditions.  As 
a  matter  of  fact,  cholera  appeared  at  Mecca  eight  times 
between  1871  and  1893.  The  European  states,  there- 
fore, could  not  be  certainly  protected  when  the  cholera 
infection  was  brought  without  hindrance  to  Mecca,  and 
the  European  pilgrim  was  allowed  to  visit  Mecca  and 
return  without  any  proper  sanitary  surveillance. 

Such  considerations  as  these  induced  the  French  Gov- 
ernment, always  alert  in  its  efforts  to  provide  adequate 
measures  for  the  prevention  of  cholera  epidemics,  to  is- 
sue a  call  for  another  Conference,  the  ninth  in  the  series, 
and  the  fourth  called  by  the  Government  of  France. 
The  object  of  this  Conference  was  to  provide  measures 
for  preventing,  by  international  agreements,  the  trans- 
mission of  cholera  from  its  native  habitat  by  pilgrims. 
The  task  was  the  greatest  and  most  important  ever 
undertaken  by  any  state  or  combination  of  states. 

This  Ninth  Conference  met  in  Paris,  on  February  7, 
1894,  and  was  attended  by  representatives  from  sixteen 
states,  viz.,  all  the  powers  of  Europe  except  Switzerland ; 
and  Persia,  and  the  United  States,  Egypt,  the  British 
possessions  in  India,  and  the  Straits  Settlements  of  the 
Netherlands. 

In  his  opening  address  the  President  of  the  Confer- 
ence, M.  Casimir  Perier,  now  President  of  the  French 
republic,  eloquently  portrayed  the  duties  of  the  assem- 
bled delegations.  "The  modern  scientific  spirit,"  he 
remarked,  "  has  proved  both  its  firmness  and  its  flexibil- 


ity in  the  course  of  extended  efforts  to  combat  the  Asi- 
atic pestilence  by  means  of  international  agreement. 
By  more  exact  information  of  the  disease  and  the  phe- 
nomena attending  its  transmission,  it  has  gained  a 
knowledge  of  prophylactic  measures  both  more  certain 
and  more  prompt.  It  has  demonstrated  that  the  more 
simple  methods  are  at  the  same  time  the  more  efficacious. 
It  has  conserved  public  interest  at  the  same  time  that  it 
has  protected  human  lives.  The  connections  which 
diplomacy  has  had  the  honor  of  concluding  have  been 
matured  in  the  laboratories  where  men  of  science  pursue 
their  disinterested  researches.  It  is  the  common  labor 
and  the  common  honor  of  science  and  diplomacy  to 
acquire  and  exercise  the  knowledge  necessary  to  recon- 
cile the  customs  which  govern  international  commerce 
and  the  laws  on  which  depend  the  protection  of  human 
life.  .  .  .  You  have  to  continue  now  the  labors 
which  were  commenced  at  Venice.  It  is  your  duty  to 
pursue  cholera  toward  its  source ;  toward  that  part  of 
Central  Asia  where  it  is  said  to  have  its  origin  so  far  as 
it  affects  us.  This  part  of  your  task  is  particularly  deli- 
cate, and  the  method  and  the  principles  which  have 
heretofore  guided  you  should  again  govern  your  actions. 
They  are  now  recognized  as  correct,  and  they  have  hence 
acquired  a  high  authority.  But  in  applying  them  you 
should  not  forget  that  sympathy  for  those  who  suffer,  in- 
dividual kindness,  and  international  fellowship,  generos- 
ity and  equity,  ought  also  to  have  their  proper  place  in 
your  deliberations.  It  is  in  these  previous  deliberations 
that  you  will  have  found  the  discretion  necessary  to 
unite  to  all  of  the  guarantees  that  health  and  the  public 
interests  may  require,  respect  for  local  customs,  usages, 
and  traditions,  and  especially  that  persuasive  influence 
which  shall  secure  to  your  decisions  the  concurrence  of 
all  upon  whom  they  ought  to  be  binding.'9 

M.  Barrere,  the  acting  President,  after  explaining  at 
some  length  the  events  which  led  to  the  present  Confer- 
ence, introduced  Professor  Proust,  who  read  an  elaborate 
paper,  in  which,  after  reviewing  the  work  of  preceding 
Conferences,  showing  how  effectually  they  had  protected 
the  immediate  approaches  to  Europe  from  an  invasion 
of  cholera,  he  proceeded  to  detail  the  questions  which 
the  present  Conference  was  called  to  consider.  They 
involved  problems  more  difficult  of  solution  than  any 
ever  presented  to  a  deliberative  body.  The  danger  to 
Europe  from  an  epidemic  of  cholera,  primarily,  depends 
upon  the  periodical  migration  of  large  bodies  of  the 
Mussulmans  from  India,  the  natural  habitat  of  the  cholera 
germ,  to  the  holy  places  of  Northwestern  Asia,  and  espe- 
cially to  Mecca.  Cholera  has  never  visited  Europe  ex- 
cept when  transported  from  the  delta  of  the  Ganges  by 
pilgrims.  These  pilgrimages  are  made  by  vast  hordes 
of  people,  the  greater  number  of  whom  are  poor  and 
feeble,  or  actually  sick,  and  all  are  accustomed  to  filthy 
habits.  It  appears  that  sixty  per  cent,  of  those  who 
leave  India  on  these  pilgrimages  never  return  to  their 
homes.  The  problem  of  preventing  epidemics  of  cholera 
in  Europe  could  only  be  solved  by  subjecting  these  pil- 
grims to  rigid  sanitary  regulations,  and  to  effectually 
accomplish  this  object  there  must  be  international  agree- 
ments. 

The  difficulties  to  be  encountered  in  adopting  and  en- 
forcing sanitary  rules  for  pilgrims  were  numerous.  1. 
The  pilgrims  themselves  would  be  intolerant  of  any 
restrictions  upon  their  performance  of  a  religious  obliga- 
tion. 2.  Sanitary  regulations  adequate  to  prevent  the 
transportation  of  cholera  infection  must  in  some  degree 
interfere  with  the  ordinary  freedom  of  commerce.  3. 
These  sanitary  rules  and  regulations,  in  order  to  be  ef- 
fective, must  be  enforced  under  the  supervision  of  a 
central  authority  and  not  by  local  authority. 

It  was  very  evident,  therefore,  that  this  Conference 
was  confronted  with  difficulties  which  no  other  had  to 
encounter.  While  it  might  prove  an  easy  task  for  the 
technical  delegates  to  formulate  an  ideal  code  of  sanitary 
rules  which,  if  rigidly  enforced,  would  effectually  pre- 
vent the  transportation  of  cholera  by  the  pilgrims,  it 


October  13,  1894] 


MEDICAL   RECORD. 


45i 


was  apparent  that  the  diplomatic  delegates  would  have 
do  slight  difficulty  in  reconciling  the  various  commercial 
and  public  interests  involved. 

It  will  forever  redound  to  the  credit  of  this  Conference 
that  it  resolutely  set  to  work  on  the  programme  laid  before 
it,  and  not  only  created  a  body  of  admirable  sanitary 
rules  governing  pilgrimages,  but  provided  adequate 
means  of  enforcing  them. 

The  programme  presented  by  the  French  delegation 
was  as  follows : 1 

I.  Prophylaxis  of  the  Pilgrimage  of  Mecca. 
II.   Protection  of  the  Persian  Gulf  ports. 
The  programme  of  discussion  was  formulated  as  follows  : 

I. — Prophylaxis  of  the  Pilgrimage  to  Mecca. 
(A)  Sanitary  police  in  Indian  ports. 

1.  Medical  inspection  of  pilgrims. 

2.  Disinfection. 

3.  Refusal  of  embarkation  of  infected  or  suspected  persons. 

4.  Refusal   of  embarkation  to  all  pilgrims  who  snail  fail  to 

show  that  they  possess  means  to  defray  the  expense  of  the 
pilgrimage ;  five  days'  observation  of  other  pilgrims. 

5.  Sanitary  passport. 

6.  Disinfecting  apparatus  on  each  vessel. 

7.  Adequate  supply  of  potable   water  protected  from  infec- 

tion. 
(ff)  Sanitary  surveillance  of  pilgrims  at  the  entrance  of  the  Red 
Sea. 

1.  Choice  of  site  for  quarantine  station. 

2.  if  Camaran  be  chosen,  improvements  to  be  instituted. 

3.  Disinfecting  apparatus. 

4.  Formation  of  board  of  management  to  be  under  the  con- 

trol of  the  Sanitary  Council  of  Constantinople. 
(O  Improvements  to  be  instituted  at  Abou-Saad  and  Vasta. 
(Z?)  Supervision  of  land  caravans  of  pilgrims  to  Mecca. 
{£)  Reorganization  of  the  sanitary  station  of  £1  Tor. 
II. — Protection  of  the  Persian  Gulf  ports. 

(A)  Establishment  of  sanitary  posts  at  Fao,  Bender-Abbas,  Koveit, 

Bender- Bouchir,  Bassorah,  Mohammerah. 

(B)  Sanitary  surveillance  at  Menama,  in  the  Bahrein  group  of  isl- 

ands. 

( C)  Sanitary  supervision  at  Mascate  and  Guadar,  in  Beloochistan. 

(D)  Constitution  of  a  sanitary  authority  to  have  charge  of  carrying 

out  quarantine  measures. 

A  wide  divergence  of  views,  in  regard  to  the  best 
method  of  treating  an  epidemic  of  cholera  very  early 
appeared  among  the  technical  delegates,  and  became 
very  pronounced  in  the  discussion  of  many  questions 
throughout  the  entire  session.  These  different  opinions 
were  as  follows : 

i.  The  French  delegates  held  that  cholera  infection 
should  not  be  allowed  to  be  conveyed  from  place  to 
place,  either  by  travellers  and  their  effects  or  by  articles 
of  commerce,  hence  they  approved  of  enforcing  such 
sanitary  rules  as  would  free  the  traveller  and  his  baggage, 
as  well  as  articles  of  commerce,  of  the  contagion  of 
cholera  at  any  place  in  their  transit  where  they  were  dis- 
covered or  suspected  to  exist.  This  policy  was  sustained 
by  every  delegation  except  that  representing  Great 
Britain  and  its  dependencies. 

ad.  The  British  delegation  held  that  the  proper 
method  of  dealing  with  cholera  is  to  perfect  the  sani- 
tary conditions  of  cities,  villages,  and  the  homes'  of  the 
people,  and  allow  the  contagium  of  the  pestilence  free 
course  along  the  routes  of  travel,  whether  by  sea  or  land. 
All  harriers  to  the  entrance  of  cholera  into  any  state 
were  condemned,  especially  any  form  of  quarantine 
which  delayed  the  progress  of  vessels  into  ports  and  the 
immediate  discharge  of  cargo.  This  public  policy  was 
supported  only  by  the  delegation  from  Great  Britain. 

3d.  The  delegate  who  represented  the  British  posses- 
sions in  India  held  that  cholera  is  due  to  epidemic  in- 
fluences quite  beyond  human  control ;  hence  he  advo- 
cated non  inteference.  This  policy  was  supported  only 
by  the  delegate  who  represented  India. 

The  scope  and  character  of  the  regulations  adopted 
can  be  illustrated  by  a  few  selections.  In  general  it  may 
be  stated  that  the  pilgrim  is  placed  under  sanitary  sur- 
veillance of  a  very  rigorous  character  from  the  moment 
he  announces  his  intention  to  go  on  a  pilgrimage,  till 
his  return  home.     1st,  He  must  obtain  a  sanitary  pass- 

1  See  Abstract  of  Sanitary  Reports  issued  by  the  U.  S.  Marine 
Hospital  Service  for  Summary  of  Conference  proceedings. 


port  from  the  local  authority.  This  rule  is  taken  from 
the  Netherlands'  Straits  Possessions.  Before  the  pass- 
port is  issued,  the  intending  pilgrim  must  prove  that  he 
has  complied  with  all  of  the  conditions  necessary  for  his 
departure ;  and  that  he  has  money  sufficient  for  the  voy- 
age, and  to  sustain  his  family  in  his  absence.  This  pass- 
port the  pilgrim  must  retain  and  show  to  the  sanitary 
authorities,  en  route,  and  he  can  enter  the  Hedjaz,  the  prov- 
ince in  which  Mecca  is  located,  only  on  presentation  of 
it,  and  on  passing  an  examination.  He  is  under  sani- 
tary observation  while  at  Mecca,  and  on  his  return  a  new 
passport  is  given  him,  which  he  must  show  to  the  author- 
ities en  route. 

At  the  port  of  departure  the  pilgrim  comes  under  the 
sanitary  police,  and  the  following  regulations  are  to  be 
enforced : 

^Medical  inspection  of  all  persons  taking  passage  on  board  a  pil- 
grim vessel  made  individually,  by  daylight,  on  land,  and  by  a  physi- 
cian appointed  by  the  local  sanitary  authority. 

Thorough  disinfection  made  on  land  under  the  direction  of  the 
physician  appointed  by  the  sanitary  authority  of  all  infected  or  sus- 
pected articles. 

Refusal  of  embarkation  to  any  person  attacked  with  cholera  or 
choleriform  disorders. 

When  a  case  of  cholera  exists  at  the  port,  embarkation  on  board 
of  pilgrim  vessels  shall  not  take  place  until  the  persons  to  be  em- 
barked have  been  segregated  and  subjected  to  observation  for  five 
days. 

Each  pilgrim  vessel  must  have  the  following  pro- 
visions : 

Every  vessel  embarking  one  hundred  or  more  pilgrims  shall  carry 
a  physician  commissioned  by  the  government  to  which  the  vessel 
belongs.  If  the  number  of  passengers  exceeds  one  thousand  a  sec- 
ond physician  shall  be  engaged. 

The  physician  should  see  that  the  rules  of  hygiene  are  observed 
on  board,  and  that  food  and  water  are  distributed  according  to 
agreement. 

Pilgrims  shall  be  lodged  between  decks. 

The  deck  should  remain  clear.  It  should  be  placed  at  the  dis- 
posal of  the  passengers. 

Passengers  shall  be  allowed  to  retain  only  such  baggage  as  is 
strictly  necessary. 

The  vessel  shall  be  provided  with  latrines  in  the  proportion  of 
one  to  each  one  hundred  passengers.  These  shall  not  be  located  in 
the  hold  or  between  decks.  They  shall  be  cleaned  three  times  daily 
and  flushed  with  sea  water. 

Each  person  shall  be  gratuitously  furnished  with  five  litres  of 
drinking-water  a  day. 

If  there  shall  arise  any  doubt  as  to  the  condition  of  the  drinking- 
water  it  should  be  boiled  and  sterilized,  and  the  captain  is  directed 
to  empty  it  overboard  and  replenish  at  the  first  stopping- place. 

Two  kitchens  shall  be  provided  for  the  use  of  the  pilgrims.  They 
shall  not  be  allowed  to  cook  elsewhere. 

Medical  care  and  attendance  shall  be  furnished  gratuitously  to  the 
pilgrims. 

A  regularly  organized  infirmary  shall  be  provided  for  the  sick. 
It  shall  be  large  enough  to  accommodate  five  per  cent,  of  the  pas- 
sengers, with  a  space  of  three  square  metres  per  capita. 

The  vessel  shall  be  provided  with  the  means  of  isolation  in  case 
of  choleraic  attack. 

Each  pilgrim  vessel  is  subjected  to  the  following  reg- 
ulations at  the  port  of  departure : 

The  captain  of  a  pilgrim  vessel  is  required  to  declare  to  the  poit 
authority,  at  least  three  days  in  advance,  his  intention  of  embark- 
ing pilgrims.  He  must  also  declare  the  date  of  intended  departure 
and  the  port  of  destination. 

The  sanitary  authority  of  the  port  shall  then  inspect  and  measure 
the  vessel.  The  consul  representing  the  flag  carried  by  the  ship 
may  assist,  if  he  so  desires,  at  this  inspection. 

The  port  authority  shall  not  permit  the  departure  of  a  vessel  until 
he  is  assured : 

(a)  That  the  vessel  is  clean,  and,  if  possible,  disinfected. 

Id)  That  it  is  in  condition  to  undertake  the  voyage,  and  that  the 
sanitary  conditions  are  good. 

(c)  That  the  food  and  fuel  provided  for  crew  and  passengers  are 
sufficient  in  quantity  and  good  in  quality. 

(a)  That  the  water  is  good  and  obtained  from  a  pure  source  ; 
that  it  is  sufficient  in  quantity,  protected  from  contamination  on 
board,  and  dispensed  by  faucets. 

(*,  /,  g,  k)  That  the  vessel  carries  distilling  apparatus  capable  of 
producing  five  litres  of  water  a  day  per  capita  for  all  persons  on 
board,  passengers  and  crew;  that  it  carries  a  disinfecting  stove  and 
has  on  board  a  physician  and  a  ship's  medicine- chest,  and  that  the 
deck  is  clear. 

The  captain  shall  post  notices  drawn  up  in  the  principal  language; 
spoken  by  the  pilgrims  stating  : 


45* 


MEDICAL   RECORD. 


[October  13,  1894 


1.  Destination  of  the  ship. 

2.  Daily  ration  of  food  and  water. 

3.  The  price  of  provisions  not  included  in  the  daily  distribution. 
The  captain  shall  not  be  free  to  leave  port  until  he  holds  : 

1.  A  list  of  the  pilgrims  whom  he  is  authorized  to  embark,  vised 
by  the  port  sanitary  authority. 

2.  A  bill  of  health  stating  the  name,  nationality,  and  tonnage  of 
the  vessel,  name  of  the  captain  and  physician,  the  number  of  persons 
embarked,  crew,  passengers,  and  pilgrims,  nature  of  the  cargo, 
place  of  departure  and  destination,  and  condition  of  public  health 
m  the  port  of  departure. 

Daring  the  voyage  the  following  requirements  are  en- 
forced: 

All  articles  that  have  come  in  contact  with  the  sick  shall  be 
promptly  disinfected.  Articles  of  no  value  should  be  thown  over* 
board  if  the  vessel  is  at  sea,  or  else  burned  if  the  vessel  is  at  port. 

In  case  of  a  death  occurring  on  board  during  the  voyage  the  cap- 
tain shall  note  the  fact  with  all  particulars. 

The  bill  received  at  the  port  of  departure  shall  not  be  altered  in 
any  way  during  the  voyage.  It  shall  be  vised  in  every  port  at  which 
the  vessel  stops  by  the  sanitary  authority  who  shall  note  thereon  : 

The  number  of  passengers  landed  or  embarked. 

Any  facts  touching  the  condition  of  the  passengers  and  any  in- 
cidents of  the  voyage. 

The  sanitary  condition  of  the  port  at  which  the  vessel  is  stopping. 

The  captain  shall  see  that  all  prophylactic  measures  taken  on 
board  during  the  voyage  are  inscribed  in  the  log. 

The  captain  shall  pay  all  sanitary  taxes. 

Arriving  at  the  Red  Sea,  and  before  proceeding  to 
Hedjaz,  the  pilgrim  ship  must  touch  at  the  sanitary 
station  at  Camaran  and  there  be  subject  to  the  following 
treatment : 

Vessels  declared  upon  medical  inspection  to  be  clean  shall  be  al- 
lowed free  pratique  after  compliance  with  the  following  regulations  : 
The  pilgrims  shall  be  disembarked  ;  they  shall  take  a  spray  bath  or 
a  bath  in  the  sea ;  their  soiled  linen  and  such  of  their  baggage  and 
effects  as  may  be  suspected  of  infection  shall  be  disinfected.  The 
duration  of  this  process,  including  landing  and  re-embarkation,  shall 
not  exceed  forty-eight  hours.  If  during  this  period  no  case  of 
cholera,  diarrhoea,  or  choleriform  disorder  shall  develop,  the  pil- 
grims shall  be  at  once  re  embarked  and  the  vessel  shall  proceed  to 
the  Hedjaz. 

Suspected  vessels — that  is  to  say,  vessels  on  board  of  which 
cholera  declared  itself  at  the  moment  of  departure,  but  on  which  no 
new  case  has  occurred  within  seven  days — shall  be  treated  as  fol- 
lows :  The  pilgrims  shall  be  disembarked  ;  they  shall  take  a  spray 
bith,  or  else  a  bath  in  the  sea;  their  soiled  linen  and  such* of  their 
baggage  and  effects  as  may  be  suspected  of  infection  shall  be  disin- 
fected, at  the  discretion  of  the  medical  officer.  The  duration  of  this 
process,  including  landing  and  re-embarkation,  shall  not  exceed 
(forty-eight  hours.  If  no  case  of  cholera  or  choleriform  disorder 
shall  develop  during  this  period,  the  pilgrims  shall  be  at  once  re  em- 
barked, and  the  vessel  shall  proceed  to  Djeddah  where  a  second  medi- 
cal inspection  shall  be  made  on  board.  If  the  result  is  favorable, 
on  the  written  and  certified  declaration  under  oath  that  no  case  of 
cholera  has  occurred  during  the  voyage  from  Camaran,  the  pilgrims 
shall  be  disembarked.  If,  on  the  contrary,  cholera  or  choleriform 
disorder  shall  have  declared  itself  during  the  voyage,  or  at  the  mo- 
ment of  arrival,  the  vessel  shall  be  remanded  to  Camaran,  and  there 
undergo  a  second  time  the  treatment  for  infected  vessels. 

Infected  vessels — that  is  to  say,  vessels  on  board  of 
which  cholera  and  choleriform  disorder  shall  have  de- 
clared itself  within  seven  days — shall  be  treated  as  fol- 
ows :  The  persons  attacked  with  cholera  or  choler- 
iform affections  shall  be  disembarked  and  isolated  in 
hospital.  Thorough  disinfection  shall  be  performed. 
The  other  passengers  shall  be  disembarked  and  isolated 
in  groups,  consisting  each  of  as  few  persons  as  possible, 
in  order  that  only  a  small  front  shall  be  exposed  to  chol- 
eraic attack,  should  the  disease  develop.  The  soiled 
linen,  utensils,  and  clothing  of  crew  and  passengers  shall 
be  disinfected ;  also  the  vessel  itself. 

The  sanitary  authorities  shall  decide  whether  the  un- 
loading of  the  larger  baggage  and  the  cargo  is  necessary, 
and  whether  the  entire  vessel  or  only  a  portion  of  it  shall 
be  disinfected. 

The  passengers  shall  remain  five  days  at  Camaran.  If 
the  cases  of  cholera  date  back  for  several  days,  the  period 
of  isolation  may  be  curtailed.  It  shall  vary  according  to 
the  date  of  the  last  outbreak  and  in  the  discretion  of  the 
sanitary  authority. 

From  Camaran  the  vessel  shall  proceed  to  Djeddah, 
where  thorough  medical  inspection  shall  be  made  on 
board.     If  the  result  is  favorable  the  pilgrims  shall  be 


disembarked.  If,  on  the  contrary,  cholera  or  choleri- 
form disorder  shall  have  developed  on  board,  either  at 
the  moment  of  arrival  or  during  the  voyage  from  Cama- 
ran, the  vessel  shall  be  remanded  to  Camaran,  and  shall 
there  undergo  for  a  second  time  the  treatment  for  in- 
fected vessels. 

Such  is  but  a  summary  of  the  rules  made  by  the  Con- 
ference governing  the  pilgrimages  from  India  by  way  of 
the  Red  Sea.  Similar  rules  were  made  to  apply  to  pil- 
grims going  by  way  of  the  Persian  Gulf,  or  approaching 
Hedjaz  from  the  north.  These  rules  were  to  be  equally 
enforced  on  the  return  of  the  pilgrims  to  their  homes  by 
any  route.  While  at  Mecca  the  pilgrims  were  under  rig- 
orous sanitary  surveillance. 

An  examination  of  these  rules  will  make  it  apparent 
that  if  they  are  rigidly  enforced  cholera  cannot  reach 
Europe  again  through  the  medium  of  Mussulman  pil- 
grimages. And  herein  we  have  the  possible  failure  of 
the  work  of  the  Conference.  Sanitary  rules  are  worth- 
less if  not  faithfully  executed,  and  yet  no  class  of  laws  is 
so  difficult  of  enforcement  as  those  designed  to  protect 
the  public  health. 

In  their  practical  application,  to  be  effective  in  the 
prevention  or  control  of  contagious  and  infectious  dis- 
eases, individual  rights,  religious  observances,  commer- 
cial interests,  and  even  national  customs,  must  be  subor- 
dinated to  the  exigencies  which  these  pestilences  create. 

It  has  been  held  that  health  laws  are  anomalies  in 
civilized  government.  They  arbitrarily  set  aside  ordi- 
nary laws  because  they  are  adapted  to  an  anomalous  con- 
dition of  the  people.  When  it  is  considered  that  the 
health  laws  created  by  the  Conference  were  to  be  applied 
to  people  intolerant  of  any  restriction  upon  individual 
liberty,  and  especially  upon  the  customary  performance 
of  ancient  religious  obligations,  it  will  be  apparent  that 
when  the  technical  delegates  had  perfected  their  work  of 
completing  the  rules  and  regulations,  a  serious  responsi- 
bility was  imposed  upon  the  diplomatic  delegates  in  pro- 
viding the  ways  and  means  for  their  execution. 

There  was  a  strong  disposition  manifested  by  those 
states  within  whose  jurisdiction  these  rules  were  to  be 
chiefly  executed,  to  be  alone  responsible  for  their  en- 
forcement. But  the  other  states  very  properly  opposed 
such  action,  alleging  that  local  interests  might  interfere 
with  that  rigid  execution  of  every  necessary  detail  so 
essential  to  success.  A  failure  of  one  state  through  which 
the  pilgrims  might  pass,  to  rigorously  apply  the  rules, 
would  imperil  the  entire  scheme.  It  was  determined, 
therefore,  after  much  discussion,  that  all  of  the  contract- 
ing powers  should  have  a  part  in  the  enforcement  of  these 
international  agreements.  The  following  method  of 
accomplishing  this  object  was  finally  agreed  upon: 

1.  The  application  of  the  measures  adopted  by  the  Conference  in 
regard  to  the  pilgrimages  shall  be  intrusted  to  a  committee  chosen 
from  among  the  members  of  the  Council  of  Health  of  Constantinople. 
This  committee  shall  be  composed  of  three  representatives  of  Tor- 
key  and  of  the  several  powers  who  accepted  the  sanitary  agreement 
signed  by  the  Conferences  of  Venice  and  Dresden.  The  president 
ofthe  committee  shall  be  an  Ottoman. 

2.  To  secure  effective  service  at  the  several  sanitary  stations,  com- 
petent corps  of  physicians,  disinfectors,  mechanics,  and  sanitary 
guards,  recruited  from  among  ex-officers,  commissioned  and  non- 
commissioned, shall  be  created. 

3.  The  expense  of  carrying  out  the  system  proposed  by  the  Con- 
ference shall  be  divided  between  the  Ottoman  Government  and  the 
Council  of  Constantinople,  according  to  the  scale  already  fixed  by 
the  several  powers  interested. 

4.  The  sanitary  authority  at  the  Ottoman  port  of  arrival  or  de- 
parture shall  draw  up  a  statement  of  any  infraction  of  this  agreement, 
to  which  the  captain  of  the,  offending  vessel  shall  attach  any  expla- 
nation he  may  have  to  make.  A  certified  copy  of  this  statement  shall 
be  transmitted  to  the  consul  representing  the  country  to  which  the 
vessel  belongs.  The  consul  shall  require  the  fine  to  be  placed  in 
his  hands.  In  the  absence  of  the  consul  the  fine  shall  be  deposited 
with  the  sanitary  authority.  The  fine  shall  ultimately  go  to  the 
Council  of  Constantinople,  when  the  consular  commission  shall  have 
declared  it  valid.  A  second  certified  copy  of  the  statement  shall  be 
forwarded  to  the  Council  of  Constantinople*  who  shall  refer  it  to  the 
consular  commission. 

5.  A  consular  commission  shall  be  formed  at  Constantinople  to 
have  cognizance  of  disputed  cases,  and  to  act  as  judge  between  the 


October  13,  1894] 


MEDICAL  RECORD. 


45.3 


sanitary  agent  and  the  ships'    captains.     It  shall  be  elected  every 
year. 

6.  The  taxes  and  sanitary  fines  shall  not  be  diverted  to  any  objects 
but  those  relating  to  the  sanitary  councils. 

In  addition  to  these  regulations  the  Conference  pro- 
vided for  the  equipment  of  suitable  stations  on  the  route 
of  the  pilgrims,  with  all  the  apparatus  necessary  to  make 
each  a  sanitarium,  where  the  traveller  will  receive  the 
most  perfect  sanitary  care  and  treatment.  The  Otto- 
man Government  had  already  created  several  stations, 
and  the  Conference  took  measures  to  perfect  them  and 
add  others.  Thus  the  island  of  Camaran,  near  the  en- 
trance to  the  Red  Sea,  it  recommended  should  be  en- 
tirely devoted  to  a  sanitarium  for  the  pilgrims  coming 
from  the  south.  For  this  purpose  all  the  present  inhabi- 
tants are  to  be  removed,  the  harbor  is  to  be  rendered 
secure  to  shipping,  and  every  facility  supplied  for  the 
comfort  of  passengers,  and  the  thorough  cleansing  and 
disinfection  of  themselves,  their  effects,  and  the  pilgrim 
ships.  In  the  same  manner,  Djebel-Tor,  at  the  northern 
extremity  of  the  Red  Sea,  is  to  be  provided  as  a  sanita- 
rium for  the  pilgrims  from  the  north.  Hie  ports  of  the 
Hedjaz,  where  the  pilgrims  debark  for  Mecca,  are  to  be 
equally  well  equipped  as  sanitary  stations.  A  large 
number  of  similar  sanitary  stations  will  be  created  along 
the  Persian  Gulf  route,  and  also  along  the  overland 
caravan  routes.  Finally,  Mecca  is  to  have  its  sanitary 
conditions  perfected,  and  a  complete  surveillance  of  the 
pilgrims  organized. 

For  nearly  two  months  the  Conference  devoted  itself 
assiduously  to  its  duties.  It  was  aided  and  encouraged 
in  its  work  by  the  highest  officials  of  the  French  Govern- 
ment. President  Carnot  frequently  met  the  delegates ; 
M.  Casimir  Perier,  the  Premier,  accepted  its  presi- 
dency. M.  Barrdre,  now  Ambassador  to  Switzerland; 
M.  Hanotaux,  now  Minister  of  Foreign  Affairs ;  Profes- 
sor Brouardel,  Dean  of  the  Faculty  of  Medicine  of 
Paris;  Professor  Proust,  Inspector- General  of  the  Sani- 
tary Service ;  and  M.  Monod,  Councillor  of  State,  com- 
prised the  French  delegation.  To  the  courtesy,  con- 
stant efforts,  and  judicious  management  of  this  delegation 
is  due  in  large  measure  the  harmony  which  characterized 
the  deliberations  of  the  Conference  and  the  happy  con- 
summation of  its  labors. 

The  code  of  sanitary  rules  governing  the  migration  of 
large  bodies  of  people  from  or  through  districts  infected 
with  cholera  which  the  Conference  finally  completed  and 
adopted,  is  based  on  the  most  advanced  principles  of 
sanitary  science.  When  this  code  is  finally  accepted  by 
the  powers  of  Europe  and  Asia,  and  by  the  United 
States,  and  then  becomes  in  effect  international  law,  it 
will  mark  the  commencement  of  an  era  which  will  be 
characterized  by  the  extermination  of  those  roving  pes- 
tilences which  have  heretofore  been  the  scourge  of  the 
human  race. 

One  feature  of  the  Conference  remains  to  be  noticed, 
which  is  of  special  interest  to  the  people  of  the  United 
States.  As  this  Conference  was  called  to  devise  inter- 
national measures  to  prevent  the  transportation  of  chol- 
era by  the  migration  of  large  bodies  of  people,  it  seemed 
to  the  delegates  from  the  United  States,  or  at  least  to  a 
majority  of  them,  that  it  would  be  a  fitting  occasion  to 
consider  also  the  closely  allied  subject  of  the  conveyance 
of  cholera  from  Europe  to  the  United  States  by  emi- 
grants. It  was  apparent  that  the  sanitary  rules  and 
regulations  relating  to  travel  and  traffic  which  would 
prevent  the  transmission  of  the  cholera  infection  from 
India  to  Europe  by  the  pilgrim,  would,  if  properly  ap- 
plied, prevent  the  transmission  of  cholera  from  Europe 
to  America  by  the  emigrant.  The  instructions  which 
the  delegates  received  from  their  Government  led  them 
to  believe  that  the  President  also  entertained  the  opin- 
ion that  the  question  of  the  transportation  of  cholera  by 
emigrants  would  be  a  legitimate  subject  of  discussion  in 
the  Conference. 

Actuated  by  these  considerations  the  delegation 
brought  the  matter  before  the  Conference  at  its  third 


session  in  a  formal  paper.  It  was  shown  in  this  state- 
ment that  cholera  has  as  yet  never  reached  the  United 
States  from  Europe  except  through  the  emigrant  classes. 
The  imminent  danger  of  an  invasion  of  the  United 
States  by  cholera,  when  it  is  prevalent  in  Europe,  will 
appear  when  we  consider : 

1st.  The  vast  numbers  of  immigrants  who  land  on  our 
shores  annually.  In  1893,  357,857  emigrants  from  Eu- 
rope arrived  at  the  single  port  of  New  York.  In  seme 
years  the  number  has  been  quite  half  a  million. 

2d.  These  immigrants  are,  for  the  most  part,  the  poor- 
est, filthiest,  and  most  insanitary  class  of  the  population 
of  the  states  of  Europe.  They  are  not  only  extremely 
filthy  in  their  persons  and  habits,  but  they  bring  large 
quantities  of  filthy  baggage  and  household  goods,  which 
are  admirably  adapted  to  preserve  the  germs  of  contagi- 
ous and  infectious  diseases  in  all  their  potency. 

3d.  The  rapidity  with  which  the  transit  of  the  ocean 
is  now  made  by  the  great  passenger  vessels — and  it  is  on 
this  class  of  steamers  that  the  bulk  of  the  immigrants 
reach  the  port  of  New  York — renders  it  possible  now  for 
an  emigrant  to  receive  the  cholera  into  his  system  in 
Europe  and  be  safely  domiciled  in  New  York  City  be- 
fore the  period  of  incubation  has  fairly  expired. 

To  meet  these  exigencies  the  United  States  has  but 
one  remedy,  and  that  is  a  rigorous  quarantine.  Such 
sanitation  of  cities,  villages,  and  the  homes  of  the  people 
as  might  make  it  safe  to  allow  the  cholera  contagium  free 
access  to  our  ports  is  impossible.  The  opinion  was  ex- 
pressed that  if,  by  an  international  agreement,  such  sani- 
tary regulations  could  be  enforced  as  would  secure  to 
the  emigrant  from  Europe  to  America  cleanliness  of 
person  and  baggage,  adequate  means  for  his  care  during 
the  voyage,  and  a  reasonable  guarantee  that  he  is  not 
the  carrier  of  the  cholera  germ,  would  be  followed  by 
greatly  diminished  restrictions,  which  our  Government 
must  otherwise  impose  upon  travel  and  commerce  in  our 
ports. 

The  communication  of  the  delegates  concluded  by 
requesting  that  the  programme  of  the  Conference  be  so 
enlarged  as  to  include  the  preparation  of  international 
sanitary  rules  governing  the  migration  of  the  laboring 
classes  of  Europe  to  America. 

At  a  subsequent  session  the  United  States  delegates 
submitted  more  in  detail,  at  the  request  of  the  Confer- 
ence, the  questions  for  consideration.  The  several  prop- 
ositions were  nearly  those  already  under  discussion  in 
regard  to  the  pilgrims,  viz. 

1.  Measures  to  be  adopted  to  enable  the  emigrants  to 
come  to  the  port  of  departure  free  from  contagious  dis- 
eases. Each  emigrant  should  obtain  from  the  local  au- 
thority a  passport  or  certificate  showing  the  sanitary 
condition  of  the  place  from  which  he  came,  the  route 
that  he  has  followed  to  the  port  of  departure,  and,  as  far 
as  possible,  the  state  of  his  health  during  his  journey. 
The  passport  for  the  pilgrim  made  nearly  the  same  pro- 
vision. 

2.  Measures  to  be  taken  at  the  port  of  departure  to 
prevent  the  germs  of  cholera  being  taken  on  board  of 
vessels,  either  by  the  emigrants  personally,  or  by  their 
clothing  or  other  effects.  These  measures  would  corre- 
spond with  those  adopted  by  the  Conference  with  refer- 
ence to  pilgrims  at  the  port  of  departure,  viz.,  detention 
for  several  days  in  reception  quarters  where  bathing  and 
disinfection  could  be  thoroughly  performed  and  any  in- 
fection present  destroyed. 

3.  Measures  to  be  taken  to  secure  the  best  sanitary 
condition  of  vessels  carrying  emigrants,  before  their  em- 
barkation, in  order  that  the  health  of  the  emigrants  may 
be  preserved  during  the  voyage.  The  excellent  sanitary 
regulations  which  the  Conference  adopted  for  pilgrim 
ships  would  apply  with  some  modifications  to  emigrant 
ships. 

4.  Measures  to  be  taken  during  the  voyage  both  to 
preserve  the  best  sanitary  condition  of  the  ship,  and  of 
the  emigrants  and  equipage,  and  to  promptly  suppress 
any  focus  of  infection  which  might  develop  on  board. 


454 


MEDICAL   RECORD. 


[October  13,  1894 


These  provisions  were  amply  made  by  the  Conference 
with  regard  to  pilgrim  ships  during  the  voyage. 

5.  Measures  to  be  taken  at  the  port  of  arrival,  which 
would  comprise  such  changes  in  the  regulations  of  our 
quarantines  as  would  adapt  them  to  the  new  conditions 
which  these  international  regulations  would  secure  as  to 
the  liability  of  emigrants  to  be  the  carriers  of  cholera  in- 
fection. 

The  communication  of  the  American  delegates  was 
received  with  marked  attention  by  the  members  of  the 
Conference.  It  was  conceded  that  there  was  such  a 
close  analogy  between  the  methods  of  conveyance  of 
cholera  infection  from  India  to  Europe  by  the  pilgrims, 
and  from  Europe  to  America  by  the  emigrants,  that  the 
international  sanitary  regulations  governing  the  migra- 
tion of  one  class  would  be  nearly  applicable  to  the  other. 
Tae  delegates  of  several  states  cordially  adopted  the 
views  of  the  American  delegates,  and  were  disposed  at 
once  to  consult  their  respective  governments  to  obtain 
the  power  to  enlarge  the  programme  in  accordance  with 
our  request.  Others,  while  acknowledging  the  great 
importance  of  the  subject,  were  of  the  opinion  that,  as 
the  present  Conference  was  called  for  a  specific  purpose, 
it  should  not  add  to  its  duties  another  obligation,  how- 
ever closely  it  might  be  allied  to  the  one  in  hand.  They 
proposed  that  the  emigrant  question  be  deferred  to  an- 
other Conference  called  for  that  special  purpose.  The 
British  delegation  opposed  enlarging  the  subjects  for  dis- 
cussion at  the  present  Conference,  and  also  to  the  calling 
of  another  Conference  to  consider  the  emigrant  question, 
basing  their  objections  upon  their  often-reiterated  opin- 
ions that  the  prevention  of  the  spread  of  cholera  should 
not  be  attempted  by  restrictions  upon  travel  and  com- 
merce, but  that  every  state  should  secure  to  its  people 
homes  so  healthy  that  they  would  defy  the  potency  of 
the  cholera  germ.  It  should  be  stated  that  at  one  of 
the  sessions  of  the  present  Conference,  on  the  occasion 
of  the  statement  of  the  above  opinion  by  the  distinguished 
medical  officer  of  the  Local  Government  Board  of  Eng- 
land, the  technical  or  medical  delegate  of  Greece,  re- 
plied that  his  Government  had  no  such  power  as  would 
secure  that  degree  of  sanitation  of  the  homes  of  the.  peo- 
ple of  which  the  English  boast,  and  it  must,  therefore, 
rely  upon  a  rigorous  quarantine  against  cholera.  As  to 
the  value  of  home  sanitation  compared  with  a  rigorous 
quarantine  in  the  protection  of  the  people  against  chol- 
era, he  reminded  the  British  delegation  that  during  the 
last  year  there  were  several  outbreaks  of  cholera  in  Eng- 
land, with  a  number  oi  deaths,  while  for  forty  years 
there  had  not  been  an  outbreak  of  cholera  in  Greece, 
though  the  pestilence  had  many  times  prevailed  in  sur- 
rounding countries. 

After  considerable  discussion  the  Conference  decided 
not  to  change  its  programme,  but  with  much  unanimity 
concurred  in  the  opinion  that  another  Conference  should 
be  called,  if  requested  by  the  Government  of  the  United 
States,  to  formulate  international  sanitary  regulations 
governing  the  migration  of  European  populations  to 
America. 

Meantime  the  delegates  from  several  of  the  powers 
received  instructions  to  unite  in  the  call  of  such  Confer- 
ence, and  two  delegations  presented  the  formal  requests 
of  their  governments  to  be  permitted  to  entertain  the 
Conference  at  their  respective  capitals.  The  United 
States  delegation  reported  the  action  of  the  Conference 
to  their  GDvernment,  and  asked  for  instructions.  The 
President  replied  that  it  was  too  late  in  the  season  to 
call  another  Conference.  Thereupon  further  efforts  to 
arrange  for  a  Conference  were  discontinued,  but  the  find 
sentiments  expressed  to  us  by  many  members  were  to  the 
effect  that,  whenever  the  United  States  Government  sig- 
nified to  the  European  powers  its  desire  to  enter  a  Con- 
ference with  them  for  the  purpose  of  establishing  an  in- 
ternational agreement  relating  to  the  sanitary  supervision 
of  emigrants  from  Europe  to  America,  all  of  the  states 
invited  would  respond. 

To  one  who  has  practically  studied  the  problem  of  the 


prevention  and  suppression  of  such  world-wide  epidemics 
as  Asiatic  cholera,  the  importance  to  the  people  of  the 
United  States  of  the  co  operation  of  the  governments  of 
Europe  with  our  Government,  in  freeing  the  emigrant 
from  the  germs  of  contagious  and  infectious  diseases  be- 
fore he  embarks  for  our  ports,  cannot  be  overestimated. 
The  proposed  scheme  of  sanitary  surveillance  of  the  emi- 
grant would  begin  at  his  domicile  abroad,  and  follow  him 
every  step  of  the  way  to  his  home  in  this  country.  His 
passport  issued  by  the  local  European  health  officer,  and 
vis6d  at  every  point  in  his  progress,  would  not  only  con- 
tain a  record  of  his  condition  as  regards  his  freedom  from 
infection  and  his  health,  but  it  would  be  his  only  guaran- 
tee that  he  could  travel  at  all  on  railways  to  the  port  of  de- 
parture or  that  he  could  embark  on  any  steamship  bound 
to  a  port  in  the  United  States.  It  is  at  once  apparent 
that  such  an  international  agreement  would  bring  to  our 
shores  only  healthy  emigrants  and  in  healthy  ships. 
Two  consequences  would  inevitably  follow,  viz.,  first 
cholera  would  never  be  brought  to  this  country  by  the 
European  emigrant;  and  second,  our  quarantine  would 
consist  only  in  a  detention  for  the  examination  of  the 
passports  of  emigrants  and  the  inquiries  and  inspections 
necessary  to  determine  that  shipmasters  had  faithfully 
complied  with  the  international  sanitary  regulations. 

Thus  closed  the  Ninth  International  Sanitary  Confer- 
ence, in  many  respects  the  most  important  of  the  series. 
It  was  in  fact  a  congress  of  nations  summoned  to  create 
a  code  of  international  laws  entirely  in  the  interests  of 
human  health,  and  consequently  of  human  happiness. 
Its  sessions  were  characterized  throughout  by  that  ear- 
nestness in  the  discussion  of  theoretical  questions  and  that 
conciliation  in  harmonizing  practical  methods  which 
distinguishes  the  modern  scientific  spirit.  We  cannot 
doubt  that  when  the  laws  which  it  enacted  are  faithfully 
executed,  not  only  will  Europe  and  Northern  Asia  be 
relieved  from  periodical  visitations  of  the  most  destruc- 
tive plague  of  modern  times,  but  that  the  vast  hordes  of 
roving  pilgrims  which  traverse  Asia,  scattering  a  pesti- 
lence which  decimates  the  people  among  whom  they 
pass,  while  it  strews  their  own  pathway  with  their  dead, 
will  be  transformed  to  an  orderly  body  of  travellers, 
characterized  by  that  physical  and  mental  health  and 
cleanliness  of  person  and  baggage  so  essential  to  the  ra- 
tional discharge  of  religious  obligations. 

But  have  not  the  nations  winch  in  this  Conference 
accomplished  so  great  a  work  in  the  relief  of  the  Mussul- 
man pilgrim,  and  the  protection  of  Europe  from  cholera, 
a  similar  duty  to  perform  toward  the  Western  emigrant, 
who,  taking  up  the  germs  of  the  plague  brought  to 
Europe,  conveys  them  in  his  filthy  person  and  effects  to 
America  ?  M.  Casimir  Perier  complimented  the  dele- 
gates to  the  Ninth  International  Sanitary  Conference  on 
the  success  which  science  has  had  in  breaking  down 
those  ancient  barriers  which  the  varied  interests  of  man- 
kind have  created,  and  urged  them  to  persevere  in  the 
good  work  until  all  such  restrictions  are  removed.  Must 
there  not  be  a  Tenth  Conference,  which  shall  unite  the 
efforts  of  the  European  powers  and  the  United  States  in 
removing  the  barriers  with  which  commerce  and  cus- 
tom protect  the  emigrant  from  the  application  of  those 
sanitary  measures  which  would  strip  him  of  every  form  of 
contagion,  and  bring  him  to  our  shores  in  good  physical 
and  mental  health  ? 


The  Prussian  Government  expends  over  £50,000  a 
year  in  support  of  the  laboratories  connected  with  the 
medical  department  of  the  University  of  Berlin.  This 
is  exclusive  of  the  salaries  paid  to  professors. 

Asphyxia  and  Tongue  Traction. — Dr.  Bories  reports, 
in  the  Tribune  Medical; ,  the  case  of  a  child  who  appar- 
ently died  during  the  performance  of  a  tracheotomy  for 
croup.  Artificial  respiration  was  of  no  avail,  but  life 
was  restored  in  five  minutes  by  rhythmical  tractions  of 
the  tongue. 


October  13,  1894] 


MEDICAL    RECORD. 


455 


THE  PLACE  OF  PHYSICAL  TRAINING  IN  THE 
MILITARY  SERVICE. 

By   JAMES   E.    PILCHER,  M.D.,  Ph.D., 

CAPTAIN   IN  TUB  M1DICU.  DEPARTMENT  OF  THE   UNITED  STATES  AKMV. 

It  is  an  admitted  fact  that  the  mortality  from  disease  at- 
tains a  considerably  higher  percentage  in  war  than  that 
from  wounds.  It  would  seem,  then,  that  the  prevention 
of  disease  is  the  most  important  function  of  the  medical 
officer  in  active  campaign.  In  peace,  where  the  mor- 
tality of  the  battle-field  is  entirely  eliminated  from  con 
sideration,  prophylaxis  plays  a  still  more  important  tole. 
Recognition  of  the  value  of  careful  attention  to  the  sug- 
gestions of  the  medical  officer  as  an  important  factor  in 
securing  the  greatest  efficiency  of  a  command  has  been  a 
matter  of  slow  growth,  but  it  has  been  progressive.  The 
influence  upon  a  command  of  the  sanitary  condition  of 
camps,  cuisine,  and  clothing,  has  come  to  be  fully  recog- 
nized through  the  active  labors  of  army  medical  officers, 
until  the  surgeon  is  no  longer  considered  a  useless  en- 
cumbrance except  when  sickness  is  present,  but  takes  his 
place  as  the  most  important  member  of  the  staff. 

It  is  singular  that,  while  the  medical  department  has 
devoted  ample  attention  to  the  prevention  of  disease  by 
the  removal  of  threatening  conditions,  it  has  almost  en- 
tirely neglected  prophylaxis  by  increasing  the  resisting 
power  of  the  soldier  himself.  It  is  true  that  the  line  has 
been  equally  unmindful  of  so  potential  an  agent  in  secur- 
ing efficiency  in  the  soldier,  devoting  centuries  to  the  de 
velopment  of  the  weapons  of  war,  entirely  regardless  of 
the  development  of  the  men  who  were  to  handle  them. 
Latterly,  however,  a  new  interest  has  arisen  in  the  sub- 
ject, and  at  some  military  posts  useful  work  has  been 
done  with  insufficient  appliances.  The  sentiment  of 
those  officers  who  have  given  physical  training  a  fair 
trial  is  unanimous  in  favor  of  its  vast  utility.  Medical 
officers,  however,  have  given  it  but  little  attention,  al- 
though they  alone  are  qualified  to  fully  understand  its 
value  or  to  supervise  its  conduct. 

The  culture  of  the  body,  to  be  correctly  accomplished, 
demands  not  only  sufficient  anatomical  and  physiologi- 
cal knowledge  to  locate  defective  parts,  but  sufficient 
pathological  perceptivity  to  appreciate  the  advantages  or 
dangers  to  be  incurred  by  training  these  parts.  That  it 
is  impossible  for  any  but  a  medical  man  to  comprehend 
the  needs  of  the  body  in  the  matter  of  training,  has  been 
recognized  by  the  better  class  of  instructors  in  physical 
culture,  from  Ling,  the  founder  of  the  Swedish  system, 
down  to  the  great  teachers  of  the  present  day,  who  have 
almost  invariably  qualified  as  physicians,  as  an  essential 
preliminary  to  the  proper  comprehension  and  application 
of  physical  culture. 

While  physical  training  may  with  propriety  be  called 
muscle-building,  it  should  be  understood  that  the  cult- 
ure of  every  other  constituent  of  the  organism  progresses 
tori  passu  with  that  of  the  muscles,  to  which  the  chief  at- 
tention is  given.  It  requires  the  most  accurate  notions 
of  the  muscular  structure  to  select  the  individual  muscle 
to  which  a  part  owes  its  weakness  or  lack  of  symmetry. 
The  anatomical  and  physiological  knowledge  necessary  to 
individualize  and  educate  distinct  muscles  in  such  a  man- 
ner as  to  produce  symmetry  and  correctness  of  contour, 
and  the  maximum  of  strength  combined  with  the  great- 
est facility  in  its  employment,  demands  special  medical 
training.  Anyone  can  run  a  tape  measure  about  an 
arm,  but  it  requires  not  only  the  information  acquired  in 
the  dissecting-room  and  the  physiological  laboratory,  but 
the  power  of  discrimination  developed  by  careful  and 
intelligent  clinical  observation,  in  order  to  discover  what 
particular  member  of  a  group  of  muscles  is  responsible 
for  the  lack  of  power  which  it  is  desired  to  correct.  Not 
only  does  it  require  the  most  correct  appreciation  of  mus- 
cular function  to  understand  the  particular  movement 
or  combination  of  movements  adapted  to  the  develop- 
ment of  a  defective  muscle,  but,  in  order  to  secure  the 
best  results,  there  must  be  a  familiarity  with  the  secondary 
and  remote  effects  upon  the  other  portions  of  the  system. 


The  perfect  man  is  a  figment  of  the  imagination.  No 
person  is  known  to  have  existed  who  was  an  embodiment 
of  perfect  health.  A  physical  examination  of  the  most 
vigorous  would  reveal  in  each  some  lesion  of  actual  dis- 
ease, some  predisposing  weakness,  or  both.  The  object 
of  physical  training  is  to  take  cognizance  of  physical  de- 
ficiencies and  correct  them  by  movements  adapted  to 
secure  growth.  Hard  labor  is  far  from  being  an  equiva- 
lent of  physical  training.  It  is  true  that  laboring  men 
acquire  great  strength  in  certain  groups  of  muscles,  but 
this  gain  is  overbalanced  by  losses  in  others.  The  plough- 
man has  strength  in  his  arms,  back,  and  legs,  but  he 
loses  in  his  respiratory  muscles  and  the  anterior  thoracic 
muscles.  The  deformities  of  occupation,  due  to  the  ex- 
cessive use  of  one  portion  of  the  body,  to  the  neglect  of 
others,  have  a  recognized  place  in  orthopedics. 

The  material  obtained  by  taking  the  average  man  is 
excellently  shown  in  Prince  Hohenlohe's  description  of 
the  men  obtained  in  the  recruitment  of  his  own  regi- 
ment. "The  barracks  were  soon  full  of  figures  that 
would  put  to  shame  the  most  exaggerated  cartoons  of  the 
comic  papers.  The  awkward  fellows,  whose  neglected 
carriage  made  them  look  like  a  set  of  botched-up  images, 
tried  hard,  but  in  vain,  to  stand  erect.  Ill  made  and 
undeveloped,  their  uniforms  would  not  fit  them,  and,  if 
altered  to  fit  their  present  figure,  would  need  to  be  re- 
made when  they  should  have  been  remodelled  by  physical 
training.  So,  before  teaching  them  a  single  movement 
of  the  military  drill,  or  providing  them  with  uniforms 
other  than  their  canvas  fatigue  suits,  they  were  drilled 
in  gymnastic  exercises  leading  progressively  and  gently 
from  the  easy  to  the  more  advanced,  until  finally  they  had 
a  reasonable  command  of  themselves.'1 

This  picture  reminds  one  somewhat  of  the  appearance 
of  the  "  candidates  "  at  West  Point.  These  young  men 
have  quite  generally  been  subjected,  before  coming  to  the 
Academy,  to  a  physical  examination  by  a  competent  med- 
ical man  and  by  him  pronounced  physically  sound.  But 
they  are  almost  to  a  man  awkward,  unsymmetrical,  and 
unevenly  developed,  making  an  appearance,  as  they  are 
marched  to  the  mess  hall,  fully  as  absurd  as  the  con- 
scripts of  Prince  Hohenlohe.  And  they  form  a  particu- 
larly instructive  contrast  with  the  "yearlings"  who  have 
enjoyed  the  advantages  of  a  year's  drill  in  physical  train- 
ing. 

Methods  of  recruiting  employed  by  the  regular  army 
in  times  of  peace  to  a  large  extent  prevent  the  admission 
into  the  military  service  of  men  with  muscles  clearly  un- 
developed or  atrophied  by  distinctly  marked  disease. 
Still  it  is  not  infrequent  in  my  observation  that  men  are 
enlisted,  particularly  by  the  regimental  recruiting  service, 
with  defects  or  deficiencies  sufficiently  pronounced  to 
contribute  to  their  life  for  the  next  two  or  three  years  an 
important  bearing  upon  their  future  health.  While  act- 
ual deformity  or  disease  is  a  bar  to  the  admission  of  the 
recruit,  the  variation  in  structure  is  so  great  that  but  a 
small  proportion  of  recruits  is  either  symmetrical  or  de- 
veloped. 

In  the  National  Guard,  where,  for  evident  reasons,  the 
physical  requirements  need  not  be  as  severe  as  in  the  reg- 
ular service,  the  field  for  physical  training  is  still  broader 
and  the  results  obtainable  still  more  striking.  Volun- 
tary service  lends  to  the  work  of  the  guardsman  an  en- 
thusiasm which  is  an  important  factor  in  the  attainment 
of  the  best  results. 

Physical  training  may  by  divided  into  two  categories : 

1.  Preparatory  training,  by  which  deficiencies  are  cor- 
rected and  a  proper  equilibrium  of  the  system  secured. 

2.  Conservative  training,  by  which  a  well  balanced 
state  of  the  system  is  maintained  after  having  once  been 
obtained. 

The  preparatory  training,  particularly,  demands  med- 
ical supervision.  Here  the  methods  of  physical  diagno- 
sis come  into  play.  Mensuration,  inspection,  and  palpa- 
tion are  of  particular  importance.  In  many  gymnasiums 
mensuration  is  the  only  diagnostic  method  employed, 
but  it  is  evident  that  it  is  necessarily  insufficient,  since 


456 


MEDICAL    RECORD. 


[October  13,  1894 


one  group  of  muscles  may  be  so  over-developed  as  to 
neutralize,  in  the  measurement  of  a  limb,  the  effect  of 
the  atrophy  of  another — the  girth  of  a  part  may  be  up  to 
the  average,  and  yet  a  very  definite  defect  may  be  readily 
detected  by  experienced  inspection,  and  its  character  ap- 
preciated by  careful  palpation. 

As  a  general  rule,  weight,  height,  and  breadth  may  be 
said  to  be  in  direct  proportion  to  the  strength.  But  the 
exceptions  to  this  rule  are  numerous  and  pronounced. 
Weight  may  be  due  to  an  excess  of  adipose  tissue,  tend- 
ing to  produce  debility  rather  than  strength.  Height 
may  be  due  to  excessive  length  of  legs  or  neck,  both  ele- 
ments of  weakness.  Breadth  may  exist  with  flaccid 
muscles  and  fatty  deposits,  which  are  incompatible  with 
great  physical  power.  As  already  suggested,  there  is 
usually  a  lack  of  harmony  in  development  between  the 
various  parts  of  the  body,  and  in  this  disproportion 
may  lie  the  source  of  marked  physical  deficiency.  The 
well  developed  chest  and  arms  are  more  than  likely  to 
be  accompanied  by  spindling  legs.  The  limbs  of  the 
left  side  are,  in  a  large  proportion  of  cases,  smaller  than 
those  of  the  right — an  asymmetry  which  extends  to 
numerous  other  details. 

The  preliminary  facts  upon  which  to  base  the  prepar- 
atory training  are  of  ten  varieties :  1,  The  weight ;  2, 
the  height  from  the  floor  of  the  knees,  the  pubic  arch, 
the  sternum,  and  the  vertex  of  the  head,  the  latter  with 
the  body  standing  and  sitting ;  3,  the  girth  of  the  head, 
neck,  chest,  waist,  hips,  thighs,  knees,  calves,  insteps, 
arms,  forearms,  and  wrists ;  4,  the  depth  of  the  chest  and 
abdomen  ;  5,  the  breadth  of  the  head,  neck,  shoulders, 
waist,  and  hips ;  6,  the  length  of  each  side  from  shoulder 
to  elbow,  elbow  to  tip  of  middle  finger,  of  the  feet  and 
of  the  body  laid  horizontally ;  7,  the  stretch  of  the  arms ; 
8,  the  capacity  of  the  lungs;  9,  the  strength  of  the 
lungs,  back,  chest,  arms,  and  forearms ;  and  10,  the  de- 
velopment of  the  body.  The  appliances  necessary  for 
obtaining  these  data  are  a  steel  tape-measure,  a  large 
pair  of  callipers,  several  spring  dynamometers,  a  spiro- 
meter, a  manometer,  a  pair  of  suspended  rings,  and  a  set 
of  parallel  bars. 

We  are  fortunate  in  having  at  our  disposal  at  the 
present  day  the  data  based  upon  a  large  number  of 
pbservations  already  made,  by  the  consolidation  of  which 
types  of  manhood  have  been  obtained.  Sargent's  obser- 
vations are  perhaps  the  best  known  and  the  most  exten- 
sive, but  in  the  records  of  the  scientific  gymnasiums  of 
the  country  a  vast  amount  of  information  can  be  obtained, 
particularly  pertaining  to  the  dimensions  of  youth  and 
early  adult  age. 

These  data  are  exactly  what  is  required  by  the  surgeon 
in  the  examination  preliminary  to  the  preparatory  train- 
ing, for  recruits  are — invariably  in  time  of  peace — young 
men.  Accurate  examination  of  the  recruit,  using  the 
eye,  the  hand,  and  the  accessory  instruments  already 
enumerated,  will  show  his  deviation  from  the  normal 
type,  from  which  the  exercises  necessary  to  assimilate 
him  to  the  normal  will  be  a  natural  deduction.  Muscu- 
lar development  depends  on  frequency  of  muscular  ac- 
tion. The  man  with  undeveloped  calves  would  be  given 
foot  and  ankle  exercises,  and  he  with  a  slender  forearm 
would  engage  in  the  wrist  and  finger  movements.  The 
flattened  che3t  would  be  brought  out  not  only  by  use  of 
the  accessory  respiratory  muscles,  but  all  exercises  would, 
by  causing  deep  and  frequent  breathing,  cultivate  the 
respiratory  apparatus.  The  muscles  of  the  neck  and  face 
can  each  be  brought  up  by  individual  and  combined 
movements.  In  connection  with  the  special  exercises 
prescribed  for  the  compensation  of  deficiencies,  the 
recruit  will  naturally  engage  with  his  comrades  in  other 
movements  which  will  at  the  same  time  keep  up  the 
general  physical  tone,  until  he  shall  have  attained  a 
sufficiently  uniform  development  to  permit  his  passing 
into  the  class  of  the  soldier  and  engaging  only  in  conser- 
vative training. 

The  time  during  which  the  recruit  remains  in  the  pre- 
paratory class  is  very  variable,  being  dependent  upon  two 


factors:  1,  The  amount  of  deviation  from  the  nonml 
type,  and  2,  the  readiness  with  which  he  responds  to 
treatment.  During  this  period  he  should  be  continually 
under  medical  supervision,  but  when  he  passes  into  the 
second  class,  the  personal  medical  inspection  need  be 
far  less  minute,  although  it  should  never  be  entirely  with- 
drawn as  long  as  the  training  is  continued. 

The  soldier  now  enters  upon  the  conservative  train- 
ing, extending  to  the  general  field  of  gymnastics  where 
the  exercises  are  numerous  and  varied.  Every  move- 
ment of  the  manual  of  arms  and  every  evolution  in 
marching  have  an  effect  upon  the  muscular  system.  But 
it  is  an  error  to  presume  that  these  are  sufficient  for 
thoroughly  maintaining  bodily  efficiency.  Not  only  are 
they  by  themselves  insufficient  for  the  maintenance  of 
symmetrical  development,  but  they  even  tend  to  the  ac- 
centuation of  asymmetry.  The  very  existence  of  the 
"  setting  up  "  drill  is  an  evidence  oi  this  fact.  But  whi?e 
the  expanded  "setting  up  "  drill,  as  now  practised,  serves 
excellently  to  correct  the  vicious  attitudes  imposed  by 
certain  phases  of  military  duty,  it  is  not  competent,  un- 
aided, to  maintain  a  high  physical  ton$.  Even  were  the 
prescribed  military  drills  efficient  in  maintaining  a  sym- 
metrical physique,  they  would  soon,  by  constant  repeti- 
tion, become  merely  mechanical  in  their  execution,  a 
fact  which  would  detract  vastly  from  their  usefulness. 
Physical  training,  in  order  to  retain  the  interests  of  its 
participants,  should  be  the  subject  of  unlimited  variation. 
There  are  no  movements  like  those  of  the  manual  of 
arms  requiring  incessant  repetition  to  secure  precision  in 
execution.  Infinite  diversity,  then,  may  be  obtained  by 
the  employment  of  the  almost  boundless  category  of 
muscular  action — running,  leaping,  climbing,  swinging, 
turning,  lifting,  striking,  and  the  like,  in  various  attitudes 
and  with  various  surroundings,  without  apparatus  and 
with  the  great  variety  of  apparatus  contributed  by  mod- 
ern inventive  genius.  Athletic  sports  are  also  a  powerful 
factor  in  stimulating  interest  in  physical  training,  and 
for  that  reason  should  be  heartily  encouraged.  The 
spirit  of  competition  thus  introduced  into  the  work  is  of 
very  considerable  advantage,  although  a  tendency,  ap- 
parent at  the  present  time,  to  subordinate  physical  train- 
ing entirely  to  a  preparation  for  participation  in  sporting 
contests,  is  to  be  deprecated. 

An  objection  urged  against  physical  training  in  the 
army  is  that  the  men  do  not  take  interest  in  it.  This 
would  hardly  be  supposed  to  be  a  valid  objection  to  any 
plan  looking  to  the  improvement  of  the  service.  And 
moreover,  it  is  not  a  valid  objection.  If  there  is  absence 
of  interest  anywhere  it  is  due  to  some  defect  in  the  man- 
agement of  the  training.  To  put  up  a  horizontal  bar 
and  a  dozen  dumb  bells,  and  magnificently  remark  to  a 
garrison:  "There  is  your  gymnasium,  use  it,"  is  dis- 
couraging enough  to  ruin  any  project.  The  untrained 
man  does  not  know  how  to  use  gymnastic  apparatus. 
He  may  have  seen  the  "  Queen  of  the  Air  "  swinging  in 
a  trapeze,  but  he  quickly  finds  that  circus  acts  are  not 
physical  training,  and  he  naturally  loses  interest  in  the 
subject.  He  would  lose  interest  in  just  the  same  way  in 
the  choicest  book  of  Arabic  that  might  be  put  before 
him.  He  must  be  taught  how  to  utilize  his  opportu- 
nities. It  is  like  any  game,  it  must  be  understood  to  be 
enjoyed.  And  here  is  where  the  work  of  the  medical 
officer  comes  into  play  and  the  instructors  in  physical 
training  find  their  functions. 

But  he  will  require  no  instruction  to  appreciate  the 
benefit  of  the  training.  The  muscular  growth  begins  at 
once ;  the  size  of  the  body  increases ;  the  circumference 
of  the  limbs  is  greater  ;  the  chest  is  enlarged,  and  the 
weight  is  augmented.  The  influence  upon  the  system  of 
the  enlargement  of  the  chest  alone  cannot  be  computed ; 
the  greater  expansion  permitted  to  the  lungs,  the  greater 
play  allowed  to  the  heart,  the  greater  amount  of  oxygen 
introduced  into  the  system,  the  greater  excretion  of  ef- 
fete matter  from  the  blood,  with  their  secondary  effect 
upon  every  cell  and  organism  in  the  body  cannot  be 
expressed.     The  increased  girth  of  the  extremities  is  not 


October  13,  1894] 


MEDICAL    RECORD. 


457 


the  only  indication  of  their  added  strength,  for  it  does 
not  take  into  account  the  firmness  and  contractile  power 
gained  even  before  the  growth  began.  The  quickened 
sympathy  between  the  brain  and  the  muscles  cannot  be 
shown  by  any  test.  The  suppleness,  the  agility,  the  self- 
confidence  that  have  developed,  cannot  be  represented 
by  figures.  The  added  keenness  of  perception,  the 
comfort  and  satisfaction  contributed  to  existence  itself 
cannot  be  estimated,  much  less  represented. 

Physical  training,  then,  should  occupy  a  twofold  place 
in  the  military  service : 

1.  In  its  preparatory  phase,  it  should  be  at  the  basis 
of  all  service  (a)  to  build  up  to  symmetry  men  whose 
physique  is  below  the  standard ;  (b)  to  improve  the  mus- 
cular harmony  of  all  recruits,  none  of  whom  are  symmet- 
rical at  enlistment ;  (c)  to  give  to  the  men  that  ready 
command  over  the  muscular  system  that  only  comes  from 
thorough  training ;  and  (d)  to  contribute  that  quickness 
of  mental  comprehension  only  to  be  derived  from  exer- 
cising in  response  to  frequently  varied  commands. 

2.  In  its  conservative  phase,  it  should  still  remain  at 
the  foundation  of  all  service.  It  is  not  enough  to  bring 
a  soldier  up  to  the  maximum  of  physical  serviceability, 
but  he  must  be  kept  there.  To  overcome  the  retrograde 
tendency  characteristic  of  all  forms  of  life  when  stimu- 
lated to  a  higher  grade,  and  no  less  present  in  physical 
development,  a  certain  degree  of  training  must  be  main- 
tained constantly. 

3.  In  both  phases  it  should  receive  (a)  the  active  per- 
sonal support  of  the  medical  officer,  for  by  strengthen- 
ing the  weaker  portions  of  the  system  it  will  increase  the 
resistance  to  disease  and  vastly  diminish  the  sick-rate  of 
his  command ;  and  (b)  his  most  careful  supervision  as 
well,  in  order  to  insure  the  proper  direction  of  the  train- 
ing and  prevent  excess  in  its  application,  an  error  in 
either  case  being  sufficient  to  preclude  a  healthful  growth. 

The  results  of  the  scientific  application  of  physical 
training  to  the  military  service  will  be  wide-reaching  in 
their  beneficial  effect. 

1.  The  serviceability  of  the  recruit  will  be  more 
quickly  obtained,  not  only  by  insuring  the  symmetrical 
growth  of  his  frame,  but  by  the  awakening  of  his  mus- 
cular activity  and  the  consequent  quickening  of  his  .men- 
tal faculties. 

2.  The  efficiency  of  the  entire  army  will  be  increased 
by  the  development  of  the  physique  of  the  units  compos- 
ing it. 

3.  The  morality  of  the  army  will  be  elevated  by  sub- 
stituting the  healthful  sports  connected  with  physical 
culture  for  the  less  reputable  amusements  in  which  sol- 
diers are  sometimes  tempted  to  indulge. 

4.  The  economical  administration  of  the  government 
will  be  materially  assisted,  for  training  the  soldier  to 
physical  vigor  will  result  in  keeping  from  the  pension 
rolls  the  names  of  many  who  would  otherwise  promptly 
degenerate  into  helpless  dependents  upon  the  bounty  of 
the  State. 

5.  Not  only  will  it  vastly  increase  the  efficiency  of  the 
military  service,  but  it  will  have  an  extensive  influence 
upon  the  entire  community.  As  the  years  roll  by,  it 
will  present  to  the  commonwealth,  upon  their  discharge 
from  the  army,  a  class  of  men,  by  their  physical  develop- 
ment and  mental  capacity,  qualified  to  be  more  than 
ordinarily  useful  citizens.  By  its  extension  to  the  mili- 
tary schools,  springing  up  all  over  the  country,  it  will 
encourage  healthful  tendencies  and  manly  inclinations  in 
our  youth.  Through  its  adoption  by  the  National  Guard 
— always  quick  to  adopt  the  best  features  of  the  regular 
service — it  will  disseminate  physical  development  and 
intellectual  activity  throughout  the  young  men  of  the 
nation.  In  every  class  of  society,  in  every  grade  of  life, 
wherever  health  is  understood  and  length  of  life  desired, 
its  influence  may  be  felt  and  its  effects  may  be  appreci- 
ated.   

Edinburgh  is  Advancing,  for  there  are  now  eight 
Women  practising  medicine  in  that  city  and  Leith. 


ETHMOIDAL  DISEASE. 

By  F.  H.  BOS  WORTH,  M.D., 

NEW  \ORK  CITY. 

Ethmoidal  disease,  both  from  the  anatomical  character 
of  the  region  involved,  and  with  reference  to  the  symp- 
toms to  which  it  gives  rise,  differs  essentially  from  dis- 
eased conditions  found  in  any  of  the  other  accessory 
cavities  of  the  nose.  For  whereas  the  maxillary,  frontal, 
and  sphenoidal  sinuses  present  to  us  a  single  cavity  con- 
fined by  bony  walls,  the  ethmoidal  cells  consist  of  a  large 
quadrangular  mass  of  small  cells,  or  trabecule,  varying 
in  size,  and  each  cell  more  or  less  completely  separated 
from  its  neighbor  by  a  thin,  bony  partition.  This  is 
fairly  well  shown  in  Fig.  1,  the  turbinated  bone  having 


Fig.  i.— The  Trabecular  Character  of  the  Ethmoid  Cells,  shown  after  the  Re- 
moval of  the  Middle  Turbinated  Bone.  From  a  Specimen  in  the  writer's  collec- 
tion. 

been  removed.  Hence  while  the  problem  which  presents 
itself  to  us  in  dealing  with  morbid  conditions  in  the  other 
cavities  consists  simply  in  making  an  opening  for  proper 
drainage  and  irrigation,  in  dealing  with  diseased  processes 
in  the  ethmoidal  cells  the  radical  arrest  or  cure  of  the 
disease,  especially  where  suppuration  has  taken  place,  de- 
mands the  opening  of  each  of  the  large  number  of  small 
cells  which  compose  this  mass.  This  is  impossible. 
Hence  we  are  compelled  to  resort  to  the  breaking  down 
of  these  small  partitions  within  the  ethmoid  body  in  such 
a  way  as  to  convert  it  into  one  single  cavity.  And  here, 
perhaps,"  it  may  be  proper  to  say,  that  in  a  diseased  con- 
dition of  any  of  the  accessory  cavities  I  think  we  will  all 
recognize  the  fact  that  the  tendency  in  every  case  of  a 
simple  inflammatory  process  which  does  not  undergo  res- 
olution, and  which  develops  into  a  chronic  inflammation, 
is  to  result  in  suppurative  action,  and  thus  the  establish- 
ment of  a  more  or  less  permanent  pus  discharge  through 
the  normal  opening,  namely,  into  the  nasal  cavity.  The 
other  respect  in  which  disease  of  the  ethmoidal  cells  differs 
from  that  of  the  larger  sinuses  is  in  that  whereas  in  the 
latter  we  have  simply  a  purulent  discharge,  in  the  former 
diseased  action  sets  up  a  train  of  symptoms  more  or  less 
neurotic  in  character,  such  as  watery  discharge  from  the 
nose,  violent  sneezing  attacks,  asthma,  headache,  neural- 
gias, which  according  to  Berger  and  Tyeman x  are  usu- 
ally intermittent  in  character ;  certain  disturbances  in  the 
muscular  control  of  the  eyeball,  asthenopia,  and  espe- 
cially what  has  been  called  aprosexia.  This  latter  really 
constitutes  one  of  the  most  distressing  symptoms  of  the 
disease,  and  has  been  described  to  me  by  patients  as  a 
sort  of  blanket  over  their  brain  which  interfered  with 
mental  activity  and  the  free  use  of  their  faculties.  It  is 
what  the  Germans  call  Retentions- Erschbpfung,  and  is 
defined  in  Billings's  Dictionary  as  "  inability  to  fix  the 
mind  upon  a  subject  or  to  retain  a  lesson,  accompanied 
by  headache,  and  due  to  over  study  or  prolonged  irrita- 
tion in  throat  or  nasal  passages." 

The  topic  which  I  am  asked  to  discuss  to  day,  as  I 
understand  it,  is  the  surgical  treatment  of  ethmoidal  dis- 
ease. Practically  I  suppose  when  we  speak  of  ethmoidal 
disease  we  refer  to  suppuration  in  these  cavities.  The 
subject  of  ethmoid  disease  is  to  me  exceedingly  interest- 
ing, and  is,  I  think,  perhaps,  the  most  interesting  which  is 

»  Dis.  Ethmoidal  and  Sphenoidal  Sinuses.  Wiesbaden,  1886.  (Com- 
pare also  Schech.) 


458 


MEDICAL    RECORD. 


[October  13,  1894 


engaging  the  attention  of  laryngologists.  I  hope,  there- 
fore, that  I  may  be  allowed  to  refer  somewhat  briefly  to 
the  whole  question  of  diseased  processes  here,  prefacing 
this  by  the  statement  that  I  regard  ethmoidal  disease  as 
not  only  by  far  the  most  frequent  of  all  diseases  of  the 
accessory  cavities,  but  as  of  very  much  more  frequent 
occurrence  than  we  ordinarily  have  been  taught  to  be- 
lieve, as  will  be  inferred  by  the  statement  that  in  the 
past  five  years  ninety-eight  such  cases  have  come  under 
observation  in  my  private  practice.  In  the  chapter  on 
acute  rhinitis,  in  all  of  our  text- books  on  throat  diseases, 
Bosworth  among  others,  there  is  described  a  disease 
characterized  often  by  nasal  stenosis,  frontal  headache, 
intra-orbital  pressure,  asthenopia,  watery  discharge,  and 
violent  sneezing,  which  I  very  frankly  confess  I  have 
rarely  seen  where  I  was  enabled  to  detect  a  rational  ex- 
planation of  the  symptoms  in  the  morbid  condition  of 
the  nasal  mucous  membrane  alone,  as  seen  by  ocular  in- 
spection. I  contented  myself  with  the  old  teaching  that 
these  symptoms  were  to  an  extent  reflex  in  character. 
I  do  not  hesitate  to  say  that  I  believe  a  very  large  pro- 
portion of  the  cases  of  so  called  acute  rhinitis  are  really 
instances  of  acute  ethmoiditis,  and  that  such  inflamma- 
tion as  may  exist  in  the  nasal  mucous  membrane  is  really 
secondary  to  the  graver  and  more  distressing  conditions 
of  the  lining  membrane  of  the  ethmoidal  cells.  I  thus  en- 
dorse the  statement  made  by  that  excellent  observer, 
Moritz  Schmidt,  of  Frankfort,1  who,  however,  assigns 
these  symptoms  of  a  head  cold  to  an  involvement  of  some 
of  the  accessory  sinuses,  not  confining  it  to  the  ethmoid 
cells. 

Among  the  cases  which  I  shall  briefly  analyze  later, 
are  a  number  of  instances,  both  of  acute  ethmoiditis 
and  suppurative  disease,  which  have  had  their  onset  in 
unmistakable  attacks  of  la  grippe,  which  leads  me  to 
hazard  the  suggestion  as  to  whether  the  influenzal  type 
of  la  grippe  is  not  really  an  invasion  of  the  ethmoid 
cells  by  the  specific  bacillus  which  is  supposed  to  be 
the  exciting  cause  of  that  disease. 

In  a  paper  on  ethmoid  disease,*  published  two  and  a 
half  years  ago,  I  described  five  varieties  of  diseased  con- 
ditions of  these  cells  which  practically  reduced  themselves 
to  three,  viz. :  1.  Extra-cellular  myxomatous  degenera- 
tion; a,  intra-cellular  myxomatous  degeneration;  and 
3d,  purulent  ethmoiditis.  I  really  think  that,  practi- 
cally, we  have  but  one  primary  morbid  condition  in  the 
ethmoid  cells,  which  progressively  and  with  more  or 
less  rapidity  develops  into  these  three.  In  other  words, 
that  these  three  conditions  are  successive  stages  of  one 
and  the  same  disease.  An  acute  inflammatory  process 
of  the  mucous  membrane  lining  these  cells  very  soon 
either  results  in  resolution  or  a  chronic  morbid  process. 
Owing  to  the  peculiar  anatomical  character  of  tins  mem- 
brane, a  chronic  inflammation  tends  to  develop  a  soft, 
jelly-like  thickening  of  the  tissue,  which  takes  on  what 
we  may  describe  as  a  myxomatous  character.  Now,  this 
may  persist  for  a  somewhat  prolonged  period  of  time, 
giving  rise  to  distention  of  the  cells,  with  its  train  of 
symptoms  already  alluded  to,  which  are,  watery  or 
muco  purulent  discharges,  violent  attacks  of  sneezing, 
headache,  intra-orbital  pressure,  aprosexia,  etc.,  and  if 
the  constitutional  habit  be  neurotic,  hay  fever,  and 
asthma,  these  symptoms  being  simply  exaggerated  on 
the  occurrence  of  more  or  less  frequently  repeated  at- 
tacks of  acute  inflammation,  to  which  the  patient  is 
liable. 

The  further  course  of  this  disease  I  take  it  to  be,  in  a 
certain  small  percentage  of  cases,  is  the  crowding  out  from 
the  ethmoid  cells,  through  the  normal  opening,  of  this 
myxomatous  tissue,  which  presents  in  the  nasal  cavity  in 
the  form  of  small  polypi.  Not  that  I  believe  the  large 
proportion  of  cases  of  nasal  polypi  have  their  origin  in 
the  ethmoidal  cells,  for  Zuckerkandl '  has  demonstrated 
conclusively  that  this  is  not  the  case.     As  the  result  of 

1  Krankheiten  der  Oberen  Luftwege.     Berlin,  1894. 

•  New  York  Medical  Journal,  November  7,  1891. 

'  Norm,  und  Path.  Anat.  der  Nasenhtile,  Band  x,  Auflage  a,  s.  360. 


this  inflammatory  process  within  the  cells,  the  thin  walls 
become  distended  and  we  have  a  somewhat  curious  de- 
velopment, by  which  the  outer  wall  of  the  cells  yields 
before  the  pressure,  and  we  have  the  middle  turbinated 
bone  crowded  outward,  and  gradually  an  extension  of 
these  cells  into  this  body.  See  Figs.  2  and  3.  And 
here  for  the  first  time  there  presents  a  condition  by  which 
we  may  recognize  a  morbid  process  in  the  ethmoid  cells 


•   Fig.  a.— Distention  of  the  Ethmoid  Cells,  with  Extension  into  the  Middle 
Turbinated  Body.    (Zuckerkandl.) 

by  ocular  inspection  through  the  nose ;  in  other  words, 
as  far  as  rhinoscopic  examination  goes,  in  the  inflamma- 
tory stage  of  the  disease,  this  distention  of  the  cells  and 
extension  into  the  middle  turbinated  body  gives  rise  to  a 
protuberance  into  the  middle  meatus,  which  is  easily 
recognized,  the  middle  turbinated  body  presenting  as  a 
rounded  ovoid  mass,  usually  in  contact  with  the  septum 
and  encroaching  notably  upon  the  middle  meatus  of  the 
nose.  At  the  same  time  this  curious  myxomatous  degen- 
eration of  the  mucous  membrane  and  lining  cells  con- 
veys itself  to  the  mucous  membrane  covering  the  outer 
wall,  which  is  now  the  middle  turbinated  body  in  the 
nose,  and  lends  additional  aid  in  the  recognition  of  the 
condition. 

These  two  conditions  constitute  what  Zuckerkandl  has 
termed  "ethmoiditis  superficialis"  and  "ethmoiditis 
profunda  ;M    the  former  term  applying  to  the  disease 


Fig.  3.— Distention  and  Extension  of  the  Ethmoid  Cells,  with  Displacement  of 
the  Middle  Turbinated  Body .    (Zuckerkandl. ) 

when  it  is  confined  within  the  cells,  and  the  latter  desig- 
nating the  disease  when  the  myxomatous  degeneration 
has  extended  to  the  nasal  cavity,  making  its  appearance 
on  the  surface  of  the  middle  turbinated  body. 

The  next  stage  in  the  development  of  the  disease  con- 
sists in  suppuration.  The  time  of  its  development  may 
be  very  early  or  very  late  in  the  history  of  the  disease, 
this  being  governed  somewhat  by  adventitious  circum- 
stances. The  method  of  its  development  seems  very 
clear.  The  inflammatory  process,  involving  the  mem- 
brane within  the  cells  necessarily  gives  rise  to  hyperse- 
cretion, which  materially  contributes  to  the  intra-cellular 


October  13,  1894] 


MEDICAL    RECORD. 


459 


distention,  and  also  results  in  a  closure  of  the  normal 
orifice.  The  necessary  consequence  is  practically  the 
formation  of  an  acute  abscess,  which,  failing  resolution, 
soon  develops  into  a  chronic  abscess,  or  chronic  suppura- 
tion of  the  cells,  for  I  believe  it  to  bean  almost  universal 
rule  that  where  we  have  a  chronic  inflammation  of  a 
mucous  membrane,  with  hypersecretion  in  a  closed  cav- 
ity, the  tendency  of  the  process  is  very  rapidly  to  develop 
into  a  purulent  action.  We  thus  have  established  a 
chronic  suppurative  disease.  The  pus  finds  its  exit 
through  either  the  anterior  or  posterior  ethmoidal  cells ; 
and  I  may  state  here,  from  a  practical  point  of  view,  that 
the  anatomical  division  of  these-  cells  into  the  anterior 
and  posterior  group  is  of  no  special  interest  to  us  in 
dealing  with  the  diseased  conditions,  in  that  I  believe 
they  are  really  converted  into  a  single  group  of  cells  by 
either  a  normal  or  a  rapidly  established  abnormal  open- 
ing between  the  two.  The  pus  makes  its  way  into  the 
nasal  chambers  through  one  of  the  normal  openings, 
either  in  front  into  the  hiatus  semilunaris,  or  through  the 
posterior  opening  into  the  superior  meatus.  Thus  on 
ocular  inspection  we  may  find  the  pus  making  its  appear- 
ance either  from  beneath  the  middle  turbinated  body  or 
from  between  the  middle  turbinated  body  and  the  septum 
above.  As  a  rule,  the  pus  from  the  anterior  and  lower 
opening  makes  its  way  into  the  lower  meatus  and  is  ex- 
pelled through  the  anterior  nares ;  while  the  discharge 
from  the  posterior  opening  makes  its  way  into  the 
pharynx,  giving  rise  to  the  symptom  so  often  complained 
of,  viz.:  that  of  dropping  in  the  throat,  in  which  way 
the  disease  may  be  confused  with  an  ordinary  nasopharyn- 
geal catarrh ;  although  J  should  say  here  that  the  secre- 
tion of  this  latter  disease  is  usually  thick  and  adherent, 
and  expelled  by  somewhat  violent  nasal  screatus,  whereas 
a  dropping  in  the  throat  should  always  suggest  the  great 
probability  of  an  empyema  of  either  the  ethmoidal  cells 
or  the  sphenoidal  sinus. 

While  the  most  natural  exit  for  the  pus  is  into  the 
nasal  cavity,  this  is  by  no  means  its  invariable  course,  as 
is  shown  by  the  large  number  of  cases  in  which  the  pus 
escapes  through  the  os  planum  into  the  orbital  cavity, 
giving  rise  to  exophthalmus  and  orbital  disease.  Further- 
more, we  occasionally  meet  with  exophthalmus  from,  dis- 
tention of  the  cells  in  the  cavity,  without  escape  of  pus, 
as  is*  still  further  and  notably  illustrated  by  the  case  re- 
ported by  Bull,1  of  ethmoidal  suppuration  in  which  an 
artificial  puncture  through  the  orbit  was  followed  later  by 
a  spontaneous  rupture  into  the  nasal  cavities,  the  ulti- 
mate cure  resulting  probably  from  the  latter. 

As  the  result  of  the  persistent  suppuration  the  lining 
membrane  of  these  cells  necessarily  becomes  soft  and 
very  much  thinned.  The  much-discussed  question  of 
necrosis  of  bone  never  has  interested  me  greatly,  because 
I  regard  its  importance  as  much  over-estimated.  Zuck- 
erkandl*  states  that  he  has  never  seen  caries  of  the 
ethmoid  cells,  thus  contravening  Woakes/  who  describes 
what  he  calls  a  necrosing  ethmoiditis  as  practically  the 
sole  cause  of  nasal  polypi.  The  membrane  covering  the 
bone  is  so  far  thinned  and  softened  that  to  the  impact 
of  the  probe  it  gives  the  sensation  of  being  exposed. 
That  it  is  genuinely  necrosed  I  do  not  believe.  The 
odor,  moreover,  which  is  almost  constantly  present  in 
these  cases  in  the  later  stage,  is  the  odor  of  sulphuretted 
hydrogen  developed  from  retained  pus,  and  not  the  odor 
of  bone  necrosis.  Hence  in  making  our  diagnosis  I 
should  not  be  disposed  to  attach  so  much  importance  to 
the  use  of  the  probe  as  many  writers  do,  depending 
mainly  for  the  diagnosis  on  the  appearances  about  the 
middle  turbinated  body  of  distention,  and  on  the  myxo- 
matous degeneration  of  the  mucous  membrane  covering 
it  This  deceptive  sense  of  necrosed  bone  can  be  ob- 
tained by  passing  the  probe  either  beneath  the  middle 
turbinated  body  toward  the  hiatus  semilunaris,  or  above 
it  toward  the  opening  of  the  posterior  ethmoidal  cells  in 

1  New  York  Medical  Journal,  1893,  vol.  lvii.,  p.  75. 

»  Loc.  dt.,  p.  361. 

*  Nasal  Polypus,  Am.  ed.,  p.  8  et  seq.    Philadelphia,  1887. 


the  superior  meatus.    I  have  frequently  detected  it  in  a 
normal  and  healthy  nose. 

Our  most  important  consideration,  of  course,  has  to 
do  with  the  question  of  treatment,  and  that  this  should 
be  instituted  early  in  the  history  of  the  disease  and  be- 
fore the  suppurative  process  has  ensued  need  not  be 
urged,  in  view  of  the  very  serious  discomfort,  and  even 
danger,  which  attends  the  stage  of  empyema,  and  the 
great  difficulty  with  which  it  is  brought  under  control 
after  pus  formation  has  become  chronic.  In  acute  eth- 
moiditis the  ordinary  measures  which  our  text  books 
recommend  in  the  treatment  of  acute  rhinitis  are  indi- 
cated of  course,  and  need  not  be  dwelt  upon,  further 
than  to  say  that  of  all  measures  I  regard  the  use  of  the 
douche  as  most  potent,  directing  that  from  one  to  two 
gallons  of  water  rendered  thoroughly  saline  be  passed 
through  the  nasal  cavities  by  means  of  the  Thudichum 
douche  at  least  twice  daily.  The  water  should  be  as  hot 
as  can  be  borne.  This  instrument  I  regard  as  devoid  of 
the  danger  to  the  ears,  of  which  Roosa  has  warned  us, 
provided  that  the  patency  of  each  nostril  be  tested  before 
its  use  and  that  the  stream  be  made  to  pass  into  the  nar- 
rowest nares,  thus  emerging  without  obstruction  from  the 
most  patent  side. 

When  the  disease  has  reached  the  chronic  stage  with- 
out suppuration,  I  believe  that,  other  measures  failing, 
surgical  interference  should  be  resorted  to  in  all  cases, 
as  we  here  have  to  deal  with  an  affection  which  does  not 
tend  to  undergo  resolution,  but  one  in  which  there  is 
imminent  danger  of  suppuration  setting  in  at  any  time. 
The  test  that  this  chronic  stage  has  been  reached  is  to 
be  found  in  the  swollen  and  distended  condition  of  the 
ethmoid  cells,  as  shown  by  the  projecting  and  swollen 
turbinated  body,  whether  the  mucous  membrane  covering 
it  be  in  a  state  of  myxomatous  degeneration  or  simply 
turgescent.  The  object  to  be  accomplished  is  to  relieve 
intra- cellular  pressure,  and  this  is  accomplished  by  uncap- 
ping, as  it  were,  the  ethmoid  cells.  The  steel-wire  loop 
of  the  Jarvis  or  Bosworth  snare  is  easily  slipped  over  the 
projecting  turbinated  body  and  the  whole  mass  removed, 
presenting  usually  in  the  form  of  an  elongated  ovoid 
shell.  This  also  reveals  to  us  the  condition  of  the  mu- 
cous membrane  within  the  ethmoid  cells,  which  may  be 
either  in  a  simple  state  of  turgescence,  or,  as  has  not 
infrequently  happened  in  my  own  experience,  a  soft, 
gelatinous  mass  of  myxomatous  tissue  is  found  filling  the 
cavity  thus  opened.  If  this  does  not  drop  out  of  place, 
it  is  very  easily  removed  by  the  mouse-tooth  forceps  or 
the  snare. 

After  pus-formation  has  occurred  the  problem  before 
us,  as  before  stated,  consists  in  converting  the  large 
number  of  small  cells  which  compose  these  bodies  into  a 
single  cavity  and  establishing  thorough  drainage.  In 
these  cases  the  primary  procedure  is,  as  before,  to  uncap 
the  cells  by  use  of  the  snare,  and  after  that  I  believe  our 
best  instrument  consists  in  the  use  of  the  dental  burr. 
Schaeffer,  Moure,  Cozzolino,  Gleitsmann,  and  others 
prefer  the  use  of  the  curette.  I  have  never  been  able  to 
freely  manipulate  this  instrument  in  the  ethmoidal  cells 
or  to  break  down  the  trabecular  walls  by  its  use.  Its 
manipulation  is  hampered,  and  its  action,  to  my  mind, 
seems  inefficient  and  not  radical  enough  in  extent. 
Griinwald's  sharp  spoon  is  a  more  efficient  instrument, 
but  still  hampered  in  its  action.  The  same  criticism 
applies  to  the  forceps  and  sharp  spoon,  as  advocated  by 
Zarinko. 

That  this  disease  can  be  radically  cured,  or  even  mod- 
ified or  controlled  to  any  great  extent,  by  the  use  of  disin- 
fecting lotions,  as  recommended  by  Lichwitz,1  Hartman* 
Michel,"  Schalle,4  Myles  *  and  Moure,6 1  do  not  believe. 
The  small  oval  or  round  burr,  attached  to  the  dental 

1  Diseases  of  Accessory  Cavities  of  Nose,  Bui.  M6d.,  Paris,  1893, 
lxxxvi.,  p.  963. 

9  Quoted  by  Berger  and  Tyrman,  Dis.  of  Ethmoidal  and  Sphe- 
noidal Sinuses,  p.  xa.     Wiesbaden,  1886. 

•  Idem, 
f  Idem. 

•  Mbdical  Record,  1802,  vol.  xlii.,  p.  607. 

•  Manuel  pratique  des  Fosses  nasales,  ad  ed.,  p.  535.     Paris,  1893, 


460 


MEDICAL   RECORD. 


[October  13,  1894 


engine,  or,  better  still,  the  De  Vilbiss  engine,  in  my 
hands  has  answered  a  better  purpose  than  any  other  de- 
vice. Manipulated  with  the  De  Vilbiss  engine  it  is  made 
to  enter  the  ethmoidal  cells  either  before  or  after  they 
have  been  uncapped,  when  the  trabecular  walls  are  easily 
broken  down  or  burred  away.  Its  motion  can  be  instantly 
arrested  at  will,  when  it  can  be  made  to  act  as  a  probe, 
exploring  the  cavity  for  exposed  bone  or  such  parts  as  it 
is  desired  to  remove.  In  this  manner  our  operation  be- 
comes not  only  intelligent,  but,  I  think,  absolutely  safe, 
a  consideration  which  of  course  is  to  be  very  carefully 
borne  in  mind,  when  we  remember  that  we  are  separated 
in  our  operation  not  only  from  the  orbit  of  the  eye  by  an 
exceedingly  thin  plane  of  bone,  but  if  we  progress  very 
far  we  are  getting  in  close  proximity  to  the  base  of  the 
brain.  I  do  not  mean  to  intimate  that  at  a  single  session 
the  whole  of  the  trabecular  which  constitute  the  ethmoid- 
al cells  can  be  opened  out  and  thoroughly  drained.  In 
many  of  my  cases  the  operations  have  been  repeated  a 
number  of  times  at  intervals  varying  from  one  week  to  a 
month,  or  even  longer.  During  the  intervals  of  course 
the  patient  is  directed  to  use  disinfecting  lotions  with  as 
much  intelligence  and  thoroughness  as  can  be  accom- 
plished by  the  ordinary  devices  which  we  place  in  the 
hands  of  our  patients  for  use.  I  have  no  special  sugges- 
tion to  make  as  to  the  character  of  these  lotions,  as  thor- 
oughness of  application  is  of  more  value  than  the  special 
character  of  the  antiseptic  used.  Moreover,  it  should  be 
stated  that  the  operation  is  not  attended  with  anything 
like  the  pain  that  we  should  suppose  when  we  consider 
the  exceedingly  sensitive  character  of  the  parts  operated 
upon.  Of  course  the  procedure  is  not  an  agreeable  one, 
but  it  is  not  an  especially  painful  one,  provided  that  we 
can  sufficiently  reach  the  parts  to  thoroughly  saturate 
them  with  a  cocaine  solution. 

I  may  seem  to  the  general  practitioner  to  be  discussing 
and  describing  not  only  radical  but  perhaps  rough  and 
even  dangerous  methods;  but  when  we  consider  the 
great  discomfort  and  distress  to  which  a  patient  suf- 
fering from  ethmoidal  disease  is  subjected,  and  the  still 
greater  danger  which  threatens  him,  as  has  occurred,  of 
involvement  of  other  sinuses  or  neighboring  cavities,  such 
as  the  orbit,  or  even  the  development  of  the  disease  in 
the  brain  tissue  itself,  I  think  there  can  be  no  question 
that  these  radical  procedures  are  not  only  fully  warrant- 
able but  absolutely  indicated. 

The  charge  has  not  been  infrequently  made  in  the  past 
few  years  that  intra-nasal  surgery  has  been  very  greatly 
overdone.  Some  of  our  English  friends  have  delicately 
suggested  that  we  attack  the  nasal  tissues  "  with  the 
energy  of  the  backwoodsman,"  "  with  more  energy  than 
discretion,11  with  recklessness  and  without  justification. 
These  charges  are  not  deserved,  and  are  unjust.  We  do 
not  confine  our  work  to  the  saw  and  burr  and  drill.  The 
very  large  majority  of  our  cases  are  dealt  with  without  re- 
sort to  surgical  measures.  But  we  meet  with  a  large  num- 
ber of  cases  in  which  other  measures  are  inadequate,  and 
these  we  attack,  not  with  the  energy  of  the  backwoods- 
man, but  with  the  trained  and  delicate  hand  of  the  sur- 
geon, who  recognizes  unmistakable  indications  and  car- 
ries them  out;  the  gratifying  result  fully  justifying  the 
means. 

As  before  stated,  during  the  past  five  years  I  have  re- 
corded in  my  private  practice  97  of  these  cases,  a  brief 
summary  of  which  I  append.  Of  the  97  cases  3  were 
carcinoma  and  4  sarcoma  of  the  ethmoidal  cells,  which 
may  be  left  out  of  consideration.  As  regards  age,  3  oc- 
curred in  the  second  decade  of  life,  14  in  the  third,  23 
in  the  fourth,  28  in  the  fifth,  18  in  the  sixth,  and  7  in  the 
seventh  decade.  Sixty-one  were  males  and  thirty  two 
were  females.  Fifteen  cases  were  inflammatory  in  char- 
acter, without  suppuration  or  polypoid  degeneration.  Of 
these,  9  were  cured,  3  were  improved,  and  3  disappeared. 
Twenty-nine  cases  showed  myxomatous  degeneration 
without  suppuration.  Of  these  12  were  cured,  10  im- 
proved, and  7  were  seen  but  once  or  twice,  and  their  prog- 
ress not   known.    Twenty-two  cases  showed  myxoma- 


tous degeneration,  or  fully  developed  polypi,  together  with 
pus  discharge.  Of  these,  9  were  cured,  10  improved,  and 
3  disappeared.  Of  the  purely  suppurative  cases  there 
were  27 ;  of  which  8  were  cured,  12  improved,  both  as 
regards  subjective  symptoms  and  the  amount  of  discharge, 
while  7  were  seen  but  once  or  twice  and  not  further 
noted.  In  nearly  all  these  cases  radical  operative  meas- 
ures were  instituted,  as  carrying  out  the  suggestions  al- 
ready made.  In  many  of  them  the  simple  irrigating 
measures  failed  to  give  relief,  either  to  subjective  or  ob- 
jective symptoms,  and  the  cells  were  opened  either  by 
the  snare  or  drill,  or,  and  in  many  cases,  both  were  used. 

•6  West  Fobtt-sixth  Smsi? 


ON 


DYSPEPSIA    NERVOSA  AND    GASTROIN- 
TESTINAL NEURASTHENIA. 

By  LEONARD  WEBER,  M.D., 


It  is  just  ten  years  since  Leube  published  his  paper  on 
"  Dyspepsia  Nervosa,"  and  defined  it  as  a  disorder  all 
the  symptoms  of  which  are  caused  by  a  functional  dis- 
turbance of  the  nervous  system,  and  especially  of  the 
nerves  of  the  stomach,  while  gastric  digestion  remained 
normal  both  as  to  time  and  chemical  process.  Leube 
found  this  class  of  patients  to  be  generally  delicate,  thin 
at  the  outset  or  in  the  progress  of  the  complaint,  rarely 
stout  or  of  healthy  appearance.  In  some  cases  there 
was  a  previous  history  of  anaemia.  Intermittens,  renal  or 
uterine  trouble,  sexual  excess,  or  some  real  disease  of  the 
stomach  that  was  cured,  but  left  a  state  of  nervous  dys- 
pepsia behind  it ;  all  cases  were  characterized  by  more  or 
less  suffering  accompanying  the  act  of  digestion,  which 
seemed  to  originate  in  the  nervous  system. 

Prominent  among  the  symptoms,  as  I  have  observed 
them,  are  a  feeling  of  fulness  and  congestion  in  the 
head,  headache,  vertigo,  cardiac  palpitation,  slight  pseu- 
do  angina,  dyspnoic  oppression,  abdominal  pulsation. 
And  on  the  part  of  the  stomach  a  sense  of  pressure  and 
fulness  in  the  epigastrium,  while  palpation  of  the  stom- 
ach generally  reveals  neither  tenderness  nor  pain.  Glo- 
bussensation  and  pyrosis  are  rather  frequent,  and  volu- 
minous eructations  of  gas  without  odor  or  taste  are  very 
generally  complained  of.  Nausea  with  occasional  vom- 
iting is  not  rare,  and  the  vomiting  may  sometimes  be 
rather  severe  and  obstinate. 

The  appetite  may  be  good,  or  bad,  or  changeable, 
and  sometimes  ceases  after  the  patient  has  swallowed  a 
few  morsels.  The  bowels  are  generally  constipated,  sel- 
dom loose,  almost  always  flatulent.  In  some  cases  nearly 
all  these  symptoms  are  present,  in  others  again  a  few  ot 
them  only.  Great  as  Leube's  merits  have  been  in  bring- 
ing the  important  subject  of  gastric  neuroses  prominently 
before  us,  it  is  nevertheless  shown,  not  only  by  the  labors 
of  Ewald,  Boas,  Rosenthal,  Bouveret,*  and  others  in  this 
special  field,  but  by  the  clinical  observations  of  most  of 
us,  I  believe,  that  Leube's  standpoint  is  not  sufficiently 
comprehensive,  and  we  have  to  widen  his  definition  of 
nervous  dyspepsia,  because  we  know  that  we  meet  numerous 
cases  with  all  the  symptoms  of  nervous  dyspepsia,  but 
also  with  disturbances  of  the  secretory  and  motory  func- 
tions of  the  stomach.  Cases  enough  have  been  described 
where  the  secretion  of  hydrochloric  acid  is  considerably 
diminished,  insufficient  for  healthy  digestion  or  even  tem- 
porarily absent,  not  only  for  days  but  weeks ;  then  normal 
again  or  increased,  hyperhydrochlorie.  There  is  gene* 
rally  a  combination  with  motory  weakness  where  hydro- 
chloric production  is  diminished  or  absent,  but  with  ab- 
normal motory  activity  where  there  is  supernormal  secre- 
tion of  hydrochloric  acid.  Gastralgia  severe  enough  to 
simulate  gastric  ulcer  with  Burkhard's  points  douloureux 
in  the  region  of  the  eleventh  and  twelfth  vertebrae  and 
in  the  epigastrium,  I  have  noted  sometimes,  but  they  are 
variable  and  fugitive,  not  permanent  as  in  gastric  ulcer, 
aside  of  the  other  pathognomonic  symptoms  of  the  latter. 
From  my  own  observations,  therefore,  I  believe  that  for  a 


October  13,  1894] 


MEDICAL  RECORD. 


461 


number  of  cases,  at  least,  the  designation  "  nervous  dys- 
pepsia" is  too  narrow,  that  they  cannot  be  considered 
and  treated  apart  from  the  other  neurasthenic  symptoms 
which  are  correlated  to  and  associated  with  it,  and  that 
it  is  gastro  intestinal  neurasthenia  as  a  part.  Neuras- 
thenia rather  than  nervous  dyspepsia  we  have  to  deal  with 
in  a  large  number  of  cases.  From  my  case-book  I  could 
add  quite  a  little  number  of  neurasthenias  such  as  described 
by  Ewald,  and  Burkhard,  and  Bouveret,  who  presented 
well-marked  dyspeptic  symptoms  with  the  chemism  of 
the  gastric  organ  altered  in  various  ways  as  marked 
above.  It  will  be  appropriate  therefore,  I  think,  to 
divide  the  cases  into  two  classes :  1,  dyspepsia  nervosa 
with  functional  disorder  of  stomach;  2,  neurasthenia 
gastro-intestinalis  in  general  neurasthenia. 

The  causes  of  nervous  dyspepsia  are  many.  Aside  of 
those  caused  by  direct  or  indirect  disturbance  of  the 
pneumogastric  centre  through  cerebrospinal  disease  or 
disease  of  peripheral  nerves,  there  are  gastralgias  by  re- 
flex through  affections  of  the  genital  organs,  gall-stones, 
renal  calculus,  a  floating  kidney,  and  the  presence  of  in- 
testinal parasites,  particularly  tape-worm.  >But  we  are 
now  concerned  with  those  forms  which  are  part  of  gen- 
eral naurasthenia  brought  about  by  physical  or  mental 
overexertion,  or  both,  excessive  care  and  excitement,  sex- 
ual excess,  debauch,  masturbation,  or  by  intoxication  such 
as  malaria,  morphine,  nicotine ;  also  those  by  hysteria  and 
such  constitutional  anomalies  as  chlorosis  and  anaemia. 

With  regard  to  age,  sex,  and  the  influence  of  life's 
vocation,  my  experience  coincides  with  that  of  all  other 
observers,  I  believe:  i.e.,  gastrointestinal  neurasthenia 
is  prevalent  among  men  between  twenty  and  thirty,  and 
is  more  often  seen  among  brain-workers  than  among 
mechanics,  though  I  have  quite  a  little  experience  with 
the  latter  class  also  in  that  direction.  Women  are  per- 
haps less  often  affected  than  men,  and,  for  reasons  easily 
understood,  at  an  earlier  period  of  life.  With  regard  to 
children  I  have  no  personal  experience  of  value,  but  some 
observers  maintain  that  the  disorder  is  not  as  rare  among 
them  as  is  generally  supposed. 

Now,  with  regard  to  the  treatment  of  dyspepsia  nervosa, 
I  have  always  been  delighted  when  I  got  hold  of  a  case 
where  I  could  remove  or  control  the  cause,  and  feel  sure 
then  to  cure,  or  almost  cure,  my  patient.  For  instance,  a 
tape- worm  by  giving  10.0  of  extr.  fil.  mar.,  a  displaced 
uterus  by  a  pessary,  a  floating  kidney  by  a  suitable  truss, 
an  irritable  urethra  by  the  use  of  the  steel-sound  and 
tepid  sitzbath.  Or  when  anaemia  or  chlorosis  was  at 
fault,  by  iron,  quinine,  and  arsenic,  salt-water  baths,  and 
change  of  climate,  and  by  the  elimination  of  malaria  and 
nicotin  poison  where  the  attacks  were  produced  by  them. 
Of  nerve  drugs,  I  am  not  in  the  habit  of  prescribing  opium 
or  cocaine,  except  where  there  is  severe  gastralgia  pres- 
ent ;  here  I  often  use  a  cold  wet  bandage  over  the  abdo- 
men with  a  coil  on  top  of  it  through  which  hot  water  is 
allowed  to  flow  for  some  time — a  plan  of  application  sug- 
gested and  recommended  by  Winternitz,  that  will  often 
bring  relief  without  morphine.  Extractum  cannabis, 
however,  introduced  by  Germain-S6e  in  the  treatment  of 
nervous  dyspepsia  where  there  is  much  sense  of  pressure 
and  discomfort  felt  after  eating,  I  have  often  prescribed  in 
doses  of  one  sixth  of  a  grain  t.i.d,  and  been  well  satisfied 
with  the  results  obtained.  Some  praise  here  the  use  of 
aqua  chloroformi  or  atropia.  Electricity  also  does  well 
here,  with  a  very  large  electrode  over  the  epigastrium,  as 
first  proposed  by  von  Ziemssen,  especially  also  where  there 
is  a  good  deal  of  motory  weakness  of  stomach.  In  cases 
accompanied  by  obstinate  vomiting,  I  have  found  noth- 
ing answer  so  well  as  to  make  the  patient  fast  for  two  or 
three  days,  giving  meanwhile  nutritive  enemata.  -  Last, 
but  not  least,  a  Weir  Mitchell  rest  and  feeding  cure  will 
be  of  service  in  certain  female  cases  too  well  known  to 
need  description,  and  in  those  of  men  who  are  much  re- 
duced and  present  hysterical  symptoms. 

I  wish  that  I  could  say  half  as  much  of  positive 
results  obtained  by  me  in  the  management  of  cases  of 
gastro-mtestinal  neurasthenia  in  neurasthenics,  leaving 


out  of  consideration  altogether  those  caused  by  organic 
disease  of  the  central  nervous  system.  So  long  as  I  did 
not  understand  the  causal  connection,  or  rather  insepar- 
able relation  and  interdependence  of  the  general  and 
local  condition,  I  tried  for  cure  and  failed  in  the  one  as 
well  as  in  the  other  state.  Now  that  I  know  we  cannot 
yet  cure  a  case  of  grave  neurasthenia,  although  they  have 
quite  occasionally  a  queer  way  of  getting  better  by  them- 
selves, I  do  not  try  any  more  to  cure  them  by  active 
treatment,  but  I  do  them  more  good  than  before.  By 
dealing  more  with  the  individual,  regulating  his  life, 
correcting  his  had  habits,  admonishing  him  to  spare 
himself  and  pay  close  attention  to  his  dietary,  physic  his 
bowels  from  time  to  time  to  remove  putrid  material,  and 
go  on  short  vacations  two  or  three  times  a  year,  I  be- 
lieve to  succeed  pretty  well  in  keeping  them  in  fair  or- 
der not  only,  but  putting  them  actually  in  the  way  to 
get  as  nearly  well  as  they  can.  Of  symptomatic  rem- 
edies I  know  none  better  than  those  mentioned  in  the 
first  class  of  cases,  which  we  may  more  truly  call  nervous 
dyspepsia  than  the  latter. 

To  be  sure,  we  all  know  of  neurasthenic  dyspeptics 
who  went  to  the  high  Alps  of  Switzerland,  or  to 
fine  places  at  the  sea,  or  to  specially  fitted  sanatoria 
here  and  abroad,  and  were  sent  home  cured.  No  won- 
der that  they  came  home  better  after  doing  the  very 
best  things  for  themselves  under  the  best  possible  condi- 
tions of  climate,  food,  care,  and  rest,  and  recreation  of 
mind  and  body ;  but  it  is  at  best  a  great  improvement 
only,  and  it  is  generally  not  very  long  before  we  see  them 
return  to  us  with  their  old  complaints. 

•5  West  Forty-sixth  Street. 


g*00t*ss  of  IPjeflijcat  jfciettce. 

The  Absorption  of  Iron.  —  Dr.  Macallum  finds  that 
inorganic  iron  is  absorbed  (in  guinea-pigs)  by  the  in- 
testinal mucous  membrane.  Whatever  iron  salt  was  ad-  . 
ministered,  whether  the  phosphate,  chloride,  sulphate,  or 
"  peptonic,"  when  the  dose  was  not  very  large,  the 
evidence  of  its  absorption  was  very  plain  in  the  villi  of 
the  upper  end  of  the  small  intestine,  but  in  them  only 
{The  British  Medical  Journal).  When  the  dose  was 
large,  the  presence  of  iron  in  the  villi  was  observed  far 
down  the  intestine,  but  the  reaction  for  iron  was  less  dis- 
tinct the  more  remote  the  villus  from  the  pylorus. 
With  very  large  doses  of  the  phosphate  or  "  peptonate  " 
the  villi  near  the  caecum  gave  an  intense  reaction.  It 
is  suggested  that  the  reason  for  this  difference  is  that 
when  the  dose  of  iron  is  small,  and  when,  consequently, 
the  quantity  of  iron  in  the  chyme  is  small,  it  is  wholly 
precipitated  by  the  alkaline,  biliary,  and  pancreatic  se- 
cretions ;  as  these  three  fluids  do  not  at  once  and  com- 
pletely mingle,  the  iron  is  not  at  once  precipitated,  and 
consequently  absorption  goes  on  in  the  first  few  inches 
of  the  intestine.  The  acidity  of  a  larger  dose  of  iron 
salt  may  be  sufficiently  great  to  destroy  the  alkalinity  of 
the  chyme  after  admixture  with  the  bile  and  pancreatic 
juice,  and,  when  this  is  the  case,  the  unprecipitated  ex- 
cess of  iron-salt  will  go  on  down  the  intestine,  and 
be  absorbed  lower  down.  When  the  oxide  or  the  re- 
duced metal  is  given,  a  certain  quantity  of  the  acid  of 
the  chyme  is  taken  up  in  effecting  their  solution,  and 
therefore  in  the  intestine  the  alkalinity  of  the  bile  and 
pancreatic  juice  must  go  farther  in  the  precipitation  of 
the  iron.  Speaking  generally,  the  larger  the  amount  of 
free  acid  in  the  chyme  the  greater  must  be  the  quantity 
of  iron  absorbed.  Sulphides  in  the  contents  of  the 
bowel  will  also  precipitate  the  iron  still  in  solution.  On 
an  ordinary  diet,  therefore,  the  extent  of  intestinal  mu- 
cous membrane  which  absorbs  iron  must  be,  in  propor- 
tion to  that  which  does  not,  remarkably  small.  Macal- 
lum, however,  thinks  it  possible  that  in  anaemia  there 
may  be  a  diminution  in  the  amount  of  the  biliary  and 
pancreatic  secretions,  a  condition  which,  for  the  reason 
above  stated,  would  prevent  precipitation,  and  thus  favor 


462 


MEDICAL   RECORD. 


[October  13,  1894 


absorption.  His  grounds  for  stating  that  iron  salts  are 
absorbed,  a  fact  which  has  been  denied,  are  drawn  from 
microscopical  examination  of  the  mucous  membrane  un- 
der various  conditions.  In  well-fed  guinea  pigs  taking 
iron,  the  intestinal  mucous  membrane,  after  treatment 
with  alcohol,  assumes,  when  treated  with  ammonium 
sulphide,  a  more  or  less  dark  color,  due  to  the  formation 
of  sulphide  of  iron,  which,  under  the  microscope,  is  seen 
to  be  limited  to  the  subepithelial  portions  of  the  tips  of 
the  villi.  Here  it  is  deposited  in  leucocytes  which  sur- 
round the  end  of  the  lacteal  vessel.  When  the  dose  of 
iron  is  larger,  or,  apparently,  when  the  administration  is 
continued  for  a  long  time,  the  iron  is  present  also  in  the 
epithelial  cells  themselves,  and  passes  from  them  by  a 
process  of  internal  secretion  into  the  plasma  of  the  ven- 
ules. These  venules  are  the  portal  radicles,  and  leuco- 
cytes containing  iron  are  found  in  capillaries  of  the  liver, 
and  the  peripheral  cells  of  the  lobules  contain  iron. 
Similar  leucocytes  are  found  in  the  spleen.  Beyond  this 
point  the  iron  was  not  traced,  and  the  question  whether 
it  is  ultimately  assimilated  and  fixed  as  inorganic  iron 
remains  unsettled ;  but  the  research  serves  to  prove  that 
iron  salts  have  not,  as  has  been  asserted,  merely  a  stimu- 
lant action  on  the  epithelial  cells  of  the  mucous  mem- 
brane. Any  stimulant  action  they  may  exert  is  a  con- 
comitant of  their  absorption.  Though  some  of  the 
subepithelial  leucocytes  of  the  villi  appear  thus  to  carry 
part  of  the  absorbed  iron  into  the  general  circulation, 
the  more  important  agent  in  the  transference  of  the  in- 
organic iron  from  the  villi  to  other  parts  of  the  body  is 
the  blood  plasma. 

Thiofonn  —Dr.  Julius  Schmidt  states  that  thioform  is 
a  grayish  yellow  powder,  which  is  a  chemical  combina- 
tion of  bismuth,  sulphur,  and  salicylic  acid.  It  is  tasteless 
and  odorless,  insoluble,  and  was  first  prepared  as  a  sub- 
stitute for  iodoform.  This  expectation  has  been  veri- 
fied in  so  far  that  surgically  its  value  is  equally  great, 
but  the  specific  action  of  iodine  as  required  in  tubercu- 
lous affections  is  not  obtained.  When  applied  to  fresh 
wounds  thioform  produces  rapid  drying  of  the  surface, 
leading  to  a  more  rapid  cicatrization  than  has  been  ob- 
served after  the  use  of  any  other  application ;  this  was 
noticed  even  in  extensive  surface  lesions,  such  as  burns, 
weeping  eczema,  and  gangrenous  patches,  the  latter 
having^  healed  in  four  days.  The  author  tested  the 
powder  in  five  cases  of  ulcer  of  the  leg  which  had  re- 
sisted other  treatment.  The  ulcer  having  been  cleaned 
and  disinfected,  the  thioform  was  thickly  dusted  over  it, 
and  covered  with  cotton-wool  and  a  bandage.  Every 
fourth  day  the  whole  dressing  was  changed,  and  though 
the  patient  continued  to  walk  during  the  treatment,  the 
cure  required  two  or  three  weeks  only.  Some  pain  was 
occasionally  produced,  but  no  sign  of  irritation  could  be 
seen.  Similar  results  in  the  practice  of  other  surgeons 
are  given.  Finally,  the  author  used  thioform  internally 
after  having  satisfied  himself  as  to  its  non-  poisonous 
character,  and  with  daily  long-continued  doses  of  fifteen 
grains,  better,  though  similar,  results  were  obtained 
than  with  salicylate  of  bismuth. 

Tuberculous  Typhlitis  and  Appendicitis. — Dr.  Re- 
ctus observes  that  the  clinical  reports  of  tuberculosis  of 
the  caecum  have  accumulated  rapidly  during  recent  years. 
The  cases  of  Bouilly,  Terrier,  Hartmann,  Reynier,  Broca, 
Roux,  Salzer,  Billroth,  and  Hochenegg,  the  anatomical 
researches  of  Duguet,  Spillmann,  H6rard,  Cornil,  and 
Hanot,  and  the  recent  descriptions  of  Pilliet  and  of  Le 
Bayon,  have  thrown  some  light  upon  this  hitherto  but 
little  recognized  affection.  The  cases  have  been  numer- 
ous enough  for  one  to  attempt  to  tabulate  a  statement  of 
the  clinical  manifestations  of  tuberculous  typhlitis  and 
appendicitis.  Reclus  himself  has  observed  two  cases 
where  a  long-continued  clinical  history  has  been  sustained 
by  post-  mortem  examinations.  This  affection  may  mani- 
fest itself  as  a  localized  tuberculosis  without  infiltration, 
without  concomitant  degeneration  of  the  lungs  and  other 
important  viscera,  developing  itself  around  the  ileo  csecal 


valve  and  its  vicinity  without  invading  the  other  tissues. 
This  suffices  to  class  this  tuberculosis  among  the  surgical 
tuberculoses ;  from  the  moment  it  is  confined  to  a  limited 
focus  and  this  focus  is  accessible,  in  such  favorable  cir- 
cumstances intervention  is  legitimate.  Therefore,  in  cer- 
tain cases — and  the  observations  are  becoming  daily 
more  numerous — perityphlic  tuberculosis  is  an  ordinary 
surgical  affection.  As  to  the  etiology  of  this  condition 
the  literature  is  scant ;  the  degeneration  here,  as  in  most 
of  the  other  tuberculoses,  seems  most  frequent  in  adult 
age,  but  the  young  do  not  escape ;  a  little  boy  aged  ten 
has  been  cited  as  dying  from  this  affection ;  the  greatest 
number  of  the  cases  published,  however,  have  been  in  in- 
dividuals who  neighbored  upon  or  who  had  passed  thirty 
years  of  age.  It  seems  that  two  distinct  anatomo-patho- 
logic  forms  may  be  described,  associated  with  different 
symptoms:  the  one  a  fibrous  or  hypertrophic  and  the 
other  an  ulcerous  variety ;  moreover  these  may  be  com- 
bined, or  there  may  be  noticed  all  the  intermediate 
stages  between  them.  The  majority  of  the  cases  thus  far 
reported  have  been  characterized  by  an  abundant  new- 
formation  which  gave  to  the  degeneration  the  appear- 
ance of  cancer.  In  this  form,  the  tumor  after  incision 
of  the  abdominal  parietes  appears  fused  with  the  double 
parietal  peritoneum,  with  new  membranous  formations 
which  cover  the  intestines  and  mark  their  limit;  the 
original  form  of  the  caecum  and  its  appendix,  the  ascend- 
ing colon,  the  ileo-caecal  valve,  and  the  termination  of 
the  ileum  cannot  be  recognized.  There  is  a  muscular 
and  a  mucous  hypertrophy  at  this  point  which  causes 
the  intestinal  wall  to  measure  at  times  up  to  three  or  four 
centimetres.  The  lesions  ordinarily  are  most  marked 
around  the  ileo-caecal  valve ;  the  valve  is  profoundly  al- 
tered from  the  beginning ;  in  its  place  is  found  an  ir- 
regular cavity,  covered  by  a  partly  ulcerated  mucosa; 
the  loss  of  substance  is  irregular,  its  edges  sinuous,  the 
base  sanguineous  with  small  rigid  villosities.  The  ap- 
pendix is  bent  upon  itself  and  adherent  at  times  in  front 
of  the  caecum,  at  times  behind  it ;  it  is  lost  in  the  thick- 
ness of  the  false  membrane. 

The  second  or  ulcerated  form  may  present  thickening 
of  the  serous  and  false  membranes  around  the  intestinal 
loops,  but  these  have  not  the  remarkable  hypertrophy  of 
the  other  form ;  on  the  contrary,  the  ulcerative  process 
predominates,  the  mucosa  has  often  completely  disap- 
appeared,  especially  at  the  site  of  the  ileo-caecal  valve, 
where  ordinarily  a  veritable  cloaca  is  found  due  to  the 
destruction  and  anastomosis  of  the  various  intestinal  seg- 
ments. The  softening  of  the  cheesy  masses  in  the  tunics 
and  the  neighboring  ganglia  has  given  rise  to  puriform 
collections,  which  run  in  various  directions,  but  generally 
make  their  way  toward  the  abdominal  wall ;  through  the 
resulting  fistulse  fecal  matter  and  pus  escape.  These  pyo- 
stercorous  canals  are  often  multiple.  There  exists  a  third 
form  which  Professor  Cornil  has  especially  studied. 
Often,  in  place  of  the  fecal  concretion  which  forms  in 
the  appendix,  some  foreign  bcdy,  bone,  a  fruit 
seed  lodges  there,  and  by  its  presence  irritates  or  perfo- 
rates the  vermiform  process  and  tuberculosis  forms,  the 
bacillary  colony  destroying  the  walls.  The  symptom  of 
the  first  form  in  the  beginning  is  the  existence  of  deep 
pains  in  the  region,  lasting  for  some  hours  during  the 
day,  then  disappearing  and  appearing  anew.  This  at- 
tack subsides  only  to  reappear  in  a  few  weeks  in  a  more 
aggravated  form.  Constipation  accompanies  it  and  may 
be  extreme.  On  examination  the  presence  of  a  tumor  is 
demonstrated  in  the  right  iliac  fossa,  hard,  resisting,  bos- 
selated,  irregular.  In  these  cases  where  softening  has 
taken  place  fluctuation  may  be  pronounced,  or  the  skin 
becomes  red  and  the  abscess  opens  with  the  formation  of 
a  fistula.  The  diagnosis  becomes  plainer  still  when  in 
place  of  the  extreme  constipation  a  rebellious  diarrhoea 
appears  resulting  from  the  abundant  and  persistent  ul- 
cerations of  the  mucosa.  The  general  health  does  not 
suffer  in  either  form  at  first.  As  to  the  treatment  of  these 
cases,  surgical  intervention  is  the  only  proper  and  justifi- 
able course. — The  Medical  and  Surgical  Reporter. 


October  13,  1894] 


MEDICAL    RECORD. 


463 


(SliiuicaX  g«pa»tmetit 

A  SOURCE  OF  INFECTION  IN  CORNEAL  AB- 
SCESS. 

By  J.  H.  THOMPSON,  M.D., 

clinical  PRoressox  of  ophthalmology,  Kansas  city  medical  college,  Kan- 
sas CITY,  MO. 

lifts  not  the  purpose  of  this  paper  to  consider  the  nature 
and  variety  of  micro-organisms  which  cause  abscess  of 
the  cornea.  The  probabilities  are  that  the  septic  cases 
are  responsible  for  most  purulent  inflammations  of  that 
tissue.  But  it  is  important  to  learn  where  these  septic 
germs  arise  and  how  they  reach  the  eye.  We  know  that 
the  tears  and  conjunctival  secretions  contain  them,  and 
late  investigations  have  proved  that  the  cutaneous  edges 
of  the  lids,  especially  about  the  roots  of  the  lashes,  are 
surgically  unclean.  The  greatest  source  of  infection  is 
the  lachrymal  sac,  and  woe  be  to  an  eye  if  its  cornea  is 
injured  during  the  course  of  a  purulent  dacryocystitis. 
I  am  inclined  to  the  opinion  that  the  pyogenic  cocci  are 
not  always  so  virulent  as  we  have  been  taught  to  believe ; 
for  very  few  eyes  could  survive  the  simplest  operation 
which  necessitated  an  incision  or  puncture  of  the  cornea. 
Therefore,  it  is  not  unreasonable  to  think  that  in  a  large 
majority  of  instances  the  conjunctiva  of  an  unwashed  eye 
is,  for  all  surgical  purposes,  aseptic. 

In  an  experience  of  fifteen  years,  during  which  time  I 
have  made  many  extractions  and  corneal  incisions,  I  have 
never  had  an  instance  of  suppuration,  and  I  do  not  take 
any  antiseptic  precautions  other  than  wiping  the  lids 
with  a  bichloride  solution,  1  to  2,000,  taking  care  that 
the  instruments  are  clean.  Of  course,  it  is  to  be  under- 
stood that  all  such  cataract  operations  were  made  on  un- 
inflamed  eyes. 

Many  cases  of  abscess  of  the  cornea  are  the  result  of 
infection  from  the  lachrymal  sac,  the  mucosa  of  the  sac 
being  in  a  condition  of  purulent  inflammation.  Many 
other  cases  of  corneal  abscess  are  not  complicated  by 
that  disease.  In  such  instances  I  have  usually  found  the 
source  of  the  infection  to  be  the  mouth.  It  is  not  an  ex- 
aggeration to  say  that  the  mouth  of  an  unclean  adult  is 
often  extremely  dirty.  Should  the  reader  desire  proof 
of  this  statement,  let  him  examine  the  teeth  of  the  ordi- 
nary dispensary  patient,  or,  what  is  more  agreeable,  take 
the  opinion  of  a  dentist.  Unless  extra  care  is  taken  by 
most  persons  the  tartar  will  collect  around  the  roots  of 
the  teeth,  which  will  ultimately  excite  an  alveolar  pyor- 
rhoea and,  finally,  recession  of  the  gums.  During  the 
course  of  that  disease  the  mouth  may  be  horrible  and  the 
smell  disgusting.  No  wonder  the  bite  of  such  persons 
cah  be  fatal.  If  we  take  a  minute  particle  of  the  mass  of 
decomposing  food  and  pus  from  between  the  rotting 
teeth  and  examine  it  through  an  eighth  objective,  after 
staining  the  cover-glass  preparation  by  Gram's  process, 
we  will  be  astonished  at  the  multitude  and  variety  of  mi- 
cro-organisms. I  cannot  conceive  how  the  pharynx  and 
nasal  passages  can  be  healthy  if  the  mouth  is  so  diseased. 
The  mass  of  organisms  cannot  remain  localized  about 
the  teeth,  but  must  infect  the  entire  mucous  tract,  and 
by  continuity  reach  the  conjunctiva.  They  do  not  nec- 
essarily inflame  that  membrane,  nor  do  they  excite  such 
disturbances  in  the  lachrymal  passages  as  would  be  de- 
tected by  the  patient  or  careless  observer,  but  the  mucous 
membrane  of  the  eye  is  infected  when  an  intentional  or 
accidental  wound  of  the  cornea  may  suppurate. 

For  some  time  I  had  been  suspicious  that  there  was 
some  relation  between  a  dirty  mouth  and  a  suppurating 
cornea,  when  the  following  case  rather  convinced  me. 

M.  B ,  aged  forty-three,  a  farmer.     While  cutting 

weeds  something  hit  him  in  the  eye.  He  did  not  pay 
any  particular  attention  to  it,  and  would  have  forgotten 
the  accident  had  not  his  eye  inflamed  three  days  after- 
ward. He  was  cared  for  by  his  family  physician,  who 
referred  him  to  me  ten  days  after  the  accident.  When 
I  saw  him,  his  cornea  was. destroyed  by  an  abscess.    He 


had  no  disease  of  the  lachrymal  passages,  but  his  mouth 
was  fouler  than  the  uninitiated  can  conceive.  His 
breath  overcame  me.  Is  it  surprising  that  he  lost  his 
eye? 

Some  weeks  ago  I  saw  another  similar  case. 

F.  N ,  aged  about  thirty,  laborer,  was  wounded  in 

the  left  eye  by  a  piece  of  stone.  He  complained  of  the 
injury  from  the  first,  and,  when  I  saw  him  several  days 
afterward,  he  had  a  suppurating  ulcer  of  the  cornea  with 
hypopion.  The  ulcer  was  round,  3  mm.  in  diameter, 
with  a  dirty  white  floor  and  ragged  edges.  There  was 
no  evidence  of  dacryocystitis,  but  there  were  evidences 
of  a  foul  mouth.  The  ulcer  was  completely  destroyed 
by  the  actual  cautery;  the  eye  bathed  every  two  hours 
with  a  bichloride  solution,  1  to  4,000.  The  patient  was 
introduced  to,  and  taught  the  mysteries  of  a  tooth-brush, 
as  much  care  being  taken  to  clean  his  mouth  as  his  eye. 
The  eye  did  not  improve,  and  when  the  hypopion  filled 
the  anterior  chamber,  I  made  the  Saemisch  cut,  and  re- 
moved the  pus  en  masse  with  forceps.  From  then  on 
the  patient  improved,  and  was  discharged  six  weeks 
afterward  with  useful  vision. 

At  present  I  have  on  hand  a  case  of  hypopion  keratitis 
evidently  caused  by  infection  from  the  mouth.  The 
patient  is  an  Italian  miner,  who  has  suffered  for  years 
from  alveola  pyorrhoea.  His  mouth  is  in  a  dreadful  con- 
dition ;  the  roots  of  all  his  front  teeth  are  exposed,  and 
the  spaces  between  them  and  the  receding  gums  filled 
with  tartar,  pus,  and  decomposing  food. 

If  the  source  of  infection  in  the  cases  above  reported 
was  the  mouth,  it  behooves  us  to  pay  some  attention  to 
oral  cleanliness  in  the  treatment  of  suppurative  keratitis ; 
and  since  this  may  account  for  some  distressing  and  un- 
expected results  following  cataract  extraction,  we  should 
be  especially  careful  in  that  regard  before  undertaking 
that  operation,  since  we  know  that  old  people  are  apt  to 
be  careless,  and  usually  suffer  from  bad  gums  and  de- 
cayed teeth. 

AN  UNUSUAL  CASE  OF  PERFORATING  AP- 
PENDICITIS—DEATH FROM  HEMORRHAGE 
DUE  TO  RUPTURE  OF  THE  COMMON 
ILIAC  VEIN. 

By  J.   C.  LEWIS,   M.D., 

PANAMA,    N.    Y. 

B.   E ,   fourteen  years  of  age,  was  taken  sick  on 

Friday,  March  23d,  with  vomiting,  chills,  and  pain  in 
the  bowels.  The  pain  increased  in  severity  until  Sun- 
day, March  25th,  when  I  was  called  to  see  her.  I  found 
the  patient  inclined  to  lie  mostly  on  the  right  side,  with 
limbs  flexed.  Temperature,  1030  F. ;  pulse,  135.  Her 
bowels  were  slightly  swollen  and  tympanitic,  with  tender- 
ness especially  marked  in  the  right  iliac  region.  The  pa- 
tient had  taken  for  her  relief  nine  of"  Carter's  "  pills  and 
one  tablespoonful  of  castor-oil,  without,  however,  obtain- 
ing any  movement  of  the  bowels  more  than  a  few  small 
scybalae,  and  at  one  time,  on  Saturday,  March  24th,  about 
a  tablespoonful  of  fresh  blood  was  passed.  The  patient 
ascribed  her  sickness  to  some  peanuts  which  she  had 
eaten  at  a  party  on  Friday  evening,  March  16th. 

The  treatment  pursued  was  the  use  of  large  enemas 
with  opiates  to  relieve  the  pain.  On  Monday  and  Tuesday 
the  symptoms  were  unchanged,  except  that  the  tempera- 
ture rose  to  1040  F.,  the  pulse  varied  from  120  to  140, 
the  countenance  became  cadaveric  and  expressive  of 
severe  pain.  The  swelling  and  tenderness  in  the  right 
iliac  region  became  more  manifest,  with  point  of  severest 
pain  an  inch  below  McBurney's  point.  On  Tuesday, 
while  up  in  a  chair,  the  patient  fainted  away,  and  it  was 
quite  difficult  to  restore  her,  and  for  an  hour  or  more 
her  breathing  was  labored.  The  enemas  had  been  con- 
tinued without  any  success.  I  became  convinced  that 
the  patient  had  appendicitis  and  recommended  an 
operation.  On  Wednesday,  Dr.  Murphy,  of  Sherman, 
N.  Y.,  saw  the  case  with  me  and  confirmed  the  diag- 
nosis, but  advised  waiting  two  days  and  keeping  up  the 


464 


MEDICAL  RECORD. 


[October  13,  1894 


use  of  the  enemas,  as  her  symptoms  seemed  somewhat 
improved,  the  pulse  having  come  down  to  100,  and  the 
temperature  to  ioo)40  F.,  and  the  countenance  was  im- 
proved, though  pain,  swelling,  and  tenderness  of  bowels 
remained  the  same. 

On  Friday,  March  30th,  with  a  view  to  an  operation, 
Dr.  Seabury,  of  Sugar  Grove,  Pa.,  was  called,  and  met 
Drs.  Murphy  and  Glidden.  The  patient's  condition  was 
unchanged,  except  that  the  pulse  was  down  to  90,  and 
the  temperature  for  the  last  two  days  had  ranged  from 
normal  to  ioo°  F.  The  result  of  the  consultation  was  a 
delay  in  the  operation.  On  Saturday,  a.m.,  the  tempera- 
ture was  only  96^°  F.,  and  the  condition  otherwise  un- 
changed, except  that  the  swelling  in  the  right  iliac  region 
seemed  less  prominent.  The  bowels  were  but  little 
swollen  and  tympanitic,  but  pain  was  not  lessened.  The 
bowels  had  not  moved  from  enemas,  which  had  been  con- 
tinued. 

Dr.  John  Parmenter,  of  Buffalo,  was  called,  and 
operated  in  the  presence  of  Drs.  Seabury,  Glidden,  Mur- 
phy, and  the  writer. 

At  the  time  of  operation  the  physical  examination 
showed  a  good  countenance,  a  clean  and  moist  tongue ; 
respiration,  20;  pulse,  100  (full  and  regular);  tempera- 
ture normal ;  abdomen  slightly  tympanitic  and  not  re- 
markably tender.  In  place  of  a  perceptible  tumor,  only 
dulness  was  manifest  in  the  right  iliac  region.  This  ex- 
tended toward  the  median  line.  Coeliotomy  was  made 
in  the  median  line,  and  after  cutting  through  the  ab- 
dominal wall  pus  welled  up  in  the  incision.  Omentum 
formed  the  background  and  seemed  intimately  adherent 
to  the  intestines  beneath.  The  pus  seemed  to  come 
mostly  from  the  right  side,  and  upon  examination  a 
large  abscess  cavity  was  discovered  in  the  right  iliac 
region.  Incision  was  made  over  this;  that  is,  at  the 
right  border  of  the  right  rectus  muscle,  through  which 
a  pint  and  a  half  of  malodorous  pus  was  removed. 
The  intestines  were  found  matted  together,  and  for  fear 
of  disturbing  the  adhesions  no  force  was  used  in  the  ab- 
scess cavity.  This  was  drained  with  iodoform  gauze,  a 
counter-opening  in  the  loin  having  first  been  made  in  or- 
der to  more  freely  drain  the  parts,  and  the  patient  was 
put  to  bed  in  practically  the  same  condition  as  before  the 
operation.  She  became  restless  in  coming  out  from  the 
anaesthesia  and  tossed  about  in  the  bed,  requiring  the  ef- 
forts of  the  bystanders  to  restrain  her.  An  hour  after 
the  operation  she  became  resdess  a  second  time  and 
showed  signs  of  collapse.  Examination  revealed  the 
bed  and  the  dressings  posteriorly  to  be  saturated  with 
blood,  and,  notwithstanding  the  generous  use  of  stimu- 
lants, she  shortly  died. 

Autopsy,  immediately  after  death,  revealed  the  follow- 
ing conditions:  There  was  pus  throughout  the  whole 
abdominal  cavity,  covering  all  the  viscera,  even  occupy- 
ing the  space  between  the  liver  and  diaphragm.  In  the 
right  iliac  region,  the  ileum  for  some  twelve  inches  was 
intensely  congested,  and  at  the  junction  of  the  ileum  and 
caecum  the  parts  were  gangrenous.  The  caecum  con- 
tained three  gangrenous  openings,  averaging  one- fourth 
of  an  inch  in  diameter.  The  distal  three-fourths  of  the 
appendix  was  gangrenous  and  separated  from  the  proxi- 
mal end,  and  lying  in  the  debris  was  a  peanut.  The 
healthy  condition  of  the  proximal  end  precluded  the 
idea  of  the  peanut  having  passed  through  from  the 
caecum  by  this  route,  so  that  the  inference  is  that  it  must 
have  come  through  one  of  the  openings  in  the  caecum 
and  was  deposited  in  the  neighborhood  of  the  appendix. 
The  portion  of  the  ileum  near  the  junction  at  the  caecum, 
as  before  stated,  was  in  a  gangrenous  condition  and  bent 
sharply  downward  to  become  attached  to  the  common 
iliac  vein:  In  this  latter  structure  a  small  opening,  out 
of  which  exuded  blood,  was  discoverable,  and  from  this 
area,  through  the  posterior  opening  in  the  flank,  blood 
had  continually  poured  until  death  ensued.  The  amount 
of  blood  exuded  in  a  given  time  must  have  been  com- 
paratively small,  and' in  all  probability  the  rupture  of  the 
vein  occurred  during  some  of  the  violent  movements  of 


the  patient  on  coming  out  from  her  anaesthesia,  for  at 
the  time  of  the  operation  no  hemorrhage  of  any  kind 
was  perceptible. 
The  following  features  seem  worthy  of  notice : 

1.  The  absence  of  marked  symptoms  of  diffuse  suppu- 
rative peritonitis. 

2.  The  cause  of  death — from  hemorrhage. 

3.  The  absence  of  fecal  impaction,  which  was  supposed 
to  exist  in  connection  with  appendicitis,  from  the  fact 
that  no  satisfactory  movement  of  the  bowels  had  been 
obtained  after  the  taking  of  so  much  physic 

4.  The  necessity  of  an  early  operation  in  cases  pre- 
senting marked  symptoms  of  appendicitis. 


THE  INFECITVTTY  OF  PHTHISIS  PULMONALIS 
—AN  INSTANCE. 

By  CHARLES  O.  MAISCH,  M.D., 

-NBW  YOftK. 

Some  weeks  ago  I  was  consulted  by  a  man  whom  I  have 
known  for  a  number  of  years,  whose  mode  of  living, 
surroundings,  and  family  were  perfectly  well  known  to  me. 

The  patient  is  a  German,  sixty-two  years  of  age,  well 
preserved,  and  weighs  about  two  hundred  pounds ;  ante- 
cedents and  family  history  good,  except  that  he  had 
pneumonia  a  year  ago. 

He  states  that  he  has  lost  forty  pounds  in  the  last  four 
months ;  his  complaints  are  those  of  a  patient  in  ad- 
vanced consumption — cough,  profuse  expectoration,  oc- 
casional hemorrhages,  anorexia,  sweating,  wasting,  etc 

Physical  examination  disclosed  both  apices  to  be  in- 
volved, and  the  sputum  I  examined  contained  the  tuber- 
cle bacillus  in  large  numbers. 

The  further  history  is  important.  Two  years  ago 
this  man  lc«t  a  son,  aged  twenty*  three,  who,  after  a 
sickness  lasting  six  or  seven  months,  died  of  pulmonary 
tuberculosis.  About  three  months  later,  the  young  man's 
mother,  who  had  been  nursing  him,  began  to  sicken.  She 
was  a  German,  fifty-nine  years  of  age,  strong,  robust,  and 
well  preserved,  weighing  upward  of  two  hundred  and 
twenty- two  pounds,  and  had  a  good  family  history. 
She  gradually  failed,  and  died  after  an  illness  lasting 
some  twenty  months,  during  the  last  of  which  she  had 
frequent  hemorrhages  from  the  lungs  and  intestines,  and 
almost  constant  diarrhoea. 

This  was  five  months  ago.  Upon  visiting  mv  patient 
at  his  home,  I  found  that  he  always  expectorated  on  the 
walls,  floors,  and  in  the  corners  of  his  apartment,  the 
place  of  special  selection  being  under  his  bed.  This  had 
also  been  the  practice  of  the  deceased  members  of  his 
family. 

The  daughter  who  takes  care  of  the  sick  man  says 
that  their  attention  had  never  been  drawn  to  any  danger 
from  this  habit,  but  that  the  physician  who  had  attended 
ordered  a  saucerful  of  black  (crude")  carbolic  acid  to  be 
kept  in  the  room,  evidently  with  tne  intention  of  com- 
bating or  lessening  the  evil. 

It  is,  of  course,  impossible  that  the  emanations  from  a 
saucerful  of  crude  carbolic  add  would  have  sufficient 
germicidal  potency  to  make  any  impression  upon  an  at- 
mosphere loaded  with  the  germs  of  latent  tuberculods. 

There  have  been  two  deaths,  a  third  member  of  the 
family  is  hopelessly  sick,  and  a  fourth,  a  daughter,  aged 
twenty-two,  is  worn  out  and  delicate  from  long  and 
constant  attention  to  the  sick  (brother,  mother,  and 
father).  She  sleeps  in  the  same  room  with  the  sick  man, 
and  slept  at  the  side  of  the  mother  during  her  illness, 
constantly  inhaling  the  dried  products  of  the  expectora- 
tion, which  were  everywhere,  and  she  now  is  in  a  fair  way 
to  become  phthisical,  if  she  is  not  so  already. 

Without  entering  upon  the  details  of  what  prophylac- 
tic measures  should  have  been  employed  in  these  in- 
stances, it  will  be  readily  seen  that,  with  proper  hygienic 
precautions  and  intelligent  co-operation  of  the  family  in 
the  first  case,  the  last  two,  and  possibly  the  third,  would 
probably  not  have  occurred. 

90  Madison  Stmet,  September  9, 1894. 


October  13,  1894] 


MEDICAL    RECORD. 


465 


Medical  Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


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


New  York,  October  13,  1894. 


OLIVER  WENDELL  HOLMES. 

How  familiar  has  been  the  sound  of  this  name !  How 
deep  is  the  regret  with  which  we  add  in  reverential  tone 
that  Doctor  Holmes  is  dead.  But  is  he  dead  ?  Do  such 
men  really  die? 

He  has  won  the  love,  the  admiration,  the  respect  of 
two  hemispheres;  his  influence  has  extended  as  far  as  the 
English  language  is  understood ;  his  teachings  have  been 
a  benefit  to  the  whole  human  race.  His  loss  is  not  one 
to  be  felt  by  one  community.  Boston  cannot  claim 
him,  nor  Massachusetts,  nor  North  America.  He  be- 
longs to  the  world.  Proud  as  we  are  to  think  of  him  as 
a  member  of  our  profession,  and  proud  as  we  are  of  his 
achievements  in  it,  we  realize  that  his  great  work  in  life 
had  more  to  do  with  making  people  better  spiritually 
than  making  them  well  physically.  Physician  by  edu- 
cation, he  devoted  himself  to  practice  and  the  acquisi- 
tion and  imparting  of  scientific  knowledge.  Poet  by 
nature,  he  spent  his  leisure  time  and  declining  years  in 
those  writings  which  have  so  endeared  him  wherever 
they  have  been  read.  Philosopher  by  thoughtful  study 
and  love  of  his  fellow-man,  he  made  for  many  life's  path 
less  rugged  by  kind  and  philanthropic  words,  and  when 
his  own  long  path  brought  him  toward  life's  foot-hills 
he  was  content  and  said,  "  he  should  sorrow  deeply  if  he 
had  the  idea  he  was  to  become  helpless  in  body  and 
mind"  This  was  spared  him.  He  reached  the  end, 
"eighty-five  years  young,"  as  he  has  expressed  it,  and 
happily  met  death  as  a  little  child  meets  sleep,  uncon- 
scious of  fatigue,  and  only  mindful  of  a  day  more  full  of 
pleasures  than  of  pain. 

To  his  students  of  twenty  or  thirty  years  ago,  as  they 
recall  the  words  of  the  genial  Professor  in  describing,' the 
arch  of  the  female  pelvis,  "  Gentlemen  !  this  is  the  tri- 
umphal arch  under  which  every  candidate  for  immortal- 
ity has  to  pass,"  the  thought  must  occur  how  nearly  has 
been  attained  that  immortality  of  which  he  spoke,  and 
how  like  a  triumphal  march  the  whole  modest  life  ! 

Almost  the  last  leaf  upon  the  tree  (for  nearly  all  his 
contemporaries  had  fallen  from  the  bough  which  bore 
the  date  of  his  birth  and  college  graduation),  he  still 
dung  to  it  with  a  vitality  which  indeed  elicited  a  smile, 
bat  one  wholly  of  admiration,  and  carrying  with  it  a 
"God  bless  you  I" 

The  ever-speaking  presence  in  his  charming  books, 
the  genial  infusion  therein  of  his  cheerful  spirit,  the 
lofty  tone  of  his  pathos,  the  sound  philosophy  of  his 


humanity,  the  soul-touching  sweetness  of  his  poetry,  the 
subtle  humor  of  his  generous  and  loving  nature,  will  keep 
him  always  with  us  through  the  never-ending  flight  -of 
future  days. 

THE    PERCENTAGE     OF    IRREGULAR    PRAC- 
TITIONERS IN  THE  UNITED  STATES. 

According  to  Polk's  Register,  Toledo,  with  a  population 
of  100,000  in  1890,  had  209  physicians  in  1892,  of 
whom  70.3  per  cent,  were  regulars.  In  Cincinnati,  a 
city  with  a  population  of  296,908,  there  are  596  physi- 
cians, of  whom  70.6  per  cent,  are  regulars.  In  Cleve- 
land, with  270,000  inhabitants,  there  are  545  physicians, 
of  whom  sixty-three  per  cent,  are  regulars. 

Out  of  the  first  hundred  names  {Medico-Surgical  Bul- 
letin) taken  from  a  list  of  physicians  in  small  towns,  ar- 
ranged alphabetically  by  post-offices,  including  Aber- 
deen, Ada,  Adams  Mills,  etc.,  we  find  sixty-six  per  cent, 
classed  as  regulars. 

The  explanation  of  this  lies  in  the  number  of  cheap 
medical  colleges.  Ohio  and  Missouri  are  States  which 
are  offensively  prominent  in  this  respect.  Thus  Ohio 
has  a  population  of  3,672,316  and  seventeen  medical 
colleges,  while  New  York,  with  a  population  of  51997,853, 
has  only  twelve. 

The  evil  is  being  slowly  corrected,  however,  and  we 
have  no  doubt  that  in  ten  years  the  percentage  of  edu- 
cated physicians  will  be  greatly  increased,  while  at  the 
same  time  that  of  cheap  medical  colleges  will  corre- 
spondingly decline. 

It  would  be  quite  unjust  also  to  suppose  that  two- 
thirds  of  American  physicians  are  irregular  practition- 
ers and  uneducated  men.  In  New  York,  for  example, 
the  law  requires  evidences  of  graduation  from  a  college 
of  respectable  standing,  and  the  percentage  of  ignorance 
is  small.    The  same  is  true  of  many  other  States. 


FOOT-BALL  AS  A  MEANS  OF  PHYSICAL  DE- 
VELOPMENT. 

The  advent  of  the  foot-ball  season  has  already  given 
rise  to  discussions  about  the  value  and  dangers  of  the 
game.  As  to  the  dangers  there  is  no  longer  much  dis- 
pute, and  it  is  stated  that  the  new  rules  will  not  make 
any  appreciable  difference.  We  can  only  trust  that  the 
record  of  last  fall's  mortality  will  not  be  repeated. 

As  to  the  practical  advantages  of  the  game  as  a  means 
of  physical  culture  and  mental  stimulus,  there  is  still 
much  controversy.  What  is  wanted  is,  however,  not  so 
many  opinions  and  more  facts.  Dr.  Beyer,  in  the  Ameri- 
can Journal  of  the  Medical  Sciences,  has  contributed 
somewhat  to  our  actual  knowledge  of  the  matter.  He 
finds  that  in  the  Annapolis  Academy  the  foot-ball  players 
are  four  per  cent,  superior  in  height,  twenty- eight  per 
cent,  in  weight,  twenty- one  per  cent,  in  lung  capacity, 
and  forty-nine  per  cent,  in  total  strength.  These  were 
only  average  players,  many  of  whom  never  played  in  a 
big  game,  and  nearly  all  the  measurements  represented 
the  player  as  he  was  at  the  beginning  of  the  training 
period.  Between  the  average  Yale  student  and  the 
average  American  foot-ball  player,  the  players  were 
one  year  and  one  month  older,  but  they  were  2.8 
per  cent,  taller,  twenty  per  cent,  heavier,  had  ten  per 
cent,   more  lung  capacity,   and  were  forty  per  cent. 


466 


MEDICAL  RECORD. 


[October  13,  1894 


stronger  than  the  fifty  mercantile  grade  of  Yale  students. 
Between  average  American  players  and  Amherst  students 
the  comparison  is  on  rather  a  different  footing,  because 
here  the  students  are  nearly  two  years  older  than  the 
players;  but  the  latter  have  a  superiority  of  three  per 
cent,  in  height,  twenty-three  per  cent,  in  weight,  twenty 
per  cent,  in  lung  capacity,  and  thirty- seven  per  cent,  in 
total  strength. 

This  all  shows  simply  that  the  bigger,  stronger,  and 
more  active  men  are  selected  for  foot-ball.  As  it  is  just 
the  opposite  class  who  most  need  physical  education, 
it  seems  as  if  these  figures  furnish  a  very  telling  argu- 
ment against  foot  ball  as  a  means  of  securing  a  good 
general  athletic  training.  The  strong  boys  train  and 
play;  the  weaker  sit  around,  drink  beer,  smoke  ciga- 
rettes, and  shout. 

Dr.  Beyer  gives  some  further  statistics  which  have 
a  rather  academic  interest.  They  show  that  after  two 
months  work  at  foot-ball,  the  player  gains  four  or  five 
per  cent,  in  weight,  about  four  per  cent,  in  lung  capacity, 
and  fourteen  to  sixteen  per  cent,  in  general  strength. 
This  gain  in  strength  continued  for  a  long  time  after 
training.  The  lung  capacity  was  not  much  increased. 
As  compared  with  rowing  and  gymnasium  work,  Dr. 
Beyer  shows  that  foot-ball  is  inferior  as  a  means  of 
physical  development,  as  by  the  first  two  methods  the 
physical  strength  was  increased  about  twenty-eight  per 
cent 

The  case  for  foot-ball  is  not  helped  by  Dr.  Beyer's 
investigation. 

AN  ANTI-CORSET  LEAGUE. 

Every  month  brings  us  news  of  a  new  "  anti-"  society. 
We  gave  notice  recently  of  the  formation  of  an  anti- 
opiate  league ;  now  the  London  papers  inform  us  of  an 
Anti-Corset  League,  which  has  been  organized  at  Liver- 
pool. 

The  objects  of  this  association  consist  in  inculcating 
true  principles  of  clothing,  which  neither  offend  the  eye 
nor  the  requirements  of  health.  The  use  of  the  corset 
will  be  specially  discouraged,  but  its  place  will  be  taken 
by  an  easy  and  natural  form  of  support,  consistent  with 
the  wholesome  development  of  the  body  and  the  due 
exercise  of  its  functions. 

This  easy  and  natural  support  is  not  to  be  the  male 
arm,  as  might  be  supposed  by  frivolous  minds,  but  is  a 
pliable,  plaited  affair,  conforming  to  hygienic  principles 
and  the  natural  curves  of  the  trunk.  There  is  no  article 
of  apparel  which  has  been  so  vigorously,  and  we  have  no 
doubt  justly,  criticised  as  the  corset ;  but  it  stays  just 
the  same,  and  we  fear  it  will  continue  to  do  so.  How- 
ever, the  Anti-Corset  League  has  our  sympathy  and 
support.  The  corset  is  always  a  source  of  some  danger, 
and  in  a  good  many  cases  does  positive  harm. 


Placarding  of  Apartments  Where  Contagious  Disease 
Exists.— At  the  last  meeting  of  the  Board  of  Health  a 
recommendation  made  by  Dr.  H.  M.  Biggs  was  adopted, 
providing  for  the  better  protection  of  the  public  by  the 
placarding  of  all  apartments  where  there  are  contagious 
diseases.  The  warning  placards  are  to  be  in  different 
colors :  white  for  diphtheria,  red  for  scarlet  fever,  and 
blue  for  measles. 


fjews  ot  tfoe  fflteetu 

Death  of  Dr.  Oertel. — Telegraphic  news  reports  the 
death  of  Dr.  Oertel,  of  the  Hygienic  Institute  of  Ham- 
burg, from  Asiatic  cholera  contracted  while  making 
investigations  of  infected  water  from  the  Vistula. 

Dr.  Pliny  Earle's  Bequest  to  Leicester,  Mass.— The 
town  of  Leicester,  Mass.,  has  received  six  thousand  dol- 
lars under  the  will  of  the  late  Dr.  Pliny  Earle,  for  the 
erection  of  a  building  for  the  public  library  of  the  town. 

Dr.  B.  Matas  has  been  appointed  Professor  of  Surgery 

in  Tulane  University,  New  Orleans. 

A  Forty-five  day  Fast. — For  forty-five  days  Professor 
George  Sloane,  of  Chicago,  has  lived  on  morphine  and 
mineral  water.  No  food  has  passed  his  lips.  He  began 
his  fast  to  relieve  pain  in  his  stomach. 

Li  Hung  Chang,  says  his  biographer,  took  a  deep  inter- 
est in  medical  missionaries,  and  among  his  contemplated 
reforms  was  the  introduction  of  Western  medicine.  "  If 
these  people,1'  he  said  to  me  one  day,  "  ever  come  into 
the  Chinese  heart,  the  physician  will  open  the  door." 

The  Serum  of  Asses. — Under  the  title  of  a  "  New 
Cure  for  Consumption,"  a  lay  contemporary,  says  the 
Medical  Press,  announces  that  Dr.  Viquerat,  of  Geneva, 
after  a  long  study  of  tuberculosis,  has  reached  some 
extraordinary  results  by  a  treatment  which  consists  in  the 
subcutaneous  injection  of  the  serum  of  asses.  Twenty- 
seven  tuberculous  patients  of  the  second  and  third  de- 
gree have  undergone  this  treatment ;  twenty  five  of  these 
cases,  it  is  said,  had  been  given  up  by  their  physicians  as 
lost,  but  were,  it  is  alleged,  entirely  cured,  the  names 
and  addresses  of  these  lucky  twenty- five  being  authenti- 
cated by  an  authoritative  report.  On  the  strength  of 
this,  it  is  further  stated  that  a  philanthropic  Genevan  has 
founded  the  Viquerat  Institute  for  the  treatment  of  per- 
sons whose  case  is  looked  upon  as  hopeless.  We  fear 
that  our  contemporary  is  the  victim  of  a  joke. 

Mushroom  Colleges. — It  is  scarcely  known  on  this  side 
of  the  Atlantic  (says  the  Medical  Press)  how  easy  a  mat- 
ter it  is  to  found  a  mushroom  college  in  the  United  States. 
In  speaking  upon  this  question  our  contemporary  the 
Lancet  Clinic  recently  observed  that,  "  In  Ohio  any  fm 
men  can  organize  and  obtain  a  legal  college  charter,  and 
with  it  in  six  weeks,  or  six  days,  can  grant  a  legal  diploma. 
Hence,  the  only  protection  for  the  people,  and  for  the 
medical  profession,  is  to  be  found  within  the  medical 
profession  itself."  Our  contemporary  adds:  "What  a 
farce !  It  is  difficult  to  understand  how  such  a  deplor- 
able state  of  things  is  allowed  to  persist.  Why  are  not 
new  laws  passed,  and  the  medical  education  of  the 
country  placed  upon  a  proper  footing?  The  public 
would  be  the  first  to  benefit  by  the  change,  and  the 
status  of  the  profession  would  at  once  be  raised."  It  is 
but  fair  to  add  that  the  conditions  in  Ohio  are  except 
tional,  and  that  in  the  great  majority  of  the  States  gradu- 
ates from  such  institutions  are  not  allowed  to  practise. 

The  Medical  Society  of  Virginia  will  hold  its  next 
annual  meeting  in  Richmond,  Tuesday,  Wednesday,  and 
Thursday,  October  23,  24,  and  25,  1894.  The  subject 
for  general  discussion,  open  to  any  physician  registered 
in  attendance,  is  appendicitis. 


October  13,  1894] 


MEDICAL    RECORD. 


467 


The  Hew  York  State  Association  of  Railway  Sur- 
geons will  hold  its  annual  meeting  Thursday,  November 
*5>  i&H*  &t  the  New  York  Academy  of  Medicine.  All 
railway  surgeons  of  the  United  States  are  invited  to 
attend. 

A  State  Medical  and  Surgical  Association  has  been 
organized  in  Jackson,  Miss.  A  membership  of  one 
hundred  and  twenty  names  was  enrolled.  The  officers 
are :  Temporary  President,  Dr.  J.  H.  Lucas,  of  Green-* 
ville,  and  Dr.  H.  H.  Hughes,  Secretary. 

The  Tri-State  Medical  Society  of  Alabama,  Georgia, 
and  Tennessee. — The  sixth  annual  meeting  of  the  above 
Society  was  held  in  Atlanta,  Ga.,  on  October  9th,  10th, 
and  nth. 

An  Excited  Practitioner. — A  Kentucky  doctor  writes 
to  the  Louisville  Medical  Monthly  like  this :  "  The  hun- 
gry and  unprincipled  learned  physician  does  more  harm 
than  an  honest  one  of  less  capacity.  He  tramples  upon 
your  feelings ;  he  lies  to  your  people ;  he  makes  capital 
out  of  your  labor ;  he  boldly  takes  possession  of  a  case 
when  he  is  accidentally  called  upon;  he  introduces  a 
speculum,  and  tells  your  patient  she  has  lacerated  cer- 
vix, from  carelessness  of  her  attendant ;  he  calls,  or 
sends  wife  (who  belongs  to  the  same  euchre  club,  or 
church),  to  see  how  she  is  getting  along.  You  call  him 
in  consultation,  and  he  drops  in  socially  afterward,  just 
because  he  was  passing.  You  can't  lance  a  boil ;  you 
must  send  for  the  surgeon  (who  treats  measles,  whooping- 
cough,  and  obstetrical  cases).  This  surgeon  is  your 
friend  socially,  but  takes  your  cases,  and  when  called  in 
your  place,  tells  the  family  how  he  would  have  treated 
the  case  if  he  had  seen  it  in  time.  A  plain  case  of  belly- 
ache is  now  a  case  of  appendicitis,  and  the  regular  fam- 
ily doctor  is  *  not  in  it.'  All  kinds  of  ovarian  troubles 
meet  with  prompt  removal  at  the  hands  of  some  so-called 
specialist.  A  family  doctor  can't  set  a  common  fract- 
ure, and  if  he  does,  on  his  return  call  he  finds  this  so- 
called  surgeon  has  taken  off  his  dressing,  and  has  dressed 
it  himself,  with  the  excuse  to  his  friend,  the  family 
M.D.,  that  he  had  to,  as  the  family  asked  him.  You  are 
called  to  a  man  hurt  in  a  railroad  accident,  or  at  a  fire, 
and  spend  all  night  ministering  to  his  sufferings ;  next 
morning  you  are  called  to  the  telephone,  and  notified 
that  the  railroad  or  fire  department  doctor  will  take  care 
of  your  patient,  as  he  is  paid  by  the  company,  and  you 
can  take  a  walk.  I  have  met  with  all  the  above  abuses 
time  and  again,  and  I  have  always  kept  my  temper,  re- 
membering a  physician  should  be  a  gentleman.  But  I 
have  changed  my  mind,  and  this  is  about  what  I  intend 
to  do :  take  the  next  unprincipled  doctor  by  the  neck, 
and  make  him  think  that  old  Drs.  Kellar,  Gilpin,  and 
Ross  are  still  alive.   Yours,  etc.,  F.  E.  Corrigan,  M.D." 

Pneumatic  Tires  for  Hospital  Ambulances.— The 
makers  of  hospital  ambulances  have  learned  something 
from  the  bicycle  makers.  They  are  now  using  the  pneu- 
matic tires,  which  save  the  jarring  and  jolting. 

Gift  to  Hospitals. — It  is  announced  from  Vienna  that 
Baron  Albeit  de  Rothschild  has  given  half  a  million 
florins  ($250,000),  to  be  called  the  "Bettina  Fund,"  to 
the  Vienna  hospitals.  Out  of  this  sum  a  pavilion  is  now 
being  built  for  women  suffering  from  cancer,  on  the 
grounds  of  the  Empress  Elizabeth  Hospital,  in  the  west- 
ern suburb  of  Rudolfaheim. 


The  Mississippi  Valley  Medical  Association  meets  at 
Hot  Springs,  Ark.,  on  November  18th. 

The  Southern  Surgical  and  Gynecological  Associa- 
tion meets  in  Charleston,  S.  C,  November  13th. 

Chicago  Medical  Colleges  Unite An  alliance  offen- 
sive and  defensive  will  probably  soon  be  entered  into  by 
the  Northwestern  University  Medical  School,  Rush 
Medical  College,  and  the  College  of  Physicians  and  Sur- 
geons, whereby  there  shall  be  between  these  institutions 
absolute  uniformity  in  respect  to  entrance  regulations, 
and  also  in  respect  to  the  methods  of  recording  condi- 
tions of  admission  of  each  member  of  the  class.  The 
primary  object  of  such  an  arrangement  is  that  each 
party  to  the  agreement  shall  promptly  inform  the  other 
parties  of  any  candidate  for  admission  to  the  class,  so 
that  the  other  parties  shall  be  protected  against  accept- 
ing rejected  candidates.  A  similar  agreement  is  in  a 
fair  way  to  be  consummated  between  the  homoeopathic 
medical  colleges  of  the  city. — Chicago  Medical  Recorder. 

Hospital  for  Life-savers. — The  Marine  Hospital 
Bureau  has  issued  a  circular  carrying  into  effect  the  law 
extending  the  benefits  of  the  marine  hospitals  to  the 
keepers  and  crews  of  life-saving  stations.  A  list  of  nine- 
teen hospitals  where  they  can  be  treated  is  given. 

The  Doctor's  Doorman, — The  French  papers,  says  the 
British  Medical  Journal,  are  commenting  with  a  kind  of 
awe  on  the  fact  that  a  site  in  the  Rue  de  Vaugirard  in 
Paris,  which  was  surveyed  the  other  day  and  valued  at 
600,000  francs  (f  120,000),  turned  out  to  be  property  of 
a  former  hall  porter  of  Ricord's.  That  sum  certainly 
represents  very  pretty  pickings,  but  we  have  little  doubt 
that  the  case  could  easily  be  paralleled  in  this  country. 
The  august  functionary  who  guarded  the  portals  of  a 
certain  court  physician  used,  it  is  said,  to  think,  like  the 
Emperor  Titus,  that  he  had  lost  a  day  when  he  did 
not  pocket  six  or  seven  sovereigns  in  "tips ;  "  another 
estimated  his  revenue  from  what  he  playfully  called  the 
"guinea  bell  "  at  ^600  a  year;  a  third  ran  his  master 
(a  celebrated  specialist  now  deceased)  as  if  he  were  a 
show,  and  had  a  regular  scale  of  prices  for  admission, 
with  reserved  seats — on  the  stairs  or  in  the  hall  opposite 
the  great  man's  door — and  other  special  privileges  for 
such  as  cared  to  pay  for  them.  This  sort  of  thing  is  still, 
we  believe,  a  custom  of  the  effete  East. 

The  Fauna  of  Dead  Bodies. — M.  M6gnin,  in  a  work 
presented  to  the  Paris  Academy  of  Medicine  on  the 
fauna  of  dead  bodies,  indicates  the  importance  of  these 
entomological  studies  wjth  regard  to  medical  jurispru- 
dence. The  insects  appear  in  relays  according  to  the 
period  of  putrefaction.  The  first  which  appears  is  the 
musca  curtonea  and  callophora.  It  is  present  on  dead 
bodies  buried  in  the  most  careful  manner.  The  eighth 
group,  coleoptera,  are  found  in  dead  bodies  which  have 
been  buried  four  years.  The  dust  that  remains  after  the 
decomposition  of  the  body  is  really  the  excreta  of  these 
animals. 

A  French  Physician,  Dr.  Grellety,  advises  doctors  to 
marry  a  pretty  woman  without  vanity,  an  intelligent 
woman  who  does  not  make  too  great  a  display  of  what 
she  knows,  and  above  all  an  amiable  one.  If  this  seems 
too  much,  profound  love  will  make  up  for  many  defi- 
ciencies. 


468 


MEDICAL  RECORD. 


[October  13,  1894 


A  Busy  Doctor. — A  Swiss  doctor  is  said  to  have 
counted  his  steps  by  a  pedometer  last  year.  The  total 
was  9,760,900,  or  an  average  of  26,740  daily.  This 
makes  about  fifteen  miles  a  day. 

Female  Eduoation  at  Johns  Hopkins. — The  remarks 
of  Dr.  Osier  at  the  recent  dinner  of  the  Harvard  Medical 
Alumni  Association  that  33.3  per  cent,  of  the  women 
medical  students  at  the  Johns  Hopkins  Medical  School 
has  been  married  at  the  end  of  the  first  session,  has  been 
gravely  quoted  by  the  medical  press  as  a  failure  in  co- 
education. Dr.  Osier  very  properly  asks  what  will  hap- 
pen at  the  end  of  the  fourth  year  ?  The  remaining  two 
women  in  the  class  stand  a  poor  show  of  graduating. — 
Maryland  Medical  Journal. 

Gift  to  a  Hospital.— The  sons  of  the  late  Fredeiick 
Billings,  of  Woodstock,  have  made  the  generous  gift  of 
l5,ooo  for  the  endowment  of  a  free  bed  in  the  Mary 
Hitchcock  Memorial  Hospital  at  Hanover.  This  is  in 
memory  of  their  honored  father. 

Wanted  Doctors  in  Stato  Hospitals.— The  State  Civil 
Service  Commission  finds  great  difficulty  in  securing 
competitors  for  places  on  the  medical  staff  in  the  various 
State  hospitals.  The  statutes  provide  for  the  appoint- 
ment at  each  hospital  of  a  woman  physician  at  a  salary  of 
$1,200  per  annum,  with  maintenance.  There  are  also 
various  places  on  the  medical  staff  of  the  several  hospitals 
with  salaries  ranging  from  $800  to  J  2,000  per  annum, 
with  board.  Each  hospital  also  employs  an  apothecary. 
Vacancies  occur  in  these  places  from  time  to  time,  and 
but  few  candidates  appear  for  the  examinations.  There 
is  not  an  eligible  list  at  present  from  which  apotheca- 
ries can  be  appointed,  and  the  commission  ordered  an 
open  competitive  examination  of  all  applicants  to  be 
held  at  its  offices  in  the  Capitol,  Wednesday,  Octo- 
ber 3d,  at  10  a.m.  The  salary  paid  in  this  place  is 
from  thirty  dollars  to  fifty  dollars  a  month,  together 
with  board. 

The  Placarding  of  "Animal  Extracts  "  on  the  public 
bulletin  boards  of  the  city  will  awaken  the  keenest  skep- 
ticism as  to  their  real  utility. 

The  Chief  Subjects  for  Discussion  at  the  French 
Medical  Congress  to  be  opened  at  Lyons  on  October 
25th  will  be  the  Etiology  of  Diabetes,  the  Clinical  Value 
of  the  Chemical  Examination  of  the  Gastric  Contents, 
and  Aphasia.  The  President  of  the  Congress  will  be  M. 
Gailleton,  Professor  in  the  Medical  Faculty  of  Lyons 
and  Mayor  of  the  city. 

Professor  Billroth'*  Widow.— The  Emperor  of  Austria 
has  granted  to  the  widow  of  the  late  Professor  Billroth  a 
yearly  pension  of  2,000  florins.  This  is  to  be  interpreted 
as  a  mark  of  special  favor,  because  according  to  the  law 
of  Austria  the  pension  allowed  to  widows  of  professors  is 
only  600  florins.  The  distinguished  surgeon  is  under- 
stood to  have  left  little  or  no  private  fortune. 

The  Quarters  for  the  Board  of  Health.— On  Septem- 
ber 29th  the  City  Health  Department  moved  from  its 
old  quarters  in  the  building  on  Mott  Street,  which  it 
shared  with  the  Police  Department  for  many  years,  to 
the  new  Criminal  Court  Building  on  Centre  Street, 
adjoining  the  Tombs  prison.  In  its  new  location  the 
Board  of  Health  will  have  much  more  ample  accommo- 


dations than  in  its  former  quarters,  and  the  facilities  for 
the  proper  discharge  of  its  functions  will  be  greatly 
increased.  Fourteen  rooms  have  been  assigned  for  its 
use  on  the  ground  floor  of  the  building,  nine  on  the 
second  floor,  and  two  on  one  of  the  other  floors. 

Unveiling  of  the  Statue  of  Dr.  J.  Marion  Sims. — It  is 
proposed  to  unveil  the  bronze  statue  to  Dr.  J.  Marion 
Sims  on  Saturday,  October  20th,  at  3  p.m.,  in  Bryant 
Park,  N.  Y.  Full  details  of  the  ceremonies  will  be 
given  in  our  next  issue. 

Dr.  Augustin  H.  Ooelet,  of  this  city,  has  been  elected 
Associate  Fellow  of  the  Philadelphia  Obstetrical  Soci- 
ety. 

The  Health  of  the  (bar. — Now  it  is  known  that  the 
Czar  is  suffering  from  contracted  kidney.  His  disease 
is  consequently  incurable. 

Unveiling  of  the  Sims  Statue. — On  November  20th, 
at  3  p.m.,  it  is  proposed  to  unveil  the  statue  of  the  late 
Dr.  J.  Marion  Sims,  and  formally  present  it  to  the  city. 
It  will  be  placed  on  the  north  side  of  Bryant  Square, 
where  the  dark  granite  pedestal  has  already  been  com- 
pleted. Addresses  will  be  delivered  by  his  Honor  the 
Mayor  of  New  York,  Dr.  Paul  F.  Mund6,  Dr.  George  F. 
Shrady,  and  others.  The  profession  is  cordially  invited 
to  attend. 


WILLIAM  A.  M.  WAINWRIGHT,  M.D., 

HAKTPOBD,    OONN. 

William  Augustus  Muhlenberg  Wainwright,  ot 
Hartford,  Conn.,  the  well  known  and  highly  esteemed 
physician  and  surgeon,  accidentally  shot  himself  while  ex- 
amining a  revolver  Sunday,  September  23,  1894.  The 
ball  passed  through  the  body,  seriously  wounding  the 
liver,  mesentery,  and  small  intestine.  Conscious  to  the 
last  and  fully  appreciating  the  nature  of  his  injury,  he 
placed  himself  in  the  hands  of  his  associate  surgeons  of 
the  hospital  for  an  operation,  which  from  the  first  was 
hopeless  excepting  to  prolong  his  life.  He  died  about 
4  p.m.  the  following  day,  twenty-seven  hours  after  the 
accident. 

Dr.  Wainwright  was  born  in  New  York  City,  August 
i3>  1844,  the  youngest  child  of  Bishop  Jonathan  Mayhew 
Wainwright.  Graduated  from  Trinity  College,  Hart- 
ford, in  1864,  he  received  his  medical  degree  from  the 
College  of  Physicians  and  Surgeons,  New  York,  in  1867, 
and  after  two  years  service  in  the  New  York  Hospital, 
settled  in  Hartford,  where  he  has  continued  in  prac- 
tice. 

A  member  of  his  city,  county,  and  State  medical  so- 
cieties and  the  American  Medical  Association,  he  was 
always  ready  to  assist  in  advancing  the  interests  of  his 
profession.  He  was  President  of  the  Hartford  County 
Medical  Association  in  its  centennial  year,  and  delivered, 
an  address  upon  its  celebration  of  that  event.  At  the 
time  of  his  death  he  was  Visiting  Surgeon  of  the  Hart- 
ford Hospital,  and  Medical  Visitor  of  the  Retreat  for  the 
Insane. 

A  handsome  man  of  commanding  presence,  of  scrupu- 
lous honesty  and  strict  integrity,  he  was  successful  in 
social  circles,  while  his  keen  perceptions,  good  judg- 
ment, and  skilful  treatment  made  him  a  leader  in  his 
profession. 

His  widow,  two  daughters,  and  two  sons  survive  him. 
The  eldest  son,  now  a  senior  in  Trinity  College,  purposes 
to  follow  his  father  in  the  profession  of  medicine. 


October  13,  1894] 


MEDICAL   RECORD. 


469 


THE  AMERICAN  ELECTRO  THERAPEUTIC  AS- 
SOCIATION. 

Fourth  Annual  Meeting,  held  in  New  York,  September 
2s,  26,  and  27,  1894. 

First  Day,  Tuesday,  September  25TH. 

The  meeting  was  called  to  order  by  the  President,  Dr. 
W.  J.  Herdman,  of  Ann  Arbor,  Mich.,  who  stated  in 
his  address  that  the  function  of  the  Association  was  to 
improve  and  standardize  electrical  apparatus,  to  improve 
electrical  nomenclature,  and  to  assist  in  fixing  a  uniform 
standard  of  electrical  measurements.  By  appointing 
each  year  committees,  whose  duty  it  was  to  report  on 
special  scientific  questions,  it  had  been  possible  to  ac- 
complish a  vast  deal  of  systematic  work,  which  must  in- 
evitably prove  in  time  of  great  aid  and  benefit  to  the 
general  profession. 

Dr.  William  James  Morton,  of  New  York,  Chairman 
of  the  Committee  on  Standard  Coils,  stated  as  his  opin- 
ion that  an  induction  apparatus  suitable  for  the  needs  of 
any  physician  would  comprise,  1,  a  standard  cell;  2,  a 
primary  coil  of  half  an  ohm  resistance,  made  of  No.  22 
wire ;  3,  a  vibrator  of  the  reed  type ;  and  4,  a  second- 
ary coil  of  No.  32  wire,  about  five  hundred  metres  in 
length.  Such  a  coil  would  give  the  two  effects  required 
— muscular  contraction  and  sedation. 

Dr.  A.  H.  Goelet,  of  New  York,  said  that  an  appa- 
ratus which  would  answer  the  purposes  of  the  neurologist 
would  not  be  suitable  for  the  gynecologist  on  account 
of  the  much  lower  resistances  encountered  in  the  latter 
class  of  work.  He  therefore  believed  that  to  be  gener- 
ally useful  a  medical  induction  apparatus  should  have  a 
combination  of  coils  of  wire  of  different  lengths  and 
sizes. 

In  the  discussion  which  followed,  the  opinion  seemed 
to  prevail  that  the  most  suitable  apparatus  of  this  kind 
for  the  physician  would  be  one  having  two  different 
coils. 

The  Committee  on  Standard  Meters  presented  its  re- 
port through  Dr.  Margaret  A.  Cleaves,  of  New  York. 
After  describing  minutely  a  careful  series  of  tests  which 
had  been  made  with  a  dozen  or  more  milliamp&emeters 
made  by  well  known  manufacturers,  the  committee  rec- 
ommended that  for  ordinary  use  the  meter  should  regis- 
ter up  to  one  hundred  milliamp£res,  and  should  be  of 
the  horizontal  type.  A  double  scale  was  desirable  on 
the  more  costly  instruments,  and  all  meters  should  be 
re-calibrated  once  a  year.  To  obtain  greater  clearness 
of  the  scale  it  was  recommended  that  the  meter  should 
read  only  in  one  direction.  The  question  of  the  value 
to  the  physician  of  knowing  the  energy  used,  in  addition 
to  the  rate  of  flow,  had  been  considered  by  the  com- 
mittee, and  the  opinion  was  expressed  that,  whereas  the 
wattmeter  was  a  very  delicate  and  expensive  instrument, 
and  the  voltmeter  and  ammeter  had  their  individual 
values,  it  was  better  to  use  them  in  connection,  and  es- 
tablish by  an  easy  mathematical  calculation  the  number 
of  watts  used,  or  fraction  of  an  electrical  horse- power  in 
a  given  treatment.  This  point  had  been  established  by 
a  series  of  observations  made  by  the  chairman  of  the 
committee. 

Physios  and  Current  Distribution  of  the  Constant 
Current.— Mr.  W.  J.  Jenks,  M.A.I.E  E.,  of  New  York 
City,  in  this  paper  gave  a  historical  sketch  of  the  meth- 
ods of  distributing  the  current  employed  in  the  various 
systems  of  electric  lighting,  and  also  the  probable  dis- 
tribution of  the  current  when  criminals  were  executed 
by  electricity.  Electricity,  he  said,  was  not  a  source  of 
energy,  but  only  an  intermediary  agent,  and  the  chief 
point  to  be  considered  in  its  distribution  was  the  one 
element  of  pressure.  In  conclusion,  he  offered  the  sug- 
gestion that  the  varying  resistances  of  the  human  body 
might  eventually  be  nude  a  means  of  diagnosis. 


Dr.  J.  H.  Kellogg,  of  Battle  Creek,  Mich.,  said  that 
this  thought  about  turning  the  varying  resistances  of  the 
body  to  account  in  diagnosis  had  also  occurred  to  him  a 
few  years  ago,  but  on  attempting  to  put  it  in  practice  he 
had  found  such  great  variations  in  the  thickness  of  the 
skin  in  different  individuals,  and  that  such  a  large  pro- 
portion of  the  entire  body  resistance  was  due  to  the  skin 
itself,  that  he  had  abandoned  the  method  as  impracti- 
cable. 

The  Physiological  Effects  of  the  Constant  Current. — 
Professor  A.  E.  Dolbear,  of  Tuft's  College,  Boston, 
then  read  a  paper  with  this  title.  He  said  that  in  a  mag- 
netic field  all  the  molecules  were  acted  upon  by  a  press- 
ure tending  to  twist  them  into  new  positions.  Dr. 
Frederick  Peterson,  of  New  York  City,  and  Professor  A. 
E.  Kennelly,  of  Philadelphia,  had  failed  in  their  interest- 
ing experiments  with  magnets  to  observe  any  appreciable 
effect  on  the  human  body,  even  though  the  brain  were 
placed  in  the  field  of  a  very  powerful  magnet.  But  these 
experiments  did  not  necessarily  prove  that  such  magnets 
exerted  no  influence  on  the  human  body ;  in  fact,  as  the 
brain  itself  was  not  a  sensitive  organ,  why  should  we  ex- 
pect that  it  would  be  affected  by  a  powerful  magnetic 
field  ?  The  reason  these  experimenters  failed  to  detect 
any  magnetic  effect  on  the  body  might  have  been  that 
the  stress  was  exerted  upon  the  molecules  only.  A  con- 
stant pressure  producing  no  muscular  movement  could 
hardly  be  expected  to  produce  a  sensation.  The  author's 
opinion  was  that  the  effect  of  magnetism  was  to  produce 
a  diminution  of  sensitivity,  and  that  theoretically  the  hu- 
man body  might  be  considered  to  be  a  mass  of  atomic 
magnets.  He  would  entirely  disassociate  magnetism  and 
chemical  affinity. 

The  Therapeutic  Uses  of  the  Constant  Current  in 
Gynecology. — Dr.  G.  Betton  Massey,  of  Philadelphia, 
then  read  a  paper  on  this  subject.  He  believed  that  the 
chief  and  initial  lesion  in  the  majority  of  uterine  and 
peri-uterine  diseases  was  a  catarrhal  condition,  and  he 
found  the  constant  current  the  best  of  all  remedial 
agents  for  the  treatment  of  catarrhal  hyperplasias. 

Ultimate  Results  of  Conservative  Electrical  Treat- 
ment in  Gynecology — Consecutive  Pregnancies. — Dr. 
George  Apostoli,  of  Paris,  sent  a  communication  with 
the  above  title.  The  writer  stated  that  the  constant  cur- 
rent was  often  an  effective  substitute  for  the  curette,  not 
only  on  account  of  the  ease  with  which  the  degree  and 
extent  of  the  action  could  be  controlled,  but  because  of 
its  microbicidal  power.  The  electrical  treatment  of 
uterine  fibroids  was  purely  symptomatic,  yet  with  it 
hemorrhage  could  be  controlled  in  ninety  per  cent.,  the 
pain  relieved  in  eighty  per  cent.,  and  the  fibroids  reduced 
in  size  in  seventy  per  cent,  of  the  cases.  Although  his 
patients  came  to  him  at  an  average  age  of  from  thirty- 
five  to  forty-five  years,  and  often  with  fibroids,  a  very 
considerable  proportion  had  become  pregnant  subsequent 
to  the  electrical  treatment.  A  detailed  account  of  thirty- 
two  such  cases  was  appended  to  the  paper. 

The  Electrotherapeutics  of  Diseases  of  the  Eye. — Dr. 
L.  A.  W.  Alleman,  of  Brooklyn,  N.  Y.,  read  a  paper 
in  which  he  detailed  the  especially  favorable  results  he 
had  obtained  from  the  use  of  the  constant  current,  1,  in 
the  removal  of  eyelashes  which  irritated  the  eyeball ;  2,  in 
granular  conjunctivitis ;  3,  in  stricture  of  the  lachrymal 
duct ;  4,  in  keratitis  and  opacities  of  the  cornea ;  and  5, 
in  retinitis  diabetica  and  retinitis  pigmentosa. 

Dr.  M.  A.  Cleaves  added  to  this  list  the  report  of  a 
case  of  optic  atrophy  treated  by  the  constant  current, 
with  improvement  in  vision  but  no  changes  in  the  fun- 
dus. 


Second  Day,  Wednesday,  September  26th. 

The  Action  of  Electricity  on  the  Sympathetic. — Dr. 
A.  D.  Rockwell,  of  New  York,  continued  the  consid- 
eration of  the  effects  obtained  from  the  constant  current 
by  presenting  a  paper  on  "The  Action  of  Electricity  on 
the  Sympathetic."    The  paper  dwelt  more  particularly 


47P 


MEDICAL    RECORD. 


[October  13,  1894 


on  the  results  of  his  experience  with  electricity  in  the 
treatment  of  exophthalmic  goitre  and  hyperidrosis. 

In  the  course  of  the  discussion  Dr.  A.  Lapthorn 
Smith,  of  Montreal,  and  Dr.  F.  B.  Bishop,  of  Washing- 
ton, D.  C,  cited  instances  in  which  the  patients  show 
a  very  strong  tendency  to  syncope  during  the  treatment. 
Most  of  the  speakers  were  agreed  as  to  the  decided  effi- 
cacy of  the  constant  current  in  the  treatment  of  goitre, 
but  Dr.  J.  J.  Putnam,  of  Boston,  did  not  think  it  so 
generally  useful  in  these  cases,  and  expressed  the  belief 
that  statistics  seemed  to  show  that  better  results  were 
obtained,  at  least  so  far  as  giving  prolonged  relief  from 
the  symptoms,  by  surgical  operation. 

Notes  on  Goitre,  and  Improvements  in  the  Appara- 
tus for  its  Treatment  was  read  by  Dr.  Charles  H. 
Dickson,  of  Toronto.  This  communication  was  supple- 
mentary to  two  or  three  others  on  the  same  subject  which 
had  been  presented  by  the  writer  at  previous  meetings. 
In  the  early  stages  of  simple  hypertrophy  a  current  of 
100  to  150  milliamp£res  should  be  given  for  ten  minutes 
at  a  time,  a  clay  electrode  being  applied  over  the  goitre, 
and  a  large  wire  gauze  electrode  between  the  shoulders. 
When  puncture  is  resorted  to,  one  should  not  be  content 
with  a  current  of  less  than  50  milliamp£res  applied  for 
eight  or  ten  minutes,  and  care  should  be  taken  to  ob- 
serve antiseptic  precautions,  and  to  see  that  the  portion  of 
the  needle  outside  of  the  capsule  is  thoroughly  insulated. 
In  his  experience,  the  pure  cystic  goitres  had  proved  to 
be  the  most  amenable  to  treatment.  His  method  was  to 
aspirate  the  contents  of  the  cyst,  inject  a  hot  solution  of 
chloride  of  sodium  (one  drachm  to  the  ounce),  apply 
through  the  trocar  a  current  of  from  50  to  100  milliam- 
p£res  for  ten  minutes,  and  then  withdraw  the  salt  solu- 
tion. It  should  be  remembered  that  puncture  alone 
involves  some  risk,  and  that  change  of  residence  and 
attention  to  hygiene  are  important  adjuncts  to  all  forms 
of  treatment. 

Dr.  Robert  Newman,  of  New  York,  referred  to  a 
method  of  treatment  which  was  employed  by  Dr.  Wat- 
kins,  of  New  York  City,  with  good  results.  A  needle 
was  connected  with  each  pole  of  the  battery,  and  cur- 
rents of  only  from  one-fourth  to  one-half  a  milliampdre 
were  found  to  answer. 

Dr.  Rockwell  objected  to  the  strong  currents  advised 
by  Dr.  Dickson. 

Dr.  Morton  said  the  object  of  using  these  strong  cur- 
rents was  to  secure  adhesion  of  the  cyst  walls,  but  the 
same  object  could  be  attained  with  a  current  of  only  5 
or  10  milliamplres  by  calling  to  our  aid  metallic  elec- 
trolysis. 

metallic  Electrolysis. — This  was  the  subject  of  a  brief 
communication  from  M.  Gautier,  of  Paris,  and  also  of  a 
paper  by  Dr.  William  James  Morton,  of  New  York. 
The  latter  detailed  some  experiments  regarding  the  dif- 
fusion into  the  tissues  of  the  metal  dissolved  from  the 
electrode.  He  had  found  that  the  apple-green  color  of 
the  tissues  after  cupric  electrolysis  was  due  to  an  inter- 
stitial deposit  of  an  amorphous  insoluble  salt  of  copper, 
and  that  there  was  also  a  soluble  salt  of  copper  deposited 
in  the  tissues.  His  experiments  had  also  shown  that  sol- 
uble electrodes  might  be  used  with  the  negative  pole,  one 
of  the  best  metals  for  such  a  purpose  being  aluminum. 
Among  the  clinical  adaptations  of  metallic  electrolysis 
might  be  mentioned  its  prompt  and  curative  action  in 
trachoma. 

Dr.  Goelet  also  made  some  remarks  on  the  clinical 
uses  of  metallic  electrolysis,  particularly  as  to  the  great 
value  of  zinc  electrolysis  in  uterine  disease.  The  good 
effect  of  the  treatment  as  regards  arrest  of  hemorrhage 
may  not  be  apparent  for  some  time. 

Dr.  Holford  Walker,  of  Toronto,  emphasized  its 
delayed  action  in  arresting  hemorrhage  by  citing  a  well- 
chosen  illustrative  case. 

Dr.  O.  S.  Phelps,  of  New  York,  reported  a  case  of 
long-standing  and  obstinate  mucous  cyst  of  the  tongue 
which  he  had  quickly  and  permanently  cured  by  cupric 
electrolysis.    He  also  exhibited  some  elliptoid  electrodes 


which  he  had  had  made  of  hard  rubber  covered  with  cop- 
per, thus  diminishing  their  weight,  and  rendering  them 
more  susceptible  of  delicate  manipulation. 

The  President  said  that  his  experience  with  metallic 
electrolysis  had  been  in  the  treatment  of  inflammations 
of  the  mucous  membranes,  and  he  thought  that  its  power 
of  reaching  into  the  innermost  recesses  of  the  tissues 
made  it  particularly  valuable  in  the  treatment  of  gonor- 
rhoea. 

Dr.  William  James  Morton,  Chairman  of  the  Com- 
mittee on  Standard  Electro-static  or  Influence  Machines, 
reported  that  the  committee  recommended  that  the 
smallest  machines  of  this  class  intended  for  medical  work 
should  have  at  least  six  revolving  disks  twenty  eight 
inches  in  diameter,  instead  of  four  disks,  as  recommended 
last  year.  It  was  considered  necessary  that  the  machine 
should  have  an  enclosing  case,  and  highly  desirable  that 
there  should  be  a  small  separate  exciting  machine  within 
the  case,  and  also  an  arrangement  for  producing  the 
static  induced  current. 

Dr.  Lucy  Hall-Brown,  of  Brooklyn,  N.  Y.,  then  ex- 
hibited a  stand  and  universal  electrode  which  she  had 
devised,  and  which  greatly  facilitated  the  giving  of  static 
electricity. 

Dr.  M.  A.  Cleaves  exhibited  a  form  of  water  rheostat 
which  she  had  had  constructed  for  the  purpose  of  con- 
trolling the  static  induced  current  at  a  distance  from  the 
machine. 

A  Report  to  Dato  of  the  Treatment  of  Urethral 
Stricture  by  the  Constant  Current  was  read  by  Dr. 
Robert  Newman.  The  report  stated  that  his  further  ex- 
perience had  only  served  to  confirm  his  former  state- 
ments and  observations.  In  some  instances  the  patients 
had  been  kept  under  observation  for  eleven  years.  In 
proof  of  his  claim  he  submitted  statistics  and  documen- 
tary evidence  from  practitioners  in  various  parts  of  the 
country. 

The  paper  was  discussed  by  Dr.  Beaver,  of  Reading ; 
Dr.  Frank  Ross,  of  Elmira ;  Dr.  F.  B.  Bishop,  of 
Washington,  D.  G;  and  Dr.  Wallace,  of  Boston,  all 
of  whom  spoke  highly  of  this  treatment  from  their  per- 
sonal experience.  Several  of  the  speakers  contended 
that  equally  good,  if  not  better,  results  were  obtained 
from  the  use  of  the  ordinary  urethral  sound  as  from  the 
bulbous-tipped  instrument  recommended  and  used  by 
Dr.  Newman.  The  latter,  however,  stoutly  contested 
this  point,  asserting  that  his  instrument  allowed  of  greater 
delicacy  of  manipulation,  and  a  more  perfect  localiza- 
tion of  the  current  at  the  seat  of  stricture. 

The  Behavior  of  Oaneer  under  Mild  Galvanic  Cur- 
rents.— Dr.  R.  J.  Nunn,  of  Savannah,  reported  the  case 
of  a  lady,  aged  sixty,  in  whom  he  had  succeeded  in 
greatly  reducing  the  size  of  the  carcinoma  of  one  breast 
by  mild  percutaneous  applications  of  the  current.  She 
then  drifted  away  into  the  hands  of  some  faith  curers. 
At  the  time  she  left  him  the  tumor  measured  two  by  two 
and  a  half  inches,  but  on  her  return  to  him  five  months 
later  it  measured  fully  thirteen  inches  in  circumference, 
and  there  were  secondary  deposits  in  the  other  breast, 
and  in  the  pelvic  and  abdominal  viscera.  The  treat- 
ment was  resumed,  and  with  benefit,  but  she  eventually 
died  of  the  disease.  His  special  object  in  reporting  the 
case  was  to  show  the  effect  of  such  mild  currents  in 
a  case  in  which  the  diagnosis  of  cancer  was  beyond  a 
doubt. 

The  President  also  related  his  experience  in  the  treat- 
ment of  tumors  by  electricity.  It  tended  to  show  that 
some  tumors  of  the  breast,  either  benign  or  of  doubtful 
malignancy,  might  be  rapidly  dissipated,  but  that  when 
the  diagnosis  of  malignancy  was  beyond  dispute  there 
was  nothing  in  such  treatment  which  could  be  considered 
at  all  curative. 

Hydro  electric  Methods,  Physics  and  Appliances  — 
Mr.  H.  Newman  Lawrence,  M.I.E.E.,  of  London, 
read  the  paper.  After  speaking  of  the  importance  of 
using  well  made  and  carefully  installed  apparatus,  he 
stated  that  nothing  surpassed  the   electric  douche  for 


October  13,  1894] 


MEDICAL  RECORD. 


47i 


giving  the  maximum  of  concentration  and  localization 
of  the  current  with  the  minimum  of  pain,  and  expressed 
the  belief  that  it  was  particularly  suitable  for  the  electri- 
zation of  the  internal  cavities  of  the  body.  The  resist- 
ances to  the  current  increased  greatly  as  the  temperature 
of  the  water  decreased.  In  the  dipolar  bath  only  a 
small  proportion  of  the  current  passes  through  the  pa- 
tient. 

The  Hydroelectric  Therapeutics  of  the  Constant 
Current. — A  communication  was  then  read  from  Dr. 
W.  S.  Hedley,  of  Brighton,  England,  on  this  subject. 
He  said  that  the  temperature  of  the  bath  should  be  be- 
tween 900  and  1040  F.,  and  a  faradic  current  should  be 
allowed  to  flow  for  a  few  minutes  before  the  patient 
leaves  the  bath.  He  had  obtained  his  best  results  with 
this  treatment  in  rheumatoid  arthritis. 

Special  Hydro  -  Electric  Appliances.  —  Dr.  M.  A. 
Cleaves  followed  with  some  remarks  on  this  subject. 
She  described  Boudet's  excellent  method  of  treating  oc- 
clusion of  the  bowel,  and  exhibited  electrodes  for  mak- 
ing such  applications  to  the  bladder,  rectum,  pelvic  tis- 
sues, ear,  and  nose.  This  was  the  most  important 
method  of  employing  cataphoresis,  and  perhaps  in  no 
disease  was  its  good  effects  so  apparent  as  in  the  treat- 
ment of  gonorrhoea  by  hydro  -  electric  applications. 
With  her  new  water  electrode,  a  description  of  which 
appeared  very  recently  in  the  Medical  Record,  a 
douche  could  be  given,  and  pelvic  exudates  thus  brought 
more  effectually  under  the  influence  of  the  current  than 
by  the  more  usual  intra-uterine  galvanic  treatment.  In 
conclusion,  the  author  detailed  some  observations  she 
had  made,  which  gave  not  only  the  number  of  watts  or 
electrical  horse-power  used,  but  also  the  number  of  joules. 


Third  Day,  Thursday,  September  27TH. 

The  Effects  of  High  Frequenoy  Discharges.— Pro- 
fessor Elihu  Thomson,  M.A.I.E.E.,  of  Lynn,  Mass., 
sent  a  communication  on  this  subject,  in  which  he  stated 
that  if  a  person  were  subjected  to  a  current  of  over  ten 
thousand  alternations  per  second,  and  a  voltage  of  one 
hundred  or  two  hundred  thousand,  comparatively  little 
sensation  would  be  experienced,  although  the  heating 
effect  might  be  sufficient  to  bring  a  no-volt  incandes- 
cent lamp  to  full  brilliancy.  Its  comparative  harmless- 
ness  he  had  demonstrated  to  b$  due  not  to  its  physical 
properties  but  to  physiological  peculiarities  of  the  nerves 
of  the  human  body. 

Some  Experiments  on  Death  by  the  Alternating 
Current — Professor  Edwin  Houston  read  a  paper, 
prepared  by  Professor  A.  E.  Kennelly  and  himself, 
on  this  subject.  The  object  of  the  experiments  was  to 
refute  the  startling  assertion  made  by  M.  D'Arsonval 
that  the  criminals  condemned  to  death  in  the  electric 
chair  were  not  really  killed  by  the  electricity,  but  sub 
sequently  by  the  post-mortem  examination.  Their  ex- 
periments seemed  to  show  that  at  least  in  the  case  of 
dogs,  where  electrocution  was  properly  carried  out,  there 
was  not  even  a  remote  possibility  of  subsequent  resusci- 
tation, and  that  death  was  instantaneous  and  painless. 

The  Treatment  of  Neuritis  by  the  Galvanic  Current. 
— Dr.  Landon  Carter  Gray,  of  New  York,  read  a 
paper  with  this  title.  He  advised  waiting  three  or  four 
weeks  if  a  motor  nerve  were  involved,  or  if  a  sensory  or 
a  mixed  nerve  were  affected,  until  the  pain  had  entirely 
subsided,  and  then  experimentally  and  very  carefully 
apply  a  galvanic  current  of  from  one  quarter  to  one 
milliampere.  It  was  important  to  use  a  broad  electrode 
above  and  beneath  the  affected  nerve,  and  to  use  a  reli- 
able rheostat  and  milliamperemeter.  The  discussion 
seemed  to  show  a  general  unanimity  of  opinion  regard- 
ing the  recommendations  made  in  the  paper. 

Sinusoidal  Current. — Dr.  J.  H.  Kellogg,  in  treating 
of  the  "  Physiological  and  Therapeutic  Effects  of  the 
Sinusoidal  Current,"  stated  that  with  fourteen  thousand 
to  sixteen  thousand  alternations  per  minute  he  had  ob- 
served a  decided  diminution  in  the  sensibility  of  the 


parts  to  which  the  current  was  applied,  so  much  so  that 
in  ten  minutes  the  strength  of  the  current  could  be 
doubled  without  producing  increased  sensation.  He 
considered  the  faradic  current  in  every  way  inferior  to 
the  sinusoidal  current. 

Dr.  Morton  remarked  that  in  actual  practice  he  had 
found  this  current  particularly  useful  for  treating  chil- 
dren, as  it  did  not  hurt  or  frighten  them,  which  could 
not  be  said  of  any  faradic  current,  however  skilfully  ap- 
plied. 

Dr.  Walker  was  also  loud  in  praise  of  the  sinusoidal 
current. 

Dr.  Goelet  thought  it  was  not  as  distinctly  tonic  as 
the  faradic,  or  so  generally  useful. 

Dr.  Hall  Brown  described  a  method  which  she  had 
devised  for  controlling  and  regulating  the  sinusoidal 
current  as  obtained  from  certain  electric  lighting  cir- 
cuits. Almost  any  induction  coil  would  make  a  suitable 
transformer  for  this  purpose,  but  such  an  apparatus  was 
preferably  constructed  of  one  layer  of  No.  20  wire  for 
the  inside  coil  and  ten  layers  of  the  same  wire  for  the 
outside  coil. 

The  following  papers  were  also  read,  but  they  were  of 
such  a  nature  as  not  to  admit  of  being  presented  in  ab- 
stract: "Some  Landmarks  in  Electro- therapeutics," 
by  Dr.  O.  S.  Phelps,  of  New  York ;  "  Some  Therapeu- 
tics of  the  Incandescent  Electric  Light,"  by  Dr.  J.  H. 
Kellogg,  of  Battle  Creek;  "On  Constant  Current  Gen- 
erators and  Controllers/ '  by  Dr.  W.  J.  Herdman,  of  Ann 
Arbor;  "General  Faradization,* '  by  Dr.  A.  D.  Rock- 
well, of  New  York ;  "Electric  Light  as  a  Therapeutic 
and  Diagnostic  Agent,"  by  Dr.  Margaret  A.  Cleaves,  of 
New  York;  "Physics  of  the  Sinusoidal  Current,"  by 
Professor  A.  E.  Kennelly,  of  Philadelphia;  "  Physics  of 
the  Static  and  Static  Induced  Current,"  by  Professor 
Edwin  Houston,  of  Philadelphia;  "The  Transforma- 
tion, Measurement,  and  Therapeutic  Applications  of 
Alternating  Currents,"  by  MM.  Gautier  and  Larat,  of 
Paris ;  "The  Physiological  Effects  and  Therapeutic  Uses 
of  the  Static  Induced  Current,"  by  Dr.  W.  J.  Morton, 
of  New  York ;  "  The  Electric  Reaction  of  Muscles  and 
Nerves  after  Great  Exercise  in  Sport,"  by  Professor  J. 
Benzonie,  of  Bordeaux;  and  "Secondary  Peripheral 
Neuritis  in  a  Stilt- walker,"  by  Professor  J.  Benzonie 
and  his  assistant,  H.  Bordier,  of  Bordeaux  both  of  the 
Faculty  oi  Medicine  of  Bordeaux. 

Dr.  A.  Lapthorn  Smith,  of  Montreal,  was  elected 
President,  and  Dr.  Emil  Heuel,  of  New  York  City,  Sec- 
retary for  the  ensuing  year. 


Ingenious  Plea  of  a  Quack.— A  man  was  recently 
tried  in  France  for  the  illegal  practice  of  medicine,  the 
charge  being  that  he  sold  Matlei's  magnetized  water. 
He  entered  the  plea  that  he  employed  a  remedy  which 
physicians  had  declared  to  be  nothing  but  water  and  en- 
tirely innocent  of  therapeutic  effect,  and  that  he  could 
not  therefore  be  accused  of  practising  medicine  in  the 
ordinary  acceptance  of  the  term.  The  learned  Tribunal 
admitted  the  force  of  the  prisoner's  plea,  and  set  him  at 
liberty. 

The  Dumber  of  Marriages  in  England  is  on  the  in- 
crease, the  first  quarter  of  1894  showing  the  highest  rate 
of  any  like  period,  with  but  one  exception,  since  1883. 
In  the  first  three  months  of  this  year  there  were  93,366 
weddings,  corresponding  to  an  annual  rate  of  12.9  per 
1,000  of  the  estimated  population.  This  is  not  less  than 
18.3  per  cent  above  that  in  the  first  quarter  of  1893, 
which  was  10.9,  and  the  lowest  on  record.  It  exceeds 
the  mean  rate  in  the  corresponding  quarters  of  the  ten 
years  1884-93  by  9.3  per  cent,  and  is  the  highest  in  the 
first  quarter  of  any  year  since  1883,  except  that  of  1891, 
when  it  was  13.7.  The  Registrar- General  points  out 
that  this  is  the  more  remarkable,  inasmuch  as  in  the  last 
quarter  of  1893  the  marriage  rate  had  been  6.9  per  cent, 
below  the  average  rate  in  the  December  quarter  of  the 
previous  ten  years. 


472 


MEDICAL   RECORD. 


[October  13,  1894 


AMERICAN    PUBLIC    HEALTH    ASSOCIATION. 

Proceedings  of  the  Twenty  second  Annual  Meetings  he  la 
in  Montreal,  September  25,  26,  27,  and  28, 1894. 

First  Day,  Tuesday,  September  25TH — Morning  Ses- 
sion. 

The   President,    Dr.    E.   P.    Lachapelle,   of  Mon- 
treal, in  the  Chair. 

The  Association  met  in  the  Hall  of  the  Y.  M.  C.  A., 
and  was  called  to  order  at  10  a.m.  by  the  President. 

Dr.  Robert  Craik,  of  Montreal,  reported  on  behalf 
of  the  Local  Committee  of  Arrangements  a  very  attrac- 
tive programme.  He  also  announced  the  social  features 
of  the  meeting.  The  Committee  had  arranged  for  trips 
over  the  Lachine  Rapids  and  down  the  St.  Lawrence  to 
Grosse  Isle. 

The  reading  of  papers  was  next  proceeded  with. 

Hygienic  Notes  made  on  a  Journey  through  Italy  in 
1894. — Dr.  H.  F.  Nuttall,  of  Baltimore,  contributed  a 
paper  on  this  subject,  which  was  read  by  Dr.  A.  L. 
Gihon,  in  the  absence  of  the  author.  This  paper  de- 
scribed the  sanitary  conditions,  particularly  in  reference 
to  water-supply  and  sewage,  of  Rome,  Naples,  Venice, 
and  other  Italian  cities.  In  Naples  poverty  and  igno- 
rance provided  an  easy  prey  to  every  epidemic  until 
1884.  But  after  the  cholera  epidemic  of  1884  the 
Government  resolved  to  spend  one  million  francs  for 
sanitation.  New  sources  of  water-supply  were  secured, 
new  sewers  built,  and  whole  blocks  of  tenements  were 
torn  down  and  replaced  by  modern  houses.  The  result 
has  been  to  impart  habits  of  cleanliness  to  the  people 
and  to  greatly  reduce  the  death  rate. 

The  Cart  before  the  Horse,  by  Dr.  Benjamin  Lee, 
of  Philadelphia.  The  object  of  the  paper  may  be  briefly 
embodied  in  the  two  following  propositions  :  1.  Copious 
water  supplies,  with  the  aid  of  what  is  known  as  modern 
plumbing,  constitute  a  means  of  distributing  fecal  pollu- 
tion over  immense  areas  through  the  soil,  through  sub- 
terranean water  courses,  and  in  surface  streams,  and 
cannot  therefore  be  regarded  with  unmixed  approbation 
by  the  sanitarian.  2.  The  question  of  drainage  and 
sewerage,  whether  for  individual  residences  or  for  com- 
munities, should  always  precede  that  of  water  supply ; 
and  no  water-closet  should  ever  be  allowed  to  be  con- 
structed until  provision  has  been  made  for  the  disposition 
of  its  effluent  in  such  a  manner  that  it  shall  not  constitute 
a  nuisance  prejudicial  to  the  public  health. 

Observations  upon  Sedimentation  in  Water. — Dr. 
Wyatt  Johnston,  of  Montreal,  read  a  paper  with  this 
title.  The  amount  of  settling  which  takes  place  in  what 
is  called  the  settling  basin  of  the  Montreal  Water- works 
is  too  small  to  be  seriously  considered.  The  capacity 
of  the  basin  being  only  twenty- three  million  gallons  and 
the  daily  consumption  about  eighteen  millions,  the  water 
really  only  passes  in  and  out  of  the  basin.  In  the  reser- 
voir the  change  in  the  water  is  also  very  rapid,  although 
not  to  the  same  degree,  for  similar  causes.  However, 
analysis  proves  that  bacteria  are  far  less  numerous  in  the 
reservoir  water  than  in  the  settling  basin.  The  melting 
of  snow  in  the  spring  has  a  tendency  to  increase  the 
number  of  bacteria  in  the  reservoir  water.  As  to  the 
value  of  sedimentation  from  a  hygienic  point  of  view,  it 
is  much  below  that  of  a  sand-filter. 

The  Long  Island  Water-basin,  Brooklyn's  Reservoir, 
by  Dr.  A.  N.  Bell,  of  Brooklyn.  After  a  lucid  de- 
scription of  the  basin,  the  author  said  that  while  the 
waste  of  streams  is  enormous,  it  is  nevertheless  easy  to 
appreciate,  from  a  knowledge  of  the  conditions  of  the 
soil  and  the  wells  sunk  in  it,  the  inexhaustible  adequacy 
of  the  Long  Island  water-basin  to  supply  water  sufficient 
to  meet  the  demands  of  Brooklyn  for  all  time. 

The  Water  of  our  Farm  Homesteads.— Dr.  Frank 
T.  Shutt,  of  Ottawa,  Canada,  contributed  a  paper  on 
this  subject.  During  the  past  six  years  the  chemical  de- 
partment of  the  Dominion  experimental  farms  has  exam- 
ined some  hundreds  of  samples  of  water  from  wells  on 


Canadian  forms,  and  the  fact  has  been  impressed  upon 
the  writer  that  the  evil  of  polluted  water  is  a  lamentably 
common  one  throughout  the  country  districts,  both  in 
the  villages  and  on  the  farms.  The  only  method  the 
speaker  knew  for  lessening  this  evil  was  by  instruction 
and  advice,  by  first  emphasizing  the  great  danger  that 
lies  in  using  water  polluted  with  excreta  or  drainage  from 
filthy  sources,  and,  second,  to  teach  the  people  that  pure 
water  is  as  much  a  necessity  for  the  farm  animals  as  for 
man.  Third,  farmers  must  be  cautioned  against  sinking 
wells  in  barnyards,  stables,  or  near  the  pig-pen  or  privy. 

Sand  Filtration  of  Water,  with  Especial  Reference 
to  Recent  Results  Obtained  at  Lawrence. — Mr.  George 
W.  Fuller,  of  Lawrence,  Mass.,  followed  with  a  paper 
with  this  title.  While  the  removal  of  pathogenic  bacteria 
by  chemicals,  including  coagulants  and  by  heat,  will 
forever  be  directly  dependent  upon  human  attention,  he 
ventured  to  predict  that  the  day  will  come  when  a  knowl- 
edge of  filtration  among  sanitary  scientists  will  be  such 
that  filters  may  be  constructed  and  operated  by  which 
water  free  from  objectionable  bacteria  will  be  supplied  to 
hundreds  and  thousands  of  citizens  and  require  the  at- 
tention of  only  a  mere  handful  of  men.  During  the  fat 
years  preceding  the  use  of  the  filter  at  Lawrence,  the 
average  annual  death  rate  from  typhoid  fever  in  Lawrence 
was  1.27  per  1,000  inhabitants.  The  population  of  Law- 
rence is  50,000,  and  this  average  is  equivalent  to  63 
actual  deaths  per  year.  During  the  past  year  there  have 
been  26  deaths  from  typhoid  fever,  a  reduction  of  sixty 
per  cent.  Furthermore,  it  has  been  learned  that  of  the 
26  who  died  12  were  operatives  in  the  mills,  each  of 
whom  was  known  to  have  drunk  unfiltered  and  polluted 
canal  water,  which  is  used  in  the  factories  at  the  sinks 
for  washing.  In  conclusion,  it  has  been  found  practi- 
cable to  protect  the  consumers  of  infected  water-supply  by 
means  of  sand  filtration. 

Borne  Deductions  from  Bacteriological  Work  on 
the  Water  of  Lake  Ontario. — This  paper  was  by 
Mr.  E.  B.  Shuttleworth,  of  Toronto.  It  dealt  with 
the  normal  bacteriological  character  of  Lake  water  and 
the  depth  of  water  as  affecting  the  number  of  bacteria, 
and  the  author  is  inclined  to  think  that  the  number  of 
bacteria  is  directly  influenced  by  season.  He  is  con- 
vinced that  in  their  nature  certain  micro-organisms  mul- 
tiply most  rapidly  at  certain  seasons  of  the  year.  He 
threw  out  the  suggestion  that  this  may  have  an  important 
bearing  in  explaining  the  prevalence  of  typhoid  fever  at 
certain  times  during  the  year.  This  seasonal  peculiarity 
is  very  well  marked  in  Toronto,  when  every  September 
shows  a  sudden  increase  in  the  typhoid  rate,  with  a  cor- 
responding decline  after  October.  Since  May  last  he 
had  been  paying  attention  to  the  temperature  of  tap- 
water,  which  seems  to  be  related  to  the  development  of 
this  disease.  He  hoped  in  the  future  to  throw  some 
light  on  this  subject,  as  the  experiments  of  numerous  in- 
vestigators had  shown  that  it  is  possible  for  micro  organ- 
isms to  exist  and  multiply  enormously  in  distilled  water, 
or,  at  all  events,  containing  only  the  minutest  traces  of 
organic  matter. 

Afternoon  Session. 

The   Pollution   of  Water-supplies. — Dr.   Charles 

Smart,  of  Washington,  D.C.,  Chairman,  read  the  report 
of  the  Committee  on  the  Pollution  of  Water-supplies. 
The  report  reviews  at  length  the  influence  which  a  pol- 
luted water-supply  may  have  had  in  the  recent  cholera 
epidemic  in  Europe,  and  upon  the  spread  of  typhoid 
fever  on  both  continents.  The  efforts  to  purify  water 
by  sand  filtration  were  also  reviewed,  wherever  made, 
and  the  report  concludes :  "  From  this  brief  review  of 
facts  and  opinions  concerning  filtration,  it  will  be  seen 
that  your  committee  hesitates  to  reaffirm  its  former 
positive  language  with  regard  to  the  sufficiency  of  filtra- 
tion as  protection  against  typhoid  fever.  Nor,  on  the 
other  hand,  do  we  regard  the  testimony  as  authorizing 
a  formal  declaration  of  opinion  in  favor  of  the  efficiency 


October  13,  1894] 


MEDICAL   RECORD. 


473 


of  filtration.  Oar  experience  in  this  country  is  extreme- 
ly limited,  but  it  is  hoped  that  the  success  achieved  at 
Lawrence  will  lead  to  the  filtration  of  other  surface 
waters,  each  of  which  will  probably  teach  an  important 
lesson  in  connection  with  bacteriological  experiments 
and  with  the  mortality  from  typhoid  fever  before  and 
after  the  construction  of  the  filter  beds.  In  view  of  an 
unbroken  record  of  typhoid  fever  in  communities  that 
use  raw  river- water,  and  an  equally  unbroken  record  of 
lessened  typhoid  rates  following  the  filtration  of  such 
river  supplies,  your  committee  considers  that  in  Washing- 
ton, D.C.,  special  attention  should  have  been  given  to 
the  improvement  of  the  general  supply.  This  country 
needs  some  practical  lessons  in  methods  of  water  purifi- 
cation." 

At  the  conclusion  of  the  report  Dr.  Gardner,  of 
London,  Ontario,  offered  the  following  resolution  : 

Resolved,  That  in  view  of  the  danger  to  the  public 
health  by  the  sewage  contamination  of  our  fresh-  water 
lakes,  rivers,  and  streams,  this  Association  memorialize 
the  different  Federal  Governments,  as  well  as  the  State 
and  Provincial  Governments,  to  pass  laws  prohibiting 
the  contamination  of  these  water-supplies  by  sewage 
from  cities,  towns,  and  villages,  and  compel  them  to 
provide  some  means  for  the  treatment  and  oxidation  of 
this  sewage  before  emptying  it  into  these  places. 

The  resolution  was  referred  to  the  Executive  Com- 
mittee and  subsequently  adopted  by  the  Association. 

Management  of  Diphtheria  Epidemics  in  Sural  Dis- 
tricts, by  Dr.  Charles  A.  Hodgetts,  of  Toronto.  The 
medical  officer  must  exercise  a  personal  supervision  not  only 
over  his  patients  but  personally  superintend  the  carrying 
out  of  all  orders,  for  upon  the  thoroughness  of  the  work 
depends  to  a  very  large  extent  the  prevention  of  further 
outbreaks  in  the  district.  He  felt  the  inhabitants  of  the 
rural  districts  should  receive  more  attention  from  the 
sanitary  authorities  than  they  had  heretofore,  and  some 
inexpensive  system  should  be  adopted  for  the  more  effi- 
cient and  prompt  management  of  epidemics  in  those 
portions  of  our  country.  Schools  should  be  closed  in 
the  district  until  such  time  as  the  inspector  has  satisfied 
himself  in  the  manner  indicated  that  the  household  of 
the  individual  scholars  thereof  are  free  from  diph- 
theria. 

Practical  Difficulties  of  Medical  Health  Officers  and 
Physicians  in  Dealing  with  Suspected  Cases  of  Diph- 
theria was  the  title  of  a  paper  read  by  Dr.  Peter  H. 
Bryce,  of  Toronto.  With  every  advance  in  our  knowl- 
edge we  find  that  the  practical  benefits  are  often  limited 
by  unforeseen  difficulties,  and  that  bacteriological  results 
bring  into  prominence  the  difficulties  which  the  health 
officer  finds  in  dealing  with  cases  of  sore  throat,  and 
which  may  be  summed  up  as  follows :  1.  That  according 
to  recent  investigations  made,  at  least  twenty-five  per 
cent,  of  diphtheria  cases  are  not  caused  by  the  Loeffler 
bacillus.  2.  That  physicians  endeavor  to  hide  cases  in 
the  supposed  interest  of  the  client,  and  conveniently 
shield  themselves  behind  the  assertion  that  they  could 
not  tell  whether  the  disease  was  diphtheria  or  not.  The 
author  drew  special  attention  to  the  difficulty  of  differen- 
tiating between  cases  of  ordinary  sore  throat  and  real 
diphtheria.  It  was  impossible  often  to  decide  that  cases 
were  really  diphtheria  without  microscopic  examina- 
tion. 

Dr.  J.  Ed.  Laberge,  of  Montreal,  read  a  paper  in 
French,  entitled  "Vaccination  as  a  Preventive  of  Con- 
tagious Diseases/'  The  paper  was  historical,  it  being 
largely  a  review  of  Pasteur's  experiments. 

Innocuous  Transportation  of  the  Dead. — This  paper 
was  read  by  Dr.  J.  D.  Griffith,  of  Kansas  City,  Mo. 
The  author  said  that  the  age  demands  a  far  greater  pro- 
tection to  the  public  health.  He  was  convinced  that  we 
owe  to  the  travelling  public  that  greater  precautions 
should  be  taken  in  the  transportation  of  the  dead  body. 
Heated  as  evidence  of  the  virulence  of  a  dead  body  that 
in  a  Normandy  village,  twenty-three  years  after  an  epi- 
demic of  diphtheria,  some  of  the  bodies  of  those  who  died 


of  the  disease  were  exhumed  and  an  epidemic  at  once  broke 
out,  first  among  those  who  opened  the  grave,  and  then 
spread  from  those  to  many  others.  Other  examples  were 
cited.  Until  the  public  are  educated  to  the  point  of 
the  thorough  sanitation  of  cremation,  the  transportation  of 
dead  bodies  by  the  railways  is,  and  always  will  be,  a  source 
of  very  great  danger.  The  speaker  urged  that  the  atten- 
tion of  the  different  legislative  bodies  of  the  country  be 
directed  by  the  Association  to  a  subject  of  such  vital  impor- 
tance. He  urged,  furthermore,  that  all  railways  cut  cff 
a  small  portion  of  their  baggage  cars  for  the  transporta- 
tion of  dead  bodies.  The  dead  body  should  be  placed 
in  a  box  lined  with  zinc,  with  a  door  very  much  after  the 
fashion  of  a  large  ice  chest.  This  done,  the  lives  of  em- 
ployees would  not  be  endangered ;  no  broken  or  open 
box  could  become  infected,  and  no  odor  could  escape 
from  the  car. 


Evening  Session. 

At  this  session  addresses  of  welcome  were  delivered  by 
Dr.  Robert  Craik,  the  Lieutenant-Governor  of  the  Prov- 
ince of  Quebec  (Hon.  J.  A.  Chapleau),  the  Mayor  of 
Montreal,  Hon.  L.  P.  Pelletier,  Provincial  Secretary, 
and  Doctor  Gregario  Mendizabal,  of  Mexico,  after  which 
the  President  of  the  Association  delivered  his  annual  ad- 
dress. 

The  President's  Address. — He  said  the  American  Pub- 
lic Health  Association,  since  its  foundation,  now  twenty, 
two  years  ago,  has  never  ceased  to  labor  for  the  advance 
ment  of  sanitary  science ;  for  the  promotion  of  measures 
and  organizations  that  should  effect  the  practical  accom- 
plishment of  the  laws  and  principles  of  public  hygiene. 
It  has  thus  realized  the  brightest  hopes  and  most  enthu- 
siastic provisions  of  its  worthy  founders,  and  has  ex- 
tended its  benefits  and  influence-  over  the  whole  ot 
North  America.  To  day  it  embraces  the  three  gieat 
countries  that  form  this  vast  continent — the  United 
States  of  America,  the  Republic  of  Mexico,  and  the  Do- 
minion of  Canada — all  three  working  together  in  broth- 
erly emulation,  recognizing  no  political  boundaries,  and 
striving  to  attain  one  unique  and  humane  object — the 
dissemination  of  all  of  the  knowledge  of  public  hygiene 
and  the  development  of  respect  for  its  decrees.  Every 
year  the  Association  changes  its  place  of  meeting,  and 
this  for  good  reasons.  The  spirit  of  its  founders  being 
to  establish  a  body  for  the  diffusion  and  popularization 
of  public  sanitary  science,  this  object  could  not  be  better 
attained  than  by  extending  to  its  greatest  limits  the  in- 
fluence of  the  Association;  and  for  this  purpose  no 
surer  means  could  be  found  than  the  bringing  together 
of  its  distinguished  members. 

President  Lachapelle  in  closing  urged  the  creation  by 
the  Government  of  a  new  department  in  their  cabinets 
—that  of  Public  Health. 


Second  Day,  Wednesday,   September  26th — Morn- 
ing Session. 

The  Executive  Committee  recommended,  which  was 
endorsed  by  the  Association,  a  new  committee,  to  consist 
of  five  persons,  entitled  "  Steamship  and  Steamboat  San- 
itation." 

Dr.  E.  Gauvreau,  of  Ste.  Foye,  Quebec,  described  in 
a  paper  the  process  followed  in  his  institution — the  Vac- 
cine Institute  of  Ste.  Foye — for  the  culture  and  collec- 
tion of  vaccine  lymph,  showing  that  every  care  is  taken 
to  insure  absolute  safety  to  the  public  using  the  points. 

Restriction  and  Prevention  of  Tuberculosis,  by  Dr. 
N.  E.  Wordin,  of  Bridgeport,  Conn.  He  showed  that 
consumption  was  an  infectious  or  communicable  disease 
and  that  the  principal  source  of  danger  of  its  spreading 
lay  in  the  sputum  ejected  by  a  phthisical  patient  when  it 
had  become  dry.  The  breath  of  a  consumptive  contained 
no  bacilli,  and  was  not  infectious.  If  the  spread  of  this 
disease  was  to  be  prevented  the  sputum  must  be  attacked. 
Phthisis  might  be  communicated   by  osculation,  and 


474 


MEDICAL   RECORD. 


[October  13,  1894 


among  the  hygienic  commandments  should  be  one  for 
the  syphilitic  and  the  consumptive,  "  Thou  shalt  not 
kis."  He  considered  that  the  most  practical  and  the 
quickest  way  of  restricting  the  spread  of  tuberculosis 
would  be  to  put  it  on  the  list  of  infectious  or  communi- 
cable diseases  to  be  reported  to  the  health  officers. 

Examination  of  the  Milk-supply  for  Tuberculosis 
in  the  State  of  Hew  York,  by  Dr.  F.  O.  Donahue, 
of  New  York  City. — He  said  that  in  May,  1892,  New 
York  State  took  a  step  forward  in  authorizing  its  Board 
of  Health  to  make  investigations  in  reference  to  the  ex- 
istence of  tuberculosis  in  cattle.  The  relation  of  the 
milk-supply  to  infant  mortality  from  tuberculosis  was  in- 
sisted upon  by  all  health  officers  who  had  made  it  the 
subject  of  systematic  observation.  That  milk  and  its 
product  will  convey  tuberculosis  had  been  proven. 
When  it  is  considered  that  milk  is  the  principal  aliment 
during  childhood,  and  enters  largely  into  the  diet  of  all 
classes,  it  was  a  highly  important  question  for  consider- 
ation. Statistics  of  New  York  State  show  that  for  a 
period  of  eight  years  last  past,  every  eighth  death  was 
caused  by  tuberculosis.  The  State  Board  of  Health 
evolved  the  lesson  that  tuberculosis  existed  in  the  dairy 
cattle  to  quite  an  extent,  and  that  special  legislation 
was  necessary  to  deal  with  it  It  is  confidently  expected 
that  future  legislation  in  this  regard  will  be  enacted 
carrying  with  it  an  appropriation  commensurate  with 
the  magnitude  of  the  work. 

Should,  the  Marriage  of  Consumptives  be  Discour- 
aged ? — Dr.  Paul  Paquin,  of  Missouri,  followed  with  a 
paper  on  this  subject.  He  held  that  the  marriage  of  a 
consumptive  with  a  healthy  person  must  lead  to  the  infec- 
tion of  the  latter,  and  that  the  children  born  of  con- 
sumptives are  always  naturally  predisposed  to  tuberculo- 
sis. Thus  the  centres  of  infection  are  increased  and  the 
danger  to  society  is  made  much  greater.  No  consump- 
tive should  marry,  and  it  is  perfectly  proper  for  science 
to  interfere  and  use  all  its  influence  to  prevent  such 
marriages. 

The  Climatic  Segregation  of  Consumptives. — Dr. 
Henry  Sewall,  of  Denver,  read  a  paper  on  this  sub- 
ject He  proposed  the  following  plan  for  the  treatment 
of  consumption  in  its  early  stages,  viz.,  he  would  estab- 
lish at  favorable  points  in  Colorado  a  series  of  cottage 
sanatoria.  The  cottage  plan  was  eminently  the  best  in 
its  adaptation  to  the  character  of  the  climate,  the  people, 
and  the  disease.  The  efficiency  and  feasibility  of  such 
an  institution  had  already  been  established  in  the  Adi- 
rondack Cottage  Sanatorium  of  New  York,  which  might 
well  serve  as  a  model  for  extensive  development.  These 
santoria  should  be  located  with  careful  regard  to  clima- 
tological  conditions,  purity  of  water  supply,  beauty  of 
scenery,  and  accessibility  to  railways. 

Dr.  John  T.  Nagle,  of  New  York  City,  in  some  re- 
marks upon  diphtheria,  said  that  the  Health  Department 
of  New  York  City  had  been  making  strenuous  efforts  to 
stamp  out  diphtheria,  and  with  this  end  it  has  instructed 
the  bacteriological  division  to  examine  gratuitously  the 
cultures  furnished  it  by  physicians  who  attend  sus- 
pected cases  of  diphtheria.  He  said  that  Dr.  Cyrus 
Edson  has  great  faith  in  the  antitoxine  treatment  of 
diphtheria,  and  it  promises  to  be  one  of  the  most  im- 
portant discoveries  of  modern  medicine,  and,  so  far  as 
could  be  judged  from  the  data  at  hand,  will  afford  us  a 
means  of  not  only  protecting  persons  from  diphtheria 
who  have  been  exposed  to  the  disease,  but  also  a  certain 
means  for  the  cure  of  the  disease  when  cases  are  sub- 
jected to  this  treatment  in  the  early  stages.  One  of  the 
most  important  and  significant  features  of  the  treatment 
depends  upon  the  absolutely  innocuous  character  of  the 
remedy,  it  having  apparently  no  influence,  either  favor- 
able or  unfavorable,  in  health  or  disease,  excepting  as  to 
its  power  of  neutralizing  the  poison  of  diphtheria. 

The  afternoon  was  devoted  to  pleasure,  the  members 
of  the  Association,  many  of  whom  were  accompanied  by 
their  wives  and  daughters,  taking  in  the  trip  which  had 
been  arranged  down  the  Lachine  Rapids. 


Evening  Session. 

Dr.  F.  Montizambert,  General  Superintendent  of  the 
Canadian  Quarantine,  gave  an  interesting  sketch,  illus- 
trated by  lantern  slides,  of  the  quarantine  appliances  at 
Grosse  Isle.  He  briefly  explained  the  mode  of  boarding 
ocean  ships,  the  examination,  disinfection,  and  hospital 
treatment. 

Some  Points  in  the  Hygiene  of  the  Young  in  Schools. 
— This  paper  was  read  by  Dr.  J.  C.  Cameron,  of  Mon- 
treal. He  pointed  out  that  mind  and  body  were  de- 
pendent upon  each  other,  and  consequently  for  the  proper 
development  of  the  individual  the  body  was  to  be  con- 
sidered and  cared  for  as  well  as  the  mind.  He  referred 
to  the  fact  that  the  physical  culture  of  school  children 
was  in  too  many  cases  improperly  cared  for,  though  in 
the  case  of  boys,  who  engaged  in  out-door  sports,  the 
effects  were  not  so  marked  as  in  girls,  who  indulged  less 
in  out  door  sports  and  were  inclined  to  be  more  seden- 
tary. Spinal  curvature  and  pelvic  deformity  were  liable 
to  result  from  assuming  an  improper  attitude  when  sitting, 
standing,  or  walking,  and  consequently  it  was  of  the  ut- 
most importance  that  school  children  should  be  taught  to 
sit,  stand,  and  walk  properly. 

Sanitation  in  Plumbing. — By  Mr.  John  Mitchell, 
President  of  the  National  Association  of  Master  Plumbers, 
New  York.  The  speaker  advocated  a  semi-annual  in- 
spection of  all  houses  for  sanitary  measures.  The  rule 
that  at  present  appears  to  be  observed,  he  said,  is  to  wait 
for  crape  on  the  door  before  asking  a  question  regarding 
the  sanitary  arrangements. 

Influence  of  Inebriety  on  Publio  Health. — This  paper 
was  read  by  Dr.  T.  D.  Crothers,  of  Hartford,  Conn. 
The  facts  he  wished  to  make  prominent  were : 

1.  The  influence  of  inebriety  on  public  health  is  of  far 
greater  magnitude  and  more  closely  associated  with  the 
various  sanitary  problems  of  the  day  than  is  realized  at 
present. 

2.  Our  present  conception  of  the  extent,  nature,  and 
character  of  inebriety  is  erroneous  and  based  on  theories 
that  are  wrong.  Our  methods  of  dealing  with  inebriates 
are  most  disastrous  and  fatal  in  not  only  destroying  the 
victim,  but  perpetuating  the  evil  we  seek  to  lessen. 

3.  These  cases  must  be  recognized  as  diseased,  and  be 
housed  in  farm  colonies,  under  military  care  and  treat- 
ment. They  must  be  organized,  employed,  and  placed 
under  hygienic  surroundings  and  made  self  support- 
ing. 

4.  The  present  duty  is  careful  medical  study  of  these 
classes  and  full  recognition  of  their  needs  and  require- 
ments. Public  sentiment  should  be  built  up  to  sustain 
rational  means  and  measures  in  their  treatment. 

5.  The  sanitary  problems  that  confront  our  civilization 
are  very  closely  associated  with  the  inebriate  class.  One 
of  the  central  sources  of  peril  to  public  health  is  inebriety. 
This  is  the  one  fountain-head  that  must  be  corrected  to 
break  up  some  of  the  evils  of  the  present  day. 

Third  Day,  Thursday,   September   27TH — Morning 
Session. 

A  Journal  of  the  American  Publio  Health  Associa- 
tion.— Secretary  Watson  read  a  short  paper  with  this 
title.  He  urged  establishing  a  quarterly  journal  in 
connection  with  the  Association,  to  replace  the  annual 
volume  of  Transactions.  He  expressed  the  belief  that 
the  establishment  of  such  a  journal  would  increase  the 
influence  and  strength  of  the  Association.  The  matter 
was  referred  to  the  Advisory  Council. 

Vaccine  and  Vaccination. — Dr  Ralph  Walsh,  of 
Washington,  D.  C,  read  the  paper.  He  summarized  as 
follows :  So-called  cow  pox  is  simply  modified  variola. 
The  admixture  of  glycerine  with  vaccine  lymph  will  de- 
stroy all  extraneous  bacteria  without  injury  to  its  peculiar 
active  principles.  The  admixture  of  glycerine  with 
vaccine  lymph  not  only  does  this,  but  prolongs  the  ac- 
tivity of  the  lymph.  The  selection  of  lymph  and  the 
simple  but  important  operation  of  vaccination  had  not 


October  13,  1894] 


MEDICAL  RECORD. 


475 


received  from  the  profession  the  attention  they  deserved. 
The  physician  should  see  that  each  infant  brought  under 
his  care  is  successfully  vaccinated  during  the  first  year  of 
its  life,  and  again  at  sixteen,  or  better,  to  the  point  of 
saturation  during  infancy.  The  accumulation  of  un- 
vaccinated  material,  and  consequently  the  increased 
danger  of  outbreaks  of  small- pox,  are  caused  by  the 
general  practitioner  failing  to  perform  his  duty  at  the 
proper  time. 

Car  Sanitation.— Dr.  G.  P.  Conn,  of  Concord,  N.  H. 
read  the  Report  of  the  Committee  on  Car  Sanita- 
tion, of  which  he  is  chairman.  The  report  maintained 
that  the  railway  companies  are  very  negligent  in  this 
respect  The  railway  car  is  virtually  and  for  the  time 
being  a  house  on  wheels,  in  which  a  varying  number  of 
people  are  expected  to  make  their  homes  for  a  longer  or 
shorter  period,  according  to  the  distance  which  they  may 
be  expected  to  travel.  Therefore,  like  a  house,  it  should 
be  constructed  upon  sanitary  principles,  in  which  venti- 
lation, heating,  and  such  conditions  as  will  allow  it  to  be 
kept  dean  are  paramount  factors  in  every  case.  Unless 
these  sanitary  principles  can  be  carried  out  and  made 
permanent,  then  this  house  on  wheels  becomes  unwhole- 
some and  unhealthy,  and  the  conditions  become  favor- 
able to  disease,  or  of  spreading  it  should  a  contagious 
or  infectious  malady  find  a  place  within  its  walls. 
According  to  investigations  it  had  been  found  that 
the  atmosphere  of  the  ordinary  coach  contained  from 
one  to  six  times  as  much  carbonic  acid  gas  as  public 
assembly  rooms,  such  as  churches,  theatres,  and  public 
halls. 

Prevention  of  the  Spread  of  Yellow  Fever. — Dr. 
Feux  Formento,  of  New  Orleans,  read  the  Report  of 
the  International  Committee  on  the  Prevention  of  the 
Spread  of  Yellow  Fever.  The  report  maintained  that 
this  plague  never  originated  in  Louisiana,  but  is  im- 
ported from  Cuba,  Mexico,  and  Central  and  South 
America.  It  recommended  attempts  to  stamp  out  the 
disease  in  the  swamps  in  those  countries,  and  the  adop- 
tion of  thorough  sanitary  measures  in  the  Southern 
centres,  where  the  disease  is  wont  to  become  epidemic. 
An  effort  to  secure  the  co  operation  of  the  governments 
of  Cuba,  Mexico,  Brazil,  and  the  Central  American  re- 
publics was  recommended. 

Dr.  N.  £.  Worden,  of  Bridgeport,  read  a  paper  on 
"Disposal  of  Garbage,"  in  which  he  advocated  its  de- 
struction in  an  incinerator. 

The  Disposal  of  Garbage  and  Refuse.— The  Report 
of  the  Committee  on  the  Disposal  of  Garbage  and  Refuse 
was  presented  by  Mr.  Rudolp^l  Hering,  C.E.,  of  New 
York  City.  It  dealt  with  the  character  of  city  refuse, 
its  collection  and  removal  from  a  building  to  the  place 
of  disposal,  and  the  several  methods  in  vogue  for  its  dis- 
posal. 

Colonel  W.  F.  Morse,  of  New  York,  dealt  briefly  with 
the  collection  and  disposal  of  the  refuse  and  garbage  of 
large  cities,  describing  what  was  being  done  in  New 
York  in  order  to  find  out  the  best  method  of  disposing  of 
its  refuse  and  garbage. 

Influence  of  the  Climate  of  Canada  on  Health. — 
This  was  the  title  of  a  paper  read  by  Dr.  W.  H.  Hing- 
ston,  of  Montreal  He  touched  briefly  on  the  geographi- 
cal situation  and  the  topography  of  the  country,  and  then 
went  on  to  show  that  after  a  residence  in  the  country,  of 
shorter  or  longer  duration,  a  change  in  the  constitution 
could  be  observed.  The  high  color  which  flushed  the 
cheeks  of  some  Europeans  faded  somewhat,  and  the  skin 
became  less  soft,  the  hair  became  darker  and  more  like 
the  aboriginal  type,  and  the  muscles  were  less  promi- 
nent The  hot  weather  did  not  last  long  enough  to  pro- 
dace  any  great  disturbance  of  the  liver,  and  the  cold  was 
exhilarating.  The  ratio  of  mortality  in  Canada  was  lower 
than  that  of  Great  Britain,  and,  with  the  exception  of 
Malta,  this  country  was  the  healthiest  station  of  the 
British  army.  Statistics  gathered  from  the  States  showed 
that  all  constitutions  were  healthier  as  they  approached 
the  Great  Northern  Lakes. 


Afternoon  Session. 

"  The  Advisability  of  Teaching  Rules  and  Principle* 
of  Hygiene  in  the  Primary  Schools  by  Means  of  Object 
Lessons,"  was  the  title  of  a  paper  read  by  Dr.  Jesus  £. 
Monjaras,  of  San  Luis  Potosi,  Mexico. 

The  Importance  of  Teaching  Hygiene  in  Elementary 
Schools. — Dr.  S.  Gauthier,  of  Upton,  Quebec,  followed 
with  a  paper  on  this  subject  The  speaker  held  that  it 
was  through  the  teaching  of  hygiene  to  the  school  chil- 
dren that  we  could  eradicate  the  unfortunate  prejudices 
which  directly  caused  the  loss  of  so  many  who  might 
have  been  the  strength,  glory,  and  pride  of  our  country. 

The  Hygiene  of  Vision  in  Schools.— Dr.  T.  D.  Reed, 
of  Montreal,  recommended  the  introduction  into  schools 
of  the  suggestions  of  the  Anthropometric  Committee  of 
the  British  Association  for  the  Advancement  of  Science, 
in  order  to  test  the  power  of  vision  and  color-sense.  He 
also  recommended  exercises  for  the  development  of  the 
power  of  rapid  and  accurate  observation. 

A  Few  Remarks  on  School  Hygiene,  by  Dr.  T.  M. 
Brennan,  of  Montreal.  The  points  in  this  paper  might 
be  summarized  as  follows :  The  rousing  of  the  general 
public  to  the  necessity  of  propagating  the  study  of  hy- 
giene ;  the  hygierfic  education  of  children,  whose  teach- 
ers must  be  proficient  in  hygiene.  In  each  school  there 
should  be  a  school  commission  endowed  with  power  to 
act.  There  should  be  some  system  of  efficient  general 
supervision,  and  the  general  co-operative  support  of  local 
and  general  Boards  of  Health  and  the  Board  of  Public 
Instruction  should  be  assured. 

An  Epidemic  of  One  Hundred  and  Twenty  Cases  of 
Paralysis  in  Children. — Dr.  Andrew  Macphail,  of 
Montreal,  contributed  a  paper  on  this  subject.  The 
paper  contained  an  account  of  an  epidemic  of  infantile 
paralysis  which  occurred  in  the  State  of  Vermont  during 
July,  August,  and  September,  and  which  the  speaker  in- 
vestigated. He  first  stated  that  the  belief  was  held  that 
it  was  an  outbreak  of  cerebro  spinal  meningitis,  but  he 
showed  in  a  lucid  manner  that  it  was  a  true  myelitis. 
He  quoted  the  notes  of  91  cases  out  of  the  1 20.  In  some 
children  the  paralysis  came  on  without  any  symptoms,  in 
others  there  was  a  preliminary  illness  of  a  few  days  resem- 
bling indigestion.  He  described  in  detail  the  fatal  cases, 
of  which  there  were  18,  and  42  in  which  there  was  per- 
manent paralysis.  There  were  also  notes  of  6  cases  in 
adults,  3  of  which  ended  fatally.  He  then  referred  to 
the  origin  of  the  malady,  giving  full  statistics  of  tempera- 
ture, rainfall,  and  humidity,  and  geological  factors. 
There  were,  besides,  12  deaths  from  the  same  cause 
among  horses,  and  fowls  were  likewise  affected.  In  con- 
clusion, he  dwelt  upon  the  necessity  for  having  in  every 
State  a  properly  conducted  laboratory  and  a  competent 
staff  to  deal  with  such  outbreaks,  and  a  Board  of  Health 
with  authority  to  investigate  epidemics  and  perform  au- 
topsies. The  paper  had  additional  interest  from  the  fact 
that  it  is  the  first  epidemic  of  the  kind  reported  in 
America,  and  the  third  which  has  occurred  in  any  coun- 
try. The  speaker  refrained  from  expressing  any  views  or 
propounding  any  theories  till  the  pathological  work 
which  he  has  in  hand  shall  have  been  completed. 

The  Advances  of  Public  Health  in  the  City  of  Mon- 
treal was  the  subject  of  a  paper  by  Dr.  L.  Laberge, 
Medical  Officer  of  Health  for  Montreal  The  author 
outlined  the  development  of  the  several  matters  con- 
nected with  the  public  health  of  the  city  and  the  legis- 
lation by  which  they  were  governed,  such  as  milk  inspec- 
tion, meat-supply,  ice-supply,  drainage,  and  public  baths. 
He  gave  an  account  of  the  present  state  of  sanitation  in 
the  city,  and  concluded  by  showing  that  during  the  last 
twenty  years  the  death-rate  had  been  reduced  by  12.87 
per  thousand. 

Myopia  in  its  Relation  to  School  Hygiene. — Dr.  A. 
A.  Foucher,  of  Montreal,  presented  a  chart  which  illus- 
trated that  myopia  is  more  prevalent  in  the  secondary 
than  in  the  primary  schools.  In  the  primary  schools  of 
Russia  it  is  fourteen  per  cent.,  while  in  those  of  Ger- 


476 


MEDICAL   RECORD. 


[October  13,  1894 


many,  Austria,  France,  Holland,  New  Zealand,  the 
United  States,  and  Switzerland  it  is  thirteen  per  cent ; 
Norway,  eleven  per  cent. ;  England,  Roumania,  and  Bel- 
gium, thirteen  per  cent.  In  the  secondary  schools  in 
Austria  it  is  thirty  eight  per  cent. ;  Switzerland,  thirty- 
six  per  cent. ;  Germany,  thirty-six  per  cent. ;  France, 
thirty-six  per  cent. ;  Russia,  thirty  six  per  cent. ;  Den- 
mark, thirty-six  per  cent.  In  Italy  it  is  thirty-eight  per 
cent.  ;  Sweden,  thirty-four,  and  in  England,  thirty- 
eight. 

Or.  G.  Mendizabal,  of  Orizaba,  Mex.,  gave  some 
"  Observations  on  Yellow  Fever  in  Vera  Cruz,  and  its 
Prevention,' '  and  he  was  followed  by  Dr.  }.  I.  Des- 
roches,  editor  of  the  Journal  d' 'Hygiene  Populaire,  and 
member  of  the  Board  of  Health  of  the  Province  of  Que- 
bec, who  discoursed  on  hygiene  in  medical  education. 

Nomenclature  of  Diseases  and  Forms  of  Statistics. 
— The  day's  session  closed  with  the  reading  of  the  re- 
port of  the  Committee  on  Nomenclature  of  Diseases 
and  Forms  of  Statistics,  by  Dr.  S.  W.  Abbott,  of  Bos- 
ton, chairman.  The  committee  considered  changes  in 
the  nomenclature  and  classification  of  diseases  and  causes 
of  death ;  uniform  methods  of  reporting  vital  statistics ; 
uniform  methods  of  estimating  population  and  death- 
rates,  and  the  adoption  of  a  standard  fif  age  distribution. 
It  is  quite  plain  that  a  fair  comparison  cannot  be  made 
of  the  death  -  rates  of  countries,  cities,  and  towns  in 
which  the  age  distribution  is  widely  different ;  hence  the 
importance  of  adopting  some  conventional  standard  to 
which  all  populations  may  be  referred,  or  with  which 
they  may  be  compared. 


Fourth   Day,    Friday,   September   28th  —  Morning 
Session. 

A  Plea  for  Vaccination.— Dr.  M.  T.  Brennan,  of 
Montreal,  Can.,  said  vaccination  should  be  performed 
with  all  the  precautions  calculated  to  insure  the  action 
of  the  pure  lymph,  free  from  all  contamination  and  the 
action  of  it.  Each  vaccinator  should  be  provided  with 
— 1,  pure  lymph  of  a  standard  strength,  if  possible;  2,  a 
vial  of  distilled  or  boiled  water  to  dilute  the  lymph ;  3, 
a  vial  containing  a  solution  of  bichloride  of  mercury ; 
4,  a  small  alcohol  lamp  to  sterilize  the  lancet,  etc. ;  5, 
Some  sterilized  absorbent  cotton ;  and  6,  some  steril- 
ized gauze.  All  these  take  up  but  a  small  space,  and 
may  be  placed  in  a  small  satchel  or  metallic  case.  The 
operation  should  be  done  under  strict  antiseptic  precau- 
tions ;  all  instruments,  dressings,  hands  of  the  operator, 
etc.,  should  be  clean. 

Infection  by  the  Bacillus  Pyocyaneus  as  a  Cause  of 
Infant  Mortality.— Dr.  H*  Cameron,  of  Montreal,  read 
a  paper  on  this  subject.  It  was  not  until  1889  that  this 
bacillus  was  found  to  produce  definite  general  infection 
in  young  children.  The  author  drew  the  following  con- 
clusions: 1.  That  the  infant  tissues  are  susceptible  to 
the  invasion  of  this  bacillus.  2.  That  the  bacillus  is  dis- 
tinctly pathogenic,  setting  up  a  disease  peculiar  to  ex- 
perimental pyocyanic  disease.  3.  That  this  disease  is 
characterized  by  a  train  of  very  definite  symptoms,  such 
as  diarrhoea,  fever,  rapid  emaciation,  rigidity  of  the  legs, 
and  hemorrhagic  and  bullous  eruptions.  4.  That  the 
disease  appears  to  be  very  fatal. 

As  this  combination  of  symptoms  occurs  not  infre- 
quently in  young  children,  especially  when  congregated 
in  nurseries  and  foundling  asylums,  the  author  ventured 
to  infer  that  a  certain  proportion  of  the  deaths  which 
now  appear  upon  our  records  of  vital  statistics  under  the 
headings  of  gastro  enteritis,  purpura,  or  marasmus,  were 
in  reality  cases  of  generalized  pyocyanic  disease. 

As  to  prophylaxis  he  had  nothing  definite  to  offer  at 
present  beyond  a  strict  observance  of  the  laws  of  hygiene, 
fresh  air,  suitable  nourishment,  and  cleanliness ;  but  he  is 
inclined  to  consider  that  this  disease  is  one  eminently 
suited  for  a  trial  of  "serum  therapeutics."  It  is  a  dis- 
ease in  which,  experimentally,  immunity  can  be  easily  pro  • 
duced  in  susceptible  animals.     This  being  so,  it  is  proba- 


ble that  the  serum  of  animals  vaccinated  against  this  dis- 
ease, or  substances  obtained  from  such  serum,  will  be 
found,  as  in  the  case  of  diphtheria,  to  have  curative  effects. 

The  closing  paper  of  the  Convention  was  read  by  Mr. 
J.  W.  Hughes,  of  Montreal.  It  was  entitled  "  Evolu- 
tionary Developments  of  Domestic  Plumbing  during  the 
Past  Twenty- five  Years.' ' 

Several  papers  were  read  by  title,  owing  to  the  absence 
of  the  authors. 

The  following  resolutions  were  offered  by  C.  O.  Probst, 
of  Columbus,  O.,  referred  to  the  Executive  Committee, 
and  adopted  by  the  Association  : 

Resolved,  That  this  Association  approves  the  sugges- 
tion for  a  co-operative  investigation  into  the  bacteriol- 
ogy of  water,  and  commends  the  efforts  of  the  commit- 
tee, in  carrying  out  this  work,  to  the  officers  of  State  and 
Municipal  Boards  of  Health,  to  the  individual  members 
of  this  Association,  and  to  all  persons  interested  in  the 
purity  of  water-supplies  for  such  special  assistance  as  they 
may  be  able  to  render. 

By  Dr.  E.  R.  Campbell,  of  Bellows  Falls,  Vt. : 

Resolved,  That  this  Association  records  its  protest 
against  the  use  of  alcoholic  liquor  as  a  beverage,  espe- 
cially among  the  young,  believing  that  such  use  is  at- 
tended with  great  danger  to  the  health,  the  individual, 
and  society. 

The  Executive  Committee  failed  to  act  on  this  reso- 
lution. 

By  Dr.  George  Homan,  of  St.  Louis : 

IVhereas,  It  is  the  sense  of  this  Association  that  the 
pollution  of  potable  waters  in  America  has  reached  such 
a  point  that  the  national  governments  should  be  asked  to 
take  cognizance  of  the  matter  with  the  view  of  devising 
means  of  prevention  and  relief;  therefore  be  it 

Resolved,  That  this  Association  memorialize  the  Con- 
gress of  the  United  States  and  ask  that  they  shall  author- 
ize the  appointment  of  a  competent  commission,  clothed 
with  power  to  fully  investigate  the  whole  subject  of  the 
pollution  of  rivers  and  lakes  by  municipal  and  manufact- 
uring waste,  and  provided  with  sufficient  means  to  en- 
able them  to  conduct  the  examination  in  such  a  manner 
as  shall  be  deemed  best,  the  results  of  said  examination 
to  be  published  from  time  to  time  for  the  public  informa- 
tion. 

The  following  officers  were  elected  for  the  ensuing 
year :  President,  Dr  William  Bailey,  of  Louisville,  Ky.; 
First  Vice  President,  Dr.  G.  P.  Conn,  of  Concord,  N.  H.; 
Second  Vice-President,  Dr.  G.  Mendizabal,  of  Orizaba, 
Mexico  ;  Secretary,  Dr.  Irving  A.  Watson,  of  Concord, 
N.  H  ;  Treasurer,  Dr.  Henry  D.  Holton,  of  Brattleboro', 
Vt. 

After  a  resolution  of  thanks,  offered  by  Dr.  A.  L.  Gihon, 
of  Washington,  D.  C,  the  Association  adjourned  to  meet 
in  Denver,  Col.,  at  a  time  to  be  fixed  by  the  Executive 
Committee.  

Menthol  in  Itching  Affeotions  of  the  Skin.— Dr. 
Colombini  strongly  advocates  this  drug  in  cases  of  ec- 
zema of  the  scrotum,  vulva,  etc.  He  uses  the  following 
formulae : 

3 .    Menthol 5  to  10  parts. 

Alcohol  100  parts. 

Or, 

$ .    Menthol 10  parts. 

Oil  of  sweet  almonds 10  parts. 

Or, 

J) .    Oxide  of  zinc ....  25  parts. 

Starch  powder 25  parts. 

Vaseline 50  parts. 

Menthol,  from    5  to  8  parts. 

Or, 

9 .    Oxide  of  zinc 10  parts. 

Subnitrate  of  bismuth 10  parts. 

Menthol 1  to  30  parts. 

Starch  powder   1  to  30  parts. 

When  the  application  is  to  mucous  surfaces  the  mixt- 
ure should  contain  a  smaller  proportion  of  menthol. — 
La  France  Medicate. 


October  13,  1894] 


MEDICAL   RECORD. 


477 


(tkrcvesvon&znce. 

OUR  LONDON  LETTER. 

(From  our  Special  Correspondent) 
DR.   THORNE    THORNE,   CB. — APPRECIATION    OF    MEDICAL 
WORK    FOR    THE    STATE — THE    DUKE    AND    THE  ARMY 
DOCTORS — CHOLERA — REPORT    OF    LOCAL   GOVERNMENT 
BOARD'S   MEDICAL   DEPARTMENT. 

London,  September  22, 1894. 

Dr.  Thorns  Thorne,  CB  ,  has  received  from  the  Queen 
an  intimation  of  Her  Majesty's  appreciation  of  the  ser- 
vices rendered  by  the  Medical  Department  of  the  Local 
Government  Board  in  the  measures  taken  to  prevent  an 
invasion  of  cholera.  It  is  reported  that  the  Queen  has 
all  along  manifested  particular  interest  in  the  efforts  to 
prevent  an  epidemic,  and  this  expression  oi  appreciation 
of  the  work  done  will  no  doubt  be  gratifying  to  the 
principal  medical  officers.  To  the  profession  it  might 
have  appeared  more  satisfactory  had  the  opportunity 
been  taken  to  give  a  step  in  the  Order  of  the  Bath. 
There  is  always  considerable  reluctance  to  convert  a 
CB.  into  a  K.C.B.,  especially  in  the  case  of  medical 
holders  of  the  dignity.  Perhaps  this  also  is  due  to  the 
absurd  jealousy  of  "  military  advisers/'  a  jealousy  which 
continues  to  work  untold  injustice.  No  one  doubts  that 
the  Duke  of  Cambridge  has  greatly  injured  the  army 
medical  officers  by  his  silly  jealousy  of  the  non  comba- 
tants, but  he  has  lately  had  a  lesson  on  the  drift  of  pub- 
lic opinion  he  would  do  well  to  take  to  heart.  He  has 
been  pushed  into  good  things  because  of  his  birth,  not 
because  of  his  knowledge  or  skill — the  Crimea  proved 
that — and  he  should  have  some  regard  for  those  who  make 
their  way  by  skill  and  knowledge  only.  If  he  continues 
to  persecute  non-combatants  {e.g. ,  the  case  of  Dr.  Briggs) 
the  day  of  reckoning  may  be  nearer  than  he  imagines. 

To  return  to  cholera.  The  disease  has  in  some  parts 
of  Europe  been  more  severe  this  year  than  last,  and  the 
danger  which  has  threatened  England  has  been  greater, 
too,  as  it  has  manifested  a  disposition  to  spread  in  differ- 
ent directions.  In  Russia  and  Galicia  it  has  been  more 
fatal,  and  still  prevails.  The  returns  from  St.  Peters- 
burg, indeed,  indicate  that  the  epidemic  is  dying  out 
in  that  city,  but  in  many  of  the  provinces  of  Russia  it  is 
unabated,  and  others  are  being  invaded.  The  Prussian 
frontier  has  been  closed  against  Russia  in  all  dangerous 
directions,  but  not  much  is  to  be  anticipated  from  the 
old-fashioned  methods  in  vogue. 

What  England  has  done  to  repel  invasion  is  chroni 
ded  in  the  report  of  Dr.  Thorne,  which  I  have  pre 
viously  noticed.  In  that  report  it  is  shown  that  the 
inspection  of  our  ports  has  been  useful  in  stimulating 
the  control  of  vessels  arriving  from  infected  ports.  In 
1892  this  method  was  perfectly  successful,  save  in  the 
cases  of  thirty-five  persons  who  landed  during  the  period 
of  incubation  or  when  the  disease  had  set  in.  Last  year 
some  cases  occurred,  as  I  reported  to  you  at  the  time,  in 
persons  who  passed  inland,  and  we  were  face  to  face  with 
the  serious  danger  of  an  outbreak  in  several  places  at 
once.  Now  that  that  peril  is  past  it  is  satisfactory  to 
know  that,  besides  the  ports,  these  inland  districts  have 
been  carefully  watched,  and,  moreover,  that  inspection 
of  other  places  exhibiting  sanitary  defects  is  being  con- 
tinued. The  report  contains  some  shocking  examples 
of  neglect  and  recklessness  on  the  part  of  some  local 
sanitary  authorities,  which  deserve  severe  blame,  and  it  is 
certainly  to  be  hoped  that  the  danger  incurred  will  be 
brought  home  to  all  concerned.  Dr.  Thorne  remarks 
that  it  is  no  part  of  his  duty  in  such  cases  "  to  appraise 
the  responsibility  attaching  respectively  to  electors  or 
elected,"  and  he  evidently  thinks  that  great  blame  is 
due  to  one,  or  probably  both.  It  is,  perhaps,  a  blot  on 
oar  institutions  that  the  densest  ignorance  does  not  dis- 
qualify an  elector,  or,  for  that  matter,  an  elected  person, 
and  the  representatives  of  ignorance  are  likely  to  be 
reckless  administrators  in  sanitary  matters.     It  is,  indeed, 


a  relief  that  the  inspection  of  the  Local  Government 
Board  is  a  reality,  and  that  its  medical  department  is  pre- 
sided over  by  so  capable  an  officer  as  Dr.  Thorne  Thorne. 
The  system  of  sanitary  supervision  he  directs  may  claim 
success  so  far,  but  no  doubt  many  details  require  per- 
fecting, and  it  is  to  be  hoped  that  the  suspicious  villages, 
and  towns  will  continue  under  observation  as  well  as  the 
ports  which  are  specially  exposed  to  danger.  For  we 
are  not  out  of  the  wood  even  in  regard  to  the  present 
year,  though  some  papers  are  already  singing  pseans  at 
our  escape ;  and  not  merely  this  year,  but  always  and  con- 
tinuously, those  precautions  which  have  proved  effectual 
must  be  maintained.  Even  those  who  still  hold  to  quar- 
antine have  accorded  us  the  approval  of  our  methods, 
which  its  success  necessarily  extorted. 


MUST  THE  PARSON  PAY? 

To  the  Editor  of  the  Medical  Record. 

Sir  :  With  your  permission  I  would  like  to  ask  Minister,, 
whose  letter  appears  in  your  issue  of  June  9th,  a  few- 
questions. 

Is  it  not  a  fact  that  laboring  men  and  clerks  who  re- 
ceive a  salary  of  forty  dollars  per  month  (some  less),  pay 
their  medical  bills  without  a  murmur  ? 

Is  it  not  also  a  fact  that  the  vast  majority  of  physicians 
do  a  great  amount  of  work  for  which  they  receive  not  a 
penny,  in  some  instances  even  furnishing  the  medicine  ?• 

Who  has  the  harder  and  more  responsible  duty  to  per- 
form— the  minister  who  prepares  his  sermon  during  the 
week  to  recite  on  Sunday,  and  who  visits  the  members  of 
his  flock  on  pleasant  sunshiny  days ;  or  the  doctor  who 
has  to  answer  calls  at  all  hours  of  the  day  or  night,  no 
matter  how  tired  and  sleepy  he  may  be,  no  matter  how 
much  snow,  ice,  or  mud  he  may  have  to  plod  through,, 
and  who,  when  he  reaches  the  bedside,  instead  of  repeat- 
ing a  prayer  which  he  has  learned  by  heart,  has  to  call 
into  play  all  the  resources  of  his  medical  knowledge,  and 
upon  whom  devolves  the  responsibility  of  restoring  the 
child  to  its  mother,  or  the  father  to  his  family  ? 

And  last  of  all,  what  do  ministers  do  to  merit  medical 
attention  gratis?  Truly  I  cannot  understand  it;  and 
while  I  would  never  hesitate  to  answer  a  call  of  charity 
at  any  time,  I  fully  concur  with  my  friend  of  Durham, 
N.  C,  that  when  one  is  able  to  pay  one  should  pay,, 
whether  he  be  minister,  lawyer,  or  laborer. 

Yours  very  truly, 

C.  H.  Carroll. 

Pavaris,  Fla.  

SOME  PRACTICAL  OBSERVATIONS  ON  MAL- 
ARIA NOT  DUE  TO  DRINKING  WELL-  OR 
SURFACE-WATER. 

To  tub  Editor  or  the  Medical  Record. 

Sir  :  The  article  on  malaria,  by  Dr.  W.  H.  Daly,  ot 
Pittsburg,  Pa.,  which  appeared  in  the  Medical  Record* 
of  September  15th,  was  especially  interesting  to  me, 
living  in  a  malarial  district  (Twenty  fourth  Ward,  New 
York  City).  According  to  his  observations,  malaria  is 
due  almost,  if  not  exclusively,  to  drinking  water  con- 
taminated by  the  germs  to  which  the  disease  is  attrib- 
uted. That  the  mist,  fog,  etc.,  rising  from  marshy 
ground ;  the  turning  over  of  earth,  incidental  to  filling 
in  and  raising  the  grade  of  roads,  are  incapable  of  caus- 
ing the  disease ;  and  that  no  matter  what  may  be  the 
condition  of  the  soil  and  drainage,  providing  we  do  not 
drink  water  containing  the  germs,  we  will  not  contract 
the  disease. 

While  I  agree  with  Dr.  Daly  that  surface-water  and 
that  from  contaminated  wells  are  one  of  the  prime  factors 
in  causing  the  disease,  I  am  compelled  to  differ  with  him 
as  to  their  being  the  distinct  cause. 

If  he  be  correct  in  his  deductions,  how  can  the  follow- 
ing cases  be  accounted  for  ? 

Some  two  or  three  months  ago,  for  the  purpose  of 
building  sewers  in  my  immediate  neighborhood,  the  city 
authorities  have  been  filling  in  and  raising  the  grade  of 


478 


MEDICAL   RECORD. 


[October  13,  1894 


one  part  of  the  road  with  earth  obtained  by  lowering  it 
at  other  points.  This  work  had  not  been  going  on  very 
long  before  I  began  receiving  patients  suffering  from  pro- 
nounced chills  and  fever.  During  the  months  of  August 
and  September  (to  date,  the  2  2d  inst.,  an  unusually  dry 
spell),  I  treated  twenty- three  cases  of  chills  and  fever, 
and  nine  cases  with  all  the  symptoms  of  malarial  poison 
excepting  the  chill. 

Now,  let  us  see  what  influence  well-  or  surface  water 
had  with  their  sickness.  Close  investigation  resulted  as 
follows :  Of  the  23  cases  where  all  the  symptoms  existed, 
but  3  had  drank  water  from  wells,  2  from  cisterns,  and 
the  remaining  18  from  the  regular  supply  furnished 
through  the  Croton  Water  Department  pipes.  Of  the  9 
cases  where  the  chills  were  absent,  only  1  case  used  well- 
water,  and  the  balance  used  Croton. 

Furthermore,  some  of  my  patients  came  from  families 
consisting  of  from  five  to  eight  members,  and  in  the  ma- 
jority of  these  cases  they  were  the  only  members  suffering 
from  the  disease,  notwithstanding  the  fact  that  the  entire 
family  were  using  the  same  water-supply,  and  living,  as 
far  as  I  could  ascertain,  under  identical  circumstances. 

Admitting  Dr.  Daly's  water  theory,  how  did  the  cases 
using  the  Croton  water-supply  contract  the  disease? 

Admitting  for  the  sake  of  argument  that  the  Croton 
water-supply  for  this  district  may  have  been  contaminated 
by  malarial  germs,  how  is  it  that  the  entire  neighborhood 
is  not  suffering,  as  we  all  use  the  same  water  supply  ? 

As  to  the  drinking  of  contaminated  water  being  one  of 
the  prime  factors,  I  can  offer  proof  positive  in  the  person 
of  myself.  Some  eight  years  ago,  the  house  in  which  I 
then  resided  had  for  its  water-supply  a  cistern  and  a 
well.  After  using  this  well-water  for  drinking  purposes 
for  a  f$w  months,  I  suffered  from  a  very  severe  attack  of 
chills  and  fever.  Upon  investigation  I  found  the  well 
was  receiving  the  leakage  from  an  out  house  as  well  as 
the  surface  drainage.  Upon  discontinuing  its  use  all 
symptoms  disappeared. 

In  conclusion,  while  admitting  the  water-supply  to  be 
a  pronounced  factor  in  causing  malaria,  it  is  not  the  dis- 
tinct or  exclusive  cause.  On  the  contrary,  my  observa- 
tions point  toward  the  mist,  fog,  etc.,  rising  from  swampy, 
marshy  ground,  stagnant  water,  decaying  of  rank  vegeta- 
tion, and  the  turning  over  of  great  quantities  of  fresh 
earth. 

Further  data  upon  this  subject  would  be  both  interest- 
ing and  instructive. 

Joseph  S.  Healky,  M.D. 

Kings  Bridge,  New  York  City,  September  aa,  1894. 


IS  BATHERS*   CRAMP  A  POPULAR  FALLACY? 

To  thb  Editor  op  thb  Medical  Rhoobd. 

Sir  :  It  was  with  great  interest  that  I  read  the  article  en- 
titled "  Bathers'  Cramp,  is  it  a  Popular  Fallacy  "  in  the 
Medical  Record  of  September  ist,  and  I  should  like  to  add 
my  small  contribution  to  the  much  that  has  been  already 
said  upon  this  subject.  I  have  suffered  from  cramp  not  only 
in  the  cold  waters  north  of  Cape  Cod,  but  also  in  the 
warmer  waters  south  of  it.  Now  the  case  quoted  does  not 
seem  to  me  to  be  one  of  genuine  cramp,  for  if  the  attack 
is  severe  it  is  quite  impossible  to  move  the  members  af- 
fected, even  in  a  "  dazed  or  mechanical  way. ' '  I  have  had 
cramp  at  times  in  one  and  both  legs,  and  in  one  or  both 
ankles.  When  attacked  in  one  leg  it  was  in  warm  river 
water,  and  to  get  ashore  was  a  comparatively  easy  mat- 
ter. When  attacked  in  both  legs,  it  was  in  the  warm 
waters  of  New  Bedford  Harbor  (Mass  )  and  it  was 
with  great  difficulty  that  I  reached  shore  by  swimming 
on  my  back,  both  legs  doubled  up  under  me,  and  drag- 
ging myself  up  on  the  beach  with  my  hands. 

This  attack  was  very  painful,  the  muscles  of  the  legs 
tightly  contracted,  violent  pains  in  the  head,  and  nausea. 
Slight  relief  was  experienced  on  the  instant  of  dragging 
the  leg  from  the  water,  but  the  pain  ceased  only  upon 
prolonged  and  vigorous  massage.  Cessation  of  local 
pain  was  followed  by  general  debility,  exhaustion,  se- 


vere headaches,  muscular  fatigue,  and  slight  nausea  for 
two  days. 

I  am  absolutely  certain  that  the  liability  to  cramp  is 
increased  by  tight  garters  worn  either  above  or  below  the 
knee,  tight  shoes,  or  other  obstructions  to  natural  circu 
lation.  I  have  investigated  several  other  cases,  have 
dragged  one  person  so  affected  out  of  the  water,  and  in  all 
there  is  a  tendency  to  double  up  the  legs,  drop  the  head 
forward  and  bend  the  arms  (as  in  the  attitude  of  writing) — 
most  favorable  conditions  to  a  death  by  drowning.  I 
believe  the  tight  garter  to  be  the  cause  of  many  such 
deaths  and  would  most  strongly  caution  all  those  who 
swim  or  bathe,  against  it.  Hoping  that  these  brief  ob- 
servations and  remedies,  which  have  certainly  been  effi- 
cient in  several  cases  of  which  I  have  had  the  treatment, 
may  be  of  interest  and  assistance  to  many  others. 

W.  Louis  Chapman. 

Lynk,  Mass- 

PERMANGANATE  OF    POTASSIUM    IN    OPIUM 
POISONING. 

TO  THE  EDITOB  OF  THB  MlDICAL  RbCOKA. 

Sir  :  Although  it  is  not  a  pleasant  task  to  harshly  criti- 
cise a  confrere,  yet  I  do  not  see  how  I  could  refrain  from 
applying  the  epithet  illogical  to  the  report  by  Dr. 
McGuire  of  a  case  of  morphine  poisoning  published  in 
the  Medical  Record  of  September  15,  1894.  Accord- 
ing to  Dr.  McGuire's  statement,  he  came  near  losing  his 
patient  by  "relying"  on  potassium  permanganate*  A 
brief  analysis  of  the  doctor's  report  will  show  the  aston- 
ishing unreasonableness  of  this  statement  One  hour 
after  the  patient  had  ingested  the  morphine,  Dr.  McGuire 
began  extending  to  hitn  his  medical  aid.  The  following 
three  hours  he  spent  in  resorting  to  the  usual  methods 
in  vogue  in  the  treatment  of  opium  poisoning,  not  omit- 
ting of  course  large  doses  of  sulphate  of  atropine,  and 
incidentally  giving  3  ss.  of  the  fluid  extract  of  ipecac, 
which  the  doctor  naively  observes  did  its  work  fairly 
well  in  an  hour  and  a  half.  After  the  lapse  of  three 
hours,  or  in  other  words,  four  hours  after  the  morphine 
had  been  taken,  Dr.  Earnest  arrived  on  the  champ  de 
batailU  with  a  one-pound  bottle  of  potassium  permanga- 
nate, out  of  which  quantity  the  patient  received  three  or 
four  grains  per  os.  Twenty  minutes  later  the  patient 
sank  into  a  deep  coma,  and  it  was  only  with  the  greatest 
difficulty  that  he  could  be  roused  again. 

This  is  the  resume  of  Dr.  McGuire's  report.  The 
reader  will  probably  agree  with  me  as  to  the  peculiarity 
of  the  doctor's  claim  "  to  have  relied  upon  potassium 
permanganate."  I  wish  he  had  done  so,  for  the  timely 
and  judicious  employ  of  the  remarkable  salt  of  perman- 
ganic acid  would  have  saved  him  a  great  deal  of  trouble 
and  anxiety.  In  the  first  place,  it  would  be  impossible 
for  anyone  reviewing  the  doctor's  report  to  know 
whether  the  three  or  four  grains  of  the  antidote  were 
sufficient,  even  if  they  had  been  administered  immedi- 
ately, as  we  have  no  report  of  the  amount  of  morphine 
taken.  Second :  In  my  original  article  on  the  subject,1 
I  suggested  the  immediate  use  of  from  ten  to  fifteen 
grains  of  the  antidote  well  diluted,  irrespective  of  the 
quantity  of  morphine  taken ;  and  by  what  peculiar  ratio- 
cination the  doctor  could  have  concluded  that  by  admin- 
istering three  or  four  grains  four  hours  later  he  was  fol- 
lowing my  method,  I  am  unable  to  understand.  As  an 
analogue,  if  the  doctor  should  prescribe  a  drachm  of  any 
medicine  to  be  taken  at  a  certain  time,  and  his  patient 
takes  five  minims  three  hours  later,  would  the  failure  of 
the  treatment  reflect  at  all  upon  the  doctor's  method  ? 
Now,  Dr.  McGuire  followed  my  method  to  the  extent 
of  using  the  antidote,  but  as  regards  time  and  quantity 
he  was  wofully  injudicious.  As  to  the  deep  coma  super- 
vening twenty  minutes  after  the  administration  of  Mn,- 
KtO„  it  is  out  of  the  question  that  the  permanganate 
could  have  caused  this.  I  have  yet  to  find  any  thera- 
peutist who  would  impute  narcotic  qualities  to  it.  This 
coma  was  only  a  relapse  which,  as  the  doctor  is  probably 
1  Medical  Record,  February  17, 1894. 


October  13,  1894] 


MEDICAL    RECORD. 


479 


aware,  is  not  an  unusual  feature  of  opium  poisoning. 
However,  it  may  have  been  aggravated  in  this  particular 
case  by  the  large  doses  of  sulphate  of  atropine  which  the 
patient  bad  injected  into  him. 

William  Moor,  M.D. 

355  Boulevard,  New  York,  September  a8( 1894. 


LEPROSY  IN   INDIA. 

To  thb  Editor  of  the  Medical  Record. 

Sir:  On  p.  699  of  the  Medical  Record  for  June  2, 
1894,  in  the  review  of  the  paper  by  Dr.  White  on  the 
subject  of  "Leprosy,"  it  is  stated  that  there  are  in 
India  two  hundred  and  fifty  lepers  to  day.  This  is 
very  far  from  the  truth,  as  the  number  given  by  the  cen- 
sus of  1 89 1  makes  the  number  119,044,  and  this  is  not 
quite  complete,  as  it  is  rather  above  this  number  than 
under. 

In  an  asylum  alone,  not  far  from  here,  there  are  over 
two  hundred.  In  the  asylum  I  have  charge  of  there  are 
one  hundred.  Besides  these  two  asylums,  in  the  Pun- 
jab alone  there  are  over  a  dozen  other  asylums  and  places 
where  lepers  voluntarily  have  congregated.  Some  of 
these  are  under  government  or  other  control,  while  others 
are  simply  places  which  the  lepers  make  a  stopping-place, 
from  which  to  go  out  daily,  or  for  a  few  days  at  a 
time,  begging  for  their  support. 

I  am  sending  you  by  tins  mail  reports  of  this  asylum 
for  1892  and  1893. 

Yours  very  truly, 

Th.  B.  Carleton,  M.D., 
Superintendent  Leper  Asylum. 

Sabathf,  Punjab,  North  India. 


TABLET  TRITURATES. 

To  tub  Editor  of  the  Medical  Record. 

Sot:  If  space  permits,  will  you  allow  me  to  point  out  a 
matter  that  needs  some  correction.  I  think  it  will  be 
acknowledged  that  tablet  triturates  have  come  to  stay,  at 
least  for  many  years  to  come,  they  are  certainly  a  "  con- 
venient and  elegant "  method  of  medication,  but  as  pre- 
pared at  present  I  think  they  are,  at  times,  far  from 
being  "  safe  and  accurate  "  as  the  manufacturers  claim. 

I  have  carefully  examined  samples  from  several  differ- 
ent manufacturers  in  various  States  and  find  the  same 
objection  to  all,  namely  that  the  ingredients  are  not 
triturated  but  simply  mixed.  This  might  do  very  well 
where  the  medicines  are  of  a  harmless  nature,  although 
by  no  means  commendable,  but  when  tablets  containing 
arsenic,  strychnine  and  the  like  are  so  carelessly  made 
that  you  can  dig  out  the  various  combinations  with  a 
sharp-pointed  knife  under  the  naked  eye,  I  think  it  is 
time  to  cry  halt.  I  verily  believe  that  I  have  seen  evil 
effects  from  several  such  tablets,  and  if  I  know  of  any 
better  make  I  should  leave  all  the  others  alone,  but,  as  I 
said  before,  I  find  them  all  alike. 

In  my  humble  opinion  all  mixtures  ought  to  be  ground 
and  triturated  so  that  the  finished  tablet  should 
exhibit  one  uniform  color  throughout  the  whole,  and 
that  the  individual  drugs  should  not  be  distinguishable 
even  under  a  moderate  magnifying  glass.  Only  such 
can  be  safe. 

"Country  Doctor." 

East  Eddihgton,  Mb.,  September  io,  1894. 


A  lew  Salt  in  an  Ammoniacal  Urine.  —Cases  of  per- 
sistent and  marked  alkalinity  of  the  urine,  due  to  long  ad- 
ministration of  much  lime-water,  will  be  found  on  ex- 
amination to  be  instances  of  ammoniacal  urine  due  to  the 
presence  of  a  salt  of  carbamic  acid.  If,  however,  the  lime- 
water  is  given  in  large  quantities  and  continuously,  it  will 
lower  the  total  output  of  ammonia  as  markedly  as  do  the 
carbonates  of  the  fixed  alkalies,  though  then  lime-water 
causes  the  appearance  of  free  ammonia,  which  sodium  car- 
bonate does  not  do. — Abel. 


Contagious  Diseases  — Weekly  Statement— Report  oi 
cases  and  deaths  from  contagious  diseases  reported  to  the 
Sanitary  Bureau,  Health  Department,  for  the  week  end- 
ing October  6,  1894. 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis 

Measles 

Diphtheria 

Small-pox 


Cases. 


Deaths. 


129 

84 

«S 

17 

«4 

4 

0 

2 

18 

4 

112 

21 

9 

1 

The  Typhoid  Spine. — It  is  very  probable  that  several 
distinct  sequelae  of  typhoid  fever  have  been  called  "The 
Typhoid  Spine."  Four  cases  of  neurosis  following  en- 
teric fever  are  described  by  Dr.  William  Osier  in  the  fourth 
volume  of  the  Johns  Hopkins  Hospital  Reports.  In  de- 
fence of  the  neurosis  theory  he  states  that  joint  and 
periosteal  troubles  are  by  no  means  rare  sequences  of  ty- 
phoid fever,  but  that  such  symptoms  do  not  usually  de- 
velop after  convalescence  has  been  for  some  time  well  es- 
tablished, and  that  the  periostitis,  which  is  seen  more 
frequently  about  the  sternum  and  ribs,  proceeds  as  a  rule 
to  suppuration.  Periosteal  swellings  may  disappear  with- 
out suppuration,  though  periosteal  thickenings  protracted 
through  weeks  and  months  usually  develop  abscesses. 
Yet  it  is  difficult  to  conceive  of  attacks  of  pain,  lasting 
for  months,  due  to  a  simple  perispondylitis,  which  in  none 
of  the  four  cases  passed  on  to  suppuration.  Though 
neurasthenia  may  not  be  the  cause  of  all  cases  of  "  The 
Typhoid  Spine,"  these  four  patients  gave  Dr.  Osier  that 
general  impression,  and  it  seems  to  him  as  probable  that 
many  of  the  cases  are  simply  examples  of  the  painful  neu- 
rosis known  as  "spinal  irritation/9  and  analogous  to  the 
painful  condition  met  with  in  the  "  hysterical  spine,"  in 
both  of  which  the  patients  may  have  pains  on  the  slightest 
movements  of  the  back  or  of  the  legs.  In  one  of  the 
cases  the  rapid  recovery  in  a  few  days,  with  the  disap- 
pearance of  all  the  symptoms,  was  quite  inconsistent  with 
a  chronic  perispondylitis.  In  the  four  cases  of  this  sequela 
of  enteric  fever,  described  by  Dr.  Gibney,  of  New  York, 
as  "The  Typhoid  Spine,"  there  was  the  production  of 
pain  on  the  slightest  movement,  whether  lateral  or  for- 
ward, and  the  absence  of  any  marked  febrile  disturbance 
or  neuralgia.  All  the  painful  backs  after  typhoid  fever 
may  not  be  neurotic,  however,  as  there  is  a  possibility  of 
the  existence  of  perispondylitis  in  some  cases. 

The  Spirit  of  Quackery  within  the  Pale  of  the  Pro- 
fession.— In  an  address  delivered  at  the  annual  meeting 
of  the  Midland  Branch  by  Dr.  J.  West  Walker,  the  au- 
thor, after  referring  to  the  characteristics  of  quackery  in 
its  barest  and  most  uncompromising  forms,  proceeded 
to  inquire  whether  or  no  the  enemy — quackery — had 
gained  an  entrance  within  the  profession.  He  animad- 
verted upon  the  tendency  on  the  part  of  certain  dealers 
to  advertise  proprietary  preparations  with  an  amount  of 
elaboration  which  appeared  to  him  to  be  quite  uncalled 
for  (The  British  Medical  Journal).  He  then  turned  to 
the  attitude  of  consultants  with  regard  to  treatment, 
taking  occasion  in  the  first  place  to  pay  a  high  compli- 
ment to  the  diagnostic  skill  commonly  exhibited,  and 
frankly  admitting  that  assistance  in  treatment  was  often 
obtained  from  them.  But,  he  added,  when  I  send  to  a 
consultant  I  invariably  ask  myself  what  novelty  shall  I 
have  to  procure,  and  this,  notwithstanding  it  is  the  rule 
to  have  my  surgery  well  supplied  with  most  of  the  estab- 
lished therapeutic  agents.  The  recently  born  mineral 
water  or  proprietary  dietetic,  the  endless  variety  of  the 
carbon  derivatives  with  their  break- jaw  names,  the  latest 
importation  from  America,  some  form,  of  course,  of  an- 
tiseptic, the  newest  tabloid,  capsule,  or  cachet,  or  some 


480 


MEDICAL    RECORD. 


[October  13,  1894 


drag,  it  may  be,  not  to  be  found  in  the  Pharmacopoeia 
nor  the  usual  trade  lists,  but  only  to  be  obtained  from  a 
particular  chemist ;  these  and  such  like  form  a  tempting 
catalogue  of  choice  novelties  from  which  selection  may 
be  made  according  to  fancy.  I  make  it  a  point  of  honor 
scrupulously  to  carry  out  the  consultant's  plan  of  treat- 
ment,  but  if  the  case  be  chronic,  say  of  cardiac  or  renal 
mischief,  I  soon  find  that  one  by  one  these  addenda  are 
dropped  and  that  the  general  management  of  the  case 
falls  back  upon  the  original  adviser.  He  has  to  bring 
into  play  all  the  skill  and  judgment  he  may  be  possessed 
of  to  meet  the  various  and  varying  symptoms  as  they 
arise,  aided  and  supported  by  the  line  of  right  principle 
which  he  has  received  ftom  his  professional  brother. 
Bat  more,  our  patients  usually  return  to  us  loaded  with 
minute  instructions  as  to  diet  and  regimen. 

Unfortunately,  especially  in  the  matter  of  diet,  these 
instructions  are  by  no  means  uniform.  Different  advls 
ers  give  different  advice.  Quot  homines  tot  sententia. 
The  old  adage  that  "  what  is  one  man's  meat  is  another 
man's  poison  "  seems  to  be  completely  lost  sight  of,  and 
anyone  whose  inclination  prompts  him  to  do  it  can  eas- 
ily ride  his  hobby  to  death  among  the  intricate  bypaths 
of  dietary  tables.  Exact  details,  both  as  to  quantity  and 
quality  of  the  fish,  oi  the  flesh,  of  the  vegetable  which 
only  are  to  be  allowed ;  nice  distinctions  as  to  what  bev- 
erages may  be  swallowed;  careful  directions  as  to  the 
time  for  the  infusion  of  tea ;  explicit  rules  as  to  meals, 
exercise,  and  habits  generally ;  these  and  similar  minu- 
tiae are  laid  down  and  eo joined  with  great  exactitude. 
If  the  patient  can  be  induced  to  have  faith  in  this  dog- 
matism and  obey  it,  if  he  adhere  strictly  to  the  diet  and 
regimen  laid  down  for  him,  if  he  become  afraid  of  the 
taunts  of  kind  friends  on  the  least  infringement  of  the 
doctor's  orders,  benefit  to  health  will  generally  follow. 
If  the  patient  who  is  in  the  habit  of  dining  off  half  a 
dozen  courses  and  of  making  his  other  meals  proportion- 
ate, who  freely  partakes  of  beer,  wine  in  variety,  and 
whiskey  and  soda — if  such  a  patient  can  be  induced  to 
forsake  his  gustful  yet  disgusting  diet  and  daily  to  take 
instead  four  pints  of  hot  water  and  sundry  messes  of 
minced  beef,  it  is  easy  to  see  that  good  will  be  done  by 
the  change,  at  any  rate,  for  a  time.  And  since  the  end 
is  usually  greater  than  the  means,  and  since  the  end  of 
professional  effort  must  ever  be  the  patient's  good,  some- 
thing may  be  said  in  favor  of  means  which  conduce  to 
such  a  desirable  end,  even  though  they  be  a  wee  bit  ir- 
regular. May  it  not  be  well,  however,  to  ask  ourselves 
and  fully  realize  the  answer  to  the  question,  How  far  are 
these  good  results  the  positive  effects  of  what  we  cause 
our  patient  to  do,  and  how  far  the  negative  effects  of 
what  we  cause  him  not  to  do?  The  removal  of  some 
vicious  habit,  some  worrying  occupation,  or  some  un- 
healthy environment  may  really  be  the  cause  of  good, 
and  our  remedies  only  contribute  to  bring  about  the  re- 
sult by  the  oblique  rather  than  by  the  direct  method. 
As  before  hinted,  the  oblique  method  may  have  some- 
thing to  commend  it,  and  the  practice  of  it  may  even,  like 
homicide,  be,  under  some  circumstances,  justifiable.  Let 
not  our  eyes  be  dusty.  If  we  strip  this  line  of  practice  of 
adornment,  and  look  upon  it  in  its  nakedness,  we  in  too 
many  instances  recognize  so  many  of  the  family  features 
that  if  we  would  call  a  spade  a  spade  we  can  designate 
it  by  none  other  than  the  family  name.  It  may  be  that 
stratagem  in  medicine,  as  in  war,  must  still  be  occasion- 
ally resorted  to ;  be  ours  the  care  lest  we  award  to  the 
victory  won  by  it  glory  in  amount  equal  to  that  which 
we  bestow  upon  the  result  of  a  hand-to-hand  encounter. 

Returning  again  to  the  subject  of  new  remedies,  Dr. 
Walker  observed  that  a  new  drug  which  was  really  useful 
required  little  advertisement.  Of  this  the  history  of  the 
introduction  of  chloral  and  cocaine  was  sufficient  proof. 
He  protested  against  the  abuse,  not  the  use,  of  adver- 
tisement; while  condemning  credulity,  he  would  not 
favor  its  opposite — a  dogged  scepticism,  which  in  an 
inexact  science,  such  as  medicine,  was  perhaps  even 
more  harmful  than  credulity.     In  conclusion,  he  uttered 


a  note  of  warning  as  to  the  practice  of  prescribing  mixt- 
ures in  strong  form,  to  be  taken  in  doses  of  one  or  two 
drachms  or  of  so  many  minims.  To  prescribe  concen- 
trated mixtures  of  strychnine,  of  arsenic,  or  of  mercuric 
perchloride,  and  direct  them  to  be  given  in  various  de- 
grees of  dilution  was,  he  considered,  a  custom  fraught 
with  danger.  To  place  side  by  side  on  the  nurse's  table, 
often  in  a  dimly  lighted  room,  two  bottles  of  equal  size 
— the  one  containing  sulphate  of  magnesia  to  be  given 
in  doses  of  two  tablespoonfuls,  the  other  containing 
chloral  to  be  given  in  doses  of  one  teaspoonful — was  a 
risky  procedure,  and  one  which,  were  the  directions 
never  so  explicit,  paved  the  way  for  that  terrible  catas- 
trophe— poisoning  by  misadventure. 

Treatment  of  the  Milk  Teeth. — According  to  The 
Lancet,  Mr.  Edmund  0*en  read  a  short  but  interesting 
paper  on  this  subject  at  a  meeting  of  the  Odontological 
Society.  He  asked  the  question  whether  it  was  always 
the  best  plan  to  stop  decayed  milk  teeth,  and  whether  it 
was  really  an  advance  in  treatment.  He  thought  that 
in  some  other  branches  of  surgery  many  so  called  im- 
provements had  in  fact  put  back  the  dial  of  surgery,  and 
that  dentists  were  carrying  conservative  treatment  too 
far,  hesitating  to  extract  from  fear  that  the  due  develop- 
ment of  the  jaws  would  be  interfered  with,  or  that  the 
second  teeth  would  have  to  scramble  for  position  after 
premature  loss  of  the  temporary  teeth ;  but  in  his  opin- 
ion the  development  was  due  to  the  presence  of  the  tooth- 
sacs  contained  in  the  substance  of  the  bone,  and,  with 
regard  to  the  crowding,  should  it  take  place,  it  could  be 
easily  remedied  by  careful  watching  and  weeding  out  if 
necessary.  He  said :  "  There  is  one  point  in  connec- 
tion with  the  dental  surgery  of  children's  teeth  which  I . 
am  sure  has  not  received  the  attention  which  it  so  ur 
gently  demands — it  is  that  children's  mouths  should  un- 
dergo regular  periodical  inspection."  Mr.  Owen  laid 
especial  stress  upon  the  removal  of  carious  teeth  where 
there  was  enlargement  of  a  lymphatic  gland  in  the  neck, 
which,  hs  said,  so  many  dentists  refused  to  do,  probably 
foreseeing  some  possible  contingency  in  connection  with 
the  eruption  of  the  permanent  teeth.  Where  the  pulp 
of  a  tooth  was  exposed  it  was  an  extremely  painful  and 
difficult  thing  to  do  to  clear  out  each  fang  thoroughly, 
and  unless  this  were  done  it  was  merely  "  rolling  a  stone 
over  a  whited  sepulchre,"  and  further  trouble  was  in 
evitable.  The  very  germ  with  which  the  dental  surgeon 
temporized  in  the  alveolar  region  was  often  subsequently 
encountered  in  a  submaxillary  glandular  abscess,  but  Mr. 
Owen  thoroughly  agreed  with  stopping  milk  teeth  where 
the  carious  cavities  were  small  or  could  be  rendered  ab- 
solutely aseptic. 

A  8tatus  to  Thomas  Sydenham  was  unveiled  by  the 
Marquis  of  Salisbury  at  the  recent  meeting  of  the  British 
Association  for  the  Advancement  of  Science,  at  Oxford. 
The  presentation  was  made  by  Sir  Henry  Acland,  Regius 
Professor  of  Medicine  to  the  University. 

Mineral  Matter  in  Teeth  and  Bonos. — The  framework 
of  the  bones  and  teeth  contains  lime,  phosphoric  acid, 
magnesia,  potash,  soda,  carbonic  anhydride,  water, 
chlorine,  and  fluorine.  The  water  of  crystallization 
passes  off  at  a  very  high  temperature,  but  the  constituent 
water  can  be  separated  only  by  fusion  with  silicic  acid. — 
Gabriel. 

Tobacoo  and  Fatigue. — Moderate  smoking,  in  one  ac- 
customed to  tobacco,  neither  increases  the  amount  of 
work  done,  nor  retards  the  approach  of  fatigue.  On  the 
contrary,  it  perhaps  slightly  diminishes  muscular  power, 
and  hastens  the  onset  of  fatigue,  though  these  positive 
effects  could  not  be  conclusively  demonstrated. — Harley. 

The  Future  of  Children  with  Hip-disease. — Accord- 
ing to  Bruns,  six  per  cent  of  patients  under  ten  years  of 
age,  who  have  been  cured  of  hip  disease,  nine  per  cent, 
of  those  between  ten  and  twenty  years,  and  seven  per 
cent  of  those  above  twenty  years  of  age,  succumb  event- 
ually to  tuberculosis  of  other  organs. 


Medical   Record 

A  Weekly  youmal  of  Medicine  and  Surgery 


Vol.  46,  No.  16. 
Whole  No.  1250. 


New  York,  October  20,  1894. 


$5.00  Per  Annum. 
Single  Copies,  ioc. 


<$rifiitml  Articles. 

CONSUMPTION:  ROUGHING  IT  VS.  THE  COD- 
DLING TREATMENT. 

By  CHARLES   E.   PAGE,  M.D., 

BOSTON,    MASS. 

"  Consumption  "  is  the  same  bite  noire  to-day  that  it  has 
ever  been.  It  is  everywhere  regarded  as  incurable,  once 
fastened  upon  its  victim.  And  yet,  the  records  of  the 
dissecting  room  prove  that  in  numerous  cases  lungs, 
"  wasted  to  one-half  of  their  normal  size  have  been  healed, 
and  after  a  perfect  cicatrization  of  the  tuberculous  ulcers 
have  for  years  performed  all  the  essential  functions  of  the 
sound  organ"  (Oswald).  This  fact,  with  all  its  great 
significance,  should  be  impressed  upon  the  mind  of  every 
medical  student.  It  is  doubtless  true  that  in  every  in- 
stance* of  all  who  live  to  tell  the  tale  of  an  inherited  or 
acquired  tendency  to  pulmonary  emphysema  and  of  its 
banishment,  we  would  find  a  history  of  either  an  en- 
forced or  a  voluntary  change  from  an  in  door  to  an  out- 
door life,  with  some  radical  modification  of  the  living 
habits  of  the  individual,  especially  in  the  matter  of  his 
activities. 

The  writer  recalls  the  case  of  a  cousin  who  was  killed 
in  California  by  being  rolled  down  a  mountain's  side 
under  a  drive  of  logs.  Possibly  the  first  log  that  rolled 
over  him  did  the  business,  but  it  was  said  by  his  com- 
panions at  the  time  that  nothing  short  of  that  sort  of 
treatment  could  ever  have  killed  this  giant  of  6  feet  3 
inches,  weighing  220  pounds,  and  noted  for  his  muscular 
strength.  And  yet,  throughout  his  boyhood  and  to  the  age 
of  fifteen,  he  was  about  the  poorest  specimen  of  humanity 
imaginable.  No  one  believed  that  this  cadaverous,  y  ellow- 
white  faced,  round-shouldered,  hollow  chested  lad,  with  a 
"grave  yard  cough,"  would  live  to  reach  maturity,  least 
of  all  become  a  robust  man.  No  news  concerning  my 
cousin's  condition  reached  me  during  an  absence  from 
home  of  about  two  years,  and  one  may  imagine  my 
amazement  when  at  our  first  meeting  I  looked  up  at  the 
face  of  a  six- foot  athlete  claiming  to  be  the  cousin  whom 
I  left  in  so  sad  a  plight. 

What  had  wrought  this  seeming  miracle  ?  Simply  an 
enforced  change  from  the  life  of  a  molly  coddle  to  that 
of  a  worker  in  the  open  air.  My  uncle  was  the  ferryman 
at  N.,  a  little  village  on  the  Kennebec,  in  Maine,  and 
owing  to  an  illness  his  only  son  was  compelled  to  take  up 
the  work,  which,  though  desultory,  required  the  putting 
forth  of  all  the  muscular  power  to  which  he  could  whip 
himself,  and  exposure  to  all  manner  of  rough  weather. 
Instead  of  dying  outright,  as  his  poor  parents  feared,  it 
was  soon  evident  that  his  new  life  agreed  with  him ;  he 
began  to  mend,  and  it  was  doubtless  owing  to  his  father's 
prolonged  sickness  that  the  boy  got  his  start  toward  robust 
health. 

Instances  more  or  less  similar  to  the  one  just  related 
are  constantly  occurring,  but  their  true  lesson  is  appre- 
ciated only  by  the  few.  Into  another  consumptive's 
head  there  came  in  some  way  the  crankish  notion  of  be- 
ginning the  practice  in  summer  of  taking  a  cold  plunge 
and  swim  in  the  neighboring  pond  and  of  continuing 
it  throughout  the  year,  breaking  the  ice  in  winter  for  his 
morning  bath.    Result :  A  perfect  cure. 

Another  case  that  came  under  my  notice  was  that  of  a 
young  man  who  had  as  a  clerk  in  a  store  fallen  into  de- 


cline and  was  forced  to  resign  his  position.  He  con- 
sulted me  and  was  for  a  time  under  my  care.  He  1  ad  at 
first  no  appetite,  little  strength,  an  emaciated  body,  and 
a  distressing  cough.  He  begun  to  improve  somewhat, 
but  was  greatly  disturbed  by  his  enforced  idleness,  with 
all  that  this  implied  to  a  man  with  an  ailing  wife  and 
child  requiring  support,  and  one  day  he  informed  me 
that  a  friend  of  his  wanted  a  man  to  drive  a  milk  wagon 
and  would  give  him  the  job,  and  by  my  advice  he  ac- 
cepted. Hustling  out  of  bed  at  1  a.m.  first  in  the  fall, 
and  then  throughout  the  winter,  for  a  long  drive,  often  in 
bitter  weather,  regardless  of  rain  or  snow ;  to  jump  off 
and  on  the  cart  in  the  delivery  of  his  wares,  gave  him  a 
boom  toward  health  that  resulted  finally  in  making  him 
a  robust  man. 

An  acquaintance  of  mine,  once  wealthy,  lost  all  of  his 
property  except  a  "  consumptive  "  horse  that  he  had  been 
keeping  "  for  the  good  he  had  done,"  and  whose  ill  con- 
dition had  resulted  from  high  living  and  a  sedentary  life. 
His  master  finally  started  a  little  grocery  business,  and 
at  the  risk  of  arrest  by  the  agent  of  the  Society  for  the 
Prevention  of  Cruelty  to  Animals,  he  began  delivering 
groceries  with  the  "  patient."  After  a  time  the  poor 
creature  began  to  show  signs  of  picking  up,  and  as  busi- 
ness increased,  the  work,  of  course,  became  harder ;  but 
the  more  he  did  the  more  he  could  do,  and  within  a  year 
this  hide  bound  victim  of  misplaced  kindness  was  again 
the  plump,  smooth,  handsome  creature  that  first  attracted 
his  master's  attention.  At  that  time  he  was  fat,  and  he 
looked  fat  now,  but  this  appearance  was  due  to  a  fully 
developed  muscular  system,  the  result  of  hard  work  and 
enough  to  eat,  with  the  natural  improvement  in  digestion 
and  assimilation  from  plenty  of  exercise  in  the  open  air. 

As  an  illustration  of  the  benefits  arising  from  chest  ex- 
ercise, we  have  the  case  of  the  consumptive  who  received 
a  wound  in  the  leg  and  had  to  employ  crutches.  Find- 
ing that  their  use  seemed  to  relieve  his  cough,  helped  him 
in  the  matter  of  "raising,"  etc.,  he  got  in  the  way  of 
hobbling  about  as  much  as  his  strength  would  permit,  ard 
this  naturally  meant  more  and  more,  until  by  the  time  he 
could  use  his  legs  with  freedom  he  was  on  the  road  to 
high  health,  and  he  did  become  healthy. 

A  few  years  ago  a  prominent  Connecticut  physician 
died,  and  an  autopsy  was  made  with  the  expectation  of 
viewing  a  "  lung  and  a  fraction,"  with  which  he  had  lived 
for  thirty  years,  after  a  prominent  Boston  doctor,  in  con- 
sultation with  the  late  Dr.  Willard  Parker,  of  New  York, 
had  declared  that  he  could  not  live  a  year.  He  had  then 
just  graduated,  and  he  took  his  case  into  his  own  hands, 
and  began  a  system  of  roughing  it,  out  in  all  weathers, 
eating  freely  of  hearty  food,  for  which  he  gained  an  ap- 
petite by  a  nip  of  brandy  at  dinner.  He  became  a  robust 
man,  and  died  finally  of  chronic  gastritis  resulting  from 
sticking  to  the  brandy  habit  I  His  lungs  were  both  sound, 
and  the  doctors'  diagnosis  was,  therefore,  absolutely 
wrong ;  but  their  prognosis  would  without  a  doubt  have 
proved  correct  but  for  his  right  about  face  and  the 
adoption  of  the  bulldozing  treatment,  so  to  say. 

The  writer  has  long  since  adopted  this  principle  in  the 
treatment  of  "  consumption,"  which  he  regards  as  a  dis- 
ease of  dyspeptic  starvation.  In  its  final  issue,  in  cases 
that  terminate  fatally,  patients  really  die  of  fatty  de- 
generation of  the  lungs)  so  far  as  the  local  lesion  is  con- 
cerned. There  is  utter  lack  of  full,  free  exercise  of  the 
lungs;  the  easygoing,  loafing  patient  does  not  half 
breathe,  from  lack  of  such  physical  exercise  as  would 


482 


MEDICAL   RECORD. 


[October  20,  1894 


cause  involuntary  deep  breathing ;  and  as  a  consequence 
the  lung  tissues  degenerate  with  fat,  as  is  true  also  of  the 
entire  muscular  system. 

Something  like  a  dozen  years  ago,  at  a  meeting  of  the 
New  Orleans  Pathological  Society,  Dr.  H.  D.  Schmidt, 
whose  researches  had  been  extended  and  minute,  made 
an  important  microscopical  demonstration  for  the  pur- 
pose of  disproving  Professor  Koch's  so-called  discovery 
as  to  the  bacilli  of  tuberculosis.  Professor  Schmidt 
claimed  to  demonstrate  that  the  "bacilli"  were  simply 
fatty  crystals,  but  he  at  least  succeeded  in  showing  that 
the  condition  of  the  lungs  was  one  of  fatty  degeneration. 
We  know,  however,  that  the  diseased  lungs  do  contain  mi- 
nute living  organisms,  but  it  is  evident  to  my  mind  that 
the  bacillus  is  simply  a  natural  scavenger  of  the  decaying 
tissue,  and  that  its  function  is  really  life-conserving. 

It  has  for  years  been  my  practice  to  treat  consumptive 
patients  on  the  plan  indicated  in  the  foregoing  para- 
graphs ;  the  roughing,  toughening,  hustling  plan,  varied 
according  to  the  special  needs  of  each  individual,  which 
occasions  a  demand  for  a  generous  amount  of  wholesome 
food,  with  appetite  and  digestion  to  correspond.  The 
result  is  as  satisfactory  when  the  treatment  is  prescribed 
by  an  expert  as  when  it  is  merely  the  outcome  of  acci- 
dent, and  I  will  venture  to  introduce  here  a  couple  of 
instances  of  radical  cure. 

B.  H ,  at  present  one  of  our  noted  American  ar- 
tists in  Paris,  came  under  my  care  in  March,  1885,  after 
a  three  years'  decline  in  Paris  and  London,  and  a  return 
to  his  native  Philadelphia  to  die,  as  they  all  believed, 
under  the  care  of  the  old  family  doctor.  The  latter 
ordered  him  to  Colorado,  as  is  still  quite  the  usual  cus- 
tom in  hopeless  cases,  to  loaf  away  the  remnant  of  his 
life.  He  returned,  however,  after  a  few  months'  stay, 
unimproved,  and  it  was  at  this  point  of  the  case  that  he 
wrote  to  me  the  history  of  his  condition  and  asked  my 

advice.    After  a  few  weeks'  correspondence  H and 

his  wife  came  to  Boston,  that  the  patient  might  be  di- 
rectly under  my  eye.  He  had,  meantime,  made  a  slight 
gain,  and  could  do  more  rather  than  "  crawl  a  mile  on 
level  going,"  as  he  described  his  physical  powers  in  his 
first  letter.  He  could  manage  a  couple  of  miles  without 
extreme  fatigue,  and  from  day  to  day  I  cracked  the  whip 
over  his  back,  so  to  say,  to  secure  something  of  a  gain 
in  speed  and  distance  at  each  trial,  as  well  as  in  the 
number  of  his  daily  walks,  with  ample  rests  between, 
chiefly  lying  down.  He  was  a  brave  fellow  and  he  en- 
tered into  the  plan  with  all  the  spirit  he  could  muster. 
Oq  rising  from  bed  he  was  directed,  as  a  daily  practice, 
to  take  a  quick  dash  of  cold  water  all  over,  a  good 
towelling,  and  an  air-bath  of  a  half- hour  or  more,  with 
such  all-around  exercises  as  he  could  manage.  After  a 
few  weeks  he  would,  naked,  pull  at  the  chest-weights  for 
an  hour  or  more  before  breakfast,  like  a  man  sawing  wood. 
Light,  low-cut,  loose  shoes,  only,  were  worn.  He  went 
barefoot  several  hours  every  day.  Before  the  end  of 
summer  he  could  do  fifteen  miles  in  the  course  of  the 
day,  at  several  stretches,  including  a  good  bit  of  run- 
ning, and  was  eating  hungrily  twice  a  day  of  pood  plain 
food.  Three  tonics  only  were  exhibited:  Fresh  air, 
fasting,  and  exercise.  My  counsel  to  him  was  what  it 
ever  is  to  all  classes  of  patients :  Never  eat  unless  hun- 
gry. To  eat  without  appetite  is  a  species  of  self-abuse 
inexcustble  for  the  sick  or  well.  Never  eat  when  tired, 
nor  exercise  actively  soon  after  eating.  Learn  to  dis- 
tinguish between  hunger  and  mere  appetite  ;  let  the  test 
be  the  least  appetizing  foods ;  and  if  hungry  enough  to 
enjoy  such,  one  may  partake  of  the  more  agreeable  kinds, 
as  a  steak  or  chop,  a  mellow  ripe  banana,  new  peas, 
corn,  string- beans,  all  of  the  seasonable  fruits,  berries, 
melons,  etc  ,  but  the  consumptive,  of  all  men,  must 
avoid  gormandizing. 

In  October,  affr  seven  months'  physical  training, 

H and  his  wife  returned  to  France,  and  within  a 

year  thereafter  he  was  enabled  to  report  himself  "  as 
sound  as  a  dollar."  I  have  heard  from  him  every  year, 
and  he  remains  still  a  typically  healthy  man. 


R.  T.  S ,  aged  twenty-three,  a  most  unpromising 

subject,  weighing  on  my  scales  99  pounds,  came  to  this 
town  to  be  under  my  care,  in  February,  1887.  His  ap- 
pearance was  so  pitiful  as  to  almost  excite  disgust.  His 
weakness  was  so  extreme  that  his  brain  was  seriously  af- 
fected. But  he  setmed  in  dead  earnest  to  get  my  ideas 
on  every  point  to  carry  them  out  to  the  letter.  He  kept 
most  of  the  time  in  the  open  air,  regardless  of  the 
weather,  worked  up  gradually  in  his  training,  indoors 
and  out.  but  he  grew  restive  from  having  nothing  to  do 
but  attend  to  himself.  He  finally  conceived  the  notion 
of  canvassing  from  house  to  house  for  orders  for  provi- 
sions as  a  means  of  keeping  himself  out  of  doors  and  his 
mind  occupied  with  something  beside  his  own  symptoms. 
His  success  was  largely  due  to  the  pity  excited  by  his 
forlorn  appearance.  He  would  get  his  orders,  and  then 
visit  the  large  markets  and  buy  the  meats  and  provisions 
to  fill  them.  He  was  therefore  a  merchant  and  had  the 
stimulus  of  looking  for  profits.  All  this  work  was  on 
foot  in  all  weathers  during  March,  and  continuously 
thereafter,  and  he  began  to  gain  in  weight  and  strength. 
In  May  he  weighed  no  pounds,  and  the  following  year 
he  tipped  the  beam  at  145,  and  was  a  bright,  handsome 
fellow. 

In  both  these  cases  the  patients  at  once,  by  my  direc- 
tion, abandoned  the  use  of  the  heavy  flannels  they  were 
wearing  when  they  consulted  me,  though  they  were,  of 
course,  well  protected  from  the  cold  when  out  of  doors 
by  means  of  outer  garments.  The  disuse  of  undei-flan- 
nels  as  an  important  part  of  hygienic  treatment  will 
doubtless  fail  to  commend  itself  to  most  of  my  readers ; 
but  in  a  very  busy  practice  during  the  past  ten  years  I 
have  invariably  urged  the  plan  upon  my  consultants,  and 
I  have  succeeded  in  a  large  number  of  instances  in  in- 
ducing them  to  abandon  the  use  of  underwear  altogether, 
not  even  compromising  with  light-weight,  and  I  have 
never  had  occasion  to  regret  it ;  but,  on  the  other  hand, 
I  have  won  the  gratitude  of  every  individual  who  has 
given  the  plan  a  fair  trial. 

Is  it  not  clear  to  every  reflective  mind  that  in  all  ordi- 
nary homes  we  and  our  patients  are  living  in  summer 
weather,  so  to  say,  even  in  mid-winter  ?  Why,  then, 
should  we  wear  winter  flannels  in  the  house  ?  The  em- 
ployment of  outer  garments  for  out-door  wear  meets  all 
the  requirements  for  comfort,  and  all  the  better  when 
the  skin  is  not  sweltered  by  flannels  in  the  heated,  often 
over-heated,  living-rooms ;  and  I  have  observed  as  an 
invariable  rule  that  those  who  have  adopted  the  plan 
here  advised  are  the  most  indifferent  as  to  the  use  of 
outer  garments  when  they  do  go  out,  even  in  winter. 
It  is  the  ones  who  swelter  the  skin  with  heavy  flannels  in 
their  warm  dwellings,  offices,  stores,  etc.,  who  shiver 
most  in  cold  weather  in  spite  of  the  heaviest  sealskin 
sacques  or  fur-lined  top  coats. 

The  writer  has  worn  no  flannels,  winter  nor  summer, 
since  February,  1880,  removing  during  this  winter 
month,  the  heaviest  of  Morley's  Scotch  undershirts  and 
drawers.  For  years  he  had,  in  his  efforts  after  comfort, 
selected  his  winter  flannels  from  garments  of  heavier 
weight  each  fall ;  but  all  to  no  purpose,  except,  seem- 
ingly* to  make  him  subject  to  a  kind  of  chills  and  fever, 
very  sensitive  to  cold  when  out  of  doors,  and  exceedingly 
uncomfortable  indoors  at  all  times,  ard  also  out  doors  in 
moderate  weather.  He  was  subject  to  f  equent  "  colds  " 
affecting  throat  and  lungs,  and  a  constant  sufferer  from 
cold  feet,  and  in  fact  was  in  a  condition  to  sltfe  into  a 
consumptive's  grave,  as  had  quite  a  number  of  his  near 
relatives  who  died  in  their  flannels !  But  now,  at  the 
ape  of  fifty  four,  he  is  one  of  the  most  robust  of  men, 
able  to  lead  most  of  the  young  men  in  a  cross  country 
run,  not  limiting  the  distance.  And  this  change  was 
produced  by  the  abandonment  of  th*  coddling  plan,  re- 
placing it  with  a  rational  application  of  the  rough-and- 
, tumble  scheme  outlined  in  this  paper. 

"It  is  not  always  realized  that  the  abilitv  of  man  to 
carry  his  climate  with  him,  or  essentially  modify  it  wher- 
ever he  chances  to  be  located,  is  a  power  that  can  be 


October  20,  1894] 


MEDICAL   RECORD. 


483 


used  for  harm  as  well  as  benefit/'  says  the  Philadelphia 
Polyclinic^  editorially.  "  When  we  depart  from  the 
guidance  of  the  immediate  sensations  and  race  instincts, 
and  shape  our  conduct  according  to  definite  ideas,  we 
accept  a  guide  that  may  be  better  or  worse  than  those  of 
nature ;  and,  in  the  matter  of  clothing,  there  can  be  no 
question  bat  that  incorrect  ideas  lead  many  into  the  very 
disease  and  danger  that  they  are  striving  to  avoid. 

"All  observation  shows  that  for  individuals  in  com- 
parative health,  no  possible  regulation  of  environment, 
either  in  the  selection  of  a  natural  climate,  in  the  con- 
struction and  heating  of  dwellings,  or  the  choice  of  ma- 
terial and  amount  of  clothing,  can  supersede,  or,  indeed, 
compare  in  importance  with  the  influence  of  the  physi- 
ological mechanism  for  the  regulation  of  heat  production 
and  heat  distribution,  within  the  body. 

"To  keep  this  in  the  most  perfect  working  order 
should  be  the  first  concern  of  one  who  fears  disease  from 
change  of  temperature ;  and  it  cannot  be  kept  in  good 
condition  without  opportunity  for  constant  and  consid- 
erable exercise.  The  natural  stimuli  which  provoke  its 
action,  and  which  are  essentially  variations  of  heat  and 
cold,  particularly  properly  proportioned  shocks  of  cold 
to  the  surface  of  the  body,  must  be  supplied  or  permitted, 
and  on  the  other  hand,  the  nervous  system,  of  which  it  is 
an  integral  part,  must  be  kept  in  good  order  by  the 
proper  balance  of  physical  and  mental  exercise  and  sleep. 
Probably  the  persons  who  suffer  most  from  '  colds '  are 
those  who,  in  their  fear  of  such  departures  from  health, 
try  hardest  to  avoid  the  changes  of  temperature  that  are 
necessary  to  keep  the  heat-regulating  organism  in  good 
condition." 

The  person  who,  on  rising  from  bed  in  the  morning, 
takes  an  air  bath  (as  everyone  should)  in  his  unwarmed, 
winter  sleeping  room,  for  ten  to  thirty  minutes,  with  a 
good  towelling  and  hand  polishing  of  the  skin,  prefaced, 
perhaps,  by  a  dash  of  cold  water  with  the  wet  hands, 
finding  himself  finally  quite  warm  though  naked,  is  in  a 
position  to  conclude  that  the  single,  ordinary  suit,  minus 
flannels,  will  sufficiently  "protect"  him  from  cold  when 
he  descends  to  the  warmer  living  rooms !  His  over- 
coat and  a  brisk  pace  will  do  the  business  for  him 
when  he  seeks  the  actual  winter  weather  without,  and 
this  vastly  better  because  of  the  freedom  of  the  skin 
indoors. 

Chilliness,  or  that  more  or  less  vague,  shivery  feeling 
that  comes  especially  to  all  clothed  animals,  is  apt  to 
mislead  the  inexpert.  Who  has  not  experienced  it  in  the 
evening,  perhaps  before  a  warm  grate,  temperature  in  the 
room  at  700  F.  or  over,  the  body  clad  in  full  winter  cos- 
tume, and  on  disrobing  for  bed  in  a  cold  room  found 
himself  comfortably  warm  ?  This  seeming  miracle  would 
happen  to  every  shivering  mortal  if  he  would  give  the 
skin  a  few  active  passes  with  his  hands  or  a  towel,  in- 
stead of  dodging  from  his  clothes  into  bed  in  cowardly 
fear  of  "  catching  cold." 

A  leading  question  with  me  in  every  consultation,  as  a 
means  of  ascertaining  how  bad  the  condition  is  through- 
out the  year,  is,  "  Do  you  catch  cold  easily  ?  "  In  the 
great  majority  of  cases  the  reply  is  in  the  affirmative. 
"Yes,  I  am  seldom  free  from  a  cold,"  one  will  say;  or, 
"  I  catch  cold  if  I  even  look  out  of  the  window."  "  I 
don't  know  whether  it  will  take  more  than  one  of  the 
air-baths  you  have  prescribed  to  kill  my  wife,"  wrote  a 
correspondent,  "  for  she  usually  gets  a  cold  if  a  fly  wings 
past  her ;  still,  live  or  die,  she  says  she  is  going  to  obey 
instructions."  She  began  abruptly  to  take  the  air  baths, 
gave  up  flannels,  and  within  six  months  this  91  j£  pound 
woman  wa?  tramping  barefoot  three  miles  at  a  stretch  in 
the  surf  along  the  beach,  and  had  gained  a  few  pounds 
of  honest  muscle,  and  was  no  longer  a  victim  of  the  colds 
delusion.  Symptoms  of  ill  condition  she  would  from 
time  to  time  observe,  due  to  some  error  in  living  habits, 
but  she  has  learned  to  call  things  by  their  right  names, 
at  least  some  things. 

Now  and  then  a  patient  is  able  to  declare  that  she  sel- 
dom has  a  cold ;  and  it  always  happens  that  she  is  one 


of  the  few  not  given  to  the  practice  of  bundling  herself 
up  as  a  means  of  avoiding  the  disorder. 

"  How  is  it  that  I  always  catch  cold  when  I  put  on  my 
winter  flannels?"  queried  a  patient,  who  was  upon  the 
point  of  making  his  usual  fall  change  of  underwear.  My 
explanation  was  so  convincing  to  him  that  instead  of 
putting  on  his  thick  flannels  he  took  off  his  thin  ones, 
and  in  the  spring  he  was  able  to  declare  that  he  had 
never,  since  his  unflannelled  boyhood,  passed  a  winter 
with  such  immunity  from  the  popular  disorder,  "  colds." 
He  had,  moreover,  he  said,  enjoyed  a  greater  average  of 
comfort  than  formerly  with  the  inner  suit. 

An  elderly  lady,  herself  a  victim  of  heavy  flannels  and 
a  "chest-protector,"  and  who  died,  finally,  from  her 
fourth  siege  of  pneumonia,  once  remarked  to  me  in  the 
presence  of  a  little  company  at  her  hotel,  that  "there 
might  be  a  great  deal  in  your  theory  about  the  mischief 
of  underwear,  after  all.  Sam  [referring  to  her  husband 
by  his  given-name]  never  wore  flannels  till  the  last  win- 
ter of  his  life.  I  had  coaxed  him  to  every  fall,  but  he 
would  not  give  up  till  one  fall  he  let  me  get  him  some 
nice  warm  flannels.  He  seemed  to  have  a  cold  all  win- 
ter long,  and  he  died  of  pneumonia  in  the  spring." 
"Well,"  I  replied,  "you  may  have  the  sublime  satis- 
faction of  knowing  that  you  were  responsible  for  Sam's 
premature  death !  "  Twenty  years  having  elapsed  since 
her  investment  in  men's  underwear,  she  was  able  to  join 
in  the  laugh  that  was  raised  by  my  somewhat  brutal  re- 
mark. 

The  conviction  has  grown  upon  me  from  many  years 
of  special  study  of  the  question,  that  a  "  cold  "  is  really 
a  filth  disease,  and  that,  as  that  wisest  of  men,  Dr.  Ben- 
jamin Franklin,  wrote,1  "  the  causes  of  colds  ate  totally 
independent  of  wet  or  even  of  cold."  If  this  is  not  true, 
how  can  we  account  for  the  efficacy  of  the  barefoot  cure 
in  certain  disorders  ?  When  an  empress  suffering  from 
neuralgia  to  the  point  of  distraction  finds  complete  cure 
from  going  barefoot  for  several  hours  every  day  in  the 
wet  grass  about  the  palace  grounds ;  when  Baron  Roths- 
child goes  to  Woreshofen  and  is  pleased  to  pay  a  large 
(voluntary)  fee  for  similar  treatment,  under  Kneipp; 
when  Dorothy  Drew,  the  granddaughter  of  the  "  Grand 
Old  Man  "  of  England,  becomes  "  irrepressibly  healthy," 
from  "  going  barefoot  all  the  year  around,  indoors  and 
out,  in  all  but  very  muddy  and  the  very  coldest  of 
weather,"  is  it  not  about  time  for  us  to  revise  the  old- 
time  notions  as  to  what  constitutes  really  wise  care  in 
the  matter  of  clothing? 

The  skin  is  a  breathing,  as  well  as  an  excreting  organ, 
and  both  these  functions  are  seriously  impeded  by  the 
second,  or  inner  suit.  Indeed,  the  employment  of  any 
clothing  at  ail,  at  times  when  not  absolutely  required  for 
protection  against  cold,  is  a  tax  upon  the  animal  organ- 
ism, and  against  us  in  the  search  for  health.  This  is 
doubtless  especially  true  concerning  the  care  of  the  feet. 
"Strip  off  your  flannels,  and  you'll  come  out  all  right," 
was  the  advice  for  which  an  uncle  of  mine,  in  Australia 
in  1853,  paid  a  guinea,  and  which  he  afterward  had  rea- 
son to  believe  would  have  been  cheap  at  ten  times  the 
cost ;  for  by  obeying  the  level-headed  old  native  doc- 
tor's advice  he  escaped  the  "climatic  fever  "  which  cost 
my  brother  his  life  there  shortly  after.  The  latter  could 
not  divest  his  mind  of  the  superstition,  still  prevalent, 
that  it  is  dangerous  to  keep  comfortable  in  hot  weather ! 

But  how  about  our  consumptive  patient,  shall  he  not 
be  allowed  to  dress  comfortably  in  winter  ?  Cc  mforta- 
bly,  yes,  by  all  means ;  but  it  is  the  greatest  average  of 
comfort  we  have  to  secure.  If  he  is  to  pass  all  of  his 
time  in  the  open  air,  in  winter,  he  may  dress  accord- 
ingly, even  to  the  use  of  underwear ;  but  as  the  average 
patient  does  nothing  of  the  sort  he  will  be  better  off 
without  it.  He  will  have  chilly  sensatiors  at  times 
whether  he  does  or  does  not  wear  flannels,  but  it  is 
vastly  better  for  him,  as  for  us  all,  to  secure  a  feeling  of 
warmth  by  means  of  a  little  "shaking  up"  exercise,  than 
to  try  to  secure  comfort  solely  by  means  of  excessive 
1  See  his  Essays,  p.  216; 


484 


MEDICAL  RECORD. 


[October  20,  1894 


clothing.  It  is  astonishing  to  one  unfamiliar  with  the 
experiment  to  observe  the  almost  instantaneous  glow  of 
warmth  that  results  from  a  little  arm-swinging,  a  few 
sharp  slaps  along  the  sides  of  the  legs,  a  bit  of  a  jig- 
dance,  or  even  a  few  simple  shrugs  of  the  shoulders 
alone ;  and  every  little  turn  of  this  sort  is  in  the  line  of 
physical  training,  from  lack  of  which,  in  ninety  nine 
cases  in  the  hundred,  our  patient  has  fallen  into  decline. 
Generally  speaking,  the  consumptive  is  one  who  has 
grown  weaker  and  weaker,  and,  however  slender  he  may 
have  become,  relatively  fatter  from  month  to  month,  the 
muscular  system  having  steadily  degenerated,  because  he 
has  exerted  himself  less  and  less,  being  forever  encour- 
aged in  this  course  through  the  mistaken  kindness  of  all 
about  him.  He  has,  therefore,  finally  become  "  tired  " 
in  a  manner  prohibiting  all  hope  of  rest  this  side  of  the 
grave,  except  it  be  sought  along  radically  changed  lines. 

Says  Dr.  Felix  Oswald : l  "  A  common  catarrh  will 
not  prevent  a  man  from  running  upstairs  or  walking  up- 
hill for  minutes  together  without  anything  like  visible 
distress;  subjected  to  the  same  test,  a  person  whose 
lungs  are  studded  with  tubercles  will  pant  like  a  swimmer 
after  a  long  dive,  and  his  heart  beats  will  most  likely  be 
doubled  in  frequency.  Combined  with  a  hectic  flush, 
night-sweats,  or  general  emaciation,  shortness  of  breath 
leaves  no  doubt  that  the  person  thus  affected  is  in  the 
first  stage  of  pulmonary  consumption.  If  the  patient 
were  my  son,  I  should  remove  the  windows  of  his  bed- 
room, and  make  him  pass  his  days  in  the  open  air — as  a 
cow- boy  or  berry-gatherer,  if  he  could  do  no  better.  In 
case  the  disease  had  reached  its  deliquium  period,  the 
stage  of  violent  bowel- complaints,  dropsical  swellings, 
and  utter  prostration,  it  would  be  better  to  let  the  suf- 
ferer die  in  peace ;  but,  as  long  as  he  were  able  to  di- 
gest a  frugal  meal  and  walk  two  miles  on  level  ground,  I 
should  begin  the  out-door  cure  at  any  time  of  year,  and 
stake  my  life  on  the  result.  I  should  provide  him  with 
clothing  enough  to  defy  the  vicissitudes  of  the  seasons, 
and  keep  him  out  doors  in  all  kinds  of  weather — walk- 
ing, riding,  or  sitting,  he  would  be  safe :  the  fresh  air 
would  prevent  the  progress  of  the  disease ;  but  improve 
he  could  not  without  exercise.  Increased  exercise  is  the 
price  of  increased  vigor.  Running  and  walking  steel 
the  leg  sinews ;  almost  any  bodily  exercise — but  especially 
arm  swinging,  wood-chopping,  carrying  weights,  and 
walking  up  hill — increases  the  action  of  the  lungs,  and 
thus  gradually  their  functional  vigor.  The  problem  is 
to  make  out  door  exercise  pleasant  enough  to  be  per- 
manently preferable  to  the  far  niente  whose  sweets  seem 
especially  tempting  to  consumptives.  This  purpose  ac- 
complished, the  steady  progress  of  convalescence  is  gen- 
erally insured,  for  differences  of  climate,  altitude,  of  age 
and  previous  habits,  almost  disappear  before  the  advan- 
tages of  an  habitual  out  door  life  over  the  healthiest  in- 
door occupations." 

But,  when  he  comes  in- doors  it  must  not  be  to  find  a 
close  atmosphere,  such  as  at  present  the  average  home 
provides ;  for,  as  Dr.  Pitcher  remarks  in  his  "  Memoirs 
of  the  Osage  Indians,"  "the  symptoms  of  consumption 
(caused  by  smoking  and  confinement  in  winter  quarters) 
disappear  during  their  annual  buffalo-hunt,  but  reappear 
upon  their  return  to  the  indolent  life  of  the  wigwam." 
And  even  an  hour  or  two  in  the  average  theatre,  church 
edifice,  hall,  or  dwelling  will  counteract  the  benefit  aris- 
ing from  spending  an  equal  length  of  time  in  the  free 
open  air.  In  this  fight  for  his  life  no  patient  can  afford  to 
hazard  his  chances  by  any  letting  up  in  the  "  medicine." 
At  best,  life  is  a  struggle ;  courage  is  demanded ;  and  in 
no  phase  is  this  more  absolutely  true  than  in  the  consump- 
tive patient's  endeavor  to  secure  a  return  of  health. 

"You'd  hardly  think  to  look  at  me,  I  guess,  that  I'd 
been  turned  out  to  die  of  consumption  before  I  came  of 
age,"  said  a  200  pound  man  of  good  muscle,  a  sturdy 
eater  and  sleeper,  to  a  New  York  Sun  reporter.  "  It's  a 
fact,  though.  I  weighed  95  pounds  when  I  left  home. 
My  folks  were  poor,  and  they  sent  me  to  Kansas  in  a 
» Physical  Education. 


prairie  schooner,  never  expecting  to  see  me  again.  I 
began  to  pick  up  as  soon  as  I  got  up  on  the  rise  of  the 
plains.  I  lived  in  a  cabin  that  was  wide  open  day  and 
night.  Then  I  went  into  the  army  during  the  war,  and 
after  that  did  a  lot  of  work  grading  and  surveying  for  a 
railroad,  and  all  the  time  I  was  living  and  sleeping  with 
only  the  sky  for  a  roof.  I  have  been  farming  it  for  the 
last  dozen  years,  and  my  windows  are  open  day  and 
night.     Air  is  the  best  medicine  there  is." 

It  is  for  a  profusion  of  this  medicine  that  people  go 
camping  out.  The  consumptive  patient  must  camp  out 
all  the  year  around,  as  does  the  writer  and  his  entire 
family,  practically.  All  one  has  to  do  is,  in  summer,  to 
run  the  curtains  up,  burn  the  smothering  screens,  open 
wide  the  windows,  top  and  bottom,  and  let  the  breezes 
blow  freely  through  the  house ;  in  winter  some  degree  of 
modification  of  this  free  ventilation  is  admissible.  This 
means  a  lot  of  dust  in  summer,  of  course,  and  the  fading 
of  the  rugs  and  furnishings,  but  it  keeps  the  color  in  the 
cheeks,  this  "  camping  out  at  home." 

"  Beware  of  draughts,"  is  the  great  cry  of  most  writers 
on  health.  In  other  words  shun  the  running  stream,  drink 
from  a  stagnant  pool.  "The  only  trouble  about  a 
draught,"  says  Oswald,  "is  that  it  is  usually  not  big 
enough !  "  And  rationally  considered  this  means  noth- 
ing out  of  line  of  true  hygiene.  It  does  not  mean  that 
even  a  well  man  should  sit  passively  in  a  strong  current 
of  cold  air  when  he  is  fatigued  or  weakened  from  any 
cause. 

It  does  mean,  however,  that  no  dwelling,  no  sick- 
room, can  be  sufficiently  ventilated  without  a  sufficient 
current.  For  winter  ventilation,  probably  no  better 
method  can  be  devised — for  the  extremely  cold  weather — 
than  to  mismatch  a  number  of  windows  in  each  room  by 
means  of  a  four  inch  board  under  the  lower  sash,  which 
allows,  through  the  middle  opening,  and  without 
"draught,"  pretty  free  influx  of  fresh,  and  the  passage 
out  of  foul,  air.  Open  grates  are  without  doubt  an  ex- 
cellent thing,  but  it  should  be  borne  in  mind  that  they 
let  in  no  fresh  air.  The  open  windows  must  do  this; 
and  in  the  warm  periods  of  mid- winter  they  should  be 
freely  opened  throughout  the  house. 

The  consumptive  patient  on  coming  in  from  his  outings 
may  well  seek  his  chamber  with  its  always  wide-open  win- 
dows, and  lie  down  with  plenty  of  blankets  for  protection, 
instead  of  sitting,  as  a  rule.  Sitting  is  altogether  unnatu- 
ral, and  the  less  of  it  he  does  the  better.  He  may  well 
avoid  all  unnatural  practices  until  he  finds  himself  safely 
"  out  of  the  woods." 

867  BovLvroN  Stout. 


The  Temperature  of  the  Electric  Are  is  said  to  be 

about  6,152°  Fahrenheit. 

Medical  Valets. — Marcellin  Pellet,  in  a  work  entitled 
"  Naples  Contemporaine,"  says  that  the  valets  of  the 
leading  physicians  of  that  city  always  accompany  their 
masters  on  their  professional  rounds,  and  receive  two 
francs  for  each  visit.  They  are  paid  no  other  salary,  and 
out  of  those  fees  have  to  meet  certain  charges,  such  as 
that  for  lighting  the  house. — Mtdecine  Moderne. 

A  Confinement  that  Didn't  Confine. — A  medical  man 
who  had  practised  among  the  North  Dakota  Indians, 
writes  that  their  women  as  a  rule  had  very  easy  labors  \ 
in  fact,  it  was  no  trouble  at  all  for  them  to  have  children. 
At  one  time  he  saw  several  women  coming  toward  the 
only  store  at  the  agency,  across  a  wide  open  space  in 
front,  each  carrying  on  her  back  a  bundle  of  sticks.  Sud- 
denly one  stopped  short,  looked  a  little  wild,  dropped 
her  bundle  of  sticks,  spread  her  feet  apart,  strained  a  mo- 
ment, and  then  stooping,  made  a  pass  toward  the  ground 
with  her  knife  that  she  drew  from  its  sheath,  picked  up 
something  which  she  wrapped  up  in  her  shawl,  and  leav- 
ing her  bundle  of  sticks  for  someone  else  to  pick  up, 
passed  on  into  the  village.  That  was  a  confinement,  and 
the  child  was  born  then  and  there. — New  York  Medi- 
cal Times. 


October  20,  1894] 


MEDICAL  RECORD. 


485 


ACUTE  BILIARY  DISTENTION  OF  THE  GALL- 
BLADDER. 

By  BEVERLEY   ROBINSON,   M.D., 

CLINICAL   PROFiSSOR  OP   MEDICINE,  AT  THK  BELLEVUB  HOSPITAL  MEDICAL  COL- 
LEGE,  NEW  YORK. 

It  is  always  a  subject  of  interest  to  clear  up,  if  possible, 
some  of  the  obscure  conditions  pertaining  to  cases  not 
infrequently  met  with  in  general  practice.  Such  an  one, 
at  least  in  certain  of  its  essential  features,  is  the  state  to 
which  the  title  of  my  article  refers.  On  two  or  more 
occasions,  during  the  past  few  years,  I  have  seen  in- 
stances of  the  following  kind :  A  patient  is  suddenly  at- 
tacked with  intense  pain  in  the  epigastric  region.  Ac- 
companying the  pain,  which  is  continuous  and  remains, 
during  the  acute  attack,  limited  to  the  epigastric  region, 
there  is  constant  nausea  and  occasional  vomiting.  The 
vomited  matter  is  composed  of  the  contents  of  the  stom- 
ach, or  is  pure  bile.  There  is  no  rise  of  temperature. 
There  is  marked  local  tenderness  on  palpation  in  the  re- 
gion to  which  pain  is  referred.  Distention  of  the  gall- 
bladder is  not  clearly  made  out,  but  it  is  suspected  and 
probable,  by  reason  of  increased  resistance  and  perhaps 
local  swelling  in  its  vicinity.  The  liver  is  usually  some- 
what enlarged.  Constipation  is  moderate.  The  motions 
are  dark  brown,  insufficient  in  quantity.  The  urine  is 
high-colored,  but  does  not  contain  any  bile.  It  is  possi- 
ble to  have  a  sub-icteric  hue  of  the  scleroses,  but  there 
is  no  other  evidence  of  jaundice.  There  may  be  a  history 
of  malaria,  or  lithsemia.  The  habits  are  occasionally  re- 
gular ;  sometimes  there  are  errors  of  diet  or  modes  of  life, 
as  to  exercise  and  excitement.  During  the  attacks  a  vom- 
itive with  ipecac,  a  stimulating  enema,  with  a  hot- water 
bag  applied  locally  over  the  stomach,  will  afford  relief. 
Usually,  however,  this  relief  is  only  slight  in  amount, 
and  the  pain  may  last  continually  for  several  hours,  and 
be  so  intense  as  to  require  the  use  of  morphine  hypoder- 
mically.  For  a  day  or  two  following  these  attacks,  the 
epigastric  region  is  tender.  Fluid  diet,  relative  quiet, 
counter-irritation  over  the  liver,  moderate  catharsis  with 
Rochelle  salts,  or  carbonate  and  sulphate  of  magnesia, 
and  the  free  use  of  Vichy  water,  will  usually  bring  such 
attacks  to  a  favorable  termination  in  a  short  time.  They 
recur  at  irregular  intervals,  usually  after  exposure,  undue 
fatigue,  emotional  disturbance,  some  imprudence  in  eat- 
ing or  drinking.  They  are  not  followed  by  jaundice ; 
no  gall-stones  are  passed.  They  improve  very  much  at 
first  with  free  evacuation  from  the  bowels  of  large,  liquid, 
dark  colored,  bilious  stools,  which  gradually  become 
lighter  in  color  as  the  individual  improves  in  health. 
After  such  an  attack  the  patient  is  usually  well  for  several 
months,  has  no  nausea,  dyspepsia,  epigastric  soreness, 
engorgement  of  the  liver,  or  as  a  rule,  other  evidence  of 
ill  health. 

Occasionally,  I  have  known  sufferers  from  these  attacks 
to  have  ambulant  neuralgic  pains,  principally  in  the 
hypochondriac  regions,  but  also  in  the  thorax,  abdomen, 
and  testicles.  Shooting  pains  in  the  testicles,  with  a  feel- 
ing of  weight  and  temporary  swelling  of  the  epididymis, 
have  been  observed.  Such  attacks  have  been  designated 
gall-stones,  acute  dyspepsia,  catarrhal  jaundice,  gastral- 
gia.  They  are  unlike  all  of  these,  and  must  be  distinctly 
separated  from  them.  When  the  abdominal  pain  is  acute 
I  have  known  appendicitis  to  be  suspected.  They  are 
obviously  different  from  this  disease.  The  subsequent 
treatment  of  such  cases,  and  between  recurrent  attacks, 
is  to  be  found  in  continuous  moderate  doses  for  several 
wseks  of  phosphate  of  soda,  sufficient  in  amount  to 
produce  a  laxative  effect  on  the  bowels.  An  underlying 
malarial  history  has  been  clearly  made  out  in  more  than 
one  instance,  and  yet  quinine  is  of  very  little  value  in 
these  cases.  Warburg's  tincture  may  be  helpful,  but  not 
infrequently  only  renders  the  condition  of  the  patient 
worse.  Arsenious  acid,  from  -fa  to  ^ff  grain,  combined 
with  ignatia,  has  seemed  to  me  to  be  the  best  and  most 
rational  curative  treatment.  After  stopping  the  phos- 
phate of  soda,  or  instead  of  it,  small  doses  every  other 


night  of  podophyllin,  or  calomel,  for  a  while  have  been 
found  very  useful.  I  direct  attention  to  these  cases,  al- 
though not  serious  as  to  their  immediate  consequences  in 
my  experience,  because  they  are  often  confounded  with 
other  affections,  and  because  sooner  or  later,  if  not 
properly  cared  for,  I  am  of  the  opinion  that  they 
lead  directly  to  the  formation  and  deposit  of  biliary 
calculi. 

Two  cases  that  I  have  observed  and  treated — one  of 
them  for  many  years — have  occurred  in  young  men  be- 
tween twenty  ana  thirty  years  of  age.  Both  of  them 
lived  an  out-door  life,  were  devoted  to  athletic  sports, 
and  generally  speaking,  were  careful  as  to  their  diet. 
Similar,  or  analogous  cases,  occur  more  frequently  among 
men  than  women.  I  have  seen  them  occasionally  in 
hospitals,  but  there  they  have  been  so  much  obscured  by 
complicating  disorders  that  I  have  not  felt  so  confident 
in  regard  to  my  diagnosis.  This  diagnosis,  which  has 
only  been  a  suspicion  for  some  time,  has  now  become  a 
confirmed  judgment  in  view  of  several  more  or  less  simi- 
lar instances  that  I  have  taken  care  of.  I  am  not  aware 
that  this  precise  affection  has  been  emphasized  or  in- 
sisted upon  by  anyone  else  in  quite  the  terms,  nor  in  the 
manner,  which  I  have  tried  to  make  clear.  Engorgement, 
or  congestion  of  the  liver,  does  not  fit  such  cases,  as  I 
believe,  although  slight  enlargement  usually  accompanies 
the  symptoms  described.  Besides,  I  have  noted  the 
other  symptoms  more  than  once,  when  there  was  no  en- 
largement of  the  liver  at  all. 

To  my  mind,  these  attacks  of  acute  distention  of  the 
gall-bladder  with  bile,  are  not  unlike,  in  their  analogy 
with  the  development  of  calculous  disease  of  the  gall- 
bladder, to  what  we  have  similarly  defined,  when  we  con- 
sider the  relationship  of  the  pre  albuminuric  stage  of 
chronic  Bright's  disease  with  the  development  of  nephri- 
tis as  a  clearly  formed  malady. 

To  give  a  plausible  explanation  of  the  etiology  of 
these  cases,  I  am  almost  forced  to  admit  the  existence  of 
a  spasmodic  contraction  of  the  gall-bladder  which  is  suf- 
ficient to  shut  off  in  part  temporary  connection  with  the 
cystic  duct.  I  cannot  believe  in  the  extension  of  an  in- 
flammatory condition  from  the  duodenum,  as  there  are 
none  of  the  previous  stomachal  symptoms  which  are  so 
usual  in  catarrhal  jaundice.  Moreover,  the  jaundice  it- 
self does  not  occur  as  it  would,  unquestionably,  if  the 
hepatic  duct  or  common  duct  were  occluded  even  for  a 
short  time.  Again,  it  is  more  than  difficult  to  admit  the 
existence  of  an  inflammatory  state  of  the  cystic  duct  which 
would  allow  the  common  or  hepatic  duct  to  remain  in- 
tact or  unaffected.  Of  course,  the  post-mortem  revela- 
tions in  similar  instances  cannot  be  given,  as  such  cases 
are  not  fatal,  and  we  are  forcibly  thrown  back  upon  the 
explanation  which  is  most  rational,  and  therefore  most 
satisfactory.  Cases  have  been  observed,  or  at  least  alluded 
to,  by  Murchison,1  in  which  the  organic  occlusion  of  the 
neck  of  the  gall-bladder  by  a  gall  stone  was  such  as  to 
allow  entrance  of  bile  into  the  gall  bladder,  but  to 
prevent  its  exit  It  is  quite  conceivable  that  a  state  may 
be  produced  after  a  dynamic  manner,  which  might  ap- 
proximate this  condition,  i  e. ,  that  of  a  plug  valve,  "  and 
where  bile  has  in  consequence  accumulated  in  the  gall- 
bladder/' 

It  has  occurred  to  me  that  cases  like  mine  have  occa- 
sionally been  confounded  with  gastralgia,  which,  how- 
ever, differs  materially  from  what  I  have  described. 
The  latter  disease  is  rarely  so  acute,  is  not  accompanied 
by  any  swelling  or  hypertension  over  the  region  of  the 
gall-bladder,  is  relieved  frequently  by  pressure,  or  with 
bromides  and  chloral  internally,  and  the  attacks  are  not 
followed  by  copious  and  frequent  bilious  stools.  In  two 
of  my  cases,  so  soon  as  the  spasmodic  condition  of  the 
gall  bladder  was  diminished,  or  suppressed,  the  symp- 
toms of  hepatic  colic  disappeared  very  rapidly  and  almost 
completely.  In  other  somewhat  analogous  instances,  they 
remained  in  a  far  less  severe  form  for  a  few  days.  The 
evidence  in  these  acute  cases  of  biliary  distention  of  the 
»  Diseases  of  the  Liver,  3d  edition,  p.  381. 


486 


MEDICAL    RECORD. 


[October  20,  1894 


gall-bladder,  is  to  the  effect  that  the  coloring  matter  of 
the  retained  bile  is  not  gradually  absorbed,  but  quickly 
eliminated  by  the  bowels.  Thus  there  is  a  radical  differ- 
ence with  chronic  cases  of  occlusion  of  the  cystic  duct 
from  calculus,  or  any  other  cause  where  the  contents  of 
the  gall  bladder  are  an  almost  colorless  mucous  fluid.  In 
either  the  acute  or  chronic  cases  of  occlusion  of  the  cys- 
tic duct,  there  need  be  no  jaundice,  nor  clay  colored 
motions.  By  directing  attention  to  the  foregoing  facts 
I  hope  to  throw  some  light  on  an  interesting  affec- 
tion, which  all  general  practitioners  must  occasionally 
see,  but  do  not  perhaps  designate  or  interpret  as  I  have 
done.  

HYPOCHONDRIASIS. 
By  D.  B.  McCARTIE,  M.D., 

NEWARK,  N.  J. 

Historical  Sketch. — Since  the  days  of  Hippocrates  and 
Galen  this  nervous  disease  has  been  known  and  written 
on.  Hippocrates  wrote  on  hypochondriasis.  The  cerebral 
nature  of  the  trouble  did  not  enter  into  the  medical  nosol- 
ogy until  much  later.  The  ancient  idea  related  to  disturb- 
ance of  the  visceral  organs  situated  under  the  ribs,  as 
the  name  implies,  and  the  gloom  or  depression  accom- 
panying the  disease  was  ascribed  as  a  result  of  deficient 
action  in  the  liver  connected  with  the  production  of  bile, 
or  in  a  perverted  action  in  the  spleen,  whence  the  term 
"splenetic."  This  pathological  idea  was  held  through 
many  centuries,  and  may  have  been  popularly  handed 
down  by  such  treatises  as  Burton's  "  Anatomy  of  Melan- 
choly." 

In  the  days  of  Cullen  the  malady  began  to  assume  a 
new  aspect  and  appear  in  its  proper  place  as  a  cerebral 
affection. 

The  disease  presents  itself  in  so  many  various  forms,  or 
rather,  its  manifestations  are  so  pronounced  that  these 
have  been  called  by  special  names,  and  even  worthy 
treatises  have  been  written  thereon.  It  is  evident  that 
all  these  phases,  so  much  written  on  at  the  present  day, 
are  manifestations  of  the  same  disease ;  but  one  symptom 
standing  out  more  prominently  than  others,  the  mental 
aspect  of  the  case  being  unobserved,  has  received  a  spe- 
cial name,  as  "  spinal  neurasthenia/'  "  cerebral  or  spinal 
hyperemia,"  rachialgia,  or  spinal  irritation,  etc.  Promi- 
nent authors  have  much  differed  about  the  nature  and 
causes  of  these  terms.  Many  have  placed  the  seat  of  the 
trouble  entirely  in  the  cord.  Griesinger  places  the  mal- 
ady in  toto  in  the  scale  of  insanity,  observing  minutely  the 
depression,  and  instancing  his  observations  by  advanced 
hypochondriacal  cases..  Again,  other  authors  place  such 
signs  as  muscular  asthenopia,  motor  weakness,  cerebral 
sensations,  sensory  sensations  in  the  skin,  etc.,  in  a  sepa- 
rate class  and  call  the  trouble  neurasthenia,  leaving  out 
the  mental  perversion,  thougtvsuggesting  that  the  malady 
occurs  in  hypochondriacal  and  hysterical  patients. 

Sir  William  Gull  in  his  able  article  differs  from  Grie- 
singer, and  places  the  disease  in  a  position  midway  be- 
tween insanity  and  hereditary  nervous  disease,  still  re- 
taining the  indefinite  name  of  hypochondriasis.  He 
observes  its  close  connection  with  insanity  and  its  pecul- 
iar course,  yet  does  not  instance  precisely  phases  of  the 
malady  which  are  often  prominent,  and  in  the  main 
absorb  all  the  other  features  of  the  disease,  as  ocular 
weakness,  neurasthenia,  sensory  hyperesthesia.  Most 
authors  seem  to  think  that  a  delusion  as  to  being  diseased 
is  the  essential  part  of  the  disease,  whereas  this  is  often 
wanting  in  definiteness,  and  motor  weakness,  irritability 
of  temper,  want  of  sleep,  and  want  of  power  to  direct  the 
attention,  or  the  so-called  neurasthenic  symptom,  is  often 
the  leading  symptom,  without  the  patient  fearing  disease, 
though  a  mental  "  cloud  "  still  hangs  over  the  understand- 
ing. Dr.  Gowers  places  the  disease  in  its  proper  category, 
and  observes  on  its  various  features,  but  does  not  com- 
bine its  symptoms.  In  speaking  of  neurasthenia  he 
simply  refers  to  hysteria,  neuralgia,  hypochondriasis,  as 
its  causes.     He  might  as  well  have  written  an  article  on 


hypochondriasis  as  on  hysteria,  and  combined  all  these 
symptoms,  which  undoubtedly  refer  to  this  peculiar  and 
frequent  and  much  discussed  disease.  Dr.  Gowers 
touches,  in  various  parts  of  his  treatise,  on  some  of  the 
features  of  the  hypochondriacal  malady,  particularly  in 
the  article  on  cerebral  hyperemia,  cephalic  sensations, 
neuralgia,  hysteria,  railway  shock,  etc.  These  symp- 
toms connected  together  form  the  varying  picture  of  hy- 
pochondriasis. 

It  has,  therefore,  a  mental  aspect  in  all  cases,  and  this 
is  probably  the  underlying  morbid  feature  of  the  malady, 
though  it  is  often  slight  and  unobserved,  but  again,  often 
so  prominent  as  to  place  the  case  in  the  melancholic  va- 
riety of  insanity.  A  better  name  than  hypochondriasis 
is  manifestly  wanted,  as  also  a  due  connection  of  all  the 
symptoms  with  the  mental  defect,  so  that  the  cases  can 
be  treated  scientifically  and  the  nature  and  course  of  the 
disease  mapped  out.  Unfortunately  it  is  too  plain  that 
it  is  so  closely  allied  to  the  higher  types  of  mental  per- 
version that  its  prognosis  depends  on  uncertainty  and 
its  treatment  is  tedious  and  non  specific. 

Definition. — The  above  name  is  badly  chosen,  since 
it  conveys  an  erroneous  impression  as  to  the  seat  of  the 
disease.  Neurasthenia,  which  is  so  often  a  leading  feat- 
ure, is  also  an  indefinite  name,  since  debility,  referring 
particularly  to  the  nervous  system,  is  as  much  a  symptom 
as  debility  from  fever  or  general  disease.  The  term  indi- 
cates many  obscure  symptoms  which  result  from  nervous 
disease,  and  should  be  known  as  a  symptom  of  cerebral 
affection  and  not  as  a  disease  in  itself. 

JStiology. — This  relates  almost  entirely  tp  hereditary 
effects,  which  are  mostly  untraced  and  indefinite  in  the 
course  of  ages.  A  definite  history  of  family  insanity  can 
be  obtained  in  very  many  cases,  or  other  mental  peculia- 
rities or  eccentricities.  In  fact  the  definition  of  insanity 
as  a  perversion  of  the  normal  state  of  thinking,  feeling,  or 
acting,  applies  very  concisely  to  this  condition,  though  the 
perversion  of  thinking  is  often  very  slight  and  not  much 
noticed  by  the  sufferer ;  whereas  in  other  cases  the  per- 
version of  thought  is  highly  accentuated  and  hypochon- 
driacal fancies  abound.  There  are  frequently  histories  of 
epilepsy  in  other  members  of  the  family,  as  in  an  uncle  or 
aunt,  and  other  nerve  disease,  as  neuralgia,  hysteria,  cho- 
rea, megrim,  etc.  The  disease  also  occurs  indirectly  or  in 
connection  with  other  diseases,  a  primary  instance  being 
the  effect  of  railway  shock  upon  the  mental  action  of 
one  prone  to  this  disease. 

The  disease  often  occurs  in  young  adult  life,  the  first 
symptoms  being  a  slight  dyspeptic  attack  or  a  trifling  sen- 
sation over  the  stomach  region,  which  the  patient  takes  for 
dyspepsia.  Ocular  weakness  often  begins  the  disease,  or 
peculiar  sensations  about  the  head  or  extremit  ies.  Sperma- 
torrhoea also  gives  the  patient  a  cause  for  complaint,  when 
in  reality  the  symptoms  are  due  to  the  commencing  cere- 
bral affection.  After  this  manner  many  slight  and  pre- 
sumably local  ailments  are  treated  as  if  distinct,  and  in- 
definite names,  as  nerve  exhaustion,  spinal  irritation,  etc, 
are  given  to  them. 

The  mental  condition  is  unobserved,  and  these  con- 
current symptoms  are  found  to  be  exceedingly  intracta- 
ble and  obstinate  of  treatment. 

Symptoms. — The  term  disease  is  very  aptly  filled  in  by 
this  nerve  derangement,  since  both  mentally  and  physi- 
cally the  patient  is  without  ease.  The  symptoms  admit 
of  no  distinct  delineation,  since  they  vary  in  form,  time, 
and  course.  A  leading  symptom  is  motor  weakness, 
which  has  been  mistaken  as  a  special  disease,  since  it  often 
predominates  and  is  necessarily  much  noticed  by  the  pa- 
tient. This  symptom  is  also  called  nerve  prostration  or 
brain  exhaustion,  when  generally  the  brain  was  not  over- 
taxed. In  fact  this  sign  is  often  predominant  in  cases 
where  no  brain  labor  has  occurred,  and  it  is  also  unrecorded 
where,  when,  and  how  the  nerve- tissue  would  give  way 
under  severe  exertion. 

Normally  the  brain  acts  without  the  cognizance  of  the 
body.  In  this  mental  affection  the  mind  is  painfully 
aware  of  its  relation  to  the  body,  and  kt'.a  its  want  of  free 


October  20,  1894] 


MEDICAL   RECORD. 


487 


and  healthy  action.  This  morbid  attention  is  a  great 
source  of  annoyance  to  the  sufferer,  and,  if  free  from  this 
condition,  the  mere  debility  or  neurasthenia  would  not  be 
more  wretched  or  prolonged  than  in  any  ordinary  case 
of  convalescence.  The  attention  is  also  fixed  on  the 
sensory  sensations  or  nerve  currents  passing  through  the 
body.  From  at  first  indefinite  sensations  in  various  parts 
a  fixed  attention  occurs,  causing  uneasy  sensations,  foci  of 
neuralgic  pains,  which  are  misconstrued  into  disease  of 
organs  situated  near  the  painful  spot.  Even  when  these 
constant  and  annoying  pains  occupy  the  attention  of  the 
patient  he  is  also  aware  of  mental  uneasiness.  These 
pains  are  most  common  over  the  epigastric  region,  and 
around  the  lower  ribs,  on  top  of  the  head,  in  the  mucous 
membranes,  in  the  outer  side  of  the  limbs.  They  usually 
remain  in  the  skin,  though  often  the  deep  nerves  are  very 
painful  to  pressure.  The  motor  nerves  are  also  much  af- 
fected. These  normal  nerve-currents  are  perverted  in 
some  way  until  great  weakness  results,  flabbiness  of  muscle, 
and  much  want  of  power  and  endurance.  The  patient 
feels  fearfully  fatigued  after  trivial  exertion.  This  is  so 
often  a  very  prominent  symptom  that  it  has  received  the 
name  of  neurasthenia ;  but  it  is  sufficient  to  prove  it  but 
a  symptom  to  remark  that  when  the  mind  is  easy  and  gay, 
or  the  patient's  attention  sufficiently  diverted,  that  the 
sense  of  fatigue  is  forgotten ;  or  again,  the  weakness  is 
cared  in  a  day,  when  the  mental  ailment  of  the  patient  is 
dissipated,  and  he  feels  like  a  new  man.  Belonging  to  the 
sensory  phenomena  are  several  lesser  signs,  as  heat  flashes 
in  warm  weather  and  cold  thrills  in  winter ;  the  hair  often 
becomes  rough  and  falls  out,  and  even  the  skin  chafes  in 
places  and  becomes  red.  When  the  sensory  sensations 
are  not  marked  enough  to  cause  neuralgia,  the  attention  of 
the  patient  being  called  to  them,  according  to  his  mental 
aspect,  forms  them  into  disease  of  the  organs  beneath. 
The  mind  being  very  diseased,  hypochondriacal  fancies 
arise,  whereas  if  the  patient  is  only  depressed,  the  sensa- 
tions act  as  a  hypersesthetic  skin  trouble,  but  none  the 
less  fix  his  attention  and  give  rise  to  extreme  annoyance. 
The  loss  of  power  he  could  tolerate,  but  the  indefinite 
sensation  is  ever  prominent  and  occupies  his  attention  in 
spite  of  all  his  efforts. 

The  mental  aspect  of  the  case  is  probably  more  per- 
sistent than  all  the  other  symptoms,  if  it  be  not  the  cause 
of  the  entire  nerve  derangement.  It  would  be  difficult  to 
say  whether  the  mental  perversion  keeps  up  the  morbid 
attention  and  brings  about  the  motor  weakness  and  sen- 
sory phenomena,  or  whether  these  disease  the  mind ; 
but  most  likely  they  are  effects  of  a  morbid  fancy,  for 
almost  all  cases  entertain  erroneous  ideas  regarding  their 
condition.  If  all  neurasthenic  cases  were  looked  into, 
mental  irritability,  weakness,  and  evident  mental  distress 
would  be  found,  though  it  were  not  developed  into 
marked  hypochondriasis,  as  it  is  in  many  cases.  But  since 
one  set  of  symptoms,  as  the  painful  neuralgic  feelings,  are 
intensified  at  one  time,  and  the  mental  ill  or  cloud  at  an- 
other, it  is  likely  they  are  parts  of  the  same  brain  change. 
They  do  not  form  a  distinct  chain  of  events,  as  in  mi- 
graine, though  frequently  there  are  distinct  remissions  and 
intervals  of  improvement,  the  morbid  condition  lasting 
much  longer  than  the  interval  of  quiet. 

The  disease  brings  with  it  a  long  train  of  varying 
symptoms  in  the  sensory,  motor,  and  mental  systems  of 
the  brain,  and  probably  affects  its  entire  mechanism 
rather  than  that  the  mental  perversion  should  cause  the 
concurrent  symotoms.  The  obscurer  centres  of  the 
brain  are  also  affected — the  heart  often  beats  slowly  and 
wants  force  and  tension.  The  respiration  often  appears 
to  the  patient  as  if  about  to  stop,  and  is  painfully  felt. 
The  sympathetic  system  suffers,  various  vaso  motor  flushes 
and  perspirations  occur,  dryness  of  the  lips  and  alimen- 
tary canal,  loss  of  aopetite.  and  constipation.  The  kid- 
neys often  secrete  much  pale  urine,  and  often  a  cloudy 
deposit  of  phosphates ;  sexual  weakness  is  common,  or 
much  sexual  irritability  occurs  The  mucous  membranes 
are  often  painful,  neuralgic  feelings  attack  the  roof  of 
the  mouth,  the  anal  region,  etc.    The  voice  is  weak,  and 


some  patients  notice  a  change  in  its  character — it  sound- 
ing not  like  their  own.  The  mental  aspect  is  very  diffi- 
cult to  investigate.  Some  patients  are  distinctly  hypo- 
chondriacal ;  some,  as  those  instanced  by  Griesinger,  even 
to  insanity ;  others  have  very  indefinite  hypochondriacal 
ideas,  the  fancy  often  changing,  and  ever  within  the 
bounds  of  possibility;  others  do  not  interpret  their  sen- 
sations as  disease,  but  complain  of  great  weakness  and 
annoyance.  They  believe  themselves  to  be  suffering  from 
no  delusions,  but  are  restless,  irritable,  and  a  peculiar 
mental  cloud  teaches  them  that  they  are  not  themselves. 
They  suffer  from  marked  melancholia,  avoid  society,  and 
are  weary  of  life.  The  mind  is  depressed,  though  there 
is  no  false  motion  of  disease.  The  patients  are  conscious 
of  a  foreign  element  in  their  existence.  It  takes  posses- 
sion of  their  motor,  sensory,  and  mental  life.  They  are 
restless  and  sleepless,  fear  things  and  persons — morbid 
anticipation  is  often  very  marked,  and  weakness  of  will 
to  act.  They  are  highly  conscious  of  themselves.  The 
memory  is  poor,  for  want  of  exercise.  The  foreign  at- 
tention in  despite  of  the  patient's  determination  absorbs 
all  his  faculties.  Concentration  of  attention  to  work  is 
impossible.  A  hypochondriac,  in  the  usual  sense  of  the 
term,  cannot  be  reasoned  with,  his  morbid  fancies  ab- 
sorbing all  his  attention,  but  in  the  less  severe  forms 
where  advice  is  sought  in  reference  to  loss  of  nerve-power, 
painful  sensations,  etc.,  it  is  always  well  to  carefully  ob- 
serve the  mental  aspect  of  the  patient,  since  we  must  hope 
for  a  cure  by  acting  on  our  knowledge  of  this  mental 
state,  and  not  on  the  athletic  means  which  are  usually 
prescribed  for  this  class  of  patients,  such  as  cold  baths, 
etc.,  which  strike  not  at  the  real  disease,  which  is  a  chronic 
perversion  of  mind,  marked  by  depression,  accompanied 
with  uneasiness  of  sensation,  loss  of  power,  and  other  ner- 
vous phenomena. 

Treatment. — The  treatment  naturally  changes  with 
the  character  of  the  case.  The  hypochondriacal  patient 
cannot  be  reasoned  with.  Those  cases  where  perverted 
mental  ideas  predominate  are  difficult  to  cure,  and  run 
through  years  of  treatment.  The  less  serious  forms,  and 
the  common  form  which  is  designated  by  the  word  neu- 
rasthenia, is  best  aided  by  means  which  aim  at  the  mental 
cure  of  the  case,  rather  than  to  try  and  tone  up  the  phys- 
ical loss  of  power.  The  course  of  the  malady  is  always 
extremely  chronic;  the  less  mental  derangement  the 
sooner  the  cure.  In  many  cases  the  mental  "  cloud  "  is 
so  slight  as  to  be  almost  unobserved  by  the  patient,  jet 
he  finds  when  this  depression  brightens  up  that  all  the 
other  symptoms  lessen  ;  the  neuralgias  cease,  the  loss  of 
power  returns,  the  patient  seeks  society.  On  this  ac- 
count the  proper  treatment  would  be  to  act  on  the  per- 
verted disposition,  divert  the  patient's  attention,  etc. 
As  in  more  protracted  and  usually  insane  cases,  when  the 
patient  feels  himself  he  is  returning  to  health,  so  like- 
wise in  those  less  manifestvand  slighter  cases,  all  the 
symptoms  disappear  when  this  feeling  of  nominal  self  re- 
turns. 

It  is  evident  that  up  to  the  present  day  no  medicine  is 
of  any  utility  in  cutting  short  this  hereditary  perverted 
action  of  the  brain,  which  is  so  curiously  allied  to  the 
more  serious  form  of  mental  aberration. 

The  so-called  nerve-tonics  are  of  very  little  good,  and 
often  cause  distinct  harm.  Arsenic  often  flushes  the 
head  and  heightens  the  sensory  irritability  and  hyper- 
esthesia of  the  skin.  The  stimulants  make  the  mental 
thought  more  distressed,  no  hilarity  occurring  as  in 
ordinary  brain  action.  The  carbon-compound  remedies 
are  useless  toward  a  cure,  but  relieve  the  pain  and  give 
sometimes  a  shade  of  more  natural  and  peaceful  brain 
action  and  cheerfulness.  Bromides  and  chloral  relieve 
sleeplessness  best,  and  the  former  continued  for  one  year 
may  do  much  toward  a  cure.  Blisters  or  plasters  ap- 
plied to  painful  parts  are  of  little  service.  The  hot 
bath  is  pleasant  before  bedtime,  but  depends  more  on 
the  patient's  frame  of  mind  than  on  any  special  efficacy, 
as  indeed  do  any  other  drugs  employed.  The  paiient  is 
perhaps  better  left  without  physic.      The  bowels  take 


488 


MEDICAL   RECORD. 


[October  20,  1894 


care  of  themselves.  The  dyspeptic  derangements  are 
vastly  exaggerated  and  probably  depend  entirely  on  su- 
perficial pains  in  the  skin  over  the  stomach  region. 
Headaches  are  often  constant,  and  also  depend  on  the 
sensations  in  the  sensory  nerves  in  the  scalp.  The 
weakness  of  sight  recovers  itself.  Massage  is  undoubt- 
edly the  best  remedy  for  the  motor  weakness  and  sen- 
sory pains — the  very  rubbing  drives,  as  it  were,  the  pain 
to  other  parts,  and  gives  agreeable  relief  and  sleep. 
Massage  continued  judiciously  for  six  months  would 
probably  cure  any  ordinary  case  of  so-called  neurasthe- 
nia if  the  patient  is  satisfied  to  wait  till  the  developmental 
errors  of  his  brain  aright  themselves. 

X08  BbLLBViLLE  Avenue. 


THE  SUCCESSFUL  TREATMENT  FOR  THE 
RESTORATION  OF  THE  INJURED  FEMALE 
PELVIC   FLOOR. 

Bv  F.  D.  BRANDENBURG,  A.M.,  M.D., 

CLEVELAND,    O. 

ACriNO  PROFESSOR  OF  GYNECOLOGY,  WESTERN  RESERVE  UNIVERSITY;  GYNECOL- 
OGIST TO  CHARITY  HOSPITAL;  CONSULTING  GYNECOLOGIST  TO  CITY  HOSPITAL, 
ETC. 

The  consideration  of  the  most  successful  treatment  for 
the  restoration  of  the  injured  female  pelvic  floor  is  of  the 
greatest  importance,  not  only  to  the  specialist  in  gyne- 
cology, but  also  to  the  general  practitioner.  The  dark 
and  gloomy  picture  of  ever-increasing  suffering  and  mis- 
ery entailed  by  the  neglect  of  injury  to  the  pelvic  floor, 
in  happy  contrast  with  the  bright  picture  of  relief  and 
cure  by  its  proper  restoration,  is  so  common,  so  apparent 
to  the  eyes  of  all,  that  it  is  unnecessary  for  me  to  offer 
any  plea  for  its  performance ;  but  rather,  it  is  my  object 
to  elicit  a  practical  discussion,  to  call  forth  the  opinions 
of  the  miny  able  surgeons  who  are  readers  of  the  Rec- 
ord, so  that  the  pathway  of  duty  may  be  clearer  as  to 
what  is  the  quickest  and  best  method  for  the  cure  of  a 
condition  whose  import  is  among  the  greatest.  In  order 
to  fully  understand  the  importance  of  this  lesion,  and  also 
to  give  the  desired  relief,  it  is  absolutely  necessary,  first 
of  all,  to  have  a  due  appreciation  of  what  constitutes  the 
normal  pelvic  floor.  A  mitral  regurgitant  murmur  will 
have  but  little  significance  to  the  student  who  as  yet 
djes  not  fully  understand  the  normal  heart-sounds;  the 
stethoscope  is  faithful  in  transmitting  both  normal  and 
abnormal  sounds,  but  we  must  know  the  first  before  we 
can  appreciate  the  second. 

Relaxation  of  the  pelvic  floor  may  present  no  visible 
lesion,  but  its  importance  may  be  far  greater  than  a  lesion 
apparent  to  all.  This  can  only  be  fully  appreciated  by  a 
study  of  the  normal  pelvic  fascia  and  muscles.  Allow 
me  to  briefly  mention  a  few  of  the  more  important  struct- 
ures involved  in  the  pelvic  floor.  The  pelvic  fascia  is 
attached  laterally  to  the  brim  of  the  pelvis,  anteriorly  to 
the  lower  portion  of  the  symphysis  pubis,  posteriorly  to 
the  spine  of  the  ischium,  and  to  a  tendinous  band,  the 
white  line,  j  >ining  these  points.  At  the  white  line  the 
pelvic  fascia  divides  into  the  recto-vesical  fascia  and 
the  obturator  fascia.  The  recto  vesical  fascia,  arising 
from  the  white  line,  extends  downward  and  inward,  cov- 
ering the  levatores  ani  muscles,  and  uniting  in  the  median 
line  with  its  fellow  of  the  opposite  side,  forms  the  true 
fascial  floor  of  the  pelvis.  This  fascial  diaphragm  is 
perforated  by  the  rectum  and  vagina,  to  each  of  which 
it  is  attached  and  gives  firm  support.  The  fascial  floor 
is  the  girder,  acting  as  a  framework  for  the  support  of 
the  various  organs  and  complicated  venous  plexuses. 
The  pelvic  veins  are  without  valves,  but  by  their  exceed- 
ingly tortuous  course  overcome  the  force  of  gravity.  In 
relaxation  of  the  pelvic  floor,  injury  affecting  the  fascia, 
the  blood  vessels  lose  their  support,  become  straighter 
and  at  the  same  time  more  distended,  thus  increasing 
the  weight  in  the  pelvis  and  giving  rise  to  the  dragging, 
bearing-down  sensation  so  common  in  patients  suffering 
from  lesion  to  the  pelvic  floor.  The  levatores  ani  arise 
anteriorly  from  the  posterior  aspect  of  the  pubes,  near 


the  symphysis ;  posteriorly  from  the  inferior  and  inner 
surface  of  the  ischial  spine,  and  between  these  origins 
from  the  white  line  that  represents  the  point  of  division 
of  the  pelvic  fascia,  they  extend  downward  and  inward 
and  are  attached  to  the  vagina,  the  rectum,  to  each  other, 
and  to  the  tip  of  the  coccyx  by  a  ligamentous  insertion. 
These  form  the  muscular  floor  of  the  pelvis.  The  only 
other  muscles  which  have  any  special  importance  are  the 
transversus  perinaei,  which  arise  from  the  tubero-ischii 
and  are  inserted  in  the  median  line  at  the  junction  of  the 
levatores  ani  and  the  pelvic  fascia.  It  is  the  function  of 
the  transversus  perinaei  to  keep  the  pelvic  fascia  tense 
and  assist  in  keeping  the  vaginal  walls  approximated; 
but  in  a  lesion  to  the  pelvic  floor  their  normal  action  is 
apt  to  be  perverted  by  retracting  the  torn  ends,  increas- 
ing the  gap,  and  making  a  bad  matter  worse.  The  fas- 
cial tension  is  more  or  less  lost,  air  enters  and  balloons 
the  vagina,  causing  sogging  of  the  vaginal  walls,  followed 
sooner  or  later  by  retroversion  uteri,  cystocele,  urethro- 
cele, rectocele,  amd  prolapse  in  its  various  stages. 

Injuries  to  the  pelvic  floor  may  be  incomplete  or  com- 
plete. Under  incomplete  we  have  two  varieties :  First, 
in  which  the  fourchette  or  vaginal  mucous  membrane 
may  or  may  not  be  torn,  perhaps  no  visible  injury ;  but 
there  is  submucous  injury  to  the  fascial  and  muscular 
floors  causing  relaxation  of  the  pelvic  floor.  Second, 
in  which  the  muscular  tissues  are  injured  and  lesion 
visible.  In  complete  laceration  of  the  perineal  body, 
the  sphincter  ani  is  ruptured ;  and  possibly  more  or  leas 
of  the  recto- vaginal  septum ;  the  ends  of  the  sphincter 
will  be  found  widely  distant  according  to  the  amount  of 
the  fascial  retraction,  due  to  the  perverted  action  of  the 
transversus  perinaei ;  the  vagina  and  rectum  being  thrown 
into  one  common  passage  according  to  the  extent  of  the 
lesion  of  the  recto-vaginal  septum.  The  pelvic  fascia  is 
not  elastic ;  if  tension  is  made  in  one  direction,  com- 
pensation must  be  made  in  another  direction,  and  when 
this  is  not  possible,  rupture  is  the  result. 

In  a  remarkable  case  I  found  the  perineum  a  hard 
ligamentous  mass ;  there  was  present  a  large  recto- vaginal 
fistula,  the  anus  being  very  patulous;  on  inquiry  I  as- 
certained that  the  child  had  been  born  through  the  anus. 
Injuries  to  the  pelvic  floor  from  the  use  of  forceps  usu- 
ally begin  externally,  first  rupturing  the  fourchette  and 
then  the  deeper  parts;  but  when  unaided  the  injuries 
are  apt  to  begin  internally,  and  we  may  have  the  various 
fistula  resulting,  and  finally  the  loss  of  the  perineal 
body. 

Another  factor  of  great  importance  is  that  of  subin- 
volution of  the  vagina,  the  normal  process  of  retrograde 
metamorphosis  being  retarded,  owing  to  laceration  of 
the  cervix  uteri,  so  apt  to  accompany  severe  lesion  of 
the  pelvic  floor.  Here  it  is  necessary  to  repair  the  injury 
to  the  neck  of  the  uterus,  and  thus  assist  nature  in  re- 
storing again  the  uterus  and  vagina  to  something  like 
their  normal  condition  before  one  is  warranted  in  re- 
pairing the  lesion  to  the  pelvic  floor. 

In  the  treatment  of  these  lesions  we  must  naturally 
consider,  first  the  incomplete  and  then  the  complete 
laceration  of  the  perineal  body.  Each  case  requires  its 
own  separate  and  appropriate  treatment ;  no  set  rule  can 
be  applied  to  all  cases.  After  a  careful  study  of  the 
normal  pelvic  floor,  each  case  will  readily  suggest  its 
own  proper  treatment.  I  care  not  what  operation  is 
used,  so  that  the  operator  fully  understands  the  amount 
of  lesion  present,  and  by  his  method  is  able  to  restore  as 
nearly  as  possible  the  normal  pelvic  floor.  Above  all 
errors,  there  is  none  more  deceptive  than  that  of  produc- 
ing a  skin  perineum.  The  patient  has  been  subjected  to 
the  inconvenience  of  an  operation,  but  her  condition  has 
not  been  one  whit  improved. 

The  repair  of  the  pelvic  floor  cannot  be  learned  from 
text- books;  it  must  be  seen  to  be  fully  appreciated  and 
understood. 

Again,  the  matter  of  diagnosis  is  sometimes  obscure.  I 
was  called  to  see  a  lady  suffering  from  incontinence  of 
faeces ;  she  had  been  delivered  of  a  child  three  months 


October  20,  1894J 


MEDICAL  RECORD. 


489 


previous.  Her  family  physician  assured  me  there  was  no 
local  difficulty ;  but  on  examination  I  found  a  complete 
laceration  of  the  perineal  body,  also  a  tear  up  the  recto- 
vaginal septum  for  fully  an  inch  and  a  half,  fully  ac- 
counting for  all  of  the  patient's  symptoms.  On  restor- 
ing the  pelvic  floor  her  disagreeable  symptoms  were  at 
once  cared.  I  may  also  add  that  in  this  case,  as  in  many 
others,  the  baby  was  kept  from  the  mother's  breast  for 
twenty- four  hours  immediately  following  the  operation, 
and  then  again  allowed  to  nurse ;  this  is  very  impor- 
tant, as  there  is  no  agent  more  powerful  to  produce  invo- 
lution than  that  of  nursing ;  it  is  nature's  way  of  pro- 
ducing retrograde  metamorphosis,  and  when  this  law  is 
violated  the  patient  invariably  pays  the  penalty.  When 
attending  a  case  of  labor  always  have  your  sutures 
ready  for  any  possible  lesion  which  may  occur ;  having 
trimmed  off  any  tags  that  may  be  necessary,  the  sutures 
can  be  readily  and  quickly  introduced,  for  the  parts  are 
then  benumbed ;  there  will  be  union  by  first  intention, 
a  normal  restoration  of  the  pelvic  floor,  involution 
hastened,  and  the  patient  spared  months  or  even  years  of 
suffering.  In  tying  your  sutures  they  should  be  snugly 
but  not  too  tightly  secured,  and  thereby  avoid  any  diffi- 
culty from  the  tumefaction  of  the  reparative  hyperemia; 
this  applies  to  any  period.  Avoid  multiplicity  of  sut- 
ures. Use  as  few  sutures  as  possible  consistent  with  the 
proper  coaptation  of  the  torn  parts.  I  have  seen  twenty, 
thirty,  and  even  still  more  sutures  used  in  complete  lac- 
eration of  the  perineal  body  involving  the  recto-vaginal 
septum.  I  have  also  seen  failures  which,  I  am  fully  con- 
vinced, were  due  entirely  to  the  multiplicity  of  sutures. 
It  is  to  be  remembered  .we  are  dealing  with  erectile 
tissue,  and  with  such  a  profusion  of  sutures  how  else 
cap  it  be  but  that  the  circulation  is  disturbed ;  an  inter- 
ference with  the  normal  action  of  the  vaso-motor 
apparatus,  and  we  have  the  classical  symptoms,  rubor, 
calor,  tumor,  dolor,  and  functiolsesa.  The  consequent 
abscess  cavity  is  obliged  to  fill  by  granulation,  and  while 
it  may  not  lessen  the  strength  of  the  pelvic  floor,  it  is  de- 
cidedly annoying  to  the  patient. 

In  preparing  a  patient  for  perineorrhaphy,  especially 
in  case  of  complete  laceration  of  the  perineal  body, 
much  of  the  success  of  the  operation  depends  on  the 
previous  attention  to  regulation  of  diet  and  action  of 
bowels.  It  is  my  custom  to  begin  fully  one  week  be- 
fore the  operation  with  regulation  of  diet.  Three  days 
before  the  operation,  calomel,  ipecac,  and  soda  tablets, 
containing  calomel,  \  grain,  are  given  hourly  till  one 
grain  is  taken.  Two  days  before  the  operation  several 
free  movements  of  the  bowels  are  secured  by  the  use  of 
Rochelle  or  Epsom  salts ;  and  the  day  before  the  opera- 
tion the  lower  bowel  is  throughly  emptied  by  enema. 
For  fully  twelve  hours  or  more  before  the  operation  the 
bowels  are  perfectly  quiet  and  remain  so  till  three  days 
after  the  operation,  as  will  be  described  later  when  speak- 
ing of  the  after-treatment. 

With  the  patient  before  you,  anaesthetized  and  in  the 
dorsal  position,  map  out  carefully  the  extent  of  the 
lesion,  as  indicated  by  the  caruncles  or  scars ;  with  the 
tenaculum  picking  up  a  point  on  the  crest  of  the  recto- 
cele  or  central  portion  of  posterior  vaginal  wall,  and 
bringing  it  down  to  the  topmost  caruncles  on  either  side 
as  already  noted,  so  that  the  slack  of  the  posterior  vaginal 
wall  will  be  taken  up  and  become  slightly  tense. 
Through  this  point  in  the  posterior  wall  a  suture  can  be 
passed  and  be  useful  as  a  guide  during  the  operation,  and 
then  removed  when  sutures  are  in  place.  Beginning  at 
scar  on  left  side,  denude  a  strip  at  edge  of  the  vaginal 
mucous  membrane,  down  along  fourchette  and  up  to 
scar  on  right  side ;  then  beginning  again  at  same  point 
on  left  side,  denude  a  strip  across  the  left  angle  to  the 
point  on  the  crest  of  the  rectocele,  and  continue  across 
right  angle  till  end  of  first  denudation  on  right  side  is 
reached.  You  have  now  mapped  out  before  you  the 
ordinary  butterfly  diagram.  Still  the  borders  denuded 
the  intervening  tissue  can  quickly  be  removed ;  in  de- 
nuding avoid  the  vessels  as  much  as  possible,  especially 


the  venous  plexuses ;  scissors  and  tenaculum  being  used 
in  the  denudation.  If  the  scar  extends  up  either  angle, 
or  there  is  marked  relaxation,  a  triangular  denudation 
should  extend  up  the  same.  Small  spurters  can  easily  be 
controlled  by  the  mere  application  of  the  artery  forceps ; 
but  if  a  vein  has  been  injured,  it  should  be  carefully 
ligated  and  clot  removed.  When  completed,  the  denu- 
dation should  be  the  same  height  on  either  side,  and  as 
nearly  uniform  as  possible.  In  suturing  I  prefer  the  fig- 
ure-of-eight suture,  using  heavy  silkworm-gut  and  the 
Hagedorn  gynecological  needle,  one-half  or  full  curve. 
If  the  angle  has  been  denuded,  a  figure-of-eight  suture 
should  be  introduced,  with  the  ends  of  the  suture  at  base 
of  triangle,  then  using  two  figure-of-eight  sutures  for  the 
trefoil  denudation. 

Two  sutures  are  sufficient  for  an  ordinary  laceration  ; 
if  the  angles  are  involved,  then  one  for  each  angle.  With 
the  left  index-finger  in  the  rectum  as  a  guide,  the  sutures 
should  be  buried  as  deeply  as  possible  to  catch  up  and 
bring  together  the  torn  or  relaxed  ends  of  fascia  and 
muscle.  Placing  a  small  loop  of  thread  on  base  of  sut- 
ure, it  facilitates  the  removal  of  suture  at  end  of  eight 
days. 

Silkworm-gut  commends  itself  for  the  ease  with  which 
it  can  be  made  aseptic,  and  its  lack  of  irritation  to  the 
surrounding  tissues. 

It  is  very  rare  to  have  pus  from  its  use,  and  it  gives  but 
little  pain  to  the  patient.  In  securing  the  sutures,  the 
limbs,  which  had  been  strongly  flexed,  are  now  brought 
forward,  the  knees  being  held  tightly  together.  A  tena- 
culum is  placed  in  the  angle  at  the  base  of  the  denuda- 
tion, and  downward  traction  is  made,  thus  lengthening 
the  denuded  portion.  The  torn  or  relaxed  pelvic  floor  is 
now  brought  together  to  its  normal  position,  and  by  thus 
taking  up  the  slack  in  the  pelvic  fascia,  giving  the  blood- 
vessels their  necessary  support,  it  also  soon  assumes  its 
normal  condition.  The  successful  performance  of  repair 
for  complete  laceration  of  the  perineal  body  is  one  of  the 
most  difficult  feats  of  plastic  gynecology.  All  that  has 
been  said  about  incomplete  laceration  of  the  perineal 
body  applies  also  to  complete,  with  the  exception  that, 
beginning  at  the  retracted  ends  of  the  sphincter  ani  mus- 
cle, careful  denudation  should  be  made  about  the  rec- 
tum, down  to,  but  avoiding  injury  of,  the  rectal  mucous 
membrane.  After  the  sutures  already  described  are  in- 
serted, with  the  addition  of  a  few  transverse  sutures  if 
the  amount  of  lesion  is  very  large,  last  of  all  I  unite  the 
rectal  mucous  membrane,  using  a  continuous  suture  of 
small-sized  catgut  and  one-half  curved  needle  with  smooth, 
round  point ;  having  tightened  my  first  layer  of  sutures, 
and  the  edges  of  the  rectal  mucous  membrane  being  in 
perfect  apposition,  I  then  use  a  second  layer,  and  even  a 
third  layer  of  sutures  if  necessary,  bringing  in  surround- 
ing tissues  and  strengthening  the  same ;  lastly,  with  the 
knees  in  the  proper  position,  the  remaining  sutures  are 
secured  as  already  described.  In  both  classes  of  cases 
the  after-treatment  consists  in  keeping  the  patient  quiet 
on  dorsal  position,  giving  hot  douches,  using  Kiistner's 
glass  catheter  if  patient  is  unable  to  urinate  easily.  No 
dressing  is  used  on  the  perineum. 

On  second  day  after  the  operation,  calomel,  ipecac,  and 
soda  tablets  are  given  as  before  operation,  and  on  third 
day  a  saline  cathartic  is  given.  The  first  movement 
should  be  soft  and  liquid,  and  especially  so  in  cases 
where  the  rectum  has  been  involved :  in  those  cases  an 
enema  containing  glycerine  and  Epsom  salts  should  be 
carefully  given,  using  pressure  with  tip  of  syringe  back- 
ward toward  coccyx,  thus  avoiding  the  slightest  tension 
on  sutures. 

Daily  movements  should  afterward  be  secured  by  ap- 
propriate medication.  Union  by  first  intention  is  se- 
cured in  these  cases,  and  success  will  crown  your  efforts 
if  the  proper  care  is  exercised.  In  the  treatment  of  a 
case  of  complete  laceration  of  the  perineal  body,  just  as 
much  care  should  be  exercised  as  in  the  treatment  of  a 
severe  fracture.  In  the  one  we  have  exudate,  in  the 
other  callus.     In  both  cases  it  takes  time  and  rest  for 


490 


MEDICAL   RECORD. 


[October  20,  1894 


the  parts  to  solidify  and  become  strong.  This  should  be 
firmly  impressed  upon  your  patient  Some  surgeons  pre- 
fer daily  movements  of  the  bowels  immediately  follow- 
ing the  operation,  by  the  administration  of  continued 
small  doses  of  a  saturated  solution  of  Epsom  or  Rochelle 
salts.  Others  prefer  constipation  for  a  week  or  more, 
even  using  opium  to  accomplish  the  same.  In  the  first 
instance  the  constant  vermicular  action  is  apt  to  prevent 
complete  union;  and  in  the  second,  the  accumulated 
scybalae  are  apt  to  do  damage  to  the  newly  united  tissue. 
The  golden  mean  of  Horace  applies  here  as  well  as  in 
many  other  cases.  The  object  attained  is  paramount  to 
the  agency  employed ;  whether  you  are  the  disciple  of 
an  American  or  a  European,  the  speedy  and  thorough 
restoration  of  the  injured  pelvic  floor  is  the  goal,  par  ex- 
cellence, to  be  reached:  I  am  happy  to  state  it  has  now 
reached  a  stage  of  development  which  insures  not  only 
relief  and  cure  to  the  patient,  but  also  a  reasonable  degree 
of  satisfaction  to  our  worthy  leaders  after  their  years  of 
tireless  exertion. 

99  Hukon  Strsbt. 

THE  SECRETION  OF  HYDROCHLORIC  ACID 
BY  THE  STOMACH  IN  HEALTH  AND  DIS- 
EASE. 

By  M.  GROSS,  M.D., 

NKW  YORK. 

According  to  Rollett  and  Heidenhain  the  difference  be- 
tween the  gastric  glands  at  the  pylorus  and  the  fundus 
consists  in  the  fact  that  the  former  contain  only  small 
bright  nucleated  cells  (Heidenhain's  Hauptzellen=main 
cells),  while  the  latter  have,  in  addition,  the  spherical 
large  cells  adjoining  the  membrana  propria  (Heiden- 
hain's Belegzellen  =  covering  cells).  Heidenhain  as- 
cribes to  the  main  cells  the  formation  of  pepsin ;  to  the 
covering  cells,  the  formation  of  hydrochloric  acid. 

The  elaboration  of  the  gastric  juice  is  divisible  into 
two  separate  acts  :  the  supply  of  the  raw  material  by  the 
blood  to  the  points  of  secretion,  shown  by  the  vivid  red- 
dening of  the  gastric  mucous  membrane  coincident  with 
the  beginning  of  the  secretion ;  and  the  chemical  trans 
formation  of  a  portion  of  this  material  into  the  specific 
constituents  of  the  gastric  juice  by  the  gland  cells. 

The  mere  fact  that  an  acid  secretion  is  formed  from 
the  alkaline  blood  bears  witness  to  the  specific  activity 
of  the  gland  cells. 

In  what  manner  is  free  hydrochloric  acid  formed  in 
the  gland  cells  from  the  sodium  chloride  supplied  by  the 
blood  ?  H.  Schulz  has  shown  that  alkaline  chlorides  in 
watery  solution  are  decomposed  by  carbonic  acid,  small 
quantities  of  free  hydrochloric  acid  being  formed.  Since 
the  blood  circulating  around  the  glands  contains  large 
amounts  of  free  carbonic  acid,  the  combined  effect  ot 
this  acid  can  liberate  a  small  quantity  of  hydrochloric 
acid  from  the  sodium  chloride.  As  it  is  probable  that 
the  formed  free  hydrochloric  acid  is  almost  immediately 
expelled  from  the  gland,  the  carbonic  acid  can  again 
displace  a  small  amount  of  hydrochloric  acid  and  thus 
the  process  of  transformation  may  continue.  While  the 
gland  cells  expel  the  liberated  hydrochloric  acid  into  the 
efferent  duct  of  the  glands  of  the  fundus,  the  carbonate 
of  sodium  formed  at  the  same  time  passes  back  into  the 
lymph  and  blood-current  (J.  Munk). 

Under  normal  conditions,  as  has  been  proved  in  the 
case  of  fistula,  the  mere  contact  of  a  foreign  body  with  the 
gastric  mucosa  stimulates  the  secretion  over  a  circum- 
scribed area  corresponding  to  the  surface  of  contact. 
But  the  secretion  occurring  in  consequence  of  the  me- 
chanical irritation  is  insufficient ;  it  becomes  at  once  more 
energetic  and  loses  its  circumscribed  character  if  absorp- 
tion, though  it  be  only  of  water,  takes  place  at  the  same 
time.  The  glandular  activity  becomes  general  over  the 
whole  of  the  stomach  and  assumes  its  normal  degree  when 
the  organ  contains  nutritive  fluids,  which  seem  to  exert  a 
powerful  influence  on  the  secretion,  probably  in  a  reflex 
way.     It  is  a  well-known  fact  that  the  swallowing  of  the 


tube  by  sensitive  individuals  may  be  a  sufficient  stimulus 
for  starting  the  secretion. 

The  first  phenomenon  which  we  can  demonstrate  in 
all  normal  gastric  contents  at  the  height  of  the  digestive 
process  is  their  acid  reaction,  which  is  due  chiefly  to  the 
excreted  hydrochloric  acid  and  to  a  slight  extent  to  the 
acid  salts  present  in  the  contents  of  the  stomach.  At 
this  period  the  acidity  is  greatest ;  it  rises  gradually  to 
this  point  from  the  onset  of  digestion,  and  again  slowly 
decreases.  At  the  moment  in  which  the  gland  cells  are 
stimulated  into  activity  by  the  ingesta  the  secretion  of 
hydrochloric  acid  begins,  and  the  latter  at  first  forms  salts 
or  hydrochlorates  with  the  inorganic  and  organic  bases, 
giving  rise  to  chlorides  and  hydrochloric  albuminates.  In 
testing  these  combinations  litmus-paper  will  turn  red, 
but  free  hydrochloric  acid  cannot  be  demonstrated. 
Sooner  or  later,  however,  saturation  occurs,  and  as  the 
glands  meantime  continue  to  secrete,  free  hydrochloric 
acid  then  appears,  which  reaches  its  maximum  at  the 
height  of  digestion  and  then  lessens  (Ewald). 

After  Ewald's  test  breakfast  (a  cup  [}4  litre]  of  tea  and 
a  roll  weighing  35  gm.)  the  maximum  of  the  secretion  of 
hydrochloric  acid  coincides  with  the  beginning  of  the 
second  hour,  and  the  hydrochloric  acid  secreted  about 
this  time  amounts  to  0.15  to  0.2  per  cent ;  after  a  plen- 
tiful mixed  diet  the  maximum  of  hydrochloric  acid  secre- 
tion ensues  later.  Although  these  figures  are  not  invari- 
able, they  are  so  nearly  correct  that  great  deviations  above 
or  below  them  must  be  looked  upon  as  pathological. 

As  opposed  to  the  normal  scretion  of  hydrochloric 
acid  (euchlorhydria),  we  speak — 1.  Of  an  anomalous  se- 
cretion of  hydrochloric  acid  when  we  have  to  deal  with  a 
retardation  or  acceleration  of  the  otherwise  normal  acid, 
that  is  to  say,  when  the  maximum  secretion  occurs  much 
later  or  earlier  than  the  time  above  given.  2.  The  se- 
cretion of  hydrochloric  acid  may  be  diminished  (hypo- 
chlorhydria.  3.  The  secretion  of  hydrochloric  acid  may 
be  increased  (hyperchlorhydria).  4.  Hydrochloric  acid 
may  be  completely  absent  (achlorhydria).  5.  There 
may  be  combinations  of  the  above  enumerated  anomalies 
of  secretion. 

If  we  bear  in  mind  that  disturbances  in  the  secretion 
of  hydrochloric  acid  (defect  or  access)  may  occur  (a), 
when  the  quality  of  the  blood  is  morbid,  thus  favoring 
or  impeding  the  secretion  of  hydrochloric  acid ;  (£),  in 
disorders  of  the  glandular  apparatus  in  consequence  of 
inflammatory  processes,  ulceration,  etc. ;  (c),  in  central 
and  peripheral  disorders  of  the  vago  sympathetic  system ; 
(</),  in  combinations  of  the  last- cited  factors,  we  must 
agree  with  Boas,  who  states  that  an  anomaly  in  the  se- 
cretion of  hydrochloric  acid  per  se  does  not  indicate 
with  any  degree  of  certainty  the  existence  of  a  disease  of 
the  stomach. 

The  access  or  diminution  of  the  secretion  of  hydro- 
chloric acid  is  a  symptom  which  indeed  bears  some  rela- 
tion to  the  different  types  of  disease,  inasmuch  as  some 
have  a  decided  tendency  to  increase  the  secretion,  others 
to  decrease  or  suppress  it  altogether.  But  this  takes 
place  only  to  the  extent  in  which  the  various  morbid 
processes  are  associated  with  anatomical  or  functional 
disturbances  which  naturally  cause  an  alteration  in  the 
production  of  hydrochloric  acid ;  hence  it  is  the  degree 
of  this  factor  in  the  morbid  process  which  determines  to 
what  extent  the  secretion  of  hydrochloric  acid  is  in- 
volved. Admitting  that  nowadays,  owing  to  succes- 
sively perfected  methods  of  examination  and  daily  in- 
creasing clinical  observations  resting  on  a  strictly 
scientific  basis,  we  are  on  a  firmer  footing  in  arriving  at 
a  correct  diagnosis  or  in  recognizing  the  indications  for 
a  successful  treatment ;  yet  it  is  true  to  day,  more  than 
ever,  that  only  the  most  careful  consideration  and  appre- 
ciation of  all  the  symptoms  developing  in  the  course  of  the 
disease,  aided  by  all  the  diagnostic  auxiliaries,  will  make 
clear  the  nature  of  the  affection  we  have  to  deal  with. 

When  we  consider  the  anomalies  of  secretion  of  the 
several  diseases  of  the  stomach  we  find  in  acute  gastritis 
almost  exclusively  a  lack  of  hydrochloric  acid ;  the  sour 


October  20,  1894] 


MEDICAL   RECORD. 


491 


eructations  and  vomiting  in  this  affection  are  usually  due 
to  acetic,  lactic,  and  butyric  acids. 

In  chronic  forms  of  gastritis  we  recognize  above  all 
the  law  of  pathology,  that  chronic  inflammations  restrict 
or  paralyze  the  specific  activity  of  the  respective  organs. 
In  those  cases  in  which,  despite  the  inflammatory  condi- 
tion of  the  gastric  mucous  membrane,  there  is  hyperchlor- 
hydria,  the  inflammatory  symptoms  are  of  a  secondary 
nature,  being  merely  sequels  or  concomitant  phenomena 
of  the  over- production  of  the  secreting  apparatus  due  to 
other,  usually  nervous,  causes.  In  such  cases  the  hyper- 
chlorhydria  exists  in  spite  of  the  partial  lesion  of  a  part 
of  the  secreting  parenchyma,  as  the  expression  of  an  in- 
creased activity  of  the  intact  remainder  (Ewald). 
^  In  simple  chronic  inflammation  (gastritis  chronica 
simplex)  the  hydrochloric  acid  is  always  diminished; 
in  mucous  inflammation  (gastritis  chronica  mucosa)  the 
hydrochloric  acid  is  usually  completely  absent;  in  the 
atrophic  form  (gastritis  chronica  atrophicans)  we  note 
complete  absence  of  combined  and  free  hydrochloric 
acid,  i.e.,  of  all  the  hydrochloric  acid  which  is  physio- 
logically active.  In  the  chronic  forms  of  gastritis,  too, 
we  often  find,  in  consequence  of  the  formation  of  acetic, 
lactic,  and  other  acids,  eructations  and  rising  o£  acid 
material  which  blunts  the  teeth  and  causes  also  a  burn- 
ing, scratching  sensation  in  the  course  of  the  oesophagus, 
the  so  called  heartburn  or  pyrosis ;  the  latter  sensation, 
if  confined  to  the  cardia,  is  also  called  cardialgia.  The 
cases,  however,  which  are  associated  with  an  intensifi- 
cation of  the  acidity  of  the  normal  gastric  juice,  i.e., 
with  hyperchlorhydria,  and  those  periodical  cases  in 
which  the  acidity  and  quality  of  the  gastric  contents  are 
normal,  despite  the  symptoms  of  pyrosis,  as  shown  by 
MacNaught,1  should  be,  with  few  exceptions,  included 
among  the  neuroses,  as  indicated  above. 

In  atonic  conditions  of  the  stomach,  as  I  have  had  oc- 
casion to  prove,3  we  find  the  secretion  of  hydrochloric 
acid  variable  in  accordance  with  the  state  of  the  gastric 
mucosa. 

In  dilatation,  however,  the  chemical  composition  de- 
pends on  the  cause  of  the  dilatation.  In  dilatation 
of  the  stomach,  in  consequence  of  cicatricial  stenosis 
of  the  pylorus  and  atonic  conditions  of  the  muscular 
structure,  we  find  almost  exclusively  a  normal  or  in- 
creased amount  of  hydrochloric  acid  in  the  contents 
of  the  stomach.  The  hydrochloric  acid  may  vary  in 
the  same  patient  on  different  days  despite  an  un- 
changed diet.  In  dilatation  of  the  stomach  we  not  rare- 
ly find  the  condition  called  continuous  acid  hypersecre- 
tion, in  which  the  stomach,  after  being  emptied  in  the 
evening,  contains  the  next  morning  often  considerable 
quantities  of  fluid  charged  with  hydrochloric  acid,  a 
point  to  be  discussed  hereafter.  All  this  shows  that 
the  stagnation  of  the  gastric  contents  exerts  no  per- 
ceptible influence  upon  the  secretion  of  the  gastric 
mucosa,  as  long  as  its  secreting  elements  in  general  are 
preserved* 

The  diagnosis  of  ulcer  of  the  stomach  seemed  to  gain 
greatly  in  certainty  by  the  fact  that  it  was  thought  an 
excessive  formation  of  acid  could  be  demonstrated  as  a 
constant  symptom.  The  credit  of  having  first  em- 
phasized the  occurrence  of  an  increased  secretion  of 
hydrochloric  acid  belongs  to  Riegel.  Ewald  declares: 
In  ulcer  of  the  stomach  the  gastric  juice  always  con- 
tains hydrochloric  acid,  often  excessive  in  amount. 
More  recent  experience,  however,  has  proved  that  while 
hyperchlorhydria  is  frequent  in  ulcus  ventriculi,  it  is  by 
no  means  constant. 

V.  Korczynski,  and  Jaworski,  too,  found  in  some  cases 
also  an  untimely — i.e.,  occurring  in  the  empty  stomach 
— so-called  continuous  acid  hypersecretion.  Removal 
of  the  contents  of  the  stomach  will  show  that  such  acid- 
ity disturbs  the  digestion,  the  protolytic  being  rapid  and 
complete,  the  amylolytic  slow  and  defective;. in  other 
words,  all  the  meat  is  often  well  digested,  while  of  the 

1  Medical  Chronicle,  January,  1885.  " 

9  Atony  of  the  Stomach,  Medical  Record,  March,  1894.  ' 


starchy  matters  a  greater  or  less  residue  is  found.  Gold- 
ing-Bird 1  first  described  the  state  of  the  hydrochloric 
acid  in  a  case  of  cancer  of  the  pylorus  with  dilatation. 
Kussmaul  and  his  pupils,  however,  were  the  first  to  treat 
this  question  methodically,  and  have  shown  that  in  the 
large  majority  of  cases  of  gastric  cancer  free  hydrochloric 
acid  is  absent,  although  such  absence  in  this  disease  has 
no  specific  importance  and  possesses  merely  the  value  of 
a  secondary  symptom.  More  recent  investigations  have 
disclosed  additional  no  less  interesting  points.  When 
the  carcinomatous  new-formation  occupies  a  small  region, 
and  the  associated  inflammation  of  the  gastric  mucosa  is 
slight,  the  secretion  of  hydrochloric  acid  may  continue 
to  be  sufficient ;  a  possible  subsequent  lack  of  hydro- 
chloric acid  may  be  the  result  of  the  slowly  developing 
cachexia.  When  the  carcinoma  springs  from  the  bottom 
of  a  gastric  ulcer,  there  may  be  at  first  even  normal  se- 
cretion of  hydrochloric  acid,  or  perhaps  hyperchlorhy- 
dria. In  the  majority  of  cases,  however,  as  stated  above, 
there  is  not  only  an  absence  of  free  hydrochloric  acid, 
but  also  of  that  loosely  combined  with  salts.  Yet  this 
lack  of  hydrochloric  acid  does  not  depend  upon  the 
carcinoma  per  se,  but  on  the  associated  catarrhal  in- 
flammation or  the  atrophic  condition  of  the  gastric 
mucosa. 

Ewald  describes  a  case  which  proves  that  when  the 
cancer  is  localized  and  the  mucosa  intact  the  secretion 
of  hydrochloric  acid  may  continue  until  a  short  time  be- 
fore death.  In  this  case  carcinoma  developing  on  an 
ulcer  could  be  excluded. 

While  some  authors  look  upon  hyperchlorhydria  and 
hypersecretion  as  an  anomaly  of  secretion  in  consequence 
of  organic  lesions,  and  only  in  a  small  number  of  cases  as 
a  neurosis,  Ewald,  among  others,  maintains  that  in  most 
cases,  excepting  those  above  enumerated,  we  are  dealing 
with  a  pure  neurosis  of  secretion.  In  the  succeeding 
sentences  I  am  following  mainly  Ewald's  deductions. 
This  author  looks  upon  hyperchlorhydria  and  hypersecre- 
tion of  the  gastric  juice  as  a  sensory  neurosis  of  the 
secretory  sphere.  Of  these  two  conditions  the  hyper- 
chlorhydria, which  must  be  strictly  separated  from  hy- 
persecretion, consists  in  an  increase  of  the  normal  hydro- 
chloric acid  secretion,  this  excessive  activity  being  due 
to  the  irritation  of  the  ingesta.  Van  Norden  found 
hyperchlorhydria  as  a  primary  neurosis,  i.e.,  indepen- 
dent of  an  organic  lesion,  in  melancholia;  Jolly,  in  hys- 
teria. It  occurs  temporarily  as  a  reflex  phenomenon 
after  gall  stone  colic  and  renal  calculi. 

Hypersecretion  or  parasecretion,  Reichmann's  "Ma- 
gensaftfluss,"  is  divided  into  the  acute  or  periodical,  and 
the  chronic  or  continuous  form.  The  former  occurs,  as 
a  rule,  without  increased  acidity.  It  appears  periodi- 
cally, usually  after  eating,  rarely  on  an  empty  stomach, 
but  seems  to  have  no  direct  connection  with  the  in- 
troduction of  ingesta.  The  condition  is  a  functional 
disturbance  of  the  nerves  of  the  stomach,  which  oc- 
curs independently  or  as  a  local  symptom  of  other 
neuroses. 

In  chronic  hypersecretion  there  is  a  continuous  forma- 
tion of  gastric  juice,  which  is  usually  excessively  acid,  so 
that  even  the  empty  stomach  contains  larger  or  smaller 
quantities  of  a  fluid  which  may  vary  greatly  in  the  con- 
tained free  hydrochloric  acid,  but  whose  degree  of  acid- 
ity is  always  increased.  In  this  condition,  too,  while 
the  tongue  is  remarkably  clean  and  the  appetite  good, 
we  find,  as  a  consequence  of  the  irritation  due  to  the 
acid  fluid,  heartburn,  gastralgia,  etc.,  which  troubles 
disappear  temporarily  after  an  albuminous  diet,  contrary 
to  the  pyrosis  resulting  from  acid  fermentation,  in  which 
albuminous  diet  has  no  ameliorating  effect. 

There  is  also  a  nervous  anacidity  (anachlorhydria)  of 
the  gastric  juice  in  hysterical  and  neurasthenic  patients 
in  whom,  therefore,  an  organic  disease  of  the  stomach 
can  be  excluded. 

The  relations  between  the  secretion  of  gastric  juice 
and  the  diseases  of  other  organs  of  the  body  have  an 

1  London  Medical  Gazette,  1843,  vol.  ii.,  p.  391. 


492 


MEDICAL   RECORD. 


[October  20,  1894 


importance  which  must  not  be  underestimated,  for  there 
is  hardly  any  internal  disorder  in  which  gastric  digestion 
is  not  largely  implicated  and  associated  with  functional 
disturbances.  This  subject  is  so  extensive  that  I  must 
dispose  of  it  here  in  a  few  words. 

In  diseases  of  the  heart,  lungs,  and  liver  it  is  mainly 
the  circulatory  disturbances  which  lead  to  symptoms  of 
congestion  and  their  sequelae,  chronic  catarrhal  condi- 
tions of  the  gastric  mucosa. 

Diseases  of  the  heart  per  sc  have  no  influence  on  the 
secretion  of  hydrochloric  acid ;  it  is  the  chronic  catarrhs 
resulting  from  congestion  which  cause  a  diminution  of 
the  secretion  of  hydrochloric  acid. 

In  diseases  of  the  nose  I  have  made  investigations 
with  the  mucopurulent  masses  from  a  purulent  rhinitis 
and  have  found  that  the  digestive  power  of  an  active 
gastric  juice  is  weakened  by  the  addition  of  such  nasal 
secretions;  small  amounts  of  hydrochloric  acid  may 
thus  be  neutralized  when  the  secretory  activity  is  de- 
pressed. 

In  chronic  diseases  of  the  lungs,  in  phthisis,  emphy- 
sema, in  chronic  forms  of  bronchitis,  etc.,  in  which,  as 
stated  above,  circulatory  disturbances  and  their  conse- 
quences come  in  question  with  reference  to  their  influ- 
ence on  the  secretion  of  hydrochloric  acid,  it  depends 
entirely  on  the  extent  of  the  anatomical  and  functional 
disturbance  present  in  the  concrete  case  to  produce  a 
corresponding  effect  on  the  gastric  glands. 

Hildebrand  found  that  the  absence  of  hydrochloric 
acid  in  phthisis  coincided  with  the  rise  of  temperature. 
As  regards  diseases  of  the  kidney l  Fenwick  proved  that  in 
chronic  renal  diseases  the  gastric  mucous  membrane  like- 
wise excretes  urea,  and  that  the  latter  during  the  process 
of  elimination  irritates  the  mucosa  of  the  stomach  and 
leads  to  catarrh,  with  consequent  diminution  of  hydro- 
chloric acid.  Bernacki  found  that  during  oliguria  and 
oedema  the  diminution  of  hydrochloric  acid  was  greater 
than  after  the  re-establishment  of  the  urinary  secretion 
and  the  disappearance  of  the  oedema ;  as  the  quantity  of 
urine  increased,  so  did  the  hydrochloric  acid. 

As  regards  the  disturbance  of  hydrochloric  acid  secre- 
tion resulting  from  diseases  of  the  sexual  organs,  E. 
Fleischer  found  diminution  of  the  acid  during  menstrua- 
tion. Recently  I  treated  a  neurasthenic  patient  who 
was  attacked  after  nearly  every  coitus  with  nausea  and 
gastralgic  pains,  sometimes  associated  with  vomiting; 
the  vomited  matters  always  contained  excessive  amounts 
of  free  hydrochloric  acid. 

Rosenheim  found  in  a  number  of  diabetic  patients  a 
temporary  absence  of  hydrochloric  acid  which  he  inter- 
preted as  a  neurosis ;  in  other  cases  he  found  the  hydro- 
chloric acid  constantly  absent  and  ascribed  the  condition 
to  an  atrophy  of  the  glandular  apparatus.' 

In  anaemia  and  chlorosis  the  activity  of  the  gastric 
glands  suffers  in  consequence  of  defective  blood  supply ; 
but  there  are  cases  enough  in  which  the  secretion  of  hy- 
drochloric acid  is  normal  or  even  excessive. 

Lastly,  with  reference  to  the  secretion  of  hydrochloric 
acid  in  malaria,  I  have  found  among  fifteen  cases  of 
masked  malaria — further  details  will  be  given  in  another 
place — nine  in  which  the  hydrochloric  acid  was  dimin- 
ished, while  lactic  acid  was  markedly  increased. 

In  conclusion,  I  shall  give  the  shortest  methods  for 
the  qualitative  and  quantitative  determination  of  hy- 
drochloric acid.  By  means  of  Congo  paper  we  ascer- 
tain whether  any  free  acid  is  present  in  the  filtered  gas- 
tric contents ;  paper  impregnated  with  Congo  red  be- 
coming violet  in  the  presence  of  acids.  To  determine 
free  hydrochloric  acid  we  employ  Gttnzburg's  reagent 
and  mode  of  procedure.  The  reagent  consists  of  phloro- 
glucin,  2 ;  vanillin,  1 ;  alcohol  (eighty  per  cent.),  100 
parts.  Of  this  solution  we  place  one  or  two  drops  in  a 
china  saucer  and  add  one  or  two  drops  of  the  stomach 
contents  to  be  tested.  If  free  hydrochloric  acid  is  pres- 
ent, a  carmine  red  ring  forms  at  the  point  where  the  two 
fluids  meet  when  the  saucer  is  carefully  heated. 

1  Virch.  Arch.,  Bd.  xviii. 


For  the  quantitative  determination  of  hydrochloric 
acid  Leo's  method  is  the  most  reliable : 

Any  present  organic  acids  having  been  determined 
and  removed,  10  c.c.  of  the  filtered  stomach  contents 
are  mixed  with  5  c.c.  of  a  concentrated  solution  ot 
calcium  chloride  (CaCl,)  and  its  acidity  is  determined. 
Then  15  c.c.  of  the  filtrate  are  mixed  in  a  dry  vessel 
with  dry  chemically  pure  powdered  calcium  carbonate 
(CaCoa),  and  after  stirring  are  run  through  a  dry  filter. 
Of  this  filtrate  10  c.c.  are  measured  off,  and  air  is 
passed  through  to  drive  off  the  carbon  dioxide  (CO,)  ; 
then  5  c.c  of  calcium  chloride  (CaCl,)  is  added  and  the 
filtration  is  repeated.  The  difference  between  the  first 
and  second  filtration  shows  the  physiologically  active  hy- 
drochloric acid. 

776  Madison  Avsmuv. 


fgKogtzBS  at  ^fit&icsCi  £clmtz. 

Putrefactive  Oases  as  Predisposing  Agents  in  Typhoid 
Infection. — Dr.  Alessi  has  made  experiments  which 
throw  some  light  upon  this  subject.  Rats,  guinea-pigs, 
and  rabbits  were  confined  in  boxes  with  perforated 
bottoms,  and  these  boxes  were  then  placed  over  open 
privies  or  cesspools,  or  over  receptacles  containing  the 
evacuations  of  the  animals.  Notwithstanding  that  they 
continued  to  eat  well,  the  animals  lost  their  liveliness, 
and  gradually  pined.  They  were  inoculated  in  this  state 
with  a  small  dose  of  typhoid  bacillus,  with  the  result 
that  they  died  in  twelve  to  thirty*  six  hours.  The 
examination  showed  signs  of  hsemorraghic  enteritis, 
swollen  Peyer's  patches  and  spleen,  and  typhoid  bacilli 
in  the  blood,  liver,  and  spleen.  The  same  dose  had  no 
effect  upon  the  majority  of  the  control  animals;  only  a 
few  showed  slight  symptoms  of  illness,  and  one  died. 
These  experiments  go  to  show  that  animals  are  rendered 
highly  sensitive  to  the  typhoid  bacillus  by  previous  in- 
halation of  the  gases  of  putrefaction.  Alessi  next  inves- 
tigated the  isolated  action  of  the  various  gases  produced 
in  putrefaction,  to  ascertain  if  any  one  were  capable  of 
creating  the  predisposition  referred  to.  The  result  was 
in  each  case  negative.  The  same  held  good  as  regards 
certain  mixtures  of  these  substances. — Centralblatt  JUr 
Bakteriologic. 

Toxicity  of  Scalded  orjBurnt  Tissues. — In  1880  Les- 
ser made  some  experiments  to  ascertain  the  effects  of  in- 
jecting the  blood  of  a  burnt  animal  into  a  healthy  one. 
He  seems,  however,  to  have  succeeded  only  in  producing 
certain  functional  disturbances,  never  a  fatal  effect. 
Vassale  and  Sacchi  followed  a  similar  line  of  investiga- 
tion, and  studied  the  effect  of  extracts  of  parts  actually 
burnt  or  scalded,  and  of  the  non-affected  parts  of  the 
same  animals,  on  healthy  animals  of  the  same  or  allied 
species.  Their  researches  show  clearly  that  the  juice  of 
parts  burnt  has  a  much  more  toxic  effect  on  animals  of 
the  same  species  than  that  of  the  non-burnt  parts  of  the 
same  animal.  This  last  juice,  in  its  turn,  has  a  toxicity 
much  greater  than  that  of  the  juice  taken  from  corre- 
sponding parts  of  a  healthy  animal,  which  is,  in  fact, 
harmless.  All  the  juices  from  a  burnt  animal  are  highly 
toxic,  and  generally  produce  lethal  effects  whether  in- 
jected hypodermically  or  into  the  veins  of  normal  ani- 
mals. The  chief  pathological  effects  produced  were 
marked  subserous  hemorrhages,  in  one  case  especially 
marked  in  the  duodenum.  Filtration  through  porcelain 
somewhat  diminishes  but  does  not  destroy  the  toxicity 
of  the  juices;  boiling,  however,  renders  them  innocu- 
ous, which  lends  support  to  the  view  that  the  toxic  prin- 
ciple is  an  albumose,  or  some  substance  coagulable  by 
heat.  These  results  are  of  interest  as  bearing  on  the 
mode  of  production  of  the  after  effects  of  burns,  at- 
tributed by  Fo£,  as  early  as  1881,  to  a  process  of  auto- 
intoxication. Not  long  ago  Kianitzin  (Ann.  di  Chiw. 
e  di  FarmacoLy  1892)  examined  the  blood,  organs,  and 
urine  of  animals  suffering  from  burns,  and  by  Brieger's 
method  obtained  a  substance  from  them  which"  was  not 


October  20,  1894] 


MEDICAL   RECORD. 


493 


to  be  found  in  normal  animals  similarly  treated.  When 
injected  into  normal  animals  it  produced  torpor,  somno- 
lence, reduction  of  temperature,  slow,  shallow  respiration, 
diarrhoea,  and  death.  The  necropsy  showed  nothing  but 
hyperemia  of  the  brain  and  kidneys.  This  substance 
was  classed  by  its  discoverer  with  muscarin,  neurin,  and 
peptoxin.  More  recently  Reiss  (Archiv  fur  Derma* 
tohgie  und Syphilis j  i.,  1893)  studied  the  effects  of  subcu- 
taneous injection  of  the  urine  of  patients  suffering  from 
burns.  Such  urine  was  very  toxic,  and  it  was  found  that 
it  owed  its  properties  to  the  presence  of  bases  of  the 
pyridin  group.  In  cases  of  severe  burn  he  recommended 
the  speedy  removal  of  the  sloughed  parts  so  as  to  mini- 
mize the  absorption  of  poisons  formed  in  the  lesion. 
Vassale  and  Sacchi  are  of  a  similar  opinion.  They  also 
recommend  the  employment  of  every  possible  means — 
such  as  keeping  the  burnt  limb  as  low  as  possible,  and 
the  application  of  bandages— of  preventing  the  too  rapid 
absorption  of  the  degeneration  products,  the  toxicity  of 
which  they  have  so  rally  established. — The  British  Medi- 
cal Journal. 

The  Hephritis  of  Typhoid  Fever. — In  a  recent  article 
on  this  subject  by  M.  L6once  Bodin,  the  author  re- 
marks that  the  forms  of  nephritis  that  supervene  during 
the  course  of  typhoid  fever  are  well  known  clinically 
(The  New  York  Medical  Journal,  August  n,  1894). 
They  occur  most  commonly  in  patients  affected  with  the 
clasical  form  of  dothienenteritis,  with  high  fever,  diar- 
rhoea, rose-spots,  tympanites,  enlargement  of  the  spleen, 
and  a  more  or  less  pronounced  typhoid  condition.  The 
renal  accidents  usually  make  their  appearance  during  the 
course  of  the  second  week.  Albumin  appears  suddenly 
and  more  or  less  abundantly  in  the  urine,  and  its  appear- 
ance is  accompanied  by  general  phenomena  of  variable 
intensity.  When  these  phenomena  are  violent,  as  some- 
times happens,  they  deserve  the  name  of  acute  uraemia, 
being  accompanied  by  almost  complete  suppression  of 
urine  and  by  oedema,  and  almost  always  terminating 
fatally  by  convulsions  or  coma.  In  another  form  they 
are  less  violent,  but  they  are  always  grave.  There  is 
blood  in  the  urine,  which  is  diminished  in  amount,  and 
the  uremic  phenomena  are  less  intense.  Finally,  and 
more  frequently,  still  less  severe  derangements  are  ob- 
served, characterized  especially  by  an  aggravation  of  the 
general  condition,  by  dryness  of  the  tongue,  by  pains  in 
the  loins,  by  headache,  and  by  the  appearance  of  a  slight 
amount  of  albumin  in  the  urine.  It  is  particularly  in 
this  third  form,  happily  the  most  frequent,  that  there  is 
especially  to  be  observed  an  exaggeration  of  the  symp- 
toms proper  to  the  typhoid  fever,  but  with  a  very  clear 
renal  character  easily  recognizable.  In  these  forms  of 
nephritis  microbes  are  generally  found  in  the  urine,  or, 
but  much  more  rarely,  in  sections  of  the  kidneys.  Or- 
dinarily they  are  micrococci,  with  or  without  the  bacillus 
of  Eberth,  streptococci,  and  staphylococci,  the  last- 
named  being  far  the  most  common.  As  these  microbes 
are  habitually  found  in  the  intestinal  canal,  it  is  very 
probable  that  they  gain  entrance  into  the  blood  through 
the  intestinal  ulcerations,  which  are  an  open  door  to  all 
secondary  infections ;  consequently,  these  cases  of  ne- 
phritis of  typhoid  fever  are  most  commonly  cases  of  sec- 
ondary nephritis. 

But  typhoid  nephritis  may  present  various  guises,  and 
the  case  reported  showed  very  special  characters  in  its 
evolution,  so  that  it  seems  to  the  author  to  be  an  exam- 
ple of  a  particular  class  of  cases,  both  clinically  and  bac- 
teriologically.  The  patient,  twenty-three  years  old,  was 
a  night  nurse  employed  in  the  Trousseau  Hospital.  She 
was  admitted  into  the  Saint-Antoine  Hospital  on  June 
1  st.  For  about  a  week  she  had  suffered  with  progressive 
loss  of  strength,  great  lassitude  on  the  slightest  exertion, 
invariable  fatigue  on  rising,  progressive  and  persistent 
impairment  of  sleep,  and  continuous  headache  which  re- 
sisted antipyrine.  She  had  lost  her  appetite  and  had 
vomited  a  few  times,  but  had  no  diarrhoea  or  bleeding 
from  the  nose.     On  examination,  the  abdomen  was 


found  soft  and  not  distended ;  there  was  no  gurgling  in 
the  iliac  fossa  or  pain  anywhere  on  pressure ;  the  tongue 
was  lightly  coated  and  pale,  but  neither  red  at  the  tip  or 
at  the  border  nor  tremulous.  There  were  no  rose-spots 
on  the  abdomen*  After  a  minute  search  two  or  three 
doubtful  eruptive  spots  were  found  on  the  back,  between 
the  shoulder-blades  and  on  the  lumbar  region.  The 
spleen  seemed  somewhat  enlarged.  The  temperature  was 
102.  i°  F.  in  the  morning  and  104  20  F.  in  the  evening. 
The  lungs  were  normal,  and  the  patient's  general  condi- 
tion was  good — she  had  no  stupor,  but  slight  prostration. 
The  urine  was  normal.  After  hesitating  between  influ- 
enza and  typhoid  fever,  the  latter  was  diagnosticated. 
On  June  5th  it  was  noted  that  during  the  night  the  pa- 
tient had  vomited  abundantly  and  that  the  matter  vom- 
ited was  greenish ;  also  that  her  general  condition  was 
aggravated  and  that  there  was  some  stupor,  with  severe 
headache,  lumbar  pains,  and  dryness  of  the  tongue.  The 
urine  was  of  a  deep  red  color  and  contained  a  notable 
quantity  of  albumin.  The  temperature,  which  had  at 
first  been  kept  down  with  quinine,  had  now  risen  to 
104.30  F.  Baths  of  the  temperature  of  66°  F.  were 
prescribed  every  three  hours.  On  the  6th  many  red 
blood-corpuscles  were  found  in  the  urine,  also  blood- 
casts  and  epithelial  debris.  Albumin  was  found  in  the 
urine  until  the  25  th,  after  which  it  was  present  only  as  a 
slight  trace  for  a  day  or  two  and  then  disappeared  defi- 
nitely and  the  patient  was  in  full  convalescence.  M. 
Bodin  calls  attention  to  the  fact  that  during  the  whole 
course  of  the  disease  at  no  time  were  the  ordinary  ab- 
dominal and  pulmonary  symptoms  of  typhoid  fever  ob- 
served, only  a  moderate  prostration  during  the  early  days. 
The  temperature  curve  was  that  of  typhoid  fever  of  me- 
dium intensity,  but  the  onset  of  the  symptoms  of  nephritis 
had  been  very  definite  and  had  impressed  upon  the  dis- 
ease a  particular  aspect.  The  small  amount  of  albumin 
found  in  the  urine  and  the  absence  of  oliguria,  save  at 
the  outset,  are  to  be  contrasted  with  the  very  decided 
uraemic  phenomena  present  from  first  to  last. 

The  bacteriological  examination  of  the  patient's  fluids 
was  made  as  follows :  Beginning  with  June  6th,  the  urine 
was  collected  every  second  day,  examined,  and  inoculated. 
On  three  occasions  the  blood  from  the  spleen  was  inocu- 
lated. The  urine  was  removed  from  the  bladder  with  a 
sterilized  metallic  catheter  after  a  thorough  cleansing  of 
the  vulva  and  meatus  urinarius  with  soap  and  a  solution 
of  corrosive  sublimate.  The  urine,  received  into  steril- 
ized tubes,  was  placed  on  a  centrifugal  machine  and  cult-  ' 
ures  were  made  in  gelose,  gelatin,  or  bouillon  directly 
from  the  deposit  thus  obtained.  The  blood  was  taken 
from  the  spleen  by  means  of  a  Roux's  syringe  boiled  for 
an  hour,  and  after  previous  disinfection  of  the  skin  over 
the  spleen.  It  was  ascertained  that  from  beginning 
to  end  the  urine  contained  a  very  great  abundance  of 
bacilli  having  all  the  characteristics  of  the  Eberth- 
Gaffky  bacillus.  The  existence  of  this  bacillus  exclu- 
sively in  the  urine  is  considered  remarkable  by  the  author, 
for  most  commonly  in  analogous  cases  there  are  numer- 
ous associated  microbes,  especially  staphylococci.  Fur- 
thermore, from  the  complete  absence  of  the  ordinary 
intestinal  symptom?  of  typhoid  fever,  he  thinks  it  prob- 
able that  in  this  case  the  intestine  was  but  slightly  if  at 
all  affected,  so  that  there  could  not  have  been  a  second- 
ary infection  by  the  microbes  which  are  ordinarily  found 
in  the  alimentary  canal.  The  author  hazards  the  hy- 
pothesis, which  he  confesses  is  somewhat  forced,  of  a 
primary  nephritis  from  infection  with  the  Eberth  bacillus, 
or  nephro  typhus  accompanied  by  a  general  condition 
and  a  temperature  curve  resembling  those  of  typhoid 
fever  without  any  of  the  usual  symptoms  of  typhoid  fe- 
ver pertaining  to  the  alimentary  canal,  the  lungs,  etc. 
Granting  this  to  have  been  the  case,  the  Eberth  bacillus 
would  have  acted  in  this  case  as  the  pneumococcus  acts 
in  certain  kinds  of  amygdalitis  in  which  the  thermometric 
curve  and  the  general  condition  of  a  frank  pneumonia 
are  observed  without  the  slightest  local  sign  of  pulmo- 
nary inflammation. 


494 


MEDICAL   RECORD 


[October  20,  1894 


Clinical  gejrartraimk 

FOUR  CASES   OF  RETINITIS  FROM  CHRONIC 
DIFFUSE    NEPHRITIS. 

By  DAVID   WEBSTER,  M.D., 

PROPSfSOR  OP  OPHTHALMOLOGY  IN  THB  NSW  YORK  POLYCLINIC  AND  IN  DART- 
MOUTH MKOICAL  COLLBGK;  SURGSON  TO  THB  MANHATTAN  BVB  AND  BAR 
HOSPITAL,   NEW  YORK. 

Case  I. — Mrs.  E.  R ,  aged  sixty-three,   consulted 

Dr.  C.  R.  Agnew  and  myself  oq  December  2,  1879.  She 
had  had  poor  sight  for  many  years,  but  could  read  until 
three  months  ago.  During  the  last  three  months  her  sight 
has  deteriorated  rapidly. 

R.  V.  =  ^q.  ;  no  improvement  with  glasses. 

L.  V.  =  counts  fingers  at  one  foot 

Ophthalmoscopic  examination  shows  incipient  cata- 
ract of  both  eyes.  The  right  has  a  large  plaque  of  retinal 
exudation  in  the  region  of  the  macula.  The  left  has 
neuro  retinitis  with  numerous  hemorrhages  of  various 
sizes  and  shapes  scattered  all  over  the  fundus. 

All  the  urine    Mrs.    R passed  in  twenty -four 

hours  was  sent  to  Dr.  E.  A.  Maxwell  for  examination. 
Dr.  Maxwell  reported  as  follows :  1,  Medium  and  broad 
hyaline  casts ;  2,  epithelial  and  granular  casts ;  3,  no 
albumin ;  4,  low  specific  gravity ;  5,  large  quantity  of 
urine.     Chronic  diffuse  nephritis. 

Case  II. — June  25,  1880.  James  W ,  aged  sixty- 

eight,  manufacturer  and  merchant,  married,  never  saw 
well  in  the  distance.  He  can  read  at  the  ordinary  dis- 
tance without  glasses.  For  the  last  two  or  three  weeks 
his  eyes  have  failed  in  reading  and  he  has  seen  motes 
and  black  threads  and  dark  spots  floating  before  them. 
He  has  had  no  pain  in  his  eyes  and  no  headache.  He 
has  been  troubled  a  good  deal  with  dizziness  on  stooping 
or  on  suddenly  turning  his  head.  He  has  had  a  cough 
for  four  or  five  years,  and  is  weak  and  short  of  breath. 

R-v.  =  VW;  ttwith-^. 

LV.  =  1«AF;«with-1V. 

As  his  pupils  were  very  small  that  of  the  right  eye  was 
dilated  by  means  of  an  atropine  wafer,  to  facilitate  oph- 
thalmoscopic examination.  We  found  floating  bodies  in 
the  vitreous  and  minute  clusters  of  changes  in  the  retina 
at  the  posterior  pole  of  the  eye. 

June  26th. — Since  the  atropine  wafer  was  put  into  the 
eye  there  has  been  smarting  and  sensitiveness  to  light. 
His  bovels  are  perfectly  regular.  Ordered  iodide  of 
potassium,  gr.  v.  ter  in  die. 

On  June  30th  his  urine  was  examined  by  Dr.  E.  A. 
Maxwell,  who  reported  as  follows:  1,  Concentrated 
urine ;  2,  no  albumin  nor  sugar ;  hyaline,  hyaline  and 
granular  casts,  medium  and  narrow,  six  to  eight  on  a 
slide;  4,  yellow,  finely  granular,  tubular  epithelium;  5, 
altered  blood  -  corpuscles,  scanty;  6,  spermatozoids, 
scanty;  7,  oxalate  of  lime.  Chronic  diffuse  nephritis, 
granular  contracted  kidney,  general  or  localized. 

Examination  of  a  second  specimen  four  days  later 
gave  similar  results. 

Case  III.— September  17,  1880.    John  T.   R , 

aged  sixty-eight,  married,  says  that  he  did  a  great  deal 
of  writing  last  February  and  from  that  time  till  five  or 
six  weeks  ago  he  had  a  great  deal  of  difficulty  in  reading, 
and  since  that  he  has  not  been  able  to  read  ordinary 
print  at  all.  He  comes  up  stairs  with  difficulty,  due,  he 
says,  to  rheumatism,  which  he  has  had,  more  or  less,  since 
1868.  He  had  it  very  badly  at  one  time,  but  was  never 
laid  up  in  bed  with  it.  He  has  been,  for  two  or  three 
weeks  at  a  time,  so  crippled  with  it  that  he  had  to  crawl 
up  stairs  and  slide  down.  He  has  a  poor  appetite,  and 
dizziness,  and  constipation,  the  latter  for  the  last  two 
years.     He  seldom  takes  physic,  however. 

Ophthalmoscopic  examination  shows  peripheral  opaci- 
ties in  the  lower  parts  of  both  crystalline  lenses.  There 
are  old  corneal  opacities  of  the  right,  and  both  have  an 
astigmatic  look.  There  are  changes  about  the  macula, 
and  a  large  area  in  that  region  looks  somewhat  (Edematous, 
or  hazy.     Both  anterior  chambers  are  markedly  shallow. 


R-  V.  =  ,U;  TVVwith  +  f 

L-  V.  =^;  f|with  +  |. 

A  specimen  of  his  urine,  examined  by  Dr.  Maxwell, 
shows:  1,  Quantity  and  specific  gravity  normal;  2, 
medium  and  broad  hyaline  casts ;  3,  tubular  epithelium ; 
4,  pigmented  bladder  epithelium;  5,  no  albumin  nor 
sugar.     Chronic  diffuse  nephritis. 

Case  IV. — February  25,  1882.   Thomas  A ,  aged 

seventy-one,  married,  merchant,  complains  of  a  blur 
over  his  right  eye  with  scintillations.  He  says  he  was 
always  near-sighted.  He  is  the  victim  of  rheumatic  gout, 
and  his  family  physician  says  he  has  organic  disease  of 
the  heart. 

R.  V.  =  U  with  -  |. 

L.  V.  =  ||  with  -  ^. 

Ophthalmoscopic  examination  shows  staphyloma  pos- 
ticum  of  both  eyes,  that  in  the  right  being  very  exten- 
sive. In  the  right  eye  there  are  retinal  exudations 
occupying  the  whole  macular  region. 

Dr.  Maxwell  examined  his  urine  and  found :  1,  Light 
color;  2,  low  specific  gravity  (1017);  3,  no  albumin 
nor  sugar;  4,  abundant  hyaline  casts  (10  or  12  on  a 
slide) ;  5,  scanty,  altered  tubular  epithelium.  Chronic 
diffuse  nephritis. 

It  is  worthy  of  remark  that  there  was  no  albumin 
present  in  the  urine  of  any  of  these  patients.  The  diag- 
nosis of  chronic  diffuse  nephritis  was  based  on  the  pres- 
ence of  casts,  and  other  abnormal  constituents  of  the 
urine. 


A  FEW  WORDS  IN  REFERENCE  TO  CARYO- 
CINETIC  CHANGES  IN  THE  RED  BLOOD- 
CORPUSCLES. 

By  WILLIAM   MOSER,   M.D., 

PATHOLOGIST  TO   ST.   CATHARINE*S  HOSPITAL,   BROOKLYN,  K.   Y. 

Ever  since  Luzet  drew  attention  to  caryocinetic  changes 
in  the  red  blood-corpuscle  in  infantile  pseudo-leucaemia 
(Jaksch)  the  discovery  has  stimulated  many  to  further 
research.  It  is  well  known  that  in  the  blood  of  infants 
nucleated  red  blood-corpuscles  are  common  even  in 
health.  They  are  like  a  nucleus  when  at  rest,  round, 
and  exhibit  no  property  of  caryocinesis.  It  is  possible 
that  it  has  this  property,  but  it  has  not  yet  been  demon- 
strated in  healthy  infants.  In  infantile  pseudo  leucaemia 
mitotic  changes  in  the  red  blood-cells  are  so  constant  and 
occur  in  such  large  numbers  that  Luzet  regarded  it  as 
characteristic  for  that  disease,  as  a  means  of  differential 
diagnosis  from  other  forms  of  anaemia.  If  we  have  an 
infant  with  an  enormously  enlarged  spleen,  and  by  ex- 
amination of  the  blood  find  large  numbers  of  red  blood- 
cells  in  process  of  caryocinesis  we  are  justified  in  making 
a  diagnosis  of  infantile  pseudo  leucaemia.  But  from  a 
given  specimen  of  blood  without  a  clinical  history  the 
diagnosis  cannot  always  be  made,  hence  it  is  not  charac- 
teristic for  this  disease.  I  base  this  statement  from  a 
specimen  of  blood  taken  from  a  case  which  was  diagnosed 
as  scurvy  by  Dr.  Fuhs  at  St.  Catharine's  Hospital.  The 
specimen  showed  the  nucleus  at  rest,  accessory  nuclei,  ir- 
regular shaped  nuclei,  the  nucleus  split  in  half,  the  ro- 
sette-shape, and  large  numbers  in  which  the  cells  were 
filled  with  threads  and  dots ;  (chromatic  corpuscles),  as 
though  the  specimen  had  been  "  fixed  "  in  Flemming's 
solution.  The  specimen  was  examined  fresh  and  can  be 
preserved  as  well  as  those  which  are  "  fixed  "  and  stained. 
Askanazy  recently  reported  a  picture  similar  to  the  one 
described  above  in  a  case  of  pernicious  anaemia.  He  saw 
caryocinesis  and  what  he  terms  "  karyolysis  "  (retrograde 
metamorphosis  of  the  nucleus)  in  quite  a  number  of  the 
cells.  In  a  fresh  specimen  he  even  saw  different  phases 
of  caryocinesis  in  a  single  red  blood-cell.  The  subject 
is  in  its  infancy,  and  much  may  yet  be  demonstrated. 
The  conclusion  can  be  safely  made  that  caryocinesis  in 
the  red  blood-corpuscles  is  not  characteristic  for  any 
given  disease,  and  further  research  may  prove  it  to  be 
more  common  than  we  now  regard  it. 

158  Ross  Strbbt. 


October  20,  1894] 


MEDICAL   RECORD. 


495 


THE  TEMPERATURE  OF  TWO  CHILDREN  DUR- 
ING SPASMS. 

By  PHILIP   S.    ROY,    M.D., 

WASHINGTON,   D.   C. 

I  offer  these  two  cases  to  support  the  views  of  Landois 
and  others  in  relation  to  the  probable  proximity  of  the 
heat  centres  to  the  motor  centres  in  the  brain. 

Cask  I  — A  white  child,  five  years  of  age,  in  the  sec- 
ond week  of  typhoid  fever  commenced  to  have  spasms 
confined  almost  entirely  to  the  right  side.  When  I  saw 
her  the  left  side  was  hot  and  dry,  the  right  (the  side  of 
spasms)  was  cold  and  covered  with  perspiration,  the  tern- 
t  perature  of  the  left  axilla  was  1030  F.,  and  in  the  right 


axilla  105^-°  F. ;  after  spasms  were  controlled  the  tem- 
perature was  the  same  on  both  sides.  The  right  side 
was  nearly  completely  paralyzed.  The  child  lived  six 
days  after  I  saw  her,  but  she  was  the  patient  of  another 
physician  who  returned  to  the  case. 

Case  H. — A  white  child,  aged  four  months,  suffering 
with  marasmus,  had  general  spasms,  the  surface  was  cold, 
each  spasmodic  seizure  lasted  about  three  minutes  fol- 
lowed by  a  period  of  rest  lasting  ten  to  fifteen  minutes. 
I  found  by  several  trials  that  during  spasms  the  tempera- 
ture was  1080  F.,  and  during  the  period  of  rest  1030  F. 
I  made  my  observations  at  different  hours.  The  child 
lived  six  hours  after  the  first  spasm  occurred.  Two  cases 
cannot  go  far  in  proof;  but  if  the  subject  has  not  already 
been  investigated  clinically  they  may  suggest  to  others  a 
similar  line  of  investigation. 


RIGHT-HANDEDNESS. 
By  J.   F.    HERRICK,    M.D., 

OTTOMWA,   IA. 

It  is  not  my  intention  to  discuss  the  motor  functions  of 
the  brain,  but  it  seems  necessary  to  say  a  few  words  on 
that  subject  to  make  clearer  my  position  further  on. 

The  motor  area  for  the  left  upper  extremity  on  the 
right  side  of  the  brain  includes  the  paracentral  lobule, 
the  anterior  central  convolution,  and  the  upper  part  of 
the  posterior  central  convolution.  On  the  left  side  of 
the  brain  the  motor  area  for  the  right  upper  extremity 
includes  the  paracentral  lobule,  the  three  upper  quarters 
of  the  two  central  convolutions,  and  a  part  of  the  upper 
parietal  From  this  it  is  evident  that  the  motor  area  of 
the  left  half  of  the  brain,  which  presides  over  the  move- 
ments of  the  right  upper  extremity,  is  greater  than  that 
of  the  right,  which  presides  over  the  movements  of  the 
left  upper  extremity.  So  it  is  with  the  areas  for  the 
lower  extremities.  On  the  left,  besides  the  parts  corre- 
sponding to  the  motor  area  on  the  right  which  presides 
over  the  leg,  it  includes  the  greater  part  of  the  parietal 
lobule. 

The  centre  for  speech  is  located  about  and  beneath 
the  lower  part  of  the  fissure  of  Sylvius,  and  is  confined 
almost  entirely  to  the  left  side  of  the  brain.  The  area 
on  the  right  side  which  corresponds  to  the  speech-centre 
on  the  left  may  be  destroyed  and  the  functions  of  the 
vocal  organs  remain  normal.  On  the  other  hand,  if  an 
injury  be  received  by  the  speech  area  on  the  left  side, 
speech  may  be  entirely  lost  and  its  recovery  depend,  es- 
pecially in  adults  and  those  advanced  in  life,  on  the  re- 
pair of  the  injury.  Then  we  see  that  the  motor  areas  of 
the  left  side  of  the  brain  are  beyond  doubt  much  greater 
than  those  of  the  right.  The  questions  that  occurred  to 
me  are :  Why  are  the  motor  areas  of  the  left  half  of  the 
brain  greater  in  extent  and  better  developed  than  those 
of  the  right  ?  and  what  connection  has  this  development 
with  "  right  handedness  ?  " 

I  will  answer  the  second  question  first  by  saying  that 
I  believe  the  greater  development  of  the  motor  area  on 
the  left  side  of  the  brain  is  a  satisfactory  reason  for  people 
using  the  right  hand  more  than  the  left.  We  will  suppose 
that  in  the  child  the  left  hemisphere  of  the  brain  is  even 
slightly  better  nourished  than  the  right.  That  better 
nourishment  would  cause  an  earlier  development  and 


result  in  an  earlier  and  more  perfect  performance  of 
their  functions  by  the  organs  presided  over  by  that 
hemisphere.  This  being  true,  the  right  hand  would  be 
brought  into  use  first,  and  that  use  would  react  on  the 
left  motor  area  and  cause  further  development,  both  be- 
cause of  the  exercise  and  by  education.  Allowing  this 
to  go  on  until  adult  life  and  we  would  have  a  full  fledged 
right-handed  man.  Physiological  exercise  of  an  organ 
acts  in  two  ways  in  perfecting  the  function  of  that  organ  : 
First,  by  increasing  its  nutrition  and  weight ;  second,  by 
educating  it  so  that  it  responds  more  promptly  and  per- 
fectly to  impulses  sent  out  from  the  centre  of  volition.  I 
believe  that  in  the  adult  the  motor  area  of  the  left  half  of 
the  brain  has  been  educated  to  respond  promptly  to  any 
act  of  volition ;  therefore  the  readiness  with  which  the 
right  hand  is  thrust  out  when  anything  is  to  be  done. 

We  will  now  return  to  the  first  of  the  two  questions 
raised  above :  Why  should  the  motor  area  of  the  left 
side  of  the  brain  be  better  developed  than  that  of  the 
right? 

If  we  recall  our  anatomy  we  will  remember  that  the 
left  common  carotid  artery  comes  off  directly  from  the 
aorta,  while  the  right  is  a  branch  of  the  innominate. 
The  axis  of  the  left  carotid  is  an  almost  direct  continu- 
ation of  the  axis  of  the  first  part  of  the  aorta,  so  that 
it  receives  almost  the  full  force  of  the  ventricular  systole. 
In  the  case  of  the  right  side  we  have  the  innominate 
coming  off  at  almost  a  right  angle  from  the  arch  of  the 
aorta.  The  right  common  carotid  is  a  branch  of  the  in- 
nominate, the  remainder  forming  the  right  subclavian, 
and  the  combined  area  of  the  two  vessels  is  greater  than 
the  area  of  the  innominate. 

It  is  evident  that  in  getting  the  blood  through  the  arch 
of  the  aorta,  the  right  angle  of  the  connection  between 
the  arch  and  the  innominate,  and  then  through  another 
angle  into  the  right  common  carotid,  there  must  be  con- 
siderable loss  of  speed.  Therefore,  if  the  blood  is 
pumped  through  the  aorta  at  the  rate  of  twelve  inches 
per  second,  we  may  suppose  that  its  velocity  in  the  large 
branches  is  ten  inches  per  second.  That  would  be  the 
rate  in  the  left  carotid,  while  in  the  right,  owing  to  the 
obstructions  named  above,  the  velocity  of  the  blood 
would  be  reduced  to,  say,  nine  inches  per  second,  or  one 
inch  less  than  that  of  the  blood  in  the  left  carotid. 
Therefore  the  volume  of  blood  sent  through  the  left 
carotid  in  a  given  time,  the  vessels  being  of  the  same 
size,  is  greater  than  that  sent  through  the  right,  and  the 
amount  delivered  to  the  left  brain  is  greater  than  that  to 
the  right.  As  further  evidence  that  the  left  half  of  the 
brain  receives  more  blood  than  the  right,  I  submit  the 
fact  that  cerebral  hemorrhage  takes  place  much  more  fre- 
quently into  the  left  hemisphere  than  into  the  right. 

The  arrangement  of  the  vessels  being  as  we  have  said, 
from  the  moment  the  child  begins  to  breathe  and  the  fora- 
men ovale  is  closed,  the  left  hemisphere  of  the  brain  is  bet- 
ter supplied  with  blood,  and,  as  was  said  above,  the  natural 
consequence  is  the  earlier  and  more  perfect  development 
of  the  left  half  of  the  brain,  and  consequently  the  func- 
tions of  the  right  side  of  the  body. 

In  conclusion  I  would  say  that  right  handedness  is 
primarily  due  to  the  anatomical  distribution  of  the  blood- 
vessels ;  and  secondarily,  in  its  perfection,  as  seen  in  the 
adult,  it  is  the  result  of  the  education  of  the  motor 
centres  of  the  left  brain,  added  to,  and  primarily  depend- 
ent upon,  the  anatomical  distribution  of  the  vessels.  In 
the  case  of  left- handed  persons  the  explanation  may  be 
anomalies  in  the  distribution  or  size  of  the  vessels. 


Alternating  Constipation  and  Diarrhoea  in  nine  out 
of  every  ten  cases,  Professor  Keen  says,  will  mean  either 
tumor  or  cancer  of  the  rectum  or  colon. — College  and 
Clinical  Record. 

The  Old  Men's  Tobaeeo. — The  Socialist  deputies  in 
the  French  Chamber  have  introduced  a  bill  to  provide 
the  inmates  of  houses  for  the  aged  with  smoking  tobacco 
and  snuff  at  a  reduced  rate. 


49« 


MEDICAL  RECORD. 


[October  20,  1894 


Medical   Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


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


New  York,  October  20,  1894. 


THE   PHYSIOLOGY  OF  BICYCLING. 

Dr.  Philip  Tissi£,  of  Bordeaux,  has  made  a  physiological 
study  of  the  performance  of  a  certain  bicycler  named 
Stephane,  and  has  drawn  from  it  some  conclusions  which 
should  be  of  interest  to  the  physician  and  the  'cycling 
world  {Archives  de  Physiologic,  October,  1894).  M. 
Stephane  attempted  to  see  how  many  kilometres  he  could 
ride  in  twenty-four  hours.  He  succeeded  in  travelling 
620  during  that  time,  getting  back  home  in  very  excel- 
lent condition.  He  fell  in  weight  during  his  trip  from 
70  kilogrammes  to  63.650,  being  a  loss  of  about  fourteen 
pounds.  His  food  consisted  of  cow's  milk,  of  which  he 
drank  2.58  litres.  Besides  this  he  took  of  tea  about  one 
pint,  of  rum  three  ounces,  of  mint  seven  ounces,  of  lem- 
onade a  pint,  and  of  champagne  about  three  ounces. 
American  trainers  would  not  consider  this  a  very  good 
diet,  but  M.  Stephane,  though  he  rode  almost  continu- 
ously, did  not  suffer  from  any  stomach  trouble.  The 
amount  of  urine  passed  during  the  trip  was  1,500  litres, 
and  its  specific  gravity  was  1.023.  During  the  succeed- 
ing twenty-four  hours  the  amount  fell  to  1,250,  and  the 
specific  gravity  rose  to  1.032.  The  total  urea  during  his 
work  was  17.07  grammes,  while  next  day  it  rose  to  31.85. 
The  urates,  phosphates,  and  sulphates  also,  while  normal 
on  the  trip,  were  much  increased  in  the  succeeding 
twenty-four  hours.  The  toxicity  of  the  urine  was  greatly 
increased.  While  riding,  the  urine  secreted  was  so  poi- 
sonous that  10  ctm.  killed  a  rabbit  weighing  1  kilo- 
gramme ;  on  the  next  day  it  took  20  ctm.  to  accomplish 
the  same  purpose. 

M.  Tisste  concludes  that  while  milk  is  a  good  food  it 
is  not  sufficient  for  prolonged  and  violent  muscular  work. 
There  should  be  more  hydrocarbons,  the  proper  ratio 
being  about  one  of  nitrogeneous  to  five  non-nitrogeneous. 
Every  person  whose  food  is  insufficient  is  liable  to  what 
Tisste  calls  acute  autophagism,  i.e.,  the  body  eats  itself 
up,  and  the  laborer  emaciates  rapidly.  Excito  motors, 
like  tea,  alcohol,  etc.,  ought  to  be  given  very  carefully. 
Their  effects  are  temporary  and  become  weakened  by 
repetition.  We  should  add  that  all  experience  shows 
that  alcohol  is  not  a  proper  excito-motor  at  all  except 
perhaps  at  the  very  close  of  effort. 

Fatigue  of  the  voluntary  muscles  may  occur  without 
cardiac  fatigue,  and  vice  versa. 

Every  person  who  subjects  himself  to  violent  and  pro- 
longed muscular  exertion  places  himself  ipso  facto  in  a 
state  of  autointoxication.  This  toxaemia  may  become  as 
high  as  it  is  in  the  severe  infectious  fevers.     Hence  it  is 


highly  important  that  a  person  who  takes  such  exercise 
should  have  perfectly  sound  skin,  liver,  kidneys,  and 
heart.  The  respiratory  capacity  ought  to  be  large,  and 
the  ordinary  maximum  should  be  nearly  as  great  as  the 
forced  maximum.  Thus  in  Stephane's  case  he  expelled 
in  ordinary  expiration  four  litres  of  air  (!)  measured  by 
a  spirometer.  In  forced  expiration  he  could  expel  only 
4. 1 66  litres.  

THE  SERUM  TREATMENT  OF   PHTHISIS. 

The  treatment  of  phthisis  by  the  serum  of  asses  is  dis-  , 
cussed  at  length  by  Dr.  Arthur  Gamgee  {The  Lancet), 
who  has  personally  investigated  Dr.  Viquerat's  claims. 
The  theory  upon  which  the  treatment  is  based  is  that  the 
ass  and  the  mule  are  almost  absolutely  immune  to  tuber- 
culosis. Hence  their  serum  will  confer  an  artificial  im- 
munity against  tuberculosis  in  man,  as  that  of  immunized 
horses  does  against  diphtheria.  Viquerat  admits  that 
asses  may  be  inoculated  with  tuberculosis,  but  they  have 
the  disease  mildly  and  always  recover.  He  increases 
their  immunity  by  inoculations  of  tubercle  bacilli.  On 
the  forty-fifth  day,  when  spontaneous  cure  has  already 
been  more  than  completed,  the  animal  is  used  to  supply 
the  curative  serum.  With  this  object  it  is  bled,  and  the 
blood  is  allowed  to  stand  over  ice,  so  as  to  allow  it  to 
dot  and  to  permit  of  the  separation  of  serum.  To  this 
serum  from  0.5  to  0.75  per  cent,  of  carbolic  acid  is 
added,  and  it  is  then  stored  in  stoppered  bottles  until 
required  for  use.  About  twelve  cubic  centimetres  aze 
injected  every  third  day.  Viquerat  states  that  when  the 
immunized  serum  of  the  ass  or  mule  is  injected  every 
second  day  into  guinea-pigs,  which  have  been  fifteen  days 
previously  rendered  tuberculous  by  the  inoculation  of 
active  tubercle  cultures,  the  tuberculous  glands  which  had 
become  enlarged  and  perceptible  rapidly  become  smaller 
and  disappear,  while  the  animal,  instead  of  dying  four- 
teen or  fifteen  weeks  after  the  inoculation,  regains  perfect 
health.  Twenty-five  cases  of  human  tuberculosis  are  re- 
ported, but  the  results  of  the  treatment  are  not  yet  very 
brilliant.  

THE  HYGIENE  OF  SORROW. 

In  a  recent  issue  of  a  New  York  newspaper  an  article  by 
Dr.  Louise  Fiske  Bryson  formulates  some  distinctly  mod- 
ern views  upon  the  views  of  grief.  The  attempt  to  act 
as  if  nothing  had  happened  after  the  advent  of  some 
misfortune,  and  to  conduct  life  exactly  as  before,  is  one 
of  the  greatest  possible  mistakes.  It  is  an  outrage  on 
nature,  which  she  resents  sharply  in  the  end.  Pay-day 
comes  sooner  or  later;  and  the  overthrow  caused  by 
blinding  catastrophe  arrives,  even  if  deferred. 

The  nervous  system  requires  complete  rest  after  blows 
caused  by  sorrow.  Recent  medical  observations  (Fer6, 
Bassi,  Schule,  Zenker)  show  that  the  physical  results  of 
depressing  emotions  are  similar  to  those  caused  by  bodily 
accidents,  fatigue,  chill,  partial  starvation,  and  loss  of 
blood.  Birds,  moles,  and  dogs,  which  apparently  died  in 
consequence  of  capture,  and  from  conditions  that  corre- 
spond in  human  beings  to  acute  nostalgia  and  "  broken 
heart,"  were  examined  after  death  as  to  the  condition 
of  their  internal  organs.  Nutrition  of  the  tissues  had 
been  interfered  with,  and  the  substance  proper  of  various 
vital  organs  had  undergone  the  same  kind  of  degenera- 
tion as  that  brought  about  by  phosphorus  or  the  germs  of 


October  20,  1894] 


MEDICAL    RECORD. 


497 


infectious  disease.  The  poison  of  grief  is  more  than  a 
name.  To  urge  work,  study,  travel,  the  vain  search  for 
amusement,  is  both  useless  and  dangerous.  For  a  time 
the  whole  organism  is  overthrown,  and  temporary  seclu- 
sion is  imperative  for  proper  readjustment. 

After  some  bereavement  the  custom  of  wearing  mourn- 
ing has  a  distinct  moral  value.  But  its  period  of  use 
must  be  brief:  a  few  weeks,  months,  perhaps  a  year; 
otherwise  dense  black  draperies  become  a  burden,  an 
aesthetic  blunder,  and  a  source  of  depression  in  them- 
selves. For  a  time  they  have  a  place,  securing  consider- 
ation from  strangers  and  silence  from  mere  acquaintance, 
since  sorrow  is  one  of  the  touches  of  nature  that  makes 
the  whole  world  kin. 

When  there  is  nearness  of  relationship  to  nature,  ram- 
bles in  the  open  air,  days  alone  with  the  sea,  alone  in 
the  forest,  console  as  nothing  else  can.  Quiet,  silent 
drives,  or  even  short  journeys  by  rail,  will  reveal  a  new 
heaven  and  a  new  earth  to  one  fatigued  and  worn  by 
sorrow.  Music,  when  it  can  be  borne,  has  a  soothing 
power  beyond  words.  Books,  too,  have  their  place, 
those  gentle  companions  without  speech  whose  calm 
society  helps  annihilate  time  and  space,  and  who  always 
receive  us  with  the  same  kindness.  The  familiar  faces 
of  newspapers  and  journals  bring  a  stray  comfort  that 
even  the  tenderest  heart  is  powerless  to  bestow.  The 
care  and  companionship  of  children  is  another  source  of 
strength.  Children  are  not  watching  to  see  how  the 
afflicted  are  bearing  up  under  sorrow,  nor  are  they  wait- 
ing for  some  expression  of  sentiment  or  the  overthrow 
of  self-control.  A  child  is  always  the  best  comforter, 
uttering  no  word  of  sympathy,  yet  rousing  interest  in 
life  because  its  nature  is  sweetness  and  light 

Grief  cannot  be  ignored,  neither  can  it  be  cheered  up. 
It  must  be  accepted,  and  allowed  to  wear  itself  away. 
Readjustment  comes  slowly.  Sorrow,  grief,  and  all 
great  misfortunes  should  be  regarded  as  conditions  simi- 
lar to  acute  infectious  diseases,  which  they  resemble  in 
result ;  and  later,  as  convalescence  from  such  diseases. 
Seclusion,  rest,  sleep,  appropriate  food,  fresh  air,  sun- 
shine, interests  that  tax  neither  mind  nor  body,  these 
are  requirements  in  this  class  of  illness.  The  care  of  the 
condition  following  depressing  emotion  calls  for  the 
same  treatment  in  greater  or  less  degree. 

WATER-BAG  BURNS. 

It  would  scarcely  be  believed  by  one  without  subjective 
or  objective  experience  in  the  matter  that  an  ordinary 
rubber  water-bag,  filled  with  what  usually  passes  for  hot 
water,  would  be  capable,  when  applied  to  the  human 
skin,  of  producing  an  extensive  and  deep  burn.  All  are 
familiar  with  this  effect  from  the  careless  use  of  the  hot 
water-bottle,  and  the  surgeon  seldom  fails  to  see  to  it  per- 
sonally that  a  proper  protection  separates  the  glass  from 
the  skin.  Conditions  of  shock,  lowered  vitality,  faulty 
circulation,  with  exsanguinated  and  cold  extremities  are 
those  in  which  heat  is  most  often  sought  to  be  externally 
applied  by  this  means,  and  it  is  just  in  these  states  of  les- 
sened power  of  resistance  that  the  tissues  are  most  apt  to 
suffer.  Since  it  is  not  so  generally  known  that  the  rub- 
ber bag  is  possessed  of  decided  powers  for  evil  as  well  as 
for  good,  it  may  be  well  for  the  trained  nurse,  no  less 
than  the  physician,  to  be  reminded  of  it.    At  a  recent 


meeting  of  the  New  York  Dermatological  Society  the 
question  was  brought  up  for  discussion  by  the  report  of 
a  severe  burn  with  deep  destruction  of  tissue  extending 
through  the  subcutaneous  fat.  An  operation  had  taken 
place,  and  the  water-bag  had  been  applied  to  the  feet 
while  the  patient  was  still  under  the  anaesthetic.  Sev- 
eral of  the  members  present  at  the  meeting  had  been 
consulted  in  similar  unfortunate  accidents,  and  as  these 
are  just  the  cases  which  sometimes  cause  patients  to  think 
they  have  grounds  for  legal  redress,  a  note  of  warning 
may  cause  us,  conscious  of  having  done  no  harm  ourselves, 
to  feel  beneath  the  covers  and  make  sure  that  the  nurse  is 
allowing  none  to  be  done. 

THE  CURE  BY  FAITH. 

New  Jersey  has  ever  had  an  enviable  reputation  for  fair- 
dealing  and  quick  justice.  It  is  seemingly  hard  upon  the 
young  New  York  doctor  when  the  heat  of  July  beats 
down  upon  this  side  of  the  Hudson  that  he  cannot  freely 
transpose  the  seat  of  his  usefulness  to  Asbury  or  Spring 
Lake  without  prolonging  his  journey  to  Trenton  and 
his  agony  in  a  three  days'  strict  "Exam."  The  jus- 
tice comes  in  when  the  quack,  driven  from  our  inhos- 
pitable shore  seeks  to  find  a  lodge  in  the  vast  wilderness 
of  Jersey  City  Heights. 

The  struggle  to  maintain  the  State's  medical  rights,  in 
the  first  place  for  Jersey  physicians,  and  secondly  for  those 
who  are  reputable,  is  beginning  to  show  signs  of  suc- 
ceeding. An  indictment  has  just  been  found  against  a 
faith-curist,  who  is  to  be  tried  under  the  new  law,  passed 
through  the  efforts  of  the  State  Medical  Board  of  Ex- 
aminers, making  it  a  misdemeanor  for  any  faith-curist 
or  tnind-healer  to  practise  in  the  State. 

We  do  not  take  it  that  the  Board  denies  the  value  of 
faith  or  the  great  influence  which  may  be  exerted  upon 
disease  by  mental  processes.  They  have,  however,  started 
out  to  see  to  it  that  whoever  wishes  to  engage  in  the 
healing  of  the  sick  must  show  himself  to  be  properly 
qualified.  Once  the  examination  passed,  the  successful 
candidate  may  employ  faith,  hypnotism,  or  any  other 
form  of  mind  influence  alone,  if  he  and  his  patients 
prefer  it  to  the  usual  way  of  giving  it  mixed  with 
drugs. 

The  trial  about  to  take  place  should  attract  some  at- 
tention, being  the  first  since  the  act  went  into  effect,  and 
it  is  said  will  be  fought  on  the  ground  that  it  is  not  con- 
stitutional.   

An  Order  of  Medical  Monks  has  been  founded  in  this 
city  in  connection  with  the  Episcopal  Church.  The 
object  of  the  order  is  thus  expounded  by  Father  John- 
son :  "  The  text  of  the  order,"  he  said,  "  will  be  « Heal 
the  sick,  and  say  unto  them,  The  kingdom  of  God  is  come 
nigh  unto  them,'  taken  from  St.  Luke  x.  9."  The  order 
was  the  idea  of  Mr.  Davidson.  It  is  the  intention  to 
found  an  order  of  medical  monks,  who  will  be  connected 
strictly  with  the  church,  and  who  will  devote  their  time 
to  the  poor  and  sick  of  the  parish.  The  only  compensa- 
tion which  the  members  of  the  order  will  receive  will 
be  what  the  parishioners  can  afford  to  give  them.  The 
members  of  the  order  will  rank  as  deacons  in  the  church. 
There  are  at  present  two  novitiates,  of  whom  one  is  a 
trained  nurse,  the  other  a  medical  student. 


498 


MEDICAL    RECORD. 


[October  20,  1894 


fjst»s  of  Uxc  W&ttfi. 

Unveiling  of  the  Sims  Monument. — The  ceremonies 
of  the  unveiling  of  the  statue  of  Dr.  J.  Marion  Sims  will 
be  held  at  3  pm,  on  Saturday,  October  20,  1894,  in  Bry- 
ant Park,  New  York  (Forty-second  Street  and  Sixth 
Avenue).  Addresses  will  be  delivered  by  Drs.  George 
F.  Shrady  and  Paul  F.  Mund6,  after  which  the  statue 
will  be  formally  presented  to  the  city  of  New  York,  on 
behalf  of  the  medical  profession  of  this  and  other  coun- 
tries, and  will  be  accepted  for  the  city  by  Mayor  Gilroy. 
The  medical  profession  and  public  are  respectfully  in- 
vited to  be  present. 

Soon  after  Dr.  Sims's  death,  in  1883,  the  move- 
ment for  the  erection  of  a  bronze  statue  was  set  on 
foot  by  the  Medical  Record,  and  the  necessary  funds 
were  subscribed  by  members  of  the  medical  profession 
in  this  and  other  countries.  American  sculptors  were  at 
first  asked  to  compete  in  a  design  for  the  work,  and 
when  all  the  designs  submitted  were  rejected  by  the  com- 
mittee having  the  matter  in  charge,  the  commission  for 
the  statue  was  awarded  to  Miiller,  of  Munich. 

The  House-warming  of  the  Hew  Bloomingdale  Asy- 
lum.— The  patients  of  Bloomingdale  Asylum  were  re- 
cently transferred  from  the  old  site  on  Harlem  Heights — 
which  had  been  occupied  for  almost  three-quarters  of  a 
century— to  the  new  institution  near  White  Plains.  The 
removal  was  made  by  easy  stages,  and  without  unpleas- 
ant incident.  The  new  establishment  being  in  running 
order,  invitations  were  recently  issued  to  members  of  the 
profession  likely  to  be  interested  in  this  line  of  medicine 
to  inspect  the  new  building.  A  large  number  of  New 
York  physicians  accepted  the  invitation,  and  were  shown 
through  the  institution  last  Wednesday  afternoon,  and 
pleasantly  entertained  by  the  officers  of  the  Asylum.  The 
new  Bloomingdale  is  located  just  on  the  outskirts  of  the 
village  of  White  Plains.  The  main  building  stands  on  a 
broad  hill-top,  commanding  a  fine  inland  view.  It 
presents  a  very  pleasing  exterior,  with  little  of  the  prison- 
like aspect  that  usually  characterizes  asylum  buildings. 
Within,  its  appointments  are  all  that  intelligent  study  of 
the  prominent  asylum  plants  in  the  world,  backed  by 
abundant  means,  could  make  them.  The  building  is 
fireproof  throughout,  and  the  utmost  attention  has  been 
given  to  its  sanitary  features.  It  is  supplied  with  water 
from  springs  on  the  Asylum  property.  The  sewage  sys 
tem  connects  with  that  of  the  neighboring  village.  The 
Asylum  has  its  own  electric  plant,  ice  machines,  and  the 
like.  A  special  feature  of  the  institution  is  that  most  of 
the  peculiar  advantages  of  the  cottage  system  of  archi- 
tecture are  secured  without  the  sacrifice  of  the  conven- 
iences of  the  linear  system.  The  entire  main  building 
may  be  said  to  be  under  one  roof,  inasmuch  as  closed 
corridors  connect  its  various  sections,  yet  these  sections 
are,  for  most  practical  purposes,  independent  and  de- 
tached buildings.  One  section  of  each  wing  has  been  es- 
pecially constructed  for  hospital  wards.  In  a  word, 
nothing  has  been  omitted  that  could  help  to  make 
the  new  Bloomingdale  strictly  up  to  date  in  all  its  ap- 
pointments, and  the  peer  of  any  asylum  plant  in  the 
world.  The  credit  for  its  many  excellencies  is  very 
largely  due  to  the  Medical  Superintendent,  Dr.  Samuel 
R.  Lyon,  who  for  many  years  has  made  hospital  con- 


struction a  special  study,  and  who  drew  the  original 
plans  for  the  new  Bloomingdale,  and  directed  and  super- 
vised the  work  of  construction  with  unremitting  energy. 
Whatever  differences  of  opinion  may  exist  as  to  the  ideal 
plan  for  an  asylum,  it  must  be  conceded  by  everyone 
that  Dr.  Lyon  has  succeeded  in  combining  the  best  feat- 
ures of  the  various  systems  to  a  remarkable  degree  in  the 
New  Bloomingdale. 

Dr.  Charles  H.  Pinney,  of  Council  Bluffs,  la.,  died 
from  injuries  received  in  a  railroad  accident,  near  Lin* 
coin,  Neb.,  on  August  9th.  He  was  Professor  of  the 
Principles  and  Practice  of  Medicine  in  the  Medical  Col- 
lege of  Council  Bluffs.  During  the  Civil  War  he  served 
as  surgeon  in  the  Ninth  Ohio  Cavalry.  Dr.  Pinney  was 
fifty-two  years  old  at  the  time  of  his  death. 

The  State  of  Connecticut  is  agitating  the  question  of 
establishing  a  State  Commission  in  Lunacy.     "  Don't" 

Dr.  Stuart  Douglas,  resident  physician  for  the  insane 
at  Bellevue  Hospital,  died  on  October  14th,  of  Bright's 
disease.  Dr.  Douglas  went  to  Alexandria,  Va.,  about  six 
weeks  ago  to  attend  his  father's  funeral,  and  when  he 
returned  to  this  city  he  complained  of  feeling  ill. 

Dr.  Douglas  was  born  in  Alexandria  thirty-three  years 
ago.  His  early  youth  was  spent  at  Leesburg,  Va.  He 
is  a  graduate  of  the  academic  and  medical  departments  of 
the  University  of  Virginia,  and  came  to  this  city  in  188 1, 
taking  a  post-graduate  course  at  the  College  of  Physi- 
cians and  Surgeons.  He  was  appointed  to  take  charge 
of  the  insane  at  Bellevue  on  October  26,  1887,  and  was 
the  only  salaried  physician  at  the  hospital.  Dr.  Douglas 
was  a  member  of  the  Southern  Society,  the  American 
Academy  of  Medicine,  and  the  Society  of  the  Alumni  of 
Bellevue  Hospital,  and  Instructor  in  Mental  Diseases  in  the 
Post-Graduate  Hospital.  The  last  piece  of  work  that  he 
did  was  the  writing  of  an  article  on  "  The  Treatment  of 
Melancholy"  which  appeared  in  the  Post-Graduate. 

Skunks  and  Typhoid  Fever. — The  skunk  farm  and  ty- 
phoid fever  epidemic  are  two  of  the  unpleasant  things 
with  which  the  residents  of  Beadner,  Wood  County, 
O.,  are  now  contending. 

The  Decreasing  Death  rate. — A  statement  prepared 
by  the  Health  Department  shows  that  the  death-rate  of 
this  city  has  been  lower  this  year  than  since  1884,  though 
then  it  was  low  as  compared  with  the  average  of  the  pre- 
ceding years.  Moreover,  the  number  of  deaths,  says 
The  Sun,  has  been  less  actually  than  in  any  year  since 
1890,  though  meantime  the  estimated  population  of  New 
York  has  increased  by  more  than  a  quarter  of  a  million, 
or  from  1,705,980  in  1890  to  1,957,452  in  1894.  If  the 
mortality  for  the  remainder  of  the  year  be  the  same  as  in 
the  corresponding  period  of  last  year,  the  total  for  1894 
will  be  less  than  in  1893  by  more  than  2,500.  The 
experience  since  January,  and  the  present  condition  of 
the  city  as  to  health,  indicate  the  probability  that  this  is 
an  overestimate  of  the  mortality  for  October,  Novem- 
ber, and  Decembef,  and  that  actually  the  total  number 
of  deaths  in  1894  will  be  less  than  in  1893  by  toward 
three  thousand,  or  not  much  above  the  total  for  1890, 
which  was  40,103.  This  would  make  the  death-rate,  or 
the  mortality  proportionately  to  1,000  in  the  population 
annually,  about  21  in  1894,  as  compared  with  23.51  in 
1890. 


October  20,  1894] 


MEDICAL 


Dr.  John  Y.  McGay  died  on  October  13th,  at  his  home 
in  Brooklyn,  forty  years  of  age. 

Sir  Joseph  Lister. — It  is  proposed  to  present  Sir 
Joseph  Lister  with  a  memorial  on  the  occasion  of  his 
retirement  from  active  work. 

Doctors  as  Companions. — The  following  passage  from 
Mr.  James  Payn's  "  Gleams  of  Memory,"  now  appear- 
ing in  the  Carnhill  Magazine,  will  be  interesting  to 
members  of  the  medical  profession :  "  Upon  the  whole, 
and  for  a  '  scratch '  companion,  I  prefer  a  doctor  to  a 
man  of  any  other  calling.  He  may  not  be  very  good  as 
a  conversationalist,  but  he  is  rarely  very  bad,  like  a 
cheroot.  He  has  had  a  genuine  experience  of  life,  and 
has  seen  down  to  the  depths  of  it ;  a  sick  man  does  not 
attempt  to  deceive  his  doctor,  or  put  the  best  face  on 
his  character,  as  he  does  with  a  priest.  Moreover,  what 
is  very  unusual,  your  doctor  knows  more  about  you,  pro- 
fessionally at  all  events,  than  you  know  about  yourself. 
He  does  not  tell  you  about  it,  it  is  true ;  not  a  word  of 
that  aneurism  you  carry  about  with  you,  and  which  will 
some  day  kill  you  in  half  a  minute,  but  your  conscious- 
ness that  he  may  possess  such  knowledge  makes  him  in- 
teresting. The  best  suggestions  I  have  had  made  to  me 
for  plots  for  my  novels  have  come  to  me  from  doctors, 
to  whom  I  have  also  had  cause  to  be  grateful  for  many 
things." 

The  Perils  of  Football.— We  have  received  from  a 
correspondent,  in  reference  to  the  fact  that  many  serious 
accidents,  and  more  than  one  death,  have  already,  and 
thus  early  in  the  season,  been  reported  from  the  football 
field,  the  following  letter :  "  All  lovers  of  football,  both 
players  and  spectators,  would  rejoice  if  accidents  due  to 
football  were  of  less  frequent  occurrence ;  and  I  feel 
sure  that  such  would  be  the  case  if  these  suggestions  were 
carried  out :  1.  Give  the  linesmen,  as  well  as  the  ref- 
eree, power  to  stop  the  play  for  a  foul  charge  or  hack. 
2.  Let  the  spectators  desist  from  such  cries  as  '  Pay  him 
out,'  etc.  3.  Let  the  players  wear  tennis  shoes,  and  not 
boots  with  steel  plates  inside  the  toes,  as  I  know  the 
modern  boots  are  now  made."  We  agree  with  our  cor- 
respondent's first  two  suggestions,  and  go  further.  It 
has  always  been  our  cry — and  we  have  been  pleased  to 
see  it  taken  up  and  echoed  approvingly  by  our  contem- 
poraries, medical  and  lay — that  the  strengthening  of  the 
authority  of  the  referee,  coupled  with  more  drastic  pen- 
alties for  the  wrongdoer,  must  be  the  most  practical 
method  of  preventing  accidents  that  arise  not  so  much 
from  the  essential  laws  of  the  game  as  from  "bad 
blood."  And  certainly  such  cries  as  "  Pay  him  out " 
are  the  very  things  to  rouse  the  evil  spirit.  Our  corre- 
spondent's third  suggestion  is  not  so  sensible.  Firstly, 
nailed  and  steel-shod  footgear  is  not  permissible  by  the 
laws  of  the  game ;  and,  secondly,  india-rubber  soles 
would  practically  alter  the  game. — The  Lancet. 

The  Attraction  of  Football  for  Intellectual  Men. — In 
an  article  on  the  present  state  of  college  football,  Profes- 
sor E.  L.  Richards,  of  Yale,  speaks  of  the  attractions  of 
the  game  for  intellectual  men  as  well  as  for  the  student 
of  muscular  science.  He  says,  speaking  of  the  relative  at- 
tractions of  football  and  other  athletic  games :  "  That 
the  game  has  had  attractions  for  intellectual  men  in  the 
past  is  shown  by  the  fact  that  the  average  scholarship  of 
men  on  the  football  teams  has  of  late  years  been  higher 


RECORD.  499 

than  that  of  men  in  the  other  athletic  organizations.  In 
the  years  1879  to  1888  the  average  standing  of  men  not 
on  athletic  organizations  was,  on  a  scale  of  4,  2.69  ;  for 
members  of  the  university  boat  crew  the  average  was 
2.52  ;  for  members  of  the  baseball  nine  it  was  2.41 ;  for 
members  of  the  football  team  it  was  2.68.  Track  athlet- 
ics were  not  in  existence  as  an  organization  through  the 
whole  decade,  but  for  the  few  years  when  there  was  a 
university  team  the  average  was  2.66.  In  the  previous 
decade,  1869  to  1878,  it  is  only  fair  to  add  that  the  aver- 
age of  the  football  men  was  slightly  below  that  of  the 
other  athletes,  it  being  2.51  to  their  2.56.  I  can  only 
account  for  the  fact  of  the  rise  of  the  average  in  the  sec- 
ond decade  by  the  change  in  the  numbers  of  the  team 
from  twenty  to  eleven — a  change  giving  opportunity  for 
more  skill,  thus  rendering  the  play  more  attractive  to 
men  of  mind.  Notwithstanding  the  present  style  of 
mass  play,  which  puts  a  premium  on  physical  strength 
and  weight,  it  was  a  surprise  to  me  to  find  that  the  aver- 
age scholarship  of  the  sixteen  men  from  the  academic 
department,  including  players  and  substitutes,  was 
higher  than  the  average  of  any  class  which  ever  gradu- 
ated. I  cannot  believe,  however,  that  the  high  scholar- 
ship of  football  players  will  always  prevail,  unless  the 
style  of  the  game  be  changed  to  one  which  admits  of 
more  open  play.  The  present  style  of  mass  play  and 
momentum  play  puts  a  premium  on  weight  and  brute 
force.  The  mingling  men  in  masses  make  injuries  more 
probable  than  in  an  open  style  of  play.  The  mass  play 
makes  the  game  as  little  as  possible  a  kicking  game.  It 
eliminates  a  great  deal  of  the  element  of  skill.  Skill 
ought  to  be  encouraged  by  setting  some  sort  of  premium 
on  it.  Increasing  the  number  of  points  scored  by  a 
drop  kick  from  the  field  might  accomplish  this  some- 
what Some  changes  in  the  rules  regarding  '  interfer- 
ence '  would  do  more.  If,  again,  '  the  warnings '  for 
'  rough  play '  were  entirely  omitted,  and  the  umpire  were 
instructed  to  send  a  man  off  the  field  at  the  first  offence, 
captains  would  train  their  men  to  avoid  these  plays  en- 
tirely. Then  the  experts,  in  reforming  the  game,  could 
not  do  better  than  turn  their  attention  to  the  umpires. 
If  a  plan  for  training  umpires  could  be  devised  it  would 
be  a  good  thing." 

Philadelphia  as  a  Medical  Centre. — According  to  the 
Philadelphia  newspapers  that  city  is  again  asserting  its 
right  to  special  prominence  as  a  medical  centre.  The 
census  of  the  medical  schools  is  as  follows  : 

University  of  Pennsylvania,  ....  875 

Jefferson, 700 

Hahnemann, 325 

Medico-Chirurgical, 300 

Woman's, 200 

2,400 

Physical  Culture  in  Unhealthy  Schools. — There  are 
one  hundred  and  eighty  sanitarily  defective  schools  in 
Chicago,  and  the  city  spends  about  £4,000  annually  on 
an  athletic  overstrain  fad  called  "physical  culture," 
whose  chief  purpose  seems  to  be  to  provide  "  professional 
foreigners"  of  the  ward-heeler  type  with  an  occupa- 
tion. The  money  wasted  on  this  "  physical  culture  " 
humbug  could  be  advantageously  employed  in  rem- 
edying the  sanitary  defects  of  a  few  schools. — Medical 
Standard, 


500 


MEDICAL    RECORD. 


[October  20,  1894 


%mixms  and  polices  at  Qoofos. 

Pain  in  its  Neuro-pathological,  Diagnostic,  Med- 
ico-legal,    AND     NEURO  -  THERAPEUTIC    RELATIONS. 

By  J.  Leonard  Corning,  A.M.,  M.D.,  Consultant 
in  Nervous  Diseases  to  St.  Francis9  Hospital,  etc. 
Illustrated.      Philadelphia:    J.  B.   Lippincott  Com- 
pany.    1894. 
As  an  aid  to  diagnosis   in  nervous  disease  the  author 
considers  pain  unique  in  importance.     The  insomnia 
and  melancholia  induced  by  it  are  in  themselves  matters 
of  serious  moment.     The  special  therapeutics  of  pain  are 
given  in  detail  and  evince  much  conscientious  research. 
This  work  is  one  of  marked  originality  and  careful 
thought    There  is  in  it  much  to  interest  the  general 
reader.     In  point  of  letter-press,  binding,  and  paper, 
the  book  presents  attractions  that  the  student  cannot 
fail  to  appreciate.     The  illustrations  are  clear,  and  add 
to  the  value  of  the  text. 

The  Care  and  Feeding  of  Children.  A  Cate- 
chism for  the  Use  of  Mothers  and  Children's  Nurses. 
By  L.  Emmett  Holt,  M  D.,  Professor  of  Diseases  of 
Children  in  the  New  York  Polyclinic,  etc.  New 
York:  D.  Appleton  &  Co.  1894. 
This  Catechism  was  originally  designed  for  the  pupils  in 
the  Practical  Training  School  for  Nursery  maids,  estab- 
lished in  1889,  and  compiled  to  meet  the  need  felt  for 
some  simple  manual.  A  series  of  questions  and  answers 
was  made  out,  on  matters  of  every-day  practical  observa- 
tion and  careful  hospital  work.  The  Catechism  is  now 
given  to  the  public,  with  the  hope  that  it  may  serve  a 
useful  purpose  in  other  institutions,  and  be  of  value  to 
mothers  and  to  the  ordinary  untrained  child's  nurse. 
The  essentials  are  strongly  emphasized  in  the  form  of 
questions  and  answers.  The  first  part,  devoted  to  the 
care  of  children,  treats  of  such  subjects  as  bathing,  eyes, 
skin,  mouth,  clothing,  nursery,  weight,  weaning,  etc 
The  second  part  deals  with  infant  feeding.  And  the 
third  is  devoted  to  miscellaneous  topics,  as  sleep,  teeth- 
ing, walking  alone,  convulsions,  colic,  contagious  dis- 
eases, etc.  The  advice  given  is  excellent  and  perfectly 
clear,  and  goes  over  all  the  ground  concerning  which 
the  doctor  is  so  often  questioned.  If  it  could  be  fol- 
lowed by  those  who  read,  it  is  safe  to  say  that  disease  in 
infancy  would  rapidly  diminish  and  the  happiness  of 
childhood  be  greatly  increased.  Sixty-six  pages  of  good 
advice  are  given,  all  for  fifty  cents.  Less  than  seven 
inches  long  and  about  five  wide,  Dr.  Holt's  Catechism 
contains  in  most  convenient  form  all  the  precepts  of 
modern  nursery  orthodoxy. 

Small  Hospitals,  Establishment  and  Maintenance. 
By  A.  Worcester,  A.M.,  M.D.;  and  Suggestion  for 
Hospital  Architecture,  with  Plans  for  a  Small  Hospital, 
by  William  Atkinson,  Architect.  New  York :  John 
Wiley  &  Sons.  1894. 
This  is  one  of  the  subjects  that  at  present  occupies  the 
public  attention — the  building  and  management  of  hos- 
pitals in  small  towns  and  villages.  Dr.  Worcester's  book 
answers  the  questions  that  directly  confront  the  promot- 
ers of  such  schemes  for  public  welfare.  In  Part  I.  full 
directions  are  given  for  inaugurating  the  hospital  and 
for  arranging  its  management.  Part  II.  is  devoted  to 
plans  for  buildings  and  hospital  construction.  While 
thoroughly  up  to  date  and  embodying  the  best  principles 
of  such  work,  the  book  is  not  too  technical  for  the  gen- 
eral reader.  The  author  realizes  that  much  as  the  suc- 
cess of  a  hospital  depends  upon  its  medical  and  surgical 
staff,  even  more  does  it  depend  upon  its  nursing  service. 
The  best  plan  is  to.  have  the  nursing  service  done  by  the 
student  nurses  of  some  training  school,  in  order  to  se- 
cure ambitious,  capable  young  women  who  are  by  nature 
fitted  to  undertake  such  work.  There  were  no  real 
trained  nurses  until  some  years  after  the  war.  It  will  be 
a  great  surprise  to  many  to  learn  that  in  former  times  in 


Bellevue  Hospital  the  nursing  was  intrusted  to  women 
who  in  the  police  courts  chose  a  term  of  service  as  hos- 
pital nurses  when  the  alternative  of  a  term  of  imprison- 
ment was  given  them !  The  book  is  earnest  and  well 
written,  and  the  plans  offer  the  greatest  possible  economy 
of  space,  together  with  convenience  and  harmony  of  de- 
sign. 

Diseases  of  the  Skin.  An  Outline  of  the  Principles 
and  Practice  of  Dermatology.  By  Malcolm  Morris, 
Surgeon  to  the  Skin  Department,  St.  Mary's  Hospital, 
London,  etc.  With  eight  Chromolithographs  and 
seventeen  Wood-cuts.  Philadelphia :  Lea  Brothers  & 
Co.  1894. 
The  clearness  of  this  book,  together  with  its  good  illus- 
trations, careful  arrangement,  and  the  practical  clinical 
presentation  of  skin  diseases  that  it  gives,  makes  its  prob- 
able destiny  one  of  general  and  well  merited  popularity. 
All  important  schemes  of  classification  are  referred  to, 
and  that  of  Unna  followed  in  the  main,  die  author  feel- 
ing convinced  that  whatever  changes  may  come  about  in 
the  manner  of  looking  at  diseases  of  the  skin,  increased 
knowledge  cannot  alter  the  principle  upon  which  this  is 
based.  The  chapters  on  pathology  and  diagnosis  are  re- 
markably interesting,  the  latter  enunciating  practical 
principles  of  definite  value.  Affections  of  the  skin  de- 
pendent on  nerve  disorder  are  next  considered;  then 
artificial  eruptions,  eczema  (thirty-four  pages),  pityriasis, 
psoriasis,  local  inoculable  diseases,  general  inoculable 
diseases,  diseases  of  the  skin- glands  and  epidermic 
appendages,  new-growths,  and  malformations.  In  the 
matter  of  treatment,  which  is  always  possible  and  unusu- 
ally practical,  great  stress  is  laid  upon  the  care  of  the 
patient  and  his  general  condition,  factors  sometimes 
overlooked  in  the  supervision  of  abnormal  states  appar- 
ently so  definitely  local  as  troubles  with  the  skin.  Of 
convenient  size  and  easy  to  handle,  Dr.  Morris's  book  has 
everything  to  recommend  it.* 

Handbook  of  Obstetric  Nursing.    By  Francis  W<  N. 
Haultain,  M.D.,  F.R.C.P.  Ed.;  Lecturer  on  Mid- 
wifery and  Diseases  of  Women  School  of  Medicine ; 
Obstetric  and  Gynecological  Physician  Royal  Dis- 
pensary;   Examiner    Royal  College    of  Physicians, 
Edinburgh;    and   James    Haig    Ferguson,    M.D., 
F.R.C.P.  Ed.,   M.R.C.S.  Eng. ;   Lecturer  on  Mid- 
wifery and  Diseases  of  Women  School  of  Medicine ; 
Obstetric  Physician  New  Town  Dispensary ;  Examiner 
Royal  College  of  Physicians ;  Late  President  Royal 
Medical  Society,  Edinburgh.     Second  Edition,  Re- 
vised and  Enlarged.     With  Thirty  -  three  Wood  En- 
gravings.    Philadelphia :  J.  B.  Lippincott  Company. 
1894. 
This  is  a  well  arranged  handbook  for  the  guidance  of 
monthly  nurses  and  midwives,  written  in  clear  and  sim- 
ple language,  very  neatly  printed,  and  of  convenient  size. 
The  authors  are  teachers  who  have  had  practical  experi- 
ence in  the  needs  of  obstetric  nurses,  and  their  book  is 
one  that  can  be  recommended.     The  illustrations  are 
instructive,  and  a  good  index  facilitates  reference. 

The  Jewish  Method  of  Slaughter  Compared  with 
Other  Methods,  from  the  Humanitarian,  Hygien- 
ic, and  Economic  Points  of  View.    By  J.  A.  Dembo, 
M.D.,  Physician  to  the  Alexander  Hospital,  St.  Peters- 
burg ;  Member  of  the  St.  Petersburg  Medical  Society  ; 
Member  of  the  Society  for  the  Preservation  of  Public 
Health,  etc.     Translated  from  the  German,  with  the 
Author's  Amendments.  London :  Kegan  Paul,  Trench, 
Trttbner  &  Co.     1894- 
The  basis  of  this  book  is  the  report  of  an  investigation 
into  the  Jewish  method  of  slaughtering  animals,  by  cut- 
ting the  carotids  and  other  large  vessels  of  the  neck, 
undertaken  at  the  instance  of  the  Russian  Societies  for 
the  Prevention  of  Cruelty  to  Animals.     The  author  be- 
lieves that  such  a  method,  used  to-day  we  believe  in  New 
York,  inflicts  a  minimum  of  suffering  upon  the  animals, 
produces  whiter  and  firmer  meat,  and,  from  the  point  of 


October  20,  1894J 


MEDICAL  RECORD. 


501 


view  of  the  purchaser,  is  the  more  economical.  His 
argument  is  well  sustained,  and  certainly  seems  to  prove 
his  point. 

Inebriety  or  Narcomania.  Its  Etiology,  Pathology, 
Treatment,  and  Jurisprudence.  By  Norman  Kerr, 
M.D.,  F.L.S. ;  Fellow  of  the  Medical  Society  of  Lon- 
don ;  President  Society  for  the  Study  of  Inebriety ; 
Chairman  British  Medical  Association  Inebriates 
Legislative  Committee;  Consulting  Physician  Dal- 
rymple  Home  for  the  Treatment  of  Inebriety ;  Vice- 
President  International  Congress  of  Medical  Jurispru- 
dence; Corresponding  Member  Medico-legal  Society 
of  New  York;  Corresponding  Secretary  American 
Association  for  the  Study  and  Cure  of  Inebriety. 
Third  Edition.     London :  H.  K.  Lewis.     1894. 

This  book  is  well  known,  through  its  earlier  editions,  to  • 
the  large  and  increasing  number  of  medical  practitioners 
who  recognize  in  inebriety  a  disease,  and  not  a  vice,  in 
the  common  acceptance  of  the  word,  worthy  of  the  same 
serious  study  as  any  other  physical  or  mental  malady, 
and  one  that  is,  in  many  instances,  amenable  to  cure 
through  the  institution  of  rational  scientific  treatment. 
By  the  term  inebriety  is  not  meant  simply  an  over-indul- 
gence in  alcoholic  liquors ;  the  word  is  employed  as  an 
inclusive  term  for  all  forms  of  drug  addiction,  narco- 
mania, the  particular  kind  of  intoxicant  employed  being 
accidental,  determined  by  environment  or  other  condi- 
tions. The  author  defines  the  word  as  meaning  "  a  con- 
stitutional disease  of  the  nervous  system  characterized  by 
a  very  strong  morbid  impulse  to,  or  crave  *or,  intoxi- 
cants." Most  inebriates  long  for  alcohol  because  that  is 
among  us  the  narcotic  in  common  use.  The  present 
edition  of  the  work  contains  a  large  amount  of  matter 
not  found  in  the  former  editions,  including  a  study  of 
ether  addiction,  at  one  time  very  common  in  Ireland ;  a 
dissertation  on  the  place  of  alcohol  in  therapeutics ;  on 
the  relation  of  insurance  to  inebriety,  and  on  the  crimi- 
nal responsibility  of  inebriates.  The  book  is  interesting 
apart  from  the  valuable  lessons  which  it  teaches,  and  we 
can  thoroughly  recommend  it  as  a  safe  guide  to  this  most 
important  branch  of  medical  science.  The  presswork  is 
all  that  could  be  desired,  and  a  complete  index  makes  it 
a  valuable  work  of  reference. 

A  Treatise  on  the  Principles  and  Practice  of  Med- 
icine, Designed  for  the  Use  of  Students  and 
Practitioners.  By  Austin  Flint,  M.D.,  LL.D., 
late  Professor  of  Principles  and  Practice  of  Medicine, 
Bellevue  Hospital  Medical  College,  New  York.  Sev- 
enth edition.  Thoroughly  revised  by  Frederick  P. 
Henry,  A.M.,  M.D.,  Professor  of  Principles  and  Prac- 
tice of  Medicine,  Woman's  Medical  College  of  Penn- 
sylvania. 8vo,  pp.  1,143.  Philadelphia  :  Lea  Broth- 
ers &  Co.     1894. 

To  the  old  students  of  the  late  Professor  Flint  this  new 
edition  of  his  classic  work  will  be  most  welcome.  Its 
peculiar  excellences  and  its  breadth  of  conception  have 
made  it  a  recognized  authority  from  the  time  its  first  edi- 
tion appeared.  The  author  was  a  born  teacher,  an  inde- 
fatigable observer,  a  painstaking  worker,  and  a  thorough 
medical  philosopher.  His  clinical  pictures  of  disease  are 
models  of  graphic  description,  minuteness  of  detail,  and 
breadth  of  treatment.  To  such  as  will  see  the  work  for 
the  first  time  there  is  an  agreeable  surprise  in  waiting. 
This  may  appear  to  be  high  praise,  but  the  work  has  so 
well  earned  its  leading  place  in  medical  literature  that 
but  one  view  can  be  expressed  concerning  its  general 
character  as  a  text-book.  The  editor  has  done  his  part 
in  bringing  it  up  to  date,  not  only  in  reference  to  treat- 
ment and  the  adaptation  of  the  newer  remedies,  but  has 
made  numerous  additions  in  the  shape  of  the  newly  dis- 
covered forms  of  disease,  and  has  elaborated  much  in  the 
commoner  forms  which  the  recent  advances  have  made 
necessary.  Among  the  new  articles  are  those  on  Pulsat- 
ing Pleurisy,  Hereditary  Chorea,  Weil's  Disease,  Syringo- 
myelia, Acromegaly,  Raynaud's  Disease,  Anthrax,  and 


Glanders.  The  section  on  General  Pathology  has  been 
omitted,  as  in  its  old  form  it  was  obsolete,  and  its  spirit 
could  hardly  be  maintained  in  any  reconstructed  form 
as  would  consistently  adapt  itself  to  progress  made  since 
it  was  first  written.  The  classifications  have  been  re- 
tained, but  some  of  the  articles,  such  for  instance  as  dys- 
pepsia, indicating  a  series  of  functional  disturbances,  have 
been  treated  under  the  different  and  now  well- recognized 
pathological  conditions. 

Although  the  doctrine  of  self- limitation  of  diseases  so 
well  advocated  by  Dr.  Flint  still  stands  prominently 
forth  in  the  admirable  natural  histories  he  gives,  the  ele- 
ment of  treatment  is  by  no  means  neglected,  in  fact  by 
the  editor  a  fresh  stimulus  is  given  to  this  necessary  de- 
partment by  a  comprehensive  study  of  all  the  new  and 
leading  therapeutic  agents. 

Aseptic  Surgical  Technique.  With  Especial  Reference 
to  Gynecological  Operations.  By  Hunter  Robb, 
M.D.,  Associate  in  Gynecology  Johns  Hopkins  Uni- 
versity. i2mo,  pp.  264.  Philadelphia:  J.  B.  Lip- 
pincott  Company.     1894. 

The  author  of  this  little  book  goes  into  the  subject  of 
asepsis  not  only  from  a  bacteriological  but  from  a  sur- 
gical point  of  view,  and  happily  combines  the  functions 
of  each  in  making  what  may  practically  and  theoretically 
constitute  the  ideal  operator.  His  treatment  of  the  sub- 
ject is  thorough  and  fully  abreast  with  the  latest  bacteri- 
ological principles  of  wound  treatment,  and  upsets  many 
of  the  cherished  notions  of  wound  irrigation  by  bichlo- 
ride, carbolic  solutions,  and  the  like.  The  careful 
descriptions  of  the  most  approved  methods  of  asepsis  by 
sterilization  of  instruments,  clothing,  and  dressings,  and 
the  insistence  of  the  elaborate  ablutions  of  the  hands  as 
practised  at  Johns  Hopkins  will  impress  the  reader  with 
a  minutia  of  detail  which  is  fully  in  keeping  with  the  im- 
portance of  doing  the  little  things  well  in  order  to  insure 
the  success  of  the  greater.  The  work  is  practical  from 
first  to  last,  and  cannot  fail  to  give  the  reader  all  the 
really  necessary  information  required  for  the  practice  of 
asepsis  in  all  the  varied  gynecological  operations.  The 
illustrations  are  numerous  and  well  executed,  particularly 
the  plate  which  forms  the  frontispiece,  and  gives  the  dif- 
ferent pathogenic  microbes. 

Text-book  of  Abdominal  Surgery.  A  Clinical  Man- 
ual for  Practitioners  and  Students.  By  Skene  Keith, 
F.R.C.S.  Ed.,  Assisted  by  George  E.  Keith,  M.B.C.M. 
8vo,  pp.  508.  Philadelphia :  J.  B.  Lippincott  Com- 
pany.    1894. 

Abdominal  surgery  has  grown  since  1880  into  such  a  rec- 
ognized speciality,  that  any  work  claiming  to  be  a  sys- 
tematic account  of  its  present  status  and  its  future  possi- 
bilities will  be  warmly  welcomed  by  progressive  operators. 
Considering  the  amount  of  literature  upon  the  subject,  the 
authors  have  experienced  no  small  amount  of  difficulty 
in  summarizing  results  and  in  reconciling  the  widely 
varied  views  of  investigators  in  this  prolific  field.  But 
the  work,  on  the  whole,  has  been  well  done,  and  stands  as 
a  model  of  its  kind  for  clearness  of  description,  reasonable 
minuteness  of  detail,  and  soundness  of  surgical  principle. 
Many  of  the  supposed  difficulties  are  simplified  in  a  way 
that  is  inviting  to  the  student  and  assuring  to  the  prac- 
titioner. Altogether,  it  shows  the  present  state  of  our 
knowledge  of  abdominal  surgery  and  creditably  covers 
the  entire  field,  treating  systematically  of  the  various  dis- 
eases of  the  different  organs  below  the  diaphragm. 

The  first  section  comprises  the  surgery  of  the  abdomen 
from  the  standpoint  of  the  general  operator,  while  the 
second  section  treats  of  the  department  of  operative 
gynecology.  Under  the  former  are  described  the  dis- 
eases of  the  stomach,  intestine,  appendix,  liver,  kidney, 
and  spleen,  which  may  call  for  surgical  treatment ;  while 
under  the  latter  are  discussed  ovariotomy,  diseases  of  the 
ovaries  and  Fallopian  tubes,  uterine  fibroids,  and  diseases 
of  the  uterus  generally.  Each  one  of  the  various  opera- 
tions are  described  in  sufficient  detail,  and  all  the  neces- 


502 


MEDICAL    RECORD. 


[October  20,  1894 


sary  directions  given  for  after  treatment.  Aseptic  pre- 
cautions are  consistently  advocated,  and  many  very 
valuable  practical  suggestions  are  offered  for  emergencies 
away  from  hospitals  and  in  remote  rural  districts.  The 
technique  of  the  different  operations  is  very  satisfactorily 
explained,  as  well  as  the  methods  of  diagnosis  and  the 
fundamental  principles  of  after  treatment.  This  is  espe- 
cially manifest  in  the  discussion  of  intestinal  lesions,  the 
choice  of  operations,  and  the  cardinal  symptoms  upon 
which  a  diagnosis  is  founded.  The  bugbear  of  intestinal 
approximation  is  robbed  of  much  of  its  perplexities  and 
difficulties  by  the  description  of  the  simple  and  effective 
methods  of  the  authors.  In  intestinal  anastomosis  Senn's 
plates  are  uniformly  advised,  but,  strange  to  say,  nowhere 
is  even  an  allusion  made  to  the  Murphy  button.  Much 
stress  is  laid  upon  electrolysis  in  the  treatment  of  uterine 
fibroids,  which  is  good  in  its  way,  as  offsetting  the  ' 
fashionable,  formidable,  venturesome,  and  unsurgical 
proceeding  of  hysterectomy  in  such  cases.  The  book  as 
a  whole  is  a  valuable  clinical  contribution,  and  is  destined 
to  become  authoritative  on  all  principles  upon  which  the 
abdominal  surgery  of  to  day  is  founded. 

History,  Constitution  and  By-laws,  and  List  of 
Members  of  the  Society  of  Alumni  of  Bellevue 
Hospital.  New  York:  De  Vinne  Press.  1894. 
We  learn  from  this  little  book  that  the  Society  of  Alumni 
of  Bellevue  Hospital  of  this  city  is  in  a  very  prosperous 
condition.  Its  membership  now  numbers  one  hundred 
and  ninety-nine. 

The  American  Institute  of  Homoeopathy.     Section  of 

Materia  Medica  and  General  Therapeutics. 
This  is  a  report  of  the  meeting  of  the  Therapeutic  Sec- 
tion of  the  American  Institute  of  Homoeopathy,  held  in 
Denver  in  1894.  The  proceedings  consisted  chiefly  in 
the  discussion  of  the  subject  of  how  to  treat  and  how  to 
learn  materia  medica.  The  little  book  contains  numer- 
ous half-tone  portraits  of  many  of  the  leading  homoeo- 
pathic practitioners  in  this  country  and  England. 

Macrobiotic,  or  Our  Diseases  and  Our  Remedies. 
For  Practical  Physicians  and  People  of  Culture.     By 
Julius  Hensel,  Physiological  Chemist.     Translated 
by  Professor  Louis  H.  Tafel,  of  Urbana  Univer- 
sity, O.,  from  the  Second  Revised  German  Edition. 
Philadelphia:  Boericke  &  Tafel. 
The  author  of  this  book  attributes  diseases  to  a  dimin- 
ished electric  force,  and  proposes  to  prevent  and  cure 
most  ills  by  his  "physiological  saltwater."     His  no- 
tions of  pathology  are  interesting.     Diphtheria,  which 
he  calls  "children's  catarrh,"  begins,  he  says,  "with 
stagnation  of  the  blood  in  the  thymus  gland,  whence  the 
products  of  the  putrefaction  of  the  albumin  of  the  blood 
are  spread  with  their  infecting  force  over  the  whole  vas- 
cular system."     The  views  set  forth  in  other  portions  of 
the  book  are  equally  sound  and  scientific. 

Transactions  of  the  South  Carolina  Medical  Asso- 
ciation.    Forty-fourth  Annual  Meeting,  held  in  Rock 
Hill,  S.    C,   April   25  and  26,  1894.      Charleston: 
Walker,  Evans  &  Cogswell  Co.     1894. 
This  volume  of  the  Transactions  for  1894  contains  the 
minutes  of  the  meeting  and  the  usual  number  of  papers, 
reports  on  special  subjects,  etc    The  next  meeting  of 
the  Association  will  take  place  in  Columbia  on  the  fourth 
Wednesday  in  April,  1895. 

Precis  de  Clinique  THfeRAPEUTiQUE.     Par  le  Dr.  A.  F. 

Plicque,  Ancien  Interne  des  Hdpitaux  de  Paris,  Lau- 

rtat  de  la  Faculty  de  M^decine,  LaurSat  des  H6pitaux. 

Paris:  G.  Steinheil.     1894. 

The  author  of  this  little  work  says  that  it  had  its  origin 

in  notes  made  for  His  own  use  during  the  early  years  of 

practice.     He  found,  in  beginning  his  life-work,  that  the 

conditions  of  private  practice  were  very  different  from 

those  of  hospital  practice,  and  required  often  the  exercise 

of  certain  faculties  and  of  a  kind  of  knowledge  not 

gained  in  institution  life.     The  work  cannot  pretend  to 


the  dignity  of  a  system  of  medicine,  being,  as  its  name 
implies,  simply  a  manual  of  therapeutics.  But  it  is  a 
good  manual,  systematically  arranged,  and  written  in  a 
lucid  style ;  the  directions  are  simple,  and  the  reader  is 
not  bewildered  by  a  long  catalogue  of  drugs  for  every 
disease.  Under  each  heading  the  indications  for  treat- 
ment are  briefly  stated,  and  then  the  author  mentions  a 
few  of  the  best  and  tried  remedies  and  gives  directions  for 
their  employment.  The  book  deals  with  internal  medi- 
cine only,  and  does  not  touch  upon  surgical,  venereal, 
or  cutaneous  disorders. 

A  Handbook  of  Medical  Microscopy  for  Students 
and  General  Practitioners,  Including  Chapters  on 
Bacteriology,  Neoplasms,  and  Urinary  Examinations. 
By  James  E.  Reeves,  M.D.,  Member  of  the  Associa- 
tion of  American  Physicians;   Ex-President  of  the 
American    Public    Health    Association,  etc.     Phila- 
delphia :     P.  Blakiston,  Son  &  Co.     1894. 
The  author  of  this  excellent  little  manual  states  in  his 
preface  that  his  object  in  writing  the  book  was  to  take 
away  from  the  practising  physician  all  excuse  for  his  neg- 
lect of  the  microscope  in  his  daily  work.     He  says,  and 
very  justly,  that  the  time  has  now  come  when  all  pro- 
gressive physicians  and  surgeons,  general  practitioners 
and  specialists  alike,  must  either  themselves  possess  suffi- 
cient skill  in  microscopic  technique  for  the  faithful  and 
proper  discharge  of  the  high  obligation  which  rests  upon 
them  in  the  diagnosis  and  treatment  of  diseases,  or  else 
be  able  to  command  the  ready  service  of  some  accom- 
plished microscopist  and  pathologist  to  do  such  necessary 
work  for  them.     The  writer  himself  is  a  general  practi- 
tioner belonging  to  the  former  class,  knowing  by  actual 
experience  the  needs  of  those  situated  like  himself,  and 
has  the  rare  gift  of  being  able  to  impart  this  self-acquired 
knowledge  to  others.     The  work  is  not  elementary  for 
the  professional  microscopist,  but  it  is  admirably  adapted 
to  meet  the  work  of  the  general  practitioner,  for  whom  it 
was  written. 

Memoirs  of  the  Boston  Society  of  Natural  History  : 
Volume  IV.,  Number  XI.    A  Bibliography  of  Verte- 
brate Embryology.     By  Charles  Sedgwick  Minot. 
Boston.     1893. 
This  bibliography  appears  to  be  a  most  exhaustive  one, 
containing  3,083  titles,  all  of  which  the  author  states  have 
been  verified  in  the  libraries  of  Boston  and  Cambridge,  or 
in  that  of  the  Surgeon-General's  Office  in  Washington. 

Gynacologische  Anatomie.  Die  GeschwOlste  der 
EierstOcke.  Von  Dr.  C.  H.  Stratz.  Berlin :  H. 
Kornfeld.  1894. 
This  beautiful  atlas  of  ovarian  tumors  consists  of  fourteen 
colored  plates,  with  fifty  figures,  delineating  a  great 
variety  of  tumors  of  the  ovary.  The  author  has  had  a 
vast  amount  of  material  to  select  from  in  Schweder's 
Clinic,  in  the  Frauenklinik  of  Berlin,  and  during  his  own 
five  years'  practice  in  Java.  He  appears  to  have  made 
judicious  use  of  this  material,  producing  an  atlas  not  only 
of  rare  tumors,  but  also  of  those  most  commonly  met  with 
in  everyday  practice.  There  are  some  forty  pages  of  de- 
scriptive text.  The  plates  are  well  executed  and  printed, 
and  the  work  does  credit  to  author  and  publisher  alike. 

Human  Physiology.  By  John  Thornton,  M.A., 
Author  of  Elementary  Physiography,  Advanced  Physi- 
ography, etc.  With  268  Illustrations.  New  York: 
Longmans,  Green  &  Co.     1894. 

All  the  essential  facts  of  human  physiology  have  been 
brought  together  in  this  handy  manual  of  some  450  pages, 
in  a  form  convenient  not  only  for  continuous  study,  but  also 
for  occasional  reference.  The  author's  style  is  as  easy 
and  smooth  as  his  descriptions  are  lucid.  The  illustra- 
tions, some  of  them  colored,  are  numerous  and  well  exe- 
cuted. To  the  general  practitioner,  who  is  not  a  special 
student  of  physiology,  we  can  recommend  this  little  work 
as  one  which  will  satisfactorily  meet  his  needs  in  this 
branch  of  science. 


October  20,  1894] 


MEDICAL    RECORD. 


503 


Vade-Mecum  du  Praticien.  Diagnostic  et  Traitement 
des  Maladies  Internes.  Par  le  Dr.  Fernand  Roux. 
Paris:  G.  SteinheiL  1894. 
This  is  a  useful  manual,  giving  the  main  points  in  the 
diagnosis  and  treatment  of  non  surgical  diseases.  The 
subjects  are  arranged  alphabetically,  convenient  for  ready 
reference,  and  the  therapeutic  suggestions  are  for  the 
most  part  sound,  and  in  accordance  with  the  latest  dis- 
coveries in  this  branch. 

Transactions  of  the  American  Gynecological  Soci- 
ety. Vol.  XIX.  For  the  year  1894.  8vo,  pp.  363. 
Philadelphia:  W.  J.  Dornan.  1894. 
This  valuable  volume  contains  several  admirable  papers 
on  hysterectomy,  others  on  face  presentations,  and  a  mas- 
terly address  by  the  President,  Prof.  Lusk,  on  the  relative 
value  of  the  various  methods  of  treating  uterine  fibroids. 

Sharp's  Tracts  on  Homceopathy.  14th  Thousand. 
8vo,  pp.  232.  Philadelphia:  Boericke  &  Tafel.  1894. 
This  is  a  collection  of  tracts  intended  for  the  defence  of 
Homoeopathy,  the  theory  of  small  dosage,  the  value  of 
the  so-called  provings,  the  advantage  of  single  doses, 
and  the  general  advantages  of  the  system.  To  such  as 
are  interested  in  the  subject  this  little  book  will  furnish 
much  food  for  reflection. 

A  Treatise  on  Appendicitis.  By  George  R.  Fowler, 
M.D.,  Examiner  in  Surgery,  Surgeon  to  St.  Mary's 
and  Methodist  Episcopal  Hospitals,  Brooklyn.  8vo, 
pp.  190.  Philadelphia:  J.  B.  Lippincott  Co.  1894. 
The  present  compact  treatise  comes  at  an  opportune 
time  for  the  discussion  of  many  questions  bearing  upon 
the  etiology,  pathology,  and  surgical  treatment  of  an 
interesting  and  very  frequent  surgical  disease.  The 
exceptional  opportunities  for  observation  which  the  prac- 
tice of  the  author  has  given  him  are  utilized  in  a  practi- 
cal and  intelligent  manner  for  the  benefit  of  his  many 
readers.  Many  of  the  mooted  points  in  the  pathology 
of  the  affection  are  discussed  with  becoming  candor  and 
independence,  and  with  a  thoroughness  eminently  com- 
mendable. Especially  interesting  are  the  views  regard- 
ing the  etiology  of  the  disease  as  bearing  directly  and 
almost  solely  upon  microbic  influences.  The  clinical 
reports  which  are  inserted  in  the  text  are  typical  of  their 
kind,  and  serve  their  full  intention  of  pointing  questions 
of  pathology  or  illustrating  lines  of  treatment.  The 
operative  technique  is  very  fully  given,  and  the  author's 
methods  are  very  intelligently  described.  The  illustra- 
tions are  numerous  and  good,  and  the  work  altogether  is 
a  great  success. 

An  Illustrated   Dictionary  of  Medicine,  Biology, 
and  Allied   Sciences,  Including  the  Pronunciation, 
Accentuation,  Derivation  and  Definition  of  the  Terms 
used  in  Medicine,  Anatomy,  Surgery,  Obstetrics,  Gyn- 
ecology,  Therapeutics,   Materia  Medica,  Pathology, 
Dermatology,   Pediatrics,   Ophthalmology,    Otology, 
Laryngology,  Physiology,  Neurology,  Histology,  Toxi- 
cology, Dietetics,  Legal  Medicine,  Psychology,  Clima- 
tology, etc.,  etc.,  and  the  various  Sciences  closely  re- 
lated to  Medicine,  such  as  Bacteriology,  Parasitology, 
Microscopy,  Botany,  Zoology,  Dentistry,  Pharmacy, 
Chemistry,  Hygiene,  Electricity,  Veterinary  Medicine, 
etc.  By  George  M.  Gould,  A.M.,  M.D.,  author  of 
"  The  Student's  Medical  Dictionary/'  "  Twelve  Thou- 
sand Medical  Words  Pronounced  and  Defined,"  "The 
Meaning  of  the  Method  of  Life,"  Editor  of  the  Med- 
ical News,  etc.    Based  upon  recent  scientific  literature. 
Philadelphia:  P.  Blakiston,  Son  &  Co.     1894. 
This  in  many  respects  admirable  work  possesses  a  great 
advantage  over  some  of  its  recent  competitors  in  that  it 
is  in  but  one  volume,  and  therefore  much  more  conven- 
ient as  a  work  of  constant  reference.    A  commendable 
feature  is  the  grouping  together  of  many  correlated  facts 
in  tables,  of  which  there  are  one  hundred  and  ten  in  all. 
The  type  employed  is  of  excellent  size,  the  printing  is  un- 
usually good,  and  the  illustrations  are  judiciously  selected 


and  not  too  numerous.  The  spelling  adopted  by  the 
editor  is  in  the  direction  of  the  phonetic,  the  diph- 
thongs being  dropped  from  words  of  Latin  or  Greek 
derivation,  as  also  the  final  e  of  the  name  of  alkaloids 
and  of  certain  other  words,  such  as  iodide,  bromide, 
iodine  and  the  like,  which  Dr.  Gould,  following  the 
suggestion  of  the  American  Association  for  the  Advance- 
ment of  Science,  writes  iodid,  bromid,  iodin,  eta  In 
some  of  the  words  of  this  class  the  alternative  spelling  is 
given,  and  in  others,  without  any  apparent  reason  for  the 
omission,  it  is  not.  The  weakest  part  of  the  book  is  in 
the  matter  of  pronunciation.  It  is  very  well  for  a  medi- 
cal lexicographer  not  to  be  too  dogmatic  in  cases  in 
which  orthoepists  themselves  are  not  in  accord,  but  his 
diffidence  should  not  go  to  the  length  of  sanctioning 
such  errors  as  al'bumin,  ab'domen,  anemic  diabe'tic, 
asthe'nia,  synechia,  or  such  wretched  cacophony  as 
making  the  final  syllable  of  cocaine  or  leucomaine  rhyme 
with  cane  or  mane.  In  the  case  of  some  words  which 
are  frequently  mispronounced,  as  the  second  one  of  the 
term  diabetes  mellitus  for  example,  the  author  gives  no 
sign  to  guide  the  would  be  orthoepist ;  and  the  pronun- 
ciation of  the  genitive  or  plural  of  several  Latin  words, 
such  as  cervix  and  paries,  over  which  even  well  educated 
people  so  often  stumble,  is  not  given  at  all  as  for  as  we 
have  been  able  to  discover.  These  are  sins  which  some 
may  consider  as  venial,  but  we  cannot  so  regard  them. 
They  do  not  absolutely  destroy  the  value  of  the  book  as 
a  work  of  reference,  it  is  true,  but  they  mar  its  perfection. 
A  dictionary  should  be  an  authority  in  matters  of  deri- 
vation, spelling,  punctuation  and  definition,  and  errors 
in  any  one  of  these  cardinal  points  are  unpardonable. 
A  dictionary  maker  should  be  in  these  matters  dogmatic, 
and  being  dogmatic  should  be  above  all  things  accurate, 
otherwise  it  is  but  a  case  of  the  blind  leading  the  blind. 
We  have  nothing  but  praise  for  the  definitions,  which 
are  clear  and  concise,  or  for  the  derivations,  but  the 
spelling  is  peculiar  and  in  many  cases  unsupported  by 
the  best  authorities,  even  by  Whitney,  whose  phonetic 
tendencies  were  so  pronounced ;  and  as  regards  pronun- 
ciation Dr.  Gould  is,  as  we  have  said,  uncertain  and  in 
not  a  few  instances  unsound.  The  author  is  already 
well  known  as  a  maker  of  dictionaries,  and  we  had 
hoped  that  this,  his  latest  work  and  the  fruit  of  his  ripe 
experience,  would  prove  to  be  the  ideal  lexicon  for  the 
busy  medical  man.  This,  unfortunately,  it  is  not,  but  it 
comes  very  near  to  it,  perhaps  as  near  as  anything  human 
can  come  to  perfectibility. 

Text-book  of  Medical  and  Pharmaceutical  Chemis- 
try. By  E.  H.  Bartley,  B.S.,  M.D.  Third  edition, 
revised  and  enlarged.  With  84  illustrations.  Phila- 
delphia: P.  Blakiston,  Son  &  Co  1894. 
This  excellent  book  contains,  in  the  most  concise  form, 
all  the  knowledge  of  medical  and  pharmaceutical  chem- 
istry. The  present  edition  has  been  greatly  enlarged, 
and  a  new  chapter  on  Physiological  and  Clinical  Chem- 
istry has  been  added ;  the  same  deals  with  the  chemistry 
of  nutrition,  digestion,  and  the  urine.  This  chapter  is 
treated  in  the  most  practical  way,  giving  the  principles 
of  feeding  and  diet,  the  clinical  examination  of  stomach 
digestion  for  diagnostic  purposes,  the  easier  methods  for 
the  examination  of  milk,  and  a  fairly  complete  guide  to 
the  clinical  examination  of  urine  and  urinary  calculi.  In 
perusing  the  tests  for  sugar  we  miss  those  of  Roberts  and 
Einhorn.  The  whole  book  reads  admirably  well,  and 
deserves  the  highest  recommendation. 

Diagnostik  und  Therapie  der  Magenkrankheiten. 

Von  Dr.  T.  Boas.     I.  Theil,  3te  Auflage.     Leipzig : 

Verlag  von  Thieme.  1894. 
The  present  edition  of  this  so  well- known  book  on  dis- 
eases of  the  stomach  has  been  greatly  enlarged  and  con- 
tains the  newest  ideas  and  inventions  in  this  field  of 
medicine.  Boas  has  given  his  personal  experiences  on 
many  pathological  anatomical  conditions  of  the  gastric 
mucosa,  illustrating  them  with  figures  of  the  correspond- 
ing microscopic  specimens.     As  to  the  early  recognition 


5°4 


MEDICAL  RECORD. 


[October  20,  1894 


of  cancer  of  the  stomach  he  puts  most  stress  on  the  pres- 
ence of  lactic  acid  in  the  stomach  contents,  this  being 
much  more  characteristic  than  the  absence  of  free  hydro- 
chloric acid.  The  book  will  be  read  with  much  profit 
by  every  practitioner. 

Transactions  of  the  Association  op  American  Phy- 
sicians. Niuth  Session.  1894. 
This  volume  contains  an  unusual  amount  of  interesting 
material,  and  covers  a  wide  range  of  medical  subjects. 
The  papers  are  short  and  practical,  and  for  the  most  part 
bear  upon  the  leading  medical  questions  of  the  day. 

Text- book  of  Practical  Therapeutics.  By  Hobart 
Amory  Hare,  M.D.,  B.Sc,  Professor  of  Therapeutics 
and  Materia  Medica,  Jefferson  Medical  College,  Phil- 
adelphia. Fourth  edition.  8vo,  pp.  740.  Philadel- 
phia :  Lea  Brothers  &  Co.  1894. 
The  fact  that  the  fourth  edition  of  this  work  has  appeared 
within  four  years  attests  its  value  to  the  general  prac- 
titioner, and  its  appreciation  by  the  medical  student 
Its  wide  application  to  the  practical  needs  of  everyday 
medicine  commended  it  from  the  first  to  the  progressive 
and  working  therapeutist.  It  is  not  only  knowing  what 
to  give,  but  when  and  where  to  give,  and  how  the  drug 
will  act  in  given  conditions,  that  makes  one  a  scientific 
practitioner  rather  than  an  ignorant  empiric.  The  book 
in  such  respects  supplies  every  need.  It  is  divided  into 
four  parts :  I.  General  Therapeutical  Considerations. 
II.  Drugs  and  their  Properties.  III.  Remedial  Measures 
other  than  Drugs,  Foods  for  the  Sick.  IV.  The  Thera- 
peutics of  Different  Diseases,  Tables  of  Doses,  an  Index 
of  Drugs  and  Remedial  Measures,  and  an  Index  of  Dis- 
eases and  Remedies.  The  author  is  well  known  as  a  pro- 
gressive therapeutist,  and  it  goes  without  saying  that 
all  the  new  or  valuable  drugs  receive  their  full  share  of 
attention,  and  it  is  a  great  deal  to  say  in  this,  as  with 
other  features,  that  the  book  is  up  to  date  in  everything 
pertaining  to  the  practical  therapeutical  needs  of  the 
practitioner.  The  additions  made  are  articles  on  Methyl- 
ene-blue,  Chloralose,  Pyrogallol,  Condurango,  Conval- 
laria,  Duboisine,  Hypodermoclysis,  Enteroclysis,  Lavage, 
and  several  additions  to  the  department  of  individual 
diseases.  The  work  has  also  been  revised  in  such  a  way 
as  to  make  it  uniform  with  the  United  States  Pharmaco- 
poeia. 

Wann  DCrfen  Gonorrheische  Heirathen  ?    Von  Dr. 

Edmund  Saalfeld.  Berlin :  H.  Kornfeld.  1894. 
This  is  a  little  brochure  dealing  with  the  subject  of  the 
marriage  of  men  who  have  had  gonorrhoea.  The  author 
believes  that  the  disease  is  curable  and  that  when  it  is 
once  actually  cured  the  man  may  marry  with  perfect 
safety  to  his  wife,  himself,  and  their  offspring,  if  any.  4  B 

Der  Alkohol  als  Gunss-  und  Arzneimittel.  Von 
Dr.  A.  Jaquet,  Privatdocent  ftir  experim.  Pharmakol- 
ogie.  Basel :  Benno  Schwabe.  1894. 
An  interesting  and  well  considered  lecture  upon  alcohol 
as  a  beverage  and  as  a  therapeutic  agent.  The  author's 
views  are  very  moderate,  and  he  believes  that  the  con- 
sumption of  alcohol  in  the  so-called  physiological  doses 
by  adults  is  not  prejudicial  to  health  or  to  a  long  life. 

A  Manual  of  Hygiene.  By  Mary  Taylor  Bissell, 
M.D.,  Professor  of  Hygiene  in  the  Woman's  Medical 
College  of  the  New  York  Infirmary  for  Women  and 
Children.  New  York:  The  Baker  &  Taylor  Company. 
Dr.  Bissell  has  done  a  good  work  in  preparing  this  stu- 
dent's text-book  on  hygiene.  Most  works  on  hygiene 
are  of  such  size  and  deal  with  the  subject  so  elaborately 
that  the  student  is  repelled,  being  unable,  indeed,  to  give 
the  time  necessary  for  the  study  of  such  a  formidable 
looking  work.  In  this  book,  which  is,  however,  by  no 
means  a  superficial  one,  the  essentials  of  the  science  only 
are  given,  and  the  reader's  attention  is  not  distracted  by 
details  of  value  only  to  the  specialist.  The  book  will  be 
found  serviceable,  moreover,  to  many  practitioners  as 
well  as  to  students. 


jfocietg  Reports. 

NEW  YORK  ACADEMY  OF  MEDICINE. 

Stated  Meeting,  October  4, 1894. 

D.  B.  St.  John  Roosa,  M.D.,  President,  in  the  Chair. 

The  Stack  Room  Completed.— Dr.  E.  H.  Grandin, 
chairman  of  the  Library  Committee,  stated  that  the  stack 
room  had  been  completed  during  the  summer  and  was 
now  the  best  in  the  country,  not  excepting  that  at  Wash- 
ington. It  had  a  capacity  of  two  hundred  and  fifty  thou- 
sand volumes,  just  five  times  as  many  as  were  now  in  the 
library.  He  made  a  strong  appeal  for  books  from  the 
overflowing  libraries  of  members,  and  for  donations  from 
their  wealthy  clientele.  The  library  was  greatly  in  need 
of  an  endowment  fund  of  at  least  one  hundred  thousand 
dollars.  Money  expended  in  this  direction  would  prove 
of  far  greater  benefit  to  the  public  than  if  it  were  used 
to  build  more  hospitals  and  dispensaries. 

Credit  was  given  by  Dr.  Grandin  to  Drs.  A.  Jacobi  and 
A.  M.  Jacobus  for  careful  supervision  of  the  work  done 
in  the  stack  room.  Dr.  Jacobi,  who  arrived  later,  at- 
tributed all  honor  for  the  same  service  to  Drs.  Grandin 
and  Jacobus. 

The  President  emphasized  Dr.  Grandin's  remarks  re- 
garding the  needs  of  the  library,  and  expressed  the  belief 
that  if  what  was  wanted  were  asked  for,  it  would  be  given. 
New  York  was  ever  ready  to  give  for  any  worthy  purpose 
when  made  to  appreciate  its  value  and  want,  but  the  medi- 
cal profession  had  been  too  modest,  and  the  community 
had  come  to  regard  their  services  as  consisting  only  in 
the  administration  of  drugs  and  the  use  of  the  knife. 
High  and  above  all  else  was  our  duty  as  citizens  of  this 
great  nation. 

Report  of  Committee  to  Constitutional  Convention  — 
Dr.  W.  R.  Pryor,  one  of  the  members  of  this  committee, 
made  a  preliminary  report.  The  committee  had  been 
received  with  courtesy,  and,  to  a  large  extent,  its  sugges- 
tions had  been  acted  upon.  The  Convention  had  agreed 
to  abolish  coroners,  but  refused  to  put  doctors  in  their 
place ;  the  Board  of  Regents  had  been  incorporated  into 
the  constitution,  as  desired  by  the  committee,  but  their 
objection  to  its  being  made  a  life  tenure  office  had  not 
been  heeded.  The  committee's  recommendation  to  make 
county  instead  of  state  office  of  charities  and  correction 
in  the  counties  of  New  York  and  Kings,  and  thereby 
rendering  the  officers  liable  to  removal  by  the  Governor, 
had  not  been  accepted,  as  it  affected  too  many  official 
heads. 

Climate  in  Therapeutics. — The  President,  in  intro- 
ducing the  author,  Dr.  C.  Fayette  Taylor,  said  he  was 
sure  the  Academy  would  be  glad  to  know  the  conclusions 
arrived  at  upon  this  subject  by  one  who  had  had  much 
experience  through  travel  and  the  reliability  of  whose 
judgment  had  been  demonstrated  by  enviable  success 
in  another  department  of  medicine,  that  of  orthope- 
dics. 

Dr.  Taylor  said  that  his  object  in  writing  the  paper 
was  to  strongly  impress  the  necessity  for  the  profession, 
in  recommending  a  change  of  climate,  to  have  a  definite 
purpose  in  doing  so  and  more  accurate  knowledge  of  the 
qualities  and  health  influence  of  the  particular  climate 
named.  Some  gave  very  indefinite  advice,  such  as  to  go 
to  California,  a  State  which  was  seven  hundred  and  seventy 
miles  long,  and  embraced  at  least  seven  different  climates. 
The  mean  temperature  of  a  locality  meant  nothing.  It 
might  be  the  same  in  climates  of  greatest  extremes  in 
their  influence  on  the  health.  The  mean  temperature  in 
the  different  climates  of  California  was  nearly  the  same, 
while  the  extremes  varied  greatly,  as  did  also  the  phys- 
iological effects.  Moisture  was  a  very  important  factor. 
Yet,  although  it  favored  growth  of  micro-organisms,  it 
did  not  follow  that  an  air  dry  enough  to  be  almost  free 
from  germs  was  necessarily  healthier.  Physicians  had 
found  it  necessary  to  send  their  patients,  especially  women 


October  20,  1894] 


MEDICAL    RECORD. 


505 


and  children,  living  in  the  dry,  high  air  of  the  eastern 
slope  of  the  Rocky  Mountains,  to  the  moister  valleys  oc- 
casionally, in  order  to  avoid  nervousness  and  loss  of  flesh. 
He  could  not  say  whether  the  peculiar  influence  of  such 
air  was  due  to  increased  action  of  the  heart  or  the  con- 
stant hammering  at  the  nerves  by  the  wind  and  sunshine. 
The  author's  conclusion  on  this  point  was  that,  while  it 
was  important  to  live  in  an  atmosphere  as  free  from  germs 
as  possible,  it  was  even  more  important  to  live  in  one 
which  would  give  vigor  to  resist  germ  influence.  It 
seemed  that  heretofore  the  study  of  climatology  had  been 
for  the  purpose  of  finding  a  place  where  consumptives 
would  not  die.  There  was  no  such  place.  There  was 
no  place  where  bacilli  would  not  get  in  their  deadly  work. 
A  question  of  wider  interest  was,  what  climate  was  best 
and  in  which  we  might  spend  the  greater  part  of  our 
lives?  There  were  many  other  diseases  of  which  men 
died  besides  tuberculosis.  Moreover,  ill  health  often  de- 
pended upon  conditions  and  habits  quite  independent  of 
climate,  and  such  as  could  be  corrected  without  change 
of  place.  A  friend  in  New  York  had  been  almost  re- 
juvenated in  three  months  by  limiting  his  diet  during  that 
time  to  oysters,  fish,  and  clam  broth.  People  went  abroad 
and  were  sent  abroad  by  physicians  in  order,  as  it  was 
stated,  to  tone  up.  Yet  in  many  instances  the  first  step 
toward  toning  up  should  consist  in  toning  down.  By 
that  the  author  meant  to  reduce  the  unnecessary  ex- 
penditure of  energy  which  had  become  a  filed  habit  of 
life.  Most  of  us  were  too  prodigal  with  our  resources  and 
squandered  more  than  the  occasion  required.  One 
wisely  answered,  when  asked  how  he  succeeded  in  always 
being  so  healthy,  "Be  comfortable/ '  We  should  learn 
to  sit  down  and  be  comfortable  where  we  are. 

Among  the  countries  of  whose  climate  the  author 
spoke  from  personal  experience  were  California,  Nevada, 
other  Western  and  also  Southern  sections  of  this  country, 
the  West  Indies,  Spain,  etc.  He  thought  a  visit  to  the 
tropics  from  time  to  time  would  prove  healthful  in  in- 
ducing habits  of  reposefulness.  Tropical  heat  was  not 
oppressive,  as  was  generally  supposed  by  those  who  had 
not  tried  it.  Wakefulness  in  the  tropics  was  a  rarity, 
while  the  relief  obtained  from  nervous  tension  and  irri- 
tability was  delightful.  The  increased  activity  of  the 
skin  freed  the  system  of  morbid  material  and  gave  rest 
to  the  kidneys  and  lungs.  It  was  a  delusion  born  of 
the  constant  assertion  of  advocates  of  negro  slavery  be- 
fore the  Rebellion  to  suppose  that  white  people  could  not 
work  in  the  tropics.  The  Windward  Islands  were  more 
favorable  for  health  than  the  Greater  Antilles,  being  too 
small  to  give  rise  to  a  land  breeze  and  consequent  im- 
purity of  air  and  change  of  temperature.  A  visit  to  trop- 
ical points  should  be  accompanied  by  a  change  of  food. 
One  should  live  largely  on  native  fruits.  Hardly  a 
better  climate  could  be  selected  than  the  southern  part 
of  Spain,  but  one  had  to  contend  with  lack  of  sanitary 
arrangements  in  the  cities.  The  author  stated  that  peo- 
ple from  the  South  could  stand  northern  winters  better 
than  those  from  the  North  could  stand  the  same  season 
in  the  warmer  climates,  and  thought  the  explanation  lay 
in  the  fact  that  the  former  had  not  previously  expended 
their  vital  reserve  in  resisting  cold.  In  visiting  mineral 
springs  one  should  place  himself  under  the  care  of  a  local 
physician,  and  not  ask,  as  many  did,  advice  of  the  hotel 
porter. 

Finally,  there  was  an  abundance  of  climate  in  our  own 
homes  if  we  would  but  open  the  windows  and  let  it  into 
our  living  apartments,  taking  due  precaution  against 
draughts  and  cold.  Too  many  were  taken  away  for  a 
change  of  climate  in  the  last  stage  of  disease  to  locali- 
ties where  they  were  deprived  of  comforts  which  could 
only  be  had  at  home,  and  were  brought  back  in  a  long 
box  by  a  baggage  car. 

Dr.  Simon  Baruch  opened  the  discussion.  For  some 
years  past  he  had  tried  to  simplify  all  problems  in  thera- 
peutics and  reduce  them  to  first  principles,  as  it  was  only 
in  this  manner  that  we  could  succeed  in  combating  dis- 
ease.   It  seemed  to  him  climatology  was  now  in  the  po- 


sition occupied  by  antiseptic  surgery  some  years  8go, 
when  it  was  customary  to  surcharge  the  air  of  the  opera- 
tion-room with  carbolized  spray,  while  the  surgeon's 
finger-nails  were  left  unclean.  He  was  in  agreement 
with  the  paper,  the  most  important  point  in  which,  he 
thought,  was  the  reference  to  climatic  advantages  of  our 
own  homes,  and  our  failure  to  utilize  them.  As  an  ex- 
ample of  what  might  be  done,  he  mentioned  the  case  of 
a  man  with  phthisis  who  was  benefited  by  a  visit  to  Min- 
nesota, which  was  advised  by  Dr.  Loomis ;  but  his  cough, 
hectic,  and  loss  of  flesh  returned  on  leaving  those  parts, 
and  he  consulted  Dr.  Baruch  with  regard  to  another  lo- 
cality. Dr.  Baruch  told  him  to  remain  in  New  York, 
and  arranged  his  rooms  so  that  he  practically  lived  in 
open  air  and  sunshine  during  the  winter  months,  with 
the  result  that  in  two  months  he  gained  twelve  pounds  in 
weight,  and  lost  his  hectic  and  cough. 

Three  Principal  Questions  in  Changing  Residence. 
— Dr  R.  C.  M.  Page  thought  that  in  considering  a 
change  of  residence  we  were  met  by  three  principal 
questions  at  the  outset :  1,  The  nature  of  the  climate  in 
its  widest  sense,  including  elevation,  extremes  of  tem- 
perature rather  than  the  mean,  soil,  drainage,  winds, 
dust ,-  2,  accessibility,  hotel  and  other  accommodations ; 
3,  condition  of  the  patient. 

He  believed  that  in  the  majority  of  cases  it  was  the 
change,  in  a  general  sense,  rather  than  the  particular  cli- 
mate to  which  benefit  was  chiefly  due.  Certainly,  how- 
ever, some  places  were  to  be  avoided  on  account  of  ad- 
verse climatic  conditions,  particularly  by  patients  with 
phthisis.  A  long,  continuous,  tiresome  journey  and  sud- 
den change  of  altitude  were  now  guarded  against  in 
Europe.  Persons  who  were  too  sick  to  take  exercise 
should  stay  at  home  among  friends. 

Would  Establish  a  Sanitarium  for  the  Poor.— Dr. 
Achilles  Rose  said  that  inasmuch  as  reference  had  been 
made  to  Detweiler's  establishment  for  consumptives  in 
Europe,  he  would  point  out  the  need  of  some  similar  re- 
sort in  this  country  where  those  could  go  with  moderate 
means  and  receive  all  the  advantages  of  a  well  regulated 
sanitarium.  The  locality  should  be  accessible  to  the 
great  cities  along  the  Atlantic  coast,  should  be  between 
1,500  and  5,000  feet  above  the  sea-level,  and  more  south. 

Dr.  Sell,  who  had  travelled  a  great  deal  and  for  a 
number  of  years,  cautioned  against  sending  patients  to  a 
place  whose  only  recommendation  might  be  its  favorable 
climate.  The  general  advice  to  go  to  Egypt  was  like 
sending  one  to  California,  without  mentioning  the  par- 
ticular part.  He  mentioned  a  number  of  places  where 
consumptives  had  had  a  cessation  of  their  symptoms  and 
lived  in  health,  but  they  were  compelled  to  stay  there 
and  not  return  to  their  place  of  nativity.  Among  these 
was  a  place  in  Mexico,  another  in  Texas,  a  third  in  Cal- 
ifornia. There  ought  to  be  a  teacher  in  climatology  in 
every  medical  school  throughout  the  country. 


Working  up  a  Practice. — The  following  advertisement 
appeared  recently  in  an  English  lay  journal :  "  Skin 
Disease. — A  Specialist,  who  cures  every  description  of 
Skin  Disease,  will  give  a  liberal  commission  to  ladies  and 
gentlemen  who  will  introduce  patients.  Every  informa- 
tion given  by  addressing  Specialist." 

The  Cholera  appears,  from  the  cable  reports,  to  be 
subsiding  in  Europe.  It  still  prevails  to  a  considerable 
extent  in  St.  Petersburg,  Moscow,  and  Warsaw,  and  the 
surrounding  districts,  but  is  rapidly  diminishing  in 
Galicia  and  other  infected  provinces  in  the  Austrian  do- 
minions. Twelve  of  these  districts  have  been  entirely 
free  since  the  middle  of  September.  A  despatch  to  the 
State  Department  from  Constantinople  announces  a  re- 
newed outbreak  of  cholera  in  that  city  and  the  outlying 
districts.  From  Hamburg  is  reported  the  death  of  Dr. 
Oertel,  Assistant  Superintendent  of  the  Hygienic  Insti- 
tute in  that  place.  His  death  occurred  from  cholera 
contracted  in  the  course  of  some  experiments  which  he 
was  making  with  cultures  of  the  comma  bacillus. 


5o6 


MEDICAL   RECORD. 


[October  20,  1894 


MEDICAL    SOCIETY  OF    THE  COUNTY    OF 
NEW  YORK. 

Stated  Meeting,  September  24,  1894. 

H.  D.  Chapin,  M.D.,  in  the  Chair. 

nominations  —  [*ne  following  nominations  were  made, 
the  election  to  take  place  at  the  October  meeting :  For 
President,  Drs.  H.  D  Chapin.  E.  H.  Grandin,  Robert 
Abbe,  V.  P.  Gibney;  First  Vice  President,  Drs.  R.  Van 
Santvoord,  H  E.  Crampton,  A.  Caille\  Wendell  Phillips; 
Second  Vice-President,  Dr.  S.  H.  Dessau ;  Secretary,  Dr. 

C.  H  Avery ;  Assistant  Secretary,  Dr.  W.  H.  Ballard  \ 
Ireasurer,  Dr.  J  dim  S.  Warren ;   Censors,  Drs.  Seneca 

D.  Powell,  Simon  Baruch,  C.  L  Gibson,  George  T.  Jack- 
son, E.  D  Fisher,  R.  W.  Wilcox,  A.  M.  Jacobus,  E.  N. 
Liell,  Charles  H.  Knight,  William  Stevens,  C  C. 
Rice. 

ffervous  Dyspepsia.— Dr.  Henry  Illoway  read  the 
first  paper  of  the  evening.  Much  literature  had  appeared 
nnder  the  title  "  Nervous  Dyspepsia,"  but  analysis 
showed  that  it  was  a  jumble  of  many  morbid  states. 
The  author's  purpose  was  to  justify  the  classification  and 
to  define  the  cases  which  properly  belonged  in  it.  The 
views  of  German  writers  were  cited,  and  disapproval  was 
expressed  of  including  the  cases  under  discussion  under 
the  term  neurasthenia  gastrica.  Neurasthenia  had  come 
to  be  a  well  established  morbid  entity,  with  certain  char- 
acteristic symptoms,  and  where  a  dyspepsia  was  depend- 
ent thereon  it  could  be  made  to  disappear  with  special 
attention  to  the  stomach  itself.  Nervous  dyspepsia  had 
been  appropriately  defined  as  an  ailment  of  the  stomach 
without  any  definite  and  fixed  pathological  or  anato- 
mico-pathological characteristics,  depending  solely  upon 
the  nerves  of  the  stomach.  The  stomach  is  primarily 
affected.  If  any  symptoms  on  the  part  of  the  general 
nervous  system  present  themselves  they  are  the  conse- 
quence of  irritation  proceeding  from  the  stomach,  and 
therefore  only  secondary  manifestations.  Treatment 
must  be  directed  to  the  stomach ;  only  in  that  way  can 
the  disease  be  cured. 

Symptoms. — The  tongue  in  the  morning  is  covered 
with  a  thin  transparent  coat,  the  red  being  visible 
through  it ;  the  patient  complains  of  lack  of  hunger,  but 
when  he  begins  to  eat  he  can  eat  as  much  as  anybody, 
but  when  he  stops  his  misery  begins.  He  complains  of 
feeling  bad  at  the  stomach,  of  a  feeling  of  heaviness  and 
distention,  of  eructations  of  gas,  which,  however,  are  at- 
tended by  some  relief  and  differing  from  hysterical  eruc- 
tation in  not  being  continuous.  The  most  unpleasant 
feeling  is  the  one  described  as  general  irritability ;  a  de- 
sire to  have  a  row  with  somebody.  There  might  be  a 
feeling  of  pressure  and  irritability  of  the  brain.  Such 
feelings  lasted  an  hour  and  a  half  usually,  sometimes 
three  hours,  and  were  renewed  after  the  next  meal. 
The  bo*els  were  usually  undisturbed,  although  an  inac- 
tive life  might  lead  to  constipation.  The  patients  were 
incapable  of  prolonged  work,  and  preferred  light  litera- 
ture. Sleep  was  usually  undisturbed.  Alcoholic  bever- 
ages were  not  well  tolerated,  although  frequently  pre- 
scribed by  physicians. 

Etiology — There  were  two  chief  causes  —  mental 
shock  and  tobacco  smoking.  Where  mental  shock  was 
the  cause,  as  loss  of  friends  or  of  property,  the  whole 
force  of  the  blow  seemed  to  be  expended  upon  the  stom- 
ach and  not  upon  the  general  system,  as  in  neurasthenia 
depending  upon  a  like  cause.  Where  tobacco-smoking 
was  the  exciting  factor  the  symptoms  would  come  on 
after  the  use  of  perhaps  a  single  cigar,  and  were  not  due 
to  excessive  indulgence  and  poisoning  of  the  system 
thereby.  The  patients  could  digest  nitrogeneous  foods 
well,  and  us  lally  there  was  a  sufficient  amount  of  hydro- 
chloric acid  and  pepsin  in  the  gastric  secretions.  In  the 
author's  experience  there  had  been  no  atony  of  the  stom- 
ach, yet  the  symptoms  seemed  to  point  to  inhibition  of 
muscular  action  in  that  organ  and  disappearance  of  the 
same  when  action  was  re  established.  The  vagus  sup- 
plying the  stomach  seemed  to  be  in  a  state  of  hyper- 


excitability,  and  the  irritability  might  be  so  great  as  to 
cause  most  of  the  food  to  be  rejected  as  soon  as  taken. 

In  differential  diagnosis  the  author  thought  it  only 
necessary  to  exclude  neurasthenia  gastrica,  and  this  he 
believed  not  to  be  a  difficult  matter.  In  this  affection 
the  patient  felt  bad  when  the  stomach  was  empty,  and 
after  eating  felt  much  stronger  and  better,  while  the  re- 
verse was  true  in  nervous  dyspepsia.  In  nervous  dys- 
pepsia the  food  tasted  good,  while  in  neurasthenia  gas- 
trica there  was  no  desire  to  eat.  In  the  latter  the  in- 
testines were  affected,  they  were  not  in  the  former. 
Neurasthenic  patients  awoke  frequently,  complained  of 
sensations  of  hot  and  cold,  and  sometimes  as  if  suffering 
from  malaria,  differing  in  these  regards  from  patients 
troubled  with  nervous  dyspepsia. 

Many  had  said  the  prognosis  was  unfavorable,  but  the 
author  had  found  it  quite  favorable.  Even  cases  of  ner- 
vous dyspepsia  of  long  standing  would  recover  nnder 
proper  methods.  He  had  seen  no  sequelae  although  he 
suspected  the  condition  might  in  time  lead  to  melan- 
cholia and  insanity.  Nor  had  there  been  complications 
except  a  slight  eczema  on  the  chin.  The  treatment  was 
not  considered  in  this  paper. 

A  Brief  Study  of  the  Physiological  Epochs  that  Pre- 
dispose to  Insanity,  with  Observations  on  the  Manage- 
ment of  Each. — Dr.  William  P.  Spratling,  in  a  paper 
with  this  title,  spoke  of  six  epochs  predisposing  to  insan- 
ity, all  of  which  were  physiological  except  one,  namely, 
heredity.  In  the  order  named  they  were — the  epoch  of 
childhood,  of  puberty,  of  maternity,  heredity,  the  men- 
opause, and  senility. 

The  peculiarity  of  the  epoch  of  heredity  was  its  varia- 
bility, embracing  the  period  when  ancestors  who  were 
inclined  to  insanity  exhibited  signs  of  the  disease.  The 
last  epoch,  or  that  of  senility,  was  pathological  rather 
than  physiological. 

Regarding  the  first  epoch,  Gowers  had  stated  that  one- 
eighth  of  all  cases  of  epilepsy,  which  not  infrequently  led 
to  insanity,  began  during  the  first  three  years,  and  with 
rickets  as  a  combined  cause,  seventy- five  per  cent,  were 
due  to  infantile  convulsions  ascribed  to  teething.  Gen- 
uine epilepsy,  however,  probably  never  arose  from  den- 
tition, but  the  convulsions  occurring  at  this  time  might 
finally  take  on  all  the  characteristics  of  epilepsy.  Any- 
thing which  interfered  with  the  nutrition  of  the  child's 
brain  was  a  serious  matter,  for  this  organ  acquired  its 
chief  growth  the  first  seven  years.  Besides  dentition  as 
a  starting  cause,  he  mentioned  blows,  fevers,  and  other 
conditions  which  changed  the  physiological  processes  of 
childhood  into  pathological,  and  thus  laid  the  basis  for 
insanity. 

Pubescence,  from  the  fifteenth  to  the  twenty  second 
year,  was  more  dangerous  to  the  female  than  to  the  male. 
In  the  former  the  change  from  childhood  was  almost  at 
a  bound,  while  in  the  latter  it  was  very  gradual.  The 
female  was  liable  to  show  melancholia,  mental  enfeeble- 
ment,  bodily  inactivity,  later  along  systematized  delusion 
which  pertained  chiefly  to  self.  The  prognosis  was  good 
when  there  was  no  history  of  hereditary  taint.  Nourish- 
ment should  be  given  in  an  easily  assimilable  form, 
and  the  secretory  and  excretory  functions  should  receive 
particular  attention  as  they  were  inclined  to  be  sluggish. 
Give  hypnotics  or  sedatives  only  when  urgently  needed. 
The  best  form  of  iron  for  the  anaemia  was  the  carbonate. 

Insanity  during  maternity  occurred  more  frequently 
in  women  about  to  give  birth  to  an  illegitimate  child. 
Infanticide  and  suicide  were  common.  To  produce  sleep 
the  author  preferred  paraldehyde.  As  showing  the  in- 
fluence of  heredity,  the  author  knew  of  a  family  mem- 
bers of  which  had  shown  insanity  during  four  generations 
on  reaching  a  certain  age. 

The  insanity  of  the  menopause  was  of  the  depressed 
type,  frequently  with  suicidal  impulse,  yet  the  prognosis 
was  favorable  where  there  was  no  hereditary  taint.  Out- 
of-door  life  and  change  of  climate  were  recommended. 

The  most  common  form  of  insanity  of  the  last  period 
was  that  of  senile  dementia.     It  was  rather  a  retrogres- 


October  20,  1894] 


MEDICAL   RECORD. 


507 


sion  of  the  mind.  In  senile  melancholia  seventy- five  per 
cent,  of  the  cases  showed  suicidal  tendency.  The  author 
had  found  most  satisfactory  results  from  opium,  and  at 
this  period  there  was  little  danger  of  the  opium  habit. 

In  discussing  the  paper  Dr.  William  Leszynski  said 
he  had  never  felt  satisfied  that  the  physiological  epoch  of 
childhood  had  much  to  do  with  the  development  of 
insanity,  although  it  was  a  settled  fact  that  hereditary 
predisposition  was  a  prime  element.  Puberty  in  the  boy 
also  had  little  influence  since  the  change  was  so  gradual. 

Dr.  E.  D.  Fisher  said  women  at  puberty  were  par- 
ticularly subject  to  nervous  disorders,  as  hysteria,  men- 
tal depression,  etc.,  and  required  a  change  of  surround- 
ings, for  their  chances  were  not  good  if  treated  at  home. 
He  endorsed  the  author's  recommendation  of  opium  in 
senile  dementia. 

Dr.  Collins  thought  some  of  the  divisions  made  in  the 
paper  somewhat  artificial,  although  they  might  serve  to 
make  the  subject  clear. 

The  epoch  of  childhood  as  predisposing  to  insanity 
particularly  seemed  artificial,  and  that  of  old  age  was  very 
variable,  and  pertained  to  degeneration  of  the  arteries. 
In  the  insanity  of  the  puerperal  period  the  time  had  ar- 
rived for  laying  more  stress  on  infection  as  a  cause. 

Dr.  Van  Fleet  thought  the  term  heredity  a  misnomer, 
that  it  had  been  much  abused ;  but  the  basis  of  his  belief 
seemed  to  be  fear  of  its  influence  on  the  imagination  of 
those  giving  a  hereditary  history. 

Dr.  Bryson  related  two  instances  to  show  the  injuri- 
ous effects  of  the  same  physical  conditions  enforced  upon 
women  as  upon  men  in  attaining  an  education.  She 
thought  the  same  mental  training  could  be  acquired  and 
yet  allow  for  differences  in  physiological  processes. 

The  usual  collation  was  served. 


(&0VXC$VQU&ZUtZ. 

OUR  LONDON  LETTER. 

(From  our  Special  Correspondent) 

SANITARY  CONGRESS — PRESIDENT'S  ADDRESS — HEALTH  EX- 
HIBITION  CONFERENCES  OF  OFFICERS  OF  HEALTH,  SAN- 

ITARV  INSPECTORS,  ETC  — OVERCROWDING  OF  HOUSES — 
DR.  &LEIN  ON  TYPHOID  —  DEATH  OF  DR.  GREENHILL, 
THE  SCHOLAR  OF  THE  PROFESSION— OPENING  OF  THE 
LONDON  MEDICAL  SCHOOLS. 

London,  September  29, 1894. 

This  week  we  have  had  another  congress,  viz.,  the  four- 
teenth of  the  Sanitary  Institute,  which  met  in  Liverpool. 
On  Monday  the  members  were  received  in  the  town- hall 
by  the  Lord  Mayor,  and  the  President,  Sir  Francis  Pow- 
ell, Bart.,  M  P.,  delivered  his  address.  He  passed  in 
review  the  progress  made  in  the  last  few  years,  especially 
in  connection  with  the  Acts  of  Parliament  which  dealt 
with  the  subject.  It  was  with  a  note  of  intense  satisfac- 
tion, if  not  of  exultation,  that  he  surveyed  the  progress  of 
the  last  twenty  years,  in  which  more  than  fifty-six  million 
pounds  had  been  expended  under  the  sanction  of  the 
Local  Government  Board,  while  local  acts  had  author- 
ized the  expenditure  of  a  further  sum  of  more  than  sixty- 
seven  millions.  He  then  passed  to  the  question  of  quar- 
antine, and  showed  how  much  better  we  have  fared  with- 
out it  in  regard  to  cholera.  On  vaccination  he  pointed 
out  that  it  is  the  part  of  true  wisdom  to  be  guided  by 
those  best  qualified  to  judge,  and  that  those  who  were  in 
doubt  might  be  reassured  as  to  the  harmlessness  of  the 
preventive  measure  by  the  increased  care  and  precautions 
which  are  taken  to  secure  the  safety  as  well  as  the  efficacy 
of  the  operation.  Among  other  subjects  noticed  were 
the  dissemination  of  phthisis,  the  alleged  increase  of  in- 
sanity, food  adulteration,  factory  legislation,  the  smoke 
nuisance,  river  pollution,  and  pauper  children.  A  cor- 
dial vote  of  thanks  was  given  to  the  President.  In  the 
evening  an  exhibition  of  sanitary  appliances,  etc.,  was 
opened  by  the  Lord  Mayor.     This  exhibition  was  kept 


open  and  musical  selections  given  each  afternoon  and 
evening.  Here  also  demonstrations  in  cooking  were 
given. 

On  Tuesday  the  several  "conferences"  began  their 
work.  That  of  the  Medical  Officers  of  Health  was  pre* 
sided  over  by  Mr.  C.  £.  Paget,  the  able  officer  of  Sal- 
ford,  whose  address  dealt  fully  with  the  questions  of  the 
Health  Acts  and  diplomas  in  public  health.  He  spoke 
freely  of  the  imperfections  he  had  observed  in  the  ad- 
ministration of  the  acts,  but  while  admitting  we  might 
not  be  able  to  remove  them  for  a  time,  urged  that  their 
continuance  cannot  rob  us  of  the  stimulus  to  exertion 
afforded  by  the  labors  of  those  who  have  gone  before. 
Moreover,  we  may  live  up  to  those  records  and  make  the 
imperfections  we  protest  against  more  and  more  glaringly 
manifest  until  those  beyond  our  profession  see  them  and 
insist  on  their  amendment,  so  that  if  we  fail  to  win  re- 
form we  shall  pave  the  way  for  others  to  secure  it. 

In  the  evening  Dr.  G.  B.  Longstaff,  gave  a  lecture  on 
the  overcrowding  of  houses  on  land,  illustrated  by  pho- 
tographs of  the  Hamburg  slums. 

On  Wednesday  Dr.  Klein  presided  over  the  Section  of 
Sanitary  Science  and  Preventive  Medicine.  His  address 
was  on  typhoid  fever,  as  to  which  he  held  that  sanita- 
rians might  continue  to  regard  the  disease  as  specific,  and 
derived  from  case  to  case ;  not,  as  some  had  suggested,  a» 
originating  de  novo  through  the  bacillus  coli  communis. 
This  does  not  render  the  duty  of  preventing  sewage  con- 
tamination less  urgent,  for  although  the  typhoid  germ 
without  the  bacillus  coli  communis  might  not  be  capable 
of  causing  typhoid  fever,  the  presence  of  that  bacillus  in- 
dicated excremental  contamination  in  which  possibly 
specific  typhoid  germs  might  be  present. 

The  conference  of  sanitary  officers  was  presided  over 
by  Mr.  Vacher,  F  R.C.S.,  and  that  of  domestic  hygiene 
by  the  Lady  Mayoress.  In  each  of  the  sections  inter- 
esting papers  were  read  and  discussions  carried  on. 
Needless  to  say  that  hospitality  and  entertainments  were 
to  the  fore,  and  that  the  members  had  reason  to  feel  sat- 
isfied with  a  pleasant  visit  to  Liverpool  combined  with 
a  show  of  zeal  in  the  cause  of  sanitary  progress. 

Dr.  Greenhill  is  no  more.  He  died  on  the  19th  at 
the  ripe  age  of  eighty-one.  He  was  one  of  the  greatest 
scholars  in  our  profession.  William  Alexander  Green- 
hill  graduated  at  Oxford  in  1841,  and  was  recognized 
everywhere  as  an  ornament  of  that  ancient  seat  of  learn- 
ing. Even  your  younger  readers  will  remember  his 
name  as  the  editor  of  the  best  edition  of  Sir  T.  Browne's 
"  Religio  Medici."  Others  will  call  to  mind  his  Latin 
edition  of  Sydenham,  his  translation  of  Rhazes,  or  his 
critical  edition  with  Latin  version  of  Theophilus. 
These  alone  should  suffice  to  show  that  the  profession 
has  lost  in  him  a  scholar  of  high  order,  but  those  who 
came  into  contact  with  him  felt  that  he  was  much  more 
— a  true  gentleman,  sincere  friend,  a  devout  Christian, 
a  sanitary  reformer,  destitute  of  self-interest,  and  withal 
crowned  with  the  deepest  modesty  and  generous  inten- 
tions. He  went  to  Hastings  in  1851,  and  practised 
there  until  he  retired  some  years  ago,  and  devoted  his 
remaining  time  to  his  literary  work,  on  which  he  was 
employed  up  to  the  date  of  his  decease  from  syncope. 
In  Hastings  his  noble  figure  was  familiar  enough,  and  he 
was  naturally  regarded  with  reverence  on  the  one  hand 
by  those  who  had  been  his  patients,  on  the  other  by 
those  who  were  aware  that  he  was  perhaps  the  greatest 
scholar  which  our  profession  has  produced  during  the 
century. 

London,  October  2, 1894. 

The  custom  of  opening  the  session  of  the  medical 
schools  with  an  "  Introductory  Lecture  "  addressed  chiefly 
to  freshmen — though  giving  way  further  to  dinners  and 
conversazioni — is  still  kept  up  at  some  of  our  hospitals, 
and  where  the  lecturer  is  fitted  for  the  post  has  much  to 
commend  it.  Formerly,  October  ist  was  regarded  as 
an  event  in  the  annus  medicus  which  every  institution  and 
every  student  ought  to  observe,  and  old  practitioners, 
whenever  they  could,  visited  their  alma  mater  on  that 


5o8 


MEDICAL  RECORD. 


[October  20,  1894 


day,  and  renewed  friendships  and  friendly  intercourse. 
The  invasion  of  the  dinner  is,  in  this  respect,  to  be  re- 
gretted, besides  which  the  lecture  afforded  the  oppor- 
tunity of  words  of  warning  and  advice  to  young  men 
which  the  teachers  have  seldom  the  opportunity  of  giv- 
ing. 

Yesterday  several  schools  opened  with  the  old  "  Intro- 
ductory."    At  the  Westminster  Hospital  Mr.  Hartridge 
congratulated  the  students  on  choosing  the  profession 
which  called  for  their  highest  intellectual  powers,  brought 
them  into  contact  with  suffering  and  pain,  and  called 
forth  those  deep  feelings  of  sympathy  which  united  man 
to  man.     N;>  other  profession  could  stand  on  the  same 
basis  for  usefulness.    Look  at  the  immense  amount  of 
work  which  was  so  freely  given  by  the  members  of  their 
calling ;  all  the  hospitals  depended  upon  it  for  their  ex- 
istence.    Look  also  at  the  health  of  this  great  city, 
with  its  millions  of  people,  and  they  would  have  some 
idea  what  medical  science  had  done  in  the  department 
of  preventive  medicine.     If  it  was  the  noblest  and  most 
useful,  it  was  at  the  same  time  the  most  arduous,  the 
most  difficult,  and  one  which  received  the  least  notice 
and  reward  from  the  state  and  the  public ;  the  former 
only  recognized  those  who  were  able  to  support  its 
claims.     Most  of  them  were  not  politicians ;  they  were 
not  a  powerful  body  to  be  conciliated,  able  to  turn  the 
tide  of  an  election  or  decide  the  fate  of  a  Cabinet. 
Much  of  this  was  their  own  fault,  because  it  was  a  duty 
they  owed  both  to  their  profession  and  their  country,  to 
take  an  interest  in  politics.     He  anticipated  the  time 
when  they  should  be  fairly  represented  in  both  Houses 
of  Parliament,  and  when  they  would  have  a  Minister  of 
Health  in  the  Cabinet.     To  the  students  he  would  say 
that  much  benefit  would  accrue  by  raising  the  standard 
of  the  entrance  examinations.     He  should  like  to  see 
Latin  and  Greek  replaced  by  modern  languages  and  sci- 
entific subjects,  which  would  be  equally  effectual  as  a 
mental  training,  and  far  more  useful.    Working  too 
much  was  almost  as  bad  as  working  too  little.     In  regu- 
lating their  study  hours  they  must  be  careful  to  look 
after  their  general  health.     Medicine  was  a  study  which 
should  be  approached  in  a  scientific  spirit,  and  they 
could  always  make  their  work  scientific,  in  whatever 
branch  they  were  engaged,  by  training  the  mind  in  the 
power  and  habit  of  accurately  observing  facts,  and  should 
always  have  the  courage  to  do  what  they  considered 
right,  and  allow  the  consequences  to  take  care  of  them- 
selves.    Referring  to  the  success  of  "  quacks  and  charla- 
tans" who  advertised  so  largely,  he  said  these  advertise- 
ments were  hardly  a  credit  to  journalism ;  most  were  of  a 
flagrant  character  and  without  a  vestige  of  truth,  out  of 
which  certain  papers  made  a  rich  harvest.     The  so  called 
religious  papers  were  the  worst  offenders.     But  of  all 
irregular  practitioners  the  bone-setter  was  the  one  whom 
the  public  held  in  the  highest  esteem.     He  knew  noth- 
ing of  anatomy,  had  never  been  in  a  dissecting  room, 
but  was  supposed  to  be  born  with  special  gifts  as  regards 
bones  and  joints.    To  the  bone-setter  every  injury  was  a 
bone  out  of  place.     He  wound  up  by  saying  that  adver 
tising  quacks,  protected  by  diplomas,  were  far  worse  than 
the  unqualified  man.  and  a  disgrace  to  the  bodies  whose 
diploma  they  held,  and  their  existence  a  disgrace  to  the 
legislation  of  a  civilized  country. 

At  St.  George's  Hospital  Dr.  Isambard  Owen  took  for 
his  subject  the  importance  of  mental  training  in  medical 
study.  Accurate  observation,  he  said,  was  the  founda- 
tion of  all  medical  work ;  to  it  there  was  no  royal  road 
— only  the  old  fashioned  way  of  constant,  close,  per- 
sonal observation  of  case  after  case,  under  skilled  super- 
vision and  systematic  reduction  to  written  or  graphic 
records  of  what  was  observed*  He  urged  that  if  school 
children  were  systematically  trained  into  more  exact 
habits  of  arithmetical  perception  and  expression  more 
would  be  done  to  render  the  rising  generation  scientific 
than  the  suppression  of  Latin  in  favor  of  biology  could 
possibly  effect.  Adverting  briefly  to  the  position  of  the 
London  University  and  the  Gresham  Commissioners' 


scheme,  he  said  that  while  a  tribute  of  sincere  gratitude 
was  due  to  them  for  their  painstaking  labors,  the  merits 
of  the  scheme  itself  were  matter  of  controversy,  and  that 
he  had  never  concealed  his  own  sense  of  the  danger  to 
soundness  of  medical  education  with  which  certain  parts 
of  it  were  charged. 

At  Middlesex  Hospital  Dr.  Robert  Boxall  touched 
upon  the  steady  increase  in  the  number  of  doctors  in 
recent  years,  and,  by  a  series  of  statistical  tables  and 
diagrams,  showed  that  the  ranks  of  the  profession  in 
England  and  Wales  had  been  gradually  swelling  out  of 
proportion  to  increase  in  population.  Drawing  deduc- 
tions from  statistics,  he  said  it  was  manifest  that  the 
outcry  which  had  been  raised  against  the  out  patient  de- 
partments of  the  large  general,  hospitals  was  unwarranted 
— at  least,  in  comparison  with  what  might  be  said  of 
more  recently  established  institutions,  most  of  which 
had  no  teaching  function  to  fulfil.  It  was  an  undoubted 
fact  that  in  all  the  hospitals  the  number  of  out  patients 
had  increased,  but  so  had  also  the  number  of  in-patients, 
and  an  outcry  against  the  one  was  no  more  justified  than 
an  outcry  against  the  other.  But,  inasmuch  as  medicine 
was  in  itself  a  progressive  science,  it  would  be  a  wonder 
indeed  if  the  medical  charities  of  Great  Britain,  which 
had  long  been  the  admiration  and  wonder  of  the  whole 
civilized  world,  failed,  as  years  rolled  on,  to  enlarge 
their  walls  and  to  increase  the  scope  of  their  utility. 

At  St.  Thomas's  Hospital  an  address  was  delivered  by 
the  Rev.  Dr.  Merry,  Rector  of  Lincoln  College,  Oxford, 
who  spoke  upon  the  half-serious,  half-jesting  strictures 
passed  by  Plato  on  the  practice  of  medicine  in  his  own 
time,  a  subject  which  the  great  philosopher  humorously 
introduced  in  the  form  of  a  criticism  on  medicine  as 
practised  in  the  days  of  Homer.  Plato  professed  to  feel 
the  greatest  satisfaction  in  the  rough  and  ready  treat- 
ment of  the  heroes  who  fought  under  the  walls  of  Troy. 
The  degenerate  system  of  coddling  Plato  strongly  con- 
demned, as  tending  to  the  survival  of  the  unfittest,  and 
the  production  of  sickly  children,  whose  presence  was 
not  to  be  endured  in  his  commonwealth.  The  very  ex- 
istence of  hospitals,  said  the  philosopher,  was  a  proof  of 
a  degenerate  age,  when  men  had  impaired  their  health 
by  intemperance  and  indolence.  No  one  had  a  right  to 
be  an  invalid,  and  the  "  coddling  "  process  would  never 
have  been  introduced  if  the  profession  had  not  been  de- 
moralized by  wealthy  patients,  who  bribed  the  doctors 
to  prolong  their  miserable  and  useless  lives.  Passing 
from  this  humorous  criticism,  the  lecturer  quoted  a  more 
serious  sentence  from  his  author,  recommending  that  the 
physician  should  not  be  in  robust  health,  and  should 
have  known  what  illness  is  in  his  own  person.  Rightly 
interpreted,  it  contained  the  golden  maxim  that  the  phy- 
sician must  not  only  bring  his  skill,  but  his  sympathy,  to 
bear  upon  his  patient.  The  world  at  large  was  taking  a 
growing  interest  in  medicine,  and  men  were  looking  in 
high  hopes  to  the  progress  of  medical  science. 

At  University  College  Professor  H.  R.  Spencer  said 
that  the  treatment  of  wounds  on  antiseptic  principles  had 
revolutionized  surgery  and  obstetrics,  and  he  believed  his- 
tory would  record  it  as  the  grandest  achievement  of  the 
century.  In  medicine,  too,  great  advance  had  been  made 
in  diagnosis  and  treatment,  as  a  result  of  the  employment 
of  the  experimental  method  of  research,  which  only  the 
ignorant  condemned.  As  to  legislation,  which  was  ur- 
gently required  for  the  benefit  of  the  public  as  well  as  the 
profession,  he  said  that  autopsies  in  cases  of  unnatural 
or  suspicious  deaths  should  be  only  performed  by  expert 
medical  jurists  and  pathologists.  Practice  by  unqualified 
persons  and  by  medical  men  whose  names  had  been 
expelled  from  the  Register  should  be  absolutely  forbid- 
den. And  the  law  should  be  severe  on  those  unprincipled 
persons  who  risked  the  lives  of  the  ignorant  poor  by  cir- 
culating among  them  the  cruel  slander  that  patients  were 
experimented  upon  in  hospitals.  Adverting  to  the 
abuse  of  hospitals  by  well-to-do  patients,  he  thought 
hospitals  should  be  able  to  recover  fees  from  persons  ob- 
taining gratuitous  treatment  by  fraudulently  representing 


October  20,  1894J 


MEDICAL    RECORD, 


509 


themselves  to  be  poor.  In  conclusion,  he  said  the  pro- 
fession they  had  chosen  was  an  arduous  one,  and  yet  it 
was  the  most  fascinating  of  all.  No  social  class  could 
look  down  upon  those  to  whom  such  sacred  interests  as 
reputation  and  life  were  intrusted.  Greater  trust  hath 
no  man  than  this,  that  he  trusted  his  life  to  his  friend. 

At  St.  Mary's  Hospital  Dr.  Scanes  Spicer  took  for  his 
subject,  "  Medicine  as  a  Profession."  Its  social  ad- 
vancement, he  said,  of  late  years  had  been  remarkable, 
and  had  been  parallel  with  the  wide  general  culture  and 
interests  of  the  average  modern  doctor,  who  was  some- 
thing more  than  a  mere  prescriber  of  physic.  Doctors 
were  more  and  more  finding  their  way  into  Parliament, 
the  Privy  Council,  and  the  national  government.  It 
was  a  grievance  with  the  profession  that  it  was  not  di- 
rectly represented  in  the  House  of  Lords,  where  the 
counsel  of  medical  men  would  not  only  add  to  the  effi- 
ciency of  public  work,  but  signalize  the  national  recog- 
nition of  the  value  of  medicine  to  the  community.  The 
increase  and  development  of  specialism  was  one  of  the 
most  striking  facts  in  the  medical  history  of  the  latter 
part  of  the  nineteenth  century.  Specialism  was  destined 
to  play  an  even  more  important  part  in  the  development 
of  medical  art.  He  defended  it  from  the  charges  of 
shallowness,  self  sufficiency,  and  unscrupulousness  that 
had  been  brought  against  it.  Attention  was  drawn  to 
the  remarkable  development  attained  in  less  than  forty 
years  in  the  specialty  of  diseases  of  the  throat  and  nose, 
due  chiefly  to  the  truly  marvellous  results  of  local  treat- 
ment. On  the  Continent  there  was  hardly  a  university 
without  one  or  more  professors  of  this  specialty,  and 
well-appointed  clinics ;  a  marked  contrast  to  the  indif- 
ference and  neglect  which  this  branch  met  with  in  the 
United  Kingdom.  Specialism  now  enjoyed,  more  than 
ever  before,  the  respect  of  thinking  members  of  the  pro- 
fession and  the  public ;  but  there  was  need  for  still  fur- 
ther rapprochement  between  specialists  and  the  general 
body  of  the  profession,  in  the  interest  of  both.  Each 
was  necessary  for  the  other,  for  no  one  could  be  an  all- 
round  specialist. 

At  the  London  School  of  Medicine  for  Women,  Miss 
Maida  Sturze,  M.B.,  London,  alluded  to  the  need  of 
cultivating  from  the  first  the  scientific  habit  of  mind, 
seeing  that  its  possession  was  invaluable  to  the  medical 
practitioner.  The  importance  of  general  culture  and  ex- 
perience as  an  aid  to  the  right  understanding  of  others, 
and  as  a  help  in  the  individualization  of  treatment  was 
pointed  out.  The  wisdom  of  devoting  time  to  learning 
something  of  the  natures  and  abundant  vitality  of  healthy 
children  was  dwelt  upon,  as  the  only  means  of  fully  un- 
derstanding their  needs  when  ill,  and  probably  in  the 
future  the  profession  would  regard  with  surprise  the  fact 
that  in  the  nineteenth  century  sick  children  were  so 
often  admitted  into  hospitals  instead  of  carrying  them 
into  the  fresh  air  and  sunshine  outside  cities. 


THE  ESQUIMAUX  AND  THEIR  TEETH. 

To  the  Editor  of  the  Mbdical  Record. 

Sir  :  It  has  long  been  a  disputed  question  as  to  what 
effect  diet,  climate,  and  mode  of  life  have  upon  the 
structural  formation  of  the  teeth  of  mankind.  Desiring 
to  make  my  observations  among  a  people  who  fitted  the 
conditions  of  such  an  investigation  as  nearly  as  possible, 
I  chose  the  Eskimo  as  my  most  available  subjects,  and 
with  that  end  in  view  I  eagerly  seized  the  opportunity  to 
become  one  of  a  number  who  visited  the  icy  shores  of 
Greenland  last  summer.  Of  the  interesting  people  who 
inhabit  this  arctic  region,  the  pure  Eskimo  are  fast  dis- 
appearing through  marriage  with  the  Danes ;  the  pres- 
ent generation  being  known  as  Greenlanders,  or  Danish 
Eskimo.  The  men  are  taller  and  lighter  in  color  than 
the  native  Eskimo,  shading  from  bronze  to  dark  tan. 
Their  hair  is  black,  generally  straight,  long,  and  un- 
kempt, and,  falling  over  their  faces,  presents  a  savage  ap- 
pearance. Their  eyes  are  small,  round,  and  very  sharp, 
with  large  deep  wrinkles  extending  from  the  outer  edge 


of  the  eye  to  their  high  cheek-bones.  These  wrinkles 
are  caused  by  the  habit  of  constantly  squinting  to  shade 
their  eyes  from  the  intetse  glare  of  the  ice  during  the 
long  arctic  day.  The  women  are  short,  rather  stout, 
and  comely  looking.  Their  skin  is  lighter  in  color  than 
the  men's.  Their  eyes  are  clear,  bright,  and  similar  in 
shape  to  the  Chinese.  Their  hair  is  twisted  in  a  haid 
knot  on  the  top  of  the  head,  held  in  a  place  by  a  ribbon 
or  a  rag,  the  color  of  which  denotes  their  station  in  life. 
Blue  for  a  married  woman,  red  for  a  single  woman, 
black  for  a  widow  with  the  addition  of  a  narrow  strip  of 
white  if  desiring  to  marry  again.  The  unfortunate  or 
fallen  women  of  the  tribe  are  designated  by  a  green  rib- 
bon bound  around  the  hair.  Their  food,  which  consists 
wholly  of  fish  and  flesh,  of  the  various  animals  which  in- 
habit this  region,  together  with  the  fat  and  oil  obtained 
from  them,  is  generally  swallowed  or  bolted  without 
mastication.  Their  teeth,  which  articulate  squarely  upon 
the  cutting  edges  of  the  incisors,  are  worn  off  in  many 
cases  nearly  to  the  gums,  giving  the  appearance  of 
double  teeth  all  around.  Caries  is  not  common,  al- 
though in  several  cases  the  first  molar  teeth  were  de- 
cayed, while  all  other  teeth  in  the  same  mouth  were 
sound.  In  color  their  teeth  have  a  yellow  cast;  the 
structure  is  more  like  ivory.  The  palatal  arch  is  broad 
and  shallow,  the  mouth  large,  with  firm  lips,  and  jaw 
square  shaped. 

From  twenty-eight  impressions  taken  in  modelling  com- 
position, I  made  as  many  plaster- of  Paris  casts  of  the  up- 
per and  lower  jaws  and  teeth,  which  were  unfortunately 
lost,  together  with  a  valuable  collection  of  Eskimo 
curios,  weapons  of  the  chase,  skin,  and  fur  garments, 
kyaks,  etc. ,  when  our  vessel  was  wrecked  off  the  Green- 
land coast,  near  Sukkertoppen.  Despite  the  unfortu- 
nate termination  of  our  expedition,  I  trust  it  will  be  my 
fortune  to  again  visit  the  Arctic  region,  and  make  a 
similar  collection  of  casts  and  notes,  to  add  to  the  large 
number  now  on  exhibition  at  the  Medical  Museum  in 
Washington. 

Roswell  O.  Stebbins,  D.D.S. 

55  West  Foety-fipth  Steekt,  New  York. 


APEX  CATARRH  OR  TUBERCULOSIS? 

To  the  Editor  or  the  Medical  IUcokd. 

Sir  :  In  your  issue  of  September  2  2d  I  notice  a  short 
paper  on  "  Diseases  of  the  Ear  and  Upper  Air  passages 
in  Apex  Catarrh,"  by  Dr.  Howard  S.  Straight,  of  Cleve- 
land, O.  If  I  may  be  permitted  the  use  of  a  small  space  in 
your  journal,  I  want  to  object  to  the  use  of  this  expres- 
sion "  Apex  Catarrh."  If  Dr.  Straight  will  make  care- 
ful, and  if  necessary,  repeated  examinations  of  the  sputa 
in  these  cases  of  so- called  apex  catarrh,  I  think  he  will 
find  that  they  are  nearly  all  cases  of  more  or  less  early 
tuberculosis.  Acute  simple  catarrhal  affections  of  the 
chest — "cold,"  "  bronchitis,"  etc. — do  not  limit  them- 
selves to  the  apices,  and  I  think  that  the  existence  of 
subacute  and  chronic  affections  of  the  apices  of  a  simple 
catarrhal  character  is  more  than  doubtful.  In  one  of 
the  cases  cited  by  Dr.  Straight  as  apex  catarrh  it  was 
certainly  so,  for  he  states  that  a  few  days  later  the  pa- 
tient, a  boy  aged  twenty,  died  "  from  a  profuse  hemor- 
rhage from  the  lungs." 

Post  mortem  records  prove  conclusively  that  tubercu- 
losis is  a  much  more  common  and  at  the  same  time  a 
less  to  be  dreaded  disease  than  is  generally  supposed, 
since  a  large  portion  of  the  dead  from  all  causes  show 
healed  tuberculous  lesions.  If  this  view  is  correct,  and 
limited  apex  catarrhs  are  tuberculous  in  character,  it  is 
certainly  a  great  gain  to  call  them  by  their  proper 
names  and  to  avoid  the  use  of  terms  which  are  mislead- 
ing and  calculated  to  give  rise  to  a  sense  of  false  security- 
very  dangerous  to  the  interests  of  the  patient.  This 
view  accords  very  well,  too,  with  what  the  doctor  has  to 
say  upon  diseases  of  the  ear  and  upper  air  passages  in 
such  cases,  since  it  is  a  matter  of  general  experience  that 
the  existence  of  even  a  slight  tuberculous  affection  in  the 


5io 


MEDICAL   RECORD. 


[October  20,  1894 


lungs  renders  disorders  of  the  ear,  nose,  and  throat  much 
more  refractory  to  treatment.  Physicians  in  phthisical 
health  resorts  have  been  trying  for  years  to  arouse  in  the 
profession  at  large  an  active  appreciation  of  the  impor- 
tance of  recognizing  tuberculosis  in  just  these  early  be- 
ginnings. In  no  other  way,  I  believe,  is  it  possible  to 
save  them.  Palliation  can  be  had  at  almost  any  time, 
but  cures  can  not. 

Yours  truly, 

H.  B.  Moore,  M.D. 

Colorado  S  things,  September  ad,  1894. 


Hetxx  Instruments* 


THE 


APPLICATION 
METHOD  TO 


OF  THE   GRAPHIC 
HEARING. 


By  W.  HARVEY  SMITH,  AM.,  M.D.,  CM., 


WINNIPEG,  MANITOBA, 


The  graphic  method,  when  employed  to  demonstrate 
physiological  or  pathological  variations  from  the  normal 
or  to  express  relations  and  ratios  between  different  bodily 
functions  or  conditions,  is  recognized  by  the  medical  pro- 


fession as  an  invaluable  adjunct  to  diagnosis.  The  chart 
here  shown  has  been  devised  for  the  purpose  of  applying 
this  method  to  hearing,  and  thus  to  provide  the  otologist 
with  a  means  of  representing  the  results  of  tuning-fork 
and  other  tests  in  a  form  more  intelligible  than  that  com- 
monly used. 

In  this  chart  the  hearing  power  is  expressed  in  percen- 
tages which  are  based  upon  the  results  obtained  from  the 
use  of  Hartmann's  tuning  forks,  the  acoumeter,  the  voice, 
and  the  watch.  The  percentage  line  on  each  side  of 
the  central  columns  is  numbered  from  o  to  200,  the 
100  line  being  the  line  of  normal  hearing  for  all  tests. 
The  percentages  employed  are  based  upon  the  averages  of 
a  large  number  of  tests  made  upon  normal  ears,  and  mod- 
ified by  comparing  them  with  Hartmann's  results. 

These  averages  have  been  printed  in  the  middle  col- 
umn opposite  the  different  tests.  Spaces  for  marking 
the  percentages  of  aerial  and  bone  conduction  ^^^ 
are  provided,  one  above  the  other,  opposite  the  [4 
different  C's.  The  aerial  conduction  is  repre-  v_y| 
rented  by  joining  together  the  consecutive 
aerial  percentages  with  black  lines,  while  red 
lines  are  similarly  used  for  the  bone  conduc 
tion.  At  the  bottom  of  the  chart  is  shown  the  result 
of  the  Weber  test  and  the  percentages  of  hearing  for  the 
acoumeter,  the  voice,  and  the  watch ;  and  in  the  spaces 
to  the  right  and  left  of  the  middle  column  the  height  of 
time  or  distance  at  which  (in  figures)  the  standard  sounds 
are  heard.  A  rapid  calculation  of  the  percentages  can  be 
made  from  the  percentage  table  which  is  printed  on  the 
back  of  each  chart. 

It  is  obvious  to  those  who  possess  a  practical  knowledge 
of  otology,  that,  owing  to  the  influence  of  constitutional 
and  other  factors,  the  results  obtained  from  any  or  all 
hearing-tests  can  give  but  an  approximate  idea  of  the 
condition  of  the  auditory  functions.  This  being  true, 
how  essential  it  is  that  that  system  should  be  adopted  for 
the  expression  of  hearing-power  which  will  afford  infor- 
mation in  the  most  intelligible  and  rational  form  ! 

By  applying  the  graphic  method  to  hearing  in  the 


manner  described,  the  slightest  deviation  from  the  normal 
can  be  perceived  at  a  glance,  and  the  comparative  differ- 
ences between  the  aerial  and  bone  conduction,  and  the  re- 
sults of  the  acoumeter,  the  voice,  and  the  watch  tests  can 
be  more  readily  appreciated  than  by  using  the  numerical 
system  at  present  in  vogue. 

These  charts  can  be  obtained  from  Mr.  E.  B.  Meyro- 
witz,  of  New  York. 

A  NEW  SNARE, 
By  WILLIAM   A.  MARTIN,  M.D., 

PROFESSOR  OP  LARYNGOLOGY,  S\H  FRANCISCO  FOLYCLXNZC. 

The  snare  described  in  the  following  lines  is  a  combina- 
tion of  the  meritorious  principles  found  in  other  snares, 
rendered  possible  by  the  shape  of  the  handle  designed 
by  the  writer.  Most  of  the  snares  in  present  use  have 
one  or  more  objectionable  features,  the  principal  one  of 
which  to  the  writer  is  the  time  lost  in  rewiring.  This  is 
particularly  the  case  in  polyclinic  practice,  where  one 
either  has  to  have  a  number  of  snares  prepared  for  use,  or 
must  have  an  assistant  with  an  extra  snare  at  hand. 

The  only  original  principle  in  the  snare  is  in  the  shape 
of  the  handle.  It  was  designed  in  this  manner  in  order 
that  the  stiff  rod  into  which  the  wire  is  threaded  could 
be  used,  and  at  the  same  time  prevent  the  obstruction  of 
the  view  by  the  hand  of  the  operator. 

The  following  are  a  few  of  the  numerous  advantages 
of  the  snare.  One  can  have  any  desired  number  of 
cannulas  with  the  contained  rod  wired  ready  for  use.  The 
time  occupied  in  taking  out  one  cannula  and  replacing  it 
with  another  is  not  more  than  half  a  minute.  The  same 
loop  can  be  shoved  out  and  used  again  and  again,  as 
often  as  six  or  seven  times. 

The  economy  in  wire  is  not  a  minor  consideration, 
especially  in  polyclinic  practice.  The  loop  can  be  turned 
and  held  in  any  desired  plane  by  simply  revolving  the 
rod.  Anyone  who  uses  the  snare  for  removing  tonsils 
will  appreciate  this  principle.  A  loop  of  larger  size  than 
permitted  in  any  other  snare  may  be  used  when  the  finger- 
rings  come  to  the  end  of  the  slide;  the  winged  screw 
may  be  loosened  and  the  rings  slid  forward  on  the  rod 
and  reclamped,  a  procedure  which  in  the  ordinary  snare 
is  awkward  and  occupies  considerable  time.  The  loop 
may  be  placed  around  the  part  to  be  removed  and  drawn 
taut  before  attaching  to  the  handle,  a  desirable  feature 
in  post-nasal  growths  where  one  has  to  use  both  hands. 
The  handle  is  threaded  as  in  the  Bosworth  snare,  so  that 
the  loop  may  be  slowly  tightened  when  desirable.  The 
same  handle  could  be  used  with  the  Schrotter  laryngeal 
instruments,  it  being  similar  to  the  Streck  handle  ex- 
cepting the  double  bend.  The  same  handle  could  also 
be  used  for  ear  instruments,  both  for  cutting  instruments 


as  well  as  for  a  snare.  Since  designing  the  above  snare 
I  see  that  a  similar  bend  for  ear  instruments  is  advocated 
by  Barclay,1  of  St.  Louis.  In  his  instruments  the  angles 
are  not  900,  but  by  prolonging  the  shaft  of  the  instru- 
ment and  the  handle  they  meet  at  an  acute  angle. 

The  snare  is  made  according  to  my  directions  by  E. 
B.  Meyrowitz,  in  the  most  satisfactory  manner,  and  he 
has  also  kindly  furnished  the  accompanying  cut. 


An  Italian  Hospital  has  been  established  in  Tunis  for 
the  benefit  of  residents  of  that  nationality. 

1  Archives  of  Otology,  vol.  xxii.,  No.  a. 


October  20,  1894] 


MEDICAL    RECORD. 


5" 


AN  IMPROVED  PHOROSCOPE. 

By   WILLIAM   F.    AIKEN,   M.D., 

SAVANNAH,   CA. 

In  using  the  ordinary  rod-test  for  heterophoria,  the 
writer  has  always  been  inconvenienced  by  the  narrowness 
of  the  opening.  About  a  year  ago  it  occurred  to  him  to 
substitute  a  series  of  parallel  rods  for  the  single  rod,  and 
a  crude  self  manufactured  instrument  has  since  then  done 
excellent  work.  Recently,  Mr.  E  B.  Meyrowitz,  of  New 
York,  has  constructed  from  drawings  an  extremely  pretty 
instrument,  as  here  illustrated.  In  practice,  the  elongated 
images  produced  by  the  sev- 
eral glass  cylinders  fuse  into 
one  long,  continuous,  and 
very  brilliant  bright  band. 
This  band  is  so  long,  indeed, 
that  when  so  placed  as  to  be 
vertical,  it  extends  from  floor 
to  ceiling. 

Apart  from  the  increased 
length  and  brilliancy  of  the 
image  produced,  the  instru- 
ment possesses  the  great  ad- 
vantage of  a  large  square  opening  before  the  pupil.  If, 
owing  to  faulty  adjustment  of  the  trial  frame  in  which 
the  instrument  is  placed,  the  pupil  fails  to  correspond 
with  the  exact  centre  of  the  opening,  it  makes  no  differ- 
ence, any  point  within  the  square  affording  a  perfect 
view  of  the  image.  This  large  working  space  saves  the 
annoyance  of  carefully  adjusting  a  heavy  trial  frame,  the 
light  single  frame  being  more  convenient,  and  more  com- 
fortable for  the  patient.  Moreover,  the  efforts  patients 
make  to  see  through  the  stenopeic  slits  and  openings  of 
other  tests  add  a  dynamic  factor  to  what  should  be  a 
purely  static  finding  as  regards  the  muscular  equilibrium ; 
with  the  large  opening  no  moving  about  of  the  head  or 
eyeballs  is  excited,  the  eyes  resting  quietly  in  their  natu- 
ral position. 

It  should  be  noted  that  the  instrument  is  a  phoroscope, 
not  a  phorometer.  The  amount  of  deviation  shown  has 
to  be  measured  with  prisms.  Using  a  rotary  variable 
prism  in  the  other  side  of  the  trial  frame,  however,  makes 
the  most  efficient  form  of  phorometer,  as  both  eyes  look 
through  large  openings,  and  either  instrument  may  be 
used  separately.  Mr.  E.  B.  Meyrowitz  has  suggested, 
nevertheless,  that  the  two  instruments  can  be  combined, 
making  a  single  phorometer,  in  case  of  demand  for  such 
an  arrangement.  I  wish  to  state  my  indebtedness  to  Mr. 
Meyrowitz  for  his  courtesy  and  readiness  in  conceiving 
and  executing  my  idea;  likewise  for  the  accompanying 
cut. 


i^sflical  Sterna. 

Contagions  Diseases  —  Weekly  Statement. — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to  the 
Sanitary  Bureau,  Health  Department,  for  the  week  end- 
ing October  13,  1894. 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis 

Measles 

Diphtheria 

Small-pox 


Cases. 


Deaths. 


106 

99 

35 

10 

53 

4 

X 

1 

18 

3 

119 

30 

1 

0 

There  are  no  Public  Baths  in  Rome,  according  to  a 
statement  recently  made  by  Professor  Celli. 

The  Oldest  Physician  in  Great  Britain  is  Dr.  Salmon, 
of  Penllyn  Court,  South  Wales.  He  was  born  in  Wick- 
ham  Market,  Suffolk,  in  1790.  He  is  also  the  oldest 
Freemason  in  the  country,  having  joined  the  order  over 
eighty  years  ago. 


The  Pain  of  Inoperable  Cancer  has  been  found  by 
Aikmann  to  yield  in  many  cases  to  salicylate  of  sodium 
in  doses  of  ten  grains  three  times  a  day. 

The  Cholera  Bacillus  becomes  attenuated,  it  is  said, 
by  exposure  to  direct  sunlight,  and  will  then  serve  as  a 
preventive  vaccine. 

Illegal  Sale  of  Patent  Medicines.— Grocers  in  Eng- 
land who  sell  patent  medicines  are  being  prosecuted,  on 
the  complaint  of  the  apothecaries,  under  the  law  prohib- 
iting the  sale  of  poisons  without  a  special  license. 

Mrs.  Sarah  Thomas,  of  Buryport,  South  Wales,  re- 
cently celebrated  the  completion  of  her  one  hundred  and 
sixth  year.  The  Princess  of  Wales  sent  her  a  letter  of 
congratulation  and  a  check  for  one  hundred  and  six 
shillings,  a  shilling  for  each  year  of  her  life. 

Delinquents  in  Olympia. — The  publisher  of  our 
esteemed  contemporary  TaXrjvos  has  been  compelled  to 
print  a  black  list  of  subscribers  to  the  journal  who  are  in 
arrears  for  three  years.  Of  these  there  are  eight,  two  of 
whom  live  in  Olympia. 

The  Face  as  a  Guide  in  Diagnosis. — The  physiog- 
nomy of  the  sick  presents  innumerable  shades  ot  expres- 
sion. These  are  certain  facial  lines  and  wrinkles  which 
are  of  positive  value  in  diagnosis,  but  in  the  use  of  these 
it  is  important  that  we  discriminate  between  those  natu- 
ral to  the  face,  and  those  which  are  developed  by  disease. 
In  childhood,  however,  there  are  few  or  none  of  the 
acquired  lines  found  in  adult  life.  We  may  therefore  be 
quite  sure  of  our  indications  in  this  class  of  cases.  1  he 
more  important  of  these  are  as  follows :  The  transverse 
rugae,  the  oculo- frontal  rugae,  the  oculo-  zygomatic  line, 
the  linea  nasalis,  the  linea  labialis,  and  the  linea  collat- 
eralis  nasi.  The  first  two  are  situated  upon  the  fore- 
head, the  first  of  which,  the  transverse  rugae,  are  formed 
by  the  action  of  the  occipito-frontalis  muscles,  and  are 
believed  to  be  indicative  of  great  pain  from  causes  out- 
side the  cavities  of  the  body.  The  next,  the  oculo- 
frontal rugae,  are  vertical  lines  extending  from  the  fore- 
head to  root  of  nose ;  they  are  formed  by  the  corrugator 
supercilii  muscles;  they  express  distress,  anxiety,  and 
extreme  pain  from  some  internal  cause,  cranial,  thoracic, 
or  abdominal.  They  oftentimes  indicate  an  imperfect 
crisis,  and  in  acute  diseases  often  a  fatal  termination.  I 
have  observed  this  many  times,  and  whenever  I  see  these 
peculiar  lines  I  am  very  solicitous  for  my  case.  In  ex- 
cessively severe  headaches  these  two  described  rugae  may 
exist  simultaneously,  and  when  during  the  course  of  an 
acute  disease  the  two  meet  abruptly,  they  denote  a  de- 
veloping serious  lesion  of  the  brain  or  some  of  its  cover- 
ings, and  when  I  meet  a  case  where  this  condition  exists, 
I  feel  justified  in  advising  of  the  grave  nature  of  the  dis- 
ease and  a  consequent  grave  prognosis,  a  lingering  case, 
if  not  fatal.  The  linea  oculo-zygomatica  extends  from 
the  inner  angle  of  the  eye  down  and  outward,  crossing 
the  face  below  the  malar  bone.  This  is  believed  to  in- 
dicate a  cerebral  or  nervous  affection  in  children,  in 
adult  life  masturbation  or  venereal  excesses,  and  is  fre- 
quently a  very  valuable  aid  in  this  class  of  cases. 

The  linea  nasalis  extends  in  a  semi  curved  direction 
from  the  upper  border  of  the  ala  nasi  downward  to  the 
outer  margin  of  the  orbicularis  oris  muscle  ;  this  line  we 
find  very  marked  in  advanced  cases  of  marasmus,  inani- 
tion or  such  diseases  as  these  simulate;  in  adult  life, 
phthisis  and  atrophy.  Where  only  the  upper  half,  the 
linea  nasalis  proper,  is  present,  it  is  quite  a  reliable  indi- 
cation of  intestinal  disease,  typhlitis  or  entero  colitis ;  it 
may  be  present  in  severe  colic,  although  not  marked,  as 
the  attack  is  remittent  and  of  short  duration.  When  the 
lower  half,  or  linea  buccalis,  is  alone  present,  it  indicates 
some  disease  affecting  the  stomach.  It  is  quite  promi- 
nent in  chronic  dyspeptics,  and  when  the  two,  as  last  de- 
scribed, together  with  the  linea  oculo  zyg^matica.  appear 
conjointly,  they  may  be  regarded  as  positive  evidence  of 
worms,  and  if  the  circumscribed  red  cheeks,  the  pallor 
of  face  around  the  mouth  inside  the  linea  nasalis,  to- 


5" 


MEDICAL   RECORD. 


[October  20,  1894 


gether  with  the  bright,  fixed,  and  wild  expression  of  eye 
are  present,  no  further  evidence  of  the  presence  of  these 
pests  is  necessary.  The  linea  labialis  extends  from  the 
angle  of  the  mouth  downward  without  marked  termina- 
tion till  lost  in  the  lower  portion  of  the  face.  It  is  usual 
in  those  diseases  which  affect  respiration,  and  is  a  more 
important  diagnostic  sign  in  childhood  than  in  adult 
life ;  it  may  be  observed  in  croup,  both  true  and  fake, 
in  acute  laryngitis  and  capillary  bronchitis;  in  adults 
most  prominently  in  asthmatic  subjects  The  linea  col- 
laterals nasi  extends  in  a  semi-curved  direction  from  the 
ala  to  the  chin.  It  is  situated  further  out,  outside  the 
lines  just  described,  and  is  a  reliable  guide  to  diseases  of 
the  thoracic  and  abdominal  viscera ;  in  fact  it  may  be 
considered  as  positive  evidence  of  a  lesion  in  one  of  these 
regions,  and  when  with  the  above  is  coupled  the  painful 
expression  about  the  mouth,  together  with  the  peculiar 
fold  on  either  side  the  mouth,  we  may  be  almost  posi- 
tively certain  that  the  lesion  is  abdominal.  It  is  very 
marked  in  typhus  abdominalis,  also  phthisis  abdominalis. 
The  above  described  are  the  more  important  and  most 
frequently  met  by  physicians,  and  to  those  who  have  not 
studied  the  physiognomy  in  this  manner  I  would  say, 
carefully  note  these  lines,  wrinkles,  and  expressions; 
they  will  aid  you  in  the  diagnosis  of  many  an  obscure 
case,  assist  you  in  a  prognosis  that  oftentimes  will  seem 
little  less  than  inspirational  to  your  patients  or  their 
friends. — Dr.  S.  M.  Spalding. 

Hitrate  of  Cobalt  is  said,  by  Dr.  Antal,  a  Hungarian 
chemist,  to  be  an  effective  antidote  to  cyanide  of  potas- 
sium. He  has  tried  it  in  upward  of  forty  cases  of  poi- 
soning by  this  substance,  in  every  instance  with  success. 

In  One  Thousand  Towns  in  Minnesota  the  people 
live  and  die  without  the  help  of  a  homoeopathic  physi- 
cian, so  says  a  contemporary  in  that  State. 

Phthisis  is  one  of  the  most  common  diseases  of  sailors, 
more  seamen  dying  from  that  than  from  either  accident 
or  heart  disease. 

Dr.  Y.  May  Kin,  now  practising  in  Kobe,  Japan,  was 
the  first  Chinese  lady  to  receive  a  medical  decree  in 
America,  and  the  first  scientifically  educated  female  prac- 
titioner in  Japan. 

Combined  Carbolic  Aeid  and  Chloroform  in  Typhoid 
Fever.— The  experiments  of  Werner,  at  St.  Petersburg, 
in  1890,  showed  that  a  one-half  per  cent,  solution  of 
chloroform  will  kill  the  bacillus  of  enteric  fever.  In 
1892  Mclntyre,  of  Glasgow,  proved  that  carbolic  acid 
controls  the  development  of  this  bacillus,  and  also  exer- 
cises an  antiseptic  action  on  the  intestinal  contents. 
Acting  on  these  hints,  Dr.  R.  H.  Quill,  of  the  British 
Army  Medical  Staff,  stationed  at  Hirkee,  India,  has 
treated  with  a  combination  of  carbolic  acid  and  chloro- 
form all  his  cases  of  typhoid  fever  for  over  a  year,  and 
reports  in  the  British  Medical  Journal  of  April  28th 
that  perfect  recovery  has  followed  in  each  case,  without 
the  advent  of  any  severe  symptoms.  In  India  the  mor- 
tality of  enteric  fever  is  much  greater  than  is  usually  ex- 
perienced in  temperate  climates,  which  fact  increases  die 
value  of  the  test.  He  used  a  mixture  of  thirty  six  minims 
of  pure  carbolic  acid,  two  fluidrachms  of  spirit  of 
chloroform,  three  fluidrachms  of  compound  tincture  of 
cardamon,  two  fluidounces  of  sirup  of  hemidesmus,  and 
added  chloroform  water  to  make  twelve  fluidounces. 
Every  two  hours  the  patient  was  given  two  tablespoon- 
fuls  of  this  carbolic  mixture  in  a  like  quantity  of  iced 
water.  On  the  first  visit  three  grains  of  calomel  were 
given  to  the  typhoid  patient.  On  the  next  day,  five 
doses  of  the  mixture  were  given,  and  ten  doses  on  the 
third  and  following  days  until  there  was  a  fall  of  temper- 
ature, and  the  general  condition  of  the  patient  was  dis- 
tinctly improved,  the  doses  then  being  gradually  re- 
duced to  seven,  five,  and  three  in  the  twenty  -  four 
hours.  To  prevent  a  relapse,  the  mixture  should  be  con- 
tinued for  at  least  a  week  after  the  temperature  is  nor- 
mal, giving  from  three  to  five  doses  each  day.    Twelve 


of  the  patients  were  in  the  station  hospital,  and  one  took 
two  fluidounces,  in  all,  of  pure  carbolic  acid  and  the 
same  of  chloroform,  while  another  took  one  and  one- 
half  fluidounce  of  each,  the  urine  occasionally  becom- 
ing high  colored,  but  never  black. 

Carbolic  acid  combined  with  chloroform  reduced  the 
average  duration  of  typhoid  fever,  with  a  continuous  de- 
pression of  the  febrile  temperature.  The  tendency  to 
diarrhoea  was  checked,  the  abdominal  distention  kept 
under  control,  and  the  stools  were  almost  completely 
deodorized.  There  was  early  cleansing  of  the  tongue, 
dryness  of  which  was  rare  and  brief.  There  was  no  ten- 
dency to  stupor  or  delirium,  and  the  patient  retained 
the  usual  clearness  of  intellect.  The  few  relapGes  were 
of  short  duration,  and  secondary  complications  did  not 
occur.  The  food  was  always  well  digested  and  assimi- 
lated, and  convalescence  was  rapid.  In  the  past,  carbolic 
acid  has  not  been  generally  adopted  as  an  intestinal  an- 
tiseptic, probably  on  account  of  the  small  doses  given. 
Full  doses,  at  short  intervals,  freely  diluted  and  suitably 
combined,  must  be  given  to  make  carbolic  acid  efficient 
in  enteric  fever. 

The  Pennsylvania  Hospital  is  to  be  renovated,  its 
drainage  being  said  to  be  very  defective. 

Asparagus  causes  a  reduction  in  quantity,  and  in- 
creased concentration  of  the  urine,  according  to  Dr. 
Elliot  Daunt. 

Dr.  Beaven  Bake,  whose  death  occurred  in  Trinidad 
on  August  25th,  succumbed,  as  we  surmised  in  a  previous 
notice,  to  yellow  fever,  which  has  been  epidemic  in  Port- 
of-Spain  during  the  past  summer. 

Dr.  Henry  Hoffmann  Donner  died  in  Frankfort-onthe- 
Main  on  September  20th,  aged  eighty-three.  Although 
a  skilful  physician,  he  was  better  known  to  the  world  at 
large  as  a  poet  and  humorous  writer.  His  best  known 
book  was  "  Struwelpeter,"  which  ran  through  no  less 
than  one  hundred  and  fifty  editions  in  Germany,  and  was 
translated  into  every  European  language. 

The  Influenza  has  been  very  prevalent  in  Buenos 
Ayres  during  the  four  months  just  past,  which  constitute 
the  winter  season  in  that  latitude. 

The  Cult  of  the  Rotten  Calf  is  the  gentle  term  applied 
to  the  prevention  of  small-pox  by  an  English  anti-  vacci- 
nationist. 

A  London  Anti  vivisection  Journal  publishes  these  pa- 
thetic lines : 

TO   A   VIV1SECTOR. 

Oh,  cruel  man,  how  dost  thou  dare, 

With  selfish  ends  in  view. 
To  torture  thus  a  creature  fair, 

Who  never  injured  you  ? 

Do  you  not  know  the  God  of  love, 

Whose  are  the  creatures  all, 
Looks  down  from  His  high  throne  above, 

And  hears  them  when  they  call  ? 

He  sees  the  hand  with  blood-stained  knife, 

He  hears  the  piteous  cry  ! 
Then  spare,  oh  spare,  that  poor  beast's  life, 

Oh  do  not  make  him  die  ! 

The  God  who  made  him  made  you  too, 

For  He  did  all  things  make; 
Then  show  much  love  in  all  you  do. 

For  your  kind  Maker's  sake. 

If  the  gentle  author  had  a  child  ill  with  diphtheria;  we 
wonder  if  he  would  consent  to  the  use  of  the  diphtheritic 
antitoxin,  a  product  of  the  vivisectionist's  work  on 
horses.  And  does  this  poet  eat  capon,  ride  the  gelding 
or  hunt  the  fox  ? 

Taking  the  Case. — Patient :  Showing  her  arm  badly 
bitten. 

Doctor :  Bitten  by  a  dog,  madam  ? 

Patient  (with  withering  dignity) .-  No,  sir.  By  an- 
other lady  1 


SUPPLEMENT  TO    THE   MEDICAL  RECORD.     October  27,    1894. 


BRONZE  STATUE  OF  THE  LATE  DR.  J.  MARION  SIMS  ERECTED  IN 
BRYANT  PARK  AND  PRESENTED  TO  THE  CITY  OF  NEW  YORK,  ON 
SATURDAY,    OCTOBER    20TH,    BY    THE    SUBSCRIBERS    TO    THE    FUND. 


Medical   Record 

A  Weekly  yournal  of  Medicine  and  Surgery 


Vol.  46,  No.  17. 
Whole  No.  1251. 


New  York,  October  27,  1894. 


$5.00  Per  Annum. 
Single  Copies,  ioc. 


DR.  J.    MARION    SIMS  — SURGEON  AND  PHI- 
LANTHROPIST. 

An  Address  Delivered  October  20,  1894,  in  Bry- 
ant Park,  New  York,  on  the  Unveiling  of  the 
Statue  of  Dr.  J.  Marion  Sims. 

By  GEORGE  F.  SHRADY,  M.D., 

MEW  YOUC 

Ladies  and  Gentlemen  :  We  have  met  on  this  occasion 
to  do  honor  to  a  medical  man,  and  through  him  to  show 
a  becoming  appreciation  of  the  labors  of  his  fellows. 

Strange  as  it  may  appear,  in  consideration  of  the  mo- 
tive which  has  actuated  this  recognition  of  valuable 
services  to  mankind,  and  the  previous  opportunities  that 
have  been,  from  time  to  time,  offered  for  conferring 
similar  honors  on  the  profession,  this  is  the  first  instance 
in  this  country  in  which  an  heroic  statue  has  been  erect- 
ed to  a  member  of  that  fraternity. 

Heretofore  Fame  has  restricted  her  tributes  to  achieve- 
ments in  every  other  line  of  high  human  endeavor — 
War,  Poetry,  Music,  Literature,  Art,  Patriotism,  States- 
manship, and  Philanthropy  have  in  turn  mounted  the 
pedestal,  while  the  Genius  of  Medicine,  with  finger  upon 
closed  lips,  has  humbly  and  mutely  awaited  the  verdict 
of  an  appreciative  humanity. 

This  new  departure  which  we  this  day  inaugurate  can 
be  hailed,  from  many  points  of  view,  as  an  omen  of  good 
import,  as  the  beginning  of  an  end  in  which  cherished 
traditions  shall  no  longer  hamper  the  well  directed  efforts 
of  such  as  work  in  other  spheres  of  human  usefulness. 
The  public,  however,  is  not  so  much  to  blame  for  lack 
of  a  general  appreciation  of  the  work  of  the  doctor  as 
would  at  first  appear.  It  has  in  reality  no  means  of  es- 
timating distinctive  merits.  It  was,  therefore,  proper, 
in  order  to  initiate  such  a  movement  as  the  present  one, 
that  the  profession  itself  should  take  the  lead,  and  indi- 
cate a  fitting  subject  for  such  an  honor.  This  was  done 
by  the  Medical  Record,  which  made  an  appeal  to  the 
profession  in  this  and  other  countries  for  funds  with 
which  to  erect  a  monument  to  the  memory  of  one  of  its 
acknowledged  leaders. 

A  committee  was  appointed,  of  which  the  late  Dr. 
Fordyce  Barker  was  chairman,  which  comprised  leading 
specialists  from  every  part  of  the  United  States.  Our 
own  city  was  represented  by  Drs.  T.  Gaillard  Thomas, 
Thomas  Addis  Emmet,  William  T.  Lusk,  William  M. 
Polk,  Paul  F  Munde,  the  editor  of  the  Medical  Record, 
and  Mr.  William  H.  S.  Wood,  as  treasuier  of  the  fund. 

The  subscriptions  were  mostly  limited  to  one  dollar 
each,  and  coming  as  they  did  from  members  of  the  pro- 
fession in  every  part  of  the  civilized  world,  attested,  in  an 
unmistakable  manner,  the  good  name  and  great  fame  of 
the  American  surgeon. 

This  distinction  came,  then,  from  his  peers,  who  were 
best  able  to  judge  his  qualifications  for  it,  and  who  with 
one  accord  were  delighted  to  honor  him. 

It  was  eminently  fitting  also  that  such  a  tribute  should 
be  paid  to  American  surgery  in  general,  through  one  of 
its  chief  representatives.  He  was  a  product  of  the  soil 
as  well  as  the  exemplification  of  one  of  the  principles 
which  has  placed  American  surgery  where  it  is  to  day, 
holding  the  Sceptre  of  the  world. 


Nothing  in  all  the  line  of  progress  during  the  century 
has  acquitted  itself  so  creditably  as  this  very  science  of 
life  saving  by  operative  procedure.  And  America  spe- 
cially points  with  pride  to  her  great  achievements  in  this 
noble  art,  to  her  notable  discoveries  in  alleviating  human 
suffering,  her  successful  efforts  in  prolonging  human  life, 
and  in  the  accuracy,  skill,  and  daring  of  her  brilliant  op- 
erators, 

America  gave  ether  to  the  world,  invented  the  new 
sleep  which  numbs  the  touch  of  sharpest  steel,  brings  sweet 
peace  in  the  eternal  war  with  agony,  and  wafts  pain  to 
oblivion  on  the  drowsy  wing  of  night.  She  opened  new 
fields  for  exploration  within  the  human  body,  made  ab- 
dominal surgery  with  its  brilliant  successes  the  possibil- 
ity of  the  age,  and  with  dauntless  blade  and  master  hand 
snatched  victory  from  the  long-hidden  entrenchments  of 
death.  In  fact  in  every  department  of  surgical  proced- 
ure the  American  surgeon  has  left  his  impress  for  good 
either  in  the  invention  of  new  methods  or  in  the  modifi- 
cation of  old  ones ;  and  has  given  American  surgery  a 
world-wide  recognition  for  originality  of  conception, 
boldness  of  execution,  and  success  of  practice. 

In  his  own  department  Sims,  a  born  and  typical 
American,  was  a  leading  worker.  He  established  a 
school  of  his  own,  which  has  now  won  fame  through- 
out the  world.  Indeed,  it  is  safe  to  say  that  Sims's 
name  is  associated  with  more  original  operations  and 
more  new  instruments  for  making  such  operations 
successful  than  that  of  any  other  American  surgeon. 
His  was  the  germinal  thought  implanted  in  a  disposition 
for  untiring  work,  which  changed  impossibilities  into 
triumphs,  restoring  health  and  happiness  to  countless 
numbers  of  suffering  womanhood. 

If  it  be  true  that  no  fame  is  lasting  unless  founded  on 
labors  which  promote  the  happiness  of  mankind,  the 
name  of  Sims  must  live  as  long  as  generations  succeed 
each  other,  and  will  punctuate  the  progress  of  history 
by  its  cherished  memory. 

But  Sims,  although  ambitious,  did  not  seek  for  fame. 
When  it  came  to  him  he  viewed  it  with  an  innocent  sur- 
prise. When  it  was  all  done,  when  during  his  tour 
of  the  capitals  of  Europe,  operating  in  the  large  hos- 
pitals and  before  the  renowned  surgeons  of  the  day, 
his  breast  studded  with  the  starry  decorations  of  France, 
Portugal,  Spain,  and  Italy,  he  could  not  understand  why 
he  was  so  cordially  noticed,  forgetting  that  he  himself 
was  the  focal  point  toward  which  all  the  then  great 
lights  centred. 

Indeed,  it  was  said  of  Sims  that  he  could  practise  and 
earn  his  living  in  any  city  of  Europe,  by  virtue  of  what 
became  for  him  a  cosmopolitan  reputation. 

He  was,  however,  virtually  alone  in  his  conviction  of 
ultimate  success.  His  few  professional  friends,  who 
were  at  first  enthusiastically  hopeful,  became,  in  the  face 
of  his  early  failures,  mistrustful  and  discouraged.  While 
they  admired  his  ardor  they  pitied  his  delusion.  In  his 
darkest  hours  came  confidential  advice  from  his  brother- 
in-law  :  "  When  you  began  these  experiments/ '  said  he, 
"  we  all  thought  that  you  were  going  to  succeed  at  once, 
and  that  you  were  on  the  eve  of  a  great  discovery.  We 
have  watched  you  and  sympathize  with  )OU,  but  your 
friends  here  have  seen  that  you  are  breaking  down  with 
overwork.  And  besides,  I  must  tell  you  frankly  that 
with  your  young  family  it  is  unjust  to  them  that  you 
continue  in  this  way.  You  have  no  idea  what  it  costs 
you  to  support  your  hospital,  now  for  over  three  years, 


5H 


MEDICAL  RECORD. 


[October  27,  1894 


and  my  advice  is  to  give  it  all  up."  His  answer  came 
quickly  and  to  the  point :  "  My  dear  brother,  if  I  live 
I  am  bound  to  succeed.  I  am  as  sure  that  I  will  carry 
this  thing  through  as  I  am  that  I  now  live.  I  have  done 
too  much  already.  I  am  going  on  with  these  experi- 
ments to  the  end,  it  matters  not  what  it  costs,  if  it  costs 
my  life." 

The  destiny  of  discovery  forced  him  against  many  ap- 
parently overwhelming  obstacles  to  finally  fulfil  his 
mission.  Thus  a  backwoods  doctor  of  Alabama,  strug- 
gling for  his  daily  bread,  hampered  by  sickness,  working 
for  the  work's  sake,  his  ardor  glowing  in  the  very 
ashes  of  his  hope,  with  desperate  cases  forced  upon  him, 
compelled  to  follow  in  a  given  line,  and  conscious  of  a 
duty  he  owed  to  his  poorest  patient,  was  ever  busy  in  his 
long  and  lonely  drives  in  devising  the  newer  means  of 
relief.  Turning  to  account  a  trivial  circumstance  in  the 
treatment  of  a  patient,  what  was  before  a  perplexing 
problem  became  a  solved  discovery.  A  new  method  of 
operating  was  thus  suggested,  and  with  an  almost  over- 
powering enthusiasm  in  the  possession  of  the  principle 
he  eagerly  put  it  to  the  test.  His  first  operation  was 
upon  a  female  slave.  It  failed,  as  did  others  upon  simi- 
lar subjects.  Bit  there  was  enough  of  encouragement 
in  each  to  prick  his  ambition  and  spur  his  purpose.  He 
must  have  suitable  means  to  the  end,  so  he  equipped  a 
little  hospital  of  his  own,  and  with  the  humblest  of  poor 
patients  accomplished  the  greatest  of  triumphs. 

The  stitches  used  in  his  operation  were  necessarily  so 
deeply  placed  that  they  could  not  be  securely  tied,  and 
were  themselves  a  source  of  infection.  And  then  another 
step  was  taken.  He  had  been  lying  awake  for  an  hour 
wondering  how  to  tie  the  suture,  when  all  at  once  an 
idea  occurred  to  him  to  run  a  perforated  shot  along  the 
string,  and  when  the  suture  was  tightened  to  compress 
the  shot,  thus  making  the  knot  secure.  He  became  so 
elated  with  the  discovery  that  he  lay  there  until  morning 
performing  in  imagination  all  sorts  of  operations  upon  the 
patients  in  his  little  hospital.  But  the  shot  did  not  answer 
every  purpose,  for  the  silk  of  the  suture  still  made  union  im- 
possible. Just  at  this  time  he  was  walking  from  the  house 
to  his  office  when  he  picked  up  a  piece  of  fine  brass  wire. 
"A  wire  is  the  thing,"  said  he.  A  neighboring  jeweller 
made  him  a  fine  wire  of  silver,  and  with  it  the  thirtieth 
operation  was  performed  upon  the  long  suffering  yet 
*  hopeful  slave  and  the  principle  was  forever  established. 
These  incidents  are  merely  sketched  to  present  an  out- 
line of  some  parts  of  his  character ;  how  the  greatest 
ending  may  have  the  most  insignificant  beginning. 
Whenever  a  great  discovery  is  to  be  made  the  idea  of  it 
compasses  the  individual  round  and  about,  it  possesses 
him  by  day  and  by  night,  at  all  hours  and  in  all  places, 
until  the  misty  conjectures  form  the  rainbow  of  promise, 
which  frames  the  prospect  of  a  world  beyond.  Thus 
Sims  found  fame  waiting  with  her  chaplet  From  little 
things  to  great  ones  is  the  lesson  of  every  invention. 
With  Sims  ail  the  successes  of  his  great  operations  hinged 
not  only  upon  the  wide  utility  of  the  famous  instrument 
now  inseparably  associated  with  his  name,  but  upon  the 
accidental  suggestion  of  a  cast-off  suspender  wire. 

So  ilso  the  little  hospital  maintained  by  himself  from 
the  limited  income  of  a  poor,  sickly,  and  hard  worked 
practitioner,  with  its  beds  occupied  by  bondwomen,  was 
the  germinal  conception  of  the  present  Woman's  Hospi- 
tal in  this  city,  the  only  institution  of  its  kind  in  the 
world,  and  an  eternal  monument  to  the  ardent  zeal  and 
lofty  purposes  of  its  brilliant  founder.  Thus  while  here 
the  statue  preserves  the  memory  of  the  good  man,  of  the 
faithful  worker,  of  the  great  inventor,  oi  the  broad  phi- 
lanthropist, the  Woman's  Hospital  becomes  for  him  and 
all  of  us  an  ever  living  principle,  extending  its  charity, 
widening  its  influences,  perfecting  scientific  skill,  and 
fulfilling  its  divine  mission  of  alleviating  suffering  and 
saving  the  lives  of  waiting  generations  of  stricken  woman- 
hood. 

Bat  Sims  was  not  only  a  leader  in  his  own  department 
but  was  always  ready  to  devise  new  methods  of  treatment 


in  the  broader  domain  of  general  surgery.  As  a  striking 
instance  of  this  he  was  the  first  to  boldly  advocate  the 
operative  invasion  of  the  abdominal  cavity  for  gunshot 
wounds  of  that  region.  When  the  lamented  Garfield 
was  shot,  Dr.  Sims,  in  a  cabled  interview  from  Paris,  ad- 
vised that  such  an  exploration  should  be  made.  Aston- 
ishing as  it  was,  and  as  much  criticism  as  it  then  pro- 
voked, it  would  be  the  first  of  all  expedients  at  the 
present  day. 

But  I  must  not  dilate  on  points  that  will  be  more  fully 
touched  upon  by  the  distinguished  speaker  who  is  to  fol- 
low me. 

Suffice  it  to  say  that  every  man  having  his  place,  Sims 
has  found  his.  If  brains,  opportunity,  environment, 
and  energy  fit  him  for  great  things,  he  is  singled  out  as 
a  memory  of  good  accomplished,  as  an  emulation  for  kin- 
dred spirits,  as  an  exponent  of  the  progressive  idea,  and 
as  an  acknowledged  benefactor  of  his  race.  The  reali- 
zation of  such  a  position  for  Dr.  Sims  is  manifest  in  the 
reverential  duties  of  this  hour,  which  consign  his  lovable 
memory  to  the  heritage  of  a  grateful  humanity. 


DR.  J.  MARION  SIMS— THE  FATHER  OF  MOD- 
ERN GYNECOLOGY. 

Being  an  Address  Delivered  October  20,  1894,  in 
Bryant  Park,  New  York,  on  the  Unveiling  of 
the  Statue  of  Dr.  J.  Marion  Sims. 

By  PAUL  F.  MUNDfi,  M.D., 


Mr.  Chairman,  Ladies,  and  Gentlemen  :  You  have 
heard  from  my  distinguished  friend,  the  preceding  speaker, 
who  and  what  manner  of  man  Dr.  Sims  w  s.  To  me  has 
been  delegated  the  honor  of  enlightening  you  as  to  the 
reasons  why  he  was  selected  for  the  peculiar  distinction 
of  having  a  statue  erected  to  his  memory.  I  say  "  pecul- 
iar distinction  "  because,  while  in  our  parks  and  squares 
are  found  the  statues  of  soldiers,  statesmen,  poets,  mer- 
chant princes,  and  clergymen,  nowhere  until  to  day,  so 
far  as  I  am  aware,  does  there  stand  a  statue  of  a  physi- 
cian. There  have  been  several  public  monuments  and 
busts  erected  to  prominent  physicians  in  other  cities, 
notably  a  monument  to  Dr.  Ephraim  McDowell,  the  dis- 
coverer of  ovariotomy,  in  Lexington,  Ky. ;  a  bust  to  Dr. 
Benjamin  Rush,  in  Philadelphia,  and  a  monument  to  the 
"  Discovery  of  Anaesthesia,"  the  heroes  of  which  are  not 
mentioned  in  the  public  garden  of  Boston.  But  this  statue 
to  Dr.  Sims  is  the  first  of  its  kind  erected  in  this  country. 
And  why  has  this  great  distinction  been  awarded  him  ? 
Simply  and  solely  because,  among  the  many  eminent 
physicians  and  surgeons  whom  America  has  produced,  he 
stands  pre-eminent  as  the  man  through  whose  genius,  per- 
severance, and  energy  a  special  branch  of  medical  science 
and  practice  was  so  renovated,  improved,  and  elevated  as 
to  create  an  era  in  medicine  and  raise  America  from  the 
place  of  the  docile  and  receptive  pupil  to  the  proud  po- 
sition of  the  teacher  of  older  nations. 

This  claim  is  allowed  Dr.  Sims  without  dispute,  even 
by  those  European  nations  who  are  most  jealous  of  their 
own  achievements  in  medical  science. 

Up  to  fifty  years  ago  the  special  branch  of  medicine  to 
which  Dr.  Sims  devoted  himself,  as  soon  as  sufficient  op- 
portunity offered,  had  made  comparatively  little  progress. 
About  the  middle  of  the  present  century  three  men  in 
Europe,  by  their  individual  efforts,  each  in  his  own  land, 
raised  this  branch  of  medicine  to  the  dignity  of  a  spe- 
cialty, and  placed  it  on  a  sound  scientific  basis.  These 
men  were  Simpson,  in  Great  Britain,  Recamier,  in 
France,  and  Scanzoni,  in  Germany.  But  in  spite  of  their 
efforts  the  treatment  of  these  diseases  advanced  but  little, 
and  the  one  needful  factor,  the  knife,  was  rarely  used. 
Then,  like  a  meteor,  appeared  the  genius  of  Sims  1  In 
the  Southern  town  where  he  had  for  many  years  followed 
the  practice  of  a  successful  general  surgeon,  as  my  prede- 
cessor has  already  stated,  accident  caused  him  to  stumble 


October  27,  1894] 


MEDICAL  RECORD. 


5*5 


on  a  method  of  operating  and  curing  a  hitherto  practi- 
cally incurable  injury.  Strange  to  say,  the  instrument 
which  enabled  him  to  achieve  this  success,  and  which 
remains  indelibly  associated  with  his  name,  owed  its  ori- 
gin to  the  happy  thought  of  a  bent  kitchen  spoon  1  An 
ordinary  man  would  not  have  grasped  the  situation ;  but 
the  genius  of  Sims  at  once  comprehended  the  immense 
value  of  his  discovery,  and  led  him  on  to  improvement 
after  improvement,  until  the  whole  procedure  was  per- 
fected. 

The  field  of  Montgomery,  Ala.,  then  became  too  nar- 
row for  his  ambition,  and  in  1853  he  came  to  New  York. 
His  one  great  object  here  was  to  establish  a  hospital  for 
the  exclusive  treatment  of  the  diseases  peculiar  to  the  fe- 
male sex ;  and  long  and  hard  did  he  work,  until,  after 
much  opposition  from  physicians  and  laymen,  and  many 
a  disappointment,  in  1855  he  was  at  last  able  to  form 
the  Woman's  Hospital  Association.  On  the  opening, 
in  1856,  of  a  temporary  hospital  in  Madison  Avenue, 
among  other  speakers  to  commemorate  the  occasion,  Dr. 
Valentine  Mott,  who  was  the  foremost  surgeon  of  his 
time  both  at  home  and  abroad,  made  the  following  re- 
marks :  "  Go  on,  Dr.  Sims,  in  your  work  of  charity  and 
benevolence !  Although  no  marble  urn  or  inanimate 
bust  may  tell  of  your  honor  and  renown,  you  will  yet 
have  in  all  coming  time  a  more  enduring  monument ; 
and  that  monument  will  be  the  gratitude  of  woman." 
The  latter  part  of  Dr.  Mott's  prophecy  has  long  since 
been  fulfilled.  And  to-day  we  are  assembled  to  cele- 
brate the  unveiling  of  the  statue  which  Dr.  Mott  scarcely 
expected  to  see  erected. 

The  limited  accommodations  of  the  hospital  soon 
proved  insufficient,  and  after  many  delays  funds  were  se- 
cured for  the  erection  of  the  first  pavilion  of  the  present 
Woman's  Hospital,  at  Forty -ninth  Street  and  Park 
Avenue,  the  land  for  which  was  given  by  the  city.  Since 
then  one  other  pavilion  and  a  number  of  cottages  for 
tumor  operations  have  been  donated  by  private  citizens. 

This  Woman's  Hospital,  founded  by  Dr.  Sims,  was 
the  first  institution  of  its  kind  in  the  world.  Its  work 
became  world-known  under  his  teachings,  and  those  of 
his  colleagues,  Emmet,  Thomas,  and  Peasiee.  And 
from  its  walls  have  issued  scores  of  young  physicians, 
and  thousands  of  professional  visitors,  who  carried  what 
they  had  there  seen  and  acquired  to  the  four  corners  of 
the  globe. 

A  sojourn  of  several  years  in  Europe  made  Dr.  Sims's 
name  familiar  to  the  medical  profession  abroad,  and 
many  opportunities  were  there  afforded  him  of  dem- 
onstrating his  peculiar  methods  of  operating.  But  his 
name  became  particularly  well  known  after  the  ap- 
pearance, in  1866,  of  the  only  book  of  any  magnitude 
which  he  ever  wrote,  the  originality  and  boldness  of 
which  aroused  admiration  and  surprise  all  over  the  pro- 
fessional world.  By  the  older  physicians  it  was  even 
regarded  with  more  or  less  distrust  and  incredulity. 
This  was  particularly  the  case  in  Germany,  then  so  very 
conservative  in  this  branch  of  medicine,  but  now  the 
boldest  of  the  bold  in  her  daring  achievements  with  the 
knife.  I  well  remember  how,  in  1867,  Scanzoni,  the 
Nestor  of  German  gynecology,  whose  assistant  I  then 
was,  brought  a  copy  of  the  translation  of  Dr.  Sims's 
book,  which  had  just  appeared,  to  the  clinic,  and  em- 
phatically expressed  to  me  his  opinion  that,  original 
and  ingenious  as  Sims's  views  and  methods  were,  he 
still  was  only  an  enthusiast,  whose  illusions  were  not 
capable  of  realization.  And  that  was  less  than  thirty 
years  ago  I  And  in  these  thirty  years  these  very  "  illu- 
sions "  of  Sims,  subject,  of  course,  here  and  there,  to  the 
modifications  of  increased  experience,  have  become  the 
accepted  rules  of  practice  all  over  the  world.  It  may 
truly  be  said  that  this  book  of  Sims  made  a  revolution  in 
modern  gynecological  practice.  The  era  of  what  must 
properly  be  called  "  modern  "  gynecology,  that  is,  oper- 
ative gynecology,  dates,  so  far,  at  least,  as  the  world  out- 
side of  the  New  York  Woman's  Hospital  is  concerned, 
from  the  year  1866.     Many  of  Sims's  views  have  re- 


mained uncontested  or  unchanged,  others  have  been 
modified,  and  others,  again,  disproved.  But  the  fact 
must  always  be  admitted  that  the  impulse  of  active  sur- 
gical interference  given  by  him  to  the,  before  him, 
largely  conservative  treatment  of  the  diseases  of  women, 
has  resulted  in  the  enormous  advances  which  this  spe- 
cialty has  made  during  the  last  twenty  five  years. 

With  Sims  came  the  revolution  which  upset  the  con- 
servative "  do  little  "  methods,  and  opened  wide  the  field 
of  active,  radical,  scientific,  and  rational  treatment  by 
surgical  means  of  the  diseases  and  malformations  which 
formerly  were  merely  palliated  or  left  unrelieved.  As 
the  exponent  of  a  new  system  in  gynecological  thera- 
peutics Sims  may  truly,  to  use  the  term  of  the  clergyman 
who  delivered  his  funeral  oration,  be  looked  upon  as  an 
"  apostle."  Without  disparagement  to  the  patient  labors 
of  previous  workers  in  the  same  field,  I  must  insist  that 
the  greatest  triumphs  in  this  specialty  have  been  achieved 
since  Sims  first  taught  us  how  to  use  his  speculum,  the 
scissors,  the  knife,  and  the  needle  for  the  cure  of  the 
diseases  to  which  he  paid  particular  attention.  J.  Mar- 
ion Sims  may,  therefore,  with  all  propriety,  be  called 
The  Father  of  Modern  Gynecology,  and  it  is  to  this 
universally  admitted  claim  that  he  owes  the  distinction  of 
being  the  first  physician  to  whose  memory  a  statue  has 
been  erected. 

The  genius  of  Dr.  Sims  was  not  limited  to  the  specialty 
with  which  for  all  time  his  name  will  be  connected. 
Quite  early  in  his  career  he  wrote  an  article  on  "  Con- 
vulsions in  Infants"  (Trismus  nascentium),  in  which  he 
advanced  the  very  plausible  theory,  borne  out  by  later 
experiences,  that  these  convulsions  could  be  prevented 
and  relieved  by  removing  the  pressure  exerted  on  the 
brain  through  the  soft  skull  of  the  child  by  the  simple 
plan  of  placing  it  on  its  side,  instead  of  permitting  it  to 
lie  constantly  on  the  back.  Again,  he  was  among  the 
first,  if  not  the  first,  to  recognize  an  abscess  of  the  liver 
and  open  it  by  a  free  incision.  Obstruction  of  the  gall- 
bladder was  also  the  subject  of  an  article  by  him,  in 
which  he  described  the  operation  of  opening  that  organ, 
and  thus  relieving  the  symptoms.  One  of  Dr.  Sims's  last 
original  achievements  has  already  been  referred  to  by 
the  preceding  speaker  —  I  mean  his  criticism  of  the 
treatment  of  the  wound  of  President  Garfield.  I  well 
remember  how  vehemently  his  views  were  opposed  by 
the  leading  surgeons  of  this  city,  who  insisted  that  it  was 
presumptuous  for  him,  a  surgeon  in  an  entirely  different 
line  of  practice,  to  offer  such  radical  suggestions  to  them. 
But  Sims's  views  soon  gained  ground,  and  to  day,  only 
twelve  years  later,  the  correctness  of  his  prophetic  asser- 
tion is  so  well  recognized  that  any  surgeon  who  would 
fail  to  carry  out  Dr.  Sims's  advice  to  at  once  open  the 
abdominal  cavity  in  case  of  injury  by  gunshot  or  other 
perforating  wound,  and  suture  the  wounded  organs, 
would  be  considered  criminally  negligent !  If  only  one 
such  case  out  of  one  hundred  is  saved  by  this  practice, 
it  is  so  much  gained,  since  without  the  operation  death 
is  inevitable. 

I  hope  I  have  been  successful  in  demonstrating  why  a 
statue  has  been  erected  to  the  memory  of  Dr.  Sims.  It 
certainly  is  not  my  object  to  deliver  a  fulsome  eulogy  of 
this  great  man.  He  needs  no  flattery.  The  record  of 
his  deeds  speaks  for  itself.  His  memory,  and  the  recol- 
lection of  what  he  has  done  for  suffering  mankind  will 
be  far  more  enduring  than  his  statue  or  the  granite  on 
which  it  stands.  Let  his  life  be  a  shining  example  for 
us  to  follow ! 

Insolated  Cholera  Cultures. — Dr.  Palermo,  of  Rome, 
has  succeeded  in  producing  an  attenuated  cholera  virus 
by  the  action  of  sunlight.  This  agent  does  not  destroy 
the  bacilli,  but  modifies  their  biological  character. 
Guinea-pigs  inoculated  with  cultures  which  had  been  ex- 
posed to  the  sunshine  for  more  than  three  and  a  half  or 
four  hours  not  only  presented  no  symptoms  of  the  dis- 
ease but  were  also  found  to  be  immune,  resisting  inocu- 
lation with  the  most  virulent  cultures. 


5i6 


MEDICAL   RECORD. 


[October  27,  1894 


SOME  UNUSUAL  CASES  OF  ABDOMINAL  SUR- 
GERY, WITH  COMMENTS.1 

By  CLINTON   CUSHING,   M.D., 

PROFESSOR  OF  GYNECOLOGY,  COOPER  MEDICAL  COLLRGK,  SAN  FRANCISCO. 

In  January,  1893,  *  was  asked  to  see  the  wife  of  a  medi- 
cal man,  who  had  been  suffering  for  several  years  with 
occasional  attacks  of  fever  accompanied  by  a  disturbed 
condition  of  the  digestion  and  by  marked  emaciation. 
The  attack  lasted  from  six  to  ten  weeks,  the  temperature 
varying  from  ioo°  to  105  °  F.  Following  the  attack  she 
would  slowly  return  to  her  normal  state  of  health.  There 
was  no  marked  pain  to  indicate  local  disease,  inability  to 
take  and  digest  food  being  the  most  pronounced  feature. 

Professors  L.  C.  Lane  and  J.  O.  Hirschfelder  saw  the 
case  in  consultation,  but  aside  from  a  diagnosis  of  chronic 
indigestion,  no  decision  was  arrived  at. 

Upon  examination  the  patient  was  found  in  no  pain, 
much  emaciated,  and  without  distention  of  the  abdo- 
men. Abdominal  and  pelvic  organs  apparently  normal, 
analysis  of  urine  negative ;  heart  and  lungs  in  good  con- 
dition, pulse  weak.  After  the  examination  I  told  the 
husband  that  I  was  unable  to  form  a  definite  opinion  as 
to  the  nature  of  the  case,  but  that  the  probability  lay  be- 
tween a  commencing  tubercular  peritonitis  and  a  small 
collection  of  pus  somewhere  in  the  peritoneal  cavity. 

I  advised  an  exploratory  incision  as  the  best  means  of 
settling  the  question.  On  February  4,  1893  (with  the 
assistance  of  Professor  Steele),  the  abdomen  was  opened 
in  the  usual  way  below  the  umbilicus  in  the  linea  alba, 
the  hand  and  arm  introduced,  and  all  the  abdominal  or- 
gans carefully  examined. 

Everything  was  found  normal  except  an  enlarged  gall- 
bladder, filled  with  gall-stones,  on  the  right  side  beneath 
the  liver.  I  advised  the  removal  of  the  bladder  with  the 
stones. 

The  opening  in  the  central  line  was  closed,  and  the 
abdomen  laid  open  just  below  the  ribs  on  the  right  side, 
the  gall-bladder  drawn  out  and  ligated  close  to  the  liver, 
and  the  whole  removed. 

The  recovery  was  uneventful,  the  fever  disappeared, 
and  since  that  time  there  has  been  no  recurrence  of  the 
trouble. 

A  question  of  importance  now  comes  up.  What  re- 
lation, if  any,  was  there  between  the  gall-stones  and  the 
fever  and  emaciation  ? 

If  the  gall-stones  were  the  cause  of  the  fever,  it  would 
appear  to  me  probable  that  they  produced  a  reflex  irrita- 
tion of  the  stomach  and  thereby  an  indigestion  of  a  suf- 
ficiently severe  character  to  account  for  the  fever.  I  am 
the  more  inclined  to  take  this  view  on  account  of  a  sim- 
ilar experience  six  years  ago  in  a  case  where  I  stitched 
the  gall-bladder  to  the  skin  and  drained  it  after  removing 
a  quantity  of  calculi. 

In  this  last  case  all  the  symptoms  were  at  once  re- 
moved by  the  operation.  In  both  cases  the  gall-bladder 
could  not  be  felt  by  palpation,  and  it  was  not  suspected 
that  there  was  any  fault  with  this  organ. 

In  any  event,  the  prompt  relief  of  the  symptoms,  and 
the  subsequent  good  health,  leads  me  to  the  conclusion 
that  the  disorder  of  the  gall-bladder  was  the  cause  of  the 
sickness.  Since  the  existence  of  the  gall-bladder  is  not 
essential  to  the  health  of  the  individual  or  to  the  function 
of  the  liver,  I  believe  its  removal,  when  diseased,  is  better 
surgery  than  to  drain  it,  or  to  secure  an  artificial  open- 
ing between  it  and  the  pylorus. 

In  April,  1893,  I  **w,  "*  consultation  with  several 
well  known  surgeons,  a  case  of  stricture  of  the  rectum  in 
a  woman,  aged  twenty-eight,  the  mother  of  two  children. 
The  stricture  was  about  a  finger  length  above  the  anus, 
and  the  contraction  of  the  gut  would  not  permit  the  in- 
troduction of  the  first  joint  of  the  finger. 

*  Read  before  the  Medico-Chlrurgical  Society  of  San  Francisco, 
Cal.,  September  3,  1894. 


The  consensus  of  opinion  was  that  the  disease  was 
probably  malignant,  and  the  majority  of  those  present 
opposed  any  surgical  procedures  owing  to  the  inaccessi- 
bility of  the  disease. 

Professor  Lane  and  myself  advised  an  operation  on 
the  ground  of  the  youth  of  the  patient  and  the  possibil- 
ity of  a  cure,  and  that  the  real  facts  in  the  matter  could 
only  be  determined  by  an  effort  to  remove  the  disease. 

On  April  22,  1893,  with  the  assistance  of  Drs.  Still- 
man  and  Rixford,  I  performed  Kraske's  operation, 
which  consisted  of  the  removal  of  the  coccyx  and  the 
lower  segment  of  the  sacrum,  the  breaking  up  of  the  at- 
tachments of  the  sigmoid  flexure  of  the  colon  to  the  pel- 
vic wall,  the  drawing  the  detached  gut  do*n,  the  re- 
moval of  six  inches  of  the  gut,  including  all  the  diseased 
portion,  leaving  about  two  inches  of  the  rectum  next  the 
anus  in  situ,  as  it  was  apparently  healthy.  The  upper  end 
of  the  gut  was  then  drawn  down  and  carefully  sutured  to 
the  end  next  the  anus,  and  the  large  wound  in  the  back 
closed  with  silk- worm  gut  sutures.  On  account  of  the 
escape  of  some  of  the  contents  of  the  bowel  between  the 
stitches,  suppuration  took  place  in  a  portion  of  the. 
wound.  A  small  recto- vaginal  fistula  formed  at  the  up- 
per end  of  the  vagina  immediately  behind  the  cervix; 
with  the  exception  of  the  fistula  the  wound. healed  read- 
ily, and  she  was  enabled  to  return  to  her  home  at  the 
end  of  two  months  much  increased  in  weight  and  in 
good  general  health.  She  returned  to  San  Francisco  in 
November  last,  when  I  closed  the  recto- vaginal  fistula, 
which  healed  readily.  There  was  left  at  the  site  of  the 
sutures  a  decided  narrowing  of  the  rectum,  but  the  strict- 
ure permitted  the  passage  of  a  Wales's  soft  rubber  bougie 
an  inch  in  diameter.  At  this  time  her  physician  writes 
me  that  after  the  lapse  of  fourteen  months  her  general  and 
local  condition  remain  excellent. 

A  microscopical  examination  of  the  removed  specimen 
demonstrated  that  it  was  an  epithelioma. 

One  who  has  never  witnessed  this  operation  cannot 
easily  conceive  how  thoroughly  the  parts  are  exposed  to 
view  as  the  operation  proceeds,  no  vessels  ligated,  haemo- 
static forceps  being  sufficient.  A  large  sponge  with  a 
cord  attached  was  passed  up  into  the  pelvis  and  protect- 
ed the  intestines  from  injury. 

It  is  yet  too  soon  to  say  that  a  permanent  cure  has 
been  made,  but  the  outlook  is  good  and  we  have  at  least 
given  the  patient  a  year  of  comparative  health,  with 
good  prospects  of  a  continuance. 

In  this  case  the  disease  was  situated  almost  exactly  in 
the  centre  of  the  pelvis,  and  could  be  reached  through  an 
abdominal  opening  only  with  the  greatest  difficulty,  and 
from  below  only  by  sacrificing  the  lower  end  of  the  gut 
with  its  sphincters  unless,  as  in  this  case,  the  opening  was 
made  as  Kraske  advises.  Had  I  to  deal  with  a  similar 
case  in  the  future,  I  would  make  a  trial  of  the  Murphy 
button  for  uniting  the  ends  of  the  gut,  as  much  time 
would  be  thereby  saved  and  the  shock  lessened.  '' 

Mrs.  G.  H ,  the  wife  of  a  medical  man  and  the 

mother  of  three  children,  applied  to  me  for  advice  re- 
garding an  enlargement  of  the  abdomen.  She  was  in 
good  general  health  except  that  she  was  unable  to  stand 
long  upon  her  feet  without  a  feeling  of  weight,  and  a 
bearing  down  sensation  in  the  lower  part  of  the  abdo- 
men. She  was  about  thirty  six  years  of  age.  An  ex- 
amination demonstrated  a  bad  laceration  of  the  cervix 
and  perineum.  There  was  marked  hyperplasia  of  the 
uterus,  and  a  smooth  elastic  tumor  in  the  region  of  the 
right  ovary  which  was  pronounced  an  ovarian  cystic 
tumor,  and  an  operation  advised. 

On  February  25,  1893,  the  patient  was  placed  under 
ether,  the  uterus  thoroughly  curetted,  the  laceration  of 
the  cervix  and  perineum  repaired,  and  afterward  the 
abdomen  opened  in  the  usual  manner.  What  was  sup- 
posed to  be  an  ovarian  cyst  proved  to  be  a  colloid  cyst 
growing  from  the  retroperitoneal  tissue  just  below  the 
right  kidney,  and  the  inner  wall  of  which  was  made  up 
in  large  part  of  the  outer  wall  of  the  ascending  colon. 
The  tumor  was  about  the  size  of  a  child's  head  at  term. 


October  27,  1894] 


MEDICAL   RECORD. 


5i7 


The  wall  of  the  sac  was  covered  by  peritoneum  about 
the  thickness  of  card-board.  The  sac  was  tapped,  but 
the  colloid  mass  had  to  be  removed  by  the  hand ;  mani- 
festly the  sac  could  not  be  removed  without  sacrificing, 
or,  at  least,  greatly  endangering,  the  wall  of  the  colon, 
so  the  cut  edges  of  the  sac  were  stitched  to  the  abdomi- 
nal wall  and  a  drainage-tube  inserted  and  fastened  into 
the  abdominal  wound. 

There  was  no  shock  and  the  recovery  was  uneventful. 
At  the  end  of  a  year  there  was  still  a  slight  discharge 
from  the  fistulous  opening,  and  the  narrow  tract  was 
syringed  out  with  a  solution  of  nitrate  of  silver,  sixty 
grains  to  the  ounce,  and  the  fistula  then  closed.  The 
ovaries  were  found  to  be  normal.  The  plastic  operation 
on  the  cervix  and  perineum  had  yielded  a  perfect  result. 

I  report  this  case,  for  retroperitoneal  tumors  of  this 
kind  are  uncommon,  if  we  are  to  judge  by  the  fact  that 
we  seldom  see  one  reported  in  the  medical  journals. 

The  error  of  diagnosis  is  easily  understood  when  it  is 
remembered  that  the  cyst  was  movable  and  was  in  direct 
contact  with  the  ovary,  and  that  the  patient's  abdomen 
was  well  loaded  with  fat.  However,  mistakes  in  diagno- 
sis in  abdominal  diseases  are  so  frequent  that  they  have 
ceased  to  cause  surprise. 

Dr.  Hennessy,  of  Napa,  sent  a  woman  to  me  February 
last,  with  a  history  of  pelvic  inflammation  ending  in  a 
discharge  of  pus  from  the  rectum  and  from  the  bladder. 
She  also  passed  gas  from  the  bladder,  from  time  to  time. 

She  was  much  emaciated  and  suffered  a  good  deal 
from  pain  in  the  region  of  the  left  ovary.  Upon  exam- 
ination an  immovable  and  tender  mass  was  found  in  the 
region  of  the  left  ovary,  and  the  diagnosis  was  made  of 
a  pus-tube  opening  both  into  the  rectum  and  bladder. 

On  March  3,  1894,  assisted  by  Dr.  Hennessy,  the 
abdomen  was  opened  and  the  diagnosis  verified.  The 
whole  left  broad  ligament  was  distended  and  filled  with 
cheesy  pus,  and  the  remnants  of  a  pus-tube  were  in  evi- 
dence. The  tube  was  ligated  with  catgut  and  removed, 
and  the  pus  cavity  in  the  broad  ligament  thoroughly 
curetted  and  afterward  mopped  out  with  a  mixture  of 
equal  parts  of  carbolic  acid  and  compound  tincture  of 
iodine,  and  a  rubber  drainage-tube  passed  through  from 
the  abdominal  wound  into  the  vagina. 

There  is  still  a  fistulous  opening  in  the  abdominal  wall, 
bat  the  patient  has  grown  fat  and  hearty,  and  bids  fair 
to  make  a  perfect  recovery.  This  case  is  somewhat  out 
of  the  ordinary. 

In  this  connection  I  would  like  to  call  the  attention 
of  the.  members  of  the  Society  to  a  practical  matter  of 
undoubted  value,  and  which  I  put  in  practice  for  the  first 
time  in  this  case. 

In  order  to  avoid  fistulous  tracts  caused  by  leaving  in 
the  abdomen  silk  ligatures  that  have  become  infected 
with  pus,  I  prefer  in  pus  cases  to  use  catgut,  but  a  seri- 
ous objection  to  catgut  is,  that  in  handling  it  with  wet 
hands,  and  when  it  is  soiled  with  blood  and  pus,  it  be- 
comes slippery,  and  when  a  knot  is  tied  down  in  the  bot- 
tom of  the  pelvis,  I  do  not  feel  sure  that  it  will  hold. 

It  occurred  to  me  that,  after  the  catgut  had  been  kept 
in  sulphuric  ether  for  ten  days  in  order  to  get  all  the  ani- 
mal oil  out  of  it  and  render  it  antiseptic,  if  it  were  put 
into  a  mixture  of  an  ounce  of  common  rosin  to  a  pint  of 
alcohol,  it  would  preserve  the  catgut  and  make  it  sticky 
so  that  it  would  stay  tied,  whether  wet  or  not. 

The  experiment  was  a  success,  and  the  catgut  stayed 
tied,  and  I  can  recommend  it  as  an  improvement. 

Two  years  and  a  half  ago  a  patient,  aged  about  thirty- 
five,  brought  me  a  letter  from  Dr.  Henry  O.  Marcy,  of 
Boston,  asking  me  to  give  her  such  attention  as  might 
be  needed.  She  was  exceedingly  nervous,  and  was  suf- 
fering from  pain  in  the  region  of  the  ovaries.  She  was 
a  widow  and  had  never  been  pregnant.  Upon  examina- 
tion the  ovaries  were  found  more  than  usually  sensitive, 
and  slightly  enlarged.  I  advised  measures  to  improve 
the  general  health  and  the  use  of  the  continuous  current 
of  electricity  to  be  passed  through  the  ovarian  region  by 
means  of  large  pads  made  of  potter's  clay.     She  did  not 


return  for  treatment  and  I  heard  nothing  more  of  her  for 
two  years.  Last  spring  she  came  to  my  office  again  for 
advice,  stating  that  after  leaving  me  over  two  years  ago, 
a  surgeon  had  performed  laparotomy  and  removed  the 
left  ovary  and  tube,  but  with  no  benefit  to  the  trouble- 
some symptoms. 

Upon  examination  she  was  found  to  have  a  ventral 
hernia  the  size  of  a  small  cocoanut  in  the  line  of  the  ab- 
dominal incision.  The  right  ovary  was  about  the  size 
of  a  duck's  egg,  and  extremely  tender,  the  right  Fallopian 
tube  was  enlarged  to  the  size  of  one's  thumb.  Behind 
the  uterus  there  was  what  appeared  to  be  a  mass  of  hard 
fecal  matter  in  the  rectum  which  prevented  my  making 
a  satisfactory  examination,  and  I  instructed  her  to  go 
-home  and  take  a  large  rectal  enema  and  to  return  for 
further  examination. 

'Upon  her  return  the  mass  was  still  felt  in  the  same 
place  and  a  digital  examination  per  rectum  demonstrated 
the  fact  that  the  mass  was  in  the  lower  part  of  Douglas's 
pouch,  and  through  the  thin  wall  of  the  gut,  I  could 
make  out  the  outline  of  a  round  flattened  mass  something 
like  the  end  of  a  spool,  but  further  consideration  led  me 
to  the  conclusion  that  it  was  a  finger-ring,  and  I  so  in- 
formed the  patient. 

She  then  told  me  that  she  had  learned  since  the  opera- 
tion that  a  valuable  ring  had  been  lost  at  the  time  and 
that  it  had  never  been  found.  This  only  confirmed  me 
in  my  original  opinion  that  the  mass  in  Douglas's  pouch 
was  a  finger-ring  buried  in  lymph. 

On  May  24,  1894,  assisted  by  Professor  C.  N.  Ellin- 
wood  and  Dr.  £.  W.  Thomas,  the  abdomen  was  opened 
and  the  right  ovary,  which  was  a  mass  of  cysts,  and  the 
enlarged  Fallopian  tube,  were  removed ;  an  attempt  was 
made  to  dissect  out  the  mass  in  Douglas's  pouch,  but  on 
account  of  the  cartilaginous  hardness  and  the  imminent 
danger  of  making  an  opening  into  the  rectum,  the  effort 
was  for  the  moment  abandoned.  The  fibrous  sheath  of 
the  rectus  muscle  was  next  dissected  free  along  the  edge 
of  the  incision  in  the  abdomen  and,  after  the  usual  sutures 
of  silk- worm  gut  were  introduced  through  all  the  tissues 
composing  the  wall,  interrupted  buried  sutures  of  heavy 
silk  were  used  to  bring  together  the  fibrous  layers  that 
had  been  dissected  out,  and  finally  all  the  structures  were 
brought  together  by  the  deep  sutures  of  silk  worm  gut, 
the  buried  sutures  being  introduced  to  prevent,  if  possi- 
ble, the  recurrence  of  the  hernia.  The  patient  was  then 
turned  upon  her  side  and  Douglas's  pouch  laid  open  from 
below,  when  the  gold  ring  with  an  emerald  setting,  as 
bright  and  clean  as  the  day  it  was  made,  came  into  view, 
and  with  a  pair  of  strong  forceps  and  long-handled  scis- 
sors was  quickly  removed  from  a  firm  bed  of  lymph  where 
it  had  laid  for  two  years.  As  a  consequence  of  the  dis- 
section a  rather  free  hemorrhage  followed,  and  a  sponge 
in  the  grasp  of  a  long-handled  forceps  was  left  in  the 
opening  for  six  hours,  which  effectually  controlled  the 
bleeding.  The  recovery  was  slow  but  uneventful,  and 
she  left  the  hospital  at  the  end  of  four  weeks.  I  am  con- 
fident she  will  now  be  restored  to  health. 

It  is  of  interest  to  know  that  so  small  a  body  could 
be  detected  after  being  in  the  peritoneal  cavity  for  over 
two  years,  but  this  can  be  understood  when  it  is  remem- 
bered how  thin  the  rectal  wall  is. 

Had  she  been  free  of  the  ovarian  and  tubal  disease,  and 
not  suffering  from  hernia,  I  doubt  that  the  simple  pres- 
ence of  the  encapsulated  ring  would  have  warranted  a 
serious  operation  for  its  removal.  Nevertheless  Douglas's 
pouch  is  one  of  the  most  sensitive  points  in  the  human 
body,  as  can  be  proved  by  passing  a  sponge  down  upon 
it  during  an  abdominal  operation.  Other  manipulations 
are  borne  without  a  sign  of  suffering,  but  if  Douglas's 
pouch  is  touched,  the  patient  begins  to  struggle. 

The  following  case  is  reported  by  Dr.  Rixford,  and  is 
a  valuable  contribution  to  the  literature  of  abdominal 
surgery,  for  it  illustrates  some  of  the  difficulties  attending 
diagnosis,  and  shows  what  may  be  done  in  the  way  of 
exploratory  incision  in  serious  conditions,  without  caus- 
ing untoward  symptoms  : 


5i8 


MEDICAL   RECORD. 


[October  27,  1894 


R.  L.  Jump,  a  physician,  has  enjoyed  generally  good 
health.  On  April  18th  he  felt  perfectly  well,  though 
for  ten  days  or  so  previously  he  had  been  troubled  with 
constipation,  a  very  unusual  condition  for  him.  During 
the  night  of  April  19th,  he  had  abdominal  pain  sufficient 
to  keep  him  from  sleeping,  situated  in  the  right  iliac  and 
umbilical  regions.  The  pain  was  constant,  and  resembled 
that  experienced  in  several  similar  attacks  which  occurred 
during  the  last  three  years,  though  it  was  not  so  severe. 
In  one  of  these  attacks  the  pain  persisted  a  week  or  more. 
During  the  evening  of  April  20th  he  was  slightly  fever- 
ish, and  more  so  the  following  evening.  Sunday  morn- 
ing he  felt  well,  and  walked  to  the  ferry,  but  by  night  he 
was  feeling  badly  and  chilly,  and  had  a  temperature  of 
102. 50  F.  by  the  mouth.  He  took  ten  grains  of  calo- 
mel and  confined  himself  to  milk  diet,  but  did  not  go 
to  bed. 

The  temperature  came  down  to  99.80  ?.  on  the  23d, 
to  99  50  F.  on  the  24th,  but  rose  again  on  the  25th  to 
1 00. 50  F.  He  took  a  second  dose  of  calomel,  after 
which  the  temperature  fell  to  990  F.  On  the  26th,  27th, 
and  28th  he  took  long  buggy  rides  and  felt  well.  Friday, 
the  27th,  the  temperature  was  normal  night  and  morn- 
ing, and  continued  so  for  three  days.  During  this  week, 
from  the  23d  to  the  30th  he  had  no  pain. 

On  Saturday,  the  28th,  he  returned  to  the  city  feeling 
welL  Sunday  he  felt  as  well  as  ever,  and  ate  with  relish 
meat  and  vegetables.  That  night  he  slept  well.  On 
Monday  afternoon,  April  30th,  he  began  to  feel  badly 
again ;  he  had  some  uneasiness  in  the  abdomen,  but  ate 
as  usual.  Temperature  102°  F.  Next  morning  he-took 
an  ounce  of  Rochelle  salts,  vomiting  part  of  it.  That 
night  he  took  five  grains  of  calomel  in  divided  doses. 
Temperature  1030  F.  He  passed  a  sleepless  night,  and 
Wednesday  morning,  May  2d,  went  across  the  bay.  The 
abdominal  pain  had  returned  worse  than  before.  Tem- 
perature, 10  40  F.  At  times  he  complained  bitterly  of  the 
pain,  and  asked  for  an  exploratory  incision. 

On  Thursday,  May  3d,  the  temperature  reached  1050 
F.,  followed  by  a  remission  to  1030  F.  Friday  morning. 
Five  grains  of  phenacetine  brought  the  temperature  down 
to  101.50  F.  The  pain  was  so  severe  that  morphia  was 
given.  On  this  day  there  were  several  fluid  stools, 
which  were  thought  to  be  due  to  the  beef  extracts  with 
which  he  had  been  fed  for  two  days. 

The  rectus  muscle  on  the  right  side  was  quite  rigid, 
and  a  decided  tumefaction  was  felt  just  below  and  to  the 
right  of  the  umbilicus.  This  point  was  very  tender  on 
pressure.  There  was  moderate  tympanites.  One  year 
and  a  half  ago  he  had  had  an  extensive  pelvic  abscess, 
which  was  incised  deeply  through  the  perineum.  In 
view  of  these  facts,  together  with  the  patient's  request, 
and  the  history  of  several  attacks  of  abdominal  pain 
mentioned  above,  and  the  rapidly  increasing  severity  of 
the  symptoms,  the  attendants  decided  upon  an  explora- 
tory incision,  it  being  thought  that  there  was  present  an 
abscess,  probably  of  appendical  origin. 

On  Saturday  afternoon,  the  5th,  Dr.  Cushing,  assisted 
by  Drs.  Stiliman,  Rixford,  and  Huffaker,  made  an  ab- 
dominal section  through  the  body  of  the  rectus  muscle 
immediately  over  the  tumor.  The  appendix  appeared 
in  the  wound  and  was  quite  normal.  The  lower  eight 
inches  of  the  ileum  were  moderately  congested,  and  in 
violent  peristalsis.  The  mesenteric  glands  of  this  region 
were  greatly  swollen,  some  being  as  large  as  almonds, 
and  of  a  purple  color.  The  total  mass  of  the  glands  was 
sufficient  to  be  felt  through  the  abdominal  wall,  and 
accounted  for  the  tumor.  One  of  the  glands  was  shelled 
out  for  examination. 

The  case  was  evidently  one  of  typhoid  fever,  in  spite 
of  the  clinical  history.  Typhoid  fever  had  been  dis- 
cussed several  times  before  the  operation,  and  was 
strongly  suggested  by  the  rapidly  increasing  fever  and 
the  fluid  stools  of  May  4th,  but  it  was  excluded  on  con- 
sidering the  history  of  previous  abdominal  trouble,  the 
period  of  defervescence  and  return  to  normal  health,  the 
severe  pain,  the  excessive  tenderness,  the  muscular  spasm, 


the  chills,  and  the  absence  of  the  typhoid  eruption  and 
stupor,  for  the  mind  was  bright  as  ever. 

There  was  considerable  dark-colored  fluid  in  the  peri- 
toneal cavity.  A  glass  drain  was  inserted.  The  wound 
was  closed  with  silk-worm  gut  sutures,  and  dressed  with 
carbolic  acid  and  glycerine.  There  was  no.  shock  follow- 
ing the  operation,  and  no  vomiting. 

Soon  after  the  operation  delirium  became  profound, 
and  continued  to  May  18th.  It  was  peculiar  in  that  the 
patient  knew  those  about  him,  and  offered  rational  sug- 
gestions concerning  his  treatment. 

On  the  next  day  after  the  operation  the  patient's 
pupils  began  to  dilate,  and  the  dilatation  soon  became 
extreme.  Then  strabismus  occurred,  lasting  several 
days.  The  head  was  retracted,  and  a  certain  degree  of 
opisthotonos  was  present.  With  these  symptoms  the 
pulse-rate  increased  to  120  and  140.  Subsultus  tendi- 
num  was  excessive.  Beginning  as  usual  in  the  hands,  it 
extended  seemingly  to  every  muscle  in  the  body ;  the 
arms  and  legs  were  thrown  about,  and  the  thoracic  and 
abdominal  muscles  contracted  spasmodically. 

The  drainage-tube  was  withdrawn  after  forty- eight 
hours,  and  the  stitches  were  removed  on  the  fifth  day, 
the  wound  having  healed  by  complete  primary  union. 
On  the  sixth  day,  while  the  attendant's  back  was  turned, 
he  tore  off  the  adhesive  strips  and  opened  the  lower  third 
of  the  wound.  No  evil  resulted  other  than  the  some- 
what delayed  healing  by  granulation  of  this  portion  of 
the  wound. 

Tympanites  was  excessive  at  times.  The  typhoid 
eruption  appeared  after  the  operation,  and  was  marked 
on  the  abdomen  and  chest,  and  a  few  petechias  were 
present  even  on  the  extremities. 

At  no  time  was  the  diarrhoea  excessive,  nor  was  there 
blood  in  the  stools.  Prostration  was  extreme,  and  the 
discharges  were  involuntary  for  a  week  or  more.  The 
greatest  care  was  necessary  to  prevent  the  formation  of 
bedsores,  and,  notwithstanding  the  patient  was  turned 
from  one  position  to  another  every  twenty  minutes,  and 
air  cushions  and  cotton  rolls  were  used,  several  small 
bedsores  did  form. 

The  temperature,  taken  by  the  rectum,  ranged  from 
1020  to  105  °  F.  from  May  2d  to  14th,  when  decided 
remissions  took  place,  and  defervescence  set  in.  On 
May  2 1  st  the  temperature  was  990  F.,  and  thereafter  re- 
mained normal.  Great  distress  was  caused  by  drying  of 
the  secretions  of  the  throat.  Several  times  complete 
casts  of  the  pharynx  had  to  be  forcibly  dislodged. 

The  case  is  remarkable  in  a  number  of  respects.  Few 
cases  of  typhoid  are  accurately  observed  at  as  early  a  date 
as  this.  There  occurred  an  interval  of  complete  defer- 
vescence following  vigorous  purgation  with  calomel  and 
restriction  to  a  milk  diet,  and  complete  return  to  health 
for  three  days.  After  this,  the  fever  rose  rapidly  but 
continuously  for  four  days.  Several  explanations  of  this 
have  been  suggested ;  one,  that  the  disease  really  began 
about  April  19th,  and  that  by  the  prompt  administra- 
tion of  calomel  it  was  aborted,  to  be  lighted  up  afresh  on 
too  early  return  to  ordinary  diet  Another  is,  that  the 
symptoms  were  due  to  an  error  in  diet  during  the  pro- 
dromal stage,  and  were  relieved  by  the  removal  of  fer- 
menting intestinal  contents  by  the  calomel. 

The  exploratory  incision  yielded  a  number  of  valuable 
observations  besides  those  mentioned ;  viz.,  the  localized 
congestion,  the  violent  peristalsis,  the  dark  fluid  in  the 
cavity,  the  enlargement  of  the  mesenteric  glands  early 
in  the  disease.  Dr.  S.  M.  Mouser,  to  whom  was  sub- 
mitted the  excised  mesenteric  gland,  reported  that  Es- 
march  tubes  inoculated  from  it  showed  only  the  typhoid 
bacillus  in  pure  culture.  This  fact  is  almost  proof  posi- 
tive against  ulceration  of  the  intestines  having  occurred, 
for  a  break  in  the  continuity  of  the  mucous  membrane 
gives  entrance  to  a  great  variety  of  bacteria  with  which 
the  intestinal  contents  swarm.  From  the  violence  of  the 
peristalsis  in  the  lower  end  of  the  ileum  as  the  coil  lay  ex- 
posed, the  explanation  of  the  colicky  pain  was  evident. 

The  remarkably  severe  nervous  symptoms  deserve  some 


October  27,  1894] 


MEDICAL    RECORD. 


5*9 


attention ;  meningitis  and  frightful  subsultus  and  violent 
delirium,  which  made  it  at  times  most  difficult  to  give  the 
patient  food ;  all  this  in  a  case  which  progressed  to  con- 
valescence without  the  slightest  evidence  of  intestinal  ul- 
ceration, and  which  was  followed  by  a  rapid  return  to 
perfect  health,  once  convalescence  was  established. 

Dr.  Jump  is  Assistant  Demonstrator  of  Anatomy  in 
Cooper  Medical  College,  and  a  most  enthusiastic  and 
thorough  student  of  his  subject.  Believing  that  he  was 
suffering  from  appendicular  trouble,  and  knowing  the 
dangers  attendant  upon  it,  he  insisted  that  an  exploratory 
incision  be  made  without  delay.  He  said,  "  If  I  should 
die  without  operation,  and  it  be  found  that  the  disease 
could  have  been  removed  by  surgical  means,  I  want  put 
on  my  tombstone,  '  A  victim  of  conservative  surgery.'  " 


THE  RATIONALE  OF  HYDROTHERAPY.1 
By  SIMON  BARUOH,  M.D., 

NSW    YORK. 

AllEMlMMG  rHYSKIAN  TO    MANHATTAN    HOSPITAI,  MKW    YORK   JUVBNILB  ASY- 
LUM, rrc. 

Recently  a  professional  friend  suggested  that,  by  devot- 
ing too  much  attention  to  hydrotherapy,  my  usefulness 
as  a  member  of  the  profession  would  be  impaired  owing 
to  a  one-sided  view  of  therapeutics.  This  suggestion  has 
"  given  me  pause/'  but  upon  reflection  I  regard  it  as 
originating  in  a  mistaken  view  of  the  duty  of  the  physi- 
cian to  his  colleagues,  and  to  humanity  at  large.  I  take 
it  that  the  physician's  first  duty  is  to  cure  disease,  his 
second  duty,  but  not  less  important,  to  garner  up  his 
dearly  bought  experience  and  offer  its  deductions  to  his 
fellow-laborers  for  criticism,  study,  and,  if  worthy,  for 
imitation. 

Through  all  my  professional  life  I  have  been  more 
deeply  interested  in  therapeutics  than  in  any  othe* 
branch.  Hence  my  contributions,  whether  medical, 
surgical,  or  gynecological,  have  been  to  the  treatment  of 
disease.  My  having  spent  the  larger  part  of  my  profes- 
sional life,  like  many  of  yourselves,  in  village  and  coun- 
try practice,  may  account  for  this  predilection  for  a 
branch  of  the  profession  which  is  to  day  too  much  neg- 
lected at  home  and  abroad. 

A  young  Viennese  doctor  recently  told  me  that  he 
knew  nothing  of  therapeutics,  because  his  teachers  were 
engrossed  in  the  diagnosis  of  living  patients,  and  in 
autopsies  of  the  dead  ones,  far  more  than  in  saving  the 
former  from  the  fate  of  the  latter. 

To  search  out  a  rationale  for  therapeutics  has  ever 
been  my  aim,  because  only  by  this  means  may  therapeu- 
tic methods  be  firmly  established  in  the  minds  of  the 
profession.  This  is  the  reason  that  has  led  me  to  the 
investigation  of  water  as  a  remedial  measure.  Here  was 
a  field  that  opened  a  valuable  mine  for  exploration. 
How  inexhaustible  and  rich  this  mine  is,  I  have  daily 
reason  to  observe.  If  I  am  persistent  in  offering  to  the 
profession  the  results  of  my  explorations  in  this  direc- 
tion, the  explanation  rests  in  the  fact  that  I  have  dis- 
covered the  same  surprising  inattention  to,  and  conse- 
quent unfamiliarity  with,  hydrotherapy  in  the  large 
majority  of  the  profession,  which  was  a  painful  discovery 
in  my  own  case.  As  the  value  of  this  much  neglected 
remedy  dawned  upon  me  in  a  somewhat  extensive  experi- 
ence gathered  in  private  and  hospital  practice,  the  ques- 
tion presented  itself:  Is  it  not  a  duty  to  agitate  this 
subject  in  the  medical  societies,  until  its  merits  and 
objections  are  thoroughly  canvassed  ? 

From  the  earliest  medical  times  water  has  been 
applied  in  medicine.  In  his  work  "  De  Aquaet  Locis," 
Hippocrates  laid  down  principles  in  hydrotherapy  which 
are  so  sound  and  practical,  that  it  would  be  a  blessing  to 
suffering  humanity  were  medical  students  indoctrinated 
in  them  to  day. 

1  Read  before  the  North  Carolina  State  Medical  Association,  April 
17.  1894. 


The  average  medical  man  goes  into  practice  with  the 
idea  that  warmth  stimulates,  and  cold  depresses.  And 
yet  Hippocrates  himself  taught  the  reverse,  which  is  the 
truth.  One  of  the  first  lessons  we  are  taught  in  surgery 
is  that  when  a  limb  is  frost-bitten  we  should  avoid  heat, 
and  apply  cold.  The  reason  is  obvious  even  to  the  tyro 
in  medicine ;  but  when  this  tyro  becomes  a  full-fledged 
doctor,  and  hears  the  cold  bath  suggested  in  typhoid 
fever,  he  at  once  objects  to  it  as  a  depressing  agent. 
To  overcome  this  prejudice,  which  is  as  deeply  rooted 
as  it  is  irrational,  has  been  exceedingly  difficult,  even  for 
some  of  the  greatest  intellects,  and  most  influential  phy- 
sicians, whose  lives  and  works  have  illumined  medical 
history.  Asclepiades,  of  Prusa,  the  bosom  friend  of 
Cicero,  was  a  warm  advocate  of  water.  Indeed  he  in- 
sisted upon  being  called  a  water  doctor,  and  he  was  the 
man  who  founded  the  school  in  which  were  equipped  for 
practice  such  illustrious  men  as  Antonius  Musa,  the  phy- 
sician who  saved  the  lives  of  the  Emperor  Augustus  and 
of  the  poet  Horace ;  Cornelius  Celsus,  the  bosom  friend 
of  Ovid,  and  also  Galen.  All  these  men  remained  true 
to  and  exemplified  the  teachings  of  their  preceptor,  ap- 
plying water  successfully  in  many  acute  and  chronic  dis- 
eases ;  and  yet  water  fell  from  the  high  estate  to  which 
they  had  brought  it.  Paulus  iEgeneta,  the  greatest 
physician  of  the  seventh  and  eighth  centuries,  was  the 
discoverer  of  the  use  ot  the  cold  douche  in  sunstroke. 
Cheyne,  Huxham,  and  Currie,  men  well  known  in  Eng- 
lish medicine,  and  Hufeland,  the  renowned  German 
medical  philosopher,  were  enthusiastic  advocates  of  hy- 
drotherapy, as  was  in  later  times  that  grand  teacher  Nie- 
meyer.  These  representative  men  are  mentioned  to 
demonstrate  that  hydrotherapy  never  was,  and  is  not 
now,  a  medical  fad,  that  it  must  surely  be  founded  on 
correct  rationale  and  on  practical  results  at  the  bedside, 
if  it  enlisted  the  advocacy  of  such  men. 

When  I  am  charged  with  undue  enthusiasm  in  this 
matter,  I  am  proud  to  be  able  to  point  to  these  men,  and 
men  like  Ziemssen,  Semmola,  Charcot,  Draper,  and  Pea- 
body,  as  confreres  and  collaborators. 

One  of  the  reasons  why  water  has  not  become  fully  es- 
tablished as  a  remedy  despite  the  advocacy  of  able  and 
conscientious  men,  is  that  its  rationale  has  not  until  re- 
cently been  studied  with  care  and  precision.  To  Pre* 
fessor  Winternitz,  of  the  Vienna  University,  we  owe  the 
first  attempt  to  invest  it  with  some  scientific  accuracy. 
As  a  follower  and  student  of  this  clinician,  I  have  endeav- 
ored to  impress  upon  my  American  colleagues  the  impor- 
tance of  not  accepting  water  as  a  remedy  only  upon  em- 
pirical grounds. 

If  it  is  to  take  a  permanent  place  in  therapeutics,  a 
place  from  which  the  whims  and  fancies,  the  prejudices 
and  fashions  of  coming  generations  shall  not  again  displace 
it,  the  rationale  of  its  action  must  be  clearly  established. 

In  this  essay  it  is  impossible  to  furnish  anything 
more  than  a  brief  outline.  The  more  succinctly  princi- 
ples are  formulated,  however,  the  more  readily  they  may 
be  accepted  or  controverted.  The  rationale  of  the  inter- 
nal application  of  water  will  be  omitted,  because  this  is 
very  simple  and  generally  appreciated.  That  diuresis, 
for  instance,  is  enhanced  by  free  drinking  of  water,  is  a 
trite  observation,  as  is  the  cleansing  effect  of  stomach 
lavage,  and  intestinal  irrigation. 

Although  the  external  application  of  water  in  disease 
has  been  carefully  studied  by  capable  physiologists  and 
clinicians,  it  has  not  obtained  such  universal  recognition 
among  practitioners  as  its  positive  effects  deserve. 

The  action  of  water  upon  the  human  organism  is  de- 
rived from  its  physical  and  mechanical  effects. 

The  physical  qualities  of  water  are  utilized  in  hydro- 
therapy because  it  is  an  excellent  vehicle  for  conveying 
the  thermic  and  mechanical  effects  aimed  at. 

Water  absorbs  and  gives  up  heat  readily ;  it  may  be 
used  in  solid,  liquid,  or  gaseous  form ;  it  may  be  applied 
to  any  limited  part  of  the  body  or  to  its  entire  surface. 

Hence  its  physical  property  alone  makes  it  a  most 
flexible  therapeutic  agent. 


520 


MEDICAL  RECORD. 


[October  27,  1894 


Thermic  agents,  as  is  well  known,  affect  living  tissues 
in  the  most  pronounced  manner. 

Smooth  muscular  fibre  contracts  under  cold,  and  ex- 
pands under  heat,  and  its  contractility  may  be  entirely 
destroyed  by  an  excess  of  either. 

By  the  conveyance  df  cold  or  heat  by  means  of  water, 
we  are  therefore  enabled  to  produce  striking  effects  upon 
the  vital  processes  which  depend  upon  muscular  activity. 
As  cold  and  heat  are  irritants,  their  reflex  effects  conveyed 
through  the  nervous  system  also  become  valuable  thera- 
peutically. Applying  these  axiomatic  principles,  we  find 
that  circulation,  respiration,  tissue  change,  and  heat-pro- 
duction may  be  positively  influenced  by  the  application 
of  water  as  a  medium  of  conveyance  of  cold  and  heat, 
that  abnormal  conditions  of  these  functions  may  be  rem- 
edied and  their  healthy  equilibrium  restored. 

That  the  application  of  cold  to  the  cutaneous  surface 
produces  pallor  and  cutis  anserina,  is  a  well- known  fact, 
as  is  also  the  rmtioncUc  thereof.  The  circular  fibres  of 
the  cutaneous  vessels,  and  the  elastic  tissue  surrounding 
the  cutaneous  capillaries  are  contracted,  and  thus  they 
are  made  to  contain  less  blood.  Stagnation  occurs  in 
the  arterial  capillaries,  while  the  venous,  being  less  eas- 
ily contracted,  remain  filled ;  the  part  becomes  cyanotic. 
If  this  stage  be  prolonged  under  extreme  cold,  necrosis 
of  the  tissues  lying  in  immediate  contact  ensues.  On 
the  contrary,  if  the  application  of  cold  be  of  brief  dura- 
tion reaction  takes  place,  the  part  is  aglow. 

In  the  first  instance  we  have  a  paralysis  of  the  inhibi- 
tory nerves,  which  allows  the  vaso-constrictors  to  exert 
full  sway ;  while  in  the  latter  the  inhibitory  nerves  are 
stimulated,  and  tonic  contraction  and  relaxation  ensue. 
The  deeper  vessels  in  the  muscular  tissue  are  more  slowly 
affected.  The  local  hyperemia  produced  by  this  reac- 
tion both  on  the  cutaneous  surface  and  in  the  deeper 
parts,  is  therefore  not  a  passive  congestion,  as  has  been 
too  often  assumed.  It  is  not  a  congestion  like  that  pro- 
duced by  the  application  of  warmth,  but  is  the  result  of 
a  vital  process,  reaction  which  is  the  physiological  se- 
quel of  the  preceding  depression.  Admitting  these 
trite  physiological  facts,  you  perceive  that  an  immense 
field  for  therapeutic  effect  is  at  once  opened. 

The  blood  which  is  driven  out  of  the  cutaneous  and 
muscular  vessels  must  be  taken  into  the  general  circula- 
tion, and  thus  produce  hyperemia  in  other  more  or  less 
distant  parts;  arousing  increased  activity  in  organs 
whose  circulation  has  been  impaired  by  disease ;  remov- 
ing the  result  of  abnormal  tissue  change  which  the  slug- 
gish organ  has  been  incapable  of  unburthening ;  stimu- 
lating it  to  more  normal  function. 

That  such'  effects  are  really  produced,  laboratory  experi- 
ment as  well  as  observation  at  the  bedside  has  again  and 
again  demonstrated. 

In  a  valuable  essay  before  the  recent  International 
Medical  Congress  at  Rome,  Professor  Winternitz,  of 
Vienna,  offered  some  practical  observations  upon  the 
changes  produced  by  thermic  agencies  upon  the  circula- 
tion of  the  blood  and  upon  its  composition  in  health. 
He  ascertained  positively  that  all  applications  of  cold 
which  involved  the  entire  surface  of  the  body,  or  a  con- 
siderable part  thereof,  resulted  in  an  increase  of  the  num- 
ber of  leucocytes ;  the  percentage  of  haemoglobin  and 
the  specific  gravity  of  the  blood  were  also  increased. 
This  remarkable  change  in  the  blood  was  more  or  less 
enduring,  its  extent  varied  according  to  the  technique 
employed,  and  sometimes  it  did  not  entirely  disappear 
even  after  a  tolerably  prolonged  period  of  observation. 

Only  in  those  cases  in  which  no  reaction  ensued,  as 
manifested  by  cutaneous  hyperemia,  did  this  effect  upon 
the  blood  fail. 

Indeed,  in  such  cases  the  erythrocytes,  and  often  the 
leucocytes,  also  were  diminished.  Sometimes  the  red 
corpuscles  were  diminished  while  the  leucocytes  were 
increased. 

Locally  the  application  of  cold,  when  followed  by  re- 
action, almost  invariably  increased  the  cellular  elements, 
specific  gravity,  and  haemoglobin  of  the  blood,  while  a 


diminution  of  all  these  ensued  in  distant  parts.  After 
flowing  foot-baths,  for  instance,  blood  taken  from  the 
toe  showed  an  increase,  while  that  taken  from  the  finger 
or  ear  lobe  showed  a  decrease.  Warmth  mostly  pro 
duced  a  diminution  of  the  cellular  elements,  haemo- 
globin, and  specific  gravity  of  the  blood.  A  comparison 
of  the  composition  of  the  latter  in  the  normal  condition 
of  health,  even  showed  that  blood  distribution  is  quite 
unequal ;  for  instance,  while  blood  taken  from  the  point 
of  a  finger  furnished  4,955,000  red  corpuscles,  and  ninety- 
one  per  cent,  haemoglobin,  blood  drawn  from  the  ab- 
dominal skin  showed  7,366,000,  and  a  hundred  and  fif- 
teen per  cent,  haemoglobin.  When,  after  this  examination, 
a  cold  compress  well  covered  was  applied  so  as  to  en- 
velop the  whole  abdomen,  the  blood  drawn  from  the  ab- 
dominal skin  and  tip  of  toe  an  hour  later,  was  found  to 
present  a  still  greater  difference  from  that  of  the  finger- 
tip drawn  at  the  same  time ;  and  while  the  cell- elements 
were  decidedly  diminished  in  the  latter,  that  drawn  from 
the  former,  underneath  the  compress,  showed  an  enor- 
mous increase  of  erythrocytes  and  haemoglobin,  some- 
times amounting  to  2,000,000  of  corpuscles,  and  over 
thirty  per  cent,  haemoglobin. 

Up  to  the  present  time  all  our  observations  upon  the 
effect  of  cold  compresses  and  poultices  were  conjectural 
and  empirical.  But  these  valuable  observations  demon- 
strated them  upon  a  clear  rationale. 

That  these  effects  may  be  utilized  to  explain  the 
rationale  of  cold  applications  in  disease,  was  demon- 
strated last  year  by  Thayer,  of  Johns  Hopkins  Univer- 
sity, who  observed  that  the  blood  drawn  from  the  lobe  of 
the  ear  of  a  typhoid  fever  patient  after  a  Brand  bath,  con- 
tained three  times  the  number  of  leucocytes  which  re- 
sulted from  a  counting  previous  to  the  bath.  Since  this 
enormous  increase  could  not  be  the  result  of  new  pro- 
duction during  the  fifteen  minute  bath,  the  conclusion 
is  inevitable,  in  view  of  Winternitz's  observation  just 
<cited,  that  the  increased  activity  of  the  circulation  in- 
duced by  the  changing  anaemia  and  hyperemia  of  the 
cutaneous  surface  resulting  from  the  cold  bath  and  fric- 
tion, has  driven  these  cells  from  their  hiding-places  on 
the  outskirts  of  the  blood-stream  and  elsewhere,  and 
brought  them  into  active  service. 

Thus  we  have  a  brilliant  explanation  of  one  of  the 
most  important  effects  of  the  cold  bath  in  typhoid,  of 
the  mildness  it  impresses  upon  its  course,  which  may  be 
charged  to  the  phogocytic  action  of  the  leucocytes  when 
actively  mingled  with  the  blood-current,  where  they 
must  come  into  living  contact  with  Eberth's  bacilli  and 
other  pathogenic  organisms.  How  different  this  physio- 
logical method  of  stirring  up  a  sluggish  circulation  is  to 
that  produced  by  medicinal  agents,  every  practitioner 
may  learn  by  comparing  the  impotence  of  the  latter  with 
the  demonstrable  results  of  the  former.  Another  result 
of  the  application  of  cold  to  the  periphery  is  the  in* 
creased  blood  pressure  produced.  The  contraction  of 
the  arterial  capillaries  induces  a  more  rapid  flow  of  blood 
into  the  veins,  while  the  deepened  inspiration,  which  is 
also  a  well  known  incident  of  the  application  of  cold  to 
the  surface,  accelerates  the  circulation  in  the  smaller 
vessels,  causes  the  blood  to  flow  more  rapidly  into  the 
left  auricle,  the  contraction  of  the  ventricle  becomes 
more  vigorous.     Thus  blood-pressure  is  enhanced. 

Cold  improves  the  muscular  tone  of  the  vessel,  in- 
creases tension,  but  warmth  relaxes  them,  causing  passive 
dilatation  and  loss  of  tone.  Although  both  produce  a 
hyperemia,  one  is  the  result  of  reaction  and  is  tonic, 
while  the  other  is  the  result  of  relaxation  and  is  atonic. 
This  trite  fact  is  sadly  disregarded  in  practice.  Its  more 
general  recognition  will  do  much  to  neutralize  and  re- 
move the  fear  of  shock  from  cold  applications  in  atonic 
conditions.  Before  entering  into  the  rationale  of  the 
clinical  application  of  these  effects,  the  reflex  action  of 
cold  and  heat  as  irritants  may  be  briefly  referred  to 
here.  That  the  idea  of  the  direct  derivative  action  of 
irritants  like  blisters  is  fallacious,  has  been  clearly  shown 
by  Naumann  and  others.     Naumann  severed  all  the 


October  27,  1894] 


MEDICAL   RECORD. 


521 


connections  of  a  frog's  head  from  its  body,  except  the 
spinal  cord,  and  then  severed  one  leg  from  the  body  after 
tying  the  vessels  (to  prevent  bleeding)  except  by  its 
sciatic  nerve.  By  applying  irritants  to  the  severed  leg 
the  blood  in  the  lungs  and  mesentery  was  made  to  flow 
more  rapidly;  when  the  irritant  was  withdrawn  it 
flowed  more  slowly.  From  this  experiment  he  deduced 
laws  which  are  of  so  much  importance  in  the  rationale  of 
hydrotherapy,  that  I  may  be  pardoned  for  summarizing 
them  here:  "  The  action  of  irritants  is  reflex  and  potent 
on  the  circulation ;  feeble  irritants  stimulate  the  latter, 
and  intense  irritants  depress  it;  effects  continue  after 
withdrawal;  relaxation  ensues  after  the  stimulation; 
cooling  follows  the  warming  effect  of  the  increased  circu- 
lation." 

That  the  circulation  of  the  blood  in  distant  parts  is 
reflexly  influenced  by  thermic  irritants,  has  been  plainly 
demonstrated  by  the  classical  experiments  of  Max 
Schueller  upon  trephined  rabbits. 

Having  the  circulation  in  the  pia  mater  directly  under 
his  eye,  he  found  that  any  irritation,  such  as  pressure 
upon  the  belly,  was  followed  by  filling  of  the  veins. 

The  application  of  cold  wet  compresses  upon  the 
belly  of  the  rabbit  was  followed  invariably  by  dilatation 
of  the  blood-vessels  in  the  pia,  and  increased  and  slowed 
pulsation  and  deepening  and  retardation  of  the  breath- 
ing. 

••The  application  of  warm  wet  compresses  to  the  belly 
of  the  rabbit  was  at  once  followed  by  a  contraction  of 
the  vessels  of  the  pia,  a  diminution  of  cerebral  pulsations, 
and  a  more  rapid  and  shallow  breathing. 

Very  hot  compresses  were  followed  by  the  same  effect 
as  cold  compresses.  And  right  here  I  may  call  atten- 
tion to  a  point  not  sufficiently  appreciated,  that  extremes 
of  heat  produce  temporarily  the  same  effect  as  extreme 
cold. 

By  dipping  the  rabbit  into  cold  or  warm  water,  i.e., 
giving  it  a  bath,  the  same  effects  were  produced  as  by 
compresses  of  the  same  temperature. 

Many  other  valuable  points  of  practical  interest  were 
ascertained  by  these  experiments,  whose  results  are  sus- 
tained by  others,  all  tending  to  demonstrate  that  the 
various  hydriatric  procedures  produce  positive  effects 
which  medicinal  agents  are  incapable  of  accomplishing. 

It  is  not  difficult  to  demonstrate  that  the  thermic  ac- 
tion of  water  upon  the  human  organism  is  capable  of 
influencing  its  every  part  and  function  in  the  most  pro- 
nounced manner. 

Beginning  with  the  skin,  we  know  that  this  is  an  organ 
of  protection  by  reason  of  its  external  layer ;  of  excre- 
tion and  heat  regulation  by  reason  of  its  glandular  and 
vascular  supply ;  of  sensation  by  reason  of  its  harboring 
terminal  nerve-fibres.  Hence  the  skin  is  the  great  out- 
post of  the  human  body.  As  a  stimulant  to  all  these 
functions  water  has  long  earned  a  well-deserved  position. 
That  by  warmth  or  cold  conveyed  through  it  we  may 
increase  or  diminish  any  or  all  of  these  functions  of  the 
skin,  need  not  be  enlarged  upon  before  this  audience. 
By  reason  of  its  action  upon  the  glands  of  the  skin  we 
may  enhance  excretion  of  products  of  tissue-changes,  as 
in  uraemia  by  warm  baths  and  hot  packs ;  by  reason  of 
this  action  we  may  increase  or  diminish  the  heat  of  the 
body,  which  is  regulated  chiefly  by  giving  off  moisture, 
and  which  may  be  powerfully  influenced  by  direct  cool- 
ing of  the  blood  as  well  as  by  reflex  effects  from  the  nerve- 
centres.  That  soothing  or  stimulating  manifestations 
may  be  produced  by  warm  or  cold  baths  is  also  so  com- 
mon an  observation  that  it  requires  only  an  enumera- 
tion in  this  category. 

Next  to  these  powerful  effects  upon  the  skin  proper,  let 
us  consider  the  effect  of  hydriatric  procedures  upon  the 
heart  and  circulation.  The  first  impression  of  cold  upon 
the  sensory  cutaneous  nerves  is  rapidly  conveyed  to  the 
brain.  Rapid  contraction  of  the  cutaneous  vessels  en- 
sues, causing  an  increased  vascular  tension,  which  is  fol- 
lowed by  slowing  of  the  pulse.  This  continues  so  long 
as  the  individual  rests,  but  the  pulse-rate  increases  with 


continuance  of  high  tension  if  exercise  be  taken  after 
the  hydriatric  procedure.  The  effect  of  cold  applica- 
tions upon  the  respiration  is  to  deepen  and  slow  it;  the 
normal  frequency  is,  however,  soon  resumed;  but  the 
deepening  effect  continues.  Hence  it  is  wise  to  send 
anaemic  and  other  patients  requiring  increased  supply  of 
oxygen,  at  once  into  the  open  air  after  cold  hydriatric 
applications. 

The  influence  of  cold  applications  upon  constructive 
and  destructive  metabolism  is  demonstrated  by  the  in- 
crease of  urinary  specific  gravity  and  of  urea  which  en- 
sues, and  which  continues  several  hours,  as  shown  by 
Juergensen  and  others,  also  by  the  increased  excretion 
of  carbon  dioxide,  discovered  by  Liebermeister  and 
Voit  after  cold  baths.  Warmth  produces  the  opposite 
effect. 

Having  now  briefly  pointed  out  the  powerful  physical 
and  thermic  effects  of  water  upon  the  human  body,  it 
remains  to  refer  to  the  mechanical  effect 

Friction  alone  has  been  shown  by  Pospischl  to  pro-, 
duce  a  great  increase  of  heat  loss.  And  Winternitz  has 
demonstrated  that  when  active  mechanical  irritation  is 
combined  with  cold  baths,  the  temperature  of  the  pa- 
tient is  more  readily  reduced. 

Indeed  Winternitz  has  announced  it  as  a  law  that  the 
amount  of  compensatory  heat  increase  which  is  incidental 
to  all  cold  baths  is  not  influenced  by  the  absolute 
amount  of  heat  abstraction,  but  by  the  degree  of  actual 
cooling  of  the  peripheral  terminal  nerve- fibres  which 
govern  the  production  of  heat  by  reflex  action. 

Mechanical  irritation,  as  friction  during  a  cold  bath, 
prevents  tremor  and  that  intense  tonic  contraction  of 
the  muscles  which  always  results  in  the  production  of 
heat.  These  facts  are  beautifully  utilized  in  the  Brand 
bath,  whose  efficiency  depends  not  any  more  upon  its 
temperature,  65  °  F.,  than  upon  the  active  but  gentle  sur- 
face friction: 

Aside  from  the  reflex  effect  produced  by  the  mechani- 
cal aid  utilized  in  hydriatric  procedures,  the  actual  press- 
ure with  which  water  may  be  applied  enables  us  to 
vary  its  effects. 

In  a  full  tub  bath  respiration  is  more  difficult,  be- 
cause of  the  pressure  of  the  water  upon  the  thorax. 

The  effect  of  a  douche  delivered  under  pressure  of  one 
or  two  atmospheres  is  stimulating  to  the  cutaneous  results 
at  the  points  of  impingement. 

The  exact  experiments  of  Maggoira,  and  Vinaj  l  demon- 
strated that  the  mechanical  effect  of  water  applied  under 
pressure  of  two  atmospheres  increase  threefold  the  work- 
ing capacity  of  the  muscles,  as  mathematically  ascer- 
tained by  means  of  the  ergograph  of  Mosso,  which  cor- 
rectly and  automatically  registers  muscular  resistance. 

The  mechanical  massage  produced  by  a  good  douche 
sets  diseased  structures  into  a  vibration  which  cannot  be 
approached  by  simple  manual  massage.  This  mechani- 
cal effect  is  constantly  utilized  most  effectively  in  feeble 
patients,  to  whose  condition  it  may  be  graded  and 
adapted. 

Locomotor-ataxia  patients  may  be  greatly  injured  by 
cold  baths  and  douches,  hence  in  these  cases  we  utilize 
advantageously  the  tonic  effect  of  hot  douches  by  com- 
bining more  or  less  the  mechanical  effects  of  pressure, 
gradually  increased  and  adapted  to  the  case. 

This  brief  outline  of  the  rationale  of  the  action  of  water 
upon  the  human  organism  may  be  fitly  concluded  by 
explaining  the  manner  in  which  it  may  be  applied  thera- 
peutically. 

We  have  several — indeed  numerous — methods  of  ap- 
plying water  externally,  all  of  which  aim  to  deduce  some 
curative  or  palliative  result  from  the  application  of  those 
principles  of  hydrotherapy  which  have  been  briefly  for- 
mulated under  the  term  rationale. 

But  we  are  capable  of  applying  water  in  the  treatment 
of  disease  with  greater  accuracy  and  more  extensive  lati- 
tude in  resultant  effect  than  is  possible  from  the  applica- 
tion of  medicinal  agents.    J  do  not  say  this  in  depreca- 
1  Blaetter:  fuer  Klin.  Hydrotherapie,  January,  1892. 


522 


MEDICAL   RECORD. 


[October  27,  1894 


tion  of  the  latter,  whose  value  no  one  is  more  ready  to 
acknowledge  than  myself. 

To  substantiate  this  proposition,  allow  me  briefly  to 
point  out  that  we  have  three  elements  of  increasing  and 
diminishing  the  therapeutic  effect  of  water  upon  the  or- 
ganism, viz.,  temperature,  duration,  and  pressure. 

That  the  temperature  is  capable  of  modifying  the 
effect  of  water  is  well  known.  A  very  high  or  a  very  low 
temperature  produces  destruction  of  tissue,  while  moder- 
ately hot  water  produces  a  rubefacient  effect. 

The  difference  in  the  effect  of  a  bath  or  other  hydriatric 
procedure  at  ioo°  F.,  and  one  at  450  F.,  need  but  to  be 
mentioned  to  be  appreciated,  and  it  cannot  be  denied 
that  every  five  degrees  more  or  less  between  these  two  ex- 
tremes must  produce  a  different  effect  in  the  same  indi- 
vidual. 

That  the  duration  of  a  bath  or  other  procedure  is  capa- 
ble of  modifying  the  effect  of  the  latter  is  also  known. 

It  would  be  easily  appreciated  by  the  experiment  of  dip- 
ping one  hand  into  water  at  400  F.  for  two  seconds,  and 
drying  it  with  friction  ;  and  then  putting  the  other  hand 
into  the  same  water  for  ten  minutes,  and  drying  with  fric- 
tion. In  the  first  case  we  would  obtain  the  stimulating  effect 
with  a  fine  glow  and  well  filled,  ruddy,  cutaneous  vessels ; 
while  in  the  second  instance  we  would  have  a  shrivelled 
skin,  of  a  cyanotic  hue,  cold  and  clammy,  which  many 
minutes,  if  not  hours,  of  friction  would  be  required  to 
react  from. 

It  may  not  be  so  evident  that  every  second  of  time  of 
exposure  to  a  hydriatric  procedure  of  the  same  tem- 
perature may  alter  its  effect.  But  this  is  really  a  fact,  of 
which  anyone  can  be  convinced  by  personal  observation. 

Pressure. — Although  the  modifying  influence  of  tem- 
perature and  duration  is  usually  recognized,  the  effect  of 
pressure  is  not  so  generally  appreciated. 

A  pressure  of  four  atmospheres  driving  a  stream  of 
water  of  any  temperature  through  a  very  minute  opening 
produces  destruction  of  the  skin  upon  which  it  impinges. 

During  one  of  the  meetings  of  the  staff  of  the  Monte- 
fiore  Home  a  good  deal  of  amusement  was  created  by 
drilling  small  apertures  into  the  thumbs  of  some  very 
skeptical  colleagues,  by  means  of  the  douche  fiUforme  of 
Lauriat. 

Driving  water  at  the  same  pressure  through  a  larger 
aperture  will  produce  a  rubefacient  effect,  while  a  stream 
of  still  less  pressure  will  produce  a  temporary  blush  only. 

Thus  we  may  produce  the  destructive  effect  of  a  caus- 
tic, or  blister,  or  the  rubefacient  effect  of  mustard  by 
simply  varying  the  pressure  with  water  of  the  same  tem- 
perature. 

When  a  stream  of  water  at  50°  F.  is  driven  upon  the 
body  under  a  pressure  of  two  atmospheres,  the  depress- 
ing (chilling)  effect  of  the  low  temperature  is  counter- 
acted by  the  massage  and  friction  due  to  the  forcible  im- 
pact. 

The  skin  emerges  from  such  an  application  in  a  glow. 
If  the  same  individual  be  bathed  by  the  pouring  of  the 
water  oyer  her  body  from  a  sponge,  the  effect  would  be 
depressing  (chilling),  and  so  much  greater  reactive  capa- 
city would  be  required  on  the  part  of  the  individual  that 
an  attendant  would  be  necessary  to  aid  it  by  friction. 

It  is  plain,  therefore,  that  we  have  a  safe  latitude  of 
seventy  degrees  (400  to  no°  F.)  in  temperature;  a  safe 
latitude  from  one  second  to  many  minutes  in  duration ; 
a  safe  latitude  up  to  thirty  pounds  in  pressure,  by  means 
of  which  we  may  modify  the  effects  of  hydriatric  proced- 
ures. 

Besides  these  mathematically  ascertainable  elements  of 
a  hydriatric  prescription  we  have  various  modifications 
in  hydriatric  technique,  as  baths,  packs,  ablutions, 
douches,  etc.,  by  means  of  which  we  may  again  render 
the  effect  very  flexible. 

One  who  has  had  occasion  to  observe  this  flexibility  of 
hydriatric  measures  cannot  fail  to  be  convinced  that  no 
similar  effect  is  deducible  from  medicinal  agents. 

It  id  difficult  if  not  impossible  (selecting  a  powerful 
remedy  for  illustration)  to  ascertain  by  any  reliable  test 


if  there  be  a  difference  in  the  effect  of  strychnia  upon 
the  pulse,  respiration,  digestion,  or  tissue-change  pro- 
duced by  any  non-toxic  dose  (from  say  ^  grain  to  -fa). 
I  am  not  aware  of  such  facts  having  been  ascertained. 

All  the  so-called  physiological  effects  described  by 
Horatio  Wood  and  others  are  predicated  upon  poisonous 
doses,  not  upon  medicinal  doses. 

The  same  observation  may  be  made  upon  many  other 
valuable  agents.  Unless  toxic  doses,  or  doses  closely  ap- 
proaching these  be  used,  there  is  no  definite  clinical  or 
rational  difference  ascertainable. 

Hydriatric  procedures,  on  the  contrary,  are  so  flexible, 
they  may  be  administered  by  such  a  variety  of  methods, 
that  their  effect  may  be  definitely  dosed,  as  it  were,  and 
correctly  ascertained. 

In  conclusion,  I  would  offer  some  illustrations  of  the 
rationale  of  a  hydriatric  procedure. 

Place  a  patient  suffering  from  any  severe  infectious  dis- 
ease, with  high  temperature,  into  a  bath  of  700  F.  for  fif- 
teen minutes,  practise  active  friction,  and  observe  the  re- 
sult. 

Elevated  temperature,  rapid  and  perhaps  feeble  pulse, 
shallow  respiration,  dulled  intellect,  lost  appetite,  con- 
centrated and  scant  urinary  and  other  secretions  indi- 
dicate  that  the  nervous  system  is  overwhelmed  by  the 
products  of  infection.  So  soon  as  he  enters  the  water 
he  gasps.  The  shock  and  subsequent  stimulus  to  the 
cutaneous  surfaces  are  conveyed  to  the  nerve-centres 
and  thence  reflected  to  the  heart,  lungs,  and  the  other 
organs. 

Observation  at  the  bedside  at  once  renders  these  effects 
patent.  The  first  effect  is  a  refreshment,  an  enlivenment 
of  the  cerebrum.  The  eyes  are  opened ;  the  face  loses  its 
apathetic  stare ;  consciousness  returns  after  one  or  more 
baths;  the  inspiration  is  deepened ;  expectoration  is  fa- 
cilitated ;  the  widening  of  the  peripheral  vessels  and  the 
stimulation  of  their  coats  relieve  the  heart ;  blood  press- 
ure is  increased,  and  the  laboring  organ  becomes  as 
quiet  as  does  a  sea-tossed  ship  in  the  hands  of  a  skilled 
mariner.  The  secreting  glands  are  aroused  to  activity. 
Moreover,  the  temperature  is  reduced,  not  so  violently 
as  by  medicinal  agents,  but  more  definitely,  more  in  ac- 
cord with  normal  tendencies.  In  brief,  all  the  manifes- 
tations of  the  disease  are  favorably  influenced  because  the 
normal  standard  is  slowly  but  steadily  and  lastingly  ap- 
proximated under  the  influence  of  repeated  judicious 
bathing. 

Even  the  most  exacting  demands  of  the  most  recent 
ideas  are  met  by  this  treatment. 

Metchnikoff  has  shown  by  his  interesting  studies  that 
inflammation  is  the  phagocytic  reaction  of  the  organism  to 
an  irritant.  Cells  are  phagocytes,  hungry  to  devour  any 
toxine  or  microbe  that  may  find  entrance  into  the  blood. 

We  may  successfully  aid  the  system  in  this  "  reaction 
against  toxines  "  by  endowing  its  main  vitalizing  agent, 
the  nerve-centres,  with  vigor,  by  furthering  elimination 
from  the  skin  and  kidneys,  by  removing  hyperemia  of 
the  organs,  and  facilitating  the  passage  of  phagocytes  into 
the  tissues ;  but  more  especially  by  rendering  the  blood 
more  alkaline,  and  thus  more  favorable  to  the  phago- 
cytes. 

A  lack  of  recognition  of  these  principles  involved  in 
the  Brand  bath  in  typhoid  fever  leads  to  disappointment 
and  disaster. 

If,  for  instance,  the  temperature  and  duration  are  not 
properly  adapted  to  the  case,  the  shock  and  subsequent 
stimulus  are  modified ;  if  the  frictions  of  the  surface  are 
omitted,  the  widening  of  the  peripheral  vessels  is  pre- 
vented and  cyanosis  will  result,  instead  of  the  ruddy  hue 
of  the  skin,  with  consequent  depressing  effect  upon  the 
heart.  The  latter,  instead  of  being  aided  by  the  tonic 
widening  and  responsive  elasticity  of  the  cutaneous  ves- 
sels, will  remain  contracted,  and  thus  embarrass  the 
heart. 

Collapse  ensues,  with  feeble  pulse,  Cheyne-Stokes-like 
breathing,  an  effect  so  rare  after  the  application  of  this 
bath  according  to  its  correct  rationale  that  I  have  never 


October  27,  1894] 


MEDICAL   RECORD. 


523 


seen  it,  but  an  effect  of  which  we  often  hear,  in  discus- 
sion, attributed  to  the  cold  bath,  instead  of  its  improper 
application. 

That  there  is  need  for  a  good  deal  of  missionary  work 
on  this  subject  I  have  frequent  opportunity  of  observ- 
ing. As  an  example,  allow  me  to  briefly  cite  a  case  in 
point.  Two  months  ago  I  was  asked  to  see,  in  consulta- 
tion with  an  intelligent  and  experienced  colleague,  a 
child  of  two  years,  in  the  latter  part  of  the  third  week  of 
scarlatina.  Desquamation  was  proceeding.  The  child 
was  suffering  from  enormous  cervical  glands,  jactitation 
with  partial  stupor,  very  high  temperature,  feeble  pulse — 
in  short,  a  clear  case  of  sepsis.  The  attendant  recited 
the  difficulty  of  controlliug  the  temperature  by  aconite, 
phenacetin,  quinine,  and  concluded  with  the  statement 
that  even  baths,  against  which  he  claimed  to  be  preju- 
diced, had  proved  ineffectual  because  the  child  collapsed 
in  them. 

On  inquiry  I  learned  that  the  baths  were  applied  fif- 
teen minutes,  beginning  with  a  temperature  of  no°F., 
and  reducing  gradually  to  8o°  F. !  If  a  correct  rationale 
had  been  followed,  such  a  bath  would  not  have  been 
ued 

The  object  in  view  was  to  lull  the  patient  to  rest,  to 
reduce  temperature  and  improve  the  heart's  action.  That 
a  temperature  of  uo°  F.  would  produce  the  opposite  ef- 
fect it  would  seem  patent  enough  even  to  one  who  has 
not  studied  the  rationale  of  hydrotherapy. 

But  to  disturb  a  child  in  this  condition  by  the  splash- 
ing and  noise  necessary  to  reduce  the  bath  to  8o°  F.,  to 
allow  water  at  such  a  low  temperature  to  come  into  con- 
tact with  a  tender  partially  denuded  skin,  even  by  slow 
degrees,  is  entirely  opposed,  as  you  will  perceive,  to  the 
rationale  I  have  offered.  A  bath  of  95  °  F.  for  eight  min- 
utes fulfilled  the  indications  effectively. 

A  few  days  ago  a  phthisical  patient  in  my  wards  at 
the  Manhattan  Hospital,  who  was  receiving  considerable 
benefit  from  a  dry  pack,  followed  by  ablutions  at  80 °  F., 
reduced  daily  until  6o°  F.  was  reached,  was  asked  how  he 
liked  the  cold  ablutions.  His  reply  was  that  he  liked  the 
treatment,  and  that  he  had  received  it  in  another  hospital 
where  they  had  even  put  him  in  tubs  of  ice-water. 

Patients  subjected  to  improper  hydriatric  procedures 
fortunately  do  not  die  from  them,  they  do  not  even  suf- 
fer materially  in  most  cases,  but  the  remedial  effect  is 
neutralized,  if  not  entirely  thwarted,  by  a  disregard  of 
the  true  rationale  f  and  thus  hydrotherapy  comes  into 
unmerited  disrepute. 

This  is  my  chief  reason  for  bringing  this  subject  to 
your  attention.  I  ask  you  to  give  the  same  clinical  study 
to  the  remedial  uses  of  water  which  you  have  devoted  to 
the  study  of  medicinal  agents  (not,  however,  to  the  neg- 
lect of  the  latter).  I  ask  you  not  to  condemn  this  valu- 
able agent  until  you  have  tried  it  fairly  according  to  the 
principles  which  are  briefly  pointed  out  in  this  paper, 
and  which  will  amply  repay  more  elaborate  investiga- 
tion. Having  mastered  these  principles  you  will  find 
that  the  clinical  application  of  water  will  afford  you  not 
only  an  auxiliary  to  the  ordinary  treatment  of  diseases, 
especially  those  which  have  become  chronic  and  intrac- 
table, but  in  many  desperate  cases  it  will  prove  a  last  but 
effective  resort. 

In  chlorosis  that  has  resisted  iron,  in  the  various  obsti- 
nate digestive  troubles,  in  phthisis,  chronic  rheumatism, 
and  neuralgia,  in  neurasthenia  and  other  functional  neu- 
roses, in  the  faulty  nutrition  of  many  organic  diseases,  I 
have  been  able  to  confirm  the  opinions  oi  Draper,  Sem- 
mola,  Erb,  Charcot,  Leyden,  and  other  clinicians,  that  we 
have  in  hydrotherapy  an  agent  of  great  power  which  is 
not  sufficiently  recognized  by  the  profession.  I  have 
come  to  regard  no  case  as  hopeless  until  a  judicious  and 
methodical  application  of  water  has  proven  ineffectual. 


Dr.  Heinrich  Pasehkis  has  assumed  editorial  manage- 
ment of  the  International  Klinische  Rundschau  of  Vi- 
enna, formerly  edited  by  Dr.  Arthur  Schnitzler. 


THE    ACTION    OF    ELECTRICITY    ON    THE 
SYMPATHETIC   NERVOUS  SYSTEM.1 

By  A.   D.   ROCKWELL,   M.D., 


The  influence  exerted  by  electricity  upon  the  sympa- 
thetic system  of  nerves  is  a  subject  of  exceeding  interest. 
There  can  be  no  question  in  regard  to  the  phenomena 
that  attend  the  direct  applications  of  either  current  in 
physiological  investigations,  and  it  is  not  surprising  that 
those  who  first  witnessed  these  phenomena  regarded  them 
as  significant  of  the  possibilities  of  this  agent  in  the 
treatment  of  diseased  states  of  the  central  nervous  system. 
Unfortunately,  external  or  percutaneous  applications  of 
electricity — galvanic  or  faradic — failed  in  great  measure 
at  that  time  to  substantiate  the  hopes  entertained,  and 
the  therapeutic  results  in  those  cases  where  the  sympa- 
thetic was  supposed  to  be  involved,  were  altogether  un- 
satisfactory. We  do  not  have  to  seek  far  for  the  causes 
of  this  failure.  They  are  to  be  found  in  an  incorrect 
appreciation  of  the  relation  of  electricity  to  the  human 
body,  based  upon  an  imperfect  knowledge  of  the  physics 
of  electricity,  and  the  lack  of  suitable  appliances  and  in- 
struments of  precision. 

In  view  of  the  wide  field  opened  to  us,  in  case  it  can 
be  demonstrated  that  in  therapeutic  doses  electricity  can 
be  made  to  appreciably  affect  the  deeper  nerve  struct- 
ures, it  seems  to  me  most  desirable  to  gather  together 
some  of  the  facts  bearing  upon  this  interesting  question. 
This  seems  to  be  the  more  necessary  because  there  are 
many  who  honestly  doubt  the  possibility  of  electrically 
stimulating  any  part  of  the  central  nervous  system  by 
ordinary  percutaneous  methods  of  application.  Cer- 
tainly no  one  who  has  witnessed  an  execution  by  elec- 
tricity can  doubt  its  power  to  directly  influence  the  most 
distant  organs ;  and  if  fifteen  hundred  volts  will  instant- 
ly paralyze  every  bodily  function,  would  it  not  be  strange 
if  fifty  volts,  or  one-fiftieth  of  the  power  necessary  to 
kill,  possessed  no  influence  on  the  brain  and  the  deeper- 
seated  nerve- structures?  Reasoning  from  analogy,  the 
facts  are  all  in  favor  of  this  probability,  for  in  the  admin- 
istration of  drugs  far  less  than  one  fiftieth  of  the  dose 
necessary  to  destroy  life  is  often  productive  of*  appreci- 
able therapeutic  effects. 

We  possess^. very  few  pathological  facts  in  support  of 
the  sympathetic  origin  of  disease,  and  therefore,  in  study- 
ing this  question,  and  the  one  that  I  am  about  to  briefly 
consider,  viz.,  the  action  of  electricity  on  the  s)mpa- 
thetic,  it  will  be  instructive  to  refer,  1,  to  the  effects  of 
electrization  on  the  exposed  sympathetic,  and  to  a  few 
of  the  ascertained  facts  in  regard  to  the  influence  of  the 
sympathetic  on  the  functional  activity  of  various  or- 
gans ;  2,  to  ascertain  phenomena  observed  after  per- 
cutaneous applications  in  the  neighborhood  of  the  s)m- 
pathetic;  3,  to  clinical  observations  illustrating  the 
effects  of  applications  of  electricity  to  the  neck  in  cer- 
tain conditions  supposed  to  be  dependent  upon  disordeis 
of  the  sympathetic 

Beginning  with  the  original  experiments  of  Claude 
Bernard  as  far  back  as  1832,  we  find  that  division  of  the 
sympathetic  causes  a  multitude  of  phenomena.  The 
cornea  flattens,  the  pupil  contracts,  the  globe  of  the  eye 
retracts,  the  palpebral  fissure  decreases  in  size,  the  con- 
junctiva reddens,  and  there  is  a  very  positive  elevation 
of  temperature  due  to  a  general  dilatation  of  the  vessels 
of  the  head  and  neck  on  the  side  operated  upon.  Elec- 
trical stimulation  of  the  cephalic  extremity  of  the  severed 
nerve,  on  the  contrary,  causes  the  vessels  to  contract,  and 
all  the  various  phenomena  to  disappear  for  the  time  being. 

The  influence  of  the  vaso-  motor  nerves  of  the  eye  was 
made  evident  a  century  ago  by  the  investigations  of 
Pourfour  du  Petit.  The  vessels  of  the  iris  dilate  on  di- 
vision of  the  sympathetic,  followed  by  immediate  con- 
traction when  the  peripheral  extremity  of  the  nerve  is 
submitted  to  electrical  excitation. 

>  Read  before  the  American  Electro-Therapeutic  Association,  Sep- 
tember as,  2894. 


524 


MEDICAL  RECORD. 


[October  27,  1894 


Brown  Sequard,  experimenting  upon  guinea-pigs  and 
rabbits,  by  dividing  the  cervical  sympathetic,  found  after 
the  lapse  of  a  few  months  an  appreciable  atrophy  of  the 
brain  of  the  same  side. 

That  the  intercranial  blood  pressure  is  in  some  degree 
regulated  by  the  cervical  sympathetic,  seems  altogether 
probable  on  account  of  the  anatomical  relationship. 
The  nerves  of  the  pia  mater,  and  those  associated  with 
the  vessels  of  the  cortical  substance,  are  traced  back  to 
the  sympathetic  plexus,  irritation  of  which  causes  im- 
mediate contraction  of  the  cranial  vessels.  Perhaps  the 
most  conclusive  experiments  in  this  direction  were  made 
by  Fisher1  in  1875.  With  the  aid  of  a  hsemato-dyna- 
mDmeter,  he  was  enabled  to  show  that  faradization  of 
the  exposed  sympathetic  of  a  horse  resulted  in  a  con- 
stant increase  of  arterial  pressure,  as  well  as  increased 
tension  of  the  arterial  walls. 

Intestinal  peristalsis  is  undoubtedly  more  or  less  under 
the  influence  of  the  sympathetic;  the  movements  of  the 
intestines  in  animals  being  arrested  on  irritation  of  the 
splanchnic  nerve,  while  the  thoracic  and  abdominal 
sympathetic  impart  accelerating  influences  to  these 
movements.  The  uro  genital  apparatus  also,  including 
the  bladder,  the  ureters,  seminal  vesicles,  and  the  uterus, 
respond  to  experimental  irritation  of  the  sympathetic 
plexus  of  the  abdominal  cavity. 

The  secretory  processes  of  the  body  depend  largely 
upon  the  influence  of  the  vasomotor  branches  of  the 
sympathetic,  the  secretion  of  the  gastric  juice  being  car- 
ried on  automatically  by  the  ganglia  situated  in  the  walls 
of  the  stomach.  The  nutrition  of  the  mucous  membrane 
must  in  a  measure  be  dependent  upon  this  system  of 
nerves,  since  extirpation  of  the  solar  plexus  is  followed 
by  hyperemia,  extravasation  of  blood,  and  ulceration. 
Stimulation  and  extirpation  of  the  abdominal  sympathet- 
ic plexuses,  affect  the  intestinal  secretion,  the  evacuation, 
and  the  general  nutrition  of  the  intestines.  The  vaso- 
motor nerves  of  the  liver  are  derived  from  the  sympathet- 
ic. These  nerves  have  their  origin  near  the  floor  of  the 
fourth  ventricle  of  the  brain,  entering  the  sympathetic, 
and  thence  with  the  blood-vessels  pass  to  the  gland  it- 
self. Puncture  of  these  vasomotor  nerves  produces 
paralytic  dilatation  of  the  vessels  and  the  production  of 
sugar — the  same  results  that  follow  puncture  of  the  floor 
of  the  fourth  ventricle  itself.  These  effects  were  supposed 
to  be  produced  by  stimulation,  but  the  experiments  of 
Cyon  and  Aladoff,  in  187 1,  made  it  quite  evident  that  the 
appearance  of  sugar  in  the  urine  came  not  from  stimula- 
tion, but  from  paralysis,  of  the  sympathetic.  Not  only 
did  they  find  that  removal  of  the  cervical  ganglia  of 
the  sympathetic  was  invariably  followed  by  diabetic  symp- 
toms, but  also  when  the  nerve-branches,  central  and 
peripheral,  with  which  it  is  connected,  are  divided.  In- 
terference with  the  function  of  the  sympathetic  affects 
the  excretion  from  the  kidneys  in  more  ways  than  the 
elimination  of  sugar.  Albuminuria,  hematuria,  with 
quantitative  and  qualitative  changes  in  the  urine,  to- 
gether with  disturbances  in  the  nutrition  of  the  kidney 
and  suprarenal  capsules,  have  often  been  observed.  The 
spleen  and  the  entire  genital  apparatus  also  have  inti- 
mate connection  with  the  sympathetic  through  their 
nerve-supply,  irritation  of  which  produces  marked  circula- 
tory disturbance  in  both  the  spleen  and  penis. 

Burckhardt2  and  Ziemssen's8  experiments  upon  the 
dead  body  indicate  the  possibility  of  directly  affecting 
the  cervical  sympathetic  through  percutaneous  applica- 
tion of  the  galvanic  current.  They  thrust  partially  insu- 
lated needles  into  the  sympathetic  from  behind,  con- 
necting their  free  ends  with  a  sensitive  galvanometer. 
Electrodes  connected  with  a  galvanic  battery  were 
placed,  one  near  the  angle  of  the  lower  jaw,  and  the 
other  at  the  manubrium  sterni,  and  when  the  circuit  was 
closed  the  movements  of  the  needle  indicated  the  ac- 
tion of  an  electric  current  on  the  nerve  itself. 

1  Deutsches  Archiv  fur  Klinische  Medicin. 

"Ibid.,  1878. 

*  Die  Electricitat  in  der  Medicin. 


Again,  if  one  electrode,  the  anode,  is  placed  at  the  man- 
ubrium sterni,  or  in  the  neighborhood  of  the  alio- spinal 
centre,  and  the  cathode  at  the  inner  border  of  the  sterno- 
cleido  muscle,  a  little  below  the  auriculo-maxillary  fossa, 
and  a  current  of  sufficient  strength  employed,  the  pupil 
of  the  same  side  may  be  made  to  instantly  dilate  on  clos- 
ing the  circuit,  followed  by  a  gradual  contraction.  The 
difficulty  of  demonstrating  this  phenomenon  in  most  per- 
sons is  due  to  their  susceptibility  to  the  action  of  the 
current,  many  suffering  from  extreme  vertigo,  and  even 
nausea  and  faintness,  before  the  current  is  sufficiently 
strong  to  produce  contractions  visible  to  the  unaided 
eye.  By  the  aid  of  the  pupillascope,  however,  it  has 
been  found  possible  to  detect  these  changes  in  the  eye 
with  even  exceedingly  weak  currents.  Changes  in  the 
pupil  so  slight  as  to  escape  direct  observation,  are  yet  as- 
sociated on  the  retina  with  what  are  called  dispersion 
circles,  the  character  of  which  accords  with  the  degree  of 
contraction  or  dilatation  of  the  iris.  While  it  seems  to 
be  entirely  probable  that  the  dilatation  and  subsequent 
contraction  of  the  pupil  on  closing  the  circuit,  are  due 
to  the  action  of  the  current  on  the  sympathetic  pupillary 
branches,  nevertheless,  it  is  impossible  not  to  take  into 
consideration  the  fact  that  reflex  influences  are  potent 
factors  frequently  in  the  movements  of  distant  parts,  and 
therefore  in  these  experiments  there  is  some  ground  for 
the  claim  that  pupillary  changes  may  be  reflex  in  charac- 
ter. 

The  circulation  is  unmistakably  influenced  by  strong 
and  prolonged  applications  of  electricity  to  the  neck  and 
neighboring  parts,  and  the  reason  why  the  test  fails  ex- 
perimentally in  so  many  cases,  is  because  of  the  inability 
of  the  ordinary  subject  to  endure  the  necessary  strength 
of  current. 

In  the  many  tests  that  I  have  made  to  determine 
whether  or  no  it  is  possible  to  get  any  appreciable  elec- 
trical effect  upon  the  sympathetic  by  percutaneous  ap- 
plications, I  have  occasionally  met  with  interesting  and 
suggestive  results.  Everyone  who  has  much  to  do  with 
the  medical  application  of  electricity,  is  aware  how 
varied  is  the  susceptibility  to  its  effects.  The  two  fol- 
lowing records  are  interesting  illustrations  of  this  fact, 
and  of  the  probability  of  direct  electrical  stimulation  of 
the  sympathetic  by  external  applications. 

Case  I. — Male,  aged  thirty- one,  with  a  normal  pulse 
of  75.  An  electrode  of  plastic  sculptor's  clay,  3  ctm. 
in  diameter,  and  connected  with  the  positive  pole  of  a 
galvanic  battery,  was  applied  to  the  hollow  just  above 
the  clavicle,  at  its  juncture  with  the  sternum.  The  cur- 
rent was  gradually  increased  to  75  m.,  which  caused  a 
decrease  in  the  frequency  of  the  pulse  of  ten  beats  in  less 
than  one  minute,  and  this  decrease  in  the  rapidity  of  the 
heart's  action  continued  so  long  as  the  electrodes  re- 
mained in  position.  On  removing  them  the  pulse 
would  almost  immediately  increase  to  its  normal  fre- 
quency, and  also  the  respiration,  which  was  invaria- 
bly affected  equally  with  the  pulse.  The  results  in  this 
case  clearly  depended  for  the  most  part  on  stimulation 
of  the  inhibitory  fibres  of  the  pneumogastric,  and  the 
fall  in  the  heart-beats  may  have  borne  no  relation  what- 
ever to  the  sympathetic  system.  None  the  less,  how- 
ever, was  the  test  of  value  in  demonstrating  the  possi- 
bility of  influencing  the  deeper  seated  nerve-structures 
by  currents  of  sufficient  strength.  Only  occasionally 
can  a  person  be  found  who  can  endure  such  a  strength 
of  current  through  small  electrodes,  and  placed  as  indi- 
cated ;  but  few  opportunities,  therefore,  have  been  af- 
forded of  getting  so  striking  a  result.  I  have  observed 
the  good  effects  of  electricity  in  chloroform  poisoning, 
but  not  through  the  use  of  the  galvanic  current,  the 
tendency  of  which  is  undoubtedly  to  inhibit  the  action 
of  the  heart.  The  induced  current,  as  ordinarily  ap- 
plied, certainly  does  not  affect  the  inhibitory  fibres  con- 
trolling the  action  of  the  heart,  and  its  undoubted  influ- 
ence over  respiration  must  be  ascribed  to  the  action  of 
the  current  on  the  accelerating  fibres  of  the  vagus  and 
sympathetic  that  refer  to  the  respiration.    The  induced 


October  27,  1894] 


MEDICAL  RECORD. 


525 


current  of  electricity,  therefore,  does  good  in  chloroform 
narcosis  in  increasing  respiratory  activity,  the  strength 
of  current  necessary  for  this  purpose  being  insufficient 
to  materially  interfere  with  the  movements  of  the  heart 
through  its  action  on  the  inhibitory  fibres  of  the  vagus 
that  control  it. 

The  next  record,  as  compared  with  the  first,  illustrates 
how  varied  are  the  susceptibilities  of  different  indivi- 
duals to  the  effects  of  electricity. 

Case  II. — Female,  aged  twenty-three,  with  a  normal 
pulse  of  72.  Electrodes  of  the  same  size  and  applied  as 
in  the  previous  case;  and  yet  15  to  20  m.,  was  all  this 
patient  could  possibly  bear  without  a  tendency  to  faint- 
ness  and  nausea.  Confining  the  strength  of  the  current 
to  a  point  below  the  production  of  these  symptoms,  it 
was  most  interesting  to  note  its  very  positive  effects 
upon  the  pulse.  This  effect  was  not  immediate,  as  in  the 
former  case,  when  currents  of  far  greater  strength  were 
used;  but  by  keeping  the  electrodes  in  position  for 
several  minutes,  it  was  found  that  the  pulse  would  inva- 
riably sink  to  65.  I  have  at  the  present  time  under 
observation  a  young  man  aged  twenty-two,  with  a 
remarkably  torpid  circulation.  His  pulse  seldom  rises 
above  48,  and  under  the  influence  of  a  strong  current  it 
can  at  will  be  reduced  to  43.  If  these  effects  upon  the 
pulse  are  due,  as  is  probably  the  case,  to  a  stimulation  of 
the  inhibitory  function  of  the  pneumogastric,  it  is  only 
an  additional  argument  in  favor  of  electrically  influencing 
the  sympathetic ;  for  if  the  vagus  is  influenced  by  per- 
cutaneous applications,  the  sympathetic  ought  also  to  be 
affected  as  the  threads  of  current  pass  from  pole  to 
pole. 

Exophthalmic  Goitre. — In  support  of  the  sympathetic 
origin  of  exophthalmic  goitre,  we  have  the  well  known 
fact  that  division  of  the  cervical  sympathetic  in  animals 
is  followed  by  a  train  of  symptoms  that  are  most  sugges- 
tively in  accord  with  those  of  Basedow's  disease,  and 
the  further  fact  that  in  a  certain  limited  number  of  cases 
pathological  anatomical  changes  have  been  found  in  the 
sympathetic  after  death. 

Among  the  many  special  phenomena  that  point  to 
this  causal  relationship,  there  is  one  of  special  interest 
referable  to  the  eye.  It  is  a  common  observation  that 
ordinarily,  when  the  plane  of  vision  is  altered,  the  move- 
ments of  the  eyeball  upward  or  downward  are  closely 
followed  by  the  upper  eyelid.  In  exophthalmic  goitre 
the  eyelid  does  not  follow  the  movements  of  the  eyeball, 
and  the  cause  of  this  deficient  mobility  Von  Graefe  as- 
cribed to  innervation  of  Muller's  unstriped  ocular  mus- 
cles, which  receive  their  nerve-supply  directly  from  the 
sympathetic  nerve.  To  my  mind,  however,  one  of  the 
strongest  arguments  in  favor,  not  only  of  the  sympathetic 
origin  of  this  disease,  but  also  of  the  possibility  of  di- 
rectly influencing  the  sympathetic  by  the  galvanic  cur- 
rent, relates  to  my  personal  experience  in  the  treatment 
of  exophthalmic  goitre. 

I  published  in  the  New  York  Medical  Record  of  Sep- 
tember 30,  1893,  an  article  on  the  treatment  of  this  dis- 
ease, based  on  45  consecutive  cases,  in  which  the  results 
of  electrical  treatment  were  so  pronounced  in  a  large 
proportion  of  the  cases,  that,  admitting  the  disease  to  be 
dependent  on  sympathetic  disturbance,  there  can  be  lit- 
tle question  but  that  these  results  were  in  the  main  due 
to  the  action  of  the  current  upon  the  sympathetic.  The 
following  case  furnishes  very  strong  evidence  in  support 
of  this  assertion. 

Case  III. — Miss  C ,  aged  twenty-three,  came  to 

me  in  September,  1893,  with  the  three  cardinal  symp- 
toms of  exophthalmic  goitre  quite  distinctly  present.  The 
pulse  was  115,  the  eyes  prominent,  and  the  thyroid  con- 
siderably enlarged.  These  symptoms  had  been  coming 
on  for  about  three  years,  and  in  connection  with  the  pro- 
tuberance of  the  eye,  the  patient  called  my  attention  to 
a  marked  dilatation  of  the  pupil  of  the  right  eye,  which 
she  only  observed  a  few  weeks  before,  and  shortly  after 
the  occurrence  of  a  feeling  of  pressure  in  the  neck  and  a 
slight  feeling  of  suffocation.    The  tumor  was  highly  vas- 


cular, made  of  tortuous  blood-vessels,  and  not  of  firm  thy- 
roid tissue. 

It  was  evident  that  the  oculo-pupillary  fibres  of  the 
sympathetic  were  involved,  and  that  the  irritation  caus- 
ing the  well  marked  and  persistent  mydriasis  must  be 
due  to  the  pressure  of  the  enlarged  blood-vessels  upon 
the  sympathetic.  Applications  of  the  galvanic  current 
were  soon  followed  by  some  appreciable  amelioration  of 
the  symptoms,  but  the  point  most  interesting  was  the 
fact  that  the  pupil  began  immediately  to  decrease  in  size, 
and  became  entirely  normal,  before  there  was  any  change 
in  the  prominence  of  the  eyes,  the  rapidity  of  the  pulse, 
or  even  in  the  size  of  the  thyroid  itself.  Such  pressure, 
however,  as  had  been  sufficient  to  produce  this  oculo- 
pupillary  symptom  had  been  relieved,  and  this  could  have 
only  come  through  a  contraction  of  the  enlarged  vessels, 
and  through  treatment  having  a  direct  influence  over 
the  sympathetic. 

We  have  in  this  case  an  illustration  of  a  simple  irrita- 
tion as  distinguished  from  a  paralyzed  condition  of  the 
sympathetic.  I  am  aware  that  damage  to  this  nerve 
more  frequently  produces  a  paralysis  with  myosis  than  a 
simple  irritation  with  mydriasis,  but  it  has  been  shown 
that  those  causes  that  produce  ultimately  a  paralysis  of 
the  sympathetic,  may  primarily  induce  only  irritation. 
A  case  was  reported  by  Ogle  of  an  abscess  of  the  neck 
which,  as  it  enlarged,  occasioned  extreme  dilatation  of  the 
pupil;  the  dilatation  disappearing  after  a  quiet  sleep. 
Subsequently  the  pupil  became  much  contracted,  but 
upon  the  abscess  being  opened  and  the  pressure  relieved, 
the  pupil  became  normal.  The  explanation  offered  of 
these  phenomena  was  this :  The  inflammatory  exudation 
and  suppuration  associated  with  the  development  of 
the  abscess,  at  first  stimulated  the  pupillary  fibres,  pro- 
ducing mydriasis.  The  secondary  or  prolonged  effects 
of  the  compression,  however,  lessened  the  conducting 
power  of  the  nerve  fibres,  inducing  paralysis  and  myosis. 
In  the  case  which  has  just  been  related  the  condition 
was  primarily  one  of  irritation,  which  might  have  merged 
into  one  of  paralysis,  had  there  been  any  material  increase 
in  the  arterial  dilatation. 

Unilateral  Hyperidrosis. — Unilateral  hyperidrosis  is 
not  of  such  rarity  as  to  entitle  it  to  special  comment, 
without  it  offers  points  of  therapeutic  or  pathologic  inter- 
est. Notwithstanding  the  well*  known  experiments  in 
which  severance  of  the  sympathetic  in  horses  produced 
a  profuse  unilateral  perspiration,  the  pathology  of  this 
somewhat  unique  symptom  has  not  been  definitely  set- 
tled. Cases  of  unilateral  hyperidrosis,  many  of  them, 
indicate  not  the  slightest  evidence  in  other  respects  of 
sympathetic  disturbance,  but  a  few  cases  have  been  placed 
upon  record,1  which  seem,  with  considerable  certainty,  to 
point  to  paralysis  of  the  sympathetic  as,  in  some  instan- 
ces, the  cause  of  persistent  unilateral  hyperidrosis.  A 
case  reported  by  Seguin 2  indicated  on  examination  no 
change  to  the  naked  eye,  but  microscopically  there 
seemed  to  be  an  abundant  granular  pigment  filling  the 
ganglionic  cells,  although  both  sides  were  alike  in  this 
respect.  A  case  reported  by  Ebstein8  revealed  more 
definite  and  pronounced  pathological  changes.  The  pa- 
tient, a  man  of  sixty,  suffered  from  paroxysms  of  angina 
pectoris,  accompanied  by  hyperidrosis  of  the  left  side. 
Microscopic  examination  of  the  ganglia  of  the  left  sym- 
pathetic revealed  varicose  and  dilated  vessels,  with  per- 
fectly normal  nerve  tissue  upon  the  right  side.  Ebstein 
therefore  claimed  that  hyperidrosis  depended  on  a  tem- 
porary or  permanent  compression  of  the  sympathetic 
nerve-elements,  resulting  in  paralysis. 

The  case  that  I  herewith  report  is  of  value,  not  only 
because  of  the  associated  symptoms  indicating  an  involve- 
ment of  both  the  vasomotor  and  oculo-pupillary  fibres  of 
the  sympathetic,  but  because  the  results  of  treatment  gave 
further  evidence  of  the  sympathetic  origin  of  the  disease. 

»  Eulenburg  &  Guttman  :  Sympathetic  System  of  Nerves,  p.  58. 
■  American  Journal  of  the  Medical  Sciences,  October,  1872. 
»  Virchow's  Archiv,  1875,  Bd.  lxii.,  p.  435,  quoted  by  Eulenburg  and 
Guttman.  _, 


526 


MEDICAL   RECORD. 


[October  27,  1894 


Case  IV. — Mr.  M ,  aged  sixty-five,  was  referred 

to  me  by  Dr.  John  H.  Demorest,  of  New  York.  This 
patient  was  greatly  enfeebled,  was  suffering  from  diges- 
tive disorders,  and  in  addition  I  found  a  profuse  unila- 
teral hyperidrosis,  involving  the  right  side  of  the  head, 
face,  and  trunk  of  the  body,  the  right  arm,  and  to  a  less 
extent  the  right  leg  and  foot.  While  the  left  side  was 
abnormally  dry  at  all  times,  the  right  was  always  moist; 
the  median  line,  front  and  back,  sharply  defining  the 
two  conditions.  The  right  ear  was  also  hotter  and  red- 
der than  its  fellow,  and  with  it  was  associated  a  persist- 
ent congestion  of  the  conjunctivae.  In  addition  to  these 
vaso  thermic  phenomena  there  existed  a  considerable 
degree  of  myosis,  suggestive  of  paralysis  of  the  oculo- 
pupillary  as  well  as  the  vasomotor  fibres  of  the  sympa- 
thetic. This  patient  was  subjected  to  thorough  and 
persistent  treatment  by  both  the  galvanic  and  faradic 
currents  of  electricity,  and  with  results  of  the  most  pro- 
nounced character.  The  patient  did  not  regain  perma- 
nent health,  nor  strength,  and,  indeed,  finally  died  from 
exhaustion ;  but  the  hyperidrosis  lessened  very  consider- 
ably after  each  treatment,  and  would  occasionally  almost 
entirely  disappear,  while,  in  an  equal  degree,  the  pupil 
dilated  and  the  heat  and  congestion  decreased.  On  the 
whole,  it  seemed  to  me  a  very  satisfactory  test  of  the 
efficiency  of  electricity  in  directly  influencing  the  func- 
tion of  the  sympathetic. 

Hemiorania. — The  following  case  of  hemicrania  is 
still  another  interesting  example  of  the  probable  part 
played  by  the  sympathetic  as  a  causative  factor  in  dis- 
ease, and  strengthens  one's  belief  in  the  power  of  elec- 
tricity to  directly  affect  the  sympathetic. 

Case  V. — Mr.  F ,  aged  thirty-three,  had  for  some 

years  been  subject  to  frequent  and  violent  attacks  of 
right  hemicrania.  Whatever  tended  to  raise  the  blood- 
pressure  in  the  head  greatly  aggravated  the  distress. 
Daring  the  attacks  the  temporal  artery  became  hard 
and  tense;  the  face  pale  and  the  eye  sunken,  with  a 
narrowing  of  the  palpebral  fissure.  The  patient  had  in- 
termittent attacks  of  nausea,  with  alternations  of  un- 
natural dimness  and  clearness  of  vision ;  while  as  the 
paroxysm  subsided,  the  face  became  abnormally  red, 
and  both  the  eye  and  ear  considerably  injected.  The 
initial  and  prominent  symptoms,  such  as  the  condition 
of  the  temporal  artery,  the  paleness  of  the  fact,  and  the 
depressed  and  altered  condition  of  the  eye,  all  pointed 
to  a  persistent  contraction  of  the  muscular  coats  of  the 
vessels  on  the  side  supplied  by  the  cervical  branches  of 
the  right  sympathetic  nerve ;  while  the  nausea  and  sud- 
den changes  in  the  character  of  the  vision  indicated 
contemporaneous  changes  in  the  intra-cephalic  blood- 
pressure,  due  to  repeated  changes  in  the  calibre  of  the 
small  blood  vessels.  We  find  also  a  rational  explanation 
for  the  secondary  injection  and  increased  heat  of  the 
face,  eye,  and  ear,  in  the  changes  from  a  condition  of 
tetanic  spasm  to  a  state  of  relaxation  and  dilatation  of 
the  overstrained  vessels.  Such  a  very  positive  condition 
of  tonic  vascular  spasm  could  be  due  only  to  some  dis- 
turbance of  the  sympathetic  nerves. 

I  refer  to  the  treatment  of  this  case  by  the  galvanic 
current,  not  because  of  any  very  remarkable  therapeutic 
effects,  for  all  efforts  were  futile  in  entirely  overcoming 
these  paroxysmal  attacks,  but  as  an  evidence  of  the 
possibility  of  directly  affecting  the  sympathetic.  A  cur- 
rent strength  of  fifty  m.,  when  applied  to  the  neck 
during  a  paroxysm  of  pain,  gave  appreciable  relief  so 
long  as  the  treatment  was  continued,  and  for  a  consider- 
able time  thereafter.  No  sooner  were  the  electrodes  in 
position — one  on  the  cilio-spinal  centre,  and  the  other 
below  the  auriculo  maxillary  fossa,  and  the  current 
gradually  increased  until  20  m.  were  registered,  than  the 
pain  abated,  and  as  one  electrode  was  moved  down 
toward  the  manubrium  sterni,  and  the  strength  increased 
to  fifty  m.,  there  was  still  further  relief  and  change  of 
symptoms.  The  face  on  the  affected  side,  which  was  so 
pale  and  sunken,  became  almost  normal  in  appearance, 
and  appreciably  warmer,  the  ear  redder,  while  the  af- 


fected eye  opened  widely;  the  eyeball  standing  out  as 
prominently  as  its  fellow.  This  treatment  was  often 
repeated,  but  with  only  temporary  relief.  The  tendency 
to  these  attacks  of  hemicrania  was  not  materially  weak- 
ened, as  had  been  somewhat  confidently  expected  on 
account  of  the  very  marked  immediate  effects  of  the 
treatment. 

Progressive  Facial  Hemiatrophy.— From  the  fact 
that  this  disease  has  been  known  to  follow  mechanical 
injury  of  the  cervical  sympathetic,  it  seems  not  improb- 
able that  it  may  be  related  to  the  sympathetic,  rather 
than  to  the  trigeminus,  with  its  vasomotor  nerves  of 
nutrition. 

While,  so  far  as  I  am  aware,  there  are  no  recorded  cases 
of  cure,  or  even  material  benefit,  following  galvanization 
of  the  sympathetic,  yet  Brunner  reports  a  case  where  the 
galvanic  current  caused  a  reduction  in  the  rapidity  of  the 
heart's  action,  dilatation  of  the  pupil,  with  redness  and 
perspiration  of  the  face.  Eulenburg  and  Guttman  also 
report  a  case  of  this  kind,  where  galvanization  of  the 
neck  caused  a  reddening  of  the  affected  side  of  the  face 
that  lasted  some  hours. 

In  confirmation  of  these  reports,  I  recall  a  case  seen 
some  years  ago  at  the  clinic  of  the  New  York  Post  Gradu- 
ate School,  in  which  strong  galvanization  of  the  neck 
quite  perceptibly  increased  the  heat  and  redness  of  the 
atrophied  side. 


geognesB  of  iJfcedical  Scimtz. 

Treatment  of  Peripheral  Neuritis. —Professor  Ley- 
den  believes  that  in  the  case  of  neuritis  following  acute 
specific  diseases,  care  during  convalescence  as  to  nourish- 
ment, rest  in  bed,  and  avoidance  of  over-exertion  con- 
tribute to  prevent  its  occurrence.  "  Etiological  treat- 
ment "  (removal  of  the  cause)  in  neuritis  due  to  alcohol 
or  lead,  and  treatment  of  the  primary  malady  as  in  dia- 
betes, is  of  the  first  importance.  There  is  no  specific 
remedy  for  multiple  neuritis,  and  treatment  by  drugs 
does  not  play  a  very  important  part.  Owing  to  the  fact 
that  rheumatism  is  not  infrequently  an  element  in  the 
etiology,  salicylate  of  sodium  and  other  anti-rheumatic 
drugs  had  been  used,  without  producing  any  good  results 
in  the  majority  of  cases.  Iodide  of  potassium  was  of  use 
only  now  and  then,  and  mercury  was  of  doubtful  value. 
Antipyrin,  phenacetin,  exalgin,  euphorbia,  and  methy- 
lene blue  were  sometimes  of  use  for  the  relief  of  pain, 
but  it  was  often  necessary  to  resort  to  morphine,  chloral, 
sulphonal,  etc.  Strychnine,  formerly  much  used,  but 
lately  fallen  into  the  background,  deserved  to  be  tried ; 
by  increasing  the  excitability  of  the  affected  muscles  it 
favored  the  return  to  normal  function  and  nutrition ;  it 
ought  especially  to  be  resorted  to  in  progressive  cases 
in  which  the  respiratory  movements  were  threatened. 
Leyden  prefers  to  use  it  as  a  subcutaneous  injection, 
gr.  Vxf  to  gr.  ^  twice  daily.  Massage  and  baths  were 
valuable  auxiliaries  which  were  indicated,  especially  the 
latter,  in  the  later  stages  of  the  disease.  General 
hygienic  treatment  was  of  much  importance.  Rest — as 
a  rule  rest  in  bed — was  of  the  first  importance  in  the 
early  stage;  in  the  later  stage,  feeding.  Finally,  in  the 
latest  stages  of  all,  moral  suasion,  rousing  the  patient's 
latent  energies,  was  often  of  great  value.  Passive  move- 
ments and  encouraging  the  patient  to  make  active 
movements,  were  generally  attended  with  better  results 
than  massage  in  this  stage.  Electricity,  formerly  used 
too  much,  was  now  used  too  little,  but  its  usefulness  was 
greatly  limited  by  the  fact  that  in  many  cases  the  pain 
caused  was  too  great  to  permit  the  treatment  to  be  con- 
tinued.— Berliner  Klinische  Wochenschrift* 

Our  Present  Knowledge  of  the  Cure  of  Malaria  by 
Means  of  Quinine. — According  to  Professor  Binz  so 
long  as  twenty-six  years  ago  he  opposed  the  then  gener- 
ally accepted  theory  that  the  curative  action  of  quinine 


October  27,  1894] 


MEDICAL    RECORD. 


527 


in  malaria  is  developed  through  the  nervous  system,  and 
propounded  the  theory  that  quinine  in  all  probability 
acts  as  a  protoplasm  poison  on  the  pathogenic  micro- 
organism, at  that  time  undiscovered,  which  is  at  the 
root  of  all  paludism.  It  has  now  been  discovered  that 
all  forms  of  malarial  fever  are  brought  about  by  organ- 
isms of  the  genus  amoeba,  which  penetrate  the  bodies  of 
the  red  blood  cells,  at  whose  expense  they  increase  in 
size,  finally  sporulating  and  destroying  their  host.  Lav- 
eran,  who  first  discovered  and  described  the  parasite  of 
tertian  ague,  also  investigated  the  action  of  quinine  on 
that  organism,  and  found  that  when  microscopical  prep- 
arations of  the  parasite  were  treated  with  quinine,  the 
vitality  of  the  disease-germ  was  speedily  destroyed,  a 
feet  which  has  been  substantiated  by  Marchiafava,  Celli, 
Grassi,  and  Feletti.  The  influence  of  quinine  on  the 
malaria  parasites  has  also  been  studied  by  examining  the 
blood  of  malaria  patients  before  and  after  the  exhibition 
of  the  drug.  In  this  instance  the  investigations  of  Lav- 
eran,  Romanoffsky,  Bacelli,  Golgi,  Marchiafava,  and 
Bignani  established  the  fact  that  the  parasites  were  killed 
by  the  quinine  absorbed  into  the  blood. 

Dr.  Mannaberg,  who  has  recently  investigated  this 
question  in  the  malarial  districts  of  Dalmatia,  Lstria,  etc., 
finds,  among  other  things,  that  about  three  hours  after 
the  exhibition  of  from  seven  to  fifteen  grains  of  quinine, 
the  amoeboid  movements  of  the  amoeboid  form  of  the 
parasite  of  tertian  ague  slacken  to  a  very  perceptible  de- 
gree, and  that  after  a  lapse  of  a  further  period  of  three 
to  six  hours,  the  number  of  parasites  in  the  blood  of  the 
patient  greatly  diminishes,  while  many  of  those  still  left 
are  torn  and  mutilated.  On  the  full-grown  parasite  of 
tertian  ague  quinine  either  produces  a  complete  cessa- 
tion of  all  movement  in  the  pigment,  whereby  the  para- 
ate  acquires  a  glittering,  cloddy  appearance,  as  though 
coagulation  had  set  in,  or  else  dropsical  swelling  is  set 
up,  or,  finally,  the  parasite  falls  to  pieces.  Shortly  after 
the  exhibition  of  quinine,  medium-sized  parasites  of  ter- 
tian ague  develop  intense  activity.  It  appears  that  qui- 
nine possesses  a  stimulating  action  before  causing  coagu- 
lation and  immobility.  This  phenomenon  has  also  been 
observed  by  Bacelli.  According  to  Golgi,  the  medium- 
sized  parasites  of  quartan  fever  acquire  a  glittering  ap- 
pearance and  tendency  to  shrivel  when  the  patient  re- 
ceives quinine  internally;  the  large  forms,  however, 
become  distended,  their  pigment  exhibits  lively  oscilla- 
tory movements,  and  they  frequently  contain  vacuolse  or 
abortive  spores.  About  three  hours  after  the  exhibition 
of  a  dose  of  seven  and  one- half  grains  of  quinine,  the 
nucleoli  of  some  of  the  amoeba  of  the  milder  forms  of 
true  quartan  had  either  partially  or  entirely  lost  their 
tinctorial  characteristics.  After  twelve  hours  of  the 
treatment  stainable  nucleoli  were  hardly  met  with  at  all, 
most  of  the  parasites  having  broken  up  into  irregular 
fragments.  From  these  and  other  experiments  it  is  evi- 
dent that  the  amoeba  of  malaria  is  not  only  visibly  en- 
feebled by  the  presence  of  quinine  in  the  blood,  but  that 
its  capacity  for  producing  viable  spores  is  greatly  dimin- 
ished.. In  those  forms  of  malaria  which  are  not  curable 
by  quinine  that  drug  has  no  effect  whatever  on  the  para- 
sites present  in  the  blood.  Bacelli,  however,  has  found 
that  many  such  severe  forms  which  defy  the  ordinary 
method  of  treatment  may  be  speedily  cured  by  injecting 
the  usual  dose  of  quinine  into  a  vein. 

In  spite  of  certain  differences  on  minor  points,  Man- 
naberg and  the  other  investigators  one  and  all  agree  that 
quinine  is  a  direct  poison  for  the  malaria  parasite,  and 
that  the  therapeutic  doses  employed  are  non  injurious  to 
the  cells  of  the  human  organism.  Any  assistance  from 
the  nervous  system  in  the  process  of  cure  is  neither  evi- 
dent nor  necessary.  With  regard  to  the  prophylactic 
action  of  quinine,  it  is  to  be  noted  that  the  drug  disap- 
pears very  gradually  from  the  blood  and  in  an  almost 
unaltered  condition.  By  this  means  any  young  amoebae 
and  spores  are  kept  in  constant  contact  with  the  drug, 
and  are  thereby  checked  in  their  further  development. 
As  to  the  part  played  by  the  leucocytes,  it  appears  that 


phagocytism  is  prominent  in  cases  of  spontaneous  cure 
of  malaria,  but  not  when  quinine  is  employed. — Provin- 
cial Medical  Journal. 

The  Halation  of  Bacillus  Coli  Communis  to  Typhoid 
Fever. — According  to  Dr.  Kellogg  it  will  be  remem- 
bered that  in  1887  Hueppe  called  attention  to  the  pos- 
sible pathological  importance  of  the  colon  bacillus,  hav- 
ing found  this  organism  in  nearly  pure  cultures  in  cases 
of  cholerine.  In  1889  Roded  and  Roux  made  extensive 
investigations  of  this  bacillus  in  relation  to  typhoid  fever 
in  which  the  conclusion  was  reached  that  the  typhoid 
germ  is  a  modified  colon  bacillus.  Several  investigations 
have  been  recorded  of  outbreaks  of  typhoid  fever  result- 
ing from  the  use  of  the  water  from  a  common  source, 
usually  a  well,  from  which  no  typhoid  bacillus  could  be 
found,  but  the  colon  bacteria  were  present  in  large  num- 
bers. The  claim  that  is  made  at  present  by  certain  bac- 
teriologists is  that  the  colon  bacillus,  which  ordinarily 
possesses  very  little  pathogenic  power,  can  be  made  suffi- 
ciently virulent  to  produce  an  effect  similar  to  that  of  the 
Eberth  or  typhoid  bacillus. 

Another  interesting  fact  is  the  observation  that  the 
colon  bacillus  becomes  increased  in  virulence  during  an 
attack  of  typhoid  fever.  Vallet  has  shown  that  rabbits 
that  were  inoculated  with  the  filtrate  from  vaults  con- 
taining excreta  from  typhoid-fever  patients  were  pro- 
tected to  an  appreciable  degree  against  the  inoculation 
of  the  typhoid  bacillus.  This  experiment  serves  to  ex- 
plain the  fact,  so  often  noted  by  sanitarians,  that  visitors 
to  an  infected  locality  are  more  likely  to  suffer  from  the 
disease  than  the  residents  who  are  accustomed  to  drink 
the  contaminated  water.  After  certain  experiments, 
which  are  too  lengthy  to  record  in  full,  Kellogg  draws 
the  following  conclusions,  based  upon  his  own  work  and 
the  results  of  other  investigations:  1.  The  bacillus 
coli  and  the  bacillus  of  Eberth  are  so*  nearly  identical  in 
their  biological  characters  that  none  of  the  numerous 
methods  proposed  for  distinguishing  them  can  be  relied 
upon  as  giving  constant  results,  a.  The  bacillus  coli 
gives  in  inoculation  experiments  identical  pathological 
effects  with  those  produced  by  the  bacillus  of  Eberth. 
3.  The  bacillus  coli  acquires,  by  passing  through  the 
body  of  an  animal,  biological  characters  closely  resem- 
bling those  of  Eberth's  bacillus.  The  bacillus  coli 
found  in  vaults  is  much  more  virulent  than  the  bacillus 
coli  of  the  intestines  or  Eberth's  bacillus.  4.  The 
bacillus  coli  is  much  more  resistant  than  the  bacillus  of 
Eberth,  and  thrives  in  vaults,  while  the  bacillus  of  Eberth 
quickly  dies  under  the  same  conditions.  5.  The  study 
of  epidemics,  and  the  bacteriological  study  of  waters 
which  have  given  rise  to  typhoid  fever,  lead  to  the  con- 
clusions that  the  bacillus  coli  at  least  shares  with  the  ba- 
cillis  of  Eberth  the  property  of  producing  typhoid  fever 
under  certain  circumstances,  and  that  the  bacillus  of 
Eberth  may  be  only  a  variety  or  modified  form  of  bacil- 
lus coli.  6.  The  contaminations  of  milk  with  the  ex- 
creta of  cows  is  a  possible  source  of  infection  with  the 
bacillus  coli  and  with  typhoid  fever.  7.  The  same  care 
ought  to  be  observed  in  the  protection  of  water  used  by 
cows  kept  for  milking  purposes  from  contamination  from 
excreta,  as  for  that  used  by  human  beings  for  drinking 
purposes.  8.  Since  vaults  and  cesspools  constitute 
depots  in  which  the  comparatively  innocuous  bacillus 
coli  acquires  malignancy  and  virulence,  rendering  it 
highly  destructive  to  human  life,  these  convenient 
nuisances  should  be  prohibited  by  law,  and  the  destruc- 
tion or  disinfection  by  proper  agents,  or  conveyance  to 
a  safe  distance  from  human  habitation,  of  all  alvine  dis- 
charges, should  be  compulsory  as  one  of  the  most  im- 
portant means  of  conserving  the  public  health. — Medical 
and  Surgical  Reporter. 


A  Hew  Convalescent  Hospital — Mr.  Yarrow,  the 
English  builder  of  torpedo-boats,  has  recently  given 
£600,000  to  build  and  endow  a  hospital  for  convalescent 
children  at  Broadstairs. 


528 


MEDICAL   RECORD. 


[October  27,  1894 


Medical   Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


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


New  York,  October  27,  1894. 


THE  SIMS'   STATUE. 

The  dedication,  in  this  country  at  least,  of  an  heroic 
statue  to  a  medical  man  marks  an  important  era  in  med- 
ical history.  Dr.  James  Marion  Sims,  dead  over  ten 
years,  comes  again  to  us  in  the  earthly  immortality  of 
bronze  and  granite.  He  once  more  looks  at  us  as  of  old, 
with  gentle  persuasiveness  and  calm  conviction,  the  in- 
dex of  a  life  well  spent,  the  unchangeable  impersonation 
of  a  living  principle.  When  the  present  generation  shall 
have  passed  away,  he  will  remain  through  coming  seasons 
and  fleeting  years,  for  unborn  eyes  to  look  upon  and  com- 
ing tongues  to  speak  his  praise.  The  benediction  of  his 
good  works  will  thrill  the  enthusiasm  of  future  workers  in 
every  line  of  human  progress.  It  is  pleasant  to  think  that 
his  example  can  hi  constantly  with  us  and  continuously 
extend  into  the  beyond.  The  lesson  of  his  life  is  now 
written,  the  lovable  memory  of  his  past  struggles,  and  the 
cordial  recognition  of  his  final  triumphs,  are  new  incen- 
tives for  lofty  purposes  and  noble  emulation  for  persistent 
endeavor.  He  was  the  founder  of  a  new  medical  faith, 
and  his  works  live  after  him.  As  the  father  of  modern 
gynecology,  he  becomes  the  exponent  of  a  living  thought 
constantly  widening  and  progressively  extending. 
Time  has  now  so  softened  the  asperities  of  criticism, 
and  calm  judgment  has  so  cooled  the  temper  of  envy, 
that  no  one  will  now  question  his  genius  or  doubt  his 
talents.  The  statue  as  it  stands  is  the  final  vindication  of 
his  faithful  work,  and  the  lasting  tribute  to  his  duty  done. 

It  is,  therefore,  with  no  small  degree  of  pride  that 
the  Medical  Record  recalls  its  initiatory  efforts  to  do 
him  honor,  and  likewise  does  it  congratulate  the  many 
subscribers,  in  this  and  other  countries,  who  through  its 
columns  so  promptly  and  generously  contributed  to  the 
fund.  The  heartiest  thanks  of  the  many  friends  and 
admirers  of  Dr.  Sims  are  also  due  to  the  distinguished 
gentlemen  who  have  so  long  served  on  the  committee, 
and  who  have  so  faithfully  discharged  the  duties  of 
their  high  office.  In  evidence  of  this  is  the  statue  itself* 
which  is  acknowledged  by  competent  authorities  to  be 
the  best  conceived  and  most  artistically  executed  of  any 
in  the  city.  That  the  contributors  to  the  fund,  and  the 
members  of  the  profession  throughout  the  world,  may 
judge  of  this  fact  for  themselves,  we  have  the  pleasure  of 
presenting  in  this  number  of  the  Medical  Record  a 
full-page  illustration  of  the  statue  as  it  now  stands  in 
Bryant  Park. 

In  completing  the  history  of  the  monument,  it  is  proper 
to  add  that  the  receipts  and  expenditures  on  account  of 


the  fund,  submitted  to  the  committee  by  William  Wood  & 
Co.,  treasurers,  have  been  duly  audited  and  found  to  be 
correct.  And  thus  endeth  our  loving  part  in  memory  of 
an  old  friend. 

COLLEGE  ATHLETICS. 

At  a  recent  meeting  of  the  Boston  Society  for  Medical 
Improvement,  Dr.  W.  M.  Conant  read  a  paper  on  the 
"  Educational  Aspect  of  College  Athletics,"  and  it  was 
discussed  at  length  by  a  number  of  prominent  physicians 
and  laymen.  The  net  result,  we  must  confess,  is  rather 
disappointing ;  for  no  particularly  new  facts  were  brought 
out,  and  there  was  a  most  placid  unanimity  of  opinion  to 
the  general  effect  that  college  athletics  form  a  beneficent 
factor  in  education.  It  hardly  requires  a  special  meet- 
ing of  savants  to  determine  this  point.  What  one 
would  like  to  know  is  the  amount  of  evil  connected  with 
athletics,  and  how  this  can  be  prevented.  The  directors 
of  gymnasia,  trainers  and  physical  educators,  furnish  us 
interesting  reports  showing  the  increase  under  training 
of  the  circumference  of  the  arm  and  the  expansion  of  the 
chest.  But  they  do  not  tell  us  of  the  hypertrophied 
hearts,  crippled  limbs,  and  lowered  scholarship.  Among 
the  3,000  students  at  Harvard,  we  gather  from  Dr.  Co- 
nant that  about  400  engage  actively  in  college  athletics. 
He  gives  us  a  list  of  about  70  foot  ball  injuries  per 
year  among  some  of  the  latter.  These  are  rather  inade- 
quate data.  It  has  often  been  urged  that  one  evil  of 
competitive  athletics  lies  in  the  fact  that  the  system 
practically  puts  on  the  shelf  the  weaker  men,  who  have 
no  special  aptitude  or  inclination  to  athletics,  but  who 
especially  need  physical  culture.  All  that  is  left  to 
these  are  the  inanities  of  wooden  dumb-bells,  wands,  and 
clubs,  things  which  no  self  respecting  intelligence  will 
long  put  up  with. 

It  is  admitted  that  college  athletics  tend  to  disparage 
scholarship,  but  to  what  extent  no  one  seems  to  know. 

In  fact,  the  only  suggestive  thing  in  the  whole  discus- 
sion is  a  remark  by  the  Mayor  of  Cambridge,  who  ex- 
pressed surprise  that  college  authorities  do  not  personally 
supervise  and  teach  athletics,  since  they  admit  that  physi- 
cal culture  is  of  so  much  importance.  The  exercises  of 
intellectual  culture  are  rigidly  controlled,  but  physical 
culture  is  left  largely  to  the  student's  inclinations  or 
whims. 

THE  DOCTOR  AND  THE  BICYCLE. 
Shall  the  doctor  ride  a  bicycle  ?  It  is  too  late  for  an 
answer  to  this  question.  He  already  does  it.  The 
wheel  has  evidently  come  to  stay,  as  a  source  of  recrea- 
tion to  the  busy  physician,  if  not  used  by  him  as  a  means 
of  locomotion  in  making  his  rounds.  It  is  probably 
even  too  late  for  us  to  discuss  the  advisability  of  the  pro- 
fessional sister  striding  the  two- wheeled  steed.  She  has 
not  only  taken  to  it  most  kindly  in  common  with  many 
of  her  sex,  but  has  already  begun  to  give  them  practical 
information  concerning  the  proper  way  to  ride,  so  as  to 
gain  the  greatest  benefit  with  the  least  danger  of  injurious 
effect.  We  have  already  called  attention  to  Dr.  Laura 
Liebhardt's  discussion  of  the  question  before  the  Colorado 
State  Medical  Society,  in  which  the  advice  is  given,  among 
other  things,  not  to  mount  during  the  first  days  of  the 
menstrual  flow,  or  at  least  only  for  short  hill  less  rides. 
Undoubtedly  injury  may  be  inflicted  upon  the  perineal 


October  27,  1894] 


MEDICAL   RECORD. 


529 


region  by  a  faulty  saddle-pressure  too  long  kept  up  and 
accidents  en  route;  but  taking  into  consideration  the 
amount  of  bicycling  now  indulged  in,  it  must  be  admitted 
that  the  physician  is  not  often  called  upon  to  prescribe 
for  any  results  of  injudicious  riding.  On  the  other  hand, 
those  who  have  carefully  watched  this  mode  of  exercise 
from  its  therapeutic  side,  must  have  observed  the  bene- 
fit derived  from  its  proper  use  in  many  conditions  of 
non-health.  In  its  present  perfected  state,  the  pneu- 
matic-tired "  safety  ' '  is  a  very  different  machine  from  the 
"  velocipede  "  of  the  sixties  and  the  "  ordinary  "  of  the 
transition  period  of  its  evolution ;  and  it  is  now,  for  the 
first  time  in  the  history  of  two-wheeled  travel  with  the 
rider  as  the  propelling  force,  that  the  serious  attention  of 
the  medical  profession  is  demanded. 

In  just  how  far  we  are  justified  in  prescribing  or  for- 
bidding it— especially  for  young  girls;  what  are  the 
dangers  to  warn  against;  at  what  point  does  benefit  cease 
and  injury  begin  ?  These  are  questions  for  the  physician 
to  decide — not  from  his  own  narrow  views  and  precon- 
ceived ideas  as  to  the  fitness  of  things,  but  from  a  true 
scientific  study  of  the  question.  For  himself  he  can  de- 
cide whether  he  considers  it  dignified  or  judicious  to  visit 
his  patients  awheel.  If  the  distance  is  too  great  for  him 
to  arrive  in  a  presentable  condition,  he  had  better  stick  to 
his  chaise.  If  the  case  is  one  of  urgency  and  he  can 
get  there  quicker,  he  need  not  fear  the  condemnation  of 
the  anxious  sufferer. 

But  whether  he  goes  adriving,  ariding,  awheel,  or 
a  foot,  the  doctor  must  bless  the  bicycle,  for  it  has  done 
more,  and  probably  will  do  more,  for  the  cause  of  good 
roads  throughout  the  country  than  any  other  one  thing, 
and  no  one  knows  better  the  necessity  of  good  roads 
than  the  doctor. 


PHYSIOLOGICAL  EPOCHS  THAT  PREDISPOSE 

TO  INSANITY. 
At  a  recent  meeting  of  the  Medical  Society  of  the 
Coonty  of  New  York,  a  paper  read  by  Dr.  William  M. 
Spratling,  on  the  "  Physiological  Epochs  that  Predispose 
to  Insanity,  with  Observations  on  the  Management  of 
Each,"  presented  in  clear  and  definite  form  certain  facts 
too  often  overlooked  and  ignored  by  the  general  prac- 
titioner and  the  public  at  large.  The  grave  responsibil- 
ity of  treating  insanity  in  its  incipiency  rests  in  greater 
degree  upon  the  physician  in  general  practice  than  upon 
the  specialist  in  diseases  of  the  mind.  The  family  doctor 
sees  usually  the  first  signs  of  incipient  mental  disorder, 
when  its  early  recognition  and  proper  treatment  may  se- 
cure the  happiest  results. 

Mercier  concisely  sums  up  the  causes  of  insanity  in 
this  way :  Insanity  is,  in  mathematical  terms,  a  function 
of  two  variables ;  that  is  too  say,  there  are  two  factors, 
and  only  two,  in  its  causation ;  and  these  factors  are 
complementary.  Both  enter  into  the  causation  of  every 
case  of  insanity ;  and  the  stronger  the  influence  of  one 
factor,  the  less  of  the  other  factor  is  needed  to  produce 
the  result.  These  factors  are  heredity  and  stress.  A 
study  of  the  various  states  of  mental  instability  arising 
directly  from  physiological  epochs,  proves  conclusively 
and  without  variation  that  heredity  and  stress,  with  their 
subdivisions,  constitute  the  only  etiological  factors. 
There  are  six  distinct  epochs  at  which  insanity  may  ap- 
pear, all  but  one  being  strictly  physiological  in  the  order 


and  nature  of  their  occurrence.  This  one,  the  epoch 
of  heredity,  may  be  called  patho-physiological.  Early 
childhood,  puberty,  maternity,  the  epoch  of  heredity, 
the  menopause,  and  senility,  are  these  fixed  times  in 
which  stress  may  serve  to  destroy  mental  health.  Early 
childhood  is  the  period  of  life  beginning  with  the  sev- 
enth month  and  ending  with  the  beginning  of  the  sev- 
enth year,  and  may  be  in  itself  said  to  predispose  only 
indirectly  to  insanity  through  its  accidents  and  inci- 
dents. Puberty  in  the  female  extends  from  the  thir- 
teenth to  the  fifteenth  year;  in  the  male,  from  the  four- 
teenth to  the  sixteenth.  The  third  physiological  epoch 
covers  the  entire  childbearing  period,  from  the  fifteenth 
to  the  forty  fifth  year.  Insanity  occurs  more  frequently 
during  the  first  than  during  the  latter  half  of  this  period. 
The  epoch  of  heredity  has  not  had  special  attention 
called  to  it  by  writers  in  this  country,  though  it  is  an 
important  and  variable  one.  It  embraces  that  critical 
period  of  the  life  of  any  individual  whose  ancestors  have 
been  accustomed  to  exhibit  evidences  of  insanity  on 
reaching  a  certain  age.  Regis  uses  the  term  phrenasthe- 
nia  to  designate  and  include  all  forms  of  inherited  in- 
sanity. The  fifth  epoch  is  that  of  the  climacteric,  from 
the  forty-third  to  the  forty-fifth  year.  Exceptionally,  the 
time  may  be  extended  a  little  either  way.  The  changes 
that  now  occur  are  the  most  clearly  perceptible  of  those 
of  any  epoch,  and  lead  oftener  to  mental  instability. 
Senility  is  the  last  epoch,  old  age ;  and  it  is  interesting 
to  note  that,  when  the  preceding  epochs  have  not  been 
strictly  physiological,  pathological  conditions  of  mind 
are  apt  to  appear  in  extreme  old  age. 

Early  childhood  presents  the  possibility  of  many  acci- 
dents and  incidents  that  may  serve  to  render  the  child 
mentally  unsound  in  the  future.  Gowers  is  authority  for 
the  statement  that  one-eighth  of  all  the  cases  of  epilepsy 
begin  during  the  first  three  years  of  life ;  and  adds  that, 
with  rachitis  as  a  combining  cause,  seventy-five  per  cent, 
of  all  cases  of  epilepsy  that  begin  during  the  first  three 
years  of  life  are  due  to  infantile  convulsions  ascribed  to 
teething.  Here  the  various  tendencies  of  an  inherited 
taint  change  a  perfectly  physiological  process,  that  ought 
to  be  free  from  danger  to  the  child,  into  a  period  fraught 
with  influences  of  a  most  pernicious  kind.  Syphilis, 
chronic  alcoholism,  insanity,  or  epilepsy,  in  the  parent, 
stamps  on  the  child's  nervous  system  a  congenital  insta- 
bility that  unfits  it  to  pass  unscathed  through  the  seri- 
ous disturbances  that  mark  the  steps  of  growth  and  de- 
velopment. Dentition  alone  is  probably  never  a  cause 
of  genuine  epilepsy;  what  it  does  give  rise  to  are  epi- 
leptiform convulsions  that  in  time  take  on  the  character 
of  true  epilepsy.  That  insanity  often  follows  epilepsy  is 
well  known.  Clouston  states  that  cases  of  prolonged  de- 
lirium ending  in  idiocy,  and  arising  out  ot  the  ordinary 
convulsions  of  dentition  have  come  under  his  observa- 
tion. And  such  cases  have  also  ended  in  true  epilepsy, 
followed  by  insanity.  Adolescent  insanity  has  appeared 
so  often,  as  well  as  other  forms,  iff  persons  earlier  the  vic- 
tims of  epilepsy,  that  it  is  impossible  to  regard  the  two  as 
coincident. 

In  the  Journal  of  the  American  Medical  Association 
for  August  18,  1894,  Wilmarth  gives  some  interesting 
facts  concerning  idiocy,  epilepsy,  imbecility,  and  in- 
sanity, as  he  studied  them  at  the  Pennsylvania  Institute 
for    Feebleminded   Children.     Out  of   one    thousand 


53Q 


MEDICAL   RECORD. 


[October  27,  1894 


admitted  to  the  institution,  he  found  that  there 
were  three  hundred  and  twenty-two  whose  condition  re- 
quired medical  treatment  before  entering,  and  whose 
afflictions  were  of  such  a  nature  as  to  indicate  that  medi- 
cal treatment  would  possibly  bring  about  a  cure.  In  this 
list,  all  cases  not  amenable  to  medical  treatment  are  ex- 
cluded, together  with  cases  in  which  congenital  defect 
was  noted  before  the  sixth  month,  or  just  before  the  com- 
mencement of  dentition.  In  seventy-five  cases  out  of  the 
three  hundred  and  twenty- two,  the  disorder  had  developed 
during  the  spasms  of  dentition ;  in  two  cases,  before 
the  sixth  month;  in  twenty-nine,  between  the  sixth  and 
twelfth ;  in  twenty-five,  between  the  twelfth  and  eighteenth 
months;  and  between  the  eighteenth  month  and  the 
twenty-fourth,  nineteen  cases  are  recorded  as  first  show- 
ing evidences  of  mental  disease.  The  growth  of  a  little 
child's  brain  is  rapid  up  to  the  seventh  year,  and  anything 
which  interferes  with  its  nutrition  is  a  serious  matter. 
Besides  dentition,  traumatism,  blows  or  falls  on  the  head, 
the  effects  of  excessive  heat,  mental  shock,  fevers  of  specific 
origin,  and  structures  and  malformation  of  the  genital 
organs,  are  causes  that  act  unfavorably  upon  the  organ- 
ism and  threaten  to  disarrange  its  more  highly  developed 
parts. 

The  excito  motor  exaltation  during  the  first  dentition 
has  its  parallel  in  the  explosive  condition  of  the  nerve- 
centres,  in  the  higher  plane  of  cerebral  activity,  during 
the  evolution  of  the  generative  function  and  of  the  sex- 
ual divergence  of  early  adolescence.  Such  epochs  may 
be  characterized  as  the  search- lights  of  psychiatry,  since 
they  serve  to  reveal  weak  spots  in  the  mental  organiza- 
tion. The  mental  disorders  that  so  frequently  develop 
at  this  age,  are  due  to  indirect  stress  of  internal  origin. 
Pubescent  insanity  may  develop  anywhere  between  the 
ages  of  fifteen  and  twenty-two.  The  epoch  of  puberty 
is  attended  with  more  danger  to  the  female  than  to  the 
male,  the  time  is  shorter,  and  the  shock  is  greater.  In- 
sanity in  the  female  at  this  epoch  is  essentially  an  acute 
neurosis,  acute  mania  being  its  commonest  form. 
Acute  mania  is  also  the  commonest  form  of  puerperal 
insanity.  Hallucinations  appear  in  about  one-quarter 
of  the  cases  in  both  sexes,  those  that  are  visual  and 
aural  predominating.  Delusions  of  poisoning  exist  fre- 
quently, and  spiritual  delusions  are  not  uncommon. 
When  uncomplicated  by  hereditary  taint,  the  prognosis 
is  good.  Nearly  four-fifths  of  persons  thus  afflicted  re- 
cover. Early  removal  from  home  is  best.  Nourish- 
ment easy  of  digestion  should  be  given,  and  the  secre- 
tory and  excretory  organs  should  receive  special 
attention,  since  they  are  liable  at  this  period  to  sluggish 
action.  Sleep  must  be  secured  by  open-air  exercise  and 
by  hypnotics;  and  narcotics  and  sedatives  avoided. 
Menstrual  irregularities,  anaemia,  etc.,  require  the  strict- 
est hygiene,  and  the  use  of  carbonate  of  iron,  extract  of 
nux  vomica  and  rhubarb  in  pill  form,  malt  extract, 
etc. 

Pregnancy,  labor  itself,  and  lactation,  have  more  im- 
portant relations  to  insanity  than  other  physiological 
epochs.  Insanity  during  pregnancy  is  more  frequent 
among  women  about  to  give  birth  to  an  illegitimate 
child.  Mental  anomalies  vary  all  the  way  from  simple 
morbid  appetites  to  well-marked  melancholia  with  suici- 
dal impulses.  Transitory  frenzy  during  labor  appears  as 
the  forerunner  of  puerperal  delirium.      Infanticide  and 


suicide  are  acts  common  to  the  subjects  of  this  condition. 
Mental  derangement  may  come  on  suddenly  after  child- 
birth or  develop  gradually  after  evidences  of  nervous 
exhaustion,  most  frequently  appearing  as  acute  mania. 
Begin  treatment  with  a  saline  aperient,  and  search  for 
and  remove  causes  of  fever.  The  condition  of  the 
blood  may  require  iron ;  but  none  of  the  chalybeate 
preparations  should  be  used  till  all  traces  of  acute  excite- 
ment have  subsided.  The  infant  must  be  removed  from 
the  mother's  care.  The  mother's  diet  must  consist  of 
milk,  beef-tea,  broth,  and  eggs,  administered  in  small 
quantities  at  frequent  intervals.  To  secure  sleep,  the 
following  may  be  used :  chloral,  bromide  of  potassium, 
sulfonal ;  paraldehyde,  two-drachm  doses,  or  more  if 
required,  in  a  small  quantity  of  port  wine.  Warm 
baths  often  suffice  to  produce  refreshing  sleep,  and, 
whenever  possible,  deserve  a  trial  before  drugs  are  given. 
The  fifth  physiological  epoch  is  the  menopause. 
Psychic  manifestations  are  well  marked.  Whenever 
there  is  inherited  tendency  to  mental  disease,  or  when 
there  have  been  eartier  attacks  of  insanity  during  one  of 
the  former  epochs,  the  menopause  has  added  dangers. 
Climacteric  insanity,  Skae  characterizes  as  a  monomania 
of  fear,  despondency,  remorse,  hopelessness,  passing  oc- 
casionally into  dementia.  Over  half  of  all  cases  are  of 
the  depressed  type.  Treatment  consists  mainly  in  a 
tonic  regimen,  out-door  life,  strict  attention  to  diet,  and 
change  of  surroundings.  Iron  and  arsenic  are  required, 
artificial  feeding  is  often  necessary,  and  sleep  must  be 
secured  by  hypnotics.  Chloral  hydrate,  in  a  single 
large  dose,  and  paraldehyde,  are  the  best.  Senile  mania 
and  senile  melancholia  occur  as  distinct  disorders.  The 
most  satisfactory  drug  for  the  treatment  of  insanities  in- 
cident to  old  age  is  opium,  beginning  with  small  doses. 
The  danger  of  establishing  the  opium  habit  is  less  than 
if  the  patient  were  in  the  prime  of  life.  Persistent  in- 
somnia and  great  restlessness  are  overcome  by  opium, 
which  seems  to  have  as  powerful  an  influence  over  human- 
ity in  its  second  childhood  as  it  has  during  humanity's 
earliest  years. 

MEDICAL  UNIVERSITY  EXTENSION. 

Wb  have  often  wondered  why  some  active  and  philan- 
thropic mind  did  not  devise  a  scheme  for  applying 
"University  Extension"  to  medicine.  And  now  we 
find  that  it  has  been  done  by  an  association  of  eminent 
English  physicians,  including  Drs.  Clifford  Allbutt,  Sir 
W.  H.  Broadbent,  John  Cavafy,  J.  F.  Goodhart,  T.  H. 
Green,  Hughlings  Jackson,  S.  Wilks,  Sir  James  Paget, 
Sir  J.  M.  Humphrey,  and  Mr.  Jonathan  Hutchinson. 

They  term  their  movement  the  "Clinical  Research 
Association."  It  proposes,  as  we  understand,  to  furnish 
the  general  practitioner  a  convenient  means  of  having 
all  forms  of  bacteriological,  chemical,  and  microscopical 
information  made  accessible  to  him  and  his  patients. 


THE  RECOGNITION  OF  MERIT. 

The  Germans  have  their  jubilees,  and  the  English  their 
"presentations."  We  notice  in  a  recent  issue  of  The 
Lancet,  that  Dr.  Walter  Murray  was  presented  with  a 
clock  for  his  bravery  in  going  to  the  rescue  of  a  police- 
man. Also,  that  Dr.  Symington  has  been  presented  with 
a  tea-tray  for  causes  not  stated.   The  habit  of  giving  some 


October  27,  1894] 


MEDICAL 


formal  recognition  to  conspicuous  merit  or  long  profes- 
sional service,  is  surely  a  most  praiseworthy  one.  We 
wish  that  in  this  country  something  of  the  kind  might  be 
done.  With  us  the  doctor  gets  recognition  sometimes 
alter  he  is  dead,  but  that  is,  after  all,  not  so  satisfactory 
to  the  person  most  concerned. 


THE  CZAR'S  DISEASE. 

To  such  medical  men  as  have  studied  the  symptoms  of 
the  disease  of  the  Czar,  as  they  have  been  reported  in 
the  vague  and  meagre  official  bulletins,  it  must  be  appar- 
ent that  the  only  way  to  reconcile  seemingly  conflicting 
accounts,  and  draw  reasonable  conclusions  therefrom,  is 
to  assume  that  the  diagnosis  made  by  Professor  Leyden 
is  the  correct  one.  Contracted  kidney,  as  is  well  known, 
is  a  very  common  affection  in  persons  addicted  to  the 
pleasures  of  the  table  and  the  excesses  of  the  cup.  The 
general  condition  of  the  distinguished  patient,  his  cor- 
pulency, and  attendant  lack  of  vital  energy,  make  him  a 
fit  subject  for  this  form  of  renal  disease.  The  distressing 
symptoms  of  paroxysmal  cardiac  dyspnoea,  due  to  feeble- 
ness of  compensatory  cardiac  effort,  the  pulmonary  com- 
plications associated  with  pleuritic  effusion,  and  the  gen- 
eral weakness  and  anasarca  caused  by  the  lowering  of 
arterial  pressure,  are  of  ominous  gravity,  and  tend  in  the 
direction  of  a  probably  speedy  dissolution.  Under  the 
circumstances,  it  will  not  be  surprising  to  learn  of  the 
appearance  of  apoplexy,  convulsions,  or  coma,  or  of  an 
equally  sudden  termination  in  syncope,  or  pulmonary 
oedema. 


A     NEW    CURE    FOR    PERNICIOUS    ANiEMIA 
AND  LEUCOCYTILEMIA. 

"While  sitting  alone,  and  in  profound  sorrow,  in  my 
library,  on  Sunday  morning  the  29th  of  April  last,  I  sud- 
denly saw  a  great  light."  It  is  in  this  somewhat  dra- 
matic way  that  Dr.  I.  N.  Danforth,  whose  wife  was  suf- 
fering from  pernicious  anaemia,  begins  his  description 
of  a  new  method  of  treating  that  disease.  The  light 
which  he  saw  was  reflected  from  the  following  paragraph 
in  a  London  journal :  "  Professor  Frazer,  of  Edinburgh, 
read  a  paper  to  the  Section  of  Medicine  "  (of  the  Elev- 
enth International  Medical  Congress,  at  Rome)  "on 
the  Effects  of  Bone  Marrow  in  Pernicious  Anaemia, 
which  attracted  considerable  attention.  He  gave  par- 
ticulars of  a  case  in  which  at  the  beginning  of  the  dis- 
ease the  haematocytes  numbered  1,000,000  per  cubic 
millimetre,  and  the  haemoglobin  twenty*  five  per  cent. 
After  a  month's  treatment,  first  with  iron,  then  with 
arsenic,  afterward  with  salol,  no  appreciable  improve- 
ment was  manifested.  At  the  end  of  that  time  bone 
marrow  was  administered  with  remarkable  results.  The 
patient  gradually  improved,  and  in  two  months  the  blood 
had  a  composition  of  4,000,000  haematocytes,  and  the 
haemoglobin  had  risen  to  eighty  per  cent.  This  case 
shows,  so  far  as  a  single  case  can,  that  in  bone  marrow 
we  may  perhaps  have  an  effective  remedy  for  what  has 
hitherto  been  practically  held  to  be  an  incurable  dis- 


RECORD.  531 

once  began  to  improve,  and  in  four  or  five  months  was 
comparatively  well. 

After  a  time,  instead  of  giving  the  marrow  in  its  nat- 
ural state,  he  cut  up  several  ribs  and  allowed  them  to 
soak  in  glycerine.  He  then  made  the  following  mixt- 
ure: 

9*    Liq.  potas.  arsenit 3  ijss. 

Acid  phosphate J  iij. 

Ext.  bone  marrow. ad  |  viij. 

M.  Sig.  :   3  ij.  after  each  meal 

The  addition  of  the  arsenic  robs  the  bone  marrow  of 
some  of  the  credit.  This  addition  was  not  made,  how- 
ever, in  Professor  Frazer's  case. 

We  note  also  that  Dr.  W.  G.  Bigger  reports,  in  a 
London  journal,  a  case  of  leucocythsemia  in  a  boy  aged 
twelve.  The  patient  was  given  three  or  four  slices  of 
bread  daily,  on  each  of  which  the  raw  bone  marrow  was 
thickly  spread.  The  improvement  in  the  boy's  condi- 
tion after  the  first  week  was  "  little  short  of  marvellous." 
The  anaemia  and  jaundice  disappeared,  and  the  skin  and 
mucous  membrane  acquired  a  healthy  color.  The  symp- 
toms due  to  the  anaemia  at  the  same  time  passed  off,  and 
in  three  weeks  the  boy  was  able  to  walk  about  without 
shortness  of  breath  or  palpitation.  The  temperature  also 
became  normal,  and  has  remained  so.  Pari  passu  with 
this  improvement  in  the  general  symptoms,  the  spleen 
diminished  in  size,  so  that  by  the  end  of  a  fortnight  the 
lower  edge  had  receded  to  a  level  with  the  anterior  spine 
of  the  ilium,  and  the  inner  edge  did  not  extend  beyond 
the  middle  line. 

The  boy  eventually  became  entirely  well.  Both  the 
cases  reported  are  apparently  examples  of  cures  of  ob- 
stinate and  dangerous  diseases.  If  we  have  a  remedy 
for  them  in  bone  marrow,  therapeutics  has  made  a  re- 
markable advance. 


Dr.  Danforth  immediately  got  some  bone  marrow  and 
began  feeding  it  to  his  patient,  whose  condition,  despite 
everything  that  had  been  tried,  was  desperate.    She  at 


A  NEW  WAY  TO  ADVERTISE. 

The  following  candid  announcement  appears  in  The 
Texas  Health  Journal.  "  To  the  Medical  Profession  of 
Texas. — I  have  devoted  many  years  to  the  exclusive 
treatment  of  diseases  of  the  eye,  ear,  nose,  and  throat. 
That  I  might  feel  doubly  assured  of  my  ability  to  treat 
these  diseases  with  the  best  possible  skill  known  to  the 
profession,  I  spent  the  last  winter,  spring,  and  summer 
in  New  York  and  Europe,  where  I  received  the  special 
clinical  instructions  under  the  most  distinguished  spe- 
cialists in  the  world.  My  many  months  of  clinical  work 
at  the  greatest  hospitals  and  clinics  in  the  world,  to- 
gether with  the  new  instruments  and  apparatus  I  pur- 
chased in  Europe,  regardless  of  price,  cost  me  nearly  two 
thousand  dollars.  I  now  respectfully  ask  that  the  general 
practitioners  of  Texas  who  have  not  the  time  and  instru- 
ments to  successfully  treat  such  cases,  kindly  consider 
my  recent  advantages  and  complete  armamentarium,  and 
intrust  to  me  the  responsibility  of  treating  such  cases. 
If  this  courtesy  is  extended  to  me,  I  will  be  true  to  the 
trust  confided.  Besides,  I  will  make  it  especially  advan- 
tageous to  every  physician  who  kindly  refers  cases  to  me 
for  treatment ;  try  and  see  if  I  do  not ;  a  hint  to  the 
wise  is  sufficient.  Furthermore,  I  will  take  pleasure  in 
treating  any  member  of  a  physician's  family,  absolutely 
free.  I  will  also  treat  any  charity  case  free  referred  to 
me  by  a  physician.     My  present  large  paying  practice 


532 


MEDICAL   RECORD. 


[October  27,  1894 


enables  me  to  do  this  without  loss  to  myself;  besides, 
the  pleasure  of  curing  those  unable  to  pay  is  sufficient 
remuneration  to  me.  I  have  opened  an  elegant  new 
office  in  the  North  Texas  Bank  building;  rooms  316, 
317,  and  318.  Call  and  see  me  while  in  the  city. 
"  Fraternally  submitted. " 

A  letter  of  this  kind  is  in  our  opinion  a  legitimate  re- 
sult of  the  approval  given  by  the  American  Medical  As- 
sociation to  the  plan  of  sending  out  cards  with  the 
words  "practice  limited  to"  eye  diseases,  gynecology, 
etc.  Instead  of  distributing  cards  to  the  profession,  the 
specialist  puts  it  in  a  medical  journal,  and  naturally  adds 
to  it  a  modest  account  of  his  unusual  experience  and 
skill.  The  next  step  would  be  for  the  general  practition- 
er to  put  in  an  announcement  of  his  special  skill  in  the 
common  run  of  diseases,  and  request  the  specialists  and 
incidentally  the  public  to  send  him  their  patients.  Very 
soon,  as  the  examples  of  these  announcements  increase, 
their  language  must  become  stronger.  For  example, 
there  are  in  Texas  a  good  many  physicians  who  have  had 
a  larger  experience  in  eye  diseases  even  than  the  writer 
of  the  above  quoted  letter.  If  his  conduct  is  approved, 
what  will  be  left  to  them  but  to  imitate  him,  or  rather 
surpass  him,  in  an  attractive  presentation  of  their  accom- 
plishments. The  results  must  be  disastrous  to  profes- 
sional dignity,  personal  veracity,  and  mutual  confidence. 

Medical  men  cannot  afford  to  enter  the  field  of  the 
advertising  agent.  The  old  way  is  often  criticised,  and 
it  is  not  perfect.  The  man  must  become  known  through 
his  works.  The  profession  is  not  so  dull  but  that  it  can 
recognize  merit,  and  it  estimates  a  man's  abilities  fairly 
well  by  his  writings  and  by  contact  with  him  in  scienti- 
fic and  social  meetings.  The  recognition  thus  gained 
comes  slowly,  but  special  skill  also  is  acquired  slowly,  and 
matters  adjust  themselves  with  a  good  degree  of  equity 
in  the  end. 

We  hope  that  the  profession  of  Texas  will  not  endorse 
the  methods  adopted  by  the  enterprising  young  oculist 
of  their  State. 


%zxo%  at  VUt  WLteb* 

County  Medical  Society  Election. — The  Medical  So- 
ciety of  the  County  of  New  York  held  their  eighty- 
ninth  annual  election  October  2  2d.  Dr.  Egbert  H. 
Grandin  was  elected  President ;  Dr.  Richard  Van  Sant- 
voord,  Dr.  Wendell  C.  Phillips,  and  Dr.  S.  Henry  Des- 
sau were  elected  Vice-Presidents  ;  Dr.  Charles  H.  Avery, 
Secretary  ;  Dr.  William  E.  Bullard,  Assistant  Secretary  ; 
and  Dr.  John  S.  Warren,  Treasurer.  The  Censors 
elected  were  :  Drs.  Seneca  D.  Powell,  Edward  D.  Fisher, 
George  T.  Jackson,  Charles  H.  Knight,  and  Charles  L. 
Gibson. 

Conference  of  Hospitals  for  Insane  in  New  York.— 

The  Eighth  Joint  Meeting  of  the  Managers  and  Medical 
Superintendents  of  the  Hospitals  of  the  State  of  New 
York  was  held,  under  the  auspices  of  Honorable  Aus- 
tin Lathrop,  at  the  Matteawan  State  Hospital,  at  Fish- 
kill  Landing,  Thursday,  October  18,  1894.  Delegates 
from  the  different  asylums  were  present.  After  an  in- 
spection of  this  model  institution  and  congratulatory 
remarks  by  the  gentlemen  present,  Dr.  H.  E.  Allison, 


the  medical  superintendent,  read  a  paper  on  the  "  Care 
and  Treatment  of  the  Criminal  Insane. ' '  Remarks  were 
made  by  Judge  Graham,  of  Utica ;  Professor  Stephen 
Smith,  of  New  York ;  Dr.  Carlos  F.  Macdonald,  Presi- 
dent of  Lunacy  Commission  ;  Dr.  S.  H.  Talcott,  of  Mifi- 
dletown,  N.  Y. ;  Senator  Amasa  J.  Parker,  of  Albany  ; 
C.  W.  Pilgrim,  of  Poughkeepsie ;  C.  G.  Wagner,  of 
Binghamton;  G.  Alder  Blumer,  of  Utica;  and  Dr. 
George  F.  Shrady,  of  New  York. 

The  Monument  to  Villemin. — On  September  30th 
the  monument  erected  to  the  memory  of  Villemin,  the 
discoverer  of  the  infectivity  of  tuberculosis,  was  unveiled 
at  Bruygre-en-Vosges,  in  the  presence  of  a  distinguished 
assembly.  Dr.  Viger,  the  Minister  of  Agriculture,  who 
is  a  member  of  the  medical  profession,  represented  the 
Government,  and  delivered  an  oration. 

The  Late  Professor  Billroth.— The  letters  of  the  late 
Professor  Billroth,  of  Vienna,  are  about  to  be  published, 
with  the  sanction  of  his  widow,  under  the  editorship  of 
Dr.  Georg  Fischer,  surgeon  to  the  Hanover  City  Hos- 
pital. Dr.  Fischer  asks  any  English  correspondents  who 
may  have  preserved  letters  of  Billroth's  to  send  them  to 
him  at  22,  Warmbuchenstrasse,  Hanover.  Any  letters 
forwarded  in  response  to  this  request  will  be  copied  and 
returned  without  delay. 

Antidote  for  Fungi  Poisoning. — Dr.  Thomas  Taylor, 
chief  of  the  Division  of  Microscopy  of  the  Department  of 
Agriculture,  speaking  of  recent  deaths  in  this  city  from 
eating  poisonous  fungi,  says :  "  The  mushrooms  eaten  in 
this  case  were  undoubtedly  the  Amanita  verna,  which, 
and  Amanita  muscaria,  are  the  most  poisonous  mush- 
rooms known.  There  is  but  one  antidote  known  for 
amanitine  or  muscarine  poison,  and  that  is  sulphate  of 
atropine.  The  use  of  atropine,  as  has  been  fully  demon- 
strated, will  quickly  neutralize  the  effects  of  muscarine 
and  amanitine  on  the  nerve-centres  of  the  human  system, 
as  well  as  those  of  the  lower  animals.  The  dose  may  be 
administered  either  by  means  of  hypodermic  injection  or 
by  the  mouth  in  the  usual  way." 

Anti-toxin  and  Diphtheria. —The  Deputies  of  the 
Lower  House  of  Hungary  proposed  to  vote  50,000  flo- 
rins to  be  used  in  treating  diphtheria  with  Behring's 
serum.  At  the  Government's  request  the  vote  was  post- 
poned pending  the  reports  of  medical  inspectors  sent  to 
France  and  Germany.  In  Buda-Pesth  the  use  of  the  se- 
rum has  given  excellent  results. 

The  anti-toxin  treatment  of  diphtheria  is  the  topic 
of  the  day  in  Berlin.  The  Children's  Hospital  (Kaiser  u. 
Kaiserin  Friedrich-Kinder-Krankenhaus  is  its  short  and 
euphonious  name)  has  published  in  the  daily  papers  an 
appeal  for  subscriptions — signed,  among  others,  by  Ru- 
dolph Virchow,  Skrzecska,  and  Siegmund — in  which  it 
is  stated  that  of  169  diphtheria  patients  treated  in  the 
hospital  with  antitoxin,  all  recovered,  except  those  that 
came  under  treatment  at  an  advanced  stage  of  the  dis- 
ease ;  that,  in  fact,  the  percentage  of  deaths  had  been 
reduced  from  42  to  17,  and  that  the  results  of  protective 
inoculation  performed  on  the  sisters  and  brothers  of  the 
diphtheria  patients  had  also  been  most  satisfactory.  It 
must  be  said,  however,  that  here  and  there  voices  are 
heard  warning  against  too  enthusiastic  hopes.  It  is  said 
that  a  much  longer  period  of  observation  must  elapse 
before  a  final  judgment  on  the  treatment  can  be  given, 


October  27,  1894] 


MEDICAL    RECORD. 


533 


and  that  possibly  the  present  cases  of  diphtheria  are 
none  of  them  of  the  severest  type,  and  that  it  remains  to 
be  seen  whether  antitoxin  will  stand  the  test  of  one  of 
the  severe  epidemics — the  foudr&yant  cases,  that  carry 
off  their  victims  in  a  few  days. — British  Medical  Journal. 
Cholera  Decreasing  in  Europe. — The  latest  advices 
received  by  the  Marine  Hospital  service  show  that  chol- 
era is  on  the  decrease  everywhere,  amounting  in  the 
case  of  Austro  Hungary  to  nearly  fifty  per  cent  The 
decrease  in  Russia  is  remarkable,  and  it  is  hoped  that  the 
advent  of  cold  weather  will  put  an  end  to  this  epidemic 
entirely.  There  are  still  many  cases  reported  in  Hol- 
land, Belgium,  and  France,  but  '.they  seem  mostly  of  a 
sporadic  nature,  and  nowhere  assume  an  epidemic  form. 
The  health  of  Marseilles  is  now  so  satisfactory  that  the 
medical  inspection  of  all  vessels  sailing  thence  has  been 
discontinued. 

A  Vow  German  Hospital.— The  corner-stone  of  the 
new  German  hospital,  at  Stanhope  Street  and  St.  Nicho- 
las Avenue,  Williamsburg,  was  laid  October  2  2d,  by 
Mayor  Schieren,  in  the  presence  of  nearly  one  hundred 
societies  and  several  thousand  people.  A  parade  of  all 
the  societies  preceded  the  laying  of  the  stone.  Twenty- 
seven  lots,  bounded  by  St  Nicholas  Avenue  and  Stock- 
holm and  Stanhope  Streets,  were  purchased,  and  a  few 
months  ago  ground  was  broken.  The  cost  of  the  hos- 
pital when  completed  will  be  about  #250,000. 

American  Aoademy  of  Railway  Surgeons.— The  first 
meeting  of  the  American  Academy  of  Railway  Surgeons 
will  he  held  in  the  parlors  of  the  Grand  Pacific  Hotel, 
Chicago,  November  9  and  10,  1894. 

Status  and  Pay  of  Japanese  Army  Surgeons. — The 
Surgeon-General  of  the  Imperial  Army  has  the  rank  of 
major-general  and  the  same  amount  of  salary,  300  yen 
per  month,  the  yen  being  equivalent  to  about  75  cents 
of  our  money.  Surgeon-inspectors,  whose  position  is 
analogous  to  that  of  colonel  and  assistant  surgeon-general 
in  the  United  States  Army,  have  the  rank  of  colonel  and 
a  salary  of  193  yen  per  month,  or  3  yen  more  than  a 
colonel  of  cavalry  receives,  and  15  more  than  a  colonel 
of  infantry.  Surgeons  of  the  first  class  rank  as  lieutenant- 
colonel,  and  their  pay,  143  yen,  bears  the  same  relation 
to  that  of  a  regimental  lieutenant-colonel  that  the  pay  of 
an  inspector  does  to  that  of  regimental  commanders. 
Surgeons  of  the  second  class,  with  the  rank  of  major, 
draw  93  yen  monthly.  Assistant  surgeons  of  the  first 
class,  and  pharmacists  of  the  same  grade,  have  52  yen,  or 
the  pay  of  a  captain.  Assistants  and  pharmacists  of  the 
second  class  rank  as  first  lieutenants  and  have  the  pay  of 
that  grade,  32  yen.  Assistants  and  pharmacists  of  the 
third  class  have  the  rank  and  pay,  26  yen,  of  the  second 
lieutenant.  These  medical,  like  other  officers  of  the 
army,  have  increased  pay  when  assigned  to  special  duty ; 
those  on  duty  in  the  War  Department,  for  instance,  hav- 
ing an  increase  amounting  to  about  one  third  of  the 
regular  salary  of  their  grade. 

Vermont  State  Medical  Society. — The  annual  meet- 
ing was  held  in  Montpelier,  October  nth  and  12th. 
The  following  officers  were  elected :  President,  Dr.  J.  H. 
Linsley,  of  Burlington ;  Vice-President,  Dr.  F.  F.  Chaffee, 
of  Stratford ;  Secretary,  Dr.  D.  C.  Hawley,  of  Burlington ; 
Executive  Committee  :  Drs.  J.  H.  Linsley,  D.  C.  Hawley, 
and  F.  R  Stoddard,  (of  Shelburne).     Publication  Com- 


mittee :  Drs.  D.  C.  Hawley,  J.  B.  Wheeler,  and  H.  C. 
Tinkham.  Zictnte  Censors :  Drs.  E.  S.  Albee,  C.  M. 
Ferrin,  and  H.  S.  Brown.  The  attendance  was  the  largest 
in  the  history  of  the  Society.  Dr.  Frederick  C.  Shattuck, 
of  Boston,  read  a  valuable  paper  on  "  The  Modern  Treat- 
ment of  Typhoid  Fever,"  and  Dr.  John  C.  Irish,  of 
Lowell,  Mass.,  presented  one  on  the  "Surgical  Treat- 
ment of  Uterine  Neoplasms."  The  annual  banquet  was 
spread  at  the  Pavilion  Hotel  at  10  p.m.  Thursday,  and 
was  enjoyed  by  about  a  hundred  and  fifty,  including  the 
members  of  the  Society,  the  Governor  of  the  State,  V. 
A.  Woodbury,  of  Burlington,  also  the  Speaker  of  the 
House  of  Representatives  and  other  officers  of  the  Legis- 
lature. The  Anniversary  Chairman  was  Dr.  A*  P.  Grin- 
nell,  of  Burlington.  The  next  annual  meeting  will  be 
held  in  Burlington. 

Hew  Ruling  by  the  Illinois  State  Board  of  Health. — 
The  Illinois  State'  Board  of  Health  will  not  recognize 
Dental,  Pharmacy,  or  Veterinary  Colleges  as  entitled  to 
recognition  for  any  part  of  a  medical  college  course. 

Some  Recollections  of  Holmes. — Mr.  Ernest  Hart 
gives  entertainingly  some  recollections  of  a  visit  which 
he  paid  to  the  late  Dr.  Holmes  a  year  ago.  "  We  fell,1' 
says  Mr.  Hart,  "to  talking  of  his  visit  to  London  in 
1886,  and  of  our  meetings  together  and  our  mutual 
friends.  He  recalled  a  brilliant  dinner  party  at  the  Re- 
form Club  on  the  night  of  his  arrival,  and  spoke  sympa- 
thetically of  his  host,  Sir  Morell  Mackenzie,  and  some 
others  of  the  party  who  were  now  no  more,  and  of  his 
daughter  who  had  charge  of  him,  whom  also  he  had  lost. 
Laughingly  he  reminded  me  of  the  '  lesson  in  English ' 
he  had  received  in  the  hall.  During  dinner  the  talk  had 
turned  on  provincial  and  American  slang.  Speaking  of 
one  of  his  latest  poems,  of  which  he  recited  a  passage,  he 
had  said  in  banter  that  he  did  not  think  it  his  worst, 
adding:  'I  tried  it  on  a  dog,  and  the  dog  didn't  die.' 
He  confessed  that  the  'American  language,'  about 
which  there  was  some  discussion,  was  not  always  identi- 
cal with  the  English,  but  'it  was  none  the  worse  for 
that.'  At  any  rate,  he  prided  himself  on  talking  pure 
English.  As  we  came  away  and  were  taking  leave,  he 
said  to  me,  apropos  of  an  engagement  for  the  next  day 
when  he  was  coming  to  lunch  with  me :  '  But  you  must 
give  me  your  ticket.'  In  handing  it  to  him  I  could  not 
help  saying:  'We  English  call  it  a  card.'  He  an- 
swered: 'I  don't  know  that  it  is  a  better  word.'  'I 
did  not  quite  relish  then,'  he  said  to  me,  '  being  taught 
English  by  a  cockney  on  the  first  day  of  my  arrival,  and 
I  have  not  forgotten  it;  but  you  see  I  bear  no  malice.' 
Speaking  of  his  student  life  in  Paris  Dr.  Holmes  said : 
'  It  was  in  the  days  of  Louis  Philippe,  in  1833-35,  that 
I  followed  the  classes  of  Louis,  who  was  the  loadstone  of 
all  the  young  American  students,  and  there  I  first  met 
Gairdner,  of  Glasgow,  with  whom  I  still  sometimes  corre- 
spond.' 'Bigelow,'  he  said,  'used  to  go  over  once  a 
week  to  London  to  hear  a  lecture,  but  that  was  uniquely 
enterprising.'  He  claimed  for  Bigelow,  afterward  a 
medical  professor  in  Boston,  that  he  was  one  of  the 
greatest  of  modern  physicians,  and  that '  a  single  lecture 
which  he  had  published  on  "  Self  limited  Disease  "  made 
"  a  revolution  in  medicine."  It  anticipated  Gull's  doc- 
trine of  "  Expectant  Medicine,"  and  laid  bare  the  secret 
of  the  temporary  success  but  the  self-evident  folly  and 


534 


MEDICAL   RECORD. 


[October  27,  1894 


failure  of  homoeopathy.9  When  a  practioner  boasted  to 
him  that  he  had  'cured  a  disease/  he  would  say: 
'Young  man,  take  care;  are  you  sure  that  you  cured? 
If  so,  perhaps  to  morrow  you  may  kill,  but  then  you  will 
only  say  that  the  patient  died.1 " 

Dr.  Holmes  on  Walshe,  Watson,  and  Paget.— Dr# 
Oliver  Wendell  Holmes  thought  Dr.  Walshe,  of  Univer- 
sity College,  an  early  contemporary,  "  the  most  philo- 
sophic of  the  physicians  of  our  day ;  "  Watson,  "  the 
most  eloquent;"  but  Paget,  "the  most  persuasive. 
Persuasive,  but  not  always  convincing.  He  is  truly  the 
Gladstone  of  Medicine,  and  left  often  in  my  mind  a 
doubt  whether  his  reservations  and  distinctions  might 
not  to-morrow  lead  him  to  a  variation  from  the  convic- 
tion to  which  almost  he  persuaded  you  to-day.  .  .  . 
But  that  is  the  infirmity,  perhaps,  of  my  dim  perception 
rather  than  of  his  circumspect  intellect." 

A  Cyclone  Struck  the  Insane  Asylum  at  Little  Rock, 
Ark.,  on  October  2d,  demolishing  three  stories  of  a 
wing  containing  two  hundred  and  sixty  patients.  Dr. 
Ingate,  one  of  the  medical  staff,  and  formerly  of  Mobile, 
Ala.,  was  killed.    Two  of  the  patients  were  killed  also. 

Castration  for  Masturbation.— Dr.  Pilcher,  Superin- 
tendent of  the  Institution  for  Imbeciles  and  Weak- 
minded  Children,  at  Winfield,  Kan.,  has  been  bitterly 
denounced  by  newspapers  in  Winfield  and  Topeka  for 
castrating  several  boys — inmates — who  were  confirmed 
masturbators.  His  predecessor,  Dr.  Wile,  had  treated 
these  boys  five  years  without  benefit,  and  Dr.  Pilcher, 
taking  a  rational  view  of  the  subject,  performed  the 
operation  for  the  same  reason  he  would  perform  any 
other  surgical  operation — for  its  curative  effect.  There 
is  a  strong  probability  that  he  will  be  ndicted  for  may- 
hem, to  the  everlasting  disgrace  of  the  civilization  of  the 
nineteenth  century. — Texas  Medical  Journal. 

A  Pathetic  Appeal.— October  is  the  month  of  cotton, 
calves,  colds,  and  collections.  We  are  not  interested  in 
any  of  these  "  forces  "  (four  c's)  except  the  latter,  and 
we  do  earnestly  hope  and  expect  that  our  good  friends 
will  not  forget  our  patience  and  long  suffering  (nor  their 
patients  and  their  long  suffering)  when  they  go  out  in 
quest  of  cash. — The  Texas  Medical  Journal. 

Anti-Handshaking  Society. — We  hear  that  a  society 
for  the  suppression  of  hand-shaking  has  been  established 
at  Baku,  in  Russia. 

The  Golf  "Cure"  for  Insomnia.— A  writer  in  the 
Scotsman,  commenting  upon  the  Marquis  of  Salisbury's 
recent  address  to  the  members  of  the  British  Association 
at  Oxford,  expressed  regret  that  his  lordship  should  be  a 
victim  to  the  modern  and  very  prevalent  disorder  of  in- 
somnia. He  went  on  to  appeal  to  the  medical  profes- 
sion for  some  prompt  and  effective  remedy  for  that  dis- 
tressing ill.  "  Would  that  the  noble  leader  of  the  Con- 
servative party  would  take  a  three  months'  course  of  golf ' ' 
was  the  inward  exclamation  of  one  who  had  himself  suf- 
fered from  insomnia,  and  was  at  the  time  rejoicing  in  a 
succession  of  nights  of  profound  and  refreshing  sleep. 
Golf  is  the  game  for  the  exhausted  brainworker  at  any 
stage  of  his  life.  No  junior  is  too  young,  no  senior  is 
too  old  to  learn  it ;  to  learn  it  and  to  enjoy  it.  The 
proof  of  the  pudding  is  in  the  eating.  On  the  golf  links 
of  St.  Andrews  the  man  of  seventy  looks  fifty,  and  the 


man  of  fifty  has  the  appearance  of  thirty-five.  Sleepless- 
ness, so  far  as  the  writer  was  able  to  discover,  in  a  three 
weeks'  sojourn  at  St.  Andrews,  is  absolutely  unknown  to 
the  regular  golf-player.  One  may  almost  say  it  is  im- 
possible. Living,  as  he  does,  in  the  open  air,  and  tak- 
ing several  hours  of  daily  exercise  without  unpleasant 
fatigue,  and  with  a  mind  constantly,  but  not  laboriously, 
interested,  he  eats  well  and  so  the  brain  is  adequately 
nourished.  The  only  trouble  with  the  remedy  is  that  a 
man  must  be  a  person  of  leisure  in  order  to  take  it. 

A  Bureau  of  Autopsy. — In  the  year  1881  there  was 
founded  at  Milan  a  unique  and  curious  institution, 
which  has  been  at  work  ever  since.  This  was  the  Loria 
Bureau  of  Autopsy.  It  was  founded,  and  placed  under 
the  direction  of  Professor  A.  Verga,  for  the  use  of  the 
inhabitants  of  Milan.  That  is  to  say,  either  courts  of 
law  or  the  family  of  a  deceased  person  can  have  a  com- 
plete examination  and  report  in  cases  where  a  death  has 
occurred  under  suspicious  or  strange  circumstances.  All 
autopsies  are  recorded,  and  may  be  consulted  for  pur- 
poses of  study.  The  Bureau  is  intended  to  serve  two 
purposes — the  advancement  of  knowledge,  and  to  remove 
one  objection  to  cremation  raised  on  the  grounds  that 
crime  may  be  less  easy  of  detection  when  the  deceased  is 
effectually  placed  beyond  the  reach  of  examination. 

The  River  Seine  "  Catch  "  of  1883.— The  following 
figures  are  published  as  a  result  of  the  attempt  to  keep 
the  River  Seine  clear  of  cadavera  for  the  year  of  1893. 
There  were  withdrawn  from  the  river  5,652  dogs,  3,307 
cats,  9,108  rats,  1,720  fowls  and  3,942  other  birds,  4,209 
rabbits,  789  pigs,  7  calves,  4  hedgehogs,  33  horses,  15 
sheep,  2  colts,  and  13  monkeys. 

Death  of  Dr.  Virginias  A.  Turpin. — Dr.  Virginius  A. 
Turpin  died  at  his  residence  in  New  York,  October  nth, 
at  the  age  of  seventy*  five  years.  He  was  a  Virginian  by 
birth.  For  many  years  he  was  regarded  as  a  high  au- 
thority on  the  subject  of  cholera,  and  during  the  epi- 
demic of  the  disease  in  the  year  1866,  he  was  called  by 
the  Board  of  Health  of  St.  Louis  to  assume  the  direction 
of  the  cholera  hospitals  of  that  city.  A  considerable 
portion  of  his  life  was  passed  in  Chicago,  where  he  en- 
joyed a  high  reputation  and  had  an  extensive  practice. 
About  two  years  ago  he  removed  to  New  York,  and  since 
that  time  his  health  has  been  gradually  failing. 

An  Appeal  to  the  Pity  and  Better  Matures  of  the  Edi- 
tors and  Publishers  of  the  British  Medical  Journal  and 
the  Lancet — You  know,  gentlemen,  that  the  paper  upon 
which  is  printed  the  "  foreign  edition  "  of  your  otherwise 
splendid  journals,  is  simply  inexpressibly  vile.  It  is  at 
once  thicker,  and  yet  more  mushy  and  rotten  than  tissue- 
paper,  and  is,  therefore,  properly  fit  for  no  purpose  what- 
soever— absolutely  none— of  civilized  or  unregenerate 
man.  We  can  only  explain  its  use  on  the  ground  of  a  con- 
tempt of  us,  the  reason  of  which  dates  back  to  Revolution- 
ary times,  or  perhaps  to  Simian  ages.  You  certainly  would 
not,  and  could  not,  treat  residents  of  the  British  Islands 
thus.  We  beg  of  you  to  remember  that  however  remote 
the  relationship  we  are  at  least  your  Teutonic  brethren, 
and  that  it  is  your  duty  to  help  on  the  cause  of  Anglo- 
Saxon  civilization.  Please  do  not  forget  that  even  an 
American  can  sometimes  grumble,  and  even  revolt,  after 
prolonged  indignity  and  injustice. — Medical  News. 


October  27,  1894] 


MEDICAL   RECORD. 


535 


UNVEILING  OF  THE  SIMS  STATUE. 

The  ceremonies  attending  the  unveiling  of  the  statue  of 
Dr.  J.  Marion  Sims  and  its  presentation  to  the  city  of 
New  York  were  held  in  Bryant  Park  on  Saturday  last, 
October  20th,  at  3  p.m. 

A  number  of  representative  medical  men,  with  female 
members  of  their  families,  occupied  places  upon  the 
elevated  platform,  which  was  decorated  with  flags  and 
which  faced  the  statue,  also  draped  in  the  American  flag. 
The  fine  October  weather  enabled  the  large  audience  in 
the  Park  to  comfortably  compose  itself  upon  benches 
provided  for  the  purpose. 

On  the  stand  were :  Dr.  H.  Marion  Sims  and  Master 
Marion  Sims  Wyeth,  the  little  grandson  of  the  original 
of  the  statue.  Others  present  were  Dr.  D.  B.  St.  John 
Roosa,  President  of  the  Academy  of  Medicine;  Dr. 
Abraham  Jacobi,  Dr.  Lewis  A.  Sayre,  Dr.  E.  L.  Keyes, 
Dr.  J.  A.  Wyeth,  Civil  Justice  Stiner,  Mr.  and  Mrs. 
Edwin  Gould,  Dr.  A.  R.  Robinson,  Dr.  and  Mrs.  Will- 
iam M.  Polk,  Drs.  Robert  W.  Taylor,  O.  D.  Pomeroy, 
Y.  R.  Goffe,  W.  G.  Wylie,  Mrs.  G.  F.  Shrady ;  Drs.  O. 
D.  Pomeroy,  D.  H.  Goodwillie,  Robert  C.  Myles,  S. 
Waterman,  A.  G.  Gerster ;  Dr.  and  Mrs.  T.  R.  Price, 
and  Dr.  W.  H.  Pancoast,  of  Philadelphia ;  Mrs.  P.  F. 
Mund6  and  Miss  Bertha  Mund6,  Medical  Director  E.  S. 
Bogert,  U.  S.  N.,  and  Hon.  A.  B.  Tappan,  who,  as  a 
member  of  the  Board  of  Park  Commissioners,  accepted 
the  statue  for  the  city.  Among  the  spectators  in  the  Park 
there  were  also  delegations  from  the  New  York  Academy 
of  Medicine,  the  New  York  Pathological  Society,  the 
American  Gynecological  Association,  the  Medical  So- 
ciety of  the  County  of  New  York,  the  New  York  Poly- 
clinic, and  the  New  York  Post-Graduate  Medical  School 
and  Hospital. 

The  Jefferson  Medical  College  of  Philadelphia,  from 
which  Dr.  Sims  was  graduated  in  1835,  sent  Dr.  W.  W. 
Keen  and  Dr.  Theophilus  Parvin  to  represent  the  Fac- 
ulty. 

Letters  of  sympathy  with  regrets  of  inability  to  be 
present  at  the  ceremonies  were  received  from  Professor 
J.  M.  Da  Costa  and  Dr.  Richard  J.  Dunglison,  of  Phil- 
adelphia ;  Dr.  George  J.  Englemann,  of  St.  Louis ;  Pro- 
fessor A.  P.  Grinnell,  of  University  of  Vermont,  Burling- 
ton, Vt. ;  Dr.  J.  C.  Reeve,  of  Dayton,  O. ;  Dr.  B. 
Bernard  Browne,  of  Baltimore ;  Dr.  M.  C.  Baldridge, 
of  Huntsville,  Ala. ;  Dr.  R.  Stansbury  Sutton,  of  Alle- 
gheny, Pa. ;  Dr.  A.  Webb,  of  Collierville,  Tenn. ;  and 
Dr.  Henry  Dickson  Burns,  of  New  Orleans,  La. 

There  were  not  only  a  goodly  number  of  ladies  occu- 
pying seats  on  the  platform  and  in  the  general  audience, 
bat  many  were  seated  in  carriages  which  lined  die  ad- 
joining streets. 

The  committee  in  charge  of  the  ceremonies  consisted 
of  Dr.  George  F.  Shrady,  Dr.  William  T.  Lusk,  Dr. 
William  M.  Polk,  Dr.  Thomas  Addis  Emmet,  and  Mr. 
William  H.  S.  Wood. 

General  Addresses. — Dr.  George  F.  Shrady  made  the 
opening  address,  in  which  he  sketched  the  character  of 
Dr.  Sims  as  a  surgeon  and  philanthropist  (see  p.  513). 

Professor  Paul  F.  Mund6,  M.D.,  followed  with  an  ad- 
dress on  Dr.  Sims  as  the  gynecologist,  the  founder  of  the 
New  American  School  (see  p.  514). 

Presentation  of  Statue  to  the  City  of  Hew  York.— 
On  the  conclusion  of  Professor  MundeVs  address  Dr. 
Shrady,  as  chairman  of  the  committee,  made  the  follow- 
ing presentation : 

"  Commissioner  Tappan :  I  have  the  great  honor,  on 
behalf  of  the  many  friends  and  admirers  of  Dr.  J.  Marion 
Sims,  and  in  the  name  of  the  medical  profession  of  this 
and  other  countries,  to  present  this  beautiful  statue  to  the 
city  of  New  York,  with  the  assurance  that  it  will  com-, 
pare  favorably  with  others  of  its  kind  in  our  parks  and 
squares,  and  in  the  hope  that  in  this  Park,  which  is  here- 
after to  be  devoted  to  the  meritorious  recognition  of  dis- 
tinguished services  in  literature,  art,  and  science,  it  may 
take  its  worthy  place." 


During  these  remarks  the  string  was  pulled  by  Master 
Marion  Sims  Wyeth,  the  five- year- old  son  of  Dr.  J.  A. 
Wyeth,  and  the  covering  fell  from  the  figure,  amid  the 
cheering  applause  of  the  multitude  assembled. 

The  Acoeptance  for  the  City  by  Hon.  A.  B.  Tappan. 
— Park  Commissioner  Tappan,  on  behalf  of  the  city, 
made  the  following  speech  of  acceptance : 

"  *  Whether  on  scaffold  high  or  in  the  battle's  van, 

The  noblest  place  for  man  to  die  is  where  he  dies  for  man  1' 

"  These  words  of  the  poet  apply,  with  slight  change, 
to  Dr.  Marion  Sims.  His  life  exemplified  the  saying 
that  the  '  noblest  life  a  man  can  live  is  where  he  lives 
for  man.'  A  citizen  of  high  repute,  a  benefactor  of  the 
human  race,  a  man  who  reached  the  most  exalted  place 
in  his  profession,  it  is  due  to  his  memory  that  all  who 
knew  him  professionally,  and  all  who  knew  him  by  repu- 
tation, should  stop  by  the  wayside  of  the  busy  field  ot 
our  daily  life  and  shed  a  tear  to  the  memory  of  his  many 
virtues  and  his  most  distinguished  services. 

"  Dr.  Sims  had,  indeed,  a  most  exalted  career  as  a 
citizen  and  as  a  professor  of  the  art  of  preservation  of 
the  human  race  and  of  the  laws  of  life  and  health.  No 
eulogy  can  do  justice  to  his  merits,  and  in  erecting  this 
heroic  statue  to  his  memory  those  who  knew  him,  and 
by  whom  this  work  was  created  and  is  erected,  are  doing 
themselves  high  honor. 

"  The  city  of  New  York  feels  most  proud  of  the  citi- 
zenship of  its  distinguished  men  in  every  department  of 
active  life.  The  profession  of  which  Dr.  Sims  was  a 
most  prominent  member  has  a  just  pride  in  the  deed  of 
to-day  in 'erecting  this  statue.  I  repeat  that  it  is  an 
honor,  not  merely  to  one  who  has  filled  and  finished 
an  exalted  career  and  has  gone  to  his  reward,  but  to 
those  who  participate  in  the  ceremonies  of  this  occa- 
sion. 

"  Mr.  Chairman,  I  might  add  much,  very  much,  to 
these  brief  remarks,  deputed  as  I  am  by  the  public 
authorities  of  our  city  to  speak  on  this  occasion ;  but 
that  task  has  been  better  performed  by  others.  The 
work  and  all  that  it  is  intended  to  perpetuate  are  now  a 
part  of  the  history  of  our  metropolis,  and  is  accepted 
with  all  the  high  honor  accorded  to  contributors  that  so 
justly  belongs  to  them.  One  word  more  and  my  agree- 
able duty  is  finished : 

"  4  Count  that  day  lost  whose  low,  descending  son 
Sees  no  good  deed  or  worthy  action  done.' 

"  Gentlemen,  this  day  has  not  been  lost.  The  deed 
in  which  we  are  all  participating  will  mark  it  in  our 
calendar  as  a  day  well  spent  and  always  to  be  remem- 
bered. We  thank  you  for  your  public  spirit  in  offering 
a  statue  of  high  excellence  in  its  workmanship,  and 
claim  it  now  as  an  additional  ornament  to  the  city  at 
large,  and  especially  to  Bryant  Park,  the  scene  of  these 
ceremonies/ 

The  statue  is  the  work  of  Mailer,  of  Munich.  It  is  of 
bronze,  in  full  length,  and  of  heroic  proportions.  It 
stands  upon  a  pedestal  of  brown  granite.  On  one  side 
is  the  inscription : 

J.  Marion  Sims,  M.D.,  LL.D. 

Born  in  South  Carolina,  1813. 

Died  in  New  York  City,    1883. 

Surgeon  and  Philanthropist 

Founder  of  the  Woman's  Hospital,  State  of  New  York. 

His  brilliant  achievements  carried  the  fame  of 

American  Surgery 

Throughout  the  civilized  world. 

In  recognition  of  his  services  in  the  cause  of 

Science  and  Mankind 

He  received  the  highest  honor  in  the  city  of  his  countrymen, 

And  decorations  from  the  Governments  of 

France,  Portugal,  Spain,  Belgium,  and  Italy. 

On  the  opposite  side  the  inscription  recites  that  the 
statue  was  "  Presented  to  the  city  of  New  York  by  his 
professional  friends,  loving  patients,  and  many  admirers 
throughout  the  world." 


536 


MEDICAL    RECORD. 


[October  27,  1894 


(IPtitticat  geprartttuetit 

TWO   COMMON  FORMS  OF  ALOPECIA,   WITH 
THEIR  TREATMENT. 

By  ELLICE  M.ALGER,  M.D., 

NEW  YORK. 
CLINICAL  ASSISTANT  IN  DERMATOLOGY  NKW   YORK  POST  GRADUATE  SCHOOL: 

The  premature  falling  out  of  the  hair  is  a  trouble  that 
causes  a  great  deal  of  mental  disquietude  in  young  people 
and  not  infrequently  leads  to  certain  more  serious  ills. 
It  is  exceedingly  common,  and  yet  comparatively  few 
cases  are  brought  to  the  physician's  notice,  for  it  is  gen- 
erally understood  that  the  family  doctor  knows  little  and 
cares  less  about  such  a  trifling  matter. 

It  should  not  be  so,  for  a  little  study  in  this  direction 
will  be  more  profitable,  both  for  him  and  his  patients, 
than  a  profound  research  into  "thyroid  feeding"  or 
leprosy. 

In  a  certain  number  of  cases  of  alopecia  no  sufficient 
cause  for  the  hair- fall  can  be  found,  even  on  careful  ex- 
amination. These  idiopathic  cases  begin,  generally,  in 
individuals  between  twenty  and  thirty,  with  a  very  grad- 
ual loss  of  hair  from  the  vertex  or  sides  of  the  forehead. 
At  the  same  time  a  progressive  decrease  in  the  size  and 
vigor  of  the  hairs  can  be  plainly  seen,  till  after  a  certain 
length  of  time  the  vitality  of  the  hair  follicle  is  exhausted 
and  complete  baldness  ensues.  The  time  required  for 
this  process  to  be  completed  varies  from  two  to  ten 
years,  and  is  usually  much  shorter  in  patients  who  lead 
sedentary  lives. 

In  looking  for  predisposing  causes  it  is  often  found 
tfiat  early  baldness  has  been  a  family  trait  for  one  or 
more  generations,  and  this  influence  in  many  cases  seems 
to  be  transmitted  along  sexual  lines ;  the  daughters  of  a 
bald  father  do  not  on  that  account  suffer  as  much  as 
though  the  mother  were  prematurely  bald.  Another  un- 
doubted factor  is  the  wearing  of  hot  or  tight-fitting  head- 
gear, since  it  is  argued  that  a  hat  tight  or  heavy  enough 
to  compress  blood-vessels  must  interfere  with  pilary 
growth  and  nutrition.  The  frequent  soaking  of  the  head 
which  many  people  seem  to  think  necessary,  is  undoubt- 
edly injurious. 

Just  how  nerve-strain  should  cause  early  loss  of  hair 
cannot  be  satisfactorily  explained,  but  it  is  beyond  ques- 
tion a  factor  in  many  cases. 

Women  are  apparently  much  less  subject  to  alopecia 
than  men,  probably  because  they  wear  different  head*  gear 
and  are  naturally  provided  with  a  more  abundant  layer 
of  subcutaneous  tissue.  Also  they  pay  much  more  atten- 
tion to  the  condition  of  the  scalp,  and  are  more  skilful 
in  concealing  their  losses  by  artificial  means. 

The  prognosis  in  these  idiopathic  cases  is  bad,  the 
gravity  increasing  as  the  layer  of  subcutaneous  fat 
becomes  less,  and  as  age  increases.  The  rate  of  progress 
is  best  indicated  by  the  size  of  the  individual  hairs  and 
their  clipped  ends  in  men,  and  their  length  in  women ; 
these  indicating  whether  they  have  matured  and  fallen 
naturally,  or  come  out  while  immature.  A  constant  fall 
of  lanugo  hairs  would  indicate  an  advanced  and  grave 
state  of  the  trouble.  The  indications  for  treatment  are 
first  prophylactic.  The  general  health  has  a  direct  bear- 
ing on  the  case ;  the  scalp  should  be  frequently  brushed 
with  a  moderately  stiff  brush  and  any  deficiency  in  the 
oily  secretions  should  be  artificially  supplied.  If  the 
trouble  seems  caused  by  a  lack  of  the  hair-forming  ele- 
ments in  the  body,  a  generous  diet  must  be  insisted  on 
and  supplemented  by  tonics,  iron,  hypophosphites,  etc. 
Locally,  stimulants  are  called  for  and  remedies  which 
shall  cause  an  unusual  supply  of  blood  in  the  scalp. 
Tr.  cantharides,  Tr.  nucis  vom.,  Tr.  capsic,  and  quinine 
all  have  more  or  less  value.  They  can  be  used  in  oily 
excipients  if  the  scalp  be  very  dry,  or  in  alcohol  if  the 
sebaceous  secretion  is  sufficient 


The  following  will  give  some  idea  of  the  local  treat- 
ment: 

9.    Tr.  cantharides, 

Tr.  capsic, 

Tr.  nucis  vom., 

Ol.  ricini ftft   3  ij. 

Alcohol  J  ij. 

Spts.  rosmarini J  j. 

M.    Sig.  :  Apply  to  scalp  night  and  morning. 

Another  very  good  thing  which  should  be  carefully 
used  is  muriate  of  pilocarpin,  either  hypodermically  or 
according  to  Lassar's  formula  as  follows : 

9 .    Pilocarp.  muriat gr.  xv. 

Vaseline |  ss. 

Lanolin f  ss. 

M.    Sig.  :  Rub  in  carefully  twice  daily. 

But  in  another  and  much  larger  class  of  cases  an  unmis- 
takable cause  appears  in  the  presence  of  a  larger  or 
smaller  amount  of  "dandruff,"  which  gives  the  name 
alopecia  furfuracea.  Clinically  this  dandruff  takes  on 
two  forms,  which  are  probably  due  to  the  same  cause. 
The  common  variety  consists  in  the  constant  shedding  of 
dry  scales.  European  writers  would  have  us  believe  that 
this  is  parasitic  in  origin ;  that  the  irritation  of  parasites 
results  in  the  shedding  of  epithelial  scales  while  yet  im- 
perfectly formed,  and  that  the  falling  out  of  hairs  and  the 
succeeding  atrophy  of  the  follicles  occur  because  they 
form  only  parts  of  the  epithelial  covering  and  are  event- 
ually subject  to  the  same  processes. 

In  another  form,  the  so-called  seborrhosal  eczema  of 
Unna,  the  scalp  is  covered  with  adherent  crust  and  scales, 
frequently  taking  the  form  of  circular  patches  and  show- 
ing a  marked  tendency  to  spread  over  the  face  and  body 
if  undisturbed.  These  patches  are  inflammatory  in  char- 
acter, especially  on  their  margins,  and  are  very  greasy. 
This  seborrhoeal  eczema  is  most  common  from  puberty 
to  about  thirty,  that  being  the  time  when  the  sebaceous 
glands  are  most  active,  and  it  has  been  demonstrated  by 
the  experiments  of  Lassar  and  Bishop  that  the  cause  is  a  . 
parasite,  but  whether  the  crusts  are  the  result  of  sebaceous 
or  sudoriferous  hypertrophy  is  still  a  matter  of  dispute. 

At  any  rate,  owing  to  parasitic  irritation,  one  of  two 
things  takes  place.  Either  the  cells  formed  in  the  glands 
and  hair  follicles  are  shed  while  yet  imperfect,  taking  the 
hair  with  them,  or  from  the  constant  production  of 
sebum  a  hypertrophy  of  the  glands  results,  followed  by 
atrophy  of  the  hair  from  pressure. 

In  this  variety  of  alopecia  the  prognosis  is  better  than 
in  the  idiopathic  form,  but  the  treatment  is  quite  differ- 
ent. To  begin  with  a  stimulating  treatment  would  ag- 
gravate instead  of  alleviate  the  difficulty,  and  this  is  the 
mistake  commonly  made.  The  first  thing  to  do  is  to 
remove  the  crusts,  and  this  is  first  accomplished  by  soak- 
ing the  scalp  thoroughly  with  some  bland  oil  at  night- 
time, and  cleaning  it  thoroughly  in  the  morning.  A 
nice  way  of  accomplishing  this  is  to  shampoo  the  head 
with  a  mixture,  made  of  egg-yolks  beaten  up  in  lime- 
water,  washing  the  scalp  thoroughly  afterward.  When 
the  crusts  are  pretty  well  gone  we  can  apply  anti-para- 
sitic treatment.  This  requires  patience,  and  application 
must  be  made  long  after  the  trouble  is  apparently  gone. 
The  remedies  at  command  are  numerous.  Perhaps  the 
most  universally  serviceable  is  sulphur  in  one  form  or 
another,  for  it  is  a  parasiticide  and  a  good  stimulant  to  the 
hair  growth,  supplying  elements  which  contribute  di- 
rectly to  its  growth.  It  can  best  be  used  in  ointment 
form.  One  of  the  nicest  preparations  is  that  devised  by 
Dr.  Jackson,  called  sulphur  cream.     The  formula  is : 

$.  Cera  alb 3  viij. 

Ol.  petrolat 5  v. 

Aq.  rose 5  ijss. 

Sod.  biborat gr.  atxxvj. 

Sulphur 3  vij. 

M.     Sig.  :  Apply  night  and  morning. 

Resorcin  is  another  valuable  remedy.  It  can  be  used 
in  ointment  in  strengths  of  from  five  to  ten  per  cent.,  but 
a  more  agreeable  preparation  is  the  following: 


October  27,  1894] 


MEDICAL   RECORD. 


537 


9.  Hydrarg.  bichlor gr.  j. 

Rcsorcin 3  ij. 

Alcohol, 

Aq afi   J  jss* 

M.    Sig. :  Apply  night  and  morning. 

Ichthyol  and  naphthol,  thymol  and  many  other  reme- 
dies have  their  advocates  and  values.  The  treatment 
must  be  persisted  in  as  long  as  any  traces  of  seborrhoea  re- 
main, the  frequency  of  applications  being  gradually  di- 
minished. Afterward  the  hair  thickens  up,  its  growth 
being  assisted,  if  necessary,  by  the  stimulating  remedies 
advised  under  alopecia  idiopathica. 

335  East  Nimbtbbmtk  Strkbt. 


SEWER-GAS  A  CAUSE   OF  PNEUMONIA. 
By  THEODORE  ZANGGER,  M.D., 

LATB  ASSISTANT  PHYSICIAN,  UNIVERSITY   HOSPITAL,  ZURICH,   SWITZERLAND. 

In  his  interesting  paper  on  "Sewer -gas  a  Cause  of 
Throat  Disease/'  in  the  Medical  Record  of  September  i, 
1894,  Dr.  Robinson  has  written  on  a  subject  of  no  small 
import.  Perhaps  the  following  two  cases,  which  I  had 
under  my  care  at  a  health-resort  in  the  Bernese  Oberland, 
may  help  to  throw  some  further  light  on  the  subject. 

Case  I. — Miss  O.  T ,  aged  fifteen,  of  healthy  pa- 
rents, pale,  anaemic,  who  had  undergone  an  operation  for 
adenoids  six  weeks  before,  sickened  with  acute  pharyngitis 
and  tonsillitis  without  any  formation  of  membrane, 
fever  remittent,  normal  or  rather  subnormal  in  the 
morning,  and  rising  to  1020  F.  and  102. 50  F.  in  the 
evening;  no  lung  symptoms  except  slight  bronchial 
catarrh.  After  three  days  the  patient  developed  a  cir- 
cumscribed pneumonia  of  the  lower  lobe  of  the  left  lung. 
Recovery  in  three  weeks.  The  drainage  of  the  chalet 
was  in  a  very  bad  state,  nauseous  odors  spreading  all 
over  the  house ;  the  drains  were  immediately  seen  to,  and 
no  other  member  of  the  household  (five  adults,  four  chil- 
dren) showed  any  illness. 

Case  II. — Miss  Z ,  fifteen  years  of  age,  weak  and 

anaemic,  still  suffering  from  albuminuria  subsequent  to 
scarlatina,  four  months  previous.  Three  weeks  later 
than  Case  No.  1,  she  was  attacked  with  acute  tonsillitis 
and  subsequent  pneumonia  of  a  portion  of  the  lower 
lobe  of  the  right  lung.  Temperature  remittent,  the  fever 
never  exceeded  1020  F.;  great  prostration.  Recovery  took 
place  in  a  fortnight.  No  other  cases  among  the  one 
hundred  and  twenty  guests  of  the  hotel.  Drainage  very 
defective,  nauseous  odors  rising  at  night  up  to  the  win- 
dows of  the  patient's  bedroom. 

At  the  same  time,  but  at  another  hotel,  there  was  one 
case  of  severe  erythematous  tonsillitis,  and  one  of  follicu- 
lar tonsillitis  simulating  diphtheria  in  all  its  symptoms. 
Both  recovered  in  from  three  to  five  days.  There  were 
no  other  infectious  diseases  at  the  time  among  the  three 
hundred  visitors  and  the  sixteen  hundred  inhabitants  of 
the  village. 

These  cases,  occurring  at  an  Alpine  resort  four  thousand 
six  hundred  feet  above  the  level  of  the  sea,  among  pa- 
tients of  the  better  classes  who  were  accustomed  to  pay 
every  attention  to  hygiene  of  the  body,  point  to  the  pos- 
sibility, or  rather,  I  would  say,  the  probability,  of  sewer- 
gas  as  causation.  The  form  of  pneumonia,  localized  as  it 
was  and  limited  to  a  small  portion  of  the  lobe  of  one 
lung,  the  remittent  type  of  the  fever,  and  perhaps  the  un- 
due amount  of  prostration  in  both  cases,  are  striking.  I 
can  explain  this  only  by  considering  the  "  causa  agens  " 
to  be  the  same  in  both  cases :  micro-organisms  contained 
in  and  disseminated  by  the  sewer- air  and  affecting  just 
these  patients  as  being  in  a  low  state  of  general  health. 
The  similarity  of  the  cases  may  even  point  to  the  simi- 
larity of  species  and  similarity  of  virulence  of  these  bac- 
teria, just  as  we  see  patients  suffering  from  typhoid  fever 
or  diphtheria  due  to  the  same  source  of  infection,  offer 
curious  analogies  as  to  the  severity  and  the  complications 
of  the  disease. 


jfoctetg  Reports. 

NEW  YORK  ACADEMY  OF  MEDICINE. 

SECTION  ON  SURGERY. 

Stated  Meetings  October  <?,  1894. 

B.  Farquhar  Curtis,  M.D.,  Chairman. 

Election  of  Chairman. — The  resignation  as  Chairman 
of  Dr.  Charles  A.  Powers,  he  having  removed  to  Denver, 
was  accepted  with  regret,  and  Dr.  B.  Farquhar  Curtis 
was  elected  to  fill  the  vacancy. 

Hernia  Treated  by  the  Wire  Mattress  Method.— Dr. 
A.  M.  Phelps  presented  a  young  man  to  illustrate  the 
treatment  of  hernia  by  the  method  which  he  had  de- 
scribed some  months  ago,  one  of  the  chief  features  of 
which  consisted  in  weaving  silver  wire  in  the  foim  of  a 
mattress  into  the  layers  of  muscle  when  closing  the 
wound,  with  a  view  to  offering  a  stronger  barrier  .against 
recurrence.  While  there  had  been  no  recurrence  in  the 
several  patients  treated  in  this  manner,  yet  it  was  too 
early  to  speak  of  a  permanent  cure,  and  he  showed  this 
patient  simply  to  prove  that  the  presence  of  the  wire  in 
the  tissues  caused  no  inconvenience  after  having  been 
worn  seven  months.  In  one  or  two  cases  there  had 
been  a  little  superficial  suppuration,  but  not  of  conse- 
quence ;  the  cases  which  he  had  treated  had  been  severe 
ones,  the  opening  large. 

Hernia  Afflicted. — The  Chairman,  Dr.  Curtis,  pre- 
sented a  man  who  had  had  double  inguinal  hernia,  the 
McBurney  operation  having  been  done  on  one  side,  the 
Czerny  on  the  other.  Both  had  given  way,  the  McBur- 
ney first,  after  which  it  had  been  followed  by  Macewen's 
operation,  which  still  held.  Four  weeks  ago  Dr.  Curtis 
performed  Basini's  operation  on  the  other  side. 

Bending  of  Neck  of  the  Femur. — The  Chairman  pre- 
sented another  patient,  a  young  man,  who  had  been  ad- 
mitted to  St.  Luke's  with  the  diagnosis  of  tubercular  ar- 
thritis at  the  hip  of  fifteen  months'  duration ;  but  when 
Dr.  Curtis  came  to  operate  he  found,  on  reaching  the 
neck  of  the  femur,  that  it  was  healthy  in  appearance,  but 
bent,  bringing  the  head  down  on  a  level  with  the  tro- 
chanter. The  neck  appeared  also  to  be  somewhat  short- 
ened. He  at  once  closed  the  wound,  and  it  healed  by 
primary  intention.  The  case  belonged  among  a  class  of 
which  Hoffmeister  had  collected  about  forty,  of  soften- 
ing of  the  neck  of  the  femur,  resulting  in  bending  and 
consequent  shortening  of  the  limb,  and  more  or  less 
mechanical  limitation  of  motion  and  pain  on  use.  The 
trochanter  projected  more  than  on  the  sound  side. 

Dr.  Royal  Whitman  presented  two  patients,  a  young 
man  and  a  boy,  with  the  same  trouble.  In  the  first  there 
was  bending  of  the  neck  of  the  femur  in  both  limbs,  pro- 
ducing the  deformity  known  as  scissors  legs,  the  two 
limbs  crossing  each  other  at  thq  knee.  In  this  case  the 
diagnosis  of  softening  of  the  neck  was  made  before  there 
was  scarcely  any  deformity,  but  his  advice  was  not  taken, 
the  patient  continued  at  his  work,  saw  various  physicians 
who  made  the  usual  diagnosis  of  hip-joint  disease,  and 
finally  of  paralysis,  because  of  his  awkwardness.  Dr. 
Whitman  intended  soon  to  divide  the  femora  and  over- 
come the  crossed  position  of  the  legs.  Flexion  and  ex- 
tension were  almost  free,  but  power  of  abduction  was 
very  limited ;  rotation  was  also  limited.  In  the  second 
case  there  was  bending  of  the  neck  of  the  femur  only  on 
one  side,  and  the  symptoms  were  like  those  in  other 
forms  of  knock- knee.  There  was  only  limitation  of  ab- 
duction in  this  case,  and  the  shortening  amounted  to 
half  an  inch.  No  case  yet  reported  had  occurred  after 
the  twentieth  year. 

Fracture  of  Ulna  and  Radius. — Dr.  Jacob  Teschner 
presented  a  boy  who  had  fractured  the  ulna  and  radius 
from  a  fall  in  July,  and  when  seen  soon  afterward  was 
found  to  have  the  end  of  the  lower  fragment  of  the 
radius  in  contact  with  the  end  of  the  upper  fragment  of 


538 


MEDICAL  RECORD 


[October  27,  1894 


the  ulna.  Four  short  splints,  one  on  each  of  the  four 
aspects  of  the  forearm!  were  applied,  and  over  these  a 
longer  splint  with  a  webbing,  extending  two  inches  be- 
yond the  fingers,  to  give  sufficient  extension  to  prevent 
the  fractured  ends  from  slipping  past  one  another.  The 
result  had  been  perfect. 

Enormous  Sarcoma  of  Ilium  Treated  Successfully  by 
Inoculations. — Dr  W.  B.  Coley  presented  the  young 
man  whom  he  had  first  shown  to  the  section  last  spring, 
through  the  kindness  of  Drs.  George  F.  Shrady  and  F. 
Kammerer,  when  there  was  an  enormous  sarcoma  of  the 
ilium  on  the  right  side.  The  patient's  health  was  de- 
clining rapidly,  an  operation  was  entirely  impractical, 
and  under  these  circumstances  he  had,  with  the  consent 
of  the  gentlemen  named,  undertaken  treatment  by  in- 
jections of  the  combined  virus  of  erysipelas  and  the  bac- 
terium prodigiosus.  The  injections  were  kept  up  over  a 
month,  during  a  part  of  which  time,  and  for  some  weeks 
after  cessation  of  treatment,  the  tumor  sloughed  and  dis- 
charged in  great  masses.  While  the  sloughing  was 
going  on,  the  patient's  condition  became  critical,  but 
afterward  he  regained  flesh  and  strength.  At  present 
there  was  only  a  slight  discharge  from  one  of  the  sinuses, 
around  which  there  was  moderate  inflammatory  thicken- 
ing. The  ilium  had  resumed  nearly  its  normal  size.  In 
a  paper  which  he  had  read  at  Washington  last  spring,  he 
had  reported  five  other  cases  which  could  be  pronounced 
cured  by  this  method,  the  total  number  so  treated  by 
him  having  been  twenty-five  at  that  time.  Since  then 
he  had  had  two  other  cases.  The  percentage  of  suc- 
cesses had  been  about  one  in  five. 

Dr.  George  F.  Shrady  remarked  that  he  had  watched 
this  case  and  the  treatment  with  great  interest  from  the 
time  it  first  entered  his  wards,  and  had  been  perfectly  as- 
tonished at  the  result.  It  was  clearly  an  inoperable  case, 
as  an  operation  would  have  involved  resection  of  the 
ilium  and  division  of  the  man  into  two  parts.  He  had 
very  little  faith  that  anything  could  be  done  by  way  of 
toxin  treatment,  but  knowing  that  this  was  an  age  of 
progress  he  asked  Dr.  Coley  to  kindly  come  into  the 
wards  and  try  that  method.  The  result  seemed  to  be 
that  the  patient  was  cured.  He  could  not  recognize  any 
of  the  original  growth,  and  there  was  reason  to  hope 
there  would  be  no  recurrence.  He  believed  now  that 
there  was  a  great  future  for  this  toxin,  and  should  never 
be  discouraged  in  inoperable  cases  until  it  had  been  tried. 
It  gave  one  reason  to  hope  that  something  might  yet  be 
found  equally  efficient  in  cancer. 

The  Chairman  referred  to  a  case  in  St.  Luke's  Hos- 
pital, of  very  large  secondary  sarcoma  of  the  clavicle,  the 
growth  of  which  had  ceased  after  using  the  injections  two 
weeks,  but  the  treatment  had  to  be  discontinued  on  ac- 
count of  deposits  in  the  lungs,  and  haemoptysis.  The 
effect  of  the  injections  had  also  been  shown  in  the  regular 
rise  of  the  temperature  every  day  or  two,  just  as  had  oc- 
curred in  Dr.  Coley's  case. 

Resection  of  Knee  for  Charcot's  Disease. — The  Secre- 
tary showed,  in  behalf  of  Dr.  Willy  Meyer,  a  man  with 
locomotor  ataxia  with  so-called  Charcot's  disease  of  the 
left  knee,  which  had  been  resected  by  Dr.  Willy  Meyer 
in  1887.  Although  the  spinal  disease  had  progressed, 
there  had  been  no  further  trouble  with  the  affected  knee. 
Bony  union  had  not  taken  place.  There  was  slight  mo- 
tion, nature  having  formed  a  sort  of  condyle  and  socket. 

Dr.  Syms  was  not  convinced  that  this  patient  was  bet- 
ter off  than  he  would  have  been  without  an  operation. 
At  the  same  time  that  Dr.  Meyer  was  about  to  operate, 
he  had  himself  a  patient  on  whom  he  wished  to  excise 
the  knee  for  Charcot's  disease,  but  the  patient  refused, 
and  afterward  partial  bony  anchylosis  formed  and  left  a 
better  joint  than  probably  would  have  resulted  from  any 
effort  to  bring  about  artificial  anchylosis. 

Improved  Osteoclast. — Dr.  W.  M.  Phelps  presented 
a  Grattin  osteoclast  which  he  had  modified  in  a  way  to 
obviate  breaking  of  the  skin  and  producing  compound 
fracture.  The  new  instrument  was  also  stronger  and 
easier  to  operate. 


Multiple  Heurc-flbromata.  Dr.  C.  N.  Dowd  read  a 
brief  paper  in  which  he  described  two  cases  of  this  affec- 
tion. The  first  was  in  a  man  aged  thirty- three,  who  dur- 
ing the  past  two  years  had  had  probably  as  many  as  two 
hundred  tumors  on  the  surface  of  the  body,  most  of  them 
freely  movable  on  the  underlying  tissue  but  attached  to 
the  skin,  the  surface  having  a  red  angiomatous  appear- 
ance. On  removing  one  it  was  found  to  be  a  fibroma  of 
the  variety  known  as  neurc-fibroma.  Such  tumors  were 
ordinarily  benign,  and  caused  trouble  only  by  their  me- 
chanical irritation  and  disfiguration. 

The  second  case  was  in  a  man  aged  thirty-five,  who  first 
noticed  a  tumor  over  the  olecranon  of  one  arm,  and 
afterward  others  over  various  parts  of  the  body,  varying  in 
size  from  a  pea  to  a  horse  chestnut.  They  had  the  ap- 
pearance of  the  tumors  in  the  other  case,  except  that  in 
some  there  was  a  tendency  to  necrosis.  There  was  no 
history  of  syphilis,  yet  mercurial  inunctions  caused  the 
tumors  to  disappear,  proving  their  syphilitic  origin.  Re- 
plying to  a  question,  he  said  there  was  no  neurotic  history. 


NEW  YORK  PATHOLOGICAL  SOCIETY. 

Stated  Meeting,  September  26,  1894. 

George  C.    Freeborn,    M.D.,   President,    in    the 
Chair. 

Report  of  the  Microscopical  Committee. — Dr.  E.  K. 
Dunham,  on  behalf  of  the  Microscopical  Committee,  re- 
ported the  results  of  the  examination  of  the  specimen  pre- 
sented to  the  Society  on  February  20,  1894 — supposed 
gumma  of  the  heart.  Because  of  the  presence  of  certain 
bodies  closely  resembling  giant  cells,  this  specimen  had 
been  referred  to  the  Committee.  The  special  object  was 
to  make  a  differential  diagnosis  between  a  possible  tuber- 
cular or  syphilitic  causation  of  the  growth.  At  that 
meeting  the  opinion  was  advanced  by  one  of  the  mem- 
bers of  the  Society,  that  the  bodies  resembling  giant- 
cells  were  derived  from  the  muscular  fibres  of  the  heart. 
Further  microscopical  examinations  had  confirmed  that 
view,  as  it  had  been  found  possible  to  select  a  series  of 
transitional  forms  explaining  the  changes.  In  order  to 
distinguish  between  tuberculosis  and  syphilis,  a  luge 
number  of  sections  were  examined  for  tubercle  bacilli, 
but  none  were  found.  The  sections  also  failed  to  show 
any  reason  for  regarding  the  growth  as  of  tubercular 
origin.  In  support  of  the  opinion  that  the  growth  was 
of  syphilitic  origin,  were  certain  appearances  in  the 
blood-vessels  which  seemed  to  indicate  a  beginning 
thickening  of  the  vascular  wall.  The  results  of  the  mi- 
croscopical examinations  were  therefore  confirmatory  of 
the  original  diagnosis. 

Giant-Cells  in  Epithelioma^. — Dr.  George  P.  Biggs 
referred  to  a  specimen  of  epithelioma,  which  he  had  pre- 
sented to  the  Society  last  November,  in  which  there 
were  giant- cells.  The  tumor  had  been  removed  from  a 
man  sixty  years  of  age,  who  had  given  a  history  of  hav- 
ing received  a  compound  fracture  of  the  inferior  maxilla 
five  years  before.  Following  this,  a  tumor  developed  in 
the  floor  of  the  mouth,  which  proved  to  be  an  epithe- 
lioma. A  small  nodule  was  said  to  have  recurred  in  the 
scar  left  after  the  operation  for  the  removal  of  the 
growth.  Later,  a  growth  appeared  in  the  submaxillary 
region  on  the  same  side,  and  this  had  grown  steadily  for 
four  months  previous  to  his  coming  under  observation. 
The  specimen  referred  to,  which  was  a  typical  epithe- 
lioma, contained  large  numbers  of  giant-cells  of  peculiar 
character,  some  of  them  very  large,  and  containing  a 
great  many  nuclei  grouped  near  the  centre  rather  than 
at  the  periphery.  The  specimen  had  been  submitted  to 
the  Microscopical  Committee,  and  Dr.  Dunham,  after 
examining  a  number  of  sections  stained  in  various  ways, 
was  able  to  demonstrate  that  these  giant-cells  had  been 
formed  from  epithelial  cells. 

He  desired  at  the  present  meeting  to  present  a  simi- 
lar specimen,  which  had  been  removed  at  the  New 


October  27,  1894] 


MEDICAL   RECORD. 


539 


York  Hospital  by  Dr.  Stimson,  from  a  man  fifty  years  of 
age  who  gave  a  history  of  progressive  loss  of  voice,  and  of 
some  pain  on  swallowing,  for  four  years.  For  five  or  six 
months  previous  to  the  operation,  he  had  suffered  from 
dyspnoea,  which  had  become  so  severe  that  an  opera- 
tion was  undertaken.  The  family  history  was  tubercular, 
but  there  was  no  personal  history  or  symptoms  of  tuber- 
culosis. The  operation  consisted  in  opening  the  larynx 
and  removing  from  its  interior  a  large  part  of  the  mu- 
cous membrane  and  a  new-growth.  Examination  of  the 
latter  showed  it  to  be  a  typical  epithelioma.  In  this 
specimen  also  were  giant-cells  apparently  of  the  same 
nature  as  those  found  in  the  first  specimen  referred  to. 
Some  of  these  cells  were  large,  others  had  only  three  or 
four  nuclei,  sometimes  grouped  in  the  epithelial  struct- 
ure and  sometimes  by  themselves.  Some  of  them  were 
round,  while  others  were  irregular  in  shape.  Tubercle 
bacilli  were  searched  for,  but  not  found.  Since  then,  in 
two  other  cases  he  had  seen  similar  cells,  but  not  as  dis- 
tinct as  in  the  microscopical  specimen  just  presented. 
They  seemed  more  prone  to  form  in  epitheliomata  of 
alow  growth.  The  literature  of  this  subject  was  very 
meagre. 

Dr.  Thomas  H.  Manley  asked  the  clinical  significance 
of  these  cells — in  other  words,  whether  their  presence 
was  to  be  considered  an  element  in  the  prognosis.  We 
know  that,  as  a  rule,  cancerous  growths,  particularly  on 
the  tongue,  were  rapidly  fatal,  and  that  sarcomata  in  this 
region  often  did  not  recur  for  a  considerable  time  after 
their  removal.  He  recalled  one  or  two  illustrative  cases 
which  had  occurred  in  his  own  practice. 

D*.  Biggs  replied  that  he  had  not  seen  a  sufficient 
number  of  cases  to  admit  of  his  stating  definitely  in  re- 
gard to  their  possible  clinical  significance,-but  in  those 
ises  he  had  reported  the  growth  had  been  quite  slow. 

The  Society  then  adjourned. 


NEW  YORK  COUNTY  MEDICAL  ASSOCIATION. 
Stated  Meetings  October  jjf,  1894. 

Samuel  B.  W.   McLeod,   M.D.,  President,  in  the 
Chair. 

1,  Posture  in  Anaesthetic  Accidents  ;  2,  The  The  of 
Sedatives  in  Heart  Disease ;  3,  The  Efficacy  of  Ichthyol 
011 Inflamed  Tissues. — Dr.  Hobart  A.  Hare,  of  Phila- 
delphia, read  a  paper  containing  brief  remarks  upon 
these  three  subjects.  Under  the  title  Posture  in  Anaes- 
thetic Accidents,  he  spoke  of  the  position  of  the  head, 
neck,  and  tongue,  and  their  influence  on  opening  or 
closing  the  glottis.  Artificial  respiration  was  often  ren- 
dered nugatory  by  placing  the  head  or  tongue  in  a  posi- 
tion which  closed  the  glottis  and  obstructed  entrance  of 
air  to  the  lungs.  If  the  tongue  were  pulled  out  and  over 
the  lower  incisors  by  the  tip  it  would  not  raise  the  epi- 
glottis ;  it  must  be  pulled  outward  and  upward  toward 
the  upper  incisors.  Regarding  control  of  the  glottis  by 
Howard's  method  of  extension  of  the  head  and  depres- 
sion of  the  neck,  Dr.  Hare  showed  by  experiment  on 
the  cadaver,  and  could  give  clinical  evidence,  that  the 
neck  must  not  be  depressed,  but  lifted,  else  the  velum  and 
tongue  would  obstruct  the  passage  of  air  through  the 
mouth,  which  would  prove  very  serious  if  the  nostrils 
should  also  happen  to  be  obstructed.  Regarding  the 
comparative  efficacy  of  Sylvester's  and  Marshall  Hall's 
methods  of  artificial  respiration,  he  had  made  some 
experiments  which  proved  that  Sylvester's  was  much 
more  efficacious  in  inflating  the  lungs.  It  was  important 
that  the  feet  should  be  held  while  the  movements  were 
being  made  with  the  arms — that  the  body  should  be 
stretched. 

Cause  of  Death  in  Chloroform  Anaesthesia.  —  Dr. 
Hare  referred  to  his  studies  in  connection  with  the 
Hyderabad  Commission,  and  said  he  was  convinced  that 
the  chief  factor  in  causing  death  in  chloroform  anaes- 


thesia was  cessation  ot  respiration  through  paralysis  of 
the  respiratory  centre  in  the  medulla,  although  he  knew 
also  of  the  influence  exerted  on  the  vasomotor  system, 
and  through  it  upon  the  heart,  and  did  not  doubt  that 
the  heart  might  first  give  out  in  certain  cases  where  this 
organ  was  diseased,  just  as  death  might  take  place  from 
cardiac  shock  brought  on  by  various  causes  provided  the 
heart  was  already  unsound.  The  death  from  chloro- 
form in  such  a  case  was  due  more  to  sudden  vascular  dis- 
tention than  to  direct  influence  on  the  heart.  He  had 
found  that  atropine  allowed  more  chloroform  to  be  used 
without  depression. 

Cause  of  Death  in  Traumatic  Shock. — The  author 
had  observed  in  many  cases  of  death  supposed  to  be 
due  to  circulatory  failure  in  traumatic  shock  that  respira- 
tion was  first  to  give  out.  He  had,  therefore,  made  use 
of  Sylvester's  method  of  artificial  respiration  in  similar 
cases,  and  had  seen  the  breathing  and  pulse  improve 
from  the  increased  quantity  of  air  made  to  enter  the 
chest. 

Sedatives  in  Heart  Disease. — The  next  part  of  the 
paper  dealt  with  the  treatment  of  heart  disease.  Digi- 
talis had  been  much  abused.  It  was  very  useful  in  certain 
cases,  but  was  contra-indicated  in  others,  while  agents  of 
an  opposite  nature,  sedatives,  not  stimulants,  were  called 
for.  These  agents  were  aconite,  atropine,  gelsemium. 
In  practice  he  found  that  he  prescribed  the  sedatives 
oftenest.  Digitalis  was  beneficial  in  those  cases  where 
the  heart  was  failing  and  unable  to  do  its  work.  The 
sedative  agents  did  best  where  the  heart  was  beating 
with  sufficient  force  or  too  much  force,  but  spasmodi- 
cally, irregularly,  and  ineffectually.  In  cases  of  compen- 
satory hypertrophy  among  laborers  or  gymnasts  the 
heart  was  likely  to  cause  trouble  when  they  ceased  their 
usual  degree  of  exertion.  Digitalis,  under  such  circum- 
stances, would  increase  the  palpitation  and  cardiac 
symptoms,  while  aconite  would  act  as  a  sedative  and 
give  relief.  Next  to  aconite  in  value  as  a  cardiac  seda- 
tive came  gelsemium,  then  veratrum  viride.  The  form  of 
cardiac  palpitation  and  oppression  complained  of  by 
medical  students  on  climbing  stairs  at  the  commencement 
of  a  term  was  usually  best  relieved  by  one  of  these 
agents. 

The  Efficaoy  of  Ichthyol  on  Inflamed  Tissues. — Dr. 
Hare  concluded  his  paper  by  citing  some  experiments 
made  on  rabbits  at  his  suggestion  in  the  laboratory, 
with  a  view  to  explain  the  influence  of  ichthyol  over  in- 
flammatory action.  Under  certain  precautions  the  skin 
of  the  rabbits  was  bruised  in  a  way  to  produce  subcutane- 
ous injection  and  inflammation.  The  rabbits  were  di- 
vided into  nine  series :  in  one  the  affected  area  not  re- 
ceiving treatment;  in  another  it  was  simply  rubbed; 
in  a  third,  ichthyol  was  applied ;  in  a  fourth,  the  ichthyol 
was  applied  with  rubbing;-  in  a  fifth,  it  was  applied 
along  with  lanolin ;  in  a  sixth,  the  latter  was  applied 
alone,  and  so  on,  the  object  being  to  determine  whether 
the  benefit  was  due  to  the  rubbing,  the  ichthyol,  the  lan- 
olin, or  to  any  combination  in  die  use  of  these  agents. 
Sections  of  the  skin  were  examined  microscopically. 
The  conclusions  drawn  from  the  experiments  were,  that 
the  inflammatory  exudate  disappeared  more  quickly 
under  rubbing  than  without ;  that  it  disappeared  most 
quickly  with  the  combined  use  of  rubbing  and  ichthyol, 
and  that  lanolin  had  no  effect.  The  rubbing  made  the 
oil-globules  penetrate  more  deeply. 

Dr.  E.  K.  Dunham  was  requested  to  open  the  discus- 
sion. He  showed  some  cultures  of  micro- organism 
which  he  had  made  with  a  view  to  determining  whether 
ichthyol  had  any  antiseptic  value.  Its  action  on  the 
growth  of  disease  germs  was  found  to  be  only  slightly 
inhibitory. 

Prolonged  Lincoln's  Life.— Dr.  C.  A.  Leale  said 
that  in  drowning  and  anaesthetic  accidents,  he  put  the 
finger  far  back  in  the  mouth  and  drew  the  tongue  for- 
ward, thus  accomplishing  what  Professor  Hare  did  by 
pulling  the  end  of  the  tongue  forward  and  upward.  He 
had  been  much  indebted  to  Dr.  Flint  for  knowledge 


540 


MEDICAL    RECORD. 


[October  27,  1894 


acquired  in  his  laboratory  regarding  artificial  respiration 
as  it  had  led  him,  when  he  found  President  Lincoln  sitting 
in  a  chair  after  the  shooting,  the  head  dropped  forward, 
breathing  stopped,  pulse  absent  at  the  wrist,  to  imme- 
diately lay  him  on  his  back  upon  the  floor  and  to  lift  the 
chin  and  thereby  restore  respiration.  The  coaguli  were 
then  removed  from  the  skull,  relieving  cerebral  pressure, 
whereupon  he  had  the  happiness  to  see  restoration  of 
lung  and  heart  action.  Miss  Keen,  the  actress,  came  in 
while  in  stage  costume,  and  seeing  the  President  lying 
upon  the  floor,  sympathetically  begged  permission  to 
hold  his  head.  Dr.  Leale  replied,  "  No,  the  head  must 
not  be  raised  an  inch,  or  else  it  may  interfere  with  res- 
piration and  cause  death." 

.  Dr.  Leale  also  referred  to  a  case  of  suicidal  attempt 
with  two  ounces  of  chloroform,  which  he  had  reported  in 
1873,  aQd  in  which  he  practised  artificial  respiration  and 
irritated  the  great  sympathetic  ganglia  by  introducing 
his  hand  a  distance  of  sixteen  inches  up  the  colon. 

Much  of  the  further  discussion  was  directed  to  the 
comparative  safety  of  ether  and  chloroform  as  anaesthet- 
ics. 

Dr.  Manley  felt  that  ordinarily  to  give  chloroform 
instead  of  ether  was  to  needlessly  imperil  the  patient's 
life.  He  inquired  the  author's  opinion  of  the  new 
French  method  of  rhythmical  traction  on  the  tongue 
where  breathing  had  ceased ;  also  of  Dr.  Fell's  method 
of  artificial  respiration. 

Dr.  Rupp  said  Dr.  A.  C.  Post  had  years  ago  taught 
and  practised  pulling  the  jaw  and  tongue  forward,  the 
finger  being  applied  to  the  back  of  the  tongue. 
.  Dr.  J.  Mount  Bleyer  said  with  reference  to  the 
method  of  artificial  respiration  credited  to  Dr.  Fell,  that 
he  had  himself  first  described  it,  in  a  paper  read  in  1886, 
one  tube  being  used  for  the  introduction  of  air  into  the 
lungs,  the  other  for  its  escape.  Further  remarks  were 
made  by  Drs.  Collyer,  McKeeby,  Brothers,  and  others. 
.Chloroform  had  its  advocates. 

Dr.  Hare  in  some  concluding  remarks  said  that  a  per- 
son's susceptibility  to  chloroform  or  ether,  like  to  some 
other  drugs,  seemed  to  depend  to  some  extent  upon  the 
climate.  In  the  South  and  in  Europe  chloroform  Ap- 
peared to  be  less  dangerous  than  in  this  section  of  the 
United  States.  Here,  judging  by  immediate  results, 
ether  was  much  safer,  but  it  was  a  question  whether  as 
much  could  be  said  of  it  if  the  after-accidents  as  nephri- 
tis, bronchitis,  etc.,  attributable  to  its  use,  were  taken 
into  consideration.  The  observations  of  those  who  had 
discussed  the  question  this  evening  were  in  harmony 
with  those  of  all  others  who  had  made  it  a  point  of 
special  investigation  that  in  chloroform  accidents  the 
respiration  ceased  before  the  heart-beat,  although  a 
contrary  view  had  generally  been  held  at  first. 

Chart  Illustrating  Mortality  Tables  TTsad  by  Life 
Assurance  Companies. — Dr.  N.  S.  Westcott  explained 
such  a  chart.  On  it  vertical  lines  were  drawn  to  the 
number  of  100,  every  fifth  one  heavier  than  the  oth- 
ers; they  were  crossed  by  horizontal  lines  up  to  any 
required  number.  The  horizontal  lines  beginning  at 
the  bottom  of  the  left  were  numbered  from  1  up,  which 
stood  for  thousands,  the  number  living;  the  perpen- 
dicular lines  beginning  at  the  left  and  bottom  were 
numbered  from  1  to  100,  the  age;  at 'the  top  the  same 
lines  contained  the  number  still  living  for  the  respective 
years,  the  number  decreasing  from  left  to  right  until 
zero  was  reached  at  the  age  of  one  hundred.  A  red 
line  was  drawn  from  the  left  upper  corner  of  the  chart, 
sloping  gradually  to  the  right  lower  corner,  dropping  as 
it  proceeded  to  each  horizontal  line  representing  the 
number  of  living  at  any  given  year.  There  was  a  rapid 
fall  in  this  oblique  line  the  first  five  years,  another  in- 
creased declination  after  the  fiftieth  year,  and  a  third, 
corresponding  in  degree  to  the  first,  beginning  at  old 
age.  By  this  chart  one  could  quickly  estimate  the  prob- 
ability of  life  at  given  ages.  Without  the  age  being 
given,  mortality  rate  per  thousand  in  any  community 
was  of  little  value. 


OUR  LONDON  LETTER. 

(From  our  Special  Correspondent.) 
THE  WINTER  SESSION — THE  MEDICAL  SOCIETIES — ^EPIDEM- 
ICS—  DIPHTHERIA — ANTITOXIN  —  EPIDEMIC  SKIN  DIS- 
EASE— EPIDEMIC  MUSCULAR  RHEUMATISM — BERIBERI — 
THE  CHELSEA  HOSPITAL  SCANDAL — HONORARY  MEDICAL 
OFFICERS  TO  PAY  WARDS. 

London,  October  6, 1S94. 

We  are  already  settling  down  to  the  work  of  the  winter 
session.  The  schools  having  opened  on  the  traditional 
October  ist,  and  a  number  of  them  having  celebrated 
the  occasion  with  a  dinner,  are  now  quietly  engaged  in 
their  usual  work.  The  societies,  too,  are  all  awakening, 
and  next  week  we  shall  be  in  the  full  tide  of  their  pro- 
ceedings. The  Obstetrical  Society  has  already  met ;  on 
Monday  the  Medical  Society  of  London  will  begin  its 
session  with  an  address  by  the  President,  Sir  W.  Dalby ; 
on  Wednesday  the  Hunterian  Society  will  be  addressed 
by  Mr.  Bryant ;  on  Thursday  the  Gynecological  Society 
will  meet ;  on  Friday,  the  Clinical  Society. 

I  have  not  yet  heard  when  the  Epidemiological  Society 
will  hold  the  first  of  its  few  meetings,  but  an  early  date 
would  seem  to  be  appropriate,  for  much  of  our  attention 
has  lately  been  demanded  by  epidemics,  and  we  seem  to 
be  threatened  with  an  outbreak  of  epidemiological  con- 
versation and  literature.  I  do  not  refer  in  this  to  chol- 
era or  the  more  distant  Eastern  plague,  but  to  diseases 
in  our  midst  with  a  more  or  less  epidemic  character. 
First  of  these  is  diphtheria,  which  has  for  some  years  been 
present  in  London,  but  seems  to  have  rather  increased. 
Last  week  there  were  sixty-seven  deaths,  and  the  numbers 
admitted  to  the  hospitals  of  the  Asylums  Board  show 
that  the  disease  has  been  more  prevalent  in  the  last 
quarter  than  in  previous  Michaelmas  quarters.  The 
same  may  be  said  of  the  numbers  of  notifications.  A 
most  interesting  point  in  reference  to  diphtheria  is  the 
success  that  has  attended  the  treatment  by  antitoxin. 
Stimulated  by  the  success  reported  from  the  Continent, 
quite  a  number  of  practitioners  have  been  using  the  new 
treatment,  and  successful  cises  are  being  rapidly  accumu- 
lated. Like  all  ether  remedies,  it  must  be  employed  in 
the  early  stage  if  it  is  to  be  effectual,  and  there  is  some 
evidence  that  it  is  even  preventive.  The  Pasteur  Insti- 
tute prepares  the  remedy  on  a  large  scale,  but  not  enough 
for  French  demand.  It  is  not  easy  to  obtain  a  supply 
here,  but  soon  perhaps  may  be.  It  is  to  be  hoped  that 
no  spurious  or  imperfect  preparations  will  come  into  the 
market.  A  considerable  time  is  required  for  preparing 
the  remedy,  and  no  little  skill.  Now  is  the  time  for  the 
British  Institute  of  Preventive  Medicine  to  show  its 
capacity  and  establish  its  position.  Some  are  calling  out 
for  the  State  to  provide  a  supply.  That  is  not  likely  to 
be  done  in  a  hurry,  and  the  British  Institute  ought  to  be 
able  to  meet  the  demand. 

The  second  epidemic  that  forces  itself  on  our  notice  is 
exfoliative  dermatitis.  Your  readers  will  remember  my 
report  on  this  three  years  ago,  when  Dr.  Savill  first  de- 
scribed it  as  "a  contagious  malady  in  which  the  main 
lesion  is  a  dermatitis,  sometimes  attended  by  vesicles, 
always  resulting  in  desquamation  of  the  cuticle,  usually 
accompanied  by  a  certain  amount  of  constitutional  dis- 
turbance, and  running  a  more  or  less  definite  course  of 
seven  or  eight  weeks."  This  disease  was  epidemic  in 
some  of  our  workhouse  infirmaries  in  1891,  and  in  them 
studied  by  Dr.  Savill.  It  has  since  recurred  each  sum- 
mer and  autumn,  but  this  year  to  a  much  greater  extent. 
It  chiefly  afreets  the  old  and  feeble,  and  the  temperature 
is  generally  subnormal.  The  mortality  in  1891  was 
12.8  per  cent.;  this  year,  so  far,  it  has  been  11.6.  A 
diplococcus  was  discovered  by  Dr.  Savill,  but  he  has  not 
been  able  to  find  it  in  later  cases.  Milk  and  other  arti- 
cles of  food  have  been  suspected  of  conveying  the  con- 
-tagium,  but  there  is  not  much  evidence  on  the  point. 


October  27,  1894] 


MEDICAL  RECORD. 


54i 


Another  disease  alleged  to  be  epidemic  in  several  lo- 
calities, is  muscular  rheumatism.  I  am  informed  that 
some  of  the  so-called  epidemics  resembled  influenza,  but 
in  others  this  was  not  the  case.  At  all  events  the  out- 
breaks were  not  very  serious.  The  attacks  lasted  some 
two  or  three  days,  and  consisted  in  sudden  pain  in  the 
head  or  chest,  with  a  rise  in  pulse  and  temperature. 
Some  observers  mention  pleurodynia  and  neuralgia  as 
being  similar,  others  notice  sweating  of  the  odor  com- 
mon in  acute  rheumatism.  No  one  that  I  know  of  has 
met  with  cardiac  complication. 

Yet  another  epidemic  is  reported.  In  a  lunatic  asy- 
lum in  Dublin  there  has  been  an  outbreak  of  beriberi. 
The  origin  of  the  disease  has  not  been  traced,  and  it  is 
not  a  little  singular  that  it  should  appear  in  our  climate 
as  an  epidemic  limited  to  an  institution  in  Dublin.  Odd 
cased  have  at  times  been  brought  to  our  ports,  but  as  a 
rule  do  not  spread. 

The  Chelsea  hospital  is  not  yet  "  out  of  the  wood.11 
The  Home  Secretary  has  declined  the  request  of  the  ves- 
try to  appoint  an  official  inquiry,  as  he  has  full  reliance 
on  the  impartiality  of  the  independent  inquiry  that  has 
been  held.  This  he  reads  as  a  condemnation  of  the  man- 
agement and  of  the  staff.  You  will  remember  that  I 
foresaw  the  medical  staff  would  be  made  the  scapegoat,  as 
usual  in  all  hospital  scandals.  The  cool  assurance  of  the 
managing  committee  in  proceeding  to  elect  a  new  staff 
when  the  old  resigned,  is  just  what  might  be  expected 
from  an  ordinary  hospital  committee.  But  this  one  was 
involved  in  the  same  condemnation — only,  as  an  Irish- 
man says,  " more  so" — as  the  staff.  The  ladies'  com- 
mittee seem  to  be  able  to  show  the  others  the  proper 
course  of  conduct,  for  most  of  these  ladies  have  sent  in 
their  resignations.  The  managers  should  do  likewise, 
and  the  governors  would  do  well  to  make  a  clean  sweep  of 
all  the  lay  committeemen,  and  start  afresh  with  new  man- 
agement by  new  men.  If  any  of  the  staff  are  still  to  be 
scapegoats,  let  them  all  go  too  into  the  wilderness  of  un- 
recognized medical  service.  Then,  if  the  profession  were 
worthy  of  its  position,  no  one  should  succeed  them  as 
unpaid  officers.  Let  the  public  pay  their  doctors,  and 
they  would  then  appreciate  their  value.  Unpaid  medical 
service  is  the  bane  of  the  profession.  A  further  develop- 
ment of  this  has  lately  occurred.  The  Great  Northern 
Central  Hospital  is  starting  pay  wards.  Patients  are  to  be 
admitted  at  two  guineas  per  week.  The  honorary  staff  is 
to  attend  the  pay  wards  on  the  same  terms  as  the  other 
parts  of  the  hospital.  Delightful,  is  it  not?  A  depart- 
ment to  be  run  at  a  profit,  and  the  doctors  to  do 
everything  for  nothing.  This  is  the  notion  of  managers 
of  our  charitable  institutions.  Ah!  " Charity,  what 
crimes  are  committed  in  thy  name." 


DANGER    FROM    INDISCRIMINATE    HOT    IN- 
TRA-UTERINE  IRRIGATIONS. 

To  thk  Eoitok  op  tub  Mkdical  Rkookd. 

Sir  :  In  the  Medical  Record  of  October  6  th  is  an  ex- 
cellent article  on  the  management  of  abortion.  In  the 
closing  paragraph,  however,  the  recommendation  is  made 
that  "  in  septic  cases  large,  hot,  antiseptic  intra-uterine 
injections  should  follow  the  cleansing  of  the  uterus.'1 
The  italics  are  mine.  In  justice  to  the  author  I  would 
say  that  I  have  repeatedly  seen  the  same  recommenda- 
tion by  good  authorities,  and  have  witnessed  the  pro- 
cedure carried  out  by  eminent  men.  Yet  it  is  this  very 
recommendation  and  practice  which  I  must  enter  a 
vigorous  protest  against  as  illogical  and  dangerous. 

Of  the  value  of  curetting  or  otherwise  clearing  the 
uterine  cavity,  with,  in  suitable  cases,  gauze- packing  and 
intra-uterine  irrigation,  in  cases  of  septic  metritis  follow- 
ing abortion,  miscarriage,  or  childbirth,  there  can  be 
no  doubt.  As  to  the  value  of  antiseptic  douches  there 
is  no  question.  That  hot  intra-uterine  irrigations  are 
invaluable  in  their  proper  place  I  am  ready  to  concede. 
But  is  this  the  place  for  a  hot  douche  ? 


I  may  state  here  that  I  have  repeatedly  observed  cases 
of  acute  septic  metritis  which  were  curetted,  the  curetting 
being  followed  by  the  hot  douche,  and  the  douche  al- 
most as  uniformly  followed  by  a  severe  chill  (often  be- 
fore the  operator  had  left  the  room),  the  chill  being  in 
turn  followed  by  fever,  sweating,  and  other  evidences 
of  acute  septicaemia.  I  have  seen  this  occur  repeatedly 
in  the  same  patient  every  time  the  procedure  was  gone 
through  with  until  the  patient  and  her  friends  begged 
the  doctor  not  to  interfere  and  "bring  on  those  dread- 
ful chills,"  while  the  doctor  assured  her  that  the  douches 
were  essential  to  her  recovery.  I  have  seen  this  occur  in 
private  practice  under  expert  gynecologists ;  I  have 
seen  it  occur  in  the  routine  of  hospital  work ;  I  have 
seen  it  occur  in  the  practice  of  the  country  doctor ;  I 
have  seen  it  altogether  too  frequently. 

Cases  of  septic  trouble  following  abortion  are  com- 
mon— much  too  common.  A  woman  has  a  miscarriage, 
perhaps  a  criminal  "miscarriage,  at  the  fourth  month  let 
us  say.  The  foetus  is  expelled.  Shreds  of  placental  tis- 
sue and  decidual  membrane  come  away,  but  some  re- 
main. The  patient  has  a  temperature  of  ioo°  or  1010 
F.  The  pulse  is  good.  There  is  mild  septicaemia.  The 
lochia  is  dark,  bloody,  profuse,  has  a  gangrenous  odor. 
If  left  to  nature  she  will  keep  on  in  this  state  for  some 
time.  Eventually  pelvic  peritonitis,  cellulitis,  or  gen- 
eral septicaemia  will  result,  or  more  fortunately  a  gradual 
separation  of  the  decidua  occurs  and  a  protracted  conva- 
lescence follows,  complicated  perhaps  by  prolonged 
metrorrhagia  and  chronic  metritis  or  other  sequelae. 

But  the  doctor  is  called.  He  is  fin  de  siicle.  He  is 
acquainted  with  bacteria, 

"  And  various  animalculae 
Of  middle,  high,  and  low  degree.' ' 

He  uses  antiseptic  vaginal  washes.  Good  !  He  ste- 
rilizes his  hands  and  instruments.  Better  1  He  clears 
out  the  uterus  thoroughly.  Best  yet !  Then  he  uses  a 
hot  intrauterine  irrigation.  Error  in  judgment!  He 
kills  a  few  more  putrid  or  septic  germs,  but  he  checks 
drainage. 

Why? 

What  have  we  to  deal  with  in  the  septic  cases  referred 
to  ?  A  uterus,  the  cavity  of  which  has  just  been  cleared 
of  decomposing  dtbris ;  but  a  uterus,  the  structure  and 
substance  of  which  is  infiltrated  with  septic  germs ;  a 
uterus  with  its  blood-vessels  and  lymphatics  filled  with 
morbific  products ;  a  uterus  which  under  rational  treat- 
ment, now  that  the  focus  of  infection  is  removed,  will 
pour  out  offensive  discharges  for  days  and  drain  itself  of 
the  poisonous  products  as  nature  intended,  by  a  free 
lochial  discharge.  That  is  the  object  at  which  we  all 
aim— elimination. 

Now  use  a  hot  injection  into  the  uterine  cavity.  The 
most  constant  and  powerful  action  of  a  hot  douche  is  to 
check  hemorrhage.  It  contracts  the  blcod  vessels.  It 
contracts  the  uterus.  It  does  it  rapidly,  thoroughly ; 
watch  the  result.  The  blood-stained  malodorous  dis- 
charge is  checked ;  drainage  is  thus  interfered  with ;  the 
distended  vessels  filled  with  poisonous  products,  cut  off 
from  their  natural  sewerage  into  the  uterine  cavity,  and 
compressed  by  the  sharp  contraction  of  the  uterus  under 
the  stimulus  of  a  hot  injection,  empty  themselves  into 
the  general  circulation,  and  a  chill,  with  general  septi- 
caemia takes  the  place  of  what  had  been  prior  to  this  time 
a  more  localized  septic  process.  This  occurs  more  fre- 
quently in  the  septic  states  following  childbirth  than  in 
those  following  early  abortions,  simply  because  the 
uterus  being  larger  contains  more  septic  material  to  be 
forced  into  the  general  circulation.  As  well  apply  an 
Esmarch  bandage  from  the  hand  up  to  the  shoulder  in  a 
cellulitis  of  the  arm  as  a  hot  injection  into  the  cavity  of 
a  uterus  swarming  with  bacteria  and  infiltrated  with 
septic  poison. 

This  argues  nothing  against  intrauterine  irrigation 
properly  performed  and  used  with  good  judgment.  But 
the  use  of  hot  injections  immediately  following  the  cuiet- 


542 


MEDICAL  RECORD. 


[October  27,  1894 


ting  of  a  septic  uterus  is  far  too  common.  That  their 
use  is  dangerous  is  reasonable  and  logical  in  theory,  and 
any  careful  observer  will  find  that  the  theory  is  borne 
out  by  clinical  experience. 

Why  use  a  hot  intra  uterine  irrigation,  when  a  warm 
one  would  be  more  comfortable  to  the  patient,  would  be 
far  safer,  and  would  fulfil  every  indication  ? 

W.  N.  MacArtnky. 


^ftt&iaxl  Stems. 

Contagious  Diseases— Weekly  Statement— Report  of 
cases  and  deaths  from  contagious  diseases  reported  to  the 
Sanitary  Bureau,  Health  Department,  for  the  week  end- 
ing October  20,  1894. 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebrospinal  meningitis 

Measles 

Diphtheria 

Small-pox 


Deaths. 


61 

103 

30 

8 

40 

a 

X 

a 

30 

0 

141 

4« 

a 

0 

Apomorphine  and  Hysterical  Attacks. — Rosser  recom- 
mends one  tenth  of  a  grain  of  apomorphine,  hypoder- 
mically,  to  break  up  and  prevent  the  recurrence  of  hys- 
terical attacks. 

Breakfast  for  Chlorotio  Girls— Dr.  Carl  Von  Noor- 
den,  in  the  International  Medical  Magazine,  May,  1894, 
speaking  of  the  dietetic  treatment  of  chlorosis  says: 
"  Most  chlorotic  girls  feel  weakest  and  worn  out  during  the 
hours  of  the  forenoon,  and  incapable  of  any  proper  kind 
of  work.  This  condition  is  uncomfortable,  and  directly 
harmful  from  the  educational  point  of  view.  The  best 
remedy  is  the  English  fashion  of  a  good  hearty  meal  at 
the  beginning  of  the  day.  Chlorotic  girls  are  advised  to 
drink  half  a  litre  of  milk  of  the  best  quality,  while  still 
in  bed,  and  to  do  it  very  slowly,  taking  fifteen  minutes 
to  drink  the  quantity  prescribed.  Half  an  hour  later 
they  should  rise  and  be  rubbed  with  a  dry,  rough,  woollen 
towel.  Then  comes  the  breakfast,  consisting  of  a  small 
cup  of  tea,  one  or  two  slices  of  buttered  toast,  and  plenty 
of  meat.  Two  hours  and  a  half  later  some  bread  and 
butter  is  to  be  eaten,  together  with  two  eggs,  this  to  be 
followed  by  a  quarter  of  a  litre  of  milk.  A  glass  of 
sherry  is  now  permissible,  if  special  reasons  warrant  it 
This  morning  regulation  of  diet  makes  the  forenoon 
hours  quite  comfortable.  Fixed  rules  for  other  meals  are 
0  f  less  importance. ' ' 

Deatl*  rates  and  Race. — I  will  not  weary  you  with 
further  details  of  figures,  which  those  of  you  who  are 
specially  interested  in  the  subject  will  find  in  the  reports 
of  the  Vital  Statistics  of  the  Eleventh  United  States 
Census,  but  will  merely  say  that  the  corresponding  data 
from  Boston,  Philadelphia,  Baltimore,  Washington,  and 
from  the  New  England  States  as  a  whole,  taken  with 
those  from  New  York  State  and  New  York  City,  and 
with  those  derived  from  a  special  investigation  of  over 
10,000  Jewish  families,  including  over  50,000  persons, 
lead  to  the  following  conclusions  as  being  probable  for 
the  United  States:  1.  The  colored  race  is  shorter  lived 
than  the  white,  and  has  a  very  high  infantile  death  rate ; 
it  is  specially  liable  to  tuberculosis  and  pneumonia,  and 
less  liable  than  the  white  race  to  malaria,  yellow  fever, 
and  cancer.  2.  The  Irish  race  has  a  rather  low  death- 
rate  among  its  young  children,  but  a  very  high  one 
among  adults,  due  to  a  considerable  extent  to  the  effects 
of  tuberculosis,  pneumonia,  and  alcoholism.  3.  The 
Germans  appear  to  be  particularly  liable  to  disorders  of 
the  digestive  organs  and  to  cancer.  4.  The  Jews  have  a 
low  death-rate  and  a  more  than  average  longevity ;  they 
are  less  affected  than  other  races  by  consumption,  pneu- 


monia, and  alcoholism,  but  are  especially  liable  to 
diabetes,  locomotor  ataxy,  and  certain  other  diseases  ot 
the  nervous  system. — Dr.  J.  S.  Billings. 

Morphinomania  in  the  Medical  Profession. — Dr. 
Jules  Rochard,  in  the  Union  Medicate,  draws  a  gloomy 
picture  of  the  increase  of  the  morphine  habit  in  France 
and  elsewhere.  The  habit,  he  finds,  becomes  incurable 
at  the  end  of  six  months  of  indulgence.  The  fair  sex 
and  the  doctors  are,  in  his  opinion,  the  most  deeply 
addicted  to  morphine.  He  draws  an  unpleasant  com- 
parison between  the  behavior  of  each  kind  of  delinquent. 
Women,  he  says,  delight  in  declaring  how  they  indulge 
in  this  vice,  and  show  ornamental  hypodermic  syringes 
to  their  friends.  Dr.  Notet  states  that  a  lady  having 
broken  the  needle  of  her  syringe  in  a  remote  country 
village,  wounded  her  skin  with  scissors  and  thrust  the 
stump  of  the  needle  into  the  wound,  injecting  herself  in 
this  manner  till  a  new  syringe  arrived  from  Paris.  Men, 
Dr.  Rochard  declares,  and  especially  medical  men,  the 
bulk  of  male  morphine  injectors,  take  the  greatest  pains 
to  hide  their  vice.  Hence  the  precise  number  cannot 
be  estimated.  He  believes,  however,  that  doctors  and 
persons  associated  with  them  form  nearly  half  the  total 
of  men  addicted  to  morphine. 

Medical  Sculpture. — Dr.  Paul  Richer,  the  director  of 
the  Salpfctrfere  laboratory,  has  been  recently  engaged  in 
enriching  that  renowned  neurological  school  with  a 
series  of  heads  and  busts  reproducing  certain  types  of 
pathological  deformities.  In  the  last  number  of  the 
Iconographie  de  la  Salpitriire  there  appears  the  photo- 
graph of  one  of  these  busts,  representing  a  subject  affected 
with  primary  progressive  myopathy.  This  patient  was 
frequently  shown  by  the  late  regretted  Professor  Charcot 
at  his  cliniques  as  a  perfect  example  of  the  myopathic 
physiognomy  of  the  Landouzy-Dtjerine  type. 

Catharsis  by  Means  of  Hypodermatic  Injections  Im- 
possible.— The  editor  of  The  Medical  Age  believes  it  to 
be  absolutely  proved  that  catharsis  cannot  be  induced  by 
the  introduction  beneath  the  skin  of  purgative  elements. 
He  relates  some  of  his  own  experiences.  A  number  of 
tablets  of  both  sulphate  of  magnesium  and  sulphite  of 
soda  were  prepared,  embodying  the  utmost  quantity 
available  for  hypodermatic  use.  These  were  employed 
in  some  thirty  instances,  and  a  quantity  distributed  among 
a  half-dozen  other  physicians,  who  used  them  in  from  fit- 
teen  to  fifty  cases  each.  In  no  instance  was  any  cathar- 
tic effect  observed,  except  now  and  again  when  a  patient 
was  informed  of  a  probable  purgative  action — here  the 
results  were  only  such  as  would  accrue  to  "  suggestion." 
In  one  instance  the  physician  experimented  upon  him- 
self, making  use  of  two  tablets  of  magnesium  sulphate  of 
one  and  one  half  grain  each,  injecting  into  the  upper 
and  external  aspect  of  the  thigh  at  8  p.m.  ;  at  10  p.m. 
he  retired  to  stool,  but  felt  no  assistance  had  been  given 
to  defecation — was  rather  constipated  than  otherwise. 
Being  very  easily  influenced  by  laxatives,  and  the  hour 
of  defecation  being  that  of  daily  habit,  he  is  quite  posi- 
tive that  no  better  test  could  have  been  given  of  the  ut- 
ter inefficiency  of  the  drug.  Further,  says  U  he  Age, 
the  evidence  per  se  is  conclusive  that  neither  magnesium 
sulphate  nor  soda  sulphite  can  be  employed  hypoderma- 
tically  as  a  purgative,  even  were  one  sure  of  a  cathartic 
effect,  since  the  dose  available  for  the  sub-cellular  method 
is  entirely  too  small  and  the  method  itself,  so  far  as  pur- 
gative drugs  are  concerned,  too  unsatisfactory  for  adop- 
tion. The  hypodermic  holds  the  keys  that  bind,  but  not 
those  that  loose. 

Trichinosis. — At  a  recent  meeting  of  the  Pathological 
Section  of  the  Buffalo  Academy  of  Medicine,  Dr.  Frank  J. 
Thornbury  made  a  preliminary  report  on  500  cases  of 
trichinosis  observed  in  his  work  as  Inspector  in  the  Bu- 
reau of  Animal  Industry  of  the  United  States  Department 
of  Agriculture,  at  Buffalo,  N.  Y.  Special  attention  was 
given  to  conditions  in  the  pathology  not  previously 
spoken  of,  comprising  peculiarities  of  encapsulation  of 


October  27,  1894] 


MEDICAL  RECORD. 


543 


the  trichinae,  degenerations,  calcifications,  pigmentations, 
etc  A  large  number  of  photographs  and  drawings  were 
presented  whichshowed  these  conditions,  and  an  extensive 
exhibit  of  rare  and  interesting  slides  under  microscopes 
was  given.  Reference  was  made  to  the  relative  fre- 
quency of  location  in  the  hog  and  extent  of  infection  of 
the  different  parts  examined  according  to  the  Govern- 
ment system  of  inspection.  The  parts  examined  com- 
prise the  diaphragm,  neck,  and  loin  respectively.  The 
entire  number  of  cases  in  which  trichinae  were  found  in 
the  diaphragm  was  399,  in  the  loin,  291,  in  the  neck, 
171.  The  average  number  of  trichinae  found  in  the 
diaphragm  in  the  entire  number  of  cases  was  8,  in  the 
loin  5,  and  in  the  neck  3.  In  the  500  cases  studied  all 
of  the  three  parts  were  infected  in  200  instances,  two 
parts  were  involved  in  136,  and  one  part  only  was  infected 
in  164  cases.  The  part  of  predilection  for  the  trichinae 
therefore  appears  to  be  the  diaphragm.  This  is  explained 
by  its  close  proximity  to  the  digestive  tract,  from  which 
the  trichinae  primarily  migrate.  It  would  appear  also 
that  the  tenderloin  is  not  to  be  preferred  as  an  article  of 
diet.  This  comprises  the  psoas  muscles.  Where  the 
hogs  are  extensively  affected  the  trichinae  are  also  usu- 
ally found  in  the  hams,  shoulders,  sides,  and,  in  fact,  in 
almost  any  part  of  the  body.  Dr.  Thornbury  has  also 
studied  the  subject  of  trichinosis  in  man  with  the  follow- 
ing results:  O/21  subjects  examined  in  the  dissecting- 
room  of  the  University  of  Buffalo,  trichinae  were  found 
in  the  muscles  in  three  cases.  The  muscles  principally  af- 
fected were  those  of  the  extremities  (one  slide  from  the 
biceps  of  the  arm  containing  fifty  of  the  parasites),  the 
diaphragm,  intercostals,  abdominal  muscles,  the  psoas, 
etc  Many  of  the  trichinae  were  old  and  calcified, 
others  were  still  alive.  One  of  the  cases  of  infection  was 
not  very  extensive,  the  trichinae  being  scattered  in  limited 
numbers  through  the  muscles  of  the  thorax  and  abdomen. 
This  observer  contends  that  many  cases  of  chronic  mus- 
cular rheumatism  are  disguised  under  this  head.  This  is 
corroborated  by  the  continued  observation  of  cases  of 
trichinosis  in  the  acute  stage  and  seeing  the  patient  suffer 
from  muscular  pains  which  under  ordinary  circumstances 
would  be  regarded  as  simply  rheumatism. 

Bicycling. — The  Paris  Academy  of  Medicine  recently 
discussed  the  question  of  bicycling,  and  came  to  the  con- 
clusion that  this  form  of  exercise  might  be  attended  with 
great  danger  to  the  heart  in  those  who  suffered  from  any 
affection  of  this  organ.  One  speaker  referred  to  the 
recent  death  of  three  persons  from  heart  disease  while 
riding  bicycles,  and  asserted  that  not  less  than  one  thou- 
sand wheelmen  in  Paris  were  suffering  from  cardiac  af- 
fections, and  were  in  danger  of  the  same  fate. 

Suicide. — The  number  of  suicides  in  England  has  in- 
creased so  much  in  recent  years,  that  the  question  has 
been  raised  whether  the  elimination  from  insurance 
policies  of  the  clause  dealing  with  that  subject  has  not 
tended  to  encourage  self-destruction.  One  of  the  lead- 
ing insurance  journals  has  taken  the  matter  up,  and  con- 
cludes that  the  cause  must  be  sought  elsewhere ;  and  that 
it  is  only  very  rarely  that  a  man  puts  an  end  to  his  life 
from  a  desire  to  benefit  his  family,  although  it  is  possible 
that,  having  already  made  up  his  mind  to  kill  himself,  he 
may  take  out  extra  insurance  for  the  sake  of  his  wife  and 
children.  Such  deliberate  suicide  is,  however,  among 
the  most  seldom  of  occurrences.  Some  German  statis- 
tics recently  published  show  that  Saxony  heads  all  the 
other  states  of  the  empire  in  the  matter  of  suicides,  the 
percentage  being  almost  double  that  of  Prussia.  One 
per  cent,  of  the  suicides  are  children  under  twelve. 

Dr.  Sacharjin,  the  Czar's  regular  medical  attendant, 
is  a  most  eccentric  person.  When  called  to  see  a  patient, 
he  insists  upon  the  removal  of  all  female  attendants  dur- 
ing the  time  of  his  visit,  and  allows  no  one  to  utter  a 
word  in  his  presence  except  in  reply  to  his  questions, 
and  in  many  other  ways  he  is  noted  for  his  blunt  frank- 
ness-, often  rudeness,  toward  his  patients,  including  those 


of  the  highest  rank.  When  the  Czar's  illness  became  so 
alarming  that  it  was  thought  best  to  have  his  physician 
constantly  within  call,  Dr.  Sacharjin  could  with  difficulty 
be  persuaded  to  come,  and  when  he  did  finally  consent 
to  take  up  his  residence  temporarily  in  the  palace,  he 
positively  refused  to  occupy  the  suite  on  the  third  floor 
which  had  been  provided  for  him,  because  he  was  accus- 
tomed to  the  ground  floor,  and  he  required  apartments 
to  be  provided  for  him  there.  When  the  Czarina  asked 
him  to  lunch  at  the  imperial  table  he  declined,  on  the 
ground  that  he  was  not  in  the  habit  of  taking  his  meals 
with  women.  He  was  allowed  to  eat  in  his  own  rooms. 
In  spite  of  his  eccentricity  he  is  in  great  demand  among 
the  aristocracy  of  Moscow  and  St.  Petersburg.  He  is 
reported  to  be  worth  7,000,000  rubles,  made  in  the  prac- 
tice of  his  profession. 

Wouldn't  Trade  with  Him.— The  following  story  is 
told  by  the  Medical  Herald,  at  the  expense  of  Dr.  F.  C. 
Hoy t,  superintendent  of  the  insane  hospital  at  Clarinda, 
Iowa.  One  of  the  chief  attractions  for  him  in  the  Mid- 
way was  Hagenbach's  "trained  animal"  show.  He  is 
noted  for  his  sympathetic  nature,  and,  after  witnessing 
the  performance,  sought  an  opportunity  to  converse  with 
the  lion- tamer.  After  a  few  preliminary  inquiries  as  to 
the  disposition  of  the  animals,  the  doctor  proceeded  to 
sympathize  with  the  king  of  the  den  concerning  his  lot, 
isolated  as  he  was  from  civilization,  and  compelled  to 
associate  entirely  with  the  wild  beasts.  Doctor  Hoyt 
digressed  eloquently  upon  the  uncertainty  of  life,  and 
expressed  his  great  satisfaction  at  not  having  to  play 
with  the  monster  lion,  who  was  nervously  pacing  his 
cage  and  growling.  The  keeper  listened  attentively, 
only  remarking  that  he  was  "used  to  it."  When  the 
doctor  turned  to  depart,  the  "king  "  courteously  asked 
for  his  card.  It  read :  "  Iowa  Hospital  for  the  Insane." 
" Great  guns!"  gasped  the  tamer,  "I  wouldn't  trade 
jobs  with  you  for  a  million  dollars." 

Data  on  Keeleyism.— Rev.  Dr.  J.  M.  Buckley,  editor 
of  the  Christian  Advocate,  of  New  York  (150  Fifth 
Avenue,  New  York  City),  solicits  specific  data  in  refer- 
ence to  "  Keeley  Institutes."  He  asks  only  for  infor- 
mation from  physicians  and  ministers,  and  desires  to 
make  a  thorough  and  impartial  investigation  of  the 
Keeley  business.  He  will  not,  we  think,  be  able  to  find 
anything  very  new  or  instructive,  unless  he  is  able  to  col- 
lect the  facts  regarding  relapses.  The  Keeley  cure  is 
atropine,  strychnine,  simple  bitters,  good  resolutions,  and 
a  certain  amount  of  hypnotism.  - 

State  Board  of  Medical  Examiners. — An  autumn  ex- 
amination will  be  held  by  the  Pennsylvania  Board.  Its 
influence  is  already  clearly  felt  in  the  solicitude  shown 
by  some  of  the  medical  schools  concerning  the  fitness  of 
students  to  pursue  the  study  of  medicine.  It  was  rare 
in  former  years  to  hear  the  dean  of  a  medical  school  ad- 
vise a  pupil  not  to  enter  or  continue  in  the  course  unless 
indeed  the  student  had  paid  all  the  fees  that  the  college 
could  exact.  We  hear  now,  however,  occasionally  of 
students  being  advised  that  they  are  not  sufficiently  pre- 
pared to  enter  upon  the  medical  course.  It  is  to  be 
hoped  that  the  Pennsylvania  Board  will  maintain  the 
position  that  was  assumed  in  the  first  examination. — 
Medical  News. 

Anatomical  Material. — The  Association  of  American 
Anatomists  has  issued  the  following  circular :  "  Dear  Sir 
— At  the  last  meeting  of  the  Association  of  American 
Anatomists,  the  undersigned  committee  was  appointed 
to  '  consider  the  question  of  the  collection  and  preser- 
vation of  anatomical  material,  and  to  report,  at  the  next 
meeting,  what  in  their  opinion  are  the  best  means  of  ac- 
complishing these  objects.'  In  order  to  make  the  work 
of  the  committee  as  comprehensive  as  possible,  and  to 
obtain  information  which  will  be  of  service  in  arriving  at 
definite  conclusions  as  to  the  best  methods  of  accom- 
plishing the  purposes  indicated  in  the  resolution,  the 
committee  has  deemed  it  desirable  to  send  to  the  teach- 


544 


MEDICAL    RECORD. 


[October  27,  1894 


era  of  anatomy,  not  only  in  this  country,  but  abroad, 
this  circular  letter,  with  the  questions  appended,  and  re- 
spectfully to  request  answers  thereto,  as  fully  as  they  can 
be  made. 

"  1.  Is  anatomical  material  obtained  in  accordance 
with  a  legal  enactment,  wholly  or  in  part  ? 

"2.  If  there  is  an  anatomical  law  in  your  country  or 
State,  please  send  a  copy  of  it  to  the  chairman  of  this 
committee,  Dr.  J.  Ewing  Mears,  1429  Walnut  Street, 
Philadelphia,  Pa.  Please  state  whether  the  law  is  satis- 
factory, whether  it  is  readily  obeyed  by  those  upon  whom 
duties  are  imposed  by  it,  and  mention  any  improvements 
you  would  suggest,  as  to  its  requirements. 

"  3.  Is  the  material  received  in  good  condition  ? 

"  4.  What  disposal  is  ultimately  made  of  the  remains  ? 

"  5.  Please  state  what  means  are  employed  to  preserve 
anatomic  material  for  the  purposes  of  dissection  or  oper- 
ative surgery.  If  injections  of  preservative  fluids  are 
used,  state  their  composition  and  the  methods  of  use,  at 
what  point  injections  are  made,  whether  at  the  heart  or 
in  the  large  arteries,  and  their  effect  in  accomplishing 
the  preservation,  with  any  changes  in  the  color  or  the 
character  of  the  tissues.  What  length  of  time  can 
material  be  used  in  dissection  by  the  methods  employed 
by  you  ?  If  preservation  by  means  of  '  cold  storage  ' 
is  employed,  please  state  the  cost  of  the  machinery 
which  it  was  necessary  to  construct  for  this  purpose,  and 
what  means  are  taken  to  prevent  decomposition  after 
the  subject  is  placed  upon  the  table  for  dissection. 

"  6.  Please  state  the  cost,  by  the  method  employed  by 
you,  for  each  subject :  a,  for  receiving  it ;  b,  for  inject- 
ing and  preserving  it. 

"7.  Do  you  obtain  an  adequate  supply  of  material  for 
the  purposes  of  anatomic  instruction  ?  How  many  stu- 
dents are  assigned  to  each  subject,  and  what  is  the 
method  of  allotment  ? 

"  8.  Please  give  any  information  which  you  may  deem 
of  importance.  As  the  report  will  be  general  in  char- 
acter the  name  of  the  informant  or  institution  will  not 
be  mentioned  by  the  committee  unless  requested. 

"  Your  compliance  with  the  request  of  the  committee, 
at  an  early  date,  will  be  fully  appreciated  as  render- 
ing assistance  to  it  in  accomplishing  its  work,  and  it  de- 
sires to  thank  you  for  the  same  in  advance. 

J.  Ewing  Mears,  M.D., 
Joseph  D.  Bryant,  M.D., 
Thomas  Dwight,  M.D." 

A  Medical  School  for  Women  is  to  be  established  in 
St.  Petersburg  through  the  initiative  of  Prince  Wolkow- 
ski,  the  educational  representative  of  Russia  at  the 
World's  Fair  in  Chicago. 

Medical  Etiquette  Among  the  Ancients. — In  an  old 
Latin  poem,  the  manuscript  of  which  has  been  found  in 
the  National  Library  at  Paris,  occur  some  interesting 
pages  in  which  the  author,  whose  name  is  unknown,  ex- 
plains the  proper  conduct  of  a  physician.  (Boston  Medi- 
cal and  Surgical  Journal,) 

"On  approaching  the  patient,  you  should  assume  a 
calm  expression  and  avoid  any  gesture  of  greed  or  vanity ; 
greet  those  who  salute  you  with  an  humble  voice  and  sit 
down  when  they  do.  Then,  turning  to  the  sick  person, 
ask  him  how  he  is,  and  examine  his  pulse  and  his  urine. 
To  the  patient  you  promise  cure,  but  immediately  on 
leaving  the  room  you  say  to  the  relatives  that  the  disease 
is  grave.  The  result  will  be  that,  if  you  cure  him,  your 
merit  is  greater  and  you  will  receive  the  greater  praise 
and  fee ;  while,  if  he  dies,  they  will  say  that  you  had  no 
hope  from  the  first." 

This  counsel  has  been  well  followed  by  some  physi- 
cians to  the  present  day.     The  directions  for  table  man 
ners  are  equally  amusing : 

"When  those  who  preside  over  the  house  ask  you  to 
the  table,  conduct  yourself  in  a  seemly  manner.  Each 
time  that  a  new  dish  is  brought  on,  do  not  fail  to  ask  for 
the  condition  of  the  patient.  This  will  give  him  great 
confidence  in  you,  as  he  sees  that  in  the  midst  of  the 


variety  of  the  repast  you  do  not  forget  him.  On  leaving 
the  table,  return  to  the  patient,  and  tell  him  that  you 
have  dined  most  excellently,  and  that  everything  was 
served  to  perfection.  The  sick  person  who  was  anxious 
about  these  points  will  rejoice  at  your  words." 

Professor  Amoyama,  of  Tokio,  who  accompanied  Dr. 
Kitazato  to  Hong-Kong  to  study  the  plague,  contracted 
the  disease  and  nearly  lost  his  life.  Happily,  however, 
he  finally  recovered,  and  has  not  returned  to  Tokio. 


BOOKS  RECEIVED. 


Food  and  Feeding.  By  Sir  Henry  Thompson.  8vo,  22a 
pages.  Published  by  Frederick  Warne  &  Co.,  London  and  New 
York  City.     Price,  $1.25. 

The  Horse.  By  George  Armitage,  M.R.C.V.S.  8vo,  271 
pages.  Illustrated.  Published  by  Frederick  Warne  8c  Co.,  New 
York  and  London.    Price,  $1.00. 

Medical  Register.  Dr.  John  Shrady,  Editor.  Published 
by  G.  P.  Putnam's  Sons,  N.  Y.     Price,  $2.50. 

The  Senile  Heart.  By  George  William  Balfour,  M.D.  8yo, 
300  pages.     Published  by  Macmiilan  &  Co. ,  London.     Price,  $1.50. 

Transactions  of  the  Medical  Society  of  New  York  for 
the  Year,  1894.     Published  by  the  Society. 

Directions  for  Laboratory  Work  in  Bacteriology. 
By  Frederick  G.  Novy.  8vo,  200  pages.  Illustrated.  Published 
by  George  Wahr,  Ann  Arbor,  Mich.     Price,  $1.50. 

Therapeutics— Its  Principles  and  Practice.  By  H.  C. 
Wood,  M.D.  8vo,  1007  pages.  Published  by  J.  B.  Lippincott 
Co. 

Prescribing  and  Treatment  for  Infants  and  Children. 
By  Philip  E.  Muskett.  i6mo,  334  pages.  (Third  Edition.)  Pub- 
lished by  Young  J.  Pent  land,  Edinburgh  and  London. 

Bread  from  Stones.  A  New  and  Rational  System  of  Land 
Fertilization  and  Physical  Regeneration.  i2mo,  135  pages.  Pub- 
lished by  A.  J.  Tafel,  Philadelphia,  Pa.     Price,  25  cents. 

The  Principles  of  Bacteriology.  A  Practical  Manual  for 
Students  and  Physicians.  By  A.  C.  Abbott,  M.D.  Published  by 
Lea  Brothers  &  Co.,  Philadelphia,  Pa.     8vo,  470  pages. 

Transactions  of.  the  Ohio  State  Medical  Society. 
1894.  8vo,  488  pages.  Published  and  Printed  by  the  Society, 
Toledo,  O. 

Laboratory  Manual  of  Elementary  Chemical  Physiol- 
ogy and  Urine  Analysis.  By  John  H.  Long.  8vo,  365  pages. 
Illustrated.  Published  by  E.  H.  Colegrove  8c  Co.,  Chicago,  I1L 
Price,  $2.50. 

Diseases  of  the  Chest,  Throat,  and  Nasal  Cavities.  By 
E.  Fletcher  Ingals,  M.D.  8vo,  686  pages.  Illustrated.  Price, 
$5.00.     William  Wood  &  Company. 

Transactions  of  the  American  Surgical  Association. 
Edited  by  DeForest  Willard,  M.D.  8vo,  33a  pages.  Illustrated. 
Published  by  William  J.  Dornan,  Philadelphia,  Pa.     1894. 

Syllabus  of  Lectures  on  Embryology.  By  W.  P.  Man- 
ton,  M.D.  8vo,  125  pages.  Illustrated.  Published  by  the  F. 
Davis  Co.,  Philadelphia,  Pa.     Price,  $1.25. 

When  All  the  Woods  are  Green.  By  S.  Weir  Mitchell. 
8vo,  417  pages.  Published  by  The  Century  Co.,  New  York  City. 
Price,  $1.50, 

Healthful  Womanhood  and  Childhood.  Plain  Talks  to 
Non-professional  Readers  Relative  to  Healthy  and  Diseased  Condi- 
tions Peculiar  to  Women,  and  Concerning  the  Care  of  Young  Chil- 
dren. By  Henry  Bixby  Hemenway,  M.D.  8vo,  290  pages.  Pub- 
lished by  V.  T.  Hemenway  &  Co.,  Evanston,  I1L     Price,  $2.00. 

Mugwumps.  By  One  of  Them.  8vo,  328  pages.  Published  by 
Arena  Publishing  Co. ,  Boston,  Mass. 

Addresses,  Papers,  and  Discussions  in  the  Section  on 
Surgery  and  Anatomy.  At  the  Fifty-fifth  Annual  Meeting  of 
the  American  Medical  Association,  held  at  San  Francisco,  Cal., 
June  5  to  8,  1894.  Printed  at  the  Office  of  the  Journal  of  the 
American  Medical  Association,  Chicago,  11L 

A  Manual  of  Human  Physiology.  By  Joseph  H.  Raymond, 
M.D.  8vo,  382  pages,  illustrated.  Published  by  W.  B.  Saunders, 
Philadelphia,  Pa.     Price,  $1.25. 

Essentials  of  Diseases  of  the  Ear.  By  E.  B.  Gleason, 
M.D.  8vo,  147  pages,  illustrated.  Published  by  W.  B.  Saunders, 
Philadelphia,  Pa.     Price,  $1.25. 

Text-book  on  Anatomy  and  Physiology  for  Nurses. 
Compiled  by  Diana  Clifford  Kimbler  8vo,  268  pages,  illustrated. 
Published  by  Macmiilan  &  Co.,  New  York.    Price,  $2.50  net. 


Medical   Record 

A  IVeekly  Journal  of  Medicine  and  Surgery 


Vol.  46,  No.  18. 
Whole  No,  125a. 


New  York,  November  3,  1894. 


$5.00  Per  Annum, 
Single  Copies,  ioc. 


©rtgitral  Articles. 

TREATMENT  OF  DIPHTHERIA.1 
By  A.    CAMPBELL  WHITE,   M.D., 

NBW  YOBK. 
RKSIDBNT  PHTSICIAN  OF  THE  WILLARD  PAKKKR  HOSPITAL. 


The  nasal  cavities  were  irrigated  every  eight  hours  with 
a  warmed  i  to  4,000  solution,  and  the  throat  every  three 
hours  with  a  1  to  3,000  solution. 

Besides  this  local  treatment,  nearly  all  the  cases  re- 
ceived frequent  doses  by  the  mouth  of  the  tincture  of  the 
chloride  of  iron  and  of  alcoholic  stimulants. 


Saltwater    Total  Num- 
Irrigation.        o[Q^ 


The  cases  of  diphtheria  included  in  this  investigation  Tv?J±ri?L°F  ALL  Case^  Showing  the  Duration  from 
were  subjected  *  three  different  modes  of  treatment.  SSSLtci ITb^"  Pseudomkmbrane  ™  ^appear- 

In  the  first  series,  the  nasal  and  throat  cavities  were  

thoroughly  irrigated,  every  one  to  three  hours,  with  warm  Number  of  Days  From  I 

salt  solution,  until  the  pseudo* membrane  had  disappeared,        Appearance  ^  Mem-  Salt  water  im- 

then  from  one  to  three  times  daily  until  the  entire  disap-       ^* 0? wSSSES-  |pySon2  spray. 

pearance  of  the  bacilli.     For  irrigation,  the  fountain  or       fler  baci,,i* 

Davidson  syringe  was  used.  

In  the  second  series,  the  cases  besides  receiving  the  treat-  l'."] '.'.'.'.. [[[.'.[.'. 

ment  given  in  the  first  series,  had  their  nares  and  throats  J 

thoroughly  sprayed  every  three  hours  (except  during  9"-' '.»"".»"'. 

the  night)  with  solutions  of  peroxide  of  hydrogen,  which  1° ; ; " ;  

varied  from  twenty-five  per  cent,  to  five  per  cent,  in  "••■• 

strength.    The  special  form  of  peroxide  used  was  that  \l. '.'..'.'.'.'.'.'.'.".'.v. 

known  under  the  name  of  pyrozone.  js 

The  following  tables  show  the  results  obtained  by  these  '7 .' '. '. '. 

comparative  tests :  l*"!!"".".';.'.'!. 

Tabulation    of  all  Cases,      Tabulation  of   all    Cases,  n'.'.'.V.'.'.'.'." '.'.'.'.". 

Showing  the  Day  of  the        Showing  Number  of   Days  22 ."."!!!!!.'.'!!.'!!. .' 

Disease  on   Which  the        on  Which  Bacilli  Persist-  2£ 

Pseudo- membrane  Disap-        ed    After    Disappearance  11 

peared.  of  Pseudo-membrane.  30!!".!!!!!".;."!!".' 

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*  Before  membrane.  In  these  four  cases  bacilli  disappeared  one  day 
before  membrane.  In  those  cases  treated  with  bichloride  irrigation 
only  were  cultures  taken  before  disappearance  of  membrane,  while  in 
some  cases  treated  with  the  salt-water  irrigation  examinations  for  ba- 
cilli were  not  made  for  two  or  three  days  after  membrane  had  disap- 
peared. 

The  third  series  of  cases  were  subjected  to  the  same 
treatment  as  the  first,  except  that  solutions  of  bichloride 
of  mercury  were  substituted  for  the  salt-water  solution. 

1  Being  the  substance  of  a  report  to  the  Health  Department  of  the 
city  of  New  York,  on  a  series  of  investigations  relating  to  the  duration 
of  the  false  membrane  and  persistence  of  Klebs-Loeffler  bacilli  in  the 
throats  of  patients  subjected  to  systematic  irrigation  with  antiseptic  or 
cleansing  solutions. 


In  using  the  pyrozone  three  different  strengths  were 
employed,  twenty  five,  twelve  and  one- half,  and  five  per 
cent,  solutions.  With  the  twenty  five  per  cent  solution 
the  average  time  for  disappearance  of  bacilli  after  disap- 
pearance of  membrane  was  6.8  days,  a  somewhat  better 
result  than  with  bichloride  or  salt  solution,  but  it  was 
very  noticeable  that  the  pseudo-membrane  treated  with 
the  stronger  solutions  of  pyrozone  lasted  much  longer 
than  would  be  expected  from  the  severity  of  the  dis- 
ease, and  certainly  much  longer  than  in  those  cases 
where  the  five  per  cent,  solution  of  pyrozone  or  the  salt 
or  bichloride  solution  was  employed.  Out  of  16  cases 
treated  with  the  twenty- five  and  twelve  and  one-half  per 
cent,  solutions  of  pyrozone  ten  had  membrane  from  ten 
to  sixteen  days,  while  in  another  quite  bad  case  traces  of 
the  pseudo  membrane  persisted  for  twenty- three  days. 

The  average  time  from  first  appearance  of  diphtheritic 


546 


MEDICAL   RECORD. 


[November  3.  1894 


membrane  to  the  disappearance  of  bacilli  in  the  twenty- 
five  per  cent,  cases  was  1 7.75  days,  this  not  being  quite  as 
good  a  record  as  that  made  by  the  bichloride  solution, 
and  about  the  same  as  that  made  by  the  water  irrigation. 
As  all  the  pyrozone  cases  received,  as  mentioned  before, 
thorough  washing  of  throat  and  nose  before  and  after 
treatment  with  the  spray,  the  results  as  shown  in  the 
tables  would  certainly  indicate  that  the  addition  of 
spraying  strong  solutions  of  peroxide  to  the  treatment 
with  plain  water  irrigation  had  no  good  results.  On  the 
contrary,  it  would  seem  from  the  long  continuance  of 
tie  diphtheritic  membrane  in  those  cases  treated  with  the 
twenty-five  and  twelve  and  one  half  per  cent,  solutions 
that  they  acted  as  an  irritant  to  the  already  inflamed 
mucous  membrane. 

The  five  per  cent,  solution  caused  no  noticeable  irrita- 
tion. The  pseudo  membrane  disappeared  in  the  usual 
time,  and  it  would  certainly  appear  to  be  the  best 
strength  (if  any)  to  use  for  this  purpose. 

Among  the  twenty  cases  on  the  bichloride  treatment, 
one,  a  boy  four  years  old,  developed  mercurial  stomatitis 
in  quite  a  severe  form,  and  another  showed  symptoms  of 
intestinal  irritation ;  both  of  them  were  undoubtedly 
caused  by  swallowing  bichloride  solution  during  irriga- 
tion, as  they  had  not  been  given  internally  mercury  in 
aay  form.  Both  soon  recovered  after  the  cessation  of 
the  bichloride  irrigation. 

Laryngeal  cases  have  not  been  included  in  this  list, 
as  the  treatment  tried  in  these  cases  could  have  no 
possible  effect  upon  membrane  or  bacilli  in  the  larynx. 
In  six  cases  in  which  these  three  tests  were  tried,  it  ap- 
parently had  no  effect  whatever,  the  bacilli  being  found 
in  the  larynx  from  thirty  to  forty  days  after  admission  to 
the  hospital. 

Since  the  tabulation  of  the  cases  in  this  report  was 
made,  I  have  had  two  cases  in  which  the  Kleb*- 
Loefflsr  bacilli  persisted  for  twenty-nine  days  and  forty- 
eight  days  respectively  after  disappearance  of  membrane. 
These  cases  received  the  bichloride  irrigation  treatment 
as  described  above,  until  all  signs  of  the  bacilli  had  dis- 
appeared. This  would  make  the  average  number  of  days 
for  the  persistence  of  the  bacilli  after  disappearance  of 
membrane  and  the  entire  duration  of  die  disease  about 
the  same  in  the  bichloride  cases  as  in  those  where  no 
antiseptic  was  used. 

The  results  obtained  in  the  special  series  of  forty  cases 
treated  with  plain  or  salt-water  irrigation  are  similar  to 
those  obtained  in  over  six  hundred  other  cases  treated  in 
a  like  manner ;  while  frequent  and  careful  experiments 
with  nearly  all  the  well  established  antiseptics  have  given 
practically  the  same  results  accomplished  by  the  pyro- 
zone and  bichloride  of  mercury  in  this  series  of  experi- 
ments. 

The  conclusions  derived  from  this  series  of  cases,  to- 
gether with  investigation  and  observation  on  a  much 
larger  number  of  cases,  lead  us  to  believe  : 

1.  That  frequent  washing  of  the  air-passages  attacked 
by  diphtheria  lessens  the  duration  and  amount  of  diph- 
theritic membrane. 

2.  The  addition  of  antiseptics,  in  sufficient  strength  to 
be  germicidal,  to  the  irrigating  fluid  is  irritating  to  the 
micous  membrane,  thereby  causing  extension  and  per- 
sistence of  false  membrane  rather  than  the  effect  de- 
sired. 

3.  The  addition  of  antiseptics  to  the  irrigating  fluid  is 
liable  to  cause  systemic  poisoning  and  disagreeable  com 
plications  from  the  swallowing  and  absorption  of  some 
of  the  fluid  used,  e.g.,  the  two  bichloride  cases  cited 
above. 

4.  Spraying  the  throat  (also  the  pernicious  treatment 
of  swabbing),  whatever  solution  is  used,  can  have  no 
good  effect,  as  the  parts  reached  by  the  spray  must  nec- 
essuily  be  very  limited,  excepting  possibly  in  the  hands 
of  an  expert.  Furthermore,  the  spray  cannot  be  used 
with  young  children,  as  anyone  can  testify  who  has  tried 
it  This  is  especially  true  of  some  solutions  where  it  is 
necessary  to  use  a  glass  syringe. 


5.  Frequent  cleansing  of  the  throat  and  nasal  cavities 
with  a  bland  solution,  such  as  plain  warm  water  or  nor- 
mal salt  solution,  is  easier  of  application,  is  more  agree- 
able to  the  patient,  and  does  all  that  any  antiseptic  solu 
tion  can  accomplish,  either  upon  duration  of  the  mem- 
brane or  the  period  of  isolation. 


A  CONTRIBUTION  TO  THE  STUDY  OF  MOD- 
ERN AMPUTATION. 

By  W.  L.  ESTES,  A.M.,  M.D., 

DIRECTOR,   PHYSICIAN,   AND  SURGBOK-IN-CHIFK  OF  ST.  I  UKB*S  HOSPITAL,   SCOTS 
BBTHLBHBM,  PA. 

The  writer  had  occasion  to  search  for  some  recent  statis- 
tics of  mortality-rates  after  major  amputation,  and  he 
was  disappointed  in  finding  very  few  available  contribu- 
tions from  American  surgeons  to  this  formerly  very  prom 
inent  and  important,  but  now  somewhat  neglected,  branch 
of  surgery.  Improved  methods  of  conservatism  have  re- 
duced very  largely  the  necessity  for  amputating  limbs, 
but  aseptic  practice  and  bloodless  methods  have  also  so 
reduced  the  mortality-rate  after  amputation,  that  statis- 
tics of  the  older  writers  are  obsolete  and  useless  as  stand- 
ards of  comparison,  and  misleading  to  students  of  sur- 
gery. 

This  study,  based  upon  the  statistics  of  a  single  op- 
erator, working  in  a  modern  hospital,  and  who  has  ec- 
deavored  to  carry  out  as  strictly  as  practicable  aseptic, 
and  especially  bloodless,  methods,  is  offered  as  a  contri- 
bution to  what  must  still  remain  a  very  important  branch 
of  surgery,  with  the  hope  that  it  will  stimulate  other 
surgeons  to  report  their  results  in  this  line,  and  so  re  es- 
tablish the  prestige  of  American  practice  in  acute  sur- 
gery. 

This  study  is  based  upon  294  single  major  amputa- 
tions, 38  complicated  cases  requiring  two  synchronous 
operations,  7  triple,  and  1  quadruple  operation,  making 
altogether  340  major  amputations. 

Only  19  of  these  were  amputations  for  pathological  or 
diseased  conditions,  so  that  there  were  321  amputations 
done  for  injuries  to  limbs,  usually  the  result  of  great  vio- 
lence, as  they  were  all  cases  from  the  railroad,  mines,  or 
factories.  In  many  of  the  cases  there  elapsed  several 
hours  between  the  time  of  the  injury  and  the  reception 
of  the  patient  at  the  hospital,  and  commonly  they  had 
to  make  pretty  long  journeys  to  reach  the  hospital. 

In  considering  the  conditions  requiring  amputation, 
pathologic  conditions  will  be  left  out  entirely,  and  only 
conditions  resulting  from  violence  will  be  considered. 

Conditions  Calling  for  Amputation. — Esmarch  *  very 
pithily  sums  up  the  whole  matter,  in  speaking  of  injuries 
in  war,  by  saying :  "  The  removal  of  a  limb  is,  as  a  rule, 
only  indicated  when  by  so  doing  the  prospect  of  saving 
the  life  of  the  wounded  is  rendered  essentially  better 
than  by  the  conservative  treatment."  I  believe  one 
would  do  well  to  follow  this  rule  in  civil  practice  also. 
Aseptic  practice  has  made  conservative  attempts  much 
safer  than  in  former  years,  however,  and  conservatism 
ought  therefore  to  be  given  a  much  wider  range  than 
formerly.  Evulsion  of  a  limb,  of  course,  admits  of  no 
question.  Compound  fractures,  if  the  bones  were  badly 
comminuted,  formerly  called  for  amputation.  Now  they 
rarely  do,  unless  too  great  a  length  of  bone  be  implicated, 
and  unless  the  soft  tissues  have  suffered  severe  laceration. 
It  is  my  rule  to  attempt  to  save  a  limb  if  not  more  than 
two  inches  of  the  principal  bone  is  comminuted.  In  at- 
tempting to  estimate  whether  or  not  the  soft  tissues  have 
undergone  too  great  injury  for  any  conservative  attempt, 
I  think  the  muscular  laceration  should  receive  less  con- 
sideration than  the  degree  of  injury  to  the  skin.  I  have 
over  and  over  again  saved  limbs  having  comminutions  of 
the  bones,  and  bad  lacerations  of  the  muscles,  but  only 
slight  injury  to  the  skin.  I  have  very  rarely  succeeded 
in  saving  a  compound  comminuted  fractured  Limb  having 
slight  lacerations  of  the  muscles,  but  extensive  injury  to 

1  Surgical  Handbuch,  p.  277. 


November  3,  1894] 


MEDICAL    RECORD. 


547 


the  skin.  I  have  found  that  one  or  two  lacerations  of 
the  skin  are  not  particularly  hurtful ;  it  is  the  complete 
death  of  the  skin  through  immense  pressure,  as  the 
weight  produced  by  the  pushing  of  a  car- wheel,  or  heavy 
beam,  or  stone.  If  all  the  muscles  at  a  given  level  are 
pulpified,  amputation  is  of  course  indicated.  As  to 
whether  injury  to  a  principal  vessel  or  system  of  vessels 
calls  for  amputation  in  a  case  of  compound  fracture  in 
every  instance,  I  should  say  decidedly — no.  Serious  in- 
jury to  the  femoral  vessels  or  brachial  vessels  high  up,  by 
a  compound  fracture,  usually  requires  amputation,  but 
one  system  of  vessels  in  the  forearm  or  leg  may  be  en- 
tirely destroyed  at  a  given  level,  and  yet  the  limb  be 
saved.  The  following  case  will  illustrate :  A  man  about 
thirty  years  of  age,  of  stout  build,  while  plastering  a  ceil- 
ing of  a  public  building,  lost  his  balance  and  fell  from  his 
scaffold  to  the  floor,  a  distance  of  some  ten  feet ;  he 
came  down  on  his  feet  in  a  standing  position ;  his  right 
leg  gave  way  and  he  fell  in  a  heap  on  the  floor.  *He  was 
picked  up  bleeding  profusely,  his  right  foot  turned  out- 
ward so  that  the  sole  was  in  the  position  of  extreme 
talipes  valgus.  He  was  brought  as  soon  as  possible  to 
the  hospital.  On  examination  it  was  found  that  the 
tibia  was  projecting  through  the  skin  and  his  drawers  on 
the  antero  internal  aspect  of  the  leg,  at  the  level  of  junc- 
tion of  middle  and  lower  thirds.  This  fragment  of  bone 
was  large,  with  sharp  jagged  spicules  projecting.  The 
skin  had  been  lacerated  almost  half  the  circumference  of 
the  leg  at  this  point,  but  by  the  sharp  fragment,  which 
occasioned  very  little  contusion  ;  the  anterior  tibial  ves- 
sels were  torn  and  bleeding.  The  fibula  was  fractured 
about  the  same  level.  Upon  enlarging  the  wound  and 
investigating  further,  the  tibia,  for  two  inches,  was  found 
comminuted.  These  fragments  were  removed,  the  an- 
terior tibial  vessels  tied,  and  the  ends  of  the  principal 
fragments  squared  off.  By  a  lineal  incision  over  the 
fracture  of  the  fibula  this  was  exposed,  two  inches  of  the 
fibula  removed  to  correspond  with  the  tibia,  and  then 
both  bones  were  wired*  The  shortening  of  limb  threw 
the  soft  tissues  up  in  a  transverse  rounded  ridge.  The 
man  made  a  good  recovery  with  a  perfectly  useful  limb. 

Compound  dislocation  of  a  large  joint  is  stated  by 
Ashhurst,  and  indeed  by  most  older  writers,  as  an  imper- 
ative call  for  amputation.  I  have  treated  compound 
dislocations  of  all  the  large  joints  of  the  limbs,  except 
the  shoulder,  conservatively,  with  excellent  results.  These 
compound  dislocations  are  usually  accompanied,  in  the 
cases  I  have  seen,  by  fracture  of  at  least  one,  or  a  part  of 
one.  of  the  bony  surfaces  of  the  joint.  It  is  necessary,  as 
a  rule,  to  remove  the  small  fragments  of  bone,  but  unless 
the  principal  vessels  are  torn,  or  the  greater  part  of  the 
circumference  of  the  skin  killed  by  pressure,  I  should 
never  amputate  primarily. 

Great  contusion  and  laceration  of  muscles,  without 
fracture  of  a  bone  and  little  injury  to  the  skin,  I  have 
found  very  rarely  require  amputation.  Certainly  no 
primary  amputation  should  be  done.  The  important 
point  is  to  relieve  the  immense  tension  of  the  skin  on 
account  of  the  hypodermal  effusion  of  blood  and  serum, 
by  immediate  ^multiple  punctures  of  the  skin,  in  order 
to  drain  away  the  effused  fluid.  No  drainage-tubes 
should  be  used,  nor  should  even  a  strip  of  gauze  be  em- 
ployed as  drain — only  canalization — as  the  least  local 
pressure  will  usually  cause  necrosis  of  the  already  badly 
nourished  skin,  and  from  this  point  infection  is  apt  to 
occur. 

Injury  to  the  skin  without  serious  injury  to  the  deeper 
tissues,  I  have  never  found  call  for  amputation.  Sponge 
grafting  and,  if  need  be,  skin  grafting,  after  separation  of 
the  necrosed  skin,  usually  avails  to  bring  about  a  useful 
healing. 

Whenever  there  is  a  question  as  to  the  advisability  of 
an  amputation,  or  any  reason  to  doubt  that  an  amputa- 
tion is  actually  necessary  in  a  given  case,  there  is  very 
little  danger  in  postponing  the  operation,  in  the  mean- 
time keeping  the  extremity  in  an  aseptic  condition  by 
thorough  surgical  cleanliness  and  perfect  drainage.     Of 


132  complicated  fractures  of  the  bones  of  the  extremities 
which  I  have  treated  in  the  last  eleven  years,  most  of 
these  compound  comminuted  fractures,  associated  com- 
monly with  other  serious  injuries,  113  were  cured,  6  im- 
proved, and  12  died ;  1  unimproved,  as  he  refused  to  be 
operated  upon  and  left  the  hospital.  Of  the  12  deaths 
one  died  of  delirium  tremens,  one  had  also  fracture  of 
three  ribs  and  injury  to  the  lungs,  besides  a  fracture  of 
the  humerus  and  extensive  lacerations  of  the  scalp.  One 
had  also  a  fracture  of  the  ilium  and  dislocation  of  the 
sacrum ;  one  had  head  injury  and  cerebritis,  of  which  he 
died ;  one  died  of  apoplexy.  So  that  only  seven  deaths 
could  be  charged  to  the  complicated  fractures  directly. 
Two  of  these  died  of  septicaemia.  Both  cases  persist- 
ently refused  amputation  until  they  were  thoroughly  auto- 
infected.  One  hundred  and  four  of  these  cases  were 
complicated  fractures  of  the  lower  extremity ;  of  these 
88  were  cured,  5  improved,  and  1 1  died ;  28  were  com- 
plicated fractures  of  the  upper  extremity ;  25  were  cured, 
1  died,  1  improved,  1  unimproved  (left  the  hospital). 

Thirty  six  of  these  cases  were  operated  upon  conserva- 
tively, that  is  for  the  purpose  of  removing  pieces  of  bone, 
uniting  fragments,  etc.  Thirty  were  cured,  limbs  re- 
stored to  full  usefulness,  2  improved,  2  required  amputa- 
tion afterward.  One  of  these  died  after  the  amputation, 
of  septicaemia.  This  man  refused  absolutely  to  have  his 
leg  amputated  at  first.  It  was  clearly  a  case  for  amputa- 
tion, as  all  the  soft  tissues  were  badly  comminuted  as 
well  as  the  bones.  The  conservative  operation  was  done 
as  a  forlorn  hope.  The  other  case  requiring  amputation 
was  done  on  account  of  the  coincident  injury  to  the 
axillary  vessels  resulting  in  a  thrombus  of  the  vessels. 

One  died  of  cerebritis  following  a  head  injury  received 
at  the  same  time.  So  that,  except  in  the  one  case  of 
septicaemia  (which  was  the  result  of  the  obstinacy  and 
ignorance  of  the  man,  and  ought  not  to  be  classed  as  a 
case  of  conservative  attempt),  there  was  no  death  which 
could  be  laid  to  the  conservative  attempts,  and  30  posi- 
tive cures. 

Schede,  in  Pitha  and  Billroth's  "  Handbuch  der  allge- 
meinen  und  speciellen  Chirurgie,"  Zweiten  Band,  Zweiter 
Abtheilung,  p.  25,  quotes  Volkmann  as  saying  he  (Volk- 
mann)  had  treated  75  complicated  fractures  of  the  large 
bones  of  the  extremities  conservatively,  without  a  single 
death;  and  Schede  himself  (vid.  ibid.)  treated  37  cases 
conservatively  with  only  one  death,  due  to  delirium 
tremens,  and  fat  embolus  of  the  lungs.  Volkmann  was 
obliged  to  amputate  in  three  of  his  cases,  and  Schede  in 
four  of  his,  for  beginning  gangrene. 

Having  settled  the  fact  that  an  amputation  must  be 
done,  the  next  point  to  determine  is  when  shall  the 
operation  be  done ;  that  is  shall  it  be  done  as  soon  as 
practicable  after  the  injury,  or  shall  it  be  postponed  for 
several  hours  ?  In  my  opinion  this  point  should  be  de- 
termined entirely  by  the  condition  of  the  patient  when 
seen  by  the  surgeon.  It  seems  to  me  the  height  of  bad 
judgment,  in  this  day  of  aseptic  methods,  to  amputate  a 
limb  when  the  patient  is  almost  moribund  from  loss  of 
blood,  or  nearly  exhausted  from  a  long  rough  journey, 
or  not  yet  recovered  from  psychical  or  primary  shock. 
In  short,  whenever  a  patient  is  almost  exhausted  for  any 
reason  soon  after  injury,  I  have  found  that  a  major 
amputation  undertaken  at  once  is  usually  followed  by 
death.  I  have  convinced  myself,  at  least,  that  the  con- 
dition ordinarily  observed  by  the  surgeon  a  few  hours 
after  a  major  injury,  and  usually  called  shock,  is  really  a 
condition  of  acute  anaemia.1  To  operate  while  a  patient 
is  in  this  condition,  as  a  rule,  is  followed  by  the  death 
of  the  patient.  If,  however,  the  hemorrhage  be  thor- 
oughly controlled  by  Esmarch's  tourniquet,  applied  over 
the  crushed  tissues  if  practicable,  and  if  not  practicable, 
applied  at  a  point  just  above  them,  and  the  comminuted 
tissues  and  the  uninjured  parts  of  the  limb  thoroughly 
cleaned  and  disinfected,  and  an  antiseptic  dressirg 
applied  over  all,  the  amputation  may  be  deferred  for 
twenty-four  or  thirty- six  hours,  or  even  longer;  while  by 

1  See  Lehigh  Valley  Medical  Magazine,  January,  1894. 


548 


MEDICAL    RECORD. 


[November  3,  1894 


careful  feeding  and  stimulation  the  patient  may  recover 
some  strength,  and  the  blood-vessels  shall  again  have 
time  to  fill  with  fluid.  Of  the  three  cases  of  hip- joint 
amputations  I  have  done  for  injuries,  each  patient  was 
so  nearly  exsanguinated  when  the  hospital  was  reached 
that  no  radial  pulse,  or  a  bare  flutter  of  a  pulse  now  and 
then,  could  be  felt,  and  the  patient  seemed  actually 
moribund.  By  the  treatment  suggested  above,  the  ampu- 
tation was  deferred  in  two  cases  for  thirty  hours,  and  in 
the  other  case  forty  hours,  and  all  of  them  recovered  after 
the  amputation.  The  former  classification  of  (1)  pri- 
mary, (2)  intermediate,  and  (3)  secondary  amputations, 
has  lost  much  of  its  significance.  Now  intermediate 
amputation  refers  rather  to  deferred  (simply  element  of 
time)  operation.  The  former  terrors,  suppuration,  sep- 
ticaemia, and  pyaemia,  are  rare ;  so  that  in  my  experi- 
ence a  so-called  intermediate  amputation  is  no  more 
dangerous  than  a  primary  one. 

If  the  patient  is  in  good  condition  I  believe  the  proper 
time  to  operate  is  immediately,  as  nothing  is  usually 
gained  by  waiting. 

The  next  point  is,  Where  shall  the  amputation  be 
done  ?  The  former  rule  and  dictum  of  the  authorities,  to 
operate  as  far  away  from  the  trunk  as  practicable,  has 
met  with  some  modification,  since  the  almost  universal 
use  of  prothetical  apparatus  after  amputations.  It  is 
generally  conceded  that  it  is  best  to  leave  as  much  as 
possible  in  amputating  the  upper  extremity  at  any  point. 
With  the  lower  extremity  there  are  certain  "  points  of 
selection."  In  a  painstaking  and  well-written  paper 
read  before  the  National  Association  of  Railway  Sur- 
geons in  1 89 1,1  Mr.  Truax  argues  against  all  tarsal  or 
medio-tarsal  amputations;  he  gives  scant  license  to 
Symes's  amputation,  and  finally  selects  the  junction  of 
the  lower  and  middle  thirds  of  the  leg  as  the  point  of  se- 
lection when  an  amputation  can  be  done  so  low  down. 
As  this  is  the  product  of  long  observation  and  experience 
as  a  manufacturer  of  prothetic  apparatus,  the  opinion  de- 
serves some  consideration.  Mr.  Truax  argues,  however, 
from  the  premises  that  tarsal  amputations  are  followed, 
as  a  rule,  by  a  condition  of  pes  equinus,  on  account  of 
the  contraction  of  the  tendo  Achillis  unantagonized,  or 
atleast  not "  balanced/'  by  the  extensors.  Furthermore, 
he  states  that  the  stumps  of  tarsal  or  medio-tarsal  ampu- 
tations are  usually  painful.  Counting  the  double  ampu- 
tations, I  have  had  12  Chopart,  and  7  Hay  amputa- 
tions ;  all  of  these  19  stumps  have  been  painless  stumps, 
and  have  generally  preserved  useful  extension.  I  cannot 
admit  Mr.  Truax's  premises,  and  therefore  think  his  ar- 
gument worthless  with  reference  to  this  point.  If  the 
well-known  fact  with  reference  to  the  bearing  of  a  false 
leg  be  remembered,  namely,  that  the  weight  does  not 
come  on  the  end  of  the  stump,  but  on  the  sides  of  the 
extremity  a  little  above  the  end  (as  an  obtuse  wedge  fits 
into  a  conical  cavity),  one  will  not  go  far  astray  in 
fashioning  his  stump.  If  he  remembers  that  the  false 
limb  must  owe  all  its  motion  to  the  stump,  he  will  be 
convinced  that  as  long  an  extremity  as  is  necessary  for 
good  leverage  should  be  left  whenever  practicable.  I 
quite  agree  with  Mr.  Truax  that  the  upper  part  of  the 
lower  third  is  the  preferable  point  for  amputations  of  the 
leg,  when  it  can  be  done ;  75  of  my  amputations  of  the 
leg  have  been  at  or  near  this  point.  I  feel  convinced  as 
much  of  the  thigh  as  possible  ought  to  be  left  in  ampu- 
tating above  the  knee,  but  when  at  all  practicable,  the 
knee-joint  amputation,  I  think,  should  be  employed  if 
an  amputation  must  be  done  as  high  up  as  the  upper 
third  of  the  leg.  The  mortality- rate  of  amputations  at 
the  several  points  below  the  knee  are  so  nearly  the  same, 
that  this  factor  has  no  practical  weight  in  determining 
the  point  of  amputation. 

Indeed,  my  experience  corresponds  with  that  of  Volk- 
mann's  and  Billroth's  clinics,  namely,  that  the  danger  of 
an  amputation  is  not  so  much  the  region  (the  locale  of 
the  operation)  as  the  size  of  the  limb  at  the  point  of  am- 
putation.    An  amputation  through  the  thigh  of  a  small, 

1  See  Transactions  National  Association  of  Railway  Surgeons,  1891. 


weazened,  dried-up  man,  whose  thigh  may  be  so  small 
that  it  can  almost  be  spanned  by  the  fingers  of  one 
hand,  is  not  nearly  so  much  of  an  operation,  nor  nearly 
so  dangerous  (the  general  condition  of  the  patient  being 
good),  as  an  amputation  through  the  calf  of  a  big,  well- 
muscled,  and  well- developed  man.  I  believe,  therefore, 
that  the  increased  danger  of  an  amputation  of  an  extrem- 
ity near  the  trunk  is  due  chiefly  to  the  fact  that  the  area 
of  the  dissection,  the  bulk  of  the  severed  tissues,  is  so 
much  greater  there  than  farther  away.  The  reason  of 
this  is,  of  course,  the  larger  the  limb  the  greater  the 
traumatism  of  the  operation,  more  blood-vessels,  more 
nerves,  and  more  muscles  are  cut.  Also,  the  larger  the 
area  of  the  wound  the  greater  the  danger  of  infection, 
and  the  more  difficult  is  it  to  make  the  operation  thor- 
oughly aseptic,  and  to  make  the  tissues  fit  well  together 
and  to  drain  perfectly. 

Method  or  Technique  of  Amputation. — The  first  and 
most  important  point  is  to  establish  an  aseptic  condition 
of  the  limb  at  and  about  the  point  selected  for  the  seat 
of  operation.  This  is  sometimes  an  extremely  difficult 
thing  to  do,  in  many  instances  almost  impracticable.  In 
cases  of  individuals  who  are  habitually  dirty,  and  who 
have  been  mangled  on  the  railroad,  in  a  mill,  or  in  a 
mine,  filth,  grease,  coal,  and  sometimes  soiled  clothing, 
are  fairly  ground  into  the  tissues.  To  make  such  a 
wound  surgically  clean  is  impracticable.  It  is  my  custom, 
in  cases  of  injuries,  to  have  all  clothing  removed  as  soon 
as  the  patient  is  in  a  condition  to  bear  this,  after  reach- 
ing the  hospital.  The  patient  having  been  carried  first 
into  a  reception-room,  near  the  operation-room,  but 
separated  from  it  by  a  hall,  the  assistants  begin  at  once 
to  cut  off  all  his  clothing,  and  to  remove  each  article 
separately  in  such  a  way  as  not  to  rub  against  nor  into 
the  lacerated  tissues  if  it  can  be  avoided.  The  nude  pa- 
tient is  then  covered  by  a  clean  blanket,  and  the  crushed 
extremity,  which  has  been  temporarily  dressed  by  the 
ambulance  surgeon  before  his  arrival  at  the  hospital,  is 
now  inspected  and  is  washed,  first  with  the  German 
green  soap  and  hot  water,  then  carefully  shaved,  and 
again  washed  with  the  soap  and  water,  then  rubbed  of 
with  alcohol,  and  then  thoroughly  washed  and  rubbed 
with  1  to  1,000  sublimate  solution,  and  then  gauze  thor- 
oughly wet  with  1  to  1,000  sublimate  solution  is  pat  over 
the  laceration  or  wound  of  whatever  kind,  and  the  limb 
at  the  point  selected  for  the  amputation  also  encom- 
passed in  this  wet  dressing.  Then  the  patient  is  taken 
on  a  clean  stretcher,  with  only  clean  blankets  over  him, 
to  the  operation-room,  and  put  upon  the  operation- 
table,  and  covered  by  a  fresh  relay  of  blankets  used  only 
for  the  operation-room,  and  those  brought  in  with  him 
are  taken  away.  All  instruments  having  been  previously 
arranged  and  sterilized,  the  patient  is  now  anaesthetized, 
and  during  this  time  the  operator  and  assistants  carefully 
wash,  brush,  and  sterilize  their  hands  and  nails.  As 
soon  as  the  patient  is  anaesthetized  an  Esmarch's  band  is 
applied  as  a  tourniquet,  the  blood  being  driven  back  by 
raising  the  extremity  for  a  short  time,  rarely  by  the  Es- 
march  band  applied  from  below  upward,  as  this  bruises 
already  injured  tissues.  Haemostasia  accomplished,  the 
limb  is  isolated  and  protected  from  the  other  limb  and 
other  surroundings  by  pure  gum  tissue  and  sterilized 
towels,  and  only  the  seat  of  operation  left  uncovered. 
The  temporary  covering  is  now  removed  and  another 
thorough  scrubbing  of  the  limb  at  the  seat  of  operation 
is  done  with  alcohol  or  turpentine,  and  then  with  a  1  to 
1,000  solution  of  sublimate.  If  the  patient  has  been 
very  dirty  and  there  was  a  large  accumulation  of  dead 
epidermis  on  the  extremity  before  it  was  shaved,  I  be- 
lieve with  Lister  that  carbolic  acid  penetrates  the  epider- 
mis better  than  sublimate  solution,  so  I  commonly  use  a 
five  per  cent,  carbolic  solution  as  well  as  the  sublimate 
for  a  final  disinfection.  During  this  last  sterilization  or 
disinfection,  the  wound  is  kept  sedulously  covered  and 
bandaged  by  wet  sublimate  dressings,  as  it  is  regarded  as 
hopelessly  infected  in  most  cases,  and  except  the  wash- 
ing and  douching  it  gets  in  the  reception-room,  no  for- 


November  3,  1894] 


MEDICAL   RECORD. 


549 


ther  attempt  is  made  to  clean  it  when  an  amputation  is 
to  be  done. 

As  to  the  operation  itself,  there  are  in  my  judgment 
and  practice  two  cardinal  points  only  to  be  regarded : 
first,  the  flaps  must  be  long  enough  and  wide  enough  to 
cover  the  stump  thoroughly  without  tension ;  and  second, 
there  must  not  be  any  hemorrhage.  As  a  matter  of  fact, 
like  most  operators,  I  have  learned  to  have  preferences 
as  to  the  kinds  of  flaps  to  be  employed  and  the  manner 
of  forming  them.  I  cannot  absolutely  deduce  from  my 
experience,  however,  that  in  the  ordinary  amputation 
the  methods  I  employ  are  better  than  those  used  by  other 
operators.  For  the  upper  extremity  I  almost  invariably 
use  anteroposterior  flaps  for  the  forearm,  and  the  cir- 
cular or  modified  circular  for  the  upper  arm.  For  the 
shoulder  joint  I  also  like  anteroposterior  flaps,  with  the 
anterior  flap  about  twice  as  long  as  the  posterior.  This 
method  enables  one  to  tie  the  brachial  vessels  before 
they  are  cut  without  any  further  inconvenience  than  a 
little  care  in  dissecting  the  inner  edge  of  the  anterior 
flap  until  the  vessels  are  isolated,  ligated,  and  cut  through. 
It  also  furnishes  good  drainage.  For  the  lower  extrem- 
ity, I  have  rarely  used  any  osteoplastic  method  in  the 
foot  For  working-men  I  think  these  stumps  require  too 
long  a  time  for  healing,  and  are  of  doubtful  utility  after- 
ward. Hay's,  Chopart's,  and  Symes's  are  my  preferences 
in  foot  amputations.  In  Chopart's,  and  in  Hay's,  indeed, 
I  have  found  it  of  great  advantage  to  leave  the  extensor 
tendons  long,  and  to  unite  them  with  the  anterior  flap. 
This  results  in  preventing  disagreeable  contractions  of 
the  tendo  Achilfis,  and  gives  freely  movable  stumps,  in 
extension  as  well  as  flexion.  In  the  lower  third  of  the 
leg,  both  anteroposterior  and  lateral  flaps  have  given  me 
great  satisfaction.  I  believe  that  Teale's  operation  is 
likely  to  give  trouble  by  the  fact  of  the  long  lateral 
cicatrix  it  leaves,  which  is  just  in  line  and  at  the  point  for 
pressure  of  a  false  limb.  In  later  years  I  have  never 
used  it.  I  have  found  the  lateral  flap  method  the  best  for 
all  the  regions  of  the  leg.  It  gives  the  best  drainage, 
least  tension,  and  results  in  the  most  useful  stumps.  At 
the  knee,  and  in  the  lower  part  of  the  thigh,  long  ante- 
rior and  short  posterior  flaps  I  have  found  best,  and  nearly 
always  employ.  For  hip-joint  amputations  I  would  em- 
ploy the  Dieffenbach  Volkmann  method  when  long  flaps 
could  be  obtained,  and  should  always  tie  the  femoral 
vessels  before  cutting  them.  When  short  flaps  are  to  be 
used  I  believe  the  method  recommended  recently  by  myself l 
and  called  the  gradual  dissection  method,  the  best.  This 
is  a  modification  or  amplification  of  Rose's  method.  It 
consists  essentially  in  first  forcing  the  blood  up  by  Es- 
march's  band,  when  this  is  practicable  or  expedient,  else 
by  elevation ;  second,  deligation  of  the  femoral  vessels  by 
double  ligatures  at  Poupart's  ligament,  and  incising  the 
vessels  between  the  ligatures ;  third,  gradual  dissection 
of  an  anterior  and  posterior  flap  successively,  taking  the 
utmost  care  to  ligate  all  known  vessels  before  they  are 
cut,  and  always  securing  immediately  all  small  muscular 
branches  as  soon  as  they  are  cut.  Exarticulation  is  per- 
formed as  in  other  methods,  after  hemorrhage  is  con- 
trolled. 

I  always  form  my  flaps  from  without  inward.  I  never 
transfix.  The  muscles  are  cut  long  enough  to  unite 
over  the  sawed  bone  and  at  different  levels — in  order  to 
make  a  hollow  cone — and  a  periosteal  flap  is  almost  in- 
variably used  when  the  amputation  is  through  the  shaft 
of  a  long  bone.  The  greatest  care  is  used  in  securing 
and  ligating  all  vessels,  veins  as  well  as  arteries.  When- 
ever a  point  persistently  oozes  after  the  tourniquet  is  re- 
moved, and  torsion,  or  torsion  and  pressure,  for  a  short 
time  does  not  suffice,  this  is  also  ligated.  When  the 
medullary  cavity  bleeds  or  oozes  it  is  packed  with  a 
bunch  of  sterilized  catgut,  which  is  covered  in  by  the 
periosteal  flaps.  Catgut  is  invariably  used  as  ligatures. 
Recently  I  have  begun  to  put  in  provisional  sutures  of 
silk,  with  permanent  sutures  introduced  during  the  an- 

1  See  Lehigh  Valley  Medical  Magazine,  January,  1894,  and  the 
Philadelphia  Polyclinic,  March  24,  1894. 


aesthesia  and  tied  in  long  loops,  and  then  pack  the 
stumps  with  iodoformized  gauze  for  twenty- four  hours, 
in  cases  of  persistent  oozing,  as  frequently  happens  after 
an  Esmarch  tourniquet  has  been  on  for  a  long  time. 
The  gauze  is  removed  after  twenty-four  hours  and  the 
flaps  apposed  by  the  sutures  already  introduced.  In  these 
cases  the  muscles  are  always  held  by  the  silver-wire 
quilled  suture,  which  I  almost  always  employ  for  this 
purpose.  Ordinarily,  however,  the  apposition  is  accom- 
plished at  once,  as  follows :  If  there  is  good  reason  to 
believe  that  the  wound  is  aseptic  when  the  operation  is 
done,  no  douche  is  used  unless  persistent  oozing  requires 
it,  then  hot  sterilized  water  is  employed.  The  periosteal 
flap  is  brought  down  and  fitted  over  the  end  of  the  bone ; 
no  suture  is  necessary,  as  a  rule.  Then  deep  sutures  of 
silver  wire  are  passed,  beginning  about  five  to  six  centi- 
metres from  the  edge  of  the  flap,  through  the  skin  and 
muscles  of  one  flap,  into  those  of  the  other  flap  and  out 
through  the  skin  at  a  point  corresponding  to  its  entrance ; 
by  means  of  two  short  quills,  in  the  shape  of  a  small 
wooden  peg  1.5  ctm.  long  by  2  or  3  mm.  in  diameter, 
the  flaps  are  brought  together  and  the  muscles  firmly  se- 
cured, and  their  surfaces  apposed.1  From  two  to  four  of 
these  quill  sutures  are  necessary  for  the  purpose.  Then 
interrupted  sutures  of  silk,  lastly  a  continuous  catgut  or 
small  silk  suture  to  nicely  appose  the  skin.  A  small  cap- 
illary drain  of  iodoformized  gauze  is  used,  for  forty-eight 
hours.  Dressings — dry  iodofotmized  gauze  and  dry 
sublimated  or  heat-sterilized  gauze.  Over  all  a  pad  of 
absorbent  cotton,  and  the  dressing  completed  by  a  splint 
to  hold  the  extremity  quiet  and  lessen  muscular  twitchings. 

The  table  on  the  following  page  shows  the  operations 
performed,  the  result,  and  percentage  of  mortality.  In  the 
list  of  single  major  amputations  I  have  not  included  ampu- 
tations done  for  purely  euthanastic  purposes,  in  cases  of 
evulsion  complicated  with  other  serious  injuries,  when 
the  patients  arrived  at  the  hospital  in  moribund  and 
utterly  hopeless  conditions.  In  the  list  of  double  and 
triple  operations,  all  operations  are  noted.  While  in 
nearly  every  case  the  condition  of  the  patient  was  des- 
perate, yet  in  none  of  the  multiple  operations  did  the 
patient  die  on  the  table,  and  I  have  thought  it  but  fair 
to  include  all  of  them.  In  the  double  amputations  it 
has  been  my  custom  invariably,  in  the  last  few  years,  to 
have  my  senior  assistant  amputate  one  limb  while  I  was 
operating  on  the  other.  Thus  the  double  amputations 
were  strictly  synchronous.  This  method  saves  time,  and 
markedly  lessens  the  quantity  of  the  anaesthetic  necessary 
to  be  given ;  this  in  my  judgment  is  a  very  important 
point.  It  will  be  noticed  that  the  multiple  operations 
are  not  always  all  of  them  amputations.  Whenever  it 
was  necessary  to  do  an  operation  of  a  gravity  equal  to 
another  amputation,  I  have  included  it  as  multiplying 
the  amputations.  The  cases  mentioned  of  lacerations 
of  the  scalp,  with  comminuted  limbs,  were  no  ordinary 
lacerations,  but  very  extensive,  and  in  themselves  very 
dangerous  wounds,  and  the  operations  for  their  repair 
were  extensive  and  more  difficult  sometimes  than  the 
amputation  which  accompanied  it. 

Of  the  deaths  following  the  single  amputations,  two 
were  from  septicaemia.  One  case  had  septicaemia  when 
he  was  admitted,  an  old-fashioned  "  intermediate  ampu- 
tation "  was  done ;  the  patient  was  in  an  extremely  weak 
condition  when  admitted,  and  he  died  about  five  days 
after  the  operation,  of  exhaustion.  The  other  case  was 
the  one  mentioned  in  speaking  of  complicated,  com- 
pound fractures — who  persistently  refused  to  have  his 
leg  amputated  until  he  was  almost  moribund  from  septi- 
caemia. 

A  third  death  occurred  from  croupous  pneumonia  fif- 
teen days  after  amputation  at  lower  third  of  thigh,  when 
the  amputation  wound  was  practically  well.  Besides 
these  cases  but  one  other  case  lived  longer  than  two 
days;  it  was  an  amputation  of  lower  third  of  thigh, 
complicated  by  crush  of  the  muscles  of  the  other  leg  ; 
it  died  in  nine  days,  of  exhaustion.  So  that,  barring 
1  This  is  a  modification  of  Lister's  lead-plate  suture. 


55° 


MEDICAL   RECORD. 


[November  3,  1894 


these  four  cases,  all  the  deaths  occurred  from  exhaustion 
within  forty- eight  hours  after  admission. 

List  of  Amputations. 


Sijvgle  Major  Amputations. 


ill  1 1H 


Amputations  of  arm 27 

Amputations  of  forearm 37 

Amputations  of  foot,  Chopari's 7 

Amputations  of  foot,  Hay's a 

Amputations  of  foot,  PirogofPs I  1 

Amputations  of  foot,  Symes's 9 

Amputations  of  leg,  lower  third 47 

Amputations  of  leg,  middle  third 28 

Amputations  of  leg,  upper  third    aa 

Amputations  of  thigh,  lower  third 1  44 

Amputations  of  thigh,  middle  third 25 

Amputations  of  thigh,  upper  third 8 

Amputations  at  hip-joint 7 

Amputations  at  knee-joint 17 

Amputations  at  shoulder- joint 13 


Total. 


294 


Synchronous  Double  Major  Operations.  j 

Amputation  at  shoulder-joint,  and  the  other  arm,  lower  third  x 

Amputation  at  shoulder-joint,  and  the  other  arm,  middle  third  a 
Amputation  at  shoulder-joint,  and  the  other  forearm,  middle, 

third.. , 

Amputation  at  shoulder-joint,  and  a  leg  lower  third 1 

Amputation  at  shoulder-joint  and  operation  for  compound  de- 
pressed fracture  of  the  cranium  I  x 

Amputation  of  both  arms x 

Amputation  oi  arm,  upper  third,  and  leg,  middle  third I  1 

Amputation  of  arm,  lower  third,  and  forearm,  middle  third . . '  1 

Amputation  of  both  forearms x 

Amputation  of  both  feet,  Chopart's 2 

Amputation  of  both  feet,  Hay's    j  3 

Amputation  of  one  foot,  Chopart's,  and  other  leg.  lower  third.  1 

Amputation  of  one  foot,  Symes's,  and  other  leg,  lower  third ..  ]  3 

Amputation  of  both  legs 7 

Amputation  at  knee-joint,  and  other  leg,  lower  third x 

Amputation  at  knee-joint,  and  other  leg,  middle  third J  1 

Amputation  at  knee-joint,  and  other  thigh,  lower  third 1 

Amputation  of  one  leg,  lower  third,  and  exsection  of  the  other) 

ankle-joint I  1 

Amputation  of  one  leg,  lower  third,  and  other  thigh,  lower 

third 3 

Amputation  of  one  leg,  middle  third,  and  other  thigh,  lower 

third ,  2 

Amputation  of  one  leg,  upper  third,  and  other  thigh,  lower. 

third '  t 

Amputation  of  both  thighs,  lower  third I  3 

Amputation  of  both  thighs,  middle  third 1 

Amputation  of  one  thigh,  middle  third,  and  all  the  toes  of, 

other  foot x 

Amputation  of  one  thigh,  lower  third,  and  >  operation  for  re-| 
moving  fragments  and  apposing,  and  draining  of  compound 

fracture  of  other  leg |  x 


Total. 


Synchronous  Triple  Operations. 
Amputation  of  thigh,  lower  third,  left  arm,  lower  third,  andj 

half  of  right  hand 

Amputation  of  thigh,    lower  third,  leg,  middle  third,  arm, 

upper  third | 

Amputation  of  thigh,  lower  ihirdj  leg,  lower  third,  and  dosing 

and  draining  extensive  laceration  of  the  scalp  

Amputation  of  thigh,  lower  third,  arm,   middle  third,  and. 

closing  and  draining  extensive  laceration  of  scalp 

Amputation  of  thigh,  middle  third,  right  foot  (Symes's),  re-' 

moval  of  fragments,  apposition  and  drainage  of  compound ' 

comminuted  fracture  of  right  humerus 

Amputation  of  both  thighs,  middle  third,  and  closing  and' 

draining  extensive  laceration  of  scalp 


Total. 


Quadruple  Operation.  i 
Amputation  of  thigh,  lower  third,  leg,  middle  third,  half  of1 
palm  of  the  hand,  and  closing  and  draining  extensive  lacer- 
ations of  scalp  and  forearm I 


Total  ... 


a. ia 
o 

434 
xi. 36 

8.00 
12.50 
14.28 

5.88 

7-99 


4.76 


4».8 


100 

SO 


.1     38 

I 


»3-68 


57.  H 


•  Died  of  cerebritis,  produced  by  the  injury  to  head. 

One  of  the  deaths  after  amputation  of  both  legs  was 
from  delirium  tremens,  on  the  fifteenth  day,  when  the 
stumps  were  practically  well. 

Except  one  case,  a  man  sixty-five  years  of  age,  who 
had  both  legs  amputated  in  the  upper  third,  and  who 
died  of  exhaustion  on  the  fifth  day,  all  the  fatal  cases 
were  young  individuals — all  under  forty- five  years  of  age, 
and  three- fourths  of  them  were  under  thirty  years  of  age. 
A  search  through  the  records  of  my  cases  shows  amputa- 
tions done  on  individuals  from  ten  to  eighty  years  of 
age,  and  as  stated  above,  only  one  of  the  fatal  cases  was 
past  forty-five  years  of  age.  Age  seems  to  have  played 
very  little  part  in  contributing  to  the  death-rate.  It  has 
happened  that  none  of  my  fatal  cases  belonged  to  the 
feminine  gender. 

Only  one  death  followed  amputation  for  diseased  con- 


dition. That  was  a  case  of  very  large  periosteal  sarco- 
ma of  the  upper  part  of  the  femur,  which  required  ampu- 
tation at  the  hip  joint.  The  man  refused  to  have  ampu- 
tation done  until  he  was  almost  exhausted.  He  died  on 
the  third  day  after  the  operation,  from  exhaustion.  His 
stomach  refused  to  retain  any  food  after  the  operation, 
and  in  his  extremely  weak  condition  rectal  alimentation 
was  not  sufficient  to  support  him. 

It  is  shown  by  the  foregoing  statistics,  that  barring 
two  cases  of  septicaemia,  one  of  pneumonia,  one  of  cere- 
britis, and  one  of  delirium  tremens — five  altogether — all 
the  fatal  cases  resulted  from  exhaustion  following  hemor- 
rhage, and  coincident  injuries.  The  most  common 
cause  was  hemorrhage.  In  order  to  make  this  apparent, 
and  to  emphasize  the  point  I  wish  to  make,  I  must  divide 
my  amputations  into  two  series.  These  amputations 
were  done  in  twelve  years.  My  observation  and  study 
during  the  first  part  of  this  period  convinced  me  that  by 
far  the  majority  of  cases  of  crushes  which  were  brought 
to  the  hospital  were  greatly  reduced,  in  many  cases  mori- 
bund, from  acute  anaemia  (from  excessive  hemorrhage), 
and  I  had  been  accustomed  to  operate  before  any  suffi- 
cient time  was  given  for  the  patient  to  recuperate.  I 
reasoned,  therefore,  that  if  by  any  arrangement  injured 
persons  could  be  saved  from  excessive  bleeding,  and,  in 
case  of  marked  acute  anaemia,  if  the  operation  be  post- 
poned for  a  period  of  hours  in  order  to  permit  the  pa- 
tient to  recuperate  somewhat,  results  after  amputatiors 
ought  to  be  better.  By  far  the  greater  number  of  in- 
jured persons  brought  to  St.  Luke's  Hospital  are  trans- 
ported over  the  Lehigh  Valley  Railroad.  I  had  dis- 
tributed along  the  railroad,  at  all  the  stations,  on  the 
wreck-cars,  and  on  ail  the  principal  passenger  trains, 
cases  containing  some  simple  antiseptic  dressings,  and 
especially  two  Esmarch  elastic  tourniquets.  As  surgeon- 
in-chief  of  the  railroad,  I  had  issued  orders  that  in  every 
case  of  serious  injury,  first  aid,  especially  the  stoppage  of 
hemorrhage,  should  be  accomplished  by  means  of  this 
apparatus.  After  this  I  also  made  it  a  rule  to  defer  op- 
erating until  a  patient  had  thoroughly  "  reacted,"  if  he 
was  in  a  very  weak  condition  when  he  arrived  at  the  hos- 
pital. Results  began  at  once  to  be  better.  The  follow- 
ing statistics  will  show  how  much  improvement  there 
was.  The  apparatus  has  been  in  use,  and  the  deferred 
operation  method  has  been  employed,  during  the  last 
six  years.  The  term  of  twelve  years  then  ought  to  be 
divided  into  two  periods  of  six  years  each.  During  the 
first  period  of  six  years  there  were  114  single  major  am- 
putations and  9  deaths,  giving  a  mortality-rate  of  7  89 
per  cent.  There  were  9  cases  admitted  in  hopeless  con- 
ditions. In  the  last  period  of  six  years,  during  which 
the  regime  has  been  in  operation,  there  were  180  single 
major  amputations  and  5  deaths — 2.77  per  cent,  mor- 
tality. There  were  only  four  hopeless  cases  admitted. 
In  the  last  period  there  were  a  larger  number  of  opera- 
tions, and  the  mortality- rate  reduced  almost  one-third. 
Again,  in  the  first  series,  having  fewer  cases,  there  were 
9  hopeless  cases  ;  in  the  last  series  there  were  only  4 
hopeless  cases,  less  than  one  half. 

The  double  synchronous  operations  exhibit  the  differ- 
ence in  even  a  greater  degree.  There  were  altogether 
38  double  synchronous  operations  and  9  deaths,  23.68 
per  cent,  mortality.  In  the  first  period  there  were  13 
double  operations  and  6  deaths,  46.25  per  cent,  mor- 
tality. In  the  last  period  there  were  25  double  opera- 
tions and  3  deaths,  only  12  per  cent,  mortality.  In  the 
first  period  there  were  two  triple  synchronous  operations, 
and  both  patients  died.  In  the  last  period  there  were 
5  triple  synchronous  operations  and  2  deaths. 

These  statistics  show  50  per  cent,  less  mortality  after 
amputations  since  the  regime  has  been  in  operation. 
The  argument  seems  to  me  incontrovertible.  I  urge, 
therefore,  the  saving  of  blood  as  the  paramount  necessity 
for  recovery  after  major  amputations,  and  in  a  line  with 
this  the  immense  importance  of  allowing  an  exsanguin- 
ated patient  time  to  recuperate  before  attempting  to  am- 
putate. 


November  3,  1894] 


MEDICAL   RECORD. 


55i 


After-treatment  and  Result  with  Reference  to 
Usefulness  of  Stump. — In  forty  eight  hours,  usually,  the 
stump  is  redressed  for  the  first  time,  and  the  primary 
drain  or  packing  is  removed.  If  there  bas  been  oozing, 
or  serum  retained,  then  the  drainage  is  continued;  if 
not,  all  drains  are  removed  and  the  flaps  allowed  to  come 
together.  After  this  a  dressing  once  a  week  suffices.  In 
a  week  the  patient  is  usually  out  of  bed.  Of  100  cases 
analyzed  with  reference  to  this  point  (all  cases  for  two 
and  a  half  years  taken),  the  average  number  of  days  in 
the  hospital  after  amputation  was  22.6. 

There  was  one  case  of  secondary  hemorrhage — a  dys- 
crasic  individual ;  oozed  most  extraordinarily  in  spite  of 
the  greatest  care,  and  finally  a  ligature  gave  way  and  the 
stump  had  to  be  reopened,  clots  turned' out,  and  the  ves- 
sel, a  muscular  branch  of  the  popliteal,  retied.  This 
occurred  after  an  amputation  at  the  knee-joint.  The 
man  made  a  good  recovery. 

It  has  been  quite  impossible  to  keep  track  of  all  cases 
operated  upon.  So  far,  however,  I  know  of  only  four 
cases  requiring  re  amputation.  Three  of  these  were  in 
young  boys,  two  having  amputations  through  upper  part 
of  the  femur  and  one  through  upper  part  of  the  humerus ; 
developed  conical  stumps,  and  exsection  of  the  end  of 
the  bone  was  necessary  afterward.  The  fourth  was  done 
for  necrosis  developing  in  a  compound  fractured  humerus 
after  an  amputation  had  been  done  lower  down.  It  was 
necessary  to  re- amputate  above  the  fracture.  All  the 
cases,  as  far  as  I  have  been  able  to  find  out,  were  able  to 
wear  false  limbs  comfortably,  except  one  case  of  double 
amputation.  This  man's  stumps  looked  typically  healthy 
and  well  formed,  but  he  said  the  constriction  of  false  limbs 
caused  him  so  much  discomfort  that  he  preferred  to  go 
about  without  the  prothetic  assistance.  He  was  quite 
comfortable  when  not  wearing  the  false  limbs. 

Mortality  rate  after  Amputations. — Aseptic  prac- 
tice and  the  saving  of  blood  during  operation,  have  rev- 
olutionized the  mortality  statistics  after  amputations. 
Schede  quotes  Billroth  as  having  said,  with  aseptic  prac- 
tice and  Esmarch  tourniquet  a  surgeon  should  consider 
himself  at  fault  if  he  loses  a  case  of  uncomplicated  ampu- 
tation, if  the  patient  dies  after  he  recovers  from  the  im- 
mediate effect  of  the  operation  (writer's  paraphrase). 
In  other  words,  nowadays  no  patient  should  die  after  an 
amputation,  unless  he  dies  from  the  immediate  traumatic 
effect  of  the  injury  or  operation.  I  would  go  further  and 
say,  if  a  thoroughly  bloodless  method  be  pursued,  and  the 
operation  be  not  done  during  the  non  tolerant  stage  of 
acute  anaemia,  statistics  after  major  amputations  ought 
to  be  as  good  as  those  of  abdominal  sections,  and  I  be- 
lieve they  will  finally  be  so. 

The  following  statistics  are  far  from  complete,  and  are 
indeed  meagre,  but  they  will  serve  to  indicate  a  compar- 
ison of  results  which  I  wish  to  urge  in  favor  of  the  meth- 
ods I  have  advocated. 

Schede l  gives  321  uncomplicated  cases  of  amputations 
done  after  the  Lister  method  of  operation,  and  after-treat- 
ment by  Socin,  Volkmann,  and  himself  (Schede),  with  a 
death-rate  of  4  4  per  cent.  Of  complicated  cases,  some 
requiring  double  operations  and  others  having  multiple 
injuries,  there  were  24,  and  n  deaths — over  forty-four 
per  cent,  mortality.2 

Messrp.  C.  F.  Dent  and  W.  C.  Bull 3  give  the  statistics 
of  St.  George's  Hospital  from  October,  1874,  to  June, 
1888,  400  major  amputations,  and  an  average  mortality 
of  twenty-one  per  cent. 

Mr.  A.  E.  Barker  *  performed  50  major  amputations  at 
University  College  Hospital,  from  1876  to  1892 — 29  for 
disease  and  2  r  for  injury — with  an  average  mortality-rate 
of  eight  per  cent. 

Mr.  Frederick  Page 'gives  687  major  amputations  per- 
formed at  the  Royal  Infirmary,  Newcastle* on-Tyne, 
from  April  1,  1878,  to  December  31,  1891,  including  22 

1  Pitha  und  Billroth :  Handbuch  der  Allgemeinen  und  speciellen 
Chirurgfe,  Zweitcr  Band,  Zweite  Abtheilung,  p.  338. 

*  Vide  ibid.,  pp.  240  and  242.         a  Lancet,  June  14,  1890,  p.  1303. 

*  Lancet.  January  2,  1893,  p.  22. 
■  Ibid.,  March  5,  1892,  p.  523. 


hip-joint  amputations,  with  general  mortality  of  eight 
per  cent;  272  amputations  for  injury,  with  12.9  per 
cent,  mortality;  and  415  amputations  for  disease,  with 
4.8  percent,  mortality. 

Dr.  A.  G.  Gerster l  gives  a  collection  of  43  cases  of 
his  own,  done  mostly  in  hospitals,  with  a  general  mor- 
tality-rate of  4.65  per  cent. 

Ashhurst,  in  the  1893  edition  of  his  "  System  of  Sur- 
gery," gives  the  following  statistics : 

Major  Amputations. 

For  Diseases.  For  Injuries. 

Mortality,  '  Mortality. 

French  hospitals 42.87    French  hospitals 57-98 

English  hospitals 22.67    English  hospitals 40.98 

American  hospitals. ....     18.60  \  American  hospitals 3*-95 

Wolfler8  collects  704  uncomplicated  amputations  done 
by  v.  Bruns,  Volkmann,  Busch,  Esmarch,  Hunter,  ard 
Schede;  the  general  mortality-rate  was  15  6  percent. 
He  gives  also  v.  Bruns's  amputations  from  October,  1878, 
.  to  October,  1880,  47  cases  and  no  deaths.  Also,  Busch, 
1873-1876,  57  cases,  with  3.5  per  cent,  mortality.  Bil3- 
roth's  Klinik,  1877-1880,  68  cases,  5.88  per  cent,  mo:- 
tality. 

Oberst '  gives  R.  Volkmann's  amputations  at  his  Klinik 
in  Halle,  from  1874  to  1880.  There  were  73  uncompli- 
cated amputations  for  injuries,  and  10.5  per  cent,  mor- 
tality; 188  amputations  for  disease,  with  3.7  percent, 
mortality — a  general  mortality-rate  of  5.3  per  cent. 
Three  hip-joint  amputations  done  for  injury,  all  died;  8 
hip-joint  amputations  done  for  disease,  twenty  five  per 
cent,  mortality.  There  were  8  double  amputations  ft  r 
injury,  3  deaths,  and  5  double  amputations  for  disease, 
no  death;  13  cases,  and  general  mortality  twenty-three 
per  cent. 

My  own  statistics  show,  for  the  whole  number  of  single 
major  amputations,  294,  with  only  19  of  them  done  for 
disease,  and  including  seven  hip-joint  imputations,  a 
general  mortality- rate  of  4.76  per  cent.  This  is  but  a 
little  higher  than  Schede's  uncomplicated  cases.  Tak- 
ing out  the  19  done  for  disease  with  1  death,  there 
were  275  amputations  for  injuries  and  13  deaths,  4.73 
per  cent.;  and  in  nearly  every  case  there  were  multiple 
injuries.  Taking  the  last  period,  however,  of  six  years, 
when  the  cases  were  exactly  of  the  same  character  as  te- 
fore,  but  when  hemorrhage  was  prevented,  and  when  the 
operation  was  deferred  until  the  condition  of  acute  ar  aemia 
was  somewhat  relieved,  there  were  during  this  period  180 
single  major  amputations  and  only  5  deaths,  or  2.77  per 
cent,  mortality ;  these  figures  include  six  hip-joint  amputa- 
tions. This  is  the  lowest  mortality-rate  I  have  ever 
seen  reported  for  a  series  of  180  major  amputations. 

The  multiple  operations  and  extremely  complicated 
injuries,  in  26  cases,  resulted  in  three  deaths,  11.5  per 
cent  mortality.  This  is  a  small  series  of  cases — these 
last — but  the  mortality-rate  is  less  than  the  single  opera- 
tions in  Ashhurst's  statistics. 

In  conclusion,  I  beg  to  say  these  statistics  speak  far 
more  impressively  and  eloquently  than  I  could  possibly 
do  for  the  saving  of  blood  and  the  conservation  of 
strength. 

Hospital  Patients  Poisoned. — An  attempt  was  made 
recently  to  poison  the  inmates  of  a  hospital  in  California 
by  putting  strychnine  into  the  coffee.  Twenty  two 
patients  were  poisoned  and  one  man  died.  The  wife  of 
the  superintendent  was  taken  sick,  but  her  life  was  saved. 
The  coffee  pot  was  examined  and  traces  of  the  poison 
were  found  in  it.  It  is  supposed  that  the  work  was  done 
by  a  Chinaman  who  had  trouble  with  the  steward  ard 
had  been  discharged.  He  had  made  threats,  and  it  is 
supposed  that  he  took  this  means  of  venting  his  malice 
on  the  inmates. 

1  Aseptic  and  Antiseptic  Surgery,  p.  60. 

9  Die  Amputationen  an  Prof.  Billroth's  Klinik,  1877-1880.  Dr.  An- 
ton WOlfler,  1882. 

9  Die  Amputationen  unter  dem  Einfl  '.sse  der  antiseptischen  Be- 
handlung,  Dr.  M.  Oberst,  188a. 


552 


MEDICAL    RECORD. 


[November  3,  1894 


TUBERCULOSIS    OF    THE    ADRENAL    BODIES 
UNACCOMPANIED  BY  BRONZING. 

By  WARREN  COLEMAN,  M.D., 

MEW  YORK. 
INSTRUCTOR  IN  BACTERIOLOGY  AT  THE  LOOM  18  LABORATORY,  j 

The  value  of  this  case  depends  upon  the  extent  and 
chronicity  of  the  lesion,  and  upon  the  fact  that  adrenal 
disease  was  not  suspected  during  life. 

The  patient  was  a  Danish  sailor,  thirty  six  years  of 
age.  He  entered  Bellevue  from  the  Chambers  Street 
Hospital  as  a  case  of  constipation.  Death  took  place 
about  three  weeks  later,  without  any  assignable  cause. 
During  his  stay  in  the  hospital,  he  attracted  attention 
only  as  a  case  of  obstinate  constipation  with  marked 
inanition.  The  man  spoke  English  imperfectly,  and  no 
interpreter  could  be  found.  Consequently  nothing  is 
known  of  his  previous  history,  and  the  history  of  his  last 
illness  is  incomplete. 

There  was  marked  asthenia  without  any  apparent  rea- 
son for  it.  On  one  occasion  an  attempt  was  made  to 
get  the  patient  out  of  bed,  but  it  had  to  be  abandoned 
because  he  complained  so  much  of  weakness.  There  is 
no  mention  of  any  attendant  syncope. 

He  ran  a  temperature,  but  the  range  was  low;  it  not 
rising  at  any  time  above  ioi°  F.  The  heart- action  was 
feeble,  and  the  surface  of  the  body  generally  gave  evi- 
dence of  a  poor  circulation.  The  pulse-rate  varied  from 
72  to  88. 

The  constipation  continued,  in  spite  of  vigorous  treat- 
ment, up  to  the  time  of  his  death.  There  is  no  record 
of  an  alternating  diarrhoea.  No  vomiting  or  nausea  was 
present  during  his  stay  in  the  hospital. 

He  manifested  certain  derangements  of  the  nervous 
system.  The  reflexes  were  much  exaggerated ;  sensation 
was  delayed ;  and  during  the  last  few  days  of  life  he  be- 
came delirious,  attempting  several  times  to  get  out  of  bed. 

At  the  autopsy  the  body  was  found  anaemic,  but  not 
much  emaciated.  The  heart  weighs  nine  ounces,  and  its 
walls  are  pale.  The  valves  are  normal.  The  right  lung 
is  bound  to  the  chest  wall  by  a  few  old  stringy  adhesions. 
The  upper  lobs  contains  several  tubercular  masses  of 
considerable  size  (1.5  ctm.  in  diameter),  in  a  state  of 
caseation,  while  throughout  the  middle  and  lower  lobes 
a  few  small  nodules  are  found.  The  pleura  is  adherent 
to  the  chest-wall  over  the  apex  of  the  left  lung,  and  there 
is  a  large  area  of  tubercular  infiltration  in  the  upper  lobe 
which  has  undergone  caseation.  The  rest  of  the  upper 
lobs  is  studded  with  miliary  tubercles.  The  lower  lobe 
contains  a  few  tubercles  in  its  substance  and  on  the 
pleura.  The  bronchial  glands  are  enlarged  and  are 
cheesy  at  the  centre. 

The  left  adrenal  body  weighs  an  ounce  and  a  half. 
Its  original  shape  has  been  lost  entirely,  it  being  irregu- 
larly oval  and  somewhat  flattened  antero-posteriorly. 
On  section  it  is  found  to  bs  caseous,  and  a  greenish- 
yellow  pus  exude3  from  several  points  on  the  cut  surface. 
All  trace  of  medulla  or  cortex  has  disappeared.  The 
cheesy  matter  has  become  calcareous  at  many  points. 
The  capsule  of  the  organ  is  much  thickened.  The  right 
adrenal  weighs  only  one  half  ounce,  and  has  contracted 
down  to  about  one-half  the  size  of  the  normal  gland. 
It  is  similar  in  shape  to  the  left,  and  contains  one  large 
calcareous  mass  with  numerous  smaller  ones  scattered 
through  its  substance.  Both  glands  are  somewhat 
nodulated. 

The  process,  as  far  as  the  adrenals  are  concerned, 
began  in  the  right  gland. 

The  other  details  of  the  autopsy  are  unimportant  as 
regards  the  present  report.  Unfortunately,  the  semi- 
lunar ganglia  and  abdominal  sympathetic  nerves  were 
not  removed  for  examination. 

Microscopic  Examination — The  left  adrenal  only 
was  submitted  to  examination,  the  right  being  too  cal- 
careous to  permit  the  cutting  of  sections.  The  gland 
tissue  has  been  replaced  by  amorphous  masses  showing 
only  the  remains  of  the  nodules  which  originally  charac- 


terized the  process.  No  trace  of  a  medullary  or  cortical 
cell  can  be  found.  In  the  outer  portions  of  the  gland, 
immediately  under  the  capsule  and  between  the  nodules, 
a  faint  fibrillar  structure  may  be  seen  with  round  cells, 
many  of  them  dead  or  abortive,  filling  the  interspaces. 
The  appearance  is  distinctly  different  from  a  true  in- 
flammatory process.  No  giant  cells  are  anywhere  pres- 
ent, a  fact  which  has  been  noticed  in  many  cases.  The 
capsule  is  much  thickened  and  is  the  seat  of  inflamma- 
tory foci.  The  inflammation  has  extended  beyond  the 
capsule  into  the  adjacent  fat.  Two  moderately  large 
caseous  masses  lie  in  the  capsule,  and  appear  entirely  dis- 
tinct from  the  inflammatory  process.  The  capsule  con- 
tains numerous  small  round  cells  and  young  connective- 
tissue  cells. 

The  glands  were  not  examined  for  tubercle  bacilli 
while  fresh,  as  it  was  intended  to  stain  for  them  after- 
ward in  the  sections.  The  difficulty,  however,  experi- 
enced in  cutting  the  sections  thin  forced  me  to  resort  to 
another  procedure.  I  thoroughly  scraped  the  cut  sur- 
faces of  the  hardened  gland,  dissolved  the  scrapings  in  a 
dilute  solution  of  liquor  potassse,  fixed  the  sediment  to 
slides  with  the  ordinary  albumin  fixative,  and  after  sev- 
eral attempts  found  the  bacilli.  Hence  there  can  be  no 
doubt  as  to  the  nature  of  the  process. 

The  integument  and  buccal  mucous  membrane  were 
carefully  examined  for  evidences  of  discoloration  without 
finding  any  but  the  normal  pigment  deposits. 

No  sufficient  cause  for  death,  aside  from  the  condition 
of  the  adrenals,  was  found  at  the  autopsy. 
<  It  is  impossible  to  fix  upon  the  duration  of  the  illness, 
because  the  history  is  so  incomplete.  The  Chambers 
Street  Hospital  is  merely  a  reception  hospital  for  medi- 
cal cases,  so  the  patient  was  transferred  to  Bellevue  after 
a  few  days. 

The  most  important  conclusion  to  be  drawn  from  this 
case  is,  that  tuberculosis  of  the  adrenal  bodies,  per  se9 
though  both  glands  be  entirely  destroyed,  is  not  produc- 
tive of  skin  discoloration. 

According  to  Wilks,1  "  we  have  no  data  by  which  to 
determine  the  time  necessary  for  the  deterioration  of 
the  capsules.  It  is  probable  that  this  is  very  lengthened, 
and  judging  from  the  cretaceous  deposit,  it  is  fair  to  con- 
jecture that  the  disease  is  extended  over  many  years." 

There  can  hardly  be  any  question  as  to  the  seat  of 
primary  infection  in  this  case.  The  appearances  pre- 
sented by  the  adrenal  bodies  leave  no  doubt  that  they 
became  involved  prior  to  the  lungs  or  bronchial  glands. 
Whether  the  disease  in  the  latter  situations  was  secondary 
to  that  in  the  adrenals,  or  whether  the  infection  was  pri- 
mary from  without,  is  an  open  question. 

I  have  examined  systematically  the  adrenal  bodies  in 
all  the  autopsies  I  have  performed  at  Bellevue  Hospital 
during  the  last  two  years,  and  this  is  the  first  instance  in 
which  I  have  found  them  to  be  tuberculous,  though 
many  of  the  cases  have  shown  extensive  tuberculosis  in 
other  parts  of  the  body. 

In  conclusion,  I  wish  to  express  my  thanks  to  Dr.  E. 
S.  Farrington,  formerly  house  physician  on  the  fourth 
medical  division  of  Bellevue,  and  to  Dr.  F.  F.  Russell, 
his  junior,  for  the  kindly  interest  they  took  in  furnish- 
ing me  with  such  facts  in  the  case  as  were  at  their  dispo- 
sal, and  the  notes  of  the  autopsy. 

5  West  Thirtieth  Street. 


A  State  Medical  Law  in  Idaho. — At  the  session  of  the 
Idaho  State  Medical  Society,  held  in  September,  the 
question  of  a  State  Board  of  Examiners  was  discussed, 
and  a  resolution  passed  urging  the  legislature  to  appoint 
such  a  board  during  the  coming  winter.  A  committee 
was  appointed  to  draw  up  a  bill  for  a  medical  practice 
act,  after  the  model  of  that  in  force  in  Washington.  Drs. 
Sweet,  Watkins,  Moore,  Maxey,  and  Fairchild  were 
nominated  to  represent  the  Society  upon  this  board  when 
created. 

»  Reynolds's  System  of  Medicine,  Article  Addison's  Disease. 


November  3,  1894] 


MEDICAL    RECORD. 


553 


TUBERCULOSIS   OF   THE   FRONTAL  SINUS. 
By  J.  FRANK,  M.D., 

SUXGBON  TO  THB  COOK  COUNTY  AND  ST.   ELIZABETH  HOSPITALS* 
AND 

S.  KUNZ,  M.D., 

CHICAGO,   ILL. 

Diseases  of  the  frontal  sinuses  are  of  interest  on  account 
of  their  infrequent  occurrence.  In  the  past  fifteen  years 
there  have  been  ninety-five  cases  reported,  the  analysis 
of  which  will  follow. 

Family  history  of  the  patient:  The  father,  who  is 
sixty- eight  years  of  age,  was  not  expected  to  live  when 
thirty-three,  physicians  having  diagnosed  his  case  as  pul- 
monary tuberculosis.  The  mother  is  fifty-eight  years  of 
age,  and  in  good  health.  Two  brothers ;  one  of  them 
mil,  the  other  had,  about  five  years  ago,  some  lung 
trouble;  diagnosis  of  same  not  known.  Two  cousins 
died  of  tuberculosis. 

Patient's  history :  Twenty-eight  years  of  age,  married, 
5  feet  8  inches  tall,  and  weighs  160  pounds.  Has  al- 
ways been  in  fairly  good  health  up  to  a  year  ago,  when 
he  began  to  lose  in  weight,  had  severe  headaches,  last- 
ing for  a  day  or  two,  recurring  every  week,  the  intervals 
being  entirely  free  from  any  ill  feeling.  He  continued 
in  this  way  for  three  months,  when  he  complained  of  the 
pressure  of  his  hat  across  the  forehead ;  he  would  fre- 
quently tilt  his  hat  back  and  thereby  gain  relief.  Three 
months  later  he  consulted  a  physician  for  some  growth 
on  the  left  side  of  the  forehead,  which  lasted  three 
weeks.  At  about  the  same  time  the  patient  noticed  a 
swelling  in  the  region  of  the  right  frontal  sinus,  which 
caused  him  incessant  pain.  Hot  fomentations,  nasal 
douches,  and  anodynes  were  given,  with  no  apparent 
relief.  On  the  morning  of  June  16th,  the  patient  no- 
ticed that  his  right  eye  was  partially  closed,  and  the 
upper  lid  was  inflamed  and  painful.  Dr.  Frank  was  then 
requested  to  see  the  patient,  who  found,  in  addition  to 
the  above-mentioned  facts,  that  the  right  eye  was  pushed 
downward  to  a  slight  extent ;  vision  was  not  impaired. 
On  outer  right  side  of  nose  there  was  a  faint  blush 
creeping  gradually  toward  the  inner  cantbus,  and  min- 
gling there  with  the  redness  of  upper  lid.  The  patient 
had  a  temperature  of  iooj^0  F.;  pulse,  96.  Kidneys 
and  heart,  negative  ;  fingers  are  clubbed.  About  meatus 
urinaris,  a  tubercular  ulcer  was  found,  which  healed 
promptly  upon  application  of  europhen.  The  lungs  on 
auscultation  revealed  vesiculo  -  bronchial  breathing ; 
rhinoscopic  examination  gave  negative  results.  A  mild 
anodyne  was  given,  and  the  patient  was  kept  under  ob- 
servation. Four  days  later  he  was  again  examined,  and 
in  palpating  the  upper  lid  a  fluctuating  mass  was  discov- 
ered in  the  region  of  the  lachrymal  gland.  Temperature 
was  ioo°  F.;  pulse,  96.  Operation  was  advised,  and  on 
June  26th  was  performed  in  the  presence  of  Drs.  Verity 
and  Edmunds,  and  assisted  by  Dr.  S.  Kunz.  A  curved 
incision  was  made,  starting  about  half  an  inch  to  the  left 
of  the  glabella,  and  extending  to  a  point  half  an  inch 
posterior  to  the  external  angular  process,  the  incision 
being  made  down  to  the  bone  and  one-fourth  of  an  inch 
above  the  eyebrow.  The  pericranium  was  found  thick- 
ened, the  tissues  having  been  pushed  back,  and  the  bone 
over  frontal  sinus  being  roughened.  The  sinus  was 
opened  with  a  hammer  and  chisel,  and  in  the  sinus  there 
was  found  a  yellowish  cheesy  mass,  which  was  removed 
with  a  sharp  spoon.  On  the  posterior  wall  of  the  sinus 
there  was  found  a  focus,  which  had  almost  gained  access 
to  the  vault.  This  focus  was  removed  by  the  sharp 
spoon,  and  a  small  portion  of  the  dura  was  all  but  ex- 
posed. At  the  right  lower  angle  of  the  sinus,  a  small 
channel  was  found,  which,  upon  being  followed  out,  led 
the  way  to  the  fluctuating  mass  in  the  upper  lid.  The 
tissues  now  being  pushed  over  the  supraorbital  arch,  the 
fluctuating  mass  was  reached,  and  was  found  to  be  about 
one  drachm  of  yellowish  pus,  coming  from  the  frontal 
sinus  by  means  of  a  small  channel  on  the  inner  surface 
of  the  frontal  bone  already  described.    The  supraorbital 


arch  was  found  diseased  throughout  its  entire  extent ; 
four  foci  were  found,  which  had  undergone  cheesy  de- 
generation. The  entire  arch  was  chiselled  away,  the 
soft  tissues  being  thoroughly  scooped ;  the  right  nasal 
cavity  was  also  scooped  out  through  the  frontal  sinus  by 
means  of  a  small  spoon.  The  sinus  was  packed  with 
iodoform  gauze,  extending  into  the  right  nasal  cavity, 
and  the  wound  sewed  up  with  interrupted  silk  sutures. 

The  wound  was  entirely  healed  on  the  eighth  day, 
with  the  exception,  of  course,  of  the  part  immediately 
above  the  sinus.  The  air  sinus  lasted  to  the  eighteenth 
day,  when  it  also  clc«ed  up.  The  patient  felt  free  from 
pain  from  the  day  of  the  operation,  and  his  temperature 
was  normal  after  the  first  day  of  operation. 

Anatomy  of  the  Frontal  Sinuses. — The  frontal  bump, 
as  it  is  termed,  does  not  exist  in  childhood,  as  the  tables 
of  the  frontal  bone  do  not  separate  until  after  puberty. 
Absence  of  the  bump,  even  in  middle  age,  does  not  nec- 
essarily imply  absence  of  the  sinus,  since  it  may  be  formed 
by  a  retrocession  of  the  inner  wall  of  the  skull.  An 
adult,  especially  an  elderly  person,  may  have  a  large 
frontal  sinus,  without  any  external  indication  of  it. .  A 
very  prominent  bump  does  not  necessarily  imply  the  ex- 
istence of  a  large  sinus,  or  even  a  small  one.  The  bump 
may  be  a  mere  heaping  up  of  bone,  a  degradation,  as  is 
often  found  in  Australian  skulls. 

The  cavities  are  larger  in  men  than  in  women,  the 
left  being  commonly  the  larger.  They  are  lined  by  mu- 
cous membrane,  and  communicate  with  the  nose  by  the 
infundibulum  and  occasionally  with  each  other  by  aper- 
tures in  their  septum. 

In  the  ninety- five  cases  reported,  we  find  the  follow- 
ing etiological  factors:  Mucocele,  24  cases;  abscess, 
51,  3  of  them  being  double ;  fracture,  1 ;  foreign  body, 
1 ;  injury,  1  ;  exostosis,  1 ;  osteoma,  7  ;  tumors,  3  ; 
cholesteatoma,  1 ;  polypi,  2 ;  periostitis,  1 ;  cyst,  2. 

In  the  cases  reported  as  mucoceles,  is  it  not  possible 
that  some  of  them  at  least  were  of  tubercular  origin  ? 
Had  the  contents  of  the  sinuses  been  examined  for  bacilli, 
tuberculosis  of  the  frontal  sinus  would  be  more  often 
heard  of. 

Through  the  kindness  of  Dr.  T.  Gramm,  the  bone  chips 
from  the  arch  were  examined  for  bacilli,  the  cheesy 
masses  and  foci  having  been  accidentally  lost ;  although 
no  bacilli  were  found  there  seems  to  be  no  doubt  about 
the  diagnosis,  from  the  character  of  the  cheesy  masses 
found  in  the  sinus,  from  the  cheesy  foci  in  the  bone, 
from  the  yellowish  pus  found  in  the  cellular  tissue  of  up- 
per eyelid,  and  from  the  history  of  patient. 

The  various  methods  of  operation  are  about  the  same, 
with  the  exception  of  the  drainage,  vulcanite  rubber  or 
soft  rubber  being  used  oftenest,  but  where  these  were 
used  the  air  sinus  remained  for  a  long  time,  some  even 
necessitating  a  plastic  operation  for  their  closure,  the 
average  length  of  time  of  duration  of  air  sinus  being 
about  eight  weeks. 

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554 


MEDICAL  RECORD. 


[November  3,  1894 


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1893. 
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Collier:  London  Lancet,  i.,  p.  304. 


CHOLECYSTOTOMY  AND  CHOLECYSTECTO- 
MY FOR  STONE  IMPACTED  IN  THE  CYS- 
TIC DUCT. 

By  MAURICE  H.  RICHARDSON,  M.D., 

VISITING    SURGEON  TO    THE    MASSACHUSETTS    GSNEJtAL    HOSPITAL;    ASSIST  AWT 
PROFBSSOB  OF  ANATOMY,  HARVARD  MEDICAL  SCHOOL. 

The  two  following  cases  seem  of  sufficient  rarity  and 
interest  to  be  placed  on  record,  for  in  a  somewhat  ex- 
tensive experience  in  the  surgery  of  the  gall-bladder  the 
writer  has  seen  only  those  in  which  the  symptoms  de- 
pended upon  the  impaction  of  a  single  large  stone  in 
the  cystic  duct,  and  in  which  the  diagnosis  was  so  ob- 
scure that  movable  kidney  was  supposed  to  be  present  by 
several  diagnosticians.  In  both  cases  the  distended  gall- 
bladder, which  could  be  felt  through  the  abdominal  wall, 
was  so  tense  and  so  movable  as  to  suggest  very  strongly 
a  floating  kidney.  In  one  case  the  symptoms  were  caused 
by  a  large  stone,  the  removal  of  which,  owing  to  its  long 
and  firm  impaction  in  the  cystic  duct,  was  accomplished 
only  by  complete  extirpation  of  the  gall-bladder  and 
cystic  duct.  In  the  other  the  stone  was  detached,  after 
prolonged  effoits,  through  the  gall-bladder  itself.  In 
both  cases  a  very  gratifying  recovery  followed. 

Case  I. — Tumor  in  the  right  side  of  the  abdomen  sug- 
gesting movable  kidney ;  absence  of  pain  and  of  other 
symptoms  of  biliary  obstruction ;  tumor  found  to  be  di- 
lated gall  bladder,  with  large  stone  impacted  in  the  cystic 
duct;  cholecystotomy ;  cholecystectomy;  recovery. 

Mrs.  W.  C ,  aged  thirty- two,  was  admitted  to  the 

Massachusetts  General  Hospital  on  June  9,  1894.  She 
was  brought  to  me  on  May  10,  1894,  by  Dr.  Zatae  Longs- 
dorff-Straw,  of  Manchester,  N.  H.,  with  the  following  his- 
tory. Has  had  five  children,  the  youngest  aged  three  and 
a  half.     She  was  well  up  to  a  year  and  a  half  ago,  when 


slight  irregularities  in  menstruation  began.  With  each 
period  there  was  pain  and  tenderness,  suggesting  a  mild 
localized  peritonitis.  During  the  past  year  there  have 
been  three  severe  attacks  of  what  seemed  to  be  a  local- 
ized peritonitis  with  symptoms  .referred  at  one  time  to 
the  right,  at  others  to  the  left  hypochondrium.  In  one 
of  these  attacks  there  was  general  distention  and  tender- 
ness. In  December,  1883,  Dr.  Straw  discovered  a  kid- 
ney shaped  tumor,  somewhat  movable,  in  the  right  side 
of  the  abdomen  at  the  level  of  the  umbilicus.  The  tu- 
mor was  supposed  to  be  a  movable  kidney.  No  surgical 
interference  seemed  advisable.  During  the  next  few 
months  there  was  a  rapid  increase  in  the  size  of  the  tu- 
mor ;  it  grew  more  tender  and  more  movable,  at  one 
time  extending  toward  the  right  groin.  The  idea  of  a 
tubal  pregnancy  was  for  a  moment  entertained.  The 
mobility  was  so  great  that  the  tumor  could  be  pushed 
well  over  to  the  left  side  of  the  abdomen.  No  constitu- 
tional disturbance  complicated  the  condition,  though 
there  was  marked  local  pain  and  soreness.  There  had 
been  some  loss  of  weight. 

I  found  a  small  oval,  tender,  non-  fluctuating  tumor  in 
the  right  side,  under  the  liver,  at  the  normal  position  of 
the  gall-bladder.  At  first  it  seemed  very  evidently  a 
movable  kidney.  Under  prolonged  and  repeated  exam- 
inations the  fundus  of  the  tumor  was  found  to  move  in 
the  arc  of  a  circle  about  the  attachments  of  the  gall-blad- 
der. 

In  this  case  the  question  of  movable  kidney  was  first 
considered.  With  the  patient  in  dorsal  decubitus  a 
movable  tumor  could  be  felt  in  the  right  renal  region. 
It  could  be  grasped  between  the  hands  on  deep  inspira- 
tion, slipping  upward  apparently  into  the  usual  position 
of  the  kidney  on  loosening  the  digital  grasp.  The  slight 
force  necessary  to  retain  the  tumor  between  the  fingers 
caused  some  complaint  of  pain.  In  the  erect  posture 
nothing  could  be  felt.  The  urine  was  normal  Re- 
peated examinations  showed  that  the  tumor  could  be 
moved  in  all  directions  about  the  normal  position  of  the 
gall-bladder.  This  kind  of  mobility,  differing  materially 
from  that  of  a  movable  kidney,  suggested  strongly  a  di- 
lated gall-bladder,  especially  since  the  other  physical 
characteristics  were  not  incompatible  with  the  latter  con- 
dition. The  absence  of  jaundice  did  not  vitiate  the  diag- 
nosis of  obstruction  to  the  cystic  duct,  nor  did  the  nor- 
mal urine  preclude  the  possibility  of  movable  kidney. 
Perhaps  the  strongest  sign  in  favor  of  the  gall-bladder  as 
the  seat  of  the  disease  was  the  direction  in  which  the 
tumor  could  be  moved.  In  a  slightly  movable  kidney 
the  only  variation  in  position  that  can  be  detected  is  the 
downward  dislocation.  If  the  kidney  can  be  moved  into 
the  epigastrium  its  downward  displacement  will  be  found 
excessive.  In  gall-bladder  dilatation,  on  the  contrary, 
the  fundus  will  be  found  no  farther  from  the  centre  of  at- 
tachment in  one  direction  than  in  another.  That  the 
kidney  should  wander  farther  in  the  downward  direction 
than  in  the  upward  is  natural,  considering  the  viscera 
which  hinder  upward  displacement.  In  the  shape  and 
size  of  the  tumor,  too,  there  are  points  of  difference, 
though  they  may  not  be  always  present.  An  oval  shape, 
smooth  and  uniform  walls,  absence  of  hilum,  etc.,  favors 
the  gall  bladder.  In  spite  of  every  precaution,  however, 
it  will  be  found  at  times  difficult  to  distinguish  between 
the  two  conditions,  and  preparations  must  be  made  to 
meet  both  at  operation. 

The  diagnosis  was  made  of  an  obstruction  in  the  cys- 
tic duct  On  opening  the  abdomen  in  the  right  linea 
semilunaris,  over  the  tumor,  a  very  large  gall  bladder, 
distended  almost  to  bursting,  was  found.  The  contents 
were  removed  by  aspiration  until  the  lax  and  distended 
walls  of  the  gall-bladder  were  easily  delivered  through 
the  wound.  The  cause  of  the  trouble  was  found  to  be  a 
large  stone  impacted  in  the  cystic  duct.  The  fluid  in 
the  gall-bladder  was  perfectly  colorless,  the  biliary  pig- 
ments having  been  absorbed,  as  is  usual  in  cases  of  long- 
continued  obstruction  at  the  cystic  duct  with  dilatation 
of  the  gall-bladder.    With  one  finger  of  the  right  hand 


November  3,  1894] 


MEDICAL   RECORD. 


555 


in  the  gall  bladder,  and  with  the  fingers  of  the  left  out- 
side the  duct,  prolonged  efforts  were  made  to  dislodge 
the  stone.  This  proved  impossible,  however,  although 
the  calculus  could  be  plainly  felt  both  inside  and  outside. 
I  was  therefore  finally  obliged  to  lay  open  the  duct  and 
to  detach  the  stone  through  the  wound.  The  roughened 
surface  of  the  calculus  was  so  intimately  connected  with 
the  changed  structures  of  the  duct  that  it  was  even  then 
hard  to  lift  the  stone  from  its  bed.  It  seemed  best, 
therefore,  in  view  of  the  great  laceration  of  the  parts,  to 
remove  the  gall-bladder  and  duct  entirely.  This  was 
done  by  passing  a  ligature  about  the  duct  just  below  the 
incision  through  which  the  stone  had  been  removed.  A 
small  gauze  drain  was  placed  next  the  ligature  and  the 
external  wound  was  closed,  except  for  about  an  inch. 
This  patient  made  a  rapid  recovery,  and  was  discharged 
on  July  21,  1894. 

Case  II. — Paroxysmal  pain  in  the  hepatic  region,  with- 
out jaundice,  for  three  years ;  tumor ;  cholecystotomy ; 
removal  of  great  numbers  of  stones  from  the  gall-blad- 
der, with  one  large  stone  impacted  in  the  cystic  duct ; 
drainage;  recovery. 

Mrs.  S.  B.  M ,  aged  twenty-five,  trained  nurse  for 

Dr.  Donnel  Hughes,  of  Philadelphia,  who  was  present 
at  the  operation.  Examined  on  July  13,  1894.  First 
suffered  from  cramps  in  the  stomach  three  years  ago. 
They  were  transitory  and  seemed  of  little  importance. 
At  first  the  attacks  of  pain  returned  at  intervals  of  sev- 
eral months,  but  within  the  last  six  they  have  occurred 
frequently  —  often  seven  times  in  two  weeks.  When 
suffering  from  the  pain,  which  is  always  located  in  the 
right  side,  the  patient  is  doubled  up;  relief  has  been  ob- 
tained only  by  the  use  of  morphine.  After  the  cessation 
of  this  distress  or  agony  there  is  a  transient  soreness 
which  extends  into  the  back.  There  has  never  been  any 
jaundice.  The  exact  region  of  the  gall-bladder  was  in- 
dicated as  the  seat  of  pain. 

On  examination  I  found  on  the  right  side  below  the 
margin  of  the  ribs  and  opposite  the  cartilages  of  the 
ninth  and  tenth,  a  tumor  oval  in  shape,  hard,  tense, 
unfluctuating,  movable,  and  tender.  From  physical  ex- 
amination alone  it  would  have  been  impossible  to  dis- 
tinguish between  a  tumor  of  the  gall-bladder  and  one  of 
the  kidney  if  it  had  not  been  for  the  two  following  facts : 
first,  the  presenting  rounded  extremity  of  the  tumor 
moved  through  the  arc  of  a  circle,  the  base  of  which  was 
somewhere  near  the  usual  attachments  of  the  cystic  duct ; 
secondly,  the  urine  was  perfectly  normal. 

The  pain,  described  as  transitory  and  resembling  colic, 
was  quite  as  suggestive  of  renal  as  of  cholecystic  disease. 
The  peculiar  kind  of  mobility  was  not  incompatible  with 
a  floating  kidney,  although  it  seemed  to  me  more  like 
die  mobility  of  a  dilated  gall-bladder  than  like  that  of  a 
movable  kidney. 

The  patient  was  advised  to  submit  to  operation,  and 
she  entered  St.  Margaret's  on  July  29,  1894.  Under 
ether  we  obtained  a  much  more  satisfactory  examination, 
by  which  almost  all  doubts  as  to  the  nature  of  the  dis- 
ease were  dispelled.  It  was  very  evident  that  the  tumor 
was  a  gall-bladder  and  not  a  kidney. 

Assisted  by  Dr.  Brewster,  I  began  the  operation  by  a 
small  incision  at  the  cartilaginous  border  of  the  ninth 
rib,  along  the  outer  border  of  the  rectus  abdominis. 
The  tumor  immediately  presented  itself  in  the  wound, 
with  the  sharp  edge  of  the  great  lobe  of  the  liver,  and  it 
proved  to  be  the  gall-bladder.  Its  walls  were  tense  and 
very  much  thickened.  The  presenting  extremity  was 
sewed  into  the  small  abdominal  wound,  and  the  gall- 
bladder was  opened.  A  large  number  of  gall-stones  of 
all  sizes,  with  a  clear,  viscid  fluid,  were  washed  out. 
The  state  of  distention,  with  the  altered  character  of  the 
fluid,  made  it  very  evident  that  there  was  an  impediment 
in  the  cystic  duct,  though  no  stone  had  been  removed 
large  enough  to  cause  so  firm  and  so  effective  an  obstruc- 
tion. Nothing  could  be  felt  in  the  cystic  duct,  with  the 
finger  in  the  gallbladder.  The  parts  were  carefully 
dried  by  means  of  aseptic  gauze,  and  the  stitches  by 


which  the  gall-bladder  had  been  attached  to  the  abdom- 
inal wound  were  removed.  Explorations  with  the  finger 
'in  the  peritoneal  cavity  then  revealed  a  large  stone  deep 
down  in  the  cystic,  near  the  common  duct.  By  biman- 
ual palpation  the  stone  was  slowly  and  with  difficulty 
started  from  its  bed  and  delivered  through  the  gall  blad- 
der. Very  soon  after  the  removal  of  this  stone  the  col- 
ored bile  from  the  gall-bladder  showed  that  the  cystic 
duct  was  now  patent.  The  gall- bladder  was  again 
stitched  to  the  wound  and  drained  by  means  of  rubber 
tube  and  sterile  gauze. 

Though  the  prognosis  seemed  almost  hopeless  to  some 
of  those  who  were  present,  the  patient  made  a  rapid  re- 
covery, without  a  single  unfavorable  symptom.  She  was 
discharged  well  in  three  weeks,  and  on  August  31, 1894, 
she  wrote  as  follows:  "lam  getting  along  very,  very 
nicely,  and  feel  better  than  I  have  felt  for  years,  and  am 
gaining  every  day.  I  haven't  an  ache  or  a  pain,  and  my 
side  is  entirely  healed,  and  there  is  scarcely  any  soreness 
inside.11 

In  these  cases  the  diagnosis  was  interesting.  The  cor- 
rectness depended  more  upon  the  situation  and  the  kind 
of  mobility  than  upon  anything  else  in  the  physical  ex- 
amination or  in  the  history.  An  interesting  point  in 
connection  with  these  cases  is  the  character  of  the  fluid. 
In  the  first  and  only  previous  case  in  which  I  had  noted 
this  symptom  *  the  gallbladder  contained  about  a  quart 
of  perfectly  colorless,  limpid  fluid.  Whether  this  fluid  is 
decolorized  bile  or  simply  the  accumulation  of  secretions 
from  the  mucous  membrane  I  am  unable  to  say.  In  view 
of  the  fact  that  in  most  cases  of  obstruction  with  jaundice 
the  bile  is  thick  and  dark  in  color,  it  would  seem  that  the 
presence  of  such  fluid  indicates  a  complete  and  protracted 
shutting  off  of  the  gall-bladder  from  the  biliary  passages. 
At  all  events,  the  existence  of  this  symptom  is  a  very 
clear  indication  that  there  is  a  complete  obstruction  in 
the  cystic  duct.  With  an  obstruction  in  the  cystic  duct, 
however,  it  does  not  follow  that  there  is  not  also  an  ob- 
struction in  the  common  duct.     This  combination  was 

illustrated  in  the  case  of  C.  C.  R ,  above  referred  to, 

in  which  the  disease  proved  to  be  cancer  of  the  head  of 
the  pancreas  extending  into  the  region  of  the  cystic  duct, 
obstructing  the  latter  as  well  as  the  common  duct. 

In  operating  upon  a  distended  gall-bladder  the  subse- 
quent manipulations  are  very  much  facilitated  by  aspira- 
tion. In  both  the  cases  reported  it  was  very  hard  to  feel 
the  stones  or  to  examine  the  cystic  duct  when  the  tumor 
first  presented  itself.  On  withdrawing  a  few  ounces  of 
fluid,  the  collapsed  gall  bladder  could  be  brought  into 
and  out  of  the  wound  with  the  greatest  facility.  The 
subsequent  manipulations  were,  therefore,  very  easy  and 
simple,  even  to  the  ligation  of  the  cystic  duct. 

These  cases,  which  perhaps  in  some  respects  may  be 
deemed  difficult,  both  as  to  diagnosis  and  as  to  surgical 
treatment,  recovered  without  any  untoward  symptoms. 

Operations  upon  the  gall- bladder  undertaken  when  the 
patient  is  in  good  health,  before  the  obstruction  has  ex- 
tended so  as  to  check  the  escape  of  bile  through  the  com- 
mon duct,  and  before  the  patient's  vitality  has  been  im- 
paired by  prolonged  illness,  are  followed  by  the  most 
brilliant  and  gratifying  results.  Undertaken  for  pro- 
longed jaundice,  however,  especially  when  it  is  necessary 
to  remove  from  the  common  duct,  a  stone  of  the  size, 
roughness,  and  fixity  of  that  in  Case  I.,  these  operations 
are  inevitably  attended  by  a  very  considerable  mortality.3 
As  in  the  removal  of  the  vermiform  appendix  when  there 
is  neither  local  nor  general  peritoneal  extravasation  the 
mortality  is  practically  nothing,  so  in  operations  upon 
the  gall-bladder  before  the  severity  of  the  local  condition 
requires  the  more  formidable  surgical  manipulations,  and 
before  the  long- continued  impactions  have  resulted  in  the 
presence  of  pathogenic  bacteria  and  the  infection  of  the 
biliary  passages,  the  results  are  gratifying  in  the  extreme. 

»  Case  I.    C.  C.  R ,  Boston  Medical  and  Surgical  Journal  of 

April  28,  1893. 

•  Vide  paper  by  J.  W.  Elliot  in  the  Boston  Medical  and  Surgical 
Journalf 


556 


MEDICAL   RECORD. 


[November  3,  1894 


The  deplorable  results  in  gall-bladder  surgery  which  are 
sometimes  unjustly  placed  at  the  door  of  the  surgeon  arise 
from  our  failure  to  heed  the  warning  of  the  disease  in  its 
incipiency — in  our  neglect  to  remove  the  source  of  future 
disasters  at  a  time  when  the  procedure  may  be  accom- 
plished with  very  slight  danger.  Hence  it  seems  to  the 
surgeon  folly,  in  cases  of  repeated  and  persistent  biliary 
obstruction,  to  attempt  the  removal  of  gall  stones  by* 
medicinal  means.  Sooner  or  later  in  most  cases  a  stone 
gets  impacted  in  one  place  or  another.  It  grows,  be- 
comes rough,  and  not  easily  detachable,  and  finally,  if  it 
does  not  cause  death  by  sudden  rupture  into  the  peri- 
toneum, the  grave  symptoms  to  which  it  gives  rise  con- 
vince even  the  most  conservative  of  the  necessity  of  an 
operation — an  operation  which  then  must  be  done  under 
the  most  unfavorable  conditions,  and  with  a  prognosis 
infinitely  graver  than  in  the  early  days  of  the  disease. 


EPILEPSY— AT    TIMES  A  BLADDER  REFLEX.1 
By  HUGH  K.  AIKEN,  M.D., 

LAUMpS,  S.  C» 

If  you  consult  any  work  upon  the  subject  of  the  "  Causes 
of  Epilepsy"  the  first  statement  you  meet  will  be  that 
heredity  plays  the  most  important  part  as  a  predisposing 
cause.  Then  follows  the  well-authenticated  fact  that 
peripheral  irritation  of  various  kinds  will  inaugurate  and 
keep  up  the  paroxysms.  There  is  also  a  group  of  what 
we  may  call  central  or  systemic  causes  producing  the 
epilepsy  that  follows  diphtheria,  scarlet  fever,  malaria, 
tertiary  syphilis,  strong  mental  impressions,  as  excessive 
joy,  grief,  or  anger.  All  these  factors  and  others  have  by 
trustworthy  observers  been  reported  as  first  producing 
the  disease.  But  most  interesting  of  all  the  foregoing 
is  the  study  of  those  cases  in  which  epilepsy  stands  out 
clearly  as  a  reflex,  and  while  cases  the  result  of  reflex  ir- 
ritation from  several  organs  have  been  recorded,  the 
writer  has  never  seen  attention  called  to  this  particular 
reflex  as  a  causative  agent  of  any  importance.  The  few 
cases  to  be  cited  would  at  least  seem  to  prove  that  some- 
times, when  otherwise  unable  to  account  for  the  seizures, 
investigation  in  this  locality  might  be  successful  and 
thus  some  light  be  shed  upon  what  would  else  remain 
obscure. 

There  may  be  some  who  will  regard  as  superfluous  any 
further  contribution  to  the  literature  of  a  disease  of  whose 
symptomatology  we  already  know  so  much  and  whose 
etiology  is  so  varied.  But  our  treatment  remains  pain- 
fully deficient.  The  criticism  of  such  readers  reduced  to 
few  words  is  always  "  If  you  have  not  some  new  remedy 
to  offer  us,  be  silent'1  Such  critics  overlook  the  fact 
that  the  mastery  of  etiology  is  the  first  step  to  satisfac- 
tory therapy.  Finding  the  cause  and  removing  it  is  the 
ideal  of  scientific  practice. 

Reading  a  journal  article  recently  on  "Suprapubic 
Cystotomy,"  I  was  struck  by  the  following,  which  I  will 
call 

Case  I.—"  A.   M.   W ,  aged  twenty,  one.     Ten 

years  ago  this  patient  was  suddenly  attacked  with  an  ur- 
gent desire  to  urinate,  which  he  could  not  explain.  This 
irritation  has  persisted  ever  since.  Three  years  after  the 
onset  of  this  attack  he  became  subject  to  epileptic  seiz- 
ures, which  would  occur  about  once  a  month  and  in 
some  manner  seemed  to  be  associated  with  his  vesical 
trouble.  .  .  .  Since  the  latter  has  been  relieved  the 
convulsions  have  ceased." 

This  extract  reminded  me  of  a  personal  experience 
which  constitutes 

Case  II. — Miss  E.  C ,  aged  thirty-eight,  had  been 

ill  eighteen  days  with  typhoid  fever.  I  had,  in  a  per- 
functory manner,  been  examining  the  bladder  daily  and 
never  found  it  distended.  In  the  middle  of  the  night  I 
was  hastily  summoned,  and  informed  that  my  patient 
was  having  convulsions.  She  had  two  after  I  reached 
her.    Briefly  described  they  were  as  follows :  Coincident 

1  Read  before  the  Laurens  County  Medical  Society,  July  34;  1894. 


with  a  momentary  loss  of  consciousness  a  wave  of  mus- 
cular spasm  would  pass  over  her,  and  then  in  an  anxious 
tone  she  would  ask,  "  Doctor,  what  is  the  matter  with 
me  ?  "  I  was  puzzled.  Groping  about  to  find  a  cause, 
I  felt  over  the  bladder  region  and  found  the  organ  fulL 
The  catheter  was  used  at  once.  She  had  no  more  con* 
vulsions,  nor  has  she  had  any  since.  No  antispasmodics 
were  given. 

What  were  these  epileptic  explosions  if  not  the  result 
of  irritation  of  the  hypogastric  or  sacral  plexus  ? 

Case  III. — Muscroft  reports  a  case  of  stone  in  the 
bladder  which  gave  rise  to  epilepsy  and  a  cure  followed 
its  removal.1 

If  phymosis  causes  infantile  paralysis,  may  not  irrita- 
tion of  the  vesical  nerves  give  rise  to  epileptic  seizures? 
I  do  not  lay  claim  to  any  great  discovery  in  connection 
with  the  cause  of  epilepsy,  and  only  record  my  limited 
observations  as  a  working  hypothesis  by  means  of  which 
something  more  valuable  may  perhaps  be  brought  out. 
The  modesty  and  diffidence  with  which  I  would  advance 
this  view  will,  I  hope,  save  me  from  the  rapacity  01J 
those  fierce  critics  who  delight  to  prick  each  little  bal- 
loon labelled  "  Theory  "  just  to  see  the  gas  escape. 

If  occasionally  epilepsy  be  due  to  irritation  about  the 
bladder,  this  fact  should  be  borne  in  mind,  and  this  is 
all  I  wofild  insist  upon.  I  feel  ashamed  of  our  boasted 
advances  in  therapeutics  every  time  a  case  applies  for 
treatment.  Every  unrelieved  sufferer  from  this  disease  is 
a  reproach  to  our  profession,  and  if  we  are  ever  to  cure 
the  morbid  condition  the  energies  wasted  in  the  search 
for  some  new  compound  that  will  act  as  a  specific  must 
be  diverted  and  applied  to  finding  the  cause  at  work  in 
each  case  as  it  comes  to  us.  In  long-standing  cases  the 
best  I  have  ever  been  able  to  do  is  to  lessen  the  severity 
and  decrease  the  frequency  of  the  attacks  by  the  use  of 
sodium  bromide,  and  while  this  is  given  in  the  smallest 
dose  that  will  accomplish  the  purpose,  even  then  I  am 
deranging  my  patient's  stomach  and  impoverishing  his 
blood  by  the  forced  ingestion  of  an  excess  of  alkali. 

Trephining  has  not  achieved  the  results  at  first  ex- 
pected from  it.  The  cicatricial  mementos  of  youthful 
exploits  have  been  carefully  excised  and  buttons  of  bone 
removed.  At  first,  he  who  was  before  "  possessed  of  a 
devil "  went  his  way  and  perhaps  sinned  no  more,  but 
after  one  or  two  years  the  insidious  petit  mal  returned. 

Some  hold  that  an  operation  of  any  sort  upon  an 
epileptic  produces  a  temporary  improvement  in  his 
disease.  Tincture  of  horse-nettle  will  do  very  well  to 
sell  at  three  dollars  per  pint,  as  an  enterprising  (?)  practi- 
tioner in  Indiana  advises  me  he  is  willing  to  do,  but  I 
have  never  seen  any  considerable  number  of  cures  to  its 
credit.  The  profession  would,  no  doubt,  appreciate  any 
further  evidence  in  its  favor  from  Dr.  Napier,  of  Blen- 
heim, S.  C,  who  first  called  attention  to  this  agent  as  a 
remedy.  We  are  all  too  prone  to  prescribe  a  palliative 
and  dismiss  these  unfortunates  with  the  reflection  that  it  is 
a  case  of  idiopathic  epilepsy  and  beyond  the  reach  of  cura- 
tive effort.  If  we  would  associate  the  ideas  of  irritation 
and  epilepsy,  and  search  diligently  for  a  cause  in  every 
case,  removing  it,  where  possible,  the  number  of  idio- 
pathic and  inexplicable  cases  of  epilepsy  would  be  re- 
duced. There  is  irritation  somewhere  and  somehow- 
brought  about  but  not  always  connected  with  a  scar. 
Having  seen  the  explosion,  work  back,  following  the  fuse 
until  we  reach  its  beginning.  There  sit  and  watch  until 
you  see  what  it  is  that  applies  the  spark,  reasoning  back- 
ward from  effect  to  cause. 


Dr.  Bathianadhan,  the  first  and  only  native  woman 
novelist  in  India,  died  recently  at  the  age  of  thirty-one. 
Her  parents  were  Marathi  Brahmans ;  she  herself  was  a 
Christian  and  the  first  woman  to  study  medicine  at  the 
University  of  Madras.  Her  first  book  was  entitled 
"Saguna,"  a  picture  of  a  high-caste  girl's  home  life; 
another,  called  "Kamala,"  has  just  been  published. 
1  Wood's  Reference  Handbook,  vol.  it,  p.  706. 


November  3,  1894] 


MEDICAL    RECORD. 


557 


THE  MANAGEMENT  OF  VALVULAR  HEART 
DISEASE,  WITH  PARTICULAR  REFERENCE 
TO   THE  USE  OF  STRYCHNINE. 

BV  L.  HARRISON  METTLER,  AM.,  M.D., 

CHICAGO,  ILL. 

Valvular  diseases  of  the  heart  all  require  about  the  same 
line  of  treatment.  So  long  as  compensation  is  complete 
and  the  accompanying  hypertrophy  or  dilatation  does 
not  give  rise  to  any  very  marked  secondary  symptoms, 
medicines  should  be  withheld  entirely,  and  none  but 
general  instructions  given  in  regard  to  rest,  diet,  and 
hygiene.  I  do  not  deem  it  wise,  as  some  authors  do,  to 
inform  the  patient,  at  this  stage  of  his  trouble,  of  the 
seriousness  of  his  condition.  The  effect  is  apt  to  be  de- 
pressing, and  therefore  deleterious,  whereas  no  immediate 
benefit  is  to  be  obtained.  From  the  treatment  and  in- 
structions given  he  will  soon  enough  suspect  the  nature 
of  his  malady,  and  the  hope  born  of  uncertainty  will  in- 
duce him  to  follow  directions  more  closely  than  the  de- 
spair awakened  by  a  gloomy  prognosis.  I  make  it  a 
rule  always  to  inform  the  family.  If,  at  the  solicitation 
of  the  family  and  the  patient  himself,  I  am  obliged  to  tell 
him  the  real  state  of  his  condition,  I  do  so  most  guard- 
edly, making  the  prognosis  as  reasonably  hopeful  as 
possible,  but  not  belittling  in  one  iota  the  nature  of  the 
cardiac  lesion.  Only  in  this  way  is  confidence  estab- 
lished, and  in  certain  cases  a  foundation  laid  for  the 
proper  observance  of  the  treatment  deemed  necessary. 

Of  the  first  importance  is  rest.  Nothing  so  recuper- 
ates a  tired  heart  as  absolute  rest.  This  does  not  mean 
merely  to  lie  down  whenever  the  feeling  of  exhaustion  is 
experienced,  but  to  keep  regular  hours  in  regard  to  ris- 
ing and  retiring;  to  regulate  the  daily  exercise  so  that  it 
falls  short  of  producing  weariness;  to  adopt  the  proper 
kind  as  well  as  amount  of  exercise;  and  to  furnish 
the  mind  with  congenial  entertainment.  A  man  may 
declare  that  he  gets  abundant  exercise  by  walking  in  the 
open  air  all  day  in  connection  with  his  business.  There 
is  neither  pleasure  nor  variety  in  that  sort.  An  hour's 
stroll  over  the  rolling  ground  of  a  park  in  company  with 
a  congenial  friend,  with  mind  free  from  business  cares, 
will  do  more  than  a  day  of  the  former  kind  of  exercise. 
Gymnasia  are  to  be  very  cautiously  recommended,  for 
they  are  frequently  badly  ventilated,  and  competition 
with  the  other  attendants  is  liable  to  lead  to  over-exer- 
tion. Any  form  of  out-door  sport  may  be  approved  of 
so  long  as  no  sudden  or  violent  movements  are  required 
by  it.  The  stomach  must  never  be  overloaded,  and  the 
nutrition  must  be  kept  at  its  maximum ;  hence  frequent 
small  meals  rather  than  heavy  dinners  are  to  be  com- 
mended. Fats,  sugars,  and  succulent  vegetables  are  to 
be  indulged  in  very  sparingly.  The  nitrogeneous,  albu- 
minous foods  are  the  best.  As  a  rule,  I  find  that  patients 
do  better  when  they  take  as  little  fluid  into  the  system  as 
possible,  and  abstain  entirely  from  all  kinds  of  stimulat- 
ing drinks.  The  following  case  illustrates  the  benefit 
derived  from  the  observance  of  general  treatment  alone : 

Case  I.  Mitral  Regurgitation — J.  P ,  boy,  twelve 

and  a  half  years  of  age.  Family  history  excellent.  Has 
had  none  of  the  severe  diseases  to  which  all  children  are 
liable.  Three  years  before  he  first  came  to  me,  June  24, 
1893,  he  had  his  first  attack  of  acute  inflammatory  rheu- 
matism. The  ankles,  wrists,  and  other  joints  were  suc- 
cessively swollen,  painful,  and  immovable.  The  mother 
says  she  treated  the  child  herself,  chiefly  with  external 
applications.  Every  succeeding  winter  he  seems  to  have 
had  similar  attacks,  in  some  ofwhich  medical  attendance 
was  engaged.  Immediately  after  his  first  attack  his 
heart  began  to  trouble  him.  At  any  time,  most  fre- 
quently at  night,  so  as  to  arouse  him  out  of  his  sleep,  he 
will  experience  a  sharp,  intolerable,  lancinating  pain 
about  the  region  of  the  heart,  but  never  down  the  left  arm. 
Sometimes  this  pain  lasts  half  an  hour,  disappearing  as  sud- 
denly as  it  comes.  At  the  same  time  pains  start  up  all 
over  the  body,  chiefly  in  the  neighborhood  of  the  joints. 
These  pains  are  of  an  aching  character.    The  heart  then 


beats  laboriously  and  violently,  so  that  he  feels  as  though 
"  it  would  beat  out  of  his  body  entirely."  He  suffers 
continuously  from  a  slight  headache.  For  the  last  three 
years  he  has  not  been  able  to  lie  on  his  left  side  without 
bringing  on  an  attack  of  cardiac  pain  and  shortness  of 
breath.  There  seems  to  be  no  dyspnoea  under  other  cir- 
cumstances. Respiration  and  digestion  are  as  yet  unaf- 
fected. Appetite  is  ravenous  and  bowels  move  regularly. 
Micturition  is  normal.  Urine  is  pale  yellow,  feebly  acid, 
specific  gravity  1. 028,  with  an  excess  of  urates  and  earthy 
phosphates,  no  albumin,  no  sugar.  The  pendent  parts 
of  the  body,  such  as  the  lower  abdomen,  are  slightly  ery- 
thematous. Passing  the  finger-nail  firmly  over  the  skin 
produces  a  white  streak  which  slowly  disappears  before 
the  returning  redness.  The  feet  are  at  all  times  slightly 
swollen  and  cyanosed.  When  the  hands  are  allowed  to 
hang  down  for  sometime  they  also  become  slightly  swol- 
len and  congested.  Hearing  and  eyesight  are  good,  and 
there  is  no  congestion  of  the  conjunctivae.  He  is  very 
regular  in  all  his  habits,  but  has  been  indulging  in  violent 
exercise,  such  as  base-ball,  and  drinking  freely  of  tea  and 
coffee.  By  a  former  physician  his  family  was  told  that 
"something  was  growing  over  the  heart.'1  Upon  in- 
spection I  found  the  left  side  of  the  chest  decidedly  larger 
than  the  right,  and  the  intercostal  spaces  less  distinctly 
marked.  The  area  of  cardiac  dulness  was  considerably 
increased  and  the  apex-beat  of  the  heart  remarkably  pro- 
nounced. One  could  see  it  thumping  against  the  tho- 
racic wall  like  a  caged  creature  striving  to  get  free. 
Palpation  revealed  an  irregularly  acting,  throbbing, 
violently  beating  heart.  The  pulsations  were  jerky  and 
apparently  performed  with  much  effort.  Upon  careful 
auscultation  I  could  distinguish  nothing  abnormal  in  the 
action  of  the  tricuspid  and  semilunar  valves,  but  the 
sound  of  the  mitral  valve,  heard  most  distinctly  near  the 
apex  of  the  heart,  consisted  of  a  coarse,  grating,  troubled 
murmur.  It  resembled  a  churning  noise  occurring  syn- 
chronously with  each  systole.  The  second  sound  of  the 
heart  was  sufficiently  accentuated.  The  radial,  femoral, 
and  temporal  pulse  were  all  feeble  and  irregular.  It 
would  have  been  an  unnecessary  cruelty  to  have  told  this 
young  lad  the  real  state  of  his  condition  and  its  probable 
termination,  though  the  parents  were  fully  advised  of 
the  same.  He  was  a  sensible  boy,  and  having  won  his 
confidence  I  had  no  difficulty  in  getting  him  to  follow 
my  instructions.  As  soon  as  he  began  to  moderate  his 
exercise,  to  study  and  lead  a  more  sedentary  life,  to 
avoid  all  stimulants  absolutely,  and  to  live  upon  a  plain, 
nutritious,  dry  diet,  the  cardiac  pain  diminished  and  left 
him  almost  entirely,  the  heart's  action  became  steadier, 
and  he  lost  his  former  expression  of  distress  and  anxiety. 
No  medicines  whatever  were  given,  and  up  to  the  last 
time  I  saw  him  he  was  still  doing  well. 

When,  as  a  result  of  beginning  failure  of  the  compen- 
satory hypertrophy  of  the  heart  with  over-dilatation,  at- 
tacks of  dyspnoea  and  vertigo  become  troublesome,  and 
other  secondary  symptoms  begin  to  make  their  appear- 
ance, I  find  that  strychnine  in  small  and  frequent  doses 
steadies  the  heart's  action  in  the  happiest  manner.  The 
appropriate  general  tonic  treatment  with  iron,  arsenic, 
and  vegetable  bitters  must  not  be  neglected,  but  used  in 
conjunction  with  the  strychnine.  Sometimes  I  have 
seen  the  strychnine  assisted  most  materially  by  the  so- 
called  heart  tonics,  such  as  digitalis,  strophanthus,  and 
convallaria.  The  following  case,  kindly  referred  to  me 
by  Dr.  Henry  M.  Lyman,  illustrates  what  has  just  been 
said: 

Case    II.     Mitral  Regurgitation. — Mrs.   S.    D , 

aged  about  fifty- seven;  mother  of  several  living  chil- 
dren. Family  history  good.  Prior  to  marriage  and  in 
early  life  health  was  excellent.  Never  had  any  pro- 
longed severe  illness,  but  has  suffered  a  number  of  at- 
tacks of  acute  and  subacute  rheumatism.  At  present 
there  is  general  weakness,  precordial  distress,  nervous 
irritability,  and  some  emaciation.  Patient  suspects 
heart  trouble,  but  has  never  been  told  (fortunately,  I  be- 
lieve) the  seriousness  of  her  condition.    There  is  a 


558 


MEDICAL   RECORD. 


[November  3,  1894 


slight  cough  with  occasional  attacks  of  dyspnoea.  Di- 
gestion is  troublesome ;  tongue  clean  and  red ;  bowels 
irregular.  There  is  a  constant  tendency  to  diarrhoea. 
Constipation  sometimes  causes  much  distress.  Vertigo 
with  slight  headache  is  not  uncommon.  The  liver  is 
enlarged  and  jaundice  occasionally  makes  its  appearance. 
The  action  of  the  kidneys  is  as  yet  but  little  affected. 
The  hypostatic  condition  of  the  lungs  produces  shortness 
of  breath  and  favors  attacks  of  capillary  bronchitis.  Of 
these  attacks  she  has  now  had  several.  The  last  while 
under  my  care,  and  from  which  she  is  now  convalescing, 
was  the  severest  she  ever  experienced.  The  cough  was 
incessant,  hard,  and  racking.  Fever  was  high;  pulse 
small  and  rapid.  There  was  pain  in  the  chest,  extreme 
shortness  of  breath,  and  loud  rales  heard  both  anterior- 
ly and  posteriorly.  Complete  heart  failure  seemed  im- 
•  minent  a  number  of  times,  a  disaster  which  was  only 
averted  by  the  free  use  of  hot  poulticing  and  stimulation, 
together  with  the  administration  of  such  cardiac  tonics 
as  ammonia,  digitalis,  strophanthus,  and  convallaria. 
For  the  happy  outcome  of  this  attack  not  a  little  credit 
is  due  a  good,  careful  nurse.  The  patient  suffers  occa- 
sionally from  hysterical  melancholia,  for  which  the  vale- 
rianate of  ammonia  is  given.  When  convalescence  be- 
gan, the  patient  having  been  several  weeks  in  bed  with 
the  present  attack,  I  began  using  the  tincture  of  nux 
vomica,  but  soon  changed  to  strychnine  and  general 
ferruginous  tonics.  Almost  immediately  the  improve- 
ment became  pronounced  and  rapid.  The  cough  dimin- 
ished, the  pulse  grew  stronger,  the  heart  beat  more 
steadily,  the  nervous  excitement  and  distress  were  great- 
ly allayed,  and  the  appetite  and  digestion  increased. 
Only  small  doses  of  the  strychnine  were  employed,  such 
43  -gV  to  *V  grain  three  or  four  times  a  day.  Soon  I  dis- 
pensed entirely  with  the  digitalis,  strophanthus,  and  con- 
vallaria, and  depended  upon  the  strychnine  alone. 
When  the  patient  began  to  go  about  the  house  she  was 
advised  to  take  maltine,  with  strychnine,  quinine,  and 
iron,  which  has  continued  to  act  as  a  most  efficient  tonic. 
She  is  now  able  to  attend  to  her  household  duties,  and  is 
as  well  as  could  be  expected  with  her  heart  trouble. 
Having  tried  many  remedies  and  travelled  both  in  Eu- 
rope and  California  in  search  of  health,  she  is  naturally 
overjoyed  at  having  found  something  that  gives  her 
greater  comfort  than  she  had  yet  experienced.  She  has 
gained  somewhat  in  weight,  is  less  nervous,  and,  as  her 
friends  tell  her,  looks  better.  I  attribute  the  result 
chiefly  to  the  strychnine,  as  I  have  seen  it  act  similarly  in 
other  cases.  Of  course  all  these  heart  cases  sooner  or 
later  fail  to  respond  to  any  medicine  or  plan  of  treat- 
ment ;  the  end  is  then  close  at  hand. 

In  the  text-books  and  general  literature  I  find  very 
little  reference  made  to  the  use  of  nux  vomica  and  its 
alkaloid  in  valvular  disease  of  the  heart.  In  view  of  my 
own  experience  with  it,  acquired  during  the  last  three 
years,  I  am  not  a  little  surprised  at  this.  Digitalis  is 
still  the  remedy  par  excellence,  when  the  heart  flags  so  as 
to  produce  alarming  dyspnoea  and  beginning  dropsy; 
but  all  authorities  agree  that  this  remedy  should  be 
withdrawn  as  soon  as  its  beneficial  effects  have  been  se- 
cured. Even  strophanthus  must  be  discontinued  after 
a  time,  though  its  administration  may  be  continued 
longer  than  that  of  digitalis.  It  is  singular  that  author- 
ities do  not  recommend  the  use  of  nux  vomica  and  its 
alkaloid  at  this  stage  of  the  treatment,  when  the  heart, 
having  regained  its  tone  under  the  influence  of  the  digi- 
talis or  strophanthus,  is  so  liable  to  relapse  unless  sup- 
ported by  a  steady  and  gentle  stimulant.  Flint  says 
that "  nux  vomica  or  strychnia  appears,  either  directly  or 
indirectly,  to  have  a  tonic  influence  upon  the  heart/' 
and  there  he  dismisses  the  subject. 

Loomis,  writing  upon  mitral  reflux  in  Pepper's  "  Sys- 
tem of  Medicine,"  asserts  that  "small  doses  of  quinine 
and  strychnine,  alternating  with  the  administration  of 
iron,  are  often  of  service."  Bartholow  suggests  the  use 
of  nux  vomica  merely  for  its  stomachic  effect.  Fagge,  as 
well  as  many  other  authors,  does  not  even  mention  it  as  a 


heart  tonic.  As  most  of  these  patients  are  anaemic  and 
debilitated,  every  remedy  that  will  strengthen  the  gen- 
eral system  and  improve  the  nutrition  will  have  a  most 
beneficial  effect  upon  the  heart.  There  is  universal 
agreement,  therefore,  that  chalybeates  and  stomachics 
are  always  useful.  As  digitalis  disturbs  the  stomach  and 
interferes  with  digestion,  it  is  evident  that  it  should  be 
avoided  as  much  as  possible.  A  steady,  continuous  sup- 
port afforded  the  heart  and  its  nutrition,  is  far  more  de- 
sirable than  the  use  of  "digitalis  and  active  hydragogue 
purgation  repeated  from  time  to  time.1'  In  regard  to 
this  all  clinicians  are  of  one  mind ;  but  there  seems  to  be 
a  lack  of  opinion  in  regard  to  strychnine  as  a  direct 
heart  tonic  and  stimulant  favorable  in  these  cases. 
Other  things  being  equal,  the  nutrition  of  the  heart  is 
better  conserved  by  a  steady,  continuous,  gentle  stimula- 
tion, such  as  is  afforded  by  small  doses  of  strychnine,  than 
by  an  occasional  powerful  propulsion  produced  by  digi- 
talis and  its  congeners.  The  former  better  favors  the 
nutrition  of  the  heart  muscle,  while  the  latter,  prolonging 
the  diastole,  only  occasionally  gives  the  heart-muscle  a 
rest.  There  can  scarcely  be  any  doubt  about  nux  vom- 
ica and  its  alkaloid  being  a  heart  tonic.  In  the  words 
of  Bartholow,  "  increased  action  of  the  heart  has  been 
experimentally  demonstrated  to  be  caused  by  strych- 
nine. "  It  has  been  proved  that  in  large  doses  strych- 
nine prolongs  the  diastolic  pause  and  augments  the  force 
of  the  systole,  and  that  these  results  are  due  to  an  action 
on  the  cardiac  ganglia  and  on  the  pneumogastric  The 
blood-pressure  and  rapidity  of  the  blood- current  are  in- 
creased by  contraction  of  the  arterioles.  In  overdose 
the  heart  is  arrested  in  tetanic  rigidity.  These  effects 
are  all  similar  to  those  produced  by  digitalis.  The  latter, 
however,  is  not  a  general  tonic,  but  rather  the  reverse, 
whereas  nux  vomica  in  small  doses  may  be  administered 
a  long  time  with  the  happiest  results  to  both  the  heart 
and  general  nutrition. 

Though  far  advanced  toward  a  fatal  issue,  the  com. 
pensation  having  long  been  ruptured,  the  following  case 
illustrated  up  to  the  very  moment  of  death  the  benefit 
derived  from  the  use  of  nux  vomica. 

Case  III.     Mitral Regurgitation.— H.  G.  T ,  aged 

sixty-six,  married,  two  children  living,  and  one  dead  of 
pulmonary  tuberculosis.  Family  history  neurotic  and 
tuberculous.  Patient  was  much  exposed  to  hardship 
during  service  in  the  Mexican  War.  Denied  specific 
disease.  Up  to  the  time  he  entered  the  army  his  health 
was  excellent.  Twice  during  campaigns  he  suffered  se- 
vere attacks  of  rheumatism,  chiefly  in  the  arms.  On  ac- 
count of  exposure  and  the  intense  heat,  he  .was  several 
times  returned  to  the  hospital  with  severe  diarrhoea. 
His  bowels  have  been  weak  ever  since.  Later  on  he  was 
unsuccessfully  operated  on  for  external  bleeding  piles.  He 
is  now  troubled  with  costiveness.  When  he  first  consulted 
me,  January,  1893,  he  was  suffering  from  a  great  deal  of 
headache  and  vertigo.  When  he  arose  in  the  morning 
his  sight  was  blurred.  He  had  frequent  attacks  of  nau- 
sea with  a  desire  to  vomit.  Digestion  has  always  been 
bad.  Has  never  used  tobacco  or  stimulants  of  any  sort. 
There  was  a  constant  hard  cough  and  much  difficulty 
with  breathing.  There  was  no  pain,  but  a  good  deal  of 
precordial  distress.  He  said  he  felt  as  though  his  lungs 
were  "filled  up;  "  had  no  appetite  whatever,  and  felt 
exceedingly  weak.  He  was  obliged  to  sit  up  most  of  the 
night  to  feel  at  all  comfortable.  Micturition  was  diffi- 
cult, but  not  so  bad  as  six  or  seven  years  ago,  when  he 
had  to  catheterize  himself.  The  patient  was  pale  and 
emaciated.  There  was  no  swelling  of  the  arms  and  legs, 
though  the  abdomen  was  slightly  enlarged.  Dropsy  had 
not  shown  itself  yet  to  any  very  marked  extent.  The  liver 
was  enlarged,  the  lungs  congested,  the  conjunctivae 
red.  Eyesight  and  hearing  were  good.  The  scrotum 
was  slightly  enlarged  with  hydrocele.  Upon  inspection 
and  palpation  the  apex-beat  of  the  heart  was  violent  and 
lower  than  usual,  while  the  area  of  cardiac  dulness  much 
increased.  With  the  ear  over  the  cardiac  apex,  could 
be  heard  a  loud,  rough,  grating  sound.     At  none  of  the 


November  3,  1894] 


MEDICAL    RECORD. 


559 


valves  except  the  mitral,  could  I  distinguish  a  murmur. 
The  mitral  murmur,  however,  was  pronounced  and  asso- 
ciated with  systole.  The  second  sound  of  the  heart  was 
feebly  audible,  though  not  sharp.  The  pulsations  were 
irregular,  tumultuous,  and  labored.  The  radial  pulse 
was  the  same  in  both  arms,  though  markedly  irregular, 
like  that  of  the  heart.  Examination  of  the  urine  revealed 
nothing  abnormal,  but  a  trace  of  albumin.  The  pres- 
ent attack  began  two  weeks  prior  to  my  first  visit,  and 
had  come  on  very  gradually.  About  ten  years  ago  the 
patient  fell  suddenly  to  the  floor  in  an  unconscious  state, 
and  was  thereafter  confined  to  his  bed  for  a  month.  A 
year  later  he  had  a  severe  attack  of  vertigo  without  un- 
consciousness, which  also  caused  him  to  fall.  On  account 
of  his  heart  trouble  he  was  unable  to  attend  to  his  busi- 
ness for  the  last  few  years.  He  was  thoroughly  ac- 
quainted with  the  seriousness  of  his  condition,  so  that,  in 
spite  of  a  certain  degree  of  obstinacy  and  nervous  irrita- 
bility which  gave  rise  to  more  or  less  impatience,  I 
succeeded  very  well  in  getting  him  to  follow  instructions. 
Absolute  rest  and  a  light  dry  diet  were  enjoined,  while 
hydragogue  cathartics,  digitalis,  and  chalybeate  tonics 
were  administered  pro  re  nata.  In  a  couple  of  weeks  he 
was  relieved  of  many  of  his  symptoms ;  could  lie  down 
and  sleep  through  the  entire  night ;  and  was  able  to  go 
out  and  take  a  little  exercise  each  day.  As  soon  as  I 
withdrew  the  digitalis,  I  replaced  it  with  the  tincture  of 
nux  vomica  or  strychnine,  to  the  well- expressed  comfort 
and  satisfaction  of  the  patient.  Thus  he  was  treated  for 
more  than  a  year,  coming  every  now  and  then  to  my 
office  for  advice,  and  doing  as  well  as  could  be  expected. 
He  declared  that  he  believed  it  was  the  nux  vomica 
that  helped  him  more  than  anything  else.       ' 

Several  weeks  ago  I  was  hurriedly  sent  for,  and  found 
the  patient  in  bed  with  a  return  of  all  the  old  distressing 
symptoms.  I  had  not  seen  him  for  a  few  weeks  prior  to 
this  attack,  and  was*  therefore  surprised  to  note  the  dis- 
tressing cough,  marked  weakness,  anasarca  of  the  lower 
extremities,  and  the  presence  of  small  ulcers  in  the 
mouth.  The  state  of  the  patient  was  indeed  serious,  and 
I  so  informed  the  family.  The  usual  treatment  with 
cathartics,  digitalis,  strophanthus,  and  convallaria  was 
instituted,  but  with  only  slight  and  temporary  benefit. 
It  was  clear  that  the  man  had  taken  to  his  bed  now  for 
the  last  time.  In  spite  of  every  effort  he  soon  became 
water-logged,  and  died  quietly  in  a  semi  conscious  con- 
dition on  the  morning  of  April  26,  1894.  Up  to  the 
moment  of  his  death  he  begged  for,  and  was  given,  fre- 
quent small  doses  of  tincture  of  nux  vomica,  as  that  gave 
him  the  most  comfort.  The  widow  afterward  informed 
me  that,  in  spite  of  all  entreaties  on  the  part  of  his  family 
and  friends,  he  had  gone  to  one  of  the  advertising  dis- 
pensaries of  this  city,  where  they  promise  cures  for 
monthly  payments ;  almost  immediately  he  began  to  foil, 
so  that  he  had  to  take  to  his  bed  and  send  for  me  a 
couple  of  weeks  before  his  death.  Death  is  liable  to 
occur  at  any  time  in  valvular  disease  of  the  heart,  but  I 
believe  this  man's  life  might  have  been  prolonged  a  while 
longer  if  he  had  not  suddenly  broken  off,  for  a  much- 
promising  advertised  treatment,  one  which  was  helping 
him  but  not  doing  it  as  rapidly  as  his  impatience  could 
endure.  While  under  my  care  the  patient  had  to  resort 
less  frequently  to  digitalis  than  he  otherwise  would 
had  he  not  taken  the  continuous  small  doses  of  nux 
vomica  which  had  been  ordered  him. 

My  notes  record  a  number  of  other  cases  in  private 
practice  in  which  nux  vomica  and  its  alkaloid  in  small 
doses  gave  great  satisfaction.  As  a  stomachic  tonic,  a 
respiratory  stimulant,  and  heart  tonic,  it  fulfils  three  of 
the  most  important  requirements  in  the  treatment  of 
valvular  heart  disease.  Under  the  head  of  treatment 
of  senile  heart,  Balfour  lauds  strychnine  as  a  "  most 
valuable  remedy,  especially  when  venous  congestion  and 
a  tendency  to  catarrh  exist,  as  is  so  constantly  the  case 
when  the  circulation  is  feeble.  In  a  great  many  cases, 
even  of  well-marked  senile  irregularity,  the  continuous 
use  of  strychnine  is  sufficient  of  itself  to  promote  a  cure, 


while  it  is  a  powerful  adjuvant  to  digitalis;  and  the 
combination  of  these  two  drugs  often  enables  the  most 
admirable  results  to  be  obtained,  quite  unattainable  by 
either  separately. ' ' 

What  Balfour  finds  true  of  the  use  of  strychnine  in 
senile  heart,  I  have  found  almost  equally  true  in  cardiac 
valvular  disease.  The  prolonged  use  of  digitalis  and 
strophanthus  has  its  disadvantages.  The  former  is  sup- 
posed to  have  a  cumulative  action  and  certainly  disar- 
ranges the  digestion ;  the  latter  is  not  always  effective  in 
relieving  the  dyspnoea,  and  is  powerless  in  preventing  or 
removing  oedema.  Nothnagel  says  that  in  a  few  cases 
convallaria  and  adonis  vernalis  do  very  well,  but  that 
as  a  rule  the  so  called  substitutes  for  digitalis  are  of 
little  use.  Caffeine  is  more  of  a  diuretic  than  a  car- 
diac tonic,  and  therefore  cannot  be  relied  upon  alone. 
Coronilla  is  slow  in  its  action  and  is  not  always 
certain.  One  feature  of  the  Oertel  treatment  I  have 
found  of  inestimable  value  in  this  class  of  cases,  and  that 
is  the  rigid  adoption  of  a  dry  diet.  In  two  or  three 
cases  a  withdrawal  of  fluid  from  the  diet,  as  much  as  could 
be  borne,  produced  in  a  short  time  a  noticeable  improve- 
ment in  the  dyspnoea  and  pain.  I  have  allowed  milk  in 
small  amounts  as  the  only  beverage,  varying  it  with 
kumyss,  matzoon,  and  buttermilk.  Remembering  the 
overburdened  condition  of  the  circulation,  with  the  at- 
tendant dropsy  and  defective  renal  function,  the  use  of 
a  dry  diet  seems  to  me  eminently  rational. 

In  conclusion,  my  best  results  in  the  management  of 
cases  of  valvular  heart  disease  have  been  obtained  by  the 
following  outlined  treatment:  Physical  rest,  associated 
with  light,  regular,  pleasurable  exercise ;  absence  of  all 
worry,  mental  anxiety,  and  sudden  emotion ;  plain  abun- 
dant, nutritious  diet,  dry  as  possible ;  absolute  avoidance 
of  all  stimulants;  the  use  of  general  tonics  and  hydro- 
pathic measures  conducive  to  the  building  up  of  the  gen- 
eral constitution.  For  the  heart,  the  continuous  use  of 
small  doses  of  nux  vomica  or  its  alkaloid,  reserving  the 
more  powerful  heart  stimulants  like  digitalis  for  threat- 
ened dropsy.  In  two  of  my  cases  I  obtained  better  re- 
sults from  the  combination  of  digitalis,  strophanthus, 
and  convallaria  than  from  either  alone.  In  others  I 
have  found  that  either  of  these  special  heart  tonics  alone 
produced  the  greatest  comfort  when  assisted  by  minute 
doses  of  strychnine.  I  believe  it  is  bad  treatment  to 
use  larger  doses  of  any  drug  than  is  absolutely  necessary, 
and  ofttimes  three  to  five  drops  of  digitalis  with  yfo  or 
■fa  grain  of  strychnine  will  act  better  than  the  larger 
doses  of  either  alone.  The  use  of  strychnine  alone  is,  in 
the  majority  of  these  cases,  the  best  for  prolonged  treat- 
ment. I  have  said  but  little  of  the  management  of  such 
special  symptoms  as  dropsy,  dyspepsia,  etc. ;  for  these, 
of  course,  will  require  special  treatment  as  they  arise. 
They  will  present  themselves  less  frequently,  however, 
the  more  the  general  health  is  built  up  and  the  action 
of  the  heart  strengthened  and  steadied. 

Columbus  Memorial  Building. 


The  Price  of  a  Physician. — Under  the  Roman  Empire 
the  prices  paid  for  slaves  were  ruled,  as  prices  always  are, 
by  the  relations  of  supply  and  demand,  the  capture  of  a 
province  being  followed  by  a  glut  in  the  market,  and  a 
consequent  fall  in  value.  The  value  of  an  ordinary  slave 
without  special  accomplishments,  fluctuated  between  five 
and  eighty  dollars,  but  that  of  a  physician  remained  nearly 
constant,  for  a  long  period,  at  the  very  respectable  figure 
of  $  10,000. 

Tuberculosis  in  Domestic  Pets.— Dr.  Foehner,  of 
Berlin,  has  examined  some  seventy  thousand  sick  domes- 
tic animals  in  the  past  seven  years,  and  of  this  number 
only  two  hundred  and  eighty- one  suffered  from  tubercu- 
losis. The  parrots  were  relatively  the  most  frequently 
affected,  twenty- five  per  cent,  of  those  coming  under  his 
care  being  tuberculous.  Of  the  cats,  only  one  per  cent, 
showed  symptoms  of  the  disease. 


5<5o 


MEDICAL   RECORD. 


[November  3,  1894 


Medical   Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


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


New  York,  November  3,  1894. 

ANAESTHESIA    BY    ETHYL  BROMIDE    AND 
CHLOROFORM. 

Dr.  W.  S.  Magill,  of  Chicago,  describes  a  new  and  rapid 
method  of  anaesthesia  by  bromide  of  ethyl  and  chloro- 
form {International  Medical  Magazine).  The  procedure 
is  as  follows : 

"  Everything  being  in  readiness  for  the  operation — in- 
struments in  order,  the  surgeon  and  aids  prepared  for  im- 
mediate action  (for  the  patient  will  be  ready  in  about  one 
minute  if  anaesthesia  is  performed  on  the  operating-table) 
— draw  out  all  pillows  from  under  the  patient's  head. 
Note  pulse  and  respiration,  and  the  time  exactly.  Open- 
ing the  bottle  of  ethyl-bromide,  pour  a  few  drops  upon 
the  folded  towel  and  pass  it  oyer  the  nose  of  the  patient  to 
accustom  him  to  the  odor.  Immediately,  upon  the  upper 
side  of  the  towel,  pour  out  about  three  grammes  of  the  re- 
agent, and,  rapidly  reversing  the  towel,  apply  it  closely  to 
the  nose  and  mouth,  so  that  every  inhalation  may  be 
taken  through  its  meshes.  For  a  moment  the  patient 
holds  the  breath,  perhaps  making  a  slight  effort  to  pull 
away  the  towel,  at  the  same  time  swallowing  in  rapid 
succession  the  saliva  which  is  secreted  abundantly.  In 
an  instant  a  long  inhalation  is  made,  followed  by  others, 
especially  if  so  commanded  in  a  decisive  voice  by  the  an- 
aesthetizer,  the  face  becomes  red,  sometimes  violently  con- 
gested, the  eyes  fixed,  the  eyelids  frequently  difficult  to 
raise  with  the  ringer,  the  lines  of  the  face  are  drawn,  the 
under  jaw  firmly  set,  and  a  general  muscular  contrac- 
tion of  short  duration  may  be  manifested.  After  three 
or  four  long  inhalations  the  patient  has  lost  all  sense  of 
pain  or  touch,  but  is  still  conscious.  This  is  the  moment 
for  operation,  if  ethyl-bromide  alone  is  used.  A  few 
grammes  again  poured  on  the  towel  and  inhaled  result 
in  complete  unconsciousness,  if  not  already  obtained, 
with  the  first  dose.  Time,  one-half  to  one  minute  and  a 
half;  pulse,  rapid  and  strong ;  respiration,  deep,  and  of 
about  normal  rapidity. 

"  At  this  moment  pour  out  upon  another  folded  towel 
about  ten  drops  of  chloroform,  throw  aside  the  ethyl- 
bromide,  and  immediately  apply  the  chloroform  towel  in 
the  same  way.  Watch  carefully  the  pulse  and  respiration. 
At  this  time  the  operation  should  commence  if  the  patient 
be  already  on  the  operating-table. 

"  The  iris  should  be  carefully  watched.  At  the  com- 
mencement of  the  ethyl-bromide  administration,  from 
normal  contraction  the  iris  dilates  the  pupil  by  its  relaxa- 
tion. The  dilatation  is  rapid,  and  at  the  moment  of 
analgesia  reaches  the  maximum,  and  alone  indicates  the 


instant  to  change  the  reagent.  The  dose  of  chloroform 
indicated  above  is  the  first  and  only  strong  one ;  the  an- 
aesthesia must  be  maintained  by  pouring  frequently  one, 
two,  or  three  drops  of  chloroform  upon  the  towel,  which 
is  immediately  reversed  and  applied  over  the  nose  and 
mouth,  taking  care  that  the  patient  has  no  chance  of  in- 
halation during  the  change." 

Dr.  Magill  finds  records  of  sixteen  alleged  cases  of  death 
from  the  administration  of  bromide  of  ethyl.  Six  of 
these  he  finds  were  really  caused  by  bromide  of  ethylene, 
and  of  the  other  ten  he  finds  that  only  one  can  be  fairly 
attributable  to  the  ethyl.     He  adds : 

"  The  practical  advantages  of  successive  anaesthesia— 
the  rapidity,  the  elimination  of  the  disagreeable  phases  of 
chloroform  or  ether  which  precede  or  retard  recovery 
from  anaesthesia  with  these  reagents,  the  diminished 
quantity  of  the  toxic  agent  required — all  these  elements 
of  superiority  combine  to  invite  the  notice  and  experi- 
mentation of  surgeons.  Its  advantages  have,  on  two  oc- 
casions, been  discussed  recently  at  the  Soci6t6  de  Chirur- 
gie  of  Paris — on  May  2  and  9,  1894 — where  Dr.  Segond 
relates  its  introduction  into  his  wards  by  Dr.  Malherbe, 
coming  directly  from  Professor  Terrier's  service.  With 
Segond  the  method  was  immediately  preferred  to  all 
others,  and  at  the  meeting  of  the  Society  his  official 
statistics  of  one  year's  use  of  successive  anaesthesia  are 
given — four  hundred  and  forty- three  cases  without  an  ac- 
cident of  any  kind.  Dr.  Bazy  related  his  first  acquaintance 
with  the  method  in  the  wards  of  Dr.  Bran,  and  its  imme- 
diate adoption  by  him.  Dr.  Monod  spoke  in  much  the 
same  way.  Dr.  Richelot  was  already  on  record  as  en- 
dorsing the  method  to  the  extent  of  preferring  it  in  all 
cases  of  heart  or  pulmonary  troubles  which  might  he 
contra- indications  of  chloroform  or  ether. 


DANGERS  OF  PRACTICAL  BACTERIOLOGY. 

A  practical  but  unfortunate  illustration  of  the  truth  of 
the  old  adage  that  "  Familiarity  breeds  contempt "  is 
shown  by  the  death  from  cholera  recently,  in  the  Ham- 
burg Hygienic  Institute,  of  Dr.  Oergel,  one  of  the  assist- 
ants in  that  Institution.  The  facts  of  the  case  are 
stated  in  great  detail,  by  Dr.  Reincke,  in  the  current 
number  of  the  Deutsche  Medical  Wocherischrift,  and  would 
seem  to  prove  that  the  ill-fated  young  physician  inad- 
vertently swallowed  some  suspected  water  which  had 
been  sent  to  the  laboratory  for  examination.  And  al- 
though subsequent  bacteriological  examination  could 
not  prove  the  presence  of  the  cholera  bacillus,  it  was 
not  at  all  improbable  that  the  water  had  become  con- 
taminated from  cholera  cultures  with  which  he  had 
been  working. 

Knowledge  is  too  often  the  result  of  dearly  bought 
experience,  and  the  fact  of  one  such  case  as  this  should 
go  far  to  counteract  the  opinion,  which  has  been  grow- 
ing apace  since  the  last  cholera  epidemic,  that  the 
comma  bacillus  is  a  much-maligned  organism,  and  is 
really  not  nearly  so  dangerous  as  was  its  repute.  Al- 
though Von  Pettenkofer  and  others  may  believe  that 
cholera  organisms  may  be  swallowed  with  impunity,  and 
Dr.  Ernest  Hart  may  avowedly  prefer  the  shelter  of  a 
well-directed  cholera  hospital  to  any  other  during  the 
prevalency  of  this  disease,  it  is  a  fact  notwithstanding 
that  a  too  intimate  association  with  the  vibrios  of  this  dis- 


November  3,  1894] 


MEDICAL    RECORD. 


56i 


•  is  liable  to  be  followed  by  disastrous  and  lamentable 
consequences. 

The  opinion  that  no  pathogenic  germ  can  act  other 
than  in  a  favorable  soil  is  continually  gaining  ground ; 
bat  the  fact  that  a  person  is  apparently  in  a  healthy  state 
is  no  safeguard.  A  slight  local  departure  from  the 
norm  in  some  part  of  the  body  may  give  the  germ  a  hos- 
pitable point  of  entrance,  and  then  sinister  manifesta- 
tions rapidly  follow. 

In  the  case  of  Dr.  Oergel,  general  health  and  resisti- 
bility  may  have  been  impaired  by  confining  and  exact- 
ing laboratory  work,  and  chances  that  were  taken  with  a 
greater  exemption  from  consequences  when  in  a  vigorous 
condition  proved  fatal  when  taken  after  a  period  of 
confining  labor. 

As  Dr.  Reincke  remarks,  it  is  to  be  hoped  that  this  sad 
event  may  not  be  without  warning  to  those  who  would 
treat  the  cholera  organism  with  too  great  familiarity. 


ST.   LOUIS  AS  A  MEDICAL  CENTRE. 

St.  Louis  is  just  now  the  centre  of  a  very  considerable 
depression  of  spirits  and  harrowing  self  analyses.  The 
trouble  began  when  Professor  Chaplin,  Chancellor  of 
Washington  University,  said  publicly  some  unkind  words 
about  the  disproportion  between  the  quantity  and  the 
quality  of  the  St.  Louis  medical  colleges.  Then  an  es- 
teemed practitioner  of  St.  Louis,  Dr.  Thomas  O'Reilly, 
a  little  later  is  said  to  have  addressed  to  the  Health  Com- 
missioner an  eloquent  protest  against  the  reckless  surgery 
and  the  excessive  cceliotomic  zeal  of  the  much  professored 
city.  The  editor  of  The  Medical  Mirror  has  been  de- 
•  voting  his  most  alluring  alliterations  and  his  elegant  and 
eulogic  eloquence  to  the  purpose  of  refuting  all  charges 
and  restoring  the  self-esteem  of  his  justly  celebrated  towns- 
men. 

"  St.  Louis,"  he  says,  "  has  been  charged  with  posses- 
sing eleven  medical  colleges,  but  there  are  really  only  six 
regular  schools.  And  why  are  there  so  many  as  that? 
Simply  because  the  two  oldest  medical  colleges  (both 
being  over  fifty  years  old)  were  not  possessed  of  a  gen- 
erous spirit  in  the  direction  of  encouraging  and  utilizing 
the  ambition  of  the  younger  brood  of  medical  men  im- 
bued with  a  taste  for  teaching.  In  other  words,  in  pro- 
portion to  population  St.  Louis  has  no  more  medical 
teachers  than  any  other  city/1  That  is  to  say,  we  pre- 
sume, if  one  counts  only  six  of  the  eleven  schools. 

As  to  the  second  charge,  a  writer  in  the  Times  and 
Register  says  : 

"  Missouri  has  sown  the  wind,  and  now  she  is  reaping 
the  whirlwind.  She  is  the  hotbed  of  medical  anarchy. 
Her  once  honored  influential  State  Medical  Society,  we 
are  informed,  has  gone  to  pieces.  She  has  only  fifteen 
medical  colleges,  and  at  the  annual  meeting  this  year  but 
seventeen  members  answered  to  the  roll-call.  A  practi- 
tioner in  that  country,  it  seems,  must  be  a  professor  or 
nothing,  and  surgery  has  run  mad  there." 

We  do  not  know  on  what  ground  Missouri  in  general 
or  St.  Louis  in  particular  should  be  characterized  as  a 
"hotbed  of  medical  anarchy."  And  we  are  quite  in 
agreement  with  the  Medical  Mirror  in  denying  that  the 
charge  of  "surgery  run  mad"  has  any  special  truth  as 
applied  to  that  locality.  There  has  been  some  reckless 
surgery  no  doubt  ever  since  surgery  began,  and  especially 


since  anaesthesia  was  introduced.  There  always  will  be 
foolhardy  people  in  every  class  of  society,  but  probably 
fewer  among  surgeons  proportionately.  There  has  been 
a  wave  of  zeal  for  laparotomy  which  has  swept  over oiearly 
all  parts  of  the  country.  It  certainly  rose  very  high  in 
New  York  at  one  time,  as  we  have  often  remarked.  We 
doubt  if  the  high-water  mark  has  ever  reached  an  equal 
point  in  St.  Louis. 

We  trust  that  the  remonstrances  of  the  Mirror  will 
clear  the  atmosphere  and  perhaps  be  successful  in  con* 
densing  the  colleges,  improving  their  status,  and  making 
of  St.  Louis  what  it  ought  to  be,  a  great  medical  centre. 


WHO  IS  PROFESSOR  ZAKHARIN? 

A  great  many  curious  stories  have  been  published  about 
the  eccentricities  of  Professor  Zakharin,  the  Czar's  phy- 
sician. His  name  is  not  familiar  outside  of  Russia,  al- 
though Russian  medical  literature  so  far  as  it  is  valuable 
is  quickly  turned  into  German,  English,  or  French.  The 
conclusion  of  many  of  the  profession  has  doubtless  been 
that  Zakharin  was  an  errant  and  eccentric  man  who  had 
gained  position  and  notoriety  rather  through  his  bizarre 
character  than  any  solid  scientific  merits.  A  St. 
Petersburg  correspondent  of  the  British  Medical  Jour- 
nal says,  however,  that,  though  eccentric,  the  Professor 
is  distinguished  by  something  more  than  eccentricity. 
He  has  the  most  extensive  and  lucrative  consulting  prac- 
tice in  Moscow,  he  fills  with  distinction  the  Chair  of 
Medicine  in  the  University  of  Moscow,  he  is  the  author 
of  "  Clinical  Lectures,"  which  is  a  classic  in  this  coun- 
try ;  and  he  has  done  more,  I  am  assured  on  the  best 
authority,  to  raise  the  status  of  the  medical  profession  in 
Russia  than  any  other  man  living. 

We  are  glad  to  learn  that  the  Professor  is  really  the 
leader  of  medicine  in  Russia.  Still  it  is  remarkable  that 
his  fame  has  heretofore  been  so  local. 


fftettrs  txt  tfee  WBLtsk. 

Disappearance  of  Cholera.— Latest  advices  announce 
such  a  decrease  of  Asiatic  cholera  in  Europe  as  to  de- 
prive the  disease  of  any  further  interest  .this  season  to 
public  health  authorities.  For  the  week  ending  October 
10th,  Surgeon  Fairfax  Irwin,  U.  S.  M.  H.  S.,  reports  a 
decline  of  nearly  fifty  per  cent,  in  the  number  of  cases 
in  Austro-Hungary,  which  has  been  the  principal  seat  of 
the  disease  in  Europe  outside  of  Russia.  In  this  latter 
country,  also,  the  decrease  has  been  marked,  and  the  be- 
lief is  expressed  that  the  advent  of  cold  weather  will  put 
an  early  end  to  the  epidemic.  The  port  of  Marseilles 
has  been  declared  free  from  the  disease,  and  inspection 
of  vessels  has  been  discontinued ;  "  sporadic  "  cases  con- 
tinue to  occur  elsewhere  in  France,  and  in  Holland  and 
Belgium,  but  these  excite  no  alarm,  and  the  cholera  epi- 
demic of  1894  in  Europe  is  practically  at  an  end. 

Dr.  George  M.  Sternberg,  Surgeon-General  of  the 
Army,  received  the  degree  of  LL.D.  from  the  Univer- 
sity of  Michigan  at  its  last  Commencement. 

The*  Hew  York  State  Association  of  Railway  Sur- 
geons will  hold  its  fourth  annual  meeting  at  the  New 
York  Academy  of  Medicine,  on  Thursday,  November 


562 


MEDICAL    RECORD. 


[November  3,  1894 


15  th,  at  9.30  in  the  morning.  At  eight  o'clock  in  the 
evening  of  the  same  day,  there  will  be  a  joint  meeting  of 
the  Section  on  Medico-Legal  Surgery  and  of  the  Medi- 
co-Legal Society. 

The  American  Academy  of  Bailway  Surgeons  will 
hold  its  first  meeting  in  the  Grand  Pacific  Hotel,  Chi- 
cago, on  November  9  and  10,  1894.  The  Academy  has 
adopted  a  motto,  which  is :  "  The  higher  the  order  of 
railway  surgery,  the  greater  the  protection  to  the  em- 
ployee, the  passenger,  and  the  company." 

The  Mississippi  Valley  Medical  Association  will 
hold  its  next  annual  meeting  at  Hot  Springs,  Ark.,  on 
November  20,  21,  22,  and  23,  1894. 

The  French  Public  and  the  Serum  Treatment  for 
Diphtheria.— A  correspondent  of  The  Lancet  writes  that 
public  interest  in  the  new  treatment  for  diphtheria  has 
taken  a  very  practical  form  at  Paris.  The  subscriptions 
now  being  received  for  the  foundation  of  an  antitoxin 
department  at  the  Institut  Pasteur,  whose  business  it  will 
be  to  supply  the  vaccine  to  the  practitioners  of  France, 
have  reached  the  total  of  £51,100.  The  Budget  Com- 
mission has,  on  the  proposition  of  M.  Rouvier,  voted 
100,000  fir.  as  a  subvention  to  the  Assistance  Publique 
for  the  same  purpose.  It  remains  for  the  Chamber  to 
confirm  this  vote.  The  Municipal  Council  has  instructed 
its  special  commission  to  arrange  with  Dr.  Roux  for  the 
distribution,  at  the  Council's  expense,  of  serum  to  differ- 
ent depdts  to  be  created  in  Paris.  The  Comit6  Consul- 
tatif  d'  Hygiene  Publique  de  France,  at  its  meeting  yes- 
terday at  the  Ministry  of  the  Interior,  resolved  to  address 
a  congratulatory  letter  to  Dr.  Roux  and  his  illustrious 
master,  M.  Pasteur,  and  also  to  ask  of  the  Government 
an  annual  credit  to  facilitate  the  diffusion  of  the  anti- 
toxin. The  enthusiasm  shown  in  favor  of  the  movement 
is  extraordinary.  For  example,  a  livery- stable  keeper 
offers  a  horse  to  the  Pasteur  Institute  to  serve  for  the 
preparation  of  the  serum.  A  vote  of  10,000  fr.  will  be 
proposed  at  the  next  meeting  of  the  Conseil  G6n6ral  de 
la  Seine.  Numerous  prefects  of  departments  having  ad- 
dressed inquiries  to  the  President  of  the  Council,  who  is 
also  Minister  of  the  Interior,  on  the  value  of  an  ti  diph- 
theric seropathy,  the  Minister  referred  the  question  to 
the  Academy  of  Medicine,  which  body  named  a  com- 
mission to  study  the  matter.  The  commission,  com- 
posed of  MM.  Bergeron,  Proust,  Cadet  de  Gassicourt, 
and  Strauss  (reporter),  to-day  delivered  its  conclusions, 
which  I  transcribe  verbatim :  "  Votre  commission  vous 
propose  done  d'6mettre  un  avis  favorable  sur  l'emploi  du 
s6rum  antidipth&ique,  et  de  formuler,  en  outre,  les  voeux 
que  rinstitut  Pasteur  soit  mis  en  mesure  de  faire  face  aux 
demandes  qui  pourront  lui  etre  faites,  soit  par  les  m6de- 
cins,  soit  par  les  pouvoirs  publics." 

Monument  to  Charcot. — The  pupils  and  former  asso- 
ciates of  Charcot,  in  Paris  and  throughout  France,  are 
engaged  in  raising  a  fund  for  the  erection  of  a  bronze 
statue  of  him  in  the  Salpetriere.  This  movement  is  now 
receiving  cordial  and  material  support  in  Germany,  in 
England,  and  in  Italy. 

It  has  therefore  seemed  desirable  to  the  New  York 
Neurological  Society  that  the  profession  in  America  join 
in  this  testimonial. 

For  this  purpose  the  society  has  appointed  a  commit- 
tee consisting  of  Drs.  Edward  D.  Fisher,  E.  C.  Seguin, 


M.  Allen  Starr,  Charles  L.  Dana,  and  C.  A.  Hcrter,  to 
bring  the  matter  to  the  attention  of  the  profession  and 
to  receive  contributions,  which  will  be  duly  acknowledged 
and  forwarded  to  the  central  committee  in  Paris. 

Death  of  Dr.  George  W.  Moody.— Dr.  George  W. 
Moody,  of  Huron,  N.  Dak,  died  of  cerebral  hemorrhage 
October  13th,  aged  forty-two  years.  He  was  educated 
in  Chicago,  graduating  from  the  Chicago  Medical  Col- 
lege in  1878.  He  moved  to  Huron,  Dak.,  in  1880,  and 
became  surgeon  of  the  Central  Dakota  Division  of  the 
Northwestern  Railroad.  A  widow  and  one  son  survive 
him. 

Professor  Carl  Fraenkel,  of  Marburg,  has  been  elected 
to  the  Chair  of  Hygiene  in  the  University  of  Halle,  ren- 
dered vacant  by  the  transfer  of  Professor  Renk  to  Dres- 
den. Professor  Fraenkel  will  not  assume  the  duties  of 
his  new  position  until  some  time  next  year,  his  place  in 
the  interim  being  occupied  by  Professor  Behring,  of  the 
Institute  for  Infectious  Diseases  in  Berlin. 

Hospital  Beds  for  Cases  of  Appendicitis. — At  the  last 
meeting  of  the  Board  of  Managers  of  the  University 
Hospital,  the  Director  was  authorized  to  set  aside  certain 
beds  to  be  used  by  Professors  William  Pepper  and  J. 
William  White  for  cases  of  appendicitis,  those  gentlemen 
being  engaged  in  a  special  investigation  of  the  symp- 
toms, treatment,  and  pathology  of  that  disease. 

Perhaps  we  will  next  have  special  hospitals  for  appen- 
dicitis. 

The  Practice  of  Medicine  by  Women  in  1578.— In  an 
address  before  the  Yorkshire  Branch  of  the  British  Medi- 
cal Association  this  summer,  Mr.  W.  H.  Jalland  stated 
that  York  seems  to  have  been  ahead  of  most  places  in 
countenancing  the  practice  of  medicine  by  women.  In 
closing  his  address  {Quarterly  Medical  Journal)  he  says  : 
"  I  find  on  reference  to  the  Corporation  Minutes  dated 
1572,  Elizabeth  XIV.,  the  following  entry:  'And  for  as 
much  as  it  appeareth  that  Isabel  Warrick  hath  skill  in  the 
science  of  surgery  and  hath  done  good  therein,  it  is  there- 
fore agreed  by  these  presents  that  she  upon  her  good  be- 
haviour shall  use  the  same  science  within  this  city  without 
let  of  any  of  the  surgeons  of  the  same.'  " 

The  Scaroity  of  Patients. — There  may  be  some  com- 
fort to  the  many  physicians  who  have  felt  the  long-con- 
tinued "  dulness  "  in  their  practice,  in  learning  that  it  is 
not  a  local  stagnation,  but  that  the  same  conditions  are 
being  felt  in  other  parts  of  the  world.    English  medical 
journals  speak  of  the  "  marvellous  health  of  the  country ;  * ' 
and  the  large  number  of  physicians  who  have  attended 
the  many  congresses  without  being  missed,  so  few  are  the 
patients.    An  Edinburgh  correspondent  of  the  Medical 
Press  writes  recently,  "  that  in  that  city  it  was  a  vacant    *W 
vacation  with  a  vengeance ;  there  was  absolutely  nothing        , 
stirring,  and  he  knew  of  one  practitioner  acting  as  locum       A 
tenens  for  seven  others  on  their  holiday,  who,  notwith-       C 
standing  this  weight  of  responsibility,  jet  found  ample 
time  to  play  golf  every  day." 

The  Four  Tears'  Course  at  the  College  of  Physicians. 
— In  the  College  of  Physicians  the  new  four  years'  course 
commences  with  the  present  season,  but  notwithstanding 
this  fact  the  registration  indicates  that  a  larger  class  will 
enter  this  year  than  last  year,  when  the  highest  number 
yet  recorded  was  reached.     In  the  session  of  1893-4  the 


November  3,  1894] 


MEDICAL   RECORD. 


563 


total  enrolment  of  students  numbered  766,  a  gain  of  112 
over  the  previous  year.  To  the  development  of  the  four- 
year  curriculum  much  attention  has  been  devoted  by  the 
Faculty.  Each  student  will  be  examined,  each  year, 
upon  the  work  of  that  year,  and  each  student  of  the  four- 
year  will  be  required  to  elect  from  a  list  of  elective  courses 
either  one  course  or  more,  as  may  be  hereafter  deter- 
mined. 

Mission  Hospital  in  China. — President  Seth  Low, 
of  Columbia  College,  and  his  brother,  have  just  built  for 
and  presented  to  the  mission  station  of  the  Protestant 
Episcopal  Church  in  Wuchang,  China,  a  well-appointed 
hospital  for  the  use  of  the  mission  and  the  people  of  the 
town. 

The  Hew  House  of  Belief  of  the  Society  of  the 
Hew  York  Hospital,  at  the  corner  of  Hudson  and  Jay 
Streets,  was  opened  for  inspection  on  Tuesday,  the  30th 
ult  It  is  to  take  the  place  of  the  emergency  branch  of 
the  New  York  Hospital,  commonly  known  as  the  Cham- 
bers Street  Hospital. 

Bellevue  Hospital. — It  is  announced  that  Dr.  Lucius 
C.  Adamson  has  been  appointed  to  succeed  the  late  Dr. 
Stuart  Douglas  in  the  charge  of  the  insane  patients. 

The  Haw  York  Cancer  Hospital.— Dr.  Charles  N. 
Dowd  has  been  appointed  a  surgeon  to  the  hospital. 

St.  Luke's  Hospital  to  be  Moved  Hezt  July.— At 
a  meeting  of  the  Board  of  Managers  of  St.  Luke's  Hos- 
pital, held  October  29th,  it  was  stated  that  an  agreement 
had  been  made  with  the  purchaser  of  the  hospital  prop- 
erty on  Fifty-fourth  Street  and  Fifth  Avenue,  by  which 
the  delivery  of  this  property  is  deferred  until  July  5, 
1895.  The  work  of  the  hospital  will,  therefore,  be  con- 
tinued without  interruption  during  the  coming  winter  at 
the  present  site.  The  new  hospital  buildings  in  113th 
Street  and  Morningside  Avenue  are  being  pressed  rapidly 
forward,  so  that  the  work  of  the  hospital  may  be  trans- 
ferred there  next  July. 

"Doctorein." — Wanted,  a  handy  and  convenient  name 
for  the  "  lady  doctor. "  A  discussion  having  for  its  aim 
the  discovery  of  an  appropriate  title  to  take  the  place  of 
the  awkward  terms  "lady  doctor,"  "woman  doctor," 
"female  practitioner,"  etc.,  has  been  started  in  the 
Glasgow  Daily  Herald.  "  Doctor  "  indicates  the  male 
practitioner;  "doctoress"  is  felt  to  be  inadmissible. 
"Doctorein,"  plainly  of  quasi-German  parentage,  is 
suggested.  "  Doctorein  Mary  Walker  "  would  be  dis- 
tinctive enough,  but  slightly  clumsy  and  un-English. 
The  irreverent  correspondent  thinks  it  reminiscent  of 
margarine — an  objection  which  may  weigh  with  the 
ts  of  the  Glasgow  Queen  Margaret  College. — 
^Lancet. 


The  Physiological  Effects  of  Cycling.— The  physio- 
logical effects  of  cycling  have  recently  been  studied  by 
Dr.  Blazhevitch,  of  St.  Petersburg,  who  publishes  his  re- 
sults in  his  "Graduation  Dissertation."  He  tabulates 
270  observations  on  104  individuals  of  both  sexes  and 
various  ages,  distinguishing  between  ordinary  riders  and 
those  who  train  themselves  for,  and  ride  in,  races  or  at- 
tempt to  cover  long  distances.  He  finds  that  the  play 
of  the  chest  is  diminished  immediately  after  riding,  es- 
pecially in  the  cases  of  women  and  children,  and  of  men 


racing  or  commencing  cycling,  the  diminution  amount- 
ing in  these  cases  to  from  1  to  1.5  centimetres.  In  men 
accustomed  to  the  exercise  the  effect  was  scarcely  percep- 
tible. The  general  effect  of  the  summer's  riding  upon 
the  male  votaries  of  the  sport  was,  according  to  Dr. 
Blazhevitch,  practically  nil.  In  women  and  children  the 
effect  was  slightly  to  increase  the  vital  capacity.  The 
arm  power  was  found  to  have  increased  more  than  the 
leg  power  in  young  persons  and  in  beginners,  but  in  the 
case  of  men  of  mature  age  who  had  previously  been  ac- 
customed to  cycling  this  was  not  so  evident.  Speaking 
generally,  the  effects  of  cycling  on  the  system  were  found 
to  be  very  similar  to  the  phenomena  noticed  by  Tsym- 
kovski  in  soldiers  who  had  been  running,  and  by  Gruz- 
deff  and  Passover  as  resulting  from  rowing. 

Fin  de  Siecle  Treatment  of  Gonorrhoea. — Among  the 
numerous  suggestions  on  the  treatment  of  gonorrhoea 
with  which  the  medical  press  abounds,  none  has  ap- 
peared which  is  so  entirely  unique  as  that  presented  by 
Dr.  Burnside  Foster  in  a  recent  issue  of  the  Journal  of 
Cutaneous  and  Genitourinary  Diseases.  The  method 
proposed  is  described  as  follows  by  the  author :  "As 
soon  as  may  be  after  we  have  established  the  diagnosis 
of  a  first  gonorrhoea,  the  patient  should  be  etherized  and 
properly  prepared ;  a  buttonhole  opening  made  in  the 
perineum,  and  drainage  of  the  bladder  established. 
Through  a  properly  contrived  apparatus  the  anterior 
urethra  could  then  be  thoroughly  flushed  with  any  anti- 
septic or  cleansing  fluid  and  treated  on  surgical  princi- 
ples. The  details  of  the  local  treatment  would  vary 
with  the  fancy  of  the  operator.  The  feasibility  of  pack- 
ing and  distending  the  anterior  urethra  with  iodoform 
gauze  suggests  itself  to  me ;  but  any  one  of  a  great  num- 
ber of  methods  would,  doubtless,  be  efficacious." 

Longevity  and  Drink. — The  British  Medical  Associa- 
tion has  been  investigating  the  question  of  longevity  in 
connection  with  the  use  of  alcoholic  beverages.  Deaths 
to  the  number  of  4,234,  taken  at  random,  show  the 
average  age  of  temperate  drinkers  to  be  sixty-three 
years ;  careless  drinkers,  fifty-nine  years ;  free  drinkers, 
fifty-seven  years ;  intemperate  drinkers,  fifty-three  years; 
total  abstainers,  fifty-one  years.  The  analysis  in  the 
case  of  those  who  reached  the  age  of  over  eighty  shows 
that  fifteen  per  cent,  were  total  abstainers,  ten  per  cent, 
heavy  drinkers,  and  seventy-four  per  cent,  moderate 
drinkers.  Of  those  who  lived  more  than  ninety  years, 
fifteen  per  cent,  were  total  abstainers,  nine  per  cent, 
were  hard,  and  seventy-five  per  cent,  moderate,  drinkers. 
These  figures  must  be  applied  with  some  caution.  A 
certain  large  proportion  of  total  abstainers  are  so,  be- 
cause of  some  form  of  ill-health  or  natural  weakness. 

The  Correction  of  Urinous  Odor. — It  is  well  known 
that  the  essence  of  turpentine  gives,  when  taken  inter- 
nally, an  odor  of  violets  to  the  urine.  This  fact  has  been 
put  to  good  account  by  a  learned  professor,  who  has  for 
some  time  been  in  the  habit  of  giving  the  essence  in  ten- 
drop  doses  three  times  daily  to  persons  afflicted  with  in- 
continence of  urine.  In  a  short  time  the  disagreeable 
odor  of  the  secretion  is  replaced  by  the  characteristic 
odor  of  the  violet,  to  the  great  satisfaction  of  those  about 
the  patient.  The  treatment  can  be  continued  without 
inconvenience  for  several  weeks,  and  is  only  counter- 
indicated  in  gastric  catarrh  and  nephritis. 


564 


MEDICAL  RECORD. 


[November  3,  1894 


©liuical  gepartmeut 

DOSES   OF  MORPHINE  HABITUES. 
By  L.  S.  OPPENHEIMER,  M.D., 

BAKTOW,   FLA. 

In  a  recent  number  of  the  Medical  Record  Dr.  Groom, 
of  Iowa,  contributes  a  note  on  the  case  of  a  lady  who  was 
supposed  to  be  taking  an  extraordinary  daily  quantity  of 
morphia — thirty  grains.  My  experience  is,  of  course, 
limited  in  these  cases,  but  I  may  safely  say  that  in  a  gen- 
eral practice  of  twenty  years  I  have  seen  not  less  than 
twenty  persons  who  were  taking  a  full  drachm  of  morphia 
every  twenty-four  hours.  The  reason  that  the  physician 
so  rarely  knows  the  actual  quantity  of  morphia  taken  by 
his  patients  and  friends  is  because  the  latter  usually  try 
to  conceal  the  fact  from  everybody,  and  the  druggist 
who  furnishes  the  article  is  the  only  person  who  can  ap- 
proximate the  quantity  consumed  in  the  majority  of  these 


A  man  of  my  acquaintance,  Mr.  B.  C.  T ,  has 

authorized  me  to  use  his  name  in  reporting  the  fact  that 
he  to  day  began  his  thirty-second  drachm  of  morphia  in 
thirty  days,  all  purchased  from  one  store.  He  attends 
to  his  daily  business  about  as  well  as  the  average  business 
man.  This  is  not  a  rare  case,  but  is  mentioned  because 
of  its  illustrating  the  above. 


PILOCARPINE  IN  URTICARIA. 
By  L.  B.  McBRAYER,  M.D., 

ASKBTUXft,  K.  C 

On  Monday,  September  1 7th,  I  read  your  valuable  journal 
of  September  15  th,  and  found  therein  an  article  by  R. 
Abrahams,  M.D.,  on  "  Pilocarpine  in  the  Treatment  of 
Acute  and  Chronic  Urticaria." 

My  little  boy,  aged  two  years  and  nine  months,  happened 
to  be  suffering  very  badly  from  this  very  unpleasant  malady 
just  at  this  time.  The  wheals  would  cover  his  face  at 
times  and  seemed  to  have  a  special  liking  for  his  nose, 
which  they  would  distort  terribly.  At  one  time  the 
wheals  coalesced  until  they  covered  nearly  the  whole  of 
the  posterior  surface  of  the  thigh.  He  had  slept  very  lit- 
tle the  previous  night,  although  I  had  given  him  two  grains 
Dover's  powder.  In  fact  it  was  the  worst  case  of  the 
kind  I  have  seen.  The  itching  was  very  annoying.  I 
had  cleared  the  bowels  out  well,  and  he  had  eaten  almost 
nothing  for  the  past  twenty- four  hours.  He  had  been 
bathed  in  solution  of  soda  bicarbonate  and  several 
other  things,  yet  he  continued  to  grow  worse.  After 
reading  the  article  I  gave  him  on  Monday  night,  at  bed 
hour,  X  grain  of  pilocarpine  muriate.  He  slept  very 
much  better,  and  on  Tuesday  morning  there  was  no  evi- 
dence whatever  of  the  urticaria. 

~.  Last  night  (Tuesday)  he  slept  as  well  as  he  ever  did 
in  his  life,  and  is  perfectly  well,  and  all  this  with  only 
one  dose  ^  grain  of  pilocarpine.  I  have  written  this 
hoping  to  emphasize  the  article  referred  to,  and  hope 
that  the  profession  may  profit  by  it. 


A  CASE   OF  ORBITAL  CELLULITIS  ABORTED. 
By  GUY  C.   M.   GODFREY,   M.D., 

r»ST    LIEUTENANT   AHD    ASSISTANT   SURGEON,  U.  8.  A«,   POST   SURGEON  FOST 
WASHAKIE,  WYO. 

Private  S ,  Hospital  Corps,  U.  S.  A.,  aged  twenty- 
two,  a  large  man,  dark-complexioned,  and  of  a  good 
family  history,  had  a  boil  near  the  outer  corner  of  his 
right  orbit.  He  had  opened  the  abscess  before  he  came 
to  me,  but  was  alarmed  at  the  condition  of  his  eye.  The 
skin  over  the  orbit  was  red  and  the  subcutaneous  tissue 
much  infiltrated.  The  lids  were  swollen  and  the  con- 
junctiva injected.  There  was  considerable  chemosis,  and 
the  cornea  was  beginning  to  be  cloudy.  He  also  had  a 
slight  fever.     In  short  all  the  symptoms  of  incipient  or- 


bital cellulitis.  I  immediately  ordered  the  boil  to  be 
dressed  antiseptically  and  had  a  wad  of  cotton  placed  in 
the  orbit,  and  over  that  a  snug  roller  bandage.  The  pa- 
tient was  then  put  to  bed.  In  about  an  hour  I  had  the 
dressings  removed.  I  then  made  a  free  incision  down- 
ward and  outward  in  the  line  of  a  wrinkle,  so  as  to  provide 
for  drainage  and  leave  no  disfiguring  scar.  I  afterward 
painted  the  skin  over  the  entire  orbit  with  a  five  per 
cent,  solution  of  nitrate  of  silver.  The  abscess  was  then 
dressed  with  powdered  boric  acid,  a  compress  of  cotton 
was  placed  in  the  orbit,  and  over  all  a  tight  roller  ban- 
dage. The  patient  was  then  put  on  strong  tonic  treat- 
ment. At  the  end  of  three  hours  I  removed  the  compress 
and  found  that,  though  there  was  still  some  redness  in 
the  skin,  the  swelling  had  mostly  disappeared  and  that 
the  chemosis  was  going  down.  I  again  painted  the  skin 
over  the  orbit  with  the  solution  of  nitrate  of  silver  and 
had  a  new  compress  put  on. 

The  next  morning  all  the  signs  of  inflammation  had 
disappeared.  The  skin  was  normal  in  color  except  where 
it  was  darkened  by  the  solution.  There  was  no  chemosis ; 
the  cornea  was  clear  and  the  patient  felt  much  better. 
The  abscess  was  washed  with  a  solution  of  bichloride  of 
mercury  (i  to  1,000)  and  dressed  with  boric  add.  The 
compress  was  not  reapplied,  but  the  tonics  were  kept  up. 
The  patient  had  an  uninterrupted  recovery,  and  has  had 
absolutely  no  trouble  with  his  eye  since  then. 

This  method  is  easy  of  application  and  most  potent  in 
results,  if  the  disease  is  taken  early.  When  the  danger  of 
the  inflammation  travelling  along  the  ophthalmic  vein  to 
the  meninges  is  so  great,  it  would  seem  that  the  method 
used  in  this  case  would  be  much  better  than  that  of  caus- 
ing pus  to  form,  and  then  draining  through  the  conjunc- 
tiva or  through  the  lower  lid. 


SYMPTOMS    OF    POISONING    FROM    A    PROB- 
ABLE OVERDOSE   OF  PHENACETINE. 

By  FRANCIS  E.  KNOWLES,  M.D., 

SOUTH  ORANGE,  M.  J. 

MISS  B ,  aged  about  thirty,  rather  stout,  and  very 

healthy,  had  a  severe  attack  of  migraine.  She  was  recom- 
mended by  her  friends  to  take  one  of  Dr.  C 's  magic 

headache  powders,  which  she  did,  but  obtained  no  relief, 
and  in  about  an  hour  and  a  half  repeated  the  dose ;  this 
also  did  not  produce  the  desired  effect  She  was  then 
advised  to  try  phenacetine ;  she  drove  down  to  the  drug 
store,  and  took  ten  grains,  drinking  with  it  a  glass  of 
carbonic  water.  She  drove  directly  home,  about  a  mile 
distant  from  the  village,  and  in  a  few  minutes  was  taken 
with  a  well  marked  chill.  Her  friends  foreboding  evil,  I 
was  sent  for  immediately.  On  arriving,  and  before  be- 
ing able  to  ask  any  questions,  I  was  told  the  history  of 
the  case  as  related  above.  I  found  the  patient  prostrated 
from  what  seemed  to  be  muscular  weakness;  there  was 
great  cardiac  depression ;  pulse  forty  per  minute,  scarcely 
perceptible  at  the  wrist;  respiration  was  labored  and 
slightly  quickened ;  there  was  general  cyanosis,  which 
was  particularly  marked  at  the  extremities ;  cold  perspi- 
ration ;  feet  and  hands  were  nearly  cold ;  she  had  an 
anxious  expression,  and  was  trembling  from  nervous  ex- 
citement. She  said  her  whole  body  felt  numb.  Heat 
was  applied,  and  the  limbs  rubbed  vigorously,  and  five- 
minim  doses  each  of  tincture  of  digitalis  and  nux  vomica 
in  a  teaspoonful  of  brandy  were  administered  every 
fifteen  minutes,  to  stimulate  the  heart  and  respiration. 
Her  condition  commenced  to  improve  immediately,  and 
in  three  hours  she  felt  well  again. 

I  examined  one  of  Dr.  C 's  magic  headache  pow- 
ders, which  of  course  is  a  patent  medicine,  and  was 
satisfied  that  it  contained  phenacetine  or  some  other 
coal-tar  derivative.  The  patient  had  been  used  to  the 
homoeopathic  treatment  all  her  life,  and  the  doses  which 
her  allopathic  friends  prescribed  for  her  proved  entirely 
too  large.  It  has  been  my  experience  with  people 
who  have  had  homoeopathic  treatment  for  a  number  of 


November  3,  1894] 


MEDICAL   RECORD. 


565 


years  that  smaller  doses  will  produce  their  physiological 
effect  than  with  those  whose  systems  have  become  accus- 
tomed to  larger  potions. 


SIXTY  GRAINS    OF    MORPHINE    AT  A  DOSE. 
By,M.  J.  SWEENEY,  M.D., 

KANE,   PA. 

I  noticed  in  the  columns  of  your  excellent  paper  of  Sep- 
tember 15th,  under  heading  "A  Large  Dose  of  Morphine," 
an  account  of  a  case  using  thirty  grains  a  day.  The  final 
sentence  in  that  article  was  "  One  ounce  of  P.  &  W.'s 
morphia  every  sixteen  days  beats  the  record  of  any  case 
I  ever  heard  of."  Allow  me  the  privilege  of  establishing 
a  new  record.  I  have  under  my  notice  now  a  case  of 
morphinism,  cured  by  Mattison's  method  of  treatment, 
who  took  sixty  grains  each  day,  not  hypodermatically 
but  by  the  mouth.  When  he  came  to  me  for  relief  from 
his  habit,  with  the  story  of  sixty  grains  per  day,  I  could 
not  believe  it  and  told  him  so.  I,  however,  gave  him 
four  15-grain  powders,  with  instructions  to  take  one  every 
four  hours,  intending  to  watch  the  effects  of  the  first  dose 
and  be  guided  accordingly.  He  deliberately  took  the  four 
powders,  emptied  them  into  the  palm  of  his  hand,  and  ate 
the  morphine  like  so  much  flour.  To  say  I  was  horrified 
is  putting  it  mildly.  I  instantly  loaded  up  my  hypo- 
dermic with  a  tenth  of  apomorphme  to  emetize  torn,  and 
when  he  objected  I  felt  like  sending  for  the  undertaker  at 
once.  His  perfect  sang-froid  and  smiling  assurances 
allayed  my  fears  a  little,  so  I  sat  down  and  decided  to 
watch  him,  interfering  forcibly,  if  necessary.  I  was  more 
than  surprised,  after  eight  hours'  observation,  to  witness 
no  untoward  symptoms  whatever.  He  is  entirely  off  the 
drug  now,  in  good  condition,  and  I  see  him  every  day. 


A  CASE  OF  ANOPHTHALMIA  DEFECTUS  OCU- 
LORUM. 

By  LEONARD  LANPES,  M.D., 
new  \orac. 

I  desire  to  put  the  following  case  on  record  on  account 
of  its  great  rarity. 

About  July  1st  I  was  called  to  see  a  Mrs.  G ,  a 

healthy  woman,  thirty  years  of  age,  who  had  just  given 
birth  to  a  female  child.  I  found  her  in  no  worse  condi- 
tion than  ordinarily  is  the  case  after  a  very  hard  labor, 
as  in  this  case.  She  asked  me  to  examine  the  child,  say- 
ing it  could  not  open  its  eyes.  I  found  a  perfectly  de- 
veloped child,  weight  about  six  pounds.  There  were 
eyelids,  eyebrows,  and  ocular  cavities,  but  when  I  suc- 
ceeded in  opening  the  lids  I  found  no  eyeballs.  It  was 
evident  that  the  child  was  born  without  eyes.  The 
woman's  family  history  was  good,  and  she  had  previously 
given  birth  to  two  children ;  both  of  them  died  a  few  days 
after  birth.  Her  husband  is  a  healthy-looking  man  of 
about  thirty-two  years  of  age,  but  I  found,  later  on,  that 
he  had  been  an  inmate  of  an  asylum,  having  been  afflicted 
with  melancholia.  He  is  now  perfectly  well,  and  his 
family  history  is  also  good.  I  took  the  case  to  Dr.  F.  F. 
Reyling,  who  kindly  examined  it  for  me,  and  he  also 
concluded  that  the  child  was  born  without  eyeballs. 
Another  peculiarity  of  this  child  is  that  it  has  six  fingers 
on  each  hand  and  six  toes  on  each  foot.  Dr.  Reyling 
tells  me  that  he  never  saw  or  heard  of  such  a  case  before. 

Since  I  have  had  this  case  in  hand  my  attention  has 
been  called  to  some  other  cases  of  a  like  character. 
There  is  now  in  the  Missouri  School  for  the  Blind,  at  St. 
Louis,  a  girl,  aged  eleven,  the  daughter  of  a  clergyman, 
who  was  born  without  eyeballs,  but  with  eyelids  and 
sockets  well  developed.  This  case  corresponds  in  every 
respect  with  the  one  above  recited,  except  as  to  the  su- 
pernumerary fingers  and  toes.  This  St.  Louis  case  was 
examined  by  Dr.  Green,  of  St.  Louis,  the  celebrated 
oculist.  The  report  of  the  school  superintendent  shows 
that  this  child  is  bright  in  intellect,  she  having  a  very 
high  percentage  in  all  studies. 


Dr.  V.  Condory,  of  Hot  Springs,  Ark.,  has  called  to 
my  attention  a  similar  case  that  came  to  his  notice  when 
he  was  on  board  the  steamship  Fatherland,  in  1871. 
Among  the  third-class  passengers,  five  hundred  in  num- 
ber, was  a  young  woman,  eighteen  years  of  age,  an  Israel- 
ite, who  gave  birth  to  a  female  child  without  eyes. 

Dr.  Edward  Frankel,  of  this  city,  refers  me  to  what  is 
said  on  this  subject  by  Dr.  Karl  Assmund  Rudolphi,  Pro- 
fessor of  Anatomy  in  the  University  of  Berlin,  1816  to 
1840:  "Anophthalmia  defectus  oculorum  is  found  in 
various  degrees ;  occasionally  both  eyes,  with  all  the  ad- 
junctive parts,  are  absent,  as  in  cases  where  the  heads  of 
one  monstrosity  are  so  joined  together  that  only  the 
occiputs  are  visible  laterally ;  while  on  the  other  hand  I 
have  on  one  occasion  seen  a  well- developed,  mature 
foetus,  which  died  after  birth — case  published  in  the  Re- 
ports of  the  Berlin  Academy,  1840  to  1850 — where  the 
right  eye  was  totally  absent,  so  that  there  were  neither 
ocular  cavities,  eyeball,  eyelids,  nor  optic  nerve,  and 
the  skin  was  smooth  from  the  forehead  to  the  cheeks ;  in 
the  brain  the  thalamus  opticus  was  rudimentary,  etc.  I 
have  also  observed  the  absence  of  both  eyes  in  an  other- 
wise well-developed  child,  in  whom  the  eyebrows,  eyelids, 
and  all  relative  parts,  were  completely  developed." 

I  have  also  noticed  in  Bruneau's  "  Old  French  Natural 
History"  a  case  of  this  kind  in  a  male  child.  The  child 
died  a  few  weeks  ago.  I  tried  very  hard  to  get  an  au- 
topsy but  did  not  succeed. 


A    CASE    OF    HYDRAMNION,  WITH    ATRESIA 
ANI  IN  THE  CHILD. 

By  FREDERIC  H.  PLUMMER,  M.D., 

ILYMPTON,  MASS. 

I  was  called  at  4  p.m.,  on  September  20,  1894,  to  Mrs. 

S ,in  labor  with  her  fifth  child.     On  reaching  her  I 

found  that  she  had  been  in  labor  for  three  days  prior  to 
my  being  summoned,  the  pains  having  been  rather  weak 
but  wearing.  The  abdominal  examination  revealed  an 
enormously  distended  uterus,  and  extreme  suprapubic 
oedema.  Palpation  failed  to  elicit  any  definite  informa- 
tion as  to  the  position  of  child,  and  the  foetal  heart- 
sounds  were  inaudible.  Vaginal  examination  showed  an 
unruptured  amniotic  sac  protruding  through  a  fully 
dilated  cervix,  with  breech  presenting,  but  not  engaging ; 
after  a  moment  of  exploration  the  presenting  part  disap- 
peared and  its  place  was  taken  very  quickly  by  the  head. 
Rectum  and  bladder  were  empty,  and  passages  well  lubri- 
cated and  dilatable.  Concluding  that  the  case  was  one 
of  hydramnion,  I  waited  until  the  head  again  came 
within  reach,  and  after  the  pain  subsided  ruptured  the 
membranes.  I  had  a  Marcy  pad  under  my  patient, 
which  quickly  filled,  but  from  the  hollowing  of  the  bed 
only  a  small  part  of  the  fluid  passed  through  the  outlet, 
the  major  part  overflowing,  soaking  a  quilt  folded  under 
her,  and  also  the  feather-bed  through  to  the  under  mat- 
tress. The  head  engaged  L.O.A.  after  rupture  of  the 
membranes  and  the  labor  was  rapidly  completed,  the 
child  weighing  five  pounds.  He  was  extremely  cyanotic, 
and  the  cord  being  so  short  as  to  prevent  my  getting 
his  face  from  between  his  mother's  thighs,  I  thought 
best  to  sever  it  immediately.  Then  after  I  had  cleared 
out  the  mouth  and  fauces,  and  given  a  few  mouth-to- 
mouth  insufflations,  the  child  commenced  to  cry  and 
breathe.  A  few  drops  of  urine  were  voided  during  his 
toilet.  The  mother  had  rather  a  free  hemorrhage,  and 
the  uterus  was  slow  in  retracting.  Firm  manipulation 
controlled  both  hemorrhage  and  relaxation,  the  placenta 
being  expelled  by  Credo's  method  twenty  minutes  after 
delivery  of  the  child.  On  account  of  possible  danger 
from  hemorrhage,  the  uterus  was  carefully  manipulated 
for  an  hour,  and  then,  as  contraction  seemed  good,  a 
binder  was  applied  and  the  patient's  toilet  made. 

These  being  the  incidents,  let  me  call  attention  to  the 
abnormal  quantity  of  the  amniotic  fluid  and  stricture  of 
the  child's  intestine.     The  receptacle  beside  the  bed 


566 


MEDICAL  RECORD. 


[November  3,  1894 


contained  two  quarts  of  fluid,  the  folded  quilt  weighed 
12^1  pounds  as  taken  from  the  bed,  its  dry  weight  as 
afterward  ascertained  being  ij£  pound,  and  there  was 
an  indefinite  amount  of  fluid  in  the  feather-bed,  probably 
half  as  much  as  was  in  the  quilt.  From  the  quantity 
collected  and  the  weight  of  the  absorbing  materials,  we 
will  find  that  the  amount  of  fluid  was  approximately 
twenty  pints,  which  seemed  to  me  to  be  an  unusual 
amount. 

The  next  morning  I  found  that  the  nurse  (one  of  the 
traditional  old  women  who  know  it  all),  no  meconium 
having  been  passed,  had  administered  a  dose  of  castor- 
oil  before  my  arrival.  The  next  day,  the  oil  being  in- 
operative, I  injected  half  a  drachm  of  glycerine,  which 
brought  away  a  mass  about  two  inches  long  and  three- 
eighths  of  an  inch  in  diameter,  of  a  light  brownish  color, 
and  appearing  like  a  small  earthworm  folded  upon  it- 
self enough  times  to  make  up  the  bulk  of  the  mass.  This 
was  followed  by  several  small  pellets,  about  the  size  of 
split  peas,  and  slightly  darker  in  color  than  the  larger 
mass.  During  the  day  vomiting  set  in,  which  soon  be- 
came dark  in  color,  apparently  from  containing  meco- 
nium, and  this  continued,  with  increase  in  number  of 
ejections  and  darkness  of  color,  till  death,  on  the  sixth 
day. 

During  this  time  he  lay  in  a  comatose  condition,  and 
after  third  day  refused  to  take  any  nourishment  per 
orem.  Gavage  was  tried  but  proved  unsuccessful,  all 
ingested  matter  being  vomited  almost  immediately.  The 
bowels  never  moved  spontaneously,  and  injections  only 
brought  away  a  few  of  the  small  pellets  of  the  same 
character  and  color  as  the  first  evacuated. 

An  autopsy  was  denied,  so  that  I  was  unable  to  verify 
my  diagnosis  of  a  stricture  of  the  gut  about  two  inches 
above  the  internal  sphincter,  but  think  the  occurrence 
of  these  abnormalities  of  mother  and  child  make  the 
case  of  sufficient  interest  to  warrant  my  reporting  it. 

I  suggested  an  operation  for  the  making  of  an  artificial 
anus,  but  it  was  refused  by  the  mother,  the  reputed  father 
having  died  of  phthisis  pulmonalis  in  the  early  part  of 
January. 


A  NEW  TREATMENT  FOR  ERYSIPELAS. 

By  W.  V.  GAGE,  M.D. 
m'cook,  neb. 

At  the  risk  of  being  assailed,  after  the  publication  of  this 
article,  with  numerous  letters  disputing  my  claim  to  orig- 
inality in  the  method  of  handling  the  above-named  dis- 
ease, I  beg  leave  to  call  your  attention  to  the  treatment 
of  erysipelas  with  the  wet  carbolic-acid  dressing.  The 
treatment,  as  far  as  I  know,  is  original ;  but  I  am  more 
than  willing  that  you  should  demonstrate  to  me  that  it 
is  in  no  way  new.  Every  physician  has  often  expe- 
rienced a  conflict  with  erysipelas,  and  has  probably 
many  times  arrived  at  the  conclusion  that  his  local  ap- 
plications did  harm,  not  much  good,  or  were  absolutely 
inert.  Strumpel  says,  "  The  chief  indications  for  treat- 
ment will  be  to  check  the  unceasing  advance  of  the  dis- 
ease; but,  unfortunately,  the  means  recommended  for 
this  purpose  too  often  fail." 

Iodine  painted  over  the  healthy  skin  at  the  border  of 
the  inflammation  seldom  arrests  the  progress  of  the  local 
manifestation ;  and  the  old-fashioned  method  with  the 
nitrate- of  silver  pencil  is  certainly  as  barren  of  results. 
In  regard  to  internal  medication,  iron  has,  no  doubt, 
been  exhibited  more  than  any  other  one  medicine. 
Probably  no  one,  however,  can  state  that  he  has  noted 
any  marked  diminution  in  the  severity  of  the  disease  un- 
der the  influence  of  its  administration.  The  same  may 
be  said  of  camphor,  benzoate  of  soda,  and  salicylic  acid. 

In  the  treatment  of  erysipelas  with  the  wet  dressing  I 
have  practically  discarded  internal  medication,  treating 
the  disease  as  a  local  manifestation,  which  it  certainly  is ; 
and  only  in  cases  where  the  patient  has  been  treated  in  a 
previous  attack  by  the  use  of  both  local  application  and 
internal  medication,  have  I  given  some  placebo  "  for  the 


blood."  I  might  add,  however,  that  I  have  employed 
sulfonal  for  sleeplessness  and  delirum,  in  some  cases, 
with  marked  results.  For  the  cure  of  the  disease  I  rely 
wholly,  however,  upon  the  local  use  of  the  wet  five-per- 
cent carbolized  dressing.  I  make  my  own  dressing  from 
the  bleached  cheese  cloth,  and  the  method  employed  for 
the  preparation  of  this  gauze  is  so  familiar  as  to  need  no 
repetition  here.  I  use  a  dressing  of  my  own  preparation, 
as  the  manufactured  article  which  we  get  in  the  shops  is 
too  dry  for  the  purpose,  while  that  which  I  keep  in  my 
office  is  put  up  in  a  large  earthen  crock  and  covered  with 
a  five-percent  solution  of  carbolic  acid.  The  treatment 
can  of  course  be  applied  to  any  case  of  erysipelas,  bat  we 
will  take  for  example  a  case  of  the  facial  manifestation  01 
the  disease.  If  the  area  of  inflammation  has  encroached 
upon  the  line  of  the  beard,  the  face  should  be  shaven,  as 
should  the  head  if  the  region  of  the  hair  be  involved.  I 
have  found  it  best,  even  though  the  eyes  are  not  yet  af- 
fected by  the  disease,  to  close  them  and  place  over  each 
one  a  fluffed  pledget  of  the  wet  gauze.  If  the  ears  are  in- 
volved a  small  portion  of  the  dressing  should  be  placed 
back  of  each  one,  so  that  they  shall  not  be  pressed  against 
the  head  by  the  bandage  which  is  to  be  applied.  Now 
apply  the  main  dressing,  which  should  envelop  the  head 
and  face,  including  all  parts  which  have  a  tendency  to 
show  the  blush  of  the  extending  disease,  being  careful  to 
let  the  dressing  extend  over  the  area  of  redness  in  all 
directions.  Over  the  dressing  a  sheet  of  rubber  tissue  or 
oiled  silk  should  be  placed,  the  edge  of  the  protective 
lapping  well  over  the  edge  of  the  gauze.  A  bandage  is 
now  applied  to  hold  the  dressing  in  place.  Care  should, 
of  course,  be  taken  to  so  fix  the  dressing  that  the  mouth 
and  nasal  cavities  shall  be  free,  although  the  eyes  are  to 
be  covered.  You  have  now  converted  your  patient's  head 
into  an  object  somewhat  resembling  an  Armour  ham,  but 
he  feels  better  at  once,  as  the  gauze  has,  by  mere  contact, 
removed  a  considerable  amount  of  heat  from  the  diseased 
area.  This  dressing  should  be  allowed  to  remain  on  for 
twenty-four  hours,  when  it  is  to  be  removed  and  replaced 
by  a  similar  one.  I  think,  if  you  have  never  employed  a 
like  treatment,  that  you  will  be  surprised  at  the  marked 
diminution  in  the  heat  and  redness  over  the  area  covered 
by  the  dressing,  even  after  the  first  twenty-four-hour 
period.  The  dressing  is  to  be  reapplied  as  long  as  the 
least  suspicion  of  redness  of  the  skin  remains. 

Compare  the  last  case  treated  by  you  with  the  first 
one  treated  by  the  above  method,  and  notice  the  differ- 
ence. Mark  the  shortening  in  the  course  of  the  disease, 
and  the  diminution  of  all  disagreeable  symptoms.  It  is 
absolutely  essential  that  all  signs  of  inflammation  should 
disappear  before  the  dressing  is  removed  for  good,  as 
you  will  otherwise  often  be  disappointed  to  notice  a  re- 
turn of  the  disease  which  you  had  supposed  cured.  Bet- 
ter a  day  too  long  in  a  bandage  than  a  repetition  of  the 
trouble.  In  order  to  satisfy  myself  as  to  the  efficacy  ot 
the  treatment,  I  have,  after  applying  the  dressing  for 
twenty- four  hours,  removed  it  and  left  the  case  without 
treatment  for  a  short  period,  on  the  return  call  finding, 
instead  of  the  soft,  pale,  moist  surface,  the  hot,  tense, 
dusky  skin  of  well-developed  erysipelas.  I  have,  up  to 
date,  handled  eleven  cases  of  the  disease  after  the  man- 
ner set  forth  above,  and  have  yet  to  be  disappointed  in 
a  single  instance.  The  cases  have  included,  besides  the 
facial  type  of  the  disease,  three  cases  of  traumatic  ery- 
sipelas, and  I  am  inclined  to  think  that,  if  anything,  the 
success  of  the  treatment  was  more  fully  demonstrated  in 
the  last-named  cases  than  in  the  so-called  idiopathic 
variety.  I  would  like  to  receive  a  report  of  cases  in 
which  there  has  been  a  failure  to  effect  a  prompt  cure 
after  pursuing  the  wet-dressing  treatment. 


Preventable  Deaths. — A  statistician  of  Moscow  has  es- 
timated, from  a  study  of  the  death  returns  of  the  States 
of  Europe,  that  at  least  forty  per  cent,  of  the  inhabitants 
of  that  portion  of  the  world  die  of  preventable  infectious 
diseases. 


November  3,  1894] 


MEDICAL  RECORD. 


567 


MALARIAL  INFECTION. 
By  A.  SCHIRMAN,  M.D., 

NEW  YORK. 

During  a  residence  near  the  Rosso-Persian  b6undary  be- 
yond the  Caucasus  it  fell  to  my  lot  to  see  a  great  deal 
of  intermittent  fever.  Malarial  diseases  in  that  region 
are  very  similar  in  their  symptoms  and  course  to  those 
endemic  in  many  parts  of  the  American  continent.  My 
experience  there  and  elsewhere  has  led  me  to  regard  the 
presence  of  potted  plants  in  living  apartments  as  pro- 
ductive of  much  malarial  fever.  It  has  been  abundantly 
shown  that  this  disease  prevails  often  in  places  which 
are  free  from  swamps  or  any  bodies  of  standing  water. 
All  that  is  necessary  to  the  propagation  of  the  malarial 
poison  is  a  small  quantity  of  moisture  in  the  soil  and  a 
vegetable  growth  in  somewhat  high  temperature.  The 
development  of  the  poison  is  arrested  when  the  air  does 
not  penetrate  the  soil  and  when  the  average  temperature 
is  not  high.  Both  excessive  dryness  and  excessive  moist* 
ore  seem  to  be  inimical  to  the  propagation  of  malaria. 
The  cities  of  Vladi  in  the  Caucasus,  of  Susal,  where  is 
the  grave  of  Haman,  and  of  Erinan,  near  Mt.  Ararat, 
and  their  environs  are  noted  for  excessive  heat  and 
moisture  and  a  great  variety  of  vegetable  growth.  Dur- 
ing my  practice  in  these  cities  I  often  had  occasion  to 
observe  that  malarial  fevers  were  more  prevalent  on 
days  following  a  warm  rain,  and  especially  among  those 
living  in  unsanitary  dwellings  where  there  were  many 
plants  and  much  decaying  animal  and  vegetable  matter. 
The  relation  between  house  plants  and  malaria  was  well 
shown  in  a  case  seen  by  me  in  Moscow.  A  woman  from 
the  Caucasus,  who  had  always  enjoyed  the  best  of  health, 
was  taken  ill  with  intermittent  fever.  She  was  treated 
for  the  fever  and  soon  recovered,  but  another  paroxysm 
occurred  soon  after  she  began  to  go  about  the  house. 
After  a  succession  of  these  attacks  I  made  an  investiga- 
tion. I  found  that  she  had  a  large  number  of  plants  in 
a  sitting-room  which  was  well  heated  but  not  ventilated. 
She  was  very  fond  of  her  plants  and  passed  the  greater 
part  of  her  time  in  this  room,  but  during  the  attacks  of 
illness  remained  in  her  bedroom,  which  was  large  and 
well  ventilated.  I  insisted  upon  the  removal  of  the 
plants  from  the  house,  and  from  that  time  the  attacks 
ceased. 


PERMANGANATE  OF  POTASSIUM  AS  AN  AN- 
TIDOTE FOR  RATTLESNAKE  BITES,  A  RE- 
CENT CASE. 

By  F.  W.  MALONEY,  M.D., 

ROCHESTER,  N.  Y. 

About  three  months  ago,  a  Mr.  P.  G was  bitten  on 

the  right  middle  finger  by  a  fair- sized  ^rattlesnake  which 
he  was  handling  at  the  time. 

He  immediately  put  the  snake  back  in  the  cage,  and 
applied  suction  with  his  mouth  to  the  wound,  this  was 
continued  for  about  fifteen  minutes,  when  he  used  a  strong 
solution  of  ammonia.  At  the  end  of  half  an  hour  the 
finger  began  to  swell.  He  tied  a  string  on  the  finger 
above  the  bite,  but  the  swelling  continued,  in  two  hours 
it  had  reached  the  wrist ;  he  then  removed  the  string  and 
made  an  incision  through  the  wound  with  his  pen-knife. 
After  partaking  of  a  large  drink  of  whiskey  he  set  out  to 
obtain  medical  aid.  Not  finding  the  person  he  desired 
he  went  to  the  City  Hospital,  where  the  house  surgeon 
made  several  free  incisions  on  the  finger,  hand,  and  fore- 
arm, as  by  that  time  the  swelling  had  extended  as  far  as 
the  elbow-joint.  The  wounds  were  then  dressed  with 
iodoform  gauze,  and  bandaged. 

The  free  bleeding  relieved  the  pain  and  some  swelling. 
The  after  treatment  was  dressings,  changed  every  day  for 
four  weeks ;  when  all  the  wounds  were  healed  he  had  no 
constitutional  symptoms,  as  the  swelling  did  not  go  be- 
yond the  elbow- joint. 

I  read  Dr.  Moor's  article  in  the  Medical  Record 


stating  the  antidotal  properties  of  permanganate  of  po- 
tassium in  morphine  poisoning,  and  a  short  time  after- 
ward another  article  on  a  case  of  snake  poisoning  treated 
by  permanganate  hypodermatically.  I  suggested  the  idea 
to  Mr.  G and  he  said  he  would  get  it,  and  be  pre- 
pared in  case  he  was  bitten  again.  He  secured  a  hypo- 
dermic syringe  and  some  permanganate  of  potash ;  taking 
a  two-ounce  bottle  he  made  a  dark  purplish  solution  of 
the  permanganate.  He  also  has  a  rubber  bandage  he 
keeps  in  the  same  box  with  the  syringe  and  solution. 
These  are  near  the  case  which  contains  the  rattlers. 

An  opportunity  presented  itself  on  Friday  afternoon 
September  28th,  by  which  he  clearly  demonstrated  the 
value  of  permanganate  of  potash  as  an  antidote  to  rat- 
tlesnake poisoning. 

Mr.  G- very  often  exhibits  the  fangs  of  a  rattle- 
snake to  the  visitors  of  his  place.  This  he  does  by 
catching  the  snake  just  behind  the  head  with  one  hand, 
and  by  a  sort  of  tongue  depressor  opens  the  mouth  of  the 
snake  with  the  other.     This  day  the  snake  might  have 

been  a  little  hungry,  and  while  handling  it  Mr.  G 

felt  a  sharp  sting  in  the  joint  of  the  left  index  finger ;  he 
dropped  his  pet  back  in  the  cage,  and  reached  for  his 
syringe  and  solution ;  an  assistant  filled  the  syringe  while 

Mr.  G tied  a  string  round  the  finger  above  the 

wound.  He  then  injected  the  solution  into  the  finger 
near  the  bite.  In  a  few  minutes  the  finger  began  to 
swell,  and  when  the  pain  became  severe  he  used  the  rub- 
ber bandage  at  the  wrist  and  loosened  the  string,  and 
again  injected  another  syringeful  of  the  solution.  There 
was  no  further  swelling  and  very  little  pain.  In  two 
days  there  was  no  sign  of  the  bite ;  he  used  the  finger  as 
usual.  He  stated  that  he  was  more  at  home  now  than 
ever  with  the  rattlers. 


PREGNANCY;  CONTRACTED  PELVIS;  DOUBLE 
DERMOID  CYST;  PORRO'S  OPERATION. 
RECOVERY  OF  MOTHER  AND   CHILD.1 

By  NEIL  MacPHATTER,  M.B.C.M.,  L.R.C.P.  Edin., 

DENVER,  COL. 

PROFESSOR  OF  CLINICAL  GYNECOLOGY  IN  GROSS  MEDICAL  COLLEGE  J  GYNECOL- 
OGIST TO  ST.  ANTHONY'S  HOSPITAL  ;  FELLOW  OF  THE  BRITISH  GYNECOLOGI- 
CAL SOCIETY. 

I  believe  the  part  assigned  to  me  for  discussion  this 
afternoon  is  a  consideration  of  the  unusual  methods  or 
extraordinary  measures  that  may  be  legitimately  resorted 
to  in  difficult  parturition,  when  the  difficulties  assume 
such  proportions  that  the  woman  cannot  be  delivered  by 
any  of  the  ordinary  means.  My  sphere  is  limited  to  a 
still  narrower  margin  than  this,  for  I  have  been  requested 
by  the  gentleman  who  so  kindly  invited  me  to  partici- 
pate in  this  discussion  to  endeavor  to  confine  my  remarks 
more  particularly  to  that  part  of  the  obstetric  art  which 
calls  for  the  use  of  cutting  instruments,  i.e.,  when  there 
exists  such  a  disproportion  between  the  natural  passages 
and  the  size  of  the  foetus  as  to  render  it  absolutely  impos- 
sible for  the  child  to  be  delivered  in  the  ordinary  manner. 
Here  we  come  upon  a  peculiarly  interesting  and  tremen- 
dously responsible  situation,  for  it  is  one  in  which  the 
lives  of  mother  and  child  are  placed  in  imminent  jeopardy, 
and  one  that  calls  for  the  most  evenly  balanced  judgment 
on  the  part  of  the  attending  physician.  In  the  remarks 
to  which  I  give  expression  I  trust  I  shall  approach  the 
subject  free  from  the  thralldom  of  preconceived  ideas 
and  unbiassed  in  the  advocacy  of  any  one  method  of  pro- 
cedure only  in  so  far  as  the  merit  of  such  a  method  de- 
mands. 

Fortunately  for  mankind,  more  particularly  for  those 
who  are  obliged  to  bear  the  burdens  and  dangers  of  par- 
turition, nature  in  her  own  inimitable  ways  and  by  or- 
dinances that  far  surpass  in  beauty  and  perfection  of 
design  the  imagination  of  man,  is  usually  quite  compe- 
tent to  fulfil  this  trying  ordeal.  Occasionally,  however, 
the  pelvis  of  the  mother  or  unnatural  development  on 
the  part  of  the  foetus  may  render  it  absolutely  impossible 

1  Read  before  the  Colorado  State  Medical  Society,  June  19, 1894* 


568 


MEDICAL  RECORD. 


[November  3,  1894 


for  the  woman  to  be  delivered  normally,  and  it  is  here 
that  the  cunning  hand  of  the  surgeon  may  be  of  the  ut- 
most importance  to  life.  It  is  highly  commendatory  to 
the  standing  of  the  profession  at  the  present  time  that 
the  principles  we  advocate  have  been  so  beneficial  to 
mankind.  The  method  in  vogue  not  many  years  ago  of 
resorting  to  the  operation  of  craniotomy,  with  the  appal- 
ling disasters  that  followed  in  its  wake,  forms  one  of  the 
darkest  pages  in  the  history  of  obstetrics.  When  one 
contemplates  the  frequency  with  which  this  operation 
was  resorted  to  in  preference  to  others  much  less  danger- 
ous, it  would  seem  that  the  spirit  of  scientific  midwifery 
was  long  lulled  to  sleep  and  that  nature  had  become 
emasculated.  The  operation  of  eviscerating  the  yet  warm 
and  quivering  body  of  an  innocent  babe  from  its  mother's 
womb  should  be  reserved  for  very  rare  and  exceptional 
cases,  such  as  hydrocephalus,  or  where  the  child  is  already 
dead.  Much  more  satisfactory  and  humane  methods  are 
the  Caesarean  section  and  Porro's  method  of  operating. 

Porro's  operation,  unlike  the  majority  of  recent  tri- 
umphs in  surgery,  is  not  one  which  has  been  resuscitated 
after  having  been  performed  and  discarded  many  years 
before,  but  is  of  comparatively  recent  origin.  The  first 
successful  case  on  record  was  performed  in  the  year  1876 
by  Porro,  of  Batavia.  It  has  since  been  performed  a 
great  number  of  times  with  comparatively  good  results. 
Heretofore,  and  even  at  the  present  time,  this  operation 
and  the  Caesarean  section  had  been  indiscriminately  ad- 
vocated when  the  condition  present  called  for  one  or  the 
other  method.  I  believe  this  to  be  a  mistake.  Whether 
the  Caesarean  section  can  have  any  advantages  over  its 
recent  rival  rests  wholly  upon  a  question  of  morals. 
Certain  it  is  that  there  are  well-defined  conditions  and 
complications  in  pregnancy  when  Porro's  method  is  the 
only  scientific  course  to  pursue. 

Each  method  may  possess  well-defined  advantages  over 
the  other,  and  in  estimating  the  relative  values  of  Porro 
and  Caesarean  sections  a  number  of  important  conditions 
should  be  remembered.  In  all  cases  where  pregnancy  is 
complicated  by  tumors,  such  as  fibroid  of  the  uterus, 
ovarian,  or  dermoids,  as  was  the  condition  in  this  case, 
hysterectomy  is  the  preferable  operation.  Where  labor 
has  proceeded  for  a  long  time  and  the  uterus  becomes  pu- 
trid, Porro's  operation  ought  to  be  the  one  selected.  In 
certain  operations  begun  as  Caesarean  sections,  but  which 
become  complicated  by  difficulties  in  the  detachment  of 
the  placenta,  uncontrollable  hemorrhage,  or  complete 
atresia  of  the  vagina,  Porro's  is  the  operation  indicated. 
These  are  some  of  the  advantages  that  this  operation  pos- 
sesses over  the  classical  one.  In  straight,  uncomplicated 
cases  I  doubt  very  much  if  the  Caesarean  method  is*  su- 
perior to  the  Porro.  The  advocates  of  the  Caesarean 
section  maintain  that  because  Porro's  operation  forever 
renders  the  woman  sterile,  the  Caesarean  method  has  the 
advantage.  This  question  again  is  one  altogether  of 
morals ;  but  given  a  woman  with  a  deformed  pelvis  and  a 
contraction  of  its  diameters  so  that  one  or  the  other  op- 
eration was  absolutely  demanded,  and  believe  the  fact 
that  one  would  save  her  life  equally  as  certain  as  the 
other,  the  one  that  would  place  her  in  such  a  condition 
that  pregnancy  could  not  again  occur  would  be  the  pref- 
erable one.  I  look  upon  this  point  alone  as  a  decided 
advantage  of  Porro  over  its  rival.  Such  a  proceeding 
would  leave  the  life  of  the  mother  absolutely  free,  so  far 
as  any  future  chances  were  concerned.  I  am  well  aware 
that  this  is  at  variance  with  the  opinions  of  many  able 
minds,  but  nevertheless  it  is  one  that  I  have  long  main- 
tained, and  is  at  least  one  of  honesty. 

There  can  exist  no  reason  why  this  operation,  if 
properly  planned  and  carried  out  with  as  much  care  and 
precaution  as  other  abdominal  sections,  should  not  be 
almost  entirely  free  from  risk,  as  far  as  the  lives  of  mother 
and  child  are  concerned.  It  is  to  be  regretted  that  in  a 
great  majority  of  instances  the  idea  of  the  operation  does 
not  enter  into  the  head  of  the  physician  until  the  patient 
becomes  almost  entirely  exhausted  from  the  reiterated 
efforts  of  the  uterus  to  expel  the  foetus.    An  operation  of 


this  character  above  all  others  should  be  done  opportunely 
and  not  left  until  the  rough  manipulations  have  exhausted 
the  woman  and  materially  reduced  her  chances.  It  can 
readily  be  understood  why  the  mortality  of  this  opera- 
tion has  remained  so  high  in  view  of  the  fact  that  it  is 
usually  done  as  a  forlorn  hope. 

An  operation  that  has  recently  sprung  into  promi- 
nence, and  one  that  is  receiving  considerable  attention,  is 
that  of  symphyseotomy.  This  method  of  delivery  is  not 
of  recent  origin,  but  is  one  that  was  described  and  ad- 
vocated by  a  French  medical  student  as  far  back  as  the 
year  1768.  At  first  his  method  was  received  with  in- 
credulity and  doubt,  but  subsequently  having  performed 
the  operation  successfully  upon  a  woman  who  had  pre- 
viously given  birth  to  four  dead  children,  his  method 
was  at  once  admitted  and  he  became  the  recipient  of 
much  adulation  and  marks  of  esteem.  He  was  looked 
upon  as  the  benefactor  of  mankind,  and  the  neglected 
student  became  in  the  eyes  of  the  nation  an  illustrious 
personage.  From  that  period  the  operation  seems  to 
have  lapsed  into  neglect  until  recently  revived. 

The  conditions  calling  for  this  method  of  operation 
are  necessarily  limited.  It  is  only  in  slightly  contracted 
pelves  that  any  benefit  can  be  looked  for,  and  the  neces- 
sity for  Porro's  method  or  the  classical  Caesarean  section 
will  begin  where  the  operation  of  symphyseotomy  ends. 
In  well-marked  contracted  pelves  this  operation  gives 
way  to  the  suprapubic  methods,  and  finds  its  advan- 
tages in  such  cases  where  the  question  of  premature  labor 
may  be  meditated. 

Whether  this  operation  will  ultimately  supplant  the 
necessity  for  inducing  premature  birth,  will  rest  with 
the  future.  At  present,  according  to  the  most  recent 
arguments,  it  is  frequently  beset  with  disastrous  results, 
sufficient  to  raise  a  doubt  of  its  surviving.  The  most 
frequent  risks  seemingly  are  septicaemia,  hemorrhage, 
ossification  of  the  symphysis,  laceration  of  the  bladder, 
with  fistulae,  and  prolapse  of  the  vagina. 

On  August  .16th  I  was  called  in  consultation  by  Dr. 
E.  J.  Rothweli  to  see  a  patient  who  was  eight  months 
and  a  half  pregnant.  The  history  given  was  that  she 
was  thirty-two  years  of  age,  had  always  enjoyed  good 
health,  and  had  been  delivered  of  twins  a  few  years  pre- 
viously by  Dr.  E.  J.  Rothweli,  weighing  three  and  a 
half  pounds  each.  Dr.  Rothweli  at  that  time  noticed 
the  condition  of  the  pelvis.  She  afterward  became 
pregnant,  and  after  the  repeated  effort  of  days  Dr.  Roth- 
weli removed  the  child  by  craniotomy.  She  was  con- 
fined to  her  bed  for  three  months  afterward.  Upon  ex- 
amination the  cervix  was  so  high  that  I  could  not  detect 
it  with  my  finger ;  I  could,  however,  make  out  that  the 
foetus  was  alive  and  that  it  was  in  the  fourth  position.  It 
was  of  large  size,  and  we  felt  certain  it  was  physically 
impossible  to  deliver  the  patient  by  the  normal  channel. 

This  we  explained  to  her  and  her  husband,  and  ad- 
vised the  removal  of  the  child  by  abdominal  section  as 
the  method  attended  by  the  least  risk.  The  following 
were  the  pelvic  measurements :  Between  anterior-supe- 
rior spines,  9f  inches ;  between  crests  of  ilia,  10  inches  ; 
conjugate  vera,  3^  inches. 

A  few  days  subsequently  she  was  removed  to  my 
private  hospital  on  Vine  Street  and  was  prepared  for  the 
operation.  We  decided  to  operate  several  days  before 
the  expected  time  of  labor. 

Thursday  morning,  August  23d,  she  was  put  under  the 
influence  of  an  anaesthetic  by  Dr.  Leavitt.  The  abdom- 
inal incision  was  made  in  the  median  line  and  was  con- 
tinued above  the  umbilicus.  Any  bleeding  points  were 
caught  up  by  pressure-forceps  and  secured.  The  trans- 
versalis  fascia  was  cut  through  to  the  full  extent  of  the 
abdominal  wound.  The  subperitoneal  fat  was  caught 
between  two  pairs  of  forceps  and  gently  cut,  layer  after 
layer,  changing  the  forceps  for  a  deeper  layer  as  each 
one  was  cut.  This  process  was  continued  until  the 
peritoneum  was  opened  and  the  uterus  bulged  forward 
into  the  wound.  Whether  to  apply  the  temporary  liga- 
ture before  raising  the  uterus  from  its  position,  as  is  re- 


November  3,  1894] 


MEDICAL    RECORD. 


569 


commended  by  the  majority  of  operators,  or  doing  so 
afterward,  as  advocated  by  Miiller  and  others,  is  yet 
under  discussion.  In  this  case  I  decided  upon  the  latter 
alternative,  for  the  reason  that  it  can  be  more  properly 
adjusted  and  the  risk  of  including  a  loop  of  intestine  or 
a  piece  of  omentum  under  the  rubber  is  obviated.  The 
increase  in  abdominal  incision  is  more  than  compen- 
sated by  the  advantages  gained. 

Before  the  incision  into  the  uterus  was  begun,  several 
warm,  flat  sponges  were  placed  between  the  uterus  and 
intestines,  for  the  double  purpose  of  keeping  them  from 
cooling  and  preventing  fluid  from  escaping  into  the  ab- 
domen. The  incision  was  vertical,  beginning  near  the 
fundus,  cutting  toward  the  cervix  about  four  inches.  I 
went  carefully  through  the  whole  extent  of  the  incision, 
layer  after  layer,  until  I  came  to  the  membrane,  which 
was  intact.  The  uterine  walls  retracted,  exposing  the 
foetus  as  through  tissue  paper.  I  ruptured  the  membrane 
and  the  uterus  contracted,  the  child  entered  the  world 
head  first,  crying  lustily,  and  was  turned  over  to  one  of 
the  attending  nurses.  Here  I  was  confronted  by  the 
unexpected  complication  of  two  dermoid  tumors  of  the 
ovaries,  and  decided  to  remove  them  also,  together  with 
the  uterus.  As  in  hysterectomy  for  fibroid  tumors  of 
the  uterus,  experience  has  taught  us  that  the  extra-peri- 
toneal method  of  fixation  of  the  pedicle  is  the  one  fol- 
lowed by  the  most  favorable  results.  The  simple  method 
of  converting  the  temporary  elastic  ligature  into  a  per- 
manent one  is  as  good  as  any,  and  saves  time.  The 
pedicle  was  now  fixed  in  the  lower  part  of  the  wound  after 
all  clots  were  removed  from  Douglas's  cul  de  sac.  In  order 
to  prevent  the  pedicle  from  retracting,  a  staple  was 
passed  through  it,  immediately  above  the  constrictor. 
The  peritoneum  was  then  sutured  separately.  The  deep 
sutures  to  close  the  abdominal  wound  were  inserted 
subsequently.  Stitches  were  inserted  as  in  other  ab- 
dominal sections  and  the  wound  dressed.  The  patient 
made  a  very  satisfactory  recovery.  Her  temperature  re- 
mained normal  for  nearly  two  weeks.  She  and  her  baby, 
as  you  may  see,  are  enjoying  the  best  of  health. 

405  California  Building,  Seventeenth  Street. 


PERMANGANATE    OF    POTASSIUM   IN  MOR- 
PHINE POISONING. 
By   HILBERT   B.    TINGLEY,    M.D., 

KCCKAWAY  BEACH,   M.   Y. 

On  July  30th  I  was  hastily  summoned  to  see  baby 
C ,  eighteen  months  of  age,  who  had  taken  two  mor- 
phine pills,  one-quarter  grain  each.  On  arriving  at  the 
house  I  found  the  child  still  conscious  with  pupils  con- 
tracted almost  to  pin  point  and  as  it  was  about  8.30  p.m. 
I  decided  that  I  had  an  excellent  case  for  the  trial  of 
permanganate  of  potassium.  I  sent  across  the  street  for 
the  bottle  of  permanganate  in  the  drug  store  immedi- 
ately opposite,  and  gave  about  one  grain  at  once,  and  as 
I  wished  to  give  this  drug  a  thorough  trial,  gave  no 
other  medicine,  not  even  an  emetic.  About  n  p.m.  I 
allowed  them  to  put  the  child  to  bed,  as  it  was  then  two 
hours  later  than  its  bedtime,  but  before  they  did  so,  I 
gave  about  one  grain  more  of  the  permanganate.  Dur- 
ing the  night  the  child  had  some  delirium  of  a  wild  nat- 
ure and  had  little  sleep,  but  next  day  appeared  none  the 
worse  for  its  overdose  of  morphine.  The  result  has 
given  me  great  faith  in  this  drug  in  these  cases. 


To  Elevate  Woman.— A  writer  in  an  ethical  journal 
has  a  new  idea  for  the  benefit  of  women.  It  is  that  men 
and  women  should  deliberate  together  and  establish  a 
rule  that  the  woman's  child  bearing  years  should  be  very 
much  reduced  in  number,  also  that  they  should  agree  to 
allow  a  longer  period  between  the  birth  of  children.  The 
lady  does  not  go  into  particulars,  so  we  are  unable  to 
give  the  details  by  means  of  which  these  reforms  are  to 
be  made  effectual. 


NEW  YORK  ACADEMY  OF  MEDICINE. 

Stated  Meeting,  October  iS,  1894. 

D.  B.  St.  John  Roosa,  M.D.,  President,  in  the  Chair. 

Reports. — Dr.  A.  B.  Judson,  statistical  secretary,  and 
Dr.  M.  Allen  Starr,  corresponding  secretary,  presented 
reports.  The  recording  secretary  read  a  written  report 
from  the  Committee  to  the  State  Constitutional  Conven- 
tion, presented  by  its  secretary,  Dr.  W.  R.  Pryor,  a 
synopsis  of  which  has  been  published.  Allusion  was 
made  to  the  necessity  for  a  committee  on  legislation, 
and  the  President  said  he  would  at  some  other  time 
gladly  entertain  a  motion  to  appoint  such  a  committee, 
as  he  felt  there  was  great  need  of  one  in  order  to  prevent 
the  passage  of  bad  laws  relating  to  medicine,  as  well  as 
to  urge  the  passage  of  good  ones.  It  was  desirable, 
however,  in  case  there  were  any  who  might  oppose  such 
a  motion,  to  first  give  notice  of  its  introduction,  in  or- 
der that  all  might  have  a  chance  to  vote  on  it  as  their 
consciences  dictated.  But  the  fact  could  not  be  repeated 
too  often  that  the  profession  must  make  its  wants  known 
if  it  would  have  them  granted. 

Defective  Vision,  in  its  Relation  to  Crime. — Dr. 
Frank  Van  Fleet  read  a  paper  bearing  this  title.  He 
believed  the  human  race  had  not  altered  since  the  be- 
ginning ;  that,  at  any  rate,  there  had  been  no  change 
since  the  earliest  time  known  to  history.  At  one  time 
man  roamed  over  the  globe  in  herds,  there  being  no 
family  ties,  no  laws,  consequently  no  criminals.  As 
people  multiplied,  it  became  more  convenient  to  settle, 
to  live  in  towns,  and  in  families ;  to  have  laws ;  and 
these  being  violated,  crime  came  into  existence.  There 
was  a  change  of  environment,  not  a  change  of  man. 
Heredity  was  a  misnomer.  Everything  was  due  to  en- 
vironment. One  who  could  control  the  education  and 
environments  of  a  child  could  make  of  it  what  he 
pleased.  An  English  child  put  in  Germany,  and  taught 
only  German,  would  grow  up  with  no  English  character- 
istics, and  differ  in  no  way  from  German  children.  If 
one  were  to  expect  criminals  to  beget  criminals,  he 
should  also  expect  intellectual  persons  to  transmit  to 
their  offspring  greater  intelligence  than  those  not  intel- 
lectual. The  author  asserted,  however,  that  the  only 
influence  which  good  parentage  could  have  was  to  give 
better  training  and  set  a  better  example  during  the  de- 
veloping period ;  the  sole  influence  of  criminal  parentage 
was  the  bad  example  set  during  growth. 

Man  received  his  education  through  the  senses.  Any 
of  these  might  be  defective,  and  warp  his  view  of  things, 
or  interfere  with  the  race  of  life.  But  it  was  with  de- 
fective vision  that  the  author  was  concerned.  His 
idea  of  the  way  in  which  this  produced  criminals 
seemed  to  be  chiefly,  at  least,  that  it  detracted  from  the 
individual's  power  to  compete  with  his  more  fortunate 
fellows.  Mention  was  made  of  the  fact,  however,  that 
defective  vision  might  cause  one  to  take  a  warped  view 
of  things.  Examination  of  the  eyes  of  a  part  of  the 
juvenile  delinquents  on  Randall's  Island,  led  him  to 
think  there  was  defective  vision  in  a  larger  percentage 
of  these  persons  than  the  average.  Ocular  defects 
should  be  corrected  as  far  as  possible,  and  those  which 
were  acquired,  such  as  ophthalmia  neonatorum,  should 
be  prevented  or  arrested  a.t  once.  A  certificate  of  ocular 
examination  and  proper  treatment  was  more  important 
than  one  of  vaccination  among  school  children. 

The  discussion  was  opened  by  Dr.  H.  D.  Chapin,  and 
continued  by  Drs.  Joseph  Collins,  Frederick  Peterson, 
John  E  Weeks,  the  President,  and  the  author.  As  far 
as  the  gentlemen  expressed  their  views,  all  disagreed  with 
the  author,  except  with  regard  to  the  importance  of  at- 
tention to  defective  vision  wherever  it  existed. 

Drs.  Collins  and  Peterson  especially  criticised  the 
stand  taken  with  regard  to  the  overwhelming  influence 


57o 


MEDICAL   RECORD. 


[November  3,  1894 


of  environment  as  compared  with  heredity,  and  failure 
to  refer  to  any  other  authority  than  an  article  by  a  po- 
lice superintendent,  when  so  many  scientists  had  studied 
and  written  upon  the  subject.  Dr.  Peterson  had  ob- 
served that  eye  troubles  were  very  common  among  the 
Egyptians  and  Arabs,  while  crime  was  extremely  rare. 

Dr.  Weeks  thought  the  author  had  adopted  a  very 
superficial  way  of  examining  the  eyes  at  Randall's  Island 
institution,  considering  the  point  which  he  was  trying  to 
prove.  The  fact  that  more  than  half  of  those  examined 
had  been  found  to  have  defective  vision  was  not  aston- 
ishing, when  it  was  remembered  that  astigmatism  was 
present  in  about  two  thirds  of  all  persons,  while  perfect 
vision  was  very  rare.  In  his  opinion  defect  of  vision 
was  not  more  productive  of  crime  than  defect  of  any 
other  sense. 

Dr.  Chapin  spoke  feelingly  of  the  want  of  accommo- 
dations in  the  eye  hospitals  and  other  institutions  in  the 
city,  for  children  suffering  with  inflammatory  eye  troubles, 
especially  those  of  a  contagious  nature. 

Dr.  Weeks  and  the  President  said  this  was  not  the 
fault  of  the  existing  ophthalmic  institutions,  but  of  the 
city  officials,  in  failing  to  provide  hospital  accommoda- 
tions for  these  patients.  Dr.  Weeks  had  found  it  possi* 
ble  to  cure  nearly  all  of  the  cases  at  the  out-door  depart- 
ment, where  the  mother  followed  instructions  and  brought 
the  patient  back  for  treatment  daily. 


SECTION   ON   GENERAL  MEDICINE. 

Stated  Meeting,  October  16,  1894. 

William  H.  Porter,  M.D.,  Chairman. 

Case  of  Sporadic  Cretinism.  —  Dr.  Morris  Manges 
presented  a  case  of  sporadic  cretinism  which  had  once 
been  on  exhibition  in  a  dime  museum  and  had  once  been 
demonstrated  before  a  medical  meeting  by  Dr.  Leszynsky. 
The  subject  was  a  male,  twenty- five  years  of  age,  forty- 
nine  inches  in  height,  weight  sixty  eight  pounds.  He 
was  born  of  healthy  parents  in  Posen  ;  the  father  was  six 
feet  in  height,  the  mother  of  ordinary  size.  Other  chil- 
dren in  the  family  were  healthy  and  normal.  When 
carrying  the  child  the  mother  had  haemoptysis.  She  de- 
scribed.him  as  a  little  old  man  when  born.  He  was  always 
dull  and  stupid  The  eyes  were  small,  the  forehead  small, 
the  bones  prominent,  the  folds  on  the  forehead  deep,  the 
scalp  loose,  the  gait  waddling,  the  hair  dry  and  wiry, 
thyroid  gland  apparently  absent.  Before  treatment  with 
thyroid  extract  there  was  some  infiltration  of  skin,  par- 
ticularly of  eyelids.  When  irritated,  the  boy  used 
vigorous  language.  Since  beginning  treatment  with 
thyroid  extract  over  two  months  ago  there  had  been 
loss  of  nine  pounds  in  weight,  the  eyelids  had  lost  their 
oedematous  appearance,  the  voice  had  become  less  stridu- 
lus, the  patient  gave  more  attention  to  his  surroundings, 
the  daily  excretion  of  urea  had  increased  from  o  8  to 
1.2  per  cent.  It  was  very  doubtful,  however,  whether  at 
this  late  date  the  thyroid  extract  could  manifest  curative 
properties  or  do  more  than  somewhat  ameliorate  the  pa- 
tient's condition. 

The  speaker  expressed  surprise  that  so  few  cases  of 
sporadic  cretinism  had  been  reported  in  this  country,  the 
whole  number  since  Osier's  first  paper  a  few  years  ago 
amounting  only  to  sixteen,  whereas  it  was  pretty  certain 
that  a  good  many  cases  were  in  existence. 

Among  the  preparations  of  the  thyroid  gland  which 
had  been  tried  on  this  patient  were  those  of  Parke,  Davis 
&  Co.,  of  Armour,  and  of  Burroughs,  Welcome  &  Co. 
The  latter  had  given  the  best  results  with  the  least  dis- 
agreeable effects.  Twenty-five  grains  were  now  being 
taken  a  day. 

Dr.  George  W.  Crary,  to  whose  case  Dr.  Manges 
had  referred,  said  that  since  the  publication  of  his  case 
he  had  received  letters  regarding  sporadic  cretinism  from 
all  over  the  United  States,  which  showed  that  the  condi- 
tion was  not  rare,  notwithstanding  the  paucity  of  the  re- 
ported cases.     By  the  use  of  the  thyroid  preparations  we 


could  easily  get  rid  of  the  glandular  growths,  could  ren- 
der the  skin  moist,  and  produce  certain  general  improve- 
ments in  the  patient's  condition  within  a  short  time,  but 
it  had  not  been  at  all  decided  that  we  could  cause  these 
diminutive  persons  to  go  on  and  develop  into  complete 
human  beings.  He  had  been  disappointed  in  the  slow- 
ness of  the  improvement  in  his  case.  It  was  quite  differ- 
ent, however,  with  myxoedema,  in  which  condition  the 
agent  possessed  wonderful  curative  properties.  Like  Dr. 
Manges,  his  experience  with  other  preparations  of  the 
thyroid  gland,  including  that  which  he  had  himself  for  a 
time  made,  had  been  less  favorable  than  with  the  tab- 
loids of  Burroughs,  Welcome  &  Co.  Unlike  the  former, 
the  tabloids  did  not  cause  rise  of  temperature  and  disa- 
greeable effects  upon  the  gastro  intestinal  tract,  and  the 
dose  with  these  was  determined  by  the  frequency  of  the 
pulse  instead  of  by  the  temperature. 

One  of  the  staff  at  the  Vanderbilt  Clinic  said  they  had 
been  treating  a  child  there  a  few  months  with  thyroid 
extract,  and  it  had  shown  marked  improvement. 

Dr.  Caill£  had  seen  some  cases  treated  by  thyroid 
preparation,  but  could  not  say  that  there  had  been  spe- 
cial improvement. 

Barly  Local  Treatment  of  Diphtheria  and  other  Af- 
fections of  the  Throat. — Dr.  Francis  H.  Williams,  of 
Boston,  read  the  paper.  It  was  based  on  studies  in  diph- 
theria in  the  hospital  at  Boston ;  also  in  private  practice. 
It  was  assumed  that  at  the  beginning  diphtheria  was  a 
local  disease.  These  studies  had  shown  the  value  of 
bacteriological  examinations  of  the  juices  in  the  throat 
in  making  an  early  diagnosis,  especially  in  apparently 
healthy  members  of  a  household  in  which  there  was  one 
known  case  of  diphtheria  ;  of  determining  whether  the 
patient  had  become  fully  convalescent ;  of  the  efficiency 
of  treatment  by  its  destruction  oi  the  bacilli.  All  pa- 
tients, however,  should  be  warned  of  tte  possibility  of 
communicating  diphtheria  even  after  bacteriological  ex- 
aminations had  ceased  to  show  bacilli  or  diphtheria. 

A  few  years  ago  the  author  had  become  convinced  that 
many  local  treatments  were  useless  or  injurious,  and  to 
determine  what  was  best  turned  to  the  laboratory. 
Many  germicides,  while  capable  of  killing  the  germs, 
did  so  only  in  poisonous  doses  to  the  patient  or  by  in- 
juring the  local  parts.  He  found  peroxide  of  hydrogen 
a  weak  germicide  in  ordinary  strength.  He  then  found 
that  the  efficiency  of  this  agent  was  increased  by  the 
presence  of  an  acid.  The  two  mixed  acted  more  strongly 
as  a  germicide  than  either  did  separately.  The  prepara- 
tions in  the  market  were  not  reliable  either  as  to  the 
strength  of  the  peroxide  or  of  the  amount  of  acid  which 
they  contained.  He  made  careful  study  and  found  that 
where  the  membrane  was  thick  and  the  case  severe  a  fifty- 
volume  solution  of  the  peroxide  was  not  too  strong  if 
one  would  disintegrate  the  membrane  and  reach  all  the 
germs.  For  the  hydrogen  dioxide  acted  not  only  as  a 
germicide,  but  was  specially  valuable  as  a  disintegrator  of 
the  false  membrane.  The  paper  contained  a  series  of 
cases,  showing  that  the  fifty- volume  solution  was  more  ef- 
ficient than  the  ten,  and  that  where  the  former  was  used 
the  throat  was  free  of  germs  of  diphtheria  and  other 
germs  by  about  the  fourteenth  day,  as  against  the  twenty- 
seventh  day  where  the  weaker  solutions  were  used.  Of 
course  the  persistence  of  the  germs  varied  with  the  se- 
verity of  the  case.  The  strength  of  the  solutions  which 
he  now  used  varied  from  twenty  five  to  fifty  volumes,  ac- 
cording to  the  severity  of  the  case.  In  a  few  days  the 
bacilli  were  found  much  diminished  in  number,  and  he 
was  strongly  inclined  to  believe  that  where  the  Klebs- 
Loe  filer  bacillus  was  present  after  the  tenth  day  under 
this  treatment  it  was  due  to  its  being  concealed  in  some 
crypt?,  or  other  hiding-place,  and  should  be  sought  out 
carefully.  In  some  cases  membrane  remained  after  the 
Klebs-Loeffler  bacillus  had  disappeared,  and  was  due 
probably  to  the  presence  of  the  staphylococcus,  which 
was  not  so  easily  killed,  and  required  the  use  of  some 
other  germicide,  as  chlorinated  soda. 

Dr.  Williams  had  used  the  stronger  solutions  of  hydro- 


November  3,  1894] 


MEDICAL   RECORD. 


57i 


gen  dioxide  in  one  hundred  cases  of  diphtheria,  of  vary- 
ing severity,  in  all  the  jliagnosis  having  been  confirmed 
by  bacteriological  examination.  It  did  not  injure  the 
mucous  membrane.  It  could  be  used  along  with  other 
compatible  germicides,  or  alternately.  It  should  be 
used  early  and  until  the  germs  disappeared.  Applications 
every  hour  or  two.  The  operator  should  always  see  the 
parts  when  making  the  applications.  Use  a  spray,  not 
more  than  six  pounds  pressure.  An  ingenious  apparatus 
was  exhibited  for  spraying  the  liquid.  All  gentleness 
should  be  observed,  and  then  harm  would  not  be  done, 
and  the  patient  would  call  for  the  treatment,  since  it 
cleansed  out  the  throat  and  nose  and  made  breathing 
easier. 

Dr.  George  L.  Peabody  being  called  upon,  made  a 
few  remarks,  but  said  he  did  not  see  enough  cases  of 
diphtheria  to  speak  with  authority  on  local  treatment. 
The  author  had  properly  emphasized  the  importance  of 
early  diagnosis  and  treatment,  whatever  the  treatment 
might  be,  if  it  were  only  beneficial. 

Peroxide  of  Hydrogen  Found  Injurious.— Dr.  A 
Catlls  mentioned  the  following  facts:  diphtheria  is 
endemic  here;  some  years  it  is  more  plentiful  than 
others;  it  may  be  a  mixed  infection,  and  may  kill  by 
the  presence  of  either  the  streptococcus  or  the  diphtheria 
bacillus ;  every  local  abrasion  favors  the  development  of 
the  germs,  which  may  be  present  even  in  seemingly 
healthy  throats;  prophylaxis  by  attention  to  the  teeth 
and  mild  germicides  and  cleansing  of  the  throat  and 
mouth  should  be  observed.  Regarding  peroxide  of  hy- 
drogen, Dr.  Williams's  experience  had  not  been  in  har- 
mony with  that  of  New  York  physicians.  Beginning 
with  the  meeting  of  the  American  Pediatric  Association 
in  Boston  a  few  years  ago,  the  profession  had  given  ex- 
pression to  its  experience  that  peroxide  of  hydrogen  ap- 
plied to  the  throat  in  diphtheria  caused  irritation,  gave 
rise  to  new  patches  of  membrane,  and  made  the  case 
more  formidable  than  it  had  been  before.  It  seemed 
impossible  to  apply  chemical  antiseptics  to  the  mouth 
and  nasopharynx  without  doing  injury,  and  he  had 
come  to  content  himself  with  gentle  mechanical  removal 
and  cleansing  by  mild  solutions  of  salt,  boracic  acid,  or 
pure  water,  through  the  nose. 

Impossible  to  Disinfect  the  Air  -  passages. — Dr. 
W.  H.  Park  said  he  would  only  give  his  personal  ex- 
perience, and  remarked  that  it  was  seldom  that  any  two' 
persons  agreed  in  all  respects.  At  Willard  Parker's  they 
had  tried  whether  it  was  possible  to  completely  disinfect 
the  air  passages,  using  even  strong  solutions  of  bichloride 
and  other  agents  for  twenty-four  to  forty-eight  hours,  in 
some  persons  who  had  no  membrane  in  the  throat,  in 
others  in  whom  a  membrane  was  present,  but  in  no  case 
could  they  make  the  throat  perfectly  aseptic.  In  a  cer- 
tain number  the  Klebs-Loeffler  bacillus  did  disappear, 
but  in  others  they  were  as  numerous  as  if  nothing  had 
been  done.  Even  if  the  membrane  quite  disappeared 
from  view,  germs  would  still  remain  and  cause  its  devel- 
opment elsewhere.  He  hoped  to  hear  from  Dr.  White, 
who  had  carried  out  treatment  at  Willard  Parker's  to 
test  the  comparative  value  of  bichloride,  of  peroxide, 
and  of  simple  salt  solution.  Bichloride,  1  to  2,500  in  the 
throat,  1  to  4,000  in  the  nostrils  was  used  in  one  class, 
peroxide  of  hydrogen  up  to  twenty-five  per  cent,  in  an- 
other, salt  solution  in  a  third.  In  all,  the  bacilli  per- 
sisted about  the  same  length  of  time,  or  even  longest 
where  the  strong  solutions  were  used.  As  to  results,  Dr. 
White  had  noticed  little  difference. 

It  was  very  difficult  to  apply  %swab  without  injuring 
the  member.  They  now  tried  simply  to  use  a  cleansing 
solution,  and  to  avoid  irritation.  He  had  been  told  by 
Dr.  White  that  very  rarely  did  an  adult  or  a  person  over 
ten  years  old  die  of  diphtheria. 

Dr.  Joseph  £.  Winters  also  thought  that  Dr.  Will- 
iams's experience  with  peroxide  of  hydrogen  was  entirely 
different  from  that  of  physicians  in  New  York.  In  fact 
the  frequent  use  of  the  agent  increased  rather  than  di- 
minished the  symptoms.   He  regarded  it  as  impractical  to 


use  any  spray  or  atomizer  in  diphtheria  in  a  child ;  as  to 
adults,  they  almost  always  recovered,  as  Dr.  Park  had 
stated.  It  seemed  to  him  that  he  could  not  resort  to  any 
form  of  local  treatment  in  the  mouth  of  a  young  child 
suffering  from  diphtheria  without  running  contrary  to 
the  first  indication  in  the  management  of  these  cases, 
namely,  not  to  exhaust  the  patient. 

Experience  at  Willard  Parker  Hospital.— Dp.  White, 
resident  physician  at  the  Willard  Parker  Hospital,  said 
that  his  experience  with  peroxide  of  hydrogen  in  diphthe- 
ria at  that  institution  had  been  very  unfavorable.  All  the 
cases  showed  some  signs  of  irritation  from  the  peroxide. 
His  remarks  confirmed  those  of  Dr.  Park  with  regard  to 
the  danger  of  irritation  in  local  treatment  of  the  mouth 
in  children  and  with  regard  to  the  rarity  of  death  in 
adults  with  diphtheria.  Cleansing  with  plain  water  or 
normal  salt  solution  was  best. 

Dr.  A.  Jacobi  dwelt  upon  the  clanger  of  making  local 
wounds  in  diphtheria  of  any  size  or  nature,  as  they  ab- 
sorbed diphtheritic  poison  very  rapidly  and  formed  new 
centres  of  infection.  For  twenty  or  thirty  years  he  had 
impressed  the  danger  of  wounds  in  the  throat  in  times  of 
diphtheria.  Bacilli  were  ubiquitous.  The  discussion  at 
the  American  Pediatric  Association  referred  to  by  Dr. 
Cailll,  regarding  the  dangers  incident  to  irritation 
caused  by  peroxide  of  hydrogen,  was  based  on  a  paper 
presented  by  Dr.  Jacobi.  A  striking  example  in  which 
the  continued  use  of  this  agent  had  prevented  perfect 
convalescence  and  caused  renewed  attacks  of  diphtheria, 
was  that  of  a  child  which  the  speaker  had  been  requested 
to  see  in  consultation  with  Dr.  Cailll.  He  advised  dis- 
continuance of  the  peroxide,  whereupon  the  child  got 
well. 

Dr.  Jacobi  used  only  physiological  salt  solution,  or 
possibly  mild  boracic- acid  solution,  or  lime-water,  intro- 
duced gently  through  the  nose.  It  was  criminal  to  bore 
into  the  mouth  of  a  child  and  try  to  pry  open  its  jaws 
while  it  was  struggling  and  becoming  exhausted.  Besides 
the  affected  parts  could  not  be  reached  in  that  way,  while 
they  could  through  the  nose. 

Dr.  Williams,  in  some  concluding  remarks,  reiterated 
the  points  in  his  paper,  that  the  peroxide  must  be  strong, 
it  must  be  acid,  and  the  treatment  must  be  carried  out 
with  gentleness.  Only  the  remarks  of  Drs.  Park  and 
White  had  a  real  bearing  upon  his  paper,  for  they  alone 
had  used  a  strong  solution  of  peroxide,  but  that  was  neu- 
tral, and  therefore  not  efficient. 


An  Ectromelic  Monster. — Dr.  A.  Schirman,  of  this 
city,  writes  concerning  a  monstrosity  "which  he  saw 
about  two  years  ago  in  Baltimore.  He  was  called  to 
attend  a  woman  in  confinement.  The  child,  a  female, 
was  born  dead.  The  frontal  bone  was  undeveloped,  the 
parietal  was  flattened,  the  occipital  was  horizontal  in 
position,  the  temporal  bones  were  very  prominent. 
There  was  a  cleft  palate,  and  the  narrowed  cranial  cav- 
ity contained  no  hemispheres.  The  mother  was  about 
thirty  years  of  age,  and  had  given  birth  to  several  healthy 
children  and  to  two  with  cleft  palate  and  hare-lip.  No 
dissection  of  the  monster  was  allowed. 

The  Way  of  the  Health  Officer  is  Hard.— In  Brook- 
lyn there  has  been  much  dissatisfaction  expressed  in  some 
quarters  with  the  health  officer,  and  a  petition  for  his 
removal  was  circulated,  and  obtained  a  number  of  sig- 
natures of  those  who  thought  he  was  too  strict  in  enforc- 
ing quarantine  and  vaccination  during  the  prevalence  of 
small-pox.  In  Detroit  the  health  officer  has  been  de- 
posed because  it  was  said  that  he  was  too  lax  in  enforc- 
ing quarantine  and  vaccination  during  the  prevalence  of 
small-pox.  In  Milwaukee,  also,  impeachment  proceed- 
ings have  been  begun  in  the  common  council  against  the 
health  commissioner,  for  the  manner  in  which  he  handled 
the  small-  pox  epidemic  in  that  city  last  winter.  It  is  not 
said  whether  he  is  accused  of  being  too  severe  or  too 
lenient  The  sanitary  via  media  is  a  very  narrow  path, 
apparently. 


572 


MEDICAL  RECORD 


[November  3,  1894 


fkncKtevon&euce. 

OUR  LONDON  LETTER. 

(From  our  Special  Correspondent) 

OLIVER  WENDELL  HOLMES— OBSTETRICAL  SOCIETY — AB- 
SCESS OF  OVARY — MEDICAL  SOCIETY  OF  LONDON — THE 
PLEASURES  OF  MEDICINE  AND  SURGERY — BERIBERI — 
CHELSEA  HOSPITAL  SCANDAL — MEDICAL  DEFENCE  UNION 
— SMALL  POX — DIPHTHERIA — DEATH  OF  MR.  BUNCH — 
SIR  JAMES  PAGET  AT  THE  ABERNETHLAN  SOCIETY — THE 
CLINICAL  SOCIETY'S  FIRST  MEETING — SMALL-POX — DIPH- 
THERIA. 

London,  October  13,  1894. 

My  first  word  this  week  must  be  to  express  the  sense  of 
loss  we  feel  here  in  the  decease  of  Dr.  Oliver  Wendell 
Holmes.  England,  as  well  as  America  and  all  English- 
speaking  countries,  were  delighted  by  his  genius,  and 
medicine  may  well  be  as  proud  of  him  as  literature. 
Since  his  last  one  hundred  days  in  Europe  he  has  been, 
if  possible,  more  one  of  us  than  ever,  and  his  death  is 
the  one  talked-of  topic  of  the  week  among  medical  and 
literary  men. 

The  Obstetrical  Society  was  the  first  to  meet  this  year, 
and  set  to  work  with  a  full  programme  on  October  3d. 
Specimens  were  exhibited  of  tubal  abortion  and  of  preg- 
nancy in  a  rudimentary  uterine  horn,  by  Dr.  Remfry ; 
of  myoma  removed  by  abdominal  hysterectomy,  by  Dr. 
Cullingworth ;  of  fibrocystic  tumor,  by  Dr.  Lewers ; 
and  the  following  by  Dr.  Duncan :  dermoid  of  left  ovary 
with  pedicle  twisted  from  left  to  right,  cystic  sarcoma 
of  omentum,  sarcoma  of  ovaries,  and  malignant  disease 
of  omentum.  There  were  some  interesting  remarks  on 
these  specimens  by  Mr.  Bland  Sutton  and  others.  Dr. 
Cullingworth  read  the  paper,  which  embodied  three  cases 
of  pelvic  inflammation  attended  with  abscess  of  the 
ovary  and  some  clinical  remarks  on  the  terminations  of 
such  abscesses,  the  illusory  character  of  temporary  sub- 
sidence of  the  symptoms  in  some  cases  of  severe  pelvic 
inflammation.  He  said  that  an  analysis  of  eighty  three 
cases,  in  which  he  had  performed  abdominal  section  for 
non-cellulitic  pelvic  suppuration,  showed  that  in  a  large 
percentage  there  was  ovarian  abscess  which  was,  next  to 
salpingitis,  the  most  frequent  form  of  non-cellulitic  sup- 
puration. Dr.  Galabin  supported  the  view  held  by  the 
author,  that  the  suppurative  inflammation  was  communi- 
cated from  the  tube  to  the  ovary,  but  this  was  contro- 
verted by  Dr.  Hayes,  and  Dr.  Griffith  believed  that  the 
ovarian  suppuration  was  usually  the  result  of  septic  in- 
flammation of  the  broad  ligament.  Dr.  Lewers  recalled 
a  case  in  which  he  found  the  inflammatory  process  be- 
tween the  layers  of  the  broad  ligament  in  the  stage  of 
phlegmon,  but  in  the  adjoining  ovary  a  small  abscess 
containing  about  a  drachm  of  pus.  The  president  (Dr. 
Herman)  mentioned  two  cases  differing  somewhat  from 
Dr.  Cullingworth's,  one  of  which  showed  the  chronicity 
of  the  process,  and  proved  that  with  our  present  knowl- 
edge the  patient  might  have  been  saved  twenty  years  of 
suffering. 

The  Medical  Society  began  work  on  Monday  last, 
when  the  president  (Sir  William  Dalby)  delivered  an 
address  on  the  "  Pleasures  of  Medicine  and  Surgery,"  in 
which  he  proposed  to  show  that  our  pursuits  may  so  oc- 
cupy us  as  to  raise  them  to  an  art  in  its  highest  sense, 
and  will  then  give  us  all  the  delights  which  art  gives  to 
its  votaries.  He  limited  the  pleasures  to  mental  proc- 
esses, excluding  those  of  sensation  and,  therefore,  those 
which  appeal  to  the  eye  and  the  ear.  The  exercise  of 
the  imagination,  he  said,  was  one  of  the  greatest  pleas- 
ures, and  he  saw  in  some  the  enthusiasm  of  the  explorer, 
and  gave  illustrations  from  both  medicine  and  surgery. 
The  activity  of  the  imagination  is  the  mark  of  genius  in 
poets  and  artists.  If  the  mental  processes  are  the  same 
in  one  who  establishes  a  great  advance  in  medicine, 
should  he  be  denied  the  attribute  of  genius  ?  He  wished 
to  place  our  art  side  by  side  with  literature  and  the  arts, 


and  held  that  it  is  worth  cultivating  not  only  for  its 
utility  but  for  the  pleasure  of  those  engaged  in  it.  Poe- 
try and  literature  give  pleasure  of  two  kinds,  emotional 
and  intellectual,  and  although  in  some  instances  they 
are  both  operative,  there  are  forms  of  literature  of  which 
the  enjoyment  is  purely  intellectual,  the  emotions  re- 
maining untouched.  So  he  claimed  for  medicine  a 
family  relationship  with  the  arts  and  literature,  and  a 
share  in  the  intellectual  pleasures  they  give. 

The  outbreak  of  beriberi  in  the  Richmond  Asylum, 
Dublin,  continues.  There  have  been  149  cases,  of 
which  1 7  have  died.  Possibly  some  other  cases  have  oc- 
curred, for  in  some  of  these  it  came  on  so  insidiously 
that  it  would  have,  perhaps,  been  overlooked  but  for  at- 
tention being  directed  to  the  epidemic.  Some  army 
surgeons  who  have  seen  beriberi  in  the  East  have  visited 
the  asylum  and  they  observed  differences  in  the  clinical 
manifestations  of  the  Dublin  cases,  but  these  they  seem 
to  think  may  be  accounted  for  by  the  difference  of  cli- 
mate. If  the  disease  is  really  beriberi  it  has  for  the  first 
time  obtained  a  footing  in  these  countries.  Some  cases 
have,  indeed,  been  brought  in  ships,  but  it  has  never 
spread.  Yet  this  outbreak  at  Dublin,  whatever  it  may 
be,  has  spread  very  rapidly.  This  is  attributed  to  over- 
crowding, always  an  important  point  in  this  disease,  and 
temporary  hospitals  are  being  erected  to  relieve  this. 

On  Wednesday  last  (October  10th)  there  was  a  gen- 
eral meeting  of  the  Governors  of  the  Chelsea  Hospital 
for  Women,  when  the  committee  gave  a  report  and  of- 
fered their  defence  and  resignation.  Some  sarcastic 
criticisms  were  offered  on  the  conduct  of  a  Board  which 
had  been  publicly  condemned  proceeding  to  elect  a  new 
staff  and  offer  suggestions  for  improved  management 
This  Board  actually  asked  for  power  to  suspend  or  dis- 
miss any  medical  officer  who  had  acted  in  a  manner  det- 
rimental to  the  interests  of  the  hospital.  What  this 
means  is  obvious  from  the  declaration  of  the  Chairman 
that  some  of  the  staff  who  had  not  been  reelected  had 
injured  the  hospital  by  circulating  a  statement  of  their 
own  defence.  And  yet  men  are  to  be  found  ready  to 
accept  this  ignominious  position  with  the  glaring  fact  of 
the  injustice  to  their  predecessors  confronting  them. 
And  we  call  ourselves  a  united  profession  and  prate 
about  ethical  conduct ! 

The  Board  also  announced  their  intention  of  appoint- 
ing  consulting  physicians  of  eminence  from  those  who 
held  office  at  the  general  hospitals.  Now  Sir  Spen- 
cer Wells,  Dr.  R.  Barnes,  and  Mr.  Hutchinson  were 
the  consulting  officers.  They  have  resigned  and  evi- 
dently in  disgust.  It  is  well  known  that  they  disclaim 
any  part  in  the  election  of  the  new  staff,  and  condemn 
the  conduct  of  the  Board  in  proceeding  to  the  election. 
If  this  condemned  Board  can  find  obstetricians  attached 
to  general  hospitals  ready  to  succeed  these  celebrated 
consultants,  such  fresh  consultants  ought  to  be  ostracized 
by  the  rest  of  the  profession. 

Notwithstanding  the  conduct  of  the  Board  a  resolution 
was  carried  not  to  accept  their  resignation — so  the  hos- 
pital is  left  tp  the  same  management  which  has  been 
condemned  in  two  special  reports  as  well  as  by  the 
Home  Secretary — a  strange  comment  on  our  methods 
of  management  and  an  agreeable  prospect  for  the  physi- 
cians who  are  willing  to  accept  appointments  terminat- 
ing yearly  as  the  humble  servants  of  such  a  Board. 

Meetings  of  members  of  the  Medical  Defence  Union 
have  been  held  in  London,  Manchester,  Birmingham, 
and  Bristol  to  discuss  the  steps  taken  by  the  council  in 
the  litigation  respecting  Drs.  Bloxam  and  Collie.  At 
these  meetings  suggestions  were  offered  as  to  the  avoid- 
ance of  such  litigation  in  future,  and  at  each  meeting 
confidence  was  expressed  in  the  council.  So  we  may 
hope  that  controversy  is  closed.  It  is  a  pity  that  all 
concerned  in  medical  defence  do  not  unite  their  forces. 

Small-pox  has  abated  lately,  but  diphtheria  has  in- 
creased. This  last  disease  has  carried  off  another  prom- 
ising young  member  of  the  profession,  Mr.  F.  V.  Bunch, 
F.R  C.S.,  Surgical  Registrar  of  University  College  Hos- 


November  3,  1894] 


MEDICAL   RECORD. 


573 


pital,  who  contracted  diphtheria  from  a  patient  in  the 
wards  and  died  on  the  5th  inst. 

London,  October  19,  1894. 

Sir  James  Paget  opened  the  one  hundredth  session  of  the 
Abernethian  Society  on  the  nth  inst.  with  one  of  his  fe- 
licitous addresses.  He  said  he  was  not  aware  that  it  was 
the  centenary  of  the  Society  or  he  might  have  prepared 
some  account  of  its  history.  It  was  quite  as  well  that  he 
did  not,  though  he  would,  I  doubt  not,  have  been  able  to 
make  the  dry  bones  of  such  a  history  live.  He  said  it 
was  sixty  years  since  he  joined  the  Society.  It  is  rather 
rare  certainly  for  anyone  to  address  a  society  after  sixty 
years'  membership,  though  I  believe  outside  the  profes- 
sion this  from  time  to  time  occurs.  Sir  James  repudiat- 
ed the  notion  that  a  man  could  not  be  a  scientist  and 
general  practitioner  at  the  same  time,  and  urged  his  au- 
dience to  add  well-observed  facts  to  the  general  store, 
illustrating  the  necessity  of  this  by  myxoedema,  first  ob- 
served twenty  years  ago  when  little  was  known  about 
the  thyroid  gland,  but  the  result  of  that  observation  was 
now  a  larger  knowledge  of  the  thyroid  than  of  many 
other  organs.  The  questions  as  to  relations  of  mixed 
diseases  were  brought  forward  and  tuberculosis  and  can- 
cer named  as  to  which  facts  were  needed.  Then  the  fal- 
lacies of  diagnosis  were  spoken  of,  and  as  they  might  lead 
to  unexpected  actions  of  drugs,  a  natural  transition  was 
offered  to  the  subject  of  therapeutics.  Then  Sir  James 
urged  that  all  the  sciences  must  work  together  not  as 
enemies  or  rivals  perhaps,  but  the  practitioner  must 
avail  himself  of  the  knowledge  afforded  by  all  without 
allowing  himself  to  be  unduly  influenced  by  any  one  of 
them. 

But  I  need  not  give  any  further  account  of  the  ad- 
dress. Suffice  it  to  say  that  Sir  James  received  on  the 
occasion  one  of  those  enthusiastic  ovations  to  which  he 
has  long  been  accustomed,  and  that  the  crowded  audi- 
ence seemed  more  than  usually  delighted. 

The  Clinical  Society  of  London  opened  the  session 
Friday  last  with  distinctly  practical  work.  Dr.  J.  M. 
Bradford  related  a  case  of  aneurism  of  the  basilar  artery. 
On  admission,  at  7  p.m.,  the  patient  was  partially  uncon- 
scious, axillary  temperature,  980  F. ;  pulse,  70,  irregular 
and  intermittent.  No  paralysis.  Respiration,  irregular. 
Abdomen  not  retracted.  Pupils  equal  and  medium 
sized.  Deep  reflexes  increased.  Patient  rather  restless. 
At  9  p.m.  he  became  comatose,  and  the  respiration  be- 
came infrequent,  ceasing  at  10  p.m.  Artificial  respira- 
tion was  kept  up  for  four  hours,  but  the  pulse  then  failed, 
and  he  died  at  2. 10  a.m.  Temperature  at  midnight  970 
F.  No  convulsions  occurred.  Autopsy  showed  numerous 
gummata  in  the  liver  and  a  fusiform  aneurism  of  the 
basilar  artery,  which  had  ruptured,  the  extravasation 
forming  a  blood-clot  one- fourth  of  an  inch  thick  on  the 
under  surface  of  the  pons  and  medulla,  and  extending 
round  the  sides  of  the  medulla  into  the  fourth  ventricle. 

Dr.  W.  Hale  White  described  two  cases  of  intra- cra- 
nial aneurism.  The  first  was  that  of  a  woman,  aged  thirty- 
four.  There  was  a  large  amount  of  clot  on  the  under 
surface  of  the  brain,  it  extended  to  the  fourth  ventricle 
and  was  one-eighth  inch  thick  all  down  the  spinal  canal 
in  the  subarachnoid  space.  The  second  case  was  that 
of  a  man  who  suddenly  fell  down  insensible  and  was 
brought  to  the  hospital.  On  admission  he  was  uncon- 
scious, the  pupils  were  fixed  and  dilated,  the  eyeballs 
were  prominent.  The  breathing  became  difficult  and 
he  died  seven  and  one  half  hours  after  admission.  Blood 
clot  was  found  in  both  the  subdural  and  subarachnoid 
cavities  nearly  all  over  the  surface  of  the  brain ;  and  it 
had  extended  along  the  sheath  of  the  optic  nerve,  ulti- 
mately getting  under  the  retina.  The  hemorrhage  came 
from  a  small  aneurism  springing  from  the  right  internal 
carotid  just  at  its  termination.  The  whole  of  the  rest  of 
the  body  was  absolutely  healthy. 

Dr.  J.  £.  Paul  read  the  notes  of  a  case  of  acute  pan- 
creatitis in  a  man  of  forty-three  years  of  age,  who  died 
eight  hours  after  admission.  Temperature  rose  to  1040 
F.   just  before  death.      The  peritoneum  covering  the 


pancreas  was  found  to  be  glued  with  recent  lymph  to  the 
posterior  surfaces  of  the  stomach.  The  pancreas  itself  was 
much  swollen,  and  hemorrhages  were  to  be  seen,  most 
numerous  in  the  tail.  Stomach  and  duodenum  healthy. 
The  rest  of  the  organs  healthy,  except  cloudy  swelling 
of  kidneys.  No  fat  necrosis.  Microscopic  examination 
showed  considerable  disintegration,  with  total  destruction 
in  parts  of  the  structure  of  the  pancreas.  Numerous 
hemorrhages  were  to  be  seen,  and  clumps  of  crystals  of 
hsematoidin. 

Dr.  Soltau  Fenwick  described  two  cases  of  fatal  form 
of  tetany  associated  with  chronic  dilatation  of  the  stom- 
ach. One  was  that  of  a  carpenter,  aged  thirty- four,  who 
stated  that  for  six  months  he  had  suffered  pain  in  the 
stomach  after  meals,  and  attacks  of  vomiting.  The  other 
had  had  symptoms  of  ulceration  for  four  years,  was  sud~. 
denly  seized  with  tonic  spasms  of  the  extremities  after  an 
unusually  severe  attack  of  vomiting.  The  condition 
closely  resembled  true  tetany,  and  the  seizures  were  re- 
peated several  times. 

This  complication  of  chronic  dilatation  of  the  stomach 
was  first  recorded  by  Kussmaul  in  1869,  and  twenty-six. 
cases  have  been  published  since.  In  the  majority  the 
gastric  symptoms  had  been  present  for  years,  and  in 
ninety-two  per  cent,  of  the  cases  which  came  to  a  ne- 
cropsy a  chronic  ulcer  in  the  vicinity  of  the  pylorus  was 
found  to  be  the  cause  of  dilatation  of  the  stomach.  In 
every  case  the  tetany  followed  severe  vomiting,  the  at- 
tacks lasting  from  one  hour  to  several  days.  In  seven 
cases  the  condition  was  further  complicated  by  seizures 
of  a  tetanic  nature,  in  which  trismus  and  opisthotonos 
were  usually  marked  symptoms,  while  in  three  others 
epileptic  convulsions  supervened.  The  disease  is  ex- 
tremely fatal,  out  of  the  twenty-six  instances  eighteen* 
terminated  in  death.  The  rational  treatment  which  has 
met  with  some  success  is  the  regular  employment  of 
lavage,  either  warm  water  or  a  weak  solution  of  resorcin. 
being  used. 

Dr.  Holman  said  that  Dr.  Ogle,  of  Reigate,  had  de- 
scribed to  him  a  case  of  a  patient  who  was  admitted  to- 
the  Cottage  Hospital  for  severe  vomiting.  The  stomach 
was  found  to  be  much  dilated.  The  patient  had  two- 
attacks  of  tetany  and  died  in  the  second.  At  the  au- 
topsy no  sign  of  ulceration  was  found,  but  the  stomach- 
reached  far  below  the  umbilicus. 

Mr.  Eve  then  read  the  notes  of  a  case  of  tuberculosis- 
lymphangitis  of  the  arm  following  a  sore  on  the  finger. 
The  patient  was  in  good  health  three  years  later  but  was 
afterward  lost  sight  of.  It  appeared  probable  that  an 
ordinary  whitlow  had  been  inoculated,  perhaps  in  wash- 
ing a  handkerchief  soiled  with  tuberculous  sputum.  For 
the  purpose  of  establishing  the  diagnosis,  guinea  pigs 
were  inoculated  with  pus  from  the  abscesses,  with  posi- 
tive results.  The  case  was  illustrated  by  colored  draw- 
ings and  photographs. 

A  similar  case,  described  by  Turner,  was  quoted,  in 
which  the  patient  succumbed  to  general  tuberculosis^ 
and  this  or  phthisis  is  the  usual  termination  of  such 
cases.  Tuberculosis- lymphangitis  almost  invariably  fol- 
lows superficial  lesions  and  usually  the  cutaneous  inocu- 
lation of  tubercle.  In  one  case  it  was  an  anatomical- 
tubercle,  in  another  a  warty  tubercle  on  the  back  of  the 
hand,  and  in  three  other  cases  the  patients  were  women 
who  developed  nodules  on  the  fingers  while  nursing 
their  phthisical  husbands.  Stress  was  kid  on  the  neces- 
sity of  an  early  diagnosis  so  that  the  disease  might  be 
extirpated  as  soon  as  possible  by  erasion  of  the  abscesses 
and  removal  of  the  nearest  chain  of  lymphatic  glands. 

The  President,  Mr.  Hulke,  referred  to  the  account  of 
tuberculosis  following  inoculation  in  a  surgeon,  who 
accidentally  inoculated  his  own  hand,  which  ultimately 
ended  unfortunately. 

Small-pox  has  declined  in  London.  No  deaths  from 
it  were  registered  last  week  and  only  nine  fresh  cases 
were  notified.  The  cases  remaining  under  treatment  for 
the  last  four  weeks  have  been  respectively  100,  98,  84,. 
and  63. 


574 


MEDICAL   RECORD. 


[November  3,  1894 


Diphtheria  has  also  declined.  The  deaths  for  the  last 
three  weeks  have  been  67,  66,  and  54*  This  number  is 
19  more  than  the  corrected  average  for  the  week.  The 
disease  is  widely  distributed  over  the  different  districts. 


CAR  SANITATION. 

To  the  Editor  op  ths  Medical  Record. 

Sir  :  The  short  reference  to  Dr.  Cann's  paper  on  "  Car 
Sanitation/1  prompts  me  to  write  you  of  some  of  the 
observations  made  by  myself  recently  regarding  this 
matter. 

What  the  Doctor  says  of  the  all  prevailing  amount 
of  carbonic-acid  gas  in  the  cars  is  beyond  question  the 
rule  in  all  cars  save  the  drawing-room  variety,  especially 
in  winter  time. 

Sufficiently  noticeable,  however,  is  this  great  amount 
of  poisonous  gas  for  those  of  us  who  took  a  train  each 
day  from  early  spring  during  all  the  summer  months  to 
note  the  fact,  and  seek  an  unoccupied  car  put  on  a  sta- 
tion above  where  we  boarded  the  train.  Of  course  be- 
fore our  car  had  gone  far  it  was  as  bad  as  the  rest,  but 
the  system  so  quickly  adapts  itself  to  circumstances  that 
we  did  not  particularly  notice  the  (act — but  did,  of 
course,  have  the  headaches  that  go  with  the  inhalation 
of  this  vitiated  air. 

Bad  as  all  this  is,  it  is  by  far  the  least  objectionable  of 
a  lot  of  other  unhealthful  things  to  be  noticed  upon  the 
trains.  Not  long  since  I  noticed  a  filthy  looking  spot 
on  the  plush-covered  back  of  a  seat  in  front  of  me,  and 
it  took  only  a  glance  to  see  that  some  "  filthy  hog,"  as 
the  lady  with  me  observed,  had  been  riding  there  before 
us,  and  had  expectorated  very  disagreeable  looking  pus 
or  muco-pus  on  this  seat  back. 

If  one's  mind  reverts  to  the  fact  that  the  germs  of  any 
one  of  several  diseases  may  have  been  lurking  in  that 
dried  sputum  he  feels  uneasy  and  wants  to  change  his 
seat,  which,  if  the  car  is  full  he  cannot  do,  and  if  he  can 
accomplish  it  how  shall  he  know  that  the  next  seat  is  bet- 
ter than  the  one  vacated,  since  not  all  disease  germs  re- 
qiire  a  visible  medium  of  transportation. 

The  unfortunate  custom  of  covering  that  portion  of 
the  back  of  the  seat  which  presents  itself  in  front  of  each 
seat  with  plush  or  some  other  dirt-absorbing  substance 
is  a  thing  easily  remedied,  for  there  is  no  reason  why 
thin  hard  wood  should  not  be  used  instead. 

As  to  the  disposal  of  germs  in  the  cars  there  is  a  very 
simple  and  not  very  expensive  way  of  doing  this.  If  a 
compartment  into  which  each  car  could  be  run  and  re- 
main for  two  hours  after  each  trip  should  be  so  con- 
structed that  a  temperature  of,  say  2400,  could  be  main- 
tained, all  animal  life  would  thus  be  destroyed. 

There  are  many  other  things  tending  to  convey  dis- 
ease and  death.  Take  the  matter  of  the  handling  of  the 
ice  for  the  ice-water  tanks.  You  shall  see  men  with 
dirty,  ill  kept  hands,  handling  the  ice  in  those  filthy 
hands  and  putting  it  at  once  into  the  tank,  wiping  their 
hands  on  already  very-much  soiled  trousers,  and  then 
repeat  the  operation  with  the  tank  in  another  car. 

Then  too  there  is  the  question  of  where  the  water  itself 
is  obtained.  On  one  of  our  leading  railroad  through 
trains  for  the  West,  the  water  is  supplied  from  the  Jersey 
City  water,  which  is  taken  from  the  lower  Passaic  River, 
a  notably  unhealthy  stream  because  of  sewage  from  fur- 
ther up,  as  note  the  cases  of  typhoid  fever  in  Jersey  City 
and  Newark  until  recently. 

All  this  is  easily  avoided,  and  the  State  should  see  to 
it  that  the  water  be  taken  from  pure  sources  and  the  ice 
also,  besides  seeing  to  it  that  the  companies  provide  suit- 
able means  of  carrying  ice  without  the  men  handling  it. 

Minor  matters,  like  the  ridiculous  custom  of  the  one 
sitting  next  a  window  being  the  sole  arbiter  of  whether 
the  window  shall  or  shall  not  be  open ;  if  open  it  may 
chance  to  let  in  very  objectionable  draughts  on  every  one, 
as  very  many  suffer  bronchitis,  etc  ,  from  it,  or  possibly 
smoke,  cinders,  and  dust  may  cloud  the  car,  and  all  suffer 


because  of  the  carelessness  or  stupidity  of  the  one  pas- 
senger who  claims  the  right  to  control  this  particular 
window. 

It  is  quite  true  that  all  these  matters  would  entail  some 
care,  possibly  some  expense  on  the  companies  if  they  are 
to  be  corrected,  but  certain  it  is  that  these  matters  all 
require  attention  and  none  of  them  are  at  all  trifling,  but 
of  grave  moment  to  the  lives  and  health  of  the  travelling 
public.  W.  Washburn,  M.D. 


THE  DANGERS  OF  -NIGHT  CALLS. 

To  the  Editor  op  thb  Medical  Record. 

Sir  :  In  the  daily  papers  of  Thursday  and  Friday  of  last 
week  appeared  sensational  reports  of  my  appearance  in 
the  Jefferson  Market  Police  Court  as  complainant  against 
a  man  whom  I  believed  had  robbed  me.  The  injustice 
which  this  publication  has  done  me  is  of  so  grave  a  nat- 
ure that  I  beg  you  to  print  the  actual  facts  of  the  case, 
which  are  as  follows  : 

At  about  3  a.m.  Thursday  morning  I  left  my  house 
to  visit  a  patient,  in  answer  to  a  messenger  call  to  West 
Forty-second  Street.  I  went  directly  there,  arriving 
about  3.30.  I  left  there  at  about  5  AM.  Arriving  in 
Seventh  Avenue  on  my  way  home  I  stopped  at  a  public 
house  and  ordered  a  sandwich.  While  paying  my  check 
at  the  cashier's  desk  I  was  jostled  by  three  men,  and  a 
roll  of  bills  which  I  had  returned  to  my  pocket  was  taken 
by  one  of  them.  The  man  ran  out  upon  the  street  and 
I  quickly  followed.  I  called  a  policeman,  and,  together 
we  started  in  pursuit  of  the  fugitive,  who  sought  refuge 
in  a  public  place  one  or  two  blocks  above.  I  identified 
the  man,  and  caused  his  arrest.  I  went  to  the  station 
house  with  the  policeman  and  his  prisoner,  and  made 
my  charges  against  him.  A  little  after  eight  o'clock  I 
appeared  against  the  prisoner  in  Jefferson  Market  Court, 
before  Justice  Hogan.  I  was  asked  by  the  Justice  if  I 
was  drunk  at  the  time  of  the  robbery.  I  indignantly 
and  truthfully  answered  "No."  The  policeman  was 
then  ordered  to  make  the  charge  against  the  prisoner. 
In  his  written  statement,  I  found  the  following :  "  De- 
fendant was  arrested  on  the  complaint  of  Dr.  Phelps, 
who  had  the  appearance  of  being  drunk,  and  was  under 
the  influence  of  liquor."  I  quietly  asked  the  policeman 
to  charge  me  with  being  drunk,  and  to  sign  his  name  to 
it  When  he  declined  to  do  so,  I  tore  up  the  statement, 
not  knowing  that  it  had  been  signed  by  the  Justice — if 
it  had  been.  The  Justice  then  held  me  in  {200  bail  for 
contempt  of  court.  By  permission  I  went  for  bail  to 
the  house  of  Dr.  George  Evans,  49  West  Thirty-ninth 
Street,  and  soon  returned.  The  Justice  imposed  a  fine 
of  1 5  and  discharged  me. 

In  support  of  the  above  I  can  furnish  statements — 1. 
From  my  patient,  showing  that  I  had  not  been  drinking 
and  was  not  intoxicated  when  I  left  the  house  soon  after 
5  a.m.  2.  From  Dr.  W.  O.  Plimton,  19  West  Eighty- 
fourth  Street,  my  medical  associate,  snowing  that  I  was 
not  intoxicated  immediately  before  I  went  to  the  police 
court;  and  3.  From  Dr.  Evans,  showing  that  I  was  not 
intoxicated  thirty  minutes  after  the  trouble  in  court — 
however  excited  I  may  naturally  have  been  at  that  time. 

I  would  deem  such  explanations  entirely  unnecessary 
for  those  who  know  me,  but  in  view  of  the  widely  pub- 
lished statements  in  the  public  press  I  deem  it  incum- 
bent upon  me  to  put  in  a  general  denial. 

With  this  brief  presentation  of  the  case,  showing  that 
I  was  assaulted  and  robbed  while  in  the  performance  of 
professional  work,  such  as  calls  a  physician  to  any  part 
of  the  city,  I  will  say  nothing  more,  but  will  leave  the 
whole  matter  to  the  judgment  of  the  reader. 

A.  M.  Phelps,  M.D. 

[It  is  obviously  unnecessary  to  dilate  on  the  facts  of 
the  case.  To  anyone  who  knows  Dr.  Phelps  the  charge 
of  drunkenness  is  ridiculously  absurd.  Indeed  it  would 
scarcely  be  worthy  of  notice  save  to  offset  a  widely  pub- 
lished scandal,  in  which  insult  was  added  to  injury,  and 
proper  redress  was  apparently  out  of  the  question.  —Ed.] 


November  3,  1894] 


MEDICAL    RECORD. 


575 


Hero  Snstroraeuts. 

A   NEW   NASAL  FORCEPS. 
By  SAMUEL  GOLDSTEIN,  M.D., 

NBW   YORK. 

SINIOR  ASSISTANT  SURGEON,  NBW  YORK  THROAT  AND  NOSE  HOSPITAL  ;  ASSIST- 
ANT SURGBON,   OUTDOOR  DSPAKTMBNT,    MOUNT  SINAI   HOSPITAL. 

How  frequently,  in  the  examination  of  the  no6e,  the  sur- 
geon finds  hypertrophy  or  exostosis  of  the  inferior  turbi- 
nated bone,  of  such  a  nature  that  only  removal  of  this 
obstruction  will  afford  the  radical  relief  the  anxious  pa- 
tient seeks. 

The  patient  comes  to  you  and  enumerates  his  symp- 
toms :  of  having  cold  upon  cold  in  the  nose ;  the  nos- 
tails  being  alternately  obstructed ;  obstructed  very  often 
to  such  an  extent  that  he  does  not  breathe  through  one 
nostril,  and  barely  with  the  other.    He  seeks  radical  relief. 

In  a  large  majority  of  cases  we  are  told  that  all  forms 
of  treatment  have  been  tried,  including  cauterization 
with  chemical  caustics,  and  the  actual  cautery.  These 
msthods  of  treatment  have  given  him  temporary  relief, 
as  the  mucous  membrane,  which  was  only  part  of  the 
trouble,  was  reduced  in  size ;  the  main  cause  of  the  trou- 
ble being  still  in  situ.  He  further  tells  us  that  he  does 
not  wish  to  be  continually  under  treatment,  but  wants 
such  operative  measures  enacted  as  will  rid  him  of  his  na- 
sal obstruction. 

The  question  naturally  arises,  can  we  place  such  a  pa- 
tient in  a  condition  that  when  we  discharge  him  we 
can  truly  say  that  his  nasal  obstruction  has  been  re- 
moved ;  that  he  may  still  contract  a  slight  nasal  inflam- 
mation, not  as  readily  as  before,  and  of  such  a  nature 
that  very  simple  treatment  will  be  effectual  ?  How  are 
we  to  accomplish  this  end,  should  the  cause  of  the  trou- 
ble be  due  to  hypertrophied  inferior  turbinated  bone? 

The  answer  to  this  query,  from  the  results  experienced 
at  the  New  York  Throat  and  Nose  Hospital,  and  my 


own,  is  in  the  removal  by  saw  and  forceps  of  a  sufficient 
amount  of  the  hypertrophied  inferior  turbinated  bone. 
The  objections  that  are  usually  made  to  the  operation  are, 
I  fully  believe,  of  little  weight.  I  will  enumerate  such 
as  I  usually  hear,  and  endeavor  to  meet  them  in  detail. 

We  are  told  that  this  bone  has  a  function,  and  should 
not  be  removed,  even  in  part ;  that  the  operation  is  at- 
tended with  too  much  shock;  that  the  hemorrhage  is 
excessive,  often  uncontrollable,  and  is  so  great  that  the 
patient  becomes  exsanguinated;  that  the  operation,  as 
done  under  cocaine  anaesthesia,  is  too  painful  for  the  or- 
dinary patient ;  finally,  that  the  results  do  not  justify  the 
means. 

I  fully  concur  with  the  statement  that  the  inferior  tur- 
binated bone,  in  its  normal  state,  has  a  function,  and  ap- 
preciate that  thoroughly.  May  I,  however,  ask,  what 
surgeon  would  hesitate  to  remove  an  extensive  exostosis 
in  any  other  region  of  the  body  ?  It  is  only  when  the 
inferior  turbinated  bone  is  so  hypertrophied  as  to  cause 
obstruction,  that  this  part  is  to  be  removed. 

In  all  of  the  operations  that  I  have  witnessed,  and  in 
those  that  I  have  performed,  there  has  been  so  little 
shock,  that  the  patient,  in  a  comparatively  short  space 
of  time,  was  able  to  retire,  and  in  some  cases,  resume 
his  usual  vocation.  Hemorrhage,  there,  necessarily  is, 
greater  or  less,  depending  upon  the  condition  of  the 
nose ;  but  never  so  great  as  not  to  be  within  the  control 


of  the  operator ;  in  the  main  so  slight  as  only  to  ooze 
for  a  short  time  after  the  operation,  and  perhaps  for 
twenty-four  hours  later.  That  there  is  some  pain  at- 
tending the  operation  is  most  true ;  but  it  can  be  min- 
imized by  the  skilful  surgeon,  who  performs  the  opera- 
tion in  a  comparatively  short  space  of  time ;  and  fur- 
thermore, much  more  quickly  by  the  aid  of  a  forceps 
that  will  grasp  the  detached  segment  of  bone  firmly,  and 
permit  immediate  withdrawal  of  the  same. 

I  hardly  believe  that  it  is  necessary  for  me  to  state 
that  the  operation  is  done  in  a  worthy  cause,  that  the 
end  amply  justifies  the  means.  Anyone  who  has  seen 
the  mouth  breather,  whose  nostrils  were  obstructed  with 
hypertrophied  inferior  turbinated  bone,  and  who  has  re- 
moved such  obstruction,  knows  the  gratitude  felt  by  his 
patient  for  the  immediate  relief  afforded. 

For  the  purpose  of  making  the  time  consumed  in 
operating  as  short  as  possible,  to  minimize  the  pain,  pos- 
sible shock,  and  hemorrhage,  I  have  planned  and  had 
this  forceps  made.  The  nasal  forceps  now  in  use  have 
their  inner  flanges  serrated,  or  partly  serrated  and  tun- 
nelled. 

There  is  always  a  flow  of  blood  resulting  from  sawing 
through  the  bone ;  after  the  bone  has  been  sawn,  and 
the  segment  hangs  pendent,  attached  only  to  mucous 
membrane  and  perhaps  some  cartilage,  the  forceps  is 
applied  to  grasp  the  segment  for  removal.  Here  con- 
siderable difficulty  is  met.  The  blood  fills  in  the  serra- 
tions, making  the  surfaces  of  the  flanges  of  the  forceps 
slippery ;  upon  their  withdrawal  we  are  surprised  not  to 
find  the  segment  in  its  grasp.  We  tell  the  patient  to 
blow  his  nose  to  clear  the  field,  and  read j  1st  the  forceps, 
and  repeatedly  meet  with  similar  disappointment  upon 
their  withdrawal.  This  is  disappointing  and  discourag- 
ing to  the  average  operator.  By  this  time  the  segment 
may  be  entirely  detached,  and  slipped  to  the  floor  of  the 
nasal  fossa  toward  the  posterior  nares.  The  forceps  is 
applied  and  re  applied  often  fruitlessly.  This  having 
consumed  much  time,  much,  if  not  all,  of  the  cocaine 
anaesthesia  has  worn  off,  and  further  manipulation 
of  the  parts  becomes  painful  to  the  patient,  who 
has  also  been  made  nervous  through  delay. 

To  prevent  this  delay,  unnecessary  manipula- 
tion, and  contusion  of  the  parts  and  subsequent 
pain,  I  place  this  forceps  before  you,  hoping  that 
it  will  prove  as  satisfactory  and  efficient  with  you 
as  it  has  been  to  me  in  my  work.  The  forceps 
consists  of  two  blades  with  scissors  handles.  The 
flanges  at  the  end  of  the  blades  are  about  the 
size  of  the  hypertrophied  portion  of  bone  usu- 
ally removed.  The  inner  surfaces  of  the  flanges  have 
five  pointed  uprights,  and  between  the  uprights  are  per- 
forations through  which  the  uprights  pass  when  the 
forceps  is  clamped.  The  inner  surfaces  of  the  flanges 
are  also  serrated  to  make  the  clamping  more  secure  The 
blades  are  bent  and  strong,  the  joint  connecting  them 
especially  so.  At  the  handle  is  a  spring  catch  that  can 
be  used  at  will,  to  insure  a  more  thorough  grip  after  the 
forceps  has  been  clamped. 

The  working  mechanism  is  simple :  After  the  hyper- 
trophied segment  of  bone  has  been  sawn  through  and 
hangs  pendent,  the  forceps  is  clamped  over  it,  and  when 
once  placed  properly,  the  pointed  uprights  piercing  the 
bone,  the  forceps  is  closed,  the  catch  sprung  tightly,  and 
then  there  is  no  possible  chance  for  slipping  to  take 
place.  Then  the  segment  can  be  twisted  off  and  re- 
moved from  the  nostril ;  or  if  not  sufficiently  sawn,  the 
forceps  is  twisted  toward  the  septum,  the  saw  re -intro- 
duced at  the  side  of  the  forceps,  the  remnant  detached,  and 
the  segment  removed.  This,  when  properly  done,  rend- 
ers the  operation  expeditious  and  successful.  This  part 
of  the  operation,  usually  occasioning  so  much  delay,  with 
the  aid  of  this  forceps  consumes  the  least  amount  of  time. 
All  parts  of  the  forceps  can  be  detached  for  cleaning. 

I  am  indebted  to  Messrs.  George  Tiemann  &  Co.  for 
the  skilful  execution  of  the  plans. 

x66  East  NiNKTif-THiPD  Street. 


576 


MEDICAL    RECORD. 


[November  3,  1894 


IJfcedical  Stems. 

Placarding  Contagious  Diseases  in  Tenements. — The 
following  official  document  has  just  been  issued  by  the 
Health  Department  of  New  York : 
"  Charles  F.  Roberts,  M.D.,  Sanitary  Superintendent. 

"  Sir  :  We  desire  to  direct  the  attention  of  the  Board 
of  Health  to  the  necessity  for  the  adoption  of  some 
more  adequate  means  to  prevent  the  extension  of  conta- 
gious disease  in  tenement- houses  and  apartment-houses, 
and  particularly  for  the  enforcement  of  isolation  of  per- 
sons sick  with  these  diseases.  The  methods  which  have 
been  long  employed  in  the  Health  Department,  i.e., 
frequent  visitation  and  instruction  by  Department  inspec- 
tors, have  been  found  to  be  only  partially  effective.  It 
has  been  the  custom  for  years  in  cases  of  contagious  dis- 
ease for  the  inspectors  of  the  Department  to  visit  the 
families  of  the  sick  persons,  inform  them  as  to  measures 
of  disinfection  and  methods  of  isolation,  and  at  the 
same  time  to  notify  other  families  in  the  house  of  the 
existence  of  a  case  of  contagious  disease  in  a  given 
apartment.  This  method  of  giving  publicity  to  the  case 
and  of  warning  other  occupants  of  the  house  is  ineffective 
in  the  accomplishment  of  the  desired  end;  i.e.,  the 
complete  isolation  of  the  patient  and  the  prevention  of 
further  infection.  Notifying  all  the  inmates  of  a  large 
tenement  is  a  very  difficult  matter,  and,  if  notified,  ex- 
perience has  shown  that  they  soon  forget  the  existence 
of  illness  in  the  house.  Repeated  inquiries  have  demon- 
strated the  fact  that  frequently  many  of  the  inmates 
of  a  house  where  there  is  a  case  of  contagious  disease  do 
not  know  of  the  existence  of  any  sickness.  Further  than 
this,  this  method  fails  entirely  to  protect  strangers  or 
visitors  who  may  go  to  the  house  or  apartment.  Ladies  in 
search  of  servants  have  been  repeatedly  found  in  houses 
or  in  apartments  where  cases  of  contagious  disease  were 
present,  and  servants  who  have  been  living  with  families 
where  there  are  cases  of  contagious  disease,  on  obtaining 
situations  frequently  go  to  their  employer's  house  carry- 
ing infection  with  them ;  or,  when  relieved  from  duty 
for  an  afternoon  or  evening,  visit  families  where  there  are 
cases  of  contagious  disease,  and  not  infrequently  carry 
infection  back  to  the  houses  in  which  they  are  employed. 
Very  commonly  washing  or  various  kinds  of  sewing  is 
secretly  done  by  other  members  of  the  family  in  apart- 
ments where  such  cases  are  ill,  and  the  garments  thus  in- 
fected on  the  premises  are  later  returned  to  the  owners. 
In  small  shops  business  is  sometimes  carried  on,  and  in 
one  of  several  instances  recently  a  number  of  cases  of  diph- 
theria were  directly  traced  to  an  infected  candy-store. 

"  Notifying  inmates  of  the  house  is  ineffectual,  further, 
because  it  has  been  found  that,  as  a  rule,  intercourse  of 
families  in  tenement-houses  is  not  with  others  in  the 
same  house,  but  with  families  which  live  in  other  houses, 
and  the  latter  are  entirely  unprotected  by  the  methods  at 
present  followed.  It  has  seemed  to  us,  after  careful  con- 
sideration of  this  subject,  that  the  desired  object  would 
be  best  obtained  by  the  placarding  of  apartments  in 
tenement-houses  where  cases  of  contagious  disease  exist, 
and  we  therefore  have  the  honor  to  recommend  that 
hereafter  the  Chief  Inspector  of  Contagious  Diseases  be 
authorized,  in  his  discretion,  to  placard  apartments  in 
tenement  houses  where  there  are  cases  of  contagious  dis- 
ease. The  following  considerations  may  render  still 
more  apparent  the  necessity  for  this  action:  1.  Under 
the  present  conditions  it  is  impossible  to  prevent  strang- 
ers and  visitors  from  entering  apartments  where  there 
are  cases  of  contagious  disease,  and  they  or  their  clothing 
thus  frequently  become  infected  and  either  they  contract 
the  disease  themselves  or  they  transmit  it  to  others. 
These  strangers  or  visitors  are  usually  not  aware  of  the 
existence  of  disease  in  the  house  or  apartment,  and  un- 
wittingly expose  themselves  and  act  as  media  for  the 
dissemination  of  the  disease.  If  the  apartments  were 
placarded,   this  means  of  dissemination  would  be  pre- 


vented. 2.  In  diphtheria,  as  has  been  repeatedly  and 
abundantly  shown  by  the  investigations  of  this  Depart- 
ment, patients  are  often  apparently  well  long  before  they 
are  free  from  the  infectious  agents,  and  in  spite  of  re- 
peated warning  from  Department  inspectors  these  pa- 
tients, especially  when  children,  mingle  with  other  chil- 
dren and  thus  transmit  the  disease  to  them.  This  is  one 
of  the  most  common  and  important  means  for  the  dis- 
semination of  diphtheria,  and  it  is  of  no  less  importance 
in  scarlet  fever  and  measles,  as  in  the  latter  diseases 
desquamation  frequently  continues  many  days  after  the 
patient  has  apparently  quite  recovered.  3.  There  are  at 
present  no  means  by  which  other  inmates  in  tenement- 
houses  can  know  when  convalescent  cases  of  contagious 
disease  have  ceased  to  be  dangerous.  They  can  only  be 
governed  by  appearances,  which,  as  we  have  seen,  are 
deceptive.  If  apartments  where  cases  of  contagious  dis- 
ease existed  were  placarded,  isolation  would  be  enforced 
by  the  other  occupants  of  the  house  until  the  department 
inspectors  allowed  the  placard  to  be  removed.  4.  The 
moral  influence  of  such  placards,  both  upon  the  inmates 
of  the  apartments,  the  inmates  of  the  house,  and  strangers 
or  visitors  to  the  house,  would  be  of  as  great  service  in 
enforcing  isolation  and  preventing  extension  of  disease 
as  the  visits  and  instruction  of  our  inspectors.  It  has 
been  found  impossible,  even  where  daily  visits  were  made 
by  medical  inspectors,  assisted  by  the  sanitary  police,  to 
enforce  the  isolation  of  children  convalescing  from  diph- 
theria and  scarlet  fever  after  the  serious  symptoms  have 
disappeared.  It  is  undesirable  at  such  times,  unless  ab- 
solutely required,  to  remove  such  patients  to  the  hospital, 
and  yet  in  the  eruptive  fevers  this  is  the  period  of  the  dis- 
ease when  there  is  greatest  danger  of  transmission  to 
others. 

"  During  the  last  year  we  have  had  a  serious  epidemic 
of  diphtheria  to  deal  with.  The  number  of  cases  re- 
ported weekly  during  the  last  months,  however,  has 
steadily  decreased.  The  schools  have  just  now  opened, 
Mid  it  seems  to  us  that  the  most  strenuous  efforts  should 
be  made  to  prevent  a  new  outbreak  of  the  disease  or  its 
reintroduction  to  the  schools.  This  measure  would  be 
of  undoubted  service  in  accomplishing  the  desired  object. 
We  would  recommend,  therefore,  that  placards  should 
be  nailed  to  the  outside  doors  of  the  apartments  in  which 
cases  of  contagious  disease  are  present,  when  in  the  judg- 
ment of  the  Chief  Inspector  of  Contagious  Diseases  this 
course  seems  to  be  desirable,  and  that  the  placards  should 
bear  the  following  inscription,  differing  as  to  the  name 
of  the  disease  in  question  and  as  to  color.  The  color 
for  diphtheria  should  be  white ;  for  scarlet  fever,  red ; 
for  measles,  blue. 

Diphtheria. 
All  persons  not  occupants  of  this  apartment  are  noti- 
fied of  the  presence  of  diphtheria  in  it,  and  are  warned 
to  avoid  entering  it  until  this  notice  is  removed.  The 
persons  sick  with  diphtheria  must  not  leave  the  apart- 
ment as  long  as  this  notice  remains  here. 

The  removal  or  defacement  of  this  notice  is  forbidden. 
By  order  of  the  Board  of  Health, 

President. 

Secretary. 

"  For  some  months  in  certain  classes  of  tuberculosis 
the  system  of  placarding  apartments  has  been  authorized 
and  employed  by  the  Health  Department,  and  has  proven 
very  satisfactory  in  the  attainment  of  the  object  desired. 
The  only  objection  apparently  to  be  urged  against  this 
measure  is  that  the  inmates  of  the  apartment  may  object 
to  the  publicity  thus  entailed.  This,  however,  is  exactly 
the  object  which  the  measure  is  justly  and  properly  de- 
signed to  subserve,  and  is,  in  our  opinion,  the  strongest 
argument  in  favor  of  its  adoption. 

1 '  (Signed)     Respectfully  submitted , 

"  Hermann  M.  Biggs. 

"  Pathologist,  and  Director  of  the  Bacteriological  Laboratory. 

"A.  H.  Doty, 

"  Chief  Inspector  of  Contagious  Diseases." 


Medical   Record 

A  Weekly  yournal  of  Medicine  and  Surgery 


Vol.  46,  No.  19. 
Whole  No.  1253. 


New  York,  November  10,  1894. 


$5.00  Per  Annum. 
Single  Copies,  ioc. 


Original  %rXit\t&. 

ON    SYMPHYSEOTOMY,    WITH    THE    REPORT 
OF  A  NEW  CASE.1 

By  HENRY  J.  GARRIGUES,  A.M.,  M.D., 

COMSULTIKG    OBSTETRIC    SURG  BON  TO  THE  NSW    YORK  MATERNITY    HOSFIT7  L  ; 
GYNECOLOGIST  TO  ST.  MARK'*  HOSPITAL  OP  NEW  YORK  CITY,   ETC. 

When  I  had  the  honor  of  reading  my  last  paper  on  sym- 
physeotomy before  the  Obstetric  Section  of  the  Pan  Amer- 
ican Medical  Congress,  in  the  month  of  September,  1893, 
I  said  that  taking  the/w  and  the  cons  into  due  con- 
sideration, I  thought  that  the  next  time  I  bad  the  op- 
portunity of  performing  the  operation  I  should  try  the 
Italian  method  first,  and  so  I  did  in  the  following  case, 
that  presents  several  points  of  interest  in  regard  to  the 
indication,  the  operation,  the  course,  and  the  result. 

Pelvic  Tumor;  Large  Child;  Italian  Method;  Wad- 
dling Gait. — Mrs.  G.  V.  D ,  aged  twenty-nine,  Ger- 
man, married,  was  admitted  to  St.  Mark's  Hospital  on 
June  27,  1894.  She  had  had  one  child,  eight  years  ago, 
which  died  at  the  age  of  eleven  weeks.  She  had  been 
suffering  from  dysmenorrhea  for  yearst  and  menstruation 
had  been  very  irregular  of  late.  She  last  menstruated  in 
August  or  September.  For  three  months  she  had  been 
suffering  from  lumbar  pain,  and  for  two  from  anasarca. 
Labor  pains  began  at  four  o'clock  in  the  morning.  She 
had  been  examined  by  a  midwife,  who  said  she  was  preg- 
nant, and  by  a  doctor,  who  said  she  had  an  ovarian  cyst, 
and  abstracted  some  fluid  with  a  hypodermic  syringe 
through  the  abdominal  wall.  She  had  considerable 
anasarca  all  over,  especially  the  face,  hands,  abdomen, 
and  legs,  and  on  boiling  about  one-sixth  of  the  urine 
coagulated.  She  was  in  labor.  The  os  was  situated  far 
forward  over  the  symphysis  and  measured  two  inches  in 
diameter.  Bag  unbroken.  Vertex  presentation.  Foetal 
heart  very  distinct,  one  inch  to  the  left  of  and  above  the 
umbilicus. 

At  4.30  PM,  the  os  was  fully  dilated,  but  the  head  made 
no  progress,  being  pressed  forward  over  the  symphysis 
pubis  by  a  soft,  non  fluctuating  mass  in  the  rectovaginal 
septum,  extending  nearly  up  to  the  cervix.  The  heart- 
sounds  had  become  so  weak  that  they  were  heard  with 
difficulty.  I  proposed  to  perform  symphyseotomy,  in 
which  my  colleague,  Dr.  Boldt,  who  happened  to  come  to 
the  hospital,  and  whom  I  requested  to  examine  the  pa- 
tient, concurred.  After  thorough  disinfection  and  the 
patient  being  in  the  dorsal  decubitus  with  bent  knees  and 
raised  feet,  I  made  an  incision  in  the  median  line  two 
inches  long  and  ending  one- half  inch  above  the  symphysis. 
Small  transverse  incisions  were  made  right  and  left,  just 
above  the  pubic  bones,  and  just  long  enough  to  admit  the 
left  index  finger,  which  was  easily  inserted  down  to  the 
lower  end  of  the  symphysis.  A  few  small  blood-vessels 
were  clamped.  Next,  Galbiati's  falcetta  was  introduced 
along  the  finger.  The  bones  were  in  close  contact  and 
the  notch  at  the  lower  end  of  the  symphysis  could  not  be 
felt.  There  was  slight  difficulty  in  finding  the  symphysis, 
but  once  found  it  was  easily  cut  from  below  upward,  and 
from  behind  forward,  using  the  left  index  finger  as  a  guide 
in  the  vagina,  and  having  the  urethra  held  by  an  assistant 
over  to  the  right  side  with  a  metal  catheter.  By  reintro- 
ducing the  finger  into  the  wound  I  felt  that  the  ends  of 

■  Read  before  the  New  York  County  Medical  Society,  October  as, 
1804. 


the  bones  were  only  separated  ore  inch,  especially  at  the 
upper  end  of  the  symphysis,  and  less  at  the  lower,  where 
they  were  bound  together  with  a  sinewy  tissue  (part  of  the 
subpubic  ligament)  which  was  easily  ruptured.  The  head 
descended  immediately  and  was  easily  extracted  with  for- 
ceps without  any  tear  of  the  vagina  or  the  perineum.  The 
child,  a  female,  weighing  ten  and  three-quarter  pounds, 
was  dark  blue,  the  heart- beat  very  slow,  no  respiration, 
and  the  meconium  pouring  out  from  the  anus.  Seeing 
the  great  danger  of  the  child,  I  removed  it  to  another 
room  and  concentrated  my  whole  attention  on  its  re- 
vival, leaving  the  care  of  the  mother  to  Dr.  Boldt,  who 
saw  a  large  artery  spurting  in  the  cervix,  which  he  tied 
with  catgut  carried  round  it  with  a  curved  needle.  The 
placenta  was  expressed  by  Credo's  method,  and  two  hypo- 
dermic injections  of  twenty-five  minims  of  fluid  extract 
of  ergot  given. 

The  child  having  been  revived  I  returned  to  the 
mother  and  found  by  actual  measurement  a  distance 
of  five  inches  (12.5  ctm.)  between  the  pubic  bones, 
merely  due  to  the  weight  of  the  thighs,  which  were  be- 
ing kept  bent,  but  without  pressure  on  the  trochanters. 
Then  two  assistants  were  directed  to  bring  the  ends  of 
the  bones  together  by  pressing  on  the  trochanters,  while 
I  held  back  the  bladder  and  vagina.  There  was  slight 
venous  bleeding  from  the  bottom  of  the  wound.  Four 
silk  sutures  were  inserted  through  the  edges  of  the  wound 
in  the  soft  parts;  nothing  was  done  to  the  ends  of  the 
bones ;  the  wound  was  packed  with  iodoform  gauze,  the 
end  of  which  was  led  out  at  the  lower  end  of  the  wound 
while  the  three  upper  sutures  were  tied.  The  vagina 
was  likewise  tamponed  with  iodoform  gauze.  While  the 
pelvic  bones  were  kept  together,  and  the  legs  were  kept 
extended,  three  straps  of  rubber  adhesive  plaster,  two 
inches  wide,  were  drawn  round  the  pelvis  and  the  tro- 
chanters, and  crossed  in  front  above  the  wound.  The 
vulva  was  covered  with  my  pad. 

The  next  morning  the  gauze  was  removed  and  the  last 
suture  tied.  The  child  was  large  and  in  excellent  con- 
dition. 

Centimetres.  Inches. 

Occipitomental  diameter 14  54 

Occipitofrontal  diameter 12.5  5 

Biparietal  diameter 10  4 

Bitemporal  diameter 8  3$ 

Circumference  of  head 38  15 

Length  of  body 56  22 

Circumference  of  chest  at  arm- pit 38  15 

Bisacromial  diameter 13.5  5± 

On  the  third  day  after  the  operation  the  mother  de- 
veloped incontinence  of  urine,  which  lasted  a  few  days. 
The  urine  contained  many  cells  from  the  kidney  epi- 
thelium and  numerous  casts  from  the  circumvoluted, 
straight,  and  narrow  tubules ;  but  these,  as  well  as  the 
anasarca  and  albuminuria,  disappeared  soon. 

July  3d  (Sixth  day). — She  had  a  rise  in  temperature 
reaching  1030  F.,  probably  due  to  mastitis,  bard,  ten- 
der nodules  forming  in  both  breasts,  but  disappearing  in 
four  days  under  the  use  of  ice-bagp.  But  the  fever  may 
also  have  been  partly  due  to  suppuration  at  the  wound. 

July  4th. — There  appeared  slight  suppuration  round 
the  stitches,  which  were  removed.  The  edges  were 
united  by  first  intention,  but  the  following  day  half  an 
ounce  of  pus  was  pressed  out  from  an  opening  at  the 
upper  end  of  the  wound,  and  a  thin  drainage  tube,  three 
inches  long,  was  inserted. 

July  7th. — The  patient,  who  was  rather  self  willed, 


578 


MEDICAL   RECORD, 


[November  10,   1894 


lifted  herself  on  the  bed -pan  by  arching  herself  on  her 
shoulders  and  heels,  without  any  pain. 

July  10th  (Thirteenth  day). — She  took  a  few  steps, 
supported  under  her  shoulders,  and  felt  solid.  On  the 
12  th  the  upper  two  thirds  of  the  symphysis  were  felt  in 
perfect  apposition,  while  at  the  lower  end  there  was  just 
room  for  the  tip  of  the  finger.  The  plaster  straps  being 
loose  were  renewed. 

July  1 8th. — The  distance  between  the  bones  was  only 
one-eighth  to  one-sixth  inch.  The  tumor  in  the  pelvis 
had  entirely  disappeared,  and  must,  therefore,  probably 
have  been  due  to  serous  infiltration,  like  that  forming 
the  anasarca.  Only  the  left  ovary  was  felt  swollen  way 
up  in  front  of  the  left  iliac  synchondrosis. 

July  20th. — She  walked  alone  by  holding  on  to  the 
furniture ;  on  the  26  di  she  walked  without  support  and 
amused  herself  by  carrying  food  to  other  patients. 

July  31st  (Thirty-fourth  day  after  the  operation). — 
She  left  the  hospital  by  her  own  request. 

O a  October  9th  I  saw  her  and  her  child.  The  latter 
was  in  excellent  condition,  and  the  mother  could  lift  it, 
but  she  had  a  waddling  gait,  some  cystocele,  and  off  and 
on  pain  in  all  the  three  j  )ints  of  the  pelvis ;  but  she 
said  she  was  improving.  By  vaginal  examination  I 
found  the  greater  part  of  the  ends  of  the  pubic  bones  in 
apposition,  but  at  the  lower  end  the  diastasis  had  in- 
creased to  half  an  inch. 

The  subject  of  symphyseotomy  has  attracted  so  much 
attention  during  the  last  two  years  that  I  may  suppose 
every  member  of  this  Society  is  familiar  with  the  chief 
features  of  it,  and  I  have  twice  treated  it  at  some  length.1 
I  shall,  therefore,  to  night,  limit  myself  to  the  discussion 
of  some  particular  points  upon  which  opinions  differ 
much  among  the  different  authors  engaged  in  the  dis- 
cussion of  this  operation,  basing  my  opinions  not  only  on 
the  limited  experience  I  have  had  with  it  myself,  but  on  a 
somewhat  extended  study  of  the  cases  reported  by  others. 

First,  however,  I  shall  briefly  call  attention  to  some 
features  of  the  case  I  have  just  reported.  The  distance 
of  five  inches  between  the  ends  of  the  pubic  bones  is 
q  lite  unusual.  As  a  rule  it  is  only  one  and  one-quarter 
to  one  and  one-half  inches  when  you  hold  the  legs 
flexed  without  pulling.  How  much  it  was  before  and 
during  extraction  of  the  large  child  I  could  not  tell.  The 
child  being  in  the  greatest  danger  of  dying,  there  was 
no  time  for  such  investigations.  What  I  can  state  for  sure 
is  that  I  did  not  meet  with  any  resistance  in  extracting, 
and  that  no  cracking  sound  was  heard,  such  as  is  reported 
invariably  to  be  distinctly  audible  when  the  sacro  iliac 
joints  are  overstretched  and  ruptured.  Perhaps  the 
great  serous  infiltration  which  produced  the  anasarca  of 
the  whole  body  and  the  swelling  in  the  pelvis  for  which 
the  operation  was  performed  may  have  caused  an  unusual 
laxity  of  the  sacro  iliac  joints. 

Secondly,  I  would  notice  the  miserable  condition  of 
the  patient's  kidneys,  the  microscopical  examination 
showing  that  all  parts  of  the  same  were  affected,  and  the 
circumstance  that  the  patient  had  been  examined  by  one 
midwife  a  ad  three  doctors  without  antiseptic  precautions. 

Either  of  these  circumstances  would  have  excluded 
recourse  to  the  Cesarean  section,  and  if  Porro's  opera- 
tion had  been  performed,  she  would  undoubtedly  have 
died.  Forceps  and  version  being  out  of  the  question,  on 
account  of  the  disproportion  between  the  size  of  the 
child  and  the  space  left  in  the  pelvis  by  the  tumor,  the 
only  alternative  would  have  been  to  kill  this  splendid 
child,  weighing  nearly  eleven  pounds,  while  symphyseot- 
omy allowed  us  to  save  both  mother  and  child. 

It  is  true  the  mother  has  a  somewhat  unsatisfactory 
gait,  but  it  is  better  to  waddle  through  life  than  to  be 
put  at  rest  under  ground. 

Passing  to  the  consideration  of  the  operation  in  gen- 
eral, I  shall  limit  myself  to  remarks  on  its  prognosis,  its 
indications,  its  methods,  and  the  question  by  whom  and 
where  it  ought  to  be  performed  ? 

» American  Journal  of  the  Medical  Sciences,  March  and  April, 
1893,  and  American  Journ  il  of  Obstetrics,  November,  1893. 


Mortality. — A  chief  point  to  be  taken  into  considera- 
tion in  ventilating  the  advisability  of  performing  a  certain 
operation  is,  of  course,  the  prospects  it.  offers  as  to  life 
and  health.  In  his  large  work  on  symphyseotomy  Neuge- 
bauer 1  has  collected  213  cases  of  modern  operations  per- 
formed between  the  beginning  of  1887  and  the  middle 
of  1893.  ®f  ^e  mothers  183  recovered,  27  died,  and 
in  3  cases  the  result  was  unknown ;  that  is,  a  maternal 
mortality  of  12.85  VeT  cent-  As  to  the  children  the  re- 
sults were  unknown  in  8  cases.  Of  the  remaining  205 
children,  7  were  dead  before  the  operation ;  9  died  dur- 
ing parturition ;  189  were  born  alive;  but  of  these  31 
died  soon,  leaving  158  as  permanently  saved.  The  di- 
rect infantile  mortality  was,  therefore,  only  4  54  per 
cent.,  but  counting  those  who  died  within  a  few  days  as 
lost  the  mortality  among  the  children  was  20.2  per  cent. 

In  connection  with  these  general  statistics  it  must 
however,  not  be  overlooked  that  the  operations  were 
performed  by  a  very  large  number  of  operators,  e.g., 
the  first  twenty-eight  American  operations  by  twenty-three 
different  operators,  and  often  in  private  houses,  so  that  very 
few  men  have  acquired  a  large  personal  familiarity  with  the 
operation,  and  that  it  often  has  been  performed  with  defi- 
cient antiseptic  precautions.  At  the  hands  of  men  ac- 
customed to  obstetrical  and  gynecological  operations 
there  has  hardly  been  any  maternal  mortality.  Thus  we 
find  Pinard  operating  18  times  and  Zweifel  23  times 
without  losing  a  single  mother,  and  the  Italians  have, 
since  January  1,  1886,  had  55  operations  with  a  loss  of 
only  two  women.2  We  are  therefore  warranted  in  saying 
that  performed  under  the  most  favorable  conditions  there 
is  practically  no  maternal  mortality  inherent  in  the  opera- 
tion. 

For  the  child  the  outlook  is  not  so  good,  but  still  bet- 
ter than  in  most  other  methods  of  delivery,  not  to  speak 
of  craniotomy,  with  which  symphyseotomy  especially 
competes,  and  by  which  the  child  is  deliberately  killed, 
and  here  again  the  skill  of  the  operator  has  diminished 
the  mortality  considerably.  Thus  in  the  above-men- 
tioned 55  Italian  operations  only  8  children  were  lost, 
i.e.,  14  55  per  cent. 

Injuries. — Several  operators,  especially  German, 
have  reported  cases  in  which  the  soft  parts  of  the  mother 
sustained  considerable  injuries — the  urethra,  the  bladder, 
and  the  vagina  being  togi  during  extraction.  On  ac- 
count of  the  greater  firmnes3  of  the  tissues  this  is  more 
likely  to  happen  in  primipare.  The  bladder  and  the 
vagina  may  also  be  caught  in  bringing  the  pubic  bones 
together.  The  sacro-iliac  joints  have  been  ruptured  and 
separated.  Such  accidents  may,  however,  to  a  great  ex- 
tent, be  avoided  by  extracting  the  child  slowly  and  in 
the  proper  direction;  by  avoiding  pressure  in  front; 
if  necessary,  by  performing  episiotomy ;  by  keeping  the 
protruding  vagina  and  bladder  back  during  approxima- 
tion of  the  bones ;  and  by  not  passing  the  proper  limits 
of  the  indications.  Most  of  these  injuries  were  success- 
fully repaired  either  by  immediate  suture  or  by  a  consec- 
utive fistula  operation. 

On  the  other  hand,  it  cannot  be  denied  that  a  certain 
number  of  women  develop  a  waddling  gait.  That  this 
is  not  so  very  rare  will  appear  from  the  fact  that  I  have 
had  one  such  case  in  two  operations,  Grandin  one  in 
four  operations,  Zweifel  three  in  twenty- three  operations, 
and  Fritsch  even  four  in  four  operations.8  But  if  this 
waddling  gait  does  not  look  well,  it  need  not  interfere  with 
perfect  health  and  strength,  even  allowing  the  woman  to 
do  the  hardest  field-work  and  carry  her  eleven  months' 
old  baby  many  miles,  as  in  a  case  reported  by  Fritsch. 

Indications  and  Comparison  with  Other  Methods. — 
Since  only  a  few  years  have  elapsed  from  the  time  of  the 
new  impetus  given  to  this  old  operation  in  1892,  it  is 
quite  natural  that  opinions  in  regard  to  its  proper  field 
should  vary  much  among  leading  obstetricians,  and  one 

1  Neugebauer  :  Ueber  die  Rehabilitation  der  Schamfugentrennung 
oder  Symphyseotomie,  Leipzig,  1893,  pp.  272  and  276. 

•  Harris :  Gynecological  Transactions,  1894,  vol.  xix.,  p.  254. 

*  Centralblatt  fur  Gynakologie,  1893,  p.  1097 ;  ibidem,  1894,  pp.  347. 
46a 


November  10,  1894] 


MEDICAL    RECORD. 


579 


has  even  the  impression  that  national  tendencies  to  preju- 
dice in  favor  of  or  against  it  have  not  been  without  in- 
fluence on  the  bias  of  the  different  authors.  Thus,  while 
Leopold  rejects  the  operation  altogether  in  primiparae, 
and  wants  it  limited  in  regard  to  the  flat  pelvis  to  cases 
of  6  to  7#  ctm.  (=  2^  to  3  inches)  true  conjugate,  with 
both  mother  and  child  perfectly  healthy ; 1  Pinard  thinks 
it  must  replace  introduction  of  premature  labor  and  every 
operation  which  exposes  the  head  of  the  child  to  a  pel- 
vic resistance  that  cannot  be  overcome  by  uterine  con- 
tractions.2 

Personally  I  think  symphyseotomy  ought  to  have  a 
rather  wide  range  in  lying-in  hospitals  and  under  circum- 
stances that  favor  a  good  result,  especially  sufficient  as- 
sistance and  the  possibility  of  having  a  reasonable  de- 
gree of  asepsis.  In  the  flat  pelvis  I  think  we  may  expect 
an  easy  delivery  when  the  conjugate  measures  at  least 
three  inches,  and  that  it  may  yet  be  performed  when  the 
conjugate  measures  only  two  and  three  fourths  inches. 
To  go  b:low  this  is  hazardous,  unless  the  child  is  abnor- 
mally small. 

The  great  gain  obtained  in  the  lateral  directions  make 
symphyseotomy  particularly  valuable  for  us  on  account 
of  the  preponderance  of  generally  contracted  pelves  in 
New  York  and  Boston,  and  perhaps  other  parts  of  the 
United  States.  As  to  the  upper  limit  for  symphyseotomy, 
it  ought,  in  my  opinion,  to  be  placed  in  a  flat  pelvis  at 
a  true  conjugate  of  three  and  one-half  inches,  and  in  a 
generally  contracted  even  at  four  inches. 

Symphyseotomy  may  render  good  service  under  other 
circumstances  than  a  narrow  pelvis,  such  as  pelvic  tumor, 
occipitoposterior  position,  impacted  mentoposterior  face 
presentations,  ear  presentations,  in  eclampsia,  etc. 

In  studying  foreign  authors  on  the  indications  for 
symphyseotomy  in  narrow  pelves,  it  should  be  borne  in 
mind  that  the  average  weight  of  new-born  children  is 
considerably  greater  in  America  than  in  Europe.  Lusk 
found  the  average  of  two  hundred  cases  in  Bellevue  Hos- 
pital to  be  7^3  pounds,  while 'Tarnier  gives  it  as  3,174 
grammes  =  7  pounds,  Spiegelberg  as  3,174  grammes  = 
6  fa  pounds,  and  Playfair  at  only  6l/2  pounds.  We  can, 
therefore,  not  descend  so  low  as  European  accoucheurs  do, 
and  must  place  the  upper  limit  for  symphyseotomy  higher. 

Craniotomy  on  the  living  child  is  a  repulsive  opera- 
tion that  has  met  with  just  condemnation  from  many 
sides.  As  long  as  the  alternative  was  only  Csesarean 
section,  I  did  not  hesitate  to  sacrifice  the  child  in  order 
to  save  the  mother,  but  since  in  symphyseotomy  we  have 
got  an  operation  almost  without  danger  to  the  mother 
and  with  moderate  danger  to  the  child,  I  do  not  think 
any  man  should  feel  compelled  to,  or  justified  in,  delib- 
erately murdering  the  child,  provided  the  necessary  con- 
ditions for  a  successful  symphyseotomy  can  be  brought 
about. 

Induction  of  premature  labor  entails  only  a  maternal 
mortality  of  five  per  cent,  against  nearly  thirteen  in 
symphyseotomy.  In  skilful  hands  there  is  hardly  any 
mortality  for  the  mother  in  either  of  these  operations, 
but  then  the  infantile  mortality  is  very  high,'  and  many 
premature  children  die.4  In  cases  in  which  the  mother's 
life  is  to  be  preferred,  which  is  the  rule,  and  we  see  the 
patient  in  time,  recourse  may,  therefore,  be  had  to  in- 
duction of  premature  labor;  but  in  cases  in  which  the 
mother  is  particularly  anxious  to  have  a  child,  symphyse- 
otomy at  term  should  be  preferred. 

In  Csesarean  section  the  infantile  mortality  is  only  six, 
against  twenty  in  symphyseotomy,  but  then  the  mater- 
nal mortality  is  twice  as  large  in  Csesarean  section, 
twenty-five  against  twelve  and  one- half  per  cent.,  and  if 
we  only  take  the  most  skilful  operators,  the  mortality  of 
symphyseotomy  is  practically  none,  against  eight  per 
cent,  in  Csesarean  -section.     One  must,  therefore,  be  a 

1  Centralblatt  far  Gynftkologie,  1894,  p.  448. 
•Ibid.,  p.  348. 

•  Forty-three  per  cent  according  to  Wyder,  Arch,  t  Gynilk.,  1888, 
voL  xxxii,  p.  60. 

*  According  to  Winckel  two-thirds,  Gynecological  Transactions, 
1894,  vol.  xix.,p.  255. 


fanatic  worshipper  of  the  latter  operation  in  order  to 
think  ot  performing  it  when  the  former  is  practicable. 
Besides,  Caesarean  section  is  only  indicated  in  aseptic 
cases. 

Symphyseotomy  competes  even  with  Porro's  operation, 
since  it  has  been  successfully  performed  after  the  patient 
had  been  in  labor  for  days,  and  bad  been  examined  with- 
out antiseptic  precautions.  But  Porro's  operation  has  a 
maternal  mortality  of  37.78  per  cent.,  and  an  infantile 
mortality  of  22.40  per  cent.1  If  the  condition  of  the 
patient  is  not  too  bad,  and  there  is  no  absolute  indica- 
tion for  Caesarean  section,  symphyseotomy  should,  there- 
fore, be  preferred. 

Even  difficult  forceps  and  version  operations  ought  to 
be  replaced  by  symphyseotomy.  If  the  true  conjugate 
is  three  inches  or  more  it  may  be  well  to  try  the  forceps 
before  performing  symphyseotomy  as  recommended  by 
Morisani,*  but  below  that  we  only  jeopardize  the  child's 
life,  and  perhaps  the  mother's  too,  by  using  the  forceps. 

I  have  a  painful  recollection  of  cases  in  Maternity 
Hospital  of  generally  contracted  pelves  with  the  male 
type,  in  which  with  all  my  strength  I  extracted  a  dead 
child,  its  mother  dying  within  a  few  days,  so  that  I  even 
resolved  in  similar  ones  to  perfoim  Caesarean  section,  but 
now  would  substitute  symphyseotomy.  Furthermore, 
all  those  cases  we  read  about  of  three  strong  men  pulling 
at  once  or  in  succession  on  a  pair  of  forceps  ought  to  be 
relegated  to  the  history  of  barbarian  times. 

As  to  version,  we  well  know  how  difficult  it  is  to  get  a 
living  child  through  the  pelvis,  if  there  is  any  apprecia- 
ble narrowness.  If  the  conjugate  is  less  than  three  and 
a  quarter  inches,  both  veision  and  the  high  forceps  opera- 
tion entail  much  greater  danger  for  the  life  of  both 
mother  and  child,  to  which  must  yet  he  added  the  dan- 
ger of  the  child  becoming  idiotic  or  epileptic.  If  the 
child  is  unusually  large,  'symphyseotomy  comes  in  as  a 
life  saving  operation  for  both  mother  and  child,  even 
when  the  pelvis  is  normal. 

This  paper  has  already  become  so  long  that  there  is 
no  time  left  for  me  to  enter  at  length  into  the  question 
of  the  modus  operandi.  I  shall  only  recommend  the 
Italian  method  as  much  the  simpler  one,  which  also  has 
given  better  results  than  the  French. 

Instead  of  the  chain-saw  needed  in  rare  cases,  which 
is  expensive  and  difficult  to  render  aseptic,  Gigli  recom- 
mends rough  steel  wire.8  It  is  not  necessary  to  unite  the 
ends  of  the  pubic  bones  with  silver  wire  (Schauta),  or, 
to  hammer  steel  pegs  into  them  and  draw  them  together 
with  silver  wire  (Regnier),4  or  to  have  special  apparatus 
to  press  on  the  trochanters,  as  proposed  by  Pinard,  Kof- 
fer,  Bidder,  and  Krassowski.*  Rubber  adhesive  plas- 
ter carried  round  the  pelvis,  while  the  legs  are  kept 
straight,  is  sufficient  for  a  good  union.  I  think  it  is  bet- 
ter to  leave  a  rubber  drainage-tube  behind  the  symphysis 
for  a  few  days.  The  extraction  ought  to  be  made  while 
the  knees  are  kept  bent,  and  not,  as  advised  by  Leopold,6 
in  the  suspension  position  (Hangelage),  which  brings  the 
ends  of  the  pubic  bones  together.  Four  assistants  are 
needed,  and  at  least  one  of  them  ought  to  be  an  expert, 
as  the  child  often  is  asphyctic,  and  there  may  be  maternal 
hemorrhage  demanding  immediate  attention. 

Who  shall  Perform  Symphyseotomy  ?— In  laying 
down  rules  for  the  indications  of  symphyseotomy  I  have 
only  treated  the  question  from  a  purely  scientific  stand- 
point, as  it  ought  to  be,  without  taking  into  consideration 
what  every  practitioner  may  be  capable  of  doing.  When 
a  man  has  a  cataract,  it  ought  to  be  taken  out :  whether 
a  particular  physician  is  competent  to  do  so  or  not,  that 
is  a  question  between  him  and  his  patient.  But  just  as 
everybody  is  not  a  fit  person  for  extracting  a  cataract, 
thus  a  man  may  be  an  excellent  physician  and  still  not 
be  the  right  man  to  have  a  symphyseotomy  performed 

»  Playfair :  Sixth  American  edition,  1893,  by  Robert  P.  Harris. 

*Morisani :  Centralbl.  f  Gynak.,  1894,  vol.  xviii.,  p.  346. 

8  Gigli :  Centralbl.  f.  Gynak. ,  1894,  p.  12a 

4  Centralbl.  f.  Gynak.,  1893,  vol.  xvii.,  p..75a- 

6  Ibid.,  1893,  pp.  75a  and  937. 

•  Leopold  :  Centralbl.  f.  Gynftk.,  1894,  vol.  xviii.,  p.  45<>- 


58o 


MEDICAL    RECORD. 


[November  10,  1894 


by.  Nobody  should  undertake  this  operation  who  is  not 
an  operative  gynecologist  or  a  general  surgeon  with  ob- 
stetrical experience.  In  some  cases  very  serious  hemor- 
rhage has  to  be  dealt  with,  in  others  severe  injuries  of 
delicate  and  important  organs  demand  immediate  re- 
pair, and  in  most  the  child  has  to  be  artificially  revived. 
This  is,  therefore,  an  operation  which  most  general  prac- 
titioners had  better  place  in  the  hands  of  a  fellow- prac- 
titioner with  experience  in  that  kind  of  work,  just  as  he 
would  send  a  patient  afflicted  with  a  cataract  to  an  ocu- 
list 

Where  should  Symphyseotomy  be  Performed  ? — As  it 
is  next  to  impossible  to  perform  an  aseptic  operation  in 
most  private  dwellings,  especially  of  the  poor,  who  are 
much  more  likely  to  require  symphyseotomy  than  the 
rich ;  as  many  and  skilled  assistants  are  needed ;  and  as 
the  after-treatment  often  is  quite  complicated;  the 
chances  for  a  good  result  with  this,  as  with  all  major 
operations,  are  much  better  in  a  hospital  than  in  private 
houses.  Wherever  it  is  possible,  patients  requiring 
symphyseotomy  should  be  removed  to  a  hospital,  be  it  a 
lying-in  hospital  or  another  institution  where  abdominal 
operations  are  usually  performed.  Such  a  place  in  this 
city  is  St  Mark's  Hospital,  and  I  shall  be  happy  to  treat 
any  case  there  you  will  place  under  my  care.  It  is,  in 
my  opinion,  no  excuse  for  killing  a  child  that  the  ac- 
coucheur is  not  prepared  to  perform  symphyseotomy,  as 
long  as  there  is  somebody  else  within  reach  whose  ser- 
vices can  be  obtained,  and  who  is  able  to  substitute  a 
life-saving  for  a  destructive  operation. 


SURGERY   OF  THE  STOMACH. 
By  W.  J.  MAYO,  M.D./ 

ROCHESTER,   MINN. 

SUKGBON  TO  ST.  MARY'3  HOSPITAL,  ROCHESTER,  MINN.  J  IX- PRESIDENT  OP 
THE  MINNESOTA  STATE  MEDICAL  SOCIETY  \  MEMBER  OP  THE  STATE  BOARD  OP 
HEALTH. 

Mr.  President  and  Members  of  the  Southern  Min- 
nesota Medical  Society  :  The  stomach  is  now  amena- 
ble to  surgical  relief  from  a  large  number  of  conditions, 
which  until  recently  have  been  supposed  to  be  purely 
medical  ir*  character,  and  in  many  respects  it  offers  un- 
expected opportunity  for  operative  interference.  In  the 
first  place,  it  is  an  organ  more  or  less  fixed  within  a  cer- 
tain definite  part  of  the  upper  abdomen.  In  the  second 
place,  in  a  large  majority  of  instances  it  can  be  irrigated 
and  rendered  fairly  clean  before  operation.  In  the 
third  place,  by  rectal  alimentation  it  can  be  given  rest 
afterward ;  and  lastly,  its  thick  muscular  walls  afford  a 
good  hold  for  suture,  while  its  blood  supply  is  of  such 
nature  as  to  give  union  after  extensive  resections,  herein 
differing  materially  from  the  thin -walled,  mesentery- 
nourished  intestine  with  more  or  less  constant  vermicu- 
lar action.  I  will  not  take  up  your  time  with  the  anat- 
omy of  the  stomach,  more  than  to  mention  that  its 
cardiac  extremity  is  the  only  fixed  point,  and  that  it  is  sus- 
pended, so  to  speak,  in  such  a  way  as  to  vary  its  position 
whether  contracted  or  dilated.  In  the  former  case, 
lying  deep  under  the  liver  against  the  crura  of  the  dia- 
phragm, and  in  the  latter  occupying  a  prominent  posi- 
tion in  the  hypogastrium.  The  lesser  omentum,  as  con- 
taining the  main  blood-vessels,  is  of  much  surgical 
importance,  as  are  also  the  relations  of  the  mesocolon 
and  other  delicate  structures  in  the  neighborhood  of  the 
pylorus.  As  pointed  out  by  Tillaux,  the  cartilage  of  the 
ninth  rib  forms  an  important,  guide  to  the  lower  border 
of  the  stomach.  The  diagnosis  of  gastric  disease,  as  a 
rule,  is  not  difficult.  The  stomach  can  be  distended  by 
ether,  as  recommended  by  Felitzet,  or  by  the  use  of  bicar- 
bonate of  soda  and  an  acid,  as  practised  by  Jacobi. 
Usually,  the  introduction  of  a  definite  quantity  of  water 
will  sufficiently  mark  its  outline,  and  by  forcing  air  into 
the  colon  per  rectum,  as  practised  by  Senn,  the  relation 
of  the  stomach  to  the  transverse  colon  can  be  mapped 
out.  By  such  means,  I  was  able  to  diagnose  a  pancreat- 
ic cyst  definitely,  the  tumor  being  shown  to  be  retro- 


peritoneal and  lying  behind  the  gastrocolic  omentum, 
the  operation  proving  the  diagnosis.  (Case  13499  St 
Mary's  Hospital  Records.) 

The  value  of  the  examination  of  test  meals  and  the 
amount  of  acid  as  affecting  the  diagnosis  of  cancer,  is 
thoroughly  laid  down  by  Von  Jaksch  in  his  "  Clinical 
Diagnosis,"  the  presence  of  free  hydrochloric  acid  being 
a  factor  in  the  diagnosis  as  against  cancer  and  in  favor 
of  ulcer.  The  effect  of  the  weight  of  tumors  in  displac- 
ing the  stomach  is  ably  shown  by  Osier  in  a  series  of 
papers,  beginning  in  the  New  York  Medical  Journal  of 
February  3,  1894.  As  preliminary  to  operation  upon 
the  stomach,  irrigation  is  of  great  value  where  it  can  be 
practised,  and,  as  pointed  out  by  Kussmaul,  much 
benefit  may  be  derived  from  lavage  where  obstruction 
exists  below,  thus  relieving  the  stomach  of  irritating 
material,  removing  the  distention  and  interference  with 
breathing,  and  putting  the  patient  into  better  condition 
for  operation.  Shall  the  stomach  be  distended  previous 
to  operation,  to  facilitate  finding  it?  I  have  personal 
reason  to  know,  in  at  least  two  operations,  that  where  the 
stomach  is  contracted  from  stricture  of  the  oesophagus 
and  the  colon  greatly  dilated  through  rectal  alimenta- 
tion, the  difficulty  of  finding  the  stomach  may  be  great. 
In  these  cases  the  stomach  was  found  by  the  sense  of 
touch,  for  after  a  little  expeiience  the  feel  of  its  thick 
walls  will  not  be  forgotten.  Previous  distention  may 
assist  in  finding  the  stomach,  but  it  complicates  the 
further  manipulation  and  introduces  an  element  of  dan- 
ger of  wound  contamination  from  escape  of  its  dilating 
contents.  I  believe  it  had  best  be  empty.  The  after- 
treatment  of  gastric  operations  is  changing  toward  the 
earlier  administration  of  food  by  the  stomach,  especially 
in  exhausted  patients,  although  rectal  feeding  is  the  rule 
during  the  first  few  days. 

Before  closing  these  general  considerations,  I  wish  to 
call  attention  to  gastric  distress  produced  by  traction  of 
adherent  omentum.  Billroth  has  written  well  upon  this 
subject,  especially  in  reference  to  the  small  buttons  of 
omentum  protruding  through  little  gaps  in  the  upper 
abdominal  wall.  Koenig  reports  some  twenty  cases 
operated  upon.  I  have  seen  several  cases  of  this  de- 
scription (863  and  1059,  St.  Mary's  Hospital  Surgical 
Record).  The  first,  a  boy  of  fifteen,  with  a  small  hernia 
of  adherent  omentum  protruding  through  a  little  defect 
in  the  median  line  above  the  umbilicus.  The  second,  a 
lady  of  fifty,  with  adherent  omentum  in  a  femoral  hernia, 
both  cases  having  no  local  symptoms  at  the  site  of  pro- 
trusion, and  both  relieved  by  operation.  I  have  also 
seen  some  cases  of  this  form  of  omental  adhesion  with 
corresponding  symptoms  in  connection  with  post  opera- 
tive ventral  hernise.  Wounds  and  injuries  of  the  stomach 
are  to  be  treated  on  surgical  principles,  and  where  evi- 
dences of  perforative  wounds  are  found  operative  re- 
pair is  imperative.  Rose  speaks  of  persistent  vomiting 
of  blood  as  a  reliable  sign  of  gastric  injury.  In  case 
there  be  injury  to  the  head  at  the  same  time,  however, 
the  possibility  of  there  having  been  blood  swallowed 
from  the  upper  passages  should  be  borne  in  mind.  For- 
eign bodies  in  the  stomach  are  a  not  infrequent  cause  of 
danger  and  suffering,  and  gastrotomy  for  the  purpose  of 
removal  has  been  greatly  perfected.  Richardson,  of 
Boston,  gives  a  careful  analysis  of  reported  cases,  and 
makes  many  valuable  modifications  in  the  technique,  when 
the  foreign  body  lies  in  the  lower  oesophagus.  Bull  also 
reports  excellent  work  in  this  direction.  The  value  of  a  . 
potato  diet  in  the  non-  operative  treatment  of  foreign 
bodies  of  the  alimentary  canal,  should  not  be  forgotten. 

Fistulae  are,  as  a  rule,  the  result  of  operative  work,  and 
rarely  come  from  accidental  or  pathological  causes. 
They  vary  much  in  the  difficulty  of  repair  on  account  of 
location,  those  adjacent  to  the  bony  framework  being 
much  more  difficult  of  operation  than  those  more  remote. 
The  great  value  of  the  provisional  suture  to  prevent  es- 
cape of  stomach- contents  during  manipulation,  is  at  once 
apparent.  Chronic  dilatation  of  the  stomach,  when  not 
due  to  organic  lesion,  may  be  caused  by  chronic  gastric 


November  10,  1894] 


MEDICAL   RECORD. 


581 


catarrh  with  sagging  of  the  fundus,  rendering  it  difficult 
for  the  stomach  to  empty  itself.  Taylor,  of  Birming- 
ham, has  studied  this  condition  carefully,  and  believes 
that  it  produces  a  kinking  at  the  pylorus  with  prominence 
of  the  mucous  fold,  causing  a  bar-like  obstruction  to  the 
emptying  of  the  stomach.  He  practises  operative  dila- 
tation of  the  pylorus  with  success.  Bircher,  followed  by 
Weir,  mechanically  raises  the  fundus,  and  reduces  its 
size  by  putting  a  longitudinal  plait  along  its  walls,  turn- 
ing a  fold  into  its  cavity.  This  operation  is  indicated 
in  those  cases  where  lavage  for  a  length  of  time  has  failed 
to  relieve  the  symptoms. 

Ulcer. — In  the  diagnosis  of  ulcer,  the  age  of  the  pa- 
tient, the  quantity  of  the  vomit,  the  lack  of  emaciation, 
which  in  ulcer  is  more  often  a  profound  anaemia  without 
great  loss  of  flesh,  the  presence  of  free  acid,  and  slow 
course  of  the  disease,  are  all  valuable  symptoms  of  ulcera- 
tion as  against  carcinoma.  Operation  may  be  demanded 
for  acute  perforation,  provided  it  can  be  diagnosed  in 
time.  As  can  readily  be  perceived,  the  location  of  the 
perforation,  whether  on  the  anterior  or  posterior  wall, 
will  greatly  influence  the  ease  of  repair.  Ulcer  of  the 
stomach  being  most  frequent  on  the  posterior  wall,  occa- 
sionally a  perforation  may  take  place  and  the  escaping 
material,  on  account  of  its  mechanical  surroundings,  be- 
come encapsulated  as  a  sub  diaphragmatic  abscess.  Weir 
points  out  the  frequency  of  left  pneumothorax  due  to  the 
secondary  results  of  perforative  ulcer.  A  case  of  sub- 
diaphragmatic abscess  came  under  my  care.  (No.  1,537, 
St.  Mary's  Hospital  Surgical  Record.)  A  Scandina- 
vian, fifty  years  of  age,  with  history  of  chronic  stomach 
trouble,  became  suddenly  ill,  developed  pain,  and  later, 
cough  and  hiccough.  A  deep  swelling  became  manifest 
in  the  sixth  interspace  just  to  the  right  of  the  sternum, 
for  relief  of  which  he  entered  the  hospital.  A  deep 
incision  was  made  and  pus  evacuated ;  but  as  a  sinus 
formed  and  failed  to  heal,  the  cartilages  of  the  sixth  and 
seventh  ribs  and  a  large  portion  of  the  lower  end  of  the 
sternum  were  resected.  The  sinus  was  followed  through 
the  diaphragm  to  the  neighborhood  of  the  lesser  omen- 
tum, where  a  small  cavity  existed;  this  was  packed  with 
gauze  and  slow  healing  followed.  The  secondary  results 
of  ulcer,  in  producing  contraction  at  the  pylorus,  may  call 
for  operation  for  obstruction,  either  the  digital  divulsion 
of  Loreta,  or  better  the  Heineke-Mikulicz  pyloroplasty. 
Weir  reports  a  case  of  this  character  in  which  gastro- 
enterostomy was  performed,  and  in  selected  cases  advo- 
cates its  expediency. 

Cancer  of  the  Stomaoh. — The  age  of  the  patient,  lack 
of  free  acid  in  the  vomit,  the  emaciation,  and  the  possible 
presence  of  peptones  and  albumin  in  the  urine,  aid  in  the 
diagnosis  of  cancer.  Gussenbauer  and  Winiwarter 
give  sixty  per  cent,  as  the  proportion  of  pyloric  cancer 
to  the  whole  number.  Bull,  with  statistics  of  thirteen 
hundred  cases  of  Stomach  cancer,  gives  the  proportion  as 
above  fifty  per  cent,  in  the  pylorus.  Butlin,  in  his  classi- 
cal work,  says  of  these  cases,  that  a  very  large  number  of 
cases  of  pyloric  cancer  die  from  obstruction  before 
glandular  infection  or  extensive  adhesion  takes  place. 
Billroth,  the  great  exponent  of  operative  surgery  of  the 
stomach,  says  that  cancer  of  the  pylorus  produces  great 
muscular  hypertrophy  and  death  from  obstruction  in  one- 
half  of  the  cases,  before  adhesions  or  glandular  infection 
supervene.  It  is  probable,  therefore,  in  the  light  of  this 
knowledge,  that  pylorectomy  and  partial  gastrectomy 
have  a  larger  field  than  has  been  supposed,  although 
Butlin,  in  a  careful  analysis  of  reported  cases  subjected  to 
operation,  takes  a  very  gloomy  view  of  the  situation. 
For  cancer  involving  the  cardiac  orifice,  gastrostomy  is 
advocated  by  Von  Hacker  for  the  purpose  of  feeding. 
Lauenstein  has  been  impressed  by  certain  unfortunate 
sequelae  of  gastrostomy  in  these  cases,  such  as  constant 
leakage,  involvement  of  the  fistula,  etc.  With  either  the 
Witzel  or  Frank  operation  of  gastrostomy  this  objection 
would  not  hold  good,  however.  For  cancer  of  the  fundus, 
Bernays,  of  St.  Louis,  practises  gastrotomy  and  curet- 
ting of  the  mass  from  within  the  stomach.     He  shows 


that  in  the  majority  of  cases  the  growth  of  the  cancer  is 
toward  its  free  cavity:  The  danger  and  difficulty  of  the 
operation  exceed  the  benefit  to  be  derived  from  it,  in  my 
opinion.  In  this  connection  an  allusion  to  the  remark- 
able disappearance  or  temporary  checking  of  the  growth 
of  tumors  after  simple  exploratory  incision,  would  not  be 
out  of  place.  Tait  first  called  attention  to  this  phenome- 
non. J.  W.  White  has  gone  extensively  into  this  sub- 
ject in  regard  to  the  curative  value  of  operations  of 
themselves,  independent  of  their  intention.  The  total 
disappearance  of  a  cancer  after  simple  abdominal  incision 
must  be  very  rare,  but  I  have  twice  seen  temporary  check- 
ing of  its  progress  after  laparotomy.  (Cases  368  and  571, 
St.  Mary's  Hospital  Surgical  Record.)  In  cancer  of  the 
stomach  a  varicose  condition  of  the  peritoneal  veins 
overlying  the  growth  is  frequently  observed  on  laparo- 
tomy, and  is  due  to  obstructed  internal  circulation  leading 
to  adhesions.  In  one  hundred  and  twenty-four  opera- 
tions on  the  stomach  and  intestines,  Billroth  gives  a 
mortality  of  fifty  per  cent. 

Operations  on  the  Stomaoh. — In  stomach  operations, 
the  abdominal  incision  for  most  purposes  will  be  the 
classical  one  of  Fenger,  parallel  with  the  left  costal  car- 
tilages, and,  unless  otherwise  specified,  is  the  one  used, 
excepting  for  fistula  and  other  conditions  where  there  is 
no  choice  of  locality.  Gastrorraphy,  due  to  the  genius 
of  Billroth,  may  be  performed  for  wounds  and  injuries, 
the  simple  Lembert  or  a  Czerny-Lembert  suture  being 
applied.  For  fistulse,  some  special  means  of  preventing 
escape  of  the  stomach  contents  during  operation  must 
be  used.  The  older  method  was  to  introduce  a  sponge 
with  attached  string,  and  hold  this  firmly  against  the 
opening.  The  provisional  suture  of  the  margins  of  the 
fistula  is  a  much  better  practice,  and  in  many  cases,  by 
trimming  away  the  attached  tissues  afterward,  can  be  left 
as  a  Czerny  suture  and  the  Lembert  applied  to  roll  it  in ; 
or  the  stomach  being  brought  well  out,  the  whole  of  the 
fistula  may  be  cut  out  and  the  Czerny-Lembert  suture 
applied.  In  1891  Bircher  invented  his  operation  for 
simple  dilatation  of  the  stomach,  by  suturing  a  fold  which 
projects  into  its  lumen  with  a  Lembert  suture.  Weir 
has  practised  this  with  marked  relief. 

Gastrotomy  for  Foreign  Bodies. — Richardson,  in 
1886,  recommended  a  large  gastric  incision  and  the  in- 
troduction of  the  whole  hand,  if  necessary,  to  remove 
bodies  from  the  lower  oesophagus.  Much  of  our  knowl- 
edge of  foreign  bodies  is  due  to  his  labors.  Bull  recom- 
mends a  small  gastric  incision,  and  with  fingers  intro- 
duced, invaginates  the  wall  into  the  stomach  cavity.  In 
either  case,  several  holding- sutures  to  manipulate  the 
stomach  with  are  better  than  the  fingers,  which  may  slip, 
or  forceps,  which  may  injure  the  vitality  of  the  wound 
margins.  Gastrotomy  for  the  purpose  of  curetting  can- 
cerous growths  has  been  performed  by  Bernays,  but 
cannot  be  commended. 

Gastrotomy  for  Dilatation.— In  1892  Loreta  practised 
gastrotomy  for  the  purpose  of  digital  divulsion  of  the 
pylorus  for  obstruction.  It  can  be  performed  for  steno- 
sis of  either  orifice  of  the  stomach.  J.  W.  Taylor  has 
made  gastrotomy  several  times  for  the  purpose  of  digital 
dilatation  of  the  pylorus,  in  cases  of  twisting  at  the  neck 
of  the  stomach  due  to  chronic  dilatation,  and  reports 
successful  cases.  Heineke  and  Mikulicz,  nearly  simul- 
taneously, performed  pyloroplasty  for  cicatricial  stenosis 
of  the  pylorus.  As  ordinarily  performed,  a  gastrotomy 
is  first  made  and  a  grooved  director  introduced  through 
the  stricture  from  the  stomach,  the  contracted  tissues  are 
then  divided  by  a  longitudinal  cut,  and  this  incision  is 
now  united  in  a  transverse  direction  by  suture.  This 
admirable  operation  has  been  performed  by  Senn  and 
many  other  surgeons,  with  the  best  of  results. 

Gastrostomy  for  the  purpose  of  feeding  is  indicated  by 
any  obstruction  between  the  mouth  and  the  stomach,  if 
it  cannot  be  relieved  by  less  dangerous  and  more  expedi- 
ent methods.  First  performed  by  Sedillot  in  1849,  it 
has  had  a  perilous  existence,  until  in  recent  years  the 
method  known  as  Fenger' s  has  usually  been  employed ; 


582 


MEDICAL  RECORD 


[November  io,  1894 


but  its  high  mortality,  the  leakage,  with  its  attendant 
loss  of  nutrition  and  irritation  of  the  surrounding  skin, 
made  it  but  rarely  resorted  to.  In  preventing  this  leak- 
age, Ferrier  made  the  important  suggestion  that  the  gas- 
tric opening  be  made  high  up  near  the  lesser  curvature. 
Most  operations  up  to  this  time  were  done  in  two  sit- 
tings, the  stomach  being  first  sutured  to  the  abdominal 
incision  and  the  site  of  the  future  fistula  marked  by 
ligatures,  to  guide  the  opening  after  adhesion  takes  place. 
In  a  case  oi  impermeable  cicatricial  oesophageal  stricture, 
I  was  compelled  to  make  a  gastrostomy  after  this  method 
for  the  purpose  of  feeding,  and  for  retrograde  dilatation 
and  division  after  Abbe's  string  method.  While  the 
eventual  recovery  was  good,  the  annoyance  of  the  con- 
stant leakage  was  great.  (Case  1,278,  St.  Mary's  Hos- 
pital Surgical  Record.) 

Hahn  modified  the  operation  by  making  the  opening 
in  the  stomach  high  up,  and  putting  the  fistula  between 
the  ribs  for  better  mechanical  closure.  This  is  done  by 
making  an  abdominal  incision  and  locating  the  stomach, 
then  a  special  short  incision  in  the  eighth  intercostal 
space  is  made,  and  by  passing  forceps  through  this  but- 
ton-hole they  can  be  applied  to  the  proper  place  on  the 
stomach  wall  by  the  fingers  in  the  large  incision,  and  the 
stomach  fixed  in  the  small  opening,  the  abdominal  inci- 
sion being  then  closed.  For  retrograde  dilatation  of  the 
oesophagus  Von  Hacker's  method  should  be  preferred, 
as,  while  it  affords  only  a  moderate  degree  of  retention, 
it  permits  of  excellent  intra-gastric  manipulation.  The 
method  consists  of  a  perpendicular  incision  through  the 
body  of  the  rectus  muscle,  which  gives  somewhat  of  a 
sphincter  action.  Witzel's  method  is  the  best  for  tem- 
porary fistula,  as  it  gives  perfect  closure  against  leakage. 
I  have  performed  this  operation  once  with  the  most  per- 
fect satisfaction.  (Case  1,679,  St.  Mary's  Hospital  Sur- 
gical Record.)  After  the  usual  incision  the  stomach 
is  drawn  well  out  and  a  small  cut  made  in  its  wall, 
through  which  a  rubber  tube  the  size  of  a  lead-pencil  is 
introduced  one  inch  toward  the  fundus.  With  a  Lem- 
bert  suture  the  free  walls  of  the  stomach  are  drawn  to- 
gether over  the  tube,  beginning  one  inch  to  the  left  and 
continuing  to  the  right  one  and  a  half  inch,  forming  a 
channel  lined  with  peritoneum.  The  stomach  is  dropped 
back  and  sutured  to  the  incision.  The  great  advantages 
of  this  operation  are  that  feeding  can  be  commenced  at 
once  without  any  danger  of  leakage,  and,  on  withdrawal 
of  the  tube,  the  peritoneal  granulation  lining  the  chan- 
nel will  heal  permanently.  This  is  of  obvious  advantage 
if  the  condition  giving  rise  to  the  operation  can  be  re- 
moved. I  can  heartily  commend  this  operation  from 
personal  experience.  Andrews,  of  Chicago,  has  modi- 
fied this  by  free  incision  of  the  stomach  and  formation 
of  a  channel  from  the  mucous  membrane.  This  is  done 
to  avoid  the  use  of  a  permanent  tube,  but  has  greater 
danger  of  infection  and  is  difficult  of  performance.  For 
permanent  gastric  fistula  the  method  advocated  by  Frank 
is  undoubtedly  the  best.  In  this  operation  a  fold  of  the 
stomach  one  and  a  half  inch  long  is  drawn  out  and 
sutured  to  the  parietal  peritoneum  at  its  base.  The 
skin  above  the  upper  margin  of  the  abdominal  incision 
is  undermined  along  the  seventh  rib  to  a  point  over  the 
'  sixth  rib,  where  an  incision  three- fourths  of  an  inch  in 
length  is  made.  The  stomach  cone  is  now  carried  under 
the  skin  flap  and  the  apex  sutured  to  this  button  hole ; 
the  abdominal  incision  is  then  closed,  giving  a  spout- 
like opening.  This  operation  is  a  model  one  for  the 
purpose  of  a  permanent  fistula.  Great  credit  is  due  to 
Willy  Meyer  for  the  popularization  of  the  Witzel  and 
Frank  operations  in  this  country. 

Resections  of  the  Stomach. — With  these  operations  the 
names  of  Billroth,  Wolfler,  and  Czerny  are  inseparably 
connected,  and  it  was  their  courageous  work  in  the  face 
of  an  appalling  mortality  which  has  made  resection  of 
the  stomach  a  legitimate  operation.  Pean,  in  1 879,  made 
the  first  pylorectomy,  though  unsuccessfully.  The  mor- 
tality of  Billroth,  the  great  exponent  of  pylorectomy,  has 
been  nearly  fifty  per  cent.,  deaths  being  due  largely  to 


collapse,  and  a  number  to  gangrene  of  the  colon  from  in- 
jury to  the  meso-colon  while  separating  the  pylorus. 
This  surgeon  employs  the  transverse  abdominal  incision, 
resects  the  stomach  in  a  V  shape,  using  a  close  Czerny- 
Lembert  suture  in  closing  the  gastric  incision,  and  sutur- 
ing the  end  of  the  duodenum  into  the  lower  angle  of  the 
stomach  wound.  The  separation  of  the  pylorus  is  very 
carefully  done,  and  just  sufficient  of  the  greater  and  lesser 
omentum  tied  off  to  permit  of  operation.  The  greatest 
care  of  the  meso  colon  must  be  taken.  The  tendency  of 
American  and  English  surgeons,  led  by  Bull,  of  New 
York,  McCormick,  Treves,  and  Greig  Smith,  of  Great 
Britain,  is  to  make  the  usual  median  abdominal  incision, 
and  after  the  pylorus  is  separated,  to  at  once  completely 
suture  the  stomach  with  the  Czerny-  Lembert  suture.  The 
pylorus  is  now  cut  away  from  the  duodenum  and  the  end 
of  the  latter  sutured,  gastro  enterostomy*  being  then  per- 
formed. This  carries  the  opening  away  from  the  danger- 
ous suture  line.  Partial  gastrectomy,  as  a  rule,  is  a  simpler 
operation,  Maydl  having  once  removed  nearly  one-half 
of  the  organ.  Complete  gastrectomy  has  been  several 
times  attempted,  notably  by  Conner,  of  Cincinnati,  but 
must  fail  on  account  of  total  destruction  of  the  meso- 
colon. Ohage,  of  St.  Paul,  in  the  midst  of  a  partial 
gastrectomy,  was  confronted  by  unsuspected  difficulties 
which  rendered  removal  impossible.  The  stomach  was 
freely  opened  above,  the  malignant  mass  turned  into  its 
cavity,  and  the  upper  cut  edge  sutured  to  the  wall  below 
the  growth.  The  patient  not  only  lived,  but  for  a  space 
of  two  years  has  been  practically  well  up  to  the  present 
time.  Gastro  enterostomy  is  indicated  by  obstruction  of 
the  pylorus,  especially  if  this  be  malignant  and  not  suited 
for  pylorectomy.  It  was  first  performed  by  Wtflfler  in 
1 88 1 ,  by  suture,  and  up  to  the  time  of  Senn's  great  innova- 
tion in  the  use  of  bone  plates  for  anastomosis,  the  mor- 
tality was  great — about  fifty  per  cent.  At  the  present 
time,  performed  by  the  aid  of  bone  plates  or  the  me- 
chanical device  of  Murphy,  it  is  a  rapid  and  safe  procedure. 
Postnikow  has  attempted  to  improve  the  suture  operation 
by  freely  incising  the  structures  of  the  stomach  and  gut 
to  the  mucous  coat,  which  is  ligated,  and  then  suturing  the 
corresponding  parts  together,  in  the  expectation  that  ad- 
hesions will  take  place  before  sloughing  of  the  mucous 
coat  completes  the  fistula.  In  all  of  these  operations,  if 
the  duodenum  cannot  be  easily  drawn  to  the  stomach,  a 
loop  of  the  jejunum  may  be  used  and  drawn  around  the 
omentum,  which  is  pushed  to  the  left  rather  than  through 
its  folds.  The  latter  practice  has  in  several  instances 
caused  death,  from  kinking  of  the  intestine  and  obstruc- 
tion. 


Education  and  Cleanliness. — The  Chicago  school 
board  has  been  discussing  the  question  of  cleanliness,  and 
as  a  result,  another  innovation,  the  bath-tub,  will  be  in- 
troduced into  the  curriculum  of  certain  schools  in  that 
city.  In  several  districts  many  scholars  possess  errone- 
ous ideas  regarding  the  proper  degree  of  cleanliness,  and 
henceforth  those  presenting  an  unhygienic  appearance 
will  receive  a  scrubbing.  The  boys  will  be  immersed  by 
the  janitor,  and  the  girls  will  take  their  ducking  under 
the  supervision  of  women  who  are  employed  as  assistant 
janitors.  The  board  deemed  it  essential  that  a  child 
should  know  the  value  of  soap  and  water,  as  well  as  the 
double  rule  of  three  or  the  theory  of  the  tides.  The 
plan  to  supply  the  schools  with  bath-tubs  originated  with 
Mrs.  J.  M.  Flower,  who  recently  retired  from  a  three 
years1  service  as  member  of  the  board  of  education,  and 
who  is  now  a  candidate  for  trustee  of  the  State  university. 
This  procedure  marks  another  step  toward  clinical  teach- 
ing in  the  schools.  Theoretical  physiology  has  been 
taught  children  for  years,  but  it  has  not  kept  them  clean. 
Under  the  new  rSgime  pupils  will  be  instructed  in  the 
practical  application  of  this  science  by  demonstrations  in 
bathing,  and  proof  of  the  superiority  of  this  method  of 
teaching  the  phenomena  of  the  human  body  will  be 
manifest  on  the  surface. — The  Physician  and  Surgeon. 


November  io,  1894] 


MEDICAL   RECORD. 


583 


A  CONTRIBUTION  TO  THE  STUDY  OF  THE 
CAUSE  OF  STRICTURE  IN  THE  MALE 
URETHRA. 

By  CHARLES   GETZ,  M.D.K 

BALTIMORE,   MD. 

The  cause  of  stricture  in  the  male  urethra  is  a  subject 
which,  it  seems  to  me,  has  not  received  the  amount  of 
attention  its  importance  deserves  in  the  majority  of  sur- 
gical textbooks.  Even  in  the  special  works  upon  the 
subject  of  stricture,  while  exhaustive  descriptions  of 
symptoms,  diagnosis,  and  treatment  are  given,  with  clini- 
cal illustrations  ad  infinitum,  still,  when  the  authors  come 
to  consider  the  cause,  they,  with  the  single  exception  of 
Sir  Henry  Thompson,  have  passed  briefly  over  this  im- 
portant field.  From  those  authors  who  have  devoted  a 
few  short  paragraphs  to  the  cause  of  stricture  there  have 
originated  ideas  and  theories  so  contradictory,  in  some 
respects,  that  instead  of  throwing  light  upon  the  subject 
they  rather  confuse  the  same. 

By  some  writers  inflammation,  especially  gonorrhoeal 
inflammation,  is  given  credit  for  causing  most  cases  of 
stricture.  Others,  again,  differ,  and  in  their  efforts  to 
reach  a  correct  conclusion  concerning  this  disputed 
point  overstep  the  proper  bounds  by  denying  gonorrhoea 
a  place  as  an  etiological  factor  altogether.  Thus  John 
Hunter,  one  of  the  most  profound  surgical  pathologists 
of  his  time,  in  describing  the  relation  of  gonorrhoea  to 
the  cause  of  stricture,  says,  "  I  doubt  very  much  if  it 
commonly  or  even  ever  arises  from  this  cause."  1  Against 
this  opinion  we  may  array  the  words  of  Sir  Astley  Cooper, 
who  says,  "If  asked  what  was  the  cause  of  stricture,  I 
should  say  in  ninety- nine  cases  out  of  every  hundred  it 
was  the  result  of  gonorrhoea."  2  The  writings  of  Hunter 
show  that  he  believed  almost  exclusively  in  a  congenital  or 
anatomical  cause  for  stricture,  while  the  words  of  Cooper 
prove  that  he  considered  the  condition  an  acquired  one 
in  nearly  every  instance.  Both  of  these  famous  old  sur- 
geons were  right,  to  a  certain  extent,  in  their  convic- 
tions, but  as  is  the  case  with  most  vexed  questions,  the 
truth  lies  between  the  two  extremes ;  and  in  the  course 
of  my  remarks  I  will  endeavor  to  prove  that  in  the  ma- 
jority of  cases  both  a  congenital  defect  and  an  acquired 
pathological  condition  are  essential  to  the  formation  of 
close  organic  stricture. 

Sir  Henry  Thompson,  in  his  book  on  stricture,  third 
edition,  page  120,  give  a  table  of  cases,  220  in  number, 
in  which  the  antecedent  or  supposed  causes  were  as  fol- 
lows :  Gonorrhoeal  inflammation  in  164  cases;  injury  to 
perineum  in  28  cases ;  cicatrization  of  chancre  in  3 
cases;  cicatrization  following  phagedena  in  1  case; 
congenital,  including  cases  in  which  the  urethra  may 
have  been  small  from  malformation,  and  those  in  which 
marked  irritability  of  the  urinary  organs  existed  from 
childhood,  accompanied  by  an  unusually  small  stream, 
6  cases ;  poisoning  by  nitrate  of  potash,  lithotrity,  mas- 
turbation, of  each  1  case;  inflammatory  stricture,  includ- 
ing temporary  stricture  and  retention  from  a  sudden 
acute  inflammation,  usually  caused  by  some  excess,  and 
disappearing  by  resolution,  8  cases ;  spasmodic  stricture 
caused  by  irritation  about  the  rectum,  2  cases ;  spasmodic 
stricture,  no  cause  assignable,  2  cases ;  spasmodic  strict- 
ure caused  by  undue  acidity  or  alkalinity  of  the  urine, 
3  cases. 

This  table  has  been  extensively  quoted  by  other  mod- 
ern writers  upon  genito-urinary  surgery  and  about  repre- 
sents the  prevailing  belief,  as  regards  cause  and  effect 
and  the  proportionate  percentage  of  each,  up  to  the 
present  time,  with  possibly  two  exceptions,  namely,  the 
congenital  variety  and  those  attributable  to  masturba- 
tion. 

The  former  (congenital  stricture),  thanks  to  our  mod- 
ern exact  methods  of  urethral  exploration,  are  more  aid 
more  frequently  recognized.  The  latter  (masturbators' 
stricture)9  which  from  one  case  in  two  hundred  and 

1  Ricord  and  Hunter  on  Veneral  Disease,  page  151. 

9  Surgical  Lectures,  reported  in  the  Lancet,  vol.  iii.-iv.,  page  222. 


twenty  as  quoted  from  Thompson's  table  has  increased 
(though  I  cannot  accept  the  fact)  proportionately  to  thir- 
teen out  of  every  one  hundred  cases,  according  to  Dr. 
Samuel  W.  Gross.1 

Before  entering  fully  upon  the  discourse  cf  the  subject 
I  will  preface  my  remarks  with  the  admission  that  I  ac- 
cept every  one  of  the  causes  of  organic  urethral  stricture 
quoted  from  Thompson's  table  as  having  an  important 
part  to  play  in  their  formation,  but  with  the  exception  of 
the  traumatic  variety  and  those  following  the  cicatriza- 
tion of  venereal  ulcers,  I  claim  that  all  the  other  stated 
causes  act  secondary  to  pre-existing  anatomical  defects. 

The  chief  source  of  error,  so  it  appears  to  me,  is  that 
most  writers,  in  describing  the  lesion,  seem  to  regard 
the  urethra  as  a  tract  anatomically  perfect  in  structure 
and  physiologically  normal  in  function  until  its  owner  is 
unfortunate  enough  to  acquire  some  form  of  urethritis, 
then,  after  a  variable  period  of  time,  the  urethra,  having 
fretted  under  a  lingering  gleet,  is  examined,  and  if  found 
contracted  at  one  or  more  points  a  diagnosis  is  recorded 
of  stricture — due  to  the  variety  of  urethritis  frcm  which 
the  patient  has  suffered. 

How  many  physicians,  when  confronted  by  a  case  of 
stricture  which  seemingly  may  have  originated  as  de- 
scribed in  the  preceding  paragraph,  will  pause  to  consider 
how  much  the  urethritis  has  had  to  do  with  the  cause  of 
the  stricture  ?  How  can  gonorrhoea,  for  example,  make 
such  serious  inroads  upon  the  integrity  of  die  parts? 
The  explanation,  based  upon  anatomical  grounds,  is 
simple.  It  is  because  all  urethrse  are  not  perfect  in 
structure.  An  overwhelming  proportion  have  extensile 
congenital  defects  of  such  a  nature  as  to  favor  the  perpet- 
uation of  inflammation  and  its  sequelae  once  it  has  been 
established.  The  urethra  is  not  an  exception  to  other 
parts,  but  is  as  often  the  seat  of  irregular  development 
and  malformation  as  is  the  nasal  septum,  the  hard  or 
soft  palate,  the  upper  lip,  and  other  structures  in  the 
mesial  line  of  the  body  which  are  formed  by  fusion  of 
opposite  surfaces. 

From  the  researches  of  the  embryologist  we  know 
that  during  the  early  period  of  foetal  development  the 
genital  furrow  exists  as  an  open  tract,  and  that  between 
the  third  and  fourth  months  the  free  edges  of  this  tract 
coalesce  or  fuse  together,  leaving  a  crevice  which  consti- 
tutes the  spongy  portion  of  the  urethra.  Now  it  is  co- 
incident with  this  period  and  process  of  foetal  develop- 
ment that  the  first  departure  from  perfect  anatomy  occurs. 
The  edges  of  the  genital  furrow  may  unite  irregularly,  the 
normal  limits  may  be  exceeded  at  one  or  more  points, 
so  that  instead  of  a  free  tract  capable  of  expanding 
into  an  even  open  canal  when  required,  we  have  bands 
and  narrowings  more  or  less  abrupt  along  this  tract 
which  interfere  with  this  free  action.  These  congenital 
bands,  if  not  prominent  enough  in  early  life  to  cause 
trouble,  still  are  capable,  even  from  natural  laws,  of  ac- 
quiring greater  prominence,  while  if  seconded  by  patho- 
logical conditions  they  become  formidable  obstruction?. 
These  congenital  bands,  or,  as  we  may  very  properly  call 
them,  embryonic  strictures,  may  be  divided  into  two 
classes  according  to  the  character  of  the  tissue  of  which 
they  are  chiefly  formed. 

The  first  and  most  common  variety  consists  of  folds 
or  puckerings  of  the  urethral  mucous  membrane,  but,  un- 
like the  natural  folds,  they  reduce  the  limits  of  expansion 
at  those  parts  of  the  urethra  where  they  are  situated. 
They  are  permanent  and  cannot  be  obliterated  by  any 
method  of  dilatation  or  condition  of  the  penis.  I  say 
condition  of  the  penis,  because  Otis,2  in  describing  the 
folds  so  frequently  met  with  at  the  peno  scrotal  angle, 
refers  to  a  case  where  the  folds  disappeared  during  an 
erection  of  the  organ.  Folds  of  that  conditional  charac- 
ter are  not  included  in  this  class.  The  true  mucous  fold 
is  a  permanent  structure,  and  no  matter  whether  the 
penis  be  flaccid  or  erect  can  always  be  demonstrated  by 
the  bulbous  bougie.     This  variety  of  congenital  narrow- 

1  Gross  on  Disorders  of  the  Male  Sexual  Organs,  1st  ed.,  p.  25. 
*  Otis,  on  Stricture  of  the  Male  Urethra,  2d  ed. ,  p  212. 


584 


MEDICAL   RECORD. 


[November  10,  1894 


ing  is  described  by  some  writers  as  an  adhesion  of  the 
mucous  surfaces.  Englisch1  found  forty  six  such  exam- 
ples in  the  urethral  canals  of  new-born  infants. 

The  second  class  of  congenital  narrowings  differs  from 
the  first  in  having,  in  addition  to  the  mucous  fold,  a 
toagh,  fibrous  connective-tissue  base,  over  which  the 
mucous  membrane  is  sometimes  freely  movable,  though 
it  may  be  adherent.  This  variety  varies  much  in  width 
and  thickness,  and  sometimes  the  fibrous  tissue  is  as 
tough  as  tendon.  This  class  is  described  by  some 
writers  as  cicatricial.  Englisch  also  mentions  having 
found  thirty  nine  examples  of  this  variety  in  the  urethral 
canals  of  new-born  infants.  These  congenital  urethral 
binds  are  very  frequently  met  with  in  the  adult,  but  be- 
cause they  are  so  constant  in  their  occurrence  we  are  not 
justified  in  considering  them  physiologicaljn  the  full 
sense  of  the  word. 

The  rule  first  proposed  by  Dr.  F.  N.  Otis,  in  regard  to 
a  fixed  relative  proportion  between  the  circumference  of 
the  flaccid  penis  and  the  internal  urethral  calibre,  is  a 
most  reliable  working  guide,  and  though,  as  previously 
stated,  most  urethral  canals  have  slight  departures  from 
this  high  normal  standard,  not  sufficient  in  many  in- 
stances to  interfere  materially  with  the  function  of  the 
parts,  still  their  frequent  existence  does  not  remove  them 
from  the  domain  of  congenital  imperfections.  I  am 
satisfied,  from  a  large  number  of  personal  observations, 
that  the  nearer  the  urethra  approaches  the  relative  pro- 
portions as  described  by  Otis,  the  more  perfect  are  its 
functions  performed;  while  if  pathological  conditions  are 
acquired,  the  symptoms  are  milder  and  more  promptly 
recovered  from.  It  is  an  easy  matter  to  demonstrate  the 
existence  of  these  congenital  defects,  but  having  done 
so,  a  more  difficult  problem  arises,  namely,  when  to 
clas3  them  in  the  category  of  true  strictures.  This  was, 
and  still  ii,  a  much-mooted  question  among  the  leading 
genito  urinary  surgeons,  and  has  given  rise  to  some  of 
the  most  heated  discussions  of  any  topic  within  the  realm 
of  surgery. 

Oris,*  for  example,  is  responsible  for  the  following  as- 
sertion :  'If  into  a  urethra,  the  normal  calibre  of  which 
is  equal  to  a  circumference  of  30  mm.  of  the  French 
scale,  only  a  29  F.  bulbous  bougie  will  pass  without  de- 
tecting obstruction,  then  the  urethra  is  not '  about  right.' 
It  is  strictured  to  the  extent  of  one  millimetre  in  circum- 
ference, and  never  can  be  a  healthy  urethra  while  that 
stricture  remains.1' 

Keys,8  on  the  other  hand,  takes  a  very  different,  con- 
servative view  concerning  these  congenital  narrowings, 
and  because  they  are  not  of  pathological  origin  de- 
preciates their  importance  almost  as  much  as  Otis 
magnifies  the  same.  He  says :  "  I  have  raised  my  voice 
for  what  it  may  be  worth,  in  protest  against  the  views  of 
the  new  school  in  urethral  pathology,  which  seems  to 
claim  that  every  natural  undulation  in  the  tissues  of  the 
pendulous  urethra  is  a  stricture  fit  for  cutting;  and  that 
all  the  ills  of  the  geni  to-urinary  passages  may  be  ac- 
counted for  by  the  existence  of  these  undulations,  and, 
usually,  made  to  disappear  when  the  latter  are  cut." 

Finally,  Berkeley  Hill,4  in  a  few  masterly  lines,  seems 
to  strike  the  happy  medium,  and  is  very  conclusive  upon 
the  question  at  issue. 

He  says :  "  If  the  balance  between  the  natural  expul- 
sive force  of  the  bladder  and  the  friction  along  the  ure- 
thra is  disturbed,  the  bladder  is  irritated,  the  kidneys  are 
affected,  and  the  beginning  of  the  long  chain  of  events 
which  terminates  not  infrequently  in  death  is  made." 

The  vesicourethral  balance  to  which  Hill  refers  is  a 
far  more  important  factor  in  normal  micturition  than  is 
generally  supposed.  That  nature  often  fails  to  make  a 
perfect  urethra  does  not  admit  of  a  doubt,  nor  is  there 
any  doubt  but  that  nature,  as  often,  develops  an  unusu- 
ally powerful  detrusor  muscle,  therefore,  the  expulsive 

1  Quoted  from  Belfield's  work  on  Diseases  of  the  Urinary  and  Male 
Sexual  Organs. 

*  Stricture  of  the  Male  Urethra,  2d  ed.,  pp.  94,  95. 

•  Keys  on  Venereal  Diseases,  5th  and  6th  pages  of  Preface. 
4  Lectures  reported  in  the  Lancet,  April  8,  1876. 


force  of  the  bladder  may  be  so  great  as  to  irritate  moder- 
ate congenital  narrowings  in  one  case,  where,  in  another, 
with  even  greater  urethral  defects,  but  less  powerful  de- 
trusor, there  may  be  no  discomfort  whatever.  If  this 
were  not  the  case  more  persons  having  these  congenital 
narrowings  would  be  complaining  of  serious  symptoms 
than  we  find  in  actual  practice.  Thus  we  have  to  con- 
sider/hand  in  hand  together,  both  the  anatomical  defects 
and  the  symptoms  of  disturbed  vesico-urethral  balance  in 
order  to  decide  when  a  congenital  narrowing  is  to  be 
classed  as  a  true  stricture.  A  narrowing  is  always  a 
stricture,  anatomically  speaking,  but  not  so  clinically,  un- 
less it  be  attended  by  symptoms. 

Congenital  stricture,  in  proportion  to  its  extent,  often 
gives  rise  to  troublesome  symptoms  in  early  life.  Vesi- 
cal irritability,  nocturnal  incontinence,  dribbling  of 
urine,  priapism,  and  precocious  sexual  habits,  are  in  many 
instances  due  to  this  cause.  Similar  symptoms  to  the 
above  have  been  noticed  time  and  time  again  by  some  of 
the  leading  genito  urinary  surgeons,  but,  strange  to  say, 
none  have  ventured  an  explanation. 

Sir  Henry  Thompson,  in  his  book  on  stricture  (3d 
edition,  page  127),  says:  "There  appears  to  be  a  ten- 
dency, strongly  marked  in  some  individuals,  to  irritability 
of  the  urinary  organs,  displayed  first  in  early  life,  of 
which  no  precise  explanation  can  be  given,  but  which 
has  sometimes  been  observed  to  precede  the  formation  of 
stricture  in  adult  age.  The  subjects  of  it  suffer  as  chil- 
dren from  obstinate  incontinence  of  urine,  particularly 
during  sleep. ' '  Again  he  remarks :  "  If  such  individuals 
acquire  a  gonorrhoea,  the  attendant  symptoms  are  more 
than  usually  severe  and  distressing,  and  permanent  strict- 
ure is  likely  to  follow.  This  state  may  be  spoken  of  as 
one  of  congenital  irritability  of  the  urinary  organs,  but  I 
have  no  solution  of  it  at  present  to  offer." 

To  my  mind  I  do  not  think  it  possible  for  a  more 
graphic  picture  to  be  drawn  of  the  symptoms  and  effects 
of  congenital  stricture  than  is  embraced 'in  Thompson's 
account  of  what  he  terms,  "  congenital  irritability."  It 
is  the  key  to  the  whole  situation.  If  there  exists  this  ir- 
ritability there  must  be  a  cause  for  it,  and,  as  the  learn- 
ed author  very  truly  remarks,  it  (the  irritability)  "  has 
sometimes  been  observed  to  precede  the  formation  of 
stricture  in  adult  age,"  what  more  convincing  proof  do 
we  want  than  that  congenital  stricture  existed  in  these 
cases  from  the  beginning,  and  that  the  irritability  is  but 
an  effect  of  their  presence  ? 

If  in  a  case  presenting  such  symptoms  the  prepuce  is 
non-adherent,  and  the  bladder  is  free  from  calculus  or 
disease,  depend  upon  it  the  clew  to  the  trouble  will  be 
found  in  the  urethra. 

In  my  experience  with  the  treatment  of  urethral  troub- 
les I  have  many  times  had  related  to  me  histories  simi- 
lar to  the  above-quoted  description  from  Thompson,  by 
patients  whose  memory  and  veracity  were  perfectly 
trustworthy.    The  following  case  will  serve  to  illustrate : 

Mr.  C ,  aged  twenty-five,  consulted  me,  in  March 

1 881,  on  account  of  a  most  distressing  irritability  of  his 
bladder.  The  symptoms  had  been  especially  marked 
since  his  nineteenth  year.  He  stated  that  nocturnal  in- 
continence had  been  a  source  of  annoyance  to  him  when 
a  child,  and  that  priapism  was  very  persistent,  at  the 
same  period  of  his  existence,  without  excitation  or  known 
cause.  About  the  period  of  puberty  he  began  to  experi- 
ence severe  cutting  pain  every  time  he  passed  his  water. 
The  pain  was  felt  immediately  within  the  meatus  and 
only  as  the  first  rush  of  urine  impinged  upon  that  point 
— after  commencing  the  act  the  balance  of  urine  could 
be  voided  without  trouble.  This  symptom  persisted  for 
many  months,  then  gradually  became  less  acute,  but  he 
was  ever  afterward  bothered  by  disagreeable  sensations 
within  the  urethra  and  other  parts  of  his  genitals.  A 
feeling  of  fulness  would  persist  in  the  urethra  after  uri- 
nating, followed  by  dribbling  some  minutes  later.  Severe 
neuralgic  pains  were  for  a  long  time  felt  in  the  gluteal 
region  and  over  the  hypogastrium.  His  urine  was  nor- 
mal in  character,  but  no  system  of  medicine  had  ever 


November  10,  1894] 


MEDICAL  RECORD. 


585 


given  him  relief  or  blunted  his  ever-pressing  desire  to 
urinate.  Thinking  that  his  trouble  might  be  due  to 
some  urethral  abnormality,  I  examined  the  parts  with  bul- 
bous bougies  and  an  expanding  meatoscope.  The  result 
of  which  examination  was  the  discovery  of  a  simple  mu- 
cous fold,  one  third  of  an  inch  from  the  meatus,  reducing 
the  calibre  of  the  canal  at  this  point  to  23  F.  Lower 
down,  at  the  peno  scrotal  angle,  were  three  distinct 
bands  reducing  the  calibre  of  the  canal  at  this  point  to 
27  F.  His  normal  calibre  at  all  other  points  was  30 
F.  I  cut  the  anterior  contraction  up  to  32  F.,  and  di- 
lated daily  with  full-sized  sounds  until  healing  was  com- 
plete.   The  result  was  immediate  and  surprising. 

Before  the  cutting  this  patient  was  incessantly  teased 
by  an  ardent  desire  to  urinate.  Thirty-six  hours  after, 
he  retained  his  water  ten  consecutive  hours  without  the 
slightest  inconvenience,  and  then  only  urinated  out  of 
curiosity  to  know  (as  he  expressed  it)  if  his  kidneys  were 
fulfilling  their  function.  Years  have  now  elapsed  and  be 
remains  perfectly  comfortable.  There  never  has  been 
the  slightest  return  of  his  old  symptoms. 

From  the  history  of  this  case  it  will  be  seen  that  un- 
usual irritability  of  the  urinary  organs  existed  from  child- 
hood, as  in  the  description  given  by  Thompson,  also 
that  all  the  symptoms  were  aggravated  in  adult  life.  -An 
examination,  however,  according  to  the  method  of  Otis, 
proved  the  existence  of  congenital  stricture  in  my  case 
(the  patient  never  having  had  gonorrhoea),  and  though 
the  narrowing  only  reduced  the  extent  of  urethral  ex- 
pansion 6  mm.,  still,  this  congenital  narrowing  was  the 
sole  cause  of  the  existence  and  persistence  of  the  symp- 
toms, as  was  proved  by  a  radical  cure  of  the  trouble  upon 
restoration  of  the  canal  to  its  full  calibre. 

When  these  congenital  narrowings  are  not  prominent 
enough  in  early  life  to  cause  trouble,  and  the  periods  of 
infancy  and  childhood  are  passed  in  comfort,  still,  the 
maturing  youth  may  fall  heir  to  many  distressing  symp- 
toms as  he  merges  into  puberty.  This  peculiarity  can  be 
accounted  for,  I  think,  as  follows:  When  the  genitals 
are  undergoing  rapid  development  in  early  adult  life, 
those  congenital  defects  which  were  in  existence,  but  not 
of  sufficient  prominence  to  cause  trouble,  at  this  time 
acquire  greater  prominence  through  failure  of  the  defec- 
tive areas  to  enlarge  in  proportion  with  the  normal  parts, 
so  that  a  canal  which  before  puberty  may  have  been  suf- 
ficient for  the  requirements  of  nature  now  becomes  too 
defective  to  perform  its  functions  without  disturbing  the 
vesico- urethral  balance. 

As  was  stated  at  the  beginning  of  this  paper,  John 
Hunter1  recognized  a  congenital  cause  as  the  starting- 
point  of  stricture.  He  says  :  "  Strictures  are  common 
to  most  passages  of  the  human  body,"  "  They  sometimes 
happen  in  the  urethra  where  no  venereal  disease  has  ever 
been." 

This  opinion  of  Hunter,  it  is  needless  to  say,  has  been 
severely  criticised.  To  use  the  words  of  Sir  Henry 
Thompson,  "  the  great  pathologist  .  .  •  stands  almost 
alone  in  this  opinion."  If  so,  let  it  be  to  his  credit. 
For  Hunter  more  than  a  century  ago,  without  the  assist- 
ance of  ball  probes,  bulbous  bougies,  or  the  urethrometer, 
but  guided  by  his  wonderful  perceptive  genius  alone,  ar- 
rived at  about  the  same  general  conclusion  which  some 
at  the  present  day  consider  new.  His  opinion  has  out- 
lived him  and  affords  us  the  most  satisfactory  clew  to  the 
cause  of  stricture.  Bryant,  in  his  "  Practice  of  Surgery," 
page  518,  says,  in  summing  up  his  statistics  of  strict- 
ure cases,  that  out  of  646  cases  in  only  273  was  the  le- 
sion preceded  by  venereal  disease,  43  were  of  the  trau- 
matic variety,  leaving  330  in  which  no  definite  cause 
could  be  assigned.  He  concludes  as  follows :  "  That  al- 
though gonorrhoea  often  precedes  a  stricture,  that  at 
least  half  the  cases  are  found  in  subjects  who  have  not 
suffered  from  such  a  disease." 

Having  occupied  the  attention  of  my  readers  long 
enough  with  the  foregoing  observations  upon  the  relative 
frequency  of  congenital  stricture,  let  us  next  proceed  to 

1  Ricord  and  Hunter  on  Venereal  Disease,  p.  151. 


study  how  these  congenital  defects  are  influenced  by 
pathological  processes,  and  how  they  form  the  nuclei,  so 
to  speak,  of  those  close  organic  strictures  which  have 
hitherto  been  generally  considered  as  entirely  of  acquired 
pathological  origin. 

In  speaking  of  the  relation  of  gonorrhoea  to  stricture 
Otis  *  says :  "I  recognize  the  fact  that  it  is  most  often 
brought  to  our  notice  through  the  occurrence  of  and  per- 
sistence of  this  disease,  and  that  all  pre- existing  strict- 
ures, or  thickenings,  or  irritations  of  the  urethral  mucous 
membrane  are  increased  and  intensified  by  it." 

With  this  opinion  I  perfectly  agree.  It  has  occurred 
in  my  experience,  and  I  think  the  same  is  universal,  that 
cases  of  gonorrhoea  will  not  always  yield  to  any  form  ot 
constitutional  or  local  treatment.  In  spite  of  all  care  it 
may  linger  on  indefinitely,  nay,  symptoms  of  stricture 
manifest  themselves  during  the  early  period  of  the  dis- 
ease. Now  with  the  knowledge  we  possess  in  regard  to 
the  formation  and  nature  of  cicatricial  tissue  is  it  at  all 
likely  that  we  should  have  such  prompt  effects  resulting 
from  an  attack  of  gonorrhoea  in  a  canal  previously  free 
from  congenital  defect  ?  Furthermore,  from  a  system  of 
treatment,  once  the  most  popular  (I  refer  to  gradual 
dilatation),  we  derive  most  positive  proof  that  congenital 
strictures  do  exist  before  and  are  the  nuclei  of  those 
which  are  supposed  to  have  resulted  entirely  from  gonor- 
rhoea. Any  surgeon  who  has  had  much  experience  in 
the  management  of  urethral  cases  has  certainly  come 
across  strictures  which  respond  finely  to  the  method  of 
gradual  dilatation  until  a  certain  limit  is  reached,  but 
beyond  which  it  is  impossible  to  progress  without  the 
strictured  parts  becoming  irritable  under  the  method  of 
treatment.  This  class  of  strictures  are  mentioned  by 
Van  Buren  and  Keys  in  their  work  on  "  Genito-urinary 
Diseases,"  page  157,  but  no  explanation  is  given  for 
their  exceptional  peculiarity. 

From  the  convictions  that  I  have  arrived  at,  after  a 
careful  study  of  the  congenital  urethral  narrowing  when 
intensified  by  inflammation,  the  cause  of  this  irritability 
seems  apparent,  and  I  will  venture  an  explanation  for  what 
it  may  be  worth.  When  a  stricture  is  treated  by  the 
method  of  gradual  dilatation,  the  mechanical  action  of 
pressure,  together  with  the  stimulus  given  to  the  circula- 
tion in  the  affected  parts,  promotes  the  absorption  of  the 
acquired  inflammatory  tissue,  which  will  go  on  under  the 
gentle  use  of  the  sound  until  the  original  or  congenital 
narrowing  is  reached,  but  the  tissue  of  the  congenital 
contraction,  unlike  the  acquired  inflammatory  tissue,  be- 
ing unyielding  and  incapable  of  absorption,  resents  the 
attempts  of  art  to  enlarge  by  dilatation  structures  which 
nature  had  in  the  first  instance  failed  to  make  of  greater 
calibre. 

Sometimes  the  gleety  discharge  and  other  troublesome 
symptoms  disappear  when  the  urethra  has  been  dilated 
up  to  its  point  of  limitation,  but  you  cannot  depend 
upon  it,  for  when  a  congenital  stricture  has  once  been 
infiltrated  by  gonorrhceal  inflammation  it  becomes  a 
treacherous  spot,  prone  at  any  time  to  light  up  trouble 
from  the  slightest  provocation. 

As  a  rule  these  congenital  narrowings  are  sensitive  to 
a  degree  far  exceeding  the  other  portions  of  the  urethra. 
They  easily  fret  and  become  irritable,  even  from  contact 
with  an  exploring  instrument.  This  irritability  is  quickly 
called  into  play  by  inflammation  affecting  the  urethral 
mucous  membrane,  and  as  it  happens  that  gonorrhoea  is 
the  most  common  form  of  acquired  inflammation  the 
urethra  is  subjected  to,  it  necessarily  becomes  the  chief 
intensifying  cause  of  congenital  stricture.  Under  the 
irritating  influence  of  the  gonorrhceal  inflammation  these 
congenital  strictures  are  thrown  into  a  spasmodic  state 
of  contraction  and  retain  a  certain  amount  of  the  acrid 
discharge  within  the  canal  instead  of  permitting  an  easy 
escape  of  the  same — simulating  small  pus  pockets  at  one 
or  more  points  along  the  urethra. 

The  more  abrupt  the  congenital  contraction  the  more 
acute,  generally,  will  be  the  symptoms,  and  from  an  in- 
1  Stricture  of  the  Male  Urethra,  2d  edition,  p.  171. 


586 


MEDICAL   RECORD. 


[November  10,  1894 


flammation  which  was  at  first  confined  to  the  mucous 
membrane  we  have  the  morbid  process,  at  these  defective 
points,  extending  into  the  deeper  structures  and  not  in- 
frequently involving  the  erectile  meshes  of  the  corpus 
spongiosum.  Therefore,  as  a  result  of  gonorrhoea!  in- 
flammation, the  tissues  composing  these  congenital  nar- 
rowings,  and  the  parts  immediately  behind  them,  are 
more  unfavorably  acted  upon  than  the  other  portions  of 
the  urethral  tract.  Bathed  in  pus  and  scalded  by  urine, 
the  healthy  epithelium  is  destroyed  at  these  points  and 
its  place  supplied  by  patches  of  granulation  tissue ;  con- 
nective tissue  corpuscles  infiltrate  the  parts,  and  as  the 
latter  proliferate  and  condense,  the  calibre  of  the  urethra 
is  lessened,  and  we  have  formed  those  dense  inodular 
strictures,  the  bugbear  of  urethral  surgery. 

If  the  urethra  is  well  developed  from  end  to  end — 
free  from  prominent  congenital  narrowings,  approaching 
the  highest  normal  type,  as  described  by  Otis,  I  believe 
we  can  safely  say  that  if  such  a  urethra  should  become 
affected  by  gonorrhoea  the  attack  would  prove  mild  and 
in  due  time  leave  the  parts  unscathed  by  the  ordeal 
through  which  they  have  passed. 

Next  in  importance  to  gonorrhoea,  if  not  equally  as 
important  as  a  cause  for  aggravating  these  congenital 
strictures,  is  pathological  urine. 

The  urethra  in  repose  is  a  collapsed  tube  which  only 
becomes  a  canal  in  reality  during  the  physiological  acts 
of  micturition  and  emission  of  semen. 

When  these  acts  are  completed  by  a  normal  urethra 
the  combined  action  of  its  muscles,  together  with  the 
wave  of  blood  which  passes  along  the  meshes  of  the  cor- 
pus spongiosum  should  extrude  every  drop  of  fluid  and 
leave  the  urethra  free  from  all  traces  of  moisture  except 
its  normal  secretion.  If,  however,  there  should  exist 
congenital  narrowings  anywhere  between  the  bulbo- 
membranous  junction  and  the  meatus  of  sufficient  prom- 
inence to  cause  undue  friction  during  the  acts  of  mictu- 
rition this  perfect  functioning  of  the  parts  cannot  occur. 
The  narrow  points  will  be  rendered  unduly  irritable  by 
the  forcible  impact  of  the  column  of  urine,  and  through 
the  resulting  contraction  of  the  urethral  muscular  fibres 
interfere  very  materially  with  the  extrusion  of  the  last 
drops  of  urine.  A  few  drops  of  urine  will  be  retained 
back  of  the  irritable  urethral  narrowing,  where,  acting  in 
the  way  of  a  foreign  body,  it  causes  any  amount  of  un- 
easiness until  it  is  expelled.  Nothing  is  more  common 
than  to  hear  persons,  in  whom  this  condition  exists, 
complain  of  a  sense  of  fulness  in  the  urethra  after  uri- 
nating. They  are  apt  to  imagine  the  act  was  incom- 
pletely performed,  and  most  likely  will  make  another  at- 
tempt shortly  after  in  order  to  ease  themselves ;  but  if  so, 
they  only  displace  the  retained  drops  in  the  urethra  by  a 
little  more  urine  from  the  bladder,  which  leaves  them  in 
the  same  uncomfortable  plight  as  before.  Sometimes  the 
drops  of  urine  are  retained  quite  a  while  before  they 
dribble  away,  or,  as  is  frequently  the  case,  the  patient,  in 
making  a  quick  muscular  movement,  as  in  rising  from  a 
chair  or  stooping  to  pick  some  object  from  the  floor, 
forces  the  retained  urine  from  his  urethra,  with  immediate 
relief. 

When  effects  like  these  are  noted  from  the  action  of 
healthy  urine  upon  the  narrow  defective  points  in  the 
urethra,  it  is  easy  to  understand  how  much  more  trouble 
is  likely  to  ensue  from  a  pathological  secretion,  such, 
for  instance,  as  the  urine  of  a  gouty  or  rheumatic  subject, 
that  of  the  habitual  dyspeptic,  or  urine  containing  in- 
flammatory products,  the  result  of  disease  in  the  upper 
urinary  tracks. 

These  abnormal  secretions  are  very  damaging  to  a 
urethra  previously  crippled  in  conformation,  and  are  just 
as  sure  to  lead  to  the  formation  of  close  organic  stricture 
as  is  a  gleet  resulting  from  gonorrhoea. 

The  irritation  resulting  from  pathological  urine  is  a 
slow-acting  cause,  and,  therefore,  all  the  more  dangerous, 
for  from  the  insidious  nature  of  the  symptoms  neither  pa- 
tient nor  physician  is  apt  to  have  his  attention  directed 
to  the  forming  stricture  until  it  has  assumed  formidable 


proportions.  On  account  of  the  slow  development  of  this 
form  of  stricture  we  are  most  likely  to  encounter  them  in 
persons  of  middle  age  and  advanced  life;  and  I  am  of 
the  opinion  that  if  a  careful  investigation  is  given  to  that 
vast  percentage  of  stricture  cases  which  occur  in  men  who 
never  have  had  venereal  disease,  a  satisfactory  clew  to  this 
cause  will  be  found  under  this  heading. 

Last  in  order,  as  a  cause  for  intensifying  congenital 
stricture,  is  masturbation.  While  it  is  a  fact  that  this 
unnatural  habit  is  entitled  to  a  place  among  the  recognized 
causes  •£  urethral  stricture,  still,  from  the  histories  of  mat 
of  the  recorded  cases,  I  am  far  from  convinced  that  it  is 
as  potent  a  cause  as  some  writers  seem  to  think.  It  is 
easy  to  understand  that  by  the  persistent  practice  of  mas- 
turbation a  congested  state  of  the  prostatic  sinus  is  in- 
duced which  finally  develops  into  a  catarrhal  inflamma- 
tion— a  condition  of  affairs  attended  by  a  muco- purulent 
discharge,  a  prostatic  gleet  in  fact,  which,  like  the  gleet 
following  gonorrhoea,  is  irritating  and  capable  of  intensi- 
fying pre-existing  congenital  defects.  But  without  in- 
flammation and  a  discharge  first  being  excited,  I  fail  to 
see  how  the  habit  of  masturbation  can  cause  stricture. 

Yet  how  many  cases  of  stricture  due  to  this  cause  have 
of  late  years  been  reported !  Many  that  are  said  to  be 
due  to  this  habit  must,  from  the  appended  histories  of  the 
cases,  have  preceded  the  practised  vice.  In  fact  nearly 
all  are  nothing  more  or  less  than  prominent  congenital 
strictures.  Because  these  strictures  happen  to  exist  in  the 
urethral  tracts  of  patients  from  whom  a  confession  of  the 
habit  of  masturbation  has  been  forced,  they  have  wrong- 
fully been  attributed  to  this  cause  entirely. 

From  among  the  tabulated  cases  of  urethral  stricture  by 
Otis,1 1  find  that  out  of  a  list  of  234  patients,  in  24  casts 
the  cause  is  attributed  to  masturbation.  I  have  not  in- 
cluded any  among  the  number  who  have  a  record  of  both 
gonorrhoea  and  masturbation.  Now  in  22  of  these  caies 
there  is  no  history  of  an  existing  or  pre  existing  discharge. 
Also  in  22  cases  the  contracted  areas  were  situated  in 
the  anterior  and  middle  portions  of  the  urethra— not 
beyond  three  and  one- half  inches,  just  where  we  most 
frequently  encounter  the  greatest  number  of  cogenital 
narrowings.  In  the  remaining  two  cases  the  contracted 
areas  were  situated  at  a  depth  of  four  inches  and  beyond. 
All  were  typical  examples  of  stricture  of  large  calibre, 
but  from  the  histories  of  at  least  twenty- two  of  these 
cases  I  am  forced  to  believe  that  the  same  contracted 
areas  would  have  been  found  even  if  the  patients  had  rot 
been  addicted  to  masturbation. 

In  not  a  few  instances  I  have  had  patients  who  were 
suffering  from  the  effects  of  congenital  stricture,  and  who 
were  not  given  to  masturbation,  describe  their  symp- 
toms as  follows :  They  would  complain  of  an  itching  or 
tingling  sensation  within  the  urethra,  and  especially 
about  that  part  enclosed  within  the  glans  penis;  some- 
times sensations  not  unlike  an  impending  orgasm  would 
be  experienced,  but  without  being  attended  by  erection 
or  erotic  fancy.  The  strictures  in  these  cases  were  sit- 
uated a  short  distance  from  the  meatus,  and  with  their 
removal  the  irritations  vanished. 

Had  these  patients  been  addicted  to  masturbation  how 
natural  it  would  have  been,  backed  by  modern  theory, 
to  have  ascribed  both  the  stricture  and  reflex  irritation 
to  that  habit? 

Of  course  it  must  be  admitted  that  like  symptoms  can 
be  produced  in  some  patients  by  the  reflex  irritations 
proceeding  from  a  congested  prostatic  sinus  induced  by 
masturbation  or  excessive  venery ;  but  to  attribute  all 
these  congenital  narrowings  in  people  who  do  mastur- 
bate to  a  habit  which  in  most  cases  has  had  nothing  to 
do  with  their  existence,  is  as  ridiculous  as  it  is  unfound- 
ed. Again,  reasoning  from  a  hypothetical  stand-point, 
if  sensations  of  the  above  nature  were  to  be  experienced 
by  persons  of  little  self-control,  is  it  not  more  than 
likely  that  they  might  yield  to  these  morbid  feelings  and 
acquire  the  habit  of  masturbation  ?  No  one  will  dis- 
pute the  fact  that  patients  who  suffer  from  vesical  calcu- 

1  Stricture  of  the  Male  Urethra,  2d  ed.,  pp.  136  and  324-350. 


November  10,  1894] 


MEDICAL   RECORD. 


587 


lus  or  adherent  prepuce  may  acquire  this  habit  from  the 
irritability  of  the  genitals,  superinduced  by  their  infirm- 
ities. Why  not,  then,  from  the  reflex  irritations  due  to 
congenital  stricture  ? 

From  all  the  information  that  I  have  been  able  to  col- 
lect upon  this  topic,  it  seems  to  me  that  stricture  of  the 
urethra  is  more  to  be  blamed  for  causing  masturbation 
than  masturbation  is  to  be  blamed  for  causing  stricture. 

If,  then,  we  take  these  congenital  urethral  narrowings 
as  the  proper  basis  from  which  most  cases  of  stricture 
arise,  and  consider  them  in  association  with  inflamma- 
tion, we  will  find  that,  with  the  exception  of  the  trau- 
matic variety  and  those  rather  uncommon  cases  resulting 
from  the  cicatrization  of  venereal  ulcers,  nearly  every  case 
may  be  classified  under  one  or  the  other  of  the  four  fol- 
lowing divisions: 

1.  Congenital  stricture  (simple),  including  all  ana- 
tomical narrowings  which  are  prominent  enough  to  inter- 
fere with  the  normal  vesicourethral  balance. 

2.  Congenital  stricture,  aggravated  by  gonorrhoea. 

3.  Congenital  stricture,  aggravated  by  pathological 
urine. 

4.  Congenital  stricture,  aggravated  by  masturbation. 
In  concluding  my  remarks  I  am  fully  aware  that  I 

have  not  presented  much  that  is  strictly  original,  more 
able  observers  having  grasped  the  leading  features  long 
before,  but  I  have  tried  to  reduce  the  subject  to  some- 
thing  like  a  system  in  the  order  of  cause  and  effect,  and 
if  my  words  have  any  weight  in  this  respect,  I  shall  not 
have  labored  in  vain. 

^3i»,North,Carby}Strj«t. 


A     PLEA    FOR     MORE    RATIONAL     MEDICA- 
TION.1 

Bv   W.    P.   OVERHOLSER,   M.D., 

UAK&1SONYIIXH,  MO. 

A  retrospective  glance  at  the  practice  of  medicine  of 
the  nineteenth  century  presents  to  our  view  marked 
changes  in  many  of  the  theories  of  our  science,  and  great 
revolutions  in  the  practices  of  our  art.  Our  advancement 
has  been  particularly  marked  by  steps  of  progression 
and  retrogression,  by  a  construction  and  reconstruction 
of  views,  by  a  continual  building  up  and  tearing  down  of 
medical  beliefs  and  opinions.  In  fact  this  tendency  has 
been  so  evident,  that  the  intellectual  effort  of  the  medical 
world  of  the  past  and  present  seems  to  have  been,  and 
continues  to  be,  characterized  by  a  propensity  to  frame 
hypotheses  and  manufacture  theories  to  meet  and  explain 
the  manifold  phenomena  of  animal  life  in  health  and  dis- 
ease. 

From  the  beginning  of  the  history  of  medicine,  when 
in  the  Grecian  temple  of  Esculapius  medical  information 
was  first  recorded,  and  the  first  steps  taken  to  reduce  the 
art  to  a  science,  by  registering  on  durable  tablets  of 
marble  disease  and  its  supposed  cures,  down  through  the 
hoary  ages  of  the  past  on  through  the  latest  centuries,  and 
even  to  the  very  threshold  of  the  present  time,  empiri- 
cism has  largely  characterized  our  work,  and  experimen- 
tation in  disease  continues  even  with  increased  ardor, 
with  but  few  positive  remedial  results. 

The  recent  laboratory  and  microscopical  researches  in 
disease,  and  experimental  work  in  normal  and  abnormal 
processes  of  the  body,  have  contributed  volume  after  vol- 
ume to  the  literature  of  medicine ;  but  notwithstanding 
the  light  these  researches  have  given  us,  as  to  the  origin, 
diagnosis,  and  course  of  many  diseases,  science  has  as 
yet  failed,  except  in  but  a  few  instances,  to  prescribe  for 
us  rules,  laws,  and  remedies  which,  when  applied  in  cer- 
tain conditions,  will  give  us  positive,  satisfactory  results. 
Correct  theories  or  doctrines  of  any  science  must  coin- 
cide with  philosophical  truth,  and  be  confirmed  by  ex- 
periment and  observation. 

A  system  of  practice  of  medicine  rational  in  its  basis, 

1  Read  before  the  Hodgen  Medical  Society  at  Harrison  ville,  Mo.' 
October  4,  1894. 


scientific  in  its  measures,  and  eminently  successful  in  its 
results,  would  be  a  system  different  indeed  from  the  one 
we  so  much  boast  of  to  day.  Absolute  facts  in  medicine 
are  comparatively  few  compared  with  its  unstable  hypo- 
thetical teachings.  It  is  true  that  many  of  our  generaliza- 
tions have  stood  the  test  of  future  experience  and  have 
therefore  been  retained,  serving  as  they  do  to  give  some- 
thing more  than  empirical  direction  to  intellectual  ef- 
fort ;  but  sometimes,  and  alas !  this  is  too  frequently  the 
case  in  medicine,  the  airy  castle  of  theory  is  found  too 
b'ght  to  withstand  the  onset  of  progressive  experience, 
and  the  structure  of  but  yesterday  is  the  ruin  of  to- 
day.1 

Is  it  not  true  that  the  conscientious  physician  of  the 
present  who  endeavors  to  gather  from  every  resource  at 
his  command  more  light  and  knowledge  of  the  mysteri- 
ous phenomena  of  disease,  is  often  confused  by  the  vari- 
ous theories  as  to  its  origin,  multitudinous  remedies  for 
its  treatment,  and  ofttimes  contradictory  clinical  experi- 
ence as  to  its  progress  and  termination  ?  We  speak  not 
disparagingly  of  our  science,  nor  do  we  seek  to  condemn 
the  work  of  those  of  our  profession  whose  untiring  efforts 
and  profound  research  have  scattered  light  and  knowl- 
edge in  many  directions.  We  are  proud  that  we  live  in 
a  period  of  the  history  of  medicine  when  every  means  of 
research  is  used  to  fathom  deeply  into  the  mysterious 
workings  of  nature ;  yet  in  this  age  of  advancement,  as  we 
look  back  over  our  field  of  work  and  find  scattered  all 
along  the  line  of  action  the  ruined  remains  of  what  *e 
once  thought  to  be  scientific  truth,  but  which  have  since 
proven  to  be  fallacies  and  inconsistencies,  we  feel  more 
forcibly  impressed  with  the  importance  of  testing  in  the 
crucible  of  truth  the  great  mass  and  bulk  of  medical  ex- 
perience and  medical  teachings  that  are  heaped  upon  us 
to-day,  and  accepting  only  the  atom  of  gold  that  may  be 
found  among  the  dross. 

It  is  a  fact  to  be  deplored  that  we  find  in  medicine 
beliefs,  theories,  and  practices  that  wear  the  guise  of 
learning,  that  ap{>ear  scholastic  in  their  teachings  and 
scientific  in  their  measures,  that  are  of  no  practical  bene- 
fit whatever  to  us  as  practitioners.  Let  me  ask  what 
has  become  of  many  of  the  measures  and  remedies  that 
not  a  few  of  our  profession,  but  a  short  time  ago  hailed 
with  wild  enthusiasm  and  accepted  with  the  utmost  con- 
fidence in  their  efficacy.  They  need  but  a  mention  : 
Koch's  tuberculin,  Kleb's  tuberculocidin,  Brown-S6- 
quard's  elixir  of  life,  and  others  of  no  better  nature ; 
what  are  they  to  day  ?  Are  they  not  simply  humiliating 
memorials  of  the  credulity  and  infatuation  of  the  physi- 
cians who  commended  and  prescribed  them  ?  Who  can 
tell  that  many  of  the  boasted  remedies  of  to-day  will  not, 
like  their  predecessors,  fall  into  disrepute,  and  in  their 
turn  serve  only  as  monuments  in  the  history  of  medicine 
to  mark  our  mistakes  and  ever  expose  our  faulty  concep- 
tions of  proper  medication. 

We  have  no  lack  to  day  of  medical  literature,  no  lack 
of  medical  theories  as  to  the  proper  treatment  of  diseases, 
no  lack  of  medical  remedies  suggested.  The  very  shelves 
of  our  bookcases  groan  with  the  weight  of  medical  lore, 
and  our  text-books  on  therapeutics  prescribe  for  us  an 
untold  number  of  remedies  for  the  various  ailments  of 
the  human  body.  In  fact,  our  science  is  becoming  so  un- 
wieldy, and  contains  so  much  that  is  unnecessary  and  im- 
practicable, that  the  medical  student  of  the  present  is 
compelled  to  wade  through  the  misty  labyrinths  of  this 
accumulated  mass  of  existing  doctrines  to  find  a  little 
practical  truth. 

We  do  not  wish  to  unjustly  criticise  the  teachings  of 
honorable  men  of  our  profession  whose  superior  talent, 
moral  worth,  and  dignified  bearing  have  immortalized 
their  names  in  the  history  of  medicine.  We  will  ever 
bow  in  humble  submission  to,  and  hold  in  high  venera- 
tion, the  devotees  of  our  science  who  seek  to  give  us  sub- 
stantial truth,  sound  inductive  philosophy,  that  will 
stand  the  test  of  practical  expeiience  and  ever  be  re. 

*  Dr.  J.  Leonard  Corning,  Medical  Register,  Philadelphia,  Pa.,  vol. 
iii. 


588 


MEDICAL    RECORD. 


[November  10,  1894 


tained  as  immutable  principles  of  eternal  truth ;  but  in 
the  present  status  of  our  medical  science  we  do  not  feel 
like  offering  an  apology  for  entering  a  plea  for  a  more 
rational  system  of  medication. 

Scientific  medication  must  harmonize  with  physiologi- 
cal laws,  and  thus  facilitate  nature  to  throw  off  disease. 
Wherever  a  diseased  process  is  going  on,  nature  is  striv- 
ing to  overcome  it.  Wherever  there  is  a  deformity  or 
impaired  use  of  any  part  or  organ  of  the  body,  nature 
tries  to  compensate  for  it.  The  contraction  of  the  mus- 
cles with  flexed  thigh  in  hip-joint  troubles  is  not  the  dis- 
ease, but  nature's  effort  to  protect  the  joint  by  fixation. 
The  hypertrophied  and  throbbing  heart  is  nature's 
method  of  compensating  for  an  imperfect  valve.  An 
abnormal  elevated  temperature  of  the  body  is  one  of  the 
chemical  results  of  her  method  of  eradicating  a  poison 
from  her  tissues.  The  adhesions  surrounding  a  Fallopian 
tube,  or  the  vermicular  appendix,  is  her  inflammatory  bar- 
rier to  prevent  the  escape  of  septic  matter  into  the 
peritoneal  cavity ;  and  so  on,  through  the  whole  category 
of  diseases,  we  will  find  that  if  we  view  their  symptomatic 
phenomena  from  a  proper  standpoint,  they  are  conserva- 
tive processes  and  nature's  best  methods  toward  effecting 
a  cure. 

To  study  closely  her  own  efforts  in  restoring  abnormal 
conditions  of  the  body  to  health,  will  ofttimes  give  us 
more  light  and  guidance  as  to  the  proper  management 
of  disease  than  that  given  us  by  the  ineffectual  specula- 
tions of  scientists,  many  of  whom  simply  write  books 
for  a  reputation,  and  by  their  plausible  theories  and 
logical  deductions  so  well  disguised  in  the  garb  of  learn- 
ing, receive  the  applause  of  the  medical  world  for  the  so- 
called  latest  and  most  rational  methods  of  scientific  the- 
rapeutics. Dr.  Aulde,  of  Philadelphia,  Pa.,  says :  "  There 
are  a  considerable  number  of  the  medical  profession  who 
now  claim  to  practise  what  is  termed  rational  medicine 
as  contradistinguished  from  empirical  medicine;  but 
when  the  question  is  asked  as  to  the  precise  influence 
which  remedial  agents  have  upon  nerve-cells  and  proto- 
plasm, no  one  can  be  found  competent  to  answer." 

Of  recent  years  so  much  attention  has  been  turned  to 
the  study  of  bacteriology,  so  elaborate  has  been  the 
work  in  this  direction,  that  there  now  seems  to  be  a  gen- 
eral consensus  of  belief  in  .the  bacterial  origin  of  all  in- 
fectious diseases. 

Bacteriologists  tell  us  that  all  communicable  maladies, 
such  as  can  be  imparted  from  plant  to  plant,  from  ani- 
mal to  animal,  from  animal  to  human  being,  from  one 
man  to  another,  are  due  to  micro-organisms.  The  in- 
finite variety  and  multitude  of  micro- organisms — the  part 
they  play  in  the  phenomena  of  fermentation  and  putre- 
faction, and  in  the  general  break-up  of  organic  life — the 
incessant  struggles  of  the  living  organisms  against  the 
microbes,  has  furnished  a  large  field  for  investigation  by 
our  bacteriologists,  and  the  measures  which  antago- 
nize their  action  and  destroy  them  in  living  tissue,  seem 
now  to  be  the  greatest  problem  of  the  present  age.  This 
has  given  origin  to  what  is  called  bacteriological  thera- 
peutics— a  science  that  is  to  give  us  measures,  medicinal 
and  hygienic,  that  will  prevent  the  multiplication  of  these 
infective  agents  in  the  human  body  and  thus  eradicate 
disease  by  antagonizing  their  action  and  preventing  the 
baneful  effects  of  their  secretions  and  excretions  (pto- 
maines, toxines,  and  toxalbumins)  upon  the  normal  cel- 
lular action  of  living  tissue. 

If  the  origin  and  course  of  all  infectious  diseases  be 
found  to  be  due  to  the  presence  of  some  form  of  bacteria, 
and  bacteriological  therapeutics  can  furnish  us  with 
germicides  that  are  available  and  safe,  a  system  of  para- 
siticide medication  that  will  successfully  prevent  the  de- 
velopment and  multiplication  of  the  microbe  in  the  body, 
then  indeed  might  we  boast  at  least  of  one  branch  of 
scientific  therapeutics.  But  let  me  ask  how  many  here 
to-day  can  testify,  by  practical  experience,  to  the  value  of 
any  medicinal  agent  that  has  thus  far  been  given  us,  that 
will  destrov  in  the  body  the  Eberth  bacillus  of  typhoid 
fever,  the  Klebs  Loeffler  bacillus  of  diphtheria,  the  strep- 


tococcus of  erysipelas,  the  diplococcus  of  pneumonia,  or 
even  Koch's  bacillus  of  tuberculosis. 

Is  it  not  a  fact  that  bacteriological  therapeutics  has 
thus  far  proven  to  be  much  more  beautiful  in  theory  than 
useful  in  practice?  The  modern  idea  of  scientific  medi- 
cation we  believe  is  slowly  drifting  away  from  so  much 
speculative  investigation  with  bactericide  agents,  and 
that  "  the  rational  treatment  of  disease  will  be  based 
more  upon  a  knowledge  of  the  effects  which  medicinal 
substances  produce  upon  the  function  of  the  cell."  1 

A  study  of  nature's  own  efforts  in  coping  with  disease 
ought  to  lead  us  to  observe,  and  in  a  measure  under- 
stand, the  methods  she  adopts  in  effecting  her  own  cures. 
The  term  vis  medicatrix  natura  is  familiar  to  us  all,  and 
frequently  spoken  of  as  the  power  by  which  nature  cures 
disease ;  but  the  factors  concerned  in  this  process,  and  the 
true  secret  of  her  success  along  this  line,  are  yet  imper- 
fectly understood.  We  believe,  however,  there  is  now 
somewhat  of  a  lull  in  the  enthusiastic  labors  of  the  bac- 
teriological therapeutists,  and  that  we  find  ourselves 
gradually  drifting  back  to  investigate  more  carefully  the 
function  of  the  cell  in  maintaining  its  integrity,  resisting 
disease,  and  restoring  normal  cellular  life  in  an  un- 
healthy condition  of  her  tissues. 

A  fundamental  principle  about  whkh  pathology  and 
physiology  are  not  any  more  at  variance,  is  that  man,  as 
well  as  any  other  animal,  and  also  vegetative  organisms, 
is  a  reiteration  of  structure ;  however  complete  in  its  or- 
ganization be  the  construction  of  a  body,  every  single 
part  and  all  of  it  can  be  traced  to  a  radical,  an  ultimate 
element  of  living  tissue — an  entity — a  cell — a  little  mass 
of  protoplasm  which  eats,  grows,  accomplishes  work,  and 
then  dies.  The  radical  entity  of  which  man  is  composed 
shows  a  repetition  of  the  phases  of  his  accomplished  be- 
ing. It  is  in  continuous  motion,  its  life  being  kept  up 
by  processes  analogous  to  those  of  the  complete  organ- 
ism. In  this  physiological  radical  of  man,  and  in  all 
other  organisms,  is  exhibited  the  function  of  disintegra- 
tion and  reintegration  of  tissue — a  continuous  change  of 
matter  constructive  and  destructive,  a  ceaseless  meta- 
morphosis of  cellular  structures  with  accumulation  and 
liberation  of  life-forces.  It  is  physiological  cell-function, 
with  laws  governing  its  action  just  as  laws  preside  over 
the  existence  and  health  of  the  developed  organism. 
All  curing  action,  whether  by  nature  herself  or  artificially 
by  the  medical  practitioner,  is  bound  to  be  within  the 
limits  of  histolysis  or  histogenesis  of  the  cellular  elements 
of  the  body.  A  point  we  wish  to  notice  in  the  practice 
of  our  work,  is  that  our  medicinal  agents  are  adminis- 
tered to  the  developed  organism  for  their  effect  upon  a 
particular  organ  of  the  body,  or  for  their  effect  ob- 
served upon  the  organism  as  a  whole,  without  a  knowledge 
of  their  effect  upon  the  organized  units — the  indivi- 
dual cellular  structures  of  which  it  is  composed — which 
are  the  only  ultimate  living  factors  in  the  production  of 
lesions  of  disease,  the  only  ultimate  living  agents  in  era- 
dication of  the  same,  and  the  only  living  factors  of  the 
animal  economy  that  can  restore  abnormal  conditions  to 
health.  All  forms  of  disease  come  from  some  modifica- 
tion of  normal  cell- function.  All  diseases  that  are  cured 
by  nature  or  medicine  must  be  accomplished  through  the 
function  of  the  cell. 

Disease  due  to  microbic  infection  is  simply  a  perver- 
sion of  the  physiological  cell-function,  an  effort  of  nature 
to  destroy  and  eliminate  the  foreign  elements  from  her 
structures.  It  is  a  conflict  between  the  subject  who  is 
smitten  and  the  particular  micro  organism  which  multi- 
plies at  his  expense,  appropriating  his  air,  water,  and 
pabulum,  disintegrating  his  tissues,  poisoning  him  by 
its  secretions  or  by  the  decomposition  which  accom- 
panies its  development.  Exacerbations  of  disease  and 
crises  are  occasioned  by  particular  efforts  of  nature  to 
overcome  the  obstacles  which  she  meets  on  her  war- path. 
It  is  a  phagocytic  reaction  of  the  organism  to  an  irritant 
(Metschnikoff ).  Ceils  are  phagocytes,  hungry  to  devour 
any  toxine  or  microbe  that  may  find  entrance  into  the 
*  Dr.  Aulde. 


November  10,  1894] 


MEDICAL   RECORD. 


589 


blood.  The  physiological,  chemical  action  of  the  cell, 
by  these  irritant  poisons  is  changed  to  a  pathological, 
chemical  one.  Nature  seeks  to  cope  with  her  intruders 
by  instituting  measures  that  are  incompatible  with  their 
existence.  If  she  fails,  her  failure  is  due  to  a  lack  of 
power  to  resume  in  normal  proportion  her  work  of  dis- 
integration and  reintegration  of  tissue  with  the  normal 
evolution  of  life- forces.  Here  I  believe  is  the  starting- 
point  of  scientific  therapeutics.  The  morphological  re- 
sults of  cell-function  in  health  and  disease,  I  believe, 
are  the  basis  upon  which  must  be  founded  all  medical 
means  of  treating  disease  by  rational  and  scientific 
methods. 

When  our  science  gives  us  a  pathological  chemistry  of 
the  cell,  with  the  physio-pathological  effect  of  medicine 
within  the  sphere  of  tissue  metabolism — a  cellular  ther- 
apy, we  may  then  hope  for  a  substantial  basis  upon 
which  to  found  our  teachings  of  a  system  of  rational 
medicine;  and  until  then,  as  Bigelow  has  said,  "  Thera- 
peutics will  continue  to  be  a  sad  mixture  of  stale  antiq- 
uity with  spurious  enthusiasms,  in  new-fashioned  crazes 
— the  theories  of  but  yesterday  becoming  the  super- 
stitions of  to-morrow,  and  the  practices  based  upon 
such  theories  the  shuttle-cock  of  each  doctor's  battle- 
dore." 

"  Students  of  other  sciences  are  not  content  with  sim- 
ple ideas,  or  even  facts,  but  are  intent  upon  discovering 
law.  With  unwearying  energy  they  systemize  their 
facts,  generalize,  and  rearrange,  and  whenever  a  law  is 
discovered  it  is  hailed  as  a  precious  boon  to  many  a  glo- 
rious messenger  of  light.  In  the  domain  of  medicine 
the  energies  of  our  students  seem  differently  employed. 
The  field  is  swarming  with  adventurers  who  seek  only 
the  discovery  of  new  material,  and  here  and  there,  as  one 
sees  a  fact  which  in  the  light  of  his  fancy  appears  to 
glitter,  he  seizes  upon  it  with  avidity  and  preserves  it  as  a 
precious  gem  for  a  short  time,  when  his  fickle  fancy  casts 
it  away  to  search  for  something  new.  And  so  they  go 
on  increasing  the  disarray  and  adding  to  the  heap  of 
rubbish  that  is  fast  accumulating  on  the  field  of  medi- 
cine, ever  seeking,  never  finding,  searching  for  specifics 
and  panaceas,  deluded  by  mirages,  but  unwilling  to  profit 
by  experience. 

"  Have  we  not  enough  of  speculative  medicine, 
enough  of  empirical  practice,  enough  of  ineffectual 
efforts  to  combat  microbic  diseases,  by  internal  parasiti- 
cide medication  ?  Let  us  halt  for  a  time  and  rearrange 
our  material,  discard  what  is  worthless,  put  in  order 
what  is  valuable  and  reduce  it  to  a  rule.  Our  palates 
have  been  tickled  long  enough  with  the  endless  variety, 
but  our  stomachs  are  worrying  for  something  substan- 
tial." 1 

As  earnest  and  conscientious  practitioners,  let  us  ever 
hold  fast  to  that  which  is  good,  and. until  our  science 
can  give  us  something  better,  let  us  not  forget  to  ever 
turn  and  listen  to  the  voice  of  nature  and  seek  to  heed 
more  closely  her  admonitions  in  disease ;  for  many  of  her 
symptomatic  phenomena  are  but  indexes  pointing  out  to 
us  her  mysterious  ways  of  cure.  Let  us  be  content  to  be 
her  humble  assistants  and  not  aspire  to  be  her  chief,  for 
nature's  skill  is  higher  than  our  own,  and  to  understand 
fully  her  methods  of  dealing  with  human  maladies  would 
be  true  knowledge  indeed.  When  rational  medicine  is 
the  practice,  we  believe  there  will  be  more  cautionary 
guidance  and  less  active  interference  in  the  measures 
nature  institutes  for  the  cure  of  her  ailments. 

In  conclusion,  to  get  at  the  basic  truths  underlying  a 
rational  practice ;  to  invigorate  the  field  of  medicine 
with  a  new  life ;  to  discover  law  for  facts ;  to  lay  a  foun- 
dation broad  and  strong  upon  which  to  build  the  super- 
structure of  our  science ;  we  beg  leave  to  enter  a  plea  for 
a  more  thorough  investigation  into  the  pathological 
chemistry  of  the  protoplasmic  entities  of  man,  ever  bear- 
ing in  mind,  as  physicians,  that  practical  medicine  to  be 
really  in  fact,  as  well  as  in  name,  scientific  medicine,  must 
be  based  upon  therapeutics  of  the  celL 

1  Dr.  Rendell :  Medical  Register  of  Philadelphia,  vol.  iii. 


•  THE  NON-OPERATIVE  TREATMENT  OF  UTER- 

INE  DISEASES.— EXPLANATORY. 

By  P.  J.  McCOURT,  M.D., 

NSW    YORK. 

In  a  previous  paper  upon  this  subject  (Medical  Record 
of  May  13,  1893)  I  endeavored  to  describe  so  clearly 
the  various  procedures  of  the  method  of  treatment,  that 
the  attentive  reader  might  follow  me  without  serious  er- 
ror ;  but  that  endeavor  has  failed  of  its  object.  Subse- 
quent to  the  publication  of  the  article,  applicants  for 
further  information  were  very  numerous ;  yet  the  queries 
propounded  were  usually  brief,  and  were  all  answered  by 
letter.  Now  that  many  have,  in  a  measure,  prepared 
themselves  to  apply  the  treatment  and  have  met  with 
obstacles,  the  extent  of  the  answers  called  for  renders 

*  reply  by  letter  impossible.  Anxious  to  see  the  method 
intelligently  tested,  and,  if  found  worthy,  generally 
adopted,  I  wish  to  give  such  details  to  the  profession  as 
will  enable  them  to  apply  the  treatment  as  successfully 
as  I  have  done. 

z.  The  preparation  of  the  sponge  should  present  no 
difficulty.  A  fine  "  Reef "  sponge  is  best  for  use,  and 
the  exact  proportion  of  hydrochloric  acid  to  water  is  not 
constant.  It  should  vary  with  the  amount  of  calcareous 
matter  in  the  sponge ;  but  about  one-half  pound  to  the 
gallon  will  usually  suffice.  Of  the  potassium  permanga- 
nate, cold  water  will  dissolve  the  amount  required  in  a 
few  minutes.  The  bleaching  fluid  may  consist  of  such 
solution  of  sodium  hyposulphite  (the  sulphite  has  recent- 
ly been  found  preferable)  as  cold  water  will  make  in 
about  thirty  minutes,  i  litre,  and  HC1  200  c.c.  (200  to 
1,000). 

2.  Cotton,  wool,  linteum,  etc.,  cannot  be  substituted 
for  the  sponge-dressing ;  nor  can  the  sponge  be  employed 
as  an  excipient  for  glycerin,  since  the  latter  will  render 
the  sponge  nearly  as  hard  and  rough  as  sand-paper. 

3.  The  sponge-dressing  cannot  be  accurately  adjusted 
to  the  parts  through  the  speculum.  The  vaginal  walls 
are  best  separated  by  the  first  and  second  fingers  of  the 
left  hand,  while  the  dressing  is  carried  to  its  position 
and  adjusted  by  the  index-finger  of  the  right  hand. 

4.  When  not  corroded  by  the  secretions,  the  sponge 
may  be  reapplied  several  times  to  the  same  patient,  after 
being  cleansed  each  time  in  the  bleaching  fluid. 

5.  Neither  septicaemia,  nor  any  appreciable  approach 
to  it  (except  in  the  breaking  down  of  myomata),  nor  any 
serious  inconvenience  to  the  patient,  has  ever  yet  result- 
ed from  the  application  of  these  dressings,  when  proper- 
ly placed  and  medicated. 

6.  At  the  beginning  of  a  course  of  treatment  the  dos- 
age should  be  very  light,  and  the  patient  may  be  treated 
three  times  each  week,  rarely  more  frequently,  for  a 
month,  or  until  such  time  as  improvement  is  apparent ; 
then  twice,  and  finally  once  a  week.  There  is  danger, 
or  at  least  waste  of  time,  in  overdoing  the  applications 
advocated  in  this  treatment.  If  the  patient  be  treated 
once  or  twice  a  day,  as  has  been  advised  by  one  of  my 
former  students  in  this  journal,  peritonitis  may  result. 

7.  In  treating  cases  of  hypertrophied  uteri,  as  the  size 
of  the  organ  diminishes  the  size  of  the  sponge  should  be 
relatively  increased,  otherwise  progress  may  cease,  or 
the  conditions  may  even  take  a  retrograde  course. 

8.  None  of  the  materials  used  in  this  treatment  can  be 
supplied  by  me. 

9.  It  is  imperative,  for  the  reasons  assigned  in  my  for- 
mer paper,  that  the  tinctures  be  made  saturated,  and 
from  the  fresh  root  or  plant.  The  employment  of  other 
preparations  for  this  purpose  will  be  certain  to  defeat 
our  object,  and  may  injure  the  patient.  The  pharmacist 
should  be  able  to  make  these  tinctures  in  season,  and  to 
have  them  prepared  where  the  plants  grow. 

10.  The  metric  system  employed  has  proven  an  obsta- 
cle to  many  of  my  readers.  It  is  only  necessary  to  re- 
member that  the  litre  contains  the  weight  of  1,000 
grammes,  or  the  measure  of  1,000  cubic  centimetres. 
Hence,  3  grammes  to  1  litre  means  simply  three  parts 


59° 


MEDICAL    RECORD. 


[November  10,  1894 


to   1,000;  6  5  grammes  to  z  litre  means  6)4  parts  to 
1,000 ;  and  so  on  throughout. 

11.  I  am  asked  to  specify  the  conditions  in  which  va- 
riation of  local  temperature  has  been  observed ;  and  it  is 
evident  that  this  observation  has  been  received  with 
some  doubt.  Disproportionate  elevation  of  intra  uterine 
temperature  has  been  found  chiefly  in  connection  with 
local  hyperemia;  and  the  temperature  has  been  found 
subnormal  in  some  cases  of  induration,  malnutrition, 
hydremia,  and  other  forms  of  defective  haematosis. 
Surely  these  observations  are  not  less  credible  than  others 
of  unequal  axillary  temperature,  editorially  noted  in  this 
journal,  February  27,  1892,  p.  240. 

12.  To  vary  the  dosage  on  the  sponge  dressing  "by 
the  fixed  rules  for  individual  cases,"  I  meant  that  we 
may  give  a  larger  dose  to  a  woman  of  strong,  coarse,  rigid 
fibre,  than  could  be  borne  by  one  of  fine,  delicate  struct- 
ure— one  whD,  in  modern  nomenclature,  is  a  "senai." 
tif,"  or  what  we  so  lately  and  erroneously  called  a  "  ner- 
vous  temperament." 

13.  A  careless  reader — so  familiar  to  all  writers — tells 
me,  while  asking  what  others  do  in  substance,  "  You  con- 
demn the  use  of  iron,  yet  call  it  a  valuable  agent,  and 
acknowledge  that  you  prescribe  it  yourself.  What  are 
your  indications  for  it  ?  "  I  condemned  no  practice  or 
practitioner,  and  merely  took  exception  to  the  prevail- 
ing massive  dosage  of  the  metal,  which  repeated  crucial 
tests  with  unvarying  results  had  taught  me  to  be  both 
unnecessary  and  toxic.  If  the  ears  are  pale  and  waxy, 
especially  when  viewed  by  transmitted  light,  iron  is  in- 
dicated. A  person  whose  ears  are  red  will  rarely  need 
iron.  The  drug  may  also  give  brilliant  results  in  many 
cases  when  there  is  a  deep,  circumscribed  redness  of  the 
face  during  pain  or  excitement,  although  in  repose  the 
face  may  be  pale  or  yellow. 

14.  Evidence  is  curtly  demanded  as  to  "  how  the 
chemistry  of  the  body  can  change  ingested  iron  into  the 
tannate  ?  "  I  did  not  so  represent  the  change,  but  the 
law  of  chemical  affinity  is  not  suspended  within  the 
body.  Several  articles  of  food — notably  tea,  coffee,  etc. 
— contain  tannin.  This  tannic  acid  will  unite  with  iron 
on  meeting  it  in  the  stomach,  intestine,  or  elsewhere,  to 
form  the  insoluble  tannate  of  iron.  The  tannate  thus 
formed  will  unite  with  animal  tissues,  living  or  dead, 
and  remain  permanently  fixed  in  the  body.  It  is  unfort- 
unate for  many  that  none  of  these  facts  are  given  in  our 
text  books  on  chemistry.  A  number  of  the  drugs 
named  in  the  paper  will,  when  indicated,  dissolve  this 
tannate  of  iron  and  eliminate  it  from  the  body. 

15.  A  ready  solvent  of  the  viscid  secretion  of  chronic 
cervical  endometritis  is  not  yet  satisfactorily  determined. 
A  few  drugs  of  undoubted  value  in  this  condition  are 
now  being  tested.  The  best  of  these  appears  to  be  ja- 
caranda  gualandi,  of  Brazil;  but  I  cannot  yet  commit 
myself  to  assert  of  any  drug  that  it  is  a  true  remedy.  It 
is  still  deemed  best  to  remove  the  tenacious  secretion  by 
the  mechanical  means  recommended  in  the  paper,  or  by 
the  curette,  when  the  indicated  remedies  named  will 
complete  the  cure. 

16.  In  the  treatment  of  uterine  fibroids  I  have  as  yet 
nothing  definite  to  add.  When  such  tumors  can  be 
readily  removed  by  operative  means,  this  course  is  rec- 
ommended. Where  obstacles  prevent,  or  danger  threat- 
ens from  operation,  the  sponge  dressing  may  be  resorted 
to  with  a  fair  degree  of  confidence.  In  twenty-six  cases 
thus  far  completed  I  have  met  with  only  two  failures. 

17.  In  treating  erosions  of  the  os  uteri,  etc.,  when  the 
sponge-dressing  adheres  to  the  eroded  surface,  and  its 
removal  is  followed  by  the  discharge  of  arterial  blood,  it 
is  evidence  that  a  wrong  drug  has  been  used,  and  a  re- 
examination of  the  patient  will  reveal  the  remedy  to  be 
employed.  A  very  weak  solution  of  silver  nitrate,  ap- 
plied by  the  hair-pencil  before  the  proper  dressing,  af- 
fords marked  relief  in  such  cases. 

18.  When  stenosis  of  the  os  or  cervix  uteri  presents, 
the  first  indication  is  to  soften  the  cervical  tissues,  which 
are  almost  constantly  indurated  in  such  conditions,  and 


then  to  open  the  cervical  canal.  Until  the  latter  object 
is  accomplished,  further  treatment  may  only  waste  time 
and  irritate  the  organs  involved.  But  once  the  cervix  is 
dilated,  and  so  maintained,  the  remedy  is  immediately 
distributed,  not  merely  to  the  endometrium,  but  to  the 
entire  system,  and  free  drainage  will  soon  be  established. 
It  has  been  frequently  observed,  however,  especially  in 
young  women,  that  stenosis  and  flexions  yield  spontane- 
ously to  the  treatment  without  instrumental  aid. 

19.  Pain  or  inflammation  has  rarely  followed  dilata- 
tion of  the  cervical  canal,  even  when  the  patient  had  not 
been  fully  prepared  for  the  operation,  or  when  she  had 
had  a  history  of  peritonitis.  The  dressing,  charged  with 
the  sanguinaria  co.,  combined  when  necessary  with  any 
other  suitable  remedy,  will  usually  subdue  pain  and  ten- 
derness in  a  few  minutes,  after  which  the  patient  may 
ride  or  walk  home  with  safety  and  comfort. 

20.  It  is  gratifying  that  so  many  of  my  correspondents 
seek  adequate  means  for  correcting  excessive  and  defi- 
cient menstruation.  The  great  majority  of  women  who 
suffer  from  uterine  diseases,  lose  by  far  too  much  blood 
each  month ;  and  but  few  other  conditions  can  so  rap- 
idly make  them  prematurely  old.  I  regard  the  normal 
menstrual  period  (some  few  cases  of  general  plethora  ex- 
cepted) as  being  three,  or  at  most  four,  days  each  lunar 
month;  and  that  limit  is  usually  established  by  a  judi- 
cious course  of  the  sponge  treatment,  whatever  the  men- 
strual history  of  the  patient  may  have  been.  Abnormal 
menstrual  flow  may  usually  be  corrected  by  a  careful  se- 
lection of  the  remedies  named  in  my  previous  paper, 
guided  by  a  study  and  appreciation  of  the  characteristic 
secretions.  If  these  fail — if  we  must  treat  the  symptom 
instead  of  the  patient — a  valuable  general  remedy  for 
menorrhagia  may  be  found  in  savine,  1  to  12  of  water. 
In  scanty  menstruation  conium  and  Pulsatilla  are  of 
equal  efficacy. 

22.  The  badinage  lavished  upon  me  for  my  "  extrava- 
gant faith  in  medicine,"  would  fill  a  small  volume. 
This  shower  of  spice  maybe  gracefully  accepted,  since  it 
disproves  nothing,  while  I  have  proven  my  positions. 
But  it  is  wise  to  bear  in  mind  that  our  patients  possess 
and  adhere  to  a  living  faith  in  medicine,  whether  we  do 
or  not.  They  also  have  faith  in  us ;  and  it  is  our  duty 
to  make  that  faith  as  well  founded  and  abiding  as  possi- 
ble. With  this  as  well  as  higher  objects  in  view,  I  have 
delved  in  many  mines — have  sought  far  and  near  for 
drugs  of  alleged  value,  and  have  studied  in  all  systems 
worthy  of  the  name.  In  nearly  all  I  have  been  able  to 
cull  gems  from  the  mass  of  detritus.  The  results  of  my 
search  have  been  given  without  reserve  to  the  profession, 
who  can  best  judge  of  their  value.  I  ask  that  those  who 
have  tested  or  who  may  test  my  method  in  practice,  will 
report  results  in  the  columns  of  the  Medical  Record. 

To  many  members  of  the  profession,  in  this  and  other 
countries,  my  grateful  acknowledgments  are  due,  alike 
for  their  welcome  criticism  and  for  their  generous  words 
of  approval  and  encouragement.  A  reprint  copy  of  the 
original  paper  will  be  sent  on  request  to  those  who  have 
not  seen  it. 

■33  West  Twenty-third  Street. 


Oliver  Wendell  Holmes  as  a  Mieroseopiit — Forty-one 
years  ago,  Dr.  Holmes,  who  was  eighty-five  years  old  on 
August  29,  1894,  taught  Dr.  £.  Cutter  how  to  use  the 
microscope  with  direct  illumination.  He  had  an  ar- 
rangement of  his  own — a  six-inch  black  disk  fastened  to 
the  tube  and  graduated  so  that  turning  the  disk  would  act 
as  a  fine  adjustment.  Dr.  Cutter  says  that  Dr.  Holmes 
worked  a  good  deal  with  the  microscope  in  those  days, 
and  that  the  intellectual  drill  derived  therefrom  may  have 
been  used  in  literature.  Is  not  the  technical  use  of  the 
microscope  in  college  as  good  a  discipline  as  the  study  of 
Greek?  Surely  the  cyclops  of  the  Odyssey  would  be 
better  understood  by  one  who  has  studied  a  living  cyclops 
taken  from  a  hydrant  and  shown  under  the  microscope. — 
The  American  Monthly  Microscopical  Journal. 


November  10,  1894] 


MEDICAL   RECORD. 


59i 


QK08V&66  of  f9ftjedical  gtimtt. 

Pylorectomy  with  Gastro  Duodenostomy  Posterior. — 
Professor  Kocher  gives  his  method  of  excising  the  pylorus. 
(University  Medical  Magazine.)  The  incision  is  made 
in  the  median  line,  and  is  10  to  15  ctm.  long. 
The  umbilicus  is  excised  and  all  bleeding  stopped.  The 
tumor  having  been  withdrawn  as  much  as  possible,  small 
openings  are  made  through  the  greater  and  lesser  omen- 
tums,  through  these  clamps  are  adjusted.  The  attach- 
ments of  the  omentum  are  then  loosened  from  the  growth 
and  the  latter  enveloped  in  gauze.  All  bleeding  is  care- 
fully stopped.  A  clamp,  resembling  an  ordinary  hemo- 
static forcep,  is  placed  on  the  duodenum  and  an  incision 
made  between  it  and  one  applied  on  the  stomach.  He 
does  not  fear  sloughing  from  pressure.  The  mucous  coat 
which  protrudes  from  the  cut  section  is  carefully  cleansed 
with  bichloride,  1  to  1,000.  The  stomach  is  then  com- 
pressed by  the  fingers  of  an  assistant,  and  clamps  placed 
next  the  growth,  an  incision  being  made  between  them 
the  growth  is  removed  and  the  cut  stomach  cleansed  and 
sutured  shut  with  a  continuous  suture.  This  is  then  in- 
vaginated  and  another  continuous  Lembert  suture  placed 
above.  The  posterior  wall  of  the  duodenum  is  then  ap- 
proximated to  the  posterior  wall  of  the  stomach  one-half 
or  three-quarters  of  a  centimetre  behind  the  closed  end, 
and  the  two  are  sewed  together  with  a  continuous  sero- 
serous  suture.  The  forceps  being  removed  from  the 
duodenum,  all  bleeding  is  stopped  and  its  interior  care- 
fully cleansed.  An  incision  is  then  to  be  made  into  the 
posterior  wall  of  the  stomach  and  the  free  edge  of  the 
duodenum  sewed  to  it  by  a  suture,  either  embracing  all 
the  coats  or  else  two  layers  applied — one  musculo-serous 
and  the  other  mucous.  The  sero-serous  layer  of  suture 
first  applied  is  then  continued  all  around.  The  cut  end 
of  the  duodenum  is  thus  fixed  directly  into  an  incision  in 
the  posterior  wall  of  the  stomach.  Of  six  cases  so  ope- 
rated on,  one  only  died,  and  it  on  the  twentieth  day. 
Asepsis  is  insisted  on,  the  lines  of  sutures  being  touched 
with  gauze  wet  with  sublimate  solution.  No  washing  of 
the  abdominal  cavity  is  to  be  employed.  The  continuous 
suture  only  is  to  be  used.  It  is  unnecessary  to  guard  the 
forceps  used  to  clamp  the  cut  ends  with  rubber,  because 
the  pressure  does  no  harm. 

The  Mechanical  Treatment  of  Chronic  Constipation. 
— Dr.  F.  Le  Marinel  believes  that  the  mechanical  treat- 
ment should  be  the  treatment  of  choice  in  a  large  num- 
ber of  forms  of  chronic  constipation.  The  manoeuvres  of 
massage  comprise  three  forms — frictions,  pressures,  and 
percussions.  In  addition,  various  active  and  passive 
movements  are  undergone — flexion,  extension,  abduction, 
adduction,  pronation,  supination,  rotation,  and  circum- 
duction. The  effects  of  medical  gymnastics  are  studied 
as  regards  the  circulation,  respiration,  animal  heat, 
chemical  phenomena,  the  muscles,  bones  and  articula- 
tions, and  the  local  results.  The  effect  of  massage  upon 
the  absorption,  muscular  system,  nervous  system,  circula- 
tion, and  local  temperature  are  fully  recorded.  {The 
American  Journal  of  the  Medical  Sciences.')  The  tech- 
nique of  various  authors  is  fully  described  and  illustrated. 
The  various  forms  of  constipation  which  are  likely  to  be 
benefited  are— (1)  from  anaesthesia  of  mucous  membrane ; 
(2)  from  muscular  paralysis ;  (3)  from  induration  of  the 
stools,  and  (4)  from  mechanical  obstacle.  The  contra- 
indications are — (1)  acute  inflammation  of  intestines, 
peritoneum,  peri- intestinal  cellular  tissue,  or  of  intra-ab- 
dominal veins;  (2)  ulcerations  (round,  tuberculous) 
of  stomach  or  intestines  ;  (3)  tumors  of  the  alimentary 
canal  (sarcomata,  carcinomata,  polypi);  (4)  volumi- 
nous faecal  masses  of  stony  hardness.  An  interesting 
comparison  is  given  of  the  value  of  diet,  habit,  purgatives, 
hydrotherapy,  injections,  electricity,  various  medicinal 
methods,  with  that  described  by  the  author,  the  general 
conclusion  being  that  of  all  these  methods  only  one  can 
be  compared  to  the  mechanical,  and  that  one  is  elec- 
tricity.    But  when  one  considers  the  question  from  the 


standpoint  of  success,  massage  shows  figures  which  are 
not  surpassed  by  electricity.  So  far  as  facility  of  applica- 
tion, massage  is  superior  in  that  it  does  not  require  any 
apparatus,  and  can  be  applied  equally  well  at  the  house 
of  the  patient  as  of  the  physician.  Further,  massage  is 
better  borne  than  electricity,  and  particularly  by  chil- 
dren. A  series  of  147  cases  is  reported,  the  treatment 
being  that  advocated  in  the  paper.  The  care  shown  in 
the  report,  the  apparent  accuracy  of  diagnosis,  the  fulness 
of  detail,  give  an  especial  value  to  the  clinical  histories. 
In  the  cases  cited,  those  of  the  synoptical  table,  and 
eleven  in  detail,  158  in  all,  radical  cure  was  obtained  in 
about  ninety  per  cent.  The  final  conclusions  are :  1. 
Mechanical  treatment  takes  rank  among  those  therapeu- 
tic agents  whose  action  is  most  energetic  upon  the  circu- 
lation, the  respiration,  and  general  nutrition.  2.  It  can 
modify  the  abdominal  circulation,  and  cause  certain  for- 
eign congestions,  notably  those  which  are  met  wish  in 
abdominal  plethora,  to  disappear.  3.  Under  its  action 
the  muscles  acquire  an  increase  in  volume  and  strength. 
4.  It  is  the  best  curative  agent  in  constipation  dependent 
upon  muscular  paresis  or  paralysis,  if  it  is  not  of  central 
nervous  origin.  5.  It  is  the  best  curative  agent  for  con- 
stipation dependent  upon  diminished  sensitiveness,  or 
anaesthesia  of  the  mucous  membrane  when  it  is  due  to 
local  causes.  6.  Finally,  it  is  formally  contra  indicated 
when  constipation  is  due  to  acute  inflammatory  lesions 
or  to  tumors. 

The  Treatment  of  the  Fever  of  Phthisis.— Dr.  Savigny 
distinguishes  three  forms  in  this  disease:  1,  The  initial 
or  continued;  2,  the  hectic  or  concomitant;  3,  the  sep- 
tic. In  the  last  form  the  purely  symptomatic  treatment 
is  powerless.  The  administration  of  the  new  antipyretics 
is  not  favorable,  for  all  of  them  diminish  the  energy  of 
the  heart,  only  influencing  the  fever  as  a  symptom,  if  in- 
deed they  have  any  notable  effect,  and  they  are  only  used 
in  rapid  tuberculosis,  and  when  humanity  demands  only 
that  the  patient  shall  be  made  more  comfortable.  Hoch- 
halt,  after  much  research,  has  come  back  again  to  ane- 
nic,  but  with  the  exception  of  recent  initial  apical  ca- 
tarrhs it  has  no  influence  upon  the  course  of  the  disease. 
Hectic  fever  is  manifestly  influenced  by  this  remedy,  but 
it  has  no  action  upon  the  initial  fever  and  upon  the  rapid 
forms  of  phthisis.  Fowler's  solution  is  recommended,  in 
commencing  doses  of  one  to  two  drops,  and  increasing, 
day  by  day,  to  five  or  six ;  rarely  more,  for  ten  drops  is 
quite  likely  to  produce  symptoms  of  poisoning.  Other 
beneficial  effects  besides  the  lowering  of  temperature  are 
the  suppression  of  night  sweats  and  an  increase  of  appe- 
tite and  body  weight.  The  continued  fever  offers  con- 
siderable resistance  to  the  treatment  by  arsenic,  for  this 
fever  is  a  manifestation  of  caseation,  and  is  an  expression 
of  the  clinical  form  of  phthisis  florida.  By  building  up 
the  system  one  can  best  combat  the  tendency  to  casea- 
tion. In  these  cases  the  condition  of  the  heart  and  cir- 
culation is  important;  Brehmer  and  Dettweiler  recom- 
mend the  prolonged  application  of  ice-bags ;  others  use 
alcohol.  Kiihle  and  Liebermeister  advise  digitalis,  which 
however,  should  be  used  with  caution ;  but  more  advan- 
tageously the  ten  per  cent,  tincture  of  coronilla,  in  ten 
to  twenty-drop  doses,  can  be  employed.  In  cases  of  in- 
itial fever  without  grave  lesion  of  tissue,  in  association 
with  fifteen  grains  of  quinine,  Hochhalt  has  seen  this 
fever  transformed  into  the  intermittent  type,  where  ar- 
senical treatment  is  useful.  In  apyretic  phthisis  creosote 
is  used ;  if  at  the  outset  it  is  not  well  borne  by  the  stom- 
ach, it  can  be  administered  in  cocoa-butter  suppositories 
— with  steady  increase  of  all  doses ;  in  commencing  with 
large  doses  there  is  danger  of  exciting  the  fever.  In  gen- 
eral the  antipyretic  treatment  consists  less  in  reliance 
upon  the  antifebrile  remedies,  properly  so  called,  which 
have  only  a  slight  and  transitory  effect,  as  in  the  use  of 
remedies  which  act  directly  upon  diseased  pulmonary  tis- 
use,  than  upon  arsenic,  the  cardiac  tonics,  and  nutrition 
by  every  means  which  can  stimulate  it. — American  Jour- 
nal  of  the  Medical  Sciences. 


592 


MEDICAL    RECORD. 


[November  10,  1894 


Medical   Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 
GEORGE   F.  SHRADY,  A.M.,  M.D.,  Editor. 

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


New  York,  November  10,  1894. 


THE  NEW  TREATMENT  FOR  DIPHTHERIA. 
Whenever  a  new  remedy  is  suggested  for  a  prevalent 
and  formidable  disease  it  is  quite  necessary  to  exer- 
cise a  becoming  conservatism  regarding  facts  which 
bear  on  the  possibility  of  a  brilliant  discovery.  The 
history  of  all  similar  cures  proves  that  the  initiative 
reports  are  not  always  borne  out  by  subsequent  results, 
and  that  nothing  more  is  gained  by  a  discussion  of  rela- 
tive merits  of  other  remedies  than  the  ventilation  of  a 
new  theory  and  the  final  mortification  of  its  ultimate 
rejection. 

On  the  other  hand  it  must  not  be  argued  that  students 
of  therapeutics  should  be  backward  in  seizing  upon  every 
plausible  means  to  an  end,  or  should  neglect  opportuni- 
ties for  the  careful  study  of  such  data  as  may  be  pre- 
sented with  a  proper  spirit  for  deliberate  judgment. 
Even  in  view  of  these  apparent  drawbacks  we  cannot 
resist  the  temptation  of  looking  upon  the  antitoxin 
treatment  of  diphtheria  as  promising  better  than  any 
that  has  heretofore  been  presented  to  the  profession. 
Making  due  allowance  for  the  remarkable  percentage  of 
cures,  even  in  malignant  cases,  we  can  safely  assume  that 
if  one-half  of  what  is  said  of  the  antidotal  power  of  the 
serum  is  true,  we  have  made  a  most  wonderful  advance 
in  the  therapeutics  of  a  most  formidable  and  fatal  mal- 
ady. There  is,  indeed,  enough  encouragement  in  the 
astonishing  results  abroad  to  warrant  an  extended  trial 
in  this  country. 

The  articles  by  Professor  Baginsky,  of  Berlin,  and  Dr. 
Louis  Fischer,  of  New  York,  in  a  recent  issue  of  the 
Medical  Record,  were  calculated  to  arouse  a  new  inter- 
est in  the  subject  by  calling  attention  to  some  remarka- 
ble results.  The  mortality  of  diphtheria  in  Berlin  during 
the  three  years  preceding  the  trial  of  antitoxin  ranged 
from  32.5  percent,  to  41.7  per  cent.  Baginsky  broke 
this  record  in  one  hundred  and  ninety-two  cases  by  re- 
ducing the  death- rate  to  fourteen  per  cent.,  while  in 
eighty-two  additional  cases,  making  in  all  two  hundred 
and  seventy-four,  the  average  mortality  was  15.3  per 
cent.  More  recent  statistics  give  in  sixty-three  cases  a 
fatality  of  5.5  per  cent.  In  France,  Professor  Roux  low- 
ered the  death-rate  from  51.71  per  cent,  to  24  33  per 
cent.  Viewed  as  plain  facts  the  showing  is  certainly  very 
remarkable. 

The  theory  of  the  action  of  the  antitoxin  serum  from 
a  bacteriological  standpoint  at  least  is  quite  tenable, 
while  clinically  there  are  no  obvious  objections  to  its 
plausibility.     It  is  in  brief  the  transference  of  acquired 


immunity  in  an  animal  to  a  similar  condition  in  the  hu- 
man subject.  The  natural  resistance  to  the  disease,  the 
vital  energies  which  are  aroused  to  overcome  the  enemy, 
are  sufficiently  reinforced  by  the  immune  serum  to  turn 
the  balance  in  favor  of  a  cure.  In  a  like  manner  the 
antitoxin  is  claimed  to  act  in  a  protective  way  for  such  as 
may  be  exposed  to  the  disease  by  a  preliminary  injection  of 
immunizing  serum,  thus  anticipating  the  evil  effects  of  the 
disease  by  neutralizing  its  septic  tendencies.  So  far  the  en- 
couraging reports  coming  from  Berlin  and  Paris  are  quite 
convincing,  and,  unless  contradicted  by  more  extended  ex- 
perience, warrant  the  brightest  hopes  for  the  future.  There 
is  certainly  a  singular  agreement  regarding  the  reduction 
of  mortality  as  observed  by  different  experimenters, 
which  gives  a  truer  scientific  complexion  to  the  facts 
than  could  be  gained  from  partial  sources  or  through 
biased  channels.  There  is,  then,  every  plausible  reason 
why  the  antitoxin  treatment  should  be  thoroughly 
tested  in  this  country.  The  great  trouble  at  the  start 
will  be  the  scarcity  of  the  remedy  and  the  difficulty  of 
obtaining  it.  This  difficulty  should  be  overcome  as 
speedily  as  possible  by  extending  its  manufacture  and  in 
establishing  necessary  laboratories  in  different  parts  of  the 
country.  Thus  far  the  only  antitoxin  that  has  been 
used  in  this  country  has  come  from  abroad,  and  is  now 
in  such  limited  quantity  as  to  be  practically  useless  for 
purposes  of  extended  experimentation.  It  is  to  be 
hoped,  however,  that  ultimately  the  supply  will  meet  the 
demand,  and  that  opportunities  may  be  afforded  for  such 
tests  of  the  efficacy  of  this  new  remedy  as  seem  to  be 
warranted  under  existing  circumstances. 


LAUS  GAMBRINO. 

It  is  rare  that  one  finds  a  physician  nowadays  who  gives 
that  unqualified  praise  of  beer,  as  compared  with  other 
alcoholic  liquors,  which  was  heard  a  few  years  ago.  The 
tendency  is  rather  to  teach  that  "  total  "  abstinence  is 
best,  and  that  beer  is  not  much  better  than  other  forms  of 
intoxicating  drinks.  The  view  once  hopefully  enter- 
tained, that  beer  was  the  best  and  safest  beverage/ and 
that  its  introduction  into  America  would  lead  to  an 
abandonment  of  spirits  and  to  less  drunkenness  and  alco- 
holism, is  not  now  generally  held.  We  read  with  some 
interest,  therefore,  an  article  in  praise  of  beer  by  Dr. 
Lambert  Ott,  in  The  Medical  News.  The  article  is 
based  on  fifteen  years1  observation  among  beer  drinkers. 
The  class  that  Dr.  Ott  has  studied  is  composed  mostly  of 
laborers  and  employees  in  breweries,  the  men  being 
mostly  Germans,  but  with  a  sprinkling  of  Irish  and 
Americans.  Some  of  these  had  drank  from  one  to  two 
gallons  of  beer  daily  for  fifteen  years  without  any  obvi- 
ous disturbance  of  the  bodily  functions. 

Dr.  Ott  seems  to  think  that  beer-drinking  has  a  dis- 
tinct ethical  value,  for  he  says :  "  The  German  brewer 
is  by  nature  an  honest,  industrious,  and  good-natured 
individual,  fond  of  his  home  and  family,  and  in  every 
way  a  congenial  person ;  even  the  Irish  and  American 
brewer  partakes  of  those  kind  and  congenial  elements  so 
common  to  the  German  brewer,  leading  one  to  believe 
that  the  constant  association  and  use  of  beer  as  a  bever- 
age begets  a  distinctive  type  of  humanity,  possessing 
natures  kind  and  pleasing.  Often  have  I  observed  young 
men,  of  slight  build,  with  no  inherited  predisposition  to 


November  10,  1894] 


MEDICAL    RECORD. 


593 


obesity,  after  a  year  or  two  in  a  brewery  acquire  a  sunny 
disposition  and  an  accumulation  of  fat,  the  attenuated 
and  introspective  dyspeptic  being  transformed  into  the 
happy  and  fat  brewer." 

The  blood  of  beer  drinkers  shows  an  increased  pro- 
portion of  red  blood-cells  and  a  diminution  of  white 
corpuscles.  Excessive  beer  drinking  leads  to  a  condi- 
tion of  mental  torpor,  which  soon  disappears,  however, 
when  the  cause  is  removed. 

According  to  Dr.  Ott,  beer  does  not  retard,  but  assists, 
digestion.  However,  in  the  summer  time,  when  large 
amounts  are  poured  into  the  stomach,  a  subacute  gas- 
tritis may  develop.  Diseases  of  the  heart  and  lungs  seem 
uninfluenced  by  large  potations  of  beer.  Cirrhotic  kid- 
ney and  hob-nailed  liver  are  never,  he  says,  found  in  the 
beer  drinker;  neither  does  beer  alone  ever  produce  de- 
lirium tremens. 

Altogether  the  beer  habit,  when  not  accompanied  with 
other  bad  habits  or  the  use  of  whiskey,  is  a  healthful  one. 

Here,  however,  is  the  weak  point  in  Dr.  Ott's  argu- 
ment. The  beer  drinker  is  very  liable  to  take  other 
drinks  after  a  while,  and  then  bad  results  follow.  The 
observations  made  upon  a  class  of  men  who  indulge  in 
hard  manual  labor,  cannot  be  applied  to  the  community 
in  general.  It  is  the  experience  of  most  physicians  that 
in  this  country,  beer  drinking,  except  in  great  modera- 
tion, leads  to  gastric  troubles,  and  to  gouty,  rheumatic, 
and  renal  disorders. 


DOCTORS  WHO  GIVE  AND   RECEIVE   "COM- 

MISSIONS." 
What  shall  be  done  with  that  peculiarly  contemptible 
species  of  huckster,  which,  protected  by  medical  diplomas, 
sends  gullible  people  only  to  those  "consultants"  and 
"  specialists  "  who  pay  them  an  underhanded  commis- 
sion for  their  favors?  That  the  thing  is  done  admits  of 
no  doubt.  Bnt  how  to  bring  about  exposure,  and  brand 
the  medical  trader  and  commission  pedler  as  he  deserves 
to  be  branded  is  a  problem  still  requiring  solution. 

The  Philadelphia  Polyclinic  is  much  exercised  over 
this  state  of  affairs,  but  has  no  practical  reform  sug- 
gestions to  offer.  According  to  this  journal:  "The 
Tri- State  Medical  Journal  published  a  letter  from  a 
physician  to  a  prominent  consulting  surgeon,  asking 
what  percentage  he  would  pay  for  cases  referred  to 
him  in  consultation.  Ophthalmic  surgeons  have  all 
had  experience  with  such  offers  from  opticians,  and  Or- 
thopedic surgeons  from  truss  and  brace  makers.  More 
than  one  hundred  years  ago  it  was  declared  reprehensi- 
ble for  a  physician  to  enter  into  collusion  with  druggists 
and  receive  a  percentage  on  the  price  of  prescriptions 
compounded,  and  the  declaration  would  hardly  have 
been  made  if  the  practice  had  not  existed.  That  it  con- 
tinues, and  from  time  to  time  assumes  new  forms,  we 
must  also  reluctantly  admit.  We  will  not  here  occupy 
space  in  arguing  against  the  practice  of  the  physician  ac- 
cepting a  fee  from  a  patient  with  the  understanding  that 
he  is  to  give  the  best  advice  which  his  knowledge  and  ex- 
perience enables  him  to  offer,  and  then  accepting  a  per- 
centage or  fee  from  somebody  else  in  consideration  of 
giving  that  advice  a  special  direction.  To  any  one  who 
really  has  the  slightest  doubt  as  to  the  immoral  and  un- 
ethical nature  of  such  a  transaction,  we  would  suggest  this 


simple  test.  Would  he  be  willing  to  do  it  openly  and 
with  the  knowledge  of  the  patient?  Let  the  doctor  who 
is  captivated  by  the  offer  in  question  state  frankly  to  his 
patient,  'I  think  you  had  better  go  to Sanita- 
rium, the  company  pay  me  jioo  for  giving  you  this  ad- 
vice ; '  or,  *  You  must  go  to  Mr.  So  and  So  to  get  your 
glasses,  who  will  give  me  33  J  per  cent,  of  the  price  you 
pay  him  for  them,  for  sending  you  there ; '  or,  '  You 
must  consult  Dr.  Medicus,  who  gives  me  $5  for  every 
patient  I  send  to  him.'  The  doctor  who  makes  such  an 
explanation  to  his  patients,  we  believe  has  a  perfect 
right  to  accept  the  stock  or  the  percentage  or  the  share 
of  the  fee.  The  doctor  who  accepts  such  compensation 
in  secrecy,  without  any  explanation  to  the  patient  of  the 
nature  of  the  influences  under  which  the  advice  is  given, 
belongs  in  the  same  class  with  the  bunco  steerer  and  the 
man  that  cheats  at  cards.  The  grocer  who  puts  sand  in 
his  sugar,  or  the  jockey  that  files  his  horse's  teeth,  are 
honorable  in  comparison.1' 

Our  Philadelphia  contemporary  calls  upon  the  profes- 
sion to  put  a  stop  to  bribery  within  the  ranks  of  a  noble 
calling.  Perhaps  its  pathetic  outcry  will  be  heeded. 
And  then,  again,  perhaps  it  will  not.  The  hardened  sin- 
ner is  generally  too  pachydermatous  to  be  affected  by 
"press  notices."  His  moral  sense  resides  in  his  pocket- 
book.  To  make  him  suffer,  his  emoluments  must  be  re- 
duced to  the  vanishing  point.  If  all  physicians  would 
resolutely  refuse  association  of  any  and  every  kind  with 
the  "commission  doctors,"  the  genus  would  soon  be- 
come extinct.  If  Philadelphia  will  only  lead,  New  York 
will  gladly  follow. 


CIRCUMCISION. 


Dr.  Alexander  L.  Hodgdon,  in  the  Medico-Surgical 
Bulletin,  lays  down  some  reasons  why,  in  his  opinion,  all 
male  infants  should  be  circumcised.  Aside  from  the 
stock  arguments  on  this  subject,  we  find  nothing  to  sup- 
port Dr.  Hodgdon's  position,  except  the  statement  that 
there  are  in  the  community  two  estimable  classes  among 
which  the  operation  is  done,  viz.,  the  Jews  and  the 
"  physician  class."  Quoting  Dr.  Remondino,  he  says : 
"  In  the  United  States,  France,  and  England,  there  is  a 
class  which  also  observe  circumcision  as  a  hygienic  pre- 
caution, where  from  my  personal  observation  I  have 
found  that  circumcision  is  thoroughly  practised  in  every 
male  member  of  many  of  the  families  of  the  class — this 
being  the  physician  class.  In  general  conversation  with 
physicians  on  this  subject  it  has  really  been  surprising  to 
see  the  large  number  who  have  had  themselves  circum- 
cised either  through  the  advice  of  some  college  professor 
while  attending  lectures,  or  as  a  result  of  their  own  sub- 
sequent convictions  when  engaged  in  actual  practice." 

It  will  no  doubt  be  somewhat  of  a  surprise  to  our 
readers  to  learn  that  they  belong  to  a  circumcised,  if  not 
a  chosen,  class.  We  doubt  if  the  facts  at  all  support  the 
assertions  of  the  writers  we  have  just  quoted.  In  most 
cases  the  foreskin  adjusts  itself  to  conditions  of  perfect 
cleanliness  at  the  time  of  puberty,  if  not  before.  Physi- 
cians are  not  so  senseless  as  to  unnecessarily  mutilate 
themselves  and  their  families.  Circumcision  is  a  relic 
of  barbarous  and  semicivilized  times,  before  soap  and 
water  and  sanitation  had  been  preached.  It  no  doubt 
served  a  useful  purpose  among  the  nomadic  tribes  of 


594 


MEDICAL  RECORD. 


[November  10,  1894 


tropical  countries.  Bat  in  these  days  physicians  should 
cease  to  preach  or  impose  upon  their  patients  an  unnec- 
essary and  irrational  mutilation. 

The  rite  which  in  these  modern  times  might  be  sub- 
stituted for  the  early  religious  ceremony  of  circumcision 
would,  according  to  some,  be  resection  of  the  spermatic 
cord  of  the  vicious  and  defective  classes,  so  that  they 
should  cease  to  propagate  their  kind.  Spermatorectomy 
will  probably  triumph  over  and  replace  circumcision,  if 
anything  does. 


THE    PREVENTION    AND    CURE    OF    SNAKE- 
BITES. 

The  early  exploitation  of  a  medical  discovery  in  a  popu- 
lar magazine  does  not  afford  the  best  evidence  that  it  is 
new  and  valuable.  If,  however,  the  discoveries  of  Dr. 
Calmette  are  not  yet  proven  to  the  satisfaction  of  the 
scientific  world,  the  confidence  of  the  doctor  in  what  he 
will  be  able  to  do  is  genuine  and  beyond  the  need  of 
demonstration. 

Dr.  Calmette  believes  that  by  the  help  of  his  thera- 
peutic serum  the  most  venomous  serpents  will  be  ren- 
dered as  harmless  as  doves.  This  substance  will,  he 
thinks,  be  kept  in  all  the  drug  stores  of  India,  Africa, 
and  America,  and  will  be  carried  in  the  pockets  of  all 
travellers  and  sportsmen  who  are  exposed  to  the  bites  of 
serpents.  The  new  antidote  has  been  prepared  and  Dr. 
Calmette's  investigations  carried  out  at  the  Pasteur  In_ 
stitute.  And  the  method  employed  is  much  the  same  as 
that  used  in  obtaining  the  immunizing  serum  of  diph- 
theria. 

It  is  known  that  venomous  serpents  are  not  suscepti- 
ble to  the  bites  of  their  fellows,  but  that  non- venomous 
serpents  have  not  this  immunity. 

This  furnishes  some  evidence  that  there  is  such  a  thing 
as  being  protected  against  snake  poison.  In  order  to 
induce  the  condition  artificially,  rabbits  and  guinea-pigs 
are  chloroformed  and  then  bitten  by  the  cobra  or  viper, 
or  are  inoculated  directly  with  the  venom.  The  blood 
of  the  animals  is  then  taken  and  its  serum  used  as  a  pro- 
tective against  bites  or  inoculations  of  other  animals.  It 
is  asserted  that  whereas  the  cobra. bite  usually  kills  the 
rabbit  in  one  or  two  hours,  if  properly  protected  the 
animal  skips  around  in  as  lively  a  manner  as  ever,  no 
matter  how  severe  the  bite. 

Dr.  Calmette  finds  that  besides  his  therapeutic  serum 
there  are  two  other  substances  which  protect  against  ser- 
pent poison,  viz.,  the  chloride  of  gold  and  the  chloride 
of  lime,  the  last  being  much  the  better.  He  has  not  had 
an  opportunity  to  try  the  chloride  treatment  on  man,  but 
his  directions  for  such  trial  are  these :  "  The  chloride  of 
lime  should  be  free  from  absorbed  water,  and,  when  used, 
should  in  all  cases  be  freshly  taken  from  a  hermetically 
sealed  bottle.  One  part  of  it  by  weight  should  be  dis- 
solved in  eleven  parts  of  boiling  water,  and  the  solution 
should  never  be  made  until  it  is  about  to  be  used,  as  I 
have  found  that  the  therapeutic  power  diminishes  by 
keeping.  This  should  be  injected  subcutaneously  with  a 
trephine  [sic]  all  about  the  wound,  and  also  under  the 
skin.  From  twenty  to  thirty  cubic  centimetres  of  the  solu- 
tion will  suffice  to  save  the  life  of  a  man  bitten,  it  being 
administered  in  doses  of  five  cubic  centimetres  each." 

As  to  the  immunizing  serum,  he  finds  that,  generally 


speaking,  about  five  cubic  centimetres  are  necessary  to 
make  the  animal  proof  against  one  milligramme  of  pure 
venom.  He  also  finds  that  he  can  use  three  distinct  spe- 
cifics in  vaccinating  a  rabbit,  and  by  all  analogy,  a  man, 
against  the  bite  of  the  most  poisonous  snake,  or  as  an 
antidote  after  they  have  been  bitten.  These  are,  first,  the 
serum  from  an  envenomed  animal  by  itself;  secondly,  this 
serum  mixed  with  chloride  of  gold  or  the  hypochlorite  of 
sodium  or  of  lime;  and,  thirdly,  either  of  these  chemi- 
cals, or,  preferably,  chloride  of  lime,  used  by  itself  with- 
out serum. 

Dr.  Calmette  has  not  experimented  with  rattlesnake 
poison,  but  he  finds  that  the  same  antidote  is  good  for  all 
the  other  venoms  he  has  tried,  and  he  feels  confident  that 
it  will  answer  for  the  rattler. 


fgtexos  tit  ttxe  ffitoelu 

Honor  to  a  Haw  York  Surgeon.— Dr.  Arpad  G.  Ger- 
ster  has  received  from  the  Emperor  of  Austria  and  King 
of  Hungary  the  high  distinction  of  the  Knight's  Cross  of 
the  Order  of  Francis  Joseph  in  grateful  recognition  of 
his  valuable  philanthropic  labors  in  founding  the  Hun- 
garian Emigrant  Aid  Association  of  this  city.  This  is 
the  first  instance  in  which  an  American  citizen  has  re- 
ceived this  honor  who  has  not  held  office  under  the  Aus- 
trian government.  It  is  eminently  fitting  also  that  a 
member  of  our  profession  should  be  thus  closely  associ- 
ated with  such  noble  work,  and  that  he  should  be  so 
worthily  rewarded. 

The  Southern  Surgical  and  Gynecological  Associa- 
tion.— The  seventh  annual  meeting  will  be  held  in  the 
Artillery  Hall,  Charleston,  S.  C,  on  November  13,  14, 
and  15,  1894.  Members  of  the  medical  profession  are 
cordially  invited  to  attend. 

Chicago  Gynecological  Society. — At  the  sixteenth 
annual  meeting  of  the  Chicago  Gynecological  Society, 
held  October  19, 1894,  the  following  officers  were  elected 
to  serve  the  ensuing  year :  President,  Dr.  Franklin  H. 
Martin;  First  Vice-President,  Dr.  A.  J.  Foster;  Second 
Vice-President,  Dr.  J.  C.  Hoag ;  Secretary,  Dr.  H.  P. 
Newman ;  and  Editor,  Dr.  T.  J.  Watkins.  The  retiring 
president,  Dr.  Fernand  Henrotin,  delivered  an  interest- 
ing annual  address,  after  which  the  society  adjourned  to 
the  annual  banquet.  Dr.  John  B.  Hamilton,  J.  B. 
Murphy,  Health  Commissioner  Arthur  Reynolds,  Alex- 
ander H.  Ferguson  and  others  were  guests  of  the  Society. 

Dr.  Pliny  Earla's  Bequest  to  Leicester,  Mass. — The 
town  of  Leicester,  Mass.,  has  received  $6,000  under  the 
will  of  the  late  Dr.  Pliny  Earle,  for  the  erection  of  a 
building  for  the  public  library  of  the  town. 

An  Accident  to  Doctor  Wiglesworth.— Dr.  J.  Wigles- 
worth,  superintendent  of  the  Rainhill  Asylum,  Prescott, 
Lancashire,  England,  was  stabbed  in  the  neck  by  a  pa^ 
tient,  who  had  obtained  a  sharpened  staple ;  the  internal 
carotid  was  severed,  necessitating  ligation  of  the  common 
carotid  artery. 

Want  no  Physiology. — The  Christian  Scientists  ol 
Burlington,  la.,  have  petitioned  the  school  board  to  ex- 
cuse their  children  from  attendance  when  physiology  is 
taught.    The  petitioners  declare  that  there  is  no  material 


November  10,  1894] 


MEDICAL   RECORD. 


595 


body,  and  object  to  having  their  children  taught  to 
believe  that  there  is  anything  so  much  in  evidence  as  a 
stomach  or  a  liver. — Times  and  Register. 
>  Outbreaks  of  Smallpox.— A  considerable  outbreak  01 
small-pox  has  occurred  in  Manchester,  Mich.,  and  neigh- 
boring towns,  and  is  causing  some  alarm.  Several  cases 
of  small-pox  have  occurred  in  Washington,  D.  C,  re- 
cently. They  have  been  traced  to  a  case  occurring  in 
the  family  of  an  employee  of  the  pension  department. 

Dr.  Boux  Decorated.— Dr.  Roux  has  received  from 
President  Casimir-Perier  the  congratulations  of  the  Gov- 
ernment and  the  Cross  of  Commander  of  the  Legion  of 
Honor,  in  recognition  of  his  work  upon  the  serum  treat- 
ment of  diphtheria. 

Foot  ball  Casualties.— The  Lancet  of  October  20th 
chronicles  three  deaths  and  four  fractures  as  the  result 
of  the  previous  week's  sport. 

A  Physician  to  be  Trustee  of  the  Boston  Public  Li- 
brary.— Dr.  Henry  P.  Bowditch  has  been  appointed  by 
the  Mayor  to  be  a  trustee  of  the  Boston  Public  Library, 

The  Antitoxin  Treatment  of  Diphtheria  in  Vienna. — 
At  the  meeting  of  German  naturalists  and  physicians 
held  in  Vienna  last  month,  one  of  the  most  attractive 
subjects  discussed  was  that  of  the  papers  of  Professor 
Behring  and  Ehrlich  on  "  Serum  Therapeutics/'  and  on 
the  "  Use  of  Behring's  Antitoxin  in  the  Treatment  of 
Diphtheria."  But  neither  paper  brought  any  new  facts 
before  the  meeting,  and  the  most  interesting  communi- 
cation concerning  this  question  was  made  by  Dr.  Was- 
sermann,  of  Berlin.  He  was  endeavoring  to  obtain  in- 
formation on  the  question  of  idiosyncrasy  as  regards 
proclivity  to  or  immunity  from  an  infectious  disease. 
For  this  purpose  he  withdrew  a  quantity  of  blood  from 
persons  who  remained  healthy  though  surrounded  by 
persons  suffering  from  diphtheria,  and  studied  the  effect 
of  this  blood  on  the  diphtheria  bacillus  and  its  toxins. 
He  found  that  the  blood  of  such  healthy  persons  de- 
stroyed the  toxin  of  diphtheria,  and  neutralized  tenfold 
its  bulk  of  the  toxin.  In  eight  persons  aged  over  forty 
years,  he  found  in  seven  the  same  antitoxic  property  of 
the  blood,  while  the  percentage  of  younger  persons  pos- 
sessing such  antitoxic  blood  was  lower,  and  reached  only 
fifty  per  cent,  of  the  children  examined  between  four  and 
fifteen  years  of  age. — Lancet. 

Professor  Ludwig  Mauthner,  of  Vienna,  died  sud- 
denly of  heart  failure.  He  had  just  been  appointed  Pro- 
fessor of  Ophthalmology  in  the  Vienna  University. 

We  Wonder  if  it  be  True.— The  Medical  News  of 
Philadelphia  remarks  that  the  first  statue  ever  raised  to  a 
medical  man  was  erected  in  Brooklyn  on  October  20th, 
to  commemorate  the  memory  of  Dr.  J.  Marion  Sims. 
This  bit  of  information  will  probably  surprise  Brooklyn 
physicians,  as  none  of  them  seem  to  have  heard  of  it. 

Dudley  Sharpe  Beynolds,  Jr.,  M.D.,  son  of  Dr.  Dud- 
ley S.  Reynolds,  of  Louisville ;  born  at  Louisville,  Feb- 
ruary 20,  1873,  died  from  the  accidental  discharge  of  a 
pistol,  at  ColHnsville,  111.,  October  22,  1894. 

Alvarenga  Prize  of  the  College  of  Physicians  of 
Philadelphia.— The  College  of  Physicians  of  Philadel- 
phia announces  that  the  next  award  of  the  Alvarenga 
Prize,  being  the  income  for  one  year  of  the  bequest  of 
the  late  Sefior  Alvarenga,  and  amounting  to  about  one 


hundred  and  eighty  dollars,  will  be  made  on  July  14, 
1895,  provided  that  an  essay  deemed  by  the  Committee 
of  Award  to  be  worthy  of  the  prize  shall  have  been 
offered.  Essays  intended  for  competition  may  be  upon 
any  subject  in  medicine,  but  cannot  have  been  published, 
and  must  be  received  by  the  Secretary  of  the  College  on 
or  before  May  1,  1895.  Each  essay  must  be  sent  with- 
out signature,  but  must  be  plainly  marked  with  a  motto 
and  be  accompanied  by  a  sealed  envelope  having  on  its 
outside  the  motto  of  the  paper  and  within  it  the  name 
and  address  of  the  author.  It  is  a  condition  of  competi- 
tion that  the  successful  essay  or  a  copy  of  it  shall  remain 
in  possession  of  the  College ;  other  essays  will  be  returned 
upon  application  within  three  months  after  the  award. 
The  Alvarenga  Prize  for  1894  has  been  awarded  to  Dr. 
G.  E.  de  Schweinitz,  of  Philadelphia,  for  his  essay 
entitled  "Toxic  Amblyopias."  Charles  W.  Dulles, 
Secretary. 

Another  Post-Graduate  School. — It  will  doubtless  be 
news  to  many  New  Yorkers  to  learn  that  there  is  a  third 
post-graduate  school  in  this  city.  It  is  called  the  Met- 
ropolitan Post-Graduate  School,  and  is  homoeopathic.     i 


WILLIAM    GOODELL,   M.D.,   LL.D., 

PHILADELPHIA,   PA. 

Dr.  William  Goodell,  the  eminent  gynecologist,  who 
had  been  in  failing  health  for  the  last  two  years,  died  at 
his  residence  in  Philadelphia,  on  October  27th,  aged 
sixty-five  years.  Dr.  Goodell  was  the  son  of  the  Rev. 
William  Goodell,  D.D.,  of  Holden,  Mass.,  and  was  born 
on  the  island  of  Malta,  while  his  parents  were  journeying 
to  Turkey,  where  his  father  was  engaged  in  missionary 
work. 

In  1849  he  entered  Williams  College,  Massachusetts. 
Graduating  three  years  later,  he  came  to  Philadelphia 
and  continued  his  studies  at  the  Jefferson  Medical  Col- 
lege, and  received  his  diploma  in  1854.  The  same  year 
Dr.  Goodell  rejoined  his  father  in  Constantinople,  and 
there  entered  upon  the  practice  of  his  profession.  In 
1857  he  married,  at  Smyrna,  Asia  Minor,  Caroline, 
daughter  of  the  late  Judge  Thomas  S.  Bell,  of  West 
Chester,  Pa.,  who  survives  him.  In  1861  he  returned  to 
America  on  account  of  the  unsettled  condition  of  politi- 
cal affairs  in  Turkey,  and  locating  in  West  Chester, 
there  commenced  practising  medicine  in  this  country. 

In  1865,  on  his  appointment  as  Physician-in-Charge 
of  the  Preston  Retreat,  at  Twentieth  and  Hamilton 
Streets,  he  came  to  reside  permanently  in  Philadelphia, 
and  continued  to  hold  this  appointment  until  his  health 
began  to  fail. 

Soon  after  coming  to  Philadelphia  he  restricted  his 
practice  to  obstetrics  and  diseases  of  women,  on  the  sub- 
ject of  which  he  was  a  prolific  contributor  to  this  and 
other  medical  journals,  and  was  also  the  author  of  "  Les- 
sons in  Gynecology." 

In  1870  he  was  appointed  Lecturer  on  Obstetrics  and 
Diseases  of  Women  at  the  University  of  Pennsylvania, 
and  in  1874  Clinical  Professor  of  the  University  in  the 
Diseases  of  Women  and  Children.  He  was  also  Hono- 
rary Professor  of  Gynecology  of  the  University,  a  mem- 
ber of  the  American  Medical  Association,  and  the  Gyne- 
cological Society ;  also  of  the  State  and  county  medical 
associations.  He  was  a  Fellow  of  the  College  of  Physi- 
cians, and  a  member  for  many  years  of  the  American 
Philosophical  and  American  Pathological  Societies,  and 
a  correspondent  of  the  Boston  Gynecological  Society,  of 
the  London  Obstetrical  Society,  and  of  the  Imperial 
Medical  Society^of- Constantinople. 


596 


MEDICAL   RECORD. 


[November  10,  1894 


%snizms  atufl  Notices  of  gaofes. 

A  Practical  Treatise  on  Orthopedic  Surgery.  By 
James  K.  Young,  M.D.  Philadelphia :  Lea  Brothers 
&  Co.  1894. 

In  his  preface,  the  author  states  that  he  has  endeavored 
to  provide  students  and  practitioners  with  a  guide  to 
Orthopedic  Surgery  in  accordance  with  the  most  approved 
knowledge  of  the  present  day.  A  noticeable  feature  of 
the  work  is  the  absence  of  long  descriptions  of  operative 
measures  for  the  relief  of  deformities  congenital  or  ac- 
quired, or  the  result  of  inflammatory  joint  or  spinal  dis- 
ease. The  author  wisely  emphasizes  the  mechanical 
treatment  of  the  various  conditions,  leaving  an  extensive 
description  of  operative  measures  to  works  on  general 
surgery,  in  whose  province  they  rightly  belong.  He  de- 
votes considerable  space  to  the  pathology  of  the  different 
affections  considered,  and  has  brought  this  part  of  the 
work  up  to  the  most  recent  views.  Want  of  space  ren- 
ders a  detailed  criticism  impossible,  but  the  author  has 
given  a  fair  and  complete  r&um6  of  the  different  ideas  in 
vogue  at  present  regarding  the  etiology,  pathology,  symp- 
toms, and  treatment  of  the  different  conditions  now  as- 
signed to  the  specialist  in  orthopedic  surgery. 

The  work  is  a  beautiful  example  of  typographical  art, 
and  is  abundantly  illustrated.  Dr.  Young's  work  gives 
evidence  of  careful  and  conscientious  research,  and  is  a 
valuable  addition  to  the  literature  of  orthopedic  surgery. 

La  Lepre.  Observations  et  Experiences  Personnelles. 
Par  le  Docteur  Jules  Goldshmidt.  Paris:  Soci6t6 
d'feditions  Scientifiques.     1894. 

What  makes  this  little  brochure  so  attractive  that  one  is 
not  apt  to  lay  it  down  until  the  fifty  pages  have  been 
carefully  read,  and  the  ten  full-page  phototype  illustra- 
tions studied,  is  the  impression  left  upon  every  para- 
graph, we  might  almost  say,  that  the  author  is  giving  not 
only  his  personal  experience,  but  a  personal  experience 
which  is  worth  giving. 

Leprosy  has  prevailed  in  the  island  of  Madeira  almost 
since  its  discovery,  or  for  some  four  centuries.  During 
the  past  twenty-six  years  of  this  time  the  author  has  lived 
there,  and  has  made  the  most  of  his  time  and  advantages 
for  studying  the  disease  in  its  many  bearings,  if  we  can 
judge  by  the  result  before  us. 

Clinical  Medicine.  A  Manual  for  the  Use  of  Students 
and  Junior  Practitioners.  By  Judson  S.  Bury,  M.D. 
Lond.,  F.R.C.P.  London:  Charles  Griffin  &  Com- 
pany, Limited.  Philadelphia:  J.  B.  Lippincott  Com- 
pany.    1894. 

This  book  comprises  twelve  chapters,  covering  all  the 
more  recent  methods  of  diagnosis.  It  is  quite  novel  to 
find  the  vast  changes  in  books  of  this  kind  within  the 
last  few  years.  The  skin,  cutaneous  eruptions,  diseases 
of  the  nails,  are  certainly  interesting.  The  examination 
of  the  blood  is  certainly  as  useful  to-day  as  an  aid  to 
diagnosis  as  any  other  special  symptom.  The  chapters 
on  the  chemical  and  microscopical  examination  of  the 
urine  have  been  most  carefully  prepared ;  so,  for  example, 
Eshach's  method  of  estimating  albumin  shows  it  to  be  up 
to  date.  This  book  reminds  us  very  much  of  that  most 
admirable  book  by  Seifert  Miller,  published  in  Germany. 
The  illustrations  are  excellent,  and  the  book  is  not  only 
admirably  adapted  for  the  position  of  manual,  but  may 
even  claim  to  be  "exactly  what  every  physician  should 
know  to-day.  It  contains  468  pages,  and  is  neatly 
printed. 

Diseases  of  the  Nose  and  Throat.  By  F.  De  Havil- 
land  Hall,  M.D.,  F.R.C.P.  Lond.  With  2  Colored 
Plates  and  59  Illustrations.  Philadelphia:  P.  Bla- 
kiston,  Son  &  Co.     1894. 

This  book  is  divided  into  three  parts.     Part  I.  treats  of 
diseases  of  the  nose,  accessory  sinuses,  and  naso-pharynx. 


Part  II.  treats  of  diseases  of  the  pharynx.  Part  IIL 
treats  of  diseases  of  the  larynx.  It  has  been  written 
from  a  medical  rather  than  a  complete  surgical  stand- 
point. It  fulfils  its  purpose,  for  it  is  written  plainly  and 
gives  all  that  the  ordinary  practitioner  requires  for  imme- 
diate reference.  The  book  is  profusely  illustrated,  and  is 
well  worth  reading. 

Some  chapters,  especially  those  on  the  specific  infectious 
diseases  affecting  the  throat,  e.g.,  scarlatina  and  diphthe- 
ria, although  very  carefully  written,  still  show  that  all  mod- 
ern therapeutics  has  not  been  included.  So,  for  example, 
antitoxine  is  not  even  mentioned  as  a  therapeutic  measure 
in  1894,  although  it  has  been  extolled  since  1891.  How- 
ever, the  book  merits  the  confidence  of  the  profession. 

The  Senile  Heart.  Its  Symptoms,  Sequelae,  and 
Treatment.  By  George  William  Balfour,  M.D. 
St.  Andrews,  LL.D.  Edin.,  F.R.C.P.Eng.,  F.R.S.  Eng. 
Consulting  Physician  to  the  Royal  Infirmary,  to  the 
Royal  Hospital  for  Sick  Children,  and  to  the  Royal 
Public  Dispensary,  Edinburgh ;  Consulting  Physician 
to  Leith  Hospital;  formerly  Physician  to  Chalmers 
Hospital,  Edinburgh,  etc. ;  Member  of  the  University 
Court  of  St  Andrews.  New  York  and  London :  Mac- 
millan  &  Co.     1894. 

This  is  a  very  clearly  expressed  and  readable  treatise 
upon  a  subject  of  great  interest  and  importance,  which  has 
perhaps  hitherto  not  received  the  careful  study  it  de- 
serves. We  are  gradually  learning  that  old  age  is  not 
the  hopeless  and  helpless  condition  that  some  used  to  re- 
gard it,  but  that  it  is  just  as  deserving  of  study  as  is  any 
other  period  of  man's  life,  and  the  rewards  of  its  study 
are  as  great  or  greater.  We  cannot  cure  old  age  any 
more  than  we  can  cure  infancy,  but  we  can  often,  by  our 
art,  change  what  would  otherwise  be  a  period  of  torment 
and  suffering  into  one  of  peaceful  content.  To  this  end 
is  the  teaching  of  Dr.  Balfour's  book,  and  no  one  can 
arise  from  a  perusal  of  it  without  feeling  that  he  is  in 
better  position  than  before  to  assuage  the  distressing  ills 
to  which  some  of  our  dear  aged  ones  may  be  subject. 
We  can  heartily  commend  the  work  as  a  valuable  contri- 
bution to  the  literature  of  old  age. 

The  Students'  Dictionary  of  Medicine  and  the  Al- 
lied Sciences.  Comprising  the  Pronunciation,  Der- 
ivation, and  Full  Explanation  of  Medical  Terms,  to- 
gether with  Much  Collateral  Descriptive  Matter, 
Numerous  Tables,  etc.  By  Alexander  Duane, 
M.D.,  Assistant  Surgeon  to  the  New  York  Ophthalmic 
and  Aural  Institute;  Reviser  of  Medical  Terms  for 
Webster's  International  Dictionary.  Philadelphia: 
Lea  Brothers  &  Co.     1893. 

The  rapid  growth  of  medical  terminology,  especially  in 
the  departments  of  bacteriology,  pharmacology,  and 
therapeutics,  makes  the  possession  of  a  reliable  technical 
dictionary  an  absolute  necessity  for  student  and  practi- 
tioner alike.  Dr.  Alexander  Duane,  who  is  well  known 
as  a  medical  writer  of  wide  experience,  and  who  has  had 
special  training  as  the  reviser  of  medical  terms  for  Web- 
ster's International  Dictionary,  has  issued  such  a  work, 
which  proves  to  be  a  model  of  conciseness,  convenience, 
and  thoroughness.  Obsolete  words  have  been  discarded, 
and  the  book  is  brought  accurately  to  date  by  ex- 
tended research  among  current  medical  journals  and  re- 
cent monographs.  The  definitions  of  diseases  include 
a  brief  synopsis  of  their  etiology,  symptoms,  and  treat- 
ment ;  the  anatomical  and  physiological  terms  are  accom- 
panied by  outlines  of  the  essential  features  of  structure 
and  function,  and  each  drug  is  described,  with  its  reputed 
action,  therapeutic  uses,  and  pharmacopceial  prepara- 
tions. 

Although  contained  within  the  limits  of  a  handy  vol- 
ume of  650  pages,  many  of  the  definitions  possess  ency- 
clopaedic value.  Useful  anatomical  and  other  data  are 
tabulated  with  originality  and  precision.  Under  the 
word  Artery,  for  example,  is  found  a  table  covering  eight 
pages,  presenting  the  origin,  lateral  and  terminal  branches, 


November  10,  1894] 


MEDICAL   RECORD. 


597 


and  their  distribution,  of  each  vessel.  Twenty  tabular 
pages  are  allotted  to  the  origin,  direction,  and  insertion 
of  the  muscles,  with  their  action  and  nerve*  supply ;  while 
thirty-two  more  are  given  to  the  "  Table  of  Bacteria  and 
Fungi,"  with  their  origin,  morphological  characters, 
proper  temperature  for  culture,  properties,  etc.,  as  well 
as  a  complete  list  of  all  bacteriological  diseases.  The  lat- 
ter is  the  most  comprehensive  and  serviceable  table  of 
the  kind  yet  issued.  The  system  of  pronunciation  is 
simple,  and  the  spelling  is  in  accordance  with  the  best 
usage  rather  than  analogy.  Derivations  from  foreign 
tongues  are  given,  those  from  the  Greek  being  in  English 
text  for  the  benefit  of  readers  unfamiliar  with  the  original. 
The  typography  and  arrangement  of  the  book  are  highly 
commendable. 

The  author  is  to  be  congratulated  upon  the  production 
of  a  work  combining  such  practical  utility  with  a  fund  of 
most  extensive  research. 

1.  Directions  for  Laboratory  Work  in  Bacteriology, 
etc.  By  Frederick  S.  Novy,  Sc.D.,  M.D. ;  Junior 
Professor  of  Hygiene  and  Physiological  Chemistry. 
Pp.  309.     Ann  Arbor,  Mich. :  George  Wahr. 

2.  Laboratory  Manual  of  Elementary  Physiology  and 
Urine  Analysis.  By  John  H.  Long,  M.D.,  Sc.D., 
Professor  of  Chemistry,  etc.,  Northwestern  University. 
With  numerous  illustrations.  Pp.  366.  Chicago :  E. 
H.  Colegrove  &  Co. 

If  there  be  "  no  royal  road  to  learning,"  the  seeker  after 
medical  knowledge  to-day  at  least  may  choose  a  princely 
road.  The  books,  whose  title-pages  are  given  above,  il- 
lustrate that  the  American  medical  teacher  is  rapidly  ap- 
proaching perfection  in  method  and  style.  Both  books 
present  the  subject-matter  in  a  clear,  comprehensible 
manner,  guiding  the  student  gradually  and  pleasantly 
through  the  intricacies  of  the  primary  work,  which  are 
usually  so  discouraging.  Neither  work  claims  originality, 
the  authors  in  both  instances  frankly  stating  that  they 
have  drawn  from  the  best  sources,  and  arranged  the  mat- 
ter for  their  purposes.  The  paper  and  type  are  good ; 
those  of  the  first  book  excellent. 

1.  Professor  Novy's  work  opens  with  clear  directions 
for  preparation  of  nutrient  gelatin,  potato  culture,  de- 
scribing the  microscope  and  method  of  examination  of 
bacteria,  hanging  drops,  staining  of  bacteria,  exam- 
ination of  colonies.  A  description  of  various  bacteria 
follows,  giving  their  origin,  form,  motility,  sporulation, 
growth,  oxygen  requirements,  temperature,  behavior  to 
gelatin,  aerogenesis,  and  pathogenesis. 

The  bacteriological  examination  of  water,  soil,  and 
air  is  briefly  described.  Pathogenic  bacteria,  methods 
of  infection,  post-mortem  examinations,  sputum  exam- 
inations, and  agar  plate  cultures,  are  followed  by  a  full 
and  mostly  clear  exposition  of  the  technique  of  direct 
microscopical  examination  of  streak  preparations  made 
from  organs  and  tissues  of  infected  animals.  Methods 
of  testing  disinfectants  occupy  the  closing  pages  of  the 
book.  The  plan  of  interleaving  the  latter  with  blank 
pages  for  drawings  which  the  student  is  expected  to 
make,  is  to  be  commended. 

2.  Professor  Long's  little  book  is  an  outgrowth  of  the 
course  given  to  the  second-year  students.  He  claims 
that  two  years  should  be  given  to  this  subject  in  all 
medical  colleges.  This  is  really  done  in  some  of  the 
New  York  and  other  colleges. 

The  first  portion  of  the  book  is  devoted  to  simple  ex- 
periments in  elementary  chemical  physiology,  describing 
and  illustrating  the  apparatus  and  technique,  chapters 
on  carbohydrates,  fats,  proteids,  the  blood,  bone  con- 
stituents, saliva,  gastric  juice,  bile ;  on  milk,  beef  ex- 
tracts, flour,  water,  and  air,  briefly  enter  into  tests  and 
general  experimental  studies. 

The  second  part  deals  with  urinary  analysis.  This  is 
especially  valuable  to  the  medical  practitioner,  inasmuch 
as  it  is  the  most  recent  exposition  of  the  subject,  and 
contains  a  valuable  appendix  of  test- solutions  and  tables. 


A  System  of  Genito-ueinary  Diseases,  Syphilology, 
and  Dermatology.  By  Various  Authors.  Edited  by 
Prince  A.  Morrow,  A.M.,  M.D.,  Clinical  Professor 
of  Genito- urinary  Diseases;  formerly  Lecturer  on 
Dermatology  in  the  University  of  the  City  of  New 
York;  Surgeon  to  Charity  Hospital,  etc  With 
illustrations.  Vol.  III.,  Dermatology.  New  York:  D. 
Appleton  &  Co.     1894. 

The  third  and  last  volume  of  this  composite  product  of 
American  work  in  the  field  of  Dermatology  and  Syphil- 
ology, surpasses  in  some  respects  the  preceding  volumes, 
which  have  already  received  favorable  notice  in  these 
columns.  The  list  of  contributors  includes  most  of  the 
familiar  names  in  matters  dermatological,  extending 
alphabetically  from  Allen  to  Zeisler,  and  geographically 
included  within  a  line  drawn  from  Montreal  to  New  Or- 
leans by  the  way  of  Chicago. 

If  the  work  consisted  in  a  series  of  monographs  by 
these  authors,  written  by  them  to  parade  each  his  own 
pet  hobby,  it  would  perhaps  make  interesting  reading  for 
those  specially  engaged  in  treating  skin  diseases ;  but  it 
would  be  of  little  real  value  to  the  physician  at  large. 
As  it  is,  the  editor  has  selected,  with  apparent  excellent 
judgment,  the  man  for  each  particular  chapter  who  was 
best  suited  to  give  a  clear,  correct,  and  at  times  necessa- 
rily concise,  account  of  all  that  is  known  upon  the  sub-  . 
ject.  In  this  way  a  practical  treatise,  for  the  most  part 
comprehensive  enough  for  a  reference  compendium,  has 
been  produced  which  most  creditably  reflects  our  present 
knowledge  of  skin  diseases,  and  while  a  true  exponent 
of  American  dermatology  of  to-day,  does  not  in  any  way 
neglect  those  diseases  peculiar  to  other  parts  of  the 
world.  As  the  editor  tells  us  in  his  prefatorial  remarks, 
some  forty  diseases  have  been  here  described  which  only 
a  few 'years  ago  were  not  to  be  found  in  text  books  as 
distinct  clinical  entities.  Especial  commendation  is  due 
the  illustrations,  which  we  must  say  are,  as  a  rule,  decid- 
edly superior  to  those  of  the  other  volumes.  There  are 
twenty-seven  colored  plates,  twenty-five  half-tones,  and 
over  a  hundred  figures  in  the  text.  Some  of  the  new- 
process  pictures  are  very  life-like.  The  editorial  work 
and  Dr.  Morrow's  own  article  on  Leprosy,  deserve  praise. 
The  publishers  have  left  little  to  be  desired,  but  we 
think  they  might  have  put  on  a  better  binding.  We  pre- 
dict for  the  work  a  large  sale  on  its  merits. 

The  Horse.  Its  Varieties  and  Management  in  Health 
and  Disease.  Revised  and  enlarged  by  George  Arma- 
tage,  M.R.C.V.S. ;  formerly  lecturer  in  the  Albert 
and  Glasgow  Veterinary  Colleges ;  Author  of  "The 
Horse  Doctor,"  "  The  Cattle  Doctor,"  etc.  London 
and  New  York :  Frederick  Warne  &  Co.     1893. 

This  little  work  is  written  in  a  simple  style  and  con- 
tains, aside  from  the  descriptions  of  disease  and  thera- 
peutic advice,  a  rather  full  chapter  on  horse-manage- 
ment, hints  on  purchasing,  shoeing,  breeding,  breaking, 
etc.  Such  a  large  proportion  of  medical  men  are  of 
necessity  horse  owners,  that  a  work  devoted  to  their 
faithful  friends  cannot  fail  to  interest. 

The  book  before  us  will  not  be  found  sufficiently 
scientific  for  the  physician  who  knows  anything  at  all  of 
the  subject,  and  he  will  feel,  in  reading  a  considerable 
part  of  the  instructions,  that  they  were  written  for 
Englishmen.  Still  an  occasional  hint  of  value  can  be 
picked  up. 

Text-book  of  Anatomy  and  Physiology  for  Nurses- 
Compiled  by  Diana  Clifford  Kimber,  Graduate  of 
Bellevue  Training  School ;  Assistant  Superintendent 
of  New  York  City  Training  School,  etc.  Pp.  268. 
New  York :     Macmillan  &  Co.     1894. 

The  author  informs  us  that  the  scheme  of  this  book  has 
been  practically  worked  out  in  class  teaching.  She  cor- 
rectly surmises  that  she  has.  devoted  too  much  space  to 
minute  structural  anatomy,  which  courses  be  defends  by 
her  experience  in   teaching.     She  claims  that  nurses 


59» 


MEDICAL   RECORD. 


[November  io,  1894 


thus  taught  would  be  led  step  by  step  to  a  correct  grasp 
of  the  subject,  and  would  thus  be  trained  to  think. 
We  apprehend,  however,  that  the  average  nurse  will 
fail  to  reach  the  author's  ideal.  Her  style  clearly  indi- 
cates that  she  has  well  measured  the  capacity  and  de- 
mands of  those  for  whom  it  is  intended.  The  mechanical 
execution  of  the  book  is  creditable  to  the  publishers. 

Transactions  of  the  Medical  Society  of  the  State 
3F  New  York  for  the  Year  1894.  Published  by 
the  Society.  1894. 
Among  the  most  interesting  of  the  contents  of  this  vol- 
ume of  transactions  are  the  discussions — abnormal  sur- 
gery, diphtheria,  and  menstruation.  There  are  also  a 
number  of  single  papers  that  are  well  worthy  of  preser- 
vation in  permanent  form. 


Clinical  §epnvttawxt. 

THE   USE  OF  ANTITOXIN  IN  DIPHTHERIA 
FOLLOWING  SCARLET  FEVER. 

By   W.    S.  GLEASON,   M.D., 

NBWBUKGir,   N.  Y, 

At  this  time,  when,  as  a  profession,  we  are  awaiting  with 
interest  the  effect  of  the  use  of  antitoxin  upon  the  human 
subject,  I  feel  that  the  following  results  should  not  go 
unrecorded : 

On  the  morning  of  October  5  th  I  was  called  to  see 
John ,  aged  eight,  a  robust  boy,  son  of  vigorous  pa- 
rents. I  found  upon  examination  well-marked  evidences 
of  scarlet  fever;  temperature,  1040  F. ;  pulse,  140;  upon 
my  evening  call,  temperature,  1050  F. ;  pulse,  144. 
The  temperature,  unless  reduced  by  antipyretics,  ranged 
between  1040  and  1050  F.,  with  but  slight  variation  be- 
tween the  morning  and  evening  observation. 

On  the  second  day  of  the  disease  a  fibrinous  exudate 
made  its  appearance  on  both  tonsils  and  pharynx,  with 
intense  tonsillar  enlargement,  and  in  spite  of  thorough 
pharyngeal  disinfection  there  was  great  difficulty  in 
swallowing.  Gradually  the  appearance  of  the  exudate 
changed  its  appearance,  and  upon  the  seventh  day  from 
the  time  of  my  first  call  I  felt  that  I  had  a  true  diphthe- 
ria engrafted  upon  the  scarlatina  angina.  Starr  brings 
out  the  fact  in  his  "  American  Text-book  of  Diseases  of 
Children.11  As  we  have  not  the  means  to  make  cultures 
in  our  city,  I  was  not  able  to  verify  the  presence  of  the 
Klebs  Loeffler  bacilli.  The  temperature,  if  unrestricted, 
remained  at  104$°  F. ;  pulse,  150;  glands  of  the  neck 
enlarged,  and  an  excoriating  nasal  discharge  was  present. 

At  three  o'clock  in  the  afternoon  of  October  12th  I 
made  my  first  injection  of  Aronson's  serum,  using  twenty 
minims,  followed  by  a  second  injection  of  forty  minims 
in  six  hours.  With  close  observation  I  could  not  appre- 
ciate the  least  reaction  as  an  immediate  result  of  the  in- 
jection. Twenty  four  hours  from  the  last  injection  the 
temperature  dropped  to  990  F.,  with  a  corresponding 
amelioration  of  the  symptoms.  There  was  an  evening 
rise  of  temperature  to  1030  F.,  but  from  that  time,  Octo- 
ber 1 2th,  to  this  date,  October  23d,  the  patient  has  stead- 
ily convalesced,  with  no  decided  fluctuation  of  pulse  or 
temperature.  I  combatted  the  scarlatinal  conditions 
with  carbolized  inunctions  to  the  body,  lime-water,  and 
peroxide  of  hydrogen  sprays  for  throat ;  and  a  judicious 
use  of  quinine  and  phenacetine  as  antipyretics.  The 
diphtheritic  manifestations  were  met  with  the  same  spray 
for  throat,  and  bichloride  irrigations,  1  to  1,000,  for  both 
throat  and  nares.  Internally,  full  doses  of  mecuric  bi- 
chloride. For  forty-eight  hours  preceding  the  use  of  the 
serum,  the  heart  flagged  and  required  careful  stimulation. 
The  fact  that  within  twenty-four  hours  after  the  use  of 
the  serum  such  a  remarkable  change  took  place  proved 
to  me  conclusively  that  the  absorption  of  septic  material 
ceased  at  once,  and  produced  a  reaction  not  found  in 
such  intense  conditions. 


EXTRA-UTERINE  PREGNANCY. 
By   WILLARD  McCHESNEY,  M.D., 

JANKSVIIXF,  WIS. 

In  the  following  case  of  extra-uterine  pregnancy  with 
retained  foetus,  no  reference  will  be  made  to  die  literature 
on  the  subject,  as  the  investigator  can  readily  refer  to  it. 
The  case  appended  presents  points  sufficiently  interesting 
to  merit  its  publication. 

Mrs.  Eugene  B ,  aged  forty-two,  a  resident  of 

Texas,  became  pregnant,  or  at  least  so  pronounced  by 
her  family  physician,  in  the  early  spring,  1889.  The 
usual  symptoms  present  in  such  cases  were  not  lacking, — 
there  was  cessation  of  menstruation,  nausea,  tenderness 
of  the  breasts,  enlargement  of  the  abdomen,  motion,  etc. 
The  husband,  from  whom  the  history  was  obtained,  did 
not  know  whether  foetal  heart  sounds  had  been  demon- 
strated.    Mrs.  B says  abdomen  continued  increasing 

in  size  until  she  had  passed  the  full  period  of  gestation. 
At  the  expiration  of  her  period  labor  did  not  come  on, 
and  for  two  months  following  there  was  a  period  of  com- 
plete quiescence.  At  the  commencement  of  the  eleventh 
month  she  had  pains,  quite  severe,  and  the  pains  were 
accompanied  by  a  discharge  from  the  genitals  of  a  sero- 
sanguinolent  character.  The  pain  and  discharge  con- 
tinued for  nearly  three  months  and  gradually  ceased. 
During  this  time  the  abdominal  enlargement  decreased 
in  size,  and  at  the  end  of  the  fourteenth  month  nothing 
remained  but  a  firm  tumor  occupying  the  right  iliac 
fossa.  At  about  this  time  menstruation  was  re-established 
and  the  patient  considered  herself  in  fair  health,  as  there 
was  no  inconvenience  from  the  tumor.  Shortly  after 
this  a  consultation  was  held  to  decide  whether  an  at- 
tempt should  be  made  to  remove  the  tumor  by  operation. 
The  husband  is  not  clear  as  to  the  conclusions  arrived  at 
at  this  time,  but  the  consulting  surgeon  advised  no  op- 
erative interference.  Mrs.  B— —  informed  me  that  the 
tumor  changed  in  size,  but  in  view  of  what  was  subse- 
quently determined,  thinks  she  was  in  error. 

From  dates  given  above  until  March,  1894,  the  health 
of  patient  was  very  good,  but  during  the  early  days  of 
March  she  was  taken  with  quite  a  severe  chill,  followed 
by  fever ;  in  a  few  days  she  had  chills  coming  on  irregu- 
larly, associated  with  fever,  diarrhoea,  and  quite  severe 
sweats.  There  was  also  some  muscular  pain  somewhat 
resembling  the  pain  of  muscular  rheumatism.  There 
was  a  rapid  waste  of  tissue  and  strength,  and  the  services 
of  a  rectal  specialist  were  called  into  requisition  for 
the  purpose  of  relieving  the  patient  of  a  very  bad  case  of 
haemorrhoids,  the  operation  to  be  done  without  the  use 
of  knife,  cautery,  or  ligature  (parenthetically,  we  have  no 
hesitation  in  saying  that  they  were  not  used).  Regardless 
of  the  rectal  operation,  emaciation  was  rapidly  progres- 
sive, diarrhoea  continued,  and  was  held  in  check  only 
slightly  by  opiates  administered  by  rectal  injections  and 
by  mouth,  and  a  northern  trip  was  advised,  trusting  that 
the  change  might  be  beneficial.  The  trip  north  was  un- 
eventful, and  the  patient  did  not  suffer  materially  from 
the  effects  of  her  journey.  Shortly  after  her  arrival, 
however,  she  became  considerably  prostrated,  and  Dr. 
Q.  O.  Sutherland,  of  Janesville,  who  was  called  in  to  see 
the  case,  diagnosed  it  as  one  of  extra-uterine  pregnancy, 
and  advised  immediate  removal  to  his  private  hospital, 
hoping  to  get  her  in  condition  to  undergo  an  operation. 
A  strong  effort  to  build  her  up  proved  of  no  avail,  and 
she  died  quite  suddenly  September  20th. 

Mr.  B kindly  permitted  an  autopsy,  which  was 

held  the  following  morning.  On  opening  the  abdomen 
the  bowels  were  found  to  be  singularly  free  from  adhe- 
sions, and  it  was  at  once  seen  that  the  right  Fallopian 
tube  was  the  seat  of  the  difficulty.  On  its  posterior  sur- 
face the  tube  was  adherent  throughout  to  the  pelvic  peri- 
toneum and  the  bowel ;  the  anterior  surface  was  free  from 
adhesions.  On  opening  into  the  tube  we  found  the 
badly  decomposed  remains  of  a  foetus,  showing  a  growth  of 
about  seven  months.  After  thoroughly  cleansing  the  foul- 
smelling  cavity,  it  was  found  that  a  free  opening  existed 


November  10,  1894] 


MEDICAL    RECORD. 


599 


between  the  foetal  sac  and  bowel,  and  that  the  tissues  in 
the  vicinity  of  the  bowel  were  necrotic.  It  was  evident 
that  an  operation,  to  be  successful,  should  have  been  per- 
formed several  months  previously. 

In  reviewing  the  case  several  points  present  themselves 
for  our  consideration.  The  principal  one  to  consider  is, 
naturally,  the  one  which  questions  the  ability  to  have 
made  an  early  diagnosis.  In  looking  over  the  case  as  it 
presented  itself  at  the  hospital,  and  reviewing  its  history, 
it  seems  hardly  possible  to  have  erred  in  making  a  diag- 
nosis. 

1.  We  have  a  clear  history  of  pregnancy  in  so  far  as 
that  fact  could  be  determined,  and  it  might  have  been 
possible  to  have  detected  the  foetal  heart- sound,  a  posi- 
tive sign. 

2.  Pains  occurring  at  the  eleventh  month,  with  a  dis- 
charge, decrease  in  size  of  the  abdomen,  and  a  firm  tumor 
left. 

3.  The  very  evident  signs  of  septic  infection  which 
first  appeared  about  March  1st,  with  the  previous  history, 
should  have  been  a  prominent  factor  in  establishing  the 
diagnosis  of  extra-uterine  pregnancy  and  decomposition 
of  foetal  remains. 

In  conclusion,  the  chances  were  strongly  in  favor  of 
recovery  had  a  diagnosis  been  made  sufficiently  early  to 
allow  an  operation,  either  by  laparotomy,  or,  as  suggested 
by  Dr.  Sutherland,  opening  directly  into  the  sac  from  the 
vaginal  vault,  and  if  cavity  was  septic,  treating  it  as  an 
ordinary  abscess  cavity. 

LEAD -POISONING    AND    THE    MORPHINE 
HABIT-REPORT  OF   A   CASE. 

By  R.  ABRAHAMS,  M.D., 

VISITING  PHYSICIAN  TO  MOUNT  SINAI  HOSPITAL,  OUTDOOR  DEPARTMENT. 

Besides  the  unusual  mode  of  acquiring  the  morphine 
habit,  and  the  strange  association  with  it,  that  of  pro- 
found lead-intoxication,  the  history  of  the  case  that  I  am 
to  report  contains  an  additional  item  which  may  well 
interest  the  physician,  his  inevitable  ally,  the  druggist, 
and  possibly  the  public,  if  it  reached  their  ear. 

I  presume  it  is  the  experience  of  almost  every  practi- 
tioner to  find,  at  one  time  or  another,  his  prescriptions 
repeatedly  renewed  without  his  advice  or  consent,  writ- 
ten or  oral — whether  the  prescription  orders  morphine  or 
rhubarb,  cautious  use  or  ordinary  care.  My  object,  how- 
ever, is  not  to  discuss  the  abnormal  relation  between  the 
physician  and  apothecary  that  such  a  practice  involves, 
but  rather  to  point  out  the  serious  trouble  that  it  may 
lead  to,  and  there  is  not  a  better  illustrative  case  than 
the  following  one. 

Mrs.  K ,  aged  forty,  mother  of  ten  children,  the 

last  one  still-born,  has  been  in  poor  health  for  the  last 
few  years ;  pale,  emaciated,  and  complaining  of  neuralgic 
pains  at  different  points  of  the  body ;  appetite  very  poor ; 
never  felt  hungry  for  meals;  bowels  moved  very  irregu- 
larly, and  colicky  pains  in  the  abdomen  were  of  frequent 
occurrence.  On  a  Friday  in  the  month  of  July,  the  day 
being  moderately  warm,  she  was  suddenly  seized  with 
severe  cramps  in  the  abdomen  and  the  legs,  incessant 
vomiting  and  diarrhoea.  Physicians  were  hastily  sum- 
moned, a  diagnosis  of  cholera  morbus  agreed  upon,  and 
treatment  accordingly  instituted.  The  next  morning,  as 
there  was  no  improvement  in  the  patient's  condition,  I 
was  asked  to  see  her,  and  the  following  is  what  I  found : 
Vomiting  and  diarrhoea  every  half-hour ;  both  dejecta 
were  copious,  one  green,  and  the  other  blackish  and  mal- 
odorous ;  the  extremities  cold ;  the  face  extremely  pale, 
pinched,  drawn  in,  and  covered  with  a  cold,  clammy 
perspiration.  The  abdomen  was  hard  and  retracted, 
very  tender  around  the  umbilicus.  The  tongue  was 
thickly  coated  and  moist ;  the  breath  peculiarly  offen- 
sive. The  pulse,  much  to  my  surprise,  was  full  and  regu- 
lar, and  the  rectal  temperature  a  small  fraction  above 
the  normal.  The  patient  continually  moved  her  hand 
toward  the  abdomen.     Now,  this  condition  of  apparent 


collapse,  with  a  good  pulse  and  a  normal  temperature, 
were,  in  my  mind,  hardly  compatible  with  an  attack  of 
cholera  morbus.  The  clinical  picture  rather  suggested 
some  form  of  profound  intoxication,  which  I  at  once  set 
about  to  find  out.  On  a  second  examination  of  the  pa- 
tient I  discovered,  much  to  my  satisfaction,  a  blue  line 
along  the  gums. 

This  was  a  key  that  unlocked  the  mystery,  and  although 
the  source  of  the  lead  supply  was  unknown,  the  diagno- 
sis, however,  was  tolerably  certain.  Later  in  the  day, 
the  patient's  husband  volunteered  the  following  informa- 
tion :  Eight  years  ago  his  wife  was  troubled  with  haemor- 
rhoids, for  which  the  physician  in  attendance  prescribed 
"  something."  His  wife  got  well,  but  the  curative  agent 
pleased  her  so  much  that  she  continued  to  take  it  to  that 
day.  He  was  totally  ignorant  of  the  contents  of  the 
"  box,"  but  he  was  positive  that  a  failure  to  supply  her 
with  it  rendered  her  unspeakably  wretched.  By  and  by, 
exercising  her  womanly  prudence,  she  laid  aside  a  good 
stock  of  her  favorite  drug  for  a  rainy  day,  as  it  were. 
She  never  experienced  any  difficulty  in  obtaining  it,  for 
she  had  a  copy  of  her  original  prescription  in  about  half 
a  dozen  shops,  where  she  could  get  it  on  the  presenta- 
tion of  the  old  label.  In  the  course  of  time  she  became 
subject  to  frequent  attacks  of  colic,  which,  however, 
always  yielded  to  an  extra  dose  of  her  medicine. 

While  narrating  this  unvarnished  tale,  he  called  my 
attention  to  a  supply  of  "  pain-killers  "  under  her  pillow, 
to  which  she  liberally  helped  herself  during  the  present 
illness,  but  with  very  little  benefit.  Now,  this  favorite 
panacea  was  in  the  shape  of  a  suppository,  which,  on  in- 
quiry, I  found  to  contain  a  third  of  a  grain  of  morphine 
and  one- half  a  grain  of  acetate  of  lead.  This  piece  of 
etiological  enlightenment  left  no  doubt  as  to  the  real  nat- 
ure of  her  condition.  It  is  hard  to  estimate  the  quan- 
tity of  lead  the  patient  consumed  during  the  eight  years ; 
for,  at  times,  she  told  me  her  colic  was  so  acute  and  the 
desire  for  relief  so  intense  that  she  filled  her  rectum 
with  suppositories  to  its  utmost  capacity,  while  in  the  ab- 
sence of  pain  she  took  the  suppositories  simply  to  supply 
her  craving  for  the  alkaloid,  as  the  habit  was  perfectly 
established.  Thus  one  drug  spurred  her  on  to  take  the 
other.  The  poor  victim  knew  that  she  could  not  be 
without  the  suppository ;  yet  her  ignorance  of  its  compo- 
sition was  only  exceeded  by  her  passion  for  it. 

The  moral  and  interest  of  this  peculiar  case  will  be 
enhanced  by  one  more,  rather  amusing,  feature  of  it  My 
patient  was  regarded  by  many  a  neighboring  woman  with 
pious  admiration.  Many  a  pain  she  relieved,  and  for  all 
I  know,  many  a  woman,  through  her  agency,  is  now 
suffering  from  the  effects  of  lead-poisoning  and  the  mor- 
phine habit.  ♦ 

From  a  pathological  standpoint,  this  case  strikes  me 
as  being  a  unique  one,  for,  excepting  the  anaemia,  the 
emaciation,  the  colic,  the  alternate  constipation  and 
diarrhoea,  the  neuralgic  pains,  and  the  "  lead  line," 
while  sufficient  to  establish  a  diagnosis  of  lead-poisoning, 
none  however  of  the  great  and  marked  nervous  symptoms 
were  present.  In  a  case  of  such  long  standing,  one  would 
naturally  expect  to  see  some  form  of  paralysis.  Although 
the  arterial  system  showed  commencing  atheroma  and 
the  urine  contained  slight  evidences  of  renal  disturb- 
ance, yet  the  nervous  system  showed  nothing  to  indicate 
any  lesion  whatever. 

Whatever  form  of  plumbism  this  case  may  be  regarded, 
its  chief  interest,  perhaps,  lies  in  its  combined  features, 
and  their  mode  of  acquirement. 

158  Clinton  Street,  New  York  City. 


Bogus  Degrees  in  England.— The  trade  in  degrees 
from  non-existent  American  universities  has  recently  re- 
vived in  England.  These  degrees  give  no  rights,  but 
their  purchasers  have  the  satisfaction  of  adding  a  few 
more  letters  after  their  names.  The  price  charged  for 
an  M.D.  or  LL.D.  is  ^30,  and  for  any  other  degree 
wished  for,  ^25. 


6oo 


MEDICAL    RECORD. 


[November  10,  1894 


NEW  YORK  ACADEMY  OF  MEDICINE. 

SECTION  ON   OBSTETRICS  AND   GYNECOLOGY. 

Stated  Meeting,  October  2j,  1894. 

Malcolm  McLean,  M.D.,  Chairman. 

Tubal  Pregnancy — Rupture,  Operation,  Death. — Dr. 
Charles  E.  Nammack  presented  a  specimen  of  tubal 
pregnancy  in  which  rupture  had  taken  place  about  the 
forty  third  day;  slight  symptoms  of  collapse,  pain,  and 
hemorrhage  manifested  themselves ;  he  advised  an  opera- 
tion. Three  consulting  surgeons  objected,  believing  that 
the  hemorrhage  was  limited  by  the  folds*  of  the  broad 
ligament,  but  the  next  morning  the  patient  went  into 
collapse  from  recurrence  of  concealed  hemorrhage,  and 
then  no  difference  of  opinion  existed  with  regard  to  the 
propriety  of  operating.  It  was  too  late,  however,  for 
the  patient  did  not  fully  rally,  and  died  fifty-two  hours 
after  removal  of  the  blood- clots  and  ovum  per  laparot- 
omy. Dr.  Nammack  said  his  object  in  presenting  the 
specimen  was  to  impress  the  danger  of  letting  extra- tubal 
pregnancy  continue,  especially  after  the  first  signs  of 
rupture,  on  the  supposition  that  the  pregnancy  was  ex- 
tra-peritoneal and  that  the  hemorrhage  would  be  limited. 
In  the  many  cases  operated  upon  by  Dr.  Joseph  Price  not 
one  had  been  encountered  in  which  the  pregnancy  was 
extra-peritoneal.  Yet  it  was  the  custom  of  general  prac- 
titioners, he  believed,  to  rely  upon  their  ability  to  say 
whether  the  hemorrhage  was  extra  peritoneal  or  intra- 
peritoneal ;  if  the  former,  to  wait,  and  in  waiting  take 
the  great  risks  of  recurrent  hemorrhage,  peritonitis,  sep- 
ticaemia, and  subsequent  trouble  from  a  damaged  tube. 

Dr.  Boldt  named  one  justification  for  temporarily 
postponing  the  operation,  namely,  shock  attending  the 
rupture. 

Dr.  J.  R.  Goffe  thought  Dr.  Nammack  need  not  go 
outside  of  New  York  to  get  confirmation  of  the  view  that 
a  prompt  operation  was  demanded  in  cases  of  ectopic 
gestation.  The  most  prominent  gynecologists  in  this 
city  had  advocated  and  practised  prompt  interference 
for  years,  among  them  being  Dr.  Janvrin,  who  had  taken 
this  position  as  many  as  ten  years  ago. 

Point  of  Origin  of  an  Ovarian  Tumor.— Dr.  J.  R. 
Goffe  presented  the  sac  of  an  ovarian  cyst,  on  one  side  of 
which,  for  a  distance  of  eight  or  nine  inches,  the  fimbri- 
ated extremity  of  the  Fallopian  tube  could  be  seen  spread 
out  like  a  veil.  Evidently  the  small  cyst  which  was  the 
commencement  of  the  tumor  had  lain  directly  under  the 
fimbriated  'extremity  of  the  tube.  Part  of  the  other 
ovary  had  also  undergone  cystic  degeneration;  two- 
thirds  of  it  were  removed ;  the  edges  were  turned  in  so 
that  no  raw  surface  would  be  exposed  to  form  adhesions. 
The  patient  was  doing  well. 

Sarcomatous  Degeneration  of  Uterine  Fibroids. — Dr. 
Goffe  also  presented  a  uterus  with  multiple  sub-perito- 
neal fibroids  and  sarcoma.  This  and  two  other  cases 
seen  by  him  recently  showed  the  importance  of  operat- 
ing early  for  uterine  fibroids  causing  symptoms  if  one 
would  spare  the  patient  malignant  disease. 

The  Chairman,  Dr.  McLean,  said  he  had  removed  an 
ovarian  tumor  weighing  over  forty  pounds,  three  or  tour 
years  ago,  and  finding  the  fimbriated  extremity  of  the 
tube  spread  largely  over  it,  he  dissected  it  off  and 
dropped  it  back  with  the  rest  of  the  tube.  Two  years 
later  he  had  occasion  to  reopen  the  abdomen  of  this  pa- 
tient for  another  disease,  and  it  was  interesting  to  note 
that  the  tube  was  healthy  and  had  diminished  to  its  nor- 
mal size. 

Hew  Pelvimeter. — Dr.  Herman  L.  Collver  pre- 
sented a  new  pelvimeter,  the  blades  of  which  could  be 
taken  apart  and  placed  parallel  with  each  other  when 
not  in  use ;  which  registered  in  both  the  English  and 
metric  systems ;  which  would  give  pelvic  diameters  up 


to  fourteen  inches,  and  which  cost  but  two  dollars,  or  a 
third  to  a  fifth  as  much  as  any  other  instrument  in  the 
market.  Cheapness  was  extremely  important  in  an  in- 
strument which  every  general  practitioner  should  keep, 
and  yet  one  which  he  was  not  likely  to  use  more  than  a 
few  times  during  a  life  practice. 

Dr.  Marx  mentioned  a  case  in  which  the  calipers  pre- 
sented by  Dr.  Collyer  measured  the  external  diameters  of 
a  very  large  pelvis,  which  others  at  his  command  had 
failed  to  do. 

Postal  Abnormality. — Dr.  E.  A.  Tucker  exhibited 
photographs  of  a  child  with  a  left  foot  and  leg  connected 
apparently  by  osseous  as  well  as  fleshy  union  with  the 
upper  dorsal  spine.  The  foot  was  perfectly  formed,  and 
one  could  make  out  what  seemed  to  be  leg,  knee,  and 
thigh.     It  was  sensitive  to  touch. 

The  mother,  Irish,  twenty  eight  years  old,  addicted  to 
drink,  mother  of  three  other  children  which  were  born 
normally,  was  brought  to  the  hospital  for  pain  in  the  left 
side  caused  by  a  kick  from  her  husband.  The  os  was 
somewhat  dilated,  but  real  labor  did  not  come  on  until 
six  days  later.  The  woman  was  very  positive  that  the  ab- 
normality was  due  to  the  kick  by  the  husband's  left  foot, 
and  was  in  the  nature  of  a  punishment  for  the  act.  Of 
course,  Dr.  Tucker  said  this  notion  was  absurd,  since  such 
a  growth  must  have  started  long  before  six  days  prior  to 
full  term,  and  doubtless  had  its  origin  in  a  blasted  ovule 
which  became  attached  to  this  foetus. 

When  during  the  labor  Dr.  Tucker  felt  the  foot  be- 
tween the  shoulders,  he  remarked  to  those  present  that 
there  probably  would  be  dislocation  of  the  leg,  and  was 
much  surprised  later  when  two  other  feet  dropped  out. 
Had  the  case  been  a  breech  presentation,  this  foot 
might  have  caught  and  caused  trouble ;  or  if  a  shoulder 
had  presented  first,  there  would  have  been  great  difficulty 
in  making  full  diagnosis. 

When  the  waters  broke,  a  small,  irregular,  soft,  whit- 
ish mass  came  away,  which  Dr.  Tucker  thought  at  first 
was  vernix,  but  on  section  was  found  to  contain  two  cysts, 
and  was  composed  of  cells,  but  the  exact  nature  of  the 
structure  was  a  mystery  to  Dr.  Prudden,  Dr.  Freeborn, 
and  others  who  had  examined  it.  There  was  a  small, 
scar-like  protuberance  on  the  heel  of  the  third  foot,  and 
the  mass  was  believed  to  have  been  attached  there. 

Extirpation  of  the  Uterus  and  Adnexa  in  Pelvic  Sup- 
puration and  Post-Puerperal  Septicemia. — Dr.  H.  J. 
Boldt  read  a  paper  with  this  title.  Pelvic  suppuration 
might  leave  multiple  abscesses,  it  might  leave  double  pyo- 
salpinx,  it  might  leave  a  mass  of  inflammatory  material 
enclosing  pus — a  variety  of  conditions  in  which  success- 
ful treatment  often  involved  operative  interference  of 
grave  nature.  In  quite  a  considerable  percentage  of  the 
cases  in  which  the  uterine  appendages  had  been  removed 
trouble  had  still  persisted,  due  to  the  fact  that  the  uterus, 
the  origin  of  the  primary,  or  seat  of  the  secondary, 
trouble,  had  been  allowed  to  remain.  The  author  was 
led  to  ask  the  question,  is  the  uterus  of  utility  to  a  person 
with  bilateral  disease  of  the  tubes  and  ovaries  to  such 
degree  that  they  have  to  be  removed  ?  The  answer,  he 
said,  must  be  in  the  negative.  Some  operators  who  en- 
tertained this  view  made  it  the  excuse  for  always  remov- 
ing the  uterus  when  they  opened  the  abdomen  and  found 
double  tubo-ovarian  disease.  But  Dr.  Boldt  had  op- 
posed such  a  course  for  the  reason  that  often  disease  in 
the  uterus  could  be  corrected,  that  abdominal  hysterec- 
tomy complicated  removal  of  the  appendages,  and  that 
if  it  should  finally  prove  necessary  to  remove  the  uterus, 
it  could  be  more  safely  done  through  the  vagina,  and 
would  be  unattended  by  risk  of  hernia,  which  was  con- 
siderable in  all  abdominal  operations.  In  comparing 
vaginal  with  supra-vaginal  hysterectomy,  the  author 
claimed  that  the  former  was  not  attended  by  greater  risk 
of  subsequent  intestinal  obstruction,  that  there  was 
greater  traumatism  and  consequent  shock  from  handling 
the  intestines  in  the  abdominal  method,  also  much 
greater  liability  to  spread  infection,  and,  as  said  before, 
liability  to  ventral  hernia  in  spite  of  all  precautions. 


November  10,  1894] 


MEDICAL  RECORD. 


601 


The  author,  being  an  advocate  of  conservative  surgery, 
advised  the  abdominal  route  wherever  there  was  a  possi- 
bility of  being  able  to  save  the  whole  or  a  part  of  an 
ovary.  But  where  it  was  possible  to  make  a  positive 
diagaosis,  which  called  for  removal  of  the  uterus  as  well 
as  of  the  adnexa,  he  advocated  the  vaginal  method,  and 
claimed  that  by  it  one  could  reach  the  uterus,  the  ap 
pendages,  and  other  diseased  structures.  An  important 
advantage  of  the  vaginal  route  was  that  it  gave  natural 
drainage  (by  gravity),  and  also  that  it  enabled  the  pa- 
tient to  return  home  in  a  much  shorter  time.  In  sup* 
purative  cases  clamps  had  usually  to  be  employed  instead 
of  sutures,  but  they  could  be  removed  in  twenty-four 
hours,  and  during  that  time  favored  drainage. 

Regarding  the  mortality  of  the  vaginal  operation,  Dr. 
Boldt  had  lost  one  patient  (almost  a  hopeless  case  to  be- 
gin with)  out  of  seven  operated  upon ;  542  in  literature 
gave  a  mortality  of  4  32  per  cent.,  at  least  295  of  them 
having  been  suppurative.  He  had  serious  doubts  whether 
one  could  collect  500  cases  of  abdominal  hysterectomy 
with  a  smaller  mortality  than  seven  per  cent. 

In  acute  general  puerperal  septicemia  he  had  washed 
oat  the  abdomen  in  four  cases,  and  they  died,  had  re- 
moved the  uterus  in  four,  and  they,  too,  had  died,  yet  he 
regarded  it  as  more  logical  to  hope  for  a  favorable  ter- 
mination from  vaginal  hysterectomy  and  removal  of  the 
tubes  than  from  removal  of  the  tubes  alone  where  the 
uterus  was  the  original  site  of  infection. 

Dr.  Von  Ramdohr  thought  that  in  cases  of  multiple 
pelvic  abscess  in  which  it  had  been  determined  to  remove 
the  uterus,  the  abdominal  route  should  be  selected,  since 
some  of  the  foci  of  infection  might  escape  notice  through 
the  vagina.  In  puerperal  cases,  also,  it  was  necessary  to 
open  the  abdomen  in  order  to  find  all  collections  of  pus. 

Dr.  Grandin  said  that  if  the  paper  was  intended  as  a 
plea  for  removal  of  septic  appendages,  he  agreed  with  the 
writer;  but  if  it  was  intended  as  a  plea  for  removal  of 
such  appendages  through  the  vagina  rather  than  through 
the  abdomen,  he  disagreed  with  him.  He  believed  in 
seeing  as  well  as  feeling  what  one  was  about,  and  it  was 
for  this  reason  that  he  was  opposed  to  returning  to  the 
old  method  of  treating  these  cases  through  the  vagina, 
even  with  the  addition  of  removing  the  uterus.  Extirpa- 
tion of  the  cancerous  uterus  through  the  vagina  might  be 
simple  in  the  hands  of  an  expert,  but  vaginal  hysterec- 
tomy in  disease  of  the  appendages,  with  all  the  possible 
complications,  such  as  adhesion  to  the  vermiform  appen- 
dix, etc.,  might  be  anything  but  simple.  The  danger 
of  hernia  in  abdominal  operations  was  greatest  where  up- 
drainage  was  practised,  but  such  drainage  had  been  aban- 
doned in  favor  of  passing  gauze  down  through  the  vagina. 

In  acute  general  puerperal  peritonitis  he  had  not 
found  the  infection  limited  to  the  uterus,  and  conse- 
quently it  would  not  have  been  sufficient  only  to  remove 
that  organ  either  by  the  vaginal  or  abdominal  method. 
There  were  multiple  abscesses  scattered  throughout  the 
abdomen,  and  it  was  by  opening  these,  washing  out,  and 
draining  under  the  liver,  under  the  spleen — in  other 
words,  resorting  to  multiple  drainage  and  cleansing,  that 
a  Western  physician  had  succeeded  in  saving  one  patient. 

Dr.  Goffe  had  had  under  observation  six  or  seven 
cases  operated  upon  by  the  method  advocated  by  Dr. 
Boldt — the  Belgian  method — and  the  impression  which 
he  had  received  was  that  it  was  a  very  blind,  a  very 
bloody,  and  unattractive  procedure.  The  abdominal 
operation  was  clearer ;  it  enabled  one  to  see  what  he  was 
doing  and  should  do,  and  left  the  way  open  for  either 
conservative  or  radical  operation,  according  to  the  more 
exact  diagnosis  made  possible  by  touch  and  sight. 

Dr.  W.  E.  Porter  could  not  agree  with  the  author, 
particularly  in  septic  disease  of  the  appendages,  believing 
that,  in  the  very  cases  in  which  the  vaginal  method  had 
been  advocated,  there  were  the  strongest  contraindications 
to  its  employment.  In  tubal  disease  it  was  impossible, 
owing  to  the  frequency  of  extensive  adhesions  and  com- 
plications, to  make  an  exact  diagnosis  and  operate  with 
safety  without  abdominal  section.    In  puerperal  cases 


the  simplest  operation,  one  least  attended  by  shock, 
would  give  the  best  results. 

Dr.  Robert  H.  Wylix  found  it  difficult  to  discuss  the 
paper  because,  he  said,  it  dealt  with  so  many  other  sub- 
jects than  those  indicated  in  the  title.  So  far  as  the 
mortality  rate  was  concerned  in  the  list  of  cases  of 
vaginal  hysterectomy  given  by  Dr.  Boldt,  the  result  had 
been  excellent,  but  it  was  not  yet  possible  to  speak  posi- 
tively of  the  remote  results,  particularly  of  the  occur- 
rence of  hernia.  It  was  a  long  time  before  we  learned 
of  the  frequency  of  ventral  hernia  following  laparotomy, 
for  operators  were  too  much  concerned  with  other  points 
to  pay  much  heed  to  this  accident.  Might  it  not  be  so 
with  regard  to  hernia  into  the  vagina  following  vaginal 
hysterectomy?  In  puerperal  septicaemia  he  could  not 
see  how  the  author  could  distinguish  between  cases  in 
which  the  infection  was  limited  to  the  uterus,  and  justi- 
fied removal  of  that  organ  through  the  vagina  and  cases 
in  which  it  had  passed  to  the  peritoneum,  which  it 
might  do  directly  instead  of  through  the  tubes.  He 
would,  therefore,  open  the  abdomen  and  then  decide 
what  should  be  done. 

Dr.  Boldt  made  some  closing  remarks.  He  thought 
it  strange  the  gentlemen  should  advocate  the  abdominal 
operation  when  the  vaginal  had  given  so  much  better 
results,  that  is,  in  the  cases  in  which  alone  he  had  ad- 
vocated it. 

MEDICAL  SOCIETY  OF  THE  COUNTY  OF  NEW 
YORK. 

Annual  Meeting,  October  22,  i8p4. 

Seneca  D.  Powell,  M.D.,  President,  in  the  Chair. 

Officers. — Many  of  the  candidates  having  withdrawn, 
there  remained  but  two  for  president,  two  for  first  vice- 
president,  eight  for  censors  (five  to  be  elected),  and  but 
one  candidate  for  the  other  offices.  Dr.  Egbert  H. 
Grandin  was  elected  President;  Dr  Richard  Van  Sant- 
voord,  First  Vice-President ;  Dr.  S.  Henry  Dessau,  Sec- 
and  Vice-President;  Dr.  Charles' H.  Avery,  Secretary; 
Dr.  William  E.  Bullard,  Assistant  Secretary ;  Dr.  John 
S.  Warren,  Treasurer;  Drs.  Seneca  D.  Powell,  Charles 
L.  Gibson,  George  T.  Jackson,  Edward  D.  Fisher,  and 
Charles  H.  Knight,  Censors. 

Report  of  the  Treasurer. — Dr.  Warren  read  his  re- 
port as  treasurer,  and  it  was  found  correct  by  the  auditing 
committee.  The  receipts  for  the  year  had  been  $4,152 ; 
adding  balance  from  last  year  and  subtracting  disburse- 
ments for  this  year,  which  amounted  to  $4,441,  left  a  bal- 
ance of  $2,392. 

Report  of  Committee  on  Hygiene.— Dr.  W.  A.  Ew- 
ing,  chairman  of  the  committee,  read  the  report  They 
had  found  that  some  of  the  dispensaries  had  acted  on 
their  advice  and  separated  children  with  contagious  dis- 
eases immediately  on  entering  the  dispensary,  not  allow- 
ing them  to  mix  with  others  in  the  general  waiting- 
room.  Some  of  the  larger  dispensaries,  however,  had 
not  yet  adopted  this  most  important  regulation  for  the 
prevention  of  spread  of  disease. 

The  work  of  the  Board  of  Health  with  regard  to  vac- 
cination and  report  of  contagious  diseases  among  school 
children,  and  the  management  of  diphtheria,  was  com- 
mended. Some  of  the  dangers  of  spreading  tuberculosis 
were  mentioned,  and  it  was  suggested  that  in  the  lower 
tenements  it  would  be  much  safer  to  do  away  with  car- 
pets than  to  leave  them  on  the  floor  as  dirty  as  they 
commonly  were. 

The  Communion  Cup,  the  Court  Bible,  and  Syphilis. — 
The  committee  was  pleased  to  report  that  some  churches 
were  dispensing  with  the  single  communion  cup  and 
were  using  one  for  each  communicant,  thereby  avoiding 
one  way  of  spreading  syphilis.  In  this  connection  at- 
tention was  also  called  to  the  danger  of  communicating 
syphilis  by  kissing  the  court  Bible,  and  it  was  suggested 
that  if  this  custom  were  continued  the  book  ought  to  be 
covered  with  a  thick  layer  of  iodoform  gauze. 


602 


MEDICAL   RECORD. 


[November  10,  1894 


The  Disposal  of  Garbage.— The  habit  of  the  authori- 
ties of  allowing  ash  cans  to  stand  until  overflowing,  and 
then  of  filling  carts  beyond  their  capacity  and  scattering 
the  ashes  and  garbage  in  the  streets,  was  condemned, 
and  the  recommendation  was  made  to  burn  the  garbage. 

Beport  of  Committee  on  Ethics.— Dr.  W.  M.  Polk, 
chairman  of  the  committee,  made  a  verbal  report,  stating 
that  few  complaints  had  been  brought  before  the  com- 
mittee and  these  had  been  settled  by  the  delinquents 
making  prompt  amends.  Regarding  complaints  against 
members  for  using  the  daily  press  in  some  foim  for  ad- 
vertising, the  committee  suggested  that  they  be  brought 
before  the  Society  itself,  with  the  hope  that  the  greater 
publicity  given  the  matter  might  have  some  restraining 
influence  on  delinquents  of  this  character. 

Dr.  Joseph  D.  Bryant,  chairman  of  the  Committee 
on  Prize  Essays,  stated  that  no  essay  had  been  received. 

On  Symphyseotomy,  with  Beport  of  a  Hew  Case. — 
Dr.  H.  J.  Garrigues  read  the  paper.    (See  p.  577.) 

Dr.  Egbert  H.  Grandin  was  requested  to  open  the 
discussion.  Prior  to  the  rejuvenation  of  s)mphyse- 
otomy  in  1890  he  was  exceedingly  sceptical.  But  per- 
sonal experience  with  it  in  two  cases  in  which  he  had 
operated,  and  in  three  others  in  which  he  had  assisted, 
had  since  proven  to  him  that  it  was  a  distinct  advance 
in  the  obstetric  art.  He  did  not  believe  the  profession 
yet  fully  realized  what  symphysetomy  meant.  It  meant 
that  we  were  no  longer  called  upon  to  take  life  in  order 
to  save  life ;  to  sacrifice  the  child  by  embryotomy  in 
order  to  save  the  mother. 

Too  few  operations  had  been  done  in  this  country  to 
enable  anyone  to  speak  dogmatically  upon  the  position 
which  symphyseotomy  was  destined  to  take,  for  we  must 
judge  by  what  can  be  accomplished  in  America,  not  by 
what  has  been  done  in  Europe.  He  believed,  however, 
that  the  time  was  approaching  when  the  general  practi- 
tioner would  have  a  practical  knowledge  of  pelvimetry 
and  of  aseptic  surgery,  and  that  then  many  children 
would  be  saved  by  elective  symphyseotomy.  If  the  op- 
eration were  done  aseptically,  before  the  woman  and 
child  had  become  exhausted,  there  should  be  no  mortality 
for  the  mother,  and  he  thought  also  none  for  the  child. 

Dr.  H.  C.  Cos  had  peformed  symphyseotomy  three 
times,  twice  within  the  past  six  weeks,  but  did  not  feel  quite 
so  enthusiastic  about  it  as  the  last  speaker.  Further  expe- 
rience was  necessary  to  enable  one  to  pass  an  intelligent 
or  final  opinion  upon  it  He  had  noticed  a  good  deal 
of  difficulty  in  extracting  the  head,  and  there  had  not 
been  as  much  gain  in  the  pelvic  diameters  as  he  had 
hoped  there  would  be.  With  the  conjugate  under  three 
inches  he  would  perform  Caesarean  section,  but  where  it 
was  between  three  inches  and  three  and  a  half  he  thought 
symphyseotomy  should  be  resorted  to,  provided  the  case 
were  seen  at  the  beginning  of  labor.  All  of  his  patients 
were  seen  early,  pelvic  contraction  was  recognized,  every- 
thing was  favorable,  but  such  conditions  were  not  likely 
to  be  present  in  cases  seen  in  private  practice.  He  had 
not  yet  made  up  his  mind  as  to  the  best  method  of  ex- 
tracting the  child.  The  cervix  not  having  been  fully 
dilated  there  was  considerable  delay  of  the  head,  and 
one  child  suffocated.  It  would  seem,  therefore,  that  the 
forceps  might  be  indicated  quite  as  often  as  version. 
Like  Dr.  Grandin,  he  expressed  preference  for  the  blunt- 
pointed  bis t out  y  over  the  Galviani  knife.  He  did  not 
believe  in  working  in  the  dark,  but  would  expose  the 
full  front  of  the  symphysis  and  see  what  he  was  doing. 
The  operation  in  this  country  was  still  subjudict. 

Dr.  Charles  Jewett  agreed  with  the  author's  con- 
clusions on  most  points.  Symphyseotomy,  compared 
with  Caesarean  section,  labored  under  two  disadvantages. 
The  first  was  the  difficulty  of  determining  the  size  of  the 
child's  head  and  mother's  pelvis,  which  it  was  not  nec- 
essary to  know  in  Caesarean  section ;  the  second,  related  to 
the  first,  was  the  fact  that  if  the  pelvis  were  overestimated 
the  operation  would  probably  prove  a  failure.  There 
was  greater  difficulty,  too,  in  the  after  care  of  a  case  of 
symphyseotomy  than  of  Caesarean  section.     In  the  for- 


mer the  bones  had  to  be  kept  in  apposition  and  the 
wound  free  from  contamination  with  urine.  He  agreed 
with  other  speakers,  that  the  operation  was  too  recent  in 
this  country  to  justify  sweeping  statements.  One  who 
placed  the  lower  limit  of  the  conjugate  diameter  at  three 
inches  would  probably  find  symphyseotomy  a  safe  open- 
tion. 

Dr.  R.  A.  Murray  thought  symphyseotomy  could  be 
done  safely  in  private  houses  as  well  as  in  hospitals,  but 
we  could  not  hope  for  the  results  which  had  been  ob- 
tained abroad  until,  like  there,  it  came  to  be  performed 
by  those  who  had  had  previous  experience.  He  called 
attention  to  the  increase  in  the  oblique  and  transverse 
diameters  as  well  as  in  the  conjugate,  which  rendered  the 
operation  especially  suitable  for  the  generally  contracted 
pelvis,  which  was  the  deformity  oftenest  found  in  this 
country.  He  also  referred  to  the  larger  size  of  the  newly 
born  in  this  country,  the  average  weight  at  the  City  Ma- 
ternity Hospital  being  about  seven  pounds  and  a  half,  as 
against  about  six  pounds  in  Italy.  Of  course  the  larger 
the  child  the  larger  must  be  the  pelvis  to  justify  symphyse- 
otomy instead  of  Caesarean  section.  Do  not  try  to  de- 
termine the  size  of  the  pelvis  by  one  or  two  fingers ;  in- 
troduce the  whole  hand. 

Dr.  Garrigues  made  some  closing  remarks.  Sym- 
physeotomy had  been  recommended  where  the  conjugate 
was  only  two  inches  and  a  fourth,  but  he  thought  three 
inches  a  safe  lower  limit  in  this  country,  and  three  and  a 
half  sufficiently  high,  for  above  that  one  should  be  able 
to  extract  by  version  or  with  forceps. 


APEX  CATARRH  OR  TUBERCULOSIS. 

To  ?m  Editor  of  tks  Medical  Rbcoxd. 

Sir  :  In  reply  to  the  very  kindly  criticism  of  Dr.  H.  B. 
Moore,  of  Colorado  Springs,  concerning  an  article  by 
myself  in  the  issue  of  September  2  2d,  allow  me  to  call 
his  attention  to  an  article  on  "Apex  Catarrh,"  in  the 
issue  of  January  6,  1894.  Also  to  a  paper  read  by  Dr. 
G.  R.  Butler,  of  Brooklyn,  N.  Y.,  before  the  Climato- 
logical  Section  of  the  Congress  of  American  Physicians 
and  Surgeons,  in  Washington,  D.  C,  May  29,  1894. 
The  title  of  this  paper  was  "  The  Methods  and  Value  of 
Exercise  and  Diet  in  the  Prophylaxis  of  Pulmonary 
Phthisis.19  The  name  apex  catarrh  is  said  to  be  objec- 
tionable. The  name  is  as  unsatisfactory  to  me  as  to  any 
one  else.  In  the  cases  called  apex  catarrh  all  the  mu- 
cous membranes  of  the  body  are  more  or  less  affected — 
the  gastro-intestinal,  as  a  rule,  the  most  of  all.  It  seems 
hardly  wise  to  name  the  disease  with  reference  to  the 
localized  bronchitis  only.  Thus  far,  however,  no  better 
name  has  been  suggested.  The  term,  "  the  pre- tuber- 
cular stage  of  tuberculosis/9  has  been  suggested.  If  all, 
or  a  large  proportion  of  cases  of  apex  catarrh,  became 
tubercular,  this  term  would  exactly  fill  the  requirements, 
but  such  is  not  the  fact.  The  great  majority  of  cases  of 
apex  catarrh  recover  within  a  few  months,  and  only  the 
exceptional  case  ever  develops  tuberculosis.  On  this 
account  I  have  avoided  any  name  calling  attention  to  a 
possibility.  While  it  is  always  possible  that  a  given  case 
may  become  a  localized  tuberculosis,  most  cases  look 
back  to  their  condition  of  depressed  health  as  a  time 
when  they  "were  a  little  run  down  from  overwork/' 
"  had  a  stomach  trouble,"  etc. 

The  conditions  of  apex  catarrh  and  tuberculosis  run 
into  each  other.  No  one  can  decide  when  the  tubercle 
bacilli  gain  a  foothold  in  the  tissues  depressed  in  resist- 
ance and  vitality  by  a  catarrhal  inflammation,  and  the 
case  pass  from  a  pre- tubercular  into  a  tubercular  con- 
dition. A  decision  can  only  be  arrived  at  by  watchir  g 
the  course  of  the  disease.  I  early  realized  my  inability 
to  decide  which  case  would  take  a  bad  course  (become 
tubercular)  and  which  one  would  recover  within  a  few 
months.    An  apex  catarrh  does  not  arise  from  an  acute 


November  10,  1894] 


MEDICAL   RECORD. 


603 


cold  in  the  majority  of  cases.  A  email  proportion  of 
cases  cannot  well  be  explained  on  any  other  basis,  and 
yet  this  question  is  one  concerning  which  I  have  much 
to  learn.  A  very  large  proportion  of  cases  of  apex 
catarrh  present  themselves  to  the  physician  when  suffer- 
ing from  an  acute  cold,  but  careful  inquiry  generally 
elicits  the  fact  that  the  patient  did  not  feel  well  before 
taking  the  last  cold. 

As  to  the  examination  of  the  sputa  in  such  cases.  If 
the  patient  has  no  disease  of  the  upper  air-passages  that 
occasions  cough  no  sputa  can  be  obtained.  In  the  great 
majority  of  cases  in  which  the  sputa  can  be  obtained  no 
tubercle  bacilli  can  be  found.  If  they  are  present  then 
the  case  is  one  of  tuberculosis  and  transcends  the  limits 
of  this  discussion. 

With  the  assistance  of  a  competent  bacteriologist  I 
pursued  this  line  of  examinations  for  two  years,  until  I  sat- 
isfied myself  that  the  tubercle  bacilli  were  not  to  be 
found  in  cases  of  apex  catarrh.  The  sputa  was  generally 
taken  from  well- marked  cases.  Because  nothing  was 
found  in  such  cases  I  reason  that  they  are  not  present  in 
cases  in  which  the  physical  signs  are  less  well  marked. 

As  to  the  case  cited  as  having  died  of  a  "  profuse 
hemorrhage/'  allow  me  to  say  the  choice  of  this  case 
was  unfortunate.  It  is  misleading,  I  confess.  The  point 
I  especially  wished  to  make  is  the  importance  of  a  chest 
examination  in  every  case  of  disease  of  the  ear  or  upper 
air  passages.  The  boy  had  a  mastoid  abscess.  I  sus- 
pected chest  disease  also,  as  I  did  not  think  that  the 
local  inflammation  necessarily  explained  his  constitu- 
tional condition.  He  had  undoubtedly  tuberculosis. 
The  consultant  was  much  older  than  myself,  and  because 
he  wanted  to  do  so  he  had  ridiculed  my  ideas  as  to  chest 
unsparingly.  He  suggested  calomel  and  rhubarb  because 
of  the  marked  gastro-  intestinal  disturbance.  I  thought  the 
chest  ought  to  be  examined  and  creosote  given  possibly. 
My  suspicion  was  that  he  had  an  apex  catarrh,  whether 
it  had  advanced  to  a  tuberculosis  I  did  not  know.  In- 
advertently the  report  of  this  case  was  not  complete 
enough.  I  see  many  cases  of  apex  catarrh.  I  see  only  a 
few  cases  of  tuberculosis  comparatively.  My  suspicions 
were  in  the  line  of  the  greatest  possibility.  I  see  prob- 
ably a  very  different  class  of  cases  than  occurs  in  Colo- 
rado Springs.  As  a  specialist  I  see  the  very  early  cases 
of  chest  disease,  whether  the  cases  referred  to  are  pe- 
culiar to  Cleveland  is  a  question.  They  are  probably  as 
frequent  in  other  cities  in  the  same  latitude,  and  of  the 
same  elevation.  I  do  not  believe  that  cases  of  this  sort 
develop  in  Colorado  Springs.  If  they  do,  all  reports  as 
to  the  freedom  of  people  living  in  that  locality  from  dis- 
ease of  the  chest  is  unreliable. 

Dr.  Moore  sees  a  different  class  of  cases  from  those  I 
have  attempted  to  describe.  He  sees  the  cases  that  be- 
come a  localized  tuberculosis,  the  cases  that  do  not  re- 
cover at  home  as  rapidly  as  desired,  and  are  sent  to  a 
higher  altitude.  In  May,  1894,  I  looked  up  the  record 
of  the  last  fifty- four  dispensary  cases  coming  under  my 
care,  and  found  that  of  this  number  eighteen,  had  an 
apex  catarrh.  No  one  would  believe  that  these  cases 
had  tuberculosis  if  I  took  that  position.  My  professional 
friends  have  more  often  claimed  that  there  was  nothing 
at  all  the  matter  with  the  chest,  that  the  patient  had  a 
primary  disturbance  of  the  stomach,  etc.  Dr.  Moore 
thinks  that  I  treat  these  cases  too  lightly.  Clinically  the 
only  reasonable  explanation  of  these  cases  is  that  they 
are  catarrhal  in  character.  The  etiology  of  tuberculosis 
used  to  be  very  complicated.  It  seems  to  me  now  to  be 
very  simple.  It  is  simply  a  question  of  "  soil  and  seed." 
The  tubercle  bacilli  are  everywhere.  Healthy  tissues  re- 
sist their  growth.  Tissues  or  cells  weakened  in  vitality 
and  resistance  through  inflammation  permit  of  their 
growth  and  development. 

A  catarrhal  inflammation  attacks  the  epithelium  lin- 
ing the  capillary  bronchial  tubes  or  air  cells  at  the  apex 
of  the  lung.  After  a  certain  stage  the  tubercle  bacilli  are 
permitted  to  grow.  Then  we  have  a  tuberculosis.  Why 
the  bacilli  gain  a  foothold  in  such  a  small  proportion  of 


cases  is  probably  explained  by  the  fact  that  the  catarrhal 
inflammation  in  the  majority  of  cases  close  up  before  the 
vitality  of  the  cells  is  greatly  interfered  with.  I  fully 
endQrse  the  doctor's  statement  as  to  the  frequency  of 
tubercular  cases  and  the  frequency  with  which  healed 
tubercular  lesions  are  found  on  autopsy.  I  do  not,  how- 
ever, feel  very  sanguine  concerning  cases  of  chest  dis- 
ease in  which  the  tubercle  bacilli  are  found.  The  great 
majority  of  such  cases,  as  I  have  been  hitherto  peimitted 
to  follow  them,  have  died  of  tuberculosis.  Whether  the 
presence  of  the  tubercle  bacilli  in  the  sputa  in  fair  num- 
bers necessarily  dooms  a  patient  if  he  remain  in  Cleve- 
land I  shall  not  say.  I  have  a  very  few  caies  on  record 
who  have  apparently  recovered. 

The  physical  signs  in  an  average  case  of  apex  catairh 
on  percussion  are — no  dulness,  sometimes  slight  tenderness 
and  slightly  increased  resistance ;  on  auscultation  trans- 
ference of  heart  sounds,  rough  breathing,  slightly  ccg- 
wheeled  breathing,  slightly  shortened  inspiration,  may  be 
slight  suppression  of  respiration,  or  may  be  transference 
of  heart  sounds  only.  I  see  many  a  case  in  which  the 
physical  signs  are  never  more  marked  than  this.  If, 
after  recovery  from  this  disease  the  patient  should  meet 
death  by  accident  or  otherwise,  and  an  autopsy  could 
be  made,  does  anyone  believe  that  a  pathologist  could 
find  any  lesion  remaining?  I,  for  one,  incline  to  think 
that  its  location  even  could  not  be  determined.  I  do 
not  believe  such  cases  are  tubercular.  Neither  do  I  be- 
lieve that  there  is  nothing  the  matter.  I  believe  that  the 
early  detection  and  treatment  of  such  conditions  are  of 
the  utmost  importance,  and  yet  I  am  accused  of  minimiz- 
ing the  importance  of  early  chest  disease  by  giving  it  an 
innocent  name.  From  Dr.  Moore's  remarks  I  infer  that 
he  either  believes  a  patient  to  have  a  healthy  chest  or 
tuberculosis,  and  recognizes  no  intermediate  stage.  I 
believe  that  there  is  an  intermediate  stage,  a  pretubefcu- 
lar  stage,  that  in  the  majority  of  cases  can  be  diagnosed 
with  the  greatest  ease.  If  I  am  wrong  in  my  reasoning 
I  shall  thank  any  one  who  will  point  out  to  me  the  error 
of  my  way. 

Very  truly  yours, 

Howard  S.  Straight,  M.D. 

185  Euclid  Avbnub,  Cleveland,  O. 


To  thb  Editor  of  the  Medical  Record. 

Sir  :  By  allowing  a  healthy  discussion  in  the  columns  of 
your  esteemed  weekly  regarding  the  question  "  Is  Apex 
Catarrh  Tuberculosis?  "  you  will  shed  abundant  light  in 
minds  that  are  still  dark.  It  goes  without  saying  that  a 
correct  understanding  of  the  pathological  process  under- 
lying the  so  called  "  apex  catarrh,"  is  of  the  utmost  im- 
portance, not  alone  to  the  physician's  reputation  and 
success,  but  to  his  patient's  future  life  and  welfare. 
Study  and  observation  have  long  made  me  a  disciple  of 
those  who  maintain  that  "  apex  catarrh  n  is  of  tubercular 
origin.  And  with  a  view  to  further  strengthen  my 
belief  and  conviction  I  have,  with  the  splendid  assistance 
of  my  friend,  Dr.  Philip  Meirowitz,  lately  examined  the 
sputa  of  a  dozen  patients,  all  of  whom  showed  the  so- 
called  "apex  catarrh."  The  patients  were  all  taken 
from  my  clinic  (Mt.  Sinai  Hospital  Dispensary)  with  re- 
gard to  no  special  selection  whatsoever.  In  every  single 
case  tubercle  bacilli  were  found.  The  number  of  them 
was  never  any  too  great,  but,  on  the  other  hand,  they 
were  never  entirely  absent.  In  a  few  cases  it  was  neces- 
sary to  examine  and  re  examine  the  same  or  different 
specimens  in  order  to  demonstrate  the  presence  of  ba- 
cilli. A  little  difficulty  in  attaining  this  end  lies  in  the 
fact  that  in  some  cases  there  is  no  sputa  to  eisminc — the 
cough  either  being  dry  or  the  expectoration  being  ex- 
tremely scanty.  But  this  inconvenience  is  easily  re- 
moved by  resorting  to  some  mild  expectorant  of  one 
kind  or  another. 

Now,  in  view  of  this  and  abundant  higher  authority, 
it  seems  to  me  that,  if  all  those  who  agree  with  Dr.  How- 
ard S.  Straight 1  in  regarding  "  apex  catarrh  "  as  "  a  lo- 
1  Medical  Rkcord,  September  22, 1854. 


604 


MEDICAL   RECORD. 


[November  10,  1894 


calizsd  capillary  bronchitis/1  sufficiently  invoked  the 
microscope,  they  would  certainly  not  be  guilty  of  such 
gross  pathological  blasphemy.  And  it  is  exactly  in  this 
form  of  phthisis  that  the  instrument  is  worth  the  invest- 
ment. The  difficulty  of  recognizing  incipient  phthisis 
is  only  exceeded  by  the  importance  of  the  recognition. 
The  great  majority  of  the  patients  with  "apex  catarrh," 
as  a  rule,  do  not  bear  as  yet  the  various  tubercular  stig- 
mata on  their  constitution.  What  brings  them  to  the 
physician  is  an  annoying  cough  or  blood  stained  sputum. 
The  cough  is  sometimes  dry,  sometimes  moist,  or  at- 
tended with  considerable  expectoration.  I  have  found 
the  following  physical  signs  in  every  case  of  tuberculosis 
of  the  apex,  or  "  apex  catarrh : "  1.  Prolonged,  harsh, 
but  more  frequently  tubercular,  expiration.  2.  A  more 
or  less  audible  sibilant  or  sonorous  rale.  3.  Moist  or  a 
crepitant  rile  at  the  end  of  inspiration.  The  tubular 
breathing  is  invariably  present,  the  other  two  come  and 
go.  I  often  heard  the  tubular  breathing  extending  to 
some  distance  below  the  clavicle.  The  microscope,  when 
appealed  to,  invariably  confirmed  the  significance  of  this 
trinity  of  symptoms.  At  the  early  invasion  of  the  apex, 
percussion  is  not  worth  trying,  especially  if  the  right 
apex  is  involved.  Only  a  little  while  ago  a  member  of 
my  family  consulted  two  physicians  about  a  slight  sore- 
ness in  the  chest.  One  prescribed  for  a  subacute  bron- 
chitis, the  other  volunteered  to  relieve  him  of  his  tur- 
binated bones.  On  seeing  him  I  suggested  a  change  of 
climate,  for  I  made  out  an  "  apex  catarrh."  Two  days 
liter  he  was  in  bed  with  haemoptysis — in  three  days  he 
had  nine  pulmonary  hemorrhages  which  exsanguinated 
him  almost  to  the  point  of  death. 

Another  instance  of  unrecognized  phthisis  of  the 
apex :  A  girl,  about  eighteen  years  of  age,  came  to  my 
office  with  a  history  of  a  dry  cough  of  long  standing.  A 
week  before  she  consulted  a  doctor  whose  name  is  famil- 
iar to  a  considerable  portion  of  the  profession  in  this 
city.  Her  mother  was  told  that  the  girl  had  only  a 
slight  catarrh  of  the  throat  which  will  pass  off  in  a  few 
days.  But  it  didn't.  On  examination  I  found  the  three 
mentioned  symptoms  at  her  right  apex,  and  somewhat 
extending  a  little  below  the  clavicle.  On  informing 
the  anxious  parent  that  her  child  had  a  "  touch  of  con- 
sumption" she  immediately  expressed  a  desire  to  con- 
sult a  professor,  a  wish  that  I  am  always  ready  to  gratify. 
I  referred  her  to  one  of  our  most  eminent  diagnosticians 
in  town,  stating  my  diagnosis.  The  following  was  his 
usual  cautious  reply :  "  The  girl  evidently  has  a  chronic 
broncho-pneumonia  of  the  right  upper  lobe.  Whether 
it  is  tubercular  or  not  can  be  known  by  the  examination 
of  the  sputum."  The  sputum  has  been  since  examined 
twice,  and  each  specimen  revealed  bacilli,  though  in 
limited  number.  I  could  mention  many  more  such  cases 
of  apex  catarrh  where  the  real  tubercular  nature  of  the  ca- 
tarrh was  entirely  overlooked.  Especially  is  this  state- 
ment true  in  cases  of  apex  catarrh  associated  with  disease 
of  the  upper  air-passages,  for  then  the  impression  takes 
root  in  the  minds  of  the  superficial  observer  that  the  same 
inflammatory  process  that  characterizes  the  mucous  mem- 
brane of  the  nose,  pharynx,  or  larynx,  exists  in  the  apex. 
Dr.  Straight  states  in  his  paper  that  with  the  improve- 
ment of  the  catarrh  of  the  apex  the  affected  upper  pas- 
sages improve.  Certainly  so  I  for  it  is  more  than  an  ordi- 
nary likelihood  that  the  catarrh  of  the  apex  is  responsible 
for  the  disturbance  of  the  upper  passages.  The  same 
gentleman  states  that  he  derived  great  benefit  from  creo- 
sote in  all  such  cases.  It  seems  to  me  that  this  beneficial 
effect  of  creosote  on  the  disease  in  question  should  have 
made  him  think  of  tuberculosis.  There  is  no  other  dis- 
ease that  is  so  favorably  influenced  by  creosote  as  pul- 
monary tuberculosis — not  one.  This  statement  is  doubly 
true  with  regard  to  incipient  phthisis.  One  has  only  to 
see  the  wonderful  improvement  of  all  the  symptoms  in 
pthisical  dispensary  patients,  a  class  of  people  mostly 
living  in  wretched  surroundings,  to  be  convinced  of  the 
specific:  action  of  creosote. 

I  have  dwelt  largely  on  this  question,  for  I  think  its 


importance  cannot  be  overrated.  It  is  but  proper  that 
we  should  call  things  by  their  legitimate  names — and 
there  is  a  good  deal  in  a  name.  In  the  great  science  of 
modern  medicine  a  rose  cannot  smell  as  sweet  by  any 
other  name.  R.  Abrahams,  M.D. 

156  CuNTOif  Strut,  New  Yohc,  October  22,  1894. 


IS  MALARIA  A  WATER-BORNE  DISEASE? 

To  tub  Editor  op  thb  Mbhcal  Record. 

Sir:  In  the  Medical  Record  of  September  15,  1894, 
Dr.  W.  H.  Daly,  of  Pittsburg,  in  a  long  letter,  most 
emphatically  asserts  that  such  is  the  case.  He  gives  his 
personal  experience  in  the  Kankakee  swamps,  he  quotes 
other  medical  men  who  think  as  he  does,  and  now  Dr. 
Norbury,  of  Jacksonville,  111.,  in  his  letter  of  October  6, 
1894,  endorses  Dr.  Daly.  Well,  I  venture  to  slightly  dis- 
agree with  the  sweeping  claim  these  gentlemen  make 
that  malaria  is  only  contracted  by  drinking  shallow  well 
or  surface  water.  This  town  has  a  water  works  and  the 
water  is  considered  good.  Every  care  is  taken  to  pre- 
vent contamination.  It  is  generally  used  by  all  who  live 
within  the  village  limits. 

Some  months  ago  the  western  part  of  the  town  had  a 
new  sewer  laid,  the  streets  were  opened  up,  and  just  as 
sure  did  they  begin  to  dig  malaria  developed  along  the 
course  of  the  ditch,  while  other  parts  of  the  town  were 
free.  The  persons  attacked  were  of  all  nationalities — 
Italians,  Irish,  Germans,  Swedes,  Negroes,  and  last  but 
not  least,  native-born  Americans.  The  water  they  used 
was  that  supplied  by  the  Water  Company,  and  so  it  went, 
as  the  street  was  opened  in  the  immediate  vicinity  were 
the  sick  to  be  found.  My  own  little  boy,  two  years  old, 
developed  an  acute  attack.  No  sewer  was  laid  near  my 
house.  He  did  not  get  it  from  or  through  any  water, 
for  what  he  drank  was  sterilized.  It  was  not  his  milk, 
for  that  went  through  the  same  process.  My  neighbor 
dug  up  a  lot  back  of  my  place  that  had  not  been  dis- 
turbed for  ages,  and  I  firmly  believe  that  turning  up  the 
soil  caused  my  child  to  sicken,  as  the  colored  servant 
girl  complained  of  the  well  known  symptoms  a  day  or 
two  after. 

In  my  practice  it  is  a  common  occurrence  to  find  nurs- 
ing infants  with  well-marked  malaria — little  things  that 
never  drank  a  drop  of  water.  I  saw  a  woman,  sixty-three 
years  old,  develop  malaria,  the  old-fashioned  kind  as 
they  say  here,  chills  and  high  fever  (1050  F.),  who  never 
had  it  before  in  her  life,  and  who  has  been  living  in  the 
same  house  and  using  the  same  water  for  six  years.  I 
looked  about  for  a  cause,  and  found  that  a  cellar  was 
being  dug  next  door.  Two  days  afterward  I  was  called 
to  see  another  member  of  the  same  family.  These  peo- 
ple attributed  their  sickness  to  the  turning  up  of  the 
ground,  and  I  certainly  agree  with  them. 

Dr.  Daly's  claim  that  we  take  in  our  malaria  on  the 
leaves  of  turnip-tops,  greens,  kale,  spinach,  cabbage,  is 
very  far-fetched,  if  not  absurd.  These  vegetables  are 
not  used  raw.  They  are  boiled,  and  if  lettuce  is  used 
uncooked,  the  majority  of  people  smother  it  in  vinegar. 

I  am  an  unfettered,  and  I  hope  an  original,  observer, 
although  I  do  not  agree  with  Dr.  Daly,  and  I  claim  that 
malaria  is  not  a  water-borne  disease  "pur  et  simple,9' 
and  that  those  old  dogmas  and  text-books  are  deserving 
of  respect,  and  were  not  so  far  wrong  after  all.  Quinine, 
et  cetera,  were  useless  in  my  child's  case. 

He  was  treated  by  Dr.  Tifft,  of  this  town.  Change 
was  recommended  by  the  Doctor,  and  so  we  sent  him  to 
his  mother's  native  place,  Pittsburg,  Pa.,  where  he  has 
made  a  complete  recovery,  and  now  drinks  the  water 
used  there,  which  certainly  is  not  uncontaminated,  and, 
considering  its  source,  should  be  fruitful  in  malaria. 
Still  I  believe  Pittsburg  has  but  very  little  of  this  dis- 
ease. 

As  to  Dr.  Norbury's  forty  Swedes,  why  he  himself 
says  they  were  peculiarly  susceptible,  and  from  my  ex- 
perience I  agree  with  him,  and  further,   that  newly 


November  10,  1894] 


MEDICAL  RECORD. 


605 


landed  emigrants  are  specially  liable  to  contract  malaria 
even  in  New  York  City.  That  it  may  be  and  is  con- 
veyed by  water,  I  admit ;  but  that  it  is  the  only  way 
that  we  can  become  affected  my  experience  has  led  me 
to  believe  differently. 

F.  W.  Dalrymple,  M.D. 

Nbw  Rochsllv,  N.  Y.,  October  io,  1894. 


THE  MARRIAGE  OF  SYPHILITICA 

A  Riply,  with  Explanations,  to  the  Queries  of  Dr. 
Burnside  Foster  in  the  Medical  Record  for  Oc- 
tober 6, 1894. 

To  tub  Editor  or  thh  Medical  Record. 

Sir  :  Hypothetical  questions  in  medico  legal  cases  are 
perhaps  justifiable,  and  are  frequently  resorted  to,  but  as 
a  role  the  answers  given  are  so  vague  that  the  meaning  is 
about  as  clear  to  the  average  hearer  as  a  strong  infusion 
of  common  earth  in  water. 

The  three  questions  propounded  by  Dr.  Foster  may 
not  be  in  any  sense  hypothetical,  but  the  majority  of  the 
readers  of  the  Medical  Record  who  have  had  any  ex- 
perience in  the  management  of  cases  of  syphilis  will  bear 
me  out  in  the  statement  that  not  one  in  fifty  can  an- 
swer question  No.  3  at  all,  and  I  will  give  my  reasons 
later  on. 

As  regards  query  No.  1.  To  answer  it :  that  he  has 
seen  any  case  at  any  period  communicated  by  a  patient 
under  his  care,  would  lead  the  readers  to  say  that  the 
physician  had  been  derelict  in  his  duty  in  not  impressing 
so  forcibly  upon  his  patient  the  dangers  he  so  constantly 
bears  about  upon  his  person  that  he  (or  she)  will  not  en- 
danger the  health  of  others  by  exposure. 

The  first  aim,  the  highest  duty  of  every  true  physician, 
is,  or  at  any  rate  should  be,  to  protect  the  health  of  those 
who  are  placed,  either  directly  or  indirectly,  in  such  a  po- 
sition as  to  be  saved  by  him  from  any  contagious  dis- 
ease. I  believe,  through  the  columns  of  another  journal, 
in  an  original  article  already  accepted,  I  shall  show  at  an 
early  day  some  arguments,  based  on  a  large  experience 
and  continuous  observation,  demanding  protection  to 
the  innocent  from  one  of  the  blighting  curses  of  our 
nineteenth  century. 

Passing  on  for  the  present  to  query  No.  2,  and  no  one 
among  the  thousands  of  readers  of  the  Medical  Record 
will  appear  who  cannot,  from  either  personal  knowledge 
or  good  evidence,  furnished  in  journals  and  medical  text- 
books, cite  cases  almost  without  limit,  where  syphilitic 
men  and  syphilitic  women  have  been  the  parents  of 
syphilitic  children,  either  alive  or  still  born,  at  full  term, 
at  all  periods  after  the  initial  sore,  limited  only  by  the 
menopause  in  the  female  or  senility  in  the  male.  In 
fact,  almost  every  physician  will  tell  you  that  it  is  the 
rule,  almost  as  certain  as  that  the  "  day  follows  the 
night,"  that  syphilitic  female  or  syphilitic  male  will 
procreate  syphilitic  progeny.  Admitted  that,  under 
proper  treatment  of  the  mother  during  gestation,  an  ap- 
parently healthy  child  may  be  born ;  but  wait  the  next 
generation  and  see  what  is  the  result,  as  is  too  often  in- 
stanced all  about  us. 

No.  3.  Any  physician,  if  allowed  to  cut  query  No.  3 
off  where  the  query  proper  ceases,  will,  and  so  every 
reader  of  the  Medical  Record  will,  answer  yes. 

With  the  limiting  conditions  attached  to  the  end  of 
the  query  proper,  as  I  said  at  the  beginning  of  this  paper, 
not  one  in  fifty  can  answer  at  all.  In  the  first  place,  our 
authorities  s'ate,  and  we  have  all  been  taught,  that  we 
should  always  say  to  every  syphilitic  case  which  comes 
under  our  care,  "  that  two  years  must  be  devoted  to  the 
careful  attention  of  the  malady."  How  many  of  our 
readers  can  keep  the  case  for  even  two  years?  How 
many  have  had  any  individual  case  "  constantly  under 
observation  "  during  four  years  ? 

If  any  physician  has  influence  enough  over  the  dulled 
sensibilities  and  selfish  natures  of  their  syphilitic  cases  to 
keep  them  under  constant  observation  for  four  years,  he 


certainly  should  have  force  of  nature  sufficient  to  prevent 
the  patient  exposing  the  innocent  to  the  danger  of  com- 
munication by  contact,  either  with  original  lesion  or  sec- 
ondary mucous  manifestations ;  at  any  time  such  danger 
may  be  present,  and  to  carry  the  influence  still  further  he 
should  not  during  that  four  years  permit  the  possibility 
of  the  syphilitic  patient  becoming  a  parent. 

To  sum  up  on  the  queries,  I  will  say :  Whether  under 
observation  or  not  a  syphilitic  can  communicate  the  dis- 
ease at  any  time,  while  either  the  original  lesion  or  any 
external  or  internal  mucous  lesion  is  present,  in  whatever 
stage  and  at  whatever  period;  that  they  do  not  do  so  even 
more  than  they  do,  is  due  to  the  force  with  which  the 
true  physician  impresses  the  patient  with  the  necessity  of 
Absolute  non-contact  A  syphilitic  man  or  a  syphilitic 
woman  can,  and  do,  become  the  parents  of  syphilitic  chil- 
dren at  all  periods  after  the  initial  sore,  limited  only  by 
the  period  of  ovulation  in  the  woman  and  the  natural 
results  of  age  in  the  male. 

Plenty  of  cases  are  obtainable  where  four,  fourteen,  or 
twenty- four  years  after  the  initial  chancre,  under  any  and 
I  may  say  all  treatments,  that  syphilitic  men  and  syphili- 
tic women  have  been  the  parent  or  parents  of  syphilitic 
children.  And  the  few  cases  that  can  be  brought  forth 
where  syphilitic  men  or  syphilitic  women  have  brought 
forth  healthy  children,  no  matter  at  what  period  the  anti- 
syphilitic  treatment  has  been  applied  (before  or  during 
gestation)  with  the  mother,  are  misleading,  and  are  but 
a  small  percentage  of  births  occurring  in  the  families  of 
parents  who  have  ever  suffered  from  syphilis.  And  if 
such,  as  before  stated,  apparently  healthy  children  be 
watched  to  the  period  of  their  maturity,  you  will  ficd 
weakened  bodies,  blunted  intellects,  early  decay ;  and  if 
they  happen  to  be  the  parents  of  the  third  generation  the 
child  must  come  under  the  Bible  declaration  and  bear 
the  "sins  of  the  parents."  Hydrocephalus,  basil- 
meningitis,  scrofula,  marasm,  idiocy,  and  the  many 
like  conditions,  are  the  harvest  reaped  from  past  genera- 
tions. With  a  brief  expression  of  my  ideas  in  the  matter 
of  "  the  marriage  of  syphilitica,"  I  will  close. 

No  matter  what  the  treatment,  and  no  matter  how  ap- 
parently cured,  syphilitics  cannot  procreate  a  fully  vigor- 
ous, healthy,  strong,  and  noble  type  of  manhood. 
Where  is  the  benefit  to  accrue  to  the  nation  that  is  pop- 
ulated with  weak  minded,  feeble  -  bodied  humanity  ? 
Breeders  even  of  stock  select  but  the  best  with  which  to 
increase  their  herds — why  should  man,  the  noblest  work 
of  God,  do  any  less  ?  What  is  the  excuse  for  willingly 
permitting  marriage  of  our  syphilitic  cases?  It  is  our 
duty  as  guardians  of  the  public  welfare,  and  holding 
the  position,  as  we  do,  of  guardians  of  the  public  health, 
to  advise  all  syphilitics  never  to  marry,  and  use  all  pos- 
sible means  to  prevent  their  marriage.  There  is  but  one 
argument  that  can  be  brought  to  bear  in  favor  of  per- 
mitting  syphilitics  to  procreate,  and  that  is  "That 
some  wealthy  man  or  woman  may  have  children  as  heirs 
to  their  estate."  It  were  far  better  that  the  estate  have 
no  heir  than  that  the  heir  must  inherit  such  a  physical 
body  as  such  parentage  bestows.  Wealth  and  a  weak 
body  are  a  poor  inheritance.  Physical  and  mental 
strength  inherited,  and  life  is  sweet. 

Professor  Richard  A.  F.  Penrose  once  said  to  the 
students  of  the  University  of  Pennsylvania,  in  a  personal 
lecture  for  their  welfare :  "  Wnen  the  superintendent  of 
a  building  wishes  to  rear  a  structure  that  shall  be  an 
honor  to  his  name,  he  selects  the  best  materials  for  its 
construction.  From  poisoned  syphilitic  bodies  you  can- 
not raise  up  sons  and  daughters  that  shall  be  an  honor 
to  yourself  and  a  benefit  to  jour  race.  For  God's  sake, 
young  men,  keep  your  building  material  first  class." 

It  now  becomes  our  duty  to  advise  everyone  the  same, 
and  also  to  prohibit,  if  possible,  by  strong  arguments 
and  the  evidences  around  us  "  the  marriage  of  syphilit- 
ics," and  use  every  means  in  our  possession  to  have  the 
building  material  of  our  patients  first  class. 

Frank  E.  Maine,  M.D. 

AuBOWf,  N  Y.,  October  a6»  1894.' 


6o6 


MEDICAL   RECORD. 


[November  10,  1894 


Contagious  Diseases  — Weekly  Statement— Report  of 
cases  and  deaths  from  contagious  diseases  reported  to  the 
Sanitary  Bureau,  Health  Department,  for  the  week  end- 
ing NDvember  3,  1894. 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis 

Measles , 

Diphtheria 

Small-pox 


Cttt)i_ 


Deaths. 


84 

87 

39 

14 

50 

7 

0 

a 

29 

3  * 

103 

29 

11 

2 

The  lew  Tork  Academy  of  Medicine  and  the  Con- 
stitutional Convention. — The  following  is  the  report  of 
the  Committee  of  the  New  York  Academy  of  Medicine 
appointed  to  confer  with  the  Constitutional  Convention : 

New  York,  October  6,  1894. 

The  President  and    Fellows    of  the    New    York 
Academy  of  Medicine. 

Gentlemen:  Your  Special  Committee  appointed  to 
confer  with  the  Constitutional  Convention  respectfully 
submits  the  following  report : 

After  several  meetings  the  Committee  decided  to  avoid 
all  questions  which  could  in  any  way  be  imputed  to  po- 
litical bias  or  a  desire  to  push  the  interests  of  the  pro 
fession.  Three  problems  were  selected  for  d  iscussion,  and 
three  recommendations  made.  All  are  of  vital  interest 
to  the  community.  Your  Committee  appeared  before 
the  appropriate  Committees  of  the  Convention  and 
recommended  the  following  amendments  to  the  Consti- 
tution of  the  State. 

From  Art.  X.,  Sec.  1,  strike  the  word  "  coroners." 
Into  the  same  article  and  section  introduce  the  words, 
"  Medical  examiners  shall  be  appointed  by  such  County 
authority  as  the  Legislature  shall  direct/' 

We  sought  the  abolishment  of  the  coroner  system  on 
the  following  grounds : 

(a)  There  should  not  be  vested  in  one  individual  the 
functions  of  a  scientist  and  of  a  judge ;  but  the  two 
should  be  kept  separate  and  distinct. 

(t>)  It  is  the  sole  purpose  of  an  inquest  to  detect  crime. 
Tnat  is  a  judicial  function,  and  the  determination  of  the 
question  "  Has  a  crime  been  committed  and  by  whom  ?  " 
rests  in  the  interpretation  of  facts  by  judicial  inquiry. 

(c)  It  is  the  sole  purpose  of  an  examination  to  deter- 
mine whether  a  death  be  due  to  violence.  The  exami- 
nation should  be  made  by  a  competent  scientist,  in  order 
that  facts  may  be  obtained  for  interpretation  by  a  judge. 

(d)  The  examiner  merely  ascertains  that  the  death  is 
one  of  violence,  the  judge,  that  a  crime  has  been  com- 
mitted. There  should  be  no  confusion  of  the  two  of- 
fices and  no  association  in  duties. 

The  confession  of  weakness  in  the  present  system  lies 
in  the  appsintment  by  coroners  of  "  coroners'  physi- 
cians." Thus  a  coroner  with  judicial  powers  appoints 
and  controls  him  who  shall  furnish  the  coroner  with  the 
data  requisite  to  his  conclusions.  A  judge  should  be 
divorced  from  interest  in  the  premises  upon  which  he 
bases  his  opinions.  The  proposed  amendment  seeks  the 
appointment  of  physicians  only  as  examiners,  and  may 
be  termed  "class  legislation."  But  already  a  "class  " 
has  control  of  examinations,  inasmuch  as  these  are  held 
by  "  coroners'  physicians."  So,  practically,  no  innova- 
tion was  sought.  The  provision  of  a  proper  judiciary 
for  acting  upon  the  findings  of  the  examiners  we  left  to 
the  Legislature. 

(<?)  It  is  our  belief  that  the  coroner  fails  too  often  to 
detect  crime,  does  not  adequately  protect  the  innocent 
because  of  that  failure,  and  that  the  present  system  is 
open  to  abuse. 

The  Convention  has  agreed  to  submit  to  the  people  an 


amendment  striking  out  of  the  Constitution  all  reference  to 
coroners ;  but  it  refused  to  substitute  any  other  system  for 
the  present  abominable  one.  This  will  leave  the  law  gov- 
erning coroners  upon  the  statute  books.  If  the  amend- 
ment is  approved,  the  office  of  coroner  merely  ceases  to 
be  a  constitutional  office.  Something  will  have  been 
gained  when  the  amendment  is  adopted. 

The  second  recommendation  by  your  Committee  re- 
lated to  the  Regents  of  the  University.  Amend  Article 
IV.  by  the  addition  of  a  Section  with  these  or  similar 
words :  "  The  Regents  of  the  University  shall  consist  of 
such  persons  as  the  Legislature  shall  direct.  The  Re- 
gents of  the  University  shall  have  the  sole  power  to  grant 
licenses  to  practise  medicine  and  surgery,  and  shall 
perform  such  other  acts  as  the  Legislature  may  direct.  ' 
The  RegentB  of  the  University  hereafter  appointed  shall 
each  serve  ten  years." 

The  Legislature  has  already  conferred  upon  the  Re- 
gents the  sole  power  to  grant  these  licenses.  Therefore, 
here  again,  no  innovation  was  sought.  But  this  power 
has  been  placed  in  the  hands  of  Regents  appointed  for 
life.  Herein  lies  a  possible  abuse  of  power.  We,  there- 
fore, asked  that  each  subsequent  appointee  should  serve 
but  ten  years.  Inasmuch  as  reappointments  could  be 
made,  efficient  officers  could  be  retained  in  office,  and  the 
limited  tenure  of  office  would  preserve  the  people  against 
the  work  of  a  mischievous  clique  in  the  Regents.  No 
fault  may  now  be  found  with  the  work  of  the  Regents, 
but  we  must  all  confess  the  possibility  of  a  bad  element 
getting  control.  Should  such  a  thing  happen,  death 
alone  could  put  a  stop  to  it.  We  would  call  your  atten- 
tion to  the  fact  that  the  Regents  are  the  only  officers 
under  the  proposed  Constitution  who  hold  a  life  tenure 
of  office. 

For  many  years  the  medical  profession  has  striven  to 
elevate  the  standard  of  medical  education  in  the  State, 
and  to  have  set  some  one  standard  of  excellence  to  which 
all  those  seeking  licenses  shall  attain.  In  these  labors 
you  have  been  conspicuous.  Even  though  the  Regents 
become  constitutional  officers,  nothing  will  prevent 
thwarted  incompetency  and  unsatisfied  greed  getting  the 
existing  beneficent  and  protecting  law  annulled.  The 
profession  must  be  as  unceasingly  alert  as  before,  lest  the 
Legislature  be  induced,  unwittingly  perphaps,  to  legislate 
unfavorably  for  the  interests  of  the  people.  The  interests 
of  the  community  demand  that  a  law  so  materially  affect- 
ing the  well-being  of  all  be  removed  from  the  possibility 
of  too  frequent  change  in  this  vital  feature.  Unless  their 
tenure  of  office  be  limited  the  incorporation  of  the  Re- 
gents into  the  Constitution  will  be  a  menace  to  the  best 
interests  of  medical  education  in  the  State,  and  for  the 
reasons  pointed  out.  Merely  making  them  constitutional 
officers  does  not  insure  to  them  the  permanent  and  sole 
right  to  grant  medical  licenses,  and  does  not  make  diem 
answerable  to  any  authority  for  misconduct.  It  is  alto- 
gether a  bad  amendment.  We  will  have  to  fight  for  all 
we  have  gained  in  the  past,  and  a  new  issue  is  introduced, 
in  that  we  will  be  compelled  to  watch  carefully  lest  evil 
men  be  made  Regents. 

Our  last  recommendation  related  to  the  great  Depart- 
ment of  Public  Charities  and  Correction,  of  which  so 
many  of  you  are  officers. 

Amend  Article  X.  to  read: 

Section  i. — "Sheriffs,  Clerks  of  Counties,  including 
the  register  and  clerk  of  the  city  and  county  of  New 
York,  district  attorneys,  and  in  the  counties  of  Kings  and 
New  York,  one  commissioner  of  prisons  and  one  com- 
missioner of  charities  shall  be  chosen  by  the  electors  of 
the  respective  counties,  once  in  every  three  years,  and  as 
often  as  vacancies  shall  happen." 

We  submit  a  brief  for  our  reason  for  requesting  that 
the  Department  of  Public  Charities  and  Correction  be 
made  into  two  county  offices : 

1.  The  condition  in  the  counties  of  New  York  and 
Kings  does  not  exist  elsewhere  in  the  State,  inasmuch  as 
the  cities  of  New  York  and  Brooklyn  are  in  themselves 


November  10,  1894] 


MEDICAL    RECORD. 


607 


the  counties  named.    There  is,  therefore,  no  reason  why 
those  city  offices  should  not  he  made  county  offices. 

2.  It  is  manifestly  preferable  that  where  a  city  is  a 
county,  in  all  important  city  and  county  offices  the 
power  of  removal  should  lie  with  the  Governor. 

3.  As  the  present  commission  is  composed  of  a  num- 
ber of  individuals,  it  is  difficult  to  punish  any  one  of  the 
commission  for  incompetency,  the  responsibility  being 
divided.  The  removing  power  is  at  the  same  time  the 
appointing.  The  present  system  is  cumbersome,  and 
fails,  in  that  more  than  one  must  consent  to  the  per- 
formance of  each  single  act,  thus  retarding  the  business 
of  the  department  over  which  the  commission  presides. 
Or  else  power  must  be  delegated  to  one  commissioner  in 
order  that  work  may  be  efficiently  and  speedily  per- 
formed. This  latter,  in  fact,  is  the  method  these  many- 
headed  commissions  adopt.  If  delegated  power  to  one 
commissioner  be  sufficiently  effective,  why  a  plurality  of 
factors? 

4.  The  proposed  addition  to  the  Constitution  deals 
with  two  great  classes  of  the  community:  those  who 
merit  punishment  at  the  people's  hands,  and  those  who 
are  their  wards.  A  certain  system  is  requisite  for  the 
execution  of  punitive  and  correctionary  laws,  another  for 
the  gratification  of  the  people's  charitable  impulses. 

Prisoners  require  for  their  management  a  system  far 
different  from  and  a  genius  almost  opposite  to  that  essen- 
tial to  the  proper  conduct  of  hospitals  and  asylums.  In- 
asmuch as  the  cities  of  Brooklyn  and  New  York  are  the 
Counties  of  Kings  and  New  York,  and  as  a  very  large 
percentage  of  th;  population  of  the  Counties  of  Kings 
and  New  York  become  inmates  of  their  correctionary 
and  charitable  institutions  during  the  year,  the  impor- 
tance of  embodying  a  suitable  article  in  the  Constitution 
relative  to  the  commissioner  of  prisons  and  the  commis- 
sioner of  charities  is  apparent.  As  before  said,  these 
cities  are  unique  in  being  counties.  The  management  of 
these  vast  armies  of  criminals,  paupers,  insane,  and  sick, 
by  one  commission,  with  two  distinct  and  dissimilar 
systems,  is  not  consistent  with  the  best  results. 

It  is  questionable  if  the  numerous  "  Boards  of  Visi- 
tors/' "  Aid  Societies,"  and  "  State  Visiting  Societies," 
etc.,  etc.,  could  have  originated,  if  satisfactory  manage- 
ment marked  these  departments. 

5.  Not  alone  the  State,  but  the  country  as  well,  has 
been  shocked  by  the  results  of  the  recent  investigation 
by  the  State  Commission  in  Lunacy. 

The  fault  lies  in  the  entirely  wrong  association  of  two 
absolutely  opposed  systems  under  one  commission. 

6.  The  one  great  argument  used  by  those  who  advo- 
cate this  association  is  that  two  commissions  would 
greatly  increase  the  per  capita  cost  of  maintaining  the 
sick  and  needy,  inasmuch  as  much  of  the  unskilled  work 
about  asylums  and  hospitals  is  done  by  criminals.  This 
contingency  could  easily  be  met  by  a  system  of  requisi- 
tions by  one  commissioner  upon  the  other,  a  system  now 
practically  employed. 

7.  It  is  a  matter  of  common  rumor,  as  well  as  a  demon- 
strated fact,  that  the  present  system  is  a  failure. 

We  therefore  request  that  these  two  commissions  be 
made  county  offices  under  the  Constitution,  and  thus  re- 
moved from  insecure  and  imperfect  legislation  in  one 
most  important  particular. 

This  amendment  was  refused  us.  So  many  more  im- 
portant questions  were  before  the  Convention  that  the 
dominant  party  feared  to  load  these  down  with  others 
which  might  enlist  enemies  against  their  recommenda- 
tions to  the  people.  We  suggest  to  you  that  in  the  future 
there  be  appointed  each  year  a  Committee  whose  duty 
it  shall  be  to  watch  legislation,  and  to  make  to  the  Leg- 
islature such  recommendations  as  you  wish  to  become 
laws. 

TEe  fate  of  the  proposed  amendments  none  can  fore- 
tell. Should  those  in  which  we  are  so  interested  be  ac- 
cepted by  the  people,  we  will  still  have  to  continue  urg- 
ing certain  changes  in  the  laws. 

The  regents  should  serve  for  such  time  as  will  protect 


us,  while  giving  us  the  most  efficient  work.  Sufficient 
medical  examiners  should  be  appointed  by  the  proper 
county  authority.  There  should  also  be  one  judge,  well 
salaried,  a  man  skilled  in  jurisprudence,  whose  sole  func- 
tion shall  be  to  determine  whether  deaths  are  due  to 
criminal  violence.  He  would  have  to  report  to  the  dis- 
trict attorney's  office.  Such  a  man  could  do  all  the 
work  now  performed  by  the  number  of  coroners.  Some 
provision  should  be  made  for  the  regulation  of  the  prac- 
tice of  midwifery.  The  injustice  at  present  is  in  com- 
pelling an  obstetrician  to  pass  a  certain  examination  be- 
fore the  regents,  while  a  small  fee  confers  almost  equal 
rights  upon  a  woman,  without  any  inquiry  as  to  fitness. 
If  license  to  practise  midwifery  were  conferred  upon  the 
competent  only,  we  believe  that  the  death  rate  would  be 
lowered,  and  one  very  great  cause  for  diseases  of  women 
appreciably  removed. 

We  would  also  call  to  your  attention  the  fact  that  by 
law  a  medical  man  is  debarred  from  being  president  of 
the  Board  of  Health,  a  most  unjust  discrimination 
against  the  very  class  of  men  from  whom  such  officer 
should  be  chosen. 

Your  committee  was  courteously  received  and  granted 
all  hearings  requested.  Taking  into  consideration  the 
dislike  which  the  legislator  has  to  the  scientist  meddling 
in  law-making,  we  have  been  fairly  successful.  We  de- 
sire to  express  to  you  our  appreciation  of  the  honor  you 
have  conferred  upon  us,  and  beg  that  wherein  we  have 
failed  of  complete  success  will  be  overlooked  in  the  ear- 
nestness of  our  efforts.  Respectfully, 

William  R.  Prvor,  M.D.,  Secretary, 

The  Action  of  Sunlight  on  Microorganisms. — The 
following  correspondence  has  been  sent  us  for  publica- 
tion: 

Rapids  P.  Om  La.,  October  15, 1894. 

Surgeon  General  U.  S.  A. 

Dear  Sir  :  I  have  discovered  that  the  rays  of  the  sun 
are  a  disinfectant  and  antiseptic.  At  1  io°  to  1 200  F.  they 
will  arrest  decomposition  and  destroy  microbes.  I  have 
directed  them  on  old  and  new  sores  on  man  and  beast, 
and  in  an  incredibly  short  time  a  sun-bath  will  destroy 
corrupt  matter  and  leave  a  bad  sore  in  a  healthy  condi- 
tion that  will  heal  up  in  a  short  time.  For  instance, 
two  bad  boils  on  the  same  person,  one  treated  with 
washes,  poultices,  etc.,  taking  a  month  or  more  for  per- 
fect healing,  the  other  in  less  than  one  hour's  exposure 
to  the  sun's  rays,  cleansed  and  healthy  and  healing  in  a 
few  days.  These,  with  a  number  of  other  tests,  lead  me 
to  the  belief  that  it  will  become  a  successful  treatment 
for  sores,  ulcers,  etc.,  of  recent  and  long  standing,  espe- 
cially in  hospital  practice. 

I  have  called  the  attention  of  our  local  physicians,  who 
tell  me  the  treatment  is  not  known  to  the  profession,  to 
their  knowledge.  I  am  not  a  physician,  but  made  the 
discovery  in  the  course  of  butchering  animals  for  market, 
the  particulars  of  which  and  subsequent  tests  I  will  send 
if  deemed  of  any  importance ;  if  proving  to  be,  I  want 
it  given  to  the  medical  profession  at  large.  Not  know- 
ing just  how  to  reach  them  I  concluded  to  write  to  the 
Medical  Department,  United  States,  which  could  make 
such  tests  as  would  prove  its  efficiency.  Mine  were 
made  with  the  direct  rays  of  the  sun  on  days  when  the 
thermometer  ranged  960  to  980  F.  in  the  shade.  I  have 
given  much  thought  as  to  how,  in  a  northern  latitude  and 
cooler  weather,  the  rays  could  be  directed  through  a 
lens  made  for  the  purpose.  Also  have  made  the  treat- 
ment on  other  ailments  besides  sores,  and  the  results 
prove  to  me  that  it  will  become  one  more  of  nature's 
remedial  agencies  in  curing  and  helping  many  ailments  to 
which  the  human  race  is  subject.  This  may  be  known 
already  to  the  profession,  but  so  far  as  I  am  concerned  it 
is  original,  and  came  about  as  the  result  of  some  things 
to  which  my  attention  was  called. 

Hoping  my  motives  may  be  understood  in  this  com- 
munication, I  am, 

Yours  respectfully, 

'James  T.  Dezendorf. 


6o8 


MEDICAL   RECORD. 


[November  10,  1894 


War  Department,  Surgeon-General's  Office, 
Washington,  October  i8,  1894. 

Dear  Sir  :  I  have  read  your  letter  of  October  15  th  with 
interest.  Very  numerous  experiments  have  been  made 
during  the  last  few  years  with  reference  to  the  action  of 
light  upon  various  microbes,  and  it  is  well  settled  that 
the  direct  rays  of  the  sun  very  promptly  destroy  the  vi- 
tality of  many  disease- germs.  Some  observations  have 
also  been  made  with  reference  to  the  therapeutic  use  of 
sunlight,  and  it  is  certainly  desirable,  in  view  of  the 
facts  already  known,  that  further  clinical  experiments 
should  be  made  in  this  direction.  Your  own  observa- 
tions are  of  great  interest,  and  the  spirit  in  which  you 
communicate  them  is  highly  commendable.  If  you 
authorize  me  to  do  so  I  will  publish  your  letter,  and  my 
reply  to  it,  in  some  medical  journal. 
Very  truly  yours, 

George  M.  Sternberg, 
Surgeon- General  U.  S.  A. 

Mr.  James  F.  Dezendorf,  Rapids  Post  Office,  La. 

A  Model  Surgical  Clinic. — Scene,  a  spacious  room. 
At  a  large  table  in  the  centre  is  seated  the  surgeon ;  his 
secretary  is  opposite,  an  enormous  folio  register  open 
before  him.  A  group  of  students  is  clustered  about  the 
table.  Benches  filled  with  waiting  patients  occupy  the 
sides  of  the  room.  The  secretary  calls  No.  120,736. 
A  man  aided  by  crutch  and  cane  limps  forward.  The 
surgeon's  examination  into  the  biography  and  genealogy 
of  the  patient  (four  folio  pages  carefully  written  out  by 
the  secretary)  being  ended,  the  attendant  removes  the 
multiple  wrappings  of  the  right  foot,  exposing  an  inflamed 
great  toe  with  ulceration  upon  one  side  of  the  nail.  The 
surgeon  gives  it  a  hasty  glance,  and  turning,  addresses 
the  students  as  follows:  "  Gentlemen,  a  few  years  ago  a 
case  of  this  kind — evidently  an  ingrowing  nail — would 
have  been  at  once  submitted  to  local  treatment,  and,  I 
admit,  with  fair  prospects  of  obtaining  a  good  result. 
But  now  that  we  have  learned  the  general  interdepen- 
dence of  the  different  organs  of  the  body,  we  feel  that  a 
thoroughly  scientific  treatment  demands  the  examination 
by  specialists  of  these  different  organs,  in  order  to  detect 
any  conditions  likely  to  be  etiological  factors  in  the 
case.  The  attendant  will  therefore  take  him  and  a  copy 
of  his  history  to  the  different  rooms  in  succession,  and 
return  here  with  their  respective  official  reports." 

{Some  Hours  Later.) 

Surgeon  (loquitur).  —  "Gentlemen,  the  patient  has 
now  returned  to  us,  and  I  ask  your  attention  while  I  read 
the  reports  of  the  various  specialists." 

Ophthalmological  Department. — Case  No.  120,736. 
This  patient  is  myopic.  As  I  recall  a  case  where  a  simi- 
lar visual  defect  was  the  cause  of  injury  to  the  great  toe 
in  a  person  who  "  stubbed  "  it  against  the  curbstone,  I 
have  ordered  appropriate  lenses  to  correct  the  difficulty, 
as  a  prophylactic  against  the  recurrence  of  the  disease. 
It  is  essential,  however,  that  this  treatment  should  be 
supplemented  by  wearing  a  loosely-fitting  shoe. 

Otologic al  Department. — Case  No.  120,736.  I  find 
no  defect  of  audition.  As  the  patient's  trouble  may  have 
arisen  from  want  of  suitable  support  to  the  foot,  I  have 
thought  it  best  to  shorten  the  stapes  leather  two  holes. 

Rhinological  Department.  —  Case  No.  120,736.  A 
case  of  nasal  toe  nail.  Wishing  to  bring  about  a  radical 
change  in  the  parts,  I  have  removed  with  the  curette  all 
adenoid  growths,  together  with  the  adherent  mucous 
membrane,  from  the  cavities  and  packed  them  all  with 
aseptic  gauze — which  should  be  removed  if  the  patient 
wishes  to  sneeze. 

Department  Abdominal  Surgery. — Case  No.  120,736. 

Drs.  A ,  B ,  and  C ,  in  consultation.     The 

history  showing  that  the  patient's  mother  during  life  lost 

a  set  of  false  teeth,  Dr.  A reasoning  that  "  tooth  and 

nail"  are  generally  associated  in  action,  is  inclined  to 
think  the  set  may  have  been  swallowed  unconsciously  and 
remained  in  the  patient's  stomach.  Of  course,  he  advises 
an  operation. 


Dr.  B ,  in  view  of  the  accepted  belief  that  "  Gal- 
lia est  omnis  divisa  in  partes  tres,"  thinks  it  possible  that 
one  of  them  may  have  wandered  down  to  the  great  toe, 
and  advises  an  exploratory  incision  of  the  gall-bladder 
to  ascertain  if  either  part  be  missing.  The  "  Gallic 
boot  of  love,"  cited  by  Dr.  O.  W.  Holmes,  seems  to  in- 
dicate a  tendency  of  the  gall  to  the  foot. 

Dr.  C concurs  entirely  with  both  of  these  opin- 
ions, but  on  general  grounds  advises  the  removal  of  the 
appendix.  The  patient,  however,  avers  that  this  has 
been  already  done,  and  that  he  has  it  in  a  bottle  at 
home,  which 'he  will  fetch  if  required.  It  is  therefore 
deemed  advisable  to  await  further  development. 

Gynecological  Department. — Case  No.  120,736.  Pal- 
pation reveals  no  abnormal  condition  of  uterus  or  ap- 
pendages. A  medical  student  calling  our  attention  to 
the  fact  that  the  patient  wears  pants  and  has  well- devel- 
oped male  generative  organs,  we  doubt  if  this  is  a  proper 
case  for  this  department. 

Department  Geni to-urinary  Diseases. — Case  No. 
120,736.  Organs  apparently  healthy.  It,  however,  is 
not  impossible  that  the  patient  may  have  had  a  stone 
(vesical)  which  was  passed  naturally  and  impinged  upon 
and  injured  the  great  toe. 

Department  of  Neuroses ',  etc. — Case  No.  120,736. 
The  result  of  a  careful  examination  of  this  case  indicates 
a  deficient  innervation  of  his  lower  extremities.  Two 
well-marked  areas  of  impaired  sensibility  or  partial  anaes- 
thesia are  located  in  the  gluteal  regions  beneath  the  tuber- 
osities of  the  ischia.  His  history  not  mentioning  this,  we 
questioned  him  as  to  how  long  the  condition  had  existed. 
His  replies  were  unsatisfactory — merely  to  this  effect,  that 

he  had  "  sat  so  long  upon  those  d d  hard  benches  that 

his got  numb. ' '    A  rubber  cushion  with  two  holes  is 

recommended,  and  the  case  should  be  kept  under  obser- 
vation. 

"There,  gentlemen,"  continued  the  surgeon,  as  he 
finished  reading  to  them  the  reports,  "you  have  the 
result  of  a  careful  scientific  inquiry  into  this  case.  I 
shall  now  send  the  patient  to  the  chiropodist  around  the 
corner,  with  instructions  to  have  the  toe  cleansed  and  a 
piece  of  sheet  lead  inserted  under  the  roughened  edge  of 
the  nail.  I  counsel  you  all  not  to  lose  the  opportunity 
of  witnessing  the  operation.  Good-morning,  gentle- 
men !  " — Boston  Medical  and  Surgical  Journal. 

An  Outbreak  of  Cholera.— The  United  States  Consul 
at  Sivas,  Turkey,  reports  some  interesting  facts  about  the 
outbreak  of  cholera  in  that  city.  The  city  is  about  five 
thousand  feet  above  sea-level,  nevertheless  the  river  which 
supplies  the  city  with  water  became  polluted  with  cholera 
dejections  at  a  village  about  a  mile  above  Sivas.  The 
water  which  the  people  drink  and  use  for  all  purposes 
about  the  house  flows  in  open  ditches,  where  the  people 
also  bathe  and  wash  their  soiled  clothing  and  rugs.  That 
which  has  served  one  family  for  its  various  needs  flows 
with  all  its  filth  to  another.  Ultimately  the  water  reaches 
the  open  sewers,  or  larger  streams,  which  traverse  the  city 
and  which  receive  all  the  excreta  of  the  population.  In 
these  larger  streams  the  people  bathe,  wash  their  clothes 
and  kitchen  utensils,  the  children  wade  and  play.  During 
the  epidemic  this  went  on  as  usual.  This  is  just  one  of 
the  myriad  examples  illustrating  the  spread  of  cholera  by 
an  infected  water-supply;  but  note  that,  in  spite  of  the 
fact  that  the  whole  population  drank  an  infected  water 
without  boiling  or  other  precaution,  the  consul  reports 
that  only  twelve  per  cent,  of  the  population  contracted 
the  disease,  and  only  one  quarter  of  these  died.  This  in- 
dicates that  a  majority  of  the  people  were  not  susceptible 
to  the  infection. — The  Sanitary  Inspector. 

Antidote  to  Snake- bite.— Dr.  Mueller,  of  Australia, 
claims  that  strychnine  is  a  certain  antidote  to  serpent 
venom.  The  Indian  Government  has  recently  had  a 
series  of  experiments  conducted  with  a  view  to  test  its 
efficacy.  The  results  thus  far  have  not  been  entirely  sat- 
isfactory, but  the  experiments  are  to  be  continued  for 
two  years  more  before  a  final  judgment  will  be  passed. 


Medical   Record 

A  Weekly  yournal  of  Medicine  and  Surgery 


Vol.  46,  No.  20. 
Whole  No.  1254. 


New  York,  November  17,  1894. 


$5.00  Per  Annum. 
Single  Copies,  ioc. 


®rijjitml  Articles. 


THE  TREATMENT  OF  DIPHTHERIA  WITH  AN- 
TITOXIN.1 

Based  upon  a  Series  of  Cases  Treated  at  Willard 

Parker  Hospital  with  "Antitoxin  Schering/' 

By   A.  CAMPBELL.  WHITE,  M.D., 

RESIDENT  PHYSICIAN  WILLARD  PARKBR  HOSPITAL,  NEW  YORK. 

History  and  experience  tell  as  the  most  dreaded  of  all 
enemies  of  man  are  the  infectious  diseases.  However 
benign  the  disease  or  mild  the  epidemic  it  always  leaves 
some  mark  of  devastation  in  its  path ;  but  one  consoling 
feature  of  these  so  much  feared  diseases  is  the  immunity 
granted  by  one  attack  against  future  invasion.  This 
power  of  immunity  seems  to  have  been  long  recognized, 
for  some  centuries  ago  in  India  and  China  self  inocula- 
tion was  practised  with  virus  obtained  from  the  pustules  of 
smallpox  occurring  in  a  mild  epidemic ;  thus  suffering  a 
mild  form  of  the  disease  protection  was  granted  during 
future  and  more  fatal  epidemics.  We  have  the  authenti- 
cated report  of  Lady  Montague,  of  England,  as  early  as 
1 7 1 7,  inoculating  successfully  her  own  son  with  small  pox. 

Although  this  practice  was  carried  out  to  considerable 
extent  for  many  years,  it  finally  became  very  unpopular 
on  account  of  its  consequent  dangers,  many  of  those  in- 
oculated unfortunately  developing  the  disease  in  its  most 
fatal  form.  The  first  really  practical  application  of  this 
point  of  immunity  was  made  by  Jenner  in  1798.  We  all 
know  the  history  of  his  valuable  discovery  of  vaccination 
against  small  pox,  and  how  it  has  rendered  that  once 
most  common  and  formidable  scourge  the  least  prevalent 
and  least  to  be  feared  of  all  the  infectious  diseases. 

From  this  time  to  the  present  most  constant  efforts 
have  been  made  toward  accomplishing  similar  results  in 
the  other  infectious  diseases,  and  the  rapid  advancement 
made  in  the  field  of  bacteriology  during  recent  years  has 
rendered  great  assistance  to  a  more  intelligent  and  prac- 
tical knowledge  of  this  power  of  immunity. 

Bacteriology  was  probably  first  successfully  applied  in 
this  direction  by  Pasteur  in  the  results  obtained  through 
his  experiments  upon  immunization  against  certain  ani- 
mal diseases.  He  obtained  immunity  against  anthrax 
and  fowl  cholera  by  the  inoculation  of  weakened  or  at- 
tenuated bacilli.  Still  later  we  have  the  same  method 
applied  to  hydrophobia,  cholera,  and  diphtheria  with 
more  or  less  salutary  results. 

This  entire  work  is  based  upon  the  principle  that  cult- 
ures of  the  most  virulent  bacilli  can  be  made  less  and 
less  virulent,  until  finally  they  are  capable  of  producing 
only  the  mildest  form  of  disease  when  injected  into  the 
living  organism.  But  however  carefully  this  process  of 
attenuation  has  been  carried  out,  however  confident  the 
experimenter  may  be  that  the  virulence  of  the  bacilli  has 
been  reduced  to  a  minimum,  there  always  must  be  some 
danger  attending  the  inoculation  of  a  human  being  with 
a  medium  containing  the  poison  of  perhaps  the  most 
fatal  disease.  To  be  successful  some  reaction  must  fol- 
low the  injection.  That  this  reaction  may  be  greater 
and  more  pronounced  than  is  desired  or  safe  must  always 
impress  the  operator  and  render  the  method  less  popular 
perhaps  than  is  deserved. 

1  Read  before  the  Pediatric  Section  of  the  New  York  Academy  of 
Medicine,  and  contained  in  a  report  made  to  the  Board  of  Health  of 
New  York  City,  November  7,  1894. 


Recognizing  this  danger,  others  have  labored  in  an- 
other direction,  i.e,}  to  obtain  the  same  power  of  im- 
munity without  using  the  disease  poison  itself.  It  has 
been  found  that  the  blood  of  animals  rendered  immune 
is  capable,  when  inoculated  in  suspectible  animals,  of 
granting  them  the  same  immunity  possessed  by  the 
animal  from  which  the  blood  was  obtained.  This 
method  is  followed  by  no  reaction.  Whether  the  serum 
thus  obtained  acts  directly  upon  the  germ  or  its  toxin, 
or  whether  it  causes  some  reaction  in  the  cellular  tissues 
of  the  body  rendering  them  proof  against  the  geim  or  its 
toxin,  is  still  a  question  of  some  dispute. 

Buchner,1  Tizzoni  and  Cattani 8  have  carried  out  ex- 
periments on  the  antitoxin  of  diphtheria  and  tetanus 
which  tend  to  show  that  the  latter  theory  is  the  correct 
one.  Still  I  believe  this  theory  is  not  universally  ac- 
cepted. Whatever  its  action,  this  inoculation  of  the  serum- 
obtained  from  an  artificially  immunized  animal  is  prefer- 
able to  the  attenuated  bacilli  method.  The  points  in 
which  the  former  differ  from  the  latter  make  the  serum 
method  the  safer  and  more  practical  of  the  two.  The 
differences  as  described  by  Aronson  *  are — (1 )  the  effect  of 
the  serum  method  takes  place  at  once;  (2)  is  accom- 
panied by  no  reaction ;  (3)  by  increasing  the  amount  of 
serum  (antitoxin)  protection  against  infection  of  any 
strength  may  be  afforded. 

This  describes  rather  incompletely  the  two  methods  of 
bacterio  therapy,  and  it  is  upon  the  second,  or  seium 
method,  that  the  treatment  of  diphtheria  with  antitoxin 
is  based ;  and  to  Behring,  working  in  the  Berlin  Insti- 
tute for  contagious  diseases,  is  due,  more  than  to  any 
other,  its  discovery  and  development.  He  found  that 
not  only  could  he  grant  immunity  to  an  animal,  but  by 
giving  larger  doses  of  the  serum  of  an  immunized  animal 
an  attack  of  diphtheria  already  artificially  developed 
could  be  modified  or  aborted.  The  method  of  obtaining 
this  serum,  as  invented  by  Behring  and  modified  by 
others,  we  will  consider  as  briefly  as  possible. 

First,  a  pure  culture  of  diphtheria  bacilli  must  be  ob- 
tained. It  has  been  found  that  the  more  virulent  the 
bacilli,  at  least  after  some  immunity  has  been  established, 
the  better  the  results  which  will  follow.  Aronson 4 
claims  that  the  strength  and  efficacy  of  his  antitoxin 
depends  chiefly  upon  this  point,  and  describes  an  elabo- 
rate method  by  which  the  virulence  of  the  bacillus  can 
be  made  fifty  to  two  hundred  times  stronger  than  fresh 
cultures  from  the  most  malignant  cases.  The  extremely 
poisonous  culture  having  been  prepared,  and  its  strength 
having  been  accurately  determined,  it  is  injected  into  the 
animal  which  is  to  furnish  the  serum,  beginning  with 
very  small  doses,  which  are  gradually  increased  until  the 
most  powerful  poison  can  be  resisted  by  the  animal.  It 
requires  many  months  to  obtain  such  an  immunity,  and 
the  constant  liability  to  the  loss  of  animals  from  an  over- 
dose of  the  toxine  is  very  great.  Animals  are  selected 
which  have  some  susceptibility,  but  of  course  must  not 
too  readily  succumb  to  the  poison.  The  guinea-pig, 
dog,  goat,  sheep,  cow,  and  horse  have  all  been  used. 
The  horse,  being  less  susceptible  and  furnishing  more 
anti-toxin,  is  used  by  Aronson,8  Roux,  and  Yersin,6  and 
I  believe  more  recently  by  Behring.    The  animal  when 


1  Munchener  Medicinische  Wochenschrift,  Nos.  24  and  25, 1893. 
9  Riforma  Medica,  October  and  November,  1893. 

*  Berliner  Klinische  Wochenschrift,  No.  15,  1894. 
«  Berlin  Medical  Society,  July,  25,  1894. 

*  Deutsche  Medicinische  Wochenscrift,  No.  19,  1894. 

*  Annals  de  l'lnstitut  Pasteur,  No.  9,  1894. 


6io 


MEDICAL   RECORD. 


[November  17,  1894 


it  has  developed  a  high  degree  of  immunity  is  ready  to 
furnish  antitoxin.  The  blood  is  obtained  from  the 
larger  veins  in  the  body,  the  animal  first  having  been  put 
under  the  influence  of  morphine  or  an  anaesthetic.  The 
serum  is  separated  from  the  blood,  and  in  this  serum  is 
contained  the  antitoxin.  It  may  be  mentioned  that  ef- 
forts have  been  made  with  some  success  to  still  further 
isolate  this  antitoxin  property  or  to  obtain  it  in  a  more 
concentrated  form.1 

Of  course  the  serum  coming  from  different  animals,  or 
from  the  same  animal  at  different  times,  necessarily  varies 
in  strength,  and  to  be  used  therapeutically  some  idea  of 
its  antitoxin  power  must  be  obtained.  Ehrlich2  de 
scribes  a  method  employed  by  Behring  for  ascertaining 
(relatively)  the  amount  of  antitoxin  in  the  blood-serum. 
This  same  method,  with  perhaps  some  slight  modifica- 
tion, is  used  by  all  others.8  He  first  determines  the 
strength  of  his  te3t-poison,  i.e.,  how  much  of  this  poison 
is  required  to  kill  a  guinea- pig. of  a  given  weight  in 
thirty  six  to  forty-eight  hours..  He  then  takes  of  the 
test  poison  ten  times  the  necessary  dose  to  kill  the  ani- 
mal, and  puts  this  amount  in  each  one  of  several  test- 
tubes,  together  with  different  amounts  of  the  serum  to  be 
tested.  Salt- water  is  added  in  sufficient  quantities  to 
make  all  of  the  same  bulk.  The  contents  of  these  tubes 
are  injected  into  as  many  animals.  The  reaction  follow- 
ing the  different  injections  determines  the  power  of  the 
solution  tested,  i.e.,  the  quantity  of  blood  serum  necessary 
to  neutralize  the  poison  (save  the  animal)  varies  accord- 
ing to  the  degree  of  antitoxin  it  contains.  The  strength 
of  the  solution  is  expressed  by  giving  the  amount  of  se- 
rum required  to  save  an  animal  of  a  given  weight  inocu- 
lated with  a  fixed  poison,  e.g.,  if  it  requires  0.001  c.c.  of 
the  serum  to  neutralize  sufficient  poison  to  kill  an  ani- 
mal weighing  300  gr.,  the  strength  of  the  serum  is  as 
1,000  c.c.  is  to  300  gr.,  or  1  part  of  antitoxin  to  300,000 
parts  of  body-weight.  This  can  be  expressed  by  simply 
saying  the  serum  is  a  1  to  300,000  antitoxin  solution. 
With  the  addition  of  a  small  amount  of  tricresol  to  pre- 
serve it  against  decomposition,  the  serum  is  ready  for 
therapeutic  purposes. 

In  appearance  the  solution  of  Behring  and  the  "  im- 
munization solution  "  of  Aronson  are  alike.  They  look 
like  diluted  blood  serum.  But  the  strong  solution  of  Aron- 
son has  the  appearance  and  consistency  of  dirty  milk. 

I  have  now  attempted  to  describe  the  bacterio-therapy 
of  antitoxin,  the  process  of  its  development,  the  methods 
for  determining  its  dose,  and  its  appearance ;  but  before 
considering  this  remedy  clinically  I  wish  to  call  your  at- 
tention to  some  of  the  more  important  clinical  features 
of  the  disease  we  are  to  treat. 

In  considering  the  results  of  any  treatment  for  diph- 
theria the  age  of  the  patients  upon  whom  the  trial  is  made 
is  always  of  vital  importance  in  ascertaining  its  value.  Any 
one  who  has  had  extensive  association  with  diphtheria,  at 
least  in  this  city,  and  more  especially  perhaps  in  hospital 
practice,  must  have  been  impressed  with  the  low  mortality 
among  adults.  Even  those  suffering  the  disease  in  its  se- 
verest form  generally  get  well.  In  one  hundred  and  eighty- 
eight  cases  of  diphtheria,  over  sixteen  years  of  age,  treated 
at  the  hospital  the  mortality  was  less  than  three  per  cent. 
The  mortality  in  diphtheria  of  children  between  five  and 
sixteen  years,  although  much  higher  than  in  adults,  is  still 
surprisingly  low  for  a  disease  commonly  considered  so 
fatal.  At  this  hospital  the  past  year  the  mortality 
among  children  of  this  age  has  been  13.6  per  cent;  in 
1893,  twenty-two  per  cent. ;  and  in  1892,  11. 7  per  cent. 

Diphtheria,  therefore,  as  far  as  mortality  is  concerned, 
is  essentially  a  children's  disease,  and  it  is  among  chil- 
dren under  five  years  of  age  the  disease  causes  such  ap- 
palling disaster.  The  mortality  in  five  hundred  and  six 
children,  under  five  years,  treated  in  the  hospital  for  the 
past  two  years,  has  been  42.7  per  cent.     Therefore  any 

1  Ehrlich   and  Brieger,  Zeitschrft   far  Hygiene   und    Infections- 
krankheiten,  vol.  xiii. 
•  Deutsche  Med.  Woch.,  No.  16,  1894. 
» Annals  de  Tlnstitut  Pasteur,  No  9,  1894. 


treatment  for  diphtheria  should  be  directed  against  the 
disease  as  it  occurs  in  young  children  in  order  to  thor- 
oughly test  its  efficacy. 

It  has  always  been  noticed,  and  is  mentioned  in  nearly 
every  treatise  on  diphtheria,  that  the  mortality  is  higher 
during  certain  months  in  the  year,  e.g.,  the  highest  mor- 
tality in  the  hospital  during  the  last  year  was  in  the 
months  ot  February,  December,  and  August,  and  the  low- 
est in  September,  June,  and  July.  The  difference  in 
mortality  between  September,  the  lowest  month,  and  Feb- 
ruary, the  highest,  was  twenty-six  percent. 

That  some  epidemics  of  diphtheria  are  more  severe 
than  others  hardly  needs  to  be  mentioned.  That  bacilli 
vary  in  virulence  we  have  mentioned  before,  and  this 
has  been  established  beyond  a  doubt  by  the  researches  of 
Brieger  and  Frankel,1  Roux  and  Yersin,2  Aronson/  and 
others.  So  we  see  the  severity  of  the  epidemic  and  the 
difference  in  virulence  of  bacilli  in  different  cases  of  the 
same  epidemic  must  also  be  considered  when  discussing 
the  value  of  any  new  treatment.  Where  diphtheria  is  the 
true  cause  of  death,  i.e.,  where  death  is  due  to  the  toxin 
generated  by  the  Klebs  Loeffler  bacillus,  the  patient 
generally  dies  at  some  time  during  the  first  ten  days  from 
toxic  infection,  extension  of  membrane  into  larynx  and 
bronchi,  or  occasionally  as  early  as  this  a  patient  appar- 
ently doing  well  will  die  from  sudden  heart  failure  or 
paralysis.  In  those  patients  who  die  later  than  the  tenth 
day  death  is  generally  due  to  pneumonia  or  paralysis, 
rarely  nephritis,  while  in  some  rare  instances  the  septic 
condition  will  persist  for  some  time  after  the  membrane 
has  disappeared,  finally  causing  death.  In  170  fatal 
cases  coming  under  our  observation  the  past  year  135  oc- 
curred within  five  days  after  admission  to  the  hospital,  17 
within  ten  days,  and  18  after  the  tenth  day.  Of  the  18 
cases  9  died  of  heart-failure  or  paralysis,  2  of  septic  in- 
fection, 1  of  meningitis,  and  6  of  pneumonia,  twenty  days 
after  admission.  Excluding  the  9  cases  of  heart-failure 
and  the  2  of  septic  infection,  all  the  cases  in  whom 
diphtheria  toxin  was  the  cause  of  death  died  within  the 
first  ten  days  after  admission,  or  the  first  thirteen  days 
of  the  disease  (the  average  day  of  admission  in  these 
cases  being  the  third  day  of  their  sickness).  Ninety  per 
cent,  of  the  cases  died  within  the  first  eight  days  of  the 
disease.  Thus,  taking  all  these  facts  into  consideration, 
a  remedy  for  diphtheria  which  will  prolong  the  life  of 
the  patient  beyond  the  thirteenth  day  will  carry  him 
beyond  almost  all  danger  of  death  and  can  truly  be 
called  a  specific. 

^  In  studying  still  further  these  cases  which  die  from 
diphtheria  toxin,  we  find  the  mortality  almost  entirely 
confined  to  those  patients  who  have  false  membrane,  not 
on  the  tonsils  and  pharynx  only,  but  added  to  this  diph- 
theria of  the  posterior  nares  or  of  the  larynx.  Those 
cases  which  do  not  have  false  membrane  in  the  nose  or 
larynx  generally  recover,  and  a  specific  remedy  tried  on 
them  could  give  no  reliable  results. 

The  proper  treatment  of  diphtheria  undoubtedly  low- 
ers the  mortality,  and  without  proper  treatment  and  at- 
tention we  believe  every  case  of  diphtheria  affecting  the 
nose  and  throat  and  larynx  would  die.  The  mortality 
of  all  cases  treated  at  the  hospital  during  the  past  two 
years  has  been  between  twenty-eight  and  twenty-nine 
per  cent.,  and  the  treatment  pursued  in  these  cases  we 
cannot  but  believe  has  had  more  than  a  little  influence 
in  maintaining  so  low  a  percentage  of  deaths.  The  es- 
sentials of  the  treatment  pursued  in  these  cases  are  as 
follows :  1.  Absolute  rest  in  bed  in  recumbent  position. 
2.  Fluid  diet.  3.  The  room  kept  at  an  even  and  rather 
high  temperature  (750  to  8o°  F.).  4.  Thorough,  fre- 
quent, and  complete  washing  of  the  nasal  and  throat 
cavities  with  a  normal  salt  solution.  5.  Tincture  of  the 
chloride  of  iron  in  large  doses.  6.  Stimulation  and 
catharsis  as  indicated.  In  addition  to  this  treatment  we 
have  depended  almost  entirely  in  the  laryngeal  cases  upon 

1  Berliner  Klin.  Woch.,  No.  16,  1894. 

*  Annals  de  l'lnstitut  Pasteur,  pp.  385,  1890. 

»  Berliner  Klin.  Woch.,  No.  25,  1893. 


November  17,  1894] 


MEDICAL  RECORD. 


611 


calomel  sublimations  and  moist  heat  applied  externally! 
with  operative  interference  when  necessary. 

That  this  treatment  faithfully  carried  out  and  in- 
telligently performed  will  prevent,  in  the  majority  of 
cases,  extension  of  membrane,  and  in  all  cases  the 
development  of  laryngeal  stenosis,  is  evidenced  by 
the  small  number  of  patients  who  suffer  extension  of 
membrane  after  entrance,  and  the  extremely  rare  event 
of  a  case  of  stenosis  appearing  after  admission.  I  only 
know  of  three  cases  developing  stenosis  after  entrance, 
and  in  every  one  there  was  an  undoubted  history  of  ex- 
posure to  a  draught  from  an  open  window.  Neverthe- 
less, in  opposition  to  all  our  efforts  with  this  method  of 
treatment,  for  which  we  claim  so  much,  there  still  con- 
fronts us  a  class  of  cases  that  furnishes  a  frightful  mortality, 
and  makes  diphtheria  the  most  fatal  of  all  the  infectious 
diseases  with  which  we  come  in  contact.  The  cases  we 
refer  to  are  always  dangerous  at  any  season  of  the  year 
or  in  any  epidemic,  however  mild  that  epidemic  may  be, 
and  it  is  from  this  class  of  patients  we  have  selected  the 
cases  for  the  antitoxin  treatment. 

The  serum  used  in  our  cases  is  made  by  Aronson,  and 
was  kindly  furnished  to  us  by  Schering  &  Glatz,  the 
agents  for  Aronson' s  antitoxin  in  this  country.  This  so- 
lution was  several  times  stronger  than  that  first  and  last 
sent  over  by  Aronson,  called  the  "  immunization  solu- 
tion" which  corresponds  to  Behring's  "normal  anti- 
toxin." Diphtheria  poison  sufficient  to  kill  control 
animals  weighing  from  300  to  400  gr.  in  thirty  eight 
to  forty-six  hours  is  completely  neutralized  by  .00025 
c.c.  to  .00033  c.c.  of  the  stronger  or  concentrated  solu- 
tion. The  age  of  the  patient,  the  duration  .of  the  dis- 
ease, and  the  severity  of  the  case,  must  all  be  taken  into 
consideration  in  determining  the  dose  to  be  given.  The 
injections  were  made  under  all  aseptic  precaution,  and 
in  no  case  was  there  any  sign  of  local  inflammation  fol- 
lowing the  injection.  Instead  of  injecting  the  entire 
quantity  in  one  place  we  selected  several  locations,  the 
interscapular  region  and  the  buttocks. 

The  following  table  shows  the  general  results  obtained, 
the  amount  of  antitoxin  injected,  and,  as  far  as  possible, 
describes  the  local  condition  of  the  different  cases : 


*     I 


m  11 


3d 

1 

.     7 

3-5 

4 

4th... 

.    4    a-8 

X 

Sth... 

.     5'  3-4 

X 

6th... 

.     x    a.o 

,. 

7th.   . 

.    a    1.3 

.. 

8ch... 

x    a.o 

•• 

■is 

11 

1 

< 


5tht...  ao    3.0 


c.c. 

8.0 
94 
5.0 
6.5 
xa.o 


188.0 


I'S 


u'l'isii 


rrrr 


z  s 


I 


p.c 

a  28.5 


So 
100 


V, 


5.     »S 


*  One  of  these  case .  was  undoubtedly  true  scarlatina,  and  another  was  diag- 
nosed as  a  doubdul  case  of  measles.  In  the  third  case  the  rash  disappeared  in  a 
few  hours  without  further  symptoms. 

t  Totals. 

This  tabulation  shows  14  were  laryngeal  cases,  with  ad- 
ditional membrane  on  throat  or  nose.  Five  of  the  cases 
were  operated  upon ;  4  intubated,  and  1  tracheotomized. 
Of  these  14  cases,  1  intubation  case,  three  years  old,  died 
on  the  twenty-fourth  day  with  lobar  pneumonia.  The 
bacilli  were  absent  in  this  case  seven  days  before  death, 
and  at  one  time  we  had  considered  the  child  recovered. 
The  tracheotomy  case,  two  years  old,  died  on  the  thirty- 
fourth  day  with  broncho-pneumonia.  In  this  case  there 
was  a  history  of  exposure  to  cold  four  days  before  death, 
and  the  bacilli  had  been  absent  some  time.  Two  cases 
not  operated  upon  died :  One  a  girl,  six  years  old  (the 
only  case  treated  over  five  years  old),  died  from  sudden 
heart-failure  on  the  twelfth  day.  On  this  patient  treat- 
ment was  not  begun  until  the  fifth  day,  and  at  that  time 


the  child  was  in  a  terrible  condition — skin  moist  and  cold, 
color  bad,  stenosis  quite  well  marked,  membrane  on  ton- 
sils, uvula,  pharynx,  and  nares,  diffuse  swelling  of  glands 
in  the  neck,  temperature  a  little  below  normal,  and  pulse, 
114,  and  weak.  Could  hardly  expect  child  to  live  twelve 
hours.  Stimulants  were  given,  irrigated  once,  and  1 2  c.c. 
of  antitoxin  injected  in  four  places.  Twelve  hours  later 
the  improvement  in  general  condition  was  marked ;  in 
fact,  the  rapid  improvement  in  this  case  was  more  notice- 
able than  in  any  of  the  others.  The  child  continued 
doing  remarkably  well  for  six  days,  when  we  considered 
her  practically  out  of  danger.  But  on  the  following  day 
the  child  suddenly  went  into  syncope  and  died  three 
hours  later,  stimulants  and  restoratives  being  of  no  avail. 
A  slight  paralysis  of  the  soft  palate  was  noticed  the  day 
before  death,  and  the  membrane  at  this  time  had  entirely 
disappeared.  We  regret  that  a  larger  or  repeated  dose  of 
antitoxin  was  not  given  in  this  case.  The  other  death 
was  from  pneumonia,  in  a  child  two  years  old,  all  signs 
of  membrane  having  disappeared  twenty  days  before 
death. 

Of  the  six  cases  which  had  no  laryngeal  complication, 
but  which  had  membrane  on  tonsils  and  pharynx  and  in 
the  posterior  nares,  only  one  died.  This  child,  five 
years  old,  developed  a  bad  scarlatina,  and  died  fifteen 
days  after  beginning  of  his  diphtheria  and  five  days  after 
beginning  of  his  scarlatina.  The  membrane  had  disap- 
peared on  the  tenth  day,  and' the  child  at  this  time  was 
in  excellent  condition.  During  the  course  of  treatment 
large  plugs  of  membrane  were  removed  from  the  nose. 
The  case  received  20  c.c.  of  antitoxin,  the  largest 
amount  given  to  any  one  patient. 

Theoretically,  the  antitoxin  could  only  have  prevented 
one  of  these  five  deaths,  the  child  who  died  with  sudden 
diphtheritic  paralysis  of  the  heart  on  the  twelfth  day  of 
the  disease,  for  in  none  of  the  other  four  cases  was  death 
due  to  the  diphtheria  toxin.  Then,  excluding  these 
four  cases,  we  have  one  death  in  sixteen,  or  a  mortality  of 
6. 2  per  cent,  in  cases,  the  average  age  being  three  years, 
selected  on  account  of  their  severity.  Including  all 
deaths  the  laryngeal  cases  showed  a  mortality  of  28.5 
per  cent,  as  opposed  to  the  regular  mortality  of  over  50 
per  cent,  and  the  other  cases  give  a  mortality  of  16.6 
percent. 

The  treatment  with  the  antitoxin  was  begun  in  the  latter 
part  of  July,  having  previously  used  the  weaker  solution 
on  several  cases,  and  extended  through  the  following 
two  months.  Twenty  cases  were  selected  for  treatment 
during  this  time,  and  every  case  was  one  in  which  a  most 
unfavorable  prognosis  would  have  been  given  at  time  of 
injection,  while  in  all  other  hospitals  where  the  serum 
treatment  has  been  applied  all  cases  have  been  injected 
without  regard  to  the  age  or  condition  of  the  patient. 
The  latter  method  gives  a  larger  number  of  cases,  but  is 
not  so  severe  a  test,  unless  the  treatment  extends  over  a 
long  period  of  time.  Good  results  obtained  in  this  way 
can  be  claimed  as  due  to  the  season  of  the  year,  or  the 
mildness  of  the  epidemic.  Our  cases  differ  in  another 
important  respect  from  most  of  those  already  reported,  t.  e. , 
the  treatment  consisted  entirely  of  injections  of  antitoxin, 
with  the  exception  of  irrigating  all  cases  once  on  ad- 
mission, and  two  cases  several  times,  for  the  purpose  of  re- 
moving membrane  which  completely  plugged  the  nose. 
Of  course  stimulation  was  given  when  indicated. 

The  temperature  of  diphtheria  is  so  variable,  being 
sometimes  low  in  the  most  severe  cases  and  high  in 
others,  it  is  impossible  to  tell  how  much  it  is  influenced 
by  any  treatment.  In  some  of  the  cases  the  rise  in  tem- 
perature after  the  injection  was  marked,  in  others  there 
was  no  decided  change,  while  in  still  others  there  was 
considerable  fall.  This  fall  of  temperature  we  notice  in 
many  cases  soon  after  the  entrance  to  the  hospital,  the 
temperature  on  admission  probably  being  the  so-called 
"ambulance  fever. "  Streptococci,  inflammation,  and 
other  complications  also  give  a  high  temperature,  and, 
of  course,  antitoxin  could  have  no  influence  on  these 
temperatures. 


6l2 


MEDICAL   RECORD. 


[November  17,  1894 


The  effect  upon  the  pulse  is  of  much  more  importance. 
In  nearly  all  cases  nine  hours  after  the  injection  the 
pulse  was  much  improved  in  strength,  volume,  and  fre- 
quency. The  two  following  representations  of  the  com- 
posite pulse  and  temperature  curves  of  all  cases  will 
show  what  influence,  if  any,  antitoxin  had  upon  the 
temperature  and  pulse : 


ISO 

AtTRm 

\3  #**n 

Itf/'vtitk 

J* 

Jisr . 

ito 

/J0 

^\ 

\ 

/io 

\ 

//Q 

too 

?* 

Fig.  i.— Composite  Pulse  Curve  of  the  Twenty  Cases. 


Fig.  a.— Composite  Temperature  Curve  of  the  Twenty  Cases. 

The  diphtheritic  false  membrane  disappeared,  on  the 
average,  on  the  ninth  day  of  the  disease.  This  is  about 
the  ordinary  duration  of  membrane  in  most  cases,  but  is 
probably  a  little  early  for  cases  so  severe  as  these.  The 
persistence  of  the  Klebs  Loeffler  bacilli,  as  would  be  ex- 
pected, was  not  apparently  influenced,  the  average  time 
for  disappearance  of  bacilli  being  the  nineteenth  day. 

Antitoxin  given  early  and  in  sufficient  quantity,  ought 
to  prevent  post  diphtheritic  paralysis,  as  it  is  now  al- 
most universally  conceded  that  the  paralyses  of  diph- 
theria are  due  to  the  toxines  absorbed,  and  generally 
follow  the  more  severe  cases.  Among  the  cases  treated 
with  antitoxin,  four  had  post  -  diphtheritic  paralysis. 
The  paralysis  was  noticed  on  admission,  the  tenth,  the 
eleventh,  and  the  eighth  days  of  the  disease,  treatment 
having  b?en  begun  on  the  seventh,  the  fifth,  the  third, 
and  fourth  days  of  the  disease  respectively. 

Albuminuria  was  present  in  three  cases — in  two  cases  on 
admission,  and  in  the  other  case  it  appeared  ten  days  after 
the  injection.  It  lasted  no  more  than  three  days  in  any 
case.  No  casts  were  found  in  the  urine,  and  no  unfa- 
vorable symptoms  could  be  traced  to  the  kidneys. 

Diphtheritic  or  septic  pneumonia  occurred  in  no  case, 
the  pneumonia  complications  all  coming  on  very  late,  as 
mentioned  before.  The  pneumonia  cases  due  to  exten- 
sion of  membrane  or  infection  from  above,  always  begin 


in  the  early  days  of  the  disease  and  die  within  a  few 
days. 

Besides  the  twenty  cases  treated  with  the  stronger  so- 
lution, we  have  injected  twelve  other  cases  with  Aron- 
son's  weaker  antitoxin,  called  the  "  immunization  se- 
rum.1' Some  of  these  cases  were  quite  mild,  and 
received  a  small  amount  of  the  serum.  They  would 
probably  have  recovered  in  any  case.  Several  of  the 
bad  cases  received  as  much  as  20  c.c.  of  the  serum.  On 
two  patients  tracheotomy  was  performed,  one  of  whom 
died  on  the  twenty- first  day  after  the  operation,  the  other 
making  a  good  recovery.  The  age  of  the  former  was 
four  years,  of  the  latter  thirteen  months.  Two  cases 
were  intubated;  one  died  and  the  other  recovered. 
Still  another  case  died  on  the  thirty-seventh  day  with 
pneumonia.  All  of  these  twelve  cases  were  under  five 
years  of  age,  and  give  a  mortality  of  twenty- five  per 
cent.  No  death  occurred  until  after  the  fifteenth  day 
of  the  disease.  There  was  not  the  marked  change  for 
the  better  in  the  general  condition  of  the  patient  some 
twelve  hours  after  injection,  as  was  noticed  in  the  cases 
treated  with  the  stronger  solution.  We  mention  these 
cases  to  show  the  difference  in  strength  between  the  two 
solutions,  and  to  demonstrate,  by  giving  larger  doses  of 
the  "  immunizing  solution,"  that  it  can  be  used  as  a  heal- 
ing fluid. 

In  drawing  conclusions  from  the  results  obtained  with 
the  treatment  by  diphtheria  antitoxin,  we  must  first  be 
satisfied  that  it  has  at  least  some  curative  power,  however 
slight  or  insignificant  that  influence  may  be.  If  we 
grant  it  has  any  appreciable  influence  when  opposed  to 
the  toxin  developed  in  a  patient  suffering  with  diph- 
theria, we  must  concede  it  is  a  specific  for  diphtheria  ; 
tor  the  degree  or  amount  of  influence  it  exerts  must,  from 
the  nature  of  the  remedy,  depend  entirely  on  the  strength 
of  the  serum  and  the  care  with  which  it  is  prepared. 

Before  deciding  this  question  we  may  with  benefit 
consider  the  results  obtained  by  others,  who  have  given 
antitoxin  a  fair  trial.  The  following  reports  have,  with 
two  exceptions,come  from  the  hospital  of  Berlin : 

Korte,1  through  Vaswinckel,  reports  60  unselected 
cases  treated  with  antitoxin.  Of  these,  30  were  severe 
cases,  with  fifty  per  cent,  recoveries;  16  were  quite  se- 
vere cases,  with  eighty- one  per  cent,  recoveries ;  14  were 
light  cases,  with  one  hundred  per  cent,  recoveries. 
Seventy  per  cent,  of  all  cases  recovered.  Those  cases 
having  been  excluded  in  which  antitoxin  could  have 
had  no  effect,  the  total  mortality  was  twenty  per  cent. 
Twenty  cases  were  tracheotomized,  with  fifty- five  per 
cent,  mortality.  The  months  previous  to  and  following 
the  treatment  gave  a  mortality  of  46.5  per  cent,  and  in 
tracheotomies  seventy- one  per  cent,  or  a  total  increase 
in  recoveries  under  antitoxin  of  26.5  percent.,  and  in 
tracheotomies  a  gain  of  sixteen  per  cent.  He  says  no 
dangerous  effects  from  the  serum  were  observed ;  a  few 
cases  had  some  rash  after  the  injection,  and  in  a  few 
cases  albumin  appeared  in  the  urine. 

Rinne,2  through  Schubert,  reports  34  unselected 
cases,  all  of  whom  happened  to  be  severe  diphtheria  in 
children,  with  a  mortality  of  17.9  per  cent  The  6 
patients  who  died  were  tracheotomy  cases.  Autopsies 
showed  death  to  be  due  to  septic  pneumonia  in  2  cases, 
mechanical  plugging  of  small  bronchi  in  2  cases  (so  that 
tracheotomy  did  not  afford  relief),  pronounced  myocar- 
ditis and  nephritis  in  1  case,  and  the  remaining  case 
died  after  being  discharged  from  hospital.  The  observer 
considers  the  serum  an  effective  cure.  The  local  sym- 
toms  improved  rapidly,  the  effect  upon  general  condi- 
tion was  more  marked  than  any  other  (especially  true  of 
those  cases  with  a  very  weak  pulse)  and  a  rash  was 
noticed  in  several  cases  following  injection.  Much 
larger  doses  were  used  than  experiments  with  animals 
would  indicate. 

Sonnamberg8  reports  44  cases,  with  a  mortality  of 

1  Deutsche  Med.  Woch. ,  No.  29,  1894. 

*  Ibid.    Cases  were  treated  at  the  Elisabeth  Kxanhenhaus,  Berlin. 

•  Ibid. ,  June  7,  1894.    Cases  treated  at  the  Krankenhaus  Moabit. 


November  17,  1894] 


MEDICAL  RECORD. 


613 


twenty-five  per  cent.  Nine  tracheotomies  give  a  mortal- 
ity of  37.8  per  cent.  Excluding  6  cases  in  whom  anti- 
toxin was  not  indicated,  the  mortality  in  all  cases  was 
l3  3  per  cent.  Improvement  of  general  condition,  rapid 
disappearance  of  membrane,  and  fall  of  temperature  was 
noticed  in  most  cases. 

Strahlman1  reports  48  unselected  cases,  with  three 
deaths  (two  of  sepsis  and  one  tracheotomy),  showing  a 
mortality  of  6.2  per  cent.  The  immunization  power  was 
tried  in  94  cases,  and  seemed  to  protect  from  five  and  a 
half  weeks  to  ten  weeks.  He  summarizes  as  follows: 
"The  changes  caused  by  injection  were  marked,  the 
membrane  disappeared  quickly,  temperature  fell  consid- 
erably, and  general  condition  improved  very  percep- 
tibly." 

Rous,  Yersin,  Martin,  and  Chaillou 2  have  studied  clin- 
ically in  l'Hdpital  des  Enfants  Malades  of  Paris,  and 
bacteriologically  in  the  Pasteur  Institute,  over  four  hun- 
dred cases  treated  with  their  1  to  50,000  antitoxin  solu- 
tion. They  chose  those  months  for  the  treatment  in 
which  diphtheria  attains  the  highest  mortality,  and  for 
comparison  had  the  statistics  of  l'H6pital  Trousseau, 
where  no  serum  was  used,  in  the  same  city,  covering  the 
same  period.  The  mortality  for  the  four  years  previous 
to  the  treatment  was  51.71  per  cent,  in  3,971  children. 
In  448  cases  entering  the  hospital  during  the  serum  the- 
rapy the  mortality  was  24  5  per  cent. ;  covering  the 
same  period  the  mortality  among  520  cases  at  l'Hdpital 
Trousseau  was  sixty  per  cent.  Therefore  27. 21  per  cent, 
represents  the  exact  benefit  obtained  by  the  antitoxin 
treatment  as  compared  with  other  years  in  the  same  hos- 
pital, and  shows  a  difference  of  35.5  per  cent,  in  favor  of 
the  serum  as  compared  with  the  regular  treatment  for 
diphtheria  in  another  hospital  during  the  same  epidemic 
and  in  the  same  city.  The  mortality  among  pure  anginas, 
without  croup  complicating,  was  twelve  per  cent.,  while 
daring  the  same  period  at  l'Hdpital  Trousseau  the  mortal- 
ity was  thirty-two  per  cent.,  and  previous  to  antitoxin  in 
the  same  hospital  it  had  been  33.94  per  cent.  The  mortal- 
ity in  croup  with  serum  treatment  was  forty-nine  per  cent. ; 
at  l'Hdpital  Trousseau  for  the  same  time  it  was  eighty-six 
per  cent.,  and  had  previously  been,  at  l'Hdpital  des  En- 
fants Malades,  73.17  per  cent.  Excluding  some  cases 
in  which  the  Klebs-LoefHer  bacilli  could  not  be  found, 
and  others  in  which  the  serum  treatment  was  not  applied, 
the  mortality  among  three  hundred  cases  of  true  diph- 
theria treated  with  antitoxin  was  twenty-six  per  cent.,  or 
twenty-five  per  cent,  better  than  any  results  obtained  by 
former  treatment  for  true  diphtheria  in  the  same  hospital. 

We  find,  then,  of  four  hundred  and  eighty-six  children 
(including  operative  cases)  treated  for  true  diphtheria  by 
various  observers,  with  different  strengths  of  antitoxin 
solutions,  one  hundred  and  sixteen  have  died,  or  a  mor- 
tality of  23  8  per  cent,  in  a  class  of  cases  in  which  about 
fifty  per  cent,  always  die. 

The  first  question — "  Does  antitoxin  accomplish  any 
appreciable  good  results  in  diphtheria? " — judging  from 
our  own  twenty  cases  alone,  can  be  answered  decidedly 
in  the  affirmative.  Otherwise  we  must  believe  is  is  some- 
times possible  to  save  over  ninety  per  cent,  of  children 
suffering  diphtheria  in  its  severest  forms  with  no  other 
treatment  than  rest  in  bed.  When  we  add  to  our  own 
cases  the  results  obtained  by  others,  we  cannot  help  but 
believe  we  have  received  in  antitoxin  not  only  a  remedy 
that  will  grant  immunity  for  a  short  period  of  time,  but 
a  specific  that  will,  in  every  case,  given  early  in  the  dis- 
ease and  in  sufficient  quantity,  prevent  death  by  the  ab- 
sorption of  the  toxine  of  diphtheria. 


Long  Life  in  Greece.  —  The  German  statistician, 
Bernhard  Ornstein,  has  computed  that  Greece  stands  in 
the  first  rank  among  European  countries  in  the  number 
of  centenarians.     He  attributes  this  to  its  climate. 

1  Allgemeine  Medicinische  Central-Zeitung,  No.  58,  1894.     Cases 
treated  in  Wildenhausen  in  Oldenburg. 
9  Annals  de  l'lnstitut  Pasteur,  No.  9,  1894. 


ANTITOXIN  IN  DIPHTHERIA. 

Second  Paper,  Being  Extended  Experience  in  this 
City  and  in  Municipal  Hospital  of  Philadelphia, 
with  Some  Practical  Points  in  the  Treatment  of 
the  Disease. 

By  LOUIS  FISCHER,  M.D., 

INSTRUCTOR  IN  DISEASES  OP  CHILDREN,  NIW  YORK  POST-GRADUATE  MBDICAL 
SCHOOL  AND  HOSPITAL  J  PHYSICIAN  IN  CHARGE  OF  MESSIAH  HOME  POR  CHIL- 
DREN J  ATTENDING  PHYSICIAN,  CHILDREN'S  DEPARTMENT,  GERMAN  POLIKLIN1K. 

In  the  Medical  Record  of  October  6th  I  published  a  re- 
port of  a  very  successful  case  of  diphtheria  treated  with 
Aronson's  antitoxin.  Since  then  I  read  an  elaborate 
paper  before  the  Post  Graduate  Clinical  Society,  October 
13th,  giving  my  results  in  many  consultations,  besides 
giving  a  brilliant  outlook  for  the  treatment  of  the  septic, 
infectious  like  diphtheria.  Moreover,  the  opportunity  for 
testing  the  value  of  this  agent  arose  in  a  hopeless  case  of 
puerperal  septicaemia,  and  with  astounding  results.  The 
details  oi  this  case  will  be  published  later  on.  It  is  safe, 
therefore,  to  assume  that  not  only  can  antitoxin  exert 
healing  influence  in  toxins  generated  by  the  Klebs- 
Loeffler  bacilli,  but  that  they  seem  to  modify,  and  possibly 
cure,  other  toxins  generated  in  the  human  organism  by 
germs  distinct  from  those  known  to  be  the  specific  cause 
of  diphtheria.  Granted,  then,  that  this  is  the  case  we  can 
not  only  modify  a  severer  type  of  the  disease,  but  prevent 
complications  which  we  all  know  to  be  the  sole  danger  in 
diphtheria,  besides  cutting  short  the  course  of  the  disease 
and  thus  preventing  serious  damage  to  the  heart  and 
kidneys. 

While  no  rule  has  as  yet  been  definitely  established  as 
to  what  cases  are  and  are  not  suitable  for  this  new  thera- 
peutic agent,  still  extensive  experience  has  already  de- 
monstrated certain  positive  facts.     They  are : 

That  diphtheria  is  not  a  self-limited  disease,  that  it  is 
always  dangerous,  and  that  if  treatment  is  commenced 
early  to  guard  against  extension  of  same,  we  can  some- 
times avoid  complications  and  save  life. 

We  are,  therefore,  justified  in  applying  antitoxin  not 
only  when  we  can  already  see  the  local  manifestations  of 
the  disease,  but  when  we  have  reason  to  suspect  that  a  pa- 
tient has  been  exposed  and  possibly  infected.  This  will 
then  bring  me  to  the  mildest  kind  of  serum,  and  which  has 
been  called  immunizing  fluid. 

This  serum,  made  by  Aronson,  is  clear,  milkish- white, 
having  a  slight  odor  of  trikresol,  of  which  it  contains 
0.2  per  cent,  to  preserve  it  and  prevent  decomposition 
of  the  albuminous  ingredients. 

If  a  child  in  a  given  family  has  diphtheria,  it  has  been 
found  that  other  children  apparently  healthy  can,  by 
receiving  small  injections  of  2  c.c,  be  kept  immune 
from  diphtheria,  and  this  immunity  can  be  prolonged  for 
several  months. 

In  fact,  Aronson  found  that  when  children  treated  in 
this  way  for  prophylaxis,  did  contract  the  disease,  the 
symptoms  were  so  mild  as  to  prove  the  fact  that  anti- 
toxin had,  in  all  probability,  neutralized  considerable  of 
toxic  matter  in  the  human  organism,  and  in  this  way  most 
likely  modified  the  course  of  the  disease. 

This  immunity  was  not  only  lasting,  but  could  be  pro- 
longed for  some  time  by  repeated  injections,  and  thus  the 
period  of  the  immunity  could  be  continued  for  many 
months. 

The  technique  of  the  preparation  of  antitoxin  is  one 
requiring  little  or  no  skill,  but  owing  to  the  great  length 
of  time  required  for  rendering  animals  immune,  this 
period  sometimes  extends  over  one  year  and  more,  hence 
the  great  difficulty  in  obtaining  large  quantities  of 
serum. 

Statistics  in  this  city  show  from  1 880-1 887,  for  a  period 
covering  eight  years,  5,923  cases,  with  2,167  deaths,  or  an 
average  of  42.62  per  cent. 

Nine  years  ago  Henoch  reported  319  cases  with  208 
deaths,  in  Berlin,  or  about  65.5  per  cent,  fatal.  At  Hos- 
pital Trousseau,  in  Paris,  1883,  °f  606  CBses  treated,  391 
died,  or  64.5  percent. 


614 


MEDICAL   RECORD. 


[November  17,  1894 


So,  taking  three  distinct  parts  of  the  world  at  about  the 
same  time,  with  most  improved  form  of  treatment,  we 
have- 

Berlin  mortality 65  5  per  cent. 

Paris. 64.5     "      u 

New  York 42.62  "      u 

Since  then,  the  true  bacteriological  origin  of  the  disease 
and  our  knowledge  of  antisepsis,  tend  to  introduce  a 
new  course  of  treatment,  although  the  old  bichloride  of 
mercury  has  stilln  umerous  adherents. 

Comparing  those  statistics  with  the  most  modern,  we 
find  Katz  reporting  128  cases  of  diphtheria,  in  a  severe 
epidemic  in  the  large  Kaiser  u.  Kaiserin  Friedrich  Hos- 
pital in  Berlin,  with  only  13. 5  per  cent,  mortality. 

When  Professor  Baginsky  detailed  the  method  of  using 
the  antitoxin  treatment,  he  especially  laid  stress  on  the 
fact  that  this  new  remedy  had  influenced  the  statistics, 
and  that  the  mortality  fell  from  thirty-seven  per  cent,  to 
thirteen  and  even  eleven  per  cent.  The  result  has 
never  yet  been  equalled  by  the  most  improved  form  of 
treatment,  and  in  our  mildest  epidemic. 

How  curious  to  note  that  under  this  new  form  of 
treatment  all  severe  symptoms  subsided  in  a  few  days, 
and  rarely  did  an  early  case  of  diphtheria  develop  com- 
plications ;  and  not  in  a  single  case  was  it  necessary  to 
relieve  stenosis  of  the  larynx  by  intubation  or  tracheot- 
omy where  the  treatment  was  commenced  early. 

Even  a  complicating  nephritis  seemed  to  appear  milder, 
showing  a  decided  influence  had  been  exerted  by  this 
new  method. 

Professor  Roux,  in  Hdpital  des  Enfants  Malades,  in 
Paris,  had  448  cases;  of  this  number  109  died,  a  mortal- 
ity of  24.33  Per  cent.,  contrasted  with  average  mortality 
of  four  preceding  years,  when  of  3,971  cases,  51.71  per 
cent.  died. 

A  critical  examination  of  the  statistics  for  this  year  in- 
volved the  drawing  of  a  distinction  between  cases  of  true 
and  false  diphtheria.  Of  the  448  children  admitted  in- 
to the  diphtheria  portion,  bacteriological  examination 
showed  that  128  cases  were  not  infected  with  true  diph- 
theria ;  further,  20  of  the  cases  were  already  moribund 
when  admitted.  There  remained,  therefore,  300  cases 
which  afforded  a  fair  test  of  the  efficacy  of  the  treatment ; 
they  yielded  78  deaths,  a  mortality  of  twenty  six  per 
cent.,  which  must  be  contrasted  with  an  earlier  series  of 
cases  subject  to  the  same  eliminations,  but  treated  by 
other  methods,  which  gave  a  mortality  of  fifty  per  cent. 

The  rule  in  the  hospital  has  been  to  give  an  injection 
of  the  serum  immediately  after  admission  of  the  child. 
The  injection  was  not  repeated  if  bacteriological  exami- 
nation showed  that  the  case  was  not  one  of  true  diph- 
theria. In  none  of  these  cases  was  the  injection  fol- 
lowed by  any  unfavorable  symptoms ;  it  was  not  painful, 
and,  if  made  with  aseptic  precautions,  was  not  followed 
by  any  local  disturbances.  In  cases  of  true  diphtheria  a 
second  injection  was  given  twenty- four  hours  after  the 
first,  and  as  a  rule  this  was  sufficient. 

If  the  temperature  remained  elevated,  a  third  injection 
even  was  given.  As  a  rule  a  child  received  an  amount 
of  serum  equivalent'  to  one  thousandth  of  its  weight,  but 
in  a  few  cases  the  quantity  reached  one  hundredth  of 
the  child's  body-weight. 

Under  the  antitoxin  treatment,  complications  were 
observed  in  only  a  few  cases,  but  in  some  paralysis 
supervened.  Occasionally,  during  convalescence  an 
urticarial  eruption  was  observed,  apparently  due  to  the 
injections.  The  treatment  appeared  to  diminish  the  lia- 
bility to  albuminuria. 

A  further  classification  was  made  of  the  cases  of  diph- 
theria by  M.  Roux.  Taking  first  the  cases  in  which  the 
larynx  was  not  involved,  he  said  that  in  120  of  these 
the  diphtheria  bacillus  was  present  alone ;  of  these  9 
died,  a  mortality  of  7.5  per  cent.  But  of  these  9  chil- 
dren, 7  did  not  survive  their  admission  into  the  hos- 
pital for  twenty-four  hours.  Eliminating  these,  the 
mortality  was  only  1.66  per  cent.  Further,  of  the  two 
remaining  children  who  died,  one  was  suffering  from 


tuberculous  peritonitis,  the  other  from  severe  measles,  so 
that  it  appeared  that  all  cases  of  pure  diphtherial  angina 
ought  to  recover  if  treated  in  time.  The  false  mem- 
brane ceased  to  develop  twenty  four  hours  after  the  first 
injection,  and  became  detached  in  all  but  seven  cases  be- 
fore the  end  of  the  third  day.  The  temperature  fell 
rapidly  in  many  cases  after  the  first  injection,  in  severe 
cases  only  after  the  second  or  third  injection,  and  then 
more  slowly.  . 

In  cases  of  diphtherial  angina,  complicated  by  the 
presence  of  other  microbes,  the  results  were  equally 
good,  except  in  those  cases  in  which  streptococci  were 
present ;  the  number  of  these  cases  was  35,  of  whom  is 
died,  a  mortality  of  34.28  per  cent.  This  must  be  com- 
pared with  a  mortality  of  eighty  seven  per  cent,  in  cases 
treated  by  other  methods. 

With  regard  to  cases  in  which  the  larynx  was  involved, 
M.  Roux  distinguished  two  classes:  1,  cases  in  which 
tracheotomy  was  not  performed,  of  which  there  were  10, 
with  1  death,  a  case  in  which  the  diphtheria  bacillus 
was  associated  with  streptococci ;  2,  cases  in-  which 
tracheotomy  was  performed,  121,  with  56  deaths,  a  mor- 
tality of  46.28  per  cent.  Among  these  there  were  49 
cases  of  pure  diphtheria,  with  15  deaths,  a  mortality  of 
30.61  per  cent. ;  but  four  of  the  patients  died  less  than 
twenty- four  hours  after  admission,  and  after  deducting 
these  the  mortality  was  22.44  per  cent.  Taking  all  the 
cases  in  which  tracheotomy  was  performed,  and  eliminat- 
ing 14t  which  died  within  twenty-four  hours  after  admis- 
sion, there  remained  107  cases,  with  42  deaths,  a  mor- 
tality of  39. 25  per  cent. 

Good  as  these  results  were,  M.  Roux  himself  thought 
that  they  might  still  further  be  improved  by  more  perfect 
isolation  of  the  patients,  since  many  of  the  deaths  after 
tracheotomy  were  due  to  broncho-pneumonia,  and  it  was 
noticed  that  a  series  of  such  cases  might  follow  the  ad- 
mission of  a  child  suffering  from  diphtheria  of  the  larynx 
associated  with  the  presence  of  streptococci.  In  favor 
of  this  argument  of  isolation  may  certainly  be  urged  the 
larger  percentage  of  recoveries  obtained  in  private  prac- 
tice in  this  country,  although  many  of  the  cases  have 
fallen  into  the  hands  of  practitioners  with  no  previous 
experience  of  the  serum  treatment.  It  may  be  also  that 
the  source  of  the  antitoxin  had  a  depreciating  influence, 
for  nothing  is  stated  beyond  that  the  serum  was  obtained 
from  the  horse.  Certain  it  is  that  the  use  of  Dr.  Aran- 
son's  antitoxin  in  the  Berlin  hospitals  was  accompanied 
by  a  larger  proportion  of  success. 

Dr.  Aronson  said  that  in  the  five  months  ending  with 
July,  he  had  treated  with  his  serum  192  patients  suffering 
from  diphtheria,  as  ascertained  by  bacteriological  exam- 
ination. The  mortality  was  fourteen  per  cent.  In  23 
cases  the  children  were  moribund  when  admitted  ;  elim- 
inating these,  there  remained  169  cases,  with  19  deaths,  a 
mortality  of  1 1 . 2  per  cent.  This  contrasted  with  a  mor- 
tality in  the  same  hospital  varying,  in  three  years  before 
the  adoption  of  the  antitoxin  treatment,  from  32.5  per 
cent,  to  41.7  per  cent. 

Eighty-two  cases  had  been  treated  by  the  serum  in 
other  hospitals  in  Berlin,  and  the  general  mortality  of 
the  whole  series  of  274  cases  was  15.3  per  cent.  The 
antitoxin  serum  had  also  been  employed  with  the  ob- 
ject of  producing  immunity  in  the  children  belonging  to 
families  in  which  a  case  of  diphtheria  had  already  oc- 
curred. Among  the  130  children  thus  inoculated,  a 
only  contracted  diphtheria,  and  that  of  very  mild  type. 

Professor  Heubner,  gives  his  experience  of  the  use  of 
antitoxin  serum  in  the  children's  department  of  the 
Charite*  Hospital,  in  Berlin.  He  insists  upon  the  im- 
portance of  early  treatment,  and  pointed  out  that,  as  the 
seium  has  no  toxic  effects,  it  might  properly  be  employed 
in  cases  which  were  only  suspected  to  be  diphtheritic. 
He  thought  it  undesirable  to  use  massage  of  the  part  in 
which  the  injection  was  made,  as  its  use  was  liable  to  be 
followed  by  some  pain,  and  it  was  quite  unnecessary,  as 
the  serum  was  very  rapidly  absorbed  without  it.  The 
points  to]  which  he  considered   attention  should    be 


November  17,  1894] 


MEDICAL   RECORD. 


615 


directed  in  considering  the  necessity  for  repeated  injec- 
tions, were  the  effect  upon  the  false  membrane  and  the 
swelling  of  the  glands,  the  behavior  of  the  temperature,  the 
condition  of  the  urine,  and  the  character  of  the  pulse. 

Technique  of  Injection. — Aronson  advised  me  to  use 
the  asbestos  and  linoleum  syringe  holding  20  c.c.  for 
injecting  the  serum.  This  syringe,  made  in  accordance 
with  these  requirements,  will  soon  be  imported  in  this 
country  by  a  leading  firm.  Our  own  instrument  makers 
will  also  manufacture  them  after  the  German  models  so  that 
they  will  soon  be  within  reach  of  all.  Having  properly 
sterilized  the  syringe  by  boiling  and  using  0.5  per  cent. 
tricresol,  I  commence  by  injecting  10  c.c.  in  mild  cases, 
and  20  c.c.  in  malignant  cases,  by  pinching  a  fold  of 
skin  in  the  intra  scapular  region,  and  allowing  the  serum 
to  be  slowly  injected.  I  believe  it  proper,  however,  to 
have  a  syringe  of  suitable  size  and  inject  the  required 
amount,  rather  than  inject  several  places,  which  is  scien- 
tifically incorrect,  and  besides  tends  to  demoralize  the 
patient  by  causing  pain  with  each  stick  of  the  hypoder- 
mic needle.  The  calibre  of  the  latter  must  necessarily 
be  quite  large,  owing  to  the  thickness  of  the  serum, 
which  is  at  times  rather  mucilaginous.  It  is  proper  to 
note  all  differences  and  effects  on  the  false  membrane 
and  the  swelling  of  the  glands,  the  behavior  of  the  tem- 
perature, the  condition  of  the  urine,  the  effect  on  the 
heart,  especially  the  pulse. 

There  should  be  no  hesitation  in  injecting  on  the  sec- 
ond day,  and,  if  absolutely  no  effect  is  seen,  repeating 
the  injection  on  the  third  day,  as  there  is  absolutely  no 
risk  from  the  injection.  It  is  a  perfectly  safe  remedy, 
and  shows  no  immediate  reaction.  It  differs  from  tuber- 
culin and  vaccine  in  that  it  causes  no  reaction.  There- 
fore, a  case  of  antitoxin  treatment  will  show  no  symp- 
toms directly  attributable  to  the  remedy,  unless  it  be  in 
some  cases  urticaria.  The  temperature  does  not  fall  by 
crisis,  but  by  lysis,  with  antitoxin  treatment.  Massage 
of  the  serum  after  the  injection  should  not  be  practised, 
according  to  Professor  Heubner,  Aronson,  Baginsky, 
and  others. 

My  opportunities  for  watching  this  line  of  treatment 
in  Berlin  last  summer,  and  also  my  experience  with 
numerous  cases  in  this  city  in  consultation  practice,  and 
also  more  recently  a  series  of  cases  injected  and  at  the 
time  of  writing  still  under  observation,  in  the  Municipal 
Hospital  of  Philadelphia,1  by  courtesy  of  Drs.  Welch, 
Bemis,  Davis,  Gould,  Kyle,  and  others,  makes  me  em- 
phasize the  care  of  patients  and  the  necessity  for  per- 
mitting absorption  to  take  place  without  massage. 

Practical  Points  in  Treatment.— Let  us  not  lose  sight 
of  the  fact  that  in  the  use  of  this  rather  new  agent,  we 
are  still  treating  diphtheria,  and  that  all  discharges,  be 
they  from  the  nose,  throat,  or  mouth,  and  possibly  faeces 
and  other  excrements,  should  be  subjected  to  a  rigid  dis- 
infection. This,  if  possible,  before  leaving  the  body. 
For  this  purpose  local  swabbing  of  all  visible  membranes 
with  a  1  to  2,000  bichloride  of  mercury  solution,  using 
glass  rods  with  some  absorbent  cotton — the  latter  to  be 
burned  immediately  after  swabbing ;  the  glass  rod  to  be 
put  into  bichloride  solution.  We  still  require  most  thor- 
ough nasopharyngeal  antisepsis  for  this  purpose,  luke- 
warm, 1050  to  no°  F.,  normal  table  salt  solution,  in- 
jecting either  nostril  until  the  stream  flows  out  of  the  other 
side,  using  considerable  force  at  times.  Great  attention 
must  be  paid  to  the  recumbent  posture,  which  has  been 
so  strongly  advocated  in  Berlin,  and  I  was  happy  to  hear 
from  Dr.  Campbell  White,  of  this  city,  in  discussing  my 
paper  on  treatment  of  diphtheria.3 

The  usual  rules  of  hygienic  measures  are  in  all  cases 
more  rigidly  to  be  looked  after  in  this  serious  illness  than 
in  any  other  class  of  diseases — bathing,  temperature  of 
the  room,  absolute  cleanliness,  good  light  (sunlight)  to 
*be  admitted.  The  dietetic  management  to  consist  of 
strong  supporting  treatment — beef  tea,  broth  made  of 

1 A  complete  report  of  cases  will  be  published  in  the  American  Jour- 
nal of  die  Medical  Sciences  for  January.  1895. 
9  See  Post-Graduate  Journal  for  October,  1894. 


veal,  mutton,  chicken — should  be  tried.  Milk  diet,  fari- 
naceous toods,  raw  scraped  steak,  fresh  eggs,  and  kumyss 
or  matzoon,  sometimes  buttermilk.  Where  we  have 
young  children  I  invariably  find  them  craving  for  liquids, 
and  here  ice-cream  is  one  of  my  most  favorite  articles  of 
diet.     Naturally,  cautiously  given. 

Stimulation  should  be  cautiously  followed  out.  So,  for 
example,  it  is  wrong  to  commence  stimulating  every  case 
from  the  beginning.  It  should  be  used  where  there  is 
weakness  of  pulse  and  where  heart's  action  is  slowed, 
and  then,  however,  if  required,  it  should  be  freely  ad- 
ministered. Good  Tokay,  and  Baginsky  advises  Greek 
wines  (Mavrodaphne)  and  other  kinds.  These  latter 
wines,  being  sweet,  are  very  greedily  taken  by  children. 
Neither  the  ice  collar  nor  any  other  form  of  external 
load  application  was  used,  in  all  my  experience  abroad  or 
in  this  country,  with  the  serotherapy. 

As  all  the  reports,  therefore,  from  Berlin,  Paris,  and 
even  America,  give  good  results,  it  is  safe  to  assume  that 
antitoxin  has  stood  the  test  of  time  and  is  the  best  rem- 
edy therefor  used.  I  do  not  believe  it  to  be  a  cure- 
all,  but  that,  with  careful  nursing,  proper  attendance,  and 
early  use  in  the  disease,  it  will  do  more  good  than  any 
hitherto  known  treatment. 

The  Aronson  serum  in  use  in  Berlin,  London,  and 
also  some  in  New  York,  has  given  me  better  results  by 
far  than  Behring's  serum,  although  it  is  now  claimed  that 
Behring's  serum  is  as  strong  as  what  Aronson  recently 
made.  In  once  case  I  used  5  c.c.  of  Aronson  serum  with 
the  same  result  as  10  c.c.  in  another  with  Behring. 

Finally,  I  desire  to  state,  in  answer  to  very  many  ques- 
tions concerning  the  length  of  time  that  serum  will  keep, 
that  it  will  keep  in  a  cool  place  about  a  few  months.  A 
great  many  unscrupulous  people,  mostly  pharmacists, 
have  already  commenced  to  offer  antitoxin,  and  I  would 
take  occasion  to  warn  against  using  any  substance  resem- 
bling antitoxin. 

Although  by  cabling  to  Berlin  three  times  I  received 
a  small  consignment,  I  am  assured  that  we  may  receive 
some  in  the  near  future,  but  that  a  general  supply  will 
be  received  about  spring  of  next  year. 

As  Paris  has  already,  similar  to  Berlin,  opened  a  gen- 
eral subscription  list  for  the  preparation  of  antitoxin, 
would  it  not  be  advisable  to  have  someone  brought  over 
from  Berlin  capable  of  making  antitoxin,  and  thus  be  as- 
sured of  the  proper  technique  ? 

No  doubt  sterilizing  milk  benefactors  might  possibly 
be  induced  to  aid  a  project  for  the  cure  and  extermina- 
tion of  one  of  the  most  fatal  diseases  of  to-day. 

Z87  SfCOND  Avhmub. 


A  Long  Term  of  Service. —  Sir  George  M.  Hum- 
phry, of  Cambridge,  England,  recently  handed  in  his 
resignation  as  senior  surgeon  to  Addenbrook's  Hospital, 
a  post  which  he  held  for  fifty  two  years.  He  received 
his  appointment  very  early  in  his  professional  career,  and 
it  was  that  chiefly  which  determined  his  residence  in 
Cambridge.  The  governors  of  the  hospital  in  accepting 
his  resignation  adopted  the  following  resolution :  "That 
the  governors  resolve  to  place  on  record  their  grateful 
sense  of  the  invaluable  services  he  has  during  half  a  cen- 
tury rendered  to  the  institution,  both  as  a  place  for  the 
relief  of  the  suffering  poor,  and  as  an  important  centre 
of  medical  education ;  that,  subject  to  his  acceptance  of 
the  office,  he  be,  and  hereby  is,  appointed  consulting  sur- 
geon to  the  hospital,  and  that  the  chairman  be  requested 
to  convey  this  resolution  to  Sir  George  Humphry,  and 
to  express  the  hope  of  the  governors  that  he  may  long 
be  spared  to  give  them  the  benefit  of  his  counsel  and  as- 
sistance.'1 

Fabrics  and  Odors. — Dress  materials  vary  greatly  in 
their  capacity  for  retaining  odors ;  silk  allows  almost  all 
odors  to  pass  through  without  leaving  any  smell  behind ; 
linen  holds  them  fast ;  wool,  though  it  lets  many  smells 
pass  through,  retains  the  odors  of  decay,  like  that  of  a 
corpse. 


6i6 


MEDICAL  RECORD. 


[November  17,  1894 


A  CASE  OF  SARCOMA  OF  THE  PALATE  SUC- 
CESSFULLY TREATED  WITH  THE  TOXINES 
OF  ERYSIPELAS.1 

By  WALTER  B.  JOHNSON,  M.D., 

PATKRSON,  N.  J. 

T.  C ,  male,  aged  sixteen,  clerk.     On  October  31, 

1893,  ne  w*s  admitted  to  St.  Joseph's  Hospital,  Pater- 
son,  N.  J.  He  was  born  of  Irish  and  Irish  American  par- 
ents, and  gives  no  history  of  any  hereditary  taint  in  the 
family  of  the  father  or  mother.  No  malignant  disease 
or  syphilis  has  occurred  in  any  branch  of  either  family. 
His  mother  states  that  when  a  child  she  was  generally 
healthy,  except  the  sickness  which  resulted  from  the  or- 
dinary diseases  of  childhood;  after  which  she  had  an 
affection  of  the  eyes  and  an  abscess  of  the  neck,  which 
was  lanced  and  has  left  a  considerable  scar.  Since  that 
time  she  never  has  been  ill  except  in  childbirth;  she 
has  borne  eight  children,  four  of  which  died  young,  of 
convulsions  or  of  the  diseases  of  children.  She  never 
had  any  still  births. 

The  patient  has  always  been  delicate,  but  has  not  fre- 
quently been  confined  to  the  house  by  illness.  He  had 
measles  when  seven  years  old,  and  two  years  ago  had  an 
attack  of  pleurisy  which  confined  him  to  his  bed  for  fully 
two  weeks.  He  has  always  suffered  from  catarrhal 
trouble  and  hypertrophy  of  the  tonsils,  and  generally 
during  each  winter  has  had  more  or  less  frequent  attacks 
of  acute  tonsillitis ;  these  attacks  were  accompanied  by 
fever,  and  he  has  never  been  considered  either  strong  or 
robust.  Six  weeks  ago  he  commenced  to  complain  of  a 
soreness  of  his  throat  and  accompanying  difficulty  of 
deglutition,  thickness  of  the  voice  sounds  on  phonation, 
and  slight  dyspnoea,  the  respiratory  function  being  per- 
formed almost  entirely  through  the  mouth.  He  had 
suffered  so  frequently  from  attacks  of  inflammatory  dis- 
ease of  the  throat,  and  had  so  strong  a  prejudice  against 
medical  treatment,  that  he  refrained  from  making  com- 
plaint and  the  trouble  was  somewhat  neglected ;  it  pro- 
gressed and  assumed  a  grave  condition  before  any  medi- 
cal opinion  was  sought. 

On  examination,  a  diseased  area  was  disclosed  which 
extended  over  the  entire  soft  palate,  pillars  of  the  fauces, 
region  of  the  tonsils,  forward  over  the  hard  palate  to 
within  one-half  inch  of  the  incisor  teeth,  backward  and 
downward,  involving  a  portion  of  the  pharyngeal  wall, 
base  of  the  tongue,  affecting  the  epiglottis,  and  invading 
the  upper  part  of  the  larynx,  but  not  extending  to  the 
true  vocal  cords.  The  infected  parts  were  thoroughly 
impregnated  with  sarcomatous  deposit,  the  soft  palate 
was  increased  to  about  three  times  its  normal  thickness, 
the  new  tissue  consisted  of  cauliflower  like  granulations 
varying  in  size  from  a  rice  kernel  to  a  good  sized  pea ; 
some  of  the  masses  which  made  up  the  growth  were 
undergoing  an  apparently  superficial  ulceration  and 
discharging  a  purulent  secretion ;  others  contained  dis- 
tended and  tortuous  vessels  which  gave  them  the 
dusky  hue  frequently  observed  in  sarcomatous  diseases ; 
the  uvula  seemed  to  have  been  destroyed.  There  were 
several  of  the  cervical  glands  involved,  the  largest  one, 
however,  was  only  about  the  size  of  a  filbert. 

The  accompanying  drawing  (Fig.  1)  indicates  the 
extent  of  the  growth  and  appearance  about  the  palate 
and  pillars  of  the  fauces. 

The  patient  did  not  present  a  robust  appearance,  al- 
though he  seemed  to  be  in  fair  condition ;  there  was 
no  cachexia.  Since  the  present  trouble  developed  he  has 
been  gradually  losing  flesh,  and  has  become  more  easily 
exhausted  on  efforts  at  walking  or  running.  His  present 
weight  is  eighty- six  pounds.  He  has  increased  difficulty 
in  deglutition,  and  can  only  take  small  quantities  of 
liquid  nourishment.  He  is  unable  to  breathe  through 
his  nose  in  consequence  of  the  great  thickening  of  the 
soft  palate,  which  compels  mouth  breathing.  A  portion 
of  the  growth  was  removed  for  microscopical  examina- 

1  Read  at  the  October  meeting,  Section  Laryngology,  New  York 
Academy  of  Medicine. 


Fig. 


tion  and  submitted  to  my  assistant,  Dr.  Joseph  W.  Will- 
iams, who  subsequently  reported  the  growth  to  be  a  spin- 
dle-celled sarcoma. 

The  treatment  adopted  was  the  hypodermic  injection 
of  the  toxic  products  of  erysipelas  and  the  bacillus  pro- 
digiosus.    The  toxines  were  obtained  from  filtered  cult- 
ures of  the  streptococcus  erysipelatosus,  and  were  used 
in  combination  with  the  toxines  of  the  filtered  cultures  of 
the  bacillus  prodigiosus.     The  toxines  were  kindly  sup- 
plied by  Dr.  William  B.  Coley,  of  New  York,  who  also 
saw  the  case  in  consultation  in  an  early  stage  of  the  dis- 
ease.    Some  of  the  solu- 
tions  were   prepared  by 
Dr.  Alexander   Lambert, 
Fellow   in    Bacteriology, 
College  of  Physicians  and 
Surgeons  of  New  York, 
and  some  by  Mr.  B.  H. 
Buxton,  recent  Fellow  in 
Bacteriology  at  the  Loom- 
is  Laboratory,  New  York. 
October  31st. — The  in- 
jections of  the  toxines  of 
erysipelas   were  com- 
menced daily  with  fifteen 
minims.     The  dose  was 
increased  each  day  until 
it  had  reached  sixty  min- 
ims.    The    bacillus   pro- 
digiosus toxines  were  used 
in  doses  of  five  minims  in 
combination  after  the  dose 
had  reached  thirty- five 
minims.     The  injections  were  sometimes  given  in  the 
arm  and  sometimes  in  the  leg,  and  generally  caused  red- 
ness, swelling,  and  pain  almost  immediately  alter  they 
were  given;  these  symptoms  were  always  present  and 
persisted  from  twelve  to  thirty  six  hours.    The  temper- 
ature varied.     It  was  elevated  after  each  injection,  to  a 
greater  or  lesser  degree,  from  990  to  1030  F.     The  pa- 
tient always  felt  cold,  and  after  some  of  the  injections 
had  chills,  some  of  which  were  much  more  severe  than 
others,  and  were  accompanied  by  nausea,  vomiting,  and 
pain  in  the  back  of  the  head  and  neck.     When  the 
chills  or  feeling  of  coldness  had  passed  away  a  profuse 
perspiration  would  follow,  and  the  condition  of  the  pa- 
tient would  be  comemuch  more  comfortable. 

The  treatment  was  continued  from  October  31,  1893, 
to  June,  1894,  during  which  time  it  was  intermitted  on 
a  number  of  occasions  for  various  reasons.  The  patient 
developed,  during  the  entire  progress  of  the  treatment,  a 
dozen  chills  in  all ;  four  of  them  were  violent,  and  after 
one,  which  was  the  most  severe,  his  temperature  rose  rap- 
idly to  1030  F.  This  chill,  which  was  very  violent,  was 
followed  by  marked  cyanosis,  pain  in  the  neck  and  head ; 
his  pulse  became  very  rapid  and  feeble,  and  his  general 
condition  was  considered  very  serious.  His  nose  and 
lips  were  subsequently  affected  by  a  severe  herpetic  erup 
tion,  and  his  physical  condition  was  such  that  he  was 
obliged  to  remain  in  bed  for  two  weeks;  during  this  pe- 
riod of  time  the  injections  were  discontinued.  No  ex- 
planation of  the  severity  of  this  attack  could  be  given,  as 
the  toxic  solutions  used  had  been  in  use  in  the  same 
doses  from  the  same  supply,  and  the  same  bottle  which 
was  used  before,  and  also  after,  this  attack  without  any 
previous  or  subsequent  marked  disturbance. 

After  the  patient  had  been  under  treatment  for  five 
months  he  developed  a  peculiar  variety  of  keratitis,  which 
was  so  severe  that  the  outline  of  the  pupil  or  coloration 
of  the  iris  could  not  be  seen  through  the  opacities  which, 
although  they  were  apparently  punctate,  were  so  closely 
coalesced  that  the  entire  cornea  was  opaque;  some  of 
the  opacities  are  still  present  and  visible,  although  their 
character  cannot  be  defined.  The  injectionc  were  stopped 
for  three  weeks,  during  the  most  severe  period  of  this 
attack.  m 

Frequently  the  patient  became  so  distressed  by  the  sore- 


November  17,  1894J 


MEDICAL   RECORD. 


617 


ness  of  his  body  caused  by  the  repeated  injections,  that 
an  intermission  of  two  or  three  days  was  taken,  and  the 
treatment  discontinued.  Also,  on  several  occasions  medi- 
cation was  stopped  in  consequence  of  temporary  ina- 
bility to  procure  the  solutions  for  injection. 

The  result  of  the  treatment  was  a  constant,  steady, 
but  slow,  improvement  in  the  condition ;  two  weeks  after 
the  injections  were  first  given  the  soreness  had  left  his 
throat  to  such  an  extent  that  he  was  able  to  swallow  not 
only  fluids,  without  pain,  but  also  considerable  quantities 
of  solids.  His  weight  increased  to  eighty-nine  pounds. 
The  granular  masses  commenced  to  disappear,  this  im- 
provement continued,  and  during  the  period  of  treat- 
ment the  deposit  of  the  sarcomatous  material  was  con- 
stantly, but  very  gradually,  disappearing,  some  of  the 
granulations  by  necrobosis  and  some  by  absorption. 
During  all  this  time  his  general  condition  steadily  im- 
proved ;  at  the  end  of  the  fourth  month  of  treatment  his 
weight  had  increased  to  ninety-three  pounds.  The  pa- 
tient's temperature  was  generally  not  materially  in- 
creased after  the  injec- 
tions, except  as  previously 
noted.  The  improvement 
was  slow  and  the  progress 
of  the  recovery  unevent- 
ful, although  the  consti- 
tutional disturbance  was 
marked  during  the  attacks 
mentioned  above.  The 
granular  swellings  gradu- 
ally disappeared  as  the  tu- 
mor mass  decreased  in 
size.  The  injections  were 
discontinued  entirely  in 
June,  since  which  time 
there  has  been  no  return 
of  the  disease ;  the  patient 
is  in  excellent  physical 
condition,  his  present 
weight  is  one  hundred  and 
seven  pounds;  he  states 
that  he  never  felt  so  well, 
and  there  are  no  annoying  symptoms  of  any  kind  pres- 
ent at  this  time,  now  about  one  year  since  the  onset  of 
the  disease. 

October  1,  1894. — On  examination  a  slight  central 
prominence  and  one  or  two  spots  of  ulceration  is  all  that 
remains  of  the  growth ;  cicatrization  and  contraction  has 
taken  place,  and  white  bands  of  adhesion  extend  from 
the  hard  palate  to  all  parts  of  the  fauces,  as  shown  in  the 
drawing  (Fig.  2).  The  uvula  and  a  small  portion  ot  the 
epiglottis  have  been  destroyed  by  ulceration. 


Fig.  2. 


Jacksonville  Meeting  of  the  Tri  State  Medical  Soci- 
ety.— The  third  annual  meeting  of  the  Tri-State  Medical 
Society  of  Iowa,  Illinois,  and  Missouri  was  held  at 
Jacksonville,  111.,  October  2d  and  3d.  The  attendance 
was  large  and  great  interest  was  manifested.  Papers 
were  read  by  Drs.  J.  H.  Etheridge,  Bayard  Holmes, 
Boerne  Bettman,  Robert  H.  Babcock,  F.  Henrotin,  and 
W.  F.  Hubbard,  of  Chicago ;  John  Punton,  of  Kansas 
City ;  James  A.  Close  and  Emory  Lanphear,  of  St. 
Louis;  W.  B.  LaForce,  of  Ottumwa,  la.;  E.  O.  Sisson 
and  F.  B.  Dorsey,  of  Keokuk,  la.;  Frank  P.  Norbury, 
Anne  H.  McFarland,  Carl  E.  Black,  and  L.  A.  Malone, 
of  Jacksonville,  111. ;  Alfred  Meyer,  of  Kankakee,  111. ; 
W.  M.  Catto,  of  Decatur,  111.;  and  Charles  W.  Rook, 
of  Quincy,  111.  The  election  of  officers  resulted  as  fol- 
lows :  President,  Dr.  James  Moore  Ball,  of  St.  Louis ; 
Senior  Vice-President,  Dr.  Bayard  Holmes,  of  Chicago  ; 
Junior  Vice  President,  Dr.  L.  A.  Malone,  of  Jackson- 
ville, 111.;  Treasurer,  Dr.  C.  S.  Chase,  of  Waterloo,  la.; 
Secretary,  Dr.  Frank  P.  Norbury,  of  Jacksonville,  111. 
St.  Louis  was  selected  as  the  next  place  of  meeting. 
Time — the  first  Tuesday,  Wednesday,  and  Thursday  ot 
April,  1S95. 


CONGENITAL  ANNULAR  STENOSIS  OF  THE 
VAGINA— AN  IMPROVED  METHOD  OF  OPER- 
ATING. 

By  HIRAM  N.  VINEBERG,  M.D., 

NEW  YORK. 

INSTRUCTOR  IN  GYNECOLOGY,  NEW  YORK  POST-GRADUATE  SCHOOL  OF  MEDICINE 
AND  HOSPITAL  ,'  ATTENDING  GYNECOLOGIST  MOUNT  SINAI  HOSPITAL  DISPEN- 
SARY,  AND  MONTEFIORB  HOME  FOR  CHRONIC  INVALIDS.  . 

Acquired  stenoses  and  atresias  of  the  vagina  are  fairly 
common  and  have  received  considerable  attention  in 
literature;  but  not  so  the  congenital  stenoses  of  the 
vagina.  The  literature  on  the  subject  is  very  meagre. 
This,  doubtless,  is  due,  in  part,  to  the  looseness  with 
which  many  authors  employ  the  terms  "atresia"  and 
"stenosis."  For  instance,  several  authors  speak  of 
"  incomplete  atresia  " — a  solecism  which  should  not  oc- 
cur in  scientific  medicine.  Either  an  atresia  (drp^aia, 
from  &,  priv.,  and  &  rptpfc,  a  perforation)  is  complete  or 
it  does  not  exist  at  all.  If  there  be  an  opening  or  a  per- 
foration, no  matter  how  small,  it  is  no  longer  a  condi- 
tion of  atresia  but  of  stenosis  or  stricture. 

The  meagreness  of  the  literature  on  the  subject  of 
congenital  stenosis  may  be  judged  from  the  circumstance 
that,  in  1890,  L.  Klein wachter 8  was  able  to  collect  only 
twenty  published  cases,  and  in  only  two  of  these  was  the 
annular  stricture  situated  at  the  junction  of  the  middle 
with  the  upper  third  of  the  vagina.  In  his  paper  he  re- 
ports two  cases  in  which  the  stricture  was  situated  in  this 
portion  of  the  vagina.  Ostermann  and  Odebrecht 8  have 
each  recently  reported  a  similar  case.  A  search  through 
literature  since  1890  has  failed  to  find  any  other  cases. 
These  six  cases,  then,  form  the  total  number  hitherto  pub- 
lished. The  two  cases  that  I  am  about  to  report  will 
bring  the  number  up  to  eight.  I  am  loath  to  believe, 
however,  that  the  condition  is  as  rare  as  these  figures 
would  indicate.  Many  cases,  no  doubt,  go  unobserved. 
They  are  frequently  overlooked  because  they  may  give 
rise  to  no  symptoms.  When  the  conditions  interfere 
with  marital  intercourse,  as  in  one  of  my  cases,  the 
woman  may  have  her  attention  drawn  to  it  and  seek 
advice.  In  other  instances  it  is  found  accidentally,  as 
in  my  first  case,  when  the  physician  makes  a  vaginal 
examination  for  some  uterine  disorder  having  no  refer- 
ence to  the  anomaly.  In  another  class  of  cases  the 
woman  may  seek  advice  on  account  of  sterility  ^Klein- 
wachter).4  In  a  further  class  of  cases  the  condition  is 
found  at  labor — Doleris,5  Murphy,6  Hemmer,7  G.  Braun,8 
Heyder.9  But  in  the  latter  class  of  cases  I  am  of  the 
opinion  that  it  is  frequently  overlooked.  For  unless 
the  accoucheur  made  a  very  careful  examination  he  would 
be  likely  to  mistake  the  thick  ring  for  an  undilated  os. 
As  these  rings  often  yield  to  the  intermittent  pressure  of 
the  head  and  the  softening  processes  attending  labor,  the 
true  condition  would  not  be  revealed. 

Case  I. — A.  A ,  single,  aged  seventeen,  was  seen  in 

consultation  with  my  friend  Dr.  J.  I.  Metzger,  March 
19,  1893.  Has  had  none  of  the  diseases  of  childhood. 
At  five  years  she  had  a  vaginal  discharge,  which  seemed 
so  unnatural  to  her  parents  that  they  consulted  a  doctor 
about  it.  He  made  light  of  the  matter,  and  it  disap- 
peared after  a  time.  In  her  seventh  year  she  had  a  simi- 
lar discharge,  and  again  in  her  twelfth  year.  Since  then 
the  discharge  has  continued  about  the  same.  In  her 
thirteenth  year  she  had  typhoid  fever,  complicated  by 
pneumonia,  but  made  a  good  recovery.  Apart  from  this 
she  enjoyed  good  health  until  six  months  ago.  Men- 
struation set  in  when  she  was  fourteen  years  of  age,  and 
was  regular  and  painless  from  the  outset.  For  the  past 
six  months  has  been  complaining  of  pain  in  both  groins, 
backache,  and  increased  vaginal  discharge.     Exercise, 

1  Read  before  the  Section  on  Obstetrics  and  Gynecology  of  the 
New  York  Academy  of  Medicine,  May  24,  1894. 


*  Prag.  Med.  Woch.,  1890,  pp.  589-591. 

»  Centrlbl.  fur  Gyn.,  1894,  No.  5,  p.  123. 

•Archives  de  Tocologie,  1886.  No.  2,  p.  135. 

4  Meissner :  Frauenzimmer  Krankheiten,  Bd.  I.,  p.  337. 

T  Neue  Zeitschrift  fur  Geburtskunde,  Bd.  IV. ,  p.  3. 

8  Centrlbl.  fur  Gyn..  1889,  No.  7. 

•Archiv.  fur  Gyn.,  1889,  Bd.  XXXVI.,  p.  502. 


*  Loc.  cit. 


6i8 


MEDICAL  RECORD. 


[November  17,  1894 


particularly  walking,  made  the  pain  in  the  groin  worse. 
These  pains  were  relieved  during  menstruation,  which 
continued  to  be  regular.  Health  otherwise  fairly  good. 
She  is  a  tall,  slightly  built  girl,  with  small,  undevel- 
oped mammae.  The  external  genitals  are  normal, 
though  rather  undeveloped,  the  pubes  is  thinly  covered 
with  hair.  The  hymen  is  ruptured  from  previous  exami- 
nation. The  examining  finger  comes  into  contact  with 
a  membranous  ring  at  about  the  upper  two-thirds  of  the 
vagina.  In  the  centre  of  this  ring  is  an  opening  barely 
admitting  the  point  of  the  index-finger.  The  ring  seems 
to  be  about  one  centimetre  in  thickness,  and  is  smooth 


^ 


y> 


j>er« 


** 


u*1 


Fig.  x. 

and  homogeneous  in  structure  (see  Fig.  1),  revealing  no 
evidences  of  cicatricial  tissue.  With  the  finger  in  the  rec- 
tum the  cervix  of  a  rather  small  retro-displaced  uterus  is 
felt  about  one  inch  above  the  stenosed  part.  The  left 
ovary  and  tube  are  normal  in  size.  From  the  right  horn 
of  the  uterus  a  moderately  thick  cord  can  be  felt  passing 
to  the  right  sacro-iliac  articulation.  The  right  ovary 
can  be  made  out  of  normal  size,  but  the  right  tube  can- 
not be  palpated. 

Diagnosis. — Annular  stenosis  of  the  vagina,  probably 
of  congenital  origin,  retro-displacement  of  the  uterus. 

On  June  15,  1893, 1  assisted  Dr.  Metzger  to  do  the 
customary  operation  of  crucial  incision  and  forcible 
stretching.  At  the  operation  it  was  found  that  the  vagina 
was  quite  roomy  beyond  the  stenosis.  The  wound  was 
packed  with  iodoform  gauze  and  afterward  kept  dilated 
by  Sims's  glass  plug.  This  part  of  the  treatment  was 
rather  unsatisfactory,  and  the  stricture  was  not  very  much 
improved  by  the  operation. 

Case  II. — B.  G ,  aged  twenty-two,  was  first  seen 

by  me  in  January,  this  year,  in  my  service  at  the  Mount 
Sinai  Dispensary.  She  was  married  four  months,  and 
sought  advice  because  coition  was  painful  to  her  and  un- 
satisfactory to  the  husband.  He  stated  that  he  could 
enter  only  for  a  short  distance,  and  then  "something  " 
seemed  in  the  way.  Her  history  was  negative.  She  had 
always  been  healthy  as  a  girl,  and  never  had  any  vaginal 
discharge.  Had  none  of  the  diseases  of  childhood,  as 
well  as  she  could  remember.  She  is  a  well-built,  fully  de- 
veloped woman,  mammae  and  external  genitals  normal. 
At  the  junction  of  the  middle  with  the  upper  third  of  the 
vagina  a  constriction  is  felt,  formed  by  a  membranous 
ring,  in  the  centre  of  which  is  an  opening  just  large 
enough  to  admit  the  point  of  the  index-finger.  With  the 
finger  in  the  rectum  a  normal-sized  uterus  is  felt,  in  ante- 
version,  lying  some  distance  above  the  constriction. 

On  January  2  2d,  assisted  by  Drs.  Rau  and  Brothers,  I 


excised  the  ring  with  scissors,  flush  with  the  vagina,  for 
about  three-quarters  of  its  circumference,  taking  care  not 
to  injure  the  rectum.  I  then  stitched  the  upper  and 
lower  edges  of  the  vaginal  mucous  membrane  by  a  con- 
tinuous catgut  suture.  Beyond  the  first  ring  the  vagina 
was  funnel-shaped,  and  at  about  the  level  of  the  cervix  was 
a  second  ring,  of  larger  calibre  than  the  first,  admitting 
the  points  of  two  fingers.  The  portio  was  very  small 
and  short,  and  the  anterior  lip  seemed  to  be  continuous 
with  the  second  ring  (see  Fig.  2).  I  made  one  attempt 
to  dilate  this  ring,  tot  did  not  persevere  in  my  efforts  as 
there  seemed  no  special  indication  for  its  removal.    I 


■0  ^ 

-t4   ri* 


**» 


l*s 


lb* 


le 


»y 


per 


i*i«u 


& 


Fig.  t. 

was  desirous  to  dilate  and  curette  the  cervix,  as  there  was 
some  cervical  catarrh,  but  experienced  some  difficulty  in 
seizing  the  small  cervix  with  the  volsellum.  With  the 
aid  and  suggestion  of  Dr  Rau  the  cervix  was  drawn  down 
by  catching  hold  of  the  second  ring  with  the  volsellum 
and  making  traction  on  it.  A  dilatation  and  curettage 
were  then  easily  done.  The  vagina  was  packed  lightly 
with  iodoform  gauze,  which  was  removed  in  forty-eight 
hours.  The  patient  was  kept  in  bed  for  a  week.  At 
the  end  of  that  time  the  vaginal  wound  had  healed  by 
primary  union.  The  vagina  was  now  quite  capacious, 
and  the  two  examining  fingers  encountered  only  a  small 
portion  of  die  ring,  which  had  not  been  excised.  This 
now  is  fully  obliterated.  Coition  ever  since  the  opera- 
tion has  been  satisfactory  and  unattended  with  pain  to 
the  woman. 

The  origin  of  individual  cases  of  malformation  of  the 
vagina  is  always  a  matter  of  more  or  less  doubt.  It  is 
not  always  easy  to  tell  whether  the  pathological  condi- 
tion is  congenital  or  acquired.  During  severe  attacks  of 
scarlatina,  measles,  and  typhoid  fever  there  may  be  an 
ulcerative  inflammation  of  the  vagina  going  on  without 
being  observed  by  the  attendant  physician.  The  local 
affection  is  entirely  masked  by  the  more  severe  and 
greater  disease.  As  a  result  of  the  ulcerative  process  a 
ring-like  stenosis  may  form,  which  may  be  smooth  and 
homogeneous,  having  all  the  characteristics  of  a  congenital 
formation.  It  may  be  well  to  remember,  however,  that 
in  children  it  is  usually  the  vulva  and  the  region  external 
to  the  introitus  that  are  affected  with  inflammatory  diph- 
theritis  and  ulcerative  processes.1  This  view  of  the  mode 
of  origin  of  membranous  stenosis  of  the  vagina  is  based 
chiefly  on  what  has  been  found  to  follow  ulcerative  pro- 
cesses in  the  vagina  following  labor.  Some  cases  in 
multipara  have  been  reported  (Olshausen  and  Odebrecht  *) 

»  Henoch :  Kinderkrankheiten,  Auf.  IV.    Berlin,  1889. 
*  CentralbL  flir  Gyn.,  1894,  No.  5. 


November  17,  1894] 


MEDICAL   RECORD. 


619 


in  which  an  annular  constriction  was  found  in  the  va- 
gina, apparently  showing  no  traces  of  cicatrization,  and 
which,  were  it  not  for  the  prior  history,  might  have  been 
looked  upon  as  of  congenital  origin. 

Bearing  all  this  in  mind,  and  recognizing  the  difficulty 
in  deciding  in  a  given  case  whether  it  is  congenital  or 
acquired,  I  think  it  may  be  safely  assumed  that  both  of 
the  cases  reported  to-night  were  congenital.  In  Case  I. 
some  doubt  might  arise,  from  the  existence  of  a  vaginal 
discharge  at  the  age  of  five  and  seven  years  respectively. 
Bat  this  discharge  was  evidently  no  more  severe  than  is 
frequently  witnessed  in  young  girls,  and  probably  would 
not  have  excited  the  attention  of  the  parents  had  it  not 
been  for  its  appearance  at  what  appeared  to  them  an  un- 
natural age.  A  condition  severe  enough  to  be  attended 
with  an  ulcerative  process  would  not  have  been  treated 
lightly  by  the  doctor  that  had  been  consulted.  In  Case 
II.  there  seems  to  be  no  room  for  reasonable  doubt 
The  patient  had  always  been  healthy  as  a  girl,  had  had 
no  severe  illness,  and  had  had  no  vaginal  discharge. 
Still,  the  existence  of  a  second  ring,  and  a  very  small, 
poorly  developed  cervix  would  speak  in  favor  of  an  ul- 
cerative process.  But  this  may  have  been,  and  no  doubt 
was,  of  intra-uterine  origin.  In  fact,  Breisky1  and 
others  maintain  that  the  cause  of  congenital  vaginal 
stenosis  is  to  be  sought  in  foetal  inflammatory  processes, 
and  that  they  probably  most  often  occur  during  the  later 
period  of  intra-uterine  development.  On  the  other 
hand,  some  other  observers,  notably  Dohrn,*  hold  that 
they  develop  in  the  same  way  as  the  hymen.  A  third 
theory  is  that  they  are  due  to  anomalous  development 
of  MUller's  ducts.  Olshausen '  claims  that  it  is  difficult 
to  explain  the  origin  of  vaginal  stenosis  on  the  theory 
of  an  anomaly  of  development,  and  for  this  reason  alone 
doubts  their  congenital  origin. 

The  diagnosis  offers  but  very  little  difficulty.  The 
examining  finger  comes  against  a  ring-like  constriction 
in  the  upper  part  of  the  vagina,  with  an  opening  varying 
in  size  from  a  few  millimetres  in  diameter  to  that  which 
will  admit  the  point  of  one  or  two  fingers.  An  examina- 
tion per  rectum  will  reveal  the  cervix  lying  two  or  three 
centimetres  above  the  constriction. 

An  apparent  stenosis  is  not  infrequently  observed  in 
pregnant  women.  It  is  situated  in  the  upper  part  of  the 
vagina,  not  far  below  the  vault,  and  though  the  constric- 
tion may  be  considerable,  it  never  offers  an  obstruction 
to  labor.  E.  Martin  already  had  called  attention  to  it, 
and  stated  it  was  a  constant  occurrence  in  primiparae  at 
the  sixth  month  of  gestation  (A.  Martin,4  Olshausen  §). 
It  is  said  to  be  produced  by  a  pressing  down  of  the  va- 
ginal vault,  forming  a  duplicative  of  the  vaginal  wall. 

The  treatment  usually  adopted  consists  in  forcibly 
rapturing  the  membranous  ring,  or  making  a  crucial  in- 
cision and  stitching  the  torn  or  incised  membrane  to- 
gether in  the  direction  of  the  long  axis  of  the  vagina.1 
The  crucial  incision  was  the  method  followed  in  the  first 
case,  and  seemed  to  me  unsatisfactory  in  that  it  required 
considerable  after-treatment  with  vaginal  plugs  to  prevent 
recontraction  and  the  immediate  result  was  far  from 
gratifying.  It  occurred  to  me  in  the  second  case  that  it 
would  be  better  to  excise  the  ring  and  stitch  the  upper  and 
lower  edges  of  the  mucous  membrane  together,  which  I  did. 
No  after-dilatation  was  necessary,  and  the  result  was  per- 
fect. Union  had  taken  place  by  primary  intention. 
There  was  no  constriction  to  be  felt  at  the  old  site  of  the 
stenosis  excepting  a  small  portion  of  the  ring  that  had 
been  left  on  the  anterior  wall.  In  a  similar  case  I  would 
excise  the  whole  ring,  though  now  in  my  case  scarcely  a 
trace  of  any  constriction  can  be  detected.  In  fact  any- 
one examining  the  patient  now  for  the  first  time  would 
find  some  difficulty  in  locating  the  site  of  the  former 

» Cyclopaedia  of  Obstetrics  and  Gynecology,  vol  x.t  p.  355.  Will* 
iam  Wood  &  Co. 

*  tTber  die  Entwickelurig  des  Hymen,  Schriften  der  GeselL  fur  Be- 
forderung  der  gesam.  Naturwissen.  zu  Marburg,  Bd.  X. 

»  Loc.  cit 

♦Centrlbl  fur  Gyn.,  1894,  No.  5,  p.  125. 

•Ibid.,  p.  124. 


stenosis.  The  late  C.  C.  Lee,  in  his  excellent  article  on 
Vaginal  Atresias,  in  the  "  American  System  of  Gynecol 
ogy," 1  and,  by  the  way,  he  also  employs  the  paradoxical 
term  "incomplete  atresia/'  speaks  of  dissecting  out  the 
atresic  bands.  He  followed  this  method  in  one  case,  but 
left  the  denuded  surface  to  heal  by  granulation.  "  The 
process  was  slow,  from  the  necessity  of  constantly  main- 
taining effective  dilatation,  but  by  degrees  it  resulted  in 
obtaining  a  perfectly  formed  vagina."  In  my  search  of 
the  literature  on  the  subject  I  find  that  Hey  der,2  in  1890, 
pursued  very  nearly  the  same  course  that  I  did.  He 
divided  the  membranous  ring  into  two  by  a  Paquelin 
cautery,  excised  each  half  with  the  scissors,  and  brought 
the  mucous  membrane  together  by  fine  silk.  Healing 
occurred  in  eight  days.  There  was  only  a  slight  con- 
striction to  be  felt  afterward. 

In  cases  where  the  stenosis  is  not  too  long,  that  is  when 
its  thickness  is  within  moderate  limits,  excision  of  the 
constricting  ring,  with  subsequent  stitching  of  the  upper 
and  lower  edges  of  the  mucous  membrane,  forms,  to  my 
mind,  the  ideal  method.  The  loss  of  blood  may  be  re- 
duced to  a  minimum  by  beginning  with  the  continuous 
suture  as  soon  as  a  small  portion  of  the  ring  is  excised, 
and  following  up  the  cutting  with  suturing.  This  plan  I 
pursued  in  my  case,  and  the  hemorrhage  was  only  trifling. 
By  introducing  a  finger  in  the  rectum  and  holding  the 
urethra  well  up  with  a  sound,  there  should  be  no  danger 
of  wounding  either  of  these  structures. 

127  East  Sixty-tost  Street. 


CIRCUMCISION— DANGERS  OF  UNCLEAN  SUR- 
GERY. 

By  HENRY  LEVIEN,  M.D., 

NSW  YORK. 

Hebrew  male  children  are  generally  circumcised  on  the 
eighth  day  of  their  birth.  This  operation  is  postponed 
only  in  case  of  the  child's  sickness,  or  when  the  babe, 
for  some  reason,  is  in  such  an  enfeebled  condition  that 
it  is  feared  the  operation  may  prove  fatal.  Then  it  is 
postponed  for  a  week  or  for  a  succession  of  weeks. 

Circumcision  is  practised  as  a  purely  religious  rite ;  the 
origin  of  its  appearance  is  to  be  looked  for  in  the  sacred 
literature  of  the  Jews,  and  as  remote  as  the  narrative  of 
Abraham,  the  Hebrew,  who  performed  the  operation  upon 
himself  when  ninety- nine  years  old ;  and  since  that  time 
his  descendants  keep  it  up  as  a  peculiar  sacrifice  which  is 
acceptable  to  God.  There  are  some  allusions,  in  the 
ancient  and  prehistoric  literature,  to  the  effect  that  this 
operation  has  been  performed  for  the  sake  of  cleanliness. 
Herodotus  (ii.,  37)  ascribes  the  origin  of  the  custom  to 
the  Egyptians.  The  same  cause  is  given  on  the  author- 
ity of  Philo  the  Jew ; 8  other  causes  being  avoidance  of 
carbuncle,  purity  of  heart.  Sanitary  reasons  may  have 
been  the  object  in  view ;  but  this,  as  well  as  the  previous 
considerations,  are  not  very  well  accepted,  for  the  reason 
that  other  nations  of  that  epoch,  not  less  intelligent  than 
the  Hebrews,  have  not  accepted  it. 

Ethnographically  considered,  circumcision  is  of  a  Se- 
mitic origin,  taken  by  the  Hebrews  most  probably  from 
the  Arabs,  though  there  are  certain  reasons  to  presume 
that  the  Egyptians  were  the  ones  whom  the  Hebrews 
imitated  in  this  practice,  the  only  inexplicable  feature 
being,  why  do  Hebrews  circumcise  on  the  eighth  day, 
while  the  Arabs,  Egyptians,  and  those  small  tribes  prac- 
tising it  in  the  western  hemisphere,  perform  the  same  on 
the  approach  of  puberty. 

To  this  short  sketch  we  will  add  only  that  this  opera- 
tion was  performed  in  ancient  times,  as*  seen  in  the 
Bible,  with  sharp-edged  stones,  and  that  a  part  of  the 
foreskin  only  was  removed. 

How  is  circumcision  performed  at  present,  at  the  house 
of  a  Hebrew,  under  ordinary  circumstances  ? 

A  look  into  the  operating-room,  and  a  short  acquaint- 


1  American  System  of  Gynecology,  vol.  Ji.,  p.  27.  *  Loc.  cit 

•  Opera,  ed.  Maugey,  ii.,  210. 


620 


MEDICAL    RECORD. 


[November  17,   1894 


ance  with  its  surroundings,  as  well  as  with  the  ceremony 
connected  with  the  operation,  I  believe,  will  be  of  in- 
terest to  those  of  my  colleagues  who  have  never  wit- 
nessed it,  and  will  probably  never  have  the  opportunity 
to  do  so.  Allow  me  to  preface  the  description  by  say- 
ing that  there  is  no  mystery  connected  with  it,  but  cer- 
tain peculiarities  of  a  rather  fanatic  nature  are  adhered 
to,  merely  because  it  is  a  custom  kept  up  for  ages.  As 
an  illustration,  I  will  mention  the  custom  of  hanging  up 
slips  of  paper,  written  or  printed,  containing  a  psalm 
and  some  cabalistic  names  of  some  angels,  designed  to 
protect  child  and  mother  from  the  grasp  of  the  devil. 
These  slips  are  to  be  seen  attached  to  the  bed,  walls,  and 
doors  of  the  bedroom,  and  remain  there  for  about  twelve 
weeks,  the  time  limit  for  the  satan  to  exert  his  demoral- 
izing influence  upon  the  new-born  and  his  mother. 

All  religious  ceremonies  and  prayers  are  best  accepted 
by  God  when  they  are  performed  in  the  presence  of  at 
least  ten  adults  (men,  not  women).  When  the  eighth 
day  approaches,  friends  are  informed  of  the  coming 
event,  and  are  invited  to  be  present  at  the  ceremony  and 
at  the  dinner  following  it.  On  this  day  the  father  at- 
tends church,  where  a  special  prayer  is  given  and  a 
hymn  sung.  In  the  rural  districts  the  infant  would  be 
carried  to  the  synagogue  and  there  operated  upon ;  but 
this  is  done  mostly  by  the  poor,  whose  apartments  are 
too  small  to  accommodate  fifteen  or  twenty  people* 
Otherwise,  the  father,  accompanied  by  all  his  friends, 
goes  home,  where  preparations  are  being  made  for  the 
operation.  The  male  guests  find  seats  in  the  front  room, 
which  will  serve  as  the  operating-room,  while  die  female 
relatives  and  friends  crowd  the  bedroom,  assisting  to 
dress  the  baby.  By  "  preparations"  is  not  meant  that 
nurses,  or  at  least  one  nurse,  is  in  attendance,  preparing 
boiled  water,  sterilized  towels,  trays  for  instruments. 
Not  at  all.  You  see  only  crowded  rooms,  where  the 
nearest  relatives  busy  themselves  by  carrying  pillows 
from  bedroom  into  operating-parlor.  One  feels  there  is 
something  remarkable  going  on,  or  something  remarkable 
going  to  take  place.  To  comfort  the  weary  and  hungry 
visitors  the  father,  greatly  agitated,  goes  from  one  guest 
to  another,  telling  them  that  "  he  n  will  come  soon. 

By  "  him  "  is  meant  the  chief  personality  of  the  day, 
the  surgeon-in-chief,  the  Mohel.  He  is  a  busy  man. 
The  Hebrews  are  a  prolific  nation,  and  the  surgeon  per- 
forms often  three  or  four  operations  in  one  (Sty.  But 
who  is  he  ?  Where  did  he  study  ?  Why  is  he  entrusted 
with  the  life  of  a  human  being  ?  Nobody  can  tell.  All 
we  know  is,  that  he  witnessed  this  operation  several 
times,  and  announced  himself  competent  enough  to  per- 
form the  same.  Generally,  but  not  always,  the  surgeon 
is  more  or  less  conversant  with  the  teachings  of  the  Tal- 
mud, and  especially  with  that  part  of  it  which  treats  of 
the  anatomy  of  the  generative  organs.  Lister,  being 
born  in  this  century,  could  not  have  imparted  his  ideas 
to  the  surgeons  of  the  Talmudical  era;  consequently 
the  Mohel,  who  receives  his  information  on  this  subject 
from  that  source  only,  bravely  goes  to  operate  without 
any  knowledge  of  asepsis  and  antisepsis.  He  has  come. 
Fresh  murmurs  begin  to  circulate  in  the  rooms;  con- 
sultations are  being  held  by  husband  and  wife  as  to 
upon  whom  to  confer  certain  honorary  rites  in  handling 
the  infant  during  operation.  At  last  appointments  are 
made.  One  man  is  to  serve  as  the  operating*  table  (a 
highly  honored  position).  This  man  will  be  seated  on  a 
high  chair  on  pillows,  and  on  his  lap  the  baby  will  lie 
during  operation.  Next  a  young  couple  is  appointed, 
generally  a  maiden  and  a  boy ;  the  first  is  to  take  the 
baby  from  the  mother's  hands  and  transfer  it  to  the 
young  man,  who  in  his  turn  brings  the  child  into 
the  operating-room,  and  hands  him  over  to  the  by- 
standers. Then  the  assistant  surgeons  are  appointed. 
When  the  father  reports  to  the  Mohel  that  everything  is 
ready,  the  latter  calls  the  assemblage  to  order.  The 
man-operating-table  takes  up  his  high  position,  the  sur- 
geon his  place,  the  assistants  crowding  around  him. 

Now  let  us  have  a  look  into  the  surgeon's  armamen- 


tarium. All  you  find  is  a  wooden  case-box,  with  one 
double- edged  knife  in  it.  It  is  not  hard  to  discover  on 
the  knife  suspicious  spots  of  dried-up  blood,  left  from 
some  previous  operation  or  operations.  I  recently  called 
the  attention  of  the  Mohel  to  the  condition  of  his  in- 
strument, upon  which  I  discovered  a  few  bloody  spots ; 
to  satisfy  me  he  tried  to  rub  the  blood  off  with  his  finger- 
nails, and  believed  asepsis  was  fully  attained.  I  was 
compelled  to  interfere  and  make  him  do  what  I  consid- 
ered proper.  The  operation  in  its  primitive  form,  as 
will  be  seen  later,  is  divided  into  four  parts,  each  being 
performed  by  a  separate  individual,  though  improve- 
ments and  modifications  are  being  instituted. 

The  signal  is  given.  The  baby  is  on  its  way  from  the 
bedroom,  and  when  it  reaches  at  last  the  operating-room, 
the  Mohel  meets  it  with  a  phrase :  "  Blessed  be  he  who 
has  come ! * '  which  is  repeated  by  all  present.  The  baby 
is  kept  on  a  pillow,  and  in  this  state  it  is  placed  on  the 
lap  of  the  high-positioned  man.  The  operation  begins. 
The  surgeon  goes  to  work.  There  is  no  washing  of 
hands,  no  scrubbing  of  finger- nails. 

First  part:  The  surgeon  steps  bravely  forward,  ad- 
justs the  baby  in  the  right  position,  and  baring  the  penis, 
grasps  the  foreskin  with  the  thumb  and  forefinger  of  his 
left  hand,  says  a  prayer,  and  cuts  it  off.  His  work  is  done. 
He  steps  aside  to  give  place  to  No.  2,  who  with  the 
pointed  nails  of  his  thumbs  tears  and  divides  the  mucous 
membrane  covering  the  glans  and  pushes  it  backward  to 
the  corona.  When  this  is  done,  forward  steps  the  third 
party,  who  takes  the  bleeding,  tender  organ  into  his 
mouth,  which  is  never  cleaned  before,  and  may  be  full 
of  decayed  teeth  and  purulent  gingivitis,  and  sucks  it 
three,  four  times,  spitting  the  blood  into  a  specially 
prepared  receptacle  with  some  special  (Palestine  ?)  sand 
in  it.     Into  the  same  is  placed  the  cut-off  foreskin. 

Fourth.  The  surgeon-in-chief  resumes  his  duty  again, 
and  an  attempt  is  made  to  dress  the  wound.  It  consists 
in  placing  a  handful  of  some  pulverized  decayed  wood 
which  is  supposed  to  have  astringent  power,  and  cover- 
ing it  with  some  rags. 

To  quiet  the  child  during  and  after  the  operation,  it  is 
customary  to  put  a  rag  with  some  predigested  food  into 
the  infant's  mouth,  thus  preventing  him  from  yelling  too 
much. 

Now  the  child  is  taken  from  the  operating-table  and 
transferred  to  some  honorary  member  of  the  assemblage. 
A  prayer  is  sung  by  the  Mohel,  while  keeping  a  glass  of 
wine  in  his  right  hand,  and  when  a  certain  point  in  the 
hymn  is  reached,  he  wets  the  tip  of  his  left-hand  little 
finger  in  the  wine,  and  saying,  "  Live  with  thy  blood/9 
he  smears  the  lips  of  the  infant  with  it.  At  the  same 
time  the  name  is  officially  given  to  the  child,  he  con- 
cludes his  prayer,  drinks  the  wine,  and  the  ceremony  is 
at  an  end.  The  child  is  now  again  handed  over  from 
one  to  another,  until  it  reaches  the  young  man,  who 
transfers  it  to  the  young  lady,  the  last  returning  the 
baby  to  the  anxious  mother.  Tables  are  now  set  in  the 
operating-room,  and  the  feast  begins.  The  dangers  of 
infection  the  new-born  has  been  exposed  to  may  be  seen 
by  the  readers  themselves. 

The  improvements  in  this  procedure,  as  mentioned 
above,  are  being  instituted  in  large  cities  only,  where  the 
Mohel  comes  in  closer  connection  with  the  physician, 
and  consist  in  the  following  modifications :  The  Mohel 
does  the  whole  work  himself,  and  instead  of  sucking 
with  the  bare  lips,  he  employs  a  glass  tube  through  which 
the  suction  process  is  performed.  The  advanced  surgeon 
uses  also  a  metal  plate  with  a  long  and  narrow  hole  in 
it,  and  uses  it  as  a  clamp ;  he  pulls  the  foreskin  through 
the  hole,  pushing  meanwhile  the  plate  toward  the  glans, 
thus  protecting  the  last  from  direct  injury.  Again,  in* 
stead  of  the  traditional  powder,  plain  or  even  iodoform 
gauze  is  used  for  dressing.  But  this  additional  instru- 
ment, the  plate,  serves  very  often  as  a  new  source  of  in- 
fection. I  found  on  this  metal  piece  dried- up  blood,  and 
had  to  insist  on  its  disinfection. 

I  will  cite  now  two  cases  I  recently  came  across, 


November  17,  1894] 


MEDICAL    RECORD. 


621 


which,  I  believe,  will  serve,  on  one  hand,  as  an  illustra- 
tion of  the  dangers  the  new-born  Hebrew  children  are 
exposed  to ;  on  the  other  hand,  with  the  above  considera- 
tions and  the  following  facts  in  view,  they  may  be  treated 
as  a  friendly  warning  and  advice  to  those  of  my  col- 
leagues who  axe  engaged  in  obstetrical  practice  among 
the  Hebrews,  to  make  it  their  business  and  a  matter  of 
conscience  to  be  present  at  every  operation,  and  super- 
vise the  whole  procedure. 

Case  I. — I  was  called  to  see  child  R on  the  30th 

of  March.  Infant,  aged  thirteen  days,  was  circumcised 
on  the  25th ;  child  was  not  well  since  operation,  but 
became  worse  on  the  28th.  The  Mohel  was  then  called 
in,  who  ordered  an  ointment  which  did  not  do  any  good. 

Present  state :  Acute  inflammation  of  the  penis,  ery- 
sipelatous oedema  of  scrotum  and  on  pubic  region.  In 
the  cervix,  behind  the  glans,  I  detected  a  small  ulcer, 
which  was  probably  the  nidus  of  infection.  Tempera- 
ture, 1050  F.;  pulse,  160;  respiration,  60.  Child  very 
restless,  crying  as  if  in  great  pain.  Every  time  the 
child  would  pass  urine  it  would  scream  and  have  con- 
vulsive movements. 

*  March  31st. — The  dressing  and  local  applications  I 
ordered  seemed  to  control  the  pain,  but  the  erysipelatous 
process  was  not  arrested,  and  spread  farther  up,  reaching 
a  point  midway  between  the  symphysis  pubis  and  um- 
bilicus. Slight  diminution  in  the  oedema  of  scrotum. 
Temperature  and  pulse  not  changed ;  respiration  labored. 

April  1st. — Child  is  reported  to  have  had  two  distinct 
convulsions;  was  very  restless.  The  abdomen  very 
tender  on  palpation ;  slight  tympanites ;  redness  up  to 
the  umbilicus.  Baby  too  weak  to  nurse ;  pulse  hardly 
perceptible  at  the  radial  artery.  There  was  certainly 
very  little  hope  to  save  the  child,  and  I  told  the  parents 
my  opinion. 

April  3d. — Have  seen  the  child  at  2  p.m.  The  lower 
abdomen,  penis,  scrotum,  and  upper  part  of  both  thighs, 
cyanotic,  just  as  if  gangrene  had  set  in.     Child  died  at 

4  P.M. 

Case  II. — I  was  called  by  a  Mohel  to  see  a  baby  whom 
he  operated  upon  the  same  day.  The  trouble,  severe 
hemorrhage  somewhere  on  the  penis,  which  hemorrhage 
he  could  not  control  by  any  means  known  to  him.  He 
was  very  anxious,  and  justly  considered  himself  respon- 
sible. On  arrival  I  learned  that  the  child  was  bleeding 
the  whole  day  and  had  lost  about  three  ounces  of  blobd. 
It  was  very  hard  to  locate  the  bleeding  point,  as  the 
penis  was  wrapped  up  in  rags,  soaked  in  a  solution  of 
liquor  ferri  chloridi,  and  on  removing  the  rags  the  whole 
penis  appeared  dark  and  swollen.  At  last  I  discovered 
the  artery  of  the  corpus  cavernosum  eroded  and  laid 
open  at  the  internal  layer  of  the  prepuce.  It  took  con- 
siderable time  to  secure  the  vessel  and  compress  it,  on 
account  of  the  swelling  and  tenderness  of  the  parts. 
Having  applied  an  antiseptic  dressing,  I  left,  instructing 
the  mother  to  call  me  at  once  if  the  hemorrhage  re- 
curred. When  I  called  on  the  next  day  I  found  the 
hemorrhage  stopped,  the  swelling  less,  but  ulcerations  of 
different  degrees  traversing  the  mucous  layer  and  the 
glans.  The  erosions  were  caused  probably  either  by  the 
misapplied  dressing,  or  while  pushing  the  mucous  mem- 
brane toward  the  cervix.     The  child  recovered. 

In  view  of  the  above  considerations  and  other  facts, 
the  question  presents  itself:  Shall  the  medical  profession 
and  boards  of  health  look  upon  these  mutilations  from 
the  hands  of  ignorant  people  indifferently,  or  shall  we 
join  with  the  State  of  Ohio  in  introducing  a  bill  prohibit- 
ing circumcision  entirely? 

In  attempting  to  solve  the  question  we  should  care- 
fully consider  the  pros  and  cons  before  expressing  a  pfosi- 
tive  opinion.  I  will  therefore  lay  before  the  medical 
world  some  considerations  for  and  against  prohibition. 

For  prohibition  speak  partly  the  facts  and  morals  of 
this  paper,  i.e.,  injuries  and  even  death  inflicted  upon 
the  new-born;  secondly,  humanitarians  find  circumci- 
sion an  act  of  cruelty  and  barbarism,  especially  as  prac- 
tised among  the  poorer  classes  of  Hebrews. 


Thirdly,  many  consider  the  whole  procedure  entirely 
unnecessary,  and  in  proof  of  it  say  that  hundreds  of 
millions  of  people  live  and  prosper,  not  being  circum- 
cised. 

Against  that  bill  the  following  reasonings  suggest  them- 
selves: 

First,  circumcision  is  a  religious  rite,  besides  being  a 
custom  of  a  race  for  about  three  thousand  years,  and  we 
believe  that  no  free  government  has  the  right  to  intrude 
upon  anybody's  religious  convictions. 

Secondly,  it  is  a  recognized  fact  that  the  Jews  are  less, 
than  uncircumcised  nations,  prone  to  venereal  ailments, 
and  when  so  affected  are  sooner  cured  than  others. 
Phimosis  and  paraphimosis,  due  to  venereal  infection,  is 
almost  unknown  among  the  Jews. 

Thirdly,  the  operation  itself,  in  the  hands  of  skilful 
and  intelligent  men,  is  not  a  severe  one,  and  children 
bear  it  well ;  and, 

Fourth,  I  would  hesitate  to  stop  a  process,  though  a 
depletory  one,  in  a  nation  in  whom  the  depletion  for 
hereditary  reasons  may  be  a  necessity  for  the  well-being 
of  the  race,  and  may  prove  disastrous  if  this  operation  is 
denied. 

There  are  but  few  men  of  the  younger  generation  who 
have  decided  to  do  away  with  circumcision  on  their 
children,  and  we  cannot  draw  any  conclusions  yet.  I, 
for  my  part,  would  suggest  to  meet  the  question  in  such 
a  way  as,  on  the  one  hand,  not  to  offend  the  religious  sen- 
timents of  a  people  by  passing  State  laws  on  their  behalf; 
on  the  other  hand,  to  protect  the  innocent  young  ones 
from  maltreatment. 

This  could  be  materialized  by  introducing  a  bill  pro- 
hibiting, not  circumcision,  but  "  circumcisers,"  from  per- 
forming operations  in  the  way  they  do  now,  and  passing  a 
law  that,  at  each  and  every  operation,  a  duly  registered 
and  practising  physician  shall  be  present,  or  such  physi- 
cian should  be  sent  from  the  local  board  of  health.  The 
physician  shall  superintend  the  operation,  and  shall  be  the 
responsible  party. 

Certainly  no  good  can  be  attained  by  licensing  circum- 
cisers,  having  them  undergo  a  certain  examination,  etc. 
The  licensed  midwife  furnishes  us  a  good  example  of 
things  half  done.  Midwives,  being  allowed  to  go  on  in 
their  practice  so  far,  will  always  take  one  step  further, 
and  a  good  deal  of  mischief  to  the  patients  under  their 
care  is  the  result.  Circumcision  is  an  operation  requir- 
ing as  much  care  and  dexterity  on  the  part  of  the  sur- 
geon as  in  any  other  surgical  work,  and  should  be  per- 
formed by  a  competent  surgeon,  or  at  least  under  his 
direct  supervision. 

C39  East  Broadway. 


The  Comma  Bacillus  and  Cholera. — A  statement  has 
appeared  in  more  than  one  of  our  lay  contemporaries  of 
the  death  from  Asiatic  cholera  of  Dr.  Oertel  (who  must 
not  be  confounded  with  the  distinguished  Munich  pro- 
fessor), of  the  Hygienic  Institute  at  Hamburg,  while  en- 
gaged in  bacteriological  investigations  of  specimens  of 
infected  water  from  the  Vistula.  It  is  said  that  he 
succeeded  in  making  cultures  of  the  cholera  bacilli 
from  this  water,  and  in  one  account  it  is  circum- 
stantially related  how  he  introduced  into  his  mouth  a 
minute  portion  of  the  cultures,  and,  although  recogniz- 
ing the  gravity  of  the  accident  and  resorting  to  the  free 
use  of  germicides,  he  developed  symptoms  of  the  disease, 
which  rapidly  proved  fatal.  If  substantiated,  this  sad 
occurrence  not  only  adds  one  more  to  the  list  of  fatali- 
ties among  experimental  investigators,  but  would  form  a 
verification  of  the  value  of  Koch's  discovery;  for,  al- 
though more  than  one  experimenter  has  ventured  to 
swallow  these  bacilli  with  impunity,  their  negative  re- 
sults cannot  weigh  against  a  clearly  proved  positive  one. 
It  is,  of  course,  quite  as  likely  that  the  disease  was  con- 
tracted in  another  way,  and  that  the  case  affords  another 
of  the  numerous  coincidences  in  which  medical  history 
abounds. — The  Lancet. 


622 


MEDICAL   RECORD. 


[November  17,  1894 


A    PLEA    FOR    IMMEDIATE    CCELIOTOMY    IN 
RUPTURED  TUBAL  PREGNANCY.1 

By  CHARLES  E.  NAMMACK,  M.D., 

NEW  YOKK. 

The  object  of  this  communication  is  to  endeavor  to  re- 
move the  impression  existing  in  the  minds  of  many 
medical  men,  that  ruptured  tubal  pregnancy  does  not  re- 
quire immediate  coeliotomy.  Tins  impression  seems  to 
be  founded  on  the  old  teaching  that  when  the  sac  rupt- 
ures in  the  early  weeks  of  pregnancy,  the  escape  of 
blood  may  be  moderate  and  run  the  course  of  ordinary 
hematocele.  Even  so  recent  a  book  as  the  "  American 
Text-Book  of  Surgery"  says  (p.  972)  that  when  the 
hemorrhage  is  into  the  connective-tissue  interspaces  of 
the  broad  ligaments,  the  treatment  should  be  purely  ex- 
pectant, but  that  intra-peritoneal  hematocele  requires 
abdominal  incision,  etc.  It  also  gives  the  differential 
points  between  the  two  varieties  of  hematocele,  but  the 
average  practitioner  who  waits  until  this  differential  diag- 
nosis shall  be  demonstrable,  will,  in  the  average  case, 
have  waited  until  his  patient  has  lost  more  blood  than 
she  can  regain. 

However  doubtful  and  problematic  the  diagnosis  of 
tubal  pregnancy  in  its  early  stages  and  prior  to  rupture 
may  be,2  there  is  fortunately  a  very  clear  clinical  picture 
presented  after  rupture  has  occurred.  The  marked  symp- 
toms are  summed  up  by  Joseph  Price,*  and  form  a  group 
which  should  be  promptly  recognized  and  immediately 
treated  by  primary  operation  in  all  cases.  Price's  statistics 
show  ninety-six  per  cent,  of  recoveries  in  personal  cases  op- 
erated on,  as  against  fifty  per  cent  recoveries  in  the  cases 
of  others  when  treated  expectantly.  Duhrssen  *  reports 
twenty-nine  cases  of  coeliotomy  for  ruptured  tubal  pregnan- 
cy, with  three  deaths — almost  ninety  per  cent,  recoveries. 

It  has  been  the  writer's  lot  to  see  the  consequences  of 
delay  in  two  cases  since  January,  1893.  The  first  of 
these  he  reported  in  the  Medical  Record  of  March  18, 
l893>  P-  343.  It  was  a  case  in  which  the  surroundings 
and  previous  history  of  intra-pelvio  suppuration  in  the 
patient  were  considered  by  two  eminent  gynecologists 
to  be  sufficient  reasons  for  postponing  operation  until 
patient  could  be  moved  to  a  hospital.  But  the  hemor- 
rhage recurred  in  a  very  few  hours,  operation  was  per- 
formed by  a  third  consultant,  when  all  hope  had  been 
abandoned  by  the  patient's  relatives,  and  she  was  liter- 
ally snatched  from  the  jaws  of  death.  The  second  case 
emphasizes  so  clearly  the  lesson  taught  me  in  that  first  case 
that  the  recital  of  it  may  help  to  firmly  fix  in  the  minds 
of  others  the  conviction  that  a  woman  with  a  ruptured 
tubal  pregnancy  should  not  be  left  until  it  is  extirpated. 

Mrs.  Mary  L ,  thirty- five  years  of  age,  consulted 

me  September  8,  1893,  and  was  found  to  be  suffering  from 
tuberculosis  of  the  lungs  and  larynx.  She  was  treated  at 
intervals  until  April,  1894,  the  pulmonary  process  not 
advancing  beyond  the  stage  of  consolidation,  and  during 
this  time  her  menstrual  periods  were  regular.  Her  last 
child  had  been  born  seven  years  before.  She  went  two 
weeks  over  time  in  April,  1894,  but  the  desired  flow  finally 
came  in  response  to  hot  foot  baths,  etc.  She  then  men- 
struated regularly  and  normally  in  May,  June,  and  July, 
her  last  flow  beginning  July  13th.  On  September  3d  she 
felt  a  sharp  stinging  pain  in  right  groin,  followed  by  slight 
show  of  blood.  The  pain  yielded  to  recumbency  and 
the  application  of  a  hot  water  bag  and  the  patient  was  up 
and  around  next  day.  On  September  16th  she  lifted  a 
basket  of  coal  from  the  elevator  and  immediately  the  pain 
recurred,  she  became  nauseated'  and  faint,  and  had  an- 
other slight  bloody  vaginal  discharge.  The  pain  after 
this  being  persistent,  and  the  weakness  and  fainting  at- 
tacks progressive,  she  sent  for  me  September  21st,  and, 
pending  my  arrival,  called  in  a  neighboring  physician, 

1  Read  before  the  New  York  Academy  of  Medicine,  Section  on  Ob- 
stetrics and  Gynecology,  October  25, 1894. 

*  T.  M.  Baldy  :  Mbdical  Record,  September  21,  1889,  p.  310. 

•  Medical  and  Surgical  Reporter,  September  30,  1893. 

4  American  Journal  of  the  Medical  Sciences,  May,  1894,  p.  601. 


who  told  her  he  suspected  tubal  pregnancy.  The  evi- 
dences of  rupture  and  internal  hemorrhage  were  plain  at 
the  time  of  my  visit.  Surgical  assistance  was  at  once 
summoned,  and  upon  the  arrival  of  the  operating  surgeons 
a  consultation  was  held.  My  opinion  that  an  immediate 
operation  was  demanded  was  overruled,  the  other  men 
being  unanimous  in  the  belief  that  the  hemorrhage  was 
limited  to  the  layers  of  the  broad  ligament,  and,  there- 
fore, extra-peritoneal,  and  that  nature  would  be  com- 
petent to  absorb  it,  or  that,  at  least,  expectant  treatment 
was  justifiable.  The  next  morning  that  patient  went  into 
collapse  from  recurrence  of  the  concealed  hemorrhage, 
and  there  was  no  longer  any  difference  of  opinion  as  to 
the  proper  procedure.  Preparations  for  immediate  opera- 
tion were  hastily  made,  chloroform  being  chosen  as  the 
anaesthetic  on  account  of  patient's  pulmonary  condition, 
and  because  vomiting  had  become  a  prominent  symptom. 
Abdominal  incision  revealed  a  quantity  of  loose  clots  and 
fluid  blood,  estimated  by  the  operator  at  three  quarts,  and 
a  ruptured  tubal  pregnancy  with  the  foetus  protruding. 
The  ovum  was  developed  so  close  to  the  uterus  that  the 
extirpation  was  difficult  and  tedious,  and  the  patient's  pulse 
stopped  when  it  was  finished.  She  rallied  under  inhala- 
tions of  amy  1  nitrite  and  the  hypodermatic  use  of  strych- 
nia and  brandy,  with  injections  of  hot  salt  solution  into 
the  cellular  tissues  and  rectum.  During  these  procedures, 
the  operator  flushed  the  abdominal  cavity,  damped  the 
cut  end  of  the  tube  at  the  uterine  junction,  and  packed 
with  iodoform  gauze  without  waiting  to  suture  the  tis- 
sues. The  patient  was  then  put  to  ted,  collapsed  from 
hemorrhage.  Despite  all  efforts  and  efficient  nursing, 
she  never  rallied,  and  died  fifty-two  hours  after  operation. 
What  the  result  would  have  been  under  operation  twenty 
hours  earlier  cannot  be  positively  stated,  but  there  is  no 
doubt  that  a  recognition  of,  and  prompt  operation  for, 
her  condition  on  September  3d,  when  the  first  symptom 
appeared,  would  have  saved  her  life. 

And  now  a  word  as  to  the  different  indications  for  treat- 
ment, depending  on  whether  the  rupture  is  intra-peri- 
toneal or  extra-peritoneal.  According  to  the  "  American 
Text-Book  of  Gynecology,"  p.  541,  "  the  safest  rule  is  to 
prepare  at  once  for  operation,"  if  intra* peritoneal  rupture 
has  occurred,  but  if  the  hematoma  is  extra-peritoneal, 
"  the  treatment  is  usually  non-operative/1  p.  542. 

This  leaves  the  patient  exposed  to  the  fourfold  dangers 
of  1,  recurrent  hemorrhage ;  2,  peritonitis ;  3,  septicaemia; 
4,  subsequent  trouble  in  the  damaged  tube.  While  not 
denying  the  possibility  that  a  pelvic  hematoma  may  re- 
main extra- peritoneal  until  it  is  absorbed,  the  writer  con- 
siders that  the  probability  of  recurrent  hemorrhages  caus- 
ing it  to  burst  into  the  peritoneal  cavity  is  so  great  as  to 
make  primary  operation  the  only  safe  procedure.  On 
this  point  Joseph  Price l  speaks  with  no  uncertain  sound 
when  he  says :  "  With  an  experience  of  eighty- three  sec- 
tions for  ectoptic  pregnancy,  I  remain  in  surgical  ig- 
norance of  extra-peritoneal  hematocele,  not  a  single  case 
did  I  encounter."  Munde's  experience  with  twelve  cases 
of  ectopic  pregnancy 2  form  an  interesting  study  and  show 
the  value  of  prompt  operation. 

»9  Ea»t  Twbnty-foukth  Stxekt. 


A  Census  of  Medical  Ken  in  Alsace-Lorraine  shows 
that  there  were  in  those  provinces  in  the  first  of  this  year 
619  physicians,  10  diplomaed  dentists,  123  veterinary 
physicians,  and  230  pharmacists.  Of  the  physicians 
there  were  529  with  German,  and  90  with  French 
diplomas. 

4  Cure  for  Dyspepsia. — A  minister  in  Ohio  was  de- 
posed some  months  ago  on  account  of  immorality.  He 
admitted  the  charge  of  having  had  irregular  relations 
with  some  of  the  women  of  his  flock,  but  defended  him- 
self on  the  plea  that  his  physician  had  recommended  it 
as  a  cure  for  dyspepsia. 

1  Medical  and  Surgical  Reporter,  September  30,  1893,  p.  5091 
*  American  Journal  of  Obstetrics,  vol.  xxix. ,  No.  5, 1894. 


November  17,  1894] 


MEDICAL    RECORD. 


623 


gwgress  of  iJfcjeflfccal  j&cteujc*. 

Cardiac  Syphilis  and  Angina  Pectoris. — At  the  Ber- 
lin Medical  Society  Dr.  A.  Fraenkel  recently  demon- 
strated a  specimen  of  cardiac  syphilis  from  a  woman, 
thirty-six  years  of  age.  When  first  seen  last  year,  she 
had  aortic  regurgitation  and  suffered  from  frequent  head- 
aches, which  were  occasionally  associated  with  fainting 
attacks.  The  heart  disease  was  supposed  to  be  conse- 
quent on  acute  rheumatism.  The  husband  was  syphi- 
litic, and  the  woman  herself  had  suffered  from  swellings 
on  the  head,  which  had  ulcerated  and  left  scars.  She 
improved  at  first  and  left  the  hospital,  but  was  read- 
mitted this  year  with  severe  attacks  of  angina  pectoris, 
in  one  of  which  she  died.  At  the  necropsy  the  left  cor- 
onary artery  was  found  quite  permeable,  but  the  orifice 
of  the  right  coronary  was  completely  obliterated  by  a 
process  of  arterio  sclerosis  (much  in  excess  of  the  pa- 
tient's years),  and  its  proper  position  could  only  be  de- 
termined by  probing  backward  along  the  lumen  of  the 
artery.  There  was  a  gummatous  tumor,  4^  ctm.  long, 
in  the  septum  ventriculorum,  and  Fraenkel  thinks  this 
shows  that  the  arterial  changes  were  really  of  syphilitic 
nature.  The  arterio-sclerotic  changes  in  the  aorta  reached 
down  to  the  bifurcation.  Fraenkel,  moreover,  remarks 
on  the  part  played  by  syphilis  in  the  etiology  of  aneu- 
risms. Walsh  thought  that  sixty  per  cent,  of  true  aneu- 
risms were  due  to  syphilis,  others  think  still  more. 
Fraenkel  himself,  during  the  last  four  years,  has  seen  19 
cases  of  aneurism  of  the  thoracic  aorta  in  which  there 
were  necropsies;  3  cases  were  in  women,  16  in  men. 
Of  the  19  patients,  9,  that  is,  forty-seven  per  cent.,  had 
had  syphilis,  and  these  were  all  under  fifty  years  of  age. 
The  case  illustrates  the  relation  of  precocious  arterio- 
sclerosis and  syphilis. — Berliner  klinisehe  Wochen- 
schrift. 

Pancreatic  Colic. — Dr.  Minnich  has  observed  a  case 
of  this  kind  in  a  man  sixty-eight  years  of  age.  At  the 
age  of  forty  he  became  troubled  with  attacks  of  colic 
which  were  attended  with  jaundice,  and  continued  dur- 
ing a  period  of  three  months,  but  disappeared  upon 
treatment.  In  the  stools  were  found  typical  biliary  cal- 
culi. There  then  followed  a  period  of  freedom  from 
attacks  for  ten  years  and  a  half,  when  attacks  of  colic 
recurred.  These  again  yielded  to  suitable  treatment. 
Seventeen  years  later  the  man  was  suddenly  awakened  at 
night  by  an  attack  of  colic  resembling  previous  attacks. 
A  second  attack  took  place  on  the  next  day,  and  a  third 
several  months  later.  At  this  time  there  appeared  a 
sense  of  oppression  in  the  epigastrium,  together  with  loss 
of  appetite  and  distaste  for  fluids.  This  condition  per- 
sisted for  about  a  month,  without  the  occurrence  of  an 
actual  attack  of  colic.  At  the  end  of  this  time  the  man 
was  seized  with  diarrhoea,  lasting  for  three  days,  and 
ending  with  an  attack  of  colicky  pain,  referred  to  the  16ft 
hypochondrium  and  to  the  epigastrium.  The  patient 
was  well  nourished,  and  presented  no  oedema.  The 
scleras  were  a  little  yellowish  and  the  skin  dry  and  of 
normal  warmth,  but  not  icteric,  although  the  seat  of 
annoying  itching  and  a  chronic  desquamative  eczema 
upon  the  exterior  surfaces  of  the  arms.  The  temporal 
arteries  were  slightly  tortuous,  but  there  was  no  other 
evidence  of  arteriosclerosis.  There  was  an  absence  of 
abdominal  tenderness,  so  that  deep  palpation  could  be 
practised,  but  without  yielding  positive  information. 
The  liver  was  not  enlarged,  and  the  gall-bladder  could 
not  be  appreciated.  The  spleen  was  likewise  not  palpa- 
ble, and  the  area  of  splenic  percussion  dulness  was  not 
increased.  There  was  no  evidence  of  dilatation  of  the 
stomach,  and  a  peritoneal  effusion  could  not  be  detected. 
The  patient  described  the  paroxysm  as  beginning  with  a 
sense  of  dull,  heavy,  constricting  pain  above  the  epigas- 
trium and  in  the  left  hypochondrium,  increasing  in  in- 
tensity and  localizing  itself  deeply  in  at  one  point  below 
the  left  costal  margin,  just  within  the  mammillary  line. 


At  the  height  of  the  attack  the  pain  extended  from  this 
point  circularly  to  the  vertebral  column  in  the  course  of 
the  costal  arch,  thence  radiating  beneath  the  left  scap- 
ula. At  the  termination  of  the  attack  pain  was  still  per- 
ceptible at  the  point  below  the  costal  margin,  in  an  area 
about  an  inch  and  a  half  in  diameter.  Careful  explora- 
tion of  this  region  failed  to  disclose  any  morbid  condi- 
tion, excepting  slight  tenderness.  The  attack  abruptly 
came  to  an  end  at  the  expiration  of  two  hours,  and  was 
followed  by  a  sense  of  hunger.  The  urine  passed  at  this 
time  was  free  from  albumin  and  sugar,  and  did  not  re- 
spond to  tests  for  biliary  coloring  matter.  From  this 
time  the  attacks  were  repeated  almost  daily,  usually  set- 
ting in  toward  the  end  of  the  day  and  lasting  from  a 
fraction  of  an  hour  to  several  hours.  The  condition  re- 
sisted the  ordinary  treatment  for  hepatic  colic  An  ex- 
amination of  the  stools  failed  to  disclose  the  presence  of 
fat  or  fatty  crystals,  or  biliary  calculi.  On  several  occa- 
sions, however,  light-gray,  round  calculi  were  found, 
which  could  be  crushed  between  the  fingers,  and  micro- 
scopically proved  to  be  constituted  of  amorphous  matter. 
They  dissolved  in  chloroform,  leaving  a  turbid  solution. 
They  fused  in  the  flame,  giving  off  a  dense  vapor  having 
an  aromatic  odor.  The  residue  yielded  the  reactions  of 
calcium  carbonate  and  calcium  phosphate.  Subsequent 
attacks  of  pain  occurred,  but  no  more  calculi  or  other 
abnormal  matter  was  found  in  the  intestinal  evacuations. 
The  condition  was  regarded  as  one  of  calculous  forma- 
tion resulting  in  obstruction  of  the  excretory  ducts  of  the 
pancreas,  and  giving  rise  to  attacks  of  colic.  The  sub- 
sequent history  of  the  patient  is  not  given,  however,  and 
the  diagnosis  therefore  lacks  confirmation. — Berliner 
klinisehe  Wochenschrift. 

Valerianate  of  Amyl. — Dr.  Blanc  describes  valerian- 
ate of  amyl,  which  is  the  odoriferous  principle  of  the 
apple,  that  is,  the  essence  extracted  by  distillation  to- 
gether with  alcohol.  Cider  has  long  been  believed  by 
the  laity  to  have  some  effect  on  calculous  formations,  and 
this  seems  to  be  borne  out  by  the  fact  that  valerianate 
of  amyl  really  has  some  solvent  action  on  cholesterin. 
It  is  a  colorless  liquid,  of  pleasant  taste  when  taken  in 
small  quantities,  and  can  be  prepared  in  the  laboratory 
by  the  action  of  valerianic  acid  on  amyl  alcohol ;  1  grain 
of  cholesterin  is  dissolved  by  4^  grains  of  valerianate 
at  370  C.  and  by  3  grains  at  400  C.  (British  Medical 
Journal').  Physiologically  the  action  resembles  that  of 
ether,  but  the  special  qualities  lie  in  its  being  a  stimu- 
lant and  sedative  to  the  liver  in  cases  of  hepatic  colic. 
It  not  only  immediately  subdues  the  attack,  but  it  pre- 
vents recurrences.  If  the  stomach  is  irritable,  ft  may  be 
necessary  first  to  employ  sulphuric  ether,  following  this 
with  two  to  three  capsules  of  fifteen  centigrammes  each, 
given  every  half-hour  until  the  crisis  is  past,  and  con- 
tinued at  longer  intervals  during  the  following  days.  In 
nephritic  colic  the  drug  acts  as  an  antispasmodic  and  gen- 
eral stimulant  only,  but  no  effect  is  produced  on  the 
renal  calculi.  Muscular  rheumatism  is  frequently  re- 
lieved, and  much  benefit  is  also  derived  from  its  use  dur- 
ing menstrual  uterine  contractions.  As  a  sedative,  it  is 
of  value  in  hysterical  manifestations.  Its  toxic  proper- 
ties being  very  slight,  as  many  as  five  to  six  capsules  can 
be  taken  daily,  but  it  is  necessary  to  guard  against  gas- 
tric disturbance. 


Syphilid  and  Aphasia. — Dr.  Jolly  reported  at  the 
Congress  of  German  Physicians,  Vienna,  a  case  of  cerebral 
syphilis  in  which  he  was  able  to  demonstrate  by  autopsy 
the  dependency  of  word  deafness  and  aphasia  on  a  com- 
plete destruction  of  the  entire  parietal  lobe,  the  two  first 
temporal  lobes,  the  angular  gyrus,  prsecuneus  and  cu- 
neus.  The  patient  was  unable  to  read  his  own  name,  to 
write  from  dictation.  The  word  deafness  Jolly  considers 
was  due  to  the  lesion  in  the  temporal  lobe,  and  the  loss 
of  speech  possibly  to  the  entire  destruction  'of  the  audi- 
tory centre  and  areas. 


624 


MEDICAL   RECORD. 


[November  17,  1894 


Medical  Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


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


New  York,  November  17,  1894. 


THE  CHANNELS  OF  INFECTION  IN  TUBER- 
CULOSIS. 
The  subject  of  tuberculosis  is  to-day  the  gravest  one 
with  which  the  physician  has  to  deal,  and  the  necessity 
of  lowering  its  frightful  mortality  by  preventing  it,  rather 
than  by  treatment,  was  never  more  keenly  appreciated. 

Although  the  general  principles  of  infection  have  been 
well  worked  out,  the  channels  of  infection  is  a  subject 
that  pathologists  are  not  entirely  agreed  upon.  Dr. 
Sims  Woodhead  has  recently  made  a  communication  in 
The  Lancet  which  has  contributed  much  to  our  enlighten- 
ment. He  concedes  that  the  tuberculous  virus  may  be 
directly  inoculated  into  the  tissues,  but  this  condition  is 
comparatively  very  rare.  Heredity,  to  which  has  been 
attributed  such  an  important  rdle  in  the  past,  plays  an 
altogether  unimportant  part  in  the  spread  of  tuberculosis, 
ranking  only  with  such  factors  as  insufficient  and  imper- 
fect food,  and  defective  hygienic  conditions. 

Tuberculosis  attacks  the  lungs  and  alimentary  canal  by 
preference,  because  it  is  here  that  the  bacillus  most  easily 
finds  the  moist  mucous  membrane  with  defective  epithe- 
lial covering  for  which  it  has  a  special  predilection. 
When  the  tubercle  bacillus  is  carried  into  the  alimentary 
canal  by  the  saliva,  by  food-stuffs,  etc.,  it  is  rendered 
innocuous  in  more  ways  than  one ;  but  perhaps  the  most 
effectual  way  is  by  its  being  taken  into  the  substance  of 
lymphocytes,  which  make  their  way  out  and  in  from  the 
lymphoid  patches,  and  which  have  the  power  of  taking 
into  their  substance  the  tubercle  bacilli.  These  lym- 
phocytes return  with  their  evil  burden  to  the  lymph- 
glands,  and  the  glands  assist  in  the  complete  destruction 
of  the  bacilli.  This  is  the  performance  that  is  continu- 
ally going  on,  and  as  the  result  infection,  local  and  sys- 
temic, is  prevented.  If,  however,  the  lymphoid  patches 
be  devoid  of  epithelium,  or  if  the  tissues  be  so  weakened 
that  their  power  of  resistance  can  be  readily  overcome  by 
comparatively  few  micro-organisms,  then  infection  will 
probably  follow.  Masses  of  adenoid  tissue,  whatever 
their  situation,  if  the  cells  are  active,  are  means  of  pro- 
tection, in  so  far  as  they  consist  of  an  enormous  number 
of  active  cells  which  are  capable  of  taking  up  large  num- 
bers of  micro-organisms. 

Masses  of  adenoid  tissue  are  found  at  the  entrance  of 
the  two  great  avenues  through  which  the  tubercle  bacil- 
lus most  commonly  seeks  entrance  to  the  system,  viz., 
the  alimentary  and  respiratory.  In  certain  animals  and 
in  man  there  is  a  ring  of  lymphoid  tissue  surrounding  the 
entrance  to  the  larynx,  and  a  similar  ring  surrounding 


the.entrance  to  the  oesophagus.  In  the  pharyngeal  ton- 
sil we  have  simply  an  enormous  local  development  at  the 
two  poles  of  the  latter  ring.  So  long  as  these  tonsils,  with 
their  accessory  lymphoid  tissue  forming  the  protective 
ring  for  the  pharynx,  remain  healthy,  or  so  long  as  they 
are  not  attacked  by  an  extraordinary  number  of  micro- 
organisms, they  are  capable  of  resisting  attack,  and  of 
dealing  with  micro-organisms  even  of  what  would  be 
called  a  most  virulent  type. 

When  the  lymphoid  tissue  is  diseased,  then  it  may  serve 
as  the  locus  of  infection.  The  lymphoid  cell  returning 
with  its  burden  of  a  tubercle  bacillus,  is  taken  into  the 
tonsil  or  the  adenoid  tissue  in  that  vicinity,  where,  under 
healthy  conditions,  it  is  destroyed  or  disintegrated.  In 
its  depraved  state  it  cannot  destroy  the  bacillus,  but,  on 
the  contrary,  the  bacillus  liquefies  the  lymphoid  cell,  the 
protoplasm  of  which  then  serves  as  a  nutrient  medium 
for  the  bacilli.  This  infection  does  not  take  place  in  the 
tonsil  so  frequently  as  in  the  glands  which  lie  beyond 
the  tonsil,  and  which  the  leucocytes  include  in  their 
itinerary  when  returning  to  the  circulation. 

Lucases  where  there  is  no  distinct  lesion  in  the  tonsil 
itself,  it  must  be  held  that  the  leucocytes,  although  able 
to  take  the  bacilli  into  their  substance,  have  not  been 
able  to  kill  them,  and  then  they  carry  the  bacilli  to  the 
gland  in  its  immediate  neighborhood,  where  they  suc- 
cumb, and  infection  takes  place  at  this  point.  A  multi- 
plication and  reinforcement  of  the  bacilli  by  their 
progeny  at  this  point,  will  carry  the  infection  farther, 
with  the  result  that  a  chain  of  lymphatics  and  lymph- 
glands  has  ultimately  become  affected. 

In  many  of  these  cases  the  process  can  be  traced  from 
the  glands  in  the  tonsil  down  into  the  neck,  and  so  on 
to  the  thorax,  by  the  mediastinal  and  post-sternal  glands 
and  by  the  intercostal  lymphatics  and  glands. 

What  has  been  stated  concerning  the  lymphoid  tissue 
of  the  tonsils  and  surrounding  cervical  glands,  might  be 
repeated  almost  verbatim  for  the  lymphoid  patches  of 
the  intestine  and  mesenteric  glands. 

The  very  cells,  then,  which  in  health  have  to  do  with 
the  destruction  of  bacilli,  and  with  protecting  the  organ- 
ism against  their  invasion,  are  those  which  appear  to  be 
immediately  responsible  for  the  conveyance  of  tubercle 
bacilli  from  the  outer  surface  to  the  tissues  beneath. 

The  rdle  played  by  the  tonsil  and  the  surrounding 
lymphoid  tissue  is,  therefore,  seen  to  be  a  very  important 
one  in  preventing  or  facilitating  infection  in  tuberculosis. 
An  important  lesson  to  be  learned  from  this  is,  that  ton- 
sil has  an  important  function  to  perform  in  the  economy, 
that  endeavors  directed  toward  keeping  it  in  a  physio- 
logical condition,  militate  against  the  dangers  of  tuber- 
culous and  other  infection,  and  that  its  removal  other 
than  for  disease  which  might  predispose  it  to  infection,  is 
hazardous. 


Scarcity  of  Doctors  in  the  Chinese  Army  and  Havy. 
— The  horrors  of  war  now  going  on  between  China  and 
Japan  appear  to  be  greatly  accentuated  by  an  almost 
inhuman  lack  of  medical  men  on  the  Chinese  side. 
From  a  letter  of  Captain  M'Giffen,  Commander  of  the 
Chinese  war-ship  Chen  Yuen,  we  learn  that  there  are 
only  two  Chinese  doctors  to  twenty  ships  and  an  army 
of  over  300,000  men. 


November  17,  1894] 


MEDICAL  RECORD. 


625 


SMALL-POX  FROM  CRADLE  TO   COUNTER. 

The  fourteen  victims  of  small  pox  who  sailed  up  the 
East  River  on  Monday  morning  last,  en  route  for  North 
Brothers  Island,  furnish  a  most  instructive  object-lesson. 
In  the  first  place,  the  number  was  considered  unusually 
large  for  this  city  to  furnish  at  one  time,  indicating  that 
the  disease  is  becoming  rare  as  compared  with  former 
periods.  Secondly,  the  subjects  all  came  from  a  very 
circumscribed  quarter  of  the  city's  area;  and  thirdly,  they 
had  all  contracted  the  disease  from  the  same  source :  a 
sick  baby  in  the  rear  of  a  grocery  shop,  the  mother  going 
from  cradle  to  counter,  waiting  upon  the  customer  and 
then  upon  the  child  again,  until  she  had  sent  out  the 
germs  to  the  whole  neighborhood  along  with  their  pur- 
chases of  tea  and  sugar. 


A  NEW  DEPARTURE  IN  MEDICAL  JURISPRU- 
DENCE. 
The  American  Journal  of  Insanity  for  October  publishes 
three  articles  by  eminent  alienists  all  bearing  on  the 
topic  which  heads  this  editorial.  The  departure  referred 
to  was  connected  with  the  trial  of  a  man  named  Schnei- 
der, a  resident  of  Washington,  D.  C,  who  murdered  his 
wife  and  brother-in-law  in  January,  1892.  He  was  tried 
in  March  of  the  same  year,  and  condemned  to  death,  no 
plea  of  insanity  having  been  put  in  at  the  time.  The 
decision  was  confirmed  by  a  Court  of  Appeal.  In  the 
following  fall,  a  stay  of  proceedings  was  granted  on  the 
ground  of  alleged  insanity.  In  January,  1893,  the  Su- 
preme Court  of  the  District  of  Columbia,  consisting  of 
Chief  Justice  Bingham  and  Justices  Hagner  and  Cox,  or- 
dered that  a  commission  of  experts,  consisting  of  Dr. 
Allan  McLane  Hamilton,  Dr.  John  B.  Chapin,  and  Dr. 
Charles  L.  Dana,  be  constituted,  with  power  to  examine 
the  prisoner  and  also  employees  and  officials  of  the  jail 
in  which  he  was  confined.  Counsel  for  the  prisoner  was 
also  permitted  to  secure  the  services  of  three  experts  with 
authority  to  make  special  examinations.  After  the  in- 
vestigation by  the  experts  had  been  finished  the  case  was 
tried  before  the  full  bench,  but  without  a  jury.  The 
prisoner's  counsel  brought  forward  his  witnesses,  includ- 
ing his  medical  experts.  The  examination  of  these  lat- 
ter gentlemen  was  made  for  the  most  part  by  the  experts 
appointed  by  the  court.  The  prosecuting  attorney  then 
presented  his  evidence  in  favor  of  the  prisoner's  sanity. 
The  whole  proceedings  lasted  over  a  week.  At  the  end 
the  Commission  appointed  by  the  court  made  a  report  in 
which  they  unanimously  reached  the  conclusion  that  the 
prisoner  was  not  insane.  The  judges,  basing  their  opin- 
ion upon  the  evidence  given  at  the  trial  and  upon  the 
report  made  by  the  Commission,  found  the  prisoner  sane 
and  he  was  executed. 

The  comments  upon  this  new  mode  of  judicial  proced- 
ure are  made  by  Dr.  John  B.  Chapin,  Superintendent  of 
the  Pennsylvania  Hospital  for  the  Insane,  who  was  one 
of  the  Commission,  and  by  Drs.  W.  W.  Godding  and  E. 
N.  Brush,  who  were  both  experts  for  the  defence.  These 
gentlemen  all  speak,  on  the  whole,  favorably  of  the 
method.  It  is  suggested  that  there  was  no  need  in  such 
a  procedure  for  the  appointment  of  experts  for  the  de- 
fence, and  also  that  there  should  be  opportunity  for  the 
prisoner  to  appeal  from  the  decision  of  the  Commission 
if  it  was  unfavorable  to  him. 


Dr.  Brush  says :  "  I  think  I  voice  the  sentiments  of  all 
my  associates  called  as  experts  by  the  counsel,  by  the 
prisoner,  that  never  has  it  been  our  experience  to  have  a 
more  fair,  considerate,  and,  touching  the  case  at  hand, 
more  intelligent  examination  than  in  this  case.  .  .  . 
The  examination  was  undertaken  in  a  dignified  manner, 
and  attracted  the  closest  attention  of  the  court.  It  was 
undertaken,  not  with  the  intention  of  producing  contra- 
dictions, or  of  surprising  the  witnesses  into  making 
faulty  or  questionable  admissions,  but  to  get  at  the  facts 
of  the  case  and  the  processes  by  which  the  witnesses 
reached  their  conclusions.  In  these  respects  the  inquiry 
was  satisfactory  and  admirable." 

The  new  departure  in  medical  jurisprudence  is  one 
which  reflects  credit  upon  the  Supreme  Court  of  Wash- 
ington. While  it  may  need  some  modifications  it  is  one 
which  deserves  the  attention  of  those  who  desire  to  see 
justice  secured  in  difficult  medico-legal  cases. 


READING    NOTICES  IN  MEDICAL  JOURNALS. 

In  these  times  of  intense  commercial  activity  it  is  not 
strange  that,  even  the  most  reputable  and  high- toned 
chemists  and  manufacturers  of  pharmaceutical  prepara- 
tions should  seek  every  legitimate  means  of  commending 
their  products  to  the  medical  profession,  who  are  their 
chief  customers.  The  time  has  been,  and  past,  when  the 
leading  dailies  and  monthlies  of  this  country  did  not  hesi- 
tate to  insert  in  their  papers  editorial  commendations  of 
articles  advertised  in  their  columns.  It  may  probably  be 
said  with  absolute  correctness,  that  none  of  these  at  the 
present  time  insert  anything  of  this  sort  without  having 
appended  to  it  in  italics  the  abbreviation  "Adv."  It 
seems  to  us  that  it  is  particularly  incumbent  upon  the 
editor  of  a  medical  journal,  that  he  should  keep  his  pages 
so  clear  from  any  suspicion  even  of  anything  which  would 
appear  to  be  in  the  interest  of  those  who  advertise  in  it, 
that  his  subscribers  may  feel  the  most  implicit  confidence 
in  his  desire  to  supply  them  only  with  that  which  is  dis- 
tinctly in  their  interest.  It  is  no  doubt  a  fact  that  often- 
times preparations  advertised  by  first-class  houses  are 
worthy  of  high  commendation,  but  if  once  it  is  found  that 
an  advertisement  is  the  means  of  obtaining  directly,  or 
indirectly,  editorial  notice  in  any  medical  journal,  the 
confidence  of  the  patrons  of  such  a  journal  in  its  disin- 
terested presentation  of  scientific  facts  must  surely  be  more 
or  less  weakened.  No  editor  is  in  a  position  to  speak 
well  of  one,  and  not  of  another.  The  only  safe  course, 
the  only  possible  course,  is  to  adhere  to  an  inflexible  rule, 
to  admit  no  article  and  to  print  no  editorial  which  either 
favors  or  condemns  the  wares  of  any  advertiser.  With 
all  the  care  which  is  exercised  to  prevent  the  insertion  of 
articles  which  even  accidentally  commend  or  condemn, 
sometimes  by  inference  only,  goods  advertised  in  the 
pages  of  this  journal,  articles  sometimes  creep  in  which 
violate  this  rule,  and  give  not  only  a  great  amount  of 
trouble,  but  have  again  and  again  caused  the  loss  of  thou- 
sands of  dollars  by  the  withdrawal  of  advertisements  which 
were  being  paid  to  us  by  first-class  advertisers,  responsible 
houses,  worthy  the  trust  and  confidence  of  the  profession. 
Holding  these  views  as  to  the  proper  conduct  of  a  medi- 
cal journal,  we  notice  with  regret  that  one  of  our  es- 
teemed contemporaries  has  recently  published,  not  only 
an  article  highly  commending  the  product  of  a  house  ad- 


626 


MEDICAL  RECORD. 


[November  17,  1894 


vertising  in  their  pages — with  which  house  or  product  we 
have  no  controversy  whatever — but  it  has  also,  most 
strangely,  commented  favorably  in  an  editorial  upon  the 
same  article.  We  have  no  doubt  that  this  is  eminently 
satisfactory  to  the  advertisers,  but  cannot  believe  that  it 
will  increase  the  respect  to  which  the  usual  conduct  of 
this  journal  entitles  it. 

The  true  value  of  any  journal  to  an  advertiser  is  not 
only  the  extent  of  its  circulation  and  the  character  and 
standing  of  its  subscribers,  but  equally,  if  not  more  so,  the 
estimation  in  which  a  journal  is  held  for  absolute  im- 
partiality and  fairness  toward  all,  and  its  single  eye  to  the 
interests  of  its  subscribers. 


THE  DANGERS  OF  BUTTER  AND  BREAD. 

A  short  time  ago  we  called  attention  to  the  investiga- 
tions of  certain  Swiss  and  Italian  bacteriologists,  who 
showed  that  the  butter  of  the  markets  was  not  sterile,  and 
might  contain  pathogenic  organisms.  Now  it  appears 
that  bread  is  not  sterilized  by  baking,  and  takes  its  place 
with  butter  as  a  possible  germ-carrying  food.  It  would  be 
sad  indeed  to  find  that  the  staff  of  life  was  really  a  staff 
of  death,  and  that  the  very  fundamentals  of  plain  and 
happy  living,  bread  and  butter  and  kisses,  were  really 
things  of  evil,  except  under  conditions  of  perfect  asepsis. 

Drs.  F.  J.  Waldo  and  David  Walsh  {The  Lancet)  have 
made  cultivations  from  sixty-two  loaves  of  bread  taken 
from  various  bake-houses  in  London.  Someone  of  thir- 
teen kinds  of  bacteria  were  found  alive  in  all  these 
loaves.     Here  is  the  appalling  list : 

Bacteria  (or  their  Spores)  found  in  a  Living  Condi- 
tion in  Freshly  Baked  Loaves  of  Bread:  Bacillus  sub- 
tilis,  Variety  1  (hay  bacillus) ;  bacillus  subtilis,  Variety 
2  (hay  bacillus) ;  bacillus  subtilis,  Variety  3  (hay  bacil- 
lus) ;  sarcina  (a),  large ;  sarcina  (£),  smaller  than  (a) ; 
bacillus  A  (large,  thick,  rounded  ends)  ;  bacillus  B  (large, 
thick,  smaller  than  A)  ;  bacillus  C  (small,  copious  spore 
formation) ;  bacillus  D  (smaller  still,  some  spore  forma- 
tion) ;  bacillus  E  (bacillus  figurans) ;  micrococcus  A 
(small  white  colonies) ;  .micrococcus  B  (rosaceus  (?),  ac- 
cidental) ;  staphylococcus  (very  regular,  larger  than 
staphylococcus  aureus). 

From  a  number  of  experiments  made  on  loaves  baked 
in  a  small  laboratory  oven,  it  was  found  that :  1.  The 
average  maximum  temperature  in  the  middle  of  an  ordi- 
nary quartern  loaf  during  baking,  varies  from  163.40 
to  186.8  F.,  and  in  small- loaves  from  186.80  to  2030  F. 
2.  There  is  a  steady  increase  of  temperature  in  the  cen- 
tre of  any  loaf  during  baking ;  thus,  in  a  quartern  loaf 
during  one  hour  it  rises  from  25  °  to  75°  C,  and  in  a  half- 
quartern  loaf  from  250  to  88°  C.  during  the  same  time. 
For  the  first  forty  minutes  the  maximum  temperature  is 
probably  not  more  than  480  or  50°  C.  The  practical 
inference  is  that  any  organisms  that  might  be  present  in 
the  centre  of  a  loaf  would  be  exposed  for  a  short  time 
only  during  baking  to  a  maximum  temperature  of  730 
to  86°  C.  (163.40  to  186.80  F.)  in  a  quartern,  and  of 
86°  to  95°  C.  (186.80  to  2030  F.)  in  a  half-quartern 
loaf. 

It  is  known  that  most  bacteria  are  not  destroyed  by 
an  exposure  to  the  temperatures  above  mentioned  as  the 
average  for  the  centre  of  a  loaf  during  baking.  The 
death-point  of  bacteria  has  been  generally  expressed  by 


Koch  and  Wolfhugel  in  the  following  passage:  1. 
Sporeless  bacteria  are  destroyed  in  one  and  a  half  hour 
by  hot  air  at  a  temperature  slightly  exceeding  ioo°  C 
(2120  F.).  2.  Spores  of  fungi  require  one  and  a  half 
hour  at  uo°  to  1150  C.  (2300  to  2390  F.).  Spores  of 
bacilli  require  three  hours  at  1400  C.  (25 20  F.).  It 
should  be  noted  that  these  statements  apply  to  dry  heat 
only.  In  the  middle  of  the  loaf  there  is  presumably 
moist  heat,  which  is,  of  course,  more  destructive  to  or- 
ganisms, and  on  that  account  we  must  make  a  consider- 
able reduction  in  the  figures  of  Koch  when  we  apply  them 
to  fungi  and  their  spores  inside  a  loa£ 
The  authors  draw  this  significant  conclusion  : 
We  see  no  particular  reason  why  the  origin  of  many 
mysterious  septic  invasions  of  the  human  body  may  not 
eventually  be  traced  to  the  agency  of  bread.  A  genera- 
tion ago  milk  was  not  suspected  of  being  the  means  of 
spreading  disease,  and  a  similar  observation  applies  to 
water.  At  any  rate,  the  subject  dealt  with  in  this  paper 
seems  to  us  to  be  well  worthy  the  attention  of  all  who 
are  interested  in  the  scientific  developments  of  prevent- 
ive medicine,  no  less  than  in  the  protection  of  the 
public  that  consumes  the  bread. 

No  specific  remedy  is  suggested  by  the  writers,  except 
that  bake-houses  and  bakers  should  be  kept  clean,  and 
that  the  whole  process  of  bread-making  be  placed  under 
sanitary  control. 


BERI-BERI  IN  NEW  JERSEY. 

It  is  not  often  we  are  called  upon  to  announce  the  pres- 
ence of  beri-beri  in  or  about  New  York.  On  several  oc- 
casions, however,  during  the  past  few  years,  one  or  more 
cases  have  been  discovered  among  the  crews  of  incoming 
vessels.  It  is  on  this  account,  and  especially  because  of 
the  very  fatal  nature  of  the  disease,  that  interest  is  awak- 
ened just  now  in  the  ill- favored  human  cargo  of  a  vessel 
from  Navassa,  which  has  entered  port  at  Perth  Amboy. 
Four  had  died  during  the  trip,  several  have  since  suc- 
cumbed, and  ten  or  more  are  ill.  There  seems  to  be  no 
doubt  that  faulty  hygiene  and  lack  of  suitable  food  were 
the  factors  determining  the  outbreak.  Beans  furnished 
the  principal  food,  it  appears,  during  the  two  weeks1 
voyage,  and,  strange  as  it  may  seem,  this  is  just  the 
article  of  diet  which  Dr.  Simmons  recommended  in  a 
monograph  on  the  subject  in  1880. 

One  of  the  chief  symptoms  is  a  condition  of  pro- 
nounced feebleness,  and  it  is  this  which  gives  the  name, 
made  emphatic  by  repetition.  Other  symptoms,  accord- 
ing to  Aitken,  are:  "Anaemia,  culminating  in  acute 
oedema,  and  marked  by  stiffness  of  the  limbs,  numbness, 
and  sometimes  paralysis  of  the  lower  extremities;  op- 
pressed breathing ;  a  swollen  and  bloated  countenance." 
The  urine  is  secreted  in  diminished  quantities,  the  oedema 
is  general,  and  effusion  of  serum  into  the  serous  cavities 
often  occurs.  Muscular  spasms  accompany  the  acute 
dropsy.  Some  of  the  older  authors  have  supposed  the 
epidemic  affection  to  be  confined  to  Japan,  while  others 
have  looked  upon  it  as  a  disease  peculiar  to  Malabar  and 
Ceylon. 

Such  instances  as  the  present  would  tend  to  show  that 
misery  and  privation  go  far  to  determine  an  outbreak  in 
any  quarter,  though  the  chief  endemic  centres  are  in 
China,  Japan,  and  India.    In  1886  a  vessel  arrived  in 


November  17,  1894] 


MEDICAL    RECORD. 


627 


New  York  from  Hong  Kong,  with  twelve  out  of  the 
crew  of  eighteen  affected  with  what  was  supposed  at  the 
time  to  be  beriberi.  Several  died,  including  the  cap- 
tain. The  food  and  water  were  in  this  instance  found 
to  have  been  far  from  wholesome. 

Recent  studies  would  indicate  that  the  nature  of  the 
disease  is  a  multiple  neuritis,  and  not  being  contagious, 
there  seems  no  fear  that  it  will  spread  beyond  the  unfort- 
unates who,  in  returning  home  from  a  life  of  hardship, 
were  subjected  to  most  unfavorable  conditions. 

THE  "  INEXCUSABLE  ATROCITIES  "  OF  SPORT. 

The  President  of  the  Society  for  the  Prevention  of 
Cruelty  to  Animals  says : 

"  It  is  an  inexcusable  atrocity  to  subject  any  animal 
to  pain  which  can  be  prevented  by  a  conscientious  use  of 
anaesthetics." 

It  might  be  supposed  that  the  gentleman  was  attack* 
ing  hunters  and  sportsmen  generally,  who  are  commit- 
ting these  inexcusable  atrocities  every  day.  As  a  matter 
of  fact  the  writer,  while  swallowing  the  camel  of  sport  is 
straining  at  the  gnat  of  vivisection.  There  are  said  to 
be  over  one  hundred  thousand  men  and  boys  in  this 
country  who  go  out  with  guns.  They  mutilate  and  half- 
kill  birds,  they  maim  the  rabbits,  deer,  and  other  ani- 
mals, subjecting  them  to  exquisite  pains  before  they  die ; 
they  chase  deer  into  the  water  and  murder  them  in  their 
helplessness,  they  ride  after  frightened  foxes  and  drive 
them  to  a  death  of  agonizing  exhaustion ;  they  hook  up 
fish  by  the  sensitive  mucous  membrane  of  the  mouth  and 
tear  them  from  their  wounds,  all  for  sport 

There  are,  perhaps,  half  a  dozen  places  in  this  country 
where  vivisection  is  done  on  anaesthetized  guinea-pigs, 
rabbits,  and  occasionally  dogs. 

Why  doesn't  the  sensitive  anti-vivisectionist  attack  the 
sportsman  ?  Is  it  because  he  is  afraid,  or  because  he  is 
a  sportsman  himself? 


fjje«rs  0f  Itue  Wte&k. 

Motormen  and  Conductors. — In  St.  Louis  men  seek- 
ing employment  on  the  rapid-transit  street-cars  are 
obliged  to  submit  to  an  examination  of  their  eyes  by  a 
competent  ophthalmologist.  This  is  done  by  the  street 
railway  companies  for  their  own  protection,  and  is  a 
plan  that  should  be  pursued  by  every  street  railway  com* 
pany. 

A  Medical  College  Burned. — On  November  3d  the 
Indiana  Medical  College  at  Indianapolis  was  burned  to 
the  ground. 

The  Horace  Wells  Anniversary  Celebration. — The 
following  circular  has  been  issued  :  Members  are  doubt- 
less aware  of  the  action  of  the  American  Dental  Associa- 
tion at  its  recent  meeting,  held  at  Old  Point  Comfort, 
Va.,  with  reference  to  holding  a  national  celebration  of 
the  fiftieth  anniversary  of  the  discovery  of  the  anaesthetic 
properties  of  nitrous  oxide  by  Dr.  Horace  Wells.  The 
Committee,  by  vote  of  the  American  Dental  Association, 
was  instructed  to  secure  two  papers  to  be  read  at  the 
celebration.  One  upon  the  "  History  of  Anaesthesia/' 
by  Professor  Thomas  Fillebrown,  of  Boston ;  and  one 
on  the  "  Benefits  of  Anaesthesia  to  Mankind,"  by  Pro- 


fessor James  E.  Garretson,  of  Philadelphia.  The  Com- 
mittee was  further  instructed  to  arrange  for  a  banquet  to 
follow  the  meeting,  at  which  distinguished  speakers  shall 
make  appropriate  addresses;  to  prepare  a  full  report  of 
the  celebration,  including  the  papers  and  addresses,  to  be 
printed  and  issued  as  a  permanent  souvenir  of  the  occa- 
sion. Arrangements  have  been  completed  to  the  extent 
of  securing  favorable  responses  from  the  essayists  named, 
whose  papers  are  now  in  course  of  preparation.  The 
banquet  arrangements  are  also  largely  completed.  To 
cover  the  expenses  attending  the  celebration,  the  fee  for 
admission  to  the  banquet  has  been  placed  at  $6.  It  is 
necessary  that  the  Committee  shall  have  ample  notice  of 
the  number  who  will  be  in  attendance,  in  order  that 
places  may  be  provided  for  all  who  may  desire  to  attend. 
Subscriptions  will  be  invited  later  for  the  souvenir  vol- 
ume, at  a  price  sufficient  to  cover  the  cost  of  publication. 
The  celebration  will  be  held  in  Philadelphia,  in  Associa- 
tion Hall,  Fifteenth  and  Chestnut  Streets,  on  Tuesday, 
December  n,  1894,  at  2  p.m.,  and  the  banquet  at  the 
Union  League,  at  6.30,  same  evening.  You  are  cordially 
invited  to  participate  in  this  event,  which  should  enlist 
the  enthusiastic  support  of  every  member  of  our  profes- 
sion. To  that  end  you  are  requested  to  send  your  check 
and  notify  the  Chairman  of  the  Anaesthesia  Committee, 
at  the  earliest  date  possible,  in  order  that  an  official  in- 
vitation may  be  sent  to  you.  It  will  be  proposed  at  the 
meeting  that  subscriptions  be  invited  for  a  permanent 
memorial,  to  take  such  shape  as  the  meeting  shall  decide. 
— J.  D.  Thomas,  Chairman,  912  Walnut  Street,  Phila- 
delphia. 

Medical  Congress  of  Mexico. — The  second  biennial 
Medical  Congress  of  Mexico  was  held  November  5  th 
to  8th,  at  San  Luis  Potosi.  Dr.  Eduardo  Liceaga  was 
President ;  and  Dr.  Luis  Ruiz,  Secretary,  both  of  the 
city  of  Mexico ;  Dr.  Jesus  E.  Monjaras  was  Chairman  of 
the  Local  Committee  of  Arrangements,  San  Luis  Potosi, 
Mexico. 

Medical  Society  of  the  State  of  Hew  York.— The  fol- 
lowing Business  Committee  has  been  appointed  by  the 
President  of  the  Medical  Society  of  the  State  of  New 
York:  Dr.  W.  C.  Phillips,  of  New  York  City;  Dr.  H. 
I*  Eisner,  of  Syracuse;  Dr.  H.  DeV.  Pratt,  of  Elmira. 

Medical  Announcements  in  the  Press. — A  New  Or- 
leans physician  sends  the  following  inquiries  to  the 
Journal  of  the  American  Medical  Association;  "Please 
inform  me  if  there  is  anything  in  the  Code  of  Ethics  to 
prevent  a  practitioner :  1,  From  announcing  in  the  daily 
newspapers  that  his  practice  is  limited  to  the  diseases  of 
special  organs ;  2,  ditto  in  the  medical  papers ;  3,  from 
announcing,  in  sealed  circular  letters  to  the  medical  pro- 
fession at  large,  that  his  practice,  etc.;  4,  ditto  to  laymen 
at  large,  etc." 

To  which  the  editor  replies :  "  Article  I.,  Section  4  v 
Duties  of  physicians  to  each  other  and  to  the  profession 
at  large :  It  is  derogatory  to  the  dignity  of  the  profes- 
sion to  resort  to  public  advertisements,  etc.  2.  While 
in  some  parts  of  the  country  physicians  do  publish  cards 
in  medical  papers,  it  is  not  regarded  as  wanting  in  the 
true  dignity  of  a  physician,  but  as  a  question  of  taste. 
3.  Certainly,  there  can  be  no  objection  to  a  sealed  cir- 
cular to  the  profession,  announcing  that  practice  is  lim- 
ited, etc.     But  we  find  that  when  a  physician  is  limiting 


628 


MEDICAL    RECORD. 


[November  17,  1894 


work  to  a  specialty,  it  soon  becomes  known  to  the  pro- 
fession of  his  town,  and  by  his  papers  on  that  subject  in 
the  medical  journals  he  soon  attracts  a  clientele.  4.  A 
circular  to  laymen  cannot  fail  to  produce  in  the  minds 
of  those  who  receive  it,  a  doubt  as  to  the  ability  of  the 
one  sending  it. 

"  A  large  acquaintance  with  the  profession  in  all  parts 
of  the  country  causes  us  to  believe  that  the  dignified 
earnest  practitioner  can  acquire  a  practice  without  re- 
sorting to  any  of  these  plans." 

And  we  would  add  that  no  physician  should  do  any  of 
these  things,  except  that  in  smaller  towns  it  seems  to  be 
a  harmless  practice  to  place  a  simple  card  announcement 
in  the  local  paper. 

Alma  Mater,  A  Sonnet  by  Oliver  Wendell  Holmes. 

— The  following  sonnet,  hitherto  unpublished,  was  sent 
to  the  Boston  Medical  and  Surgical  Journal  by  Dr.  H. 
P.  Bowditch,  with  the  statement  that  the  poem  was  writ- 
ten at  the  request  of  Dr.  Bowditch,  and  read  by  him  be- 
fore the  Harvard  Club  of  New  York : 

"  Yes,  home  is  sweet  I  and  yet  we  needs  must  sigh, 
Restless  until  our  longing  souls  have  found 
Some  realm  beyond  the  fireside's  narrow  bound 

Where  slippered  ease  and  sleepy  comfort  lie, — 

Some  fair  ideal  form  that  cannot  die, 
By  age  dismantled  and  by  change  uncrowned, 
Else  life  creeps  circling  in  the  self-same  round, 

And  the  low  ceiling  hides  the  lofty  sky. 

Ah,  then  to  thee  our  truant  hearts  return, 
Dear  Mother,  Alma,  Casta, — spotless,  kind  ! 
Thy  sacred  walls  a  larger  home  we  find, 

And  still  for  thee  thy  wandering  children  yearn, 

While  with  undying  fires  thine  altars  burn 
Where  all  our  holiest  memories  rest  enshrined." 

Our  Medical  Students.— England  has  but  552  medi- 
cal students ;  there  are  8,006  in  the  Germany  universi- 
ties, but  the  United  States  has  13,000.  We  could  loan 
England  a  few  thousand  and  have  plenty  to  spare. 

Care  of  Epileptics  and  Insane  in  Minnesota. — The 
board  of  physicians  appointed  by  the  Governor  of  Min- 
nesota to  investigate  the  insane  hospitals  and  report  on 
the  needs  of  the  insane,  have  suggested  in  their  report 
the  establishment  of  an  institution  for  the  care  of  epilep- 
tics, and  another  State  insane  hospital,  the  latter  to  be 
in  the  vicinity  of  St.  Paul  and  Minneapolis. 

Association  of  Southern  Hospitals  for  the  Insane. — 

An  association  has  been  formed  with  the  above  name, 
and  will  hold  its  first  meeting  at  Birmingham,  Ala.,  on 
November  20,  1894. 

The  Temperance  Reform  League  of  Massachusetts 
and  the  Keeley  Cure.— Dr.  B.  D.  Evans,  the  Medical 
Director  of  the  New  Jersey  State  Hospital  for  the  In- 
sane, has  been  admitted  to  membership  in  the  Temper- 
ance Reform  League  of  Massachusetts.  This  ends  a  bat- 
tle between  Dr.  Evans  and  the  Keeley  cure,  as  far  as 
Massachusetts  can  decide  it,  with  victory  in  favor  of  the 
former.  Dr.  Evans,  it  will  be  remembered,  gathered 
statistics  from  insane  asylums  over  the  United  States  and 
among  the  one  thousand  insane  patients  in  the  hospital 
of  which  he  has  charge,  compiling  valuable  and  detailed 
"  tables  of  cases  of  relapse,  suicide,  mania,  and  demen- 
tia subsequent  to  the  graduation  at  the  Keeley  Institute. M 
His  article,  which  was  published  in  the  Medical  News, 
of  May  6,  1893,  was  reprinted  in  Boston  papers,  and  his 


report  was  laid  before  the  Temperance  Reform  League. 
It  was  bitterly  denounced  by  the  "  Keeley  Cure,"  which 
applied  to  the  Temperance  Reform  League  for  an  exam- 
ination, for  this  organization  by  its  charter  from  the 
State  is  a  quasi  court,  whose  functions  are  those  of  a 
judge  who  examines  conflicting  medical  evidence  in  a 
suit  for  malpractice  and  announces  the  result.  The  end 
of  the  trial  has  been  reached,  and  Dr.  Evans  is  honor- 
ably welcomed  into  the  society,  and  thanked  for  his  ser- 
vices in  exposing  pseudo-reform,  while  the  Keeley  offices 
in  Boston  have  been  abandoned. 

Randall's  Island  Hospital,  Hew  York.— Dr.  Samuel 
E.  Milliken  has  been  appointed  surgeon  to  Randall's 
Island  Hospitals. 

Ho  Doctors'  Quarrel  Over  the  Czar.— The  daily 
papers  have  tried  very  hard  to  make  out  a  quarrel  be- 
tween the  attending  physicians  of  the  Czar.  As  a  matter 
of  fact  there  has  been  no  real  evidence  that  any  special 
differences  of  opinion  existed,  and  the  following  cable- 
gram to  The  Sun  confirms  this  view.  The  correspondent 
says:  " Professor  Leyden,  since  returning  to  Berlin,  has 
spoken  frankly  about  the  case  of  the  dead  Emperor. 
He  said  that  the  statements  circulating  at  St.  Petersburg 
about  serious  differences  between  himself  and  Dr.  Zak- 
harin  were  not  quite  correct.  There  had  been,  now 
and  then,  diverging  opinions,  but  in  consultation  the 
doctors  always  arrived  at  an  amicable  compromise.  The 
statement  that  a  quarrel  had  taken  place  about  Dr.  Zak- 
harin's  frankness  with  the  late  Czar  was  a  misunderstood 
report.  It  was  the  Czarina,  not  the  Czar,  from  whom 
the  German  professor  wished  to  conceal  the  truth  as 
long  as  possible,  out  of  regard  for  her  delicate  health 
and  because  he  believed  the  full  knowledge  of  the  situa- 
tion could  be  of  no  use  to  her.  Professor  Zakharin  was 
of  a  different  opinion.  It,  however,  is  not  probable 
that  a  quarrel  between  the  doctors  will  ensue,  as  in  1888, 
after  Emperor  Frederick's  death." 

A  Co-operative  Medical  Warehouse. — A  considerable 
number  of  medical  men  in  Berlin  have  started  a  "  War- 
enhaus,"  or  warehouse,  for  the  supply  of  many  other 
things  besides  medical  stores.  It  is  proper  and  right  for 
medical  men  to  unite  and  club  together  for  their  own 
benefit,  and  indeed  it  is  proper  and  right  for  any  indi- 
viduals of  any  class  to  act  in  a  similar  manner. 

Errata.— Dr.  H.  J.  Garrigues  writes:— "Will  you 
kindly  correct  the  following  misprints  in  the  Medical 
Record  of  November  10th:  Page  578,  second  column, 
29th  line  from  bottom,  for  'separated'  read  ' sup- 
purated.' Page  579,  first  column,  8th  line  from  top, 
for  €  introduction,'  read  '  induction.'  " 

Attempts  to  Revive  the  Electrically  Executed.— The 
idea  has  violently  seized  some  gentlemen  that  people 
executed  by  electricity  are  not  killed  by  the  shock ;  and 
the  Governor  of  New  York  has  been  petitioned  to  allow 
experiments  to  decide  whether  those  who  have  been 
"  electrocuted  M  can  be  revived. 

The  Treatment  of  Diphtheria  by  Antitoxin. — The 
first  report  on  the  therapeutic  value  of  Behring's  an- 
titoxin in  the  treatment  of  diphtheria  has  been  com- 
municated to  the  Budapest  Society  of  Physicians  by 
Professor  Johan  Bokai,  the  well-known  pediatric  phy- 
sician.   He  used  the  serum  at  the  Budapest  Stephanie 


November  17,  1894] 


MEDICAL    RECORD. 


629 


Hospital  for  Children  from  September  21st  till  October 
2  2d,  when  the  treatment  had  to  be  stopped  on  account 
of  the  lack  of  the  serum,  which  had  not  been  obtainable 
since  then  from  the  German  clinical  establishment  at 
Hoechst,  near  Frankfort.  During  the  time  stated  above 
35  cases  of  diphtheria  were  treated  with  the  serum. 
There  were  9  cases  of  pharyngeal  diphtheria!  7  cases  of 
pharyngeal  diphtheria  combined  with  nasal  diphtheria, 
4  cases  of  pharyngeal  diphtheria  combined  with  slight 
laryngeal  diphtheria,  and  15  severe  cases  of  laryngeal 
diphtheria.  There  were,  therefore,  thirty-seven  per  cent. 
of  mild  and  sixty-three  per  cent,  of  severe  cases.  The 
oldest  patient  was  twelve  years  of  age,  and  the  majority 
of  the  cases  (20)  were  below  four  years  of  age.  Five  of 
the  35  cases  died,  giving  a  mortality  of  14I  per  cent. 
This  result  seems  very  satisfactory  if  compared  with  the 
statistics  of  the  previous  epidemics.  The  following  table 
shows  the  number  of  children  treated  from  October, 
1891,  to  1894: 


October. 


1891, 
1892. 
1893. 
1894. 


Admitted. 

Died. 

Recovery. 

74 

72 

32 

56 

24 

32 

60 

37 

*3 

35 

5 

30 

Percentage  of 
Recoveries. 


43-2 

sZb1 

§5.6 


Regarding  the  immunizing  power  of  the  serum,  the  re- 
sults were  less  favorable,  and  there  were  cases  which  un- 
derwent relapse,  though  injections  of  the  serum  had  been 
made.  It  seems  that  the  serum  is  excreted  within  from 
eight  to  seventeen  days  after  the  injection,  and  that  the 
organism  loses  its  immunity  in  the  course  of  this  short 
time. — Z7ie  Lancet. 

A  Quarrel  Over  the  Diphtheritic  Antitoxin.— There  is 
an  unpleasantness  in  Berlin  over  the  diphtheria  antitoxin. 
Professor  Behring,  who  has  been  made  Professor  of  Hy- 
giene at  Halle,  recently  published  an  article  in  a  lay 
journal  in  which  he  claimed  priority  in  the  matter  of  the 
discovery  and  use  of  the  serum,  and  accused  Professor 
Virchow  of  not  giving  him  credit  and  of  recommending 
the  use  of  Aronsohn's  serum.  It  seems  that  Aronsohn, 
as  soon  as  Behring's  discovery  was  made,  at  once  went 
to  work  and  manufactured  a  serum  by  the  same  methods, 
but  made  one  that  was  stronger,  and  put  it  promptly  on 
the  market  Professor  Virchow  publicly  disclaims  any 
claim  for  himself  or  others,  however.  Evidently  there 
has  a  good  deal  of  the  commercial  spirit  crept  into  the 
manufacture  of  the  antitoxines. 

Diphtheria  Antitoxin  in  France.— C.  W.  Chancellor, 
United  States  Consul  at  Havre,  has  just  made  a  report  to 
the  Secretary  of  State  recommending  that  the  antitoxin 
should  be  supplied  by  every  State  and  Municipal  Gov- 
ernment in  the  United  States.  The  difficulties  in  the 
way  are  foreshadowed  somewhat  by  recent  experiences  in 
Paris.     He  says : 

So  far,  Dr.  Roux  has  been  unable  to  meet  the  demand 
for  the  serum,  and  he  has  had  to  confine  himself  to  send- 
ing to  the  provinces  only  a  sufficient  quantity  for  urgent 
cases ;  and  it  is  to  be  feared  that  this  state  of  things 
must  continue  for  some  time.  To  provide  for  the  needs 
of  the  entire  country,  the  Pasteur  Institute  would  have  to 
possess  a  permanent  establishment  of  over  a  hundred  and 
fifty  immuned  horses/and,  in  addition  to  the  heavy  expense 


thereby  entailed,  the  present  accommodations  are  insuffi- 
cient. Already,  it  has  been  suggested  that  auxiliary  in- 
stitutes be  established  in  all  the  principal  towns  of 
France,  the  expenses  to  be  sustained  by  the  various 
municipalities.  The  city  of  Marseilles  has  decided  to 
establish  an  institution,  and  the  municipality  of  Hon- 
fleur,  in  this  consular  district,  has  contributed  a  liberal 
sum  of  money  to  be  applied  to  the  production  and  dis- 
tribution of  the  serum  for  that  particular  community. 
A  plan  has  also  taken  practical  shape  at  Rouen  and 
Havre  to  aid  in  this  great  humanitarian  work.  Indi- 
vidual subscriptions  have  been  made  to  the  extent  of  40,- 
000  to  50,000  francs  (£7,720  to  $9,650)  in  the  two  cities 
to  supply  the  necessary  means  of  accomplishing  the  de- 
sired end.  At  Havre,  a  healthy  young  Normandy  horse 
of  four  years  of  age,  that  has  never  been  put  to  work, 
has  been  purchased  and  is  now  under  observation  in  the 
stables  of  the  veterinary  department  of  the  Government 
at  this  place.  In  order  to  take  every  precaution,  and  to- 
insure  the  success  of  the  experiment,  this  horse  has  al- 
ready been  inoculated  with  tnafcine,  an  agent  which,. 
when  inoculated  on  a  perfectly  healthy  animal,  produces 
negative  or  harmless  results.  After  this,  the  horse,  if 
perfectly  healthy,  will  be  successively  and  slowly  ren- 
dered immune  by  injecting  beneath  the  skin  of  the  neck 
or  shoulder  gradually  increased  doses  of  the  toxine  made 
by  cultivating  virulent  diphtheritic  bacilli  exposed  to 
the  air.  Immunity  being  thus  established  in  the  horse, 
which  requires  from  six  to  eight  weeks,  the  serum  of  the 
blood  of  the  animal  when  drawn  and  injected  subcuta- 
neously  into  the  human  subject  will  produce  the  desired1 
preventive  and  curative  action. 

Post-Graduate  Hedioal  School.— Dr.  George  T.  Elliot 
has  resigned  the  Professorship  of  Dermatology  at  the- 
Poet-Graduate  Medical  School. 

Library  of  the  Academy  of  Medicine. — To  meet  an 
apparent  demand,  it  is  announced  that  the  library  of  the 
New  York  Academy  of  Medicine  will  be  open  until 
10.30  instead  of  10  p.m.  The  new  regulation  will  be 
made  permanent  only  in  the  event  that  the  use  of  the 
library  between  the  hours  named  shall  be  sufficient  to 
justify  the  increased  expense. 

Ether  as  an  Intoxicant.— The  Lyon  Medical  states 
that  the  habit  of  getting  drunk  on  ether,  which  origi- 
nally came  from  England,  has  existed  in  France  for  the 
last  five  or  six  years.  The  number  of  persons  addicted 
to  this  form  of  debauchery  seems  to  be  growing  greater^ 
and  cases  are  not  uncommon  in  which  persons  drunk 
with  ether  are  arrested  in  the  streets. 

A  Biological  Laboratory  for  the  Philadelphia  Board: 
of  Health. — At  a  recent  meeting  of  the  Philadelphia 
Board  of  Health  the  Sanitary  Committee  presented  a  re- 
port recommending  the  establishment  of  a  Biological 
Laboratory  and  the  engagement  of  a  competent  bacteriol- 
ogist and  such  assistants  as  may  be  required  for  the  pur- 
pose of  conducting  investigations  of  contagious  diseases,, 
and  facilitating  diagnosis,  of  investigating  water  supplies 
and  food  supplies,  and  of  indicating  and,  as  far  as  possi- 
ble, providing  the  appropriate  remedial  measures. 

The  "  Laziest "  Man  has  at  last  met  with  his  just  re- 
ward. Dr.  George  Ross  reports  the  death  of  a  man  from 
peritonitis  due  to  rupture  of  the  bowel  brought  about  by 


630 


MEDICAL  RECORD. 


[November  17,  1894 


a  novel  and  labor-saving  method  of  taking  an  injection. 
This  ingenious  man  simply  fastened  the  rubber  hose  to 
the  bath-room  faucet  and  turned  on  the  spigot.  The  last 
time  he  gave  it  one  turn  too  much  and  hence  the  result. 
— Times  and  Register. 

Belative  Standing  of  the  Graduates  of  the  Various 
Medical  Colleges  examined  by  the  State  Board  of  Medi- 
cal Examiners,  representing  the  Medical  Society  of  the 
State  of  Pennsylvania,  June  11  -14,  1894. 


Medical  College  from  which  applicants 
graduated. 

No. 
exam- 
ined. 

No. 
failed. 

I 
2 

5 
3 
3 

1 

5 
.     9 

Perct 

of 
fail  ores. 

Aver, 
grade* 

University  of  Pennsylvania 

Woman's  Medical  College 

76 
18 
67 
26 
44 

1 

26 

I-3« 

II. II 

7.46 

6.82 

33-33 
62.50 
34.6l 

IO.82 

87.76 
8344 

82.48 
81.13 
80.68 
75.81 
7477 

Jefferson  Medical  College 

Medico-Chirurgical  College 

Western  Pennsylvania  College 

College  of  Phys.  and  Surgs.  (Bait.) . 

Baltimore  Medical  College 

Miscellaneous  Colleges 

Total 

268 

29 

82  18 

— Medical  News. 

The  Craig  Colony  for  Epileptics.— The  managers  of 
the  Craig  Colony  for  Epileptics  met  in  Albany,  N.  Y., 
November  14th,  and  consisted  of  Dr.  Frederick  Peterson, 
of  New  York ;  Mrs.  J.  B.  Wadsworth,  of  Geneseo ;  George 
M.  Shull,  of  Mount  Morris;  Mr.  Cudderback,  of  Buffalo ; 
and  Dr.  C.  £.  Jones,  of  Albany.  A  report  was  adopted 
which  will  be  presented  to  the  Legislature  recommending 
an  appropriation  of  300,000  dollars  for  the  permanent 
establishment  of  the  colony  and  the  construction  of  the 
necessary  buildings.  The  colony,  which  is  situated  in 
Livingston  County,  a  few  miles  from  Mount  Morris,  where 
r,8oo  acres  have  been  purchased  by  the  State,  is  to  be 
modelled  after  the  German  Epileptic  Colony  on  the 
cottage  plan.  The  managers  are  of  the  opinion  that  the 
colony  can  be  made  self-supporting  with  the  introduction 
of  appropriate  industries  for  the  patients.  There  are 
12,000  epileptics  in  the  State,  1,200  of  whom  are  now 
cared  for  in  the  State  hospitals. 

Dr.  William  P.  Spratling,  of  New  York  City,  was  elected 
Superintendent  of  the  colony. 

Twelve  Hundred  Physicians  have  already  registered 
as  medical  practitioners  in  Massachusetts. 

Tulane  University.— Dr.  Tiffany,  of  Baltimore,  suc- 
ceeds Dr.  tyiles  in  the  chair  of  surgery. 

Typhoid  Fever  at  Wealeyan  University.— An  epi- 
demic of  typhoid  fever  has  broken  out  among  the  stu- 
dents of  Wesleyan  University,  and  ten  cases  were  re- 
ported on  November  3d  and  4th.  One  death  has  already 
occurred  (a  Freshman),  and  one  of  the  faculty  is  danger- 
ously ill.  The  origin  is  thought  to  be  the  water  from  an 
old  well  which  has  been  found  to  be  contaminated. 

For  the  Religions  Care  of  Medical  Students. — A  re- 
ligious guild,  called  the  Guild  of  St.  Barnabas,  has  been 
started  in  London  for  the  benefit  of  medical  students. 
In  making  the  announcement  The  Guardian  remarks 
that  probably  the  class  most  overlooked  by  the  Church, 
amid  all  her  various  forms  of  work,  is  the  class  of  edu- 
cated young  men  generally.  The  urgency  of  the  case, 
so  the  writer  thinks,  becomes  even  more  obvious  when 


the  intellectual  temptations  of  the  necessary  studies  of 
medical  men  are  considered. 

Johns  Hopkins  Medical  School. — The  second  year  of 
the  Undergraduate  Department  in  medicine  opened  on 
October  1st.  There  were  31  entries,  making  in  the  two 
years  50  students  in  all.  Of  these,  13  are  graduates  of 
Johns  Hopkins  University,  8  of  Yale,  5  of  Harvard,  and 
the  others  of  the  smaller  colleges. 


AMANDA  SANFORD  HICKEY,  M.D., 

AUBVUf,    N.    Y. 

Amanda  Sanford  was  born  in  Rhode  Island  in  1838. 
When  seven  years  of  age  she  came  with  her  widowed 
mother  to  Scipioville,  in  Cayuga  County,  N.  Y.  In  later 
years,  when  speaking  of  this  time,  she  said :  "I  am 
glad  I  was  poor."  Her  education  was  obtained  at  the 
Friends'  Academy  in  Union  Springs.  After  graduation, 
in  order  to  recover  her  health,  which  had  suffered  from 
school  work,  and  to  earn  money  for  the  furtherance  of 
her  plan  to  study  medicine,  she  started  a  vegetable  gar- 
den, the  while  applying  herself  to  Greek  as  a  diversion. 
At  the  end  of  a  year,  one  hundred  dollars  in  pocket  and 
restored  in  strength,  she  began  teaching  at  the  Hawland 
School,  in  Union  Springs,  and  reading  medicine  by  her- 
self. In  two  or  three  years  she  was  able  to  enter  the 
Woman's  Medical  College  in  Philadelphia.  After  grad- 
uating there,  she  spent  eighteen  months  in  the  New 
England  Hospital  in  Boston,  and  in  the  autumn  of  187 1 
went  to  Ann  Arbor,  Mich.,  graduating  there  the  follow- 
ing spring  with  the  first  honors,  the  only  woman  in  a 
class  of  ninety.  In  1872  she  settled  in  Auburn,  and  was 
rapidly  successful  in  practice.  The  year  1879  was  spent 
in  study  in  Paris  and  London.  She  was  a  member  of 
the  original  staff  of  the  Auburn  City  Hospital,  and  con- 
tinued an  active  member  till  her  death.  She  married 
Mr.  Hickey,  of  Auburn,  in  1884. 

These  are  the  outlines  of  a  career,  unusual  in  the  im- 
pression left  upon  the  hearts  and  minds  of  associates  and 
friends.  She  was  a  woman  of  dignified  and  stately  pres- 
ence, which,  united  with  natural  reserve,  would  have 
made  her  appear  cold,  had  it  not  been  for  her  finely 
modulated,  sympathetic  voice,  and  the  gracious  serenity 
of  her  smile.  She  possessed  in  a  rare  degree  the  gifts 
of  silence,  deliberation,  and  perseverance.  But  though 
self-reliant  and  self-contained,  as  all  strong  natures  are, 
she  won  the  affection  as  well  as  the  esteem  of  those  with 
whom  she  came  in  contact.  The  gratitude  of  patients, 
poor  as  well  as  rich,  and  the  warm  attachment  of  persons 
of  varied  temperaments,  attest  the  charm  and  unselfish 
devotion  as  well  as  the  power  of  her  personality ;  while 
the  thorough-going  confidence  and  respect  of  her  col- 
leagues rewarded  the  honor  and  magnanimity  of  her  pro- 
fessional relations.  In  her  calling  die  possessed  courage 
and  skill,  operating  with  success  in  cases  of  varied  intra- 
abdominal disease.  It  was,  however,  as  the  trusted  fam- 
ily physician,  friend,  and  counsellor,  that  her  gifts  and 
character  best  expressed  themselves.  Many  mourn  for 
her  as  for  an  ideal  and  an  inspiration  lost. 

Dr.  Hickey  died  October  17,  1894,  of  pneumonia, 
contracted,  it  is  supposed,  by  chill  after  assisting  at  a 
tedious  abdominal  operation  in  an  over-heated  room. 
Death  did  not  take  her  unawares.  Her  intuition  was, 
even  in  her  own  case,  not  at  fault,  for  she  foresaw  the 
danger  while  yet  distant,  and  with  characteristic  calm 
made  dispositions  for  the  future.  In  accordance  with 
her  wish,  her  body  was  committed  back  to  earth  in  the 
village  cemetery  at  Scipioville,  where  her  life  of  study 
and  labor  and  high  usefulness  in  this  vicinity  had  its  be- 
ginning. 


November  17,  1894] 


MEDICAL  RECORD. 


631 


ShntetB  Reports. 

NEW  YORK  ACADEMY  OF  MEDICINE. 

SECTION  ON  PEDIATRICS. 

Stated  Meeting,  November  8, 1894. 

Joseph  E.  Winters,  M.D.,  Chairman. 

Ductus  Omphalo-entericus  Persistent. — Dr.  Sara  Welt 
presented  for  the  second  time  the  child  which  had  had  a 
tumor  first  observed  soon  after  birth  at  the  site  of  the  um- 
bilicus, and  which  was  proved  by  recent  removal  to  be 
formed  on  the  ductus  omphalo-entericus  persistens.  There 
was  but  little  hemorrhage,  and  it  was  checked  by  cautery. 

Antitoxin  Treatment  of  Diphtheria,  Based  upon  a 
Series  of  Oases  Treated  at  Willard  Parker  Hospital.— 
Dr.  A.  Campbell  White  read  the  paper.     (See  p.  609.) 

Observations  in  Berlin.  —  Dr.  Herman  M.  Biggs 
opened  the  discussion,  and  spoke  essentially  as  follows : 
Perhaps  it  may  be  of  more  interest  to  you  if  I  simply  give 
an  account  of  my  own  observation  of  work  done  in  the 
antitoxin  treatment  of  diphtheria  in  Berlin  the  past  sum- 
mer. The  institute  for  infectious  diseases  in  Berlin  was 
founded  by  the  German  Government  under  special  act, 
and  is  devoted  solely  to  experimental,  original  investiga- 
tion. It  has  a  corps  of  men  connected  with  it,  the  very 
best  men  in  German  scientific  medicine,  such  as  Koch, 
who  is  director,  Ehrlich,  Behring,  etc. ;  men  who  have 
been  known  for  a  long  period  for  their  observations  in 
bacteriology.  Attached  to  the  institute  is  a  hospital  for 
infections  diseases.  A  large  part  of  the  work  on  the  anti- 
toxin treatment  of  diphtheria  has  been  done  in  the  insti- 
tute, or  in  connection  with  it.  We  must  remember,  in 
judging  of  its  value,  that  it  is  not,  as  with  most  other  dis- 
coveries, or  alleged  discoveries,  in  bacterial  therapy, 
simply  a  discovery.  It  is  an  original  development,  the 
result  of  a  long  series  of  scientific  observations  which  have 
been  going  on  for  years. 

In  going  over  the  work  in  Berlin  I  was  very  much  im- 
pressed by  the  fact  that,  among  these  men  who  had  been 
working  up  the  subject  for  two  or  three  years,  or  longer, 
and  who  had  treated  a  large  number  of  cases  of  diphtheria, 
the  first  series  of  five  hundred  having  just  then  been  com- 
pleted, there  was  not  the  faintest  shadow  of  a  doubt  as  to 
the  value  of  the  antitoxin  treatment.  They  seemed  to 
feel  absolutely  convinced  that  the  experimental  stage  had 
been  passed,  and  that  the  value  of  antitoxin  as  a  specific 
in  the  treatment  of  diphtheria  was  a  thoroughly  established 
met.  That  seemed  to  me  a  most  surprising  and  a  most 
encouraging  feature  of  the  question  at  that  time.  And 
when  one  turns  to  the  other  side  and  considers  for  him- 
self the  evidence  to  justify  belief  in  the  treatment,  it  seems 
to  me  he  has  even  a  stronger  basis  for  confidence  than  the 
positive  testimony  of  others. 

Observations  in  bacteriology  have  shown  conclusively 
that,  so  far  as  infectious  diseases  are  concerned,  the  con- 
stitutional manifestations  are  not  due  immediately  to  the 
micro-organisms,  but  rather  to  the  products  of  their  life- 
processes,  and  that  death,  whenever  it  occurs,  is  almost 
invariably  the  result  of  chemical  poisoning,  the  absorp- 
tion of  these  bacterial  products.  That  these  toxins,  or 
tox-albumins,  or  ptomaines,  whatever  they  may  be,  de- 
pend on  the  micro*  organisms  and  are  their  main  offensive 
weapons,  and  that  without  them  the  micro-organisms  be- 
come almost  harmless,  and  are  unable  to  compete  with 
the  tissue-cells  in  their  struggle  for  life.  We  know  fur- 
ther that  in  all  the  infectious  diseases,  one  attack  gives 
more  or  less  complete  and  more  or  less  permanent  im- 
munity against  future  attacks.  It  has  been  shown  further, 
experimentally,  that  this  immunity  can  be  induced  arti- 
ficially, not  only  by  the  inoculation  of  animals  with  the 
micro-organisms  themselves,  but  also  by  inoculation  with 
the  chemical  products  obtained  through  cultures  of  such 
micro-organisms.  Further  observations  along  this  line 
have  shown  that  this  immunity  is  due  to  the  development 
of  something  in  the  circulation.    This  something  gives 


immunity  by  neutralizing  the  products  of  the  infectious 
organisms. 

Now,  it  has  been  possible  to  separate  these  chemical 
substances  in  some  of  the  infectious  diseases ;  they  are  the 
most  powerful  and  virulent  poisons  we  know  of.  In 
diphtheria  it  has  not  yet  been  possible  to  separate  the 
toxin,  but  we  can  measure  its  strength  biologically  by 
its  influence  on  susceptible  animals,  and  a  standard  has 
been  fixed  for  determining  the  strength  of  the  toxin. 

A  normal  toxin  solution  is  one  of  which  one-tenth  of 
a  cubic  centimetre  will  destroy  a  guinea  pig  in  a  definite 
time,  about  forty-eight  hours.  This  forms  the  standard 
by  which  the  dosage  is  determined,  as  already  stated ;  we 
do  not  know  what  the  antitoxin  is  which  is  developed  in 
the  circulation  as  the  result  of  inoculation  with  the 
chemical  products  of  micro-organisms,  but  we  suppose 
that  it  is  an  albumin ;  it  is  certainly  allied  to  albumin. 
But  we  do  know  that  it  has  the  power  to  neutralize  the 
poison  of  the  micro- organisms  which  produce  a  specific 
toxin.  We  know  that  the  amount  of  antitoxin  in  an 
animal  can  be  enormously  increased  by  repeated  inocula- 
tion with  the  toxin.  At  first  small  doses  are  employed 
and  gradually  increased.  Tolerance  is  thus  rapidly  in- 
creased. This  increased  tolerance  is  due  to  increased 
antitoxin  in  the  circulation  of  the  animal  which  is  being 
immunized,  until  finally  the  amount  of  the  neutralizing 
principle  is  relatively  enormous. 

The  amount  of  antitoxin  action  can  be  measured  by 
the  amount  of  the  normal  toxin  solution  that  it  will  neu- 
tralize. The  blood-serum  which  has  been  taken  from 
the  immunized  animal  is  mixed  outside  the  body  with 
the  toxin  solution,  and  by  the  amount  of  toxin  solution 
which  it  neutralizes  is  its  strength  and  curative  value  de- 
termined. 

There  is  no  reason  why  this  antitoxin  should  not  have 
the  same  power  inside  the  human  body  that  it  has  out- 
side. We  know  that  the  toxins  cause  the  poisoning  in 
diphtheria,  producing  constitutional  manifestations  and 
death.  We  know  that  the  antitoxin  serum  derived  from 
animals  which  have  been  immunized,  will  destroy  this 
toxin  outside  the  body,  so  that  it  becomes  absolutely 
harmless.  We  know  further  that  the  value  of  the  anti- 
toxin serum  in  the  treatment  depends  upon  its  dosage 
and  its  strength;  that  the  dose  must  be  graded  not 
only  to  the  strength  of  the  serum,  but  also  to  the  age  and 
body- weight  of  the  individual.  This  is  further  confirma- 
tion  that  it  does  not  act  in  a  biological  way,  but  chemi- 
cally. It  acts  by  neutralizing  directly,  and  its  action  is 
proportioned  to  its  strength  and  its  amount. 

It  seems  to  me  that  it  is  the  history  of  the  development 
of  the  antitoxin  treatment  of  diphtheria  which  gives  it 
peculiar  significance,  and  gives  the  greatest  encourage- 
ment for  belief  in  its  efficacy.  It  is  not  a  discovery,  an 
empirical  observation,  but  it  is  a  logical  development 
from  a  long  series  of  careful  and  thoroughly  confirmed 
scientific  observations. 

Dr.  W.  H.  Park  said :  I  shall  try,  in  discussing  the 
-antitoxin  treatment,  to  avoid,  as  far  as  possible,  repeat- 
ing what  has  already  been  said,  and  will  speak  a  little 
more  in  detail  of  animal  inoculations,  as  showing  what 
we  may  expect  in  the  treatment  of  disease  in  man.  All 
know  how  difficult  it  is  to  tell  in  human  beings  just  what 
the  therapeutic  effects  of  drugs  are,  and  perhaps  in  no 
disease  is  this  more  true  than  in  diphtheria.  Some  of 
you  may  have  read  Professor  Loeffler's  recent  article,  in 
which  he  described  a  new  method  of  local  treatment  of 
diphtheria,  stating  that  in  about  seventy  nine  cases  he 
has  not  had  a  single  death,  and  he  apparently  believes 
that  in  this  local  treatment  he  has  almost  a  sure  cure  for 
diphtheria,  leaving  out,  of  course,  laryngeal  cases.  Now 
and  then  we  read  of  some  person  having  treated  a  num- 
ber of  cases  with  bichloride  of  mercury  without  the  loss 
of  a  patient.  Yet  we  know  that  in  neither  bichloride 
nor  in  a  mixture  of  alcohol  and  other  substances  which 
Professor  Loeffier  uses,  can  we  hope  to  have  a  much 
better  percentage  of  recoveries  in  all  cases  of  diphtheria 
than  we  have  had  ordinarily,  for  it  is  in  little  children 


632 


MEDICAL  RECORD. 


[November  17,  1894 


that  the  laryngeal  and  the  fatal  cases  occur  mostly,  and 
in  them  such  local  treatment  cannot  be  carried  out.  So 
I  think  it  is  well  to  look  a  little  more  at  the  experimen- 
tal evidence  regarding  the  antitoxin  method,  in  order  to 
judge  of  its  value  in  the  treatment  of  diphtheria  in  hu- 
man beings. 

When  bacteria  are  grown  in  broth  or  other  culture 
mediums,  they  at  the  same  time  develop  the  toxins 
which  produce  lesions,  and  you  have  been  told  that 
when  these  toxins  of  bacilli  are  injected  in  animals, 
large  or  small,  in  less  than  fatal  doses,  the  animals  grad- 
ually get  tolerance ;  so  that  in  three  or  four  months  you 
can  give  them  what  ordinarily  would  be  fatal  doses,  and 
produce  no  symptoms.  Doses  which  would  kill  a  thou- 
sand guinea-pigs  will  cease  to  have  any  effect  upon  a 
single  guinea  pig  which  has  been  thus  immunized,  so 
that  something  marvellous  has  occurred  and  has  pro- 
duced antitoxin  in  the  blood.  As  you  have  already 
heard,  we  do  not  know  what  this  antitoxin  is  chemically, 
but  we  know  it  is  there,  since  we  can  measure  it  by  its 
results.  It  neutralizes  the  toxins.  But  how  ?  Different 
observers  have  different  ideas  on  this  question.  It  cer- 
tainly does  not  destroy  them.  The  antitoxins  have  been 
injected  into  animals  and  into  human  beings,  and  the 
toxins  have  thereupon  ceased  to  produce  their  harmful 
effects,  yet  they  are  still  there — both  antitoxins  and  tox- 
ins. That  is  proven  in  a  number  of  ways,  and  it  is 
only  necessary  to  mention  the  fact  here.  In  diphtheria 
they  are  so  much  alike  that  you  cannot  separate  the  tox- 
ins and  the  antitoxins  when  mixed.  But  it  has  been  found 
that  if  you  put  a  certain  amount  of  antitoxin  in  with  a 
certain  amount  of  toxin,  there  will  be  no  effect  from  the 
injected  fluid,  while  the  toxin  taken  separately  would 
kill  speedily.  Now,  it  has  been  found  that  if  you  inoc- 
ulate an  animal  with  toxin  and  immediately  afterward 
inject  antitoxin,  a  very  small  amount  of  the  latter  will 
suffice  to  prevent  the  development  of  diphtheria.  If 
three  or  four  hours  elapse,  it  will  take  a  larger  dose  of 
the  antitoxin;  after  twelve  or  twenty-four  hours  the 
dose  will  have  to  be  very  greatly  increased,  and  if  the 
animal  is  already  dying,  no  amount  of  antitoxin  will  save 
it.  So  in  diphtheria  treated  by  antitoxin  in  the  hospi- 
tals, it  has  been  found  that  where  the  injections  have 
been  begun  on  the  first  or  second  day,  they  have  done 
very  well  and  have  required  only  one  or  two  doses ;  while 
in  cases  treated  not  before  the  third  or  fourth  day,  it  has 
required  repeated  large  doses,  and  even  then  one  may 
not  succeed  in  curing  the  patient. 

Differs  from  Tuberculin. — Now,  some  of  us  may  have 
a  misty  idea  that  this  antitoxin  treatment  is  like  that  by 
tuberculin,  and  is  liable  like  it  to  inspire  too  great  hope 
to  withstand  the  test  of  time.  But  the  two  are  quite  dif- 
ferent processes.  With  tuberculin  we  inject  a  toxin  to 
develop  antitoxin  in  the  body,  while  in  diphtheria  we 
first  produce  antitoxin  in  the  bodies  of  animals,  and  only 
inject  the  antitoxin,  which  is  absolutely  harmless,  into  the 
patient  afflicted  with  diphtheria. 

You  know  that  when  serum  from  certain  flwiir^lf  is  in- 
jected into  man  it  may  create  some  disturbance,  and  this 
will  account  for  the  rash  which  has  been  produced  in 
some  instances  of  the  antitoxin  treatment  of  diphtheria. 
It  was  not  due  to  the  antitoxin.  The  serum  from  the 
horse  scarcely  ever  produces  any  symptoms. 

We  have,  then,  in  this  treatment  of  diphtheria,  a 
method  which  need  not  interfere  with  any  other  being 
carried  out  at  the  same  time,  and  one  which  will  do  no 
harm  to  the  patient. 

My  own  experience  with  the  antitoxin  treatment  has 
been  chiefly  in  watching  the  cases,  through  the  kindness 
of  Dr.  White,  at  the  Willard  Parker  Hospital.  Outside 
I  have  had  only  two  cases,  and  these  I  believe  would 
have  recovered  any  way,  but  they  probably  recovered 
more  quickly  under  the  antitoxin  treatment.  The  physi- 
cians in  attendance  were  struck  by  the  almost  immediate 
improvement  in  the  patients  following  the  injections. 

Effeot  on  the  Membrane. — Now,  it  may  strike  some 
that  if  the  antitoxin  has  no  effect  upon  the  duration  of 


the  membrane  and  on  the  duration  of  the  bacilli,  it 
shows  it  has  not  much  influence  on  the  disease.  It  must 
be  remembered,  however,  that  the  antitoxin  is  not  to  any 
marked  extent  a  general  antiseptic.  It  is  not  what  we 
may  have  been  seeking,  something  to  kill  bacilli  without 
killing  the  patient.  It  is  quite  different  It  simply  neu- 
tralizes the  poisons  which  the  germs  develop,  but  does 
not  directly  influence  the  growth  of  the  bacilli,  nor  di- 
rectly affect  the  membrane,  except  in  so  far  as  it  may 
neutralize  the  effect  of  the  poisons  in  producing  mem- 
brane upon  the  throat.  In  animals,  however,  in  which 
large  doses  have  been  employed  the  membrane  has  always 
separated  much  more  quickly  than  it  usually  does. 

In  looking  over  the  cases  treated  by  this  method  I 
found  about  1,180,  the  mortality  of  which,  instead  of 
being  forty-four  per  cent,  as  it  ordinarily  is  under  ex- 
actly the  same  conditions,  fell  to  twenty  per  cent.  Al- 
though we  cannot  judge  in  local  epidemics  by  figures,  I 
think  that  in  general  hospitals,  where  all  the  other  condi- 
tions remain  about  the  same,  we  may  be  pretty  sure  any 
marked  reduction  in  the  mortality  is  due  to  the  special 
treatment  employed.  I  certainly  feel  that  we  have  in 
this  antitoxin  treatment  a  great  outlook,  and  I  hope  we 
shall  soon  have  the  remedy  accessible  for  use  in  every 
case  here  as  well  as  elsewhere. 

Dr.  George  F.  Shrady  supposed  that  he  had  been 
invited  to  make  some  remarks  on  the  subject  on  account 
of  his  connection  with  the  Willard  Parker  Hospital,  and 
because  of  the  opportunities  which  were  thus  afforded 
him  for  verifying  the  reports  and  endorsing  the  state- 
ments of  Dr.  White  in  his  very  interesting  and  instructive 
"paper.  He  could  therefore  give  his  impressions  of  the 
results  of  the  antitoxin  treatment  only  from  a  clinical 
aspect,  and  as  one  who  had  survived  very  many  epidemics 
of  specific  remedies  for  diphtheria.  So  far  as  present 
results  showed  in  Berlin,  Paris,  and  New  York,  antitoxin 
appeared  to  give  better  statistics  than  any  other  form  of 
treatment.  Then  it  was  so  simple  in  its  administration 
that  anyone  could  use  it.  He  was  much  struck  with  the 
remarkable  change  for  the  better  which  occurred  in  some 
of  the  cases  related  by  Dr.  White,  seeming  to  prove  that 
some  profound  and  radical  curative  processes  had  mani- 
fested themselves  in  the  general  system.  The  remedy 
appeared  to  reinforce  the  natural  vital  resistance  to  sys- 
temic poisoning.  The  rationale  of  treatment  was  founded 
on  a  sound  bacteriological  basis,  and  commended  itself 
accordingly  to  progressive  clinicians.  Indeed,  the  prin- 
ciple of  immunization  would  doubtless  prove  as  impor- 
tant to  therapeutics  as  had  been  asepsis  to  operative 
surgery.  It  seemed  to  him  that  we  were,  as  far  as  the 
fundamental  principle  was  concerned,  on  the  eve  of 
brilliant  discoveries  along  that  line. 

The  present  difficulty  in  testing  the  remedy  was  its 
great  scarcity,  and  the  difficulty  of  obtaining  supplies  in 
the  near  future.  A  month  ago  he  had  cabled  to  Berlin 
for  antitoxin,  and  had  received  a  limited  supply,  but  not 
enough  for  extended  experimentation.  Aside  from  the 
opportunities  of  witnessing  Dr.  White's  cases,  Dr. 
Shrady's  personal  experience  had  been  limited  to  one 
case,  which  was  sent  to  him  by  Dr.  Fischer  from  the  Mes- 
siah Home  for  Children.  The  antitoxin  (Behring's)  was 
injected  into  the  intra-scapular  region,  with  the  result  of 
relieving  the  grave  systemic  symptoms,  and  eventually 
curing  the  child.  Thus  far  he  believed  that  the  remedy 
deserved  a  more  extended  trial,  and  he  hoped  that  soon 
the  supply  of  the  antitoxin  would  be  equal  to  the  demand. 

Dr.  W.  P.  Northrup  thought  the  paper  of  Dr.  White 
hopeful.  Like  the  opening  chapter  in  a  novel,  it  prom- 
ised well,  and  one  felt  like  turning  over  to  the  back 
pages  to  see  how  it  would  come  out.  There  were  several 
things  which  had  to  be  proved  at  so  hopeful  a  period  of 
any  remedy.  In  the  first  place,  the  cases  treated  may 
have  occurred  at  a  time  when  everybody  suffering  from 
diphtheria  got  well.  As  far  as  he  had  been  aide  to 
learn,  the  percentage  of  recoveries  in  institutions  at  tins 
particular  time  was  especially  good.  He  wished  to  join 
in  the  general  hopefulness  of  Lthis  occasion.     But  he 


November  17,  1894] 


MEDICAL    RECORD. 


633 


would  not  forget  that  we  had  had  in  the  past  many  dis- 
appointments in  remedies. 

Dr.  Northrup  had  observed,  with  others  of  his  col- 
leagues, that  in  some  of  the  European  hospitals  they 
claimed  to  get  results  by  certain  methods  of  treatment, 
say  by  intubation,  which  were  much  more  favorable  than 
had  been  obtained  here.  He  mentioned  the  fact  as  one 
to  be  borne  in  mind  when  judging  of  the  value  of  any 
method  of  treatment  based  on  experience  over  there. 
He  had  had  some  of  the  antitoxin  sent  him  for  use  in 
diphtheria,  but  had  not  been  able  to  find  a  case  in  which 
to  employ  it,  at  the  Foundling  Asylum  or  elsewhere. 
This  showed  very  well  the  sporadic  nature  of  the  disease 
at  this  time.  A  special  test  of  the  new  treatment  would 
be  found  in  rather  rare  cases  of  rapid  toxaemia  from  the 
commencement,  in  which  death  sometimes  took  place 
within  twelve  hours  from  the  first  symptoms  of  diph- 
theria. In  such  cases  nothing  else  than  possibly  the 
antitoxin  could  have  any  effect.  It  seemed  that  the  in- 
fluence of  the  antitoxin  on  the  pulse  was  the  most  hope- 
ful indication. 

Dr.  Louis  Fischer  spoke  of  his  observations  in  Berlin 
of  two  methods  of  treatment,  one  by  Aronson,  the  other 
by  Beginsky.  The  latter  informed  him  that  the  mortal- 
ity in  diphtheria  had  fallen  from  thirty-seven  per  cent, 
to  thirteen  per  cent,  under  antitoxin  treatment  The 
course  pursued  was  to  inject  at  once  every  case  brought 
to  the  hospital  with  a  pseudo-membrane.  Next  day,  the 
bacteriological  examination  having  been  made,  the  cases 
of  pseudo  diphtheria  were  separated  from  those  of  true 
diphtheria,  and  in  the  latter  the  antitoxin  treatment  was 
continued.  Dr.  Fischer  had  had  some  personal  experi- 
ence with  the  treatment  very  recently,  in  a  hospital  in 
Philadelphia,  and  it  would  appear  to  have  had  more  in- 
fluence on  the  membrane  in  the  throat  than  had  been 
described  by  others.  Although  he  had  been  favorably 
impressed  by  the  antitoxin  results,  he  did  not  think  it 
safe  to  become  too  enthusiastic. 

Sceptical. — Dr.  Henry  Berg  said  the  difficulty  in 
judging  of  the  value  of  any  method  of  treating  diphtheria 
related  to  prognosis,  or  our  ability  to  judge  of  the  sever- 
ity of  the  cases.  Frequently  the  very  ones  which  we  ex- 
pected to  terminate  favorably  died,  while  those  which 
we  expected  to  die  took  on  a  marked  change  for  the  bet- 
ter in  a  few  hours,  and  went  on  to  recovery.  He  had 
seen  nearly  all  the  cases  treated  by  antitoxin  by  Dr. 
White  at  Willard  Parker  Hospital,  and  while  he  could 
not  say  that  all  of  them  were  not  severe  cases,  yet  he 
could  not  say  that  they  were.  Some  of  them  seemed  to 
him  to  be  only  ordinary  cases  of  diphtheria,  while  some 
seemed  to  be  very  severe  ones,  although  he  was  not  posi- 
tive that  he  would  have  made  a  fatal  prognosis.  These 
facts  simply  showed  that  if  we  were  going  to  draw  deduc- 
tions with  regard  to  the  efficacy  of  any  given  treatment 
in  diphtheria  from  figures,  the  number  must  be  very 
large,  and  the  only  way  to  test  the  new  method  was  to 
place  the  antitoxin  in  the  hands  of  all  the  physicians  of 
the  city.  Dr.  Berg  thought  statistics  here  and  those 
abroad  would  point  to  the  fact  that  our  treatment  of 
diphtheria  was  either  better,  or  that  epidemics  here  were 
less  severe. 

Hew  Syringe  for  Cleansing  the  Nostrils.— Dr.  Som- 
merset  presented  a  syringe  for  cleansing  the  nasal  cavities 
in  diphtheria,  and  said  that  with  it  one  could  give  more 
force  to  the  stream  than  with  the  Davidson  syringe,  which 
was  necessary  in  rare  cases  where  the  occluding  mem- 
brane held  tenaciously  and  had  to  be  removed  to  prevent 
sepsis. 

The  chairman,  Dr.  Winters,  testified  to  the  value  of 
this  syringe.  Regarding  statistics  of  mortality-rate  as 
basis  for  judging  of  the  efficacy  of  the  antitoxin  treat- 
ment, he  thought  they  were  apt  to  be  misleading.  Or- 
dinarily the  entire  number  of  deaths  was  meant,  but  in 
some  of  these  special  statistics  certain  cases  of  death  had 
been  excluded,  which,  of  course,  would  make  a  better 
showing  for  the  antitoxin.  It  seemed  that  abroad  the 
mortality  rate  without  this  treatment  had  been  placed 


enormously  high.  In  this  city  the  Board  of  Health 
record  gave  a  death-rate  of  only  twenty- five  to  thirty- 
three  per  cent.  This  must  necessarily  be  too  high,  if 
it  was  remembered  that  all  fatal  cases  were  reported,  while 
many  non-fatal  cases  were  not  reported  at  all.  He 
thought  it  certainly  did  not  exceed  twenty- five  per  cent. 
Again,  he  doubted  whether  there  was  any  serious  infec- 
tious disease  so  badly  treated  as  diphtheria.  Faulty 
methods  being  omitted  under  the  antitoxin  treatment, 
would  in  itself  cause  a  better  mortality- rate.  Further, 
mortality  statistics  were  usually  made  up  from  cases  to 
which  a  reputable  physician  was  not  called  until  the  dis- 
ease had  well  advanced,  say  after  three  or  four  days. 
These  facts  had  to  be  taken  into  consideration  in  judging 
of  the  value  of  the  new  antitoxin  treatment.  It  would 
be  necessary  to  wait  until  long  use  by  many  physicians 
had  tested  the  method. 

Dr.  Andrew  H.  Smith  said  a  very  good  nasal  syringe 
could  be  made  out  of  any  ordinary  one,  by  attaching  to 
it  a  rubber  nipple  the  opening  in  which  was  smaller  than 
that  in  the  end  of  the  syringe,  so  that  the  nipple  would 
be  made  to  dilate  by  the  stream  and  fit  closely  to  the 
nostril  Regarding  antitoxin,  he  thought  it  would 
prove  of  inestimable  value  if  it  had  no  other  effect  than 
to  stop  the  pernicious  practice  of  applying  frequently 
local  remedies  against  the  struggles  of  the  little  patients. 

Dr.  White  closed  the  discussion. 


SECTION  ON  LARYNGOLOGY  AND   RHINOLOGY. 

Stated  Meeting,  October  24, 1894. 

Dr.  D.  Bryson  Delavan,  Chairman. 

A  Case  of  Sarcoma  of  the  Palate  Successfully  Treated 
by  the  Toxins  of  Erysipelas,  was  the  title  of  a  paper 
read  by  Dr.  W.  B.  Johnson,  of  Paterson,  N.  J.  (See 
page  616.) 

Dr.  W.  B.  Coley  said :  I  saw  this  case  before  treat- 
ment was  begun.  The  case  was  grave,  and  I  had  no 
hope  of  treatment  doing  more  than  giving  temporary 
relief.  The  result  of  my  experience  with  toxins  up  to 
last  May  I  reported  at  Washington,  before  the  Section  on 
Surgery,  Congress  of  American  Physicians  and  Surgeons. 
The  cases  reported  were  25  of  sarcoma,  9  of  carcinoma, 
and  2  or  3  where  examination  was  not  made.  Of  these 
cases,  I  reported  in  detail  5  which  I  hoped  to  cure.  None 
of  them  have  shown  any  signs  of  recurrence  of  the 
trouble.  Since  that  time  3  cases  have  gone  over  a  period 
of  three  years ;  2  over  two  years,  and  others  over  one 
year.  Since  the  publication  of  the  paper,  I  have  treated 
10  cases  of  sarcoma,  3  having  been  extraordinarily  suc- 
cessful. One  was  an  enormous  sarcoma  of  the  ilium, 
filling  the  right  side  of  the  abdomen.  I  began  toxin 
treatment,  then  the  tumor  began  to  break  down  and 
slough  out,  and  after  five  weeks  of  sloughing  the  injec- 
tions were  stopped.  The  result  of  treatment  and  conse- 
quent breaking  down  of  the  tumor  was  depressing  to  the 
patient,  but  by  stimulation  and  careful  nourishment  he 
began  to  recover,  and  I  showed  him  a  week  ago  without 
any  tumor  left  On  August  1 5  th  he  weighed  115  pounds ; 
now  he  weighs  140  pounds. 

I  have  a  case  of  a  girl,  aged  sixteen,  with  a  sar- 
coma of  four  months  in  left  scapular  region,  attend- 
ing to  the  median  line  in  back,  and  filling  axilla  to 
median  line  in  front,  attached  to  chest -wall.  In 
three  weeks  she  was  able  to  raise  her  arm.  Injections 
were  given  in  scapular  region  only.  Improvement  im- 
mediately was  marked,  and  she  is  now  cured.  I  had  and 
have  other  cases,  the  results  of  which  are  similar.  The 
preparation  which  Dr.  Johnson  used  was  erysipelatous 
and  prodigiosus  toxin,  used  in  separate  bottles,  given 
in  small  doses  in  combination.  The  two  cultures  are 
now  grown  together  and  subjected  to  heat;  58°  C.  is  suf- 
ficient to  kill  the  germs  without  destroying  the  chemical 
toxin,  and  no  loss  occurs  as  in  filtration ;  after  subject- 
ing to  heat  add  sufficient  thymol  to  make  a  saturated  so- 


634 


MEDICAL   RECORD. 


[November  17,  1894 


lution.    The  value  ot  the  toxin  lies  in  the  virulence  of 
the  culture. 

The  Chairman,  Dr.  D.  Bryson  Delavan,  said  no  efforts 
that  we  can  make  will  be  too  great  to  further  the  success 
of  these  experiments,  which  have  gone  so  far  as  to  prove 
that  they  amount  to  something  more  than  mere  experi- 
ments. They  have  cured  one  case  of  malignant  disease 
of  the  palate,  at  least. 


PRACTITIONERS'  SOCIETY  OF  NEW  YORK. 

Stated  Meeting,  October  5,  1894. 

Henry  F.  Walker,  M.D.,  President,  in  the  Chair. 

Angioneurotic  (Edema.— Dr.  Charles  L.  Dana  pre- 
sented a  man  with  this  affection.  He  was  twenty-seven 
years  of  age,  a  bar-keeper,  had  used  alcohol  moderately 
since  early  youth,  and  had  used  tobacco  excessively  since 
the  age  of  twelve,  smoking,  since  his  twentieth  year,  as 
many  as  thirty  to  fifty  cigars  a  day.  He  had  never  had 
any  venereal  disease,  malarial  affection,  rheumatism,  or 
digestive  disorder.  He  had  been  rather  nervous,  but 
that  was  all. 

One  morning  last  February,  he  awoke  to  find  the 
right  foot  swollen.  The  swelling  went  down,  but 
next  day  the  leit  toot  was  affected  in  the  same  way, 
then  the  face;  and  since  then  all  parts  of  the  body 
had  been  affected  by  such  (Edematous  swellings,  mostly, 
however,  the  face,  hands,  feet,  and  scrotum.  The 
swellings  would  increase  until  the  skin  became  very 
tense  and  hard,  resisting  pitting,  and  would  disappear  in 
from  two  hours  to  twenty- four,  none  having  lasted  longer 
than  a  day  and  night.  Some  would  make  their  appear- 
ance while  others  were  fading  away.  They  were  whitish 
m  color,  with  a  little  rose  tinge,  but  never  resembling 
wheals.  Sometimes  one  side  of  the  face  would  be  swollen 
to  the  point  of  closing  the  eye,  and  present  a  white  ap- 
pearance ;  sometimes  the  hand  would  be  of  enormous 
size.  The  patient  stated  that  he  could  sometimes  bring 
the  swellings  out  on  the  face  by  scratching,  and  quinine, 
which  some  physicians  had  prescribed  for  him,  had  been 
quickly  foUowed  by  their  appearance.  There  was  no 
organic  trouble  with  the  kidneys,  lungs,  or  heart.  The 
pulse  had  been  rather  fest,  about  ninety,  and  of  very  low 
tension,  but  not  intermittent.  He  complained  a  good 
deal  of  palpitation.  There  was  no  scotoma,  no  evidence 
of  alcoholic  injury  of  the  optic  nerve. 

Dr.  Dana  said  that  in  his  experience  these  cases  were 
rare,  and  their  cause  and  progress  was  involved  in  consid- 
erable obscurity.  Some  of  the  causes  which  had  been 
mentioned  were  malarial  affections,  fright,  trauma,  ex- 
hausting influences  of  various  kinds.  This  man's  case 
seemed  directly  due  to  tobacco,  and  that  which  seemed 
to  promptly  relieve  him  was  to  stop  the  use  of  this  arti- 
cle. He  had  had  scarcely  any  trouble  since  he  had 
given  up  smoking.  In  addition,  Dr.  Dana  had  prescribed 
a  tonic  of  mineral  acid  and  strychnia. 

The  speaker  had  observed  that  the  excessive  use  of  to- 
bacco, beginning  early  in  life,  sometimes  produced  curi- 
ous vasomotor  disturbances.  The  tobacco  seemed  to 
have  a  special  effect  in  some  cases  on  the  vasomotor 
nervous  system.  Writers  on  angio  neurotic  oedema 
classed  it  as  having  some  relationship  to  urticaria,  giant 
wheal,  and  like  conditions,  but  in  this  case  there  was  no 
dietetic  influence  nor  resemblance  of  the  swellings  to  the 
wheals  of  urticaria.  Until  lately,  the  patient  had  not 
been  free  from  the  swellings  since  February,  except  two 
weeks  in  June. 

Dr.  Francis  Delafield  had  hoped  to  hear  of  some 
particular  treatment  of  the  disease.  He  recalled  two 
comparatively  recent  cases  in  women  who  gave  no  neu- 
rotic history,  had  no  bad  habits,  were  in  comfortable  cir- 
cumstances ;  the  swellings  continued  to  develop  without 
apparent  cause  for  several  months,  and  then  ceased. 
He  did  not  know  why  they  had  the  affection,  nor  why  they 
stopped  having  it.     It  seemed  to  be  not  very  uncommon, 


and  an  efficient  plan  of  treatment  would  be  a  great  con- 
venience. 

Dr.  Dana  remarked  that  the  cases  were  probably  seen 
oftener  by  the  general  practitioner  and  dermatologist 
than  by  the  neurologist.  He  had  seen  but  three,  and  had 
not  been  able  to  keep  track  of  them,  but  knew  that  two 
got  along  fairly  well. 

The  president,  Dr.  Walker,  had  seen  a  man  in  a  few 
of  the  several  attacks  which  he  had  been  having  for  two 
or  three  years,  consisting  in  great  swelling  of  the  tongue, 
causing  it  to  protrude  from  the  mouth,  and  less  swelling 
of  the  lips,  the  condition  gradually  disappearing  after 
some  hours.  At  first  there  was  fear  the  glottis  or  larynx 
might  become  affected  and  cause  strangulation,  but  this 
fear  had  passed  off.  The  man  was  a  smoker,  a  moderate 
drinker,  had  a  rather  gross  appetite,  slight  rheumatic 
trouble,  no  constitutional  disease. 

Dr.  G.  L.  Peabody  had  also  had  a  case  in  which  the  at- 
tacks of  swelling  were  confined  chiefly  to  the  lips  and 
tongue,  in  a  man  of  thirty- five,  without  bad  habits,  not  a 
smoker,  but  of  gouty  heredity.  Dr.  Peabody  prescribed 
colchicum,  and  since  then  the  patient  had  taken  this  drug 
when  there  was  a  recurrence,  but  had  now  been  free  a  long 
time.  He  was  unable  to  say  whether  the  colchicum  had 
given  the  relief. 

Extirpation  of  Tongue  for  Cancer ;  Taste  and  Speech 
soon  Regained. — Dr.  Robert  Abbe  presented  a  man, 
fifty-three  years  of  age,  whom  he  had  first  seen  about  five 
months  before,  when  he  presented  a  cancer  on  the  back 
portion  of  the  tongue,  beginning  on  the  left  side  and  ex- 
tending to  the  right.  There  was  a  little  glandular  involve- 
ment under  the  left  jaw.  The  patient  was  dribbling  saliva, 
was  unable  to  masticate,  was  markedly  cachetic,  and  in 
deplorable  general  condition.  Dr.  Abbe  performed 
Kocher's  operation  for  removal  of  the  whole  tongue, 
and  showed  the  patient  because  of  the  remarkable  power 
of  speech  which  he  had  regained  since  the  operation,  four 
months  ago.  He  had  no  difficulty  in  making  himself 
understood  in  a  large  room,  and  was  able  to  utter  all  the 
sounds  of  the  alphabet  except  k,  which  he  pronounced  p, 
saying,  for  instance,  pip  for  kick.  The  general  health 
had  again  become  perfect.  There  was  a  slight  recurrence 
on  one  tonsil,  which  it  would  be  necessary  to  remove. 

Dr.  Dana  elicited  from  the  patient  the  fact  that  he 
had  power  of  taste,  recognizing  sweet,  bitter,  salt,  acid, 
etc.  Dr.  Dana  confessed  his  inability  to  explain  the  ex- 
istence of  this  power  where  the  tongue,  with  the  nerves 
of  taste  and  taste  buds  had  been  almost  entirely  extirpa- 
ted. It  was  supposed  that  normally  there  was  slight 
sense  of  taste  in  the  soft  palate,  but  he  had  himself  never 
been  able  to  recognize  taste  in  that  locality. 

Dr.  Sexton  brought  out  the  fact  that  the  patient  had 
a  slight  burning  sensation  at  one  part  of  the  stump,  and 
stated  that  he  had  frequently  found  division  of  the  chorda 
tympani  followed  by  a  feeling  as  if  the  tongue  were 
scalded. 

Remarks  on  the  Education  of  the  Stomach. — Dr. 
Samuel  Sexton  read  the  paper  of  the  evening,  bearing 
this  title.  In  having  chosen  as  the  subject  for  his  paper 
one  which  most  of  those  present  were  better  able  to  dis- 
cuss than  he,  he  wished  to  elicit  a  discussion  which  might 
add  to  the  comfort  and  more  perfect  manhood  of  the  com- 
ing generation.  He  was  of  the  opinion  that  most  people 
greatly  abused  their  stomachs  by  taking  too  much  food, 
and  food  of  improper  or  injurious  kind.  It  was  especially 
the  excessive  quantity  and  variety  consumed  at  a  single 
meal  which  had  most  forcibly  attracted  his  attention  at 
the  hotels  and  in  private  families.  He  cited  several 
notable  examples  of  gluttony  on  the  part  of  children  at 
the  expensive  hotels  here  and  in  Paris,  where  they  did 
not  fail  to  partake  of  all  the  numerous  courses  printed  on 
the  m£nu.  The  parents,  so  far  from  reprimanding  them 
for  their  greediness,  took  pains  to  have  the  little  heroes 
or  martyrs  fill  their  pockets  with  such  dainties  as  might 
prove  tasteful  between  meals.  The  author  thought  it 
was  necessary,  for  a  healthy  development,  to  accustom 
the  stomach  to  plain,  simple,  but  nutritious  food,  in  rea- 


November  17,  1894] 


MEDICAL   RECORD. 


635 


sonable  quantity,  with  periods  of  intermission  sufficient 
for  complete  digestion  and  rest.  The  agonies  which 
children  suffered  from  colic  and  frightful  dreams  consti- 
tuted a  part  of  the  punishment  inflicted  upon  them 
through  the  ignorance  or  thoughtlessness  of  parents  who 
permitted  and  even  tempted  them  to  make  their  stomachs 
a  dumping  ground  for  all  possible  foods  and  drinks,  and 
many  things  which  were  neither  food  nor  drink. 

During  the  discussion  Dr.  Beverley  Robinson  said  he 
supposed  all  would  agree  that  most  people  ate  too  much, 
but  he  thought  there  was  a  tendency  among  intelligent 
people  to  educate  the  stomach  and  limit  the  food  of  their 
children.  Sweets  were  ruled  out,  and  the  food  was  given 
in  moderate  quantity  and  at  stated  intervals. 

Gluttony  not  an  American  Characteristic — Dr. 
Dana  could  not  agree  with  Dr.  Sexton  if  he  meant  to  im- 
ply that  over-eating  and  gluttony  were  at  all  characteris- 
tic of  the  American  of  to  day — that  was  to  say,  the  edu- 
cated American,  the  type  we  were  developing  in  this 
country.  It  seemed  to  him  the  tendency  of  the  times 
and  of  the  race  was  to  eat  rather  less,  and  he  believed  it 
would  become  still  more  so.  A  neurotic  people,  he 
thought,  would  have  to  live  simply  and  on  a  small 
amount  in  order  to  retain  their  health,  and  the  Ameri- 
cans appeared  to  be  learning  that  feet.  His  observation 
had  been  that  it  was  rather  hard  to  get  children  of  ner- 
vous temperament  to  eat  enough.  They  often  left  the 
breakfast  table  after  having  eaten  very  little,  and  they 
ate  a  light  dinner.  He  did  not  mean  to  say  they  carried 
this  to  an  unhealthy  extent,  but  he  certainly  had  not 
seen  gormandizers  among  children  of  a  fairly  healthy 
neurotic  type.  When  one  did  see  gormandizing  in  a 
child  it  was  almost  always  a  sign  of  a  degenerative  taint 
in  that  particular  person.  It  was  a  perfectly  well-known 
characteristic  of  the  epileptic  and  imbecile  or  partially 
developed  children,  and  he  supposed,  as  Dr.  Sexton  had 
suggested,  that  gormandizing  was  some  evidence  of  ata- 
vism. He  also  thought  the  paper  was  quite  correct  in 
teaching  that  we,  as  a  neurotic  race,  who  lived  on  the 
nerves  and  drew  largely  on  the  brain,  must  eat  plainly 
and  simply.  The  only  point  where  Dr.  Dana  differed 
from  the  author  was,  that  he  thought  Americans  had 
found  this  out  largely,  and  did  live  in  that  way.  He 
had  always  thought  that  the  American's  stomach  was  a 
great  safeguard  to  him;  it  was  delicate,  and  he  soon 
found  out  that  he  could  not  eat  excessively,  drink  exces- 
sively, nor  smoke  excessively.  He  could  not  do  as  the 
Germans  aad  English. 

Dr.  Peabody  remarked  that  the  Germans  had  no  term 
expressing  dyspepsia,  and  agreed  with  Dr.  Robinson  that 
they  probably  had  better  beer  if  not  better  food. 

Dr.  Dana  said  he  had  not  stated  that  the  Germans 
had  dyspepsia,  but  he  thought  that  if  the  same  classes 
here,  as  lawyers  and  teachers,  should  eat  and  drink  as 
they  did  in  Germany,  they  would  get  sick. 

Becoming  a  larger  and  Fuller  Developed  Baoe. — 
The  President  thought  he  had  observed  that  the  chil- 
dren and  youth  in  New  York  to-day  were  larger  and  bet- 
ter formed  than  those  of  eighteen  or  more  years  ago,  and 
that  it  was  due  to  their  tetter  feeding  and  manner  of 
bringing  up.  In  other  words,  the  tendency  seemed  to 
be  toward  a  larger  and  fuller  developed  race. 

Dr.  Peabody  queried  whether  that  was  not  due  to 
athletics,  and  Dr.  Walker  agreed  that  athletics  had 
something  to  do  with  it  as  a  part  of  the  better  training. 

Brewers  Drink  a  Keg  of  Beer  a  Day. — Dr.  Sexton 
said  he  once  had  occasion  to  examine  men  who  worked 
in  a  large  brewery,  and  learned  that  it  was  the  custom 
of  those  who  had  free  access  to  the  beer  to  drink  a  keg 
apiece  each  day.  It  was  not  uncommon  for  Germans  in 
this  country  to  drink  twenty- five  glasses  or  more  a  day. 
Children  in  this  city,  he  thought,  had  too  little  exercise 
and  were  over- fed,  and  were  not  properly  educated  with 
regard  to  diet.  One  way  of  entertaining  a  child  was  to 
feed  it.  Possibly  he  was  wrong,  but  he  believed  a  very 
large  amount  of  nervous  energy  was  consumed  in  diges- 
tion, and  that  over-feeding  deprived  the  heart  of  a  good 


deal  of  nervous  power  which  it  should  receive.  The  con- 
dition of  many  patients  was  markedly  improved  simply 
by  diminishing  their  food  supply. 


Stone. — Litholapaxy  is  the  operation  when  the  patient 
is  an  adult  with  a  capacious  and  tolerant  urethra,  with  a 
bladder  free  from  severe  chronic  iDflammation,  aid  with 
a  small  or  medium-sized  stone,  or,  if  large,  of  soft  consist- 
ence. The  suprapubic  is  the  best  operation  for  large 
and  hard  calculi.  The  medio-bilateral  operation  should 
be  chosen  in  all  other  conditions,  because  it  is  the  easiest, 
safest,  and  best. — Briggs. 

Carbolic  Acid  applied  in  officinal  strength  in  surgery. 

1.  No  systemic  absorption  attends  its  use,  and  hence 
no  danger,  no  shock. 

2.  It  is  a  local  anaesthetic.  Hence  there  is  not  as 
much  pain  after  the  operation. 

3.  It  is  in  a  measure  a  haemostatic,  acting  especially 
upon  the  capillary  vessels.— Gardner. 

Ingrowing  Toenail.— Remove  all  of  the  redundant, 
hypertrophied,  or  granular  tissues  of  the  skin,  and  leave 
the  nail  alone. — Nuding. 

Lung  Surgery. — In  tuberculous  cavity  the  advan- 
tages do  not  seem  to  be  of  sufficient  magnitude  to  war- 
rant an  operation,  except  in  a  very  few  instances.  Re- 
moval from  the  lung  of  pieces  affected  with  tuberculous 
infiltration  is  obviously  in  the  realm  of  pure  experiment. 
— Chaplin. 

Bepeated  small  rectal  injections,  it  is  said,  will  relieve 
the  intense  thirst  following  abdominal  operations. 

Local  AnflBsthesia.  —A  mixture  of  ten  parts  of  chloro- 
form, fifteen  of  ether,  and  one  of  menthol,  used  as  a 
spray,  is  recommended  as  an  excellent  and  prompt 
means  of  obtaining  local  anaesthesia  lasting  for  about 
five  minutes. 

Cracked  Ice,  Sawdust,  and  Salt  thoroughly  mixed  and 
applied  over  abscess,  felon,  tumor,  or  bubo,  will  deaden 
the  skin  sufficiently  to  allow  of  painless  incision. 

Alcohol  will  be  used  less  and  less  in  surgery,  because 
scientific  investigation  has  shown  the  causes  of  many  of 
the  evils  it  was  imagined  to  counteract,  and  because, 
thanks  to  Sir  Joseph  Lister,  these  causes  have  been  got 
rid  o£ — Horsley. 

Hydroceles  of  the  Heck,  after  tapping  and  iodine  in- 
jection, either  quickly  refill,  or  such  extensive  inflamma- 
tion is  set  up  as  to  endanger  life.— Stokes. 

Granular  Lids. — Curetting  and  brushing  with  corrosive 
sublimate  is  successful  in  mild,  but  not  suited  to  bad 
cases. — Trousseau. 

Palpation  of  the  Vermiform  Appendix. — Pressure 
deep  enough  to  recognize  distinctly  the  posterior  abdom- 
inal wall,  the  pelvic  brim,  and  the  structures  between 
them  and  the  examining  finger,  forms  the  whole  secret 
of  success  in  the  practice  of  palpation  of  the  vermiform 
appendix. — Edebohls. 

Eectal  Tube. — As  a  means  of  diagnosis,  or  in  treating 
stricture  beyond  the  reach  of  the  finger,  tubes  of  any 
kind  are  absolutely  useless. — Cripps. 

Acetanilide  is  curative  in  wounds,  lacerations,  and 
internal  haemorrhoids.  It  is  cleanly,  odorless,  antiseptic. 
— Woods. 

Castration  for  Hypertrophy  of  Prostate.— Existing  ev- 
idence would  certainly  seem  to  establish  the  claim  of  the 
operation  to  further  and  much  more  extended  trial; 
and  it  shows,  I  think,  that  even  on  a  basis  of  experiment 
and  theory  alone,  I  was  justified  in  suggesting  it  to  the 
profession. — White. 


636 


MEDICAL   RECORD. 


[November  17,  1894 


Peat  Fibre,  as  now  prepared  for  surgical  purposes,  is 
a  fine,  brown,  glossy  wool,  with  a  faint  aromatic  smell. 
It  feels  a  little  rougher  than  fine  absorbent  wool,  but 
makes  a  more  comfortable  dressing,  as  it  is  much  more 
elastic.  Its  chief  advantage  seems  to  be  that  it  is  a 
deodorant. — Burgess. 

Spinal  Cord. — In  compound  fractures,  in  fractures  of 
the  spinous  processes  and  laminae,  with  injury  to  the 
cord,  in  simple  fractures  and  dislocations  of  the  bodies 
of  the  vertebrae,  if  there  is  a  reasonable  probability  that 
the  injury  is  due  to  hemorrhage,  operation  is  advisable ; 
but  in  all  other  cases,  laminectomy  is  not  an  eminently 
valuable  surgical  procedure. — Thorburn. 

T  Internal  Haemorrhoids.-— The  ligature  is  the  safest 
method  of  operating  for  internal  haemorrhoids,  as  there 
is  less  likelihood  of  its  use  being  followed  by  hemorrhage, 
stricture,  or  ulcer. — Dundore. 

Sterilize  Catgut  by  means  of  the  vapor  of  alcohol 
heated  to  1200  C,  verifying  the  sterilization  by  placing 
bouillon  in  the  same  tubes  with  the  gut ;  if  the  bouillon 
becomes  turbid  the  ligatures  should  be  rejected,  as  the 
tubes  are  infected.—  R*pin. 

Management  of  the  Intestines  after  Abdominal 
Section. — When  the  general  condition  of  the  patient  is 
fairly  good  and  the  abdomen  is  not  distending,  and 
when  there  is  not  much  colic,  let  things  take  their 
natural  course.  This  advice  holds  for  the  great  majority 
of  cases. 

When  the  physician  is  summoned  to  a  case  of  intesti" 
nal  obstruction,  he  should  at  once  point  out  to  the  patient 
the  possible  necessity  of  an  operation.  The  neglect  to 
do  this  has  cost  many  lives,  for  a  considerable  time  usu- 
ally elapses  before  a  seriously  ill  person  consents  to  a 
dangerous  operation. — Gersung. 

Hypnotic  Insensibility  to  pain  can  be  applied  to  such 
operations  as  extirpation  of  the  breast  without  the  pa- 
tient manifesting  the  slightest  sign  of  pain. — Schmeltz. 

Stricture. — External  urethrotomy  with  Syme's  staff 
and  Teale's  probe  gorget,  is  preferable  for  all  strictures 
of  the  deep  urethra  where  gradual  dilatation  is  impos- 
sible.— Rosenstein. 

Catgat  Drains.  —  By  interlacing  in  a  gabion-like 
manner  the  separate  filaments  of  catgut,  a  tube  of  any 
desired  size  and  length  can  be  made.  It  has  the  advan- 
tage of  being  capable  of  perfect  sterilization,  does  not 
present  the  inconveniences  of  decalcified  bone,  is  not 
rigid,  has  all  the  advantages  of  rubber,  resorption  can  be 
accurately  calculated,  and  by  reason  of  the  openings 
along  its  whole  extent  realizes  an  ideal  drainage. — Des- 

<5UIN. 

Intubation. — The  comparison  of  the  results  from  tra- 
cheotomy and  intubation  gives,  in  the  first  two  years  of 
life,  better  results  from  intubation  than  from  tracheotomy. 
— Von  Rankl. 

Hysterectomy. — The  operation  should  always  be  begun 
with  the  intention  of  performing  the  intra-peritoneal 
method,  and  removing  the  whole  organ  if  possible,  but 
the  operator  must  be  prepared  to  adopt  any  method, 
should  it  seem  best  to  do  so  when  the  exact  conditions 
are  found  out  during  the  progress  of  the  operation. — 
Keith. 

*  In  Cancer  of  the  oesophagus  a  gastric  fistula  should  be 
established  as  soon  as  the  scales  show  a  steady  decrease  of 
the  patient's  weight. — Meyer. 

Depressions  of  the  skull  in  the  new-born  should  be 
treated  by  immediate  resort  to  operation,  if  there  are 
symptoms  calling  for  its  performance. — Jennings. 

Uterine  Fibroid— In  all  cases  of  simple  myoma  or  of 
diffuse  progressive  hyperplasia  (the  "soft  fibroid"  of 
many  authors),  complete  removal  should  be  practised  as 
soon  as  the  diagnosis  is  established. — Reed. 


OUR  LONDON  LETTER. 

(From  Our  Special  Correspondent.) 

OPENING  MEETINGS  OF  THE  ROYAL  MEDICO-CH1RURGICAL 
AND  PATHOLOGICAL  SOCIETIES  —  SURGERY  IN  SEPTIC 
PERITONITIS  —  LAPAROTOMY  IN  PERFORATING  ULCER — 
MEDICAL  SOCIETY  OF  LONDON — TREATMENT  OF  CAN- 
CER  BY   CINNAMON — PAY- PATIENTS  IN   HOSPITALS. 

London,  October  vj% 1894. 

The  Royal  Medico  Chirurgical  Society  held  its  first  or- 
dinary meeting  on  Tuesday  evening,  when  Mr.  Lock- 
wood  read  an  important  paper  on  the  Surgical  Treatment 
of  Diffuse  Septic  Peritonitis.  In  the  cases  he  referred  to 
the  inflammation  had  no  defined  limits,  the  membrane 
was  smeared  with  lymph,  and  the  cavity  contained  thin 
purulent  fluid,  often  with  a  fecal  odor,  or  it  might  be 
full  of  gas.  The  intestines  were  paralyzed  and  distended. 
In  these  very  rapidly  fatal  cases  Mr.  Lockwood  had 
operated  for  fear  of  overlooking  a  mechanical  obstruc- 
tion rather  than  with  a  view  of  curing  the  peritonitis ; 
but  he  had  had  success  when  there  was  not  mechanical 
obstruction  and  now  detailed  the  proceedings  he 
adopted.  To  meet  the  exhaustion,  collapse,  and  disten- 
tion he  used  strychnine  and  brandy,  before  operation — 
and  warmth  both  at  the  time  and  afterward,  also  nutrient 
enemata,  stimulants,  and  warmth  as  required.  Rapid  but 
methodical  operation  was  important.  He  punctured  the 
several  coils  of  intestine  to  withdraw  the  gas  and  then  let 
out  the  faeces  through  an  incision,  which  he  afterward 
closed.  Then  of  course  he  irrigated  and  drained.  Two 
successful  cases  were  described.  The  object  of  the  paper 
was  not  to  bring  forward  novelties,  but  to  insist  on  the 
methodical  use  of  known  proceedings,  and  the  general 
feeling  seemed  to  be  that  the  cases  related  were  encour- 
aging. In  the  discussion  some  interesting  points  were 
raised.  Thus  Mr.  Hulke  regarded  the  paper  as  valuable, 
but  mentioned  that  he  had  sometimes  found  the  intes- 
tines so  soft  that  the  puncture  continued  to  leak  and  the 
attempt  to  close  it  by  ligature  only  increased  its  size.  He 
thought  no  surgeon  would  hesitate  to  enlarge  by  incision 
a  perforation  he  found  to  exist.  Mr.  Knowsley  Thorn- 
ton regarded  the  combination  of  puncture  with  incision 
and  the  protection  of  the  patient  from  shock  as  the  essen- 
tial features  of  the  treatment  advised  and  regretted  that 
he  had  not  been  more  careful  in  the  past  to*  guard  against 
chill,  shock,  and  prolonged  exposure.  He  had  long  rec- 
ognized the  danger  of  distention  as  well  as  of  the  septic 
material  spread  over  the  surface  for  which  thorough  irri- 
gation was  necessary.  Mr.  Harrison  Cripps  congratu- 
lated the  author  on  showing  how  to  deal  with  cases  which 
were  the  bane  of  abdominal  surgery.  In  cases  after  child- 
birth or  erysipelas  or  operations,  he  thought  the  poison 
had  passed  into  the  system  and  was  beyond  the  reach  of 
surgery.  Mr.  Alban  Doran  thought  so  too  and  doubted 
if  it  would  be  justifiable  to  operate  in  truly  pyaemic  cases, 
as  the  viscera  were  in  them  almost  always  affected  with 
secondary  deposits.  Dr.  Norman  Moore  said  some  of 
the  collapse  might  be  due  to  the  size  of  the  opening,  and 
mentioned  a  case  he  had  seen  within  two  hours  of  rupture 
of  a  gastric  ulcer.  Death  occurred  in  seven  hours  and 
very  few  signs  of  peritonitis  were  found  at  the  autopsy. 
Mr.  Marmaduke  Shield  had  often  punctured  through  the 
abdominal  wall  for  chronic  obstruction,  but  the  punctures 
were  apt  to  leak  and  set  up  peritonitis.  The  trocar  should 
be  as  fine  as  a  sewing-needle  and  passed  obliquely 
through  the  muscular  coat,  so  as  to  make  the  opening 
somewhat  valvular.  Mr.  Bowlby  said  two  incisions,  one 
above  and  one  below  the  umbilicus,  were  necessary  to  en- 
sure complete  flushing  when  the  peritonitis  was  due  to 
gastric  or  duodenal  rupture. 

Laparotomy  for  perforations  was  also  discussed  this 
week  at  the  Medical  Society  of  London,  where  Mr.  Mar- 
maduke Shield  read  a  paper  on  Ulcerations  of  the  Duo- 


November  17,  1894] 


MEDICAL  RECORD. 


6  37 


denum,  with  special  reference  to  the  latent  perforating 
ulcer  of  that  part,  and  related  two  cases  in  which  he  had 
operated.  In  both  the  fluid  found  in  the  cavity  was 
sweet,  and  he  thought  if  laparotomy  was  performed  early 
in  such  cases  the  fluid  would  be  found  very  different  from 
that  met  with  when  the  perforation  was  in  the  caecum  or 
lower.  The  importance  of  thorough  flushing,  a  second 
incision  for  this  purpose,  and  other  points  were  insisted 
on  by  the  author  and  the  speakers  who  followed. 

The  Pathological  Society  opened  its  session  with  a 
good  show.  Mr.  Stephen  Paget  showed  a  specimen  of 
ventral  hernia  from  a  woman  of  fifty  years  of  age.  Lap- 
arotomy had  been  performed,  but  she  did  not  rally.  He 
also  showed  another  specimen — tuberculous  recto-vesical 
fistula  from  a  man  of  about  fifty  years  of  age.  At  the 
autopsy  both  lungs  were  tuberculous,  the  right  testis  a 
caseous  mass,  and  the  cord  thickened ;  the  wall  of  the 
bladder  had  miliary  deposits ;  a  mass  of  old  tuberculous 
glands  and  scar- tissue  lay  between  the  bladder  and  rec- 
tum, and  two  fistulous  tracks  were  traced  in  this,  one  of 
which  led  from  the  bladder  to  the  rectum,  the  other  from 
the  rectum  to  the  mass,  and  back  again  to  a  lower  rectal 
opening.  Mr.  H.  Fenwick  thought  the  fistula  originated 
in  a  tuberculous  deposit  of  the  vesiculae  seminales  which 
had  broken  into  both  bladder  and  rectum.  Mr.  Bowlby 
was  also  of  this  opinion,  and  Mr.  Paget  said  he  would 
make  a  careful  examination  of  the  vesiculae,  and  report 
the  result. 

Dr.  Rolleston  showed  a  tumor  growing  from  the  upper 
end  of  the  left  supra- renal  capsule.  It  was  as  large  as  a 
chestnut;  on  section  firm,  brown,  with  hemorrhagic 
spots. 

Mr.  Targett  showed  a  polypoid  tumor  of  the  oesopha- 
gus, which  appeared  like  a  fibrous  growth  which  bad 
been  invaded  by  epithelioma.  There  was  an  ulcerating 
carcinomatous  growth  four  inches  below,  and  as  cathe- 
terism  had  been  sometimes  ineffectually  attempted,  Mr. 
Shattock  suggested  it  had  so  become  inoculated.  Had 
the  positions  between  reversed  it  would  have  been  possi- 
ble for  auto-inoculation  to  have  occurred — not  so  as  it 
was.  It  was  stated  that  the  cervical  glands  were  full  of 
epitheliomatous  growth,  but  no  secondary  nodules  were 
found  in  mucous  membrane. 

Mr.  Jackson  Clarke  gave  some  account  of  his  investi- 
gations into  variola  and  vaccinia.  He  said  his  recent 
work  confirmed  his  conclusions  regarding  carcinoma  and 
sarcoma.  Drs.  S.  M.  Copeman,  Rufter,  and  D'Arcy 
Power  controverted  the  views  of  Mr.  Clarke,  who  re- 
plied to  their  criticisms.  We  shall  probably  hear  more 
about  protozoa  during  the  session. 

Cancer  is  always  a  topic  of  sad  interest.  Yet,  not- 
withstanding many  disappointments,  how  naturally  one 
listens  to  any  reasonable  suggestion  as  to  its  treatment ! 
Chian  turpentine  has  had  its  day.  Now,  another 
medicine  is  proposed.  Neither  more  nor  less  than  cin- 
namon in  the  form  of  decoction  administered  freely. 
Dr.  Carne  Ross,  of  Manchester,  is  responsible  for  reviv- 
ing this  remedy.  I  say  reviving,  as  I  believe  is  has  been 
previously  employed  and  fallen  into  desuetude.  I  should 
state  that  Dr.  Ross  distinctly  disavows  all  pretence  that 
cinnamon  is  a  specific,  but  he  has  found  it  useful  in 
mitigating  pain,  so  much  as  to  be  a  substitute  for  mor- 
phia. Moreover,  in  some  of  the  cases  related  the 
progress  of  the  disease  seems  to  have  been  delayed  or 
arrested.  Still  we  know  that  this  sometimes  occurs 
under  other  treatment  or  none,  and  further  trials  are 
needed  before  subscribing  to  the  expectation  of  being  as 
fortunate  as  Dr.  Ross  seems  to  have  been  in  his  run  of 
cases.  I  have  no  doubt  that  cinnamon  will  be  largely 
prescribed  for  a  time  and  so  we  shall  be  able  to  judge 
whether  it  is  of  use,  and  if  so,  to  what  extent. 

Great  indignation  is  felt  and  has  been  expressed  at  the 
determination  to  admit  pay  patients  into  the  Great 
Northern  Central  Hospital.  These  patients  are  to  have 
the  attendance  of  the  Honorary  Staff.  A  petition  against 
this  proceeding,  signed  by  upwards  of  two  hundred  medi- 
cal men  in  the  northern  suburb,  has  been  presented  by  an 


influential  deputation,  but  has  not  turned  the  committee 
from  their  purpose.  It  is  certainly  open  to  question 
whether  the  committee  are  within  legal  rights  to  use  a 
building  provided  for  charity,  to  let  as  lodgings  for  in- 
valids who  are  able  to  pay.  The  injustice  of  thus  rob- 
bing local  doctors  of  their  patients  is  obvious ;  but  we 
have  made  our  services  so  free  that  the  public  sets  little 
value  on  them,  and  the  reasonable  protest  of  the  practi- 
tioners affected  will  be  called  selfish  jealousy  and  trade- 
unionism.  So  let  it  be,  the  general  practitioners  have 
their  positions  to  maintain,  and  if  the  consulting  staff 
will  not  listen  to  reason,  should  adopt  the  trade-union 
plan  which  will  be  attributed  to  them,  and  boycott  the 
staff.  Mr.  Spencer  Watson  has  resigned  his  surgency 
rather  than  be  a  party  to  the  contemplated  injustice. 
He  has  thus  set  an  example  which  his  colleagues  should 
not  have  left  him  to  do  single-handed,  and  which  they 
would  be  well  advised  to  follow  at  once  and  in  a  body. 


GOAT  SERUM  IN  TUBERCULOSIS. 

TO  THE  KDITOK  Or  THB  MEDICAL  RSCOKD. 

Sir  :  Referring  to  the  present  treatment  of  tuberculous 
disease  by  "immunized  serum,"  it  appears  from  Viquer- 
at's  investigations  that  he  found  the  ass  and  mule  to  be 
the  only  non-tuberculous  domestic  animals — though  he 
admits  that  the  immunity  enjoyed  by  these  is  not  abso- 
lute. 

There  are,  however,  two  other  domestic  animals  which 
enjoy  a  far  greater  resistance  to  tubercle  than  the  ass  or 
mule,  viz.,  the  common  goat  and  the  ewe.  The  im- 
munity of  the  goat  is  particularly  noticeable  in  Ireland, 
where  consumptives  abound,  and  where  the  goat — an 
omnivorous  feeder — has  been  known  to  eat  paper  and 
other  articles  covered  or  contaminated  with  the  expec- 
toration of  consumptives,  without  injury  or  any  loss  of 
health.  Warm  goat's  milk  has  been  highly  regarded  as 
a  remedy  in  consumption  or  "  decline,"  since  the  days  of 
Galen  (who,  by  the  way,  was  the  first  to  treat  tuberculosis 
by  strychnine — or  rather  "  Ignatius  Bean  "),  and  ewe's 
milk  boiled  with  mutton  suet  was  at  one  time  a  famous 
remedy  in  all  chest  diseases. 

Perhaps  it  may  be  worth  while  to  test  the  natural  and 
artificial  immune  serum  of  the  goat  in  future  experi- 
ments. C. 


IS  SALMON  POISONOUS  TO  DOGS? 

To  thb  Editor  of  tub  Medical  Record, 

Sir  :  There  is  a  widely  spread  belief  among  people  in 
Oregon  and  Washington,  that  salmon  is  very  dangerous, 
and  in  many  cases  fatal,  to  dogs,  when  eaten.  It  is 
claimed  that  the  flesh,  and  blood  more  particularly,  con- 
tain something  that  is  poisonous  to  the  canines.  Now, 
I  am  very  sceptical  in  regard  to  this  salmon  theory,  and 
find  that  many  intelligent  persons  disbelieve  it,  and  point 
to  the  fact  that  dogs  in  Alaska  are  fed  on  salmon  almost 
exclusively,  and  no  harm  results. 

There  is  no  doubt  but  that  more  dogs  die  here  than  in 
the  East,  but  they  ail  have  the  same  symptoms,  which  are 
there  known  by  the  general  term  of  distemper,  which  is 
in  reality  a  catarrhal  fever  with  dysentery.  A  young 
dog  will  be  taken  sick  and  mope  around  the  house,  re- 
fusing to  eat.  The  nose  becomes  hot  and  dry.  The 
ears,  feet,  and  lips  feel  cold,  and  the  mouth  has  a  bluish 
tint,  eyes  are  suffused.  Constipation  is  present  at  first, 
but  is  soon  followed  by  the  most  offensive  dysenteric  dis- 
charges, until  finally  the  poor  dog  succumbs  from  exhaus- 
tion. This  is  a  type  of  the  so  called  salmon  poisoning. 
I  have  never  seen,  in  any  work  on  diseases  of  dogs,  men- 
tion made  of  "  salmoning,"  as  it  is  commonly  called, 
and  doubt  the  existence  of  any  such  thing  as  dogs  dying 
with  the  above- described  symptoms  miles  from  any 
streams  ot  water.  Myths  die  hard,  and  superstition  is  as 
widely  diffused  as  it  ever  was,  only  it  continually  changes 
its  form.     I  should  like  the  opinion  of  the  readers  of  the 


638 


MEDICAL    RECORD. 


[November  17,  1894 


Medical  Record,  either  through  its  columns  or  by  letter, 
on  this  subject,  as  it  is  one  of  much  interest  to  dog  owners 
in  this  part  of  the  world.  Yours, 

F.  W.  Van  Dyke. 

Grant's  Pass,  Orb. 


THE    RESORCIN    TEST    FOR    FREE    HYDRO- 
CHLORIC ACID. 

To  the  Editor  of  tms  Medical  Record. 

Sir:  I  have  read  with  interest  Dr.  Julius  Friedenwald's 
article  on  the  use  of  the  resorcin  test  of  Boas  for  hydro- 
chloric acid.  For  the  last  eighteen  months  I  have  used 
this  test  to  the  exclusion  of  the  phloroglucin  vanillin  test 
and  have  found  it  sensitive  and  convenient.  "  Although 
I  have  occasionally  verified  my  tests  with  known  dilu- 
tions of  hydrochloric  acid,  I  have  made  no  such  ex- 
haustive study  as  that  of  Dr.  Friedenwald.  Still,  as 
practical  experience  is  always  good  evidence,  I  am  moved 
to  add  my  mite  and  to  thank  the  doctor  for  his  careful 
research. 

A.  L.  Benedict,  M.D. 

Buffalo,  N.  Y„  October  13, 1894. 


CAR  SANITATION. 

To  tub  Editor  of  thk  Medical  Record. 

Sir  :  The  letter  in  the  Medical  Record  of  November 
3d,  by  W.  Washburn,  M.D.,  on  the  subject  of  "Car 
Sanitation/'  is  of  great  interest,  and  I  beg  to  point 
out  an  additional  source  of  danger  and  cause  for  com- 
plaint. 

To  those  of  us  who  are  obliged  to  ride  on  the  elevated 
trains  in  the  late  afternoon,  it  will  be  remembered  that 
there  is  a  peculiar  disagreeable  odor,  quite  distinct  from 
that  due  to  the  presence  of  a  large  number  of  people. 
Indeed,  it  is  more  often  observed  when  entering  trains  at 
either  terminus  of  the  road,  when  the  cars  are  empty.  This 
odor  is  due  to  the  imperfect  combustion  of  the  oil- 
lamps,  which  produces  carbon  monoxide  (CO),  instead 
of,  as  is  the  case  when  combustion  is  perfect,  carbon  di- 
oxide (CO,).  This  carbon  monoxide,  as  is  well  known,  is 
a  very  poisonous  gas,  and  the  milder  symptoms  of  head- 
ache and  malaise  resulting  from  it  I  have  frequently 
observed,  after  riding  in  these  cars  for  twenty  minutes. 
The  reason  of  the  existence  of  this  condition  is  a  total 
disregard  on  the  part  of  the  railroad  authorities  for  the 
welfare  of  its  patrons.  The  blame  cannot  be  thrown  by 
them  upon  the  passengers,  as  perhaps  might  be  done  in 
the  case  of  collection  of  filth  from  expectorated  matter.  It 
is  all  owing  to  their  desire  for  economy.  The  lamps  are 
lighted  in  the  early  afternoon,  before  they  are  needed, 
and  then  the  wicks  are  turned  down  as  low  as  possible. 
Complaint  to  the  guards  is  of  no  avail,  they  have  their 
orders  from  those  in  authority,  and  cannot  be  blamed  for 
the  existing  condition* 

Perhaps  this  has  bsen  pointed  out  before.  If  so,  my 
excuse  for  writing  now  is  the  fact  that  the  condition 
still  exists,  and  only  by  continual  agitation  of  these 
questions  of  vicious  abuse  of  power  on  the  part  of  cer- 
tain corporations,  can  we  hope  to  have  them  removed. 

Frank  A.  Bottoms,  M.D. 

New  York. 


The  Song  of  the  Girdner  Telephone  Bullet  Probe  — 
After  the  "shootin's"  over, 
After  the  scrap  is  done, 
After  the  "  Dago's  "  punctured, 
After  the  cowboy's  fun  (?) 
Many's  the  gun  "  not  loaded," 

I  can  attend  to  all ; 
Merrily  I  will  meander 
After  the  Ball. 

S   Morris  Conant. 


Urn  instruments, 

A  NEW  SERRATED  NASAL  SCISSORS  FOR  THE 
REMOVAL  OF  HYPERTROPHIES  AND  TUR- 
BINATED TISSUES. 

By   D.  N.  RANKIN,  M.D., 

ALLEGHENY,   PA. 

The  Serrated  Nasal  Scissors  devised  by  me  has  proven 
a  very  valuable  instrument  for  the  removal  of  hypertro- 
phied  turbinated  tissues,  warty  growths  of  the  nares,  and 
exostoses  of  the  septum.  In  many  instances  it  has  taken 
the  place  of  the  nasal  saw,  from  the  fact  that  it  requires 


less  time,  pain  greatly  diminished,  and  less  hemorrhage 
in  removing  the  growth.  The  accompanying  cut  will 
show  its  appearance,  and  is  one-half  the  actual  size  of  the 
scissors.  This  instrument  was  made  for  me  in  a  most  ex- 
cellent manner  by  Feick  Bros.,  49  Sixth  Street,  Pitts- 
burg, Pa. 


ptedical  Stems. 

Contagious  Diseases  — Weekly  Statement— Report  of 
cases  and  deaths  from  contagious  diseases  reported  to  the 
Sanitary  Bureau,  Health  Department,  for  the  week  end- 
ing November  10,  1894. 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebro-spinal  meningitis 

Measles 

Diphtheria 

Small-pox 


117 

77 

16 

3 

S3 

4 

a 

3 

»5 

a 

137 

37 

19 

0 

The  Chinese  Imperial  Medical  College  of  Ken  Tain. 
— The  honor  of  establishing  the  first  medical  school, 
where  the  healing  art  will  be  taught  after  western  models, 
belongs  to  Surgeon-Captain  F.  S.  Heuston,  of  the  Brit- 
ish Army.  The  president  of  the  new  Medical  College  is 
His  Excellency  the  Viceroy  Li  Hung  Chang.  The  vice- 
presidents  are  Sheng  Taotai,  Lu  Taotai,  Lohfeng  Luh 
Taotai,  and  Mr.  A.  Irwin,  F.R.C.S.I.  The  two  last 
and  Dr.  Lin  Leien  Fai  are  the  directors.  Mr.  F.  Sb 
Heuston  is  the  professor,  and  he  is  assisted  by  the  fol- 
lowing instructors:  Dr.  Kin,  Dr.  Chow,  and  Mr.  Li. 
The  dean  is  Dr.  Lin,  and  the  proctor  Dr.  Kin.  The 
rules,  subjects  of  study,  and  examinations  are  compre- 
hensive. Candidates  for  the  degrees  in  medicine  and 
surgery  of  the  College,  before  they  are  allowed  to  present 
themselves  for  the  first  professional  examination,  must 
produce  evidence  that  they  have  passed  a  preliminary 
examination  in  general  education  and  have  been  regis- 
tered as  medical  students.  Before  receiving  his  diplo- 
mas to  practise  medicine  and  surgery  the  student  must 
be  over  twenty-one  years  of  age,  and  must  have  success- 
fully passed  each  of  the  four  professional  examinations  of 
the  College.  There  are  two  sessions :  spring  (from 
after  Chinese  New  Year  to  1st  of  July)  and  autumn  (from 
September  1st  to  Chinese  New  Year)  ;  and  the  examina- 


November  17,  1894] 


MEDICAL    RECORD. 


639 


tions  are  held  at  the  close  of  the  latter  session.  There 
are  four  professional  examinations,  held  at  the  end  of 
each  year  of  study,  and  directed  by  a  specially  appoint- 
ed Board  of  Examiners.  At  least  two  thirds  of  the  lect- 
ures must  be  attended..  Before  admission  to  the  second 
professional  examination,  evidence  must  be  produced  of 
haying  attended  a  medico  chirurgical  hospital  for  a  pe- 
riod of  six  months  after  the  first  professional  examina- 
tion, and  of  having  taken  notes  of  surgical  and  medical 
cases  to  the  satisfaction  of  the  medical  officers  of  the  hos- 
pital. Attendance  at  a  hospital  for  six  months  is  also 
required  for  the  third  examination.  At  the  same  time 
the  candidate  must  take  personal  notes  on  six  medical 
and  surgical  cases,  which  are  to  be  produced  for  inspec- 
tion, if  required  by  the  professor.  A  two  months'  course 
in  the  compounding  department  of  a  hospital,  under  a 
qualified  person,  is  also  necessary.  The  fourth,  or  degree 
examination,  requires  a  further  six  months'  attend- 
ance at  a  medico-chirurgical  hospital,  attendance  at  the 
out-door  dispensary,  and  notes,  taken  daily,  on  at  least 
five  cases  of  fever  (typhus,  typhoid  or  enteric,  scarlatina, 
small-pox,  or  measles).  The  candidate  must  also  pro- 
duce evidence  of  having  attended  surgical  operations  at 
the  hospital,  and  of  having  received  practical  instruction 
on  the  treatment  of  ophthalmic  and  aural  cases. — The 
Medical  Magazine,  October,  1894. 

Cauterizing  Ovaries  instead  of  Removing  them. — Dr. 
Pozzi,  at  Hdpital  Broca,  has  now  practised  cauterization 
of  painful  ovaries  for  over  two  years,  and  considers  the 
plan  very  successful.  In  one  case,  in  which  he  operated 
upon  both  ovaries,  the  woman  has  since  given  birth  to  a 
child.  He  performs  his  laparotomies  in  the  ordinary  re- 
cumbent position ;  draws  the  ovaries  out  of  the  abdominal 
opening.  If  the  ovary  is  totally  diseased,  he  removes  it ; 
but  if  a  part  is  found  to  be  healthy,  he  amputates  the 
affected  portion,  cauterizes  the  stump,  then  sews  the  end 
with  silk.  If  there  are  some  small  cysts,  h%  opens  them 
by  touching  with  the  Paquelin  point.  The  ovary  being 
returned  to  the  abdomen,  he  examines  and  treats  the 
other  in  a  similar  manner.  Often  as  many  as  six  small 
cysts  are  opened  in  this  way  in  each  ovary. — Therapeutic 
Gazette. 

The  Collection  and  Preservation  of  Anatomical  Ma- 
terial.— At  the  last  meeting  of  the  Association  of  Amer- 
ican Anatomists,  a  committee  was  appointed  to  consider 
the  question  of  the  collection  and  preservation  of  ana- 
tomical material,  and  to  report,  at  the  next  meeting, 
what,  in  their  opinion,  are  the  best  means  of  accomplish- 
ing these  objects.  In  order  to  make  the  work  of  the 
committee  as  comprehensive  as  possible,  and  to  obtain 
information  which  will  be  of  service  in  arriving  at  defi- 
nite conclusions  as  to  the  best  methods  of  accomplishing 
the  purposes  indicated  in  the  resolution,  it  has  been 
deemed  desirable  to  send  to  the  teachers  of  anatomy,  in 
this  country  and  abroad,  a  circular  letter,  with  the  fol- 
lowing questions  appended  : 

1.  Is  anatomical  material  obtained  in  accordance  with 
a  legal  enactment,  wholly  or  in  part  ?  2.  If  there  is  an 
anatomical  law  in  your  country  or  State,  please  send  a 
copy  of  it  to  the  chairman  of  this  committee,  Dr.  J. 
Ewing  Mears,  1429  Walnut  Street,  Philadelphia,  Pa. 
Please  state  whether  the  law  is  satisfactory,  whether  it  is 
readily  obeyed  by  those  upon  whom  duties  are  imposed 
by  it,  and  mention  any  improvements  you  would  sug- 
gest as  to  its  requirements?  3.  Is  the  material  received 
in  good  condition?  4.  What  disposal  is  ultimately 
made  of  the  remains?  5.  Please  state  what  means  are 
employed  to  preserve  anatomical  material  for  the  pur- 
poses of  dissection  or  operative  surgery.  If  injections  of 
preservative  fluids  are  used,  state  their  composition  and 
the  methods  of  use,  at  what  point  injections  are  made, 
whether  at  the  heart  or  in  the  large  arteries,  and  their 
effect  in  accomplishing  the  preservation,  with  any 
changes  in  the  color  or  character  of  the  tissues.  What 
length  of  time  can  material  be  used  in  dissection  by  the 
methods  employed  by  you  ?    If  preservation  by  means 


of  "  cold  storage  "  is  employed,  please  state  the  cost  of 
the  machinery  which  it  was  necessary  to  construct  for 
this  purpose,  and  what  means  are  taken  to  prevent  de- 
composition after  the  subject  is  placed  upon  the  table 
for  dissection.  6.  Please  state  the  cost,  by  the  method 
employed  by  you,  for  each  subject,  (a)  for  receiving  it, 
(J>)  for  injecting  and  preserving  it.  7.  Do  you  obtain 
an  adequate  supply  of  material  for  the  purposes  of  ana- 
tomical instruction  ?  How  many  students  are  assigned 
to  each  subject,  and  what  is  the  method  of  allotment  ? 
8.  Please  give  any  information  which  you  may  deem  of 
importance.  As  the  report  will  be  general  in  character, 
the  name  of  the  informant  or  institution  will  not  be 
mentioned  by  the  committee  unless  requested.; 

Education  and  Crime.— Sir  John  Lubbock  recently 
addressed  the  Sociological  Congress  in  Paris  upon  the 
effect  in  England  of  education  upon  crime.  Since  1870 
the  number  of  children  in  English  schools  has  increased 
from  1,500,000  to  5,000,000,  and  the  number  of  persons 
in  prison  has  fallen  from  12,000  to  5,000.  The  yearly 
average  of  persons  sentenced  to  penal  servitude  for  the 
worst  crimes  has  declined  from  3,000  to  800,  while  juve- 
nile offenders  have  fallen  from  14,000  to  5,000.  Sir  John 
Lubbock  sees  in  these  figures  a  confirmation  of  Victor 
Hugo's  saying,  that  "He  who  opens  a  school  closes  a 
prison.1'  In  France,  according  to  the  Paris  Temps, 
criminal  statistics  and  the  statements  of  magistrates  show 
that  as  schools  have  been  opened  prisons  have  filled,  and 
that  the  diffusion  of  education  has  been  accompanied, 
apparently,  with  increase  of  crime,  and  especially  of 
juvenile  crime.  In  attempting  to  acccount  for  this  phe- 
nomenon the  Temps  points  out  that  in  France,  under 
the  republic,  education  is  simply  intellectual  instruction. 
In  England  there  is  not  only  instruction,  but  training. 
Moral  and  religious  influences  are  brought  to  bear  upon 
the  children. 

Bacteriology  of  Hospital  Bed -Cards.  — Dr.  Trou- 
sholiavski,  in  an  inaugural  dissertation  recently  presented 
to  the  University  of  St.  Petersburg,  gives  the  results  of 
some  curious  researches  made  by  him  on  the  bacteriology 
of  hospital  case- books  and  papers.  Before  use  these  are 
almost  free  from  microbes.  Old  case-books  which  have 
been  used  at  the  bedside,  and  have  afterward  been  shut 
up  in  drawers  from  eighteen  months  to  two  years,  also 
contain  very  few  microbes.  On  the  other  hand,  papers 
which  have  been  close  to,  or  in  contact  with,  patients, 
yield  a  large  number  of  micro  organisms.  In  forty- six 
bed- cards  and  admission- cards  examined  for  the  purpose, 
the  average  number  of  micro-organisms  found  was  43  per  * 
square  centimetre  of  paper.  By  the  side  of  indifferent 
micro-organisms,  pathogenic  microbes  such  as  B.  pyocya- 
neus,  the  bacillus  of  tubercle,  and  streptococci  were  found. 
Virulent  microorganisms  placed  on  dry  sterilized  paper 
preserved  their  virulence  for  a  considerable  time;  the 
comma  bacillus  from  five  to  fourteen  days,  the  typhoid 
bacillus  for  sixty-three  days,  the  diphtheria  bacillus  for 
thirty-eight  days,  the  streptococcus  for  ninety-eight 
days. — British  Medical  Journal. 

Chicago  is  Almost  the  Healthiest  City  in  the  World, 
if  its  own  statisticians  and  health  officers  are  to  be  be- 
lieved. According  to  a  report  of  the  Health  Commis- 
sioner there  is  but  one  city,  Berlin,  that  had  a  lower 
death-rate  for  the  year  1893,  that  being  16.3,  while 
Chicago's  rate  was  16.9.  The  population  is  estimated  at 
over  600,000  above  the  United  States  census  of  1890, 
and  the  area  of  the  city  includes  a  large  tract  of  territory 
that  is  practically  open  prairie,  where  the  death-rate  is 
naturally  much  below  that  of  cities. 

Frost  Burns. — In  the  accidents  which  have  attended 
the  manipulation  of  liquid  air  and  other  substances  in  his 
laboratory,  M.  Raoul  Pictet  has  distinguished  two  de- 
grees of  burns  from  the  intense  cold.  In  the  first  the 
skin  is  reddened,  turning  blue  the  next  day.  The  spot 
doubles  in  area  on  the  following  days ;  there  is  intense 
itching,  and  five  or  six  weeks  are  usually  required  for 


640 


MEDICAL   RECORD. 


[November  17,  1894 


healing.  In  the  more  severe  burns,  those  of  the  second 
degree,  the  skin  is  rapidly  detached.  A  long  and  stub- 
born suppuration  sets  in,  and  healing  is  very  slow,  and 
altogether  different  from  that  of  burns  from  fire.  On 
one  occasion,  M.  Pictet,  while  suffering  from  a  burn  due 
to  a  drop  of  liquid  air,  seriously  scorched  the  same 
hand.  The  scorched  portion  was  healed  in  ten  or  twelve 
days,  whereas  the  cold  burn  was  still  open  six  months 
afterward. — British  Medical  Journal. 

Acromegaly  and  Gigantism. — Dr.  Sternberg  con- 
cluded, at  the  Congress  of  German  Physicians,  that  the 
study  of  the  skeleton  of  the  giant  showed  that  there  exists 
a  physiological  and  a  pathological  gigantism,  and  that  the 
latter  are  cases  due  almost  entirely  to  acromegaly.  He 
thinks  that  gigantic  growth  and  acromegaly  can  exist  in 
the  same  individual.  Twenty  per  cent,  of  the  patients 
with  acromegaly  show  evidences  of  gigantism,  and  forty 
psr  cent  of  giants  have  acromegaly.  Gigantic  develop- 
ment predisposes  to  vegetative  disturbances,  and  especi- 
ally to  acromegaly.  Enlargement  of  the  thymus  he 
thinks  is  a  part  of  the  natural  history  of  acromegaly. 
Thyroid  feeding  was  productive  of  slight  amelioration  of 
the  symptoms  of  the  disease  in  one  case  in  which  it  had 
been  employed. 

The  Use  of  Quinine  in  Influenza. — Dr.  Moss*  (Acad- 
emy of  Medicine  of  Paris)  concluded  from  his  researches 
that  quinine,  when  given  in  moderately  large  doses, 
tends  to  exert  a  preventive  action  on  the  manifestations 
of  influenza  infection.  In  three  cases  of  severe  pneu- 
monia complicating  the  grippe,  recovery,  which  the 
writer  attributed  to  the  use  of  quinine,  resulted. 

The  Decline  of  the  Pessary. — "  No  one  invents  a 
pessary  nowadays,  in  strange  contrast  to  the  time  when 
scarcely  a  man  prominent  in  the  practice  of  diseases  of 
women  did  not  invent  one. "  One  may  conclude  from  this 
that  either  all  available  pessary  devices  have  been  in- 
vented, or  that  the  use  of  the  pessary  is  to  be  discouraged. 
It  is  the  latter  view  that  Dr.  J.  G.  Blake  holds  in  a  com- 
munication to  the  Obstetrical  Society  of  Boston,  April, 
1894 ;  his  alternative  for  the  pessary,  is,  of  course,  surgi- 
cal procedure.  His  complaint  is  more  of  the  abuse  than 
the  use  of  the  pessary,  although  he  quotes  Fritsch,  a 
German  writer,  who  declared  that  he  had  spent  ten  years 
in  learning  the  treatment  by  pessaries,  and  considered  it 
the  most  difficult  in  the  whole  range  of  gynecology,  and 
that  it  is  easier  to  perform  a  laparotomy  than  to  apply 
an  accurately  fitting  pessary.  The  same  author  criticises 
their  use,  declaring  that  the  pessary  heals  palliatively,  but 
injures  definitively ;  for  it  distends  the  fornix  vagina  so 
enormously,  that  even  after  it  has  been  worn  for  years, 
a  cure  is  not  to  be  hoped  for.  On  the  contrary,  retro- 
flexion of  the  uterus  returns  after  the  removal  of  the  pes- 
sary. The  longer  the  uterus  has  been  displaced,  the 
longer  the  time  necessary  to  enable  the  reflexed  liga- 
ments to  return  to  a  normal  condition ;  and  a  few  days 
have  been  sufficient,  after  its  withdrawal,  to  have  the 
uterus  fall  back  into  its  old  position.  Among  the  means 
for  attaining  permanent  cures,  Blake  mentions  narrowing 
the  vagina ;  pregnancy  followed  by  prolonged  rest  in 
bed )  dilating  and  curetting ;  and  shortening  the  round 
ligaments.  The  first,  he  says,  is  only  called  for  in  com 
plete  prolapse,  where  no  instrument,  without  external 
support,  will  keep  the  uterus  within  the  vagina,  but  where 
it  can  be  accomplished  by  narrowing  the  canal  and  out- 
let :  these  cases  are  comparatively  rare.  The  operation 
of  dilating,  curetting,  and  packing  is  particularly  adapted 
to  the  cure  of  anteflexions,  and  to  the  removal  of  enlarge- 
ments which  attend  all  forms  of  backward  displacement. 
The  combined  dilating,  curetting,  and  Alexander,  is  to 
his  mind  the  true  solution  up  to  date  of  the  vexed  prob- 
lem of  backward  displacements.  Ventral  fixation,  by 
opening  the  abdomen,  and  by  various  other  methods 
(the  vaginal,  for  instance)  of  fastening  the  uterus,  has 
been  advocated  by  many  writers.  He  sees  no  advantage 
in  them  over  the  simple,  harmless,  and  in  most  cases 


effective,  operation  in  proper  cases,  and  of  dispensing 
with  pessaries.  He  thinks  no  one  has  yet  devised  a 
simpler,  less  dangerous,  or  more  effective  measure  for  the 
emancipation  of  women  from  the  wearing  of  pessaries, 
than  the  two  operations  of  dilating  and  curetting,  and 
Alexander. — Omaha  Clinic. 

The  Treatment  of  Basedow's  Disease  by  Thyroid 
Feeding. — Dr.  P.  Brand  reported  at  the  recent  meeting 
of  the  Congress  of  German  Physicians  (Vienna),  that  fa- 
vorable results  had  followed  the  feeding  of  sheep  and 
calves'  thyroids  in  several  cases  of  exophthalmic  goitre  in 
which  he  had  followed  this  plan  of  treatment.  Of  12 
cases  so  treated,  9  showed  marked  improvement,  reaching 
to  cure  in  some,  while  3  cases  were  not  affected.  In  all 
cases,  with  one  exception,  the  treatment  was  well  borne; 
in  this  case  the  sinister  symptoms  produced  were  head- 
ache, nausea,  anorexia,  tachycardia,  and  loss  of  flesb. 
The  symptoms  disappeared  when  the  thyroid  feeding  was 
stopped. 


BOOKS   RECEIVED. 

A  Text  book  of  Pathology,  Systematic  and  Practical 
By  D.  J.  Hamilton.  (Part  II.,  pages  515  to  1 139;  also  Part  I., 
pages  1  to  514,  both  of  Vol.  II.)  Illustrated.  8vo.  Publishers, 
Macmillan  &  Co.,  London  and  New  York.  Price,  $10.00  for  the 
two  parts. 

The  Fourth  Annual  Proceedings  of  the  Association  of 
Military  Surgeons  of  the  United  States.  8yo,  705  pages. 
Illustrated.  St.  Louis :  Buxton  &  Skinner  Stationery  Co.,  St.  Louis, 
Mo. 

Transactions  of  the  Medical  Association  of  the  State 
of  Missouri,  at  its  Thirty-second  Annual  Session.  8vo, 
218  pages.     Publisher,  Ev.  E.  Carraras,  St.  Louis,  Mo. 

A  Treatise  of  the  Diseases  of  the  Ear.  By  T.  Mark 
Hovell.  8vo,  720  pages.  Illustrated.  Published  by  J.  &  H. 
Churchill,  London.     Price,  18s. 

State  Commission  in  Lunacy,  Fifth  Annual  Report.  8vo, 
700  pages.     Printer,  J.  B.  Lyon,  Albany,  N.  Y. 

Medical  Jurisprudence,  Forensic  Medicine,  and  Toxi- 
cology. By  R.  A.  Witthaus  and  Tracey  C.  Becker.  8vo,  751 
pages.  Vol.11.  Illustrated.  Publishers,  William  Wood  &  Com 
pany,  New  York. 

Transactions  of  the  Medical  Society  of  the  State  of 
Pennsylvania,  at  its  Forty-fourth  Annual  Session.  Vol. 
XXV.    8vo,  442  pages.    Published  by  the  Society,  Philadelphia,  Pa. 

Pocket  Anatomist.  By  Dr.  C.  Henri  Leonard.  i2mo,  297 
pages.  Illustrated.'  The  Illustrated  Medical  Journal  Co.,  Pub- 
lishers, Detroit,  Mich.    Price,  $f  .00. 

Physiology  for  Beginners.   By  Dr.  M.  Foster  and  Dr.  Lewis 

E.  Shore.     121110,  242  pages.     Illustrated.     Published  by  Macmil- 
lan &  Co.,  New  York  City.     Price,  75  cents. 

Home  Treatment  for  Catarrhs  and  Colds.  By  Dr.  Leon- 
ard A.  Dessar.  i2mo,  118  pages.  Illustrated.  Published  by  the 
Home  Series  Publishing  Co. ,  New  York  City. 

Diseases  of  Women.  By  Dr.  H.  McNaughton  Jones.  i2mo, 
768  pages.  Illustrated.  Published  by  Bailliere,  Tindali  &  Cox, 
London.     Price,  12s.  6d. 

Essentials  of  Chemistry  and  Toxicology.  By  Dr.  R.  A. 
Witthaus.  32mo,  314  pages.  Published  by  William  Wood  & 
Company,  New  York  City.     Price,  $1.00. 

Text-book  of  Hygiene.  A  Comprehensive  Treatise  on 
the  Principles  and  Practice  of  Preventive  Medicine  from 
an  American  Standpoint.  By  George  H.  Rone,  M.D.  Third 
edition.   Illustrated.    Royal  octavo,  553  pages.    Cloth,  $3.00.  The 

F.  A.  Davis  Co.,  Philadelphia,  Pa. 

Practical  Uranalysis  and  Urinary  Diagnosis.  A  Manual 
for  the  Use  of  Physicians,  Surgeons,  and  Students.  By 
Chas.  W.  Purdy,  M.D.  Illustrated.  Octavo,  360  pages.  Price, 
$2.50.     The  F.  A.  Davis  Co.,  Philadelphia,  Pa, 

A  Clinical  Manual  of  Diseases  of  the  Eye,  Including  a 
Sketch  of  its  Anatomy.  By  D.  B.  St.  John  Roosa,  M.D.,  LL.D. 
One  volume.  8vo,  650  pages.  Uniform  with  the  "  Treatise  on 
Diseases  of  the  Ear,"  by  the  same  author.  Illustrated  by  178 
Engravings  and  3  full-page  plates  (2  in  colors).  Published  by  Will- 
iam Wood  &  Company,  New  York  City.  Price,  muslin,  $5'5°i 
sheep,  $6.50. 

The  Medical  Record  Visiting  List  for  1895. 

Diagnosis,  Differential  Diagnosis,  and  Treatment  of 
Diseases  of  the  Eye.  By  A.  E.  Adams,  M.D.  i2mo,  94  pages. 
Published  by  G.  P.  Putnam's  Sons,  New  York  City. 


Medical   Record 

A  Weekly  yournal  of  Medicine  and  Surgery 


Vol.  46,  No.  21. 
Whole  No.  1255. 


New  York,  November  24,  1894. 


$5.00  Per  Annum. 
Single  Copies,  xoc. 


Original  Qxticlts. 

CCELIOTOMY  IN  ECTOPIC  GESTATION  WHERE 
THE  FOETUS  IS  LIVING  AND  VIABLE,  WITH 
THE  REPORT  OF  A  SUCCESSFUL  CASE. 

By  X.  O.  WERDER,  M.D., 

PITTSBURGH,   PA. 

fbllow  or  the  American  association  op  obstetricians  and  gynecolo- 
gists ;  GYNECOLOGIST  to  mercy  hospital. 

Ectopic  gestation  is  still  a  fruitful  and  interesting  topic 
for  discussion,  particularly  that  rare  form  in  which  the 
foetus  has  survived  the  dangerous  catastrophe  of  primary 
tubal  rupture,  and  continues  to  develop  to  maturity.  The 
question  of  the  proper  treatment  of  those  cases  of  ad- 
vanced ectopic  pregnancy  in  which  the  foetus  is  living  and 
viable  is  still  in  a  somewhat  unsettled  state,  and  the  cases 
encountered  so  rare  that  the  history  of  every  such  case 
forms  an  interesting  contribution  to  the  study  of  this  un- 
common condition ;  and  also,  especially  if  successful, 
assists  in  the  development  of  a  proper  technique  in  its 
operative  treatment.  For  this  reason  I  will  ask  your  kind 
attention  to  the  report  of  the  following  case.  On  January 
23d  I  made  the  following  entry  in  my  case  book : 

Mrs.  F.  McC ,  referred  to  me  by  Dr.  Wallace,  of 

East  Brady,  Pa.,  aged  thirty-five,  had  one  child,  nine 
years  old,  since  which  time  she  remained  sterile.  Her 
puerperium  was  complicated  by  a  slight  febrile  attack  last- 
ing a  few  days  only,  after  which  her  convalescence  was 
normal.  Health  fairly  good  until  three  years  ago,  when 
she  was  under  treatment  for  some  uterine  affection,  of 
which  she  was  relieved  until  August  of  last  year.  Menses 
regular,  duration  one  week,  moderate  in  quantity,  accom- 
panied by  some  pain,  especially  in  her  back ;  rarely  cramps. 
Last  regular  menstrual  period  began  July  16,  1893.  In 
August  they  were  delayed  one  week,  and  when  they  re- 
turned they  lasted  fully  six  weeks,  but  never  profuse. 
Daring  the  first  three  or  four  weeks  she  was  able  to  be  on 
her  feet,  though  she  complained  of  some  occasional  pains, 
was  sick  at  the  stomach,  and  felt  weak.  In  the  latter  part 
of  September  she  was  suddenly  seized  with  very  severe 
cramps  and  a  feeling  of  faintness,  which  returned  in  parox- 
ysm? for  several  weeks,  confining  her  to  bed  for  at  least 
six  weeks.  In  the  early  part  of  November  she  was  able 
to  leave  her  bed  for  short  periods,  but  was  unable  to  be 
about  until  Christmas.  She  is  still  very  weak,  anaemic, 
and  emaciated,  and  has  pains  in  her  abdomen,  especially 
in  her  left  side  and  in  her  back.  Her  menses  have  never 
reappeared  since  October ;  no  leucorrhoea ;  bowels  obsti- 
nately constipated.  Micturition  frequent,  sometimes  ac- 
companied with  bearing  down  pains.  Appetite  poor. 
Since  Christmas  she  has  noticed  an  enlargement  of  her 
abdomen,  especially  on  her  left  side. 

The  lower  part  of  her  abdomen  is  enlarged  by  a  tumor 
of  the  size  of  a  five  or  six  months'  pregnancy,  two-thirds 
of  which  occupies  the  left  side  and  extends  to  a  line  mid- 
way between  symphysis  pubis  and  umbilicus,  which  is 
tender  on  palpation.  Distinct  foetal  movements  can  be 
felt,  but  the  heart-sounds  are  inaudible.  The  breasts  have 
become  enlarged  lately  and  present  the  characteristic  ap- 
pearances of  pregnancy.  The  external  genitalia  show  the 
peculiar  discoloration  of  pregnancy  to  a  slight  degree. 
The  cervix  presents  a  bilateral  laceration  to  the  vaginal 
fornix ;  -it  is  soft  and  patulous.  To  the  left  of  the  cervix, 
pushing  the  uterus  over  against  the  right  iliac  bone,  is  the 


tumor,  reaching  low  down  into  the  pelvis  and  filling  out 
Douglas's  space.  The  uterus  in  its  lower  two-thirds  can 
be  felt  distinct  from  the  tumor  and  is  enlarged,  and  when 
under  the  influence  of  an  anaesthetic,  the  following  day, 
the  upper  third  or  fundus  could  be  palpated ;  but  the  in- 
ternal or  left  cornu  and  the  border  of  the  body  seemed  to 
merge  into  the  tumor  to  such  an  extent  that  they  were 
unrecognizable  to  the  palpating  finger.  The  examination 
without  anaesthesia  was  very  painful,  and  she  seemed  un- 
usually sensitive  about  her  pelvis. 

The  diagnosis  made  was  ectopic  gestation  at  six  months 
with  a  living  foetus,  which  was  subsequently  confirmed  by 
my  friends  Drs.  F.  Blume,  J.  J.  Buchanan,  and  John  M. 
Duff.  The  patient  was  advised  to  remain  at  the  hospital, 
where  she  could  be  under  constant  surveillance  and  re- 
ceive prompt  attention  should  occasion  demand  it.  In 
spite  of  our  earnest  solicitations  she  went  home,  a  dis- 
tance of  seventy- five  miles,  but  was  prevailed  upon  by  Dr. 
Wallace  to  return  a  month  later.  An  examination  cor- 
roborated our  former  diagnosis,  and  also  noted  a  percepti- 
ble increase  in  the  size  of  her  abdomen.  She  had  suffered 
less  during  the  last  month  than  previously,  and  her  gen- 
eral health  had  improved.  She  remained  now  at  Mercy 
Hospital  for  six  weeks,  going  about  her  room  and  through 
the  building,  and  enjoying  fairly  good  health,  though  she 
complained  of  a  more  or  less  constant  soreness  in  her  ab- 
domen. It  was  decided  to  defer  operation  to  about  two 
weeks  previous  to  the  end  of  her  term,  unless  some  change 
in  her  condition  should  demand  earlier  interference. 

After  the  usual  preparations  the  operation  was  per- 
formed April  4th  of  this  year,  at  Mercy  Hospital,  in  the 
presence  of  over  twenty  physicians.  Having  placed  her 
on  the  operating-table  another  vaginal  examination  was 
made,  when  a  finger  could  be  introduced  into  the  uterus 
up  to  the  fundus  without  any  difficulty,  proving  con- 
clusively that  the  uterus  was  empty.  The  incision  was 
made  in  the  median  line  and  a  yellowish-white  cystic 
tumor  was  exposed.  As  the  placenta  at  previous  exami- 
nations had  been  located  a  little  to  the  right  of  the  median 
line,  the  sac,  the  walls  of  which  were  very  thin,  was 
opened  cautiously  by  a  small  incision  a  little  to  the  left 
of  its  centre,  through  which  at  once  the  child's  scrotum 
prolapsed.  The  opening  was  rapidly  enlarged  with  the 
fingers,  the  feet  seized,  and  the  child  extracted.  The 
head  was  in  the  left  iliac  fossa,  with  the  occiput  and  back 
pointing  to  the  spinal  column.  Only  a  few  drops  of 
amniotic  fluid  escaped  from  the  sac ;  the  child  had  no 
other  foetal  covering  except  the  cyst-wall.  The  anterior 
surface  of  the  cyst  was  perfectly  free  from  adhesions,  but 
above  and  on  the  left  side  of  the  sac  numerous  loops  of 
intestines  were  found  adherent ;  on  the  right  it  terminated 
between  the  folds  of  the  broad  ligaments  at  the  uterus, 
which  was  enlarged  to  the  size  of  a  two  months'  pregnancy. 
It  was  decided  to  extirpate  the  sac  if  at  all  possible,  and 
separation  of  the  intestinal  adhesions  was  therefore  begun, 
when  all  at  once  a  terrific  hemorrhage  from  the  bottom 
of  the  sac,  evidently  the  placenta,  put  a  sudden  stop  to 
our  efforts.  While  my  assistant  used  sponge  pressure,  I 
rapidly  clamped  the  ovarian  artery  in  the  infundibulo- 
pelvic  ligament  very  close  to  the  ileum,  and  with  another 
forceps  compressed  the  branches  of  the  uterine  artery  along 
the  left  border  of  the  uterus,  which  at  once  controlled  the 
bleeding.  The  placenta,  which  was  spread  out  over  the 
spinal  column  and  the  right  posterior  wall  of  the  pelvis, 
and  adherent  to  intestines  only  by  a  small  portion  of  its 
upper  margin,  could  now  be  separated  with  comparatively 


642 


MEDICAL  RECORD. 


[November  24,  1894 


little  loss  of  blood.  It  was  of  rather  larger  size  than  an 
ordinary  placenta,  and  devoid  of  any  foetal  membranes. 
Another  effort  was  now  made  to  peel  off  the  very  thin 
cyst-walls  from  the  intestines,  but  the  adhesions  were 
firmer  than  the  membranous  sac- wall,  which  tore  at  every 
such  attempt,  and  was  therefore  abandoned.  The  free 
portion  of  the  cyst  was  now  excised,  the  ovarian  and 
uterine  arteries  compressed  by  clamp  forceps,  tied  with 
strong  silk  ligatures,  the  forceps  removed,  and  the  re- 
mainder of  the  sac  gathered  and  drawn  together  by  silk 
sutures  attached  to  the  parietal  peritoneum,  the  cavity 
packed  with  a  Mikulicz  dressing  of  iodoform  gauze,  and 
the  abdominal  incision  closed,  as  far  as  the  gauze  dress- 
ing permitted. 

The  child,  which  at  first  was  considerably  asphyxiated, 
soon  responded  to  the  efforts  of  resuscitation  made  by 
Dr.  J.  M.  Duff,  and  seemed  hearty,  strong,  and  well  de- 
veloped, though  sadly  deformed.  There  was  marked 
asymmetry  of  the  head  and  face ;  it  had  club  feet,  and  on 
the  left  side  of  the  thorax  there  was  an  ulcerated  surface 
about  an  inch  square,  probably  produced  by  the  pressure 
of  the  left  elbow  against  that  side  of  the  body.  The  first 
two  days  it  seemed  to  be  thriving ;  it  took  its  nourish- 
ment— sterilized  milk — readily,  but  on  the  third  day  it 
became  very  restless,  its  breathing  was  rapid,  and  the  tem- 
perature 10 40  F.,  in  which  condition  it  continued  until  it 
died,  four  days  after  birth.  The  cause  of  death  was  sup- 
posed to  be  pneumonia,  but  no  autopsy  was  held. 

The  patient  rallied  well  from  the  operation,  and  the 
convalescence  progressed  very  favorably  and  smoothly, 
and  she  never  gave  rise  to  the  slightest  anxiety.  She 
was  discharged  from  the  hospital  perfectly  well,  excepting 
a  small  fistulous  opening  in  her  abdominal  wound,  and 
has  remained  in  excellent  health  ever  since,  as  a  letter 
received  from  her  a  few  weeks  ago  indicates,  though  she 
has  never  menstruated  since  last  October. 

Anatomically,  the  case  was  undoubtedly  one  of  tubal 
pregnancy  primarily,  with  rupture  between  the  folds  of 
the  broad  ligaments ;  but  that  it  was  not  a  purely  intra- 
ligamentous pregnancy  was  shown  by  the  fact  that  a 
part  of  the  sac  seemed  to  be  formed  of  amnion  only. 
There  must,  therefore,  have  been  a  secondary  rupture 
during  the  course  of  pregnancy,  at  which  the  largest  por- 
tion of  the  ovum  became  extruded  into  the  abdominal 
cavity,  while  a  part  still  continued  to  develop  within  the 
broad  ligaments.  When  this  secondary  rupture  occurred 
is  not  clear  from  the  history  of  the  case,  but  I  am  in- 
clined to  the  belief  that  it  happened  early  during  her 
gestation,  as  there  were  no  symptoms  pointing  to  any 
such  accident  after  the  sixth  month. 

In  looking  over  the  literature  of  this  subject  I  have 
been  able  to  find  sixteen  successful  cases  of  celiotomy  for 
ectopic  gestation  with  living  foetus  at  or  near  term, 
not  counting  my  own,  the  operators  being  Jessup,  A. 
Martin,  John  Williams,  J.  Lazarewitch,  August  Breisky, 
Hector  Treub(two  cases),  Joseph  Eastman,  R.  Olshausen 
(two  cases),  Carl  Braun  von  Fernwald,  G.  Rein,  John  W. 
Taylor,  Professor  Schauta,  Mordecai  Price,  and  William 
T.  Lusk.  In  Schauta's  and  Lusk's  cases  the  operation 
was  performed  before  viability  of  the  child,  namely,  at 
the  end  of  the  sixth  month,  but  as  the  technique  is  the 
same  as  at  the  end  of  term,  I  have  included  them  in  my 
list.  In  eleven,  or  with  my  own,  in  twelve  cases,  the 
placenta  was  removed  at  the  time  of  operation  with  com- 
plete or  partial  enucleation  of  the  sac,  namely,  by  Mar- 
tin, Lazarewitch,  Breisky,  Treub's  two  cases,  Eastman, 
Olshausen  (one  case),  Carl  Braun,  G.  Rein,  Schauta,  and 
Lusk ;  in  the  others  the  sac  and  placenta  were  left  and 
drained.  The  latter  class  of  cases  had,  without  excep- 
tion, an  unusually  stormy  and  protracted  convalescence, 
complicated  by  sepsis,  venous  thrombosis,  etc.,  so  that 
Lusk  very  properly  remarks  that  the  "  fortunate  results 
belong  to  the  domain  of  miracle  and  do  not  invite  to  im- 
itation," while  the  cases  with  removal  of  placenta,  par- 
ticularly those  in  which  the  whole  sac  could  be  enucle- 
ated, made  uneventful  and  speedy  recoveries. 

The  gravest  element  of  danger  in  removing  a  living 


placenta  is,  as  is  well  known,  uncontrollable  hemor- 
rhage, which  has  induced  many  of  the  older  operators  to 
postpone  operation  until  after  the  death  of  the  foetus,  be- 
cause after  the  placental  circulation  has  ceased  the  risk 
from  hemorrhage  is  comparatively  slight.  Though  this 
method  finds  a  few  advocates  even  at  the  present  time, 
the  fear  of  sepsis  in  the  ovisac,  which  so  frequently  fol- 
lows the  death  of  the  foetus,  aided  by  a  commendable  de- 
sire to  save  the  child's  life,  has  undoubtedly  been  work- 
ing a  rapid  change  in  favor  of  operative  interference 
during  foetal  life,  especially  as  this  has  been  justified  by 
the  more  favorable  results  obtained  in  this  operation 
during  late  years  by  an  improved  technique. 

The  blood  supplying  the  placental  circulation  must,  un- 
doubtedly, be  derived  mainly  from  the  ovarian  artery  and 
its  anastomosing  branches  of  the  uterine  artery.  That 
these  are  the  principal  feeders  was  well  shown  in  my  case, 
in  which  compression  of  these  arteries  checked  an  alarming 
hemorrhage  at  once.  Just  as  conclusive  an  example  of 
the  correctness  of  this  anatomical  fact  we  have  in  a  case 
reported  by  Sippel,1  in  which  he  enucleated  an  ectopic 
sac  at  seven  months,  with  a  living  child,  with  comparative 
ease,  until  it  tore  at  the  placental  insertion,  followed  by 
a  very  profuse  hemorrhage  which  compression  of  the  pla- 
centa did  not  affect,  but  which  promptly  ceased  after 
ligation  of  the  ovarian  artery — unfortunately  too  late  for 
the  patient,  who  succumbed  to  the  acute  anaemia  one 
hour  after  operation.  He  strongly  emphasizes  the  im- 
portance of  securing  the  ovarian  artery  previous  to  the 
removal  of  the  placenta.  Olshausen  and  Breisky  also 
call  particular  attention  to  this  point  in  the  technique  of 
this  operation,  which  has  been  followed  by  Lusk  and 
Schauta.  On  account  of  the  very  extensive  anastomosis 
of  the  internal  ovarian  with  the  uterine  artery  it  seems 
safer  to  me  to  ligate  both  vessels,  as  done  in  my  case. 
If  further  experience  bears  out  the  correctness  of  this 
view  in  regard  to  the  relation  of  these  bipod-vessels  to 
the  placental  circulation,  an  important  advance  will  have 
been  made  in  the  technique  of  this  operation,  and  the 
cases  in  which,  at  least,  the  placenta  cannot  be  removed 
will  be  very  exceptional,  and  limited  to  that  class  in  which 
it  has  formed  extensive  intestinal  adhesions.  Consider- 
ing the  great  danger  of  packing  and  draining,  usually 
practised  in  such  cases,  it  would  seem  preferable  to  me 
to  leave  the  placenta  without  drainage,  sealing  up  the 
abdominal  wound  hermetically.  That  the  placenta  can 
become  absorbed,  if  undisturbed,  is  demonstrated  in 
those  cases  in  which  the  foetus  has  died,  and  in  which 
everything  has  disappeared  excepting  the  foetal  bones. 
Braithwaite*  reports  a  case  in  which  the  placenta  was 
left  and  nothing  escaped  from  the  abdomen  subsequently 
except  a  very  small  piece.  Dr.  Austin  Lawrence  re- 
ports two  cases  before  the  British  Medical  Association, 
held  at  Bristol,  1894,8  in  which  he  left  the  placenta  ;  in 
one  case  it  was  absorbed,  in  the  other  the  patient  died 
from  septicaemia  on  the  twenty  fourth  day.  He  advises 
leaving  the  placenta,  but  reopening  the  abdomen  if  symp- 
toms appear.  Cullingsworth,  at  the  same  meeting,  nar- 
rated a  similar  case,  with  living  child,  in  which  the  open- 
ing in  the  membranes  was  sutured  and  the  cord  cut 
short.  There  was  satisfactory  progress  for  three  weeks; 
on  the  twenty  fourth  day,  however,  a  rigor  occurred,  and 
on  the  twenty  sixth  he  reopened  the  abdomen  and  found 
purulent  fluid  in  the  remains  of  the  amniotic  sac,  which 
he  washed  out,  but  the  patient  died  the  same  day.  At 
the  autopsy  he  discovered  that  there  was  no  suppuration 
in  the  substance  of  the  placenta,  but  the  sepsis  arose 
from  the  remains  of  the  amniotic  sac,  which  being  of  non- 
vascular tissue,  was  more  likely  to  decompose.  He  ad- 
vises, therefore,  to  leave  the  placenta,  allowing  it  to 
bleed  from  the  divided  end  of  the  cord,  so  as  to  lessen 
its  size ;  to  cut  the  cord  quite  close  to  the  placenta,  and 
to  remove  all  the  amnion  possible,  stripping  it  off  from 
the  placental  surface,  and  to  reopen  the  abdomen  at  once 

»  Centralblatt  fittr  GynSkoL ,  189a,  p.  992. 

a  Transactions  of  the  London  Obstetrical  Society.  voL  xxviii. ,  p.  33. 

■  Mbdical  Record,  New  York,  September  1, 1894. 


November  24,  1894] 


MEDICAL  RECORD. 


643 


Period 

of 

Gestation. 


Result  to  ChQd. 


Details  of  Operation. 


References. 


Living,  but  died  at 
eleven  months 
from  croup. 

Alive,  cord  pulsat- 
ing, but  did  not 
breathe;  had  a 
large  encephalo- 
cele. 


Died  in  a  few  min- 
utes. 

Lived  96  days. 


Living,  weight  over 
4  pounds.  A  year 
later  a  strong, 
healthy  boy. 


Alive  and  well, 
weight  5  pounds, 
but  died  3  weeks 
later  from  phle- 
bitis of  umbilical 


Living,  weight  4 
pounds.  Died  at 
8i  months  from 
pneumonia. 

Living,  weight  5 
pounds,  when  a 
year  old  weighed 
14  pounds. 


Placenta  not  removed ;  no  sac,  foetus  free  in  abdominal 
cavity  among  intestines. 

Placenta  removed  after  ligation  at  three  points. 


9     Feb.    11,    Carl   Braun    von,   ..   , 
1889.  Fernwald,    Vi-  I        I 

enna.  j        | 

1    i 

i 

R.    Olshausen,      '  »  ' 
Berlin.  !        I 


10  ,  Feb.    27, 


11     Feb.      4, 
1890. 


1a        1891. 


End   of 
term. 


4        9  months. 


G.  Rein,    Kiew,     35  : 
Russia. 


John  W.  Taylor, 
Birmingham, 
£ng. 


13     Jan.    10,  '  Prof.     Schauta, 
1      1801.  -    1     Vienna. 


14    Oct.    23,    Dr.  Mordecai 
189a.  Price,  Philadel- 

I      phia. 


15     Aug.   19,    Wra.    T.    Lusk, 
1893.  New  York. 


16 


1894. 


17     April    4, 

'     1894. 


Hector     Treub, 
Ley  den. 

X.    O.    Werder, 
Pittsburgh. 


37th  11 


,  9  months. 


.  Living,  weight  over 

6  pounds.    Died 

72     hours     after 

birth  from  lobular 

i      pneumonia  due  to 

I      inspiration  of  am-  1 

1      niotic  fluid.  | 

Alive,  but  very  much  , 
deformed.     Died 
>      iX    hour     after 
1      birth.  I 


I  Living,    weight    6 
pounds ;      slight 
asymmetry  of 
head.    Two  years 
1      after    operation 
I      was    hearty   and  1 
welL 
Living. 


Placenta  not  removed,  sac  drained. 


1  Placenta  and  cyst  drawn  out,  pressed  up  in  the  abdominal 
I      wound  ;  ligated  and  large  portion  removed. 

After  incision  of  the  sac,  which  bled  freely,  placenta  was 
I  perforated  with  hand,  and  after  extracting  child  bleed* 
I  ing  was  controlled  by  compressing  each  half  of  placenta 
I  by  the  hand  of  operator  and  assistant  until  removed  ; 
I  portion  of  sac  extirpated,  the  rest  intimately  adherent  to 
l  mtestines,  sewed  to  abdominal  wound  and  packed  with 
I  Mikulicz  dressing.  Supposed  to  have  been  an  ovarian 
I  pregnancy  or  a  pregnancy  in  tubo-ovarian  cyst. 
j  Tubalintra-ligamentous  pregnancy.  After  removing  child 
1  from  the  sac,  the  latter  was  drawn  out,  ligated  at  its 
juncture  with  the  uterus  and  removed,  containing  pla- 
centa and  membranes,  and  cavity  drained.  Mother  re- 
covered perfectly  in  three  weeks. 


Intraligamentous  tubal  pregnancy.  Clamped  uterine  end 
of  tube  and  broad  ligament,  and  enucleated  foetal  sac 
containing  placenta  intact,  and  quilted  the  pedicle  with 
cobbler's  stitch,  using  iron- dyed  silk. 

Foetus  free  in  abdominal  cavity,  also  largest  part  of  pla- 
centa, between  loops  of  intestines  ;  the  latter  adherent  to 
right  broad  ligament  with  only  about  one- third  of  its 
periphery.  This  last  portion  was  easily  surrounded  and 
proved  so  thin  that  two  mass  ligatures  of  silk  were  suffi- 
cient to  securely  tie  off  the  placenta  with  attached  portion 
of  broad  ligament.  Only  shreds  of  foetal  membranes 
were  attached  to  placenta. 

Child  free  in  abdominal  cavity,  placenta  adherent  to  pos- 
terior surface  of  uterus  and  nght  broad  ligament,  extends 
deep  into  Douglas's  cul-de-sac,  and  firmly  attached  to 
descending  colon.  After  ligating  right  broad  ligament  in 
number  of  places,  placenta  can  be  detached  in  a  number 
of  places  without  much  hemorrhage.  But  removal  of  sac 
necessitated  elastic  ligature  around  uterus  to  check 
bleeding  and  supra-vaginal  hysterectomy. 

Sac  and  placenta  left  undisturbed  and  drained  with  iodo- 
form gauze  packing.  Spontaneous  expulsion  of  placenta 
on  thirty-fourth  day.  Interesting  is  the  daily  copious  dis- 
charge of  fluid  per  vagina  during  the  eighth  month,  which 
was  undoubtedly  amniotic  fluid  draining  away  through 
tube.    No  amniotic  fluid  present  during  operation. 

Intra-ligamentous  tubal  pregnancy.  Sac,  placenta,  and 
foetal  membranes  removed  entire  by  enucleation  from  the 
peritoneum,  in  the  same  manner  as  practised  in  removal 
of  intra-ligamentous  ovarian  cyst. 


Tait  on  Diseases  of 
Women  and  Ab- 
dominal Surgery, 
vol.  i.,  p.  495* 

Berlin.  kGn.  Woch- 
enschrift,  Decem- 
ber 36,  1881.  R. 
P.  Harris,  Extra- 
uterine Pregnan- 
2',  Am.  Jour,  of 
e  Med.  Sciences, 
September,  1888. 

Brit.  Med.  Jour., 
December  3,  1887. 
R.  P.  Harris,  ibid. 

Vrach,  St.  Peters- 
burg, 1886.  R. 
P.  Harris,  ibid. 

Zeitschrift  fur  Ge- 
burtsch  und  Gy- 
n2k,  Band  xv., 
p.  384,  1888. 


Wiener  med.  Woch- 
enschrift,  1887, 
Nos.  48,  49,  and 
56;  and  J.  East- 
man in  Am.  Jour, 
of  Obstet,  vol. 
xxi.,  1888. 

Am.  Jour. .  of  Ob- 
stet, 1888,  p.  929. 


Deutsche  med.  Wo- 
chenschrift,  1890, 
p.  171. 


Archiv  fur  Gynik., 
Heft  ii.,  1890. 


Deutsche  med.  Wo- 
chenschrift,  1890, 
p.  171. 


!  Centralblatt  fur  Gy- 
I     nakol.,    No.     50, 
1892. 


I  7  months.       Living. 


I  Living. 


6  months.    '  Lived  24  hours. 


I 


3  weeks  be-  | 

fore  l 


a  weeks  be- 
fore term. 


Lived     several 
weeks. 

Lived  4  days. 


Foetus  free  in  abdominal  cavity,  placenta  left  behind  and 
drainage-tube  introduced,  and  umbilical  cord  drawn  out 
of  the  lower  angle  of  the  wound.  Patient  recovered  after 
very  protracted  convalescence  complicated  by  sepsis, 
thrombosis  of  left  iliac,  the  inferior  cava,  the  right  iliac 
and  right  renal  veins. 

After  tying  ovarian  artery  at  the  peritoneal  fold,  which  con- 
stituted the  residue  of  the  llgamentum  infundibulo-pelo- 
isum,  he  incised  the  peritoneal  covering  in  a  circular  line 
corresponding  nearly  to  the  largest  circumference  of  the 
sac.  The  enucleation  of  the  latter  was  readily  accom- 
plished without  rupture  of  sac-walls.  Considerable 
hemorrhage  resulted  from  detachment  of  the  ovum  from 
the  uterus,  which  was  temporarily  controlled  by  pressure 
and  later  by  sutures.  The  peritoneal  borders  of  the 
cavity  were  then  sutured  to  the  parietal  peritoneum,  and 
the  cavity  itself  was  drained  by  a  Mikulicz  tampon. 

Placenta  attached  to  uterine  attachment  of  left  tube  and 
the  entire  pelvic  viscera  of  the  left  side  from  the  spine  at 
the  back,  and  extending  up  to  the  kidney  and  covered  the 
descending  colon.  It  was  slightly  wounded  in  the  ab- 
dominal incision  and  the  cause  of  considerable  hemor- 
rhage ;  this  was  controlled  by  clamping  forceps,  which 
were  allowed  to  remain  until  first  dressing.  The  child 
was  enveloped  only  by  amniotic  sac,  to  which  were  at- 
tached the  transverse  colon  and  also  small  intestines  to  a 
slight  extent  Placenta  left  and  sac  packed  with  iodo- 
form gauze.  Last  portion  of  placenta  removed  on  thirty- 
fifth  day. 

Pregnancy  started  in  right  tube  and  subsequently  devel- 
oped to  a  great  extent  between  the  folds  of  broad  liga- 
ments. Tied  ovarian  and  uterine  arteries  of  right  side, 
and  then  enucleated  entire  sac  with  placenta. 


Foetus  free  in  abdominal  cavity.  Supra-vaginal  amputa- 
tion of  uterus ;  removal  of  placenta  and  sac.  (Private 
communication  from  R.  P.  Harris.) 

Child  enveloped  in  amniotic  sac  and  also  partly  by  folds  of 
broad  ligaments.  Placenta  removed  after  clamping  and 
subsequently  tying  ovarian  and  uterine  arteries  of  left 
side.  Part  of  sac  incised,  but  portion  had  to  be  left  on 
account  of  firm  intestinal  adhesions.  Edges  of  sac  and 
stump  of  left  broad  ligament  drawn  together  by  sutures 
and  attached  to  parietal  peritoneum,  and  drained  by 
Mikulicz  gauze  packing. 


Obstet  Trans,  of 
London  for  189  x, 

?.  1151 ;  and  Wm. 
'.  Lusk  in  New 
York  Jour,  of  Gy- 
necol, and  Obstet., 
July,  1803. 

Beitrage  fur  Casu- 
istik  Prognose  und 
Therapie  der 
Extra  -Uterine 
S  c  h  wangerschaft, 
Prag,  1891 ;  and 
Wm.  T.  Lusk  in 
New  York  Jour,  of 
Gynecol,  and 
Obstet,  July, 
1893. 

Transactions  of  the 
State  Medical  So- 
ciety of  Pennsyl- 
vania, 1893,  P- *5*« 


Wm.  T.  Lusk,  Tech- 
nique of  Primary 
Cceliotomy  in  Ad- 
vanced Ectopic 
Gestation,  in  N.Y. 
Jour,  of  Gynecol, 
and  Obstet,  July, 
1893. 

Bulletin  Mem.  Soc. 
Obstet.  et  Gyne- 
coL  de  Paris,  2894. 


644 


MEDICAL    RECORD. 


[November  24,  1894 


should  septic  symptoms  appear.1  In  addition  to  lessen- 
ing the  size  of  the  placenta  by  allowing  it  to  bleed  from 
the  severed  cord,  I  would  suggest  to  tie  the  ovarian  ar- 
tery on  that  side,  and  by  so  doing  its  blood-supply  would 
be  greatly  diminished,  though  sufficient  circulation  would 
remain  from  the  adhesions  to  keep  it  alive.  Consider- 
able shrinkage  of  the  placental  tissues  would,  no  doubt, 
follow  this  interference  with  its  normal  circulation,  and 
absorption  could  take  place  more  readily.  The  method 
of  leaving  the  placenta  and  sac  and  draining  it,  causing 
them  to  slough  out,  is  certainly  such  an  unsatisfactory 
procedure,  fraught  with  the  greatest  risk  to  the  patient, 
that  it  has  little  to  recommend  itself,  and  I  feel  confident 
will  have  no  place  in  the  future  treatment  of  these  cases. 

The  time  of  operation  in  advanced  cases  of  ectopic 
gestation  with  a  living  child,  is  still  a  matter  of  discus- 
sion. In  my  case  I  followed  the  advice  of  Tait,2  who 
advises  the  careful  guarding  and  watching  of  the  mother, 
though  I  did  not  go  as  far  as  he,  to  wait  until  false  labor 
sets  in  before  operating.  Werth  and  Olshausen,'  on  the 
contrary,  advocate  operation  regardless  of  the  child's 
life,  from  the  fact  that  such  children  only  very  rarely 
live  long  after  birth ;  the  latter  says,  "  on  the  mother's 
account  it  is  wise  to  operate  as  soon  as  possible,  because 
every  delay  is  apt  to  become  dangerous,  and  in  intra- 
ligamentous pregnancies  the  technical  difficulties  will 
only  increase."  While  no  doubt  the  welfare  of  the 
mother  is  first  in  importance,  we  owe  some  considera- 
tion to  the  life  of  the  child,  and  I  think  we  are  justified 
in  postponing  operation  in  the  interest  of  the  child,  pro- 
viding we  do  not  jeopardize  the  chances  of  the  mother 
thereby.  We  should,  therefore,  be  largely  guided  by 
the  condition  of  the  mother;  she  should  be  carefully 
watched  and  prepared  for  emergencies,  but  as  long  as  no 
untoward  symptoms  require  prompt  interference,  the 
period  of  viability  should  be  waited  for.  In  a  similar 
case,  however,  I  would  not  postpone  operation  much 
beyond  viability,  but  would  perform  celiotomy  between 
the  seventh  and  eighth  months,  in  order  to  save  the 
mother  a  long,  anxious  suspense,  and  because  the  child 
would  be  smaller,  and  therefore,  especially  in  the  ab- 
sence of  amniotic  fluid,  less  subject  to  compression  and 
consequent  deformity. 

It  is  a  matter  of  considerable  interest  to  ascertain  the 
fate  of  the  ectopic  children  which  were  delivered  alive. 
I  have  been  able  to  obtain  the  record  of  40  such  chil- 
dren. Eighteen  of  these  died  within  a  week  after  birth ; 
5  within  a  month ;  1  died  at  six  months,  of  broncho- 
pneumonia ;  1  at  seven  months,  of  diarrhoea ;  2. at  eleven 
months,  1  from  croup,  in  the  other,  cause  not  given ; 
1  at  eighteen  months,  from  cholera  infantum — making  a 
total  of  26  deaths,  and  leaving  14  children  to  be  ac- 
counted for.  Of  these,  5  were  reported  as  living  and 
well  after  operation,  with  no  subsequent  report ;  1  was 
strong  and  healthy  after  three  weeks,  but  no  report 
since;  1  was  well  at  six  months,  then  lost  sight  of;  1 
well  at  last  report ;  2  live  and  are  well  at  one  year ;  2 
living  and  well  at  two  years ;  1  (Beisone's  case)  well  at 
seven  years ;  and  1  (Tait's  case)  well  at  fourteen  and  a 
half  years.  In  regard  to  the  latter,  Dr.  R.  P.  Harris  has. 
kindly  furnished  me  the  following  interesting  informa- 
tion :  The  child  is  Marian  Sylvester,  who  is  in  good 
health  and  has  grown  to  be  quite  a  comely  girl,  living 
near  the  Woman's  Hospital  in  Birmingham.  Her 
mother,  Mary  Ann  Sylvester,  was  thirty-three  years  of 
age  at  the  time  of  operation ;  pregnancy  in  right  broad 
ligament;  she  died  on  February  4,  1880.  Operation, 
January  31  (Tait),  or  Sunday,  February  1, 1880  (Savage).4 

1  Mbdical  Record,  New  York,  September  i,  1894. 

*  Diseases  of  Women  and  Abdominal  Surgery,  p.  516. 

*  Deutsche  med.  Wochenschrift,  1890,  p.  195. 

*  Tait  operated  on  but  one  ectopic  case  in  which  the  child  lived. 
The  boy  seen  in  Tait's  house,  and  generally  regarded  as  an  ectopic 
child,  is  Hemlingford  Powell,  son  of  Elizabeth  Powell,  delivered  by 
Caesarean  section  on  October  11 ,  1881— a  private  case,  delivered  near 
Tait's  house.  Woman  died  ;  boy,  believed  to  be  now  living,  was  seen 
last  at  Tait's,  in  December,  189a.  The  confounding  of  these  two 
cases  lies  at  Tait's  own  door.  This  boy  became  ectopic,  and  the  girl 
was  not  mentioned.— R.  P.  Harris  in  private  communication. 


The  greatest  mortality  of  ectopic  children  occurs, 
therefore,  during  the  first  few  days  after  delivery,  almost 
fifty  per  cent. ;  of  22  surviving  that  period,  8  are  known 
to  have  died  within  the  first  year  and  a  half;  5  cases 
were  said  to  be  strong  and  healthy  at  birth,  but  no  sub- 
sequent report.  Five  lived  from  six  to  eleven  months ; 
5  from  one  to  two  years ;  two,  seven  and  fourteen  and  a 
half  years,  respectively. 

While  this  table  does  not  present  a  very  hopeful  pros- 
pect for  the  saving  of  ectopic  children  at  a  viable  period, 
the  fact  that  some  of  them  have  survived  the  most  dan- 
gerous periods  of  childhood,  more  than  justifies  us,  in  my 
opinion,  to  postpone  operation  until  the  viability  of  the 
child  has  been  reached  in  all  those  cases  where  we  can 
do  so  without  danger  to  the  mother. 

The  list  appended  contains  all  the  successful  cases  of 
coeliotomy  for  advanced  ectopic  gestation  with  living 
children  which  I  was  able  to  find  in  literature  up  to  the 
present  time,  with  such  important  data  as  may  prove  of 
interest  in  connection  with  the  report  of  this  case. 


A  CONTRIBUTION   TO  THE    STUDY  OF  THE 

ETIOLOGY  OF  TUBERCULOSIS.1 

By  HERBERT  M.  KING,  M.D., 

GRAND  RAPIDS,  MICK. 

In  the  light  of  the  masterly  discussion  upon  the  etiology 
of  tuberculosis  by  Professors  Gibbs,  Vaughan,  ttal.,  at  the 
recent  meeting  of  the  Michigan  State  Society,  to  which 
many  of  us  had  the  pleasure  of  listening  and  which  it  will 
soon  be  our  privilege  to  peruse  at  leisure,  in  the  volume 
of  the  Transactions  of  the  Michigan  State  Medical  So- 
ciety, 1894,  the  remarks  and  suggestions  which  I  offer  for 
your  consideration  this  evening  will  possibly  seem  very 
like  a  repetition,  in  which  much  of  the  more  delicate  def- 
inition and  technique  is  lost,  and  only  the  grosser  and 
possibly  more  superficial  elements  are  preserved. 

The  case  which  I  shall  report,  however,  has  in  some  of 
its  features  such  a  direct  bearing  upon  this  subject  of  etiol- 
ogy that  I  am  induced  to  submit  it  for  your  discussion, 
together  with  my  interpretation  of  the  evidences  de- 
duced, from  the  clinical  as  well  as  the  pathological  as- 
pects of  the  case,  which,  I  am  convinced,  are  in  support 
of  the  theory  of  the  bacteriological  origin  of  the  disease 
in  question.  A  theory  to  which  the  great  majority  of 
modern  pathologists  incline,  and  one  which  would  have 
little  or  no  opposition  were  it  not  for  such  indefat- 
igable observers  as  Professor  Gibbs  and  Dr.  Shurley, 
who,  when  least  expected,  and  when  scepticism  has  been 
lulled  by  the  constantly  accumulating  proofs  on  the  part 
of  the  German  school,  published  reports,  the  results  of 
their  observations  and  experiments,  well  calculated  to 
stagger  confidence  in  preconceived  ideas  and  shake  the 
faith  of  any  save  the  most  persistent  germ  theorist 

At  best,  it  seems  to  me,  we  are  still  groping  in  the 
dark  for  the  missing  links,  which  shall,  when  found,  con- 
nect the  bacillus  tuberculosis  in  an  intelligible  manner 
with  the  morbid  processes  of  phthisis  and  make  complete 
the  fabric  of  our  etiological  scheme.  I  believe  that  these 
"  links  "  exist,  and  will  sooner  or  later  be  discovered  and 
understood.  But  whether  as  a  result  of  the  efforts  of  the 
microscopist  or  of  those  of  the  physiological  chemist,  it 
remains  to  be  seen. 

That  the  bacillus  itself  is  not  the  absolute  and  direct 
cause  of  those  earlier  changes  in  the  parenchyma  of  the 
lung,  which  if  unchecked,  lead  on  to  cavity,  I  think  all 
must  concede,  in  view  of  recent  investigation,  which  has 
established  by  repeated  experiment  two  facts  which  seem 
to  me  to  be  insurmountable  objections  to  the  theory  of 
the  direct  relationship  existing  between  the  bacillus  and 
the  destruction  of  tissue,  even  to  the  most  sanguine  cham- 
pion of  the  renowned  Koch. 

1.  In  the  earliest  stages  of  tuberculosis,  the  hyperplastic 
interstitial  tissue,  while  clearly  showing  the  presence  of 

1  Read  before  the  Grand  Rapids  Academy  of  Medicine,  May  28, 
1894. 


November  24,  1894] 


MEDICAL  RECORD. 


645 


an  inflammatory  condition  characteristic  of  tubercle,  and 
while  still  having  present  all  of  the  other  elements  found 
in  any  stage  of  the  series  of  changes  which  follow,  except, 
perhaps,  pus,  does  not  invariably  contain  the  bacillus 
until  the  degeneration  of  the  infiltrated  tissue  supervenes. 
Since,  therefore,  the  bacillus  is  not  necessarily  present, 
it  cannot  be  the  direct  and  only  cause  of  the  localized 
hyperplasia  which  constitutes  the  tubercle. 

a.  Tubercle  bacilli  can  be  produced  by  repeated  cult- 
ures which,  apparently  possessing  all  of  the  character- 
istics of  the  specific  micro-organism  in  question,  are  inert 
to  cause  the  disease,  even  when  inoculated  into  the  most 
susceptible  animals. 

This  is  not  quite  so  convincing  an  argument  when  taken 
alone,  for  it  can  easily  be  imagined  that  in  the  process 
of  artificial  cultivation  the  bacillus  may  lose  its  virulency ; 
but  taken  together  the  two  facts  mentioned  offer  an  argu- 
ment which  cannot  well  be  met  on  the  theory  of  the 
bacillus  itself  being  the  direct  cause  of  the  first  morbid 
changes. 

On  the  other  hand,  I  am  thoroughly  convinced  that 
the  bacillus  is  the  ultimate  and  essential  factor  in  the 
production  of  tuberculosis ;  that  without  its  agency,  no 
matter  how  predisposed  by  heredity,  cachexia,  or  diathe- 
sis one  may  be,  one  can  never  develop  tuberculosis. 
The  exact  nature  of  that  agency,  however,  and  the 
rationale  of  its  action  are  still  subjects  for  speculation. 

In  considering  the  few  points  which  I  wish  to  discuss 
here,  it  will  be  necessary  to  call  attention  to  one  or  two 
etiological  factors,  which,  I  think,  are  pretty  generally 
established. 

i.  Phthisis  involves,  necessarily,  a  predisposition  to 
the  disease,  either  by  an  inherited  tendency  or  an  ac- 
quired cachexia,  constituting  what  may  be  termed  a  pre- 
tuberculous  state. 

2.  The  disease  itself  arises  from  causes  which  invariably 
originate  outside  the  body,  and 

3.  Tuberculosis  in  its  incipiency  is  never  a  local  mani- 
festation of  a  general  disturbance,  but  is,  in  the  first  place, 
a  purely  local  lesion. 

This  theory  is  fully  as  tenable  as  that  of  the  local 
origin  of  cancer.  The  encroachment  of  the  disease  from 
its  local  origin,  however,  is  so  very  insidious  and  the 
symptoms  arising  from  the  local  disturbance  so  masked 
by  those  arising  from  the  early  absorption  of  the  specific 
poison  generated,  and  which  are  the  expression  of  its 
effect  upon  the  vasomotor  system,  that  it  is  not  strange 
the  theory  is  slow  to  gain  credence.  That  such  a  theory, 
however,  if  generally  adopted,  would  have  a  material 
bearing  upon  our  treatment  of  the  disease,  must  unques- 
tionably be  conceded. 

The  communicability  of  phthisis  from  the  sick  to  the 
well  is  no  longer  a  question,  and  I  am  lately  advised  that 
in  many  parts  of  the  country  health  boards  and  railroad 
managements  require  the  same  precautions  to  be  taken, 
with  respect  to  the  shipment  of  bodies  of  persons  dying 
of  phthisis,  as  with  those  in  which  death  has  resulted  from 
any  other  of  the  infectious  diseases.  How  far  this  course 
is  justifiable  I  am  not  prepared  to  say ;  but  in  my  opinion, 
if  some  like  precaution  could  be  taken  in  the  transporta- 
tion of  the  many  thousands  of  tuberculous  patients  who 
migrate  semi-annually  throughout  the  country,  it  would 
be  serving  a  far  more  reasonable  purpose ;  and  while  we 
might  not,  for  many  years  to  come,  be  able  to  estimate 
with  any  degree  of  certainty  the  value  of  such  a  pre- 
caution, the  end,  I  am  sure,  would  justify  the  means. 

Arguing,  then,  upon  the  premise  that  tuberculosis  is 
communicable,  we  have  arising  at  the  start,  three  ques- 
tions: 1.  What  is  the  direct  agent  of  communication? 
2.  What  is  the  vehicle  or  medium  of  that  agent;  and  3. 
How  does  that  agent  reach  the  point  at  which  the  first 
serious  pathological  changes  take  place,  viz.,  the  intersti- 
tial tissue  of  the  lung. 

This  last  consideration,  I  am  aware,  has  really  more 
to  do  with  the  subject  of  the  pathology  than  that  of  the 
etiology,  but  may  with  propriety,  perhaps,  be  touched 
upon  in  this  article. 


In  answer  to  the  first  question,  it  may  be  said  that 
while  at  present  we  have  no  positive  proof  that  the  bacil- 
lus may  not,  in  some  instances,  itself  be  the  immediate 
irritating  presence  which  causes  the  infiltrated  deposit  of 
tubercle,  we  do  know  pretty  conclusively  that  certain 
matter  which  contains  absolutely  no  bacilli,  is  capable, 
when  inoculated  into  the  bodies  of  susceptible  animals, 
of  producing  morbid  changes  identical  with  tubercle, 
and  furthermore,  that  the  pathological  product  thus  gen- 
erated, does  not,  at  first,  at  least,  contain  bacilli,  but 
simultaneously  with  the  breaking  down  of  this  new 
tissue,  appear  the  bacilli.  Thus  some  of  our  most  con- 
servative observers  still  incline  to  the  belief  that  the 
bacillus  is  the  effect  and  not  the  cause  of  the  disease. 

Without  entering  into  an  exhaustive  discussion  upon 
this  question,  I  may  say  that  I  am  induced  to  take  the 
following  view  of  the  subject;  i.e.,  the  mature  bacillus 
itself  is  not  the  immediate  irritating  presence ;  neither 
is  any  ptomaine  to  which  its  existence  and  presence 
give  rise,  the  direct  cause  for  which  we  are  searching ; 
but,  those  forces  upon  which  are  dependent  the  growth 
and  development  of  the  spores  of  the  micro-organ- 
ism in  question,  require  and  necessitate  that  hyper- 
plasia, degeneration,  and  ulceration  which  constitute  the 
tuberculous  process,  and  that  each  step  of  this  process, 
as  it  were,  marks  a  certain  stage  of  embryonic  develop- 
ment on  the  part  of  the  bacillus.  Furthermore,  if  this 
process  of  infiltration  of  hyperplastic  tissue  be  positively 
arrested  for  a  sufficiently  long  time,  the  spores  become 
devitalized  and  the  bacillus  never  develops.  Thus  it  is 
seen  often  in  sections  made  in  hyperplastic  lung  tissue 
in  close  proximity  to  a  softened  tuberculous  mass,  swaim- 
ing  with  colonies  of  bacilli,  absolutely  no  bacilli  are  to 
be  found,  and  yet  the  appearance  in  every  other  respect 
is  pathognomonic  of  the  specific  disease.  With  this  in 
view,  it  is  still  an  open  question  whether  certain  agents, 
not  necessarily  germicides,  but  exercising  a  specific  ac- 
tion upon  the  interstitial  tissue  by  preventing  or  aborting 
the  hyperplasia,  would  render  impossible  the  conditions 
upon  which  depend  the  development  of  the  bacillus.  I 
very  much  doubt  if  the  mature  bacillus  itself  ever  gains 
access  from  without,  through  any  natural  channel,  to 
those  points  where  tuberculous  disease  apparently  orig- 
inates. It  seems  to  me  far  more  reasonable  to  suppose 
that  the  spores  deposited  in  the  epithelial  layer  of  the 
lining  membrane  of  the  bronchioles  and  terminal  vesi- 
cles are  absorbed  by  the  lymphatics  and  conveyed  to  the 
contiguous  connective  tissue  and  undergo  development, 
either  along  the  course  of  such  absorption  or  in  tissue 
immediately  adjacent. 

In  short,  that  if  bacilli  exist  in  the  infectious  matter 
received,  that  particular  generation  of  bacilli  never 
reaches  a  point  further  than  the  epithelial  lining,  and 
only  the  infinitely  minute  spores  which  are  beyond  the 
possibility  of  demonstration,  by  the  microscope,  at 
least,  reach  the  point  at  which  subsequently  the  tubercle 
appears. 

In  answer  to  the  second  question,  it  is  only  necessary 
for  us  to  consider  what  is  generally  conceded  to  be  the 
common  source  of  infection  ;  viz.,  the  sputum  from  per- 
sons or  animals  suffering  from  tuberculous  disease  of  the 
lung,  and  to  this  may  be  added  the  various  excreta  from 
those  in  whom  the  disease  is  located  at  points  more  or 
less  remote  from  the  lungs.  Thus  the  urine,  the  seminal 
fluid,  the  faeces,  and  in  some  instances  even  the  perspira- 
tion, might  be,  under  favoring  conditions,  the  vehicle 
of  infection ;  and  here  again,  it  is  worthy  of  considera- 
tion that  it  is  by  no  means  necessary  that  the  material 
of  infection  contain  one  single  bacillus  sufficiently  de- 
veloped to  be  recognizable  as  such.  Of  course  the 
sputum  from  tuberculous  patients  in  the  vast  majority  of 
instances  contains  colonies  of  bacilli,  easy  enough  of 
demonstration,  and  naturally  such  a  product  is  much 
more  infectious  than  that  which  contains  only  the  ele- 
mentary molecules,  simply,  however,  because  in  it  there 
is  correspondingly  a  greater  quantity  of  infection. 

The  manner  in  which  the  infectious  material  is  most 


646 


MEDICAL  RECORD. 


[November  24,  1894 


commonly  conveyed  to  the  vulnerable  parts  of  the  sus- 
ceptible individual  in  the  case  of  pulmonary  tuberculosis, 
is  generally  thought  to  be  by  means  of  dust,  which  has 
either  been  in  contact  with,  or  is  made  up  in  part  of, 
the  expectorated  matter  from  the  unfortunate  sufferer. 

We  have  no  proof,  however,  that  the  vapor  in  the  ex- 
pired air  may  not  contain  infectious  molecules,  and  al- 
though the  probabilities  are  against  it,  I  think  we  are 
justified  in  exercising  precautions  with  respect  to  its 
possible  conveyance  in  that  way.  It  is  an  interesting 
question,  and  one  which  has  a  very  practical  bearing, 
just  how  long  matter  which  in  the  first  place  is  highly 
infectious,  can  retain  its  virulency.  Experiments  with  a 
view  to  determine  this  question  have  recently  been 
made,  and  I  have  been  surprised  to  be  unable  to  find  an 
instance  where  such  experiments  have  proved  that  tuber- 
cle bacilli,  in  a  non-parasitic  state,  have  retained  their 
virulency  for  a  period  of  six  months.  In  a  series  of  ex- 
periments conducted  by  Dr.  G.  A.  Heron  and  Dr.  T, 
H.  A.  Chaplin  (London  Lancet,  January  6, 1894),  both 
of  the  City  of  London  Hospital  for  Diseases  of  the  Chest, 
a  number  of  guinea  pigs  (the  number  is  not  given)  were 
inoculated  with  tuberculous  sputum  three  months  old. 
Most  of  the  animals  died  from  septicaemia  within  a  week 
after  the  operation.  The  few  that  survived  were  in  due 
time  killed  by  chloroform,  and  of  these  not  one  showed 
any  signs  of  having  developed  tuberculosis.  The  authors 
in  this  instance  regret  that  the  number  was  too  small  to 
be  a  very  valuable  addition  to  statistics,  but  thought  it 
remarkable  that  two  months  after  inoculation  with  stale 
sputum  three  months  old,  in  which  colonies  of  bacilli 
swarmed,  five  guinea-pigs  were  free  from  tuberculous 
disease. 

My  third  question  is  answered  in  part  with  the  first. 
The  spores  having  found  their  way  into  the  epithelial 
lining  of  the  mucous  membrane,  are  with  more  or  less 
avidity,  according  to  the  subject,  taken  up  by  the  lym- 
phatics and  carried  to  and  deposited  in  those  parts  for 
which  they  appear  to  have  a  peculiar  predilection,  nat- 
urally locating  in  that  particular  part  best  suited  for  the 
conditions  which  their  development  necessitates  and 
always  as  near  as  possible  to  the  seat  of  absorption. 
Thus  in  the  bronchial  glands  the  interstitial  tissue  of  the 
lung,  the  mesenteric  glands,  the  lymphatic  glands,  points 
in  and  about  certain  of  the  bony  articulations,  the  testi- 
cles, etc. 

The  case  which  I  cite  illustrates  to  a  certain  extent,  I 
think,  some  of  those  features  in  the  early  history  of  the 
development  of  phthisis  which  have  been  and  are  still 
objured  in  the  uncertain  light  of  speculative  theory. 

It  is  one  of  acute  tuberculosis,  and  the  short  time 
which  elapsed  from  the  development  of  the  earliest 
symptoms  to  its  termination,  the  rapidity  with  which  the 
several  stages  supervened  upon  each  other,  and  my  con- 
stant association  with  the  case,  all  conduced  to  make  my 
opportunities  for  close  observation  rather  unusual  in  the 
experiences  of  private  practice. 

The  patient,  a  young  man,  aged  twenty  one,  medium 
height,  of  better  than  the  average  physical  development, 
owing  perhaps  to  a  military  training,  which  he  had  re- 
cently enjoyed,  consulted  me  first,  on  December  5, 1893, 
having  been  placed  in  my  care  by  his  family  physician. 
He  was  unmarried  and  his  occupation  was  that  of  a  clerk 
in  a  dry-goods  establishment.  A  Canadian  by  birth,  of 
Irish  extraction. 

Family  history :  Father  and  mother,  paternal  grand- 
mother, five  sisters  and  one  brother  living,  all  in  appar- 
ently good  health.  The  others  of  his  grandparents  died 
at  old  age,  and  none  from  any  lung  disease,  as  far  as 
could  be  learned.  One  younger  brother  died  about  a 
year  previous  from  phthisis;  the  last  few  months  of 
whose  illness  were  passed  in  the  same  house  and  in  ordi- 
narily close  intimacy  with  the  patient.  The  habits  and 
hygienic  surroundings,  which  form  no'inconsiderable  fac- 
tor in  the  etiology  of  phthisis,  were  in  this  case  as  follows : 
The  patient,  occupying  alone  a  small  but  comfortable 
room  at  home,  was  surrounded  with  all  the  necessities 


of  life  and  those  of  the  luxuries  which  over-fond  parents 
and  a  very  moderate  purse  could  bestow  upon  a  favorite 
child.  The  house,  isolated  from  its  neighbors  and  situa- 
ted upon  a  hill,  had  all  the  advantages  of  light  and  pure 
air ;  but,  on  the  other  hand,  ranged  against  these,  aj 
it  were,  the  patient  himself  had  lived  a  life  of  dissipa- 
tion in  late  and  irregular  hours,  sexual  excesses,  and 
indiscretions  in  the  matter  of  food  and  drink  for  a  num- 
ber of  years  prior  to  the  inception  of  the  disease ;  and 
thus  a  constitution,  which  might  otherwise,  perhaps, 
have  withstood  the  encroachments  of  the  disease,  or  at 
least  have  so  mitigated  its  course  as  to  have  prolonged 
life,  by  making  the  conditions  essential  to  the  acute  form 
impossible  (when,  to  theorize,  the  case  might  have  been 
one  of  the  ordinary  form  or,  what  is  possible,  that  variety 
known  as  fibroid  phthisis),  was  undermined  and  the  pow- 
ers of  resistance  were  greatly  enfeebled.  The  history 
given  was  in  brief  as  follows : 

The  general  health  had  always  been  good,  save  for  a 
tendency  to  contract  influenza  upon  the  slightest  expos- 
ure, which  had  been  noticeable  for  several  years.  In  the 
summer  of  1892  the  patient  had  malarial  fever.  For 
about  a  month,  however,  he  had  noticed  a  more  or  less 
persistent  cough,  especially  annoying  in  the  morning, 
unproductive  of  expectoration ;  but  four  days  prior  to  my 
examination  an  acute  exacerbation  of  the  cough,  together 
with  severe  laryngeal  symptoms,  had  supervened  and  now 
appeared  a  very  slight  expectoration  of  tenacious  mucus, 
which,  on  one  occasion  after  smoking,  had  been  streaked 
with  blood. 

Physical  examination  revealed  the  following  signs: 
Temperature,  98. 6°  F.;  pulse,  80;  respiration,  24. 

The  pharynx  and  larynx  showed  evidence  of  intense 
congestion.  The  membrane  was  hyperemic  and  the 
vocal  bands  could  not  be  distinguished  by  difference  of 
color  from  the  adjacent  walls.  Speech,  above  a  whisper, 
was  impossible.  Inspection  and  palpation  of  the  chest 
gave  negative  results,  while  percussion  elicited  a  barely 
perceptible  dulness  over  the  left  apex,  by  no  means  suf- 
ficient of  itself  to  go  far  toward  establishing  a  diagnosis. 
Auscultation  revealed  a  somewhat  prolonged  expiratory 
sound,  a  slight  increase  in  vocal  resonance,  and  just  a 
perceptible  lessening  of  the  normal  vesicular  murmur. 
On  the  5  th,  8th,  and  13th  of  the  month  the  expectora- 
tion was  saved  from  six  o'clock  at  night  to  eight  o'clock 
on  the  following  morning  and  carefully  examined  with 
the  microscope.  As  many  as  ten  mounts  were  made  from 
each  of  the  first  two  specimens  and  in  none  were  any 
pathological  elements  to  be  found.  Meanwhile,  the  in- 
flammatory condition  in  the  pharynx  and  larynx  subsided 
without  ulceration.  From  the  sputum  of  the  13th  several 
mounts  were  made,  and  owing  to  a  mere  chance  of  staining, 
I  believe,  the  specimen  was  obtained  which  was  the  only 
one  of  the  whole  number  of  mounts  which  showed  the 
existing  condition,  and  I  therefore  attribute  my  success  in 
this  instance  to  some  fortunate  accident  in  the  process 
of  staining.  There  was  no  pus  present,  and  no  free 
bacilli.  Throughout  the  whole  specimen  the  same  con- 
dition existed,  and  so  far  no  yellow  elastic  fibres  were  to 
be  found.  In  some  of  the  other  mounts  epithelium 
cells  were  present.  Indeed  in  very  few  were  they  ab- 
sent; but  in  none  could  the  presence  of  bacilli,  either 
free  or,  as  in  this  particular  mount,  involved  and  seemingly 
embryonic  in  the  protoplasm  of  the  cells,  be  demon- 
strated. The  cells,  in  a  number  of  instances,  were  found 
to  be  apparently  swollen,  and  to  contain  between  the 
periphery  and  the  nucleus  a  cloudy  or  granular  mass,  on 
the  outer  edge  of  which,  but  still  within  the  protoplasm, 
were  found  the  minute  particles  which  gradually  approach 
the  appearance  of  bacilli  as  they  near  the  periphery,  until 
at  the  outer  edge,  and  in  some  even  breaking  through 
the  cell  wall,  they  appeared  as  fully  developed  bacilli. 
In  most  of  these  cells  the  nuclei  appear  granular  and  in 
all,  even  those  in  which  the  cloudy  swelling  is  not  dis- 
cernible, an  unusual  appearance  is  manifest. 

Up  to  this  time  and  for  two  days  subsequent  there 
had  at  no  time  in  any  of  the  thirty  odd  mounts,  ap- 


November  24,  1894] 


MEDICAL   RECORD. 


647 


peared  the  least  evidence  of  breaking  down  of  tissue,  no 
pus,  and  no  yellow  elastic  fibres.  Wherever  bacilli  ap- 
pear about  to  emerge  from  the  cell,  it  is  noticeable  that 
they  are  more  fully  developed  and  that  they  take  the 
stain  in  a  more  characteristic  manner.  (I  might  say 
nere  that  the  staining  process  employed  was  a  modifica- 
tion of  that  recommended  by  Ehrlich,  requiring  an  im- 
mersion of  about  twenty-four  hours.  I  do  not  think  that 
any  of  the  more  rapid  methods  would  have  demonstrated 
this  condition.) 

On  December  15  th,  began  a  series  of  severe  and  ex- 
haustive attacks  of  haemoptysis,  recurring  at  intervals  of 
from  two  to  twelve  hours,  up  to  the  24th.  These  hem- 
orrhages originated  from  the  bronchial  walls,  in  close 
proximity  with  that  portion  of  the  upper  left  lobe  which 
had  previously  given  the  slight  evidences  of  partial  con- 
solidation. 

On  January  1,  1894,  the  blood  having  pretty  thor- 
oughly cleared  from  the  expectoration,  another  micro- 
scopical examination  of  the  sputum  was  made.  Bacilli 
were  scattered  here  and  there  throughout  the  specimen, 
not  in  large  colonies,  but  taking  the  stain  in  the  usual 
manner,  and  perfectly  pathognomonic.  Some  pus  was 
also  found.  The  evidences  of  breaking  down  of  lung  tis- 
sue were  also  distinguishable  by  the  elastic  fibres  which 
now  made  their  appearance  in  the  matter  expectorated. 

On  February  14th,  less  than  a  month  before  death, 
another  examination  of  the  sputum  was  made,  in  which 
were  seen  evidences  of  the  rapid  destruction  of  tissue  and 
the  vicious  ravages  of  the  tuberculous  process.  Pus  ap- 
peared in  large  quantities,  while  bacilli  were  seen  in 
thickly  crowded  colonies.  Yellow  elastic  fibres  were 
found  in  increasing  amounts,  and  particles  of  sloughed 
tissue,  even  perceptible  to  the  naked  eye,  could  be  distin- 
guished, while  physical  examination  revealed  a  rapidly 
growing  cavity.  Death  occurred  on  March  10th,  from 
asthenia.     No  autopsy  was  held. 

Now,  in  conclusion,  the  point  which  I  wish  to  make  is 
this :  It  is  not  the  presence  of  the  fully  developed  bacil- 
lus to  which  is  due  the  destructive  process  of  tuberculo 
sis. 

I  believe,  not  that  the  bacillus  originates,  de  novo,  in 
the  tubercle,  but  that  its  development  from  the  spore  is 
the  result  of  the  disease  process,  to  which  the  necessary 
requirements  of  the  life  and  growth  of  that  spore  give 
rise ;  that  furthermore,  when  the  bacillus  is  mature  and 
has  deposited  its  elementary  spores  in  the  body,  it  has 
fulfilled  its  mission,  is  no  longer  an  element  of  disease 
and  is  cast  from  the  body  as  an  effete  product.  How 
visionary  may  be  my  deductions  I  leave  to  your  discus- 
sion to  determi  ne. 

86  Jkffskson  Avenue. 


The  Etiology  of  Cancer. — The  French  Surgical  Asso- 
ciation recently  held  its  eighth  annual  congress.  The 
etiology  of  cancer  was  the  most  important  question  dis- 
cussed. According  to  M.  Bard,  who  opened  the  debate, 
the  differentiation  of  malignant  tumors  in  a  pathogenic 
sense  is  an  error,  whatever  may  be  their  origin  or  their 
structure.  All  the  tissues  of  the  human  organism  may 
engender  cancer,  and  there  is  no  reason  for  applying 
this  term  to  epithelial  tumors.  Each  tissie  may  be  the 
seat  of  a  specific  cancer,  and  this  cancer  owes  its  origin 
to  a  young  cell  endowed  with  an  exaggerated  power  of 
reproduction.  It  is  superabundant  vitality  which  differ- 
entiates the  cancer  cell  from  the  normal  cell.  M.  Bard 
rejects  the  microbic  theory  as  to  cancer.  Considerable 
diversity  of  opinion  on  this  point  was  expressed  by  other 
speakers.  It  is  decided  that  in  future  the  French  Surgi- 
cal Congress  will  always  meet  at  Paris  in  October,  at  the 
same  time  as  the  General  Assembly.  Many  of  the  con- 
gressisles  who  visited  the  Lyons  H6tel-Dieu  were  dis 
appointed  to  find  the  old  white  bed  curtains  (which  have 
been  discarded  elsewhere),  the  old  hospital  smell  of  by- 
gone days,  and  the  food  being  prepared  in  the  wards. 
M.  Poncet's  wards  are  being  remodelled. 


THE  RECENT  TYPHOID  EPIDEMIC  AT  WIND- 
SOR,  VT. 

By  J.  D.   BREWSTER,   M.D., 

WINDSOR,   VT. 

In  compliance  with  the  request  of  our  secretary  and 
others,  I  will  endeavor  to  give  a  brief  account  of  the 
epidemic  of  typhoid  fever  which  prevailed  in  Windsor, 
beginning  in  March,  1894.  The  first  case  reported  was 
on  March  15  th.  This  case  was  in  a  family  residing  at 
the  extreme  southern  limit  of  the  village,  and  at  the 
time  no  apparent  cause  could  be  found.  No  other  case 
developed  until  March  24th  and  25th,  at  which  time  a 
large  number  of  people  were  attacked,  almost  simulta- 
neously, with  a  febrile  condition  which  soon  showed  itself 
to  be  unmistakably  typhoid  fever.  These  cases  were 
among  all  classes  of  people,  rich  and  poor  alike,  but  all 
within  the  village  limit. 

Observation  soon  showed  the  disease  was  confined 
entirely  to  families  using  the  village  water  supply,  those 
having  wells  being  entirely  exempt,  except  in  cases  of 
children  who  drank  the  village  water  at  school.  This 
fact  led  immediately  to  the  examination  of  the  water 
system.  Windsor  was  supplied  by  a  series  of  springs 
situated  about  two  miles  or  more  from  the  centre  of  the 
town ;  these  springs  formed  a  small  brook,  which  ran 
along  a  valley  for  about  a  mile,  passing  six  farms  and 
dwelling-houses,  and  then  emptying  into  a  reservoir, 
whence  iron  pipes  conveyed  the  water  into  the  houses  of 
Windsor. 

Now,  about  forty  rods  above  the  source  of  this  brook 
a  farm-house  is  situated,  where  it  was  ascertained  a  per- 
son had,  the  previous  January,  suffered  from  a  fever- 
ish condition  about  four  weeks.  It  was  supposed  to  be 
a  non-infectious  form  of  fever,  and  was  not  reported  to 
the  local  board  of  health,  and  consequently  no  care  was 
taken  of  the  discharges  of  the  patient,  and  they  were 
thrown  into  the  vault ;  and  to  make  matters  worse,  the 
sink  drain  was  frozen  at  the  time,  so  all  wash-water  was 
thrown  out  upon  the  snow.  During  the  very  warm 
weather  which  we  had  the  first  week  in  March,  the  snow 
melted,  and  all  this  accumulation  easily  found  its  way 
into  the  brook,  and  thence  into  the  reservoir  and  our 
homes. 

This  explanation  was  unanimously  indorsed  by  the 
State  Board,  who  made  an  official  visit  to  the  place  soon 
after  the  outbreak.  The  local  Board  at  once  issued 
orders  to  have  all  water  used  for  cooking  and  drink- 
ing purposes,  boiled.  At  the  same  time  the  town  pro* 
vided  a  water  cart  to  deliver  water  from  an  adjoining 
spring. 

From  March  24th  to  30th,  about  eighty  cases  were  re- 
ported ;  from  this  date  to  April  27th,  the  cases  became 
less  frequent,  this  time  being  probably  the  limit  of  the 
primary  cases ;  the  later  ones  were  secondary,  and  mostly 
occurred  in  families  already  suffering  from  the  disease. 
Up  to  July  28th  there  vcre  130  cases,  these  occurring  in 
sixty  eight  families.  The  largest  number  afflicted  in  one 
family  being  5,  the  majority  only  1.  The  ages  ranged 
from  ten  months  to  ninety-two  years,  but  the  majority 
were  under  twenty  years  of  age,  and  a  large  per  cent,  were 
children ;  the  latter  withstood  the  disease  to  a  remarkable 
degree,  even  with  a  protracted  evening  temperature  of 
104  °  F.  The  population  of  Windsor  is  1,300,  so  about 
ten  per  cent,  of  the  inhabitants  were  affected  by  the  dis- 
ease. We  were  fortunate  in  having  only'seventeen  deaths, 
or  thirteen  per  cent.  Six  of  the  fatal  cases  had  intestinal 
hemorrhage. 

S.  H ,  aged  forty  four,  died  from  complication 

of  erysipelas.     One  died  from  perforation.   Mr.  V. « 

had  temperature  of  1060  F.,  at  death,  and  there  was  a 
rise  of  a  degree  a  short  time  after. 

M.  K ,  a  girl  fourteen  years  of  age,  was  afflicted 

with  infantile  paralysis.  She  died  in  the  tenth  week, 
and  at  death  had  seven  bed  sores,  those  on  each  hip 
leaving  bone  exposed,  which  was  also  carious.    Three 


648 


MEDICAL   RECORD. 


[November  24,  1894 


died  before  the  end  of  the  second  week,  the  average 
fatality  was  at  about  the  end  of  the  third  or  beginning  of 
the  fifth  week. 

I  will  now  give  a  brief  history  of  a  few  of  the  cases 
which  have  recovered.     Perhaps  the  most  remarkable 

one  was  Mrs.  C ,  about  thirty  years  of  age.     She 

showed  all  the  symptoms  of  typhoid — coated  tongue,  en- 
larged spleen,  rose  spots  on  abdomen,  etc. ;  but  devel- 
oped no  fever  until  the  fifty-first  day,  when  the  evening 
temperature  was  990  F.  It  ranged  from  this  to  99^°  F-  > 
until  the  sixty-third  day.  Convalescence  being  very 
protracted  after  the  thirteenth  week. 

A.   A ,  aged   seventy,  had    typhoid    symptoms, 

with  evening  temperature  of  1030  to  1050  F.,  with 
croupous  pneumonia,  rusty  sputa,  which  continued  to  the 
twelfth  day;  from  the  14th  to  the  21st,  no  fever.  From 
twenty-second  to  thirty-second  day  average  temperature, 
1020  F.;  symptoms  wholly  abdominal ;  rose  spots  pres- 
ent. Temperature  normal  to  the  fortieth  day,  from  the 
fortieth  to  fifty  fourth  there  was  fever,  the  highest  point 
reaching  101  °  F.  Symptoms:  Catarrhal  pneumonia. 
Convalescence  protracted. 

C.    A had    relapse    on    the    twenty- first    day 

with  remarkable  eruptions,  some  thirty  or  forty  large 
papules  which  soon  became  vesicula  and  many  of  them 
pustular,  while  one  was  a  true  adenitis  which  went  on  to 
suppuration,  the  abscess  containing  one-half  drachm  of 
pus.  This  certainly  was  due  to  sepsis.  This  same  case 
at  the  beginning  of  convalescence  had  suppurative  otitis 
media  and  inflammation  of  the  mastoid,  with  one  recur- 
rence. 

G.  B had  evening  temperature  of  1050  F.  first 

week,  delirium  beginning  on  the  fourth  day.  On  the 
twenty-first  day  had  subsultus  and  picking  of  clothing, 
and  insomnia,  continuing  for  a  week.  Temperature 
ranging  from  1030  to  1040  F.  at  night.  Convalescence 
set  in  after  the  seventh  week,  but  delirium  continued 
two  weeks  longer. 

Two  cases  had  phlebitis  of  the  leg.  Ten  cases  had  in- 
testinal hemorrhage. 

Mrs.  B was  confined  on  the  fourth  day.  Tem- 
perature, 1 040  F.  The  fever  ran  the  usual  course,  and 
recovery  took  place  after  the  fifth  week. 

Arthur  K ,  aged  thirteen,  after  a  mild  form  of  the 

fever,  appeared  convalescent,  when  malaria  made  its  ap- 
pearance. Temperature,  1050  F.  After  the  second  day 
the  same  symptoms  recurred  with  the  usual  course  of 
malaria.  A  large  dose  of  quinine  prevented  a  return. 
His  history  showed  he  had  had  malaria  eight  years 
before. 

The  most  prolonged  case  was  that  of  Henry  S , 

who  had  a  temperature  for  one  hundred  and  two  days. 
This  case  had  severe  hemorrhages  on  the  forty-ninth 
day.  He  was  not  moved  from  his  bed  for  one  hundred 
and  sixteen  days.  After  convalescence  he  gained  twenty- 
three  pounds  in  twelve  days. 

I  could  give  many  more  interesting  cases,  if  time  would 
allow. 

From  July  28th  to  August  30th  only  two  cases  were  re- 
ported, but  during  the  month  of  September  there  have 
been  twenty  cases,  thus  making  a  hundred  and  fifty  cases 
in  all  since  the  beginning  of  the  epidemic.  All  of  these 
later  cases,  with  two  or  three  exceptions,  have  been  among 
the  poorer  classes,  living  in  tenement- houses.  Two  of 
these  died  of  perforation;  in  both  cases  the  patients 
having  been  in  a  state  of  collapse  for  forty  eight  hours 
before  death.  Temperature,  930  to  970  F.,  and  pulse, 
125  ;  abdomen  extremely  distended.  The  accidents  in 
each  case  being  sudden,  when  everything  seemed  pro- 
gressing to  a  speedy  convalescence. 

One  fact  is  worthy  of  mention :  in  several  cases  there 
seemed  to  be  secondary  infection  coming  from  four  to 
six  days  after  apparent  convalescence,  when  there  had 
been  no  change  in  diet  or  management  of  the  patients ; 
they  usually  had  fever  for  seven  days,  when  true  conva- 
lescence occurred. 

Throughout  the  whole  time  the  sickness  prevailed,  all 


possible  precaution  was  taken  to  disinfect  discharges  and 
the  clothing  of  persons  afflicted.  The  discharges  were 
buried  after  disinfection  with  either  corrosive  sublimate 
or  copper,  and  the  clothing  was  put  in  boiling  water. 
We  all  know  how  difficult  it  is  to  impress  the  impor- 
tance of  this  upon  everyone,  and  doubtless,  among  some 
of  the  more  ignorant  classes  the  instructions  given  were 
disregarded,  thus  causing  the  later  outbreak  of  the  disease 
among  that  class. 

Windsor  has -for  twelve  years  been  remarkably  free 
from  the  disease,  not  averaging  more  than  five  to  seven 
cases  a  year.  I  will  here  state,  that  the  prison  was  en- 
tirely exempt  from  the  disease,  the  water-supply  being 
from  a  different  source. 

The  village  voted  to  discontinue  the  old  supply,  ex- 
cept for  motor  purposes,  and  now  have  their  water  from 
springs  which  flow  from  the  hillside  directly  into  a 
covered  reservoir,  from  which  the  water  is  pumped  into 
a  stand  pipe,  also  covered.  The  springs  are  for  distant 
from  any  dwellings,  and  furnish  no  possible  opportunity 
for  pollution.  No  water  supply  that  is  exposed  to 
drainage  from  dwelling-houses  can  be  safe,  for  only  the 
most  untiring  vigilance  can  prevent  some  accidents 
which  will  involve  its  consumers  in  as  sad  an  experience 
as  Windsor,  after  using  the  water  system  for  over  fifty 
years. 

I  cannot  close  this  paper  without  paying  some  tribute 
to  the  noble  way  in  which  our  citizens  responded  to  the 
needs  arising  from  such  a  calamity ;  a  mass  meeting  was 
held  in  one  of  the  churches,  and  a  committee  appointed 
to  solicit  money  and  clothing,  such  as  was  needed  for 
the  sick,  and  to  provide  food  for  the  needy  ones.  Many 
volunteered  as  watchers,  and  every  day  the  village  was 
canvassed  to  ascertain  the  needs  of  all;  the  sum  of  $700 
was  raised  to  provide  nurses  for  those  who  could  not 
provide  themselves.  Twenty-eight  nurses  were  employed, 
coming  from  Burlington,  New  York,  Hartford,  Ct.,  Wor- 
cester and  Boston,  Mass.,  thus  aiding  the  physicians  in 
no  small  degree.  No  disease  needs  more  careful  watch- 
ing than  typhoid  fever,  and  many  owe  their  lives  to  the 
never-tiring  care  of  the  faithful  nurse.  Windsor  may  well 
be  proud  of  the  generosity  of  her  people,  as  this  test  has 
proved  them.  May  the  time  be  far  distant  when  any 
other  town  shall  be  called  upon  to  prove  herself  her 
equal. 


Removal  of  the  Kestiform  Body. — Dr.  Biedl  showed 
(Royal  Medical  Society,  Vienna)  a  cat  in  which  the  resti- 
form  body  had  been  completely  removed  a  fortnight 
previously.  The  first  symptoms  after  the  excision  were 
rotation  in  the  opposite  direction,  rotation  of  the  eye- 
balls, and  forced  decubitus.  After  a  few  days,  when  the 
cat  essayed  to  walk,  it  found  great  difficulty  in  doing  so, 
not,  however,  on  account  of  paralysis,  but  because  of  loss 
of  cognizance  of  place  and  surroundings.  The  head  was 
held  toward  the  left  and  near  the  ground,  and  the  itin- 
erary was  toward  the  left  in  a  circle.  Disturbance  in  co- 
ordination of  the  muscles  of  the  right  side  of  the  neck 
and  throat  caused  it  to  eat  on  the  right  side.  The  ex- 
perimenter thought  the  conditions  presented  by  the  ani- 
mal could  be  explained  on  the  supposition  of  functional 
suppression  of  a  track  along  which  nerve  stimulation  pro- 
ceeds from  the  cerebellum. 

Von  BGlow's  Brain. — Hans  von  Billow,  the  eminent 
pianist  and  conductor,  who  died  at  Cairo,  in  February 
last,  had  for  years  been  a  martyr  to  maddening  head- 
aches. In  accordance  with  his  often  expressed  wish, 
after  his  death  Professor  Kaufmann,  of  Cairo,  who  per- 
formed the  post-mortem  examination,  extracted  the 
brain,  and  sent  it  to  a  German  physician  for  examination. 
It  now  appears  that  the  surface  origin  of  two  nerves  lead- 
ing to  the  scalp  was  imbedded  in  a  scar,  left  by  an  attack 
of  meningitis  in  early  youth.  Whether  this  scar  can  be 
held  responsible  for  the  great  artist's  many  eccentricities 
must  remain  an  open  question. 


November  24,  1894] 


MEDICAL    RECORD. 


649 


A  PLAN  OF  INFANTILE  MEASUREMENTS.1 

By  HENRY  DWIGHT  CHAPIN,  M.D., 

rxorsssoc  of  diseases  or  children  at  the  new  yokk  post-graduate  medi- 
cal SCHOOL  AND  HOSPITAL. 

The  extremely  rapid  growth  of  the  infant  after  birth 
makes  a  careful  observation  of  all  the  phenomena  con- 
nected therewith  not  only  interesting  but  important  to 
the  physiologist  and  practical  physician.  As  a  partial 
index  of  this  growth  an  accurate  system  of  measurements 
is  desirable,  not  only  as  noting  a  proper  rate  of  evolu- 
tion, but  also  for  comparative  purposes,  after  a  suffi- 
ciently large  number  shall  be  made.  In  proposing  a  plan 
of  measurements  two  extremes  are  to  be  avoided ;  first, 
in  having  too  few  for  valuable  data,  and,  second,  in  ad- 
vancing a  system  too  cumbersome  or  complicated  for 
general  adoption.  It  is  with  an  effort  to  avoid  these 
evils  that  the  present  plan  is  submitted.  All  that  is  re- 
quired is  a  tape  measure,  a  strip  of  sheet-lead,  a  pencil, 
a  pair  ot  calipers,  and  a  table. 


«A»U|1i 


Fig.  i.— Sketch  of  Skull  for  Measurement*. 

Age.       Sex. 


Nationality. 
(Parents.) 


Name 

Date. 

Great  circumference. 

Naso-occipital  arc. 

Naso-bregmatic  arc. 

Bregmato-lambdoid  arc. 

Lambda-occipital  arc  Configuration. 

Binauricular  arc  (through  bregma). 

Binauricular  arc  (through  lambda). 

Diameters  of  anterior  fontanelle  }  jjjjjf  P°»terior' 

Cephalic  index. 
Facial  length. 
Circumference  of  chest. 
Circumference  of  abdomen. 
Length  of  body. 
Weight  of  body. 
Diet. 
Notes. 

The  rapid  evolution  of  the  brain  during  infancy,  and  the 
fact  that  the  future  efficiency  and  well-being  of  the  indi- 
vidual depend  so  largely  upon  its  normal  and  healthy 
growth,  renders  a  study  of  the  head  of  great  interest,  and 
accordingly  ten  of  the  measurements  are  made  upon  the 
skull.  As  the  skull  is  fairly  representative  of  the  brain 
daring  the  years  of  its  development,  the  measurements 

>  Read  by  invitation  before  the  Section  on  Diseases  of  Children  of 
the  British  Medical  Association,  at  Bristol,  August  2,  1894. 


taken  during  infancy  are  more  instructive  as  to  brain  size 
and  development  than  those  taken  in  later  years.  The 
skull  changes  considerably  in  its  proportions  during  the 
first  three  years  of  life,  and  then  more  slowly  up  to  the 
end  of  the  seventh  year  when  it  has  very  nearly  attained 
its  full  size. 

The  circumference  is  taken  by  passing  the  tape  hori- 
zontally around  the  head,  passing  over  the  glabella  and 
a  point  just  above  the  external  occipital  protuberance. 
When  this  is  procured,  the  following  data  will  give  a 
very  rough  approximation  of  the  volume — x :  circum- 
ference:: 1350:  50.  Thus,  if  the  circumference  is  42 
ctm.,  the  approximate  volume  will  be  1.134  cu.  ctm. 
The  naso-occipital  arc  is  measured  from  the  glabella  to 
the  external  occipital  protuberance.  Before  removing 
the  tape,  the  three  arcs  composing  the  naso-occipital 
can  be  read  off,  namely,  the  naso-bregmatic,  the  breg- 
mato-lambdoid, and  the  lambdo-occipital  arcs.  In  order 
to  do  this  accurately,  the  bregma  and  lambda  should  be 
previously  marked,  and  I  have  employed  an  aniline  pen- 
cil for  this  purpose.  These  points  are 
much  more  easily  indicated  in  an  infant 
than  in  the  adult.  Where  the  anterior 
fontanelle  is  widely  open,  a  line  in  con- 
tinuation of  the  frontal  sutures  is  marked. 
The  binauricular  arcs  are  measured  by 
starting,  in  both  cases,  from  the  anterior 
rim  of  the  meatus,  and  passing  the  tape 
respectively  over  the  bregma 
and  the  lambda.  When  the 
anterior  fontanelle  is  open, 
the  antero-posterior  and  later* 
al  diameters  are  taken.  The 
cephalic,  or  length-breadth 
index,  is  measured  by  calipers, 
which  are  applied  at  the  great- 
est biparietal  and  antero  pos- 
terior diameters.  The  for- 
mula for  obtaining  this  in- 
dex is  as  follows — Length: 
Breadth : :  100 :  x.  All  ceph- 
alic indices  falling  below  78 
are  classed  as  dolicocephalic; 
from  78  to  80,  mesocephalic; 
and  above  80,  brachycephalic 
The  facial  length  is  measured  from  the  root  of  the  nose 
to  the  extremity  of  the  chin,  and,  in  the  absence  of  the 
teeth,  falls  considerably  below  the  adult  The  chest  is 
measured  at  the  nipple  line,  and  the  abdomen  at  its  point 
of  greatest  circumference. 

The  length  of  the  body  is  measured  by  extending  the 
child  upon  a  graduated  board  with  a  movable  slide  at 
one  extremity,  although  a  flat  table  with  a  couple  of 
large  books  will  answer. 

The  configuration  of  the  skull  is  taken  by  carefully 
applying  a  strip  of  sheet-lead  horizontally  around  it,  just 
above  the  ear,  the  free  ends  always  being  on  the  right 
side,  for  the  purpose  of  uniformity. 

The  tracing  is  put  upon  the  chart  by  running  the 
point  of  a  sharp  pencil  just  inside  the  lead.  It  is  well 
to  mark  the%centre  of  the  lead  in  front,  so  as  to  be 
able  approximately  to  draw  a  median  line  through  the 
configuration  and  thus  detect  asymmetry.  It  is  not 
contended  that  this  is  an  absolutely  accurate  method 
of  obtaining  a  configuration  of  the  skull,  as  the  metal 
is  so  yielding  that  there  is  a  possibility  of  its  spring- 
ing somewhat  in  transferring  it  from  the  skull  to  the 
chart. 

With  care,  however,  it  is  fairly  accurate,  and  will 
exhibit  any  form  of  asymmetry  that  is  at  all  marked.  I 
have  tried  harder  substances,  such  as  block  tin,  but 
found  it  more  difficult  and  somewhat  painful  to  apply, 
without  being  appreciably  more  accurate. 

A   lateral  configuration    is  taken   by  applying   the 
lead  over  the  parietal  region,  from  one  meatus  to  the 
other. 
Ninety-eight  cases,  from  birth  up  to  two  years,  have 


650 


MEDICAL   RECORD. 


[November  24,  1894 


been  carefully  measured  and  are  incorporated  in  the  ac- 
companying table. 


cocephalic;  and  from  eighteen  months  to  two  yean, 
dolicocephalic.     None  of  the  averages  being  below  70 


•M9 


IcLg 


«8 


I8 


IS 


Great  circumference 
Approximate  volume,cu.c. 

Naso-occipital  arc 

Naso-bregmatic  arc 

Bregmato-lambdotd  arc. . 
Lambdo-occipital  arc. . . 
Binauricular  arc  (through 

bregma) 

Binauricular  arc  (through 

lambda) 

Diameters  {  Ant. -post . . .  | 
ant,-fonL  )  Lateral 

Cephalic  index  

Facial  length . 

Circumference,  chest 
Circumference,  abdomen. 

Length  of  body i 

Weight  of  body ! 


Ctm. 

34-73 

9*7.44 

92.33 

0.22 

§.94 

4.16 

22.00 

ai.6x 
4.00 
300 
9.11 

-=79.63 
xi.44 

4-94 

S3 

49- 7« 
8  lbs.  6  ozs. 


I 


Ctm. 

3509 
969.03 

»3-o5 
9.80 
8.90 
4.80 

22.95 

!        23.05 
445 
3.70 
9.95 

,".30 

1        3«-«7 
[        30.90 

7  lbs.  5  ozs. 


,  Ctm. 
37.*5 
!  xoo5«7S 
1  94.86 
!  9-55 

33-55 

I  33-75 
4-oS 
3.t6 

^  =  78.«4 

575 

l        34" 
I        32.00 

8  lbs.  lots. 


Ctm. 

38.55 

X040.85 

;        35.83 

10.05 

I        10.  xx 

566 

'        a4.38 

i        *5°J 

3-33 
xo.xx 

—  "76*47 
13-33 

1  58.38 

xo  lbs.  12  ozs. 


Ctm. 

3894 
1051.38 
36.05 
0.83 
10.16 
6.05 

23.83 

95.22 
3-77 
338 


13.44 

31.77 

10  lbs. 


I 


Ctm. 
4*«3 
1x15.x 
27.9 
xx.6 
9.0 
7-3 

26.6 

26.9 
3.6 
3.9 

XX.2         . 
_  =  81.15 

6.3 
37'1 

12  lbs.  x  or. 


g  o  9 


§    !     H 


J*' 


Ctm. 

49.68 

1150.36 

28.81 

SX.X9 
XX.06 
6.69 

26.68 

96.68 

3-00 

!  a-75 

xx.37 


Ctm. 

44-9« 

1212.57 

30.4X 

X9.4I 


8 


14.62" 


77.77 


6.05 

66.06 
14  lbs.  13  ozs 


28.33 

97.66 
3.00 
9.41 


1*2?  - 

150 


**33  77Z, 


Ctm. 
46.81 
1263.87 
31.00 
12.68 
10.68 
7.6a 

28.31 

29.25 

1.87 
1.68 
12.00 

=  76.82 


Ctm. 
4741 
1280UJ7 
32.83 
13.16 
xi.41 
8-95 

39-33 

d£2L 

Closed. 
19.16  _ 

-  74-4* 


15.62     '  16.33 

6.75                 o-68  I          7.05 

41.16        .         41-81  47-35 

38.9*        I         39-75  46.33 

6925                 73-35  .78.16 

13  lbs.            20  lbs.  4  ozs. 


While  broad  and  positive  generalizations  cannot  be 
made  from  so  few  cases,  a  study  of  the  table  is  not  with- 
out some  interesting  suggestions.  It  must  be  remem- 
bered that  they  were  all  hospital  cases,  taken  either  from 
the  Infant  Asylum  or  the  babies'  wards,  and  many  were 
thus  much  below  par.  This  will  explain  the  low  average 
weight,  being  actually  less  in  the  cases  from  one  week  to 
one  month  old,  than  in  those  under  one  week.  Infants 
collected  together  in  numbers,  especially  in  a  hospital, 
nearly  always  lose  weight,  if  kept  very  long.  This  ten- 
dency to  scant  weight  does  not  seem  to  have  had  much 
influence  upon  bony  diameters,  in  comparing  the  skull 
measurements  of  the  table  with  adult  measurements 
already  published.  The  shrinkage  falls  principally  upon 
the  adipose  tissue.  While  the  degrees  of  health,  and  the 
irregular  number  of  cases  give  some  varying  results  in 
the  ten  classes  into  which  the  cases  are  divided,  yet  it  is 
believed,  on  the  whole,  they  represent  a  certain  type  of 
infant  development.  With  increase  in  the  age  of  the 
infants  there  is  noted  a  gradual  and  steady  enlargement 
of  the  great  circumference  of  the  skull,  and,  from  this, 
of  its  estimated  volume.  The  naso-occipital  arc  likewise 
increases  at  about  the  same  general  rate  as  the  great  cir- 
cumference. In  comparing  the  naso-occipital  arc  with 
the  great  circumference,  there  is  an  increasing  difference 
as  the  children  grew  older.  Thus,  the  difference  under 
one  week  is  12.39  ctm.,  while  at  two  years  it  is  14.58 
ctm.  The  naso-bregmatic  and  bregmato-lambdoid  arcs 
are  very  similar  in  the  series,  but  after  seven  months  the 
former  arc  becomes  slightly  larger  from  the  development 
of  the  frontal  part  of  the  brain.  Although  no  intellect- 
ual growth  can  be  said  to  take  place  under  two  years, 
there  is  an  active  evolution  of  the  front  of  the  brain,  with 
increase  of  the  perceptions.  The  binauricular  arcs 
through  the  bregma  and  lambda  are  quite  similar,  the 
average  of  the  eight  cases  between  nine  and  ten  months 
being  identical.  The  size  of  the  anterior  fontanelle,  as 
shown  by  the  antero-posterior  and  lateral  diameters, 
varies  according  to  the  development  of  the  infant. 
Where  the  fontanelle  remains  widely  open  with  the  in- 
creased age  of  the  infant,  there  will  always  be  marked 
symptoms  of  rickets  elsewhere.  Thus,  in  Case  49,  a  boy, 
aged  ten  months,  with  both  diameters  5  ctm.,  die  con- 
figuration shows  a  markedly  rickety  head,  and  the  notes 
give  other  symptoms  of  the  disease.  By  eighteen  months 
the  fontanelles  were  all  closed. 

The  cephalic  indices  showed  the  cases  to  be  divided  as 
follows:  Under  one  week,  mesocephalic ;  from  one 
week  to  one  month,  dolicocephalic ;  from  one  to  three 
months,  mesocephalic;  at  three  and  four  months, 
dolicocephalic;  five  and  six  months,  dolicocephalic; 
seven  and  eight  months,  brachycephalic ;  nine  and  ten 
months,  dolicocephalic;  eleven  and  twelve  months, 
brachycephalic ;  from  twelve  to  eighteen  months,  doli- 


or  above  90  could  be  considered  abnormal.  In  a  few 
individual  cases,  however,  the  head  was  abnormal.  Thus, 
a  Polish  infant  of  eight  months  gave  a  cephalic  index  of 
||  =  92.30.  The  fecial  length  increased  slowly,  as  would 
be  expected  from  the  absence  of  teeth,  except  in  the  older 
infants. 

A  study  of  the  configuration  shows  slight  asymmetry 
in  all  the  cases,  but  only  in  a  few  instancrs  is  it  well 

marked.  It  is  interesting 
to  note  that  the  posterior 
transverse  diameters  of  the 
configurations  are  nearly  al- 
ways greater  than  the  ante- 
rior diameters.  This  would 
be  expected,  as  the  sensori- 
motor parts  of  the  brain  are 
more  developed  in  infancy 
than  the  other  areas.  I  re- 
gret that  horizontal  config- 
urations were  not  taken  high- 
er up,  through  the  parietal 
bosses,  as  I  believe  the  con- 
trast would  have  been  greater. 
Through  the  courtesy  of  Dr. 
Peterson  I  have  made  configurations  upon  two  fetal 
skulls  in  his  possession,  one  between  three  and  four 
months,  and  the  other  at  seven  months.  The  first 
shows  an  oval,  undeveloped  brain,  and  the  second  ex- 


Fig.  a.— Fetal  SlraQ.  between  Three 
and  Four  Months. 


Fig.  3.— Fetal  Skull,  Seven  Months,  showing  the 
forcing:  out  of  the  Parietal  Bosses  by  the  Develop- 
ment of  the  Sensori-motor  Area  of  Brain. 

hibits  the  forcing  out  of  the  parietal  bosses  by  the  rapid 
evolution  of  the  sensori-motor  area  of  the  brain,  while 
the  front  of  the  skull  appears  stationary,  from  the  size  of 
the  configuration.  , 


November  24,  1894] 


MEDICAL  RECORD. 


651 


The  circumference  of  the  chest  is  several  centimetres 
larger,  on  an  average,  than  that  of  the  abdomen.  There 
would  probably  be  a  greater  difference  were  it  not  that 
so  many  of  the  cases  presented  evidences  of  rickets.  In- 
deed, I  have  come  to  look  upon  a  disproportion  of  the 
measurements  of  the  chest  and  abdomen  as  a  handy  way 
of  recognizing  rickets.  In  some  cases  the  circumference 
of  the  abdomen  was  greater  than  that  of  the  chest,  and 
then  the  other  evidences  of  rickets  were  equally  well- 
marked.  Thus,  in  one  case,  the  chest  was  23  ctm.  and 
abdomen  29  ctm. ;  in  another,  chest  38  ctm.  and  abdo- 
men 38.5  ctm.,  with  bony  changes  severe.  An  acute 
digestive  fermentation  will  not  produce  the  enlargement 
of  the  abdomen  that  is  seen  in  the  chronic  flatulent  dis- 
tention of  rickets.  Hence  the  ratio  between  the  cir- 
cumference of  the  abdomen  and  chest  is  not  only  a  sign, 
but,  to  a  certain  extent,  a  measure  of  the  degree  of  rick- 
ets. The  length  of  the  body  increased  steadily  in  all  the 
cases  measured.  The  breast-fed  babies  invariably  pre- 
sented larger  measurements  than  those  artificially  fed. 

The  sketch  of  the  skull  seen  upon  the  chart  was  de- 
signed by  Dr.  C.  L.  Dana,  and  I  am  indebted  to  him  for 
its  use. 


AN  ACCOUNT  OF  THE  LATE    EPIDEMIC    OF 
TYPHOID  FEVER  IN  MONTCLAIR,  N.  J. 

By  THOMAS  HORTON,  Sanitary  Engineer, 


MONTCLAIR  1  N.  J. 


During  August  of  this  year  there  appeared  in  Montclair 
a  small  epidemic  of  typhoid  fever  numbering  in  all  nine- 
teen cases,  resulting  in  one  death.  Its  close  succession  to 
the  more  severe  epidemic  in  the  early  spring  caused  a 
natural  anxiety  in  the  town,  and  placed  the  Board  of 
Health  in  a  responsible  position.  As  agent  and  inspec- 
tor of  such  board  much  of  the  work  was  left  to  me,  and 
an  outline  of  the  epidemic  and  the  efforts  of  the  Board  of 
Health  in  dealing  with  it  is  briefly  as  follows : 

About  July  20th  there  appeared  simultaneously  in  the 
town  two  cases  of  typhoid  fever,  one  in  a  hotel  and  the 
other  in  a  French  bakery  and  ice-cream  saloon  situated 
about  half  a  mile  from  the  hotel  Little  attention  was 
given  these  cases  beyond  the  ordinary  precautions  of  the 
attending  physician  until  about  August  1st,  when  the 
appearance  of  two  new  cases,  one  in  each  of  the  above 
buildings,  caused  a  slight  suspicion  of  an  outbreak.  All 
the  cases  were  removed  to  the  hospital,  and  on  the  devel- 
opment of  five  more  cases  by  August  4th,  a  systematic 
investigation  was  begun  to  discover  the  course  of  the 
epidemic 

I  visited  the  house  of  every  case,  made  an  inspection 
of  the  premises,  left  instructions  to  be  observed  in  the 
care  of  the  patients,  and  filled  out  a  blank  form  to  aid  in 
discovering  any  common  source  of  infection  which 
might  exist  In  each  instance  the  water,  milk,  and  ice- 
cream supply  was  investigated,  and  the  date  of  sickness  and 
the  occupation  and  place  of  business  of  the  patient  ob- 
tained. Of  the  nine  cases  thus  far  developed,  nothing  was 
found  in  common  but  the  public  water-supply  and  the  use 
of  a  few  of  the  old  wells  which  are  so  numerous  in  the 
town,  and  which,  in  many  instances,  I  knew  to  be  badly 
polluted.  At  this  time  I  hardly  suspected  the  wells  because 
three  or  four  would  have  been  involved,  and  I  thought  it 
very  improbable  for  so  many  wells  to  be  infected  at  once, 
and,  besides,  two  patients  claimed  not  to  have  used  well- 
water  at  all.  We  made,  however,  an  investigation  of 
the  public  water*  supply,  which  is  a  mixture  derived  from 
driven  wells  and  the  Newark  aqueduct.  There  was  prac- 
tically no  typhoid  in  Newark  and  other  places  supplied 
by  the  aqueduct,  at  the  time,  so  that  only  the  well- water 
was  examined.  Samples  taken  from  the  driven  wells  and 
suspicious,  large  crevices  in  the  pump-wells,  showed  the 
water  to  be  of  high  organic  purity  and  that  the  typhoid 
had  presumedly  no  connection  with  it. 

Being  confident  of  the  purity  of  the  milk  and  public 
water-supplies,  I  again  turned  my  attention  to  the  wells  and 


the  possibility  of  secondary  infection.  On  closer  investi- 
gation I  discovered  that,  in  the  case  of  the  hotel,  the  first 
patient  was  a  transient  guest  who  had  arrived  only  two 
weeks  before  developing  the  disease.  Two  weeks  is 
barely  within  the  "  incubation  period  "  for  typhoid  fever, 
and  the  assumption  is  more  strongly  in  favor  of  this  being 
an  imported  case  than  that  infection  took  place  almost 
immediately  on  arriving  in  Montclair.  Continuing  on 
this  assumption,  I  discovered  further  that  great  carelessness 
had  been  practised,  in  the  care  of  the  patients  before  the 
attending  physician  had  been  called,  and  that  the  four 
cases  which  developed  later  in  the  hotel  were  either  in 
the  direct  family  of  the  first  patient,  or  among  those  who 
had  acted  at  times  as  nurses.  This  information,  added 
to  the  fact  that  the  cases  developed  in  successive  inter- 
vals during  three  weeks,  seemed  to  justify  my  opinion  that 
these  cases  spread  through  secondary  infection,  being 
transferred  from  one  to  the  other  through  some  of  the 
many  conceivable  ways  where  careless  habits  and  igno- 
rance prevail.  In  fact  these  cases  may  be  considered  a 
small  epidemic  in  itself,  being  situated  away  from,  and 
having  no  connection  with,  the  other  typhoid  cases  in  the 
town. 

The  other  portion  of  the  epidemic,  numbering  four- 
teen cases,  was  confined  almost  wholly  to  the  locality  of 
the  bakery,  and  I  am  inclined  to  believe  originated  in 
much  the  same  manner,  being  infected  in  some  way 
from  an  old  case  in  the  building  a  month  previous.  On 
inspection  the  bakery  was  found  to  be  a  filthy  place,  kept 
by  filthy  people.  The  cellar,  from  leakage  and  want  of 
proper  drainage,  was  little  more  than  a  mire,  and  was 
dark  and  mouldy.  Old  cloth  sacks,  bottles,  and  ice- 
cream cans  were  piled  promiscuously  on  the  floor,  and 
the  ice  was  delivered  through  small  windows  on  to  a 
wooden  grating,  or  into  the  mud,  as  chance  happened. 
On  learning  that  the  ice-cream  was  made  in  this  cellar, 
and  further,  that  those  who  made  the  ice  cream  and 
worked  in  the  bakery  had  helped  in  the  care  of  the  first 
patient,  I  saw  the  dangers  which  might  possibly  follow. 
Moreover,  by  this  time  another  case  had  already  devel- 
oped in  the  house,  and  if,  as  it  appeared,  the  case  was 
secondarily  infected  from  the  one  a  week  previous,  there 
was  a  great  possibility  that  the  ice-cream  might  be  in- 
fected also  and  the  disease  spread  very  rapidly. 

I  had  the  bakery  immediately  closed,  and  to  leave  no 
stone  unturned  I  began  an  analysis  of  the  suspicious 
wells  in  this  vicinity.  The  worst  two  wells  I  had  closed 
— one  of  which  was  used  by  the  bakery,  and,  as  was  soon 
seen,  by  most  of  those  who  developed  typhoid  later. 
That  this  well  was  infected  at  the  time  of  die  outbreak 
I  very  much  doubt,  or  else  the  remaining  cases  would 
have  developed  earlier.  That  it  could  have  been  in- 
fected by  the  people  in  the  bakery  is  very  possible,  for 
the  germs  may  have  been  washed  from  infected  hands  or 
utensils  on  to  the  floor  of  the  well,  or  into  a  wooden 
catch-basin  connecting  with  the  pump,  and  from  thence 
sipe  through  into  the  well. 

At  all  events  ten  cases  developed  within  the  two  weeks 
following  the  closing  of  this  well  and  the  bakery,  and,  of 
these,  eight  had  used  the  ice-cream  and  milk  from  the 
bakery,  and  seven  had  used  this  one  well.  Whether 
both  these  influences  acted  together,  or  whether  the  use 
of  the  well  was  merely  incidental  from  its  public  loca- 
tion, can  hardly  be  settled.  But  since  all  these  cases 
developed  within  the  following  two  weeks  and  a  half,  or 
within  the  "incubation  period,"  there  seems  the  strong- 
est evidence  that  they  originated  from  one  or  both  of  the 
above  sources,  and  that  by  cutting  off  these  sources  of  in- 
fection we  prevented  a  further  spread  of  the  epidemic. 

After  this  epidemic  no  case  of  typhoid  fever  appeared 
in  Montclair  for  over  two  months  and  a  half. 


Cremation  in  England  makes  slow  progress.  A  crema- 
tory recently  erected  in  Liverpool  is  only  the  third  in 
the  country,  the  other  two  being  at  Woking  and  Man- 
chester. 


652 


MEDICAL  RECORD. 


[November  24,  1894 


BERIBERI  ON  THE  BARK  ROBERT  S.  PATTER- 
SON  AT  PERTH  AMBOY,  N.  J. 

By  ALBERT  S.  ASHMEAD,  M.D., 

NBW  YORK. 

The  bark  Robert  S.  Patterson,  of  a  gross  tonnage  of 
seven  hundred  and  fifty  eight  tons.  Captain  Henry  L. 
Burton,  thirteen  days  from  Navassa,  West  Indies,  arrived 
at  Perth  Am  boy  on  November  10th,  with  a  European  crew, 
all  in  good  health,  and  seventy  surviving  negro  passengers, 
the  whole  number  of  these  colored  people  having  been  at 
the  outset  seventy -five;  the  wanting  five  had  died  of 
some  distemper  during  the  passage.  .     . 

In  company  with  Health  Officer  Dr.  Ramsey  and  Mr. 
Tsuchiya,  of  Japan,  I  visited  the  ship  and  found  that  ten 
of  the  seventy  survivors  lay  sick  in  the  hold.  One  lay 
dead,  having  died  after  reaching  port;  across  his  chest 
lay  another  dying ;  two  others  whom  I  examined  were  also 
dying ;  seven  others  were  in  various  stages  of  the  same  dis- 
temper. I  examined  them  all,  and  found  that  the  distem- 
per was  beriberi.  One  of  the  ten  sick  men  had  acute 
pernicious,  four  of  them  moist,  and  five,  dry  beriberi. 
These  seventy  five  men,  who  had  worked  in  the  phosphate 
quarries  at  Navassa,  had  been  shipped  by  the  company, 
in  a  space  less  than  five  feet  high,  thirty  feet  wide,  and 
fifty  feet  long.  This  space  had  no  portholes.  Two 
hatchways,  each  four  feet  square,  were  the  only  ventila- 
tion. The  hatchways  had  no  sail,  nor  pipe  appliances 
for  ventilation.  A  considerable  part  of  the  space  was 
taken  up  by  straw  mattresses,  baggage,  ship  stores,  and  a 
largequantity  of  red  phosphatic  earth,  the  cargo  of  the  ship. 

It  appears  that  in  a  space  of  less  than  seven  thousand 
five  hundred  cubic  feet  seventy-five  men,  at  any  rate 
seventy  men,  lived  for  thirteen  days  and  thirteen  nights, 
with  the  least  possible  ventilation,  with  four  lanterns 
consuming  part  of  the  oxygen  necessary  for  life,  with 
all  the  foulness  engendered  by  breathing,  defecation, 
and  urination;  these  seventy-five  men  being  poorly 
clad,  and  coming  from  many  hardships  suffered  in  a 
tropical  dime,  who  were  so  apathetic  that  nothing  could 
have  induced  them  to  go  on  deck  for  fresh  air,  or  for  any 
care  of  health  or  cleanliness. 

The  crew  was  composed  of  eleven  Europeans,  none  of 
whom  was,  or  had  been  sick ;  they  occupied  a  part  of 
the  ship  which  was  thoroughly  ventilated. 

I  am  informed  by  a  leading  manufacturing  company 
of  this  city  that  phosphatic  earth,  at  which  these 
negro  passengers  had  been  employed,  and  which  com- 
posed the  ship's  cargo,  is  made  up  of  sixty  per  cent  of 
bone  phosphate  of  lime,  silica,  alumina,  and  iron,  and  is 
a  natural  fertilizer. 

Here  is  another  instance  to  strengthen  the  theory 
which  I  have  so  often  maintained  and  illustrated  by  a 
great  variety  of  facts :  charcoal  fumes  in  Japan,  carbo- 
nized unripe  coffee  cargoes  from  Java  (the  immature  cof- 
fee is  more  liable  to  fermentation),  fermenting  sugar  and 
grain  cargoes,  overcrowding  in  hospitals  (Richmond  In- 
sane Asylum,  Dublin),  disintegrating  graphite  (pure  car- 
bon) cargoes  from  Ceylon,  etc. 

It  was  evidently  in  this  case,  too,  carbonic  poison  that 
was  the  cause  of  the  outbreak.  It  could  not  have  been 
the  diet.  Even  if  this  had  been  much  worse  than  it 
seems  to  have  been  they  could  have  borne  it  for  thirteen 
days.  The  disease  broke  out  five  days  after  leaving  port, 
that  is  at  a  time  when  carbonic  poison  could  have  pro- 
duced its  effect  while  the  diet  could  not. 

I  do  not  even  admit  the  joint  operation  of  carbonic 
poisoning  and  insufficient  diet  to  produce  the  outbreak 
on  the  Robert  S.  Patterson.  In  corroboration  of  this 
opinion  of  mine,  I  quote  Dr.  J.  A.  Wetherill,1  speaking 
of  the  outbreak  at  the  Richmond  Asylum,  Dublin. 

"  Whilst  medical  officer  at  Wyndham,  East  Kimber- 
ley,  Western  Australia,  I  had  under  my  care  sixty  ab- 
original native  prisoners.  These  were  chained  up  at 
night  in  a  galvanized  iron  one  roomed  building  30  by  14 
by  12  feet.    The  only  ventilation  was  by  means  of  four 

1  British  Medical  Journal,  October  27, 1894. 


small  barred  open  windows.  The  floor  was  of  jarrah- 
wood.  Two  iron  buckets  were  allotted  to  every  three  ox 
four  men— one  into  which  the  excreta  were  passed,  the 
other  containing  drinking-water.  The  jail  was  built  on 
piles  on  the  edge  of  a  marsh  not  twenty  yards  from  the 
water  of  Cambridge  Gulf.  The  external  night  tempera- 
ture was  never  below  750  F.,  and  frequently  up  to  900 
F.  During  the  day  they  had  as  food,  per  man,  one 
pound  of  bread,  three  fourths  pound  of  meat,  generally 
salted,  one-hali  pound  of  rice,  with  three  pints  of  sweet- 
ened tea  without  milk.  Occasionally  broth  was  served 
and  the  rice  was  supposed  to  act  as  a  substitute  for  fruit 
and  vegetables,  which  were  not  procurable.  It  must  be 
remembered  that  the  natives  had  been  accustomed  to 
roam  unclothed,  wild  in  the  bush,  free  and  unrestrained, 
living  on  kangaroo,  iguana,  honey,  fish,  roots,  barks,  etc, 
sleeping  on  the  ground  with  nothing  but  the  canopy  of 
heaven  as  a  roof. 

"  Under  these  conditions  a  number  of  them — I  regret 
I  did  not  retain  the  details— developed  beriberi ;  the  prin- 
cipal feature  of  which  was  the  extensive  oedema,  and  lia- 
bility to  sudden  death  apparently  from  syncope. 

"  The  white  inhabitants  of  the  town,  none  of  whom 
were  affected,  called  the  disease  scurvy,  but  scorbutus  it 
was  not,  for  there  were  none  of  the  classical  symptoms 
of  that  disease,  such  as  hemorrhage  into  joints,  from  the 
gums,  etc.,  nor  would  it  prove  amenable  to  the  adminis- 
tration of  citrate  of  potash,  vinegar,  onions,  etc.  Beri- 
beri could  not  have  been  introduced  among  the  niggers 
from  without,  for  there  was  no  one  either  entering  or 
leaving  the  place,  a  steamer  calling  but  once  every  two 
months.  It  must,  therefore,  have  had  a  de  novo  origin, 
and  is,  so  far  as  I  know,  the  first  time  beriberi  has  ever 
been  seen  in  the  aboriginal  natives  of  Australia. 

"  From  what  I  have  read  of  the  epidemic  in  the  Rich- 
mond Lunatic  Asylum,  Dublin,  and  judging  from  my 
experience  abroad,  I  should  undoubtedly  say  the  disease 
in  the  asylum  is  beriberi." 

In  the  case  of  the  Robert  S.  Patterson  the  poison- 
ing was  not  the  result  of  the  fermentation  of  the 
cargo,  as  I  have  no  doubt  it  was  in  several  former 
inafmiNi  studied  by  me.  The  overcrowding  caused 
the  presence  of  an  excess  of  carbonic  gases,  the  cargo 
had  nothing  to  do  with  it.  This  is  the  conclusion 
which  I  draw  from  what  President  John  H.  Fowler 
of  the  Navassa  Phosphate  Company  of  Baltimore  writes 
me:  "There  have  never  been  landed  at  Baltimore 
(whither  most  of  the  phosphate  is  shipped),  coining 
from  Navassa  Island,  any  cases  of  sickness  similar  to 
those  on  the  Robert  S.  Patterson.  In  regard  to  the  sub* 
stance  contained  in  the  cargoes  from  Navassa,  we  sell 
our  phosphates  on  the  basis  of  the  contents  of  bone  phos- 
phate of  lime,  and  therefore  do  not  have  full  analyses 
made  of  the  different  lots  as  received.  We,  however,  find 
upon  referring  back  to  our  books  that  in  1891  one  of  the 
cargoes  sent  abroad  contained  3. 98  per  cent,  of  carbonic 
acid  out  of  one  hundred  component  parts." 

I  have  had  a  sample  of  this  phosphate  analyzed ;  there 
were  found  only  three  to  four  per  cent,  of  carbonates. 

Dr.  Daland  asks  me  "  What  was  the  condition  of  the 
pork  eaten  by  the  beriberi  cases  that  landed  at  Perth  Am- 
boy  ?    Was  there  any  evidence  of  decomposition  ? ' ' 

It  is  Dr.  Daland's  opinion  that  pork,  in  a  decaying 
condition,  is  a  cause  of  beriberi,  he  having  examined  a 
ship  in  Philadelphia,  the  Lanark,  on  which  a  beriberi 
outbreak  had  taken  place,  attributed  the  disease,  not  to 
the  carbonic  cargo,  5,000  tons  of  sugar,  but  to  the  pork. 
Strange  to  say,  all  these  cases  were  Mohammedans,  who, 
as  everyone  knows,  abstain  from  pork.  In  answer  to 
Dr.  Daland,  I  have  to  state  that  if  the  pork  on  the  Rob- 
ert S.  Patterson  was  bad,  it  was  eaten  as  well  by  the 
European  crew,  who  escaped  the  disease,  as  by  the 
negroes  who  caught  it.  I  have  said  in  the  above 
article  that  this  European  crew  slept  in  a  well-ventilated 
room.  Why,  should  I  ask  Dr.  Daland,  again,  have  they 
so  much  beriberi  or  kakke  in  Japan,  where  no  pork  is 
eaten  at  all  ? 


November  24,  1894] 


MEDICAL   RECORD. 


653 


That  diet  has  very  little,  if  anything  to  do  with  this 
matter,  is  sufficiently  shown  by  WetheriU's  cases,  which  I 
have  already  quoted.  His  prisoners  were  very  well  fed, 
and  yet  contracted  the  disease  from  being  confined  in 
insufficient  space. 

As  to  the  surprise  which  has  been  expressed  at  finding- 
that  beans  were  the  principal  article  of  diet  of  these  Navassa 
negroes,  when  Dr.  Simmons  (as  well  as  every  other  doc- 
tor in  Japan)  avers  that  the  Japanese  bean  (adzuki, 
phaseolus  radiatus),  is  the  very  nutriment  to  give  to  beri- 
beri patients,  I  call  attention  to  the  fact,  that  the  Japan- 
ese bean  is  used  in  this  case  simply  as  a  diuretic,  it  hav- 
ing extremely  powerful  diuretic  virtues. 


grogttess  at  fPsflical  Jfocteuce. 

The  Signs  of  Heart  Failure  in  Fevers.  —  M.  Hu- 
chard  has  made  an  important  statement  to  the  Societe 
Medicale  des  Hdpitaux  regarding  the  signs  of  heart  fail- 
ure, which,  he  thinks,  should  not  be  limited  exclusively 
to  the  determination  of  the  weakening  or  the  disappear- 
ance of  the  first  sound.  There  are,  beside  this  weaken- 
ing, two  other  symptoms  which  he  has  observed ;  these 
he  has  named  the  embryocardiac  and  the  bradydiastoliac, 
or  prolongation  of  the  cardiac  diastole  (The  Sanitarian). 
This  last  symptom  was  studied  some  time  previously  by 
M.  Huchard  as  a  new  prognostic  symptom  in  diseases  of 
the  heart.  He  insists  upon  these  facts,  and  advances 
proofs  to  support  their  correctness,  and  to  show  that 
there  are  often  great  errors  committed  in  the  diagnosis 
of  acute  myocarditis  in  fevers,  and  especially  in  typhoid 
fever.  In  this  disease  the  autopsies  he  has  made  have 
proved  to  him  satisfactorily  that  often,  in  very  grave 
symptoms  of  heart  trouble,  there  were  hardly  any  ap- 
preciable lesions  of  the  muscular  constituents  of  the 
heart,  and  reciprocally.  On  the  other  hand,  there  may 
often  appear  in  cardiac  sclerosis  considerable  myocardiac 
lesions,  and  that  even  while  life  may  last  for  a  great 
length  of  time.  In  emphasizing  these  conditions,  the 
results  of  his  personal  observations  and  of  the  previous 
observations  of  Bernheim,  of  Nancy,  in  1882,  he  has 
shown  that  many  of  the  symptoms  attributed  to  myocar- 
ditis of  typhoid  fever  must  be  referred  to  the  effect  of 
functional  disturbance,  or  to  lesions  of  the  cardiac  ner- 
vous system.  In  all  these  cases  it  is  certain  that  the 
symptoms  of  myocarditis  of  infectious  conditions,  ad- 
mitted by  the  greater  number  of  authors,  do  not  exactly 
reproduce  those  which  he  has  studied  since  1870,  with 
Desnos,  in  cases  of  variola.  This  latter  disease  may 
produce  myocarditis ;  typhoid  fever  causes  myocarditis 
with  cardiac  nervous  troubles,  which  exert  a  preponder- 
ating influence,  and  the  grippe,  which  resembles  typhoid 
in  this  respect,  as  determining  myocarditis,  but  causes 
other  disturbances  of  cardiac  innervation  which  he 
studied  four  years  ago,1  long  before  Sampson,  of  Lon- 
don, who  has  made  a  report  on  the  subject  to  die  Medi- 
cal Society  of  that  city.  These  researches  and  these  con- 
siderations have  a  great  practical  importance ;  they  show 
clearly  that  the  poison  of  typhoid  acts  on  the  heart  like 
digitalis ;  this  agent  should  not  be  employed  indiscrimi- 
nately in  the  treatment  of  a  case  of  typhoid  fever  com- 
plicated with  cardiac  symptoms.  Injections  of  caffeine, 
of  ergotine,  and  even  cold  baths,  should  be  employed  in 
preference. 

M.  Hayem  described,  in  1886,  symptomatic  myolitis, 
after  having  examined  the  hearts  of  a  great  number  of 
patients  who  had  died  from  varioloid  and  from  typhoid 
fever.  He  attributed  the  alterations  of  the  muscles  to 
changes  in  the  blood  and  in  the  blood-vessels.  Myocar- 
ditis is  much  more  marked  in  typhoid  fever  than  in  vari- 
ola, which  is  contrary  to  the  statement  of  M.  Huchard. 
Sometimes  even  a  vitreous  degeneration  of  the  muscular 
fibres  is  found  in  typhoid,  a  condition  which  does  not 

1  Soc  Med.  des  H6piL,  1890,  et  BuL  Med,  1892. 


exist  in  variola.  It  is  difficult  to  attribute  death  to 
alterations  of  the  muscular  fibres,  for  it  seems  due  rather 
to  a  toxhsemic  condition,  the  effects  of  which  are  di- 
rected as  much  to  the  vessels  as  to  the  muscles  and  the 
nerves  of  the  heart  and  other  organs.  M.  Siredey  has 
also  found  that  myocarditis  was  more  frequent  in  typhoid 
fever  than  in  variola.  In  typhoid,  the  changes  in  the 
heart  are  often  limited  to  the  arteries.  M.  Huchard  has, 
on  the  contrary,  always  observed  that  the  fibres  in  myo- 
carditis were  much  more  deeply  changed  in  variola  than 
in  typhoid.  The  following  consideration  goes  to  prove 
that  in  typhoid  the  nervous  element  should  be  added  to 
the  myelitic  In  proportion  as  sudden  deaths  are  rela- 
tively frequent  in  the  cardiac  complications  of  typhoid 
fever,  they  are  rare  in  variola.  If  the  cause  of  death  is 
of  equal  force  in  the  two  affections,  why  are  the  results 
so  different? 

Milk  Diet  and  Mioro-Organisms  in  the  Alimentary 
Tract. — In  the  Dietetic  Gazette  are  given  the  results  of 
some  recently  published  work  by  MM.  Gilbert  and 
Dominici  (Action  du  regime  lactfe  sur  le  microbisme  du 
tube  digestif,  Comptes  Rendus  de  la  Socifetfe  de  Biologie) 
on  the  number  of  bacteria  in  the  alimentary  tract  after 
the  ingestion  of  milk.  A  milk  diet  exercises  a  remark- 
able influence  on  the  number  of  bacteria  present  in  the 
faeces  of  man  and  of  animals.  A  healthy  adult  man  sub- 
mitted for  five  days  to  a  diet  consisting  in  part  of  2.5 
litres  of  milk  daily.  The  faeces  after  ordinary  food  con- 
tained 67,000  bacteria  per  milligramme.  At  the  end  of 
two  days  under  this  new  diet  they  contained  only  14,000 
bacteria ;  at  the  end  of  three  days,  5,000 ;  after  four  days, 
4,000;  after  five  days,  2,250.  The  weight  of  the  faecal 
matter,  which  ordinarily  amounted  to  175  gm.  per  day 
in  this  individual,  was  reduced  to  73  gm. ;  accordingly 
the  number  of  bacteria  daily  excreted  by  way  of  the 
rectum  was  reduced  from  11,725,000,000  to  164,250,- 
000,  /.*.,  the  milk  diet  thus  had  the  effect  of  reduc- 
ing the  bacteria  of  the  faeces  to  one  seventy-first  of  the 
normal  number. 

The  above  results  were  obtained  after  the  use  of  non- 
sterilized  milk.  In  the  case  of  a  patient  suffering  from 
ulcer  of  the  stomach,  who  had  been  nourished  on  an  ex- 
clusive milk  diet  for  twenty  days  and  had  received  noth- 
ing but  sterilized  milk  for  ten  days,  3,000  bacteria  per 
milligramme  were  found  in  the  faeces.  This  number  is  in 
close  agreement  with  the  lowest  figure  previously  recorded. 
Similar  modifications  were  produced  in  the  faeces  of  the 
dog  by  a  diet  of  sterilized  milk,  the  number  of  bacteria 
decreasing  from  25,000  or  21,000  to  1,000  or  500.  In 
rabbits,  non-sterilized  milk  caused  an  increase  in  the  rel- 
ative number  of -bacteria  and  a  decrease  in  the  absolute 
number.  Two  animals  whose  faeces  normally  contained 
thirty- five  and  forty-eight  bacteria  per  milligramme  were 
fed  for  twenty  days  on  non-sterilized  milk — one  litre  daily 
— containing  1 25  to  150  bacteria  per  milligramme.  From 
thirty  five,  the  number  of  bacteria  increased  to  fifty  seven, 
and  from  forty- eight  to  eighty-nine.  Before  the  feeding 
of  milk,  the  daily  quantity  of  faeces  was,  in  the  case  of 
the  first  animal,  175  gm. ;  in  the  second,  in  gm. ; 
the  total  number  of  bacteria,  6,125,000  and  5,328,000 
respectively.  Since  the  milk  diet  reduced  the  daily 
amount  of  faeces  to  5  gm.,  it  is  evident  that  the  to- 
tal number  of  bacteria  was  diminished  to  285,000  and 
445,000.  Sterilized  milk,  however,  decreased  both  the 
relative  and  the  absolute  number  of  bacteria.  After  being 
submitted  to  a  diet  of  non  sterilized  milk  for  twenty  days, 
the  two  rabbits  above  referred  to  were  nourished  upon 
sterilized  milk.  From  fifty- seven  and  eighty-nine,  re- 
spectively, the  number  of  bacteria  in  the  faeces  fell  to 
seven  and  ten  per  milligramme.  The  total  per  day  thus  fell 
to  35,000  and  50,000,  or  one  one-hundred- and-seventy- 
fifth  and  one  one-hundred-and  sixth  of  the  normal  num- 
ber. In  the  case  of  man,  the  dog,  and  the  rabbit,  the 
absence  of  those  species  of  bacteria  which  liquefy  gelatine, 
and  of  moulds  was  noted  during  milk  diet. 

Milk  diet  exercises  its  peculiar  action  not  only  on  the 


654 


MEDICAL    RECORD. 


[November  24,  1894 


faeces,  but  on  the  entire  gastro-intestinal  contents,  putting 
the  alimentary  canal  in  a  condition  of  partial  asepsis. 
This  does  not  result  from  any  antiseptic  power  of  the 
milk,  since,  as  is  well  known,  it  forms  a  good  nutrient 
medium  for  many  species  of  micro-organisms  and  the  coli 
bacillus  readily  grows  in  it.  The  true  explanation  is, 
perhaps,  rather  to  be  found  in  the  character  of  the 
changes  which  milk  undergoes  in  the  digestive  tract  It 
is  readily  attacked  by  the  digestive  ferments,  the  products 
formed  are  readily  absorbed  and  but  a  small  residue  re- 
mains, consisting  of  nuclein.  In  this  connection  it  is  to 
be  remembered  that  Dr.  Vaughan  has  lately  called  at- 
tention to  the  germicidal  action  of  the  nucleins  outside* 
of  the  body.  The  failure  of  bacteria  to  multiply  in  the 
intestinal  canal  during  milk  diet  may  then  be  due  to  the 
lack  of  nutrient  materials  suitable  for  their  development, 
and,  further,  to  the  antiseptic  action  of  any  nuclein  pres- 
ent. From  a  dietetic  standpoint,  the  value  of  milk  as  an 
accessory  food,  at  least,  is  apparent  in  certain  gastric 
disorders  attended  with  the  growth  of  micro-organisms, 
in  acute  or  chronic  enteritis  accompanied  by  diarrhoea,  in 
typhoid  fever,  dysentery,  and  a  large  number  of  diseases  in 
which  the  toxic  products  of  intestinal  putrefaction  are  the 
ultimate  causes  of  the  particular  symptoms  manifested. 

Apooynum  Cannabinum  in  Heart  Disease.— Dr.  Glin- 
ski  after  having  proved  by  experiments  on  cold-blooded 
and  warm-blooded  animals  that  the  root  of  the  apocy- 
num  cannabinum  contains  a  strong  poison  which  in 
large  doses  paralyzes  die  heart,  and  when  given  in  small 
quantities  retards  and  strengthens  its  beats,  decided  to 
take  it  himself,  as  he  is  suffering  from  hypertrophy  of  the 
left  ventricle,  with  intercurrent  attacks  of  dilatation  of 
the  organ,  mitral  murmur,  dyspnoea,  etc.  {The  British 
Medical  Journal.)  The  dose  was  fifteen  drops  of  the 
fluid  extract  three  times  a  day.  As  he  found  that  all  his 
symptoms  disappeared  in  two  days,  he  gave  it  also  to 
other  patients  in  the  same  quantity  in  cases  of  palpita- 
tion, disturbed  compensation,  in  which  strophantus, 
and  adonis  vernalis  had  failed  and  digitalis  seemed  con- 
traindicated.  He  gives  a.  full  account  of  some  of  his 
cases,  and  summarizes  his  experience  in  the  following 
conclusions :  1.  The  action  of  the  root  of  apocynum 
cannabinum  is  similar  to  that  of  digitalis,  without  being 
cumulative.  2.  In  cases  of  dilatation  the  fluid  extract 
rapidly  diminishes  the  area  of  dulness.  3.  It  increases 
the  daily  amount  of  urine,  stops  the  palpitation,  and  pro- 
motes the  absorption  of  transudations.  4.  With  the  ex- 
ception of  increased  pulsation  of  the  arteries  of  the  head, 
it  has  no  bad  secondary  effects.  It  was  used  either  in 
the  form  of  a  decoction  (  3  j.  to  5  viij  ),  3  to  4  table- 
spoonfuls  a  day,  or  tincture  (1  in  10),  5.  to  10  TTl,  three 
to  four  times  daily,  or  fluid  extract  in  doses  of  xo  TTl  to 
half  a  teaspoonful  three  times  daily. 

A  Rare  Tumor  of  the  Parotid  Gland.— -Dr.  SchUller,  of 
Berlin,  reports  the  following  interesting  case  in  the 
Arztlicher  Prahtiker,  No.  3a,  1894.  A  lady,  twenty- 
three  years  of  age,  had  a  hard  swelling  in  the  region  of 
the  right  parotid  gland.  As  she  said,  there  had  been  re- 
moved, nine  years  previous,  a  glandular  swelling  at  the 
same  place.  The  new  swelling  had  first  developed  rather 
slowly,  and  only  later  had  it  grown  rapidly.  When  she 
came  to  Dr.  SchUller,  March  30,  1894,  the  tumor  was  the 
size  of  a  pigeon's  egg,  was  hard,  and  apparently  blended 
with  the  surrounding  tissue.  It  was  immovable  from  its 
base,  and  felt  like  a  soft  elastic  mass  imbedded  in  a  tense 
sac.  Close  to  it  and  below,  could  be  felt  a  second, 
smaller  tumor,  of  the  size  of  a  bean.  Dr.  SchUller  op- 
erated on  April  4,  1894.  He  found  the  main  tumor 
situated  between  the  origin  and  the  anterior  ascending 
ramus  of  the  sterno-cleido-mastoid,  below,  and  close  to 
the  ear.  It  was  blended  with  the  surrounding  tissue.  At 
the  base  it  appeared  to  be  a  continuation  of  the  parotid 
tissue,  where  it  could  not  be  separated  from  the  gland, 
and  entered  deeply  into  the  retro-maxillary  fossa. 

The  tumor  was  carefully  dissected  from  the  nerves,  ves- 
sels, and  muscles ;  unavoidably  a  part  of  the  parotid  had  to 


be  extirpated.  Besides  the  main  tumor  there  were  re- 
moved nine  to  ten  glands,  from  the  size  of  a  bean  to  that 
of  a  cherry.  The  main  tumor  presented  on  transverse 
section  the  appearance  of  a  dense  fibrosarcoma  sim- 
ilar to  those  found  occasionally  in  the  testicle.  The 
-microscopical  picture,  however,  was  not  that  of  a  sar- 
coma. There  was  found  an  exceedingly  dense  granulat- 
ing tissue,  rich  in  cells,  which  enclosed  centres  of  shrunken 
and  partly  fatty-degenerated  cells,  here  and  there  with 
isolated  giant  cells.  Cheesy  degeneration  was  nowhere 
present  The  granulation  tissue  is  traversed  in  some 
places  by  extraordinarily  thick-walled  blood-vessels. 
Metamorphoses  of  tissue  such  as  this  tumor  presented  are 
(according  to  Virchow)  characteristic  of  gumma  forma- 
tion. The  main  tumor  consisted  in  its  periphery,  appar- 
ently, of  a  lymphatic  gland  which  had  undergone  gumma- 
1  tory  change,  and  the  parotid  gland  itself  was  gummatory. 
The  other  glands  showed  nothing  but  hyperplasia  caused 
by  simple  chronic  inflammation.  The  process  was  evi- 
dently one  of  hereditary  syphilis. 

Treatment  of  Phthisis.— Dr.  C.  Theodore  Williams 
has  presented  in  The  Lancet  some  practical  recommen- 
dations from  thirty  years9  experience  in  the  treatment  or 
phthisis.  After  placing  sunlight  and  fresh  air  as  the 
first  and  most  essential  things  in  the  treatment  of  phthisis, 
he  adds  a  number  of  practical  recommendations  for  the 
relief  of  symptoms.  Cough,  he  says,  should  always  be 
treated  by  promoting  expectoration,  one  of  the  best 
forms  of  expectorant  being  the  effervescing  carbonate  of 
ammonia  draught  night  and  morning,  which  will  gener- 
ally clear  the  bronchial  passages  for  several  hours.  If 
there  be  a  good  deal  of  fruitless  hacking  before  expecto- 
ration, causing  annoyance  to  the  patient,  the  addition 
of  a  few  minims  of  dilute  hydrocyanic  acid  and  half  a 
drachm  of  syrup  of  poppy  or  codeia,  will  do  no  harm  and 
considerably  allay  the  reflex  irritation.  Where  the  cavi- 
ties are  large,  or  deep,  or  basic,  and  consequently  re- 
quire great  expiratory  effort  to  clear,  combinations  of  sal 
volatile  and  spirit  of  ether  with  camphor  water,  as  in  the 
form  of  the  pharmacopoeia  of  the  Brompton  Hospital, 
answer  admirably,  while  for  old  or  feeble  persons  cham- 
pagne will  often  serve  the  same  purpose.  But  the  most 
satisfactory  way  to  reduce  the  cough  of  chronic  phthisis 
is  by  counter^irritation  to  the  chest-wall — best  by  blister- 
ing. It  will  be  found  that  relief  will  follow  in  propor- 
tion to  the  amount  of  serum  drawn  by  vesication,  and 
fly- blisters  or  acetum  cantharidis,  or  the  strong  but  very 
efficient  liquor  epispasticus,  answer  the  purpose.  Night 
sweats,  when  they  are  a  mere  flux  from  the  vessels  or 
lymphatics,  and  not  a  relief  of  pyrexia!  processes,  ought 
to  be  checked,  and  this  can  generally  be  done  by  arsen- 
ate of  iron,  y&  gr.  to  yi  gr.,  at  bedtime,  or  picrotoxine, 
A  fc7-  t0  4w  &•>  or  nitrate  of  pilocarpine,  ^  gr.,  or  the 
old  fashioned  oxide  of  zinc  in  from  3-grain  to  5-gndn 
doses,  which  generally  succeed  and  do  no  harm.  Prep- 
arations of  belladonna  and  atropine,  though  they  are 
effectual  controllers  of  night  sweats,  are  less  satisfactory, 
because  their  continuance  for  a  long  period  often  induces 
dryness  of  throat  and  mouth,  dilatation  of  the  pupils,  and 
disturbance  of  sight  accommodation.  The  treatment  of 
pyrexia  depends  very  much  on  its  cause.  Where  it  ac- 
companies tuberculization  it  probably  will  subside  of  it- 
self when  the  tuberculous  process  quiesces,  and  even  if 
persistent  will  only  prevail  in  the  afternoon.  An  effer- 
vescing saline,  with  a  few  drops  of  tincture  of  aconite  or 
a  few  grains  of  quinine,  is  all  that  is  then  wanted.  But 
pyrexia  accompanying  acute  excavation,  or  acute  excava- 
tion and  tuberculization,  is  very  troublesome  and  some- 
times quite  intractable.  Antipyretics,  of  which  there 
are  any  number,  according  to  my  experience  only  give 
temporary  relief,  and  often  do  harm  by  depressing  the 
patient's  constitutional  powers  and  producing  collapse. 
I  have  seen  the  temperature  depressed  from  pyrexia  to  a 
subnormal  reading  by  doses  of  antipyrin  or  phenacetin, 
but  always  with  bad  results,  and  after  the  use  of  the  med- 
icine has  been  omitted,  the  temperature  has  risen  as  high 


November  24,  1894] 


MEDICAL   RECORD. 


655 


as  ever  before.  The  great  object  in  the  treatment  of  this 
form  of  pyrexia  is  to  keep  the  patient  quiet  in  bed  or 
lying  on  a  couch,  and,  if  possible,  in  the  open  air,  d  la 
Dettweiler ;  to  feed  him  frequently ;  and  to  supply  alctf- 
hol  to  repair  tissue  waste,  while  administering  only  suffi- 
cient antipyretics  to  keep  the  temperature  within  moder- 
ate bounds.  Quinine  in  small  doses,  in  effervescence,  be- 
fore the  rise  or  during  the  rise  of  temperature,  will  often 
suffice,  or  Henn's  well-known  pill  twice  a  day.  Anyone 
who  studies  the  phenomena  of  lever  knows  that  temper- 
ature rise  is  only  a  small  portion  of  the  process,  and  that 
by  lowering  the  chart  we  do  not  get  rid  of  the  factors  of 
heat  production  or  of  the  wear  and  tear  of  the  tissues; 
and  so  our  best  line  is  rather  to  keep  up  strength  and 
weight  by  a  frequent  supply  of  food.  The  diarrhoea 
which  accompanies  tuberculous  ulceration  may  be  checked 
by  sulphate  of  copper  and  opium,  if  the  ulcerative  process 
be  limited  in  extent ;  but  if  there  is  much  ulceration,  and 
it  is  the  ileum  and  large  intestine  which  are  involved, 
injections  are  best.  The  enema  opii  of  the  British  Phar- 
macopoeia is  excellent  under  these  conditions,  but  I  have 
seen  a  few  of  the  most  obstinate  cases  yield  to  large  in- 
jections of  linseed  tea,  which  has  a  most  soothing  influ- 
ence on  the  irritable  ulcers. 


©liutcal  §tvnvtmmt, 

VARICOSE    ULCERS    SUCCESSFULLY   TREAT- 
ED BY  A  NEW  AND  PAINLESS  METHOD.- 

By  J.    WILL  SUMMERS,   M.D., 


using  Merck's  methyl  violet,  grs.  v.,  aqua  destillata,  f  ij. 
This  forms  a  harmless  and  entirely  painless  application. 
I  would  not  hesitate  to  use  it  on  any  chronic  ulcer. 

The  bandage  has  been  worn  most  of  the  time,  and  to 
this  date  there  has  been  no  return  of  the  ulcers. 

To  put  at  ease  the  mind  of  anyone  who  may  think 
the  internal  treatment  and  bandage  are  deserving  all  the 
credit,  I  will  state  that  both  had  been  used,  with  the 
accepted  local  treatment,  with  but  little  success  by  other 
physicians,  at  intervals,  for  several  years.  Also  ulcers 
that  began  forming  under  the  bandage  were  invariably 
-  arrested  in  their  course  by  methyl  violet.  Its  action  we 
believe  to  be  germicidal  and  highly  astringent. 

October  6, 1894. 


Mas.  B ,  aged  fifty- six.     History  of  struma  during 

childhood.  Is  the  mother  of  two  children.  General 
health  fair.  Veins  much  dilated4rom  knees  down,  with 
very  poor  cutaneous  circulation.  Has  suffered  from 
chronic  ulcers  for  many  years. 

Was  first  seen  by  the  author  December  8,  1893 ;  at 
that  time  she  presented  one  or  two  ulcers  that  had  not 
been  healed  for  five  years,  and  others  of  more  recent  date. 
The  manner  in  which  these  ulcers  appear  is  as  follows : 
First,  a  macule  which  soon  becomes  papular,  and  later 
capped  by  a  vesicle  which  soon  ruptures,  liberating  a 
bloody  serum.  The  mass  continues  to  enlarge,  forming  an 
ulcer  the  size  of  a  quarter  of  a  dollar  or  even  larger.  Dur- 
ing the  formation  and  growth  of  this  ulcer  it  is  highly  sen- 
sitive and  constantly  painful.  At  the  time  of  my  first 
visit,  after  cleansing  the  ulcers  with  a  solution  of  soda 
bicarbonate,  I  applied  a  solution  of  methyl  violet — 
care  being  taken  to  bring  it  in  contact  with  the  entire 
area  of  the  base  and  margins.  After  allowing  it  to  dry, 
each  stained  ulcer  was  covered  by  a  small  bit  of  absorb- 
ent cotton.  Mechanical  support  was  furnished  by  Mar- 
tin's elastic  bandage.  This  entire  procedure  was  re- 
peated every  morning.  On  the  second  or  third  day  it 
was  evident  that  the  healing  process  had  begun. 

At  my  first  visit  a  new  and  very  painful  ulcer  was 
forming  on  the  left  leg.  This  I  treated  for  a  few  days 
with  subnitrate  of  bismuth,  boracic  acid  being  tried 
and  found  too  painful.  No  benefit  was  derived  from 
either.  Pain  was  constant ;  on  the  third  or  fourth  day 
I  painted  it  with  methyl  violet,  and  to  my  great  surprise 
and  the  patient's  comfort,  the  pain  at  once  ceased. 

After  two  or  three  daily  applications  the  sensitiveness 
had  so  far  subsided  as  to  render  bandaging  of  that  part 
of  the  leg  possible.  All  of  the  ulcers  were  thenceforth 
dressed  daily.  At  the  appearance  of  any  new  vesicle  I 
applied  methyl  violet,  which  prevented  further  develop- 
ment. Internal  treatment  consisted  of  potassium  iodide, 
grs.  x.  to  xv.  t.i.d. 

The  patient  continued  her  duties  as  housekeeper,  and 
at  the  end  of  six  weeks  only  cicatrices  remained  to  mark 
the  site  of  her  former  ulcers. 

An  ideal  solution,  as  used  by  Dr.  M.  F.  Coomes,  of 
Louisville,  Ky.,  in  the  treatment  of  lupus,  is  made  by 


PASTILLES  AS  A  SUBSTITUTE  FOR  GAR- 
GLING TO  PREVENT  DIPHTHERITIC  IN- 
FECTION. 

By  A   ROSE,  M.D., 

MEW  YORK. 

Ws  have  to  confess  that  the  control  of  the  course  of 
diphtheria  is  very  limited.  In  view  of  this  fact  we  are 
reminded  of  the  noblest  of  our  duties,  the  duty  of  pro- 
phylaxis. It  is  true  we  are  experimenting  with  anti- 
toxin, and  it  is  to  be  hoped  that  we  shall  succeed  in  se- 
curing immunity  against  diphtheritic  infection  by  means 
of  inoculation  of  this  new  serum,  but  as  long  as  this,  our 
sanguine  hope  in  regard  to  antitoxin,  is  not  yet  real- 
ized, we  have  to  welcome  every  prSposition  to  guard 
against  diphtheritic  infection. 

It  is  generally  understood  that  a  healthy  pharynx  is  of 
as  much  importance  in  regard  to  diphtheria  as  a  healthy 
stomach  is  in  regard  to  cholera.  All  writers  on  prophy- 
laxis against  diphtheria  speak  of  the  importance  of  keep- 
ing the  mouth  and  throat  in  aseptic  condition.  Among 
the  measures  to  this  end  gargling  "  the  throat "  has  always 
been  considered  to  be  a  prominent  part.  As  everybody 
can  convince  himself  by  experimenting  with  some  col- 
ored syrup,  gargling  is  an  illusory  measure  as  far  as  the 
disinfection  of  the  pharynx  is  concerned  ;  except  when 
it  is  done  in  a  certain  skilful  manner,  as  only  adults  can  do 
it  after  having  been  well  instructed,  not  one  drop  of  the 
gargle  enters  the  pharynx,  not  even  reaches  the  tonsils. 

Dr.  A.  Szara1  recommends  therefore  to  disinfect 
mouth  and  throat  with  lozenges  composed  of  resina 
guajaci,  saccharin,  etc.  He  experimented  with  these 
and  found  that  they  possessed  germicidal  power,  that 
they  actually  did  disinfect  the  mouth  and  pharynx,  that 
the  aseptic  condition  lasted  for  one  hour.  He  does  not 
give  the  proportion,  at  least  I  did  not  find  them  given  in 
the  extract  of  his  paper  which  came  to  my  view. 
Messrs.  Eimer  &  Amend,  the  drug  firm,  made  lozenges 
for  me  which  have  the  following  formula : 

Q.  Resinae  guajaci 0.75 

Saccharine 0.01 

Sacchari  et  succi  liquiritise 0.75 

They  are  agreeable  to  take,  and  may  also  serve  in  all 
cases  of  pharyngitis  where  tinctura  guajaci  is  generally 
given.  They  are  certainly  more  palatable  than  the  tinct- 
ure, and  much  more  serviceable  than  those  lozenges  of  the 
London  Throat  Hospital  made  with  red  and  black  cur- 
rant jelly  and  containing  only  a  small  part  of  resina 
guajaci.  Dr.  J.  Bergman  8  recommends  lozenges  which 
he  calls  diphthericidium  pastilles,  which  have  the  follow- 
ing formula : 

3.  Thymol 0.002 

Sodae  benzoit o  02 

Saccharin 0.015 

And  some  gum-like  constituent. 

Either  of  these  pastilles  recommends  itself  to  be 
given  to  our  little  ones  going  to  school  in  place  of  candy 
or  chewing-gum. 

1  Ueber  eine  neue  Methode  die  Mund-  und  Rachenhdhle  zu  desin- 
ficieren.    Pester  med.-chir.  Presse,  1894,  No.  & 

a  Un  neuer  Vorschlag  zur  Prophylaxe  gegen  diphtheric  Algm. 
medL    Central.  Ztg.  1894,  No.  1. 


656 


MEDICAL  RECORD. 


Medical  Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


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


New  York,  November  24,  1894. 


SOME  MINOR    MEASURES    IN  THE    DIAGNO- 
SIS AND  TREATMENT  OF  DYSPEPSIA. 

No  doubt  the  conscientious  general  practitioner  feels  that 
he  is  often  very  much  behind  the  times  in  his  diagnosis 
and  treatment  of  some  gastric  disorders.  Medical  liter- 
ature is  full  of  elaborate  descriptions  of  the  different 
kinds  of  dyspepsia,  of  hypoacidity,  hyperacidity,  motor 
disturbances,  catarrhal  disorders,  etc.  The  methods  of  in- 
vestigating the  stomach  have  also  become  greatly  refined, 
the  test  meals,  the  washings,  syphonings,  and  electric  ex- 
plorations appear  very  formidable  to  the  doctor,  and  still 
more  to  the  patient.  We  do  not  in  the  least  wish  to 
deprecate  the  use  of  all  the  methods  of  modern  research 
and  treatment.  It  is  always  best  to  know  exactly  the 
facts,  and  not  guess  at  them  from  data  furnished  by  the 
tongue  and  descriptions  of  subjective  states.  Still  Dr. 
Dujardin  Beaumetz  has  struck  a  fruitful  topic  in  a  re- 
cent lecture  on  "  Minor  Methods  of  Diagnosticating*and 
Treating  Dyspepsias  "  {Bulletin  g'en'tral  de  la  Tterapeu- 
Hque\  Exact  science  cannot  always  be  applied,  he 
says,  and  there  exist  a  number  of  minor  measures  which 
are  always  useful  and  often  sufficiently  effective.  In 
order  to  determine  the  kind  of  dyspepsia  from  which  a 
patient  suffers,  he  should  be  made  to  take  a  few  "  test 
meals.91  The  best  meal  for  this  purpose  is  the  breakfast. 
This  should  consist  of  coffee  or  tea,  with  milk  and  a  lit- 
tle sugar,  and  one  or  two  rolls  or  slices  of  bread  without 
butter.  The  quantity  of  liquid  should  always  be  the 
same  and  never  over  a  pint.  With  a  normal  stomach 
the  repast  will  be  digested  unnoticed.  If,  however,  two 
hours  after  eating  there  is  a  sense  of  heat  in  the  stomach, 
and  a  burning  and  acidity,  then  the  patient  is  suffering 
from  hyperacid  dyspepsia.  If,  on  the  other  hand,  there 
is  abundance  of  gas,  a  sensation  of  weight  and  fulness, 
and  of  food  being  still  in  its  place,  then  there  is  hypo- 
acid  dyspepsia.  When  there  is  at  the  end  of  a  quarter 
of  an  hour  a  sensation  of  epigastric  pain,  which  gradu- 
ally increases,  then  there  is  probably  some  gastro-duo- 
denal  irritation  or  inflammation.  Finally,  the  patient 
may  suffer  from  cramps,  pains,  and  even  vomiting,  and 
then  there  is  probably  some  muscular  and  nervous  dis- 
order of  the  stomach. 

Beaumetz  insists  that  in  hyperacidity  the  heat  and 
burning  are  most  severe  three  or  four  hours  after  a  meal, 
and  are  oftener  felt  at  night  between  n  p.m.  and  1  a.m. 
In  hyperacidity,  also,  the  ingestion  of  food  often  relieves 
for  a  time  the  disagreeable  sensations.  A  knowledge  of 
the  occupation  and  habits  of  the  patient  naturally  helps 


[November  24,  1894 

greatly  in  diagnosis.  Beaumetz  thinks  that  dyspeptics 
ought  to  sleep  on  the  right  side,  because  this  facilitates 
the  passage  of  food  from  the  stomach  into  the  duode- 
num. To  promote  the  same  end  he  advises  the  drinking 
of  a  cup  of  very  hot  water,  or  preferably,  some  aromatic 
infusion,  such  as  chamomile  or  anise,  etc.,  an  hour  or  an 
hour  and  a  half  after  eating.  He  docs  not  recommend 
mineral  waters  charged  with  carbonic-acid  gas,  but  does 
advise  still  alkaline  waters  taken  half  an  hour  before 
meals  in  small  doses.  Finally,  massage  of  the  stomach 
is  recommended,  both  to  stimulate  the  stomach  walls  and 
the  secretion  of  gastric  juice. 


THE    OYSTER    AS  A    TYPHOID   FEVER    CAR- 
RIER. 

A  year  ago  or  more,  reports  were  rife  of  cases  of  typhoid 
fever  in  Berlin,  due  to  eating  raw  oysters.  Not  much 
attention  was  paid  to  the  story  at  the  time,  because  no 
positive  verification  of  it  was  made. 

Quite  recently  the  matter  has  come  up  in  a  most  strik- 
ing way,  through  the  development  of  an  epidemic  of 
typhoid  fever  among  the  students  at  Wesleyan  Univer- 
sity, Middletown,  Conn.  We  give  elsewhere  a  report  of 
this  epidemic  which  was  published  in  The  Evening  Post 
of  November  19th.  While  we  do  not,  as  a  rule,  place 
much  confidence  in  newspaper  accounts  of  medical  in- 
vestigations, the  present  one  bears  the  marks  of  being 
carefully  written  and  authoritative.  Thirty  cases  oc- 
curred altogether,  with  one  death.  All  were  among 
college  students  who  had  attended  certain  society  sup- 
pers where  raw  oysters  were  served.  Among  the  students 
who  attended  other  suppers,  where  the  oysters  were 
cooked,  no  typhoid  developed.  The  oysters  had  been 
placed  by  the  oysterman  in  the  tide-water  shallows  of  a 
river  near  New  Haven.  Typhoid  fever  had  been  pres- 
ent in  the  family  of  the  oyster  grower,  his  house  was  near 
the  river,  and  his  sewage  drained  into  it.  This  is  the 
extent  of  the  evidence  so  far  as  we  can  learn.  No  ty- 
phoid bacilli  have  yet  been  found  in  the  oysters  still 
present  in  the  river,  but  this  branch  of  the  investigation 
is  unfinished. 

On  the  other  hand,  it  is  known  that  typhoid  fever  germs 
do  not  live  in  salt-water,  and  furthermore,  it  is  a  fact  that 
just  now  typhoid  fever  is  unusually  prevalent  in  certain 
parts  of  New  England.  Thus,  for  the  week  ending  No- 
vember 8,  1894,  the  percentage  of  deaths  from  this  dis- 
ease on  the  total  deaths  was,  in  Springfield,  Mass.,  7.69 ; 
in  Newton,  Mass.,  25 ;  in  Pittsfield,  Mass.,  33.33 ;  in 
Newburyport,  Mass.,  35 ;  in  Brockton,  12.50,  and  in 
New  Bedford,  1 1.76.  The  percentage  in  New  York  was 
only  3.00,  and  in  Philadelphia,  J..62.  There  is  perhaps, 
therefore,  some  unusually  important  epidemic  influence 
that  must  be  taken  into  consideration. 

If  one  looks  over  the  mortality  lists  for  the  different 
large  cities  of  this  country,  he  will  find  that  there  is  no 
excessive  prevalence  among  the  seaboard  cities,  where  the 
raw  oyster  is  consumed  in  enormous  quantities. 

The  consequences  of  establishing  the  fact  that  the  raw 
oyster  may  be  a  means  of  propagating  typhoid  fever, 
would  be  very  far-reaching  and  would  affect  not  only 
consumers,  but  would  destroy  in  a  measure  an  extensive 
and  important  industry.  The  matter  should,  therefore, 
be  investigated  with  the  greatest  care. 


November  24,  1894] 


MEDICAL  RECORD. 


657 


THE  SUNNY  SIDE  OF  PHYSIC. 

We  have  discovered  in  The  Lancet,  and  published  else- 
where, "The  Song  of  the  General  Practitioner."  Our* 
readers  will  find  it  a  rather  lugubrious  refrain,  yet  they 
will  probably  say  that  it  tells  the  truth.  Nearly  all 
poems  on  the  medical  art  are  written  in  the  same  pa- 
thetic key.  It  is  always  the  poor  doctor  who  works 
hard  and  continuously,  who  never  rests  or  sleeps,  or  gets 
paid  for  his  trouble. 

There  must  be  some  truth  in  it  all,  but  the  public  who 
read  might  legitimately  ask  why,  if  the  doctor's  life  is 
such  a  depressing  one,  do  the  doctors'  ranks  continue  so 
crowded  ?  The  more  we  deplore  our  lot,  the  more  do 
the  youth  of  the  land  select  it.  Is  it  the  spirit  of  altru- 
ism, or  is  it  that  in  the  halcyon  days  of  youth  such  things 
as  hard  work  and  poor  pay  and  no  final  rewards,  furnish 
no  terrors  ? 

Or  is  it  that  the  public  and  the  doctor  know  the  pict- 
ure to  be  overdrawn  ?  We  suspect  that  the  latter  ele- 
ment is  a  very  potent  one  in  directing  young  men  into 
the  rugged  ways  of  medical  life.  Some  doctors  work 
hard  all  the  time,  and  all  doctors  work  hard  some  of  the 
time,  but  all  doctors,  he  thinks,  do  not  work  hard  all  of 
the  time.  Besides,  he  sees  that  many  of  the  profession 
get  comfortable  incomes  and  live  in  comfortable  homes. 
They  are  not  waked  up  every  night  to  drive  ten  miles  in 
the  darkness  and  cold.  A  great  many  of  their  bills  are 
paid ;  a  great  many  patients  are  grateful  and  loyal,  and 
sound  their  favorite  physician's  praises  in  a  way  that  is 
solacing  to  vanity  and  provocative  of  larger  practice. 
The  average  duration  of  life  of  the  doctor  is  not  quite  as 
long  as  that  of  the  clergyman — the  good  die  young,  or 
at  least  younger ;  but  still,  if  he  has  good  luck,  he  may 
grow  old,  for  some  doctors  do  reach  a  green  age.  There 
are,  in  fact,  a  great  many  pleasant  things  in  the  doctor's 
life,  and  we  trust  that  some  time  a  school  of  more  cheer- 
ful medical  poetry  will  arise  than  that  which  exists  at 
present. 


THE  REFRACTING  OPTICIAN. 

The  optician  has  given  a  great  deal  of  trouble  to  our 
medical  brethren  of  Philadelphia.  At  rather  frequent 
intervals  in  the  past  we  have  read  most  denunciatory  ac- 
counts of  his  demoralizing  and  unethical  work.  Our 
esteemed  contemporary  The  Medical  News,  which  gen- 
erally discusses  the  problems  of  human  life  with  great 
philosophy,  has  little  patience  with  the  optician — that  is 
to  say,  if  he  refracts.  For  it  is  the  so-called  R.  Os.,  or 
refracting  opticians,  who  are  really  to  blame.  We  have 
been  receiving  circulars  from  this  class  of  practitioners  in 
New  York  recently  and  have  learned  some  particulars  of 
their  deadly  work.  It  seems  that  the  R.  O.  makes  the 
following  examination : 

"For  hypermetropia,  myopia,  astigmatism,  presby- 
opia, heteraphoria,  corneal  opacities,  lens  reflex,  vitreous, 
fundus  oculi,  and  visual  acuity." 

This  really  does  seem  to  go  beyond  the  simple  limits 
of  refraction  and  physics.  The  R.  O.  offers  to  de- 
termine the  condition  of  the  cornea,  of  the  vitreous,  of 
the  retina,  and  of  the  eye-muscles.  He  offers  rather  too 
much  for  the  price  of  a  pair  of  glasses,  particularly  when 
the  doctor's  own  family  gets  them  at  half-rates. 


It  may  be  seriously  questioned  whether  the  R.  O. 
is  not  practising  medicine  if  he  diagnosticates  a  corneal 
opacity  or  an  optic  atrophy.  He  must  draw  the  lines 
much  more  closely  or  be  put  in  the  lists  of  the  unli- 
censed. 

There  is  no  reason,  however,  why  a  modest  and  genu- 
ine refracting  optician  should  not  perform  a  useful  ser- 
vice to  society.  Many  people  suffer  from  hypermetropia, 
myopia,  and  astigmatism  who  cannot  afford  to  go  to  a 
specialist.  They  must,  therefore,  either  rely  on  their 
family  physician,  go  to  a  dispensary,  or  to  the  R.  O. 
Now  we  advise  such  to  go  to  their  family  doctor  and  let 
him  decide  whether  the  optician  is  sufficient,  and  we 
advise  the  family  doctor  never  to  send  his  patient  to  the 
refracting  optician  who  proclaims  his  ability  and  readi- 
ness to  diagnosticate  almost  every  chronic  abnormality 
of  the  eye. 


Utetxrc  of  tfee  W&zzX 

The  Moxon  Medal  of  the  Royal  College  of  Physi- 
cians.— The  Moxon  Medal  of  the  Royal  College  of  Phy- 
sicians, for  distinguished  services  in  clinical  medicine, 
has  been  awarded  to  Sir  William  Jenner. 

Dr.  Timothy  M.  Ingraham,  one  of  the  best-known 
physicians  in  the  suburbs  of  Brooklyn,  died  at  his  home 
in  Flatbush,  on  November  4th,  of  cerebral  apoplexy. 
He  was  born  in  Amenia,  Dutchess  County,  in  1821.  He 
received  his  collegiate  education  at  Wesley  an  University, 
Middletown,  Conn.,  and  the  degree  of  M.D.  from  the 
Vermont  Medical  College,  in  1847. 

Typhoid  Fever  from  Oysters.— There  is  an  outbreak 
of  typhoid  fever  now  at  the  Wesleyan  College  in  Mid- 
dletown, Conn.,  in  which  the  contagion  appears  to  have 
been  carried  in  oysters.  According  to  a  despatch  in  the 
Evening  Post  the  story  of  the  disease  is  as  follows: 
The  first  case  developed  on  October  2  2d,  the  student 
being  the  son  of  a  physician  in  Vermont.  The  patient 
was  taken  home  and  died.  This  case  was  followed 
rapidly  by  others — one  fatal — until  they  now  number 
about  thirty.  They  began  to  develop  about  ten  days 
after  the  initiations  of  six  societies  at  Wesleyan,  a  supper 
being  given  by  each.  As  all  the  sufferers  had  attended 
these  suppers  investigation  was  turned  in  that  direction. 
The  Middletown  city  water  and  also  the  water  from  a 
well  on  the  campus  were  examined  and  both  found  to  be 
innocuous.  The  milk  used  at  the  initiation  suppers  was 
next  looked  into  and  was  found  to  be  perfectly  whole- 
some and  obtained  from  farms  where  the  conditions 
were  healthful.  It  was  next  found  that,  while  at  all  six 
of  the  suppers  oysters  were  used,  at  three  only  were  raw 
oysters  supplied,  and  that  all  the  victims  had  partaken  of 
them.  These  oysters  were  bought  from  a  Middletown 
dealer,  who  obtained  them  from  an  oyster  grower  living 
on  the  east  shore  of  the  Quinepiack  River,  near  New 
Haven.  He,  like  the  many  other  growers  owning  oys- 
ter establishments  on  the  Quinnipiack,  is  accustomed  to 
take  the  oysters  from  the  deep  waters  of  the  Sound  and 
lay  them  down  before  opening  for  some  twenty-four 
hours  in  the  shallows  of  the  river.  This  makes  the  oys- 
ters absorb  the  fresher  water  of  the  stream,  swells  and 


658 


MEDICAL  RECORD. 


[November  24,  1894 


whitens  them,  the  technical  phrase  among  the  oyster- 
men  being  "  giving  the  oysters  a  drink."  The  next  dis- 
covery was  that  the  oyster-grower's  wife  had  died  of 
typhoid  fever  about  the  time  of  the  outbreak  at  Wes- 
leyan, and  his  daughter  also  has  been  ill  of  the  disease. 
His  house  stands  not  far  back  from  the  river,  and  its 
short  drain  empties  into  the  latter  near  the  place  where 
the  oysters  are  bedded  temporarily.  In  addition  to  the 
Wesleyan  students  there  were  visitors  from  Yale  and  Am- 
herst, and  two  of  these,  one  from  each  college,  are  also 
ill  with  typhoid.  The  same  paper  from  which  we  have 
quoted  reports  that  a  gentleman  in  New  Haven  recently 
gave  an  entertainment  at  which  raw  oysters  were  served, 
and  six  of  his  guests  are  now  suffering  from  typhoid. 
The  bed  of  the  Quinepiack  River  is  extensively  used 
for  oysters  by  the  growers  of  Fair  Haven  and  East 
Haven,  which  for  many  years  have  been  centres  of  the 
Connecticut  oyster  trade.  Many  sewers  empty  into  it, 
and  it  is  to  be  hoped  that  the  discovery  of  the  source  of 
the  Wesleyan  outbreak  may  lead  to  the  discontinuance 
of  the  custom  of  temporary  bedding  and  to  taking  the 
oysters  directly  from  the  main  beds  in  deep  water. 

Dr.  Zaeharin's  Future.— Dr.  Zacharin,  the  eccentric 
Russian  physician  who  attended  the  Czar  Alexander  III. 
during  the  greater  part  of  his  illness,  has  not  a  very 
cheerful  future  to  look  forward  to.  The  present  Czar 
Nicholas  is  said  to  be  so  displeased  with  Dr.  Zaeharin's 
conduct  that  he  has  suggested  that  he  confine  his  prac- 
tice henceforth  to  Siberia. 

A  Bon-mot  of  Dr.  Holmes.— Dr.  Arthur  P.  Perry 
writes  to  the  Boston  Medical  and  Surgical  Journal :  "  A 
bon-mot  made  by  Dr.  Holmes  at  the  time  one  of  his  sons 
was  born,  was  lately  written  out  for  me  by  a  physician 
who  was  a  student  at  the  time ;  and,  as  it  is  as  good  as 
all  Holmes's  sayings  were,  and  I  think  has  never  been  in 
print,  I  thought  it  might  appear  in  the  Journal.  I  give 
it  verbatim  as  it  was  sent  me.  'In  the  forties  Dr. 
Holmes  was  one  of  the  instructors  in  what  was  known  as 
the  Tremont  Medical  School,  which  gave  instruction  to 
quite  a  large  number  of  students  between  the  lecture 
terms  of  the  Harvard  Medical  School.  Usually  prompt, 
we  were  one  day  surprised  by  his  non-appearance  at  the 
beginning  of  the  lecture-hour,  but  we  waited.  Finally 
he  entered  the  room,  hurriedly  glanced  around  with  a 
smile  and  said,  "  Gentlemen,  I  know  I  am  late,  but  there 
is  a  little  stranger  at  my  house."  And  then  with  an  ex- 
pression such  as  only  Holmes's  face  could  assume,  he 
continued,  "  Now  can  any  one  of  you  tell  me  what  well- 
known  business  firm  in  Boston  he  is  like  ?  "  There  was 
no  answer.  "  He  is  Little  &  Brown,"  said  the  doctor, 
with  a  twinkle  in  his  eye.'  " 

Hew  Tork  State  Medical  Examinations. — At  the 
September  examinations  for  State  medical  license  by  the 
board  representing  the  Medical  Society  of  the  State  of 
New  York,  the  number  of  candidates  was  seventy- six,  of 
whom  fifty-one  were  successful  and  twenty-five  unsuccess- 
ful. 

Tuberculous  Infection  in  a  Laboratory. — We  regret 
to  hear  the  report  that  Dr.  John  M.  Byrom,  Director  of 
the  Bacteriological  Department  of  the  Loomis  Labora- 
tory, is  suffering  from  tuberculosis  which  he  contracted  by 
inhaling  its  germs  while  engaged  in  his  professional  work. 


A  SuooeMful  Operation.— Dr.  Pulser  :  Did  you  re- 
move old  Bonder's  vermiform  appendix  ? 
Dr.  Cutter:  Yes. 

Dr.  Pulser  :  And  was  there  anything  in  it  ? 
Dr.  Cutter  :  A  cold  two-fifty  for  me. 

The  Ceremony  of  Unveiling  the  Statue  to  Claude 
Bernard  took  place  on  October  28th.  Many  members 
of  the  Academy  of  Sciences,  and  all  the  professors  and 
students  of  the  Lyons  Faculty,  betides  many  notabilities, 
military  and  political,  were  present.  The  statue,  the 
work  of  Aubert,  a  sculptor  of  Lyons,  represents  Claude 
Bernard  in  a  standing  position,  holding  a  lancet  in  his 
hand  and  inoculating  a  frog  with  curare. 

Anxiety  as  a  Cause  of  Granular  Kidney. — It  is  inter- 
esting, in  relation  to  the  ailment  of  the  Cxar,  to  recall  a 
paper  read  by  Professor  Clifford  Allbutt  at  the  annual 
meeting  of  the  British  Medical  Association,  at  Sheffield, 
in  1876.  The  subject  he  took  up  was  "  Mental  Anxiety 
as  a  Cause  of  Granular  Kidney,"  and  by  an  analysis  of 
his  case  books  he  showed  what  an  abnormally  large  pro- 
portion of  the  patients  showing  symptoms  of  granular 
kidney  had  been  subject  to  the  depressing  influence  of 
prolonged  anxiety.  He  says :  "  During  the  last  two 
years  I  have  made  notes  of  thirty-five  cases  of  gran- 
ular kidney  occurring  in  private  practice,  and  I  find 
a  marked  history  of  mental  distress  or  care,  or  both,  in 
twenty-four  of  them."  This  is  a  large  proportion,  even 
if  we  admit  that  the  pushing  inhabitants  of  West  York- 
shire worry  abnormally  concerning  this  world's  goods. 
Several  illustrative  cases  are  given,  and  one  especially  in 
which  as  a  consequence  of  an  unfortunate  investment,  a 
man,  in  a  good  position,  for  three  years  "  went  to  bed 
night  by  night  ignorant  whether  he  might  not  be  gradu- 
ally drained  of  his  all."  Dickinson  is  in  some  sense  in 
accord  with  Allbutt  on  this  question,  although  not  so 
positive.  Prolonged  mental  disturbance,  anxiety,  or 
grief  as  a  cause  of  granular  kidney  is,  he  says,  "  perhaps 
problematical ;  the  mode  of  its  operation  is  not  obvi- 
ous, but  must  be  surmised  as  through  the  nervous  system. 
A  lowering  of  nervous  force  is  to  be  recognized  at  least 
as  predisposing  to  every  form  of  albuminuria.  I  have 
seen  so  many  instances  in  which  granular  degeneration 
has  been  immediately  sequent  upon  trouble  that,  in  the 
absence  of  other  causes,  I  am  fain  to  conclude  that  men- 
tal conditions  are  sometimes  concerned  in  its  produc- 
tion."— British  Medical  Journal, 

A  Hew  Method  of  Producing  Local  Anssatheaia.— 

At  the  meeting  of  the  Hufeland  Society,  on  October  25th, 
Professor  Oscar  Liebreich  presiding,  Dr.  Schleich  read  a 
paper  on,  and  demonstrated,  what  he  terms  a  new  method 
of  anesthesia,  called  "  Infiltrations  anaesthesie."  Dr. 
Schleich  has  for  some  time  made  use  of  this  new  form  of  lo- 
cal anesthesia,  not  for  trifling  operations  only,  but  for  com- 
plicated ones,  such  as  laparotomy,  etc  He  uses  a  very 
weak  solution  of  cocaine — 1  per  mille.  The  cocaine  is 
not  dissolved  in  distilled  water,  Liebreich  having  shown, 
in  his  inquiry  on  "  ansesthetica  dolorosa  "  that  distilled 
water  injected  subcutaneously  has  a  toxic  effect ;  the  sol- 
vent used  is  the  physiological  salt  solution  of  about  half 
the  usual  concentration,  that  is,  about  0.2  to  o  3  per 
cent,  of  common  salt.  Schleich's  method  is  as  follows : 
A  small  spot  of  the  skin  near  the  field  of  operation  is  ren- 
dered insensible  by  chloride  of  ethyl,  and  here  a  few 


November  24,  1894] 


MEDICAL   RECORD. 


659 


drops  of  the  cocaine  solution  are  injected.  At  the  spot 
of  infiltration  a  bulla  immediately  arises,  which  is  abso- 
lutely without  sensation.  Pushing  the  point  of  the  syringe 
through  this  area  of  insensibility,  Schleich  again  injects  a 
few  drops;  another  bulla  arises  close  to  the  first,  and 
proceeding  from  bulla  to  -  bulla  round  the  field  of  opera- 
tion the  whole  is  infiltrated  and  rendered  quite  anaes- 
thetic This  is  done  extremely  quickly,  as  Schleich 
showed  in  the  case  of  a  man  with  a  large  syphilitic  ab- 
scess on  his  arm,  who  was  operated  on  before  the  meet- 
ing. The  man  felt  absolutely  no  pain ;  and  the  duration 
of  the  operation,  including  the  anaesthesia,  was  only 
eight  to  ten  minutes.  Dr.  Schleich  said  that  he  had  em- 
ployed his  method  of  anaesthesia  for  about  three  thousand 
operations  with  unvarying  success,  and  without  any  bad 
after-effects.  It  does  not  seem  to  us  that  the  method  pre- 
sents any  great  elements  of  novelty. 

A  French  Congress  of  Internal  Medicine  was  recently 
held  at  Lyons,  October  25th  to  29th.  The  organizers 
were  MM.  Potani,  L6pine,  and  Bard.  This  is  the  first 
national  medical  meeting  ever  held  out  of  Paris,  though 
Congresses  of  Surgeons  and  of  various  specialists  have 
had  successful  meetings  for  several  years.  The  French 
physicians  are  trying  to  get  away  from  the  complete 
dominance  of  Paris  in  medical  matters. 

Massage  Establishments  and  Prostitution.— The  Brit- 
ish Medical  Journal  presents  a  report  on  London  mas- 
sage establishments  couched  in  words  of  what  it  evidently 
considers  "  decent  plainness."  One  part  of  the  report 
is  as  follows : 

"  In  the  summer  months  the  establishments  are  closed 
for  the  most  part.  When  London  fills  up  again  they 
become  active.  We  will  leave  for  another  article  the  ex- 
plicit statements  which  we  have  to  make  as  to  the  nature 
of  the  practices  which  go  on  in  many  of  these  places; 
but  for  the  present  it  may  be  sufficient  to  state  shortly 
what  kind  of  place  the  casual  inquirer  will  find  if  he  goes 
for  the  first  time  to  some  of  the  addresses  we  refer  to. 
He  will  find  probably  a  fiat  of  four  or  five  rooms,  in  a 
fashionable  West  End  locality.  In  many  cases  the  es- 
tablishment is  on  the  first  floor  over  business  premises. 
The  approach  to  it  is  guarded  by  various  arrangements 
for  privacy.  As  the  visitor  enters,  an  electric  bell  rings 
automatically  and  he  will  find  himself  received  in  a  well- 
famished  room  by  a  lady  of  middle  age,  with  a  certain 
capable  air  of  respectability.  She  will  make  no  inquiry 
as  to  his  name,  and  probably  none  as  to  his  complaint. 
He  will  be  invited,  with  little  loss  of  time  in  prelimina- 
ries, to  adjourn  to  a  room  luxuriously  furnished,  where 
he  will  find  a  bed  or  couch  spread  with  blankets.  He 
will  be  informed,  unless  it  is  assumed  that  he  knows  it 
already,  that  the  terms  are  for  an  hour  a  guinea,  but  that 
he  can  stay  as  long  as  he  pleases  by  the  same  rate.  In 
some  instances  it  will  be  suggested  to  him  that  it  would 
be  a  good  thing  to  have  a  bath  first  and  massage  after- 
ward. It  will  be  assumed,  as  a  matter  of  course,  that  he 
intends  to  have  '  general  massage,1  that  he  will  want  a 
young  lady  to  do  it,  and  that  he  will  undress  completely. 
Madame  will  then  leave  him  to  his  own  devices.  In 
two  or  three  minutes  the  lady  assistant  will  appear,  and 
the  'treatment'  will  be  duly  administered.  He  will 
not  be  interrupted,  nor,  in  fact,  will  he  see  '  madame ' 
again  until  he  pays  her  as  he  leaves  the  house.    This 


state  of  things  in  itself  will  be  admitted  by  everybody  to 
be  sufficiently  risky.  What  it  leads  to  we  shall  feel  it  our 
duty  to  indicate  with  decent  plainness  in  another  article." 
It  does  not  seem  as  though  any  sequel  to  the  above 
was  really  needed.  Such  establishments  are  freely  adver- 
vised  in  Chicago  daily  papers,  especially  since  the  Lexow 
Committee's  work. 

Hew  Medical  Colleges. — A  new  medical  college  was 
organized  the  other  day  over  in  Alabama.  Also  a  new 
one  at  Fort  Worth,  Tex.  About  one  month  ago  two 
members  of  the  faculty  of  one  of  the  Nashville  schools 
resigned  their  chairs  on  account  of  personal  differences, 
and  are  now  industriously  at  work  "  organizing  another 
school."  More  schools  than  this  have  been  established 
from  no  better  motive.  Out  in  St.  Louis  the  opening  of 
a  new  medical  college  has  gotten  to  be  almost  a  joke. 
In  a  word,  there  is  absolutely  no  need  for  these  colleges. 
There  is  every  need,  God  knows,  for  better  medical  edu- 
cation, but  the  way  to  accomplish  it  is  not  by  increasing 
the  number  of  colleges.  Since  1880  there  have  been 
more  than  fifty  medical  schools  chartered  in  this  country, 
a  great  many  more  than  there  was  any  necessity  for. 
Fortunately  several  have  died.  There  are  1 1 0,000  doctors 
in  the  United  States.  More  than  3,000  belong  to  the 
faculties  of  medical  schools.  Of  this  number  Ohio,  with 
16  schools,  contributes  408 ;  New  York,  with  12  schools, 
540;  Missouri,  with  16  schools,  405;  Maryland,  with  7 
schools,  170;  and  Tennessee,  with  8  schools,  160,  etc. 
In  all  we  have  one  medical  school  for  every  43°>000  °* 
our  population,  or  one  for  every  730  physicians. — Atlanta 
Medical  and  Surgical  Journal. 

Safeguards  against  Smallpox.— Dr.  J.  M.  Worth- 
ington,  health  officer  of  Anne  Arundel  County,  says  the 
county  has  adopted  a  complete  system  to  detect  the  ap- 
proach of  small-pox  and  to  prevent  the  spread  of  the 
contagion.  He  said  :  "  To  provide  against  an  epidemic 
of  small- pox  the  county  commissioners,  at  a  recent  meet- 
ing, appointed  two  vaccine  physicians  for  each  election 
district,  making  fourteen  for  the  county.  With  tbis 
wise  provision  it  would  be  difficult  to  have  a  case  in  the 
county  without  its  being  at  once  known  and  attended 
to.  Isolation,  disinfection,  and  vaccination  are  the 
best-known  means  to  lessen  the  disease.  The  family 
physician  is  the  man  of  all  others  to  commence  the 
work,  and  if  he  does  his  duty  there  will  be  little  occasion 
for  panic  or  alarm.  As  a  rule,  he  knows  what  to  do  and 
how  to  do  it.  In  some  special  cases  he  may  need  the 
assistance  of  the  district  vaccine  physicians  for  the  poor 
and  unprotected.  He  'should  at  once  notify  the  health 
officer  of  his  county,  whose  duty  and  pleasure  it  would 
be  to  report  to  the  State  board  of  health.  It  should  be 
a  rare  case  of  emergency  or  necessity  to  appeal  for  aid 
or  comfort  to  the  Surgeon-General's  office  at  Washington, 
D.  C.  A  recent  notable  small- pox  scare,  affecting  the 
family  and  their  physician,  a  man  of  ability  and  high 
personal  character,  could  have  been  nipped  in  the  bud. 
A  messenger  on  foot  or  horse,  a  railroad,  double  track, 
all-steel  rails,  United  States  mail,  telephone,  and  tele- 
graph, all  should  have  been  exhausted  to  reach  the  doc- 
tor and  ascertain  the  facts  before  the  slander  was  spread 
upon  the  wings  of  the  wind." 

Errata. — Dr.  R.  Abrahams  writes:  Will  you  kindly 
correct  the  following  misprints  in  the  Record  of  Novem- 


66o 


MEDICAL  RECORD. 


[November  24,  1894 


ber  10th.  Page  604,  first  column,  fifteenth  line  from 
top,  read  "  tabular  "  for  "  tubercular."  On  the  same 
page,  twentieth  line  from  bottom  read  "  observers  "  for 
"  observer/'  Page  599,  second  column,  ninth  line  from 
bottom,  read  "  grave  "  for  "  great" 

Randall's  Island  Hospitals,  Hew  York.— Dr.  Charles 
W.  Allen  has  been  appointed  Visiting  Dermatologist  to 
the  Randall's  Island  Hospitals. 

Professor  Dr.  Klebs,  of  bacillus  fame,  is  on  a  visit 
to  this  country,  and  is  at  present  the  guest  of  Dr.  Karl 
von  Ruck,  of  Asheville,  N.  C. 

longevity. — Our  esteemed  contemporary  The  An- 
nals of  Hygiene  makes  the  astounding  assertion,  in  its 
issue  for  July  of  this  year,  that  one  person  out  of  every 
four  thousand  born  reaches  the  age  of  one  hundred 
years.  This  may  be  so  in  the  home  of  our  contempo- 
rary, but  elsewhere  life  is  too  rapid  for  any  such  blissful 
extension  of  it  as  this. 

"  The  Burst-up  of  listerism  M  is  the  way  Dr.  Donald 
Campbell  Black,  of  Glasgow,  speaks  of  the  modifica- 
tions which  have  taken  place  in  the  practice  of  antiseptic 
surgery.  He  apparently  harbors  no  kindly  feelings  for 
Sir  Joseph  Lister,  though  at  this  distance  we  are  unable 
to  guess  the  cause  of  his  enmity.  He  relieves  his  mind 
in  a  long  tirade  against  the  one  to  whom,  more  than  all 
others,  the  world  owes  the  principle  of  antiseptic  surgery, 
and  closes  with  the  following  splenetic  deliverance : 

"  I  read  in  a  recent  number  of  an  influential  medical 
contemporary  that  Sir  Joseph  Lister  had  been  awarded 
the  Albert  Medal  of  the  Society  of  Arts  '  for  the  discov- 
ery and  establishment  of  the  antiseptic  method  of  treat- 
ing wounds  and  injuries  (what  is  this?),  by  which  not 
only  has  the  art  of  surgery  been  greatly  promoted  and 
human  life  saved  in  all  parts  of  the  world,  but  extensive 
industries  have  been  created  for  the  supply  of  materials 
for  carrying  the  treatment  into  effect.9  If  it  be 
'  science '  to  give  a  transient  impulse  to  the  manufact- 
ure of '  putty '  and  calico,  then  I  have  certainly  misin- 
terpreted the  term  '  science '  during  all  the  years  that 
I  have  lived." 

A  Medioal  Library  Association  has  been  recently  or- 
ganized in  Grand  Rapids,  Mich.  The  purpose  of  the 
Association  is  the  formation  of  a  reference  library  upon 
medicine  and  allied  sciences.  The  new  organization 
starts  out  with  a  membership  of  about  fifty.  One  of  the 
features  of  the  Association  will  be  the  admission  of  non- 
residents to  membership,  whereby  for  a  small  annual  fee, 
physicians  outside  of  the  city  may  avail  themselves  of  the 
advantages  of  the  library.  A  competent  librarian  will 
be  secured,  and  the  most  approved  methods  of  catalog* 
uing  and  indexing  will  be  made  use  of.  Books  and  jour- 
nals are  being  liberally  donated  by  those  interested  in 
the  project,  and  the  success  of  the  enterprise  is  assured. 
The  following  officers  have  been  elected:  Dr.  G.  K. 
Johnson,  President;  Dr.  S.  G.  Milner,  Vice  President; 
Dr.  W.  A.  Dorland,  Treasurer;  Dr.  Reuben  Peterson, 
Secretary. 

South  Carolina  State  Medioal  Examining  Board. — 
The  second  meeting  of  this  Board,  created  by  act  of  the 
Legislature  in  January  last,  was  held  at  Columbia,  Octo- 
ber 9  th  and  10th.  Of  fourteen  candidates  four  were  re- 
jected.   The  next  meeting  of  the  Board  will  be  on  the 


fourth  Tuesday  in  April,  1895.  Anyone  wishing  to  enter 
the  State  to  practise,  between  the  meetings  of  the  Board, 
must  appear  before  the  chairman  and  secretary  to  be  ex- 
amined, and  upon  their  being  satisfied  as  to  his  qualifi- 
cations will  issue  to  him  a  temporary  license,  which 
license  is  only  good  until  the  next  meeting  of  the  Board. 
The  Secretary  of  the  Board  is  Dr.  C.  F.  McGahan,  of 
Aiken,  S.  C. 

Cannot  Experiment  on  the  Body  of  Wilson,  the  Murder- 
er.— Attorney-General  Hancock  has  written  an  opinion 
in  answer  to  an  inquiry  from  Governor  Flower  in  regard 
to  the  resuscitation  of  Wilson,  the  murderer.  The  opinion 
says :  "  In  my  judgment  neither  the  Governor  of  the 
State,  the  Superintendent  of  State  Prisons,  nor  the  War- 
den of  Auburn  Prison  has  authority  to  deliver  the  body 
of  a  convict,  after  the  execution  of  the  death  penalty  and 
a  post-mortem  examination,  to  Dr.  Gibbons  or  any 
other  individual  not  a  relative  of  the  person  executed. 
If  the  body  is  not  claimed  by  a  relative,  it  becomes  the 
duty  of  the  authorities  in  charge  to  bury  it,  and  not  to 
deliver  the  same  to  any  individual  for  the  purpose  oi 
experiment." 

The  H6w  Tork  Society  for  the  Belief  of  Widows  and 
Orphans  of  Medioal  Men  elected  these  officers  lately : 
President,  Dr.  Ellsworth  Eliot ;  Vice-Presidents,  Dri. 
David  Webster,  J.  H.  Emerson,  and  Charles  H.  Teale; 
Ireasurer,  Henry  Tuck.  President  Eliot  said  that  tie 
funds  of  the  Society  had  been  increased  almost  $60,000 
in  the  past  year. 

The  Mew  Tork  Pharmaceutical  Club. — Fifty  mem- 
bers of  the  Pharmaceutical  Club  sat  down  to  their  first 
Club  dinner  at  7  p.m.,  November  21st,  in  their  pretty 
new  rooms  at  37  East  Nineteenth  Street  No  papers 
were  read  nor  speeches  made.  The  Club  was  incorpo- 
rated in  August,  and  has  now  one  hundred  and  sixty-five 
active  members.  Its  membership  will  be  limited  to  the 
number  of  pharmaceutical  men  in  good  standing  in  the 
drug  business  who  care  to  join. 

Papers  on  scientific  subjects  connected  with  the  drug 
business  will  be  read  every  Thursday.  The  officers  are 
as  follows :  President,  Robert  J.  Bell ;  Vice-President, 
John  W.  Bachelder;  Treasurer,  Frank  A.  Barnes;  and 
Secretary,  Velie  A.  Wood. 

The  Proportion  of  Successful  Candidates  in  the  Med- 
ioal Staffs  of  the  Army  and  Havy. — During  the  year 
ending  June  30,  1894,  thirty-seven  candidates  for  the 
medical  staff  of  the  army  received  permission  to  appear 
for  examination  before  the  Medical  Board ;  of  this  num- 
ber five  were  found  qualified.  In  the  navy,  thirty  can- 
didates were  invited  to  come  up  for  examination,  of  which 
number  three  only  were  found  qualified  physically  and 
professionally  for  appointment  to  the  rank  of  assistant 
surgeons.  There  are  eight  vacancies  in  the  naval  medi- 
ical  staff;  in  the  army  medical  staff  there  are  none,  ow- 
ing to  the  action  of  Congress  in  reducing  the  number  of 
assistant  surgeons  to  one  hundred  and  ten. 

Br.  Beid  Alexander,  of  Topeka,  Kan.,  died  in  that 
city,  in  October,  of  perforation  of  the  bowel.  He  was  a 
graduate  of  the  Medical  Department  of  the  University  oi 
Pennsylvania,  in  the  Class  of  '85,  and  at  the  time  of  his 
death  was  President  of  the  Topeka  Academy  of  Medicine 
and  Surgery. 


November  24,  1894] 


MEDICAL   RECORD. 


661 


NEW  YORK  ACADEMY  OF  MEDICINE. 

Stated  Meeting,  November  1, 1894. 

D.    B.    St.  John   Roosa,  M.D.,  President,  in   the 
Chair. 

Perkins'i  Tractors. — Mr.  Isaac  Wood,  of  Rah  way,  pre- 
sented to  the  Academy,  through  the  Chairman  of  the 
Library  Committee,  Dr.  Grandin,  a  set  of  Perkins's 
tractors,  an  instrument  at  one  time  in  use  for  the  cure  of 
disease. 

Wanted,  $100,000;  Half  of  it  Immediately.— Dr. 
Grandin  reported  gifts  of  books  to  the  library  since 
last  spring.  He  then  added  that  the  term  of  office  of 
the  present  Committee  on  Library  was  about  to  expire, 
and  they  wished  before  retiring  to  make  another -urgent 
appeal  to  the  public  for  an  endowment  fund.  The 
library  was  as  free  to  the  use  of  the  public  as  to  the  pro- 
fession, yet  the  latter  had  out  of  their  own  pockets 
erected  the  best  stack  room  in  the  country,  and  the  pub- 
lic, especially  the  wealthy  portion,  were  now  urgently 
invited  in  their  own  interest  to  contribute  before  the 
first  of  January  150,000  of  the  much  needed  endowment 
fund  of  $  1 00,000  dollars. 

Library  Hours  Lengthened. — The  library  will  here- 
after be  kept  open  until  10.30  p.m.,  until  time 'shall  show 
whether  use  after  10  p.m.  will  justify  the  added  expense. ' 

Question  of  Dues. — Dr.  A.  M.  Jacobus  gave  notice  on 
the  part  of  the  Council  of  an  amendment  to  the  by-laws, 
providing  for  reduction  of  dues  of  members  residing  in 
the  State,  but  outside  of  the  counties  of  New  York, 
Kings,  Queens,  and  Westchester,  to  $5  a  year,  the  dues 
in  the  counties  named  remaining  as  at  present,  $20  a 
year.  The  unfairness  of  taxing  the  more  distant  mem- 
bers equally  with  those  residing  near  the  Academy,  with 
its  library,  was  self-evident. 

The  President  announced  that  the  anniversary  dis- 
course would  be  delivered  by  Dr.  Charles  L.  Dana, 
Wednesday  evening,  November  28th.  The  profession 
who  have  friends  among  the  public  who  may  feel  some 
interest  in  the  Academy  are  requested  to  send  their  names 
to  the  Librarian,  Mr.  Browne,  who  will  forward  them 
cards  of  invitation.  This,  the  President  said,  was  one 
means  for  making  the  public  acquainted  with  the  work 
of  the  Academy  and  with  its  invaluable  services  to  it.  It 
was  wonderful  how  little  most  of  the  sixteen  or  eighteen 
thousand  citizens  who,  out  of  the  total  two  millions,  con- 
stituted the  generous  donors  to  worthy  public  purposes, 
knew  about  the  Academy.  If  they  were  informed  of  its 
catholic  spirit,  of  the  fact  that  it  was  not  a  private  med- 
ical school,  that  it  was  established  in  the  interest  of  the 
public  welfare,  and  opened  its  library  to  the  use  of  all,  he 
thought  the  endowment  fund  for  which  the  Chairman  of 
the  Library  Committee  had  made  so  eloquent  an  appeal 
would  be  forthcoming  at  once. 

Intra-lobular  Occlusion  Jaundice. — Dr.  William  H. 
Porter  read  a  paper  with  this  title,  which  implied  that 
the  jaundice  was  due  to  occlusion,  but  not  to  a  form  of 
occlusion,  such  as  pressure  by  a  tumor,  after  the  bile  had 
entered  the  bile-ducts.  In  order  to  elucidate  the  subject 
he  outlined  the  minute  anatomy  of  the  hepatic  lobules, 
the  mechanical  processes  connected  with  the  secretion  of 
the  bile,  and  also  his  views  of  the  chemical  and  physio- 
logical processes  involved  in  the  same  act.  To  start 
with,  he  rejected  the  old  explanation  of  jaundice,  based 
on  the  view  that  the  constituents  of  the  bile  were  reab- 
sorbed into  the  blood. 

The  mechanism  connected  with  the  production  of  bile 
was  based  on  the  minute  anatomy,  as  already  suggested. 
Masses  of  protoplasm  in  the  form  of  epithelial  cells  in 
the  acini  by  virtue  of  a  function  peculiar  to  themselves 
secreted  the  bile  from  the  blood  brought  to  the  locality 
through  the  portal  system,  the  bile  thus  secreted  enter- 
ing the  radicles  of  the  bile  ducts,  and  being  finally  car- 


ried to  the  duodenum.  The  bile  was  made  from  proteid 
compounds,  during  which  oxygen  brought  from  the 
lungs  consumed  carbohydrates  and  evolved  heat,  and  it 
was  by  the  influence  of  the  heat  that  the  nerve-terminals 
were  stimulated  and  enabled  to  perform  their  function. 
During  the  act  the  cells  were  alternately  swollen  and  re- 
laxed, but  when  abnormally  irritated  by  toxic  agents, 
such  as  might  gain  entrance  to  the  portal  circulation  in 
the  form  of  chemicals  or  bacterial  products,  they  remained 
unnaturally  congested,  their  nutrition  was  impaired,  their 
function  interfered  with,  and  they  underwent  retrograde 
metamorphosis.  In  this  abnormally  swollen  state  the 
masses  of  protoplasm  were  forced  into  the  primary  radi- 
cles, which  thus  became  occluded.  As  it  had  been  proven 
that  the  blood- vessels  could  not  absorb  the  biliary  con- 
stituents, there  remained  but  one  channel  through  which 
they  could  enter  the  circulation,  namely,  the  lymphatics. 
Passing  from  the  hepatic  lymph- channels  into  the  tho- 
racic duct,  they  finally  reached  the  general  circulation 
and  were  carried  to  the  different  parts  of  the  body,  and 
unless  eliminated  they  stained  the  tissues  and  caused  jaun- 
dice and  pathological  changes  in  other  organs.  The 
kidneys  took  a  principal  part  in  the  elimination  of  the 
bile  constituents.  There  might  be  various  degrees  of 
intra-lobular  occlusion  jaundice,  depending  upon  the 
amount  of  toxic  agents  absorbed  from  intestinal  indiges- 
tion and  decomposition,  etc.,  and  the  chronicity  of  the 
case  would  depend  upon  the  continuation  of  the  active 
cause  and  the  change  induced  in  the  liver-cells.  There 
was  never  complete  occlusion  of  all  the  biliary  radicles, 
but  often  sufficient  to  cause  various  degrees^f  jaundice. 
The  diagnosis  of  this  form  of  jaundice  was  to  be  made 
by  excluding  other  forms  of  mechanical  obstruction  ly- 
ing between  the  biliary  radicles  and  duodenum.  The 
prognosis  was  usually  good  in  acute  cases,  especially  in 
persons  of  good  general  health  whose  attack  had  been 
brought  on  by  temporary  indigestion.  Where  the  kid- 
neys were  badly  damaged,  the  prognosis  was  unfavor- 
able.   Much  depended  upon  the  treatment 

The  author  followed  the  circle  of  injurious  results  of 
intra-lobular  occlusion  jaundice,  a  chief  one  being  the 
depriving  of  the  intestine  of  a  fluid  necessary  to  perfect 
digestion  and  antisepsis — the  bile.  The  nutrient  pabu- 
lum going  to  the  various  organs  of  the  body  became  in- 
termixed with  a  toxic  principle  which  interfered  with 
their  proper  nutrition,  a  fact  which  gave  one  indication 
in  treatment.  One  must  look  to  the  diet,  to  artificial 
digestives,  to  intestinal  antisepsis,  to  sunlight  and  exer- 
cise, to  hepatic  stimulants,  to  the  excretory  functions. 
The  digestive  system  must  not  be  overtaxed  by  either  too 
much  food  or  food  of  wrong  quality.  The  author  had 
found  by  experience  the  following  diet  suitable  to  many 
cases,  according  to  their  severity :  For  breakfast,  two 
ounces  of  wheat  bread,  two  eggs,  eight  ounces  of  milk, 
with  a  little  butter,  making  a  total  of  fourteen  ounces. 
For  the  mid-day  meal,  three  ounces  of  wheat  bread,  a 
little  butter,  seven  ounces  of  meat.  In  the  evening,  two 
ounces  of  wheat  bread,  a  little  butter,  eight  ounces  of 
milk,  seven  ounces  of  meat.  Before  retiring,  eight  ounces 
more  of  milk.  If  milk  could  not  be  tolerated,  use  a  fer- 
mented milk.  Fruits  and  vegetables  should  be  avoided 
because  they  were  prone  to  excite,  by  their  fermentation, 
abnormal  decomposition  of  proteid  compounds  and  de- 
velopment of  toxic  substances. 

Artificial  digestion  for  a  time  within  the  alimentary 
canal  was  best  aided  by  ox-gall  and  pancreatic  extract 
given  before  meals,  and  hydrochloric  acid  and  pepsin 
after  meals.  In  some  cases  an  additional  intestinal  anti- 
septic might  be  called  for.  Give  some  laxative  or  car 
thartic  to  overcome  constipation  and  prevent  toxic  ab- 
sorption. Sluggish  action  of  the  heart  and  circulation 
was  to  be  met  by  muriate  of  caffein  and  strychnia.  The 
biliary  radicles  were  best  reached  by  calomel  or  bichlo- 
ride of  mercury  and  arsenic. 

Dr.  Alfred  L.  Loomis  was  called  upon  to  open  the 
discussion.  He  believed  Dr.  Porter  had  presented  to  us 
the  more  advanced,  the  more  recent  views  with  re- 


662 


MEDICAL  RECORD. 


[November  24,  1894 


gard  to  the  histology  and  physiology  of  the  hepatic  lob- 
ules, and  he  had  no  criticisms  to  make  on  that  part  of 
the  paper.  When  it  came  to  the  general  question  of 
jaundice,  of  course  we  were  entering  upon  a  subject 
which  had  been  discussed  from  very  different  stand-points 
and  with  very  different  ideas  in  the  minds  of  those  who 
had  token  put.  From  the  time  that  he  began  its  study 
as  a  medical  student,  it  remained  obscure  to  him  until  he 
•came  to  take  the  position,  as  he  did  long  ago,  that  there 
was  no  jaundice  which  was  not  obstructive.  He  be- 
lieved that  was  the  position  which  we  were  compelled  to 
take  even  today.  The  question  then  arose,  just  where 
was  the  obstruction  in  any  given  case?  It  might  be  out- 
ride the  liver,  it  might  be  internal,  along  the  larger  ducts, 
and  it  was  difficult  to  exclude  obstruction  at  times  along 
•the  smaller  ducts.  For  instance,  there  might  be  a  ca- 
tarrhal jaundice  without  evidences  of  catarrh  on  the  in- 
testinal side  of  the  duct,  in  which  event  it  would  be  diffi- 
cult to  say  just  where  or  how  far  up  the  catarrh  existed. 

Regarding  infectious  jaundice,  it  had  seemed  to  him 
for  a  number  of  years  that  the  only  satisfactory  explana- 
tion lay  in  the  hypothesis  that  the  function  of  the  liver- 
-cells  was  interfered  with  in  some  way.  He  need  only 
•mention  the  different  forms  of  degeneration  of  the  liver- 
cells,  and  would  say  that  the  author's  explanation  of  the 
manner  in  which  these  cells  obstructed  the  radicles 
seemed  clear  and  satisfactory;  that  is,  that  the  cells 
themselves  became  the  obstructive  cause  of  the  jaundice, 
and  that  when,  such  obstruction  arose  jaundice  was 
brought  about  by  the  entrance  of  bile-products  into  the 
circulation* through  other  channels  than  the  hepatic 
ducts,  and  by  other  means  than  reabsorption  into  the 
blood.  The  symptoms  of  such  obstruction  were  made 
•evident  by  influence  on  the  nervous  system  and  in  icterus 
before  local  changes  took  place  in  special  organs,  as  in 
the  kidneys. 

While  listening  to  the  reading  of  the  paper  the  query 
had  suggested  itself  to  his  mind  whether  in  all  forms  of 
obstructive  jaundice,  including  cases  in  which  the  obstruc- 
tion was  in  the  larger  ducts,  the  icterus  was  not  prima- 
rily due  to  obstruction  at  the  radicles  of  the  hepatic  duct 
He  had  noticed  that  in  chronic  jaundice,  jaundice  which 
had  continued  for  years,  the  chief  change,  according  to 
-his  observation,  had  related  to  connective  tissue  develop- 
ment shooting  down  from  the  surface  into  the  centre  of 
the  lobules  like  a  framework,  and  attended  by  corre- 
sponding changes  in  the  liver-cells.  He  was,  therefore, 
-of  the  impression  that  in  jaundice  occurring  in  connec- 
tion with  interstitial  hepatitis  or  some  other  diseases  of 
the  liver,  the  change  leading  to  the  jaundice  began  in 
•the  radicles  and  that  the  secondary  changes  were  in  the 
connective  tissue.* 

Dr.  Loomis  could  confirm  all  Dr.  Porter  had  said  with 
^regard  to  diet  being  the  most  important  factor  in  the 
treatment  of  these  cases,  yet  it  seemed  to  him  that  hardly 
-sufficient  stress  had  been  placed  on  oxidation.  He  be- 
lieved from  clinical  observation  that  all  patients  with 
'jaundice  did  best  when  most  in  open  air  and  sunlight. 
As  to  diet,  he  thought  quantity  as  important  as  quality. 
He  did  not  like  plain  milk,  as  a  rule,  but  buttermilk  or 
milk  which  had  been  made  to  undergo  some  fermenta- 
tive change.  Patients  had  not  digested  plain  milk  so 
well.  With  life  in  sunlight  and  open  air  at  a  moder- 
ately high  altitude,  say  from  fifteen  to  twenty-five  hun- 
-dred  feet,  and  away  from  the  sea,  it  was  wonderful  how 
-rapidly  some  cases  of  jaundice  would  improve. 

The  Theory  Insufficient.— Dr.  Andrew  H.  Smith 
was  unable  to  explain  certain  cases  of  jaundice  which  he 
-could  recall  on  the  theory  advanced  in  the  paper,  that  it 
was  entirely  intra-lobular.  In  fact  he  could  not  recall  a 
case  of  considerable  intensity  in  which  he  was  able  to 
accurately  limit  the  process  intra  lobular,  or  to  differen- 
tiate between  other  forms  of  jaundice  and  that  which 
was  supposed  to  be  strictly  intra  lobular.  Perhaps  he 
might  in  the  future,  since  his  attention  has  been  spe- 
•  daily  directed  to  it.  It  was  difficult  to  him  to  grasp  the 
two  ideas  at  the  same  time,  that  the  bile  was  formed  in 


the  hepatic  cells,  and  that  jaundice  was  due  to  disorgani- 
zation of  those  cells.  We  saw  in  yellow  atrophy  of  the 
liver,  for  example,  very  rapid  destruction  of  the  liver- 
cells  and  substance,  and  yet  a  great  degree  of  jaundice, 
as  if  bile  production  was  very  active  at  the  very  moment 
that  it  was  destroyed.  It  seemed  to  him  that  in  many 
instances  the  question  was  chiefly  one  of  nervous  influ- 
ence, one  which  a  chemical  formula  would  hardly  reach. 
A  large  amount  of  bile,  say  a  pint  and  a  half,  was 
secreted  by  the  liver  every  twenty-four  hours,  and  while 
much  of  it  passed  out  with  the  faeces,  yet  not  a  little 
entered  the  circulation.  Notwithstanding  this,  die  col- 
oring matter  of  the  bile  did  not  appear  in  the  urine 
under  ordinary  circumstances.  There  must  be  some 
process  by  which  the  bilirubin  and  biliverdin  were  rap- 
idly destroyed.  It  seemed  to  him  that  there  was  as  much 
opportunity  for  the  production  of  jaundice,  the  appear- 
ance of  bile  at  the  surface,  from  some  interference  with 
the  destruction  of  the  bile  after  it  had  entered  the  circu- 
lation as  by  some  change  taking  place  in  the  hepatic 
structure.  It  was  difficult  to  account  for  the  sudden  oc- 
currence of  jaundice  under  certain  circumstances,  as 
mental  emotion,  on  the  theory  advanced  in  the  paper. 
There  was  a  very  marked  nervous  impression,  and  this, 
perhaps,  caused  some  disturbance  of  the  vasomotor  sys- 
tem of  the  liver,  with  less  degree  of  tension  in  the  blood- 
vessels of  that  organ  than  in  the  bile-ducts,  under  which 
circumstances  there  might  be  transferrence  of  bile  from 
the  ducts  into  the  capillaries.  This,  however,  was  mere 
supposition,  and  was  difficult  of  absolute  demonstration. 
If  the  rules  offered  with  regard  to  diet  and  medication 
were  intended  to  apply  only  to  cases  of  what  we  had 
been  accustomed  to  consider  catarrhal  jaundice  lasting 
some  weeks,  Dr.  Smith  had  no  criticisms  to  make,  but  he 
thought  more  latitude  could  be  allowed  in  jaundice  of 
less  degree,  and  especially  in  so-called  biliousness. 

Heptogenous  versus  Hssmatagenous  Jaundice. — Dr. 
R.  C.  M.  Page  said  jaundice  was  usually  described  as 
of  two  forms,  heptogenous  and  hematogenous.  The 
latter  was  claimed  to  be  due  to  disintegration  of  blood- 
corpuscles  and  the  transformation  of  their  coloring 
matter  into  bile  pigment.  Now,  bile  is  formed  in  the 
liver,  and  as  it  exists  there  in  health  there  is  no  jaundice, 
but  if  from  any  cause  it  is  retained  in  the  liver  it  is  ab- 
sorbed by  the  lymphatics,  passes  along  to  the  thoracic 
duct  and  general  circulation  and  produces  jaundice  of 
most  of  the  fluids  and  tissues  of  the  body.  This  reten- 
tion of  bile  is  due  to  obstruction.  The  mode  of  ob- 
struction in  many  cases  is  very  readily  understood — for 
instance,  in  catarrh  of  the  bile-ducts,  in  the  presence  of 
gall-stones,  of  neoplasms.  But  the  cause  is  not  so  ap- 
parent in  some  other  conditions,  as  in  suppurative  pyelo- 
phlebitis,  icterus  neonatorum,  acute  yellow  atrophy,  phos- 
phorus-poisoning. But  even  in  these  cases  there  is 
probably  obstruction  to  the  escape  of  bile  from  exten- 
sion of  inflammation  to  the  bile-ducts,  or  else  the  ducts 
become  stuffed  with  desquamative  epithelium,  or  both 
conditions  may  act,  for  the  expulsive  forces  of  the  liver 
are  so  very  feeble  that  it  requires  but  a  slight  amount  of 
resistance  to  produce  retention.  True  jaundice  depends 
upon  coloring  matter  of  the  bile  which  has  entered  the 
circulation,  and  this  entrance  into  the  circulation  is 
probably  due  in  all  cases  to  obstruction,  although  the 
obstruction  may  not  be  fully  apparent  in  rare  instances. 
If  this  be  so,  it  is  manifest  there  is  no  such  thing  as  he- 
matogenous jaundice. 

Some  closing  remarks  were  made  by  Dr.  Porter. 


Women  in  the  Scotch  Universities. — By  a  recent  or- 
dinance of  the  Scottish  University  Commission  the  uni- 
versities are  empowered  to  throw  open  to  women  such 
open  bursaries,  scholarships,  and  fellowships  as  they  may 
see  fit. 

The  Mecca  Pilgrimage  in  1893  was  much  larger  than 
usual,  aggregating  over  350,000  souls.  Of  this  number 
25,000  died,  most  of  them  from  cholera. 


November  24,  1894] 


MEDICAL   RECORD. 


663 


THE  NEW  YORK    PATHOLOGICAL  SOCIETY. 

Stated  Meeting,   October  10, 1894. 

George  C.  Freeborn,  M.D.,  President. 

Typhoid  Fever  with  an  Unusual  History. — Dr.  George 
P.  Biggs  presented  specimens  from  a  case  of  typhoid 
fever,  which  was  chiefly  interesting  on  account  of  the 
peculiar  clinical  history.  The  subject  of  the  report  was 
an  Italian  woman,  aged  nineteen,  and  married,  with  a 
negative  family  history.  About  two  weeks  previous  to 
her  admission  to  the  hospital  she  had  been  taken  with 
prostration,  headache,  pain  in  the  back  and  abdomen, 
and  was  so  ill  as  to  be  confined  to  bed.  She  felt  fever* 
ish  and  constantly  hungry.  Four  days  before  admission 
there  was  quite  a  profuse  hemorrhage  from  the  bowel, 
and  two  days  later  she  aborted  at  the  third  month.  A 
few  days  after  entering  the  hospital  the  physician  who 
had  attended  her  previously  called  at  the  hospital,  and 
said  that  one  week  before  the  abortion  an  attempt  had 
been  made  to  produce  abortion,  under  the  impression 
that  the  chill  that  she  had  had  was  a  convulsion.  It  had 
been  so  reported  to  him  by  the  friends.  At  the  time  of 
her  admission  her  temperature  was  104. 6°  F.,  the  res- 
pirations were  28,  and  the  pulse  128.  Physical  exami* 
nation  revealed  nothing  but  a  few  riles  over  the  lower 
lobes  posteriorly.  The  heart  sounds  were  normal,  and 
the  heart  action,  though  rapid  and  feeble,  was  regular. 
The  spleen  did  not  appear  to  be  enlarged.  She  was  ex- 
cessively anaemic.  The  urine  had  a  specific  gravity  of 
1,018,  and  contained  five  per  cent,  of  albumin,  but  no 
casts.  On  the  day  following  her  admission  there  was  a 
decided  chill,  and  a  subsequent  rise  of  temperature  to 
1060  F.  An  intrauterine  douche  was  given,  and  a 
number  of  old  blood-clots  removed  from  the  uterus.  On 
the  following  day  she  was  curetted,  and  a  portion  of  tis- 
sue, supposed  to  be  the  remains  of  the  placenta,  also  re- 
moved. The  discharge  from  the  uterus  was  moderate, 
and  was  without  odor ;  but  with  the  history,  and  with 
the  chills  and  fever,  it  was  thought  probable  that  her 
symptoms  were  due  to  sepsis.  On  the  third  day  of  her 
stay  in  the  hospital  there  was  a  hemorrhage  from  the 
bowel,  similar  to  that  which  is  observed  in  typhoid 
fever,  and  that  night  she  had  a  severe  chill.  She  was 
more  than  ever  prostrated  the  next  day.  Hie  urine 
had  a  specific  gravity  of  1,009,  an^  contained  two  per 
cent,  of  albumin  and  granular  casts.  She  died  one  week 
after  admission,  and  just  three  weeks  from  the  onset  of 
the  first  symptoms. 

The  lesions  at  the  autopsy  were  found  to  be  those  of  a 
typical  case  of  typhoid  fever.  The  spleen  was  about 
three  times  its  usual  size.  The  intestinal  glands  were 
greatly  enlarged.  The  typhoid  ulcers  were  limited  to 
the  lower  two  feet  of  the  ileum,  and  were  particularly 
prominent  in  the  last  nine  inches.  There  were  also  a 
few  typhoid  ulcers  in  the  ascending  colon,  and  these 
were  quite  superficial.  The  mucous  membrane  at  this 
point  was  much  congested,  and  there  were  small  hemor- 
rhages. Some  of  the  ulcers  in  the  small  intestine  were 
quite  deep.  The  body  of  the  uterus  was  cauterized  with 
a  hot  iron,  and  a  culture  taken  from  the  interior  of  the 
organ.  The  result  was  a  pure  culture  of  a  bacillus 
which  appeared  to  be  identical  with  those  obtained  from 
the  spleen.  The  uterus  was  about  ten  centimetres  in 
length,  and  six  centimetres  in  breadth  at  the  middle.  Its 
interior  surface  was  covered  with  a  whitish  fibrinous  mate- 
rial. The  cavity  was  entirely  empty.  The  peritoneum 
was  normal,  as  were  also  the  ovaries  and  Fallopian  tubes, 
showing  clearly  that  there  had  been  no  septic  process 
originating  in  the  uterus.  A  very  marked  atheromatous 
patch  was  noted  in  the  aorta.  The  other  organs  showed 
well-marked  parenchymatous  changes,  passing  into  fatty 
change.  This  was  particularly  noticeable  in  the  heart 
and  liver.  In  the  latter  organ  there  were  also  some  pe- 
culiar yellowish  areas,  the  exact  nature  of  which  had  not 
yet  been  determined.  They  were  located  in  the  centre 
of  the  lobules,  and  from  an  examination  of  a  frozen  sec- 


tion they  appeared  to  be  composed  of  a  few  fiat  globules 
and  of  granular  detritis. 

General  Tuboreulosis. — Dr.  Biggs  then  presented 
specimens  from  a  case  of  general  tuberculosis.  The 
specimens  were  removed  from  a  woman,  forty- seven  years 
of  age,  who  had  been  admitted  to  the  New  York  Hospi- 
tal on  May  16,  1894.  For  one  year  previous  she  had 
had  constant  pain  in  the  left  hip  with  a  sense  of  numb- 
ness of  the  left  thigh.  For  six  months  the  severity  of  the 
pain  had  steadily  increased.  Examination  under  ether 
showed  a  mass  about  the  size  of  a  duck's  egg  in  the  left 
iliac  fossa.  It  was  quite  tense  and  immovable.  On  ad- 
mission the  temperature  was  98. 40  F.,  the  respirations,  24, 
and  tihe  pulse,  76.  The  urine  was  alkaline,  had  a  spe- 
cific gravity  of  1,016,  and  contained  a  trace  of  albumin 
and  a  few  leucocytes.  Under  ether  a  four-inch  inci- 
sion was  made  just  above  and  parallel  to  Poupart's  liga- 
ment on  the  left  side.  This  led  the  way  to  an  extra- 
peritoneal collection  of  fluid  in  the  left  iliac  fossa.  On 
incision  six  ounces  of  a  dark-greenish  fluid  escaped.  The 
cavity  was  washed  out  and  packed  with  gauze.  No  con- 
nection between  the  cyst  and  the  other  parts  could  be 
detected.  The  fluid  was  not  examined,  The  pain  was 
relieved  by  the  operation.  On  June  25th  she  menstru- 
ated. By  the  time  the  wound  had  nearly  closed,  July 
5th,  she  was  again  complaining  of  much  pain.  The 
wound  was  re-opened,  and  with  the  finger  in  the  rectum 
another  mass  was  felt  quite  low  down.  A  similar  collec- 
tion* of  fluid  was  evacuated,  and  the  same  treatment 
adopted.  The  first  cyst  had  apparently  disappeared  by 
this  time.  The  urine  was  then  found  to  be  free  from 
albumin,  but  it  contained  hyaline  casts.  The  pain  was 
once  more  relieved  by  the  operation.  On  July  30th 
another  accumulation  of  fluid  was  evacuated.  On  August 
4th  it  was  noted  that  the  left  leg  was  quite  markedly 
adducted  and  rotated  inward,  and  that  it  was  partially 
flexed,  with  a  shortening  of  the  limb  on  that  side  of  one 
inch.  The  pain  was  now  worse,  and  the  discharge  from 
the  old  sinus  quite  profuse.  On  August  nth  this  sinus 
was  explored,  and  a  distinct,  harsh  crepitation  felt  on 
moving  the  thigh.  The  finger  could  be  passed  into  the 
hip  joint.  The  head  of  the  femur  was  found  to  be  bare, 
and  considerably  eroded.  The  patient's  temperature  at 
that  time  was  as  high  as  1030  F.  in  the  evening.  On 
August  19th  some  oedema  of  the  right  leg  and  foot  was 
noted  The  oedema  increased,  and  she  filially  died  on 
October  9th. 

The  first  specimen  presented,  the  hip- joint,  showed 
that  the  floor  of  the  acetabulum  had  been  entirely  des- 
troyed, and  that  the  opening  so  made  communicated 
with  a  large  collection  of  pus.  The  lining  of  the  acetab- 
ulum was  extensively  infiltrated  with  partially  necrotic 
tubercular  tissue.  The  head  of  the  femur  was  also  ex- 
hibited, and  was  shown  to  be  deeply  eroded.  There  was 
a  large  abscess  extending  up  behind  the  peritoneum  as 
far  as  the  diaphragm  on  the  left  side,  and  as  far  as  the 
spinal  column  on  the  right  side.  Another  abscess  ex- 
tended down  on  the  inner  side  of  the  pelvis  between  the 
layers  of  the  broad  ligament.  Then  there  were  ab- 
scesses burrowing  down  into  the  thighs.  The  pus  was 
rather  thin  and  mixed  with  blood.  There  was  another 
collection  of  about  two  ounces  of  thick  cheesy  pus  in 
the  median  line  in  the  pre- vesical  space.  The  mucous 
membrane  of  the  bladder  was  considerably  thickened 
and  congested,  and  there  were  a  few  points  of  hemor- 
rhage. Its  whole  surface  presented  a  more  or  less  granu- 
lar appearance.  In  the  trigone  were  two  perfectly  dis- 
tinct tubercles.  The  uterus  was  of  about  the  normal 
size,  and  contained  three  perfectly  characteristic  fibroids 
about  the  size  of  hickory  nuts.  The  mucous  membrane 
of  the  upper  two-thirds  of  the  body  of  the  uterus  was 
covered  with  a  yellowish- white  cheesy  layer  characteristic 
of  tuberculosis  of  the  endometrium.  The  posterior  wall 
of  die  vagina  contained  one  small  nodule  about  three 
millimetres  in  diameter,  and  this,  on  incision,  was  found 
to  contain  some  material  apparently  tubercular,  although 
the  presence  of  tubercle  bacilli  had  not  yet  been  demon- 


664 


MEDICAL   RECORD. 


[November  24   1894 


strated.  The  tabes  were  larger  and  harder  at  a  distance 
from  the  uterus,  and  were  filled  with  cheesy  matter. 
The  ovaries  were  distinctly  atrophied,  and  while  the 
tubes  were  adherent  to  them  there  was  no  evidence  of 
tubercular  matter  in  the  substance  of  the  ovaries.  There 
were  no  symptoms  referable  to  the  condition  of  the  gen- 
ital organs.  There  were  typical  tubercular  deposits 
scattered  through  both  lungs.  The  bronchial  glands 
were  deeply  pigmented,  but  contained  neither  cheesy 
nor  calcareous  matter.  The  liver  was  extremely  fatty. 
In  spite  of  the  rather  prolonged  suppuration,  none  of 
the  organs  gave  a  reaction  with  iodine.  A  nodule  was 
found  in  one  of  the  suprarenal  capsules,  which  was  prob- 
ably tubercular  in  its  nature.  It  was  fibrous  rather  than 
cheesy,  and  was  situated  superficially  in  the  suprarenal 
capsule.  The  intestines  showed  no  tubercular  lesions. 
The  peritoneal  cavity  contained  no  fluid,  and  the  peri- 
cardium and  pleura  were  perfectly  normal. 

Marked  Atheroma  of  the  Aorta. — Dr.  Biggs  also  pre- 
sented a  specimen  of  marked  atheroma  of  the  aorta. 
The  specimen  had  only  been  removed  late  that  afternoon 
by  autopsy  from  a  man  dying  with  uremic  symptoms. 
The  kidneys  showed  rather  advanced  chronic  diffuse 
nephritis.  No  special  lesions  were  found  except  in  the 
aorta,  which,  in  the  lower  portion,  showed  a  large  number 
of  greatly  softened  areas,  some  of  them  measuring  as 
much  as  2  ctm.  in  diameter,  and  apparently  on  the  point 
of  rupture. 

Dr.  Biggs,  in  answer  to  a  question  from  Dr.  H.  P. 
Loomis  as  to  what  he  considered  the  primary  lesion  in 
the  case  of  tuberculosis,  replied  that  the  lesions  in  the  hip 
and  genital  organs  appeared  to  be  of  longer  standing 
than  those  in  the  lungs.  Personally,  he  thought  primary 
tuberculosis  of  the  genital  organs  was  not  very  rare. 

Da.  R.  H.  SAYRSsaid  that  the  lesions  in  the  lungs  and 
genital  organs  seemed  to  him  much  more  recent  than 
those  in  the  hip,  and  certainly  the  clinical  history  seemed 
to  point  to  primary  disease  in  the  hip. 

Dr.  Biggs  asked  what  would  then  be  the  explanation 
of  the  tuberculosis  in  the  hip. 

Dr.  R.  H.  Sayrb  said  he  did  not  think  anyone  had 
offered  a  satisfactory  explanation  of  the  common  clinical 
fact  of  tuberculosis  of  the  joints  without  apparently  any 
prior  tubercular  lesions.  There  were  various  autopsies 
on  record  where,  so  far  as  the  gross  appearances  went, 
there  were  no  evidences  of  tubercular  processes  in  the 
lungs,  vet  there  were  quite  well  marked  tubercular  proc- 
esses in  the  organs.  Virchow  had  reported  several 
such  autopsies.  He  saw  no  reason  for  assuming  that 
tuberculosis  must  come  through  the  lungs. 

Dr.  J.  S.  Ely  thought  there  was  another  way  of  ex- 
plaining a  primary  tubercular  process  in  the  internal 
organs  where  it  occurred  in  relatively  young  persons,  and 
that  was  by  direct  transmission  of  the  tubercle  bacilli 
from  the  mother  to  the  foetus.  It  had  been  demonstrated 
experimentally,  and  inferred  from  these  experiments,  that 
the  lesions  might  lie  dormant  for  four  or  five  years.  It 
was  known  that  under  certain  circumstances,  germs 
might  remain  quiescent  in  the  body  for  a  long  time,  and 
then  become  active.  Fraenkel  had  reported  a  case  sev- 
eral years  ago,  in  which  a  deep  abscess  had  developed  a 
year  after  a  typhoid  fever,  and  in  which  the  typhoid 
bacillus  was  found  by  cultivations.  In  Vienna  not  long 
ago  a  case  of  osteo  myelitis  had  been  reported  where 
careful  search  revealed  no  fresh  source  of  infection,  but 
where  thirty-five  years  after  a  previous  osteomyelitis 
there  was  a  fresh  outbreak  in  the  same  spot.  On  chisel- 
ling away  the  bone  a  layer  of  fresh  pus  was  found  contain- 
ing the  staphylococcus  pyogenes  aureus.  It  was  sur- 
rounded by  dense  bone,  which  had  probably  encapsulated 
the  bacteria  thirty-five  years  before.  Now,  it  was  pos- 
sible that  the  hip,  in  the  case  under  discussion,  had 
become  infected  many  years  before  any  real  outbreak  of 
tuberculosis  had  been  manifested  by  physical  signs.  It 
seemed  to  him  that  the  hip  was  the  primary  source,  but 
he  also  believed  that  the  point  of  entrance  of  the  tubercle 
bacilli  was  the  lungs.    A  strong  argument  to  him  was 


the   much  greater   frequency  with  which  the   bacilli 
entered  the  lungs  than  elsewhere. 

The  President  said  that  not  long  ago  he  had  had 
sent  to  him  for  examination  a  portion  of  tubercular  tis- 
sue taken  from  a  female  nurse's  arm.  During  labor,  her 
arm  had  been  gripped  very  strongly  by  the  patient,  and 
some  time  afterward  small  nodules  had  developed  sub- 
cutaneously  at  this  spot.  On  examination,  he  had  found 
the  typical  lesions  of  tuberculosis,  as  well  as  tubercle 
bacilli  in  the  lesions.  Three  or  four  specimens  were 
taken.  More  recently  he  had  learned  that  there  had 
been  a  diffuse  tubercular  inflammation  of  the  cellular 
tissue  of  the  arm.  The  patient  appeared  to  be  perfectly 
healthy.  It  was  thought  that  the  lymph  nodes  in  the 
arm  had  contained  some  of  these  bacilli,  and  that  the 
gripping  of  the  arm,  by  rupturing  these  nodes,  had  set 
free  these  germs,  and  had  enabled  them  to  become  active 
as  a  result  of  this  traumatism. 

Dr.  H.  P.  Loomis  recalled  an  autopsy  made  about 
three  years  ago  on  a  prize-fighter.  He  had  died  of  acute 
pneumonia.  The  autopsy  showed  the  lungs  normal, 
with  the  exception  of  the  pneumonia,  but  there  was  a 
large  bronchial  gland  which  contained  typical  tubercle 
bacilli  in  large  numbers,  and  also  typical  tubercular  le- 
sions, showing  that  these  germs  might  be  stored  up  in 
the  body  for  a  long  time  without  manifesting  them- 
selves. 

Dr.  W.  G.  Hudson  presented  a  microscopical  speci- 
men for  an  opinion  as  to  its  nature. 

Dr.  H.  P.  Loomis  expressed  the  opinion  that  the 
specimen  was  undoubtedly  one  of  tuberculosis. 

Tumors  from  Dogs  were  presented  by  Dr.  J.  S.  Ely. 
The  first  tumor  was  an  ecchondro-osteo-sarcoma  of  the 
mamma  of  a  bitch.  The  specimen  was  taken  from  a 
thoroughbred  Irish  spaniel  belonging  to  Dr.  Furman. 
Last  March  this  animal  had  a  litter  of  seven  pups.  One 
of  them  nursed  persistently  on  the  left  nipple.  Shortly 
afterward  several  lumps  developed  in  this  mamma,  which 
were  lanced  by  Dr.  Furman,  and  pus  evacuated.  Three 
months  before  the  tumor  was  removed  it  had  become  so 
large  as  to  be  troublesome. 

The  second  tumor,  of  which  a  microscopical  specimen 
was  also  presented,  was  a  carcinoma  of  the  skin,  situated 
on  the  lower  surface  of  the  tail  of  a  dog,  about  one  inch 
from  the  root  of  the  tail.  These  tumors,  the  speaker 
said,  sometimes  developed  from  the  peri-anal  glands,  but 
in  this  case  there  was  no  connection  with  the  trunk. 
The  tumor  was  dense  and  lobulated. 

The  speaker  said  that  Bland  Sutton,  in  his  introduc- 
tion to  general  pathology,  had  treated  at  considerable 
length  of  tumors,  yet  he  had  not  mentioned  carcinoma 
as  common  in  the  dog.  In  a  recently  published  article  on 
tumors  in  some  of  the  lower  animals,  38  tumors  were  de- 
scribed as  having  been  observed  in  dogs,  viz.,  16  were 
adenomata,  9  were  carcinomata,  2  epithetiomata  contain- 
ing  "  pearls,"  and  n  were  sarcomata. 

Ovarian  Tumor. — The  President  presented  a  portion 
of  ovarian  tumor  showing  electro  punctures.  The  growth 
had  been  removed  from  a  woman,  forty-six  years  of  age. 
The  history  of  the  growth  extended  over  a  considerable 
number  of  years.  She  had  been  under  treatment  in  Lon- 
don for  a  long  time,  and  while  there  one  hundred  and 
thirteen  electro-punctures  had  been  made  during  a  period 
of  a  year  and  a  halt  The  tumor,  nevertheless,  continued 
to  grow.  She  entered  the  hospital  service  of  Dr.  Bache 
Emmet,  and  on  April  10,  1894,  he  removed  the  tumor 
piecemeal.  It  was  attached  to  the  left  horn  of  the  ute- 
rus. The  woman  died  of  shock.  The  tumor  was  a  large 
lobulated  mass,  the  central  portion  of  which  was  a  rather 
large  cyst.  The  greater  part  of  the  cyst  was  composed 
of  fibrous  tissue.  There  were  evidences  of  smaller  cysts 
in  the  wall.  Microscopical  examination  showed  the  tu- 
mor to  be  a  fibrosarcoma.  The  spots,  which  from  their 
gross  appearance  were  at  first  supposed  to  be  hemor- 
rhagic spots,  were  really  areas  of  necrosis.  Scattered 
through  the  tumor  were  calcareous  masses.  The  clinical 
record  was  unfortunately  very  incomplete. 


November  24,  1894] 


MEDICAL   RECORD. 


665 


OUR  LONDON  LETTER. 

(From  our  Special  Correspondent) 
THE  MEETING  OF  THE  COLLEGE  OF  SURGEONS — REFUSAL 
TO  THANK  THE  COUNCIL — CHELSEA  HOSPITAL  AGAIN — 
COVENTRY  DISPENSARY  —  CLINICAL  SOCIETY  —  SUBDIA- 
PHRAGMATIC ABSCESS  COMMUNICATING  WITH  PLEURA — 
CHLORAL   POISONING. 

London,  November  3, 1894. 

The  annual  meeting  of  the  Fellows  and  members  of  the 
Royal  College  of  Surgeons  was  held  on  Thursday,  and 
gave  one  more  occasion  for  a  protest  on  behalf  of  the 
members.  This  protest,  however,  will  no  doubt,  as 
usual,  be  calmly  disregarded  by  the  Council.  The  Pres- 
ident opened  the  proceedings  with  a  few  remarks  on  the 
Report  for  the  year,  which  had  been  already  circulated. 
Then  Mr.  Joseph  Smith,  who  had  given  notice  of  the 
oft- passed  resolution  that  members  should  have  a  voice 
in  the  election  of  the  Council,  rose  and  said  that  he  re- 
gretted no  hope  of  redress  had  been  held  out  by  the 
President.  His  motion  had  been  passed  by  several  suc- 
cessive annual  meetings,  but  it  had  never  been  acted 
upon.  This  year  the  notice  was  pronounced  not  quite 
in  order,  but  the  President  and  Council  had  permitted  it 
to  be  brought  forward.  Mr.  Smith,  however,  declined 
to  accept  any  grace  in  the  matter,  holding  that  the  dig- 
nity of  the  members  demanded  the  right  to  discuss  their 
affairs  in  a  manner  consonant  with  the  propriety  of  pub- 
lic meetings.  He  therefore  withdrew  his  motion.  There- 
upon a  resolution  in  somewhat  modified  terms  was  moved 
and  seconded.  After  some  discussion  it  was  carried  by 
twenty- five  votes  to  eight.  In  the  course  of  discussion 
the  President  said  he  was  the  son  and  grandson  of  a  gen- 
eral practitioner,  and  that  every  Fellow  was  a  member, 
though  how  that  affected  the  claims  of  members  who 
were  not  Fellows  he  did  not  explain.  Mr.  T.  Smith  de- 
clared it  would  be  ungraceful  for  the  Council  to  try  to 
deprive  Fellows  of  their  privileges.  In  that  objection  is 
the  gist  of  the  matter.  The  Fellows  claim  the  privilege 
of  electing.  Of  this  privilege  they  have  deprived  the 
members,  and  they  refuse  to  restore  a  single  vote  to  those 
who  constitute  the  great  majority. 

A  resolution  was  proposed  thanking  the  Council  for 
the  Report  and  for  their  concessions  as  to  separate  meet- 
ings for  Fellows  and  members.  Objection  was  taken  to 
this  on  the  ground  that  whatever  had  been  conceded  was 
a  right,  not  a  favor,  and  the  motion  was  rejected  by  nine- 
teen to  six.  The  numbers  show  what  a  falling  off  there 
has  been  in  the  attendance  at  these  meetings.  This  is 
caused  by  the  apathy  of  despair  at  obtaining  what  once 
seemed  possible.  The  members  are  absorbed  in  their 
daily  duties  and  can  hardly  spare  time  to  take  part  in 
political  movements.  When,  however,  they  next  arouse 
themselves  to  appear  in  their  thousands  they  may  effect- 
ually assert  their  rights. 

The  Chelsea  Hospital  scandal  seems  interminable. 
Lord  Cadogan  has  now  resigned  the  presidency  and  it 
is  reported  that  the  next  development  will  be  the  with- 
drawal of  the  royal  personages  who  are  patrons.  Still 
the  committee  stick  to  their  position  and  will  not  resign. 
It  is  suggested  that  the  newly  elected  staff  should  resign. 
But  what  would  be  the  result  ?  Others  would  step  into 
their  shoes,  just  as  on  the  last  occasion. 

An  example  of  the  want  of  unity  and  the  readiness  to 
supplant  is  also  furnished  at  Coventry.  The  dispensary 
of  that  town  has  been  figuring  in  a  correspondence  in 
which  it  is  asserted  that  if  the  staff  resigned  their  neigh- 
bors would  take  their  places.  I  expect  this  .is  a  fact, 
though  the  British  Medical  Journal  affects  to  be  shocked 
at  such  a  suggestion,  and  pretends  it  would  not  accept 
advertisements  of  the  vacancies.  This  is  really  too  good 
when  we  remember  what  advertisements  are  accepted, 
and  that  on  other  occasions  the  Journal  has  actually 
more  than  withheld  support  from  a  hospital  staff  which 


was  resigning.  But  I  turn  from  these  unwelcome  dis- 
putes to  more  practical  subjects. 

At  the  last  meeting  of  the  Clinical  Society  Dr.  Hector 
Mackenzie  and  Mr.  F.  C.  Abbott  related  a  case  of  sub- 
diaphragmatic abscess  communicating  with  the  right 
pleura  successfully  treated  by  resection  of  ribs  and  drain- 
age, in  a  boy  aged  ten.  When  admitted  into  the  hospi- 
tal there  was  an  acutely  rounded  and  reddened  swelling 
centrally  situated  in  the  epigastrium.  The  right  side  of 
the  chest  gave  the  physical  signs  of  a  pyopneumothorax, 
and  the  epigastric  swelling  freely  communicated  with  the 
right  pleura,  for  it  became  much  more  prominent  when 
the  patient  sat  up  or  coughed,  and  then  distinctly  gave 
evidence  of  fluctuation.  It  was  decided  to  drain  the 
sub-diaphragmatic  abscess  and  the  empyema  by  a  single 
opening  in  the  pleura.  On  the  second  day  after  admis- 
sion a  portion  of  the  sixth  rib  was  resected  just  behind 
the  mid-axillary  line.  Thirty  ounces  of  exceedingly  of- 
fensive thin  watery  pus  containing  some  flakes  were  evac- 
uated. On  exploring  with  the  finger  the  upper  surface 
of  the  liver  was  felt  through  the  opening  in  the  fore  part 
of  the  diaphragm.  The  whole  cavity  was  well  irrigated 
with  warm  boracic  solution  and  a  double  drainage  tube 
inserted.  The  cavity  was  washed  out  daily,  but  the  die- 
charge  continued  to  be  offensive  for  several  days.  The 
patient  left  the  hospital  on  the  forty  seventh  day  cured. 
The  lung  expanded  well,  and  the  only  sign  to  be  detected 
six  months  later  was  a  slight  relative  dulness  at  the  base 
of  the  affected  side.  The  history  of  the  illness  pointed 
clearly  to  an  abdominal  origin.  The  presence  of  air  as 
well  as  fluid,  and  the  factor  of  the  abscess  pointed  to 
perforation  of  an  air  containing  viscus,  most  probably  of 
a  gastric  or  duodenal  ulcer. 

The  President,  Mr.  Hulke,  mentioned  the  case  of  a 
lad  aged  thirteen,  for  whem  he  made  an  opening  in  the 
tenth  interspace,  and,  removing  a  piece  of  rib,  gave  exit 
to  much  foul  pus.  It  could  then  be  made  out  that  there 
was  an  opening  in  the  diaphragm  leading  down  to  an 
abdominal  abscess.  Drainage-tubes  were  inserted  and 
the  lad  made  an  excellent  recovery,  the  lung  subsequent- 
ly expanding  fully. 

Mr.  F.  C.  Abbott  said  he  had  little  doubt  at  the  time 
that  the  abscess  originated  on  the  upper  surface  of  the 
liver,  thus  shutting  off  the  greater  sac  of  the  peritoneum. 
He  pointed  out  that  most  cases  like  this  occurred  on  the 
left  side,  and  observed  that  a  gastric  ulcer  which  had  per- 
forated, would,  after  passing  into  the  lesser  sac,  naturally 
affect  the  pleura  on  the  same  side.  Perforating  ulcers  on 
the  anterior  surface  of  the  stomach  really  penetrated  the 
corresponding  pleura.  He  thought  the  best  plan  was  to 
attack  such  abscesses  through  the  thoracic  wall,  because 
the  lung  invariably  expanded  well  after.  The  danger  in 
any  event  was  certainly  less  than  would  result  from  an 
opening  made  in  the  middle  line  of  the  abdomen. 

Dr.  S.  West  questioned  the  propriety  of  getting  at 
these  abscesses  through  the  chest,  cutting  into  what 
might  prove  to  be  healthy  pleura,  and  thus  introducing 
fotd  septic  pus  into  the  pleural  cavity,  the  more  so  as  the 
abdomen  could  at  present  be  opened  with  comparative 
impunity.  He,  however,  recalled  a  case  in  which  Mr. 
Pitts  had  cut  down  upon  a  hepatic  abscess  through  the 
pleura  with  every  success.  Mr.  Peaice  Gould  observed 
that  many  of  these  cases  died  before  the  abscess  had  ex- 
tended from  the  region  of  the  duodenum  to  the  coi  re- 
sponding pleura.  He  saw  one  case  a  few  days  since,  a 
young  woman  said  to  have  a  sarcoma  of  the  liver.  There 
was  evidently  a  large  abscess  below  the  diaphragm,  and 
he  opened  it  in  the  middle  line,  immediately  below  the 
ensiform  cartilage,  giving  exit  to  a  large  quantity  of  gas, 
to  several  pints  of  fluid,  and  to  an  enormous  hydatid 
cyst  springing  from  the  upper  surface  of  the  liver.  There 
was  no  opening  in  the  diaphragm. 

Dr.  Lee  Dickinson  said  that  duodenal  ulcers  were  very 
rare  in  boys  of  this  age,  and  suggested  perforation  of  the 
colon,  referring  to  a  case  of  right  subphrenic  abscess  de- 
scribed by  Dr.  C.  J.  B.  Williams,  which  proved  to  be 
due  to  a  perforation  of  the  hepatic  flexure  of  the  colon. 


666 


MEDICAL  RECORD. 


[November  24,  1894 


Mr.  Bruce  Clarke  said  that  not  long  since  he  had 
opened  a  hydatid  of  the  liver  through  the  pleura  without 
any  untoward  sequelae. 

A  case  of  recovery  from  poisoning  by  one  ounce  of 
chloral  hydrate  was  next  communicated  by  Sir  Dyce 
Duckworth  for  Dr.  R.  J.  Colenso.  A  lady  aged  thirty- 
four,  deliberately  took,  on  December  12, 1893,  one  ounce 
of  chloral  hydrate  in  two  ounces  of  water  at  8  a.m.  At  4 
p  m.  she  was  discovered  in  her  bed  unconscious.  No  or- 
dinary rousing  measures  were  of  any  avail.  Medical  aid 
was  not  procured  till  5  30  p.m.  The  patient  was  then 
found  to  be  comatose,  with  abolition  of  all  reflexes, 
breathing  shallow  and  stertorous,  pupils  both  small  and 
very  sluggish,  pulse  130,  small  and  rather  firm;  temper- 
ature 1 00.5  °  F.  The  nature  of  the  poison  taken  was  not 
found  till  about  three  hours  subsequently.  Atropine  was 
given  hypodermically,  and  the  stomach  washed  out,  but 
the  washings  revealed  nothing  as  to  the  poison  taken. 
Strychnine,  ether,  amyl  and  other  restoratives  were  em- 
ployed, and  recovery  ultimately  occurred.  The  satisfac- 
tory result  was  doubtless  due  to  the  robust  health  and 
fine  physique  of  the  patient,  and  in  no  small  degree  to 
the  persistent  and  energetic  efforts  made  by  a  staff  of  in- 
telligent assistants,  who  labored  for  twelve  hours  to  re- 
store animation. 

The  president  alluded  to  a  case  of  a  young  woman  who 
was  proved  subsequently  to  have  taken  320  grains  of 
chloral.  The  pupils  were  contracted  almost  to  a  pin's 
point.  He  washed  out  the  stomach,  but  they  had  to  re- 
sort to  artificial  respiration  several  times  in  order  to 
keep  her  going.  He  pumped  strong  coffee  into  the 
stomach  and  ultimately  she  came  round. 

Dr.  Churton-Leeds  then  read  the  notes  of  a  case  of 
multiple  neuritis,  fatal  on  the  sixth  day,  in  a  rather  frag- 
ile girl  aged  fourteen. 


MR.  BRYANT'S  HUNTERIAN  LECTURE. 

REPORTED  BY  OUR  LONDON  CORRESPONDENT. 

The  lecture  at  the  Hunterian  Society  was  this  year  de- 
livered by  Mr.  Thomas  Bryant,  ex- president  of  the  Royal 
College  of  Surgeons.  The  topic  he  chose  for  his  address 
was  "  Some  subjects  of  Public  and  Professional  Interest." 
After  some  general  remarks  on  the  education  of  the  pro- 
fession, he  enforced  the  necessity  of  keeping  up  the 
standard  of  preliminary  studies,  and  declared  that  the 
Medical  Council  represented  not  only  the  licensing  boards 
but  the  best  views  of  the  profession  in  the  conviction  that 
those  young  men  who  have  enjoyed  the  broadest  and  deep- 
est general  education  are  the  best  fitted  to  undertake  and 
master  as  they  ought  the  many  difficulties  with  which  the 
student  of  medicine  has  to  grapple.  He  hoped,  therefore, 
that  the  time  was  not  far  off  when  for  all  university  men  an 
Arts  degree,  and  for  all  others  an  examination  of  equal 
standard,  will  be  required  before  they  are  allowed  to 
enter  the  portals  of  the  profession ;  although,  with  the 
view  of  giving  a  helping  hand  to  the  student  who,  af- 
ter taking  his  arts  degree,  must  now  have  five  years  for 
special  medical  study — it  ought  to  be  so  arranged  that 
in  his  arts  curriculum  the  subjects  of  physics,  chemistry, 
and  biology  should  be  included.  Under  this  new  regime 
the  student  would  enter  upon  his  purely  medical  work 
better  equipped  and  with  every  prospect  of  success,  and 
would  with  greater  probability  than  now  can  be  said  to 
exist,  have  unconsciously  acquired  in  his  university  train- 
ing a  cultured  mind,  and  with  it  something  of  the  true 
"professional  spirit,"  so  that  he  would  not  only  practice 
in  that  spirit,  but  when  the  business  side  had  to  be  faced 
— for  there  was  such  a  side — and  the  question  of  emolu- 
ment and  worldly  advantages  must  be  considered — he 
would  recognize  and  remember  that  he  could  only  raise 
himself  by  raising  the  profession  in  the  estimation  of 
those  who  formed  his  circle,  and  that  he  could  never  do 
so  either  by  lowering  the  position  of  his  profession  ever 
so  little,  or  by  allowing  the  "  spirit  of  trade  "  to  master 
the  "  professional  spirit,"  and  so  becoming  a  "  medical 


tradesman."  Where,  then,  asked  the  lecturer,  "is  the 
room  for  the  old  system  of  apprenticeship,  for  the  res- 
toration of  which  we  every  now  and  then  hear  a  feeble 
cry?  The  reply  to  this  could  be  but  one,  "Too  late, 
too  late.  Apprenticeship  is  as  dead  as  Caesar."  ^  This, 
he  held,  need  not  be  a  source  of  regret,  for,  reviewing  the 
system  all  round,  the  master  was  the  only  one  who,  as  a 
rule,  derived  any  certain  benefit  from  its  adoption,  for 
he  pocketed  the  premium  which  went  with  the  apprentice- 
ship— often  several  hundreds  of  pounds — and  at  the  same 
time  found  a  dispenser  or  useful  servant  in  the  unfortu- 
nate man  who  was  bound  for  five  years  to  do  whatever 
was  required  of  him.  With  the  present  heavy  demand 
upon  the  powers  and  time  of  the  student,  he  hoped  to 
hear  no  more  of  this  system,  as  it  is  an  impossibility  and 
an  anachronism.  He  thought  it  would  be  well  if  the 
teachers  during  the  last  year  of  study  would  take  some 
opportunity  of  leading  their  pupils'  thoughts  in  this  di- 
rection, for  it  was  clear  that  in  business  questions,  busi- 
ness knowledge  is  essential,  and  good  advice  at  this 
time  must  bring  forth  good  fruit.  This  might  be  done 
by  means  of  a  post  graduate  lecture,  this  taking  the  place 
with  advantage  of  the  old  "  introductory,"  which  had 
been  nearly  given  up.  He  believed  that  the  best  step  a 
student  could  take  before  entering  upon  a  practice  was 
to  spend  a  year  as  an  assistant  to  a  good  medical  prac- 
titioner ;  by  so  doing  he  would  learn  the  business  part 
of  his  profession  as  well  as  acquire  much  more  if  the 
practitioner  happened  to  be  of  a  high  class.  Medical 
schools  should  keep  a  list  of  high  class  men  in  good 
practice  who  were  willing  to  accept  qualified  students 
for  this  end,  and  both  would  no  doubt  profit  by  the 
plan. 

The  subject  of  professional  remuneration,  which  was 
now  claiming  attention,  he  felt  was  a  difficult  one  to 
handle,  but  it  had  been  the  cause  of  no  little  recent  com- 
plaining and  heartburning,  and  there  was  a  great  deal  of 
reason  for  this  feeling,  since  much  professional  work  was 
notoriously  ill  paid,  and  private  work  was  no  less  so. 
Not  long  since  an  active  chairman  of  a  provincial  county 
council  told  him  in  conversation  he  was  as  chairman 
ashamed  at  the  smallness  of  the  salaries  the  poor-law 
medical  officers  received,  and  yet  he  was  alive  to  the  fact 
that  if  the  present  ones  refused  to  continue  for  that 
amount  there  were  others  who  would  readily  accept  the 
place.  He  admitted  the  parish  parsimony  as  regards 
payments,  but  with  such  competition  before  him,  what 
was  he  to  do.  The  same  complaints  might  also  be  made 
as  regards  clubs,  and  more  particularly  of  the  so-called 
Medical  Aid  Associations.  Indeed,  rising  higher  in  the 
scale,  and  with  respect  to  honorary  appointments,  men 
who  would  wish  to  stand  well  with  their  confreres  were 
at  times  too  ready  to  accept  positions  which  others  had 
deemed  it  right  to  vacate.  In  such  men  the  "spirit  of 
trade  "  had  mastered  the  "  professional  spirit  "  and  was 
allowed  to  have  its  way.  This  conduct  all  round  was  bad 
and  sad ;  but  how  was  it  to  be  prevented  ?  Some  men 
to  put  a  stop  to  these  practices  and  other  evils  called  out, 
"  Let  the  Medical  Council  or  Royal  Corporations  cor- 
rect them ; "  while  others  looked  to  defence  associations, 
medical  associations  acting  as  courts  of  ethics,  to  pass 
judgments  and  enforce  decisions. 

He  wished  to  point  out  that  to  look  for  a  sound  rem- 
edy we  must  look  to  ourselves,  for  "  our  remedies  oft  in 
ourselves  do  lie."  To  aid  us  in  this  direction  by  all 
means' let  medical  defence  unions,  local  societies  and 
medical  associations  be  formed,  if  we  have  not  enough, 
and  more  particularly  let  these  bring  before  the  General 
Medical  Council  or  Royal  Colleges  every  grave  act  of 
professional  misconduct  of  registered  practitioners,  and 
in  so  doing  support  their  causes  with  evidences  which 
must  satisfy  their  judges ;  for  the  functions  of  these  bodies 
were  simply  judicial.  By  so  doing  the  evils  of  covering, 
of  unqualified  assistants,  of  giving  false  certificates,  of 
undue  or  gross  forms  of  advertising  and  touting  for  pa- 
tients would  speedily  be  abolished,  and  with  these  evils 
many  others  would  die.    He  suggested  a  Board  of  Dis- 


November  24,  1894] 


MEDICAL    RECORD. 


667 


cipline  to  whom  all  medical  grievances  could  by  the 
local  societies  or  associations  be  submitted,  the  duties  of 
such  a  board  being  much  the  same  as  those  of  our  own 
Royal  Colleges  of  Medicine  and  Surgery.  Such  a  strong 
appeal  court  would  have  the  confidence  of  the  profession 
and  public  and  would  help  materially  to  suppress  doubt- 
ful acts  and  check  many  evil  ones  before  they  became 
grave  enough  to  be  pronounced  "  infamous  in  a  profes- 
sional respect "  and  so  render  the  culprit  liable  to  be 
taken  off  the  register.  In  practice  we  should  never  for- 
get that  the  patients'  interests  are  those  which  should  be 
first  thought  of,  and  that  the  public  good  was  its  ulti- 
mate object ;  but  in  so  doing  let  us  remember  that  it  was 
all  important  for  the  public  interests,  as  well  as  for  the 
due  exercise  and  dignity  of  our  profession,  that  every 
practitioner  should  hold  an  independent  but  responsible 
position  and  that  in  his  professional  work  he  should  be 
left  perfectly  free  from  lay  control,  although  amenable  to 
lay  censure.  It  was  also  equally  needful  that  he  should 
be  adequately  paid  for  his  services  by  all  classes  accord- 
ing to  their  means.  All  measures,  whether  under  the 
guise  of  charity  or  termed  "provident,"  and  all  hospi- 
tals which  encourage  the  public  to  seek  professional  ad- 
vice for  nothing  or  next  to  nothing,  were  to  be  discour- 
aged as  helping  to  pauperize  and  degrade  the  public  at 
large. 

The  same  might  be  said  of  the  members  of  the  profes- 
sion who  tempted  the  public  to  do  the  same  thing  by 
means  of  private  hospitals,  touting  clubs  and  associations, 
or  who  were  ready  to  accept  at  a  reduced  figure,  over  their 
neighbors'  heads,  appointments  which  had  been  put  up 
by  laymen,  as  it  were,  to  auction  or  competition.  Medi- 
cal men  by  such  acts  adopted  the  surest  way  within  their 
power  to  lower  the  position  of  their  profession  in  general 
estimation ;  and  at  the  same  time  did  injustice  to  them- 
selves and  the  public  by  not  giving  to  the  latter  the  best 
services  the  profession  can  supply, ,while  they  must,  in  ad- 
dition, lose  their  own  self-respect  even  if  they  happen  to 
gain  cash  by  their  own  unworthy  actions.  For  let  it  be 
asked,  How  is  it  possible  for  a  man  who  is  ill-paid  or 
overworked,  or  both,  to  give  the  attention  it  is  essential 
for  him  to  bestow  on  every  case  he  has  undertaken  to  at- 
tend ;  or  to  maintain,  in  the  interests  of  the  profession, 
the  position  to  which  he  is  entitled  and  his  own  self-re- 
spect. Mr.  Bryant  then  passed  on  to  consider  the  fol- 
lowing questions :  the  working  of  public  provident  dis- 
pensaries, the  conditions  under  which  private  ones  should 
be  worked  and  sanctioned  ;  the  conditions  under  which 
clubs  should  be  worked ;  the  good  or  evil  influences  of 
medical  aid  associations  worked  for  their  own  profit  by 
laymen ;  the  duties  of  unqualified  assistants ;  and  how 
mid  wives,  or,  what  seemed  a  better  term,  "  nurse  mid- 
wives,"  are  to  be  educated  and  utilized  for  the  public 
good.  The  chief  solution  of  these  lay  in  the  hands  of 
the  general  practitioner ;  and  he  expressed  his  convic- 
tion that  clearly  formed  opinions  upon  each  of  these, 
formulated  after  due  discussion  by  such  societies  as  this, 
would  do  more  to  mould  the  professional  mind  for  good, 
and  form  a  better  basis  for  future  corporate  action  than 
any  opinions  emanating  from  the  General  Medical  Coun- 
cil or  the  two  Royal  Medical  Corporations. 

It  was  likewise  an  error  to  look  to  the  General  Medi- 
cal Council  or  Royal  Corporations  to  give,  under  exist- 
ing circumstances,  judicial  opinions  on  these  and  other 
complicated  questions.  To  ask  these  bodies  to  consider 
and  solve  ethical  questions  connected  with  professional 
work  and  professional  advancement,  and,  having  solved 
them,  to  seek  powers  to  enforce  their  views,  is  too  much 
to  expect,  even  if  it  were  desirable.  The  General  Medi- 
cal Council  has  done  good  work  in  putting  down  the 
serious  public  offence  of  "  covering  "  and  of  giving  false 
certificates,  more  especially  of  death,  by  unqualified  prac- 
titioners. It  did  good  also  in  expressing  decided  opin- 
ions on  gross  advertisements  and  other  delinquencies. 
He  assured  his  hearers  that  his  own  college — the  Royal 
College  of  Surgeons  of  England — with  its  present  limited 
disciplinary  powers,  had  not  been,  and  was  not  idle  in 


the  same  direction,  for  there  were  few  meetings  held  of 
the  council  before  which  some  complaint  of  undue 
modes  of  advertising,  and  of  the  employment  of  secret 
remedies,  with  other  illegitimate  methods  of  carrying  on 
the  "medical  trade,"  was  not  brought.  If  the  offence 
charged  was  not  serious  enough  to  justify  the  name  being 
taken  off  the  books,  a  serious  expression  of  the  council's 
opinion  upon  the  nature  of  the  act  complained  of,  and  a 
decision  that  the  misdemeanor  was  inconsistent  with  the 
declaration  made  by  the  delinquent  when  he  was  ad- 
mitted a  member  "  that  he  would  demean  himself  honor- 
ably in  the  practice  of  his  profession,  and  do  his  best  to 
maintain  the  dignity  and  welfare  of  the  college,"  were 
often  enough  to  induce  him  to  mend  his  ways  and  adopt 
more  lawful  means  of  carrying  on  his  work.  At  any 
rate,  these  expressions  of  opinion  did  great  good  and 
tended  to  stop  ways  which  lead  downward ;  and  he  be- 
lieved that  if  the  attention  of  the  council  were  more 
often  drawn  by  the  college  members  to  methods  which 
weak  men  adopted  from  their  weakness  and  which  strong 
ones  know  were  injurious  both  to  the  profession  and  the 
public,  the  action  of  the  council  for  good  would  be  more 
frequently  repeated,  to  the  great  advantage  of  the  pro- 
fession and  the  suppression  of  bad  ways.  A  society 
could  well  do  what  individual  men  might  shrink  from. 
During  the  last  seven  years — besides  all  members  of  the 
college  who  had  been  convicted  of  criminal  offences — 
six  members  have  been  removed  from  the  list  of  mem- 
bers for  issuing  advertisements  or  practising  secret  meth- 
ods of  cure  which  the  council  regarded  as  "  prejudicial 
to  the  interests  "  and  "  derogatory  to  the  honor  of  the 
college,"  as  well  as  "disgraceful  to  the  profession  of 
surgery ; "  and  six  other  members  who  had  offended 
against  our  by-laws  in  the  same  way  had  simply  been  let 
off  after  they  had  made  "  declarations,"  that  they  would 
not  so  offend  again;  while  one  other  member  was  re- 
moved for  being  associated  with  a  disreputable  museum. 
Thus  thirteen  members  had  been  brought  before  the  coun- 
cil in  seven  years  for  having  seriously  offended  against  the 
by-laws  of  the  college,  besides  many  others  who  had 
been  satisfactorily  dealt  with  by  the  President  for  minor 
offences.  But,  said  the  lecturer,  "  you  must  not  rely  on 
the  Royal  Corporations  for  the  help  which,  to  be  effec- 
tive, must  come  from  yourselves." 

Let  such  societies  as  this,  and  all  others  like  it,  exclude 
men  who  do  such  wrongs  from  their  list  of  members  if 
they  persist  in  their  bad  ways  after  they  have  been 
warned,  and  let  the  excluded  members  know  the  reason 
why  they  are  so  excluded ;  and  when  the  profession  as  a 
body  has  spoken,  greater  powers  may  be  attained  by  the 
corporations;  for  seven  years  ago,  when  the  Royal  Col- 
lege of  Surgeons  applied  to  the  Privy  Council  for  some 
enlargement  of  its  disciplinary  powers,  its  requests  were 
refused,  not,  however,  on  account  of  any  objections 
which  were  raised  by  the  Privy  Council  to  the  powers 
asked  for,  but  on  account  of  the  opposition  of  certain 
Fellows  and  ill-informed  members  of  our  own  body  who 
had  placed  themselves  in  antagonistic  positions.  If  this 
opposition  had  not  occurred,  the  disciplinary  powers  of 
the  college  would  have  been  enlarged. 

With  respect  to  "  public  provident  dispensaries,"  such 
institutions  might  be  made  valuable  both  to  the  public 
and  the  profession.  But  in  order  to  secure  these  desira- 
ble ends  it  was  all-important  that  only  such  members 
should  be  admitted  to  the  advantages  of  the  dispensary 
as  were  of  the  wage-earning  and  poorer  classes,  and  that 
the  scale  of  admission  charges  should  be  calculated  in 
single  persons  as  upon  a  percentage  of  their  wages,  and 
in  families  upon  the  aggregate  wages  of  the  family  or 
household  and  not  on  that  of  the  member  only  in  whose 
name  the  ticket  was  taken  out.  Their  doors  should  be 
opened  to  registered  members,  but  their  rules  should  be 
such  as  to  allow  of  any  of  the  "  well- to  do  poorer 
classes"  being  able  to  obtain  speedy  help  and  relief 
upon  well-defined  terms  from  any  one  of  the  doctors  of 
the  district  in  the  event  of  any  sudden  illness  or  accident 
taking  place.     Every  doctor  of  the  district  should,  more- 


668 


MEDICAL    RECORD. 


[November  24,   1894 


over,  be  admitted  a  member  of  the  staff,  should  he  wish 
to,  and  be  paid  for  the  work  he  had  done. 

With  parish  dispensaries  for  the  very  poor,  and  provi- 
dent dispensaries  for  the  "well-to-do  poor,"  the  needy 
classes  would  be  well  looked  after,  and  the  medical  offi- 
cers of  both  would  be  (airly  treated.  With  the  existence 
of  these  public  provident  dispensaries,  so  called  "  pri- 
vate dispensaries"  would  not  be  needed,  and  conse- 
sequently  should  not  be  allowed ;  since  such  dispensaries 
were  too  often  the  mere  speculations  of  needy  men  who 
traded  upon  the  poor  for  their  own  ends,  and  degraded 
the  medical  officer  to  the  level  of  a  small  and  unscrupu- 
lous tradesman.  Again,  town  and  country  clubs  were 
institutions  to  be  encouraged,  for  the  same  reasons  as 
public  provident  dispensaries;  but  it  seemed  that  the 
scale  of  charges  now  required  should  be  somewhat  higher 
than  that  which  has  been  asked  in  past  years,  for  wages 
had  been  much  raised,  and  the  medical  club  charge 
should  be  a  percentage  on  wages.  As  to  what  were 
called  "  medical  aid  associations  "  the  lecturer  was  at  a 
loss  to  know  where,  in  most  of  them,  good  was  done,  for 
it  was  clearly  degrading  for  any  qualified  man  to  do  pro- 
fessional work  as  the  paid  servant  of  a  committee  of  illit- 
erate or  even  educated  laymen,  and  consequently  to 
work  under  their  control. 

It  was  likewise  a  clear  wrong  both  to  the  public  and 
profession,  that  members  should  be  admitted  to  these  as- 
sociations who  were  not  of  the  wage  earning  or  allied 
classes,  and  who  were  well  able  to  pay  the  limited  charges 
of  a  private  practitioner.  The  medical  aid  association 
was  a  growth  of  a  diseased  nature,  and  it  ought  to  be 
either  brought  into  line  with  public  provident  dispensa- 
ries or  club  practice,  as  sanctioned  by  and  based  upon 
the  friendly  societies  act,  or  it  ought  to  be  rooted  out  of 
professional  public  work.  As  to  the  duties  of  unquali- 
fied assistants,  all  would  agree  that  they  should  be  re- 
served for  home  duties,  not  far  beyond  those  of  a 
dispensing  assistant. 

Finally  Mr.  Bryant  said  a  few  words  about  the  burning 
question  of  midwives.  He  admitted  that  in  some  dis- 
tricts they  are  necessary.  If  necessary,  it  was  evident 
that  they  should  be  efficient,  for  if  they  were  not  efficient 
they  must  be  dangerous  assistants  and  had  better  be 
away ;  and  if  they  were  to  be  efficient,  the  conclusion  was 
that  they  must  not  only  be  made  so,  but  that  their  knowl- 
edge should  be  tested  by  competent  examiners  before 
they  were  allowed  to  embark  on  their  responsible  and 
serious  duties.  He  wished  all  "  midwives,"  as  they  were 
called,  to  be  regarded  as  "nurse  midwives"  and  even 
to  be  named  such — and  he  was  pleased  to  add  that  this 
suggestion  had  been  adopted  by  the  General  Medical 
Council,  since  the  term  carries  with  it  the  meaning  that 
they  were  really  nothing  but  skilled  nurses  educated  for 
special  work.  He  wished  it  to  be  undertaken  under  the 
direction  of  the  two  Royal  Medical  Colleges  of  England 
by  means  of  examining  boards,  central  or  district,  the 
curriculum  of  study  as  well  as  scope  of  examination  en- 
tirely resting  with  the  two  royal  colleges. 


"MUST  THE  PARSON  PAY?"    AGAIN. 

TO  THE  EOfTOK  OE  THE  MEDICAL  RbCOED. 

Sir  :  As  I  am  asked  a  question  or  two  or  more  by  a 
gentleman  (I  wish  he  was  more  of  a  gentleman)  of 
Pararis,  Fla.,  it  brings  me  forward  to  trouble  you  a  lit- 
tle to  answer.  He  asks,  "  Is  it  not  a  fact  that  laboring- 
men  and  clerks  who  receive  a  salary  of  £40  per  month 
(some  less),  pay  their  medical  bills  without  a  murmur?  " 
No,  sir :  some  of  them  do,  many  of  them  murmur,  and 
some  do  not  pay  at  all.  Again,  "  Is  it  not  also  a  fact 
that  the  vast  majority  of  physicians  do  a  great  amount  of 
work  for  which  they  receive  not  a  penny,  in  some  in- 
stances even  furnishing  the  medicine?"  Yes,  sir;  but 
how  does  that  tally  with  the  first  question,  or  do  other 
people  better  off  cheat  the  doctors  ?  No  man  honors 
the  medical  profession  more  than  the  writer,  nor  have 


I  said  a  word  against  them  and  do  not  propose  to,  as  a 
class.  My  objection  to  C.  H.  Carroll's  letter  is  his  un- 
warranted inference  that  the  minister  merely  recites  his 
sermon  on  Sunday,  as  if  he  preached  but  one,  when 
many  of  them  deliver  three,  besides  week  evening  work, 
funeral  sermons  at  any  call,  and  often  receives  no  com- 
pensation. His  sarcastic  sneer  of  a  minister's  "  repeat- 
ing a  prayer  which  he  has  learned  by  heart,"  is  so  ut- 
terly unworthy  of  any  man,  let  alone  a  professional  one, 
that  it  really  places  a  stigma  on  his  manhood  (if  he  has 
any)  that  no  gentleman  would  have  placed  there.  Does 
the  man  imagine  that  a  minister  has  no  brains  to  think  ? 
Does  he  suppose  that  ministers  have  no  heart  for  human 
suffering,  no  sympathy  for  the  sick,  no  regard  for  God  ? 
that  they  merely  repeat  parrot -like  words  without  a 
thought?  expressions  without  a  feeling?  sentences  with- 
out a  care  to  comfort  the  sick,  the  sorrowing,  and  the 
mourner  ?  Does  he  have  the  opinion  that  ministers  mock 
God  with  lip  service,  without  devotion,  when  they  pray 
in  the  presence  of  human  misfortune  ?  Thank  God,  the 
medical  profession,  as  such,  are  nobler-hearted  than  the 
few  cavillers  like  this  Florida  agnostic.  If  he  will  read 
my  article  he  will  see  that  the  average  salary  of  the 
entire  ministry  is  less  than  the  $40  a  month  clerks. 
And  no  minister  in  the  United  States  gets  as  high  a 
salary  as  some  medical  men.  I  do  not  want  the  services 
of  a  man  who  so  undervalues  a  minister's  self-sacrifices, 
and  don't  expect  it.  Medical  services  have  been  ren- 
dered me  by  men  of  large  souls,  not  by  being  asked,  but 
because  they  appreciated  the  poorly  paid  services,  as  a 
rule,  of  the  large  army  of  philanthropists  in  the  Christian 
ministry.  Minister. 

Beeun,  n.  h. 


THE  MARRIAGE  OF  SYPHILITICA 

To  the  Editor  or  thb  Medical  Riookd. 

Sir  :  In  a  letter  appearing  in  your  issue  of  November 
10th,  entitled  "  The  Marriage  of  Syphilitics,"  Dr.  Frank 
E.  Maine,  of  Auburn,  N.  Y.,  answers  a  series  of  questions 
propounded  by  Dr.  Burnside  Foster,  which,  if  accepta- 
ble to  the  latter,  will  render  any  further  research  on  his 
part  quite  unnecessary.  Unfortunately,  Dr.  Maine  has 
taken  a  very  positive  stand  in  this  matter,  and  one  that 
is  wholly  unwarranted  by  either  authorities  or  facts. 
The  opinion  expressed  in  this  letter  is  opposed  utterly 
to  that  held  by  all  prominent  authorities  in  the  study  of 
syphilis,  both  at  home  and  abroad,  and  differs  wholly 
from  the  teachings  of  men  like  Bumstead,  Taylor,  F.  N. 
Otis,  Keyes,  Sturgis,  and  others,  who  haye  devoted  a 
large  part  of  their  lives  to  the  careful  and  painstaking 
study  of  this  disease  in  the  rich  fields  for  research  only 
obtainable  in  great  cities. 

While  Dr.  Maine  may  have  had  sufficient  practical  ex- 
perience in  the  study  of  syphilis,  in  its  relations  to  mar- 
riage, to  feel  justified  in  presenting  his  opinion  in  oppo- 
sition to  the  gentlemen  above  cited,  I  must  certainly 
object  to  his  classifying  scrofula  among  the  syphilitic 
sequelae,  and  would  respectfully  refer  him  to  any  of  the 
more  modern  works  on  general  pathology  under  the 
heading  tuberculosis.  As  a  matter  of  tact,  some  of  the 
most  healthy  persons  of  my  acquaintance  have  been  born 
of  parents,  one  of  whom,  at  least,  had  been  a  sufferer 
from  syphilis  before  marriage ;  nor  have  I  observed  the 
slightest  trace  of  the  disease  in  any  form  passed  down  to 
the  third  generation.  In  conclusion,  Mr.  Editor,  allow 
me  to  refer  to  the  words  of  Jonathan  Hutchinson,  F.R.S., 
the  greatest  English  syphilographer  of  today,  who  says 
in  regard  to  the  advisability  of  telling  syphilitics  that 
marriage  is  for  them  ever  to  be  avoided :  "  Such  a  course, 
or  anything  near  it,  would  prevent  thousands  of  happy 
marriages ;  would  swell  the  ranks  of  those  who  adopt 
concubinage  instead  of  wedlock,  and  while  it  would  re- 
duce the  sum  of  human  happiness,  would  probably  not 
in  the  least  diminish  the  prevalence  of  syphilis." 

Very  sincerely  yours,        W.  K.  Ons,  M.D. 

5  West  Fiftieth  Strbkt,  New  Yoek  City. 


November  24,  1894] 


MEDICAL   RECORD. 


669 


NUCLEUS    OF   RED    BLOOD  -  CORPUSCLE    OF 
MAMMALS. 

To  the  Editor  or  the  Mhdical  Record. 

Sir  :  I  read  Dr.  William  Moser's  remarks,  in  the  Med- 
ical Record  of  October  20th  last,  relating  to  the  caryo- 
cinetic  changes  in  the  red  corpuscle,  with  much  interest, 
as  I  there  recognized  various  appearances  of  blood  which 
I  discovered  during  examination  under  the  microscope 
about  seven  years  ago,  which  interested  me  greatly  at  the 
time. 

Up  to  this  date  it  appears  to  be  a  recognized  fact, 
taught  in  all  text-books,  that  a  nucleus  did  not  exist  in 
the  red  corpuscle  of  mammals,  except  in  the  embyro,  and 
as  a  consequence,  in  certain  anaemic  conditions  of  the 
blood.  I  was  always  unwilling  to  accept  that  conclusion, 
on  account  of  the  admitted  importance  of  all  nuclei  to 
cell  life,  and  thus,  as  the  blood  corpuscles  of  birds  and 
reptiles  always  contained  a  nucleus  at  all  stages  of  their 
existence,  it  seemed  highly  probable  that  thev  really 
existed  in  the  red  corpuscles  of  the  mammalia,  and, 
reasoning  by  analogy,  it  seemed  difficult  to  account  for 
their  absence,  especially  as  they  had  been  seen  in  human 
blood  in  the  foetal  stage  and  under  certain  pathological 
conditions. 

As  I  considered  that  the  nucleus  was  composed  of 
protoplasm,  it  struck  me  that  the  stain  used  by  botanists 
as  a  reagent  for  this  material  in  plants  would  be  the 
best  to  employ  to  demonstrate  the  nucleus  of  the  red 
corpuscle  of  animals,  if  it  contained  protoplasm. 

Acting  on  this  suggestion,  I  made  a  large  number  of 
human  blood  preparations  in  the  following  manner. 
Placing  a  drop  of  human  blood  on  a  slide,  3X1  inches, 
I  then  took  another  slide  and  drew  the  sharp  edge  rap- 
idly across  it  at  right  angles,  using  all  the  pressure  pos- 
sible, and  allowing  it  to  dry.  This  is  the  best  method 
of  obtaining  a  single  layer  of  blood  with  the  corpuscles 
evenly  distributed.  When  quite  dry  I  pour  over  the 
preparation  a  strong  solution  of  iodine,  and  remove  after 
about  a  minute.  It  will  dry  rapidly,  and  will  then  be 
ready  for  microscopical  examination. 

I  may  here  state  that  preparations  of  blood  treated  in 
this  manner  will  remain  in  good  form  for  an  almost  in- 
definite length  of  time,  needing  no  glass  cover  or  any 
preservative,  and  can  be  examined  dry. 

This  examination  of  preparations  of  blood,  dry,  and 
without  the  addition  of  a  glass  cover,  I  consider  an  im- 
portant feature  of  my  work,  and  accounts  for  my  seeing 
so  much  which  had  escaped  previous  observation,  be- 
cause I  noticed  that  the  addition  of  Canada  balsam  and 
other  preservatives  and  a  cover,  caused  most  of  the 
special  features  to  disappear. 

I  was  surprised  to  find  on  making  a  microscopical  ex- 
amination of  human  blood  thus  prepared,  that  all  the 
red  corpuscles  in  the  field  showed  in  each  instance  a 
clearly  defined  nucleus,  some  in  the  centre  of  the  cell, 
and  at  the  edge  in  others ;  in  many  instances  two  nuclei 
were  visible  in  the  one  cell,  and  in  rare  instances  they 
were  in  a  cluster  of  five  or  six.  In  some  instances  were 
exhibited  what  a  German  authority  calls  homogeneous 
cells,  having  merely  a  very  fine  line  as  an  outer  ring, 
and  in  some  cases  such  cells  contained  a  nucleus. 

At  the  time  I  made  a  very  fine  photograph  of  this 
slide  showing  all  these  appearances  above  described  in 
the  most  clear  and  definite  manner,  but  I  failed  to  find 
any  specialist  who  would  take  the  slightest  interest  in  the 
subject.  I  was  aware  that  Dr.  Osier,  late  of  Canada, 
and  then  holding  a  professorship  at  the  Johns  Hopkins 
University,  had  given  much  attention  to  the  microscopi- 
cal appearance  of  blood,  and  I  forwarded  to  him  copies 
of  my  original  photograph  and  enlarged  copies  of  the 
same ;  but  he  came  to  the  conclusion  that  because  they 
bad  foiled  in  their  laboratory  to  find  a  nucleus  in  the 
red  corpuscle  by  any  of  their  methods  of  staining,  that  a 
nucleus  did  not  exist,  although  he  admitted  that  I  had 
stained  and  photographed  such  an  object  which  was 
optically  perfect.    I  have  still  the  original  plate  of  my 


photograph,  and  have  shown  copies  to  hundreds  of  phy- 
sicians. 

However,  feeling  discouraged  at  the  want  of  sym- 
pathy with  my  work,  I  simply  let  the  matter  drop,  and 
was  glad  to  find  by  Dr.  Moser's  paper  that  the  subject  is 
now  claiming  attention  and  has  a  prospect  of  being  fol- 
lowed up,  as  I  consider  it  will  be  an  important  factor  in 
solving  many  of  the  most  difficult  medical  problems  of 
the  present  day,  when  systematic  and  intelligent  micro- 
scopical examination  of  the  blood  is  carried  on. 

John  Michels. 

315  Wsst  Fourteenth  Street,  New  York. 


THE  DISPENSARY  QUESTION  IN  CLEVELAND. 

To  the  Editor  of  the  Medical  Record. 

Sir  :  I  have  noticed  that  your  medical  journal  has  from 
time  to  time  denounced  the  "  dispensary  abuse,"  but  on 
the  other  hand  I  have  noticed  the  apparent  apathy  of  the 
profession  in  regard  to  this  question.  I  would  call  your 
attention  to  the  fact  that  here  in  Cleveland  we  have  got 
the  profession  at  large  agitated  over  the  question  of  the 
dispensary  abuse,  partly  brought  about  by  a  trial  going 
on  between  two  homoeopathic  physicians  in  regard  to 
this  subject,  the  judges  in  the  case  being  two  trustees  of 
their  college. 

In  my  own  case  the  trial  was  before  a  jury  in  a  Justice 
court.  I  sued  the  defendant  for  services  rendered.  The 
defendant  came  to  the  college  dispensary  looking  for  the 
surgeon  who  treated  cripples.  On  being  questioned 
he  claimed  a  willingness  to  pay*  He  stated  that  he  had 
a  correspondence  with  Columbus,  O..,  parties  who  would 
correct  the  club-feet  of  his  boy  for  I500.  He  said  that 
£500  was  too  much,  but  that  he  could  pay  a  reason- 
able fee.  I  agreed  to  do  it  for  a  reasonable  fee — less 
than  $500.  For  personal  convenience  I  very  com- 
monly have  private  patients  from  in  and  out  of  town 
go  to  the  college  building  when  a  plaster  of- Paris  dress- 
ing is  required,  but  it  is  not  applied  in  the  presence 
of  the  class.  This  is  done  at  the  college  instead  of  my 
office  on  account  of  having  plenty  of  help  at  the  college 
and  also  that  it  saves  my  office  from  being  plastered  up. 

In  this  case  I  applied  plaster  to  the  child's  feet  several 
times  at  the  college  building.  The  operation  was  per- 
formed at  University  Hospital.  The  treatment  was  con- 
tinued at  the  defendant's  home  and  my  office,  lasting,  in 
all,  about  four  months. 

The  defendant  reassured  me  over  and  over  that  he 
would  pay,  and  acknowledged  indebtedness  in  the 
presence  of  others.  Finally  when  I  tried  to  collect  my 
fee  he  denied  indebtedness,  claiming  that  I  treated  his 
child  as  a  clinical  case  before  the  class.  My  answer  to 
this  is  that  there  was  no  session  of  the  college,  and  there- 
fore there  was  no  class.  I  sued  for  2262.50.  The  de- 
fendant had  paid  on  account,  25.  The  jury  granted 
2143,  with  interest  for  three  years. 

In  discussing  the  "  dispensary  abuse "  there  is  no 
chance  for  argument  in  regard  to  the  deserving  poor — 
they  are  never  turned  away  from  dispensaries  to  my 
knowledge.  The  question  is :  "  Is  it  right  for  a  dispen- 
sary to  treat  the  well-to  do  ? ' '  My  argument  on  the  sub- 
ject is  as  follows : 
<  I  hold  that  the  services  of  dispensaries  are  maintained 
solely  for  the  poor.  That  in  return  for  the  services  ren- 
dered the  poor  patient  may  be  used  for  clinical  teaching. 
That  the  wealthy  make  donations  to  the  institution  on 
the  representation  that  the  money  is  to  be  used  in  this 
way.  That  to  obtain  donations  in  the  aforesaid  manner, 
and  then  to  use  the  funds  so  obtained  partly  for  the 
benefit  of  the  well- to  do,  is  usually  called  "  obtaining 
money  under  false  pretences,"  and  is  punishable  by  fine 
and  imprisonment. 

But  we  all  know  that  this  abuse  exists;  and  what  is 
the  cause  ?  As  I  see  it,  the  incentive  is  the  inherent 
selfishness  of  man ;  it  is  largely  brought  about  (especially 
in  the  great  cities  of  the  East)  by  the  men  at  the  top— 


670 


MEDICAL    RECORD. 


[November  24,  1894 


those  in  authority.  The  Professor  says  to  himself,  "  The 
larger  the  clinic,  and  the  more  assistants  I  have,  the 
more  important  is  my  position.  Secondly,  these  middle- 
class  patients  do  not  come  from  my  following — I  loce 
no  practice  by  it."  It  was  from  the  same  motive  that 
one  of  the  Vanderbilts  was  led  to  say :  "  The  rights  of 
the  public  be  d — d."  In  this  case  it  would  read  "  The 
rights  of  the  profession  be  d—- d." 

The  dispensary  has  no  rights  in  the  handling  of  pa- 
tients further  than  the  treatment  and  clinical  use  of  the 
poor.  It  has  no  moral  right  to  enter  into  competition 
with  the  outside  practitioner. 

But  what  about  the  rights  of  the  dispensary  physician  ? 
He  is  in  active  outside  practice  and  has  educated  him- 
self for  that  purpose.  He  is  in  open  competition  with 
all  other  practitioners  and  has  a  moral  right  to  increase 
his  practice  by  any  honorable  means,  i.e.,  in  this  case  to 
take  what  additional  practice  the  dispensary  may  acci- 
dentally or  incidentally  bring  him.  What  right  has  a 
dispensary  to  say  that  we  as  a  dispensary  acknowledge 
that  we  have  no  right  to  this  well-to-do  patient,  but  we 
shall  not  permit  you  (the  dispensary  physician)  to  treat 
him?  What  right  has  a  dispensary  to  discriminate 
against  their  dispensary  physicians  ?  Certainly  the  dis- 
pensary would  admit  the  right  of  some  other  doctor 
(who  might  be  physician  to  some  other  dispensary)  to 
have  the  patient  as  a  private  case. 

I  am  willing  to  abide  by  any  reasonable  rule  of  a  dis- 
pensary as  to  the  treatment  of  the  poor,  but  will  brook 
no  dictation  from  any  such  organization  as  to  whom  I 
shall  treat  among  the  well-to-do. 

Dr.  Bishop,  the  defendant  in  the  trial  between  the 
two  homoepathic  .physicians,  sent  out  a  card  to  the 
physicians  of  the  city  asking  the  opinion  of  the  profes- 
sion in  regard  to  the  dispensary  abuse.  He  claims  to 
have  over  one  hundred  answers  in  which  they  all  de- 
nounce the  abuse,  and  agree  that  dispensaries  are  solely 
for  the  poor,  with  the  privilege  of  using  the  patient  for 
teaching  purposes. 

William  E.  Wirt,  M.D. 

Clrvbland,  O. 


Hettr  Instrument*. 

AN  ASEPTIBLE  BISTOURY. 

The  general  desire  of  physicians  to  obtain  an  aseptible 
bistoury,  that  resembles  in  its  main  features  the  old  shell- 
handle  double  bistoury,  with  slide  catch,  has  been  com- 
plied with  by  introducing  a  new  bistoury,  of  which  the 
above  is  an  illustration.  It  is  the  same  form  and  size  as 
the  old  slide  bistoury,  its  blades  open  and  close  just  as 
readily,  and  have  the  improvement  that  they  lock  auto- 
matically, both  in  the  open  and  closed  position.  The 
advantages  claimed  are:    1.  Its  great  simplicity.     (It 


consisting  only  of  a  plain  skeleton  steel  handle  and  two 
blades.)  2.  Its  blades  are  locked  automatically,  both  in 
the  open  and  closed  position,  and  their  edges  are  pro- 
tected in  the  handle  when  closed.  3.  Its  blades  can  be 
removed  for  sterilization  in  a  simple  manner,  by  holding 
them  at  a  right  angle  with  the  handle.     4.  The  con- 


struction of  the  handle  admits  larger  blades  than  any 
other  bistoury,  which  is  in  many  cases  of  great  impor- 
tance to  the  operator. 

The  accompanying  cut  shows  the  form  and  construc- 
tion of  the  instrument.  The  small  spring  is  pressed 
outward  by  the  thumb  nail,  while  the  middle  finger 
acts  as  a  counter- pressure  against  the  side  of  the  handle, 
at  the  same  time  the  blade  is  opened  by  the  fore- 
finger. The  same  position  is  assumed  in  dosing  the 
knife.  In  this  case  the  fore  finger  presses  against  the 
back  of  the  blade.  In  readjusting  die  blade,  hold  the 
same  at  a  right  angle  to  the  handle,  so  that  the  corre- 
sponding numbers  on  the  blade  and  handle  are  in  view. 

The  instrument  is  manufactured  by  Max  Wocher  & 
Son,  surgical  instrument  makers,  Cincinnati,  O. 


Contagious  Diseases  —  Weekly  Statement — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to  the 
Sanitary  Bureau,  Health  Department,  for  the  week  end- 
ing November  17,  1894. 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebrospinal  meningitis 

Measles . 

Diphtheria 

Small-pox 


86 

106 

28 

10 

7* 

3 

1 

z 

52 

2 

166 

27 

45 

2 

Yellow  Fever  and  Mosquitoes. — Dr.  Carlos  Finlay,  of 
Havana,  believes  that  yellow  fever  is  propagated  chiefly, 
if  not  entirely,  by  inoculation,  the  principal  agent  of 
which  is  the  mosquito.  In  a  paper  in  the  Edinburgh 
Medical  Journal  iox  October,  1894,  he  presents  the  fol- 
lowing parallel,  showing  how  closely  the  vital  conditions 
of  the  mosquito  agree  with  those  which  are  known  to 
favor  or  hinder  the  spread  of  yellow  fever. 

Yellow  Fever. — Temperatures  at  which  yellow  fever 
has  been  observed  to  cease  in  New  Orleans  and  in  Rio 
Janeiro  =  150  to  180  C. 

Temperatures  which  have  proved  insufficient  to  pre- 
vent a  subsequent  reappearance  of  the  disease  without  a 
new  importation  =  o°  C. 

Temperatures  which  are  considered  to  completely  ex- 
tinguish the  infection  of  yellow  fever  =  severe  frosts. 

Mean  temperatures  which  admit  of  a  free  propagation 
of  yellow  fever  in  Havana  =  260  to  300  C. 

Coincidence  of  unprecedented  abundance  of  mos- 
quitoes with  severe  yellow- fever  epidemics,  in  Philadel- 
phia, 1 797,  and  in  the  Southern  States  of  North  America, 
1853. — {Laroehe^  ii.) 

Artificial  heat  which  has  proved  efficacious  in  definitely 
arresting  the  transmissibility  of  yellow  fever — several 
stoves  employed  to  heat  the  hold  of  the  Regalia. — 
(Laroehey  ii.,  p.  440.) 

Altitudes  at  which  epidemics  of  yellow  fever  have  been 
exceptionally  observed:  Newcastle  (Jamaica),  4,200 
feet;  and  Madrid  (1870),  2,000  feet. 

Culex  Mosquito. — Temperatures  at  which  the  mos- 
quito is  completely  benumbed  by  artificial  cooling  of  the 
air=i5°  to  190  C. 

Lowest  temperature  which  the  mosquito  will  bear,  in  a 
state  of  apparent  death,  and  after  which  it  may  yet  re- 
vive =  o°  C. 

Artificial  cold  after  which  the  mosquito  cannot  revive 
=  from  i°  to  40  C.  below  zero. 

Mean  temperatures  in  which  mosquitoes  are  most  nu- 
merous in  Havana  =  25°  to  30°  C. 

Coincidence  of  a  scarcity  of  mosquitoes  in  Havana 
with  an  unusual  diminution  of  yellow  fever  during  the 


November  24,  1894] 


MEDICAL  RECORD. 


671 


summer  of  1886,  the  reverse  coincidence  being  observed 
during  the  autumn  of  the  same  year. 

Temperatures  at  which  the  mosquito  falls  into  a  con- 
dition of  apparent  death,  but  may  still  revive  =  39 Q  to 
41 Q  C.  Temperatures  after  which  it  cannot  revive  =  41 Q 
to  490  C. 

Artificial  rarefaction  of  air  in  which  the  mosquito  is 
for  a  while  deprived  of  its  power  of  flying  or  stinging, 
but  sometimes  after  a  while  recovers  =  equivalent  to  1,000 
-6,000  feet. 

Influence  of  Bicycle  Biding  on  the  Uric- Acid  Dia- 
thesis.— Dr.  Robin  read  a  paper  before  the  Academy  of 
Medicine  of  Paris  on  this  subject,  in  which  he  stated  that 
moderate  bicycling  diminished  markedly  the  secretion  of 
uric  acid,  and  emphasized  that  this  exercise  does  not  re- 
sult in  lack  of  elimination  of  the  uric  acid,  but  really 
diminishes  its  production. 

He  finds,  on  the  other  hand,  that  in  sclerosis  of  the 
kidneys,  in  which  a  small  amount  of  albumin  is  the  most 
constant  symptom,  indulgence  in  this  form  of  exercise  is 
apt  to  markedly  increase  the  amount  of  albumin,  and  is 
therefore  contra- indicated. 

Thyroid  Feeding  in  Basedow's  Disease.— Treating 
Basedow's  disease  by  the  administration  of  thyroids  is  in 
opposition  to  much  that  has  recently  been  written  con- 
cerning the  pathogenesis  of  this  disease,  but  this  is  what 
Dr.  Voisin  (Medical  Society  of  the  Hospitals,  Paris) 
has  recently  reported.  A  young  woman  affected  with 
exophthalmic  goitre  was  given  the  thyroid  gland  of  the 
sheep  to  the  amount  of  two  drachms  daily.  At  the  end 
of  two  weeks  the  tachycardia  had  reduced  one  third,  the 
goitre  had  considerably  diminished,  as  had  the  exophthal- 
mos. When  the  case  was  reported  the  only  symptoms  of 
the  disease  were  slight  swelling  of  the  neck  and  slight 
exophthalmos.  Dis.  Dreyfus,  Brisac,  and  Beclere  ex- 
pressed their  opinion  that  thyroid  feeding  tends  to  ag- 
gravate the  disease  and  increase  its  symptoms  rather  than 
cure  it. 

Hereditary  Syphilis  in  the  Hew  born  Associated 
with  Acute  Nephritis. — Dr.  Hock  showed  at  a  meeting 
of  the  Medical  Club  (Vienna)  an  infant,  the  second  child 
of  a  syphilitic  mother,  who  eight  weeks  after  its  birth 
showed  a  syphilitic  erythema  which  disappeared  under 
the  influence  of  proto-iodide  of  mercury.  Later  the 
extremities  and  penis  began  to  swell,  and  an  examination 
of  the  urine  showed  albumin,  hyaline  casts,  and  white 
and  red  corpuscles.  Other  symptoms  of  syphilis  disap- 
peared under  the  use  of  iodide  of  potash. 

Hysterectomy  for  Uretero  -  uterine  Fistula. — Dx. 
Mackenrodt  presented  at  a  meeting  of  the  Medical  So- 
ciety (Berlin),  a  woman  on  whom  he  had  successfully 
performed  a  hysterectomy  for  the  cure  of  a  uretero- uter- 
ine fistula.  An  attempt  was  made  to  cure  the  fistula, 
a  result  of  a  forceps  delivery,  by  converting  it  into  a  ure- 
tero vaginal  fistula,  but  failing  in  this  the  operator  pro- 
ceeded to  extirpate  the  entire  uterus.  The  ureter  was 
first  separated  from  the  uterus  and  then  the  latter  re- 
moved, care  having  been  taken  to  close  the  peritoneal 
cavity,  and  also  to  arrange  an  opening  for  the  ureters  into 
the  vagina.  Three  weeks  afterward  an  oblique  opening 
was  made  in  the  bladder,  and  the  utero- vaginal  fistula 
was  attached  to  its  walls.  The  vaginal  wound  closed, 
and  the  patient  made  a  good  recovery. 

Tannigen,  a  Hew  Intestinal  Astringent. — Tannigen, 
according  to  Professors  Meyer  and  F.  Miiller,  in  the 
Deutsche  Med,  Wochenschrift,  is  a  derivative  of  tan- 
nin, and  is  a  golden-gray  odorless  and  tasteless  powder. 
In  dilute  acids  and  in  water  it  is  not  noticed,  and  is 
readily  soluble  in  alcohol.  As  it  produced  no  ill  effect 
when  given  to  animals,  Professor  Meyer  requested  Pro- 
fessor MQller  to  try  it  clinically,  and  the  latter  gentle- 
man has  for  the  last  eighteen  months  been  testing  it  with 
a  view  to  its  employment  as  a  remedial  agent.  The  dose 
given  was  from  0.2  to  0.5  grm.  three  times  a  day,  and  be- 
ing tasteless  it  was  readily  taken.   It  was  given,  however, 


in  as  large  a  quantity  as  would  lie  on  the  end  of  a  knife 
without  producing  any  ill  effect.  It  was  first  of  all 
given  in  chronic  diarrhoea  of  different  kinds,  in  dysen- 
tery, and  in  the  diarrhoea  of  phthisis.  In  far  the  larger 
number  of  cases  it  reduced  the  number  of  stools  and  im- 
proved their  consistency.  This  result  was  not,  however, 
a  constant  one,  especially  in  the  diarrhoea  of  phthisis, 
and  when  the  remedy  was  stopped  even  in  the  other 
cases  the  diarrhoea  returned.  Some  patients  took  the 
drug  for  weeks  and  experienced  no  diminution  of  its  effi- 
cacy. In  acute  diarrhoeas  it  acted,  but  not  constantly, 
and  in  the  diarrhoea  of  infants  it  produced  no  effect. 
The  proper  field,  therefore,  for  tannigen  is  the  chronic 
diarrhoeas,  and  it  possesses  the  great  advantages  over 
tannin  that  it  is  tasteless  and  does  not  distuib  the  gastric 
functions ;  it  does  not  tan  the  stomach,  but  only  the  in- 
testines. Professor  Miiller. thinks  there  is  a  decided 
want  of  such  a  remedy,  especially  in  the  diarrhoea  of 
phthisis  and  in  chronic  intestinal  catarrh,  a  remedy 
which  can  be  used  for  long  periods  with  good  effect, 
which  does  not  take  away  the  appetite,  and  which  can 
be  conveniently  taken  and  is  not  disagreeable. 

The  Parasitic  Theory  of  Eczema. — Dr.  Malcolm 
Morris  asks  and  answers  these  four  questions  regarding 
eczema : 

Are  internal  remedies  required  in  eczema  9 

The  gist  of  his  reply  is  embodied  in  these  words : 
"  My  own  view,  stated  broadly,  is  that  as  a  general  rule 
the  less  internal  medication  there  is  in  eczema  the  better. 
If  a  constitutional  dyscrasia  underlie  the  skin  affection  it 
must  of  course  be  treated  on  the  ordinary  principles  of 
medicine.' ' 

And  so  if  neuroses,  gastrointestinal  complications,  or 
special  or  general  debilities  occur,  they  require  due  at- 
tention. But  without  definite  indications  internal  medi- 
cation should  be  withheld. 

The  influence  of  diet  in  eczema. 

The  writer  here  says  :  "  I  may  frankly  state  that  my 
own  view  is  that  diet  has  no  influence  at  all  except  indi- 
rectly." Qualifications  are  entered,  of  course,  in  the 
case  of  gout  and  diabetes  complicating  eczema,  and  a 
lowered  diet  is  advised  "  if  the  lesions  are  of  an  acutely 
inflammatory  type." 

What  are  the  principles  on  which  the  local  treatment  of 
eczema  should  be  carried  out  ? 

"  Speaking  generally,  1  treat  every  case  as  if  it  were  of 
parasitic  origin.  Even  if  micro  organisms  are  not  the 
exciting  agents  in  the  causation  of  the  process  in  all 
cases,  parasitic  irritation  always  comes  into  play  sooner 
or  later  as  a  secondary  factor,  and  requires  to  be  appro- 
priately dealt  with.  The  objects  which  I  aim  at  in  the 
local  treatment  of  eczema  are,  first,  to  destroy  micro- 
organisms; secondly,  to  protect  the  inflamed  surface 
from  the  air  and  from  further  microbic  invasion ;  thirdly, 
to  sooth  irritation." 

How  is  the  tendency  to  recurrence  of  eczema  in  those 
predisposed  to  the  disease  to  be  overcome  ? 

"  Change  of  climate  is  often  productive  of  good  in 
this  direction,  especially  if  accompanied  by  complete 
rest  of  mind  as  well  as  body." 

Then,  touching  the  efficacy  of  baths  and  medicated 
waters,  about  which  so  much  has  been  said,  and  which  is 
a  matter  of  strong  popular  opinion,  the  following  sum- 
mary appears : 

1.  No  spring  known  to  me  has  any  specific  action  on 
eczema. 

2.  Sulphur  waters  have  no  special  effect  other  than 
that  due  to  their  anti-parasitic  action. 

The  Rev.  Cotton  Mather,  of  Salem  witchcraft  epidemic 
fame,  was  much  interested  in  medical  topics.  He  intro- 
duced the  practice  of  inoculation  into  New  England  at 
the  risk  of  his  life,  and  published  a  popular  work  on 
medicine  which,  as  Dr.  Oliver  Wendell  Holmes  points 
out  ("Medical  Essays"),  proves  him  to  have  been 
what  to-day  would  be  called  a  bacteriologist.  One 
of  his  capsulas  (chapters)  is  devoted  to  the  animalcular 


672 


MEDICAL   RECORD. 


[November  24,  1894 


origin  of  diseases ;  at  the  end  of  which  he  says,  speaking 
of  remedies  for  this  supposed  source  of  our  distempers : 
"  Mercury  we  know  thee  :  But  we  are  afraid  thou  wilt 
kill  us  too,  if  we  employ  thee  to  kill  them  that  kill  us. 
And  yet  for  the  cleansing  of  the  small  blood-vessels  and 
making  way  for  the  free  circulation  of  the  blood  and 
lymph — there  is  nothing  like  mercurial  deobstruents." 

The  Water-supply  of  Jerusalem.— The  Turkish  Min- 
istry of  Public  Works  has  determined  upon  the  recon- 
struction of  the  ancient  water  conduits  of  Jerusalem, 
dating  from  the  age  of  King  Solomon.  By  this  means  it 
would  be  possible  to  convey  twenty-five  hundred  cubic 
metres  of  water  daily  to  the  Holy  City.  Of  this  it  is 
proposed  to  give  one  thousand  metres  away  free  of 
charge  to  the  poor  of  Jerusalem,  the  distribution  to  take 
place  at  the  Mosque  of  Omar,  the  Holy  Sepulchre,  and 
other  places  frequented  by  pilgrims.  The  new  conduits 
are  to  be  joined  to  the  ancient  aqueducts  of  Arob,  and 
are  to  be  carried  through  a  tunnel  3,570  metres  in 
length.  The  total  outlay  in  connection  with  these 
works  is  estimated  at  2,000,000  francs. 

A  Historical  Case  of  Diphtheria. — The  influence 
which  epidemic  disease  has  had  upon  the  course  of  his- 
tory is  a  curious  subject  for  speculation,  but  most  of  the 
instances  which  have  been  adduced  by  various  writers 
who  have  occasionally  touched  upon  the  subject,  have 
been  instances  of  wide-spread  epidemics,  such  as  the 
plague  at  Athens  and  the  "Black  Death  "  in  England; 
but  the  effect  which  certain  infectious  diseases,  more  or 
less  constantly  present  in  temperate  climates,  may  have 
had  upon  historical  events  is  less  clearly  perceived.  A 
curious  instance  is  afforded  by  the  death  of  Napoleon 
Charles,  Prince  Royal  of  Holland,  the  son  of  Louis, 
brother  of  Napoleon  Bonaparte,  and  of  Hortense,  his 
stepdaughter.  This  child  died,  when  not  quite  five 
years  old,  of  a  disease,  which,  there  can  be  little  doubt, 
was  diphtheria.  The  boy  was  a  favorite  of  his  Imperial 
uncle,  and  was  generally  taken  to  St.  Cloud  when  Napo- 
leon stayed  there  in  the  summer.  Though  Napoleon 
never  seems  to  have  expressed  himself  clearly  upon  the 
Subject,  it  was  thought  by  many  that  he  proposed  to 
make  this  child,  who  was  his  nearest  male  relative  in  the 
second  generation,  his  heir.  Among  those  who  shared 
this  opinion  was  Meneval,  who,  as  private  secretary  to 
Napoleon,  had  special  opportunities  of  forming  an  opin- 
ion as  to  the  Emperor's  intentions.  If  this  child  had 
lived  Napoleon,  Meneval  thinks,  would  not  have  di- 
vorced Josephine,  would  not,  therefore,  have  exposed 
himself  to  be  insulted  by  the  Emperor  of  Russia's  refusal 
of  the  hand  of  a  grand  duchess,  and  in  all  probability 
would  not  have  gone  to  Moscow,  and  might  therefore 
very  possibly  have  founded  a  lasting  dynasty.  It  is  cu- 
rious to  remember  that  this  boy's  brother — his  uterine 
brother  at  least — did  actually  sit  on  the  throne  of  France. 
Napoleon,  who  was  very  much  moved  by  the  death  of 
his  nephew,  offered  a  prize  of  12,000  francs  to  the  author 
of  the  best  work  on  the  means  of  preventing  and  curing 
croup.  The  boy  died  on  May  5,  1807,  and  Meneval  re- 
marks that  the  superstitious  looked  upon  it  as  a  curious 
coincidence  that  Napoleon  himself  died  on  the  same  day 
of  the  same  month  fourteen  years  later. — British  Medical 
Journal. 

The  First  Recorded  Death  in  Hypnosis.— The  death 
of  Ella  Salamon,  in  Tuzer,  Upper  Hungary,  at  her  home, 
on  September  17,  1894,  while  in  an  hypnotic  state,  has 
attracted  much  attention  abroad,  owing  to  the  fact  that 
it  is  the  first  recorded  instance  of  death  of  this  kind. — 
Medical  Association. 

The  Church  Sanitary  Association  is  the  name  of  a 
society  recently  founded  in  England.  Its  membership  is 
made  up  of  the  clergy  and  laity  of  the  Established  Church 
who  believe  that  personal  cleanliness  and  the  observance 
of  hygienic  laws  are  Christian  duties.  It  proposes  to  or- 
ganize a  propaganda  by  the  establishment  of  lecture 
courses  and  the  wide  circulation  of  tracts  on  the  preser- 


vation of  health.  It  has  been  suggested  that  the  work  of 
reform  should  begin  with  the  church  buildings,  which  are 
so  often  poorly  ventilated,  draughty,  and  dark,  and  where 
people  are  often  compelled  to  sit,  with  perhaps  wet  feet 
and  damp  garments,  through  a  long  service  in  a  chilly 
cavern,  whose  stone  floor  is  covered  with  pools  from 
dripping  umbrellas. 

A  Bust  of  the  Late  Br.  Leidy  is  to  be  placed  in  the 
library  of  the  University  of  Pennsylvania. 

A  Cancer  Ward  in  a  Vienna  Hospital— Baron  Al- 
bert de  Rothschild  has  just  given  $250,000  to  build  and 
equip  a  pavilion  in  the  Empress  Elizabeth  Hospital  at 
Vienna  for  women  suffering  from  cancer.  The  money 
constitutes  a  "  Bettina  "  fund,  called  after  the  baron's 
late  wife,  who  died  from  this  disease. 

Professor  Koch  on  Cholera. — At  the  recent  meeting 
of  the  German  Public  Health  Society  at  Magdeburg,  Dr. 
Koch  said  that  it  is  now  possible  to  prevent  the  spread 
of  cholera  in  any  country,  and  he  was  certain  that  Ger- 
many would  never  be  visited  again  with  an  epidemic  if 
only  the  measures  now  adopted  were  carried  out  early 
and  energetically.  It  was  a  matter  of  indifference  to 
him  what  precautionary  measures  were  taken  in  other 
countries,  for  Germany  was  now  able  to  protect  herself 
and  keep  the  cholera  out  of  her  own  borders. 

Lepers  in  Iceland. — A  physician  was  sent  by  the 
Danish  Government  last  summer  to  make  a  special  in- 
spection tour  of  southern  Iceland  to  ascertain  the  num- 
ber of  lepers.  The  number  found  was  fifty-three,  or 
twice  as  many  as  expected.  A  hospital  is  to  be  built  to 
prevent  further  spread  of  the  disease. 

Opium-Eaters  and  the  Plague. — The  opium  dealers 
of  Hong-Kong  have  collected  data  and  issued  a  special 
pamphlet,  in  which  they  triumphantly  point  to  the  fact 
that  opium  eaters  or  smokers  were,  almost  without  ex- 
ception, exempt  from  attack  during  the  recent  epidemic 
of  the  plague. 

The  Song  of  the  General  Practitioner. 

Sung  at  the  Annual  Dinner  of  the  Bolton  and  District  Medical 
Society,  October^  1894. 

He  must  not  walk  his  rounds  for  fear  his  patients  think  him  poor, 
And  dearly  do  they  love  to  see  a  carriage  at  their  door ; 
And  if  his  horse  is  fat—"  He  must  have  little  work  to  do," 
And  if  it's  lean  the  reason  is  :  "  He  starves  the  poor  old  screw.'* 

Should  he  call  upon  his  patients  every  day  when  they  are  ill, 
His  motive  plainly  is  u  to  make  a  great  big  doctor's  bill ;  " 
If  he  visits  them  less  frequently— thus  less'ning  their  expense— 
The  chances  are  he'll  be  accused  of  wilful  negligence. 

He  must  work  all  day  and  half  the  night,  and  never  say  he's  tired ; 
For  the  public  look  upon  him  simply  as  a  servant  hired  ; 
And  should  he  take  a  holiday  he'll  find  when  he  comes  back 
Some  patients  have  resented  it  by  giving  him  "  the  sack." 

Concerning  money  he  must  seem  indifferent  to  be, 
And  folks  will  think  he  practises  from  pure  philanthropy, 
When  we  hear  about  him  boasting  of  the  guineas  that  he  earns 
We  wonder  if  they  all  appear  in  his  income-tax  returns. 

About  his  own  afflictions  he  must  never  say  a  word ; 
The  notion  of  a  doctor  being  ill  is  so  absurd  1 
And  when,  perhaps  from  overwork,  he's  laid  upon  the  shelf 
His  sympathizing  patients  say  :  **  Physician,  heal  thyself  ! " 

J.  Johnston,  M.D.,  in  Lancet. 

Cigarette  makers'  Cramps  has  attacked  the  operatives 
in  the  French  state  tobacco  factories.  It  is  very  com- 
mon in  Spain,  but  has  not  hitherto  been  noticed  to  any 
extent  in  France.  The  cramp  affects  the  muscles  of 
the  thumb  and  first  finger  of  each  hand. 

Drunkenness  in  St.  Petersburg  is  reported  to  be 
greatly  on  the  increase,  so  much  so  that  the  authorities 
nave  become  alarmed,  and  have  instituted  the  most  ener- 
getic measures  to  suppress  it.  Any  one  found  drunk  in 
the  street  is  imprisoned  for  from  one  to  three  days,  and 
the  person  from  whom  the  last  drink  was  bought,  if  he 
can  be  found,  is  fined  from  five  to  twenty-five  rubles. 


Medical  Record 

A  Weekly  Journal  of  Medicine  and  Surgery 


Vol.  46,  No.  22. 
Whole  No.  1356. 


New  York,  December  i,  1894. 


$5.00  Per  Annum. 
Single  Copies,  ioc. 


Gfrrijjitral  Articles. 

HISTORY  OF  AN  EPIDEMIC  OF  ACUTE  NER- 
VOUS DISEASE  OF  UNUSUAL  TYPE.1 
BrC.  S.  CAVERLY,  M.D., 

RUTLAND,  7T. 
PXRSIDBNT  8XATB  BOARD  OP  HEALTH. 

During  the  month  of  June,  1894,  there  appeared  in  a 
portion  of  the  valley  of  the  Otter  Creek,  in  the  State  of 
Vermont,  an  epidemic  of  nervous  disease,  in  which  the 
distinctive  and  most  common  symptom  was  paralysis. 
The  great  majority  of  the  sufferers  were  children  under 
six  years  of  age.  The  city  of  Rutland  and  town  of  Wal- 
lingford  were  first  affected,  later  the  towns  immediately 
contiguous  to  these,  and  to  this  tier  of  towns,  thirteen 
in  number,  the  outbreak  was  almost  exclusively  confined. 

A  remarkable  series  of  cases  occurring  in'  the  city  of 
Rutland  first  attracted  the  attention  of  the  physicians, 
and  later,  popular  interest.  Many  of  these  cases  were 
taken  sick  without  apparent  cause.  In  others  it  was 
ascribed  to  getting  over- heated,  or  chilled  suddenly  when 
heated,  indigestion,  and  occasionally  to  trauma.  After 
a  few  weeks  deaths  were  heard  of,  and  during  the  latter 
part  of  July  everyone  was  discussing  the  "  new  disease." 

From  my  own  observation,  and  conversation  with 
other  physicians,  it  was  plain  to  me  that  an  epidemic  of 
unusual,  if  not  of  unique,  type  was  prevailing,  and  I 
decided  that  my  connection  with  the  State  Board  of 
Health  imposed  a  duty  on  me  in  connection  therewith. 
The  investigation  thus  undertaken  in  an  official  capacity 
soon  showed  me  that  the  information  I  was  acquiring, 
while  unusual  and  valuable  from  a  public-health  stand- 
point, was  doubly  so  from  that  of  the  practitioner.  I  am 
sure,  therefore,  that  the  physicians  who  have  so  kindly 
given  me,  as  a  member  of  the  State  Board  of  Health,  the 
bulk  of  the  data  on  which  this  paper  is  founded,  will 
pardon  the  use  to  which  I  propose  to  put  this  material. 

This  epidemic  has  been  confined,  with  very  few  excep- 
tions, to  the  narrowest  part  of  the  Otter  Creek  Valley. 
The  territory  is  bounded  on  the  east  by  the  Green 
Mountain  range,  and  on  the  west  by  the  Taconic  range 
of  mountains.  North  and  south  it  has  no  natural 
boundaries.  Its  area  is  about  fifteen  miles  wide,  in- 
cluding the  sides  of  the  bounding  mountains,  and  thirty 
miles  long.  Through  this  valley,  from  south  to  north, 
flows  the  sluggish  stream  of  Otter  Creek,  dammed  at 
several  points.  The  extreme  heat  and  drouth  of  the 
early  summer  had  rendered  the  stream  unusually  low. 
The  only  reliable  figures  obtainable  as  to  temperature, 
humidity,  and  rainfall  for  Vermont,  are  furnished  me  by 
the  United  States  Weather  Bureau  Observer  at  North- 
field,  Vt.  Since  the  opening  of  the  station  at  that  place, 
in  1887,  the  average  temperature,  humidity,  and  rain- 
fall per  month,  for  the  months  April,  May,  June,  July, 
and  August,  the  months  in  which  these  conditions  could 
have  any  influence  on  an  epidemic  occurring  during  the 
summer  months,  was  as  follows : 


Temper- 
ature. 

Humid- 
ity. 

Rain- 
fall. 

Temper- 
ature. 

Humid- 
ity. 

Rain- 
fall. 

1887... 
1888... 
1889... 
1890... 

•S77*  F. 

•"•US- 

•55.3  **. 

76.7 

72.5 

74.1 
87.8 

375 
345 
3-05 
3.79 

1 891. 
1892. 

1893. 
1894. 

..56.2°F. 

..56.9°F. 

..56.5°F. 

...56.i°F. 

75.8 
74-8 

75-6 
77-3 

2.98 
3-76 
3-51 
2.25 

>  Read  before  the  Vermont  State  Medical  Society  at  its  annual 
meeting,  October,  1894. 


It  will  be  noticed  by  these  figures  that  the  only  marked 
deviation  from  the  recorded  meteorological  conditions 
of  the  past  eight  years,  which  has  occurred  during  the 
past  summer,  has  been  in  the  average  monthly  rainfall. 
This  has  been  thirty  per  cent,  less  during  the  past  spring 
and  summer  months  than  the  average  for  the  past  eight 
years  during  these  months.  While  it  was  a  matter  of  fre- 
quent remark  that  our  early  summer  was  this  year  unusu- 
ally hot,  the  official  figures  do  not  bear  out  this  statement. 

The  population  of  the  towns  affected  in  this  valley  ag- 
gregates twenty- six  thousand,  of  which  eighteen  thou- 
sand dwell  in  the  quarrying  and  manufacturing  centres 
of  Rutland,  West  Rutland,  and  Proctor.  The  usual 
sprinkling  of  foreign  elements  prevails  in  these  centres, 
while  in  the  outlying  farming  towns  the  population  is 
chiefly  of  the  regular  New  England  type. 

The  first  cases  in  this  epidemic  of  which  I  find  notes, 
occurred  in  the  city  of  Rutland  and  town  of  Walling- 
ford,  simultaneously,  about  June  17th.  The  characteris- 
tics of  the  disease  can  be  illustrated  by  a  few  cases, 
among  the  one  hundred  and  twenty  six  cases  of  which  I 
now  have  notes. 

Case  L— Boy,  three  years  of  age,  American.  Previ- 
ous health  good ;  active  child ;  healthier  than  his  brother 
two  years  older.  No  apparent  cause.  Moderate  fever; 
coated  tongue;  loss  of  appetite;  sluggish  bowels.  As 
these  symptoms  improved  it  was  observed  that  he  could 
not  walk  or  even  stand  alone.  The  weakness  was  most 
noticeable  in  the  extensors  of  the  thigh.  After  ten  days 
he  began  to  improve,  and  in  three  weeks  was  quite  well. 

This  case  is  an  illustration  of  the  mildest  type  of  these 
cases. 

Case  II.— Boy,  three  and  a  half  years  of  age,  Irish ; 
sturdy  child ;  apparent  cause  playing  too  hard.  Fever, 
1020  to  1030  F.  Incontinence  of  urine  for  ten  days; 
hyperesthesia.  Fever  abated  on  third  day.  Then  was 
noticed  paralysis  of  both  legs ;  loss  of  patella  reflex ;  no 
anaesthesia ;  slight  response  in  lower  extremities  to 
faradism.  Left  leg  improved  rapidly,  right  slowly. 
After  six  weeks  was  able  to  stand  and  take  a  few  steps 
by  taking  hold  of  chairs.  After  three  months  paralysis 
confined  to  right  glutei  and  lower  spinal  muscles,  with 
considerable  wasting.  The  weakness  of  spinal  muscles 
has  resulted  in  a  spinal  curvature. 

Case  XCHL  —  Boy,  two  years  of  age,  American. 
Had  an  attack  of  indigestion,  from  which  he  recovered, 
when  he  was  taken  on  a  long  carriage  drive.  Imme- 
diately developed  high  fever,  with  an  erythematous  rash 
and  considerable  muscular  rigidity.  After  a  few  days 
there  was  paralysis  of  both  legs  and  loss  of  patella  re- 
flexes. .  After  a  month  has  not  improved. 

Case  XCIV.— Boy,  six  years  of  age ;  healthy  child  ; 
apparent  cause  chilling  the  body;  fever,  1040  F. ;  vom- 
iting. Acute  symptoms  lasted  six  days.  On  the  sixth 
day  paralysis  of  right  arm,  followed  on  the  seventh  day 
with  paralysis  of  left  leg.  After  three  months  extensors 
of  left  thigh  and  right  deltoid  wasted  and  weak. 

These  three  cases  illustrate  a  very  common  phase  of  the 
disease.  Some  of  the  cases  fully  recovered,  and  many 
still  suffer  from  probably  permanent  impairment  of  some 
muscles. 

Case  IV.— Boy,  six  years  of  age ;  no  apparent  cause ; 
taken  sick  with  convulsions  while  playing  in  the  street ; 
these  lasted  nine  hours;  moderate  fever;  rapid  pulse; 
vomiting ;  rigidity  of  neck  and  back  muscles ;  hyperes- 
thesia of  skin ;  very  restless.    Death  on  sixth  day. 


674 


MEDICAL  RECORD. 


[December  i,  1894 


Case  XXXII. — Female!  twenty-one  years  of  age ; 
married ;  one  child,  aged  sixteen  months.  Had  been 
caring  for  child,  which  was  sick ;  somewhat  fatigued. 
Complained  of  head  and  backache.  Pulse,  80 ;  tem- 
perature, normal.  Third  day,  temperature,  103.50  F. ; 
pulse,  100.  Eyeballs  rolled  up ;  head  and  neck  drawn 
back.  Bowels  regular ;  urine  normal ;  no  albumin ;  no 
sugar.  Red  blotches  on  skin  that  came  and  went ;  urti- 
caria; temperature,  100.50  to  1020  F.  for  succeeding 
three  or  four  days.  Pulse  about  100 ;  unable  to  swallow 
or  speak;  answered  questions  by  moving  head;  in  no 
pain ;  sixth  day,  pulse,  60 ;  temperature,  98. 6°  F.  On 
the  eleventh  day  had  some  pain  in  the  stomach  (indiges- 
tion ?),  neck  became  rigid.  Pulse,  100,  and  temperature 
98. 6°  F.  during  next  two  days.  Then  pulse  sank  to  45 
and  became  irregular.  On  the  thirteenth  day  some  pain 
in  right  side  of  head  and  right  eye.  Heart  gradually 
gave  out  and  she  died. 

Case  XCVI. — Boy,  three  and  a  half  years  of  age ; 
Italian.  Headache ;  drowsiness ;  fever ;  on  second  day 
strabismus.  Pulse,  45,  irregular.  On  the  sixth  day  he 
apparently  recovered.  Played  too  hard,  and  two  days 
after  developed  same  train  of  symptoms  and  died. 

Case  CXXV. — Female, aged  twenty- nine;  American. 
Married ;  one  child,  agfed  eight  months.  Does  not  nurse 
child.  Neurasthenic;  no  apparent  cause.  No  fever; 
much  nausea;  great  head  and  backache;  marked  opis- 
thotonos ;  double  vision ;  deafness  for  several  days  and 
roaring  in  head.  Retention  of  urine ;  catheterized  eight 
days.  Soreness  of  legs  and  arms ;  no  eruption ;  pupils 
fully  dilated ;  second  day,  paralysis  of  right  arm ;  fourth 
day,  right  leg ;  fifth  day,  left  leg ;  and  sixth  day,  left 
arm ;  also  paralysis  of  abdominal  muscles  and  obstinate 
constipation;  anaesthesia  of  limbs ;  reflexes  gone.  After 
three  weeks  has  recovered  slowly  use  of  limbs  except 
leg  muscles,  which  she  is  still  unable  to  use. 

Cask  LXXXVIII.  —  Female,  aged  six  ;  American. 
Frail  child  ;  had  a  spinal  curvature  for  four  or  five  years. 
No  history  except  this.  Fever ;  nausea ;  head  drawn  to 
one  side ;  facial  paralysis.  On  third  day  paralysis  in  all 
extremities;  hyperesthesia;  soreness  of  joints;  obsti- 
nate constipation;  inability  to  use  abdominal  muscles. 
After  two  months  paralysis  continues,  except  slight  move- 
ments of  toes  and  fingers ;  considerable  wasting.  Bod- 
ily functions  fair ;  mind  and  special  senses  normal. 
Facial  paralysis  passed. 

These  five  cases  illustrate  the  severer  cases  of  the  epi- 
demic, many  of  which  were  fatal.  There  were  a  certain 
number  of  cases  exhibiting  odd  and  interesting  symptoms 
out  of  the  usual  line. 

Case  XL — Aged  seven;  American.  Whooping- 
cough  followed  by  broncho-pneumonia.  During  prog- 
ress of  the  latter  disease  had  loss  of  speech  for  two 
weeks;  delirium;  fever;  left  arm  paralyzed.  Recov- 
ered after  two  weeks. 

Case  LXXXVII. — Boy,  aged  four ;  American.  Con- 
vulsions; double  vision  for  one  week;  very  drowsy. 
Paralysis  of  external  rectus  of  one  eye,  which  remains. 

Case  XC1X  —Boy,  aged  thirteen ;  French.  Had  a 
fall  injuring  back,  followed  by  fever,  nausea,  muscular 
rigidity  of  neck.  From  this,  case  ran  along  like  an  aver- 
age case  of  typhoid  fever,  lacking  marked  typhoid  symp- 
toms except  the  fever  curve.  Fever  lasted  four  weeks. 
Following  this  was  paralysis  of  right  arm  and  right  leg. 
Paralysis  improving. 

Of  the  126  cases  of  which  I  have  notes,  all  except  six 
were  in  the  valley  above  described.  Of  these  6,  2  oc- 
curred in  the  town  of  Ludlow,  on  the  east  side  of  the 
Green  Mountains,  and  3  in  Middletown,  and  1  in  Fair 
Haven,  in  Rutland  County.  The  epidemic  died  out 
first  in  the  towns  first  affected,  and  lingered  latest  in 
those  affected  last.1  Of  the  thirteen  towns  in  the  Otter 
Creek  Valley  which  have  suffered  from  this  epidemic, 

1  New  cases,  three  in  number,  are  reported  from  Proctor  and  Pitts- 
ford  since  the  preparation  of  this  paper.  These  towns  were  chiefly 
affected  during  August,  and  the  last  cases  prior  to  these  occurred 
about  September  xst 


those  that  show  the  greatest  number  of  cases — Rutland, 
55  ;  Proctor,  26 ;  and  Pittsford,  8 — are  immediately  on 
this  stream.  The  towns  of  Wallingford  and  Clarendon, 
also  on  the  stream,  suffered  very  little.1 

It  should  be  stated  that  there  have  been,  among  do- 
mestic animals  in  this  valley,  many  cases  of  paralytic  dis- 
ease during  the  period  of  this  outbreak.  Deaths  among 
horses  have  been  found  post  mortem,  according  to  at  least 
one  veterinarian,  to  be  due  to  meningitis,  and  there  have 
been  also  deaths  among  fowls  and  dogs  described  as  par- 
alytic. 

It  has  been  remarked  by  many  physicians  that  die 
usual  diseases  of  children,  during  the  past  summer,  have 
been  attended  with  exaggerated  nervous  symptoms.  It 
is  a  source  of  great  regret  that  in  none  of  the  fatal  cases 
could  an  autopsy  be  procured,  though  extraordinary  ef- 
forts were  several  times  made  to  secure  one. 

In  collecting  statistics  of  this  outbreak  I  have  sought 
only  those  cases  attended  with  marked  nervous  phenom- 
ena, like  muscular  rigidity,  special  sense  disturbance,  or 
paralysis,  and  no  disease  by  name,  seeking  not  to  pre- 
judge the  character  of  the  disease  or  anticipate  a  diagno- 
sis. Without  detailing  further  individual  cases  I  have 
prepared  a  tabulated  history  of  the  epidemic  as  a  whole, 
collecting  the  commonest  features  of  the  cases  in  my  re- 
ported list  of  cases  by  themselves.  I  presume  my  list 
includes  ninety  per  cent,  of  all  the  cases  that  have  oc- 
curred. 

Table  i. — Age  and  Sex. 

Under  6  years Male,  33  cases. 

14  "   Female,  16     " 

14  "   Not  stated,    36     '« 

From  6  to  14  years Male,  10  cases. 

"  "     Female,  2    " 

41     Not  stated,     9     •' 

Over  14  years Male,  8  cases. 

«4  •«     Female,  5     " 

Stated  between  a  few  months  and  9  years 7     " 

Of  the  119  cases  in  which  the  age  is  given,  85  are 
under  6  years,  21  between  6  and  14  years,  and  13  were 
over  14  years.  Of  the  latter  was  one  case  70  years  of 
age.  The  genuineness  of  this  case  might  at  first  be  ques- 
tioned, but  the  train  of  initial  symptoms  was  the  same  as 
in  the  milder  cases  of  childhood,  with  paralysis  of  both 
lower  extremities,  clearing  up  after  ten  days. 

Of  the  74  cases  in  which  the  sex  was  stated,  51  were 
males  and  23  females. 

Table  2.— Nationality. 

American 35 

Irish-American 17 

French 6 

Jewish 1 

Italian 1 

Swede 1 

Not  st  ated 65 

It  has  been  noted  that  in  the  larger  centres  the  races 
affected  were  oftenest  foreign,  while  among  the  farming 
population  Americans  predominated.  It  has  not  been 
entirely  confined  to  any  one  class,  but  has  been  most 
prevalent  among  working  people  and  those  whose 
sanitary  surroundings  were  not  of  the  best. 

Table  3. — Previous  Health. 

Good 41 

Poor 10 

Not  stated 75 

Table  4. — Immediate  Cause. 

Fatigue. 2 

Whooping-cough 1 

Over-heating 22 

Chilling  body 4 

Indigestion 2 

Typhoid  fever 2 

Trauma 2 

Pneumonia 2 

No  apparent  cause  or  not  stated 89 

1The  map  on  p.  676  will  show  the  geographical  distribution  of 
the  cases. 


December  i,  1894] 


MEDICAL    RECORD. 


675 


There  has  been  but  a  single  instance,  so  for  as  I  can 
determine,  in  which  there  has  been  more  than  one  case 
in  a  family,  and  since  it  has  usually  occurred  in  families 
of  several  children,  I  think  it  can  be  safely  set  down  as 
non-contagious. 

Table  5.— Initial  Symptoms. 
A. 

T.  stated  as  above  1030  F 27 

T.    •«      ««    between  99°  and  103°  F 22 

Said  to  have  had  no  fevtr 3 

Not  stated ". ... 7.7.7.7.  74 

B. —Duration  of  Initial  Fever. 

Stated  to  be  1  day  or  less 4 

.    •■      "  •'  i»2  days-. 2 


days  •. 2 

*.      «  .<  2-     4.     6 

I*      u  "  3-4    " 7 

4-7   "      26 

«      «  •«  7_I4«»      4 

No  fever,  or  not  stated 77 

C. — Nausea. 
Stated  to  have  had  nausea  or  vomiting 25 

il        *«        *«        •«     no    11       It  U  "  J 

D. — Convulsions. 

Stated  to  have  had  convulsions 12 

All  under  14  years. 

E. — Bowels. 

Stated  to  have  been  constipated 3 

"      "      ,%    had  diarrhoea 3 

F. — Bladder. 

Stated  to  have  had  retention  of  urine 7 

"      *•      "      •'    incontinence     " 1 

G. 

Stated  to  have  had  muscular  rigidity  of  neck  or  back  or  opistho- 
tonos: 

Fatal  cases 5 

Non-fatal 15 

H. 
Stated  to  have  had  hyperawthesia  of  skin  or  soreness  of  muscles 
of  the  extremities  : 

Fatal  cases * 


Non-fatal. 


«4 


I.— Special  Senses. 

Stated  to  have  had  strabismus 2 

14  4i        partial  blindness 1 

44  u        double  vision 2 

*'  "        deafness I 

K. — Skin  Eruptions. 

Stated  to  have  had  a  simple  erythema 29 

"  "        urticaria 2 

Table  6. — Initial  Paralysis. 

No  paralysis. 6    Fully  recovered,  5 ;  died,  1 

Not  determined 7  "7 

Both  legs 66      "  '•         43     "     4 

Arm  and  leg  (same  side; 9       "  "  2     "      1 

One  arm 5       *'  u  3 

Oneleg 6      u  "  1 

Both  legs  and  one  arm 4 

Tongue  and  throat 2  "      1 

Both  arms 3 

All  extremities 4  4*     3 

Extensors  one  thigh I 

•'  Variously  in  arms  and  legs " 8       u  '*  1     "      1 

External  rectus  one  eye 1 

One  side  of  face. 1 

One  arm  and  opposite  leg 1 

All    extremities    and     abdominal 
muscles 2 

Table  7.— Paralysis  Remaining  at  Time  of  Report. 

Glutei  and  lower  spinal  muscles  of  one  side 1 

Both  legs 17 

One  leg 8 

Both  legs  and  one  arm 3 

Both  arms. 2 

Arm  and  leg  same  side 6 

Extensors  one  thigh 2 

One  arm 3 

44  Variously  in  arms  and  legs" 6 

External  rectus  one  eye I 

All  extremities 2 

One  side  of  face 1 

Extensors  left  thigh  and  right  deltoid 1 


It  will  be  seen  by  these  tables  that  6  of  these  cases 
had  no  paralysis,  as  stated,  but  all  of  these  had  distinct 
rigidity  of  the  spinal  muscles,  strabismus,  or  other  symp- 
toms referable  to  the  nervous  system,  and  are  therefore 
included  in  this  report.  Of  the  7  cases  reported  as 
"not  known"  to  have  had  paralysis,  or  in  which 
'nothing  is  said  of  any  paralysis,  all  died  with  distinct 
symptoms  of  acute  nervous  disease,  and  may  be  fairly 
supposed  to  have  died  in  the  initial  stage. 

Of  those  that  died  it  will  be  noticed  that,  besides  the  7 
that  succumbed  early  in  the  acute  stage,  4  had  paralysis 
of  both  lower  extremities,  3  of  all  extremities,  and  1 
each  had .  no  paralysis,  hemiplegia,  tongue,  and  throat, 
and  variously  paralyzed. 

Of  those  who  had  recovered  fully  at  the  date  of  the 
reports,  which  varied  from  two  weeks  to  two  months 
after  the  attacks,  5  had  no  paralysis,  43  had  paralysis  of 
both  lower  extremities,  2  of  one  arm  and  leg  of  same 
side,  3  of  one  arm,  1  of  one  leg. 

While  of  the  cases  of  which  I  have  reports,  53  have 
still  some  paralysis  at  the  time  of  the  report,  and  it  is 
probable  that  many  of  these  are  permanently  disabled. 

I  am  unable  to  make  any  statements  based  on  statis- 
tics as  to  the  number  of  cases  in  which  there  has  been  a 
wasting  of  the  affected  muscles,  for  the  time  is  yet  too 
short  in  most  cases  for  marked  wasting  to  have  occurred. 
I  hope  later  to  be  able  to  report  on  these  wrecks  of  the 
epidemic.  The  composite  picture  presented  by  the  facts  I 
have  elicited  does  not  readily  admit  of  a  name.  It  is 
at  once  noticed  that  individual  cases  can  be  readily  rec- 
ognized as  presenting  a  typical  picture  of  poliomyelitis 
anterior,  but  that  the  variations  from  the  text  book  type 
of  this  disease  are  many  and  marked.  Opisthotonos,  eye 
symptoms,  and  hyperesthesia  are  out  of  place  in  the 
phenomena  of  this  disease,  so  that  the  epidemic,  as  a 
whole,  presents  notable  departures  from  the  regular  feat- 
ures of  the  disease. 

Again,  cerebrospinal,  especially  spinal,  meningitis,  is 
quickly  seen  in  certain  phases  of  this  outbreak,  but  the 
season  of  the  year,  the  general  absence  of  the  special 
sense  disturbance,  particularly  ear  disease,  the  low  mor- 
tality, the  absence  of  purpuric  eruption  (stated  by  some 
as  the  most  important  diagnostic  point  in  this  disease  as 
an  epidemic),  are  strong  arguments  against  this  diagnosis. 
Without  further  detailing  the  arguments  that  present 
themselves  to  all  of  us  for  and  against  the  claims  of  in- 
dividual diseases  to  recognition  in  this  connection,  I  am 
glad  to  be  able  to  quote  the  opinions  of  high  authority 
in  regard  to  this  point. 

Dr.  A.  Jacobi,  whose  knowledge  of  this  outbreak  is 
gained  solely  from  my  written  description,  has  very 
kindly  permitted  me  to  quote  him  on  this  point.  He 
says :  "  All  your  cases  belong  to  the  same  class,  cerebro- 
spinal meningitis.  They  prove  that  nature  does  not 
walk  in  ruts  as  most  of  our  text  books  do,  and  that  tran- 
sitions and  variations  are  common.  Two  years  ago  I 
made  two  autopsies  in  which  the  main  lesions  were  in 
the  lumbar  portion  of  the  spine.  I  have  no  doubt  they 
had  a  chance  to  become  paraplegic  if  they  had  lived. 
The  frequency  of  paralysis  in  your  cases  is  something 
very  uncommon;  so  is  your  low  mortality;  both  prove 
that  your  cases  were  more  spinal  than  cerebral." 

This  opinion,  coming  from  so  high  an  authority  in 
medicine,  is  of  course  entitled  to  the  greatest  respect. 

Dr.  M.  Allen  Starr  saw,  in  September,  ten  of  these 
cases,  at  that  time,  of  course,  in  the  chronic  stage  of  the 
disease.  His  conclusions  in  regard  to  the  epidemic, 
which  I  am  permitted  to  give,  are :  "  The  cases  seen,  if 
seen  without  a  history,  would  have  all  impressed  me  as 
cases  of  acute  anterior  poliomyelitis,  without  a  doubt 
The  history  does  not  appear  to  me  to  contradict  this 
diagnosis,  and  while  in  some  respects  unusual,  viz.,  in 
eye  paralysis,  in  stiff  neck  and  pain,  there  is  not  as 
much  difficulty  in  assigning  them  to  anterior  poliomye- 
litis as  there  is  in  assigning  them  to  cerebro-spinal  men- 
ingitis. Epidemics  of  anterior  poliomyelitis  are  not 
unknown." 


676 


MEDICAL  RECORD. 


[December  i,   1894 


He  cites  one  reported  by  Cordier  in  Lyon  Medical, 
January  and  February,  1888 ;  one  in  Switzerland  in  1889 
(account  not  found) ;  one  near  Boston,  reported  by  Put- 
nam two  years  ago,  and  one  in  Stockholm,  reported  by 
Medim,  Neurohg.  Centralblatt,  1891,  p.  397.  Dr.  Starr 
further  says,  "  As  to  eyes,  there  are  some  cases  on  record 
of  ocular  palsy  with  infantile  paralysis.  Sachs  had  such 
a  case.     As  to  pain,  in  the  majority  of  adults  and  young 


in  several  of  the  accessorius,  and  in  others  symptoms 
referable  to  the  vagus  Disturbance  of  the  voice  and 
paralysis  of  the  muscles  of  mastication,  and  vaso-motor 
paralysis  were  seen  in  2  fatal  cases.  In  1  ophthalmo- 
plegia externa.  At  the  time  of  this  Stockholm  epidemic 
of  poliomyelitis,  during  August  and  September,  polineu- 
ritis  appeared  and  was  thought  to  be  due  to  the  same 
source.     This  neuritis   was  followed  by  considerable 


Rutland  County.    C&ftcs  indicated  by  black  dots. 


people  able  to  state  symptoms,  pain  was  complained  of. 
I  saw  such  a  case  yesterday." 

The  Stockholm  epidemic,  reported  by  Medim,  an 
account  of  which  Dr.  Starr  furnishes  me,  occurred  in 
1887.  The  disease  first  appeared  in  the  month  of  May, 
and  by  August  9th  had  assumed  an  epidemic  character. 
From  the  latter  date  to  September  23d,  Medim  saw  29 
cases,  and  knew  of  44  during  the  summer,  from  May 
to  November.  The  cases  reported  by  him,  as  a  whole, 
resemble  more  nearly  the  typical  cases  of  poliomyelitis 
than  those  in  the  Vermont  epidemic.  Three  of  his 
cases  were  fatal  in  the  acute  stage.  "There  were  no- 
ticed paralysis  of  the  abducens  in  5  cases,  disturbance 
of  speech  in  a  few;  in  1  case  paralysis  of  the  tongue, 


tenderness;  in  some  cases  twitching  and  tremor;  also 
there  was  ataxia  of  movement  during  convalescence. 
These  neuritis  cases,  however,  showed  no  wasting. 
Medim  considered  infantile  paralysis  a  specific  infectious 
disease,  in  whose  acute  stage  the  entire  organism  is 
affected.  Autopsies  by  Rissler  support  this  theory.  He 
found  in  the  spinal  cord  an  acute  parenchymatous  in- 
flammation in  the  anterior  horns,  with  degeneration  of 
the  ganglion  cells  and  secondary  degeneration  of  nerve- 
fibres  in  the  association  tracks,  in  the  anterior  columns, 
and  in  the  anterior  nerve- roots;  also  in  the  nuclei  of 
the  hypoglossus,  vagus,  facial,  and  abducens  nerves.  In 
most  of  the  cases  the  anterior  horns  were  particularly 
affected ;  in  other  cases  also  the  peripheral  nerves  and 


December  i,  1894] 


MEDICAL    RECORD, 


077 


brain  cortex.  It  was  possible  that  all  the  nerve  nuclei 
in  the  medulla  and  pons  should  be  affected." 

I  have  quoted  freely  from  Medim's  report  because  his 
is  the  only  epidemic  of  poliomyelitis  of  which  I  can  se- 
cure accurate  facts.  Dr.  Charles  L.  Dana  has  also  per- 
mitted me  to  quote  his  opinion  of  this  epidemic.  His 
knowledge  oi  the  outbreak  was  likewise  gained  from  my 
written  statements  to  him,  and  from  an  examination  of 
the  cord  and  brain  of  a  fowl  sent  him,  which  was  suffer- 
ing from  paralysis  of  legs  and  wings.  His  statement  is 
as  follows :  "Dr.  Dunham,  of  the  Carnegie  Laboratory, 
very  kindly  made  a  bacteriological  examination  of  the 
cord  and  sciatic  nerve  of  the  fowl ;  but  with  negative 
results.  Microscopic  examination  shows  an  acute 
poliomyelitis  of  the  lumbar  part  of  the  cord,  and  no 
meningitis.  Dr.  Dunham's  inoculating  needle  did  not 
strike  the  affected  part. 

"  Apart  from  the  results  of  this  case,  which,  of  course, 
may  have  no  relation  to  the  epidemic,  I  feel  the  greatest 
possible  confidence  that  the  disease  is  in  most  cases  a 
true  anterior  poliomyelitis." 

Of  course  the  epidemic  and  apparently  infectious 
character  of  the  disease  points  to  a  microbic  origin. 
That  epidemic  poliomyelitis  has  such  an  origin  is  not  a 
new  hypothesis.  Dr.  Dana  in  an  early  letter  to  me 
says:  "Roger,  Thornot  and  Masselin,  Bourges,  and 
Vincent,  produced  poliomyelitis  in  rabbits  and  guinea- 
pigs  by  inoculation  of  the  coli  bacilli,  streptococcus  of 
erysipelas  modified  by  culture." 

On  this  point  it  is  to  be  hoped  that  Dr.  Dana's  further 
examination  of  the  cord  and  brain  of  the. fowl  will  throw 
some  light 

In  a  recent  letter  Dr.  Starr  further  says  that  "  there 
is  now  a  tendency  to  revise  the  pathology  of  poliomye- 
litis," the  regular  descriptions  of  which  are  founded  on 
Charcot's  statements.  Dr.  Starr  gives  me  the  gist  of  an 
article  published  by  Goldschreider  in  the  Zeitschrift fur 
klin.  Med.,  1892,  in  which  he  says  that  his  (Goldschreid- 
er's)  conclusions,  founded  on  a  review  of  all  the  cases 
with  autopsy,  was  that  the  disease  began  with  a  "  very 
intense  congestion  of  the  central  arteries  of  the  spinal 
cord  which  come  up  on  each  side  of  the  central  canal, 
and  spread  out  in  the  central  gray  matter  and  into  the 
anterior  horns.  These  arteries  have  branches  passing 
backward  into  the  gray  matter  of  the  posterior  horns, 
but  the  posterior  horns  are  chiefly  supplied  with  blood 
from  the  peripheral  arteries,  and  hence  are  less  affected 
when  the  inflammatory  condition  is  limited  to  the  dis- 
tribution of  these  central  arteries.  After  the  engorge- 
ment of  all  the  arterial  twigs,  diapedesis  occurs  and  the 
surrounding  nervous  tissue  is  permeated  by  small  cells 
and  by  serum.  It  is  this  choking  of  the  gray  matter  by 
the  inflammatory  products  which  leads  to  the  suspension 
of  functional  activity,  and  when,  as  in  many  cases  from 
impoverished  nutrition,  the  cells  of  the  anterior  horns 
are  actually  disintegrated  by  the  inflammatory  products, 
permanent  destruction  of  the  nerve*  tissue  ensues. 

Goldschreider  believes,  therefore,  that  the  primary  con- 
dition is  a  congestion  in  the  domain  of  a  definite  set  of 
arteries,  quite  comparable  to  the  condition  occurring  in 
the  lung  in  a  pneumonia,  and  in  the  intestine  in  a  ty- 
phoid fever. 

Siemerling  has  also  written  a  very  careful  article  on 
the  "  Pathology  of  Infantile  Paralysis,"  in  the  Archiv 
fur  Psychiatrie  for  January,  1894.  His  conclusion  is  as 
follows :  "  After  a  careful  review  of  all  the  literature,  we 
reach,  therefore,  the  following  conclusion,  that  in  the 
pathogenesis  of  infantile  spinal  paralysis  the  inflamma- 
tory lesion  of  the  interstitial  tissue  in  connection  with  a 
distention  of  the  blood-vessels,  especially  in  the  region 
of  the  anterior  spinal  arteries,  plays  the  chief  rdle.  A 
primary  inflammation  of  the  ganglion  cells,  in  the  sense 
given  by  Charcot,  is  not  to  be  admitted." 

Dr.  Starr  further  says :  "  One  more  point.  If  you  con- 
sult the  descriptions  given  of  congestion  of  the  cord,  you 
will  find  many  of  the  general  symptoms  of  pain,  stiffness 
of  the  muscles,  pain  on  movement,  and  general  tender- 


ness, which  were  present  in  the  early  stage  of  your  epi- 
demic. If  now  we  grant  that  this  newer  pathology  is 
correct,  these  symptoms  are  easily  explained  on  the  the- 
ory that  the  congestion  and  the  inflammatory  processes 
were  in  your  epidemic  not  limited  to  the  domain  of  the 
anterior  spinal  arteries,  but  extended  to  the  posterior 
parts  as  well." 

The  quotations  thus  liberally  taken  from  so  competent 
authorities  leave  very  little  to  be  said  in  regard  to  the 
pathology  or  diagnosis  of  our  disease.  Admitting  Dr. 
Starr's  reasoning  in  regard  to  the  congestion  of  the  pos- 
terior as  well  as  the  anterior  portions  of  the  cord  to  be 
correct,  supported  by  his  citations  from  Goldschreider, 
Siemerling,  and  Rissler,  the  phenomena  of  this  epidemic 
can  be  reconciled  with  a  diagnosis  of  poliomyelitis.  The 
pain,  hyperesthesia,  special  sense  disturbance,  and  mus- 
cular rigidity,  the  most  important  departures  in  our  epi- 
demic from  the  established  symptoms  of  poliomyelitis, 
are  rendered  explainable  under  this  newer  pathology. 
A  diagnosis  of  epidemic  cerebro  spinal  meningitis  would 
certainly  be  more  strained.  The  disease,  cerebro*  spinal 
meningitis,  in  epidemic  form  being  more  common,  its 
symptoms  and  behavior  are  correspondingly  better  un- 
derstood than  poliomyelitis. 

Gowers  states  that  it  has  usually  prevailed  chiefly  in 
winter  and  spring,  ceasing  about  July.  This  seems  to  be 
very  uniformly  agreed  to.  Its  features  are  discomfort, 
later  pain  in  the  head,  backache,  vomiting,  stiffness  of 
neck  and  back  muscles.  Pulse  not  uniformly  rapid; 
temperature  usually  very  high,  1040  to  1060  F.  Erup- 
tions, especially  herpetic  and  purpuric,  are  common. 
Cranial  nerve  symptoms,  and  deafness  and  blindness  as 
sequelae,  are  the  rule  in  a  certain  number  of  cases.  Cases, 
and  even  epidemics,  of  an  abortive  form  of  this  disease 
are  not  unknown.  Gowers  states  that  the  mortality  var 
ries  from  twenty  to  eighty  per  cent.  Hemiplegia,  and  in 
spinal  cases  paraplegia,  are  occasional  sequelae,  but  they 
are  always  attended  by  rigidity  and  contractures  of  the 
muscles.  These  are  the  long- recognized  features  of  epi- 
demic cerebrospinal  meningitis.  There  must  be  admit- 
ted to  be  some  marks  of  similarity  between  this  descrip- 
tion and  our  epidemic.  The  almost  universal  paralysis 
in  our  cases,  and  its  irregular  and  varied  character,  are 
entirely  foreign  to  the  generally  described  features  of 
cerebrospinal  meningitis.  Likewise,  too,  the  season  of 
the  year,  the  general  absence  of  eye  and  ear  impairment, 
and  of  herpetic  and  purpuric  eruptions,  the  low  mor- 
tality, and  the  absence  of  contractures. 

In  an  epidemic  like  this,  in  which  there  is  a  blending 
of  the  symptoms  of  two  or  more  diseases,  the  decision 
must  rest  between  the  symptoms  which  are  most  uni- 
formly present  and  which  are  most  pathognomonic  of  each 
disease.  And  while,  as  Dr.  Jacobi,  speaking — we  are 
always  glad  to  admit — from  a  vast  experience  and  long 
study,  intimates  that  there  are  important  exceptions  in 
actual  life  to  the  stereotyped  description  of  the  books, 
the  exceptions  in  this  outbreak  to  the  long  established 
symptoms  of  cerebrospinal  meningitis  seem  to  be  so 
marked  as  to  really  overshadow  those  that  would  be  left 
to  establish  that  diagnosis.  Under  the  newer  pathology 
given  of  poliomyelitis,  symptoms  referable  to  the  me- 
ninges and  cerebral  ganglia  can  be  reasonably  explained. 

In  conclusion,  let  me  acknowledge  the  uniform  cour- 
tesy with  which  the  practitioners  of  Rutland  County 
have  responded  to  my  requests  for  statistics  of  this  out- 
break. The  list  includes  nearly  all  the  practising  phy- 
sicians of  this  county.  Comparatively  few  of  the  cases 
have  fallen  under  my  direct  observation,  and  without 
their  aid  it  would  obviously  have  been  impossible  to 
make  any  record  of  this  unparalleled  epidemic  approach- 
ing completeness. 


Army  Medical  Museum. — There  are  now  32,269  spe- 
cimens in  the  Army  Medical  Museum  in  Washington. 
The  number  of  specimens  received  during  the  year  end- 
ing June  30,  1894,  was  1,363. 


678 


MEDICAL   RECORD. 


[December  i,  1894 


PREMATURE  DELIVERY  OF  A  DEAD  CHILD, 
INDUCED  BY  ACUTE  APPENDICITIS,  WITH 
REMARKS   ON  APPENDICITIS  IN  WOMEN. 

By  PAUL  F.    MUNDfi,   M.D., 

MHW    YOMC. 

Although  there  is  no  real  anatomical  or  pathological 
reason  why  acute  inflammation  of  the  appendix  vermi- 
formis  should  not  occur  as  frequently  in  the  female  sex 
as  it  does  in  the  male,  it  is  only  within  recent  years  that 
the  reports  of  appendicitis  in  women  have  become  so 
numerous  as  to  attract  attention.  One  reason  for  this 
apparent  immunity  of  the  female  sex  from  this  disease 
probably  was  that  in  the  ante  operating  days  such  in- 
flammations in  the  right  iliac  region  were  looked  upon 
as  pelvic  "cellulitis,"  or  peritonitis,  the  incorrectness  of 
this  diagnosis  never  being  exposed,  either  because  the  • 
patient  died  of  general  peritonitis  and  no  autopsy  was 
made,  or  because  the  abscess  fortunately  opened  into  the 
bowel,  the  pus  was  evacuated  per  anum,  and  the  patient 
recovered  without  a  suspicion  of  the  true  nature  of  the 
case. 

I  remember  perfectly  seeing  such  a  case  of  supposed 
inflammatory  exudation  between  the  layers  of  the  right 
broad  ligament,  some  twenty  years  ago,  in  which  I  or- 
dered the  usual  blister  and  hot-poultice  treatment.  The 
idea  of  an  appendicitis,  or  perityphlitis  as  it  was  then 
called,  did  not  occur  to  me,  although  I  had  shortly  be- 
fore assisted  at  several  operations  for  perityphlitic  ab- 
scess in  men.  Some  two  weeks  after  seeing  this  woman 
I  was  called  to  her  house,  and  found  a  fluctuating  swell- 
ing in  the  median  line  between  umbilicus  and  pubes, 
which  I  aspirated.  The  true  nature  of  the  case  was 
then  revealed,  for  the  fluid  removed  had  a  decidedly  fecu- 
lent odor.  I  incised  the  abscess  freely,  and  in  course  of 
time  the  sinus  healed. 

Since  it  has  become  the  rule  to  open  the  abdomen  and 
remove  all  pus  sacs,  whether  of  ovary  or  tube,  as  soon 
as  the  presence  of  suppuration  is  discovered,  and  in  cases 
where  the  pus  points  toward  the  abdominal  skin  to  open 
the  abscess  there  freely,  as  in  a  subcutaneous  abscess  oc- 
curring anywhere  else,  we  have  met  with  more  and  more 
cases  of  unsuspected  abscesses  of  appendiceal  origin  in 
the  female,  the  existence  of  which  had  been  masked  by 
the  great  frequency  of  inflammatory  and  suppurative  dis- 
ease of  the  uterine  appendages.  I  have  seen  in  consul- 
tation and  in  the  hospital  at  least  half  a  dozen  cases  of 
exudate  in  the  right  ilio-ovarian  region  which  were  sup- 
posed to  be  due  to  pelvic  peritonitis  or  cellulitis,  where 
the  high  location  of  the  exudate  and  the  absolute  free- 
dom of  the  right  appendages  showed  the  exudate  to  be 
caused  by  appendicitis,  and  the  opening  of  the  abscess 
confirmed  this  diagnosis.  In  one  case  an  ovarian  tumor 
of  the  size  of  a  grape  fruit  occupied  the  right  hypogastric 
region ;  the  pain  and  high  temperature  were  supposed  to 
be  due  to  an  inflammation  of  the  cyst,  probably  from  a 
twisted  pedicle.  Vaginal  examination  revealed  nothing 
but  a  rigid  vaginal  vault.  On  opening  the  abdomen  the 
ovarian  cyst  was  found  not  inflamed,  and  after  its  re- 
moval an  abscess  was  discovered  between  the  layers  of 
the  broad  ligament  which  had  worked  its  way  down  from 
the  right  periappendiceal  region.  The  appendix  was 
found  to  be  gangrenous. 

It  would  be  well,  therefore,  to  bear  in  mind  in  every 
case  of  inflammatory  exudate  or  suppuration  in  the  right 
half  of  the  female  pelvis,  particularly  if  the  exudate  ex- 
tends up  as  high  as,  or  higher  than,  the  crest  of  the  ilium, 
that  the  primary  cause  of  the  exudate  may  be  an  appen- 
dicitis, whether  the  uterine  appendages  of  that  side  be 
inflamed  or  not.  If  the  appendages  are  healthy,  and  the 
exudate  is  due  to  inflammation  of  the  appendix  vermi- 
formis,  the  finger  per  vaginam  will  find  the  right  vaginal 
vault  empty,  the  uterus  normally  movable,  and  the  exu- 
date not  reachable  from  below.  We  must  not  forget  an- 
other possibility,  however,  namely,  if  the  exudate  extends 
much  above  the  crest  of  the  ilium,  it  and  the  suppuration 
may  be  of  perinephritic  origin,  and  thus  retro-peritoneal. 


I  have  recently  seen,  in  consultation  with  Dr.  D.  Froeh- 
lich,  a  lady  just  recovering  from  an  attack  of  severe  pain 
in  the  right  iliac  region,  the  seventh  in  three  yean, 
when  under  anaesthesia  the  swollen,  curled  appendix 
could  readily  be  felt  through  the  abdominal  wall. 

I  will  mention,  en  passant,  that  occasionally  an  en- 
tirely unexpected  fortunate  termination  of  the  case  may 
be  brought  about  by  the  bursting  of  the  perityphlitic  ab- 
scess into  the  bowel,  whereupon  the  swelling  in  the  right 
iliac  fossa  disappears  and  rapid  recovery  takes  place.  I 
have  seen  two  such  cases,  in  one  of  which  the  diagnosis 
was  made  and  operation  fixed  for  the  following  day;  in 
the  other,  the  swelling  was  in  the  median  line,  resem- 
bling the  distended  bladder,  and  exploratory  aspiration 
was  to  be  performed  on  the  next  morning.  In  both 
cases  during  the  night  a  chamber- vessel  full  of  stinking 
pus  was  evacuated  from  the  bowels,  the  swelling  disap- 
peared, and  the  patient  rapidly  recovered. 

The  above  instances  show  how  the  diagnosis  of  an  ap- 
pendicitis in  the  female  may  be  masked,  and  even  ren- 
dered impossible  before  the  operation,  owing  to  the  com- 
mon inflammatory  diseases  of  the  uterine  appendages, 
even  more  frequently  than  is  the  case  in  the  nude.  My 
object,  however,  in  this  short  paper  is  rather  to  lead  up 
to  the  occurrence  of  acute  appendicitis  at  a  particular 
time  in  a  woman's  life,  which  has,  to  my  knowledge,  here- 
tofore not  been  mentioned,  than  to  discuss  the  general 
subject  of  appendicitis  in  the  female.  I  refer  to  the  in- 
fluence which  inflammation  of  the  vermiform  appendix 
occurring  during  pregnancy  may  have  on  that  condition 
and  the  welfare  of  the  child. 

So  far  as  I  am  aware  there  is  no  case  on  record  of  ap- 
pendicitis during  pregnancy.  There  is,  of  course,  no 
reason  why  such  an  inflammation  should  not  occur  at  that 
time.  But,  if  any  such  case  has  been  reported,  I  have 
not  seen  it. 

The  rarity  of  the  occurrence  and  the  practical  impor- 
tance of  thinking  of  its  possibility,  and  consequently  de- 
tecting its  presence  at  an  early  stage,  have  led  me  to 
report  the  following  case  which  recently  came  under  my 
observation : 

On  the  night  of  September  21st  I  was  called  by  Dr. 

E.  Hochheimer  to  see,  with  him,  Mrs.  F ,  then  at  the 

end  of  the  eighth  month  of  her  first  pregnancy.  I  saw 
her  at  about  one  o'clock  on  the  morning  of  September 
sad,  when  she  was  in  active  labor,  the  mouth  tempera- 
ture being  1040  F. ;  the  pulse,  140 ;  the  face  much  flushed 
and  expression  anxious.  The  history  given  me  by  the 
doctor  was,  that  on  the  15th  he  was  called  to  see  the 
lady  for  "  pain  and  tenderness  in  the  lower  part  of  the  ab- 
domen, equally  severe  in  the  median  line  and  on  both 
sides.  This  was  accompanied  by  a  rise  of  temperature 
to  1010  F.,  and  eventually  to  1020  F.  on  the  fourth  day. 
Rest  in  bed,  light  diet,  and  hot-water  bag,  together  with 
occasional  ^- grain  doses  of  morphine  p.r.n.,  were  or- 
dered. The  pain  gradually  subsided  and  the  tempera- 
ture fell  till  the  evening  of  September  20th,  when  it  was 
990  F.,  and  she  was  expected  to  sit  up  on  the  following 
day.  On  the  21st,  about  9  a.m.,  she  was  seized  with 
atrocious  pains  in  the  pelvic  region,  accompanied  by 
pronounced  chill,  and  temperature  101.50  F.,  at  the  same 
time  labor  pains  began  and  continued  until  you  saw  her." 
The  foregoing  account  is  from  a  letter  to  me  written 
after  the  patient's  recovery.  With  a  large  obstetrical 
experience  and  considerable  acquaintance  with  appendi- 
citis from  personal  observation,  it  still,  very  naturally, 
did  not  occur  to  Dr.  Hochheimer  to  attribute  the  pain 
and  fever  in  this  case  to  so  unexpected  a  cause  as  appen- 
dicitis, and  when  I  saw  the  patient  the  pains  were  so  uni- 
versal over  the  whole  lower  part  of  the  abdomen,  both 
during  and  between  the  uterine  contractions,  that  it  was 
impossible  to  localize  any  one  particularly  painful  point. 
About  2.30  a.m.,  on  September  2 2d,  a  dead  child  was 
born  without  any  artificial  assistance.  Desquamation  of 
the  epidermis  on  one  leg  showed  that  the  child  had  been 
dead  at  least  twenty-four  hours.  There  was  no  difficulty 
in  delivering  the  placenta,  nor  any  post-partum  hemor- 


December  i,  1894] 


MEDICAL  RECORD. 


679 


rhage,  bat  the  patient  went  into  a  semi-delirious  condi- 
tion, and  appeared  very  much  prostrated,  so  that  further 
examination  was  postponed.  I  was  at  that  time  in  great 
doubt  as  to  the  cause  of  the  fever  and  premature  delivery 
of  a  dead  child,  particularly  as  the  history  gave  the  very 
decided  possibility  of  infection  from  scarlatina  and  diph- 
theria, to  both  of  which  diseases  the  patient  had  been 
exposed  during  the  two  previous  weeks.  The  abdomen, 
even  after  delivery,  was  universally  so  tender  that  no  re- 
liance could  be  placed  on  the  location  of  the  pain  as  an 
aid  to  diagnosis.  On  seeing  the  patient  again,  about 
twelve  hours  later,  however,  decided  dulness  could  read- 
ily be  made  out,  together  with  a  very  acute  pain  on  press- 
ure in  the  right  iliac  region,  the  outlines  of  the  uterus 
being  clearly  distinguishable.  Per  vaginam,  the  right 
vault  was  found  free.  No  particular  pain  elsewhere  in 
the  pelvis  or  abdomen.  Temperature  now  1020  F; 
pulse,  120. 

The  probability  of  general  scarlatinal  or  diphtheritic 
infection  was  now  excluded,  and  the  choice  lay  between 
typhoid  fever,  pelvic  peritonitis,  and  appendicitis,  of 
which  I  chose  the  latter  as  the  most  probable.  I  had 
never  heard  of  or  seen  a  case  of  this  kind  during  preg- 
nancy, but  could  see  no  reason  why  it  might  not  occur. 
And  I  ascribed  the  severe  pain  on  the  morning  of  the 
day  preceding  delivery  to  the  perforation  of  the  appen- 
dix and  the  discharge  of  pus  into  the  pericecal  cellular 
tissue,  since  its  discharge  into  the  general  peritoneal 
cavity  would  have  been  followed  by  general  peritonitis 
and  speedy  death.  At  any  rate  the  peritoneal  cavity 
could  safely  be  considered  closed  from  the  cavity  of  the 
abscess  by  adhesions.  As  the  patient's  condition  was 
much  improved,  I  preferred  to  wait  until  the  immediate 
shock  of  the  confinement  had  passed  away,  especially  as 
rather  intractable  bilious  vomiting  came  on,  which  de- 
pressed the  patient  both  morally  and  physically.  Dr. 
Hochheimer  and  I  therefore  decided  to  defer  the  in- 
evitable operation  for  appendiceal  abscess  a  few  days,  so 
long  as  the  patient's  condition  allowed  it ;  my  own  chief 
reasons  for  this  postponement  being  the  absence  of  any 
symptoms  requiring  immediate  operation,  the  undoubted 
sealing  off  of  the  abscess  cavity  from  the  general  peri- 
toneal cavity,  and  the  possible  danger  of  puerperal  in- 
fection from  the  abscess  after  it  was  opened.  With  the 
understanding  that  I  should  see  the  patient  again,  three 
days  later,  unless  something  unexpected  occurred,  I  left 
her  on  September  24th,  and  on  the  27th  I  found  that, 
after  nearly  normal  temperature  on  the  24th  and  25th, 
the  thermometer  had  again  shown  a  rise  to  1020  F.  on 
the  26th,  and  was  101.80  F.  when  I  saw  her.  The  dul- 
ness in  the  right  iliac  region  was  as  marked  as  ever, 
although  the  pain  was  less  severe.  I  now  advised  im- 
mediate operation,  which  was  deferred  until  the  next 
day  in  order  that  Dr.  Willy  Meyer,  at  the  request  of  the 
family,  could  he  present  to  examine  the  case  and  assist 
at  the  operation.  Accordingly  on  the  28th,  Dr.  Willy 
Meyer  concurring  in  the  diagnosis  and  indication  for 
operation  in  his  presence,  and  with  the  assistance  of 
Drs.  Hochheimer  and  B.  H.  Wells,  I  opened  the  abscess, 
which  was  found  completely  closed  by  a  thick  wall  of 
agglutinated  intestines.  Drainage  tubes  were  inserted, 
and  the  after-treatment  left  to  the  care  of  Dr.  Hoch- 
heimer.    Convalescence  was  practically  uneventful. 

I  need  scarcely  say  that  the  death  of  the  child  was  due 
to  the  high  temperature,  and  the  premature  labor  to 
the  effort  of  the  uterus  to  expel  its  dead  contents.  It 
is.  providential  that  the  high  temperature  preceding,  dur- 
ing, and  following  labor  did  not  produce,  at  least,  an 
acute  endometritis,  which  would  certainly  have  been  the 
case  had  the  cause  of  the  fever  been  a  general  septic  in- 
fection. As  a  preventive,  an  ice-bag  was  kept  on  the 
abdomen  for  several  days  after  delivery. 

I  am  indebted  to  Dr.  Hochheimer  not  only  for  the 
opportunity  of  seeing  the  case,  but  also  for  the  permis- 
sion to  publish  it  as  an  example  to  other  physicians  who 
may  happen  to  see  pregnant  women  with  acute  pain  in 
the  right  iliac  region  accompanied  by  fever.     I  think 


that  in  a  future  similar  case  I  would  open  the  abscess 
at  once,  as  soon  as  a  reasonable  probability  of  its  existence 
could  be  settled,  without  reference  to  the  pregnancy  or 
the  impending  or  completed  delivery.  I  would  rather 
take  the  chances  of  puerperal  infection  from  the  abscess 
than  of  its  unexpected  rupture  at  any  moment  into  the 
peritoneal  cavity. 

20  West  Forrv-nrrH  Steeet,  November  8, 1894. 


A  CONTRIBUTION  TO  THE  STUDY  OF  THE 
LOCATION  AND  PHYSIOLOGY  OF  THE  VIS- 
UAL CEREBRAL  CENTRE. 

As  Shown  by  a  Case  of  Monocular  Amaurosis 
which  Terminated  in  Complete  and  Permanent 
Recovery.1 

By  ALFRED  HINDE,  M.D., 

CHICAGO,  ILL. 

SENIOX  fUIGEON  TO  THE  BYE  AND  BAR  DEPARTMENT  OP  THE  CENTRAL  FEES 
DISPENSARY  ;  INSTRUCTOR  IN  DISEASES  OP  1HE  BYE  AMD  BAR,  AND  OPHTHAL- 
MOLOGIST TO  THE  NEUROLOGICAL  CLINIC  OP  RUSH  MEDICAL  COLLEGE,  CHICAGO. 

The  sparseness  of  its  literature!  because  of  infiequency  of 
occurrence,  the  apparent  seriousness  of  the  clinical  pict- 
ure, and  a  desire  to  aid  in  elucidating  an  interesting 
brain  condition,  prompt  me  to  briefly  record  the  fol- 
lowing case. 

S.  D.  T. ,  female,  American,  single,  age  nineteen, 

school-teacher,  a  florid  blonde,  in  height,  five  feet  six  and 
one  half  inches,  and  weighing  145  pounds,  was  referred 
to  me  from  an  adjoining  State,  because  of  total  blindness 
of  the  right  eye. 

She  detailed  a  good  non-neurotic  family  history,  and 
had  had  no  severe  personal  sickness.  At  the  age  of 
seventeen  she  first  menstruated  scantily,  and  thereafter 
repeated  the  function  at  intervals  of  five  weeks  for  the 
first  year.  During  the  succeeding  twelve  months  the 
intermenstrual  period  of  time  had  shortened,  and,  when 
the  case  presented  itself,  was  only  of  three  weeks'  dura- 
tion. The  discharge  continued  to  be  of  slight  amount, 
lasted  for  three  days,  and  its  commencement  was  asso- 
ciated with  pelvic  distress,  as  well  as  before,  during,  and 
after  the  period;  there  was  considerable  nerve- stoim, 
that  presented  itself  in  an  irritable  temper,  with  anorexia 
and  insomnia,  besides  vulvar  heat,  and  frequent  mictu- 
rition. 

Mentally  bright,  industrious,  and  of  studious  bent,  she 
said  she  had  lately  lost  only  slightly  in  weight,  but 
greatly  in  bodily  strength  and  endurance,  so  that  the 
least  physical  exercise,  or  mental  application,  resulted  in 
extreme  exhaustion,  and  produced  a  perfect  whirlwind  of 
unrest. 

When  eighteen  years  old,  and  "  preparing  an  essay," 
for  a  school  examination,  she  was  under  considerable 
mental  strain,  and  was  seized  with  a  condition  of  uncon- 
trollable nervousness  which  lasted  one  week  and  necessi- 
tated her  return  home.  During  this  entire  time  con- 
sciousness was  retained,  but  she  lost  all  control  of  herself 
— would  laugh  and  cry  alternately — and  though  real- 
izing her  ludicrous  behavior,  she  seemed  utterly  unable 
to  prevent  her  strange  actions.  With  rest  of  brain  men- 
tal quiet  ensued,  but  during  the  past  year  minor  recur- 
rences have  happened,  whenever  her  surroundings  were 
not  to  her  liking,  or  when  she  again  attempted  further 
studious  efforts;  and  the  attacks  were  most  pione  to 
occur  at  the  menstrual  periods. 

During  the  last  week  of  December,  1893,  she  became 
a  subject  of  the  grippe,  and  soon  after  its  onset  she 
noticed  that  the  vision  of  the  right  eye  was  failing,  and 
it  became  progressively  worse  during  the  following  six 
weeks,  so  that  at  the  end  of  this  time  not  only  no  ob- 
jective vision  was  retained,  but  also  perception  of  light 
was  annulled  ;  day  and  night  were  alike  to  this  eye.  She 
observed  that  her  recognition  of  colors,  and  that  of  ob- 
jects, was  gradually  reduced;  and  that  for  light  was 
the  latest  to  be  perceptibly  affected. 

This  condition  of  right-eye  blindness  had  lasted  for 

»  Read  before  the  Chicago  Medical  Society,  October  15,  1894. 


68o 


MEDICAL  RECORD- 


[December  i,  1894 


about  six  weeks  when  I  first  saw  her  on  March  31,  1893. 
At  this  time  there  was  no  apparent  disease  of  motility,  or 
structure  of  either  eye ;  ophthalmoscopies^  both  were 
alike  and  normal.  The  pupils  had  a  diameter  of  4 
mm.,  were  circular,  and  the  iritic  reflexes— direct  and 
consentaneous — were  actively  and  equally  present  in  the 
two  eyes.  Of  the  left  eye  there  was  no  complaint.  It 
had  more  than  average  vision  and  read  half  of  the  *J 
types  of  Snellen  at  twenty  feet  distance.  Its  color-sense 
was  perfect.  The  visual  field,  however,  was  inconstant. 
At  the  commencement  of  the  testing  it  was  perfect 
throughout  and  of  full  size,  but  before  the  dose  of  the 
examination  it  contracted  slightly  in  its  periphery,  above, 
below,  and  nasally ;  or  in  those  portions  of  the  retina 
that  are  least  richly  supplied  with  nerve-elements.  This 
decrease  in  size  of  the  visual  field  was  solely  due  to  ex- 
haustive effort,  however,  for  after  eye  rest  the  field  was 
again  found  to  be  full  sized,  but  again  contracted,  as  be- 
fore, on  continued  testing.  This  apparent  asthenopia  of 
the  peripheral  nerve-tissues  is  of  cortical  origin,  because, 
in  cases  where  both  visual  fields  are  present,  a  corre- 
sponding simultaneous  contraction  in  the  untested  field 
occurs,  thus  showing  an  exhaustion  of  function  of  cen- 
tral location.1 

Covering  carefully  the  left  eye,  a  concentrated  beam 
of  the  strongest  gas  light,  cast  within  the  pupillary  area 
of  the  right  eye,  was  said  to  be  totally  unseen,  and 
surprise  flashes  were  without  conscious  reflex  results.  The 
diplopia  confusion  tests  for  simulated  blindness  of  one  eye, 
together  with  Selling's  test  of  colored  letters  on  a  black 
ground  viewed  through  colored  glasses,  were  negative. 
Thus  was  proved  the  presence  of  the  claimed  right 
amaurosis. 

The  special  senses  of  taste,  smell,  and  hearing,  and 
that  of  ordinary  cutaneous  sensation,  were  normal  and 
alike  in  both  halves  of  the  body. 

Digital  pressure  over  the  right  supraorbital  notch  elicited 
acute  pain,  and  deep  pressure  over  the  ovarian  regions, 
more  especially  the  left,  produced  a  sickening  weakness 
which  spread  throughout  the  body,  perspiration  followed 
and  she  appeared  to  be  considerably  disturbed  and  was 
very  restless.  She  stated  that  the  symptoms  present  were 
similar  to,  but  less  severe  than  those  experienced  at  the 
first  nervous  seizure  of  spontaneous  outset,  and  almost 
exactly  like  the  minor  attacks  that  occurred  later.  Here 
was  present  an  ovarian  hyperesthesia,  besides  an  in- 
creased sensitiveness  of  the  superficial  branches  of  the 
ophthalmic  division  of  the  right  fifth  nerve. 

Galvanic  testing  developed  photopsia  in  the  left  eye, 
with  one-third  the  current  strength  required  to  produce 
the  same  result  in  the  right  eye.  A  5-milliampdre 
current  was  needed  to  arouse  flashes  of  light  in  the  right 
eye  when  first  applied,  but  before  the  termination  of  the 
testing  a  weaker  current  was  sufficient  to  start  them. 
When  compared  with  the  left,  this  indicated  a  markedly 
decreased  galvanic  reaction  of  the  right  visual  tissues, 
together  with  the  probability  of  restoration  to  the  nor- 
mal after  repeated  galvanization — because  of  the  im- 
provement in  light  perception  before  the  close  of  the 
sitting. 

The  right  auditory  nerve  did  not  develop  the  Brenner 
reaction  even  with  6-xnilliampgre  currents;  whereas, 
continued  hissing  tinnitus  was  produced  in  the  left  ear  on 
KaCl,  and  slight  transient  hissing  on  AuO,  the  testing 
pole  in  each  instance  resting  in  the  external  auditory 
canal. 

Here  we  had  a  patient  in  whom,  up  to  puberty,  there 
had  been  no  complaint,  but  when  that  time  arrived,  with 
its  disturbing  nerve-storms,  the  cerebrospinal  system 
had  to  share  with  the  sympathetic  the  existing  nerve- 
stream — the  diversion  of  a  portion  of  which  resulted  in  a 
hyperesthesia  of  the  pelvic  viscera.  Along  came  the 
grippe  infection,  reducing  still  further  the  already  weak- 
ened nerve-tone,  and  in  some  indeterminate  way  its 
ptomaines,  acting  locally  upon  especially  suitable  tis 

1  Schiele  :  Archiv  f.  Augenheilk.,  BA  xvi.,  quoted  by  Gowers,  Dis- 
eases of  the  Nervous  System,  vol.  ii.,  p.  147,  1893. 


sues,  produced  the  right-eye  amaurosis.  Thus  we  had 
present  the  anomalous  condition  of  a  strictly  localized 
cerebral  anaesthesia,  together  with  an  ovarian  hyper- 
esthesia, briefly,  a  disarrangement  of  forces  rather  than 
a  destructive  process.  The  equal  pupils  and  the  absence 
of  ophthalmoscopic  signs  proved  eye  escape.  The  pres- 
ence of  the  iritic  reflexes,  as  first  pointed  out  by  Von 
Graefe1  in  1868,  excluded  disease  as  far  back  as  the 
corpora  quadrigemina.  The  motion  of  the  irritant  lu- 
minous ray  was  still  appreciated  by  the  right  retina  and  so 
transferred,  through  rhodopsin  -  reduction  and  other 
chemical  processes,  to  the  molecules  of  its  badUary 
layer,  and  hence  backward  to  be  switched  off  at  the  re- 
flex centre  and  returned  by  the  third  nerve-trunk,  there- 
by excluding  disease  in  this  arc.  The  optic  thalamus 
and  the  posterior  limb  of  the  internal  capsule  had  es- 
caped, for  there  were  no  evident  symptoms  present  im- 
plicating these  areas.  Therefore,  we  had  remaining  only 
the  termination  of  the  visual  path  in  the  left  occipito- 
angular  cortex,  and  whatever  normal  stimula  were  con- 
ducted to  this  part  were  without  conscious  perception  or 
effect.  Here,  we  presumed,  was  the  site  of  the  patho- 
logical process,  and  the  cortical  nerve-cell  as  the  part 
especially  affected,  and,  because  of  the  increasing  ap- 
preciation of  galvanic  irritation,  we  considered  the  con- 
dition present  as  one  of  simple  inhibition  of  function — a 
rare  example  of  suppression  of  visual  will,  or  visual  con- 
sciousness of  the  left  cortical  centre,  and  that  besides  the 
psychical  condition  there  was  also  some  uncertain  molec- 
ular change  in  the  affected  cells.  Because  of  this  in- 
terpretation, a  favorable  prognosis  was  given,  and  it  was 
thought  that  insufficient  time  had  elapsed  for  permanent 
changes  in  nutrition  to  result  Yet  this  opinion  must  be 
regarded  as  very  venturesome  because  in  functional  in- 
activity, as  in  excessive  use,  there  are  physical  changes, 
and  if  the  abolition  is  sufficiently  prolonged  these  may 
be  irremovable  and  function  remain  permanently  '  abro- 
gated. Our  hopeful  opinion  was,  moreover,  founded 
upon  the  ready  institution  of  returning  function  as  shown 
during  the  galvanic  testing. 

No  time-limit  for  available  eye-use  was,  however,  haz- 
arded because  of  the  well-known  persistence  of  many 
cases  of  central  neurasthenic,  or  hysterical,  asthenopia, 
;.*.,  those  cases  where  there  is  present  perfectly  acute 
vision  momentarily,  but  in  whom  the  sight  melts  rapidly 
away  upon  attempted  continued  use,  this  being  most  prob- 
ably due  to  insufficient  nerve-charging  of  the  tissues  em- 
ployed, or  else  to  an  impairment  of  visual  will. 

Remembering  the  psychical  element  in  our  case  we 
directed  her  to  practise  and  exert  her  will  upon  all  oc- 
casions where  self-control  was  endangered;  to  restrain 
her  flightiness;  to  avoid  over-excitement  and  over- 
fatigue, both  mental  and  bodily,  and  to  live  the  details 
of  a  quiet  daily  life  with  clock-work  regularity.  The 
usual  medicines  for  the  hysterical  state  were  given. 
Above  all  things  her  impressionable  mind  was  not  per- 
mitted to  grasp  the  idea  that  she  was  the  subject  of  any 
possibly  irremovable  physical  imperfection  over  which 
she  might  pore.  She  had  no  womb  to  be  tinkered  for 
imaginary  disease  from  my  saying  so,  and  her  thoughts 
were  steered  away  from  this  end  of  her  anatomy. 

We  thus  avoided  the  institution  of  that  aura  of  melan- 
choly that  too  often  surrounds  such  cases  and  engulphs 
them,  alas !  impenetrably,  so  that  all  our  efforts  to  remove 
their  fancied  and  real  ills  are  without  avail. 

In  ordinary  health  the  storehouse  of  the  nerve-centre 
is  surcharged  with  nerve-power,  and  but  a  small  portion 
of  it  is  in  actual  use  at  any  one  time,  the  remainder  being 
retained  to  draw  from,  so  that  continuous  work  without 
conscious  fatigue  can  be  accomplished;  but  here  the 
storage  battery  was  only  sufficient  to  keep  charged  tem- 
porarily the  nerve-tissues  of  this  brain — feeble  efforts  re- 
sulted in  rapid  exhaustion,  and  in  the  elements  of  the 
left  visual  centre  it  appeared  to  be  entirely  lacking. 

To  aid  the  restitution  of  a  normal  condition  the  con- 

»  Berliner  Klinische  Woch.,  1868,  p.  aa. 
*  For  examples  see  Gowers,  loc.  cit.,  p.  165. 


December  i,  1894] 


MEDICAL  RECORD, 


681 


stant  current  was  applied  with  the  anode  to  the  closed 
right  eyelids,  and  the  cathode  to  the  left  occiput,  thus 
trying  to  bring  within  the  range  of  the  ascending  current 
the  entire  visual  path.  The  current  strength  used  was 
only  sufficient  to  arouse  and  barely  maintain  the  sensa- 
tion of  photopsia  in  the  right  eye.  The  seances  were 
daily  and  lasted  about  ten  minutes.  The  applied  current 
was  started  at  zero,  steadily  increased  to  the  exciting 
strength,  and  after  continuing  it  at  this  point  for  the  req- 
uisite time,  it  was  gradually  reduced  to  zero  again  with- 
out a  break.  The  necessary  current  was  always  strongest 
at  the  beginning  of  each  sitting,  and  before  its  close  had 
to  be  reduced  to  avoid  excessive  photopsia  with  dizziness. 
The  first  treatments  needed  a  current-strength  of  5 
milliamperes,  but  as  function  became  restored  weaker 
and  still  weaker  currents  were  sufficient.  General  gal- 
vanization and  faradization  were  also  resorted  to. 

Improvement  was  rapid,  and  after  the  fifth  treatment, 
and  with  the  left  eye  carefully  covered,  a  concentrated 
beam  of  gas  light  suddenly  flashed  into  the  right  eye, 
startled  the  patient,  and  she  said  she  "  felt  a  flickering 
sensation  "  in  it,  and  a  feeling  of  weakness  diffused  it- 
self throughout  the  body.  On  further  examination,  at 
this  time,  it  was  ascertained  that  only  the  central  portion 
of  the  retina  was  momentarily  aroused  by  the  strong 
light,  the  remaining  parts  being  wholly  anaesthetic. 
The  constant  current  had  produced  irritation  sufficient 
in  the  optic  tissues  to  start  the  subjective  light- flash,  but 
in  the  feeble  recognition  of  this  strong  light  we  had  the 
first  evidence  of  actual  light  perception — the  light-sense 
was  awakening.  From  this  on  a  daily  improvement  in 
light  sensitiveness  of  the  right  eye  was  perceptible  both 
quantitatively  in  the  centre  of  the  retina  as  well  as  in 
increase  of  area  of  sensitive  tissue.  The  first  faint  flicker 
of  light-perception  grew  steadily  stronger,  and  a  weak 
flicker  spread  nasally  over  an  increasing  surface.  Pro- 
gressing uninterruptedly  daily,  the  nasal  limit  of  the 
retina  "  felt  the  flicker,"  and,  latest  of  all,  the  temporal 
periphery  became  sensitive  to  it.  By  this  time  the  cen- 
tral retina  had  advanced  in  sensitiveness,  so  that  a  very 
much  weaker  light  was  recognized  as  such.  Of  natural 
light,  that  of  the  morning  was  first  seen  on  awakening, 
bat  after  being  observed  for  a  short  time  it  faded  en- 
tirely from  view.  Each  morning  it  appeared  stronger 
and  stronger,  lasted  longer,  and  finally  continued  all 
day.  Large  objects  then  began  to  appear,  very  indis- 
tinctly at  first  and  only  temporarily.  In  this  we  had 
the  first  commencement  of  the  returning  form  sense — 
and  eleven  days  after  the  beginning  of  the  light-sense. 
This  objective  vision  improved  rapidly,  and  progressively 
smaller  and  smaller  objects  appeared  to  view,  and  the 
larger  ones,  first  seen,  became  more  clean-cut  in  outline. 
Objective  vision  was  also  only  temporary  at  first,  but 
became  more  and  more  permanent  with  voluntary  exer- 
cise and  time.  In  forty  eight  hours  after  the  initiation 
of  objective  vision,  Snellen's  200  feet  type  could  be  read 
at  six  inches ;  and  twenty-two  days  still  later,  the  vision 
of  this  right  eye  was  I?  — ,  and  it  could  read  the  smallest 
type  of  Snellen  with  the  near  point  at  six  and  one- fourth 
inches.  Nervous  asthenopia  was  still  a  prominent  symp- 
tom, however,  for  vision  for  minute  objects  was  only 
transient.  As  the  light-field  had  contracted  on  effort 
from  periphery  to  centre,  and,  at  first,  had  totally  dis- 
appeared, so  the  patient  said  she  noticed  the  form-field 
get  steadily  smaller  and  smaller,  until  only  the  type- 
letter  looked  at  remained  visible ;  and  during  the  first 
days  even  this  melted  from  view,  all  that  remained  was 
merely  perception  of  light. 

About  the  return  of  the  color  sense  we  have  no  exact 
data  further  than  that  it  was  gradually  restored,  but  more 
rapidly  than  either  that  of  light,  or  form,  and  last  of  all, 
but  it  finally  became  as  acute  as  in  the  left  eye. 

From  this  observation  it  would  seem  certain  that  the 
light-sense  and  form  sense  are  separate  and  distinct  from 
each  other.  The  rapid  return  of  the  color  sense  inter- 
fered with  our  observation  of  it,  and  I  regret  greatly  that 
I  failed  to  map  out  the  color-fields  of  each  eye  for  pur- 


poses of  comparison.  From  the  fact,  however,  of  the 
frequently  observed  cases  of  simple  color  hemianopsia, 
without  any  affection  of  the  half  fields  for  objects  and  for 
light,  leads  us  to  believe  in  a  separate  centre  for  colors 
also.  That  there  are  separate  centres  for  light,  form,  and 
colors  has  been  recently  asserted  by  Wilbrand,1  quoted 
by  Gowers,  who  adds  that  for  light  and  form  "  it  is  not 
yet  certain  that  this  is  so,"  but,  on  account  of  the  cases 
of  simple  color  hemianopsia,  he  appears  to  agree  with 
Wilbrand,  who  suggests  that  the  color  centre  "is  in 
some  part  of  the  occipital  cortex  in  front  of  the  apical 
region,"  and  Swanzy2  places  it  in  "  the  posterior  part 
of  the  superior  and  inferior  occipitotemporal  convolu- 
tions." 

The  observation  of  cases  of  crossed  amblyopia  has  been 
frequently  made.  In  these  there  is  simply  a  reduction  of 
the  normal  acuity  of  vision  of  the  eye  opposite  to  the 
lesion — there  is  still  remaining  a  portion  of  the  visual 
function  for  light,  form,  and  color.  Our  accompanying 
case,  however,  is  unique,  from  the  fact  that  there  was  a 
complete  suspension  of  the  function  of  the  right  eye,  and, 
lasting  several  weeks,  a  true  amaurosis.  I  am  not  con- 
versant with  a  strictly  parallel  case.  Those  that  most 
nearly  approach  it  are  the  transient  monocular  amauroses 
of  purely  hysterical  origin. 

That  the  area  of  disease  was  cortical  there  can  be 
no  doubt.  That  the  half  vision  centre  of  the  occipital 
lobe  was  not  involved  is  equally  patent,  yet  it  usually 
is  affected  in  the  cortical  visual  cases.  The  few  autop- 
sies in  cases  of  crossed  amblyopia  point  to  the  angular 
region  as  the  seat  of  disease,  and  Gowers  adds  that  the 
field  of  the  same  side  as  the  lesion  is  also  represented, 
but  to  a  much  slighter  degree  than  the  one  of  the  opposite 
side,  because  there  is  usually  a  "  slight  restriction  of  the 
field  of  the  eye  of  the  same  side."  This  localization  of 
the  diseased  site  perfectly  fits  this  case,  and  we  are  led 
to  presume  that  the  intensity  of  the'acting  bacteriological 
process  in  our  case  was  greater,  in  order  to  completely 
annul  function,  than  occurs  in  the  ordinary  cases  of 
crossed  amblyopia.  If  we  are  correct  in  the  selection  of 
the  seat  of  the  disease  we  choose  at  the  same  time  the  site 
of  the  light,  form,  and  color  centres,  viz.,  the  "occipito- 
angular ' '  region.  The  phenomena  of  disappearance  and 
return  of  these  senses  would  seem  to  imply  either  separate 
centres,  as  Wilbrand  and  Gowers  maintain,  or  that  these 
functions  are  dependent  upon  different  degrees  of  physi- 
ological life  of  a  single  centre. 

We  are  here  treading  on  purely  polemical  ground, 
however,  because  though  numerically  observers  are 
agreed  that  the  visual  cortical  centre  in  man  occupies 
the  occipital  lobe,  yet  it  is  by  no  means  decided  that  it  is 
solely  limited  to  this  district,  but  that  more  probably  it 
extends  anteriorly  into  the  angular  region,  as  Ferrier 
first  pointed  out  Therefore,  with  doubts  as  to  the  exact 
limitation  of  the  whole  visual  cortical  centre  we  can 
readily  understand  the  greater  difficulty  of  the  exact 
localization  of  its  several  parts  for  light,  form,  and  color. 
On  this  account  further  exact  observations  along  this  line 
are  greatly  needed,  and  I  reiterate  Gowers's  request  that 
bedside  examination  of  medical  cases  should  be  careful- 
ly carried  out  and  the  results  recorded.  This  field  is 
particularly  one  for  the  family  physician. 

Before  full  restoration  of  visual  acuity  of  the  right  eye, 
with  equal  endurance  for  work  of  the  two  eyes,  there  was 
a  period  of  fifty- six  days  of  treatment.  By  daily  exer- 
cise the  time  limit  for  comfortable  use  of  the  right  eye 
became  steadily  more  and  more  prolonged  until  each  eye 
became  alike  in  its  working  power.  Distinct  and  easy 
near  vision  lasted  in  either  eye  only  twenty- three  min- 
utes, and  the  near  point  was  farther  off  than  the  age  of 
the  patient  would  indicate — showing  an  impairment  of 
accommodation.  With  +  1.25  D  lenses  the  normal 
near  point  (4  inches)  was  restored  and  with  these  glasses 

1  Gowers,  loc.  cit.,  pp.  147  and  155,  156. 

*  Swanzy,  Ed.  1892,  p.  409.  He  also  adds,  p.  410 :  "  It  is  also  prob- 
able that  the  centres  for  the  three  visual  perceptions  of  light,  foim, 
and  color  are  distinct  from  each  other,  and  that  they  are  arranged,  as  it 
were,  in  layers,  one  over  the  other." 


682 


MEDICAL   RECORD. 


[December  i,  1894 


binocular  vision  was  comfortable  for  a  greatly  prolonged 
time.  The  left  eye  that  had  read  half  of  the  W  types  on 
the  first  testing,  now  read  correctly  every  letter  of  this 
line.  This  would  indicate  an  improvement  in  the  form- 
sense  of  this  eye  and  predicates  a  slight  previous  affection 
of  its  centre  also,  or  may  be  it  was  due,  as  Gowers  claims, 
to  the  influence  of  the  diseased  centre  belonging  to  the 
other  eye.  The  hysterical  state  appeared  to  be  com- 
pletely overcome,  and  with  greatly  improved  general 
health  she  left  for  her  home.  Since  then  further  im- 
provement has  occurred.  She  has  resumed  her  occupa- 
tion of  teaching,  and  now,  seventeen  months  since  her 
discharge,  without  any  signs  of  eye- relapse  or  impair- 
ment of  general  health,  we  have  every  reason  to  hope  for 
the  further  permanency  of  the  recovery. 

In  conclusion,  I  may  say  that  the  evolution  of  this 
case,  as  told  by  the  patient,  and  its  involution  as  noted 
by  myself,  form  one  of  the  most  interesting  and  perfect 
clinical  pictures  that  it  has  been  my  good  fortune  to  ob- 
serve. 

16  Laflin  Street. 


THE    RATIONAL    TREATMENT   OF    DIPH- 
THERIA.1 

By  B.  VAN  D.  HEDGES,  M.D., 
rLAiNrims  n.  j. 

The  author's  warrant  in  presenting  this  subject  for  your 
consideration  lies  in  the  realization  that  we  are  living  in 
an  age  when  men  and  methods  are  judged  alike  by  the 
cold  logic  of  practical  results. 

In  an  uninterrupted  series  of  cases,  upon  which  this 
paper  is  based,  we  have  the  pleasure  of  reporting  thirty- 
five  per  cent  recoveries  in  cases  of  croup  under  five  years 
of  age  demanding  intubation,  and  a  mortality  of  only  six 
per  cent,  in  diphtheria  not  requiring  operative  interfer- 
ence. These  results,  we  believe,  are  directly  due  to  meth- 
ods of  treatment  which  it  shall  be  our  pleasure  to  discuss 
this  evening. 

How  interesting  it  would  be,  had  we  the  time,  to  turn 
our  gaze  backward  and  note  the  different  remedial  meas- 
ures in  vogue  from  century  to  century,  all  of  them  em- 
pirical, because  founded  upon  a  faulty  conception  of  its 
true  pathology  and  etiology.  But  the  mists  have 
cleared  away,  the  darkness  has  had  its  dawn,  and  in  the 
clear,  strong  light  of  modern  research  we  are  able  to 
positively  assert  that  diphtheria  is  due  to  the  presence  of 
a  definite  specific  micro-organism  that  can  be  isolated 
and  detected  in  the  very  earliest  hours  of  the  disease,  and 
that  it  is  primarily  and  essentially  a  local  trouble,  with 
secondary  constitutional  symptoms,  due  to  the  absorp- 
tism  of  septic  products  from  the  local  seat  of  lesion. 
Upon  the  proper  appreciation  of  these  two  fundamental 
truths  rests  the  modern  rational  treatment  of  diphtheria. 

It  was  the  author's  privilege,  during  the  past  year, 
while  resident  physician  at  the  New  York  Foundling 
Hospital,  to  have  had  under  close  personal  observation 
some  sixty-seven  cases  of  genuine  diphtheria,  proven  to 
be  such  in  each  instance  by  bacteriological  examinations, 
conducted  by  Dr.  Wm.  H.  Park,  of  the  New  York  Board 
of  Health.  The  assistance  thus  rendered  us  by  Dr.  Park 
in  enabling  us  to  effect  prompt  isolation  and  early  treat- 
ment was  most  valuable.  From  this  series  as  well  as 
from  the  accumulated  experience  of  others  in  this  same 
institution  during  former  yean,  the  writer  begs  leave  to 
draw  the  conclusions  embodied  in  this  present  paper. 
He  is  indebted  to  the  staff  of  attending  physicians  for  their 
kind  courtesy  in  allowing  him  full  use  of  the  histories. 

If,  then,  diphtheria  is  a  local  trouble,  with  constitu- 
tional symptoms  dependent  upon  the  amount  and  viru- 
lence of  the  toxic  ptomaines  developed  and  absorbed 
into  the  system  from  this  primary  source,  we  must  first 
consider  the 

Local  Treatment — Welsh  and  Abbott  have  shown, 
after  long  and  careful  investigation,  that  the  bacilli  are 

1  Read  before  the  Plainfield  Medical  Society,  October  I,  1894. 


most  abundant  in  the  very  outermost  layers  of  the  mem- 
brane, and  comparatively  absent  in  the  deeper  portions; 
hence  the  indication  is  to  attain  thorough  local  disinfec- 
tion, and  not  necessarily  the  entire  removal  of  the  mem- 
brane— a  radical  measure  which  is  further  contra-indi- 
cated by  the  fact  that  we  leave  behind  us  a  raw,  bleeding 
surface,  a  most  tempting  field  for  the  reinvasion  of  die 
hosts  of  germs  that  hover  about. 

As  to  the  best  means  for  obtaining  local  disinfection 
it  would  seem  as  if  the  neutral  solution  of  peroxide  of 
hydrogen  was  the  most  valuable.  Williams,  of  Boston, 
claims  the  best  results  with  a  strong  concentrated  thirty 
to  fifty  volume  solution.  Squibb' s  ten  volume  solution, 
with  the  addition  of  a  small  amount  of  bicarbonate 
of  soda  to  neutralize  the  hydrofluoric  acid  which  is  so 
often  present,  proved  equally  efficient,  and  has  the  ad- 
vantage of  being  much  less  irritating.  Bichloride  of 
mercury  has  many  drawbacks.  To  do  its  work  well,  it 
must  be  strong,  yet  in  this  strength,  if  swallowed,  it  may 
give  rise  to  serious  symptoms.  The  writer  will  never 
forget  the  sudden  and  violent  death  of  a  little  one  under 
his  care,  due  to  the  accidental  swallowing  of  three  large 
syringefuls  of  a  1  to  3,000  solution.  Carbolic  acid  and  the 
stronger  antiseptics  are  all  open  to  the  same  objection, 
but  in  peroxide,  with  its  powerful  affinity  for  inorganic 
matter,  we  have  a  remedy  which  thoroughly  disinfects 
the  outer  layers  of  the  membrane,  and  has  no  bad  effect 
upon  the  stomach  even  when  swallowed  in  large  quanti- 
ties. 

If  the  child  is  tractable  and  will  allow  the  tongue  to 
be  depressed,  either  an  atomizer  or  a  hard- rubber  syringe 
can  be  easily  used.  But  when  the  little  one  fights  and 
struggles  against  such  interference,  it  is  best  to  simply 
irrigate  through  the  nostrils,  rather  than  incur  the  risk 
of  provoking  cardiac  failure ;  and  yet  we  must  remember 
that  the  very  reason  the  child  is  sick,  the  very  reason  we 
fear  cardiac  failure,  is  because  of  these  highly  toxic  prod- 
ucts of  the  Loeffier  bacilli.  The  extent  to  which  we 
can  safely  proceed  in.  our  efforts  at  local  disinfection 
must  always  be  determined  by  the  attending  physician 
upon  the  merits  of  each  individual  case. 

After  the  throat  has  been  irrigated  and  cleansed  with 
peroxide,  we  would  advise  the  application  of  papoid, 
either  in  the  form  of  a  powder — and  for  this  purpose 
Osborn's  insufflator  is  best— or  a  strong  solution  painted 
upon  the  parts.  It  is  a  powerful  digester  of  membrane, 
acts  in  any  medium,  and  is  very  tenacious  to  any  surface 
with  which  it  comes  in  contact.  Acting  also  upon  the 
outer  layers  of  the  membrane,  it  forms  a  rational  and 
valuable  link  in  our  chain  of  treatment  It  is  much 
superior  to  any  of  the  older  combinations  of  pepsin, 
trypsin,  and  sulphur. 

The  local  action  of  the  tincture  of  the  chloride  of  iron 
— both  astringent  and  antiseptic — belongs  to  the  realm 
of  ancient  therapeutics,  and  yet  the  writer  believes  it  to 
be  most  beneficial  and  efficacious,  particularly  in  those 
cases  where  there  is  a  condition  of  profound  anaemia.  A 
most  delightful  vehicle  for  its  administration  is  the  syrup 
of  pineapple — made  fresh  from  the  fruit  and  not  from 
the  worthless  extracts  sold  in  the  shops.  Besides  making 
a  palatable  menstruum,  it  has  a  valuable  proteolytic  ac- 
tion upon  the  membrane  itself,  and  is  a  powerful  aid  to 
stomachic  digestion,  as  ably  demonstrated  by  ProfesBor 
Chittenden,  of  Yale,  in  a  recent  number  of  the  Journal 
of  Physiology. 

Just  a  word  in  regard  to  the  matter  of  prophylaxis 
while  making  these  local  applications.  To  guard  against 
any  bit  of  membrane  being  blown  into  the  eye,  it  is  well 
for  the  doctor  or  nurse  to  wear  a  pair  of  large  goggles. 
A  lovely  woman,  in  perfect  health,  who  lost  her  sight, 
and  almost  her  life,  through  an  accident  contracted  in 
this  way,  has  made  an  impression  upon  the  writer  that 
will  never  be  forgotten.  Indeed,  it  is  safer  to  wear  a 
mask  over  the  entire  face.  One  of  New  York's  well- 
known  physicians  lost  his  only  daughter,  a  few  years  ago, 
through  a  piece  of  membrane  coughed  into  his  beard  and 
retained  there  despite  subsequent  washing. 


December  i,  1894] 


MEDICAL  RECORD. 


683 


In  a  word,  then,  we  would  advise  as  local  treatment : 
1.  Thorough  disinfection  with  peroxide  solution,  with 
spray  or  syringe,  either  through  mouth  or  via  the  nos- 
trils. 2.  The  local  application  of  the  tincture  ofr  the 
chloride  of  iron,  administered  in  syrup  of  pineapple.  3. 
Insufflation  or  painting  of  papoid. 

Constitutional  Treatment. — Next  and  equally  im- 
'  portant  is  the  constitutional  treatment.  We  are  dealing 
with  a  disease  that  at  any  moment  may  strike  its  fetal 
blow.  The  battle  is  not  a  long  one,  as  in  typhoid  and 
the  protracted  fevers,  but  short,  sharp,  and  decisive, 
hence  the  necessity  for  prompt  action  at  the  very  start. 

Alcohol,  in  the  writer's  opinion,  pushed  to  the  point 
of  tolerance,  is  our  strongest  bulwark  of  defence.  It 
dilates  the  superficial  vessels,  relieving  internal  conges- 
tion, its  carbon  forms  a  direct  food  to  the  body  tissue, 
its  action  as  a  cardiac  stimulant  and  tonic  in  conditions 
of  profound  toxaemia  is  unsurpassed.  Next  to  alcohol, 
and  almost  equally  valuable,  is  strychnine,  preferably 
given  hypodermatically  through  a  small  needle,  the 
prick  of  which  the  child  scarcely  notices.  Taken  by 
mouth  it  is  too  apt  to  derange  the  stomach.  As  a  pure 
heart  tonic  strychnine  is  equal,  if  not  superior,  to  alcohol, 
and  it  is  surprising  to  what  an  extent  it  can  be  pushed 
before  we  get  the  exaggeration  of  the  deep  reflexes,  a 
point  beyond  which  it  is  unwise  to  proceed.  A  child 
three  to  four  years  of  age  will  often  take  one-thirtieth  of 
a  grain  every  four  hours  with  marked  benefit. 

The  local  action  of  the  tincture  of  the  chloride  of  iron 
has  already  been  mentioned.  In  cases  of  profound  anae- 
mia, a  condition  easily  demonstrated  by  Gower's  haema- 
globinometer,  the  constitutional  effect  is  also  valuable. 
Sometimes  the  stomach  is  intolerant  of  any  form  of  iron. 
In  such  cases  it  should  be  promptly  stopped,  for  in  nour- 
ishment properly  administered  we  have,  after  all  our 
most  valuable  aid — one  which  is  too  often  overlooked  in 
our  zeal  to  obtain  local  antisepsis  and  cardiac  stimula- 
tion. The  soreness  and  pain  that  often  accompanies 
each  act  of  deglutition,  the  irritability  and  fretfulness  of 
•  the  patient,  the  utter  loss  of  appetite,  are  all  factors  that 
conduce  toward  a  starvation  diet  if  the  watchers  are  not 
constantly  on  the  alert.  Concentrated  fluid  nourish- 
ment —  milk-punches,  eggnogs,  the  expressed  juice  of 
meat,  Rudisch's  sarcopeptones,  Mosquera's  beef-jelly, 
panopeptone,  and  the  different  forms  of  nutritious  broths 
should  be  our  main  reliance.  To  avoid  the  introduction 
into  the  stomach  of  an  unnecessary  amount  of  septic 
matter  it  is  wise  to  administer  the  nourishment  imme- 
diately after  the  local  disinfection  with  peroxide. 

The  fever,  as  a  rule,  runs  a  low  course  and  requires 
no  treatment.  A  temperature  above  1030  F.  can  be 
controlled  by  cool  sponging;  under  no  circumstances 
by  the  exhibition  of  the  coal  tar  antipyretics.  Ipecac, 
quinine,  turpeth  mineral,  veratrum  viride,  and  the  long 
list  of  drugs  formerly  held  in  high  repute,  it  is  best  to 
altogether  discard.  Preserve  the  integrity  of  the 
stomach  at  all  hazards,  so  that  digestion  and  assimilation 
may  be  as  perfect  as  possible.  See  that  the  child  gets 
the  proper  amount  of  nourishment  at  stated  intervals ; 
guard  the  action  of  the  heart  by  the  judicious  use  of  al- 
cohol and  strychnine,  and  we  have  the  gist  of  our  consti- 
tutional treatment. 

Among  the  complications  demanding  our  attention 
croup  ranks  facile  princeps.  In  nineteen  cases  that  fell 
under  the  writer's  observation  during  the  past  year,  bac- 
teriological examinations  have  shown  in  each  instance  the 
presence  of  the  Loeffler  bacilli.  They  have  been  found 
present  in  over  eighty  per  cent,  of  all  cases  examined  by 
the  New  York  Board  of  Health,  so  that  we  feel  warranted 
in  establishing  an  identity  between  the  two  diseases. 

At  the  very  first  suggestion  of  any  stenosis  we  would 
begin  with  calomel  fumigations,  burning  fifteen  or 
twenty  grains  of  the  powder  every  two  hours.  Whether 
it  acts  solely  as  a  local  antiseptic  or  constitutionally  by 
diminishing  the  plasticity  of  the  blood,  and  so  decreas- 
ing the  amount  of  fibrinous  exudation,  is  a  matter  of 
minor  import.    We  know  that  it  does  good  if  begun 


early  in  the  disease  and  vigorously  pushed.  An  um- 
brella, covered  with  a  sheet  and  raised  over  the  little 
one,  makes  a  handy  and  convenient  tent.  A  wash- bowl, 
two  cross  pieces  of  iron,  a  tin  platter,  and  an  alcohol 
lamp  complete  the  outfit.  To  avoid  the  danger  of  sali- 
vating the  nurse,  a  complication  of  no  mean  moment, 
the  room  should  be  thoroughly  aired  after  each  fumiga- 
tion. It  is  surprising  how  often  very  severe  cases  will 
yield  to  this  treatment  alone,  without  resort  to  graver 
measures.  The  inhalation  of  medicated  steam  relieves 
the  condition  of  dryness  so  often  present,  promotes  ex- 
pectoration, and  acts  as  a  local  antiseptic.  A  solution  of 
carbolic  acid,  eucalyptus,  and  turpentine— a  favorite  com- 
bination of  J.  Lewis  Smith's— is  valuable  for  this  pur- 
pose. The  addition  of  lime  water  is  possibly  of  some 
assistance. 

If  every  case  of  croup  were  given  the  benefit  of  this 
conservative  method  of  treatment,  thoroughly  and  con- 
scientiously tried  from  the  very  start,  there  would  be  a 
marked  improvement  in  our  mortality  statistics.  But 
when  the  symptoms  of  stenosis  grow  steadily  more  and 
more  pronounced,  when  the  air  no  longer  enters  the 
lower  lobes,  as  determined  by  the  absence  of  vesicular 
murmur  on  auscultation,  when  there  is  marked  intercos- 
tal and  supra-  and  infra  clavicular  retraction  with  each  in- 
spiration, then  we  only  hazard  our  patient's  chances  by 
delaying  operative  interference.  We  must  choose  be- 
tween tracheotomy  and  intubation. 

In  cases  complicated  by  intense  oedema  of  the  epiglot- 
tis and  marked  tonsillar  enlargement,  the  older  operation 
is  much  to  be  preferred.  In  simple  uncomplicated  cases 
of  laryngeal  stenosis  it  has  today  been  almost  entirely 
superseded  by  the  more  modern  method,  thanks  to  the 
genius  and  untiring  industry  of  Dr.  Joseph  O'Dwyer. 

I  should  say  its  main  advantages  were  these :  1.  It  is 
a  bloodless  operation  and  entails  a  minimum  amount  of 
shock,  the  whole  procedure  taking  less  than  a  minute  in 
the  hands  of  a  deft  operator.  2.  The  consent  of  the 
parents  can  always  be  obtained  when  the  very  first  indi- 
cation presents  itself.  There  is  no  delay  until  the  pa- 
tient's strength  and  vitality  are  both  at  such  a  low  ebb 
that  no  interference  avails.  3.  The  air,  as  it  enters  the 
lungs,  is  warmed  by  passing  first  through  the  natural 
channels.  4.  There  is  no  wound  for  reinfection ;  no  scar 
to  mar  the  beauty  of  later  life.  5 .  In  intubation  the  tube 
can  usually  be  removed  within  a  few  days.  ^  In  trache- 
otomy it  is  a  matter  of  weeks  before  recovery  is  complete. 
6.  The  tracheotomy  tube  requires  untiring  watchfulness 
day  and  night  by  trained  attendants.  Only  the  ordinary 
care  is  required  in  intubation. 

On  the  other  hand  it  has  its  disadvantages.  Mem- 
brane may  be  dislodged  and  pushed  down  by  the  intro- 
duction of  the  tube,  closing  up  its  lower  orifice.  It  hap- 
pened to  me  once  in  one  of  my  earlier  cases.  In  such 
an  emergency  the  expulsive  power  of  the  lungs  is 
usually  sufficient  to  eject  both  tube  and  membrane,  as  in 
this  case,  when  the  tube  can  be  reinserted.  To  avoid  any 
unpleasant  sequelae  of  such  a  complication,  it  is  wise  to 
leave  the  string  attached  to  the  tube,  fastening  the  free 
end  to  the  cheek  with  a  small  bit  of  adhesive  plaster, 
and  instructing  nurse  or  parent  to  pull  it  out  if  the  child 
suddenly  chokes  or  becomes  blue.  Again,  the  operation 
is  one  which  requires  a  great  deal  of  manual  skill  and 
dexterity.  If  done  in  a  bungling  manner,  extensive 
harm  can  be  committed,  and  tracheotomy,  under  such 
circumstances  is  always  to  be  preferred. 

But  the  operation  is  no  longer  an  experiment. 
Weighed  in  the  balance,  it  has  not  been  found  wanting, 
and  its  most  bitter  opponents  of  former  years  are  to-day 
its  warmest  advocates. 

Diphtheritic  conjunctivitis,  either  by  direct  contami- 
nation or  extension  through  the  lachrymal  duct  from  the 
nares,  is  fortunately  a  rare  complication.  It  demands 
most  energetic  and  prompt  treatment.  Here,  as  in  the 
throat,  we  found  the  neutral  solution  of  peroxide  most  val- 
uable. Applications  were  made  to  the  membrane  every 
half  hour,  followed  by  the  cleansing  solution  of  boracic 


684 


MEDICAL    RECORD. 


[December  i,  1894 


acid.  Out  of  four  cases  three  recovered.  In  the  fourth, 
where  there  was  also  a  complicating  malignant  scarlet 
fever,  both  corneas  became  involved,  followed  by  exten- 
sive sloughing,  before  death  supervened. 

Diphtheritic  paralysis  occurred  in  only  one  instance, 
and  yet  it  taught  us  a  most  valuable  lesson,  showing  the 
danger  of  sudden  cardiac  failure.  There  was  first  the 
paralysis  of  soft  palate,  regurgitation  of  fluids  through 
the  nose,  and  partial  disability  in  the  lower  limbs.  All 
symptoms  became  markedly  improved  at  the  end  of  two 
weeks.  Some  few  days  later,  the  child,  a  "runa- 
round  "  of  four  years,  grew  excited  while  at  play  with 
some  other  convalescents  in  the  same  room.  An  attack 
of  tachycardia  suddenly  developed,  and  death  followed 
in  ten  minutes  from  the  onset.  A  case  under  my  care, 
here  in  Plainfield,  while  sitting  upright  on  a  vessel  and 
straining  over  a  constipated  movement,  died  in  very 
much  the  same  way.  Prolonged  rest  in  the  prone  posi- 
tion, the  positive  interdiction  of  any  active  exercise  long 
after  convalescence  seems  established,  and  the  faithful 
use  of  heart  tonics,  would  seem  to  be  the  lesson  taught 
us  by  these  fatal  cases. 

Albuminuria  was  present  in  seventy-five  per  cent,  of 
the  cases,  leaving  an  acute  nephritis  that  proved  fatal  in 
only  one  instance,  and  that  two  months  later.  In  all 
the  others  the  kidney  symptoms  entirely  disappeared. 
A  rigorous  fluid  diet,  giving  the  kidneys  a  minimmq 
amount  of  work  to  perform,  and  small  doses  of  sweet 
spirits  of  nitre  where  secretion  was  scanty,  were  the  only 
measures  used. 

The  treatment  of  broncho  pneumonia,  one  of  the  most 
frequent  of  the  fatal  complications  of  croup,  hardly  falls 
within  the  province  of  this  paper.  Vigorous  counter- 
irritation  over  the  entire  chest,  with  warm  mustard  poul- 
tice at  the  very  outset,  and  the  use  of  ammonium  car- 
bonate to  promote  expectoration,  and  at  the  same  time 
stimulate  the  heart's  action,  gave  us  best  remits. 

The  new  treatment  by  injections  of  antitoxin  is  as  yet 
only  an  experiment.  Endorsed  by  Koch  and  many  of 
the  most  eminent  men  on  the  Continent,  it  is  worthy  of 
faithful  and  extended  trial.  And  yet  we  must  remember 
that  the  cure  for  tuberculosis  came  from  the  same  source. 
To-day  it  is  of  doubtful  diagnostic  value  only  to  the 
veterinary  surgeon. 

It  may  be  of  interest  to  note  for  a  moment  more,  in 
detail,  what  has  been  accomplished  in  the  treatment  of 
our  67  cases.  In  the  17  cases  of  croup  demanding  intu- 
bation there  were  6  recoveries,  or  thirty-five  per  cent. 
In  two  instances  the  children  were  brought  to  the  hos- 
pital in  a  dying  condition,  and  the  operation  was  simply 
done  for  euthanasia,  death  following  within  a  couple  of 
hours  after  admission.  Two  others  recovered  entirely 
from  their  laryngeal  stenosis,  but  died  ten  days  later 
from  a  malignant  complicating  scarlet  fever.  This 
leaves  us  13  cases  where  the  treatment  was  given  a  thor- 
ough trial,  with  6  recoveries,  nearly  fifty  per  cent. 
Among  the  other  49,  not  demanding  operative  interfer- 
ence, there  were  only  four  deaths,  and  one  of  these  was 
due  to  the  accidental  swallowing  of  a  poisonous  dose 
of  bichloride,  leaving  us  a  mortality  of  only  3,  or  six 
per  cent.  Including  all  the  fatal  croup  cases  there  is 
a  total  mortality  of  only  about  twenty  per  cent.,  a 
most  favorable  ratio  in  comparison  with  that  of  other 
institutions.  At  the  Emperor  and  Empress  Frederick's 
Children's  Hospital  at  Berlin,  during  the  last  three 
years,  the  mortality  in  1,081  cases  was  38.9  per  cent. 
M.  Roux,  of  the  Children's  Hospital  in  Paris,  reports, 
during  the  last  four  years,  3,971  cases,  with  2,029  deaths, 
a  mortality  of  over  fifty-one  per  cent.  In  this  same 
institution,  during  the  past  few  months,  448  cases  have 
been  treated  with  the  antitoxin  injections,  with  109 
deaths,  or  twenty- four  and  one-half  per  cent. 

In  conclusion,  then,  gentlemen,  we  would  beg  leave  to 
offer  the  following  suggestions  as  the  epitome  of  the 
thoughts  advanced  in  this  paper. 

Local  Treatment. — 1.  Thorough  disinfection  with 
peroxide  solution,  rendered  neutral  with  bicarbonate  of 


soda.  2.  Administration  of  freshly  prepared  pineapple 
juice,  either  alone  or  with  the  tincture  of  the  chloride  of 
iron,  if  a  condition  of  anaemia  be  present.  3.  Applica- 
tion of  papoid,  either  by  insufflation  of  powder  or  paint- 
ing with  strong  solution. 

Constitutional  Treatment. — 1 .  Alcohol  given  in  heroic 
doses.  2.  Hypodermatic  injections  of  strychnine  pushed 
until  there  is  exaggeration  of  the  deep  reflexes.  3.  Con- 
centrated nutritious  diet. 

Realizing  that  our  knowledge  must  be  drawn  from  the 
wells  of  experience,  and  that  we  have  with  us  to  night 
those  who  have  drunk  long  and  deeply  from  this  foun- 
tain source,  the  writer  hopes  that  there  may  be  a  full 
and  free  expression  of  opinion,  to  the  end  that  we  may 
be  better  able  in  the  future  to  cope  with  this  dread 
disease. 


THE  NERVOUS  SYMPTOMS  OF  PATIENTS  SUF- 
FERING FROM  CHRONIC    URETHRITIS. 

By  R.   K.   MACALESTER,  M.D., 

MEW  YOIK. 

ASSISTANT  VISITING    PHYSICIAN    TO    THE    COLUMBUS    HOSPITAL ,'    PHYSICIAN  TO 
THt  FRENCH  HOSPITAL,  AND  NEW  YORK  DISPENSARIES. 

The  nervous  disorders  that  are  often  connected  with 
chronic  urethritis  may  be  classed  under  the  acquired 
functional  nervous  diseases,  although  they  may  some- 
times attain  such  a  degree  of  severity  as  to  resemble  the 
psychoses,  and  often  lead  us  to  consider  them  as  some- 
thing more  serious  than  mere  functional  disturbances. 
They  present  certain  characteristics  and  peculiarities, 
which,  in  connection  with  the  underlying  disorder, 
form,  on  the  whole,  quite  a  typical  group  of  symptoms. 

It  is  a  well-established  fact  that  irritation  and  disease 
of  the  genito-urinary  organs  are  frequently  the  cause  of 
manifold  nervous  disturbances,  familiar  to  all  practition- 
ers, who,  however,  often  fail  to  recognize  the  connection. 
Beard,1  in  his  classical  work  on  neurasthenia,  writes: 
"  Disorders  of  the  genital  apparatus  are  continually  ex- 
citing disease  in  remote  organs.  In  men  a  little  prosta- 
titis, or  urethral  or  preputial  irritation,  not  only  phi- 
mosis, but  even  elongation,  with  secretion  of  smegma,  are 
constantly  the  sole  and  demonstrable  origin  of  hypo- 
chondriasis, dyspepsia,  and  other  nervous  symptoms." 

Furthermore,  I  have  but  to  allude  to  the  nervous  dis- 
orders coexisting  with  or  following  sexual  excesses, 
masturbation,  interrupted  coitus,  operations,  or  manipu- 
lations on  the  urethra,  etc. 

Therefore  it  is  not  surprising  that  a  person,  knowing 
that  he  has  a  gleet,  should  succumb  to  some  nervous 
malady,  the  more  so  when,  by  allowing  his  mind  to 
constantly  dwell  upon  this  fact,  it  should  become  a 
source  of  worry  and  all  kinds  of  imaginary  troubles. 
Indeed,  the  nervous  disturbances  may  progress  to  such  an 
extent  and  prominence  as  to  become  the  predominant 
feature  of  the  case,  and  the  urethral  disease  is  overlooked 
or  regarded  as  one  of  the  imaginary  troubles.  This  lat- 
ter is  to  be  all  the  more  regretted,  inasmuch  as  when  the 
true  nature  of  the  disease  is  recognized,  the  sufferer  may 
either  be  completely  cured  by  an  appropriate  treatment, 
or  at  least  greatly  improved. 

Having  had  occasion  to  observe  quite  a  large  number 
of  cases  both  here  and  in  Europe,  I  think  that  the  ner- 
vous complications  are  more  frequent  in  this  country ;  at 
least  they  are  more  conspicuous,  and  oftener  attain  a  higher 
degree  of  severity.  In  fact  it  is,  in  my  experience  in 
this  country,  rather  exceptional  to  find  a  person  who, 
being  aware  of  having  a  gleet  for  some  length  of  time, 
does  not  betray  some  marked  nervous  symptoms,  while 
in  Europe  this  is  very  common,  but  by  no  means  the 
rule. 

I  have  at  my  disposal  the  records  of  numerous  cases 
bearing  upon  the  subject  under  consideration,  but  will 
content  myself  with  detailing  the  histories  of  three,  that 
1  A  Practical  Treatise  on  Nervous  Exhaustion.    New  York,  188a 


December  i,  1894] 


MEDICAL   RECORD. 


685 


will  suffice  to  illustrate  the  more  important  features  of 
the  clinical  picture. 

Case  I.1 — M.  D ,  twenty-five  years  of  age,  sculptor, 

of  Roumanian  parentage,  single.  His  mother  always  suf- 
fered from  general  nervousness.  He  was  always  strong 
and  healthy  previous  to  the  gonorrheal  troubles.  Is 
temperate  in  the  use  of  tobacco  and  alcoholics,  drinks  a 
small  amount  of  red  wine  daily ;  is,  on  the  whole,  a  man 
of  regular  habits  and  in  moderately  easy  circumstances. 
Denies  ever  having  practised  masturbation.  No  history 
of  syphilis.  Has  had  eight  attacks  of  acute  gonorrhoea 
in  all,  or,  as  he  states,  several  of  these  may  have  been 
acute  recurrences  of  the  chronic  trouble.  The  first  he 
acquired  at  the  age  of  sixteen,  and  the  last  about  one 
year  ago,  the  acute  stage  of  which  lasted  for  two  months ; 
then  it  subsided,  and  left  him  with  the  gleet.  Had  been 
treated  by  several  doctors,  who  passed  sounds,  made  local 
applications  to  the  urethra,  etc.,  without  obtaining  any 
evident  amelioration. 

This  state  of  affairs  has  been  a  source  of  great  worry, 
anxiety,  and  discouragement  to  him,  and  he  has  been 
getting  more  and  more  nervous.  He  feels  weak,  des- 
pondent, at  times  drowsy,  has  to  frequently  quit  his  work, 
feeling  exhausted,  and  lie  down  to  rest  in  daytime ;  at 
night  has  difficulty  in  felling  to  sleep,  and  when  asleep 
is  restless,  starts  and  awakens  often ;  on  arising  in  the 
morning  feels  as  if  he  "  had  been  on  a  spree  the  night 
before,"  which  discomfort  is  not  a  little  added  to  by  his 
being  day  after  day  confronted  by  his  gautte  militaire, 
which  is  the  first  thing  he  thinks  of,  and  looks  for  in  the 
morning.  Patient  has  become  irritable,  very  excitable, 
sensitive,  and  depressed  in  spirits;  lost  his  interest  in 
people  and  things  in  general.  It  is  with  reluctance  and 
difficulty  that  he  can  accomplish  any  work  at  all.  Has 
been  obliged  to  give  up  two  or  three  "jobs  "  on  account 
of  his  inability  to  concentrate  his  thoughts  and  atten- 
tion on  his  work ;  is  overcome  with  a  feeling  of  exhaus- 
tion and  uneasiness,  so  that  he  cannot  force  himself  to 
continue.  Is  very  fond  of  changes.  His  sole  desire  and 
ambition  is  to  get  cured  of  the  terrible  disease,  as  he 
terms  it,  that  robs  him  of  his  peace  of  mind,  health,  and 
all  enjoyment  of  life;  and  if  this  cannot  be  effected, 
would  rather  die.  He  has  a  heavy  feeling  and  dizziness  in 
the  head,  and  frequent  headaches ;  complains  of  poor 
memory;  paresthesia  in  the  form  of  numbness  of  the 
extremities,  and  creeping  sensations  along  the  inner  sur- 
face of  the  thighs.  His  hands  and  feet  often  feel  cool, 
while  he  frequently  experiences  flashes  of  heat  to  the  head, 
and  cold  feelings  in  the  back.  He  thinks  the  disease 
"has  gone  to  his  eyes,"  as  things  often  look  blurred. 
Complains  of  dyspepsia,  which  troubles  him  the  most  when 
his  nervous  symptoms  reach  their  climax.  The  symp- 
toms referable  to  the  genital  organs  are :  A  continuous 
feeling  of  "weakness,"  a  prickling  sensation  and  some- 
times numbness  along  and  around  the  urethra ;  has  lost 
his  sexual  desire  to  a  great  extent ;  his  sexual  potency 
is,  however,  fair;  has  involuntary  and  premature  emis- 
sions, and  when  he  attempts  a  second  coitus  it  is  either 
very  long,  or  impossible.  Worries  greatly  over  loss  of 
semen,  which  he  notices  after  an  erection  or  defecation. 
Has  a  feeling  in  the  legs  opposite  the  scrotum  as  if  there 
was  a  hollow  place  in  his  flesh,  which  sometimes  feels 
numb,  at  others  over  sensitive. 

Status  prcesens,  July  27, 1893. — Well  nourished,  strong 
and  robust  looking,  skin  and  mucous  membrane  pale. 
Organs  of  the  special  senses  normal.  Sways  slightly 
on  standing  with  closed  eyes.  Fine  tremor  in  tongue 
and  hands.  Superficial  and  deep  reflexes  lively.  No 
objective  sensory  disturbances,  with  the  exception  that 
the  spines  of  the  dorsal  vertebrae  are  slightly  hyperesthetic. 
Extremities  feel  cool,  hands  clammy.  The  physical  ex- 
amination of  the  thoracic  and  abdominal  organs  re- 
veals nothing  abnormal.  The  urine  contains  no  albu- 
min or  sugar,  but  many  coarse  fibrous,  and  fine  mucous 

1  Cases  I.  and  III.  are  taken,  with  Dr.  Ramon  Guit&as*  (chief  of 
clinic)  kind  permission,  from  my  records  in  his  clinic  at  the  French 
Hospital,  of  which  I  am  in  charge.    Case  II.  was  my  private  patient 


threads;  it  is  clear,  and  specific  gravity  1.016.  With 
the  test  of  the  two  glasses,  both  portions  of  the  morning 
urine  contain  threads.  Sounds  could  be  passed  up  to 
26  (Charriere),  a  resistance  was  felt  in  the  pars  bul- 
bosa.  Examination  of  the  prostate  gland,  per  rectum, 
showed  this  organ  to  be  enlarged  to  about  twice  its  nor- 
mal size,  somewhat  increased  in  consistence,  and  not 
painful  on  pressure.  The  microscopical  examination  of 
the  "  seminal  loss  "  showed  it  to  be  composed  of  secre- 
tion from  the  prostate,  mixed  with  a  small  amount  of 
pus ;  there  were  no  spermatozoa  present,  but  I  was  able 
to  demonstrate  gonococci. 

Treatment.— Begun  on  July  27,  1893.  Gradual  dila- 
tation of  the  stricture,  local  applications  of  solutions  of 
argent,  nitric,  with  the  Ultzmann  syringe,  cool  sitz-baths, 
and  0.5  natr.  salicyl.  t.i.d.  were  ordered  for  the  gen- 
ito-urinary  trouble.  For  the  nervous  disorders  I  pre- 
scribed a  general  dietetic  hygienic  regime,  a  moderate 
amount  of  exercise  in  the  fresh  air,  cold  spongings  in  the 
morning,  abstinence  from  Baccho  et  Venere,  etc.,  and 
ordered  x.o  natr.  bromid.  to  betaken  in  the  evening. 

Under  this  treatment  patient  improved  rapidly.  On 
August  15,  1893,  his  stricture  had  been  dilated  up  to 
forty  two ;  a  five  per  cent,  nitrate  of  silver  solution  was 
injected ;  the  drop  in  the  morning  had  diminished  in 
size,  and  become  nearly  transparent;  the  urine  contained 
but  very  few  fine  threads,  and  the  nervous  symptoms 
had  markedly  improved.  The  treatment  was  continued, 
and  on  September  25th  the  patient  was  entirely  free 
from  any  urethral  discharge;  the  examination  of  the 
urine  revealed  no  evidence  of  disease,  the  threads  had 
disappeared,  and  he  told  me  that  he  could  no  more  find 
"  the  morning  drop,"  and  did  not  lose  any  more  semen. 
His  nervous  troubles  had  left  him  to  a  great  extent,  al- 
though he  was  still  restless,  fidgety,  and  anxious ;  but  on 
the  whole  he  was  greatly  benefited,  took  more  interest 
in  his  work  and  people,  felt  encouraged,  more  hopeful, 
and  contented  with  his  lot.  Had  he  continued  to  ab- 
stain from  Baccho  et  Venere,  and  kept  in  the  path  of  vir- 
tue, I  am  confident  that  he  would  have  made  a  complete 
recovery  in  every  respect.  But  alas !  Two  months  later 
I  learned  that  he  had  contracted  a  fresh  gonorrhoea  just 
before  he  was  about  to  marry,  and  that  he  was  again 
nearly  mad  with  despondency  and  despair. 

(The  treatment  of  the  chronic  urethritis  with  strictures, 
employed  in  all  these  cases,  is  that  which  is  recom- 
mended by  Dr.  E.  Finger,  of  Vienna,  for  old  cases,  and 
which  I  learned  in  his  clinic.  Judging  from  his  results 
and  my  own,  I  cannot  speak  too  highly  of  this  method 
of  treatment  as  being  most  reliable  and  efficient.  In 
brief  it  is  as  follows :  If  possible,  the  patient  comes  daily 
for  treatment ;  if  not,  every  two  or  three  days.  The 
strictures  are  gradually  dilated  by  means  of  the  Obcr- 
lander  dilator,  until  the  full  dilatability  of  the  normal 
urethra  is  reached.  The  gradual  dilatation  consists  in 
increasing  the  calibre  of  the  dilator  by  two  numbers  of 
the  scale  at  every  consecutive  seance.  The  dilatations 
alternate  with  applications  of  argent,  nitr.  to  the  entire 
length  of  the  urethra  by  means  of  the  Ultzmann  syringe, 
beginning  with  a  half  per  cent,  solution,  and  gradually 
increasing  to  a  five  per  cent.,  or  even  ten  per  cent.,  solu- 
tion. If  the  disease  gets  sluggish,  the  argent,  nitr.  solu- 
tion may  be  changed  for  one  of  cupr.  sulph. ,  which  can 
be  used  in  a  ten  or  twenty  per  cent,  solution  if  necessary. 
After  this  has  been  used  for  a  while,  the  argent,  r.itr. 
solutions  are  resumed,  and  often  with  a  surprisingly  good 
result  If  the  increasing  strength  of  the  applications  and 
the  dilatations  prove  too  irritable,  it  is  advisable  to  either 
not  increase  them,  or  discontinue  them  entirely,  until 
they  [are  tolerated  again.  The  golden  rule,  impressed 
upon  us  by  Finger,  was :  Never  employ  any  method 
that  will  irritate  the  urethra,  and  set  up  acute  symptoms 
or  complications.  He  prefers  this  plan  of  treatment  to 
the  local  applications  through  the  endoscope,  because 
the  introduction  of  this  instrument  is  irritative  to  the 
urethra.  During  the  treatment  the  patient  may  take 
some  astringent  or  antiseptic  internally,  such  as  acid,  or 


686 


MEDICAL  RECORD. 


[December  i,  1894 


natr.  salicyl.,  which  is  also  a  good  prophylactic  against 
cystitis.  If  the  treatment  fails  to  be  efficacious  in  the 
course  of  several  weeks,  it  is  advisable  to  discontinue  it, 
give  the  patient  a  rest  for  about  a  fortnight,  and  then  re- 
sume it.  The  advantages  of  the  Oberlander  dilator  (or  a 
similar  instrument)  are  obvious  if  we  consider  that  the 
dilatability  of  the  urethra  de  norma  is :  In  the  external 
orifice,  24,  in  the  pars  cavernosa,  30  to  35,  and  in  the 
pars  bulbosa  40  to  45  (Charriere).  The  Oberlander 
dilator  is  so  constructed  as  to  dilate  these  different  por- 
tions correspondingly  to  their  normal  relations.  There- 
fore the  use  of  ordinary  sounds  that  dilate  the  urethra 
equally  in  all  parts  is  quite  irrational.  By  this  means  a 
sufficient  degree  of  dilatation  of  the  bulbus,  for  instance, 
cannot  be  effected,  which,  nota  bene,  is  the  most  fre- 
quent seat  of  strictures,  and  the  patient  may  be  treated 
for  any  length  of  time  without  being  radically  cured.) 

The  above  history  gives  a  fair  example  of  a  patient 
who  is  a  familiar  bugbear  to  most  of  us.  When  we  have 
to  treat  such  a  subject,  we  find  him  most  exacting,  change- 
able, often  irritable,  taking  pleasure  in  disconcerting  and 
tormenting  his  adviser,  as  if  he  were  bent  upon  making 
others  share  his  misery.  It  is  no  wonder  that  such  a 
patient  wanders  from  doctor  to  doctor,  or  from  dispen- 
sary to  dispensary,  telling  everyone  that  nobody  under- 
stands his  case.  Beginning  in  a  general  medical  depart- 
ment, as  a  rule,  he  in  tujn  passes  to  the  surgical  and 
genitourinary  surgical  clinic,  and  finally,  if  nobody 
succeeds  in  curing  him,  he  is,  in  despair,  shoved  on  to 
the  neurologist. 

Notwithstanding  that  such  an  individual  is  inclined 
to  exaggerate  his  ailments,  and  taxes  our  patience  to 
the  utmost,  still  he  is  an  unfortunate  being,  for  his  men- 
tal sufferings  are  doubtless  great.  He  is  a  deserving  ob- 
ject for  our  pity  as  well  as  our  skill. 

When  such  a  patient  presents  himself  for  treatment,  I 
impress  upon  him  the  importance  of  energetically  fol- 
lowing out  the  prescribed  plan,  and  the  necessity  of  reg- 
ular attendance.  I  emphasize  the  fact  that  the  treat- 
ment will  last  for  two  or  three  months.  I  exact  a  prom- 
ise that,  once  begun,  he  will  continue  for  that  length  of 
time.  With  what  success  our  endeavors  will  be  crowned, 
under  the  circumstances,  depends  as  much  upon  the 
patient's  perseverance  as  upon  our  making  a  correct 
diagnosis  of  the  underlying  urethral  disorders,  and  ap- 
plying the  appropriate  treatment. 

Cask  II. — H.  B ,  forty-two  years  of  age,  single, 

Custom-House  employee,  born  in  the  United  States; 
father,  German ;  mother,  English.  The  family  history 
is  good.  Patient  is  a  man  of  regular  habits,  comfort- 
ably situated ;  being  the  only  son,  his  mother  has  per- 
haps spoiled  him ;  was  always  inclined  to  be  nervous; 
does  not  indulge  in  the  alcohol,  or  tobacco  habit ;  no 
rheumatic  history.  Practised  masturbation,  beginning 
at  the  time  of  puberty,  for  several  years.  Had  gonorrhoea 
and  chancroids  at  the  age  of  seventeen,  and  the  former 
disease  again  about  six  years  ago ;  the  acute  symptoms 
of  which  soon  abated  under  appropriate  treatment,  but 
ever  since  he  notices  in  the  morning  that  the  meatus  is 
either  stuck  together,  or  that  there  is  a  drop  of  yellowish 
or  white  fluid  in  it.  After  defecation,  or  overhearing 
the  conversation  of  his  colleagues,  which  in  their  leisure 
hours  is  wont  to  turn  upon  the  fair  sex,  he  either  has  an 
involuntary  emission,  or  observes  a  little  thick,  sticky, 
and  clear  discharge  from  the  urethra.  He  has  nocturnal 
emissions  every  two  or  three  weeks.  On  questioning 
him  he  gives  an  exquisite  history  of  cerebro  spinal  neu- 
rasthenia, even  to  the  minutest  details,  the  enumera- 
tion of  which,  in  order  to  avoid  repetition,  will  be 
omitted.  In  addition  to  the  general  symptoms  he  pre- 
sents others  which  are  referable  to  the  affected  parts, 
such  as  itching,  tingling  sensations  in  the  penis  and 
scrotum,  twitchmgs,  and  pains  that  start  in  the  genital 
organs,  radiate  to  the  lower  abdominal  region,  where 
they  at  times  become  quite  intense  and  are  increased 
by  urinating,  sexual  excitement,  fatigue,  or  micturition. 
He  has  other  paresthesia  of  these  parts  in  the  form  of 


hypersesthesia,  and  continuous  irritability  of  the  urethra. 
He  complains  of  numbness  of  the  whole  genito-urinary 
tract,  and  keeps  repeating:  "Doctor,  my  privates 
and  bladder  feel  as  if  they  were  dead ;  all  the  life  has 
gone  out  of  them ;  they  have  been  weakened  by  self- 
abuse,  and  I  don't  think  there  is  any  help  for  me.19 
Questioned  as  to  his  sexual  potency,  he  answers,  that  as 
he  "  takes  no  more  stock  in  girls,"  he  is  unable  to  say 
how  this  is,  but  that  he  otherwise  has  only  very  weak  erec- 
tions, even  when  the  nocturnal  emissions  occur ;  he  de- 
nies experiencing  any  sexual  desire ;  penis  always  feels 
cold. 

Patient  has  other  marked  hypochondriacal  ideas  and 
fears.  Besides  reproaching  himself  incessantly  for  his 
past  sins,  he  pours  forth  a  host  of  new  complaints  and 
ailments  at  every  seance,  as  for  instance :  "  Doctor,  I 
have  to  raise  such  a  lot  of  thick  phlegm  from  my  stomach 
that  I  am  sure  it  must  be  diseased.' '  On  his  producing 
this  one  day,  I  found  it  to  be  simply  a  minute  quantity 
of  mucous  secretion,  probably  from  the  pharynx.  He 
also  worries  over  the  smegma  on  the  glans  penis.  Hay- 
ing heard  of  paresis,  he  is  sure  he  is  developing  it ;  he  is 
sure  something  dreadful  is  going  to  happen  to  end  his 
unfortunate  existence,  etc.  He  is  in  constant  fear  of 
catching  cold ;  carries  a  cap  in  his  pocket  which  he  puts 
on  immediately  on  taking  off  his  hat ;  in  summer  he 
almost  always  has  an  overcoat  at  hand,  and  when  the 
weather  is  at  all  cool,  he  fastens  his  coat  tight  around  the 
chest,  and  the  sleeves  around  the  wrists  with  safety-pins, 
for  fear  the  cold  air  might  get  in.  He  eats  little,  al- 
though his  appetite  is  fair,  fearing  it  might  be  injurious; 
drinks  only  a  small  quantity  of  liquids,  fearing  to  have  to 
urinate  oftener  and  thus  increase  the  "  funny  painful  feel- 
ings "  in  the  genitals  and  abdomen.  Some  of  his  symp- 
toms approach  melancholia :  he  is  extremely  sensitive ; 
imagines  that  everybody  ridicules  and  dislikes  him ;  at 
times  secludes  himself  at  every  possible  occasion,  sits  for 
hours  in  the  same  chair,  and  mopes  over  his  past  sins  and 
sad  condition  ;  has  morbid  fears  of  various  descriptions ; 
according  to  his  mother,  he  has  had  hallucinations  of 
hearing  several  times,  but  this  is  quite  uncertain. 

Last  spring  he  went  to  the  Catskills  to  spend  the  sum- 
mer, but  he  could  not  stand  it  longer  than  three  weeks, 
because  some  friends  (?)  there  ridiculed  him  and  his 
eccentricities,  and  insinuated  that  he  was  fit  for  an  asy- 
lum. He  is  very  exacting  and  inquisitive  with  his  physi- 
cians ;  at  every  visit  wishes  to  be  examined  from  head  to 
foot,  and  when  told  afterward  that  there  is  no  cause  for 
so  much  worry,  he  feels  relieved  for  the  moment.  He 
has  been  discharged  by  several  doctors,  rather  abruptly, 
as  a  hopeless  "crank"  and  undesirable  patient,  after 
they  had  tried  to  cure  him  by  all  manners  and  means. 

Status  prctsens.— Short,  rather  delicate  looking,  fairly 
well  nourished,  weighs  no  pounds;  the  head  looks  too 
large  for  the  body,  but  shows  no  deformities ;  the  skin  and 
mucous  membranes  are  markedly  anaemic ;  temporal  veins 
prominent;  arteries  normal;  pulse  regular,  soft,  sixty-eight 
beats  per  minute.  The  physical  examination  is  negative. 
On  standing  with  closed  eyes,  he  feels  dizzy,  and  sways 
perceptibly.  The  deep  reflexes  are  exaggerated.  Over 
the  middle  dorsal  vertebrae  there  is  a  hypersesthetic 
area.  No  further  sensory  or  motor  disturbances. 
Eyes  normal,  the  sense  of  smell  is  very  acute,  hearing 
normal.  The  urine  is  clear,  slightly  acid,  of  high  color, 
specific  gravity,  1.021 ;  no  albumin  or  sugar ;  on  stand- 
ing a  thick  sediment  consisting  of  phosphates  is  deposited. 
Both  the  first  and  second  portion  of  the  morning  urine 
contain  finer  mucous,  and  coarser  threads.  In  the  latter 
the  gonococcus  is  present  inconsiderable  numbers.  The 
measurement  of  the  urethra  shows  two  wide  strictures : 
one  in  the  middle  of  the  pars  pendula,  and  one  in  the 
pars  bulbosa,  of  25  and  29  calibre,  respectively.  The 
prostate  gland  is  about  the  size  of  an  English  walnut,  and 
indurated.  The  palpation  of  this  organ  is  extremely 
disagreeable  to  the  patient, — as  is  also  any  manipulation 
upon  the  urethra — for  it  puts  him  in  a  state  of  excessive 
nervousness  and  excitement. 


December  i,  1894] 


MEDICAL   RECORD. 


687 


Diagnosis. — Urethritis  chronica  anterior  et  posterior, 
strictures;  prostatitis  chronica  levis,  prostatorrhcea, 
phosphaturia ;  anaemia,  neurasthenia  gravis  (hypochon- 
driasis?). 

Treatment. — Mr.  B was  sent  to  me  on  August  28, 

1893.  After  examining  him  thoroughly  and  detecting 
the  urethral  disorder,  I  expressed  the  opinion  that  this 
was  probably  the  main  seat  of  his  troubles,  and  if  it 
could  be  cured  the  other  symptoms  would  either  disap- 
pear entirely,  or  be  greatly  ameliorated.  At  this  state- 
ment he  seemed  to  be  satisfied  and  relieved,  and  con- 
sented to  undergo  the  treatment  I  proposed.  The 
treatment,  directed  against  the  genito-urinary  disorders, 
was  the  same  as  in  the  previous  case.  Iron,  arsenic,  and 
strychnine  were  ordered  as  a  tonic  for  his  anaemia,  and 
his  bowels  regulated  by  laxatives.  I  tried  to  induce  him 
to  drink  more  liquids  in  the  forms  of  mineral  waters, 
milk,  weak  tea,  etc.,  in  order  to  dilute  the  urine,  which 
was  always  small  in  amount  and  concentrated ;  but  this  . 
advice,  I  fear,  was  scarcely  heeded,  owing  to  the  sub- 
jective discomfort  he  experienced  when  having  to  urinate 
frequently. 

As  the  patient  had  already  been  "saturated"  with 
bromides,  anodynes,  and  narcotics  by  his  former  medi- 
cal advisers,  without  achieving  any  favorable  results,  I  re- 
frained from  any  medicinal  treatment  of  his  nervous 
symptoms,  and  put  him  on  a  general  hygienic  regime 
(cool  salt-water  baths,  a  cold  sponge  bath  mornings  and 
evenings,  a  moderate  amount  of  out-door  exercise,  mas- 
sage, a  cold  compress  on  his  head  if  wakeful  at  night, 
etc.),  and  general  faradization.  I  also  tried  the  mental 
treatment,  encouraging  and  sympathizing  with  him. 

This  plan  of  treatment  was  followed  out  scrupulously 
and  methodically  by  both  patient  and  physician,  and 
the  former  improved  most  satisfactorily.  In  due  time 
his  gonorrhoea  was  cured  and  his  strictures  dilated  to  the 
full  extent  of  the  normal  urethra,  which,  owing  to  his  ex- 
treme sensitiveness  and  nervousness,  was  no  easy  task.  On 
November  5,  1893, *  had  noted :  No  more  evidence  of 
strictures,  gleet  cured,  both  portions  of  morning  urine 
clear,  no  threads,  or  other  evidence  of  urethritis ;  pa- 
tient notices  no  more  discharge  of  any  description. 

His  nutrition,  color,  and  general  health  had  also 
greatly  improved,  he  gained  weight  and  strength  stead- 

iiy. 

In  regard  to  his  nervous  symptoms,  the  progress  was 
slower,  although  he  worried  less  over  his  genito-urinary 
trouble,  was  more  hopeful,  took  more  interest  in  others 
and  his  business,  could  sleep  better,  and  felt  encouraged 
by  the  result  of  the  treatment ;  still  he  had  a  number  of 
parsesthesiae  and  morbid  ideas  left  that  he  could  not  over- 
come; he  still  mourned  over  his  past  sins,  especially 
over  masturbation,  "which  must  be  the  cause  of  all  his 
troubles.'1 

On  November  1  ith  he  came  to  my  office,  complaining 
of  rheumatic  pains  in  the  lumbar  region.  I  suggested 
giving  him  static  electricity,  and  the  next  day  directed 
him  to  come  to  Dr.  Dana's  clinic  at  the  Post-Graduate 
foi  that  purpose.  But,  "the  big  machine  and  the 
sparks  "  proved  too  formidable  for  him,  especially  as  the 
latter  were — at  one  of  my  colleagues'  suggestion — applied 
rather  intensely  on  the  nape  of  the  neck  tor  the  purpose 
of  alleviating  his  neurasthenic  symptoms.  The  patient 
decided  to  discontinue  treatment  for  a  season,  and  has 
not  returned  since. 

This  case  is  very  similar  to  the  preceding ;  the  nervous 
symptome»are,  however,  of  a  severer  type.  They  show 
a  decided  tendency  to  hypochondriasis,  or  even  melan- 
cholia. It  will  be  observed  that  the  victim  of  these 
afflictions  had  practised  masturbation  for  several  years. 
A  combination  of  the  consciousness  of  this  failing  with 
that  of  the  urethral  affections  is  most  pernicious,  espe- 
cially in  a  neuropathic  subject,  and,  as  I  have  frequently 
observed,  is  prone  to  give  rise  to  a  grave  group  of  ner- 
vous and  mental  symptoms.  The  above  described  men- 
tal and  physical  wreck  is  the  result  of  such  a  combina- 
tion. 


The  following  history  is  interesting,  inasmuch  as  the 
subject  is  a  negro.  He  is  a  very  intelligent,  bright,  and 
reliable  man ;  the  clearness  and  manner  in  which  he  re- 
lates his  history,  especially  in  reference  to  his  nervous 
troubles,  is  quite  remarkable  and  unique. 

Case  III. — C.  W.  P ,  thirty- five  years  of  age, 

colored ;  married ;  works  in  a  marble  shop.  He  gives 
the  following  history:  No  syphilis.  Acute  gonorrhoea 
four  years  ago ;  has  never  been  entirely  free  from  the 
urethral  discharge  since.  For  the  last  two  years  pains 
and  abnormal  sensations  referred  to  the  region  of  the 
bladder ;  thinks  he  must  have  stone  in  the  bladder,  be- 
cause his  brother  had.  Itching  in  the  back  part  of  the 
urethra.  Is  obliged  to  urinate  every  one  or  two  hours 
in  daytime,  and  at  night  gets  up  two  or  three  times  for 
that  purpose.  States  that  urine  is  sometimes  cloudy  and 
smells  bad.  No  discharge  lately,  but  "  the  lips  "  are 
invariably  glued  together  after  sleeping  for  several  hours. 
He  has  been  treated  for  the  urethral  disorder  off  and  on 
for  two  years,  the  meatus  was  slit,  and  sounds  passed  up 
to  No.  30,  but  a  radical  cure  was  not  effected. 

Some  of  the  nervous  symptoms  of  which  he  complains 
and  details  in  his  quaint  way  are  :  A  heavy,  stupid,  and 
empty  feeling  in  the  head ;  forgetfulness ;  general  weari- 
ness and  weakness,  especially  in  the  back,  so  that  it  is 
harder,  and  more  tedious  for  him  to  get  through  his 
work.  He  formerly  saw  the  bright  side  of  things,  but  is 
now  down-hearted  and  despondent,  worrying  continuously 
over  his  health  generally,  and  especially  over  his  "  blad- 
der trouble,"  which  nobody  seems  able  to  cure.  Poor 
sleep;  in  the  morning  gets  up  feeling  unrefreshed  and 
but  little  fitted  to  begin  the  day's  labor.  "Funny, 
darting  feelings,  starting  in  the  neck  of  the  bladder  and 
extending  all  over  the  privates  and  stomach."  The 
sexual  functions  are  weak ;  has  very  little  desire  in  this 
direction. 

Status  prasens  (December  15,  1893). — Well-nourished, 
strong,  robust  man ;  color  of  mucous  membrane  good ; 
no  evidence  of  syphilis ;  arteries  and  pulse  normal. 

Examination. — Deep  and  superficial  reflexes  lively; 
sways  considerably  on  standing  with  closed  eyes ;  fine 
tremor  in  hands  on  extension ;  otherwise  no  objective 
signs  of  motor  or  sensory  disturbances.  The  physical 
examination  is  negative.  The  urine  is  neutral,  cloudy, 
contains  threads,  flakes,  and  a  small  amount  of  pus  in 
both  portions,  no  albumin  or  sugar.  The  examination 
of  the  urethra  reveals  a  wide  stricture  in  the  bulbus,  of 
32  calibre.     Prostate  slightly  enlarged. 

Diagnosis. — Urethritis  chron.  ant.  et  post.;  cystitis 
chronica  (?)  ;  stricture  of  pars  bulbosa.  Neurasthenia  of 
mild  type. 

Treatment. — The  usual  method  described  above  was 
employed  for  the  chronic  urethritis  with  an  astoundingly 
good  result.  As  he  also  had  some  dyspeptic  symptoms  I 
put  him  on  rhubarb,  soda,  and  tincture  of  nux  vomica, 
and  gave  him  some  general  directions  in  regard  to  diet 
and  hygiene. 

He  progressed  steadily  and  markedly;  in  less  than 
three  months  the  genito-urinary  trouble  was  radically 
cured  and  the  nervous  symptoms  had  entirely  disappeared. 
This  period  might  have  been  shorter,  had  the  patient 
been  able  to  come  for  treatment  oftener  than  twice  a 
week.  On  taking  leave  of  me  he  seemed  very  happy, 
and  said :  "  Doctor,  I  feel  like  a  new  man,  I  feel  stronger 
and  I  can  work  first-rate  again.  That  '  stretcher '  (di- 
lator) you  have  is  a  wonderful  instrument ;  it  has  cured 
me  entirely."  Probably  the  psychical  influence  of  the 
"wonderful  instrument"  aided  greatly  in  the  cure  of 
his  nervous  troubles  ! 

Remarks. — I  think  that  all  the  nervous  manifestations 
enumerated  in  the  foregoing  histories  can  unquestionably 
be  classified  in  the  great  symptom-complex  of  neurasthenia. 
Morbid  fears  and  other  marked  hypochondriacal  symp- 
toms are  very  common  in  neurasthenia ;  even  be  they  of 
so  severe  a  type  as  described  in  Case  II.,  they  fall  never- 
theless within  its  limits.  The  same  applies  to  the  symp- 
toms of  a  tendency  to  melancholia. 


688 


MEDICAL  RECORD 


[December  I,  1894 


Following  Dana,1  this  case  comes  under  the  classifi- 
cation :  "  The  Modified  Types,"  "  Degenerative  Neuras- 
thenia," and  Dana  rightly  says:  "This  type  of  neuras- 
thenia is  often  described  as  'sexual,'  or  as  'primary.' 
It  is  really  a  manifestation  of  neurotic  degeneracy,  and 
may  be  looked  upon  as  an  abortive  form  of  paranoia." 

Considering  how  many  sufferers  from  chronic  urethritis 
are  afflicted  with  nervous  disorders,  it  would  seem  reason- 
able to  attribute  to  the  former  an  important  part  in  the 
etiology  of  the  latter.  Whether  the  urethritis,  per  se,  is 
the  causative  factor,  or  whether  it  is  the  mental  effect  of 
this,  is  difficult  to  determine,  for  there  are  many  men  suf- 
fering from  gleet  for  years  who  are  entirely  free  from  any 
nervous  disturbances  until  they  become  aware  of  its  ex- 
istence. The  knowledge  of  this  immediately  brings  on 
nervous  prostration.  In  my  estimation  the  psychical 
factor  is  the  more  powerful  of  the  two. 

On  the  other  hand,  there  are  men  afflicted  with  chronic 
urethritis  and  neurasthenia,  notwithstanding  their  igno-, 
ranee  of  the  former's  existence.  But  if  we  consider  how 
wide-spread  both  of  these  diseases  are,  it  is  not  surprising 
that  we  should  find  both  of  them  coexisting  indepen- 
dently in  the  same  individual.  Nobody  will  deny  that 
many  of  our  more  enlightened  city  inhabitants  are  neur- 
asthenic, and  nobody  who  will  take  the  trouble  to  in- 
spect the  urine  of  his  male  patients  will  fail  to  be  con- 
vinced of  the  frequency  of  chronic  urethritis.  Moreover, 
evidence  of  this  can  be  procured  indirectly  by  other 
means,  such  as  Noeggerrath's  statistics. 

All  authors  agree  in  attributing  to  genito-urinary  dis- 
orders a  more  or  less  important  part  in  the  etiology  of 
neurasthenia.  Beard  considers  involuntary  emissions, 
partial  or  complete  impotence,  and  irritability  of  the 
prostatic  urethra  as  mere  accompanying  symptoms  of  in- 
creased irritability.  But  one  must  be  rather  sceptical  in 
regard  to  such  conditions,  for,  as  I  have  observeci,  they, 
as  well  as  many  others,  generally  turn  out  to  be  the 
manifestations,  or  consequences  of  chronic  urethritis  which 
is  the  primary  cause. 

Finally,  we  have  the  question  before  us :  Does  chronic 
urethritis  invariably  give  rise  to  nervous  manifestations? 
No,  I  think  not.  I  have  seen  men  (in  Europe)  with 
normal  nervous  systems,  who  showed  no  evidence  of  neu- 
rotic disorders  notwithstanding  the  knowledge  and  long 
duration  of  a  chronic  urethritis.  Therefore  it  is  neces- 
sary to  recur  to  a  third  etiological  factor,  viz.,  a  neu- 
ropathic constitution  or  predisposition.  Dana,  under 
neurasthenia,  puts  it  in  a  very  plausible  way.  He  refers 
to  prostatic  and  urethral  disorders  as  reflex  causes  of 
neurasthenia,  but  presupposes  a  neuropathic  constitution. 
My  own  observations  go  to  corroborate  this  view,  to 
which  I  would,  however,  add  the  psychical  factor,  viz., 
the  patient's  knowledge  of  the  urethral  disease,  which 
factor  is,  in  my  opinion,  the  most  active.  Thus,  the  im- 
portant etiological  factors  of  the  cases  under  considera 
tion  are :  the  neuropathic  constitution  or  predisposition 
as  predisposing,  the  chronic  urethritis,  and  the  patient's 
knowledge  of  its  existence,  as  exciting  causes. 

In  the  symptomatology  of  all  cases  of  neurasthenia 
connected  with  chronic  urethritis,  there  is  a  great  multi- 
plicity and  diversity  of  the  manifestations  in  one  sense, 
but  in  the  other  a  striking  monotony.  Common  to 
them  all  are  the  more  localized  nervous  symptoms,  di- 
rectly referable  to  the  genito  urinary  apparatus,  which 
clearly  point  to  these  parts  as  the  seat  of  the  disease, 
causing  the  bearer  no  end  of  worry,  anxiety,  and  discom- 
fort, and  giving  the  hypochondriacal  tone  so  prominent 
in  these  cases.  These  symptoms  have  been  sufficiently 
enumerated  and  described  in  the  foregoing  histories. 

The  symptoms  of  Case  I.  are  a  little  above  the  average 
degree  of  severity,  though  they  are  of  every-day  occur- 
rence. The  patient  was  a  healthy,  steady-going,  relia- 
ble, and  thrifty  artist  previous  to  the  onset  of  his  gleet, 
but  afterward  he  was  almost  entirely  incapacitated  for 
any  mental  or  physical  work,  unreliable,  changeable,  and 
more  or  less  an  invalid. 

1  Text-book  of  Nervous  Diseases,  New  York,  1893. 


Case  IL  shows  to  what  extent  the  neurotic  disturb- 
ances may  progress.  Here  we  have  a  perfect  mental  and 
physical  wreck  before  us,  with  marked  hypochondriacal 
symptoms  and  a  tone  of  melancholia.  It  will  be  remem- 
bered that  this  patient  had  a  neuropathic  constitution,  to 
begin  with,  and  had  practised  masturbation  for  several 
years,  which  factors  must  not  be  neglected  in  accounting 
for  the  severity  of  the  case. 

Case  III.,  presenting  no  neuropathic  history  and  being 
a  negro— the  male  sex  of  which  race,  I  believe,  is  not  so 
much  inclined  to  functional  nervous  disorders — it  is  not 
surprising  that  his  symptoms  should  be  of  a  milder  type 
and  the  course  a  more  favorable  one. 

From  these  considerations  it  would  appear  that  the 
severity  of  the  neuropathic  manifestations  depended  upon 
the  power  of  resistance  of  the  bearer's  nervous  system, 
which  is  the  case  in  all  functional  nervous  diseases. 

The  chief  features  of  the  cases  under  consideration 
may  be  summarized  as  follows :  A  history  of  gonorrhoeic 
infection.  Symptoms  of  general  cerebro-spinal  neuras- 
thenia. Nervous  disturbances  directly  referable  to  the 
genito-urinary  apparatus.  Prominence  of  the  hypochon- 
driacal symptoms,  and  a  tendency  to  melancholia. 

The  prognosis  of  the  milder  and  average  types  of  neu- 
rasthenia is,  as  in  neurasthenia  from  other  causes,  favor- 
able ;  even  more  so,  for  here  the  seat  of  the  trouble  can 
be  reached,  which,  if  cured,  and  the  physical  factor  be- 
ing, also,  thereby  removed,  the  patient  will  generally 
make  a  complete  recovery.  If  the  neurotic  trouble  is 
more  deeply  seated  and  of  a  degenerative  type,  and  there 
are  other  factors  concurring  with  the  urethral  disorder 
(such  as  a  neuropathic  constitution,  the  consciousness  of 
masturbation,  or  other  previous  or  present  vices),  then 
their  prospects  of  complete  recovery  are  doubtful,  al- 
though the  patient  may  greatly  improve.  The  troubles 
arising  directly  from  the  urethral  affection  will  disappear 
under  appropriate  treatment ;  the  other  neurotic  disturb- 
ances may  also  improve  markedly,  and  the  patient  be 
benefited  in  every  sense;  but  his  morbid  thoughts  and 
imagination  will  take  a  fresh  direction,  new  fears,  wor- 
ries, troubles,  etc.,  will  develop,  and  he  will  probably 
remain  a  neurasthenic  subject,  if  nothing  worse,  for  the 
rest  of  his  days. 

The  plan  of  treatment  of  the  chronic  urethritis  has 
been  described  in  the  foregoing,  and  some  stress  laid 
upon  it,  because  the  favorable  results  observed  in  Dr. 
Finger's  clinic,  and  in  my  own  experience,  prompt  me  to 
consider  it  a  great  advance  in  modern  science. 

In  the  milder  cases  of  nervous  disorders,  nothing  more 
than  general  directions  in  regard  to  hygiene,  diet,  and 
mode  of  living  are  required.  In  severer  cases  it  is  ad- 
visable to  resort  to  some  sedative  remedies,  for  the  treat- 
ment of  the  chronic  urethritis,  especially  in  the  begin- 
ning, often  aggravates  the  nervous  troubles  for  a  while. 
Then  the  bromides  are  very  serviceable :  Natr.  bromid. , 
1.0  in  the  evening,  or  if  necessary,  0.75  t.i.d.  Static 
electricity,  or  general  faradization,  applied  cautiously,  arfe 
useful  if  the  patient  can  "  stand  it."  It  is  also  advisable 
to  prescribe  tonics,  alone,  or  in  combination  with  an/ti- 
dyspeptic  remedies,  if  in  any  way  indicated.  The  fol- 
lowing improvement  of  the  patient's  nutrition  and  color, 
in  connection  with  the  progress  achieved  in  the  treatment 
of  the  urethral  disorder,  will  add  greatly  to  the  psyuhkal 
effect  of  the  "cure,"  endowing  the  sufferer  witbJjnore 
courage  and  hope.  This  latter  factor  is  of  no  min«f.r  im- 
portance, for  his  perseverance  in  continuing  t!ne  treat- 
ment depends  to  a  great  extent  upon  an  appreciable 
improvement.  Furthermore,  the  mental  training  of  the 
patient  is  imperative ;  he  must  follow  out  the  prescribed 
directions  implicitly,  and  be  prevailed  upon  to  entirely 
change  his  mode  of  life.  An  appreciation  of  .4br  subse- 
quent improvement  will  be  more  than  sufficient  to  deter 
him  from  falling  back  into  his  former  habits. 

Last,  but  not  least,  the  physician  must  show  much  kind- 
ness, consideration,  patience,  and  interest  for  the  sufferer. 
This  class  of  patients  like  nothing  better  than  to  be  care- 
fully and  repeatedly  examined,  assured  that  there  is  no 


December  i,  1894] 


MEDICAL   RECORD. 


689 


grave  disorder,  and  that  they  are  progressing  satisfacto- 
rily. They  always  feel  grateful  for  such  attentions  at  the 
hands  of  the  doctor,  and  even  if  the  effect  be  but  psychi- 
cal and  momentary,  it  is,  nevertheless,  deserving  of  being 
practised. 


«3  Wbst  Fimr-THiKD  Stmit. 


NOTES  ON  APPENDICITIS.1 
By  EGBERT  H.  GRANDIN,  M.D., 

MEW  YORK. 
PUSIDBNT  OF  THB  MEDICAL  SOCIETY  OP  TH»  COUNTY  OP  MEW  YOK  ;  GYNECOL- 
OGIST TO  THB  PXBNCK  HOSPITAL,  ETC. 

When  invited  to  read  a  paper  before  the  Queens  County 
Medical  Society,  I  accepted  the  honor  with  all  the  more 
pleasure  because  it  enabled  me  to  introduce  for  discus- 
sion a  topic  which,  to  judge  from  the  number  of  instances  I 
have  seen  in  consultation  in  this  neighborhood,  will  elicit 
most  valuable  information  from  your  Fellows.  Notwith- 
standing the  relatively  large  experience  which  it  has  fallen 
to  my  lot  to  have  with  appendicitis  in  the  r61e  of  consult- 
ant, I  am  about  as  much  in  the  dark  in  regard  to  the 
symptomatology  and  treatment  as  I  was  when  the  surgery 
of  to-day  replaced  the  medicine  of  yesterday  in  the  man- 
agement of  this  affection.  It  is  to  the  general  practi- 
tioner, of  which  this  body  is  largely  composed,  that  I 
look  for  the  elucidation  of  a  number  of  obscure  points, 
and  I  feel  that  my  visit  here  will  result  in  the  personal 
acquisition  of  greater  information  that  I  can  give  you. 
The  remarks  I  have  to  make  are  suggestive,  although 
founded  on  much  experience. 

I  have  come  to  the  conclusion  that  there  is  no  absolute 
group  of  symptoms  which  points  to  appendicitis,  and  that 
there  is  an  absolute  group  of  symptoms  which  calls  for 
surgical  interference.  I  do  not  believe  that  every  case  of 
appendicitis  calls  for  the  knife,  even  though  palliative 
treatment  never  effects  cure  in  an  anatomical  sense.  I 
am  firmly  convinced  that  a  trilogy  of  symptoms,  which 
I  proceed  to  dwell  upon,  stamps  a  type  of  the  disease 
—called  infectious  appendicitis — as  demanding  surgery  as 
immediate  as  possible. 

A  constant  symptom  present  in  appendicitis  is  pain. 
This  pain  at  the  outset  may  be  located  at  any  point  of 
the  abdomen  ^  it  is  often  sub  umbilical;  it  is  frequently 
diffuse  abdominal.  It  is  described  as  being  acute  and 
agonizing,  and  sooner  or  later  the  maximum  seat  of  inten- 
sity lies  over  the  ileo-caecal  valve.  This  pain,  however,  is 
not  alone  of  diagnostic  value,  since  it  is  an  associate  of 
other  intra-abdominal  lesions  besides  appendicitis.  Its 
localization  awakens  our  suspicion  that  the  cause  is  near 
the  caecum ;  its  presence,  however,  never  certifies  abso- 
lutely to  appendicitis.  A  mere  impaction  at  the  caecum 
may  give  as  much  pain.  The  decrease  in  pain,  or  its 
disappearance,  on  the  other  hand,  may,  as  I  will  show 
later,  be  a  bad  omen. 

High  thermometric  range,  associated  with  great  ab- 
dominal pain,  both  factors  being  continuous,  is  rather 
characteristic  of  instances  which  recover  symptomatically 
without  operation  than  the  reverse.  Frequently  these 
instances  terminate  in  local  abscess,  on  the  incision  of 
which  the  symptoms  subside.  It  is  the  instances  where, 
•  notwithstanding  the  temperature  subsides,  the  pulse  yet 
remains  rapid,  which  always  should  cause  anxiety,  and 
which  nearly  uniformly  demand  surgical  interference. 
The  fall  in  temperature,  the  subsidence  of  the  pain,  the 
relatively  high  pulse  rate,  point  to  beginning  septic  infec- 
tion, and  if  the  focus  be  not  removed  general  peritonitis 
sets  in  of  a  type  uniformly  fatal.  Decrease  or  absence  of 
pain,  and  flat  instead  of  tympanitic  abdomen,  mean  gener- 
ally perforation  of  the  septic  appendix.  The  aim  of  sur- 
gery ifc  this  region  is  to  forestall  perforation  and  the 
resulting  peritonitis.  The  gist  of  my  argument,  then,  is 
that  I  am  more  alarmed  by  the  subacute  nature  of  the 
symptoms  thirty-six  hours  or  so  after  the  initial  attack 

1  Read  by  invitation  at  the  Semi-annual  Meeting  of  the  Medical  So- 
ciety of  the  County  of  Queens,  October  30,  1894. 


than  I  am  by  the  maintenance  of  acute  symptoms.  In 
the  latter  event  apparent  cure  will  often  follow  on  purely 
medical  measures ;  in  the  former  instance  incision,  as 
soon  as  may  be,  frequently  offers  the  sole  hope  of  saving 
life. 

It  is  above  all  important,  in  cases  where  the  diagnosis 
of  appendicitis  is  suggested  by  the  symptoms,  to  avoid 
masking  these  latter  through  the  administration  of  opium. 
If  the  stomach  be  tolerant,  it  is  desirable  to  secure  free 
catharsis  in  the  early  stage,  since  a  loaded  caecum  not 
alone  may  simulate  appendicitis  but  intensify  its  symp- 
tomatology. High  rectal  enemata  of  ox-gall,  turpentine, 
glycerin,  and  saturated  solution  of  Epsom  salts  will  fre- 
quently be  of  service  while  awaiting  the  action  of  laxa- 
tives given  by  the  mouth.  Hypodermatic  injections  of 
a  saturated  solution  of  sulphate  of  magnesium,  given  deep 
in  the  nates  (  3  j.  doses  half- hourly)  have  also  repeatedly 
in  my  hands  had  a  purgative  action.  For  the  relief  of 
the  pain  the  ice  bag  answers  better  than  the  poultice, 
being  a  local  anaesthetic,  and  at  the  same  time  lowering 
the  temperature  without  affecting  the  heart,  as  all  the  coal- 
tar  series  of  antipyretics  may.  If,  notwithstanding  these 
remedial  measures,  at  the  end  of  thirty-six  hours  the 
symptoms  show  no  signs  of  abating,  or  else  the  abatement 
is  in  the  unfavorable  direction  I  have  noted  above  (fall 
in  temperature,  relatively  rapid  pulse,  flattening  belly), 
then,  as  the  result  of  my  experience,  I  feel  that  the  time 
has  come  for  surgery.  If  we  wait  for  the  formation  of  a 
distinct  tumor,  general  sepsis  may  set  in  before  operation 
can  be  performed ;  if  we  wait  until  there  is  evidence  of 
beginning  perforation,  operation  will  prove  nugatory. 

In  my  operative  experience,  which  includes  thirty-two 
cases,  I  have  met  every  form  of  complication — the  gan- 
grenous appendix,  the  appendix  full  of  pus  on  the  point 
of  rupture,  the  appendix  which  had  perforated  into  the 
general  peritoneal  cavity  causing  purulent  peritonitis, 
the  appendix  simply  congested  and  denuded  of  its 
peritoneal  coating  (the  so-called  catarrhal  appendix),  the 
perityphlic  abscess.  In  this  neighborhood  I  have  seen 
18  cases  of  appendicitis;  of  tins  number  I  operated 
upon  10,  with  a  loss  of  3.  In  1  case  operation  was 
refused,  and  the  patient  died  within  forty  hours.  The 
remaining  7  cases  recovered  without  operation.  The 
3  fatal  cases  following  operation  were  all  instances  of 
general  peritonitis,  a  type  which  yields  an  almost  abso- 
lute death-rate. 

Through  the  courtesy  of  your  colleague,  Dr.  R.  F. 
McFarlane,  I  am  able  to  show  you  to-day  three  patients 
on  whom  I  have  recently  operated  for  appendicitis.  The 
little  girl's  initial  attack  dated  back  about  forty  hours. 
The  rapid  pulse,  the  relatively  low  temperature,  the  di- 
minishing pain  pointed  to  perforation  or  to  beginning 
septic  infection.  Operation  was  advised  and  accepted. 
On  section  I  found  a  gangrenous,  perforated  appendix 
and  active  peritonitis.  Her  recovery  is  due  to  the  unre- 
mitting watchfulness  of  Dr.  McFarlane.  As  a  rule,  in- 
stances of  this  nature  die,  no  matter  what  the  treatment. 
In  a  case  of  the  like  nature,  seen  recently  in  New  York 
City,  with  Drs.  Smith  and  Warner,  operation  was  per- 
formed in  the  presence  of  a  temperature  of  990  F.,  pulse 
of  120,  flat  belly,  and  no  pain.  The  same  condition  of 
affairs  was  found ;  the  child  lived  ten  days,  finally  suc- 
cumbing to  septic  infection,  characterized  chiefly  by  ab- 
solute intestinal  paresis. 

In  the  little  boy  the  symptoms  were  more  acute  than 
in  the  girl.  The  fades,  however,  had  that  anxious, 
drawn,  ashy  look  suggestive  of  septicaemia.  I  opened  in 
the  usual  locality ;  behind  the  caecum  I  found  the  firmly 
adherent  appendix  yielding  fluctuation.  There  was  no 
peritonitis,  and  to  avoid  infection  of  the  cavity  I  opened 
behind,  found  a  posterior  rupture  with  pus,,  and  counter- 
drained  after  asepticizing  the  cavity  posteriorly. 

This  man  was  operated  upon  in  the  quiescent  stage. 
He  had  had  repeated  attacks  and  had  grown  weary  of 
the  interference  with  his  business.  I  found  omentum  as 
thick  as  the  thumb,  which  I  tied  off;  underneath  this  an 
adherent  caecum  which  I  separated ;  below  this  the  ad- 


690 


MEDICAL    RECORD. 


[December  1,  1894 


herent,  convoluted  appendix,  which  I  removed.  I 
drained  him  for  thirty-six  hours,  and  then  sewed  him  up 
carefully.  Contrary  to  the  advice  of  Dr.  McFarlane,  he 
left  his  bed  in  twelve  days  and  refused  to  wear  a  truss. 
His  contumacy  resulted  in  this  hernia. 

Here  are  a  half  dozen  appendices,  which  I  present  as 
samples  of  the  kind  I  have  removed.  You  notice  that 
they  are  large  and  distorted,  perforated  at  one  or  more 
places,  denuded  of  epithelium.  All  of  these,  and  such 
has  been  the  necessity  I  have  ever  been  under,  have  re- 
quired a  liberal  incision  in  order  to  free  and  remove  them 
with  safety  to  the  patient  and  without  unnecessarily  in- 
fecting the  peritoneal  cavity.  In  the  majority  of  my 
operations  I  have  utilized  the  Trendelenburg  posture, 
which  has  enabled  me  to  see  what  I  was  doing  and  to 
protect  to  better  advantage  the  peritoneal  cavity.  This 
position  you  may  improvise  at  any  time  by  tying  an  or- 
dinary hard  bottom  chair  on  a  table,  so  as  to  form  an  in- 
clined plane.  I  have  further,  in  all  pus  cases,  irrigated 
freely  with  hot  one  per  cent,  salt  solution  and  with  full- 
strength  peroxide  of  hydrogen,  neither  of  which  act  as 
irritants,  as  bichloride  does.  Further  still,  whenever  fea- 
sible, I  have  counterdrained,  and  in  large  peri-appendi- 
cital  abscesses  I  have  avoided  digging  up  the  appendix,  a 
procedure  which  can  only  result  in  breaking  down  nat- 
ure's protecting  wall  of  adhesions  and  in  thus  infecting 
the  general  peritoneal  cavity. 

Such  are  the  discursory  thoughts  I  would  offer  for  dis- 
cussion. The  principle  which  mainly  guides  me  in  se- 
lecting surgery  in  these  cases  is  the  feeling  that  it  is  pref- 
erable to  perform  an  aseptic  exploratory  section  and  be 
proved  wrong  in  diagnosis,  than  to  wait  on  nature  until 
an  operation  is  forced  upon  me  after  perforation  and  in 
the  presence  of  peritonitis. 

36  Eatp  Fifty-eighth  Street. 


THE  INDIAN  WOMAN    IN  LABOR. 
By  GUY  C.   M.    GODFREY,   M.D. 

LIEUTENANT  IN  THE  MEDICAL  DEPARTMENT,  UNITED  STATES  ARMY  ;  POST- 

fURGSOM  AT  rOBT  WASHAKIE,  WYO. 

As  the  Indians  are  very  reticent  about  their  child-births 
facts  in  the  matter  are  hard  to  obtain,  and  my  thanks  are 
due  to  Dr.  F.  H.  Welty,  the  physician  to  the  Shoshone 
Agency  in  Wyoming,  for  his  invaluable  aid  in  preparing 
this  article. 

The  Indians  at  this  agency  are  Arapahoes  and  Sho- 
shones, and  it  is  about  them  that  I  write.  The  Sho- 
shone women  are  rather  short  and  heavy  set,  with  broad 
pelves.  Their  temperament  is  lymphatic.  The  Arapa- 
hoe women,  on  the  contrary,  are  tall  and  slender,  with 
fine  figures  and  broad  pelves.  They  are  of  a  bilious  tem- 
perament. In  both  tribes  the  women  are  stronger  than 
the  men,  on  account  of  the  enormous  amount  of  work 
they  do.  As  the  habits  of  any  people  have  a  direct  bear- 
ing on  their  health,  a  few  words  in  regard  to  the  cus- 
toms of  the  Indians  will  not  be  inappropriate. 

The  women  are  very  industrious  and  perform  nearly 
all  of  the  manual  labor  done  in  the  village,  including 
chopping  wood,  carrying  water,  cooking,  etc.  They 
also  do  the  sewing  and  bead  work.  Their  recreation  is 
gambling.  They,  as  well  as  the  men,  are  filthy.  As  re- 
gards virtue,  conflicting  reports  are  heard,  some  claim- 
ing that  the  prairie  Indians  (Arapahoes,  Cheyennes, 
and  Sioux)  are  virtuous,  others  claim  that  no  Indians  are 
virtuous.  Several  years  ago  the  Shoshones  had  a  custom 
of  cutting  off  the  tip  of  the  nose  of  any  woman  caught  in 
adultery.  After  the  woman's  nose  was  clipped,  she  was 
considered  a  harlot  of  the  tribe.  When  a  woman  walks 
by  herself  she  is  not  considered  virtuous,  and  is  fair  game 
for  any  buck. '  Therefore  two  women  generally  keep  to- 
gether. A  custom  prevails  among  the  Arapahoes  of 
eight  or  ten  young  men  lying  in  wait  for  a  solitary  fe- 
male, and  when  one  appears  in  view  they  seise  and  ravish 
her.  The  girls  begin  menstruating  when  twelve  or  thir- 
teen years  of  age,  and  continue  until  they  are  forty  or 


forty-five.  They  are  very  regular.  The  half-breeds  and 
Shoshones  sometimes  suffer  from  suppression  of  the 
menses,  but  the  Arapahoe  women  are  never  known  to 
have  any  menstrual  disorders.  During  menstruation  a 
woman  retires  alone  to  a  small  wickyup  or  tepee,  and  re- 
mains there  until  the  flow  has  ceased.  Whether  this  cus- 
tom is  compulsory  or  voluntary  is  not  known.  The 
child-bearing  age  is  between  thirteen  and  forty -five. 
The  average  number  of  births  per  woman  is  about  ten  or 
twelve.  As  a  rule  they  marry  quite  young,  because  the 
constant  drudgery  of  their  lives  breaks  them  down,  and 
a  squaw  is  often  a  wrinkled  hag  at  the  age  of  forty.  The 
bucks,  on  the  contrary,  often  keep  their  age  well.  A 
young  man  takes  a  wife  and  when,  after  a  certain  num- 
ber of  years,  she  loses  the  bloom  of  youth,  he  takes  an- 
other and  so  on.  As  a  rule  the  squaws  are  quite  healthy, 
with  the  exception  of  scrofulous  subjects,  scrofula  being 
the  most  common  disease  among  them.  Cancer  is  never 
found  among  these  Indians.  During  pregnancy  there  is 
no  morning  sickness,  although  at  other  times  the  Indi- 
ans often  have  dyspepsia  from  their  gormandizing  and 
monotonous  diet.  The  pregnant  woman  is  not  consti- 
pated anymore  than  at  other  times.  As  a  rule  they  have 
no  sickness  whatever  while  they  are  with  child.  During 
labor  the  woman  lies  on  her  back  supported  in  a  semi- 
recumbent  position  by  a  head-rest  made  of  sticks  cov- 
ered with  skin  or  cloth.  This  rest  is  wedge-shaped,  about 
three  feet  long  and  two  feet  high  at  the  base.  It  is 
placed  on  the  bed  usually  occupied  by  the  patient  The 
men  are  all  required  to  leave,  and  the  patient  is  only  at- 
tended by  two  or  three  old  women  who  live  in  neighbor- 
ing tepees.  They  have  no  regular  midwives  and  rarely 
apply  to  a  white  physician  for  any  assistance  daring 
labor.  The  old  women  remove  all  of  the  clothing  below 
the  waist  and  stay  by  the  patient's  side  during  delivery. 
In  case  the  latter  is  slow  or  difficult  they  occasionally 
knead  the  abdomen  with  their  hands.  If  the  labor  is 
unusually  difficult  two  of  the  women  hold  a  stick  be- 
tween them  at  a  height  of  about  a  foot  from  the  ground 
and  across  this  the  patient  is  required  to  lie  with  the  ab- 
domen downward.  This,  of  course,  stimulates  the  con- 
tractions of  the  womb  and  causes  increased  abdominal 
pressure  from  the  patient's  weight.  The  above  consti- 
tute all  the  resources  of  the  old  women,  and  if  they  fail, 
the  "  tona-hay-hay,"  or  medicine-man,  is  called  in.  He 
is  a  very  important  personage  in  the  tribe,  and  has  the 
full  confidence  of  all.  His  art  consists  in  making  a  big 
"  pow  wow,"  calling  on  the  Great  Spirit  and  rattling  his 
"medicine-box."  He,  of  course,  does  no  good,  but  as 
Indian  labors  nearly  always  terminate  successfully  by  nat- 
ural methods,  he  gets  the  credit.  The  delivery,  as  a 
rule,  is  short  and  easy.  It  seldom  lasts  more  than  three 
or  four  hours.  The  patients  seem  to  suffer  much  less 
than  white  or  negro  women.  The  vertex  usually  pre- 
sents. Abnormal  presentations,  like  pelvic  malforma- 
tions, are  very  rare.  Only  one  case  has  been  reported  at 
this  agency  during  the  last  six  years.  Indians  are  very 
unwilling  to  talk  about  such  matters,  but  I  conclude, 
from  the  meagre  scientific  information  obtained,  that  it 
was  a  transverse  presentation.  This  case  lasted  four 
days.  The  old  women  kneaded  the  abdomen  with  their 
hands  and  hung  the  patient  across  the  stick.  These  two 
methods  having  failed,  the  medicine-man  was  called  in.  • 
He  danced,  shouted,  and  rattled  his  medicine*box  for 
two  days,  and  as  neither  spontaneous  version  nor  evolu- 
tion occurred,  the  patient  died  from  exhaustion  on  the 
fourth  day.  No  autopsy  could  be  obtained,  and  the 
mother  was  buried  with  the  child  undelivered.  No  white 
physician  was  called,  because  the  Indians  do  not  know 
the  extent  of  science  and  art  in  obstetrics.  The  Indians 
know  nothing  of  artificial  delivery,  consequently  it  is 
never  attempted.  Neither  placenta  previa  no*  tumors 
ever  occur  to  complicate  delivery.  I  have  never  heard 
of  a  prolapse  of  the  cord  occurring  in  labor,  although  I 
believe  it  does  rarely.  Retention  of  the  placenta  is  not 
unusual,  and  for  this  the  white  physician  is  generally 
called.    When  the  doctor  arrives  he  finds  that  the  med- 


December  i,  1894] 


MEDICAL   RECORD, 


691 


icine  man  has  failed,  the  old  women  make  no  attempts 
to  extract  the  placenta  beyond  tying  the  umbilical  cord 
to  the  patient's  leg.  They  do  this,  they  say,  to  prevent 
the  cord  from  slipping  up.  The  doctor  then  explains 
that  if  Credo's  method  fails  he  will  introduce  his  hand 
and  remove  the  after-birth.  This  he  does  after  taking 
the  proper  antiseptic  precautions.  Whereupon  the 
women  pat  him  on  the  breast  and  exclaim  "ohoh 
ohoh !  "  which  means  "  bless  you."  When  he  emerges 
from  the  tent  the  bucks  shake  hands  with  him  and,  sol- 
emnly pointing  upward,  say:  "Heap  big  medicine 
man!  " 

Multiple  pregnancy  is  unknown  among  full-blooded 
Indians.  Only  two  cases  have  been  reported  at  this 
agency  during  the  past  six  years,  and  in  each  case  the 
father  was  a  negro  and  the  mother  an  Arapahoe.  In 
each  case  the  children  consisted  of  a  boy  and  a  girl. 
Triplets  never  occurred.  The  duration  of  the  puerperal 
period  is  usually  only  a  few  hours.  At  the  end  of  that 
time  the  patient  is  up  and  doing  her  usual  work.  In 
scrofulous  subjects  the  period  sometimes  lasts  longer, 
even  extending  to  a  week's  duration.  In  one  case  which 
recently  came  under  Dr.  Welty's  observation,  the  patient, 
being  a  scrofulous  woman,  was  unable  to  suckle  her 
child. 

Puerperal  eclampsia  is  unknown.  Puerperal  septi- 
caemia is  very  rare,  only  one  case  having  occurred  here 
within  the  last  five  years.  This  case  was  also  attended 
by  Dr.  Welty,  who  says  that  it  was  caused  by  a  decom- 
posing retained  placenta.  The  patient,  a  syphilitic,  had 
by  that  time  contracted  puerperal  septicaemia  from  which 
she  died  ten  days  after  delivery.  Mammary  abscesses 
are  quite  frequent,  and  are  caused  by  exposure  and  the 
filthy  habits  of  the  patients.  The  maternal  mortality  is 
very  small,  only  two  deaths  having  occurred  here  in  the 
past  six  years — one  from  exhaustion  and  the  other  from 
septicaemia,  as  reported  in  the  two  cases  mentioned 
above. 

The  foetal  mortality  is  very  small,  only  two  children 
having  died  during  the  past  six  years.  Abortions  are 
rare  among  full  blooded  Indians,  but  are  rather  common 
among  half-breeds.  An  abortion  is  generally  the  result 
of  a  fall,  kick,  or  blow.  The  Indians  have  no  special 
knowledge  of  its  etiology  or  treatment.  The  foregoing 
facts  were  obtained  with  great  difficulty,  as  very  few  of 
the  Indian  women  speak  English.  They  are  backward 
about  talking  through  an  interpreter,  because  they  are 
very,  .very  much  averse  to  giving  any  man  any  knowl- 
edge of  their  sexual  troubles.  Therefore  I  offer  this  arti- 
cle, not  as  an  ultra- scientific  study  in  obstetrics,  but  as 
an  interesting  collection  of  facts  concerning  the  "  noble 
red  man's  spouse." 


VAGINAL  HYSTERECTOMY  BY  ENUCLEATION 
WITHOUT  LIGATURE   OR   CLAMP. 

By  J.  RIDDLE  GOFFE,  PH.B.,  M.D., 

MEW  YORK. 

peotessot  or  gynecology  in  the  new  yoke  polyclinic  ;  assistant  gynecol- 
ogist IN  THE  SKIN  AND  CANCER  HOSPITAL. 

The  possibility  of  enucleating  the  uterus  per  vaginam 
without  the  use  of  a  ligature  or  clamp,  is  a  recorded  fact 
in  surgical  literature,  dating  from  1822.  So  that,  in  con- 
templating this  apparently  new  procedure,  we  are  faced 
at  once  with  the  stubborn  tact  that  there  is  nothing  new 
under  the  sun, 

It  was  accomplished  for  the  first  time,  as  far  as  we 
know,  by  a  surgeon  named  Sauter,  of  Constanz,  Ger- 
many, in  the  year  1820.  The  feat  becomes  the  more 
extraordinary  when  we  consider  that  he  did  it  without 
the  use  of  an  anaesthetic  or  a  speculum.  The  operation 
was  done  for  cancer,  the  woman  was  bound  fast  to  the 
edge  of  the  bed,  and  the  tissues  were  severed  by  scissors, 
the  points  of  which  were  guided  by  the  fingers.  The 
account  is  extremely  interesting,  and  is  quoted  in  extenso 


in  a  work  entitled  "A  Handbook  of  Surgery,"  by 
Chelius,  of  Heidelberg,  and  translated  into  English  by 
South,  of  London,  under  the  title  of  "  A  System  of  Sur- 
gery." The  translation  was  published  by  Lea&  Blan- 
chard,  Philadelphia,  1847.  Although  Sauter's  patient 
recovered  without  serious  hemorrhage  or  other  accident, 
no  one  seems  to  have  followed  in  his  footsteps  till  re- 
cently, when  the  operation  was  revived  by  Pratt,  of  Chi- 
cago. 

What  the  benefits  or  advantages  of  this  procedure  may 
prove  to  be,  I  am  at  present  not  prepared  to  state.  But 
every  new  fact  or  principle  established  in  surgery,  as  in 
every  other  branch  of  science,  may  contain  in  itself 
possibilities  of  far  wider  significance  than  the  present  mo- 
ment can  imply.  At  present,  however,  we  know  that  the 
tightening  of  ligatures  on  nerve-fibres  produces  a  certain 
amount  of  shock,  and  the  placing  of  these  ligatures  re- 
quires a  certain  amount  of  time.  These  are  important 
factors  to  the  patient  in  every  operation  of  this  kind.  By 
this  method  they  can  both  be  eliminated. 

The  secret  of  avoiding  hemorrhage  in  this  procedure  is 
to  adhere  so  closely  to  the  uterine  wall  in  the  dissection, 
that  the  anastomosis  between  the  uterine  and  ovarian  ar- 
teries is  avoided,  and  only  the  small  branches  are  severed 
as  they  penetrate  the  uterus. 

The  opportunity  of  trying  this  method  presented  itself 
to  me  recently,  and  I  put  it  to  the  test.  The  patient 
was  an  Irish  woman,  forty- six  years  of  age,  who  had  been 
suffering  for  the  past  seven  years  with  complete  proci- 
dentia uteri  and  all  its  train  of  torture.  My  hope  was 
not  only  to  relieve  the  tissues  from  the  drag  of  the  heavy 
uterus,  but  to  secure  the  end  of  the  vagina  to  the  broad 
ligaments  at  a  point  sufficiently  high  to  make  them  hold 
up  the  vaginal  wall  and  bladder. 

The  field  of  operation  having  been  made  aseptic,  I 
made  a  circular  incision  around  the  cervix  through  the 
vaginal  wall  with  a  scalpel,  and  pushed  the  tissue  away 
from  the  cervix  all  around  with  the  handle  of  the  knife. 
It  occurred  to  me  that  Thomas's  spoon  saw  would  be  a 
good  instrument  for  this  dull  dissection  from  this  point 
on,  and  I  found  it  to  work  admirably,  enabling  me  to  ad- 
here very  closely  to  the  uterus,  and  to  separate  the  tissue 
with  ease  and  despatch.  Upon  reaching  the  peritoneum 
in  Douglas's  pouch  I  snipped  it  with  the  scissors,  and 
tore  it  right  and  left  with  my  finger. 

To  prevent  the  peritoneum  separating  from  the  vagina 
too  much  at  this  point,  also  as  a  preliminary  step  in  clos- 
ing the  upper  end  of  the  vagina,  I  now  passed  a  strong 
catgut  suture  through  the  wall  of  the  vagina  entering  the 
needle  on  the  peritoneal  side  and  passing  it  straight 
through  into  the  vagina,  and  then  back  again,  thus  leav- 
ing the  loop  on  the  vaginal  side.  The  two  ends  were 
then  caught  in  a  clamp  forceps  and  left  hanging  out  of 
the  vagina.  Continuing  the  dull  dissection  with  the 
spoon  saw,  I  separated  the  bladder  from  the  uterus,  even 
tearing  through  the  peritoneum  above  it  and  enlarging 
the  opening  to  either  side  with  my  finger. 

Although  I  had  been  in  momentary  expectation  of  see- 
ing a  spurting  artery  and  was  ready  at  any  moment  to  apply 
a  ligature,  no  arterial  hemorrhage  occurred.  I  therefore 
pushed  on  with  the  spoon  saw,  and  soon  had  the  satisfac- 
tion of  seeing  the  two  horns  of  the  uterus  sustained  by 
nothing  except  the  round  ligaments.  Before  severing 
these  I  passed  through  the  upper  part  of  each  broad  liga- 
ment, high  up  on  either  side  and  transfixing  the  round 
ligament,  a  single  strand  of  braided  silk,  letting  the  two 
ends  of  each  hang  out  of  the  vagina  without  having  tied 
any  knot.  The  round  ligaments  were  then  cut  away 
at  either  horn  and  the  uterus  delivered,  thus  demonstrat- 
ing that  the  uterus  can  be  enucleated  without  sufficient 
hemorrhage  to  demand  either  ligature  or  clamp. 

To  complete  the  occlusion  of  the  upper  end  of  the 
vagina,  one  strand  of  the  catgut  suture  already  placed  was 
rethreaded  and  passed  through  the  anterior  vaginal  wall, 
entering  it  on  the  peritoneal  surface  and  passing  it  back 
as  formerly  in  the  posterior  wall.  These  two  ends  of  the 
catgut  were  now  tied  together,  thus  bringing  peritoneal 


692 


MEDICAL   RECORD. 


[December  1,  1894 


surface  in  contact  with  peritoneal  surface,  and  turning  all 
raw  tissue  into  the  vagina. 

The  broad  ligaments  are  now  drawn  well  down  into 
the  vagina  by  the  silk  sutures  previously  passed,  and  se- 
curely tied  together  across  the  upper  part  of  the  vagina. 
A  light  packing  of  iodoform  gauze  completed  the  opera- 
tion. The  entire  time  consumed  was  a  few  seconds  less 
than  thirty  minutes,  much  less  time  than  it  has  ever 
taken  before. 

The  operation  was  done  at  the  New  York  Skin  and 
Cancer  Hospital,  October  12,  1894,  and  I  believe  it  is 
the  first  time  the  operation  has  ever  been  done  in  New 
York. 

The  patient  had  a  slight  hemorrhage  three  hours  after 
the  operation!  but  it  was  found  to  proceed  from  the  vagi- 
nal mil  and  was  controlled  by  a  firm  tampon  of  gauze. 
Aside  from  that,  recovery  has  been  uninterrupted. 

•23  East  Thirty-fifth  Stuit. 


gxwgttess  of  pteflital  jfctence* 

Skin  Diseases  and  Visceral  Affections.  —  According 
to  the  Medical  Bulletin  for  June  (see  also  Deutsche 
Medical  Zeitung),  Kaposi  spoke  at  the  Vienna  Medical 
Club  of  a  misapprehension  that  prevails  concerning 
Hebra  and  his  school,  to  the  effect  that  they  look  upon 
cutaneous  diseases  as  simply  external  abnormal  conditions 
having  no  relation  to  alteration  of  internal  organs.  This 
is  not  true  of  Hebra  and  his  followers.  While  opposed 
to  an  uncritical  assumption  that  such  relationship  exists, 
such  conceptions  obscuring  comprehension  and  exerting 
a  pernicious  influence  on  prognosis  and  therapy,  Hebra 
continually  recognized  such  connection  and  turned  the 
fact  to  practical  account  in  treatment.  Acne  may  be 
taken  to  illustrate  the  case  in  point.  It  is  asserted  that 
this  disorder  depends  upon  digestive  disturbances.  Yet 
when  a  disease  can  be  explained  in  its  totality,  in  its 
clinical  and  anatomical  course,  by  demonstrable  associa- 
tions, a  search  for  ulterior  causes  is  unnecessary.  Acne 
generally  occurs  at  the  age  of  puberty,  when  an  active 
physiological  process  is  going  on  in  the  follicles  of  the 
skin,though  it  may  originate  later  in  life.  There  is  usu- 
ally a  depressed  condition  of  nutrition,  atony  of  the  tissues 
involving  the  glands.  The  ducts  of  the  glands  are  not 
properly  contracted,  giving  rise  to  comedones  and  acne. 
The  keratinization  of  the  skin  is  also  abnormal,  and 
often  alterations  occur  in  the  functions  of  the  sudoripa- 
rous glands.  There  is  not  infrequently  hyperidrosis.  In 
this  class  also  belongs  acne  cacheticorum,  which  itself 
depends  upon  lowered  nutrition,  though  it  may  also  be 
due  to  psychical  influence.  In  acne  varioliformis,  more 
common  in  men  than  women,  Kaposi  spoke  of  excellent 
results  from  Carlsbad  water,  while  local,  treatment  is 
usually  of  small  benefit.  Pure  hyperidrosis*  of  the  palms 
and  soles  arises  during  youth ;  in  other  instances  it  may 
come  on  abruptly  and  continue  for  years,  disabling  the 
patient  for  work.  Here,  again,  general  depression  of 
nutrition  is  a  cause.  There  is  weakened  action  of  the 
heart,  reduced  vascular  tonicity,  and  the  hands  are  gen- 
erally cyanotic.  As  nutrition  improves,  there  is  apt  to 
be  a  change  for  the  better  in  the  hyperidrosis.  A  simi- 
lar result  takes  place  in  that  affection  recently  known 
as  erythromelalgia  and  characterized  by  the  appearance 
of  a  persistent  patch  of  congestion,  often  on  the  sole  of 
the  foot,  attended  with  swelling  and  pain.  Acne  rosacea 
is  linked  with  nutritive  disturbances,  sometimes  with 
digestive  errors,  sometimes  with  uterine  disturbances. 
Urticaria  has  been  supposed  to  be  due  to  changes  in  the 
alimentary  tract;  yet  the  mere  sight  of  the  specially 
harmful  food  will  bring  it  on  in  some  persons.  Acute 
circumscribed  oedema  is  nothing  more  than  a  giant 
urticaria  due  to  vascular  spasm. 

In  eczema,  especially  recurrent  eczema,  there  is  a  rela- 
tion between  the  skin  disease  and  internal  organs.  Fu- 
runculosis,  often  referred  by  mistake  to  glycosuria,  occurs 


in  persons  who  suffer  from  eczema.  Boils  are  not  com- 
mon in  diabetes ;  but  dermatitis  diabetica  is  not  unusual. 
How  great  the  caution  to  be  exercised  in  the  etiology  of 
skin  diseases  is  illustrated  by  elephantiasis  arabum  tropica, 
certainly  produced  by  the  filaria  sanguinis.  Yet  in  a 
typical  case  observed  by  Kaposi,  no  trace  of  filariae  could 
be  found.  To  depressed  conditions,  lupus  erythemato- 
sus may  also  be  ascribed.  But  it  is  wrong  to  consider 
pruritus  senilis  as  due  to  digestive  troubles ;  there  is  usu- 
ally atrophy  of  the  skin,  with  irritation  of  the  nerves. 
Another  form,  developing  in  middle  life,  is  accompanied 
by  albuminuria  and  glycosuria.  Pruritus  universalis  is  a 
frequent  accompaniment  of  pregnancy,  of  disease  of  the 
genital  tract,  and  may  also  depend  exclusively  upon  psy- 
chical causes.  Impetigo  herpetiformis  also  arises  in 
pregnancy.  Kaposi  has  seen  seventeen  fatal  cases  under 
such  circumstances.  Erythema,  especially  erythema 
nodosum,  and  purpura  are  the  result  of  infection.  Yet 
many  cases  exist  that  are  dependent  upon  uterine  or 
ovarian  abnormities,  and  disappear  when  these  are  reme- 
died. 

The  Treatment  of  Ophthalmia  Neonatorum. — Kalt 
recommends  irrigation  of  the  eye  with  a  1  to  5,000  solu- 
tion of  potassium  permanganate  introduced  through  a 
small  funnel,  one  end  of  which  is  placed  between  the 
eyelids,  and  the  other  connected  with  the  bottle  contain- 
ing the  fluid,  which  should  be  placed  about  a  foot  above 
the  patient's  head.  The  irrigations  should  be  made 
twice  a  day,  and  two  quarts  of  the  fluid  should  be  used  at 
each  time.  If  the  disease  is  attended  with  serious  or  ex- 
tensive trophic  changes  in  the  cornea,  the  irrigations 
must  be  used  more  frequently,  say  four  times  a  day,  and 
gradually  lessened  as  the  inflammation  disappears.  [At 
a  recent  meeting  of  the  Ophthalmologics!  Section  of  the 
New  York  Academy  of  Medicine,  this  plan  of  treatment 
was  favorably  commented  on  by  Dr.  H.  Knapp,  who  had 
seen  its  application  by  Kalt] 

Toxic  Effects  of  Thyroid  Feeding. — Bedere  presented 
to  the  Medical  Society  of  the  Hospitals,  Paris,  a  patient 
illustrating  the  cure  of  myxoedema  by  thyroid  therapy. 
During  the  course  of  her  treatment  she  accidentally  took 
a  large  quantity  of  thyroid  gland,  ninety- two  grammes  in 
eleven  days.  At  the  end  of  this  time  she  had  developed 
such  symptoms  as  tachycardia,  pyrexia,  insomnia,  tremor 
of  the  extremities,  exophthalmia,  polyuria,  albuminuria, 
and  glycosuria,  in  fact  a  complete  picture  of  Basedow's 
disease.  The  writer,  therefore,  concludes  that  the  latter 
disease  is  due  to  a  hypersecretion  of  the  thyroid  gland 
which  may  be  caused  in  more  ways  than  one.  He  thinks 
that  Basedow's  disease  should  no  longer  be  classed  as 
one  of  the  neuroses,  but  as  auto-toxic  from  an  etiological 
point  of  view. 

Oastropexy.  —  Duret  presented  to  the  Paris  Academy 
of  Medicine  a  woman  on  whom  gastropexy  had  been  per- 
formed after  all  other  measures  had  failed  to  relieve  a 
severe  enteroptosis  with  dilatation  and  descent  of  the 
stomach  into  the  infra-umbilical  region.  He  is  of  the 
opinion  that  in  cases  of  prolapse  of  the  stomach  of  long 
standing  gastropexy  is  an  efficient  method  of  treatment, 
both  with  reference  to  fixation  of  the  stomach  and  cessa- 
tion of  the  majority  of  the  morbid  symptoms. 

Acute  Pancreatitis. — Dr.  Paul  contributed  to  the  Clin- 
ical Society  of  London  the  history  of  a  case  of  acute  pan- 
creatitis in  which  the  prominent  symptoms  were  the  sud- 
den onset  of  pain,  which  was  colicky  in  its  nature  and  of 
short  duration,  constipation,  and  some  vomiting.  On  ex- 
amination, slight  distention  of  abdomen,  pulse  and  tem- 
perature somewhat  increased.  After  the  action  of  a  sim- 
ple enema  the  patient  suddenly  collapsed,  the  tempera- 
ture rose  to  1040  F.,  and  death  followed  speedily.  The 
urine  passed  just  before  death  contained  a  large  amount 
of  albumin,  and  granular  and  hyaline  casts.  Post-mortem 
examination  showed  an  acute  hemorrhagic  and  paren- 
chymatous pancreatitis.  The  remaining  organs  were 
healthy  except  a  cloudy  swelling  of  the  kidneys. 


December  i,  1894J 


MEDICAL    RECORD. 


693 


Medical  Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


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


New  York,  December  i,  1894. 

CHLORIDE  OF  CALCIUM  IN  THE  TREATMENT 
OF  ACUTE  PNEUMONIA. 

In  1893,  Dr-  A-  Crombie  called  attention  to  the  sup- 
posed value  of  chloride  of  calcium  in  the  treatment  of 
pneumonia  {Indian  Medical  Gazette,  January  18).  Dr. 
D.  M.  Moir,  of  the  Indian  Medical  Service,  confirms  this 
opinion  of  its  value  in  an  article  in  The  Practitioner  of 
November,  1894.  Dr.  Crombie  believed  that  he  showed 
that  in  lobar  pneumonia  (1)  chloride  of  calcium  reduces 
the  temperature  and  keeps  it  within  safe  or  normal  lim- 
its, in  spite  of  the  continuance  of  physical  signs ;  (2)  that 
there  is  a  tendency  for  the  morbid  process  to  be  arrested 
at  whatever  stage  the  drug  is  given  in  efficient  doses,  and 
that  the  course  of  the  disease  is  thus  shortened  or  ren- 
dered milder;  (3)  that  there  is  a  singular  freedom  from 
all  anxiety,  distress,  and  danger,  a  freedom  not  usually 
associated  with  continuous  high  temperatures ;  (4)  and 
that  there  is  a  corresponding  reduction  in  mortality. 

Dr.  Moir  reports  two  cases  in  which  the  symptoms 
were  alleviated  by  the  administration  of  this  drug.  He 
gave  it  in  doses  of  from  sixty  to  ninety  grains  daily  (ten 
or  fifteen  grains  every  four  hours). 

Many  drugs  have  a  reputed  value  in  pneumonia,  but 
none  are  yet  accepted  as  in  any  sense  standard  remedies 
in  the  disease. 

The  evidence  in  favor  of  chloride  of  calcium  is  suffi- 
cient to  demand  for  it  some  attention,  and  we  can  only 
trust  that  further  experience  will  show  that  the  drug  is 
undoubtedly  useful. 


ACUTE     ARTICULAR     RHEUMATISM     AS     A 
GERM  DISEASE. 

Birsch-Hirschfeld,  in  1 888,  reported  five  cases  of  acute 
articular  rheumatism  in  which  he  discovered  streptococci 
and  staphylococci  in  the  articulations  and  cardiac  valves. 

Bouchard  and  Charin,  in  1891,  reported  that  they  had 
found  the  staphylococcus  albus  many  times  in  the 
synovial  secretions  in  subacute  and  chronic  articular 
rheumatism* 

Triboulet,  during  the  same  year,  found  the  articular 
fluid  sterile  in  a  case  of  rheumatism  with  chorea,  but  on 
death  the  pericardial  fluid  and  the  blood  of  the  heart 
and  vena  cava  was  found  to  contain  the  staphylococcus 
albus. 

Sahli,  in  1892,  in  a  case  of  acute  rheumatism  with 
pleurisy  and  pericarditis,  found  that  the  synovial  fluid  of 


the  knee  contained  microbes  resembling  the  staphylo- 
coccus albus. 

Dr.  J.  Sacaze  {Archives  Generates  de  Medicine,  Novem- 
ber, 1894)  reports  the  results  of  his  investigations  in  the 
same  line.  Dr.  Sacaze  made,  however,  bacteriological 
examinations  of  what  he  calls  the  "  points  of  entry  "  of 
the  rheumatic  infection.  In  one  case,  a  man  had  a 
wound  on  the  foot  followed  by  acute  articular  rheuma- 
tism with  relapse.  In  the  fluids  of  the  knee-joint  he  found 
pure  cultures  of  the  staphylococcus  albus.  In  three 
other  cases  the  patients  had  an  acute  tonsillitis  followed 
by  rheumatism,  there  also  the  secretions  of  the  tonsils 
were  examined  with  the  result  of  finding  staphylococci. 

He  concludes  that  very  often  in  acute  rheumatism 
there  is  a  local  lesion  which  precedes  the  rheumatic  out* 
break.  It  is  through  this  passage  that  the  pathogenic 
microbes  enter  the  system  and  the  staphylococci  seem  to 
be  often  the  infecting  agents. 

The  history  of  gonorrheal  and  other  septic  rheuma- 
tisms supports  the  view  that  acute  inflammatory  rheu- 
matism must  be  classed  among  the  microbic  diseases. 


THE  CURSE  OF  KISSING. 

Properly  applied,  both  as  to  time  and  place,  the  partic- 
ipators being  mutually  agreeable  and  fairly  healthy, 
there  is  little  to  be  said  against  the  kiss,  practised  in 
moderation.  When,  however,  one  party  to  the  transac- 
tion is  an  infant,  not  yet  up  in  self-defence,  or  a  maiden 
whose  resistance  is  of  no  avail  against  the  physically 
stronger  aggressor,  or  an  inanimate  body  prepared  for 
burial,  we  claim  the  right  to  champion  their  cause 
against  the  reckless  kisser.  We  have  little  to  say  con- 
cerning that  form  of  disease  known  as  kissing-fever,  of 
which  instances  are  now  and  then  reported,  especially 
from  smaller  towns.  The  over-affectionate  man,  who 
lurks  in  lonely  places  and  pounces  with  his  osculations 
upon  unprotected  women,  without  distinction  as  to  size, 
age,  or  color,  belongs  in  the  same  mentally  unbalanced 
class  as  the  despoiler  of  school  girl  tresses,  the  destroyer 
of  white  lawn  dresses,  the  ink- thrower,  the  hugger— and 
when  still  more  depraved — the  ripper. 

We  leave  him  to  the  officers  of  the  law  and  the  alien- 
ists, provided  an  outraged  brother,  father,  or  husband 
has  not  already  attended  to  his  case  "out  of  court." 
The  child-kisser  by  habit  really  does  more  harm  than  the 
lady-kisser  by  disease,  for  while  the  latter  shocks  an  oc- 
casional belated  female  on  a  lonely  road,  the  former  is 
constantly  teaching  the  children  with  whom  he  comes  in 
contact  that  it  is  not  wrong  to  kiss  comparative  stran- 
gers, and  a  most  dangerous,  if  not  disgusting,  habit  is 
fostered. 

Scientists  have  never  yet  discovered  why  it  is  that 
syphilitics,  tuberculous  subjects,  persons  with  very  bad 
teeth,  and  tobacco  chewers,  are  the  greatest  kissers  of 
infant  and  youthful  humanity,  and  invariably  implant 
their  token  of  affection  directly  upon  the  lips.  Such, 
however,  is  the  fact,  as  any  careful  observer  may  discover 
for  himself. 

If  there  were  any  possibility  of  this  reaching  those  who 
alone  could  answer,  we  would  ask  why  the  maiden  aunt, 
who  never  was  very  fond  of  the  children  at  best,  insists 
upon  coming  into  the  room  and  kissing  them  as  soon  as 
they  are  down  with  the  scarlet  fever,  diphtheria,  measles, 


694 


MEDICAL   RECORD. 


[December  i,  1894 


or  the  mumps  ?  Why  must  she,  who  "  never  kissed  a 
living  man "  and  doesn't  believe  in  kissing  anyway, 
press  her  lips  to  those  of  some  cold  corpse  ?  This  death- 
kiss  may  well  be  called  a  sanitary  sin,  and  unless  we,  as 
physicians,  continually  discountenance  it,  as  well  as  put 
our  face  against  sick-bed  kissing,  we  must  hold  ourselves 
more  than  equally  responsible,  for  we  know  the  dangers 
better  than  they. 

Sanitarians  have  tried  many  times  to  introduce  songs 
among  the  people  tending  to  offset  and  counteract  that 
very  pernicious  one  which  begins :  "  There  is  no  harm 
in' kissing/'  but  they  have  never  become  popular. 

Must  we,  then,  leave  the  youngsters  in  happy  ignor- 
ance of  mouth  hygiene?  Can  we  keep  their  innocent 
minds  free  from  thoughts  of  the  bacilli  swarming  beyond 
the  ruby  lips  ?  Should  we  ever  neglect  an  opportunity 
to  strike  at  the  mouth  which  bears  a  mucous  patch  or 
where  lurks  the  poison  of  phthisis  or  to  defend  the  de- 
fenceless babe  from  the  onslaughts  of  the  male  and  female 
kisser. 


SPECIALISM    AND    MEDICAL    PRACTICE     IN 
TEXAS. 

Dr.  R.  P.  Tallby  gives  the  following  list  of  modern 
specialists  {Texas  Medical  Journal)  and  makes  some  in- 
teresting comments  upon  them.    There  are,  he  says : 

"  1.  The  eye,  ear,  nose  and  throat  specialist.  2.  The 
gynecologist  specialist  3.  The  railway  surgeon  special- 
ist. 4.  Whiskey,  opium,  etc.,  specialist.  5.  Dentist,  or 
oral  surgeon  specialist.  6.  Orificial  surgeon  specialist. 
7.  The  Arkansas  Hot  Spring  specialist.  8.  The  self- 
constituted  midwives,  and  on  down  the  line  to  the  street 
medicine  man,  the  Christian  science  doctors,  the  pile 
doctors,  the  Keeleys,  etc.,  about  whom  and  which  I 
shall  have  nothing  to  say  on  this  occasion." 

The  doctor  speaks  kindly  of  what  he  calls  real  special- 
ists who  are  masters  of  their  work  and  confine  them- 
selves to  it.  But  he  has  a  grievance  against  the  railway 
specialist  because  (and  Dr.  Talley  seems  fond  of  enumera- 
tion): 

"  i.  These  surgeons  are  backed  by  a  powerful  finan- 
cial corporation. 

"  2.  They  get  a  handsome  salary  for  a  fraction  of  their 
professional  time. 

"  3.  They  are  not  required  to  give  their  whole  time 
and  energies  to  their  specialty. 

"  4.  Out  of  all  they  get  a  big  'ad.'  by  which  they 
step  from  the  practice  from  the  employees  to  their  fami- 
lies and  friends,  as  well  as  to  the  practice  for  the  em- 
ployer, not  allowed  under  the  rules  of  the  Hospital  Asso- 
ciation. 

"This  is  all  very  nice  and  desirable  for  the  railroad 
doctors,  but  I  think  it  is  a  devil  of  a  hardship  on  the 
'  other  fellows.1 " 

Dr.  Talley  does  not  like  the  Hot  Springs  specialist. 
His  virtues,  he  says,  "  are  advertised  on  every  telegraph- 
pole,  hog-pen,  etc.,  throughout  the  entire  country. 
Unless  we  can  make  people  understand  that  water  can 
be  made  as  hot  in  Texas  as  it  can  in  Arkansas,  our  patients 
will  continue  to  slip  out  and  pay  ten  times  as  much  for 
their  troubles  as  if  they  would  try  in  any  sort  of  good 
faith  their  family  physicians/' 

Incidentally  we  are  given  a  painful  picture  of  the  over- 


crowding of  the  medical  profession  of  Texas.  In  the 
town  of  Temper,  where  the  doctor,  who  is  President  of 
the  Austin  District  Medical  Society,  resides,  there  are 
twenty-two  doctors  to  something  less  than  6,000  inhabi- 
tants, and  in  the  country  around  there  are  twenty-four 
more  within  ten  miles.  "Some  authority,"  he  adds, 
"  has  estimated  that  in  the  army,  in  time  of  war,  one 
physician  can  serve  five  hundred  soldiers,  and  that  in 
civil  life  one  thousand  and  five  hundred  patrons  are  re- 
quired to  support  one  general  practitioner.  According 
to  this  estimate,  in  my  town  we  have  eighteen  out  of 
twenty- two  doctors  to  spare,  and  if  we  cannot  get  rid  of 
this  excess,  somebody  will  be  hurt."  "  We  presume  this 
has  as  much  reference  to  the  patients  as  to  the  doctors," 
"  This  excess  in  number  leads  to  all  manner  of  '  sharp 
work '  to  get  practice.  Such  a  crowded  population  of 
doctors  reminds  me  of  a  crowded  population  of  poor 
people,  where  we  find  hot-beds  of  all  sorts  of  pernicious 
diseases,  moral  as  well  as  physical.  Why,  in  too  many 
localities  our  doctors  are  crowded,  as  well  as  illy  bred  as 
doctors,  until  the  slime  of  local  rivalry  rises  mountain 
high.  If  some  local  brother  steps  a  little  aside  from 
what  some  other  local  brother  thinks  is  ethical,  he  forth- 
with gets  all  sorts  of  infamy  heaped  upon  his  professional 
head.  Who  ever  heard  of  two  or  three  doctors  getting 
together,  singing  a  song  and  praying  for  some  profes- 
sional sinner,  who  had  perhaps  even  sinned  without 
knowing  it  ?  There  is  only  one  occasion  when  doctors 
may  get  together  and  sing  and  pray  for  one  another,  to 
wit :  When  one  dies  they  can  sometimes  meet  around 
his 'grave,  and  say  amen,  and  then  pass  resolutions  of 
condolence  with  a  prayerful  and  perfect  unanimity." 

We  wonder  why  the  doctors  of  Texas  have  been  work- 
ing so  hard  to  establish  a  medical  college  if  their  coun- 
try is  so  well  supplied.  The  causes  of  the  over-supply  in 
that  State,  as  President  Talley  should  know,  are  two- 
fold :  one  is  the  cheapness  of  medical  education ;  the 
other  the  ignorance  of  the  people  and  their  willingness 
to  accept  anyone  for  a  doctor  if  he  can  make  a  presenta- 
ble appearance  at  the  bedside,  and  shrug  his  broadly 
expressive  shoulders  at  the  other  fellow. 


NOT  ALL  DIE  YOUNG. 

One  hears  so  much  depressing  talk  about  the  life  of  a 
physician  not  conducing  to  longevity  that  it  is  cheering 
to  note  exceptions  to  the  rule. 

The  following,  cut  from  an  exchange,  is  doubly  inter- 
esting because  we  believe  we  can  beat  it. 

"  Oldest  Physician  in  the  Country. — Since  the 
recent  death  of  Dr.  James  Kitchen,  of  Philadelphia,  Dr. 
Hiram  Corson,  of  Montgomery  County,  Pa.,  is  de 
clared  by  Philadelphia  papers  to  be  the  oldest  physi- 
cian in  the  United  States  who  has  been  in  continuous 
practice.  He  will  be  ninety  years  old  next  October,  and 
has  been  in  active  practice  ever  since  1827.  He  is  still 
in  excellent  health,  with  astonishing  preservation  of  his 
physical  and  mental  powers.  Dr.  Corson  is  now  writ- 
ing his  personal  recollections  of  the  anti-slavery  move- 
ment, in  which  he  took  an  active  part,  having  assisted 
many  a  fugitive  slave  to  escape  by  the  '  underground 
railroad.'  " 

Our  entry  for  the  long  distance  championship  is  Dr. 
Hull  Allen,  of  Milford,  Conn.,  born  May  16,  1798,  and 


December  i,  1894] 


MEDICAL  RECORD. 


695 


consequently  in  his  ninety-seventh  year.  He  was  li- 
censed to  practise  medicine  at  Newark,  N.  J.,  in  1821, 
and  began  in  the  same  year  at  Sparta,  N.  J.,  subse- 
quently removing  to  Milford,  Conn.,  where  he  continued 
in  active  practice  till  1870.  Since  then  he  says  "  he 
doesn't  go  out  much  nights,19  but  until  recently  he  has 
continued  to  give  advice  to  those  who  call  upon  him  at 
his  house. 

Dr.  Allen  has  always  enjoyed  excellent  health,  and  is 
to-day  remarkably  bright  and  active  for  one  so  near  the 
hundred-mile  post  May  he  be  an  example  for  many 
years  yet  to  those  who  grieve  because  ministers  and  law- 
yers reach  a  riper  age  than  we. 


THE  ANNUAL  REPORT  OF  THE  SURGEON- 
GENERAL  OF  THE  ARMY. 

The  report  of  the  Surgeon- General  of  the  Army  for  the 
year  ending  June  30,  1894,  contains  much  that  is  of 
general  interest,  as  the  report  of  any  head  of  a  depart- 
ment so  progressive  in  his  ideas  as  General  Sternberg, 
necessarily  must.  The  question  of  the  reduction  in 
numbers  of  the  medical  staff  is  discussed  at  some  length, 
but  as  we  shall  refer  to  this  elsewhere  it  is  not  neces- 
sary to  enter  upon  the  subject  here.  An  examining 
board  had  been  convened  to  fill  the  ten  existing  vacan- 
cies, but  when  Congress  reduced  the  force  there  were  no 
longer  any  vacancies,  the  board  was  dismissed  and  the 
candidates  were  notified  not  to  appear. 

The  Army  Medical  School  has  been  in  operation  about 
a  year,  and  the  wisdom  of  its  establishment  has  been  al- 
ready satisfactorily  demonstrated.  The  principal  object 
of  its  foundation  was  to  impart  a  knowledge  of  prevent- 
ive medicine,  which  is  not  often  possessed  by  the  recent- 
ly graduated  medical  man,  and  also  to  provide  for  spe- 
cial instruction  in  military  medicine  and  surgery.  The 
school  is  established  in  the  building  recently  erected  in 
Washington  for  the  Army  Library  and  Museum,  where 
also  there  is  abundant  material  for  bacteriological  and 
chemical  study.  The  course  of  instruction  embraced 
the  following  subjects :  Duties  of  medical  officers  in  war 
and  peace,  military  surgery,  hygiene,  and  medicine,  gen- 
eral and  sanitary  chemistry,  pathology,  and  bacteriology, 
hospital  corps  drill,  first  aid  to  the  injured,  and  equita- 
tion. The  latter  was  not  so  superfluous  as  might  be  sup- 
posed, since  two  members  of  the  class  were  entirely  un- 
used to  riding.  Nine  medical  officers  were  in  attendance 
at  the  school  during  the  year. 

The  work  of  the  hospital  corps  is  referred  to  with  ap- 
proval, the  wisdom  of  establishing  this  branch  of  the 
service  having  been  amply  demonstrated.  The  number 
of  members  of  the  corps  in  service  is  790, 49  less  than  the 
authorized  quota.  The  number  has  been  purposely  kept 
down  in  order  to  keep  the  expense  of  the  corps  within 
the  limit  of  the  appropriation  for  its  support. 

Reference  is  made  to  the  Medical  Department  of  the 
National  Guard  in  connection  with  the  fourth  annual 
meeting  of  the  Association  of  Military  Surgeons  held  in 
Washington  in  May.  The  Army  Medical  Department 
looked  favorably  upon  the  organization  of  the  Association 
as  a  medium  by  'which  it  might  keep  en  rapport  with  the 
medical  corps  of  the  National  Guard,  in  view  of  a  pos- 
sible contingency  in  which  the  State  and  National  forces 
might  be  called  upon  to  act  in  concert.    The  Surgeon- 


General  of  the  Army  was  very  properly  chosen  president 
of  the  Association  for  the  present  year. 

The  health  of  the  army  was  nearly  as  good  as  during 
any  previous  year,  the  admission  rate  per  thousand  being 
1,289.04,  a  great  improvement  on  the  average  annual 
rate  for  the  past  two  years  (1,424.2)  and  only  slightly 
greater  than  the  lowest  rate  (1,247)  ever  furnished  by 
our  troops.  The  death-rate  was  6.91  per  thousand  liv- 
ing, but  little  greater  than  the  lowest  rate  ever  recorded 
in  our  army  (6.33)  and  considerably  less  than  the  aver- 
age for  the  past  ten  years,  namely,  8.51.  The  death- 
rate  from  disease  alone,  excluding  accidents  and  injuries,- 
was  4.01  per  thousand. 

Other  questions  treated  of  in  the  report  are  the  quar- 
ters, some  of  which  appear  to  be  in  a  disgracefully  di- 
lapidated condition,  poorly  ventilated,  badly  drained 
and  insufficiently  supplied  with  water.  The  food  sup- 
plied to  the  men  was  in  general  of  a  good  quality,  as  was 
also  the  clothing. 

The  reports  of  medical  officers  regarding  the  habits  of 
the  men  were  generally  favorable.  At  some  posts  where 
houses  of  bad  repute  are  established  in  the  vicinity,  the 
sick  report  often  becomes  burdened  with  the  results  of 
dissipation,  particularly  after  pay  day.  The  recruits  at 
Columbus  Barracks  are  in  particular  exposed  to  harmful 
influences  of  this  kind,  owing  to  the  location  of  the  bar- 
racks within  the  limits  of  a  city. 

Inadequate  provision  for  bathing  is  reported  from 
several  posts. 

The  benefit  accruing  from  systematic  work  in 
gymnasiums  is  appreciated  by  all  army  medical  officers. 


THE  BRUTALITY  OF  FOOT-BALL. 

The  events  of  the  past  week  have  most  thoroughly  dis- 
credited the  game  of  foot-ball  as  at  present  played.  The 
contest  at  Springfield  between  the  Yale  and  Harvard 
teams  was  one  of  the  most  unwholesome  performances 
that  ever  masqueraded  under  the  name  of  amateur  sport. 
Players  slugged  into  unconsciousness,  eyes  nearly  gouged 
out,  brains  concussed,  disabling  sprains  and  bruises  con- 
stantly interrupted  the  progress  of  the  game,  which  even 
an  ex-ball-player  and  friend  of  the  sport  declares  to  have 
been  characterized  by  "sickening  brutality.91  Besides 
this  we  hear  of  a  student  made  insane  through  injuries 
received  in  playing,  and  two  fatal  accidents  are  reported. ' 
The  number  of  young  men  who  are  permanently  injured 
and  who  go  through  life  more  or  less  crippled  in  conse- 
quence of  foot-ball  playing  can  never  be  known.  We 
should  be  sorry  to  see  foot-ball  abolished  altogether  from 
our  colleges.  There  is  no  game  that  equals  it  in  many 
ways  when  played  as  a  manly  sport  and  not  for  gate  re- 
ceipts. But  the  new  rules  are  plainly  ineffective,  and  un- 
less some  change  can  be  made,  the  game  really  deserves 
to  be  placed  under  the  supervision  of  Boards  of  Health 
working  in  co-operation  with  an  efficient  police. 


Tale  Medical  Journal  is  the  name  of  the  most  recent 
acquisition  to  medical  journalism.  It  is  edited  and  pub- 
lished by  the  medical  students  of  Yale  University  under 
the  auspices  of  an  advisory  board  composed  of  some  of 
the  prominent  alumni  of  the  university.  The  first  num- 
ber makes  a  favorable  impression.    We  wish  it  well. 


696 


MEDICAL  RECORD. 


[December  1,  1894 


Hews  of  tfxz  tfifteelu 

Antitoxin  for  Diphtheria. — Dr.  Walter  Wyman,  Sur- 
geon General  of  the  Marine  Hospital  Service,  in  his  an- 
nual report,  says  that  investigations  have  been  conducted 
concerning  the  etiology  and  pathology  of  the  eruptive 
fevers,  and  the  preventive  inoculation  against  acute  in- 
fectious diseases.  A  bacteriologist  of  the  service  is  now 
in  Europe  familiarizing  himself  with  the  latest  advances 
in  preventive  inoculation.  This  officer  has  transmitted 
to  the  bureau  a  supply  of  toxin  from  the  Pasteur  labora- 
tory, with  which  animal  immunization  has  already  been 
begun  (a  horse  having  been  purchased  for  this  purpose) 
to  obtain  the  antitoxin  serum  for  the  cure  and  preven- 
tion of  diphtheria.  On  the  return  of  this  officer  it  is 
expected  that  the  methods  of  preparing  the  toxin  and 
obtaining  the  antitoxin  serum  from  the  immunized  ani- 
mal will  be  demonstrated  from  time  to  time  to  State 
health  officers,  in  order  that  the  benefits  of  this  new 
remedy  for  diphtheria  may  be  as  widely  distributed  as 
possible. 

The  Samuel  D.  Gross  Prise.— The  quinquennial  prize 
of  %  1,000  under  the  will  of  the  late  Samuel  D.  Gross, 
M.D.,  will  be  awarded  January  1,  1895.  ^e  condi- 
tions annexed  by  the  testator  are  that  the  prize  "  Shall 
be  awarded  every  five  years  to  the  writer  of  the  best 
original  essay,  not  exceeding  one  hundred  and  fifty 
printed  pages,  octavo,  in  length,  illustrative  of  some  sub- 
ject in  surgical  pathology  or  surgical  practice,  founded 
upon  original  investigations,  the  candidates  for  the  prize 
to  be  American  citizens."  The  essays,  which  must  be 
written  by  a  single  author  in  the  English  language,  should 
be  sent  to  Dr.  J.  Ewing  Mears,  1429  Walnut  Street, 
Philadelphia,  before  January  1,  1895.  Each  essay  must 
be  distinguished  by  a  motto,  and  accompanied  by  a 
sealed  envelope  bearing  the  same  motto  and  containing 
the  name  and  address  of  the  writer* 

Death  of  Dr.  Octavius  Sturges. — We  have  to  record 
the  untimely  death  of  Dr.  Octavius  Sturges  of  London. 
While  still  in  the  prime  of  life,  Dr.  Sturges  was  knocked 
down  by  a  cab  in  Cavendish  Square  a  few  days  since,  and 
sustained  a  fracture  of  the  left  thigh.  He  appeared, 
however,  to  be  recovering  from  the  effects  of  the  acci- 
dent, and  there  was  apparently  no  special  cause  for 
anxiety,  but  he  died  suddenly  on  November  3d  leaving  a 
large  circle  of  friends  to  mourn  his  unexpected  demise. 
It  is  a  curious  coincidence  that,  within  the  short  space 
of  one  year,  the  President  and  the  Senior  Censor  of  the 
Royal  College  of  Physicians  should  both  have  died  in 
harness. 

The  Leading  Medical  Journals  in  the  United  States, 
as  might  have  been  expected,  had  much  to  say  which 
was  sympathetic  and  kind  upon  the  subject  of  the 
death  of  Dr.  Oliver  Wendell  Holmes.  The  memorial 
notices  which  seemed  to  us  to  be  most  worthy  of  the 
man  appeared  in  the  Medical  Record  and  the  Boston 
Medical  and  Surgical  Journal. — Medical  Press. 

The  Woman's  Medical  Club  of  Chicago  gave  their  first 
banquet  Wednesday  evening,  November  14th.  Gertrude 
G.  Wellington,  M.D.,  was  Chairman  of  the  Committee 
of  Arrangements. 


Iowa  Association  of  Bailroad  Surgeons.— In  pursu- 
ance to  the  call  published  September  25th,  there  was  a 
good  attendance  of  Railway  Surgeons  of  the  State  of 
Iowa,  at  Sioux  City,  on  October  10th,  when  the  Iowa 
State  Association  was  duly  organized. 

Middle  Tennessee  Medical  Association. — The  first 
regular  meeting  of  the  Middle  Tennessee  Medical  As- 
sociation was  held  November  20  and  21,  1894,  in  the 
Senate  Chamber  of  the  Capitol  at  Nashville.  The  Asso- 
ciation was  called  to  order  by  the  President,  Dr.  J. 
B.  Cowan,  Tullahoma,  at  twelve  o'clock.  A  large  num- 
ber of  physicians  were  present. 

The  Horthern  Ohio  District  Medical  Society.— The 
annual  meeting  of  the  Northern  Ohio  District  Medical 
Society  will  be  held  at  Fremont,  O.,  December  6,  1894. 

Mitchell  District  Medical  Society.— The  forty-sixth 
semi-annual  meeting  of  the  Mitchell  District  Medical  So- 
ciety will  be  held  at  Mitchell,  Ind.,  December  27  and 
28,  1894.  This  society  is  one  of  the  oldest  and  most 
favorably  known  in  the  country,  and  this  meeting  prom- 
ises to  eclipse  all  previous  ones. 

Chicago  Gynecological  Society. — At  the  sixteenth  an- 
nual meeting  of  the  Chicago  Gynecological  Society,  held 
October  19,  1894,  the  following  officers  were  elected  to 
serve  the  ensuing  year:  President,  Dr.  Franklin  H. 
Martin ;  First  Vice-President,  Dr.  A.  J.  Foster ;  Second 
Vice-President,  Dr.  J.  C.  Hoag ;  Secretary,  Dr.  H.  P. 
Newman ;  Editor,  Dr.  T.  J.  Watkins. 

Wabash  Eailway  Surgeons.— The  annual  meeting  of 
the  Wabash  Railway  Surgeons  was  held  at  St.  Louis,  Mo., 
Thursday,  November  1, 1894,  in  the  parlors  of  the  South- 
ern Hotel. 

Mew  Tork  State  Association  of  Military  Burgeons. — 
At  the  annual  meeting  of  the  New  York  State  Associa- 
tion of  Military  Surgeons,  which  was  held  in  the  build- 
ing of  the  Academy  of  Medicine  on  November  15th,  the 
following  officers  were  elected:  President,  Dr.  R.  S. 
Harnden,  of  Waverly ;  First  Vice-President,  Dr.  C.  S. 
Parkhill,  of  HornelLsville ;  Second  Vice-President,  Dr. 
J.  A.  Van  Duyn,  of  Syracuse ;  Secretary,  Dr.  C.  E.  Her- 
rick,  of  Troy;  and  Treasurer,  Dr.  J.  F.  Valentine,  of 
Brooklyn. 

Eastern  Kansas  Medical  Society.— The  Eastern  Kan- 
sas Medical  Society  met  at  Kansas  City,  Kan.,  October 
9,  1894,  and  elected  a  number  of  new  members. 

The  Mew  Hampshire  Hospital  Association.— The 
annual  meeting  of  the  New  Hampshire  Hospital  Associ- 
ation was  held  at  Concord,  N.  H.,  November  15th,  with 
delegates  present  from  Portsmouth,  Manchester,  Dover, 
Keene,  Claremont,  and  Concord.  Dr.  C.  F.  Towne  read 
an  interesting  paper  on  "  The  Relation  of  the  Citizens  to 
the  Hospitals."  This  was  followed  by  a  general  discus- 
sion of  hospital  needs.  The  next  session  will  be  held  in 
Portsmouth  in  May. 

The  Eastern  Iowa  District  Medical  Society  met  at 
Keokuk,  la.,  November  15,  1894.  Dr.  J.  A.  Scroggs, 
of  Keokuk,  la.,  president,  in  the  chair* 

A  Chicago  Physician. — Dr.  Arthur  Von  Luna  com- 
mitted suicide  on  November  23d.  He  came  to  this  coun- 
try from  Germany  last  summer. 


December  i,  1894] 


MEDICAL   RECORD. 


697 


NEW  YORK  COUNTY  MEDICAL  ASSOCIATION. 

Stated  Meetings  November  19,  1894. 

Samuel  B.   W.   McLeod,   M.D.,   President,  in  the 
Chair. 

Habitual  Constipation;  IU  Treatment.— Dr.  Henry 
Illoway  read  the  paper.  Constipation  was  becoming 
more  and  more  common,  and  was  tolerated  by  persons 
who  claimed  to  be  in  good  health  in  other  respects.  It 
was  a  relative  term,  but  was  applicable,  the  author 
thought,  to  all  cases  where  there  was  not  one  free  passage 
in  two  days.  Regularity  might  exist  and  the  person 
have  but  one  passage  a  week,  and  he  knew  of  a  woman 
who  had  her  bowel  scooped  out  once  a  month  by  a 
midwife. 

Acute  and  chronic  forms  existed,  but  the  author  con- 
sidered on  this  occasion  only  the  latter.  These  were 
divided  into :  a,  constipation  depending  directly  upon  a 
well-defined  morbid  process,  such  as  cicatricial  narrow- 
ing, cancer,  etc.,  or  secondary  to  disease  in  other  organs ; 
by  constipation  depending  upon  inaction  of  the  bowel. 
The  paper  was  confined  to  this  group.  The  author  con- 
sidered briefly  the  longitudinal  and  circular  motion  of 
the  gut,  the  several  sources  of  nerve  supply,  and  the 
influence  of  pathological  conditions  in  some  other 
organs,  as  the  heart  and  spinal  cord,  in  producing  con- 
stipation. He  did  not  think  catarrh  a  cause  of  chronic 
constipation,  and  if  cases  of  colic  were  excluded  it  was 
questionable  whether  there  was  such  a  condition  as 
entero  spasm. 

Causation. — One  frequent  cause  of  constipation  was 
neglect  to  answer  promptly  the  call  of  nature,  whereby 
tolerance  was  developed  on  the  part  of  the  mucous  mem- 
brane and  terminal  nerve-filaments.  Want  of  closets  for 
use  by  the  moving  public  was  largely  to  blame  in  this 
matter.  A  second  important  cause  was  use  of  foods  not 
containing  sufficient  residual  matter.  Our  diet  was  com- 
posed too  much  of  starches,  sugar,  fats,  and  meat.  A 
third  cause  was  the  habit  people  were  .acquiring  of  trying 
to  fill  their  heads  (by  reading)  while  emptying  their 
bowels.  A  fourth  was  relaxation  of  the  abdominal  mus- 
cles brought  on  by  absence  of  physiological  exercise  and 
deficient  oxidation.  The  author  did  not  lay  much  stress 
on  the  habit  of  purgative  taking,  although  when  carried 
to  excess  this  might  act  like  too  much  and  too  coarse 
residual  matter,  causing  over-excitation. 

Protracted  constipation  led  to  dilatation  of  the  gut, 
the  colon  having  been  found  of  a  circumference  even 
of  fifteen  inches.  In  old  people  scybalae  were  liable  to 
form.  The  existence  of  fistulas  led  the  patient  to  avoid 
passages  and  thus  tended  to  aggravate  the  constipation. 

Fecal  Intoxication. — The  author  thought  this  was 
I  liable  to  take  place  only  where  soft  faeces  flowed  over  long- 
retained  masses.  The  question  was  also  raised  as  to  the 
manner  in  which  the  breath  of  the  chronically  consti- 
pated took  on  a  bad  odor,  whether  from  the  stomach  or 
lungs. 

Prognosis  and  Treatment. — Recognition  of  the  cause 
was  of  first  importance  in  outlining  the  treatment  and 
pronouncing  a  prognosis.  Each  case  had  to  be  treated 
upon  its  individuality.  In  some  a  permanent  cure  could 
be  expected;  in  others,  only  temporary  relief.  Where 
constipation  depended  upon  disease  of  the  heart,  lungs, 
liver,  or  anatomical  abnormalities,  special  measures 
would  be  called  for.  To  overcome  an  atonic  condition 
of  the  muscular  structure  of  the  intestine  and  to  stimulate 
the  nerves  use  calabar  bean ;  nux  vomica,  arsenic,  bella- 
donna, hyoscyamus,  and  stramonium  were  sometimes 
indicated,  but  otherwise  would  prove  positively  injurious. 
Use  belladonna  for  venous  stasis.  The  author  had  not 
had  success  from  very  small  doses  of  podophyllum,  for 
%  which  claims  had  been  made  in  France.    Other  measures 


were  mechanical,  dietary,  massage,  and  electricity. 
Walking,  riding,  and  rowing  were  valuable,  especially 
walking.  Oxygen  stimulated  peristalsis.  Riding  was 
best  for  shaking  up  the  bowels,  for  congestion  of  the 
liver,  and  for  getting  rid  of  and  preventing  the  formation 
of  gas.  Hydrotherapy  was  useful,  including  injection 
of  water  at  about  750  F.  In  some  of  the  more  obstinate 
cases  use  hot  water  and  cold  water  alternately.  Massage 
was  indicated  in  all  cases  of  atonicity  and  for  the  disper- 
sion of  residues.  It  was  practised  upon  the  naked  belly, 
with  unoiled  hands. 

Faradic  electricity  was  more  effectual  than  galvanic 
over  the  abdomen,  while  the  latter  was  more  effectual 
within  the  rectum.  The  author  did  not  approve  of  dila- 
tation of  the  sphincter  in  the  treatment  of  constipation 
unless  this  were  associated  with  fistula.  Incontinence  of 
faeces  which  might  follow  was  a  most  horrible  condition. 
One  party  had  claimed  good  results  from  suggestion  in 
the  hypnotic  state. 

Constipation  in  Childhood. — Dr.  J.  Lewis  Smith 
thought  that  many  of  the  severe  standing  cases  of  con- 
stipation in  adults  dated  back  to  infancy.  It  was  a  won- 
der the  patients  lived  so  long,  but  they  often  finally  suc- 
cumbed to  the  condition  unless  the  cause,  perhaps  a 
constriction  of  the  bowel,  were  removed.  Where  an 
anatomical  cause  was  not  present,  the  diet  was  most 
likely  to  be  at  fault.  One  cause  of  delayed  movement 
of  the  bowels  in  infancy  was  greater  length  of  the  sig- 
moid flexure  than  existed  later.  Carrying  infants  exclu- 
sively in  the  horizontal  position  favored  constipation. 
Painful  defecation  would  lead  the  child  to  suppress  the 
act.  Medicines  were  not  an  uncommon  cause,  including 
purgatives  which  were  far  from  being  so  simple  and 
harmless  as  their  name  would  indicate.  He  did  not  ap- 
prove of  mothers  giving  the  baby  "  castoria,"  "  syrup 
of  figs,"  etc.  In  institutions  the  best  means  of  unloading 
the  bowels  was  by  an  injection  of  one  to  two  teaspoon- 
fuls  of  equal  parts  of  glycerine,  castor-oil,  and  sweet-oil, 
added  to  a  tablespoonful  or  two  of  water,  allowing  it  to 
remain  in  the  bowel  as  long  as  it  would.  The  glycerine 
rendered  the  masses  softer.  Curative  remedies  were 
dietetic  rather  than  medicinal.  He  had  not  found  cane- 
sugar  as  efficient  as  had  been  claimed.  Massage  was  of 
some  use.  Maltose  was  efficacious.  Some  of  it  might 
be  given  with  each  feeding  in  order  to  get  a  more  regu- 
lar movement  of  the  bowels. 

Permanent  Cure  Only  in  Recent  Cases. — Dr.  S.  W. 
Dana  thought  that  by  such  means  98  the  author  had 
mentioned — electricity,  massage,  diet,  etc.,  recent  cases 
of  constipation  could  be  permanently  cured,  but  not  so 
the  really  habitual  ones.  Trousseau  had  commended 
belladonna,  but  it  was  not  curative  in  this  country; 
neither  were  the  cannon-ball,  the  compressed  sponge,  or 
boracic  acid.  Habitual  constipation  was  associated  with 
a  sedentary  life.  There  were  cases,  more  than  we  knew 
of,  which  were  hereditary.  In  them,  to  seek  to  remove 
the  cause  would  require  going  back  to  the  parents  and 
grandparents.  As  children  these  persons  might  suffer 
little,  but  as  soon  us  they  grew  up  and  became  seam- 
stresses or  pursued  sedentary  vocations  they  became  ob- 
stinately constipated. 

Camp  Out. — Massage  would  relieve  constipation.  But 
Dr.  Dana  knew  a  better  method.  There  were  a  large 
number  of  business  men  who  went  every  October  to  the 
Adirondacks,  lived  in  a  log  hut  open  on  one  side,  spent 
their  time  hunting  and  leading  an  active  life.  These 
men  had  told  him  that  during  this  time  their  bowels, 
which  had  been  constipated  the  whole  year,  became  easy 
and  natural.  On  returning  to  the  city  they  soon  became 
constipated  again  and  had  to  take  laxatives  until  their 
next  outing. 

Dr.  Dana  did  not  know  why  there  should  be  such  an 
outcry  against  the  use  of  purgatives.  Elderly  people  es- 
pecially had  passed  the  time  for  a  permanent  cure  of 
constipation.  They  were  in  misery  unless  their  bowels 
moved.  In  many  cases  a  regular  passage  could  be 
secured  by  a  dinner-pill,  the  patients  felt  better  for  it, 


698 


MEDICAL   RECORD, 


[December  1,  1894 


and  were  not  more  given  to  ills  than  persons  who  did 
not  take  them. 

Dr.  J.  G.  Coyle  said  that  when  he  entered  upon  the 
practice  of  medicine  he  was  not  prepared  to  find  con- 
stipation in  women  exist  to  the  extent  that  it  did.  The 
cynical  and  sententious  definition  of  woman  by  a  college 
professor  seemed  not  altogether  inappropriate :  a  consti- 
pated thing  with  a  pain  in  the  side.  The  first  doctor, 
whoever  he  was,  must  have  been  employed  to  relieve 
constipation.  Massage  was  nothing  more  nor  less  than 
exercise  of  muscles,  and  with  few  exceptions  as  good  re- 
sults could  be  obtained  by  active  exercise,  but  the  pas- 
sive form  appealed  to  women.  For  men  it  should  only 
be  recommended  to  those  who  had  more  time  than  brain. 
In  atony  of  the  bowel  no  drug  was  so  effective  as  fluid 
extract  of  cascara  sagrada.  In  some  cases  strychnia  and 
belladonna  were  very  useful. 

Dr.  F.  M.  Nye  had  once  relieved  himself  of  an  attack 
of  obstinate  constipation  by  green  corn.  He  had  heard 
of  a  man  who  "  couldn't  get  a  hole  through  his  patient, 
sent  out  for  a  quart  of  yeast,  squirted  that  up  his  bowel. 
Blazes !  it  didn't  come  away,  and  that's  what  made  him 
croak."  Dr.  Nye  had  found  a  small  dose  of  calomel, 
given  regularly  for  a  time,  relieve  constipation  in  infants. 

Dr.  Achilles  Rose  exhibited  a  cannon-ball,  weighing 
over  three  pounds,  a  form  which  had  given  satisfaction 
to  himself  and  others  in  constipation. 

Dr.  Illoway,  in  some  closing  remarks,  said  Trousseau 
had  recommended  belladonna  only  in  cases  of  constipa- 
tion supposed  to  be  due  to  spasm  of  the  bowel,  and  in 
such  cases  it  was  of  value.  He  did  not  think  length  of 
the  sigmoid  flexure  in  infants  had  much  influence,  while 
milk  from  a  constipated  mother  and  use  of  soothing  syr- 
ups and  brandies  had. 

"  Xedioo-Chirurgieal  Hotes  on  the  Works  of  Hippo- 
orates  and  Galon  "  was  the  title  of  a  paper  read  by  Dr. 
R.  Harcourt  Anderson.  Mention  was  also  made  of 
anaesthetics  in  the  early  and  middle  ages. 


OJPlitxicat  §epuxtramL 

A  CASE  OF  TETANUS  NEONATORUM  —  RE- 
COVERY. 

By  EDWARD  C.  RUNGE,  M.D., 

ST.  LOUIS,  MO. 

INSTRUCTOR  OF  PHYSIOLOGY  AND  ASSISTANT  CLINICIAN  AT  THE  CLINIC  FOR 
NERVOUS  DISEASES  OF  THB  ST.  LOUIS  MEDICAL  COLLEGE  DEPARTMENT  OF 
WASHINGTON   UNIVERSITY,  ST.  LOUIS,  MO. 

On  August  7th,  Mrs.  H ,  called  me  to  see  her  new- 
born babe,  which  appeared  to  have  been  afflicted  in  a 
peculiar  way  for  some  days.  I  found  the  premises  located 
in  a  healthful  portion  of  the  city,  and  bearing  the  stamp 
of  a  good  sanitary  condition :  foul  air,  cesspools,  or  any 
other  anti-hygienic  elements  did  not  make  themselves 
apparent  upon  close  inspection.  Everything  in  the 
house  indicated  the  order  and  care  of  a  well-regulated 
household.  The  father  seemed  to  be  in  perfect  health. 
The  mother  had  enjoyed  good  health  during  the  entire 
period  of  gestation,  except  for  a  certain  "  nervousness  " 
which  was  more  pronounced  during  the  early  part  of  her 
pregnancy.  This  is  her  fourth  child,  and  the  first  one 
to  give  any  trouble.  The  foetal  movements  were  almost 
absent  during  the  last  month;  some  feeble  ones  were 
felt  just  a  week  before  birth,  which  took  place  on  July 
23d,  about  one  month  before  full  term  according  to  the 
mother's  calculations.  The  labor  lasted  nine  hours,  the 
pains  not  having  been  at  any  time  severe.  It  was  a  head 
presentation.  The  umbilical  cord  is  said  to  have  made 
four  turns  around  the  child's  neck,  and  was  severed  some 
little  time  after  birth.  The  placenta  was  not  adherent, 
and  came  away  about  ten  minutes  after  the  child.  The 
latter,  a  boy,  weighing  eight  pounds,  was  profoundly 
cyanosed,  "  almost  black,"  but  uttered  a  short  cry  very 
soon  after  his  birth.     An  enema  was  administered  at 


once,  for  some  occult  reason.  Whether  the  babe  had 
received  a  bath  at  that  time,  or  how  the  cord  was  man- 
aged, could  not  be  ascertained,  as  the  attending  midwife 
had  beaten  a  hasty  retreat  before  my  arrival,  and  the  en- 
tire anamnesis  had  to  be  elicited  from  the  mother.  The 
latter  did  not  notice  anything  unusual  about  the  babe  for 
two  days.  The  cyanotic  hue  erf  the  skin  had  given  way 
to  an  intense  redness ;  no  "  jaundice  "  was  ever  noticed. 
The  little  fellow  nursed  well  and  eagerly,  and  cried  at 
times,  but  never  lustily.  The  eyeballs  seemed  somewhat 
too  prominent,  and  an  occasional  cast  of  one  eye  was 
observed.  The  intestinal  and  renal  functions  seemed 
normal.  On  the  third  day  the  mother  was  surprised  at 
the  "unusual  strength"  displayed  by  the  babe;  it 
would  grasp  her  gown,  and  only  with  difficulty  loosen  its 
hold.  The  umbilical  cord  had  become  detached  on  some 
day  before  the  mother's  leaving  the  bed,  which  hap- 
pened on  the  tenth  day  after  confinement.  A  daily  bath 
had  been  given  since  the  detachment  of  the  cord.  On 
the  tenth  day  after  birth  there  seemed  to  appear  the  first 
difficulty  in  swallowing,  the  babe  refusing  to  take  the 
breast  Complete  locking  of  the  jaws  supervened.  This 
condition  was  aggravated  by  any  attempt  at  introducing 
the  nipple  or  a  spoon.  On  the  eleventh  day  the  spasms 
of  the  masticatory  muscles  continued  with  temporary 
relaxations,  during  which  some  milk  was  forcibly  given 
by  the  spoon.  The  milk  was,  at  times,  vomited  (or 
probably  ejected  before  it  had  reached  the  stomach). 
This  condition  was  soon  followed  by  tight  shutting  of 
the  eyelids,  stiffening  of  the  extremities,  and  by  drawing 
back  of  the  head.  The  midwife,  nothing  daunted, 
was  still  directing  her  efforts  toward  combating  this  "  un- 
usual attack  of  colic  "  with  castor- oil,  rhubarb,  and  cas- 
toria.  The  parents  finally  concluded  to  call  in  medical 
aid,  and  on  August  7  th  I  found  myself  at  the  bedside  of 
the  little  sufferer,  on  the  fifteenth  day  of  his  extrauterine 
existence,  and  on  the  seventh  day  after  the  onset  of  the 
malady. 

In  the  dim  light  pervading  the  darkened  room  the 
babe's  face  showed  a  high  degree  of  emaciation,  the  eye- 
lids were  closed,  the  countenance  pinched,  but  otherwise 
normal.  A  curtain  was  raised  for  better  inspection. 
No  sooner  had  the  bright  light  struck  the  infant's  face 
than  the  forehead  was  thrown  into  transverse  wrinkles, 
the  eyelids,  of  which  the  superior  ones  appeared  (Edema- 
tous, shut  more  tightly,  the  mouth  was  puckered  up  as 
if  in  an  attempt  at  whistling.  The  lower  jaw  was  im- 
movably fixed,  so  as  to  render  the  introduction  of  my  fin- 
ger utterly  impossible.  This  paroxysm  was  accompanied 
by  a  half -suppressed,  whimpering  cry.  I  succeeded 
with  considerable  difficulty  in  extricating  the  little  pa- 
tient from  a  mass  of  coverings,  cotton-batting,  and  lard- 
stained  rags,  and  found  him  to  be  an  apparently  folly 
developed  infant.  The  emaciation  was  general  and 
extreme.  The  skin  was  of  a  dirty  icteric  hue,  and  cov- 
ered with  a  papular  miliaria,  while  the  sclera  and  the 
mucous  membranes  did  not  show  any  icteric  discolora- 
tion. There  was  a  slight  hernial  protrusion  at  the  um- 
bilicus; the  latter  was  perfectly  healed,  and  did  not 
show  any  sign  of  inflammation,  past  or  present.  I  also 
made  out  a  right  scrotal  hernia.  The  fontanellar  pulsa- 
tions were  absent.  The  head  was  drawn  backward  by 
the  rigid  cervical  muscles ;  a  slight  degree  of  opisthoto- 
nus was  noticeable;  the  forearms  were  slightly  flexed 
and  crossed  over  each  other ;  the  fingers  were  tightly 
clasped  over  the  thumbs  in  extreme  flexion ;  the  thighs 
were  flexed  upon  the  abdomen,  and  the  legs  upon  the 
thighs ;  the  toes  were  widely  separated,  and  their  exten- 
sors in  an  almost  rhythmical  clonus.  The  abdominal 
muscles  hardened  upon  the  lightest  percussion.  The 
paroxysm  was  followed  after  some  time  by  a  period  of 
partial  relaxation,  the  rigidity  of  the  muscles  never  dis- 
appearing entirely.  The  slightest  irritation — as  by  a 
touch,  a  sound,  a  change  of  light,  a  breath  of  air — did  at 
once  cause  an  acute  exacerbation  of  all  the  tetanic  symp- 
toms. The  alvine  discharge,  removed  at  the  time  of  my 
first  examination,  was  of  a  semi-solid  consistency,  dark 


December  i,  1894] 


MEDICAL  RECORD. 


699 


brown,  and  extremely  offensive.  The  whole  picture  was 
so  characteristic  of  tetanus  neonatorum  as  to  preclude 
any  possibility  of  a  diagnostic  error. 

I  immersed  the  babe  in  a  bath  at  990  F.,  and  kept  it 
under  water  for  six  minutes.  This  seemed  to  bring  on 
considerable  relaxation,  which  lasted  just  long  enough  to 
enable  the  infant  to  take  about  one  ounce  of  dilute  milk 
from  the  bottle.  A  small  portion  of  the  milk  was  re- 
jected, and  the  removal  of  the  bottle  ushered  in  another 
paroxysm.  I  ordered  chloral  in  0.24  doses  every  four 
hours  by  rectum,  0.03  of  anti pyrin  and  0.12  of  potassic 
bromide  in  solution  cautiously  dropped  on  the  tongue 
every  two  hours ;  an  immersion  bath  at  blood-heat  every 
four  to  five  hours,  each  to  last  ten  to  fifteen  minutes ; 
nutrient  enemata,  consisting  of  milk,  egg  albumin,  and 
sodic  chloride ;  egg  water  by  the  bottle  or  spoon  when- 
ever the  child's  condition  would  permit  the  procedure.  . 
I,  of  course,  insisted  upon  the  exclusion  of  all  adventi- 
tious sounds  from  the  darkened  sick  room,  and  upon 
keeping  the  patient  well  wrapped  in  simple  coverings, 
discarding  the  complex  apparatus  of  the  conventional 
babe  dress. 

August  8th. — The  pauses  between  the  paroxysms  have 
grown  somewhat  longer ;  this  made  more  frequent  feed- 
ing possible.  The  egg-water  was  never  vomited.  Diu- 
resis was  more  active ;  the  alvine  discharges  were  more 
watery  and  less  offensive.  The  skin  felt  hot.  The  ther- 
mometer was  not  used  for  fear  of  disturbance.  Pepto- 
nized milk  was  ordered,  and  treatment  continued,  ex- 
cept for  decreasing  the  dose  of  the  chloral  to  0.12,  and 
adding  whiskey  in  repeated  five*  drop  doses. 

August  9th. — The  egg- water  and  peptonized  milk  were 
taken  in  greater  quantity,  and  retained.  The  mother 
succeeded  in  straightening  the  lower  limbs  during  the 
bath  without  producing  an  exacerbation  of  the  tetanus. 
The  nutrient  enemata  were  discontinued  on  account  of 
rectal  irritability.  Medication:  Chloral  0.12  twice, 
antipyrin  and  potassic  bromide  every  three  hours.  Baths 
the  same  as  before. 

August  10th. — The  babe  nursed  more  easily  and  will- 
ingly. It  tired  readily,  but  as  soon  as  the  bottle  was 
moved  the  sucking  was  taken  up,  without  producing  a 
masticatory  spasm  every  time.  The  face  wore  an  im- 
proved look.    Treatment  continued. 

August  1  ith. — The  skin  appeared  more  natural,  hav- 
ing lost  its  icteric  hue.  The  eyelids  opened  slightly,  and 
involuntary  winking  was  noticed  for  the  first  time.  The 
trismus  appears  very  much  less  frequently ;  the  feeding 
was  more  successful,  one  ounce  of  peptonized  milk  being 
ingested  each  time.  An  enema  brought  a  rather  copi- 
ous dark- colored  discharge.  The  fingers  could  be  sepa- 
rated with  some  effort.  The  cervical  and  dorsal  spasms 
were  still  quite  pronounced.     Treatment  continued. 

August  1 2th. — The  babe  nursed  well,  taking  about 
one  ounce  of  milk  every  two  hours.  It  seemed  to  crave 
the  bottle,  for  the  cry  had  lost  its  whimpering  character, 
and  was  evidently  appeased  by  the  bottle.  The  eyes 
were  opened,  and  remained  open  for  some  time.  The 
fingers  were  more  readily  unclasped.  The  introduction 
of  the  thermometer  into  the  rectum  caused  quite  a  severe 
tonic  spasm  of  the  muscles  of  the  lower  limbs.  At  6  p.m., 
rectal  temperature  1040  F.  Treatment  continued,  ex- 
cept chloral  given  but  once. 

August  13th.— The  patient  nursed  well.  The  intes- 
tinal discharge  showing  undigested  casein,  the  milk  was 
given  in  greater  dilution.  The  cries  were  quite  natural. 
Relaxation  was  more  persistent,  and  particularly  marked 
after  the  baths.  The  babe  was  ordered  back  to  the 
breast.  Rectal  temperature,  at  10  a.m.,  102. 20  F. ;  at 
5.30  p.m.,  1020  F.  No  chloral;  antipyrin  and  the  bro- 
mide every  four  hours ;  baths. 

August  14th. — The  breasts  began  to  yield  more  milk ; 
still  the  bottle  was  given  at  intervals.  Rectal  tempera- 
ture, at  10  a.m.,  100.90  F. ;  at  5.30  p.m.,  100.40  F. 
Treatment  continued. 

August  15th. — General  relaxation  very  marked.  Al- 
vine discharges  of  natural  color.     The  eyes  were  opened 


readily  and  quite  frequently.  Rectal  temperature,  at 
10  a.m.,  100.90  F. ;  at  6  p.m.,  101.40  F.  All  medica- 
tion suspended.    Baths  continued. 

August  1 6th. — The  patient  appeared  weak,  otherwise 
much  improved.  Relaxation  continued,  except  that  the 
fingers  were  still  flexed,  but  the  fingers  overlapped  the 
thumbs,  and  the  clasp  was  not  tight.  The  tetanic  con- 
dition has  disappeared  completely.  Rectal  tempera- 
ture, at  10  a.m.,  99.20  F. ;  at  6.20  p.m.,  101.10  F.  The 
number  of  baths  reduced  to  one  in  twenty-four  hours. 

August  17th. — Doing  well.  Rectal  temperature,  at 
10.30  A.M.,  101.20  F. 

August  1 8th. — The  babe  is  entirely  breast-fed ;  weight, 
seven  and  three-quarter  pounds.  Rectal  temperature,  at 
4.30  p.m.,  101.10  F. 

August  24th. — Weight,  seven  and  three  quarter  pounds. 

September  1st. — Weight,  eight  pounds. 

September  14th. — The  boy  seemed  bright.  All  func- 
tions were  normal.  He  had  the  full  use  of  his  limbs,  no 
muscular  impairment  whatever  being  noticeable.  Rec- 
tal temperature,  at  1.30  p.m.,  100. i°  F.  Weight,  ten 
pounds.  The  patient  appeared  in  every  respect  a  per- 
fectly normal  child. 

I  may  sum  up  the  important  features  of  this  case  as  fol- 
lows: 

The  tetanus  set  in  on  the  tenth  day  after  birth ;  all  of 
its  manifestations  disappeared  completely  on  the  fifteenth 
day  after  the  onset. 

The  development  and  course  of  the  disease  in  this  case 
place  the  latter  in  the  category  of  so-styled  chronic  tet- 
anus, with  its  less  gloomy  prognosis. 

As  to  the  therapeutic  measures,  it  would  be  impossible 
to  decide  how  far  they  have  contributed  toward  bringing 
about  the  favorable  result.  To  serve  this  purpose  they 
would  have  to  run  the  gauntlet  of  much  more  extensive 
clinical  experience.  In  managing  this — my  first — case 
of  tetanus  neonatorum,  I  had  to  overcome  a  strong  preju- 
dice against  any,  save  physiological  and  hygienic,  meas- 
ures in  dealing  with  the  new-born.  I  felt  that  the  oc- 
casion did  not  warrant  the  taking  of  extemporizing 
half-measures,  or  any  dosing  in  strict  accordance  with 
hard-and  fast  pharmacopoeial  rules ;  0.03  of  antipyrin  and 
0.12  of  potassic  bromide  every  two  hours,  and  chloral  in 
o.  24  doses  every  four  hours,  seem  a  good  deal  of  medi- 
cine for  a  patient  just  entering  upon  the  tenth  day  of  his 
earthly  existence  ;  but  the  violent  nature  of  the  malady 
rendered  the  adoption  of  truly  heroic  measures  simply 
imperative.  The  frequent  and  prolonged  bathing  was  a 
prominent  feature  in  the  management  of  the  case,  and 
I  will  say  that  it  caused  more  lasting  relaxation  than  any 
of  the  other  remedial  agents,  produced  repose  more 
nearly  akin  to  natural  sleep,  and,  at  the  beginning  of  the 
treatment,  stayed  the  trismus  for  a  sufficient  time  to  en- 
able the  patient  to  take  some  nourishment  by  the  mouth. 
Rectal  alimentation,  which  I  should  never  neglect  to  in- 
stitute, is  not  quite  as  satisfactory  in  the  new-born  as  in 
infants  at  a  later  period  of  life. 

Any  attempt  at  solving  the  question  as  to  the  etiology 
of  the  tetanus  in  the  case  under  consideration  would 
lead  directly  into  the  field  of  con jecture  and  speculation. 
The  umbilicus  having  failed  to  show  any  evident  patho- 
logical changes,  the  case  would  most  likely  be  classified 
as  one  of  non- traumatic  or  "idiopathic"  tetanus.  It 
was  not  within  my  power  to  ascertain  whether  the  baths 
given  before  the  onset  of  the  disease  were  improperly 
tempered.  Foul  air  did  not  play  any  rdle  in  establishing 
the  disease.  The  atmospheric  changes  were  devoid  of 
any  startling  features ;  from  the  reports  obtained  at  the 
local  weather  bureau,  I  learned  that  for  the  three  days 
preceding  the  attack,  and  on  the  day  of  the  attack,  the 
mean  temperature  registered  740,  8o°,  830,  82°F.;  the 
range  between  the  maximum  and  minimum,  16,  21,  16, 
21 ;  the  departure  from  the  normal,  —  4,  +  2,  +  5,  + 
4.  These  data  point  to  an  equable  state  of  the  atmos- 
pheric temperature ;  the  same  holds  true  for  the  first  ten 
days  of  the  child's  life.  The  meconium  had  been  passed 
in  a  normal  way,  and  the  alvine  discharges  had  assumed 


7oo 


MEDICAL  RECORD. 


[December  i,  1894 


their  usual  character.  In  these  and  some  more  directions 
causes  of  tetanus  of  the  new-born  have  been  sought  after. 
Upon  perusing  the  literature  on  this  subject  I  came  to 
the  conclusion  that  the  etiology  of  non-traumatic  tetanus 
is  still  a  sealed  book  to  us.  Just  to  illustrate  on  what 
extremely  weak  grounds  the  explanation  of  the  causation 
of  this  disease  sometimes  rests,  I  make  mention  of  the 
case  reported  by  Hein,  as  quoted  by  Dr.  J.  Lewis  Smith  : 
A  citizen  of  Berlin  lost,  successively,  two  children  with 
tetanus  soon  after  birth.  When  the  second  child  fell  ill 
he  observed  that  its  cradle  was  exposed  to  a  current  of 
air.  At  the  third  accouchement  the  position  of  the  cradle 
was  changed  and  the  infant  escaped !  Our  salvation 
may  possibly  lie  in  the  further  pursuit  of  such  experi- 
mental work  as  has  been  done  by  Beumer  and  Riper ;  its 
final  result  may  prove  that  every  genuine  case  of  tetanus 
neonatorum  is  of  microbic  origin.  Bearing  such  solu- 
tion of  the  problem  in  mind,  we  should  be  ever  careful  of 
giving  our  new-born  the  benefit  of  the  most  approved 
surgical  methods  while  we  are  inflicting  upon  them  their 
first,  unavoidable,  trauma.  Clean  hands,  a  thoroughly 
cleansed  cord,  aseptic  ligatures,  sterilized  scissors,  a  dry 
protective  dressing,  consisting  of  some  non-irritating 
antiseptic  powder  {e.g.,  equal  parts  of  iodol  and  boracic 
acid)  and  gauze,  are  all  essential  features  in  the  equip- 
ment of  the  modern  obstetrician  possessed  of  truly  surgi- 
cal instincts. 


A  CASE  OF  FATAL  HICCOUGH  OF  UNKNOWN 
ORIGIN. 

By  D.  B.  McCARTIE,  M.D., 

NftWABK,   N.  J. 

Within  the  last  few  months  a  new  and  continuous  form 
of  hiccough  has  appeared,  unaccompanied  by  organic 
disease  or  surgical  malady.  The  minute  history  of  all 
these  cases  I  cannot  substantiate,  but  I  know  all  were 
continuous  and  irremediable,  and  in  several  instances 
caused  death.  Some  cases  were  treated  in  the  hospitals, 
others  at  home,  with  meagre  results,  and  most  were 
looked  upon  as  excessive  forms  of  ordinary  hiccough, 
when  probably  the  disease  was  a  new  manifestation  of 
nerve  disturbance  occasioned  by  some  functional  neuro- 
sis. 

Case  L— History :  J.  C ,  bartender,  aged  twenty- 
eight  ;  habits  and  family  history  good  ;  no  special  ner- 
vous traits  in  family;  an  active,  strong  man;  weight, 
150  pounds;  middle  height.  For  yean  previous  to 
present  disease,  on  being  shaved  by  his  barber,  he  no- 
ticed that  when  the  razor  touched  a  circumscribed  spot 
on  the  side  of  his  chin,  at  the  edge  of  the  inferior  maxil- 
lary bone  beneath  the  mental  foramen,  a  trifling  scratch 
instantly  brought  on  an  attack  of  hiccough.  This  hap- 
pened repeatedly,  but  the  reflex  action  never  continued 
longer  than  for  a  few  seconds.  He  always  could  check 
it  by  the  usual  domestic  remedies,  as  sipping  water, 
holding  the  breath,  etc.  The  last  and  fatal  attack  be- 
gan after  he  had  been  shaved,  and  lasted  five  or  six 
weeks,  after  which  he  died  of  exhaustion.  The  hic- 
cough was  almost  continuous,  except  during  sleep  and 
for  some  periods  to  which  this  brief  sketch  particularly 
refers.  After  a  day  or  two  the  case  aroused  much  pop- 
ular interest,  since  the  patient  was  well  known ;  and  as 
a  newspaper  wonder  stood  out  strongly  in  long,  exciting 
paragraphs.  As  a  consequence,  cure  after  cure  was  rec- 
ommended and  tried,  with  faith  in  each  new  method, 
only  to  end  in  sad  failure.  Among  thousands  of  popu- 
lar devices  nitrite  of  amyl  was  oftenest  recommended, 
even  outside  the  medical  world. 

It  would  be  waste  of  valuable  space  to  add  any  of  the 
extraordinary  remedies  suggested ;  puffice  it  to  say  they 
all  failed.  The  medical  treatment  for  days  was  as  hope- 
less, and  in  this  department  few  remedies  were  left  un- 
tried. The  sedatives  naturally  were  tried,  but  after 
slight  relief  the  hiccough  was  renewed.  One  medical 
gentleman  suggested  the  stomach- tube,  which  was  even- 


tually the  only  means  by  which  a  short  reprieve  could  be 
obtained.  The  use  of  food  in  any  form,  after  being 
swallowed  about  half  an  hour,  caused  the  patient  such 
distress  by  augmenting  the  hiccough,  that  he  anxiously 
introduced  the  tube  or  artificially  produced  vomiting, 
for  when  the  stomach  was  empty  the  hiccough  weak- 
ened. I  saw  the  case  many  times,  and  tried  pressure  on 
the  phrenics  in  the  neck.  This  lessened  the  hiccough 
very  much  and  allayed  the  spasms  of  the  chest,  bat  on 
removal  of  die  pressure  the  phenomena  returned  as  vig- 
orously as  ever.  I  then  strapped  the  lower  ribs,  which 
apparently  lessened  the  spasms,  yet  the  patient  com- 
plained that  they  had  not  subsided  internally.  Cocaine 
pills  were  next  administered,  and  much  relief  followed ; 
but  this  was  not  sufficient  to  cause  a  sudden  disappear- 
ance of  the  trouble,  which  the  patient  and  everyone 
thought  was  to  be  obtained  by  some  mode  of  action  or 
drug.  After  this  the  patient  continued  to  hiccough  and 
grow  weaker.  Rectal  alimentation  did  little  to  main- 
tain his  strength.  About  one  week  later  an  operation 
was  performed  on  the  irritable  spot  in  the  cheek,  bat 
failed  to  cure,  having  no  scientific  exactitude  underlying 
its  performance.  On  a  second  visit  to  the  unfortunate 
fellow  I  observed  that  he  was  losing  all  his  strength,  and 
was  very  exhausted  and  wasted.  As  a  last  resource  I 
tried  massage,  and  to  my  surprise,  after  working  gently 
at  the  toes  and  lower  extremities  for  a  brief  time,  he 
complained  of  an  indefinite  feeling  about  the  epigastric 
region ;  presently  be  retched  up  some  greenish  watery 
fluid,  and  the  hiccough  stopped  immediately.  The  pa- 
tient brightened  up  and  took  some  nourishment,  which 
remained  in  his  stomach  without  producing  the  hic- 
cough. The  interval  lasted  twenty-four  hours,  when 
it  began  again.  The  man  now  despaired  and  sank 
spiritless  in  his  bed.  Being  called  again,  I  tried  the 
same  remedy  with  instantaneous  success.  The  hiccough 
stopped  two  days,  then  returned.  In  the  meantime 
hundreds  of  letters  arrived  daily,  and  continued  annoy- 
ance was  kept  up  about  the  dying  man.  He  also  tried 
every  remedy  guaranteed  as  a  sure  cure.  I  saw  him 
again  three  days  later,  and  massaged  him  all  over; 
again  instant  relief  followed,  and  he  remained  free  from 
the  attacks  an  entire  week,  at  the  end  of  which  time  they 
recurred.  I  saw  the  case  no  more,  as  now  he  submitted 
to  all  kinds  of  treatment,  plus  an  operation.  One  week 
later  he  died  of  exhaustion ;  no  autopsy. 

These  cases  appear  to  be  of  nervous  origin,  and,  like 
any  other  hysterical  malady,  are  prolonged  by  attention. 
They  appear  to  be  causeless,  except  through  functional 
nerve  perversion.  In  the  above  case  no  organic  cause 
existed,  or  in  any  of  the  group  lately  reported.  The 
disease  is  not  due  to  organic  stomach  trouble,  or  pressure 
on  the  phrenic  nerve ;  nor  does  there  appear  any  reason 
as  yet  to  ascribe  it  to  any  brain  tumor  or  lesion  which 
would  not  be  lacking  in  various  other  symptoms.  It 
remains  at  present  to  class  this  phenomenon  as  a  neurosis 
of  functional  character.  Most  works  on  medicine  ignore 
it,  except  as  a  concomitant  to  alcoholic  excess,  or  ante- 
cedent to  death,  or  accidental  to  obvious  causes,  such  as 
pressure  on  the  nerve  trunk.  The  treatment,  where  ex- 
haustion is  the  cause  of  death,  would  be  suggested  by  like 
cases  of  functional  nerve  depression,  like  that  of  bed- 
ridden or  hysterical  patients.  Little  need  be  said  on 
this  score,  except  that  the  disease  be  recognized  as  a 
disease.  Isolation,  rest,  removal  from  home,  forced 
feeding,  encouragement,  electricity,  and,  above  all,  in 
these  cases,  massage,  since  the  results  above  ascribed  to 
it  were  undoubtedly  manifest  and  instantaneously  suc- 
cessful. 


108  Bellbvillb  Avenue. 


Library  of  the  Surgeon-General's  Qffloe.— In  the  Army 
Medical  Library  there  are  now,  according  to  the  recently 
issued  report  of  the  Surgeon-General,  114,567  bound 
volumes,  and  183,778  monographs  and  theses  on  medi- 
cal subjects. 


December  i,  1894] 


MEDICAL   RECORD. 


701 


OUR  LONDON  LETTER. 

(From  Our  Special  Correspondent.) 

THE  BRADSHAW  LECTURE — INFANTILE  SCURVY  AND  RICK- 
ETS— PATHOLOGICAL  SOCIETY  —  PERFORATION  OF  THE 
PALATE  IN  SCARLET  FEVER — DEATH  OF  DR.  STURGES — 
SMALL-POX — DIPHTHERIA— CHELSEA  HOSPITAL  AGAIN. 

London,  November  10, 1894. 

The  Bradshaw  Lecture  was  delivered  on  Thursday  before 
the  Royal  College  of  Physicians.  This  year  the  Lecturer 
was  Dr.  Thomas  Barlow,  who  took  for  his  subject  "  In- 
fantile Scurvy  and  its  Relation  to  Rickets."  Dr.  Barlow 
has  worked  assiduously  at  this  subject  and  made  it  quite 
his  own,  and  was,  therefore,  listened  to  with  great  inter- 
est. It  is  now  eleven  years  since  he  stated  the  results  of 
his  observations  on  thirty -one  cases.  At  that  time  the 
disease  had  not  been  generally  differentiated,  and  such 
cases  were  spoken  of  as  "acute  rickets,1'  even  in  the 
German  school,  where  the  idea  that  they  were  scurvy  was 
repudiated  chiefly  because  sponginess  of  the  gums  had  not 
been  noticed,  but  this  symptom  has  been  since  shown  to 
sometimes  occur.  Dr.  Cheadle  first  reported  this,  and  to 
him  we  owe  to  a  great  extent  the  present  state  of  our 
knowledge  of  the  clinical  features  of  these  cases.  The 
soundness  of  his  conclusions  was  maintained  by  Dr.  Bar- 
low, who  has  himself  contributed  chiefly  to  our  knowl- 
edge of  the  pathology  of  the  disease.  In  this  Bradshaw 
Lecture  he  reviewed  the  main  clinical  and  anatomical 
aspects  of  the  disease,  recalled  the  conclusions  of  his  first 
paper,  and  then  showed  ho*  far  they  had  been  modified 
by  criticism  and  subsequent  investigations.  Copies  of 
the  drawings  of  his  original  paper  from  the  Medico-  Chit- 
urgical  Transactions,  1883,  were  submitted,  and  speci- 
mens were  exhibited  to  illustrate  the  pathological  condi- 
tions. I  must  not  omit  to  say  that  in  giving  some 
account  of  the  workers  on  the  subject,  Dr.  Barlow  did 
ample  justice  to  America,  from  which  he  said  the  most 
striking  evidence  had  come.  He  specially  mentioned 
Drs.  Northrup,  Starr,  Roche  and  others.  It  seems  that 
the  disease  must  be  more  common  on  your  side  the  At- 
lantic, and  it  would  appear  to  be  on  the  increase  with  us, 
unless  this  apparent  increase  may  be  due  to  the  increased 
knowledge  which  makes  differentiation  more  general. 
Infantile  scurvy  is  a  disease  of  spoon-fed  children.  The 
spread,  prevention,  and  cure  are  summed  up  in  this  state- 
ment. Still  there  are  some  fresh  points  in  diet  now  and 
again  cropping  up.  Thus  the  danger  of  proprietary 
foods  is  recognized,  but  it  is  not  commonly  suspected 
that  sterilization  of  milk  may  be  dangerous.  Dr.  Barlow 
spoke  cautiously  on  the  point,  but  suggested  that  pro- 
longed high  temperature  might  lessen  the  antiscorbutic 
powers  of  milk.  The  treatment  is  simple,  appropriate 
diet  and  antiscorbutic  remedies. 

Antitoxin  and  diphtheria  continue  to  occupy  much 
attention,  and  one  frequently  hears  of  fresh  cases  in 
which  the  treatment  by  serum  seems  to  have  been  most 
successful.  It  is  now  said  that  the  British  Institute  will 
soon  be  able  to  supply  the  remedy.  In  the  meantime 
supplies  from  the  continent  are  falling  off,  and  will  soon 
be  unobtainable.  The  Institute  ought  to  have  been 
ready  before  this,  as  I  some  time  since  suggested. 

There  was  a  good  show  of  specimens  at  the  Patho- 
logical Society  on  Tuesday,  e.g.,  rare  examples  of 
malignant  disease,  mediastinal  tumor,  peri- renal  hemor- 
rhage, carcinoma  of  kidney.  Dr.  £.  W.  Goodall  read  a 
paper  on  perforation  of  the  soft  palate  in  scarlet  fever, 
and  showed  a  preparation  from  a  child  of  six  months  in 
which  perforation  was  first  observed  four  days  before 
death.  He  had  seen  14  cases,  in  2  of  which  there  were 
3  perforations,  in  3  cases  a,  and  in  9  only  1.  They  oc- 
curred at  various  periods,  from  the  9th  to  the  28th  day. 
Generally  they  were  by  the  side  of  the  anterior  arch. 
They  might  persist  for  weeks,  and  were  probably  the  re- 
sult of  local  sloughing.     He  had  only  seen  perforation 


in  diphtheria  twice,  and  agreed  with  Dr.  Fowler  that  the 
lesion  is  almost  diagnostic  of  scarlet  fever. 

Dr.  Octavius  Sturges  died  this  day  week  in  conse- 
quence of  injuries  received  a  few  days  previously.  He 
was  knocked  down  by  a  cab  in  Cavendish  Square,  and 
though  at  first  no  internal  injury  was  manifest,  collapse 
set  in  and  he  died  on  the  3d  inst.  His  chief  writings 
were  on  chorea  and  pneumonia,  and  in  connection  with 
both  of  these  his  name  will  be  familiar  to  many  of  your 
readers.  He  was  senior  physician  to  the  Westminster 
Hospital,  where  colleagues  and  students  alike  held  him 
in  the  highest  esteem.  At  the  Children's  Hospital  he 
held  a  similar  position.  At  the  Royal  College  of 
Physicians  he  was  Senior  Censor.  In  all  directions  re- 
grets are  expressed  at  his  untimely  death,  mingled  with 
admiration  of  his  high  character,  unswerving  loyalty  to 
truth,  faithfulness  to  conviction,  and  kindly  sympathy 
with  pupils  and  friends.  As  a  quondam  colleague,  I 
would  add  my  testimony  to  his  upright  conduct,  and  re- 
gret that  so  estimable  a  character  should  thus  suddenly  be 
removed  from  among  us.  We  can  ill  afford  to  lose  such 
examples.  He  was  buried  on  Thursday,  and  a  number  of 
distinguished  physicians  attended  the  funeral  service. 

Small-pox  continues  to  abate  in  London.  Only  eight 
new  cases  were  reported  last  week.  In  the  provinces, 
however,  the  returns  are  less  favorable.  In  Dublin  the 
disease  continues.  In  Birmingham  69  fresh  cases  were 
reported.  In  Edinburgh  there  has  been  a  fresh  outbreak, 
to  the  extent  of  50  cases  in  nine  days,  but  I  hear  that  the 
type  is  mild. 

Diphtheria,  which  was  rapidly  falling  in  the  number 
of  its  victims,  has  not  declined  further  in  the  past  week, 
in  fact,  the  number  of  deaths  went  back  from  49  to  54. 
At  West  Ham  there  were  12  deaths  registered. 

At  last  the  committee  of  the  Chelsea  Hospital  for 
Women  have  yielded  to  the  voice  of  reason  and  resigned. 
There  is  no  gracefulness  in  the  act — it  has  been  forced 
upon  them  by  public  opinion.  I  hope  the  governors  who 
are  to  meet  shortly  will  come  in  numbers  and  refuse  to 
re-elect  one  of  the  old  Board.  I  heard  the  medical  staff 
will  recommend  the  governors  to  appoint  a  special  com- 
mittee to  deal  with  the  subject  of  elections  to  the  staff. 


IS  MALARIA  A  WATER-BORNE  DISEASE? 

To  thk  Editor  op  not  Medical  Record. 

Sir  :  Anent  the  discussion  on  the  sources  of  malarial 
infection  between  Drs.  Daly,  of  Pittsburg,  and  Dalrym- 
ple,  of  New  Rochelle — places  where  malaria  is  compaia- 
tively'rare — perhaps  a  word  from  one  who  has  spent  six 
years  in  the  Mississippi  Yazoo  Delta,  where  the  infection 
is  endemic,  would  be  of  value. 

In  the  first  place,  both  gentlemen  are  right  Malarial 
germs  are  earth- borne,  water-borne,  and  air-borne ;  in 
fact  are  disseminated  by  every  agency  that  circulates 
except  excessive  heat.  Now,  I  have  frequently  known  of 
a  succession  of  cases  of  pernicious  malaria  in  a  family 
who  drank  water  from  the  same  source.  To  illustrate : 
In  the  summer  of  1890, 1  had  two  cases  of  malarial 
hematuria,  one  of  which  was  fatal,  one  case  of  malarial 
congestion  fatal,  one  case  of  typho-malarial  fever  not 
fatal,  and  one  case  of  severe  intermittent ;  all  occurring 
in  one  family  of  six  members;  the  one  escaping  being  a 
very  old  lady.  Situated  about  three  hundred  yards  from 
this  residence  was  another  family  of  three  members. 
One  of  these  had  malarial  hematuria  and  died.  The 
other  two  had  very  severe  attacks  of  intermittent.  About 
fifty  yards  from  the  first-named  residence  was  another 
family,  numbers  not  remembered,  which  developed  two 
cases  of  malarial  hematuria,  one  of  which  was  fatal,  and 
several  cases  of  intermittent  and  remittent  fevers.  There 
were  several  other  families  living  contiguous  to  the  first- 
named  house  in  every  direction,  who  were  exposed  to  all 
the  atmospheric  and  general  causes,  but  remained 
healthy.  It  was  found  that  the  three  infected  families 
had  used  water  from  the  same  cistern,  and  this  cistern  was 


702 


MEDICAL   RECORD. 


[December   i,  1894 


cracked  and  fall  of  sipage  water.    The  families  who  had 
remained  healthy  had  used  a  different  water-supply. 

Again,  it  has  been  observed  repeatedly  in  that  section, 
that  during  a  protracted  draught,  when  the  stagnant  ponds 
and  bayous  are  all  drying  up,  exposing  their  beds  to  the 
sun,  which  soon  converts  them  to  dust  which  fills  the  at- 
mosphere, malaria  is  rife  in  all  its  forms ;  but  let  there 
come  a  good  rain  sufficient  to  bring  down  all  atmospheric 
germs  and  fix  them  to  the  earth  again,  and  there  will  be  a 
sudden  cessation  of  all  acute  cases.  This  is  so  invariable 
that  its  occurrence  can  be  predicted  with  certainty.  Of 
course,  chronic  cases  and  those  which  have  undergone 
structural  change  will  persist. 

I  have  been  told  of  severe  epidemics  caused  by  upturn- 
ing the  earth  and  by  the  exposure  of  large  areas  of  the  soil 
to  the  rays  of  the  sun,  by  "  deadening  "  the  timber,  but 
none  have  come  under  my  personal  observation. 
Yours  respectfully, 

Isaac  J.  Jones,  M.D. 

1603  South  Congress  Avxmub,  Austin,  Tex.,  November  15,  1894. 


To  Tin  Editor  or  thk  Medical  Rrcord. 

Sir:  Will  Dr.  F.  W.  Dalrymple,  of  New  Rochelle, 
kindly  answer  the  following  questions  for  the  information 
of  the  profession : 

1.  From  what  source  does  the  Water  Company  of  the 
village  of  New  Rochelle  get  its  water  supply  for  distribu- 
tion to  the  inhabitants? 

2.  If  from  wells,  what  is  the  evidence  that  there  was 
no  contamination  in  them  from  the  land  water  ? 

3.  If  from  a  stream,  what  is  the  locality  and  character 
of  the  watershed  drained  by  the  stream  which  supplied 
the  village  water  ? 

4.  What  was  the  storm-water  fall  amount  and  character 
for  the  two  months  previous  to  the  outbreak  of  malaria? 

5.  What  proportion  of  the  people  who  suffered  from 
malaria  drank  from  wells  in  the  village  ? 

6.  What  were  the  sources  of  supply  of  lettuce,  rad- 
ishes, celery,  etc.,  eaten  by  the  persons  taken  sick; 
whether  from  muck  lowlands  or  uplands? 

7.  What  were  the  sources  of  the  milk-supply  of  those 
taken  sick  ? 

8.  What  proportion  of  the  men  who  worked  in  the 
sewer  and  cellar  excavations  were  taken  sick  with  mala- 
rial fever? 

It  is  in  no  captious  spirit  that  I  ask  the  foregoing 
questions ;  I  desire  to  get  at  all  the  facts  for  the  sake  of 
accuracy,  and  I  sincerely  hope,  in  replying,  that  no  fur- 
ther epithets  will  be  indulged  in  by  the  Doctor  as  to  the 
views  I  advanced  being  " absurd;  "  for  the  Doctor  will 
probably  agree  with  me,  that  it  is  not  difficult  to  mention 
now  other  well-accepted  views  in  medical  science  that 
were  previously  more  strange  and  unlikely  than  taking 
malaria  into  the  system  in  the  water  we  drink ;  and  epi- 
thets are  neither  argument  nor  evidence,  in  this  or  any 
other  discussion.  Yours, 

W.  EL  Daly,  M.D. 

Pittsburg,  Pa. 


CIRCUMCISION— DO  WE  NEED  LEGISLATION 
FOR  IT? 

To  the  Editor  or  thk  Medical  Rbcokd. 

Sir  :  That  delicate  little  procedure  or  operation,  as  Dr. 
Henry  Levien  would  have  it  (issue  of  November  17th), 
circumcision,  is  again  attracting  the  attention  of  our  profes- 
sion, and  I  believe  there  is  no  operation  that  has  been  so 
much  discussed  or  spoken  of  for  centuries  as  this  rite  of  the 
Hebrews ;  and  it  is  not  surprising  that  it  is  the  bete  noire 
of  our  progresive  Hebrew  physicians  imbued  with  the 
spirit  of  Listerism. 

The  chief  fault  that  Dr.  Levien  finds  with  the  Mohel 
(surgeon)  is  the  ignorance  of  aseptic  surgery,  and  he  ac- 
cordingly cites  two  cases,  one  of  erysipelas  and  the  other 
of  excessive  hemorrhage,  that  occurred  as  the  result  of  the 
operation. 

Those  of  our  colleagues  that  practice  among  the  He- 


brews will  admit  that  seldom,  if  ever,  did  they  hear  of 
complications  after  circumcision  so  grave  as  to  cause 
death ;  it  is  of  so  rare  occurrence,  nay,  so  unheard  of,  that 
it  is  impossible  to  give  any  approximate  data;  it  is  infi- 
nitesimally  small.  Let  the  Board  of  Health  statistics 
answer,  how  often  do  they  contain  reports  of  deaths  as 
the  result  of  circumcision.  We  do  not  attack  modern  sur- 
gery, with  the  great  aseptic  and  antiseptic  methods,  but 
we  venture  to  say  that  in  the  best  modern  hospitals, 
where  Listerism  is  carried  out  in  a  most  rigorous  way, 
sepsis  occurs  a  hundredfold  more  than  in  that  small 
crowded  room  where  the  Mohel  is  the  surgeon-in  chief; 
and  the  surgeon  of  every  hospital  in  the  country  would 
be  proud  should  he  be  in  position  to  point  to  as  small  a 
record  of  sepsis  or  other  complications  as  the  Mohel  is 
able  to.  How  to  explain  such  a  fact  I  do  not  undertake, 
but  one  feature  of  the  Mohel's  work  is  characteristic— 
his  dexterity,  the  swiftness  with  which  he  performs  the 
only  operation  he  is  able  to,  and  which  he  has  performed 
thousands  of  times,  is  so  great  that  it  only  consumes 
one  or  one  and  a  half  minute,  including  time  of 
dressing  the  wound,  and,  as  I  witnessed  it  the  other  day, 
it  took  at  most  forty-five  seconds  in  all.  The  little 
time,  say  thirty  seconds,  which  the  wound  is  exposed 
might  explain  somehow  why  so  few  cases  of  compli- 
cations occur  in  the  Mohel's  practice. 

In  conclusion  permit  me  to  state  that:  1.  As  Dr. 
Levien  himself  admits  the  progressive  Mohel  employs  an- 
tiseptics, he  believes  only  the  city  Mohel  does.  I  had  an 
opportunity  dozens  of  times  to  witness  the  country  Mo- 
hel's armamentarium  not  complete  without  a  bottle  of 
carbolic  and  a  strip  of  iodoform  gauze. 

2.  There  are  licensed  physicians,  skilful  and  unskilful, 
and  the  same  with  the  Mohels,  but  even  the  poorest  He- 
brew always  seeks  the  services  of  the  best,  die  one  who 
is  most  popular  as  having  the  record  of  widest  experience ; 
for  should  the  father  be  unable  to  pay  the  Mohel's  fee,  the 
invited  guests  respond  to  the  Mohel's  individual  blessing 
of  those  present  by  voluntary  contributions,  thus  paying 
for  the  opportunity  to  be  present  at  a  God  pleasing  rite. 

3.  Circumcision,  as  practised  by  the  Mohel  on  the  in- 
fant, is  no  more  of  an  operation  than  vaccination,  open- 
ing an  ordinary  abscess,  or  severing  a  tongue  tie. 

4.  As  a  custom  and  religious  rite,  circumcision  cannot, 
and  should  not,  be  interfered  with  as  carried  oat  among 
them. 

Permit  me  further  to  add  that  none  of  our  most  promi- 
ment  surgeons  ever  attacked  or  ventured  an  adverse 
opinion  in  regard  to  circumcision,  for  we  never  see  any 
evil  results  from  it,  and  in  many  cases  are  sorry  our  pa- 
tients have  not  been  circumcised.  As  a  patient  of  mine, 
an  Arabian,  aged  thirty,  upon  whom  I  was  compelled  to 
perform  circumcision  about  three  months  ago,  for  para- 
phimosis with  extensive  sloughing,  exclaimed:  ''How 
ungrateful  must  I  be  to  my  father,  who  neglected  his 
duty  to  me  and  left  the  work  to  be  done  by  yon  thirty 
years  afterward." 

R.  Hochlerner,  A.B.,  M.D. 


THE  IMMUNE  SERUM  OF  THE  GOAT. 

To  thb  Editor  op  thb  Medical  Record. 

Sir:  "C."  in  the  Medical  Record,  November  17th, 
suggests  that  "  it  may  be  worth  while  to  test  the  natural 
and  artificial  immune  serum  of  the  goat  in  future  ex- 
periments." He  is  speaking  of  tuberculosis.  Let  me 
inform  your  correspondent,  that  there  are  past  experi- 
ments which  he  will  find  described  in  the  Tribune 
Mldicale  of  Paris.  Unfortunately  I  cannot  give  the 
date  of  the  articles,  having  sent  the  files  of  this  French  1 
paper  to  the  Tokio  Medical  Library ;  but  the  year  was 
either  '92  or  '93.  One  article  is  entitled  "  Goat's  Blood 
in  the  Treatment  of  Tuberculosis,"  by  Bertin  and  Picq ; 
the  title  of  the  other  is  "  Transfusion  of  Goat's  Blood  in 
Pulmonary  Tuberculosis,"  by  M.  Bernheim. 

Yours  truly, 

Albert  S.  Ashmead. 


December  i,  1894] 


MEDICAL   RECORD. 


703 


SttrgicaX  SttxgQtBtions. 

Gall-bladder.  —  The  tongue-shaped  projection,  to 
which  attention  has  been  called  by  Riedel,  is  present  in 
many  cases  of  hydrops  of  the  gall-bladder ;  it  is  not  in- 
frequently confounded  with  a  floating  kidney  on  the 
right  side. — Kshr. 

Appendicitis. — Surgical  interference  is  not  advised  dur- 
ing an  acute  attack  of  appendicitis,  except  when  grave 
symptoms  intervene,  unless  a  competent  surgeon  is  at 
hand.  Under  these  circumstances  the  case  should  be 
operated  upon  after  the  so-called  recovery. — Ashton. 

Lacerated  Cervix.— The  kind  of  suture  I  use  in  opera- 
tion for  lacerated  cervix  is  braided  silk  boiled  in  wax, 
and  these  sutures  can  be  withdrawn  with  such  ease  that 
the  patient  is  scarcely  aware  of  the  fact. — Nilsen. 


Keep 


itric-acid  bottle  away  from  your  steel  in- 


ln- 


jj  your  nitric 

struments. 

So  not  carry  nitrate  of  silver  in  the  same  case  with 
struments. 

Control  of  Hemorrhage  in  Cases  in  which  it  is  neces- 
sary to  remove  the  Arm,  the  Scapula,  and  the  Clavicle.— 
The  methods  that  have  been  employed  in  these  cases 
have  been :  (1)  Simple  compression  of  the  subclavian 
artery ;  (2)  compression  of  the  artery  after  resection  of 
the  clavicle ;  (3)  ligation  of  the  subclavian  prior  to  be- 
ginning the  amputation;  (4)  resection  of  the  middle 
half  of  the  clavicle  and  ligation  of  the  subclavian ;  (5) 
Wyeth  first  tied  the  artery,  then  formed  his  flaps,  and, 
when  the  arm,  clavicle,  and  scapula  were  connected  with 
the  trunk  by  only  the  veins  and  nerves,  secured  the  veins 
and  cut  the  nerves ;  (6)  the  artery  and  vein  have  both 
been  tied  after  resection  of  the  middle  portion  of  the 
clavicle. — Keen. 

Empyema. — No  operation  is  justifiable  unless  the  pres- 
ence of  pus  is  certain ;  unless  thorough  treatment  by 
medicinal  agents,  blisters,  etc.,  has  failed ;  or  unless  the 
symptoms,  dyspnoea,  etc.,  are  so  urgent  as  to  demand  im- 
mediate relief.  (And  the  only  way  to  be  sure  of  the 
presence  of  pus  is  by  the  use  of  the  aspirating  needle.) — 

ASHHURST. 

The  man  who  intends  to  be  a  surgeon  should  not  only 
make  a  special  study  of  surgical  anatomy,  but  should  do 
a  considerable  amount  of  practical  laboratory  work  in 
bacteriology,  pathological  histology,  and  experimental 
pathology  and  physiology. — Billings. 

The  shook  of  being  knocked  down  by  an  anaesthetic,  as 
it  is  frequently  administered,  is  very  great  indeed,  ex- 
tremely like  that  of  a  heavy  blow  on  the  top  of  the  head. 
— Ross. 

We  chloroform  the  patients  in  order  to  give  them 
ether. — Gorgas. 

Excision  of  Oasserian  Ganglion.— Hartley  improved 
on  this  operation  by  opening  the  cranium  without  incis- 
ing the  dura,  raising  the  temporo  sphenoidal  lobe,  expos- 
ing the  ganglion,  and  removing  it  as  it  lies  beneath  the 
dura  mater.  This  method  seems  to  have  the  advantage 
over  the  method  of  Rose,  in  the  precision  with  which 
the  ganglion  can,  under  favorable  circumstances,  be  re- 
moved, and  in  the  absence  of  such  disagreeable,  and 
sometimes  unavoidable,  accidents  as  wounding  of  the 
parotid  gland  or  the  seventh  nerve. — Stewart. 

Impacted  Stone  in  the  Ureter.— If  the  calculus  is 
thoroughly  squeezed  between  the  thumb  and  fore-finger, 
the  wall  of  the  ureter  being  stretched  tightly  over  it,  a 
longitudinal  incision  will,  after  the  removal  of  the  stone, 
so  contract  that  in  many  cases  its  site  cannot  be  after- 
ward discovered,  except  by  a  very  careful  search.  The 
ureter  should  not  be  sutured. — Cottrell. 


Contagions  Diseases  — Weekly  Statement. — Report  of 
cases  and  deaths  from  contagious  diseases  reported  to  the 
Sanitary  Bureau,  Health  Department,  for  the  week  end- 
ing November  24,  1894. 


Tuberculosis 

Typhoid  fever 

Scarlet  fever 

Cerebrospinal  meningitis 

Measles 

Diphtheria 

Small-pox 


14a 

103 

14 

5 

88 

13 

0 

I 

47 

a 

167 

35 

7 

6 

Pathogenesis  and  Treatment  of  Influenza. — It  is  well 
known  how  popular  the  quinine  treatment  of  influenza 
was  when  that  maladie  d  la  mode  visited  our  shores.  So 
far  as  my  knowledge  goes  this  mode  of  treatment  was 
strictly  empirical,  no  laboratory  experiments  having 
been  made  on  its  action.  The  medical  world  will  there- 
fore be  glad  to  know  that  the  experiments  of  M.  M06S6 
have  confirmed  the  good  opinion  entertained  of  the  value 
of  this  drug  in  combating  "la  grippe."  Rabbits  were 
inoculated  with  the  blood  of  influenza  patients,  and  then 
quinine  was  injected  subcutaneously.  Four  out  of  six  of 
these  animals  remained  unaffected,  while  test  rabbits  un- 
protected by  the  drug  became  very  ill.  Again,  rabbits 
inoculated  with  pure  cultures  of  Pfeifler's  microbe  (fur- 
nished by  M.  Roux)  were  quite  capable  of  supporting 
this  inoculation,  provided  subcutaneous  injections  of 
quinine  had  been  previously  practised.  Of  three  un- 
protected rabbits,  two  were  killed  by  the  inoculation. 
Efforts  to  cultivate  (on  gelatine)  the  pathogenic  bacillus 
from  the  blood  of  an  influenza  patient  were  always  un- 
successful. In  one  instance  the  pneumococcus,  and  in 
another  the  staphylococcus  were  obtained.  The  blood 
of  animals  experimentally  infected  with  influenza  yielded 
the  specific  micro-organism  only  on  one  occasion.  This 
culture  was  endowed  with  but  feeble  vitality,  and  proved 
to  be  non-virulent.  M.  Mossfe  arrives  at  the  conclusion 
that  the  influenza  bacillus  is  found  only  exceptionally  in 
the  blood,  and  that  when  so  found  its  virulence  is  en- 
feebled. It  is,  moreover,  unable  to  live  in  an  organism 
in  which  the  drug  in  question  circulates,  viz.,  quinine. 
It  would  thus  appear  that  the  exhibition  of  quinine  as  a 
prophylactic  is  justified ;  that  it  should  be  prescribed  in 
large  doses  as  an  abortive  agent ;  and  that,  finally,  grave 
secondary  infections,  especially  if  due  to  the  pneumo- 
coccus, call  for  hypodermic  injections  of  quinine. — Paris 
Correspondent  of  The  Lancet. 

A  True  Story. — A  correspondent  sends  the  following, 
for  the  truth  of  which  he  vouches :  A  young  doctor  who 
began  his  practice  in  Texas,  west  of  Houston,  was  called 
to  a  confinement  case  in  which  he,  being  green  and  ner- 
vous, naturally  had  some  trouble,  the  patient  seeming 
unable  to  make  the  supreme  effort  for  final  expulsion. 
The  only  other  occupant  of  the  wretched  quarters  was  an 
old  crone  in  a  sun-bonnet  who  was  silently  but  steadily 
rocking  herself  near  the  foot  of  the  bed.  Finally  the  old 
woman  croaked  out,  "  Doc,  I  wouldn't  bother  any  longer 
with  that  woman,  I  believe  I'd  quill  her  and  have  done 
with  it."  The  medical  man  not  knowing  what  "  quill- 
ing "  meant  answered  that  he  did  not  quite  see  the  ne- 
cessity for  that  yet.  The  old  woman  repeated  this  sug- 
gestion several  times  until  finally  the  nervous,  exasperated 
man  turned  angrily  on  her  and  said,  "  Madam,  I'll  be 
d —  if  I  will  do  it.  If  you  want  to  quill  her  you  can  do 
so,  but  I  won't."  The  crone  took  from  the  wall  a  tur- 
key-wing and  drawing  a  feather  from  it  proceeded  to 
fashion  something  like  a  long  quill  tooth-pick  and,  filling 
this  with  snuff  from  her  own.  private  stock  leaned  over 
the  patient  and  as  the  next  pain  came  blew  the  snuff  into 
the  woman's  nostrils.     Quick  as  a  flash  the  woman  re- 


704 


MEDICAL   RECORD. 


[December  i,  1894 


sponded  with  a  giant  sneeze  and  the  child  was  born  with 
the  sneeze. .  "  Thar/9  said  the  old  woman,  radiantly,  "  I 
knowed  mighty  well  that  thar  bust  would  make  her  break 
her  holt."  And  it  did,  to  the  great  instruction  of  the 
attending  physician. 

The  Doctor  in  Fiction. — Another  bad  doctor— bad 
rather  through  circumstances  than  of  deliberate  intent 
— is  pictured  in  a  new  novel.  The  medicus  discovers 
a  specific  for  cancer  (he  is  an  Englishman,  we  hasten 
to  say,  and  not  a  resident  of  New  York)  and  cures  a 
charming  lady.  Unfortunately  she  is  soon  after  killed 
in  an  accident,  and  her  husband  refuses  to  permit  an  au- 
topsy. This  does  not  down  the  scientific  enthusiast, 
however,  for  he  goes  to  the  cemetery  after  dark  and  digs 
up  his  former  patient  But  the  husband  of  the  deceased, 
unfortunately  for  himself,  appears  upon  the  scene  and 
repeats  his  refusal  to  allow  the  autopsy  to  go  on. 
Science  stops  at  no  such  trifle  as  that,  and  the  unreason- 
able husband  is  killed  and  buried  in  his  wife's  grave,  the 
body  of  the  lady  being  taken  home  by  the  doctor  and 
dissected.  The  virtue  of  the  cancer  specific  is  trium- 
phantly demonstrated  in  her  body,  which  is  then  in- 
terred in  the  garden  of  the  intrepid  scientist.  Twenty 
years  now  roll  by  in  an  uneventful  way.  The  doctor 
prospers  and  his  beautiful  daughter  cuts  her  second  set  of 
teeth  and  reaches  womanhood.  Now  comes  the  son  of 
the  murdered  man  and  dissected  woman,  and  wants  to 
marry  the  daughter  of  the  doctor-villain.  The  latter  re- 
fuses, the  young  man  grows  angry,  makes  inquiries,  and 
discovers  the  crime.  The  wretched  doctor  becomes  con- 
science stricken  when  found  out,  and  dies.  Hie  young 
couple  marry  and  are  happy  ever  afterward. 

The  Value  of  Quarantine  against  Cholera  was  demon- 
strated pretty  clearly  last  summer  in  Germany.  In  Au- 
gust and  up  to  the  middle  of  September  it  looked  most 
decidedly  as  if  the  invasion  of  the  scourge,  which  threat- 
ened Germany  the  whole  length  of  its  frontier  toward 
Austria  and  Russia,  could  not  be  stayed.  Two  months 
ago  the  deaths  by  cholera  in  the  thirty-one  western  prov- 
inces of  Russia  taken  account  of  had  already  figured  up 
three  thousand  one  hundred,  with  more  than  double  that 
number  of  cases,  and  in  Galicia  and  Bukowina,  in  Aus- 
trian territory,  there  were  one  hundred  and  forty-six 
deaths  per  day  at  that  time.  But  the  state,  with  its 
severe  precautionary  measures — the  latter  going  so  far  as 
to  hermetically  close  the  Silesian  frontier  for  weeks — 
successfully  stayed  the  spread  of  the  disease  in  Germany. 
In  every  instance  where  cases  of  cholera  occurred,  or 
were  only  suspected  as  such,  the  sufferers  were  rigorously 
isolated.  More  thorough  and  comprehensive  methods, 
too,  were  adopted  to  prevent  travellers  afflicted  with  the 
disease  from  penetrating  into  the  interior  of  Germany 
than  have  ever  before  been  employed.  Quarantine  sta- 
tions were  established  at  every  point  where  the  danger  of 
imparting  the  disease  could  possibly  lurk.  The  result  of 
these  strict  quarantine  regulations  was  that  very  few  cases 
of  cholera  occurred  in  Germany,  and  most  of  those  were 
along  the  banks  of  infected  rivers,  the  source  of  infection 
of  the  water  being  in  another  country,  beyond  the  con- 
trol of  the  German  sanitary  authorities. 

"Thyroidism ; "  its  Relation  to  Exophthalmic  Goi- 
tre and  to  Hysteria. — The  Gazette  medicate  de  Paris 
for  October  20th  contains  a  report  of  a  recent  meeting 
of  the  Societk  medicate  des  Htyitaux,  at  which  M.  B6clere 
presented  a  woman,  thirty-one  years  of  age,  who  had  re- 
covered from  myxoedema  after  treatment  with  the  thyroid 
glands  of  sheep.  She  had  taken,  by  mistake,  at  the  be- 
ginning of  the  treatment,  three  ounces  of  the  gland  in 
eleven  days,  and  this  excessive  dose  had  given  rise  to 
symptoms  of  thyroid  intoxication.  English  authors, 
said  M.  Blclere,  have  described  these  symptoms  as 
tachycardia,  instability  of  the  pulse,  elevation  of  the 
temperature,  insomnia,  agitation,  polyuria,  glycosuria, 
albuminuria,  and  partial  paraplegia,  with  a  sensation  of 
heat  and  sweating.     M.  B&l&re  had  further  observed 


an  acceleration  of  respiration,  transitory  trembling  in 
the  arms,  exophthalmia,  and  a  staring  expression  of  the 
eyes.  Was  there  not,  he  asked,  a  striking  resemblance 
between  these  symptoms  and  those  of  exophthalmic 
goitre?  Was  not  their  appearance  in  exophthalmic 
goitre  allied,  perhaps,  to  a  supersecretion  of  the  thyroid 
gland?  Furthermore,  M.  Btelere  had  seen  that,  during 
the  course  of  his  treatment,  the  patient  had  had  distinctly 
hysterical  symptoms,  although  there  had  been  no  pre- 
vious neuropathic  symptoms,  such  as  aphasia,  mono- 
plegia, and  anaesthesia  of  the  right  arm.  Might  it  not 
be  concluded  from  this,  asked  M.  Beclere,  that  the 
thyroid  juice  excreted  in  excess  was  one  of  the  exciting 
agents  of  hysteria?  Furthermore,  he  said,  when 
thyroidism  appeared  in  an  hysterical  person,  it  roused 
hysteria  in  her,  as  other  intoxications  did.  M.  Bectere 
thought  that  the  syndrome  of  exophthalmic  goitre  de- 
noted supersecretion  by  the  thyroid  gland,  and  that  it 
acted  like  the  poisonings  that  proved  exciting  causes  of 
hysterical  outbreaks. 

Boiling  Abscess  Cavities. — The  Paris  correspondent 
of  The  Lancet  describes  a  method  employed  by  Jeannel, 
of  Toulouse,  in  the  treatment  of  localized  tuberculous 
lesions,  such  as  abscesses,  ulcers,  osseous,  and  joint 
troubles,  with  boiling  water  as  a  cauterizing  and  bac- 
tericidal agent.  The  method  is  applied  as  follows :  After 
having  freely  opened  the  seat  of  mischief  and  slit  up  any 
sinuses  that  may  exist,  he  excises  if  the  lesion  involves  a 
joint.  All  the  caseous  detritus  is  then  removed  by  cu- 
reting  and  thorough  sponging  of  the  parts,  all  bleeding 
being  arrested.  Then  salt  solution,  maintained  at  the 
boiling  point  in  a  recipient  (coffee-pot)  is  allowed  to  fill 
the  cavity  through  a  thick  rubber  tube.  The  cavity  is 
then  afterward  filled  and  emptied  until  a  sufficient  de- 
gree of  cauterization  is  effected.  It  will  be  seen  that  this 
modus  operandi  is  only  possible  in  the  case  of  a  funnel- 
shaped  cavity  whose  sides  can  be  raised  and  kept  apart  by 
tenacula  and  which  is  unprovided  with  counter-openings 
— a  condition  frequently  met  with  in  practice.  A  second 
and  preferable  procedure  is  also  employed  by  M.  Jean- 
neL  This  consists  in  first  filling  the  foyer  with  cold  or 
tepid  salt  solution,  and  then  raising  the  liquid  to  boiling 
point  by  introducing  into  it  the  blade  of  a  thermo  cautery 
at  a  red  heat  One  minute  suffices  to  fill  a  cavity  the 
size  of  a  pigeon's  egg  with  boiling  water  in  this  way.  The 
thermo-cautery  method  insures  a  constant  temperature  of 
ioo°  C,  but  it  is  applicable  only  in  the  case  of  an  ab- 
scess cavity  wide  enough  to  allow  the  introduction  of  the 
blade  without  touching  the  parietes.  General  anaesthesia 
is,  of  course,  necessary,  except  in  cases  of  small  abscesses, 
when  cocaine,  locally  applied,  is  adequate.  When  the 
patient  awakes  considerable  local  pain  is  complained  of, 
but  this  disappears  the  next  day.  The  parietes  of  the  cav- 
ity— or  the  abscess  membrane,  as  this  used  to  be  desig- 
nated— becomes  gray,  and  yields  a  copious  secretion  of 
serous  discharge,  which  renders  frequent  renewal  of 
dressings  a  necessity.  In  a  few  days  a  detergent  process 
is  evident,  granulations  develop,  and  cicatrization  rap- 
idly ensues.  Suppuration  is  rare ;  in  certain  cases,  in- 
deed, primary  union  is  obtained.  The  boiling  -  water 
method  is  superior  to  ordinary  cauterizing  procedures  in 
that  it  softens,  disintegrates,  and  sterilizes  the  tissues  to 
a  greater  depth. 

The  Corset  in  France. — A  petition  has  been  presented 
to  the  French  Chamber  of  Deputies  against  wearing  the 
corset  as  injurious  to  the  health  of  the  female  part  of  the 
population.  The  Chamber  solemnly  received  the  peti- 
tion, and  passed  it  in  committee.  Meantime  a  Paris 
journalist  has  been  gathering  the  opinions  of  notable 
women.  A  great  many  of  them  denounce  the  corset, 
declaring'it  to  be  unhealthy  and  ungraceful.  They  say 
it  turns  the  figures  into  one  commonplace  mould,  spoil- 
ing pretty  ones  and  doing  nothing  to  improve  the  ugly 
ones,  yet  most  of  the  fair  ones  interviewed,  who  expressed 
themselves  in  this  fashion,  wore  the  objectionable  gar- 
ment. 


Medical   Record 

A  Weekly  yournal  of  Medicine  and  Surgery 


Vol.  46,  No.  23. 
Whole  No.  1257. 


New  York,  December  8,  1894. 


$5.00  Per  Annum. 
Single  Copies,  zoc. 


REMINISCENCES  OF  DR.  J.  MARION  SIMS  IN 
PARIS. 

By  EDMOND   SOUCHON,  M.D., 
professor  OF  anatomy  and  clinical  surgery,  tulanb  university,   nbw 

ORLEANS,  LA. 

I  have  often  related  to  my  friends  the  manner  in  which 
I  happened  to  meet  our  surgical  genius,  Dr.  J.  Marion 
Sims,  in  Paris,  and  his  first  experiences  in  the  French 
capital.  They  all  were  much  interested  in  this  as  they 
were  in  everything  pertaining  to  this  great  and  good  man, 
and  they  repeatedly  asked  me  to  write  out  the  little  story 
for  the  benefit  of  the  profession  at  large.  I,  to-day,  com- 
ply with  this  wish,  regretting  very  deeply  for  all  con- 
cerned that  my  pen  is  not  more  gifted,  so  as  to  do  better 
justice  to  my  hero  and  to  my  readers. 

In  the  fall  of  i860  I  entered  the  old  Charity  Hospital 
on  the  rue  Jacob  as  a  benevolent  student,  in  the  service 
of  the  venerable  and  world-renowned  Professor  Velpeau. 
It  was  my  first  beginning  in  the  study  of  medicine.  Fa- 
cilities to  beginners  over  there  are  not  so  great  as  they 
are  here,  in  our  Southern  hospitals  especially,  and  in  or- 
der to  have  a  chance  to  come  in  close  contact  with  the 
professor  and  the  patients,  a  simple  voluntary  student  of 
the  service  had  to  be  over  zealous  with  all,  particularly 
the  all  powerful  internes  or  lords  of  the  service.  After 
several  months  of  trial  I  had  succeeded  in  ingratiating 
myself  with  them  all,  and  having  been  intrusted  with  the 
registration  book  of  the  in  coming  and  out-going  pa- 
tients, with  the  number  of  bed,  diagnosis,  and  dates,  I 
had  managed  to  be  on  as  fairly  good  terms  with  Profes- 
sor Velpeau  as  a  little  insignificant  nobody  like  myself 
could  be  with  such  a  magnate  as  was  the  great  Velpeau 
in  such  a  place  as  the  great  Paris  at  that  period.  This 
may  seem  rather  hard  to  American  students,  but  it  is  all 
true  none  the  less. 

Early  one  morning  in  the  latter  part  of  October,  1861, 
the  year  the  War  of  Secession  broke  out,  I  was  going  to 
the  hospital,  and,  as  I  was  about  to  enter  the  gate,  my 
attention  was  attracted  at  once  by  the  face  and  appear- 
ance of  a  man  who  was  coming  toward  the  gate  also,  but 
from  the  opposite  direction.  That  the  face  and  appear- 
ance struck  me  at  once  will  readily  be  believed  by  all 
those  who  have  had  the  happiness  of  knowing  our  great 
American  surgeon.  Its  characteristic  soft  and  sweet  ex- 
pression, together  with  his  deep-set,  bright  eyes  and 
prominent,  bushy  eyebrows,  the  half  smiling  expression 
of  his  mouth,  left  uncovered  by  the  absence  of  mustache 
or  beard,  made  a  much  deeper  impression  on  me  than  a 
glance  ordinarily  produces.  I  also  at  once  recognized 
that  he  was  a  foreigner,  and  no  Englishman  at  that,  but 
surely  and  unmistakably  an  American,  perhaps,  hastily 
thought  my  young  rebel  heart,  a  Southerner ;  he  must 
be  that,  I  thought  immediately  afterward,  because  he 
looked  so  gentle  and  good,  and  yet,  withal,  so  firm  and 
self  reliant.  All  this  took  but  a  few  seconds,  and  I  con- 
tinued my  course  toward  the  ward  to  which  I  was  as- 
signed, walking  through  the  yards  with  another  student 
and  the  stranger  coming  up  behind.  When  I  reached 
the  door  of  my  ward  I  went  through  and  closed  it ;  it 
was  soon  opened  again  and  closed ;  turning  around  I 
noticed  my  •"  American.1 "  The  doctor  told  me  later 
that  at  the  foot  of  the  stairs  the  other  student  went  in 


another  direction  than  I,  and  he  was  perplexed  for  a 
moment  as  to  which  one  he  would  follow ;  after  a  little 
hesitation  he  said  to  himself:  "  Well,  I  think  I  will  stick 
to  the  little  one."    The  little  one  was  myself. 

I  walked  to  the  bed  of  the  patient  who  took  care  of 
the  white  aprons  the  students  wear  over  there,  to  protect 
their  clothes,  and,  as  I  was  putting  it  on  the  stranger 
came  up  to  me,  and  after  a  most  suave  bow,  said  in  a 
very  slow  and  deliberate  manner,  that  the  Frenchman  he 
thought  he  was  addressing  might  have  some  chance  of 
understanding  :  "  Will— Professor — Velpeau — be — here 
— to  day  ?  "  I  burst  out  laughing  and  answered  him  in 
fluent  English :  "  No,  sir,  Professor  Velpeau  is  absent 
on  his  vacation  and  will  not  return  before  two  weeks." 
The  beautiful  face  brightened  up  at  the  sound  of  the 
English  language  where  and  when  he  so  little  expected 
it  "  Where  are  you  from,"  said  he,  "  that  you  speak 
English ?  "  "  I  am  from  the  South,  from  New  Orleans,' ' 
said  I,  thinking  that  that  would  cool  his  enthusiasm  if  he 
was  a  Yankee.  But  far  from  it,  he  grasped  my  hand  and 
pressed  it  so  as  to  crush  it.  "  Why,"  said  he,  "I  also 
am  a  Southerner ;  I  lived  a  long  time  in  Montgomery, 
Ala."  That  made  us  friends  at  once.  I  showed  the 
doctor  around  the  hospital  and  finally  asked  him  what 
he  had  come  over  here  for. 

"  Well,"  said  he,  "  I  am  Dr.  Marion  Sims,  now  living 
in  New  York,  who  has  invented  a  method  of  operating 
for  vesico  vaginal  fistula  with  almost  invariable  success." 
He  looked  at  me  to  see  if  the  name  had  made  any  im- 
pression on  me,  but  it  fell  flat ;  we  had  never  heard  of 
Dr.  Marion  Sims  in  Paris.  Furthermore,  we  all  knew 
that  nobody  in  the  world  knew  anything  about  vesico- 
vaginal fistula  except  Professor  Jobert  de  Lamballe,  of 
the  H6tel  Dieu,  and,  even  under  him,  vesico- vaginal  fis 
tula  was  cured  only  exceptionally,  even  when  using  his 
precede*  de  glissement  (sliding  process),  and  the  idea  of 
this  new  man  coming  to  Paris  to  teach  French  surgeons 
how  to  cure  vesico-vaginal  fistula  almost  infallibly,  some- 
what shook  my  faith  in  my  new  friend. 

He  said  he  had  a  letter  for  Professor  Velpeau  from  Dr. 
Valentine  Mott,  of  New  York ;  that  he  was  anxious  to 
see  the  professor  to  get  a  case  to  operate  on  before  him 
and  thus  to  demonstrate  his  method.  "  Well,"  I  said, 
"  the  professor  will  be  here  in  some  fifteen  days,"  soon 
enough  for  your  good,  I  thought  to  myself. 

During  that  time  the  doctor  was  living  in  a  little 
boarding-house  in  rue  de  T University,  close  to  the  hos- 
pital. He  had  invited  me  to  dinner  upon  our  very  first 
meeting,  and  I  went  there  once  or  twice  to  give  him  all 
the  points  about  those  men  he  was  most  likely  to  meet. 
He  was  all  the  time  sanguinely  confident  and  looked  so 
sweet,  so  modest,  so  magnetic,  that  I  began  to  feel  a 
very  strong  drawing  toward  him,  and  by  the  time  Vel- 
peau was  to  return  I  was  wound  up  to  a  high  pitch  and 
as  eager  as  my  friend  that  he  should  have  a  case  soon. 

Finally  Professor  Velpeau  arrived,  and  I  sent  word  to 
Dr.  Sims  immediately ;  he  soon  came  to  present  his  let- 
ter, which  Velpeau  read  at  once  and  fluently,  but  when 
it  came  to  speaking  to  Dr.  Sims  he  was  at  a  loss  to  ex- 
press himself  and  looked  around  for  me.  It  was  always 
the  case  when  prominent  English  visitors  came  to  the 
hospital.  Although  the  Englishmen  read  and  wrote 
French  as  well  as  the  Frenchmen  read  and  wrote  Eng- 
lish, a  good  deal  better  than  I  could  then,  yet  when  it 
came  to  talking  they  had  the  greatest  difficulty  in  under- 
stnading  each  other,  and  I  was  always  hunted  up  to  help 


706 


MEDICAL   RECORD. 


[December  8,  1894 


them  along.  At  that  time  Velpeau  was  nearing  the  end 
of  a  most  hard-worked  career,  and,  although  age  and  suc- 
cess had  softened  him,  yet  he  still  bore  the  effects  of  his 
lowly,  rough,  peasant  birth,  and  of  his  hard  earned  vic- 
tory. At  times  the  stiff  haughtiness  of  the  former  years 
of  struggle  came  over  him.  It  did  so  to  some  extent 
at  that  time,  and  he  was  not  to  Sims  exactly,  what  he 
should  have  been,  as  I  thought,  and  his  coldness  to  him 
made  my  heart  ache  somewhat,  as  I  took  that  to  be  of 
ill  omen.  The  truth  was  that  the  name  American  at 
that  time  in  Paris  always  evoked  the  name  of  Barnum,  and 
the  fact  that  a  comparatively  young  surgeon  posed  as  a 
successful  operator  on  vesico  vaginal  fistula,  when  scarcely 
anyone,  not  even  Jobert  de  Lamballe,  ever  succeeded  in 
Paris,  had  rather  prejudiced  Velpeau  against  Sims. 

After  a  few,  very  few  words,  Velpeau  said  to  me,  "  Eh 
bien,  que  veut-il?"  "Well,  what  does  he  want?"  I 
translated  the  sentence  to  Sims,  who  at  once  modestly 
but  firmly  answered,  "  I  want  a  case  to  demonstrate  my 
operation,  if  the  professor  will  be  kind  enough  to  pro- 
cure one  for  me."  "  All  right,"  said  Velpeau,  "  I  will 
get  him  one,"  in  a  way  that  showed  he  had  but  little 
confidence  in  the  final  result.  Then  he  turned  around 
without  a  hand  shake  or  a  word  more  to  Sims  and  went 
on  with  his  visit.  I  felt  quite  hurt,  but  could  say,  and 
said,  nothing.  Velpeau  was  the  idol  of  all  young  aspir- 
ing surgeons,  the  demi  god  of  the  day.  Nllaton  was 
just  looming  up  then,  and  had  not  as  yet  had  his  famous 
Garibaldi  case  which  gave  him  world-wide  fame. 

For  several  days  no  case  turned  up.  Sims  was  there 
every  morning.  I  would  introduce  him  to  the  younger 
surgeons  who  always  swarmed  around  the  old  master, 
that  he  might  not  forget  them.  To  every  one  who  in- 
quired about  his  object  he  said,  "  I  want  a  case,"  and  I 
myself  would  then  also  say,  "  He  wants  a  case." 

At  last  the  case  came  !  And,  just  as  luck  would  have 
it,  a  case  of  moderate  difficulty.  "  Thank  the  Lord," 
said  I,  with  my  American  pride  roused  now  to  a  high 
pitch  for  fear  Sims  should  fail !  When  he  told  me  he 
was  sure  to  succeed  it  was  a  great  relief. 

By  this  time  the  whole  of  the  old  Quartier  Latin  had 
heard  of  the  news,  which  had  rapidly  spread  from  hos- 
pital to  hospital.  On  the  day  of  the  operation  the 
famous  little  operating  theatre  in  the  old  Charity  Hos- 
pital was  overcrowded  with  students,  and  the  arena  below 
crowded  also  with  the  most  distinguished  professors  of 
surgery  of  the  French  capital ;  Velpeau,  N61aton,  Ri- 
cord,  Malgaigne,  etc.,  all  but  Jobert  de  Lamballe,  who 
would  not  come. 

Before  beginning  the  operation  Dr.  Sims  proceeded 
to  demonstrate  it  graphically,  by  using  a  piece  of  thick 
and  hard  cotton  batting,  through  which  he  cut  a  hole 
representing  the  fistula,  then  he  pared  the  edges  slant- 
ingly in  one  strip,  next  he  passed  the  silk  threads  and 
the  wires,  etc.  The  doctor  called  on  me  to  translate  as  he 
spoke.  I  was  not  expecting  this,  and  before  such  an 
audience,  and  I  felt  shy  and  scared,  but  he  so  insisted 
with  his  sweet  eyes  and  smile  that  I  got  up,  trembling 
all  over,  and  with  a  quivering  voice  would  repeat  in 
French  each  sentence  as  he  uttered  it  in  English.  Grad- 
ually, however,  I  found  that  it  was  not  so  very  hard,  I 
became  emboldened  and  went  through  the  whole  pro- 
cedure with  comparative  comfort  After  the  demonstra- 
tion Dr.  Sims  proceeded  with  the  operation,  which  he 
performed  with  the  skill  and  grace  which  characterized  , 
him.  It  was  done  in  comparatively  no  time,  closely 
watched  and  followed  all  the  time  by  the  French  pro- 
fessors. When  the  doctor  finally  said  it  was  done,  a 
salvo  of  applause  broke  out  from  the  benches ;  the  pro- 
fessors rendered  justice  to  the  manner  in  which  the  oper- 
ation had  been  performed,  while  reserving  themselves 
mentally  until  the  day  when  the  sutures  would  be  re- 
moved. 

Dr.  Sims  attended  to  that  case  himself  in  the  ward,  and 
during  the  following  days  felt  all  along  confident  that  it 
would  be  a  success ;  and  a  success,  a  tremendous  success, 
it  turned  out  to  be. 


On  the  ninth  day  the  same  amphitheatre  was  again 
packed  to  witness  the  removal  of  the  sutures ;  the  case 
was  pronounced  cured,  and  this  was  confirmed  by  the 
French  surgeons,  who  congratulated  Dr.  Sims. 

The  enthusiasm  of  the  French  students  far  exceeded 
their  former  outburst,  and,  since  they  could  not  very  well 
carry  Dr.  Sims  on  their  shoulders  in  triumph  they  took 
hold  of  me  in  his  place,  and  the  resident  students  carried 
me  to  their  mess  room  to  breakfast  with  them ;  a  great 
and  unprecedented  honor  in  those  days,  for  I  was  but  a 
vulgar,  simple,  insignificant  first- year  student !  I  did 
more  talking  than  eating,  and  the  result  of  the  excite- 
ment of  mind  and  of  heart  was  a  very  fine  first-class 
headache  that  sent  me  to  bed  and  lasted  twenty- four 
hours. 

However,  some  seemed  to  think  that  it  might  have 
been  a  chance  cure.  But  these  were  soon  to  be  set  right. 
Immediately  after  the  success  of  the  first  case,  Dr. 
Sims  started  on  the  warpath  for  another,  which  was  soon 
procured  for  him  by  a  physician  in  private  practice. 
But  this  case  came  very  near  being  a  Waterloo.  It  was 
taken  to  a  private  place,  the  Hdtel  Voltaire,  on  the  Quai 
Voltaire.  The  patient  was  a  short,  fat,  stumpy  little 
woman,  and  very  obstinate.  She,  all  of  a  sudden,  ab- 
solutely refused  to  be  operated  upon  unless  she  was  given 
chloroform  and  put  fast  asleep.  This  much  annoyed  Dr. 
Sims,  because  in  those  days  it  was  hot  thought  quite  safe 
to  place  a  patient  on  the  left  side,  the  side  of  the  heart, 
to  give  chloroform  to  the  extent  of  keeping  her  perfectly 
still,  since  nothing  could  be  done  otherwise,  and  for  such 
a  long  period  as  an  hour  or  two.  We-  were  far  then 
from  the  ideas  of  the  present  day.  There  was  no  over- 
coming her  stubbornness  and  her  will  had  to  be  done. 
It  all  went  well  for  a  while,  a  good  while,  but,  all  at 
once,  the  breathing  became  stertorous,  the  face  blue,  and 
the  pulse  flagged.  The  operation  had  to  be  suspended 
until  she  recovered.  The  operation  was  then  resumed, 
but  soon  had  to  be  stopped  again,  for  the  same  reasons. 
Things  were  looking  a  little  blue  aiso,  and  as  though  the 
operator  would  not  be  able  to  complete  the  operation. 
But  it  was  not  to  be  so ;  it  was  to  be  completed,  but  it 
took  Sims's  whole  nerve  and  skill  to  bring  it  to  comple- 
tion. During  all  that  time  the  distinguished  guests  pres- 
ent said  and  did  nothing,  leaving  Sims  and  his  assist- 
ants to  do  all  the  fighting  and  get  all  the  odium  in  case 
of  failure,  but  all  the  credit  in  case  of  success.  At  one 
time  I  spoke  to  Velpeau  to  ask  him  what  he  thought  of 
the  condition  of  the  patient,  he  shook  his  old  silvery 
head  and  I  imparted  to  Sims  what  I  took  that  to  mean, 
that  he  might  make  the  best  of  it.  Finally  the  patient 
rallied  and  was  put  to  bed.  At  the  end  of  the  usual 
time  this  case  was  pronounced  a  success. 

A  couple  of  weeks  later  Professor  Jarjavay  secured 
another  case,  upon  which  Dr.  Sims  operated  at  the  H6- 
pital  St.  Antoine.  At  the  time  of  the  removal  of  the 
sutures,  a  week  or  so  later,  Dr.  Sims  was  not  pleased 
with  the  appearance  of  the  parts,  and  expressed  his  ap- 
prehension of  some  ulceration  setting  in  and  destroying 
the  work  done  to  a  greater  or  lesser  extent.  Professor 
Jarjavay  said  that  even  if  there  was  a  fistulette  (a  small 
fistula)  left  it  would  not  matter  much.  Although  he 
seemed  to  say  this  in  a  good  spirit,  yet  it  occurred  to 
some  of  us  that  some  people  would  be  glad  to  hail  this  as 
a  failure  of  the  so-called  infallible  American  method. 
But  no  fistulette  occurred,  and  that  case  was  also  placed 
on  record  as  a  complete  success. 

From  that  time  on  cases  were  quite  frequent,  and 
naturally  so,  since  hardly  any  were  ever  cured  before; 
the  stock  of  fistulae  was  very  great,  and  cases  were  not 
wanting.  It  was  specially  in  private  practice  that  they 
appeared  to  be  abundant,  and  Dr.  Sims  scored  success 
after  success  with  the  greatest  ease.  However,  he  again 
struck  another  hard  case,  even  a  worse  one  than  the  one 
at  the  Hdtel  Voltaire ;  it  was  the  famous  case  of  the 
"  countess  "  out  in  the  country,  in  a  chateau,  a  patient 
of  Professor  N6laton.  She  also  insisted  upon  taking 
chloroform,   and  when  the  operation  was  about  half 


December  8,  1894] 


MEDICAL   RECORD. 


707 


through  she  showed  all  at  once  most  alarming  symptoms. 
It  was  then  that  Nelaton  uttered  the  legendary,  cry 
"  Head  down/1  which  everyone  conversant  with  these 
matters  must  remember.  After  much  and  still  more 
anxiety  the  poor  illustrious  patient  was  revived  and  the 
operation  was  safely  completed.  It  turned  out  also  a 
complete  success. 

Cases  followed  one  another  wherever  the  doctor  went; 
in  Paris,  London,  Germany,  etc.,  he  was  kept  busy  with 
fistulae  and  other  female  cases.  It  was  he  who  then 
sowed  the  first  seeds  of  true  gynecological  science  and 
art  throughout  Europe,  the  science  so  eminently  and 
thoroughly  American. 

Wherever  Sims  went  he  coined  money,  although  he 
incessantly,  willingly,  and  kindly  did  much  charity 
work.  He  is  the  only  man  I  ever  knew  or  heard  of 
who  had  such  a  vogue  wherever  he  went.  No  French, 
English,  or  German  surgeon  could  go  to  the  capital  of 
another  country  and  have  such  calls  and  such  success,  no 
matter  how  great  he  was  considered  at  home. 

Dr.  Sims  made  a  host  of  friends  among  the  surgeons 
of  all  countries,  and  it  could  not  be  otherwise,  with  his 
gentle,  kind,  unpretentious  ways.  However,  some  of  his 
easy- going  American  professional  ways  did  not  suit  all 
of  them,  and  some  became  a  trifle  cold  and  reserved 
toward  him.  Perhaps  they  were  glad  to  find  some  flaw, 
ever  so  trifling,  in  such  a  beautiful  gem.  Surely,  if  they 
could  have  read  thoroughly  through  his  pure  and  simple 
heart  and  mind,  they  would  have  seen  how  unconven- 
tional were  his  ways,  and  how  little  he  thought  he  was 
giving  any  offence  or  had  any  idea  he  was  doing  wrong. 

Some  time  after  all  this  the  doctor  brought  his  family 
over  to  live  in  Paris.  From  that  time  on  the  doctor's 
history  is  known  to  all  Americans  proud  of  the  surgical 
genius  born  in  our  great  land.  One  day  he  said  in  a 
burst  of  kindness:  "How  fortunate  it  was  for  me  to 
have  met  you  that  morning  I  went  to  the  old  Charity. 
I  was  so  thoroughly  discouraged  that  I  had  about  made 
up  my  mind  to  go  back  home  I  "  Of  course  it  was  his 
goodness  which  made  him  express  it  that  way  and  with 
such  force,  for  he  surely  would  have  met  some  one  else 
to  play  the  idle  I  was  so  fortunate  and  so  happy  to  per- 
form. He  spent  his  money  lavishly :  all  the  needy 
Southerners  and  Northerners  then  in  Paris  were  recipients 
of  his  generosity. 

One  day  in  his  house,  in  the  rue  de  Balzac,  we  were 
alone  in  his  studio  when  he  all  at  once  asked  me : 
"  How  are  you  getting  along  here,  anyhow?  "  "  Well," 
said  I,  "  I  am  starving  as  slowly  as  I  can.  All  resources 
from  home  have  ceased  since  the  war  has  begun,  and  but 
for  a  little  position  of  $20  a  month,  which  Professor 
Velpeau's  influence  secured  for  me,  I  would  have  suc- 
cumbed to  hunger  and  cold  by  this  time.1'  He  replied, 
"  Anything  you  need  I  will  be  glad  to  give  you ;  I  am 
making  plenty  of  money  now.'1  I  thanked  him  very 
much,  but  gratefully  declined  any  assistance,  because,  if  I 
borrowed,  I  intended  to  return  it  some  day,  and  just 
then  it  was  rather  problematical  if  I  should  last  to  re- 
turn and  pay  any  indebtedness.  However,  he  would 
not  be  contented  unless  I  promised  him  to  come  to  him 
if  ever  I  needed  any  help.  All  this  was  said  and  done 
with  a  simplicity  which  was  overwhelming,  especially  to 
one  accustomed  by  recent  education  and  association  to 
the  good  but  exuberant  French  people. 

The  following  year,  however,  was  the  time  for  me  to 
prepare  my  competitive  examination  for  the  "  Interne- 
ship,"  i.e.,  to  be  admitted  a  resident  student  in  the  Paris 
Hospital.  That  examination  is,  over  there,  the  pons 
asinorum.  It  is  held  as  the  proof  that  there  is  some- 
thing in  the  man,  and  in  fact  very  few  are  those  who 
attain  any  eminence  in  Paris  who  have  not  gone  through 
that  ordeal.  It  is  really  a  very  hard  competitive  exam- 
ination, and  it  requires  all  the  time  of  any  student  from 
early  morning  till  late  in  the  night  to  succeed.  Very  few 
succeeded  the  first  time,  usually  it  required  two  trials  at 
one  year's  interval.  I  had  to  do  it  in  one  year  or  quit 
the  study  ot  medicine.     I  needed,  therefore,  every  mo- 


ment of  the  days  of  the  year  of  preparation,  and  there- 
fore it  was  necessary  for  me  to  renounce  my  little  situa- 
tion. Now  if  I  could  not  get  Dr.  Sims  to  assist  me  as 
he  once  proposed  to  do,  what  would  become  of  poor 
me !  Of  course  he  had  offered  his  assistance,  but  that 
was  nearly  two  years  ago,  and  perhaps  he  had  changed 
his  mind  since,  or  could  he  still  afford  to  do  it,  now  that 
he  had  a  large  family  to  provide  for  in  a  gay  and  expen- 
sive capital  ? 

I  called  at  his  house,  then  in  the  rue  de  Suresnes,  so 
familiar  to  so  many  Americans,  but  he  was  out  of  town 
and  would  not  be  back  for  some  time.  When  ?  No  one 
could  say  positively :  he  was  in  London,  they  said,  and 
very  busy  there !  Yet  time  was  flying  and  I  had  to  take 
a  decision,  and  no  Dr.  Sims  I  But  at  last  he  returned. 
I  called  in  the  middle  of  the  day,  thinking  I  had  then  a 
better  chance  of  meeting  him  done.  He  was  in  fact 
alone,  taking  his  lunch ;  as  usual,  he  greeted  me  with  his 
kind  look,  sweet  smile,  and  hearty  shake  hand.  He  in- 
vited me  to  lunch  with  him  and  I  sat  down  to  the  table ; 
but  I  could  not  swallow  a  morsel,  my  mouth  was  dry, 
my  throat  contracted,  and  my  heart  beating  very  fast. 
After  a  little  trivial  talk  I  summoned  up  all  my  courage 
and  said  to  him:  "Doctor,  you  once  told  me  that  if 
ever  I  was  in  need  to  come  to  you,  and  that  you  would 
help  me  along.  Well,  I  am  now  in  the  greatest  distress 
and  upon  you  depends  my  whole  future."  "  Why,  what 
has  happened,  Souchon,"  said  he,  with  concern  in  his 
dear  face.  ' '  Well,  sir, ' '  said  I,  "  I  have  to  give  up  my  lit- 
tle situation  in  order  to  prepare  for  my  examination  for  the 
residenceship  of  the  hospital,  and  unless  you  give  me  to- 
day the  assistance  you  offered  two  years  ago,  it  will  be 
impossible  for  me  to  do  so  and  I  must  give  up  the  study 
of  medicine."  "  Oh,  no,"  said  he,  "  don't  do  that,  I 
will  help  you  certainly  ;  how  much  do  you  want?  "  It 
was  said  with  such  natural  kindness  and  simplicity  that 
my  heart  sank  within  me  :  I  felt  as  if  a  thousand  pounds 
had  been  removed  from  my  breast.  "  Thirty  dollars  per 
month  will  suffice,"  said  I.  "  What,"  said  he,  "  a  dol- 
lar only  a  day.  Oh  no,  take  two."  I  thanked  him 
very  gratefully  but  consented  to  accept  only  one  dollar 
and  a  half  a  day,  remarking  that  I  might  never  be  able 
to  return  that  little  even.  "All  right,"  said  he,  "I 
will  take  my  chances  on  that."  He  retired  to  his 
library  and  soon  returned  with  a  check  for  the  first 
month  in  advance,  and  also  for  several  hundred  francs 
to  buy  some  little  furniture  and  clothing  which  he  said  I 
very  likely  needed.  I  should  think  I  did  need  them  ! 
From  that  time  the  check  came  every  month,  no  matter 
where  he  was — in  France,  England,  Geimany,  Russia, 
Italy,  or  America.  He  never  forgot  it  once,  and  when 
it  happened,  very  rarely,  that  he  was  a  few  days  behind, 
he  would  write  a  few  words  of  apology. 

When  at  last  I  was  so  fortunate  as  to  succeed  in  my 
examination  and  I  telegraphed  to  him  in  London,  he  im- 
mediately wired  back  that  the  news  had  sent  a  thrill  of 
joy  through  the  whole  family;  this  in 'its  turn  sent  a 
thrill  of  joy  through  me  also. 

The  doctor's  reputation  had  acquired  such  proportions 
that  the  French  Government  presented  him  with  the  dec- 
oration of  Knight  of  the  Legion  of  Honor,  the  highest  am- 
bition of  all  Frenchmen .  It  so  happened  that  I  was  present 
in  the  forenoon  of  the  day  when  the  mounted  dragoon  from 
the  State  office  brought  the  large,  many  sealed  envelope 
containing  the  brevet.  It  was  the  cause  of  great  rejoic- 
ing in  the  family  and  among  his  friends.  He  himself  did 
not  believe  very  much  in  such  trinkets,  but  he  was  happy 
because  all  around  him  were  happy.  I  was  despatched  to 
go  down  to  the  Palais  Royal  to  buy  the  ribbon  worn  in 
the  button-bole.  I  chose  it  as  nice  and  neat  as  I 
thought  he  would  like,  and  brought  it  home,  when  I  had 
the  happiness  of  being  asked  to  place  it  myself  in  the 
button-hole  on  the  left  side,  over  his  noble  and  good 
heart. 

Another  notable  instance  of  his  great  kindness  is,  when 
upon  a  visit  through  a  London  hospital,  the  physician  in 
charge  told  him  that  he  had  in  his  ward  a  Confederate 


708 


MEDICAL  RECORD. 


[December  8,   1894 


surgeon  who,  heart-broken,  had  left  the  down-trodden 
South  to  seek  rest  somewhere.  He  had  worked  his 
passage  through  to  London  by  acting  as  steward  on  board 
ship,  but  when  he  reached  London  his  little  money,  his 
feeble  health,  his  crushed  heart,  all  had  given  way  and  he 
had  stranded  in  a  London  hospital.  Sims  at  once  went 
to  him,  recognized  a  friend  from  the  same  grand  State  of 
Alabama,  cheered  him,  saw  him  well,  and  brought  him  to 
his  own  house,  and  assisted  him  back  home.  All  this  I 
was  told  by  the  man  himself,  who,  upon  his  return  home 
became  a  most  noted  teacher  of  medicine  in  one  of  our 
famed  Southern  medical  colleges. 

I  remember  Dr.  Sims  in  only  one  case  of  sickness. 
He  was  alone  in  the  Grand  Hotel  in  Paris,  without  any 
of  his  family  with  him,  when  he  sent  me  word  to  come 
and  see  him.  He  had  been  suffering  for  some  time  from 
a  repetition  of  an  attack  of  pain  and  swelling  in  the  right 
iliac  region,  and  seemed  concerned  about  his  condition. 
Surely  if  it  had  been  some  years  later  he  would  have 
been  appendicitized.  But,  thank  God,  he  got  well  with- 
out the  knife. 

Alas !  but  that  no  human  happiness  is  ever  without  a  dark 
cloud  !  It  was  my  distressing  lot  to  be  present  at  his 
house  when  the  sad  news  came  of  the  death  of  his  eldest 
son,  Granville.  It  was  but  a  short  message,  quickly  read, 
followed  by  a  cry  and  a  sob :  "  Oh  God !  Granville  is 
dead !  "  Granville  had  torn  himself  away  from  Paris  and 
his  family  and  had  gone  to  Havana  to  find  a  chance  of 
running  the  blockade.  He  was  there  waiting  for  his 
opportunity,  when  he  was  attacked  with  yellow  fever 
and  succumbed  very  quickly. 

Much  more  could  be  said  of  this  great  and  good  man 
during  his  stay  in  Paris,  but  it  would  require  some  one 
abler  than  I  am  to  do  justice  to  such  a  subject.  He  was 
surely  one  of  the  most  magnetic  men  I  ever  met,  and  he 
made  such  a  deep  impression  on  me  by  his  genius,  en- 
ergy, his  courage,  his  goodness,  his  kindness,  and  his  gen- 
tleness, that  for  many  years  ol  the  early  part  of  my  life  he 
was  the  model  and  the  guiding-star  I  strove  to  follow. 


CHOLELITHIASIS. 
By  J.  H.  HOELSCHER,  M.D., 

CHICAGO,   ILL. 

ATTENDING  PHYSICIAN  TO  TMC  ALKXIAN  BROTHKBS  HOSPITAL,  AND  MBMBEK  OF 
THK  CHICAGO   MEDICAL  SOCIETY. 

The  history  of  gall-stones  is  imperfect  Reference  to 
an  old  Latin  work,  known  as  "  Lazari  Riverri  Praxis 
Medica,"  of  the  year  1653,  gives  an  account  of  calculi 
which  were  found  in  the  faeces  and  connected  with  symp- 
toms of  hepatic  disease.  Cullen's  "  Practice  of  Medicine," 
of  1792,  contains  considerable  on  the  subject,  and  Wat- 
son's "  Practice  of  Physics,"  of  1 798,  also  contains  state- 
ments which  compare  favorably  with  some  of  our  present 
literature.  This  book  contains  the  interesting  statement 
that  animals  when  stalled  all  winter  become  affected  with 
gall  stones,  from  which  they  recover  when  fed  with  green 
grass;  this  fact  led  an  able  physician  to  the  belief  that 
grass  would  cure  gall-stones  and  jaundice. 

It  is  consistent  with  this  paper  to  give  a  synopsis  of  the 
recent  chemical  analysis  of  bile  and  whatever  pertains 
thereto.  Secreted  and  excreted  by  the  liver  cells,  it  flows 
from  the  hepatic  duct  as  a  non  viscous  liquid,  and  when 
it  comes  in  contact  with  the  ducts  and  mucous  membrane 
of  the  gall-bladder,  an  admixture  takes  place  with  a 
secretion  from  the  ducts  and  gall-bladder  which  gives  it  a 
certain  viscidity.  This  secretion  contains  a  substance 
known  as  mucoid  nucleo  albumin  of  bile. 

Perfectly  fresh  human  bile  has  a  bright  yellow  and 
slightly  reddish  color,  a  bittersweet  taste,  is  generally 
odorless,  of  alkaline  reaction,  and  a  specific  gravity  of 
from  1.005  to  1.008.  Chemically  it  consists  of:  1,  So- 
dium salts  in  combination  with  bile  acids;  2,  coloring 
substances  known  as  bilirubin  and  biliverdin ;  3,  mucoid 
nucleo  albumin.  Other  constituents  are  cholesterine, 
neutral  fats,  soaps,  lecithin,  mineral  matters,  traces  of 


iron  and  gases,  of  which  CO,  is  the  most  abundant. 
The  bile  acids  and  coloring  matters  are  secreted  by  the 
liver  cells.  Cholesterine  is  excreted  by  the  liver,  and 
exists  in  the  bile  in  a  proportion  of  from  ^  to  3  per 
1,000.  It  is  held  in  solution  by  a  combination  of  bile 
salts  and  acids.  Among  the  mineral  constituents  sodium 
salts  are  most  abundant,  and  especially  sodium  chloride  in 
the  proportion  of  5  to  1,000. 

The  quantity  of  bile  secreted  in  twenty-four  hours 
varies  from  a  pint  to  a  pint  and  a  half;  diminished  dur- 
ing abstinence  it  increases  immediately  after  meals, 
which  increase  is  maintained  about  one  hour.  From 
three  to  four  hours  after  meals  it  again  increases. 

This  brings  us  to  the  consideration  of  the  chemical 
composition,  physical  characters,  and  formation  of  gall- 
stones. They  vary  in  size  from  a  seed-like  concretion  to 
stones  as  large  and  larger  than  nutmegs ;  they  may  be 
irregularly  rounded,  smooth,  faceted,  polyhedral,  and 
very  rough  and  irregular.  They  vary  in  color  from  a 
light  yellow  to  dark  brown  or  black.  A  cross-section 
reveals  either  a  series  of  layers,  or  a  homogeneous  structure 
and  a  nucleus.  The  layers  consist  of  cholesterine;  the 
nucleus  may  consist  of  biliary  pigments  combined  with 
calcium  compounds,  mucus,  shrivelled  epithelial  cells, 
and  sometimes  foreign  bodies ;  thus  a  case  is  on  record 
where  an  ascaris  lumbricoides  formed  a  nucleus ;  Naunyn 
reports  a  case  where  a  needle  formed  a  nucleus,  and  cases 
of  gall-stones  in  animals  are  on  record  where  the  disto- 
ma  hepaticum  formed  the  nucleus. 

Chemically,  gall-stones  consist  of:  1,  Pure  cholester- 
ine; 2,  cholesterine  and  bilirubin-calcium ;  3,  calcium 
almost  entirely ;  4,  bilirubin  thirty  per  cent,  and  cal- 
cium ;  5,  a  combination  of  all  the  ingredients. 

This  brings  us  to  the  study  of  the  theories  that  have 
been  advanced  in  explanation  of  gall-stone  formation,  and 
I  shall  adopt  the  following  classification :  1,  Causes  lo- 
cated in  the  common  duct ;  2,  those  located  in  the  gall- 
bladder; 3,  those  located  in  the  bile;  4,  those  located 
in  the  liver. 

The  first  class  implies  obstruction  of  the  common  duct 
and  retention  of  bile ;  this  latter  condition  has  been 
cited  as  a  cause.  That  this  is  inconsistent  can  be  under- 
stood when  we  consider :  1,  That  the  lymphatics  absorb 
the  biliary  constituents ;  2,  chemical  analysis  of  the  fluid 
in  a  distended  gall-bladder  shows  an  absence  of  biliary 
constituents ;  3,  absence  of  bile  ingredients  precludes 
gall-stone  formations;  4,  practical  observations  have 
demonstrated  the  absence  of  gall  stones  in  hydrops  of  the 
gall  bladder,  where  the  duct  is  obstructed  by  tumors,  etc 
Gall  stones  may  cause  retention  and  are  to  be  regarded 
as  a  cause.  Under  the  second  class,  of  causes  located  in 
the  gall- bladder,  we  have  the  presence  of  foreign  bodies, 
such  as  ascaris  lumbricoides,  needles,  distoma  hepaticum, 
casts  of  intrahepatic  ducts,  and  epithelial  debris. 

Naunyn  has  advanced  the  theory  that  gall-stone  forma- 
tion is  due  to  the  entrance  into  the  gall-bladder  of  the 
bacillus  communis  coli,  which  in  connection  with  a  re- 
tarded bile- flow  causes  a  calculus  forming  catarrh ;  a  con- 
dition wherein  the  mucous  membrane  of  the  gall-bladder 
secretes  calcium  carbonate.  This  theory  is  rather  nulli- 
fied by  the  fact  that  ligation  of  the  common  duct,  followed 
by  an  injection  of  the  bacillus  communis  coli  into  the 
gall-bladder,  causes  death  rapidly  on  account  of  general 
infection ;  when,  on  the  other  hand,  the  duct  is  not  ob- 
structed, a  similar  injection  causes  neither  local  nor  gen- 
eral changes ;  possibly  because  bile  is  sterile  and  aseptic, 
and  thus  assists  in  preventing  pathological  changes.  It 
cannot  be  denied  that  the  bacillus  does  enter  the  gall- 
bladder, because  Naunyn  and  others  have  found  it  in  cases 
of  acute  cholecystitis  and  suppurative  lesions  of  the  gall- 
tracts.  These  facts  lead  me  to  believe  that  it  is  not  to 
be  regarded  as  a  cause  of  cholelithiasis,  but  rather  as  an 
agent  in  the  production  of  complications ;  indeed,  the 
presence  of  calculi  may  be  looked  upon  as  indirectly  favor- 
ing the  entrance  of  the  bacillus  communis  coli.  It  is  of 
great  interest  and  importance  to  note  the  observations  of 
Naunyn  on  individuals  affected  with  gall-stones  who  dkd 


December  8,  1894] 


MEDICAL    RECORD. 


709 


suddenly.  He  found  the  epithelium  of  the  gall- bladder 
to  contain  fat  drops  and  a  myelin-like  substance.  From 
some  of  these  myelin-laden  cells  little  masses  protruded, 
which,  becoming  detached,  were  found  to  consist  of  cho- 
lesterine  crystals.  These  he  regarded  as  rudimentary 
gall-stones ;  other  harder  masses  of  similar  composition 
had  already  developed  into  small  calculi.  Whenever  this 
development  of  calculi  from  cholesterine  masses  was 
observed  he  always  found  minute  stones  containing  a 
nucleus  which  consisted  of  bilirubin  and  calcium ;  these 
latter,  it  appears,  are  also  associated  with  swollen  epithe- 
lial cells,  which  break  down  into  small  granular  masses 
and  finally  become  surrounded  by  a  deposit  of  cholester- 
ine. 

Of  the  causes  located  in  the  bile,  Frerichs  looked 
upon  bile  stasis  as  a  cause,  and  believed  that  it  resulted  in 
decomposition  of  the  bile  salts  and  an  acid  reaction,  with 
a  precipitation  of  the  cholesterine  and  bilirubin ;  these 
remaining  in  the  gall-bladder  caused  a  cystitis,  a  condi- 
tion wherein  the  mucous  membrane  of  the  gall-bladder 
secretes  calcium  carbonate,  which  combines  with  the  in- 
gredients already  mentioned  and  thus  forms  gall-stones. 

This  theory  is  rather  disproved  by  the  fact :  first,  that 
bile  is  sterile ;  second,  no  such  chemical  change  is  possi- 
ble in  the  bile  as  it  exists  in  the  gall-bladder ;  and  third, 
decomposition  of  bile  and  an  acid  reaction  in  conse- 
quence of  exposure  to  atmospheric  germs  has  not  resulted 
in  a  precipitation  of  the  ingredients  already  mentioned. 

Of  the  causes  located  in  the  liver  tissue  nothing  is 
known.  In  fact  the  lesions  found  in  connection  with 
gall-stones  are  to  be  regarded  as  effects. 

If  we  will  now  consider  the  various  causes  of  gall- 
stone formation,  which  necessarily  involves  more  or  less 
repetition,  we  are  tempted  to  look  upon  Naunyn's  obser- 
vations as  conclusively  proving  that  the  direct  cause  of 
gall-stone  formation  is  located  in  the  gall-bladder.  I 
cannot  assume  this  view  as  consistent  with  pathological 
processes,  because  there  can  be  no  change  in  the  gall- 
bladder without  an  irritating  substance,  and  it  is  only 
reasonable  to  suppose  that  the  exciting  cause  is  to  be 
found  in  the  bile  itself.  In  order  to  support  this  opin- 
ion I  will  call  attention  to  calculi  formed  in  the  pelvis 
of  the  kidney.  From  all  that  is  known  up  to  the  present 
time,  renal  calculus  is  always  due  to  an  excess  of  some 
urinary  constituent,  such  as  urates,  cystin,  oxalate  of 
lime,  phosphates,  etc.  In  excess  these  undoubtedly 
cause  the  so-called  " calculus- forming  catarrh"  in  the 
pelvis  of  the  kidney;  moreover,  experience  has  demon- 
strated the  existence  of  a  certain  diathesis  which  precedes 
or  comes  hand  in  hand  with  renal  calculus ;  this  tends 
to  support  the  belief  that  there  is  an  excess  of  some 
urinary  ingredient. 

I  make  this  comparison  in  order  to  advance  the  theory 
that  the  primary  cause  of  gall-stone  formation,  barring 
foreign  bodies,  is  due  to  an  excess  of  bilirubin  and  cho- 
lesterine, or  to  a  diminished  quantity  of  sodium  salts 
and  bile  acids.  I  also  believe  that  the  excess  or  defi- 
ciency may  be  confined  to  any  one  of  the  essential  con- 
stituents of  bile,  and  just  as  an  excess  of  urates  or  oxalates 
may  cause  a  pyelitis,  so  an  excess  of  cholesterine  may 
cause  a  calculus  forming  catarrh  in  the  gall-bladder,  and 
give  rise  to  the  condition  so  well  described  by  Naunyn, 
which  undoubtedly  plays  the  most  important  part  in  gall- 
stone formation. 

It  is  impossible  to  say  what  changes  in  the  human 
economy  underlie  an  excess  of  essential  bile  constituents, 
and  this  is  rendered  more  difficult  when  we  consider  that 
it  affects  individuals  under  all  circumstances— the  seden- 
tary as  well  as  the  active,  the  glutton  as  well  as  the  ab- 
stemious liver. 

This  brings  me  to  the  symptomatology  of  cholelithiasis ; 
and  since  it  is  so  varied  and  different  in  a  series  of  cases 
I  will  place  some  stress  on  the  symptoms  as  they  are  ob- 
served in  connection  with  certain  shapes  of  calculi. 
The  most  common  and  readily  diagnosed  cases  are  those 
where  the  gall-bladder  contains  the  small,  smooth, 
faceted  calculi,  which  consist  of  bilirubin- calcium  and  a 


large  proportion  of  cholesterine,  etc.  These  may,  as  has 
been  observed  in  autopsies,  lie  dormant  in  the  gall- 
bladder and  never  give  rise  to  symptoms.  This  is  gen- 
erally observed  in  old  people,  and  may  be  accounted  for 
by  the  fact  that  the  gall-bladder's  contractility  is  con- 
siderably lessened  by  certain  pathological  changes  that 
accompany  old  age. 

The  symptoms  of  this  class  of  cases  ordinarily  manifest 
themselves  after  a  heavy  meal,  jolting  in  a  buggy,  or  in 
consequence  of  sudden  physical  exertion,  and  begin  with 
a  violent,  sudden,  paroxysmal,  and  colicky  pain  in  the 
epigastric  or  right  hypochondriac  regions,  which  radi- 
ates to  the  lumbar  regions,  right  shoulder-blade,  cardiac 
region,  and  sometimes  to  the  opposite  side.  Owing  to 
the  intensity  of  the  pain  the  pulse  becomes  weak,  the 
skin  is  covered  by  a  cold  perspiration,  there  is  a  feeling 
of  oppression  across  the  chest,  there  may  be  nausea,  and 
sometimes  vomiting,  which  generally  becomes  biliary ; 
this  condition  of  shock  may  be  accompanied  by  epilepti- 
form seizures  and  syncope ;  the  latter  has  proven  fatal. 
Within  twenty-four  hours  after  the  onset  of  the  attack 
jaundice  develops,  which  first  appears  in  the  sclerotic 
of  the  eye  and  rapidly  involves  the  skin  of  the  whole 
body.  Coincident  with  this  jaundice  the  urine  contains 
bile  pigments,  it  usually  deposits  an  abundance  of  lithates, 
and  the  feces  are  acholic.  Palpation  of  the  gall-bladder 
always  reveals  tenderness,  which  persists  for  two  or  three 
days,  and  sometimes  longer.  Owing  to  the  tenderness 
it  is  generally  impossible  to  feel  the  gall-bladder.  The 
pain  ceases  suddenly,  which  signifies  that  a  calculus  has 
passed  through  the  common  duct  and  entered  the  duo- 
denum, or  has  fallen  back  into  the  gall-bladder. 

Examination  of  the  faeces  during  a  number  of  consecu- 
tive days  will  bring  to  light  the  presence  of  one  or  more 
faceted  calculi.  I  wish  to  emphasize  the  importance  of 
properly  examining  the  faeces  a  number  of  days  after  the 
attack;  the  reason  for  this  precaution  becomes  apparent 
when  we  consider  that  foreign  bodies  may  remain  in  the 
intestines  two  or  three  weeks,  and  I  do  not  see  why  gall- 
stones should  be  an  exception  to  this  fact.  The  gastric 
disturbance  gradually  diminishes  in  the  course  of  a  few 
days ;  with  the  cessation  of  jaundice  and  returning  appe- 
tite the  patient  resumes  his  daily  duties.  Generally 
more  or  less  gastric  disturbance,  always  manifested  by  a 
tendency  to  gaseous  distention,  eructations,  anorexia, 
and  often  constipation,  remain  to  remind  the  victim  of 
his  illness ;  in  fact,  this  latter  condition  may  be  so  per- 
sistent that  the  patient  gradually  becomes  exhausted, 
loses  in  weight,  and  is  rendered  unfit  to  fulfil  ordinary 
mental  and  physical  exertions ;  this  condition  I  look  upon 
as  a  strong  indication  for  operation. 

The  colics  may  be  of  daily  occurrence,  or  months 
and  years  may  elapse  before  anymore  make  their  appear- 
ance. In  typical  cases  calculi  will  be  passed  with  the 
colics.  The  number  that  may  be  passed  varies  from  one 
to  several  hundred. 

The  diagnostic  features  of  these  cases  are :  1.  Colicky, 
sudden,  and  violent  pain,  beginning  in  the  epigastric  or 
the  right  hypochondriac  regions,  and  radiating  to  the 
lumbar,  cardiac,  and  hypochondriac  regions.  2.  Ten- 
derness on  pressure  over  the  dividing  line  of  the  epigas- 
tric and  right  hypochondriac  regions.  3.  Jaundice  fol- 
lowing the  colic  4.  Bile  in  the  urine.  5.  Acholic 
faeces.  6.  Calculi  in  the  faeces.  7.  History  of  previous 
attacks.  8.  Palpation  of  gall-bladder  may  reveal  the 
presence  of  calculi.  All  except  tenderness  and  tumor 
may  be  absent. 

These  are  the  typical  cases  where  a  diagnosis  is  readily 
made.     I  shall  give  a  few  histories  : 

Case  I  — Mrs.  A ,  aged  twenty-nine ;  two  children ; 

history  good ;  was  suddenly  seized  with  hepatic  colic, 
with  all  the  symptoms  already  given.  The  colics  appeared 
every  three  or  four  days,  each  one  accompanied  by  the 
passage  of  small  faceted  calculi.  This  condition  existed 
six  weeks,  during  which  she  passed  twenty-four  calculi, 
and  then  recovered  fully.  It  is  now  five  years  since  her 
illness,  and  there  has  been  no  return  up  to  date. 


7io 


MEDICAL   RECORD 


[December  8,  1894 


Case  II. — Merchant,  of  temperate  habits  and  well 
nourished,  had  attacks  of  colic  during  a  period  of  five 
years;  not  oftener  than  every  two  or  three  months. 
Calculi  were  passed  each  time,  with  typical  concomitant 
symptoms.  He  refused  an  operation,  and  during  one  at- 
tack the  duct  ruptured.  An  operation  performed  by  Dr. 
J.  B.  Murphy  verified  the  diagnosis ;  the  patient  died. 

Case  III. — Colics  had  existed  for  a  period  of  eight 
years.  They  occurred  after  long  intervals  at  first,  but 
finally  became  so  frequent  that  the  patient  was  forced  to 
a  life  of  invalidism.  All  the  concomitant  symptoms 
were  present  The  patient  passed  over  two  hundred  cal- 
culi, one  of  which  finally  became  impacted  in  the  com- 
mon duct,  intensifying  all  the  symptoms,  with  complete 
jaundice  and  a  severe  degree  of  cholaemia.  There  was 
no  distention  of  the  gall-bladder  in  this  case.  Dr. 
Parkes  (deceased)  performed  the  operation  of  cholecys- 
totomy  and  found  the  duct  thickened  and  obstructed  by 
a  calculus.  The  patient  died  on  the  third  day  after  op- 
eration. 

I  wish  also  to  call  attention  to  cases  where  the  symptoms 
persist  two  or  three  months.  They  are  accompanied  by 
a  decided  tenderness  and  increased  resistance  in  the  right 
hypochondriac  region,  increase  in  temperature  of  from 
two  to  three  degrees,  complete  anorexia,  intense  jaundice, 
and  daily  colics. 

Case  IV. — In  this  case  this  condition  was  notice- 
able. She  recovered  after  three  months'  illness  and  then 
had  attacks  of  hepatic  colic  only  four  or  five  times  in 
three  years.  I  attended  her  and  witnessed  three  attacks 
of  hepatic  colic  which  were  accompanied  by  all  the  con- 
comitant symptoms.  Seven  calculi  were  passed.  Exam- 
ination revealed  the  presence  of  a  resistant,  illy-defined, 
and  tender  mass  in  the  region  of  the  gall-bladder.  I 
advised  operation,  to  which  she  consented.  Dr.  J.  B. 
Murphy  operated,  assisted  by  Dr.  Lee  and  myself.  The 
gall-bladder  was  found  to  be  contracted,  and  surrounded 
by  a  mass  of  connective  tissue  with  firm  adhesions. 
Thirty-two  calculi  were  removed,  and  the  long  button 
was  introduced  and  removed  on  the  seventh  day.  She 
mide  an  uninterrupted  recovery. 

Case  V. — The  history  corresponded  to  that  of  the 
fourth  case.  She  had  hepatic  colics  for  ten  years.  Two 
years  ago,  in  1892,  she  was  confined  to  bed  for  a  pe- 
riod of  four  months  with  daily  attacks  of  hepatic  colic, 
and  a  constant  pain  and  tenderness  in  the  right  hypo- 
chondriac region  ;  she  also  had  chills  and  fever,  with  de- 
cided gastric  disturbances,  such  as  nausea,  vomiting,  con- 
stipation, and  anorexia;  these,  together  with  decided 
jaundice  and  cholaemia,  made  the  case  a  serious  one. 
She  always  passed  calculi  after  one  or  more  hepatic 
colics.  When  I  saw  her,  in  1894,  she  had  had  colics  ten 
days,  and  passed  only  three  faceted  calculi.  The  gall- 
bladder could  be  distinctly  felt  and  was  tender  on  press- 
ure. Operation  by  Dr.  J.  B.  Murphy.  Found  a  purple, 
congested,  and  moderately  distended  gall-bladder ;  find- 
ing that  it  remained  in  the  incision  without  support,  a 
tampon  was  introduced  and  removed  on  the  eighth  day. 
I  then  incised  the  gall-bladder,  and  in  the  course  of  a 
week  removed  three  hundred  and  eighty-five  calculi  of 
the  bilirubin-calcium  variety.  No  bile  escaped  through 
the  incision,  leading  me  to  believe  that  the  cystic  duct 
was  obstructed  by  calculi.  She  is  recovering  at  the  pres- 
ent time. 

I  cite  these  two  cases  because  both  give  a  history  of 
prolonged  disturbance  covering  a  period  of  three  months, 
during  which  time  the  pathological  changes  already  men- 
tioned must  have  taken  place.  To  recognize  this  condi- 
tion would  assist  in  arriving  at  a  conclusion  when  the 
question  of  an  operation  presents  itself. 

Differential  Diagnosis. — In  renal  colic  the  pain  begins 
in  the  lumbar  region  and  radiates  down  into  the  thigh, 
testicle,  and  hypogastric  region.  After  an  attack  the 
urine  contains  blood  and  pus.  Concretions  may  also  be 
passed.  In  the  absence  of  urinary  changes  the  history 
of  the  case  will  reveal  the  occurrence  after  active  and 
passive  motion,  and  there  will  also  be  vesical  tenesmus. 


Tenderness  over  the  kidney  will  invariably  be  present  ; 
finally,  the  absence  of  jaundice,  bile  in  the  urine,  and 
acholic  faeces  will  make  the  diagnosis  positive.  Here  I 
will  interpose  the  possibility  of  a  renal  and  hepatic  colic 
being  present  at  the  same  time ;  and  can  best  illustrate 
this  occurrence,  by  citing  the  history  of  a  case  which  I 
witnessed  in  my  own  practice  : 

A  lady,  aged  thirty  four,  married,  gave  a  history  of 
four  weeks'  illness  with  symptoms  of  nausea,  vomiting, 
chills  and  fever,  vesical  tenesmus  more  or  less  constant, 
and  violent  colics  every  three  or  four  days,  followed  by 
a  moderate  jaundice.  Physical  examination  revealed  the 
presence  of  a  movable  kidney,  which  was  tender  on  press- 
ure ;  the  gallbladder  was  tender,  but  could  not  be  felt; 
faeces  were  acholic.  The  urine  contained  bile,  lithates, 
and  pus-cells;  no  albumin  nor  sugar,  and  was  dimin- 
ished in  quantity  to  about  twenty-two  ounces  in  twenty- 
four  hours.  I  observed  several  colics,  and  found  the  first 
to  be  an  hepatic  colic  which  gradually  terminated  in  a 
nephritic  colic,  or  a  violent  boring  pain  in  the  right 
lumbar  region,  accompanied  by  vesical  tenesmus.  After 
such  an  attack  the  urine  contained  bile,  pus,  blood,  in- 
dican,  and  was  diminished  in  quantity.  The  final  out- 
come of  this  case  was  favorable,  recovery  being  com- 
plete after  the  passage  of  two  cholesterine  calculi. 

Intestinal  colic  may  be  differentiated  from  hepatic  colic 
by  the  following  symptoms:  1,  Pain  begins  in  the  um- 
bilical region ;  2,  pressure  relieves  the  pain ;  3,  pain  is 
distinctly  intermittent ;  4,  there  may  be  tympanites,  or 
contraction  of  the  abdominal  muscles ;  finally,  the  seat 
of  the  pain  is  an  important  differential  symptom ;  and 
the  absence  of  hepatic  disturbance  will  establish  the  diag- 
nosis. 

Carcinoma  of  the  pancreas  should  be  considered,  be- 
cause  there  are  cases  where  the  common  duct  has  been 
obstructed  and  given  rise  to  decided  jaundice,  bile  in  the 
urine,  and  dropsy  of  the  gall  bladder.  The  symptoms 
are :  1 ,  Rapid  emaciation  and  cachexia ;  2,  occasionally  the 
nodules  can  be  felt ;  3,  there  may  be  fatty  stools ;  4,  the 
jaundice  is  persistent,  and  there  is  no  history  of  hepatic 
colics,  which  fact  would  materially  aid  in  removing  the 
diagnosis  of  gall-stone  occlusion  of  the  common  duct. 
Absolute  differential  signs  are :  1 ,  The  presence  of  a  fixed 
tumor  in  the  umbilical  region  ;  and,  2,  the  concomitant 
symptoms  which  always  accompany  carcinoma. 

Catarrhal  jaundice  is  readily  diagnosticated  from  chole- 
lithiasis by  gastric  disturbances  followed  by  a  jaundice, 
which  remains  more  or  less  constant  from  two  to  six 
weeks ;  it  is  accompanied  by  temperature  and  sometimes 
chills ;  finally,  it  is  never  accompanied  by  hepatic  colics 
and  the  passage  of  calculi     The  history  is  important. 

Acute  appendicitis  begins  suddenly  with  a  sharp  pain 
in  the  epigastric  region,  nausea,  chills,  and  temperature, 
sometimes  diarrhoea.  Finally,  in  a  short  time  pain  be- 
comes localized  in  the  right  iliac  region,  with  decided 
tenderness,  local  tympanites,  increased  resistance,  and 
an  indurated  mass  makes  its  appearance  in  the  right  iliac 
region.  Appendicitis  can  be  diagnosticated  from  hepatic 
colic :  1,  By  the  previous  history  of  the  case ;  2,  by  the 
absence  of  jaundice,  acholic  faeces,  and  bile  in  the  urine ; 
3,  the  tenderness  in  hepatic  colic  is  generally  (though  not 
always)  most  marked  in  the  region  of  the  gall-bladder. 
It  is  oftentimes  difficult  to  make  a  differential  diagnosis. 
I  had  a  case  recently,  where  the  patient  was  seized  sud- 
denly with  acute  and  violent  pains  in  the  right  hypo- 
chondriac and  iliac  regions,  with  nausea,  vomiting,  and 
a  temperature  ranging  from  ioo°  F.  to  102  50  F.  There 
was  obstinate  constipation.  I  saw  the  case  about  four 
days  after  the  onset,  and  found  the  following  condition  : 
A  large,  fixed,  indurated,  extremely  tender  mass  in  the 
right  iliac  region,  extending  upward  toward  the  liver ; 
there  was  decided  tenderness  over  McBurney's  point; 
the  bowels  had  resisted  all  efforts  at  evacuation,  which, 
together  with  the  persistent  vomiting,  indicated  bowel 
obstruction.  Here,  then,  the  symptoms  of  appendicitis 
were  well  marked.  She  gave  a  history  of  having  had 
periodical  attacks  of  gastralgia  for  ten  years  or  more,  not 


December  8,  1894] 


MEDICAL  RECORD. 


711 


accompanied  by  jaundice  or  any  conclusive  sign  of  chole- 
lithiasis. A  closer  examination  disclosed  that  the  tumor 
in  the  right  iliac  region  had  a  round  shape,  and  extended 
upward  toward  the  liver ;  it  was  resistant  and  fluctuating. 
From  the  shape,  size,  and  apparent  origin  of  the  tumor, 
as  well  as  the  bodily  temperature  and  chills,  together 
with  the  previous  history,  I  diagnosed  impaction  of  cal- 
culi and  suppuration  in  the  gall-bladder.  With  the 
assistance  of  Dr.  Lee  I  performed  a  cceliotomy,  and 
found  the  tumor  already  described  to  be  the  gall-bladder 
intensely  distended.  Suspecting  its  contents  to  be 
purulent,  I  adopted  the  procedure  of  placing  an  iodo- 
form tampon  in  the  incision,  taking  care  to  properly 
place  the  peritoneum  in  contact  with  the  gall-bladder. 
Ten  days  later  I  incised  the  gall-bladder,  evacuating 
twenty  five  large  biliary  calculi,  and  about  ten  ounces  of 
pus;  I  introduced  a  large  drainage-tube.  About  two 
weeks  later  ten  large  calculi  were  removed,  which,  I  be- 
lieve, had  been  encysted  somewhere  in  the  gall  bladder. 
Bile  flowed  through  the  tube  immediately  after  the  opera- 
tion, and  all  symptoms  of  bowel  obstruction  disappeared. 
The  obstruction  was  undoubtedly  due  to  the  large  size  of 
the  gall  bladder  and  pressure  on  the  intestines.  The 
progress  of  the  case  was  favorable  up  to  the  eleventh 
week,  when  she  became  comatose  and  died  in  four  days, 
with  symptoms  of  cerebral  abscess. 

This  brings  me  to  the  consideration  of  gastralgia. 
The  importance  of  properly  understanding  what  we  mean 
by  gastralgia  becomes  very  apparent  when  we  recall  the 
similarity  between  it  and  hepatic  colic ;  indeed,  it  ap- 
pears to  me  that  it  is  oftentimes  a  decided  symptom  of 
cholelithiasis.  Gastralgia,  pure  and  simple,  is  typical 
neuralgia,  and  generally  makes  its  appearance  after  pro- 
dromal symptoms,  such  as  gastric  disturbance,  neuralgic 
pain  in  other  parts  of  the  body,  and  general  lassitude. 
The  pain  comes  on  suddenly,  is  intensely  acute  and  par- 
oxysmal, of  a  boring,  lancinating,  and  burning  charac- 
ter; it  always  begins  in  the  epigastric  region  and  radiates 
to  the  shoulder  blades,  hypochondriac,  and  umbilical  re- 
gions. The  pulse  is  weak  and  sometimes  irregular ;  the 
skin  is  covered  by  a  cold  perspiration,  the  abdominal 
muscles  are  generally  contracted,  and  pressure  relieves  the 
pain.  There  may  be  concomitant  pains  in  other  parts  of 
the  body.  This  condition  may  last  from  a  few  minutes 
to  several  hours  or  days.  The  urine  may  be  diminished 
in  quantity,  or  be  very  abundant  when  hysteria  is  a 
causative  agent.  There  may  be  nausea,  and  sometimes 
vomiting  terminates  the  attack.  The  symptoms  of  gas- 
tralgia will  vary  with  the  cause  or  causes.  It  occurs  in 
conjunction  with  menstruation,  gouty  diathesis,  ulcer  of 
the  stomach,  carcinoma,  malaria,  nervous  lesions,  dis- 
placed kidney,  etc.  Since  gastralgia  is  a  symptom  of  so 
many  lesions  it  becomes  apparent  that  a  process  of  diag- 
nosis by  exclusion  must  be  adopted,  and  this  applies  with 
special  force  to  cholelithiasis. 

I  shall  have  to  base  the  description  of  gastralgia  as  it 
occurs  in  cholelithiasis  on  cases  in  my  own  practice. 
The  attacks  were  extremely  irregular,  and  rarely  appeared 
oftener  than  once  every  two  or  three  months ;  or  a  series 
of  attacks  covering  a  period  of  three  or  four  years  were 
noted,  when  they  disappeared  and  did  not  return  for 
several  months. 

I  have  noticed  that  they  become  more  frequent  when 
the  pathological  changes  in  the  gall-bladder,  such  as 
thickening  and  contraction,  are  far  advanced.  Gastral- 
gia occurs  most  frequently  where  the  calculi  are  too  large 
to  enter  the  common  duct ;  naturally  the  symptoms  of 
bile  obstruction,  such  as  jaundice,  bile  in  the  urine,  and 
acholic  faeces,  are  always  lacking  in  this  class  of  cases. 
Here  gastralgia  and  a  very  persistent  gastric  catarrh, 
which  usually  resists  treatment,  are  the  prominent  symp- 
toms. 

In  every  case  of  cholelithiasis  where  this  symptom  was 
present,  I  observed  that  the  pain  commenced  in  the  epi- 
gastric region ;  it  was  intensely  acute  and  always  accom- 
panied by  signs  of  shock.  Local  examination  showed 
marked  tenderness  in  the  region  of  the  gall-bladder, 


most  acute  during  and  immediately  after  the  attack ;  it 
generally  subsided  and  almost  disappeared  in  three  or  four 
days.  This  symptom  I  have  never  found  in  these  cases. 
I  believe  the  pain  is  due  to  irritation  of  the  opening  at 
the  cystic  duct.  Recently  I  introduced  a  blunt  sound 
into  the  gall-bladder  where  cholecystotomy  had  been 
performed.  The  moment  the  sound  entered  the  cystic 
duct  the  patient  complained  of  acute  pain  in  the  epigas- 
tric region,  which  immediately  ceased  when  the  instru- 
ment was  withdrawn.  The  injection  of  sterilized  water 
into  the  gall-bladder,  with  slight  force,  elicited  the  same 
pain,  or  reflex  gastralgia. 

I  will  now  cite  a  few  cases  wherein  gastralgia  was  a 
prominent  symptom : 

Case  I. — Married  lady,  has  several  children,  and  no 
history  of  lesions,  except  chronic  gastric  catarrh  and  gas- 
tralgia. These  attacks  had  appeared  about  five  or  six 
times  a  year,  but  more  frequently  in  the  last  year,  and 
led  her  to  consult  Leube,  of  Germany,  who  made  the  di- 
agnosis of  gastralgia.  In  1888  I  was  called  to  relieve  an 
attack.  She  had  a  violent  pain  in  the  epigastric  region 
and  marked  tenderness  over  the  gall-bladder.  The  at- 
tack lasted  four  days,  and  was  accompanied  by  a  very 
slight  jaundice,  most  noticeable  in  the  sclerotic  coat  of 
the  eye.  There  was  no  bile  in  the  urine,  and  the  faeces, 
which  were  thoroughly  examined,  were  normal.  There 
was  an  apparent  enlargement  in  the  region  of  the  gall- 
bladder. Dr.  Parkes  (deceased)  operated  and  removed 
two  large  calculi  from  the  contracted  and  thickened  gall- 
bladder.   She  made  an  uninterrupted  recovery. 

Case  II. — A  well- nourished,  married  lady  was  sud- 
denly seized  with  a  violent  attack  of  gastralgia  accompa- 
nied by  vomiting  and  obstinate  constipation.  The  history 
revealed  chronic  gastric  disturbance  and  attacks  of  chronic 
gastralgia  every  three  or  four  months;  she  never  had 
jaundice,  bile  in  the  urine,  or  acholic  faeces.  Local  ex- 
amination revealed  the  presence  of  a  tumor  which  ex- 
tended downward  from  the  liver  into  the  right  iliac 
region,  and  backward  into  the  right  lumbar  region.  It 
was  tender,  fixed,  rounded,  fluctuating,  and  very  resist- 
ant. Urine  was  diminished  in  quantity  and  deposited 
lithates  in  abundance.  There  was  no  bile  in  the  urine, 
no  jaundice,  and  no  acholic  faeces.  Constipation  was 
obstinate.  The  tumor  was  immobile,  and  apparently 
separated  from  the  liver  by  a  distinct  depression.  On 
account  of  its  apparent  origin  in  the  right  lumbar  region 
I  suspected  a  nephritic  tumor,  though  the  history  did 
not  justify  this  belief.  Dr.  J.  B.  Murphy  made  an  ex- 
ploratory incision  and  found  a  distended  gall-bladder  of 
a  dark-red  color,  which  was  apparently  (Edematous. 
Calculi  were  felt,  and  a  large  sized  Murphy  button  was 
used  to  make  an  anastomosis  with  the  duodenum.  Seven 
or  eight  days  after  the  operation  two  calculi  were  passed 
per  rectum ;  the  largest  measured  one  inch  in  its  longest 
diameter,  its  shortest  seven-eighths  of  an  inch.  The 
smallest  measured  seven-eighths  of  an  inch  longest  diam- 
eter, and  three-fourths  of  an  inch  short  diameter.  The 
button  was  passed  on  the  eighteenth  day.  The  operation 
was  performed  October  7,  1892.  The  patient  has  been 
perfectly  well  and  free  from  all  physical  ailment  up  to 
date. 

Case  III. — Mrs.  C ,  married,  illy-nourished ;  has 

had  three  children.  History  gives  the  following  symp- 
toms :  Chronic  gastric  catarrh  for  twelve  years ;  attacks 
of  violent  gastralgia  about  every  three  months ;  each  at- 
tack lasted  about  four  days.  One  physician  advanced 
the  opinion  that  she  would  not  survive  another  attack. 
This  state  of  affairs,  coupled  with  a  severe  degree  of  atonic 
dyspepsia,  brought  about  an  extreme  degree  of  anae- 
mia, emaciation,  and  inability  to  perform  ordinary  house- 
work. She  had  never  had  jaundice,  bile  in  the  urine, 
acholic  faeces,  and  no  calculi  were  passed.  I  observed 
her  in  two  attacks  of  gastralgia.  The  pain  was  intense 
and  distinctly  located  in  the  epigastric  region,  and  radi- 
ated to  both  hypochondriac  and  lumbar  regions,  with 
syncope,  a  very  small  and  weak  pulse,  and  cold  extremi- 
ties.    Morphine  always  gave  relief.     Local  examination 


712 


MEDICAL    RECORD 


[December  8,  1894 


revealed  acute  tenderness  in  the  region  of  the  gall- blad- 
der, which  could  not  be  felt  on  account  of  tenderness. 
In  four  days  the  pain  had  ceased,  no  concomitant  signs 
of  gall-stones  were  noticed.  At  a  second  examination  I 
found  both  kidneys  movable  and  displaced.  'She  had 
never  had  renal  colics,  and  the  urine  presented  no  evi- 
dence of  kidney  lesion. 

(It  is  said  that  gastralgia  is  often  due  to  a  movable 
kidney.  This  I  have  not  observed  in  a  series  of  nineteen 
cases.  To  be  sure,  there  are  reflex  gastric  disturbances 
of  a  neurotic  type,  but  I  have  yet  to  see  gastralgia  due 
to  movable  or  displaced  kidney.)  Pushing  the  right 
kidney  back  I  felt  a  small,  resistant  tumor  in  the  region 
of  the  gall  bladder,  which  moved  with  respiration.  Re- 
peated examinations  always  resulted  in  finding  this  tumor. 
After  the  exclusion  of  other  abdominal  lesions,  I  made 
the  diagnosis  of  cholelithiasis.  Dr.  Murphy  examined 
the  patient  and  agreed  to  the  diagnosis.  Dr.  Murphy 
removed  two  calculi — as  large  as  nutmegs — from  the 
gall-bladder,  which  was  thickened  and  had  contracted 
down  around  the  calculi,  thereby  forming  a  distinct  sac 
for  each  calculus — giving  it  the  appearance  of  an  hour- 
glass. Anastomosis  was  made  with  the  duodenum  by 
means  of  the  Murphy  button.  The  progress  of  the  case 
was  interrupted  by  an  attack  of  acute  dry  pleuritis  on  the 
tenth  day,  which  subsided  rapidly  and  terminated  in 
acute  bronchitis.  The  button  was  passed  on  the  twenti- 
eth day.  The  patient  has  been  well  since  the  operation. 
Her  appetite  has  returned  and  the  gastric  catarrh  under- 
went rapid  improvement. 

This  completes  a  synopsis  of  three  cases,  wherein  the 
gall-stones  were  as  large  as  nutmegs,  and  gave  rise  to  at- 
tacks of  gastralgia,  cholecystitis,  constant  gastric  disturb- 
ances peculiar  to  chronic  gastric  catarrh,  constipation, 
and  general  physical  debility  in  consequence  of  defective 
digestion.  The  indigestion  was  not  limited  to  any  par- 
ticular kind  of  food ;  indeed  all  foods,  either  liquid  or 
solid,  caused  distress.  Therapeutic  remedies  gave  only 
slight  relief. 

The  indications  for  operation  in  these  cases  were :  1. 
Gastralgia.  2.  Persistent  gastric  disturbance.  3.  Ema- 
ciation and  physical  exhaustion.  4.  The  possibility  of 
complications,  such  as  carcinoma  and  suppurative  lesions. 
5.  The  safety  of  operative  procedure,  and  the  improve- 
ment of  health  that  invariably  follows. 

I  also  wish  to  report  two  other  cases  of  cholelithiasis 
wherein  the  calculi  were  large,  polyhedral  and  tetrahe- 
dral  in  shape,  with  large,  smooth,  faceted  sides. 

Case  I. — Had  been  ill  for  a  period  of  twelve  years, 
with  the  following  symptoms :  Constant  gastric  disturb- 
ance, anorexia,  general  debility,  exhaustions,  and  emacia- 
tion. She  gave  a  history  of  having  had  one  distinct 
hepatic  colic,  and  claimed  that  she  passed  some  small  sand- 
like concretions.  She  never  had  jaundice,  and  according 
to  her  own  statement  no  bile  in  the  urine  or  acholic 
faeces.  She  also  gave  a  history  of  slight  chills  followed 
by  fever.  The  most  constant  symptom  was  pain  in  the 
right  hypochondriac  region  whenever  she  worked  in  a 
stooping  posture,  or  simply  stooped.  During  all  this 
time  there  was  habitual  constipation. 

Local  examination  revealed  the  presence  of  a  pear- 
shaped,  smooth,  and  painful  tumor  in  the  region  of  the 
gall  bladder.  It  moved  synchronously  with  respiration, 
and  could  not  be  fixed  by  holding  it  between  the  two 
hands,  something  that  always  can  be  done  with  a  mova- 
ble kidney.  It  could  be  moved  slightly  from  side  to 
side,  and  since  it  appeared  to  be  distinctly  connected 
with  the  liver,  and  located  in  the  region  of  the  gall- 
bladder, as  well  as  its  smooth,  globular  shape,  I  made 
the  diagnosis  of  gallstone  impaction.  Dr.  Murphy  op- 
erated. Upon  incising  the  gall-bladder  a  puriform 
fluid  made  its  appearance  and  several  calculi  of  the  shape 
already  described  made  an  escape  through  the  opening. 
Anastomosis  with  the  duodenum  was  made  by  means  of 
the  Murphy  button.  Owing  to  the  carelessness  of  the 
nurse  I  was  handicapped  in  making  thorough  examina- 
tions of  the  stool  after  the  operation ;  at  all  events  the 


patient  made  a  good  recovery,  gained  in  weight,  regained 
her  appetite,  and  was  able  to  attend  to  her  household  du- 
ties when  I  last  saw  her.  It  is  now  over  a  year  and  a 
half  since  the  button  operation  was  performed. 

Case  II.,  which  I  mentioned  in  connection  with  ap- 
pendicitis, gave  a  history  of  attacks  of  gastralgia  every 
four  or  five  weeks,  but  sometimes  months  elapsed  before 
an  attack  made  its  appearance.  Every  attack  was  in- 
stantly relieved  by  vomiting.  She  had  never  had  jaun- 
dice, bile  in  the  urine,  or  acholic  faeces.  Here  the  cal- 
culi were  unusually  large;  there  were  thirty-five,  three 
of  them  were  rounded  and  almost  as  large  as  nutmegs,  the 
rest  were  of  the  same  shape  already  described. 

The  details  of  this  case  have  already  been  mentioned. 

Among  the  cases  of  interest,  I  have  in  mind  two  where 
the  calculi  consisted  of  cholesterine  entirely.  One  I 
have  already  mentioned  in  connection  with  renal  colic, 
and  therefore  will  not  repeat  it.  The  second  case  occurred 
in  a  lady,  aged  fifty-five  years.  She  gave  a  history  of 
having  had  colics  five  or  six  years,  not  oftener  than  once 
every  three  or  four  months.  All  the  concomitant  symp- 
toms, such  as  bile  in  the  urine,  acholic  faeces,  and  jaun- 
dice, followed  the  colics.  When  I  saw  her  she  had  been 
sick  two  weeks.  There  was  moderate  jaundice,  a  large 
quantity  of  bile  in  the  urine,  acholic  faeces,  and  colicky 
pains  bad  persisted  steadily,  the  constant  use  of  morphine 
being  necessary  to  subdue  the  violence  of  the  pain.  Be- 
yond tenderness  localized  in  the  region  of  the  gall-blad- 
der, nothing  abnormal  was  found  in  the  abdominal  cav- 
ity. Considering  the  history,  the  occurrence  of  jaundice 
within  twenty-four  hours  after  a  decided  hepatic  colic, 
the  constant  presence  of  bile  in  the  urine,  and  acholic 
faeces,  together  with  the  persistent  colics,  I  diagnosed 
obstruction  of  the  common  duct,  and  recommended  op- 
eration. Dr.  Murphy  operated,  assisted  by  Drs.  Lee  and 
Hartmann  and  myself.  The  gall  bladder  was  normal  and 
contained  no  calculi.  The  cystic  and  common  ducts 
were  so  obstructed  by  calculi  that  they  felt  like  a  string 
of  beads.  Dr.  Murphy  made  an  anastomosis  with  the 
duodenum,  using  his  button  for  this  purpose. 

The  colics  ceased  immediately  after  the  operation.  On 
the  sixth  day  three  round,  semi-transparent  cholesterine 
calculi  were  passed,  each  one  about  three-sixteenths  of 
an  inch  in  diameter.  These  were  passed  without  pain 
or  colics,  which  substantiated  Dr.  Murphy's  opinion, 
"  that  the  calculi  would  fall  back  into  the  gall-bladder 
after  the  anastomosis  was  made." 

On  the  seventh,  eighth,  and  ninth  days  more  calculi 
were  passed,  making  a  total  of  thirteen  pure  cholesterine 
calculi  which  had  obstructed  the  bile  ducts.  The  pa- 
tient passed  the  button  on  the  twentieth  day  after  the 
operation,  and  never  had  an  unpleasant  symptom  since. 
It  is  nearly  a  year  since  the  operation.  Here  the  Mur- 
phy button  operation  was  certainly  superior  to  the  more 
difficult  and  dangerous  procedure  of  cholecystotomy. 

Owing  to  the  rarity  of  pure  calcium  calculi  in  the 
gall-bladder,  I  shall  give  the  history  of  one  of  two  cases 
which  I  observed. 

Mrs.  X ,  aged  thirty-six,  married,  had  never  been 

sick  and  gave  no  history  of  hepatic  colics.  In  1888  she 
was  suddenly  seized  with  a  distinct  hepatic  colic,  followed 
within  twenty-four  hours  by  all  the  concomitant  symp- 
toms of  cholelithiasis,  such  as  jaundice,  bile  in  the  urine 
and  acholic  faeces.  Local  examination  revealed  tender- 
ness in  the  region  of  the  gall-bladder,  which  organ  could 
not  be  felt.  The  hepatic  colics  were  intense  and  con- 
tinuous for  a  period  of  three  weeks.  During  this  time 
there  was  nausea  and  vomiting,  and  rather  decided  chol- 
aemia.  Finally,  at  the  end  of  three  weeks,  I  found  an 
irregular,  rather  hard,  white  calculus  in  the  faeces,  which 
consisted  almost  entirely  of  calcium.  Following  its  ap- 
pearance the  patient  made  a  rapid  recovery,  and  has 
had  no  recurrence  up  to  the  present  time. 

The  other  case  resembled  this  in  all  respects. 

It  will  be  observed,  from  the  histories  given,  that  the 
classical  symptoms  of  cholelithiasis,  such  as  jaundice, 
bile  in  the  urine,  acholic  faeces,  and  the  passage  of  cal- 


December  8,  1894] 


MEDICAL   RECORD. 


7i3 


culi,  were  lacking  entirely  in  five  cases,  and  one  case  gave 
a  history  of  twelve  years'  illness  with  only  one  distinct 
colic.  These  facts  render  a  diagnosis  extremely  difficult, 
and  sometimes  impossible.  The  symptomatology  there- 
fore deserves  special  attention.  In  these  five  cases  the 
most  constant  symptoms  were  gastric  disturbance,  such 
as  gaseous  distention,  nausea,  fermentation  of  foods  dur- 
ing digestion,  a  constant  sensation  of  pressure  and  slight 
pains  in  the  epigastric  region,  and  constipation.  This 
condition  may  be  so  marked  that  the  patient  becomes 
emaciated,  exhausted,  and  unable  to  perform  ordinary 
physical  exertions.  This,  together  with  attacks  of  gas- 
tralgia  every  two  or  three  months,  in  conjunction  with 
decided  tenderness  in  the  region  of  the  gall-bladder  dur- 
ing the  attacks,  completes  the  picture  of  subjective  symp- 
toms in  these  cases.  A  diagnosis  by  exclusion  must  be 
adopted  and  all  other  causes  of  the  symptoms  mentioned 
eliminated.  Local  examination  is  of  the  utmost  impor- 
tance, and  must  be  practised  in  a  suspected  case.  Where 
the  calculi  are  large  and  patience  is  used,  one  can  often 
feel  a  distinct  rounded  enlargement  in  the  region  of  the 
gall-bladder,  which  is  slightly  tender  and  moves  syn- 
chronously with  respiration.  A  tumor  in  this  region 
must  be  differentiated  from  carcinoma  of  the  pancreas, 
echinococcus  cysts,  fecal  accumulations  in  the_  colon, 
renal  tumors,  movable  and  displaced  kidney. 

In  carcinoma  of  the  pancreas  we  have  cachexia,  rapid 
emaciation,  and  sometimes  fatty  stools,  an  irregular 
tumor  deeply  seated  in  the  epigastric  region,  and  some- 
times metastatic  deposit  in  other  organs.  The  tumor  is 
generally  fixed,  and  on  auscultation  one  may  hear  a  bruit 
due  to  transmitted  pulsations  from  the  underlying 
vessels. 

When  the  common  duct  is  obstructed  in  carcinoma  of 
the  pancreas,  there  will  be  intense  and  constant  jaundice, 
bile  in  the  urine,  and  acholic  faeces,  coincident  with  a  dis- 
tended gall-bladder,  which  can  be  distinctly  felt  as  a 
rounded,  smooth,  fluctuating,  and  pear- shaped  tumor,  en- 
croaching on  the  anterior  margin  of  the  liver;  sometimes 
atrophy  of  liver  tissue  takes  place  at  the  point  of  contact. 
This  tumor  moves  with  the  respiratory  movements  and  is 
distinctly  connected  with  the  liver.  In  order  to  deter- 
mine the  cause  of  hydrops  of  the  gall-bladder  in  these 
cases  the  history  is  of  importance,  and  in  connection 
with  it  the  symptoms  mentioned  will  make  a  diagnosis 
possible.  It  should  not  be  forgotten  that  cholelithiasis 
may  also  be  present. 

Echinococcus  cysts  rarely  originate  in  the  region  of 
the  gall-bladder.  When  by  reason  of  extreme  size  or 
central  origin  in  the  liver  they  occlude  the  bile- ducts,  we 
will  observe  that,  first,  the  jaundice  developed  without 
pain;  second,  it  is  persistent;  third,  the  gastric  func- 
tions are  generally  undisturbed;  and  fourth,  other  physical 
signs  of  echinococcus  cyst  would  exclude  cholelithiasis. 

Fecal  accumulations  in  the  transverse  colon  present  the 
following  symptoms :  An  irregular  mass,  superficial,  non- 
fluctuating,  and  freely  movable,  coupled  with  a  history  of 
bowel  obstruction,  intestinal  colics,  and  constipation. 
Cases  have  been  observed  where  diarrhoea  was  present. 
The  treatment  with  purgatives  will  remove  all  doubts. 

Renal  tumors,  when  smooth  and  symmetrical,  may  sim- 
ulate a  largely  distended  gall-bladder  to  such  an  extent 
that  a  diagnosis  is  made  with  difficulty.  Renal  tumors 
are  of  slow  development  and  are  always  accompanied  by 
changes  in  the  quantity  and  quality  of  the  urine,  which 
may  contain  albumin,  blood,  pus,  casts,  and  be  dimin- 
ished in  quantity.  There  may  also  be  a  history  of  renal 
colics  and  vesical  irritability.  In  a  large  hydrops  of  the 
gall-bladder  the  onset  is  generally  sudden  and  painful,  and 
by  reason  of  its  size  gives  rise  to  symptoms  of  bowel  ob- 
struction. This  I  observed  in  two  cases.  The  distended 
gall-bladder  is  generally  fixed,  smooth,  rounded,  fluctu- 
ating, and  pear-shaped,  and  very  tender  on  pressure  when 
the  distention  is  acute. 

Renal  tumors  when  large  are  more  resistant,  have  an 
irregular  surface,  and  generally  the  colon  overlies  the 
tumor.     In  hydronephrosis   the  enlargement  is  smooth 


globular,  and  fluctuating,  and  bears  a  striking  resemblance 
to  hydrops  of  the  gall-bladder. 

Especial  attention  must  be  directed  toward  ascertain- 
ing: 1,  A  history  of  sudden  increase  in  the  quantity  of 
urine  voided  and  a  corresponding  diminution  in  the  size 
of  the  tumor ;  a,  diminution  in  normal  quantity  of  urine ; 
3,  the  presence  of  renal  colics  and  lumbar  pains ;  lastly, 
it  may  depend  on  pelvic  enlargements  which  have  oc- 
cluded the  ureter  on  the  right  side. 

Movable  kidney  diners  from  distention  of  the  gall- 
bladder as  follows:  1,  It  is  bean- shaped;  2,  it  is  freely 
movable  and  can  be  replaced  to  its  normal  location ;  3, 
it  does  not  move  with  the  respiratory  movements ;  4,  it 
can  be  fixed  between  the  hands  in  spite  of  the  respira- 
tory movements;  5,  there  may  be  a  history  of  renal 
colics;  and  lastly,  there  is  no  history  of  jaundice,  bile  in 
the  urine,  and  acholic  faeces.  It  should  not  be  forgotten 
that  movable  kidney  and  cholelithiasis  may  exist  to- 
gether. I  have  given  the  history  of  two  cases.  In  case 
the  kidney  is  displaced  and  fixed  under  the  liver,  the 
diagnosis  is  more  difficult.  Careful  analysis  of  the  symp- 
toms and  history  will  always  render  diagnosis  possible. 

It  is  important  to  mention  the  physical  characteristics 
of  gall-bladders  which  have  become  elongated  and  di- 
vided in  two  or  more  sacculi,  each  one  containing  a  cal- 
culus. A  local  examination  reveals  the  presence  of  a 
rounded  elongated  tumor  which  admits  of  being  freely 
moved  from  side  to  side.  It  can  be  traced  to  the  region 
of  the  gall- bladder  and  is  attached  to  the  liver.  In  con- 
nection with  the  history  of  the  case  a  diagnosis  can  be 
made. 

This  brings  us  to  the  complications  of  cholelithiasis. 
They  are:  1,  Obstruction  of  the  common  duct;  2,  impac- 
tion of  gall- stones  and  suppuration  in  the  gall- bladder; 
3,  hydrops  of  the  gall-bladder ;  4,  contraction  and  al- 
most entire  obliteration  of  the  gall- bladder,  and  a  deposit 
of  connective  tissue  with  adhesions  to  the  surrounding 
organs;  5,  carcinoma  of  the  gall- tracts;  6,  obstruction 
of  the  cystic  duct ;  7,  cholecystitis  with  thickening  of  the 
gall-bladder  and  its  division  into  several  diverticular ;  8, 
hepatic  abscess;  9,  rupture  of  abscess  in  the  colon,  kid- 
ney, stomach,  duodenum,  and  through  the  abdominal 
wall;  10,  rupture  of  the  gall-bladder  or  bile-ducts;  n, 
obliteration  of  the  common  and  cystic  ducts. 

It  is  not  out  of  place  to  say  a  few  words  about  the 
symptomatology  of  the  complications.  Rupture  of  the 
gall-bladder  or  its  ducts  generally  occurs  suddenly  during 
an  attack  of  hepatic  colic.  I  can  best  describe  the  symp- 
toms of  this  accident  by  citing  one  of  two  cases  which  I 
treated.  A  merchant,  whose  case  has  been  mentioned  in 
this  paper,  was  seized  with  an  ordinary  hepatic  colic ; 
feeling  a  desire  to  evacuate  his  bowels  he  went  to  the 
closet,  and  while  straining  felt  something  give  way  sud- 
denly. Thereupon  the  hepatic  colic  immediately  ceased 
and  was  replaced  by  syncope,  cold  sweats,  and  a  feeling 
of  extreme  weakness.  Two  hours  later  I  saw  the  patient 
and  found  his  condition  to  be  as  follows :  Rapid,  weak, 
and  thread-like  pulse,  cold  extremities,  dyspnoea,  and  de- 
cided abdominal  tympanites ;  in  fact  the  patient  was  ap- 
parently dying.  Dr.  Murphy  performed  coeliotomy  in 
the  hope  that  drainage  would  save  life.  The  abdominal 
cavity  was  full  of  biliary  fluid;  the  intestines  floated  on 
the  latter.  Death  occurred  on  the  third  day  and  an 
autopsy  was  refused.  The  second  case  was  almost  iden- 
tical with  the  first.  An  operation  by  Dr.  Murphy  sub- 
stantiated the  diagnosis. 

When  carcinoma  of  the  gall-tracts  develops  in  the 
course  of  cholelithiasis  the  patient  rapidly  loses  in  weight, 
and  ordinarily  the  jaundice  becomes  intense  and  per- 
sistent, with  all  the  concomitant  symptoms  of  bile  ob- 
struction. Local  examination  reveals  uniform  tender- 
ness over  the  gall-bladder  and  along  the  liver-margin. 
Sometimes  it  is  possible  to  feel  carcinomatous  nodules 
which  completely  obstruct  the  bile-ducts.  The  follow- 
ing case  will  be  of  interest  and  serve  as  an  illustration : 

Dr.  Allaben,  of  Rockford,  111.,  to  whom  I  am  indebted 
for  the  history,  and  who  referred  the  patient  to  me,  had 


7H 


MEDICAL   RECORD. 


[December  8,  1894 


made  the  diagnosis  of  cholelithiasis.  The  case  was  a 
typical  one,  and  accompanied  by  jaundice,  bile  in  the 
urine,  and  the  passage  of  calculi  after  every  hepatic 
colic.  Suddenly  jaundice  developed  without  a  preceding 
colic,  it  was  persistent  and  accompanied  by  rapid  emaci- 
ation, occasional  vomiting  of  mucus  and  undigested 
food.  There  was  no  recurrence  of  hepatic  colic.  He 
also  had  chills  and  a  temperature  rising  from  one  to  three 
degrees.  This,  together  with  decided  tenderness  in  the 
region  of  the  gall-bladder  and  along  the  liver  margin,  as 
well  as  the  presence  of  a  nodular  mass  in  the  region  of 
the  gall-bladder,  completed  the  picture  of  this  case. 

Owing  to  the  intense  jaundice  and  its  time  of  occur- 
rence, as  well  as  the  concomitant  symptoms,  the  diagno- 
sis of  gall-stones  with  carcinoma  and  probably  suppura- 
tion was  made.  Operation  by  Dr.  Lee  found  the  gall- 
bladder contracted  and  shaped  like  an  hour- glass.  The 
outer  portion  contained  a  large  calculus  firmly  fixed,  and 
consequently  it  could  not  be  removed.  The  inner  por- ' 
tion  contained  a  greenish  puriform  fluid.  A  nodule 
was  also  felt.  Death  followed  in  twelve  hours.  Autopsy 
brought  to  light  what  has  already  been  mentioned.  The 
common  duct  was  completely  obliterated  and  surrounded 
by  a  carcinoma  as  large  as  a  hickory-nut  Metastatic 
deposits  were  found  in  the  liver  and  elsewhere. 

It  is  not  possible  to  predict  the  pathological  changes 
in  many  cases  of  cholelithiasis.  Sometimes  those  where 
the  symptoms  have  been  comparatively  mild  present  the 
most  decided  pathological  changes,  and  vice  versa. 

We  now  come  to  the  treatment  of  gall-stones,  which 
can  properly  be  divided  into  two  classes,  viz. :  Thera- 
peutic and  surgical.  It  would  not  be  consistent  with 
the  present  medical  knowledge  to  give  the  details  of 
every  remedy  which  has  been  used.  Among  those 
which  have  claimed  the  greatest  attention  are  such  as 
olive  oil,  arsenic,  iron  succinate,  the  mineral  acids,  and 
saline  laxatives.  It  cannot  be  claimed  that  any  of  these, 
and  others  not  mentioned,  act  as  solvents  of  gall  stones. 
Moreover,  were  it  possible  to  dissolve  them  as  contained 
in  the  gall-bladder,  we  would  not  cure  but  merely  re- 
move the  effect  of  a  cause  which  is  yet  a  mystery.  No 
doubt  the  medicines  are  of  value  in  relieving  concomi- 
tant conditions,  such  as  constipation,  gastric  disturbance, 
etc.;  thereby  temporary  improvement  is  procured.  Laxa- 
tives probably  encourage  the  elimination  of  calculi  by 
reason  of  their  action  on  the  intestines  and  bile  secretion. 
Diet  and  the  regulation  of  living  have  a  good  effect,  as 
they  do  in  other  diseases. 

Since  it  would  be  useless  to  say  more  about  the  thera- 
peusis  of  cholelithiasis,  I  will  discuss  the  surgical  proced- 
ures and  the  indications  for  interference.  When  we 
would  operate,  is  a  question  that  admits  of  much  argu- 
ment, particularly  so  when  the  patient  has  been  made  to 
believe  that  this,  that,  or  the  other  medicine  will  dis- 
solve the  stones.  I  recall  a  case  where  olive  oil  had  been 
administered ;  the  patient  passed  a  number  of  soft  green- 
ish masses  consisting  of  fatty  substances.  And  lo !  the 
people  and  others  declared  that  they  were  gall-stones 
which  were  partially  softened  by  olive  oil ;  that  mistake 
is  sometimes  encouraged  by  the  attending  physician. 

The  indications  for  operation  are:  1.  Hepatic  colics, 
coming  on  every  four  or  five  days  for  a  period  of  several 
months,  with  passage  of  calculi.  2.  Obstruction  of  the 
common  duct  by  a  calculus,  with  cholaemia  and  gall- 
bladder dropsy.  3.  Hydrops  of  the  gall-bladder,  of 
acute  development,  with  obstruction  of  the  cystic  duct. 

4.  Persistent  gastric  disturbances  with  occasional  at- 
tacks of  gastralgia,  physical  exhaustion  and  anaemia,  and 
the  presence  of  tumor  in  the  region  of  the  gallbladder. 

5.  Suppurative  cholecystitis,  due  to  gall  stones.  6.  Con- 
tinuous daily  hepatic  colics,  with  signs  of  bile-duct  ob- 
struction, and  the  absence  of  calculi  in  the  faeces.  7.  The 
possibility  of  dangerous  complications,  such  as  rupture 
of  the  gall-tract,  carcinoma,  adhesions,  etc  8.  Hepatic 
abscess,  due  to  gall-stones.  9.  Impaction  of  gall-stones 
in  the  gall-bladder.  10.  The  comparative  safety  ^of 
operative  procedures. 


Among  the  operations  ordinary  cholecystotomy  is 
most  generally  practised,  and  with  the  present  methods 
has  given  good  results.  The  ideal  operation  consists  in 
making  an  anastomosis  between  the  gall-bladder  and  the 
duodenum,  called  cholecyst-duodenostomy.  By  this 
method  we  imitate  to  an  extent  the  normal  physiologi- 
cal conditions,  and  meet  the  usual  indications  of  choleli- 
thiasis. The  gall-bladder  is  drained  thereby,  and  the 
bile  flows  into  the  intestine  when  the  cystic  duct  is  not 
obstructed.  There  is  no  fistula  left.  In  my  own  prac- 
tice that  useful  and  ingenious  contrivance,  the  Murphy 
button,  has  been  used  four  times  in  making  an  anasto- 
mosis. These  cases  have  been  under  my  observation  over 
a  year  and  a  half,  and  are  in  the  best  of  health  to-day. 

I  believe  that  sufficient  time  has  elapsed  to  demon- 
strate the  safety  of  the  operation  as  it  is  done  with  the 
Murphy  button,  and  recommend  it  wherever  the  condi- 
tion of  the  organs  will  admit  of  its  use. 

I  wish  also  to  add  that  the  four  cases  under  my  obser- 
vation were  of  a  widely  different  type.  In  Case  L,  the 
gall-bladder  was  enormously  distended  and  cedematous; 
in  Case  II.,  the  gall-bladder  was  normal  in  size,  its  walls 
thickened,  and  contained  a  purulent  fluid;  in  Case  HI., 
normal  gall-bladder  with  calculi  obstructing  the  common 
and  cystic  ducts,  which  subsequently  fell  back  into  the 
gall-bladder;  Case  IV.,  thickened  and  sacculated  gall- 
bladder. 

Another  point  in  favor  of  this  operation  is  the  impos- 
sibility of  a  return  of  gall- stones,  and  the  certainty  that 
all  the  calculi  will  escape  from  the  gall-bladder. 

In  cholecystotomy  it  is  possible  to  leave  calculi  in  the 
gall-bladder  which  may  occasion  considerable  trouble. 
Someone  made  the  statement  that  the  operation  of 
cholecyst-duodencstomy  with  the  Murphy  button  favored 
infection  of  the  gall-tracts;  this  is  not  possible;  first, 
because  bile  being  aseptic  and  sterile,  would  to  an  extent 
overcome  this  danger ;  second,  infection  with  the  bacillus 
communis  coli  (which  is  generally  found  in  suppurating 
lesions  of  the  gall  tracts)  is  harmless  when  not  confined, 
as  has  been  amply  demonstrated  by  Naunyn. 

In  any  of  the  cases  under  my  own  observation,  where 
the  Murphy  button  was  used,  no  infection  occurred. 

I  wish  to  add  that,  up  to  the  present  date,  I  have  the 
reports  of  thirty-four  cases  of  cholecyst-duodenostomy 
done  with  the  Murphy  button  for  gall-stones ;  of  this 
number  one  died,  making  thirty  three  recoveries  and 
one  death. 


LANDMARKS    OF  VISCERAL    DISEASE,   WITH 
A  NEW  THEORY. 

By  BYRON  ROBINSON.  M.D., 

CHICAGO,  ILL. 

Useful  works  on  applied  anatomy  and  pathology  of  the 
abdominal  viscera  are  very  scarce.  I  do  not  know  any 
subject  in  medicine  of  which  the  general  student  and 
practitioner  is  so  lightly  supplied.  It  must  be  acknowl- 
edged that  the  abdominal  cavity  is  filled  with  a  compli- 
cated mechanism  which  holds  body  and  soul  together ;  it 
is  the  assimilating  laboratory  of  life,  the  location  where 
food  is  worked  into  blood,  bone,  and  tissue.  This  cavity 
is  less  generally  known  than  the  cerebro  spinal  cavity. 

In  this  article  I  wish  to  speak  of  what  one  sees  in  open- 
ing the  abdomen  in  dead  bodies.  One  has  not  the  right 
to  attempt  to  study  very  much  on  the  viscera  while  lapa- 
rotomy proceeds.  I  also  think  that  by  disseminating  some 
real,  practical  knowledge  of  the  abdominal  viscera  unnec- 
cessary  laparotomies  may  be  spared.  To-day  there  are 
too  many  laparotomies  done  by  unskilled  physicians 
without  proper  facilities.  In  speaking  of  the  landmarks 
of  visceral  disease  I  mean  the  points  of  the  viscera  when 
disease  is  apt  to  arise.  Probability  is  the  rule  of  life,  and 
when  we  find  in  autopsies  that  certain  viscera  and  certain 
localities  are  liable  to  show  pathological  conditions  it  is 
wise  to  look  after  these  same  points  during  life.  The 
comparison  of  the  pathology  found  in  the  dead  abdomen 


December  8,  1894] 


MEDICAL  RECORD. 


7i5 


with  that  of  the  living  gives  ample  rewards  to  the  thought- 
ful surgeon  and  physician.  The  great  phenomenon  in 
the  dead  abdomen  which  leads  one  to  the  origin  of  dis- 
ease is  peritonitis.  Inflammation  of  the  serous  sac  may 
refer  one  back  a  quarter  of  a  century  to  events  long  for- 
gotten, but  the  "  blaze  "  on  the  peritoneum,  like  that  of 
the  surveyor  on  the  tree,  remains  to  tell  the  story  of  in- 
vasion. If  one  will  carefully  examine  at  least  twenty- 
five  adult  bodies  as  regards  the  abdominal  viscera  he  will 
be  liable  to  observe  the  main  common  visceral  disease. 
It  will  require  at  least  twenty-five  autopsies  to  be  im- 
pressed with  the  idea  that,  after  all,  visceral  disease  has  a 
peculiar  similarity,  a  liability  to  be  alike  in  each  body. 
Visceral  disease  has  common  grounds  to  start  on  and 
common  organs  to  attack.  It  persists  in  definite  locali- 
ties and  has  many  common  symptoms.  Visceral  disease 
is  much  like  meals,  which  are  generally  composed  of  a 
few  common  articles.  Meat,  bread,  and  potatoes  are  the 
common  articles  found  in  most  meals.  So,  for  example, 
one  can  find  with  a  similar  commonness  that  autopsies 
reveal  peritonitis  in  the  pelvic,  appendicular,  and  gall- 
bladder region.  On  first  opening  the  abdomen  one  will 
soon  generally  observe  whether  peritonitis  has  existed 
by  the  position  of  the  omentum — the  surgeon's  friend, 
the  patient's  man-of-war.  If  peritonitis  has  existed  the 
omentum,  or  a  part  of  it,  will  generally  be  found  trying 
to  quell  the  fire  by  covering  it  up  with  adhesions.  The 
omentum  has  covered  up  the  infectious  invader  and 
buried  the  slain  of  the  battle.  It  has  guarded  the  parts 
where  infection  is  liable  to  enter.  In  seventy-five  per 
cent,  of  bodies  the  omentum  tends  to  the  left  and  readies 
to  the  pelvis.  In  some  it  is  rolled  up  around  or  behind 
the  transverse  colon.  Sometimes  we  find  the  omentum 
so  thick  and  large  that  scarcely  a  viscus  is  in  sight.  Now, 
there  are  greater  and  lesser  districts  of  peritonitis  in  the 
abdomen.  All  peritonize  districts  depend  on  certain 
weak  points  of  viscera.  These  peritonitic  regions  are 
places  where  disease  arises  in  viscera,  for  peritonitis  is  a 
secondary  matter.  The  great  peritonitic  districts  are — 
a,  the  pelvis ;  3,  the  appendix ;  and  c,  the  gall-bladder. 
These  are  the  three  great  regions  of  peritonitis  in  man. 
I  have  scarcely  posted  an  adult  body  which  has  not 
some  trace  of  peritonitis  in  one  of  these  three  major 
regions.  In  these  peritonitic  districts  is  where  abdom- 
inal surgery  has  made  progress  and  where  life  has  been 
many  a  time  and  oft  saved  or  snuffed  out.  These  three 
regions  have  tolerated  infectious  invasion  so  long  that 
they  resist  it  and  almost  always  save  life  by  producing  a 
peritonitis  which  buries  the  invaders  in  exudate  forever. 
It  must  be  remembered  that  peritonitis  is  a  life  saving 
process,  while  it  is  infection  that  kills.  Peritonitis  is 
nature's  method  of  repair.  If  it  were  not  for  perito- 
nitis the  people  would  soon  be  swept  from  the  earth. 
Peritonitis  produces  exudates  which  bury  and  starve 
the  invading  deadly  germs.  Now,  there  are  other  regions 
of  peritonitis  which  I  call  minor  districts.  We  have  in- 
flammation around  the  sphincters  (pylorus  and  ileo-cae- 
cal  valve  and  anus),  which  is  common  in  adults,  though 
limited  in  extent.  Again  the  flexures  of  the  colon  suffer 
(hepatic,  splenic,  sigmoid)  from  inflammation.  Perito- 
nitis is  common  around  the  colonic  flexures.  The 
reason  is  that  as  the  solid  faeces,  containing  sharp,  rough, 
foreign  bodies  pass  around  the  acute  angles  of  the  flex- 
ures the  mucous  membrane  becomes  abraded  and  torn  so 
that  the  way  lies  open  for  germs  and  infection  to  pass 
into  the  gut- wall  and  peritoneum.  At  these  sphincters 
and  flexures  malignancy  as  well  as  cicatricial  strictures 
are  apt  to  arise.  The  hernial  orifices  are  very  apt  to 
catch  some  portion  of  the  gut  and  inflame  it,  starting  up 
peritonitis.  Also  we  have  what  I  designate  as  accidental 
peritonitis,  i.e.,  from  some  perforation  or  trauma  in  some 
portion  of  a  viscus  outside  of  what  has  been  designated 
as  a  distinct  peritonitis  district  (major  or  minor). 

What  I  wish  to  present  in  this  paper  as  original,  as  I 
have  never  seen  it  in  a  book  nor  heard  it  from  anyone, 
is  the  peculiar  inflammation  or  peritonitis  which  occurs 
around  the  caecum  and  under  the  sigmoid,  as  it  crosses 


the  psoas  muscle.  For  a  long  time  in  autopsies  I  have 
been  carefully  observing  local  peritonitis,  and  particular- 
ly my  attention  has  been  called  to  two  points  whose 
explanation  did  not  seem  satisfactory.  The  peculiar, 
apparently  benign  inflammation  which  one  can  so  fre- 
quently see  around  the  caecum,  and  just  under  the  sig- 
moid as  it  crosses  the  psoas  muscle,  cannot  be  wholly  due 
to  appendicitis  nor  to  the  acute  angle  of  the  sigmoid. 
First,  the  pericecal  adhesions  are  entirely  out  of  reach 
of  the  appendix.  In  fact,  it  is  the  most  distant  from  it. 
I  admit  that  the  appendix  is  often  movable  and  may  cre- 
ate inflammation  in  a  locality  and  then  leave  it  to  lie  in 
another  region.  But  physical  circumstances  were  such 
in  many  cases  that  it  appeared  unreasonable  that  the  ap- 
pendix could  produce  such  old  adhesions.  Really  there 
is  a  kind  of  pericaecal  adhesion  and  a  kind  of  appendicu- 
lar adhesion.  These  kinds  of  adhesions  may  be  totally 
separate  and  distinct  by  physical  spaces.  Now,  how  do 
I  account  for  the  inflammation  around  the  caecum  which 
is  not  appendicular?  The  answer  is  that  it  is  due  to 
the  relaxation  and  contraction  of  the  psoas  and  iliac  mus- 
cles. The  majority  of  caeca  lie  partly  on  the  psoas  mus- 
cle and  partly  on  the  iliac  muscle,  and  in  walking  these 
two  muscles  are  continually  contracting  and  relaxing. 
Should  the  caecum  be  congested  or  even  inflamed  the  ir- 
ritation produced  in  these  muscles  would  cause  an  exudate 
which  would  organize  and  result  in  bands.  Again,  as 
the  sigmoid  crosses  the  psoas  on  the  left  side,  I  have 
seen  the  peritoneum  or  its  mesentery  inflamed  so  often 
that  I  looked  a  long  time  for  a  cause.  The  cause,  in  my 
opinion,  is  due  to  the  contraction  and  relaxation  of  the 
psoas  and  iliac  muscles.  This  is  a  clearer  case  than  the 
caecal  region,  for  the  old  peritoneal  inflammations  are  so 
frequent  and  entirely  isolated  from  all  other  fields  and 
sources  of  inflammation.  The  old  bands,  dense  adhe- 
sions, and  thick,  new  cicatricial  tissue  so  frequently  found 
just  under  the  sigmoid  as  it  crosses  the  psoas  muscle  can 
be  accounted  for,  so  far  as  I  can  see,  only  by  an  irritation 
arising  out  of  the  psoas  and  iliac  muscles.  It  must  be 
chemical  or  mechanical  peritonitis  due  to  irritation. 
This  explanation  will  give  a  new  view  to  all  the  isolated 
adhesions  around  the  caecum  as  not  being  due  to  rupture 
of  the  appendix. 

In  nineteen  autopsies  made  by  me  in  special  reference 
to  the  abdominal  viscera,  where  every  point  was  observed 
in  regard  to  peritonitis  and  an  attempt  made  to  measure 
almost  every  viscus,  I  found  over  seventy-five  per  cent,  of 
old  adhesions  resulting  from  peritonitis  existing  around 
the  caecum.  I  can  say  that  many  of  the  adhesions  were 
entirely  isolated  from  the  appendix.  In  the  same  autopsies 
we  found  thirteen  cases  out  of  nineteen  with  distinct  old 
peritonitic  adhesions  under  the  sigmoid  as  it  crosses  the 
psoas  muscle.  In  many  cases  the  peritonitic  adhesions 
under  the  sigmoid  were  entirely  isolated  from  all  other 
fields,  and  many  were  in  men,  so  that  the  tubal  end  could 
not  empty  its  infection  there,  just  exactly  on  the  psoas, 
immediately  under  the  sigmoid  bend. 

It  cannot  be  explained  by  the  flexure  in  the  sigmoid, 
for  it  is  not  sharp  enough.  In  these  very  cases  the 
sigmoid  was  almost  straight  over  the  adhesions,  and 
therefore  could  not  become  angular.  When  Albers,  of 
Bonn,  said,  over  two  generations  ago,  that  the  caecum 
was  the  disturbing  element  in  man's  trouble  in  the  right 
iliac  fossa,  he  had  a  grain  of  truth  on  his  side,  for  there 
do  exist  old  adhesions  around  the  caecum  separated 
from  the  appendix  which  do  not  appear  connected  with 
the  appendix.  It  must  not  be  forgotten  that  about  all 
fatal  pathology  lies  in  the  appendix.  I  am  mathemati- 
cally investigating  one  hundred  cases  of  autopsies  on  the 
abdominal  viscera.  So  far  I  have  done  with  as  much  care 
as  possible  nineteen  autopsies  of  this  proposed  one  hun- 
dred, and  many  interesting  revelations  have  arisen.  Fur- 
ther investigation  will  either  confirm  or  deny  this  theory. 


The  Death-rate  of  Montreal  has  fallen  from  37  per 
1,000  in  1872  to  24  per  1,000  in  1892. 


7i6 


MEDICAL   RECORD. 


[December  8,  1894 


ELECTRIC    LIGHT    AS    A    DIAGNOSTIC    AND 
THERAPEUTIC  AGENT.1 

By   MARGARET   A.   CLEAVES,   M.D., 

INSTRUCTOR    IN     ELECTRO-THERAPEUTICS,    MEW    YORK    POST  GRADUATE    MEDI 
CAL    SCHOOL. 

The  attempt  to  illuminate  the  less  accessible  cavities  of 
the  human  body  had  its  origin  as  long  ago  as  the  be- 
ginning of  the  present  century.  Bozzoni,  in  1805,  first 
conceived  the  possibility  of  throwing  light  into  the  blad- 
der, but  without  much  success.  In  1853  Desormeaux 
exhibited  the  first  endoscope  before  the  Paris  Academy 
of  Medicine.  Julius  Brack,  of  Breslau,  is  said  to  have 
first  employed  the  platinum  loop  as  a  source  of  illumina- 
tion for  medical  work.  In  1867  he  exhibited  a  stomato- 
scope  designed  to  assist  in  examining  the  rectum  and 
bladder.  These  old  instruments  were  cumbersome  and 
inefficient,  but  Nitze  and  Leiter  have  constructed  a  cy- 
toscope which  has  achieved  remarkable  success. 

The  use  of  the  electric  light  in  medicine  now  covers  a 
much  larger  field  and  has  become  an  important  aid  in 
diagnosis.  By  it  the  dentist  can  detect  spots  of  de- 
cay in  the  tooth  which  without  it  would  escape  his  ob- 
servation. The  nose  and  throat  specialists  are  able  to 
search  the  minutest  recesses,  while  the  physician  who  is 
in  doubt  regarding  certain  diseased  conditions  of  the 
stomach  and  abdomen,  may  literally  study  his  obscure 
cases  in  a  new  light. 

In  1885  Dr.  Louis  J.  Lauterbach,  of  Philadelphia,  pub- 
lished an  account  of  the  use  of  the  incandescent  electric 
light  in  examinations  of  the  eye,  ear,  and  throat.  He 
recommended  for  illumination  of  the  ear  the  use  of  a 
tiny  lamp  placed  close  to  the  speculum  and  enclosed  in  a 
shield  having  a  small  circular  opening  in  it. 

In  1890,  Theodor  Heryng  was  able  to  illuminate  the 
antrum  of  Highmore  by  using  a  five-volt  incandescent 
lamp  attached  to  a  tongue'  depressor.  He  was  able  in 
more  than  thirty  cases  to  diagnosticate  latent  empyema 
without  exploratory  puncture,  and  this  diagnosis  was 
corroborated  by  the  subsequent  removal  of  the  pus. 

About  two  years  ago  Davidsohn  called  attention  to 
the  value  of  illuminating  the  eyeball  by  an  incandescent 
lamp  in  the  mouth.  Quite  recently  Burger  has  claimed 
that  luminous  sensations  in  the  eyeball  were  far  more 
distinctive  tests  than  illumination,  as  a  very  feeble  light 
was  sufficient  to  excite  the  subjective  sensations. 

On  November  1,  1893,  the  writer  had  the  pleasure  of 
demonstrating  this  point  to  a  number  of  medical  persons 
by  introducing  an  incandescent  lamp  into  the  mouth. 
On  the  lamp  being  illuminated  the  pupils  of  the  eyes  were 
seen  as  blood  red  apertures,  and  it  was  also  shown  that  if 
the  person  so  illuminated  cast  his  eyes  upward  at  an 
angle  of  45  °  he  could  discover  the  same  phenomenon. 
Mr.  N.  Stevenson  has  called  attention  to  the  curious 
fact  that  when  light  is  thus  introduced  the  pupils  do  not 
contract. 

Dr.  D.  Braden  Kyle,  of  Philadelphia,  has  recently  in- 
troduced some  improvements  for  examining  the  nasal 
cavity.  The  essential  feature  of  his  method  is  the  placing 
of  the  lamp  within  the  post-nasal  space  so  that  the  parts 
are  seen  by  direct  instead  of  by  reflected  light.  He  also 
recommends  that  the  lamp  be  protected  with  a  cap  of 
aluminum,  by  the  aid  of  which  it  can  be  used  continu- 
ously for  thirty  seconds  without  inconvenience  from 
heat.  This  lamp  was  furnished  by  Charles  Leutz,  of 
Philadelphia. 

Within  the  past  few  months  Dr.  Charles  W.  Caldwell 
has  published  an  article  in  which  he  has  considered  the 
subject  of  transillumination  of  the  mastoid  cells  as  a 
means  of  diagnosis  of  mastoiditis  interna  suppurativa. 
The  examination  must  be  made  in  a  perfectly  dark  room. 
When  the  lamp  is  inserted  well  into  the  external  audi- 
tory meatus  and  the  current  turned  on,  the  healthy  mas- 
toid is  illuminated  with  a  red  glow,  extending  from  the 
apex  to  the  lateral  sinus  and  to  the  limits  of  the  cells 

1  Read  before  the  American  Electro-therapeutic  Association,  Sep- 
tember 27,  1894. 


above.  By  placing  the  lamp  on  different  parts  of  the 
mastoid  the  limitation  of  the  cells  and  the  position  of 
the  lateral  sinuses  may  be  accurately  mapped  out,  and 
pathological  conditions  demonstrated  if  present.  If 
there  is  a  purulent  condition  in  the  cells  this  portion  will 
appear  dark.  Comparison  with  the  opposite  healthy 
side  renders  the  diagnosis  of  pus  in  the  mastoid  cells 
complete,  whether  or  not  the  usual  symptoms  are 
present. 

The  same  observer  has  also  described  a  method  of 
transilluminating  the  accessory  sinuses  of  the  nose,  by 
which  he  was  able  to  detect  a  large  mucous  polypus  by 
its  translucency,  higher  refraction,  and  globular  form, 
which  concentrated  the  light,  and  increased  the  brill- 
iancy of  the  illuminated  area. 

Dr.  Chevalier  Jackson,  of  Pittsburgh,  has  also  practised 
transillumination  of  the  nose  successfully  for  some  time 
past.  His  method  differs  somewhat  from  that  previously 
described,  as  he  uses  a  fifty-candle-power  lamp  and  a 
hollow  silvered  glass  rod. 

As  an  instance  of  the  great  clinical  value  of  electric 
illumination  in  diseases  of  the  nose  and  throat  a  case  of 
tubercular  laryngitis  has  been  reported  in  which  no 
tubercle  bacilli  could  be  found  in  the  expectoration,  but 
on  passing  an  applicator  deeply  down  into  the  passages 
under  the  guidance  of  a  brilliant  electric  light,  some 
secretion  was  found,  which  on  removal  proved  to  contain 
innumerable  tubercle  bacilli. 

The  work  of  Dr.  Max  Einhorn  in  connection  with  the 
transillumination  of  the  stomach  is  well  known.  His 
"gastrodiaphane,"  first  described  in  November,  1889, 
consists  of  a  soft  rubber  stomach  tube  containing  wire 
conductors  and  having  a  small  Edison  incandescent  lamp 
mounted  at  the  gastric  end  of  the  tube.  By  its  aid  the 
examination  is  performed  so  quickly  that  there  is  no 
danger  of  the  lamp  becoming  too  hot,  especially  as  the 
water  in  the  stomach  (swallowed  by  the  patient  just 
previously)  exerts  a  cooling  action  upon  it.  Dr.  D.  D. 
Stewart,  in  the  Medical  News  for  February  18,  1893, 
speaks  of  the  value  of  gastrodiaphany  as  follows :  "  The 
actual  utility  of  gastrodiaphany  over  other  methods  of 
outlining  the  stomach  lies  especially  in  the  application  of 
the  diaphanoscope  to  the  differentiation  of  gastroptosis 
and  gastrectasia,  as  by  it  the  determination  of  the  site  of 
the  lesser  curvature  is  far  more  readily  made  than  by  in- 
flation." 

Theodor  Heryng  has  succeeded  in  transilluminating 
the  anterior  walls  of  the  vagina.  With  the  help  of  a 
Ferguson  speculum  he  was  also  able  to  insert  an  electric 
apparatus  into  the  rectum  and  so  transilluminate  the  pos- 
terior wall  of  the  vagina  as  far  as  the  posterior  fornix. 

With  reference  to  apparatus,  it  is  a  matter  for  regret 
that  much  of  the  intended  experimental  work  has  not 
been  done  on  account  of  the  great  difficulty  experienced 
in  securing  suitable  lamps. 

The  W.  F.  Ford  Surgical  Instrument  Company  have 
furnished  a  lamp  for  transillumination  of  the  frontal  si- 
nuses, also  one  for  the  transillumination  of  the  antrum  of 
Highmore,  and  a  head  lamp.  The  Galvano  Faradic 
Manufacturing  Company  have  furnished  a  small  mouth 
lamp  for  general  use.  The  use  of  a  lamp  bps  also  been 
secured  for  the  transillumination  of  the  bowel,  known  as 
Hertyng's  lamp,  and  a  lamp  for  the  transillumination  of 
the  pelvic  tissues  devised  by  myself.  These  lamps  have 
all  been  personally  tested,  with  the  following  results : 

Ford's  head  lamp  requires  10^  volts  and  1  ampere, 
and  gives  3  candle  power.  For  use  with  a  street  current, 
it  should  be  placed  in  circuit  with  one  16  and  one  24- 
candle-power  lamp.  Ford's  lamp  for  the  transillumina- 
tion of  the  frontal  sinuses  requires  8  volts  and  .8  ampere 
and  gives  about  2-candle  power.  For  use  with  street 
current  two  16  candle-power  lamps  should  be  placed  in 
circuit.  Ford's  antrum  lamp  requires  8  volts  and  .8 
ampere  and  gives  a  little  over  2  candle  power.  For  use 
with  the  street  current,  one  16  and  one  24  candle-power 
lamps  are  needed.  The  lamp  supplied  by  the  Galvano- 
Faradic  Company,  requires  s}4  volts  and  .8  ampere  and 


December  8,  1894] 


MEDICAL   RECORD. 


717 


gives  a  little  over  1*  candle  power.  For  use  with  street 
current  it  requires  two  16  candle-power  lamps  in  circuit. 
Hertyng's  lamp  for  transillumination  of  the  bowels  has  a 
shield  or  cap  over  it  with  an  attachment  to  a  fountain 
syringe  so  that  water  is  allowed  to  flow  about  the  lamp 
and  also  through  the  terminal  opening  into  the  bowel  it- 
self. It  requires  9  volts  and  .  7  amp&re  and  gives  a  little 
over  2  candle  power. 

The  lamp  for  the  transillumination  of  the  pelvic  tis- 
sues, devised  by  myself,  requires  32  volts  and  .8  ampere, 
giving  about  8-candle  power.  It  was  intended  to  be  a 
20-candle  power  lamp,  but  as  it  passed  through  a  chapter 
of  accidents,  it  is  at  present  only  an  8  candle  power,  but 
will  be  replaced  shortly  by  one  of  20  candle  power. 
The  lamps  variously  used  and  the  results  obtained  from 
them  have  already  been  indicated  in  the  report.  The 
Edison  lamp  or  condenser  for  direct  illumination  of  the 
different  cavities  of  the  body  has  also  been  tested.  It  is 
best  suited  to  positions  in  which  the  direct  rays  of  light 
may  be  used  and  is  also  satisfactory  where  the  light  has 
to  be  reflected. 

So  far  as  the  transillumination  of  the  bowel  is  con- 
cerned, nothing  has  as  yet  been  done.  A  number  of 
observations  have  been  made  in  transillumination  of  the 
pelvic  tissues.  As  a  result  of  these  it  is  found  that  wher- 
ever there  is  morbid  material,  either  in  the  form  of 
exudative  matter  or  abnormal  growths,  as  fibroid  tumors, 
sarcoma,  etc.,  the  tissues  of  the  anterior  pelvic  and  ab- 
dominal walls  are  not  transilluminated  but  remain  abso- 
lutely black.  In  the  abnormal  conditions  which  have 
been  examined  the  pelvic  cavity  has  been  pretty  well 
filled,  so  that  there  has  been  no  transillumination.  Of 
course  with  the  morbid  material  on  one  side  only,  the 
other  side  should  be  transilluminated.  In  so  far  as  the 
writer  has  done  any  work  in  this  direction,  she  regards 
transillumination  of  rather  doubtful  utility.  The  condi- 
tions can  be  much  more  accurately  determined  by  means 
of  the  educated  finger  than  by  any  candle  power  of  elec- 
tric light  that  has  yet  been  used. 

I  have  been  able  to  obtain  translucency  of  the  tissues 
within  two  inches  of  the  umbilicus,  but  have  demon- 
strated nothing  save  the  course  of  blood-vessels. 

The  foregoing  statements  give  a  fair  idea  of  the  use  of 
electric  light  in  diagnosis,  but  they  by  no  means  compass 
all  the  methods  by  means  of  which  electric  light  is  help- 
ful in  therapeutics.  One  of  the  recent  adaptations  is 
known  as  the  electric-light  bath,  and  is  based  on  the 
proposition  that  the  properties  of  electric  light  are  simi- 
lar to  those  of  sunlight.  By  means  of  a  suitably  con- 
structed cabinet,  patients  are  subjected  to  the  rays  of  a 
number  of  incandescent  lamps.  The  temperature  can  be 
regulated  by  passing  the  current  through  a  resistance  coil 
and  may  vary  between  900  and  1500  F.,  with  a  result 
equivalent  to  a  combined  light  and  vapor  bath.  The 
skin  is  browned  as  if  by  sun-burn  and  the  effect  is  claimed 
to  be  most  salutary. 

The  writer  has  had  placed  in  her  hands  for  use  an 
apparatus  furnished  by  a  manufacturer  of  Newark, 
which  is  worthy  of  attention  as  a  means  of  experimental 
work.  It  is  a  cabinet  with  an  arc  light  arranged  in  front 
of  a  large  tin  reflector  which  can  be  raised  or  lowered  at 
will.  This  and  a  lamp  with  a  very  strong  lens  and  re- 
flector for  localization  of  the  rays  of  light  are  the  only 
apparatus  which  have  been  placed  at  my  disposal.  It  is 
impossible,  therefore,  to  say  which  form  of  apparatus  is 
best.  No  observations  have  yet  been  made  as  to  the 
efficacy  of  the  light  used  through  glass  or  similar  sub- 
stances, nor  have  investigations  been  attempted  which 
would  enable  me  to  arrive  at  any  conclusion  as  to  pos- 
sible difference  in  therapeutic  effect  between  electric  light 
and  solar  light. 

Turning  now  to  a  consideration  of  the  effect  of  light  on 
living  organisms  we  find  that  plants  have  been  forced 
into  rapid  growth  by  exposure  to  the  rays  of  the  electric 
light.  M.  D'Arsonval  has  made  many  investigations  on 
the  effect  of  both  sunlight  and  electric  light  on  various 
bacterial  growths.     He  found  that  cultures  exposed  to 


the  white  rays  were  not  colored  while  those  exposed  to 
the  red  rays  had  developed  pigment.  He  also  expressed 
the  opinion  that  light  exerted  a  more  powerful  influence 
over  bacteria  than  ozone  or  even  oxygen. 

Dr.  H.  Marshall  Ward  in  a  paper  read  before  the 
Royal  Society  showed  the  effect  of  light  on  bacilli  from 
the  Thames,  and  found  that  in  all  cases  both  solar  and 
electric  spectra  exerted  no  perceptible  action  whatever  in 
the  infra  red,  red,  orange,  or  yellow  region,  while  all  the 
bacteria  were  injured  or  destroyed  by  the  rays  from  the 
blue  or  violet  spectrum.  The  intervention  of  a  thin 
piece  of  glass  resulted  in  cutting  off  a  large  proportion  of 
the  effective  rays.  The  most  distinctive  rays,  /.*.,  those 
at  the  end  of  the  blue  and  beginning  of  the  violet,  were 
to  some  extent  effective  even  after  reflection  from  the 
inner  faces  of  a  quartz  plate  covering  the  film,  and  the 
glass  on  which  it  was  supported.  This  investigator  goes 
on  to  say  that  these  results  evidently  suggest  that  the 
naked  arc  light  may  prove  to  be  a  very  efficient  disin- 
fecting agent  for  use  in  hospital  wards,  railway  carriages, 
and  other  places  where  the  rays  could  be  projected  di- 
rectly on  the  organisms. 

Theodor  Geisler  in  1892  found  no  qualitative  differ- 
ence between  sunlight  and  electric  light,  only  a  quantita- 
tive difference.  In  the  course  of  some  experiments  on  the 
typhoid  bacillus,  he  found  the  most  decided  effect  was 
produced  by  the  rays  from  the  violet  end  of  the  spectrum. 

P.  A.  Khmelevsky,  of  St.  Petersburg,  after  prolonged 
experiments,  concluded  that  both  solar  and  electric  light 
have  an  undoubted  inhibitory  influence  on  the  growth  of 
microbes. 

Klebs-Loeffler  has  discovered  that  diffused  light  does 
not  prevent  the  development  of  cultures  of  diphtheria  at 
ordinary  temperatures  or  at  a  temperature  as  high  as  95  ° 
F.,  but  that  sunlight  arrests  this  development,  and  after 
an  exposure  of  several  days  sterilizes  bouillon.  This 
bactericidal  power  of  light  toward  the  bacillus  of  diph- 
theria is  due  almost  exclusively  to  the  rays  of  greatest 
refraction,  those  at  the  other  end  of  the  spectrum  having 
little  or  no  action  of  this  kind. 

Some  years  ago  experiments  were  made  with  Jabloch- 
koff  candles  in  the  Paris  sewers,  with  the  result  that  con- 
siderable purifying  action  was  noted. 

In  i88i(?)  Mr.  Harold  P.  Brown,  E.E.,  of  New  York, 
while  using  Brush  arc  lamps  for  lighting  the  basement  of 
a  store  in  Chicago,  noted  that  within  an  hour  after  turn- 
ing on  the  current,  the  odor  from  the  closets,  which  at 
first  was  very  offensive,  became  entirely  neutralized. 

The  writer,  who  has  an  arc-light  apparatus  in  her  office 
such  as  has  been  described,  made  the  following  observa- 
tion on  a  recent  excessively  hot  day.  The  refuse  barrels 
which  had  accumulated  over  Sunday  in  the  basement  and 
had  not  yet  been  removed  Monday  morning,  emitted  a 
very  unpleasant  odor,  which  filled  the  office.  The  arc 
light  was  turned  on  and  the  writer  left  the  room  for  half 
on  hour.  On  her  return  she  found  that  every  evidence 
of  odor  had  disappeared  and  that  the  air  seemed  perfectly 
pure,  while  in  another  part  of  the  house  which  was  not 
near  enough  to  be  affected  by  the  light,  the  odor  still 
persisted  as  before.  This  action  was  undoubtedly  due  to 
the  ozone. 

In  an  article  in  The  Medical  Week  for  August  17, 
1894,  Dr.  R.  L.  Boqles  gives  some  interesting  facts  re- 
garding the  influence  of  solar  rays  on  the  skin  and  con- 
cludes that  some  other  principle  must  be  at  work  beside 
heat.  Some  observations  of  M.  Charcot  tend  in  the  same 
direction.  The  phenomenon  appears  to  be  due  to  the 
action  of  the  chemical  rays  in  the  ultra  violet  end  of  the 
spectrum.  Mr.  H.  B.  Hewetson,  in  the  British  Medical 
Journal  ion  1893,  c*tes  ^ve  cases  m  which  eyes  became 
inflamed  after  watching  the  operation  of  electric  wiring 
by  the  arc  light,  unless  the  observer  was  protected  by  a 
shield  of  thick  ruby  glass.  It  was  found  that  the  skin 
of  the  face  and  neck  would  become  tanned  and  would 
peel  off  just  as  if  it  had  been  exposed  to  the  rays  of  the 
sun.  This  was  evidently  not  due  to  heat  but  to  the 
chemical  rays. 


7i8 


MEDICAL   RECORD. 


[December  8,  1894 


M.  Gautier  has  recently  investigated  a  curious  phe- 
nomenon, namely,  that  substances  which  have  been  sub- 
mitted to  the  action  of  electricity  or  which  have  been 
exposed  to  the  direct  rays  of  the  sun,  are  in  a  peculiar 
state  of  excitement  which  renders  them  much  more  active 
as  regards  one  another  than  are  the  same  substances  pre- 
pared by  the  ordinary  methods  of  the  laboratory. 

Such  being  the  admitted  facts,  one  is  prepared  for  the 
assertion  that  electric  light  may  be  made  a  potent  thera- 
peutic agent.  Dr.  Gatchkowski,  St.  Petersburg,  1892, 
reports  twenty-seven  cases,  chiefly  of  rheumatic  and 
neuralgic  pain,  which  he  had  quickly  cured  by  the 
electric  light,  and  Stanislaus  von  Stein  also  reports  good 
results. 

Few  observations  have  yet  been  made  by  the  writer  as 
to  the  therapeutic  value  of  electric  light.  Something, 
however,  has  been  done,  as  the  following  particulars  will 
show.  In  one  case  of  cervico-occipital  neuralgia  of  great 
severity,  coupled  with  supra-orbital  neuralgia,  the  appli- 
cation of  the  electric  light  was  found  to  be  exceedingly 
grateful  to  the  patient  and  resulted  in  relief  from  pain  for 
several  hours.  In  a  case  of  intense  pain  in  the  roots  of 
the  cervical  cord,  an  extension  of  neuritis,  the  only  way 
the  patient  was  able  to  get  sleep,  without  hypnotics,  was 
by  having  an  electric  lamp  placed  directly  over  the  cer- 
vical cord.  In  this  instance,  however,  it  is  believed  that 
the  heat  only  produced  this  grateful  result. 

The  following  experimental  observation  is  reported 
somewhat  at  length : 

J.  C ,  twenty-one  years  of  age ;  suffering  from 

anaemia  and  enuresis.  The  electric  arc-light  bath  was 
given  for  twenty  minutes.  The  patient  was  placed  upon 
a  stool  with  the  entire  body  exposed  to  the  rays  of  light, 
special  attention  being  paid  to  localizing  it  at  the  lumbar 
and  sacral  plexuses.  The  treatment  was  entirely  experi- 
mental, but  with  the  expectation  of,  at  least,  improving 
the  nutrition.  The  writer  felt  willing  to  undertake  it,  as 
she  was  confident  of  being  able,  later  on,  to  cure  the 
enuresis  by  long  percussive  static  sparks.  Hie  patient 
had  suffered  from  nocturnal  enuresis  as  far  back  as  she 
could  remember.  Menstruation  was  established  at  seven- 
teen and  was  perfectly  regular.  All  the  conditions  were 
normal  save  that  the  patient  was  decidedly  anaemic,  and 
suffered  from  facial  acne.  The  pupils  were  always  di- 
lated, and  there  was  a  tendency  to  constipation,  the 
bowels  often  moving  but  once  in  two  days — rarely  two 
or  three  days  consecutively.  The  wet  nights  were  slight- 
ly variable ;  she  would  sometimes  go  in  summer  two  or 
three  nights  without  trouble,  but  rarely  for  this  time  in 
winter.  In  all,  sixteen  treatments  were  given,  extend- 
ing over  a  period  of  one  and  a  half  months,  three  times 
weekly.  Careful  examinations  of  the  urine  were  made 
at  first,  and  the  pulse,  temperature,  and  skin  were  care- 
fully watched.  Thirteen  observations  were  taken  of  the 
temperature  and  pulse.  In  eleven  instances  the  pulse 
dropped,  and  it  was  always  of  better  volume  after  the 
bath.  In  two  instances  the  pulse  remained  unchanged 
but  its  volume  improved ;  while  in  every  instance  (thir- 
teen times)  there  was  a  rise  in  the  temperature  of  from 
one  to  eight  degrees.  The  skin  always  became  moist 
under  the  applications,  and  during  the  last  treatments 
was  very  profuse.  There  was  a  general  sense  of  well- 
being  expressed  by  the  patient  after  each  application. 
Soon  after  coming  under  treatment  the  bowels  became 
regular,  and  there  was  no  trouble  during  the  time  she 
was  under  care,  nor  since  then,  a  matter  of  nearly  six 
months,  excepting  for  a  few  days  at  one  time  after  dis- 
continuance of  treatment,  when  very  much  hurried  mak- 
ing preparations  for  leaving  the  city.  The  urine  was 
analyzed  from  time  to  time,  and  showed  a  steady  increase 
in  the  amount  of  urea  eliminated  The  patient  gained 
a  pound  and  a  half  during  the  first  two  weeks,  and  since 
that  time  has  gained  seven  pounds  more,  and  is  in  better 
health  than  for  several  years.  The  temperature  of  the 
bath  varied  on  different  days,  being  affected  by  the  out- 
side temperature,  but  it  ranged  from  900  to  ioo°  F.,  and 
the  patient  left  the  office  feeling  much  better.     No  drug 


of  any  sort  was  given  or  allowed  the  patient  during  the 
time  she  was  under  observation. 

Arrangements  have  just  been  made  with  a  dermatolo- 
gist to  have  observations  made  as  to  the  value  of  arc  light 
in  parasitic  skin  disease,  and,  in  fact,  to  carry  out  a  sys- 
tematic series  of  scientific  experiments  bearing  upon 
these  points.  The  writer  is  well  aware  that  the  value  of 
one  or  two  experimental  cases  is  open  to  question,  bat 
under  the  special  circumstances  already  referred  to  has 
thought  well  to  mention  the  few  cases  quoted,  wishing  it 
to  be  distinctly  understood  that  she  considers  the  inves- 
tigation very  incomplete  in  its  present  stage. 

It  is  interesting  to  note  that  Dr.  Dawson  Tyner,  of 
London,  commenting  upon  the  well-known  treatment  of 
goitre  by  smearing  the  part  with  red  iodide  of  mercury 
ointment  and  then  exposing  the  surface  to  direct  sun- 
light, suggests  that  the  effect  is  due  to  the  power  of  iodine 
to  cut  off  the  visible  rays  of  the  spectrum.  The  fact  that 
red  iodide  is  the  more  efficacious  points  in  this  direction, 
for  it  would  serve  to  transmit  the  heat  rays  only.  In 
this  way  the  part  is  subjected  to  the  full  blaze  of  the 
calorific  rays  without  the  vibrations  of  its  molecules  being 
altered  by  the  visible  rays.  If  this  theory  be  correct  we 
could  expose  diseased  parts  to  sunlight  or  to  a  fire  after 
the  application  of  iodine.  May  not  this  suggestion  give 
us  a  valuable  hint  in  connection  with  the  use  of  the  elec- 
tric-light bath. 

And  now,  after  studying  this  novel  and  interesting 
subject  until  we  have  begun  to  form  some  adequate  con- 
ception of  the  potency  of  light,  we  are  confronted  with 
the  rather  startling  announcement,  from  no  less  a  physi- 
cist than  Professor  Dolbear,  that  there  is  no  such  thing 
as  light — that  there  are  no  peculiar  waves  which  can  be 
called  light.  In  proof  of  this  assertion  he  describes  a 
method  of  taking  a  photograph  of  an  object  in  absolute 
darkness  by  means  of  the  ether  waves  set  up  by  working 
an  electrical  machine.  We  have  already  seen  how  similar 
are  the  effects  of  sunlight  and  the  electric  light,  but  lest 
there  should  still  be  a  lingering  doubt  in  the  minds  of 
some  individuals  regarding  this  point,  that  distinguished 
experimenter,  Nikola  Tesla,  comes  forward  and  produces 
a  faint  glow  of  light  in  a  dark  room  with  alternating  cur- 
rents of  800,000  voltage,  by  means  of  atmospheric  vibra- 
tions to  such  an  extent  that  the  phenomenon  would  no 
longer  be  electricity,  but  light ! 

68  Madison  Avenue,  Nkw  York,  October  30,  1894, 


Who  Fed  Fevers  ? — The  story  of  the  physician  who 
wished  to  have  as  his  epitaph,  "  He  fed  fevers,91  has  been 
told,  the  saying  being  usually  attributed  to  Stokes.  Dr. 
Julius  Althaus  writes  to  the  British  Medical  Journal  that 
it  was  Graves  who  said  this.  In  the  biographical  notice 
of  Graves  which  precedes  his  edition  of  the  latter's 
"  Studies  in  Physiology  and  Medicine,"  Stokes  says  : 
"Graves  was  going  round  the  hospital,  when,  on  enter- 
ing the  convalescent  ward,  he  began  to  expatiate  on  the 
healthy  appearance  of  some  who  had  recovered  from  se- 
vere typhus.  '  This  is  all  the  effect  of  our  good  feeding/ 
he  exclaimed ;  'and  lest,  when  I  am  gone,  you  may  be  at 
a  loss  for  an  epitaph  for  me,  let  me  give  you  one  in  three 
words : 

"  «  He  fed  Fevers.'  " 

Trousseau  has  alluded  to  this  point  in  his  introduction 
to  the  French  translation  of  "Graves's  Clinical  Lect- 
ures," where  he  says :  "  Graves's  maxims  relating  to  the 
regimen  of  fever  have  become  the  guide  of  practitioners  of 
all  countries ;  yet  when  he  inculcated  the  necessity  of 
giving  nourishment  in  long-continued  pyrexias,  the  Dub* 
lin  physician  assailed  single-handed  an  opinion  which 
appeared  to  be  justified  by  the  practice  of  all  ages.  Had 
he  rendered  no  other  service  than  completely  reversing 
medical  practice  upon  this  point,  Graves  would,  by  that 
act  alone,  have  acquired  an  indefeasible  claim  to  our 
gratitude." 


December  8,  1894] 


MEDICAL   RECORD. 


719 


MAY  THE  SHOCK  OF  A  RAILROAD  ACCI- 
DENT EVER  BE  BENEFICIAL  TO  THE  RE- 
CIPIENT ? 1 

By  RICHARD  C.   NEWTON,   M.D., 

MONTCLAIR,    N.  J., 

SUBGEON  TO  THI  NEW  YORK  AND  GREENWOOD  LAKE  RAILROAD ;  ATTENDING 
SURGEON  TO  THE  MOUNTAINSIDE  HOSPITAL  ;  PHYSICIAN  TO  THE  ESSEX  COUNTY 
PENITENTIARY  ;  LATE  CAPTAIN  AND  ASSISTANT  SURGEON  UNITED  STATES  ARMY. 

My  excuse,  if  one  be  needed,  for  selecting  the  above  sub- 
ject for  a  paper  before  this  learned  body  is  that  a  brief 
consideration  of  the  possible  benefits  of  a  railroad  acci- 
dent may  prove  of  interest  and  profit,  if  for  no  other  rea- 
son,  simply  because  we  have  been  made  so  familiar  with 
the  injuries,  both  immediate  and  remote,  which  a  railroad 
accident  may  inflict  upon  its  unfortunate  victims,  that  it 
may  be  worth  our  while  to  consider  the  other  side  of  the 
question,  and  to  dwell  for  a  few  moments  upon  the  bene- 
fits, if  any  there  be,  which  may  follow  such  an  accident. 

The  great  variety  and  extent  of  railroad  injuries  afford 
to  this  branch  of  surgery  an  interest  peculiarly  its  own. 
The  railroad  surgeon  is  called  upon  to  treat  lesions  more 
variable  and  complex  than  those  that  usually  come  under 
the  care  of  the  military  surgeon.  In  war  it  is  true  that 
men  are  horribly  wounded  by  missiles  and  explosives  of 
different  kinds,  are  cut  by  sabres,  trampled  by  horses, 
stabbed  by  bayonets,  etc.  They  are,  however,  seldom  or 
never  scalded  by  escaping  steam,  burned  or  drowned  in 
wrecked  cars,  or  crushed  under  heavy  bodies.  Moreover, 
soldiers  are  picked  men  in  the  prime  of  life,  and  are,  by 
their  training  and  surroundings,  inured  to  danger.  They 
look  upon  wounds,  sickness,  and  even  death,  as  some  of 
the  contingencies  of  their  profession.  In  battle,  espe- 
cially, they  are  nerved  up  to  a  high  pitch,  and  often  suf- 
fer willingly  for  the  cause  in  which  they  are  enlisted. 
It  is  not  so  with  the  victims  of  a  railroad  accident. 
These  unfortunates  are  of  all  ages  and  stations,  of  both 
sexes,  and  of  every  degree  of  bodily  strength  and  mental 
calibre.  Furthermore  they  are  injured  when  totally  un- 
prepared for  an  accident.  They  are  taken  entirely  by 
surprise,  and  the  shock  and  fright  complicate  and  increase 
their  injuries,  and  bear  a  considerable  relation  to  the  ul- 
timate result.  The  nervous  and  psychic  lesions  following 
railroad  injuries  have  for  years  engaged  the  attention  of 
the  alienist  and  neurologist,  as  well  as  the  surgeon,  and 
various  and  far-reaching  have  been  the  results  of  their 
studies.  In  these  respects  I  think  that  you  will  agree 
with  me  that  railroad  surgery  covers  a  wider  field  than 
military  surgery. 

Who,  indeed,  ever  heard  of  a  military  spine  ?  Perhaps 
this  is  one  of  the  discoveries  now  in  the  womb  of  the 
future  which  only  awaits  some  bold  accoucheur  for  its  de- 
livery and  addition  to  that  already  numerous  family  of 
disabilities  for  which  enterprising  patriots  may  draw  pen- 
sions from  a  grateful  country. 

A  surgeon  of  this  city  has  described  typhoid  spine,  and 
it  seems  probable  that,  following  in  the  steps  of  Erichsson, 
other  writers  will,  from  time  to  time,  increase  the  present 
stock  of  spines  indefinitely. 

So  far  as  the  scope  of  this  brief  paper  is  concerned,  it 
will  simplify  matters  to  consider  our  subject  under  two 
heads,  as  follows :  1.  May  a  person  suffering  from  some 
bodily  ailment  be  benefited  by  the  shock  of  a  railroad 
accident?  and  2,  May  a  person  suffering  from  some  ner- 
vous or  mental  disorder  receive  benefit  in  a  similar  man- 
ner? 

The  literature  relating  to  railroad  injuries  does  not 
provide  as  many  cases  illustrating  these  questions  as 
could  be  wished.  Yet  some  quite  striking  ones  may  be 
found,  and  doubtless  the  number  would  be  largely  in- 
creased if  railroad  surgeons  generally  would  report  cases 
of  which  they  may  be  cognizant.  Probably  nearly  every 
one  in  this  room  can  recall  cases  in  which  disease  has 
been  checked  or  even  cured  by  the  shock  and  excitement 
of  a  railroad  or  other  serious  accident. 

Hack  Tuke,  in  the  preface  of  his  book,  "  Influence  of 

1  Read  before  the  Erie  Railway  Surgeons'  Association,  at  the  Acad- 
emy of  Medicine,  New  York  City,  January  5,  1894. 


the  Mind  upon  the  Body,"  relates  the  following  case 
which  he  had  found  in  a  newspaper  under  the  heading 
"  Curative  Effects  of  a  Railroad  Collision."  I  quote 
verbatim;  "Allow  me  to  confirm  all  that  your  two 
correspondents  have  related  with  respect  to  the  alarm- 
ing collision  on  the  17th  inst.  on  the  Midland  line. 
Nothing  needs  to  be  added  either  to  their  description 
of  the  circumstance  or  to  their  just  condemnation  of 
the  reckless  negligence  which  brought  us  so  near  to 
death ;  but  the  shock  produced  so  curious  an  effect  on 
myself— an  effect  perhaps  unparalleled  in  the  history  of 
railway  accidents — that  you  will  perhaps  excuse  my 
troubling  you  with  the  details. 

"  At  my  hotel  in  Manchester  I  was  seized  with  all  the 
symptoms  of  a  violent  attack  of  rheumatic  fever,  in  fact, 
my  condition  so  alarmed  me  and  my  dread  of  a  sojourn 
in  a  Manchester  hotel  bed  for  two  or  three  months  was 
so  great  that  I  resolved  to  make  a  bold  sortie  and,  well 
wrapped  up,  start  for  London  by  the  3.30  p.m.  Midland 
fast  train  from  the  London  Road  terminus.  From  the 
time  of  leaving  that  station  to  the  time  of  the  collision 
my  heart  was  going  at  an  express  speed ;  my  weak  body 
was  in  a  profuse  perspiration ;  flashes  of  pain  announced 
that  the  muscular  fibres  were  under  the  tyrannical  control 
of  rheumatism,  and  I  was  almost  beside  myself  with 
toothache.  Crash !  smash !  bump !  and  bang !  and 
from  side  to  side  of  the  carriage  I  went  like  a  billiard- 
ball  under  a  hard  cushion  hit.  The  compartment  was 
soon  seen  to  be  sprinkled  with  the  blood  of  a  hapless 
victim  whose  face  had  come  into  crushing  contact  with 
it"  Dr.  Tuke  continues — "  The  rest  of  this  paper  was 
unfortunately  wanting,  but  I  learnt  from  other  sources 
that,  as  the  heading  intimated  the  patient  was  cured  of 
his  rheumatism." 

I  can  relate  a  somewhat  similar  case  of  serious  ac- 
cident on  shipboard  which  undoubtedly  prolonged  for 
years  the  life  of  the  young  man  who  received  the  injury. 

L.  M ,  aged  about  twenty,  came  of  a  highly  phthis- 
ical family.  His  father  and  mother,  and  all  of  their 
children,  were  consumptive.     The  latter  all  died,  soon 

after  reaching  maturity,  of  this  disease.   When  L.  M 

was  approaching  his  majority,  similar  symptoms  began 
to  manifest  themselves  in  him  to  those  that  had  appeared 
in  the  older  members  of  his  family.  He  was  sent  to  Cali- 
fornia in  a  sailing  vessel  in  the  hope  that  the  voyage 
might  be  of  benefit  to  him.  When  the  ship  was  return- 
ing to  New  York,  the  young  gentleman,  having  climbed 
into  the  rigging,  lost  his  hold  and  fell  from  a  great 
height  on  to  the  deck,  striking  the  keel  of  an  upturned 
boat.  He  sustained  fractures  of  both  legs  and  other 
serious  injuries.  In  one  leg  at  least  he  had  a  compound 
comminuted  fracture.  He  was  laid  up  for  months,  and 
it  was  supposed  that  this  accident  to  one  in  his  delicate 
condition  would  surely  prove  fatal.  For  a  long  period 
one  or  more  open  sinuses  in  his  leg  discharged  freely  pus 
and  bony  detritus.  Contrary  to  the  general  expecta- 
tion, however,  the  young  man  finally  recovered  from  his 
injuries,  although  he  walked  with  a  limp  from  shortening 
of  one  leg.  As  he  began  to  get  about  it  was  observed 
that  his  pulmonary  symptoms  had  disappeared.  He  grew 
stouter  and  stronger.  He  was  able  to  engage  in  business 
and  married  and  had  a  family.  Whether  his  death, 
which  occurred  a  number  of  years  afterward,  was  due  to 
tuberculosis  or  not,  I  have  not  been  able  to  ascertain.  It 
seems  fair  to  assume,  however,  that  his  life  was  prolonged 
by  the  accident. 

A  case  of  gout  suddenly  cured  by  fright  is  given  in 
Tuke's  work  already  cited.  I  quote  verbatim :  "  Peter 
Fether,  the  person  cured,  is  now  alive,  a  householder  in 
Reading,  seventy-three  years  of  age,  a  native  of  Germany, 
and  a  very  hearty  man.  The  first  fit  of  gout  he  ever  had 
was  about  the  year  1773,  and  from  that  time  until  1785 
he  had  a  regular  attack  in  the  spring  of  every  year.  His 
feet,  hands,  and  elbows  were  much  swollen  and  inflamed. 
The  fits  lasted  long  and  were  excruciating.  In  particu- 
lar the  last  fit  in  1 785  was  so  severe  as  to  induce  an  ap- 
prehension that  it  would  inevitably  carry  him  off,  when 


720 


MEDICAL  RECORD. 


[December  8,  1894 


he  was  suddenly  relieved  by  the  following  accident: 
As  he  lay  in  a  small  back  room  adjoining  the  yard,  it 
happened  that  one  of  his  sons  in  turning  a  wagon  and 
horses  drove  the  tongue  of  the  wagon  with  such  force 
against  the  window,  near  which  the  old  man  lay  stretched 
on  a  bed,  as  to  beat  in  the  sash  of  the  window  and  to 
scatter  the  pieces  of  glass  all  about  him.  To  such  a 
degree  was  he  alarmed  by  the  noise  and  violence  that  he 
instantly  leaped  out  of  bed,  forgot  that  he  had  ever  used 
crutches  and  eagerly  inquired  what  was  the  matter.  His 
wife,  hearing  the  uproar,  ran  into  the  room,  where  to  her 
astonishment  she  found  her  husband  on  his  feet  bawling 
against  the  author  of  the  mischief  with  the  most  passionate 
vehemence.  From  that  moment  he  has  been  entirely  ex- 
empt from  the  gout,  has  never  had  the  slightest  touch  of 
it,  and  now  enjoys  perfect  health,  has  a  good  appetite  and 
says  he  was  never  heartier  in  his  life. ' '  The  reporter  of  this 
case,  who  was  no  less  a  person  than  Judge  Rush,  brother 
of  the  famous  surgeon,  goes  on  to  say,  "To  you,  who 
have  long  been  accustomed  to  explore  diseases,  I  leave 
the  task  of  developing  the  principles  on  which  this  mys- 
terious restoration  from  the  lowest  decrepitude  and 
bodily  wretchedness  to  a  state  of  perfect  health  has  been 
accomplished.  I  well  know  that  toothaches,  headaches, 
hiccoughs,  etc.,  are  often  removed  by  the  sudden  im- 
pression of  fear  and  that  they  return  again.  But  to  see 
a  debilitated,  gouty  frame  instantly  restored  to  vigor,  to 
see  the  whole  system  in  a  moment,  as  it  were,  undergo 
a  perfect  and  entire  change,  and  the  most  inveterate  and 
incurable  disease  radically  expelled,  is  surely  a  different 
thing,  and  must  be  acknowledged  a  very  singular  and 
marvellous  event.  If  an  old  man,  languishing  under 
disease  and  infirmity  had  died  of  mere  fright  nobody 
would  have  been  surprised  at  it,  but  that  he  should  be 
absolutely  cured  and  his  constitution  renovated  by  it,  is 
a  most  extraordinary  fact,  which  while  I  am  compelled 
to  believe  by  unexceptionable  evidence  I  am  totally  at  a 
loss  to  account  for.'1 

A  case  of  the  relief  of  ascites  due  to  an  accident  is 
recorded  by  Dr.  John  Pennington,  who  says:  "  A  sailor 
in  an  ascites  fell  off  the  end  of  the  yard  into  the  sea ; 
the  weather  being  calm  he  was  taken  up  unhurt,  but 
to  use  the  sailor's  words  who  told  me  the  story,  he 
was  frightened  half  to  death  and  as  soon  as  he  was 
taken  out  of  the  water  he  discharged  a  gallon  of  urine 
or  more."  Dr.  Pennington  observes,  "the  sedative 
operation  of  fear  was  no  doubt  the  cause  of  the  cure." 

I  cannot  forbear  to  give  one  other  case  which  was  re- 
lated to  me  in  my  boyhood.  An  Irish  peasant  had  suf- 
fered for  a  considerable  time  with  fever  and  ague  and  the 
ordinary  remedies  having  failed  to  arrest  the  disease,  an 
extraordinary  one  was  employed,  some  human  ordure 
was  concealed  in  a  bowl  of  milk,  which  the  patient  was 
made  to  drink  to  the  bottom.  The  intense  disgust  and 
horror  which  the  dregs  of  this  dose  caused,  it  was  alleged, 
entirely  <  broke  the  chills/  " 

I  have  given  these  cases  at  some  length  because  they 
appear  to  me  remarkable,  and  because  their  recital  an- 
swers the  first  of  the  two  questions  that  were  asked  in 
the  beginning  of  this  paper,  viz. :  "  May  a  person  suffer- 
ing from  some  bodily  ailment,  be  benefited  by  the 
shock  of  a  railroad  accident  ?  "  There  is  no  doubt  that 
a  favorable  result  may  follow  in  certain  cases.  Naturally 
we  should  hear  of  such  results  far  oftener,  were  it  not 
for  the  fact  that  the  proportion  of  people  injured  in  rail- 
road accidents  to  the  whole  number  of  travellers  is  ex- 
ceedingly small ;  and  of  the  injured  a  very  small  per- 
centage are  suffering  from  illness  at  the  time  of  the 
accident. 

As  to  the  second  division  of  our  subject,  I  find  that 
the  time  allotted  me  is  already  about  exhausted,  and 
that  the  field  for  discussion  upon  the  effects  of  shock 
upon  the  nervous  system  in  health  and  disease  is  almost 
without  limit.  I  could  multiply  cases  almost  without 
end,  to  show  that  the  emotions — fear,  anger,  and  excite- 
ment— can,  and  frequently  have  benefited  or  even  cured 
the  most  severe  nervous  maladies.     From  the  nature  of 


such  complaints  such  a  result  seems  reasonable  enough. 
It  is  well  known  that  such  grave  nervous  lesions  as 
chorea,  paralysis  agitans,  asthma,  epilepsy  etc.,  are  fre- 
quently brought  on  by  fright  or  other  strong  emotion 
and  are  also  cured  by  similar  means. 

I  will  not  take  up  your  time  by  citing  cases  of  which  a 
number  are  given  in  Tuke's  work  already  referred  to. 
Professor  Goodell,  of  Philadelphia,  in  a  recent  lecture, 
has  related  some  remarkable  cases  of  coccyodynia  and 
other  nervous  affections  of  which  the  cause  was  mental 
or  emotional,  and  which  were  apparently  cured  by  anger, 
fright,  or  excitement. 

I  cannot  forbear  to  quote  one  case,  which  is  given 
in  Professor  Norton's  "  Life  and  Letters  of  James  Rus- 
sell Lowell,"  recently  published.  It  seems  that  while 
Mr.  Lowell  was  minister  to  Spain,  his  wife's  health  was 
apparently  in  quite  a  precarious  condition.  He  received 
a  letter  from  the  State  Department  at  Washington, 
offering  him  the  mission  to  England,  which  he  was  de- 
sirous of  accepting,  but  felt  obliged  to  decline,  as  it  did 
not  seem  possible  that  his  wife  could  be  moved.  In 
fact  she  was  confined  to  her  bed  and  seemed  perfectly 
helpless.  After  Mr.  Lowell  had  despatched  his  letter  de- 
clining the  English  mission,  his  wife's  bedclothes  took 
fire ;  whereupon  she  jumped  up  with  the  greatest  alacri- 
ty and  for  the  time  being  at  least  found  herself  quite 
well.  Mr.  Lowell  then  sent  a  telegraphic  message  to 
Washington,  in  time  to  anticipate  his  letter  of  declina- 
tion, and  accepted  the  mission. 

That  intractable  and  discouraging  disease  epilepsy  has 
occasionally  been  cured  by  a  fall  or  blow,  or  by  fright 
It  would  seem  that  the  nervous  elements  that  have  been 
disarranged  by  one  shock  might  be  shaken  back  into 
place  by  another.  I  would  explain  the  beneficial  re- 
sults that  have  followed  most  of  the  surgical  operations 
for  epilepsy  by  saying  that  they  are  caused  by  the  fright 
or  excitement  of  the  operation. 

I  believe  that  enough  has  been  said  to  prove  that  a 
railroad  accident,  horrible  as  it  is  apt  to  be,  may  be  of  ben- 
efit to  those  concerned  in  it.  As  a  therapeutic  measure 
fright  or  shock,  produced  by  such  a  means  is  of  course 
entirely  out  of  the  question. 

How  far  a  physician  may  be  justified  in  shocking  or 
frightening  a  recalcitrant  or  hysterical  patient  is  a  prob- 
lem requiring  the  nicest  discrimination  and  the  highest 
diagnostic  acumen.  Such  a  course  has  sometimes  suc- 
ceeded in  doing  good.  It  has  often  done  harm.  Of 
practical  results  our  discussion  may  have  been  barren, 
but  I  venture  to  hope  that  it  has  not  been  entirely  unin- 
teresting. 


A  Strange  Disease  in  Dublin. — A  number  of  the  in- 
mates of  the  Richmond  Insane  Asylum  at  Dublin  have 
been  attacked  with  a  disease  resembling  beriberi  in  many 
of  its  features.  The  symptoms  are  a  general  oedema,  be- 
ginning in  the  legs  and  spreading  thence  to  the  whole 
body,  followed  by  peripheral  neuritis  and  paralysis. 
There  is  no  fever,  and  albumin  has  been  found  in  the 
urine  in  a  few  cases  only.  The  heart  is  weak  and  dyspnoea 
is  complained  of.  After  a  while  the  oedema  diminishes 
and  signs  of  neuritis  appear ;  then  atoxic  symptoms  set 
in  with  loss  of  the  patellar  reflex  and  muscular  atrophy  of 
the  extremities.  Post-mortem  examination  has  shown 
hydropericardium,  oedema  of  the  lungs,  ascites,  and 
fatty  degeneration  of  the  heart  and  kidneys.  Over  a 
hundred  inmates  of  the  asylum  have  been  attacked  with 
the  malady. 

Porous  Glass  for  Windows.  — The  latest  hygienic 
craze  in  Paris  is  the  use  of  porous  glass  for  windows. 
This  is  declared  to  possess  all  the  advantages  of  the  or- 
dinary window-framing,  and,  while  light  is  as  freely  ad- 
mitted as  through  the  medium  of  common  glass,  the 
"  porous  "  further  admits  air  too,  the  minute  holes  with 
which  this  is  intersected  being  too  fine  to  permit  of  any 
draught,  while  they  provide  a  healthy  continuous  venti- 
lation through  the  apartment. — The  Hospital. 


December  8,  1894] 


MEDICAL  RECORD. 


721 


TUBERCULOSIS—ITS  ETIOLOGY  AND  PROPH- 
YLAXIS.1 
By  F.  A.  BOTTOME,  M.D., 


NEW  YORK. 


Before  the  discovery  of  the  tubercle  bacillus  by  Koch 
in  1 88 1  there  existed  a  great  difference  of  opinion  as  to 
the  etiology  of  pulmonary  tuberculosis ;  since  then  all 
the  study  expended  upon  the  subject  has  but  strengthened 
the  position  of  Koch,  and  in  this  present  year  our  Health 
Board  expresses  the  universal  belief  when  it  states :  "  Tu- 
berculosis is  a  communicable  disease  and  is  distinctly 
preventable,  and  acquired  by  the  direct  transmission  of 
the  tubercle  bacillus  from  the  sick  to  the  well." 

Indeed,  we  are  all  so  familiar  with  this  view  of  the 
etiology  of  tuberculosis  that  it  would  be  presumptuous  on 
my  part  to  go  over  this  well-beaten  ground.  Our  Health 
Board  has  distributed  among  the  physicians  of  this  city  a 
circular  from  which  I  have  just  quoted,  and  which  ex- 
presses the  latest  views  on  the  subject  in  a  clear,  concise 
way,  and  moreover  gives  the  most  practical  methods  for 
destroying  the  tubercle  bacillus  and  thus  preventing  the 
spread  of  the  disease. 

As  you  are  all  doubtless  familiar  with  this  circular  I 
shall  not  take  up  your  time  to  read  it,  but  call  your  atten- 
tion simply  to  one  paragraph,  which  reads  as  follows : 

"  It  is  a  well-known  fact  that  some  persons,  and  espe- 
cially the  members  of  some  families,  are  particularly  lia- 
ble to  tuberculosis.  So  marked  and  frequent  is  the  de- 
velopment of  the  disease  in  certain  families  that  the  af- 
fection has  long  been  considered  hereditary.  We  now 
know  that  the  disease  itself  is  very  rarely  hereditary,  but 
that  there  is  inherited  a  liability  to  the  disease  which 
renders  the  individual  a  more  easy  prey  to  the  living 
germs  when  once  they  have  gained  an  entrance. " 

This  "  liability  to  the  disease"  is  a  phase  of  the  sub- 
ject which,  it  seems  to  me,  is  often  lost  sight  of  in  the 
consideration  of  tuberculosis.  We  think  of  the  disease 
as  being  caused  by  a  specific  micro-organism,  the  tubercle 
bacillus;  but  we  forget  that  this  germ  is  powerless  un- 
less there  is  a  coincident  peculiar  state  of  the  system — 
"  a  liability  to  the  disease.'' 

Without  depreciating  in  the  least  all  that  the  Health 
Board  is  doing  to  eradicate  this  disease  by  the  destruc- 
tion of  the  tubercle  bacillus,  I  would  emphasize  the  fact 
that  there  is  another  way  of  accomplishing  this  end,  which 
should  go  pari  passu  with  the  former,  and  which  is  the 
peculiar  province  of  the  practising  physician,  i.e.,  remov- 
ing the  peculiar  state  of  the  system  which  constitutes  a 
liability  to  the  disease.  Indeed  until  the  great  work 
which  the  Health  Board  has  undertaken  in  this  line  has 
succeeded  in  lessening  to  a  very  great  extent  the  count- 
less numbers  and  universal  distribution  of  this  dread 
germ,  it  would  seem  as  if  the  removal  of  the  liability  to 
the  disease  was  easier  than  the  eradication  of  the  germ. 
And  yet  there  should  be  no  relaxation  on  our  part  in 
carrying  out  the  former  while  we  endeavor  to  accomplish 
the  latter,  since  carelessness  in  so  doing  may  result  in 
the  occurrence  of  the  disease  in  the  individual  before  we 
have  succeeded  in  removing  the  "  liability." 

It  will  not  be 'amiss,  then,  if  we  spend  some  little  time 
in  considering  what  constitutes  this  liability  and  the 
means  for  its  removal. 

This  peculiar  state  of  the  system  is  variously  designated 
tubercular  habit,  tubercular  predisposition,  tubercular 
diathesis.  That  it  is  this  diathesis  which  is  inherited 
and  not  the  disease  itself  has  been  quoted  above;  but 
not  only  may  it  be  inherited,  it  may  also  be  acquired, 
and  this  will  account  for  the  cases  of  tuberculosis  occur- 
ring in  those  whose  family  histories  show  no  trace  of  the 
disease  for  generations  back ;  in  other  words,  this  diathesis 
may  be  inherent  in  the  constitution  of  an  individual. 

Children  of  tuberculous  parents  are  frequently,  during 
the  early  period  of  their  lives,  to  all  appearance  per- 
fectly healthy  and  may  remain  so  till  the  first  symptoms 
of  the  disease  appear  in  the  cough,  hectic  flush,  and  ma- 

1  Read  before  the  Harlem  Medical  Society,  November  7,  1894. 


laise ;  while  in  others  we  recognize  at  an  early  period  cer- 
tain physical  conditions  which  warrant  us  in  predicting 
the  advent  of  tuberculosis  at  a  later  period.  Thus  they 
may  exhibit  the  slight  build,  contracted  chest,  and  deli- 
cate complexion.  But  if  it  is  true  that  in  both  these 
classes  of  cases  the  diathesis  exists,  we  must  look  for  this 
diathesis  in  some  defect  deeper  than  in  a  gross  physical 
malformation  visible  to  the  eye. 

S.  Solis  Cohn,  in  speaking  of  this  condition,  says : 
"  It  is  a  negative,  not  a  positive,  state ;  an  absence,  not 
a  presence.  .  .  .  That  which  is  wanting  in  individ- 
uals who  become  tuberculous  is  the  life  force,  the  vital 
energy,  an  energy  which  we  know  to  exist  because  of  its 
manifestations  as  fully  as  we  know  electric  energy  to  ex- 
ist." 

Vital  energy  we  know  is  an  inherent  quality  of  the  in- 
dividual cell,  so  that,  if  Cohn's  view  is  correct,  this  de- 
ficiency in  vital  energy  must  be  inherent  in  the  individ- 
ual cell,  and  whether  this  be  absolutely  true  or  not  it 
at  least  serves  as  a  working  hypothesis  and  is  consistent 
with  many  of  the  peculiar  phenomena  of  this  condition. 
For  instance,  we  know  the  cell  contains  not  only  suffi- 
cient energy  to  meet  the  ordinary  demands  made  upon 
it,  but  is  continually  storing  up  surplus  energy  (potential 
energy)  to  be  used  in  time  of  extraordinary  demand,  and 
this  would  explain  those  cases  of  tuberculosis  developing 
in  persons  apparently  healthy,  the  fact  being  that  in 
these  the  individual  cells  possess  sufficient  energy  for  or- 
dinary circumstances  but  succumb  under  an  unusual, 
though,  perhaps,  slight  demand,  and,  sinking  below  a 
certain  point,  are  in  the  proper  condition  to  constitute  a 
suitable  nidus  for  the  development  of  the  tubercle  bacillus. 

At  the  present  time  this  germ  is  so  widely  distributed 
and  exists  in  such  numbers  that  it  would  seem  as  if  there 
must  be  a  constant  warfare  between  the  germ  and  the 
cell,  the  former  laying  siege  to  the  latter,  and  waiting 
patiently  till  the  cell  shall  be  sufficiently  reduced  in 
strength  to  warrant  an  easy  victory. 

This  comparison  is  not  a  bad  one,  for  it  indicates  the 
proper  line  of  treatment.  The  vital  point  with  a  be- 
sieged army  is  to  keep  up  the  supply  of  food,  and  the 
same  is  true  of  the  cell  in  its  warfare  against  the  tubercle 
bacillus.  If  the  cell  is  sufficiently  fed,  so  that  its  vital 
energy  remains  above  par,  it  can  defy  the  tubercle  bacil- 
lus and  hold  it  at  bay  till  the  bacillus  itself  dies,  for  the 
tubercle  bacillus  cannot  multiply  unless  it  feed  upon  the 
animal  cell,  and  also  its  period  of  vitality  and  virulence 
outside  the  animal  body  has  a  limit. 

In  the  use  of  this  term,  vital  energy,  it  must  be  re- 
membered that  it  includes  that  energy  which  is  expended 
in  nutrition,  heat-production,  growth,  development,  re- 
pair, etc.,  and  also  the  stored-up  or  potential  energy 
which  is  held  in  reserve  for  some  unusual  demand  which 
may  be  made  upon  the  system. 

There  is  one  objection,  it  seems  to  me,  in  this  theory 
of  the  deficiency  of  vital  energy  in  the  individual  cell  as 
the  distinguishing  characteristic  of  this  diathesis,  and  that 
is  the  fact  that  if  lowered  vitality  were  all  that  is  neces- 
sary to  make  the  cell  a  suitable  nidus  for  the  growth  of 
the  tubercle  bacillus,  then  we  should  expect  to  find  tu- 
berculosis developing  in  all  individuals  whose  vitality 
had  been  greatly  reduced  by  some  outside  cause,  as  by 
some  one  of  the  wasting  diseases.  This,  however,  is  not 
the  case. 

It  would  seem  as  if  there  were  some  deeper  defect  in 
these  cells,  to  which,  if  there  is  added  a  deficiency  of  po- 
tential energy,  the  cells  are  vulnerable  to  the  tubercle 
bacillus ;  while  in  a  cell  not  subject  to  this  diathesis  such 
a  lack  of  potential  energy  would  not  make  it  more  vul- 
nerable. In  other  words  our  theory  is  that  it  is  this,  at 
present,  undefined  defect  of  the  cells,  to  which  if  there 
is  added  a  lack  of  potential  energy,  they  become  vulnera- 
ble to  the  tubercle  bacillus.  This  view  does  not  conflict 
with  the  recognized  methods  or  results  of  treatment,  for 
it  recognizes  the  fact  that  the  safeguard  of  the  cell,  sub- 
ject to  this  diathesis,  is  the  maintenance  of  potential 
energy,  while  in  cells  not  subject  to  this  diathesis  such  a 


722 


MEDICAL  RECORD. 


[December  8,  1894 


safeguard  is  not  necessary,  since  they  are  not  vulnerable 
to  the  tubercle  bacillus  under  any  conditions. 

Treatment — In  the  treatment  of  this  condition  or  dia- 
thesis it  must  be  remembered  that  we  are  dealing  not 
with  patients  who  have  already  developed  tuberculosis, 
but  with  those  who  simply  have  the  diathesis,  usually  in- 
herited; since  with  our  present  knowledge  we  are 
hardly  able  to  diagnose  the  inherent  cases  before  tuber- 
culosis itself  has  developed,  and  then  only  by  inference  in 
the  absence  of  family  history. 

To  put  it  in  a  more  practical  way,  what  can  we  do  for 
those  cases  which  give  a  strong  family  history  of  tuber- 
culosis, and  whose  friends,  if  not  themselves,  ask  our  ad- 
vice as  to  the  means  of  preventing  the  development  in 
them  of  this  dread  disease  ?t  Such  a  question  is  a  very 
common  one,  which  the  practitioner  is  asked  to  answer. 

If  it  is  true  that  the  safeguard  in  these  individuals 
against  the  disease  is  the  maintenance  of  potential  en- 
ergy, then  the  problem  of  treatment  resolves  itself  into 
the  consideration  of  the  best  methods  of  supplying  this 
potential  energy  to  the  cells.  The  more  we  study  the 
subject,  the  more  shall  we  be  impressed  with  the  fact 
that  the  treatment  of  this  condition  embraces  the  whole 
subject  of  hygiene,  and  doubtless  it  is  owing  to  the  vast- 
ness  of  the  subject  that  the  above  question  is  so  often 
answered  by  the  busy  practitioner  in  the  few  words, 
"  Keep  the  patient  strong  and  well.11 

So  for  as  it  goes  the  answer  is  correct,  but  its  accom- 
plishment will  not  be  attained  unless  we  go  into  explicit 
detail,  and  treat  each  case  individually,  for  we  shall  find 
a  great  difference  in  individual  cases,  and  in  the  same 
case  at  different  times,  and  each  of  these  indicate  special 
treatment. 

Of  course  it  will  be  impossible  for  me  to  do  more  than 
indicate  the  line  of  treatment,  with  perhaps  special  em- 
phasis placed  on  certain  points,  but  we  shall  be  greatly 
aided  if  we  keep  well  in  mind  the  object  of  our  treat- 
ment, the  increasing  of  potential  energy.  In  supplying 
this  energy  three  means  naturally  suggest  themselves,  in 
food,  air,  exercise,  and  by  regulating  these  we  can  ac- 
complish a  great  deal  even  among  those  who  must  of  ne- 
cessity remain  in  the  city,  where  these  cannot  be  so  eas- 
ily regulated  as  in  the  country,  and  in  special  climates. 

Food. — In  the  classification  of  food  we  find  that  dif- 
ferent classes  serve  different  purposes  in  the  animal 
economy.  Thus  the  nitrogenous  elements  serve  princi- 
pally the  purpose  of  tissue-building,  and  the  storing  up 
of  potential  energy,  while  the  hydrocarbons  and  carbo- 
hydrates are  concerned  principally  in  heat  production, 
and  from  this  fact  it  is  evident  that  the  food- supply  in 
these  subjects  should  contain  a  large  proportion  of  nitro- 
gen. Unfortunately  it  is  in  this  very  class  of  patients 
that  we  find  a  marked  perversion  of  appetite,  a  liking 
for  sweets,  a  distaste  for  meat,  and  it  will  require  all  our 
powers  of  tact  and  persuasion  to  regulate  properly  the 
diet  of  these  cases.  Some  experimenters  claim  excellent 
results  from  an  exclusive  meat  diet,  but  aside  from  the 
difficulty  of  carrying  this  out,  among  private  patients  at 
least,  the  general  consensus  of  opinion  is  in  favor  of  a 
mixed  diet  composed  largely  of  nitrogenous  foods. 

If  we  are  fortunate  enough  to  have  the  patient  under 
observation  from  the  time  of  birth,  the  problem  is  less 
difficult,  providing  we  can  enlist  the  co-operation  of  the 
parents.  The  fact  that  the  child  of  a  tuberculous  mother 
should  not  be  fed  from  the  mother's  breast,  on  account  of 
both  mother  and  child,  is  universally  conceded,  but  in 
addition  to  this,  would  it  not  be  wiser  that  a  mother  who 
inherits  merely  this  diathesis,  although  she  may  not 
have  developed  tuberculosis,  should  not  suckle  her  off- 
spring ? 

At  the  present  time  when  the  subject  of  bottle  feeding 
has  been  placed  on  a  scientific  basis,  so  that  cow's  milk 
can  be  made  almost  identical  with  human  milk,  the  re- 
moval of  the  child  from  the  breast  is  no  longer  such  a  se- 
rious question,  nor  is  there  the  unpleasant  alternative  of 
a  wet-nurse. 

It  is  possible  in  this  city  to  order  a  milk  containing 


the  albuminoids,  sugars,  and  fats  in  whatever  proportion 
the  physician  may  desire,  and  by  taking  advantage  of  this 
fact  we  can  increase  the  albuminoids  or  nitrogenous  por- 
tion in  these  cases  and  watch  the  effect. 

I  do  not  know  whether  this  has  been  done  by  anyone 
as  yet ;  but  is  there  not  here  a  field  for  investigation  to 
find  out  the  effects  of  a  larger  proportion  than  is  usually 
given,  of  the  nitrogenous  elements  in  the  diet  of  an  infant 
of  tuberculous  parents  ? 

As  the  diet  of  the  child  increases  in  variety  it  should 
still  consist  of  only  plain  wholesome  food,  largely  of  a 
nitrogenous  character.  The  child  should  not  be  per- 
mitted to  develop  an  appetite  for  sweets  and  pastry.  The 
custom  of  giving  a  child  candy  as  a  reward  or  bribe  is  a 
bad  one,  aside  from  the  questionable  moral  effect,  and  es- 
pecially is  it  true  in  the  cases  under  consideration,  for 
perfect  digestion  is  a  sine  qua  non  in  their  successful 
treatment,  and  in  these  subjects  (the)  sugars  are  very  apt 
to  cause  digestive  disturbances. 

As  the  child  grows  older  the  diet,  of  course,  varies 
somewhat ;  but  the  same  principle  holds  good.  And  in 
the  selection  of  articles  of  diet,  with  the  aim  of  giving  a 
large  proportion  of  nitrogen,  we  shall  find  a  large  num- 
ber from  which  to  choose,  for  aside  from  meat  we  find 
other  articles  containing  a  large  proportion  of  nitrogen ; 
thus  eggs  contain  about  thirteen  per  cent,  of  proteids, 
fish,  eighteen  per  cent.,  oatmeal  twelve  per  cent.,  peas 
twenty  two  per  cent.,  cheese  thirty-one  per  cent.  I 
mention  these  simply  to  emphasize  the  fact  that  meat  is 
not  the  only  nitrogenous  food,  and  that  in  regulating  the 
diet,  to  prevent  sameness,  we  can  select  food-stuffs 
which  will  still  aid  in  accomplishing  our  aim. 

Air. — The  necessity  for  fresh  air  is  as  important  as  the 
necessity  for  proper  food.  The  r61e  which  oxygen  plays 
in  the  metabolism  of  the  body  is  a  well-known  physiolog- 
ical fact,  but  is  more  often  disregarded  in  practice  than 
remembered  in  theory. 

It  would,  of  course,  be  better  for  persons  subject  to 
this  diathesis  to  live  in  some  region  where  the  air  is  ab- 
solutely pure,  and  where  the  tubercle  bacillus  is  not  pres- 
ent, but  this  is  not  often  practicable  nor  is  it  necessary. 
If  we  breathed  nothing  less  pure  than  the  out- door  air  of 
this  city  we  should  have  little  cause  for  complaint.  It  is 
the  air  in  our  dwellings  that  is  impure,  and  the  fault  is 
our  own. 

When  the  patient  is  old  enough  to  look  out  for  him- 
self we  can  advise  him,  as  far  as  possible,  to  lead  an  out-of- 
door  life,  and  in  the  case  of  a  young  man  to  select  a  bus- 
iness or  profession  where  this  will  be  possible;  but  if  the 
patient  is  an  infant  or  young  child  we  must  be  explicit 
in  our  directions  to  those  in  charge  of  the  child,  and 
teach  them  a  few  lessons  on  the  subject  of  ventilation. 

We  must  show  them  how  perfectly  possible  it  is  to 
ventilate  a  room  without  the  presence  of  draughts.  That 
it  is  only  necessary  to  have  a  communication  between 
the  outer  and  inside  air,  and  by  the  law  of  diffusion  of 
gases,  and  the  law  which  relates  to  the  difference  in 
weight  of  masses  of  air  of  unequal  temperature,  the  warm, 
impure  air  of  the  room  will  pass  out,  and  the  cool,  pure, 
outer  air  will  come  in  and  take  its  place,  and  that  the 
process  can  be  made  to  take  place  so  gradually  that  the 
temperature  of  the  room  remains  stationary. 

We  can  tell  them  that  the  simplest,  and  yet  one  of 
the  most  delicate  means  of  testing  the  purity  of  the  air  in 
a  room,  is  that  by  the  sense  of  smell ;  that  on  entering  a 
room  to  be  tested  we  should  notice  no  difference  in  point 
of  freshness  between  the  out  and  inside  air,  remembering 
that  warm  air  is  not  necessarily  impure,  and  that  in  this 
test  the  question  of  temperature  is  not  to  be  taken  into 
account 

These  are  homely  truths  and  it  would  hardly  seem  nec- 
essary to  mention  them,  and  yet  is  it  not  true  that  the 
majority  of  sleeping- rooms  have  a  disagreeable,  stuffy 
odor  before  they  are  aired  in  the  morning  ?  This  odor 
is  due  to  the  organic  matter  exhaled  from  the  lungs  and 
skin,  and  if  not  removed  from  the  air  of  the  room  is 
taken  into  the  lungs  with  each  respiration  and  constitutes 


December  8,  1894] 


MEDICAL  RECORD. 


723 


a  positive  poison.  Such  a  condition  is  bad  enough  for 
healthy  subjects,  but  for  the  cases  under  discussion,  in 
whom  the  amount  of  vitality  is  below  par,  is  a  serious 
drawback  to  our  efforts  in  overcoming  this  diathesis. 

Exercise. — As  the  child  grows  older,  and  especially 
during  the  period  of  youth,  exercise  is  important  as  a 
prophylactic  measure.  In  considering  the  subject  of 
food  we  pointed  out  the  necessity  of  increasing  the  nitro- 
genous elements ;  but  this  is  only  possible  as  it  is  com- 
bined with  active  physical  exercise.  The  nitrogen  as- 
similated is  stored  up,  principally  in  the  muscular  tissue, 
and  as  this  is  increased  and  developed  a  correspondingly 
large  amount  of  nitrogen  is  stored  up. 

£1  considering  the  different  forms  of  exercise  it  will  be 
well  to  select,  as  far  as  possible,  those  which,  of  neces- 
sity, must  be  performed  in  the  open  air,  as  fresh  air  is 
thus  obtained  at  the  same  time.  Bicycle  riding  is  an 
excellent  form  of  exercise,  providing  a  faulty  position  is 
not  adopted  ;  also  brisk  walking,  especially  when  taken 
with  some  definite  purpose  other  than  for  its  own  sake. 
Swimming,  horseback-riding,  and,  in  short,  all  recog- 
nized forms  of  healthy  out-door  exercise  will  accomplish 
the  desired  end. 

Besides  these  there  are  special  forms  of  exercise  which 
apply  particularly  to  these  subjects  in  whom  there  are 
frequently  found  a  poor  chest  development  and  deficient 
long  expansion.  Perhaps  one  of  the  best  means  for  over- 
coming these  defects  is  the  exercise  of  swimming,  in 
which  there  is,  of  necessity,  a  forced  inspiration  and  a 
special  development  of  some,  if  not  all,  of  the  muscles  of 
respiration. 

In  addition  to  these  there  is  the  exercise  with  the  so- 
called  chest-weights,  and  how  much  can  be  accomplished 
by  these  and  other  forms  of  gymnasium  apparatus  has 
been  recently  shown  in  a  paper  read  before  this  Society 
by  Dr.  Gardner  Smith.  The  only  objection  to  exercise 
in  the  gymnasium  is  the  poor  ventilation  frequently 
found  there,  but  this  is  a  fault  easily  remedied.  A  sim- 
ple yet  practicable  means  of  increasing  the  lung  expan- 
sion, including  the  apices,  which,  in  these  cases,  are  so 
apt  to  be  partially  collapsed,  is  that  in  which  the  subject, 
when  walking  in  the  open  air,  inhales  slowly  and  deeply, 
and  then  retains  the  air  in  his  lungs  for  a  few  steps,  when 
he  gradually  exhales.  In  this  way  I  have  seen  the  lung 
capacity  markedly  increased.  To  some  of  these  patients, 
on  account  of  business,  daily  open-air  exercise  or  that  in 
the  gymnasium  is  an  impossibility.  In  these  cases  I 
advise  the  purchasing  of  a  chest  weight  apparatus,  which 
is  placed  in  the  bath-room  and  used  every  morning  for  a 
short  time,  followed  by  a  cool  plunge-bath  and  brisk 
rubbing.  The  latter  serves  the  purposes  of  cleanliness, 
an  active  tonic,  and  a  means  of  hardening  the  skin, 
thereby  lessening  the  liability  to  "  catch  cold."  The  in- 
terest of  the  patient  in  his  increasing  muscular  develop- 
ment removes  the  sense  of  irksomeness  from  the  exercise, 
and  the  after  effects  of  the  cool  bath  are  such  that  it  soon 
becomes  a  great  pleasure,  and  not  to  be  foregone  by  one 
who  has  become  accustomed  to  its  use. 

These  are  a  few  of  the  salient  points  in  the  hygienic 
treatment  of  this  condition.  I  have  made  no  mention 
of  drugs  because,  in  the  majority  of  cases,  they  are  not 
called  for,  though  often  their  treatment  is  dismissed  with 
a  prescription  for  cod-liver  oil.  Any  intercurrent  disease 
must  be  treated  on  its  own  merits,  and  this  includes  the 
surgical  measures  indicated  in  diseases  of  the  respiratory 
tract,  to  which  we  should  pay  special  attention. 

In  closing,  let  me  again  emphasize  the  fact  that  the 
etiology  of  tuberculosis  is  twofold,  and  that  in  the  proph- 
ylactic treatment  we  should  pay  as  much  attention  to 
the  diathesis  as  to  the  tubercle  bacillus. 

My  excuse,  if  one  is  needed,  for  confining  myself  in 
this  paper  to  the  consideration  of  the  diathesis,  is  that  I 
feel  that  this  side  of  the  question  is  too  often  neglected 
in  practice,  and  that  while  the  exact  nature  of  this  dia- 
thesis is  theoretical,  the  treatment  based  on  this  theory 
is  highly  satisfactory. 

41  Wot  136th  Stubs  t. 


The  Surgery  of  the  Gall-bladder  and  Bile -ducts, 
with  Brief  Notes  of  Seventy  Eight  Oases.— Dr.  Rob- 
son  speaks  of  the  most  prominent  symptoms  and  com- 
plications of  cases  of  cholelithiasis  which  have  come 
under  his  observation:  1.  Spasms  or  biliary  colic  with- 
out jaundice,  the  attacks  being  repeated  at  longer  or 
shorter  intervals,  a.  Collapse  due  to  the  intensity  of 
the  pain.  3.  Spasms  followed  by  evanescent  jaundice. 
4.  Pain  followed  by  persistent  jaundice  and  enlargement 
of  the  liver.  5.  Hydrops  of  the  gall-bladder  without 
jaundice.  6.  Ileus  due  to  atony  of  the  bowel.  7.  Acute 
intestinal  obstruction  due  to  paralysis  of  the  gut  from 
local  peritonitis,  volvulus  of  the  small  intestine,  or  im- 
paction of  a  large  gallstone  in  some  part  of  the  intes- 
tine. 

In  the  majority  of  these  cases,  where  medical  treat- 
ment has  failed,  surgical  procedures  hold  out  very  good 
hope  of  success  in  nearly  every  complication,  if  the  pa- 
tient be  not  too  much  exhausted.  Cases  complicated 
with  malignant  diseases  are  very  unfavorable  for  opera- 
tion. First,  because  the  subjects  of  cancer  are,  as  a  rule, 
cachectic  and  worn  down  by  disease  before  the  surgeon 
is  called  in;  and,  secondly,  because  such  patients  are 
prone  to  hemorrhage  at  the  time  of  the  operation  or 
subsequently.  The  author  claims  that  there  is  consider- 
able risk  in  operating  on  patients  that  are  markedly 
jaundiced,  on  account  of  hemorrhage,  but  more  espe- 
cially as  the  jaundice  is  frequently  associated  with  malig- 
nant disease.  In  order  to  avert  the  danger  of  hemor- 
rhage in  jaundiced  patients  the  author  has  found  that 
the  administration  of  chloride  of  calcium  for  a  few  days 
before  the  operation  makes  the  blood  more  plastic  and 
lessens  the  tendency  to  bleeding  both  at  the  time  of 
operation  and  subsequently.  In  jaundiced  cases  he  pre- 
fers ligating  all  bleeding  points  rather  than  trust  press- 
ure forceps.  In  all  of  the  cases  operated  upon  by  the 
author,  in  which  there  was  malignant  disease  with  jaun- 
dice, the  gall- bladder  formed  a  perceptible  tumor, 
whereas,  when  the  jaundice  was  dependent  upon  gall- 
stones, no  marked  tumor  was  present.  A  valuable  diag- 
nostic point,  the  author  claims,  is  tenderness  on  pressure 
over  some  point  between  the  eighth  or  ninth  costal  car- 
tilage and  the  umbilicus.  The  so-called  diagnostic  opera- 
tion of  sounding  for  gall-stones  and  aspiration  of  a  dis- 
tended gall-bladder  the  author  believes  to  be  futile  and 
dangerous,  and  is  much  better  replaced  by  a  small  ex- 
ploratory incision,  when  treatment  can  at  the  same  time 
be  carried  out,  if  required.  The  indications  for  operat- 
ing in  these  cases  the  author  gives  as  follows :  1.  Fre- 
quently recurring  biliary  colic,  without  jaundice,  with  or 
without  enlargement  of  the  gall-bladder.  2.  Persistent 
jaundice  ushered  in  by  pain.  3.  Empyema  of  the  gall- 
bladder. 4.  Peritonitis  starting  in  the  region  of  the 
liver.     5.  Purulent  collections  about  the  gall- bladder. 

If  the  bladder  and  ducts  can  be  cleared  without  much 
difficulty,  the  opening  in  the  gall- bladder  can  be  sutured 
to  the  aponeurosis  and  drained.  If  the  ducts  cannot  be 
cleared,  one  of  the  following  procedures  may  be  carried 
out:  1.  Cholelithotrity,  the  stone  being  crushed  be- 
tween the  finger  and  thumb  or  by  padded  forceps,  a. 
Choledodectomy,  opening  the  duct,  removing  the  stone, 
and  suturing  the  duct  afterward.  A  drainage-tube  should 
always  be  inserted  in  the  right  kidney  pouch  in  these 
cases.  3.  Cholecystenterostomy.  This  operation  may 
be  easily  performed  if  the  gall-bladder  be  dilated.  The 
author  prefers  the  decalcified  bone  bobbin,  as  only  two 
sutures  must  be  applied.  4.  The  daily  injection  of  fluids 
after  an  interval  of  some  days,  through  the  cholecystot- 
omy  opening,  which  will  either  soften  or  dissolve  the 
concretion.  For  this,  hot  water,  or  a  solution  of 
taurochlorate  of  soda,  may  be  used,  or,  as  the  author 
prefers,  injections  of  olive  oil  or  a  five  per  cent,  solution 
of  oleic  acid.     5.  Cholecystectomy  may  be  required  as 


724 


MEDICAL  RECORD. 


[December  8,  1894 


a  secondary  operation  in  cases  of  stricture  of  the  cystic 
duct,  the  common  duct  being  free.  With  but  very  few 
exceptions  a  vertical  incision  along  the  upper  part  of  the 
right  similunar  line  gives  ample  room. — The  British 
Medical  Journal. 

The  Treatment  of  Obstructive  Jaundice.— Dr.  Dujar- 
din-Beaumetz  divides  this  condition  into  three  classes 
with  reference  to  its  causation:  1.  Obliteration  from  a 
calculus.  2.  Obliteration  from  inflammation.  3.  Ob- 
literation from  compression  by  tumors — the  last  belong- 
ing exclusively  to  the  domain  of  surgery. 

Hepatic  calculi  are  more  frequent  in  women,  and  it  is 
probable  that  the  corset  is  an  important  factor  in  their 
causation,  which  is  further  aided  by  the  usual  costo- 
superior  type  of  respiration.  In  these  cases  systematic 
massage  can  do  much  in  relieving  the  causative  factor. 
Of  the  cholagogues,  the  watery  alcoholic  extracts,  as 
podophyllin,  cascarUlin,  and  euonymin,  and  even  so- 
dium salicylate,  can  be  of  service.  To  these  should  be 
added  alkalies,  as  the  waters  of  Vichy  or  Vals.  For  the 
treatment  of  hepatic  colic  two  agents  have  recently  been 
introduced — oil  and  glycerine.  The  oil  has  been  the 
subject  of  numerous  papers,  and  has  achieved  consider- 
able  success,  but  it  possesses  the  marked  inconvenience 
of  being  repugnant  to  the  patients,  and  they  swallow 
with  considerable  difficulty,  at  one  time,  the  large 
amount  (seven  ounces)  which  is  required.  Glycerine  in 
much  smaller  quantity,  two  and  one-half  to  five  drachms, 
appears  to  be  equally  effective,  either  given  clear  or 
mixed  with  water.  If  the  latter  fails,  then  it  is  necessary 
to  resort  to  anodyne  suppositories,  ether  sprays  over  the 
hepatic  region,  hypodermatic  injection  of  morphine  and 
atropine,  or  even  of  chloroform  if  the  pain  is  acute.  The 
obliteration  from  inflammatory  action,  which  is  usually 
the  consequence  of  a  duodenitis,  requires  different  treat- 
ment. The  duodenitis  may  be  the  result  Qf  an  excessive 
alimentation  in  quality  and  quantity,  or  an  incomplete 
mastication.  It  is  necessary  to  regulate  and  increase 
the  number  of  meals — for  each  meal,  by  giving  rise  to 
reflex  phenomena,  produces  an  increased  flow  of  bile. 
Irritant  foods  must  be  avoided — those  which  increase 
the  gastric  acidity,  especially  alcohol  and  liquids  con- 
taining it.  In  the  advanced  stages  it  is  necessary  to  re- 
sort to  intestinal  antiseptics,  of  which  the  most  in  use 
are  salol,  benzonaphthol,  and  the  salicylates.  Salol, 
usually  the  best  of  all,  is  here  unavailing,  because  the 
bile  being  arrested,  the  contents  of  the  duodenum  are 
acid,  and  no  decomposition  of  the  drug  occurs.  To  ob- 
tain antiseptic  effects  from  benzonaphthol  one  drachm 
or  more  each  day  is  required.  Of  the  salicylates,  bis- 
muth salicylate  is  the  best.  Since  this  colors  the  faeces 
it  is  difficult  to  arrive  at  a  true  understanding  of  the 
patient's  condition  ;  to  avoid  this  inconvenience  asaprol  * 
has  been  substituted  with  advantage.  Calomel  is  useful 
because  it  is  at  the  same  time  a  purgative  and  an  antisep- 
tic ;  but  it  should  be  used  with  caution  if  the  treatment 
is  to  be  prolonged.  Constipation  is  always  an  impor- 
tant symptom,  and  the  use  of  Rubinat,  Carabana,  Vil- 
lacabras,  and  even  Carlsbad  is  advisable.  Pancreatin 
may  be  useful  in  some  cases. — American  Journal  of  the 
Medical  Sciences. 

Stomach-reefing. — This  operation  has  been  performed 
by  Dr.  Brandt  for  dilatation  of  the  stomach.  It  is  well 
known  that  the  stomach  becomes  enlarged  in  cases  of  py- 
loric stenosis  due  to  new  growth,  cicatricial  contraction, 
or  bands  of  adhesions.  The  rational  treatment  of  this 
stomach  trouble  is  the  removal  of  the  cause.  This  is 
accomplished  by  pylorus  resection  and  excision  of  pylo- 
ric cicatrices,  which  have  been  so  successfully  done  during 
the  past  few  years.  It  sometimes  happens,  however,  that 
after  opening  the  abdomen  no  such  a  cause  is  found  for  the 
dilatation.  If  the  wound  is  closed,  the  laparotomy  has 
been  nothing  more  than  an  explorative  operation,  and 
the  patient  continues  to  suffer  from  the  disease,  the  case 
being  then  regarded  as  a  medical  one  and  a  subject  for 
medical  treatment.    It  has  occurred  to  Brandt  to  treat 


these  idiopathic  cases  by  diminishing  the  size  of  the 
stomach  by  folding  in  its  wall  and  suturing  it  through 
the  serosa  and  muscularis.  The  patient  upon  whom  he 
operated  was  a  woman,  twenty-six  years  of  age.  The 
gastric  sound  could  be  introduced  till  it  struck  thepubes 
and  left  Poupart's  ligament.  Palpation  revealed  no  tu- 
mor of  the  pyloric  or  other  region,  nor  even  an  abnor- 
mal resistance.  The  patient  was  poorly  nourished  and 
greatly  reduced  in  strength.  She  was  treated  medici- 
nally by  faradization  and  lavage  of  the  stomach,  with  little 
improvement.  After  this  treatment  had  been  carried  on 
for  two  months,  Brandt  made  an  opening  into  the  abdo- 
men parallel  with  the  left  costal  arch,  and  explored  the 
stomach  and  other  abdominal  contents.  The  pylorus 
was  especially  examined,  and  nothing  found.  The  or- 
gan was  found  enormously  enlarged.  He  then  proceeded 
to  fold  in  the  anterior  wall  and  suture  it  by  two  rows  of 
transverse  sutures.  The  same  was  done  on  the  posterior 
wall  through  holes  torn  through  the  great  omentum. 
More  than  two  hundred  sutures  were  applied.  The  pa- 
tient made  an  excellent  recovery,  without  any  disturb- 
ance of  digestion,  and  was  able  to  leave  her  bed  on  the 
tenth  day.  Brandt  has  published  this  case  as  preliminary 
to  a  more  exhaustive  communication  upon  the  subject. 
The  same  operation  has  been  described  under  the  head 
of  "  gastrorapie  "  in  the  same  periodical. — Annals  of 
Surgery. 

A  New  Method  of  Resecting  the  Rectum.— Dr.  Rou- 
tier  described  (Chirurgical  Society,  Paris)  a  method  of 
resecting  the  rectum  as  devised  by  Moulonguet,  a  modi- 
fication of  Kraske's  operation.  The  first  step  is  the  same 
as  in  Kraske's  operation ;  the  sphincter  is  then  dissected 
out,  and  even  though  the  lower  portion  of  the  rectum  is 
found  healthy,  it  is  cut  away  instead  of  being  preserved, 
as  in  Kraske's  operation.  The  sphincter,  after  having 
been  dissected  out,  is  lined  by  the  upper  portion  of  the 
rectum,  which  is  pulled  down  for  this  purpose  and  sutured 
to  the  edges  of  the  wound  at  the  anus.  The  perineo- 
sacral  wound  is  then  sewn  up,  with  a  drain  in  the  lower 
portion.  In  Dr.  Routier's  estimation  the  usefulness  of 
the  operation  is  rather  limited,  especially  to  cases  in  which 
the  cancer  is  not  situated  high  up,  and  in  cases  in  which 
the  sphincter  is  intact. 

The  Lnoculability  of  Cancer. — Dr.  Gratia  reported, 
at  the  Academy  of  Medicine,  Brussels,  a  series  of  experi- 
ments, in  which  he  had  employed  grafting  and  inocula- 
tion, with  the  object  of  proving  or  disproving  the 
inoculability  of  cancer.  The  result  of  his  experiments 
led  him  to  conclude  that  cancer  does  not  seem  to  be 
inoculable  even  between  individuals  of  the  same  species. 
He  likewise  feels  justified  in  making  the  following  state- 
ments: 1.  The  parasitic  nature  of  cancer  has  not  been 
satisfactorily  proved.  2.  The  direct  or  indirect  conta- 
giousness of  this  neoplasm  has  not  been  proved ;  the 
most  that  can  be  admitted,  in  the  present  state  of  our 
knowledge  on  this  subject,  being  the  possibility  of  ingraft- 
ing, that  is  to  say,  transplanting  cancer,  and  that  only  in 
individuals  exhibiting  exceptional  predisposition  such  as 
cancerous  patients  themselves.  3.  The  etiology  and 
pathogenesis  of  cancer  are  still  undetermined. 

Myxcedema  and  Thyroid  Therapy. — Ewald  presented 
to  the  Medical  Society  of  Berlin  a  woman,  aged  fifty-two, 
who  had  been  treated  for  myxoedema  by  the  use  of  the  thy- 
roid gland  in  tabloid  form.  The  three  points  to  which 
he  called  attention  in  the  report  of  the  case  were :  1. 
The  complete  failure  of  all  other  forms  of  treatment. 
It  was  also  peculiar  that  the  hypodermatic  use  of  the 
thyroid  extract  had  been  fruitless.  2.  Investigation  of 
the  products  of  retrograde  and  constructive  metamor- 
phosis showed,  in  contradiction  to  what  has  been  re- 
ported by  English  and  Danish  observers,  that  the  urinary 
constituents  were  not  increased.  3.  The  presence  of  a 
considerable  quantity  of  sugar  in  the  urine.  He  was 
unable  to  decide  whether  this  was  due  to  the  method  of 
treatment  or  an  intercurrent  complication. 


December  8,  1894] 


MEDICAL   RECORD. 


725 


Medical  Record:  . 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


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


New  York,  December  8,  1894. 


A  NATIONAL  BOARD  OF  HEALTH. 

The  President  of  the  United  States,  in  his  recent  mes- 
sage to  Congress,  formally  and  forcibly  recommends  the 
establishment  of  a  National  Board  of  Health,  or  Na- 
tional Officer,  having  under  his  control  or  advice  matters 
pertaining  to  the 'protection  of  the  country  against  pes- 
tilence and  disease. 

It  can  be  easily  seen,  by  the  wording  of  his  recommen- 
dation, that  the  establishment  of  a  new  Department  of 
Government  is  not  intended  or  considered  at  present 
necessary.  This  is  the  view  which  has  been  taken  by 
leading  sanitarians  all  over  the  country,  and  is  the  one 
that  has  been  voiced  by  the  Academy  of  Medicine  in  its 
carefully  prepared  bill. 

There  is  little  doubt  that,  with  the  generous  and  united 
support  of  the  profession,  the  Academy  bill,  or  one  of 
similar  tenor,  could  soon  be  made  a  law.  It  is  equally 
certain  to  all  acquainted  with  the  feeling  at  Washington, 
that  the  attempt  to  establish  at  once  a  new  department 
and  a  new  cabinet  officer  would  fail.  No  such  thing  has 
ever  yet  been  done  since  the  foundation  of  the  Govern- 
ment. The  Department  of  Agriculture,  for  example,  for 
many  years  was  simply  a  Bureau,  and  had  its  usefulness 
tested  in  this  way. 

If  medical  opinion  cordially  supports  the  project 
for  a  Bureau,  it  will  get  it ;  the  rest  will  come  in  good 
time. 


THE  ORAL  EDUCATION  OF  THE  DEAF. 

The  Churchman  for  December  1st  contains  an  illustrated 
article  by  S.  Millington  Miller,  M.D.,  on  the  above 
topic.  The  writer  defends,  with  a  considerable  array  of 
facts,  the  superiority  of  the  new  oral  system  of  educating 
those  congenitally,  or  otherwise,  afflicted  with  dumb- 
ness. 

The  particular  facts  which  he  employs  with  most  tell- 
ing effect  are,  first,  that  the  intermarriage  of  deaf  men 
and  deaf  women,  necessarily  thrown  together  by  the 
manual  sign-alphabet  system,  produces  children  a  large 
proportion  of  whom  are  congenitally  deaf;  and,  second, 
that  orally  educated  deaf  persons  can  mingle  without  dis- 
ability with  the  world  at  large,  while  the  manually  edu- 
cated cannot.  He  also  points  out  that  all  Europe  is  oral, 
and  that  America  is  lagging  instead  of  leading. 

It  seems  that  some  eleven  years  ago  that  very  distin- 
guished physicist  and  inventor,  Dr.  A.  Graham  Bell,  an- 
nounced that  a  series  of  investigations  pushed  in  all  di- 


rections, and  as  exhaustive  as  he  could  make  them  at  that 
time,  showed  that  one-third  of  the  total  number  of  chil- 
dren of  deaf  and  dumb  parents  were  congenitally  deaf. 
This  means  that  they  are  also  dumb,  so  far  as  articulate 
speech  is  concerned.  In  other  words,  he  had  been 
forced  to  the  conclusion  that  the  method  of  instructing 
the  deaf  then  mainly  in  vogue  (by  the  manual  alphabet- 
sign  system),  isolated  deaf  men  and  deaf  women  from 
society  in  general,  facilitated  their  intermarriage,  and 
was  therefore  developing  a  deaf  and  dumb  species  of  the 
human  race. 

Since  that  paper  appeared,  statistics  bearing  on  this 
subject  multipled  exceedingly,  and  they  have  all  been 
sent  to  a  gentleman  who  is  an  instructor  in  a  manual  in- 
stitution, Dr.  Fay,  of  the  Gallaudet  College,  in  Washing- 
ton. 

Those  interested  in  such  matters  have  been  long  ex- 
pecting the  publication  of  these  reports,  but  their  appear- 
ance has  been  most  persistently  delayed. 

Within  the  past  few  weeks,  however,  Dr.  Fay  has  writ- 
ten to  the  Philadelphia  Press,  stating  that  he  is  now 
busily  engaged  in  sorting  out  and  arranging  this  interest- 
ing matter,  and  will  publish  it  at  the  earliest  possible  mo- 
ment. It  was  decided  by  those  who  advised  the  placing 
of  it  in  Dr.  Fay's  hands,  that  he  was  the  person  most 
competent  to  handle  the  subject. 

According  to  conservative  authorities  there  is  one  deaf 
person  in  the  United  States  to  every  fifteen  hundred 
units  of  population.  Others  place  the  proportion  as  high 
as  one  in  every  twelve  hundred.  We  take  it  for  granted, 
therefore,  that  there  are  some  fifty  thousand  deaf  persons 
in  round  numbers,  in  a  total  population  of  sixty- five 
million  people.  As  there  are  at  least  ten  persons  more 
or  less  directly  interested  in  the  welfare  of  each  deal 
person,  we  have  a  total  of  half  a  million  people  to  whom 
the  method  employed  in  educating  a  person  so  afflicted 
is  a  matter  of  vital  interest  Two-thirds  of  these  fifty 
thousand  deaf  persons  were  either  born  deaf  or  have  be- 
come so  under  the  age  of  two  years.  They  are,  therefore, 
dumb  as  regards  articulate  speech. 

There  have  been  various  systems  invented  for  the  edu- 
cation of  the  deaf.  One  of  the  earliest  references  to 
the  treatment  of  the  deaf  occurs  in  Bede's  History, 
where  Bishop  John  is  spoken  of  as  curing  "  a  dummy 
man  by  blessing  of  him."  The  earliest  schools  for  the 
instruction  of  the  deaf  were  those  of  Pedro  Ponce  de 
Leon,  in  Spain,  and  of  Jerem  Garden,  in  Italy.  Both 
of  these  men  flourished  in  the  sixteenth  century,  and 
their  method  of  instruction  in  both  cases  was  oral. 

The  cure  of  the  deaf  was  universally  regarded  at  that 
time  as  a  miracle,  and  its  instances  were  sedulously  fos- 
tered as  such  by  the  Roman  Catholic  Church. 

Jean  Paul  Bonet  introduced  and  taught  the  single-hand 
alphabet  in  Spain  in  the  first  half  of  the  seventeenth  cen- 
tury. In  the  latter  part  of  the  eighteenth  century  three 
great  schools  were  started :  that  of  the  Braidwoods,  in 
Edinburgh;  that  of  Samuel  Heinecke,  in  Germany; 
and  that  of  the  Abbfe  de  l'£p6e,  in  France.  The  Braid- 
wood  system  was  a  mixed  sign  and  oral  education,  and 
was  carried  on  by  the  family  of  that  name  for  years  as  a 
sort  of  trade  monopoly.  Samuel  Heinecke  taught  pure 
oral  speech.  The  system  of  the  Abb6  de  r£p£e  consisted 
entirely  in  a  series  of  conventional  and  pantomimic  signs. 
Among  the  latter  were  included  the  drawing  together  of 


726 


MEDICAL    RECORD. 


[December  8,  1894 


the  shoulders  and  shivering  to  indicate  "  feeling  cold ;  " 
nodding  the  head  to  express  assent!  and  shaking  it  as  a 
sign  of  dissent.  Besides  such  natural  signs  as  these,  the 
benevolent  Abb6  invented  a  number  of  conventional  or 
arbitrary  signs  to  express  certain  ideas.  The  most  primi- 
tive races  of  mankind  conversed  in  signs,  and  some  of 
these  earliest  pantomimic  signs  still  survive  among  civil- 
ized  people,  and  are  likely  to  last  forever  by  reason  of 
their  terse  expressiveness. 

So  it  occurs  that  some  of  the  most  natural  and  forcible 
of  the  Abb£  signs  are  still  taught  in  connection  with 
the  one-hand  alphabet.  The  letters  of  this  alphabet  are 
formed  by  the  rapid  juxtaposition  of  the  fingers  of  one 
hand.  They  are  arbitrary  letters,  not  at  all  like  the 
stately  and  rounded  capitals  of  the  copy-book,  but  still 
the  child  learns  by  their  combination  to  spell  out  words 
and  form  sentences,  and  so  to  converse  with  other  deaf 
children  similarly  instructed,  and  with  its  teachers.  In  a 
manual-sign  school,  speech  is  regarded  as  an  accomplish- 
ment. The  graduate  of  a  manual  school  can  only  com- 
municate with  those  unacquainted  with  his  language — 
signs — by  means  of  a  writing  pad. 

But  revenons  d  nos  mautons.  It  was  the  general  belief 
of  continental  Europe  at  the  time  when  these  great 
schools  began  their  career,  that  mentality,  or  thought, 
could  not  be  successfully  carried  on  by  any  other  me- 
dium than  that  of  articulate  speech.  The  system  of 
r£pee  was  therefore  a  startling  innovation,  as  he  had 
taught  the  oral  system  previous  to  his  elaboration  of  the 
sign  method. 

The  first  American  mover  in  this  same  benevolent 
purpose  to  remedy  a  prevalent  affliction  of  humanity  was 
Francis  Green,  who  flourished  in  the  latter  part  of  the 
last  century  in  Boston.  He  secured  statistics  showing 
the  existence  at  that  period  of  at  least  seventy  deaf  folk 
in  Massachusetts.  And  he  made  strenuous  efforts  to  start 
a  school  for  them  in  Boston,  but  unsuccessfully. 

Early  in  the  present  century  Col.  Boiling,  of  Virginia, 
two  of  whose  children  were  deaf,  made  arrangements 
with  the  Braidwoods  to  send  one  of  their  number  to  this 
country  who  should  found  a  school  in  America,  and  thus 
allow  two  continents  the  privilege  of  their  monopoly. 

In  181 7,  Dr.  Thomas  Gallaudet  was  sent  abroad  from 
Boston  to  study  the  Braidwood  system,  but  its  founders 
were  so  economical  of  their  monopolistic  right  that  the 
Doctor  wended  his  way  to  France,  visited  the  manual 
school  of  the  Abb6  de  l'£pee,  then  conducted  by  his  suc- 
cessor, the  Abb6  Sicard,  spent  several  years  in  Paris,  and 
brought  back  with  him  the  deaf-mute  Laurent  Clerc  as 
an  assistant  in  the  school  then  opened  in  Hartford,  Conn. 

The  oral  method  was  never  introduced  into  America 
until  1887.  In  the  following  year  the  president  of  the 
National  Gallaudet  College  in  Washington  called  together 
in  that  city  a  meeting  of  the  American  manualists  to 
take  action  against  the  new  heresy.  But  the  seed  had 
been  planted  in  a  good  soil  and  grew. 

In  1880,  a  great  convention  was  held  in  Milan,  Italy, 
to  settle  forever  in  Europe  the  question  of  how  the  deaf 
should  be  taught ;  to  arbitrate  between  Purist  (oralists) 
and  Non  Purists  (manualists).  Dr.  E.  M.  Gallaudet  was 
present  at  that  convention.  Since  that  day  every  child 
in  Continental  Europe  who  is  deaf  has  been  taught  by 
the  pure  oral  system.  The  very  school  of  de  L'^pee  has 
become  an  oral  school. 


But  matters  were  by  no  means  so  easily  cut  and  dried 
in  England,  until  some  five  years  ago,  when  a  Royal  Com- 
mission was  appointed  by  the  Crown  and  experts  sum- 
moned to  London  at  the  expense  of  the  English  Govern- 
ment Dr.  Bell  and  Dr.  Gallaudet  went  from  America. 
The  decision  of  this  Commission  was  that  every  child  who 
was  thus  afflicted  in  Great  Britain  should  be  taught  for  one 
year  by  the  pure  oral  method.  And  only  then  be  turned 
back  into  the  manual-sign  system  if  it  was  clear  that  the 
oral  system  was  not  suited  to  its  individual  requirements. 
This  country  is  therefore  now  going  through  the  same 
scientific  birth-pangs  as  did  Continental  Europe  before 
the  1880  convention  of  Milan.  "  Verbum  sapientibus" 
would  seem  to  be  the  only  criticism  needed. 

There  are  practically  only  two  methods  in  vogue  at 
the  present  day  for  teaching  the  deaf— the  oral  method 
(teaching  by  and  through  articulate  speech),  and  the 
manual-sign  alphabet  method.  Under  both  methods  the 
child  is  taught  writing,  composition,  arithmetic,  spelling, 
geography,  and  all  the  English  branches.  The  methods 
differ  distinctly  in  that  the  oral  system  endows  its  grad- 
uate with  articulate  speech,  and  that  the  manual- sign 
system  does  not. 


THE    MODERN    TREND    OF    GERMAN    MEDI- 
CINE. 

It  used  to  be  the  reproach  of  medical  science  in  Ger- 
many that  it  was  not  practical,  that  its  students  con- 
cerned themselves  little  with  what  should  be  the  end  and 
aim  of  the  physician,  namely  the  cure  of  disease,  the  re- 
lief of  suffering,  and  the  saving  of  life.  Once  the  diag- 
nosis made,  all  interest  in  the  patient  ceased,  unless  in- 
deed he  chanced  to  die,  when  he  again  became  an 
object  of  interest  for  pathological  purposes.  The  re- 
proach was  not  undeserved,  although  it  was  somewhat 
exaggerated.  But  now  things  have  changed,  and  a  ques- 
tion of  therapeutics  arouses  as  great  interest  as  did 
formerly  one  of  pathology.  This  change  is  'well  illus- 
trated by  the  comparative  sale  of  two  subscription  works 
now  being  issued  in  the  German  language.  One,  edited 
by  Penzoldt  and  Stintzing,  devoted  chiefly  to  the  treat- 
ment of  disease,  is  having,  so  we  are  informed,  a  very 
large  sale,  while  the  work  edited  by  Nothnagel,  the  ten- 
dency of  which  is  chiefly  pathological,  is  meeting  with 
but  indifferent  success.  The  cause  for  this  change  is 
doubtless  the  hope  of  cure  that  has  been  aroused  by  dis- 
coveries in  bacteriology.  Formerly  it  was  nearly  all 
guess-work  and  empiricism,  but  now  there  is  a  basis  upon 
which  to  build  a  science  of  therapeutics,  and  inspired 
with  the  hope  of  success,  the  German  shows  that  he  is 
just  as  willing  to  save  his  patients  as  is  anyone  else,  pro- 
vided he  has  an  incentive  for  trying. 


Garbage  Cremation. — According  to  the  Inventive  Age 
there  are  now  fifty-five  towns  and  cities  in  England 
which  destroy  their  garbage  and  solid  refuse  by  burning, 
using  an  average  of  about  ten  furnaces  each  for  that  pur- 
pose. The  combustion  of  the  material  is  used  for  the 
generation  of  steam,  by  which  the  streets  are  electrically 
illuminated,  and  other  cities  are  reported  to  be  consider- 
ing the  propriety  of  reducing  their  municipal  expenses 
by  this  means. 


December  8,  1894] 


MEDICAL   RECORD. 


727 


gtexxxs  tit  tfie  $S8teefL 

President  Cleveland's  Recommendation  ef  a  National 
Board  of  Health.— President  Cleveland,  in  his  message  to 
Congress,  makes  the  following  recommendation  :  "  I  am 
entirely  convinced  that  we  ought  not  to  be  longer  with- 
out a  national  board  of  health  or  national  health  officer 
charged  with  no  other  duties  than  such  as  pertain  to  the 
protection  of  our  country  from  the  invasion  of  pestilence 
and  disease.  This  would  involve  the  establishment,  by 
such  board  or  officer,  of  proper  quarantine  precautions, 
or  the  necessary  aid  and  counsel  to  local  authorities  on 
the  subject,  prompt  advice  and  assistance  to  local  boards 
of  health  or  health  officers  in  the  suppression  of  con- 
tagious disease,  and  in  cases  where  there  are  no  such 
local  boards  or  officers,  the  immediate  direction  by  the 
national  board  or  officer  of  measures  of  suppression,  con- 
stant and  authentic  information  concerning  the  health  of 
foreign  countries  and  all  parts  of  our  own  country  as  re- 
lated to  contagious  diseases ;  and  consideration  of  regu- 
lations to  be  enforced  in  foreign  ports  to  prevent  the  in- 
troduction of  contagion  into  our  cities,  and  the  measures 
which  should  be  adopted  to  secure  their  enforcement. 
There  seems  to  be  at  this  time  a  decided  inclination  to 
discuss  measures  of  protection  against  contagious  diseases 
in  international  conference,  with  a  view  of  adopting  means 
of  mutual  assistance.  The  creation  of  such  a  national 
health  establishment  would  greatly  aid  our  standing  in 
such  conferences,  and  improve  our  opportunities  to  avail 
ourselves  of  their  benefits.  I  earnestly  recommend  the 
inauguration  of  a  national  board  of  health  or  similar  na- 
tional instrumentality,  believing  the  same  to  be  a  needed 
precaution  against  contagious  disease  and  in  the  interest 
of  the  safety  and  health  of  our  people." 

The  Causa  of  the  Czar's  Death.— We  have  received  a 
copy  of  the  official  notice  giving  forth  the  nature  of  the 
malady  to  which  the  Czar  succumbed.  The  diagnosis 
made  by  the  physicians  in  attendance,  Dxs.  Leyden, 
Zakharin,  Girsh,  P.  Popoff,  and  Weliaminoff,  was  con- 
firmed in  the  main  by  the  results  of  the  autopsy  per- 
formed the  following  day.  This  diagnosis  was  "  chronic 
interstitial  nephritis  with  secondary  disease  of  the  heart 
and  vessels,  and  hemorrhagic  infarction  of  the  left  lung 
with  secondary  pneumonia."  The  following  is  a  trans- 
lation of  the  report  of  the  autopsy:  On  October  22, 
1S94,  at  7.30  o'clock  in  the  evening,  we,  the  undersigned, 
upon  the  occasion  of  embalming  the  body  of  the  Em- 
peror Alexander  Alexandrovich,  asleep  in  God,  found 
the  lesions  described  below.  There  was  considerable 
oedema  of  the  subcutaneous  connective  tissue  of  the  lower 
extremities,  with  a  punctate  redness  over  the  left  leg.  In 
the  left  pleural  cavity  was  200  c.c.  of  serous  effusion  of 
a  reddish  color;  in  the  right  cavity  50  c.c.  of  a  similar 
fluid.  There  was  an  old  fibrous  cicatrix  at  the  apex  of 
the  right  lung,  and  this  lung  was  somewhat  oedematous ; 
in  the  left  lung  there  was  oedema  of  the  upper  lobe  and 
a  hemorrhagic  infarct  in  the  lower  lobe,  and  this  lobe 
was  also  congested  and  contained  very  little  air.  The 
infarct  was  situated  at  the  upper  edge  of  the  lower  lobe 
and  presented  a  triangular  form  on  section,  measuring 
ij4  ctm.  in  length  by  1  ctm.  on  cross  section.  In 
the  pericardium  there  was  50  c.c.  of  a  blood-stained 


serous  effusion.  The  heart  was  considerably  increased  in 
size,  measuring  17  ctm.  in  length  and  18  ctm.  in  width. 
In  the  subserous  cellular  tissue  there  was  a  large  amount 
of  fat  (lipomatosis  cordis).  The  left  heart  was  dilated 
and  the  wall  of  the  left  ventricle  was  hypertrophied 
(2  j£  ctm.) ;  the  muscular  tissue  was  pale,  flabby,  and  of 
a  yellowish  color  (degeneratio  adiposa  myocardii).  The 
muscular  wall  of  the  right  ventricle  was  thinned  (6  mm.), 
and  of  the  same  yellowish  color.  The  valvular  apparatus 
was  perfectly  normal.  In  the  abdominal  cavity  was  about 
200  c.c.  of  serous  fluid.  There  was  a  large  collection  of 
gas  in  the  stomach  and  intestines.  The  liver  was  slightly 
enlarged  and  greatly  congested.  The  kidneys  presented 
the  following  measurements:  left,  16  ctm.  in  length, 
7  ctm.  in  width,  and  4  ctm.  in  thickness;  right,  15  ctm. 
in  length,  6]/2  ctm.  in  width,  and  4  eta-  in  thickness. 
The  capsules  were  of  ordinary  thickness  and  not  adher- 
ent. The  surface  of  the  kidneys  was  finely  granular  and 
of  a  dark-red  color.  The  organs  were  not  noticeably 
hardened.  The  cortical  substance  was  reduced  in  thick- 
ness (6  to  7  mm.)  and  yellowish,  the  medullary  portion 
was  dark*  red  in  color  (nephritis  interstitialis'cum  atrophia 
substantiva  corticitis  venum  granulosa).  In  addition 
there  was  a  serous  cyst  3  mm.  in  diameter  in  the  left  kid- 
ney. Upon  a  basis  of  what  has  been  above  described, 
we  conclude  that  the  Emperor  Alexander  Alexandrovich 
died  from  paralysis  of  the  heart  due  to  degeneration  of 
the  muscle  of  the  hypertrophied  heart,  and  interstitial 
nephritis  (granular  atrophy  of  the  kidneys).  The  report 
is  signed  by  Drs.  Klein,  Zernoff,  M.  A.  Popoff,  Altuk- 
hoff,  and  Bielousoff. 

Professor  Baginsky  and  Antitoxin. — Professor  Bagin- 
sky,  of  Berlin,  writes  concerning  his  article  in  October 
6th  issue,  and  desires  the  following  correction : 

Instead  of:  "It  was  difficult  to  ascertain  the  cause  of 
the  disease :  Twenty-five  cases  which  had  been  exposed 
to  diphtheria  were  carefully  examined  a  number  of  days, 
and  all  developed  diphtheria.  As  they  were  examined 
daily,  they  were  attended  when  the  first  symptom  ap- 
peared. Not  one  of  these  developed  nephritis  nor  car- 
diac trouble.  Their  sisters  and  brothers,  who  had  been 
previously  admitted  to  the  hospital,  some  as  severe  cases, 
died.    All  twenty-five  cases  were  discharged  cured." 

The  above  should  read  thus  :  "  It  was  extremely  diffi- 
cult to  ascertain  the  real  cause  of  the  disease  from  the 
relatives.  We  have  had  a  number  of  children,  twenty  five 
in  all,  brought  to  us  on  the  same  day  that  their  brothers 
and  sisters  were  admitted  as  diphtheria  patients,  care- 
fully examined  them,  and  found  these  children  perfectly 
healthy.  These  children  were  brought  to  us  for  in- 
spection daily,  and  took  sick  some  on  one,  two,  or 
several  days  afterward.  So  that  in  these  twenty-five 
cases  we  are  really  depending  on  proper  statistics  in  the 
beginning  of  the  disease.  All  of  these  latter  patients 
got  well  and  were  discharged  cured.  In  not  a  single 
case  did  any  symptom  of  cardiac  or  nephritic  complica- 
tion manifest  itself.  Whereas,  the  brothers  and  sisters 
that  were  first  brought  to  us  developed  not  only  severe 
types  of  diphtheria,  and  some  proved  fatal." 

Statistics  in  the  Medical  Department  of  the  Navy. 
— The  new  form  of  statistical  report  recently  issued  by 
Surgeon-General  Tryon  will  not  only  be  appreciated  by 
the  medical  corps  of  the  navy,  but  by  the  profession  at 


728 


MEDICAL  RECORD. 


[December  8,  1894 


large.  The  nomenclature  of  diseases  (adopted  by  the 
Royal  College  of  Physicians  and  Surgeons,  England)  in 
use  in  the  navy  for  many  years  has  been  abolished,  and 
a  classification  substituted  on  the  basis  of  modern  require- 
ments.  The  new  system,  commencing  January,  1895, 
will  enforce  interesting  statistics  rendered  valuable  on 
account  of  their  accuracy. 

Charles  T.  Chase,  M.D.,  of  Brooklyn,  died  on  No- 
vember 5  th,  aged  sixty- three,  the  cause  of  his  death  hav- 
ing been  chronic  interstitial  nephritis.  He  was  a  well- 
known  practitioner  of  forty  years'  standing  in  Brooklyn, 
and  the  son  of  Dr.  Charles  Chase,  of  the  United  States 
Navy. 

Dr.  Hedges's  Paper  on  Diphtheria.— By  an  oversight 
of  the  printer  the  article  of  Dr.  Hedges,  on  page  682,  was 
not  indexed. 

Football  at  Springfield.— We  must  confess  to  a  dis- 
tinct disappointment  at  the  way  in  which  the  Harvard- 
Yale  game  of  football  at  Springfield  was  conducted  this 
year.  The  promise  of  reform  in  rules  and  discipline  has 
not  been  kept.  The  number  of  disabled  men  was  un- 
usually great,  and  there  were  several  serious  injuries; 
that  these  were  in  every  case  the  result  of  "  accidents  " 
it  seems  to  be  difficult  to  admit.  The  rules  may  be 
amended  to  any  extent,  but  it  profits  nothing  if  they  are 
not  or  cannot  be  enforced.  The  penalty  for  slugging, 
or  for  purposely  attempting  in  any  way  to  injure  an  an- 
tagonist cannot  be  too  severe  or  too  severely  enforced, 
if  this  game  is  to  be  continued  as  a  competitive  sport 
among  college  men.  That  a  player  may  with  impunity 
jump  on  an  antagonist  prostrate  on  the  ground  with  the 
ball,  after  the  whistle  has  been  blown,  and  dislocate  his 
victim's  clavicle,  should  be  an  impossibility.  What  the 
umpire  does  not  see,  however,  is  supposed  not  to  occur. 
In  so  far  as  the  umpire  is  blind  he  may,  at  least,  in  that 
particular,  be  said  to  be  a  representative  of  justice;  the 
best  pair  of  eyes  may  really  miss  some  of  the  incidents 
of  the  gridiron.  Had  the  penalty  of  disqualification, 
however,  been  rigidly  enforced  from  the  beginning  of 
the  first  half  of  this  game,  there  would,  we  are  convinced, 
have  been  fewer  subsequent  "accidents." — Boston  Medi- 
cal and  Surgical  Journal. 

Dr.  William  Gay  Brockway  died  November  28th,  at 
181  West  134th  Street,  New  York,  aged  thirty-four.  He 
was  graduated  from  the  University  Medical  College  in 
1887,  and  practised  in  Harlem  until  December  last,  when 
he  went  to  Florida  for  his  health. 

Dr.  George  R.  Brash,  of  Sayville,  L.  I.,  died  of  dia- 
betes on  November  29th,  at  Colorado  Springs,  aged  fifty- 
nine.  Dr.  Brush  was  born  at  Smithtown,  L.  I.  After 
his  graduation  from  the  College  of  Physicians  and  Sur- 
geons in  1858,  he  practised  in  this  city  and  Sayville  un- 
til September,  1861,  when  he  entered  the  navy  as  assist- 
ant surgeon.  He  passed  through  the  successive  grades 
until  he  became  Medical  Inspector  in  1889,  which  rank 
he  held  at  the  time  of  his  death.  He  was  detailed  to  the 
Brooklyn  Navy  Yard  in  1892. 

A  New  Woman's  Hospital. — The  authorities  of  the 
Woman's  Hospital,  at  Park  Avenue  and  Forty-ninth 
Street,  New  York,  are  to  erect  a  new  hospital  in  Central 
Park  West,  having  acquired  the  block  between  Ninety-sec- 
ond and  Ninety-third  Street,  the  plot  extending  back  two 


hundred  and  fifty-nine  feet  in  Ninety- second  Street  and 
two  hundred  and  fifty  in  Ninety-third  Street,  with  the 
exception  of  one  parcel  of  twenty-five  feet  in  the  latter 
street  Most  of  this  property  has  been  actually  pur- 
chased and  the  remainder  is  under  contract.  The  cost 
of  the  plot  is  1331,000. 

St.  Mark's  Hospital,  New  York.— Dr.  H.  J.  Setoff  has 
been  appointed  attending  surgeon  to  St.  Mark's  Hospi- 
tal. 

The  New  Surgeon-General  of  Hew  Tork  State  V.  Ck 
is  Dr.  M.  C.  Terry,  of  Utica.  He  is  a  graduate  of  the 
Cleveland,  O.  Homoeopathic  Hospital  College  in  1872. 

The  Monteflore  Home  for  Chronic  Invalids. — The 
new  wing  of  the  Montefiore  Home  was  formally  opened 
on  November  29th.  The  occasion  was  also  the  tenth 
anniversary  of  the  founding  of  the  institution. 

Bequests  to  Hospitals.— The  late  Henry  Keney  has 
left  150,000  for  the  Hartford  Hospital. 

The  Manhattan  Dispensary,  of  this  city,  is  the  fortu- 
nate recipient  of  a  bequest  of  over  one  hundred  thousand 
dollars. 

There  seems  to  be  Considerable  Trouble  in  the  Na- 
tional Association  of  Railway  Surgeons.  The  association 
issues  a  special  proclamation  warning  its  members 
against  the  proposed  American  Academy  of  Railway 
Surgeons.  Certain  members  of  the  N.  A.  R.  S.,  in  their 
efforts  to  establish  a  rival  society,  says  the  resolution, 
"  have  used  fee- similes  of  letterheads  of  the  railway  sur- 
geons for  the  purpose  of  producing  a  false  impression  as 
to  their  standing  with  the  members  of  this  (N.  A.  R.  S.) 
association  and  its  official  organ  and  with  railway  sur- 
geons, etc."    Gentlemen,  this  is  a  N.  A.  R.  S ty 

trick,  and,  in  the  words  of  another,  "  You  shouldn't  ort 
to  have  done  it."  We  believe  in  fair  play  if  you  are 
going  to  fight. — Medical  Examiner. 

A  Tear's  Immigration. — The  annual  report  of  Her- 
man Stump,  United  States  Superintendent  of  Immigra- 
tion, shows  that  during  the  fiscal  year  ended  June  30, 
1894,  288,020  immigrants  arrived  in  this  country,  of 
whom  285,631  were  landed  and  2,389  debarred  from 
landing  because  of  being  under  contract  to  perform  labor 
made  previous  to  their  arrival.  Of  the  immigrants 
landed,  96,000  were  destined  for  New  York  State, 
42,000  for  Pennsylvania,  25,000  for  Massachusetts,  and 
22,000  for  Illinois,  the  others  being  scattered  throughout 
the  United  States,  no  other  State  receiving  a  greater 
number  than  10,000.  Immigrants  destined  for  southern 
States,  all  told,  did  not  exceed  12,000.  Of  the  immi- 
grants over  sixteen  years  of  age,  41,000  could  not  read 
or  write. 

A  German  Temperance  Society. — The  German  Soci- 
ety Against  the  Abuse  of  Alcohol  held  its  annual  meet- 
ing on  September  18th  and  19th,  at  Cassel.  Among  the 
subjects  discussed  were  Sunday  afternoon  closing  and  the 
influence  of  women  in  the  temperance  movement. 

Dartmouth  Medical  College  held  its  annual  com- 
mencement November  20th,  graduating  a  class  of  twenty- 
seven. 

An  Epidemic  of  Diphtheria  prevails  in  Yonkers,  N.  Y. 
On  November  23d  there  were  fifty-six  cases  in  the  city. 


December  8,  1894J 


MEDICAL   RECORD. 


729 


Jfacfcefeg  imports* 

NEW  YORK  ACADEMY  OF  MEDICINE. 

SECTION   ON   GENERAL  MEDICINE. 

Stated  Meeting,  November  20, 1894. 

W.  H.  Porter,  M.D.,  Chairman. 

Specimens  illustrating  varieties  of  biliary  calculi  were 
presented  by  Drs.  George  P.  Biggs  and  Morris  Manges. 

A  B6sum6  of  the  Subject  of  Biliary  Calculi. — Dr. 
Thomas  Southworth  read  a  paper  on  the  above  sub- 
ject, and  in  opening  the  discussion,  Dr.  Kinnicutt  said 
that  the  chemistry  and  symptomatology  of  biliary  calculi 
had  been  described  very  thoroughly  in  Dr.  Southworth's 
interesting  paper.  He  had  little  or  nothing  new  to  say, 
yet  it  might  be  useful  to  refer  to  some  of  the  difficulties 
of  differentiation  between  certain  lesions  of  the  larger 
ducts  and  gall  bladder,  produced  by  impacted  calculi. 
He  would  first  refer  to  the  differentiation  between  hy- 
drops in  the  sense  of  a  dilatation  of  the  gall-bladder 
through  obstruction  in  the  cystic  duct,  and  empyema  of 
the  gall-bladder  on  the  one  hand,  and  a  catarrhal  cho- 
langitis produced  by  impacted  biliary  calculi  in  the  com- 
mon duct,  also  causing  enlargement  of  the  gall-bladder. 

A  differential  diagnosis  was  very  desirable,  as  in  the 
case  of  empyema,  at  least,  prompt  surgical  interference 
was  indicated,  while  in  dilatation  with  catarrhal  cholan- 
gitis, complete  recovery  frequently  occurred  without 
operation.  Although  both  hydrops  and  empyema  of  the 
gall-bladder,  as  a  rule,  were  produced  by  impacted  cal- 
culi in  the  cystic,  rather  than  in  the  common,  duct,  and 
hence  were  unattended  with  jaundice,  nevertheless  im- 
pacted calculi  in  both  cystic  and  common  ducts  were 
not  of  uncommon  occurrence. 

In  both  empyema  and  catarrhal  cholangitis,  paroxysms 
of  chill,  fever,  and  sweating  of  an  irregular,  or  quotidian, 
or  tertian,  or  quartan  type  might  be  present.  It  was  im- 
portant to  bear  in  mind  that  such  symptoms  occurred,  as 
a  rule,  in  catarrhal  cholangitis  from  impacted  stones. 
The  fever  often  rose  to  a  very  considerable  height.  In 
a  case  which  was  recently  under  his  observation,  a 
severe  chill  was  immediately  followed  by  a  rapid  rise  of 
temperature  to  1050  F.,  and  again  succeeded  by  profuse 
sweating.  Similar  paroxysms  of  a  quotidian  type  oc- 
curred over  a  period  of  three  weeks,  and  on  operation 
several  large  stones  were  found  impacted  in  both  the 
cystic  and  common  ducts,  without  either  a  trace  of  sup- 
puration or  the  evidence,  on  the  closest  scrutiny,  of  any 
lesion  of  the  mucous  membrane.  The  autopsy,  the  pa- 
tient dying  of  uraemia,  rendered  a  very  careful  study  of 
the  ducts  possible. 

The  true  nature  of  hepatic  fever  associated  with  ca- 
tarrhal cholangitis  yet  remains  unsettled.  It  very  cer- 
tainly is  not  of  a  septic  character.  On  the  other  hand, 
an  empyema  of  the  gallbladder  may  exist  with  an  entire 
absence  of  chill,  fever,  and  sweating.  An  interesting 
case  of  this  kind  recently  has  been  reported  by  Dr.  Os- 
ier, in  which  150  c.c.  of  pus  were  removed  from  the 
gall- bladder.  A  possible  sign  of  differentiation  between 
hydrops  and  empyema  of  the  gall-bladder,  on  the  one 
hand,  and  dilatation  from  an  impacted  calculus  produc- 
ing catarrhal  cholangitis  and  hepatic  fever,  on  the  other, 
may  be  looked  for  in  the  much  greater  enlargement  of 
the  gall-bladder  in  the  former  instances.  It  is  a  clinical 
fact,  moreover,  that  in  obstruction  of  the  common  duct, 
even  when  the  dilatation  of  the  gall-bladder  is  found  to 
be  very  great,  the  physical  signs  of  its  enlargement  are  fre- 
quently unappreciable.  The  explanation  I  am  not  prepared 
to  give,  unless  it  be  that  through  the  distention  of  the 
smaller  ducts  with  bile  in  these  cases,  and  the  consequent 
enlargement  of  the  liver,  the  relations  of  liver  and  gall- 
bladder are  somewhat  altered.  A  second  point  of  differ- 
entiation in  favor  of  a  catarrhal  cholangitis  with  dilatation, 


is  in  the  persistence  of  the  ague-like  paroxysms  over  a 
very  considerable  period  of  time ;  cases  are  not  uncom- 
mon where  such  symptoms  extend  over  an  interval  of 
weeks,  and  even  months. 

In  conclusion,  Dr.  Kinnicutt  expressed  his  views  in 
regard  to  the  indications  for  surgical  interference  in  the 
different  conditions  he  had  referred  to.  In  simple  hy- 
drops from  obstruction  in  the  cystic  duct  or  neck  of  the 
gall-bladder,  the  indications  were  not  very  apparent, 
although  the  passage  of  a  large  stone  through  ulceration 
into  the  duodenum,  and  possible  intestinal  obstruction, 
should  be  borne  in  mind.  In  empyema  of  the  gall-blad- 
der, speedy  surgical  interference  was  demanded.  In 
impaction  of  a  calculus  in  the  common  duct,  the  pres- 
ence of  hepatic  fever,  even  extending  over  a  long  period, 
did  not  indicate  operation  in  his  judgment  and  from  his 
experience,  unless  the  health  seriously  suffered  thereby. 
Complete  recovery  was  entirely  possible  in  such  cases, 
even  after  many  months  of  persistence  of  these  symptoms. 
A  number  of  cases  with  this  outcome  had  passed  under 
his  personal  observation. 

Dr.  W.  Gilman  Thompson  said  that  he  was  pleased  to 
see  the  specimens  presented,  for  in  addition  to  their 
general  interest  some  of  them,  by  their  great  size,  showed 
that  it  was  possible  to  exist  in  health  without  the  use  of 
a  gall-bladder,  as  they  entirely  occupied  its  cavity — a 
fact  that  had  also  been  demonstrated  by  the  removal  of 
the  gall-bladder  without  serious  results.  In  the  treatment 
oi  gall-stones  it  was  possible  that  glycerine  and  ether 
might  dissolve  the  stone  to  a  slight  extent,  but  he  had 
not  secured  favorable  results  from  the  use  of  olive  oil; 
and  as  the  oil  is  not  taken  up  by  the  blood-vessels,  but 
by  the  lymphatics,  one  must  conclude  that  the  oil  never 
reaches  the  gall-bladder.  Most  of  the  "gall-stones" 
found  in  the  stools  after  giving  oil,  have  turned  out  to  be 
nothing  but  inspissated  oil.  The  subject  of  dietetic 
treatment  was  one  worthy  of  careful  investigation,  but 
one  on  which  little  had  been  written.  It  is  a  matter  of 
interest  to  find  whether  cholesterin  is  a  force-producer 
that  can  be  used  in  the  system,  or  is  only  a  waste  prod- 
uct. It  seemed  to  him  that  it  is  not  essentially  a  waste 
product,  for  it  exists  in  substances  where  we  would  not 
look  for  waste  matter.  It  is  found  in  eggs,  in  pulses,  and 
other  vegetables,  in  red  blood-corpuscles,  and  in  the 
brain,  and  because  it  is  present  in  these  substances  it 
could  reasonably  be  claimed  that  it  is  not  a  waste  prod- 
uct. The  fact  that  it  is  found  in  the  faeces  and  rarely 
in  the  urine,  might  be  cited  to  prove  that  it  is  waste  ma- 
terial, but  the  probability  is  that  it  never  appears  there 
in  any  greater  quantity  than  is  taken  into  the  system 
with  the  food.  As  cholesterin  is  the  substance  from 
which  gall-stones  are  chiefly  formed,  it  seems  desirable 
to  avoid  foods  containing  it,  in  the  ordering  of  dietetic 
treatment. 

Dr.  Thompson  further  said  that  in  explanation  of  the 
formation  of  gall-stones  he  did  not  see  any  need  of  a 
bacterium,  for  we  look  to  the  precipitation  of  certain  in-  . 
gredients  of  the  bile  as  the  true  factor,  and  lime  salts  in 
excess  will  do  this.  A  large  quantity  of  water  should  be 
drunk,  as  it  dilutes  the  bile  and  prevents  further  precipi- 
tation. 

Dr.  Beverley  Robinson  said  he  thought  that  many 
cases  were  diagnosed  as  gall  stones  that  were  not  such ; 
that  there  might  be  a  distention  of  the  gall-bladder  and 
severe  colic  without  the  presence  of  stone  in  the  gall- 
bladder or  the  ducts,  and  that  such  distention  was  often 
wrongly  attributed  to  gall-stones.  He  further  said  that 
he  did  not  believe  gall  stones  occurred  in  young  people, 
unless  in  exceptional  cases;  also  that  there  could  be 
spasms  of  the  gall-bladder  and  hepatic  duct,  producing 
pains  similar  to  those  of  biliary  colic. 

Dr.  Robert  Abbe  said  he  believed  that  the  surgeons 
were  as  conservative  as  the  physicians,  though  they  were 
often  looked  upon  as  less  conservative.  He  was  confi- 
dent that  patients  were  sometimes  operated  upon  for  the 
removal  of  gall  stones  who  would  recover  without  the 
operation,  yet  there  were  cases  in  which  an  operation 


730 


MEDICAL   RECORD. 


[December  8,  1894 


was  a  necessity.  He  had  operated  on  about  fifteen  very 
bad  cases,  and  cited  others  in  which  an  operation  seemed 
demanded,  but  the  patients  got  well  by  passing  the 
stones.  The  operation  was  a  comparatively  simple  one, 
for  there  was  no  danger  of  a  hernia,  and  drainage  could 
be  secured  without  trouble.  Dr.  Abbe  emphasized  the 
point  that,  opening  the  abdomen  and  examination  of  the 
gall  bladder  was  not  enough  for  a  sure  diagnosis  of  stone, 
for  the  gall-bladder  was  always  found  to  contain  consider- 
able bile,  and  this  would  interfere  with  the  discovery  of 
the  stones.  The  operator  could  not  be  certain  until  he 
had  opened  the  gall-bladder  itself.  He  had  seen  a  case 
that  had  been  operated  upon  and  no  stones  found,  but 
on  a  second  operation  and  opening  the  gallbladder  seven 
stones  were  found.  He  said  that  he  would  hesitate  most 
in  operating  on  the  aged  who  had  suffered  from  pains  for 
a  number  of  years,  and  also  in  operating  upon  the  young. 
He  cited  a  case  of  an  expert  cook  who  was  accustomed  to 
serve  in  wealthy  families,  but  biliary  colic  became  so  bad 
every  few  weeks  that  it  was  impossible  to  retain  a  posi- 
tion. He  thought  that  in  such  a  case  it  was  very  advis- 
able] to  perform  an  operation.  Dr.  Abbe  also  thought 
that  dietetic  treatment  was  very  important.  Manipula- 
tion was  often  of  service,  and  in  one  case,  that  of  a  man 
sixty  years  of  age,  the  use  of  an  ice  enema  and  manipu- 
lation caused  the  patient  to  pass  a  number  of  stones,  and 
thus  gave  relief. 

Dr.  Leonard  Weber  gave  the  history  of  several  in- 
teresting cases,  and  said  that  he  had  used  an  enema  of 
cold  water  with  very  good  results,  but  had  never  used 
ice  for  that  purpose.  One  patient  had  passed  four  or 
five  hundred  stones  ;  in  another  patient  he  had  found  a 
stone  surrounded  by  cancer,  and  in  another  there  was  a 
cicatrix  encircling  the  cystic  duct. 

Dr.  Southworth,  in  closing,  said  that  glycerine  was 
supposed  to  act  by  increasing  the  action  of  the  hepatic 
cells;  that  olive-oil  probably  reduced  the  size  of  the 
formed  stone ;  that  it  was  believed  the  cholesterin  stone 
was  formed  from  the  mucus  of  the  bile-duct  and  gall- 
bladder ;  and  that  a  stone  could  grow  to  large  size  in  a 
duct  in  a  few  days. 


Clinical  J^artment 

A  CASE  OF  CYSTIC  DEGENERATION  OF  THE 
CHORION.1 


By  L.  W.  ZWISOHN,  M.D., 

NEW  YORK. 


ho 


On  January  3d,  I  was  called  to  see  Mrs.  R.  S , 

gave  the  following  history:  aged  twenty-three ;  mar- 
ried three  years ;  has  one  child  living,  aged  nineteen 
months ;  is  greatly  emaciated,  has  headache,  sleeplessness, 
and  great  debility.  She  was  suffering  from  severe  vom- 
iting and  thought  she  felt  life ;  on  bimanual  examination 
I  found  the  uterus  very  much  enlarged  and  the  os  closed 
— to  all  appearances  a  normal  pregnancy.  I  advised  per- 
fect rest,  and  prescribed  an  anti-emetic.  On  January  10th 
I  was  summoned  in  haste  to  see  the  patient.  A  hemor- 
rhage had  occurred  and  I  deemed  it  necessary  to  tampon 
the  vagina ;  I  made  cold  applications  and  the  hemor- 
rhage was  controlled ;  the  vomiting  still  continued  and 
I  ordered  moderate  diet  with  cold  drinks,  which  afforded 
the  patient  some  relief.  On  January  25th  a  second 
hemorrhage  occurred.  I  tamponed  again,  and  six  hours 
later  the  os  was  well  dilated.  On  introducing  the  finger 
to  examine  the  condition  of  the  uterus  a  sudden  and 
rather  severe  hemorrhage  occurred.  I  had  no  time 
to  prepare  a  proper  tampon,  but  seized  the  nearest  piece 
of  cotton  at  hand,  and  packed  it  into  the  vagina.  Two 
hours  later  an  hydatidiform  mole  was  removed  piece- 
meal, with  the  fingers  of  one  hand  in  the  uterus,  and  the 
other  hand  making  pressure  from  above  externally.    The 

1  Read  before  the  Harlem  Medical  Association. 


friends  would  not  allow  the  use  of  instruments,  and  as 
there  was  no  elevation  of  temperature  I  left  the  case  to 
nature,  merely  watching  developments.  Two  days  later 
the  mother  of  the  patient  presented  to  me  the  placenta, 
which  was  expelled  during  the  night.  Since  then  the 
patient  has  been  doing  well.  Now  the  main  points  of 
interest  are : 

x.  Is  vomiting  one  of  the  main  symptoms  of  hydatid 
cyst  ?  Thomas,  Schroeder,  and  Tait  do  not  mention  it 
Play  fair  says  there  is  constant  vomiting,  and  Polk  has  re- 
ported a  case  which  is  similar  to  the  case  under  consid- 
eration. 

2.  Do  we  have  positive  signs  to  help  in  the  diagnosis 
of  hydatidiform  mole  ?  and  what  are  they  ? 

3.  Do  they  reappear  in  the  same  individual,  and  if  so, 
how  frequently  ?  for  how  long  a  period  is  the  mole  re- 
tained in  the  uterus  ?  Tait  reported  a  case  in  which  five 
moles  were  removed  from  the  same  individual  at  differ- 
ent periods.  He  says  a  mole  is  rarely  retained  more 
than  five  months. 

4.  Is  curetting  advisable  in  cases  of  hydatid  mole? 
Thomas,  Schroeder,  and  Tait  do  not  mention  this 
operation ;  Polk  performed  it  in  the  case  he  reported,  but 
in  that  case  he  says  the  mass  had  a  decided  odor  of  de- 
composition. 

5.  Is  it  possible  that  hydatidiform  mole  should  occur 
independently  of  co  nception  ? 

To  answer  these  important  questions,  I  believe  we 
have  to  consider  the  etiology  of  the  hydatid  mole.  The 
chorion  remaining  attached  to  the  uterine  walls  after  the 
expulsion  or  death  of  the  embryo  sometimes  undergoes  a 
peculiar  metamorphosis  ;  it  differs,  however,  from  the 
true  hydatids  in  absence  of  the  acephlocysts  and  is  also 
unlike  it  in  appearance  and  form ;  the  uterine  hydatids 
consist  of  little  sacs  in  a  series  as  if  strung  together, 
hence  their  grape-like  appearance;  the  true  hydatids 
are  closed  sacs,  one  within  another.  Giers  and  Graily 
Hewitt  say  it  always  follows  death  of  the  foetus.  The  fact 
that  the  morbid  growth  may  owe  its  inception  to  foetal 
disease  seems  demonstrated  by  the  cases1  where  a 
healthy  foetus  may  be  developed  at  the  moment  with  the 
hydatid  mole.  Virchow  thinks  it  originates  in  a  morbid 
state  of  the  decidua,  while  others  attribute  it  to  some  blood 
dyscrasia  on  the  part  of  the  mother,  such  as  syphilis.  The 
latter  believes  that  it  may  occur  more  than  once  in  the 
same  person,  and  that  the  exciting  cause  of  the  hydatid 
mole  is  a  morbid  maternal  condition.  The  probability 
is  that  both  views  may  be  right,  the  disease  sometimes 
following  the  death  of  the  embryo  and  at  others  being 
the  result  of  obscure  maternal  causes. 

McCHntock  says  that  hydatids  may  be  retained  in  the 
uterus  for  many  months  or  years,  or  a  portion  only  may 
be  expelled  and  the  residue  may  throw  out  a  fresh  crop 
of  vesicles  to  be  discharged  on  a  future  occasion.  This 
may  be  important  from  a  legal  point  of  view,  for  instance, 
in  the  case  of  a  widow  or  a  woman  living  apart  from  her 
husband.  It  is  possible,  as  Playfair  points  out,  that 
true  entozoa  may  form  in  the  substance  of  the  uterus, 
which  being  expelled  per  vaginum  might  be  taken  for 
the  result  of  cystic  disease.  Hewitt  also  relates  a  case 
of  an  unmarried  woman  in  whom  true  hydatids  from  the 
liver,  had  extended  to  the  peritoneum  and  burst  through 
the  vagina. 

In  such  cases  the  woman's  reputation  may  demand 
that  a  careful  examination  of  the  cyst  and  its  contents 
should  be  made. 

Symptoms. — The  first  physical  sign  is  the  rapid  in- 
crease of  the  uterine  tumor,  which  does  not  correspond 
in  size  to  the  supposed  period  of  pregnancy.  Leishman 
attributed  much  importance  to  the  unusual  hardness  or 
density  of  the  uterus.  The  uterine  tumor  is  often  irreg- 
ular, and  constant  vomiting  may  be  present.  None  of 
these  are,  however,  positive  signs  except  the  presence  of 
cysts  in  the  watery  and  bloody  discharge. 

Dr.  Holperin  related  to  me  two  cases  that  came  under 
his  observation  in  which  there  was  hemorrhage  in  both, 

»  Spiegelberg,  Lehrbtich,  p.  33a. 


December  8,  1894] 


MEDICAL    RECORD. 


73* 


and  vomiting  in  one.  In  the  second  case  he  was  unable 
to  tell,  as  he  was  called  to  deliver  the  mole  and  could 
not  obtain  the  history  of  the  case. 

Treatment — The  uterus  should  be  cleared  of  its  con- 
tents as  soon  as  possible,  and  on  account  of  the  occa- 
sional firm  adhesions  of  the  cystic  mass  to  the  uterus  too 
energetic  attempts  gat  complete  separation  should  be 
avoided.  .  ...  ;_^r"  i- 

Summary. — From  the  different  opinions  above  quoted 
we  are  justified  in  coming  to  the  following  conclusions: 
1.  Persistent  vomiting  is  one  of  the  principal  symptoms, 
but  not  a  certain  sign.  2.  The  only  positive  sign  we 
have  is  the  presence  of  the  cysts  in  the  watery  dis- 
charge. 3.  They  frequently  reappear  in  the  same  indi- 
vidual, but  for  what  period  they  are  retained  in  the  uterus 
it  is  impossible  to  say.  Although  Tait  says  it  is  rarely 
retained  more  than  five  months,  it  is  quite  possible,  as 
McClintock  points  out,  that  a  portion  may  be  expelled 
and  the  residue  may  bring  out  a  new  crop.  Thus  the 
five  different  periods  in  the  same  person  of  Tait  may  all 
be  from  the  first  mole.  4.  Curetting  is  advisable  only 
where  the  hemorrhage  continues,  and  then  with  a  dull 
curette,  as  the  parenchyma  of  the  uterus  may  be  affected 
and  its  walls  very  thin.  5.  Hydatidiform  mole  is  essen- 
tially connected  with  pregnancy. 

ja6  East  Seventy-eighth  Street. 


MENSTRUATION  AND  PREGNANCY  —  IMPAC- 
TION OF  A  FOREIGN  BODY  IN  THE  OESOPH- 
AGUS. 

By  R.  H.  PHILLIMORE,  M.D., 

COOKSHIES,   CANADA. 

The  following  two  cases  are  perhaps  deserving  of  record : 
Case  I. — On  October  5,    1893,  I  was  hastily  sum- 
moned, at  2  a.m.,  to  attend  Mrs.  C ,  an  anaemic, 

hard-working  woman,  aged  thirty  nine,  and  the  mother 
of  eight  children.  She  was  suffering  from  severe  pains, 
with  uterine  hemorrhage.  Examination  showed  the  or- 
gan to  be  considerably  enlarged,  with  tenderness  on 
pressure.  Naturally  the  first  question  to  present  itself 
was,  was  the  patient  pregnant,  and  were  the  symptoms 
those  of  threatened  abortion  ?  She  emphatically  declared 
that  she  was  not  pregnant,  notwithstanding  that  the  sa- 
pient matrons  in  attendance  were  unanimous  in  their 
belief  that  she  was.  Suitable  agents  were  administered, 
and  the  vagina  was  tamponed.  I  continued  treating  her 
almost  daily,  up  to  the  end  of  January,  1894,  when  the 
severe  hemorrhages,  which  had  returned  periodically, 
ceased;  and,  though  the  menstrual  epochs  continued 
regular,  they  were  always  attended  with  pain  and  con- 
siderable constitutional  disturbance. 

From  this  time  until  the  end  of  September,  1894,  I 
saw  Mrs.  C only  on  a  few  occasions,  when  she  in- 
formed me  that  the  condition  of  the  uterus  remained 
practically  unchanged — it  was  still  enlarged  and  tender, 
and  menstruation  was  regular.  Toward  the  latter  part 
of  this  month  she  consulted  me  in  regard  to  swelling  of 
the  extremities,  with  puffiness  of  the  eyelids.  Examina- 
tion of  the  urine  exhibited  only  a  trace  of  albumin. 
On  October  6,  1894,  I  was  again  hastily  summoned. 

"  Mrs.  C was  flooding  again."     Upon  examination 

I  found  the  uterus  apparently  in  the  same  condition,  and 
the  patient  considerably  "bloated."  Menstruation,  as 
I  have  previously  observed,  had  been  perfectly  regular, 
and  not  so  painful  as  on  previous  occasions.  She  com- 
plained, as  before,  of  pains  in  the  back  and  legs.  Ex- 
ternal examination  showed  no  change  in  the  size  of  the 
•  uterus,  but  an  internal  examination  revealed  an  os 
slightly  dilated,  with  a  tumor  presenting.  I  informed 
the  friends  of  the  condition  of  the  patient,  but  they, 
being  well  acquainted  with  the  previous  history  of  the 
case,  ridiculed  the  idea  of  pregnancy,  as  also  did  the  pa- 
tient herself.     On  the  morning  of  the  7th  she  was  de- 


livered of  a  female  foetus,  measuring  S}4  inches  in 
length. 

The  following  points  in  this  case  are  interesting:  1, 
Signs  suggestive  of  pregnancy  on  first  visit,  eventually 
proving  erroneous ;  2,  pregnancy  present  when  not  sus- 
pected; 3,  uninterrupted  menstruation  during  preg- 
nancy. 

Case  II. — On  September  18,  1894, 1  was  summoned 
to  attend  a  child,  aged  eighteen  months,  who  at  11  a.m. 
had  swallowed  an  English  farthing.  Having  placed  the 
patient  under  an  anaesthetic,  an  examination  of  the  throat 
was  made,  but  no  obstacle  was  discovered,  though  a 
horse-hair  probang  was  employed.  The  following  day 
persistent  vomiting  ensued. 

Patient  was  ordered  milk  with  raw  egg  beaten  up,  solid 
food  being  persistently  rejected.  On  this  diet  the  child 
thrived.  The  parents  having  refused  to  allow  another 
examination — although  I  repeatedly  expressed  the  opin- 
ion that  the  coin  was  lodged  in  the  throat — liquid  diet 
was  daily  administered.  On  October  7th,  nineteen 
days  after  the  accident,  the  patient  ate  a  quantity  of 
grapes  in  addition  to  its  liquid  diet.  This  was  followed 
by  emesis,  and  the  coin,  considerably  worn,  was  suddenly 
expelled.  The  patient  at  once  partook  of  a  hearty  re- 
past, consisting  of  solid  food,  and  has  now  entirely  re- 
covered from  the  effects  of  its  financial  embarrassment. 

That  the  coin  was  impacted  in  the  oesophagus  there 
can  be  no  reasonable  doubt,  and  the  case  is  instructive 
as  indicating  the  difficulty  of  detecting  foreign  bodies  in 
this  situation,  and  also  the  length  of  time  which  may 
elapse  without  injury  to  the  tube  in  which  they  are 
lodged. 


THE  TREATMENT  OF  CARBUNCLE,  WITH 
REPORT  OF  A  CASE. 

By  J.   MORTON   HOWELL,  M.D., 

WASHINGTON  COUKT    HOUSE,    O. 

In  the  month  of  May  of  the  present  year,  I  was  called  to 

see  Mr.  R.  S.  S ,  a  man  little  past  three  score  of  years. 

I  had  been  treating  him  for  some  months  previous,  for  a 
severe  prostatitis  and  functional  albuminuria.  There 
had  been  but  little  loss  of  flesh  as  a  result  of  the  diseases 
named,  but  the  patient  complained  of  weakness,  and 
was  noticeably  void  of  that  vitality  which  was  so  charac- 
teristic of  him  in  former  days.  When  I  arrived,  he  told 
me  that  he  was  suffering  much  pain  in  the  small  of  his 
back,  and  described  it  as  a  dull,  heavy  ache  with  intense 
burning. 

Upon  examination,  I  found  a  circumscribed,  oval,  and 
highly  inflamed  induration,  situated  immediately  to 
the  left  of  the  spinal  column,  at  the  juncture  of  the  dor- 
sal with  the  lumbar  vertebra.  It  measured  5.75  inches 
in  its  longer  diameter,  and  was  discharging  pus  from  a 
half  dozen  different  openings.  The  sieve-like  appearance 
presented  by  the  skin  surface,  together  with  the  form  of 
the  neoplasm  and  the  character  of  the  pain,  made  the 
diagnosis  one  of  ease. 

Owing  to  the  age  and  debility  of  my  patient,  together 
with  kidney  and  prostate  trouble  alluded  to,  the  prog- 
nosis could  be  but  grave.  To  adopt  a  form  of  treatment 
which  would  be  most  sure  to  land  my  patient  upon  the 
side  of  recovery,  was  my  desire. 

An  examination  of  authorities  shows  that  comparatively 
little  is  written  upon  this  subject,  which  furnishes  the 
mortality  that  it  does. 

The  modes  of  local  treatment,  as  suggested  by  the  va- 
rious writers,  differ  widely.  For  instance,  Ashhurst  and 
the  "Reference  Handbook  of  the  Medical  Sciences," 
recommend,  among  other  remedies,  poultices,  while  they 
are  condemned  by  the  "American  Text- book  of  Sur- 
gery." 

Without  noticing  further  the  treatment  as  found  m 
our  medical  works,  we  will  give  our  treatment  of  this 
case,  which  we  believe  may  be  made  applicable  to  any 


732 


MEDICAL  RECORD. 


[December  8,  1894 


case.  If  it  proves  to  be  an  instrument  in  the  saving  of 
a  life,  or  an  assistance  to  our  brother  practitioner  in  his 
mission  to  do  good,  it  will  have  served  its  purpose. 

After  freezing  the  parts,  two  incisions  were  made, 
crossing  each  other  at  right  angles,  being  carried  suffi- 
ciently deep  to  include  the  healthy  tissue  beyond  the  lim- 
its of  the  disease.  Bleeding  was  tolerably  free,  and 
after  sponging  the  parts  well  with  hot  water  (previously 
boiled)  a  dressing  was  made  by  application  of  dry  bo- 
racic  acid  (Wyeth's  impalpable  powder)  over  which  was 
placed  a  thick  layer  of  antiseptic  gauze,  previously  satu- 
rated with  hot  carbolized  water.  Over  this  gauze  oiled 
silk  was  placed,  which  retained  the  moisture  almost  to 
perfection.  The  burning  at  once  ceased,  the  pain  dis- 
appeared, and  the  patient  was  made  so  comfortable,  that 
in  forty-eight  hours  he  was  doing  his  regular  choring 
about  house  and  barn.  The  dressing  was  changed  once 
in  every  twenty- four  hours.  He  was  given  a  ferruginous 
tonic,  and  placed  upon  a  light  but  nutritious  diet 

I  discharged  my  patient  in  eight  days  from  my  first 
visit. 


A  CASE  OF  NEPHRECTOMY  ON  ACCOUNT 
OF  NEPHROLITHIASIS    AND    PYONEPHROSIS. 

By   HERMAN   MYNTER,    M.D., 

PROFESSOR  OP  SURGERY,   NIAGARA   UNIVERSITY,   BUFFALO,   N.Y. 

John  S ,  aged  twenty- two,  entered  the  Sisters'  Hos- 
pital on  August  2,  1894,  with  the  following  history: 

He  had  complained  for  the  last  seventeen  years  of 
periodical  attacks  of  pain  in  the  back  and  left  lumbar 
region.  Up  to  five  months  ago  the  attacks  occurred 
about  once  in  six  or  eight  weeks,  with  free  intervals,  ex- 
tended downward  in  left  scrotum  and  thigh  and  could 
only  be  relieved  by  hypodermics  of  morphia.  They 
would  suddenly  cease  and  hours  afterward  he  would  pass, 
with  great  pain,  a  whitish  soft  mass,  which  did  not  have 
the  appearance  of  a  stone,  and  then  a  profuse  flow  of 
scalding  urine.  During  the  last  five  months  the  above 
symptoms  had  increased  in  severity  and  become  continu- 
ous. The  patient  had  lost  greatly  in  weight,  suffered 
from  profuse  night-sweats,  loss  of  appetite,  occasionally 
a  dry  cough.  The  parents  were  healthy,  but  one  brother 
had  died  of  consumption.  At  the  examination  the  patient 
appeared  extremely  emaciated  and  cachectic,  with  protrud- 
ing cheekbones  and  hectic  flush.  Weight,  101  pounds. 
There  was  great  tenderness  from  pressure  in  left  lumbar 
region,  but  neither  anteriorly  nor  posteriorly,  standing  or 
lying,  could  any  swelling  or  enlargement  of  the  kidney  be 
discovered.  He  was  also  somewhat  tender  to  pressure 
over  the  right  lumbar  region.  He  passed  about  one  quart 
of  urine  in  the  first  twenty-four  hours,  half  of  which  was 
pus.  The  urine  had  a  color  like  chocolate,  specific  grav- 
ity 1,030,  acid  reaction,  and  was  loaded  with  albumin. 
Microscopically  nothing  was  seen  but  pus  corpuscles. 

By  cystoscopic  examination  under  cocaine  anaesthesia 
and  after  preliminary  irrigation  of  the  bladder,  an  excel- 
lent view  was  immediately  obtained  of  the  fundus  of  the 
bladder.  The  mucous  membrane  appeared  perfectly 
normal.  The  orifice  of  the  right  ureter  was  seen  as  a 
small  oblique  slit,  through  which  a  swirl  of  healthy  urine 
passed  every  four  or  five  seconds.  Turning  the  cystoscope 
toward  the  orifice  of  the  left  ureter  I  saw  what  appeared 
to  be  a  deep  crater-formed  ulcer,  about  two  centimetres 
in  diameter.  Nothing  appeared  for  two  or  three  min- 
utes, when  suddenly  a  cohesive,  thick,  yellowish  mass 
commenced  to  protrude  through  the  crater,  as  thick  ap- 
parently as  a  little  finger.  When  about  two  inches  of- 
this  mass  had  entered  the  bladder,  it  disappeared  from 
view  and  was  followed  by  a  profuse  discharge  of  yellow- 
ish pus,  which  quickly  obscured  the  field.  As  it  was  evi- 
dent from  this  examination  that  the  patient  suffered 
from  a  pyonephrosis  of  the  left  kidney  and  that  the  right 
kidney  was  healthy,  nephrectomy  was  advised,  although 
his  condition  was  so  miserable  that  it  seemed  impossible 


he  could  survive  such  an  operation.  The  operation  was 
performed  on  August  8th,  under  chloroform  narcosis, 
the  patient  having  been  stimulated  for  a  couple  of 
days  with  hypodermics  of  strychnia,  nitrorglycerine, 
whiskey,  and  rectal  alimentation.  The  pulse  was  then 
130,  weak;  temperature  had  ranged  between  1010  and 
103  °  F.  The  incision  was  made  along  the  erectus 
spinas  muscle  ending  near  the  crest  of  the  ileum,  combined 
with  an  oblique  incision  along  the  whole  lower  border  of 
the  twelfth  rib.  The  kidney  was  almost  wholly  covered 
by  the  ribs,  strongly  attached  to  the  colon  and  the  sur- 
rounding tissue.  During  the  process  of  enucleation, 
which  was  extremely  difficult  on  account  of  the  strong 
adhesions  and  its  high'  position,  my  whole  arm  almost 
disappearing  up  to  the  elbow  in  the  wound,  a  large  ab- 
scess in  the  kidney  itself  was  ruptured,  from  which  a  large 
amount  of  ill-smelling  pus,  estimated  at  one  pint,  escaped. 
The  hilus  was  at  last  reached,  the  kidney  brought  out 
through  the  wound,  two  clamps  attached  on  the  hilus  in 
order  to  finish  the  operation  quickly,  and  the  kidney  re- 
moved. The  ureter  was  as  large  as  a  finger.  The 
wound  was  disinfected  with  corrosive  sublimate,  loosely 
packed  with  iodoform  gauze  and  partly  sutured.  The 
patient  left  the  table  in  a  state  of  profound  shock,  pulse- 
less and  with  clammy  perspiration,  but  by  active  stimu- 
lation, he  revived  in  a  short  time.  The  operation  lasted 
about  three  quarters  of  an  hour. 

The  kidney  preserved  its  general  contour,  but  was 
enormously  enlarged,  its  volume  being  about  six  times 
that  of  the  normal.  It  measured  seven  inches  in  length, 
four  in  width,  and  three  in  thickness.  Its  weight  was 
twenty-eight  ounces ;  but  as  at  least  one  pint  of  pus  es- 
caped, its  weight  must  have  been  about  forty  four 
ounces — two  and  three  quarter  pounds.  The  capsule 
was  adherent  and  blended  with  the  renal  structure.  The 
color  in  no  place  was  that  of  a  normal  kidney,  but  that 
of  fat  and  fibrous  tissue. 

The  surface  presented  numerous  large  circumscribed 
swellings  which  on  palpation  were  soft  and  fluctuating, 
and  on  incision  were  found  to  contain  a  thick,  greenish, 
tenacious  pus.  On  the  posterior  surface  was  a  large  ab- 
scess cavity,  ruptured  during  the  operation.  On  section 
no  normal  kidney  structure  appeared.  The  upper  third 
was  a  mass  of  multilocular  abscesses  which  intercom- 
municated and  contained  pus  of  the  same  character  pre- 
viously described.  The  middle  third  was  a  mass  of  rat 
and  fibrous  tissue ;  lying  in  the  latter  was  a  large  trian- 
gular shaped  stone,  i^x^  inch,  of  a  greenish-brown 
color,  irregular  in  shape,  and  with  rough  surface.  The 
lower  third  showed  two  abscesses,  the  larger  being  three- 
fourths  of  an  inch  in  diameter.  In  one  of  the  abscesses  in 
the  upper  part  a  rough  irregular  stone  was  found.  The 
pelvis  was  greatly  enlarged,  full  of  pus,  and  contained 
several  cohesive,  yellowish  masses  of  necrotic  tissue  im- 
pregnated with  pus,  like  the  one  which  was  seen  to  pass 
with  the  cystoscope.  Scarcely  any  traces  of  kidney  tis- 
sue could  be  seen,  and  its  function  as  a  secreting  gland 
had  probably  long  ceased. 

August  9th.— Temperature,  102$  °  F. ;  pulse,  130.  He 
has  passed  19  ounces  of  urine  since  the  operation,  the 
last  of  which  is  perfectly  clear  and  normal.  He  is  ex- 
tremely weak  and  is  given  -fa  gr.  strychnia  and  yfo  gr. 
nitroglycerine  every  three  hours  hypodermatically.  He 
has  taken  one  quart  of  milk  during  the  night. 

August  roth. — Temperature,  ror°  F. ;  pulse,  120 ;  28$ 
ounces  of  clear  ^normal  urine.  Patient  takes  lots  of 
nourishment  and  rests  well. 

August  nth. — Temperature,  99$°  F. ;  pulse,  126;  3r 
ounces  of  urine.  Clamps  removed  and  cavity  irrigated 
and  loosely  packed  with  iodoform  gauze. 

August  1 2th. — Temperature,  990  F. ;  pulse,  ro8  ;  27 
ounces  of  urine.     Patient  takes  solid  food. 

August  r3th. — Temperature,  roo°  F. ;  pulse,  no;  32 
ounces  of  urine. 

He  gradually  improved,  passed  from  35  to  45  ounces 
of  urine  daily ;  pulse  and  temperature  became  normal. 

August  23d. — The  dressing  was  found  saturated  with 


December  8,  1894] 


MEDICAL  RECORD. 


73$ 


fecal  matter,  a  fistula  evidently  having  formed  into  the 
colon,  but  it  healed  in  a  couple  of  weeks. 

August  25th. — The  patient  was  sitting  up ;  the  large 
cavity  had  contracted  so  that  only  a  small  granulating 
fistula  was  left.  His  weight  had  increased  to  105 
pounds,  he  felt  perfectly  well  and  was  discharged  to  his 
home. 

September  22d. — Weight  137  pounds,  a  gain  of  36 
pounds :  patient  a  picture  of  perfect  robust  health,  urine 
normal,  fistula  closed. 

October  1st. — Weight  140  pounds. 

October  12th. — Weight  147  pounds,  patient  has  gone 
to  work  in  a  machine  shop. 

The  interest  in  this  case  is  the  ease  with  which  the 
diagnosis  was  made  by  aid  of  the  electrical  cystoscope, 
and  particularly  the  demonstration  that  the  right  kidney 
was  healthy,  and  therefore  an  operation  advisable. 
Only  by  operative  means  in  two  other  ways— an  explora- 
tive laparotomy  or  an  explorative  suprapubic  cystotomy 
with  catheterizing  of  ureters,  could  the  diagnosis  have 
been  cleared  up,  and  there  is  no  comparison  between 
these  methods  and  the  simple  cystoscopic  examination, 
done  without  any  danger  to  the  exhausted  patient.  Cys- 
toscopy necessitates,  of  course,  that  the  bladder  shall  be 
able  to  contain  five  ounces  of  clear  fluid  and  that  the 
cystoscope  shall  be  able  to  enter  the  bladder ;  luckily 
both  indications  were  fulfilled  in  this  case. 

A  second  point  of  interest  was  the  impossibility  of 
feeling  and  palpating  the  enormous  kidney  before  opera- 
tion. I  can  only  explain  this  by  the  strong  adhesions 
of  the  lower  segment  of  the  kidney  to  the  colon  and 
surrounding  tissue,  by  which  the  kidney  was  forced  to 
enlarge  upward  and  forward  below  the  diaphragm.  A 
third  point  of  interest  was  the  long  time,  seventeen 
years,  in  which  the  patient  had  suffered  from  nephrolith- 
iasis without  a  distinct  diagnosis  having  been  made,  and 
the  rapid  and  perfect  recovery  that  followed  the  removal 
of  the  diseased  organ,  the  patient  in  seven  weeks  gaining 
46  pounds  in  weight.  I  have  during  the  last  three  years 
performed  nephrectomy  four  times.  Two  operations 
were  done  on  account  of  tuberculous  kidneys.  One  of 
these  died  on  the  fourth  day  of  suppression  of  urine,  and 
the  post-mortem  examination  showed  the  remaining 
kidney  to  be  tuberculous.  A  cystoscopic  examination 
would  in  this  case  probably  have  shown  that  the  opera- 
tion was  contra-indicated.  The  second  case  recovered, 
but  died  half  a  year  later  of  general  tuberculosis  of  the 
urinary  organs.  The  third  operation  was  performed  in 
October,  1892,  on  account  of  a  large  sarcoma  of  the  left 
kidney  in  a  lady  fifty  years  of  age.  The  patient  re- 
covered, and  so  far,  two  years  after  the  operation,  no 
relapse  has  occurred  and  she  is  in  perfect  health. 


Longevity  among  Physicians. — One  of  the  most  curious 
statistical  records  that  has  been  compiled  this  century  is 
that  by  Dr.  Salzmann,  of  Essling,  Wurtemburg,  on  the 
average  duration  of  life  among  physicians.  He  found  in 
going  over  the  ancient  records  of  the  kingdom,  that  in 
the  sixteenth  century,  the  average  duration  of  life  among 
that  class  was  but  36  5  years — in  the  seventeenth  century 
45  8 — in  the  eighteenth,  49  8,  and  at  the  present  time 
they  reach  the  favorable  average  of  56.7.  It  appears 
from  the  footnotes  to  the  above  that  this  very  great  in- 
crease in  longevity  is  due  to  the  disappearance  of  the 
"black  pest,"  the  introduction  of  vaccination,  and  the 
great  diminution  in  the  number  of  typhus  epidemics, 
three  classes  of  diseases  which  formerly  decimated  the 
medical  practitioners. — College  and  Clinical  Record. 

The  Gift  of  a  Hospital. — M.  Henri  Schneider,  of 
Creuzot,  France,  has  built  and  presented  to  the  town  a 
new  hospital,  with  accommodation  for  one  hundred  and 
fifty  patients.  The  hospital  was  opened  on  September 
1 8  th,  with  religious  ceremonies  conducted  by  Monsignor 
Perraud,  Bishop  of  Autun. 


VERSION    THREE    WEEKS     BEFORE    DELIV- 
ERY. 

By  G.   STARKE,   M.D., 

NEW  YORK. 

I  beg  to  report  the  following  case  as  of  probable  interest 
to  the  medical  profession : 

Mrs.  J.  T.  S ,  age  at  present  twenty- four;  height 

about  five  feet  four  inches ;  weight  about  one  hundred 
and  twenty  five  pounds.  Four  years  ago  she  was  deliv- 
ered of  a  child  at  seven  months,  the  baby  living  but 
twenty-four  hours.  Though  a  breech  presentation,  de- 
livery at  that  age  of  foetus  was  easy.  Two  years  ago  I 
delivered  her  at  full  term  of  a  boy,  also  a  breech  presen- 
tation, with  forceps,  after  a  rather  severe  labor,  the  child 
being  in  a  state  of  asphyxiation  and  only  resuscitated 
after  half  an  hour's  work,  after  the  method  recom- 
mended by  Dr.  W.  E.  Forest  in  the  Medical  Record 
of  April  9,  1892.  The  boy  at  this  date  is  hale  and 
hearty. 

Mrs.  S again  became  pregnant,  and  having  had 

her  last  menses  December  5,  1893,  expected  to  be  con- 
fined about  September  12,  1894.  I  saw  her  on  Septem- 
ber 8th,  and  examining  her,  found  another  breech  pre- 
sentation, of  which  fact  I  informed  her,  and  it  had  a 
decided  depressing  effect  upon  her.  I  informed  her  that, 
in  view  of  her  having  had  a  hard  time  with  the  boy,  and 
his  life  at  the  time  almost  despaired  of,  if  she  consented 
I  would  endeavor  to  perform  version  and  make  an  al- 
most certainty  of  the  child  being  born  alive,  knowing 
that  she  was  very  anxious  for  it,  particularly  if  it  should 
be  a  girl.  She  consented,  and  I  performed  version,  by 
external  manipulation  alone,  inside  of  ten  minutes.  Be- 
fore leaving  her,  I  assured  myself  by  vaginal  examina- 
tion that  the  head  was  well  placed  in  the  pelvis,  and  the 
occiput  anterior  by  external  palpation. 

On  September  14th  she  sent  for  me  again,  fearing  that 
the  child  had  turned  again  to  its  former  position  during 
sleep,  but  upon  examination  found  it  to  occupy  the  same 
position  I  had  previously  placed  it  in.  She  progressed 
without  ill  consequences  till  September  28th,  when  I 
was  sent  for  at  8.30  p.m.  Arriving  at  her  house  about 
nine  o'clock,  I  was  informed  that  the  waters  had  broken 
half  an  hour  before,  as  she  was  about  to  go  out  for  a  drive. 
Upon  examination  found  the  os  dilating,  the  head  pre- 
senting in  the  L.  O.  A.  position.  Though  good  pains 
did  not  set  in  till  eleven  o'clock,  she  was  delivered  of  a 
girl  baby  at  12.30  a.m.  on  September  29th,  and  her 
progress  since  then  has  been  uneventful. 

The  interesting  circumstance  in  this  case  to  me  is  that 
version,  being  intended  to  be  performed  only  a  day  or 
two  previous  to  the  expected  time  of  expiration  of  her 
pregnancy,  was  accidentally  performed  three  weeks  be- 
fore delivery,  a  very  unusual  procedure.  However,  in 
this  case  with  most  gratifying  result,  saving  the  mother 
much  pain  and  insuring  a  shorter  labor,  and  saving  me 
very  much  anxiety. 

The  lesson  to  be  drawn  from  this  case  is  that  version 
can  be  performed  much  easier  some  time  before  labor 
sets  in,  than  after  the  uterine  expelling  forces  have  be- 
gun to  exert  themselves,  when  the  uterus  usually  resents 
any  severe  interference  or  manipulation  by  grasping  the 
foetus  tighter,  often  necessitating  anaesthetics,  besides 
running  grave  risks  of  lacerating  the  uterine  and  foetal 
tissues,  and  requiring  at  least  two  for  the  operation.  I 
had  a  similar  case  of  a  transverse  presentation  some  two 
years  ago,  where  fortunately  I  was  called  in  a  day  be- 
fore the  confinement  and  corrected  the  presentation,  re- 
sulting in  an  easy  labor. 

.  I  would  recommend  to  all  medical  men  having  the 
advancement  of  their  profession  at  heart,  in  all  doubtful 
cases,  and  when  possible,  to  examine  their  pregnant  pa- 
tients a  week  or  two  before  their  expected  confinement, 
for  the  ascertaining  and  correction  of  presentations ;  the 
same  as  we  are  recommended  to  examine  their  urine  for 
albumin  to  prevent  complications. 

x393  Frank  us  Avkkue. 


734 


MEDICAL   RECORD. 


[December  8,  1894 


(fovreBvon&mcz. 

BERIBERI  AND  BEANS. 

To  th*  Editok  or  thb  Medical  Rkcokd. 

Sir  :  In  an  editorial  notice,  Medical  Record,  Novem 
ber  17,  1894,  of  "beriberi  in  New  Jersey/1  you  speak 
of  the  "  ill  favored  human  cargo  of  a  vessel  from  Navassa, 
which  has  entered  port  at  Perth  Amboy.  There  seems 
to  be  no  doubt  that  faulty  hygiene  and  lack  of  suitable 
food  were  the  factors  determining  the  outbreak.  Beans 
furnished  the  principal  food,  it  appears,  during  the  two 
weeks'  voyage,  and,  strange  as  it  may  seem,  this  is  just 
the  article  of  diet  which  Dr.  Simmons  recommended  in 
a  monograph  on  the  subject  in  1880." 

As  I  had  the  pleasure  of  assisting  the  late  Dr.  Sim- 
mons in  some  of  the  details  of  that  work,  and  as  the 
above  reference  may  give  a  wrong  impression,  please 
allow  me  the  space  to  say  that  "  there  are  beans  and 
beans,"  and  that  in  his  monograph  Dr.  Simmons  lays 
stress  upon  the  peculiar  kind  of  bean — a  small  red 
variety — that  has  long  found  popular  favor  in  the  man- 
agement and  treatment  of  beriberi,  once  so  prevalent  in 
Japan.  The  large  common  starchy  bean  has  no  value, 
and  I  think  he  so  states  it,  though  I  have  not  the  paper 
by  me  for  reference. 

In  more  recent  years  an  unlooked-for  confirmation  of 
the  value  of  this  bean  as  a  food  in  cases  of  beriberi  is 
found  in  the  fact  of  its  large  relative  amount  of  albumi- 
noid nitrogen  composition.  It  has  been  ascertained  that 
the  chief  element  in  the  production  and  prevalence  of  the 
disease  is  the  lack  of  the  nitrogenous  foodstuffs — particu- 
larly of  the  fresh  flesh  sorts — in  the  habitual  dietaries  of 
the  natives.  The  multiple  neuritis  is  in  all  probability 
(as  believed  by  some  distinguished  investigators  in  the 
East  Indies  and  Brazil)  the  result  of  the  presence  of  a 
specific  micro-organism,  only  to  be  found  in  low  lying, 
moist  countries,  among  races  long  deprived  of  albumi- 
nous food.  Navassa  is  notoriously  an  unwholesome  guano 
and  phosphate  island  in  the  Caribbean  Sea,  occupied 
mainly  by  contract  laborers,  often  convicts,  living  under 
great  hardship  for  long  periods.  In  the  past  few  years 
the  isolated  rock  has  been  unpleasantly  heard  from,  with 
trials  for  murder  under  the  jurisdiction  of  the  criminal 
courts  of  Baltimore.  Under  the  circumstances  the  oc- 
currence of  beriberi  can  cause  no  surprise,  and  scurvy 
cannot  be  unknown  there. 

At  the  last  International  Medical  Congress  at  Rome, 
a  paper  on  beriberi  was  read  by  a  Japanese  naval  medi- 
cal officer — a  delegate  from  the  marine  department  of 
his  government— giving  statistics  and  results  of  the  pres- 
ent management  of  the  disease  in  their  navy.  With  a 
rearrangement  of  the  dietary,  the  introduction  of  a  large 
increase  of  nitrogenous  food  elements,  and  a  correspond- 
ing diminution  of  the  carbohydrates,  the  disease  has  been 
gradually  eliminated,  and  for  1893  few,  if  any,  cases  are 
reported.     It  was  formerly  very  prevalent. 

Following  a  common  rule,  beriberi  requires  for  its 
evolution  a  soil  and  a  specific  micro-organism,  in  this  in- 
stance the  lesion  being  fundamentally  in  the  white  nerve* 
tissue  of  the  peripheral  nervous  system.  Want  and  mis- 
ery, with  deprivation  of  proper  food— albumins  of  animal 
origin  mainly — will  soon  produce  the  disease  in  countries 
of  its  endemic  prevalence. 

As  an  example  of  how  beans  will  vary  (coming  back 
to  our  subject)  in  relative  composition,  I  append  some 
trustworthy  analyses,  made  by  Professor  Atwater,  of 
Wesleyan  University,  at  the  Agricultural  Experiment  Sta- 
tion, Storrs,  Conn.  If  such  differences  occur  under 
equal  conditions,  what  may  be  looked  for  with  widely 
varying  quality  of  seeds,  soil,  and  climate,  in  the  relative 
amounts  of  legumin,  sulphur,  phosphorus,  and  albumi- 
nous nitrogen  substances  upon  which  the  peculiarly  nutri- 
tive value  of  some  kinds  of  beans  depends  ?  Changes  due 
to  parasites,  fungi,  bad  keep,  age,  etc.,  are  not  consid- 
ered, yet  have  a  share  in  rendering  unfit  for  consumption 


foodstuffs,  especially  the  leguminosae  so  much  given  to 
ships. 


Per  cent. 


Percent. 


Water ;  1 1.46 

Protein *9-92 

Fat 1.81 

Nitrogenous  free  extract 60.26 


Fibre. . 

Ash 

Albuminoid  nitrogen 

Non-albuminoid  nitrogen. . 


3-*5 
3-3© 
2.78 
0.41 


8.32 

35-*4 
2048 

25.86 
4.84 
5.26 

5-40 
a  24 


Common,  as 
Purchased 
Percent. 


13.70 

2  32 
2.0I 

6a  26 


Very  respectfully  yours, 

C.  A.  Siegfried,  M.D., 
U.  S.  Navy. 

U.  S.  Steamship  Cincinnati,  November  26,  1894. 


PERMANGANATE    OF  POTASSIUM    IN   OPIUM 
POISONING. 

TO  TMK  KDITOB  OF  THB  MXUCAL  RjtCORD. 

Sir:  Having  been  unprofessionally  criticised  in  your 
journal  on  October  6th,  by  Dr.  War  field,  in  regard  to 
my  article  on  the  same  subject  as  this  brief  reply,  and 
being  again  made  the  subject  of  ridicule  from  the  pen  of 
the  original  discoverer  of  permanganate  of  potassium  as 
an  antidote  to  morphine  poisoning,  Dr.  Moor,  please 
allow  me  to  reply.  I  would  suggest  to  the  two  doctors 
that  they  read  the  articles  of  Dr.  Glenn  Anderson,  of 
Montgomery,  Dr.  Joseph  M.  Rector,  and  Dr.  Harding. 
Dr.  Warfield  says  that  Dr.  Moor  pointed  out  plainly  to 
his  medical  brethren  that  the  administration  of  potassium 
permanganate  would  chemically  render  inert  the  amount 
of  morphine  remaining  in  the  stomach  at  the  time  of 
administration.  If  Dr.  Warfield  has  the  correct  version 
of  the  discoverer's  ideas  of  this  new  antidote,  it  will  only 
save  the  use  of  the  stomach-pump  in  morphine  poisoning 
— nothing  more.  I  will  ask  Dr.  Warfield  to  read  Dr. 
Moor's  original  article,  and  then  his  reply  to  my  article, 
and  I  think  he  will  be  led  to  believe  that  Dr.  Moor  even 
claims  the  permanganate  to  be  more  than  a  chemical 
oxidizer  in  morphine  poisoning.  In  his  original  article 
Dr.  Moor  says  that  he  considers  the  permanganate  to  be 
the  antidote,  par  excellence,  for  morphine  poisoning,  and 
further :  "  I  have  strong  reason  to  believe  that  the  ad- 
ministration of  permanganate  will  be  of  service  even  after 
absorption  has  taken  place."  After  my  patient  was  in  a 
fair  way  to  recovery,  Dr.  Earnest  suggested  the  perman- 
ganate upon  physiological  grounds  of  its  alleged  effects. 
I  did  not  want  to  use  it,  as  I  had  no  faith  in  it,  but  know- 
ing the  patient  to  be  in  a  fair  condition,  I  yielded  reluc- 
tantly to  the  administration  of  the  drug.  I  do  not  claim 
that  the  permanganate  did  my  patient  any  harm  —  it 
merely  deprived  him  for  the  time  being  of  remedies  that 
would  have  been  of  positive  benefit.  I  do  not  consider 
permanganate  of  potassium  to  be  a  drug  of  any  value  in 
opium  poisoning. 

C.  Monroe  McGuire,  M.D. 

Walsbnbuxg,  Col. 


Aloohol  and  the  Bible. — Dr.  Harnack,  of  Halle,  has 
published  a  brochure  to  show  that  the  teachings  of  the 
Bible  are  against  the  doctrines  of  the  prohibitionists. 
He  cites  a  number  of  passages  from  both  the  Old  and  the 
New  Testaments  in  which  wine  is  mentioned  as  a  per- 
missible, if  not  necessary,  article  of  diet  To  "  look  not 
upon  the  wine  when  it  is  red  in  the  cup,"  he  opposes 
"  take  a  little  wine  for  thy  stomach's  sake.'9 

Dr.  M.  Bessbach  died  a  short  time  ago  in  Munich,  at 
the  age  of  fifty-two  years.  He  was  author  of  the  well- 
known  "  Lehrbuch  der  physikalischen  Heilmethoden," 
and  joint  author  with  Nothnagel  of  a  treatise  on  thera- 
peutics. 


December  8,  1894J 


MEDICAL   RECORD. 


735 


Hero  %xxstvnmmts. 

AN  ASEPTIC  AND  REALLY  SURGICAL  POCKET- 
CASE. 

By  ROBERT  H.  M.  DAWBARN,  M.D., 

PROFESSOR  OF  OPERATIVE  SURGERY,  NEW  YORK  POLYCLINIC. 

In  the  New  York  Medical  Journal  of  October  19,  1889, 
I  described,  and  showed  by  illustration,  a  pocket  case 
for  minor  surgery,  which  at  that  time  seemed  to  me 
worthy  of  mention..  To-day  the  accompanying  woodcut 
gives  some  idea  of  an  improvement  upon  that  case,  based 


upon  further  experiment  in  the  matter  of  compactness 
and  also  of  lightness.  It  seems  to  the  writer  that  this 
case,  as  now  completed,  combines  a  number  of  desiderata : 

1.  It  is  so  shaped  as  to  be  able  to  fit  into  an  upper 
vest-pocket,  and  not  to  spoil  the  fit  of  a  coat,  being  quite 
thin. 

2.  The  instruments  are  very  compactly  arranged,  there 
being  no  waste  space.  Indeed,  the  only  criticism  on  the 
case  which  occurs  to  the  writer  is  that  a  little  practice  is 
needed  in  order  to  replace  instruments  speedily  after  use. 

3.  The  case  itself  is  of  aluminum,  nickel- plated,  as 
also  are  the  handles  of  the  instruments.  Consequently 
a  great  gain  is  made  in  lightness.  Indeed,  this  case,  with 
about  double  the  number  of  instruments  contained  in  any 
other  pocket- case,  nevertheless  is  not  at  all  heavy. 

It  was  necessary  to  nickel  the  aluminum  because  of  the 
next  point,  namely, 

4.  If  either  case  or  instruments  become  soiled,  they 
may  be  sterilized  in  the  usual  way,  by  boiling,  and  to 
avoid  rust  we  always  add  an  alkali,  e.g.,  some  washing- 
soda.  Now,  it  is  known  that  alkali  attacks  aluminum, 
hence  the  necessity  for  plating  the  case  and  the  instru- 
ment handles. 

Contrast  this  ease  of  sterilizing  with  the  condition 
found  in  the  ordinary  leather,  velvet  lined  pocket-case, 
which  is  still  the  favorite  with  instrument  dealers.  In 
course  of  time  the  latter  becomes  grimy  with  dust,  and 
malodorous  from  perspiration,  and  is  impossible  of 
cleansing  in  a  surgical  sense. 

5 .  The  selection  of  instruments  is  based  upon  common- 
sense  and  the  needs  of  practical  surgery,  and  no  one  can 
claim  as  much  for  the  ordinary  pocket-case.  This  latter, 
for  instance,  rejoices  in  a  single  pair  of  artery-forceps. 
Indeed,  I  have  seen  no  other  pocket  case  with  more  than 
one,  or  at  least  two,  pairs  of  haemostatic  forceps,  whereas 
every  surgeon  knows  that  if  one  pair  be  needed,  half  a 
dozen  are  likely  to  be.  This  new  case  contains  six,  and 
the  needle-holder  may,  if  required,  make  a  seventh. 

Again,  almost  all  cases  which  I  have  examined  still 
display  that  abomination,  a  jointed  metallic  catheter. 
This  instrument  of  torture  never  fits  properly  when  it  has 
been  screwed  together  a  few  times,  and  thereafter  scrapes 
the  urethra  viciously. 

The  knives  are  a  weak  point  in  most  cases  and  show 
amateur  selection.  For  instance,  there  is  always  the 
curved,  sharp  pointed  bistoury — a  thing  which  surgeons 
do  not  use,  because  they  never  stab  and  cut  out.  It  is 
not  even  necessary  to  do  so  in  opening  a  boil,  in  these 
days  of  cocaine  anaesthesia. 


The  knives  are  too  numerous,  as  a  rule,  and  the  scalpels 
have  little,  baby-blades.  By  shortening  their  handles  it 
is  easy  to  make  room  for  blades  of  adult  size,  with  which 
a  thigh  could  be  amputated  if  need  be. 

We  may  fairly  criticise,  too,  the  needles  and  needle- 
holder  ordinarily  found ;  both  being  still  of  the  old-fash- 
ioned type ;  whereas  surgeons  use  almost  exclusively  the 
Hagedorn  needles,  and  these  cannot  properly  be  grasped 
by  the  ordinary  holder.  The  advantage  of  the  Hagedorn 
needles  is,  that  they  cut  in  such  a  way  as  to  aid  haemos- 
tasia when  the  suture  is  tied ;  and  also  to  diminish  the 
size  of  the  scar  left  by  the  needle.  The  cut  runs  like  the 
buttonholes  along  the  edge  of  a  coat ;  i.e.,  at  right  an 
gles  with  the  wound  edge.  And  this  is  just  the  reverse 
of  the  direction  of  the  wound  made  by  the  old-fashioned 
needle. 

I  beg  to  apologize  to  all  surgeons  for  these  trite  re- 
marks upon  needles ;  but  inquiry  of  dealers  shows  that 
the  great  bulk  of  the  profession  still  buy  and  use  the  kind 
which  should  be  obsolete ;  apparently  not  yet  knowing 
these  points. 

For  a  good  many  years,  now,  the  writer  has  preferred 
to  all  others  the  " patent  eye  "  or  "self- threading" 
modification  of  Hagedorn.  The  Germans  used  them  for 
a  long  time  before  they  were  much  noticed  here.  They 
call  them  "Nahnadeln  mit  federndem  Ohr."  If  prop- 
erly made,  the  needle  does  not  cut  the  thread  at  the  eye, 
and  it  can  be  threaded  in  a  moment,  with  bloody  or 
otherwise  sticky  fingers,  and  in  the  dimmest  light. 

To  continue  this  little  critique  :  We  commonly  find  in 
pocket-cases  some  more  or  less  sterile  silk,  by  way  of  su- 
ture and  ligature  material,  lying  in  one  of  the  dusty  pock- 
ets aforesaid.  Of  course  suppuration  follows  its  use; 
otherwise  it  would  disappoint  us. 

In  the  aluminum  case,  instead,  will  be  found  two  little 
bottles  with  rubber  corks.  Each  contains  a  small  glass 
reel,  and  one  is  full  of  sterile  silk,  the  other  of  sterile  cat- 
gut, medium  sizes,  each  in  absolute  alcohol.  Enough 
surgically  pure  material  is  here  to  supply  ligatures  and 
sutures  for  even  a  large  operation. 

The  same  little  aluminum  compartment  which  contains 
our  needles,  finds  room  for  a  silver  porte  caustique  ;  and 
also  for  a  few  bichloride  of  mercury  tablets,  wrapped  in 
rubber  tissue ;  enough  for  some  quarts  of  antiseptic  solu- 
tion. 

In  conclusion,  the  list  of  contents  is  appended  in  full.  As 
to  the  catheter  mentioned,  it  is  a  soft  rubber  Nfelaton  cathe- 
ter, of  medium  size ;  and  besides  its  obvious  function,  it 
acts  as  an  elastic  buffer,  preventing  any  rattling  of  instru- 
ments within  the  case.  It  may  also  serve  to  constrict 
some  small  member,  as  a  finger,  during  operation.  It 
will  supply,  if  sterile,  drainage-tubing  in  emergency.  A 
two-inch  section,  with  the  aid  of  a  large  safety-pin,  makes 
a  very  fair  tracheotomy  tube  for  infants.  It  enables  one, 
with  ease,  to  pass  twine  tied  to  it,  through  the  nose  into 
the  pharynx,  and  so  out  of  the  mouth,  thereby  permitting 
instant  control  of  nose-bleed  by  tamponing  both  anterior 
and  posterior  nares. 

Contents  of  Aluminum  Case. 

1  Scalpel,  full-sized  blade. 

1  Long,  narrow,    straight,  sharp-pointed  bistoury  (this 

may  be  used  as  a  tenotome). 
1  Metacarpal  saw. 
1  Peaslee  needle,  curved  (eye   in  point  with   handle; 

for  passing  retention  sutures). 
1  Grooved  director  and  aneurism- needle  combined. 
1  Pair  dissecting  forceps. 
1  Pair  mouse  tooth  forceps. 

1  Volkmann  sharp  spoon  (an  instrument  often  needed). 
1  Pair  scissors,  with  French  lock,  for  ease  of  cleansing. 
1  Needle  holder,  with  French  lock ;    which  is  also  a 

dressing-forceps  and  an  artery  forceps. 
1  Silver  parte-  caustique. 
1  Nelaton  catheter. 

1  Small  package  Hg.  bichloride  tablets,  in  rubber  tissue. 

2  Silver  probes,  one-eyed. 


736 


MEDICAL   RECORD. 


[December  8,  1894 


2  Bottles,  one  containing  silk,  one  catgut,  in  absolute  al- 
cohol. 
6  Haemostatic  clamps. 

Assorted  sizes  of  Hagedorn's  "self-threading  "  needles. 
The  pocket-case  thus  described  is  made  by  Messrs. 
Reynders  &  Co.,  of  this  city;  and  is  sold  at  about  the 
cost  of  other  pocket-cases. 


Contagious  Diseases  — Weekly  Statement— Report  of 
cases  and  deaths  from  contagious  diseases  reported  to  the 
Sanitary  Bureau,  Health  Department,  for  the  week  end- 
ing December  1,  1894. 


Tuberculosis 

.  Typhoid  fever 

Scarlet  fever 

Cerebrospinal  meningitis, 

Measles 

Diphtheria 

Small-pox 


zoo 

xxo 

96 
90 

I 

a 

a 

47 

a 

aoa 

59 

13 

z 

The  Physical  Strain  Involved  in  High  Speeds. — The 
exaction  that  modern  railroad  speed  makes  on  the  phy- 
sical stamina  of  railroad  men  is  demonstrated  in  the  fact 
that  seven  engineers  are  required  to  take  the  Chicago 
flyer  out  and  seven  back,  says  the  Boston  Transcript 
The  running  time  between  New  York  and  Chicago  is 
twenty-four  hours,  and  the  average  speed  is  forty-eight 
miles  an  hour.  Each  engineer  and  engine  runs  three 
hours.  Machine  and  man  return  with  a  slow  train  to 
their  starting-point  to  relieve  the  strain  on  both.  Then 
the  engineer  is  given  forty  hours'  rest  before  he  goes  on 
the  flyer  again.  This  rest  is  absolute,  no  work  of  any 
kind  being  required  of  the  engineer.  Though  the 
average  speed  is  forty- eight  miles  an  hour,  the  locomo- 
tive must  at  some  points  be  driven  at  sixty  or  more. 
The  physical  strain  on  the  men  in  the  cab  at  those  bursts 
of  speed  is  something  terrible.  The  engineer  has  fifty 
things  to  look  out  for,  and  is  being  shaken  and  swayed 
all  the  time.  The  fireman  is  constantly  feeding  the  in- 
satiate furnace.  On  the  run  of  the  Empire  State  express 
three  tons  of  coal  are  shovelled  from  the  tender  into  the 
furnace  between  New  York  and  Albany.  It  is  not  won* 
derful  that  the  engineers  of  this  train  are  given  alternate 
days  for  rest  and  recuperation.  Fast  travel  not  only 
wears  out  rails  and  machines,  but  human  creatures'  lives. 
— Scientific  American. 

Origin  of  the  Term  Anaesthetic— Mr.  Edgar  Willett, 
in  a  communication  to  the  British  Medical  Journal,  re- 
cords a  conversation  he  had  with  Oliver  Wendell  Holmes 
when  the  latter  was  in  England  in  1886.  The  discus 
sion  had  turned  on  the  subject  of  anaesthetics,  when  he 
said :  "  Do  you  know  the  origin  of  the  term  ?  "  On  re- 
ceiving a  negative  answer  he  replied,  "Then  I  will  tell 
you.  I  believe  it  was  I  who  invented  it,  and  this  is  how 
it  occurred.  Many  years  ago,  when  ether  and  chloroform 
were  only  just  coming  into  use,  Morton,  the  dentist  at 
Boston,  who  was  largely  responsible  for  the  introduction 
of  ether,  came  to  me  and  asked  me  if  I  could  suggest  for 
him  a  word  which  could  be  used  for  both  drugs,  and  also 
a  word  which  would  describe  the  effect  produced  by  their 
inhalation.  After  trying  two  or  three  words,  aesthetic  oc- 
curred to  me  as  meaning  sensitive,  and  in  consequence 
anaesthetic  as  being  insensitive  easily  followed,  with 
anaesthesia  for  the  condition  produced.  That,"  he  con- 
cluded, "was,  I  believe,  the  origin  of  the  term." 

The  Middle  Tennessee  Medical  Association,  a  recently 
organized  society,  held  its  first  meeting  in  Nashville  on 
November  20  and  21,  1894.  A  number  of  interesting 
papers  were  read  and  discussed,  and  the  meeting  was  re- 
garded as  a  success. 


Contagiousness  of  Phthisis. — It  has  been  decided  in 
Toronto  that  phthisis  is  a  contagious  disease,  and  ac- 
cordingly the  board  of  education  has  decided  to  forbid 
children  suffering  from  it  to  attend  the  public  schools. 

Count  Leo  Tolstoi  is,  as  might  have  been  expected 
from  a  consideration  of  his  other  eccentricities,  a  pro- 
nounced anti- vaccinationist.  He  holds  that  "  the  obfiga-* 
tion  of  parents  to  let  their  children  be  subjected  to  opera- 
tions deemed  necessary  by  doctors  seems  to  me  as  great 
an  outrage  as  the  obligation  of  parents  to  subject  their 
children  to  school  teaching  imposed  upon  them  by  the 
government." 

Individual  Communion  Cups. — The  Homoeopathic 
Medical  Society  of  the  County  of  Philadelphia,  at  a  re- 
cent monthly  meeting  recommended  the  abolition,  by 
all  churches,  of  the  common  communion  cup,  or  chalice, 
and  the  substitution  of  individual  cups. 

Against  Christian  Scienee. — The  Humane  Associa- 
tion, at  the  closing  session  of  its  annual  meeting,  held 
in  Evansville,  Ind.,  on  October  nth,  adopted  a  resolu- 
tion condemning,  in  strong  terms,  the  practice  of  Chris- 
tian Scientists,  and  urging  all  societies  to  investigate 
any  suspicious  deaths,  and  prosecute,  if  they  are  found 
to  result  from  the  ministrations  of  this  doctrine. 

Trusses. — Dr.  A.  Landerer,  of  Stuttgart,  recommends 
the  use  of  rubber  pads  filled  with  glycerine  for  trusses. 
He  finds  them  durable  as  well  as  comfortable,  and  says 
that  they  never  cause  atrophy  of  the  tissues  against  which 
they  press. 

The  Czar's  Death  has  been  attributed  by  some  imag- 
inative newspaper  correspondents  to  the  effect  of  poison 
secretly  administered  by  Nihilist  members  of  his  house- 
hold. This  report  is  characterized  by  Dr.  Leyden  as  pure 
fiction.  The  post-mortem  examination,  as  detailed  else- 
where, established  the  correctness  of  the  diagnosis  of 
chronic  nephritis,  with  commencing  atrophy  of  the  kid- 
ney, secondary  enlargement  of  the  heart,  and  inflamma- 
tion of  the  left  lung.    The  stomach  was  intact. 


BOOKS   RECEIVED. 


A  Text- Book  of  Volumetric  Analysis.  By  Henry  W. 
Schimps.  8vo,  400  pages.  Price,  $2.50.  Publishers,  John  Wiley 
&  Sons,  East  Tenth  Street,  New  York. 

A  Compend  ok  the  Practice  of  Medicine.  By  Daniel  E. 
Hughes,  M.D.  5th  Physicians*  Edition.  8vo,  |>68  pages.  Price, 
$2.50.     Publishers,  P.  Blakiston,  Son  &  Co.,  Philadelphia,  Pa. 

Fibroid  Diseases  of  the  Lung.  By  Sir  Andrew  Clark,  M.D., 
W.  J.  Hadley,  M.D.,  and  Arnold  Chapin,  M.D.  8vo,  200  pages. 
Illustrated.  Price,  21s  net,  cash.  Published  by  Charles  Griffin  & 
Co.,  Ltd.,  London. 

Atlas  und  Grundriss  der  Traumatischen  Fracturen  tjnd 
Luxationen.  Von  Professor  Dr.  H.  in  Greifswald.  Mit  166 
Abbildungen  Nach  originalzeich  nungen  von  Dr.  Joseph  Trumpp. 
Verlag  von  J.  F.  Lehmann,  Munich. 

The  Physician's  Complete  Account  Book.  Published  by 
Peckharo,  Little  &  Co.,  56  Reade  Street,  New  York  City. 

A  Manual  of  Modern  Surgery,  General  and  Opera- 
tive. By  John  Chambers  Da  Costa,  M.D.  8vo,  809  pages,  illus- 
trated. Price,  $2.50.  Published  by  W.  B.  Saunders,  Philadel- 
phia, Pa. 

Essentials  of  Diseases  of  the  Skin.  By  Henry  W.  Stel- 
wagon,  M.  D. ,  Ph.  D.  1 2mo,  270  pages,  illustrated.  Price,  $  1 .00. 
Published  by  W.  B.  Saunders,  Philadelphia,  Pa. 

First  Aid  to  the  Injured.  By  E.  J.  Lawless,  M.D., 
D.P.H.  8vo,  262  pages,  illustrated.  Price,  $1.25.  Published 
by  J.  B.  Lippincott  Company,  Philadelphia,  Pa. 

Manual  of  the  Practice  of  Medicine.  By  A.  A.  Ste- 
vens, A.M.,  M.D.  8vo,  501  pages,  illustrated.  Price,  $2.50. 
Published  by  W.  B.  Saunders,  Philadelphia,  Pa. 

Heart  Studies,  Chiefly  Clinical.  By  William  Ewart, 
M.D.  8vo,  486  pages,  illustrated.  Price,  15  s.  Publishers,  Bail- 
Here,  Tyndall  &  Cox,  London,  England. 

A  Dictionary  of  Medicine.  By  D.  Richard  Quain.  2  vols., 
1 26 1  pages  and  1305  pages,  illustrated.  Royal  octavo.  Published 
by  D.  Appleton  &  Co. ,  New  York. 


Medical  Record 

A  Weekly  yournal  of  Medicine  and  Surgery 


Vol.  46,  No.  24. 
Whole  No.  1258* 


New  York,  December  15,  1894. 


$5.00  Per  Annum. 
Single  Copies,  xoc. 


ON  THE  NEW  USE  OF  SOME  OLDER  SCIENCES. 

Being  a  Discourse  on  Degeneration  and  Its 
Stigmata.1 

By  CHARLES  L.  DANA,  A.M.,  M.D., 

NIW  YOBK. 

Gentlemen  and  Ladies  :  As  I  survey  the  medical  activ- 
ities of  the  present  time  they  seem  to  be  working  in 
three  distinct  streams  of  fruitful  and  progressive  effort. 
The  first,  and  just  now  greatest,  takes  in  all  that  may  be 
meant  by  bacteriology  or  the  science  of  minute  organisms. 
Through  this  we  are  learning  the  secrets  of  disease  and 
health ;  through  it  we  shall  some  day,  I  hope,  reach  a 
germ-free  millennium,  or  at  least  learn  to  live  unscathed 
among  our  little  enemies  teeming  in  the  air  and  dust. 

Next,  one  finds  that  while  medical  men  are  abandon- 
ing faith  in  old-time  Homeric  drugs  and  drugging,  they 
are  working  with  an  intenser  energy  than  ever  to  perfect 
the  technical  details  of  their  art.  In  every  branch  exact- 
ness of  observation,  precision  in  examination,  and  re 
sourcefulness  and  ingenuity  of  treatment  are  increasing, 
until  the  reproach  that  medicine  is  not  a  science  is 
slowly  losing  its  force. 

Finally,  I  see  a  new  and  extraordinary  energy  put  forth 
in  the  study  of  the  physical  characters  of  man,  and  the 
significance  of  the  lines  along  which  each  individual  is 
built.  We  are  trying  to  read  in  man's  general  conforma- 
tion the  story  of  bos  character,  his  weakness,  his  ca 
parity,  his  power  of  resistance  to  disease  and  temptation 
— in  fine,  his  moral  and  intellectual  endowments.  It  is 
because  this  movement,  though  it  has  reached  great  pro- 
portions in  Europe,  has  made  little  impression  here  that 
I  propose  to  make  one  phase  of  it  the  subject  of  my  re- 
marks to-night. 

It  is  a  doctrine  as  old  as  Hippocrates  that  different 
people  have  a  special  tendency  to  different  diseases,  and 
that  they  react  in  different  ways  to  the  influences  about 
them ;  that  one  will  have  catarrhs,  another  gout,  another 
rheumatism,  and  another  consumption;  that  one  is 
lethargic,  another  nervous,  and  another  melancholic.  It 
is  not  of  these  kinds  of  investigation  that  I  shall  speak ; 
though  this  new  science  does  in  a  certain  measure  what 
the  quasi-sciences  of  physiognomy  and  of  phrenology,  of 
diathesis  and  temperament,  once  claimed  to  do.  It  does 
not  seek  to  accomplish  its  object,  however,  by  feeling 
the  bumps  on  the  head,  or  noting  the  lines  on  the  palm, 
or  studying  the  hand-writing,  or  by  mystic  rites  per- 
formed over  a  lock  of  hair.  It  is  a  science  quite  differ- 
ent from  so-called  phrenology,  or  physiognomy,  or  chiro- 
mancy— arts  which  are  merely  incongruous  collections 
of  fatuous  guesswork.  This  coming  science  has  no  name 
that  yet  specifically  indicates  its  work.  It  is  approached 
on  the  one  hand  by  anthropologists,  and  on  the  other  by 
students  of  nervous  diseases,  of  insanity,  and  of  crime, 
and  it  receives  accessions  from  the  learned  savants  of  the 
universities  and  the  modest  instructors  in  the  gymnasia. 

It  is  a  study  of  the  human  body  in  its  largest  signifi- 
cance, a  measurement  of  the  capacity  and  fruitfulness  of 
the  soil.  By  and  by  all  the  harmful  microbes  of  the 
earth  will  be  subdued,  and  we  will  hear  no  more  of  them 
except  as  curiosities  in  germs ;  but  the  human  soil,  on 

1  Delivered  at  the  Anniversary  Meeting  of  the  New  York  Academy 
of  Medicine,  November  28,  1894. 


which  they  used  to  grow,  will  remain,  with  all  its  ever- 
increasing  complexity,  and  physicians  will  then  have 
only  the  functions  of  interpreting  its  values  and  patching 
up  its  injuries  or  inherited  defects. 

A  sort  of  dim  foreshadowing  of  this  science  is  found  in 
the  history  of  physiognomy  and  its  allied  arts.  I  use  the 
word  and  touch  upon  the  subject  with  some  hesitation. 
Five  hundred  years  ago  Petrus  de  Abano,  of  Italy,  dis-  • 
coursed  upon  it  and  was  subsequently  burned  for  heresy, 
secundum  art  cm }  in  the  flames  at  Padua.  Not  longer  ago 
than  the  times  of  George  II.  all  persons  "  fayning  to  have 
knowledge  of  Phissiognomie  or  like  Fantastical  Ymagina- 
cions  "  were  deemed  rogues  and  vagabonds,  and  liable  to 
be  publicly  whipped  or  sent  to  the  house  of  correction. 
The  attempt  to  meastfi*  a  man  by  his  looks,  however,  has 
always  been  made,  and  its  professional  votaries  have 
crystallized  their  knowledge  into  many  a  scientific  treat- 
ise of  admirable  length  and  erudition.  In  those  days 
there  were  onychiologists,  who  read  character  from 
the  nails;  podoscopists,  who  studied  the  signs  in  the 
feet;  metapo6copists,  who  read  the  face,  and  many 
other  subdivisions  of  the  general  art  of  fooling  peo- 
ple by  examining  certain  fractions  of  their  body. 
The  ancients,  however,  did  not  build  their  science  up 
securely;  they  could  not  resist  the  desire  to  mingle 
prophecy  with  their  imperfect  divination,  and  as  time 
passed  and  knowledge  grew,  both  prophecy  and  the 
various  arts  of  physiognomy  declined. 

A  little  over  a  hundred  years  ago  a  devout  clergyman 
of  Switzerland,  Louis  Lavater,  gave  the  last  impulse  to 
this  line  of  work  in  a  most  learned,  pious,  and  industri- 
ously written  treatise  on  physiognomy,  which  he  dedi- 
cated to  the  promotion  of  religion  and  right  thinking. 
Lavater  called  attention  to  the  striking  way  in  which 
physiognomy  sometimes  indicates  the  character  and  in- 
telligence of  the  individual.  Perhaps  he  overdid  the 
thing  a  little.  His  pictures  of  bad  men  were  so  fright- 
ful that  die  reader's  vanity  was  almost  compelled  to  feel 
that  he  must  be  good,  while  his  virtuous  faces  were  so 
insipid  as  to  excite  self  respecting  men  to  a  distinct  de- 
sire for  vice. 

The  soul  and  intelligence,  said  Lavater,  show  them- 
selves in  the  head  and  brow,  and  their  centre  is  the  eye ; 
the  moral  life  is  indicated  in  the  face,  and  its  expression 
centred  in  the  nose  and  cheeks ;  the  animal  and  physi- 
cal life  are  centred  in  the  stomach.  They  showed  their 
predominance  also  in  the  mouth  and  chin. 

One  day  Lavater  made  the  mistake  of  thinking  that 
an  executed  assassin  was  an  eminent  philosopher  and 
preacher,  Herder.  Worse  mistakes  have  been  made, 
but  still  such  things  impaired  the  dignity  and  secu- 
rity of  his  already  decadent  system.  Lavater's  teach- 
ings were  too  simple  in  theory  for  a  science  and  too 
complicated  in  practice  for  an  art.  His  illustrations 
remain,  and  his  head  of  Satan  in  particular  repre- 
sents a  character  which  no  one  can  see  without  desiring 
to  resemble  it.  His  physiognomy  died  in  the  arms  of 
a  more  successful  form  of  philosophy. 

It  was  only  a  few  years  later  that  an  Austrian  physician, 
Dr.  Gall,  began  his  lectures  on  what  is  still  known  as  phre- 
nology. The  story  of  how  he  noticed  the  bulging  eyes  of 
his  school  fellows  who  surpassed  him  in  their  memory, 
and  of  how  he  found  big  bumps  over  the  ears  of  murder- 
ers and  over  the  temples  of  thieves  is  probably  familiar 
to  many.  It  was  at  least  part  of  the  learning  of  my 
school-days.    Dr.  Gall  was  an  industrious  enthusiast, 


738 


MEDICAL   RECORD. 


[December  15,  1894 


and  there  is  little  in  the  phrenology  of  to  day  which  is 
not  due  to  his  labors,  though  he  had  able  helpers  and 
successors  in  Spurzheim  and  Combe.  Practical  phrenol- 
ogy now  is  really  but  a  shrewd  empiricism  based  on 
physiognomy,  and  not  upon  the  classical  bumps  at  all. 

Taking  a  standard  phrenological  bust  as  sold  by  the 
professors  of  the  art,  I  have  drawn  over  the  various 
faculties,  as  indicated  by  Gall,  lines  by  which  I  could 
map  out  the  functions  of  the  different  parts  of  the 
brain,  so  far  as  they  have  been  absolutely  determined  by 
modern  investigations.  These  show  some  curious  juxta- 
positions. Thus  the  bumps  of  murder  or  destructiveness, 
and  secretiveness  which  lie  just  above  the  ears,  correspond 
with  the  centre  for  hearing;  the  bump  of  thieving,  which 
is  a  little  in  front  of  the  ear,  lies  over  the  centre  for  the 
movements  of  the  mouth ;  while  self-esteem  and  reverence 
correspond  with  the  more  measured  activities  of  the  legs; 
I  find  also  that  parental  love  is  identical  on  the  bust 
'  with  the  sense  of  sight,  and  hope  with  the  motions  of 
the  shoulders  and  arms.  Perhaps  some  philosopher  of 
the  future  will  reconcile  these  differences  and  construct 
upon  them  an  esoteric  metaphysics;  but  at  present  it 
seems  to  me  that  physiology  has  quite  extinguished  the 
science  of  bumps.  While  the  actual  contributions  of  Dr. 
Gall  to  science  were  small,  his  work  called  attention  to 
the  importance  of  studying  th^conformation  of  the 
head  and  the  function  of  the  brain,  and  gave  an  impetus 
to  more  serious  and  fruitful  studies. 

It  is  since  Dr.  Gall's  time  that  the  word  "  degenerate  " 
has  become  one  of  common  usage  in  French  literature, 
running  through  works  on  heredity,  social  economy,  art, 
morality,  crime,  insanity,  and  disease  in  all  its  forms. 
We  find  French  literature  full  of  articles  upon  degen- 
eracy and  civilization,  degeneracy  and  crime,  degen- 
eracy and  disease.  There  is  in  France  a  whole  school 
of  the  Decadents,  as  they  more  euphemistically  are 
called.  The  term  has  been  adopted  by  the  Germans, 
and  runs  through  the  work  of  Lombroso  and  his  fol- 
lowers in  Italy.  In  England  and  this  country  its  use 
and  significance  seem  to  me  to  be  much  less  appreciated. 
Yet  since  the  first  applications  of  the  new  science  have 
been  toward  helping  us  recognize  those  who  belong  to 
the  class  known  as  degenerate  and  unstable,  I  shall  de- 
vote a  little  time  to  explaining  what  is  meant  by  the 
word. 

The  term  has  an  unpleasant  sound,  and  nobody  likes 
to  hear  dry  expositions  of  depressing  phenomena.  The 
New  Yorker  of  to  day  will  hardly  tolerate  a  tragedy ;  he 
wants  his  drama  farcical,  his  art  sensuous,  and  his  novels 
with  a  pleasant  hymeneal  ending.  I  cannot  believe  it 
possible  for  me  to  make  a  discourse  on  degeneracy  at 
once  lucid  and  attractive.  But  if  one  will  pass  the  tip 
of  the  tongue  over  the  roof  of  the  mouth,  five  or  six  out 
of  every  one  hundred  adults  will  feel  a  curious  ridge  along 
the  middle  of  the  hard  palate.  This  is  called  the  torus 
palatinus,  and  whoever  has  it  possesses  one  very  inter- 
esting mark  of  degeneracy.  The  finding  of  this  will,  I 
am  sure,  give  a  certain  percentage  of  people  a  personal 
interest  in  the  subject,  and  will  make  them  listen  with 
some  quietude  in  order  to  learn  if  it  has  any  painful  sig- 
nificance. 

I  do  not  need  at  this  day  to  refute  that  shibboleth  of 
the  Reign  of  Terror  that  all  men  are  born  equal.  We  all 
know  very  well  that  babies  start  in  life  with  very  unlike 
endowments.  For  the  purposes  of  my  explanations,  how- 
ever, I  shall  only  say  that  some  are  born  like  and  some  are 
born  unlike  their  parents.  Those  who  have  more  or  less 
fully  the  mental  and  physical  characters  of  their  family 
are  considered  technically  normal,  while  those  unlike  it 
are  degenerate.  The  degenerate  are  those  who  differ 
from  the  average  standard  as  set  up  by  the  family  from 
which  they  spring ;  'they  are  variations  from  the  health- 
fulness  of  mediocrity;  they  are  the  peculiar  people. 
Here,  for  example,  is  an  illustration  familiar  to  all.  An 
honest,  healthy,  and  respectable  couple  have  a  number 
of  children ;  most  of  them  take  after  their  parents  more 
or  less  closely  and  grow  up  honest,  healthy,  sturdy,  per- 


haps mediocre  or  somewhat  more  than  mediocre  men 
and  women.  But  one  of  the  children  is  different :  he  is 
wilful,  perverse,  impulsive,  deceitful ;  perhaps,  however, 
talented  in  music  or  art,  in  business  or  literature.  He  is 
looked  up  to  as  the  genius  or  the  doubtful  character  of 
the  family,  and  all  the  friends  wonder  where  he  got  his 
endowments.  He  is  one  of  the  degenerate.  If  his  tal- 
ent overrides  his  moral  imperfections  he  makes,  perhaps, 
a  success  of  life,  and  he  is  called  technically  simply  an 
unstable,  or  popularly  an  erratic  man.  If  his  talents 
and  bad  tendencies  are  pretty  evenly  balanced  he  is 
called  a  degenerate  of  the  superior  type,  while  if  he  dis- 
closes decided  mental  weakness  or  develops  an  epilepsy, 
or  hysteria,  or  some  curious  form  of  hypochondriasis,  he 
is  called  an  inferior  degenerate. 

From  this  last  class  are  fed  also  the  insane  and  many 
criminals.  The  weak-minded,  imbecile,  and  the  idiot 
stand  at  the  lowest  level  of  the  degenerate  class.  The 
common  characteristic  of  all  is  that  they  are  variations 
from  the  family  average,  they  have  mental  faculties  ard 
physical  powers  not  evenly  balanced,  and  if  they  marry 
they  may  accentuate  the  degeneracy,  while  eventually 
their  family  becomes  sterile  and  runs  out  This  ten- 
dency to  sterility  is  the  final  and  uniform  criterion. 
The  histories  of  prominent  families  of  Europe,  aristo- 
cratic and  royal,  are  often  cited  as  illustrations  of  this 
phenomenon.  But  it  is  not  confined  to  them,  and  we 
see  it  in  the  country  as  often  as  in  the  cities. 

There  is,  however,  a  brighter  side  to  this  picture. 
The  human  race  possesses  a  conservative  force  which 
constantly  tends  to  bring  individuals  back  to  the  avenge 
and  healthy  type.  Giants  do  not  breed  giants,  or  dwarfs 
dwarfs ;  neither  do  idiots  breed  idiots,  despite  the  reitera- 
tion* of  controversial  journalism,  nor  do  criminals  breed 
criminals.  These  classes  have  no  children,  or  their  chil- 
dren are  better  than  the  parents.  Men  and  women  of  gen- 
ius, and  even  those  of  extraordinary  talent,  follow  the  same 
rule.  Their  children  tend  to  drop  to  the  level.  There 
is  a  centripetal  force  that  brings  the  generations  back  to 
the  type  of  the  average  man.  No  amount  of  acquired 
aptitude  or  special  skill  is  transmitted  to  the  children, 
though  some  of  that  with  which  one  is  naturally  en- 
dowed may  be  passed  on.  The  degenerate  class  in  all 
its  grades  is  a  very  large  one,  embracing  five  to  ten  per 
cent,  of  adults ;  few  successful  men  can  be  said  to  be 
free  from  the  taint.  And  since  perfect  stability  of  the 
organism  is  only  found  in  the  average,  or  some  would  say 
commonplace  man,  it  may  be  said  that  degeneracy  is  a 
condition  not  altogether  undesirable.  Such  a  view  is 
quite  justifiable.  I  am  flying  in  the  face  of  the  old 
adage,  that  the  best  possession  in  life  is  mens  sana  in  cor- 
pare  sano ;  but  I  do  not  think  that  perfect  health  and 
perfect  sanity  are  things  that  any  individual  should  de- 
sire. It  is  good  for  society  as  a  whole,  but  not  so  for 
the  individual,  or,  I  might  parenthetically  and  profes- 
sionally add,  for  the  doctor. 

I  have  often  noticed  that  families  with  a  streak  of  in- 
sanity, or  inebriety,  in  their  membership  number  the 
brilliant  and  successful  men.  Only  the  insanity,  like 
the  boil,  should  affect  the  other  man.  No  man  of  genius 
had  ever  perfect  physical  proportions  or  perfectly  stable 
organizations.  On  the  other  hand,  the  portraits  of  beau- 
tiful women  are  not  the  portraits  of  women  who  have 
had  great  intellectual  attainments,  and  the  beauty  of 
women  has  only  affected  the  world's  history  indirectly 
through  lower  channels.  Perfect  beauty  means  medioc- 
rity, and  man's  desire  for  the  one  is  the  force  which 
brings  back  the  degenerate  to  the  other.1  There  is  a 
scientific  justification  for  the  fun  which  one  of  our  daily 
papers  so  often  pokes  at  pulchritude.  I  do  not  mean 
that  one  must  be  ugly  in  order  to  be  brilliant,  but  only 
that  in  women  and  men  of  talent  or  wickedness  there  is 

»  The  well-known  artist,  Mr.  A.  B.  Frost,  is  quoted  by  Robert 
Bridges  (The  Bookbuyer.)  as  saying,  referring  to  artists  models: 
14 1  might  mention  that  there  is  a  singular  peculiarity  about  the  wo- 
men. All  the  handsome  ones  are  stupid  and  can't  put  an  idea  into  a 
pose,  and  all  the  bright  ones  who  can  and  will  pose  and  help  yon 
work  are  decidedly  plain  both  as  to  face  and  figure.'* 


December  15,  1894] 


MEDICAL   RECORD. 


739 


some  deviation  from  the  standard  type  which  the  modern 
sanitarian  would  call  the  normal. 

Bat  here  I  must  make  some  important  modifications 
in  my  text.  I  have  spoken  as  though  there  were  but  two 
classes  of  people ;  1,  the  normal,  which  includes  the  great 
majority ;  2,  the  degenerate.  All  writers  have  so  far  cho- 
sen to  make  only  these  distinctions  and  have  established 
the  signs  by  which  to  divide  all  humanity  into  the  sheep 
and  the  goats. 

But  in  this,  as  it  seems  to  me,  one  important  element 
is  left  out,  or  not  sufficiently  considered.  While  most 
people  may  be  what  the  modern  aesthete  or  green  carna- 
tion critics  call  "  middle-class,"  the  remnant  are  not  all 
below  the  average,  as  their  name  "  degenerate"  would 
imply.  Assuming  at  least  that  the  human  race  is  slowly 
progressing,  it  must  be  that  the  average  man  and  woman 
is  also  becoming  of  a  slightly  higher  type ;  and  this  in 
turn  must  be  because  many  of  the  variations  from  the 
healthy  average  are  distinctly  above  it.  Some  of  the 
people  who  have  the  peculiarities  of  instability  and  ten- 
dency to  die  out,  do  nevertheless  give  birth  to  a  more 
vigorous  stock  than  they  themselves  possess.  In  other 
words,  unless  the  world  is  growing  worse  there  must  be  a 
class  of  greater  than  average  vigor,  who  may  be  called  the 
progressives  or  "  regenerates.'1  There  are,  however,  as 
yet  no  anatomical  marks  known  which  distinguish  these 
as  a  type. 

I  hope  I  have  made  measurably  clear  the  idea  of  de- 
generacy as  it  has  been  developed  and  taught  by  latter- 
day  writers.  It  forms  a  class  of  which  the  members  are 
as  far  apart  morally  and  intellectually  as  the  possibilities 
of  human  nature  allow.  Yet  it  has  common  characters 
in  the  reproductive  weakness,  in  the  defects  of  physique, 
and  in  the  instability  of  their  mental  faculties.  They 
are  all  wanderers  from  the  normal  lines.  Furthermore, 
and  this  is  die  point  to  which  I  have  all  along  been,  very 
slowly  I  fear,  tending,  they  have  about  them  certain 
marks  or  stigmata  which  indicate  their  divergence,  and 
are  badges  of  their  servitude  or  of  their  freedom.  The 
study  of  these  marks  forms  the  application  of  modern- 
ized physiognomy  and  anthropometry  to  the  determina- 
tion of  the  degenerate  classes.  This  is  the  new  use  of 
the  older  sciences. 

In  France,  Moreau,  Magnan,  F6r6,  and  others  have 
followed  up  the  work  of  Morel,  who  may  be  called  the 
father  of  the  study  of  degeneracy.  But  undoubtedly  the 
greatest  impulse  has  been  given  to  these  studies  by  Pro- 
fessor Lombroso  and  his  pupils.  This  eminent  scientist 
believes  that  criminals  are  unlike  their  own  race,  but  re- 
semble each  other  and  are  a  family  among  themselves, 
with  a  family  likeness  and  common  bodily  peculiarities. 
This  conclusion  is  one  to  which  I  cannot  at  all  agree, 
and  which  I  feel  sure  is  not  yet  subscribed  to  by  men  of 
science.  The  exact  position  in  which  Lombroso's  work 
stands,  I  shall  refer  to  later.  Meanwhile  one  cannot 
overestimate  the  value  of  the  impulse  which  he  has  given 
to  investigations  of  the  human  body.  If  there  is  ever  to 
be  a  complete  and  exact  science  by  which  we  can  in  a 
measure  infer  character  from  figure  it  will  be  very  largely 
due  to  the  work  of  the  great  Italian  criminologist. 

I  propose  now,  however,  to  go  into  some  of  the  de- 
tails of  the  curious  discoveries  that  have  been  made  by 
investigators,  not  in  Italy  alone,  but  in  all  parts  of  the 
world.  I  do  it  with  the  hope  that  my  descriptions  will 
not  lead  to  any  unpleasant  habits  of  self  examination  or 
to  surprises  that  act  disagreeably  upon  one's  vanity.  I 
shall  take  up  the  points  somewhat  at  random,  for  I  have 
not  time  to  present  the  subject  in  any  systematic  and 
complete  manner. 

Of  all  the  various  systems  of  which  the  body  is  com- 
posed, the  bones  have  been  thought  to  be  allied  most 
completely  with  the  development  of  the  nervous  system. 
Sir  William  Gull  once  suggested  that  the  Socratic  ad- 
vice yvtaOl  <t€ovtcv  should  be  interpreted  in  these  days 
"  examine  your  urine ; "  but  the  modern  physiogno- 
mist would  rather  say,  "  examine  your  bones." 

A  perfect  bony  system  is  a  rather  good  index  of  vital- 


ity at  least,  and  its  variations  and  anomalies  make  up  a 
large  part  of  the  stigmata  of  degeneracy.  The  presence 
of  excessively  long  arms,  for  example,  is  a  phenomenon 
greedily  seized  upon  by  the  Italian  school  as  indicating  a 
return  to  man's  ape- like  state,  before  he  fell  from  grace 
and  his  arborial  gambols  in  primeval  forests.1  But  long 
legs  and  a  small  chest  are  also  found  to  be  evidence  of 
degeneracy;  and  whatever  may  be  said  of  the  marks 
written  on  the  bones,  none  of  them  prove  that  their 
anomalies  aie  signs  of  a  return  to  savagery.  Degeneracy 
is  not  a  form  of  atavism. 

Naturally  the  conformation  of  the  head  and  face  has 
been  studied  with  much  earnestness  and  much  practical 
success.  The  skull  of  man  is  never  quite  symmetrical, 
but  it  tends  to  become  so ;  on  the  other  hand,  the  brain 
tends  to  become  asymmetrical,  i.e.,  the  left  side  to  be  a 
little  larger  than  the  right.  When  things  go  a  little 
wrong  in  the  human  make-up,  the  skull  shows  it  quickly 
by  getting  out  of  shape.  The  size  does  not  count  very 
much,  for  we  know  that  men  of  genius,  like  Gambetta, 
have  had  skulls  that  would  barely  be  large  enough  for  a 
boy.  But  odd  shapes  do  signify.  In  olden  times  the 
physiognomists  thought  that  men  of  evil  character 
had  a  sugar-loaf  (oxycephalic)  skull,  while  Gall  found  his 
murderer's  bump  over  the  ears.  And  modern  criminol- 
ogists lay  much  stress  on  the  size  of  the  jaws. 

There  are,  at  least,  thirty  ways  in  which  the  head  va- 
ries from  the  normal  type.  Many  of  these  are  most 
trivial,  and  it  is  only  on  the  principle  that  a  dozen  small 
things  make  an  object  of  respectable  size  that  one  is 
justified  in  giving  attention  to  the  facts  that  are  collected. 
Ordinarily  we  look  in  a  man's  face  to  see  whether  it  is 
in  general  attractive,  intelligent,  interesting,  beautiful, 
or  the  reverse.  But  the  anthropologist  looks  more 
closely  and  hunts  for  his  stigmata.  One-third  of  all 
thoroughly  bad  men,  for  example,  according  to  Dr. 
Penta,  have  a  plagiocephalic  or  twisted-shaped  skull.8 
A  still  larger  proportion,8  forty-five  per  cent.,  have  pro- 
jecting jaws,  or  prognathism,  wide  jaws  (twenty- nine  per 
cent.),  and  wide  orbits  (thirty  per  cent.) 

The  nose  in  the  criminal  is  often  rectangular,  short, 
large,  and  upturned ;  the  face  shows  early  wrinkles  and 
a  peculiar  pallor.  The  criminal  jaw  weighs  94  gm. 
(3  ounces),  the  normal  jaw  but  80  gm.  (2%  ounces) 
(Manouvries).  The  cheek-bones  are  prominent,  the  or- 
bits are  large,  the  frontal  sinuses  and  brows  protrude, 
and  the  teeth  are  defective  and  badly  placed.  The  shape 
of  the  palate  stands  in  close  relation  to  that  of  the  skull, 
and  the  neat  and  workman  like  way  in  which  nature 
joins  the  parts  in  the  middle  shows  that  she  has  done 
well  elsewhere.  When  the  palate  has  a  ridge  along  its 
centre,  torus  palatinusf  or  is  high  and  narrow,  or  uneven 
and  badly  shaped,  we  count  it  among  the  signs  of  degen- 
eracy, though  it  weighs  lightly  in  the  scale.  Criminals 
have  three  or  more  of  these  various  anomalies. 

The  size  of  the  head,  as  already  stated,  counts  perhaps 
less  than  anything  else,  unless  the  deformity  be  greatly 
exaggerated.  The  good  and  the  bad,  the  sane  and  the 
insane,  have  heads  of  about  the  same  size,  and  even 
prehistoric  skulls  do  not  show  much  inferiority.  Civili- 
zation began  and  completed  its  work  with  almost  pre- 
cisely the  same  amount  of  brain  tissue. 

The  anomalies  above  described  have  a  rather  forbid- 
ding and  perhaps  alarming  sound,  and  it  is  pleasant  to 
know  that  individually  they  are  not  very  significant.  A 
homely  face  can  be  quite  free  from  the  stigmata  of  sin, 
while  one  of  a  fascinating  and  even  beautiful  type  may 
have  much  that  suggests  degeneracy. 

»  When  the  arms  hang  straight  down  by  the  side,  the  tip  of  the 
middle  finger  is  14  ctm. ,  or  about  six  inches  from  the  knee-cap.  In 
negroes  it  is  only  five  to  eight  ctm.,  or  two  to  three  inches  (Krause). 

■  Arch,  de  Psych.,  vol.  xv. ,  p.  327. 

•Ibid. 

*  Among  71  patients  in  the  general  wards  at  Bellevue  Hospital  I 
iound  a  distinct  torus  in  4,  and  in  a  of  these  cases  the  patients  had 
nervous  disease,  in  57  patients  examined  in  the  alcoholic  pavilion,  I 
found  the  torus  in  11  cases,  or  twenty  per  cent.  The  torus  is  more 
marked  in  inebriates  than  in  the  insane,  though  palates  otherwise  de- 
ormed  are  more  frequent  in  the  latter  class. 


740 


MEDICAL   RECORD. 


[December  15,  1894 


There  are,  as  artists  and  anatomists  know,  certain  defi- 
nite proportions  between  the  circumferences  of  the  neck, 
shoulders,  chest,  waist,  and  hips.  These  proportions 
differ  for  infants,  men,  and  for  women.1  Among  the 
unstable  there  are  often  found  misfits  in  these  propor- 
tions, so  that  a  man,  for  example,  has  approximately  a 
child's  or  woman's  proportions.  This  condition  is 
known  as  feminism  or  infantilism,  and  many  striking 
illustrations  of  it  have  been  shown  by  Dr.  Charles  F6r6, 
of  Paris.  I  have,  I  am  sure,  seen  it  in  some  classical  stat- 
ues, and  I  believe  it  will  be  found  that  the  Greeks  had  a 
certain  unholy  admiration  for  some  of  these  beautiful 
but  perverted  types  of  the  human  figure. 

We  everyday  people  have  rather  agreed  to  ignore  the 
ears,  yet  it  is  remarkable  to  what  uses  they  lend  them- 
selves at  the  hand  of  science.  Laycock  thtiught  that  the 
circulation  in  the  ear  was  an  accurate  indication  of  that 
in  the  brain,  and  that  its  development  coincided  with 
that  of  the  brain  and  skull.  The  ear  to  him  was,  to  the 
brain,  as  accurate  an  indicator  as  the  tongue  is  to  the 
stomach.  Mr.  Ellis  speaks  of  an  observant  schoolmistress 
who  could  tell  when  her  pupils  were  tired  by  the  state  of 
the  circulation  in  their  ears.  Professor  Grandino,  of 
Turin,  however,  may  be  said  to  have  done  the  ear  the 
most  illustrious  service.  He  has  examined  these  organs 
in  twenty  five  thousand  healthy  men  and  women,  besides 
eight  hundred  insane  and  four  hundred  and  sixty-seven 
criminals.  I  have  before  me  the  typical%ear  as  it  should 
be,  or  at  least  as  the  Professor  depicts  it  from  the  results 
of  his  laborious  studies.  I  must  confess  that  after  having 
mastered  its  admirable  symmetries  I  have  gained  a  new 
experience  in  aesthetics.  For  now  it  gives  me  a  distinct 
delight  when  I  come  across  a  perfect  aural  organ,  such 
as  one  experiences  in  seeing  a  beautiful  picture  or  listen- 
ing to  the  harmonies  of  an  up-to-date  sonata. 

It  is  surprising  how  many  shapes  the  ear  may  take 
when  one  comes  to  look  at  it  seriously  in  the  light  of  a 
newly  growing  science  which  is  thirsty  for  morphologi- 
cal data.  There  are  at  least  seven  distinct  ways  in  which 
the  ear  can  be  wrong ;  each  corresponding  perhaps  to  a 
deadly  sin,  for  each  is  more  prominent  in  the  sinner  than 
in  the  saint.  I  am  not  going  to  enumerate  these  points, 
for  I  cannot  do  it  except  in  the  most  technical  language, 
and  besides,  I  do  not  like  to  give  people  who  are  kind 
enough  to  listen  to  my  discourse  any  opportunity  to  form 
a  poor  opinion  of  themselves.  The  long  lobes  and  a 
peculiar  wrinkle  in  the  cavity  of  the  ear  are  the  things 
which  have  most  significance. 

One  of  the  most  curious  things  discovered  by  the  pa- 
tience of  the  neurologist  has  been  the  prehensile  foot 
(pied prihensile).  Drs.  Ottolenghi  and  Carrara  examined 
the  toes  of  one  hundred  and  sixty-two  normal  people, 
thirty-one  epileptics,  fifty-six  idiots,  and  three  hundred 
and  fourteen  criminals.3  Among  normal  people  the 
distance  between  the  first  and  second  toe  at  the  base 
rarely  exceeds  3  mm.  (£  inch)  in  men,  while  in  the 
abnormal  classes  such  excess  is  three  times  as  frequent. 
The  idiot  classes  seem  to  be  especially  marked  with  this 
stigma,  so  that  it  would  be  inferred  that  the  activity  of 
the  intelligence  is  indicated  in  a  measure  by  the  distance 
between  the  toes.  This  would  seem  absurd,  were  it  not 
that  the  peculiarity  suggests  a  return  to  the  prehensile 
toe  of  the  ape,  and  is  therefore  classed  as  a  mark  of  ata- 
vism. 

I  said  some  time  ago  that  chiromancy  had  not  been 
taken  up  seriously  by  scientists.  The  lines  and  furrows 
which  have  been  studied  as  a  parlor  game,  and  about 
which  prophetic  and  pseudo  scientific  works  have  been 
written,  is  mainly  but  guesswork.     Yet  the  lines  so  deli- 

JThe  average  circumferences  in  men  and  women  are  given  by 
Krause  as  follows,  in  centimetres : 

Men.        Women. 

Circumference  of  neck. 34  3a 

"  at  level  of  iliac  region 70  73 

"  level  of  hip  bone  joints 81  84 

"  breadth  between  trochanters 34  35 

• «  shoulder  breadth 39.1  35.2 

"  hip  breadth 30.5  31.4 

a  Giorn.  della  R.  Acad,  di  Med.,  1892. 


eatery  arranged  on  the  finger-tips  are  beginning  to  assume 
some  significance.  Mr.  Galton,  in  his  work  on  finger- 
marks, established  the  fact  that  they  never  change  in  the 
same  individual,  and  that  they  may  be  to  a  certain  extent 
classified.  His  investigations  were  confined  to  normal 
people.  Alix  did  the  same  for  the  finger  tips  of  apes, 
and  now  Forgeot,  of  Lyons,  says  that  in  young  thieves 
of  Boulogne  are  traces  of  the  same  arrangements  seen  in 
apes,  and  F6r6  finds  them  among  sixteen  per  cent,  of 
epileptics.1 

Much  has  been  written  about  the  hand ;  artists  have 
depicted  its  perfections,  physiognomists  have  interpreted 
its  shape  and  expression,  cheirologists  and  the  gypsy 
queens  have  tried  to  prophecv  from  its  markings.  But 
a  study  of  its  peculiarities  by  the  inductive  method  takes 
one  into  entirely  new  fields,  and  shows  that  to  interpret 
the  significance  of  the  hand  one  must  start  on  quite  new 
lines.  There  is  something  perhaps  in  the  fact  that  the 
artistic  hand  has  somewhat  tapering  fingers,  but  beyond 
this  one  deals  with  uncertainties.  And  I  recollect  an 
idiot  youth  whose  extremities  had  the  contour  of  a  genius 
or  a  Trilby. 

If  one  examines  the  hands  of  a  large  number  of  per- 
sons with  a  nervous  endowment,  he  will  find  curious  de- 
fects in  the  length  and  relative  proportions  of  the  fingers. 
The  length  of  the  finger  is  determined  by  that  of  the 
middle  one.  If  the  index  and  medius  are  closed  upon 
the  palm,  the  ring  and  little  finger  being  left  extended, 
the  middle  finger  will  reach  close  to  the  place  where  the 
so-called  life-line  runs  down,  between  the  ball  of  the 
thumb  and  that  of  the  little  finger.  It  will  touch  the 
palm  just  below  the  highest  part  of  the  ball  of  the 
thumb.9  The  middle  finger  is  taken  as  the  standard  of 
length  by  which  to  gauge  that  of  the  others.  In  a  nor- 
mal hand  the  forefinger  reaches  just  to  the  root  of  the 
nail  of  the  middle  finger,  the  ring  finger  is  longer  and 
should  reach  nearly  to  the  middle  of  the  nail  of  the  me- 
dius, while  the  little  finger  should  reach  to  the  last  joint 
of  the  third  finger.  Now  in  inebriates,  epileptics,  neu- 
rotics, and  the  degenerate  generally,  these  proportions  are 
often  not  observed.  The  most  common  defect  is  short- 
ness, especially  of  the  third  and  little  fingers,  though 
sometimes  a  disproportionate  length  occurs.  Sometimes 
these  fingers  are  unnaturally  slender  or  the  little  finger  is 
slightly  bent.  The  most  common  abnormality  of  the 
thumb  is  excessive  shortness,  with  a  defective  mobility. 
These  peculiarities  well  accentuated  form  what  we  may 
call  the  "decadent  hand" — the  hand  that  writes  our 
sensuous  novels,  the  Hauptmann  drama,  paints  sym- 
bolic pictures,  and  exploits  pure  sestheticism.  Such 
hands  may  be  well- formed  to  the  ordinary  eye,  and  may 
be  attached  to  slender  and  graceful  limbs.  But  this 
kind  of  beautiful  hand  and  arm  is  found  quite  as  often 
among  the  children  of  alcoholics  and  among  those 
highly  cultivated  families  which  have  become  degenerated 
by  vices  and  vicious  crossing. 

The  hair  adds  a  little  to  our  knowledge  of  the  individ- 
ual, but  not  very  much.  Light  hair  and  blue  eyes  seem 
to  be  dangerous  endowments  in  the  Italian  race,  but 
this  is  not  the  case  with  the  Anglo-Saxon.  It  may  be  a 
comfort  to  know  that  hair  grows  plentifully  on  the  heads 
of  criminals,  and  that  prematurely  bald  men  are  rarely 
bad,  through  any  hereditary  defect  at  least.  The  degen- 
erate has  often  a  thick  head  of  hair  and  a  thin  beard, 
while  in  modern  society  the  normal  man  seems  to  be 
equipped  in  just  the  opposite  way.  That  twist  of  the 
hair  known  as  the  crown  of  the  head,  should  be  in  the 
middle  line,  or  very  close  to  it,  and  no  one  is  entitled 
to  more  than  one  crown.  When  it  is  found  shifted 
off  well  to  one  side,  or  is  doubled,  the  twist  becomes 
a  stigma.  Art  and  fashion  permit  one  to  tip  the  hat 
slightly  to  the  side,  but  nature  orders  that  we  wear 
our  crown  in  no  jaunty  or  frolicsome  mode.  It  is  often 
thought  that  an  abundance  of  hair  signified  a  vigorous 
vitality,  but  this  is  not  strictly  the  case.     The  excessive 

1  Les  Empreintes  dfgitales,  Lyon,  1891. 
3  Fer6 :  La  Famille  neuropathique,  p.  281. 


December  15,  1894] 


MEDICAL  RECORD. 


741 


development  of  hair  on  the  body,  particularly  in  women, 
is  regarded  as  one  of  die  minor  stigmata  of  degeneration. 

My  remarks  would  be  both  incomplete  and  misunder 
stood  if  I  left  it  to  be  inferred  that  degeneracy,  in  its 
various  forms,  is  determined  by  bodily  marks  alone. 
There  are  two  other  classes  of  stigmata,  the  physiologi- 
cal and  the  mental.  Under  the  former,  we  include 
peculiar  defects  in  the  function  and  practical  working  of 
the  body ;  under  the  other  we  include  certain  mental 
characteristics.  The  degenerate  are  apt  to  have  an 
unstable  circulation  and  a  deficient  vitality  that  responds 
abnomally  to  stimulants  of  various  kinds.  Mentally  a 
peculiar  characteristic  is  a  tendency  to  morbid  fears,  in- 
trospection, idiosyncracies  in  taste,  and  impulsive  acts. 
These  and  many  other  of  the  stigmata  occur  in  the 
normal,  however,  and  I  do  not  propose  to  enter  a  branch 
of  the  subject  which  is  much  less  definitely  worked  out 
and  less  susceptible  of  demonstration. 

I  have  now  described  to  you  the  gradual  development 
of  a  science  of  human  measurement  out  of  the  cruder 
sciences  of  physiognomy,  temperament,  and  phrenol- 
ogy. 

The  metaposcopist  of  the  Greek  school  viewed  the 
body  and  detected  in  it  signs  of  some  dominant  quality. 
The  man  was  quick  and  irascible  like  the  dog,  or  slow 
and  sensuous  like  the  pig,  brave  and  forceful  like  the 
lion,  everyone  resembling  in  feature  or  character  some 
lower  animal.  The  medueval  artist  added  to  this  the 
science  of  divination  and  prophecy.  In  the  times  of 
Lavater  the  physiognomist  tried  to  interpret  from  the  atti- 
tude, the  complexion,  and  features,  the  various  complex 
elements  of  the  individual's  disposition. 

The  phrenologist  of  the  Gall  school  went  still  further, 
and  described  all  the  intellectual  and  moral  faculties, 
mapping  out  for  the  man  the  total  sum  of  his  capacities, 
his  aptitudes,  and  his  prospects  in  life. 

The  modern  student  of  the  human  frame  is  much  more 
modest  He  asserts  only  that  he  can  by  the  presence  of 
certain  stigmata  say  whether  the  individual  is  of  stable  and 
normal  organization,  or  if  he  belongs  to  that  class  which  I 
have  described  as  the  degenerate.  Nor  does  he  pretend 
to  do  this  in  all,  but  only  in  those  whose  defects  are  well- 
defined  and  reasonably  numerous.  Perhaps  every  one 
has  some  stigma  of  degeneration ;  but  at  least  five  out  of  a 
hundred  adults  have  many  and  striking  ones.  The  degree 
of  their  degeneracy  may  be  in  a  measure  decided,  but 
cannot  be  determined  by  anatomical  marks  alone.  And 
it  is  on  this  point  that  I  must  differ  from  the  Italian  crimi- 
nologists, who  claim  that  there  is  a  criminal,  an  insane,  a 
neuropathic  type. 

In  conclusion,  let  me  say  that  the  final  work  of  modern- 
ized physiognomy  will  not  be  to  fix  upon  human  beings  any 
stigma  which  marks  them  as  necessarily  useless,  defective, 
or  dangerous.  We  have  not  discovered  a  type  of  criminal 
man,  or  of  the  insane  man,  or  epileptic  or  neurotic  man. 
All  these  have  common  marks  which  show  simply  that 
they  belong  to  the  same  somewhat  handicapped  family. 
Their  presence  in  an  individual  will  show  that  he  must 
be  especially  careful  in  educating  and  using  his  natural 
power.  The  discovery  of  degeneracy  throws  an  additional 
responsibility  upon  him,  for  there  are  few  so  bad  but  that 
with  a  proper  environment  they  can  get  along  successfully 
in  life. 

There  may  be  some  born  criminals,  but  they  are  very 
few ;  most  are  simply  persons  of  degenerate  type  who  fail 
to  husband  properly  the  endowments  they  possess.  We 
do  not  excuse  the  cripple  who  attempts  to  become  a 
sprinter,  nor  should  we  excuse  the  morally  defective  who 
indulges  in  debasing  habits  and  low  temptations. 

All  modern  studies  in  the  lines  I  am  exploiting  seem  to 
show  that  man  must  be  more  than  ever  careful  of  his  edu- 
cation, his  training,  and  his  surroundings,  and  of  using 
all  possible  moral  and  spiritual  agencies  to  strengthen  his 
defects  and  make  more  stable  his  powers.  The  future  of 
the  degenerate  depends  enormously  upon  these  factors, 
and  his  responsibility  lies  in  his  following  that  line  of 
life  which  is  right  for  him.    By  this  means  one  can  ren- 


der many  defects  harmless,  and  make  the  unstable  almost 
as  firm  in  judgment  and  healthful  in  body  as  the  happy 
possessors  of  perfectly  balanced  organizations. 

If  I  have  succeeded  in  showing  that  this  is  to  be  the 
end  and  teaching  of  modernized  physiognomy,  and  shall 
have  aroused  your  interest  in  its  progress,  my  object  will 
be  accomplished  to-night. 


THE    PRESENT    STATUS    OF    THE    SPECIFIC 
TREATMENT  OF  DIPHTHERIA. 

Bv  PROFESSOR  EDWIN  KLEBS.  M.D., 

ASHEVILLV,  N.  C. 
FOBMEftLY  OF  THE  UNIVERSITY  CF  ZURICH. 

Upon  my  recent  arrival  in  this  country  I  found  the  great- 
est interest  manifested,  both  in  professional  circles  and 
by  the  laity,  on  the  subject  of  diphtheria,  and  the  greatest 
expectations  seemed  to  prevail  on  all  sides  from  Behr- 
ing's  diphtheria  antitoxin  as  a  practically  unfailing  rem- 
edy for  the  rapid  cure  of  that  disease. 

The  reliable  information  which  has  reached  the  pro- 
fession in  this  country  from  Germany  being  compara- 
tively meagre,  and  coming,  as  I  did,  directly  from  there, 
and  having  through  previous  and  more  recent  labors  been 
intimately  connected  and  interested  in  the  subject,  I  was 
naturally  interrogated  on  all  sides  as  to  my  views,  and 
especially  so  by  Dr.  Shrady,  the  editor  of  this  journal, 
upon  whose  request  I  am  pleased  to  state  them  herewith 
for  publication. 

The  use  of  pathogenic  bacteria  for  the  production  of 
curative  remedies  may  be  in  two  directions,  and  for  two 
purposes,  first,  by  using  their  own  secretion  products 
against  them  and  for  their  destruction  (the  possibility  of 
which  is  apparent  in  the  dying  out  of  artificial  cultures 
long  before  the  nutrient  material  is  exhausted),  and 
secondly,  by  using  these  organisms  for  the  production  of 
immunity  by  their  direct  introduction  into  the  blood  of 
the  animal. 

In  the  first  place,  we  will  have  to  produce  the  curative 
remedy  from  the  culture  fluids ;  in  the  second,  from  the 
fluids  of  animals  in  whom  artificial  immunity  has  been 
produced.  The  question  arises,  "Which  is  the  surest 
and  easiest  method  ? "  The  degree  of  immunity  differs 
materially  in  the  various  diseases  due  to  specific  disease- 
germs  ;  it  is,  for  instance,  very  great  and  long  lasting  in 
variola,  very  small  and  of  short  duration  in  diphtheria, 
and  entirely  wanting  in  pneumonia. 

The  second  method  adopted  by  Behring,  to  use  the 
serum  of  animals  in  which  immunity  has  beea.  produced, 
can  therefore  only  be  followed  for  the  cure  of  diseases 
which  secure  at  least  a  moderate  degree  of  immunity  to 
persons  having  recovered  from  them,  and  if  we  accept 
the  results  of  experiments  upon  guinea-pigs  as  applying 
also  to  man,  diphtheria  belongs  to  this  class. 

In  this  connection  the  clinical  experience  must  not  be 
overlooked,  that  man  may  acquire  diphtheria  again, 
after  a  short  period  from  the  time  at  winch  all  evidence 
of  the  previous  disease  had  entirely  disappeared.  I  have 
lately  been  able  to  report  several  such  cases,1  while  the 
presence,  for  some  time,  of  virulent  diphtheria  bacilli, 
especially  in  the  nose,  after  recovery  from  the  disease, 
and  without  the  production  of  membranes,  or  of  gen- 
eral symptoms,  speaks,  nevertheless,  for  the  production 
of  at  least  temporary  immunity  in  man  also.  However 
this  may  be,  Behring  certainly  is  entitled  to  credit  for 
having  shown  that  a  great  degree  of  immunity  from 
diphtheria  can  be  obtained  in  animals  by  the  injections 
of  increasing  large  quantities  of  virulent  diphtheria  cult- 
ures into  their  blood. 

According  to  the  results  obtained  in  Europe,  the 
serum  from  such  animals  has  certainly  a  high  degree  of 
curative  property,  since  by  its  subcutaneous  injections  all 
fresh  and  light  cases  have  been  uniformly  cured,  and  the 
best  series  of  reports  of  all  cases  (severe  and  light,  in- 

>  Wiener  Med.  Wochenschrift,  Nos.  31-53,  1894. 


742 


MEDICAL   RECORD. 


[December  15,  1894 


eluding  tracheotomy  cases)  have  reached  as  high  as 
eighty- eight  per  cent,  of  recoveries. 

Some  observers,  as  for  instance,  Hahn,  of  the  Fried- 
richshain  Hospital  in  Berlin,  have  expressed  themselves 
more  doubtful  as  to  their  experience,  and  it  is  probable 
that  the  variability  in  degree  of  individual  cases  caused 
the  difference  in  the  results  obtained.  However,  upon 
these  less  favorable  reports  the  injected  quantities  were 
increased  to  100  c.c.  (a  little  over  three  fluid  ounces), 
especially  by  Ehrlich,  and  apparently  with  good  re- 
sults. 

To  come  to  an  understanding,  two  questions  will  have 
to  be  answered:  1st.  Are  there  no  dangers  connected 
with  the  use  of  Behring's  serum  ?  2d.  Cannot  the  same 
results  be  obtained  in  an  easier  and  safer  way? 

As  to  the  first  question,  the  exponents  of  the  serum 
treatment  accept  it  as  a  settled  fact  that  no  harm  can 
come  from  its  use ;  and  so  far  as  their  experiments  upon 
animals  show,  they  are  entitled  to  this  belief  But  that 
it  is  also  true  as  to  man  can  by  no  means  be  accepted  as 
proven,  if  we  will  only  remember  that  the  very  small 
quantities  of  organic  matter  which  we  inoculate  in  vac- 
cinating against  small-pox  have  undoubtedly  been  the 
means  of  transmission  of  human  diseases,  especially  syph- 
ilis and  tuberculosis.  Without,  in  the  remotest  sense, 
affiliating  with  the  opponents  to  vaccination,  who,  on  ac- 
count of  occasional  harm,  would  throw  away  the  valuable 
and  life-saving  discovery  of  Jenner,  I  recognize  never- 
theless the  danger  which  experience  shows  to  exist,  and 
believe  that  by  abandoning  human  vaccine  matter  for 
animal  lymph  the  profession  took  an  important  step  for 
the  prevention  of  incidental  infection.  But  even  bovine 
vaccine  matter  is  not  absolutely  safe,  since  we  have  no 
guarantee  of  the  absolutely  perfect  health  of  the  animal. 
For  instance,  calves  are  frequently  found  to  suffer  from 
tuberculosis,  without  recognizable  symptoms,  and  noth- 
ing short  of  the  killing  of  the  calves  and  painstaking  au- 
topsies, as  I  inaugurated  in  Austria,  before  the  vaccine 
matter  derived  from  them  is  used,  can  be  considered  as 
having  met  all  the  precautions  necessary,  and  to  which 
persons,  espscially  under  compulsory  vaccination,  would 
seem  to  be  entitled.  If,  however,  such  precautions  be- 
come a  duty  in  vaccination,  where  only  the  minutest 
quantity  of  organic  matter  is  inoculated,  how  much  more 
is  it  necessary  to  look  to  the  absolutely  perfect  health  of 
animals  from  which  we  derive  serum  for  the  treatment  of 
disease,  and  of  which  it  is  proposed  to  inject  100  c.c.  for 
the  cure  of  diphtheria  ? 

It  is,  indeed,  well  known  that  in  the  horse,  which  is 
especially  made  use  of  for  obtaining  the  serum,  there 
may  exist  latent  diseases  of  infectious  character,  for  in- 
stance a  chronic  form  of  glanders  may  be  confined  for  a 
long  time  to  the  cavities  of  the  head  and  nose,  without 
occasioning  any  discharge  whatever,  and  with  but  little 
or  no  glandular  swelling,  but  which,  nevertheless,  may  be 
a  source  for  fatal  infection.  Only  the  most  careful  post- 
mortem examinations  can  guard  us  against  the  occasional 
use  of  apparently  healthy  but  nevertheless  diseased  ani- 
mals, and  the  killing  and  examination  of  these  animals  is 
necessary  before  their  serum  previously  obtained  is  used 
for  therapeutic  purposes.  Nothing  has  as  yet  been  said 
or  published  on  this  aspect  of  the  serum  treatment,  but 
it  should  not  be  ignored  because  of  the  value  of  the  ani- 
mals and  the  long  time  necessary  before  they  have  been 
brought  to  a  state  of  sufficient  immunity ;  and  since  it  is 
only  a  question  of  money  the  State  should  step  in  and 
take  the  matter  under  its  supervision  and  control. 

The  exponents  and  followers  of  the  serum  treatment  will 
naturally  reply  that  so  far  no  harm  has  followed  its  appli- 
cation. It  is,  however,  not  at  ail  shown  that  this  dan- 
ger has  been  sufficiently  appreciated.  Of  the  severer 
cases  twenty  to  thirty  per  cent,  have  terminated  fatally 
after  applying  the  treatment,  and  who  can  maintain  that 
all  the  fetal  cases  were  really  due  to  the  disease? 

I  willingly  admit  that  the  dangers  spoken  of  may  be 
diminished  to  a  small  degree  by  the  painstaking  selection 
of  animals,  but  under  all  circumstances  the  obtaining  of 


serum  for  therapeutic  purposes  will  ever  be  a  very  costly 
method. 

This  leads  me  to  the  second  question.  Can  we  obtain 
a  bacterial  curative  substance  for  diphtheria  in  an  easier 
manner,  which  is  safer  and  cheaper  while  equally  effec- 
tive ?  I  have  for  a  long  time  followed  the  thought  that 
pathogenic  bacteria,  the  same  as  all  other  living  organ- 
isms, secrete  substances  which  are  poisonous  to  them- 
selves, of  which  the  retention  of  excrementitious  sab- 
stances  from  the  kidney  and  liver  of  man  is  a  familiar 
instance.  In  the  case  of  pathogenic  bacteria  this  is  also 
manifest  from  the  fact  that  artificial  cultures  die  out  long 
before  they  have  exhausted  the  nutrient  substances  in  their 
culture  media.  This  principle  governed  me  in  the  use 
of  tuberculocidin  and  antiphthuan  for  the  cure  of  tuber- 
culosis, and  also  of  antidiphtherine,  which  latter  I  have 
proposed  for  the  cure  of  diphtheria.  That  this  principle 
is  correct  becomes  further  evident  from  a  number  of 
quantitative  experiments  made  by  me  with  tubercle 
bacilli. 

In  the  beginning  of  July  of  this  year  I  prepared  three 
litre  cultures,  containing  500  c.c.  each,  of  old  and  new 
culture  fluids  (of  sterilized  glycerine,  pepton,  and  meat 
extract),  and  on  July  14th  I  inoculated  each  with  equal 
quantities  of  tubercle  bacilli,  from  the  same  source.  The 
results  on  August  a  ad  were  as  follows : 

No.  1  contained  only  old  culture  fluids ;  in  this  culture 
the  tubercle  bacilli  had  grown  but  little,  did  not  cover 
the  surface,  and  their  weight,  after  having  been  dried  at 
280  to  300  C,  was  only  0.046  gm. 

No.  2  contained  300  c.c.  old,  and  200  c.c  new  culture 
fluid ;  the  tubercle  bacilli  had  grown  better,  covered  the 
surface  more,  but  only  in  a  very  thin  layer,  without  at- 
tachment to  the  side  of  the  flask ;  their  weight,  determined 
in  the  same  manner,  was  0.443  &&- 

No.  3  contained  200  c.c.  old,  and  300  c.c.  new  cult- 
ure fluid ;  the  culture  approached  more  to  a  normal  one, 
covered  the  entire  surface,  and  in  a  few  points  attached 
itself  to  the  side  of  the  flask;  the  weight  of  tubercle  ba- 
cilli, determined  in  the  same  manner,  was  2.586  gm. 

The  latter  is  about  half,  or  slightly  over,  the  weight  of 
the  tubercle  bacilli  from  a  normal  culture  of  equal  size 
and  kind. 

These  experiments  show  that  considerable  quantities 
of  toxines  must  be  formed  before  the  growth  of  the 
pathogenic  germs  is  entirely  prevented ;  only  upon  en- 
tirely ripe  cultures  is  their  growth  impossible.  But  these 
experiments  show  further  that  the  growths  in  my  ex- 
periments have  by  no  means  reached  the  weight  which 
would  correspond  with  the  new  culture  fluid  which  was 
added  to  the  old. 

If  we  take  round  figures,  500  c.c.  of  new  culture 
should  furnish  in  a  certain  time  5  gm.  dried  tubercle 
bacilli;  300  c.c.  3  gm.  and  200  cc.  2  gm.  The  ex- 
periment shows,  however,  that  the  weight  fell  short  in 
all.  In  No.  1,  of  exclusively  old  culture  fluid,  only  the 
one  hundredth  part  was  obtained ;  in  No.  2,  instead  of 
3  gm.  I  obtained  only  0.45  gm.;  in  No.  3,  instead  of  3 
gm.  only  2.5,  showing  that  the  presence  of  toxines  in 
the  old  culture  fluids  exert  a  damaging  influence  upon 
growing  tubercle  bacilli. 

Quite  similar  have  been  experiments  with  cultures  of 
other  pathogenic  germs,  and  we  can  accept  as  a  law 
that  the  diminished  growth  and  the  dying  out  of  bacteria 
depend  upon  accumulation  of  their  secretions.  The  lat- 
ter substances,  which  belong  partly  to  the  albuminoid 
group,  are  partially  toxic,  and  I  distinguish  therefore  soz- 
albumin  and  toxalbumin,  which  must  be  separated  from 
each  other. 

The  soz-albumin  from  tubercle  bacilli  cultures  is  repre- 
sented in  antiphthisin,  and  of  diphtheria  bacilli  cultures 
in  antidiphtherine.  The  cost  of  production  of  the  latter 
depends  entirely  upon  the  facilities  for  large  or  smaller 
quantities,  and  it  will  be  my  endeavor  to  produce  it  so 
cheaply  that  it  will  be  within  the  reach  of  the  poorest 
family  in  the  land,  as  soon  as  I  shall  have  demonstrated 
its  clinical  value.      To  this  end  I  expect  the  arrival  of  a 


December  15,  1894] 


MEDICAL    RECORD. 


743 


large  shipment  from  my  laboratory  in  Strassburg  about 
the  first  of  the  year,  and  it  is  my  purpose  to  then  furnish 
the  remedy  free  of  all  cost  for  the  purpose  of  making 
comparative  trials  of  its  value  with  that  of  the  serum  of 
Bearing.  For  present  comparison  I  have  at  my  disposal 
a  series  of  fifty- one  cases  treated  by  various  physicians  in 
Germany  with  antidiphtherine.  Of  these  fifty-one  cases 
seven,  or  13.7  per  cent.,  died,  and  forty-four,  or  86.27  per 
cent.,  recovered.  They  include  both  light  and  severe 
cases  and  such  where  tracheotomy  was  required. 

A  similar  series  of  cases  under  serum  treatment,  re- 
ported by  Ehrlich,  shows  13  3  per  cent,  of  mortality  and 
86.7  per  cent,  of  recoveries.  The  small  difference  may 
depend  upon  the  greater  number  of  tracheotomies  in  my 
cases.  As  to  the  results  in  the  latter  alone,  I  have  five 
deaths  in  eighteen  cases,  or  a  mortality  of  27. 7  per  cent., 
which  is  as  favorable  as  under  the  serum  treatment. 

I  have  thus  far  applied  the  antidiphtherine  only  lo- 
cally, believing  that  the  process  is  a  local  one  in  the  be- 
ginning ;  my  investigations  have  shown  me  that  the  diph- 
theria bacillus  is  chiefly  found  in  the  superficial  layers  of 
diphtheritic  membranes,  and,  as  the  latter  become  older, 
in  the  advancing  edges  of  its  formation  the  bacillus  may 
be  demonstrated,  when  none  will  be  found  in  the  central 
portions.  The  application  of  antidiphtherine  has  been 
free  from  all  unfavorable  effects  whatever,  and  upon  its 
early,  thorough,  local  use  depend  its  prompt  and  curative 
effects.  Upon  a  suitable  cotton-wrapped  probe  the  rem- 
edy is  applied  upon  the  diphtheritic  patch,  the  latter 
having  first  been  cleansed  with  dry  cotton — gently  press- 
ing and  rubbing  the  soaked  cotton  upon  the  diphtheritic 
and  suspected  patches,  and  leaving  it  in  contact  as  long 
as  the  patient  can  comfortably  hold  it.  We  repeat  this 
two  or  three  times,  and  then  swab  the  entire  pharynx 
and  fauces;  great  gentleness,  and  at  the  same  time  thor- 
oughness, are  essential,  especially  with  very  young  chil- 
dren. In  the  latter  we  may,  however,  touch  the  greater 
part  of  the  fauces  and  pharynx  with  the  cotton,  at  one 
time  holding  the  latter  in  a  forceps  with  which  we  may 
also  pass  upward  behind  the  velum  and  naso  pharynx  if 
we  suspect  trouble  there.  If  none  of  the  patches  have 
been  omitted,  the  temperature  fells  in  the  course  of  three 
to  five  hours,  and  a  sense  of  well-being  returns.  If  the 
fever  does  not  subside  the  application  must  be  repeated, 
and  new  patches  be  looked  for.  In  their  absence  the 
application  mast  be  made  in  the  nose  and  naso-pharynx 
also,  where  patches  may  be  hidden  from  recognition. 

A  new  rise  of  temperature  indicates  a  new  develop- 
ment either  upon  the  old  or  a  new  focus,  and  the  appli- 
cations must  thus  be  repeated  more  or  less  frequently  ac- 
cording to  the  course  the  cases  pursue.  Under  the  most 
favorable  course  two  or  three  applications  should  be  made 
daily  until  all  evidence  of  disease  in  the  throat  has  disap- 
peared. The  membrane  soon  loosens  and  is  cast  off, 
leaving  a  smooth,  shining  surface,  covered  with  epithe- 
lium, a  very  important  result,  as  thus  streptococcus  in- 
fection is  prevented. 

The  remedy  may  also  be  used  subcutaneously  or  per 
rectum,  especially  in  severe  and  older  cases.  Beginning 
with  -^  c.c,  and  increasing  by  -^  c.c.  every  hour,  we 
reach  1  c.c.  in  nine  hours,  after  which  the  same  quantity 
is  repeated  two  or  three  times  a  day,  or  still  increased,  if 
necessary.  Animals  bear  the  subcutaneous  use  without 
any  unfavorable  effect.  For  the  present  in  the  human 
subject  I  recommend  that  the  action  of  the  heart  be 
carefully  observed  during  the  subcutaneous  use  of  this 
preparation. 


A  Bew  Medical  Fraud.— An  ingenious  swindler  is 
going  about  the  city,  collecting  money  from  poor  people 
under  the  pretence  that  he  is  an  agent  of  the  Board  of 
Health.  He  gives  it  out  that  a  new  law  compels  the 
payment  of  $2  a  year  to  the  Board,  of  which  he  is  the 
collector,  in  return  for  which  the  physicians  of  the  Board 
will  attend  the  family  free  of  charge. 


THE  "  OYSTER  EPIDEMIC  "  OF  TYPHOID  FE- 
VER AT  WESLEYAN  UNIVERSITY. 

By  H.  W.   CONN,    Ph.D., 

nOFBSSOR  OF  BIOLOGY,  WE  SLR  Y  AN  UNIVKBS1TY,   M1DDLBTOWN,  CONN. 

While  it  has  been  for  some  time  suspected  that  raw  oys- 
ters may  be  a  possible  means  of  the  distribution  of  geim 
diseases,  there  have  been  no  cases  where  the  theory  has 
been  positively  demonstrated.  The  recent  outbreak  of 
typhoid  at  Wesleyan  University  is,  in  this  respect,  there- 
fore, so  unique  as  to  be  of  especial  interest,  and  for  this 
reason  the  results  of  the  investigation  as  to  the  cause  of 
this  outbreak  are  given  below  in  some  detail. 

The  history  of  the  epidemic  was  as  follows :  About 
October  20th  there  began  to  appear  among  the  students  a 
number  of  cases  of  mild  fever,  which  were  for  several  days 
not  regarded  as  serious.  After  about  a  week,  however, 
one  or  two  of  them  developed  into  typical  typhoid  fever, 
and  several  others  were  suspected  of  being  of  the  same 
nature.  For  a  week  and  a  half  following  October  20th, 
new  cases  appeared  somewhat  rapidly,  and  by  November 
1st  there  had  appeared  among  the  members  of  the  col- 
lege about  twenty-three  cases  of  fever  of  more  or  less 
prominent  typhoid  character.  After  November  1st  the 
number  of  new  cases  diminished,  although  two  appeared 
on  November  ad,  one  on  November  5th,  and  one  as 
late  as  November  9th.  Subsequent  to  that  period  no 
new  cases  have  developed.  There  have  been  among  the 
students  about  twenty  six  cases  of  fever  which  have  been, 
with  more  or  less  reason,  regarded  as  typhoid.  Of  these 
twenty- three  have  been  pronounced  typhoid  by  the  phy- 
sicians in  charge,  while  the  others  are  of  such  a  slight 
nature  and  have  so  few  typhoid  symptoms,  as  to  make  it 
at  least  doubtful  whether  they  were  really  typhoid  fever. 
Of  the  cases  of  undoubted  typhoid,  thirteen  have  been 
very  serious,  and  the  others  not  very  serious.  Four  deaths 
have  occurred,  and  at  the  time  of  writing  there  are  one 
or  two  other  patients  in  a  critical  condition.  It  will  be 
noticed  from  these  facts  that  the  outbreak  of  typhoid 
fever  in  college  began  about  October  20th,  and  the  last 
case  appeared  about  November  9th. 

As  soon  as  the  serious  nature  of  the  disease  was  recog- 
nized, an  investigation  as  to  its  cause  was  begun.  Of 
course,  at  that  time  it  was  not  known  that  the  disease 
would  be  limited  to  the  dates  above  mentioned,  and  it 
was  regarded  as  possible  that  there  was  in  college  a  con- 
stant source  of  infection.  The  students  that  were  sick 
were  found  to  room  in  all  of  the  college  buildings,  and 
also  in  several  houses  in  town.  Moreover,  it  was 
seen  that  they  did  not  board  at  the  same  boarding-place, 
and  there  appeared  at  first,  therefore,  to  be  no  connec- 
tion between  them  except  the  college  campus.  The  first 
object  of  suspicion  was  the  water  from  two  wells  at  the 
back  of  the  college  buildings,  which  was  used  occasion- 
ally by  the  students  of  the  college  for  drinking  purposes. 
On  this  suspicion  the  use  of  the  water  was  immediately 
stopped,  and  an  examination  of  the  wells  was  made. 
Chemical  examination  showed  in  one  of  the  wells  an  ex- 
ceptionally large  amount  of  albuminoid  ammonia.  The 
examination  was  made  immediately  after  a  heavy  rain 
following  a  long  drought,  which  might  possibly  have  ac- 
counted for  this.  A  bacteriological  examination  was  set 
on  foot  according  to  the  method  of  Professor  Vaughn. 
Bouillon  cultures  from  the  water  of  each  well  were 
made  and  cultivated  for  two  days  in  a  culture  oven. 
Then  20  c.c.  of  the  culture  was  inoculated  into  the 
abdominal  cavity  of  white  rats.  The  white  rats,  how- 
ever, were  entirely  unaffected  by  the  treatment,  indi- 
cating plainly  that  pathogenic  germs  of  a  typhoid  nat- 
ure could  not  have  been  present.  Moreover,  a  little 
inquiry  soon  showed  that  the  wells  could  not  have  been 
the  cause  of  the  trouble.  In  the  first  place  several  of  the 
students  who  were  sick  had  certainly  not  drank  from  either 
of  the  wells.  Secondly,  the  wells  were  used  almost  as 
much  by  certain  young  people  from  the  town  as  by  the 
students  themselves,  and  there  was  no  corresponding  out- 
break of  typhoid  in  the  city.     In  fact,  Middletown,  at 


744 


MEDICAL  RECORD. 


[December  15,  1894 


the  time,  proved  exceptionally  free  from  all  kinds  of 
fevers.  These  facts  taken  together,  made  it  necessary  to 
exclude  the  wells  from  the  possible  sources  of  infection. 

It  was  noticed  at  the  outset  that  the  ladies  of  the  college, 
about  fifty  in  number,  were  exempted  from  the  disease. 
This,  of  course,  indicated  that  the  cause  of  the  infec- 
tion could  not  have  been  in  any  unsanitary  condition  con- 
nected with  the  public  college  buildings  in  general,  but 
must  have  been  some  source  of  infection  to  which  the 
young  men  were  exposed,  and  not  the  young  ladies. 
After  carefully  looking  over  the  facts  it  was  further  found, 
that  all  of  the  cases  of  sickness,  with  three  exceptions,  oc- 
curred in  three  of  the  college  fraternities.  The  men  did 
not  all  room  in  the  fraternity  buildings,  though  most  of 
them  did  board  at  the  fraternity  club  houses.  This  lo- 
calizing of  the  disease  to  three  fraternities  proved  the  first 
usable  point  of  departure  in  the  investigation. 

In  the  college  there  are  seven  fraternities,  and  most  of 
the  college  students  board  at  the  fraternity  clubs.  In  the 
three  fraternities  afflicted  there  were  about  one  hundred 
students,  and  among  the  one  hundred  students,  as  above 
stated,  about  twenty- five  cases  of  typhoid  developed. 
This  is  seen  at  once  to  be  an  extremely  large  proportion. 
It  is  usually  supposed  that  some  ten  to  fifteen  per  cent, 
of  those  exposed  to  typhoid  take  the  disease,  and  here 
was  a  percentage  at  least  twice  that  proportion.  This 
large  percentage  indicated  at  once  that  there  must  have 
been  some  extremely  virulent  source  of  infection  to  which 
probably  every  member  of  the  fraternities  was  subjected. 
In  no  other  way  could  the  large  percentage  of  cases 
among  the  students  be  accounted  for. 

In  the  attempt  to  locate  the  source  of  the  trouble  in 
connection  with  the  three  fraternities,  however,  every 
source  of  possible  contagion  was  investigated.  The 
plumbing  was  examined,  and  though  found  to  be  de- 
fective in  at  least  one  case,  in  the  other  houses  it  was  in 
first-class  condition.  It  was  hardly  possible  to  accuse 
the  plumbing,  however,  inasmuch  as  the  three  dubs  af- 
flicted were  situated  at  a  distance  of  half  a  mile  from 
each  other  and  were  connected  with  different  sewers. 
The  probability  that  these  three  houses  should  have  been 
defective  in  their  plumbing  at  the  same  time  was  very  re- 
mote, and  their  connection  with  different  sewers,  together 
with  the  absence  of  typhoid  in  the  city,  made  it  impos- 
sible to  accuse  the  plumbing.  The  possibility  of  trans- 
ference of  the  disease  from  house  to  house  was  also  con- 
sidered, an  attempt  being  made  to  find  some  early  case 
which  could  possibly  have  been  a  source  of  infection  to 
the  other  houses.  But  this  proved  futile.  There  were 
no  early  cases,  for  almost  at  once,  upon  October  20th, 
two  or  three  cases  developed  simultaneously,  and,  of 
course,  this  made  it  impossible  to  explain  the  epidemic 
by  personal  contagion.  It  was  found,  moreover,  that 
the  students  who  were  taken  with  the  disease  in  many 
cases  had  no  connection  whatsoever  with  the  other  fra- 
ternity houses,  either  through  their  room  mates  or  other- 
wise. Another  source  of  possible  infection  was  suggested 
in  a  lot  of  new  football  suits  which  had  recently  been 
purchased,  and  which  had  been  thought  to  have  given 
rise  to  one  or  two  cases  of  blood-poisoning.  Inquiry, 
however,  soon  showed  that  most  of  the  students  who 
were  sick  had  nothing  to  do  with  the  football  suits,  and 
they  were  of  necessity  ruled  out. 

Naturally,  one  of  the  first  objects  of  suspicion,  after  the 
disease  had  been  located  among  the  members  of  the 
three  fraternities,  was  the  table  of  the  clubs.  An  exam- 
ination was  immediately  made  into  the  sources  of  sup- 
ply of  these  three  fraternities.  All  of  them  used  the  city 
water,  which,  of  course,  made  it  impossible  to  accuse 
the  water  as  a  source  of  the  typhoid,  there  being  no  corre- 
sponding typhoid  fever  in  town.  The  milk- supply  of 
the  three  fraternities  was  also  ruled  out  by  several  facts. 
The  three  fraternities  were  supplied  by  two  different 
milkmen,  and  each  of  these  milkmen  supplied  one  or 
more  of  the  other  fraternities  in  college,  as  well  as  a 
large  number  of  customers  in  town.  Moreover,  upon  in- 
quiry it  was  learned  that  these  milkmen  had  not  ex- 


changed milk  with  each  other,  and  that  they  lived  at  a  dis- 
tance of  several  miles  from  each  other  outside  of  the  city. 
No  cases  of  typhoid  fever  could  be  located  in  or  near 
either  of  the  milk-farms,  as  having  occurred  within  the 
last  six  months.  It  was,  therefore,  impossible  to  accuse 
the  milk.  In  the  same  way  all  the  other  articles  of  food 
used  by  the  fraternities  were  investigated,  without  success. 
The  three  fraternities  did  not  have  the  same  grocer,  nor 
the  same  butcher,  nor  the  same  butter  supply,  nor  did 
they  obtain  fruits  from  the  same  sources ;  and  whenever, 
in  regard  to  any  article  of  food,  it  was  found  that  there 
was  a  point  of  likeness  between  the  three  fraternities,  it 
was  found  at  once  that  the  other  fraternities  in  college 
shared  with  them  in  having  the  same  source  of  supply. 
After  carefully  inquiring  into  every  article  of  diet  used 
on  the  ordinary  table,  it  was  found  necessary  to  exclude 
the  table  as  a  source  of  infection.  The  attempt  was 
then  made  to  find  some  special,  unusual  article  of  food 
that  had  been  used  during  the  fall  by  the  three  fraterni- 
ties, but  it  was  impossible  to  do  so. 

When  the  dates  of  the  outbreak  above  given  are  con- 
sidered, it  will  be  seen  that  they  have  themselves  almost 
conclusively  pointed  to  one  single  source  of  infection 
that  had  occurred  in  these  three  fraternities  at  a  date 
something  like  two  weeks  earlier  than  October  20th. 
The  period  of  incubation  of  typhoid  fever  is  known  to  be 
from  about  eight  days  to  about  twenty  eight  days,  and  all 
of  the  cases  came  in  such  close  connection  with  each  other 
as  to  indicate  almost  beyond  question  that  they  were  due 
to  one  single  source  of  infection,  that  occurred  within  two 
weeks  prior  to  October  20th.  On  October  12th  all  of 
the  fraternities  in  college  held  their  annual  initiation, 
followed  by  an  initiation  supper,  and  suspicion  was  soon 
thrown  upon  these  suppers.  The  date  of  the  suppers 
was  exactly  such  as  would  be  needed  to  explain  the  out- 
break, and  as  soon  as  it  appeared  that  new  cases  dimin- 
ished after  November  1st,  these  suppers  became  the  most 
probable  source  of  infection.  When  the  initiation  sup- 
pers were  taken  into  consideration,  one  of  the  three  ex- 
ceptions above  noticed  disappeared,  because  one  of  the 
men  who  did  not  belong  to  the  college  fraternities  had  at- 
tended one  of  the  three  initiation  suppers.  An  examina- 
tion of  the  bills  of  fere  at  the  suppers  in  question  was 
therefore  instituted.  It  was  found  that  nearly  every 
article  of  food  must  be  excluded,  on  the  same  grounds  u& 
the  articles  of  food  at  their  ordinary  table.  Their  milk, 
their  water,  their  ice,  their  ice-cream,  their  fruits,  their 
celery,  and  in  fact,  nearly  all  other  articles  of  diet,  they 
either  did  not  obtain  from  the  same  source,  or  obtained 
them  from  a  source  which  supplied  every  other  one  of  the 
seven  college  fraternities  as  well  as  the  people  in  town. 
There  was  found,  indeed,  to  be  but  four  points  of  union 
between  the  three  fraternities.  One  was  the  celery  used 
in  the  salad,  a  second  a  small  amount  of  fruit,  a  third  some 
ham,  and  the  fourth  the  oysters  which  were  eaten.  The 
celery,  the  ham,  and  fruit,  however,  were  from  sources 
which  supplied  other  clubs  and  a  large  part  of  the  towns- 
people, and  could,  therefore,  not  have  been  the  cause  of 
the  special  infection  confined  to  these  three  fraternities. 

As  soon,  however,  as  it  was  found  that  the  three  frater- 
nities each  ate  raw  oysters  from  the  same  oyster  dealer, 
the  problems  began,  one  after  the  other,  to  be  solved.  It 
was  found  that  none  of  the  other  four  fraternities  ate  these 
raw  oysters.  Two  of  them  ate  no  oysters,  a  third  ate 
oysters  which,  however,  had  been  cooked,  and  the  fourth 
obtained  oysters  from  an  entirely  different  source.  Nor 
could  it  be  learned  that  the  lot  of  oysters  had  been  used 
raw  to  any  extent  among  the  people  in  town,  most  peo- 
ple cooking  their  oysters.  Another  one  of  the  above- 
mentioned  exceptions  was  also  explained  at  once,  because 
the  student,  upon  being  questioned,  stated  that  about  the 
time  of  the  initiation  suppers  he  had  eaten  of  the  raw  oys- 
ters in  the  store  of  the  oyster  dealer.  The  oysters  in  ques- 
tion were  served  at  each  fraternity  on  the  half  shell,  at  the 
beginning  of  the  supper,  and  it  was,  therefore,  almost  cer- 
tain that  nearly  every  person  who  attended  the  banquet 
ate  of  them.    Correspondence  and  questioning,  however, 


December  15,  1894] 


MEDICAL   RECORD. 


745 


were  immediately  instituted,  which  resulted  in  tracing  in 
this  way  a  connection  between  every  student  who  was 
suffering  from  typhoid  and  these  oysters,  with  one  doubt- 
ful exception  of  a  student  who  has  not  yet  been  personally 
questioned.  It  was  learned  also  that  there  were  in  at- 
tendance upon  these  three  suppers,  in  addition  to  the 
students  in  the  college,  a  considerable  number  of  alumni 
from  out  of  town,  and  five  students  from  Yale  College. 
Letters  were  immediately  written,  therefore,  to  all  of 
these  persons  to  learn  if  they  had  eaten  of  the  raw 
oysters,  and  whether  they  had  suffered  from  any  febrile 
disturbances.  -  It  must  be  remembered  that  the  alumni 
were,  as  a  rule,  considerably  older  than  the  students,  and 
it  was,  therefore,  to  be  expected  that  the  alumni  would 
be  more  likely  to  be  exempt  from  the  disease  than  the 
students  themselves.  From  twenty  responses  received 
from  the  alumni  it  was  found,  however,  that  there  were 
two  cases  of  genuine  typhoid  fever,  which  had  developed 
simultaneously  with  those  in  the  college,  and  that  there 
were  three  other  cases  of  sickness  which  had  not  been  re- 
garded as  serious.  These  might  or  might  not  have  had 
some  connection  with  the  banquet  in  question,  though  it 
is  quite  doubtful.  Of  the  five  students  in  Yale  College, 
two  were  taken  with  typhoid  symptoms  at  just  four 
weeks  after  the  banquet.  Both  of  them  developed  into 
severe  cases  of  typhoid  fever.  In  regard  to  these  two 
cases  at  Yale,  it  should,  however,  be  noted  that  they 
appeared  quite  late,  indeed  four  weeks  after  the  sup- 
per had  been  held;  and  although  four  weeks  is  not 
too  long  a  period  of  incubation  to  be  possible,  still  it 
is  unusual.  They  developed,  however,  at  exactly  the 
period  that  the  last  case  in  Wesleyan  made  its  appear- 
ance. It  is  also  a  fact  that  there  were  two  other  cases  of 
typhoid  fever  in  Yale  College  that  certainly  had  no  con- 
nection with  these  banquets  or  these  oysters,  and  it  is  there- 
fore not  certain  that  these  two  cases  are  to  be  attributed 
to  these  banquets.  It  is,  however,  a  remarkable  coinci- 
dence that  of  four  cases  of  typhoid  at  Yale  two  should 
have  been  those  who  attended  the  banquet  at  Middle- 
town  and  ate  of  the  oysters  in  question,  and  that  these 
two  should  have  developed  within  the  four  weeks  follow- 
ing the  banquet.  It  is  therefore  at  least  probable  that 
these  cases  were  due  to  the  same  cause. 

It  will  be  seen  that,  as  soon  as  the  oysters  were  accused 
of  the  trouble  two  of  the  three  cases  above  mentioned  of 
typhoid  occurring  outside  the  fraternities,  were  at  once 
explained.  The  fourth  case  remained  isolated.  This 
case  was  a  member  of  the  faculty,  who  had  not  attended 
either  of  the  banquets.  He  was  taken  with  a  slight  fever, 
and  inasmuch  as  it  appeared  at  about  the  same  time  with 
the  students,  it  was  regarded  as  identical  with  the  other 
cases.  It  proved,  however,  a  very  slight  fever,  lasting 
only  a  few  days,  and  it  is  therefore  at  least  doubtful 
whether  it  was  typhoid.  Whether  this  person  ate  of  the 
raw  oysters  cannot  be  positively  determined.  It  is  a 
fact  that  raw  oysters  were  eaten  at  the  table  where  he 
boarded  at  about  the  time  of  the  banquet,  but  as  yet  no 
positive  connection  between  the  person  and  these  oysters 
has  been  made  out.  Whether,  therefore,  this  case  is  to 
be  regarded  as  an  isolated  case  of  fever  having  no  con- 
nection with  the  others  and  not  strictly  typhoid  fever,  or 
whether  it  is  a  fact  that  it  is  also  explained  by  some  con* 
nection  with  the  infected  oysters,  has  not  been  deter- 
mined. 

Inquiry  was  made  at  once  as  to  the  source  of  the 
oysters,  and  it  was  learned  that  while  they  had  grown  in 
the  deep  water  of  Long  Island  Sound,  they  had  been  de- 
posited in  the  mouth  of  a  fresh-water  creek  for  a  day  or 
more  to  freshen.  This  freshening,  as  is  well  known, 
consists  of  the  absorption  by  the  oysters  of  fresh  water 
which  causes  them  to  swell  up  and  become  plump. 
These  oysters  had  thus  been  "fattened"  before  being 
sent  to  Middletown.  Further  inquiry  showed  that,  with- 
in about  three  hundred  feet  of  the  place  where  they  had 
been  deposited,  was  the  outlet  of  a  private  sewer  coming 
from  a  house  wherein  were  two  cases  of  typhoid  fever. 
The  persons  in  question  were  a  lady  and  her  daughter. 


They  were  taken  sick  at  such  a  period  as  to  call  in  a 
physician  for  the  first  time  October  nth,  which,  of 
course,  means  that  the  disease  had  been  in  its  period  of 
incubation  for  probably  considerably  over  a  week  earlier. 
The  oysters  were  sent  to  Middletown  on  October  ioth, 
and  therefore  they  were  deposited  at  this  place  in  ex- 
actly the  time  to  receive  contamination  during  the  early 
days  of  these  two  cases  of  typhoid.  Of  those  two  cases 
one  proved  extremely  severe,  and  the  lady  died  on 
October  21st.  In  the  other  case,  the  fever,  after  running 
about  five  weeks,  disappeared  and  convalescence  set  in. 
It  is,  of  course,  very  easy  to  understand  that  the  typhoid 
germs  could  have  found  entrance  into  the  oysters  from 
this  source  of  contamination.  Now,  it  has  been  known 
for  some  time,  having  been  shown  by  Foster  and  Frey  tag, 
that  the  typhoid  germs  will  live  for  a  long  time  in  sea- 
water,  or  indeed,  in  a  concentrated  salt  solution.  Speci- 
mens of  the  oysters  from  the  creek,  however,  were  put  into 
the  hands  of  Dr.  Foote,  of  Yale  College,  who  soon  showed 
that  if  the  typhoid  germs  were  forced  in  between  the  two 
valves  of  the  shell  they  would  remain  alive  in  the  oyster 
for  a  time  sufficient  to  enable  the  oyster  to  be  carried  to 
Middletown  and  to  be  used  at  the  initiation  banquets. 
Whether  or  not  they  will  grow  and  multiply  in  oysters, 
has  not  yet  been  positively  determined. 

Shortly  after  the  oysters  had  been  placed  under  sus- 
picion, it  was  learned  that  there  were  at  Amherst  College 
several  cases  of  typhoid  fever.  Correspondence  was  in- 
stituted, which  resulted  in  showing  that  at  Amherst  there 
had  been  held  an  initiation  supper  on  the  night  of  Oc- 
tober 1 2  th.  Most  of  the  cases  of  typhoid  at  Amherst 
occurred  among  the  members  of  one  fraternity,  who,  as 
at  Wesleyan,  neither  roomed  nor  boarded  together. 
They,  however,  had  attended  the  initiation  supper  on 
October  12th,  had  eaten  of  raw  oysters  at  the  supper, 
and  inquiry  showed  that  these  raw  oysters  also  came  from 
the  same  place  as  the  Wesleyan  oysters,  and  had  been 
fattened  in  the  mouth  of  the  same  creek.  As  at  Wes- 
leyan, certain  wells  were  first  placed  under  suspicion,  but 
examination  showed  them  to  be  good.  While,  of  course, 
this  did  not  conclusively  demonstrate  that  the  cases  at 
Amherst  were  due  to  the  same  source  of  infection  as  that 
at  Wesleyan,  it  rendered  it  at  least  probable. 

The  facts  above  related,  it  will  be  seen,  point  with 
conclusive  force  to  the  oysters  as  the  cause  of  the  typhoid 
outbreak.  The  dates  of  the  outbreak,  October  20th  to 
November  8th,  plainly  point  to  one  source  of  infection 
about  October  12th.  The  fact  that  two  cases  of  genuine 
typhoid  developed  at  the  same  time  among  the  alumni, 
and  that  two  others  appeared  also  among  Yale  students, 
none  of  whom  have  had  connection  with  the  three  fraterni- 
ties later  than  the  initiation  supper,  or  before  that  time, 
plainly  demonstrates  the  initiation  supper  on  October 
1 2th  as  the  time  of  the  infection.  At  these  initiation 
suppers  only  one  article  of  food  or  drink  was  used  which 
was  not  used  by  the  other  fraternities  in  college  and  by 
the  people  in  town  in  general.  That  one  article  of  food, 
the  raw  oysters  (not  eaten  raw  by  people  in  town  in 
general),  was  learned  to  come  from  a  place  where  it  was 
certainly  subjected  to  a  probable  contamination  of 
typhoid  fever  from  two  severe  cases  of  the  disease.  The 
use  of  raw  oysters  from  the  same  locality  elsewhere,  has 
been  found,  at  least  in  one  case,  to  have  been  followed 
by  a  similar  outbreak  as  occurred  in  Wesleyan.  These 
facts  taken  together,  leave  no  possible  doubt  that  the 
Wesleyan  typhoid  fever  was  caused  by  the  oysters  in 
question. 

It  must  not,  however,  be  inferred  that  because  the  lot 
of  oysters  supplied  at  these  initiation  suppers  was  in- 
fected, therefore,  that  all  the  oysters  from  the  same  lo- 
cality would  be  thus  infected.  The  public  press  has  cer- 
tainly exaggerated  the  condition  of  affairs.  The  oysters 
from  the  same  locality  were  widely  used  in  Connecticut, 
and  doubtless  in  many  cases  have  been  eaten  uncooked. 
There  has  been,  it  is  true,  quite  a  little  typhoid  fever 
in  Connecticut  during  the  past  month,  but  it  has  not 
been  possible  thus  far  to  trace  very  much  of  it  to  the 


746 


MEDICAL  RECORD- 


[December  15,  1894 


eating  of  raw  oysters.  The  probability  is  that  the  oysters 
fattening  in  the  locality  in  question  would  not,  as  a  rule, 
be  contaminated,  but  that  it  would  only  be  an  exceptional 
condition  that  would  produce  the  result.  It  would  be 
necessary  that  they  should  be  lying  in  this  place  at  just 
the  period  when  the  typhoid  germs  were  swept  by  the 
currents  or  eddies  from  the  sewer  over  the  oyster-bed; 
and  such  a  condition,  even  though  there  might  be  con- 
tinued cases  of  typhoid  in  the  course  of  the  sewer,  would 
doubtless  not  by  any  means  be  a  constant  one.  Oysters, 
as  a  rule,  are  said  to  open  their  shells  on  flood-tide  rather 
than  ebb-tide,  and  this  would,  of  course,  make  it  more 
difficult  for  them  to  be  contaminated  by  sewage  from 
sewers  above  them  on  the  creek.  While  this  would  by 
no  means  make  the  chance  of  contamination  impossible, 
it  would  certainly  render  it  less.  It  is  not  to  be  sup- 
posed, therefore,  that  the  oysters  deposited  in  the  creek 
for  fattening  would  all,  or  indeed  many  of  them,  become 
contaminated  by  the  typhoid  material,  but  that  only  ex- 
ceptional conditions  would  produce  the  result*  Where 
a  private  sewer  containing  typhoid  excreta  opens  in  the 
vicinity  of  such  an  oyster-bed,  the  danger  must  certainly 
be  considerable.  Where  the  typhoid  material  is  mixed 
in  the  city  sewers  with  the  large  amount  of  sewage,  and 
is  subsequently  diffused  through  a  considerable  body  of 
salt  water  when  the  sewer  empties  into  the  sea,  the  dan- 
ger of  oyster  contamination  must  be  considerably  less. 
But  there  must  be  danger  to  public  health  from  oysters 
fattened  in  any  fresh  water  in  the  vicinity  of  sewage. 

Doubtless  many  cases  of  mysterious  typhoid  have  been 
due  to  such  a  cause.  To  trace  these  cases  is  a  matter  of 
extreme  difficulty.  The  peculiar  conditions  which  have 
occurred  here  have  been  such,  however,  as  to  bring  the 
matter  into  clear  light,  and  to  throw  with  certainty 
blame  of  typhoid  distribution  upon  a  source  which  has 
for  some  time  been  suspected,  but  not  demonstrated. 
That  the  practice  of  fattening  oysters  in  the  mouth  of 
rivers  and  in  the  vicinity  of  sewers  is  dangerous  to  the 
public  health,  is  beyond  question  shown  by  the  combina- 
tion of  conditions  which  have  made  it  possible  to  trace 
the  Wesleyan  typhoid  outbreak  to  the  eating  of  a  lot  of 
infected  raw  oysters. 


AN  IMPROVED  METHOD  OF  THE  RADICAL 
OPERATION  FOR  CARCINOMA  OF  THE 
BREAST.1 

By  WILLY  MEYER,  M.D., 

PROrS3tOK  OP  svigbky  at  tiw  new  vokk  post-gkadoatk  medical  school 

AMD  HOSPITAL  J  ATTENDING  SUEGEOM  TO  THE  GEBMAM  AND  NEW  YORK  SKIN 
AND  CANCER  HOSPITALS;  CONSULTING  ^SURGEON  TO  THE  NEW  YORK  IN- 
PIRMARY. 

Since  Heidenhain  has  shown  that  in  a  great  number  of 
cases  of  cancer  of  the  breast  the  pectoralis  major  muscle 
is  also  involved  by  the  disease,  and  that,  if  left  in  place, 
the  growth  is  more  liable  to  recur,8  it  has  become,  I  be- 
lieve, the  duty  of  the  surgeon  always  to  remove  this  mus- 
cle with  the  breast  and  the  axillary  contents.  Only,  if 
carried  out  according  to  this  plan,  the  operation  should 
be  called  radical. 

According  to  well-known  methods  the  surgeon  gen- 
erally first  removes  the  breast  with  the  axillary  contents. 
If  he  believes  in  doing  in  every  instance  as  radical  work 
as  feasible  in  fighting  this  treacherous  disease,  he  will 
then  cut  out  the  pectoralis  major  muscle  from  its  origin 
to  its  insertion.*    It  means  no  serious  addition  to  the 

1  Read  before  the  Section  on  Surgery  of  the  New  York  Academy  of 
Medicine,  November  12,  1894. 

"  Lothar  Heidenhain :  Ueber  die  Ursachen  der  localen  Krebsreci- 
dive  nach  Amputation  Mammae.  Verhandlungen  der  deutschen  Ge- 
sellschaft  fur  Chirurgie,  Berlin,  1889,  and  von  Langenbeck's  Archiv 
fur  klin.  Chir.,  1889,  vol.  xxxix. ,  p.  07. 

*  Heidenhain  believes  that  it  might  be  best  to  remove  the  strip  of 
periosteum  of  clavicle  and  sternum,  to  which  the  muscle  is  attached, 
with  the  latter.  Before  making  this  addition  to  the  operation,  I,  per- 
sonally, should  rather  wait  and  see  whether  future  observations  prove 
that  by  leaving  in  place  the  respective  pieces  of  periosteum  a  re- 
gional recurrence  is  favored. 


operative  procedure,  but  rather  still  more  radical  work, 
also  to  extirpate  the  pectoralis  minor  muscle  at  the  same 
time.  It  enables  the  operator  to  remove  the  loose  con- 
nective tissue  and  fat  under  this  muscle,  which  is  often 
diseased. 

Within  the  last  three  yean  I  have  operated,  according 
to  this  plan,  on  six  female  patients,  and  found  by  in- 
creasing experience,  with  reference  to  the  technique : 

i.  That  the  extirpation  of  the  pectoral  muscles,  car- 
ried out  in  this  way,  means  an  addition  of  about  fifteen 
to  twenty  minutes  to  the  operation,  including  ligatures. 

2.  That  it  saves  blood  and  time  to  first  cut  off  the  in- 
sertion of  the  muscles  on  the  humerus  and  coracoid  pro- 
cess, and  then  to  reflect  the  muscles  downward.  The 
arterisB  perforantes  being  on  the  stretch,  can  then  be 
well  seen  and  caught  with  the  forceps  close  to  the  inter- 
costal muscles,  before  being  divided.  If  we  pursue  the 
reverse  method,  viz.,  cut  off  the  origin  of  the  muscle  on 
ribs  and  sternum  first,  and  then  turn  up  the  same  toward 
the  humerus,  these  arteries  often  tear  near  the  intercostal 
muscles  and  the  ribs.  It  is  then  difficult  to  catch  and 
ligate  the  bleeding  points.1 

The  parasitic  theory  of  the  etiology  of  cancer  is  yet 
unproved.  On  the  other  hand,  inoculation  of  small 
pieces  of  cancerous  tissue  into  the  peritoneal  cavities  of 
animals  has  been  successful.  A  cancer  of  the  same  type 
developed  in  such  a  spot.  Clinical  observations  also 
make  it  highly  probable  that  small  particles  of  cancer- 
tissue,  if  entering  hitherto  healthy  tissue,  can  there  pro- 
duce the  same  growth.  Kraske  gives  a  resume  of  the 
special  literature  on  this  subject,  and  relates  two  very  in- 
teresting cases  in  this  respect.8  He  found  in  two  cases  of 
ulcerating  cancer  of  the  rectum,  where  the  tumor  could 
just  be  reached  with  the  finger,  low  down  immediately 
above  the  sphincter  muscle,  secondary  small  cancerous 
nodules  of  the  type  which  was  represented  by  the  main 
growth.  In  both  patients  a  healthy  strip  of  mucous 
membrane,  of  at  least  10  ctm.  length,  was  interposed 
between  the  original  and,  as  he  explains  it,  the  second- 
ary tumors.  He  believes  that  the  latter  originated  from 
the  proliferation  of  the  living  epithelial  cells  which  had 
severed  their  connection  with  the  primary  carcinoma, 
and  had  then  been  implanted  in  the  lower  portion  of  the 
rectal  mucous  membrane.  Small  tears  in  die  latter, 
made  by  the  examining  finger  or  instruments,  the  hyper- 
emia and  catarrhal  condition  of  the  lower  end  of  the 
rectum  always  present  in  these  cases,  will  favor  the  de- 
velopment of  the  inoculated  particles. 

With  reference  to  the  breast,  the  unavoidable  handling 
of  the  tumor  by  the  operator's  hands  and  the  assistants' 
hooks  has  been  considered  harmful,  and  called  upon  to 
explain  the  distressingly  low  percentage  of  cures  after  the 
operation.  It  has  been  assumed  that  during  these  manip- 
ulations cancer-cells,  or,  if  we  accept  to-day  the  theory 
of  the  parasitic  origin,  the  parasites  themselves,  might 
be  pressed  into  the  lymphatics  and  thus  disseminate  the 
disease  through  the  body.8  It  has  therefore  been  pro- 
posed to  attack  the  axillary  cavity  first,  clean  out  its  con- 
tents before  severing  their  connection  with  the  breast, 
and  then  to  remove  the  breast  and  axillary  contents  to- 
gether.4 This  procedure  may  be  of  some  importance. 
Yet  there  are  multiple  other  lymphatic  vessels,  which  are 

1  The  arteriae  perforantes  are  branches  of  the  intercostal  arteries. 
They  are  of  tolerably  large  sue.  After  having  traversed  the  inter- 
costal muscles,  which  they  supply  with  blood,  they  enter  and  feed 
(besides  the  serratus  anticns  major  muscle  and  a  portion  of  the  ab- 
dominal muscles)  the  pectoralis  major  muscle  and  the  mammary 
gland.  Heidenhain  emphasizes  the  fact  that  these  arteries  and  their 
ramifications  are  accompanied  by  cancerous  lymphatics  above  the 
fascia  of  the  pectoralis  major  muscle.  He  therefore  advises  to  di- 
vide the  vessels  '■  within  "  the  latter.  It  is,  in  my  opinion,  a  still  bet- 
ter plan  to  divide  them  "  underneath  "  the  muscle,  just  above  the  in- 
tercostal muscles. 

■  Ccntralblatt  fUr  Chirurgie,  p.  801,  1880. 

•  A.  G.  Gerster,  on  the  Surgical  Dissemination  of  Cancer,  New 
York  Medical  Journal,  February  s8,  1885.— It  has  been  my  personal 
misfortune  to  have  had  among  the  patients  on  whom  I  removed  a 
cancer  of  the  breast,  quite  a  number  in  whom  there  was  no  regional 
recurrence  of  the  disease,  but  who  died  within  one  year  and  a  half 
after  the  operation,  helpless,  almost  paralysed,  and  with  great  pains, 
from  metastatic  growths  in  the  spinal  column. 

*  Gerster  :  Loc.  cit 


December  15,  1894] 


MEDICAL   RECORD. 


747 


not  touched  by  the  knife  in  such  an  operation,  and  which 
can  carry  away  infectious  material  in  different  directions, 
thus,  for  instance,  to  the  opposite  side,  to  the  supra- 
clavicular region,  etc.  (It  is,  of  course,  understood,  that 
in  cases  of  long  standing  these  regions  may  have  become 


Fig.  x. 

infected  before  an  operation  for  the  removal  of  the  can- 
cer of  the  breast  is  undertaken.)  As  Dr.  Gerster  wrote 
me  the  other  day,  the  result,  as  far  as  recurrence  is  con- 
cerned, has  not  been  improved  by  this  procedure.  This 
fact  is  a  matter  of  course,  since  we  know  that  the  fascia 
of  the  pectoralis  major  muscle  and  this  muscle  itself,  as 
well  as  the  loose  fatty  tissue  below  the  same  and  below 
the  pectoralis  minor  muscle,  so  often  are  the  seat  of  can- 
cer. And  this,  not  very  rarely,  in  cases  where  the  tumor 
is  yet  comparatively  small  and  the  breast  freely  movable 
over  the  underlying  tissues. 

The  most  harm  is  surely  done  during  the  manipulations 
with  the  knife,  the  hooks,  and  the  hands  "  within  the 
operating  field  itself,"  as  long  as  we  work  "within" 
and  not  "outside  of"  the  diseased  area.  During  the 
operation  lymphatic  vessels  between  breast  and  fascia, 
those  of  the  pectoralis  major  muscle,  between  and  below 
the  pectoral  muscles,  in  the  axillary,  sub-  and  infra-clavi- 
cular fat,  all  more  or  less  filled  with  epithelial  cells,  are 
compressed,  cut,  and  torn.  Their  contents  enter  the 
fresh  wound.  Direct  local  infection  of  hitherto  healthy 
tissue  by  cancer  is  liable  to  take  place.  I  believe  that 
especially  the  primary  tearing  off  or  preparing  the  breast 
tumor  with  the  knife  from  the  subjacent  fascia  of  the 
pectoralis  major  muscle,  or  from  the  superficial  layer  of 
its  fibres,  if  the  tumor  be  adherent  to  the  fascia — as  it  hat 
been  the  general  custom  of  operators  up  to  date — may  at 
times  directly  infect  the  large  fresh  wound  with  micro- 
scopical elements  of  cancerous  tissue.  It  has  been 
shown  that  just  the  fascia  of  the  pectoralis  major  muscle 
and  the  superficial  layer  of  fibres  of  the  latter,  often  contain 
a  very  large  number  of  microscopical  cancerous  deposits. 

By  first  excising  the  breast  with  the  axillary  glands  and 
then  extirpating  the  muscles,  the  latter  procedure  form- 
ing the  second  part  of  the  operation,  we  also  increase 
the  loss  of  blood.  Many  vessels  are  cut — and  have  to 
be  tied — twice. 

In  view  of  these  considerations  I  have  thought  that 
in  order  to  avoid  local  or  remote  infection,  also  to  save 
loss  of  blood,  and  still  to  be  as  complete  in  the  work  as 
possible,  that  the  following  might  be  an  improvement : 
Not  to  excise  the  breast  tumor  in  connection  with  the 
axillary  contents  first,  and  then  to  remove  the  pectoral 
muscles  and  clean  out  the  sub-  and  infra-clavicular  space ; 
but  "  to  extirpate  the  breast,  the  contents  of  the  axillary 
and  of  the  sub-  and  infra-clavicular  region,  and  the  pec- 
toral muscles,  in  one  mass.1'  In  other  words.  I  thought 
I  would  try  and  let  the  knife  never  enter  the  infected 


area  (cancer),  but  work  "everywhere"  around  the  lat- 
ter in  healthy  tissue,  of  course  as  far  as  this  may  be 
feasible  in  such  cases. 

For  this  purpose  the  operator  must  first  come  down  to 
landmarks,  when  reflecting  back  the  flaps  of  skin,  before 
attacking  the  seat  of  the  cancer  proper.  These  land- 
marks, as  I  mapped  them  out,  would  be :  a .  Above :  ce- 
phalic vein  and  clavicle,  b.  Outward :  The  tendon  of 
the  pectoralis  major  muscle  on  the  humerus,  c.  Below : 
the  border  of  the  latissimus  dorsi  muscle,  d.  Inward  : 
The  sternal  extremity  of  the  clavicle  and  the  sternum  itself. 

My  plan  of  operation  was  the  following : 

1.  Skin  incision  as  usual,  embracing  a  liberal  piece 
of  skin  around  the  nipple,  which  incision  is  at  once  run 
up  into  the  axillary  cavity,  about  an  inch  and  a  half  to 
two  inches  farther  than  in  the  ordinary  operation.  This 
in  order  more  easily  to  reach  the  tendon  of  the  pecto- 
ralis major  muscle  on  the  humerus.     (See  Fig.  1,  A,  B.) 

2.  Additional  skin  incision  from  the  clavicle  at  the 
junction  of  its  middle  and  outer  thirds  downward,  meet- 
ing the  first  wound  at  right  angles.     (Fig.  1,  C,  D.) 

3.  Reflection  backward  of  the  three  skin  flaps  with  as 
thin  a  layer  of  the  underlying  fat  as  possible,  leaving  just 
enough  so  as  not  to  endanger  a  future  necrosis  of  the 
flaps,1  exposing:  a.  The  insertion  of  the  pectoralis 
major  muscle  on  the  clavicle  and  sternum,  b.  The  in- 
sertion of  the  same  muscle  on  the  humerus,  the  cephalic 
vein  in  Mohrenheim's  sub-clavicular  space  (guide !).  c. 
The  border  of  the  latissimus  dorsi  muscle.    (See  Fig.  2.)* 

4.  Division  of  the  pectoralis  major  muscle  in  its  tendon 
close  to  the  ^humerus  (the  raised  arm  of  the  patient 
must  be  somewhat  lowered  for  this  purpose),  and  prep- 
aration of  the  same  downward  (Fig.  2)  to  its  insertion 
on  the  clavicle.  Here  it  is  cut  off  at  once  down  to  the 
sternal  extremity  of  the  bone,  in  order  to  thoroughly  ex- 
pose the  contents  of  the  axillary  cavity  and  the  infra- 
and  sub-clavicular  region.  During  this  time  an  assistant 
exerts  some  traction  on  the  breast,  to  put  the  tissues  on 
the  stretch. 

5.  Preparation  and  excision  of  the  sub  clavicular,  infra- 
clavicular, and  axillary  fat,  glands  and  lymphatics,  with 
the  knife,  beginning  over  the  bundle  of  nerves  and 
vessels  high  up  in  the  cavity,  and  continuing  this  pro- 
cedure from  the  lower  border  of  the  subclavian  and  axil- 
lary vein  downward.  As  soon  as  freed,  these  contents, 
having  been  divided  on  the  outer  side  from  the  fat  in  the 


Fig.  2.—/,  Pectoralis  major  muscle;  /.  tendon  pectoralis  major  muscle ;  ct  v% 
cephalic  vein  ;  ^  </,  latissimus  dorsi  muscle. 

upper  part  of  the  sulcus  bicipitalis  of  the  arm,  are 
raised  and  cut  out  from  the  outer  side  inward.  This 
means,  beginning  from  the  border  of  the  latissimus  dorsi 

1  Further  experience  must  show  how  much  fat  must  be  left  at- 
tached to  the  skin.  It  means,  no  doubt,  abetter  prognosis,  with  refer- 
ence to  recurrence,  to  say :  "  the  less  the  better,"  or,  "none  whatever." 

a  This  plate  has  been  drawn  by  the  artist  without  his  having  wit- 
nessed the  operation.  He  was  obliged  to  work  guided  only  by  my 
explanations. 


748 


MEDICAL   RECORD. 


[December  15,  1894 


muscle.  This  excision  is  continued,  including  the  fat 
on  the  sub-scapularis  and  teres  major  muscles,  until  the 
chest-wall,  viz.,  ribs,  intercostal,  and  part  of  the  serratus 
anticus  major  muscles,  are  plainly  before  us,  and  until  the 
"lower"  surface  of  the  pectoral  muscles  is  reached. 
Fat  with  glands  and  lymphatics  are  nowhere  cut  into, 
bit  remain  in  one  piece  and  attached  to  the  outer  lower 
border  of  the  pectoral  muscles  in  their  normal  anatomi- 
cal relation. 

6.  Division  of  the  tendon  of  the  pectoralis  minor 
muscle  on  the  coracoid  process. 

7.  Gentle  elevation  of  the  breast  and  muscles  by  an 
assistant's  hands  in  order  to  put  the  blood-vessels  which 
enter  and  leave  the  pectoralis  major  muscle  on  the 
stretch.  As  mentioned  above,  they  are  clamped  before 
they  are  divided. 

8.  Amputation  of  the  pectoralis  major  muscle  at  its 
insertion  on  the  sternal  extremity  of  the  clavicle,  and 
of  both  muscles  at  their  insertion  on  the  ribs  and  ster- 
num with  the  knife  close  to  these  bones.  This  insertion 
forms  the  pedicle  of  the  whole  mass.  If  cut  off  along- 
side the  sternum  after  having  been  separated  from  the 
ribs,  the  extirpation  of  the  cancer  is  finished. 

9.  Suturing  of  the  wound  as  far  as  possible;  plate- 
sutures  for  the  sake  of  better  coaptation  of  the  skin-flaps, 
drainage  of  the  axillary  cavity  as  usuaL 

10.  Dressing ;  the  large  defect  is  always  to  be  covered 
with  rubber  tissue  in  order  to  favor  rapid  healing  under 
the  moist  blood-clot ;  good  compression. 

Grafting  of  the  resulting  granulating  wound,  which 
will  follow  the  removal  of  a  liberal  piece  of  skin,  may 
be  done  in  about  eight  or  ten  days  without  narcosis, 
ethyl-chloride  being  used  for  anaesthetizing  the  area 
of  the  arm  or  thigh,  from  which  the  grafts  are  taken. 
The  granulating  surface  need  not  be  scraped  for  this 
purpose.1 

On  September  19,  1894,  I  had  my  first  opportunity  to 
operate  according  to  this  plan. 

Mrs.  F.  O ,  aged  thirty-seven.  Slowly  increas- 
ing tumor  of  the  left  breast  since  eighteen  months.  It 
never  ached,  and  thus  made  the  patient  neglect  to  con- 
sult a  doctor.  Examination  on  September  15  th  showed 
a  tumor  of  goose-egg's  size  in  the  centre  of  the  breast. 
Nipple  not  retracted.  Axillary  glands  hard  and  infil- 
trated. September  19th  operation  as  just  described,  with 
the  exception  of  omitting  the  additional  incision  from 
the  clavicle  downward.  One  upper  flap  only  and  one 
lower  one  were  thus  formed.  This  was  a  mistake.  It 
somewhat  impeded  the  easy  reach  of  the  attachment  of 
the  muscle  on  the  clavicle.  I  should  advise  always  to 
make  this  incision,  especially  in  fat  patients.  I  had 
done  so,  in  fact,  in  my  former  cases,  in  which  I  first  cut 
away  breast  and  axillary  contents,  and  then  the  muscles. 
The  operation  was  not  difficult.  Only  when  preparing 
from  the  edge  of  the  latissimus  dorsi  muscle  inward  and 
upward,  in  order  to  reach  the  chest-wall  and  the  pecto- 
ral muscles  (from  below),  I  found  it  somewhat  incon- 
venient in  comparison  with  the  former  method  of  oper- 
ating, to  have  the  great  mass  of  tissue  above.  Clever 
assistants  will  here  be  of  great  help.  Temperature  never 
rose  above  ioo°  F.  First  dressing  changed  on  the  sixth 
day;  primary  union  throughout ;  drainage-tube  removed ; 
patient  out  of  bed.  To-day  arm  freely  movable.  The 
specimen  which  I  hand  around  will  show  nicely,  how  rad- 
ically the  operation  has  been  done.  The  whole  mass  is 
in  one  piece.  The  microscope  substantiated  the  diag- 
nosis of  cancer. 

As  seen  in  this,  as  well  as  in  my  former  cases,  where  I 
extirpated  the  pectoralis  major  muscle  entirely,  the  loss 
of  the  latter  never  interfered  with  the  motion  of  the 
arm.  On  the  contrary,  the  patients  were  able  to  sooner 
move  the  arm  in  all  directions  than  I  have  seen  if  the 
muscles  be  not  or  only  partially  removed.  The  strong 
inner  (clavicular)  portion  of  the  deltoid  is  fully  able  to 

1  Julius  Schnitzler  u.  Karl  Ewald :  Zur  Technik  der  Hauttrans- 
plantation  nach  Thiersch,  Central  blatt  fur  Chirurgie,  1894,  No.  7, 
page  148.  According  to  my  experience,  immediate  grafting  on  the 
very  uneven  basis  of  the  fresh  defect  is  not  advisable. 


adduct  the  arm.  Some  patients  complained  of  a  tight 
sensation  over  the  chest,  they  "  felt  their  ribs  exposed." 
This  annoyance  was  soon,  however,  overcome.  In  order 
to  avoid  stiffness  in  the  shoulder-joint,  the  patients 
should  be.  ordered  to  begin  with  active  and  passive 
motions  after  the  first  change  of  dressing,  viz.,  between 
the  eighth  till  tenth  day  after  the  operation. 

I  am,  of  course,  fully  aware  that  also  this  most  radical 
method  of  operation  will  not  prevent  recurrence  of  the 
growth  "  in  loco/'  nor  metastases  in  remote  parts,  espe- 
cially not,  if  the  patients  be  subjected  to  the  operation 
in  an  advanced  stage  of  the  disease.  Yet  I  venture  to 
consider  it  a  step  in  trying  still  further  to  reduce  the 
chances  of  probably  infecting  the  fresh  wound  and  the 
entire  system  with  cancer  by  our  work  "during"  the 
operation ;  also  to  do  as  complete  work  as  possible. 

In  this  view  I  thought  it  permissible  to  communicate 
this  method  to  the  Surgical  Section,  having  so  far  had 
only  one  personal  practical  experience. 

Mr.  President  and  Gentlemen,  the  idea  ot  removing 
the  carcinoma  of  the  breast  in  this  way  was  conceived 
by  me  last  winter.  By  a  peculiar  coincidence  not  one 
case  of  carcinoma  of  the  breast  came  under  my  care 
since  then  until  September,  even  not  during  a  four- 
months'  service  at  the  German  Hospital.  This  paper 
was  written  in  the  latter  part  of  September.  It  was 
announced  to  the  Secretary  of  the  Surgical  Section  at 
about  October  20th.  Before  doing  so,  I  had  very  care- 
fully perused  the  newest  literature,  especially  the  elab- 
orate articles  on  the  subject  by  Dennis,  Weir,  and  Bull, 
in  order  to  ascertain  whether  others*  had  removed  a 
cancer  of  the  breast  in  the  way  just  described.  I  did 
not  find  this  procedure  mentioned.  Now,  ten  days  ago, 
on  November  2d,  the  November  issue  of  the  Annals  cf 
Surgery  has  come  into  my  hands.  In  this  issue  Dr. 
William  S.  Halsted,  of  the  Johns  Hopkins  Hospital,  has 
published  a  brilliant  article  upon  the  results  of  operations 
for  the  cure  of  cancer  of  the  breast,  performed  by  him 
at  the  Johns  Hopkins  Hospital  from  June,  1889,  to  Janu- 
ary, 1894,  in  which  he  recommends  practically  the  same 
way  of  operating  just  proposed  by  me,  viz.,  the  removal 
of  the  breast,  fat,  and  glands  of  the  axillary  cavity  and  in- 
fra-clavicular region  "  in  one  mass. ' '  He  thinks  it  advis- 
able to  explore  and  clean  out  also  the  supraclavicular 
region  in  almost  every  operable  case.1  He  has  operated 
in  this  way  on  most  of  the  fifty  patients  whose  histories 
are  recorded.  As  will  be  seen  by  comparison,  our  meth- 
ods differ  in  some  respects.  I  shall  mention  those 
which  seem  to  me  to  be  of  some  importance. 

Halsted  surrounds  the  base  of  the  breast  with  an  in- 
cision, and  reflects  a  triangular  flap  of  skin  downward 
and  outward. 

I  first  reflect  back  three  flaps  of  skin,  two  upper  ones 
and  one  lower  one,  so  far,  until  I  reach  the  landmarks 
mentioned  above,  namely :  the  tendon  of  the  pectoralis 
major  muscle,  the  cephalic  vein,  the  clavicle  and  ster- 
num, the  border  of  the  latissimus  dorsi  muscle. 

Halsted's  third  step  of  the  operation  reads :  "  The 
costal  insertions  of  the  pectoralis  major  muscle  are  sev- 
ered, and  the  splitting  of  the  muscle,  usually  between  its 
clavicular  and  costal  portions,  is  begun,  and  continued 
to  a  point  about  opposite  the  scalenus  tubercle  on  the 
clavicle."  The  sixth  step  reads :  "  The  splitting  of  the 
muscle  is  continued  out  to  the  humerus,  and  the  part  of 
the  muscle  to  be  removed  is  now  cut  through  close  to  its 
humeral  attachments ;  "  and  the  eighth  to  tenth :  "  The 
lower  outer  border  of  the  minor  muscle  having  been 
passed  and  clearly  exposed,  this  muscle  is  divided  at 
right  angles  to  its  fibres,  and  at  a  point  a  little  below  its 
middle.11  "The  tissue,  more  or  less  rich  in  lymphatics 
and  often  cancerous,  over  the  minor  muscle  near  its  cor- 

1  This  is,  no  doubt,  a  very  wise  addition.  I  shall  certainly  add  this 
point  to  my  plan  of  operating  laid  down  above,  in  every  case  coming 
under  my  care.  By  lengthening  the  additional  incision  as  proposed 
by  me  (Fig.  1,  C,  D.)  upward  above  the  clavicle,  this  operation  can 
be  easily  and  rapidly  done.  Of  course,  we  shall  clean  out  the  supra- 
clavicular space  thoroughly,  by  removing  the  fat  with  glands  and 
lymphatics  also  "  in  one  piece.* 


December  15,  1894] 


MEDICAL  RECORD. 


749 


acoid  insertion,  is  divided  as  far  out  as  possible,  and  then 
reflected  inward  in  order  to  liberate  or  to  prepare  for  the 
reflection  upward  of  this  part  of  the  minor  muscle.11 
"  The  upper,  outer  portion  of  the  minor  muscle  is  drawn 
upward  with  a  broad,  sharp  retractor.  This  liberates  the 
retractor  which  until  now  has  been  holding  back  the 
clavicular  portion  of  the  pectoralis  major  muscle." 

In  the  manner  as  I  have  planned  and  performed  the 
operation/  the  belly  of  the  pectoralis  major  muscle,  as 
well  as  that  of  the  minor,  is  not  touched  at  all.  To  re- 
peat briefly  what  has  been  said  above :  I  first  cut  off  the 
humeral  attachment  of  the  pectoralis  major  muscle,  pre- 
pare its  upper  border  tree  from  the  cephalic  vein,  and 
detach  it  with  the  knife  close  to  the  clavicle.  Then  the 
muscle  is  turned  downward  and  inward,  until  the  tendon 
of  the  pectoralis  minor  muscle  can  be  cut  off  from  the 
coracoid  process.  Later — that  means  after  the  tissue 
over  the  bundle  of  vessels  and  nerves  high  up  in  the  ax- 
illa, and  after  the  axillary,  sub-  and  infra-clavicular  fat, 
glands,  and  lymphatics  have  been  carefully  prepared  in 
the  well-known  manner,  "  but  left  in  their  original  ana- 
tomical relation  to  the  breast  and  to  the  muscles91 l — both 
muscles  are  raised  and  cut  away  from  above  downward 
and  inward. 

Further:  Halsted  turns  the  mass  over  to  the  outer 
side  and  cuts  it  off  on  the  base  of  the  skin-flap,  which 
had  been  primarily  formed  and  reflected  outward.  This 
I  believe  will  be  more  convenient  for  the  operator. 

As  my  procedure  follows  the  direction  of  the  fibres  of 
the  pectoral  muscles  from  above  downward,  the  mass 
must  be  turned  upward  and  inward  first,  when  preparing 
from  the  axilla,  and  then  inward.  A  clever  assistant  will 
be  easily  able  to  hold  it  out  of  the  way.  When  the  pedi- 
cle, the  sternocostal  insertion  of  the  pectoralis  major 
muscle,  is  reached,  a  few  strokes  with  a  sharp  knife  com- 
plete the  operation. 

Further  experience  must  show  whether  Halsted's  or 
my  plan  of  operating  deserves  preference. 

I  personally  should  prefer  the  operation  as  proposed 
above  and  carried  out  by  me.  It  seems  to  me  to  be 
more  anatomical  than  that  of  Halsted.  It  also  is,  I  trust, 
still  more  radical,  since  in  every  instance  the  entire  pec- 
toralis major  muscle  (and  the  minor)  will  be  removed.  I 
think,  this  is  absolutely  necessary,  in  order  to  do  radical 
work.  Heidenhain  specially  states,  that  he  considers  a 
muscle,  which  has  been  invaded  by  cancer,  suspicious 
from  its  origin  to  its  insertion.  "  Not  a  fibre  of  the  mus- 
cle should  be  left  behind. M  On  this  ground  I  should  also 
prefer  to  abstain  from  all  splitting  of  the  pectoralis  major 
muscle  between  its  different  portions.  By  not  working 
within  the  belly  of  the  muscle  whatsoever,  we  shall,  no 
doubt,  be  best  guarded  against  infection  of  the  fresh 
wound  with  cancer,  and  against  regional  recurrence. 

The  nucleus  of  the  operation,  however,  is  the  follow- 
ing rule :  "  Lift  all  the  tissue,  that  may  be  diseased,  and 
often  will  be  found  on  microscopical  examination  to  be 
diseased  throughout,  out  of  its  bed  in  one  piece" 

That  this  kind  of  radical  operation  will  be  "  the  "  oper- 
ation for  the  extirpation  of  carcinoma  of  the  breast,  there 
can  be  no  doubt.  It  is  proved  by  Halsted's  unprece- 
dented percentage  of  cures.  He  so  far  records  cure  in 
ninety-four  per  cent,  of  his  cases,  including  the  cases 
operated  up  to  February,  1894,  a  number  which  has  never 
been  reached  by  a  surgeon  before. 

I  venture  to  hope  that,  by  absolutely  and  continuously 
working  everywhere  around  the  seat  of  disease,  by  never 
trespassing  on  the  belly  of  the  muscles,  and  always  re- 
moving the  latter  completely,  this  extremely  gratifying 
result  might  be  also  secured  by  others. 

Thus  will  then,  at  last,  it  is  to  be  hoped,  also  this  ter- 
rible foe  of  suffering  mankind,  this  dread  especially  of 
the  female  sex,  become  oftener  silenced  and  made  more 
submissive  to  the  surgeon's  knife,  provided  the  operation 
is  done  early,  before  remote  parts  of  the  system  have  be- 
come infected. 

1  The  lower  outer  border  of  the  minor  muscle  is  thus  not  clearly 
exposed,  but  remains  attached  to  the  axillary  fat 


A    RrtSUMrt  OF    THE    SUBJECT    OF    BILIARY 
CALCULI.1 

By  THOMAS  S.   SOUTHWORTH,   M.D., 

ASSISTANT  TO  THB  CHAIR  OP  MEDICINE,  VANDKEBILT  CLINIC  \  INSTRUCTOR  IN 
DISEASES  OP  CHILDREN,  NEW  YORK  POLYCLINIC  \  PATHOLOGIST  TO  THE  NURS- 
ERY AND  CHILD'S  HOSPITAL. 

To  approach  intelligently  the  question  oi  the  forma- 
tion of  biliary  calculi  it  is  necessary  to  have  a  clear  con- 
ception of  the  physiology  of  the  liver  and  of  the  biliary 
secretion  in  and  from  which  they  are  formed.  It  is  not 
essential  for  this  purpose  that  we  should  deal  here  with 
the  anatomy  and  minute  histology  of  the  liver,  but  we 
may  proceed  at  once  to  a  brief  review  of  our  knowledge 
of  the  bile  itself.  For,  although  from  the  size  of  the 
liver,  and  consequently  its  apparent  importance,  its  func- 
tion was  studied  as  early  as  that  of  any  of  the  other 
abdominal  viscera,  it  was  not  until  the  full  development 
of  the  sciences  of  organic  chemistry  and  experimental 
physiology  that  satisfactorily  definite  information  could 
be  obtained  concerning  the  secretions  and  functions  of 
this  organ. 

Bile  is  formed  continuously,  but  the  rate  at  which  it  is 
produced  is  subject  to  great  variations.  The  flow  dimin- 
ishes during  abstinence,  increases  immediately  after 
meals  for  about  an  hour,  decreases  somewhat  thereafter, 
and  again  flows  freely  during  the  third  and  fifth  hours  of 
digestion.  Much  difficulty  has  been  experienced  in  ar- 
riving at  an  approximate  estimate  of  the  quantity  secreted 
in  the  course  of  twenty-four  hours.  There  can  be  but 
little  accuracy  in  reasoning  by  analogy  from  the  secretion 
in  the  lower  animals,  and  the  operative  fistulae  in  man 
upon  which  observations  have  been  made  have  in  most 
cases  existed  under  pathological  conditions  which  would 
greatly  interfere  with  the  results  obtained.  Moreover,  as 
the  presence  of  the  bile  in  the  intestines  influences  the 
quantity  and  quality  of  the  bile  excreted  by  the  liver  the 
results  obtained  by  the  observation  of  biliary  fistulae 
must  differ  very  much  from  those  which  would  be  pro- 
duced were  the  bile  pouring  normally  into  the  intestine 
to  be  partially  reabsorbed  by  the  portal  system  and  re- 
turned to  the  liver.  Thus  we  only  know  definitely  that 
where  reabsorption  from  the  intestine  cannot  take  place, 
the  quantity  of  bile  in  man  is  from  a  pint  to  a  pint  and 
a  half  per  day.3  Under  normal  conditions  we  presume  it 
to  be  somewhat  larger. 

Comparisons  made  between  the  pressure  in  the  veins 
of  the  portal  system  and  that  in  the  bile- ducts  have 
shown  that  the  biliary  pressure  is  two  and  one- half  times 
as  great  as  that  of  the  blood  supplied  to  the  hepatic  cell, 
proving  conclusively  that  the  process  is  not  one  of  filtra- 
tion but  of  definite  secretion.  As  it  flows  from  the  intra- 
hepatic ducts  the  human  bile  is  a  non-viscid.fiuid  of  a  golden 
red  color,  sweet-bitter  taste,  feebly  alkaline  reaction,  and 
a  specific  gravity  of  about  1.010.  The  viscidity  which  we 
usually  associate  with  it  is  acquired  from  admixture  with 
a  substance  secreted  by  the  mucous  membrane  of  the  gall- 
ducts  and  gall-bladder.  This  is  known  as  the  mucoid 
nucleo- albumin  of  the  bile,  and  increases  in  amount 
in  proportion  to  the  length  of  time  the  bile  remains  in 
the  gall-bladder.  The  bile  contains  as  the  direct  secre- 
tory product  of  the  hepatic  cell  the  so-called  bile  acids, 
glykocholic  and  taurocholic  acids,  the  former  preponder- 
ating, and  the  biliary  coloring  matter  bilirubin,  which  is 
readily  oxidized  to  biliverdin,  or  by  intestinal  action 
changed  to  other  derivatives.  In  addition  to  these  specific 
products  of  the  liver  it  also  excretes  through  the  bile 
cholesterin,  neutral  fats,  soaps,  lecithin,  traces  of  a  dias- 
tatic  ferment,  mineral  matter,  and  gases,  of  which  the 
chief  is  CO,.  While,  if  we  disregard  the  very  slight  traces 
of  a  diastatic  ferment,  we  know  that  the  bile  has  no 
power  to  decompose  starches,  proteids,  or  fats,  we  are 
still  convinced  that  in  addition  to  its  excretory  functions 
it  undoubtedly  plays  a  by  no  means  unimportant  part  in 

1  Read  before  the  Section  on  General  Medicine,  New  York  Acad- 
emy oi  Medicine,  November  ao,  1894. 

9  Arthur  Gamgee :  Text-book  of  the  Physiological  Chemistry  of  the 
Animal  Body,  vol.  ii.t  p.  376. 


75° 


MEDICAL    RECORD. 


[December  15,  1894 


the  intestinal  economy  by  neutralizing  the  acidity  of  the 
chyme,  and  thus  preparing  the  way  for  pancreatic  activ- 
ity, as  well  as  its  direct  or  indirect  saponifying,  antisep- 
tic, and  laxative  effects. 

Gall-stones,  as  shown  by  autopsy  records,  are  of  much 
more  frequent  occurrence  than  we  would  suppose  were 
we  to  judge  only  from  clinical  evidence.  Schroder 
found  at  the  autopsies  in  the  Strassburg  Hospital  gall- 
stones in  4.4  per  cent,  of  the  men  and  20.6  per  cent,  of 
the  women.  They  are  rare  under  thirty  years  of  age, 
more  frequent  from  thirty  to  sixty,  and  after  the  latter 
age  occur  very  often.  Women,  and  especially  those  who 
have  borne  children,  furnish  by  far  the  largest  number  of 
cases.  The  large  majority  of  biliary  calculi  are  formed 
and  found  in  the  gall-bladder ;  certain  forms,  however, 
may  rarely  be  found  in  the  larger  ducts,  or  even  in  the 
intra  hepatic  ducts.  Stones  which  are  found  in  the  cys- 
tic or  common  ducts  have,  however,  almost  invariably 
come  from  the  gall-bladder.  Their  specific  gravity  is 
very  low,  so  low  that  when  dried  they  may  even  float 
upon  water  until  the  air  which  they  contain  has  been  ex- 
pelled. The  calculi  are  rarely  single,  but  usually  multi- 
ple (5  to  30),  and  have  been  found  in  a  single  case  to 
the  number  of  seven  thousand  eight  hundred  and  two. 
In  size  they  vary  from  fine  sand  to  masses  15  ctm.  in 
length.  The  average  size  is  that  of  a  hazel  nut.  They 
are  composed  chiefly  of  cholestrin,  bilirubin  calcium, 
and  calcium  carbonate,  singly  or  in  combination  with 
each  other.  The  color  and  consistence  depends  upon 
the  composition.  White  or  light-colored  stones  are  en- 
tirely or  largely  composed  of  cholesterin ;  brown,  green, 
and  black  tints  are  given  by  bilirubin-calcium,  biliverdin, 
and  other  derivatives  of  the  biliary  coloring  matters. 
Calcium  carbonate  is  often  found  in  a  green  external 
layer.  All  calculi  from  the  same  gall-bladder  have  usu- 
ally the  same  composition,  structure,  and  color.  Their 
shape  is  affected  by  the  space  in  which  they  lie.  The 
facets  upon  their  surface  depend  upon  their  numbers  and 
are  almost  invariably  due  to  mutual  pressure  while  soft, 
and  not  to  attrition. 

When  stones  are  sawn  in  two  they  present,  as  a  rule, 
1,  a  central  nucleus ;  2,  a  middle  zone  of  multiple  con- 
centric lamellae ;  3,  a  laminated  external  layer  or  shell. 
These  three  divisions  are  very  often  of  diverse  color  and 
composition.  The  nucleus  is  of  the  greater  interest ;  it 
is  more  commonly  formed  of  a  combination  of  biliary 
pigment  and  calcium,  called  bilirubin- calcium,  or  of 
mucus  and  epithelial  cells.  These  latter  by  desiccation 
-  may  leave  a  hollow  centre.  Very  rarely  foreign  bodies, 
such  as  needles  or  intestinal  worms,  have  been  found  as 
the  nucleus  of  the  concretions. 

The  most  common  and  most  numerous  variety  of  cal 
culi,  "  the  habitual  tenants  of  the  gall-bladder,"  are  the 
mixed  cholesterin  calculi,  yellow  or  whitish-brown  in 
color,  occurring  in  groups  of  varying  numbers,  often  70 
to  100  together,  from  the  size  of  a  pin's-head  to  that  of 
a  small  cherry,  faceted  by  mutual  pressure,  frequently 
lamellated  on  section,  and  often  soft  and  friable  before 
exposure  to  the  air.  Other  much  rarer  varieties  of  cho- 
lesterin stones  are  the  white  crystalline  and  the  stratified 
cholesterin  calculi.  The  former  are  usually  single,  often 
of  considerable  size,  of  pure  white  transparent  crystalline 
structure,  and  are  usually  found  in  a  recess  of  the  gall- 
bladder or  in  the  common  or  cystic  ducts,  encircled  by 
the  wall,  which  is  frequently  even  adherent  to  the  stone. 
The  stratified  variety,  although  containing  sixty  per  cent, 
of  cholesterin,  are  usually  darker  from  an  admixture  of 
biliary  coloring  matters,  and  more  frequently  multiple 
and  faceted  than  the  former.  On  section  they  appear 
to  be  formed  of  concentric  lamellae  of  varying  color, 
throughout  which  crystallization,  beginning  at  the  centre, 
has  advanced  to  variable  distances. 

Less  frequent  as  a  class  than  the  cholesterin  stones  are 
those  formed  of  the  compound  of  bilirubin  and  calcium. 
These  may  rarely  be  pure,  in  which  case  they  are  small, 
dark  concretions.  Usually,  however,  they  are  mixed 
with  some  cholesterin  or  calcium  carbonate,  in  which  case 


they  are  still  dark,  occur  singly  or  at  the  extreme  by 
twos  or  threes,  are  found  in  the  gallbladder  or  ducts, 
and  are  made  up  of  broad,  structureless  lamellae  which 
may  be  arranged  about  a  crystalline  cholesterin  nucleus. 
Other  occasional  forms  are  described,  including  those 
made  up  of  calcium  carbonate. 

When  we  approach  the  question  of  the  formation  of 
gall  stones  we  have  to  deal  with  a  delicate  problem.  It 
has  long  been  recognized  that  increasing  age  enhances 
the  liability  to  biliary  lithiasis,  as  well  as  anything  which 
tends  to  retard  the  movement  of  the  bile  in  its  passage. 
Now  two  of  the  main  factors  in  keeping  up  a  movement 
of  the  bile  are  exercise  and  deep  respiratory  action. 
Both  of  these  are  usually  lessened  as  age  advances,  and 
to  these  may  be  added  sedentary  habits,  and,  in  women, 
diminution  of  diaphragmatic  respiration  by  the  wearing 
of  corsets  and  during  the  existence  of  pregnancy. 

Neither  heredity,  nationality,  diet,  nor  diathesis  seem 
in  any  way  to  influence  the  incidence  of  cholelithiasis, 
for  the  amount  of  cholesterin  and  calcium  salts  in  the 
bile  bears  no  relation  to  the  general  tissue  change  or  to 
the  food  of  the  patient,  but  they  are  constant  in  their 
amounts  as  proven  by  elaborate  experimentation.  We 
know  that  while  bilirubin  is  abundant  in  the  bile,  choles- 
terin is  excreted  in  comparatively  small  quantities,  yet 
we  have  just  seen  that  the  cholesterin  stones  are  by  far 
the  largest  and  most  numerous,  while  bilirubin-calcium 
enters  into  the  composition  of  calculi  in  smaller  amounts 
and  less  frequently.  We  must  therefore  look  for  some 
local  causative  factor  which  shall  explain  the  precipita- 
tion of  the  elements  of  the  calculi  from  the  biliary  secre- 
tion. Naunyn 1  believes  this  agent  to  be  the  bacterium 
coli  commune,  which  penetrates  from  the  intestine  along 
the  ducts  to  the  gall-bladder.  When  there  is  no  stasis 
in  the  biliary  system,  and  the  gallbladder  is  frequently 
emptied  no  harm  results,  but  if  the  flow  of  bile  be  re- 
tarded the  continued  presence  of  the  bacterium  sets  up  a 
catarrhal  condition  of  the  mucous  membrane,  during 
which  calcium  salts  are  excreted  by  it  in  excess.  These 
combine  with  the  bilirubin  to  form  bilirubin-calcium, 
and  the  albumin  from  the  mucous  membrane  of  the  gall- 
bladder aids  in  its  precipitation.  On  the  other  hand, 
the  cholesterin,  of  which  by  far  the  larger  number  of 
stoneq  is  composed,  has  been  conclusively  shown  to  be 
the  product  of  the  epithelium  of  the  ducts  and  the  gall- 
bladder, and  to  bear  practically  no  relation  to  the  small 
amount  excreted  by  the  liver.  This  has  been  proven  by 
the  fact  that  the  percentage  of  cholesterin  increases  in  the 
bile  in  proportion  to  the  time  it  remains  in  the  gall- 
bladder, and  also  that  pure  cholesterin  stones  will  in- 
crease  in  size  in  the  gall-bladder  when  there  exists  com- 
plete occlusion  of  the  cystic  duct,  whereas,  for  the  growth 
of  bilirubin  stones  fresh  supplies  of  bilemust  at  least  reach 
the  gall-bladder  at  intervals.  Naunyn  found  that  in  the 
gall-bladder  of  persons  dying  with  gall-stones  the  epi- 
thelial cells  contained  or  were  extruding  myeline  masses 
of  a  glassy,  structureless  character,  which  under  the  action 
of  acetic  acid  became  clumps  of  cholesterin  crystals. 
These  myeline  masses  are  then  rudimentary  or  embryonal 
calculi,  ready  to  crystallize  upon  any  opportune  object, 
usually  about  little  masses  of  bilirubin-calcium  or  clumps 
of  epithelial  cells  and  mucus.  If  now  there  be  free  exit 
for  the  bile  through  the  cystic  duct,  these  microscopic 
masses  may  be  swept  out  by  the  flow  of  bile  into  the 
intestine,  but  if  the  flow  be  tardy,  or  there  be  obstruction, 
their  further  growth,  by  the  addition  of  subsequent  lamel- 
lae is  readily  understood. 

The  radiating  crystalline  character  which  is  noticed 
throughout  the  whole  or  a  part  of  many  of  the  pure  or 
mixed  cholesterin  calculi  requires  a  word  of  explana- 
tion. This  is  a  subsequent  change  which  takes  place 
later  and  more  slowly  than  the  growth  of  the  stone  by 
the  accretion  of  structureless  cholesterin.  The  process 
begins  in  the  centre,  either  in  an  original  cholesterin 
nucleus,  or  more  often  in  myeline  material  which  has 
penetrated  by  infiltration  and  filled  a  hollow  at  the  cen- 

1  KUnik  der  Cholelithiasis.    Lelpsic,  189a. 


December  15,  1894] 


MEDICAL   RECORD. 


75i 


tre  left  by  the  drying  or  escape  of  soft  or  semi-fluid  sub- 
stances which  formed  the  original  nucleus.  From  this 
centre  crystallization  extends  outward  in  radiating  striae 
through  the  different  lamellae,  aided  perhaps  by  fresh 
cholesterin,  which  penetrates  from  the  outer  zone  along 
minute  canals  called  infiltration  canals.  It  is  even  pos- 
sible that,  during  this  process,  in  many  cases,  bilirubin- 
calcium  may  be  dissolved  and  displaced. 

It  is  hardly  necessary  for  me  to  consume  your  time 
in  reciting  the  classic  symptoms  of  biliary  colic — sudden 
pain,  chill,  fever,  sweating,  vomiting,  and  often,  later, 
swelling  and  tenderness  of  the  liver,  distention  of  the 
gall-bladder,  discoloration  of  the  urine,  icteric  hue  of  the 
skin,  and  clay-colored  stools.  Of  far  greater  interest  to 
us,  as  pertaining  to  diagnosis,  are  the  more  unusual  varia- 
tions. It  is  very  difficult  to  understand  in  all  cases  why 
stones  which  have  lain  quiet  in  the  gall-bladder  for  a 
long  period  should  suddenly  be  forced  into  the  cystic 
duct.  Where  errors  in  diet,  over  exertion,  falls  or  jars, 
child-birth  or  menstruation  have  immediately  preceded, 
it  is  easier  to  form  an  hypothesis  and  believe  that  un- 
usual peristaltic  action  is  excited  in  the  walls  of  the  gall- 
bladder, either  indirectly  by  reflex  nervous  influences, 
or  directly  from  extension  outward  along  the  muscular 
fibres  of  the  bile-ducts  of  unwonted  peristalsis  in  the  in- 
testine. Prodromal  symptoms  in  the  way  of  sensitive- 
ness in  the  epigastrium,  chilliness  or  slight  icterus,  some- 
times exist  for  a  day  or  two  before  the  attack  of  colic ; 
but  it  is  much  commoner  for  this  to  begin  suddenly. 
Murchison1  states  that  the  attacks  occur  shortly  after  the 
ingestion  of  food ;  Naunyn,  however,  contends  that  they 
are  more  likely  to  take  place  some  hours  after  eating,  when 
the  chyme  begins  to  pass  into  the  duodeneum  and  thus 
explains  the  frequent  occurrence  of  a  first  attack  about 
midnight.  The  pain  of  biliary  colic  is  usually  severe  and 
hard  to  bear,  of  a  rending,  boring  character,  and  radiat- 
ing upward.  In  other  instances,  however,  it  may  only 
amount  to  a  slight  burning  sensation,  or  even  be  entirely 
absent.  Fever  may  either  be  absent  or  play  a  very  im- 
portant rdle.  It  is  frequently  preceded  by  a  chill,  and  is 
generally  of  short  duration,  but  may  continue  for  days 
if  the  other  conditions  persist.  Vomiting  is  usually 
severe  and  prostrating.  Occasionally  it  brings  to  light 
some  of  the  stones  which  have  caused  the  attack.  The 
muscular  contractions  or  cramps  in  the  abdomen,  legs, 
arms,  or  hands  are  of  reflex  origin.  With  these  symp- 
toms only  the  attack  may  terminate,  after  a  short  time, 
by  the  falling  back  of  the  stone  into  the  gall-bladder,  or 
by  its  passage  from  the  common  duct  into  the  intestine ; 
but  if  its  progress  is  slow  after  it  has  reached  the  com- 
mon duct  other  symptoms  are  added.  The  bile,  which 
is  secreted  continuously,  cannot  escape  by  its  usual  out- 
let but  distends  the  gall-bladder,  which  may  be  felt  in 
one-third  to  one-half  of  the  cases  under  the  right  rectus 
or  to  the  outer  side  of  that  muscle.  The  gall-bladder 
filled,  the  intra-hepatic  ducts  become  distended,  with  re- 
sulting tenderness  and  enlargement  of  the  liver,  and 
finally  the  bile  is  forced  into  the  lymphatics  and  passes 
through  the  thoracic  duct  into  the  blood.  Here  it  first 
shows  itself  in  discoloration  of  the  urine,  but  when  it 
passes  into  the  blood  more  rapidly  than  it  can  be  ex- 
creted by  the  kidneys  it  begins  to  be  deposited  in  the 
tissues,  revealing  itself  first  in  the  conjunctivae  and  later 
in  varying  intensity  in  the  skin.  The  bile  being  thus 
diverted  from  the  intestine  the  stools  become  pale  or 
day-colored  and  the  movements  constipated. 

As  is  the  case  in  many  another  affection,  of  which  the 
text-book  description  is  clear  and  classical,  in  actual  ex- 
perience there  are  many  variations  in  the  occurrence,  in- 
tensity, and  sequence  of  the  cardinal  symptoms.  As 
Charcot •  has  pointed  out,  the  chill  may  precede  the  pain, 
or  the  chill  and  fever  may  not  be  proportionate  to  the 
intensity  of  the  pain.  In  other  persons  there  may  be 
pain  and  chill  without  fever,  or  fever  without  chill,  or 
fever  without  pain.     Many  of  the  attacks,  estimated  at 

1  Clinical  Lectures  on  Diseases  of  the  Liver. 
9  Lemons  sur  les  Maladies  da  Foie.    Paris,  1887. 


fifty  per  cent.,  pass  off  without  jaundice,  or  this  may  de- 
velop, with  its  attendant  train,  as  early  as  twelve  hours 
after  the  inception  of  the  attack.  The  duration  of  the 
pain  may  be  half  an  hour  or  half  a  day,  or  it  may  persist 
continuously  or  recur  intermittently  for  several  days. 

Without  going  exhaustively  into  the  question  of  differ- 
ential diagnosis  it  may  be  mentioned  that  where  icterus  is 
absent  the  case  must  be  distinguished  from  cardialgia,  lead 
colic,  renal  colic,  fecal  impaction,  peritonitis,  appendicitis, 
and  intussusception.  Death,  though  rarely,  may  occur 
during  the  course  of  an  attack,  from  suicide,  collapse, 
syncope  from  pre-existing  cardiac  lesions,  or  rupture  of 
the  ducts  or  gall-bladder,  with  consequent  infectious  peri- 
tonitis. In  the  latter  instance  prompt  laparotomy  has 
saved  life. 

If,  as  Naunyn  claims,  in  old  age  every  tenth  man  and 
every  fourth  woman  has  gall  stones,  how  shall  we  reconcile 
this  fact  with  the  infrequency  of  biliary  colic  in  general, 
and  among  the  aged  in  particular.  S6nac  believes  that 
hepatic  colic  originates  only  between  the  twenty  fifth  and 
thirty-fifth  years,  and  that  after  sixty  stones  are  frequently 
passed  without  reaction  or  pain.  It  is  quite  possible  that 
calculi  in  the  gall-bladder  may  be  not  only  latent  but  en- 
tirely harmless ;  in  fact,  unless  their  mere  mechanical  pres- 
ence cause  ulceration  or  infectious  conditions  they  give 
no  signs  of  their  presence  until  they  enter  the  ducts. 
Arrayed  on  the  one  hand  as  factors  opposing  the  progress 
of  the  stone  are  the  small  size  and  peculiar  conformation 
of  the  ducts,  the  elasticity  of  the  walls,  and  the  reflex 
spasm  of  the  muscular  fibres  from  irritation,  as  well  as  the 
size,  consistence,  and  form'  of  the  stone  itself.  On  the 
other  hand,  assisting  its  progress  we  have  the  slight  press- 
ure of  the  bile  and  the  much  more  important  peristaltic 
contractions  of  the  muscular  coat  of  the  gall-bladder  and 
ducts.  The  cystic  duct  has  a  diameter  of  but  3  mm., 
while  that  of  the  common  duct  is  6  mm.  Here  we  per- 
haps have  an  explanation  of  the  partial  alleviation  of  the 
pain  which  often  takes  place  in  the  course  of  an  attack, 
probably  as  the  stone  passes  from  the  smaller  cystic  to  the 
larger  common  duct. 

While  after  death  the  gall- ducts  offer  much  resistance 
to  attempted  dilatation,  it  is  evident  from  postmortem 
findings'  in  those  who  had  suffered  from  repeated  passage 
of  gall-stones  that  the  ducts  can  not  only  be  dilated  but 
remain  so  permanently.  The  opening  of  the  common 
duct  into  the  duodenum  is  the  least  distensible  portion, 
as  shown  by  the  greater  frequency  with  which  stones  are 
arrested  at  this  point  than  at  any  other.  Histology  has 
contributed  the  important  fact  that  in  youth  muscular 
fibres  are  abundant  in  the  walls  of  the  ducts,  but  that  in 
old  age  they  are  much  atrophied  or  have  disappeared  en- 
tirely. 

We  are  now  in  a  position  to  understand  some  of  the 
possibilities  why  the  passage  of  stones  in  different  cases 
and  at  different  ages  may  be  accompanied  by  such  vary- 
ing reaction.  If,  as  we  may  readily  concede,  the  pain  of 
biliary  colic  is  due  to  the  stretching  of  the  ducts  and  the 
reflex  spasm  of  their  walls,  we  can  see  that  the  passage  of 
a  small  calculus  through  an  already  dilated  duct  may  be 
accompanied  by  little  or  no  pain,  while  it  is  easy  to  con- 
ceive, with  Naunyn  and  others,  that  the  atrophy  of  the 
muscular  fibres  in  old  persons  either  prevents  the  violent 
peristalsis  in  the  gall-bladder  which  forces  the  stones  into 
die  duct,  or  renders  impossible  the  reflex  spasm  of  the 
duct,  which  is  probably  the  chief  source  of  the  pain,  so 
that  gall-stones  which  are  much  more  frequent  at  this  age 
may  remain  indefinitely  in  the  gall  bladder  or  be  passed 
without  the  knowledge  of  the  patient.  A  very  few  per- 
sons escape  with  but  one  attack  of  biliary  colic  in  a  life- 
time. Most  frequently,  however,  the  attacks  are  repeated 
at  longer  or  shorter  intervals.  The  successive  attacks  in 
the  same  individual  may  be  marked  by  great  differences 
in  the  intensity  of  the  suffering,  or  one  may  be  of  short 
duration,  the  next  extend  with  exacerbations  and  re- 
missions over  several  xlays. 

One  stone  or  many  may  pass  during  a  single  attack. 
One  instance  is  recorded  where  two  hundred  and  forty- 


752 


MEDICAL  RECORD. 


[December  15,  1894 


four  calculi  were  recovered  from  the  stools  in  five  days. 
Smaller  numbers  are  much  more  frequently  found.  Much 
difference  of  opinion  has  existed  as  to  the  size  of  stones 
which  can  be  passed  through  the  ducts.  The  majority  of 
those  so  passed  are  not  larger  than  peas ;  it  is  probable, 
however,  that  calculi  as  large  as  the  kernel  of  a  hazel-nut 
can  also  pass.  The  chief  hindrance,  as  we  have  already 
seen,  is  usually  encountered  where  the  common  duct 
enters  the  duodenum.  Here  a  rupture  of  the  tissues 
with  the  formation  of  a  duodenal  fistula  may  allow  even  a 
large  stone  to  escape.  Recorded  instances  of  the  passage 
per  anum  of  very  large  stones  are  probably  the  result  of 
direct  ulceration  from  the  gall-bladder  into  the  intes- 
tine. 

Directions  are  usually  issued  that  the  stools  shall  be 
examined  for  calculi  after  an  attack  of  colic,  but  the  con- 
cretions are  not  always  found,  often  because  of  careless 
methods  or  lack  of  persistency.  The  surest  method  is 
to  pass  the  softened  stool  under  the  action  of  running 
water  through  a  piece  of  muslin  or  a  hair-sieve.  This 
treatment  should  be  extended  to  all  stools  for  eight  days, 
for  although  in  most  cases  the  stones  appear  in  the  faeces 
after  twenty-four  to  forty- eight  hours,  cases  are  recorded 
where  they  have  been  retained  until  the  eighth  day. 
Apropos  of  this  question,  one  fact  which  is  not  generally 
appreciated  is  worthy  of  especial  consideration.  Experi- 
mentation by  causing  gall-stones  of  varying  composition 
to  be  swallowed  by  healthy  men,  and  search  instituted 
therefor  in  the  stools,  has  shown  that  only  firm  or  hard 
stones,  or  those  having  a  hard  cholesterin  shell,  reappear  in 
the  dejections.  Soft  stones  and  those  of  pure  or  mixed 
bilirubin- calcium  suffer  disintegration  in  the  intestine. 
Naunyn,  in  his  extensive  researches,  has  found  but  one 
such  stone  in  the  stools,  and  that  showed  signs  of  erosion. 
It  is  therefore  evident  that  however  valuable  may  be  the 
positive  evidence  of  stones  passed  per  rectum,  the  failure 
to  find  the  same  cannot  be  considered  as  proving  that 
the  preceding  attack  of  pain  did  not  result  from  the  pas- 
sage of  a  calculus. 

Besides  the  acute  attacks  above  described,  accompany- 
ing the  expulsion  of  calculi  through  the  biliary  passages, 
there  is  a  further  extensive  group  of  affections  of  the  liver 
and  biliary  tract  dependent  upon  the  continued  presence 
of  calculi.  These  are  grouped  under  the  comprehensive 
term  "  irregular  cholelithiasis."  An  attack  of  acute  bil- 
iary colic  may  end  in  three  ways :  1,  By  the  falling  back 
of  the  stone  into  the  gall-bladder ;  2,  by  its  expulsion 
into  the  intestine ;  3,  by  its  impaction  in  the  biliary  pas- 
sages. Stones  thus  impacted  usually  give  rise,  for  a  time 
at  least,  to  repeated  attacks  of  colic,  and  it  is  evident 
that  the  occurrence  of  jaundice  and  associated  symptoms 
will  depend  upon  whether  the  site  of  the  impaction  be 
in  the  cystic  or  common  duct.  Gall  stones  are  often 
found  post  mortem  in  these  ducts.  The  majority  are 
large  stones,  larger  than  cherries,  ofttimes  they  are  the 
size  of  a  walnut  or  even  greater.  Such  atones  may  have 
been  formed  in  situ,  but  in  the  majority  of  cases  they  are 
doubtless  stones  which  have  become  impacted  and  grown 
by  accretion.  They  may  allow  the  bile  to  pass  them  into 
the  intestine,  in  which  case  they  may  exist  for  years  with- 
out harm  and  without  symptoms.  They  may  furnish  the 
necessary  factors  for  the  development  of  various  infectious 
and  ulcerative  conditions,  or  again  they  may  intermit- 
tently or  permanently  interfere  with  the  exit  of  the  bile. 
In  the  latter  event  chronic  icterus  results. 

When  chronic  icterus  is  established,  and  this  may  hap- 
pen as  readily  from  a  stone  which  has  lain  for  years  in 
the  duct  as  from  a  freshly  impacted  calculus,  the  patient 
may  succumb  as  early  as  the  tenth  day,  or  he  may  live 
for  weeks,  or  months,  or  even  years.  It  is  not  the  ob- 
struction alone  which  causes  death,  but  the  complications 
to  which  it  gives  rise.  Everything  depends  upon  whether 
the  obstruction  is  partial  or  complete.  If  the  occlusion 
of  the  duct  is  absolute,  so  that  no  bile  can  pass,  the  ducts 
behind  the  obstruction  become  dilated,  the  gall- bladder 
is  distended,  jaundice  increases,  gastric  and  intestinal  di- 
gestion become  disturbed,  and  the  patient  succumbs  from 


hemorrhage  or  from  emaciation  and  marasmus.  Where 
chronic  icterus  exists,  with  but  intermittent  or  partial  ob- 
struction, the  degree  of  icterus  is  variable,  the  liver  re- 
mains of  normal  size,  or  is  but  slightly  enlarged,  and 
there  is  no  distention  of  the  gall-bladder.  Itching  of  the 
skin  is  usually  a  distressing  symptom,  and  hemorrhages 
from  the  mucous  membranes  may  take  place,  but  the  in- 
testine continuously  or  intermittently  receives  some  bile, 
as  shown  by  the  color  of  the  faeces,  and  the  nutrition  of 
the  patient  does  not  suffer  as  rapidly  as  in  the  previous 
case. 

Among  the  common  baleful  results  of  cholelithiasis, 
more  especially  with  obstruction  of  the  common  duct,  is 
the  production  of  cholangitis,  or  an  inflammation  of  the 
biliary  radicles.  Here  again  we  find  the  bacterium  coli 
commune  as  a  specific  cause  of  the  infection  of  the  bile. 
Cholangitis  is  not  always  purulent,  even  when  it  produces 
fatal  results.  Where  the  process  has  been  distinctly  sup- 
purative, cultures  have  shown  an  admixture  of  staphylo- 
cocci and  streptococci.  Still  greater  importance  attaches  to 
the  fact  that  cholangitis  leads  to  cholecystitis  and  hepatic 
abscess.  Infectious  cholecystitis  is  excited  by  the  pres- 
ence of  the  bacterium  coli  commune  where  calculi  are 
retained  in  the  gall-bladder,  especially  when  the  cystic 
duct  is  blocked  by  a  stone.  The  contents  of  the  gall- 
bladder are  at  first  the  retained  bile  and  the  infected 
secretion  of  the  mucous  membrane.  The  biliary  constit- 
uents are,  however,  promptly  reabsorbed  and  the  gall- 
bladder then  is  filled  with  a  sero-purulent  fluid,  contain- 
ing usually  but  a  small  number  of  pus  cells.  The  more 
abundant  the  pus  the  more  applicable  to  thislcondition 
is  the  term  "  empyema  of  the  gall-bladder."  This  should 
be  clearly  distinguished  from  a  condition  known  as  "hy- 
drops of  the  gall  bladder  "  which  arises  when  the  cystic 
duct  is  blocked  without  previous  infection  of  the  con- 
tents. The  bladder  then  contains  after  a  time  a  semi- 
transparent  strongly  mucilaginous  fluid,  which  is  sterile 
and  without  any  traces  of  pus. 

Hepatic  abscess  above  referred  to  may  result  from  sup- 
purative cholangitis,  by  extension  from  an  empyema  of 
the  gall-bladder,  or  from  the  pressure  of  a  stone  in  the 
common  duct  upon  the  portal  vein  causing  thrombosis 
and  pylephlebitis.  Carcinomatous  involvement  of  the 
biliary  tract  is  of  such  frequent  occurrence  with  chole- 
lithiasis-as  to  suggest  strongly  its  dependence  upon  that 
condition.  Its  possible  existence  should  always  be  kept 
in  mind  in  cases  of  chronic  jaundice  occurring  in  old 
people. 

What,  then,  is  the  fate  of  the  stones  which  remain  in 
the  gall-bladder?  In  many  instances  doubtless  they  re- 
main unrecognized  and  innocuous,  for  they  are  revealed 
by  the  necropsy  when  no  symptoms  occurred  during  life 
which  could  be  referred  to  their  existence.  But  in  other 
cases  their  presence  is  more  or  less  pernicious.  Hyper- 
trophy of  the  muscular  fibres  of  the  gall*  bladder"  occurs, 
with  slow  contraction  of  the  viscus  about  the  mass 
as  a  whole,  or  else  it  becomes  sacculated  with  enclosure 
of  one  or  more  calculi  in  the  recesses.  Sooner  or  later 
a  desquamative  catarrh  of  the  mucous  membrane  is  set  up, 
with  thinning  or  ulceration  of  the  mucosa  from  pressure. 
Ulcerations  may  heal  with  the  production  of  cicatrices, 
or  perforation  of  the  walls  may  take  place  with  conse- 
quent peritonitis  or  the  formation  of  an  encapsulated 
abscess  beneath  the  liver ;  or  again,  where  adhesions  have 
previously  been  formed  to  the  other  viscera  or  to  the  ab- 
dominal wall,  fistulae  may  be  formed  opening  externally, 
or  into  the  stomach,  duodenum,  ileum,  or  colon.  Through 
these  latter  fistulae  the  stones  incarcerated  in  the  gall- 
bladder may  escape  into  the  gastro  intestinal  tract  and 
be  passed  per  anum,  provided  their  smallest  diameter 
does  not  exeed  3  cm.,  otherwise  they  may  be  arrested  at 
the  ileo-csecal  valve.  Larger  stones  or  masses  of  small 
stones  have  often  caused  intestinal  obstruction  and  called 
for  surgical  interference. 

The  treatment  of  biliary  lithiasis  naturally  resolves  it- 
self into  four  divisions :  1.  Treatment  of  the  acute  at- 
tack.    2.  Treatment  directed  to  resulting  conditions. 


December  15,  1894] 


MEDICAL  RECORD. 


753 


3.    Prophylaxis  against  repetition  of  the  attacks.     4. 
Surgical  indications  in  acute  and  chronic  cholelithiasis. 

During  the  acute  attack  the  indications  are  clearly  to 
relieve  the  pain,  relax  the  spasm,  facilitate  the  expulsion 
of  the  stone,  and  prevent  subsequent  complications.  The 
pain  of  biliary  colic  is  usually  so  intense  that  the  patient 
demands  that  our  first  efforts  be  directed  to  its  relief. 
This  is  most  promptly  and  efficiently  accomplished  by 
the  subcutaneous  injection  of  morphine  in  full  dose 
(gr.  }()  repeated  at  intervals  according  to  indications. 
Morphine,  however,  may  aggravate  rather  than  allay  the 
vomiting,  and  also  tends  to  decrease  the  biliary  secretion. 
It  is  therefore  best  combined  with  atropine,  which  does 
not  influence  the  secretion  of  bile,  but  does  restore  the 
disturbed  tone  of  the  muscular  fibres,  assisting  in  the 
subsequent  expulsion  of  the  stone  by  normal  peristalsis 
in  the  ducts*  Where  the  attacks  are  prolonged  opium 
and  extract  of  belladonna  by  the  mouth  are  better  borne 
than  morphine,  and  in  very  long  or  intermittent  cases 
other  analgesics — antipyrine,  chloral,  amylo  -  valerianic 
ether,  or  sodium  salicylate  may  be  wisely  substituted. 
Relaxation  of  the  spasmodic  contraction  will  be  favored 
by  prolonged  hot  baths  (95°  to  ioo°  F.),  and  chloroform 
by  inhalation  may  be  temporarily  required.  Vomiting 
is  best  allayed  by  repeated  large  draughts  of  sodium  bicar- 
bonate and  hot  water  (  3  j.-  3  ij.  to  Oj.).  This  is  at  first 
rejected  but  afterward  retained.  Later  gastric  irritation 
may  call  for  the  usual  sedatives — bismuth,  dilute  hydro- 
cyanic acid,  and  carbonated  waters.  The  pain  and  spasm 
somewhat  relieved,  our  next  interest  is  to  hasten  the  pas- 
sage of  the  calculus  through  the  duct.  For  this  purpose 
such  cholagogues  as  are  known  to  favor  the  secretion  of 
more  abundant  and  more  fluid  bile  must  be  called  into 
requisition.  Salicylate  of  soda,  besides  its  analgesic 
power,  stands  here  in  the  front  rank,  with  ox-gall,  glyc- 
erine, and  calomel.  FerrandV  experiments  not  only 
show  that  glycerine  in  massive  doses  (  3  v.-  \  j.)  is  taken 
up  by  the  lymphatics  of  the  stomach  and  carried  to  the 
liver,  where  it  produces  a  free  secretion  of  fluid  bile,  but 
its  ingestion  has  also  produced  prompt  alleviation  of  the 
pain  and  apparent  passage  of  the  stone.  Calomel,  like 
other  metals,  is  arrested  by  the  liver,  where  it  passes  into 
the  portal  system,  and  produces  a  direct  stimulation  of 
the  hepatic  cells.  Ether  and  chloroform  act  reflexly  by 
their  action  on  the  stomach.  Aloes,  euonymin,  and 
podophyllin,  and  the  benzoates  of  sodium  and  lithium 
are  also  much  vaunted  in  this  connection.  Durand's 
mixture  —  ether,  3  parts,  turpentine,  2  parts  —  once 
much  in  vogue  in  doses  of  3ss.-3j.  in  bouillon,  but 
badly  borne  by  the  stomach,  has  now  been  relegated  to 
the  treatment  of  more  chronic  cases.  Olive  oil,  recom- 
mended by  Chaiiffard  in  doses  of  §  vj.-  §  viij.,  and  given 
in  two  portions,  with  an  interval  of  a  quarter  of  an  hour, 
with  the  patient  lying  upon  his  right  side,  is  both  safe 
and  inoffensive,  and  often  well  tolerated  by  the  stomach. 
Willemin  has  seen  it  followed  by  almost  instantaneous 
relief  of  the  pain,  which  occurred  so  quickly  as  to  be 
probably  the  result  of  reflex  action.  The  more  prolonged 
the  attack,  the  greater  the  danger  of  secondary  complica- 
tions. When  congestion  is  marked  and  inflammatory 
conditions  in  the  liver  threaten,  moist  heat  applied  over 
the  liver  by  poultices  or  fomentations  relieve  pain  by 
lessening  congestion,  and  reduce  the  liability  to  inflam- 
matory reaction.  If  the  process  be  more  advanced  and 
there  be  signs  of  cholecystitis  or  hepatitis,  more  active 
antiphlogistic  remedies  may  be  indicated — eight  to  ten 
leeches,  mustard  or  vesicants,  or  cold  in  the  form  of  ice- 
bags  may  be  cautiously  employed. 

Infectious  cholangitis  and  hepatic  fever  call  for  anti- 
septics which  will  be  excreted  in  the  bile.  Calomel  is 
best  given  in  three  to  eight  grain  doses  every  two  to  three 
days.  The  benzoates,  and  especially  benzo-naphthol, 
have  been  strongly  endorsed.  Salol  and  salicylate  of 
soda  are  particularly  useful  when  there  is  fever.  In  con- 
sidering certain  of  the  above  indications  for  treatment  it 
is  impossible  to  sharply  distinguish  between  cases  of  short 
1  Gar.  des  Hop.,  September,  1894,  p.  947. 


and  long  duration!  if  we  would  avoid  useless  repetitions, 
and  much  that  has  been  said  is  applicable  to  cases  where 
the  stone  remains  impacted  in  the  duct.  In  the  intervals 
between  the  attacks,  to  remove  the  impacted  stone 
or  to  prevent  the  occurrence  of  fresh  crises,  glyce- 
rine, 3  j-  to  3  iv.  per  day,  may  be  given  in  slightly  alka- 
line water,  or  olive  oil  may  be  administered  in  $  ij.  por- 
tions at  bedtime.  A  method  taught  in  one  of  our  largest 
clinics,  and  practised  with  considerable  success,  is  the  ad- 
ministration of  the  oil,  once  daily,  in  milk,  one  table- 
spoonful  the  first  day,  and  an  additional  tablespoonful 
each  day  until  upon  the  sixth  day  six  are  taken.  What- 
ever the  method  of  giving  the  oil  may  be,  it  should  cease 
on  the  sixth  or  eighth  day,  and  not  be  resumed  until  the 
same  number  of  days  have  elapsed. 

Prophylaxis  is  of  course  only  applicable  to  those  who 
have  previously  suffered  from  the  passage  of  calculi.  It 
.  is  therefore  to  be  considered  after,  rather  than  before,  the 
treatment  of  the  acute  attack.  It  should  be  directed 
toward  securing  a  free  secretion  of  bile  by  the  use  of  chol- 
agogue  remedies,  and  toward  favoring  satisfactory  evac- 
uation of  the  bile  from  the  gall-bladder.  To  this  latter 
end  active  exercise,  massage,  and  hydrotherapy  are  use- 
ful in  themselves,  and  also  because  they  favor  deep  res- 
piratory efforts.  Our  knowledge  of  the  influence  of  diet 
upon  the  incidence  of  cholelithiasis  is  so  slight  that  we 
can  only  caution  against  over  eating  and  the  excessive 
use  of  rich  food-stuffs,  alcohol,  or  condiments.  Daily 
evacuation  of  the  bowels  should  be  secured,  and  the 
clothing  should  be  such  'as  to  allow  unimpeded  play  of 
the  .abdominal  and  respiratory  muscles.  No  case  of 
chronic  biliary  lithiasis  need  be  considered  hopeless,  or, 
if  the  symptoms  be  not  urgent,  condemned  to  surgical 
procedures,  before  testing  the  result  of  a  course  at  Vichy 
or  Carlsbad,  or  some  other  of  the  hot  sodium,  or  sodium 
and  magnesium  springs,  for  the  results  under  such  treat- 
ment are  often  surprisingly  prompt  and  successful. 

Surgical  interference  may  be  required  both  in  acute 
and  chronic  cases.  In  the  former,  where  rupture  of  the 
ducts  or  gall-bladder  has  taken  place  during  the  parox- 
ysm, with  escape  of  bile  and  threatened  peritonitis.  In 
chronic  cases,  to  relieve  an  incarcerated  calculus  in  the 
duct,  or  to  remove  Ynasses  of  calculi  from  the  gall-blad- 
der when  these  conditions  have  caused  ulceration,  infec- 
tious cholangitis,  cholecystitis,  or  empyema  of  the  gall- 
bladder, especially  where  there  is  danger  to  the  patient 
from  the  continued  temperature,  emaciation,  or  threatened 
general  infection.  Jaundice,  and  its  accompanying  hem- 
orrhagic tendency  enhances,  many  fold,  the  dangers  of 
operative  interference,  but  does  not  in  itself  constitute  a 
counter- indication. 

19  West  Forty-sixth  Stmbt* 


Football  Casualties  and  Fatalities.— B.  Foote,  a  stu- 
dent at  the  Fairfield  Seminary,  near  Little  Falls,  N.  Y., 
became  violently  insane  a  week  ago  because  of  injuries 
received  in  a  football  game  in  which  he  played  centre 
rush.  He  rushed  around  the  dormitory  all  Sunday  night 
in  his  football  suit,  and  was  only  secured  by  a  ruse  at 
daybreak.  He  was  then  taken  to  the  Utica  Insane  Asy- 
lum, where  he  is  now  confined.  Daniel  McTiernan, 
fourteen  years  of  age,  who  played  at  Worcester  on  Satur- 
day, December  8th,  in  a  school  game,  was  fallen  on  in  a 
rush,  and  was  so  injured  that  he  died  during  the  night.  At 
Shreve,  O.,  on  December  8th,  Walter  Blackburn,  nineteen 
years  of  age,  received  injuries  in  a  football  game  which 
caused  his  death.  While  "  interfering  "  with  another 
player,  Blackburn  was  thrown  heavily  to  the  ground  and 
five  or  six  of  the  players  fell  on  him.  When  he  was  ex- 
tricated he  was  paralyzed  from  the  neck  down,  and  a 
surgical  examination  disclosed  the  fact  that  the  spinal 
column  had  been  fractured. 

"  Teratalogia  "  is  the  name  of  a  new  quarterly  journal 
devoted  to  "  ante-natal  pathology."  It  is  edited  by  Dr. 
J.  W.  Ballantyne,  of  London. 


754 


MEDICAL  RECORD. 


[December  15,  1894 


Medical  Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


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


New  York,  December  15,  1894. 


THE    REPORT    OF  THE   SURGEON-GENERAL 
OF  THE  NAVY. 

The  report  of  Surgeon- General  Tryon  for  the  year  just 
past  contains  one  item  of  more  general  interest  than  such 
documents  usually  do,  namely,  the  treatment  of  pneu- 
monia. During  the  year  there  were  thirty-three  cases  of 
acute  pneumonia  admitted  to  the  hospital  in  this  city, 
and  of  that  number  thirty-one  recovered.  This  unu- 
sually low  mortality-rate  is  naturally  regarded  as  a  result 
of  the  method  of  treatment  adopted.  This  method  con- 
sisted in  the  hypodermic  injection  of  one- thirtieth  to 
one-twenty-fifth  grain  of  sulphate  of  strychnine  every 
three  or  four  hours,  together  with  a  very  free  use  of 
alcoholic  stimulants.  The  health  of  the  Navy  in  general 
was  excellent.  The  remarkable  immunity  of  the  officers 
and  men  on  board  the  ships  in  the  harbor  of  Rio  de 
Janeiro,  during  the  yellow-fever  epidemic  there  a  year 
ago,  is  referred  to  with  a  pardonable  show  of  satisfaction. 
There  was  but  one  case  of  yellow  fever  on  an  American 
man-of-war  out  of  a  total  complement  of  1,762,  and  this 
case  might  have  been  prevented  had  the  sanitary  regula- 
tions been  obeyed.  During  this  time  of  practically  com- 
plete immunity  on  American  war-ships,  there  was  disease 
on  board  the  vessels  of  every  other  nation  in  the  harbor, 
while  many  merchant  vessels  lost  nearly  their  entire 
crews.  A  circular  has  been  issued  calling  for  reports 
relating  to  the  sanitary  measures  employed  in  the  pre- 
vention of  yellow  fever  on  board  war- vessels,  and  it  is 
hoped  that  such  reliable  information  will  be  obtained 
from  the  answers  to  this  letter,  that  the  medical  depart- 
ment will  be  able  to  formulate  sanitary  rules  and  regula- 
tions on  the  subject  that  will  be  of  value  as  a  guide  to 
vessels  of  the  Navy  when  obliged  in  future  to  serve  in  an 
infected  port.  When  such  general  sanitary  rules,  em- 
bracing special  precautionary  measures  against  the  intro- 
duction of  yellow  fever  and  cholera  or  board  vessels  of 
war  have  been  formulated,  they  will  be  submitted  to  the 
authorities  with  the  request  that  they  be  made  depart- 
ment regulations. 

Concerning  the  Naval  Museum  of  Hygiene,  the  report 
states  that  the  exhibits  have  now  all  been  transferred  to 
the  building,  formerly  the  Naval  Observatory  in  Wash- 
ington, which  was  recently  set  apart  by  the  Secretary  of 
the  Navy  for  this  purpose.  "  The  interest  that  has  been 
manifested  by  the  service  and  by  professional  and  scien- 
tific bodies,  in  the  growth  and  development  of  a  museum 
identified  with  the  practical  study  and  advancement  of 
sanitary  science,  is  shown  by  the  steady  increase  in  the 


number  of  exhibits.  By  the  removal  of  the  museum  to 
commodious  and  permanent  quarters,  the  object  of  its 
organization  can  now  be  satisfactorily  fulfilled,  and 
opportunities  offered  for  accomplishing  good  work  in  the 
future.  One  hundred  and  ten  new  exhibits  were  added 
to  the  collection  during  the  past  year,  including  the 
complete  and  interesting  model  of  the  system  of  disinfec- 
tion practised  at  the  quarantine  station  at  New  Orleans. 
This  model  was  exhibited  at  the  Columbian  Exposition 
at  Chicago,  and  presented  to  the  Museum  by  the  Louisi- 
ana State  Board  of  Health.  Thirty  specimens  of  animal 
parasites,  contributed  by  the  Department  of  Agriculture, 
have  also  been  received,  remounted,  and  labelled." 

The  necessity  of  organizing  a  hospital  corps  is  insisted 
upon,  for  the  services  which  such  a  corps,  well  drilled 
and  equipped,  could  render  would  be  invaluable  to  the 
Navy.  Such  a  corps  exists  in  the  Army,  and  its  useful- 
ness has  been  demonstrated  time  and  again.  Other 
navies  are  introducing  it,  and  much  time  and  thought  are 
there  being  given  to  its  perfection,  and  the  Surgeon- 
General  therefore  urges  that  some  legislative  action  relat- 
ing to  this  subject  be  taken  by  Congress  at  an  early  date. 

Dr.  Tryon  refers  again  to  the  strange  oversight  in  rela- 
tion to  the  sick  quarters  in  the  new  ships.  "  On  board 
of  ten  vessels  no  quarters  are  designated  for  the  treatment 
of  the  sick  and  wounded ;  in  the  case  of  the  Minneapolis 
the  omission  was  probably  due  to  an  oversight,  as  this 
vessel  was  designed  on  similar  lines  to  her  sister  ship 
the  Columbia.  Subsequent  to  the  examination  of  the 
plans  of  our  uncompleted  warships,  the  drawings  of  the 
armored  cruiser  Brooklyn  and  the  battleship  Iowa  were 
submitted  to  the  Bureau  and,  in  consultation  with  the 
President  of  the  Board  of  Inspection  and  Survey,  and  the 
Bureau  of  Construction  and  Repair,  suitable  sick  quarters 
were  located."  In  view  of  the  omissions  in  the  past,  it 
is  very  reasonably  suggested  that,  hereafter,  the  medical 
department  be  consulted  as  to  the  location  of  sick-bays 
on  ships  which  may  hereafter  be  constructed. 


THE  MICROBES  OF  THE  EYE. 

The  researches  of  bacteriologists  have  shown  that  the 
conjunctival  sac  is  a  famous  feeding-ground  for  microbes 
of  all  kinds.  A  very  complete  and  learned  review  of  the 
question  by  Dr.  A.  Cu6nod  {Gazette  des  Hopitaux),  shows 
the  present  status  of  the  subject  and  indicates  that,  in 
time,  all  inflammatory  conditions  of  the  conjunctiva  will 
be  distinguished  nosologically  by  their  specific  microbes 
rather  than  by  the  vascular  reactions.  Thus,  he  shows 
that  the  acute  catarrhal  inflammations  are  due  sometimes 
to  the  bacillus  of  Weeks  and,  more  rarely,  to  a  pneumo- 
coccus  or  streptococcus  organism.  The  purulent  con- 
junctivitis of  genital  origin  is  usually  due  to  the  gonococ- 
cus.  Croupous  conjunctivitis  may  be  due  to  the  bacillus 
of  Loeffler,  but  is  oftener  a  mixed  infection. 

In  chronic  inflammatory  conditions  there  have  been 
found  the  trachoma  coccus  (Koch,  Poncet,  Michel),  the 
gonococcus,  and  a  microsporon  described  by  Noisewski. 
In  xerosis,  the  bacillus  of  pseudo-diphtheria  is  present. 
The  bacilli  of  tuberculosis  and  of  lupus  also  may  develop 
in  the  conjunctiva. 

According  to  Cuenod,  in  the  healthy  conjunctival  sac 
one  never  finds  the  microbes  characteristic  of  the  three 
principal  forms  of  acute  conjunctival  inflammation  (blen- 


December  15,  1894] 


MEDICAL    RECORD. 


755 


orrhagic,  diphtheritic,  and  contagious  catarrhal).  Only 
exceptionally  does  one  meet  with  staphylococci,  strepto- 
cocci, and  pneumococcL  The  conjunctiva  is,  therefore, 
reasonably  aseptic  in  healthy  eyes.  The  constant  flow 
of  lachrymal  fluid  across  its  surface  is  believed  to  have 
some  antiseptic  influence. 


TYPHOID  FEVER  AND  SOCIETY. 

Typhoid  fever,  like  death,  is  no  respecter  of  persons. 
A  lay  journal  laments  the  fact  that  this  very  democratic 
disease  has  attacked  several  members  of  "society  "  dur- 
ing the  past  fall,  and  has  thereby  interfered  sadly  with 
many  high  social  functions.  Dr.  Samuel  Wilks,  in  a  re- 
cent address,  asserts  that  typhoid  fever  seems  to  need  no 
specially  adapted  soil,  but  seizes  upon  the  vigorous  and 
healthy  as  quickly  as  upon  the  weak.  This  is  the  general 
experience,  though  as  age  increases  some  immunity  is 
experienced.  Most  intelligent  persons  nowadays  know 
that  typhoid  is  communicated  through  what  we  eat — and 
especially  through  what  we  drink.  In  the  houses  of  the 
intelligent  and  of  the  wealthy,  and  in  many  well-con- 
ducted hotels,  sterile  waters  are  largely  provided.  Yet 
the  disease  continues  to  affect  the  rich  and  poor.  This 
only  shows  that  the  watchfulness  is  not  complete  enough ; 
it  is  easy  to  forget  when  the  enemy  is  a  subtle  and  invis- 
ible one,  and  one  that  lurks  in  dark  and  unexpected 
places,  as  do  the  germs  of  enteric  fever. 


FRIGO-THERAPEUTICS. 

French  medical  science  seems  unhappy  without  some 
sensation.  Perhaps  the  very  latest  is  that  which  goes 
under  the  name  of  "  frigo- therapeutics."  Accounts  of 
it  have  been  telegraphed  to  our  daily  papers.  Professor 
Pictet,  we  are  told,  recently  explained  the  new  method 
before  the  Academy  of  Medicine.  He  began  the  devel- 
opment of  his  new  treatment "  by  experimenting  on  dogs, 
and  found  that  when  they  were  plunged  into  a  bath  at 
low  temperature  and  were  kept  there  for  some  time,  they 
became  ravenously  hungry.  Being  himself  a  sufferer 
from  stomach  disease,  he  had  forgotten  what  it  was  to 
have  an  appetite.  So  he  descended  into  the  refrigerating 
tank  at  a  temperature  many  degrees  below  zero.  He 
wrapped  a  thick  pelisse  and  other  warm  clothes  about 
him,  but  after  four  minutes  he  began  to  feel  hungry.  At 
the  end  of  eight  minutes  he  climbed  out  of  the  tank  with 
a  painfully  keen  appetite.  Many  such  experiments  were 
made.  All  meals  taken  after  a  short  stay  in  the  refrig- 
erator agreed  with  him.  He  found  that  his  dyspepsia 
was  cured  after  the  tenth  descent." 

This  account  has  a  very  up-todate  flavor  about  it. 
The  idea  of  curing  dyspepsia  by  making  the  patient  sit 
in  a  cold  tank  is  certainly  original,  but  it  will,  we  fear, 
apply  only  in  carefully  selected  cases,  and  the  freedom 
from  dyspepsia  may  be  accompanied  with  colds,  coughs, 
and  rheumatism. 

And  who  knows  but  that  sitting  in  a  hot  tank  might 
not  be  still  more  effective.  Dr.  Ashmead  describes,  in 
the  University  Medical  Magazine,  the  hot-tank  treatment 
of  the  Japanese,  which  there  seems  to  be  very  popular. 
He  says  that  "  In  Bungo,  Japan,  near  a  town  of  a  thou- 
sand homes  and  five  thousand  inhabitants,  on  the  coast  of 
Kiushiu,  at  the  foot  of  an  old  volcano,  there  is  a  warm- 


spring  watering-place  much  frequented  by  poor  people. 
They  crowd  there  between  the  barley  harvest  and  the 
June  rice  planting.  Eighty-two  springs  belong  to  the 
place.  A  peculiar  way  of  taking  this  treatment  is  the 
sand-bath,  and  this  is  the  manner  of  it :  Some  of 
the  springs,  all  of  them  hot,  are  so  near  the  beach  that 
they  are  covered  by  the  full  tide.  When  the  waters  re- 
cede, basins  are  dug  in  the  sand  heated  by  these,  and 
frequenting  patients  bury  themselves  in  these  holes  up  to 
the  neck.  Those  who  use  the  sand-baths  usually  remain 
for  several  hours  in  them,  umbrellas  being  held  over 
their  heads  to  protect  them  against  the  sun." 

It  is  going  to  take  a  good  deal  of  skill  to  determine 
whether  the  cold  tank  or  the  hot  sand  is  the  better  way 
to  cure  chronic  invalidism.  In  attempting  to  make  a 
choice  between  the  two  it  may  be  safest  to  follow  the 
habitual  rule  when  supping  with  the  Sheolistic  gentleman 
who  blows  hot  and  cold  in  the  same  breath,  and  use  a 
long  spoon. 


Hews  at  tUc  ftfteetu 

Spurious  Antitoxin.  —  It  is  reported  that  there  is  a 
spurious  antitoxin  in  the  market.  The  Health  Depart- 
ment has  very  properly  and  promptly  determined  to  in- 
stitute proceedings  against  such  as  can  be  proven  to  be 
offenders. 

Appointments  of  Deputy  Coroners. — Dr.  Emil  W. 
Hoeber,  Coroner-elect,  has  appointed  Dr.  John  B.  Huber 
Deputy-coroner,  with  the  very  commendable  view  of  util- 
izing autopsical  material  for  pathological  study.  The 
choice  was  made  after  consultation  with  several  leading 
physicians.  Dr.  W.  O' Meagher,  also  Coroner- elect,  has 
appointed,  with  the  same  ends  in  view,  Professor  James 
E.  Kelly,  M.D.,  well  known  as  a  skilful  surgeon,  a 
thorough  anatomist,  and  an  accomplished  pathologist. 

Errata  in  Dr.  Cleaves's  Article. — On  page  718,  first 
column,  eighteen  lines  from  the  bottom :  "  There  was  a 
rise  in  the  temperature  of  from  1  to  8  degrees,"  should 
read,  "of  from  .1  to  .8  degree." 

The  Death  of  Dr.  Stuart  Douglas. — At  the  seventieth 
stated  meeting  of  the  Society  of  Alumni  of  Bellevue 
Hospital,  held  at  the  Hotel  Brunswick,  Wednesday,  De- 
cember 5,  1894,  the  following  resolution  was  adopted : 

Whereas,  In  the  death  of  Dr.  Stuart  Douglas,  the  So- 
ciety of  Alumni  of  Bellevue  Hospital  has  lost  one  of  its 
most  esteemed  members  and  friends,  whose  ability  had 
already  brought  distinction  and  gave  promise  of  a  brill- 
iant future ;  therefore,  be  it 

Resolved,  That  this  Society  extend  to  the  members  of 
his  family  their  most  heartfelt  sympathy.  And  be  it 
further  resolved,  that  this  resolution  be  spread  upon  the 
minutes  of  the  Society,  and  a  copy  sent  to  his  family  and 
the  medical  press  of  New  York  and  Virginia.  Matthew 
D.  Field,  William  E.  Studdeford,  John  M.  Brooke, 
Committee  on  Resolutions. 

Examinations  for  the  Public  Services. — An  esteemed 
correspondent  writes  that  an  item  appearing  in  a  recent 
issue  concerning  the  proportion  of  successful  candidates 
for  the  medical  staff  of  the  Army  and  Navy,  might  con- 
vey a  wrong  impression  as  to  the  difficulties  of  the  ex- 


756 


MEDICAL   RECORD. 


[December  15,  1894 


aminations.  The  item  was  gleaned  from  the  reports  of 
the  Surgeon-general  of  the  two  services,  and  of  course 
did  not  make  mention  of  the  previous  training  of  the 
candidates.  Our  correspondent  states  that  a  large  ma- 
jority of  those  who  succeeded  in  passing  the  examina- 
tions had  studied  under  teachers  who  make  a  specialty 
of  preparing  candidates  for  such  examinations;  while 
most  of  those  who  failed  had  made  no  such  special  study. 
The  examinations  are  rigid  but  fair,  and  no  young  grad- 
uate who  studies  faithfully  under  competent  instructors 
need  despair  of  success. 

Edward  Henry  Van  Winkle,  M.D.,  died  of  paralysis 
of  the  heart,  at  25  West  Ninth  Street,  last  week,  aged 
seventy-nine.  Dr.  Van  Winkle  was  born  in  the  town 
of  Aquackanorick,  N.  J.  He  was  graduated  from  the 
College  of  Physicians  and  Surgeons,  and  began  to  prac- 
tise in  1838.    Three  years  ago  he  retired. 

Opening  of  a  Vew  Hospital  for  Incurables Seton 

Hospital,  at  Spuyten  Duyvil,  was  formally  opened  on 
December  4th.  Twenty  years  ago  Sister  Irene,  Mother 
Superior  of  the  New  York  Foundling  Asylum  in  Sixty- 
eighth  Street,  began  to  raise  funds  for  a  hospital  for  those 
afflicted  with  incurable  diseases.  She  is  an  old  woman 
now,  and  was  unable  to  attend  the  opening  of  the  in- 
stitution, but  she  had  the  satisfaction  of  knowing  that 
her  purpose  had  been  accomplished. 

The  hospital  overlooks  the  Hudson,  and  is  surrounded 
by  spacious  grounds.  It  is  named  for  Mother  Seton, 
the  founder  of  the  order  of  the  Sisters  of  Charity  in  the 
United  States.  The  building  is  of  brick,  four  stories 
high,  250  feet  front,  and  200  feet  deep.  To  the  east 
and  west  there  are  two  wings,  each  90  feet  deep.  The 
building  was  begun  about  three  years  ago  and  cost 
2 33°>o°o-  All  expenses  have  been  met  and  the  hospital 
opens  entirely  free  from  debt  It  will  be  in  charge  of 
Sister  Mary  Dolores,  and  a  board  of  managers  yet  to  be 
appointed.  The  chief  of  the  medical  staff  will  be  Dr. 
J.  West  Roosevelt 

Tablet  to  the  Memory  of  Dr.  Wells.— A  tablet  of 
bronze  erected  to  the  memory  of  Dr.  Horace  Wells,  of 
Hartford,  Conn.,  was  unveiled  on  December  nth,  with- 
out ceremony,  owing  to  the  inclemency  of  the  weather. 
It  commemorates  the  fiftieth  anniversary  of  the  discov- 
ery by  Dr.  Horace  Wells  of  nitrous  oxide  gas  as  an 
anaesthetic.  On  December  n,  1844,  the  late  Dr.  John 
M.  Riggs,  at  Dr.  Wells's  request,  administered  nitrous 
oxide  gas  to  him  and  extracted  a  tooth  without  pain. 
The  tablet  bears  a  medallion  portrait  of  Dr.  Wells  and 
the  inscription : 

"  To  the  memory  of  Horace  Wells,  the  dentist,  who 
upon  this  spot,  December  11,  1844,  submitted  to  a 
surgical  operation,  discovered,  demonstrated,  and  pro- 
claimed the  blessings  of  anaesthesia." 

Two  hundred  and  fifty  dentists  in  this  country  con- 
tributed to  the  fund  for  the  tablet.  The  Connecticut 
State  Dental  Society  gave  a  banquet  in  honor  of  the 
event. 

A  Popular  Subscription  to  Supply  the  Poor  with 
Diphtheria  Antitoxin  has  been  started  by  the  New 
York  Herald,  which  paper  subscribes  $1,000. 

The  Elmira  Reformatory. — The  commission  appointed 
by  Governor  Flower  to  investigate  the  Reformatory  has 


made  a  majority  report  in  which  it  is  said,  as  a  conclu- 
sion :  The  Elmira  Reformatory  is  not  a  perfect  institution 
in  all  respects,  as  this  report  indicates.  There  is  room 
for  improvement  in  some  matters  that  could  not  properly 
be  covered  in  this  report.  As  it  is  organized  and  con- 
ducted, however,  it  is  a  model  reformatory.  Its  results 
have  been  extraordinary  as  regards  its  success  in  the 
reformation  of  criminals.  It  probably  stands  pre-eminent 
among  the  reformatories  of  the  world.  These  results  are 
due  to  the  unselfish  devotion  of  the  managers,  and  the 
extraordinary  qualities  of  Mr.  Brockway  as  an  organizer 
and  executive  officer,  added  to  his  intimate  knowledge 
of  the  criminal  character.  The  managers  are  fully  justi- 
fied in  the  confidence  they  have  reposed  in  their  General 
Superintendent.  Whatever  defects  we  have  noticed,  as 
brought  out  by  this  investigation,  have  in  no  way  in- 
volved hardship  or  injustice  to  any  inmate,  as  far  as  has 
been  shown  by  the  evidence,  except  in  the  single  case  of 
Aaron.  This  case  is  one  among  more  than  6,000  con- 
victs who  have  been  received  at  the  institution  since  its 
establishment.  A  very  few  changes,  not  difficult  to  effect, 
and  involving  but  little  additional  cost,  would  render  this 
an  ideal  institution  of  the  kind. 

1.  The  number  of  inmates  should  never  exceed  the 
number  of  cells,  and  the  number  of  cells  should  not  be 
increased.  Doubling  up  has  evident  evils  to  which  it  is 
unnecessary  to  refer.  Intelligent  and  efficient  treatment 
of  inmates  requires  a  close  study  of  individual  character- 
istics.  We  believe  that  the  work  of  the  Reformatory 
could  be  better  done  with  a  population  of  600  than  with 
1,200. 

2.  The  Reformatory  physician  should  have  an  assistant, 
who  should  reside  in  the  Reformatory,  and  the  medical 
care  and  supervision  of  inmates  should  be  conducted  on 
the  lines  indicated  in  the  body  of  this  report. 

3.  Should  the  administration  of  corporal  punishment 
be  restored,  no  blows  should  be  given  except  on  the  but- 
tocks,  except  in  self-defence  or  in  instances  of  violent  re- 
sistance.   Very  respectfully  submitted. 

Austin  Flint,  Israel  T.  Deyo, 
Commissioners, 
A  minority  report  by  Judge  Learned  thinks  that  pun- 
ishment was  inflicted  too  often,  and  criticises  the  laws 
regarding  the  institution.  Governor  Flower  Hi«mi«— « 
the  charges.  On  the  whole,  the  general  management  of 
the  institution  has  been  amply  justified. 

Progress  of  Serum  Therapy.— A  Sero-therapeutic  In- 
stitute for  the  east  of  France  is  in  process  of  formation. 
At  Amsterdam  serum  is  being  prepared  by  Professor 
Forster.  Various  journals,  both  political  and  medical, 
are  collecting  subscriptions,  and  considerable  sums  have 
already  been  obtained.  In  Spain  the  preparation  of  se- 
rum has  been  begun  in  the  Municipal  Laboratory  of  Bar- 
celona, under  the  direction  of  Dr.  Jaime  Ferrin.  Two 
horses  are  being  immunized  by  Drs.  Robert  amd  Llor- 
ente.  Dr.  F.  Spat  writes  to  the  Munchener  medidnische 
Wochenschrift  to  point  out  that  the  germ  of  "  sero-thera- 
py  M  is  to  be  found  in  a  passage  of  Pliny  which  has  been 
overlooked  by  Sprengel,  Haeser,  and  other  historians  of 
medicine.  It  is  well  known  that  Mithridates,  the  famous 
King  of  Pontus  (b.c  124-64)  was  believed  to  have  made 
himself  proof  against  poisons,  apparently  by  a  system  of 
graduated  dosage  till  tolerance  was  established.    As  the 


December  15,  1894] 


MEDICAL   RECORD. 


757 


result  of  his  experiments  on  himself,  he  is  said  to  have 
hit  upon  a  kind  of  universal  antidote  which  was  famous 
in  the  ancient  world  under  the  name  of  mithridaticum. 
One  ingredient  in  this  antidote  seems  to  have  been  the 
blood  of  the  Pontic  duck,  which  the  King  added  be- 
cause that  fowl  lived  on  poison  (sangutnem  anatum  Pen- 
ticorum  antidotis  miseere  quoniam  vcnenum  viverent  Pliny, 
Natural  History,  Lib.  xxv.,  S.  iii.,  Ed.  Harduin,  p. 
210).  In  the  Riforma  Medica  of  October  30th,  Dr. 
Ricardo  Agostini  calls  attention  to  some  experiments  on 
the  preventive  and  curative  inoculation  of  the  diphtheria 
poison,  made  some  thirty  five  years  ago  by  Dr.  Giuseppe 
Babola,  of  Santa  Margherita  di  Montagnana.  In  1859 
that  practitioner  referred,  in  the  Gazzctta  Medica  Itali- 
ana,  to  two  such  experiments  which  might  serve  as  the 
basis  of  future  researches.  He  states  that  he  inoculated 
two  healthy  girls  with  membrane  taken  from  the  throat 
ot  a  sister  who  was  seriously  ill  with  the  disease,  the  re- 
sult being  a  very  mild  attack  in  each  case.  Some  years 
later  he  returns  to  the  subject  in  the  same  journal, 
(March  7, 1863).  In  the  same  periodical  for  February 
13, 1864,  he  reported  a  further  series  of  experiments,  for 
which  he  claimed  fairly  successful  results,  especially  as 
regards  the  prophylactic  effect  of  the  inoculation.  His 
method  was  to  make  two  or  three  punctures  on  the  arm 
with  the  point  of  a  lancet  that  had  been  dipped  in  diph- 
theria products  removed  from  a  patient's  throat  with  for- 
ceps. Babola  compares  his  method  with  vaccination  and 
the  inoculation  of  syphilis,  and  attempts  to  explain  its 
mode  of  action. 

The  Index  Hedieus  is  to  be  discontinued. 

A  Medical  Fasse-Partout.— The  head  of  the  Berlin 
police  has  decided  on  issuing  to  practitioners  in  that  city 
what  may  be  translated  as  a  "crowd  threader,"  on  the 
presentation  of  which  all  constables  will  be  bound  to  as- 
sist the  possessor  in  making  his  way  through  crowds. 
The  privilege  is  to  be  applicable  to  foot  doctors  only ; 
the  carriage-keeping  section  of  the  fraternity  must  make 
their  way  by  their  own  unaided  efforts,  or  rather  by 
those  of  their  coachmen. 

The  Profits  of  an  Amateur  Sport. — The  expenses  of 
one  football  team  (Yale)  for  one  year  (1892)  were  $15,- 
284.62  and  the  gross  receipts  $31,300.71,  leaving  the  net 
receipts  $16,016.09.  The  net  receipts  last  year  were  for 
the  same  team,  $22,914.  In  1892  the  team  paid  for 
drugs,  surgical  supplies,  medical  services,  and  rubbers, 
$857.89. 

St.  Francis  Hospital,  Hew  York. — Dr.  John  Doming 
has  been  appointed  Visiting  Physician  to  the  St.  Francis 
Hospital. 

Exportation  of  Live  Cattle  to  Germany. — The  Ger- 
man Ambassador  at  Washington  has  notified  the  Secre- 
tary of  State  that,  in  consequence  of  the  introduction  of 
Texas  fever  into  Germany  by  means  of  two  shipments 
from  New  York,  the  importation  of  fresh  beef  and  cattle 
from  the  United  States  to  Germany  will  soon  be  pro- 
hibited. No  such  disease  is  reported  among  recent  ship. 
ments,  however,  and  it  is  believed  that  that  is  only  an 
excuse,  and  that  the  real  reason  is  to  retaliate  against 
this  country  on  account  of  the  discrimination  against 
German  beet-sugar  in  the  new  tariff  law. 


JOHN  MILLS  BROWNE,  M.D., 

KX-SURGEON-G&NKRAL  UNITED  STATES  NAVY. 

John  Mills  Browne,  Ex-Surgeon- General,  United 
States  Navy,  born  in  Hinsdale,  N.  EL,  May  10,  1831. 
Graduated  at  the  Medical  Department  of  Harvard  Uni- 
versity in  March,  1852.  Appointed  from  New  Hamp- 
shire, March  25,  1853 ;  entered  the  service  as  Assistant- 
Surgeon  and  performed  first  duty  on  board  the  storeship 
Warren,  Lieutenant  Commanding  Fabius  Stanly,  at  Sau- 
celito,  opposite  San  Francisco;  in  September,  1854,  the 
Warren,  Lieutenant  Commanding  D.  McDougall,  pro- 
ceeded to  Mare  Island  and  became  the  temporary  resi- 
dence of  Commander  D.  G.  Farragut,  the  inaugurator 
and  first  commander  of  the  Navy  Yard ;  Medical  Officer 
of  the  Navy  Yard  until  May  10,  1855 ;  then  duty  on 
board  Coast-survey  steamer  Active,  Lieutenant  Com- 
manding, James  Alden  ;  attached  to  Active  until  No- 
vember, 1857;  Active  employed  in  surveying  the  coast 
and  harbors  of  California,  Oregon,  and  Washington  Ter- 
ritories in  the  winter  of  1855-56,  with  the  steamer  Massa- 
chusetts and  the  sloop  Decatur;  Passed  Assistant  Surgeon, 
May  12, 1858 ;  brig,  Dolphin,  Lieutenant  Commanding, 
John  N.  Maffit,  June  1,  1858,  Home  Squadron  off  Cape 
Verde,  Cuba,  Dolphin  captured  the  brig  Echo  with  over 
three  hundred  slaves  destined  for  the  Cuban  market; 
Echo  sent  to  Charleston,  S.  C,  subsequently  the  surviv- 
ing negroes  were  taken  to  Liberia  in  the  frigate  Nisagra ; 
October  1,  1858,  steamer  Atlanta,  Commander  D.  B. 
Ridgly,  Paraguay  expedition ;  December  25,  1858,  Hos- 
pital Norfolk,  Surgeon  Ninian  Pinkney;  May  9,  1859, 
sloop  Constellation,  Flag  Officer  William  Inman,  Fleet 
Surgeon  Thomas  D.  Smith,  Flag  Ship  of  African  Squad- 
ron ;  visited  Madeira,  Cape  de  Verde  Islands,  St.  Helena, 
Liberia,  St.  Paul  de  Loanda  and  other  ports  and  islands 
along  the  west  coast  of  Africa;  September  25,  i860,  at 
night  off  Congo  River,  Constellation  captured  the  bark 
Cora  with  seven  hundred  and  five  slaves,  which  was  sent 
to  Liberia;  commissioned  as  Surgeon  June  19,  1861 ; 
December  23,  1861,  steam  sloop  Kearsarge,  Commander 
Charles  W.  Pickering,  special  duty  coast  of  Europe; 
visited  Cadiz,  Algesiras,  Gibraltar,  Tangier,  Ferrol, 
Brest,  Cherbourg,  Boulogne  sur-Mer,  Calais,  Ostend, 
Flushing,  London,  Margate,  Ramsgate,  Deal,  Dover, 
Folkstone,  Hastings,  Queenstown,  Azores,  Madeira, 
Teneriffe;  off  Cherbourg,  June  19,  1864,  Kearsarge, 
commander  John  A.  Window,  alter  an  engagement  of 
one  hour  and  two  minutes,  destroyed  the  rebel  steamer 
Alabama;  Kearsarge  left  Europe  in  August,  1864,  for  the 
Azores,  and  from  thence  proceeded  to  Fernando  de 
Noroha  and  Las  Rocas,  off  Brazil,  in  search  of  the  rebel 
steamer  Florida,  returned  to  Barbadoes,  thence  to  St. 
Thomas,  and  arrived  at  Boston  November  9,  1864;  De- 
cember 23,  1864,  temporary  duty  Navy  Yard,  New  York ; 
April  29,  1865,  Navy  Yard,  Mare  Island;  special  duty 
to  superintend  the  erection  of  the  Naval  Hospital  at  Mare 
Island ;  duty  in  charge  of  the  hospital  at  Mare  Island, 
1870-71 ;  Fleet  Surgeon,  Pacific  Fleet,  1871-72.  Com- 
missioned as  Medical  Inspector,  December  1,  1871 ; 
Navy  Yard  and  Naval  Hospital,  Mare  Island,  1873-74; 
Fleet  Surgeon,  North  Pacific  Station,  1874-76;  Naval 
Hospital,  Mare  Island,  1876-80.  Commissioned  as 
Medical  Director,  October  6,  1878;  President  of  Medi- 
cal Examining  Board,  Washington,  D.  C,  1880-82; 
Member  of  Board  of  Visitors,  Naval  Academy,  Annapo- 
lis, Md.,  1 88 1 ;  Naval  Representative  at  the  Interna- 
tional Medical  Congress,  London,  Eng.,  1881 ;  duty  in 
charge  of  Museum  of  Hygiene,  1882-85  ;  duty  on  Board 
of  Naval  Regulations,  1882  ;  Member  of  National  Board 
of  Health,  1883;  Naval  Representative  at  International 
Medical  Congress,  Copenhagen,  1884;  Member  of  Retir- 
ing Board,  1885-88.  Chief  of  Bureau  of  Medicine  and 
Surgery,  with  title  of  Surgeon  General  of  the  Navy,  from 
April  2,  1888,  until  date  of  retirement,  May  10,  1893. 


758 


MEDICAL  RECORD. 


[December  15,  1894 


QmiwoB  mx&  Notices  of  gtoofes. 


The  Medical  Record  Visiting  List,  or  Physicians' 
Diary  for  1895.  i6mo.  New  York :  William  Wood 
&Co. 

The  present  edition  of  this  very  popular  Visiting  List 
has  been  revised  to  increase  the  amount  of  matter  calcu- 
lated to  be  useful  in  emergencies.  The  most  important 
change  is  in  the  list  of  remedies  and  their  maximum 
doses  in  both  apothecaries'  and  decimal  systems,  and  the 
indication  of  such  as  are  official  in  the  United  States  of 
America.  The  items  of  essential  information  which 
really  meet  the  pressing  emergencies  of  the  bedside  are 
«o  well  arranged  for  ready  reference,  under  appropriate 
headings,  as  to  occupy  but  a  small  amount  of  space,  leav- 
ing ample  room  for  the  simple  and  effective  record  of 
daily  visits,  weekly  charges,  ledger  posting,  and  memo- 
randa. It  still  retains  its  convenient  pocket  size,  with 
suitable  flap-cover  and  pencil-carrier. 

Therapeutics  :  Its  Principles  and  Practice.  By  H. 
C.  Wood,  M.D.,  LL.D.,  Professor  of  Materia  Medica 
and  Therapeutics,  and  Clinical  Professor  of  Diseases  of 
the  Nervous  System,  in  the  University  of  Pennsyl- 
vania. Philadelphia:  J.  B.  Lippincott  Company. 
1894. 

This  is  the  ninth  edition  of  Professor  Wood's  well- 
known  treatise  on  therapeutics,  "a  work  on  medical 
agencies,  drugs,  and  poisons,  with  especial  reference  to 
the  relations  between  physiology  and  clinical  medicine." 
There  is  little  that  can  be  said  of  a  standard  work,  such 
as  this  has  become,  whose  popularity  is  attested  by  the 
call  for  a  new  edition  every  two  or  three  years.  The 
present  edition  has  been  adapted  to  the  new  Pharma- 
copoeia of  the  United  States,  all  of  the  new  remedies 
therein  admitted,  as  well  as  a  number  of  unofficinal 
drugs,  being  carefully  and  adequately  discussed.  To  the 
few  who  do  not  know  the  work,  we  can  recommend  it  as 
one  that  shares,  with  Ringer's  Therapeutics  and  a  few  other 
classical  treatises,  the  honor  of  being  an  indispensable 
requisite  to  the  therapeutic  division  of  every  medical 
library. 

Syllabus  of  Lectures  on  Human  Embryology  :  An 
Introduction  to  the  Study  of  Obstetrics  and  Gynecol- 
ogy. For  Medical  Students  and  Practitioners.  With  a 
Glossary  of  Embryological  Terms.  By  Walter  Por- 
ter Manton,  M.D.,  Professor  of  Clinical  Gynecology 
and  Lecturer  on  Obstetrics  in  the  Detroit  College  of 
Medicine.  i2mo,  pp.  126.  Philadelphia:  The  F.  A. 
Davis  Co. 

Though  being,  in  accordance  with  its  title,  only  a  sy- 
noptical outline  of  the  facts  of  embryology,  this  little 
book  will  be  found  convenient  and  useful  for  the  general 
student.  The  essentials  of  the  subject  are  set  forth 
clearly,  a  useful  chapter  gives  hints  as  to  practical  meth- 
ods of  study,  and  a  satisfactory  glossary  is  appended. 
Interleaved  blanks  add  to  the  convenience  kof  the^book 
for  laboratory  use. 

Materia  Medica,  Pharmacy,  Pharmacology,  and  The- 
rapeutics. By  W.  Hale  White,  M.D.,  F.R.C.P. 
Edited  by  Reynold  W.  Wilcox,  MA.,  M.D.,  LL  D. 
Second  American  Edition,  thoroughly  revised.  Phila- 
delphia :     P.  Blakiston,  Son  &  Co.     1895. 

This  book  is  presented  to  the  profession  entirely  re- 
modelled according  to  the  last  edition  of  the  Pharmaco- 
poeia. It  has  been  especially  prepared  to  adapt  itself 
to  the  wants  of  American  medical  men.  It  is  concise, 
and  still  gives  clearly  all  the  points  anyone  cares  to  know 
on  the  newest  drugs,  their  doses,  method  of  application, 
in  short,  just  what  each  physician  ought  to  know. 

Especially  interesting  we  note  the  chapters  pertaining 


to  prescription  writing,  doses  of  drugs,  incompatibles, 
etc. 

Besides  the  carefully  written  chapters  on  action  of 
drugs  on  various  organs,  we  note :  1 ,  Pharmacopceial 
inorganic  materia  medica;  2,  pharmacopceial  organic 
vegetable  materia  medica;  3,  pharmacopceial  animal 
materia  medica.    Remedies  officinal  in  B.  P. 

A  great  many  new  drugs  have  been  added  to  this  new 
edition,  e.g.,  Borium  strontium  preparations,  hydrogen 
dioxide,  etc.  We  also  note  additions  of  various  or- 
ganic drugs,  strophantus,  rhamnus,  puishiano-aspido- 
sperma,  ami  many  others. 

The  authors  are  to  be  congratulated  on  the  rapid  ap- 
pearance of  this  second  edition,  and  this  book  well  de- 
serves a  place  in  the  library  of  every  practitioner. 

A  Practical  System  of  Studying  the  German  Lan- 
guage, for  Physicians  and  Medical  Students.  For 
Self- instruction.  By  Albert  Pick,  M.D.  Newtonville, 
Mass. :  Pick  &  Tanner.  1893-94. 
We  have  previously  noticed  the  first  six  parts  of  this  very 
practical  work  for  self-instruction  in  medical  German, 
and  need  only  add  that  the  complete  work  folly  justifies 
the  opinion  then  expressed,  that  the  method  offers  to  the 
diligent  student  a  less  difficult  means  than  most  other 
self-instructors  of  acquiring  the  amount  of  German  neces- 
sary for  reading  books  or  journal  articles  written  in  that 
language.  There  is  no  easy  road  to  German,  but  this 
work  appears  to  open  up  a  shorter  path  than  any  we  have 
yet  seen  to  the  acquirement  of  that  smattering  of  the 
language  which  is  all  that  most  of  us  have  the  time  or 
the  ambition  to  gain.  The  separate  parts  are  conveni- 
ent for  carrying  in  the  pocket  and  studying  in  the  car- 
riage, the  street-car,  or  during  long  vigils  of  the  night. 

A  Practical  Treatise  on  Nervous  Exhaustion  (Neu- 
rasthenia).      Its    Symptoms,    Nature,    Sequences, 
Treatment.     By  George   M.  Beard,   A.M.,  M.D. 
Edited,  with  notes  and  additions,  by  A.  D.  Rockwell, 
A.M.,  M.D.    Third  edition,  enlarged.     New  York: 
E.  B.  Treat.    1894. 
This  well-known  treatise,  for  many  years  a  classic,  ap- 
pears on  later  reading  as  interesting  and  original  as  when 
first   published.     Accepted  throughout  the  thoughtful 
world  as  conclusive,  the  ideas  that  it  embodies  are  still 
too  little  a  part  of  general  medical  knowledge.     The 
physician  who  is  endeavoring  to  practise  medicine  with- 
out them  is  earnestly  advised  to  secure  the  new  edition 
of  this  book,  and  increase  his  power  of  usefulness  by 
familiarity  with  the  symptoms  and  treatment  of  a  very 
common  and  distressing  disorder.    The  original  text  is 
made  still  more  valuable  by  Dr.  A.  D.  Rockwell's  care- 
ful notes  and  additions,  which  bring  the  work  well  up 
to  date,  and  offer  many  practical  suggestions. 

When  All  the  Woods  are  Green.    A  Novel.     By  S. 

Weir  Mitchell,  M.D.,  LL.D.,  Harvard.    New  York : 

The  Century  Co.  1894. 
Not  long  since  a  French  journal  published  an  elaborate 
article  on  medical  novelists,  the  writer  of  which,  with  the 
strange  national  egotism  of  most  of  his  race,  had  seemed 
to  think  it  needless  to  mention,  if  indeed  he  had  ever 
heard  of,  any  but  Frenchmen.  He  discovered  two 
whose  art  consisted  in  weaving  into  a  romance  some  of 
the  cases  of  sexual  psychopathy  collected  by  v.  Krafft- 
Ebing  and  others.  It  is  a  pity  the  writer  had  not  seen 
this  delightful  story  of  the  Canadian  forest,  with  its  inci- 
dents of  salmon-fishing  and  love-making,  for  it  would 
have  shown  him  that  medical  novelists  need  not  treat  of 
medical  subjects,  but  can  excel  in  the  field  of  pure  liter- 
ature without  calling  in  forbidden  topics  to  give  their 
tales  a  spice.  We  believe  that  Dr.  Mitchell's  fame  will 
rest  upon  his  work  as  a  physician  rather  than  on  what  he 
has  done  in  the  field  of  poetry  and  romance,  yet  that  he 
well  deserves  the  high  rank  which  he  already  holds  as  a 
poet  and  novelist  no  one  can  gainsay.  He  has  the  talent, 
at  least,  of  giving  us  living  men  and  women  in  his  tales, 
and  he  holds  the  interest  of  the  reader  to  the  end. 


December  15,  1894] 


MEDICAL  RECORD. 


759 


MISSISSIPPI  VALLEY  MEDICAL  ASSOCIATION. 

Twentieth  Annual  Meeting,  held  at  Hot  Springs,  Ark., 
November  20,  21,  22,  and  23,  1894. 

First  Day,  Tuesday,  November  20TH. 

The  Association  was  called  to  order  by  the  Chairman  of 
the  Committee  of  Arrangements,  Dr.  Thomas  E.  Holland, 
of  Hot  Springs.  Prayer  was  offered  by  Rev.  Joseph  A. 
Dickson.  An  address  of  welcome  on  behalf  of  the  State 
was  delivered  by  Governor  George  W.  Fishback.  Hon. 
W.  H.  Martin,  of  Hot  Springs,  followed  with  an  address 
of  welcome  on  behalf  of  the  citizens. 

The  Uses  of  Medical  Societies.— Dr.  X.  C.  Scott,  of 
Cleveland,  O.,  delivered  the  presidential  address.  All 
medical  associations,  he  said,  should  be  carried  on  for  the 
purpose  of  elevating  the  profession  and  producing  a  bene- 
ficial influence  upon  its  members,  and  also  that  they  may 
meet  face  to  face  and  thus  learn  to  know  each  other  per- 
sonally and  better.  They  should  elevate  personal  char- 
acter, afford  protection  to  professional  interests,  and  ad- 
vance personal  attainments.  To  be  successful  the  financial 
affairs  of  the  Association  should  be  conducted  with  the 
same  careful  and  rigid  supervision  that  pertains  to  any 
private  business.  He  thought  the  idea  of  reading  all 
papers  before  the  general  body  would  afford  larger  au- 
diences, create  better  and  more  interesting  discussions, 
and  consequently  result  in  greater  good  to  the  majority 
of  the  members.  Since  the  last  meeting  some  of  the 
States  have  passed  excellent  laws  governing  the  practice 
of  medicine,  surgery,  and  midwifery,  but  he  was  sorry  to 
note  that  other  States  failed  in  the  passage  of  similar 
laws. 

Some  Observations  on  the  Eights  and  Duties  of  Medi- 
cal Witnesses.— Hon.  W.  S.  Kerr,  of  Mansfield,  O., 
read  a  paper  with  this  title.  The  weight  of  expert  medi- 
cal evidence  depends  upon  two  qualities — first,  the  skill, 
learning,  and  experience  of  the  witness,  and,  second,  his 
honesty.  The  latter  quality  can  be  and  should  be  alike 
in  all.  The  former,  in  the  nature  of  things,  must  vary 
and  differ  in  degrees  almost  infinite  in  number.  The 
evidence  of  an  expert  should  be  compensated  for,  com- 
mensurate with  its  value.  In  criminal  cases  the  amount 
should  be  fixed  by  the  court,  in  civil  by  agreement  be- 
tween the  expert  and  the  party  calling  him.  The  medi- 
cal expert  should  never  have  his  opinions  for  sale. 

Bone  and  Joint  Tuberculosis,  the  Future  Field  of 
Litigation  against  Railways.— This  paper  was  read  by 
Dr.  Emory  Lanphear,  of  St.  Louis,  Mo.  The  author 
submitted  the  following  conclusions:  1.  Most  chronic 
joint  affections  are  tuberculous;  "scrofula"  has  no  ex- 
istence, being  but  an  attenuated  tuberculosis.  2.  Hie 
family  history  is  unimportant,  as  tuberculosis  is  always 
acquired,  never  inherited.  The  presence  of  tuberculosis 
in  the  family  simply  gives  a  better  opportunity  for  in- 
fection. .  3.  Infection  may  occur  very  early  in  life,  but 
the  germs  may  lie  dormant  for  many  years  in  the  lymph- 
glands,  and  local  tuberculosis  develop  only  after  an  ac- 
cident. 4.  An  injury  to  a  bone  or  joint  must  be  slight 
in  order  to  cause  tuberculosis.  If  severe,  the  resultant 
inflammation  is  not  favorable  to  the  proliferation  of  the 
bacilli.  5.  An  injury  alone  can  never  produce  tuber- 
culosis. The  bacillus  must  always  be  present  in  the 
system,  or  introduced  into  a  wound  at  the  site  ot  injury. 
6.  Per  contra,  bone  or  joint  tuberculosis  would  never 
develop  without  a  slight  local  injury.  7.  If  after  a  rail- 
road accident,  falls,  wrenches,  or  other  accidents  may 
have  possibly  occurred,  the  local  trouble  may  be  due  to 
them  as  well  as  to  the  railway  injury.  There  must  be  a 
direct  sequence  to  attribute  the  disease  to  the  local  in- 
jury. 

Enlargement  of  the  Heart  without  Valvular  Dis- 
ease.— Dr.  Robert  H.  Babcock,  of  Chicago,  read  a  pa- 
per on  this  subject.    The  author  said  that  idiopathic  en- 


largement of  the  heart,  as  Fraentzel  designates  it,  affecting 
primarily  the  left  ventricle,  is  due  primarily  to  prolonged 
high  arterial  tension,  and  this  increase  of  arterial  ten- 
sion may  be  secondary  to  a  cirrhosis  of  the  kidneys, 
chronic  arterio-sclerosis,  congenital  narrowing  of  the  ar- 
terial system,  and  some  obscure  condition  probably  de- 
pendent upon  defective  assimilation  and  elimination,  which 
is  not  fully  understood,  connected  probably  with  the  circu- 
lation of  toxines  in  the  blood.  Prolonged  high  arterial 
tension  he  considered  the  chief  factor  concerned  in  the 
production  of  this  form  of  enlargement  of  the  heart. 
The  enlargement  may  involve  either  the  right  or  the  left 
side  of  the  heart,  or  both.  Prolonged  high  arterial  ten- 
sion, when  independent  of  organic  disease  of  the  kidneys 
or  blood-vessels,  seems  to  be  due  to  what  the  Germans 
call  luxus  consumption.  It  is  observed  in  individuals  who 
belong  to  the  better  class,  who  are  more  or  less  sedentary 
in  occupation,  who  are  hearty  feeders,  and  oftentimes 
great  diners-out  The  treatment  was  divided  into,  first, 
the  treatment  of  the  stage  of  loss  of  compensation,  in 
which  the  heart  is  at  first  broken  down  in  its  resistance. 
Rest  is  the  important  factor,  along  with  cardiac  stimu- 
lants and  the  administration  of  remedies  calculated  to 
decrease  the  high  arterial  tension.  Digitalis,  strophan- 
tus, and  their  congeners  are  not  suitable  to  the  cases  in 
the  stage  of  loss  of  compensation,  since  the  effect  of 
digitalis,  and  to  a  less  degree  strophantus,  is  to  increase 
the  resistance  within  the  arterial  system,  and  thereby 
increase  the  strain,  already  too  much  for  the  impaired 
right  ventricle.  It  is  preferable  to  administer  an  ar- 
terial stimulant  rather  than  one  of  the  so-called  cardiac 
tonics.  Under  the  effect  of  rest  and  cardiac  stimulants 
improvement  in  the  condition  is  generally  manifested 
speedily. 

The  author  then  referred  to  the  Schott  method  of 
treating  these  cases,  which  consists  of  baths  and  gymnas- 
tic exercises. 

Malaria  a  Water-borne  Disease,  was  the  title  of  a 
paper  read  by  Dr.  W.  H.  Daly,  of  Pittsburg.  The 
author  said,  in  summing  up  the  evidence  in  a  given  case 
of  so-called  malaria,  it  is  important  to  remember  that 
the  water- vehicles  of  malaria  may  include  contaminated 
land  water,  taken  into  the  stomach  on  the  stalks  of  cel- 
ery or  on  the  leaves  of  lettuce,  or  it  may  find  its  vehicle 
in  the  rinsing  of  milk-cans  with  malaria  water,  or  in  the 
adulteration  of  milk  with  contaminated  water  containing 
the  Laveran  germ ;  the  cistern  water  stored  under  the 
earth  may  be  easily  contaminated  by  the  earth  water  con- 
taining the  germ,  if  the  cistern  itself  is  cracked  or  other- 
wise inefficient.  The  author  defined  his  position  on  this 
question  by  quoting  from  an  article  published  in  the 
Medical  Record  of  September  15,  1894. 

The  Influence  of  Early  Treatment  on  the  Late 
Manifestations  of  Syphilis. — Dr.  A.  Ravogli,  of  Cin- 
cinnati, said  that  syphilis  must  be  seriously  treated. 
Mercury  is  the  true  antitoxin  for  this  disease.  It  is 
necessary  in  instituting  treatment,  to  take  under  consider- 
ation the  general  condition  of  the  patient,  his  habits,  his 
general  health,  his  surroundings,  etc.,  which  have  great 
influence  in  the  toleration  of  the  medicine.  The  author 
believes  that  early,  well-directed  treatment  of  syphilis 
will  prevent  tertiary  symptoms.  Mercury  can  be  admin- 
istered either  by  the  stomach,  by  subcutaneous  injections, 
by  inunctions,  or  by  baths.  The  selection  of  the  method 
should  rest  on  the  good  judgment  of  the  physician. 


Second  Day,  Wednesday,  November  2ist. 

Intestinal  Indigestion.  —  Dr.  A.  P.  Buchman,  of 
Fort  Wayne,  Ind.,  read  a  paper  on  this  subject.  He 
said  that  intestinal  putrefaction  is,  in  its  incipient  stages, 
not  due  to  a  pathological  condition  of  the  tube  below 
the  stomach  and  duodenum,  but  is  dependent  solely 
upon  errors  of  gastric  and  pyloric  digestive  processes. 
Excess  of  food  ingested  will  universally  induce  such  pu- 
trefactive processes,  which  in  infancy  and  childhood  are 
exhibited  in  the  bowel  diseases  of  early  life,  and  can 


760 


MEDICAL   RECORD. 


[December  15,  1894 


with  reasonable  certainty  be  differentiated  from  deflec- 
tions by  other  causes,  by  the  odor  and  appearance  of  the 
dejecta.  The  toxic  elements  generated  in  this  process, 
sooner  or  later,  render  glandular  and  cell  environments 
of  the  intestinal  tube  unhealthful.  The  air  patients 
breathe,  the  water  they  drink,  and  the  food  they  eat,  are 
charged  with  a  miasm  which  absolutely  forbids  a  healthy 
reaction,  hence  most  complicated  and  decidedly  serious 
pathological  conditions  arise.  Another  chief  source  of 
intestinal  indigestion  arises  from  the  inability  of  the  tube 
below  the  pylorus  to  successfully  cope  with  the  relatively 
enormous  quantities  of  carbohydrates  and  hydrocarbons 
that  are  daily  and  continually  ingested.  The  second  and 
third  stages  of  intestinal  indigestion  were  then  dwelt 
upon.  Colon  baths  properly  medicated  are  very  useful 
in  the  general  treatment  and  care  of  patients  suffering 
with  intestinal  indigestion. 

Abortion  of  Typhoid  Fever.— Dr.  J.  E.  Woodbridge, 
of  Youngstown,  O.,  read  a  paper  in  which  he  gave  his 
experience  during  the  past  year  in  support  of  his  theory. 

The  Importance  of  Urinalysis  in  Diagnosis.— Dr.  A. 
B.  Walker,  of  Canton,  O.,  held  that  no  opinion  of  a 
case  of  any  importance  should  be  given  without  there 
having  been  made  a  careful  examination  of  the  urine. 
He  believed  many  a  case  of  Bright's  disease  might  be 
prevented,  if,  when  the  first  symptoms  of  the  disease 
manifest  themselves,  a  careful  examination  of  the  urine 
were  made,  and  the  proper  treatment  and  diet  prescribed. 
An  interesting  case  was  cited  in  point 

Physicians'  Prescriptions.— Dr.  Starling  Loving,  of 
Columbus,  O.,  read  a  paper  with  this  title,  in  which  he 
alluded  to  the  difficulties  which  young  practitioners  en- 
counter when  they  essay  their  first  prescription.  He 
said  we  seldom  read  of  mishaps  from  defectively  written 
prescriptions  in  England,  Germany,  or  France,  where 
prescription  writing  is  more  extensively  and  systemati- 
cally taught.  Sufficient  attention  is  not  always  given  in 
this  country  to  compatibilities,  chemical  and  therapeutic, 
to  solubilities,  the  influences  of  light,  temperature,  air, 
and  of  other  circumstances  affecting  the  condition  of 
drugs  and  chemicals.  Many  failures  in  treatment  and 
many  accidents,  some  serious  in  character,  result  from 
carelessness  or  want  of  accuracy  in  the  directions  given 
to  nurses  and  patients  for  the  administration  of  medicines 
after  they  have  been  brought  ready  for  use. 

Poisons.— Dr.  William  F.  Barclay,  of  Pittsburg,  fol- 
lowed with  a  paper  on  toxics.  Toxics  enter  the  circula- 
tion, and  their  action  on  the  normal  cells  produces  toxines, 
and  the  multiplication  of  these  products  brings  on  path- 
ological conditions.  Nothing  is  more  easily  demonstrated 
than  that  the  emunctories  throw  off  toxics.  We  observe 
at  once,  upon  the  entrance  of  a  toxic  into  the  circulation, 
that  all  the  functions  of  the  body  are  impaired  to  a 
greater  or  less  degree,  and  the  vital  forces  are  at  once 
disturbed  or  arrested.  Primarily  the  circulation,  and 
secondarily  the  nervous  system,  are  impaired,  and  shock 
is  superinduced.  In  the  stage  of  shock  nature  seems  in- 
tent upon  relieving  herself  of  all  effete  matter  by  the 
discharge  of  the  contents  of  each  viscus  of  the  body.  All 
such  efforts  should  be  assisted  by  artificial  means. 

Quinine  in  the  Treatment  of  Chorea,— Drs.  Frank  R. 
Fry,  and  M.  A.  Buss,  of  St.  Louis,  briefly  reviewed 
Professor  H.  C.  Wood's  theory  that  chorea  is  due  to  dis- 
turbances in  the  spinal  inhibitory  apparatus,  and  the  sug- 
gestion derived  from  it,  that  inasmuch  as  quinine  Had 
been  found  physiologically  to  stimulate  spinal  inhibition 
in  animals,  the  drug  be  given  to  patients  affected  with 
chorea.  The  writers  recited  a  number  of  their  own  cases 
from  clinic  and  private  practice,  in  the  treatment  of 
which  they  have  been  using  quinine,  and  their  results 
confirm  those  of  Dr.  Wood  and  others.  They  called 
attention  to  the  fact  that  they  have  not  used  as  large 
doses  as  others,  yet  had  very  satisfactory  results.  They 
suggest  that  this  drug  has  a  decided  value  in  the  treat- 
ment of  certain  infectious  diseases,  in  which  class,  ac- 
cording to  the  opinion  of  some  authorities,  chorea 
belongs. 


Keflex  Irritation  as  a  Cause  of  Disease. — Dr.  Edwin 
Walker,  of  Evansville,  Ind.,  said  that  no  error  in 
modern  times  has  had  such  a  tenacious  hold  on  the  pro- 
fessional mind  as  that  of  reflex  irritation  as  a  cause  of 
nervous  disease.  The  speaker  said  that  he  had  never 
seen  a  case  of  epilepsy,  insanity,  catalepsy,  hysteria,  or 
grave  neurasthenia,  nor  any  organic  disease  of  the  ner- 
vous system  cured,  or  even  permanently  benefited,  by  any 
operation  on  the  genital  tract,  done  either  by  himself  or 
anyone  else. 


Third  Day,  Thursday,  November  22D. 

The  Mental  Symptoms  of  Cerebral  Syphilis. — Dr. 
Frank  P.  Norbury,  of  Jacksonville,  111.,  read  a  paper 
with  this  title,  of  which  the  following  were  the  conclu- 
sions: 1.  Somnambulism  and  allied  states,  lapses  of  in- 
telligent conceptions  with  associated  loss  of  memory,  are 
mental  symptoms  of  cerebral  syphilis.  2.  Sudden  som- 
nolence with  ocular  spasm  or  paralysis  points  to  syphilis ; 
when  preceded  with  headache  and  monoplegia,  is  almost 
pathognomonic.  Headache,  quasi-periodical,  as  defined 
by  Gray,  with  marked  insomnia,  suddenly  ceasing  and 
followed  by  psychical  disturbance  is  due  to  syphilis.  3. 
Melancholia  or  mania,  when  following  periodical  head- 
aches, insomnia,  and  somnolence  (a)  with  ocular  spasm 
or  other  form  of  monoplegia  or  heterogeneous  paralysis, 
is  due  to  syphilis.  (£)  Pseudo  paranoia.  By  this  he 
means  cases  presenting  all  symptoms  of  paranoia,  system- 
atized delusions  depending  on  hallucinations  of  sight, 
hearing,  taste,  or  smell,  with  slight  impairment  of  general 
mental  functions,  is  due  to  syphilis,  as  we  know  that 
syphilis  causes  isolated  local  losses  of  power,  and  it  is 
noteworthy  when  the  special  senses  are  involved  that 
mental  derangement  usually  results,  (c)  Pseudo-paresis, 
characterized  by  fibrillary  tremor  of  tongue,  indistinct 
speech  (partial  or  complete  aphasia),  uncertain  and  trem- 
bling gait,  with  delusions  of  grandeur  and  occasional 
outbursts  of  maniacal  excitement,  pupillary  involvement, 
all  characteristic  symptoms  of  paresis,  but  which  yield 
readily  to  antisyphilitic  treatment,  we  can  say  it  was  due 
to  syphilis.  4.  Class  four  have  had  epileptiform  and 
apoplectiform  attacks.  We  find  cases  in  which  treat- 
ment was  undertaken  too  late.  The  symptoms  are  those 
of  terminal  dementia,  only  occurring  in  patients  of  pre- 
vious sound  mental  condition  and  with  no  special  hered- 
itary history. 

The  Surgical  Treatment  of  Injuries  of  the  Head. — 
Dr.  Charles  B.  Parker,  of  Cleveland,  O.,  contributed 
a  paper  on  this  subject,  of  which  the  following  were  the 
conclusions :  1.  In  a  case  of  doubt  as  to  the  character 
of  a  head  injury,  explore  by  incision,  if  necessary.  2. 
In  the  case  of  wounds,  especially  the  smaller  and  punct- 
ured, enlarge  them  for  exploration  and  cleansing.  3. 
In  all  cases  of  fracture,  depressed  or  fissured,  operate, 
elevating  the  depression  and  exploring  the  fissure  for  a 
depression  of  the  inner  table,  winch  so  often  occurs.  4. 
Leave  principal  fragments  of  bone  after  elevation,  if 
surgically  clean,  even  if  entirely  detached  from  the  dura 
mater  and  pericranium,  thus  averting  cerebral  hernia, 
vertigo,  and  other  cerebral  disturbances.  5.  All  these 
operative  measures  should  be  conducted  under  the  most 
rigid  aseptic  and  antiseptic  measures. 

Traumatic  Lesions  of  Cranium  and  Brain. — Dr. 
George  N.  Lowe,  of  Randall,  Ran.,  reported  four  in- 
teresting cases.  The  first  case  was  one  of  depressed 
comminuted  fracture  of  the  right  parietal  bone  at  the 
junction  of  the  temporal  bone,  caused  by  the  kick  of  a 
horse.  There  was  also  a  contused  lacerated  wound  of  all 
the  soft  tissues  along  the  entire  ramus  of  the  left  inferior 
maxillary.  In  this  case  the  author  trephined  and  elevated 
the  depressed  comminuted  bone  fragments.    Recovery. 

Castration  for  Hypertrophied  Prostate. — Dr.  B.  Mer- 
rill Ricketts,  of  Cincinnati,  reported  a  case  of  castra- 
tion for  hypertrophied  prostate.  The  arteries  were 
twisted,  the  wound  closed,  and  integument  coapted  with 
a  continuous  silkworm-gut  suture.    The  patient  rallied 


December  15,  1894] 


MEDICAL  RECORD, 


761 


well  from  the  chloroform  and  suffered  no  inconvenience 
or  pain  thereafter.  The  wound  was  examined  on  the 
fourth  day  and  primary  union  was  found  to  have  taken 
place.  The  patient  left  the  hospital  at  the  end  of  the 
sixth  day.  On  the  second  day  after  the  operation  he 
said  that  he  could  urinate  with  greater  ease,  and  that 
the  pain  was  slight;  that  he  could  sleep  four  hours  at  a 
time  during  the  night,  whereas  formerly  he  had  been 
getting  up  once  every  hour. 

Tumor  Albus  of  the  Knee-joint.— This  paper  was  read 
by  Dr.  William  E.  Wirt,  of  Cleveland,  O.  The  author 
classified  the  treatment  under  the  two  headings  of  con- 
stitutional and  local  measures,  and  the  local  under  the 
subdivisions  of  conservative  and  operative  treatment. 
The  author  first  considered  constitutional  treatment, 
and  then  the  local  treatment,  which  he  divided  into  the 
conservative  and  operative.  The  conservative  measures 
to  be  carried  out  in  the  treatment  of  this  affection  are 
counter-irritation  and  local  applications,  fixation,  pro- 
tection, rest,  and  correction  of  deformity.  These  were 
considered  under  their  respective  heads. 

Beseotion  of  the  Knee  for  Separation  of  the  Lower 
Epiphysis  of  the  Femur.— Dr.  A.  H.  Meisknbagh,  of 
St.  Louis,  said  separation  of  the  epiphysis  is  a  condition 
that  may  occur  either  on  account  of  trauma  or  disease. 
There  seems  to  be  a  difference  of  opinion  by  writers  as  to 
the  frequency  of  its  occurrence,  especially  as  the  result 
of  trauma.  Traumatic  separation  of  the  lower  end  of  the 
femur  occurs  in  about  from  one-fifth  to  one- third  of  all 
the  reported  cases,  and  in  the  majority  of  instances  pre- 
vious to  the  sixteenth  year,  seldom  later.  The  forces 
that  are  necessary  to  produce  this  separation  are  various. 
Thus  during  childbirth  traction  may  produce  it.  Volk- 
mann  states  that  he  has  produced  it  when  the  hip  is 
diseased,  when  making  rotation  in  seeking  for  crepita- 
tion, or  extension  in  the  application  of  plaster- of-Paris 
dressings. 

Other  forces  are  indirect  external  violence,  usually  of 
a  twisting  character,  or  lateral,  or  at  right  angles  to 
the  axis  of  the  limb.  The  readiness  with  which  the  dis- 
location of  the  separated  diaphysis  into  the  popliteal 
space  occurs  can  be  explained :  r,  on  account  of  the 
anatomical  structures  of  the  surrounding  parts ;  2,  the 
force  and  position  of  the  patient,  the  popliteal  space 
being  in  the  direction  of  least  resistance,  while  on  the 
anterior  aspect  we  have  the  quadriceps  tendon,  the  pat- 
ella, and  the  ligamentum  patellae.  The  occurrence  of 
pathological  separation  of  the  epiphyses  is  regarded  by 
the  latest  writers  on  surgical  pathology  and  diseases  of 
the  bones,  as  a  not  infrequent  accident  in  diseases  of  the 
bones  and  joints.  It  is  noted  in  osteomyelitis  of  the 
long  bones. 

Hydrocele —Dr.  W.  C.  Weber,  of  Cleveland,  O., 
read  a  paper  on  this  subject.  He  first  dwelt  upon  the 
anatomy  of  the  testis,  and  then  alluded  to  congenital 
and  acquired  hydrocele.  The  congenital  form  results 
from  an  imperfect  closure  between  the  cavities  of  the 
tunica  vaginalis  and  the  peritoneum.  Acquired  hydro- 
cele occurs  in  children,  and  most  frequently  in  early  adult 
life.  Its  cause  is  not  always  known,  though  traumatism 
is  probably  the  most  constant  factor  in  its  production. 
In  a  hydrocele  of  small  or  ordinary  size,  the  date  of 
its  origin  being  recent,  an  evacuation  by  means  of  a  small 
trocar  and  cannula  may  be  all  that  is  necessary  to  accom- 
plish a  core.  Should  this  fail  in  its  purpose,  it  becomes 
necessary  to  adopt  measures  whereby  sufficient  irritation 
of  the  tunica  vaginalis  may  be  produced  to  secure  inflam- 
matory adhesions  of  the  opposing  surfaces.  This  end  is 
usually  attained  by  the  injection  of  tincture  of  iodine, 
alcohol,  carbolic  acid,  perchloride  of  iron,  and  other  sub- 
stances into  the  sac  after  the  removal  of  its  adventitious 
contents.  Among  other  methods  of  treatment  may  be 
mentioned  excision,  incision,  and  the  seton.  The  author 
reported  a  case  in  which  he  used  carbolic  acid,  which 
illustrated  very  nicely  what  can  be  done  in  the  way  of 
radical  treatment  in  apparently  extreme  cases.  The  re- 
sult was  very  satisfactory. 


Treatment  of  Traumatic  Cataract  Attended  with 
Eapid  Swelling  of  the  Lens. — Dr.  James  M.  Ball,  of 
St.  Louis,  Mo.,  held  that  in  cases  of  traumatic  cataract 
with  rapid  increase  of  intra  ocular  tension,  an  operation 
should  be  performed,  and  it  should  not  be  linear  extrac- 
tion, but  an  extraction  made  with  the  Graefe  knife,  and 
with  the  incision  located  in  the  cornec-scleral  junction. 
The  knife  should  cut  from  one-third  to  twc-fifths  of  the 
corneal  circumference,  according  to  the  extent  to  which 
the  softening  process  in  the  lens  has  advanced.  If  glau- 
comatous symptoms  supervene  with  softening  of  only  a 
small  part  of  the  lens,  the  corneal  incision  should  be 
large.  If  the  softening  involve  the  whole  of  the  lens, 
the  incision  should  be  of  less  extent.  The  chief  merit  of 
the  operation  lies  in  the  avoidance  of  the  valve  which 
is  produced  by  the  linear  method.  In  other  words,  the 
author's  method  permits  of  free  evacuation  of  all  the 
lenticular  substance  with  the  least  amount  of  traumatism. 
An  iridectomy  is  not  made.  All  debris  is  removed  at 
once.  This  cannot  be  accomplished  by  the  linear 
method. 

Some  Observations  on  Sore  Throat  Due  to  Concretions 
in  the  Tonsils. — Dr.  Lewis  C.  Cline,  of  Indianapolis, 
Ind.,  read  a  paper  in  which  he  said  that  every  experi- 
enced practitioner  could  recall  cases  of  recurring  tonsil- 
litis or  sore  throat  that  often  developed  without  any  ap- 
parent cause,  but  which  were  doubtless  due  to  chronic 
inflammation  of  the  follicles,  altered  and  retained  secre- 
tions. It  was  to  this  class  of  cases  that  the  essayist  in- 
vited attention.  His  remarks  dealt  more  particularly 
with  the  cheesy  bodies,  and  not  the  calculi,  which  are 
probably  the  outgrowth  of  the  long  retained  cheesy  de- 
posits acting  as  a  nidus  for  the  deposit  of  the  more  solid 
materials,  as  phosphate  and  carbonate  of  lime,  iron, 
soda,  and  potassa,  etc.  These  concretions  are  doubtless 
the  result  of  a  catarrhal  condition  of  the  mucous  lining 
of  the  follicles,  often  coupled  with  a  uric  acid  diathesis. 
Some  writers  believe  them  to  be  parasitic  in  origin. 
They  predispose  to  attacks  of  quinsy,  and  in  the  author's 
judgment  are  the  cause  of  the  majority  of  these  cases, 
and  they  can  be  permanently  cured  by  carefully  search- 
ing for  and  destroying  all  the  crypts  and  pockets  in 
which  these  bodies  are  formed.  The  author  reported 
several  interesting  cases,  and  closed  by  stating  that  per- 
verted secretions  of  the  follicles  of  the  tonsils  from  ca- 
tarrhal inflammation  resulting  in  cheesy  concretions  were 
the  cause  of  more  sore  throats  and  quinsy  in  adults  than 
any  or  all  other  causes  combined. 


Fourth  Day,  Friday,  November  23D. 

The  Eemoval  of  the  Auditory  Ossicles  for  the  Belief 
of  Chronic  Deafness  and  Other  Abnormal  Conditions.— 
Dr.  Robert  C.  Heflebower,  of  Cincinnati,  contributed 
a  paper  with  this  title,  of  which  the  following  were  the 
conclusions:  1.  No  bad  results  attend  the  excision  of 
the  malleus  and  the  incus,  but  removal  of  the  stapes  is 
not  without  the  most  serious  danger,  both  to  life  and 
hearing.  2.  That  the  removal  of  the  malleus  and  incus 
alone  is  far  preferable  to  the  removal  of  the  stapes.  3. 
The  operation  is  of  extreme  service  in  chronic  suppura- 
tion in  suitable  cases,  frequently  avoiding  mastoid  and 
other  serious  disturbances  of  an  equally  serious  nature. 
4.  It  should  be  performed  in  cases  where  there  is  a  high 
perforation,  or  where  the  membrana  flaccida  is  perfor- 
ated, and  where  the  ossicles  are  necrotic.  5.  Tinnitus, 
headaches  of  ear  origin,  and  vertigo  are  relieved.  6.  In 
suitable  cases  it  is  invaluable  for  relieving  deafness, 
whether  from  chronic  suppuration  or  from  chronic  ca- 
tarrh and  sclerosis. 

Circumcision. — Dr.  Bransford  Lewis,  of  St.  Louis, 
Mo.,  read  a  paper  on  this  subject  in  which  he  detailed  a 
method  of  performing  that  operation,  for  which  he  claimed 
many  advantages.  The  operation  was  done  with  the  as- 
sistance of  two  instruments,  a  clamp  and  prepuce-tractor, 
which  enabled  the  operator  to  carry  out  the  following 


762 


MEDICAL   RECORD. 


[December  15,  1894 


steps  of  procedure:  1.  The  prepuce  is  drawn  strongly 
forward,  the  traction  being  applied  to  its  inner  surface 
by  means  of  the  serrated  tractor  mentioned.  2.  The 
glans  penis  being  repressed,  the  curved,  fenestrated 
clamp  is  applied.  3.  With  these  as  a  support  and  guide, 
ten  per  cent,  cocaine  solution  is  injected  between  the 
two  layers  of  foreskin,  anterior  to  the  clamp.  4.  After 
effective  anaesthesia  has  been  secured,  six  double  length 
(ten  inch)  catgut  sutures  are  run  clear  through  the  clamp- 
fenestra  and  the  four  layers  of  foreskin.  5.  With  strong 
scissors  the  latter  is  cut  off  at  one  sweep.  6.  Tractor 
and  clamp  being  removed,  the  double  -  length  sutures 
being  divided,  two  additional  sutures  are  placed  at  the 
dorsal  and  frenal  sites,  previously  occupied  by  the  tractor. 
7.  The  vessels  are  secured  and  sutures  tied  all  around. 

The  Treatment  and  Management  of  Corporeal  Endo- 
metritis was  the  title  of  a  paper  read  by  Dr.  William 
H.  Humiston,  of  Cleveland,  O.,  in  which  the  author 
said  that  nine-tenths  of  all  cases  that  he  treats  suffer  from 
some  form  of  endometritis,  and  its  baleful  influence  on 
the  sympathetic  nervous  system  is  marked  and  manifested 
by  numerous  and  varied  symptoms. 

The  first  and  important  principle  in  treatment  is  to  re- 
lieve the  passive  congestion  of  the  uterus,  and  this  is 
accomplished  by  medicated  tampons.  The  first  tampon 
should  be  medicated  with  boro-glyceride,  iodo-glycerine, 
or  icthyol-glycerine,  and  supported  by  sterilized,  non- 
absorbent  cotton  tampons.  The  septic  cases  must  be 
treated  on  modern  surgical  principles — rest,  asepsis, 
drainage,  and  curetting.  When  the  cases  are  diagnosed 
early  and  the  proper  treatment  instituted,  the  author  says 
the  abdominal  surgeon  will  not  have  his  belt  hanging  full 
of  suppurating  tubes  and  ovaries. 

The  Belation  of  Besidnal  Urine  to  Vesical  Irrita- 
tion.— Dr.  G.  Frank  Lydston,  of  Chicago,  contributed 
a  paper  with  this  title.  He  said  it  is  generally  accepted 
that  most  of  the  symptomatic  disturbances  incidental  to 
certain  chronic  bladder  diseases,  especially  in  cases  of 
prostatic  enlargement,  are  dependent  upon  the  accumu- 
lation of  residual  urine.  The  author  has  long  been  im- 
pressed with  the  idea  that  residual  urine  per  se  is  not  as 
important  a  factor  in  genito-urinary  irritation  as  is  or 
dinarily  believed.  He  is  satisfied  that  in  a  large  propor- 
tion of  adult  males  there  is  always  a  greater  or  less  resid- 
uum of  urine  remaining  in  the  bladder  after  micturition. 
If  prostatic  enlargement  or  other  obstruction  attacking 
the  mouth  of  the  bladder  develop,  we  have  the  typical 
accumulation  of  residual  urine  characteristic  of  such 
cases.  It  will  then  be  seen  that  there  may  be,  at  varying 
periods  of  life,  extreme  differences  in  the  degree  of  ac- 
cumulation of  residual  urine.  The  author  believes  that 
the  residual  urine  is  simply  an  incident  upon  which,  if 
taken  alone,  the  symptoms  of  vesical  irritation  in  no  wise 
depend.  Ideally  perfect  drainage  of  the  bas-fond  can 
only  be  accomplished  by  thorough  drainage  from  above 
the  tube  through  the  trigone  and  out  of  the  rectum. 
There  were  certain  objections  to  this  method  which  the 
author  said  it  was  not  necessary  to  dilate  upon.  He 
simply  stated  as  his  opinion  that  only  by  some  such  pro- 
cedure can  the  bas-fond  be  thoroughly  drained. 

Laparotomy  for  Pelvic  Diseases  is  no  Longer  a  ne- 
cessity.— This  paper  was  contributed  by  Dr.  R.  Stans- 
bury  Sutton,  of  Pittsburg.  The  assertion  found  in  the 
text  of  the  paper  was  founded  upon  the  following  argu- 
ment :  1.  We  have  a  substitute  for  laparotomy  in  total  ex- 
tirpation of  the  uterus  and  appendages  by  the  vagina,  either 
with  or  without  morcellement.  2.  The  operation  has 
already  been  proven  to  be  effectual  and  successful  by 
many  in  Europe  and  in  the  United  States.  3.  Total 
extirpation  of  the  uterus  and  appendages  per  vaginam 
gives  a  lower  mortality  than  laparotomy  for  the  removal 
of  the  appendages  alone.  Morcellement  of  small  fibroid 
tumors  gives  a  lower  mortality  than  laparotomy  for  the 
removal  of  similar  tumors.  4.  These  operations  by  the 
vagina  shorten  the  convalescence  of  patients,  who  are 
out  of  bed  on  the  seventh  day.  5.  In  all  cases  of  gonor- 
rhoea!, tubercular,  or  other  infectious  type  of  endometri- 


tis with  chronic  salpingitis  and  chronic  ovaritis,  a  cure  is 
not  effected  save  by  total  extirpation  of  the  uterus  and 
appendages.  The  vaginal  route  is  the  best.  6.  In  all 
cases  of  fibroid  tumors  of  the  uterus,  not  reaching  above 
or  quite  to  the  umbilicus,  when  the  uterus  must  be  sacri- 
ficed, total  extirpation  of  the  organ,  tumor,  and  appen- 
dages by  morcellement  can  be  best  effected  through  the 
vagina.  7.  Small  cysts  of  the  ovary  or  broad  ligament,  or 
solid  tumors  of  the  ovary  can  be  reached  and,  by  morcelle- 
ment and  puncture,  be  removed  through  the  vault  of  the 
vagina,  leaving  the  uterus  and  opposite  ovary  and  tube  in- 
tact. 8.  In  all  cases  of  pyosalpinx  or  of  multiple  pus  centres, 
with  coexisting  solidification  of  the  pelvic  roof,  total  ex- 
tirpation by  morcellement  per  vaginam  is  the  only  feasi- 
ble operation,  and  it  cures  the  patient.  9.  Total  extir- 
pation per  vaginam  is  followed  by  a  cure  in  the  greatest 
majority  of  cases,  as  compared  with  laparotomy.  10. 
The  following  sequels  after  laparotomies  do  not  occur 
after  total  extirpation  by  the  vagina:  cancer  of  the 
uterus,  adenoma  of  the  uterus,  tuberculosis  of  the  uterus, 
gonorrhoea!  infection,  hemorrhages  of  the  uterus,  filthy 
catarrhal  discharges  from  the  uterus,  ventral  hernia,  fecal 
and  other  fistulas,  the  mark  of  a  wound  on  the  abdomen. 
The  nerve-storms  subsequent  to  total  extirpation  are  not 
as  great  as  after  laparotomy.  The  patient  is  restored  to 
perfect  health.  This  is  not  the  case  in  more  than  fifty  per 
cent,  of  laparotomies  for  pelvic  diseases.  1 1 .  The  bacte- 
riology of  infectious  diseases  demands  removal  of  the 
uterus  with  the  appendages.  12.  Total  extirpation  by  the 
vagina  is  in  strict  conformity  to  anatomical  relations.  13. 
The  physiological  results  following  total  extirpation  are 
free  from  jarrings,  and  the  patient  is  functionally  a  smooth- 
ly running  mechanism.  1 4.  Laparotomy  for  these  diseases 
is  followed  by  all  manner  of  physiological  disturbances 
which  affect  the  vascular,  muscular,  nervous,  and  digestive 
systems.  15.  In  the  face  of  this  argument,  laparotomy 
for  pelvic  disease  is  no  longer  a  necessity,  but  in  the 
author's  opinion  should  be  abandoned  excepting  in  very 
rare  instances,  indeed. 

Modern  Surgical  Technique. — Dr.  Henry  O.  Marcy, 
of  Boston,  emphasizes  the  importance  of  a  most  careful 
bacteriological  training  on  the  part  of  him  who  would 
become  proficient  in  surgical  practice.  In  the  prepara- 
tion of  the  operating-room,  Dr.  Marcy  pointed  out  the 
ease  and  safety  with  which  an  ordinary  living  room,  by 
preference  the  kitchen,  is  made  comparatively  sterile, 
when  from  necessity  the  surgeon  is  called  upon  to  act 
promptly  and  suddenly.  In  abdominal  wounds,  where 
irrigation  is  not  advised,  he  substitutes  for  it  a  slowly 
flowing  stream  of  oxygen  gas  from  a  compressed  cylinder. 
This  sterile  gas  is  heavier  than  atmospheric  air  which  it 
displaces,  and  as  a  consequence  renders  the  wound  less 
likely  to  infection  from  the  products  of  respiration  and 
atmospheric  contamination.  Dr.  Marcy  reiterated  his 
well-known  views  upon  the  value  of  tendon  sutures,  bur- 
ied in  all  aseptic  wounds  for  the  approximation  and  re- 
inforcement of  the  structures,  emphasizing  the  importance 
of  abandoning  the  drainage-tube  in  all  aseptic  wounds, 
and  hermetically  sealing  of  the  same  with  iodoform  col- 
lodion. Aseptic  wounds  made  in  aseptic  structures 
aseptically  closed,  and  sealed,  are  always  followed  by 
primary  union. 

Election  of  Officers. — The  following  officers  were 
elected  for  the  ensuing  year:  President,  Dr.  W.  H. 
Wishard,  of  Indianapolis:  First  Vice-President,  Dr. 
Thomas  E.  Holland,  of  Hot  Springs;  Second  Vice- 
President,  Dr.  Charles  B.  Parker,  of  Cleveland ;  Secre- 
tary, Dr.  Frederick  C.  Woodburn,  of  Indianapolis; 
Treasurer,  Dr.  Harold  N.  Mover,  of  Chicago. 

The  next  meeting  will  be  held  in  Detroit,  Mich.,  Sep- 
tember, 1895.  Chairman  of  Committee  of  Arrange- 
ments, Dr.  H.  O.  Walker,  of  Detroit. 


Dr.  William  P.  Overton,  president  of  the  Queens 
County  Medical  Society,  died  recently  at  his  home  in 
Cold  Spring  Harbor,  L.  I. 


December  15,  1894] 


MEDICAL    RECORD. 


763 


NEW  YORK  ACADEMY  OF  MEDICINE. 
SECTION    ON    SURGERY. 

Stated  Meeting,  November  12 9  1894. 

W.  W.  Van   Arsdale,  M.D.,  Chairman  pro  tem. 

Lead-pencil  in  Axilla  Mistaken  for  Fracture  of  Clavi- 
cle.— Dr.  Sinclair  Tousey  presented  a  young  man 
who,  prior  to  the  time  when  he  saw  him,  had  been  going 
around  for  about  six  weeks  with  a  broken  lead-pencil, 
four  inches  long,  in  the  axilla,  which  had  been  mistaken 
at  different  hospitals  for  fractured  clavicle.  At  one  of 
the  larger  hospitals  an  abscess  had  been  opened  under 
ether,  but  it  was  decided  to  wait  until  the  supposed 
fragment  of  clavicle  had  separated  before  an  attempt 
should  be  made  to  remove  it.  When  Dr.  Tousey  saw 
the  patient  the  probe  introduced  into  one  of  the  sinuses 
came  in  contact  with  a  substance  which  felt  like  bone, 
and  as  it  was  quite  movable  he  administered  an  anaesthet- 
ic and  took  out  what  proved  to  be  a  piece  of  lead-pen- 
cil. The  patient  then  remembered  that  it  must  have 
entered  when  he  slid  down  a  lamppost  and  caught  the 
pocket  containing  the  pencil  on  a  projection.  What 
appeared  to  be  a  scratch  marked  the  point  of  entrance. 

Dr.  Francis  H.  Markoe  had  seen  a  somewhat  sim- 
ilar case,  the  accident  occurring  at  the  elbow.  A  door 
had  shut  as  the  patient  was  passing  through,  striking  her 
arm  and  shawl.  She  consulted  Dr.  Markoe  next  morn- 
ing on  account  of  pain.  He  found  no  bruise,  no  abra- 
sion, no  fracture,  but  a  hard  body  could  be  felt  lying 
across  the  elbow-joint.  Under  ether  a  long  shawl-pin  was 
extracted.     It  had  felt  much  like  a  bony  fragment. 

Carcinoma  of  Transverse  Colon ;  Excision ;  End-to- 
end  Anastomosis  with  Murphy's  Button. — Dr.  H. 
Lilienthal  presented  a  strong-looking  man,  of  middle 
age,  who  prior  to  the  time  he  first  saw  him,  in  May, 
had  been  ill  fourteen  months,  with  variable  pains  in  the 
abdomen,  paresthesia,  gurglings,  marked  emaciation. 
In  May  a  tumor  could  be  felt,  the  size  of  a  large  egg, 
apparently  in  the  transverse  colon.  Its  location  was 
confirmed  by  an  operation.  It  was  removed,  with  about 
four  inches  of  the  gut,  and  the  divided  ends  were  united 
by  a  Murphy  button  of  very  large  size,  so  large  that  it 
was  of  tight  fit  and  caused  some  fear  that  it  might  not 
come  away  safely.  As  it  had  not  passed  on  the  eigh- 
teenth day,  he  had  gentle  massage  made  over  the  abdo- 
men from  right  to  left  and  an  enema  given.  Soon  after- 
ward the  button  passed,  and  a  little  blood  with  it.  Hie 
patient  had  been  given  solid  food  from  the  sixth  day. 
Some  of  the  mesenteric  glands  were  found  enlarged,  and 
a  relapse  was  to  be  expected,  although  at  present  the 
patient  was  in  good  condition!    The  tumor  was  cancer. 

The  danger  of  using  too  large  a  button  was  shown  in 
a  second  fatal  case.  The  woman  had  a  fecal  fistula 
which  had  led  him  to  make  an  artificial  anus,  and  subse- 
quently she  had  submitted  to  laparotomy  seven  times  at 
the  hands  of  different  surgeons.  As  she  wished  the  arti- 
ficial anus  closed,  Dr.  Lilienthal  made  use  of  the  Murphy 
button  to  establish  end-to-end  anastomosis  and  then 
closed  the  wound.  The  gut  below  was  much  atrophied, 
and  the  button  proved  a  tight  fit,  so  tight  indeed  that  it 
led  to  gangrene  and  death,  the  button  having  partly 
passed  out  along  with  faeces  into  the  peritoneal  cavity.  In 
a  third  case  he  hesitated,  but  the  patient  insisted  on  hav- 
ing his  artificial  anus  closed.  After  the  experience  with 
the  second  case  Dr.  Lilienthal  used  a  button  a  quarter  of 
an  inch  less  in  diameter,  and  did  not  at  once  close  the 
artificial  anus,  but  introduced  a  strip  of  gauze  drain  down 
to  the  lower  segment  of  gut,  which,  as  in  the  other  case, 
was  atrophied.  This  patient  got  through  all  right,  the 
button  being  passed  on.  the  sixth  day.  Dr.  Lilienthal 
thought  there  was  more  danger  from  sepsis  in  anasto- 
mosis for  closure  of  artificial  anus  than  in  other  forms  of 
intestinal  resection  because  of  the  difficulty  of  cleansing 
the  wound  thoroughly  in  the  former,  whereas  Dr.  Van 
Arsdale,  during  the  discussion,  expressed  surprise  at  this 


statement,  since  he  believed  operations  for  closure  of  ar- 
tificial anus  gave  the  best  results. 

Dr.  Willy  Meyer  thought  the  button  shown  was 
enormous,  and  that  if  we  would  follow  the  directions 
given  by  Dr.  Murphy,  using  only  the  sizes  which  he  had 
indicated,  and  made  in  the  manner  which  he  had  de- 
scribed, our  results  would  be  equally  satisfactory.  The 
button  should  always  be  at  hand  on  going  to  laparotomy 
cases. 

Dr.  Van  Arsdale  had  had  a  case  of  gastroenteros- 
tomy go  wrong  in  spite  of  the  button,  the  man  dying  of 
inanition ;  nothing — no  gangrene — found  at  the  site  of 
the  button  to  account  for  death. 

Dr.  Lilienthal  said  this  sized  button  had  been  made 
by  instruction  of  Dr.  Gerster.  It  was,  however,  too 
large  except  for  anastomosis  of  the  rectum,  and  there 
even  a  larger  one  would  be  required  if  one  would  avoid 
forming  a  constriction  in  the  ampulla. 

Case  of  Ideal  Cholecystotomy.— Dr.  C.  L.  Gibson 
presented  seven  gall-stones,  as  large  as  hazel-nuts,  re- 
moved from  the  gallbladder  and  duct  at  a  single  oper- 
ation. Vague  gastric  symptoms  had  existed  several 
months  before  the  patient  entered  the  hospital.  A  tumor 
was  felt  in  the  region  of  the  right  kidney,  and  was 
thought  to  be  cystic  kidney,  the  mistake  clearing  up 
only  on  exploratory  operation,  when  it  was  found  to  be 
the  distended  gallbladder.  Convalescence  had  been 
uneventful. 

Dr.  Dawbarn  said  that  about  the  time  when  the 
Murphy  button  was  first  used  in  New  York  he  sent  to 
Chicago  and  got  one  which  he  used  in  a  case  of  gall- 
stone, the  diagnosis  having  been  confirmed  by  the  opera- 
tion. The  gall- bladder  seemed  remarkably  friable,  and 
at  autopsy— <ieath  having  occurred  in  forty  eight  hours 
—-a  distinct  tear  was  found  at  the  edge  of  the  button. 
There  was  also  a  diffuse  form  of  cancer  of  the  liver,  and 
this  had  probably  led  to  the  friable  condition  of  the 
gall-bladder,  although  this  viscus  was  not  carcinomatous. 
He  had  sent  an  account  of  the  case  to  Dr.  Murphy  be- 
fore the  latter  had  reported  a  collection  of  one  hundred 
successful  cases,  and  had  afterward  written  Dr.  Murphy  to 
learn  why  this  fatal  one  had  been  omitted.  The  answer 
was  that  he  did  not  suppose  the  author  of  the  case 
would  care  to  have  it  reported  since  it  was  unsuccessful, 
and  also  because  it  was  an  attempt  to  unite  a  cancerous 
gall-bladder  with  the  duodenum,  which  was  not  true. 

Resection  of  Beotum  for  Malignant  Growth ;  Persist- 
ent Heuralgia  in  Scar. — Dr.  Van  Arsdale  presented 
a  man,  fifty- four  years  of  age,  about  six  inches  of  whose 
rectum  he  had  excised  through  the  sacrum,  for  carcinoma, 
in  1892.  The  proximal  end  of  the  gut  was  drawn  down 
and  sutured  to  the  anus,  a  secondary  operation  was  done 
the  same  summer,  and  in  March,  1894,  two  small  carci- 
nomatous nodules  were  removed  from  the  rectal  mucous 
membrane.  Since  then  the  man  had  been  in  good 
health,  and  had  control  over  the  bowel.  Advice  was 
asked  with  regard  to  the  relief  of  pain  which  existed 
along  the  line  of  union  between  mucous  membrane  and 
skin. 

Case  of  Volvulus  of  the  Sigmoid  Flexure,  with  Com- 
ments.— Dr.  Francis  H.  Markoe  said  it  had  been  his 
intention  to  present  a  paper  on  intestinal  obstruction, 
based  on  sixteen  cases  which  had  come  under  his  obser- 
vation, but  for  lack  of  time  he  limited  himself  on  this  occa- 
sion to  a  recent  one  of  volvulus  of  the  sigmoid  flexure,  with 
comments.  The  man  had  had  symptoms  of  intestinal 
obstruction  about  eleven  days  before  he  was  brought  to 
Bellevue,  where  Dr.  Markoe  saw  him,  there  having  been 
no  passages  since  the  third  day.  He  found  the  abdomen 
much  distended,  especially  on  the  right  side.  High 
rectal  injection  was  made  in  the  knee-chest  position,  but 
nothing  came  away.  He  then  opened  the  abdomen  and 
found  a  loop  of  the  large  gut  completely  turned  upon 
itself  and  greatly  distended  with  gas.  This  was  gently 
untwisted  after  letting  out  the  gas.  An  ecchymotic 
spot,  the  size  of  a  silver  dollar,  was  found  and  the  loop 
was  secured  at  the  bottom  of  the  wound  by  a  gauze  strip 


764 


MEDICAL    RECORD. 


[December  15,  1894 


passed  through  mesentery.  There  was  no  evidence  of 
congenital  or  acquired  stenosis.  The  patient  improved 
steadily  for  four  days,  and  on  the  night  of  the  fourth  day 
had  several  passages  in  response  to  small  doses  of  calomel. 
°*  the  fifth  day  he  suddenly  collapsed,  colotomy  was 
performed  in  the  attached  loop,  but  he  died  soon  afterward 
from  perforation  at  the  ecchymotic  spot,  which  had  be- 
come gangrenous.  Dr.  Markoe  asked  discussion  on  how 
to  prevent  recurrence. 

Dr.  De  Garmo  inquired  whether  the  gangrene  took 
place  at  the  point  of  puncture  for  letting  out  gas.  He 
had  observed  tendency  to  gangrene  even  after  puncture 
with  very  small  trocar. 

Dr.  Markoe  thought  the  question  a  pertinent  one, 
but  in  this  instance  the  gangrene  had  occurred  at  the 
point  of  doubtful  vitality,  a  little  above  the  puncture. 

An  Improved  Method  of  Radical  Operation  for  Car- 
cinoma of  the  Breast— Dr.  Willy  Meyer  read  the 
paper.     See  page  746. 

Dr.  H.  J.  Boldt  said  he  had  not  removed  the  breast  in 
one  mass  as  described  in  the  paper,  but  in  two  cases 
he  had  performed  the  operation  as  radically,  removing 
muscle.  One  patient  had  died.  The  other,  who  was 
operated  upon  two  months  ago,  could  not  use  the  arm 
as  well  as  before,  and  had  some  interference  with  the 
circulation.  He  did  not  doubt  the  superiority  of  re- 
moving  all  that  it  was  intended  to  remove  in  one  piece. 

The  Axillary  Operation  Heedless.— Dr.  Thomas  H. 
Manley  said  that  according  to  his  own  experience  it 
was  entirely  needless  to  go  up  into  the  axilla  in  removal 
of  cancerous  breast.  Going  down  to  the  pectoral  mus- 
cle increased  the  danger  to  life— danger  of  injuring  the 
axillary  vessels  and  brachial  plexus.  When  the  parts 
were  closed  in,  the  scar  held  the  arm  down  and  inter- 
fered with  the  circulation  in  the  axilla.  Moreover,  the 
theory  on  which  such  extensive  removal  was  based,  that 
cancer  was  a  local  disease,  had  not  been  proven.  He 
remembered  a  statement  made  by  the  elder  Markoe, 
some  years  ago,  when  removal  of  the  axillary  glands  was 
coining  into  vogue.  Dr.  Markoe  had  said  he  did  not 
believe  in  it,  for  the  axillary  enlargement  was  only  due 
to  tumefaction,  and  this  went  down  as  predicted,  in  the 
case  on  which  he  was  operating,  after  he  had  removed 
the  diseased  breast.  Unless  it  were  in  special  cases,  Dr. 
Manley  did  not  think  such  extensive  dissection  as  had 
been  described  by  Dr.  Meyer  was  necessary. 

The  Axillary  Operation  Imperative.— All  the  re- 
mainder of  the  speakers  took  pains  to  combat  Dr. 
Manley's  view,  that  removal  up  into  the  axilla  was  not 
necessary.  Even  where  no  infiltration  in  the  axillary 
glands  had  been  apparent,  microscopic  examination  had 
shown  the  presence  of  cancer  cells.  The  statistics  oi 
cures  had  been  much  better  after  the  more  radical  ex- 
cision than  previously.  All  thought  well  of  Dr.  Meyer's 
procedure,  some  claimed  to  have  been  in  the  habit  of 
removing  muscle  along  with  the  gland  tissue,  and  the 
question  of  priority  was  raised  even  as  to  removal  in 
bulk,  commencing  in  the  axilla.  The  speakers  were 
Drs.  Dawbarn,  Gallant,  Morris,  Fowler,  Lloyd,  Van 
Arsdale,  Meyer.  Dr.  Francis  H.  Markoe  said  that  in  a 
recent  conversation  with  his  father  the  latter  had  ad- 
mitted the  superiority  of  the  radical  operation  as  having 
been  proven  by  recent  statistics. 


The  Tenement-house  Commission  appointed  by  Gov- 
ernor Flower  last  spring,  in  accordance  with  a  bill  passed 
by  both  houses  of  the  Legislature,  find  that  a  new  list  of 
more  than  five  thousand  houses  require  especial  investiga- 
tion. They  further  find  that  three-fourths  of  this  city's 
population  live  in  tenement*  Of  course  a  large  deduc- 
tion may  be  made  in  favor  of  high- class  flats  and  apart- 
ment-houses, but  the  law  does  not  discriminate  between 
Fifth  Avenue  and  Chrystie  Street.  Three  or  more  fam- 
ilies constitute  a  tenement  according  to  the  legal  defini- 
tion. 


OUR  LONDON  LETTER. 

GLADSTONE  ON  CLARK — DRUGGIST- APOTHECARIES  AND  SIR 
B  W.  RICHARDSON — THE  MARYLEBONE  EPIDEMIC — TES- 
TIMONIALS— LISTER  —  HUGHUNGS       JACKSON WALTER 

RIVINGTON — MEMORIAL  TO  BEAVEN  RAKE — DEATHS  OF 
ALBERT  NAPPER  AND  SURGEON  GENERAL  ERASER — MEDI- 
CAL COUNCIL  —  SMALL-POX  —  DIPHTHERIA  AND  ANTI- 
TOXIN—  CLINICAL  EVENINGS  AT  THE  SOCIETIES  —  IN- 
TERESTING EXHIBITS  AT  THE  MEDICAL  AND  CLINICAL 
SOCIETIES — OPENING  THE  CECUM — LARGE  CALCULUS — 
HEREDITARY  SYPHILIS — CRETINS — RUPTURED  NECK  OP 
BLADDER — EXCISION  OF  SCAPULA — EXTENSIVE  TUBER- 
CULOSIS OF  PERINEUM,  PROSTATE,  AND  RECTUM — TRE- 
PHINING FOR  EPILEPSY — CURIOUS  NODULES,  ETC. — MED- 
ICAL DEPUTATION" TO  THE  HOME  SECRETARY — MARRIED 

WOMEN  AND  FACTORY  WORK  —  DEATH  CERTIFICATION 

MASSAGE    SCANDALS — LONDON    DEATH  RATE PUBLIC 

HEALTH — DEATH  OF  DR.  DICKSON,  R.  N. 

London,  November  24,  1894. 

I  hear  that  Mr.  Gladstone  is  about  giving  to  one  of 
your  American  magazines  some  reminiscences  of  his 
late  friend  Sir  Andrew  Clark.  This  reminds  me  that 
the  considerable  fortune  left  by  the  respectable  medical 
baronet  has  given  rise  to  much  gossip  as  to  its  origin. 
It  is  not  infrequently  said  that  the  sum  was  accumu- 
lated from  practice,  and  as  it  exceeded  ,£200,000,  that 
is  enough  to  make  any  physician's  mouth  water.  I  hap- 
pen to  know,  however,  on  the  best  authority — Sir  An- 
drew's own — that  he  was  careful  and  fortunate  as  to 
investments,  and  to  them  we  must  attribute  a  considera- 
ble share  in  the  accumulation.  A  daily  newspaper  has 
lately  discussed  the  "  Fortunes  Left  by  Doctors/'  bat 
without  affording  any  important  information. 

Sir  B.  W.  Richardson  has  returned  in  his  last  Ascltpiad 
to  his  proposal  to  legalize  druggists  as  counter-prescribers. 
He  would  have  an  order  of  "  pharmaceutical  apotheca- 
ries "  to  occupy  itself  with  inferior  practice  as  well  as  dis- 
pensing, and  pretends  that  such  an  order  would  quickly 
accept  medical  etiquette  and  submit  to  the  rule  of  their 
professional  superiors.  It  is  a  pity  that,  with  all  his  abili- 
ties, Sir  Benjamin  should  have  such  self-consciousness 
as  to  fancy  he  has  only  to  speak  to  settle  any  difficulty. 
It  is  a  wonder  that  his  love  of  admiration  did  not  prompt 
him  to  drop  his  proposal  when  he  saw  how  unpopular  it 
was.  But  he  has  spoken  and  seems  to  think  that  is 
enough.  He  will  perhaps  yet  see  his  error.  The  idea  of 
relieving  the  overcrowding  and  resulting  degradation  of 
the  profession  by  flooding  it  with  unqualified  practition- 
ers, is  original  enough,  and  worthy  of  the  fertile  fancy  of 
the  Ascltpiad.  Why  does  he  not  also  offer  to  take  in  our 
sanitary  inspectors  ?  These  persons,  elect  of  our  vestries, 
are  forging  ahead,  and  in  some  districts  evidently  intend 
to  assume  as  many  as  possible  of  the  functions  of  the 
medical  officers  of  health.  Perhaps  they  hope  to  become 
the  chief  advisers  of  our  sanitary  boards.  Let  Sir  Benja- 
min extend  his  hand  in  time  and  recognize  them  as  special* 
ists  in  preventive  medicine.  Then  hygeia  would  indeed 
be  established,  and  physicians  might  be  relegated  to  an 
inferior  order. 

During  the  late  outbreak  of  small-pox  in  Marylebone 
Dr.  Greenwood  vaccinated  1,725  persons  and  revac- 
cinated  2,306.  There  was  in  fact  a  local  scare,  and  a 
rush  to  obtain  the  protection  which  had  been  so  much 
neglected.  It  appears  from  Dr.  Greenwood's  report 
that  about  twenty-six  per  cent,  of  the  inhabitants  had 
been  guilty  of  such  neglect.  After  the  performance  of 
these  operations  only  two  or  three  cases  of  small-pox  oc- 
curred in  the  whole  number,  and  these  were  already  in- 
cubating the  disease.  The  anti-vaccinators  will  find 
small  comfort  in  these  figures,  but  I  suppose  will  not 
cease  to  propagate  their  pernicious  prejudice.  Perhaps 
an  occasional  scare  of  this  kind  is  the  only  way  to  teach 


December  15,  1894] 


MEDICAL   RECORD, 


765 


them  the  futility  of  their  fad  when  the  public  finds  dan- 
ger approaching. 

Testimonials  are  much  in  vogue,  and  make  no  small  de- 
mands on  the  often  too  slenderly  furnished  purses  of 
medical  men.  Just  now  three  important  ones  are  before 
us— one  to  Lister,  one  to  Hughlings  Jackson,  and  one  to 
Rivington.  All  three  desire  the  support  of  those  whose 
finances  make  it  easy  to  subscribe.  It  may  be  thought 
that  Lister  has  already  received  all  the  honors  that  are 
necessary  during  life,  and  that  the  rest  might  be  left  for 
posthumous  commemoration  ;  but  no  doubt  the  ever- 
widening  circle  of  antiseptic  surgeons,  at  any  rate  the 
prosperous  ones,  will  hasten  to  enroll  their  names. 
Hughlings  Jackson  has  also  done  a  great  and  lasting 
work,  and  neurologists  everywhere  will  be  glad  of  the 
opportunity  to  honor  him. 

Walter  Rivington's  work  has  been  so  closely  connect- 
ed with  thfe  London  Hospital,  and  he  has  been  so  favorite 
a  teacher,  that  it  was  only  natural  for  his  numerous 
pupils  and  admirers  to  seize  the  occasion  of  his  retire- 
ment from  active  service  to  testify  their  esteem.  Ac- 
cordingly he  was  entertained  at  a  dinner  last  week,  and 
presented  with  a  silver  tea  and  coffee  service.  Mr.  Riv- 
ington thanked  the  numerous  friends  who  had  gathered 
to  honor  him,  as  well  as  those  who  were  unable  to  be 
present  but  had  subscribed  to  the  handsome  testimonial 
— adding  with  the  sly  humor  which  never  fails  him,  "  and 
also  those  who  had  judiciously  refrained  from  doing  so." 

From  testimonials  to  the  living,  it  is  natural  to  pass  to 
memorials  to  the  honored  dead.  The  work  of  the  late 
Dr.  Beaven  Rake,  of  the  Trinidad  Leper  Asylum,  is 
worthy  of  admiration,  and  his  premature  death,  leaving  a 
widow  and  children  but  ill-provided  for,  is  the  occasion 
of  a  proposal  to  raise  a  sum  of  money  for  their  benefit. 
It  is  impossible  not  to  wish  success  to  the  subscription. 
The  scientific  spirit  was  strong  in  Dr.  Rake,  and  he  died 
too  soon  to  make  suitable  provision  for  his  family — a  too 
common  occurrence  in  our  ill-remunerated  calling. 

The  death  of  Mr.  Albert  Napper  took  place  last  week, 
somewhat  suddenly,  in  the  seventy-ninth  year  of  his  age. 
He  will  be  remembered  as  the  Founder  of  the  Cottage 
Hospital  system,  now  so  generally  in  vogue  that,  to  the 
younger  members  of  the  profession  it  must  seem  strange 
that  one  life  should  cover  the  time  since  there  were  no 
such  institutions.  Mr.  Napper's  earnest  advocacy  and 
unfailing  perseverance  succeeded  in  establishing  the  sys- 
tem which  everyone  now  admires. 

Another  veteran  also  died  last  week,  Surgeon- General 
John  Fraser,  aged  seventy-five.  He  had  seen  much  ser- 
vice, including  the  Crimea  and  the  Indian  Mutiny.  He 
had  received  various  honors,  and  on  his  retirement  a 
distinguished  service  pension. 

Next  week  the  General  Medical  Council  will  be  in 
session. 

The  public  health  continues  good.  The  small-pox 
epidemic,  in  London,  has  apparently  subsided,  and  diph- 
theria deaths  have  diminished.  In  regard  to  the  last  the 
serum  treatment  is  occupying  great  attention,  and  is  be- 
ing tried  wherever  a  supply  can  be  obtained.  The  suc- 
cesses reported  are  very  striking,  and  it  is  to  be  hoped 
the  British  Institute  will  soon  be  in  a  position  to  meet 
the  demand  for  the  new  remedy. 

What  are  called  clinical  evenings  at  the  societies  are 
becoming  very  popular.  They  are  devoted  to  the  exhi- 
bition of  cases  and  specimens  with  a  few  remarks  to 
explain  them,  and  attract  larger  attendances  than  set 
papers.  The  Medical  Society  of  London  has  begun  to 
hold  such  meetings,  as  the  Clinical  has  long  done.  Both 
these  had  such  evenings  at  their  last  meetings,  and  both 
were  well  attended  and  the  exhibits  were  of  great  inter- 
est. Thus  at  the  Medical  Society,  which  met  on  Monday 
last,  Mr.  Harrison  Cripps  gave  an  account  of  a  most 
interesting  case  of  intestinal  obstruction  in  a  woman, 
aged  thirty-one,  who  had  sustained  two  severe  operations, 
but  ultimately  made  a  good  recovery  and  is  now  in  good 
health,  and  has  resumed  her  occupation  as  a  domestic 
servant. 


Mr.  Goodsall  showed  a  man  who  had  come  to  him 
with  intestinal  obstruction  due  to  cancer  of  the  rectum. 
He  performed  left  inguinal  colotomy  to  relieve  the  . 
obstruction,  but  the  colon  was  so  distended  and  packed 
with  putty-like  feces,  that  he  was  unable  to  draw  the  gut 
out  of  the  wound.  He  waited  for  seven  days  in  the  hope 
that  some  bulging  would  take  place,  but  as  the  patient  at 
that  time  began  to  get  into  a  serious  condition,  he  de- 
cided to  attack  the  csecum.  He  found  this  filled  with 
the  same  putty-like  feces,  but  managed  to  pull  it  out, 
and  he  opened  it  forthwith,  with  a  satisfactory  result. 
This  was  the  third  time  he  had  opened  the  cecum,  and  he 
was  inclined  to  regard  this  operation  in  certain  cases  as 
presenting  advantages  over  colotomy.  Among  the  other 
cases  shown  was  one  by  Mr.  Astley  Bloxam,  in  which 
thirteen  ounces  of  calculus  were  removed  by  bim  through 
a  lumbar  incision.  The  curious  point  about  the  case  was 
that  the  symptoms  at  no  time  suggested  the  presence  of 
anything  approaching  so  large  a  mass  of  calcareous 
deposit. 

Dr.  Hall  showed  a  boy  sixteen  years  of  age,  who  had 
developed  hereditary  syphilis  as  late  as  in  his  eighth  year 
of  age.  Some  other  late  cases  were  mentioned  by  those 
present,  one  of  whom  said  he  had  seen  it  as  late  as  the 
twentieth  and  even  thirtieth  year  of  age. 

Mr.  Clutton  showed  a  boy  thirteen  years  of  age,  who 
had  had  the  humerus  dislocated,  and  the  surgical  neck  of 
the  bone  fractured.  The  fracture  and  joint  were  ex- 
posed, ivory  pegs  employed,  etc.,  and  perfect  movement 
of  the  joint  resulted. 

Some  cretins  were  exhibited.  Thyroid  gland  treat- 
ment had  produced  excellent  results  in  some  of  them. 

The  Clinical  Society  of  London  held  their  meeting  on 
Friday,  November  9th.  Mr.  Hurry  Fenwick  showed  a 
patient  with  traumatic  rupture  of  the  prostatic  neck  of 
the  bladder,  who  had  been  buried  while  excavating. 
Twelve  hours  after  the  accident  suprapubic  incision  re- 
vealed the  condition,  and  the  bladder  was  drained 
through  a  perineal  incision.  Mr.  Fenwick  urged  that  in 
all  doubtful  cases  suprapubic  incision  should  precede 
the  opening  of  the  peritoneum,  and  he  believed  that 
most  extra-peritoneal  uncomplicated  ruptures  ought  to 
bee  ured. 

Dr.  W.  P.  Herringham  gave  an  acount  of  a  case  of 
scleroderma  in  a  seaman,  thirty-nine  years  of  age,  who 
had  been  for  sixteen  years  a  diver. 

Mr.  Watson  Cheyne  showed  a  man,  fifty  years  of  agc9 
from  whom  he  had  removed  the  scapula  five  weeks  pre- 
viously, on  account  of  a  large  enchondromatous  tumor  of 
seven  years'  growth,  involving  the  whole  bone  and  pro- 
jecting forward  into  the  axilla.  The  tumor  weighed 
over  ten  pounds.  The  wound  healed  by  first  intention, 
and  the  patient  left  the  hospital  sixteen  days  after  the 
operation.  The  movements  of  the  arm  are  steadily  in- 
creasing in  range  and  power. 

Mr.  Arbuthnot  Lane  showed  a  case  of  extensive  tuber- 
cular disease  of  the  perineum,  prostate,  ischiorectal 
fossa,  and  rectum,  which  he  treated  successfully  by  the 
introduction  of  glycerine  and  sulphur  into  the  cavities ; 
which  was  begun  on  September  4,  1894,  when  he 
weighed  eight  stone  eleven  pounds ;  now  he  weighs  ten 
stone,  and  is  free  from  pain. 

Dr.  Barlow  showed  a  case  of  extensive  primary  atrophy 
of  the  muscles  of  the  limbs  and  trunk,  with  lordosis  and 
some  contraction  of  hips,  in  a  lad  five  years  of  age.  No 
particular  muscles  were  atrophied  more  than  others,  the 
atrophy  being  pretty  general,  but  in  some  respects  the 
case  resembled  pseudo-hypertrophic  paralysis,  but  was 
difficult  to  classify ;  and  Dr.  Ormerod  suggested  that  it 
belonged  to  the  "myopathic"  group  of  pseudo-hyper- 
trophic cases. 

Mr.  Butlin  showed  a  man  in  whom  he  had  performed 
trephining  for  traumatic  epilepsy  following  a  fall  of 
eight  feet,  the  head  striking  against  the  mantel- piece. 
He  removed  a  second  piece  of  bone,  but  discovered 
nothing  further.  He  let  out  the  fluid  in  the  subarach- 
noid space,  and  the  man  made  a  good  recovery,  though 


766 


MEDICAL  RECORD. 


[December  15,  1894 


his  mental  condition  remained  unsatisfactory  for  some 
time. 

Mr.  Gould  mentioned  a  curious  case  of  a  man  who 
had  struck  his  head  in  a  bath.  After  operation  he  ap- 
peared to  be  better,  but  his  mental  condition  never  be- 
came satisfactory,  and  he  was  not  altogether  free  from 
fits.  He  was  lost  sight  of  for  a  time,  but  Mr.  Barker 
said  the  man  had  come  into  the  hospital  under  his  care 
some  days  since.  He  gave  an  altogether  misleading  his 
tory  of  himself,  denying  ever  having  had  fits  or  having 
been  operated  upon.  The  examination  of  the  scalp  led 
one  to  think  that  there  was  a  depressed  fracture,  but  on 
receiving  the  real  history  the  idea  of  operating  thereon 
was  abandoned,  the  supposed  depressed  fracture,  on 
shaving  the  scalp,  being  obviously  the  scar  of  Mr.  Gould's 
operation. 

Mr.  Jacobson  showed  a  man  who  had  been  operated 
on  for  bullet  wound  of  the  parietal  lobe,  inflicted  while 
skirmishing  on  the  west  coast  of  Africa,  where  he  was 
struck  by  a  bullet  which  lodged  in  the  lower  part  of  the 
left  parietal  lobe,  or  at  the  junction  of  this  with  the  tem- 
poro-3phenoidal.  He  became  unconscious,  and  after  five 
weeks  he  returned  to  England,  his  wound  closing  for  a 
time,  then,  reopening,  giving  exit  to  pieces  of  bone  and 
discharge.  During  this  period  there  had  been  no  hemi- 
plegia, no  hemianaesthesia,  no  crossed  amblyopia.  Se- 
vere headaches  frequently  occurred  when  the  wound 
closed  for  a  time.  On  June  27th  an  attempt  was  made 
at  Plymouth  to  remove  the  ball,  but  as  brain -matter  es- 
caped this  was  desisted  from.  Save  for  the  headaches 
his  general  health  was  excellent.  On  October  19th  the 
opening  was  exposed  and  enlarged,  when  one  came  upon 
the  mouth  oi  a  sinus-like  track  in  the  dura  mater,  blocked 
with  granulations.  This  membrane  was  quite  healthy 
all  round.  Two  small  pieces  of  bone  were  removed 
from  a  spot  about  three-quarters  of  an  inch  from  the 
mouth  of  the  sinus.  Two  inches  further  in,  the  probe 
struck  the  bullet,  which  was  removed  by  the  aid  of  a  sharp 
spoon.  He  made  a  rapid  recovery,  and  has  since  entirely 
lost  his  headaches. 

Dr.  Hale  White  showed  a  boy  aged  ten,  who,  when 
near  the  end  of  a  first  relapse  of  typhoid  fever,  developed 
a  severe  eczema  which  rapidly  spread — the  whole  face  and 
ears  were  covered,  the  eyes  being  affected  with  conjunc- 
tivitis— and  slowly  subsided  in  about  six  weeks. 

Dr.  Harry  Campbell  showed  a  case  of  acromegaly  in  a 
man  aged  forty-six. 

Dr.  Scanes  Spicer  showed  a  case  of  incomplete  Graves's 
disease  with  nasal  polypi,  in  a  young  woman.  After  re- 
moving a  large  number  of  polypi,  the  patient  had  im 
proved  in  some  respects,  and  he  thought  that  the  con- 
nection between  these  two  conditions  was  something 
more  than  a  coincidence. 

Dr.  G.  Stoker  said  he  had  had  a  case  of  goitre  along 
with  intra  nasal  growths,  in  whom  the  treatment  of  the 
nasal  condition  was  followed  by  the  disappearance  of  the 
goitre  within  two  months. 

Mr.  Godlee  showed  a  man  aged  twenty-eight,  with 
multiple  nodules  of  doubtful  nature  which  began  in 
April.  There  were  numerous  hard  nodules  in  the  eye- 
lids, on  the  forehead,  jaw,  arms,  condyles,  etc.,  and  on 
the  knuckles.  Microscopically,  the  nodules  were  said  to 
be  composed  of  fibrous  and  not  lymphatic  tissue. 

Mr.  Boulby  showed  a  man,  aged  fifty- eight,  with  Char- 
cot's disease  of  the  hip  with  dislocation.  The  evidences 
of  tabes  are  as  follows :  Lightning  pains  in  limbs,  dim 
vision,  and  gray  atrophy,  absence  of  knee  jerks,  and  in- 
ability to  stand  with  the  eyes  shut. 

Mr.  Edgar  Willett  showed  a  similar  case. 

On  Wednesday,  November  14th,  Mr.  Asquith  received 
at  the  Home  Office  a  deputation  got  up  by  a  committee  of 
the  British  Medical  Association.  The  object  was  to  influ- 
ence the  minister  on  three  questions,  viz.,  the  employment 
of  married  women  in  factories,  death  certificates,  and  the 
factory  laws.  The  injury  to  children  from  the  employ- 
ment of  their  mothers  in  factories  has  often  been  brought 
forward  as  an  argument  in  favor  of  legislative  prevention, 


m  and  Dr.  Reid  urged  this  view  on  the  Home  Secretary 
'  with  considerable  force,  estimating  that  the  infant  mor- 
tality was  twenty  eight  per  cent,  greater  in  factory  towns 
than  in  other  parts.  He  insisted  that  women  should  be 
prohibited  from  such  work  for  three  months  after  the 
birth  of  a  child.  Mr.  Asquith  asked  if  the  month  before 
birth  was  not  equally  important,  but  was  told  that  was  a 
separate  question,  and  apparently  the  deputation  were  not 
agreed  upon  it.  The  minister  has  evidently  thought  out 
the  subject,  and  the  newspaper  reports  show  that,  although 
he  grasped  and  sympathized  with  the  object  of  Dr.  Reid, 
yet,  looking  at  the  matter  from  a  broader  standpoint,  he 
saw  some  difficulties  in  the  way.  Thus,  though  employ- 
ers are  generally  ready  to  keep  a  woman's  place  open  far 
her  return,  it  is  by  no  means  certain  they  would  do  so 
for  a  period  of  three  months.  Again,  he  remarked  that, 
although  it  was  a  good  thing  to  check  improvident  mar- 
riages, it  would  be  the  reverse  to  engender  a  feeling  that 
the  child  was  in  the  way.  Then,  as  to  criches,  there  was 
a  rather  strong  prejudice  against  them,  and  though  only 
a  prejudice,  yet  its  existence  was  a  fact  to  be  reckoned 
with.  Mr.  Asquith  said  he  did  not  make  these  remarks 
in  a  hostile  spirit,  but  they  were  objections  that  must  be 
carefully  weighed,  and  he  promised  that  the  subject 
should  be  carefully  considered. 

As  to  death  certification,  assurances  were  offered 
on  the  part  of  the  government  of  their  concurrence,  sav- 
ing the  question  of  cost,  and  whether  the  time  of  Par- 
liament would  suffice.  There  was  also  little  difference  as 
to  the  factory  acts. 

Of  course  Mr.  E.  Hart  was  much  en  evidence,  and  he 
seized  the  opportunity  to  mention  the  massage  scandals 
lately  reported  in  the  British  Medical  Journal,  and  which 
he  is  continuing  to  publish  in  very  short  instalments 
double  leaded  and  "  to  be  continued,"  after  the  manner 
of  sensational  chapters  in  "penny  dreadful1'  periodi- 
cals. 

Mr.  Asquith  expressed  his  disinclination  to  deal  with 
such  a  subject  in  public,  and  said  it  was  not  in  his  judg- 
ment fitted  for  such  an  occasion ;  but  as  Mr.  Hart  had 
chosen  to  introduce  it,  he  would  simply  say  he  was  wil- 
ling to  receive  any  authenticated  information  to  show 
there  had  been,  or  was  likely  to  be,  any  breach  of  the  law. 
He  pointed  out  that  the  police  are  not  guardians  of 
morality  and  could  hardly  interfere  on  moral  grounds 
unless  the  law  was  infringed ;  but  Mr.  Hart  might  rely 
upon  the  co-operation  of  the  police  within  their  proper 
functions.  The  view  of  the  home  secretary  is  naturally 
unsatisfactory  to  Mr.  Hart,  who  is  evidently  already  tired 
of  the  sensation  he  has  tried  to  get  up.  Accordingly  I 
see  the  Journal  to-day  says  it  is  "  eminently  desirable  that 
the  police  should  take  this  matter  off  our  hands  as  speedily 
as  possible." 

No  doubt  that  would  be  a  course  to  afford  gratification 
to  others  than  the  staff  of  the  Journal,  but  the  probability 
of  such  success  should  have  been  weighed  before  embark- 
ing on  so  dangerous  and  disgusting  a  course  of  sensation. 
Nevertheless  all  may  hope  that  good  will  come  out  of 
the  exposure  that  has  been  made,  and  some  way  of  deal- 
ing with  the  subject  arrived  at. 

The  public  health  continues  to  be  excellent  in  spite 
of  the  most  trying  weather.  Last  week  the  death-rate 
in  London  was  only  fifteen,  although  diphtheria  still  lin- 
gers with  us.  But  the  cases  are  diminishing  week  by 
week. 

The  Registrar-General  reports  that  last  quarter  (ending 
September  30th)  was  the  first  summer  quarter  since  1837 
that  the  annual  rate  fell  below  15  per  1,000.  This  last 
it  only  reached  14.2.  Yet  the  summer  was  marked  by 
low  temperature,  excessive  rain,  and  deficient  sunshine, 
and  though  we  are  still  having  what  is  generally  declared 
"  most  unseasonable  "  weather,  the  mortality  returns  are 
most  favorable. 

Dr.  Walter  Dickson,  R.  N.,  medical  inspector  of  H. 
M.  Customs,  died  on  the  9th  inst.,  in  the  seventy-fourth 
year  of  his  age.  He  was  a  roan  of  considerable  learning 
and  literary  tastes.    He  had  done  no  little  service  in  the 


December  15,  1894] 


MEDICAL   RECORD. 


767 


Royal  Navy,  and  had  received  many  medals  and  other 
recognitions. 

His  published  writings  and  addresses  were  numerous, 
and  all  were  characterized  by  a  thorough  grasp  of  his 
subject,  which  he  put  in  an  attractive  form. 


MALARIA  AND  DRINKING-WATER. 

To  thb  Editok  or  tub  Medical  Record. 

Sir:  I  have  noticed  several  articles  on  malaria  as  a 
water-borne  disease  in  the  Medical  Record  of  the  last 
few  weeks. 

Allow  me  to  side  with  Dr.  Dalrymple,  and  suggest  a 
few  more  objections  to  the  theory  of  Dr.  Daly's. 

I  lived  as  a  boy  in  Southwestern  Missouri,  when  that 
portion  of  the  State  was  metamorphosing  from  a  stock- 
raising  to  a  farming  community,  and  am  familiar  with 
about  all  forms  of  malaria,  and  speak  from  personal  ex- 
perience. I  have  seen  families  drinking  surface  water 
remain  free  from  all  infection,  only  to  become  prostrated 
as  soon  as  they  began  breaking  land.  This  was  not  in  a 
few  instances,  but  was  the  regular  thing. 

The  old  settlers,  who  lived  on  the  creek-bottoms  and 
who  arose  early,  before  the  sun  had  dissipated  die  morn- 
ing fog,  were  always  sick,  while  their  neighbors  living 
higher  on  the  hills,  and  who  awaited  the  rising  sun  be- 
fore beginning  work,  would  frequently  escape.  Sleeping 
on  the  ground  would  always  bring  on  an  attack  of  the 
chills,  while  sleeping  twenty  feet  above  the  surface  gave 
immunity  even  when  the  same  water  was  used* 

Intermittent  fever  has  followed  the  settlement  of  this 
country  from  Indiana  to  California,  keeping  pace  with 
the  turning  of  the  sod. 

It  was  also  noticed  that  in  Ohio  and  Missouri,  during 
the  time  of  making  maple- sugar,  to  use  the  sap  with  any- 
thing like  freedom  was  invariably  followed  by  intermit- 
tent fever.  This  was  well  known  and  added  zest  to 
every  swallow  of  that  exhilarating  fluid.  This  was  before 
the  advent  of  the  plasmodia  malarise  into  medical  litera- 
ture, and  was  a  curious  clinical  fact  with  no  tenable 
theory  to  support  it  then. 

It  has  seemed  to  me,  too,  that  the  persons  who  used 
sorghum  molasses  freely  were  rather  more  susceptible 
to  the  poison  than  others,  and  that  the  young  and  grow- 
ing, who  needed  sugar  to  keep  up  muscular  growth  and 
activity,  were  more  likely  to  become  intoxicated  with 
the  poison. 

I  have  never  seen  any  account  of  cultures  of  the  Plas- 
modia, but  I  could  venture  a  guess  that  it  would  only 
grow  in  a  medium  containing  an  appreciable  percentage 
of  sugar. 

The  value  of  the  eucalyptus-tree  as  a  prophylactic,  as 
proven  by  the  experiments  made  near  Rome,  must  rest 
on  the  germicidal  qualities  of  the  rootlets — in  the  oil 
that  they  contain — and  not  in  the  minute  particles  of 
that  oil  given  off  by  the  leaves  to  the  passing  breeze. 

I  think  quite  likely  that  the  home  of  the  plasmodia  is 
in  the  sap  of  vegetable  life  rich  in  sugar.  While  water 
is  the  frequent,  perhaps  common,  source  of  infection, 
yet  I  know  that  it  does  enter  the  system  from  other 
sources  as  well. 

Rawlins  Cadwallader,  A.M.,  M.D. 

Fall  Rive*  Mills,  Cal. 


THE  MARRIAGE  OF  SYPHILITICA 

To  thb  Editok  or  thb  Medical  Rkcoed. 

Sir:  In  your  issue  for  November  24th,  under  "The 
Marriage  of  Syphilitics,"  Dr.  W.  K.  Otis,  of  New  York 
City,  criticises  the  "positive  stand"  taken  by  myself, 
in  a  previous  issue,  on  the  above-named  subject  Whether 
my  replies  to  Dr.  Burnside  Foster  are  satisfactory  to  him 
or  otherwise,  I  leave  for  him  to  answer  for  himself.  If 
my  answers  to  Dr.  Foster's  queries  are  not  acceptable  to 
himself,  he  certainly  had  better  continue  his  investiga- 
tions far  enough  and  thoroughly  enough  to  satisfy  him- 


self that  "  allowing  our  syphilitic  cases  to  marry  "  and 
procreate  is,  at  all  times  and  in  nearly  all  cases,  a  hazard- 
ous thing  to  do. 

Dr.  Otis  says,  "Unfortunately  Dr.  Maine  has  taken  a 
very  positive  stand  in  this  matter,  and  one  that  is  wholly 
(italics  mine)  unwarranted  by  either  authorities  or 
facts."  I  desire  right  hereto  ask,  "unfortunately  "  for 
whom  ?  Certainly  not  for  myself,  and  most  assuredly 
not  for  all  good  and  honored  representatives  of  pure 
American  citizenship. 

If  "unfortunately"  for  the  band  of  syphilitics  who 
would  prey  upon  innocent  purity  through  the  sacred 
marriage  contract,  or  "unfortunately  "  for  the  physician 
who  would  sanction  such  marriages,  and  overlook  the 
greatest  good  to  the  greatest  number,  and  cater  to  the 
selfish  purposes  of  thoroughly  selfish  unfortunates,  I  glory 
in  the  "unfortunately  "  "  positive  stand "  I  have  taken. 

When  Dr.  Otis  says,  "  Wholly  unwarranted  by  either 
authorities  or  facts,"  I  take  again  my  "  positive  stand," 
and  am  ready  to  take  issue  with  the  doctor  and  declare 
that  both  "authorities  and  facts,"  in  far  more  than  the 
average,  fully  bear  me  out  in  the  "positive  stand  "  I 
have  taken. 

Yes !  I  have  taken  a  "positive  stand"  and  am  ready, 
were  it  necessary,  to  stand  alone  for  what  I  believe  to  be 
right  (but  I  have  not  found  it  necessary  to  stand  alone, 
as  I  have  already  received  many  words  of  commendation 
and  encouragement  from  numerous  sources),  and  in  the 
defence  of  pure  marriages  and  the  propagation  of  a  race 
that  shall  be  an  honor  to  the  nation. 

I  desire,  furthermore,  to  be  understood  as  to  the 
sources  from  which  I  have  gleaned  a  large  percentage  of 
the  "  facts  "  which  have  led  up  to  the  formation  of  my 
opinions  and  my  "positive  stand:  "  1.  To  the  evi- 
dences furnished  by  a  careful  study  of  the  works  named 
by  Dr.  Otis,  to  which  list  I  also  desire  to  add  the  names  of 
Fournier  and  Wood.  a.  Considering  the  guarded  manner 
in  which  all  present  the  conclusion  "  that  it  may  in  cer- 
tain instances  be  safe  for  syphilitics  to  marry."  3.  To 
this  strong  line  of  evidences,  that  there  is  danger  in 
permitting  syphilitics  to  marry,  I  attach  the  evidences 
gathered  from  journal  statistics  published  during  die  past 
twenty  years;  and  4,  last  and  least,  my  own  experience 
ranging  over  a  longer  period  than  that,  which  (though, 
since  graduation,  I  have  not  had  the  advantage  of 
"  study  of  the  disease  in  the  rich  fields  for  research  only 
obtainable  in  great  cities")  have  yet  been  sufficient  to 
teach  me,  at  least,  the  dangers  of  syphilitic  marriages. 
But  I  do  not  want  Dr.  Otis  to  think  that  the  "  great 
cities"  have  all  the  "luxuries,"  for  even  in  my  own 
"  small  city  "  the  vile  enemy  to  health,  happiness,  and 
home  lurks;  and,  sad  to  relate,  we  have  rich  fields  for 
study,  and  have  plenty  of  material  from  which  to  observe 
and  draw  conclusions  respecting  that  blight  and  blot  on 
everything  good  and  pure  that  it  touches  (syphilis),  even 
in  the  country  districts. 

Having  thus  briefly  stated  the  sources  from  whence  I 
have  drawn  the  "facts'1  which  have  led  me  "to  feel 
justified  in  presenting  my  opinion  "  (no  matter  to  whom 
it  is  in  opposition),  simply  passing  the  doctor's  comment 
on  my  mention  of  scrofula,  with  the  sole  explanation  that 
in  my  former  paper  I  merely  referred  to  it  as  one  of  the 
conditions  handed  down  from  past  generations ;  barely 
adding  that  I  have  at  my  command  the  latest  "  works  on 
general  pathology  "  and  am  able  to  see  that  opinions 
differ  in  respect  to  the  subject,  I  will  pass  on  and  draw  a 
few  conclusions: 

1.  No  writer  says  every  syphilitic  can  marry. 

2.  Every  writer  declares  great  care  should  be  exercised 
in  permitting  the  marriage  of  syphilitics. 

3.  Every  writer  who  has  carefully  compiled  statistics 
(so  far  as  I  can  find),  has  followed  but  the  first  two  gener- 
ations, except  in  a  very  few  special  instances  not  amount- 
ing to  three  per  cent,  of  the  total. 

4.  The  average  ages  of  the  children,  or  second  gener- 
ation, when  pronounced  apparently  healthy  (by  all 
statistics  at  my  command),  is  a  little  over  fourteen  years. 


768 


MEDICAL  RECORD. 


[December  i  5.  1894 


5.  In  a  little  over  fifty-three  per  cent,  of  the  parents 
(first  generation)  who  had  suffered  from  syphilis  previous 
to  marriage,  the  cases  have  showto  unmistakable  evidences 
of  syphilis  subsequent  to  the  birth  of  siid  "  apparently 
healthy  child  or  children." 

Now,  allowing  a  moderate  average,  say  fifty  per  cent., 
of  the  said  remaining,  forty-seven  per  cent,  might  have 
died  from  other  causes  without  showing  a  recurrent  syphi- 
lis, but  would  had  they  lived,  and  taking  out  twenty-five 
per  cent,  more  of  the  remaining  forty- seven  per  cent,  as 
having  passed  out  from  under  observation  (and  that  is 
small  enough),  and  we  have  left  a  very  small  percentage 
as  even  questionably  safe  to  permit  marriage  to  be  con- 
tracted ;  and  who  is  competent  to  select  that  small  per- 
centage in  the  early  days  of  the  syphilitic  cases?  I  ac- 
knowledge that  I  am  not,  and  statistics  show  that  others 
have  made  serious  mistakes. 

6.  If  a  parent  who,  apparently  cured,  procreates  (and 
these  conclusions  are  arrived  at  from  the  printed  statis- 
tics of  writers  favorable  to  allowing  "  the  marriage  of 
syphilitica  "  under  certain  conditions)  children  who  at 
ten,  twelve,  or  fifteen  years  are  apparently  healthy,  and 
then  the  parent,  in  from  one  to  twenty  years  thereafter 
develops  unmistakable  evidences  of  syphilis  in  the  later 
types  of  brain  degeneration,  cerebral  and  spinal  gumma, 
syphilitic  nodes  of  various  bony  structures,  or  other  equal- 
ly or  more  grave  lesions  of  syphilis,  does  any  physician 
believe  that  that  child  of  such  parent  has  no  syphilitic 
taint  lurking  in  its  economy?  Does  any  physician  be- 
lieve that  that  child  will  not  some  day  show  unmistak- 
able signs  of  syphilis,  unless  specific  treatment  has  been 
kept  up  during  gestation  or  for  the  child  after  birth  ? 
Does  any  physician  believe  that  the  third  generation,  or 
child  of  that  child,  will  be  an  honor  to  the  human  race  ? 
I,  for  one,  do  not. 

I  quote  Dr.  Otis's  own  words :  "  Some  of  the  most 
healthy  persons  of  my  acquaintance  have  been  born  of 
parents,  one  of  whom,  at  least,  had  been  a  sufferer  from 
syphilis  before  marriage ;  nor  have  I  observed  the  slight- 
est trace  of  the  disease  in  any  form  passed  down  to  the 
third  generation."  I  must  ask  then :  1.  What  can  be 
the  condition  of  health  of  the  people  of  Dr.  Otis's  ac- 
quaintance who  have  not  been  "  blessed  "  with  one  par- 
ent, at  least,  who  has  suffered  from  syphilis  ? 

2.  What  would  have  been  the  health  of  those  "  most 
healthy  persons"  of  his  acquaintance,  had  both  parents 
been  "  blessed  "  with  pre-nuptial  syphilis  ? 

3.  Dr.  Otis's  experience,  in  his  field  of  observation, 
being  so  different  from  that  of  all  writers  down  to  the 
present  time,  will  the  readers  of  the  Medical  Record  be 
willing  to  accept  his  conclusions  and  opinions,  which 
almost  place  a  premium  on  people  who  have  had  at  least 
one  parent  who  has  suffered  from  syphilis  before  mar- 
riage? 

4.  Is  it  possible,  in  the  great  field  for  observation  which 
New  York  City  furnishes,  that  the  doctor  has  not  "  ob- 
served the  slightest  trace  of  the  disease,  in  any  form, 
passed  down  to  the  third  generation?"  I  must  infer 
that  he  has  either  shut  his  eyes  to  the  bare-faced  facts 
which  are  constantly  confronting  all  his  brethren  in  the 
profession ;  that  his  experience  has  been  very  limited ; 
or  that  he  has  not  seen  the  third  generation  yet  born. 
Conclusions  drawn  from  a  few  special  cases,  when  the 
facts  and  experience  of  thousands  of  cases  in  opposition 
as  observed  by  every-day  experience,  are  at  hand,  would 
form  a  precedent  unwarranted,  and  one  which  might  lead, 
yes,  would  lead,  to  untold  misery  if  generally  followed 
by  the  profession,  and  the  unlimited  marriage  of  syphil- 
itics  be  permitted.  It  is  the  general  public  we  are  to 
defend  for  the  best  good  of  all,  and  deal  with  those  who 
are  a  menace  to  the  general  good  in  such  a  way  as  shall 
best  fulfil  that  purpose. 

I  now  reach  the  doctor's  conclusion,  and  with  all  re- 
spect to  the  titled  author  of  those  closing  words,  I  must 
take  my  positive  stand  once  more  and  first  of  all  say :  If 
syphilitica  must  be  satisfied,  let  that  satiety  be  in  whore- 
dom and  concubinage,  its  honest  birthplace  and  proper 


habitat,  and  not  in  the  home  which  is  the  avowed  heart 
of  a  nation,  and  on  which  a  nation's  welfare  depends. 
Let  us  not  be  blinded  by  individual  calamities  and 
thereby  bring  national  degeneracy. 

The  doctor's  last  clause,  of  his  quotation,  reads,  "Would 
probably  not  in  the  least  diminish  the  prevalence  of 
syphilis."  I  admit  the  force  of  this  argument,  and 
again  I  say,  let  it  remain  where  it  belongs  and  not  let  it 
enter  the  sacred  home  of  the  pure  and  innocent,  and 
bring  upon  such  misery  and  death,  or  what  is  worse  than 
death. 

By  all  that  is  good  in  man,  by  all  that  is  dear  to  wom- 
an, by  all  that  is  sacred  of  home,  let  this  nation  be 
populated  from  the  homes  of  purity,  or  else  let  it  follow, 
as  it  certainly  will,  the  course  of  some  of  its  "  illustri- 
ous" predecessors. 

Frank  E.  Mains,  M.D. 

Aubuin,  N.  Y.,  November  98, 1894. 


THE  CAUSE  OF  BERIBERI. 

To  tub  Bmtok  or  ths  Medical  Record. 

Sir  :  Dr.  Siegfried,  in  an  article  published  in  your  journal 
of  December  8th,  declares  it  his  opinion— and  let  me  say 
the  opinion  is  not  new — that  the  chief  causative  element 
in  the  etiology  of  beriberi  is  "  the  lack  of  the  nitrogen- 
ous foodstuffs,  particularly  of  the  fresh  flesh  sorts,  in  the 
habitual  diet  of  the  natives  "  affected  by  this  disease. 

I  beg  Dr.  Siegfried  to  see  how  he  can  reconcile  the 
following  facts  with  this  theory :  Baelz  says  "  that  the 
Japanese  diet,  far  from  being  wanting  in  albumin,  is,  for 
the  lower  classes,  at  least  as  rich,  perhaps  richer,  in  albu- 
min than  the  food  of  the  poor  in  most  European  coun- 
tries." "  That  rice,"  he  says,  "  cannot  produce  kakke 
in  any  manner,  is  distinctly  shown  by  the  circumstance 
that  in  the  interior,  where  rice  is  a  much  more  impor- 
tant factor  of  the  popular  diet  than  on  the  coast,  where 
fish  is  abundant,  die  disease  is  incomparably  rarer  than 
on  the  littoral."  Of  course  the  interior  is  the  region  of 
high  ground. 

"  Persons  of  strong  constitution  are  more  frequently 
affected,"  says  Baelz,  "  than  weak  persons ;  likewise  per- 
sons placed  in  favorable  social  conditions  more  frequent- 
ly than  those  belonging  to  the  lower  classes.  Of  626 
policlinic  patients,  there  were  593  of  strong  constitution, 
27  of  middle  constitution,  and  6  of  weak  constitution. 
Such  numbers,"  says  Baelz,  "  are  simply  annihilating  for 
the  theory  according  to  which  kakke  is  the  result  of  in- 
sufficient alimentation  and  consequent  weakness.  Sim- 
mons also  speaks  very  earnestly  against  that  theory." 

"  The  best  fed,  the  best  nourished,  and  best  cared  for 
are  usually  the  most  frequent  subjects  of  the  disease, 
while  the  weak  and  destitute  are  only  exceptionally  at- 
tacked by  it." 

"  According  to  some  physicians  fat  people  are  quite 
peculiarly  disposed  to  kakke." 

"The  adzuki  bean  enjoysa  great  repute  as  a  food  for 
beriberi  patients,  which  is  well  deserved  by  its  unques- 
tionable diuretic  properties,  so  important  in  this  special 
disease." 

"  Among  the  Japanese,  the  flesh  eaters,  that  is  soldiers 
and  sailors,  the  best  nourished  part  of  the  nation,  are 
more  affected  by  kakke  than  the  rest." 

Even  with  the  addition  of  the  adzuki  bean  diet,  it  is 
considered  essential  by  every  Japanese,  or  foreign,  doctor 
in  Japan  to  send  the  patient  to  a  high  elevation.  And 
why  is  elevation  so  important  ?  Are  patients  better  fed 
on  elevated  ground  ?  Why  does  not  an  analysis  of  the 
blood  show  a  deficiency  of  red  corpuscles  ? 
Yours  truly, 
Albert  S.  Ashmead,  M.D 

New  York,  December  8,  1894. 


The  Irish  School  of  Medicine  is  said  to  be  declining 
both  in  the  quality  of  its  teachers  and  the  number  of  its 
students. 


Medical   Record 

A  Weekly  yournal  of  Medicine  and  Surgery 


Vol.  46,  No.  25. 
Whole  No.  1259. 


New  York,  December  22,  1894. 


$5.00  Per  Annum. 
Single  Copies,  ioc. 


THE    PRESENCE    OF    ALBUMIN    AND    CASTS 
IN  THE  URINE   OF  FOOTBALL  PLAYERS.1 

By  ANDREW  MACFARLANE,   A.B.,   M.D., 

INSTRUCTOR  IN  PHYSICAL  DIAGNOSIS  AND  CLINICAL  MICROSCOPY,  ALBANY  (N.  Y.) 
MBDICAL  COLLBOS. 

When  in  1827  Dr.  Richard  Bright  announced  the  clini- 
cal unity  of  dropsy,  albuminous  urine,  and  disease  of  the 
kidneys,  the  significance  of  albuminuria  became  at  once 
apparent.  Since  that  time  the  importance  of  the  ex- 
amination of  the  urine  and  the  diagnostic  value  of  the 
determination  of  its  proteid  constituents  have  held  high 
place  in  clinical  work.  The  effect  of  the  discovery  of 
this  association  of  symptoms,  however,  was  to  lead  to  the 
inference  that  the  presence  of  albumin  in  urine  always 
indicates  renal  disease,  and  renal  disease  with  a  rapidly 
fatal  termination,  a  belief  which  prevailed  until  about 
twenty  years  ago. .  But  in  the  past  two  decades  a  num- 
ber of  distinguished  clinicians,  Leube,  Senator,  Posner, 
T.  Grainger  Stewart,  Saundby,  Mahomed,  and  others, 
have  found  that  albumin  was  at  times  found  in  the  urine 
of  people  in  whom  there  was  no  detectable  disease  of  the 
kidneys.  Some  have  even  asserted  that  albumin  could 
be  found  in  the  urine  of  every  person  if  sought  for  with 
sufficiently  delicate  tests ;  thus  Posner  found  an  albumi- 
nous body  in  the  urine  in  all  of  seventy  persons ;  Chateau- 
bourg  in  592  cases  out  of  701 ;  T.  Grainger  Stewart  in 
275  healthy  soldiers,  and  in  seventeen  per  cent,  of  50 
children. 

This  claim  of  physiological  albuminuria  has,  however, 
had  many  opponents,  and  to-day  the  latter  hold  that 
renal  albuminuria  always  indicates  diseases  of  the  kid- 
neys, which,  though  concealed  for  a  time,  will  eventually 
reveal  itself.  They  assert  that  Bright's  disease  develops 
intermittently  by  acute  periods  of  inflammation  inter- 
rupted by  remissions  more  or  less  complete,  which  may 
last  for  years,  during  which  time  the  albumin  entirely 
disappears,  due  to  the  cicatrization  of  the  lesion  ;  that 
granular  kidney  seems  to  date  its  existence  to  some  period 
of  anxiety  or  worry,  and  that  increased  tension  of  the 
pulse  is  met  with  in  certain  states  of  nervous  excitement. 
Temporary  albuminuria  of  the  neurotic  is  likely,  therefore, 
in  their  opinion,  to  have  a  serious  even  if  remote  end- 
ing. 

The  believers  in  a  physiological  albuminuria  claim  that 
albuminuria  frequently  occurs  without  present  or  future 
disease  of  the  kidney,  and  unless  accompanied  by  other 
symptoms  has  no  pathological  significance.  They  main- 
tain that  the  albuminuria  which  occurs  in  conditions  of 
nervous  excitement,  after  physical  exertion,  from  the 
consumption  of  egg  albumin,  after  baths,  after  sexual 
excitement,  at  the  beginning  of  puberty,  after  marked 
sweating,  does  not  indicate  a  lesion  of  the  kidneys. 

This  incomplete  summary  indicates  briefly  the  general 
character  of  the  opposing  opinions  as  to  the  significance 
of  albuminuria.  That  this  subject  is  one  of  the  deepest 
interest  to  all  physicians  is  self-evident.  It  must  be  a 
matter  of  some  importance  to  all  of  us,  and  of  the  deep- 
est concern  to  our  patients,  that  we  properly  interpret  a 
condition  which  may  be  either  the  danger-signal  of  an 

1  Abstract  of  a  paper,  Albuminuria,  its  Detection  and  Signifi- 
cance, read  before  the  Albany  County  Medical  .Society,  November 
ax,  1894. 


incurable  malady  or  a  trivial  occurrence  of  no  special  sig- 
nificance. 

It  will  not  be  necessary  to  consider  in  detail  the  dif- 
ferent kinds  of  albuminuria,  but  merely  to  recall  them  to 
your  recollection.  I  shall,  however,  take  the  liberty  of 
considering  more  at  length  a  cause  of  albuminuria  which, 
although  always  recognized,  does  not  appear  to  have  been 
sufficiently  investigated. 

The  forms  of  albuminuria  are  naturally  divided,  for 
clinical  purposes,  into  two  great  classes — accidental  albu- 
minuria and  renal  albuminuria. 

Accidental  albuminuria  is  the  result  of  an  admixture 
of  albuminous  fluids,  as  blood,  pus,  chyle,  with  urine  it- 
self free  from  albumin.  In  such  cases  the  urine  usually 
contains  a  small  quantity  of  albumin,  and  invariably  a 
sediment  of  elements  characteristic  of  the  fluid  admixed, 
as  blood-cells,  pus-cells,  etc.  To  this  class — the  acci- 
dental albuminurias — belong  many  cases  which,  I  believe, 
have  too  often  been  denominated  functional  or  physiolog- 
ical albuminuria.  Sir  Andrew  Clark,  with  his  remarkable 
medical  acumen,  recognized  this  fact,  and  stated  that "  in 
some  young  men  excited  by  sexual  desire  and  denying  it 
indulgence,  there  was  secreted  from  the  urethra  or  its 
adjacent  glands  a  fluid  which,  mixing  with  the  urine, 
yields  evidence  of  the  presence  of  serum  albumin  "  (al- 
bumose?).  Sir  William  Gull  probably  had  this  same  fact 
in  mind  when  he  said,  "albuminuria  is  almost  as  com- 
mon in  young  men  as  spermatorrhoea."  Many  of  the 
functional  albuminurias  of  puberty,  and  probably  also  a 
number  of  the  cases  of  neurasthenic  albuminuria  prop- 
erly belong  to  this  class. 

Renal  albuminuria  may  also,  for  clinical  purposes,  be 
subdivided  into — 1.  Albuminuria,  due  to  a  primary  lesion 
of  the  kidneys.  2.  Secondary  or  complicating  albu- 
minuria, due  to  (a),  circulatory  derangements,  as  in  car- 
diac disease — this  may,  however,  eventuate  in  renal  dis- 
ease ;  (£),  febrile  conditions  depending  upon  changes  in 
blood-pressure  and  in  the  epithelium  of  the  kidneys,  and 
also  the  result  of  the  excretion  of  the  toxines  of  disease ; 
(V),  changes  in  the  composition  of  the  blood,  as  in  anae- 
mia and  chlorosis.  3.  Functional  or  so-called  physio- 
logical albuminuria,  the  result  of  muscular  exertion,  men- 
tal strain,  cold  and  cold  bathing,  diet,  and  without  any 
other  symptom  of  Bright's  disease.  Of  these  only  the 
so-called  physiological  albuminuria  need  be  considered, 
as  the  significance  of  albumin  in  the  other  forms  of  albu- 
minuria is  beyond  question. 

Functional  albuminuria  is  commonly  said  to  be  char- 
acterized by— 1 ,  absence  of  all  other  symptoms  of  Bright's 
disease;  2,  chance  detection  while  the  person  was  ap- 
parently in  good  health ;  3,  quantity  of  albumin  is  com- 
paratively small,  and  at  times  in  the  twenty- four  hours 
is  entirely  absent ;  4,  absence  of  the  casts. 

That  albumin  due  to  the  above-mentioned  causes  is  at 
times  found  in  the  urine  has  been  known  for  a  long  time. 

In  Germany,  albumin  has  been  detected  in  the  urine  of 
soldiers  after  long  marches.  In  England,  Pavy  found  al- 
bumin in  the  urine  of  Weston,  the  walker ;  T.  Grainger 
Stewart,  in  persons  after  violent  exercise,  and  Mason  in 
two  out  of  five  school- boys  after  a  run  of  six  miles.  In 
this  country  Lambert,  of  the  Equitable  Life,  has  found 
that  when  the  temperature  goes  to  zero  or  below,  or 
when  it  passes  90  °  F.,  the  percentage  of  healthy  men 
having  albumin  in  their  urine  increases  from  two  per 
cent,  to  five  per  cent.,  until  the  temperature  reaches  nearer 
the  mean.     Gray,  in  a  recent  paper,  states  that  he  has 


772 


MEDICAL   RECORD. 


[December  22,  1894 


seven  cases,  not  a  dozen  and  a  half  of  them  being  per- 
forations of  the  nasal  septum.  In  ten  of  these  seventy- 
seven  cases  a  perforation  of  the  septum  was  found  without 
any  sign  of  ulceration  or  necrosis  at  any  other  point 
within  the  nasal  cavities.  Jurasz,6  in  ten  years1  time,  at 
Heidelberg,  examined  over  four  thousand  nose  and  throat 
patients,  and  noticed  perforation  of  the  nasal  septum  in 
only  thirty-seven  of  them,  and  then  only  once  was  the  os- 
seous portion  found  perforated.  Hermet,7  in  the  course 
of  a  discussion  on  this  subject  at  a  meeting  of  the  Laryn- 
gological  Society  of  Paris,  asserted  that  perforations  of 
the  nasal  septum  are  very  rare  in  France.  They  are  not 
of  frequent  occurrence  in  New  York  City.  Taking  eight 
annual  reports  of  the  New  York  Eye  and  Ear  Infirmary 
(1874-80-84-85-87-88-89,  and  1890),  it  will  be  found 
that  ten  thousand  cases  of  nose  and  throat  diseases  were 
recorded,  two  thousand  one  hundred  and  nine  of  which 
were  diseases  of  the  nose.  And  only  twenty  cases  of 
perforation  of  the  nasal  septum  are  recorded.  During 
the  year  ending  May,  1894,  at  the  New  Amsterdam  Eye 
and  Ear  Hospital,  four  hundred  and  ninety-three  cases  of 
nose  and  throat  diseases  were  examined,  and  only  three 
times  were  perforations  of  the  nasal  septum  recorded. 
There  have  been  years  at  the  New  York  Eye  and  Ear 
Infirmary  when  not  a  single  case  of  septal  perforation 
was  seen.  Certainly  these  figures  prove  this  much — per- 
forations of  the  nasal  septum,  though  not  of  exceptional 
occurrence,  are  by  no  means  common  or  frequent. 

Sex. — Schaeffer  found  his  twenty- two  cases  seven  times 
men  and  fifteen  times  women.  In  this  respect  the  ex- 
perience of  Weichselbaum,  Hajek,  Jurasz,  others,  and 
my  own,  has  been  the  contrary,  that  is,  about  two  to  one 
in  favor  of  males. 

Age. — Jurasz  found  the  ages  of  his  patients  ranging 
from  ten  to  over  seventy  years.  And  Hajek  found  sep- 
tal ulcerations  and  perforations  oftenest  in  those  between 
twenty  and  fifty  years  of  age — that  is,  during  the  most 
active  and  most  exposed  period  of  life. 

Side  of  Development.— Perforations  develop  from 
ulcers  on  either  side  of  the  septum,  or  from  both  sides 
simultaneously.  Rossbach  found  their  point  of  origin 
oftenest  on  the  right  side ;  but  Hajek  found  it  to  be  on 
the  right  side  five  times,  on  the  left  side  nine  times,  and 
on  both  sides  simultaneously  six  times. 

My  Own  Cases. — During  the  past  two  years  I  have 
had,  in  private  practice,  seven  cases  of  perforation  of 
the  nasal  septum  in  my  care.  Five  were  men,  and  two 
were  women.  The  ladies  were  respectively  thirty- one 
and  forty- eight  years  old.  Two  of  the  men  were  in  the 
fifties,  two  in  the  forties,  and  one  was  eighteen  years 
old.  In  five  the  cartilaginous  portion  of  the  septum  was 
the  site  of  perforation.  In  one  case  the  bony  portion 
only  was  perforated,  and  that  was  a  case  of  very  late 
tertiary  syphilis.  The  seventh  was  a  traumatic  case,  and 
the  perforation  involved  both  the  bony  and  cartilaginous 
portions  of  the  septum.  Two  of  the  cases  were  seen 
while  still  in  the  ulcerative  stage,  and  several  months 
before  perforation  at  last  took  place.  In  these  cases — 
the  one  syphilitic  and  the  other  non-syphilitic — the 
trouble  began  on  the  right  side  of  the  septum.  The  syphi- 
litic presented  extensive  infiltrations  over  the  right  mid- 
dle and  inferior  turbinated  bones,  and  later  on  ulcera- 
tions, besides  perforation  of  the  hard  palate.  Necrotic 
pieces  of  bone  were  taken  from  the  palate.  The  palatal 
trouble  healed  up  quite  rapidly.  The  cartilaginous  part 
of  the  septum  remained  unaffected  while  the  patient  was 
under  observation,  and  the  trouble  remained  limited  to 
the  palatal  and  vomer  bones.  Infiltration  and  ulceration 
were  much  more  marked  in  the  right  than  in  the  left  nasal 
cavity.* 

•  This  man,  aged  fifty,  at  first  denied  ever  having  had  syphilis ;  but 
finding  his  assurances  disbelieved,  he  finally  acknowledged  having 
been  treated  for  the  disease  while  soldiering  in  Russia  and  Siberia 
twenty-five  years  ago.  Within  the  last  three  years  two  of  his  infant 
children  have  died  of  hereditary  syphilis.  The  one  *  hen  nine  months 
old,  and  the  last  when  three  weeks  old.  I  saw  the  first  child  only 
twice  before  it  died.  This  child  was  supposed  by  the  parents  to  be 
sick  with  only  diarrhoea.  It  had  coryza,  headache,  and  anal  condylo- 
mata, besides  a  roseolaceous  rash  on  the  buttocks  which  shaded  off 


In  only  one  of  the  other  five  cases  was  it  possible,  from 
the  character  of  the  existing  ulcerative  process,  to  deter- 
mine that  in  all  probability  the  trouble  began  on  the 
right  side  of  the  septum.  The  other  three  cases — not 
counting  the  traumatic  one — presented  perforations  in 
such  a  perfect  state  of  finished  development,  that  it  was 
impossible  to  say  whether  the  perforations  began  on  the 
right  or  the  left  side,  or  on  both  sides  simultaneously. 
In  the  one  woman  the  cartilaginous  portion  of  the  sep- 
tum was  bent  into  the  left  nasal  cavity,  but  not  enough 
so  as  to  block  up  entirely  the  respiratory  passages,  and 
in  this  case  it  was  plain  the  ulcerative  process  began  on 
the  right  or  concave  surface.  Once  the  perforation  was 
associated  with  atrophic  rhinitis  and  pharyngitis ;  once 
with  hypertrophic  rhinitis ;  once,  as  already  mentioned, 
with  extensive  syphilitic  infiltrations  (syphilis  nowhere 
else  than  in  the  nose,  mouth,  and  throat)  and  ulcera- 
tions; and  once  the  perforation  complicated  fracture 
and  dislocation  of  the  cartilaginous  portion  of  the  sep- 
tum. Only  two  of  the  cases  applied  to  be  relieved  from 
nasal  symptoms  that  were  directly  due  to  the  ulcero  per- 
forative process,  which  was  limited,  and  on  the  cartilagi- 
nous portion  of  the  nasal  septum. 

In  the  course  of  an  interesting  and  instructive  essay  on 
bacteria  and  cocci  in  the  nasal  cavities,  Doctor  Jonathan 
Wright  *  says,  "  The  day  of  theorizing  has  gone  by.  A 
theory  now-a-days  should  be  considered  as  little  better 
than  confession  of  ignorance 9 ' — mere  words.  With  great 
truth  has  it  been  said  that  there  are  more  false  facts  than 
false  theories.  The  fallacies  of  a  theory  do  not  worry  us 
much,  and  never  for  a  long  while.  Life  itself  is  theory, 
and  we  can  no  more  escape  from  the  necessity  of  theor- 
izing than  we  can  from  the  necessity  of  quoting  others, 
unless  we  end  by  suicide.  Such  a  thing  as  the  "  scien- 
tific imagination  "  has  been  spoken  of  by  many  scientific 
and  unscientific  orators,  and  in  varying  senses.  As  a 
not  exact  expression  for  the  highest  kind  of  mental  ac- 
tivity, it  may  be  allowed  to  pass  unchallenged.  All  the 
sciences  and  all  the  arts  owe  much  to  it,  and  so  does 
rhinology.  The  scientific  imagination  revels  in  attempts 
at  unravelling  the  riddles  that  confront  and  puzzle  us. 
It  builds  theories  by  combining  the  facts  that  are  seen  by 
all  with  those  that  are  forgotten  or  have  never  been 
known  before.  It  finds  and  marshals  facts  into  their 
co  ordinate  places.  It  breathes  life  into  facts  that  seem 
dead.  It  organizes  knowledge  and  makes  it  all-power- 
ful. And  yet,  as  has  been  said  over  and  over  again  for 
hundreds  and  hundreds  of  years,  to  quote  Glanvill,  "  we 
erre  and  come  short  of  science,  because  we  are  so  fre- 
'  quently  misled  by  the  evil  conduct  of  our  imaginations; 
whose  irregular  strength  and  importunities  doeth  almost 
perpetually  abuse  us. ' °  A  comparative  study  of  rhinologi- 
cal  writers  on  perforations  of  the  nasal  septum  reveals  to 
us  that  they  have  been  and  are  thoroughly  human,  and 
that  they  have  seen  and  reported  facts  often  enough,  only 
partially,  not  to  say  falsely ;  and  they  have  not  foiled  to 
build  theories  which  have  crumbled  away  under  the 
grinding  weight  of  time.  And  so,  by  the  irregular 
strength  and  the  importunities  of  the  imagination — not 
because  of  any  theory  as  such,  however  fallacious — writers 
who  meant  well  have  imposed  on  the  often  too  ready 
credulity  of  those  who  must  needs  consult  them  for  pro- 
fessional mental  fodder,  or  ready-made  opinion.  Let 
us  see: 

Etiology. — The  study  of  the  causes  of  perforations  of 
the  nasal  septum  may  be  considered  conveniently  under 
five  heads,  namely :  1.  Congenital  or  developmental  in- 
fluences, a.  Traumatisms.  3.  Contiguous  pathological 
processes.  4.  Diseases  that  engender  such  constitutional 
and  local  conditions  peculiar  to  syphilis,  tuberculosis, 
lupus,  scrofula,  rheumatism,  diphtheria,  fevers,  etc.  5. 
Local  inflammatory  and  allied  processes. 

down  the  thighs.  Its  life  ended  in  convulsions.  The  last  child  was 
plump  and  apparently  healthy  when  born  ;  but  soon  it  had  a  coma 
and  a  sore  anus,  and  it  died  soon  of  syphilitic  marasmus.  The  mother 
nursed  neither  of  these  children.  A  girl  six  years  old  betrays  none  **f 
the  ordinary  well-known  signs  of  hereditary  syphilis.  The  mother  is  a 
strong  woman,  and  she  states  nerer  had  any  miscarriages,  etc 


December  22,  1894] 


MEDICAL  RECORD. 


775 


Congenital  or  Developmental  Causes. — Hilderbrandt 
(anatomist)  had  a  hole  in  the  anterior  portion  of  his 
nasal  septum,  which  he  considered  congenital  because  he 
was  not  able  to  account  for  it  in  any  other  way.  In  the 
course  of  many  years  Hyrtl  observed  such  perforations 
three  times  in  anatomy  subjects.  He  too  considered 
them  congenital  in  origin.  Bosworth  *  quotes  Schmiege- 
low  as  having  seen  a  perforation  which  was  believed  to 
be  congenital,  and  in  which  case  a  large  portion  of  the 
cartilage  was  wanting.  Without  giving  specific  instances 
or  references  to  such,  £.  Klebs 10  states,  "  roundish  holes 
in  the  nasal  septum  are  observed  in  foetuses — the  borders 
of  these  perforations  are  covered  with  a  smooth  mem- 
brane, and  it  has  not  been  demonstrated  beyond  a  doubt 
whether  these  holes  are  caused  by  some  foetal  ulcerative 
process  or  by  arrested  development/1  And  no  less  an 
anatomist  and  rhinologist  than  Harrison  Allen  u  says, 
"  Congenital  defects  in  the  nasal  septum  are  apt  to  be 
multiple,  and  the  septal  opening  to  be  associated  with 
the  presence  of  a  hyperostosis  in  the  roof  of  the  mouth, 
or  asymmetry  of  the  facial  bones. "  Congenital  de- 
fects are,  says  Harrison  Allen,  as  a  rule  in  the  cartilage, 
although  they  may  be  found  in  the  perpendicular  plate  of 
the  ethmoid  bone.  A  case  of  congenital  defect  is  quoted 
from  Germs  by  Beely; "  parts  of  the  vomer  in  the  child 
were  missing,  and  the  nasal  cavities  of  both  sides  com- 
municated. In  this  case  the  hard  palate  was  very  much 
arched,  and  thus  in  a  manner  compensated  for  the  de- 
ficiencies of  the  vomer. 

Traumatic  Causes. — Bosworth  u  has  seen  perforations 
of  the  nasal  septum  result  from  injuries  to  the  nose.  In 
those  cases  splinters  of  bone  (the  vomer)  ulcerated  away 
and  left  a  defect  in  the  bony  portion  of  the  septum.  My 
case,  mentioned  above,  was  a  man  over  fifty  years  old, 
and  the  victim  of  a  runaway  accident.  Being  jerked 
from  the  carriage  seat  he  struck  his  face  against  the  pave- 
ment. The  septal  cartilage  was  dislocated  antero-infe- 
riorly  into  the  right  nasal  cavity,  and  above  into  the  left 
nasal  chamber,  besides  being  bent  or  broken  longitudi- 
nally, the  convexity  of  the  cartilage  jutting  against  the 
turbinated  bone  of  the  left  side  of  the  nose.  The  ante- 
rior portion  of  the  lamina  perpendicularis  was  fractured. 
A  probe  could  be  passed  through  from  the  right  into  the 
left  nasal  cavity,  above  and  behind,  near  where  bone  and 
cartilage  join.  The  dislocated  and  fractured  parts  were 
easily  replaced  and  fixed  by  means  of  long  and  firm 
pledgets  of  absorbent  cotton  and  borated  gauze.  The  re- 
sult is  good.  There  is  no  visible  external  deformity,  and 
there  is  no  obstruction  to  nasal  respiration.  For  four 
weeks  after  the  accident  a  healing  ulcer  was  seen  at  the 
point  where  the  probe  had  been  passed  through  the  sep- 
tum. The  ulcer  was  seen  longest  on  the  right  surface  of 
the  septum,  where  it  had  always  been  larger.  The  acci- 
dent had  caused  much  hemorrhage  from  the  nose,  and  con* 
siderable  flattening,  besides  a  good  deal  of  dizziness, 
which  persisted  for  weeks  afterward. 

An  interesting  case  of  bullet  traumatism  mentioned  by 
L5ri,14  may  be  quoted  here :  A  soldier  who  had  been  shot 
years  ago  through  the  nose,  the  bullet  having  entered  a 
little  below  the  glabella,  and,  without  injuring  the  hard 
or  soft  palate,  penetrated  into  the  pharynx,  from  whence 
it  was  expectorated.  An  irregular  fleshy  mass  extending 
from  the  lower  nasal  passages  away  up  into  the  attic  of 
the  nose,  was  found  on  both  sides.  At  the  posterior  parts 
occupied  by  this  mass  of  granulation  tissue,  the  septum 
was  found  to  be  defective. 

According  to  Harrison  Allen,15  imperfect  surgical  ope- 
rations may  give  rise  to  septal  perforations.  Zucker- 
kandl  w  quotes  a  case  from  Velpeau,  in  which  the  oper- 
ating surgeon  put  a  hole  through  a  very  much  bent 
septum  which  he  had  supposed  was  a  polyp. 

It  is  well  known  that  certain  barbarous  people  perfo- 
rate the  septal  cartilage  for  the  purpose  of  wearing  deco- 
rative rings,  and  for  purposes  of  religious  ceremonies. 

There  is  one  other  instance  of  septal  perforation,  al- 
leged to  be  due  to  causes  which  are  traumatic  rather  than 
anything  else.     I  refer  to  Professor  Bosworth's  theory,17 


by  which  he  not  only  explains  the  cause  of  nasal  hemor- 
rhages, but  also  the  manner  in  which  round  or  oval  per- 
forations are  developed  in  the  cartilaginous  portion  of 
the  septum.  The  theory  is  simple  enough,  but  so  purely 
mechanical  as  to  deny  life  to  the  septum,  and  reduce  it 
to  the  grade  of  an  inorganic  partition  without  the  power 
of  reacting  against  injury.  It  is  simply  frictional  ero- 
sion, sans  ulceration,  sans  inflammation,  sans  constitu- 
tional taint.  The  theory  is  novel  in  rhinological  and 
pathological  literature.  Cognizant  of  the  eminence  of 
the  author,  it  is  only  just  that  he  be  quoted  verbatim  et 
literatim :  "  The  most  common  cause  of  this  perforation 
is  to  be  found  in  the  projection  of  the  cartilage  into  one 
or  the  other  passage,  whereby  its  prominent  portion  be- 
comes subjected  to  the  current  of  inspired  air,  laden  as 
it  is  with  dust  and  other  impurities,  whereby  a  process  of 
erosion  is  established,  under  which  the  cartilage  is  grad- 
ually worn  away  until  an  opening  occurs.  This  is  a 
purely  local  process,  and  involves  no  suspicion  of  a  sys- 
temic taint.  The  existence  of  the  erosion  is  attended 
with  annoying  crust  formation  over  its  site,  causing  a 
frequent  picking  of  the  nose,  by  which  the  process  of 
erosion  is  much  hastened.  This  process,  as  we  see,  is 
really  a  conservative  effort  on  the  part  of  nature  to  relieve 
the  patient  of  an  obstructive  lesion  in  the  nose,  and  one, 
moreover,  which  I  have  frequently  seen  attended  with 
signal  success,  since  the  removal  of  the  obstruction 
seems  to  be  the  primary  effect  of  the  process,  while  the 
establishment  of  a  perforation  is  to  an  extent  adventi- 
tious. I  cannot  agree  with  Zuckerkandl  in  the  view  that 
these  cartilaginous  perforations  are  due  in  a  large  major- 
ity of  instances  to  an  ulcerative  or  inflammatory  action, 
in  that  the  simple  erosion  in  my  experience  is  never  at- 
tended with  either  of  these  processes. "  Reading  all  this 
simple  talk  of  Bosworth's  makes  one  think  of  a  saying  of 
Emerson's — "  power  and  purpose  ride  on  matter  to  the 
last  atom."  But  it  is  all  too  good  to  be  true.  McBride 
criticises  the  theory  quite  mildly  by  calling  its  assump- 
tion of  a  projecting  cartilage  arbitrary.  There  are 
many  points  of  cartilage  in  the  nose  that  jut  out  into  the 
current  of  inspired  air,  but  they  remain  intact  and  are 
not  filed  away  by  the  dust-laden  impure  wind ;  perhaps 
so,  for  the  sole  benefit  of  the  operating  rhinologist. 
Then,  too,  according  to  pathological  specialists,  an  ero- 
sion is  a  superficial  ulcerative  and  inflammatory  process,  in 
which  the  tissues  that  are  being  subjected  to  erosion  are 
bereft  of  regenerative,  but  not  reactive,  capacity,  because 
the  destructive  agents  are  slowly,  but  surely  and  continu- 
ously, at  work  (Weigert).  Thus,  this  theory  of  Bosworth 
demands  concessions  that  cannot  be  granted,  for  it  seeks 
to  explain  a  biological  question  by  ignoring  biological 
factors,  and  thus  runs  short  of  science,  and  becomes  a 
mechanical  mystery. 

Contiguous  Pathological  Phenomena. — It  is  known 
that  a  rhinolith,  or  a  polypus,  may  cause  a  perforation 
of  the  septum  to  take  place,  apparently  by  continuous 
pressure  against  the  septum.  Jurasz  M  reports  having  seen 
a  case  of  each. 

Influences  Engendered  by  Constitutional  Diseases, 
Scrofula,  Lupus,  Tuberculosis,  Syphilis,  Rheumatism, 
Diphtheria,  Fevers,  etc. — Scrofula,  lupus,  and  tuberculo- 
sis, though  related  affections,  and  believed  to  have  been 
such  long  before  their  consanguinity  was  accentuated  by 
Koch's  discovery  of  the  bacillus  tuberculosis,  differ  suffi- 
ciently in  their  clinical  phenomena  to  justify  the  conclu- 
sion in  the  minds  of  very  capable  clinicians  (Kaposi  and 
Voltolini  among  others)  that  they  are  not  identical  mala- 
dies. They  affect  the  mucous  membrane  and  other  tissues 
of  the  nose,  and  particularly  the  septum.  They  give  rise 
to  a  catarrhal  condition,  to  infiltrations,  to  tumors,  and 
to  perforations. 

Scrofula :  Maldenhauer "  describes  a  septal  perichon- 
dritis, due  to  scrofula,  which  ends  in  the  formation  of 
abscesses,  and  perforation  of  the  cartilaginous  portion  of 
the  septum.  Sir  James  Paget20  describes  a  similar  con- 
dition. These  abscesses  may  come  on  spontaneously, 
or  a  slight,  under  other  circumstances  indifferent,  injury, 


774 


MEDICAL  RECORD. 


[December  22,  1894 


to  the  nose  may  start  them.  The  anterior  portion  of  the 
septum  is  usually  affected,  and  as  a  rule  on  both  sides. 
Paget's  description  is:  "  Small  abscesses  form  between 
the  mucous  membrane  and  the  septum.  With  these  the 
portion  of  cartilage  beneath  may  be  softened  or  ulcer- 
ated; and  it  may  be  perforated  when  similar  circum- 
scribed abscesses  form  on  both  sides  of  it ;  but  when  the 
pus  is  discharged  there  does  not,  I  believe,  follow  any 
extension  of  ulceration  in  either  the  cartilage  or  the 
mucous  membrane,  and  they  heal  leaving  a  small  thin- 
edged  opening  in  the  septum/'  Maldenhauer's  descrip- 
tion differs  somewhat  from  Paget's,  being  more  acute  and 
involving  a  larger  area  of  surface ;  and  patients  apply  for 
relief  usually  when  the  cartilage  has  become  disorganized, 
and  a  perforation  permanent.  Maldenhauer  states,  what 
older  writers  have  too,  that  the  bony  portion  of  the  sep- 
tum may  become  defective  through  scrofulous  disease. 

Lupus :  Max  Bender  found  the  mucous  membranes  in- 
volved one  hundred  and  seventy  five  times  in  three  hun- 
dred and  eighty  cases  of  lupus  collected  at  Doutrelepont's 
clinique.  In  thirty  one  per  cent,  of  all  cases  the  disease 
began  in  mucous  membranes,  which,  says  Crocker,21  is  by 
far  more  than  is  usually  supposed.  Only  six  times  were 
the  mucous  membranes  alone  affected.  One  hundred 
and  fifteen  times  the  mucous  membrane  of  the  nose  was 
involved.  Crocker  says  that  lupus  is  almost  rare  in 
America,  and  is  seen  less  often  in  England  than  on  the 
continent  of  Europe.  It  is  more  frequently  seen  in 
women  than  in  men.  Carl  Seiler  a  says  that  he  has  never 
seen  a  case  of  lupus  of  the  nasal  mucous  membrane. 
And  Sir  Jonathan  Hutchinson  *  tells  us  that  he  has  seen 
as  many  as  three  cases  with  septal  perforation  in  one 
day.  Such  is  the  irregular  run  of  practice.  I  have  seen 
three  cases  of  lupus  in  which  the  mucous  membrane  of 
the  nose  was  affected,  but  in  none  of  them*  was  the  sep- 
tum perforated.  My  friend  Professor  George  T.  Jack- 
sonf  knows  of  about  a  dozen  cases  of  nasal  syphilis  that 
had  been  diagnosticated  as  lupus.  Two  such  cases,  he 
says,  had  been  operated  on  by  competent  surgeons  who 
supposed  that  they  were  dealing  with  lupus.  Mistakes 
of  this  kind,  Jackson  holds,  Only  show  that  the  differen- 
tial diagnosis  of  syphilis  and  lupus  is  not  always  an  easy 
matter.  Ausspitz  and  Schuster,  and  other  syphilograph- 
ers,  would  agree  with  him.  So  much  for  the  rarity  of 
lupus,  and  the  difficulty  of  recognizing  it 

Medicine,  especially  clinical  medicine,  is  still  so  im- 
perfect in  its  methods  of  investigation  and  demonstration, 
that  the  name  of  a  teacher  often  does  duty  for  alleged 
facts  or  the  validity  of  a  theory.  And  sometimes  such 
facts  and  theories  are  circulated  by  other  teachers  with 
their  endorsement  and  commendation.  At  other  times 
such  facts  become  distorted,  and  the  original  teacher  is 
falsely  quoted,  and  approximate,  not  to  say  true,  science 
comes  short.  In  so  far  as  lupus  of  the  nose  is  concerned, 
this  has  been  the  case  with  the  honored  name  of  Kaposi. 
A  number  of  respected  rhinologists  (Schech  and  Mac- 
donald  among  others)  have  quoted  Kaposi u  as  saying 
that  the  bones  of  the  nose  do  not  suffer  in  intra-nasal 
lupus.  Kaposi  says  nothing  of  the  kind.  He  simply 
makes  no  mention  of  bones  when  speaking  of  lupus  of 
the  mucous  membrane  of  the  nose.  He  does  say  on  a 
previous  page  that  lupus  spreads  via  connective  tissue, 
and  that  there  are  no  grounds  for  asserting  that  muscles 
and  bones  directly  succumb  to  lupus.  Further  on  in 
this  same  article  he  says,  concerning  the  bones  of  the 
extremities,  periostitis,  ostitis,  caries,  and  necrosis,  occur 
when  no  evident  preceding  inflammation  or  infiltration 
has  taken  place  in  the  superjacent  skin.  Rosenthal25 
makes  the  general  and  unsubstantiated  remark  that  it  is  an 
undecided  question  whether  or  not  lupus  affects  the  bones 
of  the  nose.  Haughton,*  Crocker,  Schuster,  and  Ausspitz, 
and  KLebs"  affirm  that  the  bones  as  well  as  the  cartilage 
of  the  nose  may  become  implicated  in  the  lupus  process 
and  drop  out.  Kaposi  says  that  the  septum  cutaneum 
is  less  frequently  affected  by  lupus  than  by  syphilis.     He 

•  All  women,  two  of  German  and  one  of  Irish  extraction, 
t  Oral  communication. 


also  observes,  what  others  have  remarked,  that  fungous 
lupous  granulations  may  conceal  a  perforation  of  the 
septum.28 

Tuberculosis  of  the  mucous  membrane  of  the  nose  is 
very  rare,  and  perforation  of  the  septum  due  to  it  much 
rarer.  In  sixteen  hundred  autopsies  Willigk  found  four 
hundred  and  seventy- six  tubercular  subjects,  and  in  only 
one  of  them  tuberculosis  of  the  nasal  mucous  membrane. 
It  is  believed  that  primary  tuberculosis  of  the  nasal  mu- 
cous membrane  has  been  observed,  but  such  observations 
are  not  beyond  question.  Up  to  18S9,  Seifcrt*  was 
able  to  collect  only  thirty- eight  cases  of  intra-nasal 
tuberculosis. 

Greville  MacDonald  saw  a  case  of  tubercular  perfora- 
tion of  the  nasal  septum  (case  31,  p.  339,  Treatise  on 
Diseases  of  the  Nose) ;  and  others  have  reported  similar 
cases.  Such  perforations  exist  in  connection  with  other 
tubercular  ulcerations,  infiltrations,  and  tumors  in  the 
nose. 

From  the  foregoing  remarks  on  scrofula,  lupus,  and 
tuberculosis,  it  may  be  concluded  that  only  very  rarely  can 
they  be  the  causes  of  septal  perforations.  But  that  they 
do  give  rise  to  such  perforations  cannot  be  denied ;  and 
that  even  the  c«seous  portion  of  the  septum  may  be 
perforated  by  them  must  be  allowed  as  a  possibility. 
And  however  rare  an  eventuality  they  must  needs  be 
taken  into  account  when  the  differential  diagnosis  of  any 
perforation  of  the  nasal  septum  is  being  considered. 

Syphilis.— In  1885,  G.  H.  Makenzie  (Edinburgh) 
claimed,  what  many  practitioners  believe  to  be  the  case 
to-day,  that  perforations  found  in  the  septum  are  proba- 
bly always  symptomatic  of  syphilis;  and  McBride® 
stated,  about  the  same  time,  in  criticising  Makenzie's 
claim,  that  most  specialists  (rhino-laryngologists  ?)  look 
upon  them  with  suspicion,  but  not  as  being  pathognomo- 
nic of  syphilis. 

This  is  not  an  unimportant  question.  The  gravest 
family  complications  may  arise  from  the  assertion  that 
septal  perforations  are  always  syphilitic  in  origin.  One 
of  my  cases,  a  lady  engaged  to  be  married  to  a  lawyer, 
was  told  by  me,  that  besides  other  troubles  for  which  she 
was  being  treated,  she  had  a  hole  in  the  septum  of  her 
nose.  Innocently  enough  she  told  the  lawyer  of  this, 
and  he  wasted  no  time  in  calling  on  me  to  have  the  sig- 
nificance of  the  perforation  explained  to  himself.  I  could 
positively  say  that  the  hole  had  no  particular  significance, 
and  had  nothing  to  do  with  syphilis,  hereditary  or  other- 
wise. Not  only  a  patient's  family  and  social  group  may 
be  upset  by  the  announcement  of  a  mistaken  diagnosis, 
but  the  physician  or  surgeon  may  come  to  grief  because 
of  it.  Ctuari 81  in  his  group  of  seventy-seven  cases  of 
"  ulcers,  cicatrices,  and  defects  "  of  the  nose,  found  sixty- 
two  of  these  lesions  caused  by  syphilis,  five  by  lupus, 
four  by  scrofula,  one  by  blenorrhoea,  one  by  tuberculo- 
sis, one  by  diphtheria,  and  two  were  due  to  causes  that 
could  not  be  found  out.  These  figures  illustrate  approx- 
imately the  relative  frequency  of  syphilis  as  a  probable 
cause  of  perforation  of  the  nasal  septum,  as  compared 
with  the  possible  etiological  value  of  the  other  diseases 
already  reviewed. 

Syphilis,  when  it  attacks  the  nose,  like  scrofula,  lupus, 
and  tuberculosis,  shows  a  conspicuous  liking  for  the  ante- 
rior portion  of  the  septum.  In  fifty-five  cases  of  nasal 
syphilis  recorded  by  Jurasz,  thirty-one  times  the  septum 
was  attacked,  and  only  once  the  bony  portion.  Twenty 
times  in  thirty-seven  cases  of  septal  perforation,  syphilis 
was  found  to  be  the  cause.  Only  in  three  cases  out  of  six- 
teen of  septal  perforations  could  A.B.  Thrasher  *®  (Cincin- 
nati) get  an  undoubted  history  of  syphilis.* 

Moritz  Schmidt  w  would  hesitate  in  calling  a  perfora- 
tion syphilitic  in  origin  if  it  did  not  involve  the  bony 
part  of  the  septum  as  well  as  the  cartilaginous  portion. 
This  assertion  ignores  much  common  experience,  and, 

*  Dr.  St.  C.  Campbell  saw  thirty*  five  cases  of  septal  perforations — 
all  in  the  cartilaginous  portion,  and  their  chief  causes  lie  believed  to 
have  been,  20  syphilitic,  9  anaemia,  5  ozaena,  and  1  tuberculosis. — W. 
J.  Swift  (Lefferts)  Reference,  International  Centralbl.  fur  Laryn- 
gologie,  etc.,  voL  viii.,  p.  9. 


December  22,  1894] 


MEDICAL    RECORD. 


775 


though  it  may  be  based  on  much  individual  observation, 
it  would  lead  into'  many  diagnostic  and  unfortunate 
therapeutical  mistakes  if  depended  on  as  a  diagnostic 
mark.    Bresgen81  would  have  the  favorite  site  of  syphil- 
itic ulceration  (and  consequently  of  perforation  ?)  to  be 
at  those  points  where  bones  and  cartilage  unite.     Ka 
posi  *  claims  that  the  dormal,  cartilaginous,  and  osseous 
parts  of  the  septum  may  become  perforated,  and  that 
syphilitic  perforation  will  oftenest  take  place  at  the  junc- 
tion of  the  cartilage  and  skin  portions.     These  observa- 
tions may  be  supplemented  by  one  of  Bosworth's,80  that 
"  syphilitic  ulcerations  show  a  marked  hesitancy  in  trans- 
gressing anatomical  boundaries."     All  these  observa- 
tions are  more  or  less  true,  but  anybody  with  no  very 
extensive  experience  will  have  learned  that  they  must  be 
taken  and  depended  on  with  caution.     Most  perforations 
that  are  discovered  are  round  or  oval,  but  McBride*7 
quotes  Michelson  who  says  that,  "  syphilitic  perforations 
are  usually  longitudinal,  and  tubercular  ones  round  or 
irregular."     McBride  neither  denies  nor  does  he  confirm 
this  assertion  of  Michelson's,  he  merely  passes  it  on. 
Jurasz88  tells  of  a  case  of  perforated  septum — cartilagi- 
nous portion— which  had  been  published  in  the  jour- 
nals by  another  physician  "as  being  non-syphilitic;  but 
which,  from  facts  subsequently  elicited,  was  believed  to 
be  syphilis  after  all,  not,  however,  because  of  any  par- 
ticular shape  of  the  perforation.    Another  interesting 
case  reported  by  Jurasz  may  be  referred  to :  A  young 
man,  aged  nineteen,  had  luetic  infiltrations  on  both 
sides  of  the  septum.    There  were  deep  ulcerations  be- 
sides, and  the  cartilage  beginning  to  become  denuded, 
necrosis  and  perforation  threatened  to  take  place.   Iodide 
of  potash  brought  about  a  comparative  normal  condition 
in  a  short  while — the  ulcerations  healed  and  no  perfora- 
tion developed.    A  case  of  no  less  interest  just  because 
its  history  is  somewhat  indefinite,  and  reported  by  Die- 
trich89 (Elbing),  is  instructive :  Widow,  aged  forty  five, 
moving  in  good  society,  whose  husband  had  been  an 
official.     A  nasal  catarrh  had  been  treated  with  question- 
able success  by  another  medical  man.     Recently  she  had 
slight  repeated  nasal  hemorrhages.     In  the  cartilaginous 
portion  of  the  septum  anteriorly,  there  is  now  a  perfora- 
tion about  the  size  of  a  half-dime.    Its  borders  are  ir- 
regular and  dirty  in  appearance,  with  here  and  there 
small  dirty- brown  crusts.    The  ulceration  bleeds  when 
touched  with  a  sound.    There  is  a  moderate  amount  of 
chronic  naso-pharyngeal  catarrh,  but  the  breath  is  not 
fetid,  nor  is  there  any  loss  of  the  sense  of  smell.     Syph- 
ilis not  being  suspected,  the  ulcerating  perforation  was 
looked  upon  as  simple,  and  cure  was  thought  certain 
within  a  short  time.    The  ulceration  was  treated  gal- 
vano-caustically  according   to  Voltolini's  recommenda- 
tions j  but,  instead  of  healing,  the  ulcerating  perforation 
slowly  but  surely  enlarged,  and  the  nose  had  become 
slightly  flattened.    Syphilis  was  now  looked  for,  but 
nothing  pointing  that  way,  except  that  the  lady  was 
childless  and  had  aborted  four  times,  could  be  found. 
She  was  given  iodide  of  potash,  and  immediately  every- 
thing prospered  to  a  surprising  extent.    The  ulceration 
began  to  heal,  and  finally  cicatrized  perfectly ;  and  the 
chronic  catarrh  also  improved  very  much. 

These  cases,  aside  from  their  intrinsic  interest,  offset 
the  obiter  dicta  of  the  distinguished  authors  quoted  a 
while  ago ;  but  in  connection  with  Dietrich's  case,  a  re- 
flection from  Sir  John  Hutchison  "  is  worth  remember- 
ing; even  when  there  is  a  clear  history  of  syphilis,  "if 
the  ulceration  be  slow,  and  without  tendency  to  diffuse 
inflammation,  or  exfoliation  of  bone,  it  will  usually  be 
found  that  the  internal  treatment  by  specifics  does  very 
little  good,  while  local  treatment  will  cure.11 

May  not  a  perforation  have  existed  before  syphilis  was 
acquired?  And,  is  it  not  a  valid  question  to  put,  may 
not  perforative  influences  work  their  effects,  even  while 
syphilis  is  doing  its  share  of  evil  in  the  same  body  ?  A 
syphilitic  history  surely  does  not  make  all  pathological 
phenomena  syphilitic. 
Rheumatism  may  give  rise  to  septal  perforations  due 


perhaps  to  a  rheumatic  perichondritis.  Mackenzie41  re- 
fers to  French  journals  on  this  head,  and  quotes  a  case 
from  Roger:  Young  man,  severe  articular  rheumatism 
and  well-marked  cardiac  symptoms,  lost  a  portion  of  the 
cartilaginous  septum,  the  size  of  a  grain  of  rice,  two 
months  before  he  died. 

Typhoid,  typhus,  and  other  fevers  may  give  rise  to 
ulcers  on  the  nasal  septum  which  end  in  perforation. 
But  these  are  very  rare  and  exceptional  eventualities. 
Gelli  *  reported  a  case  of  a  young  man  of  sixteen,  who, 
during  an  attack  of  typhoid  fever  had  a  good  deal  of 
nasal  hemorrhage,  from  the  beginning  to  the  end.  Dur- 
ing the  fever  he  emaciated  very  much.  The  nasal  sep- 
tum was  thin.  In  this  case  the  septal  ulceration  pro- 
gressed, and  perforation  of  the  septum  was  the  result ; 
and  all  because,  it  was  supposed,  the  patient  picked  his 
nose  so  much.* 

Diphtheria  gives  rise  to  extensive  intra-nasal  ulcera- 
tions and  even  necrosis  of  the  bones.  Chiari  reports 
such  a  case.  This  disease  may  just  possibly  give  rise  to 
septal  perforations. 

Carcinoma  has  been  known  to  perforate  the  septum. 
Hajek  *  came  across  such  a  case.  Metastatic  carcinoma- 
tous deposit  in  the  septum  broke  down  and  left  a  hole. 

Local  Inflammatory  and  Allied  Procestes.— In  the 
course  of  his  description  of  the  sequelae  and  complica- 
tions of  chronic  coryza,  Massei44  says  that  ulcers  develop 
under  crusts  deposited  on  the  surface  of  the  mucous  mem- 
brane, and  that  this  occurs  oftenest  in  people  whose  labor 
obliges  them  to  inhale  air  laden  with  irritating  substances. 
He  also  avers  that  the  lower  turbinates  are  the  common 
sites  of  this  process,  but  that  the  same  process  may  take 
place  on  the  septum  and  perforate  it.  These  ulcerations 
and  perforations,  says  Massei,  may  affect  the  lamina  per- 
pendicularis  of  the  ethmoid  bone  and  the  vomer,  and 
that  the  lower  anterior  portion  of  the  septum  almost  al- 
ways escapes. f  This  may  be  true  for  Italian  noses. 
Moritz  Schmidt,  on  the  other  hand,  locates  the  encrust- 
ing and  erosive  process  at  the  anterior  cartilaginous  por- 
tion. Bresgen  and  others,  ditto.  }.  Sob's  Cohen  *  has 
a  description  all  his  own  under  the  heading  of  Chronic 
Coryza,  and  the  sub- heading,  Fetid  Coryza,  which  reads 
(after  mentioning  that  the  disease  having  existed  some 
years,  destroying  mucous  membrane  and  bones),  "so 
that  the  cartilaginous  septum  is  in  many  instances  found 
to  have  been  pierced  through,  sometimes  in  one  or  two 
small  perforations,  but  more  frequently  in  a  single  large 
irregular  hole,  perhaps  admitting  the  end  of  the  little 
finger,  or  the  end  of  a  larger  one,  and  looking  as  if  it  had 
been  gouged  out  with  some  rude  tool." 46  These  two 
pictures  of  "  chronic  coryza  M  J  strike  one  as  being  made 
up  of  different  and  distinct  diseases,  are  confused  and  ex- 
aggerated. They  differ  as  to  the  location  of  the  ulcero- 
perforative  process. 

D.  Newman,  of  Scotland,  and  J.  N.  Makenzie,  of 
Baltimore,  Md.,47  have  found  the  anterior  (cartilaginous) 
portion  of  the  nasal  septum  perforated  in  laborers  work- 
ing in  chromic-acid  factories.  Toeplitz,  of  New  York,48 
examined  thirty-nine  laborers  employed  in  a  single  arsenic 
(Schweinfurth  GrQn)  factory,  and  found  nineteen  of  them 
with  perforations  in  the  cartilaginous  portion  of  the 

*  Dr.  George  F.  Shrady  has  kindly  given  me  permission  to  mention 
the  following  case  of  perforation  of  the  cartilaginous  portion  of  the 
nasal  septum  due  to  typhoid  fever,  which  occurred  in  his  practice  years 
ago.  The  patient  was  a  girl  (the  child  oi  a  friend),  about  ten  years  of 
age.  The  fever  was  of  a  prolonged  tedious  type,  but  the  temperature 
of  which  never  at  any  time  went  above  102&0  F.  About  the  fourth 
week  of  the  fever,  nasal  bleedings  occurred,  ard  an  ulcer  was  dis- 
covered on  the  cartilaginous  portion  of  the  septum.  This  was  readily 
noticed  because  the  child  had  wide  and  prominent  nostrils.  In  a 
short  time  the  ulcer  developed  into  a  perforation.  Dr.  Shrady  is  pos- 
itive that  nose-picking  had  nothing  to  do  with  causing  the  ulcer  to 
develop  into  a  perforation. 

t  Note  to  Massei. — On  page  124  Massei  has  a  section  devoted  to 
"  simple  catarrh,"  in  which  crusts  develop  on  the  anterior  portion  of 
the  septum  which  irritate,  and  which  in  connection  with  nose-picking 
with  the  fingers  result  in  ulceration  and  perforation  of  the  nasal 
septum. 

X  Note  to  Cohen.— Both  Cohen's  and  Massei's  pictures  refer  ap- 
parently to  the  same  mixed  pathological  conglomeration  of  diseases. 
It  is  proper  to  state  that  both  M.  and  C.  are  cognizant  that  they  are 
depicting  mixed  pathological  conditions. 


776 


MEDICAL    RECORD. 


[December  22,  1894 


septum.  Eight  others  who  had  not  been  employed  for 
so  long  a  time  in  this  factory  had  ulcers  varying  in  size 
and  depth  on  the  septum,  apparently  on  the  way  to  per- 
foration. In  none  of  these  arsenic  cases  were  the  bones 
affected.  Alexander  G.  R.  Faulerton,"  of  England, 
found  a  hole  in  the  cartilaginous  portion  of  the  septum 
(anteriorly)  of  a  man  who  happened  to  be  a  cement 
worker.  On  this  single  observation  speculations  as  to 
the  rise  and  progress  of  septal  ulcers  were  based  that 
have  been  quite  generally  adopted,  even  by  Zuckerkandl, 
as  though  Faulerton's  assumptions  had  the  sure  basis 
of  comparative  statistics  and  wide  discriminating  ob- 
servation. He  stated,  without  giving  any  proofs,  that 
such  septal  perforations  are  found  often  in  cement 
workers.  So  much  made  "sure,"  a  "rationale"  was 
easy  to  manage,  and  thus :  Cement  dust  causes  rhinitis ; 
then  formation  of  crusts ;  irritation  from  these  which  is 
relieved  by  picking  at  the  nose,  then  ulcer  in  conse- 
quence, finally  further  nose-picking,  until  ulcers  become 
perforations.  This  is  simple,  but  all  on  the  surface, 
and  leaves  much  out  of  account.  However,  R.  Otto,® 
of  Darpat,  Russia,  after  having  examined  thirty  cement 
workers,  found  only  one  who  had  a  perforated  septum. 

The  number  of  people  who  bore  about  in  their  noses 
is  very  large,  and  yet  in  comparison  how  few  septal 
perforations  are  discovered.  No  doubt  after  an  ulcer 
has  been  started,  whatever  the  cause  be,  digging  about 
in  the  nose  may  accelerate  a  progressive  ulcerative  proc- 
ess. As  a  rule,  people  do  not  hurt  themselves  when  they 
can  avoid  it,  and  when  picking  into  the  nostrils  for  the 
removal  of  crusts  or  for  counter  irritant  effect,  hastens  or 
favors  perforation,  some  grave  pathological  change  in  the 
septal  tissues  may  be  assumed.  Normally  the  mucous 
membrane  heals  very  rapidly  and  thoroughly,  and  when  it 
will  not  do  so  something  is  wrong  with  it,  and  the  rhinol- 
ogist  will  not  use  his  drills,  chisels,  saws,  scissors,  knives, 
and  cauteries.  Surely  picking  at  the  nose  does  not  deter- 
mine tuberculosis,  scrofula,  lupus,  and  syphilis  to  seek 
the  cartilaginous  septum  for  ulceration  and  perforation. 
Furthermore,  do  not  catarrhal  ulcers  so  called  heal  in  spite 
of  nose-picking  when  they  occur  in  healthy  people  ?  Yes. 
Perichondritis  and  abscess  of  the  septum  not  due  to 
scrofula,  Friedreich51  said,  almost  always  end  favorably, 
and  without  leaving  deformity  of  the  nose.  But  Wunder- 
lich  «  and  Duchek58  affirmed,  in  a  general  way,  that  those 
affections  may  leave  a  perforation  of  the  septum  or  des- 
troy it  entirely,  and  leave  the  nose  flattened  and  de- 
formed. These  processes  may  obstruct  the  nasal  passages 
partially  or  entirely,  they  may  affect  only  one  side  of  the 
septum  or  both  sides,  they  may  be  located  high  up  and 
posteriorly,  or  inferiorly  and  away  to  the  front.  So  said 
Wunderlich.  These  observations  have  been  confirmed 
by  rhinologists  of  our  day,  and  from  cases  that  they  have 
reported,  I  shall  refer  to  one  of  D.  Bryson  Delavan's.54 
An  otherwise  healthy  girl,  sixteen  years  of  age,  had  a 
very  severe  septal  perichondritis  and  abscess  on  both 
sides  of  the  septum,  and  perforation  took  place  near 
where  the  bonp  and  cartilage  unite.  After  proper  treat- 
ment the  perforation  closed  up  and  only  a  scarcely  notice- 
able amount  of  flattening  remained.  Whether  or  not 
oval  or  round  openings  of  a  permanent  character  remain 
after  the  acute  symptoms  of  these  maladies  have  subsided, 
it  is  impossible  to  affirm  positively. 

Theodore  Harke,56  in  his  post-mortem  examinations, 
came  across  an  interesting  case  of  facial  erysipelas  and 
hemorrhagic  naso  septal  lesion  that  may  be  mentioned 
here.  Erysipelas  affected  the  right  ear  and  the  face. 
The  mucous  membrane  of  the  nose  was  generally  red 
and  congested,  and  covered  with  muco  purulent  masses. 
Under  the  mucous  membrane  and  perichondrium  of  the 
left  side  of  the  septum,  a  diffuse  hemorrhage  had  taken 
place,  involving  all  the  cartilaginous  and  one  half  of  the 
bony  portions  of  the  septum.  There  were  no  signs  of 
abscess  formation.  The  covering  mucous  membrane 
was  of  a  dark-greenish  color.  Would  necrosis  and  per- 
foration have  followed  in  this  case  if  the  patient  had 
lived  ?    It  is  possible. 


Perforating  Ulcer  of  the  Vasal  Septum.— Weichsel- 
baum,  Voltolini,  Sir  J.  Hutchison,  Sir  James  Pfcget, 
Jessop,  Hajek,  Zuckerkandl,  Rossbach,  Freudenthal,  and 
others,  have  reported  cases  of  perforating  ulcers  of  the 
nasal  septum.  Analogically,  they  have  been  compared 
to  perforating  ulcers  of  the  foot  and  those  of  the  stom- 
ach. All  authors  agree  that  they  have  necessarily  noth- 
ing to  do  with  syphilis  or  tuberculosis.  The  majority 
of  German  writers  opine  with  Weichselbaum  and  Hajek, 
that  they  are  a  local  affection  due  to  parasites.  Taking 
all  the  developmental  theories  and  their  shortcomings 
into  account,  one  may  conclude  that  the  real  or  essen- 
tial causes  of  perforating  ulcers  of  the  septum  are  un- 
known, or  else  a  number  of  various  causes  and  influences 
have  to  do  with  their  origin  and  development. 

These  ulcers  are  found  in  people  who  have  neither 
syphilis  nor  tuberculosis.  They  are  found  in  people 
who  have  died  of  tuberculosis  and  were  suffering  from 
tertiary  syphilis.  They  have  been  found  in  those  who 
have  had  syphilis ;  and  in  those  in  whom  syphilis  is  ac- 
tive. One-third  of  Hajek's  M  cases  of  septal  perforations 
were  tubercular  subjects,  and  all  of  Weichselbaum's w 
sixteen  cases  had  succumbed  to  tuberculosis.  None  of 
my  five  cases  were  tubercular.  These  perforations  may 
vary  in  size  from  that  of  a  lentil  to  that  of  a  twenty-five 
cent  piece.  Usually  there  is  only  one,  but  two  and 
more  have  been  observed  in  the  same  septum. 

Their  pathological  history  may  be  divided  into  three 
stages :  A  preparatory,  an  ulcerative,  and  a  perforative 
stage. 

As  to  the  first  stage,  a  number  of  opinions,  none  of 
them  even  similar,  have  been  advanced.  A  favorite 
opinion  is  hemorrhagic,  after  some  manner  or  other. 
Voltolini  *  fancied  that  hemorrhage  from  some  ruptured 
venule  or  arteriole  was  the  origin  of  the  progressive  ul- 
cerative process,  with  the  vesicular  or  arterial  break  as 
the  centre  of  ulceration.  Nasal  hemorrhages  are  very 
common  and  frequent,  and  usually  from  the  septum ;  but 
septal  perforative  ulcers  are  rare  and  uncommon  in  com- 
parison. This  theory  of  Voltolini  is  a  mere  guess ;  and 
Voltolini  did  not  think  of  explaining  or  guessing  at  the 
tissue  changes  in  the  vessels  that  must  precede  the  vesic- 
ular break  and  predispose  it  to  spread  peripherally,  nor 
did  he  enlighten  us  about  the  causes  that  must  be  at 
work  after  the  ulcer  was  progressing,  nor  finally  by 
which  influences  it  was  stopped  short.  These  ulcers  be- 
gin on  both  sides,  at  symmetrical  points,  simultaneously 
sometimes ;  and,  in  such  cases  we  should  be  obliged  to 
assume  like  conditions  on  both  sides.  And  nobody  ever 
saw  such  a  condition  of  affairs. 

Dietrich's  *  theory  is  an  advance  on  the  logic  of  Vol- 
tolini. He  posits  that  the  nasal  septum  is  very  vascu- 
lar and  the  circulation  slow,  and  thus  prone  to  throm- 
botic and  depraved  local  nutritive  troubles.  If  injury  to 
the  mucous  membrane  like  that  caused  by  nose-picking 
starts  an  ulcer,  then  the  succeeding  steps  of  the  progres- 
sive ulceration,  it  is  supposed,  are  easily  imagined.  And 
that  is  not  the  case.  This  theory,  too,  ignores  many 
antecedent  and  post  -  ulcerative  influences.  Dietrich 
holds  that  the  presence  of  bacteria  in  the  ulcer  is  acci- 
dental and  not  essential  or  causative. 

Zuckerkandl m  has  given  us  the  most  elaborate  and 
plausible  of  all  the  hemorrhagic  theories ;  but  his  the- 
ory is  weak  and  comes  short  of  science,  because  it  does 
not  in  most  instances  cover  clinical  experience.  After 
long  mechanical  injury  of  some  kind,  as  boring  about  in 
the  nose  with  the  finger  or  inhaling  irritant  substances, 
hemorrhages  into  the  mucous  membrane  take  place,  and 
at  last  a  condition  known  by  him  as  zanthosis  is  devel- 
oped. The  mucous  membrane  assumes  a  yellowish  ap- 
pearance and  has  become  atrophied.  The  blood- vessels 
have  in  the  meantime  undergone  degenerative  changes. 
If  bacteria  and  cocci  now  get  a  chance  to  invade  the 
parts,  they  overcome  tissue  resistance  so  successfully  that 
perforation  quickly  follows  ulceration.  Most  cases  of 
perforating  ulcer  reported  by  clinicians  have  not  shown 
up  that  way.    At  any  rate,  my  five  cases  did  not. 


December  22,  1894] 


MEDICAL   RECORD. 


777 


Rosenfeld's tt  (Stuttgart)  theory  is  not  hemorrhagic, 
bat  neuropathic.  It  is  trophoneurotic ;  and  it  is  pecul- 
iar because  he  locates  the  ulcers  so  high  up  as  to  be  out 
of  the  reach  of  the  finger  nail,  and  from  the  fact  that  he 
claims  to  have  seen  these  ulcers  develop  from  within 
outward ;  that  is,  it  is  said  that  he  has  seen  cases  in  which 
perforations  developed  under  necrotic  mucous  membrane. 
This  theory  hobbles  along  without  the  help  of  germs, 
primary  degenerative  vascular  changes,  or  sinister  hem- 
orrhages, or  finger-nail  pickings,  or  finger-nail  toxic 
local  infection.  This  theory,  too,  accounts  for  but  little 
that  clinical  observation  uncovers — it  is  but  a  match 
struck  in  the  dark,  and  just  lets  us  know  how  dense  the 
darkness  is. 

And  now  for  the  bacterial  theories.  Frankel's  ■  opin- 
ion respecting  parasites  carrying  havoc  and  destructive 
ulceration,  and  finally  perforation,  into  Jacobson's  organ, 
runs  counter  to  so  much  clinical  experience,  that  merely 
to  be  mentioned  is  about  all  the  attention  it  deserves. 

Hajek's  theory  also  limps.  As  the  first  step  he  finds 
a  limited  area  of  mucous  membrane,  or  dotlets  thereof, 
discolored  a  dirty  gray,  due  to  the  formation  of  a  pseudo- 
membrane  and  degeneration  of  the  epithelium.  There 
is  nothing  passive  about  this  discolored  spot.  It  is  de- 
structively active,  and  it  is  assumed  that  the  greatest 
amount  of  activity  is  at  the  central  parts.  The  mem- 
brane becomes  disorganized,  and  makes  room  for  the 
ulcer,  which  has  sharply  defined  borders.  This  ulcer 
shelves  off  toward  the  centre,  where  it  is  deepest.  In 
time  the  ulcer  becomes  something  like  a  terrassed  cone — 
the  point  at  the  centre,  and  its  base  bounded  by  the 
borders.  At  the  beginning  of  the  ulcerative  period 
detritus  of  pseudo  membrane  and  coagulated  blood  may 
be  found  hanging  to  the  surface  of  the  ulcer  or  to  the 
borders.  Later  on  muco-purulent  crusts  may  form  over 
them  and  hide  them,  but  the  destructive  process  con- 
tinues ;  and  scarcely  ever  is  this  known  to  the  patient. 
The  mucous  membrane,  the  perichondrium,  and  the  car- 
tilage having  become  perforated,  healing  may  set  in  and 
become  complete  by  leaving  a  thin  tapering-edged  hole 
in  the  septum.  Possibly  healing  may  take  place  before 
the  perichondrium  has  become  implicated,  but  if  this 
does  occur,  it  does  so  for  reasons  unknown.  Often  these 
perforations  are  seen  with  their  edges  still  ulcerating  at 
points,  and  necrotic  cartilage  jutting  beyond  the  mucous 
and  perichondrial  coverings  of  the  septum.  Before  com- 
plete healing  has  become  established,  it  is  said  the  mu- 
cous membrane  may  or  can  be  lifted  from  its  subjacent 
tissues,  and  the  perichondrium  from  the  cartilage.  This 
could  not  be  done  in  any  of  my  cases.  This  malady 
does  not  go  on  without  some  reaction  at  or  near  the 
borders  of  the  ulcer,  and  around  the  blood-vessels ;  but 
for  the  most  part  the  process,  taken  as  a  whole,  simulates 
a  local  gangrenous  process.  And  all  these  changes,  say 
Weichselbaum  and  Hajek,  are  caused  by  bacteria  and 
cocci;  especially,  according  to  Hajek,  to  streptococci 
pyogenes  and  staphylococci  pyogenes  aureus.  Those 
cocci  do  not  wander  away  from  these  foci  of  ulceration, 
but  continue  to  play  high  jinks  there  until  perforation 
has  taken  place ;  and  the  edges  of  the  perforation  having 
become  healed,  they 

"  Fold  their  tents  like  the  Arab* 
•  And  as  lightly  steal  away." 

These  ulcerative  perforations  constitute  a  disease  sui 
generis — a  specific  disease,  and  says  Sir  James  Paget, 
"  the  definite  shape  (of  the  perforation)  may  be  a  char- 
acteristic of  their  being  due  to  parasitic  influence,  just 
as  are  the  definite  shapes  of  parasitic  diseases  on  leaves." 
However  all  this  may  be,  neither  Weichselbaum's  nor 
Hajek's  bacteriological  investigations  have  disclosed  any- 
thing of  a  specific  nature.  The  clinical  significance  of 
what  has  been  said  concerning  perforations  of  the  nasal 
septum  may  be  summarized  by  saying  that  they  vary 
according  to  their  etiology  and  pathology: 

1.  Congenital  or  developmental  perforations  are  ex- 
tremely rare ;  and,  if  we  must  believe  authorities,  they 


are  of  two  kinds  at  least :  (a) 'Those  due  to  perverse  or 
arrested  development,  such  as  are  hinted  at  by  Harrison 
Allen,  and  of  which  Germs'  case  is  an  instance ;  (£) 
those  due  to  a  pathological  process  implanted  on  the 
developing  tissues,  such  as  are  hinted  at  by  Klebs;  and 
which  a  number  of  observers  believe  they  have  seen. 
Concerning  this  field  of  observation  we  know  positively 
very  little,  and  large  opportunities  here  await  the  scien- 
tist. 

2.  Perforations  due  to  severe  direct  violence,  and  con- 
tiguous pathological  processes  must  tally  with  the  in- 
jury received  or  the  growth  giving  rise  to  them.  These 
also  are  rare  occurrences. 

3.  Perforations  due  to  constitutional  influences  are 
usually  accompanied  by  the  signs  and  symptoms  pecul- 
iar to  those  diseases,  respectively,  while  the  perforation 
is  developing.  Besides,  the  various  local  manifestations 
of  the  respective  constitutional  diseases  crop  out  at  other 
points  of  the  intra  nasal  mucous  membrane,  although 
that  of  the  septum  is  a  favorite  site  with  all  of  them. 
They  very  rarely  develop  septal  perforations,  and  when 
they  do,  other  manifestations,  peculiar  to  any  special  one 
of  diem,  show  up  with  the  perforation.  In  most  cases 
even  syphilis  is  no  exception  to  this  last  remark ;  al- 
though syphilis  may  leave  a  perforation  which  bears  all 
the  marks  of  the  so-called  "  perforating  ulcer  of  the  nasal 
septum, ' '  according  to  Jurasz  and  other  observers.  How- 
ever, the  clinical  history,  and  a  course  of  experimental 
therapeutics,  will  differentiate  them  when  any  doubt  as 
to  their  respective  character  exists.  The  mere  existence, 
however,  of  a  history  of  syphilis  in  a  patient  is  not  posi- 
tive proof  that  the  perforation  has  been  caused  by  syphil- 
itic influences. 

4.  Purely  inflammatory  affections  of  the  septum — 
perichondritis  and  abscess— may  give  rise  to  perforation 
(even  to  the  extent  of  nearly  half  an  inch  in  diameter,  as 
in  Delavan's  quoted  case)  during  the  inflammatory  proc- 
ess, but  the  defect  is  apt  to  heal  up  again  with  more  or 
less  or  no  deformity.  It  may  be  just  possible  for  a  typi- 
cal roundish  or  oval  perforation  to  result ;  but  whether 
such  have  been  seen  is  not  certain. 

5.  Most  perforations  that  are  discovered  by  many 
observers  are  almost  always  found  located  in  the  cartilag- 
inous portion  of  the  septum,  and  are  roundish  or  oval- 
shaped,  their  long  axis  being  parallel  with  the  long  axis 
of  the  cartilaginous  portion  of  the  septum.  According 
to  the  majority  of  observers,  they  have  nothing  to  do 
with  syphilis  etiologically  in  most  instances.  They  are 
in  most  instances  probably  purely  local  gangrenous 
manifestations,  possibly  due  to  bacterial  influences,  pos- 
sibly due  to  local  tropho  neurotic  causes,  possibly  to  a 
combination  of  many  causes ;  but  the  true  nature  of  this 
disease  still  remains  to  be  discovered.  There  has  been 
nothing  wrong  with  the  mucous  membrane  or  the  other 
intra-nasal  tissues  beyond  the  ulcer  or  ulcerating  perfora- 
tion, in  many  of  the  cases  that  have  come  under  observa- 
tion, according  to  the  testimony  of  a  number  of  authors. 

Therapeutics.— Patients  with  ulcerations  on,  and  per- 
forations in,  the  nasal  septum,  when  these  lesions  are  not 
discovered  casually,  come  to  be  relieved  from  the  nasal 
discomfort  caused  by  crusts  blocking  up  the  nasal  pas- 
sages, etc. ;  or  they  come  to  have  small  intermittent  nasal 
bleedings  checked ;  or  else,  in  rare  instances,  on  account 
of  whistling  noises  which  occur  when  the  air  is  quickly 
or  forcibly  inspired,  and  such  cases  have  been  observed 
by  Bosworth,  L.  Bolton  Bangs,  Hutchison,  Jessop,  and 
others. 

The  successful  treatment  of  ulcers  demands,  first  of  all, 
that  the  causative  pathological  influences  be  done  away ; 
and  next,  that  the  best  favorable  conditions  be  estab- 
lished, with  local  and  general  remedies,  for  aiding  the 
recuperative  forces  of  the  local  tissues  to  cover  the  losses 
they  have  sustained.  When  this  is  not  or  cannot  be 
done,  cure  will  be  impossible. 

The  aggregate  experience  of  all  observers  allows  the 
conclusion  to  be  drawn  that  simple  perforating  ulcers 
and  perforations  cannot  always  be  differentiated,  by 


778 


MEDICAL   RECORD. 


[December  22,  1894 


appearances,  from  those"  developed  by  syphilitic  influ- 
ences. When  this  happens,  specific  treatment  with  mer- 
curials, and  iodide  of  potash,  etc.,  will,  so  far  as  is  known, 
clear  up  the  diagnosis.  The  syphilitic  ulcerations  will 
heal  under  the  influences  of  the  specific  drugs  that  have 
no  appreciable  effect  on  the  simple  perforating  ulcer. 
Although  simple  perforating  ulcer  of  the  nasal  septum 
has  a  stage  of  growth  and  development  that  prepares 
local  conditions  which  favor  subsequent  ulceration  and 
finally  perforation,  its  therapeutics,  unfortunately,  can- 
not be  considered  after  any  such  methodical  manner. 
Our  present  knowledge  of  this  malady  obliges  us  to  fol- 
low up  the  process  by  attacking  it  with  only  such  general 
empirico-clinical  remedies  which  have  been  found  effective 
in  other  cases  of  tissue  destruction  of  a  non-specific  char- 
acter. 

Freudenthal  *  reports  the  case  of  an  otherwise  healthy 
girl,  twelve  years  of  age,  who  came  to  him  to  be  cured 
of  persistent  epistaxis.  On  the  anterior  portion  of  the 
septum  a  dirty  grayish-white  patch  or  deposit  was  dis- 
covered, besides  some  superficial  ulceration.  The  bor- 
ders of  this  ulceration  were  found  to  be  congested. 
These  finds  were  considered  typical  of  the  early  stages  of 
simple  perforating  ulcer.  The  remedies  applied  were 
mild  astringents,  which  and  in  what  strengths  are  not 
mentioned.  Freudenthal  saw  the  case  only  four  times, 
and,  when  last  seen,  the  ulcer  seemed  to  be  doing  nicely, 
and,  the  patient  not  returning  again,  the  doctor  con- 
cluded that  the  ulcer  must  have  healed.  All  of  us  may 
not  concur  in  the  diagnosis  nor  accept  the  assumed  thera- 
peutical optimism.  However,  a  case  of  mine,  already 
referred  to,  will  not  be  out  of  place  alongside  of  this  one 
of  FreudenthaTs :  A  young  man  and  student,  aged  eigh- 
teen, quite  a  cigarette  smoker,  came  to  me  on  account 
of  bleedings  from  the  nose,  besides  (right)  orbital  pains 
that  radiated  from  the  nose.  Examination  revealed  a 
flat  triangular  ulcer  on  the  anterior  portion  of  the  right 
side  of  the  septum.  The  ulcer  (very  superficial)  was 
about  the  size  of  a  three-cent  piece,  with  sharply  defined 
borders  that  were  not  particularly  congested  or  swollen. 
Its  surface  was  very  finely  granular,  but  did  not  bleed 
when  touched  with  a  probe.  There  was  some  hyperses- 
thesia  at  and  near  the  borders,  but  not  over  the  surface 
of  the  ulcer.  There  were  no  crusts,  nor  pseudo-mem- 
branal  detritus,  nor  dried  blood  on  or  about  the  ulcer. 
He  admitted  that  he  picked  his  nose,  but  only  to  get  rid 
of  crusts ;  and  then  his  nose  would  bleed,  after  which 
the  orbital  pain  would  subside  considerably.  This  young 
man  was  not  strong  and  robust,  but  not  any  more  anae- 
mic than  one  would  expect  to  find  in  a  person  confined 
to  rooms.  He  complained  of  malaise  which  might  be 
attributed  to  tobacco  or  malaria.  There  was  a  slight 
amount  of  naso-pharyngeal  catarrh. 

To  the  ulcer  itself  I  applied  a  scruple  to  the  ounce  so- 
lution of  nitrate  of  silver ;  and  to  the  nose  and  pharynx 
a  three-grain  solution  of  the  same  metal.  Internally  he 
was  given 


Ext.  nux  vomica, 
Ext.  hyoscyamus  . . . 
Quinine  sulphate  . . . 


.aa  gr.  £ 
...  gr.  iij. 


four  times  a  day.  He  was  given  general  and  local  ad- 
vice, and 

Hydrarg-rub.  oxidi gr.  v. 

Vaseline J  j . 

M.  Ft.  unguentum, 

to  be  applied  to  the  ulcer.  Two  weeks  later  I  saw  him 
again.  Generally  he  felt  better.  Locally,  appearances 
seemed  better,  although  the  ulcer  had  not  diminished  in 
size ;  it  had  not  bled  because  crusts  had  not  formed  as 
often  as  had  been  the  case  before,  and  besides  he  had 
not  been  tempted  to  pick  at  his  nose  as  often.  The  orbi- 
tal pain  was  still  present,  but  came  less  often,  and  was 
not  nearly  so  severe  as  it  had  been.  He  now  went  off 
on  his  vacation  to  the  mountains. 

The  ulcer  was  thought  to  be  simply  catarrhal;  and  its 
size  was  attributed  to  the  fingernail  injuries.    There  was 


no  sign  of  zanthosis  here,  nor  interstitial  hemorrhages!  nor 
pseudo-membranal  deposits,  nor  varicosities.  I  hoped 
with  better  air,  more  exercise,  etc.,  the  young  man  would 
return  to  his  studies  in  the  fall  with  an  intact  and  sound 
nasal  septum.  But  when  he  returned,  several  months 
later,  I  was  surprised  to  find  an  oval  perforation  in  the 
septum,  and  other  typical  appearances.  During  his  vaca- 
tion his  nose  did  not  trouble  him  in  any  way.  At  places 
the  mucous  membrane  had  healed  over  the  cartilage,  bat 
at  other  points  the  necrotic  cartilage  jutted  beyond  the 
perichondrium  and  mucous  membrane,  and  the  tissue 
struggle  for  cicatrization  was  going  on.  This  condition 
of  affairs  reminded  me  of  a  case  of  gangrene  of  the  auri- 
cle in  a  child  that  I  had  treated  at  the  New  York  Eye 
and  Ear  Infirmary.  This  gangrene  originated  from 
chicken  pox.  And  here,  too,  the  cartilage  (necrotic,  of 
course)  jutted  beyond  the  limits  of  the  skin  and  peri- 
chondria! tissues. 

For  hastening  the  process  of  cicatrization  in  these 
cases,  scraping  away  necrotic  tissues,  and  applying  nitric 
acid  have  been  recommended  and  practised  by  Jesaop. 
Others  have  used  the  solid  nitrate  of  silver.  Sir  J. 
Hutchison  has  used  and  recommended  the  acid  nitrate 
of  mercury.  The  electro- cautery  was  recommended  by 
Voltolini  and  others.  Hutchison64  also  used  the  yellow 
oxide  of  mercury  salve.  Whatever  active  treatment  in 
the  way  of  curetting  and  caustics  is  resorted  to,  too 
much  irritation  and  destruction  of  nutrient  tissues  (mu- 
cous membrane  and  perichondrium)  must  be  scrupulously 
avoided.  And  even  then,  in  spite  of  careful  constitu- 
tional treatment  and  observant  local  care,  this  healing 
process  will  sometimes  continue  to  remain  tedious,  and 
even  refuse  to  heal;  because  we  fail  to  influence  the 
cause,  of  which  everybody  is,  as  yet,  ignorant. 

406  Wbst  Thikty-fourth  Sthet. 

Bibliography. 

1  McBride's  Treatise  on  Diseases  of  the  Nose,  Throat,  and  Ear, 
p.  330.    P.  Blakiston,  Son  &  Co.,  Philadelphia.    189a. 

I  Zuckerkandl :  Normale  und  pathologische  Anatomie  der  Nasen- 
hShle,  etc.     Bd.  x,  p.  99.    W.  BraumllUer,  Wien.    1883. 

*  Hajek :  Virchow's  Archiv,  Bd.  120,  p.  506. 

*  Max  Schaeffer  (Bremen) :  Chirurg.  Erfahrungen  in  der  Rhino- 
logie  und  Laryngologie  aus  den  Jahren  1875-1885,  p.  a.  J.  F. 
Bergmann,  Wiesbaden,  1885. 

0  O.  Chiari :  Erfahrungen  auf  dem  Gebiete  der  Hals-  und  Nasen- 
Krankheiten,  p.  64.    Toeplitz  u.  Deuticke,  Wien  and  Leipzig. 

6  Prof.  Dr.  med.  A.  Jurasz :  Die  Krankheiten  der  oberen  Luftwege, 
Klinische  Beobactungen  und  Erfahrungen,  p.  70.  Carl  Winters, 
Heidelberg.    1891. 

7  Hermet :  remarked  during  a  discussion  of  Gelle's  case.  Annales 
des  Mai  de  l'Oreille,  etc. ,  xvil ,  pp.  479,  480. 

8  The  Journal  of  the  American  Medical  Association,  vol.  jriiL,  p. 
401. 

*  Franke  H.  Bosworth :  A  Treatise  on  Diseases  of  the  Nose  and 
Throat    Vol.  i.,  p.  308.    Wm.  Wood  &  Co.,  New  York.    1889. 

10  Dr.  E.  Klebs:  Handbuch  der  pathologischen  Anatomie,  Erste 
Lieferung,  p.  151.    Aug.  Hirschwald,  Berlin.    1868. 

II  Harrison  Allen,  M.D. :  A  System  of  Human  Anatomy,  etc.  Sec- 
tion vi.,  p.  62a.     Henry  C.  Lea's  Son  ft  Co.,  Philadelphia.    1883. 

"  Dr.  F.  Beely :  Gerhardt's  H'dbuch  der  Kinder-Krankheiten,  Bd. 
vL,  p.  181.    H.  Laupp,  Tubingen.     1880. 

19  Bosworth :  Treatise  cited,  p.  307. 

"  W.  Edward  Lftri :  Die  durch  Anderweitige  Erkrankungen  be- 
dingten  Veranderungen  des  Rachens,  eta,  pp.  35-36.  Fera  Erke, 
Stuttgart     1885. 

"  Harrison  Allen  :  Op.  cit ,  6aa. 

"  Zuckerkandl :  Treatise  cited,  vol.  i.,  p. 

"  Bosworth  :  Treatise  quoted,  p.  308,  voL  L 

"  Jurasz :  Op.  cit ,  p.  70. 

19  Dr.  med.  Wilhelm  Maldenhauer :  Die  Krankheiten  der  Nasenhdo- 
len,  etc.,  p.  106.    E.  C.  Vogel,  Leipzig.     1886. 

»  Sir  James  Paget.  Bart :  Studies  of  Old  Case  Books,  pp.  59-53. 
Longmans,  Green  &  Co. ,  London,  1891, 

«  H.  Radcliffe  Crocker.  M.D.,  etc.:  Treatise  on  Diseases  of  the 
Skin,  aded.,  p.  509.     P.  Blakiston  &  Son.  Philadelphia,  1893. 

•*  Carl  Seiler :  Burnett's  System  of  Diseases  of  the  Ear,  Nose,  and 
Throat,  vol.  ii..  p.  24.    J.  B.  Lippincott  Co.,  Philadelphia,  2893, 

*'  Sir  J.  Hutchison  :  Arch,  of  Surgery,  vol.  iiL,  p.  904. 

M  Hebra  u.  Kaposi :  Lehrbuch  der  Haut-Krankheiten,  1876,  Bd.  ii, 
pp.  339-345. 

»  Dr.  Carl  Fr.  Th.  Rosenthal:  Die  Erkrankungen  der  Nase,  etc, 
p.  118.    A.  Hirschwald,  Berlin,  189a. 

M  James  Haughton :  The  Cyclopaedia  of  Practical  Medicine.  Ed- 
ited by  Forbes,  Tweedie  &  Conolly,  vol  Hi.,  p.  391.  Rahley  DungU- 
son's  Edition.     Philadelphia,  H.  C.  Lea.  1867. 

17  E.  Klebs :  Op.  cit.,  p.  78  and  p.  153. 

M  Bosworth.  E.  Frankel,  Mackenzie,  and  others  quote  WiUigk.  I 
have  not  been  able  to  consult  original  work. 

••Jurasz:  Op.  cit,  p.  11. 

n  Mc Bride :  Internal.  Centralblatt  fur  Laryngologie,  iii,  p.  416. 

»»  O.  Chiari  :  Op.  cit,  p.  64. 


December  22,  1894] 


MEDICAL   RECORD. 


779 


**  A.  B.  Thrasher  (Cincinnati) :  Abstract  of  Paper,  Intel nat.  Cen- 
tralbl.  f&r  Laryngologie,  vol.  vl,  p.  54a 

*»  Prof.  Dr.  Moritz  Schmidt:  Die  Krankheiten  der Ohren  Luftwege, 
p.  164.    Julius  Springer.     Berlin,  1894. 

94  Dr.  Max  Bresgen :  Grundztlge  der  Path.  u.  Therapie  der  Nasen, 
etc.,  Krankheiten.    Urban  &  Schwarzenberg,  p.  112.    Wien,  1884. 

**  Kaposi :  Deutsche  Chirurcpe,  Lieferung,  ii    Syphilis,  p.  219. 

*•  Bosworth :  Treatise  quoted,  i. ,  p.  347. 

**  McBride :  Treatise  quoted,  p.  386. 

**  Jurasz  :  Treatise  cited. 

"  Joseph  Dietrich  (Elbing) :  Monatsschrift  fur  Ohrenheilkunde,  eta 
Bd.  24,  pp.  037-8. 

*•  Sir  J.  Hutchison's  Archives  of  Surgery,  vol  iii. ,  p.  43. 

«  Sir  M.  Mackenzie:  Diseases  of  the  Throat  and  Nose,  ii,  p.  478. 
P.  Blakiston  &  Son,  Philadelphia.     1884. 

49  Gelle,  reported  at  a  meeting  of  the  Societe  de  Laryngologie  de 
Paris.  Annates  des  Mai.  de  1  Oreille,  du  Larynx,  etc.  iS^i,  T. 
xvii.,  pp.  479-80. 

«3  Hajek:  Virchow's  Arch.,  Bd.  120. 

44  Dr  F.  Massei :  Pathologie  und  Therapie  des  Rachens,  der  Na- 
senhdhlen,  etc.  Ausgabe  von  Dr.  Emanuel  Fink,  Bd.  i.,  p.  134. 
Leipzig  (A.  Felix).     1802. 

4*  J.  Solis  Cohen,  M.D. :  Diseases  of  the  Throat  and  Nasal  Passages, 
p.  35i.     New  York,  William  Wood  &  Co.    1880. 

**  D.  Newman  :  Internationales  Centralblatt  fUr  Laryngologie,  etc., 
▼ii.,  p.  50a 

4T  J.  W.  Makenzie ;  Internationales  Centralblatt  fur  Laryngologie, 
i,  p.  10. 

*»  Max  Toeplitz,  M.D. :  Verhandlungen  des  X.  Internation.  Med. 
Congresses,  p.  25.     Berlin,  1892. 

49  Alex.  J.  R.  Foulerton  (England) :   London  Lancet,  August  17, 


pp. 


1889,  p.  314. 
*°  R.  Otto :  Internationales  Centralbl.  fUr  Laryngologie,  1892, 

"  Friedreich :  Virchow's  Handbuch  der  Spec.  Pathologie  u.  Thera- 
pie, etc.     "  Die  Krankheiten  der  Nasenhtihlen,"  p.  405. 

**  Prot  Dr.  C.  A.  Wunderlich,  etc. :  Handbuch  der  Pathologie  und 
Therapie,  Bd.  iii,  1st  Abtheil.,  p.  670. 

*»  Pro£  A.  Duchek :  Handbuch  der  Spec.  Path,  und  Therapie,  p.  451. 
Erlangen,  1864, 

"  D.  Bryson  Delavan ;  Elsberg's  Archives  of  Laryngology,  voL  iv., 

,J1Dr.  Th.  Harke:  Beitrage  zur  Path,  und  Therapie  der  Ohren 
Athmungswege,  etc.,  p.  64.     Bergmann,  Wiesbaden,  1895. 

**  Hajek  :  virchow's  Archiv.  vol.  xao. 

67  Weichselbaum :  Allgememe  Wiener  Med.  Zeitung,  1882,  the  arti- 
cle in  three  successive  numbers,  34,  35,  36. 

"  Voltolini :  Nasenkrankheiten,  p.  178.     Breslau,  1888. 

*•  Dr.  Joseph  Dietrich :  Monatsschrift  fur  Ohrenheilkunde,  etc.  Bd. 
atari  v.,  pp.  236-241. 

99  Prot  Dr.  E.  Zuckerkandl :  Normale  und  Pathologische  Anat  d. 
NasenhOhle,  etc.     Bd.  ii,  p.  62. 

41  Rosenfeld :  Internat  Centralbl  fur  Laryngologie,  Bd.  vi,  p.  370. 
1889-90.  * 

41  Made  during  a  discussion  of  Rosenfeld's  theory,  at  the  Heidel- 
berg meeting. 

«  W.  Freudenthal:  N.  Y.  Medizin.  Monatsschrift  Bd.  iii,  No.  5, 
1891,  pp.  185-190. 

•*  Sir  F.  Hutchison :  Med.  Times  and  Gazette,  July  5, 1884,  p.  7. 


HINTS  ON  THE  TREATMENT  OF  ECZEMA. 
By  MARTIN  F.  ENGMAN,  M.D., 

assistant  dermatologist  to  dbmu.t  dispensary ;  late  assistant  dr. 
dnna'i  klinhc,  Hamburg;  ex-house  surgeon  mew  york  skin  and  cancer 
hospital. 

In  giving  the  treatment  of  different  forms  of  eczema,  a 
classification  according  to  its  etiological  factors  and  a 
short  and  concise  description  of  the  different  forms  so 
classified,  will  assist  us  materially. 

Eczema  is  a  word  applied  to  a  class  of  skin  affections 
of  which  we  know  too  little.  The  definition  given  by 
most  of  our  standard  authorities  is,  that  it  is  a  catarrhal 
inflammation  of  the  skin  producing  a  multiformity  of 
lesions,  papules,  vesicles,  pustules,  etc. 

With  an  eczema  we  should  have  in  some  part  of  its 
course  a  discharge  of  some  character,  either  serous  or 
pustular.  The  term  is  one  that  has  been  and  is  too 
widely  used  to  express  conditions  which' do  not  fill  all 
that  the  definition  requires.  A  thorough  knowledge  of 
the  pathology  of  many  of  the  so-called  eczemas,  I  am 
sure  will  take  from  this  wide  cover- word  some  of  its  old- 
est occupants,  and  give  us  a  more  exact  and  practical 
knowledge. 

Eczemas  are  popularly  divided  into  acute  and  chronic, 
and  subdivided  into  papular,  vesicular,  or  pustular,  ac- 
cording to  their  clinical  and  objective  symptoms.  They 
are  also  named  from  their  location  and  manner  of  pro- 
gression. This  classification  gives  us  some  forty  differ- 
ent forms.  Of  course  such  terms  are  .very  well  for 
methods  of  description  and  give  us  an  exact  idea  of  the 
condition  and  its  appearance.  Yet  for  one  who  is  not 
familiar  with  all  of  these  technical  terms,  it  is  bewilder. 


ing  and  confusing ;  so  for  matter  of  convenience,  of  the 
moment,  I  will  give  below  a  simple  classification  accord- 
ing to  the  etiology,  and  try  to  give  in  a  few  words  a  de- 
scription of  the  different  forms. 

In  treating  an  eczema  or  any  pathological  condition 
of  the  skin,  one  must  not  forget  that  it  is  an  important 
and  active  organ  of  the  body ;  having  its  work  to  per- 
form, through  its  glands,  vessels,  and  nerves,  as  the  liver 
or  kidneys.  It  is  an  excretory  organ  of  the  greatest  im- 
portance. 

Again,  one  must  remember  that  it  is  subject  to  all  the 
external  influences,  heat  and  cold,  irritants  both  organic 
and  inorganic.  No  portion  is  free  from  organisms.  If 
scrapings  be  taken  from  any  part  of  its  large  surface  and 
examined,  cocci  and  bacilli  will  be  found  in  great  quan- 
tities. Therefore  in  treating  and  observing  the  condition 
and  course  of  an  eczema,  we  must  take  into  consideration 
all  of  these  influences.  Many  of  the  complicated  appear- 
ances of  an  eczema  are  produced  by  calling  into  active 
life  some  of  these  many  organisms,  as  the  catarrhal  in- 
flammatory condition  gives  them  soil  and  food  for  growth 
and  development,  while  some  internal  derangement  may 
be  at  the  same  time  producing  these  suitable  media. 
Again  the  eczema  may  be  alone  caused  by  the  organism 
or  organisms  having  been  brought  into  activity  or  con- 
tact with  the  skin  from  unknown  external  causes. 

We  will  divide  eczema  into  two  general  classes,  any 
form  may  of  course  be  acute  or  chronic,  according  to  the 
duration:  1.  Neurotic  eczema.  2.  Irritative  eczema; 
a,  caused  by  irritants  or  poisons  from  within  the  body 
(internal) ;  b>  caused  'by  irritants  or  poison  from  without 
the  body  (external). 

As  was  said  before,  to  conform  to  our  standard  defini- 
tion of  an  eczema,  one  should  have  a  catarrhal  inflamma- 
tion associated  with  papules,  vesicles,  or  pustules.  The 
so-called  trade  eczemas  are  from  traumatic  or  chemical 
influences  and  should  be  classed  with  the  dermatites. 

In  giving  the  above  division  we  do  not,  of  course,  in- 
clude all  the  varieties  in  an  exact  and  precise  manner,  but 
for  the  purpose,  as  to  hints  for  treatment,  it  will  suffice. 

1.  Neurotic  eczema  is  a  catarrhal  inflammation  of  the 
skin  produced  by  reflex  or  neurotic  causes.  It  is  sym- 
metrically distributed,  more  or  less  in  the  course  of  the 
nerves,  has  marked  exacerbations  and  remissions.  Oc- 
curs mostly  in  children,  but  affects  also  adults.  The  dis- 
ease is  typically  eczematous,  the  papules  forming  quickly 
into  vesicles,  which  easily  rupture  and  discharge  freely. 
The  crusts  are  very  thick  and  tough,  as  the  serum  seems 
to  quickly  dry,  covering  the  surface.  The  disease  occurs 
more  or  less  in  patches,  of  varying  size  from  that  of  an 
inch  in  diameter  to  the  covering  of  a  whole  limb.  The 
patches  are  rather  sharply  defined  with  vesicles  and  pap- 
ules at  the  periphery.  There  is  great  pruritus,  and  from 
inoculation  by  the  scratching  the  crust  soon  becomes 
very  black,  from  the  dirt  and  organisms.  If  the  crusts 
are  removed  a  weeping,  inflamed  surface  is  exposed,  but 
the  discharge  again  rapidly  crusts.  The  pus  organisms 
seem  to  find  favorable  soil  in  the  discharge,  as  one  often 
sees  punched-out  ulcerations  on  removing  the  crusts. 

It  may  be  located  anywhere  upon  the  body,  but  usually 
seeks  the  external  surfaces  of  the  extremities,  and  the 
head  and  face.  In  children  we  see  it  located  mostly  on 
the  face  or  head ;  occupying  the  cheeks,  chin,  but  leav- 
ing peculiarly  the  region  immediately  around  the  mouth 
perfectly  free.  There  is  a  very  little  thickening  of  the 
skin,  as  it  can  be  pinched  up  easily  if  the  thick  crusts  are 
thoroughly  removed.  I  think  here  the  crusting  and 
scaling  is  quicker  than  in  any  other  form  of  eczema.  We 
have  though  in  adults,  in  the  nervous  and  debilitated 
with  cold  and  clammy  hands  and  feet,  a  form  of  neurotic 
eczema,  whose  only  exhibition  is  a  few  transient  vesicles 
very  itchy  and  troublesome,  with  possibly  a  little  scaling. 

If  each  case  of  a  symmetrical  eczema  answering  to  the 
above  description  be  carefully  studied,  one  will  find  exac- 
erbations and  remissions  occurring  with  some  derange- 
ment of  the  health,  maybe  only  some  slight  thing,  but 
will  act  powerfully  refleily. 


78o 


MEDICAL   RECORD. 


[December  22,  1894 


I  have  seen  many  cases  where  the  eczema  will  clear  up 
on  the  cutting  of  a  tooth ;  when  another  is  forcing  itself 
through  the  gums  a  fresh  attack  will  occur.  In  children 
it  occurs  with  the  numerous  bowel  disorders,  diarrhoea 
or  constipation,  with  indigestion.  Cases  have  been  cured 
by  thorough  stripping  of  an  adherent  prepuce  or  circum- 
cision, the  adherent  prepuce  and  retained  smegma  caus- 
ing violent  reflex  irritation.  I  have  now  such  a  case 
under  observation,  which  has  entirely  recovered  after  cir- 
cumcision, without  any  local  treatment  whatever.  In 
women  we  have  the  disease  occurring  with  the  menstrual 
flow,  and  with  ovarian  troubles. 

It  is  of  course  often  very  difficult  to  find  the  cause  of 
the  reflex  irritation,  but  in  a  catarrhal  inflammation  of 
the  skin,  symmetrically  distributed  over  the  body,  with 
papulae  and  vesicles  which  quickly  discharge  and  crust 
we  should  look  for  a  cause  of  reflex  irritation,  which  may 
be  one  or  more  of  the  many  disorders  that  affect  the 
economy.  Such  should  be  looked  into  and  treated  as 
they  generally  are,  using  such  remedies  on  the  skin  as 
will  reduce  the  itching,  influence  the  vessels,  prevent 
crusting,  and  render  the  subjective  discomfort  of  the 
patient  more  endurable.  In  other  words,  use  sedative 
astringent  applications  as  in  any  acute  or  subacute  ec- 
zema. (Dr.  Dyer,  of  New  Orleans,  and  Dr.  Barham,  of 
Pittsburg,  have  written  some  interesting  papers  on  neu- 
rotic eczema ;  the  former  on  the  disease  in  children  and 
the  latter  in  adults.) 

2.  Irritative  eczema  is  a  catarrh  of  the  skin  produced 
by  poisonous  or  irritative  influences :  (a)  from  within  the 
body,  as  those  occurring  in  BrighYs  disease;  in  rheu- 
matism and  gout ;  in  cirrhosis  of  the  liver  and  other  he- 
patic diseases ;  in  ptomaine  poisoning  and  disturbances 
of  the  chylopoetic  system. 

(£).  From  without  (external),  which  are  parasitic  in 
origin. 

(a)  It  would  be  very  difficult,  moreover  dogmatic,  to 
draw  a  sharp  line  of  clinical  difference  between  the  first 
subdivision  of  irritative  eczema  and  that  of  the  neurotic 
type,  yet  I  think  there  are  certain  points  which  are  dis- 
tinctly different  and  assist  one  to  a  proper  etiological  di- 
agnosis. 

How  the  irritant  or  poison  acts  in  being  excreted,  I  am 
unable  to  say,  but  that  such  poisons  do  cause  eczema- 
tous  conditions  clinical  experience  teaches  every  day. 
The  skin  being  an  active  execretory  organ,  is  inflamed 
and  irritated  generally,  or  in  certain  parts  by  these  path- 
ological products. 

This  being  the  case  we,  of  course,  would  expect  to  find 
the  disease  occurring  at  points  of  active  secretion,  which  is 
generally  so,  but  I  believe  external  irritation,  mechanical 
or  chemical,  is  a  most  important  determining  factor; 
the  skin  being  in  such  a  condition  from  the  constant  ir- 
ritation of  these  poisons  that  the  slightest  violence  to  its 
texture  will  cause  an  outbreak  of  an  eczema.  In  many 
cases  we  find  it  occurring  on  the  instep  or  ankle,  from 
irritation  and  rubbing  of  the  shoe  where  ordinarily  such 
irritation  would  cause  no  disturbance  whatever.  Again, 
it  is  frequent  on  the  neck  from  the  collar  or  shirt.  In 
like  manner  in  any  situation  that  may  be  subject  to  irri- 
tation ;  the  scratch  of  a  pin  or  pride  of  the  nail  causing 
or  starting  an  outbreak,  which  may  slowly  extend  over 
the  whole  or  part  of  the  body,  the  action  of  the  delete- 
rious products  remaining  the  same. 

The  clinical  symptoms  of  an  eczema  so  produced  are 
not  widely  different  in  their  ensemble  from  one  of  the 
neurotic  type,  yet  there  are  some  characteristic  features 
which  point  to  its  proper  diagnosis. 

The  disease  may  occupy  any  portion  of  the  body ;  it 
is  indolent  in  character,  die  inflammation  starting  with 
mild  burning  and  itching,  gradually  increasing  in  inten- 
sity to  papulation,  vesiculation,  and  weeping.  The  out- 
break is  not  acute  and  violent,  covering  large  areas  at 
once,  as  in  the  neurotic  type.  The  patches  are  not 
sharply  defined  but  shade  off  into  the  apparently  healthy 
skin.  The  itching  is  of  moderate  intensity.  The  im- 
petiginous element  is  very  rare,  as  the  discharge  does  not 


seem  to  be  as  suitable  for  the  propagation  of  the  organ- 
isms as  in  the  neurotic,  in  which  we  find  thick,  dirty, 
pustular  crusts. 

Crusting  and  scaling  is  not  so  marked,  the  crusts 
being  thin  and  moist,  of  yellow  color  and  easily  detached, 
leaving  a  reddened  weeping  surface.  There  is  generally 
thickening  from  the  beginning,  which  increases  more 
rapidly  than  in  any  other  form  of  eczema.  The  inflam- 
matory changes  here  are  deeper  than  in  other  forms, 
and  there  is  a  greater  cell  diapedesis  and  infiltration. 
The  infiltration  gradually  shades  off  into  the  healthy 
skin,  and  can  always  be  readily  made  out ;  in  feet,  the 
whole  tendency  of  the  process  seems  to  be  toward  a  sub- 
acute or  chronic  type. 

The  principal  points  of  difference  between  this  and  a 
neurotic  eczema,  are :  (1)  The  location,  not  following  at 
all  the  course  of  the  nerve  distribution.  (2)  The  patches 
are  not  sharply  defined,  but  gradually  shade  off  into  the 
healthy  skin.  (3)  The  subjective  symptom  is  more  of  a 
burning  sensation  than  an  itching.  (4)  The  crusts  are 
yellow,  thin,  and  moist,  not  dry  and  thick.  (5)  The 
skin  is  found  to  be  infiltrated  after  removing  the  crusts. 
(6)  The  indolence  of  the  process.  (7)  It  is  found  most 
frequently  in  adults,  and  those  who  have  passed  middle  life. 

The  treatment  of  such  inflammatory  conditions  should 
be  both  internal  and  local. 

The  history  of  the  patient  should  be  carefully  inquired 
into  and  a  thorough  examination  made  of  the  general 
health.  The  urine  examined  for  albumin,  casts,  and 
sugar,  for  urates  and  uric  acid,  etc. ;  any  abnormal  con- 
stituents being  carefully  noted. 

In  old  drinkers  we  find  cirrhotic  changes  with  prob- 
ably albumin  in  small  quantities,  with  casts.  In  the 
rheumatic  and  gouty,  highly  acid  urine  with  full,  excited 
pulse ;  often  such  individuals  will  predict  a  crop  of  ec- 
zema by  the  color  of  their  urine,  noticing  it  to  be  highly 
colored  and  "  burning."  In  the  later  cases  of  Bright's 
disease,  where  little  urine  is  passed,  and  the  kidneys 
thoroughly  inactive,  we  often  see  very  severe  cases  of 
eczema.  I  remember  three  cases  of  Bright's  where  death 
occurred  after  a  violent  outbreak  of  eczema. 

It  would  be  useless  here  to  go  into  a  risumi  of  the 
treatment  of  gout,  rheumatism,  and  Bright's  disease,  for 
I  merely  wish  in  connection  with  this  form  of  catarrhal 
inflammation  of  the  skin,  to  point  out  the  importance  of 
careful  research  into  the  general  health  of  the  patient. 

(£)  The  second  subdivision  of  our  irritative  eczemas,  that 
is,  those  caused  by  the  effects  of  external  irritants,  is 
comparatively  a  new  field  in  dermatology,  and  one 
which  promises  much  for  the  future. 

With  this  class  are  included  the  parasitic  eczemas.  As 
was  said  before,  the  so-called  trade  eczemas  should  be 
classed  with  the  dermatites  and  not  here.  Although,  as 
in  many  other  diseases,  the  parasites  for  these  several 
conditions  have  not  been  isolated,  yet  there  are  suffi- 
cient clinical  reasons  for  treating  them  from  a  parasitic 
stand-point,  and  often  be  surprised  with  the  happy  and 
rapid  results. 

In  this  class  would  be  included  the  eczema  seborrhicum 
of  Unna,  who,  in  1887  read  a  paper  before  the  Congress 
of  Washington,  demonstrating  this  affection,  beyond  a 
doubt,  to  be  a  catarrhal  inflammation  of  the  skin,  prob- 
ably of  parasitic  origin,  and  showing  the  erroneous  ideas 
of  the  old  masters  in  relation  to  the  so  called  seborrhceas. 
From  further  study  and  research  Dr.  Unna  is  more  con- 
vinced of  the  correctness  of  his  observations  in  this  mat- 
ter, and  also  of  the  parasitic  origin  of  eczema  se- 
borrhicum, believing  his  Morrorcocci  to  be  the  specific 
cause,  as  he  finds  them  in  the  scales  and  horny  layer  of 
the  diseased  patches.  The  disease  begins  as  a  pityriasis  of 
the  scalp,  which  may  have  existed  for  years,  extends 
down  over  the  face,  neck,  or  it  may  invade  any  portion 
of  the  body,  but  a  pityriasis  or  "dandruff"  of  the  scalp 
will  always  be  found  accompanying  it.  The  eczematous 
patches  may  vary  from  a  small,  greasy,  scaly,  yellow  patch 
to  one  of  intense  weeping,  with  highly  marked  inflam- 
matory symptoms. 


December  22,  1894] 


MEDICAL    RECORD. 


781 


The  disease  is  generally  characterized  by  well- defined 
patches,  varying  in  size,  with  abrupt  borders.  The 
patch  is  covered  by  yellow,  greasy  scales,  which  are 
easily  detached.  It  spreads  peripherally,  clearing  up 
somewhat  in  the  centre;  therefore  one  or* more  patches 
may  coalesce,  forming  patches  of  various  shapes.  Its 
favorite  location  is  the  neck,  face,  back,  and  chest,  but 
may  occur  in  any  portion  of  the  body.  There  is  not 
much  itching  except  when  the  patient  is  overheated. 
The  disease  is  generally  superficial,  with  no  marked  thick- 
ening of  the  skin,  but  often  there  are  patches  of  infiltra- 
tion resembling  a  psoriasis  lesion. 

Another  type  of  parasitic  eczema  to  which  I  can  only 
here  briefly  refer,  is  a  form  that  was  first  pointed  out  to 
me  by  Dr.  George  T.  Elliot,  of  this  city.  Since  then  I 
have,  studied  the  condition  closely,  and  thoroughly  agree 
with  him  in  considering  it  of  undoubted  parasitic  origin 
and  differing  markedly  in  its  clinical  appearance  from 
the  eczema  seborrhicum  of  Unna. 

The  majority  of  cases  that  I  have  seen  occur  in  vari- 
cose conditions  of  the  legs,  and  an  eczema  here,  we  all 
know,  to  be  of  a  very  stubborn  and  persistent  character. 
These  cases,  which  have  existed  for  years  under  soothing 
applications,  internal  medication,  and  bandaging,  I  have 
seen  markedly  benefited  and  cured  by  active  parasitic 
remedies.  The  leg  is,  of  course,  subject  to  other  forms 
of  eczema,  but  I  have  found  the  parasitic  vastly  in  the 
majority,  from  the  non  resisting  powers  of  the  cells  of 
the  leg  in  those  past  middle  life.  Again,  it  is  very  fre- 
quent in  those  whose  hands  are  frequently  exposed  to 
water,  in  housewives,  working-girls,  barkeepers,  waiters, 
etc 

The  disease  occurs  as  an  undermining  of  the  epithelial 
layer,  a  splitting  or  peeling  up  of  the  epidermis,  with  few 
papules  or  vesicles  here  and  there,  all  enclosed  in  sharply 
defined  patches. 

The  intensity  of  the  process  and  the  objective  symp- 
toms depends,  of  course,  somewhat  on  the  activity  and 
amount  of  the  poison ;  on  the  location  and  on  the  pe- 
culiar idiosyncrasy  and  susceptibility  of  the  individual. 
Therefore  we  may  have  a  sharply  defined  patch  of  the 
disease,  with  only  slight  scaling  and  a  peripheral  under- 
mining and  splitting  up  of  the  epidermis,  to  an  intensely 
inflamed  one,  raised  slightly  above  the  surface,  deeply 
red,  with  hemorrhage  into  the  follicles,  and  the  charac- 
teristic progression  by  splitting  up  the  horny  layer  at 
the  borders. 

The  disease  though  as  usually  seen  consists  of  well- de- 
fined red  patches,  varying  in  size,  slightly  scaly,  dotted 
here  and  there  with  papules,  but  with  relatively  few  of 
the  latter.  The  borders  sharp,  and  if  closely  noticed 
the  horny  layer  will  be  found  to  be  loosened,  peeled 
up,  and  can  be  pulled  of£  in  large,  thin  laminae.  There 
is  very  little  itching  or  burning.  The  patches  spread 
peripherally,  several  may  coalesce,  but  there  is  generally 
only  one  or  two  in  a  locality,  the  disease  spreading  from 
these  over  a  leg  or  arm  in  a  more  or  less  serpiginous 
manner.  The  milder  cases  have  a  tendency  to  heal  in 
the  centre  leaving  a  slightly  yellow  pigmentation.  The 
whole  affection,  as  usually  seen,  is  very  dry  and  only 
slightly  scaly  unless  it  is  greatly  inflamed. 

The  favorite  location  is  the  hands  and  arms,  legs  and 
feet,  the  face,  as  these  portions  of  the  integument  are  more 
exposed  to  external  influences.  But  I  have  seen  the  disease 
generally  scattered  over  the  whole  person  in  small,  sharp- 
ly defined  red  patches.  It  can  readily  be  differentiated 
from  eczema  seborrhicum  by  i,  the  color  of  its  patches, 
which  is  decidedly  red,  while  that  of  eczema  seborrhi- 
cum is  yellow ;  2,  the  scales  here  are  dry,  and  not  yellow 
and  greasy ;  3,  the  characteristic  undermining  and  spik- 
ing up  of  the  epithelium  in  this  form,  which  you  do  not 
see  in  any  other  form  of  eczema.  It  mostly  resembles 
the  orbicular  eczema  of  the  text- books. 

The  disease  is  undoubtedly  a  parasitic  one  from  its 
clinical  manifestations,  and  is  readily  cured  by  proper 
parasitic  remedies. 

I  bring  these  few  points  forward,  not  to  stand  on  a 


high  pedestal  of  dogmatism  and  to  grandiloquently  wave 
each  case,  after  a  mere  glance,  to  its  proper  etiological 
division,  but  hoping  that  they  will  help  some  one  to  a 
more  definite  and  comprehensive  knowledge  of  the  sub- 
ject. 

131  East  Thisty  fourth  Stebbt. 


3£K00t»00  of  fpjeAicKl  jftcteuc*. 

The  Relation  of  Chololithiasii  to  Primary  Carcinoma 
of  the  Gail-Bladder.— According  to  Dr.  Ames  two  di 
rectly  opposite  views  are  held  respecting  the  relation  of 
gall-stone  formation  to  cancerous  growth  in  the  gall- 
bladder. According  to  such  men  as  Klebs,  Von  Schup- 
ple,  Murchison,  Durand  Fardel,  Krauss,  Zenker,  and 
others,  the  new  growth  may  be  directly  attributed  to  the 
prolonged  irritation  produced  by  gall-stones,  especially 
in  persons  predisposed  to  cancer.  Zenker  holds  that  an 
adenoma  develops  by  irritation,  and  that  it  changes  into 
an  adeno  -  carcinoma,  which  is  the  primary  atypical 
growth.  On  the  other  hand,  Lutton,  Lancereaux,  Lang- 
Heiniich,  Fdrster  and  others  hold  that  the  presence  of 
the  neoplasm  favors  the  formation  of  calculi,  and  is  the 
cause,  not  the  result,  of  gall-stone  formation.  It  is  a 
well-recognized  fact  that  biliary  concretions  are  found  in 
a  very  large  percentage  of  cases  of  carcinoma  of  the  gall- 
bladder. In  Courvoisier's  list,  the  percentage  in  which 
stones  were  actually  found  was  91  per  cent.  There  is 
good  reason  to  believe,  however,  that  these  figures  should 
be  larger,  as  in  a  number  of  cases  in  which  calculi  were 
not  found  there  were  such  evidences  as  scars  and  strict- 
ures of  the  ducts  to  show  the  former  existence  of  chololi- 
thiasis.  In  Musser's  cases  the  percentage  was  92  per 
cent.,  while  in  those  that  I  have  collected  stones  were 
found  in  30,  were  noted  as  absent  in  1,  and  were  not 
mentioned  one  way  or  the  other  in  7,  making  the  per- 
centage of  cases  with,  to  those  without,  concretions,  95.4 
per  cent.  These  figures  are  too  great  to  allow  us  for  an 
instant  to  suppose  that  the  association  of  these  two  con- 
ditions is  merely  accidental.  The  most  important  point 
to  be  settled,  and  the  one  which  it  seems  would  be  con- 
clusive, is  whether  the  formation  of  gall  stones  precedes 
or  follows  the  cancerous  degeneration.  Evidence  in 
favor  of  die  former  view  is  plentiful,  while  that  to  support 
the  latter  is  very  meagre,  though  there  are  a  number  of 
theoretical  considerations  used  as  arguments  that  it  will 
lead  us  too  far  to  discuss  here.  I  have  been  able  to  find 
but  one  case,  i.e.,  that  of  Ord,  cited  by  Musser,  in  which 
a  calculus  existed  which  was  definitely  proved  to  be  post- 
cancerous  in  its  formation,  and  this  stone  was  not  a  cho- 
lesterin  formation,  but  consisted  of  phosphate  and  car- 
bonate of  lime  with  altered  mucus.  On  the  other  hand, 
there  are  numerous  observations  that  go  to  prove  the  ex- 
istence of  stones  prior  to  the  carcinomatous  growth.  In 
one  of  Zenker's  cases,  for  example,  fragments  of  calculi 
were  found,  and  in  the  first  case  I  have  reported  this 
evening  the  calculi  were  much  disintegrated,  which 
would  seem  to  point  to  a  degeneration,  not  to  a  forma- 
tion of  gall-stones.  This  fact,  in  connection  with  the 
long-standing  history  of  biliary  colic,  is  conclusive,  and 
would  lead  us  to  believe  that  in  all  cases  when  there  has 
been  a  previous  history  of  biliary  colic,  and  when  no 
stones  are  found  at  autopsy,  they  have  existed,  but  have 
undergone  some  such  disintegration  before  the  death  of 
the  patient 

Again,  in  one  of  the  cases  reported  by  Klobe  an  old 
stone  was  found  with  commencing  cancer  of  the  neck  of 
the  bladder.  Klobe  states  it  as  his  belief  that  the  small 
size  of  the  gall- bladder  in  many  cases  of  cancer  would  be 
against  the  formation  of  calculi,  while  Zenker  holds  that 
the  growth  in  the  bladder  and  ducts  would  tend  to  pre- 
vent the  bile  entering  the  bladder,  and  so  prevent  the 
formation  of  stones.  Quetsch  reported  a  case  in  which 
stones  had  been  passed  by  a  biliary  cutaneous  fistula  for 


782 


MEDICAL  RECORD. 


[December  22,  1894 


three  years  prior  to  any  signs  of  cancer;  and  cases  are 
reported  in  which  stones  were  found  although  the  cystic 
duct  was  occluded ;  they  have  also  been  found  buried  in 
the  mass  of  the  neoplasm.  From  all  these  facts  it  would 
seem  that  if  we  are  justified  in  ascribing  a  causative  in- 
fluence to  local  irritation  in  case  of  cancer  in  other  situ- 
ations, we  should  look  upon  gall  stones  as  exerting  the 
same  influence  in  these  cases.  Finally,  in  closing,  we 
may  briefly  summarize  the  most  important  points,  follow- 
ing closely  the  conclusions  reached  by  Dr.  Musser,  as 
follows:  1.  Primary  carcinoma  of  the  gall-bladder  is 
much  less  uncommon  than  was  formerly  believed.  2.  It 
occurs  most  frequently  in  women,  the  ratio  being  3-5  :  1. 
3.  It  is  a  disease  more  particularly  of  the  middle  decade 
of  life.  4.  Gallstones  are  found  in  from  91-95  per 
cent,  of  the  cases,  and  probably  bear  a  causative  relation 
to  the  disease.  5.  Metastasis  is  not  extensive ;  invasion 
of  neighboring  organs  by  continuity  common.  6.  Ad- 
hesions to  adjacent  organs  frequently  occur.  Ulceration 
and  perforation  are  more  rare.  7.  Pain,  jaundice, 
cachexia,  emaciation,  tumor,  indigestion,  nausea,  vomit- 
ing, constipation,  or  diarrhoea,  with  occasional  ascites 
and  oedema,  are  the  chief  symptoms.  8.  Pain  occurs  in 
62  per  cent.  (Musser).  9.  Jaundice  occurs  in  69  per 
cent  (Musser.)  10.  Tumor  occurs  in  68  per  cent. 
([Musser).  11.  The  disease  is  always  fatal,  and  usually 
in  a  short  time,  the  average  duration  varying  according 
to  the  best  authorities  from  3  to  6^3  months.  12.  Death 
is  due  to  exhaustion,  peritonitis,  metastasis  to  other  or- 
gans, and  to  biliary  obstruction.— -Johns  Hopkins  Hospi- 
tal Bulletin. 

Intracranial  Aneurism.— The  subject  of  intracranial 
aneurism  was  discussed  by  Dr.  Bradford,  who  presented 
the  history  of  a  case,  and  by  Dr.  White,  who  related  the 
history  of  two  cases  in  young  subjects  unaffected  with 
syphilis  or  malignant  endocarditis.  Dr.  Bradford's  pa- 
tient had  slowly  developing  symptoms  such  as  vertigo, 
noises  in  the  head,  and  later,  occipital  headache  and 
stiffness  of  the  neck.  A  severe  attack  of  vomiting  was 
followed  by  intermittent  pulse  and  retention  of  urine ; 
later  in  the  same  day  he  became  comatose,  with  irregular 
breathing,  and  death  quickly  followed  without  the  occur- 
rence of  convulsions,  or  pupillary  changes.  The  autopsy 
revealed  a  ruptured  aneurism  of  the  basilar  artery. 

In  the  cases  reported  by  Dr.  White  the  symptoms  set 
in  suddenly.  The  first  patient  fell  off  her  chair  while  at 
dinner  and  became  insensible.  After  regaining  con- 
sciousness  she  had  headache,  vomiting,  bradycardia,  and 
a  few  days  later  retraction  of  the  head  and  pain  down 
the  spine.  A  week  later  complete  paralysis  of  the  left 
third  nerve.  Then  a  week  after  this,  a  fit,  and  two  days 
afterward  she  suddenly  became  worse  and  died  in  ten 
minutes.  There  was  an  aneurism  of  the  left  internal 
cirotid  near  its  termination.  There  was  a  large  amount 
of  clot  on  the  under  surface  of  the  brain ;  it  extended  to 
the  fourth  ventricle,  and  was  one-eighth  of  an  inch  thick 
all  down  the  spinal  canal  in  the  subarachnoid  space. 

The  second  case  was  a  man,  who  had  no  symptoms  ex- 
cept slight  frontal  headache,  until  he  fell  down  uncon- 
scious. Then  the  pupils  became  dilated  and  immobile, 
right  external  strabismus,  and  occasional  spasm  of  ex- 
tremities. On  the  outer  side  of  the  optic  disk  was  a  large 
subretinal  swelling.  The  drawn-off  urine  contained  sugar. 
Death  followed  rapidly  after  the  development  of  symp- 
toms. There  was  found  on  post-mortem  examination,  a 
small  ruptured  aneurism  of  the  right  internal  carotid  ar- 
tery. 

The  Treatment  of  Typhoid  Fever. —Of  all  the  branches 
of  the  medical  sciences  it  is  hygiene  upon  which  we  have 
to  look  as  the  most  promising  study  and  the  branch  of 
medicine  to  which  belongs  the  future ;  for,  notwithstand- 
ing the  great  progress  that  has  been  made  within  the  last 
few  decades  in  the  etiology  of  diseases,  the  treatment  in 
many  instances  is  not  much  further  advanced  than  it  was 
several  decades  ago.  We  still  have  to  rely  more  upon 
scientific  nursing  than  upon  the  healing  powers  of  drugs, 


and  in  many  instances  the  patients  will  do  better  without 
any  medication  whatever,  excepting,  perhaps,  when  it  is 
used  for  the  psychical  effect  upon  the  patient.  The  rules 
laid  down  by  Sir  William  Gull  could  not  be  improved 
upon  at  the  present  day.  Gull's  views  with  regard  to 
the  treatment  of  typhoid  fever  were  as  follows  :  1.  Ty- 
phoid fever  is  a  disease  which  runs  a  more  or  less  definite 
course.  It  cannot  be  stopped  or  cured  by  medicines. 
2.  The  chief  thing  to  be  done  at  the  outset  ot  an  attack 
is  to  send  the  patient  to  bed,  so  as  to  save  strength 
from  the  beginning.  3.  No  strong  purgative  medicines 
are  desirable.  4.  As  the  fever  develops  and  the  strength 
grows  less,  light  food  should  be  given  at  short  intervals 
— i.e.,  water,  toast- water,  barley-water,  milk  and  water, 
light  broths  (not  made  too  strong  or  too  gelatinous).  5. 
If  there  be  restlessness  or  much  agitation  of  the  nerves, 
wine  (port,  sherry,  or  claret)  or  brandy  in  moderate  doses 
as  short  intervals.  This  must  be  directed  medically,  but 
in  general  it  may  be  said  that  the  amount  required  is  that 
which  induces  repose  and  sleep.  6.  The  bowels  may  be 
left  to  themselves.  Ii  unmoved  for  twenty-four  or  thirty- 
six  hours  a  lavement  of  warm  water  may  be  necessary, 
but  this  will  be  directed  medically.  7.  The  restlessness 
or  wakefulness  in  fever  is  best  remedied  by  the  careful 
giving  of  wine  or  spirit  with  the  food,  or  in  hot  water. 
Sedatives  such  as  opium  are  inadmissible — mostly  in- 
jurious. 8.  The  bedroom  to  be  kept  at  a  temperature 
of  620  to  650  F.  9.  Great  care  is  necessary  to  keep  the 
bed  clean  and  sweet.  This  is  most  easily  done  by  hav- 
ing a  second  bed  in  the  room,  to  which  the  patient  can 
be  removed  for  two  or  three  hours  daily,  while  the  other 
is  thoroughly  aired  and  the  linen  changed.  10.  All 
fatigue  to  be  sedulously  avoided.  No  visitors  admitted, 
and  no  other  person  but  a  nurse  and  one  attendant  to 
help  her.  1 1 .  Patient's  room  never  to  be  left  unattended 
for  a  moment,  as  in  the  delirium  of  fever  patient  may 
jump  from  the  bed  and  injure  himself.  12.  As  to  medi- 
cines and  the  treatment  of  complications,  the  immediate 
medical  attendant  must  be  responsible.  13.  As  it  is  pos- 
sible that  the  discharges  from  the  bowels  in  typhoid 
fever  may  be  a  source  of  contagion,  it  is  desirable  that 
before  being  thrown  down  the  closet  they  should  be 
largely  mixed  with  Condy's  fluid  or  some  other  disin- 
fectant. On  the  same  principle  the  strictest  cleanliness 
must  be  observed  in  the  sick-room.  14.  There  is  no 
reason  to  believe  that  typhoid  fever  is  contagious  from 
person  to  person,  in  the  ordinary  way.  The  largest 
experience  shows  that  it  does  not  extend,  like  an  ordi- 
nary contagious  disease,  to  nurses  or  others  attending 
upon  patients  suffering  under  the  disease. — Medical  He- 
view. 

Jejunoitomy. — According  to  Dr.  Hahn  the  fistula 
must  be  made  high  up  in  the  small  intestine,  otherwise 
death  will  occur  from  inanition.  The  author  refers  to 
the  recorded  cases  of  jejunostomy,  especially  by  Maydl. 
He  thinks  that  the  making  of  a  fistula  in  the  duodenum, 
as  has  been  proposed,  is  undesirable,  owing  to  the  diffi- 
culty in  the  operation  and  to  the  impossibility  of  the  pa- 
tient feeding  himself.  Dr.  Hahn  gives  details  of  five 
cases  in  which  he  has  performed  jejunostomy.  Case  I. — 
A  man,  aged  sixty- nine,  suffering  from  gastric  carcinoma, 
recovered  from  the  operation,  but  died  a  fortnight  later 
with  increasing  weakness.  Case  II. — A  patient  with 
oesophageal  carcinoma  improved  after  the  operation. 
Nine  weeks  later  the  fistula  closed,  and  the  feeding  took 
place  exclusively  by  the  mouth.  Case  III. — A  man,  also 
with  malignant  disease  of  the  oesophagus,  died  four  days 
after  the  operation  of  increasing  inanition.  Case  IV. — 
A  girl,  aged  nineteen,  attempted  suicide  by  means  of 
strong  acid.  Nearly  two  months  later  only  a  fine  oeso- 
phageal bougie  could  be  passed.  As  the  sounding  was 
followed  by  some  bleeding,  jejunostomy  was  performed. 
She  made  a  good  recovery.  The  fistula  closed  about  a 
month  after  the  operation.  She  was  in  good  condition 
some  three  years  later.  Case  V. — A  girl,  aged  twenty- 
three,  also  drank  sulphuric  acid.    About  three  weeks 


December  22,  1894] 


MEDICAL  RECORD. 


783 


later  an  obstruction  was  found  about  thirty  centimetres 
from  the  mouth.  There  was  great  wasting.  Jejunos- 
tomy  was  done  a  fortnight  later,  but  the  patient  died 
some  eight  days  afterward.  The  indications  for  the 
operation  are,  according  to  Dr.  Halm,  the  following : 
1,  Corrosion  of  the  stomach  and  oesophagus  when  a  fatal 
result  is  to  be  feared,  as  in  the  above  cases;  2,  car- 
cinoma involving  the  cardia  and  lower  end  of  the 
oesophagus  when  gastrostomy  is  impossible ;  and  3,  car- 
cinoma of  the  pylorus  where  no  other  operation  is  possi- 
ble. The  incision  should  not  be  too  small,  so  that  the 
commencement  of  the  jejunum  may  easily  be  found.  If 
the  nutrition  of  the  patient  permit  of  it,  the  intestine 
need  not  be  opened  for  several  days,  otherwise  this  must 
be  done  at  once  or  after  twenty- four  hours. — Deutsche 
Medicinische  Wochenschrift. 

Diphtheritic  Conjunctivitis. — In  the  Gazette  des  Hdpi- 
taux,  April  24, 1894,  the  subject  of  diphtheritic  conjunc- 
tivitis is  treated  at  some  length  by  Gilbert  Sourdille,  who 
defines  diphtheritic  ophthalmia  as  the  infection  of  the 
conjunctiva  by  the  Klebs  Loftier  bacillus.  There  are  two 
distinct  kinds  of  pseudo-membranous  conjunctivitis :  the 
croupous  form,  characterized  by  a  thin,  elastic,  shin- 
ing, opaline  false  membrane,  leaving  on  removal  an 
almost  normal  mucous  surface;  and  the  true  diphthe- 
ritic form,  a  profound  interstitial  infiltration,  making 
the  conjunctiva  look  like  bacon  rind,  thick,  blood- shot, 
dirty-yellow,  and  dotted  with  ecchymotic  spots.  Unlike 
the  croupous  form,  there  is  no  detachable  membrane. 
The  first  condition  is  benign;  the  second  of  special 
gravity,  owing  to  constitutional  states,  to  climatic  influ- 
ences, to  various  chemical  and  physical  agents.  Accord- 
ing to  Mackenzie  the  nature  of  diphtheritic  conjunctivitis 
lies  in  some  inherent  disposition  of  the  mucous  surface 
itself.  A  question  arises,  as  to  whether  these  two  condi- 
tions are  not  different  degrees  of  the  same  morbid  state ; 
clinically,  the  croupous  variety  appears  to  be  the  superfi- 
cial form  of  the  same  disease,  of  which  the  second  is  in- 
interstitial  or  diphtheritic  (Venneman,  Gerke,  Kam, 
Uhthoff,  Moritz).  If  these  are  really  distinct  entities, 
then  diphtheritic  conjunctivitis  may  be  said  to  be  very 
rare ;  but  if  the  so-called  croupous  condition  enters  into 
the  group  of  affections  due  to  the  presence  of  the  Loftier 
bacillus,  the  disease  is  at  once  recognized  as  relatively 
common. 

Diphtheritic  conjunctivitis  may  be  the  first  point  of 
localization  of  this  special  bacillus,  and  is  then  a  primary 
disorder ;  or  it  may  be  an  extension  of  the  diphtheritic 
process  elsewhere,  and  is  then  secondary.  It  is  usually 
a  primary  affection,  seldom  occurring  with  the  ordinary 
diphtheritic  angina,  about  once  in  two  hundred  cases. 
It  occurs  most  frequently  in  cold,  damp  countries,  as 
Germany  is,  especially  in  the  city  of  Berlin.  In  Paris, 
it  appears  with  relative  frequency,  and  at  Nantes  some 
condition  favors  its  appearance  still  oftener.  Both  sexes 
are  equally  afflicted,  from  two  to  eight  years  of  age  being 
the  period  of  predilection.  It  is  also  seen  in  adults  and 
in  the  new- bom.  Previous  conditions  of  health  are  im- 
portant factors  in  its  production.  Infectious  diseases, 
especially  measles  and  whooping-cough,  are  among  the 
general  causes.  Much  of  the  purulent  ophthalmia  of  in- 
fants is  in  reality  diphtheritic  conjunctivitis.  Diphtheria 
of  the  ordinary  form  is  comparatively  rare  in  nurslings, 
but  in  the  eye  the  disease  manifests  itself  among  them 
with  greater  frequency  than  is  usually  supposed. 

In  the  superficial  or  croupous  form  of  the  disease,  a 
trifling  catarrh  first  appears,  with  sensitiveness  of  the 
eyes  to  wind,  artificial  light,  weeping,  a  sensation  of 
sand  in  the  eye,  etc.  Then  the  discharge  becomes 
muco-purulent,  gluing  the  eyelids  together  after  sleep. 
Careful  examination  shows  this  discharge  to  be  more 
fibrinous,  more  coagulable,  than  that  of  ordinary  ca- 
tarrh. The  conjunctiva  is  red,  vascular,  sometimes 
ecchymotic.  That  inside  the  eyelids  is  even  redder,  in- 
jected, and  oedematous.  This  state  lasts  from  twenty  to 
thirty-six  hours.    Then  the  epithelium  of  the  palpebral 


conjunctiva  undergoes  a  rapid  change.  It  takes  on  a 
brilliant  varnished  appearance.  A  fine  layer  of  trans- 
parent mucilage  seems  spread  over  it.  This  is  the  be- 
ginning of  the  false  membrane.  The  eyelids  are  more 
or  less  oedematous,  the  ciliary  border  takes  on  a  violet 
tinge,  and  the  secretion  is  citrine  in  color.  As  in  the 
insterstitial  form,  the  false  membrane  is  confined  almost 
always  to  the  mucous  surface  of  the  lid.  If  the  conjunc- 
tiva of  the  globe  is  involved,  it  is  by  extension,  and 
never  primarily.  The  false  membrane  is  thin,  elastic, 
and  adherent.  It  can  be  rubbed  off  with  a  piece  of 
linen  or  removed  by  forceps.  Sometimes  the  membrane 
is  shed  in  bits ;  sometimes  in  unbroken  form,  giving  a 
perfect  cast  of  the  parts  involved.  Underneath,  the 
membrane  is  supple,  congested,  bleeding  on  the  slight- 
est friction,  without  apparent  fibrinous  infiltration.  Yel- 
lowish spots,  here  and  there,  that  bleed  less  easily  than 
the  rest  of  the  surface,  suggest  the  beginnings  of  such  in- 
filtration. This  period  of  the  disease  lasts  from  three  to 
ten  days.  Then  begins  the  purulent  or  third  period, 
characterized  by  purulent  discharge,  decrease  of  pain 
that  has  been  pretty  severe,  and  a  reddened  granular 
condition  of  the  palpebral  conjunctiva,  now  denuded  of 
the  false  membrane.  Too  energetic  treatment  will  now 
bring  back  the  false  membrane  and  cause  it  to  persist 
with  more  or  less  obstinacy.  Suppuration  diminishes 
rapidly,  and  the  disease  is  ended  in  about  two  weeks, 
leaving  no  scars.  During  its  entire  course  there  is 
scarcely  any  fever,  some  slight  emaciation,  and  a  certain 
uneasiness.  In  spite  of  this  apparent  benignity,  serious 
complications  may  arise  at  any  moment,  especially  mor- 
bid conditions  of  the  cornea. 

In  the  interstitial  form  of  diphtheritic  ophthalmia,  the 
onset  is  variable.  Sometimes  it  begins  by  the  super- 
ficial or  croupous  form  just  described,  differing  only  by 
the  shortness  of  duration  of  these  three  stages,  that  may 
follow  each  other  so  rapidly  as  to  escape  observation. 
Then,  again,  it  appears  suddenly  as  a  full  fledged  infil- 
tration from  the  start.  The  eyelids  are  swollen,  oedema- 
tous, overhanging,  purplish,  and  the  seat  of  an  acrid 
burning.  The  surface  thermometer  may  show  one  and  a 
half  degree  of  abnormal  heat.  The  lids  are  often  one 
centimetre  in  thickness  and  of  cartilaginous  hardness. 
The  discharge  is  not  abundant.  It  is  citrine  in 
color,  dull,  flecked  with  opaline  debris,  with  a  fetid 
sanguinary  odor.  The  inside  of  the  lid  is  thickened, 
smooth,  yellowish-gray,  ecchymotic,  exactly  like  a  bit  of 
ham  rind.  It  is  perfectly  bloodless ;  and  cross-rubbing 
and  scarification  fail  to  draw  one  drop  of  blood.  The 
fibrinous  exudation  pervades  the  entire  conjunctiva,  im- 
plicating the  blood-vessels.  In  certain  cases  this  infil- 
tration is  disseminated,  appearing  in  localized  patches 
surrounded  by  a  reddened  and  vascular  mucous  mem- 
brane. The  bulbar  conjunctiva  is  at  first  slightly  in- 
jected. Then  it  is  secondarily  invaded,  though  the  false 
membrane  never  equals  in  thickness  that  on  the  palpebral 
surface.  Symptoms  increase  in  severity.  There  is  con- 
siderable fever,  loss  of  appetite,  insomnia,  emaciation, 
and  albumin  in  the  urine.  This  stage  lasts  a  week, 
during  which  the  condition  is  one  of  uniform  severity  or 
of  aggravated  symptoms.  If  there  is  perforation  of  the 
cornea,  as  often  happens,  the  situation  is  pitiable  in  the 
extreme.  The  eye,  seen  as  at  the  bottom  of  a  deep 
sewer,  moves  in  a  mass  of  bloody  corruption.  By  de- 
grees things  improve,  the  swelling  diminishes,  the  dis- 
charge changes  in  character  and  is  less  profuse,  the 
patches  disappear,  and  the  patient  generally  recoveis  if 
no  secondary  infection  occurs. 


Professor  E.  Klebi,  formerly  of  Carlsruhe  and  now  of 
Strassburg,  claims  to  have  obtained  most  satisfactory  re- 
suits  from  the  use  of  his  antiphthisin  in  the  treatment  of 
tuberculosis.  The  antitoxin  has  also  been  tried  to  some 
extent  in  America,  those  who  have  used  it  speaking  most 
enthusiastically  of  its  action.  Professor  Klebs  is  now  in 
this  country. 


784 


MEDICAL   RECORD. 


[December  22,  1894 


Medical  Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


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


New  York,  December  22,  1894. 


THE   REDUCTION  IN  THE   MEDICAL   CORPS 

OF  THE  ARMY. 
The  American  Congress  is  often  foolish  in  its  extrava- 
gances, but  it  never  betrays  a  greater  imbecility  than  in 
some  of  its  attempts  at  economy.  One  of  the  most  short- 
sighted and  unnecessary  of  these  penny-wise  efforts  was 
the  reduction  in  the  army  medical  staff,  passed  last  win- 
ter, whereby  the  country  is  saved  $30,000  a  year,  and 
the  efficiency  of  the  medical  department  is  seriously 
threatened.  In  the  annual  report  of  the  Surgeon  General 
just  issued  this  subject  naturally  receives  some  attention. 
The  members  of  the  Committee  on  Military  Affairs  of  the 
House  of  Representatives,  upon  whose  recommendation 
this  measure  was  adopted,  had  better  have  given  no  rea- 
son for  their  action  than  to  put  forth  what  they  did. 
One  of  their  arguments  was  that  there  were  210  military 
posts  in  the  country  in  1 8  70,  and  but  1 20  in  1894;  "if  193 
officers  in  this  department  were  sufficient  when  the  num- 
ber of  posts  and  stations  was  210,  there  can  be  as  great  a 
reduction  as  is  proposed  in  this  bill  when  the  number  of 
posts  and  stations  is  reduced  to  120." 

The  fallacy  of  this  is  shown  by  the  fact  that  there  were 
then  184  acting  assistant-surgeons  in  addition  to  the 
regular  staff,  while  now  there  are  none.  The  committee 
suggested  that,  if  there  were  not  enough  army  surgeons 
to  attend  to  all  the  garrisons,  private  physicians  living  in 
the  neighborhood  could  be  called  in  and  paid  by  the 
visit.  In  reply  to  this  the  Surgeon-General  shows  that 
the  expense  to  the  Government  in  paying  for  medical 
attendance  by  the  visit  would  in  most  posts  be  greater 
than  the  pay  of  an  assistant-surgeon. 

"  Moreover,  a  post  medical  officer  has  various  and  im- 
portant duties  to  perform  in  addition  to  caring  for  the 
sick.  In  fact,  his  presence  as  a  member  of  the  garrison 
is  more  important  than  that  of  any  other  officer,  for  no 
other  officer  can  perform  his  duties,  whereas  any  line 
officer  present  can  perform  the  duties  of  quartermaster, 
commissary  of  subsistence,  adjutant,  or  commanding  offi- 
cer of  a  garrison." 

But  it  is  mainly  as  injuriously  affecting  the  efficiency 
of  the  medical  department  in  case  of  war  or  active  service, 
that  the  parsimony  of  Congress  is  to  be  deplored.  The 
Surgeon-General  very  justly  says  that  the  weakness  of  a 
Medical  Department,  consisting  in  part  of  medical  men 
attending  and  paid  by  the  visit,  would  be  mainly  felt  when 
troops  were  ordered  out  for  active  service.  The  principal 
reason  for  supporting  an  army  in  time  of  peace  is  that  an 
efficient  organization  may  be  maintained  which  will  be 


ready  for  service  in  any  emergency,  and  serve  as  a  nucleus 
for  the  larger  army  which  will  be  required  in  case  of  war. 
This  applies  to  the  Medical  Department  as  well  as  to  the 
fighting  force.  The  duty  of  our  medical  officers  is  not 
only  to  attend  to  the  sick  at  their  stations,  acting  at  the 
same  time  as  health  officers  for  their  command,  but  to  be 
prepared,  and  to  prepare  their  Hospital  Corps  detach- 
ments, for  any  emergency,  and  especially  for  field  service. 
The  call  to  service  in  the  field  is  more  common  in  our 
army  than  is  generally  supposed.  During  the  year  1893 
the  number  of  medical  officers  who  were  out  with  the 
various  detachments  which  constituted  the  average  field 
strength  was  69.  The  largest  number  of  medical  officers 
out  in  one  month  was  23,  in  September,  with  detach- 
ments aggregating  2,954  men,  and  giving  an  average 
strength  for  the  month  of  1,663  men.  It  is  for  such  field 
service  that  the  need  of  the  junior  officers  of  the  Medical 
Department  is  chiefly  felt.  In  1892,  76  medical  officers 
were  on  field  service,  the  average  number  of  men  thus 
serving  having  been  1,010.  In  1891,  93  medical  men 
were  out  with  various  detachments  of  troops  having  an 
average  strength  of  899  men,  and  in  1890,  143  medical 
officers  with  an  average  strength  of  1,210  men.  If  at- 
tendance on  the  sick  at  military  posts  be  made  the  gauge 
of  the  strength  of  the  Medical  Department,  no  provision 
of  medical  officers  can  be  made  for  troops  on  active  ser- 
vice unless  certain  posts  be  deprived  of  their  medical 
officers* 

"It  must  be  remembered  also, that  medical  officers  are 
as  liable  as  other  officers  to  break  down  under  the  ex- 
posures and  accidents  of  field  service,  or  from  other 
causes.  During  the  past  three  years  a  little  over  five  per 
cent,  of  them  have  been  constantly  non-effective  from 
sickness,  or  10  officers  out  of  the  192  allowed  by  law 
up  to  the  time  of  the  passage  of  the  current  appro- 
priation bill.  Again,  these  officers  are  as  much  en- 
titled as  other  officers  to  leaves  of  absence ;  but  inas- 
much as  the  Regulations  of  the  Army  prescribe  that 
leaves  will  not  be  granted  'so  that  a  post  will  be  left 
without  competent  medical  attendance,'  many  of  the 
medical  officers  have  to  do,  year  after  year,  without  leaves 
such  as  are  enjoyed  by  others.  During  the  past  ten  years 
the  leaves  of  absence  granted  to  medical  officers  were 
equivalent  to  an  average  leave  annually  of  a  little  less 
than  fourteen  days  for  each.  To  enable  the  Department 
to  permit  its  officers  to  have  one  month's  leave  annually, 
and  at  the  same  time  provide  competent  medical  attend- 
ance at  post,  a  strength  of  8.3  per  cent  is  needful  over 
and  above  that  necessary  to  man  the  post." 

"In  view  Of  these  considerations,"  Dr.  Sternberg 
concludes,  "  I  regard  with  regret  the  policy  which  has 
cut  off  fifteen  officers  from  the  Department." 

The  regret  will  be  shared  by  all  who  have  been  ac- 
customed to  point  with  pride  to  the  efficiency  of  our 
army  medical  service. 


The  Sew  York  Orthopedic  Dispensary  and  Hos- 
pital has  received  from  Mrs.  Richard  T.  Auchmuty, 
$  1 0,000,  to  endow  two  free  beds  in  perpetuity,  in  mem- 
ory of  her  husband;  from  Mr.  James  H.  Jones,  $5,000, 
to  endow  a  free  bed  in  perpetuity;  from  "a  friend  " 
$4,000,  to  build  a  modern  operating  room;  and  from 
two  of  the  trustees,  $500,  to  furnish  and  equip  the  same. 


December  22,  1894] 


MEDICAL   RECORD. 


785 


TYPHOID  FEVER  IN   THE  DISTRICT  OF  CO- 
LUMBIA. 

The  city  of  Washington  has  long  had  the  unenviable  rep- 
utation of  being  one  of  the  cities  most  visited  by  typhoid 
of  any  in  the  country.  The  Medical  Society  of  the  Dis- 
trict of  Columbia  recently  appointed  a  committee  to  in- 
vestigate the  causes  for  the  prevalence  of  the  disease  there, 
and  to  suggest  measures  adapted  to  its  suppression.  In 
the  search  for  these  causes  the  committee  investigated  es- 
pecially the  water-supply,  the  drainage,  and  the  milk-sup- 
ply. The  water-supply  of  the  District  is  derived  from  the 
Potomac  River  and  from  wells.  The  water  derived  from 
the  first  source  is  comparatively  good,  as  the  river  flows 
for  the  most  part  through  a  mountainous  country,  and 
there  are  no  large  cities  on  its  banks  above  Washington. 
The  water  of  the  wells,  however,  is  almost  uniformly  bad, 
sewage  bacteria  having  been  found  in  a  great  majority  of 
the  samples  of  well-water  examined.  This  is  readily  un- 
derstood from  the  condition  of  the  soil,  saturated  with 
fecal  matter  escaping  from  leaky  sewer  pipes  and  overflow- 
ing privies.  A  study  of  the  geography  of  the  typhoid  dis- 
tricts has  shown  that  there  is  a  coincidence  between  a 
soil  polluted  with  the  leakage  of  the  excreta  from  typhoid 
fever  patients,  the  drinking  of  infected  well-water,  and 
an  extensive  distribution  of  typhoid  fever ;  that  where 
these  first  two  conditions  exist  to  the  greatest  degree  ty- 
phoid fever  is  most  prevalent. 

The  committee  concludes,  as  a  result  of  its  investiga- 
tion, that  "  the  daily  pollution  of  the  soil  by  the  fecal 
discharges  of  our  patients  suffering  from  typhoid  fever, 
with  the  resulting  contamination  of  well-water,  must  be 
recognized  as  the  chief  source  of  the  diffusion  of  the  dis- 
ease. It  is  a  case  of  auto-infection.  We  are  daily  breed- 
ing the  poison  which  poisons  us,  and  the  inevitable  round 
from  intestine  to  soil,  from  soil  to  well,  and  from  well 
back  to  intestine,  goes  on  and  on  with  the  most  tragic 
uniformity.  We  sustain  all  the  conditions  favorable  to 
rapid  and  perfect  propagation  of  the  bacilli.  Granches 
and  Deschamps  have  experimentally  shown  that  typhoid 
germs  placed  on  the  surface  of  frequently  moistened 
ground  will  penetrate  nearly  two  feet  into  the  soil,  and 
will  there  retain  life  for  five  and  a  half  months.  They 
multiply  rapidly  in  illy  drained  soil,  live  for  an  indefinite 
time  in  privy  vaults,  and  have  a  much  longer  existence 
in  cisterns  and  wells  than  in  running  water.  In  Wash- 
ington we  supply  all  these  necessary  conditions — leaking 
privies  for  the  reception  of  the  excreta  and  their  con- 
tained germs,  a  damp  and  illy  drained  soil  for  their  re- 
ception and  rapid  growth,  neighboring  wells  for  the 
resulting,  the  inevitably  resulting,  contamination  of 
drinking-water  consumed  by  a  thirsty  population.  What 
more  conveniences  can  we  supply?  What  more  success- 
ful means  can  we  adopt  to  raise  our  mortality  to  a  point 
higher  than  that  of  Brooklyn,  New  York,  Baltimore,  and 
Boston  ?  We  are  among  the  most  successful  cultivators 
of  the  deadly  bacillary  plant  in  this  country/9 

To  remedy  this  condition  the  committee  urges  the 
abandonment  of  all  wells  within  the  city  limits,  the  sedi- 
mentation and  filtration  of  the  Potomac  water,  the  puri- 
fication of  the  existing  sewerage  system,  and  the  building 
of  new  sewers  in  parts  not  yet  supplied  with  drainage,  the 
suppression  of  all  privies  in  the  city,  and  finally  the  care- 
ful inspection  of  dairies  and  regulation  of  the  sale  of 


milk.  There  is  no  innate  reason  why  Washington  should 
not  be  one  of  the  healthiest  cities  in  the  country.  A 
great  deal  has  been  done  for  the  sanitary  improvement 
of  the  city  in  the  past  thirty  years,  but  much  yet  remains 
to  be  done.  It  is  a  hopeful  sign  that  the  Medical  Society 
of  the  District  has  taken  the  matter  up,  and  if  the  District 
commissioners  will  but  follow  the  recommendations  of 
the  Society,  one  of  the  chief  causes  of  mortality  in  the 
city  may  be  suppressed. 


THE    LIVER    AND    ITS    GLYCOGENIC    FUNC- 
TION. 

Dr.  Pavy  has  recently  made  some  rather  radical  state- 
ments regarding  the  functions  of  the  liver  in  its  relation 
to  sugar  and  to  the  pathology  of  diabetes. 

This  distinguished  investigator  asserts  that  there  is  no 
increase  of  sugar  in  the  blood  leaving  the  liver,  that 
glycogen  is  not  converted  into  sugar,  that  sugar  does  not 
disappear  in  the  circulation,  and  that  it  is  all  excreted  by 
the  liver.  The  liver  in  fine  has  no  more  to  do  with 
sugar  than  other  tissues,  and  not  so  much  perhaps  as  the 
muscles. 

Dr.  D.  Noel  Paton,  however,  in  an  article  on  the 
"Physiology  of  the  Carbohydrates1'  (Edinburgh  Medi- 
cal and  Surgical  Journal,  December,  1894),  denies  seria- 
tim these  views  of  Pavy,  and  says  that  not  one  of  them  is 
proven.  "  The  evidence  for  the  constant  production  of 
sugar  in  the  liver,"  he  says  "  the  evidence  that  glycogen 
is  a  source  of  sugar,  the  evidence  that  sugar  disappears  in 
the  general  circulation  (I  do  not  say  is  used  in  the  tis- 
sues), is  overwhelming,  and  thus  the  glycogenic  theory 
of  Bernard  holds  its  ground  unshaken." 

Dr.  Paton  further  asserts  that  one  of  the  great  func- 
tions of  the  liver  is  to  produce  sugar  will  not,  at  the 
present  time,  be  denied  by  any  physiologist.  The  theory 
of  Pavy,  repeated  in  nearly  every  text-book,  that  the  liver 
is  a  sugar  destroying  and  not  a  sugar-forming  organ, 
rests  on  so  unsubstantial  a  basis,  and  has  been  so  com- 
pletely refuted  by  the  work  of  Seegen  and  other  investi- 
gators, that  it  need  not  be  considered. 

When  experts  disagree,  it  is  difficult  for  those  who  are 
not  in  possession  of  special  physiological  knowledge  to 
decide.  We  trust,  however,  that  the  truth  will  soon  be 
reached,  for  there  are  few  questions  of  more  practical  in- 
terest than  that  of  the  physiological  chemistry  of  sugar. 


FILLING  FORCED  VACANCIES. 

The  trouble  in  Philadelphia  concerning  the  dropping  of 
an  attending  physician  from  the  staff  of  the  Philadelphia 
Hospital,  has  a  wider  significance  than  that  which  per- 
tains to  the  results  of  an  ordinary  election  of  officers. 
In  this  instance  the  Commissioners  of  Charities  and  Cor- 
rection, who  make  such  appointments,  presumed  to  de- 
cide upon  the  merits  of  a  vital  and  scientific  question  of 
medical  treatment,  without  consultation  with  the  staff, 
and  in  an  under  handed  manner  to  elect  another  gentle- 
man in  the  place  occupied  by  the  alleged  offender.  This 
rebuke  was  made  more  pointed  by  re-electing  all  the 
other  members  of  the  medical  board.  It  is  surprising  to 
learn  that  the  medical  board  had  no  disposition  to  resent 
this  insult,  and  still  more  so  to  know  that  a  good  man 
could  be  found  to  accept  the  position  thus  made  vacant, 


786 


MEDICAL   RECORD. 


[December  22,  1894 


and  thus  tacitly  acknowledge  the  validity  of  the  prin- 
ciple. 

Dr.  Walk,  who  was  the  only  member  of  the  board  of 
trustees  to  support  Dr.  Daland,  very  properly  maintained 
that  the  question  of  medical  treatment  in  the  hospital 
was  a  technical  matter,  and  that  laymen  were  not  com- 
petent to  decide  it.  If  the  board  had  any  objection  to 
any  method  of  treating  patients,  it  should  have  had  a 
commission  of  physicians  to  pass  upon  it  It  was,  in 
fact,  not  within  the  sphere  of  the  board. 

Such  doings  are,  fortunately,  not  common,  and  gen- 
erally occur  when  managing  boards  are  ignorant  of  their 
duties  and  when  a  staff  lacks  pluck  and  spirit.  There 
are  always  men  waiting  for  vacant  places,  no  matter  how 
they  are  created.  Managers  know  this  and  act  accord- 
ingly. The  principle  involved  is  one  thing  and  the  place 
is  the  other.  Usually  they  do  not  come  near  enough  to 
each  other  to  get  acquainted. 


A  BELATED  ASSAULT    ON    THE   GERM- 
THEORY. 

We  do  not  know  whether  anyone  pays  attention  to  the 
attacks  of  Mr.  Lawson  Tait  upon  vivisection  and  the 
germ-theory  of  disease.  At  any  rate,  no  one  who  reads 
this  gentleman's  last  criticism  of  microbic  pathology, 
"based  on  the  Baconian  Method,"  will  entertain  any 
longer  the  idea  that  Mr.  Tait  understands  what  he  is  writ- 
ing about  when  he  takes  up  this  subject.  His  "  Bacon- 
ian "  argument  is  that,  because  his  own  surgical  mortality 
is  light,  therefore  the  germ-theory  is  false,  strikes  one  as 
possessing  simply  the  merit  of  an  infantile  simplicity. 
The  germ-theory  of  disease,  or  of  some  diseases,  is  as 
firmly  established  as  any  fact  in  human  science,  and  Mr. 
Tait's  mortality-rates  must  be  made  to  fit  the  facts ;  the 
facts  are  not  to  be  stretched  to  the  Procrustean  bed  of 
hospital  statistics.  Evidently  Mr.  Tait  believes  that 
"the  sun  do  move." 


FURTHER     REPORTS    OF     THE    ANTITOXIN 
TREATMENT. 

Reports  regarding  the  use  of  the  antitoxin  of  diphtheria 
continue  to  come  in  from  all  parts  of  the  world.  In 
Paris,  Roux's  serum  has  reduced  the  mortality  fifty  per 
cent,  according  to  published  statistics.  In  London 
"good  results"  have  been  obtained  at  St.  Bartholo- 
mew's Hospital  in  cases  not  too  far  advanced.  The  in- 
vestigations of  the  efficacy  of  the  serum  are,  however, 
being  conducted  with  much  secrecy,  according  to  the 
British  Medical  Journal.  Three  kinds  of  serum  are 
used,  Behring's,  Aronson's,  and  that  made  in  London. 
Whatever  the  future  results  will  be  when  the  remedy  is 
widely  employed,  it  has  not  yet  been  used  enough  to  les- 
sen the  very  large  mortality  from  diphtheria  in  the  city 
of  London. 

At  Buda-Pesth,  Professor  Bokai  has  reported  the  re- 
sults of  the  treatment  of  35  cases  of  diphtheria  with  Beh- 
ring's serum.  The  number  of  children  who  died  was  5, 
giving  a  mortality-rate  of  14.28  percent.  Of  the  30 
children  who  recovered  intubation  was  done  in  12.  Drs. 
Gottstein  and  Schleich,  of  Berlin,  have  attacked  both 
the  theory  of  the  antitoxin  treatment  and  the  hospital 
statistics  which  have  been  quoted  in  its  support. 


At  a  recent  meeting  of  the  Medical  Society  of  Munich, 
which  was  attended  by  more  than  three  hundred  practi- 
tioners, the  serum  treatment  formed  the  subject  of  a  pro- 
longed discussion.  Professors  Buchner,  von  Ranke,  and 
C.  Seitz  presented  a  report  on  the  subject,  and  resolutions 
were  passed  to  the  effect  that  the  time  was  not  yet  ripe 
for  a  definite  judgment  as  to  the  value  of  the  method,  and 
that  trials  of  the  remedy  on  an  extensive  scale  would  be 
necessary  to  settle  the  question.  It  was  considered  im- 
portant that  this  view  should  be  impressed  not  only  on 
the  profession,  but  on  the  public.  A  committee,  consist- 
ing of  Professors  Buchner,  von  Ranke,  Bollinger,  Oertel, 
C.  Seitz,  von  Kerschensteiner,  and  Wertheimer,  was 
appointed  to  study  the  whole  question  thoroughly. 

In  France,  the  War  Department  has  authorized  the 
antitoxin  treatment  in  the  army ;  the  cities  of  Lille  and 
Havre  have  voted  money  for  undertaking  the  new  treat- 
ment. 

In  Belgium,  a  sero-therapeutic  service  has  been  organ- 
ized in  Brussels,  and  similar  work  has  been  begun  in 
Milan,  Piacenza,  Turin,  and  at  Lisbon. 

In  this  city  the  Board  of  Health  has  already  begun  to 
prepare  the  serum,  and  a  plant  is  being  established  in 
Washington  under  the  direction  of  the  Marine  Hospital 
Service. 


H*ws  of  tfee  fflleetu 

Dr.  William  H.  Flint,  having  suffered  from  a  bron- 
chial ailment,  since  an  attack  of  grippe  which  he  had  in 
the  spring  of  this  year,  has  decided  to  leave  New  York  for 
some  time,  in  the  hope  of  regaining  his  health.  Dr.  Flint 
hopes  to  resume  his  practice  in  this  city  early  next  fall. 

The  Twenty-fifth  Anniversary  of  the  Northwestern 
Medical  and  Surgical  Society  was  celebrated  by  an 
evening  reception  to  the  members,  their  wives  and  guests, 
on  Thursday  evening,  December  13  th,  at  the  house  of  the 
President,  Dr.  W.  Gill  Wylie,  28  West  Fortieth  Street, 
New  York.  About  one  hundred  and  twenty-five  persons 
were  present,  and  the  evening  was  thoroughly  enjoyable. 
This  society  is  one  of  several  in  this  city  organized  be- 
tween 1865  and  1870,  just  after  the  war ;  and  its  public 
celebrations  have  become  famous  for  the  generous  social 
spirit  among  the  members  and  friends. 

Hewark  is  to  have  a  new  hospital  for  contagious  and 
infectious  diseases. 

Br.  Martin  L.  Banney  died  at  his  residence  in  this 
city,  317  West  Twenty-ninth  Street,  on  December  14th, 
in  his  sixty  fifth  year.  He  had  practised  medicine  in 
this  city  for  more  than  forty  years,  and  was  one  of  the 
best  known  physicians  on  the  west  side.  He  was  the 
brother  of  the  late  Dr.  Lafayette  Ranney.  Dr.  Ranney 
leaves  two  children  and  two  brothers. 

National  Association  of  Eailway  Surgeons.— The 
following  are  the  officers  for  1894  and  1895  :  President^ 
Dr.  Samuel  S.  Thorn,  of  Toledo,  O. ;  First  Vice-Presi- 
dent, Dr.  N.  Y.  Leet,  of  Scranton,  Pa. ;  Second  Vice- 
President,  Dr.  C.  H.  Wilkinson,  of  Galveston,  Tex.; 
Third  Vice-President,  Dr.  B.  L.  Riardon,  of  Toronto, 
Canada ;  Fourth  Vice-President,  Dr.  W.  B.  Morrow,  of 
Walton,  N.  Y.;  Fifth   Vice  President,  Dr.  A.  O.  Will- 


December  22.  1894] 


MEDICAL   RECORD. 


787 


iams,  of  Ottumwa,  la. ;  Sixth  Vice-President,  Dr.  G.  A. 
Hollister,  of  Toledo,  O. ;  Seventh  Vice-President,  Dr. 
W.  R.  Priest,  of  Concordia,  Kan.;  Secretary,  Dr.  J.  M. 
Dinnen,  of  Fort  Wayne,  Ind. ;  Assistant  Secretary,  Dr. 
J.  H.  Ford,  of  Wabash,  Ind. ;  Treasurer,  Dr.  Eugene 
R.  Lewis,  of  Kansas  City,  Mo.;  Editor  of  Journal,  Dr. 
R.  Harvey  Reed,  of  Columbus,  O.;  Executive  Committee, 
Dr.  C.  K.  Cole,  of  Helena,  Mont. ;  Dr.  A.  J.  Mullen, 
Jr.,  of  Michigan  City,  Ind.;  Dr.  J.  B.  Murphy,  of  Chi- 
cago, 111.;  Dr.  A.  A.  Thompson,  Waxahachie,  Tex.; 
Dr.  D.  E.  Welsh,  of  Grand  Rapids,  Mich. ;  Dr.  C.  D. 
Evans,  of  Columbus,  Neb.;  Dr.  F.  H.  Peck,  of  Clinton, 
N.  Y.;  Chairman  Committee  on  Transportation,  Dr.  W. 
B.  Outten,  of  St.  Louis,  Mo. ;  Chairman  Committee  on 
Arrangements,  Dr.  A.  I.  BoufHeur,  of  Chicago,  111. 

The  Promised  Life  of  Sir  Andrew  Clark  is  being  pre- 
pared by  Canon  MacColl,  with  the  co-operation  of  Dr. 
W.  H.  Allchin.  An  introduction  will  be  contributed 
.by  Mr.  Gladstone.  The  book  is  not  expected  to  be 
ready  for  some  time  yet. 

A  Typhoid  Antitoxin. — A  rumor  was  current  on  the 
Stock  Exchange  of  Frankfort  on-Main  the  other  day, 
that  the  Hochst  Works  would  shortly  bring  on  the  mar- 
ket a  typhoid  antitoxin  of  Behring's  discovery.  The 
consequence  was  a  decided  rise  in  Hdchst  shares ! 

Bequests  to  Medical  Institutions  of  Philadelphia. — 
By  the  will  of  the  late  Dr.  William  Goodell,  of  Phila- 
delphia, the  sum  of  $ 50,000  is  donated  to  the  Medical 
Department  of  the  University  of  Pennsylvania.  The 
College  of  Physicians  will  from  the  same  source  fall 
heir  to  $10,000. 

Kentucky  School  of  Medicine. — On  the  22d  inst.  the 
Faculty  of  the  Kentucky  School  occupied  for  the  first 
time  their  commodious  new  hospital  and  dispensary. 

Honors  to  Medical  Ken. — The  Sultan  has  conferred 
the  honor  of  Grand  Officer  of  the  Medjidieh  Order 
on  M.  Monod,  Director  of  the  Assistance  Publique  of 
France ;  Professor  Grancher  and  M.  Roux,  of  the  Pas- 
teur Institute ;  and  M.  Pozzi,  the  well-known  gynecolo- 
gist. M.  Martin,  of  the  Pasteur  Institute,  has  received 
the  decoration  of  a  Commander  of  the  same  Order. 

Ohio  State  Association  of  Bailway  Surgeons. — The 
annual  meeting  of  this  body  was  held  at  Dayton,  Octo- 
ber nth  and  12th. 

The  Southwestern  Association  of  Bailway  Surgeons. 
— The  following  are  the  officers  of  this  organization : 
President,  Dr.  C.  A.  Smith,  of  Tyler,  Tex.;  Vice-Presi- 
dents, Dr.  E.  A.  Neeley,  of  Memphis,  Tenn.;  Dr.  W. 
G.  Jameson,  of  Palestine,  Tex. ;  Dr.  E.  F.  Yancey,  of 
Sedalia,  Mo. ;  Dr.  B.  F.  Eads,  of  Marshall,  Tex. ;  Dr. 
N.  J.  Pettijohn,  of  Kansas  City,  Mo. ;  Secretary,  Dr.  J. 
A.  Lightfoot,  of  Texarkana,  Ark.;  Treasurer,  Dr.  L.  H. 
Callaway,  of  Nevada,  Mo. 

The  Association  of  Military  Surgeons  of  the  United 
States. — The  following  are  the  officers  for  1894  and 
1895 :  President,  George  M.  Sternberg,  Brigadier- 
General  and  Surgeon- General,  U.  S.  Army,  of  Washing- 
ton, D.  C;  First  Vice  President,  Louis  W.  Read,  Colo- 
nel and  Surgeon-General,  N.  G.  Penn.,  of  Norristown, 
Pa.;  Second  Vice-President,  Albert  L.  Gihon,  Medical 
Director,  U.  S.  Navy,  of  Washington,  D.  C;  Secretary, 


Eustathius  Chancellor,  Lieutenant  Colonel  and  Medical 
Director,  N.  G.  Mo.,  of  515  Olive  Street,  St.  Louis,  Mo.; 
Assistant  Secretary,  Julian  M.  Cabel,  Captain  and  As- 
sistant Surgeon,  U.  S.  Army,  of  Washington  Barracks, 
Washington,  D.C.;  Treasurer,  Lawrence  C.  Carr,  Major 
and  Surgeon,  N.  G.  Ohio,  of  143  W.  Seventh  Street, 
Cincinnati,  O.  Meets  at  Buffalo,  N.  Y.,  May  21,  22, 
and  23,  1895. 

A  Bequest  to  the  Massachusetts  General  Hospital.— 
By  the  will  of  the  late  Thomas  E.  Proctor,  the  Massa- 
chusetts General  Hospital,  of  which  he  was  a  trustee,  re- 
ceives J 1 00,000.  This  sum  is  to  be  held  in  trust  until 
principal  and  interest  reach  the  amount  of  $400,000. 

The  West  Side  German  Dispensary.— The  members 
of  the  staff  have  founded  a  clinical  society  styled  the  So- 
ciety for  Medical  Progress  of  the  West  Side  German 
Dispensary.  The  officers  are :  Dr.  Augustin  H.  Goelet, 
President;  Dr.  Lewis  Morris  and  Dr.  V.  Fuentes,  Vice- 
presidents;  Dr.  Aristides  Agramonte,  Secretary  ;  and  Dr. 
H.  C.  Hazen,  Treasurer. 

Diphtheria  in  St.  Louis. — Diphtheria  is  so  prevalent 
in  certain  portions  of  St.  Louis  as  to  be  considered  epi- 
demic. A  large  number  of  the  earlier  cases  are  said  to 
have  been  reported  by  the  physicians  as  "croup"  or 
"laryngitis." 

The  German  Medical  Society  of  the  City  of  Sew 
York  held  a  festival  last  Saturday  evening,  at  the  Arion 
Club,  to  celebrate  its  thirty-fourth  anniversary.  The 
entertainment  consisted  of  a  dinner  followed  by  a  ball. 
Speeches  were  made  by  Drs.  Jacobi,  Willy  Meyer,  Vul- 
pius,  and  Heitzmann. 

Manufacture  of  Vaccine  Virus  by  the  State  of  Illi- 
nois.— A  committee  has  been  appointed  by  the  Illinois 
State  Board  of  Health  to  promote  legislation  by  the  next 
General  Assembly  for  the  establishment  of  a  State  vaccine 
farm.  It  will  be  remembered  that  within  the  last  year 
efforts  were  made  to  secure  such  legislation  in  Massachu- 
setts. These  attempts,  unfortunately,  were  not  success- 
ful. 

Beoeipts  from  Portrait  Exhibition. — The  exhibition 
of  portraits  of  women,  organized  by  a  number  of  ladies 
of  society,  which  has  just  closed  at  the  Academy  of  De- 
sign, netted  about  $20,000  for  St.  John's  Guild  and  the 
Orthopedic  Dispensary. 

The  Antitoxin  Treatment  of  Tetanus.  —  Dr.  £. 
Schwarz  reported  last  week  on  a  case  of  tetanus  treated 
by  Tizzoni's  antitoxin.  The  treatment  was  commenced 
on  the  second  day  of  the  disease,  and  the  spasms  disap- 
peared under  the  treatment,  but  the  temperature  rose  dur- 
ing this  time  from  37.30  C.  to  4o-3°>  and  the  patient,  after 
the  fourth  injection,  died  from  heart  failure.  It  was  clear 
that  the  leucocy  tosis  was  increased  in  consequence  of  the 
treatment.  The  number  of  the  leucocytes  was  11,000 
before  the  first  injection,' rising  to  18,000  on  the  next 
day,  and  was  17,000,  16,000,  and  15,000  on  the  follow* 
ing  days.  Dr.  Schwarz  recommended  the  use  of  strong- 
er doses  of  the  antitoxin  than  those  prescribed  by  Tiz- 
zoni. 

A  Gold  Cup  for  Discovering  a  Sew  Microbe. — The 
citizens  of  Nagasaki  have  presented  Professor  Kitasato 
with  a  beautiful  gold  cup  in  honor  of  his  discovery  of  the 
bacillus  of  the  plague. 


788 


MEDICAL   RECORD. 


[December  22,  1894 


GEORGE  A.   PETERS,  M.D., 


NSW  YORK. 


Dr.  George  A.  Peters,  one  of  the  most  prominent 
of  New  York  Surgeons,  died  December  6th,  of  chronic 
Blight's  disease.  Dr.  Peters  was  graduated  from  the 
College  of  Physicians  and  Surgeons  in  1846,  and  his  ca- 
reer was  a  most  successful  and  interesting  one.  For  the 
last  four  years  he  had  retired  to  a  large  extent  from  active 
practice,  but  at  the  time  of  his  death  he  was  still  consult- 
ing surgeon  to  the  New  York,  St.  Luke's,  St.  Mary's,  and 
the  Woman's  Hospital. 

During  his  medical  course  he  was  a  private  pupil  of 
the  late  Dr.  Alfred  C.  Post.  After  his  graduation  he 
served  the  prescribed  period  on  the  house  staff  of  the 
New  York  Hospital,  and  a  few  years  later  he  was  ap- 
pointed a  surgeon  to  that  institution,  also  to  St.  Luke's 
Hospital.  Although  his  hospital  work  was  wholly  sur- 
gical, he  was  for  many  years  one  of  the  most  successful 
and  popular  of  the  general  practitioners  of  New  York. 

FRANK  L.  SIM,  M  D^ 

MEMPHIS,  TKNN 

Dr.  Frank  L.  Sim,  died  at  his  residence  in  Mem- 
phis, Tenn.,  November  23, 1894.  He  had  been  in  failing 
health  for  several  months.  Dr.  Sim  was  born  in  Gol- 
conda,  I1L,  April  29,  1834.  'His  literary  education  was 
received  at  Hanover  College,  Indiana.  He  graduated 
from  the  medical  department  of  the  University  of  Louis- 
ville in  1855,  and  a  year  later  received  an  ad  eundem  de- 
gree in  the  Pennsylvania  Medical  College.  Returning 
home  in  the  spring  of  1857,  he  practised  medicine  with 
his  father  till  1861,  when  he  left  that  part  of  the  country 
and  shortly  afterward  entered  the  Confederate  service  as 
a  contract  surgeon  in  the  army,  then  stationed  at  Colum- 
bus, Ky.  Circumstances  induced  him  to  locate  in  Mem- 
phis, where  he  ever  since  devoted  himself  to  the  practice 
of  his  profession.  He  remained  at  his  post  of  duty  dur- 
ing the  dark  days  of  Memphis  in  the  various  epidemics 
of  cholera  and  yellow  fever.  In  1882,  Dr.  Sim  became 
the  editor  of  the  Mississippi  Valley  Medical  Monthly,  but 
afterward  changed  to  the  Memphis  Medical  Monthly, 
under  which  name  he  has  continued  its  editor  and  pub- 
lisher. Dr.  Sim  at  the  time  of  his  death  was  Professor  of 
the  Principles  and  Practice  of  Medicine  in  the  Memphis 
Hospital  Medical  College  and  was  Dean  of  the  Faculty. 

Dr.  C.  P.  Gage,  of  Concord,  N.  H.,  died  on  Novem- 
ber 26th,  aged  eighty-three.  He  was  one  of  the  original 
members  of  the  American  Medical  Association,  and  had 
been  president  of  the  New  Hampshire  Medical  Society. 


gtortettrs  atufl  fj0tiaes  of  QooHs. 

Transactions  of  the  Forty-ninth  Annual  Meeting 
of  the  Ohio  State  Medical  Society,  held  at  Zanes 
ville,  May  16,  1894.    Toledo,  O. :   Blade  Printing 
and  Paper  Co. 
Contains  the  usual  assortment  of  papers,  many  of  them 
of  considerable  interest.    As  might  be  expected,  tuber- 
culosis comes  in  for  rather  a  large  share  of  attention. 
Papers  on  sterilization  and  immunity,  and  pleas  for 
higher  medical  education,  and  for  the  cremation  of  the 
dead,  are  also  noteworthy  as  illustrating  tendencies  of  the 
times. 

A  Manual  of  Human  Physiology.      Prepared  with 
Special  Reference  to  Students  of  Medicine.     By  Jo- 
seph H.  Raymond,  A.M.,  M.D.     Philadelphia:  W. 
B.  Saunders. 
Believing  that  only  the  main  principles  of  the  subject  of 
physiology  can  be  imbibed  by  the  medical  student  dur- 
ing the  limited  time  of  his  study,  the  author  has  at- 


tempted to  make  these  available  in  condensed  form. 
Without  too  fully  endorsing  the  view  that  students  should 
be  trained  on  manuals— especially  in  this  day  when  the 
tendency  everywhere  is  to  lengthen  medical  courses — 
one  may  at  least  admit  the  value  of  concise,  direct,  and 
unequivocal  elucidation  of  principles;  and  it  may  be 
freely  conceded  that  the  essentials  of  human  physiology 
are  compressed  within  the  three  hundred  and  sixty-five 
pages  of  this  manual  in  a  most  attractive  form.  Numer- 
ous creditable  illustrations — some  of  them  colored — rein- 
force the  text. 

Fifth  Annual  Report  of  the  New  York  State  Com- 
mission in  Lunacy.  From  October  1,  1892,  to  Sep- 
tember 30,  1893.  Albany:  James  P.  Lyon,  State 
Printer. 
Judged  quantitatively,  this  report  certainly  shows  great 
advances  on  the  part  of  the  Commission  in  Lunacy,  inas- 
much as  it  is  six  times  as  bulky  as  the  first  report, 
issued  in  1889.  Considered  as  to  quality,  the  advance 
is  not  so  striking.  Of  course  there  are  good  suggestions 
in  the  report,  but  there  is  much  that  might  advanta- 
geously have  been  omitted  or  greatly  condensed — for  ex- 
ample, the  copy  of  the  estimate  for  supplies,  and  the  . 
monthly  treasurer's  report  of  the  Rochester  Hospital, 
which  fills  fifty  printed  pages,  and  the  endless  legal  papers 
giving  details  of  the  squabble  between  the  Commissioners 
in  Lunacy  and  the  authorities  of  Queens  County. 

Whatever  the  failings  of  the  Commission  in  Lunacy,  it 
has  never  been  accused  of  lack  of  self-appreciation,  and 
in  this  regard  the  present  report  shows  no  falling  off. 
Should  the  future  historian  come  upon  these  volumes,  he 
will  certainly  be  excusable  if  he  reaches  the  conclusion 
that  in  the  last  decade  of  the  nineteenth  century  the  ill- 
used  insane  had  but  three  friends  in  the  State  of  New 
York,  these  being,  of  course,  the  Commissioners  in  Lu- 
nacy. But  should  the  same  historian  come  across  sundry 
letters  and  other  unofficial  documents  relating  to  the 
same  subject  that  may  chance  to  be  preserved,  we  fear  he 
will  be  sadly  puzzled.  For  in  point  of  fact,  there  are 
other  friends  of  the  insane  in  New  York,  and  not  a  few 
of  them,  differing  very  widely  from  these  reports  in  their 
estimate  of  the  value  of  the  work  of  the  Commission  in 
Lunacy. 

Twelfth  Annual  Report  of  the  Provincial  Board 
of  Health  of  Ontario.    Being  for  the  year  1893. 
Printed  by  order  of  the  Legislative  Assembly.     To- 
ronto :  Warwick  Brothers  &  Rutter.     1894. 
Contains  reports  on  many  topics  having  to  do  with 
sanitation,  some  of  them  only  of  local  interest,  others 
more  general  in  their  application,  but  all  illustrating  the 
wide-spread  interest  in  preventive  medicine  that  marks 
our  generation. 

The  Principles  of  Bacteriology  :  A  Practical  Manual 
for  Students  and   Physicians.      By  A.   C.  Abbott, 
M.D.,  First  Assistant,  Laboratory  of  Hygiene,  Uni- 
versity of  Pennsylvania,   Philadelphia.      Second  edi- 
tion, enlarged  and  thoroughly  revised.    With  94  Illus- 
trations, of  which  17  are  Colored.    Philadelphia:  Lea 
Brothers  &  Co.     1894. 
Although  this  second  edition  contains  double  the  letter- 
press of  the  first  edition,  the  author  explicitly  states  that 
he  has  adhered  closely  to  his  original  plan,  making  no 
attempt  to  cover   the  field  exhaustively,  but  referring 
only  to  species  that  "are  comparatively  common,  or  of 
importance  in  enabling  the  student  to  acquire  a  funda- 
mental working  knowledge,  capable  of  wider  application." 
It  is,  in  short,  a  work  for  beginners  and  general  students, 
and  as  such,  of  course  lays  no  claim  to  originality  of 
matter ;  but  its  method  is  concise  and  clear,  and  it  gives 
just  such  an  account  of  the  practical  manipulations  of 
media  and  cultures  as  will  prove  of  value  to  the  student 
who  must  learn  laboratory  methods  by  himself.     A  satis- 
factory summary  of  the  present  status  of  the  various 
theories  of  infection  and  immunity  has  been  added  to 
this  edition. 


December  22,  1894] 


MEDICAL  RECORD. 


789 


jfocietg  Qupovte. 

SOUTHERN    SURGICAL     AND    GYNECOLOGI- 
CAL ASSOCIATION. 

Seventh  Annual  Meeting)  Held  in  Charleston,  S.  C,  No- 
vember 13,  14,  and  is,  1894, 

First  Day,  Tuesday,  November  13TH. 

The  Association  met  in  Artillery  Hall,  and  was  called  to 
order  at  10  a.m.  by  the  President,  Dr.  C.  Kollock,  of 
Cheraw.  Prayer  was  offered  by  the  Rev.  Dr.  Campbell, 
of  Charleston.  An  address  of  welcome  was  delivered  by 
the  Mayor  of  Charleston.  Dr.  Brodie,  of  Charleston, 
followed  with  an  address  of  welcome  on  behalf  of  the 
local  profession,  and  President  Kollock  responded  in  be- 
half of  the  Association. 

Br.  Warren  Stone. — Dr.  William  E.  Parker,  of 
New  Orleans,  read  a  "  Memorial  Address  "  on  Dr.  War- 
ren Stone,  which  was  prepared  by  the  late  Dr.  A.  B. 
'Miles,  of  New  Orleans.  He  said  as  Professor  of  Surgery 
in  the  University  of  Louisiana  for  thirty-five  years,  as 
Surgeon  to  the  Charity  Hospital  for  thirty- eight,  and  as 
general  practitioner  from  1832  to  1872,  whose  experience 
covered  eighteen  epidemics  of  yellow  fever  and  cholera 
in  New  Orleans,  the  name  of  Warren  Stone  is  impressed 
indelibly  upon  the  local  history  of  a  remarkable  period. 
In  his  surgical  clinics  he  taught  the  advanced  surgery  of 
the  old  school.  He  taught  the  principles  of  drainage  in 
suppurative  arthritis,  in  hepatic  abscesses,  andinpyothorax. 
He  advocated  resection  of  the  rib  to  facilitate  the  drainage 
in  suppurative  pleuritis.  Whether  in  operative  work  or 
in  the  liberation  of  pus  he  made  free  incisions.  He  was 
among  the  first  in  the  cure  of  aneurism  of  the  vertebral 
artery.  In  the  surgery  of  the  arteries  he  was  an  expert. 
During  fourteen  years  of  his  work  at  the  Charity  Hospi- 
tal, he  operated  without  an  anaesthetic.  Realizing  the 
difficulties  under  which  he  labored,  he  was  ready  to  wel- 
come the  new  era  in  surgery  then  about  to  dawn.  The 
lives  of  many  men  are  mirrored  in  their  books  and  pub- 
lished papers,  but  the  writings  of  Dr.  Stone  give  but 
meagre  knowledge  of  his  work,  or  his  position  as  an 
authority  on  surgery  in  the  South.  No  man  in  the 
profession  was  ever  so  universally  beloved  as  Dr. 
Stone.  In  his  relations  with  other  physicians  he  was 
gentle  and  considerate,  never  intrusive  or  aggressive. 
Many  of  the  physicians  in  Louisiana  to  day  who  knew 
him  in  life,  speak  of  him  affectionately  as  "  Old  Stone/' 
and  always  with  some  expression  of  endearment  and  re- 
spect. His  position  in  New  Orleans  may  be  compared 
with  that  of  Physick,  in  Philadelphia,  Mott,  in  New 
York,  Lister,  in  London,  Velpeau  in  Paris. 

Gonorrhoea  in  Women. — Dr.  J.  B.  S.  Holmes,  of 
Atlanta,  read  a  paper  with  this  title.  He  said  there  was 
no  disease  that  affected  women  that  should  engage  the 
serious  and  thoughtful  consideration  of  the  physician 
more  than  gonorrhoea.  There  was  no  doubt  but  that 
many  of  the  chronic  diseases  of  the  ovaries  and  tubes 
that  came  under  the  observation  of  gynecologists  were 
due  to  this  disease.  In  the  majority  of  cases  the  poor 
woman  was  ignorant  of  the  fact  that  she  had  had  or  has 
any  specific  disease.  Indeed,  her  husband  might  tell  the 
physician  that  months  or  even  years  before  his  marriage 
he  was  a  subject  of  gonorrhoea,  which  was  cured  and  had 
since  shown  no  evidence  of  a  return. 

The  essayest  could  conceive  of  nothing  more  danger- 
ous than  curetting  the  uterus  in  the  presence  of  immense 
pus-tubes  with  pelvic  adhesions.  The  drawing  down  of 
the  organ  necessary  for  curettage  may  break  up  pelvic 
adhesions  and  pour  out  the  contents  of  pus-sacs  into  the 
peritoneal  cavity,  which  would  result  in  the  majority  of 
cases  in  death  to  the  woman.  If  her  life  is  saved  at  all, 
it  will  only  be  done  by  a  prompt  abdominal  section, 
with  thorough  irrigation  and  drainage  of  the  abdomen. 
Then  why  not,  in  the  first  instance,  when  pus  is  detect- 


ed, promptly  remove  it  by  surgical  interference.  We 
then  treat  the  woman  rationally  and  give  her  the  very 
best  and  only  chance  of  relief  and  restoration  to  health. 

Dr.  George  J.  Engelmann,  of  St.  Louis,  called  atten- 
tion to  the  importance  of  differentiating  between  latent 
or  chronic  gonorrhoea  and  the  acute  form  of  the  disease. 
He  does  not  look  upon  acute  gonorrhaea  as  a  dangerous 
disease  in  women,  but  he  does  the  latent  or  chronic 
form.  He  has  not  seen  serious  results  from  the  acute 
form,  but  it  is  the  infection  which  is  not  observed  from  a 
supposedly  cured  gonorrhoea  in  the  male  which  produces 
the  suffering  in  women. 

Dr.  Bedford  Brown,  of  Alexandria,  Va.,  took  excep- 
tion to  the  statement  made  by  Dr.  Engelmann  in  regard 
to  the  non-danger  of  acute  gonorrhoea  in  females,  and 
cited  the  case  of  a  female  in  whom  acute  gonorrhoea  ran 
its  course,  terminating  finally  in  fatal  nephritis.  In  this 
case  there  was  first  urethritis,  then  cystitis,  ureteritis,  pye- 
litis, and  acute  nephritis. 

Dr.  Richard  Douglas,  of  Nashville,  thought  Dr. 
Engelmann  had  sounded  the  keynote  in  that  there  is 
quite  a  difference  in  the  infection  from  acute  gonorrhoea 
and  the  latent  form  of  the  disease.  Infection  from  the 
latter  was  a  mixed  infection,  not  only  with  the  gonococ- 
cus,  but  with  the  streptococcus  and  staphylococcus  also, 
and  that  accounts  somewhat  for  the  virulence  of  the 
trouble.  That  gonorrhoea  is  the  cause  of  uterine  fibroids, 
he  could  scarcely  accept,  although  he  thought  Dr.  Price 
was  the  author  of  that  idea. 

Dr.  Joseph  Taber  Johnson,  of  Washington,  D.  C, 
said  in  the  treatment  of  pus-tubes  the  result  of  gonor- 
rhoea! infection,  the  very  radical  suggestion  of  Dr. 
Holmes  was  correct,  viz.,  to  resort  to. abdominal  section, 
as  he  was  satisfied  that  gonorrhoea!  pus  tubes  were  incur- 
able by  conservative  measures.  In  addition  to  the  re- 
moval of  pus-tubes,  if  present  on  both  sides,  the  uterus 
should  be  removed  also,  because  it  is  through  the  infected 
mucous  membrane  of  the  uterus  that  the  tubes  them- 
selves have  become  infected. 

Dr.  William  P.  Nicolson,  of  Atlanta,  said  the  general 
surgeon  was  concerned  in  the  treatment  of  gonorrhoea  as- 
well  as  the  specialist.  We  are  told  that  a  urethra  has- 
been  inflamed  and  subsequently  restored  to  its  normal 
condition,  and  yet  years  afterward  the  man  transmits 
gonorrhoea  to  his  wife.  It  is  hard  for  him  to  accept  such 
a  doctrine.  If  a  man  goes  for  months  and  years  with  a 
gonorrhoea  absolutely  producing  no  effect  whatever,  if 
he  is  not  well,  how  are  we  to  tell  him  that  he  is  not? 
We  are  told  by  the  essayist  that  gonorrhoea  is  contracted 
by  the  female  when  there  is  absolutely  no  evidence  what- 
ever of  disturbance  in  the  urethra  of  the  male,  or  that 
there  is  no  trouble  by  which  he  can  propagate  disease. 

Dr.  A.  M.  Cartledge,  of  Louisville,  thought  the 
essayist  failed  to  differentiate  between  cases  of  subacute 
and  chronic  salpingitis  and  the  cases  of  acute  infection 
from  gonorrhoea.  He  threw  out  the  suggestion  that 
physicians  were  not  fully  conscious  of  the  great  preva- 
lence of  artificial  abortions  in  youug  married  women  of 
the  better  as  well  as  the  lower  class,  and  he  believes  that 
in  these  cases  of  secondary  infection  from  pathogenic  or- 
ganisms we  have  a  more  fertile  source  for  the  develop- 
ment of  the  tubular  and  ovarian  disease  than  from  gon- 
orrhoea. 

Dr.  W.  E.  B.  Davis,  of  Birmingham,  Ala.,  considered 
the  disease  a  dangerous  one.  The  views  of  Tait,  how- 
ever, in  regard  to  gonorrhoea  were  extreme.  We  have  a 
frequent  cause  of  tubal  disease  in  the  puerperal  state,  in 
delivery  at  term  or  in  premature  deliveries,  frequently  in 
artificial  abortions,  brought  about  by  mechanical  means. 
More  or  less  infection  occurs  after  all  cases  of  abortion, 
but  if  the  patient  is  in  good  condition  at  the  time,  she 
will  not  be  materially  affected.  If  we  have  a  soil  that  is- 
favorable  for  the  development  of  septic  germs,  we  will 
get  a  severe  inflammation — a  mixed  infection. 

Dr.  W.  D.  Haggard,  of  Nashville,  desired  to  place 
himself  on  record  as  opposed  to  the  removal  of  the  uterus 
and  tubes  for  pyosalpinx  as  the  result  of  gonorrhoea,  be* 


790 


MEDICAL  RECORD. 


[December  22,  1894 


licving  that  by  dilatation  and  judicious  curetting  patients 
can  be  relieved  of  an  endometritis  produced  by  gonor- 
rhoea. 

Dr.  John  D.  S.  Davis,  of  Birmingham,  Ala.,  emphasized 
the  importance  of  using  the  microscope  in  connection 
with  gonorrhoea  and  carefully  examining  the  pus.  Ex- 
perience has  demonstrated  that  the  latent  effects  of  gon- 
orrhoea were  not  always  directly  due  to  the  gonococcus 
per  se,  but  to  a  mixed  infection ;  that  is,  we  have  an  in- 
flammation as  a  result  of  the  gonococcus,  which  is  fired 
up  by  another  infection  from  the  streptococcus.  When 
we  have  a  mixed  infection,  we  have  as  a  result  pus-tubes, 
suppurative  peritonitis,  and  finally  death  of  the  patient  if 
surgical  interference  is  not  resorted  to. 

Dr.  Hunter  McGuire,  of  Richmond,  entered  a  pro- 
test against  the  doctrine  that  a  man  can  have  gonorrhoea 
and  not  get  well.  As  for  the  idea  that  a  man  who  has 
had  gonorrhoea  should  not  get  married,  it  is  preposterous. 
He  had  seen  thousands  of  cases  get  well  and  remain  so. 

Dr.  Holmes,  in  closing,  said  he  was  aware  that  many 
cases  of  acute  gonorrhoea  resulted  in  no  secondary 
trouble,  because  they  were  recognized  early  and  cured  by 
judicious  treatment.  He  wished  to  be  understood  as  not 
indorsing  the  views  of  Mr.  Tait,  that  gonorrhoea  in  the 
male  was  never  cured,  but  he  insisted  that  general  prac- 
titioners were  often  too  careless  in  advising  patients  who 
have  been  the  subjects  of  gonorrhoea  to  get  married. 

Some  Oases  of  Acute  Intestinal  Obstruction  With 
Deductions  was  the  title  of  a  paper  read  by  Dr.  A.  Mor- 
gan Cartledge,  of  Louisville,  in  which  he  reported  six 
cases,  three  of  which  terminated  fatally.  The  author 
said  that  the  limited  number  of  operated  cases  reported 
in  his  paper,  together  with  an  individual  observation  of 
probably  as  many  more  not  subjected  to  operation,  con- 
form to  the  accepted  belief  of  the  hopeless  nature  of 
acute  intestinal  obstruction  unless  treated  by  early  lapa- 
rotomy. 

While  the  author  does  not  contend  that  we  can  dis- 
pense with  opium  in  the  treatment  of  these  cases,  cer- 
tainly where  obstruction  is  in  the  least  suspected  we 
should  withhold  its  use  until  a  diagnosis  can  be  made: 
The  practice  of  masking  every  abdominal  condition 
characterized  by  pain  with  opium  is  far  too  prevalent, 
and  its  practice  gains  additional  calamity  as  surgery 
advances  in  knowledge  which  refers  relief  of  these  very 
conditions  concealed  by  the  cloak  of  opium  and  ignor- 
ance. 

The  practical  and  cardinal  points  in  avoiding  a  fatal 
delay  and  making  an  early  diagnosis,  are  to  be  found  in, 
sudden  abdominal  pain;  a  rapidly  accelerating  pulse; 
the  vomiting  of  much  more  fluid  in  a  given  time  than 
taken  by  the  mouth ;  the  green  tinged  character  of  this 
fluid ;  the  anxious  expression  of  countenance  when  no 
opium  has  been  used,  the  fact  that  although  enema  may 
be  stained  by  the  contents  of  the  colon  there  is  no  ex- 
pulsive movement  of  the  bowels,  and  the  passage  of  no 
gas. 

The  burning  question  now  is  to  educate  men  to  know 
that  action  to  be  successful  must  be  quick ;  that  timely 
aid  depends  upon  the  man  who  first  sees  the  case ;  that 
when  a  physician  from  any  reason  suspects  that  a  pa 
tient's  bowels  will  not  move,  he  should  drop  everything 
else  and  centre  all  his  time  and  attention  upon  that  pa- 
tient. He  should  not  waste  his  gray  matter  by  trying  to 
determine  if  it  be  a  probable  intussusception,  volvulus, 
band,  diverticulum  or  what  not— leave  that  for  the  oper- 
ation to  determine ;  it  is  the  most  reliable  way  to  find  out. 


Second  Day,  Wednesday,  November  14TH. 

Hernia  of  the  Diaphragm.— Dr.  F.  W.  McRae,  of 
Atlanta,  Ga.,  reported  a  case  of  this  kind.  The  author 
brought  this  subject  before  the  Association  for  considera- 
tion, not  alone  because  it  offered  an  inviting  field  for 
experiment  and  investigation,  but  also  because  of  a  recent 
interesting  case  where,  without  warning,  he  was  forced  to 
meet  the  emergency  without  time  for  research  into  the 


literature  of  the  subject,  and  while  he  was  not  then  sus- 
tained by  a  knowledge  of  the  opinions  of  the  leading 
authorities.  He  finds  from  subsequent  investigation  that 
the  course  pursued  was  in  accord  with  the  recommenda- 
tions of  such  eminent  authorities  as  Laennec,  Bowditch, 
Guthrie,  and  Marcy.  In  the  case  reported,  strangulation 
had  occurred  five  days  before  the  doctor  saw  him.  Had 
an  early  diagnosis  been  made,  he  feels  sure  the  strangula- 
tion could  have  been  relieved  and  the  patient's  life  pro- 
longed. The  opening  in  the  diaphragm  was  accessible, 
and  he  believes  it  could  have  been  dosed  with  a  fair 
chance  of  permanent  recovery.  The  case  serves  to  em- 
phasize the  necessity  for  early  operation  in  all  cases  of 
acute  obstruction  of  the  bowels. 

Gunshot  Wound  of  the  Spleen  and  Kidney. — Dr.  Louis 
McLane  Tiffany,  of  Baltimore,  Md.,  reported  the  fol- 
lowing case :  The  patient  was  a  male  negro,  twenty  years 
of  age.  Two  hours  previous  to  entering  the  University 
Hospital,  March  21, 1894,  he  had  been  shot  with  a  small- 
calibre  rifle  from  a  distance  of  twenty  feet,  the  weapon 
being  directly  behind  him,  and  he  being  erect.  His 
urine  was  slightly  albuminous ;  the  pulse,  temperature, 
and  respiration,  normal.  There  was  a  bullet  wound 
three  inches  to  the  left  of  the  spine  just  below  the  last 
rib,  from  which  blood  oozed.  After  properly  cleansing 
the  wound  it  was  enlarged,  and  it  was  found  that  the 
kidney  had  been  injured  and  that  a  bullet  had  passed  on- 
ward, presumptively  into  the  peritoneal  cavity.  The 
wound  was  filled  lightly  with  gauze  by  the  resident 
physician,  and  Dr.  Tiffany  was  notified.  External 
examination  of  the  abdomen  by  touch  and  palpation  re- 
vealed nothing,  not  even  painfullness. 

The  patient  was  anaesthetized,  laid  on  the  belly,  and 
the  wound,  after  being  enlarged,  was  examined.  The 
upper  portion  of  the  left  kidney  was  perforated,  and 
dark  blood  flowed  from  the  peritoneal  cavity  beyond. 
This  large  wound  was  filled  with  gauze,  the  patient  turned 
on  the  back,  and  the  abdomen  freely  opened  along  the 
left  semilunar  line.  A  moderate  amount  of  blood  was 
free  in  the  peritoneal  cavity ;  no  wound  of  the  intestine 
could  be  discovered,  but  the  spleen  was  found  perforated, 
blood  flowing  freely  from  the  wound  of  entrance,  as  well 
as  from  the  wound  of  exit ;  the  latter  wound,  in  the  con- 
cavity of  the  organ,  was  slightly  the  larger  of  the  two. 
The  perforation  through  the  spleen  was  about  three 
inches  from  the  free  lower  border.  Unwilling  to  subject 
the  patient  to  splenectomy,  the  essayist  attempted  to 
arrest  the  bleeding  in  the  following  manner:  A  long 
needle  threaded  with  silk  was  passed  entirely  through  the 
spleen  central  to  and  parallel  with  the  bullet  track ;  the 
long  ligature  was  then  tied  over  the  free  border  of  the 
organ  so  as  to  press  the  surfaces  of  the  wound  together 
tightly  enough  to  arrest  bleeding,  yet  not  to  tear  through 
the  splenic  tissue ;  the  ends  of  the  ligature  were  cut 
short,  the  peritoneal  cavity  cleaned  by  copious  irrigation 
with  hot  water  and  the  abdominal  wound  closed.  The 
kidney  was  tamponed  with  gauze  through  the  dorsal 
wound.  Convalescence  was  uneventful;  the  anterior 
wound  healed  by  primary  union ;  urine  flowed  from  the 
dorsal  wound  for  two  days  only,  union  by  granulation 
taking  place.  The  patient  left  the  hospital  well,  April 
2  2d. 

In  this  case,  the  wound  being  small,  hemorrhage  was 
not  profuse,  and  no  abdominal  organ  save  the  spleen 
was  wounded. 

Nsbvus. — Dr.  William  Perrin  Nicolson,  of  Atlanta, 
Ga.,  reported  a  severe  case  of  nsevus,  which  was  only 
cured  by  the  use  of  galvano-puncture.  The  case  was  one 
of  a  large  growth  occupying  the  groove  from  the  angle 
of  the  jaw,  up  to  and  covering  a  portion  of  the  ear,  and 
extending  out  upon  the  cheek,  the  entire  tumor  being 
almost  the  size  of  a  hen's  egg. 

Dr.  Nicolson  formulated  the  following  conclusions  as 
having  been  reached  in  the  long  period  covered  in  the 
treatment  of  this  case :  1.  That  while  this  treatment 
may  not  be  applicable  to  all  cases,  in  many  of  those  that 
are  reached  by  difficult  dissection,  and  are  subject  to 


December  22,  1894] 


MEDICAL   RECORD. 


791 


dangerous  hemorrhage,  as  well  as  an  unsightly  looking 
scar,  this  is  undoubtedly  to  be  preferred  to  any  other 
surgical  proceeding.  The  time  required  in  a  cure  is 
more  than  balanced  by  the  entire  preservation  of  the 
skin  and  the  absence  of  danger  from  operative  work.  2. 
That  as  to  the  quantity  and  quality  of  the  current  to  be 
employed,  as  many  as  six  cells  of  a  zinc-carbon  battery 
may  be  sufficient  in  small  growths,  while  twelve  cells  of 
the  same  is  perhaps  the  maximum  to  which  it  should  be 
carried  if  the  current  from  the  positive  pole  alone  should 
be  employed.  3.  The  method  of  applying  needles. 
Various  forms  of  needles  may  be  employed,  but  the  or- 
dinary steel  needle  gives  equally  satisfactory  results,  as 
the  eschar  produced  in  the  skin  at  the  point  of  entrance 
is  not  sufficient  to  amount  to  anything,  and  the  needles 
can  thus  be  changed  at  each  sitting.  That  only  one  of 
them  should  be  inserted  into  the  tumor,  while  the  nega- 
tive pole  should  be  attached  to  a  sponge  electrode  mois- 
tened with  a  salt  solution,  and  placed  upon  some  indif- 
ferent point,  care  being  taken  to  remove  it  from  point  to 
point  in  order  to  prevent  blistering  the  skin.  4.  Method 
of  attacking  the  tumor.  Better  results  are  -obtained  by 
passing  the  needle  in  from  the  periphery  of  the  growth 
on  a  line  horizontal  with  the  skin,  and  in  directions  ra- 
diating from  the  circumference  toward  the  centre. 
Several  of  these  punctures  should  be  made  at  each  oper- 
ation. The  length  of  the  entire  setting  should  not  ex- 
tend to  more  than  twenty  minutes  or  half  an  hour,  while 
intervals  of  two  to  three  weeks,  or  longer,  should  be  left 
between  operations  to  know  whether  there  may  not  be  a 
progressive  shrinking  away  of  the  tumor.  5.  As  to  the 
method  of  cure.  He  thought  that  several  elements  en- 
tered into  attaining  the  result,  of  which  the  coagulum  of 
the  blood  was  one,  and  perhaps  the  least.  The  two  re- 
maining elements  were  the  subsequent  contraction  of 
the  small  eschar  produced  in  radiating  lines  from  the 
tumor,  and  the  effect  of  the  current  upon  the  vasomotor 
nerve  supply. 

He  felt  sure  that  a  thorough  trial  of  this  method  as  to 
the  settling  of  the  various  points  considered,  would  re- 
sult in  its  adoption  in  the  treatment  of  perhaps  a  large 
majority  of  these  cases  where  we  have  a  large  elevated 
blood- tumor  with  which  to  deal.  He  also  believed  that 
perhaps  pricking  the  surface  with  the  needle  attached  to 
a  positive  pole  of  battery,  might  result  in  a  series  of 
small  scars,  which  would  result  in  removing  the  ugly 
port-wine  marks  so  common  in  this  trouble. 

Operations  for  Complete  Perineal  Laceration. — Dr. 
Joseph  Price,  of  Philadelphia,  said  that  there  are  many 
men  who,  essaying  to  be  authorities  on  the  surgical  dis- 
eases of  the  major  order,  have  no  conception  whatever  of 
injuries  of  the  perineum  and  cervix  so  far  as  their  intelli- 
gent repair  is  concerned.  Indeed,  there  are  many,  with 
a  large  obstetrical  practice,  who  labor  under  the  delusion 
that  they  have  never  ruptured  a  perineum,  and  that  all 
their  patients  have  entirely  normal  perinea.  This  mis- 
conception is  due  to  improper  teaching  more  than  to 
any  other  cause.  Perineal  lacerations,  unless  extending 
through  the  skin  to  or  through  the  sphincter  may  escape 
detection  unless  by  thorough  digital  examination.  All 
these  tears  should  be  approached  as  distinct  surgical 
lesions  to  be  repaired  in  the  line  of  their  anatomical  de- 
struction, and  not  as  cosmetic  operations,  whose  object 
is  to  obtain  superficial  appearances  without  regard  to 
perfection  and  utility.  Heaping  up  of  tissue  outside 
the  lines  of  resistance  and  tension,  or  mere  thickening  of 
mucous  membrane  and  skin  does  not  make  a  true  per- 
ineum, neither  does  a  set  of  outside  sutures,  however 
much  they  may  draw  the  parts  together,  afford  any  ana- 
tomical counterpart  of  a  perineum.  From  this  basis  all 
the  so-called  outside  flap-splitting  operations  for  perineal 
tears  are  only  puckering  operations,  bringing  parts 
within  the  sutures  that  have  never  been  severed,  and  in 
many  cases  taking  them  out  of  their  proper  relations. 
Big  sutures,  heavy  ligatures,  clumsy  instruments,  have  no 
more  place  here  than  in  other  surgery.  The  ordinary 
short,  strong  sewing  needle  fills  the  bill  exactly  in  most 


cases,  though  the  Emmet  stray-fine  short  needle  for  gen- 
eral use  is  preferable.  Silk-worm  gut  or  silver  wire  is  the 
preferable  suture.  The  Emmet  operation  as  originally 
suggested,  and  afterward  modified  by  its  distinguished  de- 
viser, is  the  foundation  for  all  successful  operations  on  the 
lacerated  perineum,  either  with  or  without  sphincter  tear. 

Dr.  Price,  in  closing,  said  the  tears  of  perinea  are 
often  unavoidable,  but  their  restoration  is  always  pos- 
sible, and  their  neglect  is  criminal. 

President's  Address. — President  Kollock  then  de- 
livered his  annual  address.  He  fiist  thanked  the  Asso- 
ciation for  the  honor  conferred  upon  him  in  electing 
him  as  President.  He  then  alluded  to  the  death  of  Drs. 
William  T.  Briggs,  of  Nashville,  and  A.  B.  Miles,  of 
New  Orleans.  Dr.  Briggs's  life  had  been  one  of  useful- 
ness, lie  had  done  excellent  and  remarkably  brilliant 
work,  and  had  achieved  an  enviable  reputation.  Dr. 
Miles,  who  had  been  made  Professor  of  Surgery  in 
Tulane  University,  was  a  man  full  of  youthful  activity 
and  manly  vigor,  who  by  patient  study  and  diligent  re- 
search, aided  by  a  brilliant  intellect,  had  won  for  himself 
a  high  position  in  the  profession,  and  in  the  estimation 
of  his  fellow-men.  To  know  him  was  to  admire  and  love 
him.  His  life  was  gentle  and  the  elements  so  mixed 
in  him,  that  Nature  might  stand  up  and  say  to  all  the 
world,  "  This  was  a  man." 

While  in  all  branches  of  gynecology  good  progress 
had  been  made,  he  noted  with  pleasure  that  surgery  had 
had  its  triumphs.  Many  reports  of  cases  show  enlarged 
experience  and  continual  improvement  in  the  treatment 
of  appendicitis,  hernia,  intestinal  obstruction,  and  many 
other  ills  that  flesh  is  heir  to. 

Action  of  Chloroform  on  the  Functions  of  the  Human 
Brain  and  Spinal  Cord. —  Dr.  Bedford  Brown,  of 
Alexandria,  Va.,  read  a  paper  on  this  subject.  He  cited 
the  history  of  two  cases  of  extensive  compound  com- 
minuted fracture  of  the  frontal  bone  and  serious  injury 
and  destruction  of  a  portion  of  the  frontal  lobes  of  the 
brain  as  the  basis  of  his  paper.  One  of  these  cases  of 
injury  was  caused  by  a  kick  of  a  newly  shod  horse,  the 
other  by  a  spent  grape-shot  in  battle.  The  subjects  of 
both  of  these  injuries  retained  perfectly  their  powers  of 
consciousness  and  sensation. 

The  fracture  in  the  first  case  involved  a  large  portion 
of  the  frontal  bone.  The  fractured  bones  were  driven 
back  into  the  substance  of  the  brain  quite  an  inch  in 
depth,  lacerating  the  frontal  lobes  extensively.  There 
was  a  loss  of  about  two  tablespoonfuls  of  brain.  During 
the  operation,  which  lasted  more  than  an  hour,  the 
patient  was  placed  under  the  influence  of  a  compound  of 
chloroform  three  parts,  and  ether  one  part,  four  different 
times.  Through  this  large  opening  in  the  skull  the  brain 
could  be  seen  perfectly  and  its  varying  changes  of  action 
under  chloroform  could  be  observed  perfectly.  The  in- 
variable action  of  the  anaesthetic  was  to  suppress  hemor- 
rhage, to  quiet  cerebral  pulsation  and  to  positively  reduce 
circulation  in  the  brain  and  arterial  tension.  These  pe- 
culiar effects  were  observed  as  many  as  three  or  four 
different  times.  When  the  patient  was  threatened  with 
collapse  from  chloroform,  stimulants  injected  in  the 
rectum  produced  increased  circulation  and  arterial  ten- 
sion in  the  brain  promptly. 

Any  struggling,  mental  excitement,  or  resistance  while 
inhaling  chloroform  caused  marked  increase  in  cerebral 
circulation  and  pulsation,  with  increase  of  hemorrhage. 

The  second  case  was  that  of  a  Confederate  soldier, 
who  in  battle  received  a  spent  grape-shot  in  his  fore- 
head, causing  an  extensive  compound  comminuted  fract- 
ure of  the  os  frontis,  driving  the  fractured  bones  back 
more  than  an  inch  into  the  frontal  lobes.  The  wound 
in  the  skull  was  quite  two  inches  in  diameter,  and  more 
than  an  inch  in  depth.  This  patient  was  subjected  to 
chloroform  three  times  during  the  operation,  which  lasted 
an  hour.  The  action  of  chloroform  on  the  functions  of 
the  brain  in  this  was  similar  to  that  in  the  first.  When 
under  full  anaethesia  each  time  the  cerebral  hemorrhage 
ceased,  the  cerebral  pulsations  diminished  to  a  mere 


792 


MEDICAL  RECORD. 


[December  22,  1894 


tremor,  and  the  arterial  circulation  was  markedly  re- 
duced. This  occurred  three  different  times  during  the 
operation.  The  action  of  alcoholic  stimulants  resorted 
to  in  this  case  to  prevent  collapse  from  chloroform  in- 
creased the  cerebral  pulsations  and  circulation  in  a  posi- 
tive manner. 

Hydro-Pyonephrosis ;  Successful  Removal  of  a  Forty- 
Pound  Tumor  of  the  Kidney.  —  Dr.  Joseph  Taber 
Johnson,  of  Washington,  D.  C,  reported  the  case. 
The  patient  was  sixty-three  years  of  age,  and  had  in- 
herited and  possessed  until  five  years  ago  a  remarkably 
good  constitution.  At  this  time  a  lump  appeared  in  his 
right  side  in  the  region  of  the  liver,  and  was  supposed  up 
to  the  date  of  the  operation  to  be  caused  by  enlargement 
and  abscess  of  that  organ.  This  lump  gradually  in- 
creased in  size,  and  the  patient  had  gradually  lost  flesh 
and  strength  until  the  date  of  the  removal  of  the  lump, 
when  he  could  not  have  weighed  more  than  eighty 
pounds.  At  no  time  did  he  suffer  from  pain,  and  only 
a  few  weeks  with  fever. 

There  were  several  points  of  interest  in  this  case,  viz  : 
failure  of  a  number  of  good  men  to  make  a  diagnosis, 
though  the  patient  was  under  observation  for  nearly  five 
years.  Failure  of  repeated  examinations  of  the  urine  to 
detect  the  slightest  evidence  of  disease  of  the  kidney. 
The  only  explanation  the  writer  suggests  is  that  the  dis- 
ease at  the  time  of  analysis  and  subsequently  had  so  de- 
stroyed the  function  of  the  kidney  as  to  prevent  the  es- 
cape of  any  urine  at  all,  and  that  the  specimen  examined 
came  from  the  other  organ,  which  fortunately  was 
healthy.  Failure  of  such  large  quantities  of  foul  smell- 
ing pus  to  produce  more  sepsis.  Absence  all  through  the 
history  of  pain  or  fever.  The  median  line  incision,  the 
separate  ligation  of  the  renal  vessels,  and  the  ligation 
and  dropping  of  the  ureter. 

The  writer  is  aware  that  the  lumbar  incision  is  pre- 
ferred by  nearly  all  nephrectomists,  and  that  they  often 
bring  out  the  cut  end  of  the  ureter  and  fasten  it  to  the 
abdomen.  While  the  lumbar  incision  may  be  best  in 
small  tumors  and  otherwise  disease  of  kidneys,  it  cer- 
tainly could  not  have  succeeded,  the  author  believes,  in 
a  case  of  the  magnitude  of  the  one  here  reported,  not 
only  on  account  of  its  great  size,  but  also  because  of  its 
being  so  extensively  adherent  to  the  omentum  and  ab- 
dominal wall.  The  colon  had  to  be  carefully  separated 
from  the  anterior  surface  of  the  tumor. 

Gunshot  Wounds  of  the  Abdomen. — Dr.  W.  L.  Rob- 
inson, of  Danville,  Va.,  reported  two  gunshot  wounds  of 
the  abdomen,  lacerating  the  liver  and  bowel.  In  neither 
case  were  the  symptoms  commensurate  with  the  injury ; 
neither  shock,  hemorrhage,  nor  pulse  portrayed  the  ne- 
cessity for  operation.  Yet  in  view  of  the  ninety-two  per 
cent,  mortality  from  gunshot  wounds  of  the  abdomen 
without  operation,  he  did  not  hesitate.  The  first  case 
came  so  near  dying  on  the  table  and  his  light  being  im- 
perfect at  12  o'clock  at  night,  he  only  found  the  liver 
wound,  failing  to  find  the  hole  in  the  posterior  border  of 
the  hepatic  flexure  of  the  colon.  The  patient  died  in 
three  days.  His  second  case  was  operated  on  promptly, 
and  the  injury  in  the  transverse  and  descending  colon 
was  promptly  repaired  with  the  Murphy  button.  The 
man  was  on  a  spree  and  had  had  no  action  from  bowels 
for  three  days.  He  pressed  out  much  fecal  matter,  but 
should  have  taken  more  time  and  ruptured  the  bowel  as 
far  as  practicable.  For  two  dap  no  unfavorable  symp- 
toms presented  themselves,  but  on  the  night  of  the  sec- 
ond day  distress  from  tympanites  and  pain  began.  He 
suggested  to  his  associates  the  propriety  of  reopening  the 
abdomen,  but  enemata  and  grain  doses  of  calomel  were 
tried.  This,  the  author  considered,  was  his  fatal  mistake, 
for  the  waiting  of  ten  hours  had  lost  him  the  chance  of  a 
life-saving  operation.  He  reopened  and  with  medium 
trocar  emptied  the  bowel  of  gas,  but  exudative  lymph 
was  manifest  on  bowels,  and  obstruction  of  button  by 
fasces  existed.  The  button  held  its  tissue  firmly,  and  no 
leakage  had  occurred.  He  washed  out  the  cavity,  but  pa- 
tient died  in  ten  hours  of  shock. 


Movable  Kidney.— This  paper  was  read  by  Dr. 
George  Ben  Johnston,  of  Richmond,  Va.  At  the  out- 
set the  author  emphasized  three  propositions :  1.  Mova- 
ble kidney  is  extremely  common.  2.  It  is  capable  of 
producing  very  distressing  symptoms,  and  in  many  in- 
stances is  a  menace  to  life.  3.  It  is  curable  by  a  simple 
and  safe  operation. 

The  author's  own  experience  with  movable  kidney 
from  a  surgical  standpoint  extends  back  a  little  more  than 
three  years.  Prior  to  the  first  nephrorrhaphy,  which  he 
performed  in  May,  1891,  those  cases  he  has  met  with 
were  given  little  or  no  thought.  Since  the  date  men- 
tioned, he  has  looked  with  more  interest  on  his  cases,  and 
has  come  to  marvel  at  the  frequency  of  the  malady.  He 
has  examined  a  limited  number  of  persons  likely  to  be 
the  subjects  of  movable  kidney  since  his  first  operation 
for  its  relief,  and  in  a  comparatively  small  number  of 
subjects  he  has  encountered  twenty-seven  cases.  Ede- 
bohls,  who  had  studied  five  hundred  cases,  fixes  the  rate 
at  one  for  every  five  or  six  women  examined.  Under 
gives  about  the  same  rate.  Osier  makes  no  statistics, 
but  mentions  it  as  a  common  occurrence  in  his  hospital 
wards.  The  records  of  these  observers  and  Dr.  John- 
ston's cases  justify  the  assertion  that  it  is  a  ^pmmon 
malady. 

It  occurs  more  often  in  women.  He  had  never  seen 
one  in  a  male  subject.  Age  is  a  factor  in  its  production. 
His  own  cases  have  been  in  subjects  varying  in  age  from 
twenty  to  thirty-five  years.  In  only  one  instance  has  he 
seen  it  in  a  women  over  forty.  Both  kidneys  may  be 
movable  at  the  same  time.  The  right  is  the  one  that  is 
affected  in  the  preponderating  majority  of  the  observed 
cases.  This  is  accounted  for  by  the  relation  of  the  kid- 
ney to  the  liver  on  this  side. 

Two  anatomical  facts  help  to  explain  the  preponder- 
ance of  the  right  over  left  kidney  displacement.  1,  The 
greater  length  of  the  right  renal  artery,  and  a,  the  firmer 
attachments  of  the  left  kidney.  The  author  has  twice 
seen  a  movable  kidney  follow  obstruction  of  the  ureter. 
It  happened  that  both  of  these  cases  were  on  the  left 
side.  The  increased  weight  of  the  kidney  due  to  accu- 
mulated urine  and  congestion  must  have  played  an  impor- 
tant part  in  the  etiology  of  the  dislocation  in  these  two 
cases. 

In  many  cases  of  movable  kidney  there  are  no  symp- 
toms. In  others,  the  symptoms  are  extremely  distressing, 
producing  great  mental  disquietude,  as  well  as  intense 
physical  suffering.  In  a  proportion  of  cases  the  symp- 
toms are  grave.  Torsion  of  the  ureter  is  common,  partial 
occlusion  by  bending  is  not  uncommon,  inducing  a  dis- 
tention of  the  pelvis  by  dammed- up  urine.  Hydro- 
nephrosis may  follow.  Calculus  is  thus  invited  by  reason 
of  poor  drainage.  Apart  from  tumors  of  the  kidney  itself, 
the  condition  most  likely  to  be  mistaken  for  movable 
kindey  is  distended  gall-bladder. 

Nephrorrhaphy  is  not  indicated  in  every  case  of  dislo- 
cated kidney,  but  only  in  such  cases  as  manifest  distress- 
ing or  dangerous  symptoms.  When  gastrointestinal 
disturbance  impairs  the  general  health,  when  nervous 
symptoms  are  severe,  when  the  dragging  abdominal  pains 
are  constant,  when  disease  of  other  organs  is  simulated, 
when  hydronephrosis  is  threatened,  when  one  or  more 
attacks  of  torsion  have  occurred,  the  operation  is  imper- 
ative. 

The  author  then  outlined  his  method  of  operating  on 
movable  kidney,  and  closed  his  paper  with  a  report  of 
seventeen  cases. 

Acute  Peritonitis. — Dr.  Richard  Douglas,  of  Nash- 
ville, read  a  paper  with  this  title.  Appreciating  the 
condition  under  which  the  colon  bacillus  will  escape 
from  its  natural  habitat  and  become  actively  pathogenic, 
and  knowing  the  supply  is  unlimited,  the  dose  being 
governed  alone  by  the  integrity  of  the  bowel,  naturally 
we  accord  to  this  bacillus  the  first  place  in  the  causation 
of  peritonitis. 

In  obedience  to  the  teachings  of  experimental  work> 
the  surgeon  must  accept  the  classification  of  Pawlowski 


December  22,  1894] 


MEDICAL   RECORD. 


793 


of  two  forms  of  peritonitis.  1.  That  produced  by  chem- 
ical agents,  with  which  we  are  not  concerned,  2.  That 
produced  by  infection.  The  latter  is  more  tangible.  It 
is  fully  in  accord  with  our  idea  of  the  genesis  of  the  dis- 
ease. It  harmonizes  with  clinical  work.  With  Mor- 
decai  Price,  the  author  agrees  that  every  case  of  general 
peritonitis  has  a  demonstrable  cause,  and  that  cause  is 
septic  in  character.  Pathological  manifestations  of  peri- 
toneal infection  are  subject  to  many  variations  which,  in 
a  great  measure,  indicate  the  virulence  of  the  poison  and 
guide  us  in  forming  a  prognosis,  but  to  simplify  matters, 
the  author  considered  it  under  two  heads,  which  illus- 
trated the  microscopic  and  macroscopic  changes  the 
results  of  general  peritonitis. 

It  is  an  indisputable  fact  that  the  type  and  virulence 
of  the  inflammation  is  largely  dependent  upon  the  origin, 
hence  in  our  bed-side  work  we  may  consider  the  subject 
under  the  following  etiological  classification : 

Infection  from  Without.— Immediate :  This  is  direct 
infection  of  the  peritoneal  membrane  through  penetrat- 
ing wounds  of  the  abdomen,  either  accidental  or  surgi- 
cal. Mediate :  This  form  embraces  all  cases  of  contami- 
nation of  the  peritoneum  occurring  from  extension  of 
adjacent  infected  areas,  as  leakage  from  mural  abscesses, 
or  puerperal  infection. 

Infection  from  Within. — Immediate:  Visceral  per- 
foration or  rupture  and  direct  inoculation  of  the  perito- 
neal membrane  with  escaping  contents,  as  in  perforating 
typhoid  or  gastric  ulcer,  appendicitis,  or  rupture  of  gut 
and  bladder.  Mediate:  Infection  by  emigration  of 
micro-organisms  through  visceral  wall  of  impaired  resist- 
ance, as  in  incarcerated  hernia,  intestinal  obstruction, 
ruptured  ovarian  cyst. 

The  author  then  reported  a  few  illustrative  cases. 
One  case  was  reported  of  general  purulent  peritonitis. 
The  patient  recovered,  and  the  author  considers  that  it 
was  due  entirely  to  free  incisions,  thorough  irrigation, 
and  ample  drainage. 


Third  Day,  Thursday,  November  15TH. 

History  of  Vaginal  Extirpation  of  the  Uterus.— Dr. 
George  J.  Englemann,  of  St.  Louis,  read  a  paper  on 
this  subject,  in  which  he  stated  that  at  the  New  Orleans 
meeting  of  the  Association  he  was  deeply  interested  in 
vaginal  hysterectomy,  which  he  presumed  was  a  com- 
paratively new  operation  with  very  recent  modifications ; 
but  Dr.  Lewis,  of  that  city,  called  his  attention  to  an 
old  French  pamphlet,  showing  that  the  operation  had 
been  done  in  the  '20's.  Since  then  he  has  found  it  was 
done  still  earlier,  precisely  as  it  is  done  to-day,  the  opera- 
tion having  developed  step  by  step. 

Dr.  Lewis,  of  New  Orleans,  La.,  in  the  discussion 
stated  that  the  first  vaginal  hysterectomy  was  performed 
by  Dr.  Dabourg  in  the  little  town  of  Autell,  France. 

Reminiscences  of  Br.  J.  Marion  Sims  in  Paris. — Dr. 
Edmond  Souchon,  of  New  Orleans,  La.,  read  a  paper 
with  this  title  (see  p.  705). 

Cancer  of  the  Gravid  Uterus.— Dr.  George  H. 
Noble,  of  Atlanta,  Ga.,  read  a  paper  entitled,  "  A  Case 
of  Carcinoma  of  the  Parturient  Uterus,  Removed  Three 
Days  after  Confinement ;  Recovery."  The  woman  had 
previously  been  confined,  sustaining  a  laceration  of  the 
cervix  uteri,  which  perhaps  was  a  factor  in  the  cause  of 
the  disease.  In  the  first  few  months  of  the  last  preg- 
nancy the  patient  was  treated  locally  by  her  family  phy- 
sician, and  there  was  nothing  to  cause  a  suspicion  of  ma- 
lignancy. Almost  the  entire  vaginal  portion  of  the 
cervix  was  destroyed,  less  than  one- fourth  of  its  circum- 
ference remaining  intact.  The  induration  extended 
deep  into  the  uterine  tissue,  but  could  not  be  felt  be- 
yond the  limits  of  that  organ.  The  roughened  ulcerated 
surface  was  easily  traced  for  a  considerable  distance 
within  the  cervix,  the  os  being  dilated  to  about  five  cen- 
timetres in  diameter.  Her  condition  was  unpromising, 
and  surgical  interference  was  clearly  interdicted,  so  the 


os  and  vagina  were  cleansed  thoroughly  and  lightly 
dressed  with  gauze.  She  was  then  placed  profoundly 
under  the  influence  of  morphia  sulphate  with  a  view  of 
arresting  labor,  securing  rest,  and  recuperation  sufficient 
to  permit  evacuation  of  the  uterus,  which  occurred  spon- 
taneously twelve  hours  later.  The  child  was  poorly 
nourished  and  lived  only  a  few  weeks,  finally  dying  of 
inanition. 

The  main  point  in  the  paper  was  to  show  the  feasibil- 
ity of  hysterectomy  in  the  puerperal  state  for  cancer  of 
the  uterus,  as  the  case  reported  clearly  demonstrated, 
even  though  it  is  too  early  to  claim  immunity  from  the 
return  of  the  disease. 

Ligation  of  Arteries.— Dr.  John  A.  Wyeth,  of  New 
York,  reported  two  cases  of  ligation  of  the  external 
carotid  artery.  The  reason  for  narrating  these  two  cases 
was  to  bring  before  the  Association  a  consideration  of  the 
inflammatory  changes  which  occur  in  arteries  which 
have  been  ligated,  and  to  discuss  at  length  the  best 
methods  to  pursue  in  these  operations  to  secure  the 
greatest  safety  to  the  patient. 

In  tying  arteries,  an  important  point  to  consider  is 
the  selection  of  a  ligature.  It  seems  to  the  author  that 
in  the  animal  ligatures,  and  especially  in  well-prepared 
and  properly  asepticized  catgut  is  found  the  best  ligature 
material.  For  the  last  ten  years  he  had  used  catgut 
almost  without  exception,  only  once  or  twice  using  silk, 
and  then  in  the  ligation  of  the  large  venous  trunk  close 
to  the  root  of  the  neck,  in  which  he  was  fearful  that  the 
animal  ligature  might  slip  from  the  blood-pressure  in  the 
act  of  vomiting  as  the  patients  came  out  from  under  the 
influence  of  the  anaesthetic. 

Porta,  in  four  hundred  experiments,  found  that  in 
from  one  to  two  years,  seventy  per  cent,  of  catgut  liga- 
ture had  become  absorbed,  thirty*  six  per  cent,  of  silk, 
sixty-six  per  cent,  of  hemp  and  flax,  and  twenty  per 
cent,  of  horse-hair.  Order  of  rapidity :  catgut,  hemp, 
silk,  horse-hair. 

Simultaneous  Appearance  of  Canoer  in  Breast  and 
Uterus.— This  paper  was  read  by  Dr.  James  Evans,  of 
Florence,  S.  C.  The  subject  of  this  interesting  manifes- 
tation of  the  disease  was  a  lady  of  fifty-three  years  of 
age,  married,  and  the  mother  of  six  children.  A  striking 
peculiarity  in  the  history  of  the  case  was,  that  when  the 
disease  was  most  active  and  destructive  in  the  breast,  it 
rather  checked  and  retarded  its  tendency  in  this  direction 
in  the  uterus.  Excision  of  the  cervix  and  removal  of  the 
breast  were  proposed,  but  declined. 

Tke  author  closed  by  saying  that  although  there  is  a 
very  general  concensus  of  opinion  among  surgeons  that 
the  most  successful  treatment  of  cancer  affecting  the 
breast  and  uterus  is  early  and  radical  removal  by  the 
knife,  yet  it  is  doubtful  in  the  opinion  of  the  author  if 
the  operation  is  advisable  when  the  disease  appears  in 
multiple  form  and  in  distant  organs.  When  the  disease 
is  confined  solely  to  the  uterus  and  recognized  at  an  early 
stage  of  its  invasion,  the  prompt  removal  of  the  organ  is 
usually  followed  by  permanent  recovery ;  in  fact,  recur- 
rence less  often  takes  place  than  removal  from  any  other 
organ  or  part  of  the  body. 

Varicocele. — Dr.  W.  E.  Parker,  of  New  Orleans, 
reported  seven  cases  of  varicocele  treated  by  incision, 
ligation,  and  shortening  of  the  scrotum.  An  incision, 
varying  in  length  according  to  the  size  of  the  varicocele 
is  made,  and  the  scrotum  shortened  by  converting  the 
wound  from  a  longitudinal  into  a  transverse  one.  All 
cases  which  recovered  with  union  by  first  intention  are 
still  doing  well,  the  period  since  the  first  operation  being 
seven  months.  At  the  conclusion,  he  laid  the  following 
general  indications  for  the  treatment  of  varicocele.  The 
milder  form  should  be  treated  with  a  suspensory  bandage 
with  proper  attention  to  diet,  exercise,  and  bowels.  A 
varicocele  should  be  operated  upon:  r.  If  it  is  of  large 
size.  2.  If  it  is  painful.  3.  If  marked  nervous  symp- 
toms are  present.  4.  If  the  testicle  is  atrophying.  5.  If 
the  varicocele  is  increasing  rapidly.  6.  If  it  is  an  obsta- 
cle to  entering  a  public  service.     7.  If,  on  account  of  a 


794 


MEDICAL  RECORD. 


[December  22,  1894 


patient's  occupation,  a  suspensory  is  troublesome  and  he 
desires  an  operation. 

Eibroid  Tumor  of  the  Uterus  with  Suppurating 
Ovary  Discharging  per  Rectum. — Dr.  Rufus  B.  Hall, 
of  Cincinnati,  O.,  reported  the  following  case :  The  pa- 
tient,  aged  forty-four,  ,was  known  to  have  a  fibroid  tumor 
for  five  years.  She  had  suffered  from  sepsis  for  five 
weeks  previous  to  the  operation.  In  addition  to  the 
fibroid  tumor  was  a  large  suppurating  ovary  holding  about 
two  pints  of  pus,  which  was  discharged  per  rectum  every 
eight  or  ten  days.  The  suppurating  ovary  was  densely 
adherent,  and  after  its  removal  disclosed  a  large  opening 
in  the  rectum.  The  operation  included  total  extirpation 
of  the  fibroid  uterus  with  the  suppurating  ovary,  and  re- 
pair of  the  intestinal  rent.  There  was  no  leakage  of  the 
injured  bowel  after  the  operation.  The  patient  recov- 
ered. 

The  speaker  drew  the  following  conclusions:  The 
question  of  operation  during  sepsis  is  one  that  will  admit 
of  discussion  both/*?  and  con,  but  in  the  end  it  must  be 
decided  by  the  merits  of  the  individual  cases  and  not  by 
rule.  As  to  technique,  total  extirpation  was  given  the 
preference,  as  it  gives  the  ideal  condition  both  theoreti- 
cally and  practically  for  after  treatment.  The  Baer 
method  was  condemned,  as  it  does  not  give  thorough 
drainage — a  thing  absolutely  necessary  where  there  are 
extensive  raw  surfaces  which  have  been  bathed  in  pus, 
and  no  peritoneum  to  close  off  the  general  peritoneal 
cavity.  The  strengthening  of  the  suture  line  with  a  tag 
of  adventitious  tissue  was  advised.  The  packing  of  the 
pelvis  with  gauze  to  protect  the  cavity  from  intestinal 
leakage,  should  any  occur,  and  to  prevent  intestinal  ad- 
hesions, was  recommended.  The  gauze  is  usually  re- 
moved on  the  fourth  day  and  peroxide  of  hydrogen  used 
as  a  wash  for  the  cavity  several  times  daily. 

Again,  forcible  dilatation  of  the  sphincter-am  muscle 
to  cause  incontinence,  thus  relieving  the  intra-intestinal 
pressure  from  accumulating  gases,  the  doctor  says,  adds 
greatly  to  the  chances  for  recovery.  He  first  employed 
it  for  this  purpose  on  February  6,  1893,  m  *&  operation 
for  extrauterine  pregnancy  with  extensive  bowel  injury, 
the  patient  recovering.  He  says,  as  far  as  he  knows,  he 
is  the  first  man  to  practice  forcible  dilatation  for  this 
purpose. 

Pelvic  Surgery.— Dr.  J.  G.  Earnest,  of  Atlanta,  Ga., 
contributed  a  short  paper  in  which  he  reported  some 
complicated  cases  of  pelvic  surgery.  Two  cases  were 
detailed  simply  to  illustrate  a  method  of  treatment  that 
under  certain  circumstances  is  safer  for  the  patient  and 
just  as  apt  to  give  relief  of  symptoms  as  total  extirpation 
of  the  tumor ;  also  to  emphasize  a  growing  conviction 
the  author  has  that  intestinal  adhesions  are  frequently 
tinkered  with  when  it  would  be  best  to  let  them  alone. 
The  essayist  was  no  advocate  of  timid  and  imperfect 
surgery,  but  in  cases  where  the  tumor  can  be  effectually 
dealt  with  without  disturbing  old,  thoroughly  organized 
adhesions,  which  the  history  and  condition  of  the  patient 
clearly  show  to  be  harmless,  and  in  view  of  the  fact  that 
if  those  adhesions  are  loosened  they  will  almost  certainly 
anchor  at  some  other  point  where  they  may  be  a  source 
of  constant  annoyance,  or  even  produce  a  fatal  obstruc- 
tion of  the  bowel,  he  believes  it  best  to  leave  diem  undis- 
turbed. 

The  Removal  of  an  Intra  uterine  Eibroid  Tumor 
by  Moroellement  without  Hemorrhage.— Dr.  Herbert 
M.  Nash,  of  Norfolk,  Va.,  read  a  short  paper  on  this 
subject.  In  September,  189a,  he  saw  in  consultation 
Mrs.  A ,  aged  about  forty-two,  the  subject  of  intract- 
able hemorrhages  from  the  uterus,  lasting  from  two  to 
three  weeks  of  each  month,  and  which  had  been  habitual 
for  several  years.  The  uterus  could  be  plainly  felt  above 
the  pubes,  and  by  the  conjoined  method,  sound,  etc., 
the  diagnosis  of  intra  uterine  fibroid  was  made.  Not 
wishing  at  that  time  any  radical  procedure,  she  contin- 
ued under  the  care  of  her  physician,  whose  best  efforts  to 
control  the  hemorrhage  proved  fruitless.  On  July  ix, 
1893,  she  entered  the  hospital  for  surgical  treatment. 


On  August  26th  the  essayist  operated  under  ether.  It 
was  found  quite  impossible  to  dilate  the  os  to  the  extent 
desired,  but  there  was  room  enough  for  the  manipulation 
without  dividing  the  cervix,  and  no  difficulty  was  found 
in  seizing  the  presenting  mass — the  attachment  of  which 
to  the  uterine  walls  had  been  made  out  to  be  sessile — 
with  a  strong  vulsellum.  Upon  making  traction  with 
some  force,  in  order  to  determine  the  best  method  of 
procedure,  the  tissue  gave  way,  and  the  withdrawn  part 
of  the  detached  mass  was  quite  large,  but  no  bleeding 
followed.  This  fact  decided  the  doctor  to  proceed  by 
morcellement,  and  with  forcepr,  scissors,  and  the  instru- 
ment he  exhibited,  the  whole  growth  was  removed  piece- 
meal, and  with  only  a  slightly  colored  serous  discharge. 
The  previous'  packing  had  been  so  effectual  that  the  growth 
itself,  and  indeed  the  uterine  walls,  appeared  to  have  been 
exsanguinated.  The  fragments  removed,  when  under 
strong  compression,  presented  a  mass  of  fibroid  tissue 
nearly  as  large  as  an  ordinary  cocoanut.  When  the  pa- 
tient left  the  hospital  the  uterus  had  contracted  firmly, 
and  measured  a  fraction  over  three  and  one  half  inches 
in  depth,  occupied  its  proper  position  in  the  pelvis,  and 
the  patient  is  to  day  entirely  well,  with  perfectly  noimal 
functions. 

Election  of  Officers. — The  following  officers  were 
elected  :  President,  Dr.  Louis  McLane  Tiffany,  of  Balti- 
more, Md. ;  First  Vice  President,  Dr.  Ernest  S.  Lewis, 
of  New  Orleans,  La. ;  Second  Vice-President,  Dr.  Man- 
ning Simon,  of  Charleston,  S.  C;  Treasurer,  Dr.  Rich- 
ard Douglas,  of  Nashville,  Tenn.;  Secretary,  Dr.  W.  E. 
B.  Davis,  of  Birmingham,  Ala. 

After  introducing  and  adopting  resolutions  of  thanks, 
the  Association  adjourned  to  meet  in  the  city  of  Wash- 
ington, D.  C,  the  second  Tuesday  in  November,  1895. 


THE  NEW  YORK  PATHOLOGICAL  SOCIETY. 

Stated  Meeting,  November  14,  1894. 

George  C.  Freeborn,  M.D.,  President,  in  the  Chair. 

Spontaneous  Babbit  BepticsBinia. — Dr.  Alexander  Lam- 
bert reported  a  spontaneous  outbreak  of  septicaemia  hem- 
orrhagica occurring  among  rabbits.  Among  the  rabbits 
confined  in  the  animal  house  connected  with  the  patho- 
logical laboratory  of  the  College  of  Physicians  and  Sur- 
geons, there  occurred  in  January,  1894,  a  large  number 
of  deaths  from  an  unknown  cause.  These  deaths  were 
among  the  rabbits  which  had  been  operated  upon,  and 
among  the  healthy  animals.  The  majority  of  these  rab- 
bits were  fresh  from  the  country,  and  had  been  confined 
but  a  few  days  in  the  animal  house.  Nearly  thirty  died 
within  two  weeks.  Autopsies  showed,  in  the  majority  of 
cases,  a  slight  congestion  of  the  lungs  and  an  enlargement 
of  the  spleen.  All  the  other  organs  were  apparently  nor- 
mal. Cover  glass  smears  and  cultures  of  the  heart's  blood 
of  several  of  these  animals,  gave  a  small  bipolar  stained 
bacillus,  the  morphology  and  biology  of  which,  the 
speaker  said,  he  would  give  later  on  in  these  remarks. 
In  one  case  there  was  a  universal  exudative  peritonitis. 
The  exudate  was  largely  fibrinous,  with  but  little  puru- 
lent fluid,  and  the  intestines  were  matted  together.  The 
spleen  was  large  and  dark ;  the  other  abdominal  organs 
were  apparently  normal.  Both  pleural  cavities,  and  the 
pericardial  sac,  were  filled  with  fibrinous  exudate  and  pur- 
ulent fluid.    The  lungs  were  congested. 

In  one  other  case  the  abdominal  organs  were  apparently 
normal,  except  that  the  spleen  was  small  and  pale.  Both 
lungs  were,  however,  crowded  and  flattened  against  the 
vertebral  column  by  an  abundant  exudate.  The  exuda- 
tion in  the  right  pleural  cavity  was  reddish-yellow  and 
fibrinous,  and  that  in  the  left  pleural  cavity  was  a  yellow 
purulent  fluid.  The  pericardium  was  also  filled  with  a  yel- 
low purulent  fluid. 

Cover-glass  smears  and  cultures  of  the  peritoneal  and 
pleural  exudates  gave  a  bipolar  stained  bacillus,  similar 
to  that  in  the  heart's  blood  of  the  other  rabbits  already 


December  22,  1894} 


MEDICAL  RECORD. 


795 


mentioned,  and  having  the  following  characters:  The 
bacillus  was  small  and  round-ended,  the  ends  being  more 
deeply  stained  than  the  centre.  Sometimes  the  bacillus 
was  uniformly  stained,  especially  after  being  in  contact 
for  a  long  time  with  the  staining  fluid.  These  bacilli 
may  present  themselves  as  small  ovoids,  hard  to  differen- 
tiate from  cocci.  They  stain  easily  with  the  anilin  colors, 
but  are  decolorized  by  Gram's  method.  The  size  varies 
from  1.5  i*.  long  by  0.56  ft  broad,  to  0.7  p,  long  by  0.49 
ft  broad,  the  average  being  1.1  /x  long  by  0.53  p.  broad. 
They  appear  single,  and  sometimes  united  in  pairs  or  in 
rows  of  three  to  four  elements.  They  are  non-motile, 
and  do  not  liquefy  gelatin.  In  gelatin  plates  they  form 
small,  light  yellow,  finely  granular,  sharp-edged  colonies, 
which,  after  a  few  days,  usually  show  a  darker  yellow  cen- 
tre and  concentric  rings.  The  deeper  colonies  are  of  the 
same  appearance.  The  colonies  are  often  circular,  often 
ovoid.  Sometimes  the  colonies  just  below  the  surface 
seem  to  grow  better  than  the  surface  colonies.  In  punct- 
ures in  gelatin  the  growth  usually  commences  just  below 
the  surface,  extending  in  a  thin,  white,  finely  granular 
streak  to  the  bottom  of  the  puncture,  the  lower  half  of 
the  growth  being  made  of  fine,  separate  dots.  The  upper 
half  of  the  growth  is  formed  by  the  coalescence  of  the 
small  colonies.  The  growth  remains  slight.  Sometimes 
there  is  a  surface  growth ;  when  this  occurs  it  is  a  gray- 
white,  slightly  raised  growth  extending  but  little  around 
the  puncture  opening.  In  agar  at  37.50  C,  a  thin, 
smooth  edged  surface  growth  occurs,  extending  not  far 
beyond  the  inoculation  line.  This  is  a  bluish-white 
by  transmitted  light,  gray- white  by  reflected  light.  The 
growth  extends  to  the  bottom  of  a  puncture,  and  slightly 
around  the  puncture  opening.  The  growth  is  similar,  but 
slower  at  room  temperature.  On  Wurtz  litmus,  lactose 
agar,  a  good  growth  occurs,  but  with  no  change  in  the 
color  of  the  litmus,  and  without  formation  of  gas.  In 
simple  meat  broth  (one  per  cent,  commercial  peptone, 
one- half  per  cent,  salt,  and  meat  infusion)  the  growth  is 
abundant,  causing  a  diffuse  turbidity  of  the  medium  with 
a  whitish  ring  around  the  edge  at  the  surface  of  the  broth, 
with  an  abundant  grayish-white  viscid  sediment.  At 
times  the  growth  is  more  flocculent  than  at  others.  The 
broth  remains  turbid  after  two  months.  With  growth 
for  forty-eight  hours  at  37.5°  C.  in  broth  with  one  per 
cent,  peptone,  and  half  per  cent,  salt,  the  indol  reaction 
is  obtained  by  the  addition  of  sulphuric  acid  without  the 
addition  of  nitrites. 

In  a  bent  tube  containing  broth  with  one  quarter  per 
cent,  peptone,  one  half  per  cent,  salt,  and  two  per  cent, 
glucose,  the  medium  becomes  turbid,  but  no  gas  is 
formed,  the  growth  occurring  more  abundantly  in  the 
open  than  in  the  closed  end  of  the  tube.  In  broth  with 
o.r  per  cent,  peptone,  and  0.02  per  cent,  potassium  ni- 
trate, on  addition  of  six  drops  of  naphthalamine  sulphate 
and  a  few  crystals  of  sodium  anilate,  it  gives  a  pink  color, 
showing  that  it  reduces  the  nitrates  to  nitrites.  The 
bacillus  grows  in  milk  without  coagulation,  but  with' the 
formation  of  an  acid. 

As  a  rule,  I  have  not  been  able  to  obtain  any  visible 
growth  on  potato,  though  a  very  slight  invisible  growth 
was  proven  to  exist.  The  one  exception  to  this  rule  was 
in  the  case  of  the  rabbit  with  pleurisy  without  peritonitis. 
This  single  exception  may  have  been  due  to  some  differ- 
ence in  the  composition  of  the  potato  itself,  as  potatoes 
reacting  0.2  per  cent.,  and  0.08  per  cent,  acid  to  phen- 
olphtalein  were  used.  A  moderate  growth  was  obtained 
in  an  anaerobic  hydrogen  broth- tube. 

To  test  the  pathogenesis  of  the  above  germs,  broth- 
cultures,  grown  for  forty  eight  hours  at  37.50  C,  were 
used.  Seven  rabbits  were  given  intra-peritoneal  injec- 
tions of  r  c.c.  or  2  c.c.  Two  rabbits  were  injected  with 
germs  obtained  from  the  heart-blood  culture,  2  c.c.  be- 
ing given  to  each.  Both  were  found  dead  in  thirty 
hours.  Two  were  injected  with  germs  from  the  pleurisy 
cultures,  one  of  them  with  2  c.c.  and  the  other  with  1 
c.c.  The  former  was  found  dead  in  thirty  hours,  and 
the  latter  in  thirty-six  hours.    Three  were  inoculated 


with  germs  from  the  peritonitis  cultures,  the  first  with 
2  c.c,  the  second  with  2  c.c,  and  the  third  with  1  c.c. 
The  first  animal  was  found  dead  in  sixteen  hours ;  the 
second  rabbit  remained  alive ;  the  third  remained  alive 
even  after  receiving,  one  week  later,  2  c.c.  more.  The 
inoculations  were  made  late  in  the  afternoon,  and  on  the 
following  morning  it  was  found  that  the  animals  had  lost 
their  appetite,  that  they  remained  crouching  in  a  corner, 
and  could  not  be  made  to  run  around,  and  that  when 
laid  on  their  sides  they  regained  their  crouching  posi- 
tion with  difficulty.  When  handled,  they  showed  no 
evidence  of  pain.  Two  had  a  decided  diarrhoea.  The 
autopsies  showed  the  animals  emaciated  \  the  bellies 
more  or  less  distended ;  the  inguinal  and  axillary  glands 
enlarged  and  congested ;  the  subcutaneous  vessels  over 
the  abdominal  wall  filled  with  blood.  Where  the  needle 
had  passed  through  the  abdominal  wall  was  an  area  of 
purulent  hemorrhagic  oedema  of  considerable  extent. 
In  two  cases  this  was  very  large.  It  did  not  infiltrate 
the  abdominal  wall  itself  to  any  great  extent,  but  was 
superficial  in  the  subcutaneous  tissue.  On  opening  the 
abdominal  cavity,  the  intestines  were  seen  to  be  adhe- 
rent to  the  parieties,  and  glued  together  with  purulent 
fibrinous  masses.  Over  the  surface  of  the  large  intestine 
were  scattered  petechial  hemorrhagic  spots,  and  large 
and  small  hemorrhagic  areas.  The  small  intestine  did 
not,  as  a  rule,  show  a  hemorrhagic  inflammation,  though 
in  one  case  it  was  very  marked,  the  Peyers  patches 
showing  deeply  infiltrated  with  blood,  and  the  stomach 
on  its  greater  curvature,  and  extending  over  on  to  the 
lesser  curvatures,  showing  a  great  number  of  trans- 
verse hemorrhagic  striations.  The  omentum  always 
showed  numerous  hemorrhagic  areas.  The  parietal 
peritoneum  was  congested.  The  fluid  exudate  varied 
from  a  slight  increase  of  serous  fluid  to  a  large  amount 
of  turbid,  purulent  fluid,  or  bloody  exudate.  The  spleen 
was  invariably  large  and  soft,  and  of  a  deep  purple  color. 
The  liver  and  kidneys  were  normal  in  appearance.  The 
lungs  were  sometimes  normal  in  appearance,  sometimes 
deeply  congested.  In  two  cases  the  pericardial  sac  was 
filled  with  turbid  fluid.  The  thymus  gland  showed  in 
all  cases  numerous  hemonhagic  spots.  The  trachea  and 
bronchi  showed  marked  submucous  hemorrhagic  infil- 
tration, except  in  the  rabbit  dead  in  sixteen  hours,  in 
which  case  they  were  normal.  The  spinal  cord  in  the 
three  cases  examined  showed  petechial  hemorrhagic 
spots  on  the  membranes.  The  brain  of  these  three  ani- 
mals did  not  show  any  abnoimal  appearances. 

The  two  animals  which  survived  the  inoculations  were 
killed  after  ten  days,  they  having  shown  no  loss  of  appe- 
tite, or  other  symptoms.  The  one  which  had  received 
x  c.c,  and  then  a  week  later  2  cc  intra-peiitoneally, 
showed  no  lesions  whatever.  The  other  having  received 
2  cc,  showed,  at  the  seat  of  inoculation,  a  large  subcu- 
taneous abscess  of  yellowish  white  creamy  pus.  There 
was  no  oedema,  and  but  very  slight  inflammatory  changes 
around  it.  There  were  no  other  lesions.  No  cultures 
were  made  of  this  abscess,  but  cover- glass  preparations 
gave  the  bipolar,  stained,  round-ended  bacillus. 

In  the  rabbits  dying  with  peritonitis,  cultures  and 
cover- glass  smears  were  made  in  all  cases  from  the  ab- 
dominal wall  abscesses,  peritonitic  adhesions,  spleen,  left 
kidney,  liver,  and  heart's  blood,  and  in  the  two  cases 
associated  with  pericarditis,  from  the  pericardial  exudate 
also.  The  cultures  and  cover-glass  smears  thus  obtained 
showed  pure  cultures  of  the  geim  used  for  the  inocula- 
tions. 

Similar  outbreaks  of  septicaemia  among  rabbits  are  de- 
scribed by  Smith,1  and  Eberth  and  Mandry.*  The  germ 
so  far  described  agrees  very  accurately  with  that  isolated 
by  Smith,  in  morphological  appearance,  size,  culture, 
growth,  and  symptoms,  and  lesions  induced  in  rabbits 
inoculated  with  pure  cultures. 

The  bacillus  of  spontaneous  rabbit  septicaemia  de- 

1  Smith  :  Journal  of  Comparative  Medicine  and  Surgery,  vol.  viii., 
p.  24. 
a  Eberth  and  Mandry  :  Virchow's  Archiv,  Bd.  121 ,  p.  340. 


796 


MEDICAL  RECORD. 


[December  22,  1894 


scribed  by  Eberth  and  Mandry,  differs  in  its  motility, 
culture,  peculiarities,  and  pathogenesis  for  rabbits,  and  is 
a  different,  though  closely  related,  micro-organism.  The 
germ  I  have  isolated  also  agrees  in  morphology,  culture 
growth,  and  pathogenic  peculiarities  ior  rabbits,  with  the 
American  swine  plague  bacillus  described  by  Welch l  in 
1889.  This  germ  appears  to  belong  to  the  wide-spread 
family  of  bacteria  which  contains  the  chicken  cholera  of 
Pasteur,  the  rabbit  septicaemia  of  Koch  and  Gaffky,  the 
Wildseuche  of  Hueppe,  the  Rinderseuche  of  Kitt,  the 
Schweineseuche  of  Schutz,  the  Buffelseuche  of  Oreste 
and  Armanni,  and  the  American  swine  plague. 

The  comparative  studies  of  Caneva8  and  Bunzl-Fer- 
dern  8  show  the  close  relationship  of  the  members  of  this 
group,  and  these  authors  consider  some  of  them  as  proba- 
bly identical.  Hueppe 4  also  believes  in  this  probable 
identity,  and  classes  these  under  one  name,  as  the  bacil- 
lus septicaemia  hemorrhagicae,  from  the  form  of  septi- 
caemia to  which  they  give  rise.  Bunzl-Ferdern  and 
Caneva  further  classify  as  belonging  to  the  same  family, 
but  to  another  group,  the  bacillus  of  spontaneous  rabbit 
septicaemia  of  Eberth  and  Mandry,  the  French  swine 
plague  at  Marseilles,  of  Rietsch,  Jobert  and  Martinaud, 
and  the  ferret  plague  of  Eberth  and  Schimmelbusch. 

As  soon  as  it  was  appreciated  that  a  plague  was  de- 
stroying the  rabbits,  all  animals  then  in  the  animal  house 
were  removed,  and  the  house  and  cages  thoroughly 
washed  out  with  a  five  per  cent,  carbolic  acid  solution. 
After  a  few  days  the  animals  were  returned  to  their 
cages,  and  no  further  infection  occurred. 

Splenic  Leukaemia.— Dr.  W.  P.  Northrup  reported  a 
typical  case  of  splenic  leukaemia.  The  patient  was  a  man 
thirty  years  of  age,  who  had  been  sent  to  him  by  Dr. 
Toms,  of  Bellport,  L.  I.,  who  had  made  the  diagnosis. 
The  man's  work  as  an  electrical  engineer  had  exposed 
him  to  very  high  temperature,  and  to  a  high  voltage  of 
electricity.  He  had  been  in  exceptionally  good  health 
up  to  six  weeks  before  admission,  at  which  time  the  pres- 
ent trouble  was  first  noticed. 

When  first  seen  by  the  speaker  his  feet  were  greatly 
swollen,  his  skin  was  bronzed,  his  nasal  respiration  was 
greatly  obstructed,  and  he  was  quite  deaf.  These  symp- 
toms were  afterward  decided  to  be  due  to  adenoid 
growths,  and  to  enlargement  of  the  tonsils.  There  were 
numerous  small  nodules  under  the  skin,  and  the  parotid 
gland  was  prominent  and  very  sharply  defined.  The 
cervical,  supra*  clavicular,  axillary,  and  inguinal  glands 
were  also  distinctly  enlarged.  The  spleen  was  enormous- 
ly enlarged,  extending  eleven  and  three- quarter  inches 
below  the  free  border  of  the  ribs.  The  ratio  of  the  white 
blood-cells  had  been  variously  estimated  by  different  ob- 
servers as  1  to  3  and  1  to  4.  They  were  largely  mono- 
nuclear cells,  small  lymphocytes.  There  were  few  multi- 
nuclear  cells.  They  were  for  the  most  part  neutrophile ; 
very  few  eosinophils  His  temperature  ranged  from 
normal  in  the  morning  to  1020  F.,  in  the  evening  for  the 
first  week,  and  reached  during  the  last  five  days  of  his 
illness  a  maximum  of  1030  F.  The  heart's  action  was 
rapid,  but  the  pulse  was  full  and  of  very  lax  tension. 
This  was  a  very  striking  feature  of  the  case.  He  also 
suffered  from  a  marked  hard  swelling  of  the  gums— a 
hemorrhagic  gingivitis— very  tender,  with  superficial  ul- 
cers. Night  sweats  were  also  quite  severe.  All  that  was 
accomplished  by  treatment  was  an  improvement  in  the 
condition  of  the  gums.  Finally,  he  was  taken  with  syn- 
cope, followed  by  marked  delirium,  coma,  and  death. 
When  last  estimated,  the  haemoglobin  was  between  thirty 
and  thirty-five  per  cent. 

The  autopsy  was  made  by  Dr.  George  A.  Turtle,  who 
found  that  the  retro-peritoneal  and  mesenteric  glands  were 
enlarged.  The  liver  was  of  the  nutmeg  variety,  and 
weighed  one  hundred  and  one  ounces,  while  the  spleen, 
which  was  simply  hypertrophied,  weighed  seventy-three 

J  Welch :  Johns  Hopkins  Bulletin,  vol.  i.,  December,  1889. 

•  Caneva :  Centralbl.  f.  Bakterion  und  Parasitikenkunde,  vol.  ix.,  p. 
557. 

*  Bunzl-Ferdern  :  Centralbl.  f.  BakL  und  Parasit.  vol.  ix.t  p.  787. 
4  Hueppe  :  Berliner  Klin.  Wochenscrift,  1886,  Nos.  44,  45,  46 


ounces.  The  thymus  gland  was  enormously  hypertrophied. 
On  section,  it  showed  simple  hyperplasia.  There  was  no 
evidence  of  internal  hemorrhage  in  the  various  cavities, 
as  had  been  expected,  but  on  the  dura  mater  at  the  vor- 
tex were  limited  areas  which  appeared  to  be  either  local- 
ized pachymeningitis  or  lymphoid  growths.  There  was 
nothing  to  indicate  any  change  in  the  marrow  of  the 
bones.  Specimens  removed  from  the  dura  mater  were 
exhibited. 

Dr.  James  Ewing  said  that  he  had  counted  the  blood- 
corpuscles  in  this  case.  At  the  first  count  there  had 
been  425,000  white  and  880,000  red,  and  on  the  second 
count,  430,000  white  and  925,000  red  blood-cells. 

Dr.  Northrup  also  presented  some  white  gall-stones 
which  had  been  removed  post-mortem  from  a  gall-blad- 
der.    They  were  composed  almost  entirely  of  cholesterin. 

A  Frog  with  a  Supernumerary  Hind  Leg  was  present- 
ed by  Dr.  J.  S.  Ely.  The  condition,  he  said,  was  a  rare 
one,  and  had  not  been  observed  before  at  the  college  lab- 
oratory, although  many  frogs  were  kept  there.  The  ques- 
tion arose — Was  this  frog  an  abnormal  twin,  or  was  this 
simply  a  dichotomy  of  one  of  the  lower  extremities? 
Bland  Sutton  says  that  all  these  dichotomies  occur  much 
more  frequently  in  the  lower  animals  than  in  the  human 
subject,  and  he  gives  figures  of  both  frog  and  toad  show- 
ing such  a  condition. 

The  speaker  said  that,  as  to  whether  this  was  a  "  para- 
sitic monstrosity  "  or  not,  he  would  say  that,  although 
the  extra  extremity  seemed  to  be  one  extremity,  there 
was  at  the  distal  portion  a  suggestion  of  there  being  two 
feet,  there  being  six  phalanges  instead  of  five.  When 
first  seen,  the  frog  was  alive,  yet  no  motion  in  the  super- 
numerary limb  had  been  observed,  and  no  reflex  move- 
ments could  be  excited. 

Lipomatosis  of  the  Heart.— Dr.  James  Ewing  pre- 
sented the  specimen.  The  heart  had  been  taken  from  a 
woman  forty  years  of  age,  who  had  been  received  into 
the  Roosevelt  Hospital  in  a  dying  condition,  so  that  no 
physical  examination  had  been  made.  The  heart  showed 
the  thickness  of  the  muscle  at  the  tip  of  the  left  ventricle 
to  be  less  than  one-sixteenth  of  a  millimetre,  and  at  the 
thickest  portion  half  an  inch.  The  muscular  wall  of  the 
left  auricle  was  almost  invisible.  The  right  side  of  the 
heart  was  similarly  affected.  There  was  a  very  moderate 
amount  of  interstitial  myocarditis,  and  but  little  fatty 
degeneration  of  the  muscle.  The  other  viscera  showed 
very  advanced  fatty  degeneration.  There  was  a  phthisi- 
cal process  in  the  apex  of  one  lung. 

Thrombosis  of  the  Auricle  of  the  Heart.— The  speci- 
men was  presented  by  Dr.  George  P.  Biggs. 

A  laborer,  thirty-nine  years  of  age,  was  brought  to  the 
New  York  Hospital  in  an  almost  moribund  condition,  and 
consequently  there  was  no  clinical  history.  Some  fluid 
was  drawn  off  from  the  chest  to  relieve  the  urgent  symp- 
toms. At  the  autopsy,  there  was  no  subcutaneous 
oedema  found.  The  peritoneal  cavity  was  normal. 
Each  pleural  cavity  contained  about  500  c.c.  of  serous 
fluid,  and  the  pericardium  250  c.c.  of  similar  fluid.  The 
heart  was  very  greatly  enlarged,  and  the  cavities  distend- 
ed with  blood  to  their  fullest  extent.  This  blood  was 
almost  entirely  in  the  form  of  post-mortem  clots.  The 
distention  of  the  cavities  was  greatest  in  the  left  auricle, 
the  clot  being  fully  as  large  as  a  man's  fist.  The  dilata- 
tion markedly  predominated  over  the  hypertrophy. 
There  was  an  unusually  large  appendage4  to  the  left 
auricle,  and  in  this,  and  extending  into  the  auricle,  was  a 
thrombus  measuring  10  ctm.  transversely,  4  ctm.  verti- 
cally, and  2%  to  3j£  ctm.  antcro-posteriorly.  It  was 
perfectly  solid  throughout,  and  distinctly  stratified. 
The  organ  was  enormously  dilated,  yet  notwithstanding 
this  the  walls  were  considerably  thickened.  The  mitral 
orifice  was  extremely  narrow  and  the  cusps  were  adher- 
ent, so  that  the  orifice  had  been  converted  into  a  narrow 
slit,  having  extremely  rigid  walls.  The  left  ventricle 
was  very  greatly  dilated.  The  cusps  of  the  aortic  valve 
were  thickened,  and  slightly  retracted.  The  dilatation 
on  the  right  side  of  the  heart  was  marked,  but  not  so  ex- 


December  22,  1894] 


MEDICAL   RECORD. 


797 


treme  as  on  the  other  side.  The  tricuspid  orifice  was  so 
much  relaxed  that  four  fingers  could  be  easily  passed 
through  it.  There  was  also  a  largfe  infarction  occupying 
nearly  one-half  of  one  of  the  kidneys. 

Stenosis  of  the  Tricuspid  Orifice.— Dr.  Biggs  then 
presented  a  specimen  showing  stenosis  of  the  tricuspid 
orifice.  In  this  heart  the  tricuspid  orifice  was  narrowed 
so  as  to  admit  only  two  fingers  with  difficulty.  It  was 
removed  from  a  woman  aged  twenty-seven,  who  had 
been  in  good  health  up  to  three  years  previously,  at  which 
time  she  had  had  an  attack  of  acute  articular  rheumatism. 
She  had  recovered  from  this,  but  a  few  weeks  before 
coming  to  the  hospital  had  suffered  a  second  attack.  At 
the  time  of  admission,  the  temperature  was  elevated; 
the  heart  was  displaced;  there  were  said  to  be  double 
systolic  murmurs  present — one  at  the  apex,  and  one  at 
the  base ;  there  was  slight  pulsation  in  the  veins  of  the 
neck.  The  urine  showed  only  a  trace  of  albumin  at 
first,  but  later  on  the  albumin  reached  as  high  as  sixty 
per  cent.  She  developed  marked  anasarca,  and  finally 
died  with  symptoms  of  ursemic  poisoning.  The  chief 
features  of  the  autopsy  were  the  lesions  in  the  heart,  and 
an  advanced  chronic  diffuse  nephritis.  The  mitral,  aor- 
tic, and  tricuspid  valves  showed  lesions  of  a  similar  char- 
acter, consisting  of  some  thickening,  and  of  a  number  of 
small  vegetations  on  the  free  border.  The  mitral  valve 
admitted  only  one  finger;  the  narrowing  at  the  aortic 
and  tricuspid  orifices  was  not  great.  There  were  small 
thrombi  in  both  auricular  appendages  in  this  case,  and 
also  behind  the  tricuspid  valve.  There  were  numerous 
infarctions  in  both  lungs.  The  great  point  of  interest 
was  the  appreciable  narrowing  of  the  tricuspid  orifice. 

Miliary  Tuberculosis  of  the  Liver. — Dr.  Biggs  pre- 
sented still  another  specimen.  It  had  been  removed 
from  a  case  of  tuberculosis  which  had  run  a  rather  rapid 
course,  with  marked  hectic  symptoms  and  hoarseness. 
At  the  autopsy  the  larynx  was  found  to  be  considerably 
ulcerated,  and  the  lungs  showed  tuberculosis  chiefly  in 
the  form  of  a  large  area  of  cheesy  pneumonia,  extending 
down  one  bronchus,  and  involving  nearly  two-thirds  of 
the  lower  lobe.  There  were  old  lesions — small  cavities 
and  pigmented  fibrous  cicatrices — in  both  apices.  The 
chief  point  of  interest  was  the  liver,  which  was  very  close- 
ly studded  with  small  tubercles — a  very  diffuse  miliary 
tuberculosis  of  the  liver  without  similar  lesions  in  the 
other  organs  visible  to  the  naked  eye. 

The  speaker  said  he  had  only  seen  this  condition  once 
before,  and  then  in  a  case  of  tuberculosis  presenting  no 
unusual  clinical  features.  &..  zsz; 

Dr.  J.  S.  Ely  said  he  had  seen  a  large  number  of  tu- 
bercles in  the  liver  in  guinea-pigs  which  had  been  inocu- 
lated with  tubercle  bacilli  in  the  abdominal  cavity.  Of 
course,  there  was  also  a  peritonitis  under  those  circum- 
stances. This  had  suggested  to  him  that  in  the  case  un- 
der discussion  the  infection  had  gone  to  the  liver  by  the 
portal  circulation,  and  in  that  way  had  been  filtered 
largely  out  of  the  blood. 


What  is  the  Status  of  the  Ophthalmic  Colleges  ?— In 
Chicago  are  two  institutions,  the  so-called  ophthalmic 
colleges,  which  manufacture  oculists  and  opticians  ad 
nauseam.  In  either  case,  a  course  lasting  six  weeks  suf- 
fices to  lead  to  a  diploma.  This  diploma  is  not  a  degree 
in  medicine,  in  midwifery,  in  dentistry,  or  in  veterinary 
science.  It  is  sui  generis  and  has  no  standing  in  law. 
If  its  possessor  has  been  a  registered  physician  who  has 
complied  with  the  medical  practice  act  of  the  State  in 
which  he  lives,  he  has  a  legal  standing ;  but  his  diploma 
from  the  ophthalmic  college  does  not  of  itself  entitle  him 
to  practise.  Dozens  of  graduates  from  these  institutions 
are  engaged  in  medical  practice  either  as  "  opticians  "  or 
as  "oculists."  Under  the  circumstances  we  wish  to 
know:  What  is  the  status  of  the  ophthalmic  colleges? 
Will  the  Illinois  State  Board  of  Medical  Examiners  please 
answer? — Medical  Fortnightly. 


NEW  YORK  ACADEMY  OF  MEDICINE. 

SECTION  ON  OBSTETRICS  AND   GYNECOLOGY. 

Stated  Meeting,  November  22,  1894 

Malcolm  McLean,  M.D.,  Chairman. 

Axis-Traction  Forceps. — Dr.  T.  J.  McGillicuddy  ex- 
hibited an  axis-traction  forceps  which  he  had  devised 
in  1889,  after  a  visit  to  Paris,  where  he  learned  that,  be- 
cause of  certain  objectionable  features,  the  Tarnier  for- 
ceps had  been  discarded,  even  by  Tarnier  himself.  His 
instrument  consisted  of  an  ordinary  Simpson  forceps 
with  the  additional  feature  of  short  folding  handles  pro- 
jecting backward  at  a  right  angle  from  the  others.  These 
shorter  handles  exerted  traction  in  the  axis  of  the  brim. 
On  folding  them,  the  instrument  could  be  used  as  the 
ordinary  obstetric  forceps.  In  an  experience  of  over 
one  hundred  cases  they  had  proven  very  satisfactory. 

The  advantages  claimed  by  Dr.  McGillicuddy  for  this 
instrument  were:  1.  That  with  its  use  axis  traction  is 
simple  and  uncomplicated.  2.  That  it  is  superior  to 
Tarnier's,  in  the  fact  that  while  using  it  axis-traction  at 
the  superior  strait  is  perfect.  3.  That  while  in  relation 
to  Tarnier's  instrument,  a  great  deal  has  been  said  of 
the  indicator,  in  this  forceps  the  indicator  is  in  the 
hands  of  the  operator,  and  tells  his  conscience  musculaire 
the  direction  of  traction  as  well  as  the  resistance.  4. 
That  it  does  away  with  the  trouble  of  Pajot's,  Smith's  or 
other  methods,  and  in  its  use  one  has  plenty  of  power 
and  perfect  control.  5.  That  it  is  easier  to  make  rota- 
tion in  the  posterior  positions  with  the  adjunct  handles, 
if  it  is  thought  best  to  use  the  forceps  for  that  purpose. 
6.  That  it  is  easy  of  application,  and  in  its  dual  character 
it  has  all  the  advantages  of  axis-traction  and  the  ordinary 
forceps,  and  saves  the  expense  of  buying  two  instruments 
where  one  will  do. 

The  Tarnier  instrument  is  complicated,  cumbersome, 
and  expensive,  nullifying  its  good  points — if  it  has  any — 
and  has  been  condemned  by  the  Paris  Obstetrical  and 
Gynecological  Society  for  these  reasons.  Its  theory 
may  be  very  pretty  and  interesting  for  those  who  have 
not  had  much  experience  in  forceps  delivery,  but  prac- 
tically it  is  a  useless  and  harmful  instrument.  No 
woman  should  be  delivered  except  by  axis- traction,  and 
with  these  axis-traction  handles  you  can  determine  the 
exact  amount  of  resistance  and  the  proper  amount  of 
force  to  employ,  and  readily  and  easily  use  it. 

Dr.  Leischman,  in  writing  of  the  long  forceps  and 
high  operation,  says :  "  It  is  now  very  generally  be- 
lieved by  those  who  have  had  the  greatest  experience, 
that  a  large  proportion  of  the  unfortunate  results  depend 
upon  improper  instruments,  and  especially  upon  the  use 
of  such  as  are  deficient  in  power."  The  observations 
which  on  this  point  we  have  already  quoted  from  Dr. 
Barnes,  apply  here  with  peculiar  force.  Power  and  con- 
trol are  co-relative  factors  toward  the  attainment  of  the 
result  which  we  desire,  and  if  there  is  a  deficiency  in  the 
former,  we  can  have  but  little  confidence  in  the  issue  of 
the  case. 

With  this  forceps  we  pull  directly  in  the  axis  of  the 
brim.  One  cannot  grasp  the  handles  of  the  ordinary 
forceps  with  comfort  with  both  hands  and  still  make  any 
great  axis- traction.  Most  physicians  say  that  the  hands 
become  cramped  and  lose  all  their  muscular  power  after 
pulling  for  a  short  time. 

In  cases  attended  with  some  difficulty,  who  has  not 
seen  physicians  with  their  feet  placed  against  the  side  of 
the  bed  or  the  buttocks  of  the  patient,  hanging  on  to  the 
handles  of  the  forceps  and  pulling  away  with  all  their 
strength,  while  bathed  in  a  profuse  perspiration.  These 
violent  exertions  are  entirely  wrong  and  unnecessary,  as 
the  arms  alone  should  be  used,  and  the  body  placed  in  a 
position  where  the  traction  can  be  easily  arrested  if  there 
is  any  slipping  of  the  blades.  It  is  the  improper  use  of 
the  wrong  kind  of  forceps  that  makes  it  such  fatiguing 
and  dangerous  work. 


798 


MEDICAL   RECORD. 


[December  22,  1894 


Dr.  E.  A.  Tucker  said  that  axis  traction  meant  noth- 
ing more  than  palling  in  the  axis  of  the  parturient  canal, 
and  without  it  he  could  not  understand  how  delivery  could 
be  effected.  He  believed  that  he  could  get  as  good  axis- 
traction  without  complicated  mechanism  as  with.  He 
had  used  the  Tarnier  instrument  many  times,  but  had 
since  utterly  discarded  it,  and  his  feelings  were  about 
the  same  with  regard  to  all  such  instruments.  The 
obstetrician  was  apt  to  trust  too  much  to  the  instrument, 
and  not  to  his  own  sense  of  the  proper  direction  in  which 
to  pull.  One  should  be  able  to  deliver  with  traction 
exerted  by  one  hand,  if  at  all.  The  mistake  was  com- 
monly made  of  hurrying  things  after  applying  the  for- 
ceps, instead  of  giving  the  head  time  to  mould.  He  had 
given  even  as  long  as  fifty  minutes  after  applying  the 
forceps,  thirty  of  which  were  consumed  in  moulding  the 
head  before  any  advance  was  made. 

Dr.  Marx  thought  well  of  axis-traction  instruments, 
which  he  believed  were  being  used  more  instead  of  less 
in  this  country. 

Dr.  Collyer  and  others  also  made  some  remarks. 

Chloroform  Bottle. — Dr.  £.  A.  Tucker  exhibited  a 
chloroform  bottle  which  he  had  found  in  use  among 
firms  who  handled  acids,  the  glass  stopper  being  so 
formed  as  to  permit  of  escape  of  the  fluid  by  drops  or  in 
a  stream,  as  might  be  desired.  He  said  it  was  cheaper 
and  better  than  the  bottle  he  had  devised  and  shown  to 
the  Section  some  months  ago. 

Nymphfebulation.  —  Dr.  Herman  L.  Collyer  ex- 
hibited photographs  of  a  case  of  nymphfebulation,  or 
locking  of  the  nymphae,  practised  on  the  young  woman 
by  her  husband  during  his  periods  of  absence.  She  had 
come  from  Germany,  was  twenty-eight  years  of  age,  had 
been  married  ten  years.  She  had  known  her  husband 
before  marriage  in  the  oM  country,  and  when  she  came 
to  meet  him  here  he  resorted  to  this  method  of  keeping 
her  out  of  mischief  while  he  was  away.  He  first  perfo- 
rated the  labia  minora,  and  after  the  pain  and  swelling 
had  diminished  he  introduced  a  small  padlock,  which  he 
would  remove  on  his  return.  He  had  practised  this 
five  years.  Dr.  Collyer  said  he  had  known  of  cases 
where  buckles  had  been  fastened  over  the  labia,  but  this 
was  the  only  one  known  to  him  of  perforating  and  lock- 
ing them  together. 

Entanglements  and  Shortening  of  the  Umbilical  Oord. 
— Dr.  T.  J.  McGillicuddy  read  the  paper.  Probably 
in  twenty-five  per  cent,  of  all  labors  the  cord  was  either 
around  the  neck  or  in  some  other  abnormal  position 
which  it  assumed  during  the  movements  of  the  foetus. 
It  might  cut  off  the  blood- supply  and  thus  cause  death  of 
the  foetus ;  where  the  cord  was  unusually  long  it  might  be 
found  wrapped  two  or  more  times  around  the  neck,  or 
arotmd  the  neck,  shoulders,  and  body.  The  author  re- 
lated two  cases  of  death  in  the  early  months  from  con- 
striction of  the  cord,  in  one  the  cord  being  found  wound 
around  the  neck  three  times,  in  the  other  encircling  the 
shoulder  and  body  as  well.  A  third  pregnancy  had  gone 
to  about  term  before  the  strangulation  had  taken  place, 
due  to  the  cord  drawn  tightly  around  the  neck  once.  In 
the  fourth  case  the  woman  had  been  in  labor  thirty-four 
hours.  On  extracting  the  child  it  was  found  in  a  state 
of  decomposition,  the  cord  around  the  neck  and  shoulder. 
A  fifth  case  of  death  of  the  foetus  was  related,  then  a  sixth 
case  in  which  the  shortening  of  the  cord  produced  by 
being  wound  around  the  neck,  had  resulted  in  acute  in- 
version of  the  uterus  fourteen  hours  before  he  saw  the 
patient.  Some  other  cases  were  referred  to  in  literature, 
and  then  attention  was  called  to  the  medico -legal  interest 
of  such  cases,  for  the  mother  might  be  charged  with 
strangling  her  newly-born,  when  in  reality  the  strangula- 
tion had  taken  place  in  utero  from  winding  of  the  cord 
about  the  neck.  He  also  thought  it  was  a  cause  of  hem- 
orrhage by  traction  on  the  cord  thus  shortened.  He  had 
seen  an  infant  with  the  cord  wound  four  times  around  its 
neck.  In  every  labor  he  felt  for  it  as  a  possible  com- 
plication. Excessive  pulling  upon  the  cord  sometimes 
caused  flexion  of  the  head  upon  the  sternum  and  pre- 


vented the  occiput  from  presenting.  The  abnormal  posi- 
tion of  the  cord  also  favored  exhaustion  of  the  mother 
from  delayed  delivery.'  Labor  was  easier  in  the  sitting 
or  squatting  posture,  and  it  tended  to  relieve  the  cord  to 
a  certain  extent. 

A  Pathetic  Case. — Dr.  A.  Palmer  Dudley  had  seen 
a  few  cases  in  which  the  cord  was  wound  around  the  neck 
of  the  child  one  or  twice.  In  one  the  woman  had  been 
infected  by  syphilis  from  her  husband,  had  had  several 
abortions  in  consequence  before  he  saw  her  and  dis- 
covered the  syphilitic  history  and  gave  iodide  of  potassium. 
He  succeeded  in  carrying  her  along  to  near  term,  when 
one  night  she  was  suddenly  awakened  by  a  rat  gnawing 
at  her  face.  In  her  fright  she  jumped  completely  over  in 
bed,  and  from  that  time  ceased  to  feel  foetal  movements. 
Dr.  Dudley  instituted  labor,  but  the  child  was  born  dead, 
having  the  cord  wrapped  twice  around  its  neck,  where  it 
had  left  a  blue  line.  They  feared  for  the  mother's  reason, 
and  she  died  suddenly  some  days  later,  exact  cause  un- 
known. 

Spontaneous  Rupture  of  the  Oord. — Dr.  Simon  Marx 
said  there  were  only  two  cases  of  spontaneous  rupture  of 
the  cord  known  to  him.  One,  mentioned  by  Dr. 
McGillicuddy,  having  come  under  his  own  observation, 
and  undoubtedly  due  to  the  presence  of  a  gumma  in  the 
cord.  The  woman  was  syphilitic.  Entanglement  of  the 
cord  was  quite  common.  If  around  the  neck  at  labor,  the 
propriety  of  tearing  or  cutting  it  and  extracting  rapidly 
arose ;  otherwise  strangulation  might  occur  from  tension. 

Dr.  E.  A.  Tucker  thought  the  diagnosis  of  shorten- 
ing of  the  cord  or  threatened  strangulation  could  be 
made  by  careful  study  of  the  case.  Umbilical  souffle, 
rapid  beating  of  the  foetal  heart,  and  tumultuous  move- 
ments were  an  aid.  Where  possible,  he  slipped  the  cord 
over  the  head  when  wound  around  the  neck,  but  foiling 
in  this,  he  extracted  quickly,  and  had  not  lost  a  child. 

The  Chairman  spoke  of  interference  with  natural  ro- 
tation where  the  cord  was  wound  around  the  neck  or 
shoulders.  In  this  way  many  cases  of  obstinate  posterior 
positions  could  be  accounted  for.  The  remedy  was  to 
unwind  the  child  in  the  opposite  direction,  turning  it 
completely  around. 

Surgical  Treatment  of  Anteflexion  of  the  Uterus.— 
Dr.  Charles  Bell  White  read  the  paper.  A  sharp 
bend  in  the  axis  of  the  uterus,  which  could  not  be 
straightened  by  the  finger  or  by  bimanual  palpation, 
was  accompanied  in  some  cases  by  retroposition,  in 
others  by  descent  of  the  uterus.  In  both  forms  the  cer- 
vix was  apt  to  be  elongated  and  the  case  likely  to  be 
mistaken  for  ordinary  retroversion.  He  thought  the 
condition  began  with  menstruation,  the  heavy  uterus, 
lacking  in  tone  and  support,  becoming  bent  forward  and 
gradually  becoming  fixed  in  that  position.  Dysmenor- 
rhoea  was  attributed  to  interference  with  circulation,  not 
to  obstruction  of  the  outflow  from  the  uterus.  The  or- 
dinary forms  of  surgical  treatment  comprised  divulsion, 
curettement,  amputation  of  the  cervix,  salpingo  oopho- 
rectomy. He  did  not  know  that  anyone  had  advocated 
lifting  the  uterus  and  fixing  it  in  the  new  position.  He 
had  so  treated  one  case.  The  girl  had  suffered  greatly, 
and  as  other  means  had  failed,  he  resorted  to  laparotomy, 
expecting  to  find  the  utero-sacral  ligaments  taut  and  the 
cause  of  the  retroposition  of  the  anteflexed  uterus,  but 
was  surprised  to  find  them  relaxed.  Lifting  the  uterus, 
he  noticed  that  it  straightened  the  bend,  and  therefore 
he  fastened  the  fundus  to  the  anterior  wall.  The  result 
had  been  complete  relief.  Alexander's  operation  of 
shortening  the  round  ligaments  would  not  lift  the  uterus 
and  straighten  it.  He  would  advise  anterior  fixation 
only  in  severe  cases. 

Dr.  W.  E.  Porter  would  treat  anteflexion  and  the 
dysmenorrhoea  accompanying  it  by  such  measures  as  di- 
vulsion, Wylie's  stem  drain,  tampon,  boro  glyceride. 

Dr.  Collyer  did  not  think  so  severe  an  operation  as 
laparotomy  justifiable ;  that  cases  could  be  relieved  by 
other  measures.  He  would  not  introduce  a  stem,  but 
would  rely  upon  gauze  for  drainage. 


December  22,  1894] 


MEDICAL  RECORD. 


799 


Dr.  Jarman  had  seen  the  case  reported  by  Dr.  White, 
and  approved  of  the  treatment  where  other  measures 
failed  to  give  relief  from  severe  symptoms.  Ventral  fix- 
ation was  preferable  to  taking  a  reef  in  the  round  liga- 
ments within  the  abdomen,  as  suggested  in  the  remarks 
of  Dr.  Porter,  for  the  reason  that  these  ligaments  might 
stretch  sufficiently  to  let  a  knuckle  of  gut  fall  between 
the  uterus  and  abdominal  walls,  and  become  strangulated. 

Dr.  A.  P.  Dudley  explained  the  dysmenorrhea  on 
the  basis  of  interrupted  circulation,  which  also  was  a  cau- 
sative factor  of  the  original  condition.  The  difficulty 
with  Dr.  White's  operation  was  to  obtain  consent  to  its 
performance  from  the  patient. 

Dr.  White  closed  the  discussion. 


OUR  LONDON  LETTER. 

(From  our  Special  Correspondent) 

MBDICO-CHIRURGICAL  SOCIETY  —  ACTINOMYCOSIS — PATHO- 
LOGICAL SOCIETY — MALIGNANT  DISEASE  OF  LARYNX — 
ACUTE  SEPTIC  EPIPHYSITIS — MALIGNANT  DISEASE  OF 
GROIN  AND  SECONDARY  DEPOSITS — EPITHELIOMATOUS 
CYSTS — WOLFFIAN  ADENOMA  OF  KIDNEY. 

London,  November  28, 1894. 

The  Societies  are  making  heavy  demands  on  our  time 
and  attention  just  now,  though  it  often  happens  that 
some  of  the  most  interesting  are  ill-adapted  for  a  brief 
report. 

At  the  last  meeting  of  the  Medico- Chirurgical  there 
was  a  discussion  on  actinomycosis,  which  interested  es 
pecially  the  dermatologists  but  which  cannot  be  profit- 
ably reduced  to  a  paragraph,  and  the  paper  on  which  it 
was  founded  was  hardly  worth  summarizing. 

At  the  Pathological  Society  there  was  an  interesting 
exhibition  of  a  number  of  specimens,  and  the  reports  of 
the  cases  gave  rise  to  some  valuable  remarks.  Thus  Mr. 
Stephen  Paget  showed  one  of  malignant  disease  of  the 
larynx  of  a  man  aged  sixty-four.  A  question  arose  as  to 
whether  it  could  be  a  sarcoma  or  carcinoma,  and  it  was 
referred  to  the  Committee  on  Morbid  Growths. 

Mr.  Stephen  Paget  also  showed  a  specimen  of  acute 
septic  epiphysitis  from  a  boy  aged  thirteen.  A  member 
questioned  the  correctness  of  the  name,  and  suggested  it 
was  a  case  of  acute  pyaemia  from  the  first,  the  wound 
being  probably  inoculated  with  a  streptococcus. 

Mr.  C.  A.  Morton  showed  a  malignant  growth  in  the 
glands  of  the  groin  following  the  subsidence  of  a  painful 
enlargement  of  the  glands,  with  secondary  growths  in 
the  skin  at  a  distance  from  the  primary  tumor.  The 
glands  of  both  groins  were  enlarged  and  very  painful, 
and  then,  on  the  subsidence  of  this  condition,  malignant 
growth  appeared  in  those  of  one  side.  The  patient  was 
a  man,  aged  forty- one.  Many  months  later  a  similar 
growth  appeared  in  the  glands  of  the  other  groin,  and 
secondary  growths  in  the  skin  and  subcutaneous  tissue  of 
the  abdominal  wall,  and  in  the  lungs.  The  spleen  was 
not  affected.  There  was  no  source  of  primary  infec- 
tion. The  histology  of  the  growth  was  that  of  sarcoma 
rather  than  lymphadenoma ;  but  the  clinical  history 
suggested  that  the  disease  was  not  simply  primary  sar- 
coma of  the  glands. 

Mr.  Bowlby  showed  an  epitheliomatous  cyst  of  the 
neck  from  a  man,  aged  fifty-eight ;  the  tumor  had  been 
noticed  about  two  months  before  death.  A  similar  speci- 
men was  shown  by  Mr.  F.  C.  Wallis.  The  patient  was 
sixty  years  of  age,  and  noticed  the  swelling  six  weeks  be- 
fore he  went  to  the  hospital,  in  January  last,  when  the 
swelling  was  the  size  of  an  orange.  The  growth  event- 
ually fungated,  and  the  man  died.  A  section  showed 
typical  squamous-ceiled  carcinoma. 

Mr.  Bland  Sutton  said  these  cases  were  of  great  clin- 
ical importance  on  account  of  the  rapidity  with  which 


they  proved  fatal.  They  had  been  described  by  German 
writers  as  "  branchiogenous  carcinoma/'  and  by  Eng- 
lish pathologists  as  "  malignant  cysts."  If  these  tumors 
arose  in  the  bronchial  clefts  they  would  probably  appear 
in  infancy  or  youth,  and  not  after  midlife.  He  regard- 
ed the  cervical  lesion  as  secondary,  the  primary  lesion 
being  some  small  neoplasm  hidden  away,  perhaps  in  a 
pharyngeal  recess,  and  easily  overlooked.  One  he  had 
seen  had  this  origin. 

Mr.  Shattock  doubted  if  the  epithelioma  in  a  bron- 
chial cyst  was  usually  squamous.  He  had  recently  in- 
vestigated a  case  and  found  that  the  epithelium  was  co- 
lumnar and  ciliated. 

Mr.  Shattock  also  exhibited  microscopic  sections  of 
large  adenoma  of  the  kidney  of  a  child,  and  discussed 
the  reasons  for  thinking  that  such  growths  arose  in  the 
Wolffian  body ;  he  did  not  himself  see  that  any  proof 
had  yet  been  adduced. 


"ORIGIN  OF  THE  TERM  ANESTHETIC." 

To  tub  Editor  or  tub  Mkncal  Record. 

Sir  :  I  notice,  in  your  issue  of  December  8th,  an  ac- 
count of  a  conversation  upon  this  point,  between  Mr. 
Edgar  Willett  and  Dr.  Oliver  Wendell  Holmes,  when 
the  latter  was  in  England,  in  1886. 

It  is  quite  possible  that  Dr.  Holmes  had  forgotten  that 
he  had  written  to  Dr.  Morton  a  letter  elaborately  anal- 
yzing the  varied  appropriateness  of  several  names,  and  I 
take  pleasure  in  sending  to  you  from  among  my  father's 
correspondence  a  copy  of  Dr.  Holmes's  original  letter, 
exactly  corroborative  of  the  conversation  above  referred 
to.     Dr.  Holmes's  letter  reads  as  follows : 

"  Boston,  November  21 ,  1846. 

"  My  Dear  Sir  :  Everybody  wants  to  have  a  hand  in 
a  great  discovery.  All  I  want  to  do  is  to  give  you  a 
hint  or  two,  as  to  names,  or  the  name,  to  be  applied  to 
the  state  produced  and  the  agent. 

"The  state  should,  I  think,  be  called  'anaesthesia.' 
This  signifies  insensibility,  more  particularly  (as  used  by 
Linnaeus  and  Cullen)  to  objects  of  touch  (see  '  Good- 
Nosology,'  p.  259).     The  adjective  will  be  *  anaesthetic.' 

"  Thus  we  might  say  the  state  of  anaesthesia,  or  the 
anaesthetic  state.  The  means  employed  would  be  prop- 
erly called  the  anti-  aesthetic  agent.  Perhaps  it  might  be 
allowable  to  say  anaesthetic  agent,  but  this  admits  of 
question. 

"  The  words  anti-neuric,  aneuric,  neuro  leptic,  neuro- 
lepsia,  neuro  etasis,  etc.,  seem  to  be  anatomical ;  whereas 
the  change  is  a  physiological  one.  I  throw  them  out  for 
consideration. 

"  I  would  have  a  name  pretty  soon,  and  consult  some 
accomplished  scholar,  such  as  President  Everett  or  Dr. 
Bigelow,  Sr.,  before  fixing  upon  the  terms,  which  will  be 
repeated  by  the  tongues  of  every  civilized  race  of  mankind. 

"  You  could  mention  these  words  which  I  suggest  for 
their  consideration ;  but  there  may  be  others  more  ap- 
propriate and  agreeable.  Yours  respectfully, 

"  O.  W.  Holmes. 

"  Dr.  Morton." 

When  the  young  child  now  known  as  anaesthesia  had 
been  born  into  the  world  by  the  public  demonstration  of 
a  painless  capital  operation  at  the  Massachusetts  General 
Hospital,  October  16,  1849,  it:  h*d  no  name,  and  none 
could  be  immediately  found  for  it,  since  the  language 
of  the  day  had  not  as  yet  been  called  upon  to  express 
the  act  or  the  state  produced  by  the  act.  It  was  neces- 
sary to  christen  it.  Accordingly,  a  meeting  was  held  at 
the  house  of  Dr.  A.  A.  Gould,  at  which  were  present 
Dr.  Henry  J.  Bigelow,  Dr.  O.  W.  Holmes,  and  Dr. 
Morton,  and  Dr.  Gould  read  aloud  a  list  of  names  which 
he  had  prepared.  On  hearing  the  word  "Letheon," 
Dr.  Morton  exclaimed,  "  That  is  the  name  the  discov- 
ery shall  be  christened."  Dr.  Gould  and  the  others  also 
favored  this  name,  derived  from  the  mythological  river 


8oo 


MEDICAL   RECORD. 


[December  22,  1894 


Lethe.  But  after  a  subsequent  consultation  with  Dr. 
Holmes  and  a  consideration  of  the  terms  suggested  by 
him  in  the  above  letter,  Dr.  Morton  adopted  the  terms 
anaesthesia,  anaesthetics,  and  "  etherization,"  the  terms 
now  in  common  use. 

While  upon  this  subject  it  may  interest  your  readers  to 
read  another  letter  of  Dr.  Holmes's,  written  forty  seven 
years  later  on — in  fact,  only  a  few  months  before  his 
death — wherein  no  failure  of  his  vigor  or  felicity  of  ex- 
pression is  wanting.  This  letter,  now  in  the  possession 
of  the  writer,  has  been  published  only  in  part,  in  the 
August  number  of  the  Century  Magazine  of  the  present 
year,  in  an  article  entitled  "  Dr.  Morton's  Discovery  of 
Anaesthesia."     It  reads  as  follows  : 

"  Boston,  April  2,  1893. 

"  My  Dear  Sir  :  Few  persons  have  or  had  better  rea- 
son than  myself  to  assert  the  claim  of  Dr.  Morton  to  the 
introduction  of  artificial  anaesthesia  into  surgical  prac- 
tice. The  discovery  was  formally  introduced  to  the 
scientific  world  in  a  paper  read  before  the  American 
Academy  of  Arts  and  Sciences  by  Dr.  Henry  J.  Bigelow, 
one  of  the  first,  if  not  the  first,  of  American  surgeons. 

"  On  the  evening  before  the  reading  of  the  paper  con- 
taining the  announcement  of  the  discovery,  Dr.  Bigelow 
called  at  my  office  to  read  the  paper  to  me.  He  pref- 
aced it  with  a  few  words  which  could  never  be  forgotten. 

"  He  told  me  that  a  great  discovery  had  been  made, 
and  its  genuineness  demonstrated  at  the  Massachusetts 
General  Hospital,  of  which  he  was  one  of  the  surgeons. 
This  was  the  production  of  insensibility  to  pain  during 
surgical  operations  by  the  inhalation  of  a  certain  vapor 
(the  same  afterward  shown  to  be  that  of  sulphuric  ether). 
In  a  very  short  time,  he  said,  this  discovery  would  be  all 
over  Europe.  He  had  taken  a  great  interest  in  the  al- 
leged discovery,  had  been  present  at  the  first  capital 
operation  performed  under  its  influence,  and  was  from 
the  first  the  adviser  and  supporter  of  Dr.  W.  T.  G.  Mor- 
ton, who  had  induced  the  surgeons  of  the  hospital  to 
make  trial  of  the  means  by  which  he  proposed  to  work 
this  new  miracle.  The  discovery  went  all  over  the  world 
like  a  conflagration. 

"  The  only  question  was  whether  Morton  got  advice 
from  Dr.  Charles  T.  Jackson,  the  chemist,  which  entitled 
that  gentleman  to  a  share,  greater  or  less,  in  the  merit 
of  the  discovery. 

"  Later  it  was  questioned  whether  he  did  not  owe  his 
first  hint  to  Dr.  Horace  Wells,  of  Hartford,  which  need 
not  be  disputed.  Both  these  gentlemen  deserve  '  hon- 
orable mention '  in  connection  with  the  discovery,  but 
I  have  never  a  moment  hesitated  in  awarding  the  essen- 
tial credit  of  the  great  achievement  to  Dr.  Morton.  This 
priceless  gift  to  humanity  went  forth  from  the  operating 
theatre  of  the  Massachusetts  General  Hospital,  and  the 
man  to  whom  the  world  owes  it  is  Dr.  William  Thomas 
Green  Morton. 

"  Experiments  have  been  made  with  other  substances 
besides  sulphuric  ether,  for  the  production  of  anaesthesia. 
Among  them,  by  far  the  most  important,  is  chloroform, 
the  use  of  which  was  introduced  by  Sir  James  Y.  Simp- 
son. For  this  and  for  the  employment  of  anaesthetics  in 
midwifery  he  should  have  all  due  credit,  but  his  attempt 
to  appropriate  the  glory  of  making  the  great  and  immor- 
tal discovery,  as  revealed  in  his  contribution  to  the  eighth 
edition  of  the  '  Encyclopaedia  Britannica,'  is  unworthy 
of  a  man  of  his  highly  respectable  position.  In  the 
ninth  edition  of  the  same  work  his  article  '  Chloroform  ' 
is  omitted  and  a  fair  enough  account  of  the  discovery  is 
given  under  the  title  '  Anaesthesia.1 

"  Yours  very  truly,  O.  W.  Holmes." 

I  am,  yours  very  truly, 

William  J.  Morton. 

New  Yore  City,  December  9,  1894. 


LOCALIZATION    OF    VISUAL    CEREBRAL 
CENTRE. 

TO  THB  RDITOK  OP  THE  MSDICAL  RbCORD. 

Sir  :  In  the  Medical  Record  for  December  1st,  there 
appears  an  article  entitled  "  A  Contribution  to  the  Study 
of  the  Location  and  Physiology  of  the  Visual  Cerebral 
Centre/'  which  is  so  misleading  in  its  conclusions,  that 
it  seems  justifiable  to  call  your  attention  and  that  of  your 
readers  to  its  errors.  Since  the  appearance  of  Nothna- 
gel's  classical  work  on  Cerebral  Localization,  it  has  been 
agreed  that  the  only  facts  upon  which  reliance  can  be 
placed  in  determining  the  location  of  function  in  the 
brain  are  to  be  derived  from  cases  of  small  lesion  of  long 
standing  with  accurate  autopsy. 

The  entire  tendency  of  recent  investigation  upon  the 
visual  area  of  the  brain,  as  shown  in  Henschen's  great 
works,  "PathoiogiedesGehirns"  (1893)  and  Vialet,"Les 
Centres  C6r6braux  de  la  Vision"  (1893),  and  Noyes, 
"Diseases  of  the  Eye"  (1894),  is  to  prove  that  the  pri- 
mary cortical  visual  centres  lie  about  the  calcarine  fissure 
in  the  occipital  lobe,  that  the  angular  gyrus  has  nothing 
whatever  to  do  with  vision,  and  that  there  is  no  lesion 
behind  the  optic  chiasm,  either  in  thalamus  or  visual 
radiation  or  cortex  anywhere  which  will  produce  a  blind- 
ness in  one  eye  alone.  All  lesions  posterior  to  the  chi- 
asm produce  homonymous  hemianopsia.  The  entire 
consensus  of  opinion  is  opposed  to  the  view  first  advanced 
by  Ferrier  and  the  English  school,  that  blindness  in 
one  eye  can  be  produced  by  a  cortical  lesion,  and  the 
only  case  with  autopsy,  cited  by  Gowers,  is  unsatisfac- 
tory and  inconclusive,  because  of  an  imperfect  clinical 
examination  of  the  visual  field. 

In  the  article  which  I  beg  leave  to  criticise,  the  author 
has  failed  to  recognize  this  consensus  of  opinion,  citing 
only  the  English  case.  He  reports  a  case  without  au- 
topsy, which  is  manifestly  inconclusive,  and  which  an 
ordinary  observer  would  easily  recognize  as  a  case  of 
hysterical  blindness,  regarding  the  nature  of  which  theo- 
ries abound  but  knowledge  is  wanting;  the  recovery 
alone  being  sufficient  to  prove  that  no  serious  localizable 
cerebral  lesion  was  present. 

Fearing  that  the  readers  of  your  journal  might  be  mis 
led  by  this  article,  I  have  taken  the  liberty  to  point  out 
its  fallacies. 

Yours  very  respectfully, 

M.  Allen  Starr. 

■a  West  Fokty-kighth  Stukt,  December  4,  1894* 


Female  Apotheoariei. — Paris  has  only  one  apothecary 
shop  controlled  by  a  woman,  while  Brussels  has  five. 
London  had  1,340  female  apothecariesvin  1891. 


A  Fight  for  a  Tooth. — A  peculiar  case  occurred  lately 
in  Gera,  and  has  not  yet  been  definitely  decided.  A 
gentleman  who  had  suffered  for  some  time  from  tooth- 
ache consulted  a  dentist,  and  on  his  advice  consented  to 
have  the  offending  molar  extracted.  This  was  skilfully 
effected,  not  without  some  trouble,  for  the  tooth  proved 
to  be  a  perfect  monster  in  size,  with  roots  measuring  as 
much  as  two  centimetres.  The  dentist  was  naturally 
desirous  of  preserving  such  a  trophy,  and,  although  the 
patient  claimed  the  tooth  as  his  property,  refused  to  part 
with  it.  An  action  was  accordingly  commenced  on  the 
charge  of  defraudation,  the  defendant  claiming  he  acted 
by  the  right  of  a  time-honored  custom,  and  that  the 
tooth  on  being  removed  was  a  res  nultius,  and  belonged 
to  the  first  who  took  possession.  I  am  afraid  this  will 
prove  quite  a  difficult  quibble  to  settle. — Berlin  Corre- 
spondent Occidental  Medico/  limes. 

A  Thirty-Pound  Kan. — Abner  Astrop,  a  dwarf,  died 
recently  at  his  home  in  Johnson  County,  Ky.,  at  the  age 
of  fifty-two  years.  His  weight  was  but  thirty  pounds, 
and  he  was  two  inches  less  than  three  feet  tall.  His 
parents  established  him  in  a  small  cross- roads  store  when 
he  was  twenty  years  of  age,  and  he  spent  his  life  in  it, 
refusing  to  exhibit  himself  in  museums. 


Medical  Record 

A  Weekly  Journal  of  Medicine  and  Surgery 


Vol.  46,  No.  26: 
Whole  No.  1260. 


New  York,  December  29,  1894. 


$5.00  Per  Annum. 
Single  Copies,  zoc. 


<&rijjitral  &vtitlzs. 

IS  IT  THE  BEGINNING  OF  THE  END? 

By  JAMES  WEIR,  Jr.,  M.D., 

OWCNSBORO',   KV. 

When  we  come  to  examine  the  history  of  the  world  we 
find  evidence  that  certain  nations  have,  at  times,  reached 
a  high  state  of  prosperity,  and  have  then  degenerated  to 
such  a  degree  that  they  have  either  passed  entirely  out 
of  existence,  or  have  lapsed  into  a  state  of  semi  barbarity. 
This  has  generally  been  brought  about  by  conquest, 
but  the  races  conquered  had  first  become  enfeebled 
by  their  habitudes  of  thought  and  manner  of  living.  It 
is  a  well-established  fact  that  luxury  brings  debauchery, 
and  that  debauchery  occasions  degeneration.  All  na 
tions  that  have,  heretofore,  reached  the  zenith  of  their 
prosperity,  have  been  engulfed,  at  some  time  or  other, 
in  the  maelstrom  of  luxurious  habits,  and  have  fallen 
under  the  lethal  influence  of  a  degeneration  occasioned 
solely  by  debauchery;  for  the  luxury  and  debauchery 
of  one  class  brought  increased  poverty  on,  as  well  as 
excess  in,  other  classes,  and  poverty  and  excess  are  prom- 
inent factors  in  the  production  of  degeneration,  as  we 
shall  see  further  on  in  this  paper.  Says  the  brilliant 
author  of  "  Psychopathia  Sexualis,"  Krafft-Ebing  : 
"  Periods  of  moral  decadence  in  the  life  of  a  people  are 
always  contemporaneous  with  times  of  effeminacy,  sen- 
suality, and  luxury.  These  conditions  can  only  be  con- 
ceived as  occurring  with  increased  demands  upon  the 
nervous  system,  which  must  meet  these  requirements. 
As  a  result  of  increase  of  nervousness,  there  is  increase 
of  sensuality,  and,  since  this  leads  to  excesses  among  the 
masses,  it  undermines  the  foundations  of  society — the 
morality  and  purity  of  family  life.  When  this  is  de- 
stroyed by  excesses,  unfaithfulness,  and  luxury,  then  the 
destruction  of  the  state  is  inevitably  compassed  in  mate- 
rial, moral,  and  political  ruin." 

Such  was  the  condition  of  the  Latin  race  when  the 
fierce  and  hardy  Vandals  overran  the  Roman  peninsula ; 
such  was  the  condition  of  the  Assyrians  when  Babylon 
fell  beneath  the  onslaughts  of  the  great  Macedonian; 
such  was  the  condition  of  the  Egyptians  when  the  north- 
ern myriads  swept  down  upon  the  fertile  valley  of  the 
Nile  and  destroyed  forever  the  once  powerful  and  all  con- 
quering kingdom  of  the  Pharaohs ;  and  such,  too,  was 
the  condition  of  the  French  nation  in  1794,  when  An- 
archy unfurled  its  red  banner  at  the  head  of  the  most 
gigantic  social  revolution  the  world  has  ever  known.  At 
the  present  time,  community  of  interests,  as  well  as 
higher  civilization,  would  utterly  forbid  the  total  subju- 
gation of  one  civilized  nation  by  another,  such  as  oc- 
curred in  the  olden  times ;  hence  no  nation  need  fear 
annihilation  from  such  a  source.  The  danger  comes  from 
another  point  and  consists  in  the  almost  certain  uprising, 
at  some  time  in  the  future,  of  degenerate  individuals  in 
open  warfare  and  rebellion  against  society. 

The  question  whether  the  world  is  growing  better  or 
worse  is  often  debated,  and  can  be  answered  affirmatively 
on  both  sides.  Better,  because  superstition,  bigotry,  and 
dogmatism  have  given  way,  to  a  great  extent,  to  the  toler- 
ance and  freedom  of  higher  civilization  and  purer  ethics 
in  normal,  healthy  man ;  worse,  because  crime  (and  I 
mean  by  crime  all  antisocial  acts)  has  greatly  increased 


on  account  of  the  pernicious  influence  of  degeneration. 
That  superstition,  bigotry,  and  dogmatism  are  on  the 
wane,  and  that  they  will,  sooner  or  later,  be  entombed 
in  that  depository  of  obsolete  savage  mental  habitudes — 
absolute  and  utter  oblivion — a  glance  at  the  success  that 
science  has  achieved  in  the  warfare  waged  against  it  by 
the  Church,  will  at  once  declare.  (Throughout  this 
article  I  use  the  word  Church  to  express  priests  of  any 
and  every  denomination,  whether  Jew,  Gentile,  or  Pa  gar, 
Protestant  or  Catholic.)  A  short  incursion  into  this 
subject,  i.e.,  the  Church's  warfare  on  science,  is  absolutely 
necessary,  for  the  triumph  of  science  over  its  enemies 
— superstition,  bigotry,  and  dogmatism,  coincidently, 
ignorance  and  illiterateness — shows  that  the  civilized 
world,  at  the  present  time,  is  markedly  different  in  some 
respects  from  the  world  of  ancient,  mediaeval,  and  even 
comparatively  recent  times;  and,  in  summing  up,  this 
changed  condition  will  be  a  weighty  factor  in  making  up 
an  answer  to  the  question  which  heads  this  paper. 

When  Olympus  first  faded  away  from  the  enlightened 
eyesight  of  the  Greeks,  and  changed  into  space  be- 
sprinkled with  stars ;  when  Zeus  no  longer  held  his  di- 
vine court  on  its  mystic  summit ;  when  oracles  became 
mute  and  the  fabled  wonders  of  the  * '  Odyssey ' '  either  van- 
ished or  resolved  themselves  into  prosaic  commonplaces 
under  the  investigations  of  the  sceptic  or  the  accidental 
discoverer,  the  Church  made  a  most  strenuous  protest 
against  the  destruction  of  its  traditions.  Some  of  these 
early  seekers  after  truth  were  killed  and  their  goods  con- 
fiscated. The  Church  issued  its  edict  against  heresy 
(and  any  doctrine  that  taught  a  belief  antagonistic  to  the 
accepted  tenets  of  pagan  mythology  and  theogony  was 
heresy),  and  hurled  its  anathemas  against  the  heretic. 
Olympus,  in  the  eyes  of  the  Church,  still  existed,  and 
Zeus,  the  man-god,  still  quaffed  the  sacred  ambrosia  in 
its  shady  groves.  The  Sirens  still  sang  their  entrancing 
songs,  whale  Scylla  and  Chaqbdis  were  ever  stretching 
out  eager  arms  toward  unwary  mariners.  Gigantic  one- 
eyed  Cyclops,  with  Polyphemus  as  their  leader,  still 
patrolled  the  shores  of  Sicily  and  kept  their  "  ever-watch- 
ful eyes  "  turned  toward  the  open  sea.  The  hardy  Greek 
sailor  landed  on  the  Cyclopean  island,  and  discovered 
that  Polyphemus,  and  Arges,  and  Brontes,  and  Steropes, 
and  all  the  other  one  eyed  monsters  were  nothing  but 
sea-wrack,  bowlders,  and  weeds.  He  sailed  farther,  past 
Scylla  and  Charybdis,  and  discovered  no  greater  dangeis 
than  sharp  rocks  and  whirlpools.  Yet  farther  he  sailed 
out  into  the  mysterious  sea,  and  the  only  Siren's  song  he 
heard  was  the  whistling  of  the  wind  through  the  cord- 
age of  his  vessel.  In  vain  the  Church  thundered  against 
the  daring  investigator.  Neither  fiie,  nor  sword,  nor 
imprisonment,  nor  death  itself,  could  check  the  march  of 
truth.  Mythology  and  pagan  theogony  had  received 
their  death-blows ;  superstition,  bigotry,  and  dogmatism 
were  elbowed  aside  and  gave  place  to  dawning  science. 
The  Church  held  that  that  which  had  been  believed  by 
pious  men  for  untold  ages  must  necessarily  be  true. 
Science,  in  the  garb  of  philosophy,  with  cold,  dispas- 
sionate criticism  proved  that  these  hitherto  accepted 
truths  were  arrant  fallacies.  The  poets  and  writers  then 
took  up  the  subject,  and  finally  the  people  fell  into  line, 
so  superstitious,  bigoted,  dogmatic  mythology  died,  in- 
tellectuality took  its  place,  and  higher  civilization  took  a 
step  forward. 

With  every  new  discovery,  with  every  victoiy  o\er 
superstition,  bigotry,  and  dogmatism,  civilization  took  a 


802 


MEDICAL    RECORD. 


[December  29,  1894 


step  upward  until  it  stands  to  day  as  far  above  the  civi- 
lization of  those  old  days  as  do  the  giant  stems  of  the 
mighty  red-woods  above  the  chaparal  and  undergrowth 
of  the  California  forests.  In  its  battle  with  superstition 
civilization  has  grown  strong,  hardy,  and,  above  all, 
vigilant.  This  last  quality  it  will  need  most  of  all  in  its 
coming  battle  with  the  combined  hosts  of  antisocial 
degenerates.  In  its  battle  against  the  Church  civilization 
has  gained  the  right  to  think  for  itself.  It  has  de- 
manded, and  is  now  receiving,  to  some  extent,  the  right 
of  education,  of  erudition ;  and  education  is,  and  will 
be,  a  most  potent  warrior  against  degeneration. 

That  a  luxurious  manner  of  living  eventually  leads  to 
debauchery,  and  that  debauchery  is  a  prime  factor  in 
creating  degeneration,  no  physiologist  of  the  present  day 
will  for  one  instant  deny.  I  wish  to  show,  in  this  paper, 
that  luxury  is  hurrying  us  toward  a  social  cataclysm,  be- 
side which  the  downfall  of  the  Roman  Empire,  the  de- 
struction of  ancient  Egyptian  and  Babylonian  civiliza- 
tions, and  the  bloody  days  of  the  French  Revolution,  will 
sink  into  utter  insignificance. 

A  brief  r/sum/  of  certain  historical  epochs  will  be  nec- 
essary in  order  to  furnish  a  parallel  from  which  I  wish  to 
draw  several  indisputable  and  incontrovertible  conclu- 
sions. 

The  Roman  people,  under  the  leadership  of  its  ancient 
heroes,  was  a  nation  of  hardy  warriors  and  husbandmen. 
That  pre-eminent  military  genius,  Julius  Caesar,  had 
carefully  fostered  this  warlike  spirit  in  the  bosoms  of  his 
compatriots,  and  by  a  series  of  brilliant  campaigns  had 
made  the  Roman  nation  the  most  powerful  on  the  face 
of  the  globe.  The  Roman  legions  were  not  only  vic- 
torious on  land,  extending  their  conquests  into  Iberia, 
farther  Gaul,  and  still  farther  Britain,  but  the  Roman 
triremes  also  swept  the  Mediterranean,  from  the  Pillars 
of  Hercules  to  the  shores  of  Syria  and  Egypt.  Wealth 
poured  into  the  country  from  all  sides  and  the  people 
revelled  in  a  boundless  prosperity.  Luxury  had  already 
begun  to  enervate  the  hardy  soldiery  at  the  time  of  Cae- 
sar's assassination,  yet  not  enough  to  show  degeneration 
and  demoralization.  The  empire  under  the  first  emperors 
steadily  grew  richer  and  more  powerful,  and  the  luxury 
of  the  rich  more  unlimited  and  licentious.  At  length  a 
change  can  be  noticed.  The  Roman  legions,  hitherto 
victorious  over  every  foe,  are  now  frequently  vanquished;,, 
conquered  tribes  uprear  the  standard  of  revolt  and  refuse 
to  pay  tribute ;  the  territorial  boundaries  of  the  empire 
materially  shrink,  and  its  once- conquered  provinces  pass 
out  of  its  dominion  forever.  The  gradual  degeneration 
of  this  nation  is  faithfully  mirrored  in  the  characters  of 
the  emperors  who  governed  it.  Nero,  Caligula,  Tiberius, 
Caracaila,  and  Messalina,  the  depraved  wife  of  Claudius 
and  daughter  of  Domitia  Lepida,  herself  a  licentious  and 
libidinous  woman,  were  but  accentuated  types  of  the  lux- 
urious and  debauched  nobility.  Not  only  did  the  no- 
bility become  victims  of  degeneration,  but  the  poorer 
classes  also  lost  their  virility,  until  at  last  we  find  the 
stability  of  the  nation  preserved  through  the  instrumen- 
tality of  foreign  mercenaries.  The  greatness  of  this  once 
wide-spread  empire  dwindled  away,  the  freedom  of  its 
institutions  contracting  along  with  its  shrinking  bounda- 
ries, until  we  find  it  lapsed  into  a  state  of  barbarian  des- 
potism under  the  son  of  Aurelius ;  and,  had  it  not  been 
for  outside  influences,  it  would  have  eventually  fallen 
into  a  state  of  utter  and  complete  savagery. 

Now,  let  us  turn  to  a  much  older  civilization.  When 
the  first  conquerors  of  Egypt,  about  whom  history  can 
tell  us  so  little,  first  occupied  the  fertile  valley  of  the 
Nile,  the  country,  in  all  probability,  was  inhabited  by 
negroes.  This  conquering  race  drove  out  or  enslaved 
the  native  population  and  founded  the  ancient  kingdom 
of  Egypt.  This  kingdom  waxed  strong  and  mighty  un- 
til at  the  time  of  Rameses  the  Great,  three  thousand  two 
hundred  years  ago,  it  was  the  most  powerful  monarchy 
in  the  whole  world.  This  mighty  son  of  Ra,  Meiamoun 
Ra,  or  Rameses,  as  he  is  most  generally  styled,  was  a 
warrior  and  a  statesman.     He  led  his  victorious  troops 


north,  east,  and  west,  conquering  nations  as  he  went, 
until  he  dominated  and  brought  into  a  state  of  vassalage 
over  two-thirds  of  the  then  known  world.  Wealth 
flowed  into  his  kingdom  from  all  the  surrounding  coun- 
tries, consequently  luxury,  with  its  never-failing  asso- 
ciate, debauchery,  made  their  appearance  and  the  deca- 
dence of  this  mighty  kingdom  set  in.  It  is  true  that 
many  Pharaohs  reigned  after  Rameses,  and  that  the  mon- 
archy maintained  its  greatness  for  a  long  period  of  time ; 
but  luxury  had  taken  hold  on  the  people  at  the  time  of 
their  greatest  prosperity  and  had  sown  the  seeds  of  de- 
generation, which  flourished  and  grew  apace,  until  the 
emasculated  and  effeminate  people  yielded  up  their  inde- 
pendence to  the  conquerors,  and  passed  out  of  existence 
as  a  nation  forever. 

Now,  let  us  turn  to  a  recent  civilization.  At  the  time 
of  Louis  XVI.  the  French  nation  was  thoroughly  under 
the  influence  of  degeneration  consequent  to  a  luxury  and 
licentiousness  that  had  had  a  cumulative  action  for  sev- 
eral hundred  years.  The  peasantry  and  the  inhabitants  of 
the  faubourgs,  owing  to  their  extreme  poverty,  itself  a 
powerful  factor  in  the  production  of  degeneration,  had 
lapsed  into  a  psychical  state  closely  akin  to  that  of  their 
savage  ancestors.  The  nobility  were  weak  and  effemi- 
nate, the  majority  of  them  either  sexual  perverts,  or 
monsters  of  sensuality  and  lechery.  The  middle  class, 
then  as  ever  the  true  conservators  of  society,  seeing  this 
miserable  state  of  affairs,  attempted  to  remedy  it.  Not 
fully  understanding  the  dangers  of  such  a  procedure,  they 
allowed  the  degenerate  element  to  share  in  their  delibera- 
tions. Their  moderate  and  sensible  counsels  were  quickly 
overruled  by  their  savage  associates,  who  brought  about  a 
Reign  of  Terror  (with  such  psychical  atavists  as  Marat, 
Danton,  and  Robespierre  at  its  head),  the  like  of  which 
the  world  had  never  seen  before  nor  has  ever  experienced 
since.  I  have  demonstrated,  in  the  three  instances  of 
history  cited  above,  that  degeneration  has  invariably  fol- 
lowed luxury,  and  that  a  social  and  political  revolution 
has  been,  invariably,  the  result  of  this  degeneration; 
therefore,  as  we  ourselves  are  entering  upon  an  epoch 
closely  akin  to  the  three  several  epochs  just  mentioned, 
it  will  be  well  for  us  to  study  the  phenomena  that  bring 
about  such  revolutions. 

It  is  conceded  by  everyone  that  man  completed  his 
cycle  of  physical  evolution  many  thousands  of  years  ago. 
Since  his  evolution  from  his  pithecoid  ancestor  the  forces 
of  nature  have  been  at  work  evolving  man's  psychical 
being.  Now,  man's  psychical  being  is  intimately  con- 
nected with,  and  dependent  on,  his  physical  being,  there- 
fore it  follows  that  degeneration  of  his  physical  organism 
will  necessarily  engender  psychical  degeneration.  Hence, 
if  I  can  prove  that  man,  by  leading  a  life  of  luxury  or 
one  of  poverty  and  want,  produces  physical  degeneration, 
it  will  naturally  follow  that  psychical  degeneration  will 
also  accrue;  and,  as  one  of  the  invariable  results  of 
degeneration  is  atavism  or  reversion,  both  physical  and 
psychical,  the  phenomenon  of  a  social  revolution  charac- 
terized by  pronounced  savagery  and  barbarity,  in  which 
society  is  overthrown  and  anarchy  instituted  in  its  stead, 
will  no  longer  appear  strange  and  unnatural. 

Neurasthenia,  or  the  loss  of  nervous  tonicity,  is  a  prime 
factor  in  the  production  of  degeneration.  The  offspring 
of  neurasthenic  parents  always  show  degeneration  in 
some  form  or  other.  That  luxury  produces  neurasthenia 
can  be  demonstrated  beyond  the  shadow  of  a  doubt 
Nine  tenths  of  the  clientele  of  the  gynecologist  is  derived 
from  the  wealthy,  luxurious,  and  fashionable  class.  The 
same  may  be  said  of  the  neurologist  and  alienist.  Pa- 
resis and  kindred  forms  of  insanity  are,  almost  exclusively, 
forms  of  degeneration  affecting  wealthy  people,  while  the 
proportion  of  sexual  perverts  among  the  rich  is  remarkably 
high. 

Let  us  see  if  we.  cannot  discover  some  of  the  fee- 
tors  in  the  causation  of  such  wide-spread  and  abundant 
neuroses  among  those  fashionable  and  luxurious  individ- 
uals who  arrogate  to  themselves  the  title  of  "  Society." 
Man  is,  naturally,  a  diurnal  animal,  but  the  fashionable 


December  29,  1894] 


MEDICAL    RECORD. 


803 


world  has  reversed  the  natural  order  of  things  and  has 
made  him  a  nocturnal  animal.  Now,  the  long  continued 
influence  of  artificial  light  exerts  a  very  deleterious  effect 
on  the  nervous  system ;  hence  it  is  not  to  be  wondered 
at  that  so  many  men  and  women  of  society  are  neuras- 
thenic. Not  only  are  those  individuals  who,  voluntarily 
and  preferably,  spend  the  greater  portions  of  their  lives 
in  artificial  light,  rendered  nervously  irritable,  but  those 
also  who  are  driven  by  force  of  circumstances  to  turn 
night  into  day  are  likewise  afflicted.  Several  years  ago 
I  met  a  distinguished  editor  at  Waukesha,  who  was  suffer- 
ing greatly  from  nervous  exhaustion.  He  told  me  that 
he  was  so  situated  that  he  did  all  of  his  work  at  night, 
often  writing  until  three  o'clock  in  the  morning.  1  ad- 
vised him  to  quit  this  and  to  do  his  editorial  work  dur- 
ing daylight.  Not  long  after  he  wrote  me  that  he  had 
followed  my  advice,  and  that  he  was  a  new  man  in  point 
of  health.  The  loss  of  nervous  vitality  makes  itself  evi- 
dent by  a  feeling  either  of  exhaustion  or  irritability. 
The  fashionable  devotee,  in  order  to  counteract  this, 
either  stimulates  the  system  with  alcohol,  or  exorcises 
the  "  fidgets  "  by  the  use  of  sedatives,  such  as  chloral  or 
morphia.  The  baneful  effects  of  such  medication  are 
not  at  once  appreciable,  but  if  continued  for  any  length 
of  time  they  will  eventually  result  in  a  total  demoraliza- 
tion of  the  nervous  system.  Time  and  again  have  I 
seen  fashionable  men  and  women,  at  the  close  of  the 
season,  veritable  nervous  wrecks.  What  necessarily 
would  be  the  effect  of  physical  and  psychical  lesions  like 
these  on  a  child  begotten  by  such  parents  ?  The  inevit- 
able result  would  be  degeneration  in  some  form  or  other. 
Again,  many  men  and  women  stand  the  drain  of  a  fash- 
ionable season  on  their  nervous  systems  without  attempt- 
ing to  recoup  through  the  agency  of  drugs,  and  at  the 
end  find  themselves  physically  and  psychically  ex- 
hausted. They  go  to  the  seaside  or  some  other  resort, 
and,  in  a  measure,  recover  their  nervous  vitality,  only  to 
lose  it  again  during  the  next  season.  This  continues  for 
season  after  season,  the  nervous  system  all  the  time  be- 
coming weaker,  until  some  day  there  is  a  collapse  end- 
ing in  hysteria,  paresis,  or  some  other  of  the  hundred 
forms  of  neurotic  disorder.  What  will  be  the  effect  on 
the  progeny  resulting  from  the  union  of  such  individ- 
uals ?  Again  the  answer  must  necessarily  be— degenera- 
tion. Artificial  light  is  not  the  only  cause  of  this  nervous 
irritability*  The  long  and  continued  intercourse  of  the 
sexes  in  the  ball-room,  where  the  women  are  dressed  so 
decollete  that  they  excite  sensuality  in  the  men,  very  fre- 
quently without  the  men  being  conscious  of  the  fact, 
must  necessarily  exert  a  deleterious  effect  on  the  nervous 
system.  Contact  of  the  sexes  in  the  dance  is  only  pleas- 
urable because  of  that  contact.  I  am  fully  aware  of  the 
fact  that  this  idea  is  scouted  and  denied  by  those  who 
indulge  in  the  waltz  and  kindred  dances.  They  claim 
that  no  thought  of  carnality  ever  enters  into  their  feel- 
ings. I  know  from  personal  experience  that  they  are 
honest  in  this  declaration,  yet  from  a  psychical  stand- 
point they  are  wofully  in  error.  ^Estheticism  and  car- 
nality are  by  no  means  as  dissociate  as  the  aesthete  would 
have  us  believe.  All  pleasurable  emotions  that  have 
their  inception  in  the  senses  are  fundamentally  of  carnal 
origin.  The  waltz  is  aesthetic,  yet  all  of  its  pleasure  is 
based  on  an  emotion  closely  akin  to  sensuality.  Men 
derive  no  pleasure  from  waltzing  with  one  another,  nor 
do  women  under  like  circumstances. 

Nature  demands  in  the  interest  of  health  a  certain 
amount  of  exercise.  The  luxurious  society  man  or  woman 
utterly  disregards  this  demand  of  nature,  consequently 
indigestion,  with  all  of  its  associated  ills  steps  in,  and  be- 
comes an  additional  factor  in  the  production  of  nervous 
exhaustion.  To  tempt  the  appetite,  highly  seasoned  foods, 
many  of  which  are  deleterious  and  injurious,  are  prepared 
and  taken  into  the  torpid  and  crippled  stomach.  Finally, 
nature  rebels  and  the  unfortunate  dyspeptic  is  forced  to 
go  through  life  on  a  diet  of  oatmeal,  or,  weakened  by 
lack  of  healthy  sustenance,  the  brain  gives  way  and  the 
victim  passes  the  remainder  of  his  or  her  life  in  a  lunatic 


asylum.  Children  begotten  by  miserable  invalids  like 
these,  beyond  a  peradventure,  must  necessarily  be  de- 
generate. Indigestion  is  not  the  only  ill  that  nature  in- 
flicts for  any  disregards  of  her  laws.  She  is  a  rough 
nurse  but  a  safe  one,  consequently  she  forbids  the  rear- 
ing of  her  hardiest  creation,  man,  in  hot  houses,  as 
though  he  were  a  tender  exotic.  The  luxurious  individ- 
ual pampers  his  body,  following  the  dictates  of  his  own 
selfish  desires  and  utterly  disregarding  the  laws  of  nature, 
and,  before  he  reaches  middle  age,  discovers  that  he  has 
become  an  old,  old  man,  weak  in  body,  but  still  weaker 
in  mind.  The  children  resulting  lrom  the  union  of  the 
various  neurasthenics  described  above  are  necessarily  de- 
generate. As  they  grow  up  they  show  this  degeneration 
by  engaging  in  all  kinds  of  licentious  debauchery,  and 
unnatural  and  perverted  indulgences  of  appetite.  In 
nine  cases  out  of  ten  they  will  spend  the  fortunes  inher- 
ited from  their  parents  in  riotous  debauchery,  and  will 
eventually  sink,  if  death  does  not  overtake  them,  to  the 
level  of  their  fellow-degenerates — those  who  have  been 
brought  into  existence  by  poverty  and  debauchery,  and 
who  await  them  at  the  foot  of  the  social  ladder.  Among 
such  degenerate  beings  the  doctrines  of  socialism,  of  com- 
munism, of  nihilism,  and  of  anarchy  have  their  origin. 

Now,  let  us  turn  our  attention  to  the  evidences  of  lux- 
ury and  debauchery,  and  the  consequent  evidences  of 
degeneration  which  obtrude  themselves  on  all  sides.  The 
reckless  extravagance  of  the  nobility  of  the  Old  World  is 
well  known.  Vice  and  licentiousness  even  penetrate  to 
the  royal  households,  and  princes  of  the  blood  pose  as 
route  and  debauchees.  As  I  have  demonstrated  else- 
where, degeneration  in  the  wealthy  classes  of  society  gen- 
erally makes  itself  evident  by  the  appearance  of  psycho- 
sexual  disorders.  The  horrible  abominations  of  the 
English  nobility,  as  portrayed  in  the  revelations  of  Mr. 
Stead,  aze  well  known.  Charcot,  Sega'as,  F6r6,  and 
Bouvier  give  clear  and  succinct  accounts  of  the  vast 
amount  of  sexual  perversion  existing  among  the  French, 
while  Krafft-Ebing  informs  us  that  the  German  empire  is 
cursed  by  the  presence  of  thousands  of  these  unfortu- 
nates. When  we  come  to  examine  this  phase  of  degen- 
eration in  our  own  country,  we  find  that  it  is  very  preva- 
lent. This  is  especially  noticeable  in  the  larger  cities, 
though  we  find  examples  of  it  scattered  broadcast 
throughout  the  land.  The  editor  of  one  of  our  leading 
magazines,  in  a  remarkable  series  of  letters,  has  shown 
that  the  wealthy  New  Yorkers  revel  in  a  luxuriousness 
that  is  absolutely  startling  in  its  license.  Thousands  aie 
expanded  on  a  single  banquet,  while  the  flower  bills  for 
a  single  year  of  some  of  these  modern  Luculli  would 
support  a  family  of  five  people  for  three  or  four  years. 
Bachanalian  orgies  that  dim  even  those  of  the  depraved, 
corrupt,  and  degenerate  Nero  are  of  nightly  occurrence. 
Drunkenness,  lechery,  and  gambling  are  the  sports  and 
pastimes  of  these  ultra  rich  men,  and  it  is  even  whispered 
that  milady  is  not  much  behind  milord  in  the  pursuit  of 
forbidden  pleasures. 

Psycho- sexual  disorders  are  not  the  only  evidences  Of 
degeneration  in  the  wealthy,  by  any  means.  Many  a 
congenital  criminal  is  born  in  the  purple,  who  shows  his 
moral  imbecility  in  many  ways.  Sometimes  he  sinks  at 
once  to  the  level  of  a  common  thief,  but  generally  his 
education  keeps  him  within  the  pale  of  the  law.  Always, 
however,  his  sensuality  is  unbounded,  and  he  will  hesitate 
at  nothing  in  order  to  gratify  his  desires.  This  unbridled 
license  has  already  bad  its  effect  elsewhere.  We  see 
that  it  has  even  corrupted  the  guardians  and  conservators 
of  the  public  peace.  The  recent  investigation  of  the  po- 
lice board  of  New  York  shows  a  degree  of  corruption 
that  is  simply  overwhelming,  and  that  the  same  state  of 
affairs  exists  in  Chicago,  New  Orleans,  St  Louis,  and 
other  large  cities,  I  have  every  reason  to  believe.  There 
are  yet  other  evidences  of  degeneration ;  witness  the 
eroticism  that  is  to  be  found  in  our  literature.  Unless  a 
book  appeals  to  the  degenerate  tastes  of  its  readers  it 
might  just  as  well  never  have  been  published.  This  is 
not  cynicism;  it  is  plain,  unvarnished  truth — witness 


8o4 


MEDICAL  RECORD. 


[December  29,  1894 


the  success  of "  His  Private  Character,"  of  "  Is  This 
Your  Son,  My  Lord?"  of  hundreds  of  other  works  of 
the  same  character.  Again,  turn  to  the  stage  and  we 
find  the  same  thing.  Tne  tragedies  and  comedies  of 
Shakespeare  are  shelved,  while  society  plays  and  "  living 
pictures  "  hold  the  boards.  Salacity,  with  only  sufficient 
covering  to  barely  hide  downright  lewdness,  is  everywhere 
apparent.  Now,  what  is  the  result  of  all  this  ?  There 
can  be  but  one  answer,  and  that  is  degeneration.  That 
which  happened  centuries  ago  will  happen  again,  for 
man  is  governed  by  the  same  laws  of  nature  now  as  he 
was  then. 

Statistics  show  that  insanity  is  markedly  on  the  in- 
crease. This  is  not  to  be  wondered  at  when  we  take 
into  consideration  the  fact  that  debauchery  is  the  rule, 
and  not  the  exception,  among  certain  classes  of  people. 
Syphilis,  one  of  the  most  productive  causes  of  degenera- 
tion, is  exceedingly  active  throughout  the  whole  civilized 
world.  Blashko  states  that  one  out  of  every  nine  or  ten 
men  in  the  city  of  Berlin  is  tainted  with  syphilis.  This 
is  wholly  attributable  to  the  unbounded  sensuality  of  the 
people.  Crime  of  every  description  is  rearing  its  hydra- 
head  and  clasping  in  its  embrace  an  alarming  proportion 
of  human  beings.  I  have  shown  elsewhere l  that  the 
congenital  criminal  is  the  result  of  degeneration,  and 
that  he  comes  from  all  classes  of  society.  He  is,  how- 
ever, most  frequently  the  product  of  the  lower  class,  and 
lives  and  dies  among  his  congeners.  I  have  shown  also a 
that  the  anarchist,  the  nihilist,  and  the  socialist  belong 
to  the  same  category  of  degenerate  beings.  Poverty, 
brought  on  by  the  luxury  of  the  rich,  by  war,  and  by 
high  taxation,  has,  during  the  last  millenary  period,  been 
very  fertile  in  the  production  of  degenerates  in  the  Old 
World.  Lack  of  food  and  sanitation,  the  usual  adjuncts 
of  poverty,  are  powerful  factors  in  the  production  of  de- 
generate individuals.  The  Old  World  has  gotten  rid  of 
these  people  as  rapidly  as  possible  by  unloading  them  on 
our  shores.  Year  after  year,  practically  without  restric- 
tion, thousands  of  these  antisocial  men  and  women  have 
swarmed  into  our  country,  until  we,  comparatively 
speaking  a  nation  just  born,  contain  as  many  of  these 
undesirable  citizens  as  any  of  the  older  nations.  They 
still  continue  to  enter  our  gates,  and  we  are  adding  to 
their  number,  as  I  have  shown,  by  our  own  production. 
Some  day — and  I  greatly  fear  that  day  is  not  very  far 
distant — some  professional  anarchist  (for  there  are  pro- 
fessional anarchists  as  well  as  professional  thieves)  will 
consider  that  the  time  is  ripe  for  rebellion,  and,  raising 
the  fraudulent  cry  of  "  Labor  against  Capital,"  instead  of 
his  legitimate  cry,  which  is  "  Rapine,  Murder,  Booty  !  " 
will  lead  this  army  of  degenerates,  composed  of  anarchists, 
socialists,  nihilists,  sexual  perverts,  and  congenital  crim- 
inals, against  society.  And  who  will  bear  the  brunt  of 
this  savage  onslaught?  The  ultra-rich?  By  no  means.. 
The  great  middle  class — the  true  conservators  of  society 
and  civilization,  will  fight  this  battle.  It  will  be  a  strife 
between  civilization  and  degeneration,  and  civilization 
will  carry  the  day.  There  would  have  been  no  French 
Revolution  had  the  middle  class  been  as  wise  then  as  it 
is  to  day.  They  were  taken  by  surprise  at  that  savage, 
bloody  time,  but  as  soon  as  they  recovered  how  quickly 
they  brought  order  out  of  chaos !  Education  is  the  bul- 
wark of  civilization,  and  the  great  middle  class,  freed  of 
dogmatism,  bigotry,  and  superstition,  is  welcoming  edu- 
cation with  open  arms.  It  is  gaining  recruits,  and  is 
strengthening  its  defences,  so  that  when  the  end  comes 
its  enemies  may  find  it  fully  prepared.  When  this  fight 
takes  place,  millions  of  dollars'  worth  of  property  will  be 
burned,  and  thousands  of  lives  will  be  sacrificed,  but 
when  the  smoke  of  battle  clears  away  civilization  will 
be  declared  the  victor.  And  the  ultra  rich,  what  of 
them  ?  They  will  simply  open  their  purses,  like  they  did 
in  ancient  Rome,  and  pay  for  the  privilege  of  being  pro 
tected.     The  sober  middle  class  is  a  business  people,  and 

>  Vide  American  Naturalist,  The  Recidivist. 

*  Vide  Century  Magazine  for  October,  The  Methods  of  the  Rioting 
Striker  an  Evidence  of  Degeneration. 


they  will  demand  and  obtain  assistance  from  their 
wealthy  brethren.  From  the  signs  of  the  times  and  the 
evidence  before  me,  I  have  no  hesitation  in  declaring 
that  I  believe  that  the  beginning  of  the  end  is  at  hand. 
This  social  cataclysm  may  not  occur  for  many  years, 
yet  the  agencies  through  which  it  will  finally  be  evolved 
are  even  now  at  work,  and  are  bringing  the  culmination  of 
their  labors  ever  nearer  and  nearer  as  time  passes. 

"  Waveland." 


EDUCATION  A  FACTOR  IN  THE  PROPHY- 
LAXIS OF  DISEASES  OF  WOMEN.1 

By  FRANCES   STORRS,    A.B.,  M.D., 

TOPKKA,   KAM. 

Fifty  one  years  ago  Dr.  Oliver  Wendell  Holmes, 
whose  loss  we  mourn  to-day,  published  a  paper  upon  the 
contagiousness  of  puerperal  fever,  and  struck  the  first 
blow  for  prophylaxis  in  the  diseases  peculiar  to  women. 
The  clear  argument  of  that  famous  classic  won  its  way  in 
the  face  of  bitter  opposition  and  learned  opinion — this, 
too,  without  the  aid  either  of  microbe  or  microscope. 
To-day  the  spirit  of  that  paper  is  recognized  as  the  spirit 
of  medical  progress  in  the  last  half-century.  Prophy- 
laxis has  revolutionized  the  practice  of  medicine,  and 
wrought  a  firm  foundation  for  the  splendid  superstructures 
of  our  systems  of  State  medicine  and  boards  of  public 
health.  Parallel  with  the  development  of  the  prophy- 
lactic management  of  disease,  even  dependent  upon  that 
management  for  success,  has  been  the  growth  and  per- 
fection of  modern  surgery.  Hand  in  hand  they  have 
entered  hospical  and  infirmary,  wards  for  children  and 
lying-in  women,  and  the  results  have  been  good  to  hear* 

It  is  a  curious  fact  that  to-day,  in  the  department  of 
gynecology,  the  so-called  diseases  of  women,  prophy- 
laxis has  been  so  nearly  lost  sight  of,  while  surgery  has 
usurped  the  field.  I  need  not  remind  you  of  the  multi- 
plicity of  the  surgical  articles  upon  gynecological,  sub- 
jects in  medical  literature  during  the  past  ten  years,  their 
name  is  legion,  and  many  are  already  relegated  to  the 
dark  ages ;  but  the  indices  to  our  recognized  authorities 
upon  gynecology  are  worth  considering  for  a  moment, 
and  will  illustrate  my  point.  In  the  "  Cyclopaedia  of 
American  Gynecology,"  published  in  1888,  we  look  in 
vain  for  any  article  relating  directly  to  the  etiology  of 
the  prevalence  of  disease  among  women.  Indirectly, 
several  of  the  authors  speak  of  the  causes  of  certain  con- 
ditions, but  only  in  brief.  Dr.  George  T.  Harrison,  in 
writing  upon  uterine  displacements,  in  the  second  vol- 
ume, makes  the  pertinent  statement :  "  Prophylaxis  is 
usually  left  out  of  the  question  by  systematic  writers." 

In  the  "  Cyclopaedia  of  Gynecology,"  brought  out  by 
William  Wood  &  Co.,  in  1887,  chiefly  the  work  of  Ger- 
man writers,  the  eight  volumes  contain  no  reference  to 
prophylaxis,  and  only  very  casual  reference  is  made  to 
etiology. 

Pozzi  deals  only  with  pathological  details  and  treat- 
ment. 

Garrigues,  in  a  work  of  660  pages,  devotes  less  than  six 
to  the  discussion  of  "  Etiology  in  General "  Prophy- 
laxis is  spoken  of  here  and  there,  but  at  no  great  length. 

Thomas,  fifteen  years  ago,  and  the  recent  Thomas  and 
Mund6,  devote  one  chapter  to  the  etiology  of  uterine 
disease,  and  throughout  these  books,  especially  the  later 
work,  appear  constant  hints  as  to  the  prevention  of  cer- 
tain conditions.  Tait  has  no  chapter  on  etiology,  but  be 
never  fails  to  make  his  opinions  upon  the  causes  of  spe- 
cific conditions  clear. 

There  is  little  difference  of  expression  in  these  scant 
comments  upon  etiology.  Briefly,  the  causes  of  these  so 
common  pathological  conditions  in  women  are  of  two 
varieties : 

1.  Etiological  factors  for  which  the  woman  is  chiefly 

1  Read  before  the  Eastern  Kansas  Medical  Society,  at  Kansas  City, 
Kan.,  October  ot  1894. 


December  29,  1894] 


MEDICAL   RECORD. 


805 


responsible.  2.  Etiological  factors  for  which  someone 
else  is  chiefly  responsible. 

Under  the  first  head  belongs  the  list  which  Thomas 
gives:  "Neglect  of  outdoor  exercise;  excessive  develop- 
ment of  the  nervous  system;  improprieties  of  dress; 
imprudence  during  menstruation ;  imprudence  after  par- 
turition; prevention  of  conception  and  induction  of 
abortion ;  marriage  with  existing  uterine  disease ;  "  and 
I  add  from  Garrigues,  *'  over- education,  particularly  in 
music."     These  the  woman  might  prevent. 

Under  the  second  head :  Child-bearing  and  its  conse- 
quences, many  evil  results  of  which  the  doctor  might 
prevent ;  and  infection  by  the  gonococcus,  which  in  or- 
dinary cases  the  husband  might  prevent. 

Here  are  eighty-five  per  cent,  of  the  diseases  of  women. 
To  the  remaining  fifteen  per  cent,  belong  the  neo- 
plasms and  malformations,  which  we  shall  turn  over  to 
the  surgeon  without  protest  or  comment. 

Concerning  the  last-mentioned  etiological  factor,  the 
gonococcus :  If  the  infection  of  the  utero-tubal  tract  by 
the  germs  of  gonorrhoea  meant  inevitable,  sudden  death  to 
the  woman  thus  infected,  some  means  would  be  found 
potent  enough  to  reduce  such  fatalities  to  the  minimum. 
But  since  it  means  only  a  life  of  such  misery  that  death  is 
a  longed-for  release,  wives  and  mothers  continue  to  be  ex- 
posed to  that  infection ;  and  too  often,  alas !  the  protec- 
tion of  the  physician  is  given  the  offender  rather  than 
the  innocent  offended.  And  the  modern  gynecologist, 
secure  in  his  new  found  ability  to  diagnose  pus  tubes, 
views  with  complacency  the  seed- sowing  that  is  every- 
where before  his  eyes,  and  smiles  a  little  as  he  contem- 
plates the  harvest  of  long  rows  of  ticketed  jars. 

Concerning  child-bearing  as  a  cause  of  uterine  disease, 
too  much  has  been  written  to  warrant  even  a  passing  re- 
mark from  me.  Yet  something  must  be  radically  wrong 
somewhere,  that  so  many  neglected  cases  of  lacerated 
cervix  and  perineum,  with  the  accompanying  subin voluted 
uteri  and  long  train  of  nervous  symptoms,  com*  into  the 
specialist's  hands. 

It  is  with  the  first  variety  of  etiological  factors,  how- 
ever, that  this  paper  has  principally  to  deal.  There 
seems  to  be  a  tendency  in  all  these  works  to  accept  the 
present  condition  of  woman  as  an  inevitable  one,  even  im- 
plying that  they  prefer  to  be  ill,  and  choose  a  life  of  per- 
nicious dressing  and  reckless  imprudence,  especially  to 
exaggerate  nervous  phenomena  and  induce  uterine  affec- 
tions. What  wonder  that  the  art  of  extirpation  has  sup- 
planted the  science  of  prevention  in  .  treating  such 
irrational  beings,  and  that  the  very  latest  and  most 
approved  method  of  dealing  with  diseased  pelvic  organs 
is  to  preserve  them  entire  in  alcohol,  as  being  too  com- 
plicated a  mechanism  for  the  ordinary  woman  to  be  en- 
trusted with ! 

It  is  far  from  my  purpose  to  decry  the  results  of  surgi- 
cal gynecology.  No  one  realizes  more  keenly  than  I 
the  utter  futility  of  "  treating  "  a  tube  distended  with 
pus,  and  that  we  need  no  further  demonstration  of  the 
fact  that  most  pathological  processes  of  long  standing  in 
the  pelvis  are  only  aggravated  by  much  of  the  so-called 
conservative  treatment. 

But  to  return  to  the  list  of  the  causes  of  disease  above 
quoted  as  being  those  for  which  woman  herself  is  largely 
responsible.     One  of  them  is  hardly  worth  a  discussion. 

Woman's  dress  bears  the  brunt  of  masculine  denuncia- 
tion whenever  her  ill  health  is  mentioned ;  yet  I  venture 
to  assert,  as  a  matter  I  have  been  at  no  small  pains  to  in- 
vestigate, that  nine  tenths  of  the  women  in  the  ordinary 
walks  of  life  dress  comfortably,  and  of  the  women  who 
have  learned  to  think  for  themselves,  the  other  tenth  is 
busy  inventing  some  advanced  and  enlightened  costume. 

For  all  the  rest  of  the  imprudence,  carelessness,  and 
the  like  in  that  list  enumerated,  there  is  but  one  excuse, 
which  is  no  more  an  excuse  in  dealing  with  physiological 
law  than  in  the  violation  of  the  voice  of  civil  authority, 
but  which  is  too  often  pleaded  as  an  excuse  in  both  cases ; 
that  is  ignorance,  and  an  ignorance  which  is  density  it- 
self. 


Two  great  necessities,  contingent  upon  mere  physical 
existence,  confront  every  woman ;  by  conformity  to  their 
laws  she  must  lose  or  win,  live  or  die.  Nature  insists 
upon  self-preservation  and  preservation  of  the  species. 
Moreover,  she  scorns  to  perpetuate  a  deteriorating  type. 
How  little  the  ordinary  wife  and  mother,  even  in  these 
boasted  fin  de-siecle  days,  knows  of  the  real  significance 
of  life,  or  those  mighty  forces  that  know  no  deviation  ; 
and  how  little  she  is  prepared  for  the  part  she  must  needs 
play,  whether  she  will  or  no,  in  this  fierce  struggle  for 
mere  survival.  If  it  takes  three  years  of  constant  study 
and  clinical  observation  to  fit  a  man  to  wait  upon  a  woman 
in  confinement,  and  to  faithfully  discharge  the  few  small 
duties  nature  has  left  undone  at  that  time,  how  much 
longer  ought  it  to  take  to  fit  that  woman  for  her  part  in 
the  preceding  nine  months,  and  for  the  responsibility 
which  becomes  hers  at  that  time? 

Tait  alone,  of  the  authors  whom  I  have  mentioned, 
speaks  of  the  ignorance  of  women  in  regard  to  the  vital 
processes  of  their  nature,  as  largely  responsible  for  the  prev- 
alence of  uterine  disease.  He  condemns  such  ignorance 
as  unnecessary  and  inexcusable,  and  suggests  that  it  may 
be  removed  by  the  study  of  the  analogous  sciences ;  that 
the  laws  of  reproduction  are  the  same  wherever  manifested ; 
and  to  the  observer  of  plant  life  who  has  witnessed  the 
development  and  understands  the  structural  significance 
of  anther,  oviduct,  and  ovary,  the  ordinary  processes  of 
sexual  life  present  no  mysterious  difficulty  of  compre- 
hension. I  may  be  pardoned  for  differing  with  % o  great 
an  authority,  but  in  my  school-days,  when  fitting  for  col- 
lege, with  a  head  full  of  Latin,  Greek,  and  pure  mathe- 
matics, a  very  nice  little  work,  written  upon  the  analo- 
gous botany  idea,  was  put  into  my  hands  as  a  safe  and 
proper  thing  for  me  to  read.  I  don't  think  it  did  me 
any  harm,  but  it  left  a  very  confused  idea  of  the  semi- 
physiological,  semi-sentimental  aspect  of  the  subject  so 
distasteful  that  I  never  cared  to  investigate  the  subject 
further. 

What  all  women  need  as  a  preparation  for  their  highest 
function  in  life,  is  a  thorough  training  in  anatomy  and 
physiology.  That  train  ing  should  begin  at  an  early  age  in 
preparation  for  the  advent  of  menstruation,  the  physio- 
logical import  of  which  process  should  be  made  as  clear 
as  our  best  authorities  can  make  it.  From  fourteen  to 
eighteen  or  twenty,  the  aim  of  the  young  woman's  train- 
ing and  education,  in  school  and  out,  should  be  toward 
physical  perfection.  Systematic  exercise  in  the  gymnasium 
and  out  of  doors  should  be  a  daily  certainty,  and  the  full 
process  of  gestation  and  parturition,  with  the  develop- 
ment of  the  embryo,  and  the  growth  and  needs  of  the  in- 
fant, should  be  unfolded  in  continuous  instruction. 

Any  interference  in  the  natural  order  of  development 
in  the  young  girl  should  be  taken  in  its  very  incipiency. 
Interference  in  nutrition,  which  is  often  succeeded  by 
pathological  conditions  only  amenable  to  the  surgeon's 
knife,  may  be  easily  handled  in  their  early  stages.  When 
women  turn  their  attention  to  acquiring  physical  fitness 
for  motherhood,  there  will  be  less  demand  for  the  pro- 
fessional laparotomists. 

In  all  seriousness,  this  is  no  Arcadian  dream.  There 
is  not  a  mother  alive  but  would  spare  her  daughter  the 
suffering  she  has  undergone  in  acquiring  the  "  Wisdom 
of  Experience."  The  difficulty  is,  she  does  not  know 
how,  but  she  does  feel  her  ignorance.  Over  and  over 
again  they  say  to  me,  "  If  I  had  only  known." 

More  than  that,  there  is  a  growing  dissatisfaction  with 
the  results  of  our  present  system  of  higher  education  for 
woman.  The  women  who  go  out  from  our  colleges  to 
fulfil  the  law  of  their  destiny  by  becoming  the  mothers  of 
families,  feel  that  some  very  essential  subjects  are  left  out 
of  our  college  curricula,  and  they  would  be  glad  enough 
to  exchange  a  few  books  of  Homer,  or  even  the  enjoyment 
of  Dante. in  the  original,  for  some  sound  facts  about  life 
and  health. 

Garrigue  says  that  our  girls  are  over  educated,  and  es- 
pecially in  music.  Not  over- educated,  but  educated  in 
books  too  soon.     Physical  education  must  come  first,  and 


8o6 


MEDICAL   RECORD. 


[December  29,  1894 


there  will  be  plenty  of  time  afterward  for  culture  and 
art. 

It  doubtless  has  occurred  to  some  of  you  that  this  paper 
would  better  have  been  read  before  some  enthusiastic 
bydy  of  organized  women,  who  might  forthwith  form 
themselves  into  a  club  for  the  collection  of  bones  and  the 
exchanging  of  specimens. 

Not  at  all.  Clubs  are  well  enough  in  their  place,  but 
this  is  a  question  involving  the  great  modern  principle  of 
prophylaxis  in  medicine. 

If  the  diseases  of  women  are  many  of  them  preventable, 
then  should  the  medical  profession  have  a  care  that  they 
are  prevented.  If  women  are  reasonable  beings — and  who 
would  deny  that  they  are — then  they  can  be  taught,  and 
it  is  the  medical  profession  who  must  decide  what  they 
are  to  be  taught. 

Dr.  Holmes  has  given  a  priceless  example  to  the  pro- 
fejsion  of  America,  and  he  lived  to  see  the  second  and 
third  generations  rise  up  and  call  him  blessed.  No  greater 
tribute  can  be  paid  his  life  and  works  than  by  the  per- 
petuation of  the  spirit  in  which  his  work  was  done,  the 
enthusiasm  for  the  science  of  prophylaxis  wherever  dis- 
ease is  found. 


EMERGENCY  CASES  OF  SKIN  DISEASES. 
By  FRED.  J.  LEVISEUR,  M.D., 

DERMATOLOGIST  TO  BAMDAIX'S  ISLAND  HOSPITALS. 

When  the  surgeon  is  called  in  cases  of  emergency,  he 
certainly  will  be  pleased  to  find  a  wound  already  cleanly 
covered  with  a  temporary  dressing,  or  a  fractured  limb 
in  an  improvised  splint.  Wrong  or  delayed  action  in 
these  cases  is  frequently  followed  by  very  serious  conse- 
quences. The  first  help  in  some  skin  diseases  is  not  of 
such  great  importance,  it  is  true,  but  it  is  a  fact  that  mis- 
takes are  made  continually  which  it  takes  a  good  deal  of 
time  or  trouble  to  correct  afterward.  In  his  paper,  read 
at  Rome,  and  entitled  "Non  Nocere,M  l  Dr.  A.  Jacobi 
has  collected  a  treasure  of  advices  and  warnings.  It  is 
to  be  regretted  that  time  and  space  limited  his  remarks 
to  certain  affections  occurring  in  infancy.  Harm  is  done 
quite  frequently  in  the  treatment  of  skin  diseases,  and  es- 
pecially in  emergency  cases,  1  e.y  cases  in  which  the  pres- 
ence of  alarming  symptoms  or  the  apprehension  of  the 
development  of  such,  prompts  the  patient  to  seek  imme- 
diate medical  help. 

Make  a  Correct  Diagnosis  .—A  correct  diagnosis  form- 
ing the  basis  for  our  therapeutical  action  is  essential  in 
the  first  place.  Acute  eczema,  for  instance,  is  sometimes 
mistaken  for  erysipelas,  even  by  the  better-versed  physi- 
cian. I  am  referring  to  that  special  form  of  eczema 
which  makes  its  appearance  in  the  face  near  the  ears, 
nose,  or  eyes,  and  consists  of  a  patch  with  round,  dis- 
tinct border  line.  Its  color  is  brownish  red.  Its  sur- 
face is  covered  entirely  or  in  part  by  a  thin  layer  of 
brown  crust.  In  the  very  beginning  close  inspection 
will  reveal  the  presence  of  millet-sized  vesicles.  In  the 
majority  of  cases,  however/  the  appearance  will  already  . 
have  been  changed  by  the  application  of  some  irritating 
lotion  or  salve,  applied  under  the  impression  that  the  af- 
fection is  erysipelas.  The  itching  is  now  aggravated  un- 
til it  becomes  almost  unbearable.  The  patient's  general 
condition  suffers  considerably  from  sleepless  nights  or 
from  the  weakening  effects  of  morphine  or  chloral ;  and 
if— as  happens  not  infrequently — the  patient  becomes 
somewhat  feverish,  the  phantom  of  erysipelas  is  complete. 
One  should  carefully  bear  in  mind  the  characteristic  symp- 
toms of  erysipelas.  Typical  cases  begin  with  a  chill  and 
vomiting,  followed,  after  twelve  to  twenty- four  hours,  by 
an  eruption,  which  at  first  consists  of  a  spot  of  about  the 
size  of  a  silver  dollar,  irregular  in  outline  and  painful  on 
pressure.  Its  border  is  somewhat  raised,  and  it  pro- 
gresses rapidly,  not  unlike  a  miniature  wave.  At  a  later 
stage  the  entire  face  may  become  swollen,  the  eyes 
closed,  the  ears  thickened,  and  possibly  the  affected 
*  Mbdical  Record,  May  19, 1894. 


area  studded  here  and  there  with'  bullae  or  crusts.  The 
fever  is  usually  high,  and  the  patient  makes  at  once 
the  impression  of  being  seriously  sick.  To  return  to 
eczema,  there  is  generally  a  history  of  nasal  catarrh,  a 
chronic  affection  of  the  middle  ear,  or  a  conjunctivitis. 
We  are  justified,  I  believe,  in  assuming  that  the  patho- 
logical cause  of  this  particular  form  of  eczema  is  a  micro- 
organism, not  yet  known,  but  differing  essentially  from 
Fehleisen's  coccus  of  erysipelas  and  Rosenbach's  of  ery- 
sipeloid. E.  Fridenberg l  and  a  few  others  before  him 
report  that  they  have  observed  this  eczema  to  occur  after 
the  instillation  of  mydriatics.  I  have  no  objection  to  the 
name  dermatitis  periocularis  medicamentosa,  but  I  be- 
lieve it  better  not  to  call  it  pseudo  erysipelas.  Elliot % 
defines  erysipeloid  as  an  inflammation  of  the  skin  which 
develops  in  a  wound  as  the  result  of  its  infection  with 
certain  special  micro-organisms  found  in  dead  or  de- 
composed animal  matter.  It  manifests  itself  primarily 
in  the  form  of  a  sharply  defined,  slightly  elevated,  dark, 
violaceous,  almost  livid  red  zone,  which  appears  around 
the  point  at  which  the  infection  has  taken  place.  The 
area  of  redness  extends  peripherally,  and  at  the  same 
time  involution  and  fading  of  the  portion  first  attacked 
takes  place.  During  the  entire  course  of  the  process 
itching  and  burning  exist,  being  oftentimes  exceedingly 
annoying.  There  is  no  desquamation  or  scaling  of  the 
epidermis  at  any  stage,  and  no  systemic  disturbance. 

Again,  erysipeloid  should  not  be  confounded  with 
pseudo- erysipelas.  This  latter  affection  is  usually  ush- 
ered in — according  to  Kaposi 8 — by  a  chill  and  fever,  and 
consists  of  a  tense,  painful  swelling,  of  vivid  red  color. 
It  is  found,  as  a  rule,  to  affect  the  extremities.  After 
two  or  three  days  the  tissues  break  down  and  suppu- 
ration sets  in,  often  followed  by  an  enormous  destruction 
of  the  subcutaneous  tissue,  fasciae,  muscles,  bones,  and 
joints. 

The  eruptions  caused  by  the  internal  use  of  drugs  often 
simulate  other  diseases.  Caspary4  remarks  correctly, 
that  the  physician  who  is  called  upon  to  treat  an  acute 
eruption,  the  diagnosis  of  which  is  not  beyond  doubt, 
should  think  of  the  possibility  of  having  to  deal  with  a 
drug  eruption,  and  try  to  find  out  by  inquiring  of  the 
patient  or  those  around  him.  Morrow9  says  that  the 
scarlatiniform  rash  of  belladonna,  quinine,  chloral,  mor- 
phia, etc.,  may  be  distinguished  from  scarlatina  by  its 
sudden  onset,  without  prodromic  symptoms,  and  the  ab- 
sence of  fever  and  high  temperature.  The  rubeolaform 
eruption  of  antipyrine,  copaiba,  etc.,  maybe  differen- 
tiated from  measles  by  the  same  negative  evidence.  The 
pustular  eruption  of  bromine  and  iodine  may  closely 
simulate  small  pox.  There  are  some  popular  patent 
medicines  in  the  market  which  contain  some  iodine  and 
are  liable  to  produce  lesions,  the  umbilicated  character 
of  which  may  suggest  small  pox. 

The  difficulty  to  discriminate  between  varicella,  vari- 
oloid, and  variola,6  is  a  subject  which  has  been  discussed 
so  often  that  I  hardly  need  enlarge  upon  it.  Varicella, 
as  is  well  known,  is  a  disease  occurring  mostly  in  chil- 
dren from  six  months  to  ten  years  old.  It  has  very  slight 
prodromic  symptoms,  and  consists  of  the  appearance  of 
successive  separate  crops  of  superficially  seated  vesicles. 
Severe  constitutional  symptoms  are  absent. 

The  hemorrhagic  affections  of  the  skin  may  furnish 
emergency  cases  which  are  difficult  of  diagnosis.  Purpura 
hemorrhagica  may  be  confused  with  scurvy,  or  the 
hemorrhages  of  haemophilia,  leucocythaemia,  and  perni- 
cious anaemia.  Fortunately,  the  treatment  of  these 
hemorrhagic  affections  is  so  similar  that,  by  mistaking 
one  for  the  other  at  first,  no  serious  consequences  will 
follow. 

If  I  were  not  prevented  by  the  limitation  of  space  from 

1  N.  Y.  Medicin.  Monatsschrift,  November.  T804. 

*  G.  T.  Elliot,  in  Morrow's  System  of  Genito-urinary  Diseases,  etc., 
p.  130. 

8  Patholgie  11.  Therapie  der  Hautkrankheiten,  1893. 
4  Archiv  f.  Derm,  u   Syph. ,  I. ,  1804. 

*  System  of  Genito-urinary  Diseases,  etc.,  p.  353. 

*  Variola  and  Vaccinia.  Published  by  the  New  England  Vaccine 
Company. 


December  29,  1894] 


MEDICAL  RECORD. 


807 


going  into  details,  I  could  extend  the  list  of  possible  mis- 
takes much  further  by  mentioning  rarer  cases;  for  in- 
stance, erythema  scarlatiniforme,1  precocious  malignant 
syphilis,  pemphigus  vulgaris  and  foiiaceus,  dermatitis 
exfoliativa  neonatorum,  pityriasis  rubra,  scleroderma,  etc. 
It  may  suffice  to  quote  in  this  connection  Dr.  H.  R.  Crock- 
er's advice,  which  is,  to  make  the  diagnosis  in  a  given  case 
by  settling  the  following  questions  in  the  order  named : 
"  How  long  has  the  patient  had  the  disease  ?  What  was 
its  cause  ?  What  symptoms,  especially  as  regards  itching, 
fever,  etc.,  attend  or  preceded  the  eruption  ?  What  is  its 
cause?" 

Ohmann  Dumesnil2  says  that  diagnostic  skill  of  the 
highest  character  will  frequently  prove  of  little  or  no 
avail  in  cases  of  eruptions  due  to  the  artifices  of  malinger- 
ers. The  ingenuity  and  tact  of  the  physician  are  called 
into  requisition,  and  it  is  more  the  motive  of  the  patient 
than  the  actual  condition  which  will  lead  to  any  suspi- 
cion. 

Look  Out  for  Possible  Complications.  —  It  is  not 
sufficient  to  merely  make  a  correct  diagnosis,  but  it. 
is  also  necessary  to  be  on  the  lookout  for  complica- 
tions. The  case  of  a  patient  in  one  of  the  city  hos- 
pitals is  still  fresh  in  the  minds  of  many.  A  man  who 
suffered  from  alcoholism  and  at  the  same  time  had  a 
tuberculo  pustular  syphilide,  contracted  small- pox.  The 
symptoms  of  the  latter  disease  were  so  much  obscured 
by  the  other  two  affections  that  the  failure  to  make  a  cor- 
rect diagnosis  was  perfectly  pardonable.  The  patient 
died,  and  the  true  nature  of  the  disease  which  caused  his 
death  was  revealed  upon  the  dissecting  table. 

The  following  complication  came  under  my  personal 

observation :  M.  H ,  a  boy,  nine  months  old,  had  an 

infantile  eczema  on  both  cheeks  for  which  the  family  phy- 
sician prescribed  tinctura  rusci  to  be  painted  on  the  affected 
parts  every  day.  At  first  there  was  some  improvement, 
but  suddenly  a  very  acute  pustular  dermatitis  spread  over 
the  face.  On  opening  the  lids  of  the  left  eye,  which  was 
closed  by  considerable  swelling,  I  found  a  small  pustule 
in  the  centre  of  the  cornea.  Dr.  Gruening,  who  was 
consulted  at  once,  predicted  (and  such  was  the  result), 
that  a  central  opacity  of  the  cornea  causing  strabismus 
would  remain. 

I  also  had  occasion  to  observe  a  peculiar  complication 
in  a  severe  attack  of  urticaria : 

O.  S ,  a  boy  nine  years  of  age,  who  was  subject  to 

outbreaks  of  urticaria  after  eating  fish,  one  evening,  at  a 
children's  party,  partook  of  the  forbidden  food  and  im- 
mediately developed  alarming  symptoms.  He  was  taken 
home  almost  unconscious,  unable  to  breathe,  his  lips  and 
tongue  were  bluish  red  and  swollen,  and  the  body  covered 
with  large  wheals.  I  was  informed  that  he  was  suffering 
at  the  time  from  adenoid  vegetations  in  the  vault  of  the 
pharynx,  for  which  he  was  under  treatment.  Six  years 
later,  after  taking  a  teaspoonful  of  white  vaseline,  which 
was  recommended  to  him  as  an  effective  laxative,  by  a 
friend,  he  had  again  an  attack  of  urticaria  with  ex- 
tremely severe  dyspnoea,  etc.  Examination  showed  that 
the  adenoid  vegetations  had  returned  in  spite  of  repeated 
operations  which  had  been  performed  in  the  meantime. 
The  treatment  in  both  attacks  consisted  of  putting* the 
patient  into  a  bath  tub  and  sponging  him  with  cold  water 
until  breathing  was  somewhat  easier.  On  account  of  the 
pharyngeal  swelling  it  was  not  deemed  safe  to  give  him 
an  emetic,  and  a  tablespoonful  of  castor  oil  was  admin- 
istered. 

Dr.  Mendel  has  reported  a  case  which  in  some  respects 
closely  resembles  the  above.  An  exanthema  caused  by 
copaiva  was  complicated  by  the  presence  of  adenoid  vege- 
tations. There  was  a  great  deal  of  swelling,  pain  in  the 
pharynx,  and  severe  dyspnoea.8 

Be  Careful  in  the  XTse  of  Antipruritic  Remedies. — 
It  is  a  fact  well  known  but  deserving  to  be  emphasized 

1  C.  W.  Allen :  Concerning  some  Unusual  Eruptions,  Mbdical 
Rbcord,  August.  1893. 

*  Some  Points  in  the  Diagnosis  of  Diseases  of  the  Skin,  Cincinnati 
Medical  News,  i.,  1891. 

*  Bulletin  Medical,  24,  1894. 


again,  that  our  best  antipruritic  remedies,  tar  and  its 
chief  derivative,  carbolic  acid,  do  more  harm  than  good 
in  cases  of  general  pruritus.  They  may  afford  some  tem- 
porary relief,  but  the  skin  is  liable  to  get  irritated,  fu- 
runculi  may  form  everywhere,  and  the  patient  is  apt  to  fall 
from  the  Scylla  of  itching  into  the  Charybdis  of  general 
dermatitis  or  furunculosis.  Besides,  a  peculiar  intoler- 
ance of  the  integument  against  all  local  treatment  is  fre- 
quently established.  If  a  new  attack  occurs  it  may  be  so 
severe  as  to  drive  the  patient  almost  crazy  and  to  the 
verge  of  committing  suicide.  In  such  cases  a  hypodermic 
injection  of  morphine,  chloral  internally,  or  even  chloro- 
form anaesthesia,  must  be  resorted  to.  A  cold  douche  or 
bath  containing  sulphur,  carbonate  of  soda,  alum,  or 
sublimate  may  be  given  a  trial.  There  is  no  doubt  that 
mental  depression  is  one  of  the  most  important  factors  in 
the  etiology  of  this  distressing  affection.  The  physician 
called  in  such  an  emergency  case  should  therefore  carry 
out  his  treatment  with  energy  and  tact. 

The  old  error  of  treating  the  most  prominent  symp- 
toms instead  of  the  disease  is  frequently  committed  in  pre- 
scribing antipruritic  remedies  for  acute  general  eczema, 
drug  eruptions,  or  similar  acute  inflammatory  conditions 
of  the  skin.  The  following  case  may  serve  as  an  illustra- 
tion of  the  truth  of  this  statement : 

Mrs.  A.  P ,  forty  six  years  of  age,  had  had  for 

years  a  slight  chronic  eczema  on  the  fingers  of  both 
hands.  During  a  sickness  of  a  member  of  her  family  she 
happened  to  come  in  frequent  contact  with  preparations 
of  carbolic  acid,  and  thus  developed  an  acute  eczema  on 
the  hands,  forearms,  and  face.  In  order  to  relieve  the  in- 
tense itching,  her  family  physician  gave  her  a  wash  con- 
taining some  carbolic  acid.  Soon  after  the  first  applica- 
tion a  most  acute  eczema  spread  over  the  entire  body,  and 
when  I  was  called  to  see  the  patient,  I  found  her  in  a 
deplorable  condition.  She  had  to  be  swathed  in  band- 
ages saturated  with  zinc-calamine  solution  for  several 
hours,  after  which  her  body  was  covered  with  Lassar's 
paste  spread  on  strips  of  linen.  Wherever  possible  these 
strips  were  bound  down  with  bandages.  This  treatment 
not  only  relieved  her  itching  but  was  also  the  first  step 
to  a  final  cure. 

The  Use  of  Antiseptic  Remedies. — Antisepsis  in  the 
treatment  of  skin  diseases  differs  in  a  great  many  re- 
spects from  surgical  antisepsis.  A  healing  by  first  in- 
tention, of  most  lesions,  is  not  to  be  expected ;  certainly 
not  if  the  corium  has  been  destroyed ;  but  even  if  it  is 
only  impaired,  denuded  of  the  epidermis,  or  if  bulls 
have  been  formed,  the  process  of  reparation  can  solely 
be  accomplished  by  catarrhal  (epithelial)  suppuration,  the 
product  of  which  is  the  "  dry  scab  n  under  which  heal- 
ing takes  place  easily  and  undisturbed.  This  is  nature's 
own  antiseptic  routine,  which  we  should  try  to  imitate 
as  far  as  possible  by  using  remedies  which,  although 
inert  as  it  were,  are  capable  of  absorbing  moisture  and 
forming  a  coating  that  furnishes  protection  against  ail 
and  against  infection  from  the  outside.  In  this  sense 
these  remedies  are  better  antiseptics  than  those  which 
have  earned  their  reputation  in  the  realm  of  surgery  as 
being  destroyers  or  antagonists  of  microorganisms. 

In  emergency  cases  of  dermatitis  ambustionis  of  the 
second  degree,  *.*.,  burns  and  scalds,  the  old-fashioned 
carron  oil  or  corn  starch,  with  the  addition  of  boric  acid, 
oxide  of  zinc,  salicylic  acid,  bismuth,  dermatol,  etc.,  is 
far  more  effective  and  reliable  than  iodoform.  Or,  if 
lotions  or  the  continuous  bath  are  used,  solutions  of  boric 
acid  or  liquor  aluminii  acetici  (ten  per  cent.)  are  prefer- 
able to  solutions  of  carbolic  acid,  sublimate,  etc.  In 
herpes  zoster  simple  cornstarch,  dusted  on  freely  and 
bound  down  carefully  by  the  aid  of  a  thick  layer  of  ab- 
sorbent cotton,  is  by  far  the  best  treatment.  In  two 
cases  of  this  disease  I  have  seen  the  lesions  break  down 
and  an  extensive  dermatitis  develop  under  a  dressing  of 
iodoform  gauze.  In  a  case  of  intertrigo  between  the 
legs  of  a  female  infant,  a  dressing  with  carbolic  acid  gave 
rise  to  deep  ulceration.  In  short,  it  has  been  my  expe- 
rience in  such  emergency  cases  that  I  was  more  often 


8o8 


MEDICAL  RECORD. 


[December  29.  1894 


concerned  in  the  removal  of  antiseptics  previously  ap- 
plied and  their  bad  effects,  than  in  advising  their  use. 

I  present  this  epitome  in  the  hope  of  creating  an  in- 
creased interest  in  this  class  of  cases  of  skin  diseases 
which  are  apt  to  confront  the  practitioner  at  any  mo- 
ment and  should  not  find  him  unprepared,  but  able  to 
meet  all  requirements. 

41  Hofjmah  Arms,"  640  Madisoh  Avknuv. 


THE  CARD  INDEX  OR  CARD  CATALOGUE  AS 
ADAPTED  TO  HISTORY-TAKING  IN  PRIVATE 
PRACTICE. 

By  ROBERT  L.    DICKINSON,    M.D., 

LECTURER    ON    OBSTETRICS,   AND  ASSISTANT    OBSTETRICIAN.   LONG    ISLAND  COL- 
LEGE HOSPITAL  ;  OBSTETRICIAN  TO  KINGS  COUNTY   HOSPITAL. 

Synopsis. — This  method  of  keeping  records  consists  in 
using  one  or  more  cards  (measuring  about  6  x  6} 
inches)  for  each  case,  the  cards  being  ranged  under  an 
alphabet  index  and  stacked  on  edge  in  a  drawer  or  box, 
and  folded  down  the  middle  for  carrying  in  the  pocket. 

Such  a  system  (the  card  size  being  immaterial)  is  the 
only  portable,  elastic,  simple,  orderly  and  self  indexing 
way  of  keeping  records  and  is  as  readily  used  at  the  bed- 
side  or  operating  table  as  in  the  office. 


Disadvantages  of  Books.— Books  are  inelastic.      If 
the  case  runs  to  the  foot  of  one  page,  where  shall  it  be 


continued  ?  One  can  rarely  guess  at  the  space  required 
in  beginning  a  history.  The  next  page  is  occupied  ;  one 
must  skip  to  the  first  blank  page,  or  borrow  part  of  a 
page  near  by,  with  the  result  that  a  long  record  will  be 
in  scraps  through  one  or  more  case-books  and  scattered 
so  that  the  parts  of  the  history  cannot  be  assembled.  A 
separate  index,  in  a  separate  book,  is  required  after  a 
while,  in  order  to  avoid  searching  the  index  of  each  book. 
Books  are  not  portable.  Notes  taken  at  the  house  or 
hospital  must  be  copied  or  pasted  in.  Books  grow  worn 
and  shabby  from  much  handling,  if  large,  and  if  thin 
many  are  required.  After  all  the  other  cases  are  closed 
up,  one  may  have  still  to  use  an  old  book  for  a  single 
case.     He  cannot  keep  its  history  with  his  recent  cases. 

Disadvantages  of  Sheets. — Sheets  of  stiff  paper  may  be 
kept  in  alphabetical  order  in  a  letter  file  or  binder,  but 
they  inevitably  become  frowsy  at  the  corners,  they  do 
not  stack  on  edge,  they  are  not  readily  run  through  the 
fingers  like  the  leaves  of  a  book  when  a  bunch  of  them 
under  a  certain  letter  is  picked  up,  as  cards  are,  and  they 
are  generally  too  large  for  carrying  in  the  pocket.  The 
method  is  only  suited  to  hospital  conditions.  Dr.  Rich- 
mond Lennox  and  I  have  used  both  sheets  and  cards 
and  find  we  save  much  time  and  discomfort  with  the 
cards. 

Advantages  of  Cards.— Portability.— For  office  use 
cards  will  be  found  to  be  handier  than  a  book,  and  the 
specialist,  above  all  men,  will  find  them  convenient.  For 
bedside  notes  this  is  the  only  handy  method.  For  im- 
mediate record  of  consultation  work  and  for  operative 


1 


Smith,  Mrs.  John.  3a.  Father  tuberc.  Pneumon.  6  years  ago.  Slender,  overworking,  worrier.  Headaches  every  2-3  dys  ;  good 
eyes  ;  goDd  dig.,  but  costive.  Piles,  rarely  bleeding  ;  chest,  right ;  clothes  tight ;  corset  springs  3  inches  ;  urine:  60  oz  ,  1023 ;  no  alb. 
or  casts. 


G.   Mar.  6  yrs ;  2  children  ;  oldest,  4 ;   ygst,  1 ;  o  Misc. 

labors  severe,  forceps.  Puerperiums  fever. 

Menses^  formerly   not  painful,    irregular. 

Now  pain,  none  slight,  Severe  cramps  front  R.  L.  iliac  reg. 

Backache,     before,     .during,     after,    b.twecn,     constant. 

In  bed  1%  dys.     Much  dragging. 

Flow  free,   scanty.  Clots,  membrane. 

Irregular  every  20-30  days,  weeks,  lasting  6  dys.  Last  men. 

7je- 
Vag.  discharge  constant^  prof use^  slight  mucus,  puruly  foul. 
Urination  frequent,  not  painful.  Dyschezia^   dyspar. 

Walking,  working,  not  painful.     Dates  trouble  from  last 

labor. 


Retroversion. 
Subinvolution. 
Induration  right  brd. 
Ext.  hetmorrhoids. 
Uterus  mobile. 
Ovaries    moderately 
placed,  not  tender. 


Kg- 


dis- 


Partial  reposition  ich.  tamp,  iac  to  cervix.  Basham's  mixture ;  cascara  ;  loose  clothing ;  sea-bathing.  23  Je,  same.  29  Je,  backache 
and  leuc  ,  less  do.  5  July,  s.  r.,  Smith  pessary.  10,  easier  period  ;  impr.  position  ;  3  Aloin  Strych.,  bellad.  20,  hard  r.  pess.;  much 
better  ;  7%  cavity,  and  so  forth. 


Fig.  i. — Card  for  taking  case  histories, 
notes,  are  also  shown. 


Actual  size.    The  rubber  stamp  that  is  ust  J  to  print  part  of  the  history,  if  desired,  and  the  stamp  of  aa  outline  ferjgrapbic 


December  29,  1894] 


MEDICAL    RECORD. 


809 


and  obstetric  cases,  it  is  exactly  adapted,  while  for  medi- 
co-legal cases  notes  made  on  the  spot  are  the  only  ones 
the  medical  man  may  consult  in  the  witness  chair.  In 
reporting  a  single  case  or  a  group  of  cases  at  a  society 
meeting,  or  in  getting  together  case  histories  in  writing 
a  paper,  the  cards  required  are  picked  out  and  sorted  as 
desired.  One  carries  in  the  pocket  the  cards  of  patients 
ill  at  home,  selecting  those  needed  as  one  leaves  the 
office,  and  dropping  the  convalescents. 

Elasticity. — Whether  there  be  twenty  cases,  or  two 
thousand  or  twenty  thousand,  the  whole  history  of  each 
patient  is  assembled  and  whatever  the  number  of  histories 
they  are  always  in  order,  yet  there  is  always  room  for 
more. 

Self-indexing. — The  cards  are  ranged  under  an  alpha- 
bet printed  on  buff  bristol  cards  (guides)  that  stand 
taller  than  the  history  cards.  This  index  can  be  in 
twenty-six  letters  or  carried  to  two,  three,  or  four  letters, 
as  in  the  Burr  index,  i.e.,  Bradley  might  come  under  B 
in  the  simple  way,  Br  for  the  two-letter  method,  Bra  for 
the  three-letter  index.     Beyond  two  thousand,  however, 


Fig.  3.— Clip  to  hold  cards 


over 


or  wallet  of  average  size,  with  one  fold.    This  fold  must 
be  upright,  so  that  cards  will  stack  and  turn  easily  when 
replaced  in  the  drawer.     Paper  stock  cuts 
economically  to  this  size.    The  material 
is  the  thinnest  that  will  stand  on  edge 
without  sagging.    The  ruling  is  a  standard 
adopted  by  librarians  as  suiting  the  aver- 
age handwriting ;  and  all  these  things,  and 
other  important  details,  are  based 
on  the  long  study  and  elaborate 
experience  of  the  Library  Bureau, 
makers  of  standard  supplies  for  our 
great  Libraries.     Satisfaction  will 
be  wanting  from  the  hands  of  an  or- 
dinary printer ;  a  perfect  edge,  ab- 
solute exactness  of  size,  and  an  even 
distance  of  ruled  top-line  from  the 
top,  so  that  the  names  appear  in 
exactly  the  same  spot,  are  all  essen-  S^S^TSrta: 

tial  tO  Speed  and  COmfort  in  running    the  rear  before  and  after  fast- 

a  bunch   of  cards.     The  Li-  S^hi  uppeTco^er.  mS" 
brary  Bureau  (of  146  Frank-  dieton  paper  fastener. 
lin  'Street,  Boston,  and  Stewart  Building,  Broad- 
way, New  York)  do  very  handsome  and  satisfac- 
tory work  at  reasonable  rates. 

The  proportions  and  details  of  this  arrangement 
have  been  the  outcome  of  much  study,  and  all  the 
fittings  are  kept  in  stock.  Variations  in  size  of 
card  will  cost  more  in  money  and  delay,  but  varia 
tions  in  details,  such  as  a  printed  form,  any  ruling 
or  none,  or  any  kind  of  card  as  to  thickness,  color, 
or  variety  of  tints  of  edge  for  different  kinds  of 
cases,  are  easily  adapted.  For  some  specialists,  as 
ophthalmologists,  whose  notes  are  brief  and  who 
write  small,  the  standard  postal  size,  nearly  3x5 
inches,  works  very  well  and  is  much  cheaper  Ope 
who  writes  large  may  desire  a  wider  ruling  than 
three  sixteenths  of  an  inch,  but  it  is  to  be  clearly 
understood  that  my  plan  will  not  suit  men  who 
take  copious  notes  in  a  large  handwriting. 

Practically  it  is  found  that  two-hundred  to  three 
hundred  cards  make  a  working  list  for  a  busy  man. 
The  consultation  cases,  and  the  patients  gone  or 
moved  away,  can  go  under  a  separate  alphabet  in 
the  back  of  the  drawer  when  the  lists  grow  bulky. 

Fig.  a.-Box  to  hold  the  cards,  where  a  drawer  is  not  available.    The  ru«rd  rod  here  Another  alphabet  may  SCTVt  tO  index  diseases,  Or 

shown  at  the  bottom  of  the  box  is  used  in  library  work  to  prevent  removal  of  the  cards,  but  .  *  .£  t»      «~  u*   u  • 

is  unnecessary  in  private  practice.    One  of  the  blocks  that  slant  the  cards  at  the  proper  angle  interesting  Cases,  OT  tlie  SUDjeCtS   OU  WtUCn   One  IS 

is  seen,  with  the  hole-  **•••  -*—■«•«■ »»»-  ~~»~i»  «f  *i— .  — .-  ui — i.  * is...... :»  r 1 r  .  ._•..«..«  «  .« 

cards. 


les  that  steady  the  catch  of  the  rear  block  to  adjust  it  for  any  number  of   gathering   data,    but   at    first   all    Cards   may  Stand 

under  the  single  alphabet,  if  desired. 

In  libraries  the  cards  are  made  fast  in  place  by  a  guard- 
rod  running  through  a  hole  in  the  bottom  of  each  card. 
A  turn  of  the  drawer  knob  unlocks  the  rod,  and  as  it  is 
slipped  out  the  card  is  freed.  This  can  be  applied  to 
our  cards,  but  it  is  unnecessary. 

The  full  outfit  consists  of, 


we  use  the  "  directory "  method  by  entering  every 
twenty-fifth  name  on  a  guide,  as  I  have  done  in  the  identi- 
ncation-and-rating-card- index  to  the  thousands  of  men 
examined  for  the  civil  service  commission.  Practically, 
however,  after  a  while  we  keep  a  small  working  list  under 
an  alphabet  in  the  front  of  the  drawer,  and  under  a 
separate  alphabet  behind  stand  the  histories  which  we 
are  not  liable  to  need  again. 

Details. — The  cards  I  am  using  are  6  x  6|  inches, 
thin,  blue-ruled,  with  red  line  for  headline,  standing  on 
edge  in  a  drawer  where  I  look  down  on  them  at  my  side. 
When  Mrs.  Bradley  arrives  I  pick  up  the  bunch  of  B's 
and  run  them  through  as  quickly  as  one  does  the  index 
of  a  book.  For  long  cases  cards  can  be  fastened  together 
very  solidly  and  conveniently  by  a  Middleton  Clip  at 
the  upper  right-hand  corner.  It  is  small  and  thin  and 
does  not  have  to  be  punched  through  the  paper. 
Sketches  or  loose  notes  are  readily  pasted  on  the  cards 
or  can  be  kept  in  envelopes  of  the  exact  size  of  the  cards 
provided  for  this  purpose,  at  a  small  additional  cost. 
Instead  of  a  drawer — and  in  any  deep  drawer  a  partition 
can  be  fastened — a  box  with  lid  and  lock  can  be  had,  but 
a  drawer  is  most  convenient. 

For  the  beginner  it  is  especially  important  to  start  with 
a  system  that  cannot  be  outgrown,  that  is  elastic,  and 
that  will  train  him  to  orderly  methods. 

Reasons  for  this  Size,  Ruling,  Grade  of  Paper,  etc. — 
The  card  is  the  largest  that  will  go  into  the  pocket-book 


1,000  cards,  weight  No.  7506,  ruled  with  double  red  line  at 

top,  29  blue  lines  -ft  inch  apart,  not  punched,  costing.     $4.00 

1  alphabet  index  (A-Z  guides)  buff  bristol  board,  costing. . .         .95 

2  blocks,  the  rear  sliding  in  slot  with  catch,  so  as  to  set  the 

case  for  any  number  of  cards,  in  a  drawer  6i  by  14$ 
inches,  or  longer,  oak,  mahogany  or  walnut,  with  han- 
dle and  label  holder 4.50 

Or  box,  oak,  mahogany  or  walnut,  with  lock 3.50 

The  whole  outfit  costing,  with  box 8.00 

with  drawer 9.00 

One  may  start  with  fewer  cards,  but  it  is  best  to  get  two 
A-Z  indexes.  The  Middleton  paper  fasteners  can  be 
ordered  also,  or  procured  at  a  stationer's.  In  ordering, 
specify  carefully :  Box  with  or  without  lock ;  or  drawer ; 
kind  of  wood  desired;  two  blocks,  one  with  catch; 
label-holder;  number  of  cards,  ruled  or  plain,  un- 
punched  ;  and  number  of  alphabet  guides. 

Note. — I  have  found  that  this  method  is  in  use  in  the 
Johns  Hopkins  Dispensary,  but  many  details  have  been 
bettered  in  these  plans,  as  experience  shows.  Many 
business  houses  employ  the  large  cards  extensively. 

14s  Clinton  Sntarr,  Bbooklyn,  N.  Y. 


8io 


MEDICAL   RECORD. 


[December  29,  1894 


PUERPERAL  FEVER.1 

BY  THERESA  BANNAN,  M.D., 

SYRACUSE,  N.  Y. 

Puerperal  fever  is  defined  as  a  septicaemia  developed 
from  the  absorption  of  foul  material  through  wounds 
due  to  parturition*  the  most  common  source  of  such 
material  being  the  uncleanliness  of  the  attendants. 
Hence  in  these  days  of  asepsis  and  antisepsis  the  physi- 
cian who  reports  a  case  oi  puerperal  fever  almost  chal- 
lenges the  charge  of  gross  negligence. 

It  will  be  unnecessary  for  me  to  touch  on  the  litera- 
ture of  this  subject,  since  it  is  the  foundation  of  modern 
obstetrics.  In  a  city  the  size  of  this,  where  there  is 
no  large  maternity  hospital,  the  infectious  character  of 
lying-in  fever  is  rarely  brought  to  the  notice  of  the  pro- 
fession. The  following  cases  occurred  in  the  Maternity 
Department  of  one  of  our  hospitals,  being  the  first  cases 
of  the  kind  in  the  history  of  the  institution. 

An  outline  of  the  care  given  during  the  puerperium 
will  not  be  out  of  place.  The  patient  is  prepared  for 
labor  by  a  bath,  a  bichloride  vaginal  douche,  and  an 
enema.  Care  is  taken  that  the  bladder  is  emptied.  A 
short  night-dress  is  supplemented  by  a  folded  sheet  tied 
around  the  hips.  Cotton  stockings  reaching  half-way 
up  the  thigh  complete  the  toilet  Everything  about  the 
patient  and  her  bed  is  clean.  The  nurses  wear  their 
regular  uniform,  and  the  physician  is  dressed  in  a  cotton 
gown.  The  diagnosis  of  the  presentation  is  first  at- 
tempted by  external  palpation,  the  internal  examination 
being  made  when  labor  is  undoubtedly  present.  The 
hands  are  prepared  for  this  examination  by  being  thor- 
oughly scrubbed  with  soap  and  water — and  then  bathed  in 
a  1  to  3,000  bichloride  solution.  The  examining  finger 
is  protected  from  any  contact  until  it  enters  the  vagina. 
Unnecessary  examinations  are  avoided,  although  the  peri- 
neum is  generally  stretched  to  diminish  the  chances  of 
laceration.  As  soon  as  the  head  has  cleared  the  vulva 
one  hand  grasps  the  fundus  of  the  uterus  while  the  other 
assists  the  delivery  of  the  body.  The  placenta  is  ex- 
pressed within  five  or  ten  minutes,  ergot  given  in  routine, 
and  a  vaginal  douche.  A  sterilized  pad  and  abdominal 
binder  are  applied,  and  the  woman  is  removed  to  the 
ward.  Vaginal  douches  are  given  twice  a  day  for  one 
week,  not  because  it  is  considered  necessary,  but  because 
it  seems  best  in  a  hospital.  Such  is  the  routine  of  the 
Maternity  Department,  and  such  was  the  care  of  the  two 
following  cases : 

Case  I. — L.  E ,  aged  eighteen,  unmarried,  pri- 

mipara,  had  been  in  the  hospital  two  or  three  months. 
She  had  always  been  in  good  health  and  continued  so 
during  pregnancy.  Urine  normal.  Labor  began  about 
midnight  of  July  9,  1894,  and  she  was  delivered  about 
7  a.m.  Vertex  presentation,  first  position.  Perineum 
was  stretched,  and  laceration  of  first  degree  occurred  and 
was  not  repaired.  Placenta  and  membranes  expelled  en- 
tire. Everything  normal  until  the  morning  of  the  second 
day,  when,  at  7.30  a.m.,  the  temperature  was  found  100.80 
F.  Four  hours  later  the  patient  had  a  severe  chill,  accom- 
panied by  pains  in  the  abdomen,  and  a  temperature  of 
103. 20  F.;  pulse,  100;  respiration,  30.  Ergot  was  given, 
and  two  drachms  of  sulphate  of  magnesium  and  quinine, 
grains  two,  £*.</., was  begun.  Free  perspiration  followed 
the  chill  and  the  bowels  moved  freely,  but  at  10  p.m. 
temperature  had  reached  104. 8°  F. ;  pulse,  147;  respi- 
ration, 56.  Phenacetine,  five  grains,  and  another  dose 
of  salts  were  given,  hoping  to  produce  a  fall  of  tempera- 
ture by  natural  channels  of  radiation.  But  the  next 
morning,  at  7.30,  temperature  was  104.40  F. ;  pulse, 
1 20 ;  respiration,  40.  At  10  a.m.  the  uterus  was  irrigated 
with  sterilized  water.  This  was  done  not  because  it  was 
indicated,  the  lochia  being  normal,  the  uterus  hard  and 
not  sensitive,  but  because  I  wished  to  protect  myself 
from  censure,  knowing  well  that  the  majority  of  physi- 
cians would  condemn  such  an  omission.  No  shreds  or 
clots  were  washed  out,  and  no  odor  was  perceptible  in 

1  Read  before  the  Syracuse  Academy  of  Medicine,  October  23, 1894. 


the  return  flow.  The  double  tube  was  used.  Two  hours 
after  irrigation  the  patient  had  a  severe  chill,  and  the 
temperature  went  up  to  105°  F.  Once  again  the  uterus 
was  irrigated,  this  time  with  the  single  glass  tube  and  a 
1  to  8,000  bichloride  solution.  Nothing  was  washed  oat 
except  a  little  fresh  blood  produced  by  the  tube.  Com- 
pletely satisfied  that  if  the  source  of  infection  was  within 
the  uterus,  irrigation  was  not  the  indicated  treatment, 
no  other  irrigation  was  made.  The  abdominal  uneasi- 
ness disappeared,  however,  after  the  second  irrigation, 
whether  because  of  it  or  of  the  antipyrine,  five  grains, 
which  was  given  twice,  while  the  two  grains  of  quinine 
were  increased  to  five.     Salines  were  also  continued. 

About  this  time  the  search  for  the  focus  of  infection 
disclosed  three  abrasions  on  the  inner  sides  of  the  labia 
minora.  These  were  covered  with  a  grayish  exudate, 
forming  the  so-called  diphtheritic  patches.  Vaginal 
douches  of  bichloride  were  ordered  three  times  a  day,  and 
the  parts  to  be  separated  by  iodoform  gauze.  Under 
the  two  doses  of  antipyrine  the  temperature  fell  to 
1 00. 6°  F. ;  pulse,  70,  and  remained  so  duriog  the  night. 

To  make  an  impression  on  the  fever  calomel  and  bi- 
carbonate of  soda,  ten  grains  each,  with  fifteen  grains  of 
quinine,  were  administered  at  one  dose,  but  three  hoars 
later,  11.30  a.  m  ,  she  had  another  severe  chill  and  tem- 
perature, 102.40  F.;  pulse,  90.  This  being  the  third  chill, 
and  occurring  at  the  same  time  each  day,  a  malarial 
element  seemed,  in  the  absence  of  other  factors,  to  be  a 
cause  of  the  high  temperature.  Quinine  was  given  in 
large  doses  until  cinchonism  was  produced.  There  was 
no  splenic  tenderness  nor  mammary  disturbance.  Feel- 
ing that  the  lacerated  perineum  might  have  some  causal 
influence,  although  it  had  not  been  covered  with  the 
grayish  patch,  it  was  now,  on  the  fifth  day,  gently  scraped 
and  repaired.  Peroxide  of  hydrogen  was  now  applied 
to  the  gray  patches  every  three  hours,  and  was  continued 
until  they  disappeared.  At  9  p.m.  the  temperature 
reached  the  highest  point  of  the  day,  1030  F.  Daring 
the  night  it  remained  at  1020  F.,  and  at  noon  of  the  fol- 
lowing day,  when  a  chill  was  expected,  there  was  only  a 
sensation  of  chilliness  with  temperature  101.40  F.  This 
seemed  favorable;  but  three  hours  later  the  thermometer 
recorded  1040  F.  Antipyrine  was  employed  to  reduce 
the  temperature,  and  small  doses  of  calomel  and  the 
salines  were  given  to  keep  the  bowels  loose. 

Next  day  at  9  a  m.  temperature  was  100.40  F.,  and  at 
noon  1050  F.;  pulse,  100,  without  a  chill.  In  spite  of 
antipyrine  it  continued  1040  F.;  pulse,  no,  all  the  after- 
noon until  9  p.m.  Quinine  in  full  doses  and  phenacetine 
were  used,  but  temperature  was  103°  F.  all  night,  and 
during  the  following  morning  continued  to  rise.  With  a 
feeling  akin  to  desperation  all  medication  was  ordered 
stopped  except  salol  and  phenacetine,  two  and  one-half 
grains  each,  which  were  given  every  two  hours,  alternating 
with  phenacetine,  five  grains.  Regular  diet  was  given 
instead  of  liquid.  Such  a  step  was  decided  upon  be- 
cause of  the  inefficiency  of  the  treatment,  which,  whether 
local  or  systemic,  appeared  to  produce  no  effect  on  the 
course  of  the  disease.  Moreover,  the  patient  was  very 
comfortable,  even  during  the  highest  fever.  Only  dar- 
ing the  chill  did  she  complain  of  discomfort,  and  so  in- 
credible did  the  presence  of  so  much  fever  seem  that  she 
was  watched  while  the  temperature  was  being  taken  to 
exclude  trickery. 

Under  the  salol  and  phenacetine,  begun  on  the  eighth 
day  after  labor,  temperature  continued  to  fell  until  it 
was  990  F.,  and  remained  down  for  one  day.  On  the 
next  day,  the  tenth,  at  9  a.m.,  temperature  was  1030  F.; 
pulse,  98,  and  at  noon  103.40  F.;  pulse,  116.  Fowler's 
solution  was  now  begun,  for  its  tonic  and  antimalarial 
effect,  quinine  having  been  abandoned.  The  tempera- 
ture remained  at  102. 40  F.  all  the  afternoon,  and  in  spite 
of  the  antipyretics,  reached  1030  F.  in  the  early  morning. 
It  varied  from  1010  to  1020  F.  for  the  next  two  days  and 
the  antipyretics  were  stopped.  Without  again  reaching 
ioo°  F.  it  returned  to  normal,  and  the  patient  went  on  to 
recovery,  much  the  worse  physically  for  her  experience. 


December  29,  1894] 


MEDICAL   RECORD. 


811 


Five  days  after  the  delivery  of  Case  L,  another  woman 
was  delivered  in  the  same  room,  under  identical  condi- 
tions, and  placed  in  the  same  ward  with  her.  Though 
her  labor  had  been  long  and  tedious,  necessitating  man- 
ual dilatation  of  the  os  and  constant  attention  to  free  the 
anterior  lip  from  the  occiput,  she  passed  a  perfectly  nor- 
mal puerperium. 

Case  II. — A.  H. ,  forty  years  of  age,  primipara, 

unmarried,  was  delivered  under  the  same  conditions  as 
Case  I.  on  August  30,  1894.  She  had  slight  pains  all 
day,  and  at  7  p.  m.  they  became  vigorous,  and  she  was 
delivered  about  11  30  p.m.,  being  a  short  labor  for  one 
of  her  age.  Everything  was  normal  until  the  head 
cleared  the  vulva,  when  the  cord  was  found  so  tightly 
around  the  neck  that  the  least  traction  imperilled  its 
continuity.  The  head  had  become  so  elongated  from 
pressure  that  the  cord  could  not  be  slipped  over  it,  so 
was  tied  and  cut  and  the  child  extracted.  There  was  no 
laceration  of  the  perineum. 

Next  day  the  temperature  was  99-4°  F.;  but  thirty  six 
hours  after  delivery  reached  102.8  F.,  rising  to  103.20 
F.  in  the  evening.  At  3  p.m.  of  the  following  day  tem- 
perature was  104. 6°  F.;  pulse,  120.  Ten  grains  of  qui- 
nine and  salines  were  given,  and  the  next  morning  tern, 
perature  was  101.40  F.,  and  in  the  afternoon  103. 20  F. 
The  following  day,  the  fifth  day  after  delivery,  tempera- 
ture was  103. 6°  in  morning,  and  105. 20  F.,  with  pulse 
1 28,  in  the  afternoon.  During  this  day  the  abdomen  had 
become  very  much  distended  with  gas  in  the  intestines. 
Pressure  discovered  not  the  least  pain  in  any  part,  and 
except  for  the  difficulty  of  respiration,  due  to  the  dis- 
tention, the  patient  felt  very  comfortable.  In  the  even- 
ing Dr.  Allen  saw  the  case  with  me,  and  discovered  a 
slight  bogginess  in  the  left  broad  ligament.  Diphtheritic 
patches  were  sought,  but  not  found  until  the  following 
morning. 

The  treatment  decided  upon  was  to  give  an  intra-ute- 
rine  douche  and  note  the  effect,  and  to  support  the  pa- 
tient's strength  by  strychnia,  whiskey,  and  peptonized 
food.  The  lochial  discharge  was  normal.  Next  morn- 
ing a  uterine  irrigation  of  1  to  3,000  bichloride  was 
made,  which  washed  out  two  or  three  small  inoffensive 
clots.  The  abdominal  distention  had,  in  the  meantime, 
increased  and  was  treated  by  turpentine  enemata  and 
stupes,  and  also  by  turpentine  per  mouth.  The  rectal 
tube  was  inserted  also,  and  the  tincture  of  nux  vomica 
substituted  for  strychnia,  nevertheless  the  temperature 
remained  stationary  at  104. 20  F.;  pulse,  120;  respira- 
tion, 28  to  44.  On  the  following  day  improvement  by 
the  lessened  distention  was  noted ;  the  pulse  did  not  rise 
above  120,  but  the  temperature  was  103. 40  F.  in  the 
morning,  104.80  in  the  evening.  The  diphtheritic 
patches  had  been  treated  as  in  Case  I.,  but  nothing  seemed 
to  control  the  fever,  and  as  the  temperature  was  1040  F. 
the  following  morning,  the  phenacetine  and  salol  were 
given  twice  and  temperature  fell  to  1010,  ascending  to 
103.6°  F.  at  9  p.m.  One  ounce  of  sulphate  of  magnesium 
was  then  given,  smaller  doses  having  little  effect.  The 
temperature  remained  at  104  40  F.  all  the  following  morn- 
ing, yielding  somewhat  to  the  antipyretics  in  the  after- 
noon. The  salts  having  little  effect  one  ounce  of  castor- 
oil  was  given,  and  the  salol  and  phenacetine  administered 
every  two  hours.  Still  the  temperature  fluctuated  be- 
tween 1030  to  104.80  F.,  with  pulse  120.  The  oil  was 
repeated,  and  next  morning,  the  eleventh  after  delivery, 
temperature  99-2°  F.  at  9  a.m.  and  104. 20  F.  at  noon. 
This  was  the  last  rise,  and  patient  went  on  to  recovery. 
At  the  first  rise  of  temperature  the  patient  had  been 
removed  to  the  medical  ward. 

The  Maternity  Ward  was  thoroughly  fumigated  and  the 
labor- room  furniture  washed  with  bichloride.  Within  a 
week  two  women  were  confined,  one  of  whom  entered 
in  labor.  She  developed  two  diphtheritic  patches,  but 
had  not  the  slightest  disturbance  of  temperature  or  pulse. 
The  only  change  in  care  was  the  omission  of  douches 
after  labor. 

The  above  cases  are  similar  in  having,  as  far  as  could 


be  discovered,  the  same  cause — diphtheric  patches  on  the 
abrasions  due  to  parturition.  The  fever  was  unusually 
high  in  both  cases,  while  the  discomfort  produced  was 
slight.  They  differ  in  that  one  case  severe  chills  oc- 
curred, while  the  pulse  rarely  corresponded  with  the  tem- 
perature ;  in  the  other  case  great  abdominal  distention 
and  much  cardiac  disturbance  were  present.  Both  women 
had  emotional  paroxysms,  which,  no  doubt,  somewhat 
disturbed  the  nervous  poise.  The  treatment,  though  far 
from  satisfactory,  was  in  accordance  with  my  best  judg- 
ment. To  repeatedly  irrigate  the  parturient  canal  when 
not  clearly  indicated  seemed  meddlesome.  Antipyretics 
were  not  used  early  lest  they  should  obscure  the  condi- 
tion without  affecting  the  cause.  When  all  other  treat- 
ment failed  to  reduce  the  temperature,  and  the  evils  of 
its  constant  elevation  were  feared,  antipyretics  then  used 
confessed  failure  along  more  scientific  lines  of  treatment. 
The  preservative  power  of  Mother  Nature  was  not  for- 
gotten. Both  patients  received  excellent  care,  day  acd 
night,  from  the  nurses  in  charge,  and,  whatever  the 
cause  of  their  illness,  it  would  seem  far  removed  from 
neglect. 

503  Wairen  Street. 


CASES  OF  MONSTROSITIES,  WITH  SPECIAL 
REFERENCE  TO  THE  THEORY  OF  MATER- 
NAL IMPRESSIONS.1 

By  JOHN  H.  BARRY,  M.S.,  M.D., 

LONG  ISLAND  CITV,  N.  V. 

Medical  genius  and  scientific  investigation  have  done 
much  to  make  the  physician  of  to-day  feel  envious  of  the 
proud  advantage  he  holds  over  the  minds  of  long  ago. 

But  the  self  same  scepticism,  the  same  disinclination 
to  attempt  a  translation  of  the  wonderful  and  the  mon- 
strous, actuates  us  as  actuated  our  forefathers,  and  we 
pause  spell- bound  at  the  diverse  manifestations  of  the 
workings  of  an  Infinite  Being,  just  as  they  acknowledged 
their  inability  to  cope  with  the  miraculous  and  myste- 
rious. 

Thus  it  is  that  the  etiology  of  monstrosities  is  as  vague 
as  ever,  and  medical  pride  bows  in  abject  submission 
when  confronted  with  the  task  of  averting  the  misfor- 
tune, or  even  comforting  the  pangs  of  sorrow  and  dis- 
tress incident  upon  a  monstrous  conception.  It  is  with 
no  likelihood,  then,  of  diverting  from  the  well-beaten 
path,  but  rather  to  furnish  my  quota  of  evidence,  that 
the  record  of  the  appended  cases  has  been  undertaken 
for  your  interest  and  possible  instruction. 

Case  I.     Anencephalus. — Mrs.   A ,   twenty- four 

years  of  age,  primipara,  was  delivered  on  October  18, 
1893,  °f  3Ln  anencephalic  infant,  presumably  full  teim, 
and  bearing  the  following  gross  characteristics:  No 
frontal  bone  developed  above  supra  orbital  ridges,  latter 
marking  summit  of  skull ;  collapsed  membraneous  cov- 
ering over?  frontal  area  of  calvaria;  three  segments  of 
dense  tissue,  resembling  placental  tissue,  arising  from  a 
common  stem  in  the  region  of  foramen  magnum,  each 
segment  being  about  the  size  of  an  almond.  Bulging 
eyes,  frog- faced  countenance;  ovoid  contour  to  chest 
and  trunk  plainly  observable  while  babe  lies  prone.  Six 
fingers  on  either  hand ;  six  toes  on  either  foot.  Ten- 
dency to  apposition  of  plantar  surfaces  of  feet  when 
brought  in  contiguity.  Spinal  column  intact ;  no  spina 
bifida :  notable  tumefaction  of  abdomen.  Lived  about 
three  minutes.     No  autopsy  allowed. 

Case  II.  Hernia  Cerebri  {Occipital  Meningocele ; 
Breech  Presentation).  —  On  August  29,  1894,  same 
mother  as  in  Case  I.,  delivered  spontaneously  what  was 
presumably  an  eight  months' -foetus,  bearing  the  follow- 
ing characteristics :  Frontal  bone  present ;  marked  cleft 
antero-posteriorly  extending  from  nasal  process  of  frontal 
bone  to  anterior  fontanelle.  Superior  angles  of  either 
half  of  frontal  bone  marked  by  delayed  osseous  develop- 
ment, the  same  condition  obtaining  in  anterior  and 

1  Read  before  Queens  County  Medical  Society,  October  30, 1894. 


8l2 


MEDICAL   RECORD. 


[December  29.  1894 


posterior  superior  angles  of  parietals  and  anterior  supe- 
rior angles  of  occipital  bone,  so  that  each  semilunar 
segment  going  to  form  anterior  and  posterior  fontanelles 
contrived  to  form  unduly  large  ones,  into  which  the  tip 
of  finger  could  be  readily  inserted.  Skull  development, 
notwithstanding,  more  perfect  than  in  Case  I.  Coun- 
tenance nearer  normal,  more  or  less  ovoid  contour  to 
chest  and  trunk.  Spinal  column  seemingly  intact; 
marked  luxation  of  hip-joint  in  flexed  position ;  double 
genu  recurvatum ;  plantar  surfaces  of  feet  clearly  apposed 
(talipes  varus) ;  six  toes  on  either  foot ;  six  fingers  on 
left  hand ;  five  on  right  hand.  A  hernia  the  size  of  a 
goose  egg,  and  analogous  in  its  nature  to  the  sense  of 
feeling  imparted  by  squeezing  a  loop  of  intestine,  was 
situated  over  region  of  foramen  magnum.  A  smaller 
hernia,  the  size  of  a  hen's  egg,  situated  over  region  of 
upper  cervical  vertebrae.  On  attempting  reduction  of 
larger  hernia,  smaller  one  enlarged,  and  vice  versa. 
There  was  also  to  be  found  a  circular  cleft  of  hard  pal- 
ate, about  midway  between  alveolar  process  of  superior 
maxilla,  and  vault  of  pharynx,  of  about  the  calibre  of  a 
thermometer  case.  Marked  abdominal  tumefaction. 
In  left  hypochondriac  region  could  be  felt  large,  irreg- 
ular, resisting  tumor,  possibly  a  misplaced  viscus.  Lived 
about  fifteen  minutes.  No  autopsy  allowed,  but  photo- 
graphs  obtained. 

Case  III.     Birth-mark  on  Neck. — Mrs.  C ,  aged 

twenty-nine,  primipara,  about  seven  months  pregnant ; 
consulted  me  on  April  24,  1894,  for  diffuse  cervical 
phlegmon,  at  that  time  unilateral.  Palliative  measures 
were  resorted  to  in  the  hope  of  checking  suppuration, 
but  to  no  purpose.  With  considerable  diffidence  regard- 
ing patient's  delicate  condition,  chloroform  was  admin- 
istered on  April  26  th,  and  an  incision  made  in  right  cer- 
vical region,  but  without  reaching  pus  of  any  account. 
Wound  was  packed  with  iodoform  gauze,  and  immediate 
effect  of  operation  was  to  diminish  tension  and  swelling 
of  tumor.  On  morning  of  April  28th,  tension  and  swell- 
ing were  much  exaggerated  over  original  condition,  and 
diffuse,  deep  seated  adenitis  of  left  side  of  neck  was 
clearly  observable.  Symptoms  of  septicaemia  appeared 
and  rapidly  progressed ;  foetal  heart-sound  was  looked 
for  with  negative  result.  Radical  operation  was  sug- 
gested and  refused,  and  a  grave  prognosis  given.  On 
morning  of  April  29th  labor  pains  came  on,  and  the 
patient  was  delivered,  within  a  few  hours,  of  a  premature 
foetus,  presumably  dead  about  forty- eight  hours,  with  a 
denuded,  swollen,  circular  area  about  one  and  one  half 
inch  in  diameter  in  left  cervical  region  and  correspond- 
ing to  the  site  of  the  mother's  latter  formed  phlegmon. 

Patient  went  on  with  a  temperature  of  1050  F.,  and 
pulse  of  160,  and  died  at  xo  p.m.  of  same  day. 

Case  IV.  Supernumerary  Digit. — Mrs.  B ,  forty- 
two  years  of  age,  multipara,  was  delivered  on  October  4, 
1894  of  a  female  child,  with  last  phalanx  of  a  little  finger 
hanging  by  a  slender  thread  from  middle  of  fifth  finger 
of  left  hand.  Specimen  snipped  off  and  here  presented. 
No  history  of  maternal  impressions  could  be  elicited. 

In  reviewing  the  literature  of  the  subject  of  maternal 
impressions,  we  find  recorded,  in  turn,  all  phases  of  mon- 
strosities, some  of  which  will  bear  recital  in  an  abbre- 
viated form : 

x.  Anencephalus  attributed  to  maternal  impressions : 
Mother  saw  while  pregnant  the  body  of  a  man,  the  top 
of  whose  head  had  been  cut  off  in  a  railway  accident 
{University  Medical  Journal,  Philadelphia). 

2.  E.  Giraud,  in  the  International  Journal  of  Surgery  , 
New  York,  reports  a  case  of  anencephalus  which  lived 
twelve  days,  moaning  constantly. 

3.  Same  author,  and  Armstrong,  in  London  Lancet ', 
report  cases  of  anencephalus  with  spina  bifida  (latter's 
case,  whole  length  of  spinal  column),  in  which  mothers 
were  scared  by  just  such  sights  while  two  months  pregnant. 

4.  E.  T.  Shelley,  in  New  York  Medical  Journal,  re- 
ports anencephalus,  born  at  seven  months.  Brain  was 
represented  by  dark  mass  on  child's  neck  and  back ; 
spinal  canal  open  for  some  distance  down  back. 


5.  In  Annual  of  Universal  Medical  Sciences,  1894,  is 
reported  a  case  of  occipital  meningocele  which  lived  sev- 
eral days  without  cerebral  symptoms. 

6.  Venables  (Halifax)  delivered  female  foetus,  well 
developed  except  head.  Face  depressed,  ears  not  fully 
developed ;  calvaria  entirely  absent ;  skin  covered  red- 
dish, pulpy  mass,  having  slight  resemblance  to  brain. 
Frontal  bone  rudimentary. 

7.  Clarke  {British  Meaical  Journal)  also  showed 
monster  of  this  kind,  with  double  genu  recurvatum, 
talipes,  and  proptosis  of  one  eye. 

8.  M.  M.  Brown  {Medical  World,  Philadelphia)  re- 
ports complete  spina  bifida;  absence  of  occipital,  pari- 
etal, and  frontal  bones. 

9.  J.  B.  Elkins  (Massachusetts  Medical  Journal,  Bos- 
ton) reports  case  of  diaphragmatic  hernia;  lived  one 
hour.  At  autopsy,  coils  of  intestine  in  left  pleural 
cavity,  as  were  also  spleen,  pancreas,  stomach,  and  entire 
intestinal  tract,  with  the  exception  of  a  small  loop  of 
duodenum,  ascending  colon,  and  rectum.  Left  lung 
collapsed ;  liver  had  fallen  downward  and  occupied  nearly 
whole  of  abdominal  cavity. 

10.  Joseph  Collins,  in  Medical  Record,  reports  a 
case  of  complete  transposition  of  viscera  in  a  foetus,  and 
the  same  is  reported  of  a  girl  fourteen  years  of  age. 

11.  Croon,  in  Edinburgh  Medical  Journal,  reports  a 
case  of  blind  intestine ;  no  viscera ;  abdomen  filled  with 
loose,  fibrous  tissue. 

12.  Theresa  Bannon  in  Medical  Record,  June  23, 
1 894,  reports  a  case  of  anencephalus  in  which  spinal  cord 
and  nerves  as  far  as  eighth  dorsal  were  exposed,  all  bone 
development  having  been  arrested  in  posterior  spinal 
arches ;  all  joints  rigid ;  defective  muscular  development 
at  umbilicus  two  inches  in  diameter. 

13.  Any  number  of  cases  are  reported  of  polydac- 
tylism  and  syndactylism. 

I  shall  endeavor  to  treat  of  the  several  aspects  sug- 
gested by  these  cases ;  of  their  etiology,  in  the  abstract ; 
of  interesting  points  of  diagnosis,  with  especial  refer- 
ence to  Case  I.;  of  their  bearing,  pro  and  con,  upon  the 
theory  of  maternal  impressions;  of  observations  regard- 
ing said  theory ;  and  lastly,  as  to  the  duty  of  the  phy- 
sician toward  impressionable,  nervous,  pregnant  women. 

And  first  as  to  etiology.  Psychic  impressions,  anxiety, 
grief,  fear,  have  long  been  looked  upon  as  the  sheet- 
anchor  in  our  translation  of  the  cause  of  monstrosities. 
Further,  we  know  that  any  cause  tending  to  produce 
separation  of  the  fecundated  ovum  from  uterine  mucous 
membrane,  e.g.,  endometritis,  attempts  at  abortion,  etc., 
to  be  operative  in  producing  monstrosities.  Syphilis  is 
set  down  as  a  cause,  and  hydramnios  as,  at  least,  a  frequent 
concomitant.  Regarding  etiology  in  the  abstract,  we 
learn  that  even  before  the  ovum  reaches  the  uterus  the 
mucous  membrane  becomes  thickened  and  vascular,  so 
that  its  opposing  surfaces  entirely  fill  the  uterine  cavity. 

Those  changes  differ  in  degree,  but  not  in  kind,  to 
those  taking  place  at  each  menstrual  epoch.  As  a  result, 
a  distinct  membrane  is  formed  which  affords  the  ovum  a 
safe  anchorage  and  protection  until  its  connections  with 
the  uterus  are  more  fully  developed.  Is  it  not  possible 
that  in  such  cases  as  result  in  monstrosities  this  change 
in  the  mucous  membrane  is  not  perfected,  and,  as  a  re- 
sult, we'  have  a  barren  soil  for  the  development  of  the 
ovum  ?  Or  again,  the  decidua  serotina,  that  part  of  the 
decidua  vera  on  which  the  ovum  rests,  and  which,  nor- 
mally, is  characterized  by  its  extreme  vascularity  and 
serves  the  purpose  of  supplying  nutriment  to  the  foetus 
may  be  imperfectly  developed,  and,  as  a  result,  an  im- 
perfect or  anomalous  foetus  developed?  The  fact  that 
psychic  impressions  are  more  operative  in  the  first  three 
months  of  pregnancy,  during  which  time  adhesion  of 
decidua  vera  and  refiexa  has  not  taken  place,  would 
seem  to  be  corroborative  of  this  view.  The  division  of 
blastodermic  membrane  into  epiblast  and  hypoblast,  and, 
later,  into  mesoblast,  being  imperfect  or  irregular  from 
any  cause,  may  operate  to  the  end  of  an  imperfectly  de- 
veloped foetus,  as  we  learn  that  these  layers  have  each  its 


December  29,  1894] 


MEDICAL  RECORD. 


813 


special  province  in  the  formation  of  the  foetus.  The  epi- 
blastic  membrane!  going  to  form  just  those  parts  of  the 
foetus  which  are  more  frequently  undeveloped  in  mon- 
strosities must,  as  a  matter  of  course,  be  most  frequently 
impaired. 

As  to  the  cases  in  point :  Mrs.  A ,  mentioned  in 

Cases  I.  and  II.  had  distinct  predilection  for  lower  animal 
tastes.  She  was  much  devoted  during  her  first  pregnancy 
to  the  care  of  a  dog  and  a  pet  rabbit,  the  latter  of  which 
was  to  be  frequently  seen  nestled  in  her  lap  or  poised  on 
her  shoulders.  Her  friends  repeatedly  discouraged  these 
attentions  on  her  part,  but  to  no  purpose.  Regarding 
her  second  pregnancy,  she  studiously  eschewed  these  at* 
tentions,  and  her  statement  warrants  the  belief  that  if 
impressions  were  potent,  or  operative  to  the  end  of  a  mon- 
strous conception,  they  could  only  be  found  in  the  fact 
that  she  was  constantly  upbraided  with  her  misfortune, 
and  most  agreeably  informed  that  she  could  beget  noth- 
ing better  than  a  dog. 

With  regard  to  Case  III.  I  can  only  say  that  patient 
had  considerable  misgivings  regarding  what  effect  any 
operation  might  have  upon  her  as  yet  unborn  child,  and 
that,  sick  as  she  was,  she  apprehended  disfigurement  of 
her  baby,  and  inquired  immediately  upon  its  birth  as  to 
whether  it  bore  any  birth  marks. 

Regarding  Case  IV.,  as  already  stated,  no  history  of 
maternal  impressions  could  be  elicited,  save  the  far- 
fetched one  of  an  injury  to  the  ankle  of  one  of  her  other 
children  early  in  her  last  pregnancy,  about  which  she 
was  considerably  exercised. 

Case  I.  proved  a  very  interesting  one  in  the  matter  of 
diagnosis.  Upon  examination  the  presenting  part,  on 
the  one  hand,  lacked  the  symmetry  and  density  of  the 
normal  globular  head;  on  the  other  hand,  manifested 
many  points  of  difference  from  a  presenting  breech. 
The  jut  of  tissue  arising  from  the  region  of  the  foramen 
magnum,  and  referred  to  in  the  history  of  the  case,  was 
a  very  confusing  feature.  It  felt  not  unlike  a  prolapsed 
cord,  and  feeling  more  satisfied,  at  best,  that  it  was  a 
head  rather  than  a  breech,  and  being  able  to  trace  and 
feel  its  insertion,  the  thought  occurred  whether,  though 
never  having  heard  or  read  of  it,  a  funis  could  arise  from 
any  other  situation  than  that  of  the  umbilicus.  The  ap- 
plication of  the  forceps  lent  only  some  vague  informa- 
tion, for  while  their  easy  and  perfect  fitting  made  it 
more  certain  that  a  head  was  engaging,  the  supposed  pro- 
lapsed cord,  with  its  point  of  insertion,  came  better  into 
the  range  of  the  examining  finger,  and  was  more  confus- 
ing and  embarrassing  than  ever.  Finally,  in  despair,  I 
acknowledged  my  inability  to  diagnose  the  condition,  and 
declared  to  the  attendants  that  the  case  must  be  a  freak, 
which  in  truth,  and  I  take  no  credit  for  saying  it,  proved 
to  be  a  most  admirable  diagnosis. 

Case  II.  was  immediately  diagnosed  upon  the  begin- 
ning of  labor  as  a  breech  presentation.  It  was  born 
spontaneously  and  unexpectedly  after  but  a  few  pains. 
When  born,  this  foetus  appeared  to  have  considerably 
more  vitality  than  one  reported  as  Case  I. 

As  to  the  theory  of  maternal  impressions,  there  seems  to 
be  a  general  opinion  among  writers  on  the  subject  that  a 
psychic  impression  is  more  apt  to  produce  an  effect,  if  of 
considerable  duration  ;  that  feelings  of  anxiety,  grief,  and 
fear  stand  in  closer  etiological  relation  to  the  impression 
theory  than  those  of  joy  and  delight ;  that  impressions 
occurring  during  early  pregnancy  are  more  potent  in  re- 
spect to  defects  of  development,  while  impressions  oc- 
curring late  in  pregnancy  are  more  apt  to  be  attended 
by  scars  or  marks  upon  the  foetus.  Further,  the  fact  of 
a  mother  anticipating  a  defective  child,  and  the  state- 
ment on  the  part  of  a  mother  made  prior  to  birth  of  a 
child,  respecting  reasons  why  she  might  expect  a  de- 
formed or  monstrous  foetus  are  each  given  its  respective 
weight  in  arguments  pro  and  con  upon  the  plausibility 
of  the  maternal-impression  theory. 

In  a  table  of  ninety  most  remarkable  cases,  published  by 
Professor  W.  C.  Dabney,  of  Virginia,  in  Keating's  "  En- 
cyclopaedia of  Diseases  of  Children,"  it  is  observable 


that  a  very  large  majority  of  casfsare  referred  to  the 
early  period  of  pregnancy. 

Regarding  cases  in  aforesaid  table  which  can  be 
deemed  in  any  way  correlated  to  those  mentioned  in  this 
paper,  we  find  that  Case  IX.  is  that  of  a  mother  fright- 
ened by  a  rabbit— child  born  with  hare- lip ;  two  subse- 
quent children  normal. 

Case  LXXXV.,  mother  frightened  by  a  pet  squirrel 
attempting  to  bite  her.  Child  born  with  compact  mass 
of  hair  extending  from  eyebrows  over  head  and  back, 
and  closely  resembling  a  squirrel.  Also  two  well  de- 
veloped incisor  teeth.  Case  XC,  wherein  child  was 
born  dead,  with  large,  fresh-looking  blebs  correspond- 
ing in  site  to  extensive  burns  mother  had  received 
thirty  six  hours  prior  to  birth  of  child,  shows  consider- 
able parallelism  to  Case  III.  of  this  paper,  both  as  re- 
gards necessary  brevity  of  impression  and  the  fact  of 
scar  or  mark  rather  than  defect  of  development. 

Regarding  Anticipation  on  the  part  of  Mother. — In 
Cases  L,  II.,  and  IV.  mothers  did  not  expect  defect. 
In  Case  III.  mother  did  apprehend  birth  mark. 

Regarding  Duration  of  Impression. — In  Cases  I.  and 
II.  probably  long.  In  Case  III.  not  longer  than 
seventy-two  hours. 

Regarding  Circular  Cleft  of  Palate.— Embryologists 
say  that  superior  maxillary  processes  of  first  branchial 
arches  come  together  during  the  first  eight  or  ten  weeks 
of  foetal  life,  and  at  the  ninth  week,  or  soon  afterward, 
the  hard  palate  is  closed,  and  on  it  rests  the  septum  of 
the  nose.  So  that  if  Case  II.  is  to  be  explained  on  the 
theory  of  maternal  impressions,  such  impression  must 
have  taken  possession  of  patient  early  in  pregnancy  in 
order  to  account  for  circular  cleft  of  palate. 

Dr.  W.  T.  Taylor,  of  Philadelphia,  has  reported  the 
case  of  a  lady  who  gave  birth  to  five  children  in  succes- 
sion, each  of  whom  had  cleft  palate.  In  the  first  in- 
stance defect  was  attributed  to  maternal  impression. 
And  as  defect  was  slighter  in  each  successive  child,  it  is 
supposed  impression  was  gradually  effaced.  And  right 
here  is  a  point  regarding  Cases  I.  and  II.  Case  II.  being 
doubtless  nearer  normal  than  Case  I.,  can  we  find  the 
reason  for  it  in  the  fact  of  a  less  intense  causative  prin- 
ciple in  the  latter  pregnancy,  of  a  less  impressionable 
nervous  organization  on  the  part  of  the  patient  ? 

The  theory  of  maternal  impressions,  from  the  litera- 
ture of  the  subject,  may  be  summarized  or  epitomized, 
without  any  claim  to  original  observation,  as  follows : 

Maternal  Impressions. — A.  (i)  Are  responsible  for 
foetal  defects,  or  (2)  are  not  responsible.  B.  (1)  If  re- 
sponsible, then  it  must  #  be  shown  that  impression  was 
made  at  a  period  of  pregnancy,  antedating  developmental 
period  of  deformed  part.  (2)  If  not  responsible,  then  all 
deformities  are  due  to  errors  of  development.  C.  Judg- 
ment dictates  latter  premise  untenable,  as  many  marks 
doubtless  occurred  late  in  pregnancy,  when  development 
was  practically  complete.  D.  Long  impressions  more 
apt  to  influence  foetus.  Short  impressions  less  apt  to 
influence  foetus. 

Foetal  Defects. — A.  Mental:  Due  to  emotional  dis- 
turbances; as  to  how  caused,  we  know  absolutely  noth- 
ing. As  to  frequency,  only  six  out  of  four  hundred  and 
forty- three  cases  made  out  in  a  certain  statistics.  B. 
Bodily:  Vascular,  supposedly  most  frequent,  doubtless 
very  frequent,  but  often  overlooked. 

In  conclusion,  what  can  be  the  practical  import  of 
these,  or  any  other  observations  uponnhe  subject  at  issue  ? 

It  seems  to  be  the  concensus  of  opinion  that  one  can- 
not go  far  wrong  by  assuming  it  to  be  his  duty  to  dis- 
courage morbid  reflection,  worriment,  or  apprehension 
ot  defective  progeny  in  the  minds  of  nervous,  impres- 
sionable, pregnant  women.  If  the  minds  of  our  preg- 
nant patients  are  schooled  in  the  aversion  of  voluntary, 
catastrophal  sightseeing,  are  taught  that  it  is  rather  the 
prolonged  impression  that  is  more  operative  for  harm,  it 
is  just  possible  that  monstrous  conceptions  might  be  a 
less  frequent  misfortune. 

126  Ninth  Stkbbt,  Long  Island  City. 


814 


MEDICAL  RECORD. 


[December  29.  1894 


Medical  Record: 

A  Weekly  Journal  of  Medicine  and  Surgery. 


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


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


New  York,  December  29,  1894. 


AN    ATTACK    ON    THE    DIPHTHERIA    ANTI- 
TOXIN*. 

A  paper  of  the  greatest  interest  and  importance  was  read 
at  a  recent  meeting  of  the  Berlin  Medical  Society,  by 
Dr.  Hansemann.  The  paper  carries  especial  weight  be- 
cause the  author  is  announced  as  an  assistant  of  Professor 
Virchow's,  and  his  work  and  conclusions  are  presumably 
endorsed  by  the  dean  of  modern  pathology. 

Dr.  Hansemann  comes  out  in  flat  contradiction  of  the 
alleged  properties  and  powers  of  the  Bearing  immunizing 
serum.  He  asserts  that  in  Bretonneau's  diphtheria  the 
Loeffler  bacillus  is  not  always  present,  and  is  not  its  sole 
cause.  This  view  will  appeal  to  some  clinicians  and 
bacteriologists  at  least,  for  it  is  admitted  that  the  Loeffler 
bacillus  is  present  in  some  very  mild  cases  of  diphtheria 
as  well  as  in  apparently  healthy  throats,  while',  on  the 
other  hand,  it  is  also  known  that  a  streptococcus  diph- 
theria (or  sore  throat)  is  sometimes  extremely  severe  and 
dangerous. 

Dr.  Hansemann  asserts  that  Loeffler's  bacillus  is  found 
constantly  in  rhinitis  fibrosa,  without  producing  diph- 
theria, and  that  these  alleged  pathogenic  microbes  may 
multiply  in  the  throat  without  modifying  the  course  of 
the  diphtheria.  All  this,  we  believe,  will  have  to  be  ad- 
mitted by  pathologists  who  have  without  bias  studied  the 
disease.  Dr.  Hansemann  asserted  further  that  in  the 
case  of  animals  an  injection  of  a  Loeffler  bacillus  culture 
caused  not  diphtheria,  but  a  disease  sui  generis,  the 
Loeffler  bacillus  disease;  that  epidemic  diphtheria  had 
never  been  observed  in  animals;  that  guinea-pigs,  in 
contact  with  diphtheria  patients,  had  never  taken  diph- 
theria ;  but  that  a  case  is  known  where  a  cat,  with  which 
a  child  suffering  from  diphtheria  had  played,  had  de- 
veloped all  diphtheria  symptoms,  without,  however,  any 
Loeffler  bacilli  being  discoverable. 

He  then  proceeded  to  describe  the  three  qualities 
claimed  for  the  antitoxin — namely,  its  therapeutic  action, 
its  harmlessness,  and  its  immunizing  power.  He  said 
that  the  present  statistics  give  an  erroneous  impression 
(as  already  shown  by  Gottstein  in  his  recently  published 
pamphlet),  as  many  children  suffering  from  lighter  forms 
of  throat  complaints  are  now  sent  to  the  hospitals  to 
be  treated  with  serum,  thus  swelling  the  proportion  of 
cured  cases,  which  would,  he  said,  otherwise  not  be 
higher  than  the  usual  average.  He  said  that  the  serum 
injections  could  by  no  means  be  considered  harmless,  as 
affections  of  the  kidneys  had  frequently  followed — in 
one  case  more  severe  in  type  than  had  ever  yet  been 


observed  after  diphtheria.  He  said  that  it  was  clear, 
from  Behring's  new  directions  to  increase  the  immuniz- 
ing dose  from  sixty  to  one  hundred  and  fifty  unities, 
that  no  results  have  yet  been  achieved  as  far  as  immu- 
nizing goes. 

The  final  criterium  of  the  efficacy  of  the  antitoxin 
treatment  is  clinical  experience.  Even  if  Hansemann's 
pathology  is  correct,  therefore,  it  will  make  no  differ- 
ence provided  the  diphtheria  patients  get  well 

The  difficulties  in  estimating  exactly  the  value  of  a 
new  therapeutic  procedure  which  comes  loudly  heralded 
and  solidly  endorsed  are  very  great.  Unusual  attention 
is  paid  to  every  patient,  greater  watchfulness,  more 
thorough  supervision,  and  earlier  diagnosis  and  treatment 
are  always  found.  These  factors  must  all  be  considered 
in  estimating  the  results  of  the  serum  treatment. 

It  would  be  not  only  a  disappointment  to  all  well- 
wishers  of  humanity,  but  would  be  a  serious  blow  to  the 
rising  prestige  of  medical  science,  if,  after  all,  the  serum 
treatment  should  fall  short  of  its  high  expectations. 


EVERY   MAN  HIS  OWN  EDITOR. 

It  is  a  well-known  fact  that  many  large  business  firms 
publish  a  special  journal  to  advertise  their  particular  line 
of  industry.  These  journals  are  all  printed  by  the  same 
house  and  contain  the  same  articles,  but  differ  in  the 
title  page,  being  in  one  city  Brown  <5r*  Co's  Monthly*  in 
another  Smith  6r  Co.'s  Magazine,  etc. 

According  to  the  Medical  News,  an  attempt  to  foist 
this  ingenious  product  of  modern  journalism  upon  the 
medical  profession  is  being  made.  A  circular  contain- 
ing the  propositions  made  gives  these  interesting  de- 
tails: 

"  First,  we  will  get  out  a  journal  in  every  way  as  good 
as  the  one  you  have  in  hand  each  month,  in  size,  quality, 
etc.  We  will  allow  you  one  page  to  be  filled  with  your 
own  items  of  interest  relating  to  your  own  doings,  those 
of  your  patients,  friends,  and  institution,  or  whatever 
you  may  choose.    We  will  carefully  eliminate  the  word 

from  the  journal.     Instead  of  it  being  called 

the Medical  Journal,  as  now,  you  may  give  it  any 

name  you  choose,  as  the  Grand  View  Sanitarian,  or  The 
Lewiston  Medical  Reporter,  or  whatever  seems  appro- 
priate to  you  for  your  location  and  institution.  In  the 
space  now  used  for  our  motto,  '  A  magazine  for  the  doc- 
tor and  his  family,'  we  will  print  your  name  as  local 
editor,  publisher,  or  whatever  you  wish. 

"  We  shall  be  glad  to  have  at  any  time  short  articles  of 
practical  value  and  general  interest  from  yourself  or  col- 
leagues for  publication  in  the  body  of  the  journal,  which 
we  will  insert  as  we  find  opportunity. 

"  In  return  it  is  hoped  you  will  take  at  least  one  hun- 
dred copies  of  the  journal  each  month  at  $6  a  hundred, 
additional  copies  to  be  furnished  you  at  the  rate  of  5 
cents  each.  In  no  case  can  less  than  100  copies  be 
sent.  The  pay  in  each  instance  must  accompany  the 
order,  and  also  copy  for  your  local  news  page,  and  be 
received  at  the  home  office  by  the  15th  of  each  month. 
The  price  we  have  made  you  is  cost.  (No  publishing 
house  in  the  country  could  get  you  up  exclusively  100 
such  journals  as  ours  for  less  than  $225.)  We  are  able 
to  make  this  price  to  you  only  on  account  of  the  great 


December  29,  1894] 


MEDICAL   RECORD. 


815 


number  we  issue.     Our  pay  comes  through  our  adver- 
tising columns,  which  are  valuable  and  appreciated. 

"  The  gain  to  be  derived  by  you  taking  hold  of  this 
enterprise  is  great,  we  believe,  beyond  all  proportion  of 
the  cost.  In  the  first  place,  it  binds  you  to  nothing. 
You  are  at  liberty  to  stop  whenever  you  choose.  You 
may  secure  subscribers  to  your  journal  in  your  own 
town  and  county.  It  will  be  worth  more  than  the  reg- 
ular price  and  make  it  pay  for  itself  in  dollars  and 
cents.  You  can  send  other  copies  to  desirable  parties 
with  your  compliments  and  attention,  which  will  win 
and  hold  their  regard.  Other  copies  left  with  your 
druggist  for  judicious  distribution  will  be  like  bread  cast 
upon  the  waters.  But  undoubtedly  the  greatest  benefit 
of  all  will  be  the  prestige  that  your  connection  with  such 
a  journal  will  give  you  and  your  institution  wherever  it 
goes. 

"  In  short,  there  is  no  end  to  the  usefulness  to  which 
doctors  may  and  do  put  their  journals.     Please  give  this 
matter  the  careful  attention  its  importance  merits. 
"Very  truly  yours, 

"  The Medical  Journal  Co., 

" ,  Manager \ 

"  P.  S. — In  case  you  do  not  care  to  furnish  copy  for 
local  page  at  any  time,  a  notice  with  cut  of  your  institu- 
tion can  occupy  the  space  very  effectively." 

This  plan,  as  will  be  seen,  enables  every  doctor  to  have 
his  own  journal  if  he  wishes. 

We  do  not  think,  however,  that  it  will  succeed,  and 
hence  spare  our  readers  any  elaborate  comments.  The 
trouble  will  lie  in  the  fact  that  all  medical  journals  ap- 
peal to  the  same  class  of  readers,  and  the  appearance  of 
syndicate  journals  will  soon  be  detected  and  exposed. 


MOUTH  HYGIENE. 

The  care  of  the  patient's  teeth  is  a  matter  too  often 
neglected  by  the  medical  adviser,  principally,  no  doubt, 
because  of  the  important  position  the  dentist  now  occu- 
pies in  relation  to  every  well-to-do  family.  The  vast 
majority,  however,  of  those  seeking  medical  advice  never 
go  near  a  dentist  unless  for  the  purpose  of  having  a  root 
extracted.  School  children,  the  inmates  of  homes,  asy- 
lums, prisons,  and  even  hospitals  are  shamefully  neglected 
in  this  particular.  In  most  public  institutions  not  only 
is  the  tooth-brush  unknown,  but  it  is  almost  an  impossi- 
bility to  secure  proper  cleansing  of  the  teeth  even  in 
those  taking  mercury,  for  instance,  where  the  danger  of 
salivation  is  much  increased  by  this  neglect.  Many  in- 
stitutions have  gentlemen  of  the  dental  profession  con- 
nected with  their  boards,  but  the  teeth  are  much  more 
apt  to  be  overlooked  than  any  other  portion  of  the  econ- 
omy, and  their  every-day  toilet  slighted.  It  is,  indeed, 
not  an  uncommon  experience  to  find  those  who  in  health 
never  omit  the  morning  brush,  go  for  days  and  weeks 
together  without  proper  mouth-cleansing  when  they  are 
sick— the  time  above  all  others  when  the  brush  is  most 
required.  Of  course,  if  the  patient  is  too  ill  an  antiseptic 
mouth-wash  may  replace  it  in  a  measure.  A  little  vol- 
ume of  popular  essays  on  the  care  of  the  teeth  and  mouth 
has  just  been  published  by  Victor  C.  Bell,  A.B.,  D.D.S., 
and  we  mention  it  here,  not  because  of  any  new  ideas  or 
theories  it  embodies,  nor  because  of  its  literary  merit  or 


beauty  of  illustration,  for  many  things  are  more  attractive 
than  casts  of  irregular  teeth  and  pictures  of  false  sets. 
Such  information  as  it  contains,  however,  is  most  im- 
portant for  all  to  know,  and  if  the  advice  given  were  fol- 
lowed many  a  pain  would  be  spared  and  many  a  tooth 
saved. 

The  proper  care  of  the  teeth  of  school- children  is  re- 
ceiving more  attention  in  England  than  it  formerly  did, 
and  no  little  credit  is  due  to  Dr.  Cunningham,  of  Cam- 
bridge University,  for  his  efforts  in  behalf  of  school  chil- 
dren's teeth  and  his  contributions  on  this  subject  to  the 
Seventh  International  Congress  of  Hygiene  and  Demog- 
raphy, and  his  essay  on  oral  hygiene,  for  which  he  was 
awarded  the  gold  medal  prize  at  the  International  Den- 
tal Congress  held  in  Chicago  during  the  World's  Fair. 

This  gentleman  says  that  parents  and  schoolmasters  pay 
so  much  more  attention  to  the  quality  of  the  child's  food 
than  they  do  to  an  efficient  dental  mechanism  for  its 
mastication,  because  of  their  ignorance  of  its  importance 
and  of  the  advantages,  both  economic  and  educational, 
to  be  derived  from  adequate  attention  to  the  teeth. 

In  speaking  of  tooth  powders  he  says,  "  The  principal 
action  should  be  mechanical  rather  than  medicinal. 
The  powder  should  be  very  finely  grained  and  should 
contain  no  cuttle- fish  powder,  no  powdered  oyster- shells, 
no  pumice  powder.  It  should  consist  of  alkaline  sub- 
stances and  contain  no  acid  ingredients,  nor  such  as  are 
capable  of  changing  to  acid  in  the  mouth.  All  ferment- 
able substances  such  as  carbo  hydrates  are  contra*  indi- 
cated." He  agrees  with  Miller,  that  precipitated  chalk 
should  form  the  basis  of  a  powder,  and  also  recommends 
a  dash  of  neutral  or  slightly  alkaline  soap.  He  also  con- 
siders a  tooth-soap  preferable  to  tooth-powder. 

The  physician  needs  not  to  be  told  how  great  is  the 
necessity  to  the  economy  of  sound  teeth,  nor  need  we 
enumerate  the  pathological  conditions  traceable  to  their 
decay ;  but  all  must  admit  and  regret  the  shocking  lack 
of  general  information  upon  this  important  subject,  and 
the  need  for  instruction,  especially  in  the  schools.  We 
commend  therefore  the  diffusion  of  knowledge  concern- 
ing teeth,  and  if  the  woodcuts  of  artificial  upper  dentures, 
interdental  splints,  cleft  palates,  obturators,  and  drills 
contained  in  Dr.  Bell's  book  will  have  the  effect  of  fright- 
ening people  into  an  early  visit  to  a  dentist,  and  if  in- 
fants will  gaze  upon  irregular  dentition  as  depicted  upon 
page  61,  and  never  after  suck  their  thumbs,  much  will 
have  been  gained  for  the  cause  of  mouth  beauty  as  well 
as  mouth  purity. 


HOSPITAL  STAFFS  AND   MANAGING  BOARDS. 

The  recurrent  irritation  between  medical  boards  of  hos- 
pitals and  the  trustees  shows,  if  nothing  else,  that  there 
is  something  wrong  in  the  system  as  it  usually  exists.  We 
do  not  say  that  medical  boards  are  always  right  and  lay 
trustees  always  wrong,  but  we  do  assert  that  a  method  of 
management  that  provokes  constant  quarrelling  and  out- 
breaks of  ill-feeling  is  seriously  at  fault. 

In  our  opinion  the  fault  lies  chiefly  in  the  fact  that  the 
medical  staffs  are  not  allowed  sufficient  share  in  the  man- 
agement. In  some  hospitals  their  advice  is  asked  only 
as  a  matter  of  form,  and  the  rules  absolutely  forbid  any 
physician  being  a  member  of  the  managing  board.  The 
capacity  of  physicians  to  manage  their  executive  and  or- 


8i6 


MEDICAL   RECORD. 


[December  29,  1894 


ganizing  skill,  have  been,  we  are  sure,  much  underrated. 
Few  men  who  attain  that  large  success  which  gives  to 
them  hospital  positions,  do  not  possess  considerable  busi- 
ness capacity.  When  this  is  combined  with  technical 
knowledge,  it  makes  the  physician  a  person  whose  coun- 
sel is  eminently  valuable  in  directing  the  management 
of  a  great  hospital. 

If  this  fact  were  better  known  and  more  wisely  appre- 
ciated, we  should  not  have  a  hospital  scandal  every  year, 
to  fret  the  soul  and  disturb  the  serenity  of  academic  dis- 
cussions. 

We  refer  to  this  now  because  Philadelphia  has  just  been 
much  disturbed  by  hospital  controversies.  The  Medical 
News  of  December  8th  describes  a  "  flagrant  instance 
of  the  outrageous  impertinence  of  laymen,  in  their  office 
of  hospital  trustees,  in  disposing  of  the  services  of  physi- 
cians in  a  dictatorial  and  unjust  manner." 

The  protest  of  the  News  had  little  effect,  for  in  its 
issue  of  December  2  2d  it  says:  "We  little  expected 
that  a  more  striking  illustration  of  the  same  spirit  would 
so  soon  be  shown,  as  happened  the  next  week  in  Phila- 
delphia. A  member  of  the  visiting  staff  of  a  great  hos- 
pital was  displaced  ignominiously  and  without  warning, 
without  an  official  charge  being  made  against  him,  or 
an  official  opportunity  being  offered  him  for  replying  to 
possible  charges.  Not  even  an  official  notice  was  sent 
him  of  his  summary  dismissal.  From  newspaper  reports 
one  learns  that  the  reasons  for  this  remarkable  proceed* 
ing  were  that  the  physician  thus  contemptuously  treated, 
in  order  that  he  might  obtain  blood  from  the  patient's 
finger  for  purposes  of  diagnosis  and  investigation,  had 
not  given  quinine  to  a  patient  so  soon  as  he  might  have 
done." 


ONLY  IMPORTED  ANTITOXIN  EFFECTIVE. 

By  resolution  of  the  New  York  City  Board  of  Health, 
Drs.  T.  Mitchell  Prudden,  and  Herman  M.  Biggs,  were 
requested  to  "  prepare  and  submit  some  plan  for  the  de- 
termination of  the  strength  and  purity  of  the  various 
preparations  of  antitoxin  which  are  now,  or  may  be  here- 
after, offered  for  sale  in  the  city  of  New  York,  so  that  the 
public  may  have  some  guarantee  that  only  genuine 
preparations  of  antitoxin  of  proper  strength  are  furnished 
for  sale." 

In  response  to  this  request  a  report  was  made  to  the 
Board  of  Health,  in  which  it  was  stated  essentially  that 
no  trustworthy  antitoxin  is  as  yet  manufactured  in  this 
country. 

They  assert  that  it  is  of  the  utmost  importance  to  those 
who  use  this  remedy  that  there  should  be  some  reliable 
guarantee,  for  every  preparation  placed  upon  the  market, 
that  it  has  been  prepared  by  competent  persons,  and  that 
in  every  case  it  possesses  the  requisite  purity  and  power. 
The  preparations  now  occasionally  furnished  in  this  coun- 
try, in  small  quantity,  by  the  German  pharmaceutical 
houses,  Schering  and  the  Farbwerke  (Hochst-am-Main). 
have  specific  guarantees  as  to  strength  and  purity  by  bac- 
teriologists of  universally  recognized  skill  and  experience. 
Unless  some  such  security  is  afforded,  it  would  be  quite 
easy  for  unscrupulous  persons  willing  to  commit  such  a 
crime,  to  place  on  the  market  small  bottles  of  yellowish 
fluid  labelled  "antitoxin,"  containing  an  inefficient 
amount  of  the  healing  agent,  or  even  none  at  all,  and 


for  a  time  at  least  profit  by  the  extraordinary  demand 
for  it,  perhaps  at  the  cost  of  life  and  at  the  risk  of  dis- 
crediting a  most  potent  and  beneficent  remedy. 

That  this  is  not  a  merely  fancied  and  only  possible 
menace  to  the  welfare  of  those  stricken  with  this  dreaded 
disease,  and  so  often  the  wards  of  the  Department  of 
Health,  is  shown  by  the  fact  that  already  in  the  city  of 
New  York  several  different  preparations  of  alleged  diph- 
theria antitoxin,  said  to  have  been  prepared  in  this 
country,  and  wholly,  so  far  as  we  can  learn,  without 
proper  guarantee  of  efficiency,  have  been  furnished  and 
used  for  the  treatment  of  diphtheria.  One  of  these 
preparations  has  been  already  subjected  to  the  necessary 
crucial  tests  by  the  Department,  and  found  wholly  inef- 
ficient and  inert. 

It  is  not  stated  whether  tests  were  made  of  the  im- 
ported articles. 


DR.   CONAN  DOYLE  IN  CHICAGO. 

No  visitor  to  this  country  has  received  warmer  hospitality 
or  treatment  more  fully  commensurate  with  his  reputa- 
tion than  Dr.  Conan  Doyle.  We  trust  that  he  is  not 
responsible  therefore  for  circulating  stories  reflecting  on 
the  intelligence  and  even  vanity  of  his  hosts.  The  Brit- 
ish Medical  Journal  publishes  the  following  somewhat 
weird  tales  of  the  doctor's  Chicago  experiences  : 

"  He  was,"  says  the  Journal,  "  introduced  to  the  lead- 
ing literary  club  of  Pigstickopolis  as  '  Canon '  Doyle. 
This  led  to  his  being  mistaken  for  an  ecclesiastical  dig- 
nitary, and  at  a  breakfast  given  in  his  honor  the  creator 
of  '  Sherlock  Holmes '  was  considerably  taken  aback 
by  being  invited  tr  'ask  a  blessing/  He  is  also  said 
to  have  been  overwhelmed  with  requests  to  preach  in  half 
the  churches  of  Chicago.  He  was  deluged  with  letters 
addressed  to  the  'Rev.  Dr.  Doyle/  'Rev.  Canon 
Doyle/  'Very  Rev.  Canon  Doyle/  and,  finally,  by 
swift  promotion,  'Right  Rev.  Dr.  Doyle.'  To  add  to 
the  tribulations  of  the  distinguished  writer  whom  we  are 
still  proud  to  claim  as  a  professional  brother,  though  he 
has  definitively  exchanged  the  lancet  for  the  pen,  he  has 
been  mistaken  for  the  creature  of  his  own  imagination, 
and  it  is  said  was  actually  invited  by  the  Mayor  of  Chi- 
cago to  enter  the  service  of  the  municipality  as  Chief  of 
the  Detective  Police.  Such  are  some  of  the  penalties  of 
fame." 


The  Philadelphia  Board  of  Charities  and  Correction 
has  appointed  Dr.  Hobart  A.  Hare  a  member  of  the 
staff  of  physicians  at  the  Philadelphia  Hospital,  in  place 
of  Dr.  Judson  Daland,  who  has  been  dropped.  The 
reason  given  for  this  action  on  the  part  of  the  board  is, 
that  Dr.  Daland  is  alleged  to  have  allowed  certain  pa- 
tients suffering  from  malaria  to  go  untreated  for  a  cer- 
tain length  of  time  in  order  that  he  might  study  the  de- 
velopment of  the  peculiar  organism  which  produces 
malaria.  To  a  board  capable  of  such  action  for  such 
reasons  it  probably  makes  very  little  difference  what  crit- 
icisms may  be  made  upon  its  action,  but  we  think  it 
likely  that  the  medical  profession  and  the  medical  press 
will  not  rest  content  without  knowing  more  and  saying 
something  about  such  a  policy. — Boston  Medical  and 
Surgical  Journal. 


December  29,  1894] 


MEDICAL   RECORD. 


817 


Hears  of  rtte  $KiteetL 

The  Death  of  Dr.  George  A.  Peters.— The  following 
resolutions  were  passed  December  7,  1894,  by  the  Medi- 
cal Board  of  St.  Luke's  Hospital.  "  After  many  years  of 
faithful  and  distinguished  service  as  Attending  and  Con- 
sulting Surgeon  of  St.  Luke's  Hospital,  the  career  of  our 
honored  colleague,  Dr.  George  A.  Peters,  has  come  to 
its  inevitable  close.  His  career  has  been  more  intimate- 
ly, and  for  a  longer  period,  identified  with  the  history  of 
this  hospital  than  that  of  any  surgeon  ever  connected 
with  its  staff.  Dr.  Peters  was  appointed  an  attending 
surgeon  on  the  organization  of  the  first  medical  staff  of 
the  hospital  in  March,  1859.  He  retired  from  active 
service  in  December,  1863.  lie  was  consulting  surgeon 
until  January,  1872,  when  he  was  reappointed  on  the  at- 
tending staff  and  again  retired  from  it  in  December,  1887. 
From  that  time  until  his  death  he  was  consulting  sur- 
geon, and  President  of  this  Board.  During  the  entire 
period  of  the  existence  of  this  Hospital,  therefore,  Dr. 
Peters  gave  to  it  his  best  energies  and  his  loyal  service. 
For  twenty  years  he  performed  active  service  in  the 
wards,  and  for  fifteen  years  he  gave  to  his  colleagues  the 
benefit  of  the  ripe  judgment  which  was  the  fruit  of  his 
large  experience.  In  his  personal  and  professional  relap 
tions  to  his  associates  and  subordinates,  Dr.  Peters  al- 
ways commanded  confidence  and  respect.  Toward  his 
patients  his  conduct  was  marked  by  a  cheerful  and  sym- 
pathetic spirit,  and  by  a  quaint  and  characteristic  humor 
which  often  dispelled  gloom  and  inspired  courage.  His 
work  as  a  physician  and  surgeon,  both  in  public  and 
private  practice,  was  distinguished  by  a  singularly  keen 
perception  and  alert  intelligence,  by  remarkable  readi- 
ness in  resources,  by  practical  common  sense,  and  above 
all,  by  an  earnest  purpose,  at  any  sacrifice  of  time  and 
strength,  to  help  those  who  sought  his  skill  and  counsel. 
The  long  and  intimate  association  of  Dr.  Peters  with  the 
administration  of  St  Luke's  Hospital  will  endear  his 
memory  to  the  managers,  and  to  his  colleagues  of  the 
Medical  Board.  In  the  history  of  this  institution,  no 
one  has  earned  more  truly  the  commendation  and  the 
reward  promised  to  '  the  good  and  faithful  servant.' 
"  Signed,  W.  H.  Draper,  M.D., 
"Robert  Weir,  M.D., 

"  Committee:' 

Dr.  Thomas  B.  If  orris  died  suddenly  on  Friday,  De- 
cember 2 1  st,  at  his  home,  106  Pennsylvania  Avenue, 
Brooklyn,  in  his  sixty- third  year.  He  came  to  this  coun- 
try from  Ireland  when  he  was  a  boy.  He  became  prom- 
inent in  the  Democratic  organization  in  Brooklyn,  and 
served  as  Coroner,  Commissioner  of  Charities,  and  Super- 
intendent of  the  Poor. 

An  Outbreak  of  Eabies. — Sixteen  persons  were  bitten 
by  a  mad  dog  in  Salem,  N.  J. ,  recently.  Six  of  them  have 
been  put  under  treatment  at  the  New  York  Pasteur  Insti- 
tute. Of  ten  bitten  persons  three  were  found  to  be  unin- 
jured owing  to  the  protection  afforded  by  clothing. 

Bacteria  in  Railway  Cars.— Investigation  of  the  at- 
mosphere of  English  railway  coaches  shows  that  there 
are  sixteen  thousand  microbes  to  the  cubic  inch  in  the 
first  class,  thirty-four  thousand  in  the  second  class,  and 
seventy -eight  thousand  in  the  third-class  compartments. 


There  is  a  suspicion  that  the  railroad  managers  have 
prompted  these  statistics  in  order  to  check  the  waning 
popularity  of  the  expensive  classes. 

Physicians  Strike. — The  physicians  of  the  city  of 
Newburgh,  forty  in  number,  and  of  the  town  of  Corn- 
wail,  recently  met  and  passed  resolutions  which  they  pre- 
sented to  the  Orange  County  Board  of  Supervisors,  in 
session  at  Goshen,  in  which  they  demand  that  the  scale  of 
prices  fixed  by  the  Board  for  attendance  of  physicians  at 
coroners'  inquests  be  increased  from  $$  to  $  10  for  post  mor- 
tems  and  for  autopsies  from  $15  to  $30.  Drs.  Wooley  and 
Jova,  a  committee  representing  the  physicians,  appeared 
before  the  Board  of  Supervisors  yesterday  and  stated  that 
under  no  circumstances  would  the  physicians  act  unless 
the  prices  demanded  be  paid.  The  Board  refused  to 
raise  the  rates,  claiming  that  the  price  established  is  good 
pay,  and  that  it  would  be  unfair  to  the  physicians  of  oth- 
er parts  of  the  county  to  pay  more  to  those  from  New- 
burgh and  Cornwall.  The  Newburgh  Coroner  will  be 
compelled  to  employ  a  doctor  from  one  of  the  county 
towns  not  in  the  combine  at  future  inquests.  An  effort 
was  made  to  get  all  the  physicians  in  the  county  to  or- 
ganize in  the  strike,  but  it  did  not  succeed.  Coroners' 
inquests  are  very  expensive  in  Orange  County,  and  cost 
the  tax-payers  from  £5,000  to  £7,000  a  year,  while  the 
State  of  Massachusetts,  under  a  different  system,  is  taxed 
but  little  over  three  times  as  much  per  year  for  inquests 
as  this  county.  Yesterday  the  Supervisors  passed  a  reso- 
lution requesting  Senator  Lexow  and  the  two  Orange 
County  Assemblymen  to  advocate  the  abolition  of  the 
office  of  Coroner  by  the  Legislature,  as  provided  by  the 
amended  Constitution,  and  to  adopt  a  more  modern  and 
economical  system. 

Antitoxin  Legislation  in  France. — The  Paris  corre- 
spondent of  the  Medical  Press  writes  (November  28th), 
that,  in  view  of  the  danger  to  the  public  likely  to  arise 
from  the  uncontrolled  manufacture  and  sale  of  curative 
serums  and  antitoxin,  the  French  Government  is  invited 
to  incorporate  in  the  bill  Regulating  the  Practice  of 
Pharmacy,  a  section  specially  dealing  with  this  class  of 
remedies.  In  order  to  ensure  that  the  horses  employed 
in  the  preparation  of  serum  are  perfectly  healthy,  and 
generally  to  provide  for  the  requisite  skill  and  care  being 
brought  to  bear,  the  following  clauses  are  proposed: 
That  attenuated  virus/therapeutical  serum,  modified  tox- 
ines,  and  similar  products  intended  to  be  used  in  the 
prophylaxis  or  treatment  of  contagious  diseases,  can 
neither  be  sold  nor  distributed  gratuitously  without  a 
personal  permit  to  be  accorded  by  the  Government  on 
the  advice  of  the  Council  of  Public  Health  and  the 
Academy  of  Medicine,  such  permit  to  be  temporary,  and 
its  maintenance  to  be  subject  to  the  result  of  periodical 
inspections  by  a  special  commission.  The  products  in 
question  are  to  be  sold  exclusively  by  duly  qualified 
pharmacists,  and  each  phial  is  to  bear  the  source  and 
date  of  the  preparation.  Provided  always  (as  the 
lawyers  say)  that  these  regulations  will  not  be  held  to 
apply  to  Jennerian  vaccine,  whether  human  or  animal. 

The  Value  of  Pancreas  Extract  in  Diabetes. — Dr. 
P.  Watson  Williams,  of  Bristol,  England,  reports  three 
cases  of  diabetes  treated  with  extract  of  pancreas,  and  he 
thinks  that  practically  nothing  can  be  accomplished  by 
this  mode  of  treatment  as  at  present  employed. 


INDEX. 


Abbott,  A.  C,  notice  of  book  by,  788. 
Abbott,  George  E.,  a  snare  wire  receiver, 

35°- 

Abdomen,  penetrating  wound  of  the,  319. 

Abdominal  surgery,  erysipelas  as  a  compli- 
cation of,  151 ;  some  unusual  cases  of, 
516 ;  the  incision  in,  440. 

Abernethian  Society,  centennial  celebration 
of  the,  573. 

Abortion,  criminal,  9 ;  management  of,  428 ; 
medico-legal  aspect  of,  151;   treatment 

of,  353. 

Abrahams,  R.,  apex  catarrh  or  tuberculosis, 
603,  659 ;  lead-poisoning  and  the  mor- 
phine habit,  599;  pilocarpine  in  the 
treatment  of  urticaria,  342. 

Abrams,  Albert,  physiological  pulmonary 
atelectasis,  268. 

Abscess,  boiling  treatment  of,  704 ;  sub-dia- 
phragmatic, communicating  with  the 
pleura,  665 ;  sub-phrenic,  154. 

Absinthe,  the  consumption  of,  16. 

Academy  of  Medicine,  American,  336 ;  of 
New  York,  see  New  York  Academy  of 
Medicine;  of  Paris,  library  of  the,  439. 

Acanthosis  nigricans,  125. 

Acetanilid  in  medicine  and  surgery,  153. 

Acromegaly  and  gigantism,  640. 

Adams,  Robert  S.,  Klebs- Loeffler  bacillus 
in  healthy  throats  and  in  measles  throats, 
402. 

Adamson,  Dr.  W.  R.,  death  of,  49. 

Adeno-carcinoma  of  the  skin  starting  in  the 
sweat-glands,  86. 

Adrenals,  tuberculosis  of  the,  without  bronz- 
ing, 552. 

Advertise,  a  new  way  to,  531. 

Aiken,  Hugh  K.,  epilepsy  at  times  a  blad- 
der reflex,  556. 

Aiken,  William  F.,  an  improved  phoroscope, 
Six.        t 

Albuminuria  in  foot-ball  players,  769 ;  meth- 
od of  testing  for,  414. 

Alcohol  and  sunstroke,  39. 

Alexander,  Dr.  Reid,  death  of,  660. 

Alexander's  operation,  ten  years'  experience 
with,  33. 

Alger,  Ellice  M.,  two  common  forms  of 
alopecia  and  their  treatment,  536. 

Alopecia,  two  common  forms  of,  and  their 
treatment,  536. 

Amaurosis,  quinine,  219. 

Amblyopia,  toxic,  45. 

Ambrose,  Daniel  R. ,  a  rare  case  of  sclero- 
corneal  stab,  360. 

Ambulance,  a  private,  405  ;  an  electric,  337. 

Ameer  of  Afghanistan,  physician  to  the 
household  of  the,  128. 

Amenorrhea  after  oophorectomy,  94. 

American  Academy  of  Medicine,  336. 

American  Association  of  Genito-urinary  Sur- 
geons, 116. 

American  Association  of  Obstetricians  and 
Gynecologists,  440. 

American  Climatological  Association,  120, 
181. 

American  Dermatological  Association,  86. 

American  Electro  therapeutic  Association, 
469. 

American  Gynecological  Society,  79. 

American  Laryngological  Association,  21,  58. 

American  Medical  Association,  section  on 
obstetrics  and  diseases  of  women,  147  ; 
section  on  practice  of  medicine,  310  ; 
section  on  surgery,  152. 

American  Neurological  Association,  88,  179. 


American  Orthopedic  Association,  143. 

American  Pediatric  Society,  84. 

American  Physiological  Society,  53. 

American  Public  Health  Association,  472. 

American  Surgical  Association,  82. 

Amputation,  modern,  contribution  to  the 
study  of,  546;  near  the  ankle,  27. 

Amyl,  valerianate  of,  623. 

Anaemia,  pernicious,  new  cure  for,  531. 

Anaesthesia,  by  cerebral  pressure,  57;  by 
ethyl  bromide  and  chloroform,  560; 
new  agents  to  produce,  1 1 1 ;  posture  in 
accidents  during,  539;  the  German 
commission  of,  50;  to  celebrate  the 
discovery  of,  378 ;  use  of  ethyl  bromide 
for,  in  France,  128. 

Anaesthetic,  origin  of  the  term,  736,  799* 

Anaesthetizers,  a  plea  for  public,  239. 

Anastomosis,  intestinal,  with  Murphy's  but- 
ton, 763. 

Anatomical  material,  collection  and  preser- 
vation of,  543*  639. 

Anatomy,  plea  for  the  better  teaching  of,  153. 

Andrews,  Dr.  Judson  B.,  death  of,  177. 

Aneurism,  intracranial,  782;  of  the  basilar 
artery,  573 ;  of  the  aorta,  latent,  a  dis- 
tinguishing sign  of,  123. 

Animal  extracts,  therapeutic  value  of,  431. 

Angina  pectoris,  151. 

Angioma  serpiginosum,  87. 

Announcements,  medical,  in  the  press,  627. 

Anophthalmia  defectus  oculorum,  565. 

Anthrax  in  London,  241. 

Anti-diphtherin  of  Klebs,  192. 

Anti-opiate  Society,  438. 

Anti-phthisin  of  Klebs,  783. 

Ant  is,  a  group  of,  416. 

Antiseptic  surgery,  points  to  be  remembered 
in  the  practice  of,  333. 

Antitoxin,  diphtheria,  an  attack  on  the,  814 ; 
only  imported  effective,  816;  legislation 
in  France,  817. 

Anti- vaccinationists,  dangerous,  351. 

Anti-vivisection  absurdities,  64,  209,  627. 

Antrum  of  Highmore,  early  operation  in 
diseases  of  the,  59 ;  follicular  odontoma 
*     invading  the,  59  ;  sarcoma  of  the,  312. 

Anus,  fistula  and  fissure  of  the,  153. 

Aorta,  a  distinguishing  sign  of  latent  aneu- 
rism of  the,  123  ;  atheroma  of  the,  664. 

Apex  catarrh  of  the  lungs,  369,  509,  602, 
659. 

Aphasia,  syphilitic,  623. 

Apium  graveolus,   therapeutic  employment 

of,  75- 

Apoplexy,  infantile,  and  infantile  paralysis, 
146. 

Apothecaries,  female,  800;  prescribing  by, 
764. 

Appendicitis,  308  ;  an  unusual  case  of  perfor- 
ating, 463 ;  cases  of,  441 ;  acute,  med- 
ical aspect  of  four  recent  cases  of,  421  ; 
acute,  surgical  aspect  of  four  recent 
cases  of,  424  ;  notes  on,  689 ;  prema- 
ture delivery  of  a  dead  child  induced 
by,  678 ;  treatment  of,  301  ;  tubercu- 
lous, 462. 

Appendix,  palpation  of  the,  635. 

Armatage,  George,  notice  of  book  by,  597. 

Army,  annual  report  of  the  Surgeon- General 
of  the,  695 ;  reduction  in  the  medical 
service  of  the,  241,  784. 

Arteries,  ligation  of,  793. 

u  As  others  see  us,"  335,  415. 

Ascites,  echinococcus  cyst  simulating,  107. 

Ashmead,  Albert  S.,  beriberi  on  the  bark 
Robert  S.  Patterson  at  Perth  Amboy, 
N.  J.,  652 ;  cause  of  beriberi,  768  ;  in- 


troduction of  leprosy  into  Japan,  255  ; 
the  immune  serum  of  the  goat,  702  ;  two 
more  cases  of  preventive  inoculation  of 
immunized    scarlet -fever  blood   serum, 

351. 
Asphyxia,  tractions  on  the  tongue  for,  141, 

454. 
Ass,  the  serum  of  the,  in  tuberculosis,  466. 
Association  of  American  medical  colleges, 

318. 

Association  of  American  Physicians,  23,  91. 

Asthenopia,  muscular,  treatment  of,  26. 

Asthmas,  reflex,  202. 

Ataxia,  251. 

Atelectasis,  physiological  pulmonary,  268. 

Atheroma  of  the  aorta,  664. 

Athletics,  college,  528. 

Atkinson,  William,  notice  of  book  by,  500. 

Aulde,  John,  a  modern  idea  in  scientific  med- 
icine, 165. 

Autopsy,  a  bureau  of,  534. 

Axilla,  lead-pencil  in  the,  mistaken  for  fract- 
ured clavicle,  763. 


B 


Babes,  Victor,  notice  of  book  edited  by,  307. 

Babies,  summer  comfort  for,  42. 

Bacteria,  effect  of  various  metals  on  the 
growth  of,  23  ;  in  the  eye,  754;  in  rail- 
way cars,  817;  in  the  water  of  Lake 
Ontario,  472 ;.  modifications  of,  in  mixed 
cultures,  23. 

Bacterial  growth  and  formation,  313. 

Bacteriology,  dangers  of  practical,  560 ;  of 
hospital  bed-cards,  639. 

Baginsky,  Adolf,  treatment  of  diphtheria, 
with  special  reference  to  the  efficacy  of 
antitoxin,  417,  727. 

Balfour,  George  William,  notice  of  book  by, 

59*. 
Balfour,  Mr.  Arthur,  on  science,  189. 
Bancroft,  Dr.  Joseph,  death  of,  275. 
Bannan,  Theresa,  puerperal  fever,  810. 
Barry,  John  H. ,  cases  of  monstrosities,  with 

special  reference  to  the  theory  of  ma. 

ternal  impressions,  811. 
Bartley,  E.  H.,  notice  of  book  by,  503. 
Baruch,  Simon,  the  rationale  of  hydrothera- 

Basedow's  disease.    See  Exophthalmic  goitre. 
Bashore,  Harvey,  bathers'  cramp,  285. 
Basilar  artery,  aneurism  of  the,  573. 
Bathers'  cramp,  285,  478. 
Baths  in  inflammatory  affections  in  children, 

284. 
Beard,  George  M.,  notice  of  book  by,  758. 
Beck,  Carl,  statistical  facts  and  inaccuracy, 

94- 

Beebe,  Alfred  L.,  diphtheria  and  pseudo- 
diphtheria,  385, 

Beer  in  lunatic  asylums,  381 ;  praise  of, 
592  ;  the  consumption  of,  332,  635. 

Bellamy,  Russell,  a  typhoid  fever  bed-bath  ap- 
paratus, 253. 

Benedict,  A.  L.,  the  resorcin  test  for  free 
hydrochloric  acid,  638. 

Beriberi,  182;  and  beans,  734,  768;  cause 
of,  768  ;  in  a  Dublin  asylum,  541,  572, 
720  ;  in  New  Jersey,  626,  652. 

Bernard,  Claude,  a  statue  to,  336,  658. 

Bicycle,  medical  views  concerning  the  use  of 
the,  159,  188,  496,  5281  543»  5*3,  67i- 

Biggs,  Hermann  ML,  report  to  the  New 
York  City  Health  Department  on  the 
use  of  bacteriological  examinations  for 
the  diagnosis  of  diphtheria,  321. 


December  29,  1894] 


INDEX. 


819 


Bile,  digestive  action  of,  18. 

Billings,  John  S.,  report  of  vital  statistics  by, 
277. 

Bissell,  Mary  T.,  notice  of  book  by,  504. 

Bistoury,  an  aseptible,  670. 

Blackwell,  Elizabeth,  notice  of  book  by,  211. 

Bladder,  brain  centres  of  the,  55 ;  choice  of 
operation  for  stone  in  the,  1 16  ;  excision 
of,  for  epithelioma,  162  ;  exfoliation  of 
mucous  and  submucous  coats  of,  preceded 
by  renal  and  vesical  calculus,  117  ;  lac- 
eration of  the,  complicating  fracture  of 
the  pelvis,  72 ;  papilloma  of  the,  164 ; 
relation  of  residual  urine  to  irritation  of 
the,  762  ;  removal  of  stone  in  the,  83  ; 
rupture  of  the,  347,  765  ;  tuberculosis  of 
the,  lactate  of  cocaine  in,  224 ;  tumors 
of  the,  153.     See  also  Cystitis. 

Blair,  Louis  E.,  some  further  observations 
on  reflex  asthma,  202. 

Bleyer,  Jf.  Mount,  the  phonograph,  its 
physics,  physiology,  and  clinical  import, 
261. 

Blindness,  prevention  of,  150. 

Blood  corpuscle,  red,  amoeboid  movements 
°ff  173 ;  red,  caryocinetic  changes  in, 
494;  nucleus  of  the  red,  669;  third, 
value  of,  in  tuberculosis,  41. 

Bloomingdale  Asylum,  house-warming  of  the, 
498. 

Blumenthal,  Oliver  A. ,  Politzer's  opinion  on 
medical  education  in  America,  191. 

Boas,  I. ,  notice  of  book  by,  503. 

Bogle,  J.  C,  Must  the  parson  pay  ?  3a 

Bones,  mineral  matter  in,  480. 

Book  Notices  : 

Abdominal  Surgery,  Text-book  of,  by 
Skene  Keith,  501. 

Alkohol  als  Genuss-und  Arzneimittel,  von 
A.  Jaquet,  504. 

American  Gynecological  Society,  Trans- 
actions of  the,  503. 

Anatomie  und  Physiologie,  Jahresbericht 
iiber  die  Fortschritte  der,  276. 

Anatomy  and  Physiology,  Text-book  of, 
for  Nurses,  by  D.  C.  Kimber,  597. 

Anatomy,  Essentials  of,  by  C.  B.  Nan- 
crede,  211. 

Anatomy,  Manual  of  Practical,  by  D.  J. 
Cunningham,  277. 

Appendicitis,  a  Treatise  on,  by  G.  R. 
Fowler,  503. 

Aseptic  Surgical  Technique,  by  H.  Robb, 
501. 

Association  of  American  Physicians, 
Transactions  of  the,  504. 

Bacteriology,  Directions  ior  Laboratory 
Work  in,  by  F.  S.  Novy,  597. 

Bacteriology,  Principles  of,  by  A.  C.  Ab- 
bott, 788. 

Basedow,  la  Maladie  de,  by  F.  Chamber- 
lain, 212. 

Bee- hive  Repertory,  by  Stacy  Jones,  211. 

Bellevue  Hospital  Alumni  Association, 
constitution  of  the,  502. 

Biography  of  American  Physicians  and 
Surgeons,  edited  by  R.  French 
Stone,  276. 

Boston  Society  of  Natural  History,  Me- 
moirs of,  502. 

Braithwaite's  Retrospect,  277. 

Bucharest,  Annales  de  PInstitut  de  Patho- 
logic et  de  Bacttriologie,'  edited  by 
Victor  Babes,  307. 

Census  Report,  Vital  Statistics  of  New 
York  and  Brooklyn,  by  J.  S.  Bill- 
ings, 277. 

Chemistry,  Text-book  of  Medical  and 
Pharmaceutical,    by  E.   H.  Bartley, 

SOS- 
Children,  Care  and  Feeding  of,  by  L.  E. 

Holt,  500. 
Children,  Text-book  of  the  Diseases  of, 

edited  by  L.  Starr,  276. 
Clinical  Medicine,  by  J.  S.  Bury,  596. 
Clinique    Th6rapeutique,    Precis   de,  par 

A.  F.  Plicque,  502. 
Dermatologische  Zeitschrift,  edited  by  O. 

Lassar,  276. 
Dermatology,  Practical   Lectures  in,    by 

C.  W.  Cutler,  212. 
Dictionary  of  Medicine  and  Allied   Sci- 
ences, by  A.  Duane,  $96. 


Book  Notices  : 

Dictionary  of  Medicine  and  Allied  Sci- 
ences, by  G.  M.  Gould,  503. 

Electrolyse  linlaire,  traitement  des 
Retr^ciseraents  par,  by  J.  A.  Fort, 
•     212. 

Embryology,  a  Bibliography  of  Vertebrate, 
by  C.  S.  Minot,  502. 

Embryology,  Human,  Syllabus  of  Lect- 
ures on,  by  W.  P.  Man  ton,  758. 

Genito-urinary  Diseases,  Syphilology,  and 
Dermatology,  System  of,  edited  by  P. 
A.  Morrow,  597. 

German,  Practical  System  of  Studying, 
by  Albert  Pick,  211,  758. 

Gonorrheischc,  wann  Dtirfer,  Heirathen, 
von  E.  Saalfeld,  504. 

Gynakologische  Anatomie,  von  C.  H. 
Stratz,  502. 

Gynecology,  a  Text-book  of,  by  J.  C. 
Wood,  211. 

Heart,  Congenital  Affections  of  the,  by 
George  Carpenter,  212. 

Homoeopathy,  American  Institute  of,  502. 

Homoeopathy,  Sharp's  Tracts  on,  503. 

Homoeopathy,  the  Truth  about,  by  W. 
H.  Holcombe,  307. 

Horse,  the,  by  George  Armatage,  597. 

Hospital  and  Charities  Annual,  by  H.  C. 
Burdett,  307. 

Hospitals,  Establishment  and  Mainten- 
ance of  Small,  by  A.  Worcester  and 
William  Atkinson,  '500. 

Hydatid  Disease,  by  J.  D.  Thomas,  277. 

Hygiene,  Manual  of,  by  Mary  T.  Bissell, 

5°4. 
Index  Catalogue  of  the  Library  of  the 

Surgeon  -  General's     Office,     United 

States  Army,  307. 
Inebriety    or    Narcomania,    by   Norman 

Kerr,  501. 
Injured,  Prompt  Aid  to  the,  by  Alva  H. 

Doty,  276. 
Insanity,  Outlines  of,  by  Francis  Walms- 

ley,  212. 
Jewish  Method  of  Slaughter,  by  J.  A. 

Dembo,  500. 
Laryngological  Association,  Transactions 

of  the,  277. 
Lepre,  by  Jules  Goldschmidt,  596. 
Leuksemie,   die  Behandlung  der,  by   H. 

Vehsemeyer,  212. 
Lunacy,  Fifth  Annual  Report  of  the  New 

York  State  Commission  in,  788. 
Lungentuberculose,    Behandlung    mittels 

Koch'scher  Inject ionen,  by  E.  Thor- 

ner,  277. 
Macrobiotic,  by  J.  Hensel,  502. 
Magenkrankheiten,  Diagnostik  und  The- 

rapie  der,  von  I.  Boas,  503. 
Materia  Medica,    Pharmacy,  Pharmacol- 
ogy, and  Therapeutics,  by  W.  Hale 

White,  758. 
Medical  Record  Visiting  List,  758. 
Medical  Society  of  the  State  of  New  York, 

Transactions  of,  597. 
Medicine,   Flint's  Treatise  on  the  Prin- 
ciples and  Practice  of,  revised  by  F. 

P.  Henny,  joi. 
Medicine,  Practice  of,  by  E.  M.   Hale, 

307. 
Microscopy,  Handbook  of  Medical,  by  J. 

E.  Reeves,  502. 
Nervenkrankheiten,  Lehrbuch  der,  by  H. 

Oppenheim,  277. 
Nervous  Diseases  and  Insanity,  Essentials 

of,  by  J.  C.  Shaw,  an. 
Neurasthenia,  Practical  Treatise  on,    by 

Beard  and  Rockwell,  758. 
New  York    State    Medical    Association, 

Transactions  of  the,  307. 
Nose  and  Throat,  Diseases  of  the,  by  F. 

DeH.  Hall,  596. 
Nursing,  Handbook  of  Obstetric,  by  Haul- 
tain  and  Ferguson,  500. 
Ohio  State  Medical  Society,  transactions 

of  the,  788. 
Ontario,  Annual  Report  of  the  Provincial 

Board  of  Health  of,  788. 
Orthopedic  Surgery,  Practical  Treatise  on, 

by  J.  K.  Young,  596. 
Osseous  Deformities  of   the  Head,  Face, 

Jaws,  and  Teeth,  by  E.   S.  Talbot, 

276. 


:  du  Canada, 


Book  Notices  : 

Pachyderma  Laryngis,  by  W.  Sturmann, 
211. 

Pain  in  itsNeuro-pathoIogical  Diagnostic, 
Medico- legal,  and  Neuro-  therapeu- 
tic Relations,  by  J.  L.  Corning,  500. 

Pelvic  Surgery,  Manual  of  Nursing  in,  by 
L.  S.  McMurtry,  211. 

Pharmacy,  Essentials  of,  by  L  E.  Sayre, 
212. 

Physiology,  Essentials  of  Chemical,  by  W. 

D.  Halliburton,  212. 
Physiology,  Human,  by  J.  Thornton,  502. 
Physiology,  Human,  a  Manual  of,  by  J. 

H.  Raymond,  788. 
Physiology,   Laboratory  Manual  of,  and 

Urine  Analysis,  by  J.  H.  Long,  597. 
Praticien,    Vade.      Mecum    du,   par    F. 

Roux,  503. 
Sanitary  Reports,  Weekly   Abstract    of, 

vol.  viii.,  307. 
Senile  Heart,  by  G.  W.  Balfour,  596. 
Sex,    Human   Element  in,   by   Elizabeth 

Black  well,  211. 
Skin,  Diseases  of  the,  by  Malcolm  Morris, 

joo. 
South     Carolina    Medical     Association, 

Transactions  of  the,  502. 
Surgery,  a  Retrospect  of,  by  F.  J.  Shep- 
herd, 277. 
Systeme  nerveux,  Nouvelles  Ide'es  sur  la 

Structure  du,  by  S.  K.  Cajal,  277. 
Tabes  Dorsalis,  Untersuchungen  iiber,  by 

E.  Leyden,  277. 

Therapeutics,  Principles  and  Practice  of, 

by  H.  C  Wood,  758. 
Therapeutics,  Text-book  of  Practical,  by 

H.  A.  Hare,  504. 
Throat,  Clinical  Manual  for   Diseases  of 

the,  by  T.  W.  Downie,  212. 
University  des  Etats  Unis  et  du 

by  O.  Laurent,  an. 
When  all  the  Woods  are  Green,  by  S. 

Weir  Mitchell,  758. 
Wizard,  a  Modern,  by  R.  Ottolengui,  212. 
Women,  Text-book  on  the  Diseases  of,  by 
H.  J.  Garrigues,  211. 
Books  as  carriers  of  infections,  320. 
Boracic  acid,  306. 

Bosworth,  F.  H.,  ethmoidal  disease,  457. 
Bottome,   Frank  A.,   car   sanitation,    638; 
etiology  and  prophylaxis  of  tuberculo- 
sis, 721. 
Bradshaw  lecture,  the  annual,  701. 
Brain,  abscess  of  the,  220  ;  action  of  chloro- 
form on  the,  791 ;  acute  softening  of  the, 
101 ;  concussion  of,  152 ;  ingravescent 
hemorrhage  in  the,  treated  by  ligature 
of  the  common  carotid  artery,  1 80 ;  loca- 
tion and  physiology  of  the  visual  cere- 
bral centre,  679,  800;  operations  upon 
the,  309 ;  surgery  of  the,  notes  on,  43 ; 
traumatic  lesions  of  the,  760 ;  trephining 
for  traumatic  clot,  344  ;  tumors  of  the, 
non-operative  treatment  of,  90. 
Brandenburg,  F.    D.,  the  successful  treat- 
ment  for  the  restoration  of  the  injured 
female  pelvic  floor,  488. 
Bread  and  butter,  dangers  of,  626. 
Bread,  sterilization  of,  416. 
Breast,  cure  of  cancer  of,  by  radical  opera- 
tion, 225 ;  improved  method  of  radical 
operation  for  cancer  of,  746,  764 ;  sim- 
ultaneous appearance  of  cancer  in  the 
uterus  and  the,  793  ;  tumors  of  the,  246, 

380. 

Brewster,  J.  D.,  the  recent  typhoid  epidemic 
at  Windsor,  Vt.,  647. 

Briggs,  M.  D.,  an  unusual  accident  to  the 
respiratory  tract,  173. 

Bright's  disease,  insanities  of,  437. 

British  army,  venereal  disease  in  the,  142. 

British  Institute  of  Preventive  Medicine,  189. 

British  Medical  Association,  213,  222,  243, 
278. 

British  Scientific  Congress  at  Oxford,  286. 

Brockway,  Dr.  William  Gay,  death  of,  728. 

Browne,  Dr.  John  Mills,  obituary  of,  757. 

Brown,  Sanger,  provisional  treatment  of  in- 
sanity, 299. 

Brown-Sequard,  last  illness  of,  32. 

Brush,  Dr.  George  R.,  death  of,  728. 

Bryant,  Mr.  Thomas,  Hunterian  lecture  by, 
666. 


820 


INDEX. 


[December  29,  1894 


Bull,  William  T.,  cure  of  carcinoma  of  the 
breast  by  radical  operation,  225. 

Bullets,  explosive  power  of  modern,  41a 

Bullitt,  James  B.,  a  case  of  face  presentation 
with  rotation  into  the  sacral  cavity,  136. 

Billow,  Hans  von,  brain  of,  648. 

Bunch,  Mr.  F.  V.,  death  of,  572. 

Burdett,  Henry  C,  notice  of  book  by,  307. 

Burial,  premature,  false  report  of,  382. 

Burns  from  water-bags,  497. 

Bury,  Judson  S.,  notice  of  book  by,  596. 

Butter  and  bread,  dangers  of,  626. 

Butter,  tuberculosis  in,  437. 


Cadwallader,  Rawlins,  malaria  and  drinking- 
water,  767. 
Caecum,  opening  the,  in  cases  of  rectal  can- 
cer, 765. 

Cajal,  S.  R.,  notice  of  book  by,  277. 

Calculi,  biliary,  resume*  of  the  subject  of,  729, 
749;  vesical,  choice  of  operation  for, 
116;  vesical,  removal  of,  83. 

Canada,  influence  of  the  climate  of,  on 
health,  475. 

Canadian  Medical  Association,  308. 

Cancer,  cause  of,  96,  647 ;  cinnamon  in  the 
treatment  of,  407,  636 ;  discussion  on, 
1 52 ;  galvanism  in,  470 ;  houses  infected 
by,  192;  inoculability  of,  724;  of  the 
bladder,  excision  for,  162 ;  of  the  breast 
and  uterus,  simultaneous  appearance  of, 
793 ;  °f  tne  breast,  cure  of,  by  radical 
operation,  225  ;  of  the  breast,  improved 
method  of  radical  operation  for,  746, 
764 ;  of  the  colon,  excision  of  the,  763 ; 
of  the  gall-bladder,  relation  of  cholelithi- 
asis to,  781 ;  of  the  liver,  stomach,  and 
lungs,  184;  of  the  oesophagus,  185;  of 
the  rectum,  resection  for,  763;  of  the 
stomach,  154,  186  ;  of  the  stomach,  chlo- 
rate of  sodium  in,  207  ;  popular  belief  in 
the  use  of  clover  for,  376  ;  relief  of  the 
pain  of,  511;  supposed  germ  of,  142  ; 
treatment  of,  with  toxines  of  erysipelas, 
82,  310;  various  specimens  of,  709. 

Cancer-cells,  examination  for,  in  living  tis- 
sue, 351. 

Carbolic  acid,  poisoning  by,  22a 

Carbuncle,  treatment  of,  731. 

Card  index  as  adapted  to  history-taking  in 
private  practice,  808 

Cardiac  pleurogram,  56. 

Carlton,  Th.  B.,  leprosy  in  India,  479. 

Carpenter,  George,  notice  of  book  by,  212. 

Carriage  for  medical  men,  440. 

Carroll,  C.  H. ,  Must  the  parson  pay  ?  477. 

Cartwright,  Silas  S.,  the  treatment  of 
quinsy,  ill. 

Castration  for  hypertrophied  prostate,  760 ; 
for  masturbation,  534;  for  tuberculosis, 
163 ;  implantation  of  an  artificial  testis 
after,  164. 

Cataract,  lid  elevator  in  operations  for,  287  ; 
traumatic  treatment  of,  761. 

Catarrh,  aural  and  laryngeal,  intra-nasal 
growths  as  factors  in,  204. 

Catgut,  sterilization  of,  by  heat,  318. 

Catharsis  by  means  of  hypodermic  injections 
impossible,  542. 

Cattle  quarantine  station,  306. 

Caverly,  C.  S.,  history  of  an  epidemic  of 
acute  nervous  disease  of  unusual  type, 

673- 
Celery,  therapeutic  use  of,  75. 

Cells,  staining  of  living,  371. 

Cellular  therapy,  165. 

Cellulitis,  orbital,  abortion  of  a  case  of,  564. 

Cemeteries,  gold  mines  in,  314. 

Census  of  London,  315. 

Centenarian,  death  of  a,  159. 

Cerebrospinal  fluid,  lumbar  puncture  for  re- 
moval of,  90. 

Cerebrospinal  meningitis,  157. 

Chamberlain,  Frederick,  notice  of  book  by, 
212. 

Chapin,  Henry  Dwight,  a  plan  of  infantile 
measurements,  649. 

Chapman,  W.  Louis,  Is  bathers'  cramp  a 
popular  fallacy  ?  478. 

Charcot,  Professor  J.  M.,  proposed  mon- 
ument to,  562. 


Charcot's  disease,  resection  of  the  knee  for, 

538. 
Chase,  Dr.  Charles  T.,  death  of,  728. 
Chelsea  Hospital  for  Women,  trouble  in  the, 

190,  222,  316,  541,  572,  665,  701. 
Chicago,  healthfulness  of,  639 ;  hospitals  in, 

43»- 

Children,  baths  in  inflammatory  affections 
in,  284  ;  insurance  of,  a  protest  against, 
142 ;  treatment  of  typhoid  fever  in,  435  ; 
tuberculosis  in,  374 ;  typhoid  fever  in,  1. 

China,  medical  education  in,  140,  638. 

Chloral,  poisoning  by,  666. 

Chloroform,  action  of,  on  the  brain  and 
spinal  cord,  791 ;  death  from,  in  Mel- 
bourne, 142  ;  points  in  the  administra- 
tion of,  no;  the  Hyderabad  commis- 
sion on,  158,  189. 

Chlorosis,  tissue  metabolism  in,  46. 

Chlorotic  girls,  breakfast  for,  542. 

Cholecystenterostomy  with  Murphy's  but- 
ton, 283,  339. 

Cholecystotomy,  an  ideal,  763;  and  chole- 
cystectomy for  stone  impacted  in  the 
cystic  duct,  554. 

Cholelithiasis,  708 ;  relation  of,  to  primary 
carcinoma  of  the  gall-bladder,  781. 

Cholera,'  cause  of,  446  •  insolated  cultures 
of.  515;  preventive  inoculations  against, 
78,  210,  337  ;  the  epidemic  of,  114, 142, 
177.  190,  209,  242,  275,  282,  286,  306, 
3i6,  337,  38f.  477,  S05,  533.  S61,  608, 
672 ;  transmission  of  the  spirillum  of, 
by  the  house-fly,  38 ;  value  of  quaran- 
tine against,  704;  the  comma  bacillus 
in,  621. 

Chorea,  quinine  in  the  treatment  of,  760. 

Christian  science,  25,  175,  736. 

Church  Sanitary  Association,  672. 

Circulation  time  in  organs,  55. 

Circumcision,  dangers  of  unclean  surgery  in, 
6i9»  702  J  results  from,  173,  342,  593, 
761. 

Clark,  L.  Pierce,  tabes  dorsalis  in  a  woman 
twenty-three  years  old,  379, 

Clavicle,  fracture  of,  lead  pencil  in  the  axilla 
mistaken  for,  763. 

Clay,  Professor  John,  death  of,  125. 

Cleanliness,  inculcation  of,  in  schools,  582. 

Cleaves,  Margaret  A.,  a  new  electrode  for 
hydro-electric  applications  of  the  con- 
stant current,  252;  electric  light  as  a 
diagnostic  and  therapeutic  agent,  7 16. 

Clergymen,  payment  for  medical  attendance 
fy>  30.  477,  668. 

Climate  in  therapeutics,  317,  505. 

Clinic,  a  model  surgical,  608. 

Clover,  popular  belief  in,  as  a  remedy  for 
cancer,  376. 

Club-foot,  an  astragalus  removed  from,  156 ; 
anatomy  of,  193;  cure  of,  in  adults, 
145 ;  elastic  traction  in  the  treatment 
of,  145. 

Coal-tar,  medicaments  derived  from,  351. 

Cocaine,  a  new  method  of  local  anaesthesia 
by,  174. 

Cold,  therapeutics  of,  755. 

Coleman,  Warren,  tuberculosis  of  the  ad- 
renal bodies  unaccompanied  by  bronz- 

>g,  552. 

Colic,  pancreatic,  623. 

Colleges,  mushroom,  466. 

Collins,  Joseph,  some  recent  measures  in  the 
treatment  of  epilepsy,  with  special  ref- 
erence to  the  use  of  opium,  355. 

Collyer,  Herman  L.,  a  pocket  pelvimeter, 
287. 

Colorado,  meteorological  data  of,  181. 

Comegys,  C.  G. ,  baths  in  inflammatory  affec- 
tions in  children,  284. 

Commissions  given  and  received  by  doctors, 

593- 

Communion  cups,  individual,  272,  736. 

Commutator,  a  short-circuiting,  57. 

Congress  of  American  Physicians  and  Sur- 
geons, 21,  S3,  70,  116,  143,  179. 

Conjunctivitis,  diphtheritic,  783. 

Conklin,  W.  J.,  splenectomy,  with  report 
of  a  successful  case,  103. 

Conn,  H.  W.,  the  "oyster  epidemic"  of 
typhoid  fever  at  Wesleyan  University, 

743. 
Constipation,  mechanical  treatment  of,  591 ; 
treatment  of  habitual,  697. 


Constitutional  Convention,  report  of  the 
committee  of  the  New  York  Academy 
of  Medicine  appointed  to  confer  with 
the,  606. 

Contagious  diseases  in  tenements,  placarding, 
576  ;  weekly  statement,  30,  65,  94, 128, 
159,  191,  224,  256,  288,  318,  351,  383, 
416,  448,  479,  511,  S42,  606,  638,  670, 

703,  736. 
Contract  medical  practice,  192. 
Convulsions,  high  temperature  during,  495. 
Cooke,  Professor  Josiah  Parsons,  death  of, 

?o6- 

Cordier,  A.  H. ,  surgical  problems  in  intra- 
pelvic  and  abdominal  diseases,  419. 

Corion,  cystic  degeneration  of  the,  730. 

Cornea,  ulcer  of,  treatment  by  general  prac- 
titioner, 28. 

Corning,  J.  Leonard,  notice  of  book  by,  500, 

Coroner  system  and  the  State  constitution, 
114. 

Corset,  opposition  to  the,  466,  704. 

Cough,  simple  remedy  for,  382. 

Counter-prescribing  by  druggists,  proposal 
to  legalize,  64. 

Craig  colony  for  epileptics,  407,  630. 

Craig,  Thomas  C,  transmission  of  the  chol- 
era spirillum  by  the  intestinal  dejecta 
of  the  house-fly,  38. 

Cranio- tabes,  312. 

Crary,  George  W.,  thyroid  treatment  of 
psoriasis,  427. 

Cremation,  advantages  of,  446  ;  in  England, 

651. 

Creosote  in  phthisis,   121. 

Cretinism,  sporadic,  570. 

Cretins,  skulls  of,  63. 

Crime,  defective  vision  in  relation  to,  569  ; 
relation  of  education  to,  639. 

Criminal  psychology,  296. 

Cross,  W.  A.,  a  case  of  lymphadenoma 
(Hodgkin's  disease)  accompanied  by 
features  characteristic  of  myxcedema  and 
others  suggestive  of  acromegaly,  269. 

Crossfield,  Fred.  S.,  tuberculosis  of  the 
larynx  and  pharynx,  411. 

Croup  and  diphtheria,  26. 

Cunnane,  W.  B.,  a  case  of  fracture  of  the 
pelvis,  fracture  of  the  femur,  and  lacer- 
ation of  the  bladder — recovery,  72. 

Cunningham,  D.  J.,  notice  of  book  by,  277. 

Current,  constant,  physics  and  current  dis- 
tribution of,  469. 

Cushing,  Clinton,  some  unusual  cases  of  ab- 
dominal surgery,  516. 

Cutler,  Condict  W.,  notice  of  book  by, 
212. 

Cyanide  of  potassium,  a  large  dose  of,  29  ; 
nitrate  of  cobalt  as  an  antidote  to,  512. 

Cyanodide  or  ferrocyanide  of  potassium, 
256. 

Cyanosis,  a  case  of,  85. 

Cystitis  and  pyelonephritis  due  to  the  colon 
bacillus,  119;  causation  of,  238.  See 
also  Bladder. 

Czar,  illness  and  death  of  the,  439,  531,  727, 
736. 


Dabney,  Dr.  William  C,  death  of,  337. 
Dalrymple,  F.  W.,  is  malaria  a  water-borne 

disease  ?  604. 
Daly,  W.  H.,  some  practical  observations  on 

so-called  malaria  being  a  water-borne 

disease,  327,  702. 
Dana,  Charles  L. ,  on  the  new  use  of  some 

older  sciences,  737. 
Danielssen,  Dr.  Daniel  Cornelius,  death  of, 

274. 
Dare,  Dr.  Charles  H.,  death  of,  408. 
Davis,  Dr.  George  W.,  death  of,  407. 
Davy-Faraday  research  laboratory,  189. 
Dawbarn,  Robert  H.   M.,  an  aseptic  and 

really  surgical  pocket-case,  735. 
Dead,  innocuous  transportation  of  the,  473. 
Deaf,  oral  education  of  the,  725. 
Deafness,  otic  gymnastics  as  a  cure  for,  128; 

relief  of,  by  freezing  the  anchylosed  os- 
sicles, 384 ;  removal  of  the  ossicles  for 

the  relief  of,  761. 
Death    by    electricity,   471 ;    preventable, 

566;  signs  of,  159. 


December  29,  1894] 


INDEX. 


821 


Death-rate,  decreasing,  in  New  York,  498 ; 
and  race,  542. 

Degeneration  and  genius,  131,  242;  and  its 
stigmata,  737. 

Delirium  tremens,  traumatic,  246. 

Delivery,  version  three  weeks  before,  733. 

Dembo,  J.  A.,  notice  of  book  by,  500. 

Dentistry,  instruction  in,  in  France,  192. 

Dermatitis,  epidemic,  301 ;  exfoliative,  540. 

Dermographism,  301. 

Diabstes,  a  family  history  of,  173 ;  condi- 
tion of  the  heart  in,  and  its  relation  to 
diabetic  comi,  123;  cramps  in  the  legs 
in,  416 ;  the  value  of  pancreas  extract 
in,  817. 

Diagnosis,  the  face  in,  511. 

Diaphragm,  abscess  beneath  the,  communi- 
cating with  the  pleura,  665 ;  hernia  of 
the,  790. 

Diarrhoea,  treatment  of,  440. 

Dickinson,  George  S.,  a  comparative  study 
between  the  results  obtained  by  exami- 
nation of  the  stomach  contents  by  means 
of  a  stomach  tube  and  Einhorn's  stom- 
ach-bucket, 331. 

Dickinson,  Robt-rt  L,  the  card  index  as 
adapted  to  history  taking  in  private 
practice,  808. 

Dickson.  Dr.  Walter,  death  of,  766. 

Diet,  effect  of  the  mother's,  upon  the  nurs- 
ling, 300. 

Digestion,  part  of  the  bile  and  Briinerian 
glands  in,  18. 

Diphtheria,  an  historical  case  of,  672  ;  and 
croup,  26 ;  and  pseudo-diphtheria,  220, 
385;  antitoxin  treatment  of,  241,275, 
288,  305,  375,  377,  417,  4i8,  439.  53;, 
540,  562,  S9«,  595,  59^,609,  613,  628, 
629,  631,  696,  727,  741,  786  ;  bacterio- 
logical examination  in  the  diagnosis  of, 
321 ;  bacillus  of,  in  healthy  throats 
and  measles  throats,  402 ;  difficulties  of 
health  officers  in  dealing  with  suspected 
cases  of,  473  ;  disease  of  the  heart  in, 
384;  germs  in  cheese,  178;  manage- 
ment of  epidemics  of,  in  the  country, 
473;  pastilles  as  a  substitute  for  gar- 
gling in  the  prevention  of,  655  ;  syringe 
for  cleansing  the  nasal  cavities  in,  633 ; 
treatment  of,  545,  570,  6S2. 

Diphtheria  antitoxin,  an  attack  on  the,  814. 

Diploe,  venous  tumors  of  the,  83. 

Dipsomaniac,  power  of  a,  49. 

Diseases,  nomenclature  of,  476. 

Dislocation  of  the  hip,  congenital,  Hoffa's 
operation  for,  143 

Dispensary  question  in  Cleveland,  669. 

Divorce,  syphilis  as  a  ground  for,  32. 

Dixon- Jones,  Mary  A.,  criminal  abortion,  9. 

**  Doc,"  the  Nemesis  of,  113. 

Doctors,  definitions  of,  140. 

Doctor**  wife,  some  experiences  of  the,  336, 
414. 

D'Oench,  F.  £.,  an  unusual  case  of  toxic 
amblyopia,  45. 

Dogs.  Is  salmon  poisonous  to  ?  637  ;  tumors 
from,  664. 

Donner,  Dr.  Henry  Hoffmann,  death  of, 
512. 

Dosimetric  medication,  256. 

Doty,  Alva  H.,  notice  of  book  by,  276. 

Douglas,  Dr.  Stuart,  death  of,  49S,  755. 

Dowd,  Charles  N.,  some  considerations  on 
different  types  of  exudative  inflamma- 
tion, 289. 

Downie,  James  Walker,  notice  of  book  by, 
212. 

Doyle,  Dr.  Conan,  in  Chicago,  816. 

Drains,  catgut,  636. 

Drug*,  new.  and  new  names  of,  68;  syn- 
thetic, from  coal-tar,  351  ;  where  they 
come  from,  271. 

Drunkenness  in  St.  Petersburg,  measures  to 
suppress,  672. 

Duane,  Alexander,  notice  of  dictionary  by, 
596. 

Dulles,  Charles  W.,  hydrophobia  statistics 
desired,  382. 

Dunlap,  Dr.  Alexander,  Dr.  Reeve's  me- 
moir on,  208. 

Dust  diseases  and  their  prevention,  47. 

Dwarf,  death  of  a,  800. 

Dwight,  Thomas,  methods  of  estimating  the 
height  from  parts  of  the  skeleton,  293. 


Dyspepsia,  nervous,  460,  506 ;  some  minor 
measures  in  the  diagnosis  and  treatment 
of,  656. 

Dystocia,  induced  labor  in  the  absence  of, 
278. 


Eastman,  Joseph,  the  author's  method  of 
supra-pubic  hysterectomy,  284. 

Echinococcus  cyst  simulating  ascites,   107. 

Eczema,  hints  on  the  treatment  of,  779 ;  par- 
asitic theory  of,  671. 

Edes,  Robert  T. ,  palatable  and  digestible 
milk,  224. 

Editor,  every  man  his  own,  814. 

Education,  a  factor  in  the  prophylaxis  of  dis- 
eases of  women,  804 ;  and  crime,  639. 

Electric  light  as  a  diagnostic  and  therapeutic 
agent,  716. 

Electricity,  action  of,  on  the  sympathetic 
nervous  system,  469.  523 ;  apparent 
death  by,  176;  value  of,  in  the  diag- 
nosis and  prognosis  of  affections  of  the 
peripheral  nerves,  199. 

Electrode,  a  new,  for  hydro-electric  applica- 
tions of  the  constant  current,  252. 

Electrolysis,  metallic,  47a 

Element,  a  new,  316. 

Elmira  Reformatory,  investigation  of  the, 
18,  756. 

Ely,  John  Slade,  on  the  relations  of  pathol- 
ogy and  practical  medicine  as  bearing 
upon  the  pathological  departments  of 
our  hospitals,  229. 

Embden,  Oscar,  dangers  of  glycerine  in- 
jections into  the  uterus  for  the  purpose 
of  inducing  premature  labor,  105. 

Empyema,  treatment  of,  703. 

End,  is  it  the  beginning  of  the  ?  801. 

English  as  a  universal  language,  338. 

Engman,  Martin  F.,  hints  on  the  treatment 
of  eczema,  779. 

Enteric  fever,  see  Typhoid  fever. 

Enteritis,  membranous,  219,  346;  mucous, 
cures  of,  240. 

Enterolith,  a  case  of,  341. 

Enuresis,  nocturnal,  treatment  of,  440. 

Epididymis,  syphilis  of  the,  75. 

Epididymitis,  tubercular,  castration  for,  35. 

Epilepsy,  308 ;  at  times  a  bladder  reflex, 
556;  some  recent  measures  in  the  treat- 
ment of,  355  ;  the  eye  and  surgical  treat- 
ment of,  176;  traumatic,  trephining 
for,  765. 

Epileptics,  care  of,  in  Minnesota,  628 ; 
Craig  colony  for,  407,  630. 

Epithelioma,  giant-cells  in.  538. 

Equivalence,  law  of,  in  medical  science,  310. 

Erysipelas,  a  new  treatment  for,  566  ;  and 
tuberculosis,  antagonism  of,  308  ;  as  a 
complication  of  abdominal  surgery,  151 ; 
toxin,  sarcoma  of  the  palate  treated  by, 
616,  633. 

Esquimaux,  the  teeth  of,  509. 

Estes,  W.  L.,  a  contribution  to  the  study  of 
modern  amputation,  546. 

Ether  as  an  intoxicant,  629. 

Ethics,  code  of,  in  New  Jersey,  151. 

Ethmoid  bone,  disease  of  the,  457. 

Ethyl  bromide  and  chloroform,  anaesthesia 
by,  560  ;  use  of,  as  an  anaesthetic  in 
France,  128. 

Etiquette,  medical,  among  the  ancients,  544. 

Ewing,  A.  C,  a  few  aphorisms  relating  to 
obstetrics  69. 

Exophthalmic  goitre,  184  ;  nature  of,  125  ; 
thyroid  feeding  in,  640,  671. 

Explosive  compounds,  160. 

Eye,  a  source  of  infection  in  corneal  abscess, 
463 ;  an  improved  cilia  forceps,  350 ; 
earning  value  of,  mathematically  ap- 
praised, 178 ;  foreign  body  in  the,  for 
six  years,  380 ;  glasses  vs.  muscle-cut- 
ting, 447 ;  microbes  of  the,  754  ;  rare 
case  of  sclero-corneal  stab,  360. 

Eyesight,  periodical  testing  of,  in  schools,  51. 

Eye-strain  headaches,  309. 


Face,   plastic  operation  on  the,  340  ;   sar- 
coma of  the,  156  ;  the,  in  diagnosis,  511. 


Face  presentation  with  rotation  into  the 
sacral  cavity,  136. 

Faith-cure  in  New  Jersey,  497. 

Fallopian  tubes,  treatment  of  distention  of, 
without  laparotomy,  442. 

Fast,  a  forty-five  day,  466. 

Fatigue,  relation  of  tobacco  to,  480. 

Fecundity,  instances  of,  224,  305,  413 ;  re- 
wards for,  14a 

Feek,  Robert  G.,  remarkable  use  of  bicar- 
bonate of  sodium,  380. 

Fees  for  medical  services,  666 ;  of  doctors, 
lawyers  on  the,  139. 

Femur,  bending  the  neck  of  the,  537. 

Ferguson,  J.  H.,  notice  of  book  by,  500. 

Fever,  250  ;  the  man  who  fed,  718. 

Fibula,  fracture  of  the  head  of  the,  by  mus- 
cular action,  340. 

Fiction,  the  doctor  in,  704. 

Fingers,  losers  of,  383. 

Fischer,  Louis,  diphtheria  antitoxin  or 
healing  serum  in  the  treatment  of  diph- 
theria, 418,  613. 

Flagg,  Robert  N.,  a  painless  labor,  346. 

Flat-foot,  143,  247. 

Flies,  transmission  of  pathogenic  bacteria 
by,  38. 

Flint,  Austin,  notice  of  book  by,  501. 

Foetus,  abnormality  of  a,  600. 

Foot,  osteosis  of  the  skin  of  the,  187. 

Football,  a  game  of,  728 ;  albumin  and  casts 
in  the  urine  of  players  of,  769 ;  as  a 
means  of  physical  development,  465  ; 
attractions  of,  for  intellectual  men,  499 ; 
casualties  and  fatalities  from,  853  ;  perils 
of,  490 ;  the  brutality  of,  695. 

Forceps,  obstetrical,  149,  797. 

Foreign  body  in  the  ej  e  for  six  vears,  380 ; 
in  the  oesophagus,  731  ;  in  the  respira- 
tory tract,  173. 

Formalin  and  bacterial  growth,  313. 

Fort,  J.  A.,  notice  of  book  by,  212. 

Fortunes  left  by  doctors,  764. 

Foster,  Burnside,  the  marriage  of  syphilitics, 
448. 

Fowler,  George  R.,  notice  of  book  by,  503. 

Fracture  of  the  head  of  the  fibula  by  mus- 
cular action,  340;  of  the  lower  end  of 
the  humerus,  treatment  of,  152 ;  of  the 
skull,  depressed,  trephining  for,  345 ;  of 
the  ulna  and  radius,  537  ;  and  sprains 
of  the  ankle,  massage  in,  371 ;  into 
joints,  fixation  in  the  treatment  of,  146. 

France,  measures  to  increase  the  birth-rate 
in,  288;  medical  legislative  section  in, 
78;  new  medical  law  in,  160;  the  late 
President  of,  and  his  surgeons,  191. 

Francis,  Richard  P.,  a  case  of  pneumonia  in 
an  infant  five  months  old,  treated  with 
inhalations  of  oxygen,  109. 

Frank,  J  ,  tuberculosis  of  the  frontal  sinus, 

553- 
Fraser,  Dr.  John,  death  of,  765. 
Freckles,  treatment  of,  305. 
Freeman,  Leonard,  secondary  suture  of  the 

sciatic  nerve,  409. 
Freeman,  Rowland  Godfrey,  Pasteurized  milk 

as  suppUed  to  the  poor  of  New  York, 

x33- 
Friedenwald,   Julius,    resorcin  test  for   the 

detection  and  quantitative  estimation  of 

free    hydrochloric    acid  in  the    gastric 

juice,  430. 
Friedreich's  disease,  non  hereditary,  171. 
Frigo-therapeutics,  755. 
Frost-burns,  639. 
Fruit-eating,  a  new  fad,  232. 


G 


Gage,  Dr.  C  P.,  death  of,  788. 

Gage,  W.  V.,  a  new  treatment  for  erysipelas, 
566. 

Gall-bladder,  acute  biliary  distention  of  the, 
485 ;  relation  of  cholelithiasis  to  pri- 
mary carcinoma  of  the,  781  ;  surgery  of 
the,  246,  723. 

Gall-stones,  resume  of  the  subjeot  of,  729,. 
749- 


822 


INDEX. 


[December  29,  1894 


Gangrene,  traumatic,  248. 

Garbage,  disposal  of,  207,  475,  726. 

Gardner,  H.  D.,  immediate  repair  of  a  lac- 
erated cervix,  78. 

Garrigues,  Henry  J. ,  notice  of  book  by,  21 1 ; 
on  symphyseotomy,  577,  602. 

Gas  habit,  376. 

Gasserian  ganglion,  excision  of  the,  703. 

Gxstropexy,  692. 

Generative  organs,  female,  abnormal  condi- 
tions of,  associated  with  melancholia  or 
mania,  135. 

Genius  and  degeneration,  131,  242. 

Germ  theory,  a  belated  assault  on  the,  786. 

German  medicine,  modern  trend  of,  726. 

German  Temperance  Society,  728. 

Gerster,  Dr.  Arpad  G.,  honors  to,  594. 

Gestation,  ectopic,  282. 

Getz,  Charles,  the  cause  of  stricture  in  the 
male  urethra,  583. 

Gibson,  C.  L.,  castration  for  primary  tuber- 
cular epididymitis  in  a  patient  eighty- 
one  years  old,  35. 

Gifford,  H.,  the  shady  side  of  the  surgical 
treatment  of  trachoma,  231. 

Goat,  serum  of,  in  tuberculosis,  637,  702. 

Godfrey,  Guy  C.  M.,  a  case  of  orbital  cel- 
lulitis aborted,  564 ;  the  Indian  woman 
in  labor,  69a 

Gone,  J.  Riddle,  vaginal  hysterectomy  by 
enucleation  without  ligature  or  clamp, 
691. 

Goldschmidt,  Jules,  notice  of  book  by,  596. 

Goldstein,  Samuel,  a  new  nasal  forceps,  575 ; 
a  new  uvulatome,  314. 

Goitre,  electrical  treatment  of,  470;  ex- 
ophthalmic, see  Exophthalmic  goitre. 

Gonorrhoea,  fin-de-sidcle  treatment  of,  563  ; 
in  women,  789;  treatment  of,  at  the 
Necker  Hospital,  319. 

Goodeli,  Dr.  William,  obituary  of,  595. 

Gorton,  Eliot,  a  case  of  insanity  due  to  the 
menstrual  function — oophorectomy — re- 
covery, 235. 

Gould,  George  M.,  notice  of  dictionary  by, 

5<>3- 

Gout,  and  rheumatUm,  affinity  of,  401  ;  in- 
testinal, 46. 

Grandin,  Egbert  H.,  notes  on  appendicitis, 
689. 

Granular  kidney,  anxiety  as  a  cause  of,  658. 

Graves's  disease,  see  Exophthalmic  goitre. 

Greenhill,  Dr.,  death  of,  307. 

Grief,  emotion,  and  infection,  406. 

Grisstm,  J.  D. ,  pseudo-rabies  complicated  by 
delirium  tremens,  341. 

Groom,  W.  S.,  a  large  dose  of  morphine, 

340- 
Gross,  M.,  the  secretion  of  hydrochloric  acid 

by  the  stomach  in  health  and  disease, 

490. 
Grosse  Isle  quarantine  station,  183. 
Grflnhut,  Dr.  Bernhard,  death  of,  275. 
Guaiacol  in  phthisis,  121. 
Gunshot  wound  of  the  abdomen,  792  ;  of  the 

lungs  and  heart,  204 ;  of  the  spleen  and 

kidney,  790. 
Guthrie,  W.  E.,  excision  of  head  and  four 

inches  of  shaft  of  humerus,  333. 
Gynecology,  electricity  in,  469;  studies  in, 

26. 


H 


Hematocrit,  an  improved,  57. 

Hsematometra,  282. 

Hagedorn  needle,  a  holder  for  the,  116. 

Hairs,  ingrowing,  174. 

Hale,  Edwin  M.,  notice  of  book  by,  307. 

Hall,  F.  DeHaviland,  notice  of  book  by, 

Halliburton,  W.  D.,  notice  of  book  by,  212. 

Hance,  Irwin  H. ,  use  of  crude  tuberculin  in 
cows,  74. 

Hand,  epithelioma  of  the,  313. 

Hare,  Hobart  A. ,  notice  of  book  by,  504. 

Harlequin  foetus,  86. 

Hartley,  Frank,  anatomy  of  club-foot,  193. 

Hart  wig,  Marcell,  an  echinococcus  cyst  sim- 
ulating ascites,  107. 

Hat-pin,  swallowing  and  extraction  of  a,  380. 


Haultain,  F.  W.  N.,  notice  of  book  by,  500. 

Hawkes.  J.  Marshall,  trephining  the  frontal 
bone  for  chronic  headache,  237. 

Hay  fever,  hygienic  treatment  vs.  "  ear- 
rubbing"  for,  284. 

Head,  surgical  treatment  of  injuries  of  the, 
760. 

Headache  from  eye-strain,  309;  trephining 
for,  237. 

Healey,  Joseph  S.,  some  practical  observa- 
tions on  malaria  not  due  to  drinking 
well-  or  surface  water,  477. 

Health  authorities,  a  conflict  between  state 
and  national,  275. 

Health  Bureau,  National,  20,  27,  77,  725, 
727. 

Health  Congress  in  London,  222. 

Health  Department  of  New  York,  new  quar- 
ters for  the,  468. 

Health  officers,  tribulations  of,  571. 

Hearing,  application  of  the  graphic  method 
to,  510  ;  see  also  Deafness. 

Heart,  abnormalities  of  the,  311;  action  of 
calcium  on  the,  54 ;  and  lungs,  gunshot 
wound  of,  206 ;  apocynum  cannabinum 
in  disease  of  the,  654  ;  condition  of,  in 
diabetes,  and  its  relation  to  diabetic 
coma,  123 ;  disease,  baths  and  massage 
in,  376 ;  diseases  of,  in  infectious  fevers, 
384  ;  dosimetric  granule  tonic  for  the, 
7  j  ;  enlargement  of,  without  valvular 
disease,  759 ;  functional  diseases  of  the, 
24.8;  idiopathic  hypertrophy  of  the,  and 
degeneration  of  the  heart  muscle,  46 ; 
lipomatosis  of  the,  796 ;  pain  in  the  re- 
gion of  the,  after  influenza,  124  ;  pri- 
mary tumor  of  the  wall  of  the,  185  ; 
Schott  treatment  of  disease  of  the,  123  ; 
signs  of  failure  of  the,  in  fevers,  653 ; 
stenosis  of  the  tricuspid  orifice,  796 ; 
syphilis  of  the,  and  angina'pectoris,  623 ; 
the  use  of  sedatives  in  disease  of  the, 
539 ;  thrombosis  of  the  auricle  of  the, 
796 ;  valvular  disease  of,  strychnine  in, 
557  ;  varix  of  the  right  auricle  ending  in 
rupture,  5  ;  wild  cherry  as  a  tonic  for 
the,  2a 

Heart-tonics,  value  of  combining,  147. 

Hedges,  B.  Van  D.,  the  rational  treatment 
of  diphtheria,  682. 

Heffron,  John  L.,  *  study  of  the  medical 
aspect  of  four  recent  cases  of  acute  ap- 
pendicitis, 421. 

Height,  estimating  the,  from  different  parts 
.   of  the  skeleton,  293. 

Helmholtz,  Professor  II .  L.  F.f  obituary 
notice  of,  338. 

Hemicrania,  ophthalmic,  273. 

Hemiplegia,  infantile,  craniotomy  for,  180. 

Hemorrhage,  accidental,  280;  cerebral,  90; 
control  of,  in  amputation  of  the  arm, 
703. 

Hemorrhoids.  153. 

Henry,  Frederick  C,  notice  of  book  by, 
501. 

Hensel,  Julius,  notice  of  book  by,  502. 

Hernia,  discussion  on,  153  ;  in  the  aged, 
246  ;  radical  treatment  of,  442  ;  treated 
by  the  wire-mattress  method,  537. 

Herpes  zoster,  protozoa-like  bodies  of,  87. 

Herrick,  Henry  J.,  a  case  of  transposition 
of  the  viscera,  10*. 

Herrick,  J.  F.,  right-handedness,  495. 

Heterophonia,  treatment  of,  26. 

Hiccough,  fatal,  of  unknown  origin,  700. 

Hickey,  Dr.  Amanda  Sand  ford,  obituary  of, 
630. 

Higgins,  F~  W.,  a  large  dose  of  cyanide  of 

potassium,  29. 
Highmore,  antrum  of,  see  Antrum. 

Hill,  J.  SutclifTe,  large  dose  of  sulphonal  for 

a  child,  337. 
Hill,    W.   J.,   premature  labor  before  the 
sixth  month — survival  of  the  child  for 
one  week,  344. 
Himalayas,  climate  of  the,  96. 
Hinde,  Alfred,  a  contribution  to  the  study 
of  the  location  and  physiology   of  the 
visual  cerebral  centre,  679. 
Hindu  medicine,  a  revival  of,  288. 
Hip,  Hoffa's  operation  for  congenital  dislo- 
cation of  the,  143  ;  disease  of  the,  acetab- 
ular form  of,  157  ;  disease  of  the,  in  the 
aged,  246. 


Hochlemer,    R.,   circumcision,  Do  we  need 

legislation  for  it  ?  702. 
Hodgkin's  disease,  a  case  of,  269. 
Hoelscher,  Dr.  J.  H.,  cholelithiasis,  708. 
Hog  cholera  in  Kansas,  337. 
Holcombe,  W.  H.,  notice  of  book  by,  307. 
Holland,  the  universities  of,  346. 
Holmes,  Dr.  Oliver  Wendell,  death  of,  465  ; 


reminiscences  of,  533,  590,  659,  736, 
799  ;  sonnet  by,  628 ;  the  eighty-fifth 
birth-day  of,  275. 


Holt,  L.  Emmett,  notice  of  book  by,  500. 

Hopkins,  George  C,  two  cases  of  tre- 
phining of  the  skull,  344. 

Horton,  D.  B. ,  fracture  of  the  head  of  the 
fibula  by  muscular  action,  340. 

Horton,  Thomas,  an  account  of  the  late 
epidemic  of  typhoid  fever  in  Montclair, 
N.  J.,  651. 

Hospital,  a  long  service  as  surgeon  to  a, 
615;  poisoning  of  the  inmates  of  a,  552 ; 
the  Chambers  Street,  49;  stalls  and 
managing  boards,  815. 

Hospital  Sunday  collection  in  London,  19a 

Hospitals,  free  treatment  of  pay  patients  in, 
637;  managing  boards  of,  and  travel- 
ling healers,  113;  naval,  240;  New 
York  State,  doctors  wanted  in  the,  468  ; 
pathological  department  of,  229. 

Howell,  J.  Morton,  treatment  of  carbuncle, 

731- 
Hubbard,  Dr.  Samuel  T.,  in  mcmoriam  of, 

159- 

Humerus,  excision  of  head  and  four  inches 
of  the  shaft  of,  333. 

Hunt,  Dr.  Ezra  M.,  death  of,  20. 

Hunterian  lecture,  the  annual,  666. 

Hupp,  John  C,  anomalous  foetal  nutrition 
in  twin  gestation,  74,  141. 

Hutchinson,  Proctor  S.,  death  of,  126. 

Hutton,  T.  J.,  treatment  of  cerebrospinal 
meningitis,  341. 

Hydramnion  with  atresia  am  in  the  child, 
565. 

Hydrocele,  761. 

Hydrochloric  acid  in  the  gastric  juice,  re- 
sorcin  test  for,  430,  638 ;  secretion  of, 
in  health  and  disease,  490. 

Hydro-electric  therapeutics,  470. 

Hydronephrosis,  etiology  and  treatment  of, 
138. 

Hydrophobia,  death  from,  50 ;  Pasteur  on, 
52;  pseudo-,  complicated  by  delirium 
tremens,  341 ;  statistics  on,  desired, 
382. 

Hydrosalpinx,  443. 

Hydrotherapy,  the  rationale  of,  519. 

Hygiene,  address  on,  27 ;  and  demography, 
International  Congress  of,  446 ;  awards 
at  the  International  Exposition  of,  52 ; 
in  schools,  475 ;  lectures  on,  to  legisla- 
tors, 64 ;  mouth,  815 ;  report  of  the  com- 
mittee on,  of  the  Medical  Society  of  the 
County  of  New  York,  601. 

Hyperpyrexia,  160. 

Hypochondriasis,  486. 

Hyrtl,  Professor  Joseph,  characteristics  of 
the  late,  141;  death  of,  114;  reminis- 
cence of  the  late.  355. 

Hysterectomy  for  uretero-uterine  fistula, 
671;  supra-pubic,  147,  284;  vaginal, 
by  enucleation  without  ligature  or  damp, 
691  ;  vaginal,  for  cancer  of  the  uterus, 
281. 

Hysteria,  apomorphine  in,  542 ;  tongue  trac- 
tion in,  378. 


Ichthyol,  antiseptic  power  of,  138;  efficacy 
of,  on  inflamed  tissues,  539. 

Ichthyosis  congenital,  86. 

Idaho,  State  medical  law  in,  5C2. 

Ilium,  sarcoma  of  the,  treated  by  erysipelas 
virus,  538. 

Ill,  Edward  J.,  management  of  abortion, 
428. 

Immigration,  a  year's,  728. 

Immunity,  446. 

Impetigo  herpetiformis  and  pemphigus  vege- 
tans, relation  of,  88. 

Income-tax  and  professional  workers,  115- 


December  29,  1894] 


INDEX. 


823 


Incorporated  Medical  Practitioners*  Asso- 
ciation of  Great  Britain,  63. 

Incurables,  opening  of  a  new  hospital  for, 
756. 

Indian  Medical  Congress,  115. 

Indians,  labor  among,  484,  690. 

Indigestion,  intestinal,  759. 

Inebriety,  influence  of,  on  public  health,  474  ; 
strophantus  for,  320. 

Infancy,  migraine  in,  383. 

Infant  life,  international  congress  for  the 
protection  of,  1 14. 

Infantile  measurements,  a  plan  of,  649. 

Infants,  infection  by  the  bacillus  pyocyaneus 
as  a  cause  of  mortality  in,  476. 

Infection,  books  as  carriers  of,  32a 

Infectious  diseases,  coexistence  of,  238. 

Inflammation,  exudative,  different  types  of, 
289. 

Influenza,  216;  pathogenesis  and  treatment 
°f»  7<>3  5  tachycardia  and  cardiac  pain 
after,  124 ;  use  of  quinine  in,  64a 

Ingersoll,  Dr.  Horace,  death  of,  377. 

In  graham,  Dr.  Timothy  M.,  death  of,  657. 

Insane,  care  of  the,  in  Minnesota,  628 ;  con- 
ference of  hospitals  for  the,  in  New 
York,  532;  transportation  of  the,  to 
hospitals,  76,  158,254. 

Insane  asylum  management,  Dr.  Weir 
Mitchell  on,  48. 

Insanity  and  crime,  177  ;  from  tea-drinking, 
160 ;  in  Great  Britain,  315  ;  increase 
of,  in  Great  Britain,  254 ;  inheritance 
of,  209 ;  menstrual,  235  ;  physiological 
epochs  predisposing  to,  506,  529  ;  pro- 
visional treatment  of,  299 ;  treatment  of 
convalescence  of,  179;  with  Bright's 
disease,  437. 

Insomnia,  the  golf  cure  for,  534. 

International  Medical  Congress,  awards  at 
the,  210. 

Intestinal  indigestion,  759. 

Intestines,  acute  obstruction  of  the,  790; 
end  to  end  anastomosis  of,  with  Mur- 
phy's button,  326;  gout  of  the,  46; 
laparotomy  for  perforating  ulcer  of  the, 
637  j  micro-organisms  in  the,  after  in- 
gestion of  milk,  653  ;  new  method  for 
treating  diseases  of  the.  96;  occlusion 
of  the  ileo-csecal  valve  by  a  plug  of  mu- 
cus, 188;  operative  treatment  of  per- 
forating ulcer  of  the,  244 ;  restoration 
of  the  continuity  of  the,  with  mechani- 
cal devices,  445  ;  toxins  in  the,  384. 

Intussusception  in  the  infant  surgical  treat- 
ment of,  442. 

Iodism,  prevention  of,  32. 

Iron,  absorption  of,  461. 

Italy,  hygienic  notes  on,  472  ;  university  re- 
forms in,  275. 


j 


Jacket,  paper,  its  history  and  applications, 
218. 

Jacobi,  A.,  an  explanation  and  a  correction," 
224. 

Jacobson,  Nathan,  four  recent  cases  of  acut  o 
appendicitis  considered  from  their  sur- 
gical aspect,  424. 

Jaisohn,  Philip,  method  of  testing  for  albu- 
minuria, 414. 

Japan,  introduction  of  leprosy  into,  255 ; 
the  French  language  in,  96. 

Japanese  army  surgeons,  status  and  pay  of, 

533- 

Jaquet,  A.,  notice  of  book  by,  504. 

Jaundice,  intra  lobular  occlusion,  661 ;  treat- 
ment of  obstructive,  724. 

Jeffery,  Aaron,  some  minor  points  to  be  ob- 
served in  administering  chloroform,  1 10. 

Jejunostomy,  782. 

Jennings,  Charles  G.  R.,  a  case  of  loose 
cartilage  in  the  knee-joint,  137. 

Jerusalem,  water-supply  of,  672. 

Johns  Hopkins  University,  female  education 
at  the,  468. 

Johnson,  Walter  B.,  a  case  of  sarcoma  of 
the  palate  successfully  treated  with  the 
toxins  of  erysipelas,  616,  633. 

Joints,  fixation  in  the  treatment  of  fractures 
into,  146. 


Jones,  Isaac  I.,  is  malaria  a  water-borne 
disease?  701. 

{ones,  Stacy,  notice  of  book  by,  211. 
ournals,  medical,  in  the  United  States,  438. 
Jurisprudence,  medical,  a  new  departure  in, 
625. 


Kammerer,  Fred.,  osteoplastic  resection  of 
the  sacrum,  97. 

Keen,  W.  W.,  oophorectomy  vs.  oophorec- 
tomy, 64. 

Keith,  Skene,  notice  of  book  by,  501. 

Keloid,  skin-grafting  for,  174. 

Kennedy,  A.  D.,  transportation  of  insane  to 
hospitals,  158. 

Kerr,  Norman,  notice  of  book  by,  501. 

Kidney,  congenital  absence  of  one,  349 ;  gun- 
shot wound  of  the,  790;  movable,  151, 
792 ;  relation  of  insufficiency  of,  to  sur- 
gical operations,  444 ;  removal  of  a  fortv- 
pound  tumor  of  the,  792;  stone  in 
the,  nephrectomy  for,  732  ;  surgical, 
treatment  of,  82,  325 ;  tubercular,  sur- 
gical interference  in,  118;  uric  acid 
infarcts  of  the,  312. 

Kimber,  Diana  Clifford,  notice  of  book  by, 

597. 

King,  Herbert  M.,  etiology  of  tuberculosis, 
644. 

Kissing,  the  curse  of,  693; 

Klebs,  Edwin,  the  present  status  of  the  spe- 
cific treatment  of  diphtheria,  741. 

Knee,  resection  of,  for  separation  of  the 
lower  epiphysis  of  the  femur,  761  ; 
spring-,  237. 

Knee-jerk,  crossed,  88. 

Knee-joint,  'etiology  of  deformities  of  the, 
129,  143;  loose  cartilage  in  the,  137; 
tumor  albus  of  the,  761. 

Knowles,  Francis  £.,  symptoms  of  poison- 
ing from  a  probable  overdose  of  phen- 
acetin,  564. 

Krieger,  G.  £.,  recent  investigations  of  the 
therapeutic  value  of  organic  fluids,  espe- 
cially spermine,  431. 

Kumyss,  poisoning  by,  141. 

Kunz,  S.,  tuberculosis  of  the  frontal  sinus, 
553. 


Labor,  a  painless,  346;  Indian  women  in, 
484,  690 ;  premature,  before  the  sixth 
month,  344;  separation  of  the  after- 
coming  head,  282;  sloughing  of  the 
cervix  after,  138. 

Lamkin,  J.  S ,  the  relationship  between 
bovine  and  human  tuberculosis,  412. 

Lamphear,  Annette  £.,  cyst  of  pharyngeal 
tonsil,  137. 

Lanphear,  Emory,  a  new  aseptic  trephine, 

3*3- 

Landes.  Leonard,  a  case  of  anophthalmia 
delectus  oculorum,  565. 

Lane,  Dr.  L  C,  gift  of,  to  Cooper  Medi- 
cal College,  318. 

Laparotomy,  extra-median  incision  in,  302  ; 
for  pelvic  disease  not  necessary,  762. 

Laryngectomy,  new  method  of,  60. 

Larynx,  carbolic  acid  in  cysts  of  the,  62 ; 
cockle  burr  in  the,  60 ;  extirpation  of 
the,  84 ;  neoplasms  of  the,  60. 

Lassar,  O.,  notice  of  journal  edited  by,  277. 

Laurent,  O.,  notice  of  book  by,  211. 

Lead-poisoning  and  the  morphine  habit,  599. 

Leeches,  extract  of,  in  the  prevention  of 
thrombosis,  137. 

Leipsic,  students  in,  178. 

Legacy,  a  doctor's,  93. 

Legislation  of  interest  to  physicians,  30;  an- 
titoxin, in  France,  817. 

Legislators,  lectures  on  hygiene  to,  64. 

Lendon,  Alfred  Austin,  notice  of  book  edi- 
ted by,  277. 

Lepers,  a  missionary  to,  in  trouble,  448  ;  a 
Russian  colony  for,  140. 

Leprosy  in  Iceland,  672  ;  in  India,  479  ;  in- 
troduction of,  into  Japan,  255. 

Leszynsky,  William  H.,  the  value  of  electric- 
ity in  the  diagnosis  and  prognosis  of 
affections  of  the  peripheral  nerves,  199. 


Letters  from  London,  63,  93,  124, 158,  189, 
222,  286,  315,  381,  477,  507,  540,  572, 
636,  665,  701,  764,  799 ;    from  Vienna, 

Leucocythaemia,  new  cure  for,  531 ;  splenic, 
796. 

Levien,  Henry,  circumcision,  619. 

Leviseur,  Fred.  J.,  emergency  cases  of  skin 
diseases,  806. 

Lewis,  J.  C. ,  an  unusual  case  of  perforating 
appendicitis,  463. 

Leyden,  E  ,  notice  of  book  by,  277. 

Liell,  Edward  Nicholas,  nephritis  of  preg- 
nancy and  its  sequelae,  368. 

Life,  value  of,  in  cases  of  accident,  13a 

Life  insurance,  some  curious  details  of,  416  ; 
companies,  chart  illustrating  mortality 
tables  used  by,  540. 

Ligaments,  broad,  ligature  and  division  of 

the,  94. 
'Lightning-stroke,  51. 

Lister,  Sir  Joseph,  award  of  the  Albert  med- 
al to,  78. 

Little,  Dr.  William  J.,  death  of,  177. 

Liver,  abscess  of  the,  156;  abscess  of,  mis- 
taken for  empyema,  184 ',  functional  dis- 
orders of  the,  309  ;  glycogenic  function 
of  the,  785  ;  miliary  tuberculosis  of  the, 
797;   movable,    133;   rupture  of   the, 

154. 
Liverpool,  causes  of  the  high  death-rate  of, 

338- 

Locomotor  ataxia,  251 ;  in  a  woman  twenty- 
three  years  old,  379. 

London,  letters  from,  63,  93,  124,  158,  189, 
222,  286,  315,  381,  477,  5<>7»  540,  572, 
636, 665,  701,  764,  799 ;  medical  schools, 
opening  of  the,  507  ;  mortality-rate  of, 
125. 

Long,  John  H.,  notice  of  book  by,  597. 

Longevity,  660;  among  physicians,  695,  733 ; 
effect  of  alcohol  upon,  563 ;  in  Russia, 
448. 

Lonsdale,  Dr.  Philip,  death  of,  274. 

Loveland,  Bradford  C,  water  in  diet  and 
therapeutics,  33a 

Lucky  numbers  and  lucky  medical  students, 
192. 

Lungs,  a  new  disease  of  the,  336  ;  and  heart, 
gunshot  wound  of,  206 ;  apex  catarrh, 
509,  602,  659 ;  apex  catarrh  of,  disease 
of  the  ear  and  upper  air- passages  in, 
369  ;  extreme  interstitial  emphysema  of 
the,  188 ;  physical  signs  of  oedema  of 
the,  182  ;  surgery  of  the,  635 ;  throm- 
bosis and  infarction  of  the,  1 55. 

Lymphadenoma,  with  features  suggestive  of 
myxcedema  and  of  acromegaly,  269. 

Lymphangitis,  tuberculous,  of  the  arm,  573. 


M 


McBrayer,  L.  B.,  pilocarpine  in  urticaria, 
564. 

McCartie,  D.  B.,  a  case  of  fatal  hiccough 
of  unknown  origin,  700  ;  hypochondri- 
asis, 486. 

McChesney,  Willard,  extra-uterine  preg- 
nancy, 598. 

McCourt,  P.  J.,  non-operative  treatment  of 
uterine  diseases,  589. 

McCullough,  John  W.  S.,  results  from  cir- 
cumcision, 342. 

McFarlane,  Andrew,  post-graduate  medical 
study  abroad,  232. 

McGee,  W.  C,  medical  colleges  and  the 
medical  profession,  316. 

McGuire,  C.  Monroe,  unsuccessful  employ- 
ment of  potassium  permanganate  m 
morphine  poisoning,  343,  734. 

McMurtry,  Lewis  C,  notice  of  book  by, 
211. 

Macalester,  R.  K.,  the  nervous  symptoms  of 
patients  suffering  from  chronic  urethritis, 
684. 

Mac  Armey,  W.  N.,  danger  from  indiscrim- 
inate mtra-uterine  irrigations,  541 ;  is 
pleurisy  rheumatic  ?  366. 

Macfarlane,  Andrew,  albumin  and  casts  in  the 
urine  of  football  players,  769. 

MacPhatter,  Neil,  a  case  of  Porro's  opera- 
tion, 567. 


824 


INDEX. 


[December  29,  1894 


Magill,  William  S.,  medical  opportunities  of 
Paris,  126. 

Maillot,  Dr.  Francis  Clement,  death  of, 
142. 

Maine,  Frank  £.,  the  marriage  of  syphilitics, 
605,  767. 

Maisch,  Charles  0. ,  the  infectivity  of  phthisis 
pulmonalis,  464. 

Malaria  and  enteric  fever,  mixed  infection 
of,  23;  infection  of,  567;  organism  of, 
in  the  blood  plaque,  408 ;  our  present 
knowledge  of  the  cure  of,  by  means  of 
quinine,  526;  water-borne  theory  of, 
182,  327,  447,  477,  604,  701,  759,  767. 

Maloney,  F.  W.,  permanganate  of  potassium 
as  an  antidote  to  rattlesnake  venom, 

567. 

Malony,  J.  A.,  the  physics  of  the  phono- 
graph, 382. 

Mann,  Edward  C,  a  new  cardiac  tonic 
dosimetric  granule,  73. 

Manton,  Walter  Porter,  notice  of  book  by, 

758.   . 
Marcy,  William  H.,  skin  grafting,  206. 
Marriage  in  England,  471  ;  of  syphilitics, 

448,    635,  668,  767;    the   decline  of, 

383- 
Marsh,  James  P.,  gunshot  wound  of  lungs 

and  heart,  with  survival  of  patient  for 

fifteen  hours,  206. 
Martin,   Robert  W. ,  an   improved  conical 

rectum  speculum,  350. 
Martin,  William  A.,  a  new  snare,  510. 
Massachusetts  State  Board  of  Registration, 

50. 
Massage,  establishment  for,  and  prostitution, 

222,  659,   766;  in   gynecology,    149; 

notes  on  pelvic  and  general,  45. 
Masturbation,  castration  for,  534. 
Maternal  impressions,  811. 
Mauthner,  Dr.  Ludwig,  death  of,  595. 
May,  Charles  H.,  an  improved  cilia  forceps, 

3SO. 
Mayo,  W.  J.,  surgery  of  the  stomach,  580. 
Measles  in  Samoa,  72. 
Meckel's  diverticulum,  strangulation  of,  83. 
Medical  colleges,  and  the  medical  profession, 

316;  is  there  a  need  for  more  ?  1 1 2 ;  new, 

659  ;  to  limit  the  number  of,  381. 
Medical  education,    in  America,    Politzer's 

opinion  on,    191  ;    some  questions  of, 

666. 
Medical  legislators  in  France,  439. 
Medical  Library  Association  at  Grand  Rap* 

ids,  660. 
Medical  men  as  companions,  499. 
Medical  practice,  act  concerning,  in  Great 

Britain,  215  ;  contract,  192. 
Medical  schools,  cramming  in,  25. 
Medical  societies,  the  uses  of,  759. 
Medical  Society  of  New  Jersey,  1 50. 
Medical  Society  of  the  County  of  New  York, 

506,  601. 
Medical    Society  of  the  Missouri    Valley, 

373. 
Medical  Society  of  the  State  of  Pennsylva- 
nia, 24. 
Medical  staff  of  the  Army  and  Navy,  ex- 
amination for,  755. 
Medical  stulents,  religious  care  of,  630. 
Medical  University  Extension,  530. 
Medical  warehouse,  co-operative,  628. 
Medication,  a  plea  for  rational,  587. 
Medicine  as  a  profession,  509  ;  pleasure  of, 

572. 

Melanosis,  artificial,  24. 

Meniere's  disease,  42. 

Meningitis,  cerebrospinal,  76,  157,  341  ; 
tubercular,  27. 

Menstrual  insanity,  a  case  of,  235. 

Menstruation,  282 ;  during  pregnancy,  731. 

Mental  training,  importance  of,  in  medical 
study,  508. 

Merit,  the  recognition  of,  530. 

Merycism,  181. 

Metabolism  in  chlorosis,  46. 

Metric  system  in  Great  Britain,  210. 

Mettler,  L.  Harrison,  management  of  val- 
vular heart  disease,  with  particular  ref- 
erence to  the  use  of  strychnine,  557. 

Mexico,  second  medical  congress  of,  627. 

Meyer,  Willy,  an  improved  method  of  the 
radical  operation  for  carcinoma  of  the 
breast,  746,  764. 


Michels,  John,  nucleus  of  red  blood  corpus- 
cle of  mammals,  669. 

Michigan,  "jag  cure  act  *  in,  319. 

Micro-organisms,  action  of  sunlight  on, 
607. 

Mid  wives'  registration  question  in  England, 
9?.  215,  316. 

Migraine  in  infancy,  383. 

Military  service,  the  place  of  physical  train- 
ing in  the,  455. 

Milk,  bacteria  in  the  intestines  after  the  in- 
gestion of,  653  ;  chemical  and  bacterio- 
logical characters  of,  24;  from  tuber- 
culous cows,  336  ;  human,  bacteria  in, 
174;  palatable  and  digestible,  224; 
Pasteurized,  as  supplied  to  the  poor  of 
New  York,  133  ;  the  digestion  of,  113 ; 
value  of  boiled,  as  an  article  of  diet, 
436 

Milk-supply,  examination  of,  for  tuberculo- 
sis, 474. 

Milk  teeth,  treatment  of  the,  480. 

Mind,  address  on  diseases  of  the,  26  ;  influ- 
ence of,  upon  the  body,  309 ;  sedatives 
to  the,  407. 

Mind-curers,  Professor  James1  splea  for  the, 77. 

Mineral  waters,  rules  for  bottling,  in  France, 
274. 

Miners,  life-saving  appliance  for,  242. 

Minot,  C.  S.,  notice  of  bibliography  by,  502. 

Mississippi  Valley  Medical  Association,  759. 

Mistakes,  value  of,  256. 

Mitchell,  Dr.  Howard  F.,  death  of,  210. 

Mitchell,  S.  Weir,  notice  of  book  by,  758. 

Moffat,  Henry,  cholecystenterostomy  with 
Murphy's  button,  339. 

Molluscum  contagiosum,  contagiousness  of, 
86. 

Monks,  medical,  178,  497. 

Monster,  an  ectromelic,  571. 

Monstrosities,  with  special  reference  to  ma- 
ternal impressions,  811. 

Montgomery,  Charles  J.,  history  and  treat- 
ment of  a  case  of  traumatic  tetanus  and 
sequela,  44. 

Montreal,  advances  of  public  health  in,  475. 

Moody,  Dr.  George  W.,  death  of,  562. 

Moor,  William,  permanganate  of  potassium 
in  opium  poisoning,  478 

Moore,  II.  B.,  apex  catarrh  or  tuberculosis? 
509. 

Morphine,  large  dose  of,  340,  564,  565; 
potassium  permanganate   in    poisoning 

by.  343»  478.  5*9- 
Morphinomania  in   the  medical  profession, 

383.  542. 

Morris,  Malcolm,  notice  of  book  by,  500. 

Morrow,  Prince  A.,  notice  of  book  edited 
by,  597. 

Mortality  rates  m  town  and  country,  243. 

Morton,  William  J. ,  origin  of  the  term  an- 
aesthetic, 799. 

Moser,  William,  a  few  words  in  reference  to 
living  cells  versus  staining,  371 ;  caryo- 
kinetic  changes  in  the  red  blood  corpus- 
cles, 494 ;  have  the  red  blood  corpuscles 
amoeboid  movements?  173. 

Mosher,  Dr.  Francis  G.,  death  of,  438. 

Mosquitoes  as  carriers  of  yellow  fever,  670. 

Mountain  sickness,  experimental  determina- 
tion of  the  cause  of,  374. 

Mouth,  care  of  the,  in  sick  persons,  334 ; 
hygiene,  815. 

Mullen,  J-  J  ,  a  successful  plastic  operation 
the  " 


Marion  Sims,  the 
y,  514;  pre- 
bild  indi 


on  the  face,  340 

Munde\  Paul  F.,  Dr. 
father  of  modern 

mature  delivery  of  a  dead  child  induced 
by  acute  appendicitis,  with  remarks  on 
appendicitis  in  women,  678 ;  ten  years' 
experience  with  Alexander's  operation 
for  shortening  the  round  ligaments  of 
the  uterus,  33. 

Muscle,  chemistry  of,   54 ;  volume  changes 
in,  during  activity  and  rest,  56. 

Mushroom  poisoning,  sulphate  of  atropine  as 
an  antidote  to,  532. 

Mynter,  Herman,  nephrectomy  on  account 
of  nephrolithiasis  and  pyonephrosis,  732. 

Myopia  in  relation  to  school  hygiene,  475. 

Myxcedema,  448;   infantile,  85, 1 184;  thy- 
roid feeding  in,  192,  724., 

i 


N 


Naevus,  790. 

Nammack.  Charles  E.,  a  case  of  non-heredi- 
tary Friedreich's  disease,  171 ;  a  plea 
for  immediate  cceliotomy  in  ruptured 
tubal  pregnancy.  622  ;  psoriasis  treated 
by  thyroid  extract  with  negative  result, 

343- 
Nancrede,  Charles  B.,   notice  of  book  by, 

211. 

Napper,  Mr.  Albert,  death  of,  765. 

Nasal  forceps,  a  new,  575. 

National  guard,  medical  department  of  the, 
219. 

Naval  hospitals,  240 

Navy,  report  of  the  surgeon-general  of  the, 
754  ;  statistics  in  the  medical  department 
of  the,  727. 

Negro,  the,  as  a  hospital  interne,  115. 

Nephrectomy,  444  ;  for  nephrolithiasis  and 
pyonephrosis,  732. 

Nephritis,  acute,  hereditary  syphilis  associ- 
ated with,  671 ;  chronic,  lactose  in,  151: 
granular,  anxiety  as  a  cause  of,  658 ;  of 
pregnancy  and  its  sequelae,  368  ;  of  ty- 
phoid fever,  493 ;  retinitis  from,  494. 

Nerves,  peripheral,  electricity  in  the  diagno- 
sis and  prognosis  of  diseases  of  the,  199. 

Nervous  disease  of  an  unusual  type,  history 
of  an  epidemic  of,  673. 

Nervous  force,  effect  of  fatigue  on  the  rate 
of  transmission  of,  53. 

Neuritis,  multiple,  from  excessive  consump- 
tion of  tea,  1 10  ;  treatment  of,  by  elec- 
tricity, 471  ;  treatment  of  peripheral, 
526. 

Neuro  fibromata,  multiple,  538. 

Neuroglia  stain,  a  new,  88. 

Neuromata,  multiple,  88. 

Neuroses,  nutritional  element  in  the  causa- 
tion of,  84. 

New  Jersey,  health  of,  150. 

New  York  Academy  of  Medicine,  504,  569, 
661 ;  anniversary  discourse,  737 ;  report 
of  committee  appointed  to  confer  with 
the  constitutional  convention,  606 ;  Sec- 
tion on  General  Medicine,  570,  729; 
Section  on  Obstetrics  and  Gynecology, 
600,  797 ;  Section  on  Pediatrics,  631 ; 
Section  on  Surgery,  537. 

New  York  County  Medical  Association,  218, 
539.  697. 

New  York  Pathological  Society,  91,  154, 
183,  220,  311,  347.  538*  633,  794. 

New  York  Pharmaceutical  Club,  66a 

Newkirk,  Dr.  Jacob,  death  of,  408. 

Newton,  Richard  C,  may  the  shock  of  a 
railroad  accident  ever  be  beneficial  to 
the  recipient?  719. 

Night  calls,  the  dangers  of,  574. 

Norbury,  Frank,  is  malaria  a  water-borne 
disease?  447. 

Normandy  cattle,  immunity  of,  from  tuber- 
culosis, 16. 

Norris,  Dr.  Thomas  R.,  death  of,  817. 

Nose,  cauterization  of  the,  310;  cutting 
operations  on  the  septum,  58 ;  growths 
in  the,  as  factors  in  aural  and  laryngeal 
catarrh,  204 ;  metallic  electrodes  in  dis- 
ease of  the,  23;  papillary  hypertrophy 
of  the  mucous  membrane,  22 ;  perfor- 
ations of  the  septum,  771 ;  polypus 
of  the,  21  ;  red,  electrical  treatment  for, 
306;  serrated  scissors  for  removing 
hypertrophies  of,  638. 

Novy,  Frederick  S.,  notice  of  book  by,  597. 

Noyes,  William  B  ,  an  easy  method  of  bath- 
ing in  typhoid  fever,  43 ;  enteric  fever 
in  infancy,  1. 

Nuclein,  physiological  and  therapeutic  value 

off  S3- 
Nursling,  effect  of  the  mother's  diet  upon  the, 

300. 
Nymphfebulation,  79S. 


Obesity,  thyroid  extract  in,  178. 
Obstetrics,  aphorisms  relating  to,  69 ;  studies 

in,  26. 
Oculo-motor  paralysis,  recurrent,  89. 


December  29,  1894] 


INDEX. 


825 


Odontoma,  follicular,  invading  the  antrum, 

59- 

CEdema,  acute  supia  glottic,  108 ;  angio- 
neurotic, 42,  634. 

CEsophagus,  cancer  of  the,  185  ;  foreign  body 
in  the,  731 ;  perforation  of,  by  a  sword 
swallower,  220 ;  stricture  of  the,  248. 

Old  age,  and  the  death  rate,  319;  hernia  in, 
246 ;  hip- disease  in,  246  ;  operations  in, 

35- 

Oldest  man  in  the  world,  176. 

Omphalo-enteric  duct,  persistent,  631. 

Oophorectomy,  pronunciation  of  the  word, 
64.     See  Ovariotomy. 

Ophthalmia  neonatorum,  treatment  of,  692. 

Ophthalmic  hemicrania,  273. 

Ophthalmologics!  Congress,  eight  interna- 
tional, 306,  316. 

Opium,  the  Indian  commission  to  study,  381 ; 
potassium  permanganate  as  an  antidote 

to.  343,  345.  448,  478.  569.  734- 
Oppenheim,  H.,  notice  of  book  by,  277. 
Oppenheimer,   JL.    S.,    doses    of   morphine 

habitues,  564. 
Optician,  the  refracting,  657. 
Orbital  cellulitis,  abortion  of  a  case  of,  564. 
Osteomalacia,  91. 
Osteomyelitis,  acute  vertebral,  16. 
Osteosis  of  the  skin  of  the  foot,  186. 
Otis,  W.  K.,  the  marriage  of  syphilitics,  668. 
Ottolengui,  Rodrigues,   notice  of  book  by, 

212. 
Outerbtidge,    Paul,   report    of  complicated 

cases  involving  uterus,  tubes,  and  ovaries, 

tieated  successfully,  166. 
Ovarian  disease,  pseudo-,  282. 
Ovariotomist,  an  early,  208. 
Ovariotomy,  248,  443 ;  amenorrhea  after, 

94- 

Ovaritis,  46. 

Ovary,  abscess  of  the,  572;  and  fallopian 
tubes,  diseases  of  the,  309  ;  cauteriza- 
tion o£  instead  of  removal,  319,  639 ; 
papilloma  and  papillomatous  cysts  of  the, 
183 ;  point  of  origin  of  a  tumor  of  the, 
600;  sarcoma  of  the,  311 ;  tumor  of  the, 
664. 

Overholser,  W.  P.,  a  plea  for  more  rational 
medication,  587. 

Overton,  Dr.  William  P.,  death  of,  762. 

Oxytocic,  sugar  as  an,  439. 

Oysters,  typhoid  fever  carried  by,  656,  657, 

743-       t .  . 
Ozone  in  phthisis,  124.  • 


Pagani,  Dr.  Joseph,  death  of,  77. 

Page,  Charles  £.,  consumption  :  roughing  it 
vs.  the  coddling  treatment,  481 ;  hy- 
gienic treatment  vs.  '*  ear -rubbing"  for 
"  hay- fever,"  284 ;  summer  comfort  for 
babies,  42. 

Pain,  pleasure,  and  aesthetics,  304. 

Palate,  perforation  of  the,  in  scarlet  fever, 
701  ;  sarcoma  of,  treated  by  erysipelas 
toxins,  616,  633. 

Pancreas,  carcinoma  of  the  head  of  the,  91. 

Pancreatic  and  hepatic  tissue,  chemical  prod- 
ucts of  the  anaerobic  putrefaction  of,  91. 

Pancreatic  colic,  623. 

Pancreatitis,  acute,  573,  692. 

Paralysis,  in  a  telephone  employee,  147 ;  in 
children,  an  epidemic  of,  475  ;  infantile, 
and  infantile  apoplexy,  146;  infantile, 
excision  of  the  knee  for  crippling  after, 
145  ;  recurrent  oculo-motor,  89. 

Paris,  medical  opportunities  of,  126 ;  med- 
ical students  in,  20. 

Park,  William  Hallock,  diphtheria  and 
pseudo-diphtheria,  385. 

Parotid  gland,  rare  tumor  of  the,  654. 

Parotiditis,  chronic  double,  283. 

Patent  medicines,  and  Texas  doctors,  19  ; 
restriction  of  the  sale  of,  320 ;  scourge 
of,  190. 

Paternal  impressions,  303. 

Pathology  and  practical  medicine,  new  re- 
lations of,  as  bearing  upon  the  path- 
ological department  in  hospitals,  229. 

Patients,  scarcity  of,  562. 


Patterson,  Dr.  Theophilus,  death  of,  377. 

Peat  fibre  for  surgical  dressings,  636. 

Pelvic  abscess,  diagnosis  and  treatment  of, 
442  ;  treatment  of,  435. 

Pelvic  diseases,  laparotomy  not  necessary 
for,  762  ;  surgical  problems  in,  419. 

Pelvimeter,  a  new,  600  ;  a  pocket,  287. 

Pelvis,  fracture  of,  with  laceration  of  the 
bladder,  72  ;  treatment  of  inflammatory 
troubles  of  the,  443. 

Pendleton,  Edward,  points  to  be  remem- 
bered in  the  practice  of  antiseptic  sur- 
gery, 333. 

Penis,  epithelioma  of  »he,  117. 

Pennsylvania  State  Board  of  Medical  Ex- 
aminers, 543. 

Perineum,  influence  of  laceration  of,  on  the 
uterus,  80 ;  operations  for  complete 
lacerations  of  the,  791  ;  restoration  of 
the,  488. 

Peritonitis,  acute,  792 ;  chronic,  with  intes- 
tinal and  abdominal  fistula?,  168 ;  diffuse 
septic,  surgical  treatment  of,  636 ;  tub- 
ercular, recovery  from,  after  operation, 

445- 

Permanganate  of  potassium,  as  an  antidote 
to  rattlesnake  venom,  567  ;  in  opium 
poisoning,  343,  345,  448, 478,  569,  734. 

Pertussis,  26  ;  cold  baths  in,  64 ;  treatment 
of,  440. 

Pessary,  the  decline  of  the,  640. 

Peters,  Dr.  George  A.,  obituary  of,  788; 
resolutions  on  death  of,  817. 

Pettenkofer,  Professor  Max,  resignation  of, 
140. 

Pexinogen,  54. 

Pharmacy,  laws  relating  to  the  practice  of, 
427. 

Pharyngeal  tonsil,  cyst  of  the,  137. 

Pharyngitis,  exudative,  60. 

Pharynx,  mycosis  of  the,  62. 

Phelps,  A.  M.,  etiology  of  deformities  oc- 
curring in  the  knee-joint,  129  ;  the  dan- 
gers of  night  calls,  574. 

Phelps,  W.  C,  a  case  of  enterolith,  341. 

Phenacetin,  poisoning  from  an  overdose  of, 
564. 

Philadelphia  as  a  medical  centre,  499. 

Philadelphia  Hospital,  high-handed  action 
of  the  commissions  concerning  a  physi- 
cian to  the,  785. 

Phillimore,  R.  H.,  the  patent  medicine 
scourge,  190 

Phillips,  George  A. ,  a  family  history  of  dia- 
betes, 173. 

Phonograph,  physics  of,  382  ;  physics,  phy- 
siology, and  clinical  import  of,  261. 

Phoroscope,  an  improved,  511. 

Phosphorus  butter.  160. 

Phthisis.     See  Tuberculosis. 

Physic,  the  sunny  side  of,  657. 

Physical  culture  in  unhealthy  schools,  499. 

Physician,  confidential  relations  of  the,  272, 
416  ;  the  composite,  437. 

Physicians  strike,  817. 

Pick,  Albert,  notice  of  book  by,  211,  758. 

Pilcher,  James  E.,  the  place  of  physical 
training  in  the  military  service,  455. 

Pinney,  Dr.  Charles  H.,  death  of,  498. 

Pirogoffs  operation,  modifications  of,  24. 

Placenta  previa,  148. 

Plague,  the,  20,  49,  114,  141,  177,  209,  241, 
286,  288,  337,  544. 

Pleurisy,  Is  it.  rheumatism  ?  366. 

Pleurogram,  the  cardiac,  56. 

Plicque,  A.  F  ,  notice  of  book  by,  502. 

Plumbing,  sanitary,  474. 

Plummer,  Frederic  H.,  a  case  of  hydramnion, 
with  atresia  ani  in  the  child,  565. 

Pneumatic  cabinet,  377. 

Pneumonia,  chloride  of  calcium  in  the  treat- 
ment of,  693  ;  in  an  infant  tieated  with 
inhalations  of  oxygen,  109  ;  sewer-gas  a 
cause  of,  537  ;  strychnine  in  the  treat- 
ment of,  754. 

Pocket-case,  an  aseptic  and  really  surgical, 

735- 
Poisons,  760. 
Polypus,  nasal,  21. 
Pons,  internal  capsule,  caudatum  and  lentic- 

ula,  circumscribed  softening  of  the,  89. 
Porro's  operation,  567. 
Portland,  hospitals  in,  318. 
Post-graduate  medical  study  abroad,  222. 


Post,  Sarah  E.,  notes  on  pelvic  and  general 
massage,  45. 

Pott's  disease,  early  diagnosis  of,  85  ;  rubber 
heels  for  patients  with,  145. 

Practitioner,  an  excited,  467  ;  genera],  song 
of  the,  657,  672  ;  the  country,  and  post- 
graduate study,  378. 

Practitioners'  Association  of  Great  Britain, 

*3- 

Practitioners,  irregular,  in  the  United  States, 

46;. 
Practitioners*  Society  of  New  York,   283, 

634. 

Pregnancy  at  an  advanced  age,  178 ;  effects 
of  quinine  upon,  301 ;  extra-uterine, 
282,  598,  600  ;  extra-uterine,  cceliotomy 
in,  when  the  foetus  is  living  and  viable, 
641  ;  extra-uterine,  immediate  cceliot- 
omy in  ruptured,  622 ;  hemorrhage  in 
late,  280;!  menbtiuation  during,  731; 
nephritis  of,  and  its  sequelae,  368. 

Pregnant  women,  the  care  of,  441. 

Prescriptions,  760. 

Preston,  George  J.,  the  malarial  organism 
in  the  blood  plaque,  408. 

Preventive  medicine,  future  of,  244. 

Prize,  Alvarenza,  595  ;  for  an  essay  on  tuber- 
culosis, 78,  305,  318;  of  the  Accademia 
dei  Lincei,  274 ;  Orloff-Davidoff,  64 ; 
the  Samuel  D.  Gross,  696. 

Prostate,  abscess  of  the,  347  ;  castration  for 
hypertrophy  of  the,  635,  760;  hyper- 
trophy of  the,  184. 

Prostitution  and  massage  establishments, 
659  ;  in  Berlin,  384. 

Prtmus  virginiana  as  a  heart  tonic,  20. 

Pruritus,  menthol  in,  476 ;  treatment  of,  47. 

Pryor,  John  H.,  a  case  of  acute  supra- 
glottic  oedema  without  apparent  cause, 
108. 

Psoriasis,  24;  thyroid  treatment  of,  343, 
427. 

Psorothermosis,  87. 

Psychology,  criminal,  296. 

Ptyalinogen,  54. 

Puerperal  fever,  810. 

Puke,  venous,  significance  of  the,  404. 

Pulmonea,  336. 

Pupils,  unequal  dilatation  of  the,  in  tubercu- 
losis, 320. 

Purgatives,  inefficiency  of,  when  injected 
hypodermically,  542  ;  time  of  action  of, 
287. 

Putnam,  W.  E.,  notes  on  brain  surgery,  43. 

Pyelitis,  acute,  in  infants,  85. 

Pylorectomy  with  gastro-duoden ostomy  pos- 
terior, 591. 

Pyonephrosis,  nephrectomy  for,  732. 

Pyothorax,  resection  in,  29,  94,  158. 

Pyrexia,  250. 

Pyuria,  93. 


Quack,  ingenious  plea  for  a,  471. 
Quack,  nurses,  305. 

Quackery  in  Paris,  318 ;  in  Russia,  192  ;  the 
spirit  of,  in  the  pale  of  the  profession, 

479- 

Quacks,  collective  investigation  of,  115. 

'•  Quilling  "  as  an  oxytocic,  703. 

Quinine,  acquired  idiosyncrasy  for,  showing 

peculiar  cutaneous  manifestations,   87 ; 

amaurosis  from,  219. 
Quinsy,  see  Tonsillitis, 


R 


Rabies,  see  Hydrophobia. 

Race  and  death-rates,  542. 

Rachitis,  143. 

Railway  accidents  in  the  United  States,  408; 
car  sanitation,  475,  574,  638;  injuries, 
bone  and  joint  tuberculosis  excited  by, 
759  5  physical  strain  involved  in  high 
speed  on,  736;  surgeon,  development 
of  the,  208 ;  surgeons,  National  Asso- 
ciation of,  728,  786 ;  Southwestern  As- 
sociation of,  787. 

Rake,  Dr.  Beaven  Neave,  obituary  of,  379. 

Rankin,  D.  N. ,  new  serrated  scissors  for  re- 
moving hypertrophies  and  turbinated 
tissues,  638. 


826 


INDEX. 


[December  29,  1894 


Ranney,  Dr.  Martin  L.,  death  of,  786. 
Ravoth,  Dr.  Fr.,  some  surgical  observations 

of,  3Si 

Raymond,  Joseph  H.,  notice  of  book  by, 
788. 

Raynaud's  disease,  42. 

Reading  notices  in  medical  journals,  625. 

Rectal  tube,  dangers  of  the  long,  238. 

Rectum,  conical  speculum  for  the,  350; 
diseases  of  the,  160  ;  new  method  of  re- 
section of  the,  724;  resection  of,  for 
cancer,  763. 

Reeves,  James  £.,  notice  of  book  by,  502. 

Reflex  irritation  as  a  cause  of  disease,  760 ; 
nasal,  256. 

Remittent  (non-malarial)  fever,  40. 

Reprint,  abuse  of  the,  408. 

Resorcin  test  for  free  hydrochloric  acid  in 
the  stomach,  430,  638. 

Respiration,  types  and  methods  of,  67. 

Respiratory  paths  in  the  cord,  57. 

Respiratory  tract,  peas  in  the,  173. 

Restiform  body,  removal  of  the,  648. 

Retinitis  from  chronic  diffuse  nephritis, 
494. 

Reynolds,  Dr.  Dudley   Sharpe,   Jr.,   death 

.     of'595*  •    , 

Rheumatism,  acute  articular,  as  a  germ  dis- 
ease, 20,  693;  and  gout,  affinity  of, 
401  ;  due  to  tonsillar  diseases,  63  ;  gas- 
troenteric, 91 ;  is  pleurisy  a  form  of, 
366. 

Richardson,  Maurice  H.,  cholecystotomy 
and  cholecystectomy  for  stone  impacted 
in  the  cystic  duct,  554. 

Richmond,  Nelson,  Is  there  a  northern  re- 
mittent (non  malarial)  fever  ?  40. 

Rickets,  infantile  scurvy  in  relation  to,  701. 

Right-handedness,  495. 

Robb,  Hunter,  notice  of  book  by,  501. 

Robinson,  Beverley,  acute  biliary  distention 
of  the  gall-bladder,  485 ;  sewer-gas  as  a 
cause  of  throat  disease  ;  or  the  effect  of 
bad  drainage  on  the  throat,  257. 

Robinson,  Byron,  landmarks  of  visceral 
disease,  714 ;  the  cervical  ganglion  of 
the  uterus,  403. 

Rockwell,  A.  D  ,  action  of  electricity  on  the 
sympathetic  nervous  system,  469,  523 ; 
notice  of  book  edited  by,  758. 

Rose,  A.,  "  As  others  see  us,"  415 ;  pastilles 
as  a  substitute  for  gargling  to  prevent 
diphtheritic  infection,  655. 

Rosenberry,  H.  L.,  incontinence  .  of  urine 
and  faeces  cured  by  circumcision,  173. 

Rossbach,  Dr.  M. ,  death  of,  734. 

Roux,  Fernand,  notice  of  book  by,  503. 

Roy,  Philip  S  ,  temperature  of  two  children 
during  spasms,  495;  three  cases  of 
nervous  diseases,  42. 

Royal  College  of  Surgeons,  politics  in  the, 
158,  665. 

Runge,  Edward  C,  a  case  of  tetanus  neona- 
torum, 698. 

Rupp,  Adolph,  perforations  of  the  nasal 
septum,  771 ;  who  is  to  blame?  381. 

Russian  Physicians,  the  Society  of,  285. 


Saalfeld,  Dr.  E.,  notice  of  book  by,  504. 

Sabathu  Leper  Asylum,  177. 

Sacrum,  osteoplastic  resection  of  the,  97. 

Safranin  reaction  in  sputum,  302. 

St.  Louis  as  a  medical  centre,  561. 

Salicyd-  chloroform,  50. 

Salmon,  Is  it  poisonous  to  dogs  ?  637. 

Sanborn,  Dr.  Noah,  death  of,  337. 

Sanitary  congress  in  Liverpool,  507. 

Sanitary  regulations,  necessity  of  interna- 
tional, governing  the  migration  of  large 
bodies  of  people,  449. 

Sanitary  Sunday,  192. 

Sarcoma  treated  by  erysipelas  toxins,  538, 
616,  633. 

Satterlee,  Richard  H.,  Is  it  time  to  call  a 
halt  ?  447. 

Sayre,  Lucius  E.,  notice  of  book  by,  212. 

Scalded  tissues,  toxicity  of,  492. 

Scalp,  cylindroma  of  the,  184. 

Scapula,  excision  of  the,  765. 

Scarlet  fever,  disease  of  the  heart  in,  384  ; 
perforation  of  the  palate  in,  701  ;  pre- 
ventive inoculation  against,  351. 


Schools,  hygiene  in,  474,  475 ;  periodical 
testing  of  eyesight  in,  51 ;  physical  cult- 
ure in  unhealthy,  499. 

Schirman,  A.,  malarial  infection,  567. 

Scbumpert,  T.  E.,  internal  urethrotomy  for 
stricture,  170. 

Sciatic  nerve,  secondary  suture  of  the,  409. 

Sclerosis,  infantile  amyotrophic  lateral,  180. 

Scoliosis,  an  improved  machine  for  treating, 

145. 

Scorbutus,  infantile,  146;  infantile,  in  its 
relation  to  rickets,  701. 

Sculpture,  medical,  542. 

Seitz,  Albert,  examination  for  cancer-cells 
in  living  tissue,  351. 

Seminal  vesicles,  extirpation  of,  for  tuber- 
culosis, 163;  inflammation  of  the,  118. 

Semmelweiss,  monument  to,  416,  446. 

Seoul,  Woman's  Hospital  in,  242. 

Septicaemia,  medical,  m  children,  86;  spon- 
taneous, in  the  rabbit,  794. 

Sero- therapy,  progress  of,  756. 

Sewage,  electrical  treatment  of,  94. 

Sewer-gas  a  cause  of  pneumonia,  537 ;  ef- 
fects of,  243,  257. 

Shaw,  John  C,  notice  of  book  by,  211. 

Shepherd,  Francis  J.,  notice  of  book  by, 

«77. 

Sherman,  W.  H.,  the  relationship  between 
bovine  and  human  tuberculosis,  412. 

Shock  of  a  railway  accident,  may  it  ever  be 
beneficial?  719. 

Shorthand  in  medicine,  114,  224. 

Shoulder-joint,  amputation  at  the,  309 ;  dis- 
ease of  the,  146. 

Shrady,  George  F.,  Dr.  J.  Marion  Sims,  sur- 
geon and  philanthropist,  513. 

Siegfried,  C.  A.,  beriberi  and  beans,  734. 

Sigmoid  flexure,  diverticula  of  the,  220; 
volvulus  of  the,  763. 

Sim,  Dr.  Frank  L.,  obituary  of,  788. 

Sims,  Dr.  J.  Marion,  reminiscences  of,  in 
Paris,  705;  statue  to,  513,  514,  528, 
535  ;  surgeon  and  philanthropist,  513 ; 
the  father  of  modern  gynecology,  514. 

Singer1  s  nodes,  61. 

Sinusoidal  current,  471. 

Skeleton,  estimating  the  height  from  differ- 
ent parts  of  the,  293. 

Skin,  symmetrical  atrophy  of  the,  87. 

Skin-disease,  an  epidemic,  301 ;  and  visceral 
affections,  692 ;  emergency  cases  of, 
806 ;  thyroid  treatment  of,  427  ;  treat- 
ment of  the  more  ordinary,  309. 

Skin-grafting,  206  ;  for  keloid,  174. 

Skull,  bullet  wound  of  the,  766 ;  measure- 
ments of  the  infantile,  649 ;  trephining 
for  depressed  fracture  of  the,  345  ;  two 
cases  of  fracture  of  the,  43. 

Small-pox,  former  ravages  of,  52 ;  in  Eng- 
land»  15?,  316 ;  in  Leicester  and  the 
anti- vaccinationists,  125;  Lady  Mary 
Montagu  on  inoculation  of,  319 ;  safe- 
guards against,  659. 

Smell,  the  sense  of,  771. 

Smith,  Carl  B.,  hydronaphthol  in  pulmo- 
nary phthisis,  72. 

Smith,  Dr.  S.  Hanbury,  death  of,  378. 

Smith,  E.  A. ,  climate  as  affecting  the  princi- 
ples of  applied  therapeutics,  317. 

Smith,  J.  Gardner,  types  and  methods  of 
respiration,  67. 

Smith,  Stephen,  the  necessity  of  interna- 
tional sanitary  regulations  governing  the 
migration  of  large  bodies  of  people  in 
the  prevention  of  the  spread  of  contagi- 
ous and  epidemic  diseases.  449. 

Smith,  William  G.,  varix  of  the  right  auri- 
cle ending  in  rupture,  5. 

Smith,  W.  Harvey,  application  of  the  graph- 
ic method  to  hearing,  51a 

Snake-bites,  protection  against,  594. 

Snake-poison  a  toxic  proteid,  406  ;  antidote 
to,  567,  608. 

Snare,  a  new,  51a 

Snare  wire  receiver,  350. 

Snow,  Sargent  F. ,  intra  nasal  growths  as 
factors  in  aural  and  laryngeal  catarrh, 
204. 

Sodium  bicarbonate,  large  consumption  of, 
380. 

Sorrow,  the  hygiene  of,  406. 

Souchon,  Edmond,  reminiscences  of  Dr.  J. 
Marion  Sims  in  Paris,  705. 


Soul,  a  location  for  the,  271. 

South  Carolina  State  Examining  Board, 
660. 

Southern  Surgical  and  Gynecological  Associ 
ation,  789. 

Southworth,  Thomas  S.,  a  resume'  of  the 
subject  of  biliary  calculi,  749. 

Specialism  and  medical  practice  in  Texas, 
694. 

Speed,  high  physical  strain  involved  in,  736. 

Spence,  Arnot,  a  question  of  fact  and  accu- 
racy in  statistics,  29 ;  the  reliability  of 
statistics,  158. 

Sperk,  Dr.  Edward,  death  of,  237. 

Spermine,  therapeutic  value  of,  431. 

Spinal  cord,  action  of  chloroform  on  the, 
791  ;  action  of  strychnine  on  the,  58 ; 
respiratory  paths  in  the,  57. 

Spine,  acute  osteomyelitis  of  the,  16;  sur 
gery  of  the,  246 ;  the  typhoid,  109,  479. 

Spleen,  a  lacerated,  312  ;  gunshot  wound  of 
the,  790. 

Splenectomy,  103. 

Sprains  of  the  ankle,  massage  in,  371. 

Spratling,  William  Philip,  the  excessive  con- 
sumption of  tea  as  a  cause  of  multiple 
neuritis,  no. 

Sputum,  safranin  reaction  in,  302. 

Staphylococci,  renewed  virulence  of,  after 
long  period  of  latency,  374. 

Starke,  G.,  version  three  weeks  before  de 
livery,  733. 

Starr,  Louis,  notice  of  book  edited  by,  276. 

Starr,  M.  Allen,  location  of  the  visual  cere 
bral  centre,  800. 

Stebbins,  Roswell  O.,  the  Esquimaux  and 
their  teeth,  509. 

Steele,  Thomas  B.,  the  swallowing  of  a  hat- 
pin, and  its  subsequent  extraction,  38a 

Stephenson,  F.  B.t  some  surgical  observa- 
tions of  Dr.  Fr.  Ravoth,  351 ;  the  So- 
ciety of  Russian  physicians,  285. 

Sterilization  of  doctors,  178. 

Stewart,  Thomas  M.,  foreign  body  in  the  eye 
for  six  years,  380. 

Stewart,  William  W.,  end-to-end  intestinal 
anastomosis  by  the  use  of  Murphy's 
button,  with  report  of  case,  326. 

Stomach,  cancer  of  the,  154,  186 ;  cancer  of, 
chlorate  of  sodium  in,  207;  diagnosis 
and  treatment  of  diseases  of  the,  310 ; 
dilatation  of,  associated  with  tetany,  573 ; 
education  of  the,  634 ;  examination  of 
the  contents  of,  by  the  stomach-tube  and 
Einhorn's  stomach-bucket,  331 ;  new 
methods  for  treating  diseases  of  the,  06; 
operative  treatment  of  perforating  ulcer 
of,  244,  302  ;  resorcin  test  for  free  hydro- 
chloric acid  in  the,  430,  638  ;  surgery  of 
the,  580. 

Stomach  reefing,  724. 

Stone,  Dr.  Warren,  memorial  address  on, 
789. 

Stone  in  the  bladder,  treatment  of;  635. 

Stone,  R.  French,  notice  of  book  edited  by, 
276. 

Storrs,  Frances,  education  a  factor  in  the 
prophylaxis  of  diseases  of  women,  804. 

Stowell,  Wm.  L.,  feeding  after  weaning,  65. 

Strabismus,  failure  in  the  surgical  treatment 
of  internal,  28. 

Straight,  Howard  S.,  apex  catarrh  or  tuber- 
culosis, 602 ;  notes  on  disease  of  the  ear 
and  upper  air-passages  in  apex  catarrh, 

369. 

Stratz,  C.  H.,  notice  of  book  by,  502. 

Stricture,  formation  of,  and  urine  leakage, 
116;  oesophageal,  248;  urethral,  24; 
urethral,  cause  of,  583 ;  urethral,  electro- 
lysis in,  470 ;  urethial,  internal  urethrot- 
omy for,  170 ;  urethral,  relief  of  deep, 
without  external  urethrotomy,  117  ;  ure- 
thral, treatment  of,  153. 

Strophantus,  Jo. 

Strychnine,  action  of,  on  the  spinal  cord,  58. 

Study,  Joseph  N.,  the  typhoid  spine,  109. 

Sturges,  Dr.  Octavius,  death  of,  696,  701. 

Sturmann,  W.,  notice  of  book  by,  211. 

Suicide,  543;  exhibition  of  the  brain  of  a, 
179. 

Sulphonal,  large  dose  of,  for  a  child,  339. 

Summers,  J.  Will,  varicose  ulcers  treated  by 
a  new  and  painless  method,  655. 


December  29,  1894] 


INDEX. 


827 


Sunlight,  action  of,  on  micro  organisms.  607. 
Sunstroke,    305;    and    alcohol,  39;  deaths 

from,  142. 
Supra-renal  tumor,  404. 
Surgeon,  the  art  of  the,  216. 
Surgery,  pleasures  of,  572. 
Surgical  technique,  modem,  762. 
Swasey,  Edward,  a  lid  elevator  for  cataract 

operations,  287. 
Sweeney,  M.  J.,  sixty  grains  of  morphine  at 

a  dose,  565. 
Sydenham,  Thomas,  a  statue  to,  316,  480. 
Sympathetic,  action  of  electricity  on  the, 

469,  5*3-  .    ,      . 

Symphyseotomy,  577,  602 ;  vs.  induction  of 
premature  Labor,  81. 

Syndicate,  a  medical,  283. 

Syphilis,  aphasia  from,  623 ;  as  a  ground 
for  divorce,  32;  contagious  period  of, 
154;  excision  of  the  initial  lesion  of, 
117;  extra-genital,  210;  hereditary, 
associated  with  acute  nephritis,  671  ;  in- 
fluence of  early  treatment  in  the  late 
manifestations  of,  759 ;  late  hereditary, 
765  ;  mental  symptoms  of  cerebral,  760 ; 
of  the  epididymis,  75  ;  period  of  com- 
municability  of,  120. 

Syphilitica,  the  marriage  of,  448,  605,  668, 
767. 


Tabes  dorsalis,  251. 

Tablet  triturates,  479. 

Tachycardia  after  influenza,  124. 

TafeC  L.  H.,  notice  of  book  translated  by, 
502. 

Talbot,  Eugene  S.,  notice  of  book  by,  276. 

Tannigen,  a  new  intestinal  astringent,  671. 

Tariff,  lowered  duties  on  drugs  under  the 
new,  209. 

Tarsoclasis,  145. 

Taylor,  Dr.  David,  death  of,  125. 

Tea,  multiple  neuritis  from  the  excessive 
consumption  of,  1 10. 

Tea-drinking,  insanity  from,  160. 

Teeth,  mineral  matter  in,  480;  treatment  of 
the  milk,  480. 

Telephone,  paralysis  in  a,  employee,  147  ; 
taking  the,  to  bed,  383. 

Temperance  Reform  League  of  Massachu- 
setts and  the  Keeley  cure,  628  ;  break- 
last  of  the,  315. 

Temperance  reform,  physicians  as  pioneers 

Temperatures,  sensible,  181. 

Tenement-houses,  placarding  contagious  dis- 
eases in,  576 ;  report  of  the  commis- 
sion on,  764. 

Terry,  Dr.  M.  C,  the  new  Surgeon-General 
of  the  N.  Y.  S.  N.  G.,  728. 

Testelin,  a  monument  to,  377. 

Testimonials  to  medical  men,  765. 

Testis,  implantation  of  an  artificial,  after 
castration,  164 ;  tumor  of  the,  119. 

Tetanus,  anti  toxin  o£  416,  787 ;  neonato- 
rum, 698 ;  puerperium,  149 ;  traumatic, 
report  of  a  case  of,  44. 

Tetany  associated  with  dilatation  of  the 
stomach,  573. 

Texas,  specialism  and  medical  practice  in, 
694. 

Thalamus,  lesion  of  the,  89. 

Therapeutics  at  the  International  Medical 
Congress,  48. 

Therapy,  cellular,  165. 

Thermogen,  the,  242. 

Thermogenesis,  cutaneous  application  of  cer- 
tain alkaloids  as  regulators  of,  113. 

Theses,  some  ancient  medical,  in  Paris,  192. 

Thioform,  462. 

Thirst  following  abdominal  section,  cause  of, 


Thomas,  John  Davies,  notice  of  book  by, 

277. 
Thompson,  J.  H.,  a  source  of  infection  in 

corneal  abscess,  463. 
Thome,  Dr.  Thorne,  public  health  services 

of,  477- 
Thorner,  E  ,  notice  of  book  by,  276. 
Thornton,  James  B.,  congenital  deformity, 

346. 


Thornton,  John,  notice  of  book  by,  502. 

Throat,  malignant  tumors  of  the,  importance 
of  early  diagnosis  of,  62 ;  neurasthenic, 
62 ;  sewer  gas  as  a  cause  of  disease  of 
the,  257. 

Thrombosis,  extract  of  leeches  in  the  preven- 
tion of,  137 ;  primary,  of  the  pulmo- 
nary artery,  311. 

Thyroid  extract,  dangers  of,  306;  new 
method  of  giving,  439. 

Thyroid  feeding,  for  Basedow's  disease,  640, 
671 ;  in  myxoedema,  724 ;  in  psoriasis 
and  other  skin  diseases,  427 ;  toxic  ef- 
fects of,  692. 

Thyroidism,  relation  of,  to  exophthalmic 
goitre  and  hysteria,  704. 

Tobacco  and  fatigue,  480. 

Todd,  Dr.  John  M.,  death  of,  210. 

Toe-nail,  ingrowing,  635. 

Tolstoi  on  vaccination,  736. 

Tongue,  extirpation  of  the,  for  cancer,  634 ; 
sarcoma  of  the,  154;  tractions  on  the, 
for  asphyxia,  141,  454 ;  traction  on  the, 
in  hysteria,  378. 

Tonsil,  concretions  in  the,  sore  throat  due 
to,  761 ;  mycosis  of  the,  62 ;  pharyn- 
geal, cyst  of  the,  137 ;  rheumatic  affec- 
tions due  to  disease  of  the,  63 ;  sarcoma 
of  the,  6 1. 

Tonsillitis,  treatment  of,  111,  242. 

Tooth,  fight  for  a,  800. 

Toxins,  antidiphtheritic,  see  Diphtheria  ;  in- 
testinal, 384. 

Trachoma,  shady  side  of  surgical  treatment 
of,  231. 

Transfusion,  claim  for  damages  by  one  giv- 
ing blood  for,  95 

Trent,  J.  H. ,  cyanide  or  ferrocyanide  of  po- 
tassium, 256. 

Trephine,  a  new  aseptic,  313. 

Trephining  for  traumatic  clot,  344. 

Trichinosis,  542. 

Trismus  neonatorum,  313. 

Tri  -  State  Medical  Society,  Jacksonville,' 
meeting  of  the,  617. 

Trusses,  glycerin  pads  for,  736. 

Tuberculin,  diagnostic  use  of,  in  cows,  74. 

Tuberculosis,  and  erysipelas,  antagonism  of, 
308 ;  articular,  152 ;  asses1  serum  for, 
466;  bovine,  150,  186  •  bovine,  diag- 
nostic use  of  tuberculin  in,  74  ;  conta- 
giousness of,  310;  channels  of  infection 
in,  624  ;  Colorado  as  a  climate  for  suf- 
ferers from,  27 ;  creasote,  guaiacol,  and 
benzoyl  of  guaiacol  in,  121 ;  etiology  of, 
644,  721 ;  general,  93,  663 ;  goat  serum 
in,  637 ;  hydronaphthol  in,  72 :  immune 
serum  of  the  goat  in,  702  ;  in  butter, 
437  ;  in  children,  374  ;  in  domestic  pets, 
124,  559  ;  infection  of,  in  a  laboratory, 
658  ;  of  the  adrenals  without  bronzing, 
552;  of  the  bladder  and  kidneys,  186; 
of  the  bladder,  lactate  of  cocaine  in, 
224;  of  the  frontal  sinus,  5^3;  of  the 
larynx  and  pharynx,  411;  of  the  semi- 
nal vesicles,  extirpation  for,  163  ;  ozone 
in,  124;  osseous,  excited  by  railway  in- 
juries, 759  ;  perineal,  injections  of  glyc- 
erin and  sulphur  for,  765 ;  peritoneal, 
recovery  from,  after  operation,  445  ; 
prophylaxis  of,  27,  309,  721 ;  pulmo- 
nary, climatic  segregation  of  persons  af- 
fected with,  474 ;  climatic  treatment  of, 
120;  pulmonary,  contagiousness  of, 
464,  736 ;  pulmonary,  marriage  of  per- 
sons affected  with,  474;  pulmonary, 
roughing  it  vs.  coddling,  481 ;  pulmo- 
nary, treatment  of,  654;  pulmonary, 
treatment  of  the  fever  of,  591 ;  rarity  of, 
in  the  highlands  of  Pennsylvania  and 
New  York,  181 ;  relationship  between 
bovine  and  human,  412  ;  renal,  surgical 
interference  in,  1 18  ;  restriction  and  pre- 
vention of,  473;  sanitarium  treatment 
of,  120;  social  causes  of.  405  ;  State 
prevention  of,  122 ;  strychnine  in,  27 ; 
the  serum  treatment,  496  ;  unequal  dila- 
tation of  the  pupils  in,  320 ;  value  of 
third  blood-corpuscle  in,  41. 

Tuberculous  lymphangitis  of  the  arm,  573. 

Tumors,  malignant,  toxines  of  erysipelas  in, 
82. 

Turpin,  Dr.  Virginius  A.,  death  of,  534. 


Twin  gestation,  anomalous  foetal  nutrition  in, 

74.  Hi. 

Twins,  double  pay  for,  286. 

Typhoid  fever,  310;  a  bed-bath  apparatus 
for  use  in,  253  ;  abortion  of,  760 ;  and 
malaria,  mixed  infection  of,  23 ;  com- 
bined carbolic  acid  and  chloroform  in, 
512  ;  diseases  of  the  heart  in,  384 ;  easy 
method  of  bathing  in,  43 ;  in  children, 
treatment  of,  435 ;  in  infancy,  1 ;  in 
Montclair,  N.  J.,  651:  in  the  Dis- 
trict of  Columbia,  785 ;  lactophenin  in, 
302 ;  nature  and  prevention  of,  507 ; 
nephritis  of,  493 ;  no  class  distinction  in, 
755 ;  or  typhus  fever,  a  doubtful  case, 
155  ;  origin  of,  274  ;  recent  epidemic  of, 
at  Windsor,  Vt.,  647  ;  relation  of  the 
bacillus  coli  communis  to,  527  ;  relation 
of,  to  drinking-water,  447 ;  susceptibility 
to  vaccination  after,  310;  the  oyster  as 
a  carrier  of,  656,  657,  743 ;  treatment 
of,  782 ;  treatment  of,  twenty-five  years 
ago,  51  ;  with  an  unusual  history,  663; 
with  extensive  ulcerations,  155. 

Typhoid  infection,  putrefactive  gases  as  pre- 
disposing agents  in,  492. 

Typhoid  spine,  the,  109,  479. 

Typhus  fever,  in  Paris,  405;  or  typhoid 
fever,  a  doubtful  case,  155. 

Tyrrell,  R.  Shawe,  the  affinity  of  gout  and 
rheumatism,  401. 


U 


Ulcers,  varicose,  treated  by  a  painless  meth- 
od, 655. 

Ulna  and  radius,  fracture  of  the,  537. 

Umbilical  cord,  compression  of,  during  for- 
ceps delivery,  174;  entanglements  and 
shortening  of  the,  798;  spontaneous 
rupture  of  the,  798. 

UnderhiU,  Mr.  W.  L.,  death  of,  125. 

United  States,  observations  on  medicine  in 
the,  335. 

Universities,  Professor  Jebb  on  the,  315. 

Ureter,  impacted  stone  in  the,  703. 

Uretero-ute  ine  fistula,  hysterectomy  for, 
671. 

Ureters,  inflammation  of  the,  81. 

Urethra,  electrolysis  in  stricture  of  the,  470 ; 
relief  of  deep  stricture  of,  without  ex- 
ternal urethrotomy,  117;  stricture  of 
the,  24;  stricture  of,  cause  of,  583; 
treatment  of  stricture  of  the,  153. 

Urethritis,  nervous  symptoms  of  patients 
with  chronic,  684. 

Urethrotomy,  internal,  for  stricture,  170. 

Urinalysis,  importance  of,  in  diagnosis,  760. 

Urine,  ammoniacal,  a  new  salt  in,  479;  cor- 
rection of  the  odor  of,  563;  inconti- 
nence of,  cured  by  circumcision,  173 ; 
leakage  and  stricture  formation,  1 16. 

Urticaria,  pilocarpine  in,  342,  564. 

Uterus,  adenoma  of  the  cervix,  94 ;  Alex- 
ander's operation  for  shortening  the 
round  ligaments,  32  ;  cancer  of  the  grav- 
id, 793 ;  cervical  ganglia  of  the,  403  ; 
danger  from  indiscriminate  irrigations  of 
the,  541 ;  dangers  of  glycerine  injections 
in  the,  for  the  purpose  of  inducing  prema- 
ture labor,  105  ;  extirpation  of,  for  my- 
omata,  279  ;  extirpation  of,  in  pelvic  sup- 
puration, 600 ;  fibroid  of  the,  discharged 
per  rectum,  794;  fibroid  of  the,  removed 
by  morcellement  without  hemorrhage, 
794 ;  fibroids  of  the,  279 ;  immediate 
repair  of  a  lacerated  cervix,  78  ;  inflam- 
matory disease  of  the,  443 ;  injections 
into  the  cavity  of,  in  antiquity,  382  ;  li- 
gation of  the  arteries  of  the,  for  the  cure 
of  fibroid  tumors  and  the  checking  of 
hemorrhage,  441 ;  ligation  of  the  circular 
artery  of  the,  219  ;  non-operative  treat- 
ment of  disease  of  the,  589;  operative 
treatment  of  fibroids  of  the,  147  ;  resec- 
tion of  the,  279  ;  rupture  of  the,  79,  80 ; 
sarcomatous  degeneration  of  fibroids  of 
the,  600;  simultaneous  appearance  of 
cancer  of  the  breast  and  of  the,  793 ; 
sloughing  of  the  cervix  after  labor,  38 ; 
surgical  treatment  of  anteflexion  of  the 


828 


INDEX. 


[December  29,  1894 


798 ;  total  extirpation  of,  in  disease  of 
the  adnexa,  175  ;  treatment  of  corporeal 
endometritis,  762;  treatment  of  fibroids 
of  the,  79;  treatment  of  retro-displace- 
ments of  the,  80;  tubes  and  ovaries, 
complicated  cases  involving,  166;  vag- 
inal hysterectomy  for  cancer  of  the,  281 ; 
vaginal  hysterectomy,  history  of,  793. 
Uvulatome,  a  new,  314. 


Vacation,  advantages  of,  438. 

Vaccination,  a  plea  for,  476 ;  illustration  of 

the  value    of,    764 ;    susceptibility   to, 

after  typhoid  fever,  310. 
Vaccine  and  vaccination,  474. 
Vagina,  congenital  annular  stenosis  of  the, 

617. 
Vaginismus,  treatment  of,  436. 
Valentine,  Ferd.  C,  the  doctor's  wife,  414. 
Van  Dyke,   F.  W.,  is  salmon  poisonous  to 

dogs  ?  637. 
Van  Etten,  Dr.  Solomon,  death  of,  49. 
Van  Winkle,  Dr.  Edward  Henry,  death  of, 

756. 
Varicocele,  793 ;  plastic  operation  for,  153 ; 

treatment  of,  by  means  of  a  truss,  351. 
Varicose  ulcers  treated  by  a  painless  method, 

Vasoconstriction  and  vaso -dilatation,  reflex, 

55- 
Vehsemeyer,  H.,  notice  of  book  by,  212. 
Vena  cava    superior,   obliteration    of   the, 

404. 
Version  three  weeks  before  delivery,  733. 
Vienna,  letter  from,  446. 
Villemin,  a  monument  to,  532. 
Vineberg,   Hiram   N.,   congenital    annular 

stenosis  of  the  vagina — an    improved 

method  of  operating,  617. 
Viscera,  a  case  of  transposition  of,  108. 
Visceral  disease,  landmarks  of,  714. 
Vision,  defective,  in  relation  to  crime,  569. 
Volkmann,  the  late  Professor,  a  monument 

to,  178,  377. 
Volvulus  of  the  sigmoid  flexure,  763. 


Vomer,  exostosis  and  enchondroma  of  the, 

Vulva,  progressive  cutaneous  atrophy  of  the, 
445- 


W 


Wagner,  Charles  W.,  transfer  of  the  insane 
to  hospitals,  254. 

Wainwright,  Dr.  William  A.  M.,  obituary 
of,  468. 

Walmsley.  Francis,  notice  of  book  by,  212. 

Ward,  J.  M.,  membranous  enteritis,  346. 

Warfield,  Clarence,  the  antidotal  action  of 
potassium  permanganate  in  opium  poi- 
■    soning,  448. 

Washburn,  W.,  car  sanitation,  574. 

Wasse,  G.  M.,  dosimetric  medication,  256. 

Water  in  diet  and  therapeutics,  330 ;  purifi- 
cation of,  128;  sand- filtration  of,  472  ; 
sedimentation  in,  472. 

Water-sampling  apparatus,  312. 

Water-supply,  danger  of  abundant,  without 
sewerage,  472  ;  of  farms,  472 ;  of  Jerusa- 
lem, 672  ;  pollution  of,  472. 

Watkins,  Robert  L.,  value  of  third  blood- 
corpuscle  in  tuberculosis,  41. 

Weaning,  feeding  after,  65. 

WeBer,  Leonard,  dyspepsia  neivosa  and  gas- 
trointestinal neurasthenia,  460. 

W«bster,  David,  retinitis  from  chronic  dif- 
fuse nephritis,  494. 

Weir,  Jas.,  Jr.,  criminal  psychology,  296; 
genius  and  degeneration,  131,  242  ;  is  it 
the  beginning  of  the  end?  801. 

Weir,  Robert  F.,  cases  in  genito  urinary 
su'gery,  161;  surgical  treatment  of  sur- 
gical kidney,  325. 

Wells,  Brooks  II.,  treatment  of  abortion, 

353- 

Wells,  Dr.  Horace,  celebration  of  the  dis- 
covery of  anaesthesia  by,  627  ;  erection 
of  a  tablet  to  the  memory  of,  7(6. 

Werdrr,  X.  O.,  coeliotomy  in  ectopic  gesta- 
tion where  the  foetus  is  living  and  viable, 
641. 

White,  A.  Campbell,  treatment  of  diph- 
theria, 545,  609,  631. 

White,  W.  Hale,  notice  of  book  by,  758. 

Whooping  cough.    See  Pertussis. 


Wiener,  Alexander  C,  treatment  of  fracture 
and  sprains  of  the  ankle  by  massage, 

371. 

Wife,  the  doctor's,  336,  414. 

Wiggin,  Frederick  Holme,  a  case  of  chronic 
peritonitis,  with  intestinal  and  abdomi- 
nal fistula —  enterorrhaphy — recovery, 
168. 

Wilcox,  Re>nold  W.,  notice  of  book  edited 

by,  758. 

Williamson,  Dr.  Charles  H.,  death  of,  338. 

Windows,  porous  glass  for,  720. 

Winking,  reflex  time  of,  57. 

Wirt,  William  E.,  the  dispensary  question 
in  Cleveland,  669. 

Witnesses,  medical,  rights  and  duties  of,  759. 

Wood,  H.  C,  notice  of  book  by,  758. 

Wood,  James  C,  notice  of  book  by,  211. 

Worcester,  A  ,  notice  of  book  by,  500. 

Woman' s  hospital,  a  new,  728. 

Women,  causes  of  diseases  peculiar  to,  17  ; 
education  a  factor  in  the  prophylaxis  of 
diseases  of;  804 ;  gonorrhoea  in,  789 ;  in 
medicine,  438 ;  medical  students  in  Glas- 
gow, 209 ;  physicians  in  America,  240 ; 
practice  of  medicine  by,  in  1572,  562. 

Wright,  Dr.  C.  R.  Alder,  death  of,  315. 

Wry-neck,  operation  for,  146. 

Wylie,  W.  Gill,  some  abnormal  conditions 
of  the  generative  organs  associated  with 
melancholia  or  mania,  135. 


Yellow  fever,  in  quarantine,  337 ;  mosquitoes 
as  carriers  of,  670 ;  prevention  of  trie 
spread  of,  475. 

Young,  James  K. ,  notice  of  book  by,  596. 


Zakharin,    Professor,  the  Czar's  physician, 

543,  56l. 
Zangger,    Theodore,  sewer-gas  a  cause   of 

pneumonia,  537. 
Zenner,  Philip,  acute  softening  of  the  brain, 

101. 
Zwisohn,  L.  W.,  cystic  degeneration  of  the 

colon,  730. 


\SSVSNTY-TWO  PAGES  IN  THIS  NUMBER.] 


7 


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-      ORIGINAL  ARTICLB8. 

Th«  Presenoeof  Albumin  and  OmU 
In  the  Urins  of  Football  Players. 
Br  Andrew  Maofarlana,  A.B., 
M.D.,  Albany,  N.  Y 788 

Ferforationii  of  the  Nasal  Septum ; 
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and  Treatment.  By  Adolph 
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Hints  on  the  Treatment  of  ■osema. 
By  Martin  F.  Bngman,  M.D., 
New  York 7TO 

PROORB88  OP  MBDICAL 
8CIBNCB. 

The  Relation  of  OholoUthlaala  to 
Primary  Oarolnoma  of  the  Gall- 


781 


Intracranial  Ansttrism— The  Treat- 
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tomy 78S 

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BDITORIAL8. 

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Oobps  op  TBsAurr 784 

Ttphoid  Pbyjcb  »  in  Distsiot 

o»  Columbia 786 

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Fujtotxoh... 786 

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Theobt 788 

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Illnaw  of  Dr.  William  H.  FUnt,  of 
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fifth  Anniversary  of  the  North- 
western Medical  and  Bnrgioal  So- 
ciety—A  New  Hospital  for  New- 
ark, N.  J.— Death  of  Dr.  Martin 
L.  Banney,  of  New  York  Oily  — 
National  Aaaooiation  of  Railway 


786 


The  Promlfed  Life  of  Sir  Andrew 
Olark,  by  Oanon  MaoOoll— A  Ty- 
phoid Andfrrrln  —  Beqneati  to 
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phia —  Kentucky  School  of  Med- 
icine —  Honor*  to  Medioal  Men- 
Ohio  State  AaMOiatlon  of  Railway 
Surgeons  —  The  Southwestern 
Aaaooiation  of  Railway  Burgeons 
—  The  Aaaooiation  of  Military 
Burgeons  of  the  United  States  — 
A  Bequest  to  the  Massachusetts 
General  Hospitai-The  West  Side 
German  Dispensary— Diphtheria 
in  St.  Louis— Thirty-fourth  Ad- 
versary of  the  German  Medioal 
Society  of  the  City  of  New  York 
—Manufacture  of  Vaccine  Vims 
by  the  State  of  Illinois- Receipts 
from  Portrait  Exhibition  —  The 
Antitoxin  Treatment  of  Tetanus 
—A  Gold  Oup  for  Discovering  a 
New  Microbe 


787 


OBITUARY. 
George  A.  Peters,  M.D.,  New  York  788 
Frank  L.   Sim,  M.D„  Memphis, 

Term 788 

0.  P.  Gats,  M.D.,  Oonoord,  N.  H. .  788 

RBVIBWS  AND  NOTICES. 

Transactions  of  the  Forty-ninth 
eOhlof 


Annual  Meeting  of  the  01 

Medical  Society too 

A  Manual  of  Hunan  Physiology. 
Prepared  with  Special  Reference 
to  Btndents  of  Medicine.  By  Jo- 
seph H.  Raymond,  A.M.,  M.D..  788 

Fifth  Annual  Report  of  the  New 
York  State  Commission  in  Lu- 
nacy. From  October  1, 1886,  to 
September  80, 1893 788 

Twelfth  Annual  Report  of  the  Pro- 
vincial Board  of  Health  of  On- 
tario,   Being  for  the  Year  1898..  788 

The  Principles  of  Bacteriology:  A 
Practical  Manual  for  Students 
and  Physicians.    By  A.  O.  Ab- 


bott, M.D.    Second  Bdition,  En- 
larged and  Thoroughly  Bevtoed.  788 

BOCIBTY  RBPORT8. 

BOUTHB&lf  SUBGIOAL  AHD  am- 

oologioal  Association  : 

Seventh  Annual  Meeting,  held  in 
Charleston,  8.  0.,  November 
18,  14,  and  16,  1894.  First 
Day,  Tuesday,  November  18th. 
Dr.  Warren  Stone- Gonorrhoea 
in  Women 789 

Some  Oases  of  Acute  Intestinal 
Obstructions  with  Deductions.  790 

Second  Day,  Wednesday,  Novem- 
ber 14th.  Hernia  of  the  Dia- 
phragm —  Gunshot  Wound  of 
the  Spleen  and  Kidney— Nievus  790 

Operations  for  Complete  Perineal 
Laceration  —  President's  Ad- 
dress —  Action  of  Chloroform 
on  the  Functions  of  the  Human 
Brain  and  Spinal  Oord 791 

Hydro-pyonephroais ;  Successful 
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mor of  the  Kidney  —  Gunshot 
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tonitis   79t 

Inf cotton  from  Without  —  Infec- 
tion from  Within 798 

Third  Day,  Thursday,  November 
16th.  History  of  Vaginal  Extir- 
pation of  the  Uterus— Reminis- 
cences of  Dr.  J.  Marion  Sims  in 
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—Simultaneous  Appearance  of 
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Varicocele 798 

Fibroid  Tumor  of  the  Uterus  with 
Suppurating  Ovary  Discharg- 
ing per  Rectum  —  Pelvic  Sur- 
gery —  The  Removal  of  an  In- 
trauterine Fibroid  Tumor  by 
Moroellement  without  Hemor- 
rhage -Election  of  Officers....  794 


r: 


Thb  Nbw  Yobz  Pathological 


Stated  Meeting,  November 
1894.     Spontaneous  Babbit 


«CAL       *     <£/ 

nr  14.  .  *     /I  % 


794 


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the  Heart 796 

Stenosis  of  the  Tricuspid  Ori- 
fice —  Miliary  Tuberculosis  of 
the  Liver 797 

NbwYobh  Aoamsti  or  Mm**- 
am: 

Section  on  ObtUtric*  and  C*j*m» 
ooloav*  Stated  Meeting,  No- 
vember 92,  1894.  Axis  Trac- 
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Chloroform  Bottle-  Nymphfebn- 
lation  —  Entanglements  and 
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Oord— A  Pathetic  Oase- Spon- 
taneous Rupture  of  the  Cord— 
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CORRB8PONDBNCB.  , 

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Phenacetine  -  Bayer   is   indicated   in   all 
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|JWp]VTAf*Fnril\IP   an(^  al*  *orms  °*  Pam-     It  *s  the  safest, 

*    IICHAVC  I  1 1^1  Li  whiie  the  most  active  and  reliable  of  the 

r>  a  \/r^r^  antipyretics  and  analgesics.     Phenacetine- 

sI3AYclv  Bayer  is  supplied  in  ounces,  tablets  and 

pills ;  also  in  pills  and  tablets  combined  with 


Analgesic  Anodyne 


Salophen,  Sulfonal,  quinine,  caffeine,  etc. 


Piperazine- Bayer  -  Europhen  -  Sulfonal"  Bayer  -  Salophen  -  Lycetol 
PAMPHLETS  FORWARDED  ON  APPLICATION. 

W.  H.  Schieffelin  &  Co.,  New  York. 


MEDICAL  RECORD. 


* 


ACTOPHENIN 


-OC.H. 


Lactyl-para-phenetidin  :    C,H4<N^  <£  CH(0H)CH,. 

A  Specific  for  Antipyretic, 

Typhoid  Antineuralgic, 

Fever.  Analgesic. 


Dote:    8  grains  three  to  six  times  dally. 


Dr.  A*  JAQUET,  of  Basel,  in  a  clinical  report,  says  that  "Lactophenin  is  the  most 
remarkable  of  all  new  antipyretics." 

Dr.  0.  von  ROTH  of  Vienna,  concludes  that  "  Lactophenin  "is  at  least  equal  in 
therapeutic  effect  to  Salicylate  of  £oda,  with  added  advantages." 

Prof.  R.  von  JAKSCH,  of  Prague,  Dr.  LANDOWSKI,  of  Paris,  Prof.  SCHniEDEBERO, 
of  Strassburg,  and  other  distinguished  clinicians  have  likewise  added  favorable  reports  and 
endorsements. 

Reprints  of  instructive  reports,  and  general  literature  with  sample  will  be  mailed  to 
physicians  free  on  request. 

C.  F.  BOEHRINGER  &  SOEHNE,  7  Cedar  St.,  NEW  YORK. 


Ferratin 


is  the  *'  Ideal  Iron  Com- 
pound" ;  it  is  both  a  Tonic 
and  a  Food* 

Discovered  by  Prof.  O. 
Schmiedkberg  and  Dr.  Mar- 
fori,  it  was  examined  thor- 
oughly in  physiological  and 
clinical  respects,  declared 
fully  equal  to  original 
claims,  and  has  in  a  short 
time  proved  to  be  of  the 
highest  therapeutical  value. 

Ferratin  is  now  in  use 
by  physicians  everywhere, 
has  received  the  endorse- 
ments  of  high  authorities 
and  leading  medical  jour- 
nals, and  is  assuming  first 
rank  among  Iron  Prepara- 
tions. 


Prof.  Germain  See,  in  a 

clinic  recently  stated,  that 
Ferratin  wa&  indicated  in  : 

Those,  of  both  sexes,  af- 
fected with  chlorosis ; 

Those  weakened  by  too 
rapid  growth  and  puberty  ; 

Those  suffering  from 
anaemia  from  hard  work, 
mental  or  physical,  though 
patients  have  the  appear- 
ance of  good  health ; 

Those  fatigued  by  study, 
especially  young  folks;  ard, 
in  short, 

All  in  whom  a  diminution 
of  red  blood,  corpuscles  had 
ensued,  due  no  matter  to 
what  causes. 

Literature  and  Sample 
will  be  mailed  free  to  phy- 
sicians on  request. 


C.  F.  BOEHRINGER  &  SOEHNE,  7  Cedar  St.,  NEW  YORK. 


MEDICAL  RECORD. 


REASONS 
WHY 


MARKS 


)    ARTIFICIAL   LIMBS  WITH    RUBBER 
HANDS    AND    FEET    ARE    THE 


BEST. 


R  P  Q  A  U  8  E — Th*y  •*•  tbe  mD*t  comfortable  to  wear.     They  are  fitted  upon 
w  scientific   principles  by  competent  and  skilled  fitters  who   are 

familiar  with  the  anatomy  of  human  stumps. 

A.  A.  MARKS,  QLBN  SPRINGS.  S.  C  ,  Angufct  3,  1894. 

Diab  Pre :— I  received  the  artificial  leg  which  yon  made  for  me  and  com- 
menced using  H  on  the  13th  of  the  same  montb.  I  mas  tssy  itaat  it  flta  the  best  of 
any  artificial  leg  I  hare  ever  had.  S.  S.  B  BAB  DON. 

BECAUSE — They  obviate  ooncussions  to  stumps.  The  sponge  rubber  foot 
affords  a  yielding  medium  to  walk,  run,  jump  or  alight  upon 
without  jarring. 

A.  A.  MARKS,  WANGANUI,  Niw  ZEALAND,  Jane  19,  1694. 

Dear  8ib:— On  September,  1891,  yon  forwarded  to  me  an  aitlflclal  leg  for 
my  son.  It  baa  given  tbe  greatest  satisfaction.  My  son  has  worn  it  continuously, 
he  can  do  all  sorts  of  wotk,  he  can  walk  all  day  In  a  rough  country  and  never  be- 
comes sore  or  lame.    He  has  Jumped  ten  flight  of  hurdles,  8  feet,  8  Inches  high  in 


ISO  yards.    I  have  seen  him  Jump  a  standard  wire  fence. 


0.  M.  TAYLOR 


BECAUSE — The  method  of  fitting  and  construction  do  not  require  strangulating 
or  choking  slip  sockets  in  order  to  keep  the  stumps  from  abraiding. 

A.  A.  MARKS,  OTTAWA,  OHIO,  July  80,  1-94. 

Dbab  Sib  :— The  leg  which  I  purchased  from  you  for  my  daughter  about  a  year 


ago  has  been  worn  constantly.    When  bbe  received  the  lev  It  was  a  perfect  fit. 
.„     ..         ...  .      re  It  to  school  "    "'  *        "" 

Respectfully, 


.—   ,      .  .-  -  .-  My 

dsughter  put  It  on  and  wore  It  to  school  the  first  day.    The  stump  has  never  been 
~  J.  S.  CART  WRIGHT, 


chafed  or  sore. 


C.fi. 


BECAUSE — They  are  noiseless.  The  absence  of  complicated  ankle  articulations 
removes  absolutely  the  tell-tale  thud,  thump,  and  flop  which  are 
the  most  objectionable  features  of  all  other  artificial  legs. 

"  Mr.  Marks  makes  absolutely  the  best  artificial  leg  I  have  ever  seen.  The  core 
of  the  foot  is  covtred  with  India  rubber  so  that  from  the  instep  to  tbe  toes  and  back  to 
the  heel  the  foot  Is  simply  solid  spiing  lubber.  The  elasticity  of  tbe  toes  and  heel 
compensates  for  the  absence  of  ankle  motion,  and  in  waking  thf re  is  none  of  the 
Jarring,  »dot  and  go  one '  walk  so  characteristic  of  the  Jointed  foot." 

Dr.  LKWIS  A.  SAY  RE.  Lecturer  at  Be.levne  Hospital. 


A  treatise  of  430  pages  sent  free.    Address 


p********™    A.  A.  MARKS,  701  Broadway,  New  York. 

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6 


MEDICAL  RECORD. 


THE  IDEAL  PULMONARY  INSPIRATOR 

Sold  only  on  Prescriptions  from  Physicians. 

A  perfected  apparatus  for  the  treatment  of  diseases  of  the 
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This  instrument  is  used  and  prescribed  by  many  eminent  phy- 
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Prof.  Clarence  0.  Bice,  of  the  Poet-Graduate  School  of  New  York 

City. 
Prof.  George  B.  Fowler,  of  the  Poet-Graduate  School  of  New 

York  Oily,  and  Bellevue  College,  New  York  City. 
Pro!  Judson  C.  Smith,  of  the  Post-Graduate  School  of  New  York 

City. 
Prof.  B.  C.  H.  Page,  of  the  Polyclinic  and  Hospital  of  New  York 

City. 
Prof.  Bobert  C.  Miles,  of  the  Polyclinic  and  Hospital  of  New  York 

City. 
Prof.  O.  B.  Douglas,  of  the  Manhattan  Eye  and  Ear  Hospital  off 

New  York  City. 
Prat  H.  Holbrook  Curtis,  Nose,  Throat,  and  Lung  Specialist,  New 

York  City. 
Remember  we  deal  only  with  Bhyeieian*. 

Descriptive  Pamphlet  with  price-list  sent  on  application. 

C.  B.  UNDERWOOD  &  CO.,  No.  15  East  14th  Street,  New 


JUST   PUBLISHED. 

A  CLINICAL  MANUAL 


OP 


DISEASES  OF  THE  EYE, 

Including  a  Sketch  of  its  Anatomy. 
By  D.  B.  ST.  JOHN   ROOSA,  M.D.,  LL.D., 

Professor  of  Diseases  of  the  Eye  and  Ear  in  the  New  York  Post-Graduate  Medical  School  and  Hospital ;  Surgeon  to  the  Manhattan  Eye  and  Ear  Hospital ; 

formerly  Professor  of  Diseases  of  the  Eye  in  the  University  of  the  City  of  New  York,  and  in  the  University  of  Vermont ;  Consulting  Surgeon  to  the 

Brooklyn  Eye  and  Ear  Hospital;  President  of  the  New  York  Academy  of  Medicine:  Honorary  Member  of  the  Medico-Chirurgical 

Society  of  Edinburgh  ;  Honorary  Fellow  of  the  Academy  of  Medicine  of  Havana,  Cuba,  etc.,  etc. 


This  work  presents,  in  a  convenient  and  eminently  practical  form,  the  results  of  the  author's  long  and 
extensive  experience  in  the  treatment  of  diseases  of  the  Eye.  Space  has  not  been  wasted  over  discussions 
of  doubtful  points,  but  the  aim  has  been  to  produce  a  book  which,  as  the  preface  states,  shall  be  "a  complete 
and  safe  guide  to  the  practitioner."  • 

Part  I.  contains  a  "Sketch  of  the  Anatomy  and  Physiology  of  the  Various  Parts  of  the  Eye  and  its 
Appendages." 

Part  II.  presents  "The  Relative  Frequency  of  Different  Diseases  of  the  Eye,  Methods  of  Examination, 
Therapeutics  and  Surgery  of  the  Eye." 

Part  III.  treats  of  "  Diseases  of  the  Eyelids,  the  Lachrymal  Apparatus,  the  Conjunctiva,  Eyeball,  and  Orbit," 

Part  IV.  discusses  "Conditions  of  the  Eye  Requiring  the  Use  of  Glasses — Errors  of  Refraction  and 
Accommodation — Strabismus — Affections  of  the  Ocular  Muscles." 

This  work  consists  of  one  volume  of  650  pages  octavo,  uniform  with  the  Treatise  on  the  Diseases  of  the  Eart 
by  the  same  author.  It  is  profusely  illustrated  by  178  engravings  in  the  text,  nearly  all  original,  two  full-page 
chromo-lithographic  plates,  and  a  full-page  black  plate.     Bound  in  extra  muslin  at  $5.50,  and  in  sheep  at  $6.50. 


WILLIAM  WOOD  &  COMPANY,  Publishers, 


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MEDICAL  RECORD. 


NEW  URINARY  TEST  CASE. 


This  ease  contain*  in  oompaot  and  convenient  form  all  the  apparatus 
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hold  Test  Tubes,  Large  Funnel,  etc;  the  other  TJrinometers,  Small 
Funnel,  Beakers,  eta  Bight  Besgent  Bottles  (filled  sxfd  labeled)  are 
arranged  in  back  of  Case.  A  drawer,  beneath,  is  for  Litmus  Paper, 
Stirring  Rods,  etc. 

TBLK    CASE    CONTAINS: 


8  Rbaokmt  Bottles, 

9  Glass  Funhkls, 
1  Alcohol  Lamp, 

9  BSAKSS8, 

1  Evaporating  Dish,  Poroelaw, 

9  BVAFORATIMO  DISHB8,  GLASS, 


14  Abbobtid  Test  Tubes, 
1  Test  Tube  Holder, 
1  Ubieometee. 
1  Graduated  Pipette, 
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Litmus  Paper. 


80  arranged  that  each  Article  Is  ready  for  Immediate  use  when  the  Case  is 

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Thii  table  is  offered  as.  a 
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fitted  and  finished,  and  when 
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leg  and  foot  rests,  making  II 
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The  following  advantages  are  claimed  for  this  table : 

1.  That  its  presence  in  an  office  will  never  excite  suspicion. 

2.  That  it  is  perfectly  adapted  for  examination  in  all  positions. 

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That  its  moderate  price  makes  it  easily  obtainable  by  every 
physician. 

Perfectly  adapted  to  examinations  and  treatment  on  diseases  of  the 
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Prioe,  $50.00  net.  Boxing,  $9.50. 

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Many  unsolicited  commendatory  letters,  from  physicians  using  this  table* 
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An  Invaluable  Discovery  In  the  Preparation  of  Opium. 

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upon  which  Its  bad  effects  depend.  It  possesses  all  the  sedative,  anodyne,  and  antl-spasmodlo  powers  of  Opium :  To  produce  sleep  and  oomposure ;  to  re- 
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MEDICAL  CHEMISTRY-  ByJ0™^PER- 


A  PRACTICAL 
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THE  OLD   HOSPITAL 

AND   OTHER   PAPERS. 

By   D.   B.   ST.   JOHN    ROOSA,    M.D.,    LL.D, 

Being  the  second  revised  and  enlarged  edition  of 
"A  DOCTOR'S   SUGGESTIONS." 


In  this  edition,  besides  the  change  in  the  title,  there  hare  been  added  three 
new  essays,  making  eleven  in  all.  As  the  author  states  in  his  preface.  "  the 
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the  Vi  Urometer  eet  upu  corresponding  motion  in  the  tympanic  membrane,  which  in  tnrn  transmits  a  correspond- 
ing motion  to  the  bones  of  fcbe  mid  tile  ear.  The  articulations  of  these,  often  rendered  more  or  less  immovable  as 
a  result  <tf  disease,  are  ng-ain  ma* It:  free  to  act  in  a  normal  manner.  The  adhesions  are  stretched,  broken,  and 
obliterated.     Send  for  one  of  our  descriptive  pamphlets.    Address 

The  Vibrometer  Company, 

no  N.  Holliday  Street,  BALTIMORE,  MD. 


X££  HAWKES'  PAPER  JACKET 

The  THINNEST.  LIGHTEST,  and  STRONGEST 
Spinal  Support  Ever  Invented. 

Weighs  8  to  15  ounces;  only  3-32  of  an  inch  thick;  will  support  200  pounds 
weight  light  enough  for  the  weakest  child ;  strong  enough  for  the  most  muscular 
laborer.    Only  a  good  plaster  mould  necessary.    No  other  measurements  required. 

Designed  to  supersede  plaster,  leather,  wood,  felt,  and  the  various  iron  braces. 

For  descriptive  circular,  specific  directions  for  making  suitable  mould,  prices, 
with  discounts  to  physicians,  and  further  particulars,  address 

THE  DRS.  HAWKES.  1343  Lexington  Ave..  N.  Y.  City. 


MEDICAL  RECORD. 


TOTTSSA.INTS 

EXTRACT  OF  MALT. 

This  justly  popular  preparation  is  a  pure  product,  made  in  vacuo,  according  to  approved  methods 

with  the  most  modern  machinery,  by  an  experienced  chemist.     It  is  of  syrup  consistency, 

agreeable  taste,  and  reidily  mixes  with  milk,  beer,  or  other  customary  vehicle. 

It  is  offered  in  bulk,  for  hospital  use,  and  in  regular  12  cm.  round  bottles, 

holding  1  lb.  by  weight,  plain  or  in  the  following  combinations: 


CASCARA  8AGRADA.  A  popular  and  excellent  combination  of  tonic 
laxative  and  nutritive  properties.  Bach  tablespoon* ul  contains  thibty 
grains  of  Cascara  Sagrada. 

PYROPHOSPHATE  OF  IRON.  For  Ansmla  and  Chlorosis.  Each  table- 
spoonful  contains  ax  grains,  or  8  per  cent,  of  Pyrophosphate  of  Iron. 

DIALYZED  IRON.  For  Anaemia  and  Chlorosis.  Each  tablespoon* ul  contains 
twxltb  grains  of  DhUysed  Iron. 

IODIDE  OF  IRON.  For  Scrofula,  Syphilis,  etc.  Each  tablespoonfnl  con- 
tains one  grain  of  lodte  of  Iron. 

IRON  AND  PEPSINS.  Each  tablespoonfnl  contains  thbxb  grains  each  of 
Iron  and  Pepaine. 

IRON  AND  LIME.  For  all  diseases  of  the  Longs.  Each  tablespoonfnl  con- 
tains three  grains  each  of  Iron  and  lime. 

IRON  AND  QUINIA.  For  Strengthening  the  System.  Each,  tablespoonfnl 
contatns  two  grains  of  Citrate  of  Iron  and  Qnlnia. 


PBPBINE.     For  Promoting  Digestion, 
grains  of  Pepslne. 


Each  tablespoonfnl  contains  six 


IODIDE  OF  CALCIUM.    For  Phthisis.    Bach  tablespoonfnl  contains  three 
grains  of  Iodide  of  Calcium. 


IODIDE  OF  POTASSIUM, 
tlons,  Effusions,  etc 


For  the  Absorption  of  Products  of  Inflamma- 


HYPOPH08PHITK  OF  LIME.  For  Phthisis  and  all  Diseases  of  the  Lungs. 
Each  tablespoonfnl  contains  six  grains  of  the  Hypophosphite  of  Lime. 

THE  HYPOPHOSPBITB9.  For  Phthisis  and  all  Diseases  of  the  Lungs. 
Each  tablespoonfnl  contains  six  grains  of  the  Hypophosphltes. 

COD  LIVER  OIL.  For  all  Diseases  of  the  Lungs.  Each  teaspoonfal  con- 
tains one  dram  of  Cod  Liver  OIL 

COD  LIVER  OIL  AND  LIME.  For  all  Diseases  of  the  Lungs.  Each  tabie- 
spoonf  ui  contains  thirty  grains  of  Cod  Liver  Oil  and  six  grains  of  Hypo- 
phosphite  of  Lime. 

COD  LIVER  OIL  AND  IODIDE  OF  IRON.  For  all  Diseases  of  the  Lungs. 
Each  tablespoonfnl  contatns  thirty  grains  of  Cod  Liver  Oil  and  one 
grain  of  Iodide  of  Iron. 

COD  LIVER  OIL  AND  CITRATE  OF  IRON  AND  QUINIA.  For  all 
Diseases  of  the  Lungs  and  for  Strengthening  ef  the  Blood.  Bach  table- 
spoonful  contains  two  grains  of  Citrate  of  Iron  and  Ovinia,  and  thirty 
grains  Cod  Liver  OH. 

QUINIA.    (Tasteless.)   Each  tablespoonfnl  contains  three  grains  of  Quinla. 

HOPS.  An  Excellent  Aromatio  Tonic.  Each  tablespoonfnl  contains  two 
grains  of  Extract  of  Hops. 


PLAIN,"  ii  Bottles,  dozen,  $4.00;  li  Bilk,  nil,  $4.00.  ALL  COMBINATIONS,  u  Bottles,  dozen,  $5.00;  U  Bill,  OIL,  $4.00. 

Manufactured  by  LEHN  &  FINK,  New  York. 

For  Sale  by  ALL  JOBBERS. 


THIRD    EDITION. 


PRACTICAL  HUMAN  ANATOMY. 

By  FANEUIL  D.  WEISSE,  M.D., 

Professor  of  Practical  and  Surgical  Anatomy  in  the  Medical  Department  of  the  University  of  the  Oiqr  of  New  York ; 
Professor  of  Regional  Anatomy  in  the  New  York  College  of  Dentistry,  etc,  etc. 


A  Working  Guide  for  Students  of  Human  Anatomy  and  a  Retrospect  for  Prac- 
titioners of  Medicine  and  Surgery. 


PRESS   NOTICES. 


•The 


The  plates  are  decidedly  clear,  and  neither  too  diagrammatic  as  m 
Ehgnah  works,  nor  too  highly  nnislied,  as  to  some  IVenoh  produetfoiis.w 

"An  structures  receive  lair,  systematic  treatment,  and  the  author 
wisely  avoids  departing  from  the  paths  of  what  neurologists  term  'coarse' 


4  As  a  work  of  reference  for  any  anatomist,  surgeon,  or  physician  it 
rves  to  be  placed  in  every  library  attached  to  medical  or  biological  lnstl- 
■Oidsh  Mescal  Journal, 

"  The  book  In  lte  entirety  surpasses  to  point  of  practical  utility  anything 
ever  offered  the  profession." 

-  "  me  dissections  of  the  female  perineum  alone  are  worth  to  a  surgeon 
Ike  price  of  the  book." 

"  As  a  book  of  reference  a  practitioner  can  use  It  to  advantage  without 
sauoh  study  or  search.0 

"In  our  Judgment  this  work  is  a  desideratum  to  the  surgeon's  library 
long  needed."— Daniel's  Texas  Medical  Journal. 

Br.  Welsse,  taking  up  Gray's  plan,  to  a  certain  extent,  and  improving 
wjxm  It,  has  succeeded  in  giving  na  a  work  of  far  more  practical  utility  than 
anything  of  the  kind  that  we  have  ever  seen." 


••  Medical  students  will  never  regret  taking  our  advice  in  obi 

in  preference  to  any  other  anatomy  extant/'—  The  Texas  Courier*, 
Of  Medicine. 

"In  the  outset  we  can  say  that  no  student  of  medlome,  no  surgeon,  no 
physlolan  can  afford  to  be  without  this  work.  If  we  were  able  to  have  but 
one  anatomy  in  our  library,  this  would  be  the  one  we  would  choose." 

^Buffalo  Meaical  ana  Svrgical  Journal. 

"This  is  an  admirable  work,  and  will  always  find  a  place  upon  the 
shelves  of  every  live  practitioner  of  surgery  and  medicine." 

"  The  plates  elucidate  every  part  so  well  that  they  appear  to  speak  to  us.* 

"  The  explanations  of  the  illustrations  are  brief  but  to  the  point,  and  each 
sentence  expresses  no  more  or  less  than  knowledge  of  the  partjuatlflee." 

—me  Southern  Practitioner. 

"Taken  as  a  whole,  this  book  is  one  which  reflects  high  credit  upon 
American  medicine."— PhUaaelpMa  MeaUsal  Times. 

**  The  plates  are  almost  an  drawn  from  nature,  and  deserve  great  praise." 

"We  congratulate  Br.  Welsse  on  the  sucoess  of  his  work,  which  wt 
believe  wfl]  be  a  favorite  with  students.1* 

—Boston  Meatoal  ana  Surgical  Journal. 

"We  Should  expect  it  to  become  the  favorite  ds- Atlantic  dissector's 
manual."- American  Journal  of  the  MeOioal  Sciences. 


In  one  Svo  volume,  with  two  hundred  and  twenty-two  full-page  plates,  exquisitely  executed.     Price,  4m 
muslin,  $6.00;  in  leather,  $7.00.    In  four  volumes,  enameled  doth,  round  corners,  $6.00. 

SEND  FOB  SAMPLE  PLATES  (gratis)  TO 

WILLIAM  WOOD  &  COMPANY.  43  TO  47  EAST  10th  STREET.  NEW  YORK. 


IO 


MEDICAL  RECORD. 


TREATMENT  OF  nTTESTDTAL  ATPEOTI05S 
AID  HEDE08EB  OF  THE  EE8PIEAT0EY  OSQAHS. 


We  are  too  liable  to  regard  any  affection  of  the  lanes, 
except  consumption,  as  "nothing  more  than  a  hard  cold.'' 
Influenza,  bronchitis^  pleurisy,  and  many  cases  of  pneumonia 
are  included  under  this  division.  Pain,  cough  and  fever  are  the 
three  principle  symptoms.  To  control  any  one  of  these  three 
is  many  times  sufficient  to  cause  the  others  to  disappear,  so 
closely  are  they  related  to  one  another. 

,  In  a  "Note  on  Codeine,"  in  the  London  Lancet,  Dr.  James 
Braithwaite,  of  Leeds,  says :  "Codeine  seems  to  have  a  special 
action  upon  the  nerves  of  the  larynx;  hence  it  relieves  a 
tickling  cough  better  than  any  ordinary  form  of  opium.  It 
was  in  my  own  case  that  I  first  began  to  use  codeine.  For 
more  than  twenty  years,  usually  once  every  winter,  I  have  been 
seized  with  a  spasmodic  cough  just  before  going  to  sleep,  which 
becomes  so  severe  that  I  am  compelled  to  get  up  and  sit  by  the 
fire.  After  an  hour  or  two  I  return  to  bed  and  am  free  from 
the  cough  till  the  next  winter.  Many  years  ago  I  found  that 
one-half  grain  of  codeine,  taken  about  two  hours  before  bed- 
time, absolutely  stops  the  attack  and  leaves  no  unpleasant 
effect  the  next  morning." 

We  find,  however,  that  where  there  is  great  pain,  the  anal- 
gesic effect  of  codeine  may  not  be  sufficient,  and  a  combination 
with  antikamnia  is  required.  Sometimes  chronic  neuroses 
may  be  cured  by  breaking  the  continuity  of  the  pain,  for  which 
purpose  we  have  found  this  combination  peculiarly  suited. 

Clinical  reports  in  great  numbers  are  being  received  from 
many  sections  of  this  country,  which,  while  verifying  Dr. 
Braithwaite's  observations  as  to  the  value  of  codeine,  place 
even  a  more  exalted  value  upon  the  advisability  of  always 
combining  it  with  antikamnia  in  treatment  of  any  neuroses  of 
the  larynx,  coughs,  bronchial  affections,  in  fact,  all  grippal 
affections  and  their  seauelse,  as  well  as  chronic  neuroses ;  the 
therapeutical  value  of  Doth  being  enhanced  by  combination. 
The  tablets  of  "Antikamnia  and  Codeine,"  containing  4% 
grains  antikamnia  and  J£  grain  codeine,  meet  the  indications 
almost  universally. 

Supplementary  to  the  foregoing,  Dr.  Chas.  H.  Stowell, 
editor  of  the  National  Medical  Review,  in  an  article  on  the 
Treatment  of  Intestinal  Affections,  says :  "Remove  the  cause ; 
repair  the  damage."  As  we  become  better  acquainted  with 
the  germ  theory  of  diseases  so  does  this  motto  become  a  better 


guide.  We  cannot  always  follow  its  teachings.  Often  before 
we  know  the  enemy  is  present,  serious  damage  has  been  done. 
Then  the  work  of  repair  is  accomplished  only  with  great  diffi- 
culty. Happily  this  is  not  always  the  case.  When  the 
invading  enemy  is  within  reach  of  our  modern  antiseptics 
we  can  often  completely  destroy  it,  and  that,  too,  even  before 
serious  damage  has  been  done.  But  no  matter  how  slight 
the  injury,  it  is  often  associated  with  such  a  disturbance  of  the 
nervous  system,  due  to  peripheral  irritation  or  to  the  absorption 
of  the  poisonousgerm  products,  that  pain,  more  or  less  acute, 
is  produced.  While  this  pain  lasts  the  system  is  in  no  con- 
dition to  recuperate.  The  nervous  irritation  must  be  relieved 
for  a  speedy  recovery  to  take  place. 

Now,  in  the  case  of  Affections  of  the  Gastro-Intestinal  Tract, 
have  we  a  drug  which  can  be  safely  taken  internally,  that  will 
destroy  pathogenic  germs  ?  We  believe  such  a  remedy  exists 
in  salol.    Hare  says,  "it  is  worthy  of  note  that  this  drag  rarely 

S reduces  untoward  effects."  He  says  further  that  salol  "is  of 
le  greatest  value  in  duodenal  catarrh  and  catarrhal  jaundice." 
And  he  further  adds  it  is  "of  great  value  in  disorders  of  the 
intestine.  Indeed,  there  is  no  remedy  which  can  exert  the 
same  power  for  good  in  cases  of  intestinal  indigestion  and 
fermentation."  He  further  adds  that  "it  renders  the  intesti- 
nal canal  antiseptic,  and  so  removes  the  cause  of  the  disorder, 
instead  of  locking  the  putrid  material  in  the  bowel,  as  does 
opium."  He  regards  salol  "as  one  of  the  most  valued  drugs  in 
the  treatment  of  intestinal  affections."  We  may  set  it  down, 
therefore,  as  set  forth  by  this  eminent  authority,  that  salol  will 
remove  the  cause  of  the  great  majority  of  the  diseases  of  the 
digestive  tract.  What  other  remedy  nave  we.  than  opium, 
which  will  quiet  the  nervous  system  and  control  the  pain ;  which 
will  not  lock  up  the  secretions  of  the  body  or  produce  the  un- 
desirable symptoms  following  that  drug?  Such  a  remedy  is 
found  in  the  new  coal-tar  product,  antikamnia.  It  would  ap- 
pear, therefore^  that  a  combination  of  these  two  remedies,  salol 
and  antikamnia,  is  exactly  indicated  in  the  large  class  of 
intestinal  disorders,  in  order  that  the  cause  may  be  removed 
and  the  damage  repaired.  We  need  not  enumerate  these 
affections  in  detail;  for  such  ailments  as  duodenal  catarrh, 
catarrhal  jaundice,  fermentative  dyspepsia,  diarrhoea,  dysen- 
tery, cholera,  cholera  infantum,  typhoid  fever,  diarrhoea  of 
phthisis,  etc.,  etc.,  at  once  occur  to  the  mind  of  each  practi- 
tioner. "Antikamnia  and  Salol  Tablets, "  containing  2  >£  grains 
of  each  antikamnia  and  salol,  offer  the  best  vehicle  for  exhibit- 
ing this  combination,  giving  one  every  two  or  three  hours. 


The  D1TTRICH  OZONB  PREPARATIONS  are 
Genuine.— Volume  per  cent  of  Osone  established  by  analysts  of  big* 
ohfflmlftfcl  authority  and  warranted.    Sale,  and  easy  of  administration  and 
application  to  both  children  and  adults. 
▲QUZON,  osonlsed,  dlitilled,  and  sterilised  water,  containing  •  Tola,  per 

oent.  of  Osone. 
KODOZOlf  OL,  oBonlied  ood-ttrer  oil.  6  toIs.  per  cent,  of  Osone. 
THBaiPOL.  osonlsed  regetable  oil,  8  vols,  per  cent  of  Osone. 
KBEOZONOL.  osonlsed  oU  of  tar,  10  vols,  per  cent,  of  Osone. 
▲  JSfKOZOL,  osonlsed  essential  oils,  75  vols,  per  oent  of  Osone. 
OZOIf  IZHI>  CRJSOSOTB,  In  capsules,  containing  4  or  t  minims  of 

pure  osonlsed  creosote. 
•SON IB  MACHINES.    For  pb jsldans'  use. 
These  Osone  preparations  and  machines  are  referred  to  In  the  following 

Kbllcattons:  «fThe  Internal  Administration  of  Osone  to  the  Treattnentpf 
thlsls"  by  Dr.  H.  8.  Norris.  New  York.  M Osone  in  Diphtheria,"  by  Dr. 
Irving  S.  Haynes,  New  York.  •'  Osone  in  Atrophic  Catarrh£_ by  Dr.  CUurenoe 
O.  Rice,  New  York.  "  Osone  and  Its  Uses  In  Medicine."  by  Dr.  W.  J.  Morton, 
New  York.  "  The  Therapeutic  Value  of  Inhalations  of  Osone,"  by  Dr.  August 
GsUle,  New  York. 

CUntoal  reports  upon  appHoatUm, 

THE   OZONE    COMPANY, 

lew  T«rk0flee,lttlait88d  Stmt.  ftiotfo  Offloe,  mitt  1115,  XaMme  IwaW. 


KUTNOW'S 

MPROVED  EFFERVESCENT  CMUSND  POWDER, 

a  pleasant  and  effective  rem- 
edy for  Indigestion,  Con- 
stipation, Acid  Dyspepsia, 
Gout,  Diabetes,  and  Liver 
Derangements. 

KUTNOW  BROS., 

52-54:  Lafayette  ttaee, 

nwToix 
Advertised  to  the  Profee- 

orDtrLeaisOaiissaft  fiion  Only. 

In  prescribing  kindly  use  the  name  KUTNOW 
to  avoid  all  chance  of  error  on  the  part  of  Druggists. 


Important  Notice  to  Member*  of  the  Medical  Profession  in  the  United  States  and  Canada. 


THE  LANCET. 

%  gtnxtml  tt  Irittrt  **&  <#mig»  P*4irittt,  gkgrtrf- 
(txitMm,  kvA  Jgm$. 

(ENGLISH  EDITION,  IMPORTED  WEEKLY  AS  ISSUED.) 


Messrs.  WM.  WOOD  &  CO.,  having  made  special 
menu  for  a  large  weekly  supply  of  this  Journal,  are  now  prepared  t» 
forward  Copies  of  the  same  to  any  part  of  the  United  States  or  Canada 
at  a  considerably  reduced  rate  of  Subscription — f&oo  per  Annua, 
invariably  in  advance,  including  postage.  No  subscriptions  con- 
tinued beyond  the  dates  paid  for. 

THE  LANCET  (founded  in  1823)  is  the  original  and  leadiag 
Medical  Journal  in  Great  Britain. 


Terms  of  Subscription— #8.00  per  Annum  in  Advance.    Thick  Paper  Edition. 

ORDERS  AKD  SUBSCRIPTIONS  TO 

WILLIAM  WOOD  &  COMPANY,  43.  45  and  47  East  10th  Street,  New  York. 


MEDICAL  RECORD. 


ii 


NATIONAL   AND    STATE 
MEDICAL    SOCIETIES    OF   AMERICA. 


NATIONAL. 


AMERICAN  ASSOCIATION  OF  GENITOURINARY 
SURGEONS. 
Annual  Meeting  at  Niagara  Palls,  last  week  in  May,  1890. 
Wm.  K.  Ona,  MD.,  Bee,  L.  Bolton  Bangs,  M.D.,  Prest, 

6  West  60th  St.,  New  York  City.  31  East  44th  St ,  New  York  City. 

AMERICAN   ASSOCIATION    OP   OBSTETRICIANS  AND 
GYNECOLOGISTS. 
Annual  Meeting  at 
William  Warbsn  Potter,  M.D.,  Sec,       J.  Henry  Carstenb,  M.D.,  Preat., 
284  Franklin  St.,  Buffalo,  N.  Y.  Detroit.  Mich. 

AMERICAN    ACADEMY    OF    MEDICINE. 

Annual  Meetlug  at  Baltimore,  May  4  and  6, 1895. 

Charles  MoIntibs,  M.D.,  Sec,  J.  McFaddkn  Gaston,  M.D.,  Preat., 

JBaston,  Pa.  Atlanta,  Ga. 

ASSOCIATION  OF  AMERICAN  PHYSICIANS. 
Annual  Meeting  at  Washington,  D.  C.  May  88, 89  and  30, 1805. 
Henry  Hun,  M.D.,  See.  William  Osleb,  M.D.,  Preet., 

149  Washington  Aye.,  Albany,  N.  Y.       l  W.  Franklin  St.,  Baltimore,  Md. 

ASSOCIATION    OF    ACTING    ASSISTANT    SURGEONS    OF 

THE  U.  S.  ARMY. 

Annual  Meeting  appointed  by  the  President. 

W.  Thornton  Parker,  M.D..  Recorder,       Daniel  Smith  Lamb,  M.D.,  Prest, 

Grooveland.  Mass.  Washington,  D.  C. 

AMERICAN    DERMATOLOGICAL    ASSOCIATION. 
Annual  Meeting  at  Montreal,  Can.,  about  Sept.  16, 1895. 
Charles  W.  Allen,  M.D.,  Sec.,         Samuel  Sherwell.  M.D.,  Preet., 

640 Madison  Aye.,  N.  Y.  City.         83  Schermerhorn  St.,  Brooklyn,  N.  Y. 

AMERICAN    GYNECOLOGICAL    SOCIETY. 
Annual  Meeting  at  Washington,  D.  C,  May  88, 1896. 
Henrt  C.  Cob,  M.D.,  Sec.,  Matthew  D.  Mann,  M.D.,  Prest, 

ST  E.  54th  St.,  New  York  City.  Buffalo,  N.  Y. 

AMERICAN    MEDICAL   ASSOCIATION. 
Annual  Meeting  at  Baltimore,  May  7, 1896. 
W.  B.  Atkinson,  M.D.,  8ec.,  Donald  Maclean,  M.D.,  Preat., 

1400  Pine  St.,  Philadelphia,  Pa.  Detroit,  Mich. 

AMERICAN  NEUROLOGICAL  ASSOCIATION. 
Annual  Meeting  at  Boston. 
Graeme  M.  Hammond,  M.D.,  Sec ,      Philip  Ooombb  Knapp,  M.D.,  Prest., 

58  W.  46th  St.,  New  York  City.  Boston,  Mass. 

AMERICAN    LARYNGOLOGICAL  ASSOCIATION. 
Annual  Meeting  at  Rochester,  N.  Y.,  May,  1895. 
Chas.  H.  Knight.  M.D.,  Sec,  John  O.  Rob,  M.D.,  Prest, 

147  West  57th  St.,  New  York  City.  Rochester,  N.  Y. 

AMERICAN  OPHTHALMOLOGICAL  SOCIETY. 
Annual  Meeting  at  New  London,  Conn.,  July  84, 1895. 
&  B.  St.  John,  M.D.,  Sec.,  Geo.  C.  Harlan,  M.D.,  Prest., 

84  Pratt  St.,  Hartford,  Conn.  Philadelphia,  Pa. 


THE  AMERICAN    ORTHOPEDIC  ASSOCIATION. 
Annual  Meeting  at  Chicago,  September  19, 80  and  91, 1896. 
Rotal  Whitman,  M.D.,  Sec.,  John  Ridlon,  M.D.,  Prest, 

186  West  59th  St.,  New  York  City.  log  state  St. ,  Chicago,  111. 

AMERICAN  ELECTRO  THERAPEUTIC  ASSOCIATION. 
Annual  Meeting  at  Toronto,  Can.,  first  week  of  September,  1896. 
Emil  Heuel,  M.D.,  Sec,,  A.  L.  Smith,  M.D.,  Prest, 

369  Willis  Ave.,  New  York  City.  Montreal,  Can. 

CANADIAN  MEDICAL  ASSOCIATION. 
Annual  Meeting  at  Kingston,  Ont,  August  88,  89  and  80, 1695. 
F.  N.  G.  Starr,  M.D.,  Sec.,  William  Bayard,  M.D.,  Prest., 

894  Markham  St,  Toronto,  Ont  St  John,  N.  B. 

THE    MEDICO-LEGAL    SOCIETY. 

Annual  Meeting  at  New  York,  Dec.  18. 1894. 

Meets  second  Wednesday  each  month  (except  July  and  August)  at  Academy 

of  Medicine. 
Clark  Bell.  Bsq.,  Sec,  H.  W.  Mitchell,  M.D.,  Prest.. 

New  York,  N.  Y.  New  York,  N.  Y. 

THE  ASSOCIATION    OF   MILITARY    SURGEONS 

OF  THE  UNITED  STATES. 

Annual  Meeting  at  Buffalo,  May  31,  88  and  83, 1896. 

Bustathiub  Chancellor,  M.D.,  Sec.,    8urg.Gen  Geo.  M.  Sternberg,  Prest, 

515  Olive  St,  St  Louis.  Mo.  Washington,  D.  C 

NATIONAL  ASSOCIATION  OF  RAILWAY  SURGEONS. 

Annual  Meeting  at  Chicago. 

Jab.  M.  Dinnen,  M.D.,  Sec.,  S.  3.  Thorn,  M.D ,  Prest, 

Fort  Wayne,  In<L  Toledo.  Ohio. 

AMERICAN  PEDIATRIC  SOCIETY. 
Annual  Meeting  at  Hot  Springs,  Va.,  last  week  in  May,  1896. 
Samuel  8.  Adams,  M.D.,  Sec.,  F.  Fobcbheimrr,  M.D.,  Prest., 

1639  K  St.,  N.  W.  Washington,  D.  C.  Cincinnati,  Ohio. 

ARMY  AND  NATY  MEDICAL  ASSOCIATION. 
Annual  Meeting  at  Decatur,  111.,  May.  1896. 
Edward  P.  Bartlett.  M.D.,  Sec.,  E.  P.  Cook,  M.D.,  Prest, 

Springfield.  111.  Mendota,  IB. 

TRI-STATE  MEDICAL  SOCIETY. 
Annual  Meeting  at  St.  Louis,  Mo.,  April  8,  8  and  4, 1896. 
Frank  P.  Norbubt,  M.D.,  Sec.,         Jambs  Mooreb  Ball,  M.D.,  Prest, 
Hoffman  Fld'g,  Jacksonville,  HI.  810  Olive  St.,  St  Louis,  Mo. 

MISSISSIPPI  VALLEY  MEDICAL  ASSOCIATION. 
Annual  Meeting  at  Hot  Springs,  Ark.,  Not.  80,  81,  89  and  88, 1894. 
F.  C.  Woodburn,  M.D.,  Sec,  X.  C.  Soott,  M.D.,  Prest.. 

Indianapolis,  Ind.  Cleveland,  Ohio. 

MEDICAL  SOCIETY  OF  THE  MISSOURI  VALLEY. 
Annual  Meeting  at  Council  Bluffs,  la.,  September  19, 1895. 
Spring  Meeting— Migratory-  3d  Thursday  in  March. 
F.  S.  Thomas,  M.D.,  Sea,  A.  F.  Jonas,  M.D.,  Prest., 

Council  Bluffs,  la.  Omaha,  Neb. 


STATE. 


MEDICAL  ASSOCIATION  OF  THE   STATE   OF   ALABAMA. 

Annual  Meeting  at  Mobile,  April  16  to  19, 1895. 
Jambs  Reid  Jordan,  M.D. ,  Sec.,   Richard  Matthew  Fletcher,  M.D.,  Prest., 
Montgomery,  Ala.  Madison,  Ala. 

THE   ARKANSAS    MEDICAL    SOCIETY. 
Annual  Meeting  at  Little  Rock,  May  1, 1895. 
L.  P.  Gibson,  M.D..  Sec,  A.  C.  Jordan,  M.D.,  Prest, 

Little  Rock,  Ark.  Pine  Bluff,  Ark. 

CONNECTICUT    MEDICAL    SOCIETY. 
Annual  Meeting  at  New  Haven,  May  1, 1895. 
N.  R.  WORDIN,  M.D.,  Sec.,  Francis  N.  Braman,  M.D.,  Prest, 

174  Fairfield  Ave. ,  Bridgeport  Conn.  New  London,  Conn. 

THE  MEDICAL  SOCIETY  OF  THE  STATE  OF  CALIFORNIA. 

Annual  Meeting  at  San  Francisco,  April  16, 1895. 
Wm.  Watt  Kerr,  M.D.,  Sec,  G.  L.  Simmons,  M.D.,  Prest., 

688  Sutter  St.,  San  Francisco,  Cat  Sacramento,  Cal. 

COLORADO    STATE    MEDICAL    SOCIETY. 
Annual  Meeting  at  Denver,  June  18, 19  and  80, 1896. 
Caret  Kennedy  Fleming.  M.D.,  Sec,     Hubert  Work,  M.D.,  Prest., 

Denver,  CoL  Pueblo,  Col. 


MEDICAL  ASSOCIATION,  DISTRICT  OF  COLUMBIA. 

8eml-Annual  Meeting  at  Washington,  April  8, 1896. 
James  D.  Morgan,  M.D.,  Sec,  George  B.  Harrison,  M.D.,  Prest, 

919 15th  St,  N.  W.,  Washington,  D.C.    60S  14th  St.,  N.  W.,  Washington,  D.C. 

MEDICAL    SOCIETY    OF    DELAWARE. 
Annual  Meeting  at  Wilmington,  June  11, 1896. 
Wm.  C.  Pierce,  MD.,  Sec,  Frank  Bbllyillb,  M.D.,  Prest, 

887  Washington  St,  Wilmington,  DeL  Delaware  City,  Del. 

FLORIDA    STATE    MEDICAL    SOCIETY. 
Annual  Meeting  at  Gainesville,  April  16, 1895. 
J.  D.  Fbrnandiz,  M.D.,  Sec,  J.  D.  Rush,  M.D.,  Prest, 

Jacksonville,  Fla.  Apalachicola,  Fla. 

THE   MEDICAL   ASSOCIATION    OF    GEORGIA. 
Annual  Meeting  at  Savannah,  April  18, 19  and  80, 1895. 
Dan.  H.  Howell,  M.D.,  Sec,     Willis  F.  Westmoreland,  M.D.,  Prest, 

Atlanta,  Ga.  Atlanta,  Ga. 

ILLINOIS  STATE  MEDICAL  SOCIETY. 
Annual  Meeting  at  Springfield,  111.,  May  14, 15  and  16, 1S96. 
John  B.  Hamilton,  M.D.,  Sec,  Daniel  R.  Browbr,  M.D.,  Prest, 

Room  80  p.  O.  Building,  Chicago,  III.  Chicago,  R]. 


12 


MEDICAL  RECORD. 


NATIONAL    AND    STATE 
MEDICAL    SOCIETIES    OF   AMERICA. 


STATE— CONTINUED. 


INDIANA  STATE  MEDICAL  SOCIETY. 


IOWA  STATE  MEDICAL  SOCIETY. 

Annual  Meeting  at  Creston,  April  IT,  1896. 
J.  W.  Coksnowkr,  M.D.,  Sec.,  A.  L.  W bight,  M.D.,  Prest., 

Dee  Moines,  la.  Carroll,  la. 

INDIAN    TERRITORY   MEDICAL   ASSOCIATION. 

Semi-annual  Meeting  at  Wagoner,  December  18,  18M. 
Q.  R.  Ruoker,  M.D.,  Sec,  Mklvin  C.  Masks,  M.D.,  Prest., 

Olaremore,  Ind.  Ter.  Claremore.  Ind.  Ter. 

IDAHO  STATE  MEDICAL  SOCIETY. 
Annual  Meeting  at  Boise  City,  Sept.  9, 10  and  11, 1896. 
C.  L.  Sweet,  M.D.,  Sea  and  Treas.,  I.  H.  Moors,  M.D.,  Prest., 

Boise,  Idaho.  Pooatello,  Idaho. 

KANSAS    MEDICAL    SOCIETY. 
Annual  Meeting  at  Topeka,  May,  1896. 
Q.  A.  Wall,  M.D.,  Sec.,  H.  &  Priest,  M.D.,  Prest., 

Topeka,  Kan.  Concordia,  Kan. 

KENTUCKY    STATE    MEDICAL    SOCIETY. 
Annual  Meeting  at  Harrodsburgh.  June  6, 1896. 
Steele  Bailey,  M.D.,  Sec.,  J.  B.  Martin,  M.D.,  Prest, 

Stanford,  Ky.  Louisville.  Ky. 

THE  LOUISIANA  STATE  MEDICAL  SOCIETY. 
Annual  Meeting  at  New  Orleans,  May  T,  1896. 
P.  B.  MoCutohon,  M  D.,  Sec.,  R.  Matas,  M.D.,  Prest., 

669  Prytanla  St.,  New  Orleans,  La.     TB  South  Ramport  St.,  New  Orleans,  La. 

MAINE   MEDICAL    ASSOCIATION 
Annual  Meeting  at  Portland,  June  6, 1896. 
Chas.  D.  Smith,  M.D.,  Sec.,  W.  P.  Giddings,  M.D.,  Prest.. 

1S6  Free  St.,  Portland,  Me.  Gardiner,  Me. 

MEDICAL  AND  CHIRURGIOAL  FACULTY  OF  MARYLAND. 

Annual  Meeting  at  Baltimore,  April  98, 1896. 
Jas.  M.  Craighill,  M.D.,  See,  Robert  W.  Johnson,  M.D.,  Prest, 

1780  N.  Charles  St,  Baltimore,  Md.         101  W.  Franklin  St.  Baltimore,  Md. 

MASSACHUSETTS  MEDICAL  SOCIETY. 
Annual  Meeting  at  Boston,  June  11  and  19, 1896. 

F.  W.  Goes,  M.D.,  Sec.,  F.  K.  Paddock,  M.D.,  Prest., 

Roxbury,  Mass.  Pittafleld,  Mass. 

MICHIGAN  STATE   MEDICAL  SOCIETY. 
Annual  Meeting  at  Bay  City,  first  week  In  June,  1896. 
Chas.  W.  Hitchcock,  M.D.,  Sec.,  Henry  O.  Walker,  M.D.,  Preit, 

99  Henry  St.,  Detroit,  Mich.  Detroit  Mich. 

MINNESOTA  STATE  MEDICAL  SOCIETY. 
Annual  Meeting  at  St  Paul,  June  90,  91  and  99,  1894. 
Chas.  B.  Witherle,  M.D.,  Sec.,  W.  J.  Mayo,  M.D.,  Prest, 

Bndicott  Arcade  Bldg.,  St  Paul,  Minn.  Rochester,  Minn. 

MISSISSIPPI    STATE   MEDICAL    ASSOCIATION. 
Annual  Meeting  at  Jackson,  ApxU  10, 1896. 
H.  H.  Haralson,  M.D.,  Sea,  P.  W.  Rowland,  M.D..  Prest., 

Forest  Miss.  Coffeevllle.  Miss. 

MISSOUBI  STATE  MEDICAL  ASSOCIATION. 
Annual  Meeting  at  Hannibal,  May  91, 1896. 
Frank  R.  Fry,  M.D.,  Sea,  J.  M.  Richmond,  M.D.,  Prest, 

8188  Pine  St.,  St.  Louis,  Mo.  St  Joseph.  Mo. 

MEDICAL  ASSOCIATION  OF  MONTANA. 
Annual  Meeting  at  Anaconda,  April,  1896. 
W.  M.  Bullard,  M.D.,  Sea.  Geo.  W.  Kino,  M.D.,  Prest., 

Helena,  Mont.  Marysville,  Mont. 

NEW  HAMPSHIRE  MEDICAL  SOCIETY. 
Annual  Meeting  at  Concord,  May  80  and  81, 1895. 

G.  P.  Conn,  M.D.,  Sec ,  David  P.  Goodhue,  M.D.,  Prest., 

Concord,  N.  H.  Springfield,  N.  H. 

NEW  YORK  STATE  MEDICAL  ASSOCIATION. 
Annual  Meeting  at  New  York,  October  16, 16  and  IT,  1896. 
R.  D.  Ferguson,  MD,  Sec.,  Thomas D.  Strong, M.D.,  Prest, 

Troy,  N.  T.  Westfleld,  Chautauqua  Co.,  N.  Y. 

THE  MEDICAL  SOCIETY  OF   THE  STATE  OF  NEW  YORK. 

Annual  Meeting  at  Albany,  Feb.  6, 1895. 
F.  C.  Curtis,  M.D.,  Sec.  George  H.  Fox,  M.D.,  Prest., 

17  Washington  Aye.,  Albany,  N.  Y.  18  R.  81st  St,  New  York  City. 


MEDICAL  SOCIETY  OP  NEW  JERSEY. 
Annual  Meeting  at  Cape  May,  June  95  and  96, 1896. 
William  Pierson,  M  D.,  Sec,  O.  H.  Sproul,  M.D.,  Prest., 

Orange,  N.  J.  Flemlngton,  N.  J. 

NEBRASKA  STATE  MEDICAL  SOCIETY. 

Annual  Meeting  at  Grand  Island.  May,  1895. 

Geo.  Wilkinson,  M.D.,  Sec,         Hamilton  B.  Lowry,  M.D.,  Prest, 

Omaha,  Neb.  Lincoln.  Neb. 

MEDICAL  SOCIETY  OP  THE  STATE  OP  NORTH  CAROLINA. 

Annual  Meeting  at  Goldsboro,  May  14, 16  and  16, 1896. 
Robert  D.  Jbwett,  M.D.,  Sec,  John  H.  Tucker,  M.D.,  Prest., 

Wilmington,  N.  C.  Henderson,  N.  a 

NEW  MEXICO  MEDICAL  SOCIETY. 
Annual  Meeting  at  Las  Vegas.  July  10. 1896. 
Francis  H.  Atkins,  M.D..  Sec,  G.  W.  Harrison,  M.D.,  Prest., 

East  Las  Vegas,  New  Mez.  Albuquerque,  New  Mez. 

THE  OHIO  STATE  MEDICAL  SOCIETY. 
Annual  Meeting  at  Columbus,  May  15, 16  and  17, 1895. 
Thos. Hubbard,  MD ,  Sec,  D.  N.  Kinsman, M.D., Prest, 

Toledo,  Ohio.  Columbus,  Ohio. 

OREGON  STATE  MEDICAL  SOCIETY. 
Annual  Meeting  at  Portland,  June,  1895. 

F.  Cauthorn,  M.  D.,  Sec,  J.  A.  Fulton,  M.D.,  Prest., 

Portland,  Ore.  Astoria,  Ore. 

ONTARIO  MEDICAL  ASSOCIATION. 
Annual  Meeting  at  Toronto,  June  5  and  6, 1896. 
J.  N.  R.  Brown,  M.D.,  Sec.  R.  W.  Bruce  Smith,  M.D.,  Prest, 

659  Church  Street,  Toronto,  Canada.  Seaforth,  Ontario,  Canada. 

THE  STATE  MEDICAL  SOCIETY  OP  PENNSYLVANIA. 
Annual  Meeting  at  Chambeniburg,  May  si,  1895. 
Wm.  B.  Atkinson,  M.D..  Sea,  John  B.  Roberts,  M.D.,  Prest, 

1400  Pine  St,  Philadelphia,  Pa.  Philadelphia,  Pa, 

RHODE  ISLAND  MEDICAL  SOCIETY. 
Annual  Meeting  at  Providence,  June  6, 1896. 
William  R.  White,  M.D. ,  Sec. ,  Robert  F.  Notes,  M.D.,  Prest, 

Providence,  R.  L  Providence,  R.  I. 

SOUTH  DAKOTA  STATE  MEDICAL  SOCIETY. 
Annual  Meeting 

W.  J.  Mattum.  M.D.,  Sec.  and  Treas.  R.  T.  DOTT,  MD.,  Prest 

Alexandria,  80.  Dak.  Alexandria,  So.  Dak. 

SOUTH  CAROLINA  MEDICAL  ASSOCIATION. 
Annual  Meeting  at  Columbia,  April  94, 1896. 

Thomas  J.  McKie,  M.D.,  Sea,  Edward  F.  Parker,  M.D.,  Prest, 

Woodlawn,  8.  C.  Charleston,  S.  a 

TENNESSEE  STATE  MEDICAL  SOCIETY. 
Annual  Meeting  at  Nashville,  April  9, 1896. 
S.  8.  Crockett,  M.D.,  Sec,  F.  L.  Sim,  M.D.,  Presto 

Nashville,  Tenn.  Memphis,  Tenn. 

THE  TEXAS   STATE  MEDICAL  ASSOCIATION. 

Annual  Meeting  at  Dallas,  April  94, 1895. 
H.  A.  West,  M.D.,  Sec,  J.  W.  McLaughlin,  M.D.,  Prest. 

Galveston,  Texas.  Austin,  Texas. 

VERMONT  STATE  MEDICAL  SOCIETY. 
Annual  Meeting  at  Burlington,  October  10  and  11. 1896. 
D.  C.  Hawlet,  M.D.,  Sec,  A.  B.  Bibber,  M.D..  Prest, 

Burlington,  Vt  Montpelier,  Vt 

MEDICAL  SOCIETY  OP  VIRGINIA. 
Annual  Meeting  at  Wythevllle.  Va.,  October,  1896. 
J.  F.  Winn,  M JD.,  Corresponding  Sec,   Robert  J.  Preston,  M.D.,  Prest, 

Richmond,  Va.  Marlon,  Va. 

THE  WASHINGTON  STATE  MEDICAL  SOCIETY. 
Annual  Meeting  at  Seattle,  May,  ISM. 
R.  L.  Thomson,  M.D.,  Sec,  Darius  Mason,  M.D.,  Prest , 

Spokane,  Wash.  Spokane,  Wash. 

THE  WISCONSIN  STATE  MEDICAL  SOCIETY. 
Annual  Meeting  at  West  Superior,  June  5,  6  and  7, 1896. 
Charles  S.  Sheldon,  M.D.,  Sea,  Almon  R  Clarke,  M.D.,  Prest, 

Madison.  Wis.  Sheboygan,  Wte. 

THE  MEDICAL  SOCIETY  OF  WEST  VIRGINIA. 
Annual  Meeting  at  Rlklns,  Jury,  1895. 

G.  A.  Asohman,  M.D.,  Sec,  D.  Mater,  M.D.,  Prest. 

Wheeling,  W.  Va.  .Charleston,  W.  Va 


Societies  not  found  in  this  list  have  not  responded  to  our  request  for  information. 


MEDICAL  RECORD. 


13 


^ 


JMflM 

COCA  WINE. 

A.  New   Liquid    Preparation. 


BACH  FLUID  OUNCE  CONTAINS 


ERYTHROXYLON  COCA, 


30  GRAINS. 


<y 


Please  mention  this  Journal. 


Owing  to  the  great  diastasic  strength  of  Maltine,  there  will  be  found  in  a  dose 
of  "Maltine  with  Coca  Wine"  (notwithstanding  that  it  contains  only  40%  of  Maltine), 
diastase  enough  to  convert  more  starch  than  can  be  converted  by  a  dose  of  any  unat- 
tenuated  extract  of  malt  now  made,  whether  dry  or  semi-liquid.  It  should  be  borne  in  mind 
that  the  employment  of  wheat  and  oats,  in  addition  to  malted  barley  in  its  preparation,  has 
raised  Maltine  far  above  the  level  of  a  mere  extract  of  malt,  and  has  placed  it,  in  the  almost 
unanimous  estimation  of  the  medical  profession,  in  the  front  rank  of  food  products  as  well 
as  digestive  agents. 

We  will  send  to  any  physician,  who  will  pay  expressage,  an  eight-ounce  bottle  of 
"  Maltine  with  Coca  Wine  '  and  an  eight-ounce  bottle  of  any  other  preparation  selected  from 
our  list. 

THE   MALTINE  MANUFACTURING  CO., 

168  Duane  Street,  New  York  City. 


* 


FOB 

WateMnstrnments, 
Ditiiings,  Towels, 

or  anything  required 
during  an  operation. 

All  Copper, 

with  removable 
jackets,  permitting 
cleansing.  Complete 
with  gas  buxnera. 

Send  for  Circular. 


MAX  WOCHER  &  SON, 

Surgical  Instrument  Makers, 

OFFICE  AND  HOSPITAL  FUKNirUBE,  ORTHOPEDIC  APPLIANCES, 
105  West  Sixth  Street,      -      Cincinnati,  O. 

DOCTOR,  NOTICE  THESE  PRICES! 

Hiek'B  Thermometer,  Bnbber  Case,  guaranteed $1.00 

Hiek's  Thermometer,  Sterling  Sliver  Case  and  Chain 3.50 

Hick's  Thermometer,  Lens  Front,  Certified 1.60 

Blegant  Aluminum  Case  Hypodermic  Syringe,  with  Finger  Rests  and 

Expanding  Plunger 8  00 

Grave's  Bivalve  Speculum,  Nickel-plated 1.10 

Coin  Silver  Probes 85 

H ypodermio  Needles,  flt  any  Syringe. SO 

Any  of  above  sent,  post-paid,  on  receipt  of  price.   Money  refunded  if  not  as 
represented.    PHYSICIANS'  SPECIALTY  CO.,  P.O.  Box  8818,  N. Y.  City. 

Pictures  for  Physicians'  Offices  and  Libraries. 

Send  far  illustrated  Catmloffue, 
WM.  WOOD  A  CO.,  NEW  YORK. 


^rethusa 


SPRINO 


THE  PUREST 

OF 

TABLE  WATERS. 

Contains  but  i#  grains  of  solid    ?  . 
material  in  58239  grains.      -        ^*^ 

NITRATES 
AND  ORGANIC  MATERIAL  | 
ABSENT. 

VK      Analysis  by  PSOF.  CmTTKNDKN. 

SAMPLE  BOTTLES 

Sent  free  of  expense  to  any  physician  of  good  standing. 


/^rethuaa    *)prilig  ^^ater  Qo., 

SEYMOUR,  CONN. 


14  MEDICAL  RECORD. 


CALCULI  DISSOLVED 

By  the  Buffalo  Lithia  Water 

MIAUII     UCDQCDT    PI  AIDflDIIC     of  Petarrirawr,  Va.,  ex-President  end  Honorary  FeUow  Media* 
.  junn  ntnotni  luuDunnt,  8o^iety  of  rirgMa>  ^  a  fetor>  dated  SepUmber  8j  189a^  to 

Dr.  E.  0.  Laird,  Besident  Physician  at  the  Buffalo  Lithia  Springs,  Bay*: — 
"I  send  by  this  mail  a  bos  of  Calculi,  passed  at  various  times  within  the 
last  year  by  Hon.  T.  J.  Jarratt,  our  former  Mayor,  whilst  drinking  the 
Buffalo  Lithia  Water.  They  give  him  but  little  pain  now  when  passing.  I 
have  never  critically  examined  the  broken  Calculi  passed  in  such  quantities 
from  Mr.  Jarratt' a  bladder,  but  am  under  the  impression  that  the  most  of 
them  are  magnesian  phosphates.  There  were  specimens,  however,  which 
presented  the  appearanoe  of  oxylates,  and  some,  I  remember,  impressed  me 
specially  as  being  uric  acid.  I  do  not  pretend  to  account  for  the  mode  of 
their  solution  by  the  Buffalo  Lithia  Water.  There  is  nothing  in  its  analysis 
which  would  warrant  such  results ;  but  the  results  are  there,  and  seeing  is 
believing.  I  can  only  suppose  that  in  Nature's  alembic  there  has  been  sosse 
subtle  solvent  evolved,  too  subtle  to  be  caught  by  our  coarse  re-agents, 
which  makes  this  wonderful  disintegration.      'There  are  many  things  in 

heaven  and  earth  not  dreamt  of  in  our  philosophy/  and  his  is  a  short  creed 

IUiistrmdoii  of  the  Calculi  referred  to  by  Dr.  Clal-  ,  .    „ 

borne.  The  engraving  was  made  from  a  photograph      who  only  believes  what  he  can  prove  or  explain." 
and  represent!  the  exact  ahape  of  the  Calculi ;  thej 
are  four  times  Use  of  above. 


URIC  ACID  DIATHESIS 

Treatment  with  Buffalo  Lithia  Water 

By  eminent  physicians  as  follows; 

FIR  HIINTFR  MrPIIIRF  **JB:  "*n  Urio  Acid  Gravel,  and  indeed  in  diseases  generally  dependent  upon 
UP.  niin  I  tn  mUUUint  ^  Uric  Ao£d  pi^e^  Buffalo  Lithia  Water,  Spring  No.  2,  is  a  remedy  of 
extraordinary  potency.  I  have  prescribed  it  in  cases  of  Rheumatic  Gout,  which  had  resisted  the  ordinary  remedier, 
with  wonderfully  good  results.  I  have  used  it  also  in  my  own  case,  being  a  great  sufferer  from  this  malady,  and 
have  derived  more  benefit  from  it  than  from  any  other  remedy." 

Fir  J  T  I  PRI  ANPHARn  ProfeaBOr  Montreal  Clinic,  SM.,  SN.,  Y.U.  "I  have  used  Buffalo  Lithia 
Ul.    J.    I  .    LCDLUnUnHnU,    Water  ^  the  moBt  obgtinmte  ^^  of  Chronic  Inflammation  of  the  Bladder, 

in  Stone  of  the  Bladder,  in  Uric  Acid  Gravel,  with  the  most  efficacious  results." 

DR     WM     R     TOWLFS    ProfeMOr  of  Anatomy  and  Materia  Medica  in  the  Medioal  Department  of  the  UmV 


Yirginia.  "  Buffalo  lithia  Water,  Spring  No.  2,  has  proved  mr 
efficacious  in  many  diseased  conditions  than  any  of  the  simple  Alkaline  Waters.  I  feel  no  hesitancy  whatever  in  saying 
that  in  Gout,  Rheumatio  Gout,  Rheumatism,  Stone  in  the  Bladder,  and  in  all  diseases  of  Uric  Add  Diathesis,  I  know 
of  no  remedy  at  all  comparable  to  it.     Its  effects  are  marked  in  causing  a  disappearance  of  Albumen  from  the  Uiine." 

DR  HARVFY  I  RYRR  of  Baltimore>  President  and  Professor  of  Obstetrics  and  Diseases  of  Women  and 
Un.  nHniLI  L.  UinU,  children  ^  ^  Baltimore  Medical  College,  formerly  Professor  of  Practioal  Medicine, 
etc.  "  I  have  witnessed  the  best  results  from  the  action  of  the  Buffalo  Lithia  Water,  Spring  No.  2,  in  Chronic  Gout, 
Rheumatic  Gout,  Rheumatism,  Gravel  and  Stone  in  the  Bladder,  and  I  do  not  hesitate  to  express  the  opinion  that  in 
all  diseases  depending  upon  or  having  their  origin  in  Uric  Acid  Diathesis,  it  is  unsurpassed,  if  indeed  it  is  equaled,  by 
any  water  thus  far  known  to  the  Profession." 


Water  in  eases  of  one  dozen  half -gallon  bottles,  $5.00  f.  o.  ft.  here. 
Sold  by  all  first-class  Druggists 

THOS.  F.  GOODS,  Proprietor 

Buffalo  Lithia  Springs,  Va. 


MEDICAL  RECORD. 


IN  CHRONIC  ARTICULAR  RHEUMATISM, 

in  all  diseases  of  mucous  membranes,  and  pain  in  the  par- 
enchymatous organs*  which  were  formerly  called  rheuma- 
tism, and  attributed  to  cold,  or  for  which  no  other  cause 
has  been  found,  are  readily  relieved  by 


HENRY'S  TRI-IODIDES. 


I  ranORWI  IT  ANO  NKQUOfTlV  TMd  IT  MVMkT  FOR  •out.  O.  J.  RADEMAKER,  M.  O.,  LOUISVILLE,  KY. 


OF  nm  ALKALOIDS  tfr  Mtfr*  matfiMato  of: 

thjbtt  OBADfs  anew  oolchioSE 

TBHTTORAnra  FKTTOLAOA  DB0AXMU; 

TiJ?II-a5AI,!L?OLA1^7,l  ©UWJAMABA; 
AUD  TEN  ORAXV8  BAU0TLAT1  SODA 


RENZ  A  HENRY, 

OHEMI8T8, 
LOUI8VILLE.KY. 


DOSE-Om  < 


Sows  la  wtftw,  will  r* 
1Ut«  tS«  pals  of  ini, 
•rat*  or  ehreato  rfcrama. 
Um  lm  atz  boon. 


PROPRIETORS 

ELIXIR  THREE  CHLORIDES 

Ideal  Alterative-Teiiique. 


15 


U 


MOFERRU 


.BLOOD-IRON 


Is    Soluble,    Non-Styptic, 
Non-Irritating,  and 

Non-Constipating. 

It  Is  Haemoglobin  in  its  best  form,  viz.; 
OXYH/EHOOLOBIN. 

CLINICAL  EXPERIMENTS  HAVE  PROVEN  ITS  ~        A  M   A  C  KA  I  A 
GREAT    VALUE    IN  THE    TREATMENT   OF  fiWH  r\  C  IY|  I  f\  , 

CHLOROSIS,  AND  ALLIED  DISORDERS. 

For  literature,  samples,  and  farther  particulars,  address 

FREDERICK  STEARNS  &  CO.,  Detroit,  Mich. 
Third  Edition.   Revised  and  Enlarged. 
DISEASES  OF  THE 

CHEST,  THROAT,  AND  NASAL  CAVITIES, 

INCLUDING 

Physical  Diagnosis  and  Diseases  of  the  Lungs,  Heart,  and  Aorta,  Laryngology  and  Diseases  of  the 
Pharynx,  Larynx,  Nose,  Thyroid  Gland,  and  Oesophagus. 

By    E.    FLETCHER    INCALS,    A.M.,    M.D. 

Professor  ol  Laryngology  and  Practice  of  Medicine.  Rush  Medldal  College ;  Profeaaor  of  Diaeasea  of  Throat  and  Cheat,  Northwestern  University  Women* 

Medical  School ;  Profeaaor  of  Laryngology  and  Bhlnology,  Chloago  Polyclinic,  etc 


EXTRACT  PROM   PREFACE. 

I  have  not  discussed  questionable  theories,  and  have  not  referred  to  methods  of  treatment  which  do  not 
dtronglycommend  themselves  to  my  judgment. 

The  favor  with  which  the  preceding  edition  of  this  work  has  been  received  leads  me  to  believe  that  I 
have  succeeded  in  my  efforts,  not  only  to  aid  laryngologists  in  their  daily  work,  but  also  to  place  these  subjects 
clearly  before  students,  and  a  large  class  of  general  practitioners  who  of  necessity  must  be  prepared  to  meet 
any  emergency.  . 

PRESS  NOTICES  OF  THE  SECOND  EDITION. 


"  We  heartily  recommend  the  book  to  thoae  who  desire  to  become  thor- 
oughly acquainted  with  the  beat  literature  upon  diseases  affecting  the  re- 
spiratory tract"—  Therapeutic  QaseUe. 

"  An  excellent  book  of  reference  for  the  student  to  laryngology,  or  the 
practicing  physician,  and  is  essential  to  the  library  of  the  laryngoToelat." 
— Boston  Medical  and  Surgical  Journal. 

"  The  appendix  is  rich  in  therapeutic  formula)— valuable  alike  to  the  gen- 
eral practitioner  and  specialist— so  that  thla  Is  the  one  book  that  both  laryn- 
gologists, etc,  and  general  practitioners  should  have." 

—Virginia  Medical  Monthly. 


"  It  Is  the  work  of  a  specialist  along  broad  lines,  and  of  one  whose  ipeds> 
Ism  is  the  concentration  and  essence  of  jears  of  general  practice. 

"  The  volume  is  one  of  value  alike  to  the  special  and  general  worker,  and 
we  congratulate  Dr.  Ingals  upon  the  successful  accomplishment  of  a  con- 
fessedly difficult  work*- Medical  Record. 

"The  physical  signs  of  disease  occupy  the  most  prominent  place  and 
there  is  no  book  In  which  they  can  be  better  studied,  since  their  direct  con- 
nection In  the  text  with  the  description  of  the  other  features  of  disease  is 
calculated  to  give  the  student  a  more  complete  picture  than  he  would  get 
from  a  work  on  physical  diagnosis  alone"— Northwestern  Lancet. 


One  volume  octavo,  of  718  pages,  illustrated  by  244  wood-engravings  and  a  oolored  plate.    Muslin,  $5.00. 

WILLIAM   WOOD   &   COMPANY,  Publishers,  New  York. 


16 


MEDICAL  RECORD. 


How  Our. 


Glycerine  Suppositories 

Are  Made. 


Fl«,  t. 


Fl«.  t. 


We  first  make  a  Hollow  Shell  and  Cap  of  Pure  Cocoa  Butter  only — Fig.  1. 

We  then  fill  this  Cocoa  Batter  shell  with  Pure  Glycerine,  and  seal  it  with  the  cap,  thus  making  a  firm  smooth 
suppository,  containing  nothing  but  Pure  Cocoa  Butter  and  Pure'  Glyoerine,  the  Glycerine  being  in  Uqwdform — Fig.  2. 

This  Cocoa  Butter  shell  melts  at  the  temperature  of  the  body  and  liberates  the  Glycerine,  allowing  it  to  oome  in 
direct  contact  with  the  mucous  membrane. 

The  Glyoerine,  being  a  liquid,  is  free  to  distribute  itself  over  the  mucous  membrane,  stimulating  the  surfaces,  and 
soon  producing  an  easy  movement  of  the  bowels. 

The  Cocoa  Butter  is  softening  and  lubricating,  and  prevents  the  griping  that  sometimes  follows  the  use  of  Glyoerine 
In  the  rectum. 

Two  of  our  Suppositories,  separated  by  a  wafer,  are  packed  in  a  glass  vial — Fig.  3. 

Six  of  these  vials,  twelve  suppositories,  are  packed  in  a  wooden  box,  secure  against  breakage  or  deterioration. 

We  are  glad  to  send  samples,  without  charge,  on  application,  and  mention  of  the  Medical  Rvjokd. 

One  box,  twelve  Suppositories,  Fifty  Cents. 


HALL   &   RUCKEL,   Wholesale  Druggists, 


2I69  218  *  220  Greenwich  Street, 


NEW  YORK 


ARE  YOU   EDUCATED 

on  the  subject  of 
baths}  If  yon 
are  you  know 
that  a  porcelain- 
lined  bath  is  the 
best. 

Ours  is  the 
best    porcelain- 
lined  bath. 
If  you    are 

willing  to  take  one  said  to  be  just  as  good,  the  dealer  will  make  a  little 
more  on  it.  If  you  want  the  best,  see  that  "S.  M.  OO."  is  on  the  bot- 
tom ;  this  is  the  make  that  is  guaranteed. 


STANDARD   MFG.  CO., 

Box  1464  N,  -  -  PITTSBURG,  PA. 


OATAXjOGUB  free. 


DRUG  ERUPTIONS: 

A  Clinical  Stady  off  the  Irritant 
Effects  off  Drags  Upoa  the  Skin. 

By  PRINCE  A.  MORROW,  A.M.JILD., 

Clinical  Prof essor  of  venereal  Diseases ;  for- 
merly Clinical  Lecturer  on  Dermatology  in 
the  University  of  the  City  of  Hew  York :  Con- 
sulting 8urgeon  to  the  BeUerue  Out-Door 
Department;  Snnreon  to  Charity  Hospital. 
Dermatologlcal  Dlrision;  Member  or  the 
American  Dermatologies!  Association,  etc  . 

One  Volume.  Octavo.  204  Pages.  Illustrated 
with  one  Chromo-lithografhed  Plate.  Bound  m 
Fine  Muslim.    Price,  p. 7s 

WM.  WOOD  &  CO.,  Medical  PnMshers, 
43  to 47  B.  ie*hSC,  NEW  YORK. 


Diseases  of  the  Bladder 
and  Urethra  in  Women.  By 
Alexander  J.  C.  Skene,M.  D. 

Second  Edition,  Thoroughly  Revised. 

One  Volume.  Octavo,  38a  Pages.  MM.«.  *-*- 
Illustrated.    Fine  muslin  binding.      **"««.  •»*•• 

WM.  WOOD  &  CO.,  Publishers, 
43  to  47  East  toth  Street,     -     New  York. 


A    <TM&A/TIS»     ON 

BRIGHT'S  DISEASE  OF  THE  KIDNEYS. 

ITS  PATHOLOGY,  DIAGNOSIS,  AND  TREATMENT, 

With  Chapters  on  the  Anatomy  of  the  Kidney,  Albuminuria,  end  the  Urinary  8ecretion. 

By  HBNRY  B.  MILLARD,  M.A.,  M.D.9 

Felew  of  the  Academy  of  Medicine  of  New  York  and  of  the  American  Academy  of  Medicine ;  Foreign  Corresponding  Member  of  the  Academy  of  Medicine  of  Parishes* 

Third  Edition,  revised  and  enlarged.    Complete  in  one  volume,  octavo,  of  311  pages,  with  numerous  original  Illustrations,    Beautifully 

printed  on  heavy  paper  and  bound  in  imported  cloth.    Price,  fa.00. 

WILLIAM  WOOD  &  COMPANY,  Publishers.        -        -        -       43-  45  &  47  East  ioth  Street,  New  Y«»k. 


MEDICAL  RECORD. 


17 


RICHARD  KHY  &  CO.. 


17  Park  Placet  -  Few  York,  HT.  T., 


MANUFACTURERS  AND  DEALERS  DS 

Surgical  Instruments/ 


ASEPTIC  OPERATING 


—  AND  — 


Hospital  Furniture. 


Please  inspect  and  compare  before  buying. 


No.  16297 -HOSPITAL  WARD  8TAND  FOR 
DRESSINGS. 


Price  Lists  upon  Application. 


THE  STANDARD  HYPNOTIC, 


Dose— One-half  to  one  fid.  drachm  in  water  or  syrup. 

THE  STANDARD  ANODYNE, 


Dose— One  fid.  drachm,   represents  #  gr.  morphia  In  anodyne 
principle,  minus  its  constipating  effect. 

THE  STANDARD  ALTERATIVE, 


Dose— One  or  two  fid.  drachms  as  indicated. 

Clinical  reports  from  eminent  physicians  throughout  the  World 

furnished  on  application. 


CHEMISTS'  CORPORATION, 

ST.  LOUIS,  MO.,  U.  S.  A. 


i8 


MEDICAL  RECORD. 


FRELIGH'S    TABLETS, 

(Cough  and  Constituent,) 

70S  THE  PREVENTION  AND  CUBE  OF 

PULMONARY   PHTHISIS. 

FORMUUE. 

•    * — 


COUCH  TABLETS, 

EACH  TABLET   CONTACTS 

Morph.  Sulph.  (fa  gr.),  Atropia  Sulph.  (yj^  gr.), 
Oodeia  (fa  gr.),  Antimony  Tart,  (fa  gr.),  Ipecac, 
Aconite,  Pulsatilla,  Dulcamara,  Causticum,  Graphite, 
Bhus-tox,  and  Laohesis,  fractionally  so  arranged  as  to 
accomplish  every  indication  in  any  form  of  cough. 


*     * 


CONSTITUENT  TABLETS. 

EACH  TABLET  OOVTAIHS 

Arsenicum  (J^gr.),  Precipitate  Oarb.  of  Iron,  Phos. 
lime,  Oarb.  lime,  Silica,  and  the  other  ultimate 
constituents,  according  to  physiological  chemistry 
(normally),  in  the  human  organism,  together  with 
Garaccaso,  Cocoa,  and  Sugar. 


PRICE,  THREE  DOLLAR8  PER  DOUBLE  BOX. 

Containing  sufficient  Tablets  of  each  kind  to  last  from  one  to  three  months  according  to  the  condition  of  the  pfitiimi* 


While  the  above  formula  have  been  in  use,  in  private  practice,  over  80  years,  and  we  could  give  testimonial* 
from  well-known  clergymen,  lawyers,  and  business  men,  we  prefer  to  leave  them  to  the  unbiased  judgment  of  the 
profession  with  the  following  offer :  On  receipt  of  60  cents,  and  card,  letter-head,  bill-head,  or  other  proof  that  the 
applicant  is  a  physician  in  active  practice,  we  will  send,  delivered,  charges  prepaid,  one  of  the  regular  (double)  boxes 
(retail  price,  Three  Dollars),  containing  sufficient  of  each  kind  of  Tablets  to  test  them  three  months  (in  the  majority  of 
oases),  in  some  one  case.  Card,  letter-head,  or  some  proof  that  the  applicant  is  a  physician  in  active  practice  must 
aooompany  each  application.    Pamphlet,  with  full  particulars,  price-list,  eta,  on  request. 

As  we  furnish  no  samples  through  the  trade,  wholesale  or  retail,  for  samples,  directions,  price-lists,  eta,  address 


106  A  IOe  FULTON  «T.| 


I.    O.    WOODRUFF   A   CO., 

Manufacturers  of  Physicians'  Specialties, 


NEW  YORK  OITY.  ' 


JUST    PUBLISHED. 


OPERATIVE  SURGERY. 

By  TH.  KOCHER,  M.D., 

PROFESSOR  AT  THE  UNIVERSITY  AND  DIRECTORY  OF  THE  SURGICAL  CLINIC  AT  TBS  BERNE  UNIVERSITY. 

8vo,  288  pages,  163  illustrations.    Extra  muslin,  $3.00. 


Dr.  Kocher  has  endeavored  to  produce  a  work  that  shall  materially  assist  in  acquiring  that  mastery  of 
operative  technique  which  is  absolutely  indispensable  to  the  successful  surgeon.  The  book  is  divided  into 
four  parts. 

Part  I.  is  taken  up  with  general  observations,  including  remarks  and  directions  regarding  Anaesthesia, 
the  Treatment  of  Wounds,  and  the  Selection  of  the  Direction  of  the  Incision,  which  last  is  always  of  pri- 
mary importance. 

Part  II.  treats  of  Special  Operations  upon  the  Skull,  the  Face,  the  Cervical  Triangles,  the  Spinal  Col- 
umn,  the  Lumbar  Region  and  the  Abdomen,  the  Extremities,  etc,  etc. 

Part  III.  treats  of  Excisions  (Resections)  of  the  Extremities. 

Part  IV.  of  Amputations  and  Exarticulations. 

The  general  observations  and  introductions  preceding  these  different  portions  are  remarkably  suggestive 
and  practical.  The  operations  themselves  are  clearly  and  minutely  described,  and  the  illustrations  add  dis- 
tinctness to  the  graphic  descriptions.  The  Journal  of  the  American  Medical  Association  (Feb.  17th)  says  of 
it :  "  The  book  is  remarkable  for  its  extreme  simplicity  of  style,  its  entire  freedom  from  superfluities  of  any 
sort,  and  its  directness.  These  are  indeed  always  characteristics  of  a  master,  whether  the  topic  be  warp 
religion,  law,  or  medicine"  


WILLIAM  WOOD  AND  COMPANY, 


NEW  YORK. 


MEDICAL  RECORD.  19 


PANOPEPTON 


is  the   entire    edible    substance  of 


prime,  lean  beef  and  best  wheat  flour,  thoroughly  cooked, 
properly  digested,  sterilised  and  concentrated  in  vacuo, 
and  preserved  in  a  sound  sherry. 

Panopepton  is  the  food  par  excellence  for  invalids; 
in  all  acute  diseases,  fevers,  etc.;  in  convalescence;  for 
the  large  class  of  persons  who  from  feebleness  or  de- 
ranged digestion,  or  antipathy  to  ordinary  foods,  require 
a  fluid,  agreeable,  and  quickly  assimilable  food. 

Panopepton  proves  an  effective  resource  against  sleep- 
lessness when  this  is  due  to  excessive  fatigue,  stress  of 
mental  work  or  malnutrition. 

Panopepton  is  at  once  a  grateful  stimulant  and  food. 
Originated  and  manufactured  by  Fairchild  Bros.  & 
Foster,  New  York  City. 


MEDICAL  RECORD. 


''THE  great  popularity  of  PA  VARA  PILLS  has  induced  many  druggists  to  substitute  or 

recommend  other  pills,  of  inferior  quality  and  less  price,  in  place  of  them.    Physicians 

can  prevent  such  substitution  by  advising  their  patients  not  to  accept  PAVARA  PILLS 

from    a  druggist    unless   put   up   in   the   original 
packages,  with  the  outside  wrapper  unbroken. 


j&. 


teLrwwrma 


■toUVER,  SICK  HEW* 


LM 


— 1  fXVARA 

Pa  vara    Pillc  p™^* 

produce  natural  movements  of  the  bowels,  without  to  uyer  sickhw^ 

pain,  nausea,  or  any  inconvenience. 
These  Pills  have  a  world-wide  reputation  for  being 


Directions 


the  standard  remedy  for 


Constipation. 

11HPJ 


5*3^  --* 


For  Constipation  during  Pregnancy  these  Pills 
are  a  perfect  remedy.      Formula   printed  on   the 
Thousands  of  physicians  now  use  and  prescribe   them, 


^s&HpsS 


IH  outside  label.     Thousands  of  physicians  now  use  and  prescribe   them.     Trial  samples 
III  will  be  mailed,  free  of  charge,  to  any  physician  who  is  not  familiar  with  their  merits. 

Ift  Prepared  by  C,  L.  Toruvr.  New  YorfcWP.  O,  Box  Ml,-. Depot :  119  Fnlton  Street. 


>^^^^^^^^^^^^^^^^^^^^^^^^^  ^ 


Mellirfs  Food 

FOR 

INFA1VTS    -AJNTD    TTSTV  A  T..TDS, 

RECEIVED  AT  THE 

CALIFORNIA    MIDWINTER    EXPOSITION, 

SAN    FRANCISCO,  1894, 

TWO   GOLD   MEDALS  AND  TWO 
SPECIAL  DIPLOMAS  OF  HONOR. 

San  Francisco,  July  2nd,  1894. 
TO  THE  DOLIBER-GOODALE  CO.,  Boston,  Mass. 

Dear  Sirs  :  —  Mellin's  Food  was  selected  for  use  in  the  Emergency  Hospital  at  the 
California  Midwinter  Exposition  on  account  of  its  well-known  superior  qualities  as  a  food  for 
invalids  and  the  delicately  sick. 

I  am  pleased  to  inform  you  that  it  has  been  in  constant  use  during  the  entire  time  of 
the  Fair,  and  has  always  given  such  complete  satisfaction  that  no  other  prepared  food  has 
been  needed  in  the  Hospital. 

Yours  truly, 
(Signed)  Martin  Regensburger,  M.D.,  Medical  Director  in  Chief. 

A  liberal  sample  bottle  o*  M ELLIN'S  FOOD,  tuffloient  for 
trial,  will  be  tent  free  to  any  phytioian  requesting  it. 

DOLIBER-GOODALE   CO.,  291  Atlantic  Avenue,  Boston,  Mass. 


MEDICAL  RECORD. 


21 


PHYSICIANS    PRESCRIBE 


GRANULATED  EFFERVESCENT 

SAL  APERIENT 


A.  &  HI. 


FOB 


K.  &  M. 


CONSTIPATION, 

(PARTICULARLY  USEFUL  IN  HEMORRHOIDS;) 


'VETITB   VJSCS1 


SPECIFY  "KEASBEY  <fc  MATTISON"  WHEN  PRESCRIBING 


KEASBEY    &    MATTISON    CO., 


HYDROZONE 

IS  THE   STRONGEST  ANTISEPTIC   KNOWN. 

One  ounce  of  this  new  Remedy  is,  for  its  Bactericide  Power,  equivalent  to 
two  ounces  of  Charles  Marchand's  Peroxide  of  Hydrogen  (medicinal),  which  ob- 
tained the  Highest  Award  at  the  World's  Fair  of  Chicago,  1893,  for  its  Stability, 
Strength,  Purity  and  Excellency. 

CURES  DISEASES  CAUSED  BY  GERMS: 

DIPHTHERIA,  SORE  THROAT.  CATARRH,  HAY  FEVER,  LA  GRIPPE,— OPEN  SORES  J  ABSCESSES,  CAR- 
BUNCLES, ULCERS,— INFECTIOUS  DISEASES  OF  THE  GENITO-URINARY  ORGANS,— INFLAMMATORY  AND 
CONTAGIOUS  DISEASES  OF  THE  ALIMENTARY  TRACT:  TYPHOID  FEVER,  TYPHUS,  CHOLERA,  YELLOW 
FEVER,— WOMEN'S  WEAKNESSES:  WHITES,  LEUCORRHCEA,— SKIN  DISEASES i  ECZEMA,  ACNE,  Etc. 

SEND  FOR  FREE  BOOK  OF  158  PAGES  GIVING  FULL  INFORMATION. 

Physicians  Rjuottwg  Twenty-Five  Gents  Postal  Oedee  will  Receive  Fees  Sample  by  Mail. 

AVOID  IMITATIONS. 

HYDROZONE  is  put  up  only  in  small,  medium  and  large  size  bottles,  bearing  a  red  label, 
white  letters,  gold  and  blue  border. 


QLYCOZONB 

CURBS 

DI8BA8B8  of  tb«  STOMACH. 


thfa  publication. 


LEADING  DHU04IST*. 


Prepared  only  by 


ChnmUt and  gradual tftJu  "EccU  Central* duArtstt Mamu/acturu  <U Pari*-  {Frm*a± 

28  Prince  St,  New  Tort 


22 


MEDICAL  RECORD. 


NERiZES. 

Suppose  we  find  the  patient  a  little  giddy  upon  rising  in 
the  morning.  This  means  that  the  nerves  do  not  have  perfect 
control  of  the  muscular  system.  As  a  test  for  this,  direct  the 
patient  to  stand  with  his  feet  close  together,  shut  his  eyes,  and 
if  the  tendency  is  to  reel  it  is  another  evidence  of  lowered  nerve 
tone.  Or  stand  with  the  arms  extended,  shut  the  eyes,  and  then 
try  to  bring  the  tips  of  his  forefingers  together  in  front  of  him. 
If , they  pass  by  or  meet  imperfectly,  it  shows  the  same  thing. 
Or,  the  person  may  not  be  able  to  think  as  quickly  as  he  should. 
To  test  this  ask  the  patient  three  simple  questions  in  rapid. suc- 
cession, as,  "Where  were  you  just  before  you  came  into  this 
room?"  "What  were  you  doing?"  "How  long  did  you  remain?" 
The  rapidity  with  which  the  answers  are  given  indicate  the  rap- 
idity of  brain  action.  All  these  things  show  that  it  is  of  the 
utmost  importance  that  the  nervous  system  should  be  kept  in 
tone.  Otherwise,  every  part  of  the  body  languishes.  This  con- 
dition indicates  the  use  of  CELERINA  (Rio)  in  teaspoonful  doses 
four  times  a  day,  TO  INCREASE  THE  NERVE  CAPITAL  OF 
YOUR  PATIENT. 

RIO  CHEMICAL  CO.,  St.  Louis,  Mo. 


A  full  otto  botUo  of  CELERINA  mill  6*  oent  FREE  to  any  Pkyol- 1 
ekm  mho  ml$h—  to  toot  tt  If  ho  mill  pay  tho  express  okargoo.    » 


THE  DELANO  OIL  ATOMIZER,  No.  548. 


Hood  In  position. 


Hood  removed:. 


1*4*  Atomizer  is  designed  for  Atomising  OU  Vaseline*  Fluid 
Oosmolinef  Alboline9  Benmoinol9  Glymol,  etc.,  etc. 

The  treatment  of  inflammation  of  the  nose  end  throat  with  Oil  Vaseline  or  some  of  its 
■eflfflnatkwia  as  given  above  ie  ojiiversallv  established,  and  is  generally  regarded  as  the 
tat  method  of  treating  these  oomplainta. 

The  Delano  Atomiser  is  very  simple  in  oonstrnotion,  is  not  liable  to  get  clogged  np, 
■ai  produces  a  strong,  heavy  spray. 

.  The  hood  or  oap  that  covers  the  spray  tabes  is  removable,  whioh  gives  free  aoosss 
te  the  tabes  in  osse  they  should  get  dogged  ap,  and  the  shape  of  the  liquid  or  oil  tube  in 
Me  bottle  allows  the  instrument  to  be  used  in  a  horisontal  position.  The  metal  parts  are 
■Jekeled,  and  the  bulb  fa  fitted  with  metal  valves. 

This  fa  the  best  instrument  at  a  moderate  prioe  that  has  been  placed  on  the  market, 
sad  the  impressing  demand  for  it  oonvinoes  us  that  it  is  giving  satisfaction  wherever  it  is 

BIAlfUFACTURBD    BY 

Z.   DELANO,   Boston,   Mass. 


DAVIDSON  RUBBER  CO., 

/br  tM  United  flW»  BOSTON,  MASS, 


Elixir  Six  Iodides 


This  Elixir  is  prepared  from  the  Chemically  Pars 
Salts.    Results  can  be  looked  for  from  its  ad- 
ministration that  could  not  possibly  he 
expected  from  the  Commercial  Salts. 
FORMULA.— Sach  fluid  drachm  contains  i 


let  Iodldvm  1-116  grain,  Ferrl  Iodldom  Mi  grata, 
Hydrargyrl  Iodldnm  1-1*5  grain,  Manganesll  Iod*- 
dum  1-10  grain,  Potsssll  Iodldom  one  grain,  Bodfl 
Iodldnm  one  grain,  with  Aromattca. 

MEDICAL  PROPERTIES -The  greatest  esta* 
of  thli  oomoffiotton  is  it  relieves  those  obsourv  and 
chronic  obstruoUono  to  gland  ocMon— the  Kdney, 
Ueer,  pancreas,  ss  well  as  the  lymphatic  system, 
which  may  exert  so  great  sn  tnfluenoe  for  evil  on 
the  economy.  It  enjoys  the  confidence  of  the 
Medical  Profession,  as  its  nee  Is  indicated  m  a 
wide  range  of  diseases,  particularly  so  to  serat- 

•fotttanann(a,slta  diseases,  both  scaly  snd  j 

lor;  has  remarkable  curative  effects  in  ~ 
Steeaeee  snd  other  manifestations  of  si 
infection,  chronic,  uterine,  and  peivio  dUeassa, 
snd  In  oomplamu  where  an  aUerattoe  and  umte  Is 
Indicated. 

This  combination  proves  that  the  untied  action 
o/  remedies  Is  often  reqalslte  when  either,  alone,  to 
Insufficient.  Physicians,  when  presenting,  will 
please  write : 

~       BUxir   8iX   IodiOSS-WAUDOrQKMJD^B-OmO 

Bottle, 

The  druggist  will  please  write  directions  on  his 
own  label.  ELIXIR  SIX  IODIDES  to  always  sold 
to  eight  os.  oval  bottles  snd  mbvbb  in  bulk. 

Attention  Is  also  called  to  oar  Bllxlr  Six  Bra- 
■alelee,  Bllxlr  Six  Hyp*FfcesB>Mltee, 
am*  Bllxlr  Six  Aperients,  which  are 
celled  for  clinical  efficiency  snd  palatabUlty. 

Samples  of  the  four  Elixirs  wfll  be  sent  to  i 
Physician  by  express,  prepaid,  on  receipt  off 

Wholesale  price  per  dosen :  Iodides,  $8.00 ;  B 
phosphites,  $6.00 ;  Bromides,  Ss.00 ;  Aperlens,  | 
8ead  far  Descriptive  Clrealar. 

These  Elixirs  are  kept  to  stock  by  Wholesale 
Druggists  generally  thronghont  the  Untied  States. 

THE  WAUCR-BRCCW.  PMABsUCOmCAL  CL, 

(mO9IF0S41ll>) 

Head  Office,  180  W.  Regent  St.,  Glasgow,  Scotlaad 
WBSTsUtN  DBPOT.  U.  S.  A., 

17  W.  Fifth  St.,  Kansas  City,  Ms. 


9 


MEDICAL  RECORD. 


23 


|1 

5  s*.! 


vXCs 


*3 


D£SIR£E       \Qrav'lt  Vesical  calculi;   Completes 
"   ▼  ( of  the  Kidneys. 

DDtriPfTCr  J  Diseases  of  the  Lher;  Diabetes  mi 

(  Disorders  of  the  stomach. 

■■PEMTRIOE    \The  best  natural  Table  water 
(  ever  known. 

DSFOT  AT  ALL  MnfBBAL  WATBB8  DbALBBS. 

PAMPHLET  in  PARIS.  4,  Rue  de  Greffalh* 


SAINT-RAPHAEL 


.Tonic,  strengthening,  digestive  wine.  Ordered  fo* 
mak  and  fatigued  stomachs,  in  chlorosis,  anomiap  and  t# 
convalescent  people.  Unrivaled  adjnvanl 
in  consumption.  Excellent  flavor. 
Jktwr*  of  worihUa  imitation*.  Sea  that  yam 
[I  get  m  each  bottle  the  Tr ade  Mirk  here  oppoaHi 
and  the  Warranty  Stamp  of  the  Manufao* 
torero1  Union. 
I.  MIGXI,  2  W eat  13th  Str**l.  tioar  Fifth  Avftntto.  NEWTOEK, 

A,  XIQUES,  67  *  a9  Dsottur  Str«*t.  KCW  ORLEANS. 
Vattry  MM  li£lj,  &  CO.,  laio  OhutAul  St.,  PHILADELPHIA, 

UlIT-tAPMAIt  WIIE  8SWAIY.  fxl jutot  (Drtna,  trance). 


The  "Master"  Surgical  Elastic  Stockings. 

FOB  VABICOtB  VBaHB,   WBA1   AND  SWOLLEN    JOINTS,  DROPSY  OF  TUB 

LIMBS,    SPRAINS,    BtC 


THE  PATENT  NON-ELASTIC  STATS  AND  ADJUSTABLE  LOOPS, 

By  the  aid  of  which  they  can  be  drawn  on  easily,  like  pulling  on  a  boot.   They  will  last  much  longer  than  the  old  style. 
as  the  stays  prevent  them  from  being  torn  apart  tn  drawing  them  on. 

ALL  KINDS  AND  SIZES  IN  THRRAJ)  OB  SILKKLAflUC.   Made  nnder  B.  Master's  Patents,  Not.  »,  UtL 
March  81 1888.   Bend  for  descriptive  circular  and  prtoe-hst  to 


POMEROY    COMPANY, 

Daniel  Pombbot,  Pres. 


SPECIALTIES:! 


785   Broadway,   New   York. 

Ghabijb  B.  Dsah,  flea 
POMEROY'S   FRAME   TRUSS, 
Dr     MEICS   CASE'S   SPINAL   APPARATUS, 
THE    "  MASTER"    PATENT    ELASTIC   STOCKING, 


IN  REFERENCE  TO 


A  SULPHONIC  SALT  OF  ALUMINUM 


ALUMNOL 


IT  PRECIPITATES 


THE  NEW  A8TRINGENT. 


ALBUMEN  WHICH  RE  DISSOLVES  IN  EXCESS 
IT  ACTS.  THEREFORE 


BOTH 
SUPERFICIALLY 

AS  A8TRINCENT  AMD  ANTISEPTIC  IN 

RHINO-LARYNGOLOGY 

GYNECOLOGY 

OPHTHALMOLOGY 

OTOLOGY 

DERMATOLOGY 

IT  IS 


SUPERFICIALLY 

AND 

DEEPLY 

DEEPLY 

AS  RESOLVENT  AND  RE8QRBENT  IN 

CHRONIC  SKIN  AFFECTION8 
INDOLENT  CALLOUS  ULCERS 
PLASTIC  EXUDATES 
LYMPHADENITIS 
EPIDIDYMITIS,  ETC. 


ODORLESS-INNOCUOUS-UN-IRRITATINC 

EMPLOYED  IN       POWDER-SOLUTION-OINTMENT 
FOR  FURTHER  INFORMATION  SEE  LITERATURE. 


MANUFACTURED  BY 
PARBWERKE  VORM  MEISTER  LUCIUS  A  BRUNINC, 
HOECH8T  O.  MAIN  (GERMANY). 


SOLE  LICENSEES  FOR  U.S. 

SCHULZE-BERCE  A  KOECHL, 

79  MURRAY  8T.,  N.  Y. 


24 


MEDICAL  RECORD. 


DR.   D^CLAT'S 

ANTI-SEPTIC 

PREPARATIONS. 


From  Mbdioal  Rboobd,  N.  Y.,  May  8, 1890,  p.  507. 

Dr.  Glenn  has  used  Dr.  DecJat's  preparations  of  phenio  acid, 
both  internally  and  externally,  with  gratifying  results,  for  the 
last  ten  yean.  During  this  time  he  has  employed  phenio  acid  ai 
his  chief  remedy  in  all  oases  of  malarial,  typhoid,  and  scarlet 
I evers,  diphtheria,  erysipelas,  blood-poisoning,  as  a  local  applica- 
tion to  all  wounds,  whether  the  result  of  accident  or  surgical 
operation,  and  has  found  the  result  so  satisfactory  that  there  is 
little  left  to  be  desired. 

Since  he  has  been  following  this  plan  of  treatment,  in  typhoid 
fever,  for  example,  he  has  never  had  a  diarrhoea  occur  in  any  of 
his  patients ;  never  a  hemorrhage  from  the  bowel ;  never  a  serious 
tympanites ;  never  a  death.  He  believed  that  with  these  prepara- 
tions of  phenio  acid,  and  antif ebrin  as  an  aid,  physicians  possessed 
the  treatment,  par  4ocdbru36%  of  all  symotie  diseases. 


I  will  send  on  request  of  physicians  mentioning  MEDICAL 
Rbcokd,  an  abstract  of  Medical  Reports  on  the  Uses  of  Deolat'a 
Preparations  in  all  Zymotic  Diseases,  Garbnnole,  Tumors,  Oanoer, 
Tuberculosis,  Diabetes,  Rheumatism,  Skin  Diseases,  eta 


J.  MILHAU'S  SON, 

DRUGGIST  AND    IMPORTER, 

And  General  Agent  for  the  Dtfclat  Mfg.  Co., 

Established  ih  1818.  183  Broadway,  If.  Y. 


Hamilton's  System  of 


[Now  Ready  im  2  Vols. 


LEGAL  MEDICINE. 

A  COMPLETE  WORK  OP  BEFEKEMGE  FOR  MEDICAL  AID  LEGAL  FRACBBflMEBS. 

By  ALI^AH  MoLAJTE  HAMILTON,  M.D., 

Coninltiiig  Physician  to  the  Insane  Asylums  of  New  York  City. 
AisUted  by  LAWBBNOE  GODKDf,  Esq.,  of  the  Hew  York  Bar,  sad  Others. 
Its  list  of  thirty  contributors  includes  the  Dames  of  the  i 


writers  and  authorities  upon  Medical  Jurisprudence  in  America, 
reference  it  will  be  found  an  invaluable  help  to  medical  men,  and  to  those  of 
the  legal  profession  who  desire  the  aid  of  the  most  advanced  and  sound  opin- 
ions of  practical  students  of  forensic  medicine.  So  much  opprobrium  has 
been  attached  to  the  word  "  expert,"  that  It  has  been  the  aim  of  the  Editor  and 
his  colleagues  to  give  the  work  a  decided  judicial  and  impartial  tone,  so  that 
it  may  be  consulted  with  confidence  by  all  as  an  authority  of  the  highest  order. 

Until  recently  the  literature  of  Medical  Jurisprudence  in  the  United  States 
has  been  exceedingly  meager  and  limited  in  scope  and  character.  Foreign 
books  are  inapplicable  for  want  of  conformity  to  the  legal  usages  of  this 
country. 

A  marked  feature  of  the  work  la  the  introduction  of  short  articles  upon 
legal  subjects  by  distinguished  members  of  the  American  Bar.  The  cases  cited 
are  recent,  and  ohiefly  American,  and  up  to  date  in  theory  and  practice. 

PARTIAL  LIST  OF  (COLLABORATORS. 

WALTER  HAINES.  A.M.,  M.D.,  Chicago. 
V.  C.  VAUGHN,  A.M.,  Ph.D..  M.D.,  Ann  Arbor. 
F.  A.  HARRIS,  M.D.,  Boston. 
LEWIS  BALCH.  Ph.D..  M.D.,  Albany. 
CHARLES  L.  DANA,  A.M.,  M.D.,  New  York. 

F.  R.  STURGI8,  M.D.,  New  York. 
A  T.  BBJSTOWR.  M.D.,  Brooklyn. 
BRANDRBTH  STMONDS,  M.D.,  New  York. 
B.  8ACB8.  A.M..  M.D ,  New  York. 

J.  F.  BABCOCK,  M.D.,  Boston. 
CHARLES  JEWETT.  M.D.,  Brooklyn. 
CHARLES  K.  MILLS.  A.M.,  M.D  ^Philadelphia. 
CHARLES  Q.  CBADDOCK,  M.D.,  St.  Louis. 

G.  E.  PELLBW,  Ph.  D.,  New  York. 
P.  COOMBS  KNAPP.  MJX,  Boston. 

GEO.  RYEB80N  FOWLER.  M.D.,  Brooklyn. 

Judos  C.  8.  PRATT,  Brooklyn. 

Judos  SIMEON  B.  BALDWIN,  Connecticut. 

JOHN  B.  PARSONS,  Esq..  New  York  Bar. 

R.  C.  McMURTRIR.  Esq..  Philadelphia  Bar. 

WM.  B.  HORNBLOWB&  Esq..  New  York  Bar. 

Il «, „ 

fully  Illustrated.    In  mechanical 


CONDITIONS.—  The  work  is  comprised  in  two  large  royal  octavo 
volumes  of  about  seven  hundred  pases  each,  fully  IDuaf    '   * 
execution,  the  best  known  to  the  six  of  book-making. 

In  cloth,  per  volume,  $6.00 ;  lull  sheep,  per  volume,  $6.60. 
Sold  by  subscription.  SdHcitoravxtnted.  Descriptive  circulars  on  application. 

E.  B.  TREAT,  Publisher,  Ho.  6  Coopei  Union,  Hew  York. 


TREATISE  ON   GYNECOLOGY, 

MEDICAL  AND  SURGICAL. 

By  S.  POZZI,  M.D., 

Vrofesseur  Agrege'  a  la  Faculte  de  Mrfdecine ;  Chlrurgien  de  PHdpital  Lourcine-Pascal,  Paris ;  Honorary  Fellow  of  the  American  Gynaecological 

Society. 

Translated  prom  the  French  Edition  under  the  supervision  op,  and  with  Additions  by 

BROOKS  H.  WELLS,  M.D., 

Lecturer  on  Gynaecology  at  the  New  York  Polyclinic ;  Fellow  of  the  New  York  Obstetrical  Society,  and  the  New  York  Academy  of  Medicine. 


This  work,  the  latest  and  most  comprehensive,  and  by  far  the  best  which  has  appeared  for  many  years  on  the  subject 
«f  practical  Gynaecology,  is  the  result  of  the  author's  long  practical  experience  of  a  hospital  service  at  Lourcine,  devoted 
-especially  to  the  diseases  of  women. 

It  is  essentially  practical  in  method,  and  treating  the  subject  as  it  does  both  from  the  surgical  and  the  medical  stand- 
point, is  calculated  to  be  of  the  utmost  value  to  the  general  practitioner  as  well  as  to  the  specialist  But  few  changes 
have  been  made  or  thought  necessary  in  translating  Prof.  Pozzi's  work  into  English,  the  endeavor  having  been  to  follow  the 
original  as  closely  as  possible.  A  number  of  editorial  notes,  referring  mainly  to  minor  points,  have  been  added.  Many 
•of  the  illustrations  are  original,  having  been  drawn  under  the  supervision  of  the  author,  and  appear  here  for  the  first  time. 

Certain  cuts  of  instruments  and  accessories  have  been  omitted  or  replaced  by  those  which  American  practice  has  found  to 
be  better  suited  to  our  needs. 

A  voluminous  and  complete  bibliography  accompanies  the  work  together  with  a  complete  index  in  each  volume. 

Pozzi's  Gynaecology  will  consist  of  two  royal  octavo  volumes  of  about  6oo  pages  each.  Volume  I.  contains,  in  addition  to 
the  very  numerous  wood-cuts,  six  plates  in  colors.     Volume  II.  will  contain  nine  colored  plates. 

As  a  specimen  of  book-making  Pozzi's  Gynaecology  is  very  handsome,  being  beautifully  printed  on  extra  heavy  paper  and 
bound  in  red  English  muslin,  brown  sheep,  and  dark  green  half-morocco,  at  $6.oo,  $7.00,  and  $8.00  per  vohime,  respectively. 

A  complete  descriptive  circular  will  be  mailed  free  upon  application,  to  any  address. 

The  work  is  sold  by  subscription  only.  

WILLIAM  WOOD  &  COMPANY,  Medical  Publisher*,  43  to  47  East  Tenth  Street.  New  York 


MEDICAL  RECORD. 


25 


THSL 


Animal  Extracts 

Prepared  aocording  to  the  formula  of 

DR.    WIN.    A.    HAMMOND, 

In  his  laboratory  at  Washington,  D.  C,  and  under  his  immediate  supervision. 


Dr  G.  L.  Dana,  Professor  of  Nervous  Diseases  in  New  York  Poet-Graduate  Medical  School,  writes 
in  the  Sanitary  Era  for  January,  1894 : 

"ANIMAL  EXTRACTS  :  I  am  so  firm  a  believer  in  the  rationality  of  this  line  of  therapeutical  investi- 
gation that  I  am  willing  to  brave  some  misunderstandings  in  connection  with  the  use  of  such  preparations. 
There  is  no  more  reason  to  doubt  that  there  should  be  therapeutical  properties  in  extracts  obtained  from 
animal  organs  than  that  there  should  be  such  from  vegetable  organs.  We  might  just  as  reasonably  expect 
good  therapeutical  properties  from  the  extract  of  a  gland  as  from  the  extract  of  a  root  or  a  leaf  or  a  bean. 
The  remarkable  results  obtained  from  the  use  of  the  thyroid  gland  in  myxoedema  is  of  itself  abundant 
justification  of  this  position." 

The  Animal  Extracts  0EREBR1NE,  OARDINE,  MEDDLUNE,  OVARINE,  MUSCULINE,  THY- 
RODENTS,  and  TESTINE  are  being  used  now  with  gratifying  success  by  progressive  physicians  all  over  the 
country.  All  existing  literature  on  the  subject  will  be  muled  and  the  Extracts  forwarded  on  receipt  of  price, 
$2.50  per  bottle,  by 

COLUMBIA  CHEMICAL  COMPANY, 


Wholesale  Agent,  J.  MHHAF8  SOH,  183  Broadway,  Hew  York. 


WASHINGTON,  D.  C 


A  COMPLETE  DRY  CELL  GALVANIC  BATTERY 

and  SWITCH -BOARD   for  Utilizing 
the  Incandescent  Current,  Combined. 

The  Tetter  Complete  Portable  Dry  Cell  Galvanic 
Battery  is  the  most  pexfeot  Electro-Medical  Apparatus 
made.  The  Controller  and  Mil-ammeter  can  be  used 
independent  of  the  oells,  in  connection  with  the  In- 
candescent Current,  where  same  is  available. 

Dry   Cell    Galvanic   Batteries,   from 
SIO.00  up. 

Table  Bases,  Wail  Bases,  Cabinets,  ete.9  for 
Dry  or  Liquid  Cells,  or  for  the  Constant 
Incandescent  Current. 

Send  fob  Illustrated  Catalogue. 
By  means  of  the  Vetter  Current  Tap,  Storage  Batteries  can  be  charged  free  of  cost* 
BATTERIES  FOR  HIRE — 

J.  C.  VETTER    <fc    CO., 

MAMUrAOTURIBS  AND  PATENTBI8  OF 

Dry  Cell  Galvanic  and  Faraiic  Batteries,  Carbon  Current  Controllers, 

MIL-AMMETERS,  Etc., 

104  East  23d  Street  (Meyrowits  Building),  New  York. 


Send  for  a 
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OF 


WM.  WOOD  &  CO.'S 
Publications; 


An  Index  of  the. 

PRACTICE  OF  MEDICINE. 

By  W.  M.  CARPENTER,  M.D. 


i6mo,  304  pages,  full  leather  with 
tuck,  price,  $2.50. 


WM.  WOOD  &  CO.,  NEW  YORK. 


THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY 


By  PRANK  HA3HN05  HAMILTON,  A.M.,  M.D.,  LL.D., 
Late  Pro/steer  of  the  Practice  of  Surgery,  with  Operation*,  and  of  Clinical  Surgery,  in  Bellevue  Hospital  Medical  College 


Consulting  Surgeon  U 


Bellevue  Hospital:  to  t%4  Bureau  of  Surgical  and  Medical  Relief  for  the  Out-Door  Poor.  afBellevue  Hospital  7  to  St.  ElinahethU 
Hospital  and  to  the  Hospital  for  the  Ruptured  and  Crippled  ;  Fellow  of  the  New  Yorl 


York  Academy  0/ Medicine,  etc. 


Third  Edition.    One  royal  octavo  volume  of  over  one  thousand  pages,  illustrated  with  47a  fine  wood-engravings.    Price,  bound  in  Cloth,  ten*  s 
fc  Leather,  $6.50.    Will  be  sent,  post-paid,  on  receipt  of  price.  «         •  •  «"-**•»»  0 

WILLIAM    WOOD    &    COMPANY,    Pubushers,    Nh>w   York. 


26 


MEDICAL  RECORD. 


LITHIA  WATER 

III 

Tablet  Form. 

The  medicinal  ingredients  of  a 
glass  of  lithia  water  compressed 
into  the  form  of  an  epervemxnt 
tablet. 

They  are  perfectly  soluble,  and 
their  use  is  suggested  in  ail 
where  Lithia  is  indicated* 


BetaU  60c.  &  $1.00  per  bottU. 


SCHOONMAKERS  FLEXIBLE  SUPPOSITORIES. 

GLYCERITE  TANNIN  lO  min, 

VAGINAL  JTo.  800. 

A  new  and  convenient  preparation  of  Tannio  Acid  for  Gynaecol- 
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Bach  Suppository  contains  ten  minims  of  Glyoerite  of  Tannin, 
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They  are  offered  to  the  Profession  in  boxes  of  one  dozen  each. 
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— Southern  California  Practitioner. 


Brain  Surgery. 

By  n.  ALLEN  STARR,  il.D.,  Ph.D., 

Professor  of  Diseases  of  the  Mind  and  Nervous  [System,  College 
of  Physicians  and  Surgeons,  New  York. 


8vo,  306  pages,  parchment  muslin.     Elegantly  illustrated  by 
more  than  fifty  engravings.     Price,  $3.00. 


The  author  discusses  the  subject  of  Brain  Surgery  under  the 
following  heads  :  Diagnosis  of  Cerebral  Disease,  Trephining  for 
Epilepsy,  Trephining  for  Imbecility,  for  Cerebral  Hemorrhage, 
for  Abscess  of  the  Brain,  for  Tumor  of  the  Brain,  for  Hydro- 
cephalus, for  Insanity,  for  Headache,  and  other  conditions,  and 
concludes  with  a  most  interesting  discussion  of  the  Operation  of 
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"All  in  all,  this  work  of  Dr.  Starr  can  justly  take  its  place  net 
only  in  the  library,  but  even  on  the  table  as  a  safe  and  conservative 
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WILLIAM   WOOD    &   COMPANY, 

NEW  YORK. 


PHYSICIANS'  GLASS  SIGNS. 

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the  Back  and  Nervous  System  In  their 
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8YRUPUS  ROBORAN8. 
PEPTIC  ESSENCE. 


«yr.  Hfpoaaos.  Oomp.  with  Quin.  Siangan,  and 
StrychTrSTgr.  Strychnine  taVeaspoonroa. 

As  a  nerve  stimulant  and  restor*dre  in  wasting 
and  debilitating  diseases,  as  a  constructive  agent 
In  Insomnia.  Pneumonia,  Tuberculosis,  Bronchial 
Asthma,  Marasmus,  Strumous  Diseases  and  Gen- 
eral Debility,  this  compound  has  no  superior. 

8YBTJPU8  BOBORANS  Is  In  perfect  solution  and 
will  keep  in  any  climate. 

Dr.  T.  H.  SnroxT  writes :— In  a  ease  of  Tertiary 
Sypniins,  very  anmmlo,  the  Iodides  were  revolting 
to  the  stomach,  bemg  vomited  when  taken. 
Syrupus  Boborsns  given  three  weeks  with  im- 
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A  Powerful  Digestive  Fluid  in  Palat- 
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nsaw  soto  that  asanas  tad  BUsb  Ptpda  oosttlt  «ly 
rtptii,  watts  la  PiWr'i  Hello  lists*  wt  bars  tU  ths 
dlfSftlr*  ftmtsta.  These  are  preserved  In  solution 
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roll  therapeutic  value,  which  Is  exerted  m  and 
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It  Is  a  Stomachic  Tonic  and  relieves  Indigestion, 
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For  nursing  mothers  and  teething  children  it  hat 
no  superior. 


Samples  sent  anon  application*         Hani  one  emarajes  at  yenr  expeause. 

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Seat,  post-paid,  on  receipt  of  the  price. 


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CONGENITAL    OCCLUSION    AND    DILATA- 
TION OP  THE   LYMPH   CHANNELS.  .  . 
By  S.  C.  Bosey,  M.D.    One  volume  of  aoa  pages, 
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ESSENTIALS  OF  CHEMISTRY. 


Inorganic  and  Organic,  for  the  use  0/ Students  of  Medicine. 
Twelfth  Edition.     By  R.  A.  WITTHAUS,  A.M.,  M.D. 

One  volume,  321110,  330  pages,  muslin.    Price,  $1.00.    "  A  vest-pocket  compendium  of  Chemistry."— Medical  and  Surgical  Journal. 

Published  by  WILLIAM  WOOD  &  COMRANY,         ...         -         NEW  YORK. 


MEDICAL  RECORD.  27 


Medical  Journals 

.    .    .    PUBLISHED  BY    .    .    . 
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MEDICAL   RECORD. 

A   "Weekly   Journal    of    Medicine    and    Stargery. 


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The  Medical  Record  has  for  years  been  the  leading  organ  of  the  medical  profession  in  America,  and  has  gained 
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The  American  Journal  of  Obstetrics 

AND    DISEASES    OF    WOMEN    AND    CHILDREN. 
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The  Journal  is  not  the  organ  of  any  society,  being  entirely  independent,  and  consequently  free,  to  select  for  pub- 
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Society  Proceedings,  Book  Reviews,  and  Abstracts  of  current  literature  in  its  scope  are  carefully  prepared 
features  which  aid  to  the  completeness  of  the  Journal. 

In  order  to  add  to  its  usefulness  and  attractiveness,  special  attention  is  given  to  the  matter  of  illustrations,  and  al 
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Lithographic  and  other  plates  are  frequently  introduced,  and  add  immensely  to  the  usefulness  and  beauty  of 
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SPASMODIC  COMPLAINTS 

Uterine  Disorders  and  Obstetrics. 

Hayden's  Viburnum  Compound. 

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Send  your  address  for  our  large  Illustrated  Hand-book,  free  to  physicians. 


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MEDICAL  RECORD.  29 


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I  Do  not  forget 

That  the  diseases  of  childhood  are  not  the  diseases  of  adult  life.     You  should  read  each  month 
the  only  journal  devoted  exclusively  to  this  very  important  branch  of  medicine.    It  is  the 


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5 


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3 
5 
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5 
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51  _^ 


Archives  of  Pediatrics 

(Founded  in  1884,  and  owned  by  Wm.  Perrv  Watson,  M.D.) 

Edited  by  Dr.  Dillon  Brown,  M.D,  Adjunct  Professor  of  Pediatrics  in  the  New  York  Polyclinic. 
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A   PRACTICE  OF   MEDICINE, 

Prepared  for  Students  and   Practitioners. 
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Professor  of  the  Theory  and  Practice  of  Medicine,  Medical  College  of  Ohio,  etc,  etc. 

One  large  octavo  volume  of  840  pages,  illustrated  by  three  hundred  engravings  and  one  chromo* 
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This  book  will  commend  itself  to  the  profession,  because  it  not  only  advocates  but  actually 
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No  work  on  the  subject  hitherto  published  has  equaled  this  in  the  profusion  and  excellence  of 
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WILLIAM  WOOD  &  COMPANY,  -  NEW  YORK. 


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MEDICAL  RECORD. 


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A  TEXT- BOOK  ON   DISEASES  OF 

THE  EYE. 

By  HENRY  D.  NOYES,  M.D., 

Professor  of  Ophthalmology  and  Otology  in  Bellevue  Hospital  Medical  College ;  Executive  Surgeon  to  the  New  York 
Eye  and  Ear  Infirmary  ;  recently  President  of  the  American  Ophthalmological  Society,  eta 


£oyal  octavo,  816  pages,  richly  illustrated  with  chromo-lithographic  plates  and  engravings.    Second 
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This  book  has  long  been  before  the  profession  and  has  an  acknowledged  pre-eminence  as  a  standard 
fext-book.     A  new  and  revised  edition  has  just  been  issued. 

Numerous  additions  have  been  made,  and  in  particular  those  parts  of  cerebral  anatomy  and  pathology 
•/hich  have  a  bearing  upon  the  eye  have  been  discussed  at  unusual  length  for  such  a  work. 

Throughout  the  attempt  has  been  made  to  s-et  forth  the  most  recent  and  well-established  views  in 
ophthalmology,  and  references  have  been  abundantly  inserted  to  facilitate  further  research.  There  are 
two-hundred  and  sixty-nine  illustrations  exclusive  of  charts  and  lithographic  plates. 

"The  book  before  us  is  a  brilliant  testimonial  of  the  extensive  knowledge \  vast  experience,  untiring 
industry,  and  literary  ability  of  its  celebrated  author.  Is  presents  the  actual  stand-point  of  ophthal- 
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— Knapp's  Archives  of  Ophthalmology, 


WILLIAM  WOOD  &  COMPANY, 


NEW  YORK. 


MEDICAL  RECORD. 


3i 


OFFICIAL  ANNOUNCEMENTS 
OF  MEDICAL  COLLEGES. 


Long  Island  College  Hospital 

AND  HOAQLAND  LABORATORY, 

BROOKLYN,  NEW  YOBK. 

BJBSSIOW  1894-96. 

The  Regular  Term  vrtll  commence  September  2ft,  1994.  am  continue  rtx  monika. 
The  Beating  an4  Recitation  Term  wtdc&mmen*™  MttrvA  28.  1S&4. 

The  So«p!t*r»iid  EUiiiwiisary*  iu  which  If.Ttf  patient*  were  treated  In  tttt,  art 
In  ta«Huna  building  with  the  Collet-  and  two  or  tone  noun  on  dally  devoted 
to  Clinical  Tew  bins  and  Physical  Dia*fiioii«.  Quizs«s  are  held  by  Iba  Professors 
ud  their  osiiiBLA.il ta  Ibroutfiiout  tbfl  course,  without  coat*  Students  also  rv.ttve 
instructions  at  ihe  E>-«  and  Eur  HoSfitsJ  (7.000  patients  annually  treated},  ami  she 
BrooklFn  Hospital  itt.OQuj,  The  resident  Main  of  tliew>.  snd  of  fit.  Jo  ha 'ft,  St. 
Man%  fit,  Catherine's,  Methodist  E[;it§cc|ul,  and  KJuit'M  Count?  @oHt-ltaL»,  also 
the  Burgeons  of  the  City  Ambulance  Service,  &re  am  minted  in  Dually,  ami  the 
positions  sr«  open  to  tho  graduate*  of  the  Loop  Island  ColJtve  HoppftaL 

Special  Instruction  ifc  given  witiutut  c&rt,  in  Ovuecolugy,  Midlife ry,  Inwaaea  of 
the  Bye.  Ear,  Throat.  Noae,  Skin,  and  Nervoiit  frvvtem.  Practical  Obstetrics,  aif 
taught  by  daily  eierctaes  on  the  Manikin,  Including  ail  the  operative  procedural 
forceps,  version,  etc,  and  by  alteD  dance  on  case*  of  kid  ft  Dement  In  the  Wards  of 
the  Maternity  and  Out-door  Obstetric  Service.  In  the  Boaaland  Laboratory, 
instruction  b  jttvpii  in  Ba«terlofo|f¥h  lucrosOOpg.  and  Pathology, 

Pais.— MmtncuLation  for  the  Collegiate  year.  16  ;  Lett  urns  and  Clinics  of  Regu- 
lar Turin,  f  1Q0  ;  Graduation,  125  ;  Lectures  and  ClLnicu  of  Heading  and  BacitatlOB 
Term.  NO. 

Good  board  can  be  bad  in  Brooklyn  for  IS  a  week. 

For  pari! Millars  ai  to  lectures*  clinics,  and  fee*,  send  for  Annual  Auuoun; «,  L.-mt 
to  J.  ft,  IU\jhisi»,  M.D,,  Secretary  of  faculty,  Long  Inland  College  Hospital, 
Brooklyn,  N.  Y. 

AL.KX.  «T,  O.  *MNM,  M.D.,  presidam  of  tfte  Ooiiesje. 


Bellevue  Hospital  Medical  College, 

CITY  OF  NEW  YORK. 

Sessions  of  1895-96. 

Tne  Rsgulab  Session  begins  on  Monday,  September  88,  1895,  and  con- 
tinues for  twenty-six  weeks.  During  this  session,  in  addition  to  the  regular 
didactic  lectures,  two  or  three  hours  are  daily  allotted  to  clinical  instruc- 
tion. Attendance  upon  three  regular  courses  of  lectures  is  required  for 
graduation.  Tbe  examinations  of  other  accredited  Medical  Colleges  in  the 
elementary  branches  are  accepted  by  this  College. 

The  Spring  Session  consists  of  daily  recitations,  clinical  lectures  and 
exercises,  and  didactio  lectures  on  special  subjects.  This  session  begins 
March  28, 18M,  and  continues  until  the  middle  of  June. 

The  Cabnegib  Labobatobt  is  open  during  the  collegiate  year  for  lnstruo 
tion  in  microscopical  examinations  of  urine,  practical  demonstrations  in 
medical  and  surgical  pathology,  and  lessons  in  normal  histology  and  in  path- 
ology, including  bacteriology. 

For  the  annual  Circular,  giving  requirements  for  graduation  and  other 
information,  address  Prof.  Austin  Flint,  Secretary,  Bellevue  Hospital  Medi- 
cal College,  foot  of  Bast  88th  Street,  New  York  City. 


New  York  Post-Graduate  Medical  School  and  Hospital. 

THIRTEENTH  YEAR.     SESSIONS  OF  1894-95. 


The  Autumn  and  Wintbb  Sessions  of  ibis  Institution  will  begin  on  September  17th.  The  hospital  of  the  School  contains  190 
beds.  The  teachers  of  the  Institution  are  also  connected  with  the  following  named  Hospitals  and  Dispensaries :  St.  Luke's,  Bellevue, 
the  Presbyterian,  Woman's,  Charity,  Mt.  Sinai,  German,  Skin  and  Cancer,  New  York  Cancer,  St  Mark's,  Ruptured  and  Oiippled, 
Manhattan  Bye  and  Ear,  New  York  Bye  and  Ear  Infirmary,  Maternity,  Randall's  Island,  New  York  Dispensary,  Out- Door  Department 
of  New  York  and  Bellevue  Hospitals,  Insane  Pavilion  of  Bellevue  Hospital,  German  Poliklinlk,  German  Dispensary,  Monteflore  Home,  and 
others.  The  Laboratory  is  well  equipped  for  pathological,  histological,  and  bacteriological  investigations.  The  Babies'  Wards  contain 
60  beds  and  give  great  facilities  for  the  study  of  infantile  disease.  Instruction  is  given  in  surgical  anatomy  and  operations  on  the 
cadaver.  The  instruction  is  intended  for  general  practitioners  who  wish  to  acquire  a  knowledge  of  all  departments  of  medicine  and 
surgery,  as  well  as  for  those  who  are  practicing  in  any  special  department  Every  branch  of  medicine  and  surgery  is  taught  by  a 
system  of  personal  and  private  instruction ;  no  formal  lectures  are  given. 

For  Catalogue  and  Schedule,  address 

CLARENCE  C.  RICE.  M.D.,  Secretary, 

Second  Ave.  and  Twentieth  8t~>  New  York  CUy. 


D.  B.  ST.  JOHN  ROOSA,  M.D.,  LL.D.,  President. 
F.  E.  FARRELL.  Superintendent. 


SOCIETY  OF  THE  LYING-IN  HOSPITAL  OF  THE  CITY   OF   NEW  YORK. 


XDWABD  W.  LAMBERT.  M.D., 


WILLIAM  M.  POLE,  M.D. 


(Organised  1796.) 
CONSULTING   PHYSICIANS. 

THOMAS  M.  MABKOE.  M.D.,        WM.  T.  LUSK,  M.D., 
ATTENDING  PHYSICIANS. 

J.  W.  MABKOE,  M.Dm       8.  W.  LAMBEBT,  M.D.,      J.  CLIFTON  EDGAR,  M.D.,        H  MoM.  PAINTER,  MJ>..        AUSTIN  FLINT,  Ja,,  M.D. 

The  Midwifery  Dispensary  has  been  absorbed  by  this  Institution.       The  number  of  deliveries  during  18*1,  856;  during  1898,  8,070.      The  'i 

ttve  building  is  in  the  most  densely  populated  tenement-house  district  in  the  city.  There  are  accommodations  for  twenty  students,  the  regular  term  of  lnstras- 
Uon  being  two  weeks,  with  six  to  fifteen  detlveites  for  each  student.  Instruction  ts  given  during  the  entire  year  and  is  open  to  practitioners  of  nudlclne  sai 
'  \  who  have  attended  one  course  of  medlcaJJecturea.    Studenta  are  admitted  in  the  order  to  which  their  applicattona  are  received,  or  they  may  be 

'thetwi 


en  practicable.  While  waiting  they  can  attend  the  various  hospital  clinics,  dispensaries,  eld,  In  the  city.  All  d<  liveries  are 
attended  at  their  houses  ss  in  private  practice.  Lodging,  instruments,  and  medicines  are  furnished  at  the  hospital  during  i 
ites  are  issued  to  those  who  have  performed  the  service  satisfactorily.  For  further  information,  apply  to 


to  special  dates  when 
antsmptlc.  and  all  oases  are  ati 
weeks'  service,  and  certificates 

CHA8.  FORD,  Superintendent,  314  Broome  Street,  New  York  City. 

■pedal  tnstructlon  upon  the  manikin  given  by  the  attending  physicians.         Senarate  apartments  for  graduates- 

HEW  YORE  POLYCLINIC  AND  HOSPITAL 

A  Clinical  School  for  Graduates  in  Medicine.  Lectures  continuous  throughout  the  year.  Physicians  may  enter  at  any  time.  The 
winter  Session  extends  from  September  25th  to  June  15th.  The  clinical  material  is  unlimited,  and  practical  instruction  is  given 
in  every  department  of  medicine.  The  opportunities  for  seeing  operations  in  every  branch  of  surgery  are  unlimited.  Practical 
obstetrics,  clinical  mlorosoopy,  and  intubation  are  also  taught  in  the  sohooL    For  further  information,  address 

I*.  BMMBTT  HOLT,  MJX,  Secretary, 
214.218  Bast  34th  Street  New  York, 

A  PRACTICAL  TREATISE  ON  RENAL  DISEASES 

AND 

URINARY    ANALYSIS. 

By  WILLIAM  HENRY  PORTER,  M.D., 

Professor  of  Clinical  Medicine  and  Pathology  in  the  New  York  Post-Graduate  Medical  School  and  Hospital ;  Curator  to  the  Presbyterian  Hospital. 
One  octavo  volume  of  three  hundred  and  sixty  pages,  illustrated  by  one  hundred  fine  wood-engravings.     Bound  in  extra  muslin,  price,  ?3#0O> 

WILLIAM  WOOD  &  COMPANY,  Publishers,        -        43,  45  and  47  East  10th  Street,  New  York. 


32 


MEDICAL  RECORD. 


OFFICIAL  ANNOUNCEMENTS 
OF  MEDICAL  COLLEGES. 


MEDICAL    DEPARTMENT    OF 

Harvard   University, 

BOSTON.  MASS. 

One  hundred  and  twelfth  Annual  Announcement 
(1804-05). 

Instruction  It  given  hj  Lectures,  Beeltatlons, 
Clinical  Teaching  end  Practical  Exercises  through- 
oat  the  Academic  year.  The  year  begtm  September 
8T,  ISM,  and  ends  the  last  Wednesday  In  Jane, 
1806.  Persons  who  hold  no  degree  In  Arts  or 
Science  mast  pass  an  examination  for  admission 
to  this  School.  The  admission  examination  will  be 
held  In  June  at  Boston,  Andover,  Qulncy,  Oroton, 
Southboro,  Worcester,  Exeter,  N.  H.,  Concord,  N.H. 
New  York,  Albany,  Buffalo,  Rochester,  N.  Y.. 
Philadelphia,  Washington,  Chicago,  Cle?eland, 
Cincinnati,  St.  Louis,  Minneapolis,  Denver,  San 
Vrandsoo,  Belmont,  CaL,  Portland,  Ore.,  and 
Bonn,  Germany ;  in  September  at  Boston  only. 
Examlnatlo  1  for  advanced  standing  Sept.  84,  ISM. 

A  catalogue  containing  detailed  information  and 
of  examination  papers,  will  be  sent  on 


DR.  WM.  L.  RICHARDSON, 
Dean,  Harvard  Medical  Sohool.  Boston, 


University  of  Colorado 

MSDIGAL   DBTAKMEMT. 

Three  years' graded  coarse.  Instruction  daring 
the  first  year  Is  given  in  Boulder,  and  daring  the 
second  and  third  years  In  Denver,  owing  to  the 
superior  clinical  advantages  of  the  latter  dry.  The 
District  Court  has  recently  decided  that  the  Uni- 
versity of  Colorado  has  a  right  to  teach  medicine 
wherever  the  beat  clinical  advantages  are  obtain- 
able. Practical  laboratory  work  In  Chemistry, 
Histology,  and  Pathology.  The  next  session  com- 
mences the  first  week  In  September.  1884. 

Tuition  Is  free  to  residents  of  Colorado.   Non- 
residents pay  a  nominal  fee  of  twenty  dollars. 
H.  W.  MoLautblix.  M.D,  Secretary.  a 
Berth  Block,  Denver,  CoL 

Woman's    Medical    College 

OF  THB  NEW  YORK  INFIRMARY, 
991  Mast  16th  Street,  MMW  YOBK. 

Session  of  18*4-95  opens  October  1,  1884. 
Four  years*  graded  course.  Instruction  by  Leo- 
tores,  Clinics,  Recitations,  and  practical  work,  un- 
der supervision  la  Laboratories  and  Dispensary  of 
College,  and  in  New  York  Infirmary,  operations 
and  CUnlos  inmost  of  the  City  Hospitals  and  Dto- 
pensarles  open  to  women  students.  For  Catalogues, 
ate.,  address  EMILY  BLACEWBLL,  M.D..  Dean, 
sal  Bast  isth  Street. 


FOB 

BOTE 


COLLEGE 

Physicians  and  Surgeons, 

•OSTON,  MAMT 

connected. 
Equal  prlvUtgea  for  both  asses. 

Hol Edward  Amy,  PraUai  S3  statist 

New  illustrated  catalogue  free. 


Mil  Mm  lira]  ScM 

BOSTON,  MASS. 

For  men  and  women.  Will  oom- 
menoe  its  next  oourae  of  lectures  on 
Weoneeday,  October  3,  1894. 

For  particulars,  address 
Prof.  Charles  P.  Thayer,  M.D.,  Sec- 
retary, 74  Boylston  Street,   Boston. 

DARTMOUTH  MEDICAL  COLLEGE, 

HANOVBB,  JT.  W. 

SUMMER  AND  FALL  SESSION. 
Lectures  begin  July  IS.  1895,  and  continue 
twenty  weeks.      Healthful  climate  and  excel- 
lent corps  of  teachers.    Mary  Hitchcock  Hos- 
pital completed     For  circular,  address 
C.  P.  FROST,  M.D.. 

Hanover,  N.  H. 


Northwestern  University 

MEDICAL   8CHOOL. 

(Chicago  Medical  College,) 

The  regular  oourae  includes  four  yean  of 
eight  months  each.  The  laboratory  equip- 
ment is  complete.  The  clinical  faolitiea 
are  exceptionally  fine.  For  circulars  of  de- 
tailed information,  address  the  Secretary. 
Dr.  FRANK  BILLINGS, 

235  State  Stf  Chicago,  I1L 

■EDI00-0HIRUR8I0AL  00LLE8E 
OF  PHILADELPHIA. 

Winter  Session  will  begin  October  td  and  con- 
tinue until  May*  Prellnunarj  Session  begins  Sep- 
tember 4th. 


The  Curriculum  Is  graded ;  a  preliminary 
inatlftn  and  three  Annual  Winter  Sessloi 
required.  Laboratory  Instruction  In  Chemistry, 
Histology,  Pathology,  Hygiene,  and  Physiology, 
with  Bedside  Instruction  In  Medicine,  surgery, 
and  Gynecology  Is  a  part  of  the  regular  course. 
All  the  specialties  are  folly  and  practically 
taught.  Fourth  Year,  free  to  those  In  attend- 
ance three  sessions,  to  all  others,  $100. 

For  announcement  or  Information,  apply  to 
ERNEST  LAPLACE,  OLD..  Dean, 
IBM  8.  Rlitenhousc  Square,  Philadelphia*  Fa, 

UNIVERSITY  OF  MICHIGAN. 

DEPARTMENT  OF  MEDICINE  AND   SUBGEBT. 

ftrtv-nftaTey,  otnassetag  Eaaisy,  Oot  i,  MM. 

The  Coarse  of  instruction  oomprlses/oir  eoUeglsts 
rears  of  mas  months  each.    Examination  for  admls* 

Fasa:— For  the  first  year— Besidents  of  Michigan, 
fSS.OO :  non-residents.  800.00.    For  each  subaeaueni 


wJSSi.   Graduation  ftetarall  alike,' 01040* 
°*^ASre^ 

tlE  JEFFERSON  MEDICAL  00LLE8E 

OF  PHILADELPHIA. 
tsa  tttk  aaaaal  Santa  of  tat  JsSmmb  Esttool  OoUtgt 

•egiai  OoMoet  lit  sad  wsnsuti  7  aostat. 

Each  student  is  Immediately  and  personally 

taught  m  Obstetrics  and  Uynooology,  Physical 

Diagnosis,  Laryngology,  Ophthalmology,  Medical 

Chemistry,  Pharmacy,  Materia  Medica,  and  Ex 

rlmental  Therapeutics,  Anatomy,  Histology.  and 

pertmental  Physiology,  Minor   Surgery,  Ban 

Operations  on  the  Cadaver,  Pathology, 

~~       >  Tberapeutlos,    Dermatology, 

,  and  Genlto-urlnary  Diseases. 


partmental  Therapeutics,  Anatomy,  Histology,  and 
Experimental  Physic' 

Operations 

rj,    Eleotro 

die  Surgery, 

Three  annual  regular  sessions  are  required. 


daglng.  Opi 

Neurology.    Bteotro  Tberai 

Orthopaedic  Si 


Bedside  instruction  fa  Medicine,  Oynascotooy. 
Surgery,  and  Obstetrics  is  a  part  o/  the  third  year 
saw  as.   No  extra  fee. 

The  Annual  Announcement  will  be  sent 
an  appnoatioo  to 

J.  W.  HOLLAND,  M.D.V  Dean. 

Albany  Medical  College. 

MEDICAL    DBPABTKBUT,    UHIOH    CNIVIRBITT. 
180448. 
ALBANY,  N.  T. 
Begolar  Term  begins  September  85,  1804  and 
closes  April  16, 1895. 

Instruction  by  Lectures,  Beeltatlons,  Cantos, 
Laboratory  Work,  and  Practical  Operations.  Three 
year  strictly  graded  course.  Hospital  advantages 
excellent. 

FBES-Matriculatlon,  IB:  Lectures,  $100  (Per- 
petual Ticket,  t*o0) ;  Dissection,  $10  (material  free); 
Laboratory  Courses  In  Chemistry,  Histology,  and 
Pathological  Anatomy,  each,  810.00 ;  Graduation 
Fee,  fas. 

Catalogues  and  Circulars  containing  foil  Infor- 
mation, sent  on  application  to  , 
WILLIS  O.  TUCKER,  M.D..  BMSTBAn, 
Albany  Medical  Collect,  Albany,  N.  T. 


SEND  FOR  A   CATALOGUE 

—  Of  — 

H.  WOOD  I  CO/8  PUBLIC1TI0R 


BOWDOIN   COLLEGE. 

MEDICAL   DEPARTMENT. 

The  T5th  Annual  Coarse  of  Lectures  at  the  Medi- 
cal School  of  Maine  win  begin  January  10, 1896, 
and  continue  twtnty-four  (04)  week*. 

FACULTY,— Ibbail  T.  Daka,  MJ>.,  Pathology 
and  Practice ;  ALrun  Mitchell.  M.D.,  Obstetrics 
and  Diseases  of  Children ;  Frbobsice  H.  Qamnnm, 
M.D.,  Anatomy ;  Hon.  Luctltob  A.  Bhbet,  A.M., 
Medical  Jurisprudence ;  Stepheh  H.  Wkees,  M  D., 
Surgery  and  Clinical  Surgery ;  Chakles  O.  Hmr. 
M.D.,  Materia  Medica  and  Therapeutics ;  Fuahk- 
um  C.  ROBiraoM,  A.M.,  Chemistry ;  Chakles  D. 
Smith,  M.D..  Physiology  and  Public  Health ;  Job* 
P.  Thomtsoh,  M.D.,  Diseases  of  Women;  Alios* 
R.  Moultom,  M.D.,  Mental  Diseases ;  Willis  B. 
Moultok,  M.D.,  CUnlcal  Instructor  in  Diseases  of 
Eye  and  Bar ;  Admbox  I.  Thatkb,  M.D.,  Demon- 
strator of  Anatomy;  William  L.  Daka,  M.D., 
Demonstrator  of  Histology. 

Circulars,  containing  lull  Information,  may  be 
obtained  upon  application  to  the  Secretary. 

ALFBBD  MITCHELL.  sLD.,  Secretory. 

BBUMBWIOX,  MB..  August  8,  1804. 


wcsTam  ramsYLVMM  moicm.  csuek 

medical  DBPAmrnxirr  op  tub 

wistoh  raivusiTT  or  pbevotltaeia. 

Regular  Session  begins  0d  Tursday  in  Sept..  180s 
-lasts  six  months.  Spring  Session  begins  Id  Tues- 
day in  April.  1806  -lasts  ten  weeks.  Three  years' 
graded  course.  Poor  years  required  after  April, 
1806.  Unequaled  Hospital  and  Dispensary  advan- 
tages. Thoroughly  equipped  Laboratories.  Cttnt- 
cai  Instruction  regularly,  and  opportunities  unsur- 
passed. For  particular*,  see  announcement— 
enures*  Prof.  T.  M.  T.  MCKENNAN,  Sec  Faculty, 
810  Penn  Avenue,  Pittsburgh. 

correspondence  should  be  addressed  to 

Prof.  W.  J.  A8DALB,  Sec  Board  of  Trustees, 
nor  Penn  Ave.,  Pittsburgh,  Fa. 


THE  BALTIM0IE  MEDICAL  C0LLE0L 

Puldoiiabt  Fall  Counts  begins  September 
1st  i  Regular  Wnrni  Cocas*  begins  October  1st 

Excellent  Teaching  Facilities;  Magnificent 
New  College  Building;  Superb  Lecture  Halls;  large 
and  completely  equipped  Laboratories;  capacious 
Hospital  and  Dispensary ;  Lyln*4n-Department  for 
teacnlng Clinical  Obstetrics; TLarge  CUnlca.  Bead 
tor  Catalogue,  and  address 

DAVID  8TREs7IT,  M.D.,  Dean, 

St^  Balttmote,  MOL 


Yale  University, 

DEPARTMENT    OF  MEDICINE, 

Tue  currleulum  Is  graded  to  extend  U 
three  years,  and  consists  chiefly  of  personal 
mrueuon  in  Class-rooms,  Laboratories,  and  catmosg 
Udaotic  lectures  are  retained  to  certatabnneaea, 

The  eoilege  year  contains  thirty  four  weeka,  sua 
oeglos  on  the  first  Thursday  in  October. 

FEES.— Matriculation,  $0.00;  Tuition,  nrat  and 
second  year,  each  $140;  third  year,  $80^0,  Grad- 
uation, 800.00. 

For  announcements,  giving  particulars  of  fee 
course  and  requirements  for  admission  and  grad- 
uation, send  to  Da.  HERBERT  E.  SMITH,  DUAn, 
Hew  Haven,  Conn. 


NIAGARA  UHTERSITY. 

Medical  Department,  BuJBhlo,  X .  Y. 

/The  next  regular  course  of  lectures  win  begin 

September  86. 1804,  and  clou  May  10, 1800.    Goad 

laboratory  and  hospital  advantages.     Obstetric 

opportunities  unexcelled.  For  announcement*  etc. 

Address  ALVIN  A.  HUBBELL,  M.D.. 

810  Franklin  St..  Buffalo,  N.  T. 

A  MANUAL  OF  OBSTETRICS, 

By  E.  L.  PARTRIDGE,  M.D. 

(Wood's  Pocket  Manuals.) 

3*mo,  jos  pages,  profusely  illustrated  with  min- 
iature engravings.    Muslin,  $i.oo. 

WM.  WOOD  *  CO.,  NEW  YORK. 


MEDICAL  RECORD. 


33 


OFFICIAL  ANNOUNCEMENTS 
OF  MEDICAL  COLLEGES. 


Chicago  Polyclinic  and  Hospital. 

A  clinical  school  for  Praotltlonars  of  Medtctne. 
The  Institution  la  thoroughly  equipped  for  Post- 
graduate Instruction  in  all  branches  of  Kedldne 
and  Surgery ;  nneqoaled  Hoipltal  Facilities,  abun- 
dance  of  clinical  material.  Bxcellent  advantages 
for  Laboratory  work,  practical  Anatomy  and 
Operative  Surgery.  For  Information  or  the 
announcement,  apply  to  the  Corresponding  Sec- 
retary, Br.  M orean  R.  Brown,  1T4  to  176  Chicago 
Avenue. 

KEOKUK  MEDICAL  COLLEGE. 

The  regular  Fall  and  Winter  Session  opens 
September  4, 1894.  and  will  continue  six  months. 

The  faculty  la  composed  of  experienced  medical 
teachers.  Clinics  regularly  at  St.  Joseph's  BoapltaL 

A  ten  weeks'  reading  and  recitation  course  fol 
towing  the  regular  Winter  Beaalon  la  provided. 

Fees  for  the  regular  Session,  Matriculation, 
10.00;  Lecture  Fees,  Including  Hospital  Ticket, 
188.00;  Graduation  Fee,  $80.00.  Material  at  coat. 
For  circular  or  Information,  address 

J.  A.  80ROGQ8,  M  D ,  Secretary,  or 
T.  J.  MAXWBTJU  M.D..  Cor.  Secretary,  Keokuk,  la. 

QEOROETOWN    UNIVERSITY. 

MEDICAL  DEPARTMENT. 
Forty-alxth  Session  opens  October  1, 1804,  and 
win  continue  seven  months. 

Instruction  is  given  by  lectures,  recitations,  cMni 
eal  teaching,  and  practical  demonstrations.  In  the 
subjects'  of  Anatomy,  Chemistry,  Physiology, 
Hygiene,  Histology,  Pathology,  and  Bacteriology 
al  practical  Instruction  Is  given  in  well 
>ped  laboratories. 
"  nt  and  ample  clinical  facilities  are  fur- 
For  annual  announcement,  address  the 


equipped  laboratories, 

2X4 


xoeUent  and  ami 

nmnyl.    For  *nnn*» 

Dean.  G  L.  MAQRUDKB,  M.D. 

81*  Vermont  Ave.,  Washington,  D.  a 


of 


He*lesd 

WESTERN  RESERVE  UNIVERSITY, 

GLKVZLAHD,  o», 


Presents  a  three  years' 

ft  term  of  eight  months.  Instruction  by  recti 

lectures,  cunios,  qulsses,  and  practical  ' 


course,  each  year 
tatlons, 


Ample  laboratory,  dispensary,  and  hospital 

Mas  and  equipments  are  provided  for  an  students. 

Tickets,  per  year,  $100. 

Ticket  for  whole  course,  fsffO. 
Special  courses  as  desired,  and  advanced  stu- 
dents given  standing  according  to  assured  aoqulre- 
ssents.   Tear  begins  the  middle  of  September. 
Omasum  F.  Thwhto,  D  D.,  President  of  University. 


Baltimore  University. 

SCHOOL  OF  MEDICINE. 

The  Regular  Course  of  Lectures  in  this  Institu- 
tion wUlbegln  October  1st. 

The  teaching  faculties  are  excellent.     Large 
Qmlea,etc. 
For  Catalogue  and  other  information,  address 
B.  W.  KILAU,  M.D.,  Dean. 

1887  Madison  Ave.,  Baltimore,  Md. 


Cutaneous  riemoranda 

By  H.  Q.  Pifford,  H.D. 


(  Wood's  Pocket  Manuals.) 

32mo,  274  pages,  muslin,  $1.00. 
WM.  WOOD  &  CO..  NEW  YORK. 


University  of  California. 

MEDICAL  DEPARTMENT. 
Sam  FaAMcmoo,  -      California. 

The  Session  of  18M  wfll  begin  January  7th,  and 
oontfnue  six  months.  Four  courses  of  lectures 
are  required.  The  clinical  facilities  are  unsur- 
passed. Fees:  Matriculation,  $6.00.  Lectures, 
$100.  Graduation,  $25.00. 
For  annual  announcement,  address 

B.  A.  MoLBAN,  M  DM  Dean, 

806  Kearny  Street. 


Woman's  Medical  College 
of  Pennsylvania. 

Tne  Forty-flfth  Akhual  Sbbsioh  opens  Sept. 
as,  18M.  A  four  years'  graded  course  of  Lectures, 
Qnlsses,  Laboratory,  and  Clinical  Work  offers 
superior  advantages  to  students,  who  are  also  ad- 
mitted to  the  olmtos  of  the  public  Hospitals. 

Address  CLARA  MARSHALL,  M.D.,  DXAM, 
181 8.18th  8L,  Phila. 


Essentials  of  Chemistry, 

Inorganic  and  Organic,  for  the  Use  of 

-'■  '  nts  In  JV7 


Students  I 

Twelfth  Edition. 

By  R.  A.  WITTHAUS,  A.M.,  M.D. 

One  volume,  321m),  320  pages,  muslin,  price,  $1.00. 
WM.  WOOD  &  CO.,  NEW  YORK. 


OT8o  laborious  a  task  as  the  compilation  of  this  closely  printed  volume  of  nearly  900  pages  has  not  been  previously  attempted  by  any  bacteriologist.   Da 
the  publishers,  too,  the  highest  praise  is  due  lor  the  admirable  series  of  illustrations  with  which  the  text  Is  supplied."— Edinburgh  Medical  Journal* 

A  MANUAL  OF  BACTERIOLOGY 

By  GEORGE  M.  STERNBERG,  M.D., 

Surgbon-Genbral  U.  S.  Army; 

Director  of  the  Hoagland  Laboratory  (Brooklyn,  N.  Y.) :  Honorary  Member  of  the  Epidemiological  Society  of  London ;  of  the  Royal  Academy  of  Medicine 
of  Rome;  of  the  Academy  of  Medicine  of  Rio  de  Janeiro ;  of  the  American  Academy  of  Medicine,  etc.,  etc. 

Illustrated  by  four  heliotype  and  four  chromo- lithographic  plates  and  321  engravings.      8vo,   850  pages.      Price,   maroon 

muslin,  $8.00;  leather,  $9  00. 


This  work  is  divided,  generally,  into  four  sections.  In  the  first  the  author  deals  with  classification,  morphology,  and  general  bacterio- 
logical technique.  In  the  second  he  takes  up  the  general  biological  characters  of  micro-organisms.  In  the  third  division  the  patho- 
genic organisms  are  considered,  and  in  the  fourth  the  saprophytic  forms.  The  more  practically  important  parts  of  the  work  are  printed 
in  large  type,  while  matters  of  less  importance  appear  in  smaller  type. 

In  the  first  section  the  descriptions  of  methods  will  be  found  unusually  clear  and  terse  and  the  illustrations  admirably  calculated  to 
elucidate  the  text 

The  third  section  is  the  most  important  of  all,  dealing,  as  it  does,  with  micro-organisms  in  their  relations  to  disease.  The  general 
questions  of  their  mode  of  action  and  their  manner  of  introduction  into  the  body,  together  with  the  susceptibility  and  immunity  of  animals, 
is  discussed,  and  the  various  organisms  associated  with  specific  morbid  conditions  are  described  in  detail. 

Part  four  is  devoted  to  the  consideration  of  saprophytic  bacteria,  and  includes  chapters  on  those  found  in  air,  water,  soil,  on  the  surface 
of  the  body  and  exposed  mucous  membranes,  in  the  stomach  and  intestines,  etc.,  etc. 

In  all,  Dr.  Sternberg  gives  an  account  more  or  less  full  of  four  hundred  and  eighty-nine  species. 

The  book  concludes  with  a  remarkably  complete  bibliography,  including  all  important  articles  and  works  on  the  subject  from  the 
earliest  times.    It  contains  two  thousand  five  hundred  and  eighty-two  references. 

The  work  consists  of  a  single  royal  octavo  volume  profusely  and  beautifully  illustrated  throughout  the  text  by  numerous  carefully 
prepared  wood-engravings  and  "half-tone"  process  cuts,  many  of  the  latter  being  direct  reproductions  of  photo-micrographs,  and  all 
executed  and  printed  in  an  exceptional  manner.  Also  four  full-page  heliotype  plates  from  photo-micrographs  by  the  author  of  the 
important  pathogenic  bacteria,  and  four  full-page  chromo-lithographic  plates. 

Price,  delivered  free  at  any  address  in  the  United  States,  muslin,  $6.00 ;  sheep,  $9.00. 


WWL  WOOD  &  CO.,  Publishers,  43f  45  &  47  East  Tenth  Street,  New  York. 


34 


MEDICAL  RECORD. 


PRIVATE  HOSPITALS, 
SANITARIUMS  AND  RETREATS. 


fiREERMONT-  ON  -THE -HUDSON 

for  Mental  and  Nervous  Diseases. 
Balnh  Lyman  Parsons,  KJ>., 

Balph  Wait  Parsons,  stj)., 

Sing  Slug,  H.T. 
Cnrr  Office  :  u  Bast  44th  Street, 
Mondays  and  Fridays  from  *M  to  4.M  PJL 

LAKE  VIEW. 

A  imall  private  home  for  care  and  treatment 
of  Nervous  and  Mild  Mental  Diseases. 

Located  at  Burlington,  Vt.  Extensive  view  of 
Lake  Champlaln,  Adirondack  and  Green  Moun- 
tains. High  rooms— large  sonny  windows— steam 
neat  in  every  room -pleasant  wafts  and  drives 
Patients  are  members  of  toe  Doctor's  own  flamllj 
affording  a  comfortable  borne  while  under  oon- 
stent  medical  treatment  and  the  care  of  experi- 
enced nurses. 

Special  rates  for  continued  cases. 

Address,  for  circular,  terms,  etc, 

DB.  J.  M.  CLAJtKB,  Burlington,  Vt, 

BRUNSWICK    HOME. 

AMITYVILLE,  LONQ  ISLAND. 

▲  private  institution  for  the  care  and  treatment 
of  epileptics,  feeble-minded,  and  alcoholic  habitues; 
duly  licensed  by  the  State  Commission  In  Lunacy; 
one  hour  from  New  York  and  Brooklyn ;  five  min- 


utes from  railway  station;  pleasantly  situated  close 
to  Great  South  Bay ;  beautiful  drives  and  walks ; 
home  comforts  and  careful  medical  supervision 


day  and  night;  private  attendant  If  required; 
electric  light,  modern  conveniences,  and  sanitary 
Improvements.    Stage  meets  trains. 

For  terms  and  information,  address 
J.   T.  W.  BOWK,  M.D,  Physician  in  Charge. 
(Late  of  New  York  City  Asylums  for  the  Insane.) 

THE  WILLARD  NERVINE  HOME. 

For  the  treatment  of  Nervous  Prostration  and 
other  diseases  of  the  Nervous  System  Also  known 
as  "Use  Nervine"  and  "The  Best-Cure." 
Under  the  supervision  of  Or  A.  J.  Wlllard  (Yale 
'68),  Burlington,  Vermont.  This  Is  an  attractive 
modern  building,  of  the  Queen  Anne  style  of  archi- 
tecture, situated  on  tbe  "  College  Hill,"  and  com- 
manding a  one  view  of  the  Adlrondacks  and  Lake 
Cbamplaln.  It  has  every  necessary  appliance  for 
Its  special  purroee,  sunshiny  rooms  with  numer- 
ous ore-places,  a  large  solarium,  convenient  ve- 
randas, and  ample  grounds.  Dr.  Wlllard's  medical 
system,  based  upon  extended  study  and  experience, 
is  largelya  modification  of  the  Mitchell  Rest  Treat- 
ment. This  Is  simple  and  scientific  and  has  thus 
far  yielded  very  satisfactory  results,  other  meth- 
ods, however,  are  used  according  to  the  indications 
of  the  esse.  Full  Information  and  satisfactory 
references  furnished.    Correspondence  solicited. 

DR.  FLIPPIN'8 

PRIVATE   SANITARIUM, 

For  the  cure  and  treatment  of 

Coatisiptioi  aid  all  Cfemic  Diseases. 

For  terms  and  references,  address 

Dr.  J.  MEIGS  FLIPPIN, 
Ihomasville,  JT.  C. 

SPECIAL   RATES   TO 

Private  Hospitals,  Sanitarium*, 

And  Retreats. 


DARIEN  HOME  AMD  SANITARIUM, 

Darien  (N.  Y.  N.  H.  <&H.  R.B.),  Conn. 

A  country 
home  for  the 
private  care 
and  treat- 
ment of  Men- 
tal and  Nerv- 
ons  Diseases. 
Alcoholic  and 
NarooticHab- 
itues.  Delight- 
fully situated 
near  Roton 
Point,  on  Long 
Island  Sound, 
88  miles  from  Grand  Central  Depot,  N  Y.  City. 
Excellent  buildings,  healthful  and  beautiful  sur- 
roundings, pleasant  walks  and  drives.  Patients 
met  at  Stamford,  Conn.  (50  minutes  fiom  Grand 
Central  Depot),  when  notified.  Maw  York  City 
offloa  hours  (at  615  Lexington  Ave.),  WP.i 
Thursdays,  and  by  appointment.  For  terms  and 
information,  call  at  New  York  City  office,  ls-l  P.M. 
dally,  or  address  J.  JOS.  KINDRED,  A.D.* 
Medical  Superintendent,  Darien,  Conn, 


Mate  Hospital  for  Mental  Diseases, 

Brookline,  near  Boston,  Massachusetts. 
Established  18T9. 

WALTER  CHANNING,  M.D.,  Superintendent. 
Post-office  Address, 

Garner  Boylston  St,  and  Chestnut  Hill  Ave*, 
BBOOKUNE,  MASS. 


DR.  S.  a.  WEBBER, 

Lately  Superintendent  of  Adamaf 
Nervine  Asylum,  will  reoeiyf 
patients  with  nervous  diseases,  not 
insane,  in  his  house, 

116  Marlboro'  Street,  Boston,  Mtm 

The>  Private  Institution  for 

FEEBLE-MINDED  YOUTH 

At  BARRE,  MASS., 
EBTaBUSHKD  JUHE,  1848, 

aflers  to  parents  and  guardians  superior  facfh 
lies  for  the  education  and  Improvement  of  thlt 
slass  of  persons,  sod  the  comforts  of  an  elegant 
aountry  home, 

GEO.  A.  BROWN.  M.D. 


THE    PINES, 

AUBURN,  NEW  YORK. 
A  Physician's  Home  for  thet  Care  and  ' 
of  Nervous  and  Mental  Invalids. 


Duly  lloensed  by  the  State.  Number  of  i 
limited  to  twelve.  A  special  nurse  for  each  paOsoL. 
Oulalne  excellent.  Buildings  substantially  con- 
structed and  well  furnished.  Pleasant  srounOs, 
twenty  acres  In  extent;  elevated,  secluded,  sad 
within  a  mile  of  railway  stations  and  center  of  tat 
city.  Address  all  communications  to 
FREDERICK  8EPTON.  M.D., 

Phystdan  In  Charge. 

MENTONE,   FRANCE. 

Physicians  contemplating  sending  patients  to 
the  south  of  France  for  the  coming  autussn  and 
winter  can  procure  the  best  of  accommodation 
with  the  most  delightful  sunoundings  of  tat 
Riviera,  at  Mentone,  between  Marseilles  and  Genoa, 
being  the  residence  (Villa  Laurent!.  Bass  Bay. 
Mentone)  of  WILLIAM  FRANCKEN.  M.Dl.  cf 
the  Amsterdam  University  and  of  the  Parte  Faculty. 
In  summer,  Medical  Director  of  the  seaside  resort 
st  Schevenlngen.  Holland.  Full  particulars  ob- 
tained personally  or  by  addressing  Pro!  A. 
FRANCKEN,  14*  Hooper  St.  Brooklyn,  N.  T^or 
Colonel  W.  R.  Hopkins,  Stamford,  Oonn. 

WALNUT    LODGE    HOSPITAL, 

HABSFOnn,  Oohw . 
Organised  in  1880  for  the  special 

•  of  ALCOHOL  AND  OPIUM  INKRRIA1 


Elegantly  situated  In  the  suburbs  of  the  etty,  win 
every  appointment  and  appliance  for  the  — " 
ment  of  this  class  of  esses,  lndudtns;  Ti 
Russian,  Roman,  Saline,  end  Medicated 
This  Institution  Is  founded  on  the  weH-r 
fact  that  Inebriety  la  a  disease,  and  c 

all  these  oases  require  rest,  change  of  t 

living.  In  the  best  surroundings,  eta,  etc. 

Applications  should  be  addressed 

T.  D.  CROTHS28.  MJX. 
8up*t  Walnut  Lodge,  Hartford,  Cans. 

WALDEMERE 
oso---r:B:ai-flioxTzarx>v 

SEaunsuronecst,  If.  T. 

For  the  private  care  and  treatment  of  Mental  and 
Nervous  Diseases,  Aloohotto  and  Narcotic  Habft- 
ues.  Waldemere  Is  twenty  miles  from  Grand 
Central  Station,  New  York  Oty.  Trains  every 
hour.  Applications  can  be  made  at  US  n^w^m 
Avenue,  New  York  City.  9  to  11  A.  M 

Da.  R.  N.  CARPENTER,  Superintendent 

CROMWELL  HALL, 

tar  Mervous  and  Mental  Dfasaana, 

CROMWELL,  CONNECTICUT. 

Established  18TT. 

W.^B.  Hillock,  M.D.  F.  K.  wsmpwr 

Monthly  Office  Hours  in  New  York.  1  to  4  PJL 
Tmlrd  Thursday,  at  «T  West  60th  St. 

First  Tuesday,  st  8»  Madison  An 


l»  S^JBsTX-F^JEULXTBC 

For  Mental   and    Nervous  Diseases, 

WOO&HA.TMX,  X.  J„  cm  mile  from  Brooklyn.  Telephene:  7-1,  M«s*  JToew  Tar*. 

NBwYoaKOvFiOE:  Dr.  F.  A  McGUIRE,  I   Brooklyn  Office  :  Dr.  R.  a  F.  COMBES, 

681  Lexington  Ave.,  8-10  A.  M.,  1-2 and  6-8 P.  M.   |  887  Greene  Avenue.  MlV^c-TP.I, 


Saratoga  Springs,  N,  Y.f- 

Beoeivee  persons  reoommended  to  it  by  their  home  physicians  for  Treatment*  Changs, 
Best,  or  Recreation.     Send  for  illustrated  circular. 


THB    BAR    AND    ITS     DISEASES, 

BEING  PRACTICAL  CONTRIBUTIONS  TO  THE  STUDY  OF  OTOLOGY. 

By   SAMUEL    SEXTON,   M.D., 

Autal  Surgeon  to  the  Now  York  Eye  and  Ear  Infirmary  ;  Fellow  of  the  American  Otologics!  Society  :  Fellow  of  the  New  York  Academy  of  MHHnt ;  asembsc  af 

fha  M*Hm*a1  (Motv  i\t  tit*  P/Mintv  rtf  N»«r  Vftrlr     inrl  nf  thm  Prakrit  «nn»*>a'  &vi«>hr  at  Nnr  VnrV 


the  Medical  Society  of  the  County  of  New  York,  and  of  the  Practitioners'  Society  of  New  York. 
Bdlted  by  CHRISTOPHER  J.   COLLES,  M.D. 


la  this  work  the  author  has  not  attempted  to  present  a  treatise  on  the  ear  embracing  the  entire  field  of  Otology ;  but  the  particular  subjects  embraced  by  tbe 
I  to  which  he  has  directed  more  special  attention,  cannot  fail  to  be  of  service  to  the  General  Practitioner,  while  not  devoid  of  interest  to  the  Otologist. 
The  work  is  illustrated  with  numerous  original  wood-eagravings ;  contains  473  large  octavo  pages,  and  is  furnished  with,  a  complete  index.    Price* 


£4.00. 

WILLIAM 


WOOD  &  COMPANY,   Publishers, 


43  to  47  East  10th  Street,  New  York. 


MEDICAL  RECORD. 


35 


PRIVATE  HOSPITALS, 
SANITARIUMS  AND  RETREATS. 


KOMWA.LK,  CONNECTIGTTT. 

For  the  care  and  treatment  of  Insanity  and 
Nervous  Diteasos.  Alcoholic  and  Narcotic 
Habitoiee.  Address  EDWIN  EVERETT 
SMITH,  M.D.,  Booth  Wilton,  Connecticut. 

Wednesdays,  2.80  to  480  P.M. 

18  Bast  47th  Street,  New  York  City. 


Mental  and  toons  Diseases  of  Women. 

A  separate  department  for  this  class  re- 
quiring pelvic  operations  or  treatments  has 
been  connected  with  Or.  Via  dt  Warker's 
Private  SaaatariMB  far  Wwata,  and  under  his 
charge.     For  terms,  address 

Dr.  ELY  VAN  DB  WARKBE, 

Syracuse,  N.  Y. 


Miss  ALSTON'S  HOUSE, 

106  East  88th  Street,  New  York  City. 
Miss  A  L.  Alston,  for  nearly  elgbt  years  Super- 
intendent of  Mount  Sinai  Training  School  for 
Norses,  has  opened  a  house  for  the  reception  of 
private  patients.  All  classes  of  patients  will  be 
received  (including  maternity  oases)  except  pa- 
tients suffering  from  contagious  diseases  or  in- 
sanity. For  farther  particulars  or  for  circulars, 
send  to  above  address. 

Tlie  Riolxard.  Gundry  Home, 

CatonavtOe,  Balto.  Co.,  MO., 
Wot  Mental  and  Nkryoub  Dihbjses,  Oram,  and 
Alcoholic  Addiction.   For  circulars,  rates,  etc. 
•ddress         Da.  B.  F.  GUNDBY,  box  107. 

BrnmoBi :  Dr.  Henry  M.  Hurd  and  Dr.  Wm, 
Jaler,  Johns  Hopkins  Hospital.  Baltimore,  Md.i 
Or.  John  Morris,  Baltimore,  Md.;  Dr.  H.  A  Tobey, 
Foledo.  O.;  Frauds  White,  Esq.,  Baltimore,  M<tj 
3Umor  Meredith,  Esq.,  Baltimore,  Md. 

Dp.  Gundry  can  be  consulted  at  the  Baltimore  Of- 
tee^l  B.  Centre  St.,  Tuesdays,  from  12  to  1,  or  by 
appointment. 


Broadview  Sanitarium, 

HOLYOKE,  MA88., 

For  the  private  care  and  treatment  of  Nerv- 
ous and  Mental  Diseases,  Alcoholic  and 
Narcotic  Habitues. 

For  terms  and  information,  address 
L.   11    SELLING,    M.D.,   Medical    Supt. 


THK    HIGHLANDS. 

A  private  hospital  established  in  1875  by  Ira 
BuaeelL  M.D.,  for  the  treatment  of  mild  nervous 
and  mental  diseases,  the  opium  and  alcoholic 
habits,  and  nervous  debility.  The  principles  of 
home  and  family  life,  non  restraint  and  open  air 
are  carried  to  an  extreme.  The  surroundings  are 
sxceptlonally  pleasant 

For  circulars,  terms,  references  from  all  parts  of 
Che  United  States,  address  the  Superintendent. 
Dr.  FMPgMOT  W. ~~"    '  


THE  INEBRIATES'  HOME,  FORT  HAMILTON,  N.  T. 

INCORPORATED    1866- 
A  Hospital  for  the  Treatment  of  ALCOHOLISM  and  the  OPIUM  HABIT. 


President:  Bon.  F.  8.  If  ASSET.  Consulting  Physlolaai  1*  D.  MASOM,  M.B. 

Bfedloal  Superintendent:  JAMBS  A.  BLANOHABD,  Bf.D.  Assistant  Physlolan:  F.  T-.  DOUEARB,  Bf.D. 

flie  building  is  situated  in  a  park  of  twenty-six  acres,  overlooking  and  commanding  line  views  of  the  Narrows,  and  the  upper  and  lower 
hay  of  New  York  Harbor. 

Hie  accommodations,  table,  attendance,  and  nursing  are  of  the  best  character  and  suited  to  first-class  patients. 

For  manner  and  terms  of  admission,  apply  to  the  Superintendent,  at  the  Institution,  Fort  Hamilton,  Brooklyn,  ft  T. 

KIRKE'S  HAND-BOOK  OF  PHYSIOLOGY.     13th  Edition. 

Hand-book  of  Physiology. 

BY 

W.  MORRANT  BAKER,  F.R.C.S., 

Late  Surgeon  to  and  Lecturer  on  Physiology  at  St.  Bartholomew's  Hospital,  etc., 

AND 

VINCENT  DORMER  HARRIS,  M.D.,  Lond.,  F.R.C.P., 

Examiner  in  Physiology  at  the  Conjoint  Board  of  the  Royal  College  of  Physicians  and  Surgeons,  and  in  the  University  of  Durham  ;  Demonstrator 
of  Physiology  at  St.  Bartholomew's  Hospital ;  Physician  to  the  Victoria  Park  Hospital  for  Diseases  of  the  Chest. 

THIRTEENTH   REVISED  EDITION. 

Kirke's  Physiology  has  long  been  the  text-book  in  this  branch  of  medical  science,  and  the  fact  that  so  many 
revisions  (this  is  the  thirteenth)  have  been  made  attests  sufficiently  the  value  of  the  book,  and  the  wisdom  of  its 
manner  of  treating  the  subject.  The  Preface  announces  that  in  the  preparation  of  this  edition  the  authors  have 
endeavored  to  furnish  the  student  with  an  account  of  Physiology  brought  up  to  the  present  time.  The  whole  book 
has  undergone  a  very  thorough  revision,  and  the  scope  of  the  work  has  been  to  some  extent  enlarged. 

PRESS  NOTICES. 


"  Recent  advances  in  physiological  research  have  rendered  nec- 
essary the  addition  of  much  new  matter,  and  the  rewriting  of  por- 
tions of  the  old  text  About  50  new  illustrations  have  been  added. 
In  its  present  form  it  is  undoubtedly  one  of  the  best  text-books  on 
physiology  extant."—  The  Toledo  Medical  and  Surgical  Reporter. 

"The  Messrs.  Wood  do  not  intend  to  forget  the  juniors  and 

five  them  therefore  the  best  works  at  a  nominal  price.     There  is 
ardly  a  practitioner  of  some  years  who  did  not  learn  the  princi- 
ples o:f  physiology  from  Kirke's,  and  any  work  which  reaches  an 
elevcratn  edition,  shows  its  itrinsic  value/' 
—  The  North  American  Journal  of  Homoeopathy,  Philadelphia. 


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language  for  the  clearness  of  statement  of  established  facts  in  the 
science  of  which  it  treats." — The  Sanitarian,  New  York. 

*■  Indeed,  the  order  of  subjects  and  arrangement  .of  matter 
throughout  the  volume  are  most  excellent,  ajid,  as  a  hand-book, 
the  absence  of  all  controversial  argumentation  on  settled  points 
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structive, and  this  is  the  chief  end  of  a  picture  in  a  work  on  phy- 
siology."—  The  American  Practitioner,  Louisville,  Ky. 


The  thirteenth  edition  of  Kirke  is  complete  in  one  volume  of  840  pages,  profusely  illustrated  by  over  500  engrav- 
ings, many  of  them  in  various  colors,  and  a  chromo-lithographic  plate.     Price,  muslin,  $4.00;  leather,  $5.00. 

WILLIAM  WOOD  &  COMPANY,  Publishers,  New  York. 


3« 


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NERVE    PROSTRATION 

ND     OTHE>R     FUNCTIONAL     DISEASES      OK     DAILY     LIF! 

By  ROBSON    ROOSE,    M.D.,  LL.D.,  F.C.5., 

Fellow  of  the  Royal  College  of  Physicians  in  Edinburgh. 
8ROOND     REVISED     AND     ENLARGED     BDITION. 


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aeeonnt  of  functional  disorders  has  been  favorably  received  by  the  profession.  In 
and  while  some  portions  hare  been  condensed,  others  (notably  the  chapters  dealing 


been  oot  of  print  for  some  time,  its  author  feels  justified  fat 
.  the  preparation  of  a  Second  Edition,  each  chapter  has  been 

t  portions  hare  been  condensed,  others  (notably  the  chapters  dealing  with  Neurasthenia)  have  been  considerably  amplified.  It  ha 
desirable  to  give  a  description  of  various  toxic  neuroses— vis :  those  due  to  akhohol,  opfcun.  etc,  and  to  supplement  the  section  on  Disorders 
Organs  by  adding  a  chapter  on  Corpulence.      »    One  voltuoe  of  603  pagca,  octavo,  btond  ta  oraalta,  price,  $4.90. 

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rMEDlCAL- 


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CONTENTS. 

_„._. _ ---.-„,„  .  .  .........  -Maximum 

Adult  Doses  by  the  Mouth,  in  Apothecaries'  and  Decimal  T 


Calendar— Estimation  of  the  Probable  Duration  of  Pregnancy— Approximate  Equivalents  of  Temperature,  Weight,  Capacity,  Measure,  etc- 
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Addresses— Addresses  of  Patients  and  Others— Cash  Account. 


Record  of  Obstetrical  Practice— Record  of  Vaccinations— Register  of  Deaths— 


Notices  from  the 
Medical  Press. 


44  One  of  the  best  of  the  kind." — Therapeutic  Gazette. 

44  This  is  one  of  the  best  we  have  seen." — Canadian  Practitioner. 

44  Wm.  Wood  &  Co.  issue  their  Visiting  List  in  the  same  style  they  do  all  their  publications — excellence 
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In  genuine  black  CALF  SKIN  wallet,  with  flap,     ...       30  and  60  Patients  per  week,  with  or  without  dates,  $3.00  and  $3.25 
In  genuine  black  SEAL  SKIN  wallet,  without  flap,  .       30  and  60  Patients  per  week,  with  or  without  dates,  $3.00  and  $3.25 

In  genuine  black  SEAL  SKIN  wallet,  with  flap,     ...       30  and  60  Patients  per  week,  with  or  without  dates,  $3.50  and  $4.00 
The  Six  Month*'  Book*  for  the  inside  will  bo  sold  separately  at  Thirty  Cents  each  for  30  Patients  per  week,  and  Fifty  Cent*  eaohfor  90  Patients  per  men. 

N.  B.— No  goods  can  be  shipped  unless  the  money  Is  sent  with  the  order. 

WM.  "WOOD  &  CO.,  Medical  Publishers,  43,  45  &  47  East  10th  St.,  New  York. 


MEDICAL  RECORD.  37 


TWO  VOLUMES  ARE  NOW  READY. 

Medical  Jurisprudence, 
Forensic  Medicine,  and  Toxicology. 

By  R.  A.  WITTHAUS,  A.M.,  M.D., 

PROFESSOR  OF  CHEMISTRY,  PHYSICS,  AND  HYGIENE  IN  THE  UNIVERSITY  OF  THE  CITY  OF  NEW  YORK,  ETC.,  ETC., 

And  TRACY  C.  BECKER,  A.B.,  LL.B., 

COUNSELLOR-AT-LAW,  PROFESSOR  OF  CRIMINAL  LAW  AND  MEDICAL  JURISPRUDENCE  IN  THE  UNIVERSITY  OF  BUFFALO. 

WITH  THE  COLLABORATION  OF 

August  Becker,  Esq.;  Chas.  A.  Boston,  Esq.;  W.  N.  Bullard,  M.D.;  J.  Clifton  Edgar,  M.D.;  D.  S.  Lamb,  M.D.; 

W.  B.  Outten,  M.D.;  HON.  Wm.  A.  Poste  ;  Edward  S.  Wood,  M.D.;  E.  V.  Stoddard,  M.D.;  Hon. 

Goodwin  Brown;  J.  C.  Cameron,  M.D.;  E.  D.  Fisher,  M.D.;  H.  P.  Loomis,  M.D. ; 

Roswell  Park,  M.D.;  Irving  C.  Rosse,  M.D.;  F.  P.  Vandenbergh,  M.D. ; 

J.  H.  Woodward,  M.D.;  George  Woolsey,  M.D ;.  J.  Parmenter, 

M.D.;  J.  C.  Johnston,  M.D.;  W.  T.  Parker,  M.D. 


It  is  the  aim  of  this  work  to  afford  information  upon  all  points  concerning  which  the  physician  may  seek  the 
lawyer's  advice,  and  upon  questions  concerning  which  the  counsellor-at-law  may  consult  the  physician. 

The  division  of  Medical  Jurisprudence  treats  of  the  relations  of  the  physician  to  the  community  and  before  the  law, 
the  legal  regulations  governing  the  obligations  of  physicians  and  patients,  the  statutory  provisions  establishing  and 
limiting  privileged  and  confidential  communications,  the  rights  and  duties  of  expert  witnesses,  the  physician's  liability 
for  malpractice,  and  the  statutes  of  the  different  States  governing  admission  to  the  right  to  practice  medicine. 

In  the  department  of  Forensic  Medicine  the  lawyer  and  the  physician  may  find  the  most  recent  information 
upon  all  medical,  surgical  or  obstetrical  questions  which  may  present  themselves  in  the  course  of  criminal  or  civil 
proceedings,  presented  by  writers  who  are  acknowledged  experts  in  the  several  branches  of  which  they  treat. 

In  the  first  volume  violent  modes  of  death  other  than  by  poisoning,  and  including  the  modern  subject  of  death 
or  injury  by  electricity,  are  fully  discussed.  The  second  volume  contains  treatises  upon  the  applications  of  the  micro- 
scope to  the  detection  of  blood  and  the  identification  of  hairs,  stains,  etc.;  upon  questions  pertaining  to  the  function 
of  generation,  including  abortion,  infanticide,  rape,  disputed  pregnancy  and  delivery,  sexual  incapacity  and  unnatural 
crimes,  and  upon  the  more  recently  developed  subject  of  railway  injuries.  The  third  volume  will  be  devoted  to 
the  medico-legal  relations  of  the  functions  of  vision  and  audition,  including  injuries  to  the  eye  and  ear,  to  the  crim- 
inal and  civil  aspects  of  the  mental  condition,  and  to  life  and  accident  insurance.  The  fourth  volume  will  treat  of 
the  subject  of  poisoning.  __ ^ _ 

The  entire  volume  shows  a  manifest  purpose  on  the  part  of  its  contributors  to  present  whatever  they  have  found  to  be  of 
medico-legal  utility  in  the  latest  advances  in  medical  science  :  and  all  concerned  in  the  preparation  of  the  work — editors,  collab- 
orators and  publishers — can  be  congratulated  cordially  upon  the  genuine  success  which  has  marked  their  endeavor. " 

— Boston  Medical  and  Surgical  Journal. 

"  It  may  be  expected  to  take  a  high  rank  among  the  manuals  of  its  class." — Medical  News. 

"  The  book  will  be  found  extremely  valuable,  not  only  as  a  reference  book,  but  as  an  instructive  and  readable  one." 

—Journal  0/  American  Medical  Association. 

"  It  is  safe  to  say  that  if  the  succeeding  volumes  of  this  work  come  up  to  the  high  standard  of  excellence  as  established  by 
Volume  I.  it  will  be  many  years  before  there  is  a  work  on  medical  jurisprudence  to  compare  with  it.  It  is  by  far  the  best  work  on 
the  subject  yet  published." — Texas  Medical  Journal. 

"  Every  teacher  of  legal  medicine  must  have  this  work,  and  every  cultivated  physician  will  find  its  reading  both  profitable 
and  most  entertaining." — The  American  Practitioner  and  News. 

"  We  recommend  it  cordially  to  the  legal  profession,  believing,  from  a  careful  examination  of  this  first  volume,  that  it  is  of 
sterling  merit  and  by  far  the  best  contribution  upon  the  subject  which  has  yet  been  published." — The  Green  Bag,  Boston,  Mass. 

"  Probably  the  most  comprehensive  work  upon  subjects  too  often  inadequately  taught  in  the  schools,  both  medical  and  law. 
This  we  believe,  is  the  best  of  its  class  yet  issued." — Massachusetts  Medical  Journal. 


This  important  publication  will  consist,  when  completed,  of  four  large  octavo  volumes  of  about  eight  hundred 
pages  each. 

Two  volumes,  covering  the  Legal,  Thanatological,  Thanato-Biological,  and  Biological  aspects  of  the  subject 
now  completed,  and  the  remaining  two  volumes,  on  Mental  Condition  and  General  and  Special  Toxicology,  will 
follow  shortly. 

These  volumes  are  printed  in  the  best  manner,  from  new  type,  illustrated  wherever  desirable  by  line  and 
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38 


MEDICAL  RECORD. 


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BREWERY,  HUDSON,  N.Y. 


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Oculist*  Ten-Cases, 
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H.  W.  HUJNTE&,  Optician, 

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FOB  THE 


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OPEN  ALL  NIGHT. 

PATHOLOGICAL  SPECMEHS. 

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ana  book  plates  in  oil  oolor,  miorosoope  draw- 
ings by  oamera  lucida,  and  prooeas  drawings 
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Hoars,  10  to  4,  exoep*  Tuesday  afternoon. 

References,  Dr.  Noyes,  Dr.  Roosa,  Dr. 
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k  Go.,  and  others. 


AH  ELEHSSTABT  COTTBBE 


Inorganic  Pharmaceutical 


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Designed  Especially  for  Students  of 
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TMe  Operative  Barbery  e>f  Hallamaat 

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One  volume  of  31  pages  y  16**0,  muslin, 

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GONORRHOEA, 

Being  the  Translation  of 

Blenorrhoea  of  the  Sexual  Organs  and  its 
Complications. 

By  Dr.  ERNEST   FINQER, 

Docent  at  the  University  of  Vienna. 

One  octavo  volume,  of  330  pages,  with  numerous  engravings  In  the  text, 
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MEDICAL  RECORD. 


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sician in  large  apartment  with  an- 
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PriTate  Hospital  for  Sale  or  Lease. 

Situated  at  eorner  of  Lexington  Avenue  and 
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Clothing,  ana  Furniture. 

MEDICAL  SUPPLY  DEPOT,  U.  S.  ARMY, 
New  York  City,  December  5, 1894. 

Will  be  sold  at  auction  at  29  Burling  Slip,  this 
city,  Janaary  8th,  1SS6.  at  IS  M.,  by  Burdett  A 
Dennis,'  auctioneers,  a  large  quantity  of  hospital 
property,  no  longer  required,  consisting  of  Chlor- 
ide of  Lime  in  1  irs.  Instruments  in  cases,Butchers' 


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Medical  Journals,  and  miscellaneous  supplies. 
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WOMAN'S    HOSPITAL, 

In  the  State  of  New  York, 
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New  York,  Dec,  4,  1894. 
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on  Thursday,  Jan.  8, 1895,  at  three  o'clock 
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to  present  themselves  will  apply  to  the 
Secretary,  No.  18  East  80th  Street. 
BACHE  MoE.  EMMET, 

Secretary  Medical  Board. 

Manual  of  General  Medicinal 
-  Technology  .... 

Including  Prescription  Writing. 
By  EDWARD  CURT1SS,  A.M.,  M.D. 

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Address,  naming  this  Journal, 

Dr.  DAWBARN, 

106  Wert  74th  atrMt,  Hew  Tort. 
MEDICAL  PRACTICES. 

Do  yon  wish  to  boy,  sell,  or  exchange  a  Medical 
Practice,  Dental  Practice,  or  Jirug  Busi- 
ness In  the  Nortb,  East,  South,  or  West  ? 

Medical  Practices,  Dentil  Practices,  and  Drug 
Stores  bough t,  sold,  snd  exchanged.  Partnerships 
arranged.  Assistants  and  Substitutes  provided. 
List  of  a  large  number  of  Practices  and  Drug 
Stores  for  sale,  and  all  further  information  sent 
free  oo  application  to  the 

NATIONAL  MEDICAL  PRACTICE  EXCHANGE, 
614  Lexington  Avenue,  New  York  City. 

Home  for  an  Invalid. 


Having  three  furnished  rooms,  in  a  pleas- 
ant suany  housa  in  Brookline,  Mass  ,  that 
have  been  occupied  by  an  invalid  lady  and 
nurse  for  the  last  five  years,  I  would  be 
glad  to  correspond  with  any  one  who  wished 
to  find  a  home  for  an  iofirm  or  nervous  pa- 
tient, obliged  to  have  a  nurse  or  maid  and 
needing  all  the  rooms. 

Please  address 
"H.  J.,"  Box  49,  Boston,  Mass. 

PHYSICIANS' 

Complete  Account  Book. 

Size,  7XxlO,  soo  pages.    Long  and  Short  A  ocounts. 
Sample  pages  on  application. 

PRICE,  $3.00. 

PECKHAM,  LITTLE  A  CO.,  Publishers, 

.  6*  Reade  Street,  New  York  City. 

Dr.  Martin's  Vaccine  Virus 

The  firm  of  Dr.  Henry  A.  Martin 
&  Son  has  terminated.  Dr.  Francis  0. 
Martin,  the  only  surviving  son  of  the 
late  Dr.  Henry  A.  Martin  (who  intro- 
duced Animal  Vaccination  into  Amer- 
ica in  1870),  has  been  devoted  to  the 
subject  of  vaccination  for  nearly  twenty 
years,  and  continues  uninterruptedly 
the  propagation  of  Pure  Animal  Vao 
cine  Lymph  oommenoed  by  his  father. 
All  genuine  Dr.  Mabtits  Vaccine 
Vietjs  most  be  obtained  directly  from 
him.  Terms:  10  Large  Ivory  Points, 
$1.00;  2  Points,  25  eta.  Address  Dr. 
FRANCIS  O.  MARTIN,  Eoxburj 
Station,  Boston,  Mass. 

8END  FOR  A  CATALOGUE 

—  OF  — 

f  I  WOOD  &  CO.'S  PUBLICATIONS. 


SANDER  ft  SONS  Eucalypti 
Extract  (Eucaltptol).  Whenever 
mention  is  made  of  "Oil  of  Euca- 
lyptus "  we  beg  you  to  bear  in  mind 
that  such  reference  applies  to  our 
preparation,  styled  for  distinction, 
"Eucalypti  Extract  (Eucalyptol),!; 
there  being  manufactured  besides 
our  preparation,  the  wholesale  price 
of  which  is  eight  dollars  per  doien 
ounce  bottles,  no  oil  exclusively 
produced  from  the  leaves.  Other 
oils  of  Eucalyptus  found  in  the 
market— worth  about  ten  cents  an 
ounce— are  common  terebmthinous 
products  of  no  medicinal  value.  A 
test  will  at  once  convince ;  the  dif- 
ference is  too  striking,  and  allows  of 
no  mistake.  To  avoid  disappoint- 
ment we  would  suggest  to  specify, 
when  prescribing,  our  manufacture. 
Samples  gratis  through  Dr.  Sander, 
Dillon,  Iowa.  Meyer  Bros,  Drug  Co., 
Be.  Louis,  Ha,  Sole  Agents. 

SECOND  EDITION. 

PRACTICAL 
MICROSCOPY. 

A  Coyne  of  Normal  Histology 
for  Students  and  Practitioners  of  Medicine 

-    By  MAURICE  N.  MILLER,  M.D. 


"  This  book  we  would  commend  most  highly.  Thar* 
U  no  want  of  excellent  books  on  the  same  subject,  bolt 
as  a  rale,  they  are  adapted  for  the  advanced  student 
and  skilled  microscopist.  Again,  the  work  differs  from 
many  more  pretentious  works,  in  that  the  illustrations, 
which  are  numerous,  are  mostly  originaj,  being  fine? 
the  author's  pen  drawings.19 

—Buffalo  Medical  ana  Surgical  JoumaU 

"  We  know  of  no  book  equal  to  this  for  students  whe 
wish  to  take  up  the  study  of  histology  during  vacation* 
or  for  practitioners  who,  having  had  no  laboratory 
advantages  during  pupilage  nor  time  now  to  devote  to 
work  in  post-graduate  schools,  still  desire  to  gam  sonw 
knowledge  of  microscopy  for  its  practical  uses." 

—Columbus  Medical  Journal, 

Complete  in  one  octavo  volume  of  217  pages 

with   12$  illustrations.     Price, 

muslin  binding,  $2,00. 

WILLIAJTl  WOOD  &  COilPANY. 

Publishers, 

43  to  47  East  loth  St.,  New  York, 

ATLAS  OP  ROMAN  ANATOMY. 

By  C.  E.  BOCK. 

. .  One  volume,  large  4to,  consisting  of  thirty- 
. .  eight  steel  plates,  most  of  them  hand- 
. .  colored  ;  with  explanatory  text  Muslin 
. .  binding,  price,  $15.00. 

WM.  WOOD  &  CO.,  New 


40  MEDICAL  RECORD. 


The  Thyroid  Gland. 

Whatever  may  be  the  truth  as  to  the  virtue  of  the  so-called  "animal  extracts"  there  seems 
to  be  no  doubt  as  to  the  efficacy  of  the  sheep's  thyroid.  It  has  been  used  chiefly  in  the 
treatment  of  Goitre  and  Myxoedema  by  physicians  on  both  sides  of  the  Atlantic,  with  most 
gratifying  results;  but,  as  these  ailments  are  rare  in  the  United  States,  the  opportunities  for 
testing  this  treatment  have  been  limited.  Recently,  however,  some  prominent  skin  specialists 
have  used  Desiccated  Thyroids  with  great  benefit  in  skin  diseases  such  as  Lupus,  Psoriasis, 
Scleroderma,  etc.,  and  we  have  heard  of  successful  experiments  in  the  treatment  of  obesity 
by   the  same   means. 


m  We  quote  by  permission   from  Dr.  Solomon  Solis- Cohen's  lecture  on  the    "Therapeutic    Proper- 


1 

I 
I 

i 

I 

i 


ties    of    Animal    Extracts,"   (Philadelphia   Polyclinic,    Nov.    15,  '93). 

"The  administration  of  the  Sheep's  Thyroid  is  based  on  the  same  principle  as  that  upon 
which   we   administer   Pepsin   or   Pancreatin    in   digestive    disorders." 

We  prepare  desiccated  Thyroid  Glands  in  a  concentrated  form,  six  grains  representing  one 
entire  average  gland  of  the  sheep.  The  usual  dose  is  from  two  to  six  grains  three  times  a 
day.  We  also  prepare  Thyroid  Tablets  (5  grs.),  each  tablet  containing  two  grains  desiccated 
Thyroids.  i 

The  price  of  our  Desiccated  Thyroids  is  $1.00  per  oz.,  packed  in  ounce  bottles;  the  B 
Tablets,  50  c.  per  oz.  in  ounce  bottles.  To  any  member  of  the  medical  profession  desir-  P 
ing    to    experiment,    we   shall   be   glad  to   send   samples,    free.  B 

Armour  &  Company,  Chicago.  | 


False  claims  as  to  its  containing  50  per  cent.  Norway  oil. 

Such  attenuation  of  oil  globules  in  other  emulsions. 

Question  as  to  the  advantage  of  the  Phosphates. 

Difficulty  in  mixing  with  water  or  milk. 

Chemical  modification  of  the  oil. 

Nauseousness  or  eructation. 

Saponification. 

Disappointing  results. 

Emulsion  so  efficient  as  ^^  M  II        I       I  J^\  ^N  f 


DO 
YOU 
KNOW 
BEANS? 


Cocoa  Beans,  we  mean?  Many  are  unfamiliar  with  them;  but, 
as  with  good  coffee,  a  rich  cocoa  cannot  be  made  from  a  poor  bean. 
Phillips'  Digestible  Cocoa  represents  the  entire  constituents  of 
the  choicest  beans,  the  fat  being  retained  and  predigested  with 
Pancreatine,  while  the  addition  of  the  Phosphates  renders  it  peculiarly 
serviceable  to  the  brain- worker,  the  invalid,  and  the  nursing  mother. 
A  truly  delicious  beverage.  Try  it.  The  proof  of  the  Cocoa  is  in 
drinking  it. 

The  Chas.  H.  Phillips  Chemical  Co.,  77  Pine  St,  Hew  York 


B.P.LBindeiye. 
NOV  26  189  &